Pharmacology Exam 3 Study Guide

Parenteral/Injectables: - Heparin type: heparin, enoxaparin -Non-heparin products: Argatroban Oral anticoagulants: - Vitamin K anatagonists- ex. Warfarin/Coumadin (Oldest on the market) -NOACs/DOACs (New)- Apixaban, Rivaroxaban, Dabigatran, edoxaban -Before administering anticoagulants, check CBCs- Hgb, Hct, Plts

Anticoagulants (stop the clotting cascade. Works in the second stage of hemostasis)

Work on preventing platelet aggregation. The "platelet plug" Intent is to stop an arterial thrombus Aspirin- USED TO TREAT: -Primary: •Coronary Stenting •Acute MI -Other uses: •Ischemic Stroke •TIAS •Chronic Stable Angina/Unstable Angina •Analgesic/Anti-inflammatory •Antipyretic •Pediatrics- Kawasaki (NEVER GIVE TO CHILDREN- outside of this disease) MOA: irreversible (lasts entire 7 days of platelets cycle) ADVERSE EFFECTS (Aspirin): A- Asthma S- Salicylism if overdose (N/V/D, rapid breathing- hyperventilation) P- Premature closing of PDA/platelet disaggregation/Peptic ulcer disease I- Intestinal bleeding R- Reye's Syndrome/Ringing in the ears(tinnitus)/Renal Impairment/Rapid Breathing/RESPIRATORY ALKALOSIS I- Idiosyncratic Reaction N- Noise (Tinnitus)/Nephropathy Boxed warning (Aspirin): Increased risk for GI Bleeding, Ulcers Nursing considerations (Aspirin): GI concerns- -Patients can use an enteric coated tablet, take with food or water/milk to reduce GI upset ◦Educate for S/S of GI Bleed ◦Higher risk with smoking/alcohol/corticosteroids -Educate that this is a lifelong med Salicylism- Pepto Bismol (Bismuth Subsalicylate- don't give to kids) ◦Educate patients about S/S ◦Tinnitus, N/V/D, sweating, increased breathing ◦RESPIRATORY ALKALOSIS Reye Syndrome- ◦Avoid aspirin in children and adolescents ◦Avoid pepto bismol! ◦Especially avoid if they have a virus Avoid aspirin in children and adolescents ◦Avoid pepto bismol! ◦Especially avoid if they have a virus CONTRA-INDICATIONS: -Active Bleeding -Peptic Ulcer Disease -Children (especially if infected with a virus) Administration: Can take with food/liquids, can use E.C. ----------------------------------------------------------------- P2Y12 ADPreceptor antagonists: Clopidogrel + Ticagrelor "grel" USED TO TREAT •Primary Indications •Percutaneous Coronary Intervention (STENT placement) •Ischemic Stroke Other Uses: •TIAs •Chronic Stable Angina/Unstable Angina •Peripheral Artery Disease •Much more off label ADVERSE EFFECTS (Clopidogrel)- -Dyspnea (13% ticagrelor, 8% clopidogrel) -**Bleeding Risk (main concern) -Clopidogrel vs ASA (GI - 2% vs 2.7%, ICH- 0.4% -0.5%) -Thrombotic Thrombocytic Purpura (TTP) •Petechiae that suggests bleeding, Potentially fatal•Thrombocytopenia, hemolytic anemia, neurologic symptoms, renal dysfunction, fever CONTRA-INDICATIONS (Clopidogrel) -Active Bleeding -Peptic Ulcer Disease Nursing considerations (Clopidogrel): -Educate patients that if they experience shortness of breath they need to notify their provider (this could be heart related, or more likely caused by the drug) •Patients should be educated on looking out for S/S of bleeding, and keep a medication list and notify all prescribers they are on this medication (dentists, surgeons, etc.) -Patients should be educated to immediately report signs of bruising (especially petechiae), and/ or changes in urine (discoloration). •Patients should be instructed to NEVER miss a dose, especially after a stent. Missing just a few doses can increase the risk for coagulation in a new stent (and cause a new occlusion) (ADHERENCE IS KEY) Surgery- Anytime a patient is going for surgery regardless if they are on an Anticoagulant or Antiplatelet, the provider needs to come up with a game plan on when to stop the medication prior to surgery! (Blanket Rule: stop antiplatelet/anticoagulant 1 week prior)

Antiplatelet Drugs (Work in stage 1 of blood clotting) The Original-Aspirin (type of NSAID) P2Y12 ADP Receptor Antagonists- ClopidGREL, TicaGRELor

USED TO TREAT (Continuous IV drip) •patients who have developed HIT •Hx of HIT with active PE/DVT ADVERSE EFFECTS •Same as heparins, except treats HIT, does not cause HIT CONTRA-INDICATIONs •SAME as "parins"- active bleed, peptic ulcer disease, epidural, neuro/spinal procedures

Argatroban

General term for any process that stops bleeding Two Stages ◦1) Formation of a platelet plug- ANTIPLATELETS ◦2)Coagulation (reinforcement of platelet plug with fibrin to form clot)- ANTICOAGULANTS

Hemostasis

USED TO TREAT- ◦DVT prophylaxis (subcutaneously) ◦General adult dose is 5,000 units SC every 8 or 12 hours ◦COVID-19, higher dose - works fast/instantaneous compared to warfarin ◦Pregnant patients- ◦DVT/PE treatment(therapeutic) ◦Continuous IV drip (therapeutic), May see initial large bolus, followed by slow continuous infusion ◦***CAN be used in Pregnant Patients ◦Prevent Stroke in Atrial Fibrillation ◦Prevent DVT/PE in POST OP Hip/Knee Patients -Other uses: ACS, unstable angina, MI, stroke, used as an anticoagulant in dialysis or open heart surgery, or help flush lines to prevent coagulation. MOA: stops clotting cascade and prevents fibrin formation DVT PROPHYLAXIS administration: ◦Heparin 5000 units subcutaneously three times daily (or twice daily) ◦SUBCUTANEOUS ADMINISTRATION:•For subcutaneous injections, use a 20‑ to 22‑gauge needle to withdraw medication from the vial. **Then, change the needle to a smaller needle (25‑ or 26‑gauge, ½ to ⅝ inches long).•Administer deep subcutaneous injections in the abdomen, ensuring a distance of at least 2 inches from the umbilicus•Do not aspirate•Apply gentle pressure for 1 to 2 min after the injection.•Rotate and record injection sites. 90 degree angle. DVT TREATMENT:◦Heparin IV drips are weight based◦Some patients may receive a large bolus dose followed by a continuous IV drip (to reach steady state!)◦We need to check baseline levels, followed by levels every 6 hours (4-6 per ATI) until two levels return within range◦What Levels?- aPTT (only in IV!), & CBC= Complete Blood Count, includes H/H= hemoglobin/hematocrit + platelet,◦Heparin does NOT break down a blood clot. Heparin is NOT a clot buster. MONITORING: How do we know IV heparin is in an appropriate range? ◦aPTT (activated Partial Thromboplastin Time)◦Baseline: 30- 40 seconds◦ATI TARGET: 60-80 seconds (1.5-2.5 times the normal range) Adverse effects: Subcutaneous use- ◦Local site injection reactions can occur, rotate sites (just like we rotate our patches) ◦Heparin Induced Thrombocytopenia (HIT)- Low platelet count <100,000 mm3. Some people make antibodies that attack heparin and platelets. Result: thrombocytopenia. The remaining platelets are actually hyperactive- clotting risk! BLEEDING ◦Watch out for signs/symptoms: Early indicators- Nose bleeds, gum bleeding, tarry stools, extreme/sudden headache, abdominal pain, vomiting of blood (coffee ground emesis)◦Blood in urine (reddish/pink urine)◦Petechiae, bruising, hematoma◦Drop in blood pressure, Increased heart rate, increased breathing, decreased level of consciousness◦Education is KEY! Your patient needs to know what to report◦Monitor Hemoglobin and Hematocrit Levels + Platelets (CBC) ◦Subcutaneous use-◦Local site injection reactions can occur, rotate sites (just like we rotate our patches) ◦Heparin Induced Thrombocytopenia (HIT)◦Some people make antibodies that attack heparin and platelets◦Result: thrombocytopenia. The remaining platelets are actually hyperactive- clotting risk! Hematoma risk ◦All anticoagulants ◦CONTRA-INDICATIONs-AVOID in epidurals + neurosurgery, Swelling can cause paralysis, Osteoporosis - LONG TERM -History of HIT (heparin induced thrombocytopenia) •Low H/H, platelet count- why?•Pork allergy- from intestinal mucosa from pigs, Pork- religious•Recommend consulting- •Neurosurgery, Epidurals, etc.•Peptic Ulcer Disease/GI Bleeding•Active Bleeding •IV heparin- BAG- 24 hours- what happens if pump malfunction- administration error•Infuses over 1 hour! REVERSAL AGENT/ANTIDOTE- •Protamine Sulfate- KNOW!- "PARINS" Nursing considerations: Monitor Labs prior and during administration ◦CBC= (Hgb/Hct), Platelets (normal range for hemoglobin is: For men, 13.5 to 17.5 grams per deciliter. For women, 12.0 to 15.5 grams per deciliter. Normal levels of hematocrit for men range from 41% to 50%. Normal level for women is 36% to 48%. Normal platelet count ranges from 150,000 to 450,000) ◦Low CBCs would suggest a BLEED ◦Remember Signs and Symptoms of bleeding ◦aPTT (only in IV) -Low /Sub-therapeutic would require INCREASED heparin dose -High/ Supra- therapeutic would require DECREASED heparin dose You should NOT give while patient has an epidural or had recent neuro/spinal surgery•Check with provider if patient is going for surgery and your patient is scheduled for a dose of heparin•Don't give to someone with active bleeding (unless benefit outweighs risk- like DIC) ◦Patients aren't just labs- Observe your patient! S/S of bleeding Education- Patients should learn signs and symptoms of bleeding◦Instruct patients to do things like use electric shaver, soft bristle toothbrush to reduce risk for a bleed◦Remind patients that other medications can increase their risk for bleeding (NSAIDS, herbals- ◦NSAIDS+ASA◦Herbals- G's,F's and S's - Garlic, Ginger, Fish Oil, etc.)

