Week 5: Chapter 48 Drugs Affecting Blood Coagulation

Adverse effects of Heparin

-Hair loss -Bruising -Bleeding -Chills -Fever -Osteoporosis -Suppression of renal function

Liver disease can impact the ability of _______ _________ to form, which can cause bleeding disorders.

clotting factors

Bleeding disorders are treated with

clotting factors.

Which clinical finding enables the nurse to conclude that the heparin therapy is effective in a client who has atrial fibrillation with rapid ventricular response and is started on a continuous heparin infusion? a. Atrial fibrillation converts to a sinus rhythm. b. The heart rate is stabilized at 70-90 beats per minute. c. The International normalized ratio (INR) is within normal range. d. An activated partial thromboplastin time (aPTT) is twice the usual value.

d. An activated partial thromboplastin time (aPTT) is twice the usual value. Heparin is an anticoagulant administered to clients with atrial fibrillation to prevent formation of mural thrombi. The desired anticoagulant effect is achieved when the activated partial thromboplastin time is 1.5-2 times normal.

Which information about a client who has heart failure would the nurse communicate to the health care provider before administration of the prescribed digoxin? a. Apical pulse rate 96 beats/minute b. Bilateral foot and ankle pitting edema c. Crackles heard at the base of both lungs d. Potassium level of 2.3 mEq/L (2.3 mmol/L)

d. Potassium level of 2.3 mEq/L (2.3 mmol/L) Symptoms of digging toxicity, including life-threatening dysrhythmias, can occur when digoxin is administered to a client with hypokalemia. The nurse would hold the digoxin and notify the HCP, anticipating that potassium supplements would be prescribed before administration of digoxin.

Hemorrhagic disorder

disorder such as hemophilia in which excess bleeding occurs

Fourth step in clotting process

extrinsic pathway which happens outside the vessel; its working to clot the blood that is outside the vascular system.

IV heparin

high alert medication, often it's own dedicated line, runs at low rate and if it increases by accident can cause a lot of bleeding

Contraindications to antiplatelet drugs

-Allergy -Pregnancy -Lactation Caution: bleeding disorder, recent surgery, closed head injury

Contraindications to thrombolytic agents

-Allergy -Pregnancy and lactation -Any condition that would be worsened by the dissolution of clots

Drug-drug interactions for thrombolytic agents

-Anticoagulants -Antiplatelet

Adverse effects of thrombolytic agents

-Bleeding -Cardiac arrhythmias -Hypotension -Hypersensitivity

Thrombolytic agents

Actions: breaks down fibrin threads in a clot to dissolve it; stimulate the plasma system; activates natural anti-clotting system Indications: Acute MI (goal is to give w/in 6 hrs of MI symptom onset), pulmonary emboli, ischemic stroke Pharmacokinetics: injected and cleared from the body through liver metabolism

Adverse effects of Aspirin

Acute aspirin toxicity w/ hypernea possibly leading to: -Fever -Coma -Cardiovascular collapse -Nausea -Dyspepsia -Heartburn -Epigastric discomfort -GI bleeding -Blood loss -Dizziness -Tinnitus -Difficulty hearing -Anaphylactic reaction

Adverse effects of anticoagulants

-Bleeding -GI upset -Hepatic dysfunction -Alopecia -Dermatitis -Bone marrow suppression (lowers immune system) -Prolonged and painful erection

Adverse effects of antiplatelet drugs

-Bleeding (most common, may be seen as bruising or petechiae) -H/A -Dizziness -Weakness -GI distress/nausea

Pharmacokinetics of anticoagulants

- Different based on the drug · Heparin, immediate onset, given IV or subq, doses have to be accurate, given IV on heparin lock pump, · Warfarin, onset of action of 3 days, useful for long term conditions, metabolized in liver

Contraindications to anticoagulants

-Allergy -Bleeding conditions (hemophilia) -GI ulcers -Recent trauma/surgery -IUD can affect risk of bleeding -Pregnancy -Renal or hepatic disorders Caution: CHF, thyrotoxicosis, senility, psychosis

Adverse effects of Urokinase

-H/A -Hypotension -Rash -Bleeding -Breathing problems including bronchospasm -Pain -Fever

Drug-drug interactions for anticoagulants

-Heparin and oral anticoagulants, salicylates, penicillins, or cephalosporins (can lead to increased bleeding) -Heparin and nitroglycerin (decrease in anticoagulation) -Warfarin-number of documented interactions

Indications for antiplatelet drugs

-Reduce risk of recurrent TIAs or strokes -Reduce death or nonfatal MI -MI prophylaxis -Anti-inflammatory, analgesic, and antipyretic effecs

Pharmacokinetics of antiplatelet drugs

-Well-absorbed and bound to plasma proteins -Metabolized in the liver and excreted in the urine -Can be given IV or PO, depending on the medication

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. "This medication will help dissolve the blood clot." D. "This medication starts working immediately after the first dose."

