|
Drug |
Drug Class |
Mechanism of Action |
Adverse Effects |
Nursing Implications |
|
heparin |
#1. ________ |
Inactivates clotting factors thrombin and factor Xa through the increased activity of antithrombin |
Critical adverse effect: #2. __________________ **Critical Allergic reaction** #3. _____________ |
Monitor(labs): #4. ____________ Reversal/antidote: #5. _____________ Administered Route: #6. (2 answers)_______________ |
|
Apixaban (Eliquis) |
Anticoagulant |
inhibits platelet aggregation (factor Xa) induced by thrombin. |
Critical adverse effect: #7. ________________ |
1. Increased risk of hemorrhage in pregnant patients 2. Increased risk of bleeding in patients with renal impairment |
|
Warfarin (Coumadin) |
#8. ___________ |
Decreases the production of vitamin K-dependent clotting factors. (Vit K synthesis) |
· bruising · ____#9_______ (after long term use) |
Monitor(labs): INR (2-3 is normal) Reversal/antidote: #10. ____________ Nursing Implications: Avoid in pregnancy or breast feeding Frequent monitoring of PT and INR |
|
enoxaparin (Lovenox) |
anticoagulant |
#11. _____________ |
· Critical adverse effect is hemorrhage · Critical allergic: · #12 ________ (induced by**hint) |
Monitor(labs): #13 __________ Antidote: #14 _______________ |
|
fondaparinux |
#15 ______________ |
#16 ______________ |
1. Can cause epidural bleeds. |
Labs to monitor: None Nursing Implications: · Avoid giving in patients with decrease level of consciousness, complains of back pain or is paralyzed. · Do not administer to patients for at least 6 hours after #17_______or with a #18__________ epidural |
|
Rivaroxaban (Xarelto) Apixiban (Eliquis) Edoxanban (Savaysa) |
Anticoagulants |
Inhibits factor Xa |
Risk for neurological impairment |
Lab monitoring: No routine clot studies Nursing Implications: · Avoid over the counter medications (Vit E, ginkgo biloba, fish oils, garlic, NSAIDS) · Teach patients to avoid bleeding by doing the following: (3 examples)___#19______ |
|
Drug |
Drug Class |
Mechanism of Action |
Adverse Effects |
Nursing Implications |
|
Aspirin (Acetylsalicylic Acid) Indication: Reduce risk of CVA, TIA, prevent of MI Treatment during episodes of unstable angina and MI Prevention: occlusion of stents |
#20. __________ |
Decrease platelet aggregation |
Side effect: · #21_________(given in high doses) · Bruising · Gastric upset Adverse reaction: · GI bleed · hemorrhagic stroke (uncontrolled HTN) |
Monitor(labs): platelets Antidote for ASA toxicity: #22 _______(There are 2 optional answers that will be accepted. Monitor for signs of: ***toxicity tinnitus, hyperventilation, |
|
Clopidogrel (Plavix) |
Antiplatelet |
#23 _________ |
Side effect: · diarrhea · gastric discomfort Adverse Reaction: · bleeding · #24 ________ |
Monitor (labs): #25 __________ Administered: po |
|
Abciximab Indicated: after cardiac procedures |
Antiplatelet (Glycoprotein (GP) receptor inhibitors) |
Blocks GP IIB/IIIa receptors that stop platelet aggregation |
Critical adverse reaction: · hemorrhage · Thrombocytopenia |
Monitor: hgb & Platelets ***Assess for bleeding in 1. #26 _____ 2. #27_______ 3. IV insertion sites Nursing Implications 4. ECG changes 5. No needle sticks or new IV injections |
|
Drug |
Drug Class |
Mechanism of Action |
Adverse Effects |
Nursing Implications |
|
tPA Alteplase Streptokinase |
Thrombolytics |
Break down, or lyse or existing clots |
1. Bleeding Severe Effect: 1. Severe bleeding |
