West Coast University NUR 120

West Coast UniversityNUR 120Hematologic System (Blood Disorders) Iron Deficiency AnemiaPernicious AnemiaThrombocytopeniaImmunologic System (Immune System Disorders)HIV/AIDSThe Hematologic System The hematologic system is the:BloodBlood CellsLymphAnd organs involved with blood formation

Bone MarrowIs the blood-forming (hematopoeitic) organ.Produces most of the cells of the blood including: RBC erythrocytes WBC leukocytes and PlateletsBone Marrow also is involve in the immune responses.

Bone MarrowReleases: 2.5 billion RBC each day in healthy adult.2.5 billion platelets and 1 billion white blood cells per kilogram of body weight.Fetus blood components are produced in the liver and spleen and by the last trimester in the bone marrow.

Bone MarrowAt birth:Blood producing marrow is present to every bone. Flat bones sternum, skull, pelvis, and shoulder girdles contain active blood producing marrow throughout life.As person age blood producing marrow decreases in the long bones and in small and irregularly shaped bones.

Blood Producing Bone Marrow18 years blood production is limited to the ends of the long bones

Adulthood fatty tissue replaces inactive bone marrow.

Blood Producing Bone MarrowProcess of blood production:Bone marrow first produces stem cells.Stem cells are immature, undifferentiated cells that are capable of maturing into any one of several types of blood cells: RBCs, WBCs, or platelets depending on the bodys need. Also called pluripotent, multipotent and totipotent.

Blood Cell Development Cont:Committed Stem Cell- also called the precursor cell or the unipotent stem cell enters maturational pathway and then differentiate into one cell type.

Committed stem cell actively divide but require the presence of a specific growth factor for Maturation and some hormones

E.g. cytokines.

ErythropoietinIs a growth factor made in the kidneys that is specific for RBC.RBC growth factor produced in the kidney in same amount as RBCs destruction. When tissue oxygenation is less than normal (hypoxia) the kidney increases the production of erythropoietin.Synthetic erythropoietin (PROCRIT, EPOGEN, EPO) has the same effect on bone marrow as the naturally occurring erythropoietin.

ErythropoiesisErythropoeisis the production of RBC. - Process where it involves selective maturation of stem cells into mature erythrocytes. - This process ensures that there is enough RBCs for good oxygenation without too many cells that could thicken the blood and slow its move.

Blood ComponentsBlood is composed of plasma and cells.Plasma part of the bodys extracellular fluid. Similar to interstitial fluid.Contains several more times protein the interstitial fluid.E.g. Albumin, Globulins, and FibrinogenCells RBCs, WBCs, and Platelets.

Albumin, Globulin and FibrinogenAlbumin- Increases the osmotic pressure of the blood which prevents plasma from leaking into the tissues.Globulins - have many function e.g transporting other substances and protecting the body against infection.Fibrinogen is a protein molecule that can be activated to form fibrin.Fibrin molecules assemble together to form structures important in the blood clotting process.

Red Blood Cells (Erythrocytes)Largest proportion of the blood cells.Mature RBCs has no nucleus and has biconcave disk shape.Has flexible membrane that allows RBC to change shape without breaking as they pass through a narrow, winding capillaries.

Red Blood Cells (ErythrocytesNumber of RBC varies from person to person according to gender, age and general health.Normal range 4,200,000 to 6, 100,000/mm3.Life span 120 days after being released into the blood.Old cells are trapped and destroyed in the tissues, spleen and liver. Some part of destroyed RBCs (Iron) are recycled and used to make RBCs.

Red Blood Cells (Erythrocytes)RBCs produce hemoglobin (Hgb).The heme part of hemoglobin molecules needs a molecule of iron. Only when a heme molecule that is complete with iron can it transport up to four molecules of OXYGEN.The globin portion carries Carbon Dioxide. RBC also can buffersand help maintain acid-base balanceHemoglobinHas the ability to combine loosely with oxygen. With only a small amount of drop of O2 level in the tissues, a greater increase in the transfer of O2 from hemoglobin to tissues occurs.Transfer of O2 to tissues is called oxygen dissociation.

