DRUGS AFFECTING COAGULATION OBJECTIVES 1.

Define the following terms: • Anticoagulant – substances that keep blood from clotting; prevent blood blots from forming or extending; don’t break down existing clots; given IV, SC, or PO • Clot – thrombus; results from excessive coagulation (hypercoagulation) • Clotting cascade – series of steps initiated by tissue damage and platelet activation, which mobilize clotting factors that are circulating in the blood. Active clotting factors work with Ca++ to form fibrin, which signals completion of blood coagulation and end of blood loss. End result is formation of a stable blood clot. Occurs over 2 pathways: (one or both may be activated in response to injury) o Intrinsic – clotting factors in blood activated by damage to blood vessel o Extrinsic – clotting factors activated by damaged tissue • Clotting factor – plasma protein that causes blood clotting; inactive in blood until mobilized by injury • Coagulation – blood aggregation, clotting • Embolus (embolism) – any undissolved matter carried in a blood or lymph vessel to another location where it lodges and occludes the vessel • Fibrin – an insoluble protein that stabilizes the temporary plug formed by platelets to seal the injured vessel • Fibrinolysis – process of breaking down a formed clot • Hemophilia – uncontrollable bleeding due to genetic deficiencies of normal clotting factors • Hemostasis – series of events to slow blood flow, stop blood loss at injury site, and prevent extensive blood loss when the body begins bleeding • INR (Interational Normalized Ratio) – standardized unit developed to measure therapeutic levels of warfarin; determined by math equation and reflects pt’s PT compared w/ standardized PT value • (Activated) Partial thromboplastin time (aPTT) • Plasmin – activated plasmin lyses the blood clot about 1-2 days after bleeding stops • Platelets (thrombocytes) – fragmented cells that assist in blood clotting and clot formation • Prothrombin time (PT) • Thrombin – converts fibringogen (factor I) to fibrin, and also activated factor XIII (a fibrin-stabilizing factor); thrombin is converted from prothrombin (factor II)

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a large amount of fibrin.5-2X control (ie. and nursing management of the prototype anticoagulants. like surgery) – give anticoagulation therapy for 3 months 2 . but bolus is given initially.• • • Thromboembolism – fragment of a thrombus that breaks off. CPVs.parenteral • Prevents conversion of prothrombin  thrombin • Affects fibrin. pharmacokinetics. control = 12 sec. ANTICOAGULANTS HEPARIN . adverse effects. and few platelets Vitamin K – fat-soluble vitamin that is continually produced in GI tract. heparin and warfarin. prevents formation of stable clot • Low dose therapy is prophylactic • aPTT: o 1:1 is normal clotting time o No standardized number  look at effect and see if clotting time is longer o Therapeutic aPTT = 1. then therapeutic aPTT = 18-24 sec) o If aPTT is > 2X control   risk for adverse effects (ie. arterial thrombi consist of mostly platelet aggregated held together with thin fibrin strands. and venous thrombi consist of mostly RBCs. Describe the pharmacotherapeutics. travels through bloodstream and lodges in a vessel to occlude blood flow Thrombus – blood clot. followed by continuous infusion • Low risk for recurrent thrombosis (ie. absorption depends on amount of fat and bile o deficiency of vitamin K   normal clotting factors made   bleeding risk in pts on warfarin o infants more susceptible b/c intestinal flora inactive at birth o high levels decrease warfarin effectiveness 2. risk factor reversible. bleeding) Pharmacotherapeutics • Prevent extension of blood clot for DVT and pulmonary embolisms • SHORT-TERM prophyaxis post-operatively • NOT recommended as adjunct for ischemic strokes • Continuous IV infusion needed to achieve full anticoagulation. pharmacodynamics.

if aPTT control time = 30 sec. let platelet count get back to normal. so need to know half-life to determine steady state. active bleeding other than DIC • Allergies to beef or pork • Pre-existing prolonged bleeding time • High activity level and susceptibility to injury • Safe for pregnant women Adverse Effects • Bleeding • Heparin-induced thrombocytopenia (HIT) – life-threatening! D/C heparin. only used when pt is symptomatic and bleeding out. ie. and anaphylaxis. D/C infusion and wait for clotting time to decrease) Nursing Management • Monitor aPTT to confirm therapeutic lengthening of clotting time. dyspnea.5-2X control aPTT (ie. no apparent risk factors or persistent risk factors like cancer) – give anticoagulation therapy for 6 months to indefinitely Pharmacokinetics • Administered IV or SC • Onset of action: IV – immediate. bradycardia.High risk for recurrent thrombosis (ie. bleeding disorders. otherwise. and treat thrombosis with LEPIRUDIN (Refludan) and ARGATROBAN (Argatroban) • OD  GIVE ANTIDOTE = PROTAMINE SULFATE (don’t give protamine sulfate too fast b/c can cause hypotension. important for when you take aPTT) • Destroyed by gastric acid – not absorbed from GI tract Pharmacodynamics • Rapidly promotes inactivation of factor X (factor X blocks prothrombin  thrombin) • Limits formation of stable clot by affecting fibrin • Prolongs clotting time w/o affecting bleeding time • No effect on already formed blood clots Contraindications/CPVs • Thrombocytopenia. SC – 20-60 min • Half-life = 1-2 hrs (full therapeutic effect occurs at steady state. 1. therapeutic level = 45-60 sec) • 3 .

