Pharm Exam 3

What is the coagulation cascade?

- Series of cascading reactions that result in fibrin clot formation - As one substance is activated, it activates next protein - Some reactions take place on platelets - End result is formation of an insoluble fibrin clot

When administering heparin subcutaneously, what are the administration alerts?

- never draw back the syringe once the needle has entered the skin - never massage site

With long term use of proton pump inhibitors, there is an increased risk of what?

-Osteoporosis - related fractures of the wrist. Interferes because they aren't absorbing calcium -Kidney problems (interstitial nephritis) b/c of the calcium -Micronutrients deficiency B12 and hypomagnesemia -Concurrent use with warfarin may increase the likelihood of bleeding.

What are the natural defenses of the stomach?

-Stomach cells secrete a thick mucus layer and bicarbonate ions to neutralize the HCl. -In duodenum, stomachs contents are further neutralized by bicarbonate from pancreatic and biliary secretions.

Anti-platelet drugs include:

-aspirin -ADP blockers -glycoprotein IIb/IIIA receptor antagonists

Notify physician if these signs/symptoms occur for a patient on anticoagulant therapy.

-coffee ground emesis -black, tarry stools or frank blood in stools -blood in urine (reddish -blooding that won't stop with appropriate pressure. (small-medium cuts hold pressure for 5 minutes)

Bleeding precautions for a patient on anticoagulant therapy:

-soft-bristled toothbrush -electric razor instead of one w razor -No rectal meds or temperature -Avoid IM medications -Minimize finger sticks or other punctures and prepare to hold pressure longer afterwards -Avoid contact sports or things that increase the risk for head trauma -Make the home environment as safe as possible

The onset of action of a S/C administration of heparin is within __________ hours.

1 hour

What is the therapeutic range of serum warfarin levels?

1-10 mcg/mL INR 2-3

The two pathways that lead to coagulation

1. Intrinsic pathway 2. Extrinsic pathway

pH of stomach is usually about

1.5 - 3.5

Normal range for a PT level is:

10-12 seconds

Administer aluminum antacids (aluminum hydroxide, AlternaGEL) at least ____________ hours before or after drugs.

2 It affects the absorption of other medications. Medication timing is important.

INR is checked for patients on older anticoagulants like Coumadin or Warfarin. The therapeutic range for INR:

2-3

Normal range for aPTT:

30-40 seconds Critical greater than 70.

Normal blood clotting occurs within _____________ minutes.

5-6

Deep Vein Thrombosis (DVT)

A blood clot in a deep vein, most often an extremity

What are the four fat-soluble vitamins?

A, D, E, K

The antidote for Heparin? a. Protamine sulfate b. Vitamin K c. Narcan d. Flumazenil

A. Protamine sulfate

Which of the following statements about Wafarin (Coumadin) are incorrect. 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.

Tarry stool could be as a result from ___________________________.

Anticoagulation therapy

Ondansetron (Zofran)

Antiemetic

Warfarin (Coumadin) may given to patients with _________________ to prevent clots.

Atrial fibrillation.

Older adults may have a Vitamin __________ deficiency from atrophy and decreased stomach acid production (leading to pernicious anemia).

B12

What are the classifications of laxatives?

Bulk-forming laxatives Saline cathartics Stimulant laxatives Surfactant Herbal agents Opioid antagonists

Use Zofran with caution in ______________ patients.

Cardiac

Surfactant (stool softener)

Causes more water and fat to be absorbed into stools. Used postop to prevent patient from straining

The binding of heparin to antithrombin III inactivates __________________ _________________ and inhibits thrombin activity.

Clotting factors

Cathartic is a term that implies a stronger and more ____________________________.

Complete bowel emptying (preceding colonoscopy or barium enema)

Thrombin Time (TT) is a lab tests that tests for what?

Determines if adequate fibrinogen is present for normal coagulation.

What is the Black Box Warning for heparin?

Epidural or spinal hematomas may occur when heparin or LMWHs are used in patients receiving spinal anesthesia or lumbar puncture. Because these can result in long-term or permanent paralysis, frequent monitoring for neurologic impairment is essential.

