Heparin vs Warfarin

Question 1

This med enhances the activity of antithrombin III- this inhibits thrombin in order to stop the conversion of fibrinogen to fibrin. It works on the intrinsic pathway of coagulation, so whenever there is internal trauma to the vascular system

Answer 1

Heparin

Question 2

this med is part of the family of indirect thrombin inhibitors

Answer 2

Heparin

Question 3

this med belongs to the family of vitamin K antagonist

Answer 3

Warfarin

Question 4

Vitamin K is used in the liver to make _____________-

Answer 4

clotting factors

Question 5

_________ inhibits clotting factors from using vitamin K

Answer 5

Warfarin

Question 6

Which pathway does Warfarin work on ?

Answer 6

Extrinsic pathway of coagulation, activated when there is external trauma

Question 7

Heparin and Warfarin are both ______ - they slow down the clotting process in different ways

Answer 7

anticoagulants

They are not used to break/lysis a clot
rather they are used to prevent/treat blood clots

Question 8

comment on the onset of heparin to Warfarin………

Answer 8

Heparin has FAST onset compared to Warfarin (takes 3-5 days to get to therapeutic levels)

Once INR gets to therapeutic levels using Warfarin, heparin will be weaned off

Question 9

How long does Heparin stay in the system compared to Warfarin ?

Answer 9

Heparin stays in for hours. Warfarin stays in for days

Question 10

How is Heparin administered ? What should you remember about the injection procedure?

Answer 10

Subcutaneous injection - goes into the fatty tissue.
2 inches away from navel. 1 inch away from scars. Rotate injection sites. Don’t massage or rub.

Intravenously- (continuous)

Question 11

What lab value do we monitor for Heparin ?

Answer 11

aPTT (activated partial thromboplastin time)

Question 12

Heparin dosing is based on

Answer 12

weight

Question 13

normal aPTT and therapeutic levels

Answer 13

30-40 seconds

Therapeutic: 1.5-2 times the normal, around 60 seconds

Question 14

How is Warfarin administered ?

Answer 14

Only PO

take at same time every day
If dose is missed: If remembered same day, take the dose

If remembered next day, skip previous dose and take scheduled dose due that day. Write it down what day they missed and let MD know

Question 15

With Warfarin, what lab do we monitor ?

Answer 15

INR
normal INR is 0.75-1.25
Therapeutic levels: 2-3

Question 16

Heparin antidote

Answer 16

Protamine Sulfate

Question 17

Warfarin antidote

Answer 17

Vitamin K

Question 18

Heparin is usually used ______term while Warfarin is used _________ term

Answer 18

short; long

Question 19

Can heparin be used during pregnancy ?

Answer 19

YES

Question 20

Can Warfarin be used during pregnancy?

Answer 20

NO

Question 21

Watch out for this side effect with Heparin

HIT

Answer 21

Heparin induced Thrombocytopenia (HIT)

characterized by reduced platelet counts (thrombocytopenia) and a seemingly paradoxical increase in thrombotic events

Question 22

What is Heparin induced Thrombocytopenia characterized by and what is the main cause ?

Answer 22

characterized by reduced platelet counts (thrombocytopenia) and a seemingly paradoxical increase in thrombotic events

underlying cause is development of antibodies against heparin-platelet protein complexes. These antibodies activate platelets and damage the vascular endothelium, thereby promoting both thrombosis and a rapid loss of circulating platelets

Question 23

If a patient is on heparin for long term and at a high dose, watch out for

Answer 23

osteoporosis

Osteoporosis can occur due to long-term, high doses of Heparin. Bone fractures would indicate this patient is experiencing this complication. Heparin can stimulate osteoclasts and inhibits osteoblast, which affects the strength of the bones.

Question 24

What to remember about diet with Warfarin ?

Answer 24

Avoid excessive intake of green leafy vegetables- broccoli, spinach, kale - these foods are high in vitamin K, which can lower the INR level to non therapeutic levels

Also, alcohol interferes with Warfarin so avoid alcohol

Question 25

Which meds should patients on heparin avoid taking ?

