PH 15 Drugs Affecting the Hematologic System.pdf

14 Drugs Affecting the Hematologic System LEARNING OUTCOMES 1. Describe the clotting mechanism in the human body. 2. Explain the difference between anticoagulant drugs and fibrinolytic drugs. 3. List the names, actions, possible side effects, and adverse effects of the common platelet inhibitors. 4...

14 Drugs Affecting the Hematologic System LEARNING OUTCOMES 1. Describe the clotting mechanism in the human body. 2. Explain the difference between anticoagulant drugs and fibrinolytic drugs. 3. List the names, actions, possible side effects, and adverse effects of the common platelet inhibitors. 4. Explain what to teach patients and families about platelet inhibitors. 5. List the names, actions, possible side effects, and adverse effects of the common direct thrombin inhibitors. 6. Explain what to teach patients and families about direct thrombin inhibitors. 7. List the names, actions, possible side effects, and adverse effects of the common indirect thrombin inhibitors. 8. Explain what to teach patients and families about indirect thrombin inhibitors. 9. List the names, actions, possible side effects, and adverse effects of the vitamin K antagonists. 10. Explain what to teach patients and families about vitamin K antagonists. 11. List the names, actions, possible side effects, and adverse effects of fibrinolytic drugs. 12. List the names, actions, possible side effects, and adverse effects of erythropoiesis-stimulating agents. 13. Explain what to teach patients and families about erythropoiesis-stimulating agents. KEY TERMS anticoagulants (ĂN-tī-kō-Ă-gyă-lěnts, p. 266) Drugs that interfere with one or more steps in the blood clotting process that either reduce or prevent new clots from forming, or prevents existing clots from getting larger. clot (klŏt, p. 266) A semi-solid amount of coagulated (thickened) blood. May also be referred to as a thrombus. deep vein thrombosis (thrăm-BŌ-sěs, p. 270) A clot lying in a deep vein, usually in the legs. direct thrombin inhibitor (DTI) (THRŎM-bĭn ĭn-HĬ-bă-těr, p. 266) Anticoagulants that delay blood clotting by directly inhibiting the enzyme thrombin. embolism (ĚM-bě-lĭ-zěm, p. 270) A blockage in an artery by a blood clot or air bubble. 487 erythropoiesis-stimulating agent (ESA) (ĭ-rĭth-rō-pōĭ-Ē-sě, p. 276) Drugs that are synthetic forms of the hormone, erythropoietin, which stimulate the bone marrow to make more red blood cells at a faster rate. fibrin (FĪ-brěn, p. 266) A protein formed by fibrinogen during the clotting process that assists with the formation of a clot. fibrinogen (fī-BRĬ-ně-jěn, p. 266) A protein found in the blood's plasma that is converted to fibrin when a blood clot is formed. fibrinolytic drug (fī-brĭ-nō-LĬ-tĭk, p. 275) A drug that uses enzymes to dissolve fibrin. indirect thrombin inhibitors (THRŎM-bĭn ĭn-HĬ-bă-těr, p. 266) Anticoagulant drugs that reduce clot formation by increasing the protein antithrombin III. platelet inhibitor (PLĀT-lět, p. 268) Drugs that inhibit the functions of platelets, interfering with blood clotting within arteries. thrombin (THRŎM-bĭn, p. 266) An enzyme that acts on fibrinogen (a protein found in the blood plasma) to convert it to fibrin to help clots form. vitamin K antagonist (VĪ-tě-mĭn, p. 273) Anticoagulant drugs that interfere with blood clotting by reducing the amount of vitamine K available to help the liver form clotting factors. Drugs that affect the hematologic system can work by interfering with blood clotting, reducing existing blood clots, or stimulating the production of red blood cells (RBCs). Many of these drugs are taken by patients on a daily basis, and others are given only in hospital settings. To help in fully understanding the action of these drugs, it is important to review the normal clotting mechanisms. Blood Clotting The ability of the blood to flow freely through blood vessels is critical in providing cells with oxygen and nutrients, and in removing waste products from tissues and organs. However, when blood vessels are damaged, clot formation is needed to prevent blood from leaving the circulatory system, causing excessive bleeding. A clot is a semisolid amount of coagulated (thickened) blood that blocks blood flow in a blood vessel. So at all times, the body has functions that keep circulation going, balanced along with blood functions that can start the formation of blood clots in areas of injury. In health, blood circulates to all tissues and organs continuously, and forms clots only when and where they are needed. One of the body's protective functions is to clot blood in response to tissue injury. Any damage to the cells starts a series of reactions to protect the body (Fig. 14.1). A variety of clotting factors made by the liver are present in the blood to act quickly in an organized series of events called a cascade that results in the formation of a blood clot. Specifically, tissue and blood vessel damage results in the formation of thromboplastin, which then acts on prothrombin in the bloodstream to form the clotting factor thrombin. Thrombin is an enzyme that then acts on fibrinogen (a protein found in the blood plasma) to convert it to fibrin, a netlike substance in the blood that traps blood cells and platelets to form the matrix, or frame, of a blood clot. Vitamin K must be present to produce prothrombin and other clotting factors that 488 are made in the liver. In addition to calcium, clotting factors, and red blood cells (RBCs), platelets and magnesium are needed in clot formation. FIG. 14.1 Blood coagulation and clot lysis. As part of the circulatory system, the arterial vessels carry oxygenated blood throughout the body. If these small arteries become plugged with thrombi (clots made of fibrin, platelets, and cholesterol), oxygen cannot get to the tissues and death may result. Abnormal blood clotting may produce a thrombus (a single clot) in the coronary artery, which nourishes the heart muscle. Emboli (small pieces of a blood clot) may break off from a site of a thrombus or a thrombophlebitis (inflammation and blood clot in a vein) in the lower extremities and travel through the bloodstream to block vessels in the brain or lungs. In the brain, this blockage can cause stroke or death. In the lungs, the blockage can interfere with oxygenating the blood. Anticoagulants Anticoagulants are drugs that interfere with one or more steps in the blood clotting process. These drugs can reduce or prevent new clots from forming and can help to prevent existing clots from getting larger (extending). They cannot dissolve formed clots. Anticoagulants are mistakenly called “blood thinners,” but they do not actually thin the blood. Drugs that act as anticoagulants are classified as platelet inhibitors, direct thrombin inhibitors (DTIs), indirect thrombin inhibitors (ITIs), and vitamin K antagonists. A summary of anticoagulants is provided in Table 14.1. Table 14.1 Anticoagulants 489 Platelet inhibitors: These drugs use a variety of mechanisms to prevent platelets from sticking together (aggregating) to form a platelet plug that starts the blood clotting cascade. DRUGS/ADULT DOSAGE RANGE NURSING IMPLICATIONS • Avoid taking over-the-counter drugs, especially those that contain NSAIDs, because these aspirin (Ecotrin, low-dose aspirin, Asaphen , increase the risk for bleeding. Entrophen ) 81–325 mg orally once daily • Antacids interfere with antiplatelet drugs, so teach patients to