Class Notes: Coag and Lipidemia PDF

Class Notes: Coag and lipidemia Ch 9 Thrombogeneis: formation of blood clots - Dependent on hemostasis, endothelial function, platelets, coag factors - Hemostasis- where body is optimal and works its best - If body is not at optimal working, impacts clot formation -...

Class Notes: Coag and lipidemia Ch 9 Thrombogeneis: formation of blood clots - Dependent on hemostasis, endothelial function, platelets, coag factors - Hemostasis- where body is optimal and works its best - If body is not at optimal working, impacts clot formation - Endothelial ( lining of blood vessels) function- if it is working improperly can impact clotting - Platelets- cause red blood cellls to stick together - When you have a lot you clot more frequently - When you have less you bleed more - Coagulation factors - 2-12 - Clotting factors come from the liver Hemostasis: maintenance of the vascular system Clot lysis (thrombolysis)- body is breaking up clots (process listen below) - Plasminogen (released from the liver) forms with the clot - The clot serves its function of protecting from hemorrhage - Once complete, Plasmin is produced to help breakdown the clot - Clots are constantly being formed and destroyed within the body - Clots form as a result of Vit K clotting factors: II, VII, IX, X; Pure anticoags to affect factors IX, X, XI, XII; or through platlett function Hematoma- internal bleeding, localized blood clot, takes longer to resolve Plasmin works slower Types of clots Arterial: such as with atherosclerosis - These clots cause heart attacks - Can cause strokes (95% of all strokes are clot related) Venous: such as DVT - If you have DVT worry is small portions of the clot breaking off and migrating to other parts of the body such as the lungs and causing PE, migrating to the brain and causing stroke, etc. Atherosclerosis: Discuss pathophys Anticoag drugs: - Heparins- short acting anticoagulant ( Heparin is more so for prevention of new clots and mainly given in the hospital due to monitoring) - Anticoag naturally present in the body: liver and lungs - Sometimes not enough is produced in the body - Hemostasis is off - Exogenous: bovine lung, porcine intestine - Must be given SQ or IV: GI track does not absorb - Action - Combines with antithrombin III (body produces this) to inactivate factors: IX, X, XI, XII - Inhibits additional clot after the initial clot has formed. - Won't break down the clot that is already there - Can be used prophylactically - Given prior to some surgeries (ortho mainly) - More likely to form a clot - See Table 9.2 pg151(won't be a question on the exam) - Side Effects - Hemorrhage - If heparin is a anticoagulant, it will cause issues with bleeding - Internal bleeding (brain mainly) - More so with if you have a fall while on this med - GI tract- bloody stool, bloody vomit - Bloody urine- tea colored urine - Lungs- cough up blood - Brushing teeth - Women- can have heavy, prolonged menstrual periods - Cause anemia - Nose bleeds - While shaving - HIT (don't worry about) - Drug interactions: See Box 9.1pg 143 - Ceflasporin- abx - Penicillins - Warfarin (Coumadin) - Contraindications - Conditions or medications that would prevent prescription of this drug - Hemophiliac - Pregnancy - Stomach ulcers (can cause a GI bleed) - Monitoring: - aPTT (activated partial prothrombin time) - blood gets taken to lab and lab tests for how long it takes for blood to clot - Normal value is 25-30 seconds - With heparin you are looking for 2-3x that amount - 75-100 seconds - If I takes 2-3 mins to clot - Pt has too much heparin in the body - You would stop the drip and contact the provider - Protamine sulfate is the antidote if Pt gets too much heparin - What should the nurse assess to see if Heparin is working? - aPTT - usually done 1-2 a day - Heparin is typically given in stomach BID - What patient teaching should the nurse do for a patient taking heparin? - Don't fall, eliminate any hazards in your household - Rugs, stairs, pets, tall beds, wires, - Injection site might bleed - May have more bruising, even just bumping into things - Use an electric razor - Vit K Antagonists - Warfarin ( Coumadin brand name) - Most Pt's get started on this before being D/C, and while on heparin drip - Most common oral anticoag - Action - Works in the liver to block synthesis of vit K dependent clotting factors: II, VII, IX, X - Takes up to 5 days to work - Vit K is the