(pharm) Ch 9: Drug Therapy for Coagulation Disorders

cilostazol (Pletal)

-drug class: phosphodiesterase III inhibitor (PDE III inhibitor), antiplatelet -indications: PVD, intermittent claudication -action: inhibits PDE III, making more cAMP available, inhibiting platelet aggregation and producing vasodilation. -major side effects: bleeding

liver

Warfarin is more likely to cause bleeding in clients with ___________ disease because of decreased synthesis of vitamin K.

A (Avoid all invasive procedures, including giving IM injections, while the client is on heparin therapy.)

What intervention does the nurse include in the plan of care for a client receiving a continuous intravenous infusion of heparin? A) Avoid IM injections B) Assessing for symptoms of respiratory depression C) Measuring hourly urinary outputs D) Monitoring BP hourly

clopidogrel (Plavix)

-drug class: adenosine diphosphate (ADP) inhibitor, antiplatelet -indications: peripheral vascular disease (PVD), post percutaneous transluminal coronary angiography -action: inhibits ADP from binding to it's platelet receptor, thereby inhibiting platelet aggregation -major side effects: bleeding, abdominal pain, flu-like symptoms, thrombocytopenia -interactions: garlic, ginger, green tea, NSAIDS, anticoagulants, SSRIs, PPIs, grapefruit juice -route: PO

heparin

-drug class: antithrombotic/ anticoagulant -indications: prevention of venous thrombosis and prevents extension of existing thrombi -action: binds with antithrombin III, inactivates thrombin, prevents conversion of fibrinogen to fibrin. -major side effects: bleeding, bruising, petechiae, fatal hemorrhage (GI or cerebral), HIT. -daily lab values: measured by aPTT, should be 1.5 to 2.5 times the reference value -antidote: protamine sulfate -subcutaneous and IV

Enoxaparin (Lovenox)

-drug class: antithrombotic/anticoagulant, Low Molecular Weight Heparin (LMWH) -indications: prevention of DVT and PE after orthopedic or abdominal surgery -action: accelerates activity of antithrombin III -major side effects: bleeding, injection site hematoma, pruritic rash -does NOT require frequent lab monitoring -interactions: aspirin, protamine sulfate (antidote) -rotate inj site and inject 1-2 inches away from the umbilicus.

warfarin

-drug class: coumarins, anticoagulants -indications: prevention of venous thrombosis and prevents extension of existing thrombi -action: inhibits hepatic synthesis of vitamin K, affecting 4 vitamin K dependent clotting factors -major side effects: bleeding, bruising, fatal hemorrhage (GI or cerebral), hematuria -frequent lab testing: measured by PT (should be 1.5x to 2x the reference) and INR (should be 2-3) -full therapeutic effect takes several days, so it is started 2-3 days prior to discontinuation of heparin -many drug interactions! herbal include st. johns wort, ginkgo, and ginger. -antidote: phytonadione (vit K) - takes 24-48 hrs to work, FFP may be used also -route: PO

Dabigatran (Pradaxa)

-drug class: direct thrombin inhibitor, anticoagulant -indications: prevention of DVT and PE, thrombus prophylaxis for HIT, unstable angina, AFIB, and stroke. -actions: inhibits thrombin from converting fibrinogen to fibrin -major side effects: bleeding, bruising, epistaxis, GI upset -use caution in pts with creatinine clearance <30mL/min or if they are older than 75 -route: IV and subcut -antidote: Idarucizumab -take with food to lessen GI upset

Rivaroxaban (Xarelto)

-drug class: factor Xa inhibitors, anticoagulant -indications: prevention of DVT and PE, thrombus prophylaxis for HIT, unstable angina, AFIB, and stroke. -action: blocks activity of clotting factor Xa, preventing clot formation -major side effects: bleeding, bruising, epistaxis, elevated liver enzymes -administer 1-2x daily, large doses (>15mg) should be taken w/ food, take in the evening for AFIB

alteplase (Activase)

-drug class: plasminogen activator, thrombolytic -indications: to dissolve thrombi, management of acute, severe thromboembolic disease (such as MI, PE) -action: stimulates conversion of plasminogen to plasmin, a proteolytic enzyme that breaks down fibrin, the framework of a thrombus. -major side effects: hemorrhage, nausea, vomiting, hypotension, anaphylactoid shock -interactions: NSAIDs -administer within 3-6 hrs of thrombus formation -IV bolus or pump, 18 gauge

A, B, D, E (The nurse should monitor the patient receiving thrombolytics for adverse effects, such as bleeding, allergic reactions, and cardiac dysrhythmias. An increased heart rate with a decreased BP usually indicates blood loss from bleeding.)

A patient arrived in the emergency department 2 hours after an acute ischemic stroke. The patient is given an intravenous (IV) injection of alteplase tPA. It is most important for the nurse to monitor what? (Select all that apply.) A.Bleeding B.Vital signs C.PT levels D.Allergic reactions E.Electrocardiogram

C

A patient is prescribed aspirin, 81 mg, and clopidogrel. The nurse identifies the drug classification of clopidogrel as A. anticoagulant. B. thrombotic inhibitor. C. antiplatelet. D. thrombolytic.

B (Low-molecular-weight heparins are derivatives of standard heparin and were introduced to prevent venous thromboembolism. The other drugs are platelet inhibitors. Antiplatelets are used to prevent thrombosis in the arteries by suppressing platelet aggregation.)