take antiplatelet drugs 1 hour cilostazol (Pletal) 100 mg orally twice daily before or 2 hours after taking antacids. clopidogrel (Plavix) 75 mg once daily ticagrelor (Brilinta) 180 mg orally once as a loading • Most oral antiplatelet drugs are better tolerated when given with food to prevent nausea. • Teach patients the symptoms of bleeding and to report any signs of abnormal bleeding to the dose, then begin 90 mg orally twice daily healthcare provider. ticlopidine (Ticlid) 250 mg orally twice daily • Teach patients to avoid the foods, herbs, and supplements that can interfere with antiplatelet drugs. • Teach patients not to stop taking these drugs without talking to their provider. At times antiplatelet drugs may need to be held for certain surgical or dental procedures. Discuss all drugs with each healthcare provider. • Antiplatelet drugs should be avoided during the last trimester of pregnancy and should not be taken while breast-feeding. Direct thrombin inhibitors: These drugs bind to prothrombin and prevent its conversion to thrombin, which is needed to convert fibrinogen to fibrin. With less thrombin, less fibrin is available to form the network that is the mesh forming the base of a clot. DRUGS/ADULT DOSAGE RANGE NURSING IMPLICATIONS apixaban (Eliquis) 2.5–5 mg orally twice daily • Watch for signs of abnormal bleeding and teach patients to report abnormal bleeding, including desirudin (Iprivask) 15 mg subcutaneously every 12 heavy menses, to the healthcare provider. hours or 0.1 mg/kg/h continuous IV • Monitor patients for signs of allergy or hypersensitivity to these drugs, such as wheezing, dabigatran (Pradaxa) 150 mg orally twice daily shortness of breath, chest tightness, facial swelling, rash, or hives. rivaroxaban (Xarelto) 20 mg daily or 15 mg orally • Teach patients to avoid aspirin or NSAIDs while taking thrombin inhibitors because serious twice daily hemorrhage or death could occur. • Keep the drugs in the original containers; do not place in plastic pill containers because they are sensitive to light. Indirect thrombin inhibitors: These drugs indirectly prevent the conversion of prothrombin to thrombin by increasing the amount of active antithrombin III. This substance has the action of interfering with the conversion of prothrombin to thrombin. DRUGS/ADULT DOSAGE RANGE NURSING IMPLICATIONS heparin, heparin sodium (Calcilean , Hepalean ) • The IV flow rate for continuous heparin infusion is ordered by the prescriber and based on aPTT test results, so monitor aPTT results and report them to the healthcare provider. IV: adult dose for bolus is based on patient • Watch for signs of abnormal bleeding and teach patients to report abnormal bleeding, including weight; usually 5000–10,000 units IV bolus, heavy menses, to the healthcare provider because these may indicate overdosage. followed by continuous IV infusion Subcutaneous injection: 8000–10,000 units every 8 • Monitor patients who are receiving heparin for wheezing, shortness of breath, chest tightness, facial swelling, rash, or hives because these are indications of allergy or hypersensitivity to the hours or 5000–20,000 units every 12 hours drug. Low Molecular Weight Heparins • Teach patients to avoid aspirin or NSAIDs while taking heparin preparations because excessive enoxaparin (Lovenox) 1 mg/kg every 12 hours or 1.5 bleeding risks are greatly increased. mg/kg once daily subcutaneously • Assess patients who are receiving heparin for low platelet counts and indications of clot dalteparin (Fragmin) 100–200 U/kg/day once daily extension because these are signs of heparin-induced thrombocytopenia, a life-threatening subcutaneously reaction to heparin. tinzaparin (Innohep) 175 U/kg once daily • Ensure the heparin antidote, protamine sulfate, is available so that it can be given quickly in case subcutaneously of overdose. fondaparinux sodium (Arixtra) available in single• LMWHs are given by deep subcutaneous injection. Do not expel air bubble or aspirate before giving dose, prefilled syringe of 2.5–10 mg once daily injection. Do not rub the injection site. All of these actions can cause excessive bleeding, bruising, subcutaneously and tissue damage at the injection site. • Ask patients who are prescribed prefilled syringes of fondaparinux sodium (Arixtra) whether they have a latex allergy because these products contain latex rubber-tipped needle covers. Vitamin K antagonist: Vitamin K is critical to the production of many clotting factors in the liver. These drugs reduce or prevent the formation of vitamin K in the intestinal tract. With less vitamin K, fewer clotting factors are made in the liver. DRUGS/ADULT DOSAGE RANGE NURSING IMPLICATIONS warfarin (Coumadin) 2–10 mg orally daily for 2–4 • Teach patients to limit the amount of green, leafy vegetables they eat because these vegetables days; then dose is adjusted based on INR are a natural source of vitamin K that can reduce the effect of warfarin. laboratory test results • Monitor patients' INR to determine effectiveness. • Remind patients to keep all appointments for INR laboratory tests because the dosage is changed based on the test results. • Stress the importance of not taking aspirin or NSAIDs with this drug because it can lead to excessive bleeding. • Teach patients the signs of abnormal bleeding to report to the healthcare provider. • Ensure that the warfarin antidote, vitamin K, is available so it can be given quickly in case of an overdose. • Caution women of childbearing age who are taking warfarin to avoid pregnancy, because this drug can cause birth defects and bleeding. • Many drugs and herbal supplements interfere with the action of warfarin and should be avoided. Indicates Canadian drug. Memory Jogger The four classes of anticoagulant drugs are: • platelet inhibitors • direct thrombin inhibitors • indirect thrombin inhibitors • vitamin K antagonists 490 Platelet Inhibitors Action Platelet inhibitors or antiplatelet drugs act through different mechanisms to prevent platelets from sticking and clumping together (aggregating) to form a platelet plug. Platelet aggregation is an important defense mechanism when the body is injured and results in sealing the entry into the vascular system and preventing blood from going into body tissues. Platelet inhibitors work in the cardiovascular system, sometimes in specific places, to prevent clotting events in a patient who might be having reduced blood circulation to the heart before a myocardial infarction (heart attack). Common platelet inhibitors are aspirin, clopidogrel, dipyridamole, eptifibatide, prasugrel, ticlopidine, tirofiban, and cilostazol. Uses Platelet inhibitors are often the first drugs used to prevent clots in blood vessels (vascular system). These drugs are often given prophylactically (prevention) when a patient has a condition that may produce blood clots, to prevent further extension of the clot, or to prevent the further development of blood clots. Although they can prevent some clotting, they can do nothing to dissolve clots that have already developed. Some of these drugs are used in situations where blood vessels become blocked, to keep venous and arterial grafts open and to prevent strokes. They may be given as additional drugs (adjuncts) to thrombolytic therapy in those patients who have had a heart attack to prevent them from having another one. Acetylsalicylic acid (ASA), or aspirin, is the most commonly used antiplatelet drug. ASA reduces the