hematologic medications Flashcards
What are the three anemias?
iron
pernicious (b12)
megaloblastic
low iron or globin
. Cytoplasmic-
low Vit B12 or folic acid
Nuclear
What are the three anemias?
iron deficiency
pernicious
megaloblastic
What medications are given for iron deficiency anemia?
ferrous sulfate
iron dextran
what medications are given for pernicious anemia?
vitamin b12
cyanocobalamin
what medications are given for megaloblastic anemia?
folic acid
vitamin b12 and cyanocobalamin too
what are the two RBC maturation defects ?
cytoplasmic -low iron or globin
nuclear -low vitamin b12 or folic acid
excessive RBC destruction is also known as?
hemolytic anemia
what are the two subcategories of excessive RBC destruction?
intrinsic RBC abnormalities
extrinsic mechanisms
can be caused by:
blood loss
decreased dietary iron
decreased absorption of iron
blood loss
surgery
child birth
GI bleeding
menstral blood loss
extreme hemorrhoids
iron deficiency anemia
______ red blood cells are dark red
normal
person with iron deficiency anemia has ______ and more ______ blood cells
smaller, pale
What are the two megaloblastic anemias?
pernicious anemia
folic acid deficiency
this is when you make large cells, but there aren’t enough of them, and they’re immature
megaloblastic anemia
______ or ______ can be due to not getting enough in your diet (folic acid or b12) or your body can be improperly absorbing it
intrinsic factor missing that causes them not to asorb them in their stomach can cause this anemia (gastric bypass can actually cause this)
infants can get it due to a lack of dietary intake
pregnancy (folic acid) can cause this anemia too
pernicious, folic acid deficiency anemia
______ anemias are where the cells are being destroyed
hemolytic
sickle cell anemia is a ?
hemolytic anemia
desire to eat ice (laundry detergent, dirt)
pika
What are the three major s/s of anemia?
low iron levels -check labs
imbalance between O2 delivery and demand
rapid loss of blood may be present
what are symptoms of imbalance between O2 deliver and demand?
fatigue, weakness, abnormal HR or BP, decreased exercise or activity level, dyspnea, weight at or below normal for age, height, and body build, discoloration of the nails and skin, fissures on the lips
what color can nails be with anemia?
pale
t/f: anemia can cause you to bruise more eaisly?
true
is SHOB a symptom of anemia?
yes
What do you need to draw along with your CBC when checking for anemias?
iron levels
fissures on on the lips or splits in the sides of the mouth are signs/symptoms related to anemia
fissured tongue is also a symptom of anemia
When is giving iron (ferrous sulfate or Iron dextram) contraindicated?
type of anemia not associated with iron deficiency
iron overload
drug allergy
if they have iron deficiency anemia, what do you need to investiage?
you need to figure out why they’re having an iron deficiency. Is it menstrual, GI bleed? diet lacks iron? you need to figure out what is really going on
What is the normal HGB lab for adult males?
13-18 g/ 100mL
What is the normal HGB lab for adult females?
12-16 g/ 100mL
what are dietary sources high in iron?
muscle meats
liver
egg yolks
yeast
What should you take along with iron to increase absorption?
Vitamin C
What should you not give PO iron with as it interferes with absorption?
antacids
do mens’ vitamin supplements have iron in them?
no, they do not usually
What is the normal HCT (hematocrit) level for an adult male?
45-52%
What is the normal HCT (hematocrit) level for an adult female?
