Anticoagulants & Antiplatelets Cheat Sheet

Table of Contents: 1. Coagulation-Modifying Drugs 2. Antiplatelets 3. Anticoagulants 4. Fibrinolytics Anticoagulants & Antiplatelets Anticoagulants Heparins: heparin, enoxaparin Vitamin K antagonist: warfarin Direct oral anticoagulants (DOACs): rivaroxaban, apixaban, dabigatran 1. Coagulation-Modifying Drugs Coagulation-modifying drugs prevent or treat clots by affecting different steps of hemostasis (FIGURE 1). Fibrinolytics tissue plasminogen activator (tPA): alteplase, tenecteplase Cardiovascular Antiplatelets aspirin ADP inhibitors: clopidogrel, prasugrel FIGURE 1. HEMOSTASIS Clients taking any coagulation-modifying drugs are at HIGH RISK for bleeding: y #1 priority = preventing life-threatening hemorrhage. y To prevent bleeding in clients taking antiplatelets or anticoagulants: 1. Monitor coagulation studies and CBC (platelets, hemoglobin) at regular intervals before and during therapy.
2. Avoid combining medications that cause bleeding (NSAIDs, taking multiple anticoagulants at once). 3. Monitor for unusual bleeding:
TABLE 1. SIGNS OF EXCESSIVE BLEEDING Hold medication and notify HCP for: y Unusual or excessive bruising or bleeding (petechiae, bleeding from gums) y Prolonged bleeding y Altered mental status (cerebral hemorrhage) y Blood in the stool, urine, or emesis (dark stools, coffee-ground emesis) y Shock (HR,BP)  Monitor clients taking antiplatelets or anticoagulants for any unusual bleeding or bruising (petechiae, prolonged bleeding, bleeding from the gums) or blood in the stool, urine, or emesis. 2. Antiplatelets Antiplatelets (FIGURE 2): Prevent platelet plug formation in the treatment and prevention of MI and stroke: a. Aspirin y Aspirin also has NSAID effects (see ANALGESICS CHEAT SHEET). b. ADP inhibitors: y Clopidogrel y Prasugrel Antiplatelets risk for bleeding:
Contraindicated in active bleeding y Monitor CBC (platelets, hemoglobin).
Notify HCP for unusual bleeding (TABLE 1).
Discontinue antiplatelet medications at least 7 days before surgery so the body can produce new, functioning platelets.  Discontinue antiplatelet medications (aspirin, clopidogrel) at least 7 days before scheduled surgery. © Bootcamp.com 6 2. Antiplatelets, Continued Cardiovascular FIGURE 2. ANTIPLATELETS AT A GLANCE a. Aspirin (ASA)
Contraindicated in clients <18 years old with flu-like symptoms due to risk for Reye syndrome y Adverse effects: y GI upset and ulcers:
Avoid in clients with peptic ulcer disease.
Take with food or milk and a full glass of water. y Aspirin toxicity:
Monitor for symptoms of toxicity: Tinnitus, hyperventilation, and respiratory alkalosis b. ADP Inhibitors y Can be given together with aspirin as dual antiplatelet therapy (DAPT) after coronary stent placement y Taking clopidogrel with a proton-pump inhibitor (PPI) reduces its antiplatelet effect by half (risk for stroke, MI).
Avoid PPIs (omeprazole, esomeprazole) in clients taking clopidogrel. TABLE 2. ANTIPLATELETS SUMMARY Medications Top Considerations All antiplatelets: y Contraindicated in active bleeding y Discontinue 7 days before surgery. y Notify HCP for unusual bleeding (TABLE 1). Acetylsalicylic acid (ASA) aspirin Cautions: y Risk for Reye syndrome: Avoid in clients <18 years old with flu-like symptoms. y Avoid in clients with peptic ulcer disease. y Report tinnitus and hyperventilation, which are signs of toxicity. Administration: y Take with food or milk and a full glass of water. ADP inhibitors clopidogrel prasugrel Administration: y Avoid combining with PPIs (omeprazole). © Bootcamp.com 2 3. Anticoagulants Cardiovascular FIGURE 3. ANTICOAGULANTS AT A GLANCE Anticoagulants: Prevent clot formation in the treatment of DVT, PE, MI, and stroke (including from atrial fibrillation or mechanical heart valves) (FIGURE 3). Anticoagulant medications include: y Heparins (injectable): y Heparin (unfractionated) y Low-molecular-weight heparin (LMWH) (enoxaparin) y Vitamin K antagonist: y Warfarin y Direct oral anticoagulants (DOACs): y Factor Xa inhibitors: Rivaroxaban, apixaban y Thrombin inhibitors: Dabigatran Anticoagulants risk for bleeding: y Because clients taking anticoagulants cannot form clots, platelet plug formation is their only remaining defense against life-threatening hemorrhage.
