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140 Cards in this Set
- Front
- Back
Fibrinolysin |
enzyme that breaks down the fibrin meshwork that stabilizes blood clots; also referred to as plasmin |
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Hemostasis |
prevention or stoppage of blood loss from an injured blood vessel and is the process that maintains the integrity of the vascular compartment |
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Heparin-induced thrombocytopenia (HIT) |
immune-mediated prothrombotic reaction resulting in a decrease in platelet count associated with heparin administration in patients with detectable HIT antibodies |
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Plasmin |
enzyme that breaks down the fibrin meshwork that stabilizes blood clots; also referred to as fibrinolysin |
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Plasminogen |
inactive protein found in many body tissues and fluids, is bound to fibrin and becomes a component of the clot. |
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Prothrombotic reaction |
adverse effect that leads to thrombogenesis |
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Thrombogenesis |
formation of a blood clot |
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Thrombolysis |
breakdown or dissolution of blood clots |
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Thrombolytics |
drugs that dissolve blood clots |
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Thrombosis |
formation of a blood clot |
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Thrombus |
blood clot |
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Anticoagulant, antiplatelet, and thrombolytic drugs are used for: |
prevention and management of thrombotic and thromboembolic disorders |
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Atherosclerosis |
the basic disease process that often leads to pathologic thrombosis; begins with accumulation of lipid-filled macrophages (i.e., foam cells) on the inner lining of arteries |
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Arterial blood clots in the cerebral, pulmonary, or cardiac system can produce a |
cerebrovascular accident, pulmonary embolism, or myocardial infarction, |
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Venous blood clots may lead to |
DVT; classic symptoms include leg swelling and pain on palpation in the calf or thigh |
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Anticoagulant drugs |
prevent formation of new clots and extension of already existing clots, do not dissolve clots that have already formed. Widely used in thrombotic disorders, they aremore effective in preventing venous thrombosis than arterial thrombosis. |
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Antiplatelet drugs |
drugs used to prevent arterial thrombosis |
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Thrombolytic drugs |
used to dissolve thrombi and limit tissue damage in selected thromboembolic disorders. |
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three types of anticoagulants |
heparins, vitamin K antagonists, and direct thrombin inhibitors (DTIs). |
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Heparin |
pharmaceutical preparation of the natural anticoagulant produced primarily by mast cells in pericapillary connective tissue, and it is the prototype anticoagulant. |
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Endogenous heparin |
found in various body tissues, most abundantly in the liver and lungs. |
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Exogenous heparin |
obtained frombovine lung or porcine intestinal mucosa and standardized in units of biologic activity. |
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Heparin prototype |
Heparin |
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Vitamin K antagonists prototype |
warfarin |
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Direct thrombin inhibitors prototype |
lepirudin |
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Heparins other drugs in class |
Dalteparin Enoxaparin Fondaparinux* |
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Vitamin K antagonists drugs in class |
none? |
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Direct thrombin inhibitors other drugs in class |
Argatroban Bivalirudin Dabigatran etexilate Desirudin Rivaroxaban |
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Antiplatelet Drugs class |
Adenosine diphosphate receptor antagonists |
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Adenosine diphosphate receptor antagonists prototype |
clopidogrel |
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Adenosine diphosphate receptor antagonists other drugs |
Prasugrel Ticlopidine Tirofiban |
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Other antiplatelet drugs |
Abciximab Anagrelide Aspirin Cilostazol Dipyridamole Eptifibatide |
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Thrombolytic Drugs prototype |
Alteplase |
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Thrombolytic other drugs in class |
Drotrecogin alfa, activated Reteplase, recombinant Streptokinase Tenecteplase |
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Drugs Used to Control Bleeding |
Aminocaproic acid Protamine sulfate Tranexamic acid Vitamin K |
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Heparin administration route |
