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West Coast University NUR 120


West Coast UniversityNUR 120. Hematologic System (Blood Disorders) Iron Deficiency Anemia. Pernicious Anemia. Thrombocytopenia. Immunologic System (Immune System ... – PowerPoint PPT presentation

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Title: West Coast University NUR 120

West Coast UniversityNUR 120
  • Hematologic System (Blood Disorders)
  • Iron Deficiency Anemia
  • Pernicious Anemia
  • Thrombocytopenia
  • Immunologic System (Immune System Disorders)

The Hematologic System
  • The hematologic system is the
  • Blood
  • Blood Cells
  • Lymph
  • And organs involved with blood formation

Bone Marrow
  • Is the blood-forming (hematopoeitic) organ.
  • Produces most of the cells of the blood
  • RBC erythrocytes
  • WBC leukocytes and
  • Platelets
  • Bone Marrow also is involve in the immune

Bone Marrow
  • Releases
  • 2.5 billion RBC each day in healthy adult.
  • 2.5 billion platelets and
  • 1 billion white blood cells per kilogram of body
  • Fetus blood components are produced in the
    liver and spleen and by the last trimester in the
    bone marrow.

Bone Marrow
  • At birth
  • Blood producing marrow is present to every bone.
  • Flat bones sternum, skull, pelvis, and shoulder
    girdles contain active blood producing marrow
    throughout life.
  • As person age blood producing marrow decreases in
    the long bones and in small and irregularly
    shaped bones.

Blood Producing Bone Marrow
  • 18 years blood production is limited to the
    ends of the long bones
  • Adulthood fatty tissue replaces inactive bone

Blood Producing Bone Marrow
  • Process of blood production
  • Bone marrow first produces stem cells.
  • Stem cells are immature, undifferentiated cells
    that are capable of maturing into any one of
    several types of blood cells RBCs, WBCs, or
    platelets depending on the bodys need. Also
    called pluripotent, multipotent and totipotent.

Blood Cell Development Cont
  • Committed Stem Cell- also called the precursor
    cell or the unipotent stem cell enters
    maturational pathway and then differentiate into
    one cell type.
  • Committed stem cell actively divide but require
    the presence of a specific growth factor for
    Maturation and some hormones
  • E.g. cytokines.

  • Is a growth factor made in the kidneys that is
    specific for RBC.
  • RBC growth factor produced in the kidney in same
    amount as RBCs destruction.
  • When tissue oxygenation is less than normal
    (hypoxia) the kidney increases the production of
  • Synthetic erythropoietin (PROCRIT, EPOGEN, EPO)
    has the same effect on bone marrow as the
    naturally occurring erythropoietin.

  • Erythropoeisis the production of RBC.
  • - Process where it involves selective
    maturation of stem cells into mature
  • - This process ensures that there is enough
    RBCs for good oxygenation without too many cells
    that could thicken the blood and slow its move.

Blood Components
  • Blood is composed of plasma and cells.
  • Plasma part of the bodys extracellular fluid.
    Similar to interstitial fluid.
  • Contains several more times protein the
    interstitial fluid.
  • E.g. Albumin, Globulins, and Fibrinogen
  • Cells RBCs, WBCs, and Platelets.

Albumin, Globulin and Fibrinogen
  • Albumin- Increases the osmotic pressure of the
    blood which prevents plasma from leaking into the
  • Globulins - have many function e.g transporting
    other substances and protecting the body against
  • Fibrinogen is a protein molecule that can be
    activated to form fibrin.
  • Fibrin molecules assemble together to form
    structures important in the blood clotting

Red Blood Cells (Erythrocytes)
  • Largest proportion of the blood cells.
  • Mature RBCs has no nucleus and has biconcave disk
  • Has flexible membrane that allows RBC to change
    shape without breaking as they pass through a
    narrow, winding capillaries.

Red Blood Cells (Erythrocytes
  • Number of RBC varies from person to person
    according to gender, age and general health.
  • Normal range 4,200,000 to
  • 6, 100,000/mm3.
  • Life span 120 days after being released into
    the blood.
  • Old cells are trapped and destroyed in the
    tissues, spleen and liver. Some part of destroyed
    RBCs (Iron) are recycled and used to make RBCs.