Clients taking anticoagulants should not take NSAIDs for pain or fever (aspirin, ibuprofen), as these have antiplatelet effects.
Hold anticoagulants for thrombocytopenia (low platelets). y Contraindicated in clients with epidural anesthesia or lumbar puncture (risk for spinal or epidural hematoma) y Limit invasive procedures (IM injections, venipuncture). y Monitor CBC, coagulation times (INR or PTT), and have the correct antidote available in case of bleeding (see FIGURE 3).
Notify HCP for unusual bleeding (TABLE 1). © Bootcamp.com 3 3. Anticoagulants, Continued y Injectable: Can be given via SQ (VTE prevention) or IV (VTE treatment)
Heparin does not “dissolve” clots, but stops existing clots from growing so they can be dissolved gradually by fibrinolysis (see FIGURE 1). y High-risk medication:
When given via IV, must only be delivered using a programmable infusion pump to prevent accidental bolus.
PTT monitoring required: y Titrate infusion rate as prescribed to achieve a goal PTT (usually 60-80 sec): y Draw PTT every 4-6 hr. y If PTT is too high, stop infusion and assess for bleeding. y If PTT is too low, increase the infusion rate.
Have antidote available: Protamine sulfate y Heparin-induced thrombocytopenia (HIT): y In HIT, antibodies attack platelets that are bound by heparin  Widespread thrombosis + Platelet consumption  Thrombocytopenia (low platelets)
If client develops thrombocytopenia, stop the heparin, notify the HCP, and prepare to give a non-heparin anticoagulant (such as dabigatran). y Clients with a history of HIT can never receive any heparin products, including LMWH or heparin flushes. b. Enoxaparin c. Warfarin y Inhibits synthesis of vitamin K clotting factors
Keep vitamin K intake consistent. y Do not suddenly increase or decrease intake of leafy green vegetables (spinach, kale, brussels sprouts).
Vitamin K (phytonadione) is the antidote for warfarin-induced bleeding. y Contraindicated in pregnancy (risk for fetal hemorrhage)
International normalized ratio (INR) monitoring required: y Goal INR is 2-3 times the control value (or 2.5-3.5 if given for a mechanical heart valve). y Takes 5-7 days to reach therapeutic INR
Not for emergency treatment of clots y Client may require heparin or LMWH as “bridge therapy” until INR is therapeutic. y Significant drug interactions: y Avoid all OTC medications or supplements not prescribed by the HCP, especially “SAG” medications: y St. John’s wort y Aspirin and other NSAIDs y G: Supplements that contain Garlic, Ginseng, or Ginkgo biloba y Remember: Taking warfarin with these can make your face SAG (facial droop) from brain bleeding. y Teach clients how to prevent and recognize bleeding at home (TABLE 3). y Low-molecular-weight heparin (LMWH) (enoxaparin) has a longer duration of action than unfractionated heparin and does not require PTT monitoring. y Easier for clients to self-administer at home y Given via SQ only:
Never give IM (full dose will be absorbed too rapidly).
Rotate sites >2 cm from umbilicus.
Do not eject air bubble from prefilled syringe. The bubble is present to ensure the full dose is administered.
To prevent hematomas, hold pressure after injection, but do not rub the site.  For clients receiving IV heParin, monitor the PTT and prepare to give Protamine sulfate for excessive bleeding. For clients receiving warfarIN, monitor the INR and prepare to give vitamIN K for excessive bleeding.  Instruct clients receiving anticoagulant medications (heparin, rivaroxaban) to use an electric razor, a soft-bristled toothbrush, and to avoid contact sports and construction work. © Bootcamp.com 4 Cardiovascular a. Heparin 3. Anticoagulants, Continued y Never double a missed dose. y Do not abruptly stop the medication. y Do not take aspirin or NSAIDs (ibuprofen) for pain or fever. y Use an electric razor and soft toothbrush. y Avoid activities with risk for injury (construction work, contact sports). y Contact HCP for unusual bleeding or bruising, like: y Petechiae y Prolonged bleeding y Bleeding from the gums y Blood in the stool, urine, or emesis TABLE 4. ANTICOAGULANTS SUMMARY Medications All anticoagulants: y Monitor CBC and hold for thrombocytopenia. y Notify HCP for unusual bleeding (TABLE 1). y Client teaching: y Do not abruptly stop the medication. y Never double a missed dose. y Avoid NSAIDs (aspirin, ibuprofen). y Use an electric razor and soft-bristled toothbrush. y Avoid activities with risk for injury (contact sports, construction work). Heparins heparin enoxaparin d. Direct oral anticoagulants (DOACs)
Unlike warfarin, DOACs work immediately and do not require INR monitoring.
