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acute and chronic disorders that require anticoagulation therapy

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MI, unstable angina, A-Fib, Indwelling devises such as indwelling heart valves, conditions in which blood flow may be slowed and blood may pool, such as major orthopedic surgery; also used in prevention of DVT

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common disorders where anticoagulant therapy is contraindicated

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Leukemia, pregnancy, gastrointestinal infection (colitis), recent surgery or other invasive medical procedures; also know drug allergies and acute bleeding risks as well as thrombocytopenia

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major action and use of heparin

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Works by binding to anti-thrombin III (AT-III) which turns off three main activating factors: Activated II (thrombin), activated X, and activated IX -Mainly work to prevent the formation of a clot or thrombus

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routes of administration for heparin and list appropriate nursing measures for each

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IV and SQ ONLY!! Requires careful monitoring of PT/INR; Nurses also want to assess for adverse effects, such as bleeding. Nurses want to be mindful of drug interactions and other common adverse effects such as hematoma, nausea, anemia, thrombocytopenia, fever and edema

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laboratory test that determines Heparin's effect

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PT/INR

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adverse effects of Heparin and list appropriate nursing action for each

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-Bleeding, a hematoma at site of injection, nausea, anemia, fever, edema; Heparin induced thrombocytopenia (HIT), which is an allergic reaction mediated by the production of IgG antibodies -Because of Heparins short half life (1 to 2 hours) stopping the treatment can alleviate these symptoms -Toxicity and Over Dosing: Hematoma, melena (blood in stool) and gum or mucus membrane bleeding. Stopping treatment can completely reverse symptoms in 5 minutes. Must have order for Protamine Sulfate

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Protamine Sulfate

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the antagonist used to manage heparin toxicity

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benefits of using low molecular weight heparin eg. Enoxaparin (Lovenox).

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Lab monitoring isn't necessary because of its high bioavailability and greater affinity for factor Xa. It is available only in injection form.

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Compare the action of Coumadin to Heparin in relation to the clotting process

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-Heparins: Inhibit thrombin clotting factors. -Coumadin: Inhibits vitamin K dependent clotting factors (available in PO form only).

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Compare the onset and duration of action of parenteral and oral anticoagulants

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Perenteral Anticoagulants - Onset Immediate (20-60min), Duration: Dose dependent -Oral Anticoagulants - Onset: 12-24 hours, Duration: 2-5 Days

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State the rationale for continuing parenteral anticoagulant therapy three days after starting oral therapy

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Peak time for oral anticoagulant therapy is 3-4 days. Peak time for perenteral is 4-5hrs. The rational for continuing perenteral therapy is that it will take 3 days for the full effect of the oral therapy to take place.

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lab test for determining the effect of Coumadin on the clotting process.

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PTT

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Vitamin K

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List the antagonist for Coumadin

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pertinent information to teach patients receiving either parenteral or oral anticoagulants

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It is important to take meds at the same time every day. It is important inform them of bleeding precautions and to remember to follow up with doctor to monitor blood levels

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the mechanism of action of the antiplatelet drugs

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Mechanisms of action vary depending on the drug. Many of the antiplatelet drugs affect the cyclooxygenase pathway -Prevents platelet plugs from forming, which can be beneficial in defending the body against heart attacks and strokes

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three indications for the use of antiplatelet drugs

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Aspirin recommended for stroke prevention - Plavix reduces the risk of fatal and nonfatal thrombotic stroke -Plavix also used as prophylaxis against transient ischemic attacks, as well as post - MI thromboprevention

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the side effects, adverse effects and nursing responsibilities associated with the administration of antiplatelet drugs

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Drowsiness, dizziness, confusion, flushing, nausea, vomiting, GI bleeding, diarrhea, heartburn; thrombocytopenia, leukemia, anemia, bleeding, rash and itching --Should be constantly monitored for signs and symptoms of bleeding during and after use: epitaxis, hematuria, hematemesis, excessive bruising, blood in stools and bleeding gums --Aspirin should be taken with food and 6-8oz of water to avoid GI upset --Encourage patients to change positions slowly and to take their time going from lying to sitting to standing due to dizziness and postural hypertension

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the mechanism of action for the thrombolytic agents

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Thrombolytic - used to break up existing thrombus -Thrombolytics are coagulant modifiers that lyse the thrombi in the blood vessels that supply the heart with blood (coronary arteries). This reestablishes blood flow to the blood-starved heart muscle

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Identify three indications for the use of the thrombolytics

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Acute MI, Arterial Thrombosis, DVT, occlusion of shunts or catheters, PE, and acute ischemic stroke.