37-48%
should iron be taken with food?
yes, it can cause a lot of GI problems such as constipation and tarry stools
GI related
Staining
Anaphylaxis _________
IV Route is safer than IM
1st = Give test dose first
2nd = Give second dose slowly12.4 mg/min
Hypotension (Parenteral Route)
Elderly respond better to lower doses
Lower doses = lower adverse effects
Side effects of iron
Iron Dextran
may have to take something for constipation
can cause abdominal upset, nausea
Staining is related to the injections
if they have IV it can cause staining as well, will be there a very long time
if there is an increased need, they will received it IV or IM
side effects of iron
what do you need to do before giving iron IM?
do a test dose
t/f: lower doses of iron have lower adverse effects?
true
GI symptoms melena (dark bloody stools), hematoemesis, N/V, diarrhea
Can lead to acidosis
Shock hypotension, tachypnea, pallor then cyanosis, coma
S/S of iron poisoning/toxicity
what are s/s of iron poisoning/toxicity
GI symptoms- melena (dark bloody stools), hematoemesis, N/V, diarrhea
Can lead to acidosis
Shock -hypotension, tachypnea, pallor then cyanosis, coma
What are side effects of iron?
GI
staining
anaphylaxis to iron dextran
hypotension (parenteral route)
how is an overdose of iron treated?
bowel irrigation
chelating agent: deferoxamine
When is iron contraindicated?
hemolytic anemia
hemochromatosis
hemosiderosis
What are cautions for iron?
peptic ulcer disease
ulcerative colitis
severe hepatic and/or renal impairment
can you crush iron?
NO, you cannot crush iron
are dosages sometimes confusing with iron?
yes
pernicious anemia is a type of ______ anemia
megaloblastic
you would have to take a lot of ______ to actually cause problems, there is not really toxicity associated with it
b12
cyanocobalamin nascobal is administered how and for what?
intranasal, pernicious anemia
cyanocobalamin injection is given how?
is used to treat what condition?
SQ or IM
pernicious anemia
Skin and mucous membranes affected
(GI disturbances)
Neurological changes
(Numbness, tingling, CNS damage)
Dysrhythmias, heart failure, infection, bleeding
Signs of anemia
(Fatigue, pallor)
signs of b12 deficiency
what are signs of b12 deficiency?
Skin and mucous membranes affected
(GI disturbances)
Neurological changes
(Numbness, tingling, CNS damage)
Dysrhythmias, heart failure, infection, bleeding
Signs of anemia
(Fatigue, pallor)
What are cardinal signs for pernicious anemia?
beefy red tongue
pallor
neuropathy
what are the normal levels for b12?
200-900
What does this sign indicate?
pernicious anemia (beefy red tongue which is a cardinal sign of pernicious anemia)
What causes b12 deficiency?
malabsorption (lack intrinsic factor)
poor dietary intake
What are some side effects of b12 deficiency ?
itching
diarrhea
fever
hypokalemia
will folate (B9) treat pernicious anemia ?
no it will not
dairy, fortified cereals, and meats all contain?
b12
What labs do you need to get for B12 deficiency?
B12, Hgb, Hct, RBC, reticulocyte counts
anticonvulsants, aminoglycoside antibiotics, folic acid, and long acting potassium supplements
Decrease the effectiveness of oral b12
Wait ______ hour before or______ hour after eating before administering intranasal form of b12
1, 2
injections do not cause issues like iron injections
b12 injections
–shows how quickly new red blood cells are being made
reticulocyte count
Improvement of reticulocyte count
(0.8-2.5%)
Absence of megaloblasts in bone marrow
Normal or increased Hgb and Hct levels (part of CBC)
Improvement of neurological symptoms (tingling in hands and feet)
goals for anemia treatment
Folate and B9 are?
folic acid
required for:
DNA, Erythropoiesis
Prevent neural defects in fetus
Treat malabsorption syndrome
folic acid
Treats megaloblastic anemias
folic acid
pallor, fatigue, palpitations, paresthesia (tingling feeting)
Signs of deficiency of folic acid
women who are at the age of wanting to get pregnant
treats megaloblastic anemias but the ones related to folic acid
mostly related with neural tube defects
folic acid
side effects of folic acid?
rare, localized rashes
Contraindications/Caution for folic acid
Indiscriminate use with any anemia not r/t folic acid deficiency
Sulfonamides
Sulfasalazine
Methotrexate
(last two are used with auto immune disorders)
These meds decrease folate levels:
normal lab range for folic acid?