Activated Partial Thromboplastin Time (APTT, PTT) is a lab test that does what?

Evaluates the intrinsic system of the coagulation cascade and monitors Heparin therapy.

Enoxaparin (Lovenox) inhibits _________________

Factor X

True/False. You must monitor aPTT with Enoxaparin (Lovenox) administration.

False. Not necessary b/c it has a longer duration.

True/False. Antacids are slow-acting.

False. They act fast and last only 2-3 hours.

What type of vitamins, in high amounts, can be toxic and cause hypervitaminosis?

Fat-soluble vitamins (A, D, E, K) Do not take in excess. You should monitor.

Vitamin B9 (folic acid)

Found in plant products, leafy green vegetables, citrus fruits

Where are water soluble vitamins absorbed?

GI tract and blood They are excreted in the urine. We don't store Vitamin B or C, which is why they need to be taken on a daily basis.

Where are fat soluble vitamins absorbed?

GI tract with lipids

What are the adverse effects of ferrous sulfate?

GI upset, constipation, diarrhea, dark stool

Peptic ulcers can be _____________ ulcers in stomach or ______________ ulcers in small intestinal.

Gastric ulcer / Duodenal ulcer

Two types of histamine receptors

H1 and H2

______________________are effective at suppressing the volume and acidity of parietal cell secretions.

H2 receptor antagonists

What should you be monitoring for a patient taking Warfarin?

INR

What can you instruct a patient about drug-drug interactions with warfarin?

Increased effect of warfarin with alcohol, NSAIDS, diuretics, SSRIs, steroids, antibiotics, vaccines, and vitamins. Pt should not take any other prescription or other OTC drugs unless approved by HCP.

H2 receptors are responsible for what?

Increasing acid secretion in the stomach

When are thrombolytics are contraindicated?

Internal bleeding, recent surgery, severe hypertension, intracranial tumor, atriovenous malformation (if vein/artery are weak/bulging)

What type of medication is used to promote the evacuation of the bowel?

Laxatives

What is ulcerative colitis?

Mucosal erosions in the large intestine. Abdominal cramping, frequent bowel movements, weight loss, bloody diarrhea, high fever, and dehydration

____________ can destroy the mucus layer of the stomach.

NSAIDS NSAIDS/corticosteroids/platelet inhibitors are second most common cause of PUD.

Overdose treatment for Diphenoxylate with Atropine?

Narcan

Hypokalemia from diarrhea could lead to what?

Nausea/vomiting

Do you crush ferrous sulfate tablets?

No

Can a patient with a BP of 160/90 take warfarin?

No, contraindicated for severe HTN

Can you administer heparin IM?

No, its contraindicated due to bleeding risk.

Blood group ______________ is more susceptible to peptic ulcer.

O

How is Zofran administered (route)?

PO, IV, IM, oral, transdermal patches, and orally disintegrating tablets

What do you monitor for a patient on Warfarin (Coumadin)?

PT/INR Warfarin can cause major or fatal bleeding.

_______________________ are the first defense in hemostasis.

Platelets

Bulk forming laxatives

Psyllium (Metamucil) - contain fibers, preferred for prevention and treatment of constipation. Slow in action.

Folic acid is necessary for production of what?

RBCs

Enoxaprin (Lovenox) is given _______________ (type of administration).

SQ

How does sucralfate help treat the peptic ulcer?

This drug produces a thick, gel-like substance that coats the ulcer, protecting it against further erosion to promote healing. Consists of sugar and aluminum hydroxide. Can be taken four times daily.

Prothrombin is transformed into ______________________ by the prothrominase complex.

Thrombin

True/False. Heparin inhibits the conversion of thrombin to fibrinogen.

True

True/False. Ranitidine is administered after meals.

True.

True/False. Treatment of diarrhea is based on the cause and is usually self-limiting.

True.

Patients prone to kidney stones should not take what due to hypercalcemia?

