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320 Pharmacology > Hematology: Coagulation Modifying Agents > Flashcards

Hematology: Coagulation Modifying Agents Flashcards

1
Q

What is the therapeutic range for Partial Thromboplastin Time (PTT)?

A

40-70 seconds

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2
Q

What is the therapeutic range for Prothrombin Time (PT)?

A

18 seconds

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3
Q

What is the therapeutic range for International Normalized Ration (INR)?

A

2-3

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4
Q

What do anticoagulants do? What is it used for?

A
  • Inhibit the action or formation of clotting factors
  • Uses vary: prevent clot formation to prevent the extension of an established clot
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5
Q

What do antiplatelet drugs do?

A

Inhibit platelet adhesion at the site of blood vessel injury; essentially, stopping your platelets from sticking together

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6
Q

What do thrombolytic drugs do?

A

Lyse (break down) existing clots in the coronary arteries; reestablishes blood flow to the heart muscle

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7
Q

What do antifibrinolytic / hemostatic drugs do?

A
  • All varying MOAs, but all prevent the lysis of fibrin
  • Promote blood coagulation
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8
Q

Describe anticoagulants. What are they used to prevent?

A
  • Also known as antithrombotic drugs
  • Prevent intravascular thrombosis by decreasing blood coagulability
  • Used prophylactically to prevent
    ~ Clot formation (thrombus)
    ~ An embolus (dislodged clot)
    » Brain vessel -> stroke
    » Coronary artery -> myocardial infarction (MI)
    » Lungs -> pulmonary embolism
    » Vein in the leg-> deep vein thrombosis (DVT)
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9
Q

List examples of older anticoagulant drugs.

A
  • Heparin (Unfractionated)
  • Warfarin
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10
Q

What is a common nursing consideration among all anticoagulants?

A

Assess for symptoms of bleeding and blood loss

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11
Q

What is a common patient education point among all anticoagulants?

A

Report any symptoms of unusual bleeding or bruising to HCP

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12
Q

What are some considerations when administering a subcutaneous anticoagulant injection?

A
  • Administer subcut; do NOT expel the air bubble
    ~ Inject the entire needle at 45 or 90 degree angle (depending on what you can pinch)
    ~ Do NOT aspirate or massage
    ~ Do NOT administer IM (danger of hematoma)
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13
Q

What is a common patient education point for anticoagulants and antiplatelets?

A

Advise client to notify HCP of medication regimen prior to
treatment or surgery

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14
Q

How do you administer heparin for DVT prophylaxis?

A

5000 units subQ/subcut two or three times a day; aPPT does not need to be monitored when used for prophylaxis (or IV catheters)

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15
Q

What are some considerations for when heparin is used therapeutically as a continuous IV infusion?

A
  • Measurement of aPTT (usually every 4-6 hours until therapeutic effects are seen; then daily once achieved)
  • Antidote for overdose/toxicity is protamine sulfate
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16
Q

Heparin indication?

A

Prophylaxis & tx of various thromboembolic disorders

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17
Q

Heparin adverse effects?

A

Hem: BLEEDING, heparin induced thrombocytopenia (HIT), thrombocytopenia, hematoma, anemia

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18
Q

Heparin drug interactions?

A

Aspirin & NSAIDS (decreased platelet activity); Oral anticoagulants, antiplatelet drugs, and thrombolytics (additive effects)

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19
Q

Describe heparin-induced thrombocytopenia (HIT).

A
  • Immune mediated adverse drug reaction caused by the emergence of antibodies that activate platelets in the presence of heparin
  • May reduce platelets counts to as low as 5000/mm3
  • May lead to increased resistance to heparin therapy
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20
Q

Heparin nursing considerations?

A
  • Monitor aPTT and hematocrit prior to and periodically during therapy
  • Subcut: observe injection sites for hematomas, ecchymosis, or inflammation
  • For an overdose, protamine sulfate is the antidote
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21
Q

Heparin patient education?