Answer 25

Aspirin, NSAIDS, OTC herbals without talking to physician because it can affect bleeding times

Question 26

Precautions for patients on Heparin or Warfarin

Answer 26

Aspirin, NSAIDS, OTC herbals without talking to physician because it can affect bleeding times

No contact sports (risk for bleeding)

Use electric razors and soft bristle tooth brush

Teach patients S/S of bleeding - look at gums - is there oozing of blood? Any pinkish/reddish urine? Dark, tarry stool? Coffee grounds vomiting ?

Avoid IM injections because of bleeding risk

Question 27

Your patient is started on a Heparin drip. You administer a bolus of Heparin and start the drip per protocol as ordered by the physician. What will be your next important nursing action?*

Answer 27

Collect an aPTT level in 6 hours per protocol.

Question 28

A patient is ordered to start an IV continuous Heparin drip. Prior to starting the medication, the nurse would ensure what information is gathered correctly before initiating the drip?*

Answer 28

Weight

Question 29

“It enhances the activation of antihrombin III, which prevents the activation of thrombin and the conversion of fibrinogen to fibrin.

Answer 29

Heparin

Question 30

In Heparin therapy, the nurse would want to make sure the documented ___________ of the patient is current and accurate.

Answer 30

weight

This medication is weight-based. Therefore, for proper dosing to be administered, a correct weight should be used.

Question 31

Any aPTT value greater than ___________-seconds places the patient at risk for bleeding

Answer 31

80

Question 32

11. A patient is on a continuous IV Heparin drip. As the nurse you are monitoring for any adverse reactions. Select all the signs and symptoms that would indicate this patient is having an adverse reaction to this medication:
A. Hematuria 
B. Decreasing platelets 
C. Increased blood glucose
D. Low hemoglobin and hematocrit 
E. Positive stool guaiac test

Answer 32

The answers are A, B, D and E. Hematuria, low hbg/hct and positive stool guaiac test all indicate the patient is bleeding. A decrease in platelet level could indicate the patient is developing Heparin-induced thrombocytopenia, which is also an adverse reaction to Heparin.

Question 33

What happens in HIT ?

Answer 33

HIT is where the body makes antibodies against Heparin because it’s binding to platelet factor 4 (a blood protein). This creates antibodies that will bind to the heparin and PF4 complex, which activate the platelets. Small clots will form (hence new clots or worsening of clots) and the platelet count falls…hence thrombocytopenia.

Question 34

A patient develops Heparin-Induced Thrombocytopenia (HIT). As the nurse, you would expect the Heparin to be discontinued and the patient to be started on what other type of anticoagulant?
A. Direct thrombin inhibitor
B. Protamine sulfate
C. Switched to subcutaneous Heparin injections
D. Vitamin-K agonist

Answer 34

The answer is A. The Heparin is discontinued and direct thrombin inhibitors can be started like: Argatroban, Bivalirudin etc.

Question 35

4. Warfarin (Coumadin) affects the formation of certain clotting factors. Select below ALL the clotting factors this medication affects:
A. I
B. V
C. II 
D. VII 
E. XI
F. X 
G. IX

Answer 35

The answers are: C, D, F, and G. Warfarin (Coumadin) affects FOUR clotting factors that require vitamin K to form. These clotting factors are: 2, 7, 9, and 10 (II, VII, IX, X)

Question 36

Your patient was started on Warfarin (Coumadin) a week ago for the treatment of a DVT. Which findings below would indicate an adverse reaction to this medication? Select all that apply:
A. Patient reports a severe and sudden headache
B. Melena
C. Chvostek’s Sign
D. Hematuria
E. Coffee ground emesis
F. Bleeding gums

Answer 36

The answers are A, B, D, E, and F. An adverse reaction would be associated with bleeding. Patients who take Warfarin should be monitored for signs and symptoms that bleeding is occurring internally. Example would be: sudden/severe headache (represents intracranial bleed), melena (dark, tarry stools…represent blood), hematuria (urine reddish or pink), coffee ground emesis (bleeding in the stomach), or bleeding gums….along with tachycardia, hypotension, nosebleeds, or bruising for no reason. Chvostek’s Sign is associated with a low calcium level (hypocalcemia).

Question 37

A patient, who is taking Warfarin (Coumadin), asks what he should do if he misses a dose. Your response would be:

Answer 37

Take the dose when remembered, if on the same day. However, if not remembered on the same day but the next day, skip the missed dose and take the next dose at the regular scheduled time