CPG Bleeding Precautions.pdf - CLINICAL PRACTICE GUIDELINE Bleeding Precautions(Adult EXPECTED OUTCOME Patient will identify ways to minimize risk of

CPG Bleeding Precautions.pdf - CLINICAL PRACTICE GUIDELINE...

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Unformatted text preview: CLINICAL PRACTICE GUIDELINE: Bleeding Precautions (Adult) EXPECTED OUTCOME: Patient will identify ways to minimize risk of bleeding. Patient/nurse will recognize early signs of bleeding. SUPPORTIVE DATA: Bleeding precautions should be implemented for the following reasons: ∙​ ​ ∙​ ​ ∙​ ​ ∙​ ​ patient has known or suspected coagulopathy patient’s lab values are abnormal as seen in ​Table 1 patient is taking medication listed in ​Table 2​. patients receiving hemodialysis, peritoneal dialysis or continuous renal replacement therapy (CRRT) RESEARCH BASED GRADING SYSTEM*: A.​ = ​ Evidence from well-designed meta-analysis B.​ ​= Evidence from well-designed controlled trials, both randomized and non-randomized with results that consistently support a specific action (e.g., assessment, intervention or treatment) C.​ ​= Evidence from observational studies (e.g., correlational, descriptive studies) or controlled trials with inconsistent results D.​ ​= Integrative reviews, national clinical practice guidelines, professional organization standards E.​ = ​ Expert opinions or multiple case reports *​Adapted from: Herr, K., Titler, M., Sorofman, B., Ardery, G., Schmitt, M., & Young, D. (2003). Evidence-based protocol: Acute pain management in the elderly. Iowa City, IA: The University of Iowa. Refer to Procedure for discontinuing sheaths on cardiac catheterization patients. TABLE 1 LAB VALUES LAB TEST PATIENT VALUE Prothrombin Time >​ 21 sec INR >​ ​2.0 Platelet Count <​ 75,000 micro/L PTT >​ 45 sec Fibrinogen < 100 mg/dL TABLE 2 ANTICOAGULANTS, ANTIPLATELETS, AND THROMBOLYTICS Medication Class Medications Low molecular weight heparins Dalteparin (Fragmin®), Enoxaparin (Lovenox®) Thrombolytic agents Alteplase (Activase®, Tissue Plasminogen Activator) IV antiplatelet agents/Glycoprotein IIb/IIa antagonists Abciximab (Reopro®), Eptifibatide (Integrilin®), Tirofiban (Aggrastat®) Direct thrombin inhibitors Argatroban, Lepirudin (Refludan®), Bivalirudin (Angiomax®) Miscellaneous Subcutaneous Heparin Intravenous Unfractionated Heparin Warfarin (Coumadin®) Fondaparinux (Arixtra®) Oral antiplatelet agents Clopidogrel *(Plavix®), Ticlopidine (Ticlid®), Aspirin, Aggrenox (aspirin and extended release dipyridamole), Dipyridamole, Soma Compound (carisoprodol plus aspirin) Patient Monitoring and Care Rationale/Special Considerations 1.​ ​Patients may require increased frequency of assessment based on risk factors. 1.​ ​Risk factors during Warfarin therapy: (Grade C)​5,6,14 ​ ∙​ ​ ∙​ ​ Age ​>​ 65 years ∙​ History of stroke History of GI bleed Any of the following comorbidities: recent MI, Hct <30%, Cr >1.5 or diabetes mellitus ∙​ ​ ​Higher levels of anticoagulation [Targeted INR of 2.5 (range: 2 - 3) is associated with a lower risk of bleeding than therapy targeted at an INR > 3] ∙​ ​Concomitant use of NSAIDs, aspirin, or aspirin containing products ∙​ Risk factors during Heparin therapy: (Grade B)​6,15,16 Recent surgery, trauma ∙​ ​ Concomitant thrombolytic therapy or GP IIb/IIIa inhibitor therapy ∙​ ​ ∙​ ​ ∙​ ​ Renal failure Age > 70 years Concomitant use of NSAIDs, aspirin, or aspirin containing products ∙​ ​ ASSESSMENT 2.​ ​Observe for signs and symptoms of bleeding.​1,2,3 2.