Sudden spike in INR after change in mental status

Nurses General Nursing

Published

Nurses Month 2024 | Discounts & Freebies AORN Celebrates Nurses Month

I work in long term care and I have a resident who has had a change in mental status and has seriously declined in the past couple of weeks. It started with what seems like acute delirium then continues with increased confusion, aphasia, mood swings and uncontrollable emotions. She has also gone from nearly independent with a walker to completely dependent with extensive two assist. She's treated with Coumadin (always has been) and is regularly stable until today. She's been on 2.5 of Coumadin and INR spiked from 2.09 to 6.01 in a week. No medication changes. No diet changes. Any suggestions or input??

Up Vote Up Vote ×

I assume she had some blood work done. If not, she needs it. This could be due to renal or liver failure, or septicemia from a UT. As you know, the elderly often don't exhibit the classic symptoms.

Up Vote Up Vote ×

She's been checked twice for UTI (2nd time on family insisting) in the last couple weeks and she's had CBC, BMP, MAG done for labs. If there's any other I'm missing them. We also did a CXR in the beginning worried about infection or CHF. Everything so far has checked out. I'll have to double check to see if she's had a liver panel

Up Vote Up Vote ×
Specializes in Cardiac, Home Health, Primary Care.

Check liver. Liver can affect coagulation and cause mental status change especially if ammonia levels rise

Up Vote Up Vote ×
Specializes in Hospice.

Did the INR spike before or after the mental status change?

Up Vote Up Vote ×
Specializes in ICU, LTACH, Internal Medicine.

Check advanced liver panel (AST, ALT, hepatites B and C, alk phos, bilirubine direct and indirect, albumin, LDH, ammonia, lactate) STAT. Access for jaundice, liver size, ascites, blood glucose and astherix ("flapping tremor") several times every day. Get the doc on board. Review all meds, do not start anything new unless essential for life. Better yet, send the guy in acute ASAP.

Up Vote Up Vote ×

After the mental status change

Up Vote Up Vote ×
Specializes in ICU, LTACH, Internal Medicine.
After the mental status change

Well, it was CHECKED and, therefore, NOTICED after mental status change, wasn't it? AFAIK stable patients in LTC do not get draws daily.

What the OP describes is a picture of impending liver failure unless proven otherwise. All the labs mentioned can stay WNL for a while if the process progresses slow enough, but the mental status changes, especially sudden mood swings, and jumping INR, are highly characteristic. My second differential would be accidental overdose of Coumadin or another medication affecting Coumadin action and brain micro bleed as a result. In any case, the patient needs to be in acute care.

Up Vote Up Vote ×

The other problem is the family is convinced it is a stroke (some of her symptoms can be related to that) so they don't want her sent out to the hospital, they feel it would be too much on her. I'll be asking for as much as we can provide for a work up in our facility and if something pops hopefully it's obvious enough to convince family for hospitalization

Up Vote Up Vote ×
Specializes in med/surg.

Even if this patient is a DNR, they need further testing it doesn't sound like your facility might have. This patient went from a needs minimal assist , talking patient, to a altered level of conciousness, total assist, with elevated INR. This is or was probably treatable .I would get that doctor on the horn and get an order for a CT head, INR, pt ptt, with CMP, liver functions and CBC If it was due to a Coumadin mistake ( wrong dosage, bloodwork not properly monitered) there could be legal implications. Good Documentation. Good Luck.

Up Vote Up Vote ×
Specializes in ICU, LTACH, Internal Medicine.
The other problem is the family is convinced it is a stroke (some of her symptoms can be related to that) so they don't want her sent out to the hospital, they feel it would be too much on her. I'll be asking for as much as we can provide for a work up in our facility and if something pops hopefully it's obvious enough to convince family for hospitalization

"Mrs. X., your mom's blood got very thin and cannot make cloths. She takes coumadin, that's blood thinning med, for (....), but for some reason this med stopped work as expected. Yes, she was taking it for eons but now its action is out of control. Here in LTC we really cannot figure out why it happened, and also cannot treat it, because treatment will require your mom's blood to be closely controlled, with labs done every day and doctors seeing her every day. This cannot be done while she is here, we're not a hospital. I am very concerned about your mom's safety because her blood is so thin. If she falls and get an internal injury, her blood will not make a cloth and she will (yes, say this!) quickly bleed to death. She needs to be in hospital where this problem can be quickly corrected and where doctors can get a good look on her and figure out why did it happen in the first place".

Repeat as needed, correct details as appropriate. Do not forget to make them sign refuse of hospitalisation if they insist. Do not sugar-coat. Good luck!

Up Vote Up Vote ×
Specializes in CCRN.

It sounds like she may need a head CT and/or MRI to r/o stroke....

Up Vote Up Vote ×
+ Add a Comment