NR 512 Week 2: Comparing Classes of Medication
Comparing Classes of Medication
This is a graded discussion: 25 points possible due Jan
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Week 2: Comparing Classes of Medication 59 72
In this first discussion, we will be taking a very close look at two different classes of medications and how we can explore the three Ps through this very in- depth exploration.
Compare and contrast an antiplatelet drug to an anticoagulant drug. Be sure to contrast them based on the pharmacokinetics of their action. Integrate their pharmacokinetics with the related pathophysiology. Also, include the related physical assessments that will apply. Be sure to include which patients would be a candidate to receive each of these therapies independently include classic examples of each.
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When looking at medications, it is important to study and understand how they impact pathophysiology, pharmacology, and physical assessment, or the 3Ps. Not only is it important for us, as nurses, to understand this, but it’s important for us to understand how to explain this to nurses in training, and break it down for patients, as well. For the purposes of this threaded discussion, I will be exploring an oldie but goodie antiplatelet medication, aspirin (ASA), and the anticoagulant medication, Xarelto. Patients like my father, with risk factors such as heart disease, deep vein thrombosis (DVT), and a factor V Leiden r506q mutation, are candidates for taking both Xarelto and ASA, and the reason these two medications have been chosen (Bardal, Waechter, & Martin, 2011; Janssen, 2018).
Some medications like ASA fall under multiple classifications, in this case, antiplatelet, anti-inflammatory, and antipyretic (Bardal et al., 2011). The antiplatelet properties of ASA stem from the anti-inflammatory action, through blockage of the cyclooxygenase (COX) enzyme, which in turn impedes the formation of cyclic endoperoxide and subsequent conversion to thromboxane A2(TXA2) within platelets, thus interfering with platelet aggregation, and prostaglandin E2 (PGE2), which decreases inflammation, fever, pain, and secretions (Bardal et al., 2011). The end result of blocking platelet aggregation is the reason ASA is essential for heart disease, peripheral vascular disease, post-operative blood clot prevention, and congenital heart disease, while the anti- inflammatory effects of ASA are vital for arthritis control, pain relief, and fever reduction (Bardal et al., 2011).
The anticoagulant medication, Xarelto, directly targets the Xafactor in the clotting cascade and blocks it (Bardal et al., 2011; Janssen, 2018). In doing so, Xarelto blocks the conversion of prothrombin to thrombin, an enzyme that prompts fibrinogen to convert to fibrin, a protein that gives clots strength; and the disruption of thrombin formation also blocks the activation of factors V, VIII, and XI, and blocks platelet clumping (Bardal et al., 2011; Janssen, 2018). All of these effects interfere with the clotting process, and similar to ASA, can be vital for individuals with blood clots such as DVT, those predisposed to blood clots, heart and peripheral vascular disease, atrial fibrillation, and post-operative blood clot prevention (Bardal et al., 2011; Janssen, 2018).
An important difference between ASA and Xarelto is the half-life of effects. For example, Xarelto has an elimination half-life of nine hours, whereas ASA’s is two hours, however, the antiplatelet effect from ASA cannot be reversed and lasts for the life of the platelet cell, meaning, five to seven days, hence the need to stop ASA at least seven days prior to surgery (Bardal et al., 2011; Janssen, 2018). This is a vital aspect to include in patient education.
Physical assessment of patients taking anticoagulants and/or antiplatelet medications must include a bleeding assessment, including an assessment for bruising, bleeding gums, nose bleeds, rectal bleeding, hematemesis or vomiting coffee grounds, blood in the urine, stomach upset, or petechiae (Bardal et al., 2011; Dains, Baumann, & Scheibel, 2012; Janssen, 2018). In
addition to a thorough physical assessment, a medication, supplement, and over-the-counter medication reconciliation must take place as well, to ensure no drug interactions are occurring (Bardal et al., 2011; Dains et al., 2012; Janssen, 2018).
References
Bardal, S. K., Waechter, J. E., & Martin, D. S. (2011). Applied pharmacology. St. Louis, MO: Elsevier Saunders.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care (4th ed.). St. Louis, MO: Elsevier Mosby.