Red Blood Cells (Erythrocytes)
  • RBCs produce hemoglobin (Hgb).
  • The heme part of hemoglobin molecules needs a
    molecule of iron. Only when a heme molecule that
    is complete with iron can it transport up to four
    molecules of OXYGEN.
  • The globin portion carries Carbon Dioxide. RBC
    also can buffersand help maintain acid-base

  • Has the ability to combine loosely with oxygen.
  • With only a small amount of drop of O2 level in
    the tissues, a greater increase in the transfer
    of O2 from hemoglobin to tissues occurs.
  • Transfer of O2 to tissues is called oxygen

Substances needed to form Hemoglobin and RBCs
  • Iron ( Fe)
  • Vitamin B12 ( Cyanocobalamin)
  • Folic Acid ( Folate)
  • Copper (Ug)
  • Pyridoxine ( Vit. B6)
  • Cobalt (Co) and
  • Nickel
  • Lack of these substances can lead to ANEMIA

White Blood Cells(Leukocytes)
  • Performs action critical to inflammation or
  • May types of WBCs all have specialized functions.
  • Most are formed in the Bone Marrow
  • WBCs protect the body from the effect of
    invasions by organisms.

  • First internal line of defense against invaders
    especially bacteria.
  • Destroys invaders through phagocytosis.
  • Responsible for continuous, instant, nonspecific
  • The number of actual mature neutrophils is used
    to measure a clients risk for infection the
    higher the numbers, the greater the resistance
    against infection.

  • They are also known as monocytes when they are
    not mature.
  • Move from blood to tissues when they mature.
  • Lung alveolar macrophages
  • connective tissues- histiocytes
  • Brain Microglial cell
  • Liver Kupffer cell
  • Peritoneum Peritoneal macrophage
  • Bone Osteoclast
  • Joints Synovial type A cell
  • Kidney mesanglial cell.

Macrophages ( Function)
  • Important in immediate inflammatory response.
  • Stimulates the longer-lasting immune response of
    the of the anti-body mediated immunity (AMI).
  • Phagocytosis
  • Repair of injured tissues
  • Antigen presenting/processing
  • Secretions of cytokines that helps to control the
    immune system.

  • Make up 1 of the total circulating WBCs.
  • These cells cause the manifestations of
  • Contains vasoactives amines that act on blood
    vessels. Includes heparin, histamine, serotonin,
    kinins, and leukotrienes.
  • When release into the blood most of these
    chemicals act on the smooth muscles and blood
    vessel walls.
  • Heparin inhibits blood and protein clotting
  • Histamine constricts small veins and respiratory
    smooth muscles. Constrictions inhibits blood flow
    and decrease venous return. This results in blood
    collection to capillaries and small arterioles.
  • Kinins dilate arterioles and increase capillary
    permeability. Theses actions cause blood plasma
    to leak into interstitial space (vascular leak

  • Contains many vasoactive chemicals also. Usually
    make up 1 to 2 of the total WBC count.
  • Function- act against infections of parasitic
  • Increases in number during an allergic reaction
    because eosinophils degrade the vasoactive
    chemicals released by the other leukocytes.

  • They are the smallest of the blood cells.
  • Fragments from giant precursor cell in the bone
    marrow known as Megakaryocytes.
  • Stick to injured blood vessel walls and form
    platelets plug that can stop the flow of blood
    from the injured site.

  • They also produce substances important to
  • Help keep blood vessels intact by beginning
    repair of damage to small blood vessels. They
    perform most of their functions by aggregation
  • Production in the bone marrow is also precisely
    controlled by growth factors (thrombopoieitin).
  • After leaving the bone marrow, they are stored in
    the spleen and then released slowly to meet the
    bodys need.
  • Normally 80 of platelets circulates and 20
    stored in the spleen.
  • Life span 1 2 weeks

Accessory Organs of Hematopoiesis
  • Spleen located under the diaphragm to the left
    of the stomach.
  • Composed of three types of tissues white pulp,
    red pulp and marginal pulp.
  • These help to balance blood cells production and
    blood cells destruction and assist with immunity.
  • The spleen destroys old or imperfect RBCs, breaks
    down the hemoglobin released from destroyed RBCs
    stores platelets and filters antigen.
  • Thus after splenectomy, clients are not efficient
    at ridding the body of disease-causing organisms
    and are at greater risk for infection and sepsis.