A patient is prescribed Warfarin (Coumadin) for the treatment of a blood clot. What is the therapeutic INR range for this medication? A. 2-3 B. 1-3 C. 4-8 D. 0.5-2.5

A. 2-3

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. A 45-year-old male patient with alcoholism and an active GI ulcer. D. A 52-year-old male who needs a liver transplant.

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. A 55-year-old male patient who is post-op day 1 from brain surgery. C. A 36-year-old male patient with active peptic ulcer disease.

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. Decrease in platelet level C. Development of a new thrombus

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

A. Direct thrombin inhibitor

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. Hematuria B. Decreasing platelets D. Low hemoglobin and hematocrit E. Positive stool guaiac test

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. Heparin can be used during pregnancy. B. Heparin has a short half-life. C. Heparin works to affect the intrinsic pathways of clotting.

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

A. Patient reports a severe and sudden headache B. Melena D. Hematuria E. Coffee ground emesis F. Bleeding gums

What is the antidote for Heparin? A. Protamine sulfate B. Vitamin K C. Flumazenil D. Narcan

A. Protamine sulfate

Drug-drug interactions of antiplatelets

Another drug that affects blood clotting

Nursing considerations for antiplatelet drugs

Assess: -History and Physical Exam and known allergy -Pregnancy and lactation -Known bleeding disorders, recent surgery, or closed head injury -Baseline status including body temperature; skin color, lesions ; affect, orientation, and reflexes; pulse, blood pressure, and perfusion; respirations and adventitious sounds; CBC; and clotting studies prior to giving meds -Tell pts to watch for bleeding while brushing teeth, use electric razors -can be helpful to give small frequent meals due to gi distress -Assess acute pain b/c of side effects -Fall precautions -In general, ask how the pt is feeling

Nursing considerations for anticoagulants

Assess: -History and Physical Exam and known allergy -Recent history of surgery -Active internal bleeding -CVA w/in the last 2 mos -Aneurysm -OB delivery -Organ biopsy -Recent serious GI bleeding -Rupture of non-compressible blood vessel -Recent major trauma (including CPR) -Blood-clotting defects -CVD -Uncontrolled HTN -Liver disease -Pregnancy/lactation -VS -Pt can have ineffective tissue perfusion -Clotting studies -Renal and hepatic function tests -CBC -Guaiac test for occult blood in stool if the pt has been on anticoagulants for a long time -ECG -Watch for bleeding -No IM injections -Pt teaching: often advised to have med alert bracelet, use electric razor, watch for signs of bleeding

Nursing considerations for thrombolytic agents

Assess: -History and physical exam and known allergy -Recent surgery -Active internal bleeding -CVA w/in the last 2 mos -Aneurysm -OB delivery -Organ biopsy -Recent serious GI bleeding -Rupture of a non-compressible blood vessel -Recent major trauma (including CPR) -Known blood-clotting defects -CVD -Uncontrolled HTN -Liver disease -If pt is on heparin, discontinue heparin before giving -Baseline status to include VS (check apical pulse for arrhythmia), skin, orientation, appropriate lab values and ECG -No IM medications -Assess mentation and fall precautions -Pt may have decreased CO due to arrhythmias and bleeding -alert others (nursing aides) that they are on these meds to make sure pt isn't falling or having excess bleeding,

You're providing discharge teaching to a patient who will be going home on Warfarin (Coumadin). Which statements by the patient demonstrate they understood the educational material provided? Select all that apply: A. "I will switch and use a hard bristle toothbrush." B. "When I shave I will be sure to use an electric razor." C. "I will be sure that I eat a diet rich in spinach, kale, and broccoli." D. "I will avoid drinking any alcoholic beverages."

