Pharmacological Effects of Anti-coagulant Medications in the Management of Ischemic Stroke and Nursing Implications
Abstract
This article examines the effects of the anticoagulants among the patients with ischemic stroke. Anti coagulants are drugs given to a patient to stop blood from clotting. This happens when blood forms a clot within the vessels. The clot may move to the vital organs and prevent movement of air and nutrition. This causes death. Coagulation of blood happens to patients of stroke. There are drugs needed and care given for such patients to get better. This requires the nurses’ implications.
Keywords: Venous Thromboembolism, (VTE), National Patient Safety Goals (NPSG), Activated partial thromboplastin time (APTT), nonsteroidal anti-inflammatory agents (NSAIDs)
Pharmacological Effects of Anti-coagulant Medications in the Management of Ischemic Stroke and Nursing Implications
Introduction
At least 700,000 people suffer from stroke each year in America. Stroke is caused by blockage of blood within its system. The blockage results to lack of blood flow in some areas of the brain. The injury of these parts of the brain is referred to as ischemia. In this case, one or more areas within the brain may be damaged. The person affected can lose various abilities depending on the part of the brain that has been injured. These injuries can come in form of a person losing the ability to speak, walk or move one side of the body. The damages may be temporal or permanent, and the functions affected may be lost completely or partially (Berry, 2010). The result is dependent on the severity of the brain damage, the time the first treatment is administered, among other factors.
Recent research confirms that people have assumed sedentary lifestyles (Caplan, 2006). In addition to the high cholesterol intake, majority of the adults are at high risk of health complications such as VTE. VTE is among the four main causes of death among the Americans. A third of the VTE patients succumb within thirty days (Hutton, 2005). Among the leading alert medications is the anticoagulant. Hence, there is need for patients to be protected against the effects of anticoagulation therapy. The realization has led to the introduction of basics of medication to the nurses. These basics form the fundamental rights which include: patient, medication, route, dose and time. If all nurses can adhere to these basics of education, then few errors can occur.
Statistics also show that stroke is among the leading causes of lifelong injuries and death (Hutton & Caplan, 2003). Early management of disease together with preventive measures has bore fruit of reducing further brain damage. Treatment is based on the type: the ischemic and the hemorrhagic stroke. Underlying medical problems are viewed as a cause of prolonged treatment of the disease. Platelets are blood components that exist in form of tiny cells. They only clump during bleeding or in abnormal conditions, forming the clotting of blood. Anticoagulants are mostly referred as blood thinners. This is because they act by reducing blood clots within the arteries. Due to their nature, anticoagulants are rarely administered to ischemic patients.
Treatment of Early Stroke
For ischemic patients, treatment involves restoration of blood flow into the brain as quickly as possible. Aspirins, anticoagulants and alteplase are used as the first treatment of stroke (McBane, 2010). Thrombotic therapy (alteplase) involves the use of tissue plasmigen activator (tPA). This treats by dissolving clots which block the flow of blood within the brain arteries. Its benefit lies within the fast coordination of the hospital to offer emergency services with the neurologist available. Previous statistics prove that this medicine has much more benefits than side effects (Davis, 2005). Out of fifteen patients who were administrated with thrombotic therapy, one of them developed excessive bleeding. The statistics further reveals that the result can be fatal. It leads to personal choice of drug consumption. Aspirin is administered when thrombotic drugs cannot be given. It is an early treatment drug against acute ischemic stroke.
Anticoagulant Therapy
This works by interfering with the process of clotting. Frequent indications for the use comprise: treatment of disseminated intravascular syndrome, prophylaxis and management of pulmonary embolism and venous thrombosis (Jennings, 2008). Prevention of thrombo-embolic complications related to vascular and cardiac surgery. Coagulation examination must be carried out before administration of an anticoagulant. It allows any abnormal results to be taken to the physician first. The normal ranges are:
- Platelets 150 – 400 x 109/ L
- APPT 30-40 sec.
- PTT 60-70 sec.
- PT 11 – 13 sec.