Administered: #28 _(route)_ ONLY Nursing Implications: 1. Monitor for mental status changes 2. No new IV, ABGS 3. Never give through a (route) #29 _________. 4. Do not give within 2 weeks of surgery 5. Do not give to patients with active #30 _______ 6. Can only be administered from #31______ hours from onset of symptoms 7. Monitor for cardiac changes/dysrhythmias 8. Uncontrolled hypertension or b/p (180/110) |
|
Drug |
Drug Class |
Mechanism of Action |
Adverse Effects |
Nursing Implications |
|
Erythropoietin Alfa |
Hematopoietic Agents |
#32_____________ |
· #33 ________ · Cardiovascular events- MI, CVA, DVT |
Monitor (labs): #34 _____ & _______ ***Iron levels- key ingredient with the production of RBCs Nurse Implications: 1. Monitor: #35 (hint: which main vital sign) 2. Do not administer if hemoglobin 10-11 |
|
Filgrastim Indicated for Neutropenia |
Hematopoietic Agents |
Increase production of neutrophils (in the bone marrow) |
· Enlarge spleen · __#36___ pain · Leukocytosis |
Monitor baseline (labs): CBC and platelet counts Administered: IV & subQ |
|
Oprelvekin |
Hematopoietic Agents |
Simulate platelet production |
· #37_______ (sign of fluid overload) · anemia · Cardiac dysrhythmias Severe Reaction: · Anaphylaxis |
Administered: #38 _____ Monitor (labs): platelet counts, electrolyte status Nursing Implications: · Fluid retention: Teach patient to contact provider if symptoms worsen. · Use with caution in patients with cardiac history- a-fib, a-flutter |
|
Iron Sulfate Iron deficiency anemia, dietary supplement (prevention) |
Hematinic Agents |
Replacement of iron which is critical for hemoglobin function |
Adverse Reaction · #39_______** · Nausea · Dark Tarry stools Serious Side effect with IV route: #40_______ |
Patient Teaching 1. Take with vitamin #41_______ source. 2. Infusion: Give a test dose when administering #42 (which route). Keep epinephrine on h and for anaphylaxis. 3. Teach patient to increase fiber and drink plenty of fluids to reduce constipation |
|
Folic Acid Indicated: Folic acid anemia, dietary supplement |
Hematinic Agents |
Replacement for folic acid |
1. Nausea 2. Flatulence 3. Rash |
1. Teach patient dietary/lifestyle changes: – Increase consumption of foods high in #43_______ (e.g., green vegetables, liver). 2. If alcoholism underlies dietary deficiency, offer counseling for alcoholism, as well as dietary advice. |
|
Vitamin B12 |
Hematinic Agents |
Replacement Vitamin B12 anemia, Dietary supplement, absence of intrinsic factor |
1. Headache 2. Nausea Serious Adverse Reaction 1. #44________** (low lab value) 2. Pulmonary edema 3. Anaphylaxis |
1. Labs to Monitor: ***Serum ___#45___ Teach patient s/s of hypokalemia and instruct them to contact provider immediate. 2. Treatment duration- is #46 (how long) |
Answer Sheet
**Make sure you read the instructions.
· You must turn BOTH documents in to receive full credit. NO EXCEPTIONS.
· Provide your answers in the correct order. Make sure your numbers match what is given, or it will be marked incorrect.
· There is only one answer per blank. If the question indications there is more than one answer, then you must have all correct to receive credit.
· **You do not have to use this specific format. As long as you submit the answers in the correct order it will be accepted. However, if you decide to use this format, make sure the answer matches and form it is NEAT. Written answers will be accepted as long as they are in a pdf form so they can be read and graded.
