Would you question this order?

[dura_mater]

A little background first, I am a new grad, still on orientation and the other day I had a MD write an order that just didn't seem right. I asked some of my colleagues, and they all seemed to be ok with it, but I wanted to get some more input.

So I was taking care of a pt admitted for ALOC, dehydration and weakness. The pt's history was advanced AIDS, MI x2, pacer, BPH, and atrial thrombus. When this pt was admitted the INR was 6.7, he was on coumadin at home but obviously it was not to be continued while admitted.

Fast forward to the next day, when I was getting report on him, his INR is now 7.7. The off going nurse and I catch the MD and bring up the high INR to him, and his response was basically: "well, I'm not going to do anything about it, because he has an atrial thrombus, so I don't want to clot him up any more".

The MD proceeded to write an order that stated:

Don't call unless the INR is >10 or the pt is actively bleeding

Our policy is to call the MD for any critical lab values, and an INR gets to be critical way before it reaches 10. This order just seemed to be weird to me, it almost seemed like I was just waiting for him to bleed out before the MD wanted to address the situation.

I would love some input from you all, as I am just in the process of learning what/when to question and/or stand up to improper orders.

Thanks

[LouisVRN, RN]

Yes, I would definitely question the order and I would continue to call him, even if it was just "I know you said you didn't want to know if Mr. X's INR was greater than 10, but its now 9.2 instead of 7.7 that it was this morning, would you like to consult a hematologist?"

I would also be asking everyone who came in to see the patient for a hematology consult.

Should the patient have an adverse outcome I would rather defend why I called the doctor a gazillion times than why I did not because the doctor wrote an order. Just because the patient has a clot somewhere doesn't mean he can't have a bleed somewhere else. (ETA: And just because he is bleeding, doesn't mean it will necessarily be immediately obvious) I would be very very careful with this patient in general.

ETA you can always CYA by saying "I'm sorry Dr. so and so our policy states we have to call you with critical results..."

[nursynurseRN]

Well It is a little weird, but does the doctor know the patient? Since there is a order for it I think you are covered. What did the charge nurse say? It makes sense what he said that there is a thrombus and doesn't want to clot him up so the doctor does have a rationale and he did say to call for active bleeding. So I think I would be ok with it since there is an order. The other thing is... what would the doctor do? He didnt continue any anticoagulants.... so what could he do? give him platelets or something? If I was the doctor I wouldnt give him anything and just wait because I wouldnt want the clot the pt has to get bigger and casue more problems. I think the doctors hands are tied at this point.

[OttawaRPN]

Can't AIDS cause thrombocytopenia which further increases the risk of bleed? What if the bleed is in his brain, GI or liver or other non-obvious location? The fact that he's already ALOC and weak would set off some red flags!

That's a terrible order, I would keep harassing this md with any change in his condition. Watch out for bloody stools, bleeding gums, petechiae, bruising, epistaxis, skin lesions and above all.... DOCUMENT, DOCUMENT, DOCUMENT.

[kayern]

Bad advise by one other poster..........DON'T EVER APOLOGIZE to a physician when following your institutions policy. If the policy is to call, then call. Ours allows the nurse not to call if the critical value is less critical (INR 7.0 now 6.0 = decreasing) and the physician has documented in his note that he was aware of the INR 7.0. Otherwise you call...............remember its your license ESPECIALLY if the critical is trending in the wrong direction, 7.0 now 9.0. CALL CALL CALL

[dura_mater]

The platelets were 101 on the day that the INR was 7.7

I was watching this pt very closely for s/s of bleeding, I didn't see anything. Mouth, nose, skin all looked good. Also stool for OB was negative x3. I don't think they did a head CT, there was no neuro doc on the case either. I think they were thinking that the ALOC was r/t dehydration and advanced AIDS.

There was a GI doc on the case as well, but we don't have hematology at our hospital. The primary MD didn't even write an order to recheck the INR in the morning, so how would we have even known if it was increasing or decreasing. My preceptor and I at least got the GI doc to write an order to recheck the INR in the morning.

I just keep kicking myself for not questioning this order further....

I did come back the next day and a different primary MD (one within the same group as the 1st) was on the case. Now the pts PT/INR was 92.3/>9.5 (apparently the lab can't even quantify an INR >9.5), and the platlets had dropped to 88. This new MD thought it was crazy that the prior one didn't want to treat the high INR, or even be notified. So she wrote orders for Vit K 10mg x 2 days, and to call for all critical labs.

This whole case just left me so confused as to what/which order I should be questioning since they seemed to be completely opposite of eachother.

[Been there,done that, ASN, RN]

That doctor was not interested in obtaining the ideal INR for the patient.Any reversal agent would probably not be in the patients best interest. But, a hemotology consult would be ideal.

Too bad, it is YOUR responsibility to advocate for your patient .. and Have to "suggest" the proper consult!

[dura_mater]

That doctor was not interested in obtaining the ideal INR for the patient.Any reversal agent would probably not be in the patients best interest. But, a hemotology consult would be ideal.

