Bugayong, Santa Angelica P. Dumlao, Jeremy P. Joaquin, Annalou A. Liwan, Christine Joy L. Lozada, Sarah Jane F.

Luis, Maryrose V. Luis, Rosemarie V. Mangaoil, Precious Gay G.

 Anticoagulant

medicines reduce the ability of the blood to clot (coagulation means clotting). This is necessary if the blood clots too much, as blood clots can block blood vessels and lead to conditions such as a stroke or a heart attack. Major side effects: BLEEDING

ORAL ANTICOAGULANTS interfere with the hepatic synthesis of vitamin K- dependent clotting factors (factors II, prothrombin, VII, IX, and X), resulting to their eventual depletion and prolongation of clotting times. PARENTERAL ANTICOAGULANTS interfere with the conversion of prothrombin to thrombin blocking the final step in clot formation but leaving the circulating levels of clotting factors unaffected.

Treatment and prevention of pulmonary embolism and venous thrombosis and its extension Treatment of atrial fibrillation with embolization Prevention of DVT Prophylaxis of systemic embolization after acute MI Prevention of thrombi following specific surgical procedures and prolonged bedrest (low-molecular-weight heparins)

Heparin Heparin is an anticoagulant supplied as a solution for injection. Although it is prescribed in low doses for people at risk of blood clots such as those suffering from atrial fibrillation, it is also used during open-heart surgery, blood transfusions bypass surgery and kidney dialysis in order to stop the blood from clotting.

Warfarin Warfarin, also known by the brands name of Coumadin and Jantoven, is a commonly-prescribed blood thinner that works by inhibiting vitamin K-dependent coagulation factors. It is usually taken orally, though it is also available as a solution for injection.

Mrs. Robinson, 56, is recovering satisfactorily from gall bladder surgery. She develops tenderness, pain, and warmth in her right calf. Her physicians determine that she has developed phlebitis and orders:

Bedrest Continuous heat application to the right call Insert saline lock and give heparin 10,000 unit by IV stat, then 5,000 unit q6h PTT before first dose of heparin and daily there after

This therapy is continued for 4 days after which the client is started on the following medication schedule:

Warfarin sodium (Coumadin) 10mg daily Heparin 5000 unit q6h on 3/18; 2500 units on 3/19 Discontinue heparin 3/20 after 12am dose

Prothrombin times are done daily. The results are called to Mrs. Robinsons physician who adjusts the dose of warfarin sodium accordingly. Mrs. Robinson responds well to therapy and is discharged on March 26 with prescription for warfarin sodium 5mg p.o. once daily.

What are the advantages and disadvantages of using a heparin lock for administration of Heparin?
Heparin Locks, or Hep Locks, are small tubes attached to a catheter, inserted into the arm and held in place with tape in order to administer drugs and fluids without injecting patients multiple times unnecessarily. Heparin lock refers also as one method of intravenous medication administration.
ADVANTAGES The purpose of intravenous administration is to induce a rapid response, as intravenous administration is the fastest way to deliver medication; therefore advantages of using heparin lock in administering heparin are to be injected easily, making life simple for nursing staff, less painful for patients and Heparin lock helps in patient being mobile and need not be restricted to the bed.

DISADVANTAGES Perhaps disadvantage of having hep lock in administering heparin is that, hep lock is directly into the blood vessels, so whenever that the heparin was injected in high strength of dosage it may cause serious errors sometimes fatal to the patient. Therefore using heparin lock in administering heparin always check the strength of heparin to be given.

What nursing observations should be made while Mrs. Robinson in receiving heparin?

Nurses must be observant in monitoring PTT values when a patient is receiving heparin. As heparin has a short half-life, its activity within the body varies constantly, so it is important to monitor the PTT on a continuous basis. Nurses must also observant in checking the platelet. As heparin can also depress the production of platelets, it is important that the patient receiving heparin have regular assessments to determine platelet counts. The nurse should also check to see that the patient receiving heparin is not taking other medications that could potentiate or interfere with the intended therapeutic action of heparin.

What nursing observations should be made while Mrs. Robinson in receiving heparin?

Monitor for bleeding. Check color of urine, occult blood in stool, and/or changes in vital signs. Encourage smoking cessation. (Nicotine decreases the effect of heparin. Patient should not smoke while on heparin therapy.) Monitor CBC in female patients who are menstruating. (Anticoagulation may cause excessive blood loss during menses.)

What general guidelines should be followed when administering heparin through a saline lock?
NURSING ACTION
Explain nature and purpose of heparin lock to patient. His or her understanding will facilitate proper functioning of the lock. Follow Guidelines: Use of winged infusion Set using #21 gauge intermittent infusion reservoir a) Prepare selected site for infusion reservoir; venipuncture b) Apply tourniquet to the patients arm. Cleanse rubber injection port of heparin lock. Firmly rub, using alcohol sponge.

