Warfarin Reversal Strategies and Anticoagulation Therapy

This assignment delves into various aspects of warfarin therapy, including reversal strategies, interactions with other medications, and patient adherence. It covers a range of topics such as the use of zymogen-like Fxa variants, anticoagulation drug therapy, and knowledge gaps among healthcare providers. The assignment also touches upon case studies like the deadly consequences of fluconazole-warfarin interaction and the importance of time in therapeutic range for warfarin users. It aims to provide a detailed understanding of warfarin therapy and its complexities.

Running head: HEALTH EDUCATION PLAN FOR MRS.GAMBLE
Health education plan for Mrs. Gamble
Name of the Student:
Name of the University:
Author Note:

1HEALTH EDUCATION PLAN FOR MRS.GAMBLE
Introduction:
Health education can be given both before and after the occurrence of the disease. It is
divided into three categories that includes primary, secondary and tertiary education. Primary
education mainly focuses on good health of students, whereas secondary education deals with
the measures to avoid accidents. Tertiary education is based on intervening knowledge and
basic education to people that helps them to overcome from the diseased condition. In the
given case study Mrs. Lillian Gamble was suffering from many diseases since eighteen years
ago.She was found to be in atrial fibrillation and was also commenced on warfarin therapy. In
the given case study, it was mentioned that she lacks sufficient knowledge about her warfarin
therapy. This report will highlight the basic tertiary health education on warfarin therapy that
she should follow, some barriers and teaching-learning process based on this therapy and
lastly, some educational materials on Warfarin therapy that will help her to overcome
knowledge deficits regarding warfarin treatment.
Discussion
Knowledge deficits in Warfarin therapy and learning needs:
Knowledge always plays in influential role in recovering a patient from his or her
diseased condition. According to the given information, Mrs. Gamble lacks sufficient
knowledge about warfarin that she was prescribed by doctors due to atrial fibrillation. The
key issue that she should know is both about the benefits and risks of the warfarin therapy. As
per given information her age is 78years, which is again a big barrier for this therapy.She
only remembers to not to take broccoli and green vegetables. Aids to be taken is making her
know that since these foods enriched in vitamin K, doctor advised her not to include this in
her diet. She should also aware of the fact that this therapy always needs regular blood tests
to evaluate its impact. A proper dose adjustment is also required for drug administration. She

2HEALTH EDUCATION PLAN FOR MRS.GAMBLE
should know which brand of warfarin the doctor has advised her since there are two brands of
warfarin available in the market. It is also her duty to gain knowledge on interactions of other
drugs with warfarin as this may also cause some lethal effects. She also needs to stick on to a
regular dosing and should know the action to be taken when a dose is accidentally omitted.
Studies were conducted to survey the knowledge deficit of patient in warfarin therapy. It was
found that most of them lacks the knowledge about this therapy (Wang et al., 2014).
Mrs. Gamble was also suffering from some visual difficulties which is again a barrier
to her. She was fitted with glasses by optometrist. This visual impairment can increase more
by watching television and videos for longer time.She is interested in reading and writing
exercise book. .This visual inability is hampering her from selecting the correct dose from
bottles of warfarin. Some effects of alcohol and food stuffs are also reported that she should
be aware.She will enrich her knowledge by reading books based on warfarin therapy. This
will serve as an aid to overcome the knowledge deficit.
Goals of teaching-learning process in Warfarin therapy:
According to Bloom’s taxonomy, educational learning objectives are based on three
hierarchical domains. This includes learning objectives in cognitive, affective and
psychomotor or sensory domains (Boles, Goncher & Jayalath, 2015). In the given case study
the main learning objective Mrs. Gamble falls under cognitive domain. She lacks in knowing
the basic concepts, specific terminologies and in recognizing some facts about warfarin
therapy. The objective or goal set up by the teaching process should be specific.This process
should aware her about the side effects and various drug- drug interactions. Educational units
must analyze and identify the real cause of the disease. Teaching process should ensure her
that she can measure her success by knowing in detail that what International normalized
ratio (INR) means and what it optimize. The standardized way of measuring Prothrombin
value (PT) expression is INR ("Warfarin INR therapeutic target. Therapeutic INR values.",