or INR = 2-3) • Prophylaxis for LONG-TERM risk of thrombus formation (mitral vale replacement.4-1.51.• • • • • • • • • Measure aPTT 6-8 hrs (ie. hematocrit.7X control.4-1. stool. platelet count before starting therapy Use IV pump Don’t administer other drugs in heparin line! Give protamine sulfate if active bleeding occurs WARFARIN (Coumadin) – oral • PT measured against a control. vagina.5-1. 4-5 half-lives) AFTER infusion to ensure steady state reached Check aPTT each time dose is changed Notify MD/NP if aPTT too low/high Don’t disrupt infusion.5 • Prophylaxis for pts w/ Atrial fibrillation (at high risk for cardioembolic stroke) Pharmacokinetics • Binds to albumin in plasma • Peak action occurs in 1-9 hrs • Therapeutic (anticoag) effects occur in 24 hrs • Steady state/max effect occurs 3-4 days after dosing beings Pharmacodynamics • Competitively blocks vitamin K.6X control. hypercoagubility) – PT = 1.5 Pharmacotherapeutics • Given after heparin therapy to finish tx for DVP or PE (thrombus/embolism – PT = 1. prevents activation of prothrombin and other factors (doesn’t affect already activated factors – need 3-4 days to achieve steady state and max effect) 4 . Insert new lines asap b/c will lose therapeutic effect Monitor for signs of bleeding – gums. urine.5-3. nose. IV sites Check aPTT.7X control INR 2-3 2.5-3.6X control 1. or INR = 2. reading will vary Thrombus/embolus Mechanical Heart Valve PT (sec) 1.

vomiting. Apply the principles of drug therapy for coagulation problems to their effects on the clotting cascade. abdominal cramps • Fetal warfarin syndrome Nursing Management • DON’T drastically increase dietary vitamin K intake   therapeutic effect • NO ASPIRIN or ACETAMINOPHEN & NO EXTRA • Give initial loading dose to reach therapeutic range faster. cranial. bleeding disorders (hemophilia. open wounds. thrombocytopenia) • Patients undergoing surgery where hemorrhage is possible (spinal. diarrhea. > therapeutic effect of warfarin) • Low pre-op Hgb   response to warfarin Contraindications/CPVs • Active bleeding. arterial bypass grafting) – usually D/C 7 days before surgery • Vitamin K deficiency (increases bleeding/hemorrhage risk and decreases synthesis of normal clotting factors) caused by: o poor dietary intake o obstructed bile duct o long-term antibiotic therapy which affects normal GI flora (decreased vitamin K synthesis) • Newborns – deficient in vitamin K b/c intestinal flora inactive at birth • **NOT for Pregnant women   fetal warfarin syndrome defects • Older adults – more sensitive to effects of warfarin • Diet high in vitamin K – decreases effectiveness of warfarin • Interacts w/ a lot of drugs Adverse Effects • Bleeding • Hemorrhage • Nausea. GI. eye. 5 .• Metabolized through P-450 pathway (if pt metabolizes poorly. GI tract ulcerations. follow with maintenance dose • Give dose at 6:00 PM to allow for early morning blood draws for PT or INR • OD  GIVE ANTIDOTE = VITAMIN K 3.

5-1.5-2X control aPTT) -blood draws for PT and INR -hematocrit -platelet count Tx/Prophylaxis of thrombus or embolus: PT: 1. and/or INR for selected conditions related to thrombus and embolus formation.4. and antidotes associated with these two prototype drugs. CPVs. ANTICOAGULANT ENOXAPARIN (Lovenox) • Low MW heparin • Limited effect on thrombin • Less interaction w/ platelets 6 . pharmacokinetics. Compare and contrast the pharmacotherapeutics. with the prototype anticoagulants heparin and warfarin.5-3. pharmacodynamics. lab tests.5-3. adverse effects.4-1.5 6.5-1.5 Antidotes Protamine sulfate Vitamin K 5. State the expected aPTT.7X control time INR: 2. heart valves: PT: 1.6X control 1. Explain and differentiate the onset of action.7X control INR 2-3 2.6X control time INR: 2-3 Prophylaxis for mech.4-1. WARFARIN Thrombus/embolus Mechanical Heart Valve PT (sec) 1. HEPARIN WARFARIN Onset of action IV: immediate 24 hrs SC: 20-60 sec Lab Tests -aPTT (1. PT. and nursing management of the anticoagulant enoxaparin.

