pharmacology question: warfarin

CT Pixie, BSN, RN · Dec 8, 2012

26. What should the nurse teach a patient about precautions before dental surgery when the patient is prescribed long-term warfarin therapy?
a. No action is needed ??
b. Inform the dentist of the most recent international normalized ratio (INR) results. ???
c. Stop warfarin 3 days before dental surgery.
d. Take half of the normal dose of warfarin for 3 days before dental surgery.
My book states: "Does warfarin increase bleeding during dental surgery? Yes, but not that much. Accordingly, most patients needn't interrupt warfarin for dental procedures, including dental surgery. However, it is important that the INR be in the target range"
would a dentist need to know if the INR is in range or just the health care provider?

Well I'm leaning toward B. Coumadin patients are educated to inform medical/dental professionals that they are on that med. I would say C & D are totally wrong IF the prescribing doctor didn't tell the patient to do either one of them. While the need to stop or reduce the dose might be necessary, more often than not its not required.

I'm saying B b/c the dentist should be aware of the INR so that they are aware before hand that there may be more bleeding than the norm and so that the dentist can collaborate with the doctor before the procedure.

firefly101 · Dec 8, 2012

okay that makes sense. thank you for your response!

Esme12, ASN, BSN, RN · Dec 8, 2012

Well I'm leaning toward B. Coumadin patients are educated to inform medical/dental professionals that they are on that med. I would say C & D are totally wrong IF the prescribing doctor didn't tell the patient to do either one of them. While the need to stop or reduce the dose might be necessary, more often than not its not required.
I'm saying B b/c the dentist should be aware of the INR so that they are aware before hand that there may be more bleeding than the norm and so that the dentist can collaborate with the doctor before the procedure.

I agree.....:)

Double-Helix, BSN, RN · Dec 9, 2012

would a dentist need to know if the INR is in range or just the health care provider?

In this situation, the dentist is the healthcare provider.

emerjensee · Dec 9, 2012

I think the answer is actually C.. Withhold the Coumadin 3 days prior to surgery.

I just had a clinical preceptor who is also an FNP tell me that a friend of hers was found bled out because she didn't tell her Dentist she was on a blood thinner before dental surgery.. How completely horrible...

Always always always as a patient if he or she is on blood thinners before outpatient surgery.

-emerjensee

pre-nurseshan · Dec 9, 2012

I can't give the nursing rationale, but I can tell you thatin 10 yrs as a dental assistant, any time we had patients scheduled for anything other than fillings or crowns (anything where bleeding was more likely) that had to be off coumadin for a period of time (it might have been 3 days) and I never had one inform us of an INR.

CT Pixie, BSN, RN · Dec 9, 2012

But a nurse cant tell a patient to stop a med without a dr order. While it may be that it will be ordered..the nurse cant take it upon herself to make the decision and tell the pt to stop taking it.

OKNurse2be · Dec 14, 2012

When my 90 something grandmother had to have a dental procedure a couple years back, there was a bunch of back and forth between her physician and the dentist because the dentist refused to perform the procedure with the labvalues the way they were and her physician was reluctant to change her warfarin orders. I would think this boils down to ABC's. Anytime there is a potential for bleeding then the provider should be informed in some way or other and let them be the ones to tell the pt to withhold the med for however long.

psu_213, BSN, RN · Dec 14, 2012

I think the answer is actually C.. Withhold the Coumadin 3 days prior to surgery.
I just had a clinical preceptor who is also an FNP tell me that a friend of hers was found bled out because she didn't tell her Dentist she was on a blood thinner before dental surgery.. How completely horrible...
Always always always as a patient if he or she is on blood thinners before outpatient surgery.
-emerjensee

What authority does the nurse have to independently tell a pt to stop their medication? (The answer would be none.)

psu_213, BSN, RN · Dec 14, 2012

that had to be off coumadin for a period of time (it might have been 3 days)

That is up to her dentist in consultation with whomever is managing his/her coumadin to decide. The most accurate answer probably should read "alert the dentist you are on coumadin and alert your PCP that you are going to have dental surgery soon" rather than just "tell the dentist your INR." The reason other answers are wrong: A. you can't do nothing. Maybe the dentist will still do the surgery, but that is his decision, not the nurses. C&D. these courses of action can only be 'ordered' by the prescribing physician or the dentist. It is not in the nurse's scope of practice to decide how/if the pt takes his/her coumadin. If the nurse either tells the pt to hold coumadin or alter the coumadin dose, this is practicing medicine by the nurse.

nurseprnRN, BSN, RN · Dec 14, 2012

I think the answer is actually C.. Withhold the Coumadin 3 days prior to surgery.
I just had a clinical preceptor who is also an FNP tell me that a friend of hers was found bled out because she didn't tell her Dentist she was on a blood thinner before dental surgery.. How completely horrible...
Always always always as a patient if he or she is on blood thinners before outpatient surgery.

1) As a nurse, YOU do not tell (teach) a patient to change or discontinue any prescribed medication without a physician order. Trick distractor answer to find out whether you really knew this about your role.

2) As noted, the dentist is a healthcare provider, is quite aware of the effects of anticoagulation medications, and is quite qualified and licensed to manage this. The only correct answer is B. Actually, any dentist would have kept any patient for long enough to assure that bleeding was under control before sending him/her home whether or not the patient disclosed anticoagulation (including ASPIRIN, an antiplatelet medication).

3) Many people including, alas, physicians and nurses who know better, refer to anticoagulation medications (both antiplatelet and those acting on other parts of the clotting cascade) as "blood thinners." Unfortunately, and inaccurately, this puts people in mind of paint thinned by solvents or watered-down milk, or maybe thin, inadequate clothing. The problem then becomes that they are not aware of the actual physiological reason their medications are prescribed to reduce risk for embolic events, either stroke or deep vein thrombosis and pulmonary embolus. I have had patients tell me they are "always cold since taking that blood thinner." The risk of discontinuing the medication because the effects are inaccurately communicated is great, and very real. Anticoagulants do not "thin" the blood. They decrease blood clotting to decrease the chances of a clot in the heart from causing stroke or clot in a vein traveling to the lungs by preventing it from growing larger while the body's natural processes break it down for disposal. Side effects include easier bruising and bleeding. There, is that so hard?

4) Those old FOAFs (friend of a friend's) are always in such dire straits. :rolleyes: I don't believe a word of it. Nobody "bleeds out" from a tooth extraction. Maybe has some excess bleeding, but not to the point of exsanguination. Unless the patient in question was days away from medical care, any unexpected excess bleeding from warfarin or heparin would have been addressed handily by reversing the effects. How do you do that, you ask? Look it up, and don't be so sure of everything you hear.