Hi. Welcome to our video series on dealing with clots.
We’ll cover anticoagulants and the platelets and thrombolytics in this video series.
Okay, first of all, we're dealing with people who are good at making clots.
And we wanna bring right at the forefront the first point is that all anticoagulants,
antiplatelets and thrombolytics increase the patient’s risk of bleeding, okay?
So we give these to people so we know they are good at making clots, we don’t want them to make more clots
and even with thrombolytics, we're boom, we are lysing clots -
but all of these medications come with the risk of bleeding that’s inappropriate -
bleeding that puts your patient at risk, so first off, before we talk about any medications,
that’s what we want you to have in mind.
Any patient on the medication that makes it more difficult for them to clot has really good clinical applications
but also comes with risks, so it’s important as a nurse that you should monitor for signs and symptoms of bleeding.
So make sure you circle the word monitor.
You should monitor for clinical signs and symptoms of bleeding and teach your patients how to self-monitor
so they know when they start seeing these signs and symptoms it’s time to notify the healthcare provider.
Okay, so first we've established these drugs that deal with clots and hoping that new ones aren’t made.
We wanna make sure that the patient understands, just like you do,
that there's an increased risk for bleeding and that could be problematic.
We’ll break it down.
So nurses and healthcare providers, we've got some extra tools that we can use.
We’ll monitor lab work to help monitor the effectiveness of these medications.
So while the patient is in the hospital it’s really easy to get lab work.
When they go home on some of these medications, the patient will have to be compliant,
that means they're gonna have to come back into lab and have lab work drawn
which usually people aren’t super excited about doing.
I mean I can tell you when I was on one of these medications,
I hated going for lab work cuz you had to wait and go to a special place,
so address that with your patients that you recognize that once they go home
and if they have to come back for follow up labs that it is inconvenient but it is also very important for their safety.
So in the hospital for an anticoagulant medication, we’ll draw a lab test called the PT/INR.
That’s a prothrombin time, that’s for patients who go home on warfarin.
Now there can be a warfarin in the hospital but remember I told you if you go home on a certain medication,
this is one of those medications that you go home on that you need to come back to the lab for testing.
So make sure you write a note with warfarin, just right there, just kinda star that
and write back, outpatient testing also.
Okay, next step for heparin, we're gonna use a test a little aPTT.
So when you see, hear it say aPTT, that’s really what we mean, the little aPTT.
And finally there's another test that you won't see quite as often, you’ll see the PT/INR and you’ll see little aPTT,
but you won't see the heparin Anti-Xa level quite as often,
but we can use it with unfractionated heparin and with some patients
we can even use it with low molecular weight heparin.
Now why that matters and we've got that in this first part,
is because one of the benefits of low molecular weight heparin is that we don’t usually do testing for it.
So, make sure you put that that’s a special case there that we would use this test,
the heparin Anti-Xa level, that would be a special case with low molecular weight heparin but we can do it if we need it.
Okay, now let’s look at how these three groups of drugs work.
First of all, the anticoagulant, that name right there gives us the tip
because this disrupts the coagulation cascade, so that means there's less fibrin produced,
with less fibrin produced things are less sticky, so its kinda like you give less Velcro in the body for these clots to stick together.
So anticoagulant is against coagulation, it disrupts that cascade, you have less fibrin
so you’ve got less stickiness and therefore less clots.
Next, antiplatelets. So we've looked at the anticoagulants, now we're gonna look at the antiplatelets.
Hey, the names are so cool on this meds, it helps you remember their mechanism of action.
Antiplatelets are against platelet aggregating or clumping together.
So anticoagulants, they break up that coagulation cascade and you have less fibrin and stickiness;
antiplatelets inhibit platelet aggregation or clumping together.
Okay, so these are the two drugs that you're gonna see the most of in your practice.
The third one is thrombolytics, okay?
Underline, L-Y-T-I-C-S. Anytime you see that, that should remind you about like lysis, things blowing up.
So I'm gonna lyse a thrombo, that means clot. So thrombolytic -- boom! They blow up clots.
And it is indiscriminate, let’s say it blows up any clot in your body,
not just the one that maybe giving us problems with blood supply to your heart or to your brain,
it goes after any clot in your body, and that’s really important
because this is the most dangerous of these three families, because when we give it,
if the patient has a clot in a particular part that we need them to have that clot,
let’s say it’s keeping them from having a head bleed and a thrombolytic is given, and that boom!
That clot bursts open, that patient is at risk for some severe head problems.
So, anticoagulants, antiplatelets, thrombolytics. What you'll see most of -- anticoagulants and antiplatelets.
Thrombolytics are given in an extreme emergency after we've ruled out all the contraindications,
meaning, we've given our best clinical education guess that this drug is gonna be as safe as we think it can be for this patient.
We’ll talk more about that detail, but I want you to know from the get go, thrombolytics are awesome,
but they also come with a really high price tag if they don’t go well.
Okay, so we've really hit the point hard that you have an increase risk of bleeding
with these three types of drugs, these three families or classes of drugs.
So, what's important is that you recognize even the subtle symptoms of increased risk for bleeding.
