Download Thrombocytopenia and Disseminated Intravascular Coagulation

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Thrombocytopenia and Disseminated Intravascular Coagulation (DIC)
John Miller
Thrombocytopenia
 Platelet count less than 100,000 per mL blood
 Can lead to abnormal bleeding
 Results from one of three mechanisms
o Decreased production
o Increased sequestration in spleen
o Accelerated destruction
 Autoimmune
 Heparin Induced
Secondary Causes: Diseases
 Immune or Idiopathic thrombocytopenic purpura
 Vitamin B12 anemia
 Folic acid anemia
 Aplastic anemia
 Leukemia
 Alcoholism
 DIC
 Infectious mononucleosis
 Viral infections
 HIV disease
Secondary Causes: Drugs
 Thiazide diuretics
 Aspirin
 Ibuprofen
 Indomethacin
 Naproxen
 Sulfonamides
 Phenytoin
 Cimetidine
 Digoxin
 Furosemide
 Heparin: Heparin Induced Thrombocytopenia
 Morphine
Assessment
 Excess menstrual bleeding
 Bleeding gums
 Petechiae
 Purpura
 Bruising
 Epistaxis
 Hematuria
 Thrombi: Arterial and Venous
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Diagnosis
 CBC with platelet count
 Antinuclear antibodies
 Serologic studies
 Bone marrow examination
Bone Marrow Aspiration and Biopsy https://youtu.be/NkdsLHBCreI
Treatment
 Medications
o Oral glucocorticoids
o Withdrawal of heparin therapy is vital.
 Platelet transfusions
 Plasmapheresis or plasma exchange therapy
 Surgery
o Splenectomy
Laparoscopic Splenectomy https://youtu.be/A4f3ldRfD9M
Plasmapheresis https://youtu.be/DVg78KXKhK4?list=PLJDkCQzyiW6bD6jEezbbqwzuUkhgnphCQ
Living with NMO- Plasmapheresis & The View of Bayshore from the Hospital https://youtu.be/0KEqZprSIic
Nursing Care
 Diagnoses, outcomes, and interventions
o Ineffective Protection
o Impaired Oral Mucous Membranes
Thrombocytopenia NCLEX® Review | NRSNGacademy.com https://youtu.be/GXIEWkHR4NM
Case study: 55-year-old man with thrombocytopenia http://www.healio.com/hematologyoncology/news/print/hemonc-today/%7B8a437625-dcd4-401c-9fd1-79dad20e7c6e%7D/case-study-55-yearold-man-with-thrombocytopenia
Ineffective Protection
 Bleeding risk associated with platelet counts
o Minimal with counts greater than 50,000 mm3
o Moderate when the count is between 20,000 and 50,000 mm 3
o Significant when the count falls below 20,000 mm3
 Assess for bleeding
 Monitor vital signs, heart, and breath sounds every 4 hours. Frequently assess for other manifestations of
bleeding:
o Skin and mucous membranes for petechiae, ecchymosis, and hematoma formation
o Gums, nasal membranes, and conjunctiva for bleeding
o Overt or occult blood in emesis, urine, or stool
o Vaginal bleeding
o Prolonged bleeding from puncture sites
o Neurologic changes: headache, visual changes, altered mental status, decreasing level of
consciousness, seizures
o Abdominal: epigastric pain, absence of bowel sounds, increasing abdominal girth, abdominal
guarding or rigidity.
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Prevent bleeding
 Procedures to avoid
o Rectal temperatures
o Urinary catheterization
o Parenteral injections to the extent possible
o Diagnostic procedures such as biopsy or lumbar puncture should be avoided if the platelet count
is less than 50,000 mm3.
o Procedures that use large-bore needles should be delayed until the platelet count is increased.
 Apply pressure to puncture sites for 3 to 5 minutes; apply pressure to arterial blood gas sites for 15 to 20
minutes.
 Instruct patient to avoid
o Forcefully blowing the nose or picking crusts from the nose
o Straining to have a bowel movement
o Forceful coughing or sneezing.
