module 4 test 4
how do you minimize the risk of bleeding?
- Minimize physical manipulation of the patient - Avoid subQ and IM injections - Minimize invasive procedures - Minimize concurrent use of anticoagulants (for example, heparin, warfarin, dabigatran) - Minimize concurrent use of antiplatelet drugs (for example, aspirin, clopidogrel)
main things with rivaroxabon
- anticoagulant - prevents DVT, PE and stroke by binding to factor 10 and inactivating thrombin
ADR of heparin
- bleeding - low platelet count - do not use after surgery of eye, brain, spinal cord - cloudy urine - pelvic pain - headache
ADR of warfarin
- can cross placenta - alopecia - dermatitis - don't use vitamin K food because it reverses effects
if the APTT test comes back BELOW 60, what does this indicate and what should you do?
- increases risk of developing a clot - need to increase the drug
if the APTT test comes back ABOVE 80 what does this indicated and what should you do?
- risk of bleeding - may have to decrease rate of drug
what drugs decrease absorption of ferrous sulfate?
- tetracycline - food - antiacids
t/f: heparin breaks up existing clots
FALSE
t/f; Warfarin is useful for treating existing thromboses and for emergencies because the onset of action is immediate.
FALSE! not useful for existing problems because the action of this drug is delayed
how do you teach your patient to take dabigatran?
swallow pills whole with or without food
Signs of Iron Deficiency
-anemia -pale conjunctiva -pale skin color -atrophy of papillae on tongue -brittle, riged, spoon-shaped nails -thyroid edema
what are sources of iron
1) Meat 2) Chicken 3) Fish 4) Eggs 5) Milk and 6) Enriched Flour
what is the range when testing an INR
2-3
when is it best to use alterplase?
2-3 hours of the event (stroke, MI, pulmonary embolism)
what is a normal aptt time
40 seconds - want patient to be between 60-80 seconds
what 4 factors need vitamin K
7, 9, 10, 2
Which patients below are NOT candidates for Warfarin (Coumadin)? Select all that apply: A. A 45-year-old male patient with alcoholism and an active GI ulcer. B. A 55-year-old female with a heart valve replacement. C. A 36-year-old female with a deep vein thrombosis. D. A 52-year-old male who needs a liver transplant.
a and d
what is it important to monitor frequently in a new patient taking heparin
Aptt
Arterial thrombosis
Formed when platelets adhere to the arterial wall, continued aggregation leads to occlusion of the artery, localized harmful results
which way of administration of cyanocobalamin is good for severe, neurologic events?
IM!
Heparin MOA
Inactivates Factor Xa and inhibits conversion of prothrombin to thrombin
what tests do you monitor when on warfarin?
PTINR
You're providing care to a patient who has been receiving long-term doses of Heparin. What finding in this patient demonstrates the patient may be experiencing a complication that can occur due to long-term use of this drug? A. Uncontrolled hypertension B. Bone fractures C. Hyperkalemia D. Raynaud's Syndrome
The answer is B. Osteoporosis can occur due to long-term, high doses of Heparin
venous thrombosis
The formation of blood clots within a vein. The clots commonly form in the veins of the lower extremities. Result from slowing of the blood return to the heart.
You're educating a patient's family member about Warfarin (Coumadin) and how it is used to treat blood clots. Which statements by the family member require you to re-educate them about how this medication works? Select all that apply: A. "This medication will help dissolve the blood clot." B. "This medication will prevent another blood clot from forming." C. "This medication will help prevent the blood clot from becoming bigger in size." D. "This medication starts working immediately after the first dose."
a and d
A patient who is taking warfarin (Coumadin) has just vomited blood. The nurse notifies the provider, who orders lab work revealing a PT of 42 seconds and an INR of 3.5. The nurse will expect to administer: a. phytonadione (vitamin K1) 1 mg IV over 1 hour. b. phytonadione (vitamin K1) 2.5 mg PO.
a
monitor Aptt and leaves body fast a. heparin b. warfarin
a
rapid onset a. heparin b. warfarin
a
A patient with atrial fibrillation is receiving warfarin (Coumadin). The nurse notes that the patient's INR is 2.7. Before to giving the next dose of warfarin, the nurse will notify the provider and: a. administer the dose as ordered. b. request an order to decrease the dose. c. request an order to give vitamin K (phytonadione). d. request an order to increase the dose.
