Simple Pharm

Blood thinners drug class examples (3) & list drugs of each class

1. anti coagulants: heparin, enoxaparin, & warfarin (frequent blood draws to assess therapeutic range) 2. anti platelet aspirin & clopidogrel 3. Thrombolytics: tPA, & ("-ase")

Anticoagulants action

Anticoagulants interfere with the blood's clotting process by inhibiting proteins that cause clots to form.

Difference between anticoagulants, anti platelets, and thrombolytics

Antiplatelet medications prevent platelets from clumping together to form clots; thrombolytics bust clots when already formed

If a blood thinner has a "p" is the name, it most likely…

lowers platelets

Which platelet lab value would you hold a blood thinner & notify the HCP?

platelets < 150,0000 ("platelets under 150 is very RISKYYY")

Blood thinner meds purpose

thins out the blood; increases bleeding which will kill or harm client if not careful

PTT (aPTT)-Partial Thromboplastin Time

Measures: Time it takes for clotting factors in the intrinsic pathway to form a clot. If elevated: Risk of bleeding, consider heparin toxicity or clotting factor deficiency

INR - International Normalized Ratio

Measures: Time it takes for clotting factors in the extrinsic pathway to form a clot. If elevated: Bleeding risk increases 'hold warfarin, give Vitamin K if needed

Clotting tests vs. Platelet tests

simply, clotting tests… NOT platelet function tests; it's likely a clotting factor issue

Normal platelets =

Platelet plug formation is working

If a patient is bleeding but their platelet count is normal…….

Still bleeding. Problem must be further down the clotting cascade. Suggests a clotting factor deficiency or dysfunction

PT/INR vs aPTT associations

PT/INR 'Think warfarin, liver disease, vit K deficiency; aPTT 'Think heparin or hemophilia

Saying for heparin and warfarin

"heparin acts in a hurry, warfarin has a weaker start"

Pill form vs Injection form (Blood thinners)

pill->warfarin; injection->heparin & enoxaparin

Therapeutic lab ranges (Heparin & Warfarin)

PTT (46-70 sec)-> heparin; INR (2-3 sec, on mechanical heart valve: 2.5-3.5)) -> warfarin

Antidote for heparin and warfarin?

Heparin: Protamine Sulfate; Warfarin: vitamin K

Vitamins/herbal supplements to avoid on blood thinners?

know: EGGOS. -Vitamin E, -Gensing, Gingko, Garlic, Oils - Omega 3 Fish, - St. John's wort

When should thrombolytics be given?

within 3 to 4.5 hours after ONSET OF SYMPTOMS. after this they are NOT effective

Thrombolytics safety

these are the most powerful blood thinners- no NEEDLES AT ALL and all other bleeding risk precautions

Thrombolytics contraindications (x4)

specific: - active bleeding (not affect menstrual bleeding.)

recent surgery/trauma 2 weeks

Angio malformations

thrombocytopenia

When to use bleeding precautions?

-On any blood thinner (anticoagulants, anti platelet, thrombolytics) -Bleeding disorders (hemophilia, liver disease, DIC) -Elevated PT/INR or aPTT

Bleeding precautions: Injury prevention

Avoid injury & trauma; ->Use electric razor (NOT blades); ->Use soft toothbrush (no flossing unless provider approves); ->No contact sports; ->Avoid straining during bowel movements 'give stool softeners

Watch for bleeding signs (1-3)

1. Unusual bruising; 2. Black or bloody stools; 3. Hematuria (bloody urine)

Watch for bleeding signs (4-6)

4. Gums bleed when brushing; 5. Nosebleeds that are frequent or hard to stop; 6. Heavy or prolonged menstrual bleeding

Bleeding precautions: Medication education

Avoid NSAIDs like ibuprofen, aspirin unless prescribed; Report any new Rx or supplements (some herbs interact e.g., garlic, ginkgo, ginseng)

Bleeding precautions: Maintenance education

Take anticoagulants exactly as prescribed; Frequent blood tests may be needed (e.g., INR if on warfarin)

Meds that work at the SA node to slowwww HR down

ABCD. A: Adenosine, B: Beta Blockers, C: CCB, D: Digoxin

Atropine purpose

increases HR ("HR really high like on top of a pine tree"); given for symptomatic bradycardia-seeing s/sx of low perfusion; goal: normal sinus rhythm

