Chapter 37

Anticoagulant & Thrombolytic

Drugs
Mrs. Davis, MSN/RN
2020
 Hemostasis & Thrombosis
• Hemostasis: complex process by which fibrin forms and blood clots

• Thrombosis: process/formation of a blood clot; Deep Vein Thrombosis

(DVT)
• Thrombus: blood clot

• Embolus: thrombus that detaches from a blood vessel wall and travels
through the bloodstream

• Pulmonary embolism: goes to the lung and obstructs a pulmonary vessel

• Myocardial infarction occurs if the embolus detaches and occludes a

vessel supplying blood to the heart
 Oral & Parenteral Anticoagulants
• Anticoagulants: prevent the formation and extension of a thrombus;
(once the presence of a thrombus has been established anticoagulant
therapy can prevent additional clots from forming)
 Warfarin/Coumadin: oral anticoagulant; Peak activity is reached 1.5
to 3 days after therapy is initiated
 Fractionated and unfractionated heparin
 used prophylactically in patients who are at high risk for clot
formation
 used to prevent DVT in patients undergoing hip; knee; abdominal
surgeries - apixaban (Eliquis); rivaroxaban (Xarelto)

• Low–molecular-weight heparins (LMWHs) - enoxaparin (Lovenox)

 Produce stable responses when administered at recommended
dosages; bleeding less likely to occur
 Oral & Parenteral Anticoagulants:
Actions
• anticoagulants interfere with the clotting mechanism of the blood

• Warfarin interferes with the manufacturing of vitamin K–dependent clotting

factors by the liver
• Warfarin: depletes prothrombin (essential for the clotting of blood)

• Heparin: Heparin is inactivated by gastric acid in the stomach; must be given by

injection
 Inhibits formation of fibrin clots
 Inhibits conversion of fibrinogen to fibrin
 Inactivates factors necessary for clotting of blood

• LMWHs: inhibit clotting reactions by binding to antithrombin III; preventing the

formation of new blood clots
 Oral & Parenteral Anticoagulants:
Uses

• Prevention (prophylaxis) and treatment of DVT

• Prevention/treatment of atrial fibrillation with embolization
• Prevention/treatment of PE
• Adjuvant treatment of MI
• Prevention of thrombus formation after valve replacement surgery
 Oral & Parenteral Anticoagulants:
Uses Review
Nursing Alert
pg. 422
• Parenteral anticoagulants are used specifically for the following:
• Prevention of postoperative DVT/PE
• Prevention of clotting in arterial/heart surgery; extracorporeal
(occurring outside the body) circulation; dialysis procedures; blood
transfusions; blood samples for laboratory purposes
• Prevention of a repeat cerebral thrombosis (stroke)
• Treatment of coronary occlusion; acute MI; peripheral arterial embolism
• Diagnosis/treatment of disseminated intravascular coagulation (DIC) a
severe hemorrhagic disorder
• Maintaining patency of intravenous (IV) catheters (very low doses of 10 to
100 units)
 Oral & Parenteral Anticoagulants:
Adverse Reactions
• bleeding which may range from very mild to severe (skin such as bruising
and petechiae; bladder; bowel; stomach; uterus; mucous membranes

• Nausea; vomiting; abdominal cramping; diarrhea

• Alopecia (loss of hair)
• Rash or urticaria (hives)
• Hepatitis (inflammation of the liver); jaundice (yellowish discoloration of
the skin and mucous membranes); thrombocytopenia (low platelet
count); blood dyscrasias (disorders)
• local irritation when heparin is given by the subcutaneous route;
hypersensitivity reactions which include fever; chills; asthma-like
reaction; anaphylactic reaction
 Oral & Parenteral Anticoagulants:
Contraindications
• Contraindicated in patients:
 With known hypersensitivity to drugs; active bleeding; hemorrhagic
disease; tuberculosis; leukemia; uncontrolled hypertension;
gastrointestinal (GI) ulcers; recent surgery of the eye or central nervous
system (CNS); aneurysms; severe renal/hepatic disease

