Hematological System Medications Diane McLean RN MSN Nursing 202

Various Drugs Anticoagulants Inhibit the action or formation of clotting factors Prevent clot formation Antiplatelet drugs Inhibit platelet aggregation Prevent platelet plugs Thrombolytic drugs Lyse (break down) existing clots Hemostatic or Antifibrinolytic drugs Promote blood coagulation

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

Anticoagulants Have no direct effect on a blood clot that is already formed Used prophylactically to prevent Clot formation (thrombus) An embolus (dislodged clot)

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

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

Anticoagulants: Mechanism of Action… All ultimately prevent clot formation heparin Low-molecular-weight heparins warfarin (Coumadin)

Anticoagulants Prevention of clot formation also prevents: Stroke Myocardial infarction (MI) Deep vein thrombosis (DVT) Pulmonary embolism (PE)

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

Anticoagulants: Adverse Effects Bleeding Risk increases with increased dosages May be localized or systemic May also cause: Nausea, vomiting, abdominal cramps, thrombocytopenia, others

Anticoagulants heparin Monitored by activated partial thromboplastin times (aPTTs) Parenteral Short half-life (1 to 2 hours) Effects reversed by protamine sulfate Obtained from sheep, cows, and pigs

Anticoagulants… Low-molecular-weight heparins enoxaparin (Lovenox) and dalteparin (Fragmin) More predictable anticoagulant response Do not require frequent laboratory monitoring Given subcutaneously

Anticoagulants … warfarin sodium (Coumadin) Given orally only Monitored by prothrombin time (PT) and INR (PT-INR) Vitamin K can be given if toxicity occurs Herbals potential interactions Feverfew Garlic Ginger Ginkgo ginseng

Antiplatelet Drugs Prevent platelet adhesion Aspirin dipyridamole (Persantine) clopidogrel (Plavix) and ticlopidine (Ticlid) ADP inhibitors tirofiban (Aggrastat), eptifibatide (Integrilin) New class, GP IIb/IIIa inhibitors

Antiplatelet Drugs… Indications Antithrombotic effects Reduce risk of fatal and nonfatal strokes Adverse effects Vary according to drug

Antifibrinolytic Drugs Prevent the lysis of fibrin Results: promote clot formation Used for prevention and treatment of excessive bleeding resulting from hyperfibrinolysis or surgical complications

Antifibrinolytic Drugs… aminocaproic acid (Amicar) desmopressin (DDAVP) Similar to ADH Also used in the treatment of diabetes insipidus

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

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

Thrombolytic Drugs Drugs that break down, or lyse, preformed clots Older drugs streptokinase and urokinase Newer drugs Tissue plasminogen activator Anisoylated plasminogen-streptokinase activator complex (APSAC)

Thrombolytic Drugs… streptokinase (Streptase) anistreplase (Eminase) alteplase (t-PA, Activase) reteplase (Retavase) tenecteplase (TNKase) drotrecogin alfa (Xigris)

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

Thrombolytic Drugs: Indications Acute MI Arterial thrombolysis DVT Occlusion of shunts or catheters Pulmonary embolus Acute ischemic stroke

Thrombolytic Drugs: Adverse Effects BLEEDING Internal Intracranial Superficial Other effects Nausea, vomiting, hypotension, anaphylactoid reactions Cardiac dysrhythmias

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

Heparin: Nursing Implications Intravenous doses are usually double checked with another nurse Ensure that SC doses are given SC, not IM ½ to 5/8” 25 to 28 gauge needle SC doses should be given in areas of deep subcutaneous fat, and sites rotated

Heparin: Nursing Implications … 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

Heparin: Nursing Implications… IV doses may be given by bolus or IV infusions Anticoagulant effects seen immediately Laboratory values are done daily to monitor coagulation effects (aPTT) Protamine sulfate can be given as an antidote in case of excessive anticoagulation 1mg = 1mg

LWMHs: Nursing Implications Given subcutaneously in the abdomen Rotate injection sites Protamine sulfate can be given as an antidote in case of excessive anticoagulation

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

Warfarin: Nursing Implications Many herbal products have potential interactions—increased bleeding may occur Capsicum pepper Garlic Ginger Gingko Ginseng Feverfew

Anticoagulants: Patient Education Education should include: Importance of regular lab testing Signs of abnormal bleeding Measures to prevent bruising, bleeding, or tissue injury

Anticoagulants: Patient Education… 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 OTC products, including herbals