a - range is from 2-3
clopidogrel (select all that apply) a. prevent blockage of coronary stents b. prevent stenosis of stents, MI, Stroke c. remove thrombin that already formed d. binds with factor 10a to inactivate thrombin
a and b
Which patients below would be at a HIGH risk for developing adverse effects of Heparin drug therapy? Select all that apply: A. A 55-year-old male patient who is post-op day 1 from brain surgery. B. A 45-year-old female patient with a pulmonary embolism. C. A 36-year-old male patient with active peptic ulcer disease. D. A 43-year-old female with uncontrolled atrial fibrillation.
a and c
Your patient on Heparin develops Heparin-Induced Thrombocytopenia (HIT). What signs and symptoms in the patient confirm this diagnosis? Select all that apply: A. Decrease in platelet level B. Increase in platelet level C. Development of a new thrombus D. Increase in hemoglobin level
a and c
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
a, b d and e
Select all the TRUE statements about the medication Heparin: A. Heparin can be used during pregnancy. B. Heparin has a short half-life. C. Heparin works to affect the intrinsic pathways of clotting. D. Heparin can be administered orally, intravenously, or subcutaneously.
a, b, c
last signs of toxicity when taking ferrous sulfate
acidosis, necrosis, liver toxicity, pulmonary edema
what drug does this? binds with plasminogen to form an active complex and promote lysis of fibrin
alterplase a clot buster
what is an aPTT test? Why is it used with heparin?
an efficacy test that monitors the ability for function of the intrinsic and extrinsic pathway - to see if the drug is working
what is this? A condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume.
anemia
antiplatelet drugs are good for treating what?
arterial thrombosis
how is alterplase given?
as a bolus dose
where does intrinsic stage 1 and extrinsic stage 2 meet?
at factor 10A
A patient is admitted to the emergency department with chest pain. An electrocardiogram shows changes consistent with an evolving myocardial infarction. The patient's cardiac enzymes are pending. The nurse caring for this patient will expect to: a. administer aspirin when cardiac enzymes are completed. b. give alteplase (Activase) within 2 hours. c. give tenecteplase (TNKase) immediately. d. obtain an order for an INR.
b
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? A. Vital signs B. Weight C. PT/INR level D. EKG
b
A patient is scheduled to take a dose of Warfarin (Coumadin) at 1800. The patient's INR level is 6. As the nurse you will? A. Administer the dose as scheduled B. Hold the dose and notify the physician C. Double the dose D. Hold today's dose but administer tomorrow's dose as scheduled.
b
A patient will begin taking dabigatran etexilate (Pradaxa) to prevent stroke. The nurse will include which statement when teaching this patient? a. Dabigatran should be taken on an empty stomach to improve absorption. b. It is important not to crush, chew, or open capsules of dabigatran. c. The risk of bleeding with dabigatran is less than that with warfarin (Coumadin). d. To remember to take dabigatran twice daily, a pill organizer can be useful.
b
A patient, who is taking Warfarin (Coumadin), asks what he should do if he misses a dose. Your response would be: A. Double the dose the next day and notify the physician. B. 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. C. Hold all doses and call the doctor. D. Split the dose the next day.
b
__________ heparins have higher bioavailability and longer half-lives, so routine coagulation monitoring is not necessary and fixed dosing is possible a. heparin unfractioned b. heparin low molecular weight
b
long onset and long half-life a. heparin b. warfarin
b
A patient is taking Warfarin (Coumadin). What order received from the physician requires that you ask for an order clarification? A. Check PT/INR daily B. Administer Prednisone IM daily C. Ambulate three times per day D. Draw CBC in the morning
b - avoid any other medication with warfarin!
A nurse caring for a patient receiving heparin therapy notes that the patient has a heart rate of 98 beats per minute and a blood pressure of 110/72 mm Hg. The patient's fingertips are purplish in color. A stat CBC shows a platelet count of less than 100,000 mm3. The nurse will: a. administer oxygen and notify the provider. b. discontinue the heparin and notify the provider. c. request an order for protamine sulfate. d. request an order for vitamin K (phytonadione).
b -This patient is showing signs of heparin-induced thrombocytopenia, so the heparin should be discontinued immediately and the provider should be notified. The purplish color of the fingertips is caused by thrombosis, not hypoxia, so oxygen is not indicated. This patient may need continued anticoagulation therapy, so a request for protamine sulfate is not correct.
