Download Situation MARTIN NABER, age 56, arrives at the urgent care clinic

Situation
MARTIN NABER, age 56, arrives at the urgent care clinic with severe bruising of the arms and lower legs
and scattered petechiae. He reports he has had nosebleeds and generalized fatigue for the last week. He
states that he has been so fatigued that he has been unable to continue to work for an entire work day
and he has aborted his training for his next marathon.
When drawing blood samples, the phlebotomist notes Mr. Naber is bleeding more than expected, and
applies a pressure dressing to the venipuncture site.
Background
Past medical History (PMH): osteoarthritis which he treats with OTC Aleve, GERD which he treats with
OTC cimetidine (Tagamet). He recently had an infected wound on his left great toe that was treated with
Cefuroxime.
Social History: He is married and lives with his wife in a rural area just west of Phoenix. He is a farmer
and boards horses. He has no children but volunteers with a local after school program for high risk
children.
Assesssment
Assesssment
Height: 5’8” Weight=240 lbs.
CBC: Hgb=12.4, Hct=38.0, RBC=4, Platelets=35,000, WBC=9.2
Physical assessment:
Head: Hair: normal distribution.
Face: symmetrical, smile, frown intact, dentition in fair repair (could use dentures), petechial rash
Mouth: oral mucosa intact. Buccal mucosa pale with petechiae.
Eyes: inferior conjunctiva pale, sclera white.
Thorax: AP: Transverse 1:2 ratio, HR=92 at rest, RR=20 at rest, BP=146/72. O2 sat on room air is 96%
Lungs are clear. Heart rate is regular with a systolic murmur.
Abdomen: No visible scars, no visible pulsation, no prominent venous pattern, no visible lumps or
masses. Bowel sounds + in all 4 quadrants. Abdomen is non- tender to palpation.
Upper Limbs: normal ROM, weak push pull bilaterally, spoon nails, capillary refill < 3 sec. Bruising
scattered
Lower Limbs: normal strength bilaterally, ROM limited in both hips, capillary refill > 3 sec. thick toe nails.
Scattered bruising in different stages of healing.
The physician suspects Immune Thrombocytopenic Purpura (ITP).
Admission orders:
Bedrest with bathroom privledges
Medications:
Cimetidine 800mg twice daily orally
ASA 81 mg orally daily
Solu-Medrol 125 mg IM every 4 hours
IV NACL 1 liter every 8 hours
The physician suspects Immune Thrombocytopenic Purpura (ITP).
You will be creating a concept map for Pernicious Anemia then presenting this to the class today.
1. Briefly describe the pathophysiology and potential complications of Immune
Thrombocytopenia Purpura
Thrombocytopenia is a reduction of platelets below 150,000/μL
Acute, severe, or prolonged decreases from this normal range can result in abnormal
hemostasis that manifests as prolonged bleeding from minor trauma to spontaneous
bleeding without injury..
In ITP, platelets are coated with antibodies. Although these platelets function normally,
when they reach the spleen, the antibody-coated platelets are recognized as foreign and
are destroyed by macrophages. In addition, it is now known that decreased platelet
production and the presence of infection, such as Helicobacter pylori or viral infection,
may contribute to this disorder. Platelets normally survive 8 to 10 days. However, in ITP
survival of platelets is shortened.
2. Does Mr. Naber have risk factors for the development of ITP?
He was recently on cephalosporin use along with NSAID and H2 blocker.
3. What are the collaborative lab tests?
CBC: assess platelets, and for signs of bleeding
aPTT: measures how well the coagulation sequence is functioning. Used with heparin
PT: a liver. It converts to thrombin in the clotting cascade.It measure the amount of time
for clot formation. Usually measured with INR:
Bone marrow exam is done to rule out production problems as the cause of
thrombocytopenia (e.g., leukemia, aplastic anemia, other myeloproliferative disorders).
4. What nursing interventions are appropriate for a patient undergoing a bone marrow
biopsy?
5. What are appropriate focused subjective assessments for a patient who has ITP?
Question the patient looking for specific signs and symptoms
General: dizziness, weakness, joint pain, headaches, fainting etc.
Head: Epistaxis (nosebleeds) Bleeding gums
Thorax: tachycardia
GI: tarry stools or frank bleeding lower or upper GI
GU: hematuria,
Depends on where the bleed is if he has one.
Diet, the use of herbals and other OTC meds, Alcohol use other medications that may have the
adverse effect of thrombocytopenia.
6. What are appropriate focused objective assessments for a patient who has ITP.
Vitals, CBC with a peripheral smear (to look at the cell size ad color), B12 level, Shillings test to
confirm Pernicious anemia.
Vital signs
7. Highlight medications that correlate to this patients diagnosis.
Do you have any concerns regarding home medications or the ones ordered in the hospital?
8. List the potential complications for a patient with thrombocytopenia.
Hemorrhage, injury
9. What interventions need to be initiated to prevent complications?
See patient care plan for the treatment for bleeding precautions.