NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Surgical Interventions for Vascular Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Femoral Popliteal Bypass Graft

Focus topic: Medical–Surgical Nursing

Definition: Prosthetic or autologous vein graft is anastomosed to the artery proximal and distal to the atherosclerotic obstruction.

Assessment
A. Observe peripheral circulation pre- and postoperatively.

  • Check for presence of distal pulses—use Doppler if necessary.
  • Check that extremities are warm and pink postoperatively.
  • Compare both extremities.

B. Check vital signs, particularly blood pressure.
C. Check for comorbidity (heart or renal disease).

Implementation
A. Mark on skin where pulses are palpated or heard.
B. Keep leg flat post-operatively initially—avoid wound strain.
C. Monitor edema in operative leg—usual but may require compression hosiery and diuretic; resolves in 4–8 weeks.
D. Administer perioperative antibiotics, postoperative anticoagulants, and antithrombotics as prescribed and monitor drug lab effects.
E. Report bleeding from wound.
F. Encourage ambulation/exercise post-discharge.

Medical–Surgical Nursing

Medical–Surgical Nursing: Aortic Aneurysms

Focus topic: Medical–Surgical Nursing

Definition: A localized abnormal dilatation of the vascular wall occurring most often in the abdominal aorta and less commonly in the thoracic aorta.

Characteristics
A. Caused by weakening of arterial wall due to atherosclerosis; thoracic aneurysm due to trauma, Marfan syndrome.
B. Risk factors include dyslipidemia, diabetes mellitus, smoking, hypertension, family history.
C. Highest incidence in older men—25% also have peripheral vascular occlusive disease.

Assessment
A. Evaluate symptoms to determine area involved.

  • Abdominal aneurysm.
    a. Pulsating mass in abdomen may be palpated.
    b. Bruit over aorta.
    c. Lumbar pain radiating to flank and groin indicates impending rupture.
    d. Detected by abdominal computed tomography (CT) scan or sonography.
  • Thoracic aneurysm.
    a. Pain—most are asymptomatic—substernal, back or neck.
    b. Symptoms due to pressure—dysphagia, hoarseness, dyspnea.
    c. Most accurate means for imaging are CT scan and MRI.
    B. Assess vital signs to obtain baseline data.
    C. Evaluate peripheral pulses.

Implementation
A. Control hypertension—with antihypertensives (e.g., beta blocker).
B. Prepare asymptomatic client for surgery if aneurysm exceeds 5 cm in diameter.
C. Monitor fluid balance. Administer whole blood when needed.
D. Prepare symptomatic client for immediate surgery.
E. Provide postoperative nursing management.

  • Follow same procedures as for open heart surgery if client has thoracic aneurysm; monitor vital signs and hemodynamic variables.
  • Observe circulatory status distal to graft site.
  • Observe all peripheral pulses and temperature of extremities.
  • Monitor renal function with accurate intake and output (cross clamp of aorta during surgery).
  • Observe for emboli to brain or lung.
  • Monitor neurological signs.
  • Monitor for complications.
    a. Hypertensive preoperatively, but can easily become hypotensive due to excessive bleeding.
    b. Acute renal failure. (Monitor intake and output [I&O.])
    c. Hemorrhage from graft site. (Assess for back bruising.)
    d. Cerebral vascular accident.
    e. Paraplegia.
    f. Infection.

Medical–Surgical Nursing: Commonly Used Drugs for the Cardiovascular System

Focus topic: Medical–Surgical Nursing

Summary of Cardiac Drug Categories

Focus topic: Medical–Surgical Nursing

ACE Inhibitors: Use to treat high blood pressure, post heart attack and kidney disease. Also useful in management of heart failure by decreasing stress on heart muscle.
Antiarrhythmics: Help heart to beat in a regular rhythm.
Anticoagulants: Slow down blood-clotting process. Prescribed for blocked arteries or blood clot in an artery.
Antioxidants: Prevent chemical reaction in blood causing oxidation, which leads to plaque formation.
Antiplatelets: Prevent platelets from clumping or forming clots. They lower the risk of heart attack. Beta Blockers: Lower heart rate and blood pressure, thus reducing work of the heart.
Calcium-Channel Blockers: Used for high blood pressure to prevent artery spasm or angina, or to control rapid heartbeat.
Cardiac Glycosides: Help to maintain normal heart rhythm and rate. Also strengthen heart muscle.
Cholesterol-Lowering Agents: Lower blood cholesterol levels, reducing risk of developing coronary heart disease.
Diuretics: Lower blood pressure by allowing kidneys to rid body of excess fluid.
Nitrates: Dilate blood vessels, which decrease workload of the heart. Primary indication is to prevent or stop angina.