6-15 mcg/ml
Risk factors
Baseline and periodic labs
Folic Acid, RBC, reticulocyte counts, & Hgb/Hct
assessment for folic acid
Signs/symptoms of anemia improve
Absence of neural tube defects in newborns
success with folic acid deficiency
Rare genetic disorder
Natural coagulation and hemostasis factors are limited or absent.
hemophilia
Patients with __________ can bleed to death if coagulation factors are not given.
hemophilia,
can bleed to death with an injury that the rest of us would survive (often have to come get whatever factor at the hospital that theyre defieient in to clot)
hemophilia
most common type of hemophilia?
hemophilia A
Genetic
Caused by missing or defective factor VIII (a clotting protein)
hemophilia A
hemophilia A is missing which clotting factor?
factor VIII, factor 8
also known as christmas disease
hemophilia B
Hemophilia B is missing which clotting factor?
factor 9, IX
Less common than Hemophilia A
Genetic
Caused by missing or defective IX (a clotting factor)
hemophilia B
What medications are given for hemophilia?
Factor VIII and factor IX
Excessive bleeding and easy bruising
Bleeding can happen in the joints
Injury causes prolonged bleeding
Internal bleeding can occur with “slight” injury
symptoms of hemophilia
treatment for hemophilia?
Synthetically produced factors (or can be derived from human blood)
put _____on the bleed, it can decrease bleeding
ice
Observe and report signs of bleeding
From gums, skin, stool or emesis
Swelling of joints
Monitor I & O & color of urine
Assess for allergic reaction
Monitor BP, pulse, respirations
hemophilia assessment
what labs do you need to monitor for hemophilia?
Hematocrit (Hct)
Direct Coombs test
Plasma factor VIII levels
Platelet count
anytime you give a factor you want to assess for ______and monitor labs: _________
allergic reactions , Hct, direct coombs test, plasma factor level, platelet count
Monitor BP, HR, RR
Obtain history of current trauma, estimate blood loss
Assess for renewed or increased bleeding q 15-30 minutes
Immobilize joint and apply ice
Obtain blood type and cross prior to administration
Apply pressure to all venipuncture sites for at least________, avoid injections when possible
Coagulation lab studies
aPTT, plasma fibrinogen, platelet count, PT, factor IX plasma concentrations
5 minutes
Assessment for giving factors
go ahead and get _____ while youre doing the IV bc theyre more prone to bleeding
blood
Reduce bleeding opportunities
Apply pressure to IM, IV sites- 5 min
Reduce IM and venipuncture
Avoid ASA and NSAIDs
Advise patients to consult health care professional prior to ______and to bring adequate supply to factor 8
travel
Tell your doctor or dentist before any/all medical or dental care, emergency care, or surgery
Avoid products containing ASA or NSAIDs
Bleeding assessment & prevention Know this!
patient education for hemophilia and clotting factors.
Emboli to brain- ______
Emboli to lung- ______
Emboli to vein in leg- _______
a clot is also known as a ______?
stroke
pulmonary embolism
Deep vein thrombosis
emboli
What drugs are used to prevent or dissolve thrombi?
anticoagulants
antiplatelets
[thrombolytics which dissolve clots, but its not on the exam]
drug class inhibits clotting factors?
anticoagulants
______ inhibit clotting factors are used to prevent clots, not break them
anticoagulants
What are the parenteral administration anticoagulants?
heparin
low molecular weight heparin: enoxaparin, dalteparin
What are the oral anticoagulants?
