Anticoagulant Therapy Education (Home Health Care) - CE/NCPD

ALERT

If bleeding cannot be stopped, continue to apply pressure to the injury and contact emergency medical services.

OVERVIEW

Anticoagulant therapy is used to manage and reduce the incidence of venous thromboembolism (VTE), pulmonary embolism (PE), and stroke in patients with atrial fibrillation (AF) and for short-term therapy for some postoperative patients.^{undefined#ref3">3} The use of anticoagulant therapy can be complex, with benefits, such as reduced risk for thrombus extension, stroke, or fatal PE, usually outweighing the risk for life-threatening bleeding complications.⁴

Vitamin K antagonists, such as warfarin, unfractionated heparin, and low-molecular-weight heparin (LMWH) are recommended for patients with mechanical heart valves and valvular AF and can be initiated and managed in an outpatient setting. Direct oral anticoagulants are recommended for treatment of non–cancer-associated VTE, whereas LMWH is recommended for cancer-associated VTE. LMWH is provided via a subcutaneous injection and does not require laboratory monitoring. Oral vitamin K antagonists require monitoring for a targeted international normalized ratio (INR).

Oral factor Xa inhibitors, such as rivaroxaban, apixaban, and others, are approved for prevention of strokes in patients with nonvalvular AF, postoperative thromboprophylaxis with knee and hip replacement surgery, and treatment of deep vein thrombosis (DVT) and PE.¹ These medications do not require routine laboratory monitoring. The advantages of Xa inhibitors are their efficacy in preventing stroke, a lower incidence of bleeding, fewer drug and food interactions, and no requirements for laboratory monitoring. These benefits make it a more favorable choice with practitioners for home care patients.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Instruct the patient, family, and caregivers about the requirement for laboratory monitoring (prothrombin time [PT] and INR) if the patient is prescribed warfarin for anticoagulant therapy.
• Explain to the patient, family, and caregivers that laboratory monitoring is not required when using oral factor Xa inhibitors (e.g., rivaroxaban, apixaban, non–vitamin K antagonist oral anticoagulants). Provide instructions specific to the prescribed medication.
• Instruct the patient, family, and caregivers to maintain a log of PT and INR results if using an anticoagulant therapy that requires monitoring.
• Instruct the patient, family, and caregivers to avoid the use of over-the-counter nonsteroidal antiinflammatory drugs (NSAIDs), including aspirin and ibuprofen, while on anticoagulant therapy. These medications, when used in addition to anticoagulants, increase the risk of bleeding.
• Instruct the patient, family, and caregivers to avoid foods that are contraindicated with some anticoagulant therapies. Check with the practitioner or pharmacist for medication side effects with certain foods if the patient is prescribed warfarin.
• Instruct the patient to report the use of herbal supplements, such as St. John’s wort, which may decrease the effectiveness of the anticoagulant medication.¹
• Instruct the patient to avoid herbal therapies that may increase bleeding risks (e.g., garlic, ginkgo biloba, dong quai).¹
• Instruct the patient, family, and caregivers that a soft-bristle toothbrush should be used.
• Instruct the patient, family, and caregivers to use an electric razor instead of a blade for shaving to avoid cuts.
• Instruct the patient, family, and caregivers to be mindful of the risks for falls or injury from sharp objects.
• Instruct the patient, family, and caregivers to use ice to reduce swelling and bleeding on bruised skin.
• Instruct the patient, family, and caregivers to use pressure to stop bleeding on open cuts.
• Instruct the patient, family, and caregivers on when to call for help if a bleed cannot be stopped.
• Instruct the patient, family, and caregivers that warfarin is considered a hazardous medication. Caution should be used when handling or administering warfarin, especially if pregnant or breastfeeding.
• Instruct the patient, family, and caregivers to notify other practitioners, including dentists, that anticoagulants have been prescribed.
• Encourage questions and answer them as they arise.

STRATEGIES

1. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient, family, and caregivers.
3. Verify the correct patient using two identifiers.
4. Explain the strategies to the patient, family, and caregivers and ensure that the patient agrees to a discussion regarding treatment.
5. Prepare an area in a clean, convenient location.
6. Review with the patient, family, and caregivers the anticoagulant therapy being used: its purpose, intended effects, requirements for monitoring (if needed), and side effects.
7. If the patient is taking warfarin for anticoagulant therapy, review with the patient, family, and caregivers the need to monitor INR levels per the practitioner’s orders.
8. Review with the patient, family, and caregivers drug interactions that may occur with medications for anticoagulant therapy (Table 1).
9. Review with the patient, family, and caregivers the complications that may occur with anticoagulant therapy (e.g., bleeding, bruising, hematoma at the injection site when using LMWH, skin necrosis when using warfarin).
10. Review with the patient, family, and caregivers foods that are contraindicated with some anticoagulant therapies and that should be avoided. Check with the pharmacist for medication side effects with certain foods.

