Thrombolytics: Nursing pharmacology

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alteplase (Activase), reteplase (Retavase), 
tenecteplase (TNKase)
*High Alert Medications*

Directly bind to fibrin proteins in the clot and preferentially act on fibrin-bound plasminogen; convert plasminogen into its active form, plasmin, which cuts the fibrin into smaller pieces and dissolves the clot
  • Myocardial infarction
  • Pulmonary embolism
  • Ischemic stroke 
  • Thrombosis of prosthetic heart valves and stents
  • Bleeding; e.g., bleeding from the injection site, gastrointestinal bleeds, hemorrhagic stroke
  • Reperfusion arrhythmia
  • Hypersensitivity reactions like anaphylaxis
  • Nausea
  • Vomiting
  • Fever
  • Before major surgeries
  • After recent trauma
  • Active internal bleeding
  • Suspected aortic dissection
  • History of intracranial hemorrhage or ischemic stroke
  • Coagulopathies
  • Severe hypertension
  • Older than 75 y.o.
  • Pericarditis
  • Active peptic ulcer
  • Diabetic retinopathy
  • Hepatic disease
  • Pregnancy and breastfeeding
  • Anticoagulants (heparin and warfarin)
  • Antiplatelet medications (aspirin and clopidogrel)
  • Vital signs, and cardiac and neurological status
  • Laboratory test results
    • CBC
    • Hematocrit
    • Coagulation studies: PT, aPTT, INR
    • Renal and hepatic function
      • MI: cardiac enzymes
      • PE: ABGs
  • Patient IV

Monitoring and interventions
  • Vital signs
  • Signs and symptoms of active bleeding
  • Neurological and cardiac status
  • Coagulation studies
  • Avoid any unnecessary venipuncture, arterial sticks, IM injections
    • Manage puncture site bleeding with pressure dressing
    • For active bleeding
      • Stop thrombolytic administration
      • Notify the healthcare provider
      • Prepare to administer aminocaproic acid, blood products
  • Evaluate for evidence of clot dissolution and reperfusion, absence of side effects, and a return to normal hemodynamic status
  • Purpose of medication
  • Discharge teaching
    • Minimize bleeding and bruising
    • Self-monitoring for bleeding
    • Recognize symptoms of clot formation

Memory Anchors and Partner Content


Thrombolytics, also called clot busters, are medications that break up clots, and are used for the short-term emergency management of thrombotic conditions, such as myocardial infarction, pulmonary embolism, ischemic stroke, and thrombosis of prosthetic heart valves and stents.

Now, thrombolytics are usually derived from enzymes involved in fibrinolysis, or the gradual degradation of the fibrin mesh. These include alteplase, reteplase, and tenecteplase, which are derived from tissue plasminogen activator, or tPA, through recombinant DNA technology, and act locally at the clot site.

Thrombolytics are given intravenously. Once in the blood, they act on a protein produced by the liver called plasminogen, and convert it into its active form called plasmin.

These medications directly bind to fibrin proteins in the clot and preferentially act on plasminogen trapped in the fibrin mesh, also called fibrin-bound plasminogen. The resulting plasmin then acts as a protease and cuts the fibrin into smaller pieces.

This allows the trapped red blood cells and platelets to float away, dissolving the clot.The main side effect of all thrombolytics is undue bleeding from other sites, including the injection site, gastrointestinal bleeds, and hemorrhagic stroke.

In severe cases, thrombolytic-associated bleeding can be treated with medications like aminocaproic acid, which acts by binding to plasminogen and plasmin, ultimately inhibiting their action on fibrin.

If aminocaproic acid fails, other transfusion products can be administered, such as platelets or coagulation factors in the form of fresh frozen plasma.


Thrombolytics, also known as clot-busting drugs, are a class of medications that are used to dissolve blood clots. These drugs work by converting plasminogen to plasmin, an enzyme that breaks down fibrin, a protein that forms the backbone of blood clots. By breaking down fibrin, thrombolytics can dissolve blood clots and restore blood flow to the affected area.

Thrombolytics include drugs like alteplase, reteplase, and tenecteplase, typically given for the acute management of pathological blood clots like in embolic or thrombotic strokes. The main side effect of thrombolytics is undue bleeding from other sites, including injection sites, gastrointestinal bleeding, and hemorrhagic stroke. This is why they are contraindicated in hemorrhagic strokes and head trauma.

Nursing considerations when administering thrombolytics include conducting a thorough baseline assessment, monitoring for side effects, and evaluating the therapeutic response. Client teaching is centered around minimizing bleeding and bruising, as well as recognizing signs and symptoms of bleeding or additional clot formation.


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