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zimmie256

I could use some help with some basic research I'm putting together about how oral anticoagulants are used...

- When in an outpatient setting are oral anticoagulants used?

- Why or in what circumstances are various anticoagulants prescribed? (Why Warfarin over Plavix or vice versa). Basically what criteria are used to decide which anticoagulant to prescribe? I'm assuming the main competitors are warfarin, plavix, aspirin, and heparin?

- When are low molecular weight heparins used over high molecular weight and why?

Any help you can offer on some or all of these questions will be greatly appreciated... Thanks!
 
Z

zimmie256

Any help would be appreciated... Need to get this to my boss by 6... Any suggestions for sources to find this info would be very helpful.

From what I've found low molecular weight heparins may be better because of more consistent dose effect response... Also that low molecular weight heparins are more likely to be used for post-surgical patients than other anticoagulants.
 
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zimmie256

find yourself a pharm review book. all of your answers will be concise and easy to find.

Thanks for the reply. Unfortunately I won't start med school until the fall, so I don't have a ready supply of pharm review books. But that is very good to know about in case I need to do longer term follow-up with this project.
 
Z

zimmie256

You could try google.

We aren't going to do your homework for you.

I did try Google. Found some information. Some outdated. Some conflicting. Some good. It's tough not having journal subscriptions, what can I say... If you read my other post, I asked for suggestions of other sources to research myself as well, not looking for a handout here...
 

albaniandoc

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I could use some help with some basic research I'm putting together about how oral anticoagulants are used...

- When in an outpatient setting are oral anticoagulants used?

- Why or in what circumstances are various anticoagulants prescribed? (Why Warfarin over Plavix or vice versa). Basically what criteria are used to decide which anticoagulant to prescribe? I'm assuming the main competitors are warfarin, plavix, aspirin, and heparin?

- When are low molecular weight heparins used over high molecular weight and why?

Any help you can offer on some or all of these questions will be greatly appreciated... Thanks!

I work as a nurse in surgery so my pharmacology is pretty limited right now, since I don't deal with drugs first hand, however I will give it my best shot:

Coumadin, widely used for patients with A fib, PE, DVT or those with mechanical heart valves. There is a scale of INR levels which determines the dosage. I think for mechanical valves is pretty high up there, something like 2.5. You take the drug daily and get INR level constantly to adjust the dosage. Patients are very prone to bruising and bleeding. The drug prevents clotting factors from forming. This way clots don't form. It blocks conversion of several factors in the clotting cascade by inhibiting the final active clotting factor. It is reversed with an injection of Vitamin K. We have to do it once in a while in the hospital when the patients come with GI bleeds. It is used a long term drug for chronic patients, again like a mechanical valve.

Heparin, from what I understand is the IV form of coumadin and is easily reversed with protamine sulfate and is used for patients in the hospital for pretty much the same reasons as coumadin and also acute stroke or heart attack. It falls under platelet aggregation inhibitor. The advantage over coumadin is that heparin has a short half life I think after an hour the PT levels return to normal. Heparing is used as a short term drug until patients can be started on coumadin. For example you are on coumadin because a history of stroke. So you come to the hospital a couple of days early and get started on heparin and stopped on the coumadin. Then you do the procedure and afterwards you can start anticoagulation therapy again.

Plavix is used for CAD, PVD or cerebrovascular disease. I see it mostly used after caths when stents are placed or acute heart attacks. To us Plavix is nasty because causes a lot of bleeding in the OR. Plavix cannot be reversed because it blocks some sort of receptors on the platelets therefore making them not usable. The treatment for it give the patient a bunch of blood products. Under optimal conditions the patient should stop Plavix five days before surgery.

Usually, low molecular weight heparins come in a tiny TB syringe and can be given once daily for prophylaxis, under the skin, after surgery, especially surgical procedures where immobility is expected thus increasing the risk for clots to form. Patients can inject low molecular weight heparin like Lovenox by themselves, so it reduces their hospitalization time.

Finally, it seems like everyone is on ASA nowadays. It is used as prophylaxis for patients at high risk for CAD or strokes. Like patients that have high blood pressure or those with dyslipidemia. It also blocks platelet aggregation by I think changing a conformation of sorts. It is also irreversible and the patients going for surgery will have to stop a few days ahead of time.