Your patient is being discharged home and will be required to self-administer injectable Heparin. You are observing the patient administer their scheduled dose of Heparin to confirm that the patient knows how to do it correctly. What action by the patient requires you to re-educate them about how to administer Heparin? A. The patient injects the needle into the fatty tissue of the abdomen. B. The patient injects the needle 1 inch away from the umbilicus. C. The patient rotated the injection site from the previous dose of Heparin. D. The patient does not massage the injection site after administering the medication.
b - should be 2 inches
what do you do if the liquid sulfate stains your teeth?
dilute drug in water, drink it with a straw or rinse your mouth after use
why should you avoid alcohol when on warfarin?
because it increases risk of bleeding
how come when you diagnose a patient with iron deficiency their serum iron capacity looks like it increased?
because it reduces the amount of iron available because it is all being used
why should you not give warfarin in emergencies?
because the peak takes a few days to hit
warfarin decreases the effectiveness of what drug?
birth control
A nursing student who is preparing to care for a postoperative patient with deep vein thrombosis asks the nurse why the patient must take heparin rather than warfarin. Which response by the nurse is correct? a. "Heparin has a longer half-life." b. "Heparin has fewer adverse effects." c. "The onset of warfarin is delayed." d. "Warfarin prevents platelet aggregation."
c
A patient has been receiving heparin while in the hospital to treat deep vein thromboses and will be discharged home with a prescription for enoxaparin (Lovenox). The nurse provides teaching for the nursing student who asks about the advantages of enoxaparin over heparin. Which statement by the student indicates a need for further teaching? a. "Enoxaparin does not require coagulation monitoring." b. "Enoxaparin has greater bioavailability than heparin." c. "Enoxaparin is more cost-effective than heparin." d. "Enoxaparin may be given using a fixed dosage."
c
Apostoperative patientreports pain in the left lower extremity. The nurse notes swelling in the lower leg, which feels warm to touch. The nurse will anticipate giving which medication? a. Aspirin b. Clopidogrel (Plavix) c. Enoxaparin (Lovenox) d. Warfarin (Coumadin)
c -Enoxaparin is a low-molecular-weight heparin and is used in situations requiring rapid onset of anticoagulant effects, such as massive DVT
what drug helps with vitamin b12 deficiency
cyanocobalamin
A patient has been taking warfarin (Coumadin) for atrial fibrillation. The provider has ordered dabigatran etexilate (Pradaxa) to replace the warfarin. The nurse teaches the patient about the change in drug regimen. Which statement by the patient indicates understanding of the teaching? a. "I may need to adjust the dose of dabigatran after weaning off the warfarin." b. "I should continue to take the warfarin after beginning the dabigatran until my INR is greater than 3." c. "I should stop taking the warfarin 3 days before starting the dabigatran." d. "I will stop taking the warfarin and will start taking the dabigatran when my INR is less than 2."
d
A patient is receiving heparinpostoperatively to prevent deep vein thrombosis. The nurse notes that the patient has a blood pressure of 90/50 mm Hg and a heart rate of 98 beats per minute. The patient's most recent aPTT is greater than 90 seconds. The patient reports lumbar pain. The nurse will request an order for: a. a repeat aPTT to be drawn immediately. b. analgesic medication. c. changing heparin to aspirin. d. protamine sulfate.
d
A patient, who is receiving continuous IV Heparin, has an aPTT of 105 seconds. What is your next nursing action per protocol? A. Continue with the infusion because no change is needed based on this aPTT. B. Increase the drip rate per protocol because the aPTT is too low. C. Re-draw the aPTT STAT. D. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high.
d
What is the antidote for Warfarin (Coumadin)? A. Flumazenil B. Narcan C. Protamine Sulfate D. Vitamin K
d
Which statement below BEST describes how Heparin works as an anticoagulant? A. "It inhibits clotting factors from synthesizing Vitamin K." B. "It inactivates the extrinsic pathways of coagulation." C. "It prevents Factor Xa from activating prothrombin to fibrinogen." D. "It enhances the activation of antihrombin III, which prevents the activation of thrombin and the conversion of fibrinogen to fibrin."
