Patient With Thrombocytopenia Revision

PATIENT WITH IDIOPATHIC THROMBOCYTOPENIA PURPURA

A Case Study

Presented to

The Clinical Instructors

AUP College of Nursing

Silang, Cavite

In Partial Fulfillment

Of the Requirements in

Maternal & Child Health Nursing Care Management

Presented By:

Jabat, Sienna

Adante, Lindy

Sales, Raymond

Tuazon, Stephen

March 13, 2011

CHAPTER I

INTRODUCTION

Idiopathic thrombocytopenic purpura is a blood disorder characterized by an abnormal

decrease in the number of platelets in the blood. Platelets are cells in the blood that help stop

bleeding. A decrease in platelets can result in easy bruising, bleeding gums, and internal

bleeding. ITP is a disease that affects all ages, but is more common among children and young

women.

There are 2 forms of ITP: acute and chronic. The acute form, which is normally found in

children, is a disease that is self-limiting usually following a viral infection of 1-6 weeks. This is

most commonly seen in young children (2 to 6 years old). The symptoms may follow a viral

illness, such as chickenpox. Acute ITP usually has a very sudden onset and the symptoms

usually disappear in less than six months (often within a few weeks). The disorder usually does

not recur. Acute ITP is the most common form of the disorder. In the chronic form, the onset of

the disorder can happen at any age, and the symptoms can last a minimum of six months or

several years. Adults have this form more often than children, but it does affect adolescents.

Females have it two to three times more often than males. Chronic ITP can recur often and

requires continual follow up care with a blood specialist (hematologist).

Idiopathic- means the cause is unknown.

Thrombocytopenia- means a decreased number of platelets in the blood.

Purpura- refers to the purple discoloring of the skin, as with a bruise.

Significance of the Study

As will be made evident in the follow presentation of research, ITP is becoming more and

more of a problem as prevalence rates increase. In the United States alone, it affects

approximately four to eight per 100,000 children under the age of 15 each year. The purpose of

performing this study is to provide knowledge to all those present with vital information that will

aid them in handling future cases and incidences relating to the topic.

As students and professional healthcare providers, we have the responsibility to care for

our patients affected by this disease as well as others. By obtaining knowledge and proper

understanding of the disease and how it works, ITP’s progression and prevalence can be

monitored, controlled, and ultimately stopped.

Objectives of the Study

At the end of this case presentation, students will be able to:

1) Define Idiopathic Thrombocytopenic Purpura

2) Identify risk factors associated with the disease

3) List signs and symptoms related to ITP

4) Know what body systems ITP affects and how

5) Understand the pathophysiology and disease process

6) Apply proper management in caring for patients with ITP

7) Formulate appropriate nursing care plans for patients with ITP

CHAPTER II

PATIENT DATABASE

Demographic Data:

Baby Ayesha E. Tompong was delivered via normal spontaneous delivery by her mother

Evalyn Tompong at Calamba Medical Center with the service of Dr. Fonte Delmundo on July

31, 2010. Ayesha currently resides at BLK 71 Lot 10 Phase 2 Asia 2 Kapayapaan Ville,

Canlubang, Calamba City, Laguna. Ayesha was admitted in the Pediatric Department of

Calamba Medical Center on November 16, 2010 with a chief complaint of rashes and epistaxis.

She was diagnosed with Idiopathic Thrombocytopenic Purpura.

Developmental Tasks:

a) Erik Erikson (Psychosocial Development)

Stage: Infancy

Age:Birth-18 months

Central task: Trust versus Mistrust

Developmental task: Learn to build trust with others. This is so important because the

baby needs to feel attention in order to develop security within environment.

Whenever the baby cry the mother gives her a comfort we can see that the child has a

trust to her mother, that every time I check her V/S the child cries so the part of the

mother is to give her a comfort so the baby builds a trust.

b) Sigmund Freud (Psychosocial Development)

Stage: Oral

Age: birth to 1 ½ years

Developmental task: Mouth is the center of pleasure (major source of gratification and

exploration), security is primary need, Major conflict: weaning.

The main focus of this task is to make feeding a pleasurable experience giving the child a

sense of comfort and security. This is met by the mother breastfeeding the baby to initiate

satisfaction of baby’s needs.

Health History

a) Family History

- (+) hypertension on father’s side

- (+) asthma on mother’s side

b) Past Medical History

-NSD

-cough and colds 6 days prior to admission

-a fever 3 days prior to admission

c) History of Present Illness

Six days prior to admission the mother brought baby Ayesha to the local health center to

have her DPT vaccination. The mother verbalized that the procedure that they used was

improper, because the equipment was not cleaned properly. Also, alcohol was not used to

disinfect the injection site. After two days, the baby had a high fever with a temperature of 38

Celsius. The mother also noticed blood coming from Ayesha’s nose and rashes all over the body.