3HEALTH EDUCATION PLAN FOR MRS.GAMBLE
2018). This is monitored to make sure that warfarin remains in an effective range. Too low
value of INR means it is not possible to cure blood clotting whereas its high value signifies
the risk of bleeding has increased. In healthy people, INR of 1.1 is considered as normal. The
range if INR is 2.0 to 3.0. As per information INR value of Mrs. Gamble is 1.5, which means
she is towards normal (McAlister, Wiebe & Hemmelgarn, 2018). The process will be
established in such a way that helps the patient to track her improvement. Teaching process
should give ample knowledge to her about the therapy in simple way that includes use of easy
languages and many pictures related to this therapy. She is very fond of reading storybooks.
She thus can be supplied with some books that is related to this topic. Teaching process
should aware her about several drug-drug interactions (Hersh et al., 2017). They should make
her understand to value it and to possess some lifestyle changes that help her to achieve the
goal. This process should instruct her that she should take correct dosage of medicine as
prescribed by her doctor at correct time. Lastly, teaching process should make her aware
about the time required to get a positive response from the therapy. They must conduct a
regular blood test for her to examine the INR value and ensure that after two months of this
therapy INR value will achieve a normal value.
Teaching aids and educational plans:
Teaching aids required for Warfarin therapy include the detailed knowledge of the
mechanism of action of Warfarin. This can be achieved by group discussion in some health
care unit and some of her friends or relatives can make her understand this concept in simple
languages by face to face conversation. Health clinics should inform her that the main goal of
warfarin therapy is to lower the clotting factor of blood (Harter, Levine & Henderson, 2015),
that may sometimes lead to bleeding. She was suffering from Atrial fibrillation that increase
heart rate and risk of stoke as well. Topics of health clinic should involve that patient must
take the same dose of warfarin as prescribed. She should be informed that not to change the

4HEALTH EDUCATION PLAN FOR MRS.GAMBLE
dosage unless instructed. Education session should use Warfarin Flipchart (Health, 2018) that
contain pictures and texts in simple language. Educational checklists should be maintained
where all key points should be mentioned. Reinforcement of key messages should be done
when the patient will feel difficulty in understanding the language. Two available warfarin
brands are Marevan and Coumadin (Tideman, Tirimacco & St John, 2015). The same brand
should be taken unless doctor specifies to change. In the given case study doctor prescribe
Coumadin brand to the patient of dose 2 mg. Patient was unable to pick up the tablet of right
dose. Patient should be informed that her prescribed tablet is lavender in color. This will help
the patient to identify the correct brand of right dose.
Sequence of education based on warfarin therapy:
The patient is seen to have very little knowledge about the use of warfarin. As the
patient had stayed for very less time in the hospital, she did not have the opportunity to
develop her health literacy on the use of warfarin. She knows that she should not eat green
leafy vegetables at all but she has no idea that about the reasons for which the healthcare
professionals had denied her to eat green leafy vegetables. She needs detailed education about
how to maintain her warfare therapy attributes so that she can leave a safer and better quality
life.
The first thing that she should be educated about the action of warfarin and the ways it
is protecting her from and threats. The better she knows about the action of the warfarin and
its significance on her healthcare, it would be helpful for her to comply with the medication
regime. She should be taught that warfarin is a blood thinning medication that is essential to
prevent her from threats of atrial fibrillation. When the heart beats in an irregular manner,
there is a high chance of development of blood clots. This may result the patient to suffer
from strokes. In order to prevent this warfarin is provided. It prevents clotting of blood and
keeps blood in moving position (Brajas et al., 2015).

