Dosage tightrope makes Coumadin education vital
Patients taught to monitor food intake
"Coumadin is one of those drugs where there is potential for unnecessary hospital readmissions or complications. However, if people are properly instructed, they should comply quite nicely," says Magdalyn Patyk, MS, RN, advanced practice nurse for patient education at Northwestern Memorial Hospital in Chicago.
That’s why the educational department at Northwestern partnered with the pharmacy department to create a patient education sheet for Coumadin. The nurse initiates teaching at the bedside when the drug is prescribed and patients are given the instruction sheet.
Patients also use the closed circuit television system to watch a video produced by Dupont Pharmaceuticals Company in Wilmington, DE, called Coumadin Treatment and You. Dupont is the manufacturer of Coumadin. If patients have trouble understanding the instructions or are on a complicated medication regimen, a pharmacist is asked to teach.
Physicians can refer patients to an outpatient Coumadin dosing clinic that monitors the dosage of the medication. (For information on the Coumadin video, see editor’s note at the end of this article.)
While clinics are often established for a single disease state such as diabetes, it is rare for a clinic to be established for a drug, but Coumadin clinics are becoming more common. Staff at these clinics monitor patients who are on the drug, adjusting dosage to make sure the patient is taking the right amount, explains Alan Chan, PharmD, clinical operations manager for Kaiser Permanente Walnut Creek (CA). If the dosage is too high, there is a risk for bruising and bleeding; if it is too low, there is a risk for blood clots.
At the clinics, patients are taught to report any new drugs they are prescribed and to inquire about over-the-counter medications in case there are ingredients that would have an adverse effect, such as aspirin, which can increase the risk of bleeding. "Whenever a patient is started on a new drug, they should report it to the person who monitors their blood work, for Coumadin happens to interact with a lot of drugs, and some are significant, while others are not," says Chan.
Alcohol needs to be limited to only one drink a day. Eating habits are also important because certain foods, such as leafy green vegetables (which contain vitamin K), can change the drug’s effect. For example, if a patient wants to eat a salad with dinner, the drug is adjusted to account for that, but if the patient abruptly quits eating salads, the dosage would need to be adjusted again.
Most clinics recommend that people call when there are diet or medication changes, rather than waiting to report changes when they come for lab work. "Patients are our best source of information. They would know about their medications, diet, and alcohol intake better than anyone else," says Chan.
To complement the in-house teaching at Northwestern, Patyk has created a Coumadin education program at the patient resource center. It consists of a packet of materials that includes information on obtaining a medical alert bracelet or card for Coumadin, the instruction sheet, a dosage tracking calendar, and a sheet for taking notes while watching the video Coumadin Treatment and You.
"When they come into the health learning center, we tell them we are giving them an overview of the essentials they need to know when they are on Coumadin," says Patyk.
The essential education includes a description of what the drug does and does not do; an explanation of the dosage adjustment process and the importance of blood work; the importance of monitoring over-the-counter and prescription drugs to make sure they will not intensify the effect of Coumadin and the avoidance of double-dosing; signs and symptoms that should trigger a doctor’s visit; and an overview of ways to take the medication properly. Those who come for the teaching usually are family members of patients who are in the hospital or patients who want to review the information after they are released from the hospital. (See example of Coumadin teaching sheet, inserted in this issue.)
One of the most important aspects of the education is tracking the doses. That’s because forgetfulness is the greatest barrier to compliance. "The best way to counteract forgetfulness is to take the drug on a regimen, such as every morning at the same time. Then you tend to remember," says Chan. Help patients develop a plan for taking the drug on a regular basis, he advises. This might include providing a pillbox to distribute the medication or providing a tracking calendar. Sometimes just putting an X on the calendar so they don’t take the drug twice in one day works.
[Editor’s note: To obtain a free copy of the video Coumadin Treatment and You, contact Dupont Pharmaceuticals Company. Telephone: (800) 268-6234. Web site: www.coumadin.com.] n
For more information on Coumadin education, contact:
• Alan Chan, PharmD, Clinical Operations Manager, Kaiser Permanente Walnut Creek, 1425 South Main St., Walnut Creek, CA 94596. Telephone: (925) 295-4467. E-mail: [email protected].
• Magdalyn Patyk, MS, RN, Advanced Practice Nurse, Patient Education, Nursing Development, Northwestern Memorial Hospital, 251 East Huron, Suite 4-708, Chicago, IL 60611-2908. Telephone: (312) 926-2173. Fax: (312) 926-1741. E-mail: [email protected].
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