Substances needed to form Hemoglobin and RBCs Iron ( Fe)Vitamin B12 ( Cyanocobalamin)Folic Acid ( Folate)Copper (Ug)Pyridoxine ( Vit. B6) Cobalt (Co) and NickelLack of these substances can lead to ANEMIA

White Blood Cells(Leukocytes)Performs action critical to inflammation or immunity.May types of WBCs all have specialized functions.Most are formed in the Bone MarrowWBCs protect the body from the effect of invasions by organisms.

NeutrophilsFirst internal line of defense against invaders especially bacteria.Destroys invaders through phagocytosis.Responsible for continuous, instant, nonspecific protection.The number of actual mature neutrophils is used to measure a clients risk for infection: the higher the numbers, the greater the resistance against infection.

MacrophagesThey are also known as monocytes when they are not mature.Move from blood to tissues when they mature. Lung alveolar macrophages connective tissues- histiocytes Brain Microglial cell Liver Kupffer cellPeritoneum Peritoneal macrophageBone OsteoclastJoints Synovial type A cellKidney mesanglial cell.

Macrophages ( Function)Important in immediate inflammatory response. Stimulates the longer-lasting immune response of the of the anti-body mediated immunity (AMI).PhagocytosisRepair of injured tissuesAntigen presenting/processingSecretions of cytokines that helps to control the immune system.

Basophils Make up 1% of the total circulating WBCs.These cells cause the manifestations of inflammation.Contains vasoactives amines that act on blood vessels. Includes heparin, histamine, serotonin, kinins, and leukotrienes. When release into the blood most of these chemicals act on the smooth muscles and blood vessel walls.Heparin inhibits blood and protein clottingHistamine constricts small veins and respiratory smooth muscles. Constrictions inhibits blood flow and decrease venous return. This results in blood collection to capillaries and small arterioles.Kinins dilate arterioles and increase capillary permeability. Theses actions cause blood plasma to leak into interstitial space (vascular leak syndrome)

Eosinophils Contains many vasoactive chemicals also. Usually make up 1% to 2 % of the total WBC count.Function- act against infections of parasitic larvae.Increases in number during an allergic reaction because eosinophils degrade the vasoactive chemicals released by the other leukocytes.

PlateletsThey are the smallest of the blood cells.Fragments from giant precursor cell in the bone marrow known as Megakaryocytes.Stick to injured blood vessel walls and form platelets plug that can stop the flow of blood from the injured site.

PlateletsThey also produce substances important to coagulation. Help keep blood vessels intact by beginning repair of damage to small blood vessels. They perform most of their functions by aggregation (clumping).Production in the bone marrow is also precisely controlled by growth factors (thrombopoieitin).After leaving the bone marrow, they are stored in the spleen and then released slowly to meet the bodys need. Normally 80% of platelets circulates and 20 % stored in the spleen.Life span: 1 2 weeks

Accessory Organs of Hematopoiesis Spleen located under the diaphragm to the left of the stomach. Composed of three types of tissues: white pulp, red pulp and marginal pulp.These help to balance blood cells production and blood cells destruction and assist with immunity.The spleen destroys old or imperfect RBCs, breaks down the hemoglobin released from destroyed RBCs stores platelets and filters antigen. Thus after splenectomy, clients are not efficient at ridding the body of disease-causing organisms and are at greater risk for infection and sepsis.

Liver Main production site for prothrombin and most of the blood clotting factors. Proper liver function and bile production are critical to the formation of Vitamin K in the intestinal tract. Vitamin K is essential for producing blotting factors VII, IX, and X. Large quantities of whole blood and blood cells can be stored in liver.Also converts bilirubin to bile and stores iron within the protein ferritin. Small amount of erythropoeitin are also produced in the liver.

Assessments of the Hematopoeitic System/Functions Health History base on Gordons Functional Health PatternActivity Exercise Pattern questions guide: Ask on energy level in comparison of last year.How rested after a typical night sleep.Any experiences of dizziness or light headednessIs the heart seems to pound?How much exercise do you get? How often? What type?Do you feel you have enough energy to do what you want or need to do?