DRUGS THAT AFFECT THE BLOOD
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Drugs Affecting the Blood
NSG 220
This Photo by Unknown Author is licensed under CC BY-SA-NC
1
Types of Drugs
Thrombolytics
Clot Busters
Highest Bleed Risks
Anticoagulants
Treat and prevent thrombosis clot
MOA (mechanism of action)- Inhibits Vit. K in the liver that interferes with the blood clotting mechanism by blocking thrombin
Antiplatelets
Lower platelet aggregation
Mechanism of action- prevent platelets from clogging up
2
Antiplatelets
Indicated for: Ischemic strokes, TIA (transient ischemic attacks), unstable angina, coronary stenting, Acute MI, previous MI & prevention of MI
Aspirin salicylic acid ASA
PO, IV and rectal preparations
Too much ASA toxicity
Tinnitus- ringing in ears- high doses or long-term use
Elevated blood pressure and tachycardia possible bleed
Contraindicated for patients with thrombocytopenia
Clopidogrel (Plavix)- po only
Indicated for: Strokes (CVA), prevent stenosis of coronary stents
Takes effect with 2 hrs. of the first dose, peak effect 3-7 days of treatment
Administered with PPI (proton-pump inhibitors) such as Omeprazole to prevent GI bleeding, however, can also reduce the efficacy of Clopidogrel
Discontinue at least 5 days before surgery d/t bleeding risk
Dipyridamole (po & IV)
Indicated for prevention of thromboembolism following heart valve replacement
given w/other antiplatelets- Aspirin
Aside effects- headache, dizziness, & GI disturbances
Ticlopidine (po)
Indication: CVA prevention and coronary artery occlusion
Can be given with aspirin or for patients who can not take aspirin
Platelets (thrombocytes) are cells in the blood that clump together to begin the clotting process. They are the first responders when there is injury. They also initiate the inflammatory response of the innate immune system. The four main platelet functions are:
3
Antiplatelets
Prevent platelets from forming clots, DO NOT decrease the number of clots
Indication: post MI/ACS or to prevent MI, CVA, TIA, PAD (peripheral artery disease) & prevent re-occlusion of vessels
Before you administer the medication
Monitor labs
Hemoglobin- if less than 7
Platelets (150,000-400,000)
***less than 150K- Call the provider, *less than 50K- Urgent
Hold the medication for abnormal labs, Notify the provider
Anticoagulants
Drugs used to prevent and treat thrombosis
Venous thrombi stagnate develop when blood flow is slow when blood settles, fibrin is produced causing the red blood cells and platelets to form a thrombus.
Thrombosis- 2 types
Venous-blood clot in the vein
Venous thrombus has a tail that can break off causing an embolus
Embolus can travel to the lungs causing a pulmonary embolism
Arterial- blood clot in the artery.
Harmful effects are local causing blockage and decrease perfusion to area or organ(s)
Anticoagulants
Used for: prevention growth of existing clots and/or new clots
Do not dissolve clots
Indicated for: prevention of DVT
MOA: blocks the formation of fibrin (forms seals on clots)
Administration: IV or subcutaneous
Monitor Labs: pTT (46-70)
(the lower the number the thicker the blood, the higher the number the thinner the blood)
**Dosage of medication will be based on these labs.
Anticoagulant Drugs
Heparin (Administered IV or subcutaneous
MOA: Activation of antithrombin, resulting in the activation of factor Xa and thrombin
Prescribed short-term (days to weeks)
Works quickly within minutes (usually 20mins)
Usually given for DVTs or after MI (heart attack) to prevent clots from growing
Low Molecular Weight heparin (Enoxaparin and Dalteparin)
MOA: Activation of antithrombin, resulting in the activation of factor Xa and thrombin and some activation of thrombin
Administered subcutaneous only (never aspirate or rub the site)
Patient can administer this medication at home
Assess H & H (hemoglobin and hematocrit) and blood pressures that drop by 20 points
Monitor platelets – ***HIT**
Warfarin (po only)
MOA: Activation of antithrombin, resulting in selective inactivation of factor Xa
Takes days to take effect (usually 5 days) but last a long time once taken
Life-long therapy – Most patients have to take it rest of their life was started
Monitor labs for frequently (daily for 5 days) for therapeutic ranges (INR, but also Prothrombin time (PT)
Clinical Pearl- A patient who is started on heparin in the hospital can start taking coumadin. They CAN be taken at the same time.
Patients who take warfarin will often be referred to coumadin clinics. Where there labs are monitored frequently
Monitor for HIT (half of the platelets are decreased with 24 hours after starting heparin/low molecular heparin
7
Monitor
Labs
Heparin monitor aPTT
If ptt is over 70 stop the heparin drip
Any signs of bleeding (iv site, urine) stop the infusion- notify provider
Antidote protamine sulfate
Warfarin- monitor INR
Antidote Vitamin K ***do not give Vit K unless the patient has had warfarin for 5 days (after switching from IV Hep)
Teach patient to eat vit K in moderation when eating.
Eat leafy green vegetables and foods such as liver.
Bacteria in the intestine produces vitamin K. When antibiotics are taken, they kill the bacteria and
Antibiotics increase INR.
