Anticoagulants, Antiplatelets, and Thrombolytics

Miscellaneous antilipemic agents -Meds -Action -RN consider

-Meds: ezetimibe (zetia) which is usually prescribed with a statin, omega-3 fatty acids (lovaza) -Action of zetia: blocks absorption of cholesterol from small intestine to decrease elevated cholesterol, increases HDL -RN consider zetia: common adverse effects are abdominal pain, diarrhea, take at night because body releases more of it into the bloodstream Action of lovaza: reduces synthesis of triglycerides in the liver; MOA is unknown, decreases elevated triclyceride levels RN consider lovaza: diet modification Side effects lovaza: back and abdominal pain, nausea, bloating, bad taste in mouth, weakness, diarrhea

Thrombolytics -Action -Risks -What to assess for -Meds

-Used to break up clots -Streptokinase, Alteplase, Tenectaplase -Risk for anaphylaxis with streptokinase -Assess for bleeding, EKG (d/t dysrhythmias), DO BLOOD DRAWS PRIOR TO GIVING MEDS, significant hemorrhage at site of necrotic tissue *use or risk of distal tissue necrosis*

Prothrombin Time (PT)

11 - 12 sec is normal Warfarin therapeutic level is 1.25-2.5 x normal

INR normal level

2.0-3.5

Antiplatelets: aspirin dosage used for anticoagulation and for antiplatelet

80-100mg

Embolus

A clot that breaks off and travels through the blood stream

Fibrin Definition

A solid substance (formed from fibrinogen) that makes a clot harder to break up. It forms the mesh or net that holds platelets in place

Fibrinogen definition

A specialized protein or clotting factor found in blood. When a blood vessel is injured, thrombin, another clotting factor, is activated and changes fibrinogen into fibrin.

The nurse would question an order for colesevelam (Welchol) if the patient has which condition in the medical history? A. Impaction B. Glaucoma C. Hepatic disease D. Renal disease

A. Impaction

Which intervention is essential before the nurse administers tenecteplase? A. Perform all necessary venipunctures. B. Administer aminocaproic acid (Amicar). C. Have the patient void. D. Assess for allergies to iodine.

A. Perform all necessary venipunctures.

Which nursing intervention is essential for the patient receiving alteplase? A. Assess for reperfusion dysrhythmias B. Monitor liver enzymes C. Administer prescribed vitamin K if bruising is observed D. Monitor blood pressure and stop medication if blood pressure drops below 110 systolic

A. assess for reperfusion dysrhythmias

Warfarin (Coumadin) -Normal/Therapeutic levels -Food interactions -Interactions w drugs -Contraindications -RN considerations

Action: inhibits hepatic synthesis of vitamin K, which affects clotting factors Uses: thrombophlebitis, embolism formation d/t a-fib, increases clotting time, used for venous and arterial disorders at high risk for clot disorders Target INR 2-3.5 RN considerations: Watch for green leafy vegetables, d/t monitor HR, BP bleeding risk so avoid razors, use soft toothbrushes, avoid contact sports, Contraindicated with alcohol, blood dycrasias, ulcers, hemophilia, severe HTN (d/t weakened area of the heart which can lead to blockage or susceptibility to aneurism)

What is the treatment for a person with severe hypertriglyceridemia?

Addressing secondary factors, statin and very low fat diet, avoid refined carbohydrates and alcohol. Omega-3 fatty acids, fibrates

The patient has an international normalized ratio (INR) value of 1.5. In response to this, the nurse could anticipate the health care provider placing which order? A. administer an additional dose of Warfarin B. Hold the next dose of Warfarin C. increase the heparin drip rate D. Administer Protamine sulfate

Administer an additional dose of Warfarin

Antidote for hemorrhage

AminoCaproic Acid

What is the antidote for ribarxaban (xarelto) and apixaban (eliquis) when bleeding will not stop

Andexxa

Arterial versus Venous thrombosis

Arterial= platelets and red blood cells trapped by fibrin Venous= Red blood cell clots when platelets and fibrin bind

Uses of each antiplatelet drug

Aspirin (anticoagulant and antiplatelet) Plavix (prevents future and second heart attack, strokes Persantine (antiplatelet, vasodilator) used with anticoagulants post heart valve replacement Pletal- antiplatlet and vasodilator (used to treat intermittent claudication of legs)

