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Thrombolytics: Nursing Pharmacology

Notes

Notes

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

CLASS
Thrombolytics
MECHANISM OF ACTION
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
INDICATIONS
  • Myocardial infarction
  • Pulmonary embolism
  • Ischemic stroke 
  • Thrombosis of prosthetic heart valves and stents
ROUTE(S) OF ADMINISTRATION
IV
SIDE EFFECTS
  • Bleeding; e.g., bleeding from the injection site, gastrointestinal bleeds, hemorrhagic stroke
  • Reperfusion arrhythmia
  • Hypersensitivity reactions like anaphylaxis
  • Nausea
  • Vomiting
  • Fever
CONTRAINDICATIONS AND CAUTIONS
  • 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)
NURSING CONSIDERATIONS: THROMBOLYTICS
ASSESSMENT AND MONITORING
Assessment
  • 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
CLIENT EDUCATION
  • Purpose of medication
  • Discharge teaching
    • Minimize bleeding and bruising
    • Self-monitoring for bleeding
    • Recognize symptoms of clot formation
Memory Anchors and Partner Content
Transcript

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.

In addition, thrombolytics, when given following a myocardial infarction, can precipitate an abnormal cardiac rhythm, or a reperfusion arrhythmia, which is usually benign. Other side effects include hypersensitivity reactions like anaphylaxis, nausea, vomiting, and fever.

Due to the risk of bleeding, thrombolytics are contraindicated in clients with active internal bleeding, suspected aortic dissection, or recent trauma in the past three months, as well as those with any history of intracranial hemorrhage or ischemic stroke in the past three months, and coagulopathies or bleeding disorders.

In addition, thrombolytics should be avoided before major surgeries. Thrombolytics should be used with caution in clients older than 75 years, as well as in those with severe hypertension, pericarditis, active peptic ulcer, or diabetic retinopathy.

Thrombolytics should also be used with caution in clients with hepatic disease, who can have a defective production of clotting factors and plasminogen; as well as during pregnancy and breastfeeding.

Finally, thrombolytics should be used with caution in clients taking anticoagulants like heparin and warfarin; and antiplatelet medications like aspirin and clopidogrel; which can increase the risk of bleeding.

Alright, before administering an intravenous thrombolytic to your client, be sure to perform a baseline assessment, including vital signs, and cardiac and neurological status.

Then, review the client’s latest laboratory test results, including CBC, hematocrit, coagulation studies like PT, aPTT, and INR, as well as renal and hepatic function.

Sources
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