warfarin
heparin is given through ______
______ is a low molecular weight heparin –easy to give, not as dangerous as giving large amount of heparin IV
IV, Enoxaparin
–works by inhibiting vitamin K synthesis, bacteria in GI are what make vitamin K, vitamin K helps clot formation
warfarin
For quick anticoagulation needs (stroke, pulmonary embolism, massive DVT)
Prevent clots during specific surgeries/procedures
Prevent post-op venous thrombosis (mostly given subQ)
DOES NOT LYSE A CLOT
IV doses should be double checked with another nurse
heparin indications
binds with antithrombin 3 which turns off the coagulation pathway
heparin
Emergency anticoagulation therapy
Situations where clot formation is a risk
Slowed blood flow
Prevent AND/OR Treat DVT and PE
Anticoagulation “Bridge”
LMWH indications enoxaparin
most of the time used for prevention or for someone who has a DVT after surgery
LMWH enoxaparin
post surgery, slow blood flow, prevent or treat DVT, pulmonary embolism
indications for enoxaparin LMWH
_______________: will stop oral warfarin and instead use lovenox during a certain period pre operatively
anticoagulation bridge
Thrombocytopenia (low platelets)
Uncontrolled bleeding
contraindications for Heparin/LMWH
Hemophilia
Peptic Ulcer
Decrease any punctures, procedures that cause bleeding
cautions for heparin/ LMWH
Hemorrhage
Thrombocytopenia and HIT
Stop heparin if platelets less than 100,000/mm3
Hypersensitivity reactions (more likely with IV)
Small initial “test” dose
Chills, fever, urticaria
Neurological damage
Adverse effects of heparin and LMWH
______ short half life (1-2 hours)
______ 4.5 hours (up to 7)
Heparin, LMWH
What do you do if someone has an overdose to heparin or LMWH or toxicity to it?
administer 1 mg protamine sulfate … 1Mg of heparin overdose Slow IV injection: 20 mg/min or 50 mg in 10 min
replace blood loss
protamine sulfate
reversal drug for heparin, give 1 mg protamine for every 1 mg of heparin overdose with slow injection rate
______ subcutaneous or IV
______ subcutaneous, 2 in from umbilicus
Pinch skin, 90° angle, do not aspirate
Needle gauge consideration _______
Techniques to reduce bruising
Do I administer this air bubble?
Safety considerations
administration for heparin considerations.
Heparin, LWMH , use the smallest, yes administer air bubble
tell them to avoid picking their nose
make sure you have the right concentration
considerations/education for heparin
syringe comes prefilled with a bubble, do not take it out bc it helps to seal it
go in 90 degrees, do not Z track it, don’t rub site afterwards
two inches away from belly button in any direction
don’t give in legs ONLY GIVE in ABDOMEN
administration for enoxaparin
Treats venous thrombosis
Prevention and treatment for patients with atrial-fibrillation and prosthetic heart valves
Prevention recurrent MI, TIA, PE, and DVT
uses for warfarin
is oral and inhibits vitamin K synthesis
used to treat and prevent blood clots and a fib, heart valves, MI,
give vitamin K to reverse
warfarin
May be started while the patient is still on heparin until PT/INR levels indicate adequate anticoagulation
Full therapeutic effect takes several days.
Monitor PT/INR regularly; keep follow-up appointments.
warfarin
PO _______ is generally something they start before they go home
they have to go in for labs to have levels checked (time frame depends)
some people will be on the med for life
warfarin
Pregnancy category X
Thrombocytopenia (low platelet count)
Uncontrolled bleeding
Specific surgeries
__________deficiency, liver disorders or alcoholism
contraindications for warfarin, Vitamin K
Hemophilia
Severe HTN
Peptic ulcer
Dissecting aneurysm
Threatened abortion
caution for warfarin
Bleeding… hemorrhage
Hepatitis
Lethargy
Muscle pain
Skin Necrosis
“Purple toes” syndrome
warfarin adverse side effects
what is this condition and what is it caused by?
purple toes syndrome (skin necrosis), its an adverse effect of warfarin
What do you do for a warfarin overdose?
Discontinue warfarin
Start Phytonadione (vitamin K)
PO preferred, IV available (dilute it)
2.5 mg PO, 0.5 to 1 mg IV
Clotting Factor Transfusion
Fresh frozen plasma
Whole blood transfusion
first: stop med
get lab
get order for phytonadione which is vitamin K
PO is preferred if able
warfarin toxicity protocol
what is the preferred method of admin for phytonadione?
