CARE OF PATIENT ON Anti coagulants

CARE OF PATIENT ON Anti coagulants- NURSING PPT

1. Care of patient on anticoagulants MATHEW VARGHESE V MSN(RAK ),FHNP (CMC Vellore ), CPEPC Nursing officer AIIMS Delhi 1 [email protected]

2. Drugs and coagulation Anticoagulants: prevent thrombus formation and extension by inhibiting clotting factors e.g. heparin, low molecular weight heparin, coumarins / warfarin. Antiplatelet drugs: reduce risk of clot formation by inhibiting platelet functions e.g. aspirin. Fibrinolytic agents: dissolve thrombi already formed e.g. streptokinase . 2 [email protected]

3. HEPARIN (UFH) 3 [email protected]

4. Indication of anti-coagulants Myocardial Infarction (MI) Deep venous Thrombosis (DVT) Pulmonary Embolism (PE) Unstable Angina Arterial Thromboembolism Anticoagulants are also used in blood transfusions, and dialysis procedures 4 [email protected]

5. Parenteral Anticoagulants Indirect Thrombin inhibitors E.g.. Heparin and heparin- related agents 5 [email protected]

6. Heparin and related H- agents Heparin is an injectable rapidly acting anticoagulant Active in vitro and in vivo Low–molecular–weight forms (LMWHs), 1/3 the size of UFH are used as well and have many advantages over UFH 6 [email protected]

7. Heparin: Mechanism of action Indirect Thrombin Inhibitor It acts indirectly by increasing the activity of the endogenous anticoagulant “ antithrombin III” (1000 folds) which inhibits activated clotting factors mainly thrombin (factor IIa ) and Xa When Heparin binds to antithrombin III, it causes conformational changes that accelerates its rate of action 1000 fold 7 [email protected]

8. UFH : Pharmacokinetics Heparin is not absorbed from the GIT It should be administered by IV or SC injection. Not injected IM as it causes hematomas at injection site Once in the blood stream, UFH binds to plasma proteins, endothelial cells and macrophages Heparin does not cross the placenta; therefore it is the drug of choice as anticoagulant during pregnancy 8 [email protected]

9. Diagnostic tests Close monitoring of the activated partial thromboplastin time ( aPTT ) is necessary in patients receiving UFH. ACT CBC- To r/o HIT PT 9 [email protected]

10. Disadvantages of UFH The need for regular monitoring ( aPTT ) UFH carries a risk of heparin-induced thrombocytopenia (HIT), a fall in the platelet count and increased risk of thrombosis due to binding to platelets UFH has Very Narrow therapeutic index ,it leads to high risk of bleeding 10 [email protected]

11. Adverse effects The major adverse effect of heparin is bleeding Allergic reactions (chills, fever, urticaria ) as heparin is of animal origin and should be used cautiously in patients with allergy Long-term heparin therapy is associated with osteoporosis Heparin-induced thrombocytopenia (HIT ) 11 [email protected]

12. Heparin Toxicity Discontinuation of the drug Heparin is strongly acidic and is neutralized by i.v . Protamine sulfate (a strongly basic protein) It combines with heparin to form a stable complex devoid of anticoagulant activity 12 [email protected]

13. Nursing care Check for S/S of bleeding Epistaxis Gum Bleeding Hemoptysis Hemet emesis Melina Ecchymosis Petechiae Heavy Menstrual Hemorrhage Bleeding from wounds 13 [email protected]

14. Nursing care Check for HIT Heparin is discontinued 6-12 hrs before surgery and restarted at 200 -400 U/hr after 4-6 hrs after surgery 14 [email protected]

15. Low-Molecular-Weight Heparins LMWHs are derived from the chemical or enzymatic degradation of UFH into fragments approximately one third to the size of heparin. Have equal efficacy, without frequent laboratory monitoring ( suitable for outpatient therapy) Have a more predictable anticoagulant response ( better bioavailability, longer t 1/2) Binding to platelets and osteoblasts are reduced with LMWH compared with UFH 15 [email protected]

16. Lmwhs EXAMPLES Clexane Enoxaparin Uses Treatment of DVT Treatment of ACS Prevention of DVT Treatment of PE 16 [email protected]

17. Available forms 30 mcg (0.3ml) 40 mcg (0.4ml) 60 mcg (0.6ml) 80 mcg (0.8ml) 100 mcg (1ml) 17 [email protected]

18. Contraindications of LMWHs In C/o GI bleeding HIT Neonates Hemophilia Heparin allergy 18 [email protected]

19. Adverse effects Nausea Diarrhoea Fever Edema in feet and hands Injection site swelling, redness, bruising, tenderness 19 [email protected]

