Coagulation Modifier Drugs Flashcards
Alteplase (tissue plasminogen activator, t-Pa)
Functional Classification
Thrombolytic enzyme
Alteplase (tissue plasminogen activator t-Pa)
Mechanism of Action
Produces fibrin conversion of plasminogen to plasmin; able to bind to fibrin, convert plasminogen in thrombus to plasmin, which leads to local fibrinolysis, limited systemic proteolysis
Alteplase (tissue plasminogen activator t-Pa)
Uses
Lysis of obstructing thrombi associated with acute MI, ischemic conditions that require thrombolysis (i.e., PE, unclotting arteriovenous shunts, acute ischemic CVA), central venous catheter occlusion (Cathflo)
Alteplase (tissue plasminogen activator, t-Pa)
Contraindications
Active internal bleeding, history of CVA, severe uncontrolled hypertension, intracranial/intraspinal surgery/trauma (within 3 mo), aneurysm, brain tumor, platelets 1.7 or PR >15 sec, arteriovenous malformation, subarachnoid hemorrhage, intracranial hemorrhage, uncontrolled hypertension, seizure at onset of stroke
Alteplase (tissue plasminogen activator, t-Pa)
Side Effect
CV: SINUS BRADYCARDIA, CHOLESTEROL MICROEMBOLIZATION, VENTRICULAR TACHYCARDIA, ACCELERATED IDIOVENTRICULAR RHYTHM, BRADYCARDIA, RECURRENT ISCHEMIC STROKE, hypotension
EENT: OROLINGUAL ANGIOEDEMA
INTEG: urticaria, rash
SYST: GI, GU, INTRACRANIAL, RETROPERITONEAL BLEEDING, Surface Bleeding, ANAPHYLAXIS, fever
Alteplase (tissue plasminogen activator, t-Pa)
Nursing Considerations
ASSESS:
- Treatment is not recommended for patients with acute ischemic stroke >3hr after symptom onset or with minor neurologic deficits or rapidly improving symptoms
- VS, BP, pulse, respirations, neurologic signs, temp at least q4hr; temp >104 degree F (40 degree C) indicates internal bleeding; monitor rhythm closely; ventricular dysrhythmias may occur with hyperfusion; monitor heart, breath sounds, neurologic status, peripheral pulses; assess neurologic status, neurologic change may indicate intracranial bleeding; those with severe neurologic deficit (NIH SS>22) at presentation have increased risk of hemorrhage
- FOR BLEEDING during 1st hour of treatment and 24hr after procedure: hematuria, hematemesis, bleeding from mucous membranes, epistaxis, ecchymosis; guaiac all body fluids, stools; do not use 150mg or more total dose because intracranial bleeding may occur
- HYPERSENSITIVITY: fever, rash, itching, chills, facial swelling, dyspnea, notify prescriber immediately; stop product, keep resuscitative equipment nearby; mild reaction may be treated with antihistamines
- Previous allergic reactions or streptococcal infection; alteplase may be less effective
- BLOOD STUDIES (Hct, PLATELETS, PTT, PT, TT, APTT) BEFORE STARTING THERAPY; PT or APTT MUST BE LESS THAN 2x CONTROL BEFORE STARTING THERAPY TT OR PT q3-4hr DURING TREATMENT
- MI: ECG CONTINUOUSLY, CARDIAC ENZYMES, RADIONUCLIDE MYOCARDIAL SCANNING/CORONARY ANGIOGRAPHY; CHEST PAIN INTENSITY, CHARACTER; MONITOR THOSE WITH MAJOR EARLY INFARCT SIGNS ON CT SCAN WITH SUBSTANTIAL EDEMA, MASS EFFECT, MIDLINE SHIFT
- PE: PULSE, BP, ABGs, RATE/RHYTHM of RESPIRATIONS
- OCCLUSION: have patient exhale then hold breath when connecting/disconnecting syringe to prevent air embolism
- CHOLESTEROL EMBOLISM: purple toe syndrome, acute renal failure, gangrenous digits, hypertension, livedo reticularis, pancreatitis, MI, cerebral infarction, spinal cord infarction, retinal artery occlusion, bowel infarction, rhabdomyolysis
PERFORM/PROVIDE:
- Avoidance of invasive procedures, inj, rectal temp
- Pressure for 30 sec to minor bleeding sites; 30 min to sites of atrial puncture followed by pressure dressing; inform prescriber if this does not attain hemostasis; apply pressure dressing
