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Coagulation Disorders (Coagulopathy)

Coagulation Disorders (Coagulopathy). Presented by: Nardalyn Johnson, RN MSN Student Alverno College April 22, 2010 In collaboration with: Jim Molnar, APRN – Preceptor Jan Theis, APRN MSN 621 Instructors: Patricia Bowne Luanne Wielichowski. Coagulation Disorders. INTRODUCTION

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Coagulation Disorders (Coagulopathy)

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  1. Coagulation Disorders (Coagulopathy) Presented by: Nardalyn Johnson, RN MSN Student Alverno College April 22, 2010 In collaboration with: Jim Molnar, APRN – Preceptor Jan Theis, APRN MSN 621 Instructors: Patricia Bowne Luanne Wielichowski

  2. Coagulation Disorders INTRODUCTION The Interventional Radiology (IR) department multidisciplinary team works with patients who have various types of coagulation disorders. Hemostasis management is complex due to the wide array of patient co-morbidities and demographics. Malloy, P.C., Grassi, C. J., Kundy, S., Gervais, Miller, D. L., Osnis, R. B. et al. (2009). Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional Radiology.

  3. Objectives Review importance of hemostasis management in IR Review coagulation disorders Review the coagulation cascade (intrinsic and extrinsic pathways) Identify common lab tests Identify common medications that can affect hemostasis Focus on clinical application of hemostasis in IR Special Note: Whenever you see an underlined word, move the curser over the underlined word to view more information Coagulation Disorders

  4. Coagulation Disorders Wellcome Images A group of conditions that cause an individual to experience either: Excessive bleeding Excessive Clotting Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.

  5. Case Study A 49 yr old male Presents to IR for placement of a permCath to initiate dialysis. He returns to IR the following day due to excessive bleeding during dialysis. BP 159/75 HR 76 Temp 97.8 Lab: INR 1.8 (0.9 – 1.3)

  6. Coagulation Disorders Click the diagram to reveal the answer Why Does the IR multidisciplinary team need to be concerned about patients with clotting or bleeding disorders? Hemostasis management

  7. Hemostasis Definition: Hemostasis is the process of stopping blood loss. This process occurs via the hemostatic mechanism known as blood coagulation It is regulated by “activators” and “inhibitors”. Seals blood vessels and prevents blood loss and hemorrhage If Normal Causes inappropriate blood clotting or excessive bleeding If Abnormal Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY

  8. Why is Hemostasis Management Important? • Prevents cancellation of IR procedures due to appropriate • pre-op procedure not done • Prevents excessive bleeding pre, intra, or post procedure • Decreased risk for post-procedural thrombosis • Achieves hemostasis pre, intra, and prior to discharge • Helps with healing • Provide appropriate patient education • Identify new protocols for patients with coagulation • disorders • Early identification of at risk patients pre-procedure Nursing Outcomes http://www.vascularsolutions.com/company-info/contact

  9. Coagulation Disorders Hemostasis management for patients undergoing percutaneous image-guided procedures can be complex due to the wide range of procedures and equally wide range of patient demographics and co-morbidities. Microsoft clipart Microsoft clipart Some patients are on special medications that increase their risk for bleeding or have internal stents or other devices that predispose them to forming clots. Malloy, P.C., Grassi, C. J., Kundy, S., Gervais, Miller, D. L., Osnis, R. B. et al. (2009). Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional Radiology.

  10. A Closer Look at “Hemostasis process” Five Stages for Achieving Hemostasis Click each box along the pathway to reveal the steps Move the curser over the underlined word to view more information Vessel spasm Formation of platelet plug, platelet adhesion, & aggregation Formation of fibrin clot and activation of intrinsic or extrinsic coagulation cascade Clot retraction Clot dissolution Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY

  11. Coagulation Disorders Clot retraction: is when the blood clot becomes smaller, squeezing serum from the clot and joining the edges of the broken vessel Clot retraction normally occurs within ____time after a clot is formed NO……. This is not enough time and you are at risk for bleeding Incorrect… This is abnormal and could be due to low platelet count 5 to 10 minutes 8 to 10 hours CORRECT! This is key for hemostasis 2 to 4 hours 20 – 60 minutes TRY AGAIN……. It begins shortly after formation

