Anticoagulation and INR Management — Home Health Training

Anticoagulation is one of the most common reasons for skilled nursing in the home, and one of the most common reasons a home health patient ends up in the emergency department.

Warfarin — what the patient needs to know

These are the teaching points to work through and document. The patient, or their caregiver, should be able to say them back.

Take the dose at the same time each day.
If you forget a dose and remember within 8 hours, take it. If more than 8 hours have passed, wait until the next day and take only that day's prescribed dose.
Never take a double dose.
The medication can be taken before or after food.
Check off each dose as you take it. A daily log removes the "did I take it?" question, which is where double-dosing comes from.

Vitamin K and diet

The goal is consistency, not avoidance. A patient who eats a salad every day is easier to manage than one who eats none for three weeks and then has three in a row.

High vitamin K foods to keep steady: kale, spinach, collards, broccoli, Brussels sprouts, cabbage, green tea.

Also teach:

Alcohol changes INR unpredictably; discuss honestly rather than prohibiting
New medications and antibiotics frequently interact — the patient should tell every prescriber they are on warfarin
Over-the-counter NSAIDs, aspirin, and many supplements increase bleeding risk

Drawing the INR

Blue top (sodium citrate) — fill to the line. An underfilled citrate tube gives a falsely elevated INR, and a dose gets changed off it.
Draw on the schedule the physician set, and before any dose change takes effect where possible
Get the result to the physician the day it arrives, and document who you told and when
Know who is responsible for chasing the result — see Labs, Specimens, and Results Follow-Up

See Lab Tube Cheat Sheet for the full tube guide.

What to assess every visit

Bruising — new, unusual, or unexplained
Bleeding gums, nosebleeds, blood in urine or stool, coffee-ground emesis
Falls, or any head strike since the last visit
Adherence — count what is left against what should be left
New medications, including anything started by another prescriber
Diet changes
Understanding of when to call

When to call the physician

INR outside the ordered range
Any bleeding that does not stop with pressure
Blood in urine, stool, or vomit
A fall with a head strike — on an anticoagulant this is urgent regardless of how the patient looks
New or worsening confusion or severe headache
A new medication that interacts

Bleeding precautions to teach

Soft toothbrush, electric razor
Care with knives, and with gardening and tools
Remove trip hazards — see Home Safety Assessment
Medical alert identification
Tell every clinician, including the dentist

DOACs are not warfarin

Apixaban, rivaroxaban, dabigatran and similar agents do not require routine INR monitoring, which is often the first thing a patient tells you. They still need:

Strict adherence — the half-life is short, so a missed dose is a bigger deal than with warfarin, not a smaller one
Renal function monitoring — dosing depends on it
The same bleeding precautions and the same fall response

Do not let "I don't need blood tests" become "I don't need to be careful."