Critically Ill & Anticoagulantion Flashcards by Jade Ring

Findings:

Warmth, redness, pain, inflammation, and induration along course of vein. Appears as palpable cord, Edema Rare

Induration of muscle, venous distention, edema, deep reddish color

Superficial vein Thrombosis/ Venous Thrombosis

Warmth, redness, pain, inflammation, and induration along course of vein. Appears as palpable cord, Edema Rare (Superficial vein Thrombosis)

Induration of muscle, venous distention, edema, deep reddish color (Venous Thrombosis)

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DVT happen 3 ways

Venous statis: Not moving

Endothelial damage: Release clotting factors / Activation of platelets

Blood hypercoagulability: imbalance in clotting mechanism, increase in fibrin production

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Biggest concern of DVT

Pulmonary Embolism

Obstruction of Pulmonary Vessel by particulate matter, most often a clot

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Fat & air emboli

Amniotic fluid

Tumors

Can all cause

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Long bone being broken

Femur, Pelvis, Sternum

Can cause

Fat emboli -> PE

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How can an air emboli happen

Improper IV med administration

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Thrombus from a DVT breaks loose & lodges in a pulmonary artery

Describes

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Audible S³ or S⁴ heart sound
Petechiae
Hemoptysis
Syncope
Tachy
Hypotension
SUDDEN

Manifestaciones of PE

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ABG

Describe

Start: Respitory Alkalosis

End: Metabolic Acidosis

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V/Q Scan does….

Illustrates how well they are perfusion & ventilation

Diagnose a PE
It measures the airflow (ventilation) and blood flow (perfusion) in your lungs.

You breathe in and are injected with radioactive material while a provider takes pictures of your lungs

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Do you want the clot to break apart in DTV

No this will cause PE

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How does Heparin disolve a DVT

It Doesn’t

Stops it from getting bigger

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First thing to do in drug therapy for PE

Clotting study drawn as a baseline

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5000 - 10000 U Heparin given via IVP
followed by a drip

PTT: Kept between ____

50 - 70 seconds

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Coumadin (Warfarin) work…

Warfarin blocks enzyme that uses vitamin K to make clotting factors.

Ability of blood to clot is reduced.

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What is PT

Normal

Normal on anticoagulants

Prothrombin time (PT)
Time it takes for (plasma) in blood to clot.

Normal 10–13 seconds

Warfarin (Coumadin) multiply by 1.5 - 2.5

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Normally an INR of _____ is normal

Warfarin INR range of_____

<1.1

Warfarin 2 - 3

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A normal partial thromboplastin time
(PTT) is _____

Heparin PTT

25–35 seconds

50 - 70 seconds

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INR stands for…

International Normalized Ratio

How long it takes blood to clot

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Measures how long it takes for a blood clot to form based on a protein called prothrombin. PT detects abnormalities in the extrinsic and common pathways of the coagulation cascade.

Measures how blood clots within a blood vessel (intrinsic pathway). PTT detects abnormalities in the intrinsic pathway

PT or PTT

PT
Measures how long it takes for a blood clot to form based on a protein called prothrombin. PT detects abnormalities in the extrinsic and common pathways of the coagulation cascade.

PTT
Measures how blood clots within a blood vessel (intrinsic pathway). PTT detects abnormalities in the intrinsic pathway

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Which type of blood clot is likely to cause a stroke

Left Atrium of the Heart

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How to handle clot once it is formed

Start (this med)

Then

Bridge (this med)

Heprin (DVT & PE) / (MI & Unstable Angina)

Bridge (Coumadin aka Warfarin)

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When treating blood clots

First give (Heparin)

Bridge with (Coumadin aka Warfarin)

(Coumadin aka Warfarin) is used to treat this condition

Coumadin aka Warfarin treats Atrial Fibrillation

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Epidural/spinal med administración
Uncontrolled bleeding
Severe thrombocytopenia / HIT (Heparin-Induced Thrombocytopenia)
Hemorrhagic Stroke

Are what?

Contraindications for Heparin

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4 contraindications for Unfractionated heparin

Epidural/spinal med administración Uncontrolled bleeding Severe thrombocytopenia / HIT (Heparin-Induced Thrombocytopenia) Hemorrhagic Stroke

Dosing heparin ___ units / kg/ IV bolus Then ___ units/ kg/hr adjusted by PTT results

80 U / kg / IV bolus Then 18 U/kg/ hr adjusted by PTT results

Labs PTT / INR Baseline Then PTT __ hrs post-bolus or __ hrs post-rate change

PTT 8 hrs post-bolus or 6 hrs post-rate change

Once PTT is stabilized How often

Daily

Dosing of HEPARIN CBC x __ days

PT (INR) associated with Coumadin us thus pathway... APTT associated with heparin is associated with...

PT (Extrinsic) Inury outside blood vessel APTT (Intrinsic) Injury inside blood vessel

Dosing of heparin Treatment ____ days with/without starting warfarin therapy

3 - 5 days

Heparin Rapid onset Half-life...