​ ​Contact physician for signs and symptoms of bleeding. General: ∙​ ​Contact physician for signs and symptoms of bleeding and/or abnormal lab values. ​ ∙​ ​ ∙​ ​ ∙​ ​ ∙​ ​ Petechia, abnormal bruising ∙​ Unexplained hematoma Epistaxis (nosebleed) Bleeding gums Decrease in hemoglobin and hematocrit Shock: ​ ∙​ ​ ∙​ ​ ∙​ ​ Tachycardia, hypotension ∙​ ∙​ ​Contact physician for signs and symptoms of bleeding. Contact rapid response team (RRT)(non-critical care areas). Pale, ashen color usually with diaphoresis Change in mental status Tachycardia Bleeding/oozing from: ∙​ ​Apply direct pressure if applicable. Contact physician for signs and symptoms of bleeding. ​ ∙​ ​ ∙​ ​ ∙​ ​ Arterial and venous sties ∙​ Surgical/procedure sites Skin tears Oral mucous membrane Neurological: Headache ∙​ ​ Change in level of consciousness (disorientation, decreased level of arousal) ∙​ ​ ∙​ ​ Pupillary abnormalities Visual changes (blurred vision, double vision) ∙​ ​ Intensity of anticoagulant effect is an important risk factor for intracranial hemorrhage, with the risk increasing dramatically with an INR > 4. (Grade B)​4,6,11,12 ∙​ ​ Contact physician for signs and symptoms of bleeding. ∙​ ​ ​ nticipate need for stat CT scan of the A head. ∙​ ​ ∙​ ​ Facial droop ∙​ ​Contact rapid response team (RRT)(non-critical care areas). ∙​ Speech changes (slurred or garbled speech) Nausea/vomiting ∙​ ​ ​Weakness of extremity or extremities on one side of the body ∙​ ​ ∙​ ​ ∙​ ​ Change in sensation ∙​ Seizures Dizziness, ataxia Gastrointestinal (GI)/Genitourinary (GU): ​Hematemesis (vomiting of blood, coffee ground emesis) ∙​ ​Contact physician for signs and symptoms of bleeding. Include description of stool or emesis if applicable. ∙​ Melena (black, tarry stools) ∙​ ​ ∙​ ​ ∙​ ​ ∙​ ​ Abdominal pain and/or distention Routine point of care testing (POCT) for occult blood without signs and symptoms of bleeding is compromised by numerous factors yielding false positives and false negatives. (Grade C​13​ and supported by CCHS Gastroenterology) ∙​ ​ Hematuria ∙​ ∙​ ​ ∙​ Blood in feces Rectal bleeding Excessive menstrual bleeding ​ Test for fecal/gastric occult blood per physician order and notify physician if test is positive. ​ Retroperitoneal bleeding: ​ ∙​ ​ ∙​ ​ Back or abdominal pain ∙​ Ecchymotic flanks Contact physician for signs and symptoms of bleeding. Contact rapid response team (RRT)(non-critical care areas). ∙​ ​ Hypotension Pulmonary: ​Shortness of breath, decreased breath sounds ∙​ ∙​ Hemoptysis ​ INTERVENTIONS 3.​ ​Display "Bleeding Precautions" sign outside patient door as appropriate for setting. ​Contact physician for signs and symptoms of bleeding. ∙​ ∙​ Possible hemothorax ​ 4.​ ​Document "Bleeding Precautions" on the Message Center, Nursing Profile (PowerChart), Medication Administration Record, CIR, and on the Interdisciplinary Plan of Care and Teaching Record. 5.​ ​Inspect stools, urine and emesis to look for visual signs of blood. Instruct patient to save stool, urine and emesis for inspection. ​Contact physician for signs and symptoms of bleeding. Include description of stool or emesis if applicable. ∙​ Routine POCT for occult blood without signs and symptoms of bleeding is compromised by numerous factors yielding false positives and false negatives. (Grade C​13 and supported by CCHS Gastroenterology) ∙​ ​ Test for fecal/gastric occult blood per physician order and notify physician if test is positive. ∙​ 6.​ ​Apply direct pressure to all venipuncture sites for a minimum of 3-5 minutes, or longer if needed to achieve hemostasis. Venipuncture should be performed as infrequently as possible. Do not bend arm after venipuncture. ​ ∙​ ​Increases risk of bruising/hematoma formation. 