NPN 130CHAPTER 38
ANTICOAGULANT & THROMBOLYTIC DRUGS
COAGULATION CASCADE
• Each factor that is activated acts as a helper that enhances the next reaction. • The end results-> a large collection of fibrin (clot) forms a plug in the vessel stopping the bleeding.•Very normal, happens daily throughout the body
COAGULATION CASCADE
DEFINITIONS• Thrombosis is the formation of a blood clot, or
thrombus• May form in any vessel (artery or vein)
impending blood flow
• When a thrombus detaches itself from the wall of a vessel and is carried throughout the bloodstream, it is called an embolus.• Embolus will travel until it reaches a vessel too small• Pulmonary Embolism- embolus obstructs pulmonary
vessel• Myocardia Infarction (MI)- embolus occludes a vessel
supplying blood to the heart
EMBOLUS
THROMBUSTHROMBOSIS
EMBOLISM
FYI•Anticoagulants: Prevent formation of blood clot
•Antiplatelets: suppress platelet aggregation
• Thrombolytics: help to eliminate clot
ANTICOAGULANTS
• Prevent the formation and extension on a thrombus.
•No effect on an existing thrombus and do not reverse damage from the thrombus
•Commonly referred to as “blood thinners,” but do not actually thin the blood
ANTICOAGULANTS
• Warfarin (coumadin)
• Most commonly prescribed oral anticoagulant• Drug of choice for long-term therapy• Before administration, check PT
(prothrombin time)/INR (international normalized ratio)for clotting times• Symptoms of overdose includes
bleeding. TX with VIT K (antidote-reverses effects of coumadin) or withhold 1-2 doses
ANTICOAGULANTSACTIONS
• Interferes with clotting mechanism
•Warfarin (Coumadin):• Interferes with vit K clotting factors->
results in depletion of prothrombin (essential for clotting)
ANTICOAGULANTS
• Heparin Sodium, Low Molecular Weight Heparin (LMWH)• Before administration, check aPTT (activated
partial thromboplastin time) for clotting times• Enoxaparin (Lovenox)• LMWH require less laboratory monitoring (very
stable responses)• Bleeding less likely with LMWH• If overdose, give Protomine sulfate
(antidote) or discontinuation of drug will correct problems
• Must use infusion pump for safe administration
ANTICOAGULANTSACTIONS
•Heparin:
• Inhibits formation of fibrin clots• Inhibits conversion of fibrinogen to
fibrin • Inactivates factors necessary for the
blood to clot
ANTICOAGULANTS
• Fondaparinux (Arixtra)• Inhibit parts of the coagulation cascade• Used to prevent DVT
USES
•Prophylaxis of DVT•Atrial fibrillation•Prevention/treatment of PE•Adjuvant treatment of MI•Prevention of thrombus formation after valve replacement surgery
PARENTAL ANTICOAGULANTS
•Prevention of post-op DVT and PE
•Prevention of clotting in arterial and heart surgery, dialysis, blood transfusions
PARENTAL ANTICOAGULANTS
•Diagnosis and treatment of disseminated intravascular coagulation (DIC)->severe hemorrhage disorder
•Maintaining patency of if IV caths
ADVERSE REACTIONS
• Bleeding!!!• Skin (bruising and petechiae)• Bladder• Bowel• Stomach• Uterus • Mucous membranes
ADVERSE REACTIONS
• Local irritation when heparin is given subQ route•N/V/D•Hepatitis• Thrombocytopenia (low platelet count)• Blood dyscrasias
CONTRAINDICATIONS
•Known allergy•Active bleeding•Hemorrhagic disease (except DIC)•Leukemia•Ulcers•Recent eye surgery
CONTRAINDICATIONS
•Renal disease•Hepatic disease•Pregnancy•Allergy to pork•Aneurysms
PRECAUTIONS
•Fever•Malignancy•Heart failure•Diarrhea•Pregnancy•Renal/Hepatic disease
•Spinal Procedures (risk of epidural hematoma)
HERBAL ALERT
• Warfarin (Coumadin) has the potential to interact with several herbal remedies. Must let PMD know if taking any herbal supplements
• Increased risk of bleeding if combined with:• Celery• Chamomile• Garlic• Ginger
ANTIPLATELET DRUGS
• Thrombin forming in venous system are made up of fibrin and RBC (Anticoagulants)
• Arterial thrombosis formation is from platelet aggregation (Antiplatelets)
ANTIPLATELET DRUGSACTIONS
•Decreases the platelets ability to “stick” together-> this stops the clot from forming
•Treatment for at risk cardiac and stroke clients