1.5 hrs

Protamine Sulfate is....

Reversal agent for heparin

Heparin doesn't lyses clots How is it adminster

IV or SQ

What is the Prophylaxis amount of heparin How often check PTT in prophylactic treatment?

5000 - 10000 U, SQ every 8 - 12 hrs No need to check PTT

IV heparin always,always requires ...

IV infusion pump Guardrail medication

What is required for starting a new bag or changing rate on heparin (Safety)

2nd RN

Low molecular weight heparin aka

Enoxaparin (Lovenox)

Half life of Low molecular weight heparin LMWH Aka enoxaparin (Lovenox)

3-6 hrs

Enoxaparin (Lovenox) LMWH Indications (3)

Treatment VTE DVT Prophylaxis Unstable Angina

Dosing of LMWH aka Enoxaparin (Lovenox) 1mg/ kg every 12 hrs for.... 40 mg. SQ every 24 hrs for.... 30 mg SQ every 24 hrs for....

1mg/ kg every 12 hrs for treatment 40 mg. SQ every 24 hrs for Prophylaxis 30 mg SQ every 24 hrs if CrCl <30 ml. min Creatine Clearance

Coumadin = Vitamin __ Antagonist

Coumadin (vit K Antagonist) Prevent systemic embolism (4) types

A Fib Valvular heart disease Prosthetic heart valve Antiphospholipid antibody syndrome

A Fib Valvular heart disease Prosthetic heart valve Antiphospholipid antibody syndrome Can cause systemic embolism Which medication can help

Coumadin Vitamin K Antagonist

Contradictions for... Epidural/spinal med administración Uncontrolled bleeding Severe thrombocytopenia / HIT (Heparin-Induced Thrombocytopenia) Hemorrhagic Stroke Pregant Alcohol liver disease Going to OR

Coumadin Vitamin K Antagonist

Safety concerns for Coumadin PT/ INR Daily + CBC INR for A fib, stroke, DVT/PE ... Mechanical valve ...

A fib, stroke, DVT/PE 2-3 Mechanical valve 2.5-3.5

Reversal agent for Coumadin (Warfarin)

Vit K

List foods high in vitamin K

Leafy greens: Kale, spinach, Swiss chard, collard greens, and cabbage Cruciferous vegetables: Broccoli and Brussels sprouts Other vegetables: Asparagus and green beans Fruits: Kiwi and avocado

Coumadin (Warfarin) Interactions: (3)

Min alcohol use NSAIDS Foods high in vit k Leafy greens: Kale, spinach, Swiss chard, collard greens, and cabbage Cruciferous vegetables: Broccoli and Brussels sprouts Other vegetables: Asparagus and green beans Fruits: Kiwi and avocado

____ is used temp to replace Warfarin before surgery Reduces Bleeding Risk Called: ____ Bridging

Lovenox x 2

Dabigatran, rivaroxaban, apixaban Are all which class of blood thinners What makes them different from past blood thinners

NOAC Novel oral anticoagulants Only work on 1 part of the Clotting Cascade. Dabigatran: Direct thrombin inhibitor rivaroxaban & apixaban Factor x (10)a

Recommend time to hold NOAC: Dabigatran, rivaroxaban, apixaban PRIOR TO SURGERY

1-2 days (CrCl >50ml / min) 3-5 days (CrCl<50ml/min)

To prevent emboli formation/ dislodgement Massage legs to help circulation

False This will dislodged emboli

SCD, TED hose, ROM, Ambulation & ______ Help in prevention of PE

Hydration

Pulmonary infarction Pulmonary HTN Cor pulmonale Dysrhthmias Are all ...

Complications OF PE

4 complications of PE

Pulmonary infarction Pulmonary HTN Cor pulmonale (pulmonary heart disease, Right side heart failure. Caused by long-term high blood pressure in the lungs and right ventricle of the heart.) Dysrhthmias

Acute respiratory FAILURE ABG PO² = <___ mmHg PCO² = > ___ mmHg

PO² = <60mmHg PCO² = >50mmHg

A syndrome of rapidly progressing non-cardiac pulmonary edema & respiration failure

ARDS Acute respiratory Distress syndrome

Positive End Excivatory Pressure PEEP Does..

Keeps alveoli open during ARDS

Fracture of which ribs result in pneumothorax

1 - 4

Loose segment of chest wall left due to adjacent rib fractures

Flail chest

Difference between Closed & Open pneumothorax

Open: Penitration of chest wall (knife) Closed: No penetrante of chest wall

Pneumothorax Trachea moves... (Affected / Unaffected) side

Unaffected side

Possible leathal Asymptomatic first, later resp failure Bloody sputum, decreased breath sounds, crackles/ wheeze Possible chest tube / intubation

Pulmonary contusion

How long can a picc line stay in place

Long term Up to a year or longer

What can a picc line be used for?

