Transcript Chapter_28
CHAPTER 28 Coagulation Modifier Drugs Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Hemostasis The process that halts bleeding after injury to a blood vessel Complex relationship between substances that promote clot formation and either inhibit coagulation or dissolve a formed clot Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 2 Coagulation System “Cascade” Each activated factor serves as a catalyst that amplifies the next reaction Result is fibrin, a clot-forming substance Intrinsic pathway and extrinsic pathway Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Coagulation Modifier Drugs Anticoagulants Inhibit the action or formation of clotting factors Prevent clot formation Antiplatelet drugs Inhibit platelet aggregation Prevent platelet plugs Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Coagulation Modifier Drugs (cont’d) Hemorheologic drugs Thrombolytic drugs Alter platelet function Lyse (break down) existing clots Hemostatic or antifibrinolytic drugs Promote blood coagulation Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Anticoagulants Also known as antithrombotic drugs Have no direct effect on a blood clot that is already formed Used prophylactically to prevent Clot formation (thrombus) An embolus (dislodged clot) Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Anticoagulants: Mechanism of Action Vary, depending on drug Work on different points of the clotting cascade Do not lyse existing clots Heparin and low–molecular-weight heparins Turn off coagulation pathway and prevent clot formation warfarin (Coumadin) fondaparinux (Arixtra) Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Anticoagulants: Mechanism of Action (cont’d) All ultimately prevent clot formation Heparin Low–molecular-weight heparins warfarin (Coumadin) fondaparinux (Arixtra) Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Anticoagulants (cont’d) Prevention of clot formation also prevents: Stroke Myocardial infarction (MI) Deep vein thrombosis (DVT) Pulmonary embolism (PE) Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Anticoagulants: Indications Used to prevent clot formation in certain settings where clot formation is likely Myocardial infarction Unstable angina Atrial fibrillation Indwelling devices, such as mechanical heart valves Major orthopedic surgery Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Anticoagulants: Adverse Effects Bleeding Risk increases with increased dosages May be localized or systemic Heparin-induced thrombocytopenia (HIT) May also cause: Nausea, vomiting, abdominal cramps, thrombocytopenia, others Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 14 Anticoagulants (cont’d) Heparin Monitored by activated partial thromboplastin times (aPTTs) Parenteral Short half-life (1 to 2 hours) Effects reversed by protamine sulfate Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Anticoagulants (cont’d) Low–molecular-weight heparins enoxaparin (Lovenox) and dalteparin (Fragmin) More predictable anticoagulant response Do not require laboratory monitoring Given subcutaneously Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 16 Anticoagulants (cont’d) warfarin sodium (Coumadin) Given orally only Monitored by prothrombin time (PT) and INR (PT-INR) Vitamin K can be given if toxicity occurs Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Antiplatelet Drugs Prevent platelet adhesion aspirin dipyridamole (Persantine) clopidogrel (Plavix) and ticlopidine (Ticlid) • ADP inhibitors tirofiban (Aggrastat), eptifibatide (Integrilin), abciximab (ReoPro) • New class, GP IIb/IIIa inhibitors Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 18 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 19 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20 Antiplatelet Drugs: Indications Antithrombotic effects Reduce risk of fatal and nonfatal strokes Acute unstable angina and MI Adverse effects Vary according to drug Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 21 Antifibrinolytic Drugs Prevent the lysis of fibrin Result in promoting clot formation Used for prevention and treatment of excessive bleeding resulting from hyperfibrinolysis or surgical complications Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 22 Antifibrinolytic Drugs (cont’d) aminocaproic acid (Amicar) desmopressin (DDAVP) Similar to ADH Also used in the treatment of diabetes insipidus Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 23 Antifibrinolytic Drugs: Indications Prevention and treatment of excessive bleeding Hyperfibrinolysis Surgical complications Excessive oozing from surgical sites such as chest tubes Reducing total blood loss and duration of bleeding in the postoperative period Treatment of hemophilia or von Willebrand’s disease Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 24 Antifibrinolytic Drugs: Adverse Effects Uncommon and mild Rare reports of thrombotic events Others include: Dysrhythmia, orthostatic hypotension, bradycardia, headache, dizziness, fatigue, nausea, vomiting, abdominal