and emergency revascularization in pts w/ Q-wave MI • Longer half-life. but less than heparin CPVs (same as heparin) • Thrombocytopenia. remove loose scatter rugs. obtain adequate lighting. only administer SC 1X/day  good for long-term therapy • A good F/U for initial heparin therapy Pharmacokinetics • Most absorbed after SC • Widely distributed Pharmacodynamics • Affects activated factor X (decreases aPTT) • Affects clotting factor C and antithrombin • Limited effects on thrombin Adverse Effects • Bleeding. bleeding disorders. use handrails 7 . wear nonskid footwear. active bleeding other than DIC • Allergies to beef or pork • Pre-existing prolonged bleeding time • High activity level and susceptibility to injury • Safe for pregnant women Nursing Management • Teach patients how to self-administer • Take drug on time • Follow regular dosage schedule • Get follow-up blood analyses done as recommended • Safety – clear pathways. MI.• Very predictable dose response • Don’t need to constantly monitor aPTT Pharmacotherapeutics • Reduce death.

HTN. family hx) • Prophylaxis against thromboembolic complications in CV disease (MI and TIA = transient ischemic attack) • Atrial fibrillation to prevent stroke (noncardioembolic) Pharmacodynamics • Irreversibly inhibits platelet COX and synthesis of thromboxane A (vasoconstrictor that facilitates platelet aggregation) for the life of the platelet Adverse Effects • Bleeding • GI ulceration and bleeding • Hemorrhagic stroke • neutropenia Contraindications/CPVs • Peptic ulcer disease.7. men > 40 y/o. and nursing management of aspirin when used for antiplatelet effects. CPVs. pharmacodynamics. CPVs. other mediators of inflammation) • Anti-thrombotic effects (inhibits prostaglandin responsible for platelet aggregation) Pharmacotherapeutics • Prevents MI & stroke (Give w/i 24-48 hrs of onset) • Adjunct in revascularization procedures • Decrease incidence of coronary heart disease in those w/ increased risk (ie. 8. adverse effects. seizures) 8 . smoking. adverse effects. obesity. pts on anticoagulant therapy • Gout • Renal/liver impairment or disease • Children < 16 y/o w/ varicella or flu-like illness  Reye syndrome (swelling in brain. bleeding disorders. pharmacodynamics. Describe the pharmacotherapeutics. DM. ANTIPLATELETS ASPIRIN • Anti-inflammatory effects (peripheral inhibition of prostaglandin synthesis. postmenopausal women. and nursing management of clopidogrel and aspirin. Compare and contrast the pharmacotherapeutics. hyperlipidemia.  intracranial pressure.

peripheral artery disease (PAD) • Manage acute coronary syndrome (post-MI w/ elevated QT) • Prevent thrombosis post coronary stent • Reduce platelet adhersion/aggregation Pharmacodynamics • Irreversibly modifies platelet ADP receptor  inhibits binding of ADP to platelet receptor  inhibits platelet aggregation  prolongs bleeding time Adverse Effects • Bleeding • GI distress: abdominal pain. smoking. nausea (but not ulcers or GI bleeding like w/ aspirin) • neutropenia Contraindications/CPVs • peptic ulcers or intracranial hemorrhage • platelet function • liver function 9 . vascular death. diarrhea. indigestion. stroke. alcohol Give with milk or food to relieve GI distress Get CBC. platelet count. liver/renal function tests for pts on long-term therapy Nursing Management • • • • • • CLOPIDOGREL (Plavix) Pharmacotherapeutics • Prevent atherosclerotic events in patients who have had/are at risk for MI.• • Pregnant and lactating women (pregnancy category D) asthma NEVER give to pregnant women in 3rd trimester b/c high risk of maternal hemorrhage and adverse fetal effects NEVER give to children < 16 y/o w/ flu-like symptoms (Reye syndrome) Caution for pts > 60 y/o Ask about OTCs.