B. "When I shave I will be sure to use an electric razor." D. "I will avoid drinking any alcoholic beverages."

What is considered a normal INR level in a person who is NOT taking Warfarin (Coumadin)? A. 10-12 seconds B. 0.75-1.25 C. 2-3 D. 5-7

B. 0.75-1.25

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. Administer Prednisone IM daily

How do antiplatelet medications work? A. Interfere with the clotting cascade B. Alter the formation of the platelet plug C. Stimulates the plasmin system D. Initiates the clotting cascade

B. Alter the formation of the platelet plug

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

B. Bone fractures

You are writing a care plan for a patient who is taking an anticoagulant. What would be an appropriate nursing diagnosis? A. Evaluate patient for PT greater/equal to 2/5 B. Establish safety precautions C. Notify the health care provider of any patient receiving this drug D. Maintain Narcan on standby

B. Establish safety precautions

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. Hold the dose and notify the physician

Heparin is an anticoagulant. What family of anticoagulant medications does this drug belong to? A. Direct thrombin inhibitors B. Indirect thrombin inhibitors C. Vitamin K antagonists D. Factor Xa inhibitors

B. Indirect thrombin inhibitors

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. 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.

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. The patient injects the needle 1 inch away from the umbilicus.

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. Weight

Actions of thrombolytic drugs

Break down the thrombus that has been formed by stimulating the plasmin system

A patient is receiving continuous IV Heparin. In order for this medication to have a therapeutic effect on the patient, the aPTT should be? A. 0.5-2.5 times the normal value range B. 2-3 times the normal value range C. 1.5-2.5 times the normal value range D. 1-3.5 times the normal value range

C. 1.5-2.5 times the normal value range

What is the approximate NORMAL level range for an activated partial thromboplastin time (aPTT)? A. 20-25 seconds B. 2-3 seconds C. 30-40 seconds D. 60-80 seconds

C. 30-40 seconds

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

C. II D. VII F. X G. IX

Warfarin (Coumadin) is an anticoagulant. What family of anticoagulant medications does this drug belong to?* A. Direct thrombin inhibitors B. Indirect thrombin inhibitors C. Vitamin K antagonists D. Factor Xa inhibitors

C. Vitamin K antagonists

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. "It stops the coagulation process by blocking the formation of clotting factors in the liver that require Vitamin K to form."

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

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. Collect an aPTT level in 6 hours per protocol.

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. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high.

What is the antidote for Warfarin (Coumadin)? A. Flumazenil B. Narcan C. Protamine Sulfate D. Vitamin K

D. Vitamin K

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

Prototype antiplatelets: Aspirin

Indication: reduce risk of TIA or stroke, MI, can be used to reduce inflammation, prevent pain, and reduce fever Action: stops platelets from coming together by stopping formation of thromboxane A2 *Oral tablet, watch for acute toxicity and bleeding

Prototype anticoagulant: Warfarin

Indications: AF, artificial heart valves, PE, prevention and treatment of thrombus, PE, MI emboli Actions: decreases the production of Vitamin K dependency in the liver Route: Oral, takes 3 days to work and effects last 4-5 days Monitoring INR: PT 1.5-2.5 x the control value Antidote: Vitamin K, which can be used for reversal for warfarin if needs to be reversed quickly, works by promoting liver synthesis of clotting factors, if given as parenteral dose its 6-9 hours, oral=12-48 hours, if not working, whole blood can be used as an antidote instead

Prototype anticoagulant: Heparin

Indications: Prevent PE, venous thrombosis, AF, used to diagnose and treat DIC, clotting in lines Actions: inhibits thrombus and clot production by blocking the conversion of prothrombin to thrombin and fibrinogen to fibrin Route: IV Onset: Immediate Peak: Minutes Duration: 2-6 hrs Route: SubQ Onset: 20-60 min Peak: 2-4 hrs Duration: 8-12 hrs Monitoring: WBCT 2.5-3 x control Antidote: Protamine sulfate, which works by forming stable salts with heparin when they come into contact in the body which reverses anticoagulation, also IV med and can be very dangerous, have to have emergency equipment available

Prototype thrombolytic agent: Urokinase

Indications: pulmonary embolus (PE) Actions: breaks down fibrin clots and lyses thrombi and emboli Route: IV

Actions of anticoagulants

Interfere with the clotting cascade and thrombin formation (stimulates the thrombin system)

INR is a calculation based on

PT test result -INR is too low can mean risk for dangerous blood clots -INR too high can mean risk for dangerous bleeding

Pharmacokinetics of Aspirin

Route: Oral Onset: 5-30 min Peak: 15 min to 2 hours Duration: 3-6 hours T 1/2: 15 min to 12 hours Metabolized in the liver and excreted in the urine

How would a nurse respond to the spouse of a client with an intracranial hemorrhage who asks the nurse, "Why aren't they administering an anticoagulant?" a. "It is not advisable because bleeding will increase." b. "If necessary, it will be started to enhance circulation." c. "If necessary, it will be started to prevent pulmonary thrombosis." d. "It is inadvisable because it masks the effects of the hemorrhage."

a. "It is not advisable because bleeding will increase." An anticoagulant should not be administered to a client who is bleeding because it will interfere with clotting and will increase hemorrhage.

