Sherrie Dornberger, RNC, CDONA, FACDONA, executive director, NADONA

We have quite a few residents on INRs (with a diagnosis of Atrial Fibrillation) that we cannot regulate as hard as we try. Do you have any suggestions we should look at?

Some residents will never get to the level a doctor may want them to reach. Therefore, I encourage you to get to the INR that works best for the resident. However, be sure you have done inservices for the staff and families on foods and supplements. Families may bring in some of the resident’s favorite foods such as grapefruit, cranberry juice and soy milk, all of which would affect the PI/PTT or INR levels. 

The other area you may want to look at as a facility is products such as Boost and Ensure, which both also affect the levels. If a resident doesn’t eat well one or two days, staff might give him or her a supplement, thinking they are helping the resident take in calories, without realizing they are affecting their warfarin levels.

Be sure that if you have a resident whose levels you are unable to regulate, you get your team together, including the CNAs, family, dietician, pharmacist, doctor, nurses, activities personnel — and the resident, if she is able to attend. 

It could be that while everyone thought they were the only one doing something special, there were at least five “something specials” happening daily and thus, the levels you are trying so hard to control are way out of order! 

Schedule the dietician to do some training right away with the resident, family and staff. 

Remember, you are NOT alone. Use the resources at your fingertips! Be sure you also use a good PT/INR/ Coumadin flow sheet. This will be worth its weight in gold. Also, it is important that if levels are drawn today, you receive the results the same day.