Drugs to lower blood pressure

ABCD. A: ACES & ARBS, B: Beta Blockers, C: CCB, D: Diuretics, Dilators

Parameters to hold cardiac meds

1: HR<60, 2. Sys BP<100; always want to lower these numbers SLOWLY, think about landing a plane

ARBS stand for

Angiotensin II Receptor Blockers

ACE Inhibitors & ARBs drug endings

ACE ("-pril") ->lisinopril, ramipril; ARBS: ("-sartan") > losartan, valsartan, Irbesartan

ACE Inhibitors (-pril) / ARBS (-sartan) Function

Antihypertensives. Act to lower BP (not HR!); Decreases Sodium and Water; INCREASES Potassium…bc both decrease ALDOSTERONE production

Why ACES are primary choice?

"-prils" are the PRIMARY choice. "-sartan" comes second if ACEs don't work or if too many s/e

ACE Inhibitor saying

(annoying ACE cough), but they usually ace the job.

Mechanism (ACE vs ARB)

-ACE blocks enzyme that converts angiotensin 1 to II; -ARBS block the receptor angiotensin II combines to

Unique ACE Inhibitors side effects

can cause angioedema ****Life-threatening 'swollen lips/tongue/face 'AIRWAY!; ACE dry, persistent cough

Angioedema definition

"Angio" = blood vessels, "Edema" = swelling; Deep, sudden swelling beneath the skin or mucous membranes due to leaky blood vessels.

Why ACES/ARBS cause hyperkalemia?

They work by blocking the effects of angiotensin II, which reduces the release of aldosterone, a hormone that helps regulate potassium excretion.

ACES vs ARBS: Watch for…

• renal impairment, - hyperkalemia ( (k>5.0); - avoid salt subs (contain potassium)

Why ACES ARBs? (first tried unless not tolerated)

More research & proven outcomes; Protect kidneys in diabetes (slowing progression of diabetic nephropathy); Cost-effective.

Side effects of antihypertensives

dizziness, abnormal heart rhythm, headaches; Orthostatic Hypotension = SLOW position changes

Do we give ACE and ARBs if the HR < 60?

YES -> these have no affect on HR, only BP

ACES and ARBs key other considerations

avoid using with pregnant clients; Teratogenic- crosses the placenta and causes serious harm to fetus

Avoid food high in Potassium with ACE inhibitors (-prils) such as…

Green leafy vegetables, Oranges, Bananas, Avocado, Melon, Dried apricot, Kidney beans; Also salt substitutes and LIVER

Potassium > 5.0 EKG changes

Peaked T waves, ST elevation

Potassium high/low nursing priority

(muscle spasms, weakness, palpitations); **Any Potassium level high or low, first action by the nurse is: CARDIAC MONITOR

Beta Blockers (-olol) function

(Lowers HR & BP); ***so assess BEFORE giving

Inotropic

force of contraction

Chronotropic

heart rate (rate of contraction)

Dromotropic

conductivity of heart

Three negative tropics for Beta Blockers

1. Negative chronotropic (lower rate), 2. Negative Inotropic (less force), 3. Negative dromotropic (less beats)

Beta Blockers effect on heart workload

Decreases resistance, workload, & cardiac output

Beta Blockers side effect: heart

bradycardia-> HR < 60 and Systolic BP < 90 or < 100 (HOLD DRUG)

Beta Blockers side effect: Breathing

Breathing problems (wheezing) →→ HOLD for COPD and Asthma pt's

Beta Blockers side effect: Heart Failure

BAD for Heart failure pt's! can worsen heart failure; -> New edema, worsening crackles in the lungs, rapid weight gain, new JVD PRIORITY report to HCP

Beta Blockers side effect: Diabetes

Can mask/hide the signs and symptoms of Hypoglycemia (Low blood sugar); Monitor blood sugar closely; <70 question medication

Why not give Beta blockers to asthmatic or COPD pts?

beta blockers & NSAIDS causes bronchospasms; Non-selective beta blockers block beta-2 receptors in the lungs which normally cause bronchodilation. Blocking = bronchoconstriction.