Heparin/"parin" (parenteral anticoagulant)

You are caring for a patient on a cardiac unit who has a brand new DVT. The patient is currently on a heparin drip and receiving warfarin therapy. Today's INR is 1.5. The patient asks you, "Why am I receiving two anti-coagulants at the same time? Is this safe?". What is your response?

"The heparin is used to keep you anti-coagulated until the warfarin is therapeutic. Once the warfarin is working, we will stop the heparin drip."

USE: - Mucolytic: Inhaled version to thin secretions. Can see used in cystic fibrosis. -Antidote for Acetaminophen. Protects Liver. Oral Version- Smells like rotten eggs. Intravenous Version- this is what we use for overdose

Acetylcysteine

Assist primary drugs in relieving pain: Antidepressants, Anticonvulsants, Corticosteroids, Lidocaine patches. Examples: Duloxetine, Amitriptyline -Original use: Antidepressant -Adjuvant Pain Use: treat peripheral neuropathy from Diabetes Gabapentin -Original Use: Initially came to market as seizure medication -Adjuvant Pain Use: treat post-herpetic neuralgia from Shingles

Adjuvant Drugs

Use: treat CHRONIC gout (Patients will be on this daily!) (Allopurinol can be used for tumor lysis syndrome) MECHANISM OF ACTION: ◦Inhibit Xanthine oxidase- this is needed to make uric acid. End result- less uric acid. ADVERSE EFFECTS: ◦Allopurinol- Delayed Hypersensitivity Reactions (SJS/TEN- Type 4/IV). Rarely kidney injury. GI distress (GIVE WITH FOOD!) ◦Febuxostat- Cardiac Risk- FDA BOXED WARNING. Higher risk for cardiovascular events! GI distress (GIVE WITH FOOD) SJS/TEN S/S r/t Allopurinol: ◦Skin Rash ◦Fever ◦Lips peeling ◦Mouth sores ◦Sore throat ◦Fatigue NURSING CONSIDERATIONS: Allopurinol- Give with food. watch uric acid levels. Pt. should report s/s of SJS/TENS. Continue therapy, it can actually worsen gout attacks when first starting. Febuxostat- Screen patients for cardiac disease. Higher risk for cardiovascular events. Check uric acid levels. Give with food.

Allopurinol and Febuxostat

Medications that relieve pain without causing loss of consciousness;"Painkillers" -Can be: Opioid analgesics: ex: Morphine Non-opioids/Adjuvant analgesic drugs: ex: Acetaminophen (Tylenol®)

Analgesic Drugs

Score of 1-3= "MILD" pain -Non-opioids- like acetaminophen +/- adjuvant therapy Score of 4-6= "MODERATE TO SEVERE" -Weak opioid- hydrocodone + non opioid- acetaminophen combo drug (Vicodin® or Norco®) Score of 7-10= SEVERE pain -Strong opioid- Morphine

Analgesic pain ladder

USED TO TREAT: These are used to treat diarrhea MECHANISM OF ACTION: These function as opioid agonists only in the periphery (GI tract) ADVERSE EFFECTS: Constipation! Extreme usage/abuse- bowel obstruction. Lomotil® (diphenoxylate + atropine) Why was atropine added?- to discourage abuse) NURSING CONSIDERATIONS: Limit use of anti-diarrheals. These can cause serious consequences (bowel obstruction). C.Diff- can cause toxic megacolon. Administration: Screen for C.diff. Make sure patient does not have an obstruction/any GI issues.

Anti-Diarrhea Opioids: loperamide, diphenoxylate

USE: Treat or abort (No pregnancy) an oncoming migraine (PRN) MECHANISM OF ACTION: Causes VASOCONSTRICTION of cranial blood vessels. Suppresses release of CGRP to block inflammation associated with the trigeminal vascular system. ADVERSE EFFECTS: -Do NOT give within 24 hours of a triptan- the two together can cause extreme vasospastic reaction! -Also Teratogenic (AVOID IN PREGNANCY) -Risk for Physical Dependence (can have withdrawal- HA-headache?, N/V) - GI- N/V/D- give with food - Toxicity: Called Ergotism (This is what was believed to happen at Salem Witch Trials) - ERGOTISM: Convulsions- seizures/spasms, muscle pain, Hallucinations- CNS, Extreme vasoconstriction to extremities (dry gangrene) NURSING CONSIDERATIONS: Same as triptans Administration: -Give as soon as symptoms appear. -With or without food (ATI recommends w/food)

Anti-migraine Ergot Derivative: Ergotamine (DHE)

-Preferred method of treatment for hospitalized patients with DM -Mimics a healthy pancreas by delivering basal insulin constantly as a basal (slow release throughout the day) and then as needed as a bolus (at mealtime) -Basal insulin is a long-acting insulin (insulin glargine) -Bolus insulin (insulin lispro or insulin aspart)

Basal-Bolus insulin dosing

COX 1- "good": Gastric mucosa protection, Platelet aggregation, Supports renal function. COX 2- "bad": Sites of tissue injury "inflammation", In brain- mediates fever and pain, Blood vessels- dilation, stops platelet aggregation, Colon - "colon cancer." Associated with Cardiac issues. **In summary: Prostaglandins generally cause VASODILATION, Prostaglandins PROTECT the GI Tract, Prostaglandins cause PAIN and FEVER. TXA2 (Thromboxane) causes platelets to form a platelet plug (precursor to a blood clot). Our NSAIDS block prostaglandins. They reduce PAIN and FEVER, but you LOSE the protection of the GI Tract (these can cause stomach ulcers)

COX Enzymes (COX 1, COX 2) (look at phone)

TXA2; protective prostaglandins in stomach

COX I

Inflammatory prostaglandins; hyperalgesia (enhanced sensitivity to pain)

COX II

-Findings include agitation, anxiety, insomnia, flu‑like manifestations, opioid cravings. -Physical- rhinorrhea (runny nose), yawning, sweating (diaphoresis), pilo-erection (goose bumps), abdominal cramping, and diarrhea. -May see autonomic dysfunction (hypertension, tachycardia) -Manifestations are non‑life‑threatening, although suicidal ideation can occur. -Options: Clonidine helps slow down autonomic hyperactivity -Options: Methadone + Buprenorphine (Prescribers need special privilege to prescribe Suboxone)

Characteristics of Opioid Withdrawal Syndrome

Acute pain: Sudden onset Usually subsides once treated Chronic pain: Persistent or recurring Lasts 3 to 6 months Often difficult to treat Tolerance Physical dependence

Classification of pain by onset and duration

Anticoagulants (Antithrombotic drugs, second stage of hemostasis)- VEINS - DVT/PE prevention/treatment - VEINS ◦Inhibit the action or formation of clotting factors ◦Prevent clot formation Antiplatelet drugs- coronary arteries- ARTERIES ◦Inhibit platelet aggregation ◦Prevent platelet plugs Thrombolytic drugs ◦Lyse (break down) existing clots

Coagulation modifier drugs

STAGE ONE- Formation of platelet plug (UNSTABLE) ◦Damaged blood vessel ◦platelets come into contact with collagen on exposed surface of damaged vessel ◦platelets adhere to damage site (von Willebrand Factor via GP 1b) ◦adhesion initiates platelet activation ◦activation leads to platelet aggregation ◦aggregation- complex process that results in formation of fibrinogen bridges between glycoprotein IIb/IIIa receptor on adjacent platelets ◦aggregated platelets create a plug that stops bleeding (unstable plug) STAGE TWO- Coagulation (STABLE) ◦defined as production of fibrin (I) ◦Done by two pathways ◦Intrinsic (contact activation pathway) ◦Extrinsic (tissue factor pathway) ◦Both ultimately converge at factor Xa (10 a) Intrinsic (contact activation pathway) ◦activated by blood exposure to collagen ◦stimulates conversion of XII to XIIa ◦eventually activate factor X, where both pathways meet ◦ultimately results in Fibrin Extrinsic (tissue factor pathway) ◦activated by trauma to vascular wall ◦thromboplastin released ◦stimulates conversion of VII to VIIa ◦activate factor X, where both pathways meet ◦ultimately results in Fibrin

Coagulation pathophysiology

USED TO TREAT: ◦Acute Gout (Gout Flare Ups). Sometimes used for other reasons like pericarditis. MECHANISM OF ACTION: ◦Stops microtubules of WBCs, therefore stops WBCs from entering joints and attack gout crystals. If WBCs attack joints, they further increase inflammation. ADVERSE EFFECTS:◦May target microtubules of our own rapidly multiplying cells. Early warning of this is GI symptoms, late warning is systemic organ damage- Death. Mild GI symptoms- (give w/food). If become severe (N/V/D) immediately notify provider. Toxic levels- Myelosuppression- (3 lineages) Nursing considerations: Educate patients to immediately report severe GI symptoms or myelosuppression, rhabdomyolysis. Administration: Example dosing of flare up: Colchicine 1.2 mg at sign of flare up, followed by 0.6 mg in one hour (max 1.8 mg on day of 1 flare up). Not typically seen as a daily (with exceptions)