antidote - In dark green, leafy veggies - Spinach is the highest - Alcohol is a natural anticoagulant - If drink on this med, more risk for bleeding - Side effects - Hemorrhage - N/V abd pain, dizziness, joint/muscle pain ( very rare) - Black box warning - It can cause major or fatal bleeding - Monitoring - INR- international Ratio, monitoring for warfarin - usually a finger stick - Normal INR is less than 1 - If on anticoagulant like warfarin- want 2-3 - Preg category X - If woman do need an anticoagulant it would be lovenox - Woman with frequent abortions due to cloating issues are Rx lovenox - Lovenox- low molecular weight of heparin - Direct Factor Xa inhibitors (category) ( this class of medication is on the BEERs list) - Xa turns prothrombin into thrombin to promote clotting. These drugs inhibit this factor to prevent clot formation. - Elliquis ( less bleeding, as effective as warfarin) - Rivaroxaban (Xarelto) - As effective as Warfarin, but associated with less bleeding - Action - Inhibits platelet activation and fibrin clotting of factor Xa - Used in treatment and prevention of venous thrombus and stroke, afib - Afib- atria does not contract fully, it "quivers", the ventricles do contract normally - Blood moves slower in the atria, causing blood clots - Eventually heart failure - Adverse effects - Similar to others - Hemorrhage - Monitoring - No INR or lab tests necessary - Interactions: - See box 9.9 pg 148 - On BEERS - The population taking this is those classified under BEERS - Other anticoagulants - Aspirin - Amioderone - Atorvastatin and estrogen derived meds slow down the effectiveness of these meds - Antiplatelet drugs - Prevent one or more steps in the prothrombotic activity - Inhibit platelet activity, adhesion, aggregation, procoagulant activity - Adenosine diphosphate receptor antagonist ( Will not be asked about this name) - Clopidogrel (Plavix) - Action: - Irreversibly blocks ADP receptor on platelets - Nothing sticks together - Onset 2 hours.. but loading dose needed - Higher dose needing initially, then back off to lower normal dose - Uses: - Stents, MI, CVA, Atherosclerosis, CAD, AFib (some) - Side effects; - Pruritus (itching), rash, purpura (purple hemmoragic rash of the skin), diarrhea - Thrombotic thrombycytopenic purpura TTP- purple discoloration to the mucosa membranes, normally in the mouth - Hemorrhage - Neutropenia (severe)- low neutrophils in CBC - See Table 9.3 pg 162 - Administering - Taken daily - What nursing actions are necessary to assess the therapeutic effects of this drug? - Prevent bleeding, refer to other actions - Aspirin - Thromboxane A2 inhibitor - Inhibits synthesis of prostaglandins - Prostaglandins-Chemical that is released in the body in response to stress or injury - Cause fever and pain - Provides antiplatelet properties - Makes red blood cells less "sticky" - Uses: - Artificial heart valves: prevents clots - Immediate use for suspected MI, CVA, TIA - If medic present to house of someone having CP and suspected of MI, they will have pt chew 2 adult aspirins - Antiplatelet activity reverses after drug is stopped - Takes 14 days to leave system - Interacts with NSAIDS but not acetaminophen - Thrombolytic drugs - Alteplase (rTPA)- mainly done in ED only given for STEMI ( ST Elevated MI) - Encourages plasminogen to plasmin, which breaks down a clot - "Clot buster" - Administered IV - Heparin, warfarin and antiplatelets are given after rTPA to prevent further clot formation - Side effects; bleeding.. - Contraindications: See pg 167 - Who can give rTPA? - What nursing actions are necessary when giving this drug? 1. What assessments are MOST important at this time? Why? a. Monitor for bleeding because he just received a dose of TPA i. Prevent death, don't want a hemmorage 2. What type of medication is this? What type of lab monitoring should the nurse expect? b. Anticoagulant, need to do a APTT 3. What is happening here with the labs? What does this mean? What should the nurse do next? c. Blood is "too thin" not clotting quick enough ii. Stop the heparin, clamp the IV iii. Contact the provider 4. What precautions should the nurse take at this point? d. Pt is now at risk for another clot, and another MI which brought him in e. Monitor for bleeding 5. What does this mean? f. Pt is now within range of clotting 6. What does this lab value indicate? g. He is theraputic, blood is good level to prevent clots 7. What patient teaching