1. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 27 Coagulation Modifier Drugs

2. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

3. Mosby items and derived items © 2007, 2005, 2002 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

4. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulants  Have no direct effect on a blood clot that is already formed  Used prophylactically to prevent  Clot formation (thrombus)  An embolus (dislodged clot)

5. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

6. Mosby items and derived items © 2007, 2005, 2002 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

10. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulants: Mechanism of Action (cont’d) All ultimately prevent clot formation  heparin  Low-molecular-weight heparins  warfarin (Coumadin)

11. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulants  Prevention of clot formation also prevents:  Stroke  Myocardial infarction (MI)  Deep vein thrombosis (DVT)  Pulmonary embolism (PE)

12. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

13. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulants: Adverse Effects  Bleeding  Risk increases with increased dosages  May be localized or systemic  May also cause:  Nausea, vomiting, abdominal cramps, thrombocytopenia, others

14. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

15. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulants (cont’d)  Low-molecular-weight heparins  enoxaparin (Lovenox) and dalteparin (Fragmin)  More predictable anticoagulant response  Do not require frequent laboratory monitoring  Given subcutaneously

16. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

17. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antiplatelet Drugs  Prevent platelet adhesion  Aspirin  dipyridamole (Persantine)  clopidogrel (Plavix) and ticlopidine (Ticlid) ADP inhibitors ADP inhibitors  tirofiban (Aggrastat), eptifibatide (Integrilin) New class, GP IIb/IIIa inhibitors New class, GP IIb/IIIa inhibitors

18. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

20. Antiplatelet Drugs (cont’d) Indications  Antithrombotic effects  Reduce risk of fatal and nonfatal strokes  Adverse effects  Vary according to drug

21. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

22. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antifibrinolytic Drugs (cont’d)  aminocaproic acid (Amicar)  desmopressin (DDAVP)  Similar to ADH  Also used in the treatment of diabetes insipidus

23. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

24. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

25. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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)

26. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Thrombolytic Drugs (cont’d)  streptokinase (Streptase)  anistreplase (Eminase)  alteplase (t-PA, Activase)  reteplase (Retavase)  tenecteplase (TNKase)  drotrecogin alfa (Xigris)

27. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

28. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Thrombolytic Drugs: Indications  Acute MI  Arterial thrombolysis  DVT  Occlusion of shunts or catheters  Pulmonary embolus  Acute ischemic stroke

29. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Thrombolytic Drugs: Adverse Effects  BLEEDING  Internal  Intracranial  Superficial  Other effects  Nausea, vomiting, hypotension, anaphylactoid reactions  Cardiac dysrhythmias

30. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

31. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Heparin: Nursing Implications  Intravenous doses are usually double checked 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

32. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

33. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Heparin: Nursing Implications (cont’d)  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

34. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. LWMHs: Nursing Implications  Given subcutaneously in the abdomen  Rotate injection sites  Protamine sulfate can be given as an antidote in case of excessive anticoagulation

35. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

36. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Warfarin: Nursing Implications  Many herbal products have potential interactions— increased bleeding may occur  Capsicum pepper  Garlic  Ginger  Gingko  Ginseng  Feverfew

37. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulants: Patient Education Education should include:  Importance of regular lab testing  Signs of abnormal bleeding  Measures to prevent bruising, bleeding, or tissue injury

38. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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 OTC products, including herbals

39. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

40. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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)

41. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

42. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Coagulation Modifier Drugs Nursing Implications (cont’d)  Monitor for adverse effects  Increased BP, headache, hematoma formation, hemorrhage, shortness of breath, chills, fever