  • Main production site for prothrombin and most of
    the blood clotting factors.
  • Proper liver function and bile production are
    critical to the formation of Vitamin K in the
  • intestinal tract.
  • Vitamin K is essential for producing blotting
    factors VII, IX, and X. Large quantities of whole
    blood and blood cells can be stored in liver.
  • Also converts bilirubin to bile and stores iron
    within the protein ferritin.
  • Small amount of erythropoeitin are also produced
    in the liver.

Assessments of the Hematopoeitic System/Functions
  • Health History base on Gordons Functional Health
  • Activity Exercise Pattern questions guide
  • Ask on energy level in comparison of last year.
  • How rested after a typical night sleep.
  • Any experiences of dizziness or light headedness
  • Is the heart seems to pound?
  • How much exercise do you get? How often? What
  • Do you feel you have enough energy to do what you
    want or need to do?

Assessments of the Hematopoeitic System/Functions
  • Family History and Genetic Risk- Bleeding
    Disorders e.g. Hemophilia
  • Personal History e.g. liver function, known
    immunologic or hematologic disorder, and current
    drug use? Check all drugs pt is taking in the
    past 3 weeks/
  • Ask about use of ATBs.(prolonged use can lead to
    clotting problems or bone marrow depression.
  • Diet History
  • Socioeconomic Status
  • Current Health Problems

Physical Assessment
  • Skin Assessment- Inspect color of the skin, nail
  • Note People with darker skin pallor and
    cyanosis easily detected in the oral mucous
    membrane and the conjunctivae of the eye while
    jaundice is in the roof of the mouth.
  • Head and neck assessment lymph nodes ,
    symmetrical, light palpation.
  • Respiratory Assessment
  • Cardiovascular Assessment
  • Renal and Urinary Assessment
  • Musculoskeletal Assessment paresthesias of
    lower extremity
  • Abdominal Assessment
  • CNS assessment
  • Psychosocial Assessment

Common Assessment Abnormalities
  • Skin pallor, jaundice, cyanosis, leg ulcers
    (malleoli), purpura (ecchymosis- decrease Plts),
    peticchia (pinpoint bleeding),hematoma.
  • Eyes- yellow sclera, pallor (conjunctiva).
  • Nose epistaxis low Platelet Ct.
  • Mouth pallor, gingival/mucosa ulceration.
  • Lymph Nodes- enlarge, tender to touch.
  • Heart and Chest tachycardia, gt100 bpm,
  • Orthostasis,
    Hypertension ( initial reaction of anemia).
  • Abdominal Hepatomegaly, Splenomegaly
  • Nervous System Paresthesis of feet and hand,
    low B12 or Folate. Weakness low Hgb.
  • Musculoskeletal Pain in pelvis, ribs, spine,
  • Joint swelling hemophilia, sickle cell

Hematologic Changes Associated with Aging
  • As bone marrow ages, it produces fewer blood
    cells. Total RBC and WBC are lower in older
  • Platelets count do not appear to change with age.
  • Antibody levels and responses are lower in older

Hematologic Changes Associated with Aging
  • Changes the cellular and plasma component of
  • Several factors causes decrease blood volume in
    older adults and tend to have lower levels of
    plasma proteins and decreased plasma osmotic
    pressure ( decreased intake of dietary protein)
    which also causes some loss of blood volume into
    the interstitial space.

Hematologic Changes Associated with Aging
  • Lymphocytes become less reactive to antigen and
    have a loss of immune function.
  • WBC count does not rise as high in response to
    infections in older people and younger people.
  • Hemoglobin levels also change with age.
    Hemoglobin levels in men and women fall after
    middle age. Iron deficient diets may play in a
    role in this reduction.

Iron Deficiency Anemia/Pernicious
  • Anemia is an abnormally low amount of
    circulating red blood cells (RBCs ), hemoglobin
    concentration, or both.
  • Iron Deficiency Anemia is the most common
    anemia. Lack of Iron (Fe) that promotes formation
    of Hgb.
  • Pernicious Anemia due to deficiency of
    intrinsic factor produced by gastric mucosa which
    is necessary for absorption of Vit B 12.