She was brought to Calamba Medical Center for treatment.

Nursing Assessment

Assessment for Idiopathic Thrombocytopenic Purpura

Normal Findings Book Picture Actual signs and symptoms of Patient

INTEGUMENTARY

Even in color Hair Distribution

even Warm to touch Good Skin turgor No lesions, lumps

or masses Firm nails Acynotic nail beds Good capillary refill

(<3 sec)

Pallor/ Jaundiced of mucous membranes

Pallor/Cyanotic nail beds

Pallor of gums, conjunctiva and palmar creases

Petechiae, purpura, and large bruises

Cool to touch Nails become

brittle and may lose the normal convex shape; over time, nails become concave and fingers assume clublike appearance.

Poor capillary refill time

General Pallor Pale palpebral conjunctiva Warm to touch (+) Petechiae (+) Purpura (-) Bruises

RESPIRATORY

Symmetrical Chest expansion

Eupnea

Increased in RR, rhythm and depth

Easy fatigability

Increased RR, rhythm and depth (Tachypnic)

(+) Epistaxis

Clear breath sounds No adventitious

sounds heard

Decreased oxygen saturation levels (RBCs)

Epistaxis Gingival bleeding

CARDIOVASCULAR

Adequate Cardiac Output

HR of 80-140 (for infants)

No murmurs or gallops

Normal rate and rhythm

Adequate venous return

Heaves Distended neck

veins Edema Signs of phlebitis Heart murmurs Heart Gallops Irregular heart

rhythms Orthostatic

hypotension Abnormal BP

(increased)

(+) Increased HR (+) Thready pulse

GENITO-REPRODUCTIVE

Yellow to amber in color

No protenuria, or hematuria, glucose, ketones

Urine output of 30cc per hour

Urine specific gravity of 1.015- 1.025

Normal menstruation

Hematuria Dark brownish gold

urine Protenuria Profuse menstrual

bleeding

Normal

MUSCULOSKELETAL

Normal gait and balance

Good muscle tone/strength

Good skeletal

Rib/Sternal tenderness

Difficulty in ROM Swelling or joint

pain

Normal

formation No fractures,

deformities. Full ROM

Bone deformities (flat bones)

HEMATOLOGIC

Normal RBC, WBC production

Normal Hemoglobin and Hematocrit

♪ Normocytic, Normochromic RBC

Decreased RBC production

Decreased Hemoglobin/ Hematocrit

Decreased bleeding time

Increased clotting time

(+)Decreased RBC production

(+)Increased clotting time (+)Decreased bleeding time (+)Decreased hemoglobin (+)Decreased hematocrit

CHAPTER III

THE DISEASE ENTITY

A. Medical Diagnosis with Chief Complaints

The patient was brought to Calamba Medical Center on November 16, 2010 accompanied

with both parents with chief complaints of rashes and nose bleeding. She was diagnosed with

Idiopathic Thrombocytopenic Purpura.

B. Theoretical Background

1. Blood

Most cells of a multicellular organism cannot move around to obtain oxygen and

nutrients or eliminate carbon dioxide and other wastes. Instead, these needs are met by

two fluids: blood and interstitial fluid. Blood is a connective tissue composed of a liquid

extracellular matrix called blood plasma that dissolves and suspends various cells and

cell fragments. Blood transports oxygen from the lungs and nutrients from the

gastrointestinal tract. The oxygen nutrients subsequently diffuse from the blood into the

interstitial fluid and the into body cells. CO2 and other wastes are then moved in the

oppostie direction, from body cells to interstitial fluid to the blood. Blood then transports

the wastes to various organs—the lungs, kidneys, and skin—for elimination from the

body.

2. Functions of the Blood

Blood, which is a liquid connective tissue, has 3 general functions:

A. Transportation.

As previously stated, blood transfers oxygen and nutrients all over the body.

Blood also transports heat and waste products to various organs for elimination from

the body.

B. Regulation.

Circulatory blood helps maintain homeostasis of all body fluids. Blood helps

regulate pH through the use of buffers. It also helps adjust body temperature through

the heat-absorbing and coolant properties of the water in blood plasma and its

variable rate of flow through the skin, where excess heat can be lost from the blood to

the environment. In addition, blood osmotic pressure influences the water content of

cells, mainly through interactions of dissolved ions and proteins.

C. Protection.

Blood can clot, which protects against its excessive loss from the cardiovascular

system after an injury. In addition, its white blood cells protect against disease by

carrying phagocytosis. Several types of blood proteins including antibodies,

interferons, and complement, help protect against disease in a variety of ways.

3. Physical Characteristics of Blood

Blood is denser and more viscous than water and feels slightly sticky. The

temperature of blood is 38°C, about 1°C higher than oral or rectal body temperature, and

it has a slightly alkaline pH ranging from 7.35-7.45. Blood constitutes about 20% of

extracellular fluid, amounting to 8% of the total body mass. The blood volume is 5 to 6

liters in an average-sized adult male and 4 to 5 liters in an averaged-sized adult female.