Medical–Surgical Nursing: Specific Drug Categories

Focus topic: Medical–Surgical Nursing

Diuretics
A. Action: most diuretics block sodium reabsorption in tubules of kidney, thereby eliminating water.
B. Agents.

  • Thiazide and thiazide-like diuretics.
    a. Common preparations: Diuril (chlorothiazide), Hydrodiuril (hydrochlorothiazide), Hygroton (chlorthalidone), Exna (benzthiazide), Enduron (methyclothiazide), etc.
    b. Thiazide-like: Thalitone (chlorthalidone), Lozol (indapamide), Zaroxolyn, Mykrox (metolazone).
    c. Administration: oral and parenteral.
    d. Advantages: potent by mouth; effective antihypertensives.
    e. Disadvantages: electrolyte imbalances; loss of potassium, metabolic alkalosis, hypotension, hyperlipidemia.
    f. Nursing implementation.
    (1) GI upset, gout, hyperglycemia.
    (2) Allergic reaction.
    (3) Monitor kidney function (BUN, serum creatinine), signs of hypokalemia.
  • Potassium-sparing agents.
    a. Common preparations: Aldactone (spironolactone), Dyrenium (triamterene).
    b. Administration: oral only.
    c. Advantages: conserve potassium.
    d. Disadvantages: weak diuresis; usually not effective when used alone.
    e. Nursing implementation.
    (1) Electrolyte imbalance; hyperkalemia.
    (2) Gynecomastia and nitrogen
    retention.
    (3) If diarrhea or GI problems occur, give after meals.
    (4) If drowsy, headache, or lethargy, decrease dose as ordered.
  • Loop diuretics: moderate to severe volume overload.
    a. Common preparations: Lasix (furosemide), Bumex (bumetanide), Edecrin (ethacrynic acid), Demadex (torsemide).
    b. Administration: oral and parenteral.
    c. Advantages: rapid, potent action useful in cases of severe pulmonary edema and refractory edema.
    d. Nursing implementation/evaluation.
    (1) Note weight loss with diuresis.
    (2) Monitor/watch for signs of electrolyte imbalance (potassium and chloride loss); dehydration.
    (3) Thirst, nausea, skin rash; monitor blood pressure.
    (4) Hyperuricemia, secondary aldosteronism, hyperglycemia.
    (5) Give oral doses with food to decrease GI side effects.
    e. Adverse reactions: hypotension, electrolyte imbalance, rash, azotemia.

Nitrates
A. Action.

  • Promotes vasodilation by reducing vascular tone in arteries and veins.
  • Decreases venous blood return to heart ( preload)—primary action.
  • Decreases peripheral arterial vascular resistance (afterload)—in larger doses.
  • Reduces myocardial oxygen consumption and pulmonary congestion.

B. Uses.

  • First-line therapy for acute angina.
  • Heart failure related to ischemic heart disease.

C. Agents.

  • Short acting—for acute attack or prophylactically.
    a. Sublingual—Tridil (nitroglycerin) for acute attack (repeat in 3- to 5-minute intervals).
    b. Buccal spray.
    c. IV sodium Nipride (nitroprusside)—for heart failure decompensation combined with Depostat, Intropin (dopamine) or Dobutrex (dobutamine).
  • Long acting.
    a. Oral—Imdur, Ismo (isosorbide mononitrate).
    b. Nitro-Dur (nitroglycerin), transdermal.
  • Extended release—buccal tablets; capsules.

D. Major side effects.

  • Headache is a common side effect.
  • Postural hypotension.
  • Cyanide poisoning with sodium nitroprusside use.