ANTIPLATELET DRUGS
•Clopidogrel (Plavix)
•Eptifibatide (Integrilin)
ADVERSE REACTIONS
•Heart palpitations
•Bleeding•Dizziness/headache•N/V/D/Constipation, dyspepsia
CONTRAINDICATIONS
•Known allergy•Pregnancy/lactating•Congestive heart failure•Active bleeding•Renal or hepatic impairment
CONTRAINDICATIONS
• Pancytopenic patient (Number of RBC, WBC and Platelets are low)
• Thrombotic Thrombocytopenic Purpura (TTP)• Disease that causes blood to clot abnormally ->
not enough platelets to help form clots in other areas of the body-> leads to purpura (bruises) or petechiae (dots)
PETECHIAE
THROMBOLYTIC DRUGSACTION
•Thrombolytics dissolve blood clots already formed
•Also called fibrolytics
•These drugs reopen occluded blood vessels
THROMBOLYTIC DRUGS
• Alteplase (Activase)
• Streptokinase (Streptase)
USES
•Heart attack•Pulmonary emboli•Deep vein thrombosis• Ischemic stroke•Central venous catheters occlusions
CONTRAINDICATIONS/PRECAUTIONS
•Known allergy•Active bleeding•Aneurysm•Major surgery or trauma within last 10 days
NURSING PROCESS
• Medication history• Lab tests• Vital signs
Pre administration Ongoing assessment
• Assesses for signs/symptoms of bleeding• Heparin dosing• Hypersensitivity• Vital signs• Lab tests
INFORMATION TO KNOW
• Avoid alcohol• Antiplatelets can lower all blood counts including
WBC-> increased risk of infection• If unusual bleeding occurs, omit next dose of drug
and contact PMD • Use a soft tooth brush/electric razor• These drugs may inactivate oral contraceptives->
EDUCATE!!!• Inform all medical personnel of drug therapy
REVIEW!
• Rita Simms is a 28-year-old Caucasian woman. She is being discharged from the hospital today after a recent deep venous thromboembolism. She is being discharged with a prescription for warfarin (Coumadin) 5 mg with directions to take 1 tablet daily at 5 PM. The physician has asked the nurse to complete discharge counseling with Ms. Simms.
REVIEW!
How often will Ms. Simms need her prothrombin time and international normalized ratio tested?
2. What are the signs of warfarin overdosage?
3. What should Ms. Simms be told about starting new medications?
NPN 130 CHAPTER 52
IMMUNOSTIMULANT DRUGS
HEMATOPOIETIC SYSTEM
• Blood is a complex fluid that circulates continuously through the heart and blood vessels and to body tissues. 3 major components: • Red blood cells (erythrocytes)- supply our
cells with oxygen from the lungs to this tissues• White blood cells (leukocytes)- protect our
bodies from dangerous microorganisms• Platelets (megakaryocytes)- control
bleeding from microscopic and major tears in our tissues
HEMATOPOIETIC SYSTEM
• Chronic diseases can causes an inadequate number of cells to be made -> the body is then unable to meet demands for oxygen transport, blood coagulation or preventing invasion of microorganisms.
• Goal of treatment is to stimulate the body to make more specific blood cells; called hematopoiesis
HEMATOPOIETIC DRUGS TX ANEMIA
• Anemia is a condition caused by an insufficient amount of hemoglobin delivering oxygen to the tissues.
• Anemia can result from • Blood loss• Excessive destruction of RBC’s• Inadequate production of RBC’s• Deficits in nutrients i.e. iron deficiency anemia
CHRONIC ILLNESS
• Treatment of chronic illnesses and disease itself such as cancer and chronic kidney disease can lead to anemia
• In chronic kidney disease, the kidneys have a reduced ability to produce erythropoietin. Erythropoietin stimulates production of RBCs
• Cancer treatment suppresses bone marrow’s ability to produce RBC’s
ANEMIA
• Symptoms of anemia may include:• Fatigue• Shortness of breath• Headache• Pallor
ERYTHROPOIESIS-STIMULATING AGENTS
• ESA’S stimulate erythropoiesis (process of making RBC’s)• Used to treat anemia associated with • Chronic kidney disease• Chemotherapy for cancer treatment
• Epoetin alfa (Epogen, Procrit)
IRON DEFICIENCY ANEMIA
• When the body does not have enough iron to supply its own needs.
• Iron is a part of hemoglobin that picks up oxygen from the lungs and carries it to the body tissues.