Nursing process for drugs to improve blood flow

Assess: Monitor vital signs, especially bp and hr Inform patient that a desired response may take up to 1.5-3 months advise patient not to smoke or drink alcohol encourage pt to change positions slowly to avoid orthopedic hypotension

The patient asks the nurse to explain the difference between dalteparin and heparin. Which response by the nurse is accurate? A. "There is no real difference. Dalteparin is preferred because it is less expensive." B. "Dalteparin is a low-molecular-weight heparin that is more predictable in its effect and has a lower risk of bleeding." C. "I'm not sure why some health care providers choose dalteparin and some heparin. You should ask your doctor." D. "The only difference is that heparin dosing is based on the patient's weight."

B. "Dalteparin is a low-molecular-weight heparin that is more predictable in its effect and has a lower risk of bleeding."

A patient is receiving warfarin for a chronic condition. Which patient statement requires immediate action by the nurse? A. "I will take my medication in the early evening each day." B. "I will increase dark-green, leafy vegetables in my diet." C. "I will contact my health care provider if I develop excessive bruising." D. "I will avoid contact sports"

B. "I will increase dark-green, leafy vegetables in my diet."

Which statement indicates the patient understands discharge instructions regarding cholestyramine? A. "I will take cholestyramine 1 h before my other medications." B. "I will increase fiber in my diet." C. "I will weigh myself weekly." D. "I will have my blood pressure checked weekly."

B. "I will increase fiber in my diet"

A patient is started on warfarin therapy while also receiving intravenous heparin. The patient is concerned about the risk for bleeding. What will the nurse tell the patient? A. "Your concern is valid. I will call the doctor to discontinue the heparin." B. "It usually takes about 3 days to achieve a therapeutic effect for warfarin, so the heparin is continued until the warfarin is therapeutic." C. "Because of your valve replacement, it is especially important for you to be anticoagulated. The heparin and warfarin together are more effective than one alone." D. "Because you are now up and walking, you have a higher risk of blood clots and therefore need to be on both medications."

B. "It usually takes about 3 days to achieve a therapeutic effect for warfarin, so the heparin is continued until the warfarin is therapeutic."

Which nursing intervention will decrease the flushing reaction of niacin? A. Administering niacin with an antacid B. Administering aspirin 30 min before nicotinic acid C. Administering diphenhydramine hydrochloride (Benadryl) with niacin D. Applying cold compresses to the head and neck

B. Administering aspirin 30 min before nicotinic acid

Which assessment finding in a patient taking an HMG-CoA reductase inhibitor will the nurse act on immediately? A. Decreased hemoglobin B. Elevated liver function tests C. Elevated HDL D. Elevated LDL

B. Elevated liver function tests

A patient diagnosed with hypercholesterolemia is prescribed lovastatin. Based on this medication order, the nurse will contact the health care provider about which reported condition in the patient's history? A. Chronic pulmonary disease B. Hepatic disease C. Leukemia D. Renal disease

B. Hepatic disease

The patient is started on ezetimibe for elevated cholesterol. The nurse demonstrates understanding of the mechanism of action of this drug when including which statement in the patient education presentation? A. This drug inhibits cholesterol synthesis in the liver. B. This drug inhibits cholesterol absorption in the bowel. C. This drug sequesters bile acids in the small bowel. D. This drug increases pancreatic secretion facilitating lipid breakdown.

B. This drug inhibits cholesterol absorption in the bowel

A patient who has been taking warfarin is admitted with coffee-ground emesis. What can the nurse anticipate being prescribed for this patient? A. Vitamin E B. Vitamin K C. Protamine Sulfate D. Calcium Gluconate

B. Vitamin K

A patient is receiving an intravenous heparin drip. Which laboratory value requires immediate action by the nurse? A. Platelet count of 150,000 B. Activated partial thromboplastin time (aPTT) of 120 sec C. INR of 1.0 D. Blood urea nitrogen (BUN) level of 12 mg/dL

B. aPTT of 120 seconds

A patient has arrived at the emergency department and requires immediate surgery. He has been receiving heparin. Which intervention is essential? A. Teach the patient about the phenytoin. B. Administer protamine sulfate. C. Assess the INR before surgery. D. Administer vitamin K.