Colchicine

-Nonadherence with medication regimen, sodium and/or fluid restriction -Acute myocardial ischemia -Uncorrected high blood pressure -AF and other arrhythmias -Recent addition of negative inotropic drugs (e.g.,verapamil, diltiazem, beta blockers) -Pulmonary embolus -Initiation of drugs that increase salt retention (e.g.,steroids, thiazolidinediones, NSAIDs) -Excessive alcohol or illicit drug use -Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism) -Concurrent infections (e.g., pneumonia, viral illnesses) -Additional acute cardiovascular disorders (e.g., valve disease endocarditis, myopericarditis, aortic dissection)

Common Factors That Precipitate Acute Decompensated HF

What if you developed HIT or have a heparin allergy? "parin"- NO LMWH- NO enoxaparin, NO unfractionated heparin- Heparin! (BASICALLY NO HEPARIN/"PARINS"!!) Give a Direct Thrombin Inhibitor- Argatroban

Competitors to Heparin-type drugs

- Potency vs. Efficacy: Potency is an expression of the activity of a drug in terms of the concentration or amount of the drug required to produce a defined effect (EX: 1 mg of Hydromorphone is = 7 mg of Morphine so it's 7 times more potent than morphine), whereas clinical efficacy judges the therapeutic effectiveness of the drug in humans (ex: 1 mg Hydromorphone and 7 mg Morphine are equally effective) -Equianalgesia: Ability to provide equivalent pain relief by calculating dosages of different drugs or routes of administration that provide comparable analgesia - Opioid tolerance: A common physiologic result of chronic opioid treatment Result: larger dose is required to maintain the same level of analgesia -PHYSICAL Dependence: Physiologic adaptation of the body to the presence of an opioid. Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with psychologic dependence (addiction). -PSYCHOLOGICAL Dependence: A pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief

Concepts

Arachidonic Acid converted to many analogs: - Prostaglandin(PG) and Thromboxane (TXA) -Function: TXA2 (thromboxane) ----> Platelet aggregation -Prostaglandins (PGI2, PGE2): Vasodilation (blood vessels, kidneys), Stop platelet aggregation (PGI2- Prostacyclin), Inflammation and pain, Protect gastric mucosa, Promotes uterine contraction at term, Potentially cause colon cancer* PG= Prostaglandins -Tissue Injury (peripheral site of injury)- PG- promote inflammation and sensitize receptors to pain -Stomach- PG- help protect gastric mucosa (REDUCED PARIETAL CELL SECRETION) -Platelets-TXA2- stimulates platelet aggregation -Blood vessels- PG- causes vasodilation, inhibits platelet aggregation -Kidney-PG- causes vasodilation of afferent arteriole- maintains renal blood flow -Brain- PG- Fever and perception of pain -Uterus- PG- Promote contractions at term

Cyclooxygenase (COX-I, COX-II)

Calf Pain/Tenderness/Swelling/Shortness of Breath

DVT/PE s/s

Diabetes mellitus (DM) is not a single disease but a group of progressive diseases. It is often regarded as a syndrome rather than a disease. (Two types: Type 1 & Type 2) Signs and symptoms: - Elevated fasting blood glucose (higher than 126 mg/dL) or a hemoglobin A1C (HbA1C) level greater than or equal to 6.5%. - BIG THREE: Polyuria, Polydipsia, Polyphagia - Glycosuria - Unexplained weight loss - Fatigue -Blurred vision TYPE 1 DM: -Autoimmune disease, attacks pancreas and pancreas is no longer able to produce insulin ("Insulin dependent diabetes) Type 2 DM: Most common type: 90% of all cases •Caused by insulin deficiency and insulin resistance •Many tissues are resistant to insulin: Reduced number of insulin receptors. Insulin receptors less responsive.

Diabetes Mellitus (DM)

Prediabetes: ◦Categories of increased risk for DM ◦HbA1C of 5.7% to 6.4% ◦Fasting plasma glucose levels higher than or equal to 100 mg/dL but less than 126 mg/dL ◦Impaired glucose tolerance test (oral glucose challenge) - Screening recommended every 3 years for all patients 45 years and older

Diabetes Screening

Type 1 ◦Insulin therapy Type 2 ◦Lifestyle changes◦Oral drug therapy◦Insulin when the above no longer provide glycemic control Glycemic goal of treatment: - HbA1C of less than 7% - HbA1C diagnostic criteria;◦<5.7 = Normal ◦5.7 to 6.4 = Prediabetes ◦>6.5 = Type 2 diabetes Fasting blood glucose goal for diabetic patients of 70 to 130 mg/dL Estimated average glucose

Diabetes Treatment

4 Major Insulin Groups ◦Rapid Acting: insulin lispro (Humalog®), aspart (Novolog®), glulisine (Apidra®) ◦Regular Acting: Regular insulin (Humulin R®/Novolin R®) ◦Intermediate Acting: Neutral Protamine Hagedorn (NPH) insulin (Humulin N®) ◦Long Acting: insulin glargine (Lantus®), insulin detemir (Levemir®)

Diabetes drugs to know: Injectable insulins-

Used to treat: ◦1) Heart Failure (negative chronotropic) ◦2) Atrial Fibrillation (negative dromotropic, negative chronotropic) -Adverse effects: ◦Due to Digoxin + Potassium competing, we must have normal potassium levels (magnesium and calcium too)! ◦Dig Tox= Hypokalemia, Hypomagnesemia, HYPERcalcemia TOXICITY EFFECTS (usually suggesting toxicity) ◦Heart Related- ◦Dysrhythmias! ◦Bradycardia or another dysrhythmia ◦Can also see hyperkalemia due to toxicity ◦GI related- ◦Anorexia (loss of appetite ---> weight loss), Nausea, Vomiting ◦CNS related- Fatigue, Confusion ◦Vision disturbances- yellow tint, "Halos", blurred vision• What can cause toxicity?◦hypokalemia, hypomagnesemia, hypercalcemia ◦Digoxin Normal range (narrow therapeutic drug)= 0.5 -2 ng/ml HOW TO TREAT TOXICITY? ◦What if we see EKG changes or symptomatic?- Check a digoxin level ◦ANTIDOTE- Digibind ®- Digoxin specific Antibody Fab fragments (digoxin immune Fab) DRUG- DRUG INTERACTIONS- LOTS! ◦Diuretics--Most patients with heart failure are on diuretics! -Low potassium will increase the risk for digoxin induced dysrhythmias/toxicity (Digoxin competes with potassium) -Hyperkalemia can cause less digoxin response ◦ACE-Inhibitors/ARBs--can increase K+ and decrease digoxin response ◦Drugs/Foods that can bind up Digoxin -Bile Acid Sequestrants- Cholestyramine -Sodium Polystyrene Sulfate- Potassium Binder (Kayexalate can treat hyperkalemia) -High Fiber foods like Bran (may reduce absorption of digoxin) -Pharmacokinetics: •Drug is renally eliminated •Requires adjustment in renal impairment •Often times a target of drug calculation questions •Digoxin often written as either micrograms (mcg) or milligrams (mg) •125-250 mcg = 0.125-0.25 mg (SOURCE OF DRUG CALCULATION ERRORS) -Nursing considerations: Nurses should assess potassium levels (3.5 -5 mEq/L) Encourage a diet high in potassium Be aware of medications that can alter potassium (diuretics!) Assess heart rate before administration (negative dromotropic) Check APICAL pulse! Educate patients to check their pulse at home before use Normal range (60-100 bpm) Notify provider if HR<60 (withhold dose if < 60) Notify provider if patient has palpitations Should see improved Urine Output (>30ml/hr) Digoxin levels should be checked periodically (range is 0.5-2 ng/ml) Educate patient about S/S of toxicity (think of GI and CNS related)

Digoxin

1) POSITIVE INOTROPIC activity- Blocking the Na+/K+ ATPase pump (treats HF by helping heart pump more blood out to the rest of the body, such as kidneys) 2)NEGATIVE CHRONOTROPIC activity- Digoxin has been found to be parasympathomimetic (causes vagal stimulation) and also increases baroreceptor sensitivity (treats atrial fibrillation by slowing heart beat down) 3) NEGATIVE DROMOTROPIC activity- Cholinergic activation in atria (AV node), less at Purkinje (treats Atrial fibrillation by slowing down any crazy rhythms) RESULT?- Improved Cardiac Output and Increased Renal Perfusion= Increased Urine Production and decreased RAAS activation

Digoxin mechanism of action

DVT Prophylaxis (hospitalized/immobile)- ◦Travelling- ◦Pregnancy- Hypercoagulable ◦Cancer- hypercoagulable (do NOT use anticoagulants with leukemia! They bleed easily) ◦Atrial Fibrillation (irregular heart beat)- Stroke ◦Mechanical heart Valve- ◦Many other considerations

Diseases states to be concerned about with coagulation and use of anticoagulants (conditions to use anticoagulants)

A brand new nursing student is administering subcutaneous heparin to a patient. Which of the following actions are true in regards to heparin administration?

