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Pathopharm I > Coagulation Cascade > Flashcards

Coagulation Cascade Flashcards

1
Q

Plasma

A

Contains many substances dissolved in water

Component: proteins + water + other solutes (includes electrolytes)

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2
Q

Plasma proteins

A

Albumin (most abundant; 57% of plasma proteins)
Globulins (HDL, prothrombin, hormone-transporting proteins)
Clotting proteins (I.e. fibrinogen)

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3
Q

Blood cellular components

A

Erythrocytes, leukocytes, neutrophils, eosinophils, basophils, monocytes/macrophages, lymphocytes, natural killer cells, platelets

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4
Q

Platelets

A

Not true cells (cell fragments)
Contain cytoplasmic granules which can release adhesive proteins, and coagulation/growth factors in response to vessel injury

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5
Q

Platelet count

A

Normal: 150,000-400,000
Thrombocytopenia: <100, 000
Additional platelets are stored in the spleen

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6
Q

Platelet aggregation process

A

Blood vessel damage->increased platelet adhesion->platelets release contents of granules (degranulation)->platelets aggregate by adhering to the vascular wall and other platelets->platelet plug formed (temporary)->clotting cascade initiated/activated

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7
Q

Blood clot

A

Meshwork of fibrin strands, platelets, and trapped cells; blood clot plugs the damaged vessel and stops the bleeding (enables hemostasis); blood clots stabilize the platelet plug

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8
Q

Platelets and blood clots

A

Platelets are the primary activators of blood clot formation

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9
Q

Thrombin

A

Active enzyme form of prothrombin (a plasma protein)

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10
Q

Why is thrombin so important?

A

Catalyzes the conversion of fibrinogen to fibrin, and fibrin is an important component of blood clots

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11
Q

Blood clot components

A

Fibrin mesh
Platelets
Trapped blood cells

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12
Q

Intrinsic clotting pathway

A

Involves factors:

12, 11, 9, 10, 2, and 1

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13
Q

Factor II

A

Prothrombin

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14
Q

Factor IIa

A

Thrombin (active)

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15
Q

Factor I

A

Fibrinogen

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16
Q

Factor Ia

A

Fibrin

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17
Q

Extrinsic clotting pathway

A

Factors involved:

3, 7, 9, and 10

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18
Q

Factor III

A

Tissue factor

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19
Q

Factor Xa

A

Catalyzes the conversion of prothrombin to thrombin; thrombin then catalyzes the formation of fibrin; factor common to both the intrinsic and extrinsic pathway

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20
Q

Intrinsic vs. extrinsic clotting pathway

A

Blood clot formation occurs primarily through the extrinsic pathway but the extrinsic pathway can trigger the intrinsic pathway for MORE thrombin formation; extrinsic pathway is activated first then the intrinsic is turned on

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21
Q

Clotting factors activated by thrombin

A

5, 7, 8, 11, and 13

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22
Q

Factor XIII

A

Activated by thrombin; stabilizes the fibrin network by forming cross links between fibrin strands

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23
Q

Serum

A

Plasma minus clotting factors

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24
Q

Antithrombin III

A

Circulating inhibitor of thrombin (inhibits clotting)

