NURS3190 - Hematologic Disorders, Blood

What are the steps of clot formation?

1) Platelets plug the wall damage

2) Fibrin creates a mesh over platelets

3) RBCs cover fibrin mesh

Which Clotting/Anticoagulant medications stop step 1?

Antiplatelets

Which Clotting/Anticoagulant medication class stops step 2?

Heparin and Direct Thrombin Inhibitors

Which Clotting/Anticoagulation medication class stops step 3?

Warfarin and Xa Inhibitors

Which Clotting/Anticoagulant medication class stops step 2 and 3?

Low Molecular Weight Heparin

Nursing Considerations for ALL Anti-clotting/Anticoagulant Medications

• Know and monitor signs of bleeding (external/internal)

• Monitor labs when necessary

• Encourage foods soothing for GI

• Know foods that thicken blood (vitamin K)

Three Antiplatelet Medication Classes FOR ARTERIES

• Adenosine Diphosphate Receptor Inhibitor (ADP Inhibitor)

• Glycoprotein IIb/IIIa Receptor Agonist (GPIIb/IIIa)

• Protease-Activated Receptor-1 Antagonist (PAR-1)

Adenosine Diphosphate Receptor Inhibitors (ADP) Generic Names

Clopidogrel

Prasugrel

Ticagrelor

ADP Inhibitor Route

PO

GPIIB/IIIA Receptor Antagonist Route and Use

• IV before and IMMEDIATELY after cardiac procedure

Glycoprotein IIb/IIIa Receptor Antagonic (GPIIb/IIIA) Generic Name

Epitifibatide

GPIIb/IIIa Route and Use

• IV before and after cardiac procedures

Protease Activated Receptor-1 Antagonist (PAR-1) Generic name

Voraxapar

PAR-1 Route and Combo

PO with clopidgrel

Anti-Platelet Reversal, Uses, Nursing Considerations

• Reversal = platelets

• Suppresses platelet aggregation

• Prevents arterial thrombosis/MI/stroke/TIA

• Take orally daily EXCEPT GPIIb/IIIa

Direct Thrombin Inhibitors Generic Names

Dabigatran

Desirudin

Argatroban

Direct Thrombin Inhibitors Reversals

Fresh Frozen Plasma (FFP)

Idarucizumab

Direct Thrombin Inhibitors Route and Action

• PO, SubQ, IV

• Directly inhibits thrombin from converting fibrinogen to fibrin (STOPS STEP 2)

Anticoagulant Generic Name

Heparin

Heparin Action

• Activates antithrombin

• Inhibits thrombin and Xa

• Inhibits fibrin (step #2)

Heparin Use

Evolving stroke, DVT, low dose after ortho surgery

Heparin Reversal and Nursing Considerations

***Reversal - Protamine Sulfate

• Monitor PPT (1.5-2)

• Monitor aPPT (60-80x)

***MONITOR FOR HIT (heparin induced thrombocytopenia)

Vitamin K Antagonist Generic Name

Warfarin

Warfarin Action

• Inhibits clotting Factor II, VII, IX, X (Stops Step 3)

Warfarin Use

Prevents thromboembolisms

Warfarin Reversal and Nursing Considerations

***Reversal - SEVERE BLEEDING, IMMEDIATE REMEDY = Fresh Frozen Plasma/Whole Blood

***Reversal - Vitamin K (takes 24-48 hours to work)

• Toxicity - Blue halo vision, dizziness

• Monitor INR and PT

• Keep intake of Vitamin K consistent

• Use soft-bristle toothbrush

Warfarin INR and PT Ideal Range

INR - 1.0

PT - 10-13

Select Factor Xa Inhibitor Generic Name

Rivaroxaban

Apixaban

Select Factor Xa Inhibitor Action

Selectively inhibits clotting Factor Xa (Stops step 3)