Review
 During lactation Lifespan Considerations
pg. 422

 Use during pregnancy can cause fetal death (oral agents are in pregnancy
category X; parenteral agents are in pregnancy category C)

 LMWHs are contraindicated in patients with a hypersensitivity to pork

products
 Oral & Parenteral Anticoagulants:
Precautions
• Used cautiously in patients with:
 Fever; heart failure; diarrhea; diabetes; malignancy; hypertension;
renal/hepatic disease; psychoses; depression
 Apixaban is monitored because of the greater chance of stroke when
discontinued
 Anyone with a potential site for bleeding/hemorrhage

• Women of childbearing age: use a reliable contraceptive to prevent

pregnancy
Review
Nursing Alert
pg. 423
 Oral & Parenteral Anticoagulants:
Interactions Review
Herbal Considerations
Interactant drug: Effect of interaction: pg. 423
Aspirin, acetaminophen, Increased risk for bleeding
NSAIDs, chloral hydrate
Penicillin, aminoglycosides, Increased risk for bleeding
isoniazid, tetracyclines,
cephalosporins

Beta blockers, loop diuretics Increased risk for bleeding

Disulfiram, cimetidine Increased risk for bleeding
Oral contraceptives, Decreased effectiveness of the
barbiturates, diuretics, vitamin anticoagulant
K

Grapefruit and its juice will increase serum

levels of apixaban and rivaroxaban
 Antiplatelet Drugs: Actions & Uses
• antiplatelet drugs are used to prevent thrombus formation in
the arterial system
• aspirin therapy; antiplatelet drugs include adenosine diphosphate (ADP)
receptor blockers; glycoprotein receptor blockers

• Aspirin: prohibits aggregation (sticking together) of platelets for lifetime of

platelet; prevent/decrease clot formation
•
• ADP blockers: alter cell membrane; preventing aggregation

• Glycoprotein receptor blockers: prevent enzyme production; inhibit platelet

aggregation

• Antiplatelet drug therapy: treats acute coronary syndrome; myocardial

infarction; stroke; intermittent claudication
Antiplatelet Drugs: Adverse Reactions

• Common adverse reactions:

 Heart palpitations
 Bleeding
 Dizziness and headache
 Nausea; diarrhea; constipation; dyspepsia
 Antiplatelet Drugs:
Contraindications & Precautions
• Contraindicated in patients:
 With known hypersensitivity to the drug; congestive heart failure; active
bleeding; thrombotic thrombocytopenic purpura (TTP)
 During pregnancy and lactation - Clopidogrel (pregnancy category B); others
are (pregnancy category C); none have been studied in humans

• Used cautiously in:

 Elderly patients; pancytopenic patients; those with renal/hepatic impairment

• If TTP is diagnosed – stop the medication immediately

• Antiplatelet drugs should be discontinued 1 week before any surgical procedure

Antiplatelet Drugs: Interactions
Use specific guidelines provided for each product

Interactant drug: Effect of interaction:

Aspirin and NSAIDs Increased risk for bleeding

Macrolide antibiotics Increased effectiveness of anti-

infective

Digoxin Decreased digoxin serum levels

Phenytoin Increased phenytoin serum

levels
 Thrombolytic Drugs

• dissolves blood clots that have already formed within the walls of a blood
vessel

• reopen blood vessels after they become occluded

• thrombolytic drugs (fibrolytic)

• alteplase recombinant (Activase)
• tenecteplase (TNKase)
 Thrombolytic Drugs: Actions

• break down fibrin clots by converting plasminogen to plasmin

• reopens blood vessels after their occlusion and prevents tissue necrosis

• bleeding is a great concern when using these agents

• Before these drugs are used potential benefits must be weighed carefully
against potential dangers of bleeding
 Thrombolytic Drugs: Uses

• Used to treat:
 Acute stroke or myocardial infarction by lysis (breaking up) blood
clots in coronary arteries