Causes of Anemia
  • Blood Loss
  • Inadequate RBC production
  • Increase RBC destruction
  • Insufficient or defective hemoglobin

Common Risk Factor for Anemia
  • Acute or Chronic Blood loss menorrhagia, GI

  • ulcers/bleed
  • Increased Hemolysis defective hemoglobin

  • cell), impaired glycolysis (G6PD- Glucose
    6phosphate dehydrogenase) deficiency anemia,
    transfusion reaction, autoimmune diseases.
  • Mechanical Trauma to RBCs mechanical heart
    valve, cardiopulmonary bypass.

Common Risk Factor for Anemia
  • Dietary Insufficiency Iron Deficiency
  • - Vit. B
    12 deficiency
  • - Folic
    Acid Deficiency
  • - Pica or
    persistent eating of substances not normally
    considered food (non-nutritive value ) for at
    least 1 month.
  • Bone Marrow Suppression exposure to
  • radiation or
  • Aplastic anemia
    results in
  • decreased
    number of red blood
  • cells as well
    as decreased platelets and
  • WBC.

Diagnostic Procedures for Anemia
  • Lab Assessment
  • 1. CBC (Complete Blood Count)
  • RBC major carrier of Hgb in the blood
  • Hgb- transport O2 and Co2 to and from
    the cells
  • and can be used as index of oxygen
  • capacity of the blood.
  • Hematocrit (Hct) percentage of RBCs in
  • to the total blood volume.
  • Platelets important for clcot

RBC indices to determine type and cause of most
  • Mean Corpuscular Volume (MCV) size of red blood
    cell Normocytic, microcytic, macrocytic.
  • Mean Corpuscular Hemoglobin (MCH) to determine
    the amount of hemoglobin per RBC.
  • Normochromic normal amt. of Hgb per cell,
  • Hypochromic decreased amt. of Hgb per cell.
  • Mean Corpuscular Hgb Concentration (MCHC) to
    indicate Hgb amt. relative to the size of the
  • In Iron deficiency anemia there is decreased
    MCV, MCH, MCHC and classified as microcytic,
    hypochromic anemia.
  • In pernicious anemia there is increased MCV and
    classified as macrocytic anemia.

Diagnostic Studies/Procedures for Anemia
  • 2. Iron Studies
  • Total Iron Binding Capacities (TIBC)
    reflects an indirect measurement of serum
  • Serum Ferritin is indicator of total body
    iron stores.
  • Serum Iron measures the amt. or iron in the
  • Low serum iron and elevated TIBC indicates
    iron deficiency anemia

Diagnostic Studies/Procedures for Anemia
  • Hemoglobin Electrophoresis separates normal Hbg
    from abnormal. Use to detect thalassemia and
    sickle cell disease.
  • Schillings Test measures Vit. B12 absorption
    with and without intrinsic factor. It is used to
    differentiate between malabsorption and
    pernicious anemia.
  • Procedure in a form of handouts.
  • Bone Marrow Examination diagnoses aplastic
    anemia(failure of bone marrow to produce RBC as
    well as WBCs and platelets).

Nursing Care after Bone Marrow Aspiration
  • Apply pressure to the site for 5 to 10 minutes
  • Assess V/S frequently.
  • Apply pressure dressing.
  • Monitor for signs of bleeding and infection for
    24 hours.
  • Pt. going for Bone Marrow aspiration is
    position based on area where they will obtain the
    sample. Either prone or side lying.
  • Local anesthesia to the site of aspiration is
    given and pt. is mildly sedated.

Nursing Assessment for Anemia.
  • Pallor especially in the ear and nail beds,
  • crease and conjunctiva.
  • Fatigue exercise intolerance, lethargy,
  • hypotension.
  • Tachycardia
  • Heart murmurs
  • Heart failure
  • Signs of bleeding- hematuria, melena,
  • Dyspnea
  • Irritability difficulty concentrating
  • Cool skin, cold intolerance.

