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Drug Class

Mechanism of Action

Adverse Effects

Nursing Implications


#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. ____________


#5. _____________

Administered Route:

#6. (2 answers)_______________

Apixaban (Eliquis)


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)


#10. ____________

Nursing Implications:

Avoid in pregnancy or breast feeding

Frequent monitoring of PT and INR

enoxaparin (Lovenox)


#11. _____________

· Critical adverse effect is hemorrhage

· Critical allergic:

· #12 ________ (induced by**hint)

Monitor(labs): #13 __________

Antidote: #14 _______________


#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)


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 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)


#23 _________

Side effect:

· diarrhea

· gastric discomfort

Adverse Reaction:

· bleeding

· #24 ________

Monitor (labs):

#25 __________

Administered: po


Indicated: after cardiac procedures


(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 Class

Mechanism of Action

Adverse Effects

Nursing Implications





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 Class

Mechanism of Action

Adverse Effects

Nursing Implications

Erythropoietin Alfa

Hematopoietic Agents


· #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)

during therapy

2. Do not administer if hemoglobin 10-11


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


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:


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


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.







6. (2 answers)













19. (3) answers
















34. (2 answers)













Drugs Affecting the Blood

NSG 220

This Photo by Unknown Author is licensed under CC BY-SA-NC


Types of Drugs


“Clot Busters”

Highest Bleed Risks


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


Lower platelet aggregation

Mechanism of action- prevent platelets from clogging up



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:



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


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)


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




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.



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 IV’s (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 tt’s crossed. You can use this to remember which lab to watch


Memory Tricks


Platelets 150K-400K

<150 K

<50 K critical low = “Thrombocytopenia”


pTT – “2 t’s make the letter H”

46-70 pTT

Warfarin (in=“IN”r)

INR 2-3 Therapeutic Range

Antiplatelets – monitor “platelets”




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


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


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.


Decreased number, size or hemoglobin RBCs.

Loss of blood (acute or chronic)

Hemolysis- destruction of RBC’s

Poor dietary intake of iron, Vit. B, folic acid


bone marrow dysfunction or deficiency of substances for RBC production or maturation.



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


Vitamin B12 Deficiency


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)



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 Chron’s where uncontrolled inflammation if the terminal ileum can lead to this deficiency.


Folic Acid Deficiency

Required for DNA synthesis. Identical to vitamin B12 deficiencies.


Poor diet*


Sprue- intestinal disease which decreases folic acid uptake

ETOH use (acute or chronic)*


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.


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.


Erythropoietin Alfa

MOA: Stimulate RBC production in bone marrow and erythropoietin in the kidneys


Anemia due to chronic renal failure


HIV patietns and takig zidovudine (Retrovir)


Erythropoietin alfa*

Darbepoetin alfa (Aranesp)


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 isn’t’ 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 isn’t 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.


High risk populations

Cancer Patients- accelerate tumor progression

Postoperative patients not given an anticoaugulant- increased risk of developing DVT’s

Dialysis patients- increased risk of cardiovascular events.

Monitor h & h – do not give for hemoglobin levels higher than 10 to 11 mg/dl


MOA: Stimulate neutrophil production kidneys reduce neutropenia


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


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.