This is pretty much the down and dirty on these drugs. Other people can chip in.
 

stoic

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to fix the misinformation:

heparin is NOT the IV form of coumadin. they are completely different drugs. heparin works by accelerating the action of antithrombin III. antithrombin III chews up thrombin and factor X, so the clotting cascade is inhibited. the action of LMWH is basically the same, but the pharmokinetics are completely different. Heparin is given IV or subQ, LMWH is given subQ.

coumadin works by inhibiting vit. K epoxidase, which inhibits the formation of several clotting factors. reverse coumadin (sort of) by giving vit. K. coumadin is an oral medication.
 

Tired

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Coumadin, widely used for patients with A fib, PE, DVT or those with mechanical heart valves.

Agh!

There is a scale of INR levels which determines the dosage. I think for mechanical valves is pretty high up there, something like 2.5. You take the drug daily and get INR level constantly to adjust the dosage.

This is a little closer . . .

Patients are very prone to bruising and bleeding.

Agh!

The drug prevents clotting factors from forming. This way clots don't form. It blocks conversion of several factors in the clotting cascade by inhibiting the final active clotting factor.

Agh! And you have a self-contradiction in here!

It is reversed with an injection of Vitamin K.

Agh!

It is used a long term drug for chronic patients, again like a mechanical valve.

Agh!

Heparin, from what I understand is the IV form of coumadin and is easily reversed with protamine sulfate and is used for patients in the hospital for pretty much the same reasons as coumadin and also acute stroke or heart attack.

Double Agh! No, Triple!

The advantage over coumadin is that heparin has a short half life I think after an hour the PT levels return to normal. Heparing is used as a short term drug until patients can be started on coumadin.

Quintuple Agh! Oh my God! You didn't even read your pharm books before you wrote this!

For example you are on coumadin because a history of stroke.

Now I'm having a stroke! Get me coumadin, or any other inappropriate treatment, quick!

Plavix is used for CAD, PVD or cerebrovascular disease. I see it mostly used after caths when stents are placed or acute heart attacks.

AGHHHHH! Not only did you not look in your books, you didn't even look at eMedincine or UpToDate!

Plavix cannot be reversed because it blocks some sort of receptors on the platelets therefore making them not usable. The treatment for it give the patient a bunch of blood products.

The entire left side of my body is numb.

Finally, it seems like everyone is on ASA nowadays. It is used as prophylaxis for patients at high risk for CAD or strokes. Like patients that have high blood pressure or those with dyslipidemia. It also blocks platelet aggregation by I think changing a conformation of sorts. It is also irreversible and the patients going for surgery will have to stop a few days ahead of time.

Heart beat irregular . . . breathing labored . . . pupils blown . . . dying . . . dying

This is pretty much the down and dirty on these drugs. Other people can chip in.

Okay, I'll "chip in". This post demonstrated several things:

1) When you are a pre-med or med student, be very very wary of giving out medical information. People will listen to you, but that does not make you right. The MEDICAL INFORMATION you posted above is HORRIBLY INCORRECT on multiple levels. If you are a pre-med, I urge you to save this post and review it after you have taken pharm. If you are a med student, you should be embarrassed.

2) Nursing education on pharmacology is woefully inadequate.

3) No one should ever post medical information on SDN. You should immediately remove this post, lest some poor patient google "coumadin" and stumble on this mish-mash of falacies. If it's not down in the next 24hrs, I'm reporting it to the mods with the request that they remove it for you. This post was not referenced, full of horrible errors, and could potentially cause confusion among those outside health care.
 
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albaniandoc

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Dude, at least I offered some help. That's all I got from memory from nursing school a few years back. Like I said, I do not deal with drugs or prescribe them. I work in OR, scrub circulate and assist. This is basically my basic level understanding of these drugs. I never said I was an expert or claimed to be the supreme authority.
But again, at least I took initiative to help the poor guy. You spent more time picking apart my post then offering any actual help. Nice going.
 

albaniandoc

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Agh!



This is a little closer . . .



Agh!



Agh! And you have a self-contradiction in here!



Agh!



Agh!



Double Agh! No, Triple!



