Days 9 to

1. Measure PT/INR every 3 to 5 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 elevate the extremity and 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 re quires continued treatment with UFH, remeasure aPTT, and adjust dose if necessary.

4. Obtain CBC or platelet count. If the patient is treated with UFH or LMWH and platelet count has dropped by more than 50% from baseline or is less than 120 x 103/mm3 (120 x 109L), evaluate the patient for HIT.

5. Document activities in medical record.

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