Days 6 to

1. Measure PT/INR every 2 to 3 days. Obtain CBC or platelet count.

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 previous patient education regarding vitamin K intake and potential drug-drug interactions with warfarin.

3. Hold or adjust warfarin dose as necessary. Discontinue UFH, LMWH, or fonda-parinux if INR is greater than 2 on two consecutive occasions. If the patient requires continued treatment with UFH, measure aPTT, and adjust dose if necessary.

4. If the patient is treated with UFH or LMWH and platelet count has dropped by greater than 50% from baseline or is less than 120 x 10 /pL, evaluate the patient for HIT.

5. Document activities in medical record.

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