Days 3 to

1. Measure PT/INR every 1 to 2 days.

2. Interview the patient to determine if there is worsening or new symptoms related to VTE. Inquire about and evaluate patient adherence to therapy. Ask the patient about overt bruising or bleeding, particularly at the injection site, as well as changes in stool or urine color. Advise the patient to limit physical activity if pain persists and to elevate the extremity; increase activity as tolerated. Reinforce pre vious patient education regarding vitamin K intake and potential drug-drug interactions with warfarin.

3. Hold or adjust warfarin dose as necessary. If the patient is being treated with UFH, measure aPTT daily, and adjust dose if necessary. If the patient is being treated with an LMWH or fondaparinux, continue therapy.

4. Document activities in medical record.

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