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Thrombocytopenia

& ITP

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 Director & Planners:

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

Susan DePasquale, CGRN, MSN, FPMNHP-BC, Lead Nurse Planner

Accreditation Statement:

NurseCe4Less.com is accredited as a provider of continuing nursing

education by the American Nurses Credentialing Center's Commission on

Accreditation.

Credit Designation:

This educational activity is credited for 1.5 hours. Pharmacology content is

15 minutes. Nurses may only claim credit commensurate with the credit

awarded for completion of this course activity.

Course Author & Planner Disclosure Policy Statements:

It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and

best practice in clinical education for all continuing nursing education (CNE)

activities. All authors and course planners participating in the planning or

implementation of a CNE activity are expected to disclose to course

participants any relevant conflict of interest that may arise.

Statement of 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.

Learning Objectives:

1. Define thrombocytopenia (mild, moderate, severe)

2. Recognize causes of thrombocytopenia

3. Identify complications of thrombocytopenia

4. Discuss several treatment options for ITP

5. Discuss various bleeding precautions that patients should follow

Target Audience:

Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical

Nurses, and Nursing Associates

Course Author & Director Disclosures:

Elisabeth Sosa, MSN, ARNP, AOCNP, William S. Cook, PhD,

Douglas Lawrence, MS, Susan DePasquale, CGRN, MSN, FPMHNP-BC –

all have no disclosures.

Acknowledgement of Commercial Support: None exists.

Activity Review Information:

Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC.

Release Date: 7/14/2014 Termination Date: 7/14/2017

Please take time to complete the self-assessment Knowledge 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. Which patient would you LEAST expect to develop

thrombocytopenia?

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


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 1 2 3 4 5

<LLN-

75,000/mm^3

<75,000-

50,000/mm^3

<50,000-

25,000/mm^3

<25,000/mm^3 -

LLN- lower limit of normal. (National Cancer Institute, 2009)


Causes of thrombocytopenia

There are many reasons why a low platelet count may be noted on lab work.

While the focus of this course is ITP, it is important to have an

understanding of other causes of thrombocytopenia, as ITP is a diagnosis of

exclusion. For example, psuedothrombocytopenia may occur. This happens

when platelets clump together and give a falsely low platelet count. The

platelets can clump when they are placed in lavender EDTA

(ethylenediaminetetraacetic acid) tubes. It is important to recollect the sample

in a blue sodium citrate tube to determine if the patient does in fact have

thrombocytopenia. Dilutional thrombocytopenia can occur when a patient

receives a large number of red blood cell transfusions.

Normally, the patient would need to have received more than 15 to 20

transfusions in a 24-hr period for this phenomenon to occur. Distributional

thrombocytopenia occurs when a large percentage of platelets are stored in

the spleen instead of in circulation. This is seen in patients with

splenomegaly, cirrhosis, and portal hypertension. While the actual number of

platelets is normal, the peripheral count is low and this will be noted as

thrombocytopenia on the CBC. Bleeding is uncommon in this case (Baldwin,

2003; Lichtman et al., 2011).

MAJOR CAUSES OF THROMBOCYTOPENIA

The major causes of thrombocytopenia are noted below and will be

discussed in more detail in the following paragraphs.

Reduced platelet production

Increased platelet destruction

As mentioned previously, platelets are produced in the bone marrow. If

cancer penetrates the bone marrow, such as in leukemia, lymphoma,


metastatic cancer with bone involvement, or multiple myeloma, platelet

production suffers. In oncology patients being treated with radiation therapy

in which the radiation field involves large amounts of bone marrow, platelet

production also diminishes. Certain drugs can also affect platelet production

(see below).

Certain viral infections, such as rubella, mumps, Epstein-Barr,

cytomegalovirus, HIV, and varicella, can also inhibit platelet production. This

can also happen in patients with typhus and Rocky Mountain spotted fever.

Chronic alcohol abuse and illicit drug use also affect platelet production. In

addition, patients with vitamin B12, folate, and/or iron deficiency may also

have thrombocytopenia. These substances are necessary for normal bone

marrow function (Baldwin, 2003; Lichtman et al., 2011).

