Thrombocytopenia is characterized by a low platelet count, measuring below 150,000/mm³ (150 – 400 x10⁹/L). A normal platelet count is 150,000 – 400,000/mm³. Platelets are blood cells that aid in coagulation efforts for normal blood clotting. Low platelet counts increase the risk of bleeding.
Thrombocytopenia occurs when the bone marrow doesn’t make enough platelets, such as with leukemia or other blood cancers. Platelets may also be destroyed by some disease processes. The spleen may also cause thrombocytopenia, as this organ stores one-third of the body’s platelets. The spleen may hold on to too many platelets.
There are different types of thrombocytopenia which include the following:
- Immune thrombocytopenia (ITP) – This is the most common acquired thrombocytopenia and is characterized by the irregular destruction of platelets, often related to autoimmune diseases that cause the body to destroy its own platelets.
- Thrombotic thrombocytopenic purpura (TTP) – This is a rare condition characterized by thrombocytopenia, hemolytic anemia, fever (in the absence of infection), neurologic abnormalities, and renal abnormalities. This condition causes microthrombi to deposit in the capillaries and arterioles, using up large amounts of platelets.
- Heparin-induced thrombocytopenia (HIT) – This condition is characterized by the development of thrombocytopenia 2 to 10 days after the initiation of heparin therapy. This condition causes platelet destruction and vascular endothelial injury due to an immune response to heparin.
Other causes of thrombocytopenia may include:
- Pregnancy
- Bacteremia
- Viral infections
- Exposure to toxins
- Excessive alcohol consumption
- Chemotherapy
In most cases, thrombocytopenia is asymptomatic. But, the most common clinical manifestation is bleeding in the mucosal or cutaneous membranes. Bleeding can manifest as nosebleeds, gingival bleeding, and bleeding into the skin in the form of petechiae, purpura, and superficial ecchymoses. Severe drops in platelets below 10,000/mm³ can result in internal hemorrhaging causing death.
Thrombocytopenia can be confirmed with a regular blood test. The patient’s medical history and clinical examination can help determine the cause of thrombocytopenia.
Nursing Process
Interprofessional and nursing care for patients diagnosed with thrombocytopenia will mainly depend on the cause of the condition. In some cases, treating the underlying disorder may be sufficient to manage the condition. Nurses are primarily responsible for the prevention of bleeding, the early recognition of the signs of bleeding, and prompt intervention for its management. Patient education is also important to help the patient, and family members understand the disease process, promptly report any complications, and initiate interventions to help prevent complications.
Nursing Care Plans Related to Thrombocytopenia
Risk for Bleeding
Thrombocytopenia is characterized by a low platelet count, increasing the patient’s susceptibility to bleeding and bruising.
Nursing Diagnosis: Risk for Bleeding
Related to:
- Disease process
- Low platelet count
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at the prevention of signs and symptoms.
Expected outcomes:
- The patient will remain free from any signs and symptoms of bleeding
- The patient’s platelet count will remain within therapeutic limits
Assessment:
1. Perform a thorough physical examination.
Physical assessment can help detect signs and symptoms of bleeding in patients with thrombocytopenia. Watch for signs of bleeding, including epistaxis, gum bleeding, and bruises.
2. Assess vital signs.
Excessive bleeding can cause hypotension, tachycardia, and mental status changes.
3. Monitor lab values.
A complete blood count should be obtained, and red blood cells, hemoglobin, hematocrit, and platelet counts should be assessed.
Interventions:
1. Continuously monitor coagulation values.
If the patient receives IV heparin therapy, the aPTT and PT values should be monitored per facility guidelines. If these values are out of therapeutic range, bleeding may occur.
2. Provide antidotes as necessary.
Reversal agents such as protamine sulfate for heparin and vitamin K for warfarin may be necessary for excessive bleeding.
3. Review and identify medications that can increase the risk of bleeding.
Medications, including aspirin, NSAIDs, anticoagulants, and other alternative supplements, can increase the risk of bleeding.
4. Provide medications as ordered.
Steroids can increase the platelet count. Immunoglobulins can stop the immune system from destroying platelets, and other medications can help boost platelet production.
5. Prepare and assist in platelet transfusion.
Patients with critically low platelets are often transfused with blood products to boost and correct the platelet count.