Insert #25 gauge needle of syringe containing normal saline solution into injection port. Small gauge needle will prevent large puncture openings.
Flush cannula-reservoir system with flush solution (usual volume is 1-2ml)

What general guidelines should be followed when administering heparin through a saline lock?
NURSING ACTION
Perform venipuncture
After confirming the position of the needle in the vein, secure wings with adhesive Inject 2ml of normal saline solution Remove saline syringe with needle from injection port. Apply antimicrobial ointment to insertion site, cover with 2 by 2 inch gauze square, secure with inch tape Replace with needle and syringe containing heparin holding solution. Inject 0.5ml heparinized saline solution (or other prescribed dose) Remove needle and syringe from injection port.

What general guidelines should be followed when administering heparin through a saline lock?

NURSING ACTION
Prepare the medication to be administered by drawing it into the appropriate syringe. Draw 2ml. of normal saline solution into each of 2 syringes. Heparin is incompatible with many antibiotics, saline solution is used before and after administration to prevent mixing 2 incompatible drugs. Draw heparized saline solution into a syringe if prescribed Explain to the patient what are you about to do. Cleanse injection port of the heparin with alcohol. insert normal saline syringe needle into port and aspirate slightly. When positive blood return is not obtained, monitor site carefully to detect infiltration.

What general guidelines should be followed when administering heparin through a saline lock?

NURSING ACTION
Inject normal saline solution to flush reservoir of heparinized saline and remove. Insert medication syringe, administer drug, and remove syringe. Insert saline syringe, and flush reservoir slowly, then remove syringe. Saline solution will clear the reservoir of medication and prepare the way for heparinized saline solution. Inject heparinized saline solution into reservoir if prescribed Removal heparin syringe and needle from injection port.

What general guidelines should be followed when administering heparin through a saline lock?

NURSING ACTION Maintain patency of heparin lock by flushing it every 8 hours. If resistance is met, device should not be flushed. Attempt to remove occlusion via aspiration. If unable to restore patency. Remove IV device. Record all actions and medications. Heparin lock should not be left in place longer than 48-72 hours. IV administration sets for intermittent therapy should be changed every 24 hours or immediately upon contamination. A new sterile needles should be used for each entry into the intermittent cannula device. Since the tubing is not maintained as a closed system, it is at higher risk for infection.

Why is the client receiving both heparin and an oral anticoagulant for several days?

In the case of the patient who receives both heparin and an oral anticoagulant for several days, it is given because the patient has Deep vein thrombosis and the treatment of venous thromboembolism usually starts with concomitant administration of heparin or low-molecularweight heparin and a vitamin K antagonist. The oral anticoagulant, which is given for several days (usually 5days), is stopped once the vitamin K antagonist produces a therapeutic level of anticoagulation. Although the introduction of low-molecular-weight heparin has simplified the initial treatment of venous, problems remain. Low-molecular-weight heparin must be given by daily subcutaneous injection and vitamin K antagonists require routine coagulation monitoring, which is inconvenient for patients and physicians.

What instructions would you provide to Mrs. Robinson regarding the oral anti coagulant she will be taking at home?

Educate patients as well as their family members or other people who live with the patients or assist with their care.
RATIONALE: To make them aware because healthcare provider is the best source of information for questions and concerns related to medical problem. It is important to seek guidance from a provider who is familiar with the individual condition.

What instructions would you provide to Mrs. Robinson regarding the oral anti coagulant she will be taking at home?

Do not miss any doses. If you do miss a dose and remember on the same day, take it as soon as you remember. Do not double the dose
RATIONALE: This could increase your risk for bleeding. Keep a record of missed doses to give to your doctor or pharmacist. Contact your doctor or pharmacist if you miss 2 or more doses in a row

What instructions would you provide to Mrs. Robinson regarding the oral anti coagulant she will be taking at home?

Do not take the following unless your doctor has told you to. Aspirin Other NSAIDs (non-steroidal antiinflammatory drugs) celecoxib (Celebrex) diclofenac (Voltaren), ibuprofen (Motrin, Advil) indomethacin naproxen (Aleve, Naprosyn) piroxicam (Feldene)
RATIONALE:These medicines can affect blood clotting and may cause serious bleeding in your stomach

What instructions would you provide to Mrs. Robinson regarding the oral anti coagulant she will be taking at home?

Avoid!!!

Alcohol Larger than usual amounts of foods rich in vitamin K (such as liver, vegetable oil, egg yolks, and green leafy vegetables)

RATIONALE: Can counteract the effect of Warfarin

What instructions would you provide to Mrs. Robinson regarding the oral anti coagulant she will be taking at home?

Do not take Warfarin if you are or may become pregnancy

RATIONALE: Can cause fatal hemorrhage in the developing baby

Avoid activities and sports that could cause an injury and bleeding
Store at room temperature in a tightly closed container away from light Inform the patient of the family about the side effect of Warfarin