COAGULATION MODIFIER

DRUGS
Lilley Reading and Workbook, Chap 27
COAGULATION MODIFIER 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

 Clotformation (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

 & low-molecular-weight heparins enoxaparin (Lovenox)

 Turn off coagulation pathway and prevent clot formation
 Warfarin (Coumadin)

All ultimately prevent clot formation

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

 Stroke
 Atrial fibrillation
 Myocardial infarction (MI) / Unstable Angina
 Deep vein thrombosis (DVT)
 Pulmonary embolism (PE)
 Indwelling devices, such as mechanical heart valves
 Major orthopedic surgery
ANTICOAGULANTS:
ADVERSE EFFECTS

 Bleeding
 Riskincreases 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)
 Goal: Therapeutic range based on body weight based dosage
 aPTT between 1.5 – 2.5 times normal control level

 Parenteral – IV bolus followed by infusion

 Never mixed with any other medication
 Short half-life (1 to 2 hours)
 Effects reversed by protamine sulfate
 Obtained from sheep, cows, and pigs
 HEPARIN: NURSING IMPLICATIONS
 Anticoagulant effects seen immediately

 Laboratory values are done daily to monitor coagulation effects (aPTT)

 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

 Bleeding precautions
ANTICOAGULANTS

 Low-molecular-weight heparins

 enoxaparin (Lovenox)
 dalteparin (Fragmin)

 More predictable anticoagulant response

 Do not require frequent laboratory monitoring
 Given subcutaneously – rotate sites
 Patient may be instructed for home administration
 Bleeding precautions
 Protamine sulfate can be given as an antidote in case of excessive
anticoagulation
 ANTICOAGULANTS

 warfarin sodium (Coumadin)

 Given orally only – usually late afternoon – same time daily

 Monitored by INR (INR) - 2-4 depending on diagnosis

 (Prothrombin time – lab-specific -- 1 ½ - 2 ½ times the control 12-15 sec)
 Dose changed according to INR results

 phytonadione (Vitamin K) can be given if toxicity occurs

 WARFARIN - 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
 Usually started 2-3 days prior to heparin infusion being
discontinued - until PT-INR levels indicate adequate anticoagulation
 Full therapeutic effect takes several days
 Monitor PT-INR regularly—keep follow-up appointments
 Antidote is phytonadione (Vitamin K)
WARFARIN -- NURSING IMPLICATIONS
 Many herbal products have potential interactions—
increased bleeding may occur

 Capsicum pepper
 Garlic
 Ginger
 Gingko
 Ginseng
 Feverfew
ANTIPLATELET DRUGS

Indications

 Antithrombotic effects
 Reduce risk of fatal and nonfatal strokes

 Adverse effects
 Vary according to drug
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:
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
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

 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
 Surgicalcomplications
 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
 Tissueplasminogen activator (TPA)
 Anisoylated plasminogen-streptokinase activator complex
(APSAC)
THROMBOLYTIC DRUGS (CONT’D)

 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 – Code Green

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
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)
ANTICOAGULANTS:
PATIENT EDUCATION
Education should include:

 Importance of regular lab testing

 Signs of abnormal bleeding

 Measures to prevent bruising, bleeding, or tissue injury

 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
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

 Monitor for adverse effects

 Increased BP, headache, hematoma formation, hemorrhage,
shortness of breath, chills, fever
 REVIEW
Antiplatelet agents act by:

1. preventing extension of existing clots.

2. preventing platelets from uniting.
3. dissolving existing clots.
4. increasing blood viscosity.
 REVIEW
Doses of heparin are based on what laboratory
report?

1. warfarin serum level

2. activated partial thromboplastin time
(APTT)
3. Lee White clotting time
4. prothrombin time (PT) and INR
 REVIEW
Nursing responsibilities involved in the
administration of heparin subcutaneously
include:

1. checking calculations with a second

qualified nurse.
2. using a 20-gauge needle to inject the
drug.
3. injecting the drug deep intramuscularly
(IM).
4. aspirating before injecting the drug.
 REVIEW
Clopidogrel (Plavix) is used to:

1. dissolve existing arterial blood clots.

2. prevent further movement of an embolus.
3. prevent platelet aggregation.
4. prevent extension of an existing
thrombus.