IV or SubQ only Rationale: GI tract does not absorb this drug |
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Heparin pharmacokinetics |
After intravenous (IV) injection, it acts immediately. After subcutaneous injection, it acts within 20 to 30 minutes. Metabolism takes place in the liver and the reticuloendothelial system. Excretion, primarily in the form of inactive metabolites, occurs in the urine. Hemodialysis does not remove it. |
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Heparin prophylactical use |
to prevent DVT and pulmonary embolism |
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patients at risk for certain disorders take low doses of heparin prophylactically because of these disorders |
Major illnesses (e.g., acute myocardial infarction, heart failure, serious pulmonary infections, stroke) Major abdominal or thoracic surgery A history of thrombophlebitis or pulmonary embolism, including pregnant women Gynecologic surgery, especially in patients who have been taking estrogens or oral contraceptives or have other risk factors for DVT Restrictions such as bed rest or limited activity expected to last longer than 5 days |
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Heparin therapeutic use |
a. for management of acute thromboembolic disorders (e.g., DVT, thrombophlebitis, pulmonary embolism). b. to prevent further thrombus formation and embolization. c. use in disseminated intravascular coagulation (DIC), |
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disseminated intravascular coagulation (DIC), |
a life-threatening condition characterized by widespread clotting, whichdepletes the blood of coagulation factors. The depletion of coagulation factors then produces widespread bleeding. |
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Goal of heparin therapy in DIC |
prevent blood coagulation long enough for clotting factors to be replenished and thus be able to control hemorrhage. |
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in addition, clinicians use heparin to: |
prevent clotting during cardiac and vascular surgery, extracorporeal circulation, hemodialysis, and blood transfusions, and in blood samples to be used in laboratory tests. |
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True or false: Heparin does not cross the placental barrier and is not secreted in breast milk |
True, making it the anticoagulant of choice for use during pregnancy and lactation. |
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Heparin contraindications |
GI ulcerations (e.g., pepticulcer disease, ulcerative colitis), intracranial bleeding, dissecting aortic aneurysm, blood dyscrasias, severe kidney or liver disease, severe hypertension, polycythemia vera, and recent surgery of the eye, spinal cord, or brain. |
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Drugs That Increase the Effects of Heparin |
AlteplaseIncreases the risk of bleeding AntithrombinIncreases pharmacologic effects CephalosporinsLead to potential coagulopathies and risk of bleeding Direct thrombin inhibitorsIncrease the risk of bleeding Drotrecogin alfaIncreases the risk of bleeding Penicillins (parenteral)Lead to altered platelet aggregation and increased risk of bleeding. Platelet inhibitorsIncrease the risk of bleeding WarfarinMay prolong and possibly invalidate the PT; if receiving both heparin and warfarin, draw blood for the PT at least 5 hours after the last IV heparin dose |
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Drugs That Decrease the Effects of Heparin |
AntihistaminesDecrease the anticoagulant effect DigoxinDecreases the anticoagulant effect NicotineDecreases the anticoagulant effect Nitroglycerin (IV)Decreases the anticoagulant effect StreptokinaseLeads to relative resistance to anticoagulation TetracyclineDecreases the anticoagulant effect |
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Herbs and Foods That Increase the Effects of Heparin |
Chamomile, garlic, ginger, ginkgo, ginseng, high-dose vitamin E |
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True or False No herbs or foods that decrease the effects of heparin have been identified. |
True, some herbs increase effects not decrease |
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activated partial thromboplastin time (aPTT) |
sensitive to changes in blood clotting factors, except factor VII, to regulate heparin dosage. Normal or control values of indicate normal blood coagulation, and therapeutic values of adequate anticoagulation indicate low levels of clotting factors and delayed blood coagulation |
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during heparin therapy, aPTT should be at |
1.5 to 2.5 times the control or baseline value |
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aPTT normal control value |
25 to 35 seconds |
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aPTT therapeutic values of adequate anticoagulation |
45 to 70 seconds, approximately. |
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intermittent administration; 1 hour; thromboembolism;LMWHs |
aPTT may be drawn at any time; with ___________, blood for the aPTT should be drawn approximately ______ before a dose of heparin is scheduled. It is not necessary to monitor aPTT with low-dose standard heparin given subcutaneously forprophylaxis of __________ or with the _____ (e.g., enoxaparin). |
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Disadvantages of heparin |
