Question

Georgia Wells is a 71 year old patient who is post operative day two patient from a hemiarthroplasty of the left hip. She is alert and cooperative. Today she is describing her pain on a 1-10 numeric scale as a 9 with any movement. She also has a history of heart failure, and hypertension.

Current Vitals: pulse-100, resp. 20, bp-140/90, sat 100% on 2Liters of oxygen via nasal cannula.

AM labs today: WBC-12,000 (normal 5-10,000), all others labs are normal

Scheduled Medications: vancomycin (Vancocin), Lisinopril (Prinivil), cardvedilol (Coreg), docusate sodium (Colace), bisacodyl (Dulcolax), warfarin (Coumadin), subcutaneous heparin. (all scheduled medications are due at 0900 and all medications are given PO except the heparin)

PRN Medications: hydrocodone/acetaminophen (Norco)

1. Based on your problem focused assessment prioritize & organize Ms. Wells medications and discuss the order you would anticipate giving them.

2. Be able to discuss the rationale for your decisions based on your assessment. Please only use the data you have been given assess the patient however you can make note of any additional assessment information you would want to know. (The dose of the medication is not significant to answering these questions)

3. Are you concerned with giving the patient both warfarin and heparin? Why or why not?

4. What labs would you want specifically for each of these two medications (warfarin and heparin)

Answer 1

1.The medications should be 1st antibiotic vancomycin and analgesic acetaminophen

.then in my opinion antihypertensive and anticoagulant.warfarin heparin to prevent stroke and CVT. i,e venous occlusion then as carvedillol then for stool softner like docusate sodium or others

2. Pain may be due to infection of artificial joint or hip flexor tendinitis

As the surrogate markers of sepsis is leucocytosis and pulse rate more than 100 here we can assess that pain may be due to infection.12000 TLC

3.Simultaneous use of the two has advantage.the suppressor effect of warfarin on different proteins does not increase the risk of thrombosis. In case of heparin withdrawal again there is chance of occlusion in veins.due to reduction in antithrombin lll level.simultaneous use of both helps in getting more time to increase in antithrombin lll level .

4.warfarin only partially block clotting of blood not complete stoppage of clotting.so close monitoring is needed by blood test with which adjustment of daily dose can be done.Here we do prothrombin time for assessing the time required for clot formation and expressed as INR (international normalized ratio)It is done in Pathological laboratory. Regarding heparin,the accepted guideline is to be guided by aptt value.In venous thrombo embolism monitoring of heparin therapy occurs where dose of heparin is titrated to an aPTT of 1.5-2.5 times of control value.Similalry it is also a coagulation profile test done in pathological laboratory.