Do not aspirate the injection Inject at a 90 degree angle Rotate and Record Injection Sites

Used to treat: -Heart failure/shock! (late stages) ◦Hemodynamic Support ◦Inotropic Support for Heart Failure -Adverse effects: ◦Alpha 1- Hypertension ◦Beta 1-Too much demand on heart (tachycardia, dysrhythmias, ischemic damage)- EKG IV infusion- risk of infiltration/extravasation- SERIOUS DAMAGE! (Antidote: Phentolamine) Intended outcomes: Depending on indication what is our goal? LOW Dose- increased urine output! (DA/dopamine= renal perfusion, oxygenate kidneys ----> inc. urine output) MODERATE Dose- increased Cardiac Output (DA and Beta 1) HIGH Dose- Improved BP (DA + Beta 1 + Alpha 1) NURSING CONSIDERATIONS: ◦DA- urine output, improvement of the AKI/ARF (SCr/BUN down) ◦Beta- inotropic support ◦Alpha- BP

Dopamine

Compensated Heart Failure -home/stable/chronic/controlled -Medications designed to prevent worsening -Target RAAS, SNS •Decompensated Heart Failure (heart failure exacerbation) -acute/hospitalization/uncontrolled -Diuretics -Vasodilators (dilate arteries) •+ Inotropic Support -Kidneys>Heart

Drug therapy in heart failure

USED TO TREAT ◦DVTprophylaxis (subcutaneously) ◦DVT/PE treatment (therapeutic, weight based) (subcutaneously) NO IV DOSAGE!! ADVERSE EFFECTS: -Same as heparin ◦Bleeding, avoid in epidurals/neuro ◦Monitor CBC (Hgb,Hct,Plts) -still risk for HIT ("parin") CONTRA-INDICATIONS •History of HIT (heparin induced thrombocytopenia) •Low H/H, platelet count- why?•Pork allergy- from intestinal mucosa from pigs, Pork- religious•Recommend consulting- •Neurosurgery, Epidurals, etc.•Peptic Ulcer Disease/GI Bleeding•Active Bleeding -REVERSAL AGENT/ANTIDOTE•Protamine Sulfate- KNOW!- "PARINS" ADMINISTRATION: -Prefilled syringes are available in various dosages for subcutaneous injection -Rotate sites between right and left anterolateral and posterolateral abdominal walls at least 2 inches from umbilicus. -Do not expel the air bubble in the syringe unless adjustments must be made to the dose. -Pinch up an area of skin, inject at a 90° angle, and insert needle completely. -Do not aspirate. -Inject entire contents of syringe. -Do NOT rub the site for 1 to 2 min after the injection. -Apply GENTLE PressureRotate and record injection sites.

Enoxaparin (Low Molecular Weight Heparin- LMWH)

Cardiac Glycoside -Digoxin ◦Vasodilator -BiDil® (hydralazine+isosorbide) ◦Angiotensin Receptor- Neprilysin Inhibitor (ARNI)- Sacubitril + Valsartan ◦ Inodilator -Milrinone •VASOPRESSORS/SHOCK -Dopamine -Dobutamine -Phenylephrine -Isoproterenol -Norepinephrine -Epinephrine

Heart Failure (HF) drugs

Milrinone Dopamine Dobutamine

Heart Failure: Positive Inotropic Agents

USED TO TREAT: Joint pain, swelling, inflammation (arthritis, tendinitis, bursitis, etc.) Fever, Mild - moderate pain (Remember these are DIFFERENT FROM ASPIRIN!) -Mechanism of Action: REVERSIBLY inhibit both COX-I and COX-II pathways- Stops prostaglandin production in both (Reduces pain, inflammation, fever) - Adverse effects: GI effects, bleeding. *Ketorolac- max of 5 days usage! Increased blood pressure (can lead to MI/Stroke). Renal impairment (potential for AKI). ***Not to be used in heart failure (sodium/fluid retention)! -NURSING CONSIDERATIONS: -GI Concerns: take with food or water/milk. Educate for S/S of GI Bleed- Higher risk with smoking/alcohol, steroids, other NSAIDs, anticoagulants. -Kidney Concerns: Monitor urine output, BUN, creatinine. Usually only a concern if dehydrated + other nephrotoxic meds, or history of renal issues. Encourage patients to stay hydrated! -MI/Stroke Concerns: Educate patients to use lowest dose for the lowest time frame to avoid long term usage. Patients can monitor blood pressure. Remember aspirin is the unique exception that protects from heart attack and stroke. - Fluid Retention Concerns: Avoid in heart failure patients! -Nursing considerations: Interactions: Increased risk for bleeding- watch out with "blood thinners" like warfarin/heparin. Steroids can hurt GI tract (risk for ulcer/bleed). Alcohol can increase risk for bleeding. Watch out with other NSAIDs! -Administration: take with food/liquids

First Generation NSAIDs: ibuprofen, naproxen, ketorolac, indomethacin, diclofenac - Common suffixes: "profen" - Ibuprofen, ketoprofen, flurbiprofen. "fenac"- Diclofenac, Bromfenac, KetotrolAC

INOTROPIC •Contractility •Cardiac Muscle •+ increase the FORCE of myocardial contraction (STRENGTH) •- decrease the force •CHRONOTROPIC •Heart rate •SA Node •+ increase the RATE of the heart beat •- decrease the RATE of the heart beat •DROMOTROPIC •Conduction Velocity •AV node ,bundle of His, Purkinje Fibers •+ increases CONDUCTION of electrical impulses - decreases CONDUCTION of electrical impulses Note: Heart failure patients should weigh in daily! ◦If 2 lb weight gain in 1 day OR 5 lb in 1 week, need to notify provider (developing fluid overload)

Heart failure definitions

In general, heart failure patients should weight in daily! If 2 lb. weight gain in 1 day OR 5 lb. in 1 week, NEED TO NOTIFY PROVIDER (fluid overload development) Goals for treatment: 1) If fluid overloaded- remove excess fluid (loop diuretics such as furosemide) 2) Increase cardiac output to reduce end organ dysfunction ◦Inodilator: ◦Milrinone ◦Inotropic Support: ◦Dobutamine/Dopamine

Heart failure exacerbation

Colchicine, Allopurinol, Probenecid, Febuxostat

Gout Drugs ("C.A.P. the F'n uric acid!")

Gout- simply excessive uric acid that forms uric acid crystals in joints and tissue. Can cause swelling and pain. Two major causes of build up of uric acid: 1) Under-excretion: Kidney not eliminating uric acid properly. Often induced by diuretics like hydrochlorothiazide (HCTZ). 2) Over Production -Tumor Lysis Syndrome: destruction of Tumors by chemotherapy- Tumors release DNA byproducts that convert to uric acid. Diet induced- "Disease of Kings" "Rich Mans Disease": Diets rich in Alcohol, meat, seafood, mushrooms, lots more can result in overproduction of uric acid.

Gout and its causes

◦NSAIDS ◦IV Corticosteroids for acute attack ◦OR....: Colchicine, Allopurinol, Probenecid, febuxostat (FOCUS ON THESE)

Gout treatment

-Anti-inflammatory properties -Used to treat migraine headaches, menstrual cramps, inflammation, and fever -May cause GI distress, altered taste, muscle stiffness -May interact with aspirin and other NSAIDs, as well as anticoagulants A general rule for herbals: If you see an Herbal that starts with G or F, usually the concern is bleeding risk if added with an anticoagulant like Warfarin. List of common herbals that interact with Warfarin: Ginger, Gingko biloba, Garlic, Glucosamine, Feverfew, & Fish Oil.

Herbal Products: Feverfew

-Not regulated by the FDA -USE: Used to treat the pain of OA Adverse effects: GI discomfort, Drowsiness, headache, skin reactions (glucosamine) Drug interactions: Enhances effects of warfarin, May increase insulin resistance (glucosamine).

Herbal Products: Glucosamine and Chondroitin

Which of the following lab values would be suggestive of active bleeding in a patient on warfarin?

Hgb of 7 g/dL Pulse of 110 beats per minute Hct of 25%

Remember that the PEAK time of insulin has greatest risk for HYPOGLYCEMIA. You should always have glucose ready just in case! -Early Signs ◦Confusion, irritability, tremor, sweating, SNS activation -Late Signs ◦Hypothermia, seizures ◦Coma and death will occur if not treated. Treating hypoglycemia: CHECK A GLUCOSE LEVEL FIRST! -Hypoglycemia is <70 mg/dL. - If patient is alert, Give 15 grams of carbohydrates. Hospitals will always have glucose tablets. -If at home, can do 4 ounces of orange juice, 2 oz of grape juice. -If patient has altered mental status, Give IV glucose (DEXTROSE) Or IM Glucagon. Should eat some food as well.

Hypoglycemia Symptoms

Manifested by muscle weakness, confusion, lethargy, anorexia, nausea, and changes in the ECG

Hypokalemia

Manifested by agitation, twitching, hyperactive reflexes, nausea, vomiting, and ECG changes

Hypomagnesemia

P - phenytoin S - Smoking P - phenobarbital O - Oxcarbazepine R - rifampin C -carbamazepine S - St. John's Wort (OTC herb)

Inducers: PS - PORCS

P - protease inhibitor (HIV) A - azole antifungal (fluconazole,ketoconazole) C - cimetidine M - macrolides (Azithromycin ACE?) A - amiodarone N - non-DHP Calcium Channel Blockers (diltiazem, verapamil) ♥'s Grapefruit juice

Inhibitors: PACMAN loves Grapefruit juice!

- All insulins are HIGH RISK MEDICATION! -Serious potential for fatal harm (Diabetes medications, Anticoagulants, Antibiotics) -USE: 1) Primarily for hyperglycemia ◦type I and II diabetes 2) Can also use fast acting insulin for hyperkalemia -Mechanism of Action: In general, insulin promotes cellular uptake of glucose (glycogen storage). Moves potassium+ glucose into cells. Differences between insulins are their onsets, peaks, durations. Before giving insulin, you should assess: - Primary/Required: Blood Glucose! ◦Hypoglycemia is defined as <70 mg/dL ◦Consider holding if <130 (provider preference) ◦Consider holding dose if patient not eating -Secondary: ◦Potassium-We check this while patients are on IV DRIPS ◦Hemoglobin A1C ◦3 month average of glucose levels ◦Goal <7% ◦If this is high or low would you hold your medication? (Give insulin lispro, aspart, glulisine, and regular with meals!)