cramps, diarrhea, others Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 25 Thrombolytic Drugs Drugs that break down, or lyse, preformed clots Older drugs streptokinase and urokinase Newer drugs Tissue plasminogen activator (t-PA) Anisoylated plasminogen-streptokinase activator complex (APSAC) Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 26 Thrombolytic Drugs (cont’d) anistreplase (Eminase) alteplase (t-PA, Activase) reteplase (Retavase) tenecteplase (TNKase) Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 27 Thrombolytic Drugs: Mechanism of Action Activate the fibrinolytic system to break down the clot in the blood vessel quickly Activate plasminogen and convert it to plasmin, which can digest fibrin Reestablish blood flow to the heart muscle via coronary arteries, preventing tissue destruction Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 28 Thrombolytic Drugs: Indications Acute MI Arterial thrombolysis DVT Occlusion of shunts or catheters Pulmonary embolus Acute ischemic stroke Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 29 Thrombolytic Drugs: Adverse Effects Bleeding Internal Intracranial Superficial Other effects Nausea, vomiting, hypotension, anaphylactoid reactions Cardiac dysrhythmias; can be dangerous Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 30 Nursing Implications Assess: Patient history, medication history, allergies Contraindications Baseline vital signs, laboratory values Potential drug interactions—there are MANY! History of abnormal bleeding conditions Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 31 Heparin: Nursing Implications Intravenous doses are usually doublechecked with another nurse Ensure that SC doses are given SC, not IM SC doses should be given in areas of deep subcutaneous fat, and sites rotated Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 32 Heparin: Nursing Implications (cont’d) Do not give SC doses within 2 inches of: The umbilicus, abdominal incisions, or open wounds, scars, drainage tubes, stomas Do not aspirate SC injections or massage injection site May cause hematoma formation Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 33 Heparin: Nursing Implications (cont’d) IV doses may be given by bolus or IV infusions Anticoagulant effects seen immediately Laboratory values done daily to monitor coagulation effects (aPTT) Protamine sulfate can be given as an antidote in case of excessive anticoagulation Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 34 LWMHs: Nursing Implications Given subcutaneously in the abdomen Rotate injection sites Protamine sulfate can be given as an antidote in case of excessive anticoagulation Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 35 Warfarin Sodium: Nursing Implications May be started while the patient is still on heparin until PT-INR levels indicate adequate anticoagulation Full therapeutic effect takes several days Monitor PT-INR regularly—keep follow-up appointments Antidote is vitamin K Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 36 Warfarin: Nursing Implications Many herbal products have potential interactions—increased bleeding may occur Capsicum pepper Garlic Ginger Gingko Ginseng Feverfew Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 37 Anticoagulants: Patient Education Education should include: Importance of regular lab testing Signs of abnormal bleeding Measures to prevent bruising, bleeding, or tissue injury Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 38 Anticoagulants: Patient Education (cont’d) Education should include (cont’d): Wearing a medical alert bracelet Avoiding foods high in vitamin K (tomatoes, dark leafy green vegetables) Consulting physician before taking other meds or over-the-counter products, including herbals Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 39 Antiplatelet Drugs: Nursing Implications Concerns and teaching tips same as for anticoagulants Dipyridamole should be taken on an empty stomach Drug-drug interactions Adverse reactions to report Monitoring for abnormal bleeding Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 40 Thrombolytic Drugs: Nursing Implications Follow strict manufacturer’s guidelines for preparation and administration Monitor IV sites for bleeding, redness, pain Monitor for bleeding from gums, mucous membranes, nose, injection sites Observe for signs of internal bleeding (decreased BP, restlessness, increased pulse) Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 41 Coagulation Modifier Drugs: Nursing Implications Monitor for therapeutic effects Monitor for signs of excessive bleeding Bleeding of gums while brushing teeth, unexplained nosebleeds, heavier menstrual bleeding, bloody or tarry stools, bloody urine or sputum, abdominal pain, vomiting blood Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 42 Coagulation Modifier Drugs: Nursing Implications (cont’d) Monitor for adverse effects Increased BP, headache, hematoma formation, hemorrhage, shortness of breath, chills, fever Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 43