5HEALTH EDUCATION PLAN FOR MRS.GAMBLE
The second thing is that she has no idea about which medication to be taken, although
she is aware of the doses of medication that needs to be taken. It is seen that she was advised
to take three types of medication of Coumadin – 1mg, 2 mg and 5 mg. She knows that 4 mg
of medicine is to be taken with two tablets of 2 mg medication. However, she has selected
wrong medication where she had only taken two 1 mg tablets. Hence, it is important for her
to know about the correct medication from the displayed color of the medication. She should
be suggested to recognize the correct medication with the proper identification of the color.
She should be educated by telling her that 1mg tablets are light tan in color, 2 mg tablets are
lavender in color and 5 mg tablets are green in color. Once, the patient gets accustomed with
the color of the tablets, the chance of making mistakes in taking the correct number of tablets
with the proper doses would be reduced (Piran et al., 2017).
Another issue she has is that she is not aware the reason that is preventing her from
taking her favorite diet of green leafy vegetables. There are certain foods that interact and
thereby affect the activity of warfarin. Food items that are high in vitamin K are needed to be
avoided. This is mainly because vitamin K is responsible for blood clotting (Lane et al.,
2015). As the green leafy vegetables are rich in vitamin K, therefore, it should be avoided.
Broccoli, cabbage, brussel sprouts and similar others are high in vitamin K and therefore,
these food items should be avoided (chan et al., 2015).
Critical appraisal for the suitable article:
The article named “ Living with Warfarin- Information for patients ” has been found
to be more relevant and informative. Some of the reasons include it gives detailed
information about Warfarin, how it works and more importantly about why one should take
Warfarin. It is mentioned that it lowers the risk of the blood clotting rate. It has also given
information about the two brands with relevant pictures. Different colors of tablets according
to their doses are mentioned in detail. This will definitely give Mrs. Gamble a clear idea to

6HEALTH EDUCATION PLAN FOR MRS.GAMBLE
select the prescribed dose that is lavender in color. Moreover, it also highlights INR and its
range in detail. It is also mentioned that why patient needs to perform blood test at regular
interval. It is required to track the clotting time of blood. Regular blood test is also required
until the right dose is identified.
Various side effects of this therapy and proper dosing information are also mentioned.
Bleeding is the major side effect that increases with the rise of INR. To avoid this, INR needs
to keep this within target range. This article also highlighted some safety measures while
taking warfarin at home. This includes taking the medicine as prescribed by the doctor and
not to change the dose until instructed. Diet should not be changed abruptly and alcohol
consumtion should be limited . Most importantly this article also gives ample information
about when to take the medication. It can be taken before, after or along with the meal, but it
needs to fit into her daily routine. It suggests to take the medication with the meal. This
article will also help the patient to know about the affect of other medicines in this therapy. A
clear chart of some common medications that may interact with warfarin is given in page 9 of
the article. This will be very much helpful to her. She should approach to her doctor or
pharmacist and make them know about the drug she is taking along with warfarin. Some
drug- food interactions are also been pointed out. These include foods with high vitamin K
may interact. So it proposes to eat a healthy balanced diet. Lastly, it also highlights about the
effect of warfarin therapy on surgery or dental procedures. Patient should let her doctor know
about the therapy before starting surgery since there is high risks of bleeding.
In this way. this article is more relevant as it provides information in more details
with simple languages. It deals with every aspect of the therapy more widely as compared to
other.

7HEALTH EDUCATION PLAN FOR MRS.GAMBLE
Conclusion
This can be concluded from the above discussion that though Mrs. Gamble was
suffering from many diseases, yet there are ample cures available. She mainly lacks the
knowledge in Warfarin therapy. Many dietary and lifestyle changes along with many
medications are suggested. It also highlighted some barriers and teaching aids that will help
the patient to overcome from the disease. It was reported that she lacks knowledge on
Warfarin therapy. This report tried to incorporate some knowledge to her. It also analysed the
mechanism of action of this therapy, some side effects and recommended many suggestions
regarding this therapy. Lastly, this report selected one article that is found to be more relevant
and informative as well.

