1. Thrombocytopenia Chapter 31 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

3. Normal Hemostasis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

4. Nursing Management Nursing Assessment Past Health History Medications Functional Health Patterns Objective data Fever, lethargy, bleeding, splenomegaly, abdominal distention Lab data Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

5. Etiology and Pathophysiology of Thrombocytopenia Reduction of platelets Results in abnormal hemostasis Prolonged or spontaneous bleeding Diagnostic Studies ↓ Platelet count Normal 150,000-300,00 depending on the lab Prolonged bleeding < 50,000/μL Hemorrhage ↓ 20,000/μL Peripheral blood smear Medical history Clinical examination Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

6. Thrombocytopenia Clinical Manifestations Patients are often asymptomatic. Most common symptom is mucosal or cutaneous bleeding. Petechiae – microhemorrhages Purpura – bruise from numerous petechiae Ecchymoses – larger lesions from hemorrhage Prolonged bleeding after routine procedures Internal bleeding may manifest as weakness, fainting, dizziness, tachycardia, abdominal pain, or hypotension. Hemorrhage is a major complication. Insidious or acute Internal or external Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

7. Causes of Thrombocytopenia Inherited Acquired Immune thrombocytopenia purpura (ITP) Thrombotic thrombocytopenia purpura (TTP) Heparin-induced thrombocytopenia (HIT) Collaborative Care Based on etiology of the disorder Removal or treatment of the underlying cause or disorder may be sufficient. Avoid aspirin and other medications that affect platelet function or production. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

8. Nursing Management Thrombocytopenia Nursing Implementation Avoid IM injections. If subcutaneous injection is unavoidable, use small-gauge needles and application of pressure or ice packs after. Teach home self-care measures to reduce risks that could cause bleeding such as items around the house, kitchen, bathroom, etc. Ambulatory and home care Monitor patients for response to therapy. Teach avoidance of causative agents, trauma, and injury. Teach clinical signs and symptoms of bleeding. Encourage regular medical exams. Manage quality of life issues. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

9. Immune Thrombocytopenic Purpura (ITP) Collaborative Care Therapy initiated if platelets ↓ 30,000/μL Corticosteroids Alters spleen’s recognition of plts and increases life span of plts Depress antibody formation. Reduce capillary leakage Splenectomy Effectiveness of splenectomy Spleen stores about 1/3 of the body’s platelets, so its removal increases the number of platelets in circulation. Good or bad? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

10. Immune Thrombocytopenic Purpura (ITP) Collaborative Care Platelet transfusions Used to increase platelet counts in life-threatening hemorrhage Never used prophylactically because of antibody formation Indicated for platelet count < 10,000/μL or if bleeding is anticipated before a procedure Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

11. Immune Thrombocytopenic Purpura (ITP) Most common acquired thrombocytopenia Syndrome of: abnormal destruction of circulating platelets Primarily an autoimmune disease Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

12. Thrombotic Thrombocytopenic Purpura (TTP) Called TTP-HUS as it is most always associated with Hemolytic-Uremic Syndrome Associated with enhanced aggregation of platelets that form into microthrombi Medical emergency Bleeding and clotting occur simultaneously. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

13. Thrombotic Thrombocytopenia Purpura (TTP) Collaborative Care First treat underlying disorder or remove cause. Plasmapheresis is used to aggressively reverse platelet consumption. Continued daily until platelet counts normalize and hemolysis has ceased Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

14. Polycythemia Production and presence of increased numbers of RBCs. Hypervolemia and hyperviscosity of blood can occur 2 types (Primary) Polycythemia vera Secondary Polycythemia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

15. Polycythemia Primary (vera) – chronic disorder. RBC, WBC and Plts involved, leading to increased production of all cells. Median age is 60 yrs of age. Enhanced viscosity and blood volume congests organs and tissues with blood. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

16. Polycythemia Secondary- hypoxia driven or hypoxia independent. Driven– hypoxia stimulates the EPO (erythropoietin) production in kidneys and stimulates RBC production. Need forO2 could be caused by high altitude, cardiac disease, lung disease or hypoxia. Hypoxia independent- EPO is produced by a malignant or benign tumor tissue in kidneys. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

17. Polycythemia Clinical Manifestations: HA, vertigo, dizziness, tinnitus, generalized pruritus, paresthesia and erythromelalgia. Cardiac symptoms such as angina, heart failure, and thromboembolism can occur. Collaborative Care- Reduce blood volume and viscosity by phlebotomy. Usually remove 300-500ml of blood every 2-3 months Assess I&O, IV fluids, nutritional status and c/o pain. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

18. Hemophilia X-linked genetic disorder caused by defective or deficient coagulation factors. Lifelong, hereditary, no cure Any bleeding episode can lead to a life threatening hemorrhage Anemia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

19. Hemophilia- Clinical manifestations Slow persistent bleeding from minor trauma or cuts Delayed bleeding from minor injuries or losing baby teeth Uncontrollable hemorrhage from dental surgery Epistaxis- blow to the face GI bleeding, ulcers or gastritis Hematuria, poss renal failure from GU trauma Splenic rupture from falls or abdominal trauma Ecchymoses and subq hematomas Hemiarthrosis- bleeding into joints Pain to paralysis from nerve compression from hematoma formation All can lead to hemorrhage Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

20. Hemophilia Usually first found after circumcision, prolonged bleeding Bleeding after tissue trauma- (boys, sports)- hemiarthrosis ( stiff, painful) is an emergency Do not give aspirin, aspirin containing products or NSAIDS to these pts Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

21. Hemophilia- Collaborative Care Preventive Care Non contact sports, soft toothbrushes, electric razors, etc. Treatment of complications of the disease Replacement therapy during acute episode Clotting factors, (VIII, IX) Antifibrinolytic therapy DDAVP (stimulates increase in factor VIII) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.