Quintuple Agh! Oh my God! You didn't even read your pharm books before you wrote this!



Now I'm having a stroke! Get me coumadin, or any other inappropriate treatment, quick!



AGHHHHH! Not only did you not look in your books, you didn't even look at eMedincine or UpToDate!



The entire left side of my body is numb.



Heart beat irregular . . . breathing labored . . . pupils blown . . . dying . . . dying



Okay, I'll "chip in". This post demonstrated several things:

1) When you are a pre-med or med student, be very very wary of giving out medical information. People will listen to you, but that does not make you right. The MEDICAL INFORMATION you posted above is HORRIBLY INCORRECT on multiple levels. If you are a pre-med, I urge you to save this post and review it after you have taken pharm. If you are a med student, you should be embarrassed.

2) Nursing education on pharmacology is woefully inadequate.

3) No one should ever post medical information on SDN. You should immediately remove this post, lest some poor patient google "coumadin" and stumble on this mish-mash of falacies. If it's not down in the next 24hrs, I'm reporting it to the mods with the request that they remove it for you. This post was not referenced, full of horrible errors, and could potentially cause confusion among those outside health care.


I think the only thing you are offering is sarcasm. What would be your explanation of the question asked ??
 
D

deleted109597

I'll answer for him. If asked by an attending, I would answer it truthfully to the best of my ability.
If asked by someone on the internet as a homework assignment, I would tell him to do it himself. There are ways to look it up that don't involve online journals. I bet wikipedia works just fine for it.
Well what do you know, it does.
 

mjl1717

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I work as a nurse in surgery so my pharmacology is pretty limited right now, since I don't deal with drugs first hand, however I will give it my best shot:

Coumadin, widely used for patients with A fib, PE, DVT or those with mechanical heart valves. There is a scale of INR levels which determines the dosage. I think for mechanical valves is pretty high up there, something like 2.5. You take the drug daily and get INR level constantly to adjust the dosage. Patients are very prone to bruising and bleeding. The drug prevents clotting factors from forming. This way clots don't form. It blocks conversion of several factors in the clotting cascade by inhibiting the final active clotting factor. It is reversed with an injection of Vitamin K. We have to do it once in a while in the hospital when the patients come with GI bleeds. It is used a long term drug for chronic patients, again like a mechanical valve.

Heparin, from what I understand is the IV form of coumadin and is easily reversed with protamine sulfate and is used for patients in the hospital for pretty much the same reasons as coumadin and also acute stroke or heart attack. It falls under platelet aggregation inhibitor. The advantage over coumadin is that heparin has a short half life I think after an hour the PT levels return to normal. Heparing is used as a short term drug until patients can be started on coumadin. For example you are on coumadin because a history of stroke. So you come to the hospital a couple of days early and get started on heparin and stopped on the coumadin. Then you do the procedure and afterwards you can start anticoagulation therapy again.

Plavix is used for CAD, PVD or cerebrovascular disease. I see it mostly used after caths when stents are placed or acute heart attacks. To us Plavix is nasty because causes a lot of bleeding in the OR. Plavix cannot be reversed because it blocks some sort of receptors on the platelets therefore making them not usable. The treatment for it give the patient a bunch of blood products. Under optimal conditions the patient should stop Plavix five days before surgery.

Usually, low molecular weight heparins come in a tiny TB syringe and can be given once daily for prophylaxis, under the skin, after surgery, especially surgical procedures where immobility is expected thus increasing the risk for clots to form. Patients can inject low molecular weight heparin like Lovenox by themselves, so it reduces their hospitalization time.

Finally, it seems like everyone is on ASA nowadays. It is used as prophylaxis for patients at high risk for CAD or strokes. Like patients that have high blood pressure or those with dyslipidemia. It also blocks platelet aggregation by I think changing a conformation of sorts. It is also irreversible and the patients going for surgery will have to stop a few days ahead of time.

This is pretty much the down and dirty on these drugs. Other people can chip in.


you're literally killing us and decreasing our credibility..... [IT AINT law school, over here there could be big time consequences and penalties for false information]
 

georgia_md

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I could use some help with some basic research I'm putting together about how oral anticoagulants are used...

- When in an outpatient setting are oral anticoagulants used?