d
Which statement below BEST describes how Warfarin (Coumadin) works as an anticoagulant? A. "It inhibits the formation of thrombin and fibrin in the clotting process." B. "It increases the production of Factor Xa, which blocks thrombin and decreases the clotting process." C. "It binds to antithrombin and reverses the clotting process." D. "It stops the coagulation process by blocking the formation of clotting factors in the liver that require Vitamin K to form."
d
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? A. Collect a PT level in 6 hours per protocol. B. Collect an INR level in 4 hours per protocol. C. Collect a Troponin level in 6 hours per protocol. D. Collect an aPTT level in 6 hours per protocol.
d
A patient who takes warfarin for atrial fibrillation undergoes hip replacement surgery. On the second postoperative day, the nurse assesses the patient and notes an oxygen saturation of 83%, pleuritic chest pain, shortness of breath, and hemoptysis. The nurse will contact the provider to report possible _____ and request an order for _____. a. congestive heart failure; furosemide (Lasix) b. hemorrhage; vitamin K (phytonadione) c. myocardial infarction: tissue plasminogen activator (tPA) d. pulmonary embolism; heparin
d - heparin is used in emergency situations
A patient who takes warfarin (Coumadin) is brought to the emergency department after accidentally taking too much warfarin. The patient's heart rate is 78 beats per minute and the blood pressure is 120/80 mm Hg. A dipstick urinalysis is normal. The patient does not have any obvious hematoma or petechiae and does not complain of pain. The nurse will anticipate an order for: a. vitamin K (phytonadione). b. protamine sulfate. c. a PTT. d. a PT and an INR.
d -This patient does not exhibit any signs of bleeding from a warfarin overdose. The vital signs are stable, there are no hematomas or petechiae, and the patient does not have pain. A PT and INR should be drawn to evaluate the anticoagulant effects.
what anticoagulant is safer in patients with a fib or post op?
dabigatran
signs and symptoms of hemorrhage
decrease in blood pressure, bruising, and lumbar pain
what is a full mature red blood cell called?
erythrocyte
TRUE OR FALSE: If a patient's INR level falls too low, there is a risk of clot formation and the Warfarin (Coumadin) dose needs to be decreased. True False
false
t/f: warfarin breaks up existing clots
false
what drug is the main choice to help iron deficiency
ferrous sulfate
what two drugs help iron deficiency
ferrous sulfate and iron dextran
what can mask b12 symptoms when taking cyanocobalamin ?
folic acid
what drug does this? affects intrinsic pathway of coagulation by binding to antithrombin 3 to prevent thrombin and prevent conversion of fibrinogen to fibrin to slow clots and prevent clots from getting bigger
heparin
what is the main ADR of cyanocobalamin
hypokalemia
how does red blood cells develop?
in bone marrow! - they mature in the blood - need iron, erythropoietin in kidney to support DNA synthesis
when is the best time to take ferrous sulfate?
in-between meals so the drug does not decrease its rate of absorption if it was taken with food
iron is essential for what?
oxygen binding to hemoglobin
what is so great about alterplase?
it has NO allergies or hypotension episodes
overdose in heparin can be indicated by
low blood pressure, tachycardia, and lumbar pain
early signs of toxicity when taking ferrous sulfate
nausea, vomit, diarrhea, shock
what is a main sign and symptom of vitamin b 12 deficiency
neurologic changes! - numbness - tingling - memory loss
what is vitamin b 12 deficiency from
pernicious anemia, gastric bypass, decrease acid secretion
what is the antitode for heparin?
protamine sulfate
what is it important to have near you when giving iron dextran?
resuscitation equipment just incase they go into analphylactic shock
what is hemostasis
stoppage of bleeding
what is vitamin b12 essential for
synthesis of DNA
the amount of iron we absorb is regulated by what?
the small intestine
what is it important to check before PRESCRIBING heparin?
their weight because the drug is based on weight
when do you NOT give alterplase?
when you are already bleeding
t/f: warfarin stays in the body for awhile
true
what help increase the absorption of iron in the body
vitamin C
what reverses the effects of warfarin
vitamin K food like mayo, olive oil, canola oil
what drug do you have to make sure to give at the same time preferable at night EVERYDAY.
warfarin
when is cyanocobalamin absolutely necessary to take?
when you lack intrinsic factors
how should you go about taking other drugs when on heparin?
you should tell your provider what other drugs you are on and if they approve you you can take them. other than that do not take any other drugs when on this!