A
  • Instruct patient to avoid medications that contain aspirin or NSAIDs
  • Caution patient to avoid IM injections and activities leading to injury
  • Advise patient to use a soft toothbrush, not to floss and to us an electric razor during heparin therapy
  • Educate patient on the importance of carrying an identification card or a medical alert bracelet or necklace at all times
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22
Q

Warfarin drug profile?

A
  • Most commonly prescribed oral anticoagulant; PO only
  • Careful monitoring of the prothrombin time/international normalized ratio (PT/INR)
  • A normal INR (without warfarin) is 1.0, but a therapeutic INR (with warfarin) ranges from 2 to 3
  • Dietary considerations- vitamin K consistent diet
  • Antidote for overdose/toxicity is Vitamin K
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23
Q

Warfarin indication?

A
  • Prophylaxis & tx: venous thrombosis, pulmonary embolism, a-fib
  • Management of MI
  • Prevention of thrombus formation after prosthetic valve replacement
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24
Q

Warfarin adverse effects?

A
  • Hem: BLEEDING
  • Derm: purple toes (rare, affects 1 in 5000 clients)
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25
Q

Warfarin nursing considerations?

A
  • Monitor stool and urine for occult blood before and periodically during therapy
  • Monitor PT and INR
  • Monitor CBC, renal, and liver enzymes before and periodically throughout therapy
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26
Q

Warfarin patient education?

A
  • Avoid cranberry juice or products during therapy
  • Avoid IM injections, use a soft toothbrush, avoid flossing, and shave w/ an electric razor during therapy
  • Do not to drink alcohol or take Rx, OTC, herbal products or start or stop any new medications during warfarin therapy w/o advice of their HCP
  • Carry identification describing medication regimen at all times
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27
Q

List an example of a Low-molecular weight heparin (LMWHs). [Anticoagulant]

A

Enoxaparin

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28
Q

Enoxaparin drug profile?

A
  • Higher degree of bioavailability and longer elimination half-life
  • More predictable anticoagulant response, lab monitoring is not necessary
  • Injectable form
  • Used for prophylaxis and treatment
  • “Bridge therapy”
  • Pre-filled syringes
    ~ Do not expel air bubble
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29
Q

Enoxaparin indication?

A
  • Prevention/Prophylaxis of venous thromboembolism (VTE), DVT, and/or PE
  • Treatment of DVT w/ or w/o PE (with warfarin)
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30
Q

Enoxaparin contraindication?

A

patients w/ an indwelling epidural catheter

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31
Q

Enoxaparin adverse effects?

A

Hem: BLEEDING, thrombocytopenia, hematoma, anemia

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32
Q

Enoxaparin drug interactions?

A
  • Risk of bleeding may increase by concurrent use of drugs that affect platelet function and coagulation:
    ~ Warfarin
    ~ Aspirin
    ~ NSAIDs
    ~ Clopidogrel
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33
Q

Enoxaparin nursing considerations?

A
  • Monitor CBC, platelet count at the beginning and periodically throughout therapy
    ~ They can be restarted on any LMWH 2 hours AFTER the indwelling epidural catheter is removed
  • Administer subcut; do NOT expel the air bubble
  • The ONLY time this medication is given IVP is for a STEMI
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34
Q

Enoxaparin patient education?

A
  • Instruct patient in correct technique for self-injection care, and disposal of equipment (if using at home)
  • Do not to take aspirin, naproxen, and/or ibuprofen w/o first discussing w/ their provider while on enoxaparin therapy
  • Notify HCP of therapy before dental or medical treatments or surgery
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35
Q

Describe “Bridge Therapy.”

A
  • “Bridging” refers to the use of short-acting anticoagulants (heparin or LMWH) during the interruption of warfarin
    ~ Warfarin is stopped 5-6 days before surgery to allow its anticoagulation effects to wane
    ~ Bridging w/ either heparin or LMWH is started 3 days before surgery w/ the last dose given 24 hours before surgery
    ~ Bridging is resumed no earlier than 24 hours after surgery
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36
Q

List examples of Direct Thrombin Inhibitors. [Anticoagulant]

A
  • Dabigatran
  • Argatroban
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37
Q

Dabigatran drug profile?