risk for major blood vessel blockage that can lead to acute myocardial infarction (MI), ischemic stroke, angina, and peripheral arterial disease. Although ASA use is helpful, it also carries the risk for gastrointestinal (GI) bleeding in older patients, those with a history of peptic ulcer disease, and patients using other nonsteroidal anti-inflammatory drugs (NSAIDs) or more than one antiplatelet therapy. See Chapter 12 for information on the actions and nursing implications for aspirin. Clopidogrel (Plavix) is a drug that is used for patients who have had an MI caused by a clot (thrombus) formed in a coronary artery. For patients who have had a stent placed into the coronary artery as a result of severe narrowing or blockage of the artery, clopidogrel prevents platelets from sticking to the stent mesh. For these patients, clopidogrel must be taken daily for a year or longer to prevent clots from developing and plugging up the stent. It is also used in peripheral arterial disease (PAD) to prevent blood clots in the legs, for prevention of an MI, and as additional therapy along with thrombolytic drugs to prevent further strokes after a patient has had a recent ischemic stroke. Expected Side Effects Most drugs that affect the blood clotting system have the potential to cause bleeding, especially when used in combination with other antiplatelet drugs. Easy bruising is common; for example, bleeding of the gums can occur when the patient brushes his or her teeth. GI effects such as diarrhea, nausea, dyspepsia (stomach discomfort after 491 eating), vomiting, flatulence, and anorexia (lack of appetite) have been experienced. Skin effects such as rash, pruritus (itching), and purpura (bruising) have been reported. Adverse Reactions Excessive bleeding, including acute hemorrhage, is the most common adverse effect. Allergic reactions to aspirin and NSAIDs generally occur within a few hours of taking the drug. Symptoms of allergic reactions include itching, hives, and runny nose, with more severe reactions causing swelling of the lips, tongue, or face. Acute cardiovascular events can occur when these drugs are stopped abruptly, so they should never be discontinued without the advice of the patient's healthcare provider. Some of these drugs, including clopidogrel, can result in a decrease in platelet counts (thrombocytopenia) and white blood cell counts (neutropenia). Safety Alert! For any patient who is taking anticoagulants, watch for early signs of bleeding: • easy bruising of knuckles, elbows, or any body part that experiences pressure (e.g., under watchband) • new or excessive bleeding of gums when brushing teeth • blood in the urine or stool, or tarry-colored stool • tachycardia • hypotension • shortness of breath • GI pain Drug and Food Interactions Anticoagulants have many interactions with other drugs and foods that can increase the risk for bleeding or decrease the effectiveness of the drug. Platelet inhibitors, such as aspirin and NSAIDs taken with other drugs that reduce coagulation, can cause excessive bleeding. Alcoholic beverages can also increase the risk for bleeding because of their effect on the liver, where some clotting factors are formed. Other drugs, such as vitamin K and oral contraceptives, decrease the effects of anticoagulants. Antibiotics can have a variable effect on blood clotting when taken with anticoagulants. Some drugs that protect the GI system, such as proton pump inhibitors, can interact with clopidogrel and decrease its effectiveness. Green, leafy vegetables contain vitamin K and can decrease the effectiveness of anticoagulants. Many herbal products, vitamins, and supplements can interfere with anticoagulants. For example, St. John's wort further increases the risk for bleeding when used while taking an anticoagulant. In addition, multivitamins contain vitamin K, which reduces the effectiveness of warfarin (Box 14.1). Chapter 19 describes many herbal, vitamin, and supplemental products and some of their interactions with drugs. 492 Box 14.1 Foods, Herbs, and Supplements That Affect the Clotting System Foods That May Interfere With Anticoagulants Tomatoes, onions, dark, leafy greens, broccoli, garlic, bananas Herbs and Supplements That Increase the Risk for Bleeding in Anticoagulated Patients Angelica Cat's claw Chamomile Chondroitin Feverfew Fish oil Vitamin E Ginkgo Goldenseal Grape seed extract Green leaf tea Horse chestnut seed Psyllium Turmeric Nursing Implications and Patient Teaching Assessment. Before giving the first dose of any platelet inhibitor, it is important to ask the patient what other drugs he or she has taken in the past week, including over-the-counter (OTC) drugs, vitamins, minerals, and herbal products. Many of these drugs and products can interact with platelet inhibitors and greatly increase the risk for bleeding. Ask whether he or she currently has any bruising or bleeding, especially from the gums, nose, or mouth, which is a sign of low platelet count and increased bleeding risk. Assess for signs of internal bleeding, such as: • severe abdominal pain and tenderness • vomiting or diarrhea that is frank red blood or coffeecolored • cold, clammy skin Examine the mouth and skin for any signs of bleeding, such as pale mucous 493 membranes, bruising, or the presence of petechiae (tiny red/purple spots on the skin, caused by a minor bleed into the skin) (Fig. 14.2). FIG. 14.2 Petechiae. (Modified from Marks J, Miller J: Lookingbill and Marks' principles of dermatology, ed 5, Philadelphia, 2013, Saunders.) Planning and implementation. Give platelet inhibitors and record the drugs given and the patient's response. Monitoring the patient's vital signs will alert you to possible adverse reactions. Tachycardia and hypotension can occur with bleeding, so monitor pulse and blood pressure at least once per shift. Report the location and amount of bruising, or petechiae that occurs. Assist with the collection of any ordered blood work required to monitor therapy. Evaluation. Changes in vital signs and levels of consciousness provide important feedback about the possible risk for bleeding that can occur with these drugs. Watch for skin-related signs of bleeding, such as bruising or petechiae. Watch for signs of overdose and internal bleeding as therapy progresses. This includes bleeding gums when brushing teeth, blood in the urine, or coughing up blood. Determine whether the patient understands why he or she is taking the drug and the symptoms of overdose. Have the patient report any signs of bruising or easy bleeding. Direct Thrombin Inhibitors Action All direct thrombin inhibitors (DTIs) prevent the formation of blood clots, or thrombi, by interfering with the enzyme thrombin (factor II). This action increases the time it takes for blood to clot, preventing new clots from forming. These drugs do not dissolve clots that have already occurred. Dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa) are examples of DTIs (see Table 14.1). All of these drugs act to stop the coagulation process through binding to both free thrombin in the blood and thrombin that is bound to fibrin, stopping the 494 clotting cascade. Uses DTIs are used to prevent clots in both arteries and veins. They can also be used to prevent and treat deep vein thrombosis (DVT) or pulmonary embolism (PE), or to prevent clotting from atrial fibrillation, an abnormal heart rhythm where the upper chambers of the heart, the atria, quiver instead of