Tums (antacids)

Crohn's disease

Ulcers in the distal (terminal) portion of the small intestine. Abdominal pain, cramping, and diarrhea. Similar to ulcerative colitis.

Upon discontinuation of warfarin therapy, the anticoagulant activiy may persist for how long?

Up to 10 days

How does heparin's weight-based nomogram calculate dose?

Uses pt weight, aPTT and clinical indication for drug (DVT/coronary syndrome) to calculate dose

The first step if inflammatory bowel treatment is with...

Usually 5-aminosalyicylic acid (5-ASA) medications because they are safe and well-established therapies for the disorder.

Taking folic acid may decrease available __________________.

Vitamin B12

Give ferrous sulfate with foods high in what?

Vitamin C - such as orange juice and strawberries

Name two water soluble vitamins

Vitamin C and B

Warfarin (Coumadin) inhibits the action of

Vitamin K

What can you administer if life-threatening bleeding occurs during warfarin therapy?

Vitamin K

What is the Vitamin K antagonist that can be given to prevent thromboembolic events in high-risk patients following an MI or an atrial fibrillation episode?

Warfarin

What method is used when giving ferrous sulfate IM?

Z-track method (deep muscle)

EAQ: A pregnant client with iron-deficiency anemia is prescribed iron supplements daily. To help the client increase iron absorption, the nurse would suggest the client eat foods high in which substance? a. Vitamin C b. Fat content c. Water content d. Vitamin B complex

a. Vitamin C Aids in the absorption of iron

The antidote for Warfarin (Coumadin) is ________________. a. Vitamin K b. Heparin c. Vitamin D d. coagulation factors

a. Vitamin K

What laboratory test would you want for a patient on heparin therapy?

aPTT

What is the preferred site for Enoxaparin (Lovenox)?

abdomen *rotate sites, don't inject same location, do not massage after injecting

Proton Pump Inhibitors inhibit the pump that produces ________________________.

acid

What can heparin-induced thrombocytopenia (HIT) cause?

an increase in adverse thromboembolic events

What line of medications neutralize the stomach acid?

antacids

What type of drug is Ranitidine?

anti-ulcer drug/H2 receptor antagonist/ blocks H2 receptors to decrease acid production inhibits acid secretion in parietal cells

Herbal agents

available OTC, like Senna, irritate bowel and increase peristalsis. Castor oil, flaxseeds, and dandelion.

Fibrinolysis is initiated ________________ to ________________ hours after clot formation and continues into the clot dissolves. a. 1 - 2 b. 24 - 48 c. 4 - 6 d. 48 - 72

b. 24 - 48

__________________ is required in order for the liver to make four different clotting factors. a. Vitamin C b. Vitamin K c. Vitamin D d. Vitamin A

b. Vitamin K

Thrombolytics are medications used to _______________________ life-threatening clots (MI, stroke). a. excite b. dissolve c. expand d. mobilize

b. dissolve

The end product of the coagulation cascade is: a. fibrinogen b. fibrin clot c. platelet aggregation d. vasoconstriction

b. fibrin clot

What family of anticoagulants medications does heparin belong to? How does it act? a. direct thrombin inhibitors b. indirect thrombin inhibitors c. Vitamin K antagonists d. Factor Xa inhitors

b. indirect thrombin inhibitors

The majority of clotting factors are synthesized and secreted by which organ? a. blood vessels b. liver c. the kidneys d. the lungs

b. liver

The enzyme tissues plasminogen activator (TPA) activates _____________________________ (which is present in the fibrin clot) to _________________________. a. platelets / plasma b. plasminogen / plasmin c. WBCs / RBCs d. fibrinogen / fibrin

b. plasminogen / plasmin

Do not remove the ___________ with an Enoxaparin (Lovenox) prefilled syringe.

bubble Rationale: It seals the med into the tissues and prevents it from spreading into the SQ space and decreases the hematomas

What is steatorrhea?

bulky, foul smelling fatty stools.

