Anticoagulants (part 2)

Question 1

How does Warfarin (Coumadin) work?

Answer 1

Inhibits production of vit. K, which plays a role in blood clotting

Question 2

List 5 indications for giving Warfarin

Answer 2

1) A-fib
2) Valvular heart disease
3) CVA
4) DVT & PE prevention
5) Post joint replacement

Question 3

How long does it take Warfarin to take effect?

Answer 3

4-7 days

Question 4

What labs are required for Warfarin?

Answer 4

Narrow therapeutic range
→ PT/INR: want INR at 2-3 (for mechanical heart valve = 2.5-3.5)

Question 5

What time of day should Warfarin be given?

Answer 5

In the evening

Question 6

What type of anti-coagulant drug is highly protein bound?

Answer 6

Warfarin (Coumadin)

Question 7

What is the antidote for Warfarin?

Answer 7

Phytonadione (Vitamin K)

Question 8

Comparing Heparin to warfarin:

Heparin Hint: 4

Answer 8

1) Works fast
2) IV/ SQ route
3) Labs to check: PTT
4) Antidote: Protamine sulfate

Question 9

Comparing heparin to warfarin:

Warfarin Hint: 4

Answer 9

1) Works slow (4-7 days)
2) Oral route
3) Labs to check: PT/INR
4) Antidote: Vitamin K

Question 10

Comparing heparin to warfarin:

Both drugs Hint: 2

Answer 10

1) Both withhold a coagulation factor
2) Both can be given at same time (heparin first then warfarin in evening)

Question 11

Direct factor Xa inhibitors are considered what category anti-coag?

Answer 11

Anti-coagulants

Question 12

How do direct factor Xa inhibitors work?

Answer 12

Prevent factor Xa from changing prothrombin to thrombin by binding directly to factor Xa

Question 13

What do direct factor Xa inhibitors reduce risk of?

Answer 13

Stroke & embolism in pts w/ non-valvular induced a-fib, & DVT, PE

Question 14

List 4 drugs considered direct factor Xa inhibitors

Answer 14

1) Apixaban (Eliquis)
2) Rivaroxaban (Xarelto)
3) Edoxaban (Lixiana, Savaysa)
4) Dabigatran (Pradaxa)

Question 15

Suffix for direct factor Xa inhibitors

Answer 15

“Ban” or “an”

Question 16

Do you need to monitor labs for direct factor Xa inhibitors?

Answer 16

NO

Question 17

Direct factor Xa inhibitors in comparison to warfarin

Answer 17

DOACs significantly decrease risk of bleeding in comparison to warfarin

Question 18

List 8 patient teaching points for direct factor Xa inhibitors

Answer 18

1) Meds must stay in original bottle
2) Pills should NOT be crushed
3) Don’t stop taking for GI issues (unless black tarry stool/ frank red stool)
4) Hold before surgery
5) Don’t take with Clopidogrel
6) Watch for drug interactions
7) Must reduce dose in renal failure
8) Caution in abrupt stopping

Question 19

What is the antidote for Dabigatran ONLY

Answer 19

Praxbind (Idarucizumab)

Question 20

What is the antidote for Apixaban & Rivaroxaban ONLY

Answer 20

Andexanet (Andexxa)

Question 21

List 2 nursing considerations for DOACs

Answer 21

1) Must know Cr & liver enzymes
2) Can NOT stop abruptly

Question 22

Anti-platelets vs. Anti-coagulants:

Anti-platelets

Answer 22

High-velocity disease states affecting arteries
1) CVA
2) CAD
3) PAD

Question 23

Anti-platelets vs. Anti-coagulants:

Anti-coagulants

Answer 23

Low-velocity disease states affecting veins & left atrium
1) PE
2) A-fib
3) DVT

Question 24

How do thrombolytic agents work? Hint: 2

Answer 24

1) Promotes conversion of plasminogen to plasmin leading to fibrinolysis
2) Breaks up the fibrin threads; “Clot buster”

Question 25

List 4 natural clot busters

Answer 25

1) ADH 2) Epinephrine 3) Stress 4) Physical activity

Question 26

Indications for giving thrombolytic agents

Answer 26

**Life-threatening disorders** 1) Acute stroke (i.e. ischemic stroke) 2) Acute MI

Question 27

When would a very low dose of a thrombolytic agent be given?