Aspirin
Functional Classification
Nonopioid analgesic, non-steroidal anti-inflammatory, antipyretic, antiplatelet
Aspirin
Chemical Classification
Salicylate
Aspirin
Mechanism of Action
Blocks pain impulses in CNS, reduces inflammation by inhibition of prostaglandin synthesis; antipyretic action results from vasodilation of peripheral vessels; decreases platelet aggregation
Aspirin
Uses
Mild to moderate pain or fever including RA, osteoarthritis, thromboembolic disorders; TIAs, rheumatic fever, post MI, prophylaxis of MI, ischemic stroke, angina, acute MI
Aspirin
Contraindications
Pregnancy (D) 3rd trimester, breastfeeding, children <12yr, children with flulike symptoms, hypersensitivity to salicylates, tartrazine (FDC yellow dye #5), GI bleeding disorders, vit K deficiency, peptic ulcer, acute bronchospasm, agranulocytosis, increased intracranial pressure intracranial bleeding, nasal polyps, urticaria
Aspirin
Side Effects
CNS: stimulation, drowsiness, dizziness, confusion, SEIZURES, headache, flushing, hallucinations, COMA
CV: rapid pulse, pulmonary edema
EENT: tinnitus, hearing loss
ENDO: hypoglycemia, hyponatremia, hypokalemia
GI: Nausea, Vomiting, GI BLEEDING, diarrhea, heartburn, anorexia, HEPATITIS
HEMA: THROMBOCYTOPENIA, AGRANULOCYTOSIS, LEUKOPENIA, NEUTROPENIA, HEMOLYTIC ANEMIA, increased PT, aPTT, bleeding time
INTEG: Rash, urticaria, bruising
RESP: wheezing, hyperpnea
SYST: REYE’S SYNDROME (CHILDREN), ANAPHYLAXIS, LARYNGEAL EDEMA
Aspirin
Nursing Considerations
ASSESS:
- PAIN: character, location, intensity; ROM before and 1 hr after administration
- FEVER: temp before and 1 hr after administration
- Hepatic studies: AST, ALT, bilirubin, creatinine if patient is receiving long-term therapy
- Renal studies: BUN, urine creatinine; I&O ratio; decreasing output may indicate renal failure (long-term therapy)
- Blood studies: CBC, Hct, Hgb, PT if patient is receiving long-term therapy
- HEPATOTOXICITY: dark urine, clay-colored stools, yellowing of skin, sclera, itching, abdominal pain, fever, diarrhea if patient is receiving long-term therapy
- ALLERGIC REACTIONS: rash, urticaria; if these occur, product may have to be discontinued; patients with asthma, nasal polyps, allergies: severe allergic reaction may occur
- OTOTOXICITY: tinnitus, ringing, roaring in ears; audiometric testing needed before, after long-term therapy
- SALICYLATE LEVEL: therapeutic level 150-300mcg/ml for chronic inflammation
- Edema in feet, ankles, legs
- Product history; many product interactions
Aspirin
Overdose Treatment
Lavage, activated charcoal, monitor electrolytes, VS
Clopidogrel (Plavix)
Functional Classification
Platelet aggregation inhibitor
Clopidogrel (Plavix)
Chemical Classification
Thienopyridine derivative
Clopidogrel (Plavix)
Mechanism of Action
Inhibits ADP-induced platelet aggregation
Clopidogrel (Plavix)
Uses
Reducing the risk of stroke, MI, vascular death, peripheral arterial disease in high-risk patients, acute coronary syndrome, transient ischemic attack (TIA), unstable angina
Clopidogrel (Plavix)
Contraindications
hypersensitivity, active bleeding
Clopidogrel (Plavix)
Side Effects
CNS: headache, dizziness, depression, syncope, hypesthesia, neuralgia
CV: edema, hypertension, chest pain
GI: nausea, vomiting, diarrhea, constipation, GI discomfort, GI BLEEDING, PANCREATITIS, HEPATIC FAILURE
GU: GLOMERULONEPHRITIS
HEMA: epistaxis, purpura, BLEEDING, NEUTROPENIA, APLASTIC ANEMIA, AGRANULOCYTOSIS, THROMBOTIC THROMBOCYTOPENIC PURPURA
INTEG: rashm pruritus, ANAPHYLAXIS
MISC: UTI, hypercholesterolemia, chest pain, fatigue, INTRACRANIAL HEMORRHAGE, TOXIC EPIDERMAL NECROLYSIS, STEVENS-JOHNSON SYNDROME, flulike syndrome
