Pharm-Anticoag, platelets, thrombolytics

What is hemostasis?

The process of stopping bleeding through platelets and clotting factors

What is the primary mechanism of anticoagulants?

Prevent fibrin clot formation by inhibiting clotting factors (do NOT dissolve existing clots)

What is the primary mechanism of antiplatelets?

Prevent platelet aggregation and clumping

What is the primary mechanism of thrombolytics?

Dissolve existing clots by activating plasminogen → plasmin

What is the therapeutic aPTT range for heparin?

60-80 seconds

What is the therapeutic INR range for warfarin?

2.0-3.0

What is the antidote for heparin?

Protamine sulfate

What is the antidote for warfarin?

Vitamin K (phytonadione); for severe bleeding: plasma or PCC

What is the antidote for enoxaparin (Lovenox)?

Protamine sulfates

What labs should be monitored for heparin therapy?

aPTT ; platelet count

What labs should be monitored for warfarin therapy?

PT/INR regularly

Do DOACs require routine lab monitoring?

No routine monitoring needed

What is HIT (Heparin-Induced Thrombocytopenia)?

Serious adverse effect where platelet count drops ≥50%, causing paradoxical thrombosis; can lead to CVA, MI, limb loss, death

What should you do if HIT is suspected?

STOP heparin immediately; patient may never be able to take heparin again; treat with Argatroban

What is the most common and serious adverse effect of all anticoagulants?

Bleeding/hemorrhage

What are key nursing assessments for anticoagulant therapy (ADPIE - Assessment)?

Baseline labs (aPTT, INR, PT, platelets, H&H); bleeding history and risk factors; current medications and dietary habits

What are nursing diagnoses for anticoagulant therapy (ADPIE - Diagnosis)?

Risk for bleeding related to anticoagulant therapy; Deficient knowledge regarding medication safety

What are nursing implementations for anticoagulant therapy (ADPIE - Implementation)?

Double-check dosing (high-alert medication); monitor lab values; assess for bleeding signs; educate on precautions; administer antidote if needed

What should be evaluated in anticoagulant therapy (ADPIE - Evaluation)?

Labs remain in therapeutic range; no signs/symptoms of bleeding; patient verbalizes understanding of safety measures

What route is heparin administered?

IV or SubQ

What route is enoxaparin (Lovenox) administered?

SubQ only

What route is warfarin (Coumadin) administered?

PO (oral)

What route are DOACs administered?

PO (oral)

How should enoxaparin be administered SubQ?

Use pre-filled syringe; do NOT expel air bubble; inject at least 2 inches from umbilicus

How should heparin be administered SubQ?

Inject 2 inches from umbilicus; do NOT massage site

What is a Black Box Warning for warfarin?

Pregnancy (teratogenic)

What is a Black Box Warning for DOACs?

Thrombosis if stopped abruptly due to short half-life

What is a Black Box Warning for LMWHs (like enoxaparin)?

Spinal hematomas with epidural or spinal anesthesia

What foods interact with warfarin?

Vitamin K foods (green leafy vegetables) - maintain CONSISTENT intake, not elimination; also avoid cranberry and excess alcohol

Do DOACs have dietary restrictions?

No dietary restrictions (major advantage over warfarin)

What is the antidote for DOACs like rivaroxaban and apixaban?

Andexanet Alfa

What is the antidote for dabigatran (direct thrombin inhibitor)?

Idarucizumab or Prothrombin Complex Concentrate (PCC)

What are common antiplatelet medications?

Clopidogrel (Plavix), Ticagrelor

What is the typical aspirin dose for MI/stroke prevention?

81-325 mg PO daily

What is the typical clopidogrel (Plavix) dose?

75 mg PO daily

Is there an antidote for antiplatelet medications?

No antidote available

What is a Black Box Warning for clopidogrel (Plavix)?

Genetic abnormalities affect drug metabolism, reducing effectiveness

What drug interaction should be avoided with clopidogrel?

PPIs/Omeprazole (reduces effectiveness)

What medications should be avoided with antiplatelets?

NSAIDs (ibuprofen, naproxen) - increases bleeding risk

What are nursing assessments for antiplatelet therapy (ADPIE - Assessment)?

Baseline bleeding risk; GI history (ulcers, GERD); current medications (NSAIDs, other anticoagulants)

What are nursing diagnoses for antiplatelet therapy (ADPIE - Diagnosis)?

Risk for bleeding related to antiplatelet therapy; Risk for injury related to increased bleeding tendency

What are nursing implementations for antiplatelet therapy (ADPIE - Implementation)?

Assess for bleeding signs; educate to avoid NSAIDs; teach stroke/MI symptoms (CAB); use soft toothbrush and electric razor

What does CAB stand for in stroke/MI warning signs?

Chest pain, Arm weakness, Balance/vision changes

What are common thrombolytic medications?

Alteplase (tPA), Reteplase, Tenecteplase (TNKase), Streptokinase

What is the time window for tPA in acute ischemic stroke?

Within 3-4.5 hours of symptom onset

What is the time window for thrombolytics in acute MI?

Within 12 hours of MI symptoms

What is the most feared complication of thrombolytic therapy?

Intracranial hemorrhage

What are absolute contraindications for thrombolytics?

Recent surgery/trauma (2-3 weeks); active internal bleeding; history of stroke; HTN (>185/110) ; recent head injury; bleeding disorders

What are nursing assessments for thrombolytic therapy (ADPIE - Assessment)?