a.parenteral injection is necessary, b.the drug has a short duration of action, which means that there is a need for frequent administration. |
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Assessing for therapeutic effect of heparin |
assesses for the absence or reduction of signs and symptoms of thrombotic disorders (e.g., less edema and pain with DVT, less chest pain and respiratory difficulty with pulmonary embolism, absence of uncontrolled bleeding). It is also necessary to ensure that aPTT values are within the therapeutic range. |
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Assessing for adverse effects |
assesses the patient for signs of overt bleeding or HIT |
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Heparin antidote |
Protamine sulfate |
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Warfarin (Coumadin) |
most commonly used oral anticoagulant and is the prototype vitamin K antagonist |
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Warfarin pharmacokinetics |
well absorbed after oral administration. Administration with food may delay the rate but not the extent of absorption. The drug is highly bound to plasma proteins (98%), mainly albumin. Metabolism takes place in the liver. Excretion, primarily as inactive metabolites, occurs in the kidneys. Renal impairment does not affect drug metabolism but may decrease excretion of the drug. |
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foods high in vit. K (decreases effect of warfarin) |
broccoli, brussels sprouts, cabbage, cauliflower, chives, collard greens, kale, lettuce, mustard greens, peppers, spinach, tomatoes, turnips, and watercress. |
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Enoxaparin teaching |
you need an injection usually every 12 hours. You or someone close to you may be instructed in injecting the medication, or a visiting nurse may do the injections, if necessary. |
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Warfarin teaching |
you need to avoid walking barefoot; avoid contact sports; use an electric razor; avoid injections when possible; and carry an identification card, necklace, or bracelet (e.g., MedicAlert) stating the name of the drug and the health care provider’s name and telephone number. |
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Enoxaparin self-administration teaching |
wash hands and cleanse skin to prevent infection; inject deep under the skin, around the navel, upper thigh, or buttocks; and change the injection site daily. If excessive bruising occurs at the injection site, rubbing an ice cube over an area before the injection may be helpful. |
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Warfarin self-administration teaching |
as with all medications, take as prescribed. Because the prescriber may set a dosing schedule that could vary from 1 day to the next, do not rely on memory but keep a written record of the date and the amount of medication taken. |
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Warfarin; warfarin; Vit.K; warfarin; Warfarin; 3 to 5 days; warfarin |
_________ acts in the liver to prevent synthesis of vitamin K–dependent clotting factors (i.e., factors II, VII, IX, and X). Similar to vitamin K in structure, ________ therefore acts as a competitive antagonist to hepatic use of vitamin K. Conversely, _________ serves as the antidote for ________. ________ has no effect on circulating clotting factors or on platelet function, so the anticoagulant effects do not occur for ______ days after ________ is started because clotting factors already in the blood follow their normal pathway of elimination. |
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Warfarin |
_________ is most useful in long-term prevention or management of venous thromboembolic disorders, including DVT, pulmonary embolism, and embolization associated with atrial fibrillation and prosthetic heart valves. |
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Warfarin |
_________ therapy after myocardial infarction may decrease reinfarction, stroke, venous thromboembolism, and death |
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Which body organ eliminates warfarin? |
Liver |
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The primary adverse effect: warfarin other side effects |
associated with _____therapy is hemorrhage. Additionally, nausea, vomiting, abdominal pain, alopecia, urticaria, dizziness, and joint or muscle pain may occur. |
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T or F Warfarin, a pregnancy category X medication, is contraindicated during pregnancy because it crosses the placenta and may produce fatal fetal hemorrhage. |
True. Warfarin in pregnancy category X. Black box warning! |
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Drugs That Increase the Effects of Warfarin |
acetaminophen (high dose), allopurinol, amiodarone b. Alteplase, androgens, aspirin and other nonsteroidal anti-inflammatory drugs, azithromycin, bismuth subsalicylate, carbamazepine, chloral hydrate, chloramphenicol, cimetidine, ciprofloxacin and other quinolone antibiotics, cisapride, clarithromycin, clofibrate, cotrimoxazole, direct thrombin inhibitors, drotrecogin alfa, heparin, macrolide antibiotics, omeprazole, pravastatin, propranolol, quinidine, ranitidine, ritonavir, sertraline, simvastatin, streptokinase, sulfinpyrazone, sulfonamide, tamoxifen, tetracyclines, thyroid hormones, tricyclic antidepressants, vancomycin , vitamin E c. Antithrombin d. Cephalosporins |