Iron Deficiency Anemia
  • What Causes Iron Deficiency Anemia?
  • Poor absorption of iron by the body (Vitamin C
    aides in iron absorption)
  • Inadequate daily intake of iron
  • Pregnancy
  • Growth spurts or blood loss due to heavy period
    or internal bleeding.
  • Anemia develops slowly after the normal stores of
    iron have been depleted in the body and in the
    bone marrow.
  • Women, in general, have smaller stores of iron
    than men. Women also lose iron more frequently
    than men because of the blood loss during

Iron Deficiency Anemia
  • Signs and Symptoms specific for Iron Deficiency
  • Pale skin color (Pallor)
  • Fatigue
  • Irritability
  • Dizziness
  • Weakness
  • Shortness of breath
  • Sore tongue (smooth sore bright red tongue)
  • Brittle nails
  • Decreased appetite (especially in children)
  • Headache - frontal.
  • The tests are Red blood cell measures 4 x 10 (12
    power), hemocrit (below 36, NV m 40-54 ml/dl,
    w 37 -47 ml/dl, and hemoglobin( below 10 g/dl)
    NV- m 13-18 g/dl, w 12.0 16.0 g/dl. Size of
    red blood cells (microcytic), serum iron level
    (low), and iron binding capacity in the blood

Iron Deficiency Anemia
  • Treatment of Iron Deficiency Anemia
  • Ferrous salts of iron are absorbed much more
    readily and are generally preferred.
  • Commonly available oral preparations
  • Ferrous Sulfate, Ferrous Gluconate and
    Ferrous Fumarate (Hemocyte). All three forms are
    well absorbed. Ferrous sulfate is the least
    expensive and most commonly used oral iron
  • For iron replacement therapy, a dosage equivalent
    to 150 to 200 mg of elemental iron per day is
  • Ferrous sulfate, 325 mg of three times a day,
    will provide the necessary elemental iron for
    replacement therapy.
  • Hematocrit levels should show improvement within
    one to two months of initiation of therapy.
  • Take with meals if GI side effects occurs.
  • Give with Vit. C for better Iron absorption
  • D0 not take with 2 hours of milk or antacids.
  • Stools will be black.
  • May cause constipation. Increase fluid intake and
    foods high in fiber.
  • Use of straw for liquid iron to prevent teeth

Treatment of Iron Deficiency Anemia
  • Injectable iron dextran, containing 50 mg of iron
    per mL, is supplied in a 2-mL single-dose vial.
  • Adverse reactions include headache, dyspnea,
    flushing, nausea and vomiting, fever,
    hypotension, seizures, urticaria, anaphylaxis.

Pernicious Anemia
  • Body stores of vitamin B12 are adequate for up to
    five years.
  • Symptoms are attributable primarily to anemia,
    although Glossitis, Jaundice, and Splenomegaly
    may be present. Vitamin B12 deficiency may cause
  • Decreased vibratory and positional sense
  • Ataxia
  • Paresthesias and
  • Confusion.
  • Treatment of Vitamin B 12 Deficiency Anemia.
    Intramuscular, oral or intranasal preparations
    are available for B 12 replacement.
  • In patients with severe vitamin B12 deficiency,
    daily IM injections of 1,000 mcg of

.Pernicious Anemia
  • Can not be prevented if due to lack of intrinsic
    factor. .
  • Some develop pernicious anemia due not getting
    enough Vitamin B12 in their diets.
  • Eating foods high in vitamin B12 can help prevent
    low vitamin B12 levels.
  • Good food sources of vitamin B12 include Meats
    such as beef, liver (glandular meats), and
    poultry, Fish and Shellfish, yeast, Egg and Dairy
    products, such as milk, yogurt, and cheese,
    cereals and other fortified foods that have
    vitamin B12 added, Vitamin B12 also is found in
    multivitamins and in B-complex vitamin
  • Supplements for people at risk for vitamin B12
    deficiency, such as strict vegetarians or people
    who have had stomach surgery is needed.
  • Older adults may have trouble absorbing vitamin

Nursing Diagnosis - Anemia
  • Activity Intolerance
  • Anxiety
  • Ineffective tissue perfusion
  • Fatigue
  • Self-Care Deficit
  • Risk for Infection

