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Thrombocytopenia And

Thrombocytopenic Purpura

Elisabeth Sosa, MSN, ARNP, AOCNP

Elisabeth Sosa, MSN, ARNP, AOCNP is a certified adult oncology nurse practitioner. She practices within a large private-practice hematology/medical oncology group in Central Florida. She has previously been published in the Clinical Journal of Oncology Nursing (CJON).

ABSTRACT

Thrombocytopenia can occur for a number of different reasons. These include congenital disorders, bone marrow disorders, infectious causes, drug effect, and immunologic causes. The purpose of this course is to provide a brief review of thrombocytopenia, with a focus on idiopathic thrombocytopenic purpura (ITP). The course will discuss the definition of thrombocytopenia, as well as grading the severity. This course will also review complications of thrombocytopenia, including bleeding. Readers are provided with an understanding of how thrombocytopenia and ITP are treated and knowledge of bleeding precautions. Bleeding precautions increase patient safety when the platelet count is dangerously low. It is important that health care personnel have an understanding of thrombocytopenia so that patients can be treated appropriately and complications can be avoided.

KEYWORDS: thrombocytopenia, platelets, hematology, idiopathic thrombocytopenic purpura

Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the policies of and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Pharmacology content is 0.5 hours (30 minutes).

Statement of Learning Need

Nurses are required to be knowledgeable about how thrombocytopenia occurs. ITP, idiopathic thrombocytopenia, is a cause of thrombocytopenia that nurses need to understand and be able to educate patients about in terms of bleeding risk and disease management.

Course Purpose

To help nurses develop an understanding of the treatment of thrombocytopenia, specifically idiopathic thrombocytopenic purpura (ITP), as well as the bleeding precautions in patients with thrombocytopenia.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Elisabeth Sosa, MSN, ARNP, AOCNP, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures.

Acknowledgement of Commercial Support

There is no commercial support for this course.

 

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC.

Release Date: 1/1/2016 Termination Date: 7/14/2017

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

1. Your patient has a platelet count of 7,000. What grade is the

thrombocytopenia?

a) Grade I

b) Grade II

c) Grade III

d) Grade IV

2. Which of the following medications is NOT known to cause

thrombocytopenia?

a) Heparin

b) Lisinopril

c) Penicillin

d) Valproic acid

3. How is ITP diagnosed?

a) Using a special blood test that is sent to a reference lab

b) Bone marrow biopsy

c) It is a diagnosis of exclusion

d) Ultrasound of the abdomen

4. Which of the following is a complication of thrombocytopenia?

a) Intracranial bleeding

b) Anemia

c) GI bleed

d) All of the above

5. Which of the following is NOT known to cause thrombocytopenia?

a) Bone marrow disorder

b) Vitamin D deficiency

c) HIV

d) Rheumatoid arthritis

Introduction

The following case study may be seen in the outpatient primary care setting. The objective of this case study is to illustrate how some patients with thrombocytopenia, specifically idiopathic thrombocytopenic purpura (ITP), may present. Suggestions will be made later in this course on how the patient should be treated, including appropriate diagnostic testing, pharmacological treatment, and supportive care.

Case Study: Mary

| |

|Mary is a 45-year-old female with no significant medical history. She develops symptoms including urinary frequency and pain when |

|urinating. She presents to her primary care physician (PCP) and is diagnosed with a urinary tract infection. After verifying her allergies,|

|the physician prescribes a course of Bactrim for the patient. After several days, Mary’s urinary symptoms resolve. However, she begins to |

|notice bruising on her arms and legs. She has not experienced any trauma to these areas. Mary also has several nosebleeds. |

|Mary returns to her PCP to discuss her new symptoms. A complete blood count (CBC) is drawn and notes a normal white blood cell count (WBC) |

|of 5.4 and normal hemoglobin of 13.1. However, the platelet count is abnormal at 45,000. Mary’s medical records do not show evidence of |

|thrombocytopenia in the past. Mary’s PCP refers her to a hematologist right away for further evaluation of thrombocytopenia. |

Definition of Thrombocytopenia

Platelets are a type of blood cell that are produced in the bone marrow by megakaryocytes. The megakaryocytes inside the bone marrow release platelets, or fragments of cytoplasm, into the bloodstream. Once in the bloodstream, the platelets exist for eight to twelve days. Typically, phagocytes in the spleen remove platelets from the circulation. Approximately one third of platelets are stored in the spleen (Baldwin, 2003).

Normal platelet count is between 150 and 400. Thrombocytopenia is defined as a platelet count less than 150 (Lichtman, Kaushansky, Kipps, Prchal, & Levi, 2011; Winkeljohn, 2013). However, there are varying degrees of thrombocytopenia. Grading is illustrated in Table 1. Platelets play an important role in hemostasis, which is the process of a blood clot being formed from the fluid part of blood. When there is injury to the vessel wall, platelets create a hemostatic plug to stop the bleeding. If there is a problem with platelet production or function, or if platelet destruction is occurring, thrombocytopenia can ensue and lead to significant bleeding complications (Rodriguez & Gobel, 2011).

