F - Hematological disorders: Thrombocytopenia Wk8

Question 1

Whats Thrombocytopenia?

Answer 1

1. low number of platelets / thrombocytes in the blood
2. <150,000 per microliter
3. platelets are involved in blood clotting -> increased risk of bleeding

Question 2

What are the types of thrombocytopenia?

Answer 2

based on the cause, thrombocytopenia can be subdivided into three main groups.

A. conditions associated with impaired platelet production
1. inherited thrombocytopenia;
2. viral infections, like HIV and HCV infections 3. folate and vitamin B12 deficiencies;

4. aplastic anemia
   - bone marrow suppression -> decreased production of platelets & WBCs & RBCs

B. increased platelet destruction / consumption
- includes non-immune & immune-mediated

Non-immune:
- thrombotic thrombocytopenic purpura TTP
- disseminated intravascular coagulation DIC

2. increased consumption of platelets during formation of abnormal clots
   - fewer platelets left in circulation

immune-mediated thrombocytopenias include heparin-induced thrombocytopenia, or HIT, and immune thrombocytopenic purpura, or ITP
immune-mediated thrombocytopenia, the body produces antibodies that bind platelets and induce their destruction.

C. conditions associated with the impaired distribution of platelets

1. hypersplenism
   - occurs when there’s liver cirrhosis and portal hypertension
   - blood backs up into the spleen -> up to 90 percent of the total platelets can enter -> nearly no platelets left in the blood
2. massive blood transfusions
   - platelet concentration falls
   - large volume transfusions of platelet-free products, like packed RBCs or IVs
   hemodilution = same amount of platelets now circulate in a much larger circulating volum

Question 3

What are the risk factors for developing thrombocytopenia?

Answer 3

1. autoimmune conditions
   - rheumatoid arthritis
   - infections with some strains of E. coli that can cause HUS
2. cancers
3. alcohol
4. use of medications like aspirin and heparin.

Question 4

Whats the pathology of thrombocytopenia?

Answer 4

1. difficult to form platelet plug at the site of injury -> increased risk of bleeding
   - if bleeding occurs, takes more time to stop
2. can cause life-threatening complications if not recognised in time -> might experience spontaneous bleeds
3. for clients with thrombotic thrombocytopenic purpura, platelets tend to aggregate excessively at abnormal sites -> microthrombi -> thrombosis-related complications like DVT, pulmonary embolism, organ infarctions, or stroke

Question 5

What are the clinical manifestations of thrombocytopenia?

Answer 5

1. bruising easily after minor trauma
2. mucosal bleeding, like gingival bleeding or nosebleeds
3. cutaneous bleeding
   - can manifest as petechiae: pinpoint superficial skin bleeds
   - purpura, or coalesced petechiae
4. ecchymoses, which are even larger areas of accumulated blood.

Patients with TTP are at a higher risk of thrombosis so they might have a stroke with symptoms like headaches,
changes in vision,
unilateral weakness or paralysis of face, arm or leg,
difficulty talking or swallowing, and confusion
at a higher risk of pulmonary embolism and have symptoms like chest pain and shortness of breath.

Question 6

Whats the treatment of thrombocytopenia?

Answer 6

in thrombotic thrombocytopenic purpura
1: plasma exchange

heparin-induced thrombocytopenia:
1. discontinuation of the medication
2. administration of a direct thrombin inhibitor, like dabigatran or argatroban.

immune thrombocytopenic purpura:
1. 1st line: glucocorticoids
2. IV immunoglobulins
- If both treatments fail, undergo splenectomy / removal of the spleen

no matter the cause:
- platelet transfusion is indicated in all clients with a severe hemorrhage or platelet count below 10,000/microliter

Question 7

Diagnosis of thrombocytopenia?
USE CONTENT FROM DR TANUSHRIS LECTURE

Answer 7

starts with the client’s medical history and physical assessment.

CBC reveals a platelet count below 150,000/microliter.

Coagulation studies can also be done, but it’s important to remember that with thrombocytopenia, prothrombin time and partial thromboplastin time are normal
- test gives information regarding secondary hemostasis, not platelet plug formation. A peripheral blood smear usually reveals scarce platelets
fecal occult blood testing and urinalysis can reveal blood in the stool or the urine

a bone marrow biopsy
reveal abnormal megakaryocytes = platelet problems / scarce amounts of all blood cells and their precursors, in aplastic anemia

immune-mediated thrombocytopenia, detection of autoimmune antibodies

Question 8

What is the nursing care you’ll be providing for clients with thrombocytopenia?

Answer 8

A. prevention and early detection of bleeding
- avoid IM and subcutaneous injections
- If must do subcutaneous injection, use a small gauge needle & apply pressure on the injection site for 5 to 10 minutes after
- avoid rectal temperatures to avoid trauma to rectum
- limit use of automatic blood pressure cuffs to prevent capillary breakage and bruising
- fall precautions to keep them safe from injury.

2. intervene when bleeding occurs
   - place direct pressure to the site for 10 minutes.

report to HCP:
- if bleeding continues after pressure is applied
- they develop signs and symptoms of hemorrhage like tachycardia, hypotension, headache, vision changes, or altered mental status
- if their platelet levels continue to decrease

Answer 8

client and family teaching. Begin by explaining that platelets are necessary to form blood clots, and since their platelet count is low, they’ll need to take precautions to prevent bleeding.

Review your client’s plan of care and the lifestyle changes they’ll need to implement to decrease the risk of bleeding. Instruct them to avoid medications that can prolong bleeding, like aspirin and NSAIDs, and advise them to always check with their healthcare provider before starting a new medication or supplement. Then, talk to them about the importance of avoiding activities that put them at risk for injury, like contact sports, biking, and ice skating, and suggest low impact alternatives like walking, swimming, and yoga.

Also, remind them to take extra care when using sharp objects like scissors, knives, and other tools, and teach them to use an electric razor for shaving. Also, talk to them about the importance of using a soft toothbrush, to avoid alcohol based mouthwashes that can dry their gums, and to talk to their healthcare provider before dental cleanings.

Lastly, explain how avoiding constipation can help prevent rectal bleeding, and review ways they can promote regular elimination by staying well hydrated, including plenty of fiber in their diet, engaging in daily physical activity, using the prescribed stool softener as directed, and to avoid the use of suppositories or enemas.

Next, teach them to avoid blowing their nose forcefully or scratching inside their nose to prevent nose bleeds. If they do get a nose bleed, inform them to sit down, lean forward, and apply firm pressure to the nostrils and the bridge of the nose.

If your client menstruates, explain that they need to avoid the use of tampons, and encourage them to keep track of the number of pads they use with each monthly period. If they feel they are bleeding more than normal, instruct them to notify their healthcare provider.

Finally, review symptoms of bleeding that require them to contact a healthcare provider, like if they notice blood in their urine, stool, vomit, or sputum; or if they experience sudden weakness and fatigue, difficulty talking, confusion, headache, or changes in vision. Lastly, emphasize the importance of keeping all of their appointments with their healthcare provider to monitor their lab values and prevent complications.