narrow therapeutic range; potential to interact with many herbal remedies. Should not be combined with the following bc increase bleeding:

• celery, chamomile, clove, dong quai, feverfew, garlic, ginger, kingko, ginseng, green tea, onion, passion flower, red clover, St. John’s wort, and turmeric.  ANY HERBAL USED WITH CAUTION ON WARFARIN

• PT and INR are used to monitor pts response to Warfarin therapy.
• Daily dose determined based on PT/INR
• Therepeutic range is 1.2-1.5 times control value
• Values greater than 2 do not provide further therapeutic effects and assoc with more bleeding
• The INR “corrects” routine PT results from different laboratories.  INR more consistant standard and is maintained bt 2 and 3.  Values above 5 can be dangerous and values below 1 are ineffective.

• anisinidone
• warfarin (Coumadin)

• heparins
• heparin
• heparin sodium lock flush solution
• low-molecular weigh heparins
• dalteparin (Fragmin)
• enoxaparin (Lovenox)
• tinzaparin (Innohep)

LMWHs

• dalteparin (Fragmin)
• enoxaparin (Lovenox)
• tinzaparin (Innohep)

• misc anticoagulant
• used to prevent DVT in lower body surgeries
• produces stong anticoagulant effect with narrow therepeutic index
• associtated with hemorrhagic complications

Coumadin

oral anticoagulant (sometimes given parenterally)

most used anticoagulant

                                                               i.      interfere w/ manufacture of vit-K dependent clotting factors by liver resuling in depletion of clotting factors II (prothrombin) and others.  Depletion of prothrombin accounts for most of actions of Warfarin.

                                                               i.      inhibits formation of fibrin clots

                                                              ii.      inhibits conversion bibrinogen to fibrin

                                                            iii.      inactivates several factors of clotting process

                                                            iv.      cannot be taken orally bc is inactivated by gastric acid, must be an injection.

                                                               i.      bind to antithrombin III, blocking synthesis of factor X and thrombin formation

a.        bleeding, from mild to severe.  Can be seen all over body; includes bruising, bladder, bowel,uterus, etc

b.       Other reaction rare, but can be

                                                               i.      N/V, ab cramps, diarrhea

                                                              ii.      alopecia

                                                            iii.      rash, urticaria

                                                            iv.      hepatitis, jaundice

                                                             v.      thrombocytopenia (low platelets)

                                                            vi.      blood dyscrasias (disorders)

                                                          vii.      local irritations when subcut

                                                         viii.      hypersensitivities including fever and chills, asthma like rxns and anaphylaxis

a.        active bleeding (except when caused by DIC)

b.       hemorrhagic disease

c.        TB

d.       leukemia

e.        uncontrolled HTN

f.         GI ulcers

g.       recent eye or CNS surgery

h.       aneurysm

i.         severe renal/hepatic disease

j.         lactation

k.        pregnancy – can cause fetal death (orals are cat X and parenterals are C), child bearing women must use contraception

l.         LMWHs in pts w/ hypersensitivity to pork products

a.        fever

b.       HF

c.        diarrhea

d.       diabetes

e.        malignancy

f.         HTN

g.       renal/hepatic disease

h.       psychoses

i.         depression

j.         spinal procedures

k.        all pts with a potential site for bleeding or hemmorhage

a.        aspirin, APAP, NSAIDS – increased risk for bleeding

b.       chloral hydrate for sedation – increased risk for bleeding

c.        beta blockers – increases risk for bleeding

d.       loop diuretics – increased risk for bleeding

e.        disulfiram for GI distress – increased risk for bleeding

f.         cimetidine – increased risk for bleeding

g.       oral contraceptives, decreased effectiveness of anticoag

h.       barbiturates – decreased effectiveness of anticoag

i.         diuretics – decreased effectiveness of anticoagulant

j.         vitamin K – decreased effectiveness of anticoagulant

Mostly fibrin and RBCs

Anticoagulants used more for venous system thombi prevention

Mostly platelet aggregates

Antiplatelet drugs used for aterial thrombi

• abciximab
• anagrelide
• cilostazol
• clopidegrel
• dipyridamole
• eptifibatide
• ticlopidine
• tirofiban

ANTIPLATELET DRUGS

Prevent platelet aggregation, which more often is cause of arterial thombi

Arterial thrombi are mostly platelet aggregation

Are treated with antiplatelet drugs

Can be caused from arrythmias like a-fib

Venous thrombi are mostly fibrin and RBCs

Treated with anticoagulants

Usually from lower extremity venous stasis and DVT

a.        decrease platelets ability to aggregate in blood.