B. administer protamine sulfate

A patient taking warfarin asks for an aspirin for a headache. What is the nurse's best action? A. Administer 650 mg of acetylsalicylic acid (ASA) and reassess pain in 30 min. B. Teach the patient of potential drug interactions with anticoagulants. C. Explain to the patient that ASA is contraindicated and administer ibuprofen as ordered. D. Explain that the headache is an expected side effect and will subside shortly.

B. teach the patient of potential drug interactions with anticoagulants

Why might LMWH be ordered for a post-op orthopedic patient?

Because they are immobile after surgery so blood flow slows down making PE and DVT more possible

The National Cholesterol Education Program thinks that cholesterol can be lowered in diets how?

By reducing saturated fat and cholesterol in diet, and therapeutic lifestyle changes (diet >7% of calories from sat fat; >200 mg of dietary cholesterol/day and increase soluble fiber), weight management, and physical activity)

The patient who is prescribed cilostazol questions the nurse about the addition of the drug to the drugs currently prescribed. The patient states, "I already take something for my platelets." Which response by the nurse provides the best information to the patient?A. Cilostazol also lowers blood pressure to improve arterial blood flow. B. Cilostazol interferes with the last step of lipid deposit in walls of vessels. C. Cilostazol promotes vasodilation, improving blood flow to the extremities. D. Cilostazol decreases blood viscosity, improving flexibility of erythrocytes.

C. "Cilostazol promotes vasodilation, improving blood flow to the extremeties

A nurse is preparing to administer enoxaparin sodium to a patient for the prevention of deep vein thrombosis. Which is an essential nursing intervention? A. Draw up the medication in a syringe with a 22-gauge, 1½-inch needle. B. Utilize the Z-track method to inject the medication. C. Administer the medication into subcutaneous tissue. D. Rub the administration site after injecting.

C. Administer the medication into subcutaneous tissue

A patient is taking pravastatin sodium. Which assessment finding requires immediate action by the nurse? A. Headache B. Slight nausea C. Muscle pain D. Fatigue

C. Muscle pain

The nurse reviews the history for a patient taking atorvastatin. What will the nurse act on immediately? A. The patient takes medications with grape juice. B. The patient takes herbal therapy including kava. C. The patient is on oral contraceptives. D. The patient was started on penicillin for a respiratory infection.

C. the patient is on oral contraceptives

Which patient's statement indicates a need for further medication instruction about colestipol? A. "The medication may cause constipation, so I will increase fluid and fiber in my diet." B. "I should take this medication 1 h after or 4 h before my other medications." C. "I might need to take fat-soluble vitamins to supplement my diet." D. "I should stir the powder in as small an amount of fluid as possible to maintain potency of the medication."

D. "I should stir powder in as small an amount of fluid as possible to maintain potency of the medication"

Which statement made by the patient indicates to the nurse that understanding about discharge instructions on antihyperlipidemic medications has occurred? A. "Antihyperlipidemic medications will replace the other interventions I have been doing to try to decrease my cholesterol." B. "It is important to double my dose if I miss one in order to maintain therapeutic blood levels." C. "I will stop taking the medication if it causes nausea and vomiting." D. "I will continue my exercise program to help increase my high-density lipoprotein serum levels."

D. "I will continue my exercise program to help increase my high-density lipoprotein serum levels"

The nurse evaluates that the patient has understood discharge teaching regarding warfarin based on which statement? A. "I will double my dose if I forget to take it the day before." B. "I should keep taking ibuprofen for my arthritis." C. "I should decrease the dose if I start bruising easily." D. I should use a soft toothbrush for dental hygiene."

D. I should use a soft toothbrush for dental hygiene

What vital signs are expected with internal bleeding?

Decreased blood pressure, increased heart rate

Where is necrotized tissue located in respect to a clot?

Distal to the clot

What is the difference in having Factor Xa (10-A) oral anticoagulants? Is there a difference for patients?