Janssen. (2018). Xarelto. Retrieved from http://www.janssenlabels.com/package-insert/product-monograph/prescribing- information/XARELTO-pi.pdf
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(http Janet Belford-Burleigh
(h5ps: /chamberlain.instructure.com/courses/37809/users/65844)
Jan 14, 2019
Dr. Alteza,
My apologies. I was having absolutely no success in locating an article on Chamberlain's library over the weekend for my initial posting. Not sure if there was an issue with the library search engine or it was my internet, as I have been having a lot of difficulty with that recently.
According to Gee (2018), one of the benefits of Xarelto over the more traditional choice, Coumadin, is the better predictability of control, and rapid onset of therapeutic coverage. Another advantage over Coumadin is, Xarelto has been found to have a lower risk of cerebral hemorrhage (Gee, 2018).
As nurses, part of our job in patient education is making sure patients not only understand the in's and out's of their medications, but also that they have a provider lined up to manage speciality medications like Xarelto, and a follow-up appointment scheduled (Gee, 2018). As a former nurse trainer for years for Coumadin-taking patients and home INR testing, one of the areas I used to counsel patients on quite a bit was carrying a list of medications in their wallet, in case of emergency. It amazed me that most patients had never been instructed to do that.
Reference
Gee, E. (2018). Principles and nursing management of anticoagulation. Nursing Standard, 32(23), 50-63. doi: 10.7748/ns.2018.ell060
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(http Antonieta Alteza (Instructor)
Jan 15, 2019
Hi Janet,
I’m sorry to hear you were having issues accessing the online library. Sometimes it helps to contact the librarian by phone, so he/she can help you trouble-shoot the problem.
In the last few years, FDA has approved three new oral anticoagulant drugs – Pradaxa (dabigatran), Xarelto (rivaroxaban), and Eliquis (apixaban). On the basis of clinical trials that included more than 50,000 patients from around the globe, FDA concluded that all three drugs were either equivalent to, or more effective than, warfarin in
preventing strokes, with an acceptable risk of bleeding. Of particular interest, the three new drugs were substantially
less likely than warfarin to cause a particular kind of bleeding leading to stroke – a “hemorrhagic stroke,” a stroke caused by bleeding into the brain, which is different from the strokes caused by the clots that go to the brain in atrial fibrillation (Unger, 2015, para. 5,6).
I am glad that you mentioned the importance of patient education. As a former nurse trainer for Coumadin-taking patients, what common misconceptions did patients have about anti-coagulants and/or anti-platelets?
Dr Alteza
Unger, E.F. (2015). Atrial fibrillation and new oral anticoagulant drugs. Retrieved from https://www.fda.gov/drugs/newsevents/ucm405148.htm
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(http Janet Belford-Burleigh
(h5ps: /chamberlain.instructure.com/courses/37809/users/65844)
Jan 16, 2019
Dr Alteza,
Thank you for the tip about the librarian. Unfortunately, the hours I had to work on the assignment, I knew the librarians were not there. I will definitely keep this in mind in the future, however. Thank goodness for textbooks and pharmaceutical inserts!
You asked a great question about patient misconceptions. Yes, there were many, from a piece of spinach or broccoli could never be eaten again (or perhaps this is what they wanted!), to it didn't matter what they ate, to the Coumadin was for breaking up the clot and to prevent another one, and a high INR reading could be fixed by eating a salad, there was no need to call the doctor. I can recall several times when I trained patients on a weekend, when customer service was closed, and ran into urgent results, necessitating urgent calls to their provider and emergency room referrals for full labs and vitamin K administration. Usually, the patients were resistant to a call to their provider, however, under the circumstances, it was my duty to ensure they were safe. Of course, education in each of these misconceptions was important.
Have a great evening!
Janet
Reply
(http Antonieta Alteza (Instructor)
Jan 17, 2019
Hi Janet,
Like you, I used to hear many myths and misconceptions about diabetes when I was a Certified Diabetes Educator. The ones I will never forget are:
- "The sugar (in diabetes) is only in the urine, and not in the blood."
- "I gave myself more insulin, because my blood sugar was low." Needless to say, there were many teachable moments.