  12. The Intrinsic and Extrinsic Coagulation Cascade The coagulation cascade is one component of the hemostasis process. For coagulation to work successfully, we need both the “Intrinsic pathway” and the “extrinsic pathway.” Both pathways are interrelated and link to form the common pathway. Here is a list of Factors that help to build the coagulation cascade Sometimes you will see them referenced by their original name. Other times you will see only the roman numeral references. Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY

  13. Blood vessel damage Return to Calcium (Ca 2+) A Closer Look at “Normal Coagulation Cascade” The Intrinsic Pathway The Extrinsic Pathway Damaged Tissue (from activePLT) Factor XII Ca2+ Tissue Factor (III) Cascade reaction Proconvertin(VII) Factor X Plasma thromboplastin antecedent (XI) Factor V Factor III Ca 2+ PF3 RBC & PLT get caught in mesh Forming blood clot Prothrombin Activator Prothrombin (II) Thrombin Cross-linked Fibrin mesh Fibrinogen (I) Fibrin (monomer) Fibrin (polymer) Factor XIII See step-by-step explanation on next slide Slide created by Nardayn Johnson

  14. The Coagulation Cascade Explained (See previous slide) • The extrinsic pathway gets initiated when there is damage to blood vessels or surrounding tissue (usually a fast process). • Factor III is released in response to damaged tissue which then activates Factor VII with the help of calcium ions. • The intrinsic pathway (a slower process) is then activated when factor XI gets activated by Factor XII from active platelets. • Activated factor XI and factor VII cause a cascade reaction which leads to the activation of factor X. • Activated Factor X with the help of calcium ions, Factor III, Factor V, and PF3 activates prothrombin activator which then converts prothrombin to thrombin. • Next, thrombin converts fibrinogen to fibrin which forms a loose mesh. • Fibrin along with factor III forms a denser network of mesh fibers which can trap RBC & PLT forming a successful clot. Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY

  15. The Intrinsic and Extrinsic Coagulation Cascade Microsoft clipart • Blood coagulation requires systematic activation of coagulation factors controlled by activators and inhibitors. • It is vital to promoting healing after a patient undergoes any percutaneous imaging procedure. Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.

  16. Return to Protein C The Intrinsic vs. Extrinsic Coagulation Cascade The activation of one procoagulation factor/enzyme leads to the activation of the next factor, similar to a domino effect. “Most of the inactive procoagulation factors are present in the blood all the time.” (Porth, 2005) The Intrinsic pathway A slow Process Begins in the blood itself The Extrinsic pathway A faster Process Begins with damage to blood vessel or surrounding tissue Need both for Hemostasis Extrinsic pathway Gets activated Small amount of Thrombin formed Stimulus to Intrinsic pathway Formation of more Thrombin Produce large Amount of Fibrin Damage to tissue Coagulation Successful + Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.

  17. The Intrinsic vs. Extrinsic Coagulation Cascade CASE STUDY: Recall the 49 yr old male who presented to IR for placement of a permCath to initiate dialysis. He returned to IR the following day due to excessive bleeding problems during dialysis. A defect in which pathway would cause bleeding problems? Intrinsic Pathway Try Again There’s a better answer Think about the procedure performed Extrinsic Pathway Try Again. This is not be most correct response Both Correct!

  18. The Intrinsic vs. Extrinsic Coagulation Cascade Jim Molnar, 2010 – (Preceptor) Molnar. J. (2010). Thrombolytics. Froedtert hospital Radiology Department.

  19. The Intrinsic vs. Extrinsic Coagulation Cascade Abnormality in the clotting process can result if there is a problem with one or more factors (Porth, 2005). This can lead to inappropriate activation at any point along the pathway depending on the factor(s) causing the problem (Nowak, 2004). Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott. Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY

  20. View coagulation pathway Why are Ca 2+, Vitamin K, Protein C, and Platelets Important? Ca2+ Calcium (ionized) • Calcium plays a key role in the coagulation cascade. • It is “required in all but the first two steps of the clotting process.” • (Porth, 2005) • 3 types of calcium (calcium salts, protein bound, and ionized calcium) • **ionized calcium** aid in coagulation cascade • Calcium = Factor IV • Only need a small amount so patients with calcium deficiency will not • necessarily exhibit any significant effect on coagulation cascade. • If calcium gets inactivated when it is removed from the body, then blood • will not clot. • Think about the EDTA tubes that you use to collect blood. They contain chelating agent that • inactivates Ca++ that prevents the blood from clotting. Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY