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Drugs That Decrease the Effects of Warfarin |
a. Chlordiazepoxide, haloperidol, intravenous lipid emulsions (contains soybean oil), isotretinoin, meprobamate, spironolactone b. Chlorthalidone c. Ethchlorvynol, trazodone d. Etretinate |
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Herbs and Foods That Increase the Effects of Warfarin |
Angelica Cat’s claw Chamomile Chondroitin Cranberry juice Feverfew Garlic Ginkgo Goldenseal Grape seed extract Green tea Psyllium Turmeric |
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Herbs and Foods That Decrease the Effects of Warfarin |
Ginseng St. John’s wort Vitamin K Foods high in vitamin K (broccoli, brussels sprouts, cabbage, cauliflower, chives, collard greens, kale, lettuce, mustard greens, peppers, spinach, tomatoes, turnips, and watercress) |
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QSEN Safety Alert: Warfarin |
When warfarin therapy begins, daily evaluation of INR is necessary until a stable daily dose is reached (the dose that maintains the prothrombin time [PT] and INR within therapeutic ranges and does not cause bleeding). A therapeutic PT value is approximately 1.5 times control, or 18 seconds. Thereafter, a patient’s INR values require checking every 2 to 4 weeks for the duration of oral anticoagulant drug therapy. If a prescriber changes the warfarin dose, more frequent INR measurements are necessary until a stable daily dose is again established. |
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INR value above 3.0 |
Institutions often have protocol for the therapeutic range of INR. In the absence of a protocol, the nurse holds the dose if the INR is _________ and notifies the health care provider. |
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Assessing for Therapeutic Effects: Warfarin |
nurse assesses for the absence or reduction of signs and symptoms of thrombotic disorders (e.g., less edema and pain with DVT, less chest pain and respiratory difficulty with pulmonary embolism, absence of uncontrolled bleeding, hematuria or blood in the stools). It is also necessary to ensure that PT and INR values are within the therapeutic range. |
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Assessing for Adverse Effects |
nurse assesses for signs of bleeding, including excessive bruising of the skin, bleeding from IV sites or the gum line, and blood in urine or stool. |
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INR and PT therapeutic values |
INR: 2.0 and 3.0 PT: 1.5 times control or 18 seconds Normal baseline or control PT is ~12 seconds |
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DTIs benefits/ advantages |
a. inhibition of both circulating and clot-bound thrombin b. more predictable dose–response anticoagulant effect c. inhibition of thrombin-induced platelet aggregation d. lack of production of immune-mediated thrombocytopenia |
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indirect inhobitors of thrombin |
Heparin and warfarin |
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Lepirudin Pharmacokinetics (DTI) |
__________, which cannot be absorbed by the GI tract, is administered intravenously and is distributed to the extracellular fluids. The metabolic pathway has not been established. The drug is excreted in the urine, and the systemic elimination is proportional to the glomerular filtration rate. Typically, the elimination half-life is 60 minutes. |
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Lepirudin Action |
__________ is a highly specific direct inhibitor of thrombin, but unlike heparin, its mechanism of action is independent of antithrombin III. DTIs have no known antagonists. Given intravenously, the drug has an onset within 30 to 90 minutes and has a duration of action for up to 24 hours. Safety and efficacy in children have not been established. |
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Lepirudin use |
__________ is available for HIT, acute coronary syndrome, prophylaxis and treatment of venous thromboembolism, and management of atrial fibrillation. This drug and the other DTIs are less suitable for long-term treatment because administration by injection is necessary, therapeutic drug monitoring is not widely available, and no pharmacologic antidote to reverse the effects is available. |
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Argatroban |
second agent, after lepirudin, to be indicated for HIT. But unlike lepirudin, __________ is eliminated in the liver and can be used in people with end-stage renal disease. Administered intravenously, argatroban is very short acting due to its reversible binding to thrombin and differs from lepirudin, which irreversibly binds to thrombin. |
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Antiplatelet drugs |
prevent one or more steps in the prothrombotic activity of platelets |
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arterial thrombi |
composed primarily of platelets, may form on top of atherosclerotic plaque and block blood flow in the artery. They may also form on heart walls and valves and embolize to other parts of the body. |
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prototype ADP receptor antagonist |
clopidogrel (Plavix) |