Factor Xa allows for less frequent monitoring, no need for restrictions on green leafy veggies

Define Thrombosis

Formation (Aggregation) of venous or arterial clot

Lipoproteins

HDL's (good) >40 mg/dl LDL's (bad) <100 mg/dl VLDL (bad) Chylomicrons

Heparin -Route -Side effects -RN considerations

Heparin is an IV, SQ, or IV drip medication Injections should be administered in the abdomen at a 45 degree angle RN consider bleeding risk

Factor Xa SQ alternative is Fondiparinux (Arixtra) Why? How often is it given?

It is synthetic so anyone can have it (vegans, people who usually don't take meds due to religious reasons) It is taken SQ 1x a day in the abdomen

What are post-operative patients usually prescribed to treat or prevent blood clots and why is that med class chosen?

Low molecular weight heparins because patients will be less mobile and blood flow will be slowed down making DVT and PE more possible

Antiplatelets -Meds, routes -Uses -Contraindications -What to watch for -Interactions

Meds: Aspirin, Plavix, Persantine, Pletal Routes PO Uses: limits formation of platelets in post- MI, post stroke pts, prevents arterial thrombosis caused by platelet aggregation Adverse rxns: GI upset, N/V, loss of appetite, potential for hemorrhage, risk for bleeding, dizziness, weakness, HA RN consider: Avoid IM/SQ injections d/t bleeding, monitor platelet count, give w meals if GI upset occurs, make sure OTC meds dont already contain aspirin, Interactions: Gingko Biloba with plavix (increases risk for bleeding)

Low Molecular Weight Heparin -Meds and route -Advantages -RN consider

Meds: Lovenox, Fragmin, Innohep Route: SQ (administer in abdomen and rotate sites Advantages: more stable, longer acting, decreased risk of bleeding RN consider: anti-platelet meds need to be held (aspirin), check Ptt and Aptt labs

Niacins (Nicotinic acid) -Meds -Action -RN consider -Interactions -Side effects -Contraindications

Meds: Nicotinic acid (vitamin b3) Action: inhibits VLDL synthesis by liver cells Use: lowers cholesterol and triglycerides, lowers risk of second heart attack; treats atherosclerosis RN consider: orthostatic hypotension, flushing (warmth, itching, redness, tingling), titrate dose and aspirin, will subside with time. Risk for rhabdomyelosis (esp when taking statin), monitor glucose d/t hyperglycemia risk, if taking colestipol or cholestyramine take at least 4-6 hours before/after take niacin. Niacin has been associated with small increases in PT time so if pt is also on anticoagulants monitor PT closely. Elderly pts with diabetes, renal failure, or hypothyroidism are at risk (monitor for s/s muscle pain, tenderness, weakness during first few months of therapy and when doses are increased) Contraindications: Liver disease, peptic ulcer disease, arterial bleeding, caution with extended release meds and alcohol, unstable angina or in acute phase of an MI especially if they take nitrates, calcium channel blockers or adrenergic blocking agents

Direct Thrombin Inhibitors -Action -Meds and routes -Side effects -RN consider

Meds: Pradaxa (PO), Argatroban and Bivalitudin (IV), Desirudin (SQ) Action: Inhibits thrombin from converting fibrinogen to fibrin, easily able to stop/start (besides pradaxa) Sfx: bleeding RN consider: bleeding, not for pts with prosthetic mechanical heart valves, doesnt require regular coagulation monitoring, avoids risk for heparin induced thrombocytopenia

Bile acid binding resins -Action -Meds -RN consider -Advantages -Interactions -Side effects

Meds: cholestyramine (questran, prevalite), colestipol (colestid), colesevelam (welchol) Action: Blocks bile acid in stomach from being absorbed, forcing the liver to pull cholesterol from the blood, reducing cholesterol levels Advantages: lowers LDL, helps diabetic pts manage blood sugar, can be used in combination with a statin or niacin to aggressively lower LDL levels by 50% and elevate HDL levels Interactions: Binds to other drugs (Digoxin, Warfarin, Thyroid meds, vitamins A, D, E, K and increases their effects) Side effects: cholestyramine: GI side effects (constipation), severe diarrhea (risk for fluid imbalance and dehydration) RN consider: If constipation, increase H2O and fiber, if still continues with cramping pain suggest to MD to switch to another med. Take other meds 1 hour before or 4-6 hours after bile acid meds