  21. Why are Ca 2+, Vitamin K, Protein C, and Platelets Important? VITAMIN K Is a fat soluble vitamin and without it your blood will not clot FUNCTION OF VITAMIN K: • Needed by liver to produce clotting factors • Needed to produce clotting Factors such as VII, IX, X and to synthesize • Protein C • Helps to regulate calcium…keeping it in your bones and out of your blood • Watch patients who are taking warfarin as it can decrease clotting by • interfering with vitamin K and increase risk for excesses bleeding after a procedure • You do not need much—just enough to prevent you from bleeding to death • Older patients will need more vitamin K http://www.hemophilia.org/NHFWeb/MainPgs/MainNHF.aspx?menuid=176&contentid=378&rptname=bleeding

  22. View Positive feedback Why are Ca 2+, Vitamin K, Protein C, and Platelets Important? Protein C A special anticoagulant protein. Activated Protein C functions as an anticoagulant, limiting clot formation (down regulates the coagulation cascade). Resistance to activated Protein C prevents Protein C from cleaving to Factor V and/or VIII. You need the help of vitamin K to help build Protein C. Do not confuse this with “C-reactive protein.” This is produced in the liver and is a bi-product of inflammation. Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY

  23. Why are Ca 2+, Vitamin K, Protein C, and Platelets Important? You found out during testing that JT has a Protein C deficiency. This deficiency predisposes him to __________? Venous Thrombosis Click here

  24. Why are Platelets important for Hemostasis? Wellcome Images • Platelets are very important in hemostasis management • You need enough to prevent excessive bleeding, but too many can be problematic because they cause hypercoagulation • Some patients may have internal stents or other devices that predispose them to forming clots • Cancer patients who have decreased platelet count are at increased risk for bleeding King, K. W. (2010). Platelet Activation and von Willebrand Factor (vWF). IU School of Medicine.

  25. Why are Platelets important for Hemostasis? CASE STUDY KLS presents to IR for permCath evaluation due to poor blood flow. This is his third visit to IR in one mouth. KLS requests a new catheter because he believes something is wrong with the current catheter. Lab tests prior to procedure reveal: INR=1.0 (0.9-1.3), Plt = 654 (150-350), PTT 24 (25-33) You change the catheter, but two weeks later he is back again. It makes no sense to keep changing the catheter. It appears his body is forming thrombi around the catheter causing decreased blood flow. Medical Decision: In addition to performing a catheter stripping procedure, he is started on Aspirin 325 mg by mouth MWF to help decrease platelet aggregation. Aspirin would help to decrease platelet aggregation. Microsoft clipart

  26. Medications that Affect Coagulation Cascade Some patients are on special medications that increases their risk for bleeding Microsoft clipart Anticoagulants (heparin, warfarin) These medications can complicate a procedure if not managed appropriately. Thombolytics (tPA) Anti-platelet agents (ASA, Plavix, ticlid)

  27. Medications that Affect Coagulation Cascade Anticoagulants Warfarin: is “prescribed to ~2 million new patients per Year in US” (USA Today, 2010). Therefore, your chance of having a patient on this medication is high. E.g. prescribed to patients with history of DVT, PE, prosthetic heart valve etc. Anticoagulants help with hemostasis by preventing inappropriate blood clotting in vessels. They chip away at clot making it smaller Prevents thrombosis in veins Close hemostasis management is important pre, intra, and post procedure to prevent excessive bleeding complications. Remember labs: INR, PT Two commonly used drugs in the US are: Warfarin (Coumadin) Heparin Vitamin K antagonist Activate anti-thrombin III Decrease production of Factors II, VII, IX, X Blocks thrombin Prevent thrombosis Heparin - released from tissue basophils and inactivates thrombin. Sternberg, S. (2010). Gene test cuts complications from blood thinner warfarin. USA Today.

