Anticoagulants, Antiplatelets, Thrombolytics Drugs Nursing Considerations & Management

Notes

These groups of drugs affect clot formation and resolution by hindering different steps in clotting formation which include altering the formation of platelet plug (antiplatelet drugs), interfering the clotting cascade and thrombin formation (anticoagulant drugs), and stimulating the plasmin system to break down the formed clot (thrombolytic agents).


Table of Common Drugs and Generic Names

Here is a table of commonly encountered antiplatelet, anticoagulant, and thrombolytic agents, their generic names, and brand names:

Classification Generic Name Brand Name
Antiplatelet agents aspirin Aspro Clear, Disprin
cilostazol Pletal
dipyridamole Persantine
tirofiban Aggrastat
Anticoagulants warfarin Coumadin
dabigatran Pradaxa
rivaroxaban Xarelto
Thrombolytic Agents alteplase Activase
reteplase Retavase
tenecteplase TNKase
urokinase Abbokinase
Others:
Low-molecular weight heparins dalteparin Fragmin
enoxaparin Lovenox
tinzaparin Innohep
Anticoagulant adjunctive therapy lepirudin Refludan
protamine sulfate
vitamin K
Hemorrheologic agent pentoxifylline Trental

Disease Spotlight: Thromboembolic and Hemorrhagic Disorders

Disorders that directly affect coagulation process are divided into two main categories: 1) thromboembolic disorders, which involve overproduction of clots; and 2) hemorrhagic disorders, which is characterized by ineffective clotting process leading to excessive bleeding.

Thromboembolic disorders include medical conditions (e.g. CAD) which involve overproduction of clots which result into decreased blood flow and total vessel occlusion. Manifestations include hypoxia, anoxia, and even necrosis. These disorders are treated by drugs that interfere with normal coagulation process to prevent formation of clots.

On the other hand, less common hemorrhagic disorders is characterized by excessive bleeding. These are treated by drugs that promote the clotting process. Some of these conditions include:

  • Hemophilia: characterized by genetic lack of clotting factors
  • Liver disease: characterized by non-production of proteins and clotting factors necessary for clot formation
  • Bone marrow disorders: characterized by insufficient quantity of platelets rendering them ineffective

Antiplatelet Agents

Description
  • This drug class exerts its action by decreasing the responsiveness of platelets to stimuli that cause it to clump or aggregate. Through this, formation of platelet plug is decreased.
Therapeutic Action
  •  By blocking receptor sites on the platelet membrane, platelet adhesion and aggregation is inhibited.
  • Also, platelet-platelet interaction as well as interaction of platelets to clotting chemicals are prevented.
Indications
  • Primarily indicated for cardiovascular diseases that have potential for development of vessel occlusion.
  • Other indications include maintenance of arterial and venous grafts, preventing cerebrovascular occlusion, and including them as adjunct to thrombolytic therapy for treatment of myocardial infarction.
  • One drug, anagrelide, blocks the production of platelets in the bone marrow.

Children

  • Only heparin and warfarin are indicated for children but these drugs alone require careful dose calculation.

Adults

  • Caution is particularly important to prevent injury (e.g. using electric razor and soft-bristled toothbrush).
  • It is also important that adults are educated on what to do should bleeding occurs (e.g. applying firm pressure) as well as what signs of bleeding should be watched out for.
  • Other drugs taken should be documented because there are a lot of drug interactions with these drug class. It should also be emphasized that periodic blood tests is expected to monitor the effect of therapy.

Pregnant women

  • For pregnant women, it is not advisable unless the benefit to the mother would clearly outweigh the risk for the fetus. On the other hand, for lactating women, it is generally inadvisable.

Older adults

  • Are more susceptible to drug toxicity and drug-to-drug interactions.
  • Careful monitoring of liver and kidney function is important for this age group.
  • Therapy is always started at the lowest level possible and adjusted accordingly.
Pharmacokinetics
Route Onset Peak Duration
Oral 5-30 min 0.25-2 h 3-6 h
T1/2: 15 min – 12 h
Metabolism: liver
Excretion: bile
Contraindications and Cautions
  • Allergy to antiplatelet agents. Prevent severe hypersensitivity reactions.
  • Known bleeding disorder. Increased risk of excessive blood loss
  • Recent surgery. Increased risk of bleeding in unhealed blood vessels
  • Closed head injuries. Increased risk of bleeding in injured blood vessels of the brain
  • History of thrombocytopenia. Anagrelide decreased bone marrow production of platelets.
  • Pregnancy, lactation. Generally inadvisable because of potential adverse effects to fetus or neonate
Adverse Effects
  • CNS: headache, dizziness, weakness
  • GI: GI distress, nausea
  • Skin: skin rash
  • Hema: bleeding (oftenly occurs while brushing the teeth)
Interactions
  • Increased risk of bleeding if combined with another drug that affects blood clotting.
Nursing Considerations

