ANTICOAGULANT & THROMBOLYTIC DRUGS

NPN 130 CHAPTER 38

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

ANTICOAGULANTS ACTIONS
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

ANTICOAGULANTS ACTIONS

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

Spinal Fever Procedures (risk Malignancy of epidural Heart failure hematoma) Diarrhea Pregnancy Renal/Hepatic disease

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 DRUGS ACTIONS 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 DRUGS ACTION

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
Pre administration Ongoing assessment

Medication history Lab tests Vital signs

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?

IMMUNOSTIMULANT DRUGS
NPN 130 CHAPTER 52

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 RBCs Inadequate production of RBCs 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 marrows ability to produce RBCs

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

ERYTHROPOIESIS-STIMULATING AGENTS
ESAS stimulate erythropoiesis (process of making RBCs) 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 RBCs. 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 & USES IRON DEFICIENCY ANEMIA

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

IRON DEFICIENCY ANEMIA DRUG 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 ANEMIA DRUG ADMINISTRATION

IM dose can stain surrounding tissue. Must use ZTrack 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 MedicalSurgical Book that is used for Health Deviations