- Why or in what circumstances are various anticoagulants prescribed? (Why Warfarin over Plavix or vice versa). Basically what criteria are used to decide which anticoagulant to prescribe? I'm assuming the main competitors are warfarin, plavix, aspirin, and heparin?

- When are low molecular weight heparins used over high molecular weight and why?

Any help you can offer on some or all of these questions will be greatly appreciated... Thanks!

There are many factors that affect coagulation. And when I say factors, I really do mean "factors". Theses factors are involved in the two main pathways of coagulation; the intrinsic and the extrinsic. Coumadin affects the extrinsic and heparin affects the intrinsic. The lab test PT/INR is used to measure the effects of coumadin, aka warfarin. For example, when PT/INR is increased, then the the dosage of coumadin is decreased. It's not rocket science.
 
Z

zimmie256

Not homework. As I said, it's for work as my BOSS was the one who needed the info. This was basically something just thrown at me out of the blue on a very busy day at work. I had limited resources and limited time, so I thought perhaps people studying these things would be able to offer a quick answer based on their knowledge and experience.

Thank you for those who did reply with info, I appreciate the gesture and the effort. To those who replied just to criticize me, that's fine. But frankly I don't know why you'd want to take the effort to even reply or why you were so bothered by the question being posted to feel you had to criticize...

And for the person who suggested Wikipedia, I never use Wiki without corroboration. I've caught way too many errors in there about subjects I know very well, so for questions that I don't have the answer to, I'm unwilling to trust it except perhaps as a starting point. For the same reason, I added to my original post to ask for other resources to check in addition to SDN responses.
 

georgia_md

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you're literally killing us and decreasing our credibility..... [IT AINT law school, over here there could be big time consequences and penalties for false information]


I doubt anyone takes any medical "advice" posted on these forums too seriously
 
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DieselPetrolGrl

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- When in an outpatient setting are oral anticoagulants used?

- Why or in what circumstances are various anticoagulants prescribed? (Why Warfarin over Plavix or vice versa). Basically what criteria are used to decide which anticoagulant to prescribe? I'm assuming the main competitors are warfarin, plavix, aspirin, and heparin?

- When are low molecular weight heparins used over high molecular weight and why?

Any help you can offer on some or all of these questions will be greatly appreciated... Thanks


in a outpatient setting oral anticoags are used when you have a risk for thrombosis (and consiquently emboli) the risks would depend on the three factors: stasis, endothelial injury, hypercoag state. I.e if the patient is on bedrest or has prior Hx of thrombus formation and emboization (hx of stoke, mi, dvt).

Warfarin is oral.
Plavix is not an anticoag but an anti-platelet I believe.
Convenience and cost also govern prescription. I.e heparin is taken via IV so warfarin is often used for patients who are released (oral). Also you take the patients Hx intoa account -- some patients are prone to heparin induced thrombocytopenia or have warfarin sensitization (protein C hetrozygotes).
Asprin is a thromboxane inhibitor (A2) so also a anti-platelet not coag casade inhibitor per say.

LMWH have a lower risk for HIT but the risk is not removed. It is used as a initiator Rx pre warfarin (which takes days to drive down vit K and take effect) and in most cases (i.e. malignancy associated hypercoagubility) it is better than heparin unfractionated form.


(dont quote me -- i am not yet dead)
 

Tired

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Dude, at least I offered some help. That's all I got from memory from nursing school a few years back. Like I said, I do not deal with drugs or prescribe them. I work in OR, scrub circulate and assist. This is basically my basic level understanding of these drugs. I never said I was an expert or claimed to be the supreme authority.
But again, at least I took initiative to help the poor guy. You spent more time picking apart my post then offering any actual help. Nice going.

First of all, it is inappropriate to offer medical advice on SDN. By utilizing your position as an RN working in an Operating Room, you set yourself up as an authority on the subject. Your little disclaimers aside ("I do not deal with drugs or prescribe them"), you need to understand that by virtue of the title in your user name, you possess a level of authority in the minds of random internet users who may wander through here. Your post constitutes medical advice that is both false and misleading.