Several hormones, regulated by negative feedback, ensure that blood volume and osmotic

pressure remain relatively constant. Especially important are the hormones aldosterone,

anitdiuretic hormone, and atrial natriuretic peptide, which regulate how much water is

excreted in the urine.

4. Components of Blood

Blood has 2 components: (1) blood plasma, a watery liquid extracellular matrix

that contains dissolved substances, and (2) formed elements, which are cells and cell

fragments. Blood is about 45% formed elements and 55% blood plasma. Normally more

than 99% of the formed elements are cells named for their red color—red blood cells

(RBCs). Pale, colorless white blood cells (WBCs) and platelets occupy less than 1% of

total blood volume. Because they are less dense than red blood cells but more dense than

blood plasma, they form a very think buffy coat layer between the packed RBCs and

plasma in centrifuged blood.

5. Platelets

Under the influence of the hormone thrombopoietin, myeloid stem cells develop into

megakaryocyte-colony-forming cells that, in turn, develop into precurser cells called

megakaryoblasts. Megakaryoblasts transform into megakaryocytes, huge cells that

splinter into 2000 to 3000 fragments. Each fragment, enclosed by a piece of the

plasma membrane, is a platelet (thrombocyte). Platelets break off from the

megakaryocytes in red bone marrow and then enter the blood circulation. Betweeen

150,000 and 400,000 plateltes are present in each uL of blood. Each is disc-shaped,

2-4 um in diameter, and has many vesicles but no nucleus.

Platelets help stop blood loss form damaged blood vessles by forming a platelet plug.

Their granules also contain chemicals that, once released, promote blood clotting.

Platelets have a short life span, normally just 5-9 days. Aged and dead platelets are

removed by fixed macrophages in the spleen and liver.

6. Complete Blood Count (CBC)

A complete blood count is a very valuable test that screens for anemia and various

infections. Usually included are counts of RBCs, WBCs, and platelets per uL of whole

blood; hematocrit; and differential white blood cell count. The amount of hemoglobin in

grams per milliliter of blood also is determined. Normal hemoglobin ranges are: infants,

14-20 g/100mL of blood; adult femals, 12-16 g/100mL of blood; and adult males, 13.5-

18 g/100 mL of blood; and the normal bleeding time is 1-3 mins, and the clotting time is

3-5 mins.

7. Blood Clotting

Normally, blood remains in its liquid form as long as it stays within its vessels. If it is

drawn form the body, however, it thickens and forms a gel. Eventually, the gel separates

fromt he liquid. The straw-colored liquid, called serum, is simply bood plasma minus

the clotting proteins. The gel is called a clot. It consists of a network of insoluble protein

fibers called fibrin in which the formed elements of blood are trapped.

The process of gel formation, called clotting or coagulation, is a series of chemical

reaciton that culminates in formation of fibrin threads. If blood clotes too easily, the

result can be thrombosis—clotting in an undamaged blood vessel. If the blood takes too

long to clot, hemorrhage can occur.

Clotting involves several substances known as clotting (coagulation) factors. These

factors include calcium ions, several inactive enzymes that are synthesized by

hepatocytes and released into the bloodstream, and various molecules associated with

platelets or released by damaged tissues. Most clotting factors are identified by Roman

numerals that indicate the order of their discovery (not necessarily the order of their

participationint he clotting process).

Etiology: Predisposing Factors:

Idiopathic *Previous Viral Infection

Virus enters body

Antibodies bind to platelet auto-antigens Accelerated platelet destruction

Phagocytosis of platelets by WBC’s Protein (IgG) on platelet cell membrane stimulates

Platelet destruction by antibody production of autoantibodies

Somatic Mutation Adheres to platelet membrane

Chemical, physiological, and biological changes Spleen reacts to the platelet

in the host/target cell (platelet) Platelets are destroyed by phagocytic cells

Inhibits normal cell growth Autoimmune Response

Uncontrolled growth and proliferation of Coagulation is depleted

defective cells Bleeding from many small blood vessels throughout the body

CHAPTER IV

Pathophysiology

Of

Idiopathic Thrombocytopenic Purpura

Bleeding Disorders

Respiratory: Cardiovascular: Genito-Reproductive: Gastrointestinal: Integumentary: Musculoskeletal: Hematologic:

>Epistaxis >Hypovolemia >Hematuria >Hematochezia >Petechiae >Brittle bone > Bleeding time

>Bleeding gums >Hypotension >Profuse menstrual >Hematemesis >Purpura >Fracture > Clotting time

>Irregular heart rhythm bleeding >Melena >Bruises > Easy Fatigability

>Thready pulse >Spleenomegaly

Profuse Bleeding

Blood volume for circulation

Hypovolemic Shock

Multiple Organ Failure

Death

The etiology of thrombocytopenia is unknown. However, there are predisposing factors

that affect this disease and its process. Among the modifiable effects is the lifestyle of the host,

the environment, and low economic status. Among the non-modifiable effects are sex, age, and

heredity.

