Coagulation Modifiers Flashcards
What are the steps in the
Blood Vessel Injury Healing Process?
Blood coagulation/clotting process
- Local vasoconstriction to seal off small injury (makes surface area of injury smaller)
- Platelet aggregation forms a platelet plug
- Hageman factor is activated (clotting factor)
- Intrinsic pathway (inside the vessel) converts prothrombin to thrombin to seal system
- Extrinsic pathway (outside the vessel) clots the blood that has leaked out of the vascular system
Lifespan Considerations for Coagulation Modifiers
In Children
- Most common: Antihemophiliac agents for children with hemophilia
- Injury and safety precautions: no contact sports, soft toothbrushes, no flossing
- Teach what to do if bleeding begins: constant firm pressure, call provider
- Drugs are based on weight and age
- Low-molecular weight heparins preferred
- Monitor closely
Lifespan Considerations for Coagulation Modifiers
In Adults
- Injury prevention: soft bristled toothbrush, no flossing, electric razor, no contact sports
- What to do if bleeding begins: constant firm pressure, call provider
- Caution with other meds due to interactions
- Medic Alert bracelet
- Extreme caution in pregnancy and lactation; choose alternate feeding method
- Periodic blood tests (less testing with newer meds)
- Monitor for signs of bleeding
Lifespan Considerations for Coagulation Modifiers
In Older Adults
- Look closely for drug interactions
- Impaired liver and kidney function: run liver and kidney function tests
- Start low, go slow
- Safety and Injury Prevention: Fall prevention, electric razors, soft toothbrush, no flossing
- Careful monitoring with additions, deletions, or changes to medication regimen (including dose changes)
Antiplatelet Agents
Mechanism of Action
Alters the formation of the platelet plug
* Blocks the receptor site on the platelet membrane which prevents platelets from sticking together and clumping (aggregating)
Antiplatelet Agents
Indications
- CV diseases that are prone to clogged vessels
- Keep surgical grafts open/patent
- Prevent cerebrovascular occlusion (strokes and TIAs)
- Adjunct to thrombolytic therapy after MI and to prevent another MI
- Aspirin: Antiinflammatory, antipyretic, analgesic
Antiplatelet Agents
Drug Names
Aspirin
Clopidogrel
Ticagrelor
Antiplatelet Agents
Contraindications
Absolute:
* Allergy
Cautions:
* Bleeding disorder (higher risk of bleeding)
* Recent surgery
* Closed-head injury
Antiplatelet Agents
Adverse Effects
🩸 BLEEDING: major effect! Monitor for black stools, bruising, petechiae, epistaxis
🧠 CNS: Headache, dizziness, weakness
🤢 GI: Nausea
Antiplatelet Agents
Drug Interactions
- Another drug that affects blood clotting
- Herbal supplements
Antiplatelet Agents
Assessment
History:
* Allergy, pregnancy, lactation, bleeding disorders, recent surgery, closed head injury
Physical:
* vitals, skin, CNS, perfusion
Labs:
* CBC
* Clotting studies
Antiplatelet Agents
Nursing Diagnoses/Conclusions
- Injury Risk (r/t CNS and bleeding effects)
- Impaired comfort (r/t GI effects)
- Knowledge deficit
Antiplatelet Agents
Implementation/Patient Teaching
- Safety precautions: electric razors, soft toothbrush, no flossing, no contact sports
- Small, frequent meals for GI effects
- Increased precautions for bleeding during invasive procedures
- Mark the chart of any patient receiving this drug
- Ice and pressure can help stop bleeding
Anticoagulant Agents
Mechanism of Action
- Interferes with the normal cascade of events involved in the clotting process
Anticoagulant Agents
Indications
Prevent new clot formation
* Atrial fibrilation
* Bed Bound
* Certain surgical patients
Prevent existing clots from getting bigger
* Deep vein thrombosis (DVT)
* Pulmonary Embolism (PE)
* Myocardial Infarction (MI)
Genetic disorders
(missing part of the clotting cascade)
Anticoagulant Agents
Drug Names
Warfarin
Heparin
“-xaban”
Rivaroxaban
Apixaban
Dabigatran
Anticoagulant Agents
Contraindications
Absolute:
* Allergy
Relative:
* conditions that would be worsened if bleeding occurs (recent trauma, GI ulcers, spinal puncture)
Cautions:
* Renal & hepatic disorders
Anticoagulant Agents
Adverse Effects
🩸 Excessive bleeding
* priapism
* Increased menstrual flow
* Black tarry stools
* Epistaxis
Heparin-induced thrombocytopenia (HIT): “allergy” to heparin - can never have heparin again
Anticoagulant Agents
