Patient Case Recently Question & Answer Guide (With Explanation)

This type of question evaluates analytical and critical thinking skills.

What This Question Is About

This question relates to patient case recently and requires a structured academic response.

How to Approach This Question

Use appropriate theories and support your answer with clear reasoning.

Key Explanation

This topic involves patient case recently. A strong answer should include explanation, application, and examples.

Original Question

Patient Case Recently, we had a patient in her late 40s that was admitted to the intensive care unit for an extensive right lower extremity deep vein thrombus (DVT) with pulmonary embolus causing right ventricular strain. She was placed on a Heparin drip, high dose, protocol. She was hemodynamically unstable. She eventually was taken to Interventional Radiology (IR) for a pulmonary thrombectomy and catheter direct lysis of her right lower extremity (RLE). After successful clot retrieval from her lungs and RLE, she was transitioned off the Heparin drip and placed on a Rivaroxaban (Xarelto), 15 mg twice daily for 21 days, and then a maintenance dose of 20 mg daily. However, shortly after discharge she returned with increased leg swelling. A follow-up ultrasound revealed that there was an increase in clot development. Despite the patient stating she had been compliant in her medication regime; she was considered a Xarelto failure. The failure was considered to be mostly likely due to her high body mass index (BMI). Her BMI is 46. Although not contraindicated, there is not enough research to support the safety and effectiveness of direct oral anticoagulants (DOACs) in patients with BMIs >40 (Lachant et al., 2021). She was then placed on Warfarin. Influential Factors In this patient and in others, DOACs are appealing as they do not require frequent monitoring of levels and have an immediate onset. Additionally, there are not as many dietary restrictions when compared to that of Warfarin. However, access to the reversal agent is not as easy and often, more expensive. The reversal agent for Rivaroxaban is Anedexanet alfa (Andexxa). Both renal and hepatic impairment can increase the risk of bleeding in patients who use Rivaroxaban (Rosenthal & Burchum, 2021). According to Rosenthal & Burchum (p. 385), in those patients with liver impairment, Rivaroxaban should be avoided. Certain medications may also increase the risk of bleeding when taken concurrently with DOACs such as antiplatelet medications. Plan of Care Given that this patient went home on Warfarin, it is important to have a teaching plan that includes dietary education, monitoring of International Normalized Ratios (INR), importance of notifying providers when on anticoagulants, and signs of bleeding. Dietary education is important for Warfarin as “dietary vitamin K can reduce the anticoagulant effects of warfarin” (Rosenthal & Burchum, 2021, p. 382). It is important that this patient be informed to keep a steady diet to avoid drops in her INR level. Knowing which foods contain vitamin K will also help her be more conscientious. Education compliance of both medication regime and monitoring is important. Maintaining a therapeutic INR is important to prevent future complications in clot development and adverse hemorrhagic complications. It is important to teach her the signs and symptoms bleeding to look for such as coffee ground emesis, dark stools, nose bleeds, etc. Lastly, providers also need to be sure to instruct the patient on notifying all future providers that they are on anticoagulants as any future procedure or surgery that is performed, the anticoagulant may need to be held as she will now be at risk for bleeding. Prior to holding of this medication, it will also be important to check with the prescribing provider in the event that a “bridging” agent, such a Enoxaparin (Lovenox) may be indicated. suggest additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described.

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