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Thrombolytics
Used to treat emergency conditions: CVA (cerebral vascular accident), MI (myocardial infarction, PE (pulmonary embolism) & other conditions (i.e., clot removal from central line or dialysis catheter)
Medications: Alteplase, Reteplase, Tenecteplase
MOA: break down, or lyse of fibrin in thrombi (usually dissolve newly formed clots)
Administration: IV only
**only drug that dissolves clot**
Usually given within 3-4.5 hours from onset of symptoms
No new injections at all. The IVs (usually 2) is what you will use. No other injections. Never through central lines
If you make the H for heparin it looks like 2 tts crossed. You can use this to remember which lab to watch
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Memory Tricks
Anticoagulants
Platelets 150K-400K
<150 K
<50 K critical low = Thrombocytopenia
Heparin
pTT 2 ts make the letter H
46-70 pTT
Warfarin (in=INr)
INR 2-3 Therapeutic Range
Antiplatelets monitor platelets
clopidogrel
Aspirin
Abciximab
Memory Tricks (cont.)
AVOID any patients with active bleeding
with liver problems because liver makes coagulation factors (vitamin K). No vitamin K (clotting factor= risk of bleeding)
Peptic ulcers (bleeding)
Think about any situations that can cause or a concern for bleeding (i.e., medications, disease process, sign or symptoms of bleeding)
Patient teaching
Safety
Environment (situations in which patient can injure themselves) rugs, dim rooms
Patient care
Soft bristle toothbrushes, no razors, no flossing, avoid constipation, no alcohol-based mouth wash,
Always wear a medical alert bracelet
Avoid trauma where injuries can occur
Drugs for Deficiency Anemia
Hematinic Agents
NSG 220
This Photo by Unknown Author is licensed under CC BY-SA
1
Anemia (Overview)
Deficiency in the number of red blood cells or in the quality and amount of the hemoglobin. Low hemoglobin level decrease oxygen-carrying capacity to mee the physiologic needs of the body.
Causes:
Decreased number, size or hemoglobin RBCs.
Loss of blood (acute or chronic)
Hemolysis- destruction of RBCs
Poor dietary intake of iron, Vit. B, folic acid
Chemotherapy
bone marrow dysfunction or deficiency of substances for RBC production or maturation.
2
IRON DEFICIENCY ANEMIA
Most common type of anemia
Cause: Slow, chronic blood loss (GI bleeding, peptic ulcers, heavy menstrual bleeding, etc.), impaired absorption of iron, diet (lack of)
Drug Treatment
Ferrous Sulfate
IV Dextran
Ferrous fumarate
Ferrous succinate
Administered: IV, PO
Action: Used to treated the production of normal hemoglobin and the RBCs for transportation and utilization of oxygen
Iron Supplements
Adverse Effect- GI related- constipation*, nausea*, diarrhea, dark green to black stools, teeth staining (liquid preparations)
Can be toxic if given in large doses (accidental or intentional)
Patient Teaching:
Take with Vitamin C (ascorbic acid) to promote the absorption of iron*
Do not give with antiacids or tetracyclines*
Liquid preparations can stain teeth (dilute with a liquid, rinse mouth afterwards)
Encourage to eat food rich in iron- liver, eggs, meat, fish
4
Vitamin B12 Deficiency
Cause
Impaired Absorption
Pernicious Anemia
Megaloblastic Anemia
Neurological Damage
GI disturbances
Severe B12 anemia
Mortality due to hypoxia to peripheral and cerebral hypoxia?HF and dysrhythmia
Drug Treatment
Vitamin B12 (Cyanocobalamin)
Hydroxocobalamin
Methylcobalamin
Administered: intranasal, subQ, or PO never IV
Nursing Implications
Treatment duration is usually life long
Use with caution in patients who receive folic acid.
Hypokalemia can develop during early therapy.
Monitor serum potassium levels
Teach patient s/s of hypokalemia and instruct them to contact provider immediate.
Vitamin B12 is essential for the synthesis of DNA- required for the growth and division of cells.
Lack of Vit B12 causes anemia and injury to the nervous system.