The disease process begins on the normal proto-hematogene or the production of blood.

This normal production of blood promotes healthy cell growth. ITP begins to attack and destroy

the bone marrow in the body. This triggers a somatic mutation causing chemical, physical, and

biological changes in the host/ target cell (platelets). This chages inhibits normal genetic cell

growth, thus, leading to the uncontrolled growth and proliferation of defected cells within the

body. The destruction of bone marrow stated earlier accelarates platelet destruction due to the

fact that the location of platelet production is in bone marrow itself. The body’s response to this

cascade of events is for the protein IgG found on platelet cell membranes to begin to stimulate

the production of autoantibodies which adhere to the platelet membrane itself. The spleen, the

storehouse of platelets, reacts to the unrecognized platelet and begins to destroy them as if they

were foreign bodies. The body’s autoimmune system begins to kick-in at this time and attempts

to fight off the unrecognized platelets. This response leads to the coagualation, or depeletion of

platelets. Since platets are the main ingredient or components of blood clotting, bleeding from

any small blood vessels throughout the body begins to become a liabity.

Excessive bleeding can affect multiple systems found in the body. In the upper

respiratory tract, epistaxis and bleeding gums can be observe.

Within the cardiovascular system, an excess loss of blood leads to hypovolemia, or

decrease in blood volume, which then leads to hypotention made evident by irregular heart

rhythm and a thready pulse.

Bleeding in the Genito-Reproductive system exhibits hematuria, also known as blood in

the urine. Furthermore, if the patient is found to be on their menstrual cycle, profuse bleeding

may be observed.

Hematochezia, bleeding in the upper Gastrointestinal Tract, hematemesis, vomitting

blood, and melena, or lower GI tract hemorrhaging are evidences of blood within the system.

Spleenomegaly, or the swelling of the spleen results from the body’s response in attacking the

platelets found to be in contact with autoantibodies are stored in the spleen causing an over

accommodation of cells, thus swelling occurs.

Out of all the system, integumentary system is the most obvious in detecting ITP with

unaided eye. Becuase coagulation is depleted and bleeding can occur from any small blood

vessels, petechiae, purpura and bruises are present.

Because the bone marrow is a part of the musculoskeletal system, bones starts to become

brittle because of the destruction of the bone marrow. Fractures are also one of the things that

the health care team should watch our for.

The most objective and the most realiable system in our body and can really diagnose

blood disorders is the hematologic system. Bleeding time is decreased and the bleeding time,

increased clotting time and beause of the bleeding experience by the patient, easy fatigability is

easily noted.

Any bleeding in the body affects its hemodynamics. Profuse bleeding can lead to

decreasing blood volume in the body. If the hemodynamics are not stable and not treated

promptly, hypovolemia may result, particularly in this case. If hypovolemia is not corrected

immediately, the body will try to compensate to maintain its function and keeping the vital

organs running. As the body compensates, the condition of the patient is improving. When the

body reaches the point that it cannont compensate for the loss anymore, the body starts to shut

down one by one, thus, leading to hypovolemic shock. Hypovelemic shock can be fatal becasue

multiple organ failure occurs, thus, leading to death.

CHAPTER V

NURSING CARE PLAN

PROBLEM #1: Fever

Cues:

Subjective:

“Pinabakunahan namin siya sa center tapos anim na araw bago namin siya dalhin sa hospital, nilgnat na siya ng mataas” as verbalized by

patient’s mother.

Objective:

-Temp:38-39 (November 10, 2010)

-flushed skin; warm to touch

-Irritibality

Nursing Diagnosis:

Hyperthermia related to inflammatory response

Fever is considered one of the body's immune mechanisms to attempt a neutralization of a perceived threat inside the body. Temperature is

ultimately regulated in the hypothalamus. When the set point is raised, the body increases its temperature through both active generations of

heat and retaining heat and vasoconstriction both reduces heat loss through the skin and causes the person increases temperature. (NCP 7th

Edition; Doenges; pp 775 )

Planning

NIC: Thermoregulation

Goal:

Short term:

At the end of the shift of nursing intervention the patient’s temperature will decrease from 38-39 to 37.2.

