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Neurology. APTT, PTT, PT, INR. The Tests We All Must Pass. Chronological Order of the Presentation Introduction APTT & PTT PT & INR Nursing Interventions Differences Current Research Summary Questions. The Cold Hard Facts. We all die, but first we must live

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the tests we all must pass
The Tests We All Must Pass
  • Chronological Order of the Presentation
    • Introduction
    • APTT & PTT
    • PT & INR
    • Nursing Interventions
    • Differences
    • Current Research
    • Summary
    • Questions
the cold hard facts
The Cold Hard Facts
  • We all die, but first we must live
  • We control our bodies via a large neurological system
  • Depriving this neurological system of blood flow = death
  • Thromboli can impede blood flow
  • Therefore thromboli = death
the selfish gene
The Selfish Gene
  • We all want to live
  • Keeping blood flowing to neurological system prolongs life
  • Thromboli impedes blood flow
  • Antithrombolitic therapy prevents thromboli formation
  • Therefore antithrombolitic therapy prolongs life
too much of a good thing
Too Much of a Good Thing...
  • Too much antithrombolitic therapy = prolonged bleeding
  • Prolonged bleeding decreases blood flow to neurological system
  • Decreased blood flow to neurological system can cause death
  • Therefore too much antithrombolitic therapy can cause death
how to walk the line
How to Walk the Line
  • Develop tests to measure clotting factor
  • APTT & PTT
  • PT & INR
aptt ptt
  • APTT – Activated Partial Thromboplastin Time
  • PTT - Partial Thromboplastin Time
  • Use intrinsic factors to initiate coagulation pathways
  • Coagulation is timed and compared to a standard
  • Test used to diagnosis and monitor
  • 70 seconds…
pt inr
  • PT – Prothrombolin time
  • INR – International Normalization Ratio
  • Firm fibrin clot formation initiated by tissue thromboplastin (factor III) and calcium
  • Timed test
pt inr1
  • Uses the equation: INR = (PTclient)x ISI


* ISI - International Sensitivity Index *

  • INR = 1
  • INR = 2-3
  • INR = 2.5-3.5
nursing interventions
Nursing Interventions
  • Both are blood tests = similar interventions
  • Require interventions at all stages of the test:
    • Pre-test
    • Intra-test
    • Post-test
pre test
  • Education
  • Client Health History
    • Bleeding disorders
    • Surgeries, lab tests, diagnostic tests
  • Current and recent medications
    • Anticoagulants, acetylsalicylic acid, herbs, nutritional suppliments, and nutraceuticals
intra test
  • Follow directions
  • Breath normally
  • Avoid unnecessary movement
  • Identify client
  • Label vials accordingly
  • Fill tube completely
  • Have sample analyzed within 4 hours
post test
  • Observe venipuncture site
  • Provide instructions regarding excessive bleeding and bruising
  • Educate regarding prolonged APTT or high INR
  • Reinforce health care provider information or instructions
  • Notify client’s health care provider if INR < 2 or APTT < 53 seconds
where are the differences
Where are the Differences
  • INR internationally recognized and understood
  • APTT uses kaolin, celite or elegia acid to speed up reaction time, therefore increasing the speed of the test
  • APTT not recommended for prophylactic low-dose heparin therapy
  • INR affected by more drugs
  • INR may be performed on samples older than 4 hours*

* A topic of current research

current research
Current Research
  • Certified Diagnostic Plasmas for INR
  • Are 2.0-3.0 INR values optimal?
  • Obtaining INR and APTT values using different analyzers
  • INR self testing by clients
  • APTT value < 70 seconds
  • INR value 2.0-3.0
  • APTT and INR instrumental in anticoagulation therapies, should be monitored closely to ensure adequate dosing
  • Cha, C.H., Park, C.J., Kim, D.H., Kim, M.J., Cho, Y.U., Jang, S. & Chi, H.S. (2010) Direct international normalized ratio determination using multicalibrators is more responsive than the conventional method for measuring prothrombin time. International Journal of Laboratory Hematology, 32(4), pp. 392–397. doi: 10.1111/j.1751-553X.2009.01195.x
  • Christensen, T.D., Jensen, C., Larsen T.B., Maegaard, M., Christiansen, K. & Sørensen, B. (2010) International normalized ratio (INR), coagulation factor activities and calibrated automated thrombin generation -- Influence of 24 h storage at ambient temperature. International Journal of Laboratory Hematology, 32(2), pp. 206-214. doi: 10.1111/j.1751-553X.2009.01170.x
  • Peng, L., Yan, C., Wu, X. & Nie, L. (2009) Comparability of the results of PT–INR with local MNPT and APTTR with MNAPTT on different coagulation analyzers in China. International Journal of Laboratory Hematology, 31(3), pp. 352-358. doi: 10.1111/j.1751-553X.2008.01071.x
  • Plesch, W. & van den Besselaar, A. M. H. P. (2009) Validation of the international normalized ratio (INR) in a new point-of-care system designed for home monitoring of oral anticoagulation therapy. International Journal of Laboratory Hematology, 31(1), pp. 20-25. doi: 10.1111/j.1751-553X.2007.00998.x
  • You, J. H. S., Chan, F. W. H., Wong, R. S. M. & Cheng, G. (2005) Is INR between 2.0 and 3.0 the optimal level for Chinese patients on warfarin therapy for moderate-intensity anticoagulation? British Journal of Clinical Pharmacology, 59(5), pp.582-587. doi: 10.1111/j.1365-2125.2005.02361.x
  • A wise person once observed:

“Nurses are like the blood of the health care system...without them it would die.”