PO is preferred
t/f: warfarin has a lot of drug/drug interactions
Many but ntk Foods high in vitamin K
if your patient eats a lot of _________ its alright, but they cant suddenly start eating it, they also don’t need to stop eating all of their ________
don’t take with salicylates
vitamin K, vitamin K foods
warfarin
don’t take _________ along with warfarin
OTC herbs
aPTT 45-70 seconds (heparins)
PT 18-24 seconds (warfarin)
INR 2-3 for MI, Afib, PE, venous thrombosis
INR 2.5-3.5 for mechanical heart valves, reoccurring systemic embolism
No more thrombi developing
warfarin treatment is effective when these occur
aPTT time should be? (with heparins)
45-70 seconds
PT time should be ? (warfarin)
18-24 seconds
INR should be _________ for a MI, Afib, PE, venous thrombosis
2-3
INR should be _____ for mechanical heart valves, reoccurring systemic embolism
2.5-3.5
Obtain baseline ______________________
Continue to monitor through therapy with heparins
CBC, platelet count, HCT.
get a ___ anytime youre wondering about their clotting ability
CBC
Apply pressure to new venipuncture sites
Avoid unnecessary IM injections or IV routes, if possible
monitoring for heparin admin (also for people with blood disorders)
Bleeding assessment
Guaiac fecal occult stool
Visual assessment
monitoring for heparin administration
will have to apply extra extended pressure if they’re on an _________
don’t use a _____ razor, have them use an _____
anticoagulant , straight, electric razor
Inhibit platelet aggregation
antiplatelets
what is the antiplatelet we go over?
aspirin
Prevent acute MI and re-occurance of MI
Prevent ischemic stroke or transient ischemic attacks (TIAs)
Other uses: analgesic, antiinflammatory, antipyretic (depends on the med)
Available in many combinations with other prescription and nonprescription drugs
indications for antiplatelet use
Aspirin and ______
Used for antiplatelet purposes
dipyridamole
Thrombocytopenia, bleeding disorders
Third trimester of pregnancy
Active bleeding-trauma, GI bleeding, Recent hemorrhagic stroke** (bleeding in brain)
Vitamin K deficiency
Cross allergy to other ______
“Flu-like symptoms in children or adolescents
Reyes Syndrome
contraindications for aspirin
NSAIDs
Peptic ulcer disease
Severe kidney or hepatic disorders
Older adults
cautions for aspirin use
is a rare, serious condition that causes swelling in the liver and brain. it most often affects children and teenagers recovering from a viral infection, commonly the flu or chickenpox.
Reye’s Syndrome
GI effects
Nausea/Vomiting, dyspepsia
Hemorrhagic Stroke
Assess for weakness on one side of the body,
speech changes, headache
Prolonged bleeding time, gastric bleed
Thrombocytopenia
Tinnitus, hearing loss
side/adverse effects of aspirin
81mg is called _____ aspirin
Children’s/Baby’s
Discontinue 1 week prior to surgeries
Effects last this long too
aspirin education
Good tissue perfusion
No abnormal bleeding
Absence of thrombi
aspirin is effective if these criteria have been met
Inhibits platelet aggregation by preventing binding of ATP to platelet receptors
antiplatelet drugs
contraindication/cautions are similar to aspirin except for?
clopidogrel is category B pregnancy risk, should not take when breastfeeding
Side effects of antiplatelets are similar to aspirin with the exception of?
tinnitus
What are the antiplatelet ATP inhibitors?
clopidogrel
ticlopidine
Concurrent use of NSAIDS, anticoagulants, thrombolytics, antiplatelets
drug/drug interactions of ATP inhibitor antiplatelets
Chest pain, edema
Abdominal pain, diarrhea, nausea
Thrombocytopenia
Flu-like symptoms
Bleeding issues:
Epistaxis
Prolonged bleeding time
Gastric bleeding
side effects of ATP inhibitor antiplatelets
For unstable angina/MI
For thromboprevention
IV medication
Given in ICU
antiplatelet glypoprotein inhibitors,
eptifibatide,
tirofiban
What are the antiplatelet arterial vasodilators?
Pentoxifylline
Dipyridamole
Cilostazol
