**Im a new grad RN with 2 months experience**
I work at an assisted living facility. One of our residents is on Coumadin. A lab tech comes and draws her blood at our facility and then the results are sent to her cardiologist. So the labs were drawn at 5am on a wednesday. The day shift nurse called the doctor asking for new coumadin orders (PT/INR levels were fine) he did not respond. The coumadin is given at 4pm on my 3-11 shift. If faxed the doctor and called him requesting new orders, i got no response. the next day the day nurse called and faxed and got no response, so i tried again several times on my shift and still no response. The pattern continued the next day until finally a nurse for the cardiologists office called.
At this point the residents coumadin dose had been held for 2 nights because I had no new orders. She told me "you put the resident at risk by holding the dose, you should have given the coumadin, you didn't need new order, you should have known to continue to give the same dose unless we specifically tell you to hold the dose, you didn't need to have orders to do that"
Was I wrong for holding the dose without new orders after trying many times to get them from the doctor? Is she right and should I have given the dose when the labs came back without a new doctors order if the INR was fine??? I had the lab reports but not a Drs order to continue on the same regimen. Normally the Dr or his nurse calls our facility or faxes and says to "continue the regimen as it was previously"
Jun 17, '12
Just one opinion- but I would assume that you have to follow your facility's policy. Idk if you had one available, but usually if we are in a tough spot and we can't get the doc on the phone- we contact the nurse manager/ supervisor and she can tell you what she wants you to do- helps cover yourself
Jun 17, '12
How was the order written? Does it specify to hold the coumadin after lab is done until the doctor notifies you to continue it? In patients with a history of long term use of coumadin it is not uncommon to continue the current dosage until the doctor orders otherwise.
In the future ask that any orders for coumadin specify what the doc wants to do in regard to lab results; i.e. hold, continue, whatever. This way you will know precisely how to handle the situation. Most of all chalk this up to a learning experience and realize that it is only the first of many times in your nursing career when you will learn from a mistake. It happens to every nurse. What makes a good nurse are the ones who learn and don't repeat the mistakes.
Jun 17, '12
. does the order say there are to be new orders every time there is a pt/ inr draw? We would hold the does for a high inr and notify dr, keep the same dose for therapeutic level but notify Dr, press whomever you have to (Oncall etc) to get a new order when its low..
Jun 17, '12
If a pt's INR is in the therapeutic range, I advise the pt to continue with the current coumadin dosage, otherwise the INR with go down. Find out for sure what your facility's procedure is regarding INR.
Jul 3, '12
Where I work you only hold the Coumadin if there is an order to do so.
Jul 8, '12
This is where nursing judgement comes in. Standard protocol for INR is 2-3- no change. The Dr always has a protocol. Do you not have a copy of that? If you do not, have him send you a copy. This will let you know how urgent it will be to get a hold of him or his nurse. You should not have let her go 2 day without her med as long as you knew it was in therapeutic range. You definitely should have asked your nurse manager. If you have a protocol you can write the change yourself if your facility will let you do this. You have the order. You then still need to fax a copy of the order change(no change)on what you did so everyone is always on Board and no one can say you did not let them know. This will maintain the safety of your Pt. not having anyone call you back for 2 days. That solution might be something your nurse manager might take into consideration.
Jul 9, '12
If the resident is in therapeutic range, I give the dose and keep trying to get the recheck order. If the INR is high, I hold the coumadin and if it is low I still give the coumadin, all while trying to get new orders.
I would contact my DON if two days went by, and we had no new recheck order.
Jul 10, '12
I'd have continued giving the coumadin, especially had i known the levels were WNL, IMHO.
but others make a point that perhaps your facility requires new/updated orders for every PT/INR check at which point the MD should have provided instrution to have the the pt's MAR updated in a timely manner
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