beating normally to move blood out of the atria and into the ventricles. The advantage of DTIs is that they do not require the frequent laboratory blood testing as part of the monitoring process that is required by warfarin. DTIs are used much like warfarin and other anticoagulants. They are prescribed for patients who are at risk for systemic embolism and stroke, especially for patients who have atrial fibrillation that is not caused by a heart valve problem. They are also used for prevention of blood clots after some types of surgeries. Expected Side Effects The DTIs can cause bleeding. Easy bruising is common, for example, bleeding gums when the patient brushes his or her teeth. Another common side effect of DTIs is gastric upset when taken on an empty stomach. Adverse Reactions By far, the most common adverse reactions from DTIs are excessive bleeding and thrombocytopenia. Early signs of overdose or internal bleeding include bleeding from the gums while brushing teeth, excessive bleeding or oozing from cuts, unexplained bruising or nosebleeds, and unusually heavy or unexpected menses in women. These are the “must know” symptoms that suggest the patient needs prompt attention. Drug Interactions DTIs can interact with many commonly prescribed drugs and some supplements, such as atorvastatin, azithromycin, carvedilol, clarithromycin, cyclosporine, diltiazem, and St. John's wort, to name a few. When taken together, the concentration of DTIs increases, which greatly increases the risk for excessive bleeding. When taken with carbamazepine, dexamethasone, phenobarbital, phenytoin, or rifampin, the concentration and action of DTIs is reduced, decreasing their effectiveness. Antacids may also reduce the action of DTIs. Drug Interaction Alert • Common drugs that increase the activity and bleeding risks with DTIs are atorvastatin, azithromycin, carvedilol, clarithromycin, cyclosporine, and diltiazem. • Drugs that decrease the effectiveness of DTIs are carbamazepine, dexamethasone, phenobarbital, phenytoin, rifampin, and antacids. 495 Nursing Implications and Patient Teaching Assessment. Assess patients for any of the following, which may be a sign or symptom of serious bleeding: • unusual bruising • blood in the urine, stool, or vomitus • coughing up blood • headaches, dizziness, or weakness • recurring nosebleeds • unusual bleeding from gums • menstrual bleeding that is heavier than normal Planning and implementation. Teach the patient and family members to take DTIs on time. When a dose is missed, the scheduled dose should be taken as soon as possible on the same day. However, if there will be less than 6 hours between scheduled doses, the missed dose should not be taken. Accidental overdose may lead to excessive bleeding. If needed, the reversal agent (idarucizumab) can be prescribed by the healthcare provider. Teach patients and family members not to discontinue DTIs without talking to the healthcare provider who prescribed it because the risk for serious clotting events increases. Instruct patients to keep DTIs in the original bottle to protect the drug from moisture and light. Teach them not to put DTIs in pill boxes or pill organizers. Teach patients not to chew or break the capsules before swallowing them because the drug may be absorbed too rapidly or destroyed by stomach acid. Instruct patients to take DTIs with a full glass of water to prevent stomach irritation and improve absorption. Evaluation. Watch for signs of overdose and internal bleeding. These include bleeding gums when brushing teeth, blood in the urine, or coughing up or vomiting of blood. Have the patient or family explain to you the purpose of taking this drug and the symptoms of overdose. Note any signs of bruising or easy bleeding, and document your findings according to agency policy. Indirect Thrombin Inhibitors Actions Indirect thrombin inhibitors (ITIs) are anticoagulant drugs that decrease clot formation by increasing the amount and action of a protein called antithrombin III. This protein inhibits thrombin from doing its job in the blood clotting cascade, and 496 clot formation is reduced. Commonly used ITIs are heparin sodium (Calcilean , Hepalean ); low-molecular-weight heparin (LMWH), dalteparin (Fragmin), enoxaparin (Lovenox), tinzaparin (Innohep), and fondaparinux (Arixtra). Heparin is given only by injection because it cannot be absorbed orally. LMWH is a special formulation with a more steady anticoagulation effect than unfractionated heparin sodium. LMWH works by binding to antithrombin and inhibiting factor Xa, which disrupts part of the clotting cascade. The half-life of LMWH is longer than heparin sodium, ranging from 2 to 4 hours after intravenous injection to 3 to 6 hours after subcutaneous injection. Therapy with heparin sodium must be monitored for its anticoagulation effect by a blood test known as the activated partial thromboplastin time (aPTT). The prescriber maintains or adjusts dosages according to this test result. The LMWH formulation does not require testing. Uses Anticoagulant therapy with heparin is used to prevent new clot formation or to stop existing clots from growing in size. Heparin therapy is used prophylactically (as a preventative) during and after many types of surgery, especially surgery involving the heart or circulatory system. It is also used in patients with heart valve disease, in patients with some dysrhythmias (irregular heartbeats), and in patients receiving hemodialysis. Any patient on bed rest for a long time is at risk for the development of blood clots, especially patients with a history of clotting problems or recent orthopedic, thoracic, or abdominal surgery. LMWH is used especially in the prevention of venous thromboembolism and may often be used when pulmonary embolism is present. Expected Side Effects Heparin sodium can cause easy bleeding and bruising, pain, redness, warmth, irritation, or skin changes where the drug was injected. Other side effects may include foot itching or bluish-colored skin. Adverse Reactions A number of other adverse reactions may occur, including hemorrhage, thrombocytopenia, shortness of breath, wheezing, chills, fever, alopecia, and hypersensitivity (allergic) reaction. In cases of heparin overdose, protamine sulfate is given to counteract the effect of heparin. Serious adverse reactions include heparininduced thrombocytopenia (HIT) and heparin-induced thrombocytopenia and thrombosis (HITT). In HIT, antibodies against heparin are formed and activate platelets, which then clump together and cause small clots in the bloodstream, and the platelet count falls. If major clots develop and block vessels, the condition is even more serious and is called HITT. Drug Interactions Heparin can interact with aspirin, NSAIDs, glucocorticoids, and other anticoagulants (warfarin) to increase the risk for GI bleeding. Antihistamines, digoxin, nicotine, and tetracycline decrease the anticoagulant effect of heparin. 