b.       aspririn prohibits affregation for life of the platelet

c.        ADP blockers alter platelet cell membrane

d.       Glycoprotein receptor blockers prevent enzyme production

           I.    

a.        heart palpitations

b.       bleeding

c.        dizziness and headache

d.       Nausea Diarrhea Constipation dyspepsia

a.        pregnancy/lactation

b.       HF

c.        active bleeding

d.       thrombotic thrombocytopenic purpura (TTP)

e.        Have not been well studied in human pregnancy (so contraindicated?) but are categories B and C

f.         Discontinue antiplatelyets drugs 1 week before any surgery

a.        Elderly

b.       pancytopenic pts

c.        renal/hepatic impairment

a.        aspirin & NSAIDS à bleeding

b.       macrolide antibiotics à increases effectiveness of antibiotic

c.        digoxin à decreases serum digoxin

d.       phenytoin for seizures à increases phenytoin levels

a.        break up fibrin clots by converting plasminogen to plasmin, which is an enzyme that break down fibrin in a blood clot.  They also break up functional clots that are repairing vessel leaks, therefore bleeding is a great concern when using these agents.  For all, benefits must outweigh risk of bleeding.

a.        Acute MI by lysis of blood clots

b.       Blood clots causing pulmonary emboli and DVT

c.        Suspected occlusions in central venous catheters

a.        Bleeding, internal, GI, genitourinary tract, brain; external also

b.       Allergic reaction

a.        active bleeding

b.       Hx stroke, aneurysm and recent intracranial surgery

a.        pts recent major surgery (w/in 10 days)

b.       pts, w/in 10 days, have had stroke, trauma, childbirth, GI bleeding, trauma

c.        hypertension,diabetic retinopathy

d.       any condition where bleeding is possible

e.        pts receiving oral anticoagulants

f.         All are preg cat C, except from urokinase which is B

a.        Increased risk from bleeding à any other drug that prevents clotting like aspirin, dipyridamole or anticoagulant

                                                               i.      For anticoag or thrombolytic, Hx of all drugs taken previous 2-3 weeks; notify PCP of drugs taken

1.        PT (prothrombin time) and INR (international normalized ratio) is normally determined before therapy

2.        Warfarin not given unless PT/INR baseline taken, so dosaging can be individualized

                                                              ii.      Before giving heparin, get vitals and before first dose aPTT is taken for baseline

1.        Most common test to monitor heparin is aPTT (activated partial thromboplastin time)

                                                            iii.      If pt has DVT, examine extremity for color and temp, check for pedal pulse, note rate and strength.  Recored difference bt affected and unaffected extremities.

1.        Note redness and ask to describe symptoms

2.        Affected extremity may be edemous and have a positive Homan’s sign – sign of DVT

3.        Homan’s sign is when there is pain in calf when foot is dorsiflexed

                                                            iv.      For thrombolytics complete blood count (CBC) usually drawn before given

1.        Thronbolytics are usually given in an ICU bc need close monitoring for 48 hours or more afterwards

                                                             v.      If there is pain bc of the clot, do thorough pain assessment

                                                               i.       Pt requires close observation and monitoring.  Assess for signs of bleeding

1.        Assess gums, nose, stools, urine, NG tube

2.        Assess LOC routinely to monitor for intracranial bleeding

                                                              ii.      Pt taking Warfarin for first time often req daily dose adjustment based on daily PT/INR results

1.        withhold drug and notify if PT exceeds 1.2 to 1.5 times control value of the INR ratio exceeds 3.

2.        A daily PT/INR is taken until stable and when any other drug is added to regimen

3.        After stabilized, is monitored q 4-6 weeks

                                                            iii.      Heparin dosage adjusted according to daily aPTT monitoring.  Therepeutic dose is 1.5-2.5 times the normal

1.        the LMWH has little to no effect on aPTT

2.        Periodic platelet counts, hematocrit and test for occult blood in stool should be performed throughout course of therapy

3.        NURSING ALERT – for pts receiving heparin IV get periodic blood coagulation tests (q 4 hours usually); performend less frequently for long-tern therapy.

4.        For heparin, nurse observes for signs of thrombus q 2-4 hours

5.        Signs and symptoms of thrombus formation vary, evaluate and report any complaints or any changes in condition to PCP.