So when my patient start showing me these signs,
I'm gonna be really suspicious when I know that they're on one of this three families of medications.
They tell me their gums are bleeding, they have nosebleeds that they cannot stop -- I'm talking about longer than ten minutes.
They start to notice blood in their body fluids, it might be in their urine,
they might be vomiting and see it, it could be in their stool or might even be in their phlegm
which is my least favorite body fluid of them all.
Also a patient might notice they have increased bruising.
So these are things that people may not necessarily associate with,
hey, I'm having an adverse effect from this medication.
But it’s when you absolutely need to teach them and they need to follow up with their healthcare provider.
Some slight bleeding of your gums, that’s okay, but if the patient is showing us multiple symptoms,
we need to draw some lab work and make sure that they're safe.
So it’s important that you recognize these signs and symptoms, and even on a test question,
they may indicate something subtle like this in which of the patient statements is it most important that you follow up on?
Well, if you know somebody’s on one of these three families of medications
and they're having a side effect that indicates bleeding, that would be the most important statement to follow up on.
Now, if the bleeding has progressed to shortness of breath or chest pain -
let me explain why that signs and symptoms is really alarming.
If the patient is bleeding, they might be bleeding internally so you might not see the blood leaving their body,
but it might be filling up there abdominal cavity.
If that blood is getting out, as leaking out of the intravascular system,
right, it’s no longer in blood vessels, then you have less blood available, with hemoglobin,
to carry oxygen around to the rest of the body.
So if they have had some pretty significant bleeding, their hemoglobin is gonna drop.
Hemoglobin’s job is to carry oxygen to the rest of the tissues in the body,
so without enough blood in the space it’s supposed to be, in your vessels,
if your patient has suffered enough bleeding that they are short of breath,
they can even have an MI or a heart attack or like what we talked here, chest pain.
That’s a warning sign that you’re gonna be getting into trouble.
So bleeding gums, that’s an early sign; shortness of breath or chest pain, that means we’re in big, big trouble.
Now they’ve got a cut or somewhere a break in the skin and you just can’t get it to clot,
that’s something else that should be followed up on.
We know that they are prone to bleed longer and for it to take a longer period of time for bleeding to clot,
but it should eventually clot even on any of these medications.
Now changes in mental status or level of consciousness that is a huge red flag.
So remember, the top ones, nah, they’re kind of like that’s really less that we might have a problem.
If we have somebody with shortness of breath or chest pain, put a big red star by that one, that’s an airway problem.
That’s gonna be an emergency.
What about change in mental status or level of consciousness, well, I really want to think that’s an emergency too,
because the patient could be bleeding in their head.
Particularly if you’re with a lot of our elderly patients are at risk for falling.
If they fall and bump their head, and then they have a mental status and change in the level of consciousness,
that is a red flag that that patient maybe bleeding in their head
and the reason they’re having mental status changes or level of consciousness changes,
is because of the pressure that’s building up in their head because of the extra blood.
Now, you can understand why that is such an emergency.
And the final one changes in vital signs, this is really significant blood loss.
What you'll see in vital signs will be the blood pressure will be lower, let’s say roughly less than a 100,
and the heart rate will be higher. Okay now, why is that?
If I’ve got a lower blood pressure why is my heart rate higher?
Well, that is actually is the answer.
If I have so much blood that’s leaking out into my body or out of my body, my blood pressure is gonna drop
because there’s less volume in my intravascular space.
My heart rate is gonna race because my heart says, oh, my gosh!
We don’t have very much, we're gonna try to move around just as fast as we can,
that’s the sign of hypovolemia, low volume.
So looking back at this slide, the first one, those are kind of earlier signs that we’re having trouble.
Shortness of breath or chest pain, whoa, that’s an airway problem.
That’s a big deal and the later sign.
For looking at changes in mental status, that’s a big deal and wow, a little bit later sign
and finally, if they’ve lost enough blood, that is impacted their blood pressure
and their heart rate that is indeed a late sign and really a problem.
Minor ones, the first bullet point where you see bleeding gums, etc. prolonged bleeding that doesn’t clot -
those are ones that we're looking at as those are kind of more than ones that you're likely to see.
The other problems are huge emergencies, so make sure you got those starred.
Now, why do we put those a little bit out of order?
Because that’s a great strategy when you’re studying, as you’re going through list of things,
you’re always asking yourself why, why would somebody in this medication be short of breath?
Why would somebody in this medication have a change in mental status?
Ask yourself why, why, why? And then you work through the prioritizing like we did together,
that will help you recognize your top nursing priority question in an exam,
but most importantly, when you’re taking care of a patient, assessing them and evaluating their symptoms.
Okay, so here’s a big red exclamation point.
Contact the healthcare provider if you’re unable to stop any bleeding or experienced a major accident or trauma.
Now pause the video right here and without looking back at that previous slide,
I want you to write down three red flag signs, three major emergencies for somebody who’s on one of these medications.
Okay, now feel free to look back at your notes,
but I hope you hit shortness of breath or someone having chest pain, change in mental status or level of consciousness,
and blood pressure lowering and heart rate rising which would indicate hypovolemia. Good job!
If you didn’t get them, no problem, write them down now and just come back and review them when you review your notes.