NURS 133 Enoxaparin and AcetyIsalicylic Acid

jasmine's version from 2016-05-26 02:47

Section 1

Question Answer
Enoxaparin (Lovenox) A low molecular weight heparin; Low molecular weight heparins are less effective at inactivating factor lla due to their shorter length compared to unfractionated heparin; However, treatment of DVT with or without pulmonary embolism with Warfarin; Used to prevent and treat deep vein thrombosis (DVT)) or pulmonary embolism, and is given as a subcutaneous injection; Results in decreased thrombin and ultimately the prevention of fibrin clot formation; Used to prevent ischemic complications (with aspirin) from unstable angina and non-ST-segment-elevation MI; Treatment of acute ST-segment-elevation MI (with thrombolytics or percutaneous coronary intervention)
Enoxaparin actions Potentiate the inhibitory effect of anti-thrombin on factor Xa and thrombin
Enoxaparin therapeutic uses Prevention of thrombus formation
Elimination/Excretion of Enoxaparin Primarily eliminated renally
Adverse/Side Effects of Enoxaparin Bleeding; Amemia
Contraindications of Enoxaparin Hypersensitivity to specific agents or pork products; Cross-sensitivity may occur; Some products contain sulfites or benzyl alcohol and should be avoided in patients with known hypersensitivity or intolerance; Active major bleeding; History of heparin-induced thrombocytopenia; Dalteparin: Regional anesthesia during treatment for unstable angina/non-Q wave MI
Use Enoxaparin cautiously in Severe hepatic or renal disease (adjust dose accordingly); retinopathy (hypertensive or diabetic); Untreated hypertension; Geri: May have increase risk of bleeding due to age-related decrease in renal function; OB, Lactation, Pedi: Safety not established; Should not be used in pregnant patients with prosthetic heart valves without careful monitoring
Enoxaparin exercise extreme caution in Spinal/epidural anesthesia (increase risk of spinal/epidural hematomas, especially with concurrent NSAIDs, repeated or traumatic epidural puncture, or indwelling epidural catheter); Severe uncontrolled hypertension; Bacterial endocarditis; Bleeding disorders
Drug/Food interactions of Enoxaparin Risk of bleeding may be increase by concurrent use of drugs that affect platelet function and coagulation, including warfarin, aspirin, NSAIDs, dipyridamole, clopidogrel, ticlopidine, abciximab, eptifibatide, tirofiban, and thrombolytics; Increase bleeding risk with arnica, chamomile, clove, feverfew (Eurasian plant of the daisy family used to treat headaches), garlic, ginger, ginkgo, Panax ginseng, and others
Medication administration of Enoxaparin Subcut and IV
Nursing interventions of Enoxaparin Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black, tarry stools; hematuria; fall in hematocrit or BP; guaiac-positive stools); bleeding from surgical site-notify health care professional if occur; Assess for evidence of additional or increased thrombosis; Monitor neurological status frequently for signs of neurological impairment-may require urgent treatment; Monitor for hypersensitivity reactions (chills, fever, urticaria); Monitor patients with epidural catheters frequently for signs and symptoms of neurologic impairment; Subcut: Observe injection sites for hematomas, ecchymosis, or inflammation; Lab test considerations: Monitor CBC, platelet count, and stools for occult blood periodically during therapy; If thrombocytopenia occurs (platelet count <100,000/mm^3), discontinue therapy; If hematocrit decreases unexpectedly, assess patient for potential bleeding sites; Special monitoring of aPTT is not necessary; Monitoring of anti-Xa levels may be considered in patient who are obese or have renal dysfunction-obtain 4 hours after injection with enoxaparin; Toxicity and overdose: For enoxaparin overdose, protamine sulfate 1 mg for each mg of enoxaparin should be administered by slow IV injection
High alert for Enoxaparin Unintended concomitant use of two heparin products (unfractionated heparin and low molecular weight heparins) has resulted in serious harm and death; Review patients’ recent and current medication administration records before administering any heparin or low-molecular-weight heparin product-cannot be used interchangeably either; Subcut: Administer deep into subcut tissue and alternate sites; If excessive bruising occurs, ice cube massage of site before injection may lessen bruising; To avoid the loss of drug, do not expel the air bubble from the syringe before the injection; For enoxaparin, to enhance absorption, inject into left or right anterolateral or posterolateral abdominal wall ONLY; Direct IV: Use multi-dose vial for bolus injections-administer through a pre-existing IV line, and flush line with 0.9% NaCl or D5W before and after administration
Client education of Enoxaparin Instruct patient in correct technique for self injection, care and disposal of equipment; Advise patient to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to health care professional immediately; Instruct patient not to take aspirin or NSAIDs without consulting health care professional while on therapy
Evaluation/Desired outcomes of Enoxaparin Prevention of DVT and pulmonary emboli; Resolution of DVT and pulmonary embolism; Prevention of ischemic complication (with aspirin) in patients with unstable angina or non-ST-segment-elevation MI; Prevention of recurrent MI or death in patients with acute ST-segment-elevation MI
Potential nursing diagnoses of Enoxaparin Ineffective tissue perfusion (indications); Risk for injury (side effects)