Which medication is indicated to prevent progression of a myocardial infarction for a client admitted to the emergency department with crushing chest pain? a. Aspirin b. Atropine c. Gabapentin d. Epinephrine

a. Aspirin Early administration of aspirin in the setting of acute MI has been demonstrated to significantly reduce mortality. Aspirin inhibits the action of platelets, preventing their ability to clump together and form clots. The mechanism of acute coronary syndrome usually is ruptured plaque in one of the coronary arteries with clot formation obstructing blood flow. Prompt administration of an antiplatelet agent, such as aspirin, significantly reduces damage and can be lifesaving, the earlier the better; hence the reason why it is part of emergency management treatment.

Thromboembolic disorders predispose a person to the formation of

clots and emboli

Which technique will the nurse employ to prevent excessive bruising when administering subcutaneous heparin? a. Administer the injection via the Z-track technique. b. Avoid massaging the injection site after the injection. c. Use 2 mL of sterile normal saline to dilute the heparin. d. Inject the medication into the vastus laterals muscle in the thigh.

b. Avoid massaging the injection site after the injection. The site of the injection should not be massaged to avoid dispersion of the heparin around the site and subsequent bleeding into the area.

Which antidote would the nurse anticipate administering to a client whose laboratory report establishes a warfarin overdose? a. Physostigmine b. Vitamin K c. Iron dextran d. Protamine sulfate

b. Vitamin K Warfarin inhibits formation of vitamin K-dependent clotting factors. Its effect is overcome by increasing vitamin K.

Adverse effects of Warfarin

bleeding, alopecia, rashes

Which action would the nurse take after noting that client who has been on anticoagulant therapy after hip surgery is being discharged with no anticoagulant prescription? a. Explain to the client that anticoagulant therapy will no longer be needed. b. Suggest that the client take aspirin daily to prevent venous thrombosis. c. Contact the health care provider to clarify whether anticoagulant therapy is needed. d. Instruct the client to call the health care provider to ask about anticoagulant medications.

c. Contact the health care provider to clarify whether anticoagulant therapy is needed. Because it is unclear what the anticoagulant needs are for this client, the nurse would contact the health care provider for clarification.

Which foods will the nurse discuss when teaching a client who has a new prescription for warfarin? a. Dairy products b. High-fiber fruits c. Green leafy vegetables d. Whole-grain breads and cereals

c. Green leafy vegetables Green leafy vegetables are high in vitamin K, which will affect the effectiveness of warfarin because warfarin works by reducing the synthesis of vitamin K-dependent clotting factors. Clients taking warfarin are taught to try to eat about the same amount of vitamin K-rich foods daily to help stabilize the needed warfarin dose.

The cardiovascular system is a _______ system where things move from a ________ pressure to a _______ pressure.

closed, higher, lower

A PT test measures

how long it takes for a clot to form in blood sample

Signs and symptoms of thromboembolic disorder

hypoxia, anoxia, necrosis where blood flow is decreased

Actions of antiplatelets

inhibit platelet adhesion and aggregation by altering the formation of the platelet plug; block receptor sites on the platelet membrane

Third step in clotting process

intrinsic pathway which is what happens within a blood vessel; a series of events that end with the conversion of prothrombin to thrombin which seals the system.

Clotting factors are developed in the

liver.

First step in clotting process

local vasoconstriction, allows spot to heal, can seal off any breaks

Coronary artery disease (CAD) or cardiovascular disease (CVD) is a common condition that causes

narrowing of the coronary arteries

Second step in clotting process

platelets aggregate or come together to stick onto site of injury., chemicals are released that attract other platelets which can create a platelet plug and stop the bleeding

Meds for CAD and CVD work to

prevent the formation of clots.

A thromboembolic disorder can cause a piece of ______ to break off, travel throughout the CV system, and clog a vessel.

thrombus