Nursing Plans and Interventions
  • Instruct client to alternate periods of activity
    with periods of rest.
  • Teach client about diet
  • Food selection and preparation to maximize
    intake of
  • A. Iron rich food e.g. red meats, organ
    meats, whole wheat and whole wheat products,
    spinach, carrots.
  • B. Folic Acid sources e.g. green vegetables,
    liver, citrus fruits for Folic Acid
  • C. Vit. B 12 rich foods.
  • Instruct in need for Vitamin Supplements

Vitamin Supplements
  • Give Iron preparation with meals to
    prevent/decrease GI irritation.
  • Administration of Iron
  • Dos Use Z-Track technique of administration
  • Use air bubble to avoid
    withdrawing medication
  • into subcutaneous tissue.
  • Donts Do not use deltoid muscle.
  • Do not massage injection site.
  • Administer B12 and Folic acid orally except to
    client with pernicious anemia who should receive
  • If parenteral Iron is required, use Z-track
    method for administration to prevent staining the

Complications and Nursing Implications
  • Monitor client for s/s of hypoxemia.
  • - dyspnea, decreased O2 saturation, central
  • - administer oxygen therapy. Monitor SaO2.
  • - Administer blood transfusion as ordered.
  • Blood Transfusion lead to an immediate
    improvement in blood cell counts and client sign
    and symptoms.
  • Use only saline to flush IV tubing or to run
    with blood. Never add medications to blood
  • Two RNs should simultaneously check the
    physicians prescription, the clients identity,
    and the blood bag label.

Complications and Nursing Implications
  • Assess neurologic status of client with
    macrocytic anemias.
  • Vit. B 12 is essential for neurologic
    function. Administer supplements.
  • Notify the physician in any changes in
  • GI Bleeding is a most common cause of anemia in
    older adults.
  • Anemia maybe misdiagnosed as depression or

  • Thrombocytopenia - is any disorder in which there
    are not enough platelets. Platelets are cells in
    the blood that help blood to clot. This condition
    is sometimes associated with abnormal bleeding.
  • Reduction of platelets below 150,000/ul.
  • Acute, severe, or prolonged decreases from this
    normal rannge can result in abnormal hemostasis
    that manifest as prolonged bleeding from minor
    trauma to spontaneous bleeding w/o injury.
  • Symptoms
  • Bruising
  • Nosebleeds or bleeding in the mouth
  • Rash (pinpoint red spots called petechiae)
  • Mild thrombocytopenia can occur without symptoms.

  • Can be inherited (Wiscott-Aldrich Syndrome ) or
  • Acquired autoimmune diseases, increased
    platelets consumption, splenomegaly, marrow
    supression and bone marrow failure.
  • Is often divided into three major causes of low
  • 1. Low production of platelets in the bone
  • 2. Increased breakdown of platelets in the
  • bloodstream (called intravascular)
  • 3. Increased breakdown of platelets in the
    spleen or
  • liver (called extravascular).

Disorders that involve low production in the
bone marrow include
  • Aplastic anemia
  • Cancer in the bone marrow
  • Infections in the bone marrow (very rare)
  • Myelodysplasia
  • Use of certain drugs may also lead to a low
    production of platelets in the bone marrow,
    although this is rare

Causes and Risk Factors
  • Acquired thrombocytopenia may result from the use
    of certain drugs, such as quinine, quinidine,
    rifampin, heparin, nonsteroidal anti-inflammatory
    agents, histamine blockers, most chemotherapeutic
    agents, allopurinol and alcohol.
  • Common causes of decreased platelet production
  • 1. marrow aplasia (when the marrow is not
    developing naturally)
  • 2. fibrosis (an abnormal formation) or
    infiltration with malignant cells.

Drugs that cause drug-induced thrombocytopenia
  • Diabetes drugs taken by mouth (hypoglycemic
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Penicillin
  • Quinidine
  • Quinine
  • Ranitidine
  • Some drugs used to treat arthritis conditions
  • Sulfonamides
  • Diuretics - Thiazides

Common causes of decreased platelet production
  • Occur transiently after a viral infection (such
    as Epstein-Barr) or infectious mononucleosis.
  • Idiopathic thrombocytopenic purpura (ITP), an
    autoimmune disorder.
  • - Cause is unknown. When reach spleen this
    platelets were recognize as foreign and are
    destroyed by macrophages.
  • Thrombotic thrombocytopenic purpura (TTP), which
    is an uncommon disorder associated with anemia.
  • - Characterized by hemolytic anemia,
    neurologic abnormalities , fever in absence of
    infection and renal abnormalities.