Here are important nursing considerations when administering antiplatelet agents:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

  • Assess for the mentioned contraindications to this drug (e.g. hypersensitivity, acute liver disease, pregnancy etc.) to prevent potential adverse effects.
  • Conduct thorough physical assessment before beginning drug therapy to establish baseline status, determine effectivity of therapy, and evaluate potential adverse effects.
  • Obtain baseline status for complete blood count and clotting studies to determine any potential adverse effects.
Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

  • Disturbed sensory perception related to CNS effects
  • Acute pain related to CNS and GI effects
  • Risk for injury related to CNS effects and bleeding tendencies
Implementation with Rationale

These are vital nursing interventions done in patients who are taking antiplatelet agents:

  • Administer drug with meals to relieve GI upset.
  • Provide comfort measures for headache because pain due to headache may decrease patient compliance to treatment regimen.
  • Educate patient on ways to promote safety like using electric razor, soft-bristled toothbrush, and cautious movement because any injury at this point can precipitate bleeding.
  • Educate patient on drug therapy including drug name, its indication, and adverse effects to watch out for to enhance patient understanding on drug therapy and thereby promote adherence to drug regimen.
Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

  • Monitor patient response to therapy (e.g. increased bleeding time, prevention of occlusive events).
  • Monitor for adverse effects (e.g. bleeding, headache, GI upset).
  • Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
  • Monitor patient compliance to drug therapy.

Anticoagulants

Description
  • By interfering with clotting cascade and thrombin formation, anticoagulants are able to interfere with the normal clotting process.
Therapeutic Action
  •  Warfarin, an oral agent in this class, reduces Vitamin K-dependent clotting factors. As a result, clotting process is prolonged.
  • Two new oral agents, dabigatran and rivaroxaban, directly inhibits thrombin (last step in clotting process) and factor Xa, respectively.
  • Heparin and antithrombin block formation of thrombin from prothrombin.
Indications
  • Among the many indications for this drug class include: stroke and systemic emboli risk reduction, nonvalvular atrial fibrillation, and deep vein thrombosis.
  • Heparin is used for prevention of blood clots in blood samples, dialysis, and venous tubing. It also does not enter breastmilk so it is the anticoagulant of choice for lactating women.
  • Antithrombin is a naturally-occurring anticoagulant and is a natural safety feature in the clotting system.

Children

  • Only heparin and warfarin are indicated for children but these drugs alone require careful dose calculation.

Adults

  • Caution is particularly important to prevent injury (e.g. using electric razor and soft-bristled toothbrush).
  • It is also important that adults are educated on what to do should bleeding occurs (e.g. applying firm pressure) as well as what signs of bleeding should be watched out for.
  • Other drugs taken should be documented because there are a lot of drug interactions with these drug class. It should also be emphasized that periodic blood tests is expected to monitor the effect of therapy.

Pregnant women

  • For pregnant women, it is not advisable unless the benefit to the mother would clearly outweigh the risk for the fetus. On the other hand, for lactating women, it is generally inadvisable.

Older adults

  • Are more susceptible to drug toxicity and drug-to-drug interactions.
  • Careful monitoring of liver and kidney function is important for this age group.
  • Therapy is always started at the lowest level possible and adjusted accordingly.
Pharmacokinetics
Route Onset Peak Duration
IV Immediate Minutes 2-6 h
Subcutaneous 20-60 min 2-4 h 8-12 h
T1/2: 30-180 min
Metabolism: cells
Excretion: urine
Contraindications and Cautions
  • Allergy to anticoagulants. Prevent severe hypersensitivity reactions.
  • Known bleeding disorder, recent trauma/surgery, presence of indwelling catheters, threatened abortion, GI ulcers. These conditions can be compromised by increased bleeding tendencies.
  • Pregnancy, lactation. Warfarin is a contraindication.
Adverse Effects
  • Warfarin is associated with alopecia, dermatitis, bone marrow depression, and less frequently with prolonged and painful erections.
  • Direct drug toxicity is characterized by nausea, GI upset, diarrhea, and hepatic dysfunction.
Interactions
  • Anticoagulants, salicylates, penicillin, cephalosporin: increased bleeding if combined with heparin
  • Nitroglycerin: decreased anticoagulation if combined with heparin
  • Cimetidine, clofibrate, glucagon, erythromycin: increased bleeding if combined with warfarin
  • Vitamin K, phenytoin, rifampin, barbiturates: decreased anticoagulation if combined with warfarin
  • Antifungals, erythromycin, phenytoin, rifampin: alteration in metabolism of dabigatran and rivaroxaban
Nursing Considerations