Section 2

Question Answer
Acetylsalicylic Acid Also known as aspirin; Inflammatory disorders including Rheumatoid arthritis, Osteoarthritis; Mild to moderate pain; Fever; Prophylaxis of transient ischemic attacks and MI (long term)
Acetylsalicylic Acid actions Decreases platelet aggregation; Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins
Acetylsalicylic Acid therapeutic uses Decreased incidence of transient ischemic attacks and MI (long term); Analgesia; Reduction of inflammation; Reduction of fever
Elimination/Excretion of Acetylsalicylic Acid Extensively metabolized by the liver; inactive metabolites excreted unchanged by the kidneys depends on urine pH; As pH increases, amount excreted unchanged increases from 2-3 percent up to 80 percent
Adverse/Side Effects of Acetylsalicylic Acid GI bleeding; dyspepsia, epigastric distress, nausea; Anaphylaxis, laryngeal, edema
Contraindications of Acetylsalicylic Acid Hypersensitivity to aspirin, tartrazine (FDC yellow dye #5), or other salicylates; Cross-sensitivity with other NSAIDs may exist (less with non-aspirin salicylates); Bleeding disorders or thrombocytopenia (more important with aspirin); Children or adolescents with viral infections (May increase the risk of Reye’s syndrome); Peri-operative pain from coronary artery bypass graft (CABG) surgery
Use Acetylsalicylic Acid cautiously in History of GI bleeding or ulcer disease; Chronic alcohol use/abuse; Severe renal disease (magnesium toxicity may occur with magnesium salicylate); Severe hepatic disease; Cardiovascular disease or risk factors for cardiovascular disease (May increase risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, especially with prolonged use); OB: May have adverse effects on fetus and mother and, in general, should be avoided during pregnancy, especially during the 3rd trimester; Lactation: Safety not established; Geri: Increase risk of adverse reactions especially GI bleeding; more sensitive to toxic levels
Drug/Food interactions of Acetylsalicylic Acid Aspirin may increase the risk of bleeding with warfarin, heparin, heparin-like agents, thrombolytic agents, ticlopidine, clopidogrel, abciximab, tirofiban, or eptifibatide, although these agents are frequently used safely in combination and in sequence; Ibuprofen may negate the cardio-protective anti-platelet effects of low-dose aspirin; Aspirin may increase risk of bleeding with cefoperazone, cefotetan, and valproic acid; May increase activity of penicillins, phenytoin, methotrexate, valproic acid, oral hypoglycemic agents, and sulfonamides; May decrease beneficial effects of probenecid; corticosteroids may decrease serum salicylate levels; Urinary acidification increases reabsorption andmay increase serum salicylate levels; alkalinization of the urine or the ingestion of large amounts of antacids increase excretion and decrease serum salicylate level; May blunt the therapeutic response to diuretics, and anti-hypertensives; Increase risk of GI irritation with NSAIDs; Increase anticoagulant effect and bleeding risk when using aspirin with arnica, chamomile, clove, feverfew, garlic, ginger, ginkgo, Panax ginseng, and others; Foods capable of acidifying the urine (corn, meat, beans, fish, fowl, most grains, coffee, plums, prunes, cranberries, etc.) may increase serum salicylate levels
Medication administration of Acetylsalicylic Acid PO
Nursing interventions of Acetylsalicylic Acid Patients, who have asthma, allergies, and nasal polyps or who are allergic to tartrazine, are at an increased risk for developing hypersensitivity reactions; Assess for rash periodically during therapy-discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis, and/or eosinophilia; Pain: Assess pain and limitation of movement-note type, location, and intensity before and at the peak after administration; Fever: Assess fever and note associated signs (diaphoresis, tachycardia, malaise, chills); Lab test considerations: Monitor hepatic function before anti-rheumatic therapy and if symptoms of hepatotoxicity occur-more likely in patients, especially children, with rheumatic fever, systemic lupus erythematosus, juvenile arthritis, or pre-existing hepatic disease; If severe abnormalities or active liver disease occurs, discontinue and use with caution in future; Monitor serum salicylate levels