Drug Interactions
Any drug that affects bleeding
* NSAIDs/Salicylates
* Antiplatelets
* Thrombolytics
Herbal Supplements (can increase bleeding)
NUMBER of many drug interactions Check drug guide
Anticoagulant Agents
Assessment
History:
* Allergy, pregnancy, lactation
* Conditions that would be worsened if bleeding occurs
Physical:
* Vitals, heart sounds, lung sounds, skin, CNS, orientation, perfusion
Labs:
* CBC (Hgb, Hct)
* Clotting studies
* Renal and hepatic function tests
* guaiac test for blood in stool
Anticoagulant Agents
Nursing Diagnoses/Conclusions
- Injury risk (r/t bleeding)
- Altered tissue perfusion (r/t blood loss)
- Altered cardiac output (r/t blood loss)
- Disturbed body image (r/t skin changes… bruising)
- Knowledge deficit
Anticoagulant Agents
Implementation/Patient Teaching
- Check lab values during treatment
- Monitor for signs of blood loss (epistaxis, petechiae, neuro status for brain bleed)
- Establish safety precautions: electric razor, soft toothbrush, no contact sports
- Increase bleeding precautions during invasive procedures
- Mark chart of patient receiving this drug
- Maintain antidotes on standby:
Warfarin: Vitamin K
Heparin: Protamine sulfate - Monitor patient carefully when change in medication
- Ice, pressure for bleeding
- Wear medic alert bracelet
- Keep follow up appts.
- Teach patient to report bleeding to provider
Therapeutic value to watch with Warfarin
INR: 2-3
(higher than a normal value because of treatment)
Therapeutic values to watch with Heparin
- aPTT 60-80
- anti-Xa (anti-10A)
Low-Molecular-Weight Heparins (LMWH)
Mechanism of action
- Inhibit thrombus and clot formation by blocking factors Xa and IIa (10a and 2a)
- Do NOT greatly affect thrombin, clotting, or prothrombin times = fewer systemic adverse effects
- Block angiogenesis, the process that allows cancer cells to develop new blood vessels
Longer half-life than other anticoagulants = longer lasting effects
Low-Molecular-Weight Heparins (LMWH)
Indications
- Specific uses in the prevention of clots and emboli formation after certain surgeries or while on bed rest
Low-Molecular-Weight Heparins (LMWH)
Drug Names
Dalteparin
Enoxaparin
Thrombolytic Agents (AKA: Clot Busters)
Mechanism of Action
Activates plasminogen to plasmin, which in turn breaks down fibrin threads in a clot to dissolve it
Thrombolytic Agents (AKA: Clot Busters)
Indications
- Acute MI
- Pulmonary emboli
- Ischemic stroke
Thrombolytic Agents (AKA: Clot Busters)
Drug Names
“-teplase”
Alteplase
Reteplase
Tenecteplase
Thrombolytic Agents (AKA: Clot Busters)
Contraindications
Absolute:
* Allergy
Cautions:
* Any condition worsened by dissolution of clots (recent surgery, trauma, recent stroke, GI bleed, recent childbirth)
* Liver disease
Thrombolytic Agents (AKA: Clot Busters)
Adverse Effects
🩸 Bleeding
Thrombolytic Agents (AKA: Clot Busters)
Drug Interactions
- Anticoagulants
- Antiplatelets
(increased bleeding)
Thrombolytic Agents (AKA: Clot Busters)
Assessment
History:
* Allergy, pregnancy, lactation
* Conditions that would be worsened if bleeding occurs
Physical:
* Baseline: vitals, heart sounds, lung sounds, skin, CNS, perfusion
Labs:
* clotting studies
* Renal and hepatic function tests
* CBC
* guaiac stool test
Thrombolytic Agents (AKA: Clot Busters)
Implementation/Patient Teaching
- Discontinue heparin if it is being given before administering a thrombolytic agent
- Check lab values
- Monitor for signs of blood loss (epistaxis, blood in stool, petechiae, surgical sites, IV sites)
- Institute treatment within 6 hours after onset of symptoms of acute MI
- Arrange to type and cross-match blood to have on hand
- Monitor cardiac rhythm continuously if the drug is being given for acute MI
- Increase bleeding precautions during invasive procedures
- Mark chart if patient is receiving this drug
- Ideally wait 24 hours after thrombolytic admin to do any type of invasive procedure
Hemorrheologic Agent: Pentoxifylline
Mechanism of Action
- Xanthine that decreases platelet aggregation and decreases fibrinogen concentration in the blood
Helps blood flow in compromised blood vessels
Hemorrheologic Agent: Pentoxifylline
Indication
Intermittent claudication
Hemorrheologic Agent: Pentoxifylline
Adverse Effects
💓 Many CV stimulatory effects
* racing heart/palpitations
* anxiety
* flushing
* angina
What are bleeding disorders treated with Clotting Factors?
