Hematology: Coagulation Modifying Agents Flashcards
1
Q
What is the therapeutic range for Partial Thromboplastin Time (PTT)?
A
40-70 seconds
2
Q
What is the therapeutic range for Prothrombin Time (PT)?
A
18 seconds
3
Q
What is the therapeutic range for International Normalized Ration (INR)?
A
2-3
4
Q
What do anticoagulants do? What is it used for?
A
- Inhibit the action or formation of clotting factors
- Uses vary: prevent clot formation to prevent the extension of an established clot
5
Q
What do antiplatelet drugs do?
A
Inhibit platelet adhesion at the site of blood vessel injury; essentially, stopping your platelets from sticking together
6
Q
What do thrombolytic drugs do?
A
Lyse (break down) existing clots in the coronary arteries; reestablishes blood flow to the heart muscle
7
Q
What do antifibrinolytic / hemostatic drugs do?
A
- All varying MOAs, but all prevent the lysis of fibrin
- Promote blood coagulation
8
Q
Describe anticoagulants. What are they used to prevent?
A
- Also known as antithrombotic drugs
- Prevent intravascular thrombosis by decreasing blood coagulability
- Used prophylactically to prevent
~ Clot formation (thrombus)
~ An embolus (dislodged clot)
» Brain vessel -> stroke
» Coronary artery -> myocardial infarction (MI)
» Lungs -> pulmonary embolism
» Vein in the leg-> deep vein thrombosis (DVT)
9
Q
List examples of older anticoagulant drugs.
A
- Heparin (Unfractionated)
- Warfarin
10
Q
What is a common nursing consideration among all anticoagulants?
A
Assess for symptoms of bleeding and blood loss
11
Q
What is a common patient education point among all anticoagulants?
A
Report any symptoms of unusual bleeding or bruising to HCP
12
Q
What are some considerations when administering a subcutaneous anticoagulant injection?
A
- Administer subcut; do NOT expel the air bubble
~ Inject the entire needle at 45 or 90 degree angle (depending on what you can pinch)
~ Do NOT aspirate or massage
~ Do NOT administer IM (danger of hematoma)
13
Q
What is a common patient education point for anticoagulants and antiplatelets?
A
Advise client to notify HCP of medication regimen prior to
treatment or surgery
14
Q
How do you administer heparin for DVT prophylaxis?
A
5000 units subQ/subcut two or three times a day; aPPT does not need to be monitored when used for prophylaxis (or IV catheters)
15
Q
What are some considerations for when heparin is used therapeutically as a continuous IV infusion?
A
- Measurement of aPTT (usually every 4-6 hours until therapeutic effects are seen; then daily once achieved)
- Antidote for overdose/toxicity is protamine sulfate
16
Q
Heparin indication?
A
Prophylaxis & tx of various thromboembolic disorders
17
Q
Heparin adverse effects?
A
Hem: BLEEDING, heparin induced thrombocytopenia (HIT), thrombocytopenia, hematoma, anemia
18
Q
Heparin drug interactions?
A
Aspirin & NSAIDS (decreased platelet activity); Oral anticoagulants, antiplatelet drugs, and thrombolytics (additive effects)
19
Q
Describe heparin-induced thrombocytopenia (HIT).
A
- Immune mediated adverse drug reaction caused by the emergence of antibodies that activate platelets in the presence of heparin
- May reduce platelets counts to as low as 5000/mm3
- May lead to increased resistance to heparin therapy
20
Q
Heparin nursing considerations?
A
- Monitor aPTT and hematocrit prior to and periodically during therapy
- Subcut: observe injection sites for hematomas, ecchymosis, or inflammation
- For an overdose, protamine sulfate is the antidote
21
Q
Heparin patient education?
A
- Instruct patient to avoid medications that contain aspirin or NSAIDs
- Caution patient to avoid IM injections and activities leading to injury
- Advise patient to use a soft toothbrush, not to floss and to us an electric razor during heparin therapy
- Educate patient on the importance of carrying an identification card or a medical alert bracelet or necklace at all times
22
Q
Warfarin drug profile?
A
- Most commonly prescribed oral anticoagulant; PO only
- Careful monitoring of the prothrombin time/international normalized ratio (PT/INR)
- A normal INR (without warfarin) is 1.0, but a therapeutic INR (with warfarin) ranges from 2 to 3
- Dietary considerations- vitamin K consistent diet
- Antidote for overdose/toxicity is Vitamin K
23
Q
Warfarin indication?