497 Nursing Implications and Patient Teaching Assessment. Heparin is derived from animal tissue and is more likely to cause an allergic reaction than other anticoagulants. When giving it to patients who have a history of allergy, observe them closely. This drug should be used cautiously in patients with liver or kidney disease or hypertension, during menses, after delivery, or in patients with indwelling catheters. A higher incidence of bleeding may be seen in older patients. Planning and implementation. Dosages for heparin are given in heparin units. Heparin is given only by IV injection, IV infusion, or subcutaneous injection. Heparin is not given by IM injection because these injections produce hematomas, irritation, and pain at the injection site. Do not shake the bottle containing the heparin; only roll it carefully between your hands before inserting the needle. If the heparin solution is discolored or contains a precipitate or particles at the bottom of the bottle, do not use it. Heparin is strongly acidic and is incompatible with many other drugs in solution, so it must not be piggybacked with other drugs into an infusion line. Never mix any drug with heparin in a syringe when bolus therapy is given. Drug Alert Administration Alert Roll the heparin bottle between your hands rather than shaking it. Do not give heparin in the same IV line or same syringe with any other drug. Use a small (25-gauge) needle and a tuberculin syringe for the subcutaneous injection (often given in the abdomen around the umbilicus). Subcutaneous heparin is usually given every 12 hours. There are several things to remember about heparin injection. First, once the needle has been inserted into the patient, do not attempt to pull back on the plunger or aspirate blood before injection. Second, do not move the needle while the heparin is being injected. Third, do not massage injection sites before or after injection. Doing any of these things increases tissue damage from the heparin. Avoid giving IM injections of other drugs while the patient is receiving heparin, because hematomas and bleeding into nearby areas may occur. LMWH preparations are given by deep subcutaneous injection (Fig. 14.3). 498 FIG. 14.3 Deep subcutaneous injection for low-molecular-weight heparin. (From Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier.) Top Tip for Safety When injecting subcutaneous heparin, do not pull back on the syringe to aspirate for blood or move the needle in the tissue during the injection. Do not massage the injection site. All of these actions increase the risk for bleeding, bruising, and tissue damage at the injection site. Rotate the sites of subcutaneous injections of heparin to avoid formation of hematomas (see Chapter 4 and Fig. 4.14 for recommended rotation sites). In the hospital setting, once the heparin is drawn into the syringe, double-check the dose drawn up with another nurse, because of the adverse effects if inaccurate doses are given. If intermittent IV therapy is prescribed, blood for partial thromboplastin time (PT) determination should be drawn an hour before the next scheduled heparin dose. Blood for partial thromboplastin times can be drawn any time after 8 hours of continuous IV heparin therapy. However, blood should not be drawn from the tubing of the heparin infusion line or from the vein being used for infusion. Blood should always be drawn from the arm not being used for heparin infusion. Continuous intravenous therapy with heparin is first started by a bolus of heparin that is based on the weight of the patient (usually 5000 to 10,000 units). Obtaining an accurate weight is important before initiating heparin therapy. Check intravenous heparin infusions frequently, even if pumps are in good working order, to ensure the proper dose is being given. If heparin is being given at the same time as warfarin, blood should not be drawn for PT within 5 hours of IV heparin administration, or within 24 hours if heparin is given subcutaneously. Patients who require rapid anticoagulation are commonly hospitalized. Heparin is usually started for an immediate effect and gradually replaced by oral anticoagulants. The most commonly used blood test for determining the therapeutic range for heparin is the activated partial thromboplastin time (aPTT). The dosage of heparin is considered adequate when the aPTT is about 1.5 to 2.5 times the laboratory control value. PT and international normalized ratio (INR) tests are ordered when the patient is started on oral anticoagulants and at regular intervals thereafter. The normal range for the INR is 0.8 to 1.2, with a therapeutic target range of 2.0 to 3.0. For patients with mechanical heart valves, this therapeutic range is slightly higher at 499 2.5 to 3.5, because of the high risk for clots forming within the valve itself. When the oral anticoagulant shows proper effect, and the prothrombin activity is in the therapeutic range, heparin therapy may be stopped and the oral anticoagulant therapy continued. It is important for you to be sure that the heparin antidote, protamine sulfate, is available for use whenever patients are on heparin therapy while hospitalized, in the event of accidental overdosage or an acute bleeding event. You will need to urgently contact the appropriate healthcare provider for an order before giving protamine sulfate. Evaluation. If heparin is given by continuous IV infusion, the coagulation time should usually be determined every 4 hours in the early stages of treatment. Many medical centers have adopted protocols that indicate heparin dosing based on previous aPTT results, and determine when the next aPTT should be drawn. Watch for signs of allergy, such as difficulty breathing, wheezing, swelling around the eyes, itching, rash, or hives. Watch for signs of overdose and internal bleeding as therapy progresses. Check with the patient and/or family to ensure they understand the dosage schedule, side effects, adverse effects, and which signs of adverse effects to report to the healthcare provider. These include bleeding gums when brushing teeth, blood in the urine, or coughing up blood. Teach patients to report all drugs and supplements taken. Top Tip for Safety • Teach women of childbearing age to notify the healthcare provider if they are pregnant or plan to become pregnant while using heparin. There is a risk for birth defects and bleeding in the last trimester that is associated with heparin use in pregnancy. • If anticoagulation is needed for an expectant mother, heparin is the anticoagulant that will be used. • Breast-feeding is safe during heparin therapy because the drug is not found in breast milk. • The heparin antidote protamine sulfate should be available in the event of accidental overdose or hemorrhage. • Monitor the patient's platelet counts for declines that can be associated with HIT or HITT. Vitamin K Antagonists Vitamin K is necessary for the production of specific proteins that are needed in the clotting process. Vitamin K antagonists, which are anticoagulant drugs that interfere with blood clotting by reducing the amount of vitamin K that is available to help the liver form clotting factors, are from the coumarin category of drugs. The most common drug in this class is warfarin (Coumadin). 