Taking blood specimens Inserting: Blood, IV fluids, Meds, TPN Total parenteral nutrition

One advantage of a PICC line is it can be placed when there is a systemic infection T or F

F No central venous catheter can be placed during systemic infection

Von Willebrand disease (VWD) is ....

a bleeding disorder that affects the blood's ability to clot properly. It's caused by a deficiency in the quality or quantity of von Willebrand factor (VWF), a protein that helps blood cells stick together when you bleed. VWD is the most common hereditary blood-clotting disorder in humans

Alteplase is administered for... When...

Saving myocardium post MI Within 6hrs

Phytonadione is...

Vitamin K Antidote to Warfarin (Coumadin)

Thrombocytosis vs Thrombocytopenia

Thrombocytosis >450,000 Thrombocytopenia <150,000

PTT What is considered a therapeutic Time with a control of 30 seconds?

Therapeutic levels for heprin are 1.5 / 2.5 time of the control 45 - 75 seconds

DIC Rare Clotting Disease has two stages: Stage one Overactive clotting leads to blood clots throughout the blood vessels, which can reduce or block blood flow and damage organs. Stage two The overactive clotting uses up platelets and clotting factors that help the blood to clot, leading to bleeding in other areas Take note of which levels

Platelets, PT, PTT

Why does a client with cirrhosis have bleeding precautions

Due to lack of producing clotting factors

Which medication affects INR

Warfarin (Coumadin)

Which medication affects PT

Warfarin (Coumadin)

Which medication affects APTT

Heparin

Homan's sign is... Associated with which disease

Calf pain upon Dorsiflexion of foot Thrombophlebitis

Which lab value should a nurse monitor when client is receiving warfarin sodium therapy?

PT. PT should be 1.5 - 2.5 control value PTT is monitored with heparin

Should a client with thrombophlebitis elevate affected extremity? Why?

Yes Elevation helps blood flow by gravity and decreases venous pressure (Relieving edema & pain)

Why do neonates recieve vit K at birth?

They are unable to produce their own Due to lack of intestinal flora to make the vitamin

Difference between pt and irn

A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results

What chemical process does PT measure

How long it take blood to clot Turing prothrombin into thrombin Activates fibrinogen into fibrin

PT / INR (Extrinsic) Normal PT Normal IRN Value Anticoagulant IRN Value (Type of medication associated) aPTT Normal value Anticoagulant associated Value (Type of Anticoagulant)

PT / INR Norm PT 10 - 12 secs Normal INR <1.1 Anticoagulant INR Value 2 - 3 aPTT Normal 25 - 35 seconds Anticoagulant Value 1.5 - 2.5 Normal Value

Approx. Normal range for aPTT results

25 - 35 sec Heparin = 1.5 - 2.5 x this value

Patient is receiving a heparin IV drip. What will therapeutic values be for the aPTT

1.5 - 2.5 x normal Values 25 - 35 = Normal values

Therapeutic range for Warfarin to be effective

INR 2 - 3

Approx range for pt values

10 - 12 seconds

INR of 1 on Warfarin =

Not effective in preventing blood clots

Patients pt is 30 seconds. Which of the following contribute to this findings A. None, it is a normal findings B. Vitamin K defincey C. Liver disease D. Warfarin

B. Vitamin K defincey C. Liver disease D. Warfarin

Patients aPTT time is 32 seconds. The nurse would interpret this as...

Normal findings Between 25 - 35

Working on the intrinsic pathway Inhibits thrombin, which converts (fibinogen to fibrin) Coumadin/ Heparin Antagonist of vitamin K, which is used in the liver to make clotting factors. Coumadin/ Heparin

Working on the intrinsic pathway Inhibits thrombin, which converts (fibinogen to fibrin) Heparin Antagonist of vitamin K, which is used in the liver to make clotting factors. Warfarin

Onset Duration: Heparin vs Warfarin

Heparin = fast 20 - 30 minutes Warfarin= slow 3 - 5 days Duration: Heparin: Hours Warfarin: Days

How is Heparin Warfarin Administered

Heparin: IV / SQ Warfarin: Oral med

Which can be used during pregnancy Heparin or Warfarin

Warfarin can be used during pregnancy

Osteoporosis can be caused by Heparin/ Warfarin

Heparin

Excessive Green leafy vegetables will do what to IRN levels

Lower (thicker/ clotting blood)

Gold standard test to diagnose PE

Pulmonary CT angiography

Difference between heparin & Lovenox Which does require aPTT monitoring

Lovenox has a longer half-life aPTT doesn't need to be monitored on Lovenox

Treatment for ARDS

Mechanical ventilation using low tidal volume Positive end-expiratory pressure prevent alveoli collapse Prone posistion Render unconscious

aPTT is for...

IV heparin

Lungs have... Positive pressure during ( exhalation/ inhalation) and Negative Pressure during ( exhalation/ inhalation)

Positive pressure during exhalation and Negative Pressure during inhalation.

PEEP

Positive end-expiratory pressure Used to keep alveoli open

D-dimer blood test

measures protein fragment present when a blood clot dissolves. The level of D-dimer in the plasma is usually increased when there is acute pulmonary embolism (PE). A normal D-dimer level is below 500 micrograms/L