Anti-Coagulants

The Anti-Coagulants
The anticoagulants interfere with the coagulation process by interfering with the clotting cascade and thrombin formation. These agents are used to inhibit clot formation, but they do NOT dissolve existing clots. The Anticoagulants commonly used are: Heparin Warfarin (Coumadin) Dicumarol

Heparins
These are anticoagulants given orally or parenterally- SQ and IV. Heparin is naturally found in the human liver that normally prevents clot formation. Heparin is strongly acidic because of the presence of sulfate and carboxylic acid groups in the heparin chain.

Heparin
The mechanism of action of Heparin Heparin (Liquamen Sodium) acts prophylactically to prevent the formation of blood clots in the vasculature. It combines with ANTITHROMBIN III, a substance in our blood sometimes called heparin factor that inactivates THROMBIN. By inhibiting the action of thrombin, conversion of fibrinogen to fibrin does not occur and the formation of a fibrin clot is prevented.

Heparins
Clinical Indications of Heparins deep vein thrombosis pulmonary embolism coronary thrombosis, patients with artificial heart valves and stroke patients

Heparins
Contraindications of heparin Anticoagulants are not given to patients with bleeding disorders, peptic ulcers and patients who underwent recent eye/brain/spinal surgery. It is NOT given to patients with severe liver and renal disease, hemophilia, and CVA. Heparin is a large protein molecule that cannot pass through the placenta easily and can be given to pregnant women.

Heparins
Pharmacokinetics: the Adverse Effects of Heparin INCREASES the clotting time and also DECREASES the platelet count. In this regard, monitoring of the aPTT/PTT (N= 20-30 seconds) and platelet count is required. Hematologic effects: increased bleeding, thrombocytopenia Skin-itching and burning Hypersensitivity reactions like chills, fever, urticaria or anaphylaxis can occur since heparin is obtained from animal sources. Life threatening adverse effect is Hemorrhage

Heparins
The Nursing process and Heparin Assessment Patient history Physical examination- the nurse obtains baseline vital signs and physical assessment. She must obtain laboratory results of the complete blood count, platelet count and activated partial thromboplastin time (aPTT), and clotting time.

Heparins
IMPLEMENTATION:

Monitor the aPTT closely (it should be 1.5-2.5 times normal value) Monitor vital signs and hematological status regularly. Monitor signs of bleedinghematuria, epistaxis, ecchymoses, Hypotension and occult blood in stool Have available ANTIDOTE for heparin- PROTAMIME SULFATE

Heparins
IMPLEMENTATION: Instruct the client not to use any over the counter drug without notifying the physician Administer heparin subcutaneously in the abdominal region, using a 25-28-gauge needle at a 90-degree angle. DO NOT MASSAGE OR RUB THE AREA as this may cause bruising. Advise patient not to smoke, use electric razors to shave, use soft toothbrush and control sudden hemorrhage by direct pressure for 5-10 minutes. Provide gently skin and oral care.

Heparins
Evaluation Monitor the effectiveness of the medication: Decreased formation of clot PTT is 2x the normal

The Oral Anticoagulants

There are three commonly used oral anticoagulant agents in the hospital Warfarin- most commonly used, synthesized from dicumarol Dicumarol Anisindone

The Oral Anticoagulants

Pharmacodynamics: the mechanism of Action of the Oral agents These agents INHIBIT the liver synthesis of the Vitamin K clotting factors factors II, VII, IX, and X.

The Oral Anticoagulants

Clinical indications of oral anticoagulants These drugs are used to prevent blood clotting in patients with thrombophlebitis pulmonary embolism and embolism from atrial fibrillation. Because Warfarin crosses the placental barrier, it is NOT given to pregnant mothers.