Here are important nursing considerations when administering anticoagulants:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

  • Assess for the mentioned contraindications to this drug (e.g. hypersensitivity, acute liver disease, pregnancy etc.) to prevent potential adverse effects.
  • Conduct thorough physical assessment before beginning drug therapy to establish baseline status, determine effectivity of therapy, and evaluate potential adverse effects.
  • Obtain baseline status for complete blood count and clotting studies to determine any potential adverse effects.
Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

  • Ineffective tissue perfusion related to blood loss
  • Disturbed body image related to direct drug toxicity characterized by rash and alopecia
  • Risk for injury related to bleeding tendencies and bone marrow depression
Implementation with Rationale

These are vital nursing interventions done in patients who are taking anticoagulants:

  • Assess for signs signifying blood loss (e.g. petechiae, bruises, dark-colored stools, etc.) to determine therapy effectiveness and promote prompt intervention for bleeding episodes.
  • Establish safety precautions (e.g. raising side rails, ensuring adequate room lighting, padding sides of bed, etc.) to protect patient from injury.
  • Maintain antidotes on bedside (e.g. protamine sulfate for heparin, Vitamin K for warfarin) to promptly treat drug overdose.
  • Evaluate effectiveness by monitoring the following blood tests: prothrombin time (PT) and international normalized ratio (INR) for warfarin; and whole blood clotting time (WBCT) and activated partial thromboplastin time (APTT) for heparin.
  • Educate patient on drug therapy including drug name, its indication, and adverse effects to watch out for to enhance patient understanding on drug therapy and thereby promote adherence to drug regimen.
Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

  • Monitor patient response to therapy (e.g. increased bleeding time)
  • Monitor for adverse effects (e.g. bleeding, bone marrow depression, alopecia, etc.).
  • Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
  • Monitor patient compliance to drug therapy.

Thrombolytic Agents

Description
  • Thrombolytic agents promote clot resolution, the process of activating the plasmin system to break down the thrombus or clot that has been formed.
Therapeutic Action
  •  The conversion of plasminogen to plasmin is the body’s natural anticlotting system. Thrombolytic agents’ action to activate this promotes breakdown of fibrin threads and dissolution of formed clots.
  • It is necessary to prevent vessel occlusion and therefore, to deliver adequate blood flow to body systems.
Indications
  • For treatment of acute MI, pulmonary embolism, and acute ischemic stroke.
  • Also for clearing of occluded intravenous catheters and central venous access devices.

Children

  • Not indicated for this age group.

Adults

  • Caution is particularly important to prevent injury (e.g. using electric razor and soft-bristled toothbrush).
  • It is also important that adults are educated on what to do should bleeding occurs (e.g. applying firm pressure) as well as what signs of bleeding should be watched out for.
  • Other drugs taken should be documented because there are a lot of drug interactions with these drug class.
  • It should also be emphasized that periodic blood tests is expected to monitor the effect of therapy.

Pregnant women

  • For pregnant women, it is not advisable unless the benefit to the mother would clearly outweigh the risk for the fetus.
  • On the other hand, for lactating women, it is generally inadvisable.

Older adults

  • Are more susceptible to drug toxicity and drug-to-drug interactions.
  • Careful monitoring of liver and kidney function is important for this age group.
  • Therapy is always started at the lowest level possible and adjusted accordingly.
Pharmacokinetics
Route Onset Peak Duration
IV Immediate End of injection N/A
T1/2: unknown
Metabolism: plasma
Excretion: unknown
Contraindications and Cautions
  • Allergy to thrombolytics. Prevent severe hypersensitivity reactions.
  • Known bleeding disorder, recent trauma/surgery, acute liver disease, cerebrovascular accident within 2 months, GI ulcers. These conditions can affect normal clotting factors and normal plasminogen production.
  • Pregnancy, lactation. Potential adverse effects to fetus or neonate.
Adverse Effects
  • CV: cardiac arrhythmias, hypotension
  • Hema: bleeding (most common)
  • Hypersensitivity reaction (uncommon) is characterized by rash, flushing, and bronchospasm.
Interactions
  • Anticoagulant, antiplatelet: increased risk of bleeding
Nursing Considerations