7.​ ​Observe the puncture site not only for bleeding from the surface puncture, but also for bleeding that can occur subcutaneously.​7 8.​ ​Avoid IM injections. If injections are necessary, reduce hematomas and bleeding by: a.​ using small gauge needles b.​ ​ c.​ rotating sites ​ not massaging sites ​ 9.​ ​Avoid arterial sticks if possible and apply pressure for a minimum of 15 minutes or longer if needed to achieve hemostasis. 9.​ ​For arterial sheath removal, refer to ​CPG: Sheath Removal Vascular Hemostasis, Post-Diagnostic/Interventional Cardiac Catheterization; Electrophysiology Study​. 1.​ ​For BP measurement, remove cuff every 8 hours to assess arm for purpura.​8,9 10.​ ​No significant difference in the prevalence of purpura is found between patients monitored with an automatic cuff versus When possible, alternate cuff site every 8 hours to reduce the potential for injury, edema, or petechiae.​8,9 patients monitored with a manual cuff. (Grade B).​10 Avoid use of an arm with an IV, failed venipuncture or pre-existing purpura.​8,9 Avoid use of a non-invasive BP machine in the continuous/STAT mode. Avoid use of excessive pressure by turning machine off between patients. Turning machine off between patients allows machine to rest. 2.​ ​Avoid invasive procedures such as enemas, naso-tracheal suctioning, gastric tubes and rectal temperatures. 11.​ ​If invasive procedures are ordered, ensure that physician is aware of patient's anticoagulation status and monitor closely for bleeding. 3.​ ​For evaluation and treatment of any fall, refer to ​Falls: Standing Orders by Protocol Falls​. 12.​ ​Persons on bleeding precautions may be at higher risk for serious injury. 4.​ ​Consider bowel regimen to decrease risk of constipation. (Refer to ​Constipation Algorithm​) 5.​ C ​ ontrol nausea and vomiting. 6.​ ​Use soft toothbrush and gentle friction for mouth care. Use electric razor for shaving. PATIENT EDUCATION (Grade D)17,18 ​ 7.​ R ​ eview key concepts including: a.​ Mechanism of action of medication ​ b.​ c.​ 16.​ ​Provide appropriate patient education material/activities based on patient's learning preferences, and document on Education Record: Time of day to take medication ​ ➢​ Explanation of appropriate lab test and testing schedule. ​ ​Consult Pharmacy for Warfarin teaching. Patient education TV videos: ➢​ d.​ Signs and symptoms of bleeding. Distribute Bleeding Precautions FYI. ​ ​ ∙​ Enoxaparin (Lovenox®) (#060) ​ e.​ f.​ g.​ h.​ i.​ ​Need to contact physician for any illness, injury, change in physical status or signs and symptoms of bleeding. Need to inform all healthcare providers that they are on anticoagulation therapy, especially if undergoing an invasive procedure, surgery or dental work. ​ Importance of Medical Alert bracelet/necklace. For Warfarin: ​ ​ ∙​ ​ Importance of maintaining a log of INRs and Warfarin dose. ∙​ Importance of Warfarin ID card. ​ ∙​ ​ ∙​ ​ Warfarin (Coumadin®) (#063) Dalteparin (Fragmin®) (#064) For Your Information Sheets: ➢​ ​Importance of minimizing trauma risks associated with activities at high risk for injury. ​ Fondaparinux (Arixtra®) (#61) ∙​ ​ Warfarin ∙​ ​ ∙​ ​ ∙​ ​ Warfarin Patient Education Medication Record Bleeding Precautions ➢​ Lovenox Home Kit (Aventis Pharmaceuticals) ➢​ ​A Patient's Guide to Using Coumadin (Bristol-Myers Squibb Company) ​ ADDENDUM I Standing Orders by Protocol FALLS: ADMITTED AND OBSERVATION PATIENTS Page 2 of Standing Orders by Protocol FALLS: ADMITTED & OBSERVATION PATIENTS THE PURPOSE OF STANDARDS AT CHRISTIANA CARE HEALTH SERVICES IS TO PROVIDE GUIDELINES FOR PRACTICE,​ ​CARE, AND DOCUMENTATION; THESE STANDARDS DO NOT REPLACE​ ​OR OVERRIDE CLINICAL JUDGMENT. REVISED DATE: October 2008 KEY REFERENCES: 1.