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25
Tissue factor pathway inhibitor
Inhibits factor Xa (factor that converts prothrombin to thrombin)
26
Fibrinolytic system
System that dissolves an already formed clot; involves activation of plasminogen to plasmin (active); plasmin digests fibrin; t-PA is an example of a plasminogen activator
27
Goals of coagulation therapy
Prevent clot formation, break apart existing clots, increase circulation/perfusion, decrease pain, prevent further tissue damage
28
Greatest concern of anti-coagulants?
Bleeding; side effect of ALL anti-coagulants; bleeding can be internal or external; know sites at risk for bleeding; monitor HgB/HCT/vitals
29
Anti-coagulants
Inhibits the action or formation of the clotting factors; PREVENTS the formation of clots; interferes with the clotting cascade
30
Anti-platelets
Inhibit platelet aggregation and prevent platelet plug formation; best for preventing heart attacks and strokes; remember platelet aggregation occurs before the coagulation cascade
31
Heparin MOA
Activates antithrombin III which indirectly inactivates clotting factors 2 (thrombin) and 10; inactivation of these clotting factors prevents blood clot formation; heparin inhibits fibrin formation (because thrombin is inactivated)
32
heparin that only inactivates factor Xa and NOT factor II (thrombin)
Low molecular weight heparin enoxaparin (Lovenox)
33
heparin indications
Conditions requiring quick anti coagulation; evolving stroke/PE/massive DVT; adjunct therapy for patients having open heart surgery or dialysis; low-dose therapy for post-op DVT prophylaxis/prevention; to treat disseminated intravascular coagulation
34
Heparin nursing considerations
Only given parenteral (IV/SUBQ), can be given 5000 U injection 2-3x a day or as an IV drip with bolus (usually weight based)
35
Heparin nursing considerations
Starts working quickly (20-30 minutes for SUBQ; immediately for IV); antidote is protamine sulfate, use cautiously in patients with spinal/epidural anesthesia; high risk (must double check other another RN prior to rate changes/bolus)
36
Heparin onset (SUBQ)
20-30 minutes
37
Heparin onset IV
Immediate
38
Heparin antidote
Protamine sulfate
39
Heparin adverse effects
Bleeding, hematoma, anemia, thrombocytopenia
40
What to monitor to assess bleeding from heparin
Vitals, bruising, petechiae, hematoma, black tarry stools
41
Heparin induced thrombocytopenia (HIT)
Adverse effect of heparin where the platelet count is reduced/low due to the heparin; low platelet count paradoxically leads to thrombosis
42
Heparin induced thrombocytopenia nursing considerations
Monitor platelet count Discontinue heparin immediately if platelet <100,000/mm3 Non-heparin anticoagulants can be used as a substitute if anticoagulation needed
43
Heparin labs
Anti-Xa or aPTTT | IV heparin dosed based on clotting time labs
44
enoxaparin (Lovenox)
Low-molecular weight heparin
45
enoxaparin (Lovenox) indications
Blood clot prophylaxis and treatment
46
enoxaparin (Lovenox) adverse effects
Bleeding, thrombocytopenia, heparin induced thrombocytopenia (HIT)
47
enoxaparin (Lovenox) nursing considerations
Doesn’t require labs, only given in injectable form, advantage is it can be given at home, antidote is protamine, use cautiously in patients with spinal/epidural anesthesia
48
Protamine
enoxaparin antidote
49
enoxaparin (Lovenox) nursing considerations
Do not give with heparin; do not give with other anticoagulants except warfarin PO for PE/DVT treatment; black box warning for potential spinal hematoma if patient has epidural catheter; given in pre-filled syringes; slower onset of action compared to heparin but longer half-life; rotate injection sites
50
Black box warning: enoxaparin
Potential spinal hematoma if patient has an epidural catheter
51
Pre-filled syringe of enoxaparin
Do not expel the air bubble
52
warfarin (Coumadin) MOA
Inhibits vitamin K synthesis which, in turn, inhibits the production of vitamin K-dependent clotting factors: 2 (thrombin), 7, 9, and 10
53
warfarin indications
VTE/DVT/PE prevention, thrombotic event for patients with a fib or heart valves, reduce recurrence of TIA/MI
54
warfarin adverse effects
Bleeding, lethargy, muscle pain, purple toes
55
Vitamin K (IV)
warfarin antidote; if vitamin K does not work give fresh frozen plasma or whole blood
56
warfarin nursing considerations
Only given PO once a day usually at 5p (onset: 24 hours; duration: 2-5 days)
57
warfarin nursing considerations
Contraindicated for pregnant/breastfeeding women, must monitor/teach for signs of bleeding, hold before surgeries, has many drug interactions, has food interactions, avoid alcohol, wear medical alert bracelet/use soft toothbrush or electric toothbrush