Increased destruction of platelets can happen for many different reasons,

but can be categorized into immunologic and nonimmunologic reasons.

Immunologic destruction occurs due to antibodies. Sometimes this happens

because of autoantibodies. This is noted in chronic lymphocytic leukemia,

systemic lupus erythematosus, rheumatoid arthritis, thyroiditis,

inflammatory bowel disease, and autoimmune hemolytic anemia. On the

other hand, thrombocytopenia can take place due to alloantibody-mediated

destruction. This is seen after transfusions and bone marrow/stem cell

transplantation. This is also seen in pregnancy, such as with preeclampsia,

eclampsia, gestational thrombocytopenia, and HELLP syndrome (hemolysis,

elevated liver tests and low platelet count). Immunologic platelet destruction

is also noted in septic patients. A number of drugs can also lead to platelet

destruction (Baldwin, 2003; Lichtman et al., 2011).

Nonimmunologic causes of platelet destruction also contribute to

thrombocytopenia. This is seen in disseminated intravascular coagulation

(DIC), thrombotic thrombocytopenic purprura (TTP), hemolytic uremic


syndrome, and sepsis. In patients on cardiopulmonary bypass, the machine

may physically damage platelets (Baldwin, 2003).

DRUGS THAT MAY CAUSE THROMBOCYTOPENIA

Medications that may cause thrombocytopenia are listed below (Baldwin,

2003; Lichtman et al., 2011):

Drugs affecting platelet production:

Chemotherapy

Estrogen

Anticonvulsants

Thiazide diuretics

Drugs causing platelet destruction:

Heparin (Heparin-Induced Thrombocytopenia HIT)

Barbiturates

Gold salts

H2 blockers

Methyldopa

Digoxin

Procainamide

Penicillin

Sulfonamides

Quinidine

Quinine

Valproic acid


ITP: What is it?

The list of causes of thrombocytopenia is quite long and exhaustive. ITP is

an acquired condition with no obvious cause of thrombocytopenia and is

therefore diagnosed by excluding other causes of thrombocytopenia. In

adults, ITP usually does not resolve by itself. In patients with ITP, platelets

have a shorter survival time in the bloodstream due to being stored in the

spleen and being destroyed by antibodies. These antibodies may also impair

platelet production. The incidence of ITP is higher in young women than

young men. In older adults, the incidence is equal (Lichtman et al., 2011).

ITP: How is it diagnosed?

In order to diagnose ITP, other causes of thrombocytopenia must be

excluded. This entails a thorough review of medications, as well as a

complete history and physical. Use of herbal products should be discussed.

Specifically, patients should be asked about use of chamomile, ginger,

gingko, and kelp. In addition to asking about alcohol use, usage should be

quantified. Patients should be asked about past surgeries and any bleeding

complications (Baldwin, 2003; Winkeljohn, 2013; Winkeljohn, 2010).

Physical examination should focus on ecchymosis, petechiae, and spleen and

liver size. As far as diagnostic tests are concerned, a CBC with manual

differential should be ordered. Viral studies, such as human

immunodeficiency virus (HIV) and hepatitis, should also be done to rule out

infectious causes of thrombocytopenia. The patient should be assessed for

nutritional deficiencies, which include vitamin B12 level, folic acid level, and

iron studies. Coagulation studies should be ordered as well. The presence of

bleeding should be assessed through urinalysis and stool testing for occult

blood. In addition, liver enzymes should be checked. An abdominal

ultrasound is useful in determining the presence of an enlarged spleen. Bone


marrow biopsy is not routinely done, unless the patient is older than 60

years of age (Baldwin, 2003; Winkeljohn, 2013; Winkeljohn, 2010).

Complications of thrombocytopenia

Patients usually do not experience symptoms until the platelet count falls

below 20,000. The major complication of thrombocytopenia is bleeding. This

includes spontaneous bleeding from the mouth, nose, and GI tract. Patients

may also have hematuria and hemoptysis. Women may experience

menorrhagia. Two very serious complications, which typically do not occur

unless the platelet count is less than 5,000, are spontaneous intracranial

bleeding and uncontrollable gastrointestinal bleeding. In patients undergoing

surgical procedures, they may experience extended bleeding. Blood loss can

lead to anemia, and may be significant enough to require transfusions of

packed red blood cells (Baldwin, 2003).