MS: arthralgia, back pain
RESP: upper respiratory tract infection, dyspnea, rhinitis, bronchitis, cough, BRONCHOSPASM
Clopidogrel (Plavix)
Nursing Considerations
ASSESS:
- THROMBOTIC/ THROMBOCYTIC PURPURA, fever, thrombocytopenia, neurolytic anemia
- Symptoms of stroke, MI during treatment
- Hepatic studies: AST, ALT, bilirubin, creatinine (long-term therapy)
- Blood studies: CBC, differential, Hct, Hgb, PT, cholesterol (long-term therapy)
Dabigatran (Pradaxa)
Functional Classification
Anticoagulant-thrombin inhibitor
Dabigatran (Pradaxa)
Mechanism of Action
Direct thrombin inhibitor that inhibits both free and clot-bound thrombin, prevents thrombin-induced platelet aggregation and thrombus formation by preventing conversion of fibrinogen to fibrin
Dabigatran (Pradaxa)
Uses
Stroke/systemic embolism prophylaxis with nonvalvular atrial fibrillation
Dabigatran (Pradaxa)
Contraindications
Hypersensitivity, bleeding
Dabigatran (Pradaxa)
Side Effects
CNS: INTRACRANIAL BLEEDING CV: MYOCARDIAL INFARCTION GI: abdominal pain, dyspepsia, peptic ulcer, esophagitis, GERD, gastritis, GI BLEEDING HEMA: BLEEDING INTEG: rash, pruritus SYST: ANAPHYLAXIS (RARE)
Dabigatran (Pradaxa)
Nursing Considerations
ASSESS:
- BLEEDING: blood in urine or emesis, dark tarry stools, lower back pain; caution with arterial/venous punctures, catheters, NG tubes; monitor vital signs frequently; elderly more prone to serious bleeding
- THROMBOSIS/MI/EMBOLI: swelling, pain, redness, difficulty breathing, chest pain, tachypnea, cough, coughing up blood, cyanosis
- POST-THROMBOTIC SYNDROME: pain, heaviness, itching/tingling, swelling, varicose veins, brownish/reddish skin discoloration, ulcers; use of ambulation, compression stockings, adequate anticoagulation can prevent this syndrome
- Serum Creatinine
Enoxaparin (Lovenox)
Functional Classification
anticoagulant, antithrombotic
Enoxaparin (Lovenox)
Chemical Classification
Low-molecular-weight heparin (LMWH)
Enoxaparin (Lovenox)
Mechanism of Action
Binds to antithrombin III inactivating factors Xa/IIa, thereby resulting in a higher ratio of anti-factor Xa to IIa
Enoxaparin (Lovenox)
Uses
Prevention of DVT (inpatient or outpatinet), PE (inpatient in hip and knee replacement, abdominal surgery at risk for thrombosis; unstable angina/non-Q-wave MI
Enoxaparin (Lovenox)
Contraindications
Hypersensitivity to this product, benzyl alcohol, heparin, pork; active major bleeding, hemophilia, leukemia with bleeding, peptic ulcer disease, thrombocytopenic purpura, heparin-induced thrombocytopenia
Enoxaparin (Lovenox)
Side Effects
CNS: fever, confusion GI: nausea HEMA: HEMORRHAGE, HYPOCHROMIC ANEMIA, THROMBOCYTOPENIA, BLEEDING INTEG: ecchymosis, inj site hematoma META: hyperkalemia in renal failure SYST: edema, peripheral edema
Enoxaparin (Lovenox)
Nursing Considerations
ASSESS:
- Blood studies (Hct/Hgb, CBC, coagulation studies, platelets, occult blood in stools), anti-factor Xa (should be checked 4 hr after inj); thrombocytopenia may occur
- Renal studies: BUN/creatinine baseline and periodically
- BLEEDING: gums, petechiae, ecchymosis, black tarry stools, hematuria; notify prescriber
- NEUROLOGIC SYMPTOMS in patients who have received spinal anesthesia
Enoxaparin (Lovenox)
Overdose Treatment
Protamine SO4 1% sol; dose should equal dose of enoxaparin
Eptfibatide
Functional Classification
Antiplatelet agent
Eptifibatide
Chemical Classification
Glycoprotein IIb/IIIa inhibitor
Eptifibatide
Mechanism of Action
Platelet glycoprotein antagonist; this agent reversibly prevents fibrinogen, von Willebrand’s factor from binding to the glycoprotein IIb/IIIa receptor, thus inhibiting platelet aggregation
Eptifibatide
Uses