A
- Prophylaxis & tx: venous thrombosis, pulmonary embolism, a-fib
- Management of MI
- Prevention of thrombus formation after prosthetic valve replacement
24
Q
Warfarin adverse effects?
A
- Hem: BLEEDING
- Derm: purple toes (rare, affects 1 in 5000 clients)
25
Warfarin nursing considerations?
- Monitor stool and urine for occult blood before and periodically during therapy
- Monitor PT and INR
- Monitor CBC, renal, and liver enzymes before and periodically throughout therapy
26
Warfarin patient education?
- Avoid cranberry juice or products during therapy
- Avoid IM injections, use a soft toothbrush, avoid flossing, and shave w/ an electric razor during therapy
- Do not to drink alcohol or take Rx, OTC, herbal products or start or stop any new medications during warfarin therapy w/o advice of their HCP
- Carry identification describing medication regimen at all times
27
List an example of a Low-molecular weight heparin (LMWHs). [Anticoagulant]
Enoxaparin
28
Enoxaparin drug profile?
- Higher degree of bioavailability and longer elimination half-life
- More predictable anticoagulant response, lab monitoring is not necessary
- Injectable form
- Used for prophylaxis and treatment
- “Bridge therapy”
- Pre-filled syringes
~ Do not expel air bubble
29
Enoxaparin indication?
- Prevention/Prophylaxis of venous thromboembolism (VTE), DVT, and/or PE
- Treatment of DVT w/ or w/o PE (with warfarin)
30
Enoxaparin contraindication?
**patients w/ an indwelling epidural catheter**
31
Enoxaparin adverse effects?
Hem: BLEEDING, thrombocytopenia, hematoma, anemia
32
Enoxaparin drug interactions?
- Risk of bleeding may increase by concurrent use of drugs that affect platelet function and coagulation:
~ Warfarin
~ Aspirin
~ NSAIDs
~ Clopidogrel
33
Enoxaparin nursing considerations?
- Monitor CBC, platelet count at the beginning and periodically throughout therapy
~ **They can be restarted on any LMWH 2 hours AFTER the indwelling epidural catheter is removed**
- Administer subcut; do NOT expel the air bubble
- The ONLY time this medication is given IVP is for a STEMI
34
Enoxaparin patient education?
- Instruct patient in correct technique for self-injection care, and disposal of equipment (if using at home)
- Do not to take aspirin, naproxen, and/or ibuprofen w/o first discussing w/ their provider while on enoxaparin therapy
- Notify HCP of therapy before dental or medical treatments or surgery
35
Describe "Bridge Therapy."
- "Bridging” refers to the use of short-acting anticoagulants (heparin or LMWH) during the interruption of warfarin
~ Warfarin is stopped 5-6 days before surgery to allow its anticoagulation effects to wane
~ Bridging w/ either heparin or LMWH is started 3 days before surgery w/ the last dose given 24 hours before surgery
~ Bridging is resumed no earlier than 24 hours after surgery
36
List examples of Direct Thrombin Inhibitors. [Anticoagulant]
- Dabigatran
- Argatroban
37
Dabigatran drug profile?
- First oral direct thrombin inhibitor approved for prevention of strokes and thrombosis in patients with nonvalvular atrial fibrillation
- Prodrug that becomes activated in the liver
- **Antidote of overdose/toxicity is idarucizumab**
38
Dabigatran indication?
Decreased risk of stroke (associated w/ a-fib)
39
Dabigatran adverse effects?
Hem: **BLEEDING with increased GI Bleed**
Misc: Fever, shortness of breath, urticaria (r/t hypersensitivity reaction)
40
Dabigatran drug interactions?
- Risk of bleeding may increase by concurrent use of anticoagulants and antiplatelet
- Rifampin and St. John’s wort can cause decreased drug effect
41
Dabigatran nursing considerations?
- Do NOT exchange capsules for oral pellets; doses are not equal
- Do not chew or crush capsules, it must be swallowed whole
- Do not administer with milk or milk products
- Administered BID, about 12 hours apart with a FULL glass of water
42
Dabigatran patient education?
May bleed more easily or longer than usual
43
Argatroban drug profile?
- Synthetic direct thrombin inhibitor
- Only given IV route
44
Argatroban indication?
Prophylaxis of thrombosis in patients with heparin-induced thrombocytopenia (HIT)
45
Argatroban adverse effects?
- Hem: BLEEDING
- Misc: Fever, shortness of breath, urticaria (r/t hypersensitivity reaction)
46
Argatroban drug interactions?
