PhD, MS, MSN, RN, APRN-BC, CCRN, CDCES, CNE
One class of medications that are high-alert and high-maintenance medications are known as anticoagulants. Nurses frequently administer anticoagulants in hospitals and long-term care facilities and need to be aware of the need to closely monitor lab values, therapeutic range, and potential bleeding complications. In this blog, the important concepts of anticoagulants will be reviewed.
An anticoagulant is a class of medication that helps prevent the formation of blood clots and reduces the ability of blood to clot. Blood clotting, known as coagulation, is an important process that helps prevent bleeding when you are injured.
As a normal component of blood, platelets are the formed element responsible for natural clotting to protect the body against excessive bleeding and the normal range is 150,000-400,000/ml of blood. Blood clots can form inside blood vessels without a specific injury, leading to serious health risks of ischemia and inflammation.
Anticoagulants work by interfering with the body’s natural clotting mechanisms. They can inhibit the production or function of certain clotting factors in the blood, making it more difficult for clots to form. By doing so, they reduce the risk of clot-related complications, such as deep vein thrombosis (DVT), pulmonary embolism (PE), stroke, or heart attack.
Anticoagulants are commonly prescribed to individuals at risk of developing blood clots due to various medical conditions, such as atrial fibrillation (an irregular heart rhythm), deep vein thrombosis, pulmonary embolism, heart valve conditions, or those who have undergone certain surgeries.
Anticoagulants can be administered orally as pills, injected subcutaneously or intravenously, or delivered through an infusion pump. Nurses are able to administer all types. It is important to note that anticoagulants do not dissolve existing blood clots as they only prevent the formation of new ones.
In certain situations, other medications called thrombolytics may be used to break down existing clots. A powerful thrombolytic is Tissue Plasminogen Activator (TPA) given for those who qualify and have had an ischemic stroke.
As anticoagulants affect the body’s ability to clot, they also increase the risk of bleeding. Therefore, individuals taking anticoagulants need to be closely monitored to ensure the medication’s effectiveness and to prevent complications. It is essential to use anticoagulants under medical supervision and to follow the prescribed instructions carefully to achieve the desired benefits while minimizing the risks associated with bleeding.
When a patient is receiving anticoagulant therapy, several laboratory tests may be monitored to assess the effectiveness and safety of the treatment. The specific tests and monitoring frequency may vary depending on the type of anticoagulant being used and the patient’s individual circumstances.
Regular blood tests, such as the international normalized ratio (INR) or prothrombin time (PT), are conducted to assess the blood’s ability to clot and adjust the dosage accordingly. The following are some common lab tests that are typically monitored:
This test measures the time it takes for blood to clot and compares it to a standard value of 1-2. Some labs may vary but generally 1-2 is normal. It is commonly used to monitor patients taking the anticoagulant warfarin.
The target INR range varies depending on the indication for anticoagulation (e.g., atrial fibrillation, DVT, prosthetic heart valves) and is determined by the healthcare provider. The therapeutic range should be 2-3 times greater than the normal range.
This means that if an INR is > 5 the medication should be titrated down or discontinued to prevent bleeding. Nurses must implement careful monitoring to evaluate if anticoagulation therapy is effective or not.
Similar to the INR, the PT test measures the time it takes for blood to clot. It is often used in conjunction with the INR to monitor patients on warfarin therapy. Depending on the lab, the general range is 9-12.
Think of the word PT and the P flipped looks like a 9 and then the T stands for 12 to help you remember the general normal range. If the PT is > 12, it is taking longer for the person to clot, which is good if the desired outcome is to prevent ischemia, but not good if the patient is bleeding.
This test assesses the time it takes for blood to clot through the intrinsic pathway. It is primarily used to monitor patients receiving unfractionated heparin or low molecular weight heparin (LMWH).
Think of PTT as being double PT (because it has two T’s) so double the normal range of PT (9-12) and you get 18-24 as the generally normal range of PTT. Also, put a line between the middle of the two T’s and it looks like an H, which reminds you that this lab test is often done to evaluate effectiveness of heparin administration.
This test measures the activity of specific anticoagulants, such as low molecular weight heparin (LMWH) or fondaparinux. It helps determine if the anticoagulant level is within the desired therapeutic range.