  28. Medications that Affect Coagulation Cascade Microsoft clipart Microsoft clipart Huber, C. (2007). Anticoagulant Therapy Management. Cedar Rapids Healthcare Alliance. http://en.wikipedia.org/wiki/Anticoagulant

  29. Medications that Affect Coagulation Cascade Why Give Heparin by IV or SC preparation Versus taking it by mouth? Answer It is unable to cross membrane of GI Tract

  30. Medications that Affect Coagulation Cascade A patient scheduled for central line placement in IR with a recent history of Pulmonary Emboli (PE) Anticoagulant medication: Warfarin 4 mg by mouth daily Recent lab: INR 2.1 (0.9-1.3) Which of the following instructions should be given to the patient? Click on the correct response: a)Hold Warfarin 3 days before procedure Initiate Lovenox therapy Hold AM dose of Lovenox prior to procedure Recheck INR prior to procedure • Correct Due to different half live of preformed clotting factors b) Hold Warfarin 7 days before procedure Initiate Lovenox therapy Hold AM and PM dose of Lovenox prior to procedure Recheck INR prior to procedure X No Only need 3 days c)Hold Warfarin 5 days prior to procedure X Try Again

  31. Medications that Affect Coagulation Cascade Article Published by USA Today 3/16/2010 Title: Gene Test Cuts Complication from Blood Thinner Warfarin Points from article: It takes time for a doctor to settle on a safe and effective dose when prescribing warfarin. “Roughly 1 in 5 patients are hospitalized for bleeding within six months of starting the drug. Others develop a life-threatening blood clot.” “Warfarin is the second-greatest cause of hospitalization due to drug complication.” “Warfarin is prescribed to 2 million new patients in the USA each year.” Genetic tests can be used to personalize warfarin treatment and decrease the rate of hospitalization. See full article at: http://www.usatoday.com/news/health/2010-03-16-warfarin-gene_N.htm Sternberg, S. (2010). Gene test cuts complications from blood thinner warfarin. USA Today.

  32. Medications that Affect Coagulation Cascade TB reported to IR for tunneled catheter evaluation with a report from the dialysis center of poor blood flow. Medical decision: tPA catheter Post evaluation: Catheter flush & aspirate w/o difficulty FMLH Radiology Thombolytics (tPA) A clot-busting medication Important for cell migration and tissue healing Increase activity = increase bleeding Decreased activity = thrombosis A protein that breaks down blood clot Catalyses Plasminogen tPA Plasmin Fibrin Degradation Thrombolytic drug. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Thrombolytic_drug

  33. Medications that Affect Coagulation Cascade Anti-platelet agents Two commonly used drugs in the US are: Aspirin (ASA) Ticlid Suppress platelet aggregation Prevent thrombosis in arteries while anticoagulants (Warfarin & heparin, Prevent thrombosis in veins Inhibit COX enzyme Blocks ADP receptor on platelet surface Decrease Platelet Synthesis of TXA2 Decrease Pathway in platelet activation Antiplatelet. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Antiplatelet_drug Prevent Thrombus formation King, K. W. (2010). Platelet Activation and von Willebrand Factor (vWF). IU School of Medicine.

  34. Some Important Labs You Need to Know About If the procedure is invasive, hemostasis status should be assessed and closely monitored. Tests needed will be based on the procedure you will perform. FMLH Radiology Malloy, P.C., Grassi, C. J., Kundy, S., Gervais, Miller, D. L., Osnis, R. B. et al. (2009). Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional Radiology.

  35. Functions of the Liver Most clotting Factors are produced in the liver Microsoft clipart * * Dependent on vitamin K for synthesis in liver Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY

  36. What Happens if the Liver is Damaged? Liver Damage Tissue Damage Decrease Clotting Factor Synthesis Compromise Bile synthesis Shortage of Vitamin K Depletion of Clotting Factors Decrease clotting Factor synthesis Wellcome Images Hypocoagulation • Liver disease (e.g. liver cancer, cirrhosis, fibrosis, hepatitis) will decrease the synthesis of all liver dependent clotting factor • Your body will take longer to clot, thereby increasing the risk for bleeding • INR lab - Will be elevated with severe liver damage Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.

  37. Whathappens if the Liver is Damaged? Case Study Patient with increased liver function test present to IR for liver biopsy History of ESRD, kidney transplant, on immunosuppression, basal cell carcinoma, fatty liver Lab: Liver fn panel, Plt 99 (150-350) Hgb 7.2 Stat type & cross IR medical team decision: 2 units packed RBC ordered, 1 unit infused prior to procedure

  38. Role of Inflammation & Effects on Coagulation • Inflammation is a biochemical and cellular process that occurs in vascularized tissues • Inflammation in the liver will affect coagulation Inflammation Liver Damage Tissue Damage Decrease Clotting Factor Synthesis Wellcome Images Depletion of Clotting Factor Hypocoagulation Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.