Assessments of the Hematopoeitic System/FunctionsFamily History and Genetic Risk- Bleeding Disorders e.g. HemophiliaPersonal History e.g. liver function, known immunologic or hematologic disorder, and current drug use? Check all drugs pt is taking in the past 3 weeks/Ask about use of ATBs.(prolonged use can lead to clotting problems or bone marrow depression.Diet HistorySocioeconomic StatusCurrent Health ProblemsPhysical AssessmentSkin Assessment- Inspect color of the skin, nail beds. Note: People with darker skin pallor and cyanosis easily detected in the oral mucous membrane and the conjunctivae of the eye while jaundice is in the roof of the mouth.Head and neck assessment lymph nodes , symmetrical, light palpation.Respiratory AssessmentCardiovascular AssessmentRenal and Urinary AssessmentMusculoskeletal Assessment paresthesias of lower extremityAbdominal AssessmentCNS assessmentPsychosocial AssessmentCommon Assessment Abnormalities Skin pallor, jaundice, cyanosis, leg ulcers (malleoli), purpura (ecchymosis- decrease Plts), peticchia (pinpoint bleeding),hematoma.Eyes- yellow sclera, pallor (conjunctiva).Nose epistaxis low Platelet Ct. Mouth pallor, gingival/mucosa ulceration.Lymph Nodes- enlarge, tender to touch.Heart and Chest tachycardia, >100 bpm, palpitation. Orthostasis, Hypertension ( initial reaction of anemia).Abdominal Hepatomegaly, SplenomegalyNervous System Paresthesis of feet and hand, low B12 or Folate. Weakness low Hgb. Musculoskeletal Pain in pelvis, ribs, spine, sternum Joint swelling hemophilia, sickle cell anemia.

Hematologic Changes Associated with AgingAs bone marrow ages, it produces fewer blood cells. Total RBC and WBC are lower in older adults.Platelets count do not appear to change with age. Antibody levels and responses are lower in older adults.

Hematologic Changes Associated with AgingChanges the cellular and plasma component of blood. Several factors causes decrease blood volume in older adults and tend to have lower levels of plasma proteins and decreased plasma osmotic pressure ( decreased intake of dietary protein) which also causes some loss of blood volume into the interstitial space. Hematologic Changes Associated with AgingLymphocytes become less reactive to antigen and have a loss of immune function.WBC count does not rise as high in response to infections in older people and younger people. Hemoglobin levels also change with age. Hemoglobin levels in men and women fall after middle age. Iron deficient diets may play in a role in this reduction. Iron Deficiency Anemia/Pernicious Anemia is an abnormally low amount of circulating red blood cells (RBCs ), hemoglobin concentration, or both.Iron Deficiency Anemia is the most common anemia. Lack of Iron (Fe) that promotes formation of Hgb.Pernicious Anemia due to deficiency of intrinsic factor produced by gastric mucosa which is necessary for absorption of Vit B 12.

Causes of AnemiaBlood LossInadequate RBC productionIncrease RBC destructionInsufficient or defective hemoglobin

Common Risk Factor for AnemiaAcute or Chronic Blood loss menorrhagia, GI ulcers/bleedIncreased Hemolysis defective hemoglobin (sickle cell), impaired glycolysis (G6PD- Glucose 6phosphate dehydrogenase) deficiency anemia, transfusion reaction, autoimmune diseases.Mechanical Trauma to RBCs mechanical heart valve, cardiopulmonary bypass.

Common Risk Factor for AnemiaDietary Insufficiency Iron Deficiency - Vit. B 12 deficiency - Folic Acid Deficiency - Pica or persistent eating of substances not normally considered food (non-nutritive value ) for at least 1 month.Bone Marrow Suppression exposure to radiation or chemicals. Aplastic anemia results in decreased number of red blood cells as well as decreased platelets and WBC.Diagnostic Procedures for AnemiaLab Assessment: 1. CBC (Complete Blood Count) RBC major carrier of Hgb in the blood Hgb- transport O2 and Co2 to and from the cells and can be used as index of oxygen carrying capacity of the blood. Hematocrit (Hct) percentage of RBCs in relation to the total blood volume. Platelets important for clcot formationRBC indices to determine type and cause of most anemiasMean Corpuscular Volume (MCV) size of red blood cell : Normocytic, microcytic, macrocytic.Mean Corpuscular Hemoglobin (MCH) to determine the amount of hemoglobin per RBC. Normochromic normal amt. of Hgb per cell, Hypochromic decreased amt. of Hgb per cell.Mean Corpuscular Hgb Concentration (MCHC) to indicate Hgb amt. relative to the size of the cell.In Iron deficiency anemia there is decreased MCV, MCH, MCHC and classified as microcytic, hypochromic anemia.In pernicious anemia there is increased MCV and classified as macrocytic anemia.Diagnostic Studies/Procedures for Anemia2. Iron Studies Total Iron Binding Capacities (TIBC) reflects an indirect measurement of serum transference. Serum Ferritin is indicator of total body iron stores. Serum Iron measures the amt. or iron in the blood. Low serum iron and elevated TIBC indicates iron deficiency anemiaDiagnostic Studies/Procedures for AnemiaHemoglobin Electrophoresis separates normal Hbg from abnormal. Use to detect thalassemia and sickle cell disease.Schillings Test measures Vit. B12 absorption with and without intrinsic factor. It is used to differentiate between malabsorption and pernicious anemia. Procedure in a form of handouts.Bone Marrow Examination diagnoses aplastic anemia(failure of bone marrow to produce RBC as well as WBCs and platelets).