E. Nursing implementation.

  • Development of tolerance minimized with intermittent therapy.
  • Advise client to take drug, in short-acting doses, while sitting or lying down to prevent hypotension.
  • Drug should be replaced in 3 months after opening bottle.
  • Instruct client to notify physician if severe headache, weakness, blurry vision, irregular heartbeat, or dry mouth is experienced.

Medical–Surgical Nursing: ACE Inhibitors

Capoten (captopril), Lotensin (benazepril), Vasotec (enalapril), Zestril (lisinopril), Univasc (moexipril), etc.

A. Action.

  • Angiotensin-converting enzyme (ACE) inhibitor.
  • Inhibits renin–angiotensin–aldosterone activity.
  • Effective for heart failure (reduces mortality and improves cardiac function).
  • Used as initial therapy for early CHF.
  • Stimulates synthesis of nitric oxide and prostaglandin.
  • Used postinfarction to reduce ventricular remodeling.

B. Adverse side effects.

  • Hypotension—especially with first dose.
  •  Dry, irritating cough is often present.
  • Swelling of lips, tongue, or glottis may occur.
  • Renal insufficiency.

C. Nursing implementation.

  • Instruct client to take medication at same time every day.
  • Instruct client to move from lying to sitting to standing position slowly.
  • Avoid salt substitutes that could lead to hyperkalemia.
  • Notify physician if cough, fatigue, or nausea develop.

Beta-Adrenergic Blockers
Inderal (propranolol), Lopressor (metoprolol), Tenormin (atenolol), Sectral (acebutolol), Zebeta (bisoprolol), Coreg (carvedilol), etc.
A. Action.

  • Blocks cardiac response to sympathetic stimulation—slows heart, decreases blood pressure, slows AV conduction.
  • Pure beta or beta1-specific action.
  • Coreg (carvedilol): alpha and beta blocker for heart failure.

B. Uses.

  • Prevent chronic angina; used in unstable angina.
  • Slow heart rate, slow AV conduction, lower blood pressure.
  • Prolong life in postinfarction clients.
  • Prevent sudden death.
  • Improve left ventricular function.

C. Contraindications/major side effects.

  • Bronchospasm (COPD), wheezing.
  • Bradyarrhythmias.

Angiotensin Receptor Blockers
A. Action: appropriate alternative for vasodilation if clients are intolerant to ACE inhibitors due to cough, edema, or rash.
B. Example: Cozaar (losartan).

Cardiac Glycosides
Lanoxin (digoxin), Crystodigin (digitoxin)
A. Action.

  • Increases contractile force (pumping ability of heart positive inotropism), which increases cardiac output in systolic heart failure ( ejection fraction < 40%).
  • Slows heart rate.
    a. Direct effect.
    b. Increases vagal tone and decreases sympathetic tone.
  • Slows conduction through AV node.
  • Increases nonpacemaker cell automaticity that may cause arrhythmias.

B. Uses.

  • Systolic heart failure—increases contractility, reduces oxygen needs, increases cardiac efficiency, and reduces heart size.
  • Supraventricular tachyarrhythmias—slows ventricular rate by slowing conduction of impulses through AV node.

C. Dosage.

  • Individualized to client and clinical situation; loading dose, then maintenance dose (usually 0.25 mg daily).
  • Monitor blood level with Lanoxin (normal is 0.9–2.0 mg/mL).

D. Major side effects—signs of toxicity.

  • Cardiac.
    a. Bradycardia.
    b. Conduction disturbances (advanced AV block).
    c. Arrhythmias, due to increased automaticity (premature ventricular beats).
  • Gastrointestinal.
    a. Anorexia.
    b. Nausea and vomiting.
    c. Diarrhea.

E. Nursing implementation.

  • Monitor for toxic effects—incidence high.
    a. Signs and symptoms: anorexia, nausea, vomiting, bradycardia.
    b. Elderly are more sensitive to Lanoxin, so monitor carefully for toxicity.
  • Check apical pulse before administering Lanoxin drugs.
    a. If below 60, hold dose and notify physician.
    b. If above 120, check for toxicity/ arrhythmias.
  • Client teaching.
    a. Ensure that client understands drug action and dosage.
    b. Monitor pulse before taking medication.
    c. Report unusual effects (toxic symptoms).
    d. Store in tightly covered, light-resistant containers.
  • Precautions.
    a. Hypokalemia—predisposes client to toxicity.
    b. Renal failure—predisposition to Lanoxin toxicity.
    c. Should not be given with advanced AV block.
    d. Increased risk of toxicity when given with antiarrhythmics.