- Risk of bleeding may increase by concurrent use of antiplatelet drugs, thrombolytic drugs, or other anticoagulants
- Increased bleeding w/ herbals such as: feverfew, garlic, ginger, & gingko
47
Argatroban nursing considerations?
- Monitor VS periodically during IV therapy
- Assess H/H, platelet count prior to and during drug therapy
- Minimize arterial and venous punctures, IM injections, use of urinary catheters, NG tubes
- Monitor for cues of anaphylaxis
- All parenteral anticoagulants should be DC’d before argatroban therapy is initiated
48
What three drugs have similar drug interactions?
Fondaparinux, Aspirin, Alteplase
49
Describe drug interactions of Fondaparinux, Aspirin, and Alteplase.
- Risk of bleeding may increase by concurrent use of warfarin or drugs that effect platelet function including: aspirin, NSAIDs, heparin, cephalosporins, and clopidogrel
- Increased risk of bleeding w/: dong quai, feverfew, garlic, ginger, and gingko
50
List examples of Selective factor Xa inhibitors. [Anticoagulant]
- Fondaparinux
- Rivaroxaban
- Apixaban
51
Fondaparinux drug profile?
- Black box warning for potential spinal hematomas w/ epidural catheters
52
Fondaparinux indication?
Prevention and/or treatment of DVT and PE
53
Fondaparinux contraindication?
Patients with:
- body weight < 50 kg
or
- creatinine clearance (CrCl) < 30 mL/min
54
Fondaparinux adverse effects?
- Hem: BLEEDING
- Misc: Fever, angioedema (r/t hypersensitivity reaction)
55
Fondaparinux nursing considerations?
- Thrombocytopenia can occur; call provider to DC if plts < 100,000/mm3
- Administer subcut; do NOT expel the air bubble
~ Rotate sites frequently in the abdomen
56
Fondaparinux patient education?
- Instruct patient in correct technique for self-injection care, and disposal of equipment (if client is using at home)
- Report any itching, rash, fever, swelling, or dyspnea to HCP
- Do not to take aspirin and/or NSAIDs w/o first discussing w/ their provider while on enoxaparin therapy
57
Rivaroxaban drug profile?
- PO only
- Black box warning-potential spinal hematomas
- **Antidote for overdose/toxicity is andexanet alfa**
58
Rivaroxaban indication?
- Prevention and/or treatment of VTE, DVT, and/or PE
- Decreased risk of a stroke and other major CV events (MI)
59
Rivaroxaban adverse effects?
Hem: BLEEDING
60
Rivaroxaban drug interactions?
- Increased risk of bleeding w/ other anticoagulants, aspirin, clopidogrel, fibrinolytics, and NSAIDs
- St. John’s wort may decrease levels
61
Rivaroxaban nursing considerations?
- OK to crush tablet and mix with applesauce
- OK to administer medication in a GI feeding tube
62
Rivaroxaban patient education?
Report any unusual bleeding or bruising
63
Apixaban drug profile?
- PO only
- Black box warning-potential spinal hematomas
- Not recommended for patients w/ prosthetic heart valves
- **Antidote for overdose/toxicity is andexanet alfa**
64
Apixaban indication?
- Decrease risk of stroke associated w/ a-fib
- Prevention of DVT that may lead to a PE after an ortho surgery
65
Apixaban adverse effects?
- Hem: BLEEDING
- Misc: Hypersensitivity including anaphylaxis
66
Apixaban drug interactions?
- Risk of bleeding may increase by concurrent use of anticoagulants, aspirin, clopidogrel, fibrinolytics, and NSAIDs
- Concurrent use of St. John’s wort can decrease levels and increase risk of thrombosis
67
Apixaban nursing considerations?
- Assess cues of bleeding, DVT, PE, and/or stroke
- Tablets can be crushed for patients who can't swallow
- OK to crush and mix w/ 60 mL of water or D5W and administered through NG tube
68
Apixaban patient education?
Notify HCP if skin rash, cues of an allergic reaction occur
69
List examples of antiplatelet drugs.
- Aspirin
- Clopidogrel
70
Aspirin drug profile?
- Available in many combinations with other prescription and nonprescription drugs
- For stroke prevention, daily dose of 50-325 mg recommended by American Stroke Society, but **in clinical practice 81mg/day (“baby” aspirin) is the most common dosage**
71
Aspirin indication?
Stroke prevention
72
Aspirin contraindication?
**Children and teenagers (Reye’s syndrome)**
73
Aspirin adverse effects?
- GI: GI BLEEDING, dyspepsia, epigastric distress, nausea
- MISC: hypersensitivity reactions (anaphylaxis and laryngeal edema)
74
Aspirin drug interactions?