Long term:

After 1-2 days of nursing intervention the patient’s body temperature will be stable within normal range between 36.4-37.2

NOC: Temperature Regulation

Nursing Intervention:

Independent:

1. Monitored vital signs. Compensatory changes in vital signs and development of dysrhythmias reflect effects of hypoxia or cardiovascular

system. (Ibid)

2. Performed tepid sponge bath.To decrease temperature by means of evaporation and conduction.

3. Regular checking of V/S. q1. To check if there is changing on V/S also in the Temp.

4. Discuss importance of adequate fluid intake. To prevent dehydration.

Dependent:

1. Administered Paracetamol. It decreases the fever and inhibits the effect of pyrogenes on the hypothalamic heat regulating center.

Evaluation

Short term:

Goal met. At the end of the shift of nursing intervention the patient’s temperature decreased from 38-39 to 37.2.

Long term:

Goal met. After 1-2 days of nursing intervention the patient’s body temperature became stable to 37.2.

PROBLEM #2: Body weakness

Cues:

Subjective:

“Palaging tulog siya halos hindi na niya ginagalaw ang katawan niya”, as verbalized by the patient’s mother.

Objective:

-Irritability

-Restlessness

-Discomfort

-Minimal decrease in feeding/ decrease sucking during feeding

Nursing Diagnosis:

Fatigue r/t decreased RBC and decreased Hemoglobin.

RBC is responsible for the delivery of oxygen to our body. Decreased levels caused decreased supply of oxygen to different parts of the body

which eventually leads to fatigue. Intolerance in activity may affect the client physiologically and psychologically, and may not complete

required or desired daily activities. (Geisller- Murr;2005 :389)

Planning

NOC: Energy Conservation

Short term:

After the end of the shift the patient will be able to tolerate activity as evidenced by raising her hands to her parents.

Long term:

After 2-3 days of nursing interventions, the patient will be able to experience comfort as and responding positively through smiling and moving

spontaneously.

Planning:

NIC: Energy Management

Independent:

1. Provided quiet environment and uninterrupted rest periods. Encouraged parents to have rest periods for the child before feeding.

Restores energy needed for activity, cellular regeneration, and tissue healing. (Doenges;2006:232

2. Evaluated action of irritability and fatigue of the patient from parents. Effects of anemia may be cumulative, necessitating assistance.

(Doenges;2006:232)

3 .Recommended breastfeeding for the baby. Breastfeed milk is more nutritious for infants. It has certain antibodies that give more protection

to the baby against diseases. (Doenges;2006:233)

4. Instructed parents and assisted in changing position at least every 2 hours (supine/side lying). Reduces risk of tissue ischemia/injury.

(Doenges;2006:233)

Dependent

1. Provided supplemental fluids such as IVF#5 (D5 IMB5 00cc x 20cc/hr). To avoid dehydration and exhaustion. (Doenges;2006:233)

Evaluation

Short term:

Goal met. After the end of the shift the patient was able to raised her hands with her parents and other relatives.

Long term:

Goal met. After 2-3 days of nursing intervention the patient experienced comfort and was able to smile back and energetic movement whenever

her parents makes cooing sound.

PROBLEM #3: Decreased Hemoglobin and RBC count

Cues:

Subjective:

“Nung mga nakaraang araw napansin ko na dumodugo ang ilong nang baby ko”, as verbalized by the patient’s mother.

Objective

-Hemoglobin: 102

-RBC’s: 3.5

-Hematocrit: 0.30

Nursing Diagnosis:

Deficient fluid volume r/t

Platelets are cells in the blood that helps to stop bleeding, so if your platelets will decrease, what else can help your blood to increase, but

nothing.

Planning:

NOC: Blood Coagulation

Short term:

After 8 hours of nursing intervention the patient’s will manifest an absence of bleeding.

Long term:

After 3-5 days of nursing intervention the patient’s platelet count will return to within the normal range of 150-400 k

Nursing Intervention

NIC: Bleeding Precautions; Chemotherapy Management; Blood Product Administration

1. Monitored platelets daily. Risk of bleeding increases as platelet count drops:

<20,000/mm3 = severe risk

20,000 to 50,000/mm3= moderate risk; may note prolonged bleeding at invasive sites

50,000 to 100,000/ mm3= mild risk; does not usually require treatment.

>100,000/mm3= No significant risk.

2. Monitored coagulation parameters (fibrinogen, thrombin time, bleeding time, fibrin degradation products) if indicated. Changes in

coagulation profile maybe marked by ecchymosis, hematomas, petechiae, blood in body excretions, bleeding from body orifices, and change in

neurological status.

3. Inspected patient irregularly for evidence of the following:

Spontaneous petechiae (all skin surfaces, including oral mucosa)

If any significant bleeding occurs, monitored vital signs closely until bleeding is controlled.

Early assessment facilitates prompt treatment and reduced risk for complications. Patient safety is priority.

Dependent:

1. Administered IVIg. Immunoglobulins are proteins manufactured in the body that the immune system uses to produce antibodies and various

factors, which are used to communicate with immune system cells and modify the immune reaction.