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side effects, associated with the use of thrombolytics

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Internal, intracranial and superficial bleeding. Also hypersensitivity, nausea, vomiting and hypertension

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overdose with the use of thrombolytics

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No specific antidotes; discontinue use, nurses should monitor vital signs, monitor for bleeding and take bleeding precautions

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Anticoagulants

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Used to keep the blood in the liquid state; chemicals that retard the tendency of the blood to become more viscous by natural post mortem processes or prevent any other adverse reactions from occurring between the blood and the other embalming chemicals.

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Antifribinolytics

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Drugs that prevent the lysis of fibrin and in doing so promote clot formation.

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Antiplatelet drugs

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decrease platelet's ability to stick together in the blood and form a clot, beneficial in preventing heart attacks and strokes.

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Clot

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Insoluble solid elements of the blood that have chemically separated from the liquid componets of the blood.

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Coagulation

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The process of blood clotting

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Coagulation casade

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The term used to describe the series of events that occur in the process of blood clotting

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Intrinsic pathway

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the process of forming a clot that doesn't require any tissue damage. The presence of platelets + Facrot XII + "activators" is enough to start this pathway.

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Extrinsic pathway

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process of hemostasis or blood clotting which is activated when the tissue is injured

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DVT

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Deep venous thrombosis

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Embolus

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a clot that breaks loose and travels through the bloodstream. When it causes sudden closure of a blood vessel, this dangerous event is an embolism.

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Fibrin

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Protein threads that form the basis of a blood clot

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Fibrin specificity

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Newer thrombolytic drugs actative the conversion of plasminogen into plasmin, only in the presence of an established clot having fibrin threads, rather than systemic plasminogen activation thru out the body.

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Hemophilia

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a group of hereditary bleeding disorders in which there is a defect in clotting factors necessary for the coagulation of blood

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Hemorheologic drugs

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Drugs that alter the function of platelets without compromising their blood clotting properties.

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Hemostasis

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the stoppage of bleeding

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Hemostatic

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a drug that stops the flow of blood within the vessels

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Plasmin

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enzyme formed from plasminogen that dissolves blood clots

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Plasminogen

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an inactive form of plasmin that occurs in plasma and is converted to plasmin by organic solvents

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Pulmonary embolism

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blockage of the pulmonary artery by foreign matter or by a blood clot

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Stroke

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a sudden loss of consciousness resulting when the rupture or occlusion of a blood vessel leads to oxygen lack in the brain

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Thromboembolic events

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Events in which a blood vessel is blocked by an embolus carried in the bloodstream from the site of it's formation. The tissue supplied by the blocked artery may tingle, become cold, numb, Cushitic, and eventually necrotic ( dead).

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Thrombolytic drugs

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Dissolve B. Examples of Drugs 1. Alteplase (tissue plasminogen activator recombinant, tPA, Activase) 2. Streptokinase 3. Urokinase C. Indications 1. MI 2. Strokes 3. Pulmonary embolus 4. DVT D. Side effects / nursing care 1. Bleeding 2. Heparin therapy may be started following thrombolytic treatment 3. When given for myocardial infarction should be given within 6 hours of episode. 4. When given for cerebrovascular accident should be given within 3 hours of episode.

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Thrombus

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a blood clot formed within a blood vessel and remaining attached to its place of origin

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Tissue plasminogen activator

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a thrombolytic agent (trade name Activase) that causes fibrinolysis at the site of a blood clot.

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Fibrinogen

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A blood protein essential to blood clotting. The conversion of fibrinogen to its active form (fibrin) is among the final steps in clot formation, and is triggered by thrombin.

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Anticoagulants

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Prevent coagulation. Haparins: requires blood level monitoring LMWH: do not require blood tests, both inhibit thrombin Coumarins (warfarin) inhibit vit k clotting factors. Adverse affects: bleeding

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Antiplatelets

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Interfere with platelet function. Plavix

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Antifibrolytics

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Prevent the lysis of fibrin, promotes clot formation.

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Thrombolytics

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Dissolves of preformed clot. Activase

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Coumarin dosage

answer

Oral drug, 2-10mg day, pt or INR determines maintenance dose.

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Heparin dosage

answer

IV or SC; test w/ PTT (protamine sulfate is antidote); dosage is in UNITS 5000 units SC prophalaxis. IV infusion 20,000-40,000 units/ day.

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Lovenox dosage

answer

SC 30-40 mg every 12 hrs. For prophylaxis

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activated partial thromboplastin time

answer

aPPT blood test used to determin how long it takes clots to form to regulate heparin dosage

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International Normalized Ratio

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INR; a more consistant measure of coagulation for coagulation studies regardless of thromboplastin reagent used. Accepted from World Health Organization; makes results not dependent upon reagent used. Used for PT/INR studies usually for monitoring patients on coumadin/warfarin. Pt on drugs should have range 2.0 to 3.0, high risk patients should be 2.5 to 3.5

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