Thanks for sharing, Dr Alteza
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(http Natalie Friess
(h5ps: /chamberlain.instructure.com/courses/37809/users/46369)
Jan 19, 2019
Dr. Alteza and class,
In response to the question: "what common misconceptions did patients have about anti-coagulants and/or anti- platelets?"
I don't really have personal experience in discussing anti-coagulants or anti-platelets with patients or families (being in the recovery room, most of my patient/family teaching is related to respiratory or pain management), however in my community, in church and family, it is very common among older adults to be on some sort of anti- thrombotic therapy. I think the term 'blood thinner' can lead to misconceptions. I have heard some say because
they are on blood thinners that their blood is less thick and that makes them cold. This is untrue, calling it a blood 'thinner' gives the perception that the blood is actually a thinner consistency, which in fact it has nothing at all to do with that. Also, attributing to being cold because the blood is perceived to of a thinner consistency is also a misconception - temperature maintenance has nothing at all to do with how 'thick' or 'thin' one's blood is!
Natalie Friess
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(http Leslie Williamson
(h5ps: /chamberlain.instructure.com/courses/37809/users/51315)
Jan 20, 2019
1. Long before I was a nurse, I had to be on Coumadin following a DVT. I had very little medical knowledge as I as only 19 years old and following the patient education I received, I had so many misconceptions about what I could and could not do while on coumadin. I was that I could not eat any leafy greens while on the medication. I know now that you can eat leafy greens if consumed consistently in moderation (Jones, 2017). I was also told by the patient educator that I could not participate in any of the physical activities. After our education I remember feeling scared to death that I was going to fall and bleed even walking. This was a huge blow to me since staying in shape was necessary as I was in the military. I think patient education needs to be more patient specific for these reasons. Had the educator known that physical fitness was a huge part of my life she could have suggested safer alternative methods of exercise. Incorporating the healthcare team with patient-centered care principles to make physical care activity recommendations can lead to successful outcomes for patients with chronic conditions (Brooks, Fong, McCabe, & Mulder, 2018).
Brooks, J., Fong, E., McCabe, E., & Mulder, K. (2018). "In the Driver's Seat": A patient education resource to guide individualized decision-making about physical activities. Haemophilia, 24(1), 166-p167
Jones, P. (2017). Discharge Instructions for Warfarin Therapy. Health Library: Evidence-Based Information. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx? direct=true&db=nup&AN=2012059607&site=eds-live&scope=site
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Dear Dr. Alteza and Classmates,
Antiplatelet drug therapy and anticoagulant drug therapy work on the clotting mechanisms of the blood. However, the effects have different points and duration of action making them effective on different disease processes.
Antiplatelet drugs, like aspirin, work to stop an enzyme in the body that allows for the adhesive factor of platelets called aggregation (Bardal, Waechter, & Martin, 2011). This action of stopping the function of aggregation last the life of the platelet, usually seven days. Without the adhesive factor patient will bleed easier from trauma such as surgery. It makes it important to factor in physical assessment to assess is a patient has taken heparin in the last seven days. History of heart attack or stent placement will lead a nurse to ask if the patient has been using any antiplatelet drugs.
Anticoagulant drugs, like warfarin (coumadin), are also used in the prevention of clot making in the body. Anticoagulants work on the chain of action further from the start of action then antiplatelets and so allow these drugs to have reversal agents. As anticoagulants work on inhibiting the action of vitamin K coagulation factors a quick reversal agent would be a dose of vitamin K. This makes taking a patient history including what the patient likes to eat very important. Foods that are dark leafy greens are high in vitamin K making it difficult to regulate their dose and subsequent pharmacokinetic effects in the body (Goshgarian & Gorelick, 2017).
When looking at what type of patient should be on each drug therapy consideration of their history and disease process must be done. Most older adults are on low dose antiplatelet drug therapy as it has been shown to prevent heart attack as antiplatelet drug therapy works best in the arterial vessels (Bardal, Waechter, & Martin, 2011). Patients who present with pain in the calves, history of atrial fibrillation, or stroke will benefit most from an anticoagulant drug therapy as these disease processes present blood clotting issues in venous vessels (Goshgarian & Gorelick, 2017). It is the responsibility of nurses to understand pharmacokinetics and pathophysiology to best support their patients.
Thank you Rachel
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