                                                            iv.      Monitor for signs of hypersensitivity reactions

1.        report chills, fever, hives to PCP

                                                             v.      Examine skin temp and cole with DVT for signs of improvement

                                                            vi.      Take vitals q 4 hrs or more if needed

                                                               i.       

1.        check prothrombin flow sheet/labs of current PT/INR status, notify PCP before admin if results out of parameters

2.        Dose may be loaded (higher dose initially to get to therapeutic level) for 2-4 days

3.        PT/INR is monitored daily as dose is decreased to maintainence level

4.        If not loaded, takes 3-5 days to reach therapeutic dose

5.        warfarin maybe not used if needs quick anticoagulation, but may be followed after rapid anticoag with heparin

6.        doses of warfarin determined by PT/INR

7.        oral warfarin usually given evening, why?

8.        NURSING ALERT – optimal dose is when PT is 1.2 to 1.5 times controls.  Sometime PT 1.5-2 may be prescribed

9.        NURSING ALERT – diet affects warfarin – with increased vit K, INR more stable; important for patients to have daily vit K to stabilize warfarin

2.        Heparin - Onset of anticoag immediate, max effects w/in 10 mins and clottin time returns to normal 4 hours

4.        Avoid IM heparin b/c loal irritation, pain, hematoma

5.        Dosage of heparin is Units/mL

6.        NURSING ALERT – errors are made by misreading doage units on heparin.  Be very careful

7.        Continuous IV infusion (vs intermittent IV admin) requires infusion pump, check q 1-2 hours to ensure working right

8.        Inspect needle site for inflame, pain, tenderness along pathway of vein – if occurs, dc infusion and restart on another vein

9.        When subcut, rotate sites.  Recommended are abdomen, but avoid near umbilicus, 2 inches around bc increased vascularity

10.     Other sites can be buttocks, lateral thigh, upper arms (fatty parts)

11.     For DVT prevention injections, do not dispel air bubble; pinch skin, inject 90 angle so bubble goes in last

13.     Inspect subcut sites for inflamm and hematomas

14.     Blood coag tests orderd before/during therapy to adjust heparin doses; coag tests usually 30 min before heparin infusion and extremity opposite infusion site

15.     When subcut heparin, an aPTT test q 4-6 hours after injection; optimal is 1.5-2.5 X control

16.     LMWHs do not require close monitoring with coag tests

17.     Periodic CBC, platelet count, stool analysis for occult blood may be ordered

18.     Thrombocytopenia may occur with heparin or antiplatelet admin;

19.     With heparin, mild and transient thrombocytopenia may occur 2-3 days after beginning heparin, tends to resolve

20.     Nurse immediately reports platelets less than 100,000mm³ bc may be dc.

21.     Overdosage of antiplatelet drugs dealt with withholding or infusing platelets

22.     NURSING ALERT – withhold and contact immed if:

a.        PT exceed 1.5 X control

b.       Evidence of bleeding

c.        INR greater thatn 3

1.        Use ASAP once determine thrombus; greatest benefit is within 4 hours of thrombus formation, though good effedt within 24 hours.

2.        Are powder form and must be reconstituted

3.        Assess for bleeding q 15 minutes during first hour, q 15-30 for next hours, and at least q 4 hours until completed.

4.        Vitals at least q 4 hours

5.        If pain, may get opioids

6.        Once clot dissolves, severe pain usually goes away

M/M

Risk for Injury rt excessive bleeding due to admin of anticoag, thrombolytic or antiplatelet

1.        bleeding can occur even when INR within safe limits

2.        All med staff must know of pt on anticoags and know what to look for

3.        Protamine sulfate (for od anticoag?)

4.        Signs of bleeding

a.        drop BP, rise pulse, notify PCP

b.       bruising, slight bleeding can signify potential worse bleeding

c.        ab pain, coffee ground emesis, black tarry stools,

d.       hematuria,

e.        joint pain

f.         coughing up blood

g.       sometimes just no warning

5.        inspect urinal, bedpan, cath dain for pink-red and stool bright red-black

6.        Check cath bag q 2-4 hours and when emptied

7.        Oral anticoags may tinge urine reddish orange, making difficult to assess hematuris, so may need urinalysis

8.        Check emesis basin when empties, ng suction units q 2-4  hrs and when emptied

9.        skin, mucouse membranes inspectd daily for bruising/bleeding. Nosebleeds. Injection sites. Oral care after brushing check toothbrush and gums