• Low iron results from low RBC’s. Causes include:• Heavy menstrual bleeding• Poor absorption of iron• Lack of iron in diet
IRON DEFICIENCY ANEMIA
• Ferrous (Feostat)• Can give PO
• Iron Dextran (Dexferrum)• IM, IV
ACTIONS & USESIRON DEFICIENCY ANEMIA
•Elevate serum iron levels•Absorbed better on empty stomach•Uses:•Oral•Parenteral
IRON DEFICIENCY ANEMIADRUG ADMINISTRATION
• Best absorbed with empty stomach but due to GI upset, may take them with food• Milk and antacids interfere with iron
absorption->do not give at same time• Due to fatal anaphylactic reactions, before
giving IM/IV, do “test dose” and monitor for dyspnea, rashes, fever
IRON DEFICIENCY ANEMIADRUG ADMINISTRATION
• IM dose can stain surrounding tissue. Must use Z-Track method (ch 2)• Pull skin laterally, displacing tissue to side approximately
1 inch. Hold in this position while injection is given• Wait 10 seconds to ensure med has entered muscle
tissue, then release while withdrawing needle• This prevents backflow of drug into subcutaneous tissue
• NEVER GIVE IM IN DELTOID!!• If giving liquid iron, mix with water or juice and
drink through a straw to prevent staining the teeth
ADVERSE REACTIONS
•Gastrointestinal • Nausea, vomiting,• Constipation- How to treat?• Dark (possibly black) stools
•Generalized• Headache• Backache• Allergy to med
CONTRAINDICATIONS/PRECAUTIONS
•Known allergy to drug
•Parenteral form can cause anaphylactic- type reactions. Only used when oral supplement is contraindicated
FOLIC ACID DEFICIENCY ANEMIA
• Folic acid necessary for production of RBC in the bone marrow
• Folic acid is found in the following foods:• Green, leafy vegetables• Fish• Poultry• Meat• Whole grains
ACTIONS
• Treats anemias caused by deficiency of folic acid
• Given orally
• Folic Acid (folvite)• Can give PO, IM, IV, Subcut
PREGNANCY
• Women need more folic acid during pregnancy. Women with folate deficiency are at increased risk for complications of pregnancy and fetal abnormalities.
• Studies show decreased risk for neural tube defects (spina bifida or meningocele) if taking folic acid before conception and early preganancy.
ADVERSE REACTIONS/INTERACTIONS
• Adverse Reaction:• Rare• Allergic hypersensitivity with parenteral
administration
• Interactions:• Increased risk of seizure activity if
administered with hydantoins (Dilantin).
CONTRAINDICATIONS/PRECAUTIONS
•Folic acid contraindicated•Pernicious anemia•B12 deficiency
• Potential for fetal harm small, use as directed by OB
VITAMIN B12 DEFICIENCY ANEMIA
•B12 is essential to cell growth, reproduction, myelin, and making of blood cells
• Intrinsic factor (found in stomach) is necessary for absorption of B12 in the intestine
ACTIONS
• Vitamin B12 deficiency seen in:• Vegetarians- Vegan• Gastrectomy (removal of the stomach)• Ulcerative colitis (inflammatory problem)• Gastric carcinoma (cancer)
•Once B12 deficiency is corrected, monthly injections for maintenance may be needed
VITAMIN B12 DEFICIENCY
•Vit B12 is found in:•Meats (beef, pork, chicken)• Seafood•Dairy• Eggs
ADVERSE REACTIONS
•Mild diarrhea•Itching• RBC production
CONTRAINDICATIONS/PRECAUTIONS
• Known allergy• Pulmonary disease•Megaloblastic anemia (can cause electrolyte imbalances)• Absorption decreases with• Alcohol • Neomycin (antibiotic)• Colchicine (used in treatment of gout)
ASSESSMENT
• Physical Assessment• Symptoms of anemia???• Lab tests- check RBC• Vital signs- provides baseline
ANEMIA
EVALUATION
•Therapeutic- How to tell?•Bowel movements?•Demonstrate understanding•Compliance•Dietary?
REVIEW!
A nurse is caring for a patient who has been prescribed drug therapy for anemia at a healthcare facility. The healthcare provider has ordered laboratory tests to determine the type, severity, and possible cause of the anemia. What are the different types of anemia?
Which symptoms of anemia should the nurse look for in the patient?
REVIEW!
The physician has prescribed parenteral iron for a patient. The physician has ordered the nurse to observe the patient receiving iron.When is parenteral iron used?
How should iron be administered IM?
Which gastrointestinal reactions should the nurse look for in the patient?
NORMAL LAB LEVELS
• RBC: 4.6 – 5.0 million/McL• Folic acid: 3 – 17 ng/mL• Vitamin B12: 100- 700 pg/mL• Hemoglobin: 12-17.5g/dL• Iron: 60-170 mcg/dL
• http://www.nlm.nih.gov/medlineplus/ency/article/003488.htm
All values other than Iron taken from Appendix C in back of your Medical-Surgical Book that is used for Health Deviations
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