Patient education: bleeding precautions

It is very important that nurses educate thrombocytopenic patients about

their risk of bleeding and interventions to minimize the risk. Patients should

avoid activities that increase the risk of bleeding. For example,

thrombocytopenic patients should use soft toothbrushes and be careful when

flossing to decrease the risk of oral bleeding. Patients should be instructed to

shave with electric razors instead of blades. Also, they should be advised

not to engage in contact sports. Patients should also be assessed for risk of

falls. Nurses should discuss tips to prevent falls, such as creating a safe

environment in the home. Patients, especially elderly patients, may need

assistive devices (Winkeljohn, 2013).


Patients with low platelet counts should avoid unnecessary invasive

procedures. These patients should also be instructed on a bowel regimen to

prevent constipation and straining. Thrombocytopenic patients should not

use suppositories or enemas. Other activity to avoid includes sexual activity,

which can increase risk of bleeding. Patients should be advised to use

lubricant when engaging in sexual activity. If the platelet count is severely

decreased, they should abstain. Patients should also be instructed to avoid

certain medications that may affect platelet function, such as ibuprofen and

aspirin (Winkeljohn, 2013).

BLEEDING PRECAUTIONS

Education of patients with thrombocytopenia are highlighted below:

Use soft toothbrush and be careful when flossing

Avoid shaving; if you must shave, use an electric razor

No enemas or suppositories

Use lubrication when engaging in sexual activity

No contact sports

Prevent falls

Avoid invasive procedures if at all possible

General treatment of thrombocytopenia

Treatment of thrombocytopenia varies and is based on cause. For example,

in patients with HIT (heparin-induced thrombocytopenia), all heparin should

be discontinued immediately. Lovenox is also not recommended (Sanofi-

Aventis, 2013). Other forms of anticoagulation should be used instead.

Platelet transfusions are generally not indicated due to risk of clots.


In drug-induced thrombocytopenia, the substance causing thrombocytopenia

should be stopped right away. If the patient is asymptomatic, no further

intervention is required and the platelet count should return to normal in

seven to ten days. Platelet transfusion is only indicated if there is a high risk

of bleeding or the platelet count is less than 5,000 (Baldwin, 2003).

In patients with chemotherapy-induced thrombocytopenia, platelet

transfusions are usually warranted if the platelet count is less than 10,000.

If bleeding is present, such as epistaxis or rectal bleeding, platelet

transfusions should be arranged even if the platelet count is over 10,000. If

patients require an invasive procedure, such as endoscopy or bone marrow

biopsy, the platelet count should be at least 50,000 (Damron et al., 2009).

Treatment of ITP

Corticosteroids

ITP is initially treated with corticosteroids, usually prednisone at a dose of

1mg/kg daily. Once platelets increase, prednisone should be tapered. The

tapering schedule is based on the platelet count. The average response time

is seven to 28 days. Dexamethasone is sometimes used as well. The dose is

usually 40 mg daily for four days and may be repeated. Oftentimes, patients

with ITP will respond to initial treatment, but may relapse. If this happens,

corticosteroids can be used again. Side effects of corticosteroids include

increased appetite, weight gain, difficulty sleeping, and headaches.

Prolonged use of steroids can cause osteoporosis, immunosuppression, and

diabetes mellitus (Lichtman et al., 2011; Winkeljohn, 2010; Winkeljohn,

2013).


Immunoglobulin (IVIG)

Intravenous immunoglobulin (IVIG) is another treatment option. Platelets

will generally increase quite rapidly, with a response rate of two to seven

days. IVIG is generally infused slowly at first, then titrated as the patient

tolerates. Patients usually receive premedication with acetaminophen and

diphenhydramine to prevent infusion reactions. The large volume of the

infusion can also be a concern. Side effects include headaches, chest

pain/tightness, shortness of breath, fevers, chills, back pain, and flu-like

symptoms. More serious complications include renal failure, meningitis,

anaphylaxis, and thromboembolic events (Shelton, Griffin, & Goldman,

2006; Winkeljohn, 2013).

