CARE OF PATIENT ON Anti coagulants

CARE OF PATIENT ON
ANTICOAGULANTS
MATHEW VARGHESE V
MSN(RAK),FHNP (CMC Vellore),
CPEPC
Nursing officer
AIIMS Delhi
1
MATHEWVMATHS@YAHOO.CO.IN

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

HEPARIN (UFH)
3

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

PARENTERAL ANTICOAGULANTS
Indirect Thrombin inhibitors
E.g.. Heparin and heparin- related agents
5

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

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

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

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

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

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

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

NURSING CARE
 Check for S/S of bleeding
 Epistaxis
 Gum Bleeding
 Hemoptysis
 Hemet emesis
 Melina
 Ecchymosis
 Petechiae
 Heavy Menstrual Hemorrhage
 Bleeding from wounds
13

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

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

LMWHS
 EXAMPLES
 Clexane
 Enoxaparin
 Uses
 Treatment of DVT
 Treatment of ACS
 Prevention of DVT
 Treatment of PE
16

AVAILABLE FORMS
 30 mcg (0.3ml)
 40 mcg (0.4ml)
 60 mcg (0.6ml)
 80 mcg (0.8ml)
 100 mcg (1ml)
17

CONTRAINDICATIONS OF LMWHS
 In C/o GI bleeding
 HIT
 Neonates
 Hemophilia
 Heparin allergy
18

ADVERSE EFFECTS
 Nausea
 Diarrhoea
 Fever
 Edema in feet and hands
 Injection site swelling, redness, bruising,
tenderness
19

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

 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

22

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

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

ORAL ANTICOAGULANTS
“VITAMIN K ANTAGONISTS”
 Warfarin
25

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

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

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

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

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

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

AVOID VITAMIN K RICH FOOD
32

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

ADVERSE EVENTS
 Sudden headaches
 Fatigue
 Dizziness
 Unusual bruising
 Bleeding gums
 Nose bleeds
 Heavy menstrual bleeds
 Heamturia
 Melina
 Hemoptysis
 Hematomas
 Ecchymosis
 Petechiae 34

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

CARE OF PATIENT ON Anti coagulants

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CARE OF PATIENT ON Anti coagulants