NR 293 Week 4 Concepts; Clotting

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Robin Williams

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Nursing

Course

NR 293 Pharmacology

Institute

Chamberlain

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49

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Week 4 Concepts: Clotting Coagulation Modifiers Prepare: Coagulation Modifiers Coagulation Modifiers Coagulation modifiers are a group of medications that both promote and prevent clot formation as well as lysing a preformed clot and reversing the action of anticoagulants. Warfarin Warfarin is an anticoagulant medication whose mechanism of action is to prevent clot formation by inhibiting particular clotting factors. Coagulation Modifier Drugs Coagulation modifier drugs is a class of medication that includes medications? heparin aspirin acetaminophen warfarin Self Check: Hemostasis Review Coagulation Cascade System The coagulation cascade system is triggered by an injury to a blood vessel, which then triggers either an intrinsic or an extrinsic pathway of intricate steps, each step triggering the next when clotting factors are/is activated. The ultimate result of this system is a large concentration of fibrin. Reverse of the Coagulation Process The reverse of the coagulation process is the fibrinolytic system. Fibrinolysis is the breakdown of thrombi. This is an important part of hemostasis in order to prevent excessive coagulation, blocked blood vessels, or mobilized thrombi called an embolus. Self Check: Coagulation Modifier Drugs Coagulation Modifiers The coagulation modifier drugs are broken down into several subclasses or categories based on their hemostasis reversal or promotion action. Which items are mechanisms of action for this class of drug? Select all that apply. Thrombus prevention Thrombus mobilization Lysing of a preformed thrombus Anticoagulation reversal Thrombus promotion Antiplatelet reversal Self Check: Mechanism of Action Mechanism of Action Medication Subclass Mechanism of Action Alteplase Thrombolytic Which one of these coagulation modifier drugs has a mechanism of action that is to lyse a thrombus that has already formed? Match it to its subclass. Reversal Drug Which of these medications is a coagulation modifier whose subclass is a reversal drug? Select all that apply. aminocaproic acid apixaban protamine sulfate vitamin K Reflect: Coagulation Modifiers Antifibrinolytics What is another term for antifibrinolytics? Antithrombotics Antiplatelets Hemorheologics Hemostatics Promoting Coagulation A coagulation modifier drug whose mechanism of action is to promote coagulation of the blood is called a(n) and is used to. antifibrinolytic, manage excessive bleeding anticoagulant, prevent clot formation thrombolytic, lyse clots that have already formed antiplatelet, interfere with platelet function Anticoagulants What is another term for anticoagulant? Hemostatics Antiplatelets Hemorheologics Antithrombotics Antifibrinolytics Coagulation Modifier Drugs and Subclasses Anticoagulants Enoxaparin Heparin Warfarin Dabigatran etexilateapixaban Antiplatelets clopidogrel bisulfate abciximab Thrombolytics alteplase Antifibrinolytics aminocaproic acid Hemorheologics pentoxifylline Reversal Drugs coagulation factor Xa (recombinant) idarucizumab protamine sulfate phytonadione Match the coagulation modifier drug’s subclass to the correct medications. Note: Several of the subclasses have more than one medication listed as correct choices. Reversal and Coagulation Modifier Drugs Choose the correct word(s) from the drop-down list to complete the following statements regarding reversal drugs. Protamine sulfate is the reversal drug for heparin. Phytonadione is the reversal drug for warfarin. Idarucizumab is the reversal drug for dabigatran etexilate. Coagulation factor Xa (recombinant) is the reversal drug for rivaroxaban. Indications for Use Match the indications for use of coagulation modifying drugs by dragging the class on the right to the correct description. Antiplatelet drugs inhibit platelet aggregation and formation of platelet plugs, which are helpful in preventing heart attacks and strokes. Hemorrhagic drugs alter platelet function without interfering with normal platelet activity. Thrombolytic drugs are a classification of drugs that are used to break down clots or thrombi that have formed. Antifibrinolytic drugs are hemostatic drugs that promote blood coagulation for conditions of excessive bleeding. Hemostasis Vocabulary From the drop-down menu, select the term that best fits the definition. The process of thrombi formation – Coagulation A clot forming substance that is the result of the coagulation system, which also triggers the fibrinolysis system – Fibrin The process of thrombi breakdown – Fibrinolysis A rare genetic disorder in which certain factors needed for coagulation and hemostasis are inadequate or nonexistent – Hemophilia Any process that stops bleeding – Hemostasis Use of compression to achieve hemostasis – xxxMechanical means of hemostasis Use of clamping or cauterization to achieve hemostasis – xxxSurgical means of hemostasis Use of coagulation modifier drugs to achieve hemostasis – xxxPharmacologic means of hemostasis A mobilized thrombus – Embolus Blood clot – Thrombus Subclasses Prevent clot formation by inhibiting particular clotting factors Anticoagulants Prevent clot formation by interfering with platelet function Antiplatelets Lyse clots that have already formed Thrombolytics Promote the coagulation of blood Antifibrinolytics Reduce blood viscosity Hemorheologics Act as antagonists to the other medications Reversal drugs Match the coagulation modifier drug’s subclass to its mechanism of action. Anticoagulants (warfarin; heparin) Prepare: Anticoagulants Actions of Anticoagulants Anticoagulants perform which of the following actions? Act directly on platelet aggregation Prevent thrombosis Breakdown fibrin Lyse pre-formed clots Anticoagulant Subclasses Which of these anticoagulants belongs to the subclass heparins? clopidogrel warfarin rivaroxaban enoxaparin Coumarins How do coumarins prevent thrombus formation? Working with other drug classes to decrease the thickness of blood Inhibiting vitamin K-dependent clotting factors Directly impacting platelet aggregation Breaking down the fibrin in clots Self Check: Thromboembolic Event Which of the following patients is least at risk of a thromboembolic event? Someone on a direct flight from Detroit, Michigan to Sydney, Australia Someone who has been in a coma for a week following a stroke Someone who has a broken foot and is learning to walk with an orthopedic boot Someone who has a mechanical heart valve Someone recovering from a bilateral knee replacement Self Check: Heparin Heparin Toxicity Which of the following statements are correct regarding heparin toxicity? Select all that apply. Heparin toxicity may be treated intravenously with the reversal drug protamine sulfate in severe cases Because of heparin’s long half life, the toxic effects of heparin cannot reversed by discontinuing heparin alone The heparin must be stopped immediately The toxic effects of heparin may be reversed by discontinuing heparin alone Increased Anticoagulants Which of the following medications when taken with heparins, can cause an increased anticoagulant effect (bleeding risk)? Aspirin and other NSAIDs, oral anticoagulants, antiplatelets, and thrombolytics Antithrombotics, oral antibiotics, and prothrombins Acetaminophen, oral anticoagulants, and antithrombotics Aspirin and other NSAIDs, oral antibiotics, and antithrombotics Self Check: Warfarin (Coumandin) Warfarin Which of the following statements regarding warfarin are accurate? Select all that apply. It takes several days to reach therapeutic levels It is the most commonly prescribed parenteral anticoagulant There is a black box warning regarding bleeding risk specific to warfarin To treat warfarin toxicity, high doses of diluted vitamin K intravenously can reverse the effects within 6 hours Self Check: Black Box Warnings Premature discontinuation of the medication because it can lead to increased thrombi dabigatran For patients with an epidural catheter (may cause spinal hematomas) Apixaban / Rivaroxaban / Enoxaparin Serious bleeding risk warfarin Match the following anticoagulants with its black box warning. Reflect: Anticoagulants Adverse Effects Which of the following are medications used for treatment of adverse effects associated with heparin? Select all that apply. idarucizumab vitamin K prothrombin complex concentrate (human) Direct thrombin inhibitors protamine sulfate About Anticoagulant Medications The first oral selective Xa inhibitor to become available rivaroxaban Requires frequent monitoring of serum bleeding times (such as aPTT and INR) to determine if therapeutic level has been reached and if toxicity is present heparin When taken with warfarin causes a 50% or higher increase in INR cordarone Inhibit thrombin (clotting factor IIa) Direct thrombin inhibitors When taken with heparins can cause an increased bleeding risk due to decreased platelet activity Non-steroidal anti-inflammatory (NSAID) Direct thrombin inhibitor dabigatran Do not require frequent monitoring