Calcium Channel Blockers function

Calms the heart! "Very Calming Nature"

Nifedipine effect

only decreases BP; "-dipine"s only decrease BP bc cause vasodilation of blood vessel arteries

Cardizem and Verapamil effect

decreases BP and HR

CCB parameters to assess

ALWAYS before giving the drug -> Assess HR and BP, HOLD drug if BP systolic <100 or HR < 60. (Except for Nifedipine, can give bc only decreases BP)

CCB key nursing considerations

• Change positions slowly, - Bad headaches-normal S/E, - avoid grape juice: increases CCB levels and toxicity

NCLEX: CCB drip drop in HR

If on CCB drip, if the HR has a BIG drop like < 50 bpm, stop the drip and notify HCP

Grapefruit juice interactions

CCBs, Statins, Some benzodiazepines, Certain immunosuppressants, Some antiarrhythmics

When is grapefruit juice promoted?

Usually not promoted; Some meds require acidic environment (Iron supplements + Vitamin C rich juice)

Prune juice used for

constipation relief

Digoxin toxicity level

highly TOXIC; - Digoxin level > 2.0 = TOXICITY/BAD -> NOTIFY HCP ASAP

Digoxin safety considerations

-> Vision changes (fuzziness, difficulty reading, haziness, color changes), N/V, anorexia, dizziness or lightheadedness

Digoxin Test Tip: Risk group

Older patients with decreased kidney function are at HIGHER risk for digoxin toxicity

Digoxin: Lab monitoring

-Monitor BUN and Creatinine (Cr is #1); Cr > 1.3 = huge risk for toxicity

Potassium effect on Digoxin

**Low Potassium increases risk for Digoxin toxicity!! K+ < 3.5

Which pt is most at risk for Digoxin toxicity?

-Pt on potassium wasting diuretics (furosemide or hydrochlorothiazide); - Kidney failure (Cr > 1.3)

What to assess before giving digoxin?

Apical HR (full 60 sec) (5th intercostal space left midclavicular); holding if HR < 60 bpm; also creatinine & K+ levels

Digoxin purpose

(has no effect on BP), positive inotropic and neg chronotropic; decrease workload of heart & increasing cardiac output

Vasodilators function

Decreases blood pressure by dilating blood vessels and decreases vascular resistance; (Lowers preload and afterload); ***always check BP before giving

List of Vasodilator (5)

1. Nitroglycerin, 2. Nitroprusside, 3. Hydralazine, 4. Isosorbide, 5. Minoxidil

Nitroglycerin use

treat conditions like angina (chest pain) and acute heart failure

Vasodilators killer precautions

• No viagra = No Sildenafil (-afil); -STOP if systolic BP < 100, or BP drops by 30 points or more; -STOP if confusion, irritability, lack of coordination, cold, pale, clammy

Normal s/e of vasodilators

• Headaches, - Hypotension, - Hot flushing or facial redness

Vasodilator teaching

• Slow position changes

Drugs where Headache is a Common, Non-Emergent Side Effect

1. Nitroglycerin, 2. Nitroprusside, 3. Hydralazine, 4. Isosorbide, 5. Minoxidil, - CCB, Viagra, - SSRIS/SNRIS, - oral contraceptives

1 drug used for acute or worsening HF

Diuretics

Diuretics purpose/function

drains fluid from heart/body…decrease BP by diuresing the fluid

List potassium wasting diuretics

• Furosemide: acts FAST, - Hydrochlorothiazide

Diuretic first line for: crackles, edema, weight gain

furosemide

Teach clients on potassium wasting diuretics?

• AVOID LICORICE ROOT (Lowers K+); -use salt subs (elevates potassium lost); - eat green & leafy

Potassium HIGH YIELD (normal)

Normal: 3.5-5.0

Potassium high/low S/S

Muscle spasms, muscle cramps, muscle weakness, paresthesia

Potassium imbalance: First nursing action

• Put pt on cardiac monitoring!

High Potassium EKG

5 = Peak T waves, ST elevation

Low Potassium EKG

< 3.5 = Flat T waves, ST elevation, U wave

Teach clients on potassium sparing diuretics?

avoid potassium rich food and salt substitutes (Avocados, bananas, oranges, melons, liver, green leafy vegetables, kidney beans)

Potassium sparing risk

****Risk for peaked T waves & ST elevation in severe Hyperkalemia

List potassium sparing diuretics

spironolactone, triamterene

Potassium administration (Never…)

NEVER IVP, IM, or free hang Potassium IV!

Potassium IV limit

Never exceed 10 mEq/hr via peripheral line.

Potassium administration (Pump vs Gravity)

Always use a pump, never gravity.

How to dilute potassium?

Dilute potassium in NS or D5W (never give undiluted).

Potassium: Renal assessment

Check renal function before administering; If urine output is < 30 mL/hr hold potassium and notify HCP.