  39. chronic inflammatory process (outside the liver) can trigger the clotting cascade. Clotting causes damage through lack of perfusion (ischemia) to vital organs, such as the liver, kidneys, heart which would then activates the clotting cascade which increase clotting. Role of Inflammation & Effects on Coagulation Chronic Inflammation Decrease activity of natural anticoagulant mechanism Impairs Fibrinolytic system Hypercoagulation Esmon, C. T. (2005). The interactions between inflammation and coagulation . British Journal of Haematology. 131(14) 417-430.

  40. Whathappens if the Liver is Damaged? Which of these Factors is not synthesized in the liver? Click on the correct response: X Incorrect a) Prothrombin (Factor II) Correct Source: Platelets and endothelium b)Antihemophilic Factor (Factor VIII) c) Hageman Factor (Factor XII) X No d)Stuart-Prower Factor (Factor X) X Try Again

  41. Stress Adaptation Response & Effects on Coagulation Microsoft clipart • The stress response protects the individual from threats to homeostasis. • Trauma as a result of percutaneous image-guided procedurescan induce the stress response Case Study 50 yr old Male presents to IR for treatment with drug eluting bead chemoembolization Diagnosed with neuroendocrine cancer w/liver metastasis Had multiple hypertensive crises recently BP 133/65 R=18 HR 72 wt=245# The patient is at risk of a hypertensive crisis Med requested = Alpha blockade Medication ordered = phentolamine (REGITINE) 5 mg Reason: Phentolamineprevent stress response (hypertensive crisis) which may occur due to stress or due to a surgical procedure. Hypertension damages the blood vessels thereby affecting the coagulation cascade Hehne, R. A. (2004). Pharmacology for Nursing Care. (5th Ed). Saunders. Missouri

  42. Role of Aging & Effects on Coagulation Aging Aging Vitamin K Deficiency ** **Defective Vessel Support Due to Weakness in Connective Tissue Decreased Clotting Factor Synthesis by Liver Microsoft clipart Increased Vessel Fragility Hypocoagulation Increase Bleeding Risk ** Older patients will need more vitamin K ** With aging, the skin becomes thinner so tissues supporting underlying blood vessels are more fragile Toloza, E, (2005). Bruises. Department of Emergency Medicine, University of Texas at Houston School of Medicine.

  43. Role of Genetics & Effects on Coagulation Microsoft clipart Deficiencies in clotting factors may be due to genetics Factor VIII/IX Deficiency Hemophilia Factor V Deficiency Owren’s Disease Factor X Deficiency Stuart-Prower Factor Deficiency Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott. For all Bleeding and Clotting Disorders. Retrieved March 8, 2010 from http://www.hemophilia.org/NHFWeb/MainPgs/MainNHF.aspx?menuid=176&contentid=378&rptname=bleeding Taylor, A.K. (1997). Venous Thrombosis and the Factor V (Leiden) Mutation. The Mountain States Genetics Foundation (14).

  44. Video Links A review of the coagulation cascade can be found at the following link 1. http://www.hopkinsmedicine.org/hematology/Coagulation.swf Microsoft clipart

  45. A Closer Look at the “Hemostasis Process” List The Five Stages for Achieving Hemostasis Click each box to reveal the correct response Vessel spasm Formation of platelet plug, platelet adhesion, & aggregation Formation of fibrin clot Activate intrinsic or extrinsic coagulation cascade Clot retraction Clot dissolution Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY

  46. Summary The Interventional Radiology (IR) department multidisciplinary team work with patients who have various types of coagulation disorders. Hemostasis management is complex due to the wide array of patient co-morbidities of patients undergoing percutaneous image-guided procedures in IR. This complexity is further complicated by the wide range of procedures and patient demographics. Some patients are on special medications that increases their risk for bleeding or have internal stents or other devices that predispose them to forming clots. The use of Thombolytics (tPA), anti-coagulants (heparin, warfarin), or anti-platelet agents (ASA, Plavix, ticlid) can complicate a procedure if not managed appropriately. Medical interdisciplinary team understanding of the various coagulation disorders will assist in medical care to patients. This would include pre-op measures to prevent lengthy delays or costly cancellation of procedures.

