Updated Care Plan for Anticoagulation

Category / Primary Body System:

Hematologic / Medication Management

Problem:

The patient is at risk for complications due to anticoagulation medication use.

Goal:

The patient will not exhibit signs or symptoms of bleeding for 90 days.

Plan/Approach:

1. Medication Administration:

   • Step: Administer anticoagulation medication as ordered.
   • Rationale: Proper administration of anticoagulants ensures therapeutic efficacy and minimizes the risk of complications.
   • Actions: Follow the prescribed dosage and schedule precisely, and document each administration.

2. Laboratory Monitoring:

   • Step: Check lab levels as ordered.
   • Rationale: Regular monitoring of lab values, such as INR or aPTT, ensures the patient remains within the therapeutic range and helps prevent bleeding or clotting complications.
   • Actions: Schedule and conduct lab tests as prescribed, review results promptly, and adjust medication as necessary in consultation with the healthcare provider.

3. Patient Education:

   • Step: Educate the patient or responsible person about anticoagulation medication.
   • Rationale: Education empowers the patient and caregivers to manage the medication effectively and recognize early signs of complications.
   • Actions: Provide comprehensive education on the purpose, dosage, potential side effects, and precautions associated with anticoagulant use. Provide written materials and encourage questions.

4. Bleeding Monitoring:

   • Step: Monitor the patient for signs and symptoms of bleeding and notify the MD if any are observed.
   • Rationale: Early detection of bleeding allows for prompt intervention, reducing the risk of severe complications.
   • Actions: Regularly assess the patient for signs of bleeding, such as bruising, blood in urine or stool, prolonged bleeding from cuts, and report any findings immediately to the MD.

5. Safe Shaving Practices:

   • Step: Use an electric razor as needed when shaving.
   • Rationale: Electric razors reduce the risk of cuts and bleeding compared to traditional razors.
   • Actions: Ensure the patient has access to an electric razor and educate them or caregivers on its use.

6. Dietary Management:

   • Step: Follow diet as ordered.
   • Rationale: Certain foods can affect the efficacy of anticoagulation medication, so dietary management is essential to maintain therapeutic levels.
   • Actions: Educate the patient on dietary restrictions or recommendations, particularly regarding vitamin K intake if on warfarin, and ensure they adhere to the prescribed diet.

7. Injection Site Rotation:

   • Step: Rotate injection sites if the route of administration is via injection.
   • Rationale: Rotating injection sites helps prevent tissue damage and reduces the risk of localized bleeding or bruising.
   • Actions: Instruct the patient or caregiver on proper injection techniques and ensure they rotate sites regularly.