Nursing Care after Bone Marrow AspirationApply pressure to the site for 5 to 10 minutes Assess V/S frequently.Apply pressure dressing.Monitor for signs of bleeding and infection for 24 hours. Pt. going for Bone Marrow aspiration is position based on area where they will obtain the sample. Either prone or side lying. Local anesthesia to the site of aspiration is given and pt. is mildly sedated.

Nursing Assessment for Anemia.Pallor especially in the ear and nail beds, palmar crease and conjunctiva.Fatigue exercise intolerance, lethargy, orthostatic hypotension.TachycardiaHeart murmursHeart failureSigns of bleeding- hematuria, melena, menorrhagia.DyspneaIrritability difficulty concentrating Cool skin, cold intolerance.

Iron Deficiency Anemia What Causes Iron Deficiency Anemia?Poor absorption of iron by the body (Vitamin C aides in iron absorption)Inadequate daily intake of ironPregnancyGrowth spurts or blood loss due to heavy period or internal bleeding.Anemia develops slowly after the normal stores of iron have been depleted in the body and in the bone marrow. Women, in general, have smaller stores of iron than men. Women also lose iron more frequently than men because of the blood loss during menstruation.

Iron Deficiency AnemiaSigns and Symptoms specific for Iron Deficiency AnemiaPale skin color (Pallor) FatigueIrritabilityDizzinessWeaknessShortness of breathSore tongue (smooth sore bright red tongue) Brittle nailsDecreased appetite (especially in children)Headache - frontal.The tests are: Red blood cell measures 4 x 10 (12 power), hemocrit (below 36%, NV m: 40-54 ml/dl, w: 37 -47 ml/dl, and hemoglobin( below 10 g/dl); NV- m: 13-18 g/dl, w: 12.0 16.0 g/dl. Size of red blood cells (microcytic), serum iron level (low), and iron binding capacity in the blood (elevated).

Iron Deficiency AnemiaTreatment of Iron Deficiency Anemia Ferrous salts of iron are absorbed much more readily and are generally preferred. Commonly available oral preparations Ferrous Sulfate, Ferrous Gluconate and Ferrous Fumarate (Hemocyte). All three forms are well absorbed. Ferrous sulfate is the least expensive and most commonly used oral iron supplement. For iron replacement therapy, a dosage equivalent to 150 to 200 mg of elemental iron per day is recommended.Ferrous sulfate, 325 mg of three times a day, will provide the necessary elemental iron for replacement therapy. Hematocrit levels should show improvement within one to two months of initiation of therapy.Take with meals if GI side effects occurs.Give with Vit. C for better Iron absorptionD0 not take with 2 hours of milk or antacids.Stools will be black.May cause constipation. Increase fluid intake and foods high in fiber.Use of straw for liquid iron to prevent teeth staining.

Treatment of Iron Deficiency Anemia Injectable iron dextran, containing 50 mg of iron per mL, is supplied in a 2-mL single-dose vial. Adverse reactions include: headache, dyspnea, flushing, nausea and vomiting, fever, hypotension, seizures, urticaria, anaphylaxis.