Second, you're right, I picked apart your post and offered zero help whatsoever. That is because I do not give medical information on SDN. I am much closer to being an MD than you are (3mo), but even if I were a practicing Hematologist, I would not offer medical information here. Rule #1 on the first day of medical school: Never give medical advice unless you have seen and examined the patient first. The OP has presented himself as a random guy seeking information for a work-related project. I find that suspect to the extreme, and it is just as likely that he is really a patient seeking information on medications he has been prescribed.

Finally, even if the OP is who he says he is, I still would not offer medical advice. Why? Because forums on SDN appear on Google. That's how I found this site in the first place. Any random patient seeking information on drugs who types in "Coumadin + Heparin" could potentially run across your horribly eroneous post, thereby resulting in misinformation and confusion. You think you were "taking a stab at the question", but a random person who sees your post will take it as medical information from a Registered Nurse.

I will ask once again that you delete your post. If you will, I will delete everything I have written here as well, including this post. Then we can all go about our business as though this never happened.
 

anon-y-mouse

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Dude, at least I offered some help. That's all I got from memory from nursing school a few years back. Like I said, I do not deal with drugs or prescribe them. I work in OR, scrub circulate and assist. This is basically my basic level understanding of these drugs. I never said I was an expert or claimed to be the supreme authority.
But again, at least I took initiative to help the poor guy. You spent more time picking apart my post then offering any actual help. Nice going.

"Helping" someone with WRONG INFORMATION is worse than not helping someone at all. I hope you don't carry this trait through to medical school... I have a few classmates who "help" others with erroneous information all the time, and it drives me insane.

To the original poster, even if it was a "busy day at work", this is information that YOU ARE PAID TO RESEARCH, and you should have discovered the answers for yourself. This is the professional version of getting other people to do your homework for you. :thumbdown: :thumbdown:
 
Z

zimmie256

Well as the OP, I'm happy to say that I have quit my job (not over anticoagulants :laugh: ). So to those who have apparently been so heavily burdened by my asking these questions, don't worry, it won't happen again. :rolleyes: However I see nothing wrong with using peers as a resource or for suggestiong possible sources of information (which frankly, is in large part what SDN is for). Gotta say, I never expected such rancor over a question I thought was no big deal...

But anyway, happy weekend to everybody! I know I don't expect to think about anticoagulants any more on my Saturday night...
 

georgia_md

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Well as the OP, I'm happy to say that I have quit my job (not over anticoagulants :laugh: ). So to those who have apparently been so heavily burdened by my asking these questions, don't worry, it won't happen again. :rolleyes: However I see nothing wrong with using peers as a resource or for suggestiong possible sources of information (which frankly, is in large part what SDN is for). Gotta say, I never expected such rancor over a question I thought was no big deal...

But anyway, happy weekend to everybody! I know I don't expect to think about anticoagulants any more on my Saturday night...


They were trivial questions that any 10 year old can google and find the answers to. SDN is not here to answer homework questions.
 

fakin' the funk

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There are many factors that affect coagulation. And when I say factors, I really do mean "factors". Theses factors are involved in the two main pathways of coagulation; the intrinsic and the extrinsic. Coumadin affects the extrinsic and heparin affects the intrinsic. The lab test PT/INR is used to measure the effectives of coumadin, aka warfarin. For example, when PT/INR is increased, then the the dosage of coumadin is decreased. It's not rocket science.

Apparently, it IS rocket science. :scared:
 

georgia_md

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- When in an outpatient setting are oral anticoagulants used?

- Why or in what circumstances are various anticoagulants prescribed? (Why Warfarin over Plavix or vice versa). Basically what criteria are used to decide which anticoagulant to prescribe? I'm assuming the main competitors are warfarin, plavix, aspirin, and heparin?

- When are low molecular weight heparins used over high molecular weight and why?

Any help you can offer on some or all of these questions will be greatly appreciated... Thanks


in a outpatient setting oral anticoags are used when you have a risk for thrombosis (and consiquently emboli) the risks would depend on the three factors: stasis, endothelial injury, hypercoag state. I.e if the patient is on bedrest or has prior Hx of thrombus formation and emboization (hx of stoke, mi, dvt).