8HEALTH EDUCATION PLAN FOR MRS.GAMBLE
References:
A Lane, D., V Barker, R., & YH Lip, G. (2015). Best practice for atrial fibrillation patient
education. Current pharmaceutical design, 21(5), 533-543. Retrived from:
http://www.ingentaconnect.com/content/ben/cpd/2015/00000021/00000005/art00002
Barajas, M. R., Formea, C. M., McCormick, J. B., Abdalrhim, A. D., Han, L. C., McBane, R.
D., ... &Kullo, I. J. (2015). A patient-centered approach to the development and pilot
of a warfarin pharmacogenomics patient education tool for health
professionals. Currents in Pharmacy Teaching and Learning, 7(2), 249-255. Retrived
from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339072/pdf/nihms660845.pdf
Boles, W. W., Goncher, A., &Jayalath, D. (2015). Categorising conceptual assessments
under the framework of bloom’s taxonomy. Retrived from :
http://eprints.qut.edu.au/95630/3/95630.pdf
Chan, H. C., Chan, L., Chen, X. Y., Cho, H. T., Lin, C. T., Chan, K. W., ...&Leu, W. J.
(2015). Evaluating the patient-education outcome of warfarin-related health literacy in
a pharmacist-based warfarin clinic-experience in a regional hospital in
Taiwan. Pharmacotherapy: The Journal Of Human Pharmacology And Drug
Therapy, 35(5), e68. Retrieved from: https://insights.ovid.com/pharmacotherapy-
human-pharmacology-drug-therapy/pharm/2015/05/000/evaluating-patient-education-
outcome-warfarin/24/00006562
Greene, L. A., Thalji, N. K., &Camire, R. M. (2015). Zymogen-like Fxa variant as novel
warfarin reversal strategy: pre-clinical evaluation and mechanism of action. Journal
of Thrombosis and Haemostasis, 13, 491. Retrived from:

9HEALTH EDUCATION PLAN FOR MRS.GAMBLE
https://insights.ovid.com/thrombosis-haemostasis/jthrh/2015/06/002/zymogen-fxa-
variant-novel-warfarin-reversal/1316/00149457
Harter, K., Levine, M., & Henderson, S. O. (2015). Anticoagulation drug therapy: a review.
Western Journal of Emergency Medicine, 16(1), 11. Retrieved from :
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4307693/pdf/wjem-16-11.pdf
Health, C. (2018). Warfarin Flipchart. Issuu. Retrieved 24 April 2018, from
https://issuu.com/communicationsmiddlemore/docs/warfarin-flipchart
Hersh, E. V., Saraghi, M., Lowstetter, J., Moore, P. A., &Aminoshariae, A. (2017).
Fluconazole-Warfarin Interaction: A case report with deadly consequences.
Australasian Medical Journal (Online), 10(6), 544. Retrived from:
https://search.proquest.com/openview/11024e95bdb5f1cb9d62f0aa1b263b17/1?pq-
origsite=gscholar&cbl=54991
McAlister, F. A., Wiebe, N., &Hemmelgarn, B. R. (2018). Time in therapeutic range and
stability over time for warfarin users in clinical practice: a retrospective cohort study
using linked routinely collected health data in Alberta, Canada. BMJ open, 8(1),
e016980. Retrived from: http://bmjopen.bmj.com/content/8/1/e016980
Piran, S., Schulman, S., Salib, M., Delaney, J., Panju, M., &Pai, M. (2017). Direct oral
anticoagulants in the real world: insights into canadian health care providers’
understanding of medication dosing and use. Canadian Journal of General Internal
Medicine, 12(3). Retrived from:
https://www.researchgate.net/profile/Siavash_Piran/publication/321263080_Oral_anti
coagulant_dosing_administration_and_storage_a_cross-
sectional_survey_of_Canadian_health_care_providers/links/

10HEALTH EDUCATION PLAN FOR MRS.GAMBLE
5a1777ccaca272df0808b420/Oral-anticoagulant-dosing-administration-and-storage-a-
cross-sectional-survey-of-Canadian-health-care-providers.pdf
Tideman, P. A., Tirimacco, R., & St John, A. (2015). Warfarin and beetroot. AN
INDEPENDENT REVIEW, 150. Retrived from :
https://www.researchgate.net/profile/Ingrid_Hopper2/publication/282607159_Warfari
n_brands/links/571aabf108ae6eb94d0c7e95.pdf
Wang, Y., Kong, M. C., Lee, L. H., Ng, H. J., &Ko, Y. (2014). Knowledge, satisfaction, and
concerns regarding warfarin therapy and their association with warfarin adherence
and anticoagulation control. Thrombosis research, 133(4), 550-554. Retrieved from :
http://www.thrombosisresearch.com/article/S0049-3848(14)00011-5/abstract
Warfarin INR therapeutic target. Therapeutic INR values.. (2018). Globalrph.com. Retrieved
24 April 2018, from http://globalrph.com/warfarin_inr_targets.htm