A
  • First oral direct thrombin inhibitor approved for prevention of strokes and thrombosis in patients with nonvalvular atrial fibrillation
  • Prodrug that becomes activated in the liver
  • Antidote of overdose/toxicity is idarucizumab
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38
Q

Dabigatran indication?

A

Decreased risk of stroke (associated w/ a-fib)

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39
Q

Dabigatran adverse effects?

A

Hem: BLEEDING with increased GI Bleed
Misc: Fever, shortness of breath, urticaria (r/t hypersensitivity reaction)

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40
Q

Dabigatran drug interactions?

A
  • Risk of bleeding may increase by concurrent use of anticoagulants and antiplatelet
  • Rifampin and St. John’s wort can cause decreased drug effect
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41
Q

Dabigatran nursing considerations?

A
  • Do NOT exchange capsules for oral pellets; doses are not equal
  • Do not chew or crush capsules, it must be swallowed whole
  • Do not administer with milk or milk products
  • Administered BID, about 12 hours apart with a FULL glass of water
42
Q

Dabigatran patient education?

A

May bleed more easily or longer than usual

43
Q

Argatroban drug profile?

A
  • Synthetic direct thrombin inhibitor
  • Only given IV route
44
Q

Argatroban indication?

A

Prophylaxis of thrombosis in patients with heparin-induced thrombocytopenia (HIT)

45
Q

Argatroban adverse effects?

A
  • Hem: BLEEDING
  • Misc: Fever, shortness of breath, urticaria (r/t hypersensitivity reaction)
46
Q

Argatroban drug interactions?

A
  • Risk of bleeding may increase by concurrent use of antiplatelet drugs, thrombolytic drugs, or other anticoagulants
  • Increased bleeding w/ herbals such as: feverfew, garlic, ginger, & gingko
47
Q

Argatroban nursing considerations?

A
  • Monitor VS periodically during IV therapy
  • Assess H/H, platelet count prior to and during drug therapy
  • Minimize arterial and venous punctures, IM injections, use of urinary catheters, NG tubes
  • Monitor for cues of anaphylaxis
  • All parenteral anticoagulants should be DC’d before argatroban therapy is initiated
48
Q

What three drugs have similar drug interactions?

A

Fondaparinux, Aspirin, Alteplase

49
Q

Describe drug interactions of Fondaparinux, Aspirin, and Alteplase.

A
  • Risk of bleeding may increase by concurrent use of warfarin or drugs that effect platelet function including: aspirin, NSAIDs, heparin, cephalosporins, and clopidogrel
  • Increased risk of bleeding w/: dong quai, feverfew, garlic, ginger, and gingko
50
Q

List examples of Selective factor Xa inhibitors. [Anticoagulant]

A
  • Fondaparinux
  • Rivaroxaban
  • Apixaban
51
Q

Fondaparinux drug profile?

A
  • Black box warning for potential spinal hematomas w/ epidural catheters
52
Q

Fondaparinux indication?

A

Prevention and/or treatment of DVT and PE

53
Q

Fondaparinux contraindication?

A

Patients with:
- body weight < 50 kg
or
- creatinine clearance (CrCl) < 30 mL/min

54
Q

Fondaparinux adverse effects?

A
  • Hem: BLEEDING
  • Misc: Fever, angioedema (r/t hypersensitivity reaction)
55
Q

Fondaparinux nursing considerations?

A
  • Thrombocytopenia can occur; call provider to DC if plts < 100,000/mm3
  • Administer subcut; do NOT expel the air bubble
    ~ Rotate sites frequently in the abdomen
56
Q

Fondaparinux patient education?

A
  • Instruct patient in correct technique for self-injection care, and disposal of equipment (if client is using at home)
  • Report any itching, rash, fever, swelling, or dyspnea to HCP
  • Do not to take aspirin and/or NSAIDs w/o first discussing w/ their provider while on enoxaparin therapy
57
Q

Rivaroxaban drug profile?

