PATIENT_____________________________________

DATE

PROBLEM

GOAL

TO DATE

INTERVENTIONS

RESP

DISC

Anticoagulant Therapy

Potential for injury

Assess patient / caregiver management of Oral Medications: Patient's ability to prepare and take all prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals

Able to take medication(s) at the correct times if:

(a) individual dosages are prepared in advance by another person; OR

(b) given daily reminders; OR

(c) someone develops a drug diary or chart

Unable to take medication unless administered by someone else

Patient will be free of bruising, bleeding, or injury

Patient / caregivers will verbalize understanding of diagnosis and treatment

Patient / caregivers will demonstrate correct administration of medications

Maintain pressure on skin tears, blood draw sites, and IV sites for at least five minutes

Administer medications as ordered

Obtain lab specimens, monitor lab reports, and notify physician promptly of results

Evaluate medications and diet for adverse interactions

Assess patient / caregiver understanding of diagnosis and treatment, and identify areas of knowledge deficit for teaching

Educate patient / caregivers on food and medication interactions

Instruct patient / caregivers to:

Use caution when turning, positioning, or transferring

Inspect skin with daily care and observe for bruising

Observe for signs of bleeding, and report to physician immediately

Monitor for hematuria, tarry colored stools, bleeding after brushing teeth

Follow medication orders as prescribed