The Oral Anticoagulants

Contraindications and precautions Oral anti-coagulants are NOT given to patients with bleeding disorders, peptic ulcers, severe renal/liver diseases, hemophilia, CVA blood dyscrasias and eclampsia. It is NOT given to pregnant mothers because it is teratogenic and can cause abortion

Pharmacokinetics:

The Oral Anticoagulants

Oral anticoagulants prolong the clotting time and are monitored by the Prothrombine Time (PT- average of 9-12 seconds). This is usually performed before administering the next dose. The PT level should be 1.5-2 times the reference value to be therapeutic. The normal International Normalized Ratio(INR) is 1-2. If the patient is on oral anticoagulant therapy, the INR is maintained at an INR of 2.0-3.0. If the INR is below the recommended range, warfarin is increased. If it is above the recommended range, warfarin should be

The Oral Anticoagulants

Pharmacokinetics: the Adverse Effects of Warfarin Hematologic effects: increased bleeding, thrombocytopenia Anorexia, nausea, vomiting, diarrhea, abdominal cramps, rash and fever. Alopecia, bone marrow depression, and dermatitis.

Life threatening adverse effect is Hemorrhage

The Oral Anticoagulants

The Nursing process and Warfarin

Assessment Patient history-. The nurse determines the current medications taken, PREGNANCY, and history of recent surgery. Physical examination- the nurse obtains baseline vital signs and physical assessment. laboratory results of the complete blood count, platelet count and Prothrombin time, INR and clotting time.

The Oral Anticoagulants

Implementation Monitor vital signs and hematological status Monitor signs of bleedinghematuria, epistaxis, black tarry stools, echymoses, Hypotension and occult blood in stool Have available ANTIDOTE for warfarin- VITAMIN K or phytonadione.

The Oral Anticoagulants

Implementation Advise patient not to smoke, use electric razors to shave, use soft toothbrush and control sudden hemorrhage by direct pressure for 510 minutes. Provide gently skin and oral care.
Instruct the patient to avoid foods high in vitamin K like spinach, nuts

The Oral Anticoagulants

Evaluation Monitor the effectiveness of the medication

Check the PT and INR

Decreased formation of blood clots Should be 2x the normal

Anti-platelets
These are agents decrease the formation of the platelet plug by decreasing the responsiveness of the platelets to various stimuli that would cause them to stick and combine together on a vessel wall
Aspirin Dipyridamole Sulfinpyrazone Ticlopidine Clopidogrel Glycoprotein receptor antagonists
Abciximab Eptifibatide Tirofiban

Anti-platelets
The mechanism of action of platelet inhibitors These agents INHIBIT the aggregation of platelets in the clotting process by blocking receptor sites on the platelet membrane, preventing platelet-to-platelet interaction, thereby prolonging the bleeding time.

Anti-platelets
Clinical indications Prevention of myocardial infarction and stroke Prevention of a repeat myocardial infarction Prevention of stroke for those with transient ischemic attack In patients with graft to maintain its patency.

Anti-platelets
Pharmacodynamics: the adverse effects of Antiplatelets Bleeding is the most common side effect GIT- gum bleeding, gastric bleeding, tarry stools CNS- headache, dizziness and weakness Skin- petechiae, bruising, allergy ASPIRIN toxicity: tinnitus

Anti-platelets
Nursing considerations Determine if the patient is allergic or sensitive to the medications Monitor closely the vital signs and bleeding areas Instruct the patient to take drug with food Monitor the bleeding time, clotting time and platelet count

Anti-platelets
Nursing considerations Suggest safety measures including the use of an electric razor and avoidance of contact sports. Provide increased precautions against bleeding during invasive procedures. Use pressure dressings and ice to decrease excessive blood loss. Monitor for tinnitus

The Thrombolytics
These thrombolytic agents are used to activate the natural anticlotting fibrinolytic mechanism to convert plasminogen to plasmin, which destroys and breaks down the fibrin threads in the blood clot (FIBRINOLYSIS). The result is clot disintegration. The commonly used thrombolytics ---ase Streptokinase Urokinase Tissue plasminogen activator (t-PA) or alteplase Anistreplase Reteplase

The Thrombolytics
The mechanisms of actions of each agent Streptokinase and urokinase are ENZYMES that act SYSTEMICALLY to dissolve the blood clots by activating plasminogen to plasmin.

The Thrombolytics
Clinical indications of thrombolytics Myocardial infarction Pulmonary embolism Thromboemboilic stroke Peripheral arterial thrombosis and to open clotted IV catheters.

The Thrombolytics
Pharmacokinetics: The adverse effects of Streptokinase CVS- Hypotension and dysrhythmias (usually upon reperfusion of the heart) Hematological: increased bleedingthe most common effect. Headache, nausea, flush, rash and fever Allergic reaction- especially steptokinase and urokinase Major adverse effect- hemorrhage.