Insulin

SUBCUTANEOUS: ◦Most of our insulins are given subcutaneously ◦Injections, Pumps INTRAVENOUS: ◦Insulin can be given as IV for emergency purposes ◦Rapid insulin as IV push to treat hyperkalemia or critically high glucose ◦Rapid/Regular insulin can be given as a continuous IV infusion for HHS/DKA patients INHALED: ◦There is an insulin inhaler! (Won't discuss) ◦Insulin is NOT absorbed orally

Insulin Administration

Rapid‑acting: Lispro insulin ◦ONSET: 15 to 30 min ◦PEAK: 0.5 to 2.5 hr ◦DURATION: 3 to 6 hr Intermediate‑acting: NPH insulin •ONSET: 1 to 2 hr •PEAK: 6 to 14 hr •DURATION: 16 to 24 hr Short‑acting: Regular insulin ◦ONSET: 0.5 to 1 hr ◦PEAK: 1 to 5 hr ◦DURATION: 6 to 10 hr Long‑acting: Insulin glargine •ONSET: 70 min •PEAK: None •DURATION: 18 to 24 hr

Insulin Onsets/Peaks/Durations

UNOPENED ◦In general, keep UNOPENED insulin in refrigerator ◦Use normal expiration date on vial ◦Keeping it refrigerated makes it last longer and prevents any bacterial growth OPENED ◦Once opened, can keep at room temperature (No one wants cold insulin injected into their abdomen!) ◦New BEYOND USE DATE- must discard after 28 days

Insulin storage

Use: Diabetes Adverse effects: Hypoglycemia, Lipo-hypertrophy, Hypokalemia, Weight gain Nursing considerations: Rotate injection sites weekly, Monitor BG- should educate about S/S of hypoglycemia, Biggest hypoglycemia risk is during PEAK Administration: -SUBCUTANEOUS, CLOUDY INSULIN!!!! -Administer 30 minutes before a meal -45 to 90°angle, Small needle (28 to 31 gauge), shorter length -Sites: Arms, Thighs, Abdomen

Intermediate Acting Insulin: Neutral Protamine Hagedorn (NPH) insulin (Humulin N®/Novolin N®)- SC

Aspirin is unique why?

It has a protective effect! and irreversible

USED TO TREAT: ◦Chronic Gout (Patients will be on this daily!) MECHANISM OF ACTION: ◦The kidneys eliminate uric acid. Probenecid increases the elimination of uric acid in the urine. ADVERSE EFFECTS:◦Alters urine- so kidney stones, kidney injuries. Can also cause gout attacks in initiation. GI upset (give with food). NURSING CONSIDERATIONS: Hydrate up! Check uric acid levels. Also watch out for rash. Give with food.

Probenecid

Cause pain and inflammation

Prostaglandins

USE: Diabetes Adverse effects: Hypoglycemia, Lipo-hypertrophy (rotate sites weekly•Each day, rotate around ½-1 inch from previous site, then after 1 week, go to new site), Hypokalemia (Seen with high doses•We check potassium if on insulin drips), Weight gain Nursing considerations: Rotate injection sites weekly, Monitor BG- should educate about S/S of hypoglycemia, Biggest hypoglycemia risk is during PEAK Administration: SUBCUTENAEOUS, CLEAR INSULIN -This insulin does NOT Peak, therefore does not matter with or without food -45 to 90° angle, Small needle (28 to 31 gauge), shorter length -Sites: Arms, Thighs, Abdomen

Long Acting Insulin "Basal" insulin glargine (Lantus®)- SC 100 units/ml insulin detemir (Levemir®)- SC Insulin glargine (Toujeo®) - 300 units/ml (different concentration, but still glargine!)

-Migraine with aura/indicator that migraine is coming (30%) -Migraine WITHOUT aura (70%)

Migraine characteristics

Neurovascular disorder of intracranial vessels: -DILATION -INFLAMMATION Promotion of Migraine: CGRP (calcitonin gene related peptide) ◦Inhibition of Migraine: Serotonin (5-HT) Therefore, treatment includes Blocking CGRP & Increasing 5-HT (Serotonin)

Migraine pathophysiology

1)Treat/abort oncoming migraine ◦OUR FOCUS: Sumatriptan- "Triptans", Ergotamine 2)Prevent future migraines 3) Individualize the approach (headaches can be unique) 4)Prevent physical dependence

Migraine therapy goals

In a patient with fluid overload and shortness of breath at rest, which of the following medications would likely be administered?

Milrinone

-USED TO TREAT: Pain management. BUPRENORPHINE- Addiction management (Substance Use Disorders) MECHANISM OF ACTION: Depends on the drug. Example: Buprenorphine is a partial agonist at Mu receptors, antagonist at kappa receptors Example: Nalbuphine is antagonist at Mu, agonist at Kappa receptors ADVERSE EFFECTS: Same as our other opioids (MORPHINE) Nausea, Respiratory Depression, Miosis, Constipation, etc. UNIQUE 1. Less abuse potential (not as strong- less risk for euphoria). Nalbuphine is actually NOT on DEA Controlled Substance/Schedule List 2.Less Respiratory Depression (Ceiling effect) 3.Less Analgesic Effect (Ceiling effect) 4.Partial agonists usually have higher affinity than other opioids (Example: Patient on chronic morphine, prescriber doesn't know, gives dose of nalbuphine. Nalbuphine affinity > morphine affinity, so nalbuphine kicks morphine off receptor. Pain was previously controlled by morphine, so patient now experiences pain not controlled by nalbuphine) Administration: Check for other opioids. Pain Score. Sedated? Respiratory Rate If on other CNS depressants, give at separate times Extra: Blood Pressure, Pulse

Mixed/Partial Agonists: Buprenorphine, Butorphanol, Nalbuphine, Pentazocine

When is it appropriate to mix insulins? ◦NOT A COMMON PRACTICE ◦We have Premade Mixed Insulin Vials sold commercially Can mix: A + B ◦A) Rapid (ex: humalog) OR Short Acting (humulin) ◦B) NPH -Mix "clear to cloudy" (Nancy Reagan RN- air in NPH, air in regular, withdraw regular, withdraw NPH) -Roll vials between hands instead of shaking them to mix suspensions. (NEVER SHAKE INSULIN- You can degrade it) NEVER MIX Long acting insulins (glargine or detemir) with any other insulins!

Mixing insulin

USED TO TREAT: PRIMARY USE: Moderate to Severe Pain, Severe Pain (NOT MILD!- Remember the Analgesic Pain Ladder!) Other uses: Cough (anti-tussive)- weaker opioids such as codeine in liquid form. They can suppress the cough function in the brain. If someone is "coughing up a lung" can also see weak ones to treat the pain caused by extreme coughing in severe situations. Frequently given with Non-Opioids as a multi-modal pain approach Example: Percocet® is Oxycodone + Acetaminophen Norco® is Hydrocodone + Acetaminophen Mechanism of action: Agonists of opioid receptors in the CNS and periphery (Binds to Mu + Kappa) ADVERSE EFFECTS: Mnemonic "M-O-R-P-H-I-N-E": M-Miosis (constriction of the pupil) O-Out of it (sedated) R-**Respiratory depression P-Pruritus (common) H-Hypotension (dizzy) & Head injury(avoid!) I-Infrequency (referring to urinary retention or constipation) N-Nausea E- Emesis Respiratory depression- Works on part of the brain that controls breathing -Think of other diseases/drugs that can make this worse! -Excessive CNS sedation (CNS DEPRESSION): CNS depression- DROWSINESS/SLEEPY! (may see patients on stimulants to counteract) -Nausea / vomiting Direct stimulation of the Chemoreceptor Trigger Zone (CTZ) Miosis (pinpoint pupils) -Diaphoresis/Flushing -Urinary Retention -Constipation/gastroparesis: Binds to receptors peripherally (GI tract) AND the bladder Do NOT GIVE IN BILIARY COLIC, do NOT give in Paralytic Ileus -Do Not Use in Head Injury Per ATI, they can cause transient increases in ICP -Tolerance / dependence / EUPHORIA/ addiction Withdrawal, dangerous? (Goose Bumps) -Itching (histamine release)- NOT ALLERGIC REACTION Common reaction with opioids -ALLERGIC REACTIONS- Anaphylaixs- IgE Mediated Cross reactivity/sensitivity with other opioids -hypotension/bradycardia (although not a good diagnostic) Suppress the baroreceptor reflex and histamine release helps cause vasodilation -Dizziness/Lightheadedness Counsel your patients NOT TO OPERATE MACHINERY Change positions slowly -Opioid Analgesics: Drug-Drug Interactions RESPIRATORY DEPRESSION: (MUST KNOW!) don't mix with Alcohol,Antihistamines,Barbiturates,Benzodiazepines SEROTONIN SYNDROME: (not all opioids) **Monoamine oxidase inhibitors (MAO-Is) CONTRAINDICATIONS/PRECAUTIONS: Known drug allergy (or allergy in same Drug Class. If pt. is allergic to oxycodone, risk for cross-sensitivity), Giving with other CNS Depressant Drugs (Drug-Drug Issue), Use with extreme caution in patients with: Severe Asthma/COPD, **Respiratory insufficiency,Elevated intracranial pressure, Morbid obesity or sleep apnea, Paralytic ileus, Age populations: Geriatrics- Declined metabolism, renal function, may need lower doses, fall risk; Pediatrics- NO CODEINE!; Pregnancy and Breastfeeding (Codeine, Tramadol can cross! So NO codeine or tramadol in pregnancy & breastfeeding). Genetics- Enzyme metabolism Poor Metabolizers, Rapid Metabolizers -True allergy concern: throat itching, tongue/lip/eyelid swelling (angioedema), difficulty breathing, hives -No allergy just side effects: general itching, flushing, nausea/vomiting, hallucinations, rash (*Rash needs to be evaluated further- is this maculopapular, is this the start of SJS/TEN?) Nursing considerations: MANAGEMENT OF CONSTIPATION (best to use prophylaxis to PREVENT constipation): -Opioids lock up GI Motility- Peristalsis -Patients NEVER develop a tolerance to this -Minimally effective treatment: Instruct patients to increase fiber/fluid + exercise -BEST way to treat constipation: Remember "all mush, no push", recommend a drug BEFORE they get constipated (prophylaxis!- they need stimulants, not stool softeners) -Urinary Retention: Assess I's & O's, make sure patients are aware of their voiding patterns (Avoid anticholinergics when possible) -CNS Sedation: Instruct patients to avoid operating heavy machinery -Nausea and Vomiting: If this occurs, can pre-medicate with anti-emetics if in hospital, Can also take with FOOD!!! -Dizziness/Orthostatic hypotension: Change positions slowly, be aware of fall risk ADMINISTRATION- Prior to administration: - assess pain levels- treat according to pain scale - Take vital signs- if respiratory rate is < 12, hold the dose! SAFETY AND MITIGATION (REMS DRUGS) -Opioid Epidemic- Reduce Substance Use Disorders (SUD) Outpatient prescriptions are written for the smallest amount of pills as well as the smallest duration possible. No refills, need a new prescription!

