NPN 130CHAPTER 38

ANTICOAGULANT & THROMBOLYTIC DRUGS

COAGULATION CASCADE

• Each factor that is activated acts as a helper that enhances the next reaction. • The end results-> a large collection of fibrin (clot) forms a plug in the vessel stopping the bleeding.•Very normal, happens daily throughout the body

COAGULATION CASCADE

DEFINITIONS• Thrombosis is the formation of a blood clot, or

thrombus• May form in any vessel (artery or vein)

impending blood flow

• When a thrombus detaches itself from the wall of a vessel and is carried throughout the bloodstream, it is called an embolus.• Embolus will travel until it reaches a vessel too small• Pulmonary Embolism- embolus obstructs pulmonary

vessel• Myocardia Infarction (MI)- embolus occludes a vessel

supplying blood to the heart

EMBOLUS

THROMBUSTHROMBOSIS

EMBOLISM

FYI•Anticoagulants: Prevent formation of blood clot

•Antiplatelets: suppress platelet aggregation

• Thrombolytics: help to eliminate clot

ANTICOAGULANTS

• Prevent the formation and extension on a thrombus.

•No effect on an existing thrombus and do not reverse damage from the thrombus

•Commonly referred to as “blood thinners,” but do not actually thin the blood

ANTICOAGULANTS

• Warfarin (coumadin)

• Most commonly prescribed oral anticoagulant• Drug of choice for long-term therapy• Before administration, check PT

(prothrombin time)/INR (international normalized ratio)for clotting times• Symptoms of overdose includes

bleeding. TX with VIT K (antidote-reverses effects of coumadin) or withhold 1-2 doses

ANTICOAGULANTSACTIONS

• Interferes with clotting mechanism

•Warfarin (Coumadin):• Interferes with vit K clotting factors->

results in depletion of prothrombin (essential for clotting)

ANTICOAGULANTS

• Heparin Sodium, Low Molecular Weight Heparin (LMWH)• Before administration, check aPTT (activated

partial thromboplastin time) for clotting times• Enoxaparin (Lovenox)• LMWH require less laboratory monitoring (very

stable responses)• Bleeding less likely with LMWH• If overdose, give Protomine sulfate

(antidote) or discontinuation of drug will correct problems

• Must use infusion pump for safe administration

ANTICOAGULANTSACTIONS

•Heparin:

• Inhibits formation of fibrin clots• Inhibits conversion of fibrinogen to

fibrin • Inactivates factors necessary for the

blood to clot

ANTICOAGULANTS

• Fondaparinux (Arixtra)• Inhibit parts of the coagulation cascade• Used to prevent DVT

USES

•Prophylaxis of DVT•Atrial fibrillation•Prevention/treatment of PE•Adjuvant treatment of MI•Prevention of thrombus formation after valve replacement surgery

PARENTAL ANTICOAGULANTS

•Prevention of post-op DVT and PE

•Prevention of clotting in arterial and heart surgery, dialysis, blood transfusions

PARENTAL ANTICOAGULANTS

•Diagnosis and treatment of disseminated intravascular coagulation (DIC)->severe hemorrhage disorder

•Maintaining patency of if IV caths

ADVERSE REACTIONS

• Bleeding!!!• Skin (bruising and petechiae)• Bladder• Bowel• Stomach• Uterus • Mucous membranes

ADVERSE REACTIONS

• Local irritation when heparin is given subQ route•N/V/D•Hepatitis• Thrombocytopenia (low platelet count)• Blood dyscrasias

CONTRAINDICATIONS

•Known allergy•Active bleeding•Hemorrhagic disease (except DIC)•Leukemia•Ulcers•Recent eye surgery

CONTRAINDICATIONS

•Renal disease•Hepatic disease•Pregnancy•Allergy to pork•Aneurysms

PRECAUTIONS

•Fever•Malignancy•Heart failure•Diarrhea•Pregnancy•Renal/Hepatic disease

•Spinal Procedures (risk of epidural hematoma)

HERBAL ALERT

• Warfarin (Coumadin) has the potential to interact with several herbal remedies. Must let PMD know if taking any herbal supplements

• Increased risk of bleeding if combined with:• Celery• Chamomile• Garlic• Ginger

ANTIPLATELET DRUGS

• Thrombin forming in venous system are made up of fibrin and RBC (Anticoagulants)

• Arterial thrombosis formation is from platelet aggregation (Antiplatelets)

ANTIPLATELET DRUGSACTIONS

•Decreases the platelets ability to “stick” together-> this stops the clot from forming

•Treatment for at risk cardiac and stroke clients

ANTIPLATELET DRUGS

•Clopidogrel (Plavix)

•Eptifibatide (Integrilin)