20. Nursing implications Monitor CBC, S/S of bleeding Check for Heamturia Check for stool occult blood Don’t breast feed while taking drugs Not to rub the injection site Report ant bleeding signs Should not expel the air in the prefilled syringe. It help to prevent the leakage of drug from site of injection as well as to deliver complete amount and dose of drug to the client Stop 6-12 hrs prior to surgery 20 [email protected]

21. Nursing implications Place client on supine position for injection Give injection between right and left anterolateral and poseterolateral abdominal wall Hold the skin fold between the thumb and forefinger and insert the whole length of needle in to skin fold Hold skin fold through out the injection Don’t rub injection site Store injection 15to 20 degree Celsius 21 [email protected]

22. Nursing implications 22 [email protected]

23. Synthetic Heparin Derivatives Fondaparinux is a synthetic compound that inhibits factor Xa by antithrombin but does not inhibit thrombin Advantages: Fondaparinux can be given once a day at a fixed dose without coagulation monitoring Less likely than UFH or LMWHs to trigger HIT 23 [email protected]

24. Differences between UFH and LMW Heparins Drug characteristics Heparin (UFH) LMWH IV ½ life 2 hours 4 hours Bioavailability after SC injection 20% 90% Anticoagulant response variable Predictable Major adverse effect Frequent bleeding HIT, osteoporosis Less frequent bleeding Setting for therapy Hospital Hospital and OPD Laboratory monitoring Needed aPTT Not Needed 24 [email protected]

25. Oral Anticoagulants “Vitamin K antagonists” Warfarin 25 [email protected]

26. Available forms of warfarin 1 mg 2 mg 3 mg 5 mg Uses Treat and prevent Blood clots in vein or arteries Reduce risk of stroke (Ischemic stroke) MI 26 [email protected]

27. Mechanism of Action of Warfarin Inhibits synthesis of Vitamin K-dependent coagulation factors II, VII, IX, & X as well as anticoagulant proteins C & S Does not have any effect on already-synthesized coagulation factors; therefore, the therapeutic effects are not seen until these factors are depleted 27 [email protected]

28. Coumarins : Warfarin Act only in vivo Bioavailability 100% 98% bound to plasma proteins (albumin) Monitoring anticoagulant effect of warfarin by measuring PT, which is expressed as an International Normalized Ratio (INR) 28 [email protected]

29. INR range maintained in our centre SURGERY INR A V R 2-3 M V R 2.5-3.5 TVR (BIO) 1.5-2.0 DVR 2.5-3.5 FONTAN 2-2.5 CABG+ENDARCTERECTOMY 1.5-2 AF 2-2.5 29 [email protected]

30. Disadvantages of Warfarin therapy Variable, unpredictable effect necessitating regular INR monitoring and dose adjustment Narrow therapeutic window leading to increased risk of severe bleeding Slow onset and offset of action Numerous interactions with foods containing vitamin K and drugs Warfarin is contraindicated during pregnancy as it can cross the placental barrier and cause abortion, hemorrhagic disorder in the fetus and birth defects 30 [email protected]

31. Food interactions with oral anticoagulants Green tea and leafy green vegetables Beverages such as green tea. Vegetable oils that include soybean, olive. Peas and green onions Dairy products such as yogurt Patients taking warfarin should be advised to avoid garlic supplements Note: Vitamin E may increase warfarin effect. 31 [email protected]

32. AVOID VITAMIN K RICH FOOD 32 [email protected]

33. Warfarin Toxicity Stop the drug IV injection of vitamin K Fresh frozen blood In c/o Missing of dose Take missed dose as soon as you remember If its too long time – skip the dose Don’t take extra medicine 33 [email protected]

34. Adverse events Sudden headaches Fatigue Dizziness Unusual bruising Bleeding gums Nose bleeds Heavy menstrual bleeds Heamturia Melina Hemoptysis Hematomas Ecchymosis Petechiae 34 [email protected]

35. Patient education Avoid activities that may increase the risk of bleeding or injury Take extra precautions to prevent bleeding while shaving and brushing Avoid food high in vitamin K Liver Leafy vegetables Grape fruit juice Cranberry juice Pomegranate juice Avoid alcohol Avoid NSAIDs and use Pain killers cautiously 35 [email protected]

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