of serum bleeding times due to its more predictable anticoagulant response Low-molecular-weight heparins (LMWHs) Match each anticoagulant medication or subclass/category to its true statement. Adverse Effects What are the most common adverse effects for anticoagulants in general? Select all that apply. Hypokalemia Peripheral edema Bleeding Thrombocytopenia Necrosis of the skin and “purple toes” syndrome Thrombocytosis Abdominal cramps Statements About Heparin True Statements False Statements Statements About Heparin Heparin used therapeutically requires frequent monitoring of serum bleeding times Unfractionated heparin is commonly known as simply “heparin” Enoxaparin has a higher degree of bioavailability and longer elimination half-life than heparin Heparin when used as a DVT prophylactic and as a catheter flush require additional monitoring of serum bleeding times Low-molecular weight heparins (LMWHs) require frequent monitoring of serum bleeding times Dalteparin is a type of unfractionated heparin Drag the below statements into the correct column, indicating which are true and which are false, regarding the subclass of anticoagulants known as heparins? Selective Xa Inhibitors Which of these medications is an oral selective Xa inhibitor that is used for prevention of strokes in patients with atrial fibrillation (a-fib)? fondaparinux sodium apixapan rivaroxaban enoxaparin Indications of Use Given their general mechanism of action, anticoagulants are indicated for which of these uses? Select all that apply. Treat deep vein thrombosis Prevention thrombus formation that may result from a long plane ride Dissolving thrombi that have formed Prevention of emboli associated with ambulation following surgery Prevent stroke Preventing thrombi formation Promote thrombus formation on and/or around mechanical heart valves Treat pulmonary embolism Prevent myocardial infarction Treatment of unstable angina Categories of Heparins Which of the following are categories of heparins? Select all that apply. Direct thrombin inhibitors Unfractionated heparin Selective factor Xa inhibitors Coumarins Low molecular-weight heparins (LMWHs) Antiplatelets (clopidogrel) Prepare: Antiplatelets Antiplatelets How do antiplatelets prevent clot formation? Preventing platelet adhesion at the site of the thrombus Preventing platelet adhesion at the site of the blood vessel injury Preventing platelet production Preventing platelet mobilization Mechanism of Action Which of the following statements is true regarding acetylsalicylic acid’s antiplatelet mechanism of action? Select all that apply. It alters the platelet membrane so that it can no longer receive the signal to aggregate and form a clot It inhibits platelet aggregation by preventing the release of adenosine diphosphate (ADP), platelet factor IV, and TXA2, all substances that stimulate platelets to aggregate or form a clot It irreversibly prevents platelets from regenerating a necessary enzyme It prevents platelet adhesion Indications of Use for clopidogrel Which of the following are indications for use of clopidogrel? Select all that apply. Reduce the risk of stroke resulting from a thrombus Transient ischemic attack (TIA) prophylaxis Prevention of thrombus following a myocardial infarction (MI) Improve exercise tolerance in the elderly Self Check: Mechanism of Action Which of the following is true regarding the mechanism of action of antiplatelets? They prevent platelet adhesion at the site of blood vessel injury z They perform the same function in terms of the coagulation cascade as anticoagulants They prevent platelets from mobilizing They inhibit clotting factors that are needed for fibrin Self Check: Aspirin Acetylsalicylic acid Acetylsalicylic acid prevents platelet aggregation by permanently blocking the platelet’s ability to regenerate an enzyme called cyclooxygenase for the entire seven (7) day lifespan of a platelet. This enzyme is needed in a process that leads to platelet aggregation and vasoconstriction. Therefore, acetylsalicylic acid results in vasodilation and the prevention of platelet aggregation/clot formation. Self Check: Antiplatelet Subclass Antiplatelet Subclass Which of the following statements are accurate regarding the antiplatelet subclass glycoprotein (GP) IIb/IIIa inhibitors? Select all that apply. Used to treat unstable angina and MI Used during procedures such as angioplasty, typically in ICU or cardiac catheterization lab settings They are administered orally Eptifibatide, tirofiban, and abciximab are GP IIb/IIIa inhibitors Self Check: clopidogrel (Plavix) Clopidogrel Which of the following