- Hemophilia
- Liver Disease
- Bone Marrow Disorders
Antihemophilics
Mechanism of Action
- Replace clotting factors that are either genetically missing or low in a particular type of hemophilia
Antihemophilics
Indications
- Prevent blood loss from injury or surgery and to treat bleeding disorders
Antihemophilics
Drug Names
“factor”
All medications in this category have the word factor in their name
Antihemophilics
Contraindications
Absolute:
* Anaphylactic Allergy
Antihemophilics
Adverse Effects
Involve risks associated with the use of blood products
* Infections such as hepatitis
* Headache, flushing, fever, chills, lethargy
* Stinging, itching, burning at the site of injection
Antihemophilics
Assessment
History:
* Allergy, pregnancy, lactation
Physical:
* Skin, heart and lung sounds, CNS, perfusion, vital signs
Labs:
* clotting studies
Antihemophilics
Nursing Diagnoses/Conclusions
- Altered tissue perfusion (r/t changes in coagulation)
- Impaired comfort (r/t CNS, skin, or injection site)
- Anxiety or fear
- Knowledge deficit
Antihemophilics
Implementation/Patient Teaching
- Ensure the appropriate clotting factor is being used for the patient
- Administered by IV route ONLY
- Check lab values (clotting studies)
- Monitor pt for any sign of thrombosis (clots)
- Decrease infusion rate if headache, chills, fever, or tingling occurs
- Arrange to type and cross-match blood and have onhand
- Mark the chart of any patient receiving this drug
Hemostatic Agents
Mechanism of Action
Systemic
Prevent systemic clot breakdown to prevent blood loss
Topical
For surface injuries involving so much damage to the small vessels in the area that clotting does not occur and blood is slowly and continually lost
Hemostatic Agents
Indication
Hyperfibrinolysis = hyper clot breakdown
Hemostatic Agents
Drug Names
Systemic
Aminocaproic Acid (oral or IV)
Topical
Absorbable gelatin
collagen
fibrin
thrombin
(sponges, sprays, topical)
Hemostatic Agents
Contraindications
Absolute:
Systemic:
* Allergy
* Acute disseminated intravascular coagulation (DIC) = clotting and bleeding at the same time
Topical:
* Allergy
Cautions:
Systemic:
* Cardiac, renal, or hepatic disease
Topical:
* NONE
Hemostatic Agents
Adverse Effects
Systemic
* Excessive clotting, CNS, GI, weakness, fatigue, malaise, muscle pain
Topical
* Infection with sponges
Hemostatic Agents
Drug Interactions
Systemic:
* Heparin, oral contraceptives/estrogen
Topical:
* NONE
Hemostatic Agents
Assessment
History:
* Allergy, pregnancy, lactation, cardiac, renal or hepatic dysfunction
Physical:
* skin, heart and lung sounds, CNS, perfusion, abdominal assessment, vital signs
Labs:
* clotting studies, renal function tests, hepatic function tests
Hemostatic Agents
Nursing Diagnoses/Conclusions
- Altered sensory perception (r/t CNS effects)
- Impaired Comfort (r/t GI, CNS, muscle effects)
- Injury Risk (r/t CNS, blood clotting)
- Knowledge deficit
Antidote for Warfarin
Vitamin K
Antidote for He🅿️arin
🅿️rotamine sulfate
