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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.