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

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

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

Coagulation Modifier Drugs Nursing Implications … Monitor for adverse effects Increased BP, headache, hematoma formation, hemorrhage, shortness of breath, chills, fever

Iron Essential mineral in the body Oxygen carrier in hemoglobin and myoglobin Stored in the liver, spleen, bone marrow Iron deficiency results in anemia

Iron … Dietary sources: meats, certain vegetables and grains Dietary iron must be converted by gastric juices before it can be absorbed

Iron … Some foods enhance iron absorption Orange juice, veal, fish, ascorbic acid Some foods impair iron absorption Eggs,* corn, beans,* cereal products containing phytates *Eggs and beans are also common dietary sources of iron

Iron … Supplemental iron may be given as a single drug or as part of a multivitamin preparation Contradindicated with Hemolytic anemia Oral iron preparations are available as ferrous salts Ferrous fumarate, ferrous gluconate, ferrous sulfate Parenteral form: iron dextran Give with normal saline not 5% dextrose

Iron: Indications Prevention and treatment of iron-deficiency syndromes Administration of iron alleviates the symptoms of iron-deficiency anemia, but the underlying cause of the anemia should be corrected 4 week (absence of fatique)

Iron: Adverse Effects Nausea, vomiting, diarrhea, constipation, stomach cramps, and pain Causes black, tarry stools Liquid oral preparations may stain teeth Injectable forms may stain skin and cause pain upon injection Avoid reclining position for 15 to 30 minutes-avoid esophageal irritation or corrosion Antacids/milk decrease absorption Whole/not crushed Take with food to help reduce GI distress but it also may decrease absorption

Iron Dextran Parenteral use (IM or IV) Z-track method, deep into a large muscle mass May cause anaphylactic reactions, including fatal anaphylaxis Test dose usually given, then remainder of dose after 1 hour

Folic Acid Water soluble, B-complex vitamin Essential for erythropoiesis Primarily used to prevent and treat folic acid deficiency Malabsorption syndromes are the most common cause of deficiency

Folic Acid … Should not be used until actual cause of anemia is determined May mask symptoms of pernicious anemia, which requires treatment other than folic acid Untreated pernicious anemia progresses to neurologic damage

Folic Acid: Indications Folic acid deficiency anemia Tropical sprue Prenatal prophylaxis of neural tube defects

Other Blood-Forming Drugs cyanocobalamin (vitamin B12) erythropoietin (Epogen, Procrit

Nursing Implications Assess patient history, medication history, including drug allergies Assess for potential contraindications Assess baseline laboratory values, especially Hgb, Hct, reticulocytes, others Obtain nutritional assessment

Nursing Implications… Ferrous salts are contraindicated in patients with ulcerative colitis, PUD, liver disease, other GI disorders Iron dextran is contraindicated in all anemias except for iron-deficiency anemia

Nursing Implications … For liquid iron preparations, follow manufacturer’s guidelines on dilution and administration Instruct patient to take liquid iron preparations through a straw to avoid staining tooth enamel

Nursing Implications … Oral forms of iron should be taken between meals for maximum absorption, but may be taken with meals if GI distress occurs Oral forms should be given with juice, but not with milk or antacids

Nursing Implications … Patients should remain upright for 15 to 30 minutes after oral iron doses to avoid esophageal corrosion Patients should be encouraged to eat foods high in iron/folic acid

Nursing Implications … For iron dextran, a small test dose should be given After 1 hour, if no reaction, the remainder of the dose can be given Administer deeply into a large muscle mass using the Z-track method

Nursing Implications … For IV doses of iron dextran, give carefully according to manufacturer’s instructions Have resuscitative equipment available in case of anaphylactic reaction

Nursing Implications … Determine cause of anemia before administering folic acid Oral folic acid should be given with food Folic acid may also be given IV and added to total parenteral nutrition solutions

Nursing Implications … Monitor for therapeutic responses Improved nutritional status Increased weight, activity tolerance, well-being Absence of fatigue Monitor for adverse effects

Medications to Know Coumadin Neupogen (filgrastim) Persantine Rituxen (rituximab) Iron Dextran Filgrastin Oral Iron Epogen (procrit) Folic Acid Activase (alteplase) Cyanobalamin Trental Oprelvekin Lovenox Lovenox Fragmin Heparin ASA Indications & expected outcomes; nursing interventions, Patient teaching, labs, antidotes/dosages, etc.