regarding the warfarin should the nurse provide? h. Risk for bleeding i. Prevent falls and bruising j. Diet, be consistent with the leafy greens, but don't binge Chapter 10: Dyslipidemia Cholesterol, Phospholipids, triglycerides all form lipids in the blood - Total ( less than 200), HDL( greater than 40), LDL(less than 150), Triglycerides ( measure to fat and sugar in blood, less than 150) - Required for normal cellular function - Found in most cells in the body - People die when cholesterol gets too low. - Total Cholesterol less than 100= death - Amount in the blood highly correlated with dietary intake of saturated fats and cholesterol products - Cheeseburgers - Red meats - Cookies, cakes, pies, brownies, candies - Gravy, processed meats - Liver producing too much (hereditary) - Increased levels associated with atherosclerosis, heart disease, CVD - May be primary (familial) or secondary (diet, diabetes) - Metabolic syndrome: - Central obesity- fat around the abdomen - Elevated triglycerides - Reduced HDL - HTN - Hyperglycemia, especially fasting - Manifestations - Variety of presentations. - Often assymptmatic - Found out based on random blood draw - As low as 6 years old can have dyslipidemia - Routinely start checking cholesterol levels on children at 11 - Processed sugar and carbs - Inactivity - Management - Lifestyle interventions - Changing diet ( you are what you eat) - Increase veggies and fruits - Increase lean meats- fish, venison, chicken, turkey, lean pork - Exercise - Decrease processed foods, refined carbs, and processed sugars - Losing weight - Exercising - Se box 10.2 pg 178 - Reduces total, LDL, VLDL, Triglycerides - Can slightly raise HDL as well as - Uses as primary prevention for CAD, CVD - Uses as treatment for CAD, CVD - Action: First pass effect in the liver, lowers drug availability in the blood - Best time to take is with your evening meal - By the time that you are sleeping and liver is peaking at rate of producing cholesterol, your blood drug levels are increased, absorbed more - CYP450 enzymes necessary for metabolism in the liver - Causes increased drug interactions and food interactions (grapefruit) - Avoid grapefruit, interacts with the med and causes not to work - Takes the same enzyme pathway - Various patient populations: good choice for aggressive LDL reduction - Side Effects - Generally well tolerated - Nausea, diarrhea, constipation, headache , rash - Hepatic dysfunction (elevated LFTS) - Can damage the liver - ALT - LST - Myopathies - Range from muscle soreness to rhabdomyolysis - Rhabdomyolysis- kidney weakness - Increased age, frail, small body frame, high dose, hypothyroid, renal disease increase the risk - Preg category X - For all Statins - Best administered with evening meal as liver synthesizes most cholesterol at night Bile Acid Sequestrants Cholestyramine (questran) - Action - Binds with cholesterol in the intestine and prevents absorption. - Excreted in feces - Useful as adjunct therapy, questionable monotherapy - Side effects - GI - Constipation - Contraindicated with biliary obstruction - Administration - Take with plenty of water - Do not take within 4-6 hours of other drugs - Time of day does not matter Fibrates Fenofibrate (tricor) - Increase oxidation of fatty acids in the liver - Decrease hepatic production of Chol, LDL, Trigly, Increase HDL - Use - High triglycerides and as addition to statins - Adverse effects - GI related - Gallstones - Administration - Give with food to increase absorption **Case** Refer to the above case for case history. Jay's lipid profile returns as: TChol 288 HDL 25 LDL 200 Trig 350 He is prescribed atorvastatin 20 mg prior to hospital discharge 1. What patient teaching regarding the atorvastatin are important for the nurse to discuss? Why? a. Take in the evening around your last meal b. Avoid grapefruit c. Be aware of any muscle aches d. Change diet, and increase exercise 2. What dietary recommendations are important for Jay. e. No grapefruit f. Avoid processed meats, processed sugars, and refined carbs. g. Avoid red meat and fatty fish ( Salmon) h. Increase intake of veggie and fruit. Mainly increase broccoli, Brussels sprouts, cabbage, cauliflower. i. Eat potatoes, beans, and corn in moderation j. Increase lean meats such as fish, lean pork, venison, chicken, turkey 3. What type of lab follow up do you expect for his hyperlipidemia? k. Every 6 months i. Lipid profile ii. CMP iii. LFT