Fibrates -Meds -Action -Side effects -RN considerations

Meds: gemifibrozil (Lopid), fenofibrate (Tricor) Action: lower triclyceride levels; MOA is unknown RN consider: avoid giving gemifibrozil with anticoagulants or decrease, monitor INR levels, greater bleeding risk with Fenofibrate Watch for liver or renal disease pts, increases effect of warfarin and sulfonureas, restrict alcohol, watch VLDL, LDL, triglyceride and cholesterol levels. Encourage diets low in fat, cholesterol and sugar

Triglycerides: moderate and severe ranges and target range

Moderate 150-499 Severe 500+ Target <150

Define intermittent claudification

Narrowing of arteries due to poor circulation or aging

Activated partial thromboplastin time (aPTT) Normal and therapeutic level with Heparin use

Normal: 20-35 seconds Therapeutic: 30-85 seconds

What test should be done for Warfarin and what is the normal ranges?

PT (22-38seconds) and INR 2-3.5

Antidote for direct thrombin inhibitors

Praxbind

Anticoagulants function

Prevent new clots from forming

If a med has a warning about avoiding with a hx of peptic ulcers, what should be suggested

Proton pump inhibitor because it reduces the amount of stomach acid that leads to the opening up of the ulcers

What labs should be checked for a patient on Heparin and what are their normal ranges?

Ptt (1.5-2x 60-70 seconds) and Aptt (normal 20-35 seconds, therapeutic 30-85 seconds)

Anticoagulants -Risks in venous and arterial clots -Route of meds, meds

Risks for arterial clots- risk for coronary thrombosis, MI, thrombotic stroke, clogging of artificial heart valve (no platelets should be given to pts with artificial heart valves) Risks for venous-DVT and PE's Meds: Coumadin/Warfarin PO Interactions: St. Johns Wort (decreases effectiveness)

HMG-CoA reductase inhibitors (statins) -meds -side effects -RN considerations

STATINS meds: simvistatin (zocor), atorvastatin (lipitor), rosuvastatin (crestor) action: inhibits enzyme responsible for converting HMG-CoA to mevalonate, untimately reducing liver cholesterol RN consider: teach pt to not abruptly stop d/t rebound acute MI; monitor liver enzymes, take with full glass of H2O for it to work more effectively, report muscle aches immediately, best to take at night especially simvastatin because body releases more of it into bloodstream, yearly eye exams side effects: rhabdomyelosis risk especially when combined with niacins, change in eye sight

Platelet definition

Small particles in the blood that control bleeding, they form clusters to assist in clotting

Anti-platelet function

Suppress platelet formation to prevent clots

Define heparin induced thrombocytopenia and explain the concern

Thrombocytopenia is when there is a low platelet count. This is a concern because the risk for bleeding increases.

What is the main goal when taking a SQ/IV/IV drip anticoagulant?

To transition to an oral anticoagulant over a span of 2-5 days

Thrombolytics function

Used to dissolve blood clots

Antidote for Warfarin?

Vitamin K

Define hyperlipidemia

high concentrations of lipids in the blood -Major cause of atherosclerosis

Drugs to improve blood flow: Statins, BP meds, antiplatelets -meds -action -RN consider -Side effects

meds: statins, BP meds (ramipril, prazosin, nifedipine), antiplatelets (clopidogrel, aspirin, cilostazol), Pentoxifylline (a hemorrheologic) Action of statins, bp meds, and antiplatelets: treat peripheral vascular disease (PVD) and peripheral artery disease (PAD) due to arteriosclerosis and hyperlipidemia Action of pentoxifylline: decreases blood viscosity, improves flexibility of erythrocytes, improves microcirculation and tissue perfusion, inhibits platelet aggregation Action of cilostazol: causes peripheral vasodilation and inhibits platelet aggregation RN consider: monitor for s/s or numbness and coolness in extremities, claudication, leg ulcers and treat with peripheral vasodilators to increase blood flow, too much of pentoxifylline can cause tachycardia, areflecia, and GI distress Side effects (cilostazol) dizziness, HA, peripheral edema, GI distress, tachycardia, palpitations, blood dycrasias, dysrhythmias

Heparin Antidote

protamine sulfate