Warfarin is oral.
Plavix is not an anticoag but an anti-platelet I believe.
Convenience and cost also govern prescription. I.e heparin is taken via IV so warfarin is often used for patients who are released (oral). Also you take the patients Hx intoa account -- some patients are prone to heparin induced thrombocytopenia or have warfarin sensitization (protein C hetrozygotes).
Asprin is a thromboxane inhibitor (A2) so also a anti-platelet not coag casade inhibitor per say.

LMWH have a lower risk for HIT but the risk is not removed. It is used as a initiator Rx pre warfarin (which takes days to drive down vit K and take effect) and in most cases (i.e. malignancy associated hypercoagubility) it is better than heparin unfractionated form.


(dont quote me -- i am not yet dead)


Wow, informative post :thumbup: . Reminded me of a time, when I was a medical technologist, and somebody mis-labeled two specimens which were either plasma or serum. I came up with the idea of testing for coag factors; i.e. vitamin K dependant factors. The serum was depleted of it, but the plasma wasn't. I saved the day! I was a hero :D :thumbup:
 

somedude98317

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I work as a nurse in surgery so my pharmacology is pretty limited right now, since I don't deal with drugs first hand, however I will give it my best shot:

Coumadin, widely used for patients with A fib, PE, DVT or those with mechanical heart valves. There is a scale of INR levels which determines the dosage. I think for mechanical valves is pretty high up there, something like 2.5. You take the drug daily and get INR level constantly to adjust the dosage. Patients are very prone to bruising and bleeding. The drug prevents clotting factors from forming. This way clots don't form. It blocks conversion of several factors in the clotting cascade by inhibiting the final active clotting factor. It is reversed with an injection of Vitamin K. We have to do it once in a while in the hospital when the patients come with GI bleeds. It is used a long term drug for chronic patients, again like a mechanical valve.

Heparin, from what I understand is the IV form of coumadin and is easily reversed with protamine sulfate and is used for patients in the hospital for pretty much the same reasons as coumadin and also acute stroke or heart attack. It falls under platelet aggregation inhibitor. The advantage over coumadin is that heparin has a short half life I think after an hour the PT levels return to normal. Heparing is used as a short term drug until patients can be started on coumadin. For example you are on coumadin because a history of stroke. So you come to the hospital a couple of days early and get started on heparin and stopped on the coumadin. Then you do the procedure and afterwards you can start anticoagulation therapy again.

Plavix is used for CAD, PVD or cerebrovascular disease. I see it mostly used after caths when stents are placed or acute heart attacks. To us Plavix is nasty because causes a lot of bleeding in the OR. Plavix cannot be reversed because it blocks some sort of receptors on the platelets therefore making them not usable. The treatment for it give the patient a bunch of blood products. Under optimal conditions the patient should stop Plavix five days before surgery.

Usually, low molecular weight heparins come in a tiny TB syringe and can be given once daily for prophylaxis, under the skin, after surgery, especially surgical procedures where immobility is expected thus increasing the risk for clots to form. Patients can inject low molecular weight heparin like Lovenox by themselves, so it reduces their hospitalization time.

Finally, it seems like everyone is on ASA nowadays. It is used as prophylaxis for patients at high risk for CAD or strokes. Like patients that have high blood pressure or those with dyslipidemia. It also blocks platelet aggregation by I think changing a conformation of sorts. It is also irreversible and the patients going for surgery will have to stop a few days ahead of time.

This is pretty much the down and dirty on these drugs. Other people can chip in.

Nurses are an invaluable asset in medicine. Doctors and patients alike will always need nurses....we are all equal but there are different roles we play. This is a classic example of the difference in roles between docs and nurses...although your intentions are good, these intentions are like those that pave the way to hell....

no fault of your own, but nursing pharmacology is different from medical pharmacology its just not as in depth, you have no business in trying to give this guy sound medical advise no matter how good your intentions are.

although your altruism and nature of wanting to help people in admirable, i think it should be channeled within the realm and scope of your licensed practice, that being NURSING.
 

Tired

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Wow, informative post :thumbup: . Reminded me of a time, when I was a medical technologist, and somebody mis-labeled two specimens which were either plasma or serum. I came up with the idea of testing for coag factors; i.e. vitamin K dependant factors. The serum was depleted of it, but the plasma wasn't. I saved the day! I was a hero :D :thumbup:

You should put this in the "Have you ever saved a life?" thread.
 
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