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Nursing Care Plan | Idiopathic Thrombocytopenia Purpura

Idiopathic thrombocytopenia purpura (ITP) is an acquired hemorrhagic disorder that is characterized by an increased destruction of platelets because of antiplatelet antibodies. The antibodies attach to the platelets, reduce their life span, and lead to a platelet count below 100,000 mm3 but occasionally as low as 5000 mm3. idiopathic thrombocytopenia purpura can be divided into two categories: acute and chronic. Acute idiopathidiopathic thrombocytopenia purpura is generally a self-limiting childhood disorder, whereas chronic idiopathic thrombocytopenia purpurapredominantly affects adults and is characterized by thrombocytopenia of more than 6 months. The most life-threatening complication of idiopathic thrombocytopenia purpura is intracerebral hemorrhage, which is most likely to occur if the platelet count falls below 1000 mm3. Hemorrhage into the kidneys, abdominal cavity, or retroperitoneal space is also possible. Prognosis for acute idiopathic thrombocytopenia purpura is excellent, with nearly 80% of patients recovering without treatment. The mortality rate from hemorrhage is 1% in children and 5% in adults. Older age and a previous history of hemorrhage increase the risk of severe bleeding in adults. Prognosis for chronic idiopathic thrombocytopenia purpura is good, with remissions lasting weeks or even years.

Acute idiopathic thrombocytopenia purpura is thought to be a response to a viral infection. Generally, a viral infection, such as rubella or chickenpox, occurs 2 to 21 days before the onset of the disease. Acute idiopathic thrombocytopenia purpura may occur after live vaccine immunizations and is most prevalent during the winter and spring months when the incidence of infection is high. It is also associated with human immunodeficiency virus (HIV). Chronic idiopathic thrombocytopenia purpura generally has no underlying viral association and is often linked to immunologic disorders, such as lupus erythematosus, or to drug reactions.

Nursing care plan assessment and physical examination
Ask if the patient has recently had rubella or chickenpox or a viral infection with symptoms such as upper respiratory or gastrointestinal (GI) symptoms. Ask if the patient was recently immunized with a live vaccine. Check for a history of systemic lupus erythematosus; easy bruising; or bleeding from the nose, gums, or GI or urinary tract. Because the symptoms of chronic idiopathic thrombocytopenia purpura are usually insidious, patients may not have noticed an increase in symptoms. With a female patient, ask for the date of the last menstrual period, whether recent menses lasted longer and were heavier than usual, or whether she is pregnant. Ask if the patient has had HIV testing.

Physical examination of patients with acute idiopathic thrombocytopenia purpura reveals diffuse petechiae (red to purple dots on the skin, 1 to 3 mm in size) or bruises on the skin and in the oral mucosa. Chronic idiopathic thrombocytopenia purpura patients may have no obvious petechiae. Other clinical features of idiopathic thrombocytopenia purpura include ecchymoses (areas of purple to purplish-blue, fading to green, yellow, and brown with time), which can occur anywhere on the body from even minor trauma. In both types of idiopathic thrombocytopenia purpura, the spleen and liver are often slightly palpable, with lymph node swelling. Ongoing assessment throughout patient management is essential to evaluate for signs of life-threatening bleeding.

Children with acute idiopathic thrombocytopenia purpura are usually brought to the pediatrician by highly anxious parents, who are concerned with the sudden appearance of easy bruising, petechiae, and occasionally, bleeding gums and nosebleeds. Because these symptoms are so commonly associated with leukemia, parents and children need swift diagnosis and reassurance. Pregnant women are concerned about their own health, as well as the health of the fetus.

Nursing care plan primary nursing diagnosis Risk of injury related to increased bleeding tendency.

Nursing care plan intervention and treatment plan
Treatment for idiopathic thrombocytopenia purpura is primarily pharmacologic. Because the risk of hemorrhage occurs early in the course of acute idiopathic thrombocytopenia purpura, therapy is focused on a rapid, sustained elevation in platelet counts. Children with non–life-threatening bleeding are not generally given transfused platelets because the antiplatelet antibody found in their serum is directed against both autologous and transfused platelets. If the patient fails to respond within 1 to 4 months or needs a high steroid dosage, splenectomy is usually considered. Splenectomy is effective because the spleen is a major site of antibody production and platelet destruction; research suggests that splenectomy is successful 85% of the time. In the face of life-threatening bleeding, such as intracranial or massive GI hemorrhages, a splenectomy is indicated.

Many children are managed as outpatients with frequent outpatient visits for therapeutics and platelet counts. If the platelet count is less than 15,000 mm3, the condition may be considered serious enough to warrant hospitalization. Institute safety precautions to prevent injury and the resultant bleeding and to assist with ambulation. Protect areas of hematoma, petechiae, and ecchymoses from further injury. Avoid intramuscular injections, but if they are essential, apply pressure for at least 10 minutes after the intramuscular injection and for 20 minutes after venipuncture. Avoid nasotracheal suctioning, if possible, to prevent bleeding. If a child is being managed as an outpatient, discuss the home environment with the parents or caregivers. Encourage the parents to set up one or two rooms at home (such as the child’s bedroom and the family room) as a protected environment. Pad all hard surfaces and corners with pillows and blankets and remove obstructions, furniture, and loose rugs.

Teach the patient and significant others about the nature of this disorder and necessary selfassessments and self-care activities. Teach the patient to report any signs of petechiae and ecchymoses formation, bruising, bleeding gums, and other signs of frank bleeding. Encourage the patient to stand unclothed in front of a mirror once a day to check for areas of bruising. Headaches and any change in level of consciousness may indicate cerebral bleeding and, therefore, need to be reported to the healthcare workers immediately. Teach the signs and symptoms of blood loss, such as pallor or fatigue. Demonstrate correct mouth care for the patient and significant others by using a soft toothbrush to avoid mouth injury. Recommend electric shavers for both men and women. Teach the patient to use care when taking a rectal temperature to prevent rectal perforation. Recommend care when clipping fingernails or toenails. If any bleeding does occur, instruct the patient to apply pressure to the area for up to 15 minutes or to seek help. Teach the patient to avoid aspirin, ibuprofen in any form, and other drugs that impair coagulation, with particular attention to over-the-counter remedies.

Provide a private, quiet environment to discuss the patient’s or parents’ concerns. The period of diagnosis is an anxious one, and parents need a great deal of emotional support. If the child is managed at home, parents need an opportunity to express their fears.

Nursing care plan discharge and home health care guidelines
To prevent bleeding episodes, the patient should avoid both physical activity that may lead to injury and medications that have anticoagulant properties. Instruct the patient or caregiver when to notify the physician and how to monitor for bleeding in the stool, urine, and sputum. Remind the patient or caregiver to notify any medical personnel of bleeding tendencies. If the patient is a school-age child, encourage the parents to notify the school of the diagnosis, treatment, and complications.

Explain all discharge medications, including dosage, route, action, adverse effects, and need for routine laboratory monitoring. If the patient is being discharged on a tapering corticosteroid dosage, be sure the patient or caregiver understands the schedule. If the patient had a central line placed for IV therapy, be sure the patient or caregiver has been properly trained in care, dressing changes, and sterile techniques. Teach the patient that antacids and oral drugs taken with meals can reduce gastric irritation. Weight gain, anxiety, and mood alterations are frequent side effects of steroid therapy. Parents and families need to be encouraged to lift activity restrictions when the child’s platelet count returns to a safe range.
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