What is a cause of platelet deficiency? Select all that apply. a. Vitamin D deficiency b. Lack of omegas in diet c. folic acid deficiency d. Vitamin b12 deficiency e. liver failure

c. folic acid deficiency d. Vitamin b12 deficiency e. liver failure

What organ produces the clotting factors, including fibrinogen? These factors are proteins circulate through the blood in an inactive form. a. kidneys b. adrenal cortex c. liver d. lungs

c. liver

What digests the fibrin strands to remove the clot? a. fibrinogen b. eosinophils c. plasmin d. platelet aggregation

c. plasmin

Zofran is given prophylactically. Given at least 30 minutes prior to what treatment?

chemotherapy/radiation

Pancrelipase is given in ____________ ____________ to help digest fats and prevent steatorrhea.

chronic pancreatitis

Heparin prevents the enlargement of existing __________________ and the formation of new ones.

clots

Anticoagulants inhibit specific ____________________ ____________________ in the coagulation cascade.

clotting factors

With hemostasis, once the flow of blood is reduced with the aggregation of platelets, this allows the process of _______________________ to occur and a blood clot is formed with ___________________ ______________________.

coagulation / fibrin strands

When Vitamin K is inhibited by Warfarin (Coumadin), it in turn suppresses the hepatic synthesis of ___________________ _____________________.

coagulation factors Takes several days to reach maximum effect.

Patients with liver impairment usually have ________________ _________________ , mainly risk for bleeding. a. abnormal coagulation b. kidney impairment c. heart problems d. normal coagulation

d. abnormal coagulation

Serious conditions can occur as a result of emboli like: a. hypoxia, hypercapnia b. enlarged pulmonary arteries, dyspnea c. peripheral congestion d. pulmonary embolus, MI, stroke

d. pulmonary embolus, MI, stroke

Effect of a single dose of aspirin may persist for as long a week. What would you tell a patient ahead of surgery?

d/c aspirin use one week before operation or invasive procedure

It is more common for a patient to have multiple vitamin ________________ instead of just one.

deficiencies

Diets, alcohol abuse, and drug abuse contribute to vitamin __________________.

deficiency

Patients will hemophilia may receive aminocaproic acid immediately following ______________________________ _______________________.

dental procedures

What is fibrinolysis?

dissolution of a clot

Heparin does not ___________________ existing clots.

dissolve

Thrombolytics are used for

dissolving clots They can prevent ischemia in the heart; prevent paralysis.

A traveling clot is called an

embolus

The final product of the coagulation cascade is a ____________________ ____________________ that stops blood loss also called a _________________________.

fibrin clot / thrombus

Diarrhea may lead to what?

fluid, acid-base, or electrolyte disorder. This is especially important in children and elderly.

A genetic deficiency in certain clotting factors (Factor 8, VIII).

hemophilia

What is a natural substance in the liver and lining of blood vessels that prolongs coagulation time and prevents excessive clotting within blood vessels?

heparin

What is a serious complication of heparin therapy?

heparin-induced thrombocytopenia (HIT) --occurs in up to 30% of patients taking the drug. More severe symptoms usually appear after 5-10 days of therapy

Parietal cells in the gastric glands secrete 1-3L of what each day?

hydrochloric acid

Heparin is given IV has an ___________________ onset of action.

immediate

What is the onset of action for heparin IV?

immediate

When should thrombolytic therapy drug being after symptoms?

immediately

How does aminocaproic acid work?

inactivates plasminogen, the precursor of the enzyme plasmin that digests the fibrin clot

When administering IV Ferrous sulfate, careful to prevent __________- because iron is highly irritating to tissues.

infiltration

H1 receptors produces the classic symptoms of what?

inflammation and allergy (runny nose, itching, sneezing)

Sulfasalazine (Azulfidine) suppresses _______________________

inflammation for inflammatory bowel disease

Heparin is an indirect thrombin _______________________.

inhibitor

Parietal cells secrete ___________ ______________ which is essential for the absorption of vitamin _________________.