10.     NURSING ALERT – pts on antcoags and having a spinal puncture at risk spinal/epidural hematoma formation which can cause paralysis. Frequently monitor neuro status

11.     NURSING ALERT – sometimes anticoag given with thrombolytic, extra risk of bleeing, pt requires extra monitoring

12.     Contact PCP immediately if internal or uncontrolled bleeding bc may need blood transfusion, etc

13.     Montor vitals q hour or more 48 hrs after discontinue thrombolytic

14.     Contact PCP if marked change in vitals, or signs of hypersensitivity reactions to thrombolytics (asthma like, hives, rash, hypotension) immediately

M/M

Individual Effective Therapeutic Regimen Management rt inability to communicate drug use if incapacitated when admin anticoag, thrombolytic, antiplatelet drug

In other words, if the patient become incapacitated, how will it be known that he or she is taking on of these drugs, and how should the nurse help with this problem?

1.        Many food and drug interactions must be described

2.        Must have way to alert others in emergency of anticoag therapy (bracelet, etc)

3.        Pt must notify all health care providers performing treatments or tests

4.        Pt undertand why pressure after needle pokes

5.        Lab persons who draw blood must know, must use prolonged pressure

M/M      

                                                              ii.      Anxiety rt fear of atypical bleeding during thrombolytic drug therapy

1.        Conditions requiring thrombolytics are urgent and usually in ICU or operating room

2.        Chance for bleeding

3.        Frightening and anxiety provoking

4.        Reassure pt and family that measure are taken to dx and tx bleeding early as possible

5.        Assure that bleeding will be reported ASAP and pressure for at least 30 mins should stop it (or pressure dressing)

a.        Signs are

                                                                                                                                       i.      melena (blood in stool)

                                                                                                                                      ii.      petachiae

                                                                                                                                    iii.      oozing from superficial injuries (shaving cuts, etc)

                                                                                                                                    iv.      excess menstrual bleeding

b.       Report to PCP immediately

c.        Also if PT above 1.5 X control, or INR over 3, PCP may dc for a few days or order vit K (phytonadione)

d.       Phytonadione (K) is oral anticoag (warfarin) antagonist should be readily available when pt on warfarin

e.        Withholding warfarin one or two doses may quicky resolve

f.         Assess for further bleeding sites until PT below 1.5 X control or until no more bleeding

g.       PT usually goes to safe levels within 6 hours of vit k admin

h.       May req blood transfusion if severe bc vit K has delayed onset

a.        usually dc of drug sufficient bc heparin duration of action short

b.       If severe, may order PROTAMIN, specific heparin antagonist/antidote, also antagonist for LMWHs

c.        Protamine immediate onset and lasts 2 hours

d.       Protamine given slowly IV 10 min; monitor BP and pulse q 15-30 mins for 2 hours (or more)

e.        Immediately report sudden decrase in BP or increase in pulse, observe for more bleeding until labs okay

f.         May order transfusion if excessive blood loss

                                                               i.      clinical pharmacies often responsible for teaching

                                                              ii.      Important to educate pt on early warning signs of bleeding, may help pt cooperate with therapy also

                                                            iii.      Report active bleeding emmediately

                                                            iv.      INR will be periodically monitored, keep apts bc dosaged may need change

                                                             v.      Do not take OTCs without approval

                                                            vi.      Inform dentist or other doctors before treatment or other drugs

                                                          vii.      Take at same time each day

                                                         viii.      Do not change brands without consult

                                                             ix.      Avoid alcohol unless oked

                                                              x.      Inlude food with K to help maintain INR value

1.        green vegetable

2.        beans

3.        broccoli

4.        cabbage

5.        cauliflower

6.        cheese

7.        fish

8.        yogurt

                                                             xi.      Antiplately drugs can lower all blood counts, including WBC and may be at greater risk for infection during first 3 months of treatment

                                                           xii.      If evidence of bleeding, omit dose and contact PCP immediately

                                                          xiii.      Anisindione may cause red-orange urine if alkaline

                                                         xiv.      Use soft toothbrush, electric razor

                                                           xv.      Child brearing wome use contraception to avoid pregnancy

                                                         xvi.      Have medical ID like MedicAlert bracelet to inform other med profs, etc

Warfarin is usually oral

Heparin must be parenteral (subcut, IV)