• Serum creatinine

• CBC with platelets

3. Medications:

• Screen the patient's pharmacy profile for potential drug-drug interactions with anticoagulation therapy

• Initiate UFH or LMWH or fondaparinux by injection (see Table 10-3 for dosing guidelines)

• Start warfarin sodium orally every evening (see Fig. 10-9 for dosing guidelines)

• Start pain medication if necessary (avoid nonsteroidal anti-inflammatory drugs)

4. Patient education:

• Educate the patient regarding the purpose of therapy and importance of proper monitoring of anticoagulant drugs. Assist the patient to determine an appropriate provider for long-term monitoring of anticoagulation therapy.

• If LMWH or fondaparinux is selected, teach the patient how to self-administer (if the patient or a family member is unwilling or unable to self-administer, visiting nurse services should be arranged). Initial injection should be administered in the medical office or hospital.

• Inform patient about the effects of vitamin K-rich foods on warfarin therapy. Moderate intake (less than 500-1,000 mcg) of vitamin K is acceptable. Provide patient with written material regarding vitamin K content of foods.

• Inform the patient about the potential drug-drug interactions with warfarin, including over-the-counter medications and dietary supplements (Tables 10-8, 10-9, and 10-10). Instruct the patient to call the health care practitioner responsible for monitoring warfarin therapy before starting any new medications or dietary supplements.

• Instruct the patient regarding nonpharmacologic strategies including elevation of the affected extremity and antiembolic exercises such as flexion/extension of the ankle (for lower extremity VTE) or hand squeezing/relaxation (for upper extremity VTE).

5. Next steps:

• If the patient is to be treated at home, dispense to the patient a 5-to 7-day supply of prefilled LMWH or fondaparinux syringes in patient-specific dose.

• If the patient is to be treated with UFH, measure aPTT (or antifactor Xa activity) 6 hours after initiating the IV infusion. Adjust dose if necessary (Table 10-5) and measure aPTT (or antifactor Xa activity) every 6 hours after each dose change until therapeutic. Measure aPTT (or antifactor Xa activity) daily thereafter.

• Arrange for follow-up and long-term anticoagulation therapy management. Communicate with the patient's primary care physician and/or refer to a local antith-rombosis service, if available. If the patient is to be treated primarily in the hospital, these arrangements can be made 1 to 2 days prior to hospital discharge.

6. Document all activities in medical record.

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