Pernicious AnemiaBody stores of vitamin B12 are adequate for up to five years.Symptoms are attributable primarily to anemia, although Glossitis, Jaundice, and Splenomegaly may be present. Vitamin B12 deficiency may cause: Decreased vibratory and positional sense Ataxia Paresthesias and Confusion.

Treatment of Vitamin B 12 Deficiency Anemia. Intramuscular, oral or intranasal preparations are available for B 12 replacement.

In patients with severe vitamin B12 deficiency, daily IM injections of 1,000 mcg of cyanocobalamin.

.Pernicious Anemia Can not be prevented if due to lack of intrinsic factor. .Some develop pernicious anemia due not getting enough Vitamin B12 in their diets. Eating foods high in vitamin B12 can help prevent low vitamin B12 levels. Good food sources of vitamin B12 include: Meats such as beef, liver (glandular meats), and poultry, Fish and Shellfish, yeast, Egg and Dairy products, such as milk, yogurt, and cheese, cereals and other fortified foods that have vitamin B12 added, Vitamin B12 also is found in multivitamins and in B-complex vitamin supplements. Supplements for people at risk for vitamin B12 deficiency, such as strict vegetarians or people who have had stomach surgery is needed.Older adults may have trouble absorbing vitamin B12.

Nursing Diagnosis - AnemiaActivity Intolerance AnxietyIneffective tissue perfusionFatigueSelf-Care DeficitRisk for InfectionNursing Plans and Interventions Instruct client to alternate periods of activity with periods of rest.Teach client about diet : Food selection and preparation to maximize intake of A. Iron rich food e.g. red meats, organ meats, whole wheat and whole wheat products, spinach, carrots. B. Folic Acid sources e.g. green vegetables, liver, citrus fruits for Folic Acid Anemia/Deficiency. C. Vit. B 12 rich foods.Instruct in need for Vitamin Supplements

Vitamin SupplementsGive Iron preparation with meals to prevent/decrease GI irritation.Administration of Iron: Dos Use Z-Track technique of administration Use air bubble to avoid withdrawing medication into subcutaneous tissue. Donts Do not use deltoid muscle. Do not massage injection site.Administer B12 and Folic acid orally except to client with pernicious anemia who should receive parenterally.If parenteral Iron is required, use Z-track method for administration to prevent staining the skin.

Complications and Nursing Implications Monitor client for s/s of hypoxemia. - dyspnea, decreased O2 saturation, central cyanosis. - administer oxygen therapy. Monitor SaO2. - Administer blood transfusion as ordered. Blood Transfusion lead to an immediate improvement in blood cell counts and client sign and symptoms. Use only saline to flush IV tubing or to run with blood. Never add medications to blood product. Two RNs should simultaneously check the physicians prescription, the clients identity, and the blood bag label. Complications and Nursing Implications Assess neurologic status of client with macrocytic anemias. Vit. B 12 is essential for neurologic function. Administer supplements. Notify the physician in any changes in mentation.

GI Bleeding is a most common cause of anemia in older adults.Anemia maybe misdiagnosed as depression or debilitation.ThrombocytopeniaThrombocytopenia - is any disorder in which there are not enough platelets. Platelets are cells in the blood that help blood to clot. This condition is sometimes associated with abnormal bleeding.Reduction of platelets below 150,000/ul.Acute, severe, or prolonged decreases from this normal rannge can result in abnormal hemostasis that manifest as prolonged bleeding from minor trauma to spontaneous bleeding w/o injury.

Symptoms:Bruising Nosebleeds or bleeding in the mouth Rash (pinpoint red spots called petechiae)Mild thrombocytopenia can occur without symptoms.

Causes

Can be inherited (Wiscott-Aldrich Syndrome ) or Acquired autoimmune diseases, increased platelets consumption, splenomegaly, marrow supression and bone marrow failure. Is often divided into three major causes of low platelets: 1. Low production of platelets in the bone marrow 2. Increased breakdown of platelets in the bloodstream (called intravascular) 3. Increased breakdown of platelets in the spleen or liver (called extravascular).

Disorders that involve low production in the bone marrow include:

Aplastic anemia Cancer in the bone marrow Infections in the bone marrow (very rare) MyelodysplasiaUse of certain drugs may also lead to a low production of platelets in the bone marrow, although this is rare

Causes and Risk FactorsAcquired thrombocytopenia may result from the use of certain drugs, such as quinine, quinidine, rifampin, heparin, nonsteroidal anti-inflammatory agents, histamine blockers, most chemotherapeutic agents, allopurinol and alcohol.