6. Use care with invasive procedures.
Patients may still require IV insertion, IM injections, or other invasive procedures. Remember that needles can cause prolonged bleeding and to hold pressure on the area for as long as possible to allow the blood to clot.
Risk for Deficient Fluid Volume
Deficient fluid volume can occur in patients with thrombocytopenia due to bleeding. Patients with low platelet count will have difficulty forming blood clots and are at risk for bleeding.
Nursing Diagnosis: Risk for Deficient Fluid Volume
Related to:
- Excessive bleeding
- Poor coagulation
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at the prevention of signs and symptoms.
Expected outcomes:
- The patient will remain free of signs of bleeding, as evidenced by vital signs within normal limits
- The patient will exhibit hemoglobin and hematocrit values within therapeutic limits
Assessment:
1. Assess and monitor vital signs.
Alterations in vital signs like decreased blood pressure can indicate possible bleeding and fluid loss.
2. Assess laboratory values.
Blood test results, specifically low hematocrit and hemoglobin levels, can indicate blood loss.
Interventions:
1. Monitor the patient’s intake and output.
Maintaining accurate records of the patient’s intake and output can help monitor the patient’s fluid volume and hydration status.
2. Administer fluid replacement as indicated.
Fluid replacement promotes better blood circulation and can help replenish fluid loss.
3. Provide blood transfusions as ordered.
Transfusion of blood products, including packed red blood cells, platelets, and plasma, may be indicated for patients with excessive bleeding to increase the intravascular volume.
4. Educate the patient on the signs and symptoms of bleeding.
Fluid loss due to bleeding can occur anytime. Patient education is vital to ensure that the patient is aware of the signs and symptoms of bleeding and possible complications.
Deficient Knowledge
Patient education is an integral part of the management of thrombocytopenia. Lifestyle modifications are needed to prevent bleeding. A thorough understanding of the disease process is key to adherence to the treatment regimen.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Misinformation
- Inadequate information
- Inadequate commitment to learning
- Inadequate interest in learning
- Inadequate participation in care planning
As evidenced by:
- Incorrect verbalization of the disease process
- Inaccurate follow-through of instructions
- Inadequate adherence to lab testing
- Development of severe bleeding
Expected outcomes:
- The patient will verbalize understanding of the disease process, prognosis, and treatment recommendations
- The patient will implement two strategies to prevent bleeding
Assessment:
1. Assess the patient’s knowledge about thrombocytopenia.
Determining the patient’s knowledge about the condition can help determine interventions for care and additional information needed for patient education.
2. Determine learning methods.
Information will be successfully received if presented in the way the patient learns best, such as through written, visual, or auditory forms.
Interventions:
1. Educate the patient on bleeding precautions.
- Use caution with sharp objects
- Only use electric razors
- Brush the teeth gently
- Avoid aspirin-containing medications
The patient should also not strain with bowel movements or insert anything rectally to prevent damaging the mucosal lining and causing internal bleeding.
2. Encourage lifestyle modifications.
Lifestyle modifications, including avoidance of risk-taking behaviors such as dangerous sports that may lead to injury, can help lower the risk of bleeding complications.
3. Educate the patient about signs of possible thrombocytopenic complications.
Early detection of signs and symptoms like easy bruising, sudden bleeding with unknown cause, blood in the urine or stool, bleeding in the gums and nose, and neurologic symptoms can indicate complications and progression of the disease. These signs and symptoms must be reported for prompt management.
4. Educate on the need for splenectomy.
The removal of the spleen may be required for immune thrombocytopenia (ITP) or when other treatments have failed. The spleen plays a role in immune function, so the patient will need to take extra precautions to prevent infections.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Platelet Disorders. Thrombocytopenia. Updated: March 24, 2022. National Heart, Lung, and Blood Institute. From: https://www.nhlbi.nih.gov/health/thrombocytopenia
- Thrombocytopenia. Cleveland Clinic. Reviewed: October 20, 2022. From: https://my.clevelandclinic.org/health/diseases/14430-thrombocytopenia
- Thrombocytopenia (low platelet count). Mayo Clinic. Reviewed: April 19, 2022. From: https://www.mayoclinic.org/diseases-conditions/thrombocytopenia/symptoms-causes/syc-20378293
- Thrombocytopenia (Low Platelet Count). Stephanie Watson. WebMD. Reviewed: April 19, 2022. From: https://www.webmd.com/a-to-z-guides/thrombocytopenia-causes-treatment