Acute coronary syndrome including those undergoing percutaneous coronary intervention (PCI)
Eptifibatide
Contraindications
Hypersensitivity, active internal bleeding; history of bleeding, stroke within 2 yr; major surgery with severe trauma, severe hypertension, history of intracranial bleeding, current or planned use of another parenteral GP IIb/IIIa inhibitor, dependence on renal dialysis, coagulopathy, AV malformation, aneurysm
Eptifibatide
Side Effects
CV: STROKE, hypotension
GU: hematuria
HEMA: THROMBOCYTOPENIA
SYST: BLEEDING, ANAPHYLAXIS
Eptifibatide
Nursing Considerations
ASSESS:
- THROMBOCYTOPENIA: platelets, Hgb, Hct, creatinine, PT/APTT baseline INR within 6 hr of loading dose, daily thereafter, patients undergoing PCI should have ACT monitored; maintain APTT 50-70 sec unless PCI to be performed; during PCI, ACT should be 200-300 sec; if platelets drop <100,000mm3, obtain additional platelet counts; if thrombocytopenia is confirmed, discontinue product; draw Hct, Hgb, serum creatinine
- BLEEDING: gums, bruising, ecchymosis, petechiae; from GI, GU tract, cardiac cath sites, IM inj sites
PERFORM/PROVIDE:
- Discontinue product prior to CABG
- All medications PO if possible; avoid IM inj, all catheters
Fondaparinux (Arixtra)
Functional Classification
Anticoagulant, antithrombotic
Fondaparinux (Arixtra)
Chemical Classification
Synthetic, selective factor Xa inhibitor
Fondaparinux (Arixtra)
Mechanism of Action
Acts by antithrombin III (ATIII)-mediated selective inhibition of factor Xa; neutralization of factor Xa interrupts blood coagulation and inhibits thrombin formation; does not inactivate thrombin (activated factor II) or affect platelets
Fondaparinux (Arixtra)
Uses
Prevention/treatment of deep venous thrombosis, PE in hip and knee replacement, hip fracture or abdominal surgery
Fondaparinux (Arixtra)
Contraindications
Hypersensitivity to this product; hemophilia, leukemia with bleeding, peptic ulcer disease, hemorrhagic stroke, surgery, thrombocytopenic purpura, weight <30 ml/min), active major bleeding, bacterial endocarditis
Fondaparinux (Arixtra)
Side Effects
CNS: Fever, confusion, headache, dizziness, Insomnia
GI: Nausea, Vomiting, diarrhea, dyspepsia, Constipation, increased AST, ALT
GU: UTI, urinary retention
HEMA: Anemia, minor bleeding, purpura, hematoma, THROMBOCYTOPENIA, MAJOR BLEEDING (INTRACRANIAL, CEREBRAL, RETROPERITONEAL HEMORRHAGE), POSTOPERATIVE HEMORRHAGE, HEPARIN-INDUCED THROMBOCYTOPENIA
INTEG: increased wound drainage, bullous eruption, local reaction-Rash, pruritus, inj site bleeding
META: hypokalemia
OTHER: hypotension, pain, Edema
Fondaparinux (Arixtra)
Nursing Considerations
ASSESS:
- Monitor patients who have received epidural/spinal anesthesia or lumbar puncture for neurological impairment
- Blood studies (CBC, anti-Xa, Hgb/Hct, prothrombin time, platelets, occult blood in stools), thrombocytopenia may occur; if platelets <100,000/mm3, treatment should be discontinued; renal studies: BUN, creatinine
- For bleeding: gums, petechiae, ecchymosis, black tarry stools, hematuria; decreased Hct, notify prescriber
- For risk of hemorrhage if coadministering with other products that may cause bleeding
- For hypersensitivity: rash, fever, chills; notify prescriber
Heparin
Functional Classification
Anticoagulant, Antithrombotic
Heparin
Mechanism of Action
Prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing inhibitory effects of antithrombin III
Heparin
Uses
Prevention of deep venous thrombosis, PE, MI, open heart surgery, disseminated intravascular clotting syndrome, atrial fibrillation with emoblization, as an anticoagulant in transfusion and dialysis procedures, prevention of DVT/PE, to maintain patency of indwelling venipuncture devices; diagnosis, treatment of DIC