periodically with prolonged high-dose therapy to determine dose, safety, and efficacy, especially in children with Kawasaki disease (According to a website ( regarding Kawasaki disease, it is an Autoimmune disease; Inflamed medium-sized blood vessels throughout the body; Largely seen in children under five years of age; Affects many organ systems, mainly those including blood vessels, skin, mucous membranes, and lymph nodes-rarest yet most serious effect on heart, where it can cause fatal coronary artery aneurysms in untreated children; The conjunctivae of the eyes, and the mucous membranes of the mouth appear as a strawberry [red with dots] and inflamed; Swelling of the hands and feet is often seen and lymph nodes in the neck are often enlarged; A recurrent fever, often 37.8 degree Celsius [100 degree Fahrenheit] or higher is characteristic of the acute phase of the disease; In untreated children, fever may last about 10 days, yet my range from 5 to 25 days; Often begins with fever not very responsive to normal treatment of paracetamol [acetaminophen] or ibuprofen; Most prominent symptom of acute phase is high fever [above 100], remittent, and is followed by extreme irritability; May have partial response to antipyretic drugs and does not cease with the introduction of antibiotics; however with intravenous immunoglobulin and aspirin the fever is gone after 2 days. Bilateral conjunctival inflammation reported to be most common symptom after fever; bright red, swollen lips and cracking and bleeding-strawberry tongue); Prolongs bleeding time for 4-7 days and, in large doses, may cause prolonged prothrombin time-monitor hematocrit periodically in prolonged high-dose therapy to assess for GI blood loss; Toxicity and overdose: Monitor patient for the onset of tinnitus, headache, hyperventilation, agitation, mental confusion, lethargy, diarrhea, and sweating-if symptoms appear, withhold medication and notify health care professional immediately
Implementation of Acetylsalicylic Acid Use lowest effective dose for shortest period of time; PO: Administer after meals or with food or an antacid to minimize gastric irritation-food slows yet does not alter the total amount absorbed; Do not crush or chew enteric-coated tablets; Do not take antacid within 1-2 hours of enteric-coated tablets; Chewable tablets may be chewed, dissolved in liquid, or swallowed whole; Some extended-release tablets may be broken or crumbled yet most not ground up before swallowing
Client education of Acetylsalicylic Acid Instruct patient to take with full glass of water and to remain in an upright position for 15-30 minutes after administration; Advise patient to report tinnitus; unusual bleeding of gums; bruising; black, tarry stools; or fever lasting longer than 3 days; Caution patient to avoid concurrent use of alcohol with this medication to minimize possible gastric irritation; 3 or more glasses of alcohol per day may increase the risk of GI bleeding. Caution patient to avoid taking concurrently with acetaminophen or NSAIDs for more than a few days, unless directed by health care professional to prevent analgesic nephropathy; Teach patients on a sodium-restricted diet to avoid effervescent tablets or buffered-aspirin preparations; Tablets with an acetic (vinegar-like) odor should be discarded; Instruct patients to notify health care professional if rash or signs and symptoms of hypersensitivity reaction occurs; Advise patients on long-term therapy to inform health care professional of medication regimen before surgery (aspirin may need to be withheld one week before surgery); Pedi: CDC warns against giving aspirin to children or adolescents with varicella (chickenpox) or influenza-like or viral illnesses due to possible association with Reye’s syndrome; Transient ischemic attacks or MI: Advise patients receiving aspirin prophylactically to take only prescribed dose (increasing dose has not been found to provide additional benefits)
Evaluation/Desired outcomes of Acetylsalicylic Acid Relief of mild to moderate discomfort; Increased ease of joint movement (may take 2-3 weeks for maximum effectiveness); Reduction of fever; Prevention of transient ischemic attacks; Prevention of MI
Potential nursing diagnoses of Acetylsalicylic Acid Acute pain (indications); Impaired physical mobility (indications)