Medical–Surgical Nursing: Calcium-Channel Blockers (Ion Antagonists)

Focus topic: Medical–Surgical Nursing

Calan, Isoptin (verapamil), Cardizem (diltiazem), Procardia (nifedipine), Norvasc (amlodipine)
A. Action.

  • Inhibits the influx of calcium ions across cell membrane.
  • Decreases heart rate as conduction is slowed through SA and AV nodes.
  • Reduces extension of non-Q MI. Increases myocardial oxygenation by causing coronary vasodilation (Isoptin, Cardizem).
  • Decreases peripheral vascular resistance (especially Procardia)—dilates blood vessels.

B. Uses.

  • Prescribed for angina—especially vasospastic angina.
  • Slows ventricular response to atrial tachyarrhythmias.
  • Antihypertensive agents.

C. Major side effects.

  • Cardizem (diltiazem hydrochloride)—nausea, edema, bradycardia.
  • Calan, Isoptin (verapamil hydrochloride)— hypotension, peripheral edema, vertigo, bradycardia.
  • Procardia (nifedipine)—nausea, peripheral edema, headache, flushing, dyspnea, reflex tachycardia.

D . Nursing implementation.

  • Cardizem: Observe for hypotension; report irregular heartbeats, or bradycardia; do not discontinue suddenly.
  • Calan, Isoptin: Give on empty stomach; do not discontinue suddenly; monitor for bradycardia, constipation.
  • Procardia: Give on empty stomach.

Antiarrhythmic Drugs

Focus topic: Medical–Surgical Nursing
Quinidex (quinidine), Pronestyl (procainamide hydrochloride), Xylocaine (lidocaine), Cordarone (amiodarone)
A. Action.

  • Increases recovery time of atrial and ventricular muscle; prolongs repolarization.
  • Decreases myocardial excitability.
  • Increases conduction in cardiac muscle, Purkinje fibers, and AV junction (exception: Xylocaine).
  • Decreases contractility (exception: Xylocaine).
  • Decreases automaticity.

B. Uses.

  • Quinidex (quinidine) used for atrial fibrillation, atrial flutter, supraventricular tachycardia, premature systoles.
  • Pronestyl (procainamide hydrochloride) used for premature ventricular systoles.
  •  Xylocaine (lidocaine) is drug of choice for short-term management of ventricular tachyarrhythmias associated with MI.
  • Cordarone (amiodarone) for life-threatening arrhythmias unresponsive to other agents.

C. Major side effects.

  • Quinidex.
    a. Cinchonism—nausea, vomiting, diarrhea, tinnitus, vertigo, visual disturbances.
    b. Hypersensitivity, thrombocytopenia.
    c. Conduction disturbances.
    d. Potentiates Lanoxin toxicity.
  • Pronestyl.
    a. Anorexia, nausea, vomiting, diarrhea.
    b. Systemic lupus erythematosus.
    c. Agranulocytosis.
    d. AV block.
  • Xylocaine.
    a. Central nervous system (CNS) disturbances—drowsiness, slurred speech, blurred vision, seizures, coma.
    b. Cautious use in clients with liver disease or low cardiac output (metabolism of drug slowed).
  • Cordarone.
    a. Visual disturbances.
    b. Bradycardia, hypotension.
    c. Liver function abnormality.
    d. Potentiates Lanoxin toxicity.

D . Nursing implementation.

  • Monitor ECG and assess vital signs.
  • Client teaching.
    a. Observe for individual drug side effects.
    b. Notify physician if arrhythmia develops.
  • Monitor blood levels as indicated.

Sympathomimetic Agents

Focus topic: Medical–Surgical Nursing
A. Action.