TIME-SENSITIVE - assess symptom onset time; complete contraindication checklist; baseline neuro assessment and vital signs; bleeding risk factors

What are nursing diagnoses for thrombolytic therapy (ADPIE - Diagnosis)?

Risk for bleeding related to thrombolytic therapy; Risk for altered cerebral tissue perfusion

What are nursing implementations for thrombolytic therapy (ADPIE - Implementation)?

Use checklist to verify NO contraindications; monitor neuro status Q15 min during infusion; avoid invasive procedures and IM injections; monitor for bleeding; have emergency equipment ready

How often should neuro checks be done during tPA infusion?

Every 15 minutes during infusion, then per protocol (Q30 min x 6 hrs, then Q1 hr x 16 hrs in first 24 hours)

What should you do if a patient on tPA complains of worst headache of life?

STOP infusion immediately - suspect intracranial hemorrhage; notify provider emergently; prepare for emergency intervention

What is the antidote for alteplase, reteplase, and tenecteplase?

None available

What is the antidote for streptokinase,anistreplase and urokinase?

Aminocaproic acid

What patient education should be provided for all anticoagulants/antiplatelets?

Avoid contact sports; use soft toothbrush and electric razor; report unusual bleeding; inform all healthcare providers; wear medical alert bracelet

When should anticoagulants/antiplatelets be held before surgery?

5-7 days before procedures

What is a thrombus?

Blood clot attached to vessel wall

What is an embolus?

Blood clot that breaks off and travels

What ischemic diseases result from clot formation?

CVA (stroke), DVT, MI (heart attack), PE (pulmonary embolism)

What are risk factors for clot formation?

Vein injury, slow blood flow/immobility, increased estrogen, chronic diseases, history of DVT/PE, obesity, advanced age, central venous catheters

What is the normal platelet range?

150,000-400,000/μL

What is thrombocytopenia?

Low platelet count (

What are signs of bleeding to monitor?

Gums, urine, stool, bruising, nosebleeds, petechiae, hematomas

What is the ABC priority for anticoagulation therapy?

A: Assessment first (check labs, assess for bleeding); B: Bleeding risk (know antidotes, watch contraindications); C: Communication & Education (patient teaching, report critical values)

Case: Patient on warfarin with INR 1.4 - what does this mean?

Subtherapeutic (goal 2.0-3.0); patient at risk for clot extension

Case: Patient on warfarin with INR 5.0 - what does this mean?

Supratherapeutic; patient at increased bleeding risk; may need vitamin K or dose adjustment

What should you teach a patient starting warfarin about Vitamin K foods?

Maintain CONSISTENT intake of Vitamin K foods (green leafy vegetables), not elimination; consistency is key

Why is aspirin not recommended for all elderly patients?

(no CVD history); individualized decision based on cardiovascular risk, age, bleeding risk factors, and benefit vs. risk analysis

What does CAB stand for in aspirin decision-making?

C: Cardiovascular risk assessment; A: Age and bleeding risk factors; B: Benefit vs. risk analysis

Who benefits most from aspirin therapy?

Patients with history of MI, stroke, cardiovascular disease, or high cardiovascular risk factors (secondary prevention)

What is TTP (Thrombotic Thrombocytopenic Purpura)?

Rare but serious adverse effect of clopidogrel causing blood clots in small vessels

What is the advantage of LMWHs over heparin?

Can take at home, decreased HIT risk, no routine monitoring needed

What is the disadvantage of DOACs compared to warfarin?

Short half-life (cannot miss doses), more expensive, not recommended if CrCl

Why is warfarin contraindicated in pregnancy?

Teratogenic effects (can cause fetal harm)

How should dabigatran capsules be administered?

Do NOT open, crush, or chew capsules; keep in original container for stability

What GI side effect is common with aspirin?

GI bleeding, especially with long-term use or in elderly patients

What should a patient on anticoagulants use instead of a razor?

Electric shaver to reduce bleeding risk

What type of toothbrush should anticoagulation patients use?

Soft bristle toothbrush to prevent gum bleeding

What is bridge therapy and which drugs are used?

Short-term anticoagulation while waiting for warfarin to become therapeutic; uses heparin or LMWH

Why does warfarin take several days to become therapeutic?

It inhibits synthesis of NEW clotting factors; existing factors must be depleted first

What enhances absorption of iron supplements?

Taking with food or Vitamin C

What is a serious adverse effect of epoetin alfa when Hgb >11 g/dL?

MI, CVA, CHF, tumor growth (SEVERE)

What should you NOT do with filgrastim or epoetin alfa vials?

Do NOT shake vial; do NOT use if discolored or contains particles

What is the treatment for iron-deficiency anemia?

Ferrous sulfate/gluconate/fumarate

What are common side effects of oral iron supplements?

GI upset, constipation, dark stools, teeth/sclera staining

What is a critical safety warning about iron supplements?

overdose in children

What is the treatment for pernicious (Vitamin B12) anemia?

Cyanocobalamin

What is the treatment for folate-deficiency anemia?

Folic Acid 

What inhibits absorption of folate and B12?

Alcohol

What is neutropenia?

(<1,500/μL)

What is the treatment for neutropenia?

Filgrastim

What are serious adverse effects of filgrastim?

Splenic rupture, ARDS, anaphylaxis

Remember: for thrombolytics

Always verify contraindications and work within therapeutic window for stroke and MI patients - delays can cause permanent tissue damage

What is the treatment medication for Chronic kidney disease anemia

Epoetin Alfa

Contraindications for administering Epoetin Alfa

Hgb >11g/dL