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Clopidogrel shortcomings |
delayed onset of action, irreversible inhibitory effects on platelets with no reversing agent or antidote, and significant individual variability in platelet response. |
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Clopidogrel pharmacokinetics |
rapidly absorbed after oral administration and undergoes extensive first-pass metabolism in the liver. Platelet inhibition may occur 2 hours after a single dose, but the onset of action is slow, so that an initial loading dose is usually administered. The drug has a half-life of about 8 hours. The drug is excreted in the urine and feces. |
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Clopidogrel Action |
irreversibly block the ADP receptor on platelet cell membranes. Effective dose-dependent prevention of platelet aggregation can be seen within 2 hours of a single oral dose, but the onset of action is slow, so that a loading dose of 300 to 600 mg is usually administered. Platelet inhibition essentially lasts for the lifespan of the platelet. With repeated doses of 75 mg/d, maximum inhibition of platelet aggregation is achieved within 3 to 7 days. Platelet aggregation progressively returns to baseline about 5 days after discontinuing the drug. |
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Clopidogrel Use |
reduction of myocardial infarction, stroke, and vascular death in patients with atherosclerosis and in those after placement of coronary stents. Specific uses include prevention of vascular ischemic events in patients with symptomatic atherosclerosis or with acute coronary syndrome (with or without ST-segment elevation). In addition, after placement of an intracoronary stent for the prevention of thrombosis, patients may take this drug in conjunction with aspirin (dual antiplatelet therapy). |
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Clopidogrel |
People with atrial fibrillation who are unable to take vitamin K antagonists take ___________ instead |
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Clopidogrel |
Adding ___________ to aspirin in people with atrial fibrillation reduces the rate of major vascular events compared with aspirin alone but is associated with a greater risk of bleeding. |
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Clopidogrel |
alternative antiplatelet drug for patients who cannot tolerate aspirin. |
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Liver |
Because clopidogrel is metabolized in the _____, it may accumulate in people with hepatic impairment. Caution is necessary. |
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Clopidogrel adverse effects |
The most common adverse effects associated with this drug are pruritus, rash, purpura, and diarrhea. Thrombotic thrombocytopenic purpura, hemorrhage, and severe neutropenia have also occurred. |
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Clopidogrel contraindications |
Contraindications to this drug include hypersensitivity to the drug or any other component. It should not be used in patients with active bleeding in conditions such as intracranial hemorrhage or peptic ulcer disease. A category B medication, the drug requires cautious use in pregnant and lactating women. |
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Clopidogrel: Nursing Implications |
The FDA has issued a BLACK BOX WARNING ♦ concerning the use of this drug in the 2% to 14% of the US population who are reduced metabolizers of the drug. As a result of genetic variations in CYP2C19 function, the drug may be less effective in altering platelet activity in these people. These “poor metabolizers” may remain at risk for heart attack, stroke, and cardiovascular death, and alternate dosing of the ___________ or the use of other antiplatelet drugs should be considered. Tests are available to determine if a patient is a poor metabolizer. |
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Clopidogrel route and dosage |
PO 75 mg once daily with or without food |
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Aspirin pregnancy category |
D (if full dose aspirin is taken in the third trimester) |
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Aspirin Use |
Prevention of myocardial infarction |
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Aspirin route and dosage |
PO 81–325 mg daily Prevention of thromboembolic disorders in patients with prosthetic heart valves or TIAs |
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Eptifibatide (Integrilin) pregnancy category |
B - requires cautious use in pregnant and lactating women |
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Eptifibatide (Integrilin) Use |
Acute coronary syndromes, including patients who are to be managed medically and those undergoing PTCA |
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Eptifibatide (Integrilin) Route and Dosage |
IV bolus injection, 180 mcg/kg, followed by continuous infusion of 2 mcg/kg/min. See manufacturer’s instructions for preparation and administration. |
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Drugs That Increase the Effects of Clopidogrel |
AspirinIncreases the risk of bleeding AtorvastatinMay affect antiplatelet activity Barbiturates, carbamazepine, rifampin, rifapentineEnhances antiplatelet effect Nonsteroidal anti-inflammatory drugsIncrease the risk of bleeding Platelet inhibitorsIncrease the risk of bleeding RifabutinMay increase metabolism of clopidogrel ThrombolyticsIncreases the risk of bleeding |