​ H ​ ickey, J.V. (2003). ​Neurological and neurosurgical nursing ( ​ 5​th​ ed.). Philadelphia: Mosby. 2.​ ​Scroggins, N.N. (2000). Hemorrhagic disorders associated with thrombolytic therapy. ​Critical Care Nursing Clinics of North America, 12​(3), 353-363. 3.​ ​Raskob, G.E., & Kilzer, W. (2003). Bleeding complications of antithrombotic therapy. In J. Loscalzo & A.I. Schafer (Eds.), ​Thrombosis and Hemorrhage​ (3​rd​ ed.). Philadelphia: Lippincott, Williams & Wilkins. 4.​ ​Hylek, E.M., & Singer, D.E. (1994). Risk factors for intracranial hemorrhage in outpatients taking Warfarin. ​Annals of Internal Medicine, 120(​ 11), 897-902. 5.​ ​Beyth, R.J., Quinn, L.M., Landefield, C.S. (1998). Prospective evaluation of an index for predicting the risk of major bleeding in outpatients treated with warfarin. ​American Journal of Medicine, 105,​ 91-99. 6.​ ​Levine, M.N., Raskob, G., Beyth, R.J., Kearon, C., & Schulman, S. (2004). Hemorrhagic complications of anticoagulant treatment: The seventh ACCP conference on antithrombotic and thrombolytic therapy. ​Chest, 126​(3), 287S-310S. 7.​ ​Ernst, D.J., Ernst, C. (2003). Phlebotomy tools of the trade: Part 5, protecting yourself from phlebotomy-related lawsuits. ​Home Health Care Nurse, 21(​ 5), 340-344. 8.​ ​Ramsey, M. (1994). Blood pressure monitoring: Automated oscillometric devices. ​Journal of Clinical Monitoring, 7​, 56-67. 9.​ ​Ramsey, M. (1994). Automatic oscillometric NIBP versus manual auscultatory blood pressure in the PACU. ​Journal of Clinical Monitoring, 10,​ 136-139. 10.​ ​Saul, L., Smith, J., & Mock, W. (1998). The safety of automatic versus manual cuffs for patient receiving thrombolytic therapy. ​American Journal of Critical Care, 7(​ 3), 192-196. 11.​ ​Rosand, J., Eckman, M., Knudsen, K., Singer, D.E., & Greenberg, S. (2004). The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. ​Archives of Internal Medicine, 164​(8), 880-884. 12.​ ​Oden, A., & Fahlen, M. (2002). Oral anticoagulation and risk of death: A medical record linkage study. ​British Medical Journal, 325(​ 7372), 1073-1075. 13.​ ​Harewood, G.C., McConnell, J.P., Harrington, J.J., Mahoney, D.W., & Ahlquist, D.A. (2002). Detection of occult upper gastrointestinal tract bleeding: Performance differences in fecal occult blood tests. ​Mayo Clinic Proceedings, 77(​ 1), 23-28. 14.​ ​Landefeld, C.S., McGuire, E., & Rosenblatt, M. W. (1990). A bleeding risk index for estimating the probability of major bleeding in hospitalized patients starting anticoagulant therapy. American Journal of Medicine, 89,​ 569-578. 15.​ ​EPILOG Investigators. (1997). Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization. ​New England Journal of Medicine, 336​(24), 1689-1696. 16.​ ​Campbell, N.R.C., Hull, R.D., Brant, R., Hogan, D.B., Pineo, G.F., & Raskob, G.E. (1996). Aging and heparin-related bleeding. ​Archives of Internal Medicine, 156, ​857-860. 17.​ ​Institute for Clinical Systems Improvement. (2003). Health Care Guideline: Anticoagulation Therapy Supplement, 3​rd​ ed. Appendix E, p.30. 18.​ ​Institute for Clinical Systems Improvement. (2003). Health Care Guideline: Anticoagulation Therapy Supplement, 3​rd​ ed. Appendix C, pp 25-26. bleedprecautions.htm ...
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  • Nursing, Fecal occult blood, Thrombolysis

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