Disorders that involve the breakdown of
platelets include
  • Disseminated Intravascular Coagulation (DIC)
  • Disseminated intravascular coagulation
    (DIC) is a serious disorder in which the proteins
    that control blood clotting become abnormally
  • Drug-induced nonimmune thrombocytopenia
  • Drug-induced thrombocytopenia occurs when
    certain drugs or medications destroy platelets or
    interfere with the body's ability to make enough
    of them.
  • Drug-induced immune thrombocytopenia
  • If a medicine prevents your bone marrow from
    making enough platelets, the condition is called
    drug-induced nonimmune thrombocytopenia.
    Chemotherapy drugs and a seizure medication
    called valproic acid may lead to this problem.
  • Hypersplenism
  • Immune thrombocytopenic purpura (ITP)
  • Thrombotic thrombocytopenic purpura

Symptoms of Thrombocytopenia
  • Sudden onset of petechiae and ecchymoses from
    bleeding into mucous membranes or on the skin.
  • Malaise, fatigue and general weakness (with or
    without accompanying blood loss).
  • Adults may have large, blood-filled bullae in the
  • If the platelet count is between 30,000 and
    50,000/mm3, bruising with minor trauma may be
  • If it is between 15,000 and 30,000/mm3,
    spontaneous bruising will occur. Ave. 20,000/mm3.
    life treathening hemorrhages.

Diagnostic Studies
  • Platelet count decreased, any reduction below
    150,000 u/l.
  • Platelet transfusion is recommended when count
    is below 10,000 u/l unless client is actively
  • Lab test to assess secondary bleeding
  • - Prothrombin time
  • - activated Partial Thromboplastin Time.
  • If PT/aPTT are elevated this may indicate DIC.

  • PT/PTT are laboratory tests that measure the
    clotting time (how long it takes blood to clot.)
  • PT/PTT are blood tests and INR is a ratio
    calculated from the PT.
  • Prothrombin, or factor II, is one of several
    clotting factors produced by the liver. This test
    measures the integrity of the extrinsic and
    common pathways of coagulation.
  • The prothrombin time (PT) measures the clotting
    time from the activation of factor VII through
    the formation of the fibrin clot. Adequate
    amounts of vitamin K are needed to produce
    prothrombin. Warfarin (Coumadin) is sometimes
    prescribed as a "blood thinner" because it is an
    effective vitamin K antagonist (blocks the
    formation of vitamin K).
  • The reference range for prothrombin time is
    usually around 1215 seconds
  • The normal range for the INR is 0.81.2

  • The activated partial thromboplastin time (PTT)
    measures the function of several other clotting
    factors, found in the intrinsic and common blood
    clotting pathways.
  • It measures the clotting time from the activation
    of factor XII through the formation of the fibrin
    clot. PTT prolongations are caused by factor
    deficiencies (factors VIII, IX, XI, and/or XII),
    or inhibitors (most commonly, heparin).
  • Heparin prevents clotting by blocking certain
    factors in the intrinsic pathway.
  • The greater the PT/PTT values, the longer it
    takes the blood to clot. HIGH PT/PTT risk for
    BLEEDING. LOW PT/PTT risk for blood clots/

  • The INR stands for International Normalized
  • The INR is calculated from the PT and is intended
    to allow valid comparisons of results regardless
    of the type of PT reagent used among different
    laboratories (INR patient PT / mean normal
  • The INR is a method of standardizing the PT for
    coumadin anticoagulation.
  • Before the INR, different labs using different
    reagents had different controls and widely
    differing PT value ranges. An INR of 1 means
    the blood clots "normally" for that pt. The
    greater the INR, the longer it takes the blood to

  • The warfarin (Coumadin) dosage for people being
    treated to prevent the formation of blood clots
    is usually adjusted so that the prothrombin time
    is about 1.5 to 2.5 times the normal value (or
    INR values 2 to 3).
  • A patient may take warfarin to anticoagulate for
    atrial fibrillation (target INR around 2.5) or
    for a mechanical heart valve (target INR 3).
  • An INR of 3 means the blood takes about three
    times as long to clot compared with the normal
    value for that pt.