Evaluation

Short term:

Goal met. After 8 hours of nursing intervention the patient manifested no signs of active bleeding.

Long term.

Goal met. After 3-5 days of nursing intervention the patient’s platelet count will returned to within the normal range of 150-400 k

PROBLEM #4: Rashes

Cues:

Subjective:

“Napansin kong may rashes ang kamay ng anak ko.” Mother stated

Objective

-Rashes

-Disruption of skin surface (epidermis)

-Poor capillary refill (4-5 sec)

Nursing Diagnosis:

Impaired skin integrity related to altered immune system as manifested by rashes

Altered epidermis due to bleeding and tiny purple spot on the skin

Planning

NOC: Skin and mucous membrane

Short term:

After 8 hours of nursing intervention the patient will be able to manifest decreased rashes, redness on the skin

Long term:

After 2 weeks of nursing intervention the patient will be able to improved or have good capillary refill and regain skin integrity such as remove

the rashes

NIC: Infection Protection

Independent:

1. Assess the history of condition, including age at onset, date of first episode, original site, characteristic of skin, and any changes that

have occurred. Redness, swelling, pain, itching are signs of the body’s immune response to localized tissue trauma.

2.Maintain proper environmental conditions, including room temperature and ventilation. To provide evidence of the effective of skin

regimen.

3. Maintain proper environmental conditions, including room temperature and ventilation. -Providing comfortable environment.

Dependent:

Evaluation:

Short term

Goal met. After 8 hours nursing intervention the patient manifested decreased rashes and redness on the skin

Long term

Goal met. After 2 weeks of nursing intervention the patient’s rashes all over the body will gone.

PROBLEM #5: Difficulty of breathing

Cues:

Subjective:

“Nahihirapan ang anak kong huminga”, as verbalized by the mother.

Objective:

-RR: 65 bpm (November 16, 2010)

-Seen patient’s lying in bed asleep.

-Pallor of skin and mucous membrane

- Bluish discoloration on left and right upper arms

-difficulty of breathing at rest noted.

Nursing Diagnosis:

Impaired gas exchanged related to decreased oxygen carrying capacity of blood due to bleeding.

A changed in patient’s respiratory rate or pattern maybe one of the earliest indication of the need of oxygen therapy. The change in respiratory rate may result from hypoxymia which is a decreased in arterial tension in the blood manifested by difficulty of breathing.

Planning

NOC: Respiratory status gas exchange

Short term:

After 5 minutes of nursing intervention the client will be able demonstrate the improve ventilation /oxygenation .

Long Term:

After the end of the shift of nursing intervention the patient will be able to have good airway clearance.

Nursing Intervention:

NIC: Respiratory monitoring: oxygen therapy

Independent:

1.Assess patient’s V/S and evaluate for any adverse effect of CO2 toxicity (such as difficulty of breathing). Excessive CO2 blood level may cause respiratory obstruction

2 . Promote frequent position such us sitting and deep breathing exercised. Promote lung expansion.

3. Provide fluid with electrolytes provide supplemental fluid and calories. To prevent dehydration.

Dependent:

1. Adjust O2 level if patient’s shows adverse effect as indicated. ( Oxygen as ordered).Complication usually from prolong O2 therapy.

Evaluation:

Short term:

Goal met. After 5 minutes of nursing intervention the client demonstrated the improve ventilation /oxygenation

Long term:

After 8 hours of nursing intervention the patient have good airway clearance.

PROBLEM #6: Pallor

Cues:

Subjective:

SUBJECTIVE:

“Napansin kong maputla ang anak ko at medyo mabilis din ang paghinga .” Mother stated.

OBJECTIVE:

-pale skin

-thready pulse

-Poor capillary refill 4-5 sec.

-restlessness

-hemoglobin of 102 (Normal value: 130-180 gm/L)

Nursing Diagnosis

Ineffective tissue perfusion related to decreased circulating blood volume due to bleeding

Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level. Tissue perfusion problems can exist without decreased cardiac output; however there may be a relationship between cardiac output and tissue perfusion.

NOC:Tissue perfusion: cardiac

Short term:

After 30 minutes of nursing intervention the patient will be able to improved tissue perfusion

Long term:

After 1 day of nursing intervention the patient will be able to maintain vital signs and increase tissue perfusion

Nursing Intervention:

NIC: Circulatory care

Independent:

1. Assess skin for coolness, pallor, cyanosis, diaphoresis, delayed capillary refill. Changes may reflect diminished circulation/hypoxia potentiating capillary occlusion.

2. Monitor vital signs carefully. Assess pulse for rate, rhythm, and volume. Note hypertension; rapid, weak, thread pulse; and increased/shallow respirations. Sludging and sickling in peripheral vessels may lead to complete or partial obliteration of a vessel with diminished perfusion to surrounding tissues.