This test evaluates the levels of red blood cells, white blood cells, and platelets in the blood. It is important to monitor platelet counts periodically as anticoagulants can potentially cause a decrease in platelet numbers.
Some anticoagulants, such as direct oral anticoagulants (DOACs), are eliminated from the body through the kidneys. Monitoring renal function helps ensure that the dosage of the anticoagulant is appropriate and that adjustments are made if necessary.
Due to the kidneys creating erythropoietin, any kidney disorder may impact the production of this hormone, which impacts the production of red blood cells, resulting in possible anemia.
It is important to note that the frequency of these tests may vary depending on the patient’s condition, stability of anticoagulation, and the specific medication being used. Daily lab tests are often completed in an acute hospital setting, whereas weekly, or even monthly lab checks are done for outpatients.
Regular communication and follow-up with a healthcare provider are crucial to ensure proper monitoring and adjustment of anticoagulant therapy. Many times it is a nurse case manager who may be reviewing lab studies on anticoagulation patients for managed care organizations to decrease complications and produce optimal outcomes.
When a patient is on anticoagulant therapy, nurses should monitor for various complications to ensure patient safety. Here are some key complications that nurses should be vigilant for:
Anticoagulants increase the risk of bleeding, so nurses should carefully assess for signs of bleeding, both external and internal. This includes monitoring for excessive bruising, prolonged bleeding from cuts or wounds, bleeding gums, nosebleeds, blood in urine or stool, and signs of gastrointestinal bleeding (e.g., black, tarry stools or vomiting blood). Neurological changes such as severe headaches, altered mental status, or focal neurological deficits may indicate intracranial bleeding.
Severe bleeding or hemorrhage is a critical complication that requires immediate medical attention. Nurses should be alert for signs of significant bleeding, such as hypotension, rapid or weak pulse, pallor, cool clammy skin, or signs of shock.
While anticoagulants reduce the risk of blood clots, inadequate anticoagulation or missed doses can increase the risk of thromboembolic events. Nurses should monitor for signs and symptoms of deep vein thrombosis (DVT), such as leg pain, swelling, warmth, or redness, as well as signs of pulmonary embolism (PE), including sudden shortness of breath, chest pain, and rapid breathing.
Some patients may experience adverse reactions or hypersensitivity to anticoagulant medications. Nurses should be attentive to signs of allergic reactions, such as rash, itching, hives, difficulty breathing, or swelling of the face, lips, tongue, or throat. Additionally, they should assess for other drug-related side effects such as nausea, vomiting, dizziness, or changes in liver function.
Anticoagulants can interact with other medications, leading to altered anticoagulation effects or increased bleeding risk. Nurses should review the patient’s medication profile and be alert for potential drug interactions. They should encourage patients to inform them about any new medications or supplements they may be taking to prevent adverse interactions.
Nurses should ensure that patients on anticoagulant therapy undergo regular INR monitoring as prescribed by the healthcare provider. They should be familiar with the target INR range for the specific indication and anticoagulant being used and communicate any significant changes to the healthcare team.
Nurses should assess the patient’s understanding of anticoagulant therapy, including medication adherence, dietary restrictions (if applicable), and precautions to minimize bleeding risk. They should address any knowledge gaps, reinforce education, and provide resources for ongoing support and education.
Anticoagulants can increase the risk of bleeding from falls or injuries. Nurses should assess the patient’s mobility, help as needed, and implement fall prevention strategies, such as keeping the environment free from hazards and using assistive devices when necessary.
Regular communication with the healthcare provider is vital to report any changes in the patient’s condition, complications, or concerns related to anticoagulant therapy. Prompt identification and management of complications can help minimize risks and optimize patient outcomes.
Patient education plays a crucial role in the safe and effective use of anticoagulant medications. Here are some important points to include in patient education for individuals taking anticoagulants:
Provide detailed information about the specific anticoagulant prescribed, including its purpose, dosage, frequency, and potential side effects. Explain the importance of taking the medication exactly as prescribed and the potential risks associated with missed doses or altering the dosage without medical guidance.
Emphasize the increased risk of bleeding while on anticoagulant therapy. Instruct patients on signs of bleeding complications (e.g., prolonged bleeding, easy bruising, red or dark urine/stool) and when to seek medical attention. Advise patients to take precautions to minimize the risk of injury, such as using a soft-bristle toothbrush, avoiding activities with a high risk of injury, and using caution when handling sharp objects.