500 Actions Vitamin K antagonists inhibit the enzyme needed for final activation of vitamin K. Without adequate amounts of vitamin K, the liver cannot make blood coagulation factors II, VII, IX, and X. Blood clotting requires the actions of all of the clotting factors, so limiting any clotting factor reduces blood clot formation. Uses For long-term therapy in chronic conditions that might involve problems with clot formation (such as coronary artery disease, atrial fibrillation, knee and hip replacement surgery, and immobility), warfarin (Coumadin, Jantoven, Warfilone ) is the drug of choice. Warfarin is given orally for the prevention of blood clots and emboli. Patients typically begin warfarin while on heparin. Heparin is then discontinued when the INR blood clotting test reaches the therapeutic range. Expected Side Effects The potential for easy bruising and bleeding is common. For example, bleeding gums may occur when the patient brushes his or her teeth; blood in the stool or urine is also common. Warfarin may produce GI upset (e.g., diarrhea or nausea), headache, and skin rash. Adverse Reactions Adverse reactions of warfarin include excessive bleeding, or hemorrhage that can be seen with very heavy menstrual bleeding, frank blood or dark, tarry stools, or coffeecolored vomitus with excessive dosage. Warfarin can cause skin necrosis (death) that can occur within the first 10 days of therapy, and is associated with larger dosages (Fig. 14.4). Obese, menopausal women are at greatest risk for this rare adverse reaction. Warfarin can also cause birth defects or death to the fetus. It is not given during pregnancy. FIG. 14.4 Warfarin-induced skin necrosis. (From Hoffman R, Benz EJ Jr, Shattil SJ, Furie B, Silberstein LE, McGlave P, Heslop H: Hematology: Basic principles and practice, ed 5, Philadelphia, 2008, Churchill Livingstone.) In response to some bleeding disorders or warfarin overdosage, vitamin K (phytonadione [AquaMEPHYTON]) may be given either orally or parenterally to help stimulate the liver to resume manufacture of prothrombin and serve as an anticoagulant antagonist. However, this clotting activity may not return for 48 to 72 hours. Blood products that contain clotting factors may have to be given to stop 501 severe bleeding. Even in urgent situations, giving phytonadione requires an order from the healthcare provider. Top Tip for Safety Signs that suggest internal bleeding include: • abdominal pain or swelling, back pain, or constipation (resulting from paralytic ileus or intestinal obstruction); • bloody or tarry stools, bloody or dark-colored urine, coughing up or vomiting blood or “coffee-ground” substance; • dizziness or cold, clammy skin; • severe or continuous headache; and • tachycardia (fast pulse), hypotension (low blood pressure), and tachypnea (rapid breathing). Drug and Food Interactions Vitamin K antagonists, such as warfarin, interact with many other drugs. Use a drug reference or consult with the healthcare provider or pharmacist as needed for patient care or teaching, because the list of drugs that interact with vitamin K antagonists is very long. In general, many antibiotics, anti-inflammatory drugs, antidysrhythmics, GI drugs, statins, and steroids can lengthen bleeding time effects of warfarin, whereas antacids, antihistamines, barbiturates, large doses of vitamin C, and oral contraceptives can shorten it. Lengthening the bleeding time greatly increases the risk for hemorrhage and death. It is critically important for the patient and family to accurately report all current drugs before beginning therapy with warfarin. Vitamin K antagonists also interact with many herbal preparations and supplements, so patients should consult with the healthcare provider before beginning any of these while taking these drugs. Anticoagulant effects may be increased with acute alcohol intoxication, but decreased with chronic alcohol abuse. Some antidiabetic drugs taken with anticoagulants may increase the effect of either the diabetes drug or the anticoagulant, so close patient monitoring is needed. Eating excessive amounts of green, leafy vegetables (i.e., spinach, broccoli) can interfere with the purpose of vitamin K antagonist therapy, decrease bleeding time, and reduce effectiveness of the treatment, leading to new blood clot formation. Nursing Implications and Patient Teaching Assessment. Obtain a complete health history from the patient, including the current health problem, medical and surgical histories, and any drug and food allergies or hypersensitivity reactions. Ask the patient for a current, accurate list of all drugs being taken, including herbal products, supplements, or OTC drugs. Ask about any conditions that would prevent the use of some anticoagulants, such 502 as alcoholism, blood diseases and conditions associated with bleeding, or uncontrolled hypertension. Patients with heart failure may be more sensitive to vitamin K antagonists. Make absolutely sure that female patients who are taking a vitamin K antagonist are not pregnant or breast-feeding. A pregnancy test may be performed for women of childbearing age before beginning these drugs. Teach sexually active women who are taking warfarin to use two reliable methods of birth control. Planning and implementation. Warfarin can have an unpredictable and variable effect in some patients, especially in older adult (>65 years) patients and those of Asian descent. Warfarin has a very narrow range (therapeutic index) that produces the anticoagulant effects without also producing bleeding in the patient. Frequent blood tests for PT/INR are done to monitor bleeding risk while still providing the anticoagulation needed. To avoid variation in testing methods, a system called the INR is used to standardize PT reporting. In a person who is not receiving anticoagulation therapy, the normal INR is 0.9 to 1.1. The typical INR goal for a patient who needs anticoagulation therapy is 2 to 3, except in mechanical cardiac valve replacement, in which a higher INR is necessary to prevent clot formation. The INR goal may be different for specific disorders that require anticoagulation. Initially, the PT/INR may be done daily, but after stabilization, tests are performed at 1-week to 4-week intervals, depending on patient response. For hospitalized patients and those in long-term care facilities, be sure to obtain the blood tests on time, and report abnormal findings to the healthcare provider as soon as they are received. The antidote for warfarin overdosage (vitamin K) should be available at all times. Caution patients to wear a MedicAlert bracelet or carry an identification card indicating the use of an anticoagulant. Teach patients and family members about warfarin, the expected side effects, and adverse effects that should be reported immediately. Teach patients and family members to avoid adding any drugs, herbs, and supplements without the express permission of the healthcare provider, because these agents can interfere with the actions of warfarin. Teach patients to swallow the tablets whole, without cutting, crushing, or chewing them, to ensure proper drug absorption. Protect the drug from humidity and light exposure (they are dispensed in an opaque plastic container or a dark-colored glass container) because the drug's activity is reduced by exposure to light and moisture. Do not transfer the drug to another storage container. Teach patients and family members to avoid increasing the intake of green leafy vegetables, because these contain vitamin K and can decrease the effectiveness of warfarin. Instruct patients to avoid alcohol while taking warfarin because alcohol ingestion changes the drug's activity. Teach patients to keep all appointments for laboratory tests and visits to the healthcare provider because blood clotting can change and dosage changes may be needed based on test results. Teach patients to use caution when brushing teeth, trimming nails, and shaving. (An electric shaver should be used when possible.) 