Here are important nursing considerations when administering thrombolytics:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

  • Assess for the mentioned contraindications to this drug (e.g. hypersensitivity, acute liver disease, CVA within 2 months, etc.) to prevent potential adverse effects.
  • Conduct thorough physical assessment before beginning drug therapy to establish baseline status, determine effectivity of therapy, and evaluate potential adverse effects.
  • Obtain baseline status for complete blood count, fecal occult blood test (FOBT), and clotting studies to determine any potential adverse effects.
Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

  • Decreased cardiac output related to cardiac arrhythmias and potential for bleeding
  • Risk for injury related to clot-dissolving effects
Implementation with Rationale

These are vital nursing interventions done in patients who are taking thrombolytics:

  • Assess for signs signifying blood loss (e.g. petechiae, bruises, dark-colored stools, etc.) to determine therapy effectiveness and promote prompt intervention for bleeding episodes.
  • Establish safety precautions (e.g. raising side rails, ensuring adequate room lighting, padding sides of bed, etc.) to protect patient from injury.
  • Evaluate effectiveness by monitoring coagulation studies to adjust drug dose appropriately.
  • Educate patient on drug therapy including drug name, its indication, and adverse effects to watch out for to enhance patient understanding on drug therapy and thereby promote adherence to drug regimen.
Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

  • Monitor patient response to therapy (e.g. dissolution of blood clot and return of blood flow)
  • Monitor for adverse effects (e.g. bleeding, anemias, hypotension, etc.).
  • Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
  • Monitor patient compliance to drug therapy.

Practice Exam

Welcome to your MSN Exam for Anticoagulants! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

Exam Details

  • Number of Questions: 15 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Nurse Amelia gives a hint, "We aim for a sweet spot where clotting is prevented without undue risk of bleeding. This value is not as low as our usual baseline INR for a person not on anticoagulation."

1 / 15

1. As part of her patient rounds, Nurse Amelia was explaining the importance of maintaining a balance with Warfarin dosage to Mr. Collins. She mentioned that there is an INR value above which Warfarin doesn't offer extra therapeutic benefits to most patients, but instead increases the risk of bleeding. That value is:

💡 Hint

Nurse Elliot hints, "For surgeries with a low risk of bleeding, we don't typically require a transition to another anticoagulant. However, we do need to ensure the coagulation status is within a safe range prior to the procedure."

2 / 15

2. In preparing a patient on Warfarin for a surgery with a low risk of bleeding, Nurse Elliot reviewed the correct protocols. Which of the following did his review confirm as the correct approach?

💡 Hint

Nurse Rebecca hints, "You'll want to think about Warfarin's role in the coagulation cascade. It doesn't directly interact with thrombin, nor does it encourage clot breakdown, like fibrinolysis does."

3 / 15

3. Late in the evening, Nurse Rebecca was engaged in a lively discussion with her colleagues about various medications. The topic of Warfarin came up, and one of the new nurses was curious about its mechanism. Rebecca mentioned that Warfarin:

💡 Hint

When monitoring anticoagulant therapy, it's crucial to measure the blood's ability to clot, but in a standardized way, considering factors such as differences in lab reagents. By the way, the name of this test even hints at its universality. Understanding the nuances of patient care is always rewarding!

4 / 15

4. Nurse Martinez, keen on ensuring optimal patient care, was explaining to a patient on oral anticoagulant therapy the need for regular tests to monitor the drug's effects. He pointed out that the recommended test to keep track of the efficacy of oral anticoagulant therapy is:

💡 Hint

When managing anticoagulation in high-risk situations like surgery, we want to minimize both bleeding and clotting risks. This often involves a carefully choreographed dance of stopping, starting, and substituting medications. Remember, the balance of risks and benefits is key in these critical situations. What a dynamic world healthcare is, right?

5 / 15

5. Nurse David found himself facing a challenging scenario with a patient on Warfarin who was at a high risk of thromboembolism and scheduled for a surgery associated with a high risk of bleeding. David knew the best course of anticoagulation strategy would involve:

💡 Hint

The world of anticoagulation is vast and varied, with many different tools in the toolkit. Each has its unique strengths, and sometimes, one type can offer several advantages over another. The journey of learning in pharmacology never ends!