3. Maintain adequate fluid intake. Monitor urine output. Dehydration not only causes hypovolemic but increases sickling and occlusion of capillaries. Decreased renal perfusion/failure may occur because of vascular occlusion.

4. Maintain environment temperature and body warmth without overheating. Prevent vasoconstriction; aids in maintaining circulation and perfusion. Excessive body heat may cause diaphoresis, and adding to insensible fluid losses and risk for dehydration.

Collaborative:

1.Assist with treatment of underlying condition such as medications, fluid replacement/rehydration , as indicated. To improve tissue perfusion/organ function.

Evaluation:

Short term:

Goal met.

After 30 minutes of nursing intervention the patient manifested good tissue perfusion with pinkish color.

Long term:

Goal met.

After 1 day of nursing intervention the patient improved tissue perfusion as evidence by stabilized vital signs, adequate intake/ output, normal capillary refill.

CHAPTER VI

THE MANAGEMENT

DIAGNOSTIC TEST:

1. Complete Blood Count (CBC)

Type of Test: Blood

Body System and Functions: Hematological System

Normal Findings:

Hematocrit:

Male 41.5%-50.4%

Female 35.9%-44.6%

Hemoglobin:

Male 14.0-17.5 g/dL

Female 12.3-15.3 g/dL

Red Cell Count 4.7-6.1 M/mL

White Cell Count 4.8-10.8 K/mL

Platelet Count 150-400 K/mL

Neutrophils 35%-70%

Lymphocytes 25%-45%

Monocytes 0%-12%

Eosinophils 0%-7%

Basophils 0%-2%

Test Description: The CBC is a combination report of a series of tests of the peripheral blood.

The quantity, percentage, variety, concentrations, and quality of blood cells are identified. The

tests usually included in a CBC are hematocrit, hemoglobin, red cell count, red blood cells

indices, white cell count, and differential white blood cells count. Red blood cell indices consist

of the following tests: stained red cell examination, and platelet count. The differential white

blood cell count consists of neutrophils, eosinophils, basophils, lymphocytes, and monocytes.

November 20, 2010

Blood Component Normal Value (CMC) Patient’s ResultRBC (3.9-5.2 x 10^6/uL) 3.5Hematocrit (0.40-0.54) 0.30Hemoglobin (130-180 gm/L) 102WBC 4.5-11 X 10^9/L 4.5Bleeding Time 1-3 min 1Clotting Time 2-5 minPlatelets 130-400 x 10^3 Ul 120

2. Immune Globulin for I.V.- IV Route only

Immunoglobulins are proteins manufactured in the body that the immune system uses to

produce antibodies and various factors, which are used to communicate with immune system

cells and modify the immune reaction. There are 4 immunoglobulin subtypes, immunoglobulin

M (IgM), immunoglobulin A (IgA), immunoglobulin G (IgG or gamma globulin) and

immunoglobulin E (IgE). IgG are the basic component used in the manufacture of long-acting

antibodies. Immune globulin products derived from human plasma were first used in 1952 to

treat patients with conditions of immune deficiency and chronic lymphocytic leukemia. These

first immune globulin transfusions were administered intramuscularly. In the early 1980s

intravenous preparations of immune globulin (IVIG) were first used to treat patients with

idiopathic thrombocytopenic purpura, an autoimmune condition causing platelet deficiencies.

IVIG is used in many different autoimmune disorders, and most IVIG is produced from

pooled human plasma derived from multiple blood donors. IVIG typically contains more than 95

percent unmodified IgG with intact immune signaling functions along with trace amounts of IgA

and IgM, cytokines, soluble complement, and HLA molecules. IVIG is an immunomodulator

in that it balances the immune system, strengthening immune systems that are too weak

and reducing activity in overactive immune systems. IVIG also contains anti-idiotypes that

neutralize various autoantibodies.

3. Paracetamol- 100mg/ml, 0.5 drops, P.O, PRN

Direct action unclear. Pain relief may result from inhibition of prostaglandin synthesis in

CNS, with subsequent blockage of pain impulses. Fever reduction may result from vasodilation

and increased peripheral blood flow in hypothalamus, which dissipates heat and lowers body

temperature.

The preparation is indicated in diseases manifesting with pain and fever: headache,

toothache, mild and moderate postoperative and injury pain, high temperature, infectious

diseases and chills

4. Solucortef- 20mg, IV

Solu-Cortef is a corticosteroid. Corticosteroids are hormones produced naturally by the

adrenal glands which have many important functions on every organ system. Corticosteroids

affect the heart and its response to natural chemicals that affect heart rate. They also affect water

and salt balance in the body and allow the body to cope with stress. They do so by increasing the

rate and force of the heartbeat, increasing blood supply to essential areas, such as the heart, brain

and muscles, and increasing the body’s supply of energy by raising blood sugar levels. Solu-

Cortef is also used to control symptoms caused by sudden low levels of corticosteroids in the

body. This can be due to many reasons, including abnormal stress in disorders such as Addison’s

disease, or surgical removal of the adrenal glands. Low blood levels of corticosteroids must be

treated with replacement therapy to ensure the body functions normally. Solu-Cortef is also

used to treat inflammation, and does so by acting within cells to prevent the release of

certain chemicals tat are important in the immune system. These chemicals are normally

involved in producing immune and allergic responses, resulting in inflammation. Decreasing the

release of these chemicals in a particular area reduces inflammation.