503 Teach patients to apply pressure to stop bleeding from accidental cuts or scrapes. If bleeding persists after 10 minutes, tell the patients to contact their healthcare provider. Tell patients not to suddenly stop taking any of the oral anticoagulants because this may trigger severe cardiovascular problems and clotting. Instruct patients to avoid contact sports or other activities that could lead to injuries. The effects of anticoagulants usually require at least 2 days to recover blood clotting ability once anticoagulation is stopped. Lifespan Considerations Older Adults Older adults may be more sensitive to the effects of anticoagulants, and a lower maintenance dose is usually recommended for the older adult patient, along with very close supervision and monitoring. This is particularly true for patients who receive warfarin and may be vitamin K deficient because of low intake of green, leafy vegetables. Evaluation. Warfarin takes up to 72 hours before it reaches an effective level for anticoagulation. Heparin is given when an immediate anticoagulant effect is required; so often the hospitalized patient will be receiving both heparin and warfarin at the same time. Thus monitoring of the PT/INR is especially critical during this period. Memory Jogger Heparin and warfarin can be taken at the same time, whereas most other anticoagulants cannot. Watch for signs of overdose and internal bleeding as therapy progresses. Indications include bleeding gums when brushing teeth, blood in the urine or stool, and coughing up or vomiting blood. Assess whether the patient understands why he or she is taking the drug, as well as the symptoms of overdose. Have the patient explain to you the actions he or she would take when signs of bruising or easy bleeding are noted. Remind patients to always consult the prescriber before starting any new drug (including OTC drugs and vitamins), changing a drug dose, or discontinuing any drug. Many drugs can change the effects of an anticoagulant in the body. Determine whether the patient and family members understand the dietary instructions regarding the intake of green, leafy vegetables (e.g., broccoli, cabbage, collard greens, lettuce, and spinach). See Box 14.1 for a list of herbs that increase the risk for bleeding or interfere with anticoagulant action. 504 Top Tips for Clinical Care • Teach patients to tell their dentist and all their healthcare providers that they are taking anticoagulants. • Patients who are taking anticoagulants and who require dental or surgical procedures may need to discontinue the drug before surgery to avoid problems with bleeding. Surgical procedures may be a particular risk if patients have a traumatic injury or require emergency surgery. • Drugs such as clopidogrel (Plavix), used after stent placement, should never be abruptly stopped without consultation with a cardiologist. Abruptly stopped clopidogrel in this case might prompt the stent to become blocked with a clot. Fibrinolytic Drugs Action Fibrinolytic drugs (formerly called thrombolytic drugs) actually do dissolve and break down existing blood clots. For this reason they are sometimes referred to as “clot busters.” Fibrinolytic drugs work by converting plasminogen to the enzyme plasmin, which degrades or breaks down fibrin clots, fibrinogen, and other plasma proteins. These products are used especially for lysis (dissolving) of thrombi and are used only in a critical care setting. A summary of fibrinolytics is provided in Table 14.2. Table 14.2 Fibrinolytics Fibrinolytics: These drugs dissolve clots by activating plasminogen to plasmin, which is an enzyme that breaks down the fibrin fiber network that is the mesh holding a clot together. DRUGS/ADULT DOSAGE NURSING IMPLICATIONS RANGE alteplase (Activase, tPA; • Before therapy, ensure the patient has no history of active internal bleeding, recent stroke, spinal surgery, blood Activase, rtPA ): adult dose is pressure >200/120 mm Hg, bleeding disorders, pregnancy or delivery, head trauma, prolonged cardiopulmonary resuscitation, or pending aortic dissection because these conditions are absolute contraindications for fibrinolytic based upon condition being therapy. treated • Watch for signs of hemorrhage, especially bleeding into the brain, because these drugs greatly increase the risk for Myocardial Infarction bleeding anywhere. 15 mg IV bolus, then 50 mg IV • Monitor patients who are taking heparin for wheezing, shortness of breath, chest tightness, facial swelling, and rash over 30 min, then 35 mg IV or hives because this drug is made from animal products and has a higher risk for causing allergy and over 60 min; followed by hypersensitivity. heparin therapy • Monitor coagulation laboratory tests because drug dosages are based on the results of these tests. Pulmonary Embolism • Monitor for the presence of severe headache or changes in alertness because these may signal stroke from bleeding 100 mg IV over 2 hours; followed in the brain. by heparin therapy • Avoid giving IM drugs because of the risk for bleeding. If IV line is removed, apply pressure for 30 minutes. Stroke 0.9 mg/kg IV over 1 hour (limit total dose to 90 mg, with 10% of the dose given as a bolus) reteplase (Retavase) adult dose: 10 units IV bolus, then another 10 units IV bolus 30 min later tenecteplase (TNKase) adult dose is based on weight: 30–50 mg IV pusha a Not given by LPN/VN. Indicates Canadian drug. 505 Uses Fibrinolytic drugs are used in the acute care setting such as the emergency department or intensive care unit. These drugs are given for a variety of reasons, including acute MI, acute pulmonary emboli, acute ischemic stroke, and acute arterial occlusion. These drugs dissolve clots and emboli, ultimately reducing the extent of cellular damage from arterial blockage. Timing is a critical factor for using these drugs. If fibrinolytics are begun within 12 hours of a heart attack or 3 hours of the onset of a stroke, the blood clot blocking the artery can be dissolved and blood flow restored. The most commonly used fibrinolytic drugs are alteplase (Activase, tPA), reteplase (Retavase), and tenecteplase (TNKase). Be careful not to confuse tPA and TNKinase. Although both are fibrinolytics, the dosages and administration are different. These drugs are high-alert drugs and are given through an IV line. Memory Jogger All fibrolytic drugs are given IV and are high-alert drugs. Expected Side Effects Bleeding is the most obvious side effect of fibrinolytic drugs. Bleeding of the gums or injection or IV sites can occur. Low blood pressure (hypotension) can also occur. Adverse Reactions Allergic reactions and hypersensitivity can occur with symptoms of shortness of breath, wheezing, chest tightness, facial swelling, skin rash, or hives. Hemorrhage is the most critical adverse reaction that can occur. In addition, because these drugs break up clots, there is a risk for stroke, especially in older adult patients with hypertension. There are contraindications for receiving fibrinolytic drugs, in which case they cannot be given. These contraindications include known bleeding disorders, pregnancy or recent delivery (<24 hours), history of stroke within the past 2 months, hypertension with a blood pressure >200/120 mm Hg, head trauma, and aortic dissection. Drug Interactions Giving fibrinolytic drugs together with other anticoagulants increases the potential for bleeding and hemorrhage. Nursing Implications and Patient Teaching Assessment. Fibrinolytic drugs are given by the healthcare provider or advanced practitioners in life-threatening situations of MI or