Pharm Module 2 part 1

formation of clot in artery or vein cause

usually from decreased circulation

goal of antiplatelets and anticoagulants

make you bleed, prevent clots

Antiplatelets

keep clot from growing bigger and new ones from forming

when to use antiplatelets

need to effect arteries, to stop platelets from sticking together, like if someone has chest pain

when to use anticoagulants

for effecting arteries & veins, to keep clot from growing bigger and new ones from forming 

thrombolytic drugs

clot busters, break clot up, dissolve it

aspirin

antiplatelet drug, not given to pediatrics, take with food can hurt GI, an NSAID, also called ASA,

aspirin used as antiplatelet

used to prevent acute MI (ex: take an ER baby aspirin once daily if at risk for MI), if pt comes into hospital with active chest pain they will use chewable one (will want them to have 324 mg for this- 4 81 mg tablets)

P2Y12 ADP receptor blockers (AKA P2Y12 blocker)

antiplatelet that inhibits prolonged bleeding time

most common P2Y12 blockers

clopidogrel and prasugrel

aspirin side effects

gi upset, gi bleeds, gi ulcers, hemorrhagic strokes, prolonged bleeding time, thrombocytopenia, tinnitus (ringing of ears) or hearing loss show aspirin overdose

signs of aspirin overdose

tinnitus (ringing in ears) or hearing loss

aspirin can hurt GI so

take w food and take enteric coated tablets

if pt comes in with active chest pain

give them 4 chewable 81 mg aspirin (324 mg)

taking a baby aspirin everyday used for

preventing MI or CVA

can you take aspirin and clopidogrel together

yes just be watchful for signs of bleeding (ex petechiae)

what herbs to avoid when on anticoagulants or antiplatelet

garlic, ginco, ginger, ginseng

Antiplatelet consideration with surgery

discontinue 7 days taking before surgeries

platelet count before starting antiplatelets

should be 150,000-400,000

signs and symptoms of bleeding

bruising, pink urine, tarry stools, petechiae, dark vomit, tired, pale

what to monitor for with pt on antiplatelets

vital sings, signs of hearing loss or stroke

what to teach pt on antiplatelets or anticoagulants

Use soft bristle toothbrush and electric razor

Anticoagulants and what they inhibit

prevent new clots from forming, inhibits thrombin & factor Xa

LMWH

Low molecular weight heparin

Heparin job

prevent clotting

enoxaparin

a LMWH

Warfarin

an anticoagulant vitamin K inhibitor

Argatroban

anticoagulant, thrombin inhibitor

factor Xa pronounced

factor 10 a

Direct factor Xa inhibitors (anticoagulants)

Apixaban, rivaroxaban

problem with anticoagulants like rivaroxaban

Newer and safer, less lab work monitoring needed, but more expensive than warfarin and heparin

adverse effect of anticoagulants and antiplatelets

bleeding or hemmoraging

anticoagulant uses

treatment for A-fib, MI, ischemic strokes, artificial heart valves, can be used prophylactically

how anticoagulants are used prophylactically

w history of clots to prevent new one, or prevent in pts laying down all day in hospital bc at higher clot risk in hospital

when not to use anticoagulant

to treat a hemmorhagic stroke

adverse effects of heparin

bleeding / hemorrhage, heparin induced thrombocytopenia, toxicity or overdose (bleeding), allergic reactions

how is heparin given

subcut or IV

Enoxaparin is nice because

it requires less frequent monitoring than regular heparin, only given subcut not IV, longer half life so have to give less often

what to teach pt on heparin

use a oft bristle toothbrush, teach how to do subcut injection on self, electric razor, how to monitor for bleeding

when is heparin contraindicated

in any disorder that increases the risk of bleeding (bleeding ulcers, hemmoragic stroke, blood disorders like hemophilia, eye brain or spine surgeries, thrombocytopenia)

heparin pregnancy category

C (so safer option than Warfarin)

how is heparin measured

in units

IV heparin

Can’t be hung by gravity needs pump, and needs to be at separate line alone continuously- can’t mix w others so put in separate IV

before starting IV heparin or changing rate

get aPPT and weight from patient, both need to be accurate can’t go off of earlier’s labs, verify with second nurse

aPTT

Activated partial thromboplastin clotting time, over 70 means at bleeding risk

PTT

Partial thromboplastin time, the time it takes for a patient's blood to form a clot as measured in seconds, the lower the number the thicker the blood

aPPT therapeutic range

1.5-2 times the baseline, 60-80 seconds

PPT therapeutic range

1.5-2 times the baseline 120-140 seconds

pt platelet count before administering heparin

more than or equal to 100,000

when to hold heparin

if aPPT is over 80

why important to check HR and BP for pts on antiplatelets or anticoagulants

increased BP and HR means they are compensating for blood loss

what to do if a patient gets too much heparin (hemorrhage or toxicity)