ADVERSE REACTIONS

•Heart palpitations

•Bleeding•Dizziness/headache•N/V/D/Constipation, dyspepsia

CONTRAINDICATIONS

•Known allergy•Pregnancy/lactating•Congestive heart failure•Active bleeding•Renal or hepatic impairment

CONTRAINDICATIONS

• Pancytopenic patient (Number of RBC, WBC and Platelets are low)

• Thrombotic Thrombocytopenic Purpura (TTP)• Disease that causes blood to clot abnormally ->

not enough platelets to help form clots in other areas of the body-> leads to purpura (bruises) or petechiae (dots)

PETECHIAE

THROMBOLYTIC DRUGSACTION

•Thrombolytics dissolve blood clots already formed

•Also called fibrolytics

•These drugs reopen occluded blood vessels

THROMBOLYTIC DRUGS

• Alteplase (Activase)

• Streptokinase (Streptase)

USES

•Heart attack•Pulmonary emboli•Deep vein thrombosis• Ischemic stroke•Central venous catheters occlusions

CONTRAINDICATIONS/PRECAUTIONS

•Known allergy•Active bleeding•Aneurysm•Major surgery or trauma within last 10 days

NURSING PROCESS

• Medication history• Lab tests• Vital signs

Pre administration Ongoing assessment

• Assesses for signs/symptoms of bleeding• Heparin dosing• Hypersensitivity• Vital signs• Lab tests

INFORMATION TO KNOW

• Avoid alcohol• Antiplatelets can lower all blood counts including

WBC-> increased risk of infection• If unusual bleeding occurs, omit next dose of drug

and contact PMD • Use a soft tooth brush/electric razor• These drugs may inactivate oral contraceptives->

EDUCATE!!!• Inform all medical personnel of drug therapy

REVIEW!

• Rita Simms is a 28-year-old Caucasian woman. She is being discharged from the hospital today after a recent deep venous thromboembolism. She is being discharged with a prescription for warfarin (Coumadin) 5 mg with directions to take 1 tablet daily at 5 PM. The physician has asked the nurse to complete discharge counseling with Ms. Simms.

REVIEW!

How often will Ms. Simms need her prothrombin time and international normalized ratio tested?

2. What are the signs of warfarin overdosage?

3. What should Ms. Simms be told about starting new medications?

NPN 130 CHAPTER 52

IMMUNOSTIMULANT DRUGS

HEMATOPOIETIC SYSTEM

• Blood is a complex fluid that circulates continuously through the heart and blood vessels and to body tissues. 3 major components: • Red blood cells (erythrocytes)- supply our

cells with oxygen from the lungs to this tissues• White blood cells (leukocytes)- protect our

bodies from dangerous microorganisms• Platelets (megakaryocytes)- control

bleeding from microscopic and major tears in our tissues

HEMATOPOIETIC SYSTEM

• Chronic diseases can causes an inadequate number of cells to be made -> the body is then unable to meet demands for oxygen transport, blood coagulation or preventing invasion of microorganisms.

• Goal of treatment is to stimulate the body to make more specific blood cells; called hematopoiesis

HEMATOPOIETIC DRUGS TX ANEMIA

• Anemia is a condition caused by an insufficient amount of hemoglobin delivering oxygen to the tissues.

• Anemia can result from • Blood loss• Excessive destruction of RBC’s• Inadequate production of RBC’s• Deficits in nutrients i.e. iron deficiency anemia

CHRONIC ILLNESS

• Treatment of chronic illnesses and disease itself such as cancer and chronic kidney disease can lead to anemia

• In chronic kidney disease, the kidneys have a reduced ability to produce erythropoietin. Erythropoietin stimulates production of RBCs

• Cancer treatment suppresses bone marrow’s ability to produce RBC’s

ANEMIA

• Symptoms of anemia may include:• Fatigue• Shortness of breath• Headache• Pallor

ERYTHROPOIESIS-STIMULATING AGENTS

• ESA’S stimulate erythropoiesis (process of making RBC’s)• Used to treat anemia associated with • Chronic kidney disease• Chemotherapy for cancer treatment

• Epoetin alfa (Epogen, Procrit)

IRON DEFICIENCY ANEMIA

• When the body does not have enough iron to supply its own needs.

• Iron is a part of hemoglobin that picks up oxygen from the lungs and carries it to the body tissues.