    A diet that includes food high in vitamin K (e.g., green leafy vegetables, kale, Swiss chard, collard greens, spinach, beef liver) may decrease the INR of a patient using warfarin for anticoagulant therapy. Explain that the patient should continue eating the foods normally eaten but should not increase intake of vitamin K–rich foods.

11. Instruct the patient to report the use of herbal supplements, such as St. John’s wort, which may decrease the effectiveness of the anticoagulant medication.¹
12. Instruct the patient to avoid herbal therapies that may increase bleeding risks (e.g., garlic, ginkgo biloba, dong quai).¹
13. Review with the patient, family, and caregivers strategies for safety to avoid falls.
    1. Remove scatter rugs.
    2. Place nonskid bathmats in the bathroom and install handrails, when possible.
    3. Use skid-proof slippers indoors and shoes outdoors.
    4. Be mindful of pets underfoot.
14. Review with the patient, family, and caregivers strategies to avoid cuts and bruises.
    1. Use an electric razor for all shaving needs.
    2. Be mindful of risks when using sharp objects (e.g., kitchen knives, gardening tools, power tools).
    3. Pad sharp corners of side tables.
    4. Be mindful of the risks associated with any contact sports or activities where falling is likely.
15. Review with the patient, family, and caregivers strategies for when a bleed occurs.
    1. Provide pressure to a bleeding wound for several minutes, giving enough time for clotting to occur.
    2. Be aware that bleeding may not stop quickly if the patient is treated with anticoagulant therapy.
    3. Review indications for calling for assistance if bleeding cannot be controlled or stopped and the patient experiences lightheadedness or nausea.
16. Remove PPE and perform hand hygiene.
17. Document the strategies in the patient’s record.

EXPECTED OUTCOMES

• Patient, family, and caregivers demonstrate understanding of education provided.
• Patient, family, and caregivers verbalize understanding of bleeding precautions.
• Patient, family, and caregivers demonstrate understanding of monitoring requirements, if appropriate, and dietary requirements when treated with anticoagulant therapy.

UNEXPECTED OUTCOMES

• Patient, family, and caregivers unable to demonstrate understanding of education provided
• Uncontrolled bleeding, leading to hypovolemic shock
• Patient, family, and caregivers unable to demonstrate understanding of monitoring requirements, when appropriate, or dietary requirements when treated with anticoagulant therapy

DOCUMENTATION

• Education
• Patient’s progress toward goals
• Unexpected outcomes and related interventions

OLDER ADULT CONSIDERATIONS

• Risk for falls is an important consideration for older adults on anticoagulant therapy.
• Older adults with cognitive deficits may be unable to adhere to correct medication administration when dose changes occur or to perform routine monitoring as needed when using anticoagulant therapy.
• Older adults on certain anticoagulant therapies have a greater risk of bleeding complications and events.²

REFERENCES

1. Lilley, L.L., Rainforth Collins, S., Snyder, J.S. (2023). Chapter 26: Coagulation modifier drugs. In Pharmacology and the nursing process (10th ed., pp. 405-429). St. Louis: Elsevier.
2. Shendre, A. and others. (2018). Influence of age on warfarin dose, anticoagulation control, and risk of hemorrhage. Pharmacotherapy, 38(6), 588-596. doi:10.1002/phar.2089
3. Wigle, P., Hein, B., Bernheisel, C.R. (2019). Anticoagulation: Updated guidelines for outpatient management. American Family Physician, 100(7), 426-434. (Level VII)
4. Witt, D.M. and others. (2018). American Society of Hematology 2018 guidelines for management of venous thromboembolism: Optimal management of anticoagulant therapy. Blood Advances, 2(22), 3257-3291. doi:10.1182/bloodadvances.2018024893 (Level VII)

ADDITIONAL READINGS

National Institute for Occupational Safety and Health (NIOSH). (2017). NIOSH list of antineoplastic and other hazardous drugs in healthcare settings, 2016. Retrieved March 2, 2023, from https://www.cdc.gov/niosh/docs/2016-161/ (classic reference)*

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports