Chapter 32: Idiopathic Thrombocytopenia Purpura (ITP) (Children)

Question 1

Immune Thrombocytopenia (ITP)

Answer 1

cause is unknown

• disorder of increased platelet destruction caused by antiplatelet antibodies
• these antiplatelet antibodies attach to the child’s own platelets, and the body’s immune system eliminates the platelets, erroneously identifying them as bacteria

Question 2

Characteristic Features

Answer 2

• thrombocytopenia (abnormal decrease in the number of blood platelets)
• purpura (discoloration caused by hemorrhage beneath the skin)

Question 3

How is ITP Classified?

Answer 3

by duration; lasting a few months to a year or chronic, lasting longer than a year

Question 4

Chronic Immune Thrombocytopenia

Answer 4

lasts longer than 12 months

Question 5

Signs and Symptoms

Answer 5

clinical presentation of ITP is generally a previously healthy child who may have had a recent viral infection

• petechiae
• bruising
• mucocutaneus bleeding
• epistaxis
• menorrhagia
• internal bleeding such as a intracranial hemorrhage (rare)

Question 6

Diagnosis

Answer 6

• hx and physical exam
• mostly appear healthy, with the exception of bruising and bleeding
• no tests confirm diagnosis
• newly diagnosed ITP is often benign, self-limiting, and often occurs in children younger than 10 after an upper respiratory infection; after childhood diseases such as measles, rubella, mumps, and chickenpox; and even after infection with parvovirus B19

Question 7

Diagnosing Idiopathic (immune) Thrombocytopenia Purpura

Answer 7

-no definitive tests to establish the diagnosis
-other disorders such as lupus, leukemia, and lymphoma must be ruled out
>numerous tests to confirm diagnosis:
-CBC and peripheral smear examination, coagulation analysis, and possible bone marrow aspirate to rule out underlying malignancy
>CBC often shows isolated and usually severe thrombocytopenia (platelet count of less than 20,000)
>Peripheral smear is often normal with the exception of thrombocytopenia with normal-size to large platelets

Question 8

Normal Platelet Count vs Thrombocytopenia

Answer 8

• CBC will often show severe thrombocytopenia: platelet count less than 20,000
• Normal: 150,000 to 400,000

Question 9

Nursing Care

Answer 9

-most patients with acute ITP may have spontaneous resolution with no tx
-tx for ITP among pediatric hematologists is not consistent
>General Guidelines:
-children who have a platelet count greater than 20,000 and are asymptomatic do not require treatment and platelet counts are monitored
-small toddlers and active children with bruising and petechiae with platelet counts less than 20,000 are treated aggressively to avoid the most serious complication of a life-threatening intracranial bleed
-unless severe life-threatening bleeding is present, transfusion of platelets is not recommended to treat acute ITP because the antibodies attach to the infused platelets and destroy the new platelets in a similar fashion as the destruction of the patient’s own platelets

Question 10

General Guidelines to Follow for Treatment

Answer 10

• children who have a platelet count greater than 20,000 and are asymptomatic do not require treatment and platelet counts are monitored
• small toddlers and active children with bruising and petechiae with platelet counts less than 20,000 are treated aggressively to avoid the most serious complication of a life-threatening intracranial bleed
• unless severe life-threatening bleeding is present, transfusion of platelets is not recommended to treat acute ITP because the antibodies attach to the infused platelets and destroy the new platelets in a similar fashion as the destruction of the patient’s own platelets

Question 11

Medical Care

Answer 11

-steroid administration
-intravenous immune gamma globulin (IVIG)
-anti-D antibody (WinRho SDF)
>children with low platelet counts and acute bleeding require inpatient hospitalization and close observation b/c of potential of a cerebrovascular bleed
>my also receive a 2 to 3 day course of IVIG intravenously; IVIG is to prevent antibody attachment to the platelets, thereby preventing platelet destruction in the spleen; see a rise in platelet cunts within 48 hours
>inpatient care includes bedrest, monitoring of vital signs and adverse reactions during IVIG therapy and daily blood counts

Question 12

Administration of IV anti-D antibody

Answer 12

newest treatment for acute ITP with an Rh(D)-positive blood type
-action: to bind to the RBCs, which are selectively destroyed in the spleen of instead platelets
-the anti-D antibody coats the Rh(D)-positive RBCs with antibody, only for Rh(D)-positive patients
-the anti-D coated cells saturate the capacity of the spleen receptors, and the platelets are spared
>side effect: hemolytic anemia that often resolves as the IgG disperses; other side effects: fever, chills, or headache after infusion)

Question 13

Immune Gamma Globulin (IVIG)

Answer 13

used to prevent antibody attachment to the platelets, thereby preventing platelet destruction in the spleen

• rise in platelet count within 48 hours
• care includes bedrest, monitoring of vital signs and adverse reactions to IVIG, and daily blood counts

Question 14

Surgical Care: Splenectomy

Answer 14

for whom medical tx has failed and there have been acute life-threatening bleeding episodes

• must be older than 5 years old
• have low platelet counts that impact their activities of daily living

Question 15

Post-operative Nursing Care

Answer 15

• monitoring vital signs as per policy until condition stabilized
• administering IV fluids, pain medications, and antibiotics if ordered
• assessing surgical site for the signs and symptoms of bleeding or infection
• monitoring intake and output

Question 16

Institutional Guidelines r/t Intravenous Immune Gamma Globulin (IVIG)

Answer 16

is a blood product and may require informed consent base don institutional guidelines

• this plasma-based product is derived from multiple donors and has the potential to transmit infectious diseases
• during administration of this blood, frequent vital sign are monitored to observe for possible adverse reactions, such as fever, chills, hypotension, nausea, and headache
• safe administration must include product-specific information for administration guidelines such as administration rates

Question 17

Education/Discharge

Answer 17

• Important: SAFETY
• restrict activities such as contact sports and high-risk activities such as bicycle riding, roller skating, and riding motor scooters
• instructed how to maintain bleeding at home
• most common sites of bleeding: minor cuts, scrapes, nosebleeds
• apply pressure to the injury site
• if bleeding from nose, have the child lean down and forward, pinch the bridge of nose, and apply ice
• for severe bleeding that does not stop with pressure, seek medical attention
• avoid acetylsalicylic acid (Children’s Aspirin) or other aspirin-containing products, injections, use of straight-edge razors, tampons, or inserting a thermometer or suppository into the rectum
• report s/s of bleeding immediately
• provide a safe environment to prevent trauma such as using a nail file as opposed to clippers
• wear a medical alert bracelet with chronic ITP

Question 18

What Children should Avoid With ITP

Answer 18

• acetylsalicylic acid (Children’s Aspirin) or other aspirin-containing products
• injections
• straight-edge razors
• tampons
• rectal thermometer or suppository

Question 19

How to take care of a nosebleed

Answer 19

have the child lean down and forward, pinch the bridge of the nose, and if possible, apply ice

Question 20

Most Serious Complication of ITP

Answer 20

Intracranial Bleed
>must report changes in:
-level of consciousness or behavior
-severe headaches
-vision changes, 
-ataxia (loss of coordination of voluntary muscle movements)
-slurred speech
-complaints of weakness or numbness
-severe vomiting not associated with nausea