The Thrombolytics
Implementation. Monitor signs of active bleeding from mouth and rectum bleeding- hematuria, epistaxis, echymoses Have available ANTIDOTE for thrombolytics: AMINOCAPROIC ACID! Have available blood for emergency use. Advise patient not to smoke, use electric razors to shave, use soft toothbrush and control sudden hemorrhage by direct pressure for 5-10 minutes. Provide gently skin and oral care. As much as possible, avoid frequent venipuncture.

The Thrombolytics
Evaluation Monitor the effectiveness of the medication
Clot lysis

The Agents to treat bleeding

Aminocaproic acid and tranexamic acid
These are fibrin stabilizers that maintain or stabilize the clot in the bleeding vessels

The Agents to treat bleeding

Protamine sulfate
This agent antagonizes the anticoagulant effects of heparin. It is derived from fish testis and is high in arginine content. The positive charge interacts with the negative charge of heparin to forma stable inactive complex.

The Agents to treat bleeding

Vitamin K
Vitamin K is given to antagonize the effects of the oral anticoagulants. The response to Vitamin K is slow, requiring about 24 hours thus, if immediate hemostasis or bleeding control is required, fresh frozen plasma should be ordered by the physician.

The antianemics: Iron preparations and Epoetin

Iron preparations Iron is important for hemoglobin formation.
The iron preparations are: Ferrous sulfate Ferrous fumarate Ferrous gluconate

The antianemics: Iron preparations and Epoetin

Side-effects: GIT- constipation (usually), diarrhea, vomiting, epigastric pain, gastric ulceration and darkening of stools. Liquid preparation can stain the teeth, and injectable iron can cause tissue discoloration Other- dizziness

Anti-Anemics

The antianemics: Iron preparations and Epoetin

Drug-Drug interaction Tetracyclines and penicillamine- combine with iron preparations and render the iron unabsorbable. Antacids and cimetidine- decrease iron absorption and effects Foods can impair iron absorption but they should be taken with iron to reduce GI discomfort. Milk containing foods, coffee, tea and eggs are NOT given with iron because they delay iron absorption.

Implementation Encourage the patient to eat iron-rich foods like liver, lean meat, egg yolk, dried beans, green leafy vegetables. Administer iron preparations orally with foods to decrease GI discomfort. If increased absorption is necessary, administer IN BETWEEN meals with full glass of water or juice. It is best to offer citrus juices because the vitamin C content can increase iron absorption. Instruct the patient to swallow the whole tablet and remain upright for 30 minutes to prevent esophageal corrosion from reflux. DO NOT administer iron together with or within 1 hour of ingesting tetracyclines, antacids, milk and milk-containing products. Advise clients to increase fluid intake and consume

The antianemics: Iron preparations and Epoetin

The antianemics: Iron preparations and Epoetin

Implementation Warn the patient of possible iron poisoning if tablets are left within childs reach. Emphasize that the therapeutic effect of iron therapy may not be apparent until several weeks. If injecting a parenteral iron preparation, inject DEEP IM utilizing the Z-track method to avoid leakage into the subcutaneous tissues and skin. Offer straw if giving liquid iron preparation to avoid staining the teeth. To prevent undue alarm, instruct the patient that the stools may turn black or dark green. This is a harmless occurrence.

The antianemics: Iron preparations and Epoetin

Evaluation The nurse evaluates the effectiveness of the drug therapy by determining that the client is not fatigued, with absence of pallor, and with hemoglobin results within desired range.

Erythropoietin
The mechanism of action of epoetin alfa (Epogen) This drug acts like the natural glycoprotein erythropoietin to stimulate the production of RBC in the bone marrow.

Erythropoietin
Clinical indications It is given SUBCUTANEOUSLY or INTRAVENOUSLY for the treatment of anemia associated with renal failure or for patients on dialysis. It is also used in patients for blood transfusion to decrease the need for blood in surgical patients.

Erythropoietin
Pharmacodynamics: the adverse effects of epoetin alfa CNS- headache, fatigue, asthenia, dizziness and seizures- these are due to the cellular response to the glycoprotein. GIT- nausea, vomiting and diarrhea CVS- hypertension, edema and chest pain due to increase RBC number