 Blood clots causing pulmonary emboli and DVT

 Suspected occlusions in central venous catheters

 Thrombolytic Drugs:
Adverse Reactions

• Bleeding – most commonly seen

 Internal bleeding: GI tract; genitourinary tract; brain
 External bleeding: broken skin such as venipuncture sites; recent
surgical wounds

• Allergic reactions
 Thrombolytic Drugs:
Contraindications & Precautions
• Contraindicated in patients:
 With known hypersensitivity; active bleeding; history of stroke;
aneurysm; recent intracranial surgery

• Used cautiously in patients:

 Who have recently undergone major surgery (within 10 days) such as
CABG; stroke; trauma; vaginal/c-section delivery; GI bleed
 hypertension; diabetic retinopathy; any condition in which bleeding is
a significant possibility
 Currently receiving oral anticoagulants

• thrombolytic drugs are classified (pregnancy category C); urokinase is

(pregnancy category B)
 Thrombolytic Drugs:
Interactions

• Increased risk for bleeding when co-administered with medications that

prevent blood clots or with an anticoagulant (aspirin, dipyridamole)
 Nursing Process: Assessment
• Preadministration assessment:
  preventative anticoagulant therapy – if any limited mobility
 Examine extremity for color and skin temperature
 Vital Signs; check for pedal pulses; noting rate and strength of pulses;
document any difference between affected/unaffected side
 Note areas of redness or tenderness and ask patient to describe
current symptoms
 affected extremity may appear edematous; positive Homans sign (pain
in the calf when the foot is dorsiflexed) may be elicited which suggests
DVT
 Obtain drug history for the past 2-3 weeks
 first dose of warfarin is not given until blood is drawn; prothrombin
time (PT); international normalized ratio (INR); dose individualized
based on the results of PT/INR; most commonly used test to monitor
heparin is the activated partial thromboplastin time (aPTT)
 Nursing Process: Assessment

 Thrombolytic agents are typically used under urgent circumstances

such as a heart attack or stroke
 complete blood count is usually drawn before the administration of
the thrombolytic agents
 (CT) may be performed
 Most patients receiving a thrombolytic agent are admitted or
transferred to an intensive care unit; close monitoring is necessary for
48 hours or more after therapy
 patient experiencing pain because of the blood clot include a thorough
pain assessment
 Nursing Process: Assessment
Review
• Ongoing assessment: Nursing Alert
pg. 425
 continually assess the patient for any signs of bleeding and hemorrhage
 Areas of assessment include the gums; nose; stools; urine; nasogastric
drainage
 Level of consciousness should be assessed on a routine basis to monitor
for intracranial bleeding
 Patients receiving warfarin for the first time often require daily
adjustment of the dose based on the daily PT/INR results; PT exceeds
1.2 to 1.5 times the control value/INR ratio exceeds 3 notify physician
Review
before the drug is given (some physicians will give an order with
Box 37.1 parameters as to how to administer the medication based on the lab
pg. 425 results); INR stabilized it is monitored every 4 to 6 weeks;  therapeutic
dosage is attained when the aPTT is 1.5 to 2.5 times the normal
 platelet counts; hematocrit; test for occult blood in the stool should be
performed throughout the course of heparin therapy
 Nursing Process: Assessment

 monitor for any indication of hypersensitivity reaction

 Report reactions such as chills; fever; hives to physician;
 Examine skin temperature/color in the patient with a DVT for signs of
improvement
 Check/document vital signs every 4 hours or more frequently if
needed
 heparin (prophylaxis) observe the patient for signs of thrombus
formation every 2 to 4 hours
 Signs/symptoms of thrombus formation vary depending on the
area/organ involved evaluate/report any complaint or change in the
patient’s condition to the physician
 Nursing Process:
Nursing Diagnoses