intrinsic factor / B12 As we age, intrinsic factor decreases

Ferrous Sulfate (Iron) is used for

iron deficiency anemia

Where are fat soluble vitamins stored?

liver

The duration of Enoxaprin (Lovenox) is __________________ than that of heparin.

longer

Enoxaparin (Lovenox) is also called

low-molecular weight heparin

diarrhea caused by

medications, lactose, infections of the bowel, ulcerative colitis, Crohn's disease, and IBS/others

Deficiency of folic acid in pregnancy is associated with

neural tube defects

Heparin is given ___________________________ (route).

parenterally

Chief cells secrete...

pepsinogen

Proton Pump Inhibitors are the most frequently used to treat __________ ___________ _________.

peptic ulcer disease

Fibrinogen is?

plasma protein that is converted to fibrin in the clotting process with the help of thrombin

Heparin can be used to __________________ thromboembolic events arising from open heart and vascular surgery, dialysis procedures, or in patients with unstable angina.

prevent

Warfarin (Coumadin) is administered for the _______________________ of clots that may cause stroke, MI, DVT, PE.

prevention

Anticoagulants are drugs used to _________________________ bleeding time and thereby ______________________thrombi from forming or enlarging.

prolong / prevent

What do antifibrinolytics do?

promote blood coagulation for patients with excessive bleedings from surgical sites

Stimulant laxatives

promote peristalsis by irritating bowel mucosa. Can cause laxative dependence and depletion of fluid/electrolytes

What is the antidote for heparin?

protamine sulfate

What can you give as an anecdote if a serious hemorrhage occurs during heparin therapy?

protamine sulfate (1mg for ever 100 unites of heparin)

Saline Cathartics (Osmotic Laxatives)

pull water into fecal mass to create watery stool - produces BM quickly/used for colonoscopy

Hemophilia is an inherited deficiency of a specific clotting factor. Pharmacotherapy includes _________________________ the missing clotting factor through periodic ______________________.

replacing / infusions

The blood clot is formed to protect from excessive hemorrhage; however internally the clot may ___________________ blood flow to the affected area without fibrinolysis.

restrict

Ondansetron (Zofran) acts by blocking ________________ receptors in the GI tract as well as chemoreceptor trigger zone in the brain.

serotonin

How long does it take for Warfarin to reach its maximum effect?

several days

When should Proton Pump Inhibitors be given?

should be given on an empty stomach or 30 minutes before meals

Diphenoxylate with Atropine (Lomotil) is administered as an antidiarrheal because it acts how?

slows peristalsis. At higher doses, the anticholinergic effects of atropine, such as drowsiness, dry mouth, and tachycardia, will be experienced.

With the process of hemostasis, platelets become _____________ and_______________ slowing blood flow.

sticky / aggregate

Docusate sodium (Colace) are given to post-op patients to prevent______.

straining

Do not administer Sulfasalazine (Azulfidine) to patients who are allergic to which drugs?

sulfonamide antibiotics or furosemide (Lasix)

Prothrombin Time (PT) is a lab test that tests for what?

test of the ability of blood to clot

What is hemostasis?

the stopping of bleeding and the repairing of damage *bleeding from a wound can cause shock or possible death *too much clotting could use to stroke

We want a patient on heparin to have an aPTT 1.5 - 2.5 times the normal value range of aPTT to achieve a ___________________________ effect and prevent ______________________ ________________________.

therapeutic / blood clots

The most common coagulation disorder

thrombocytopenia (deficiency of platelets)

Heparin can be used at higher doses to _________________ conditions in which immediate coagulation is necessary, such as a confirmed DVT and PE.

treat

Peptic ulcers require ________-therapy.

tri (two antibiotics and one PPI) Clarithromycin, amoxicillin, and omeprazole Clarithromycin, metronidazole, and omeprazol/lamzoprazole. 7-14 day regimen

Heparin is also called

un-fractionated heparin

Psyllium may decrease the absorption and effects of what medications?

warfarin, digoxin, antibiotics

Heparin therapy is based on a _____________-based nonogram and _____________ values.

weight / aPTT