Too bad, it is YOUR responsibility to advocate for your patient .. and Have to "suggest" the proper consult!

I will definitely use this case as a learning experience, and next time have the conviction to suggest the hematology consult (or whatever the pt truly needs).

Thank you all for your input, being on the floor as a practicing RN, in these types of situations, just reminds me of how much I have to learn.

I just want to be the best pt advocate I can. This pt in particular really touched my heart, and I am struggling with the thought that I might not have been his best advocate.

[mVSd]

Hard to know who's right and who's wrong when it's all so new to you but I have to wonder if the 1st MD's point was to watch and balance the pt/inr levels against each other to determine the optimum stabilization point for the patient while agressively addressing the ALOC...and just not communicating his intention clearly to you?

[General E. Speaking, RN, RN]

I recall that our pharmacy has new guidelines. I think they are something similar to this below. I was surprised when I had a patient with an INR of 8 (trending up) and the doctor just wanted us to monitor as he wasn't actively bleeding. Didn't seem aggressive enough.

Here's what I found on the internet. I believe it is up to date.

INR

INR 5 – 9: Omit 1 to 2 doses• Increase the frequency of INR monitoring (daily)• Resume therapy at 10-20% lower dose when INR reaches patient’s target range• If the patient is at high risk of serious bleeding, consider administering vitamin K1 1 mg orally x 1.

INR > 9: Discontinue warfarin temporarily• Consider administering vitamin K1* 2.5 mg orally x 1 • Increase the frequency of INR monitoring (daily) and give additional vitamin K1. If INR is not substantially reduced by 24-48 hrs• Resume therapy at 20% lower dose when INR reaches patient’s target range and monitor INR closely until stable. Consider more frequent routine INR monitoring.

Of course, the guidelines change with patient risk factors and actively bleeding. As far as the reporting of critical labs, if they are trending down but still critical we get an order from the doctor not to notify. I believe the "do not to notify unless > 10" will cover you for critical lab reporting.

You must be careful about watching for active bleeding. That's a whole new ball game.

[glasgow3]

One thing that should be kept in mind is that the patient was taken off of his coumadin on admission. The physician was no doubt expecting that in the absence of the coumadin, the patient's INR would gradually trend down, yet keep him sufficiently anticoagulated that the thrombus would not increase in size. But as you found out, an INR can continue to increase even in the absence of coumadin with certain physiological states, with medications other than coumadin such as asa, certain antibiotics etc. But that first physician's error was in not ordering additional INRs to adequately determine that the INR was actually declining. In the absence of active bleeding, I don't think that his order was totally "off the wall" under the circumstances when the INR was 7.7.

Now as to the nursing end of it: Specified parameter of 10.0 or not, if the INR continued to trend upwards much higher I personally would have notified the physician. Why? Cause I can. Patients in that range are at a huge risk for major bleeding and I don't want to be "dinged" by some attorney for not holding an ordered med that might be known to raise an INR right before the patient bleeds out and dies or has a brain bleed. So I'd be sneaky...I'd call the physician at a somewhat reasonable hour with the info and before he had a chance to complain that the ordered parameter had not yet been reached, I'd ask for an order for bedrest. If he wouldn't give me one, I'd document it (along with the upward INR trend). In my experience at that point the doc would "get my drift".

Most facilities have exceptions to the notification of physicians for critical values so that they are not called at 4 am with a high creatinine on an ESRD patient and the like. Make sure you know and follow your facility's policy. But don't expect that policy to completely cover you.

The second physician's decision was a "no brainer": the situation and appropriate action was much clearer than the the day before. (although I do agree it was crazy/careless for him to not order INRs.)

Another good tactic when you are uncomfortable or unsure about an order is to run your concerns up the nursing chain of command and document your actions. This not only buys you time/covers you to some degree but it keeps them occupied which, in turn, keeps them out of your hair for a while.

[himilayaneyes]

I would watch that patient very closely. S/S of bleeding aren't always obvious. Doctors don't always intervene for high INR. They let it come down naturally. I can understand this since the patient has an atrial thrombus. Plus, the pt's coumadin is on hold. I at least hope they're doing daily INRs and some ob stools. With this high INR, the patient could be bleeding internally. However, if you're concerned you can still call him or put a note in the chart. Although he wrote an order, what does your hospital policy say. Hospital policy always trumps physician orders. If he gets upset, you can say "I'm sorry you feel this way (not apologizing, just sorry he feels that way...therapeutic). However, hospital policy states to call you with every critical result." Then document it. Cover your butt. If you're day shift, you can just mention it to him when you see him and document it then rather than calling him. But please be very careful b/c at my old facility, there was a physician who didn't want to listen to the nurse when she reported an INR of 5 to him and decided to do surgery anyway. Long story short, patient died from internal bleeding...physician was fired. However, he's still practicing and the patient is still dead. Protect your license and your patients above all.

P.S. Patients ALOC may have been r/t to his AIDs. HIV-1 Encephalopathy and AIDS Dementia Complex: eMedicine Neurology