58
warfarin lab monitoring
PT/INR; must monitor MONTHLY after therapeutic level reached
59
Normal INR without warfarin
About 1
60
Therapeutic INR with warfarin
2-3.5
61
Drugs that interact with warfarin
amiodarone, fluconazole, erythromycin, metronidazole, sulfonamide antibiotics, cimetidine
62
Foods high in vitamin K to avoid with warfarin
Kale, broccoli, brussel sprouts, cabbage, pickles, asparagus, kiwi, okra, green bean, lettuce
63
apixaban (Eliquis), rivaroxaban (Xarelto) MOA
Direction inhibition of factor Xa
64
apixaban (Eliquis), rivaroxaban (Xarelto) indications
Prevent stroke in a-fib patients, post-op thrombosis prophylaxis, DVT/PE treatment
65
apixaban (Eliquis), rivaroxaban (Xarelto) adverse effects
Bleeding, hematoma, dizziness, rash, GI distress, peripheral edema
66
apixaban (Eliquis), rivaroxaban (Xarelto) black box warnings
Formation of spinal hematomas if patient has epidural catheter, risk of thrombosis if discontinued abruptly
67
apixaban (Eliquis), rivaroxaban (Xarelto) nursing considerations
Drug interactions, no routine monitoring required, do not give with other anticoagulants, monitor liver function (labs: ALT/AST/GGT)
68
apixaban (Eliquis), rivaroxaban (Xarelto): drugs that decrease their effects
phenytoin, carbamazepine, rifampin, St. John’s wort
69
apixaban (Eliquis), rivaroxaban (Xarelto): drugs that increase their effects
CYP3A4 inhibitors (amiodarone, erythromycin, ketoconazole, HIV meds, diltiazem, verapamil, grapefruit juice)
70
apixaban (Eliquis), rivaroxaban (Xarelto) antidote
andexxa recombinant factor Xa, inactivated-zhzo)
71
Anti-platelets
aspirin, clopidogrel (Plavix)
72
aspirin MOA
Blocks prostaglandin synthesis through the COX enzyme pathway; blocks platelet aggregation; prevents platelets from aggregating
73
aspirin indications
Prevent/treat MI, prevent ischemic stroke
74
aspirin side effects
Nausea, vomiting, drowsiness, confusion, bleeding
75
aspirin nursing considerations
Given PO (chew baby aspirin if an acute event/do not chew enteric coated), monitor for bleeding, do not crush enteric coated, do NOT give to children with a viral infection bc it can lead to Reye syndrome
76
aspirin contraindications
Thrombocytopenia, active bleeding, blood cancers, traumatic injuries, GI ulcers, vitamin K deficiency, recent hemorrhagic stroke
77
DDAVP (desmopressin)
Aspirin antidote
78
clopidogrel (Plavix), ticagrelor (Brilinta) MOA
Antiplatelet ADP inhibitor; alters the platelet membrane so that it can no longer receive the signal to aggregate and form a clot
79
clopidogrel (Plavix), ticagrelor (Brilinta) indications
Reduce risk of stroke, TIA prophylaxis, post-MI
80
clopidogrel (Plavix), ticagrelor (Brilinta) contraindications
Thrombocytopenia, active bleeding, blood cancers, traumatic injuries, GI ulcers, vitamin K deficiency, recent hemorrhagic stroke
81
clopidogrel (Plavix), ticagrelor (Brilinta) side effects
Chest pain, edema, flu-like symptoms, abdominal pain, diarrhea, nausea, epistaxis (nose bleed), rash, pruritus
82
clopidogrel (Plavix), ticagrelor (Brilinta)
Given PO
83
Black box warning for clopidogrel
For patients with certain genetic abnormalities, who may have a higher rate of cardiovascular events from reduced conversion of this medication to its active metabolite
84
Black box warning for ticagrelor
Increased risk of bleeding with aspirin > 100 mg
85
Medications that reduce clopidogrel effectiveness
Calcium channel blockers, amiodarone, NSAIDS, PPIs
86
clopidogrel (Plavix), ticagrelor (Brilinta) antidote
desmopressin (DDAVP) or platelet transfusion
87
argatroban, bivalirudin class
Direct thrombin inhibitors
88
argatroban, bivalirudin MOA
Inhibits thrombus formation by inhibiting factor IIa (thrombin); prevents activation of fibrin from fibrinogen by inhibiting thrombin
89
argatroban, bivalirudin indications
To treat HIT, for patients undergoing procedures (like percutaneous coronary intervention or PCI) who are at high risk for HIT
90
argatroban, bivalirudin adverse effects
Bleediing
91
argatroban, bivalirudin nursing considerations
IV only, for argatroban be careful with patients with liver dysfunction, monitor labs (anti-Xa, H&H, platelets)
92
Protamine sulfate
heparin antidote Given IV and SLOWLY Side effect: hypotension
93
Anticoagulants requiring lab monitoring
heparin (anti-Xa and aPTT) | warfarin (PT/INR)
94
High risk anticoagulant requiring second RN check before rate changes/bolus
heparin

Pathopharm I (10 decks)

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