  47. QUIZ • 1. The process of stopping blood loss is known as? • Coagulation cascade • Clot retraction • Hemostasis • Clot dissolution • 2. For coagulation to work successfully we need these two pathways. Both pathways are interrelated and link to form the common pathway. • IR pathway AND clot retraction pathway • Intrinsic pathway AND Extrinsic pathway • Internal pathway AND External pathway • None of the above • 3. Calcium (Factor V) plays a key role in the coagulation cascade. It is “required in all but the first two steps of the clotting process. The type of calcium needed in the coagulation cascade is? • Calcium salts • Protein bound calcium • Ionized calcium • Unbound calcium • 4. Identify two commonly used anticoagulant medication used in the US. They can affect hemostasis for patients undergoing percutaneous image-guided procedures in IR. • Warfarin AND Heparin • Aspirin AND Ticlid • Tissue plasminogen activator (tPA) AND Streptokinase (SK) • Prednisone AND Dexamethasone • 5. Identify the organ where most of the clotting factors are synthesized: ____________________ Answers 1. C 2. B 3. C 4. A 5. LIVER Click here to reveal the answers

  48. References Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott. Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY Hehne, R. A. (2004). Pharmacology for Nursing Care. (5th Ed). Saunders. Missouri Rayfield, S., Manning, L. (1998). Nursing made Insanely Easy. (2nd Ed). ICAN Louisiana Sternberg, S. (2010). Gene test cuts complications from blood thinner warfarin. USA Today. Huber, C. (2007). Anticoagulant Therapy Management. Cedar Rapids Healthcare Alliance. Guyton, A.C., Hall, J.E. 2000. Medical Physiology. 10th edition. Saunders. Malloy, P.C., Grassi, C. J., Kundy, S., Gervais, Miller, D. L., Osnis, R. B. et al. (2009). Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional Radiology. Hemostasis. Retrieved March 24, 2010 from http://www.mhhe.com/biosci/esp/2002_general/Esp/folder_structure/tr/m1/s7/trm1s7_3.htm Tissue Plasminogen Activator (tPA). Retrieved March 24, 2010 from http://www.americanheart.org/presenter.jhtml?identifier=4751 Symptoms of Coagulation Disorders. Retrieved March 24, 2010 from http://www.signsofbleeding.com/index.php?page=4 Tissue plasminogen activator. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Tissue_plasminogen_activator Coagulation Cascade. Retrieved March 12, 2010 from http://www.hopkinsmedicine.org/hematology/Coagulation.swf Thrombophilia or Hypercoagulable States. Retrieved March 12, 2010 from http://www.peds.ufl.edu/residency/resources/hematology/th_states.pdf Radiological Society of North America (2010). Radiology Info: the Radiology information for patients. Radiological Society of North America, Inc. For all Bleeding and Clotting Disorders. Retrieved March 8, 2010 from http://www.hemophilia.org/NHFWeb/MainPgs/MainNHF.aspx?menuid=176&contentid=378&rptname=bleeding Thrombolytic drug. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Thrombolytic_drug King, K. W. (2010). Platelet Activation and von Willebrand Factor (vWF). IU School of Medicine. Molnar. J. (2010). Thrombolytics. Froedtert hospital Radiology Department. Anticoagulants. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Anticoagulant Antiplatelet. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Antiplatelet_drug Ganda. K. (2005). The Clotting Pathway. TUFTSOPENCOURSEWARE ,Tufts University. Toloza, E, (2005). Bruises. Department of Emergency Medicine, University of Texas at Houston School of Medicine.

  49. References Taylor, A.K. (1997). Venous Thrombosis and the Factor V (Leiden) Mutation. The Mountain States Genetics Foundation (14). mcGilvray,I. , Rotstein, O.D.(2001). Assessment of Coagulation in Surgical Critical Care Patients. Department of surgery, University of Toronto and Toronto General Hospital, Canada. Esmon, C. T. (2005). The interactions between inflammation and coagulation . British Journal of Haematology. 131(14) 417-430. Contact Information Nardalyn Johnson, RN narjohnson@gmail.com

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