Morphine prototypes: morphine, codeine, hydromorphone (dialaudid), oxycodone, hydrocodone

Common uses: • Atrial fibrillation (non-valvular) •DVT/PE treatment/prophylaxis ADVERSE EFFECTS (rivoroxaban, apixaban): ◦Same as our general anticoagulants ◦Bleeding ◦Avoid in epidurals ◦Avoid with other anticoagulants, NSAIDS! NURSING CONSIDERATIONS (rivaroxaban, apixaban): •Nurses should check CBC (H/H + Plts) before administering•Instruct patients to be aware of s/s of bleeding•Patients should take consistently at same time, do not miss a dose CONTRA-INDICATIONS (rivoraxaban, apixaban) -Active Bleeding -Peptic Ulcer Disease -Neurosurgery/epidural - NSAIDs -Smoking -Alcohol (EtOH) -other Blood thinners Antidote (for apixaban)- Andexxa®/Andexanet alfa Administration: Rivaroxaban must be given with food! ADVERSE EFFECTS (Dabigatran): Same as our general anticoagulants ◦Bleeding ◦Avoid in epidurals ◦Avoid with other anticoagulants, NSAIDS -Unique to Dabigatran, huge GI upset, GERD! NURSING CONSIDERATIONS Dabigatran: •Nurses should check CBC (H/H + Plts) before administering •Instruct patients to be aware of s/s of bleeding •Patients should take consistently at same time, do not miss a dose CONTRA-INDICATIONS -Active Bleeding -Peptic Ulcer Disease -Neurosurgery/Epidural Antidote (for Dabigatran)- Praxbind® (Idarucizumab) Administration: Dabigatran Must be given with full glass of water. If GI upset occurs even with full glass of water, can give with meals. Also be careful with renal impairment in dabigatran!

NOAC/DOAC = Alternative oral therapy instead of warfarin (work instantaneously and don't have diet concerns or INR checks like Warfarin) Types- •Factor Xa Inhibitor- rivaroxaban, apixaban •Direct Thrombin Inhibitor - Dabigatran

NSAIDS block the COX pathway

NON-OPIOIDS: First group- NSAIDS (Non-Steroidal Anti-Inflammatory Drugs) mechanism

1. Salicylates/Irreversible NSAIDS: ASPIRIN ONLY! 2. Non-Salicylates/ Reversible NSAIDS: All other NSAIDS are in this category. This group has many further sub classifications

NSAIDS 2 Main Groups

USED TO TREAT: Pain Same as our other opioids: Frequently given with Non-Opioids as a multi-modal pain approach (Example: Ultracet® is Tramadol + Acetaminophen) --------------------------------------------------------------------------- TRAMADOL MECHANISM: Binds to opioid receptors increases Serotonin and Norepinephrine in the nociceptive pathway. Different from other opioids because it increases Serotonin. UNIQUE ADVERSE EFFECTS of TRAMADOL: This medication can lower the seizure threshold (SEIZURE RISK!). Increases Serotonin- watch out for SEROTONIN SYNDROME. Do NOT use in breastfeeding (similar concern to Codeine). ---------------------------------------------------------------------------- METHADONE SPECIAL USE: SUBSTANCE USE DISORDERS Pain relief too MECHANISM: Binds to opioid receptors + inhibits NMDA receptors UNIQUE ADVERSE EFFECTS: This medication can prolong the QT interval (dysrhythmia risk). Patients require periodic EKGs. ---------------------------------------------------------------------------- FENTANYL: MECHANISM: Binds to opioid receptors. **MOST POTENT OPIOID- 100 x's more potent than morphine (besides the other "fentanyls" carfentanil, sufentanil, etc) Comes in several forms: IV pushes- critical care only (ICU, ED, OR) Lozenge/Lollipops- oral mucosa- acute cancer pain Patch- Transdermal- CHRONIC PAIN ONLY EDUCATE ABOUT PROPER DISPOSAL! - B/C kids and pets can eat them accidentally AVOID HEATING PADS! SLOW TO KICK IN- NEVER FOR ACUTE PAIN! (can take 12 hours) NEVER FOR OPIOID NAÏVE!* ---------------------------------------------------------------------------- Meperidine Can be used for shivering in the OR -MECHANISM: Binds to opioid receptors UNIQUE ADVERSE EFFECTS: CANNOT be given with MAO-I drugs, Meperidine can only be given short term- Has a CNS toxic metabolite called Normeperidine that can cause seizures

Non-Morphine Opioid Agonist Prototypes: Tramadol, methadone, fentanyl, meperidine (Adverse effects for all- same as morphine mnemonic)

USED TO TREAT: Pain or Fever Mechanism of action: Works on hypothalamus (heat regulating center)= treats fevers. Works on inhibiting prostaglandins CENTRALLY= treats mild pain. Reduces Pain and Fever, but NOT Inflammation! Why?- Because it only works in the BRAIN! Won't help with the inflammation of a swollen ankle. Adverse effects: - Extremely rare at therapeutic dosages. NO gastric ulceration, renal impairment, bleeding compared to NSAIDS! - **Liver toxicity / damage: High doses result in large levels of toxic metabolite and rapidly deplete glutathione. Do not exceed 1000 mg/dose. 4000 mg/day (FDA is urging max for 3000 mg/day). If you drink more than 3 alcoholic beverages day- MAX is 2000 mg/day ACETAMINOPHEN ESSENTIALS: -Confusion with different names -Safe to use in children (BUT, watch our dose limit)- CHILDREN ARE WEIGHT BASED DOSING. -Overodse S/S- Patients may present ASYMPTOMATIC OR Present with = Diaphoresis, N/V/D. **This damages Liver- LFTS will RISE! (ANTIDOTE: Acetylcysteine (Acetadote®)) -Administration: Doesn't matter, can take with or without food.

Non-NSAID: Acetaminophen also known as APAP or Paracetamol or Tylenol

Before giving drugs that alter glucose levels: - Assess the patient's ability to consume food. -Assess for nausea or vomiting. -Hypoglycemia may be a problem if antidiabetic drugs are given and the patient does not eat. -If a patient is NPO for a test or procedure, consult the primary care provider to clarify orders for antidiabetic drug therapy. -Only NPH insulin is cloudy! DO NOT ADMINISTER other insulins if they are cloudy or any insulins that are discolored or if a precipitate is present. Be aware of drugs that can increase or decrease glucose levels ◦Caution with other diabetes medications! ◦Oral diabetes med + insulin = higher risk for HYPO event ◦Beta blockers (can mask S/S of hypoglycemia + suppress the liver) ◦Diuretics + Steroids known to cause HYPERglycemia- HCTZ- HyperGLUC (Hyperglycemia as well) -Corticosteroids like prednisone

Nursing implications and considerations for drugs that alter glucose levels (INSULINS)

USED TO TREAT: Primarily as an antidote for opioids MECHANISM OF ACTION: Competitive antagonist at opioid receptors (has an extremely high affinity). Competitively binds to mu and kappa receptors. NURSING CONSIDERATIONS: Assess and monitor Respiratory Rate. Short half life- patients may need a continuous IV drip. Patients pain relief will reverse/come back. Assess vitals- Blood pressure increase and heart rhythm irregularities may occur. What happens if you give the maximum dose and patients respiratory depression has not reversed? - They probably took a NON-OPIOID. Administration: Use in suspected overdose. Should reverse in a few minutes, but remember it has short duration of action (1-2 hours), must monitor RR and reassess frequently for ~4 hours.

Opioid Antagonist: Naloxone (Narcan)

Three main Symptoms (TRIAD)- Respiratory Depression, Pinpoint pupils (miosis) (not always!), Coma

Opioid overdose (treat with Naloxone!)

-Narcotics is a term that is no longer used when referencing opioids! -Poppy plant/seeds- >Opium-> morphine -Before administering opioids, assess for pain level and respiratory rate! Mechanism of Action: Three main opioid receptors: Mu (some opioids work here), Kappa (some opioids work here) Locations of Receptors (Good and Bad!): Brain ( Reward Pathway- Euphoria, Addiction), Brain Stem (Respiratory Center- slow or stop breathing), Spinal Cord (pain relief), Peripheral Neurons (pain relief), GI Tract (side effects like constipation/urinary retention) (Opioids will NOT help with inflammation. This is also likely MILD PAIN, opioids are meant for MODERATE TO SEVERE pain)

Opioids

To keep hemostasis under control, the body:

PROMOTES clotting◦platelets, von Willebrand Factor, activated clotting factors, thromboplastin, TXA2, ADP INHIBITs clotting◦prostacyclin, anti-thrombin III, Proteins C & S, and plasmin(plasminogen)

Injuries can release an "Inflammatory soup" containing...