  • Adrenalin (epinephrine hydrochloride): beta and alpha stimulation—increases heart rate, contractility, and peripheral vascular resistance; bronchodilation.
  • Levophed (norepinephrine).
    a. Alpha-adrenergic stimulation—peripheral vasoconstriction.
    b. Beta stimulation mild.
  • Isuprel (isoproterenol hydrochloride): beta stimulation.
    a. Increases heart rate, contractility, and oxygen consumption.
    b. Decreases vascular resistance.
    c. Bronchodilation.
  • Depostat, Intropin (dopamine)—precursor of norepinephrine.
    a. Raises blood pressure.
    b. Increases myocardial contractility.
    c. Increases cardiac output and perfusion.
    d. Dilates renal vessels; improves urine output.
  • Dobutrex (dobutamine hydrochloride).
    a. Cardiac stimulation, but no significant increase in heart rate.
    b. Increases cardiac output.

B. Uses.

  • Adrenalin: allergic states, anaphylactic shock.
  • Levophed.
    a. Elevates blood pressure.
    b. Used for hypotension, cardiac arrest.
  • Isuprel.
    a. Cardiogenic shock with high peripheral vascular resistance.
    b. AV block—increases pacemaker automaticity
    and improves AV conduction.
  •  Depostat, Intropin—precursor of norepinephrine.
    a. Cardiogenic shock (hypotension).
    b. Heart failure.
  • Dobutrex.
    a. Short term for heart failure.
    b. Cardiac surgical procedures.

C. Major side effects.

  • Adrenalin.
    a. Chest pain, arrhythmias, tachycardia, hypertension.
    b. Hyperglycemia.
  • Levophed.
    a. Anxiety (mimics physiological reaction to stress), headache.
  • b. Hypertension.
    c. Arrhythmias.
  • Isuprel.
    a. Tachyarrhythmias, especially ventricular tachycardia.
    b. Hypotension.
    c. Headache, skin flushing, angina, dizziness, weakness.
  • Depostat, Intropin.
    a. Renal vasoconstriction with high dose.
    b. Hypertension.
    c. Tachycardia, arrhythmias.
  • Dobutrex.
    a. Arrhythmias, palpitations.
    b. Angina, chest pain, shortness of breath.

D . Nursing implementation.

  • Carefully monitor ECG and vital signs.
  • Prevent IV infiltration of vasoconstricting agents—could cause tissue necrosis (central vein preferred).
  • Client teaching.
    a. Recognition of side effects.
    b. Diet—high fiber to reduce constipation.

Antihyperlipidemic Agents

Focus topic: Medical–Surgical Nursing
A. Action.

  • Lowers low-density lipoprotein (LDL) cholesterol levels and triglycerides. Raises highdensity lipoprotein (HDL) cholesterol.
    a. Binds with bile acids in the intestine and excreted in feces, resulting in removal of LDL and cholesterol.
    b. May interfere with absorption of Lanoxin, thiazides, beta-adrenergic blockers, fatsoluble vitamins, folic acid, and Vancocin (vancomycin).

B. Uses and side effects.

  • Bile acid sequestrants: Questran (cholestyramine).
    a. Causes liver to produce bile acid from cholesterol.
    b. Lowers LDL and total cholesterol.
    c. May raise serum triglyceride level.
    d. GI side effects (constipation, flatulence, nausea).
  • HMG-CoA reductase inhibitors: Mevacor (lovastatin) or Zocor (simvastatin).
    a. Blocks synthesis of cholesterol.
    b. Lowers LDL cholesterol and triglycerides; raises HDL cholesterol.
    c. May cause constipation, diarrhea, liver enzymes elevation, muscle aches.
  • Fibric acid derivatives: Atromid-S (clofibrate), Lopid (gemfibrozil), Tricor (fenofibrate).
    a. Inhibit liver synthesis of triglycerides and very-low-density lipoprotein (VLDL).
    b. Used for hypertriglyceridemia and type III hyperlipidemia.
    c. GI side effects common; gallstones.
    d. May increase effects of anticoagulants and hypoglycemics.
  • Nicobid, Niacor (nicotinic acid [niacin]).
    a. Inhibits VLDL production in liver.
    b. Decreases low-density lipoprotein (LDL) level; raises high-density lipoprotein (HDL) level.
    c. Used in mixed dyslipidemias.
    d. Used in combination with other antihyperlipidemics.
    e. May cause cutaneous flushing, pruritus, hepatitis.