Causes of B12 anemia is due to impaired absorption and rarely due to diet. Pernicious anemia (due to absence of intrinsic factors) is one you may remember in pathophysiology. Megaloblastic Anemia due to oversized erythroblasts (megaloblasts) and oversized erythrocytes (macrocytes) due to impaired DNA synthesis. I can also be cause by neurologic damage when there is demyelination (damage) to the neurons of the spinal cord and brain. GI disturbances autoimmune diseases such as Chrons where uncontrolled inflammation if the terminal ileum can lead to this deficiency.
5
Folic Acid Deficiency
Required for DNA synthesis. Identical to vitamin B12 deficiencies.
Cause
Poor diet*
Malabsorption
Sprue- intestinal disease which decreases folic acid uptake
ETOH use (acute or chronic)*
Indicated:
Prophylactic- pregnancy women
Severe deficiency Megaloblastic anemia.
Treatment: Folic Acid
Administered: IV,PO, subQ and IM* (only for patients with impaired GI absorption only)
Identical to Vitamin B12 deficiencies. Megaloblastic anemia is the most common. However, the provider must determine which one is he cause- Vitamin B12 deficiency or Folic Acid deficiency.
“lack of folic acid may result in leukopenia, thrombocytopenia, and injury to the oral and GI mucosa. It can also case neural tube defects in early pregnancy which is many women are encouraged to take during pregnancy.
6
Hematopoietic Agents
Hematopoiesis is the process by which our bodies make red blood cells, white blood cells, and platelets.
RBC production occurs in the bone marrow
The actual process erythropoiesis occurs in the bone marrow
Erythropoietin hormone is produced and secreted in the proximal tubules of the kidney (& liver). It stimulates RBC production
See process below
When there is anemia or hypoxia, levels of erythropoietin rise and trigger increase of erythrocytes synthesis (erythropoiesis= production of red blood cells)
Bone Marrow is the site of hematopoiesis- hemato means blood and poiesis means to make.
Erythropoietin is a hormone that is produced predominantly in the kidneys. Erythropoietin is made to protect RBCs from destruction. They also stimulate stem cell of the bone marrow to increase RBC production.
When there is sufficient oxygen in the blood circulation, the production of erythropoietin is reduced, but when oxygen levels go down, the production of erythropoietin goes up.
7
Erythropoietin Alfa
MOA: Stimulate RBC production in bone marrow and erythropoietin in the kidneys
Indication:
Anemia due to chronic renal failure
chemotherapy
HIV patietns and takig zidovudine (Retrovir)
Treatment:
Erythropoietin alfa*
Darbepoetin alfa (Aranesp)
Long-acting
Administered: IV or subQ
Nursing implications:
Monitor H&H as well as iron levels
Monitor blood pressure before therapy
Due to increase hematocrit
Do not administer if hemoglobin >11 gm/dL (twice a week)
Do not agitate (shake) the vial
When there isnt enough of red blood cells then medications are prescribed to increase the production of red blood cells. Remember red blood cells are produced in the marrow, the kidneys produce erythropoietin to protect the RBCs. When there isnt enough RBC
Increased risk of DVTs, CVA (strokes) or myocardial infarctions (MI)
Can cause HTN**Monitor blood pressure before therapy due to increase hematocrit
In order for erythropoietin to produce, there must be adequate store of iron, folic acid and vitamin B12 available.
8
High risk populations
Cancer Patients- accelerate tumor progression
Postoperative patients not given an anticoaugulant- increased risk of developing DVTs
Dialysis patients- increased risk of cardiovascular events.
Monitor h & h do not give for hemoglobin levels higher than 10 to 11 mg/dl
Filgrastim
MOA: Stimulate neutrophil production kidneys reduce neutropenia
Indication:
Chemotherapy myelosuppressive reduce risk of infections
Patients undergoing bone marrow transplantation
Severe chronic neutropenia
Administered: IV or subQ
Can not be taken orally due
Adverse Effects
Bone pain
leukocytosis
Nursing implications:
Filgrastim is given to reduce the risk of infection in patients undergoing cancer chemotherapy. Many anticancer drugs act on the bone marrow to suppress production of neutrophils, greatly increasing the risk of infection. By stimulating neutrophil production, filgrastim can decrease infection risk.
Increased risk of DVTs, CVA (strokes) or myocardial infarctions (MI)
Can cause HTN**Monitor blood pressure before therapy due to increase hematocrit
In order for erythropoietin to produce, there must be adequate store of iron, folic acid and vitamin B12 available.
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