Heparin
Contraindications
hypersensitivity, hemophilia, leukemia with bleeding, peptic ulcer disease, severe thrombocytopenic purpura, severe renal/hepatic disease, blood dyscrasias, severe hypertension, subacute bacterial endocarditis, acute nephritis; benzyl alcohol products in neonates/infants/pregnancy/lactation
Heparin
Side Effects
CNS: Fever, chills, headache
GU: HEMATURIA
HEMA: HEMORRHAGE, THROMBOCYTOPENIA, ANEMIA
INTEG: Rash, dermatitis, urticaria, pruritus, delayed transient alopecia, hematoma, cutaneous necrosis (SUBCUT)
META: hyperkalemia, hypoaldosteronism
SYST: ANAPHYLAXIS
Heparin
Nursing Considerations
ASSESS:
- Bleeding, hemorrhage: gums, petechiae, ecchymosis, black tarry stools, hematuria, epistaxis, decrease in Hct, BP; HIT may occur after product discontinuation
- Blood studies (Hct, occult blood in stools) q3mo
- Partial prothrombin time, which should be 1.5-2.5x control; for continuous IV inf, check aPTT baseline 6hr after initiation and 6hr after any dose change; use aPTT for dosing adjustments; after therapeutic aPTT has been measured 2x, check aPTT daily
- Platelet count q2-3days; thrombocytopenia may occur on 4th day of treatment
- HYPERSENSITIVITY: rash, chills, fever, itching; report to prescriber
Heparin
Overdose Treatment
Withdraw product, protamine 1mg protamine/100 units heparin
Warfarin (Coumadin)
Functional Classification
Anticoagulant
Warfarin (Coumadin)
Chemical Classification
Coumarin derivative
Warfarin (Coumadin)
Mechanism of Action
Interferes with blood clotting by indirect means; depresses hepatic synthesis of vit-K-dependent coagulation factors (II, VII, IX, X)
Warfarin (Coumadin)
Uses
Antiphospholipid antibody syndrome, arterial thromboembolism prophylaxis, DVT, MI prophylaxis, after MI, stroke prophylaxis, thrombosis prophylaxis
Warfarin (Coumadin)
Contraindications
Pregnancy (X), breastfeeding, hypersensitivity, hemophilia, leukemia with bleeding, peptic ulcer disease, thrombocytopenic purpura, hepatic disease (severe), malignant hypertension, subacute bacterial endocarditis, acute nephritis, blood dyscrasias, eclampsia, preeclampsia, hemorrhagic tendencies; surgery of CNS, eye; traumatic surgery with large open surface, bleeding tendencies of GI/GU/respiratory tract, stroke, aneurysms, pericardial effusion, spinal puncture, major regional/lumbar anesthesia
Bleeding
Warfarin (Coumadin)
Side Effects
CNS: Fever, dizziness, fatigue, headache, lethargy
CV: angina, chest pain, edema, hypotension, syncope
GI: Diarrhea, nausea, vomiting, anorexia, stomatitis, cramps, HEPATITIS, cholestatic jaundice
GU: HEMATURIA
HEMA: HEMORRHAGE, AGRANULOCYTOSIS, LEUKOPENIA, EOSINOPHILIA, anemia, ecchymosis, petechiae
INTEG: Rash, dermatitis, urticaria, alopecia, pruritus
MISC: epistaxis, hemoptysis, mouth ulcers, taste disturbances, priapism, dyspnea
MS: bone fractures
SYST: ANAPHYLAXIS, coma, cholesterol, microembolism, EXFOLIATIVE DERMATITIS, PURPLE TOE SYNDROME
Warfarin (Coumadin)
Nursing Considerations
ASSESS:
- Blood studies (Hct, PT, platelets, occult blood in stools) q3mo; INR: in hospital daily after 2nd or 3rd dose; when in therapeutic range for 2 consecutive days, monitor 2-3x wk for 1-2wk then less frequently, depending on stability of INR results; Outpatient: monitor every few days until stable doses then periodically thereafter, depending on stability of INR results
- Bleeding gums, petechiae, ecchymosis, black tarry stools, hematuria; fatal hemorrhage can occur
- Fever, skin rash, urticaria
Warfarin (Coumadin)
Overdose Treatment
Administer vit K
Alteplase (tissue plasminogen activator, t-Pa)
Chemical Classification
Tissue plasminogen activator (TPA)
