1. Drugs Used to Treat Thromboembolic Disorders Chapter 27 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

2. Slide 2 Chapter 27 Lesson 27.1 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

3. Slide 3 Objectives Describe conditions that place an individual at risk for developing blood clots Analyze Figure 27-1 to identify the site of action of warfarin, heparin, and fibrinolytic agents State the primary purposes of anticoagulant therapy Identify the effects of anticoagulant therapy on existing blood clots Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

4. Slide 4 Objectives (cont’d) Explain laboratory data used to establish dosing of anticoagulant medications Describe procedures used to ensure that the correct dose of an anticoagulant is prepared and administered Identify specific nursing interventions that can prevent clot formation Develop objectives for patient education for patients receiving anticoagulant therapy Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

5. Slide 5 Thromboembolic Diseases Include the process of forming a blood clot or thrombus Fragments of a thrombus can break off and circulate until trapped in a capillary, creating an embolus Clotting cascade is activated when a blood vessel is injured, or with increased viscosity Intrinsic clotting pathway Extrinsic clotting pathway Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

6. Slide 6 Nonpharmacologic Treatment of Thromboembolic Diseases Prevention of conditions that cause clots to form  Immobilization with venous stasis  Surgery, trauma to lower limbs  Heart failure, vasospasm  Cancers of the lung, prostate, stomach, pancreas  Pregnancy, oral contraceptives Ways to prevent stasis: leg exercises, wearing stockings, leg elevation, sequential compression devices Revascularization treatments: percutaneous coronary intervention, coronary artery bypass graft Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

7. Slide 7 Drug Therapy Goals for Thromboembolic Diseases Primary purpose is to prevent platelet aggregation or inhibit steps in the clotting cascade Four types of agents  Platelet inhibitors  Anticoagulants  Glycoprotein IIb/IIIa inhibitors  Thrombolytics Anticoagulation therapy prevents new clot formation or extension of existing clots Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

8. Slide 8 Laboratory Tests for Thromboembolic Diseases Coagulation tests  PT (prothrombin time)  aPTT (activated partial thromboplastin time)  INR (international normalized ratio)  Platelet counts Diagnostic tests  PT, aPTT, hematocrit, platelet count, Doppler studies, exercise testing, serum triglycerides, arteriogram, cardiac enzyme studies Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

9. Slide 9 Correct Dosing Key in the treatment of conditions used to control clots Use medication administration record for scheduling Mark one-time dosages clearly Never administer anticoagulants before first checking the chart for most recent laboratory results Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

10. Slide 10 Patient Education for Anticoagulation Therapy Diet and nutrition  Limit intake of leafy green vegetables  Drink six to eight 8-ounce glasses of fluid daily Exercise and activity after surgery to prevent venous stasis Do not flex knees or place pressure under knees; avoid being motionless Medication regimen  Dose and timing, common and serious adverse effects, drug interactions Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

11. Slide 11 The Clotting Cascade Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

12. Slide 12 Chapter 27 Lesson 27.2 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

13. Slide 13 Objectives State the nursing assessments needed to monitor therapeutic response and development of common and serious adverse effects from anticoagulant therapy Explain the specific procedures and techniques used to administer heparin subcutaneously, via intermittent administration through a heparin lock, and via IV infusion Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

14. Slide 14 Objectives (cont’d) Identify the purpose, dosing determination, and scheduling factors associated with the use of protamine sulfate Describe specific monitoring procedures to detect hemorrhage in the patient taking anticoagulants Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

15. Slide 15 Drug Class: Platelet Inhibitors Actions  Inhibit platelet aggregation Uses  Primary prevention of MIs and stroke; prevent blood clots from forming Common adverse effects  Abdominal distress, hypotension Serious adverse effects  Neutropenia, agranulocytosis, bleeding Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

16. Slide 16 Drug Class: Anticoagulants Actions  Low molecular weight heparin (LMWH) Uses  Prevent deep vein thrombosis after hip replacements or abdominal surgery; prevent MIs, combined with aspirin Common adverse effects  Hematoma formation, bleeding at injection site Serious adverse effects  Bleeding, thrombocytopenia Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

17. Slide 17 Drug Class: Anticoagulants Drug: heparin Actions  In the presence of heparin, antithrombin III neutralizes thrombin, factors IXa, Xa, XI, and XII, as well as plasmin Uses  Treat deep vein thrombosis, pulmonary embolism, cerebral embolism Can be given subcutaneously, IV push, IV infusion Dosages vary depending on route Monitor aPPT, platelets, hematocrit Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

18. Slide 18 Assessment for Bleeding Monitor to detect hemorrhage Symptoms of internal bleeding  Decreased blood pressure, increased pulse, cold clammy skin, faintness, disorientation Consider all areas of the body that could begin to bleed (visible and internal) Monitor laboratory values  aPPT, platelets, hematocrit Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

19. Slide 19 Drug Class: Glycoprotein IIb/IIIa Inhibitors Drugs: abciximab (ReoPro), eptifibatide (Integrilin), tirofiban (Aggrastat) Actions  Block receptors on platelets, preventing aggregation and clot formation Uses  Prevent clots forming from the debris often released during percutaneous coronary intervention (PCI) procedures Serious adverse effects  Bleeding, thrombocytopenia Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

20. Slide 20 Drug Class: Fibrinolytic Agents Drugs: streptokinase, alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase) Actions  Stimulate the bodies own clot-dissolving mechanism, converting plasminogen to plasmin, which digests fibrin Uses  Dissolve fibrin clots secondary to coronary artery occlusion (MI), pulmonary emboli, cerebral emboli, deep venous thrombosis Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.