Anti-Rh (D) immune globulin

Anti-Rh(D) immune globulin is another treatment option that is given

intravenously. The response time is about three to seven days and response

usually lasts for greater than three weeks. This treatment is not indicated for

patients who are Rh negative or who have undergone a splenectomy. Side

effects of treatment include hemolysis, headaches, fever, chills, nausea,

vomiting, and allergic reactions (Lichtman et al., 2011; Winkeljohn, 2013).

Rituximab

Rituximab can be used if the other options listed above were not effective.

This medication is an infusion given weekly for four weeks. Response is

usually seen in about a week. This medication can be quite costly. Side

effects include infusion reactions, including anaphylactic-type reactions.

Fevers, chills, rigors, and headaches may also occur (Winkeljohn, 2013).


Splenectomy

Another option, if previous treatments are deemed ineffective, is removal of

the spleen (splenectomy). However, this treatment is usually not done until

at least six months after diagnosis. Increase in platelets is usually noted

several days after splenectomy. Complications include infection, abscess,

adhesions, and hernia. Patients should receive the haemophilus influenzae

type B, meningococcal, and pneumococcal vaccines at least two weeks

before splenectomy. Patients without a spleen are also at increased risk of

infection for the rest of their lives and should be properly educated

(Lichtman et al., 2011; Winkeljohn, 2013).

Eltrombopag

Eltrombopag is a newer oral medication for ITP. This medication is taken

daily. If discontinued, the platelet count will decrease. Response is noted in

seven to 28 days. The medication is usually well tolerated. Side effects

include bone marrow fibrosis and changes in liver function tests. Patients

should be monitored for thrombotic and thromboembolic complications

(Winkeljohn, 2013).

Romiplostim

Another fairly new medication is romiplostim, which is given subcutaneously

once a week. Patients remain on this medication indefinitely. If discontinued,

the platelet count will decrease. Response is seen in seven to ten days. Side

effects are similar to those seen in eltrombopag (Winkeljohn, 2013).


On Reflection: Mary (case study at the beginning of the course)

Mary’s platelet count is 45,000, which is consistent with Grade III

thrombocytopenia. She presents to the hematologist immediately for further

evaluation. The hematologist performs a thorough history, including review

of medications she is currently taking, as well as medications she has taken

recently. The hematologist is concerned about recent exposure to Bactrim

and advises Mary to avoid this medication in the future. The rest of her

history does not reveal any significant findings.

The hematologist performs a physical exam and notes scattered bruises. He

does not appreciate hepatosplenomegaly. The physician proceeds with

further workup to include complete blood count (CBC), peripheral smear,

complete metabolic panel including liver function tests, and abdominal

ultrasound. He also asks the phlebotomist to collect a CBC in a blue tube. He

also checks HIV, hepatitis, CMV, and EBV. In addition, he orders iron

studies, as well as B12 and folic acid levels.

The office nurse educates Mary on signs and symptoms to report

immediately. She also discusses bleeding precautions with the patient. Mary

has no evidence of bleeding and therefore does not require treatment at this

time. Mary is advised to return to the office in one week to discuss results

and repeat the CBC.

At Mary’s next visit, her workup is overall negative. Repeat CBC now shows

an improved platelet count of 100,000. It is determined that Mary likely

experienced drug-induced thrombocytopenia due to Bactrim. However, the

doctor brings Mary back for another CBC in two weeks. Platelets are now

back to normal and bruising has resolved.


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 the NURSECE4LESS.COM course planners evaluate

nursing knowledge needs met following completion of this course by completing

the self-assessment Knowledge Questions after reading the article.

Correct Answers, page 22.


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


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


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


Footnotes:

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

http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-

14_QuickReference_8.5x11.pdf

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

http://products.sanofi.us/lovenox/lovenox.html

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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