PROSTAGLANDINS (NSAIDS/Corticosteroids can help suppress Prostaglandins from the Inflammatory Soup)

-An unpleasant sensory and emotional experience associated with actual or potential tissue damage -A personal and individual experience -Whatever the patient says it is -Exists when the patient says it exists -Pain is subjective (No secret blood level or parameter we can objectively measure) -Pain is the "Fifth Vital Sign"

Pain

Numeric rating scale of 0-10 (ADULTS): 0=no pain, 10 = worst pain ever experienced Faces of Pain Scale (PEDIATRICS)

Pain scales

Produces two hormones that play an important role in regulation of glucose homeostasis: 1. Insulin (tells body to store glycogen; promotes glucose storage), 2. Glucagon (promotes glucose release, so antidote for hypoglycemia) •Glycogen: Excess glucose stored in liver and skeletal muscle tissue •Glycogenolysis: Conversion of glycogen into glucose when needed -INSULIN: Direct effect on fat metabolism •Stimulates lipogenesis and inhibits lipolysis •Stimulates protein synthesis •Promotes intracellular shift of potassium and magnesium into the cells •Cortisol, epinephrine, and growth hormone work synergistically with glucagon to counter the effects of insulin.

Pancreas

Peripheral Opioid Antagonist: Methylnaltrexone USED TO TREAT: Opioid Induced Constipation (OIC) MECHANISM OF ACTION: Competitive antagonist at opioid receptors (has an extremely high affinity) only for the GI TRACT "An Antidote for Opioid Induced Constipation" ADVERSE EFFECTS: Abdominal bloating, cramping because GI tract starts back up NURSING CONSIDERATIONS: Do NOT use if someone has a bowel obstruction! Administration: Assess patient for any GI issues (should not use for obstruction), Make sure patient was using opioids (this is only for opioid induced constipation- OIC, doesn't help with non-opioid constipation).

Peripheral Opioid Antagonist: Methylnaltrexone

Pure Opioid Agonists for Pain: -Morphine Prototypes:Morphine, Codeine, Hydromorphone, Oxycodone, Hydrocodone -Non-morphine Prototypes: Methadone, Fentanyl, Meperidine, Tramadol -Anti-diarrheal Opioids: Loperamide, diphenoxylate-atropine -Mixed Opioid Agonists:Buprenorphine, Butorphanol, Nalbuphine, Pentazocine -Opioid Antagonist (Antidote): Naloxone -Opioid Antagonist for Opioid Induced Constipation: methylnaltrexone

Pharmacotherapy drugs to know list

Used: ◦PDE3- CHF ◦MILRINONE: ◦Severe, decompensated HF (late stages, palliative care)/heart failure exacerbation ◦Bridge to await a heart transplant ◦Palliative therapy ◦GOAL: To increase cardiac output and reduce end-organ dysfunction -Mechanism: "Inodilator"- VASODILATOR AND POSITIVE INOTROPIC AGENT (lowers BP, Increases CO) -Adverse effects: ◦dysrhythmias (ventricular) ◦Hypotension CONTRA-INDICATIONS: ◦Can't use if MI or dysrhythmia -Nursing considerations: Nurses should assess blood pressure periodically Nurses should monitor EKG for abnormalities -Administration: IV continuous drip, check EKG, assess vitals

Phosphodiesterase 3 Inhibitor: Milrinone (inotropic agent)

Digoxin works on sodium-potassium ATPase pump in cardiac myocytes. What are the following expected outcomes on cardiac myocytes with digoxin use?

Positive Inotropic Negative Dromotropic Negative Chronotropic

Premade combinations •Humulin 70/30 •Novolin 70/30 •Humalog 75/25 •NovoLog 70/30 (Bigger number represents the Longer acting insulin/NPH)

Pre-made insulin mixtures

- Mu receptor: Analgesia, decreased GI motility, Euphoria, physical dependence, respiratory depression, CNS sedation, urinary retention -Kappa receptor: Analgesia, decreased GI motility, miosis, sedation

Responses produced by specific opioid receptors

- Used to treat diabetes -Adverse effects (all insulins): Hypoglycemia, Lipo-hypertrophy Hypokalemia, Weight gain -Nursing considerations: Rotate injection sites weekly to prevent fat deposits/lipohypertrophy Monitor BG- should educate about S/S of hypoglycemia Biggest hypoglycemia risk is during PEAK -Administration: SUBCUTANEOUS or IV , SHOULD LOOK CLEAR! Administer 15 minutes before a meal or with the meal (do NOT give if food is not there yet)-45 to 90°angle, Small needle (28 to 31 gauge), shorter length Sites: Arms, Thighs, Abdomen

Rapid Acting Insulin: insulin lispro (Humalog®)- SC aspart (Novolog®), glulisine (Apidra®)- SC Admelog® (insulin lispro), Fiasp ® (insulin aspart)

USED TO TREAT: Diabetes, DKA/HHS (usually drips), Hyperkalemia Emergencies (IV push) Adverse Effects: Hypoglycemia, Lipo-hypertrophy, Hypokalemia, Weight gain Nursing considerations: Rotate injection sites weekly, Monitor BG- should educate about S/S of hypoglycemia, Biggest hypoglycemia risk is during PEAK Administration: - SUBCUTENAEOUS, CAN ALSO USE IN CONTINUOUS IV DRIPS FOR DKA/HHS - This insulin is CLEAR - Administer 30 minutes before a meal -45 to 90°angle, Small needle (28 to 31 gauge), shorter length Sites: Arms, Thighs, Abdomen

Regular Acting Insulin: regular insulin (Humulin R®/Novolin R®)- SC or IV

-USE: -Once daily Aspirin dosing - 81 mg or 325 mg for MI/stroke reduction/Thromboprevention (prevention of clots) Note: Other NSAIDS can negate this effect! Ex: If you take ASA w/ibuprofen, you lose the cardio protective benefit (don't take with other NSAIDs) -PRN or frequent Aspirin dosing for pain management (every 4-6 hours): Rheumatoid Arthritis, Osteoarthritis, Joint pain, swelling, inflammation (arthritis, tendonitis, bursitis, etc.), Fever. -Mechanism of Action: Half life of aspirin is ~20 minutes, This is why you have take these constantly (q4-6 hours) for pain relief. Irreversibly binds to COX enzymes (1&2) of platelets. -Adverse Effects: Bleeding (BOXED WARNING)- Inhibition of platelets (thromboxane A2), Gastric distress, heartburn, nausea-Aspirin irritates the stomach lining, Gastric bleeding / ulceration (Inhibit PG in stomach, Worse with Hx of smoking/alcohol, PUD), Renal impairment (Inhibit PG which normally allow healthy blood flow to kidneys which increases risk for kidney injury and blood pressure increase due to Na+ and H20 Retention), Reye syndrome (pronounced like Rye bread) - associated with aspirin use in children (avoid using Aspirin in <12 years old) *** Salicylism toxicity: Presents as-Tinnitus, Sweating, Headache, Dizziness, CONFUSION, Respiratory Alkalosis (rapid breathing), N/V/D (When in doubt, expect most overdoses to cause Nausea and Vomiting) ** Aspirin Adverse effects Mnemonic: A- asthma S- salicylism poisoning P- premature closing of PDA/Platelet disaggregation/peptic ulcer disease I- intestinal bleeding R- Reye syndrome/Ringing in the ears, renal impairment/rapid breathing I- idiosyncratic reaction N- noise (tinnitus)/nephropathy NURSING CONSIDERATIONS: -GI Concerns- Patients can use an enteric coated tablet, take with food or water/milk to reduce GI irritation, Educate for S/S of GI Bleed, Higher risk for GI bleed with smoking/alcohol/steroids, history of GI issues like PUD. -Kidney Concerns- Monitor urine output, BUN, creatinine. Usually only a concern if dehydrated + other nephrotoxic meds. -Fluid Retention Concerns- NSAIDS, including aspirin, can cause the body to retain salt and water. MONITOR WEIGHT! -Salicylism /Salicylate Poisoning- Educate patients about S/S (Tinnitus, N/V/D, sweating, increased breathing) -Reye Syndrome: Avoid aspirin in children and adolescents AND also avoid Pepto Bismol®, why?- Has subsalicylate. Especially avoid if they have a virus. (EXCEPTION- You can give children with Kawasaki disease aspirin b/c the benefits outweigh the risks!) -Drug-Drug interactions: - Increased risk for bleeding- watch out with "blood thinners" like warfarin/heparin. Note: It is common to see patients on aspirin + Warfarin or other "blood thinners", but increases the risk of bleeding -Steroids can hurt GI tract (risk for ulcer/bleed). When adding NSAIDS, there is an additive risk for ulcers. -Smoking/Alcohol can increase risk for bleeding.When adding NSAIDS, there is an additive effect. -Other NSAIDs!- If someone is taking Aspirin + Ibuprofen, there is increased risk for all of the adverse effects! (Don't take more than one NSAID at the same time!) -Administration: take with food/liquids. Can use enteric coated tablets to protect stomach lining.

Salicylates: Aspirin (ASA-acetyl salicylic acid)- (ONLY CARDI-PROTECTIVE & IRREVERSIBLE NSAID!)