give them antidote protamine sulfate (1-1.5 mg per 100 mg of heparin given)

warfarin is given

orally, takes 3-5 days to show full effects on body

if pt comes in with clot give them what med first

heparin before warfarin because heparin is injection or IV so faster than oral warfarin

warfarin used for

anticoagulant, to treat DVT, prevent thrombus formation in those with A-fib or prosthetic heart valves, prevent MI, TIA, PE, and DVT

warfarin adverse effects

hemorrhage, hepatitis

what labs to monitor with pt on warfarin

PT and INR

what to monitor with pt on heparin

aPPT or PPT

warfarin pregnancy category

X, contraindicated, cannot give to pregnant pts

warfarin drug interaction

highly protein bound

what warfarin dose is based off of

INR lab value

INR

international normalized ratio, blood test tells you how long it takes for your blood to clot, lower means clotting, high means bleeding, normal for healthy person is less than 2

INR therapeutic range

2-3

PT therapeutic range

1.5 to 2 times control, 18 to 24 seconds

PT lab

prothrombin time, test measures how long it takes for a clot to form in a blood sample

when to notify provider about INR

if it is over 3

monitoring for pt on warfarin

VS, signs of bleeding, signs of hepatitis (may need provider to order liver function tests),

when pt switching from heparin to warfarin

Keep them on heparin/enoxaparin until INR is therapeutic while taking warfarin waiting for it to work (8-10 hrs for fist effect, 3-5 days for full effect)

too much warfarin treatment

vitamin K is antidote

Supra-therapeutic INR

means INR is really high like 6

what to do if warfarin pt is supra-therapeutic

hold warfarin dose until INR comes down

pt teaching for warfarin

have pt tell dentist before any procedures bc bleeding risk, use a soft toothbrush and electric razor, avoid aspirin, wear a medic alert bracelet, keep consistent level of vitamin K in diet to try and avoid big spikes of it (will lower INR and cause clots), avoid smoking, avoid sitting standing or crossing legs for too long

why not smoke on warfarin

bc smoking increases metabolism of warfarin so does not work as well higher chance for clot

remember PT lab test always goes with

INR, warfarin

way to remember antidote for heparin

Protamine & Heparin = Prince Harry

way to remember antidote for warfarin

Warfarin & Vitamin K = William & Kate

where thrombolytic drugs are used and time frame

seen more in ED, give w/in 3 hours of symptoms to work so teach pts to come in right away w stroke symptoms

types of thrombolytic drugs

Streptokinase, alteplase, t-PA

indications for thrombolytic drugs

ischemic stroke, acute MI, DVT, PE

adverse effects of thrombolytic drugs

bleeding, reperfusion arrhythmias (need to have pt on continuous bedside monitor to check for this)

nursing considerations for pts on thrombolytic drugs

monitor vital signs, labs, CT scan

Erythropoietic growth factors

epoetin alfa, makes more red blood cells

Leukopoietic growth factors

filgrastim, makes more white blood cells

Thrombopoietic growth factors

oprelvekin, make more platelet blood cells

epoetin alfa

growth factor to make more RBC and raise BP

epoetin alfa indication

treat severe anemia after chemo, cancer, kidney disease, HIV treatment

Darbepoetin alfa

a long-acting erythropoietin (increases RBCs), used in CKD & anemia caused by chemo

why check pt BP before giving epoetin alfa

Ppl w kidney disease often have high BP on their own so need to check BP before giving them a drug to raise it again

epoetin alfa side effects and ADRs

HTN, risk for thrombotic events, DVT, headache & body aches (the aches show BP is high and stroke could occur soon)

epoetin alfa contraindications

HTN

do not give epoetin alfa if H&H is

11 or higher

Filgrastim

Increases production of neutrophils (WBCs)

filgrastim indications

decreases infection risk for ppl w immunosuppression

filgrastim SE and ADR

bone pain (bc the WBCs are made in bones, tell them this is normal and acetaminophen can be taken), leukocytosis, splenomegaly and risk of splenic rupture (long term use)

filgrastim nursing considerations

CBC, bone pain, effectiveness determined by WBC amt getting higher, infections less

Oprelvekin

Increases the production of platelets

indications for oprelvekin

thrombocytopenia, cancer wiping out platelets

side effects and ADRs with oprelvekin

fluid retention, cardiac dysrhythmias, eye effects, allergic reactions and possible anaphylaxis

oprelvekin nursing considerations

monitor for side & a/e, monitor CBC, effectiveness determined by platelet amt getting higher