C. Nursing implementation.

  • Review dietary restrictions (AHA diet).
  • Encourage regular exercise program.
  • Vitamin supplementation may be indicated.
  • HMG-CoA reductase inhibitors taken in evening.
  • Encourage smoking cessation.

Platelet Inhibitors

Focus topic: Medical–Surgical Nursing
Aspirin (acetylsalicylic acid; ASA), Persantine (dipyridamole), Ticlid (ticlopidine)
A. Action.

  • Agents interfere with platelet adhesion or aggregation.
  • Used to prevent venous thromboembolism and arterial thrombosis (cerebrovascular accident [CVA, MI]).

B. Uses and side effects.

  • Aspirin (acetylsalicylic acid).
    a. Inhibits platelet formation of thromboxane A (reduces adhesiveness).
    b. Low dose used in angina, acute coronary syndromes, MI, transient ischemic attack (TIA), postcardiac surgery, postcoronary artery interventional therapy.
    c. Prolongs bleeding time; interacts with Coumadin (warfarin) to prolong prothrombin time (PT).
    d. Monitor for GI bleeding; tinnitus.
    2. Persantine (dipyridamole).
    a. Increases platelet cyclic adenosine monophosphate (AMP) levels.
    b. Used for peripheral vascular disease, prosthetic heart valves, TIA.
    c. May cause hypotension.
  • Ticlid (ticlopidine).
    a. Blocks platelet recruitment by binding to adenosine diphosphate (ADP) receptor on platelet.
    b. Same indications as aspirin.
    c. Used if unable to tolerate aspirin.
    d. May cause bleeding, neutropenia, thrombocytopenia; may increase serum lipids.
  • GPIIb/IIIa antiagonists: Plavix (clopidogrel) oral; Reopro (abciximab) IV.
    a. Inhibit platelet aggregation.
    b. Used as adjunct to interventional coronary procedures (angioplasty, stent placement).
    c. Used in unstable angina.
    d. May cause hypotension, bradycardia, serious bleeding.

C. Nursing implementation.

  • Recommend appropriate safety precautions for bleeding.
  • Discuss possible drug interactions (consult physician before taking OTC medications).
  • Reinforce teaching of early signs of stroke, heart attack, DVT.
  • Monitor closely for bleeding (especially following interventional therapies).

Anticoagulant Therapy

Focus topic: Medical–Surgical Nursing
A. Action.

  • Medications used to prevent intravascular thrombosis by decreasing blood coagulability.
    a. Heparin IV, sub q.
    b. Coumadin (warfarin sodium) PO.
    c. Lovenox (enoxaparin) sub q.
  • Pharmacological action.
    a. Prevents fibrin deposits.
    b. Prevents extension of a thrombus.
    c. Prevents thromboembolic complications.

B. Contraindications for use of drug.

  • Blood dyscrasia.
  • Liver and kidney disease.
  • Peptic ulcer.
  • Chronic ulcerative colitis.
  • Active bleeding (except disseminated intravascular coagulation [DIC]).
  • Spinal cord or brain injuries.

C. Drugs and foods to avoid when on anticoagulant therapy.

  • Leafy green vegetables (foods high in vitamin K) more than usual—antagonist.
  • Salicylates/NSAIDs, Tylenol (acetaminophen), and steroids potentiate.

D. Nursing implementation—safety precautions.

  • Keep antagonist nearby; see Antagonist, next column.
  • Observe for signs of bleeding (gums, ecchymosis, hematuria, melena).
  • Avoid/prevent bleeding.
  • Carry identification card (Coumadin [warfarin]).
  • Keep appointments for blood work (PT).
  • Teach first aid for bleeding.

Intravenous/Subcutaneous Anticoagulants

Focus topic: Medical–Surgical Nursing
Heparin sodium, Lovenox (enoxaparin)
A. Mode of administration: IV or sub q (inactivated orally).

B. Action.

  • Interferes with formation of thrombin from prothrombin.
  • Prevents thrombin from converting fibrinogen to fibrin.
  • Therapeutic dose by continuous infusion (e.g., 1000 U/hr) prolonged partial thromboplastin time (PTT).
  • Dose lasts 3–4 hours if given IV intermittently (3500–5000 U q 8–12 hr) for prophylaxis.