Table 1. National Cancer Institute Common Terminology Criteria for Adverse Events: Thrombocytopenia

|Grade |

Summary

Thrombocytopenia can occur for many different reasons. It is important that the cause of thrombocytopenia is determined promptly so that patients can be treated appropriately. Thrombocytopenia can lead to bleeding complications, including severe and life-threatening gastrointestinal bleeding and intracranial bleeding. Patients may require platelet transfusions. If blood loss is severe, patients may even require transfusions of packed cells. ITP is a diagnosis of exclusion when other causes of thrombocytopenia are ruled out.

Nurses play an integral role in caring for these patients and keeping them safe. Teaching patients and their families about bleeding precautions often becomes the responsibility of the nurse. Following bleeding precautions and preventing falls can help prevent further harm. As part of the health care team, nurses are in an excellent place to improve patient outcomes.

Please take time to help course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

1. Your patient has a platelet count of 7,000. What grade is the thrombocytopenia?

a. Grade I

b. Grade II

c. Grade III

d. Grade IV

2. Which of the following medications is NOT known to cause thrombocytopenia?

a. Heparin

b. Lisinopril

c. Penicillin

d. Valproic acid

3. Which patient would you LEAST expect to develop

a. 67-year-old female with acute leukemia receiving chemotherapy

b. 25 year old male with no past medical history, no history of infections, and not taking any medications

c. 30 year old female who is 38-weeks pregnant and has proteinuria

d. 55-year-old female with history of chronic alcohol abuse and cirrhosis

4. How is ITP diagnosed?

a. Using a special blood test that is sent to a reference lab

b. Bone marrow biopsy

c. It is a diagnosis of exclusion

d. Ultrasound of the abdomen

5. Which of the following is a complication of thrombocytopenia?

a. Intracranial bleeding

b. Anemia

c. GI bleed

d. All of the above

6. What should your female patient with a platelet count of 5,000 avoid?

a. Shaving her legs with a razor

b. Walking

c. Sexual activity

d. Both A & C are correct choices

7. Which of the following is NOT known to cause thrombocytopenia?

a. Bone marrow disorder

b. Vitamin D deficiency

c. HIV

d. Rheumatoid arthritis

8. In patients with HIT (heparin-induced thrombocytopenia), what should they avoid?

a. Heparin

b. Lovenox

c. Platelet transfusions

d. All of the above

9. You are caring for a patient with ITP. What would be the standard starting dose of prednisone in a patient who weighs 65 kg?

a. 40 mg daily for four days

b. 30 mg twice a day

c. 65 mg daily

d. 65 mg twice a day

10. Your patient with ITP has O negative blood type. Which

treatment is NOT appropriate for this patient?

a. Anti-Rh(D) immune globulin

b. IVIG (intravenous immune globulin)

c. Dexamethasone

d. All of the above treatments are appropriate for the patient

Correct Answers:

1. D. Grade IV

2. B. Lisinopril

3. B. 25 year old male with no past medical history, no history of

infections, and not taking any medications

4. C. It is a diagnosis of exclusion

5. D. All of the above

6. D. Both A & C are correct choices

7. B. Vitamin D deficiency

8. D. All of the above

9. C. 65 mg daily

10. A. Anti-Rh(D) immune globulin

References Section

The reference section of in-text citations include published works intended as helpful material for further reading. Unpublished works and personal communications are not included in this section, although may appear within the study text.

1. Baldwin, P. D. (2003). Thrombocytopenia. Clinical Journal of Oncology Nursing, 7(3), 349- 352.

2. Damron, B. H., Brant, J. M., Belansky, H. B., Friend, P. J., Samsonow, S., & Schaal, A. (2009). Putting evidence into practice: Prevention and management of bleeding in patients with cancer. Clinical Journal of Oncology Nursing, 13(5), 573-583.

3. Lichtman, M. A., Kaushansky, K., Kipps, T. J., Prchal, J. T., & Levi, M. M. (2011). Thrombocytopenia. In J. Shanahan & H. Lebowitz (Eds), Williams manual of hematology eighth edition (pp.554-574). New York: McGraw Hill Medical.

4. National Cancer Institute. (2009). Common terminology criteria for adverse events v4.0 (NIH Publication No. 09-7473). Retrieved from

5. Rodriguez, A. L. & Gobel, B. H. (2011). Bleeding. In C. Yarbro, D. Wujcik, & B. Gobel (Eds.), Cancer Nursing (pp. 745-771). Sudbury, Massachusetts: Jones and Bartlett Publishers.

6. Sanofi-Aventis (2013). Lovenox prescribing information. Retrieved from

7. Shelton, B. K., Griffin, J. M., & Goldman, F. D. (2006). Immune globulin IV therapy: Optimizing care of patients in the oncology setting. Oncology Nursing Forum, 33(5), 911-921.

8. Winkeljohn, D. (2010). Idiopathic thrombocytic purpura. Clinical Journal of Oncology Nursing, 14(4), 411-413.

9. Winkeljohn, D. (2013). Diagnosis, treatment, and management of immune thrombocytopenia. Clinical Journal of Oncology Nursing, 17(6), 664-666.

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