USED TO TREAT: Joint pain, swelling, inflammation (arthritis, tendinitis, bursitis, etc.), Fever, Mild - moderate pain MECHANISM OF ACTION: Selectively inhibits COX-2 enzyme ADVERSE EFFECTS: Same as other NSAIDS-GI effects, bleeding, Increased blood pressure (*MI/Stroke), renal impairment (potential for AKI), Not to be used in heart failure (sodium/fluid retention), *unique to celecoxib- SULFA Allergy NURSING CONSIDERATIONS: GI Concerns- Take with food or water/milk, Educate for S/S of GI Bleed- Higher risk with smoking/alcohol, Kidney Concerns, Monitor urine output, BUN, creatinine-Usually only a concern if dehydrated + other nephrotoxic meds. MI/Stroke Concerns- Educate patients to use lowest dose for the lowest time frame, Patients can monitor blood pressure. Fluid Retention Concerns- Avoid in heart failure patients. Sulfa allergy- Avoid! Note: Let's work on a running Sulfa allergy list -ADMINISTRATION: Take with food/liquids

Second generation NSAIDS: celecoxib

USED TO TREAT: Aborting (Avoid in pregnancy!) an ONGOING migraine attack to relieve headache and associated symptoms. (PRN) MECHANISM OF ACTION: Binds to serotonin receptors found on intracranial blood vessels and causes vasoconstriction ADVERSE EFFECTS: -Chest pain - (50% of patients): chest pressure/arm heaviness in a large percentage of users. Transient- meaning these are self-limiting and usually not dangerous -Coronary Artery Vasospasm/Angina: Avoid in CAD, HTN, hx of MI, or other heart disease (CARDIOVASCULAR DISEASE MAY BE A CONTRAINDICATION!) -Teratogenesis: **Avoid in pregnancy! NURSING CONSIDERATIONS: Non-pharmacological approaches to migraine treatment: -Lying down in a dark/quiet room can help prevent severe migraine manifestations -Foods that can contain tyramine should be avoided (ex: strong or aged cheese, processed red meats) -Avoid triggers/stress (Emotions, Certain Drugs, Lights/Noises, Certain Foods (besides Tyramine)) -Keep in mind not to use in heart disease ◦Patients should be aware of transient chest pain/arm heaviness. -Subcutaneous doses should work fast (few minutes at most for chest pain) -Oral doses- patients report pain anywhere from 30-60 minutes after ingestion -Do not give with MAO-Is: Serotonin ^^ (also warning with SSRIs. watch out for other drugs that also increase serotonin!) ADMINISTRATION: ◦Use when symptoms are EARLY to abort the oncoming migraine (At first sign of migraine) ◦May repeat dose in 1 to 2 hours if needed ◦Each different route has a "max dose in 24 hours" limit -Give as soon as symptoms appear (oral version, intranasal version, SC version)

Serotonin 1B/1D Receptor Agonists: Sumatriptan (Common suffix, "Triptans")

-SQ rapid-acting (lispro or aspart) or short-acting (regular) insulins are adjusted according to blood glucose test results. -Typically used in hospitalized diabetic patients or those on total parenteral nutrition or enteral tube feedings -SQ insulin is ordered in an amount that increases as the blood glucose increases -Disadvantage: delays insulin administration until hyperglycemia occurs; results in large swings in glucose control

Sliding-scale insulin dosing

2 million

TIME IS BRAIN- Amount of neurons that die each minute, these do NOT rejuvenate! (With a stroke, time lost is brain lost)

USED TO TREAT: -Ischemic Stroke -Massive Pulmonary Embolism -Massive Myocardial Infarction -Central venous catheter clearance (tiny dose) NOTE: There is a NARROW WINDOW on when you can use the drug. Most STROKE guidelines allow within 3 to 4.5 hours of symptom ONSET! NO ANTICOAGULANTS/ANTI-PLATELETS FOR 24 HOURS AFTER MOA: Clot buster, destroys clots AFTER they've developed! ADVERSE EFFECTS: •SERIOUS RISKS with systemic use •Death (ASSENT-2 trial ) 30 days ,6.2% •ICH at 30 days, 0.94% •Major Hemorrhage at 30 days, 5.9% •Strict Inclusion/Exclusion Criteria on when to use DO NOT GIVE ANY ANTICOAGULANTS/ANTIPLATELETS FOR 24 HOURS AFTER RECEIVING A THERAPEUTIC DOSE NURSING CONSIDERATIONS: Nurses should monitor for S/S of bleeding ◦This medication must be used as soon as possible! (3 to 4.5 hr window for stroke) ◦Check baseline labs and look at other medications- is PT/aPTT elevated? Are they on an anticoagulant? Hold off! ◦CBC (H/H, plts) ◦PT/PTT- elevated- this is bad! -Minimize bruising or bleeding by limiting venipunctures and subcutaneous/IM injections. Hold direct pressure to injection site or ABG site for up to 30 min until oozing stops◦Assess patient afterwards◦Watch out for bleeding◦Monitor patient for headache (what could be the cause?) CONTRA-INDICATIONS: ◦Active Bleeding ◦GI Bleed/ Peptic Ulcer Disease ◦On active anticoagulants ◦Hemorrhagic Stroke

Tissue Plasminogen Activator (TPA/"Clot busters"): alteplase "plase"

Used to treat: DVT/PE treatment, secondary prophylaxis/prevention ◦A.fib ( stroke prevention) ◦*Mechanical Heart valves (prevent stroke/clot formation) ◦Cancer patients (higher risk for clotting) ◦ACS, unstable angina, MI, stroke, lots more MOA: Opposite of vitamin K MONITORING •Prothrombin time (PT)- how long it takes to clot, International Normalized Ratio (INR) •Baseline (when pt. first starts on warfarin) PT 11-12.5 seconds •Goal PT- 18-24 seconds (1.5-2 times the baseline) •Baseline INR 1•INR goal•2-3 for Most Conditions, 2.5-3.5 for Mechanical Heart Valves (WARFARIN is SLOW to kick in (3-5 days)! There is also potential to have a pro-coagulable state when starting heparin) ADVERSE EFFECTS: FDA Boxed warning: Bleeding ◦S/S of bleeding -Changes in urine, bowel movements- black, tarry -tachycardic -Nose bleeds -Unusual bleeding from mouth/gums -Headache/upset stomach -Coughing up blood/ coffee ground emesis -Fall- head injury- get to hospital -Skin Necrosis (RARE <1%)- B/C Protein C is inhibited by Warfarin -Purple Toe Syndrome (RARE <1%) Caused by cholesterol embolism CONTRA-INDICATIONS: -Pregnancy Category X •Peptic Ulcer Disease •Active Bleeding -Epidural -Neurosurgery •REVERSAL AGENT/ANTIDOTE- •Vitamin K (Phytonadione/Aquamephyton®) and K Centra Drug interactions (LOTS): Non specific •Other drugs that increase risk for bleeding •Drugs that are CYP enzyme inducers/inhibitors •Antibiotics- (less Vit K- increased effectiveness of warfarin) •Seizure medications big culprits (INDUCERS) •Phenytoin, carbamazepine, phenobarbital •St. John's Wort (herbal- anti-depressant) INDUCER •NSAIDS- Bleed risk (recommend acetaminophen/Tylenol instead) •Herbal Supplements (many F,G,S herbals ^ Bleed risk) •Gingko biloba, Ginger, Garlic, Glucosamine, etc. •Fish Oil, Feverfew •Saw Palmetto •St. Johns Wort (inducer- decreases warfarin levels) Alcohol and Smoking: •Severely interact! Patients should not smoke or drink •DIET- The Vitamin K Diet: •LIMITATION AND CONSISTENCY of vitamin K intake is Key •Recommend eating these foods in MODERATION •DON'T AVOID Vitamin K!- Nutrients •Educate patients about Vitamin K containing foods•kale, spinach, Brussels sprouts, collard or mustard greens, lettuce, chard, and green tea and many more •NO Cranberry juice (contradictory) ADMINISTRATION: Bridging therapy: -New onset DVT/PE ◦Start on heparin (or other anticoagulant) IV drip and warfarin while in the hospital. Wait until INR is therapeutic ◦ (5 days of overlap warfarin/heparin) before discharge ◦Day 1 ED put on heparin drip, warfarin (3-5 days to kick in) INR=1 ◦Day 2, heparin (PTT 60 -80 seconds) + warfarin (PT/INR, INR 1.3) ◦Day 3, heparin (PTT 60 -80 seconds) + warfarin (PT/INR, INR 1.6) ◦Day 4, heparin (PTT 60 -80 seconds) + warfarin (PT/INR, INR 1.9) ◦Day 5 warfarin (PT/INR, INR 2.2)- GO HOME! - (only time warfarin is used with another anticoagulant) -Surgery ◦On warfarin prior to arrival, stop warfarin, start on heparin. Once INR drops low enough, perform surgery. Restart warfarin/heparin until INR therapeutic, stop heparin and discharge on warfarin NURSING CONSIDERATIONS: -Assess patient labs before administration (CBC- looking at H/H + Plts) KNOW RANGES -Check an INR/PT before administering! KNOW RANGES (Therapeutic INR for Warfarin is 2.0-3.0) -Besides looking at labs, nurses should instruct patients to report any s/s of bruising/bleeding (low BP, high pulse/tachycardic) PATIENT EDUCATION:◦Vitamin K: Diet◦Other drugs to watch out for: NSAIDS, FGS Herbals, Smoking, EtOH◦Signs/ Symptoms of bleeding◦Monitoring◦What if I fall?◦Notify all healthcare providers that they're taking warfarin (Dentists, etc.) -Instruct patients to do things like use electric shaver, soft bristle tooth brush to reduce risk for a bleed! -Patients will periodically get an INR checked- make sure they follow up with their provider! -Patients should receive in depth instructions including warfarin INR goal, diet, other medications to be concerned about, and dosing

Warfarin (Vitamin K antagonist)

INR and PT

When monitoring for therapeutic effectiveness of Warfarin, which of the following lab values are monitored?