C. Lab findings.

  • Prophylactic dose not monitored by PTT.
  • Therapeutic dose—weight-based dose adjusted to achieve desired PTT; values 1.5 to 2 times normal values.

D . Antagonist.

  • Discontinue infusion (short half-life).
  •  Protamine sulfate: 1 mg protamine sulfate for each 100 U of heparin in last dose if necessary.

E. Used for treatment of various conditions.

  • Quickly stops development of clots.
  • Serious unstable angina.
  • Certain strokes.
  • Severe thrombophlebitis.
  • Acute pulmonary edema.

F. Nursing implementation.

  • Check PTT or clotting time routinely for weight-based dosing per IV titration.
  • Check patency of IV.
  • Assess client for bleeding.
  • Avoid aspirin during anticoagulant therapy.
  • Instruct client to carry medical alert card.
  • Take the following precautions when administering drug sub q into abdomen:
    a. Use small needle (27 gauge).
    b. Form pouch of skin on abdomen no closer than 5 cm around umbilicus—avoid extremities.
    c. Administer injection at 90-degree angle sub q.
    d. Do not aspirate needle or massage skin around injection site to prevent ecchymosis.

Oral Anticoagulants

Focus topic: Medical–Surgical Nursing
Dicumarol, Coumadin (warfarin sodium), Miradon (anisindione)
A. Mode of administration: oral.
B. Action.

  • Prevents utilization of vitamin K by liver.
  • Depresses hepatic synthesis of several clotting factors.
  • Decreases prothrombin formation.
  • Takes 24–72 hours for action to develop and continues for 24–72 hours after last dose.

C. Antagonist.

  • Vitamin K—AquaMephyton (phytonadione) IM or IV.
  • Returns to hemostasis within 6 hours.
  • Blocks action of Coumadin (warfarin) for 1 week.

D . Nursing implementation.

  • Check prothrombin or INR time before giving.
    a. Keep prothrombin time at 18–30 seconds (normal is 12–14 seconds).
    b. Keep INR between 2 and 3.5.
  • Give at same time each day.
  • Teach client to avoid usual intake of foods high in vitamin K (kale, spinach, collards, turnip greens, Swiss chard, parsley, and other dark leafy vegetables), grapefruit and grapefruit juice, alcohol, ASA, NSAIDs, Tylenol (acetaminophen).
  • Encourage client to wear Med-Alert bracelet.
  • Avoid invasive procedures (IM injection) and injury.
  • Check with physician before taking any OTC medications.
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Thrombolytic Agents

Focus topic: Medical–Surgical Nursing
A. Action.

  • Activates formation of plasmin, which digests fibrin and dissolves formed blood clots—limits infarct size.
  • Stimulates conversion of plasminogen to plasmin (fibrinolysin).
  • Prescribed for acute pulmonary emboli, deep vein thrombosis, arterial thrombosis, and coronary thrombosis.
  • Greatest benefit if initiated in 1–3 hours.

B. Agents infused.

  • Streptase (streptokinase); Abbokinase (urokinase).
  • Tissue plasminogen activator: Activase (alteplase).
  • Eminase (anistreplase, APSAC).
  • Retavase (reteplase).
  • TNKase (tenecteplase) was FDA approved in 2000.
    a. Can be administered in one single injection to dissolve clots rather than 90-minute infusion.
    b. Advantage over Activase is that TNKase is more specific for a clot in coronary artery.

C. Major side effects.

  • Serious bleeding (increased fibrinolytic activity).
  • Fever up to 100°F/37.7°C.
  • Allergic reactions; rash (Streptase).
  •  Reperfusion arrhythmias when used for coronary clots.

D. Contraindications for use.

  • Recent major surgery, GI bleed.
  • History of CVA.
  • Bleeding tendency.
  • Uncontrolled hypertension.
  • Pregnancy.

E. Nursing implementation.

  • Obtain PTT, PT, fibrinogen level, and platelet count.
  • Monitor infusion of IV (use controller or pump).
  • Monitor closely for signs of bleeding, blood pressure.
  • a. 24 hours for pulmonary embolism.
    b. 24–72 hours for deep vein or arterial thrombosis.
  • Avoid invasive procedures.
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