Common causes of decreased platelet production: 1. marrow aplasia (when the marrow is not developing naturally)2. fibrosis (an abnormal formation) or infiltration with malignant cells.Drugs that cause drug-induced thrombocytopeniaDiabetes drugs taken by mouth (hypoglycemic agents)Nonsteroidal anti-inflammatory drugs (NSAIDs) Penicillin Quinidine Quinine Ranitidine Some drugs used to treat arthritis conditions Sulfonamides Diuretics - Thiazides

Common causes of decreased platelet production:

Occur transiently after a viral infection (such as Epstein-Barr) or infectious mononucleosis. Idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder. - Cause is unknown. When reach spleen this platelets were recognize as foreign and are destroyed by macrophages. Thrombotic thrombocytopenic purpura (TTP), which is an uncommon disorder associated with anemia. - Characterized by hemolytic anemia, neurologic abnormalities , fever in absence of infection and renal abnormalities.

Disorders that involve the breakdown of platelets include:

Disseminated Intravascular Coagulation (DIC) Disseminated intravascular coagulation (DIC) is a serious disorder in which the proteins that control blood clotting become abnormally active.Drug-induced nonimmune thrombocytopenia Drug-induced thrombocytopenia occurs when certain drugs or medications destroy platelets or interfere with the body's ability to make enough of them.Drug-induced immune thrombocytopenia If a medicine prevents your bone marrow from making enough platelets, the condition is called drug-induced nonimmune thrombocytopenia. Chemotherapy drugs and a seizure medication called valproic acid may lead to this problem.Hypersplenism Immune thrombocytopenic purpura (ITP) Thrombotic thrombocytopenic purpura

Symptoms of Thrombocytopenia

Sudden onset of petechiae and ecchymoses from bleeding into mucous membranes or on the skin. Malaise, fatigue and general weakness (with or without accompanying blood loss).Adults may have large, blood-filled bullae in the mouth. If the platelet count is between 30,000 and 50,000/mm3, bruising with minor trauma may be expected. If it is between 15,000 and 30,000/mm3, spontaneous bruising will occur. Ave. 20,000/mm3. life treathening hemorrhages. Diagnostic Studies Platelet count decreased, any reduction below 150,000 u/l. Platelet transfusion is recommended when count is below 10,000 u/l unless client is actively bleeding. Lab test to assess secondary bleeding: - Prothrombin time - activated Partial Thromboplastin Time. If PT/aPTT are elevated this may indicate DIC. PT/INR and aPTTPT/PTT are laboratory tests that measure the clotting time (how long it takes blood to clot.)

PT/PTT are blood tests and INR is a ratio calculated from the PT.Prothrombin, or factor II, is one of several clotting factors produced by the liver. This test measures the integrity of the extrinsic and common pathways of coagulation. The prothrombin time (PT) measures the clotting time from the activation of factor VII through the formation of the fibrin clot. Adequate amounts of vitamin K are needed to produce prothrombin. Warfarin (Coumadin) is sometimes prescribed as a "blood thinner" because it is an effective vitamin K antagonist (blocks the formation of vitamin K). The reference range for prothrombin time is usually around 1215 seconds; The normal range for the INR is 0.81.2

PT/INR and aPTTThe activated partial thromboplastin time (PTT) measures the function of several other clotting factors, found in the intrinsic and common blood clotting pathways. It measures the clotting time from the activation of factor XII through the formation of the fibrin clot. PTT prolongations are caused by factor deficiencies (factors VIII, IX, XI, and/or XII), or inhibitors (most commonly, heparin). Heparin prevents clotting by blocking certain factors in the intrinsic pathway.The greater the PT/PTT values, the longer it takes the blood to clot. HIGH PT/PTT = risk for BLEEDING. LOW PT/PTT = risk for blood clots/ stroke.

INR The INR stands for International Normalized Ratio. The INR is calculated from the PT and is intended to allow valid comparisons of results regardless of the type of PT reagent used among different laboratories (INR = [patient PT / mean normal PT]). The INR is a method of standardizing the PT for coumadin anticoagulation. Before the INR, different labs using different reagents had different controls and widely differing PT value ranges.