Inform patients about potential interactions between anticoagulants and other medications, including over-the-counter drugs, herbal supplements, and certain foods (e.g., foods high in vitamin K in the case of warfarin). Encourage them to consult with a healthcare professional before starting any new medication or supplement. Natural herbs that begin with the letter “g” should be avoided such as ginseng, ginkgo biloba, and garlic which can increase the risk of bleeding.
Explain the importance of regular laboratory monitoring to assess the effectiveness and safety of anticoagulant therapy. Emphasize the need to keep scheduled appointments for blood tests and to communicate any changes in health status or medication intake to their healthcare provider.
Discuss the impact of diet and lifestyle choices on anticoagulation. For example, for patients taking warfarin, educate them about maintaining a consistent vitamin K intake by not drastically changing their consumption of foods rich in vitamin K (e.g., leafy green vegetables).
Encourage a balanced diet and regular exercise to support overall cardiovascular health. It is important to generally avoid vitamin K foods as vitamin K contributes to the effectiveness of clotting; however, the reason for being on an anticoagulant is to not clot as quickly.
Provide instructions on how to properly store anticoagulant medications, including temperature requirements and keeping them out of reach of children. If self-administration is required, demonstrate, and explain the correct technique for taking the medication (e.g., swallowing whole and not crushing or splitting).
Emphasize the importance of informing other healthcare providers, dentists, and pharmacists about anticoagulant therapy. Encourage patients to wear a medical alert bracelet or carry a card indicating their use of anticoagulants in case of emergencies.
Discuss travel considerations such as carrying an adequate supply of medication, having a written list of medications and their dosages, and planning for emergency medical care at the destination if needed.
Stress the importance of regular follow-up appointments with their healthcare provider to monitor anticoagulation status and adjust the medication if necessary. Encourage patients to ask questions, seek clarification, and voice any concerns they may have throughout their treatment.
It is important to provide written materials and encourage patients to keep a record of their medication regimen, appointments, and any notable changes or symptoms they experience. Reinforce the importance of open communication and collaboration between the patient and healthcare provider to ensure optimal anticoagulant therapy management.
When providing online resources to patients who are on anticoagulants, it is important to ensure that the sources are reputable, evidence-based, and from trusted healthcare organizations. Here are some reliable online resources that nurses can recommend to patients:
The AHA provides comprehensive information on heart conditions, stroke prevention, and anticoagulant therapy. The website offers educational materials, guidelines, and resources for patients. Website: www.heart.org
The CDC offers information on blood clot prevention, deep vein thrombosis (DVT), and pulmonary embolism (PE). They provide resources for patients, including fact sheets, videos, and frequently asked questions. Website: www.cdc.gov/ncbddd/dvt/index.html
This website is managed by the National Blood Clot Alliance, a nonprofit organization dedicated to raising awareness about blood clots, clotting disorders, and anticoagulant therapy. It offers patient education materials, support resources, and information on research and advocacy. Website: www.stoptheclot.org
The Mayo Clinic website provides reliable information on various health topics, including anticoagulant therapy. Patients can find educational articles, videos, and frequently asked questions about anticoagulants and related conditions. Website: www.mayoclinic.org
The Anticoagulation Forum is a professional organization focused on anticoagulation management. While it primarily targets healthcare professionals, its website includes patient-focused resources such as educational materials, videos, and patient support group information. Website: www.acforum.org
MedlinePlus, managed by the U.S. National Library of Medicine, offers reliable health information for patients. The website includes an extensive section on anticoagulant medications, their uses, potential side effects, and safety tips. Website: medlineplus.gov
It is important for nurses to review the resources themselves to ensure they align with current guidelines and recommendations. Additionally, nurses should always encourage patients to consult with their healthcare provider for personalized guidance and to address any specific concerns or questions related to their anticoagulant therapy.
Anticoagulants are an impressive class of medications that are helpful and effective in preventing blood clotting. Like any medication, they have potential side effects and nurses need to understand how they work, how to teach patient education concepts about safety measures, and which labs need to be ordered for appropriate monitoring. You too can be a blood clot buster by busting out your knowledge of safe and effective anticoagulant use!
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