Impaired Oral Mucous Membranes
 Frequently assess the mouth for bleeding. Inquire about oral pain or tenderness.
 Encourage use of a soft-bristle toothbrush or sponge to clean teeth and gums.
 Instruct to rinse the mouth with saline every 2 to 4 hours. Apply petroleum jelly to lips as needed to
prevent dryness and cracking.
 Instruct to avoid alcohol-based mouthwashes, very hot foods, alcohol, and crusty foods. Teach to drink
cool liquids at least every 2 hours.
Disseminated Intravascular Coagulation
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Syndrome characterized by widespread intravascular clotting and bleeding
Can be severe and life-threatening or very mild
Etiology and Risk Factors
 Infection is the leading cause.
 Others
o Trauma and burns
o Liver failure
o Open heart surgery
o Obstetric complications
o Tumors
o Fat emboli
o Cirrhosis
o Shock
o Septicemia
Pathophysiology
 Begins with endothelial damage
 Initiates clotting cascade
o Clotting factors are depleted.
o Widespread clotting occurs within the microvasculature
 Thrombi, emboli impair tissue perfusion, leading to ischemia, infarction, necrosis
 Microemboli form in organ systems causing infarction and necrosis.
 Results in acute renal failure, pulmonary emboli, coma, gangrene of extremities, and/or
ARDS.
 Excess thrombin within the circulation overwhelms naturally occurring coagulants.
 Clotting factors and platelets consumed faster than they can be replaced
 Clotting activates fibrinolytic process that begin to break down clots
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Hemorrhage occurs.
Assessment
 Chronic DIC may be asymptomatic.
 Microvascular thrombosis
o Multiple organ system problems or even failure.
 Oliguria, acute renal failure
 Pulmonary emboli, acute respiratory distress, crackles
 Delirium, seizures, coma
 Peripheral ischemia and necrosis
 Hemorrhagic
o Prolonged bleeding in different organs systems, from invasive procedures, and spontaneously.
o Range from oozing to hemorrhage
 Purpura, petechiae, ecchymosis
 Prolonged bleeding from venipuncture
 Severe uncontrolled hemorrhage
 Tachycardia, hypotension
 Dyspnea, hemoptysis, respiratory congestion, crackles
Disseminated Intravascular Coagulation Definition & Causes https://youtu.be/FLi3YlworsI
Diagnosis
 CBC and platelet count
 Coagulation studies
 Fibrin degradation products (FDPs) or fibrin split products (FSPs)
Labs
 Increased bleeding times: PT, aPTT
 Low platelet count (thrombocytopenia): less than 100,000 (less than 20,000: spontaneous bleeding)
o Normal 150,000-450,000
 Fibrinogen level decreased
 D-Dimer (fibrin fragments) positive
 FDP (fibrin degradation products) positive
Treatment
 Toward underlying disorder, preventing further bleeding or massive thrombosis
 Heparin may be administered to interfere with clotting cascade.
 Replace clotting factors and volume
o RBCs (without anticoagulant or washed) for blood loss
o Fresh frozen plasma for clotting factors
o Cryoprecipitate not given much
 Control thrombosis.
o Antithrombin III
o Aminocaproic acid
o Activated protein C
Diagnostic Update: Monitor patients for disseminated intravascular coagulation and case study
http://www.nursingcenter.com/static?pageid=817180
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Nursing Care
 Diagnoses
o Ineffective Tissue Perfusion
o Impaired Gas Exchange
o Pain
o Fear
Nursing Interventions
 Assess all body systems for emboli and bleeding.
 Prevent or minimize trauma.
o Lab draws: longer pressure on site
o IV sites: observe for bleeding
o Avoid injections
o Frequent turning, reduce shear
 Support organ systems effected, such as respiratory, CV, renal, etc.
DIC (Disseminated Intravascular Coagulation) NCLEX® Review https://youtu.be/np6aiDcrU2Y