*see other card
- Ibuprofen may negate the cardioprotective antiplatelet effects of low-dose aspirin
- Increased risk of GI irritation with NSAIDs
75
Aspirin nursing considerations?
- If platelet count falls below 80,000/mm3, hold medication and call provider (anticipate therapy to be DC’d)
- Administer after meals or w/ food or an antacid to minimize gastric irritation
76
Aspirin patient education?
- Report unusual bruising, bleeding or tinnitus
- Educate that concurrent alcohol use may cause gastric irritation
~ 3+ glasses of alcohol may increase the risk of GI bleeding
77
Clopidogrel drug profile?
- Most widely used ADP inhibitor
- Oral use
- Black box warning for patients w/ certain genetic abnormalities, who may have a higher rate of CV events d/t reduced cardioversion to its active metabolite
78
Clopidogrel indication?
- Acute coronary syndrome (STEMI, Non-STEMI, unstable angina)
- Patients w/ established peripheral arterial disease, recent MI, or recent stroke
79
Clopidogrel adverse effects?
- GI: GI BLEEDING
- MISC: hypersensitivity reactions including anaphylaxis
80
Clopidogrel drug interactions?
- Reduced effectiveness with amiodarone, CCBs, NSAIDS, & PPIs
- Risk of bleeding may increase by concurrent use of: aspirin, NSAIDs, heparin, LMWH, thrombolytic drugs, warfarin
- Opioids may decrease absorption of clopidogrel and decrease antiplatelet effects
- Increased risk of bleeding w/: feverfew, garlic, ginger, and gingko
81
Clopidogrel nursing considerations?
- Assess for GI bleeding, stroke, and MI throughout therapy
- Monitor for thrombocytopenia
82
Clopidogrel patient education?
- Notify HCP if cues of bleeding occur
- Avoid taking PPIs
83
List an example of a thrombolytic drug.
Alteplase
84
Alteplase drug profile?
- Very short half-life (~5 mins)
- Parenteral form only
- **Aminocaproic acid may be used as an antidote**
85
Alteplase indication?
- Acute MI, acute ischemic stroke, PE
- Occluded central venous access device
86
Alteplase adverse effects?
Hem: BLEEDING
87
Alteplase drug interactions?
*see other card
- Effects may be decreased by antifibrinolytic drugs including aminocaproic acid
88
Alteplase nursing considerations?
- For acute ischemic stroke
~ Begin therapy as soon as possible after the onset of symptoms; **MUST be given w/in 3- 4.5 hours of symptom onset**
- For PE
~ Monitor pulse, BP, hemodynamic labs, respiratory status
- For DVT
~ Observe extremities & palpate pulses of affected extremities
- For MI
~ Monitor ECG/EKG, heart and breath sounds
~ Assess for chest pain
- For catheter occlusion
~ Monitor ability to aspirate blood
89
List examples of an antifibrinolytic drugs.
- Aminocaproic Acid
- Desmopressin
90
Aminocaproic Acid drug profile?
- Synthetic antifibrinolytic drug
- Oral or parenteral preparations
91
Aminocaproic Acid indication?
Management of acute, life-threatening hemorrhage and blood oozing from surgical sites
92
Aminocaproic Acid adverse effects?
CV: dysrhythmias, hypotension (IV only)
93
Aminocaproic Acid drug interactions?
- Concurrent use w/ estrogens, may result in a hypercoagulable state
- Concurrent use w/ clotting factors, may increase risk of thrombosis
94
Aminocaproic Acid nursing considerations?
- Monitor BP, pulse, and respiratory status
- Monitor bleeding
- Monitor platelet count
- Usually given IV until bleeding is controlled
95
Aminocaproic Acid patient education?
- Notify if bleeding reoccurs or if thromboembolic symptoms develop
- IV administration: make position changes slowly to avoid orthostatic hypotension
96
Desmopressin drug profile?
- Synthetic polypeptide
- Similar to vasopressin, which is an antidiuretic hormone
97
Desmopressin indication?
Hemophilia and von Willebrand’s disease (to stop bleeding)
98
Desmopressin adverse effects?
- F and E: hyponatremia
- Neuro: Seizures
99
Desmopressin drug interactions?
Loop diuretics, systemic glucocorticoids, or inhaled glucocorticoids increase the risk of severe hyponatremia
100
Desmopressin nursing considerations?
- Assess client for cues of bleeding
- Monitor BP and HR during IV infusion
- Monitor labs
101
Desmopressin patient education?
Notify if bleeding is not controlled or if headache, dyspnea occurs
