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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
Q

Tissue factor pathway inhibitor

A

Inhibits factor Xa (factor that converts prothrombin to thrombin)

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26
Q

Fibrinolytic system

A

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

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27
Q

Goals of coagulation therapy

A

Prevent clot formation, break apart existing clots, increase circulation/perfusion, decrease pain, prevent further tissue damage

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28
Q

Greatest concern of anti-coagulants?

A

Bleeding; side effect of ALL anti-coagulants; bleeding can be internal or external; know sites at risk for bleeding; monitor HgB/HCT/vitals

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29
Q

Anti-coagulants

A

Inhibits the action or formation of the clotting factors; PREVENTS the formation of clots; interferes with the clotting cascade

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30
Q

Anti-platelets

A

Inhibit platelet aggregation and prevent platelet plug formation; best for preventing heart attacks and strokes; remember platelet aggregation occurs before the coagulation cascade

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31
Q

Heparin MOA

A

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)

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32
Q

heparin that only inactivates factor Xa and NOT factor II (thrombin)

A

Low molecular weight heparin enoxaparin (Lovenox)

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33
Q

heparin indications

A

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

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34
Q

Heparin nursing considerations

A

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)

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35
Q

Heparin nursing considerations

A

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)

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36
Q

Heparin onset (SUBQ)

A

20-30 minutes

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37
Q

Heparin onset IV

A

Immediate

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38
Q

Heparin antidote

A

Protamine sulfate

39
Q

Heparin adverse effects

A

Bleeding, hematoma, anemia, thrombocytopenia

40
Q

What to monitor to assess bleeding from heparin

A

Vitals, bruising, petechiae, hematoma, black tarry stools

41
Q

Heparin induced thrombocytopenia (HIT)

A

Adverse effect of heparin where the platelet count is reduced/low due to the heparin; low platelet count paradoxically leads to thrombosis

42
Q

Heparin induced thrombocytopenia nursing considerations

A

Monitor platelet count
Discontinue heparin immediately if platelet <100,000/mm3
Non-heparin anticoagulants can be used as a substitute if anticoagulation needed

43
Q

Heparin labs

A

Anti-Xa or aPTTT

IV heparin dosed based on clotting time labs

44
Q

enoxaparin (Lovenox)

A

Low-molecular weight heparin

45
Q

enoxaparin (Lovenox) indications

A

Blood clot prophylaxis and treatment

46
Q

enoxaparin (Lovenox) adverse effects

A

Bleeding, thrombocytopenia, heparin induced thrombocytopenia (HIT)

47
Q

enoxaparin (Lovenox) nursing considerations

A

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
Q

Protamine

A

enoxaparin antidote

49
Q

enoxaparin (Lovenox) nursing considerations

A

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
Q

Black box warning: enoxaparin

A

Potential spinal hematoma if patient has an epidural catheter

51
Q

Pre-filled syringe of enoxaparin

A

Do not expel the air bubble

52
Q

warfarin (Coumadin) MOA

A

Inhibits vitamin K synthesis which, in turn, inhibits the production of vitamin K-dependent clotting factors: 2 (thrombin), 7, 9, and 10

53
Q

warfarin indications

A

VTE/DVT/PE prevention, thrombotic event for patients with a fib or heart valves, reduce recurrence of TIA/MI

54
Q

warfarin adverse effects

A

Bleeding, lethargy, muscle pain, purple toes

55
Q

Vitamin K (IV)

A

warfarin antidote; if vitamin K does not work give fresh frozen plasma or whole blood

56
Q

warfarin nursing considerations

A

Only given PO once a day usually at 5p (onset: 24 hours; duration: 2-5 days)

57
Q

warfarin nursing considerations

A

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
Q

warfarin lab monitoring

A

PT/INR; must monitor MONTHLY after therapeutic level reached

59
Q

Normal INR without warfarin

60
Q

Therapeutic INR with warfarin

61
Q

Drugs that interact with warfarin

A

amiodarone, fluconazole, erythromycin, metronidazole, sulfonamide antibiotics, cimetidine

62
Q

Foods high in vitamin K to avoid with warfarin

A

Kale, broccoli, brussel sprouts, cabbage, pickles, asparagus, kiwi, okra, green bean, lettuce

63
Q

apixaban (Eliquis), rivaroxaban (Xarelto) MOA

A

Direction inhibition of factor Xa

64
Q

apixaban (Eliquis), rivaroxaban (Xarelto) indications

A

Prevent stroke in a-fib patients, post-op thrombosis prophylaxis, DVT/PE treatment