6 / 15

6. During a staff meeting, Nurse Thompson was asked to share the advantages of low molecular weight heparin (LMWH) over unfractionated heparin, based on her experiences. Thompson stated that LMWH:

💡 Hint

In dire circumstances, it's vital to have an antidote that directly addresses the mechanism of the offending agent. Reflect on how Warfarin works, and you'll understand the choice of its reversal agent. It's like solving a puzzle; each piece has its perfect match. Careful, thoughtful interventions are the heart of nursing!

7 / 15

7. Nurse Benedict was part of a critical care team responding to a patient with life-threatening bleeding from excessive warfarin. In such circumstances, he knew the urgency of reversing the anticoagulant effect of warfarin. Which of the following would be used for this purpose?

💡 Hint

Anticoagulation isn't just a short-term solution. For some patients, it's a lifelong necessity. Think about the conditions that might carry ongoing risks for clotting. It's truly remarkable how our treatment strategies can adapt to the chronicity of certain conditions, isn't it?

8 / 15

8. While briefing her team, Nurse Amelia emphasized that certain patients might require anticoagulant therapy for an indefinite period. Which conditions would necessitate this long-term approach?

💡 Hint

Nurse Leona hints, "Remember that some anticoagulants can cross the placenta, while others can't. So, not all the options listed are typically avoided during pregnancy."

9 / 15

9. Nurse Leona was counseling a newly pregnant patient with a history of clotting disorders. She carefully considered which anticoagulant medications are generally avoided during pregnancy. Which of the following anticoagulants fell into this category?

💡 Hint

Nurse Edwards provides a helpful hint, "Remember, LMWHs have a very specific target within the coagulation cascade. They don't affect the broader pathways typically evaluated by prothrombin time or APTT."

10 / 15

10. Nurse Edwards was reviewing the treatment protocol for a patient who was on low molecular weight heparins (LMWHs). He knew these usually didn't require monitoring. However, in certain situations, monitoring might be necessary. He pondered over which of the following would be measured in such cases:

💡 Hint

Nurse Sarah offers a clue, "Remember, the aim is to minimize patient discomfort and inconvenience, while ensuring safety and effectiveness of the treatment. We don't typically need multiple checks per day, especially not in the beginning stages of therapy."

11 / 15

11. As Nurse Sarah settled into her day shift, she had a new task to set a monitoring schedule for Mr. Johnson, who recently started on Warfarin. Sarah carefully planned the most suitable frequency of INR monitoring for a patient in this situation, which would be:

💡 Hint

Heparin is a fascinating anticoagulant with its own unique set of characteristics. From its mode of action to its monitoring, there's a lot to learn about this drug. Keep in mind that understanding how a drug works can help you anticipate how it's monitored. The world of pharmacology never ceases to amaze, doesn't it?

12 / 15

12. In a group discussion about anticoagulant therapy, Nurse Isaac was asked to provide some insights about Heparin. He mentioned that regarding Heparin, the following statement(s) are correct:

💡 Hint

Nurse Adrienne hints, "Consider the specific counteracting agent for Heparin. It's not about replacing blood cells or coagulation factors, nor is it a vitamin K-related issue."

13 / 15

13. Late in her night shift, Nurse Adrienne faced a critical situation with a patient who had an excessive anticoagulant effect from Heparin. She knew she needed to act fast to reverse this effect. Which of the following would she utilize for rapid reversal?

💡 Hint

Warfarin is a medication that doesn't work immediately. It's like a seed you plant in a garden; it takes some time to grow, but not too long. Think about the average time you would give a plant seed to sprout and grow visibly, and this might just guide you to the answer. Remember, patience is a virtue, even in pharmacology!

14 / 15

14. Nurse Grayson was educating a patient about her new medication, Warfarin. The patient was curious about how soon they could expect to see an anticoagulant effect. Grayson explained that the time taken for observable anticoagulant effect of Warfarin is:

💡 Hint

Nurse Jennifer shares a helpful hint, "Let's not forget that Warfarin is primarily used as an anticoagulant, ideal for conditions where preventing clot formation is the main objective. It's not as commonly prescribed for conditions where clot dissolution or enhancing blood flow is the primary treatment goal."

15 / 15

15. During her morning rounds, Nurse Jennifer encounters Mrs. Lawrence, an 85-year-old woman with a complex medication regime. Among the prescriptions, she notes Warfarin. Jennifer reflects on the approved clinical applications of this drug. Which one below is not recognized as an approved indication for Warfarin?