Hemostasis

The process that halts bleeding after injury to a blood vessel

Complex relationship between substances that promote clot formation and either inhibit
coagulation or dissolve a formed clot
Coagulation System
Cascade"
Each activated factor serves as a catalyst that amplifies the next reaction
Result is fibrin, a clot-forming substance
Intrinsic pathway and extrinsic pathway
Coagulation Modifier Drugs
Anticoagulants
Antiplatelet drugs
Hemorheologic drugs
Thrombolytic drugs
Hemostatic or antifibrinolytic drugs
Anticoagulants
Inhibit the action or formation of clotting factors
Prevent clot formation
Also known as antithrombotic drugs
Have no direct effect on a blood clot that is already formed
Used prophylactically to prevent
Clot formation (thrombus)
An embolus (dislodged clot)
Heparin
warfarin sodium (Coumadin)
Antiplatelet drugs
Inhibit platelet aggregation
Prevent platelet plugs
Hemorheologic drugs
Alter platelet function
Thrombolytic drugs
Lyse (break down) existing clots
Hemostatic or antifibrinolytic drugs
Promote blood coagulation
Anticoagulants: Indications
Used to prevent clot formation in certain settings where clot formation is likely
Myocardial infarction
Unstable angina
Atrial fibrillation
Indwelling devices, such as mechanical heart valves
Major orthopedic surgery
Anticoagulants:
Adverse Effects
Bleeding
Risk increases with increased dosages
May be localized or systemic
Heparin-induced thrombocytopenia (HIT)
May also cause:
Nausea, vomiting, abdominal cramps, thrombocytopenia, others
Heparin
Monitored by activated partial thromboplastin times (aPTTs)
Parenteral
Short half-life (1 to 2 hours)
Effects reversed by protamine sulfate
Low-molecular-weight heparins
enoxaparin (Lovenox) and dalteparin (Fragmin)
More predictable anticoagulant response
Do not require laboratory monitoring
Given subcutaneously
warfarin sodium (Coumadin)
Given orally only
Monitored by prothrombin time (PT) and INR
(PT-INR)
Vitamin K can be given if toxicity occurs
Antiplatelet Drugs
Prevent platelet adhesion
aspirin
dipyridamole (Persantine)
clopidogrel (Plavix) and ticlopidine (Ticlid)
ADP inhibitors
tirofiban (Aggrastat), eptifibatide (Integrilin), abciximab (ReoPro)
New class, GP IIb/IIIa inhibitors
Antiplatelet Drugs: Indications
Antithrombotic effects
Reduce risk of fatal and nonfatal strokes
Acute unstable angina and MI
Adverse effects
Vary according to drug
Aspirin (ASA)
Salicylate antiplatelet
Do not give to children and teenagers with flulike symptoms - risk of Reye's
syndrome
Effects last 7 days
Irreversibly inhibits COX in platelets, so effects will last for lifespan of platelet
Clopidogrel (Plavix)
Alters platelet membrane so it can no longer receive signal to aggregate and form clot

Somewhat better than aspirin at reducing the number of heart attacks, strokes, and
vascular deaths for patients at risk
Combination of clopidogrel and ASA
effective in patients with known cardiovascular disease, but not those with just risk
factors
Antifibrinolytic Drugs
Prevent the lysis of fibrin
Result in promoting clot formation
Used for prevention and treatment of excessive bleeding resulting from
hyperfibrinolysis or surgical complications

aminocaproic acid (Amicar)

desmopressin (DDAVP)
Similar to ADH
Also used in the treatment of diabetes insipidus
Antifibrinolytic Drugs:
Indications
Prevention and treatment of excessive bleeding
Hyperfibrinolysis
Surgical complications
Excessive oozing from surgical sites such as chest tubes
Reducing total blood loss and duration of bleeding in the postoperative period
Treatment of hemophilia or von Willebrand's disease
Antifibrinolytic Drugs:
Adverse Effects
Uncommon and mild
Rare reports of thrombotic events
Others include:
Dysrhythmia, orthostatic hypotension, bradycardia, headache, dizziness, fatigue,
nausea, vomiting, abdominal cramps, diarrhea, others
Thrombolytic Drugs
Drugs that break down, or lyse, preformed clots
Older drugs
streptokinase and urokinase
Newer drugs
Tissue plasminogen activator (t-PA)
Anisoylated plasminogen-streptokinase activator complex (APSAC)

anistreplase (Eminase)
alteplase (t-PA, Activase)
reteplase (Retavase)
tenecteplase (TNKase)
Thrombolytic Drugs:
Indications
Acute MI
Arterial thrombolysis
DVT
Occlusion of shunts or catheters
Pulmonary embolus
Acute ischemic stroke
Thrombolytic Drugs:
Adverse Effects
Bleeding
Internal
Intracranial
Superficial

Other effects
Nausea, vomiting, hypotension, anaphylactoid reactions
Cardiac dysrhythmias; can be dangerous
Nursing Implications
Patient history, medication history, allergies
Contraindications
Baseline vital signs, laboratory values
Potential drug interactions—there are MANY!
History of abnormal bleeding conditions
Heparin: Nursing Implications
Intravenous doses are usually double-checked with another nurse
Ensure that SC doses are given SC, not IM
SC doses should be given in areas of deep subcutaneous fat, and sites rotated
Do not give SC doses within 2 inches of:
The umbilicus, abdominal incisions, or open wounds, scars, drainage tubes, stomas
Do not aspirate SC injections or massage injection site
May cause hematoma formation
LWMHs: Nursing Implications
Given subcutaneously in the abdomen
Rotate injection sites
Protamine sulfate can be given as an antidote in case of excessive anticoagulation
Warfarin Sodium:
Nursing Implications
May be started while the patient is still on heparin until PT-INR levels indicate adequate
anticoagulation
Full therapeutic effect takes several days
Monitor PT-INR regularly—keep follow-up appointments
Antidote is vitamin K
Warfarin:
Nursing Implications
Many herbal products have potential interactions—increased bleeding may occur
Capsicum pepper
Garlic
Ginger
Gingko
Ginseng
Feverfew
Anticoagulants:
Patient Education
Importance of regular lab testing
Signs of abnormal bleeding
Measures to prevent bruising, bleeding, or tissue injury
Wearing a medical alert bracelet
Avoiding foods high in vitamin K (tomatoes, dark leafy green vegetables)
Consulting physician before taking other meds or over-the-counter products, including
herbals
Antiplatelet Drugs:
Nursing Implications
Dipyridamole should be taken on an empty stomach
Drug-drug interactions
Adverse reactions to report
Monitoring for abnormal bleeding
Thrombolytic Drugs:
Nursing Implications
Follow strict manufacturer's guidelines for preparation and administration
Monitor IV sites for bleeding, redness, pain
Monitor for bleeding from gums, mucous membranes, nose, injection sites
Observe for signs of internal bleeding (decreased BP, restlessness, increased pulse)
Coagulation Modifier Drugs:
Nursing Implications
Monitor for therapeutic effects
Monitor for signs of excessive bleeding
Bleeding of gums while brushing teeth, unexplained nosebleeds, heavier menstrual
bleeding, bloody or tarry stools, bloody urine or sputum, abdominal pain, vomiting blood
Monitor for adverse effects
Increased BP, headache, hematoma formation, hemorrhage, shortness of breath, chills,
fever