Critically Ill & Anticoagulantion Flashcards
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)
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
Biggest concern of DVT
PE
Pulmonary Embolism
Obstruction of Pulmonary Vessel by particulate matter, most often a clot
Fat & air emboli
Amniotic fluid
Tumors
Can all cause
PE
Long bone being broken
Femur, Pelvis, Sternum
Can cause
Fat emboli -> PE
How can an air emboli happen
Improper IV med administration
Thrombus from a DVT breaks loose & lodges in a pulmonary artery
Describes
PE
Audible S³ or S⁴ heart sound
Petechiae
Hemoptysis
Syncope
Tachy
Hypotension
SUDDEN
Manifestaciones of PE
PE
ABG
Describe
Start: Respitory Alkalosis
End: Metabolic Acidosis
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
Do you want the clot to break apart in DTV
No this will cause PE
How does Heparin disolve a DVT
It Doesn’t
Stops it from getting bigger
First thing to do in drug therapy for PE
Clotting study drawn as a baseline
5000 - 10000 U Heparin given via IVP
followed by a drip
PTT: Kept between ____
50 - 70 seconds
Coumadin (Warfarin) work…
Warfarin blocks enzyme that uses vitamin K to make clotting factors.
Ability of blood to clot is reduced.
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
Normally an INR of _____ is normal
Warfarin INR range of_____
<1.1
Warfarin 2 - 3
A normal partial thromboplastin time
(PTT) is _____
Heparin PTT
25–35 seconds
50 - 70 seconds
INR stands for…
International Normalized Ratio
How long it takes blood to clot
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
Which type of blood clot is likely to cause a stroke
Left Atrium of the Heart
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)
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
Epidural/spinal med administración
Uncontrolled bleeding
Severe thrombocytopenia / HIT (Heparin-Induced Thrombocytopenia)
Hemorrhagic Stroke
Are what?
Contraindications for Heparin
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
3
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
K
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 pressureduring 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