A patient is recovering from surgery to replace her right hip. In the early postoperative phase, the nurse anticipates administration of which drug to prevent deep vein thrombosis? A. Dipyridamole B. Low-molecular-weight heparin C. Abciximab D. Anagrelide

D (Two oral anticoagulants form a new anticoagulant category called Xa inhibitors. Rivaroxaban (Xarelto) was FDA-approved in July 2011, and apixaban (Eliquis) was FDA-approved in December 2012. These drugs do not require routine coagulation monitoring and are given q.d. or b.i.d. The other medications are administered intravenously.)

A patient visits an outpatient clinic. The patient has been noncompliant with anticoagulation therapy and states, "I don't like having to have blood work all of the time." The nurse anticipates prescription of which medication? A. Abciximab B. Tirofiban C. Eptifibatide D. Rivaroxaban

A,B,D

The FDA has issued a black box warning for the use of protamine sulfate due to the risk of which conditions? (Select all that apply.) A) Severe hypotension B) Cardiovascular collapse C) Cardiogenic pulmonary edema D) Pulmonary hypertension E) Pulmonary vasodilation

A (Intravenous heparin is indicated for rapid anticoagulant effect when a thrombosis occurs because of a deep vein thrombosis (DVT), pulmonary embolism (PE), or an evolving stroke. The effects of subcutaneous heparin take longer to occur. Clopidogrel (Plavix) is an antiplatelet drug that is mainly for prophylactic use in prevention of myocardial infarction or stroke. Vitamin K is the antidote for warfarin, and protamine is the antidote for heparin.)

The patient develops a deep vein thrombosis. The nurse anticipates administration of which medication? A. Intravenous heparin B. Clopidogrel C. Vitamin K D. Protamine sulfate

B (Today, the international normalized ratio (INR) is the laboratory test most frequently used to report PT results; a value of 2 to 3 is considered acceptable. Partial thromboplastin time (PTT) and activated partial thromboplastin time (aPTT) are laboratory tests to detect deficiencies of certain clotting factors, and these tests are used to monitor heparin therapy. Tarry stools indicate GI bleeding. Green leafy vegetables contain vitamin K, which is the antidote for warfarin (Coumadin).)

The patient is being discharged home on warfarin therapy. Which information will the nurse include when teaching the patient? A. Results of activated partial thromboplastin time (aPTT) will determine if the medication is effective. B. International normalized ratio (INR) results should be between 2 and 3. C. A normal response to warfarin is for your stools to look tarry. D. Increase the amount of green leafy vegetables in your diet.

C (Laboratory tests such as PT or INR are performed to regulate warfarin (Coumadin) dose. The patient should avoid consuming large amounts of green, leafy vegetables; broccoli; legumes; soybean oil; coffee; tea; cola; excessive alcohol, and certain nutritional supplements such as coenzyme Q10. Patients are encouraged to perform oral hygiene and use a soft tooth brush to prevent gums from bleeding. Patients should be instructed to use an electric razor when shaving.)

Which information will the nurse include when teaching a patient about warfarin therapy? A. Increase the amount of green, leafy vegetables in your diet. B. Rinse your mouth instead of brushing your teeth. C. Follow up with laboratory tests such as PT or INR to regulate warfarin dose. D. Use a new razor blade each time you shave.

C

Which patient would be least likely to be prescribed clopidogrel? A) A 72-year-old patient with a history of CAD B) A 52-year-old patient with a recent angioplasty C) A 76-year-old patient with osteoporosis D) A 64-year-old patient with PVD

anticoagulants

________________ prevent the formation of clots that inhibit circulation.

antiplatelets

_________________ prevent platelet aggregation.

thrombolytics

___________________ attack and dissolve blood clots that have already formed.

Phytonadione (Vitamin K)

___________________ is the antidote for warfarin (Coumadin) -takes 24-48 hours to work -fresh frozen plasma or platelets may be used

heparin

contraindications for ____________: -GI ulcerations (e.g., peptic ulcer disease, ulcerative colitis) -active bleeding -severe kidney or liver disease -severe hypertension -recent surgery of the eye, spinal cord, or brain.

anticoagulants

monitoring for side/adverse effects of ____________________: -Monitor PT, INR for warfarin, and aPTT for heparin before administering anticoagulant. -Examine patient's nose, mouth, skin, urine for bleeding. -Teach patient to inform dentist -Advise patient to use a soft toothbrush to prevent bleeding gums. -Advise patient to avoid large amounts of green, leafy vegetables or be consistent with intake. (with warfarin)

heparin

special nursing implications for ___________: -Patient history, medication history, allergies -Contraindications -Baseline vital signs, laboratory values -Be sure to obtain patient's accurate weight -Never mix with other medication -IV bolus followed by infusion; always on a pump -Obtain daily lab values; Always draw blood from the opposite arm. -Results needed before each dose is ordered -Bleeding precautions

1.5-2.5

the therapeutic level of heparin should be __________ - ________ times the reference value for aPTT.

2-3

the therapeutic level of warfarin is measured by PT and INR. INR should be ________ to _________. -hold dose if above this range

1.5-2

the therapeutic level of warfarin is measured by PT and INR. PT levels should be ________ to __________ times the reference value.