A
  • PO only
  • Black box warning-potential spinal hematomas
  • Antidote for overdose/toxicity is andexanet alfa
58
Q

Rivaroxaban indication?

A
  • Prevention and/or treatment of VTE, DVT, and/or PE
  • Decreased risk of a stroke and other major CV events (MI)
59
Q

Rivaroxaban adverse effects?

A

Hem: BLEEDING

60
Q

Rivaroxaban drug interactions?

A
  • Increased risk of bleeding w/ other anticoagulants, aspirin, clopidogrel, fibrinolytics, and NSAIDs
  • St. John’s wort may decrease levels
61
Q

Rivaroxaban nursing considerations?

A
  • OK to crush tablet and mix with applesauce
  • OK to administer medication in a GI feeding tube
62
Q

Rivaroxaban patient education?

A

Report any unusual bleeding or bruising

63
Q

Apixaban drug profile?

A
  • PO only
  • Black box warning-potential spinal hematomas
  • Not recommended for patients w/ prosthetic heart valves
  • Antidote for overdose/toxicity is andexanet alfa
64
Q

Apixaban indication?

A
  • Decrease risk of stroke associated w/ a-fib
  • Prevention of DVT that may lead to a PE after an ortho surgery
65
Q

Apixaban adverse effects?

A
  • Hem: BLEEDING
  • Misc: Hypersensitivity including anaphylaxis
66
Q

Apixaban drug interactions?

A
  • Risk of bleeding may increase by concurrent use of anticoagulants, aspirin, clopidogrel, fibrinolytics, and NSAIDs
  • Concurrent use of St. John’s wort can decrease levels and increase risk of thrombosis
67
Q

Apixaban nursing considerations?

A
  • Assess cues of bleeding, DVT, PE, and/or stroke
  • Tablets can be crushed for patients who can’t swallow
  • OK to crush and mix w/ 60 mL of water or D5W and administered through NG tube
68
Q

Apixaban patient education?

A

Notify HCP if skin rash, cues of an allergic reaction occur

69
Q

List examples of antiplatelet drugs.

A
  • Aspirin
  • Clopidogrel
70
Q

Aspirin drug profile?

A
  • Available in many combinations with other prescription and nonprescription drugs
  • For stroke prevention, daily dose of 50-325 mg recommended by American Stroke Society, but in clinical practice 81mg/day (“baby” aspirin) is the most common dosage
71
Q

Aspirin indication?

A

Stroke prevention

72
Q

Aspirin contraindication?

A

Children and teenagers (Reye’s syndrome)

73
Q

Aspirin adverse effects?

A
  • GI: GI BLEEDING, dyspepsia, epigastric distress, nausea
  • MISC: hypersensitivity reactions (anaphylaxis and laryngeal edema)
74
Q

Aspirin drug interactions?

A

*see other card
- Ibuprofen may negate the cardioprotective antiplatelet effects of low-dose aspirin
- Increased risk of GI irritation with NSAIDs

75
Q

Aspirin nursing considerations?

A
  • If platelet count falls below 80,000/mm3, hold medication and call provider (anticipate therapy to be DC’d)
  • Administer after meals or w/ food or an antacid to minimize gastric irritation
76
Q

Aspirin patient education?

A
  • Report unusual bruising, bleeding or tinnitus
  • Educate that concurrent alcohol use may cause gastric irritation
    ~ 3+ glasses of alcohol may increase the risk of GI bleeding
77
Q

Clopidogrel drug profile?

A
  • Most widely used ADP inhibitor
  • Oral use
  • Black box warning for patients w/ certain genetic abnormalities, who may have a higher rate of CV events d/t reduced cardioversion to its active metabolite
78
Q

Clopidogrel indication?

A
  • Acute coronary syndrome (STEMI, Non-STEMI, unstable angina)
  • Patients w/ established peripheral arterial disease, recent MI, or recent stroke
79
Q

Clopidogrel adverse effects?