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Drugs That Decrease the Effects of Clopidogrel |
Amiodarone, dalfopristin, delavirdine, diltiazem, quinupristin, Vaprisol, zafirlukastAffect cytochrome 450 3A4 enzymes, which play a role in clopidogrel metabolism Clarithromycin, erythromycin, ketoconazole, verapamilReduce antiplatelet activity OmeprazoleMay lead to inadequate platelet response Selective serotonin reuptake inhibitorsMay increase the risk of bleeding |
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Herbs and Foods That Increase the Effects of Clopidogrel |
Garlic Ginkgo biloba Ginger Green tea Horse chestnut |
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Assessing for Therapeutic Effects: Clopidogrel |
assesses for the absence of vascular ischemic events (e.g., pain, cyanosis, coolness of extremities). In addition, he or she ensures that hemoglobin and hematocrit levels are within normal limits. |
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Assessing for Adverse Effects: Clopidogrel |
assesses for common adverse effects, including pruritus, rash, purpura, and diarrhea; thrombotic thrombocytopenic purpura and hemorrhage; and severe neutropenia. |
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Antiplatelet drugs teaching consideration use |
are given to people who have had, or who are at risk of having, a heart attack, stroke, or other problems from blood clots. For prevention of a heart attack or stroke, you are most likely to be given ______ (e.g., aspirin, clopidogrel). |
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5 to 7 days |
Antiplatelet drugs should be withheld ______ days prior to a planned surgical procedure. |
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Aspirin (self-administration) |
Take _______ with food or after meals, with 8 ounces of water, to decrease stomach irritation. However, stomach upset is uncommon with the small doses used for antiplatelet effects. Do not crush or chew coated tablets (long-acting preparations). |
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Main use of thrombolytic agents |
management of acute, severe thromboembolic disease, such as myocardial infarction, pulmonary embolism, and iliofemoral thrombosis. |
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Goal of thrombolytic therapy |
reestablish blood flow as quickly as possible and prevent or limit tissue damage. In coronary circulation, restoration of blood flow reduces morbidity and mortality by limiting myocardial infarction size. In cerebral circulation, rapid thrombus dissolution minimizes neuronal death and brain infarction that produce irreversible brain injury. |
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Decrease reformation of thrombus |
Anticoagulant drugs, such as heparin and warfarin, and antiplatelet agents are given following thrombolytic therapy to _________. |
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prototype recombinant tissue plasminogen activator (rtPA) |
Alteplase (Activase) |
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Alteplase pharmacokinetics |
Administration of this drug is by IV infusion. Metabolism occurs predominately in the liver. Following discontinuation of the infusion, more than 50% of the drug is cleared, with more than 80% clearance within 10 minutes. Excretion takes place in the urine. Whether this drug crosses the placenta or is excreted into breast milk is unknown. |
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Alteplase Action |
__________ is a protein that lyses unwanted fibrin blood clots by catalyzing the conversion of plasminogen to plasmin. |
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Alteplase Use |
Indications for alteplase include lysis of acute coronary arterial thromboembolism associated with evolving transmural myocardial infarction or acute pulmonary thromboembolism. Clinicians also considered it as first-line therapy for the treatment of acute ischemic stroke in selected people. |
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Alteplase Adverse Effects |
bleeding (avoid invasive procedures) omit anticoagulants and antiplatelet while using thrombolytics symptomatic brain hemorrhage 3% mortality rate 6% - 8% risk of symptomatic hemorrhage |
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rtPA antidote (Alteplase) |
Aminocaproic acid |
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Alteplase contraindications |
Due to an increased risk of bleeding, this drug is contraindicated in patients with uncontrolled severe hypertension, aneurysm, arteriovenous malformation, known coagulopathy or internal bleeding, intracranial or intraspinal surgery or trauma within the past 3 months, intracranial mass, recent major surgery, or current use of oral anticoagulants. This drug can increase the risk of cerebral embolism in people with atrial fibrillation or atrial flutter. |
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Alteplase pregnancy category |
C |
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Alteplase route and dosage |