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Prevention of Ischemic Stroke
For patients with history of ischemic, doctors should prescribe drugs that can prevent recurrence of the stroke. The treatment includes anti-platelet and anticoagulant medications. Surgical procedures are at times considered when it is necessary to open up blockages (Skidmore-Roth, 2007). To prevent recurrence of ischemic stroke, anti-platelet therapy is administered. One of these anti-platelet therapies given after an occurrence of a stroke to prevent its recurrence is Dipyridamole. It is given in form of release. The patient takes it two times daily. This drug is mostly combined with aspirin. Common side effects of this drug are stomach upsets diarrhea and headaches. The patient on medication is expected to show improvement after the first one week.
Clopidogrel is an antiplatelet drug also used after a patient has had a stroke. It is useful in preventing any recurrence. Previous studies have proved that this drug is much better than aspirin. Hence, it is highly recommended as an alternative drug to aspirin. In can, however, not be used in combination with aspirin. This is because it increases the chance of brain bleeding. The side effects of this drug are rashes, diarrhea, gastrointestinal bleeding and stomach upset. Aspirin, as an anticoagulant, is effective in higher doses than in smaller doses (Ansell, 2007). It is also very cheap in price compared to dipyridamole and clopidogrel.
Anticoagulant therapy is used in prevention of stroke. The therapy comprises the warfarin and dabigatran. Warfarin is a pill that is taken orally. It is used in patients who have a high probability of forming clots. Such patients must be monitored closely to prevent further bleeding and to reduce any enlargement of blood clots. Dabigatran is used to thin blood, and it is mainly used by patients with atrial fibrillation of the heart. It is better than Warfarin as it requires little supervision. It is, however, more expensive than Warfarin.
Revascularization refers to the process of restoring flow of blood in a part of the brain (Sullivan, 2006). For the stroke patients, it refers to the surgical procedure of opening the carotid artery. This prevents occurrences of stroke as it increases blood in the brain. In order to know the extent of the blockage, the patient is advised to go for an ultrasound imaging test or the conventional arteriogram. Carotid endarterectomy is a procedure done to open up blocked tubes. Its risks are equal to its successes. Risks are inclusive of stroke, bleeding, brain injury or death. Another alternative is the placement of stent in the tube at the neck. This carries a higher risk than carotid endarterectomy.
Complications
Several patients face other problems after they have had stroke. These complications are viewed as risky. This is because majority of deaths caused by stroke are mainly due to complications. Immediately after stroke, the care givers and the family members can reduce the risk of some of these diseases. Major complications comprise heart failure, blood clots, pneumonia, and difficulty in taking meals, bed sores, falls, urinary tract infections and bleeding in the digestive system (Jennings, 2008). Most of the patients of stroke are affected by blood clots. These clots always move along the blood vessels. They can cause blockages anywhere in the body. This leads to difficulty in walking which may further lead to paralysis. Such patients are mostly treated with heparin.
Nursing Implications
After stroke, it can be difficult to know what may happen next. The medical profession should prepare the care givers and the families about the long term risk and death. It is, however, indispensable to watch and wait. Anticoagulants are used when the patient is bleeding or during menstruation. When brushing their teeth, the patients should use toothbrushes with soft bristles. In addition, they are to use electric razor. These are measures put to reduce chances of bleeding. For negative effects of this management to be reduced, patients must be educated to be able to protect themselves from any injury or bleeding. In case they see any bleeding signs in the gums, urine or stool, they should report it immediately to the physician. Patients should also avoid using aspirin, NSAID or steroids since they highly react to the anticoagulants.
There are times when the patients must use anticoagulants. However, caution should be exercised to avoid further bleeding. Aspirin is mainly used to prevent further production of thromboxane A2. The effect of antiplatelet of this anticoagulant lasts for 7 days. Only patients with a lower risk of stroke can use this drug. Gastrointestinal side effects caused by the use of aspirin can be relieved by reducing the dose given. Warfarin can also be used alongside heparin. It is because warfarin takes longer to react. The drug is, however, necessary because it is used to prevent recurrence of thrombi. A daily dose of about 10 mg is administered until the normal ratio is achieved. Others incorporate the use of vitamin K in to the management. Equally, the doses can be adjusted depending on the age and severity of the problem. Factors such as drug interactions, compliance of the patient, diet and metabolism of the drug affect the administration of the drug.
