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INTRODUCTION

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HIGH ALERT

dalteparin (dal-te-pa-rin)

Fragmin

Classification

Therapeutic: anticoagulants

Pharmacologic: antithrombotics

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Indications
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Prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) in surgical or medical patients. Prevention of ischemic complications (with aspirin) in patients with unstable angina, non–Q–wave MI. Unlabeled Use: Systemic anticoagulation for other diagnoses.

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Action
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Potentiates the inhibitory effect of antithrombin on factor Xa and thrombin. Therapeutic Effects: Prevention of thrombus formation. Decreased incidence of death or recurrent MI.

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Adverse Reactions/Side Effects
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CNS: dizziness. GI: reversible increase in liver enzymes. Hemat: BLEEDING, thrombocytopenia.

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PHYSICAL THERAPY IMPLICATIONS

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Examination and Evaluation
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  • Assess for signs of bleeding and hemorrhage, including bleeding gums, nosebleeds, unusual bruising, black/tarry stools, hematuria, and a fall in hematocrit or blood pressure. Notify physician or nursing staff immediately if dalteparin causes excessive anticoagulation.

  • Monitor symptoms of DVT (pain, swelling, warmth, redness) to determine if drug therapy is effective in preventing or reducing venous thrombosis. Request or administer objective tests (Doppler ultrasound) if symptoms increase.

  • In patients with DVT, watch for signs of pulmonary embolism (shortness of breath, chest pain, cough, bloody sputum). Notify physician or nursing staff immediately if these signs occur.

  • Be alert for acute arterial or venous thrombosis caused by heparin-induced thrombocytopenia (HIT). Although the risk of HIT is lower compared with traditional heparin, dalteparin may initiate an immune reaction in certain patients where antibodies attack circulating platelets. Although most cases of HIT are minor and asymptomatic, some patients may experience life- or limb-threatening platelet clots, resulting in MI, ischemic stroke, acute leg ischemia, or venous thromboembolism. HIT can occur during and up to several weeks after heparin therapy. Any signs of increased clotting should be reported immediately.

  • Assess dizziness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician and nursing staff, and caution the patient and family/caregivers to guard against falls and trauma.

  • Assess injection site for pain, swelling, and irritation. Report prolonged or excessive injection-site reactions to the physician or nursing staff.

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Interventions
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  • Use caution with any physical interventions that could increase bleeding, including wound débridement, chest percussion, joint mobilization, and application of local heat.

  • Recommend or implement other physical methods to decrease DVT and prevent thromboembolism, including graduated compression stockings and intermittent pneumatic compression pumps.

  • Implement early mobilization and ambulation to reduce the risk of new or increased DVT. Early ambulation appears to be safe in patients with DVT if the patient is adequately heparinized (INR values in acceptable range), does not have an active pulmonary embolism, or have other risk factors that contraindicate ambulation.

  • Use caution during aerobic exercise and other forms of therapeutic exercise in patients with unstable angina or MI. Assess exercise tolerance frequently (blood ...

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