Ischemic stroke:IV infusion, 0.9 mg/kg total dose administered (not to exceed 90 mg), with 10% of the total dose administered as an initial IV loading dose over 1 min, and the remainder administered over 60 min.Myocardial infarction or PE:IV infusion, 100 mg over 3 h (first hour, 60 mg with a bolus of 6–10 mg over 1–2 min initially; second hour, 20 mg; third hour, 20 mg)Myocardial infarction: accelerated IV infusion, 100 mg total dosage administered as a 15 mg IV bolus, followed by 50 mg IV infused over 30 min, and then 35 mg IV infused over the next 60 min.IV infusion, 100 mg over 3 h (first hour, 60 mg with a bolus of 6–10 mg over 1–2 min initially; second hour, 20 mg; third hour, 20 mg) |
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Alteplase Nursing Implication |
It is necessary to minimize intramuscular injections in patients who are receiving systemic thrombolytic therapy, because bleeding, bruising, or hematomas may develop.The nurse assesses patients for cardiac dysrhythmias, including sinus bradycardia, premature ventricular contractions, and ventricular tachycardia resulting from reperfusion following coronary thrombolysis. He or she must promptly identify and report any evidence of bleeding. |
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Thrombolytic agent; alteplase |
Before a _____________ is begun, it is essential to check INR, aPTT, platelet count, and fibrinogen to establish baseline values and to determine whether a blood coagulation disorder is present. Two or three hours after __________ is started, the nurse ensures that the fibrinogen level is measured to determine that fibrinolysis is occurring. Alternatively, he or she can check INR or aPTT for increased values because the breakdown products of fibrin exert anticoagulant effects. During and following _________ administration, the nurse monitors blood pressure frequently and ensures that it is well controlled. The ISMP lists _________ as a high-alert drug because of its potential risk of causing significant harm when used in error. |
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Drugs That Increase the Effects of Alteplase |
Aspirin or other salicylates, abciximab, cilostazol, clopidogrel, dalteparin, dipyridamole, enoxaparin, eptifibatide, fondaparinux, heparin, nonsteroidal anti-inflammatory drugs, tinzaparin, tirofiban, warfarinIncrease the risk of bleeding |
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Alteplase route and consideration |
Administration is IV as a bolus injection or infusion. The nurse administers all infusions using an IV infusion device. It is necessary to reconstitute this drug as indicated and not to shake it. |
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Herbs and Foods That Increase the Effects of Alteplase |
Cat’s claw Dong quai Evening primrose Feverfew Garlic Ginkgo Ginseng Green tea Horse chestnut Red clover |
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Alteplase assessing for adverse effects |
nurse assesses for evidence of bleeding. In addition, it is necessary to determine that the condition leading to initiation of this therapy is reversed and that there is a return of function. If bleeding does occur, it is most likely from a venipuncture or invasive procedure site, and local pressure may control it. If bleeding cannot be controlled or involves a vital organ, it is necessary to stop the drug and replace fibrinogen with whole blood plasma or cryoprecipitate. Giving aminocaproic acid or tranexamic acid may also be appropriate. When the drugs are used in acute myocardial infarction, cardiac dysrhythmias may occur when blood flow is reestablished. Therefore, antidysrhythmic drugs should be readily available. |
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Aminocaproic acid (Amicar) Use |
Control bleeding caused by overdoses of thrombolytic agents or bleeding disorders caused by hyperfibrinolysis (e.g., cardiac surgery, blood disorders, hepatic cirrhosis, prostatectomy, neoplastic disorders); antidote for tPA -IV, PO |
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Protamine sulfate |
Treatment of heparin overdosage |
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Vitamin K (Mephyton) |
Antidote for warfarin overdosage PO 10 to 20 mg in a single dose |
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Risk factors for thromboembolism include |
Immobility (e.g., limited activity or bed rest for more than 5 days Obesity Cigarette smoking History of thrombophlebitis, DVT, or pulmonary emboli Heart failure Pedal edema Lower limb trauma Myocardial infarction Atrial fibrillation Mitral or aortic stenosis Prosthetic heart valves Abdominal, thoracic, pelvic, or major orthopedic surgery Atherosclerotic heart disease or peripheral vascular disease Use of oral contraceptives |
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S&S DVT and thrombophlebitis |
usually occur in the legs. The conditions may be manifested by edema (the affected leg is often measurably larger than the other) and pain. Homans’ sign (pain in the calf when the foot is dorsiflexed) is generally unreliable as a clinical sign of DVT. If thrombophlebitis is superficial, it may be visible as a red, warm, tender area following the path of a vein. |
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Pulmonary embolism S&S |
if severe enough to produce symptoms, is manifested by chest pain, cough, hemoptysis, tachypnea, and tachycardia. Massive emboli cause hypotension, shock, cyanosis, and death. |
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Signs and symptoms DIC |
usually manifested by bleeding, which may range from petechiae or oozing from a venipuncture site to massive internal bleeding or bleeding from all body orifices. |