A
  • GI: GI BLEEDING
  • MISC: hypersensitivity reactions including anaphylaxis
80
Q

Clopidogrel drug interactions?

A
  • Reduced effectiveness with amiodarone, CCBs, NSAIDS, & PPIs
  • Risk of bleeding may increase by concurrent use of: aspirin, NSAIDs, heparin, LMWH, thrombolytic drugs, warfarin
  • Opioids may decrease absorption of clopidogrel and decrease antiplatelet effects
  • Increased risk of bleeding w/: feverfew, garlic, ginger, and gingko
81
Q

Clopidogrel nursing considerations?

A
  • Assess for GI bleeding, stroke, and MI throughout therapy
  • Monitor for thrombocytopenia
82
Q

Clopidogrel patient education?

A
  • Notify HCP if cues of bleeding occur
  • Avoid taking PPIs
83
Q

List an example of a thrombolytic drug.

84
Q

Alteplase drug profile?

A
  • Very short half-life (~5 mins)
  • Parenteral form only
  • Aminocaproic acid may be used as an antidote
85
Q

Alteplase indication?

A
  • Acute MI, acute ischemic stroke, PE
  • Occluded central venous access device
86
Q

Alteplase adverse effects?

A

Hem: BLEEDING

87
Q

Alteplase drug interactions?

A

*see other card
- Effects may be decreased by antifibrinolytic drugs including aminocaproic acid

88
Q

Alteplase nursing considerations?

A
  • For acute ischemic stroke
    ~ Begin therapy as soon as possible after the onset of symptoms; MUST be given w/in 3- 4.5 hours of symptom onset
  • For PE
    ~ Monitor pulse, BP, hemodynamic labs, respiratory status
  • For DVT
    ~ Observe extremities & palpate pulses of affected extremities
  • For MI
    ~ Monitor ECG/EKG, heart and breath sounds
    ~ Assess for chest pain
  • For catheter occlusion
    ~ Monitor ability to aspirate blood
89
Q

List examples of an antifibrinolytic drugs.

A
  • Aminocaproic Acid
  • Desmopressin
90
Q

Aminocaproic Acid drug profile?

A
  • Synthetic antifibrinolytic drug
  • Oral or parenteral preparations
91
Q

Aminocaproic Acid indication?

A

Management of acute, life-threatening hemorrhage and blood oozing from surgical sites

92
Q

Aminocaproic Acid adverse effects?

A

CV: dysrhythmias, hypotension (IV only)

93
Q

Aminocaproic Acid drug interactions?

A
  • Concurrent use w/ estrogens, may result in a hypercoagulable state
  • Concurrent use w/ clotting factors, may increase risk of thrombosis
94
Q

Aminocaproic Acid nursing considerations?

A
  • Monitor BP, pulse, and respiratory status
  • Monitor bleeding
  • Monitor platelet count
  • Usually given IV until bleeding is controlled
95
Q

Aminocaproic Acid patient education?

A
  • Notify if bleeding reoccurs or if thromboembolic symptoms develop
  • IV administration: make position changes slowly to avoid orthostatic hypotension
96
Q

Desmopressin drug profile?

A
  • Synthetic polypeptide
  • Similar to vasopressin, which is an antidiuretic hormone
97
Q

Desmopressin indication?

A

Hemophilia and von Willebrand’s disease (to stop bleeding)

98
Q

Desmopressin adverse effects?

A
  • F and E: hyponatremia
  • Neuro: Seizures
99
Q

Desmopressin drug interactions?

A

Loop diuretics, systemic glucocorticoids, or inhaled glucocorticoids increase the risk of severe hyponatremia

100
Q

Desmopressin nursing considerations?

A
  • Assess client for cues of bleeding
  • Monitor BP and HR during IV infusion
  • Monitor labs
101
Q

Desmopressin patient education?

A

Notify if bleeding is not controlled or if headache, dyspnea occurs

320 Pharmacology (36 decks)

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