chamberlain college of nursing nr565 week 5 study guide outline nr 565 week 5 study guide outline v2latest
2020
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NR 565 (NR565)
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NR565 Week 5 Study Guide _Outline
Chapter 18: Drugs Affecting the Hematopoietic System
Chapter 19: Drugs Affecting the Immune System
Chapter 27: Anemia
Chapter 37: HIV & Aids
Many questions are written to assess your clinical application of the material from
the textbook, in real-world scenarios.
Chapter 18: Drugs Affecting the Hematopoietic System
• Know the pharmacodynamics, pharmacotherapeutics clinical use, drug
interactions and adverse drug reactions for:
• o Anticoagulants
• Pharmacodynamics Oral anticoagulants such as warfarin (Coumadin)
inhibit the hepatic synthesis of several clotting factors, including factor X.
The decline in clotting factors is a function of the half-life of each factor,
which varies from 5 hours for factor VII to 72 hours for factor II.
• Heparin inhibits the activity of several activated clotting factors by
accelerating the activity of antithrombin III. LMWH enoxaparin (Lovenox)
potentiates the activity of antithrombin III and inactivates factors Xa and IIa
(thrombin). Dabigatran (Pradaxa) is a direct thrombin inhibitor. Thrombin is
required for the conversion of fibrinogen to fibrin in the clotting cascade,
thus dabigatran's inhibition of thrombin prevents thrombi from forming.
Fondaparinux (Arixtra) is a selective inhibitor of antithrombin III and a
factor Xa inhibitor. An anticoagulant, rivaroxaban (Xarelto), is a highly
selective factor Xa inhibitor that inhibits thrombin formation and the
development of thrombi. Apixaban (Eliquis) is a selective inhibitor of factor
Xa.
• Aspirin antagonizes the cyclooxygenase pathway and interferes with platelet
aggregation. NSAIDs have this same action. NSAIDs are not used as
antiplatelet drugs, but this explains why concurrent use with anticoagulants
is contraindicated
, • Ticlopidine (Ticlid) and clopidogrel (Plavix) reduce platelet aggregation by
inhibiting the ADP pathway of platelets. Unlike aspirin, they have no effect
on prostaglandin metabolism. Ticagrelor (Brilinta) reversibly interacts with
the platelet P2Y12 ADP-receptor to prevent platelet activation. Vorapaxar
(Zontivity) is a protease-activated receptor-1 (PAR-1) antagonist, inhibiting
thrombin-induced and thrombin receptor agonist peptide-induced platelet
aggregation
• Precautions and Contraindications All anticoagulants are contraindicated
for patients who are hypersensitive to the drug or actively bleeding or who
have hemophilia, thrombocytopenia, severe hypertension (HTN),
intracranial hemorrhage, infective endocarditis, active tuberculosis, or
ulcerative lesions of the GI tract. Heparins are contraindicated in advanced
hepatic or renal disease. They may be used in patients who are actively
bleeding to treat disseminated intravascular coagulation (DIC). Heparin is
Pregnancy Category C.
• LMWHs are contraindicated for patients with allergies to pork, sulfites, or
benzyl alcohol; uncontrolled bleeding; and in patients who have antiplatelet
antibodies.
Use caution in hepatic dysfunction and use of warfarin and increased risk of
bleeding with adults
Warfarin crosses the placenta and can cause hemorrhagic disorders in the fetus and
serious birth defects. It is Pregnancy Category X and should not be administered
during pregnancy.
Rivaroxaban (Xarelto) was given a Black-Box Warning in August 2013 indicating
the premature discontinuation of anticoagulants including rivaroxaban may lead to
thrombotic events. An increased risk of stroke is seen in patients with atrial
fibrillation when transitioning to warfarin. Rivaroxaban is Pregnancy Category C
and is not recommended for use in pregnant women. Apixaban (Eliquis) was given
a similar Black Box warning regarding premature discontinuation leading to
thrombotic events when it was approved. Although there are no well-controlled
studies, apixaban is Pregnancy Category B. Hypersensitivity to aspirin and cross-
sensitivity with NSAIDs may occur, contraindicating the drug. Aspirin
hypersensitivity is more prevalent in patients with asthma, nasal polyps, or chronic
urticaria. Reye syndrome has been associated with its use in children and teenagers
who have influenza or chickenpox. Reversible hepatotoxicity has occurred.
Ticagrelor has a Black-Box Warning to not use in a patient with active
pathological bleeding or history of intracranial hemorrhage. Ticagrelor should be
discontinued 5 days prior to any surgery.
, Dabigatran has a Black-Box Warning concerning discontinuation increasing risk of
thrombotic events. There is no reversal agent available for dabigatron if excessive
bleeding occurs.
Vorapaxar has a Black-Box Warning to not use in patients with a history of stroke,
transient ischemic attack (TIA), intracranial hemorrhage, or active pathological
bleeding. Vorapaxar is Pregnancy Category B, with no congenital malformations
found in animal studies,
• Also know:
o Use of anticoagulants in pregnancy:Enoxaparin is Pregnancy Category B.
Teratogenicity and fetal death have been reported as well for tinzaparin, although a
clear cause-and-effect relationship was not established. Fondaparinux is also listed
as Pregnancy Category B but without adequate or well-controlled studies in
pregnancy. LMWHs do not cross the placenta and do not cause teratogenicity or
fetal bleeding (Bates et al, 2012). The American College of Chest Physicians
recommends LMWH as the first-line drug for women who require antithrombotic
therapy during pregnancy (Guyatt et al, 2012). The pharmacokinetics of LMWHs
are altered during pregnancy. LMWH passes in small amounts into breast milk but
has low oral bioavailability and may be safely used during breastfeeding
Aspirin is Pregnancy Category C and Pregnancy Category D in the third trimester.
Aspirin should be avoided during lactation, especially in young infants (LactMed,
2010). If a woman is on chronic high-dose aspirin therapy, salicylates levels should
be monitored in the infant
ADRS: all anticoags can cause excessive bleeding, heparins: anemia and
thrombocytopenia, Bleeding is the major adverse effect of ribaroxaban, pain
(3.7%), upper abdominal pain (1.7%), osteoarthritis (1.7%), dyspepsia (1.3%), and
fatigue (1.0%). The major adverse effect seen with apixaban is bleeding with major
bleeding occurring in 2.13% of patients who used it for a year.
Aspirin can produce gastric erosions that increase the risk of serious upper GI
bleeding. This adverse effect is more likely when it is used in combination with
other anticoagulants such as warfarin. Salicylism (tinnitus) associated with the use
of aspirin occurs at serum levels above 200 mcg/mL. In addition to tinnitus,
indications of aspirin toxicity are headache, hyperventilation, agitation, mental
confusion, lethargy, diarrhea, and sweating
Dyspnea is the major nonbleeding-related adverse effect seen with ticagrelor, with
13.8% of patients reporting symptoms. The dyspnea was mild to moderate in
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