• Risk for Injury related to excessive bleeding because of drug therapy

• Readiness for Enhanced Health Management related to preparing to

communicate drug use if incapacitated

• Anxiety related to fear of atypical bleeding during thrombolytic drug

therapy
 Nursing Process: Planning

• Expected outcome
 Optimal response to therapy

 Support of patient needs related to management of adverse reactions

 confidence in an understanding of the medication regimen

 Nursing Process: Implementation

• Promoting an optimal response to therapy

 Oral administration of anticoagulants:
 To hasten the onset of the therapeutic effect a higher dose heparin
(loading dose) may be prescribed for 2 to 4 days followed by a
maintenance dosage warfarin adjusted according to the daily
PT/INR
 drug takes 3 to 5 days to reach therapeutic levels
 typically given in the evening at a specified time
 diet can influence the PT/INR values; maintain a consistent
daily intake of vitamin K
 Nursing Process: Implementation
Review
Nursing Alert
• Parenteral administration of anticoagulants: pg. 426
 Administration of heparin: intermittent IV; continuous IV infusion
(application of firm pressure after the injection helps to prevent
hematoma formation); subcutaneous route (rotate sites and
document on medication record)
 onset of anticoagulation is almost immediate after a single dose
 Maximum effects occur within 10 minutes of administration
 Clotting time returns to normal within 4 hours
 dosage of heparin is measured in units and is available in various
dosage strengths as units per milliliter; best practice – double check
dose with another nurse prior to administering medication
Nursing Process: Implementation

 Heparin IV needs to be on a pump and checked every 1-2 hours

 Inspect needle site for signs of inflammation; pain; tenderness along
pathway of vein – if present stop infusion; restart in another vein
 Closely monitor blood coagulation tests; complete blood count;
platelets; stool analysis
  LMWHs and the DTIs do not require close monitoring of blood
coagulation tests
 platelet count of less than 100,000 mm3 should be brought to the
physician’s attention; may discontinue the heparin therapy
 Overdose of antiplatelet drugs managed by withholding treatment or
by infusion of platelets
Review
Nursing Alert
pg. 427
 Nursing Process: Implementation
• Administration of thrombolytics:
 optimal therapeutic effect within 4 to 6 hours or as soon as possible
after the symptoms are identified; greatest chance of recovery from an
ischemic stroke is when the tPA drug is administered within 3 hours
(small window of opportunity)
 Timing of the onset of symptoms is important; get estimates of the
timing of symptoms
 Assess patient for bleeding (every 15 minutes during the first 60
minutes of therapy; every 15 to 30 minutes for the next 8 hours; every
4 hours until therapy is completed); vital signs monitored
continuously (hence ICU admission)
 Administer opioid analgesic for pain management; once clot dissolves
pain decreases
 Nursing Process: Implementation
• Monitoring and managing patient needs:
 Risk for injury
 Bleeding can occur any time during therapy
 nursing personnel and medical team members should be made
aware of warfarin therapy; if bleeding occurs the physician may
decrease the dose; discontinue the heparin therapy; order the
administration of protamine sulfate
 Check for signs of bleeding: Review
Nursing Alert
drop in blood pressure; rise in pulse rate
pg. 427
urine; stool
visually check nasogastric suction
Bruising/bleeding from injection sites
check toothbrush; gums after oral care
 Nursing Process: Implementation

• Readiness for Enhanced Health Management:

 be aware of the many food and drug interactions
 medical alert bracelet and list of drugs being taken should be on
the patient at all times
 notify all health care providers of the anticoagulant or antiplatelet
therapy when diagnostic tests or other treatments are performed
  prolonged pressure on the venipuncture site is necessary
Nursing Process: Implementation
 Anxiety:
 Bleeding is the most common adverse reaction when thrombolytic
drugs are administered
 Conditions requiring thrombolytic treatment are typically of an
urgent nature and treatment occurs in special care units of the
hospital such as the intensive care unit or operating room
 Reassure patient and communicate with family member
 Assess for signs of bleeding and hemorrhage
Internal bleeding may involve the GI tract; genitourinary tract;
intracranial sites; respiratory tract
Signs/symptoms of internal bleeding may include abdominal
pain; coffee ground emesis; black, tarry stools; hematuria; joint
pain; spitting/coughing up blood
Nursing Process: Implementation
 monitor all potential bleeding sites - catheter insertion sites;
arterial/venous puncture sites; cutdown sites; needle puncture
sites
 uncontrolled bleeding or the bleeding appears to be internal stop
the drug/immediately contact physician Review
 whole blood; packed red cells; fresh frozen plasma may be Nursing Alert
required pg. 428
 Continuous monitoring of vital signs for at least 48 hours after the
drug is discontinued
 Contact physician if marked change in one or more of the vital
signs
 signs of an allergic (hypersensitivity) reaction such as difficulty
breathing; wheezing; hives; skin rash; hypotension report
immediately to the physician
 Nursing Process: Implementation
• Managing anticoagulant overdosage:
 Oral anticoagulants
 PT exceeds 1.5 times the control value or INR exceeds 3
 Monitor for symptoms of warfarin overdosage:
Blood in stool; petechiae
Oozing from superficial injuries
Bleeding gums; excessive menstrual bleeding
 discontinue anticoagulant therapy; order vitamin K
(phytonadione); anticoagulant antagonist should be available
when a patient is receiving warfarin
 Assess patient for bleeding until the PT is below 1.5 or bleeding
episodes cease
 PT returns to safe level within 6 hours of vitamin K being given;
whole blood/plasma for severe bleeding
 Nursing Process: Implementation
• Managing anticoagulant overdosage:
 Parenteral anticoagulants:
 discontinuation of the drug is sufficient to correct
overdosage because the duration of action of heparin is brief
 hemorrhaging severe protamine the specific heparin
antagonist or antidote may be given (onset immediate;
duration 2 hours); IV push over 10 minutes
 After administration of protamine: monitor blood pressure and
pulse rate every 15-30 minutes for 2 hours
 Observe new evidence of bleeding until blood coagulation tests are
within normal limits
 Blood transfusions or fresh frozen plasma may be ordered
 Nursing Process: Implementation

• Educating the patient and family:

 clinical pharmacist responsible for anticoagulant teaching; A
thorough review of dosage regimen; possible adverse reactions; early
signs of bleeding help the patient cooperate with the prescribed
therapy; you as the nurse reinforce and validate learning of
patient/family
 Follow the dosage schedule prescribed; report signs of bleeding
immediately
 PT/INR will be monitored
 Don’t stop taking the drug unless physician instructs you to do so
 inform dentist or medical/nursing team of therapy before any
treatment
Nursing Process: Implementation
 Take medication at the same time every day
 Don’t change brands of drugs without notifying physician
 Avoid alcohol
 Know foods high in Vitamin K (green leafy vegetables)
 Therapy lowers blood counts; may be at greater risk of infection
during the first 3 months of treatment
 evidence of bleeding (unusual bleeding/bruising; bleeding gums;
blood in the urine/stool; black stool; diarrhea; omit next dose and
notify physician immediately
 Soft toothbrush; electric razor
 Use reliable contraception to avoid pregnancy
 Wear medical identification band
 Nursing Process: Evaluation
• Therapeutic drug effect is achieved; blood coagulation is controlled

• Adverse reactions are identified; reported; managed successfully with

appropriate nursing interventions

• No evidence of injury

• Patient enhances health management effectively

• Anxiety is managed successfully

• Patient and family express confidence and demonstrate an understanding

of the drug regimen
 Question #1

Is the following statement true or false?

Hemostasis is the process of clotting; this is beneficial when injury tears a

vessel.
 Answer to Question #1

True

Hemostasis is the process of clotting; this is beneficial when injury tears a

vessel.
 Question #2

Is the following statement true or false?

A thrombus is a clot that forms in a vessel and impedes blood flow.

 Answer to Question #2

True

A thrombus is a clot that forms in a vessel and impedes blood flow.

 Question #3

Is the following statement true or false?

Anticoagulants do reverse damage already done by a clot.

 Answer to Question #3

False

These drugs do not affect existing clots, nor do they reverse damage already
done by a clot. These drugs are used to prevent further clot development.
 REVIEW:

Review
Key Points
pg. 429

Review
Drug Table
pg. 429

Complete:
Key Terms
&
Chapter Review