pharmacodynamics. must initiate w/i 3 hrs of onset of stroke and after IC bleeding has been ruled out by CT scan) • Massive pulmonary embolism 10 . pregnancy and lactation Nursing Management • Take with food to relieve GI distress • Check WBCs if signs of infection • D/C 7 days before surgery to prevent excessive bleeding • Apply pressure on wounds until bleeding stops • Avoid behaviors that may lead to injury • Make home environment more “fall proof” 9. CPVs. pharmacokinetics. Describe the pharmacotherapeutics. THROMBOLYTICS ALTEPLASE RECOMBINANT • Drug of choice for CVA • Fewer systemic effects • Tissue plasminogen activator (tPA) • Converts plasminogen to plasmin when fibrin is present. pharmacodynamics. adverse effects. CPVs.• • • CV status Neuron status Children < 18 y/o. Describe the pharmacotherapeutics. must have fibrin to work) Pharmacotherapeutics • Acute evolving MI from acute coronary artery thrombus (initiate at onset of symptoms) • Acute ischemic stroke (ONLY drug to treat this. and nursing management of streptokinase. and nursing management of thrombolytics (prototype: alteplase recombinant). 10. attaches directly to fibrin in clot (ie. adverse effects.

Co-antiplatelet therapy (aspirin) • Current pregnancy or delivery of child w/i last 10 days • Older adults – more susceptible to IC bleeding Nursing Management • IV pump • NO invasive procedures • Monitor for: o signs of bleeding o VS changes (fever. platelet count. PT.Pharmacokinetics • IV for immediate effect • Rapid clearance – 80% cleared w/i 10 min after infusion has completed Pharmacodynamics • Binds to fibrin in a clot and converts trapped plasminogen to plasmin  fibrinolysis (break down of clot) Adverse Effects • Bleeding (but less than streptokinase) Contraindications/CPVs • Active internal bleeding. arrhythmias. Hgb level. suspicion of subarachnoid hemorrhage • Recent (w/i last 2 months) stroke • IC surgery or sever head trauma • Intraspinal surgery or trauma • IC neoplasm • Seizure at onset of stroke • Arteriovenous malformation or aneurysm • Severe uncontrolled HTN (systolic BP ≥ 180 or diastolic BP ≥ 110) • Co-Anticoagulant therapy (heparin). hypotension) o blood work abnormalities o respiratory problems (bronchospasm) • Lab values: hematocrit. evidence of IC bleeding on pre-tx evaluation. aPTT • Reconstitute in sterile water 11 .

fibrinogen. and other clot-forming proteins) • fibrin NOT needed for plasminogen activation Adverse Effects • severe bleeding  GIVE ANTIDOTE = AMINOCAPROIC ACID • life-threatening bleeding (b/c it changes fibrin throughout body)  blood transfusion • allergic reactions: fever. or accelerated Cardiac monitor during and after tx (when MI) Check RR. dyspnea.• • • • • Don’t shake or agitate too much Infuse over 90 min (recommended) or over 3-hrs. extensive DVT • arterial thrombosis • opens occluded arteriovenous catheters (w/ lower doses) How it works: • activates plasminogen and acts w/ plasminogen to convert plasminogen to plasmin (dissolves fibrin. chills (in 30% of pts) • hypotension CPVs 12 . ABGs (when pulmonary embolism) Check BP closely (when acute ischemic stroke) STREPTOKINASE • BREAKS DOWN formed blood clots Indications • Treat acute evolving MI • Treat acute evolving thrombotic CVA • pulmonary embolism • acute. pulse ox.

life support) 13. Life-threatening Adverse Effect ANTICOAGULANTS Heparin Warfarin ANTI-PLATELETS Aspirin Clopidogrel THROMBOLYTICS Alteplase Recombinant Streptokinase Heparin-induced thrombocytopenia (HIT) Fetal warfarin syndrome Salicylate Poisoning Neutropenia or bleeding? Bleeding Severe bleeding Don’t give to pregnant women or to women that have delivered w/i past 10 days. 13 . treat any thrombosis. arrhythmias. 12. give activated charcoal. blood transfusion Prevent/Minimize/Tx D/C heparin. minimize. Caution w/ older adults b/c more likely to have IC bleeding. wait for platelet count to get back to normal. Prepare teaching plans for patients receiving specific anti-coagulant therapy at home. anti-platelet agents. Administer lepirudin (Refludan) and argatroban (Argatroban) Don’t give to pregnant women No antidote (gastric emptying. and treat these life-threatening effects.Nursing Management • IV pump • NO invasive procedures • Monitor for: o signs of bleeding o VS changes (fever. and thrombolytics. List measures to prevent. List the life-threatening adverse effects of each of the anti-coagulants. hypotension) o blood work abnormalities o respiratory problems (bronchospasm) 11.

Apply nursing management principles to case studies of patients receiving home coagulation therapy.14. 14 .