An INR of 1 means the blood clots "normally" for that pt. The greater the INR, the longer it takes the blood to clot.

INR The warfarin (Coumadin) dosage for people being treated to prevent the formation of blood clots is usually adjusted so that the prothrombin time is about 1.5 to 2.5 times the normal value (or INR values 2 to 3). A patient may take warfarin to anticoagulate for atrial fibrillation (target INR around 2.5) or for a mechanical heart valve (target INR 3). An INR of 3 means the blood takes about three times as long to clot compared with the normal value for that pt.

Nursing Responsibilities for Lab Studies Nurse needs to closely monitor platelet count and other anticoagulation therapy. Nurse need to monitor hematocrit and hemoglobin levels.Nursing Assessment Subjective Data important health information past health history medications Functional Health Patterns health perceptions health management : Family history of bleeding problems, malaise. nutritional-metabolic : bleeding gingiva, coffee-ground or bloody vomitus, easy bruising.Activity exercises: fatigue, weakness, fainting, epistaxis, hemoptysis, dyspnea.Cognitive-perceptual: pain and tenderness in bleeding areas, headache. Sexuality-reproductive: menorrhagia, metrorrhagiaNursing Assessment Objective Data: General: Fever, lethargy Integumentary: petecchia, ecchymosis, purpura GI: Splenomegaly, abdominal distention, guiac-positive stools.Possible findings: Platelet count< 150,000/ul prolonged bleeding time, dec. hemoglobin and hematocrit; normal or elev. Megakaryocytes in bone marrow examination. Tests & diagnosis

Complete blood count (CBC) shows low number of platelets. Blood clotting studies (PTT and PT) are normal.Other tests that may help diagnose this condition include:Bone marrow aspiration or biopsy Platelet associated antibodies

ComplicationsSevere bleeding (hemorrhage) is the main complication. This can include:Bleeding in the brain (intracranial hemorrhage) Gastrointestinal bleeding (vomiting blood or blood in the stools) When to contact a healthcare provider : Call a healthcare provider if unexplained bleeding or bruising is noted.

Collaborative Care Thrombocytopenia ITP

TTPCorticosteroidsPlatelets transfusionsSplenectomyIV immunoglobulinDanazolAnti-Rho (D)Immunosuppressives. e.g. cytoxan, Imuran, Rituxan

Plasmaparesis (plasma exchange)High dose prednisoneSplenectomyDextranChemotherapy e.g. vincristine, vinblastinImmunosuppressives.Collaborative Care Thrombocytopenia Heparin-Induced ThrombocytopeniaDecrease Platelet Production Direct thrombin inhibitor e.g. lepirudin Indirect thrombin inhibitor e.g. arixtraPlasmapheresis (plasma exchange)Protamine SulfateCoumadinThrombolytic agents

Identification and treatment of cause.CorticosteroidsPlatelet transfusionsOprelvekin (Neumega)TreatmentsRemoval of the offending agents should correct the condition. Corticosteroids may be used to increase platelet production. Lithium carbonate or folate may also be used to stimulate the bone marrow production of platelets. Platelet transfusions may be used to stop episodic abnormal bleeding caused by a low platelet count.

Patient Teaching Thrombocytopenia Notify HCP for any manifestations of bleeding.Ask HCP for restriction for in normal activities. E.g. vigorous exercises. Sturdy shoes or slippers for walking.Do not blow nose forcefully. Place head up and apply firm pressure on the nostrils and bridge of the nose.Do not bend down with your head lower than your waist. Prevent constipation by drinking plenty of fluids and do not strain when having BM.Shave only with electric razor. Do not use blade. Do not pluck eyebrows or other body hair.

Patient Teaching Thrombocytopenia Do not puncture skin, e.g. getting tattoos or body piercing . Avoid using any medications that can prolonged clotting such as aspirin. Be careful also with herbs with same effects. Use soft bristle tothbrush to prevent injuring the gums. Flossing is also usually safeif it is done gently using the tape floss. Do not use alcohol -based mouthwashes as they can dry gums and increase bleeding.Women who are menstruating should keep tract of the number of pads that are used per day.Ask HCP before you have any invasive procedures done such as dental cleaning, manicure, or pedicure.