Heparin is also employed to reduce the formation of blood clots. It acts at multiple sites to stop the clots from enlarging. It also prevents exchange of fibrinogen to fibrin. Very few patients can use this drug and hence, its dosage is also very specific. Plavix is another antiplatelet agent. It works by inhibiting the first two phases of platelet aggregation (Jennings, 2008). It inhibits the aggregation that is stimulated by other ADP. Plavix is administered to reduce the threat in critically ill patients. To reduce the gastric side effects, this drug should be administered with food. The drug is mostly prescribed to patients as it does not require consistent monitoring of the blood. Thus, it best suits patients on long term therapy. When administering heparin, complete occult blood and blood count should be studied. Lab tests have to be monitored strictly. To avoid bolus infusions when administering heparin intravenously, the nurse should avoid piggybacks. She should also create a separate line in addition. Ticlid is another drug that is used to inhibit the threat of stroke in patients. To reduce further bleeding in patients, platelet transfusions should be administered. There is need for care givers to stop the treatment for around five days for patients receiving anticoagulant therapy. This is to prevent early death rate (Huttona & Caplan, 2003).
Caution should be exercised as the dose given may be higher than that of preventive measures. Patients are advised to often move their limbs to prevent any clotting of the blood from taking place. This may require the help of a therapist. A stroke patient may develop dysphagia. This may lead to inhalation of saliva or food into the lungs. Caregivers need to exercise great care as this can lead to death. To determine whether a patient is at risk of dysphagia, water should be given to see if they have the ability to swallow. If this test turns negative then no food should be given orally. Instead, nutrition and medication should be given through the vein. Training programs and exercises can be introduced for the patients to swallow without the help of the nerves and the muscles. In addition, additives can be added to the food to make the liquids thick. The use of a catheter is employed to patients who have the difficulty of passing urine. Care givers should eliminate the risk of the patient contracting a urinary infection. This can be implemented by using it only when necessary, removing the catheter as soon as possible and changing the catheter.
At times a person loses the ability of recovering from stroke. This increases the chance of long term disability. The main cause of this problem is malnourishment before and after stroke. There should never be a reduction of the nutritional quantity taken in. This should be elevated prior to the patient being discharged. Feeding tube should be placed through the nose to the stomach to ensure the wellness of the patient. Patients who have had severe stroke may most likely have GI bleeding; thus, medication ought to be administered to lower the amount of gastric acid being produced. Heart problems such as irregular heart rhythm are also a common occurrence after stroke. More than 70% of the patients develop this problem later on. Before administration of drugs, other causes of the problem need to be ruled out. Tests carried out to ascertain the cause includes ECG and electrocardiogram (ECG). Bed sores are problems that occur because the patient could have lied on one area for so long. The skin injury may take different forms from mild to deep ulcers. This increases the risk of the patient to other infections. Care givers should help the patient turn every two hours. Patients should be placed at different angles to prevent them from exerting pressure on their hip bone. Pillows can be used to elevate the ankles and the knees to reduce pressure at those areas. However, the head of the bed should not be elevated frequently.
In addition to this, exercises need to be carried out. Exercises are to strengthen the muscles and enable the patient walk again. As the patient is exercising, the risk of falling should be totally eliminated. This is because fall is categorized among the risks to life threatening complications. A care giver should be assigned to every patient to eliminate such risks. If the patient has been discharged, home hazards should be removed. Loose rugs can be kept away from the patient’s path and lighting system can be improved for the sake of the patient. The care giver and family members should ensure that the patient is well clothed to avoid any loose cloths that may cause falls.
Conclusion
More than 450,000 American citizens are suffering from stroke related illnesses (Aplan 2006). This is because of the kind of sedentary lives people have opted for. Thus, there is need for people to take physical exercises seriously. Good nutrition, rest and removal of stress all play a very big part in the natural prevention of the disease. To prevent recurrence of stroke, aspirin and warfarin anticoagulants should be administered (Hutton, 2005). They are used in the treatment and prevention of clotting disorders. These drugs have side effects and vary in dosage from person to person, raising the issue of their nursing implications. Such implications include monitoring of laboratory results and administration of therapy. This should be exercised before and after drug administration. Finally, emerging issues like dissolution of clots require the introduction of thrombolytics.