stroke. They are most helpful when given within the first hour after the onset of symptoms from the thrombosis. Ask the patient or family when chest pain (for MI) or stroke symptoms first began to determine the exact time sequence of events and what happened before the patient was brought to the hospital. Ask whether the patient has a history of prior stroke or bleeding 506 disorder. Ask whether any other drugs, such as aspirin, have been taken. Aspirin helps reduce platelet adhesion; for patients suspected of having an MI, the standard protocol is to have the patient chew a 325-mg aspirin (ASA) tablet. The aspirin may have been taken at home or given by paramedics before arrival at the hospital. Ask the patient or family whether he or she has had surgery or given birth within the past 48 hours. Planning and implementation. Fibrinolytic drugs come as a powder that requires reconstitution. Have all of the equipment and materials assembled and ready for infusion. Carefully monitor and record the vital signs of the patient who is receiving thrombolytic therapy. Report these findings to the healthcare provider. Once the fibrinolytic drug has been given, do not remove IV lines or give IM injections because of the risk for severe bleeding. If an IV line must be removed, apply pressure to the area for 30 minutes. Evaluation. Monitor the patient carefully for bleeding. Bleeding may be superficial, coming from the infusion site. Other more significant bleeding indicates overdose and is shown by hematuria (blood in the urine), hematemesis (blood in the vomitus), abdominal pain and swelling, tachycardia, tachypnea, and hypotension that can indicate internal bleeding. Patient and family teaching. Ensure that the patient and family understand the purpose, risks, and benefits of fibrinolytic therapy. Teach the patient to report any unusual symptoms, signs of allergic reaction to the drug, and any unusual bleeding that occurs. Erythropoiesis-Stimulating Agents Action Erythropoiesis-stimulating agents (ESAs) are synthetic forms of the hormone erythropoietin, which is naturally produced by the kidneys when red blood cell (RBC) counts decline because of anemia. The decrease in RBCs results in poor tissue oxygenation, because the hemoglobin in the RBC carries oxygen to the body organs and tissues. So anemia signals the kidneys to secrete erythropoietin, which then travels to the bone marrow, stimulating the marrow to increase production of RBCs. This process is known as erythropoiesis. The synthetic forms of erythropoietin work just like the natural hormone. ESAs come in vials or in prefilled syringes, and are given by IV or subcutaneous routes. A summary of ESAs is provided in Table 14.3. Table 14.3 Erythropoiesis-Stimulating Agents Erythropoiesis-stimulating agents: These drugs induce the bone marrow to increase the production of red blood cells and some other blood cells. 507 DRUGS/ADULT DOSAGE RANGE darbepoetin alfa (Aranesp) 0.45 mcg/kg IV or subcutaneously each week; can be given in divided doses epoetin alfa (Epogen, Procrit, Eprex ) 50–100 U/kg IV or subcutaneously three times weekly to maintain hemoglobin level at prescribed range NURSING IMPLICATIONS • Monitor blood pressure for increases due to increased blood viscosity (thickness), headaches, body aches, fever, or chills. • Monitor blood counts, especially hemoglobin, to help determine drug effectiveness. • Follow directions for drug mixing and preparation because these vary by product and drug effectiveness depends on correct administration. • Check for signs or symptoms of allergic reactions, which are possible adverse effects of these drugs. • Teach patients to immediately report chest pain or shortness of breath, drooping face, or numbness in face or extremities, calling an ambulance to the emergency department; these are signs of heart attack or stroke, and ESAs increase the risk for these health problems. Indicates Canadian drug. Uses ESAs are usually given to patients with a condition that causes anemia, and who need to increase the production of RBCs. Patients with chronic kidney disease cannot make enough erythropoietin to provide adequate oxygen to tissues. Patients who are anemic from the effects of chemotherapy on the bone marrow or who may be anemic before surgery are often prescribed ESAs. These drugs reduce the need for transfusions and reduce the complications of transfusions, such as fluid overload. Expected Side Effects Pain at the injection site is the most common side effect of ESAs. Generalized body aches and pain, skin rash, redness, or warmth at the injection site can occur. Adverse Reactions The use of ESAs is not without significant risks. As RBC production increases, the blood itself becomes thicker. This can result in a higher risk for hypertension, blood clots, stroke, and MI (heart attack). In some advanced cancers, increased tumor growth occurred when ESAs were given. There is a risk for severe allergic reactions to ESAs. Nursing Implications and Patient Teaching Assessment. Assess the patient's vital signs and weight. Report the presence of hypertension, which may need to be controlled before beginning ESAs. Obtain a complete health history, especially for a history of stroke, blood clots, MI, other blood clotting disorders, or sickle cell disease. Ask about symptoms of allergic reactions if the patient received ESAs in the past. Ask about the presence of latex allergy because the covers of prefilled syringes contain latex. Assess the result of the patient's complete blood count. Notify the healthcare provider if the hemoglobin is 12 g/dL (or higher) before giving ESAs. Monitor the patient's iron status (transferrin, serum ferritin) levels and notify the healthcare provider of results before beginning ESAs. Planning and implementation. Give supplemental iron as ordered by the healthcare provider. Do not expose the ESA vial to light and do not shake the vial. After giving the drug, discard any unused or leftover drug in the vial or in the prefilled syringes. 508 Do not give intravenous (IV) ESAs with any other drugs. Give subcutaneous injections in the outer area of the upper arms, the abdomen (except for the 2-inch area around the umbilicus), the front middle of the thigh, or the outer area of the buttocks. Teach the patient and family the following: • Weigh yourself daily and report a weight gain of 2 lb in 24 hours or 4 lb in a week to your healthcare provider because these drugs can cause water retention. • Go immediately to the nearest hospital if you have chest pain because these drugs increase blood thickness and raise blood pressure, which can increase your risk for having a heart attack. • Inform your healthcare provider if you are pregnant, breast-feeding, or plan to become pregnant. Evaluation. Report signs of an allergic reaction, such as rash, wheezing, facial swelling, difficulty breathing, or hypotension. Report signs of stroke, or the presence of chest pain or shortness of breath, or increases in the patient's blood pressure. Get Ready for the NCLEX® Examination! Key Points • Anticoagulants are used to prevent new clots from forming and existing clots from getting larger. • Fibrinolytics dissolve existing clots and reduce the formation of new clots. • All anticoagulants and fibrinolytics greatly increase the risk for excessive bleeding. • Before starting anticoagulation therapy, ask the patient which other drugs (prescribed or OTC), vitamins, or herbal supp