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11/13/24, 8\:20 PM Guide | Warfarin counselling

Warfarin counselling

Table of contents

Before beginning

Begin by reviewing the patient's medical background to establish the current indication for warfarin and the patient's target
INR range.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain the reason for the consultation

Ideas, concerns & expectations

Ideas
Explore what the patient currently understands about warfarin and why they are being prescribed it\:
" H a v e y o u h e a r d o f w a r f a r i n ?"
" W h a t d o y o u a l r e a d y k n o w a b o u t w a r f a r i n ?"
" D o y o u k n o w w h y p e o p l e t a k e w a r f a r i n ?"
Concerns
Ask if the patient has any concerns about warfarin\:
" I s t h e r e a n y t h i n g t h a t w o r r i e s y o u a b o u t t a k i n g w a r f a r i n ?"
Expectations
Explore what the patient is hoping to get out of the consultation\:
" W h a t w e r e y o u h o p i n g w e' d d i s c u s s t o d a y ?"

How warfarin works

Using patient-friendly language, explain how warfarin works.
" W a r f a r i n i s a t y p e o f m e d i c i n e k n o w n a s a n a n t i c o a g u l a n t . b l o o d c l o t c o u l d f o r m .
"
I t h e l p s t o t h i n t h e b l o o d , m a k i n g i t l e s s l i k e l y t h a t a d a n ge r o u s
" W a r f a r i n c a n b e u s e d t o t r e a t p e o p l e w h o h a v e a p r e v i o u s b l o o d c l o t i n t h e l e g o r l u n gs . I t c a n a l s o b e u s e d t o p r e v e n t f u t u r e
b l o o d c l o t s i n p e o p l e w h o a r e a t h i g h r i s k o f h a v i n g t h e m i n t h e f u t u r e , s u c h a s p e o p l e w i t h a n i r r e gu l a r h e a r t b e a t o r a n a r t i
h e a r t v a l v e .
"
" T h e a c t i o n o f w a r f a r i n c a n b e r a p i d l y r e v e r s e d w i t h a n a n t i d o t e i n s i t u a t i o n s w h e r e w e n e e d t o r e d u c e t h e r i s k o f b l e e d i n g."
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INR

Explain the role of INR in monitoring the e
" T h e I N R i s a m e a s u r e o f h o w l o n g i t t a k e s b l o o d t o c l o t . I n h e a l t h y p e o p l e a n I N R o f 1 i s n o r m a l . S i n c e y o u a r e a t a h i gh e r r i s k
f o r b l o o d c l o t s w e w a n t y o u r b l o o d t o b e t h i n n e r t h a n n o r m a l a n d t h e r e f o r e t a k e l o n g e r t o c l o t . A s a r e s u l t , t h e t a r ge t r a n ge f o r
y o u r I N R w o u l d b e b e t w e e n 2- 3 , m e a n i n g i t t a k e s t w o t o t h r e e t i m e s a s l o n g f o r y o u r b l o o d t o c l o t c o m p a r e d t o s o m e o n e n o t
t a k i n g w a r f a r i n .
"
“ I n o r d e r t o e n s u r e t h a t w e k e e p y o u r b l o o d w i t h i n t h e n e c e s s a r y r a n g e w e w i l l n e e d t o m o n i t o r y o u r I N R l e v e l e v e r y s o o f t e n ;
t h i s i s d o n e t h r o u g h a b l o o d t e s t . T h e b l o o d t e s t s w i l l i n i t i a l l y b e f r e q u e n t ( e v e r y 3-4 d a y s u n t i l t w o c o n s e c u t i v e r e a d i n gs a r e
w i t h i n r a n g e ) , a n d t h e n a f t e r t h i s , y o u w i l l b e t e s t e d t w i c e w e e k l y f o r 1-2 w e e k s ( a ga i n u n t i l t w o c o n s e c u t i v e r e a d i n gs w i t h i n
r a n g e ) . T h e r e a f t e r , t e s t i n g c a n i n c r e a s e t o l o n g e r p e r i o d s ( e .g . e v e r y 1 2 w e e k s ) . Y o u r d o s e o f w a r f a r i n w i l l b e a d j u s t e d b a s e d o n
t h e I N R r e s u l t s w i t h t h e a i m o f k e e p i n g i t w i t h i n t h e t a r ge t r a n ge .
”

How to take warfarin

Key points to communicate when discussing warfarin use\:
" W a r f a r i n s h o u l d b e t a k e n a t t h e s a m e t i m e e a c h d a y t o k e e p t h e l e v e l s o f w a r f a r i n s t e a d y .
"
" T a b l e t s h a v e d i
"
" I f y o u f o r g e t t o t a k e a d o s e y o u s h o u l d t a k e i t a s s o o n a s y o u r e m e m b e r , b u t i f y o u d o n' t r e m e m b e r t i l l t h e f o l l o w i n g d a y y o u
s h o u l d s k i p t h e m i s s e d d o s e . Y o u s h o u l d n e v e r t a k e t w o d o s e s t o ge t h e r t o m a k e u p f o r a m i s s e d d o s e a n d y o u s h o u l d
i n f o r m y o u r d o c t o r o r w a r f a r i n c l i n i c a b o u t a n y m i s s e d d o s e s a t y o u r n e x t a p p o i n t m e n t .
"
" W h e n e v e r y o u a r e g o i n g t o p u r c h a s e o r b e p r e s c r i b e d a n e w m e d i c a t i o n y o u s h o u l d l e t t h e d o c t o r o r p h a r m a c i s t k n o w t h a t
y o u t a k e w a r f a r i n s o t h e y c a n a v o i d p r e s c r i b i n g m e d i c a t i o n s w h i c h a l t e r y o u r w a r f a r i n l e v e l .
"
" W h e n y o u s t a r t t a k i n g a n e w m e d i c a t i o n y o u s h o u l d l e t y o u r d o c t o r o r a n t i c o a gu l a n t c l i n i c k n o w s o t h a t t h e y c a n c o n s i d e r i f
y o u r w a r f a r i n l e v e l s n e e d m o n i t o r i n g m o r e f r e q u e n t l y .
"
" Y o u s h o u l d c o n t i n u e t o t a k e y o u r w a r f a r i n t a b l e t s r e g u l a r l y u n t i l y o u h a v e b e e n t o l d t o s t o p .
"
" W a r f a r i n i s n o t s a f e t o b e u s e d d u r i n g p r e g n a n c y a n d t h e r e f o r e y o u s h o u l d h a v e a n e
b e f o r e y o u s t a r t t a k i n g w a r f a r i n .
"