• Low iron results from low RBC’s. Causes include:• Heavy menstrual bleeding• Poor absorption of iron• Lack of iron in diet

IRON DEFICIENCY ANEMIA

• Ferrous (Feostat)• Can give PO

• Iron Dextran (Dexferrum)• IM, IV

ACTIONS & USESIRON DEFICIENCY ANEMIA

•Elevate serum iron levels•Absorbed better on empty stomach•Uses:•Oral•Parenteral

IRON DEFICIENCY ANEMIADRUG ADMINISTRATION

• Best absorbed with empty stomach but due to GI upset, may take them with food• Milk and antacids interfere with iron

absorption->do not give at same time• Due to fatal anaphylactic reactions, before

giving IM/IV, do “test dose” and monitor for dyspnea, rashes, fever

IRON DEFICIENCY ANEMIADRUG ADMINISTRATION

• IM dose can stain surrounding tissue. Must use Z-Track method (ch 2)• Pull skin laterally, displacing tissue to side approximately

1 inch. Hold in this position while injection is given• Wait 10 seconds to ensure med has entered muscle

tissue, then release while withdrawing needle• This prevents backflow of drug into subcutaneous tissue

• NEVER GIVE IM IN DELTOID!!• If giving liquid iron, mix with water or juice and

drink through a straw to prevent staining the teeth

ADVERSE REACTIONS

•Gastrointestinal • Nausea, vomiting,• Constipation- How to treat?• Dark (possibly black) stools

•Generalized• Headache• Backache• Allergy to med

CONTRAINDICATIONS/PRECAUTIONS

•Known allergy to drug

•Parenteral form can cause anaphylactic- type reactions. Only used when oral supplement is contraindicated

FOLIC ACID DEFICIENCY ANEMIA

• Folic acid necessary for production of RBC in the bone marrow

• Folic acid is found in the following foods:• Green, leafy vegetables• Fish• Poultry• Meat• Whole grains

ACTIONS

• Treats anemias caused by deficiency of folic acid

• Given orally

• Folic Acid (folvite)• Can give PO, IM, IV, Subcut

PREGNANCY

• Women need more folic acid during pregnancy. Women with folate deficiency are at increased risk for complications of pregnancy and fetal abnormalities.

• Studies show decreased risk for neural tube defects (spina bifida or meningocele) if taking folic acid before conception and early preganancy.

ADVERSE REACTIONS/INTERACTIONS

• Adverse Reaction:• Rare• Allergic hypersensitivity with parenteral

administration

• Interactions:• Increased risk of seizure activity if

administered with hydantoins (Dilantin).

CONTRAINDICATIONS/PRECAUTIONS

•Folic acid contraindicated•Pernicious anemia•B12 deficiency

• Potential for fetal harm small, use as directed by OB

VITAMIN B12 DEFICIENCY ANEMIA

•B12 is essential to cell growth, reproduction, myelin, and making of blood cells

• Intrinsic factor (found in stomach) is necessary for absorption of B12 in the intestine

ACTIONS

• Vitamin B12 deficiency seen in:• Vegetarians- Vegan• Gastrectomy (removal of the stomach)• Ulcerative colitis (inflammatory problem)• Gastric carcinoma (cancer)

•Once B12 deficiency is corrected, monthly injections for maintenance may be needed

VITAMIN B12 DEFICIENCY

•Vit B12 is found in:•Meats (beef, pork, chicken)• Seafood•Dairy• Eggs

ADVERSE REACTIONS

•Mild diarrhea•Itching• RBC production

CONTRAINDICATIONS/PRECAUTIONS

• Known allergy• Pulmonary disease•Megaloblastic anemia (can cause electrolyte imbalances)• Absorption decreases with• Alcohol • Neomycin (antibiotic)• Colchicine (used in treatment of gout)

ASSESSMENT

• Physical Assessment• Symptoms of anemia???• Lab tests- check RBC• Vital signs- provides baseline

ANEMIA

EVALUATION

•Therapeutic- How to tell?•Bowel movements?•Demonstrate understanding•Compliance•Dietary?

REVIEW!

A nurse is caring for a patient who has been prescribed drug therapy for anemia at a healthcare facility. The healthcare provider has ordered laboratory tests to determine the type, severity, and possible cause of the anemia. What are the different types of anemia?

Which symptoms of anemia should the nurse look for in the patient?

REVIEW!

The physician has prescribed parenteral iron for a patient. The physician has ordered the nurse to observe the patient receiving iron.When is parenteral iron used?

How should iron be administered IM?

Which gastrointestinal reactions should the nurse look for in the patient?

NORMAL LAB LEVELS

• RBC: 4.6 – 5.0 million/McL• Folic acid: 3 – 17 ng/mL• Vitamin B12: 100- 700 pg/mL• Hemoglobin: 12-17.5g/dL• Iron: 60-170 mcg/dL

• http://www.nlm.nih.gov/medlineplus/ency/article/003488.htm

All values other than Iron taken from Appendix C in back of your Medical-Surgical Book that is used for Health Deviations