Answer 27

If a pt has a port-a-cath and part of the catheter clots off

Question 28

Thrombolytics can ONLY be given within ___-___ hrs of onset of Sx

Answer 28

3-4 hrs of onset

Question 29

Thrombolytics cause an extreme risk of ____

Answer 29

Bleeding

Question 30

List 5 drugs considered thrombolytic agents

Answer 30

1) **Tenecteplase (TPA)** 2) Alteplase 3) Reteplase 4) Streptokinase 5) Urokinase

Question 31

List 7 contraindications for giving thrombolytic agents

Answer 31

1) Uncontrolled BP (185/110 or >) 2) Hx of hemorrhagic stroke, aneurysm, or AV malformations 3) Heparin in last 48 hrs 4) Current oral anti-coag 5) DOAC use 6) Surgery within last 3 mos 7) PLT count < 100,000 / µL

Question 32

What is the only way thrombolytic agents can be admin & why?

Answer 32

Through peripheral line so we can compress the site if pt starts bleeding

Question 33

List 4 ways thrombolytics can NOT be given

Answer 33

1) Central line 2) SubQ 3) IM 4) NO ABGs (goes into artery)

Question 34

List 2 things to monitor when giving thrombolytics

Answer 34

1) VS 2) Neuro status → N/V → H/A → changes in LOC

Question 35

What could neuro changes indicate when giving thrombolytics?

Answer 35

Signs of increased ICP (bleeding into the brain) this is the last thing we want

Question 36

How often do you check VS when giving thrombolytics?

Answer 36

**Tx it like a post-op pt** → Start w every 5 min for 30 min; then every 15 min for few hrs; then every 30 min until stable

Question 37

What to do if pt is prescribed a thrombolytic but is complaining of a H/A?

Answer 37

**Possible CVA** → MUST get head CT before admin

Question 38

What type of precautions should pts receiving thrombolytics be put on?

Answer 38

Bleeding precautions

Question 39

List 2 important things to NOT do if pt is receiving thrombolytics

Answer 39

1) NO other anti-coag for at least 24 hrs 2) NO other invasive procedures

Question 40

List 8 signs of excessive bleeding to note if pt received thrombolytic agent

Answer 40

1) Passing blood in urine 2) Passing blood in stool 3) Severe bruising 4) Prolonged nosebleeds (> 5-10 min) 5) Vomiting blood/ coughing up blood (esp. if frank red blood) 6) Sudden severe back pain 7) Difficulty breathing / chest pain 8) Heavy or ↑ bleeding during menses or any other vaginal bleeding in btwn menses

Question 41

What should the nurse do if a pt takes an extra dose of any of the anti-coagulants?

Answer 41

**Biggest thing → check their labs** → Plts → depending on med PT/INR

Question 42

Question 1: How many days do anti-platelets need to be stopped before surgery? A. 1 B. 3 C. 7 D. 10

Answer 42

C. 7

Question 43

Question 2: How many days does it take for Warfarin to become therapeutic? A. 2 days B. 5 days C. 10 days D. 14 days

Answer 43

B. 5 days

Question 44

Question 3: Which of the following lab tests is used to monitor Warfarin therapy? A. aPTT B. CBC C. PT/INR D. Platelets

Answer 44

C. PT/INR

Question 45

Question 4: Which of the following antidotes is used to reverse enoxaparin? A. Acetylcysteine B. Protamine Sulfate C. Andexanet (Andexxa) D. Praxbind

Answer 45

B. Protamine Sulfate

Question 46

Question 5: All of the following are contraindications for tPA therapy (i.e. Alteplase) except? A. Current anticoag use B. Hx of CVA in last 12 mos C. Plt count < 100,000 D. Sx onset in last 5 hrs

Answer 46

D. Sx onset in last 5 hrs

Question 47

Question 6: Which of the following medications is NOT an anti-platelet medication? A. Clopidogrel B. Dabigatran C. Aspirin D. Ticagrelor

Answer 47

B. Dabigatran

Question 48

Question 7: When evaluating a pt for potential administration of a thrombolytic agent, which of the following assessment findings makes the pt ineligible for Tx? A. Social drinking B. Left hemiparesis C. Headache D. Uncontrolled HTN

Answer 48

D. Uncontrolled HTN