Bleeding whilst on warfarin

The main side e
bruising). These side e
important to discuss the di
situations.
Less serious bleeding
" I t i s n o r m a l t o b l e e d m o r e e a s i l y w h e n t a k i n g w a r f a r i n a s t h e m e d i c a t i o n w o r k s b y t h i n n i n g t h e b l o o d . b l e e d i n g i n c l u d e \:
p e r i o d s t h a t a r e h e a v i e r a n d l a s t l o n g e r t h a n n o r m a l
b l e e d i n g f o r a l i t t l e l o n g e r t h a n u s u a l i f y o u c u t y o u r s e l f
o c c a s i o n a l n o s e b l e e d s ( t h a t l a s t f o r l e s s t h a n 1 0 m i n u t e s )
b l e e d i n g f r o m y o u r g u m s w h e n y o u b r u s h y o u r t e e t h
b r u i s e s t h a t c o m e u p m o r e e a s i l y a n d t a k e l o n ge r t o f a d e t h a n u s u a l
T h i s t y p e o f b l e e d i n g i s n o t d a n g e r o u s a n d s h o u l d s t o p b y i t s e l f . I f i t h a p p e n s , t h e b l e e d i n g b o t h e r s y o u o r d o e s n o t s t o p .
"
k e e p t a k i n g t h e w a r f a r i n , C o m m o n t y p e s o f
b u t t e l l y o u r d o c t o r i f
Serious bleeding
" O c c a s i o n a l l y , y o u c a n h a v e s e r i o u s b l e e d i n g f r o m t a k i n g w a r f a r i n . T h i s c a n b e d a n g e r o u s a n d n e e d s u r ge n t m e d i c a l a t t e n t i o n .
"
" S t o p t a k i n g w a r f a r i n a n d c a l l y o u r d o c t o r o r a n t i c o a gu l a n t c l i n i c , o r go t o A & E i f y o u e x p e r i e n c e \:
r e d p e e o r b l a c k p o o
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l a r g e b r u i s e s o r b r u i s e s t h a t h a p p e n f o r n o r e a s o n
n o s e b l e e d s t h a t l a s t l o n g e r t h a n 1 0 m i n u t e s
b l o o d i n y o u r v o m i t o r y o u' r e c o u g h i n g u p b l o o d
s e v e r e h e a d a c h e s ,
a n y b l e e d i n g f r o m a c u t o r i n j u r y t h a t w i l l n o t s t o p o r s l o w d o w n"
n u m b n e s s o r t i n gl i n g i n y o u r a r m s o r l e gs , o r f e e l v e r y t i r e d , w e a k

Other side e

Common side e
Common side e
a mild rash
hair loss
These side e
bothersome.
Serious side e
Serious side e
jaundice
skin necrosis
As a result, patients should be advised to seek urgent medical review if they develop\:
yellowing of the skin
painful swollen areas of skin

Lifestyle advice

Diet
Drastic changes in diet, especially an increase in consumption of foods high in vitamin K (such as broccoli, kale, or spinach) can
potentially a
anticoagulant clinic so necessary dose adjustments and monitoring requirements can be ful
to interact with warfarin and enhance its anticoagulant e
Alcohol
Patients should limit their alcohol intake to a maximum of one or two drinks a day and never binge drink. If there are major
changes in alcohol consumption (e.g. the patient stops drinking, or starts drinking more) the INR can be a
Other
Patients should be advised to take extra care when carrying out routine tasks such as brushing teeth or shaving; a soft
toothbrush or an electric razor can help. Patients should also be advised to inform their dentist that they take warfarin when
booking an appointment as this may have implications for dental procedures.

Yellow booklets & alert card

At the start of treatment, all patients should be provided with two yellow anticoagulant booklets, an INR monitoring booklet
and a patient information booklet. Patients should also be provided with an anticoagulant alert card.
Patients should be advised to always carry the anticoagulant alert card with them in case of an emergency and always take
the yellow INR monitoring book with them to each appointment at the anticoagulant clinic and if possible to other
appointments (e.g. GP, pharmacy reviews, dental appointments etc).
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The patient information book is a useful resource since it provides the patient with a point of reference and reinforces what has
been covered in this guide.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
If you feel that the patient would bene
and also direct the patient to the yellow anticoagulant information booklet for further reading.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

1. NHS.uk. Warfarin. Available from\: [LINK].
2. BNF. Warfarin. Available from\: [LINK].
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/counselling/warfarin-counselling/ 4/4