statements is true regarding clopidogrel? It has a black box warning for patients with hypertension It is used for the reduction of thrombotic stroke risk, transient ischemic attack (TIA) prophylaxis, and the post- myocardial infarction (MI) prevention of thrombosis It is administered by subcutaneous injection It works by altering the platelet membrane to signal platelets to aggregate and form a clot Adverse Effects Which of the following are common adverse effects of clopidogrel? Select all that apply. Chest pain Flu-like symptoms Joint pain Constipation Edema Abdominal pain Fatigue Hypotension Epistaxis Reflect: Antiplatelets Adenosine Diphosphate (ADP) Receptor Inhibitor Medications Which of the following statements are true regarding ADP Inhibitor medications clopidogrel, prasugrel, and ticagrelor? Select all that apply. Ticagrelor has a black box warning related to increased bleeding risk and use of aspirin in doses over 100 mg Dipyridamole is used for patients who do not respond to clopidogrel Prasugrel has a black box warning of an increased bleeding risk in clients with a history of stroke and those who weigh less than 60 kg They are all similar except that prasugrel is used primarily after interventional cardiac procedures Unlike prasugrel and ticagrelor, clopidogrel does not have a black box warning Platelet Adhesion and Aggregation Place the steps of the platelet aggregation process in order, from the point of the damaged blood vessel to the point of clot formation. 1. Blood vessel is damaged by some sort of trauma or a rupture of plague from the vessel wall 2. Hemostasis and blood flow is disrupted Collagen from the damaged vessel stimulates platelet adhesion Stimulation of platelet aggregation (accumulation) at the site of the damage 5. The accumulation of platelets form a platelet plug 6. The platelets change shape and release the substances they contain (platelet recruiters and vasoconstriction) 7. The coagulation cascade is triggered so that fibrin can form a clot to stop the bleeding Dipyridamole Which of the following statements is true regarding dipyridamole? Select all that apply. Used in the prevention of various thromboembolic complications, including as a postoperative adjunct to warfarin When used with clopidogrel, acetylsalicylic acid, and other nonsteroidal anti-inflammatory drugs (NSAIDs) produces additive antiplatelet activity and increased bleeding potential A glycoprotein (GP) IIb/IIIa inhibitor which is administered intravenously to treat acute unstable angina and myocardial infarction (MI) Prevents platelet aggregation by blocking the formation and/or release of several platelet stimulators (such as adenosine diphosphate (ADP) and thrombin) that cause platelets to aggregate Clopidogrel Clopidogrel is a(n) oral medication in the adenosine diphosphate (ADP) receptor inhibitor subclass whose mechanism of action is to alter the platelet membrane preventing it from receiving the signal to aggregate. Antiplatelet 0212944Choose which antiplatelet corresponds with each statement. Effectiveness of clopidogrel Which of the following medications can reduce the effectiveness of clopidogrel? Select all that apply. acetylsalicylic acid amiodarone calcium channel blockers heparin nonsteroidal anti-inflammatory drugs (NSAIDs) proton pump inhibitors Adverse Effects Antiplatelets are contraindicated in patients with which of the following? Select all that apply. Ulcer disease Severe liver or kidney disease Vitamin K deficiency Leukemia Uncontrolled hypertension Active bleeding Hemophilia Recent stroke Pregnancy Recent surgery Contraindications for acetylsalicylic acid Acetylsalicylic acid is contraindicated in which of the following scenarios? Select all that apply. In patients who are at risk for stroke or myocardial infarction (MI) In combination with nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with a known allergy to acetylsalicylic acid In combination with steroids or nonsteroidal anti-inflammatory drugs (NSAIDs) Older adults who exhibit flu-like symptoms Nursing Application: Coagulation Modifiers Prepare: Nursing Application for Coagulation Modifiers Black Box Warnings The nurse should be aware that black box warnings are present for which antiplatelet medications? Select all that apply. clopidogrel rivaroxaban prasugrel ticagrelor Therapeutic Effects Which assessment findings indicate a therapeutic response to coagulation modifying drugs? Select all that apply. Improved circulation Decreased blood pressure Improved tissue perfusion Increased pain Main Complication Which of th

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