65
Q

apixaban (Eliquis), rivaroxaban (Xarelto) adverse effects

A

Bleeding, hematoma, dizziness, rash, GI distress, peripheral edema

66
Q

apixaban (Eliquis), rivaroxaban (Xarelto) black box warnings

A

Formation of spinal hematomas if patient has epidural catheter, risk of thrombosis if discontinued abruptly

67
Q

apixaban (Eliquis), rivaroxaban (Xarelto) nursing considerations

A

Drug interactions, no routine monitoring required, do not give with other anticoagulants, monitor liver function (labs: ALT/AST/GGT)

68
Q

apixaban (Eliquis), rivaroxaban (Xarelto): drugs that decrease their effects

A

phenytoin, carbamazepine, rifampin, St. John’s wort

69
Q

apixaban (Eliquis), rivaroxaban (Xarelto): drugs that increase their effects

A

CYP3A4 inhibitors (amiodarone, erythromycin, ketoconazole, HIV meds, diltiazem, verapamil, grapefruit juice)

70
Q

apixaban (Eliquis), rivaroxaban (Xarelto) antidote

A

andexxa recombinant factor Xa, inactivated-zhzo)

71
Q

Anti-platelets

A

aspirin, clopidogrel (Plavix)

72
Q

aspirin MOA

A

Blocks prostaglandin synthesis through the COX enzyme pathway; blocks platelet aggregation; prevents platelets from aggregating

73
Q

aspirin indications

A

Prevent/treat MI, prevent ischemic stroke

74
Q

aspirin side effects

A

Nausea, vomiting, drowsiness, confusion, bleeding

75
Q

aspirin nursing considerations

A

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
Q

aspirin contraindications

A

Thrombocytopenia, active bleeding, blood cancers, traumatic injuries, GI ulcers, vitamin K deficiency, recent hemorrhagic stroke

77
Q

DDAVP (desmopressin)

A

Aspirin antidote

78
Q

clopidogrel (Plavix), ticagrelor (Brilinta) MOA

A

Antiplatelet ADP inhibitor; alters the platelet membrane so that it can no longer receive the signal to aggregate and form a clot

79
Q

clopidogrel (Plavix), ticagrelor (Brilinta) indications

A

Reduce risk of stroke, TIA prophylaxis, post-MI

80
Q

clopidogrel (Plavix), ticagrelor (Brilinta) contraindications

A

Thrombocytopenia, active bleeding, blood cancers, traumatic injuries, GI ulcers, vitamin K deficiency, recent hemorrhagic stroke

81
Q

clopidogrel (Plavix), ticagrelor (Brilinta) side effects

A

Chest pain, edema, flu-like symptoms, abdominal pain, diarrhea, nausea, epistaxis (nose bleed), rash, pruritus

82
Q

clopidogrel (Plavix), ticagrelor (Brilinta)

83
Q

Black box warning for clopidogrel

A

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
Q

Black box warning for ticagrelor

A

Increased risk of bleeding with aspirin > 100 mg

85
Q

Medications that reduce clopidogrel effectiveness

A

Calcium channel blockers, amiodarone, NSAIDS, PPIs

86
Q

clopidogrel (Plavix), ticagrelor (Brilinta) antidote

A

desmopressin (DDAVP) or platelet transfusion

87
Q

argatroban, bivalirudin class

A

Direct thrombin inhibitors

88
Q

argatroban, bivalirudin MOA

A

Inhibits thrombus formation by inhibiting factor IIa (thrombin); prevents activation of fibrin from fibrinogen by inhibiting thrombin

89
Q

argatroban, bivalirudin indications

A

To treat HIT, for patients undergoing procedures (like percutaneous coronary intervention or PCI) who are at high risk for HIT

90
Q

argatroban, bivalirudin adverse effects

91
Q

argatroban, bivalirudin nursing considerations

A

IV only, for argatroban be careful with patients with liver dysfunction, monitor labs (anti-Xa, H&H, platelets)

92
Q

Protamine sulfate

A

heparin antidote
Given IV and SLOWLY
Side effect: hypotension

93
Q

Anticoagulants requiring lab monitoring

A

heparin (anti-Xa and aPTT)

warfarin (PT/INR)

94
Q

High risk anticoagulant requiring second RN check before rate changes/bolus

Pathopharm I (10 decks)

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