Care Plan for Anticoagulation
Care Plan for Anticoagulation
Category / Primary Body System
- Hematological System
Problem
- Patient is at risk for complications due to anticoagulation medication use.
Goal
- Patient will not exhibit signs or symptoms of bleeding for 90 days.
Plan/Approach
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Medication Administration
- Administer anticoagulation medications as ordered.
- Rotate injection sites if the route of administration is via injection to prevent localized tissue damage.
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Monitoring and Assessment
- Check lab levels as ordered, such as INR, PT, aPTT, and CBC, to monitor the effectiveness and safety of anticoagulation therapy.
- Monitor the patient for signs and symptoms of bleeding (e.g., bruising, bleeding gums, hematuria, melena) and notify the MD immediately if any are observed.
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Patient and Family Education
- Educate the patient and/or responsible party about anticoagulation medication, including the importance of adherence, potential side effects, and signs of bleeding.
- Instruct the patient to use an electric razor for shaving to minimize the risk of cuts.
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Dietary Management
- Implement the diet as ordered, ensuring it does not interfere with the effectiveness of anticoagulation therapy (e.g., consistent intake of vitamin K).
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Communication and Documentation
- Document all findings, interventions, and patient education thoroughly.
- Notify the MD of any changes in the patient's condition or lab results promptly.
Rationale
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Medication Administration
- Proper administration of anticoagulation medications ensures therapeutic levels are maintained, reducing the risk of thromboembolic events.
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Monitoring and Assessment
- Regular monitoring of lab values and clinical signs helps detect any adverse effects of anticoagulation therapy early, allowing for prompt intervention.
- Rotating injection sites prevents complications such as hematomas and tissue necrosis.
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Patient and Family Education
- Educating the patient and family promotes understanding and adherence to the treatment plan, reducing the risk of complications.
- Using an electric razor minimizes the risk of cuts and subsequent bleeding.
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Dietary Management
- A diet that does not interfere with anticoagulation therapy helps maintain consistent medication effectiveness.
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Communication and Documentation
- Thorough documentation and prompt communication with the healthcare team ensure that any issues are addressed quickly and appropriately.
Actions
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Medication Administration
- Administer prescribed anticoagulation medications on schedule, documenting administration and any adverse reactions.
- Rotate injection sites regularly if administering via injection, and document each site used.
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Monitoring and Assessment
- Check lab levels as ordered, reviewing results promptly and notifying the MD of any abnormal values.
- Monitor the patient for signs and symptoms of bleeding daily, such as unusual bruising, bleeding gums, nosebleeds, blood in urine or stool, and excessive menstrual bleeding, and report any findings to the MD.
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Patient and Family Education
- Conduct education sessions with the patient and/or responsible party, covering the purpose, dosage, and potential side effects of anticoagulation medications, as well as the importance of adhering to the prescribed regimen.
- Instruct the patient on using an electric razor and other safety measures to avoid cuts and bruises.
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Dietary Management
- Ensure the patient's diet is in line with medical recommendations, avoiding foods that can interfere with anticoagulation therapy.
- Consult with a dietitian as needed to provide personalized dietary advice.
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Communication and Documentation
- Document all interventions, findings, and education provided in the patient's medical record.
- Communicate any changes in the patient's condition or lab results to the MD/RNP/PA promptly.
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