5. Comprilex- 1mL, P.O, OD

Comprilex kills actively growing tubercle bacilli by inhibiting the biosynthesis of

mycolic acids which are the major components of the bacterial cell wall of Mycobacterium

tuberculosis. Pyridoxine hydrochloride: Pyridoxine hydrochloride is converted to its active

forms, pyridoxal phosphate and pyridoxamine phosphate, required in the metabolism of proteins,

carbohydrates and fats. It enables body tissues to obtain energy from metabolism to

carbohydrates, fats, and proteins by functioning as coenzymes for various metabolic and

biochemical reactions.

GENERAL EVALUATION OF THE STUDY

A. Implication of the study to:

1.Nursing Education

Nursing education is the furtherment and complete utilization of resources to equip one’s

self with the knowledge and skills necessary to enable him/her to perform at maximum capacity

not only as a nurse in the workplace, but as a certified healthcare provider where ever the calling

may be. We as nurses must be educated in order to apply ourselves within our scope of practice.

2. Nursing Practice

Upon availing of proper education, we must then begin to practice what was taught to us

in order to fulfill that which is expected of us. The field in which we work is full of unexpected

twists and turns and we must be ready to face these head on. Our goal in this chosen career is to

practice the unique set of skills given to us by our mentors to gradually build confidence and

maturity so that we as professionals may be able to restore, promote, and maintain the good

health of those under our care.

3. Nursing Research

There is a continual desire to strive in improving the status and prestige that is our

profession. As the years go by, technology is furthering its grasp challenging our very foundation

of reality. We must continue to update ourselves with the new and upcoming trends, studies, and

research that are being incorporated each and every day. In order for us to meet the demand, we

must fervently yet patiently strive to stay informed, and by doing such, we as nurses can provide

the best care for our patients.

B. Summary and Conclusion:

Hematologic diseases are complex disorders that require the nurse to understand the

hematopoietic system. The nurse is often involved in the administration of blood and blood

products for treatment of these various disorders. Many of the blood disorders are life-

threatening; others are easily controlled with proper nutrition or regular medication.

Because blood and blood product transfusions are widely used in the treatment of

hematologic disorders, it is vital that you understand this procedure, the implications of these

procedures, and the proper techniques of administration so the client will receive safe and

effective care.

Idiopathic Thrombocytopenic Purpura is a blood disorder characterized by an abnormal

decrease in the number of platelets in the blood. Knowledge of the interaction of the genetic

profile coupled with a person's lifestyle, work environment, and family context provide a more

holistic picture of a person's health profile. The clinical implications are that this knowledge will

provide opportunities for health professionals to advise families on individualized treatment

options or to tailor health promotion to future disease states based on genes and their interaction

with the environment.

Educational programs have significant positive effect on increase in knowledge of

parents about the disease. No significant differences were found between the three groups tested

in terms of the mean age, gender, level of education, job, number of affected children, and age of

the child. However young parents were better educated as regards knowledge about blood

disorders such as Idiopathic Thrombocytopenic Purpura.

My patient has a good prognosis if she continues to adhere to the medical advices her

physician ordered. Continues transfusion of platelets and IgG can do so much for my patient,

combined with proper nutrition and adherence to her medications.

CHAPTER VII

REFERENCES

Book Sources

1. Kozier & Erb’s Fundametals of Nursing 8th edition

2. Fogarty PF, Segal JB. The Epidemiology of Immune Thrombocytopenic Purpura. Curr Opin Hematol.2007

3. Nugent DJ. Immune Thrombocytopenic Purpura of Children. Hematology Education. 2006

4. Semple JW. Pathophysiology of Autoimmune Diseases. 2002

5. McMillan R. Hemorrhagic disorders: Abnormalities of Platelet and Vascular Function. 23rd Ed. 2007

6. Buchanan GR, Adix L. Grading of Hemorrhage in Children. JPediatrics. 2008

7. Blanchette V, Bolton-Maggs P. Diagnosis and Management of Childhood Diseases. 2008

Internet Sources

1. http://www.nhlbi.nih.gov/health/dci/Diseases/Itp/ITP_Treatments.html

2. http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/hematology/bledidio.html

3. http://www.nlm.nih.gov/medlineplus/ency/article/000535.htm