Select Factor Xa Inhibitor Use

Prevention and treatment of DVT/PE

Select Factor Xa Inhibitor Reversal and Nursing Considerations

***Reversal = Andexanet alfa (Factor Xa)

• No routine labs needed

Low Molecular Weight Heparin Action

Inhibits thrombin, inhibits X factor (stops Step 2 and 3)

Low Molecular Weight Heparin Use

Prevents DVT/PE

Low Molecular Weight Heparin Nursing Considerations

***Reversals - Andexanet Alfa (Factor Xa) and Protamine Sulfate

• SubQ

• No labs

• Weight-based dosing

Three Meds that Stimulate Bone Marrow

Filgrastim

Oprelvekin

Epoetin

Filgrastim/Pegfilgrastim Treatment

Neutropenia/Leukopenia (low WBCs)

Filgrastim/Pegfilgrastim Key Points

• Boosts WBCs by stimulating bone marrow

• For patients experiencing cancer medication treatment and radiation therapy

Oprelvekin Treatment

Thrombocytopenia (low platelets)

Oprelvekin Key Points

• Boosts platelets by stimulating bone marrow

• Synthetic Interleukin-11

• SubQ

Epoetin Treatment

Anemia (low RBCs)

Epoetin Key Points

• Man-made erythropoetin (EPO)

• Primarily for people with CKD (chronic kidney injury)

Epoetin Nursing Considerations

• Monitor BP

• Increases risk of MI, CVA, DVT, seizure

What is Iron Deficiency Anemia?

• Insufficient iron

• Impaired Hgb synthesis

Iron Deficiency Anemia Causes

• Low dietary iron

• Chronic bleeding

• Duodenal malabsorption

• Severe liver disease

Iron Deficiency Medications

• Oral: Ferrous Sulfate

• Parenteral: Iron Dextran

Iron Deficiency Medication Nursing Considerations

• Parenteral routes ONLY administered if patient is unable to take oral medications

  • IV preferred

• Oral liquid iron stains teeth

• IV, deep IM, Z-track

• Vitamin C increases iron absorption

What is Pernicious Anemia?

• Malabsorption of dietary B12 caused by lack of intrinsic factor

  • B12 converts cells to active form, essential for DNA syntehsis

• Causes RBCs to become MEGALOBLASTIC

  • Immature, large blood cells that carry less Hgb

Pernicious Anemia Causes

• Lack of dietary B12

• Veganism

Pernicious Anemia Symptoms

• Beefy red tongue

• Neuropathy

Pernicious Anemia Treatment

• Parenteral B12 for life/intranasal B12

• Vegans: Sunflower Margarine

B12 Supplementation Nursing Considerations

• Monitor B12 every 3-6 months

• Can cause increase in RBC, causing hypokalemia

Bleeding Disorder Treatments

• Factor VIII (makes clots)

• Antihemophilic Factor

• Emicizumab-Kxwh

• Desmopressin

• Tranexamic Acid

• Clotting factor, plasma, blood replacement

Emicizumab-Kxwh considerations

• Monoclonal antibody

• Monitor for rhabdomyolysis

Desmopressin (Ddavp): ADH nursing considerations

• First-line treatment for Von Willebrand and Factor VIII disorders

• Administered intranasally

***MONITOR FOR HYPONATREMIA

Tranexamic Acid Class

Antifibrinolytic Plasminogen Activator Inhibitor

Tranexamic Acid Action

Binds plasminogen/plasmin → Stops fibrinolysis (stops clots from breaking down)

Tranexamic Acid Therapeutic Use

• Reduces/stops bleeding due to:

  • Heavy menstrual cycle bleeding

  • Hemorrhagic (hypovolemic) shock

Thrombolytics Generic Names

Dalteplase, Alteplase

Thrombolytics Action

• Disintegrates clots

• Reverses clots

• FOR VEINS

Thrombolytics Reversal and Nursing Considerations

***Reversal = Aminocaproic Acid

• Monitor for hemorrhaging