Clients should not abruptly stop the medication or double a missed dose. y Teach clients to prevent and recognize bleeding at home (TABLE 3). y Antidotes available to reverse bleeding: y Rivaroxaban, apixaban: andexanet alfa y Dabigatran: idarucizumab Vitamin K antagonist warfarin Cautions: y Risk for HIT: If client develops thrombocytopenia, stop the heparin and notify the HCP. Administration: y Monitor PTT when giving IV heparin. y Antidote: Protamine y Never give IM. y Do not rub the injection site or eject the air bubble from a prefilled syringe. Cautions: y Takes 5-7 days to start working: Not for emergency treatment of clots y Several drug interactions: Avoid all medications and supplements not prescribed by the HCP (“SAG” medications). Administration: y Monitor INR. y Antidote: Vitamin K y Keep a consistent intake of leafy green vegetables. 4. Fibrinolytics y Fibrinolytics: Given as “clot busters” to treat STEMI, stroke, and unstable PE by dissolving existing clots: y Tissue plasminogen activator (tPA) y Alteplase y Tenecteplase y See STROKE CHEAT SHEET for more information on tPA considerations. Top Considerations Cardiovascular TABLE 3. CLIENT TEACHING FOR ANTICOAGULANTS Direct oral anticoagulants (DOACs) Administration: y Unlike warfarin, DOACs work quickly and do not require INR monitoring. rivaroxaban apixaban dabigatran  Instruct clients taking warfarin to keep a consistent intake of vitamin K (spinach, kale) and to avoid OTC medications, especially those containing St. John’s wort, aspirin or other NSAIDs, or “G” supplements (garlic, ginseng, ginkgo). © Bootcamp.com 5  Instruct clients taking warfarin to avoid OTC medications, especially those containing “SAG” medications: _____, _____, or _____. What should you teach the client regarding vitamin K intake?  Antiplatelets (aspirin, clopidogrel) should be discontinued at least _____ days before scheduled surgery.  To prevent bleeding, clients taking anticoagulants should use a(n) _____ razor, _____-bristled toothbrush, and avoid _____ sports and _____ work.  For clients receiving IV heparin, monitor ______ (which lab?) and prepare to give ______ (which antidote?) for bleeding. For clients receiving warfarin, monitor _____ (which lab?) and prepare to give _____ (which antidote?) for bleeding. Cardiovascular  Monitor clients taking antiplatelets or anticoagulants for unusual bleeding or bruising (such as petechiae or bleeding from the _____) or occult blood in the _____, _____, or _____. Answers: 1. gums, stool, urine, emesis 2. 7 days (1 week) 3. PTT, protamine sulfate, INR, vitamin K 4. St. John’s wort, aspirin or other NSAIDs, “G” supplements (garlic, ginseng, ginkgo), Keep a consistent intake of leafy green vegetables 5. electric razor, soft-bristled toothbrush, contact sports, construction work References: Burchum, J. R. & Rosenthal, L. D. (2025). Lehne’s pharmacology for nursing care (12th ed.). Elsevier. Lilley, L. L., Collins, S. R., & Snyder, J. S. (Eds.). (2023). Pharmacology and the nursing process (10th ed.). Elsevier. Callahan, B., Hand, M., & Steele, N. (Eds.). (2023). Nursing: A concept-based approach to learning (4th ed., Vol 1). Pearson. Tyerman, J., Cobbett, S., Harding, M. M., Kwong, J., Roberts, D., Hagler, D., Reinisch, C. (Eds.). (2023). Lewis’s medicalsurgical nursing in Canada: Assessment and management of clinical problems (5th ed.). Elsevier. Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (Eds.). (2023). Lewis’s medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier. Ignatavicius, D., Heimgartner, N., & Rebar, C. (Eds.). (2024). Medical-surgical nursing: Concepts for clinical judgment and collaborative care (11th ed.). Elsevier. Attributions: y Hemostasis: Created with BioRender.com y Antiplatelets at a Glance: Created with BioRender.com y Anticoagulants at a Glance: Created with BioRender.com © Bootcamp.com 6