Nursing Responsibilities for Lab Studies
  • Nurse needs to closely monitor platelet count and
    other anticoagulation therapy.
  • Nurse need to monitor hematocrit and hemoglobin

Nursing Assessment
  • Subjective Data important health information
  • past health
  • medications
  • Functional Health Patterns
  • health perceptions health management Family
    history of bleeding problems, malaise.
  • nutritional-metabolic bleeding gingiva,
    coffee-ground or bloody vomitus, easy bruising.
  • Activity exercises fatigue, weakness, fainting,
    epistaxis, hemoptysis, dyspnea.
  • Cognitive-perceptual pain and tenderness in
    bleeding areas, headache.
  • Sexuality-reproductive menorrhagia, metrorrhagia

Nursing Assessment
  • Objective Data
  • General Fever, lethargy
  • Integumentary petecchia, ecchymosis, purpura
  • GI Splenomegaly, abdominal distention,
    guiac-positive stools.
  • Possible findings
  • Platelet countlt 150,000/ul prolonged bleeding
  • dec. hemoglobin and hematocrit normal or elev.
    Megakaryocytes in bone marrow examination.

Tests diagnosis
  • Complete blood count (CBC) shows low number of
  • Blood clotting studies (PTT and PT) are normal.
  • Other tests that may help diagnose this condition
  • Bone marrow aspiration or biopsy
  • Platelet associated antibodies
  • Complications
  • Severe bleeding (hemorrhage) is the main
    complication. This can include
  • Bleeding in the brain (intracranial hemorrhage)
  • Gastrointestinal bleeding (vomiting blood or
    blood in the stools)
  • When to contact a healthcare provider
  • Call a healthcare provider if unexplained
    bleeding or bruising is noted.

Collaborative Care Thrombocytopenia
  • TTP
  • ITP
  • Plasmaparesis (plasma exchange)
  • High dose prednisone
  • Splenectomy
  • Dextran
  • Chemotherapy e.g. vincristine, vinblastin
  • Immunosuppressives.
  • Corticosteroids
  • Platelets transfusions
  • Splenectomy
  • IV immunoglobulin
  • Danazol
  • Anti-Rho (D)
  • Immunosuppressives.
  • e.g. cytoxan, Imuran, Rituxan

Collaborative Care Thrombocytopenia
  • Heparin-Induced Thrombocytopenia
  • Decrease Platelet Production
  • Direct thrombin inhibitor e.g. lepirudin
  • Indirect thrombin inhibitor
  • e.g. arixtra
  • Plasmapheresis (plasma exchange)
  • Protamine Sulfate
  • Coumadin
  • Thrombolytic agents
  • Identification and treatment of cause.
  • Corticosteroids
  • Platelet transfusions
  • Oprelvekin (Neumega)

  • Removal of the offending agents should correct
    the condition.
  • Corticosteroids may be used to increase platelet
  • Lithium carbonate or folate may also be used to
    stimulate the bone marrow production of
  • Platelet transfusions may be used to stop
    episodic abnormal bleeding caused by a low
    platelet count.

Patient Teaching Thrombocytopenia
  • Notify HCP for any manifestations of bleeding.
  • Ask HCP for restriction for in normal activities.
    E.g. vigorous exercises. Sturdy shoes or slippers
    for walking.
  • Do not blow nose forcefully. Place head up and
    apply firm pressure on the nostrils and bridge of
    the nose.
  • Do not bend down with your head lower than your
  • Prevent constipation by drinking plenty of fluids
    and do not strain when having BM.
  • Shave only with electric razor. Do not use
  • Do not pluck eyebrows or other body hair.

Patient Teaching Thrombocytopenia
  • Do not puncture skin, e.g. getting tattoos or
    body piercing .
  • Avoid using any medications that can prolonged
    clotting such as aspirin. Be careful also with
    herbs with same effects.
  • Use soft bristle tothbrush to prevent injuring
    the gums. Flossing is also usually safeif it is
    done gently using the tape floss.
  • Do not use alcohol -based mouthwashes as they can
    dry gums and increase bleeding.
  • Women who are menstruating should keep tract of
    the number of pads that are used per day.
  • Ask HCP before you have any invasive procedures
    done such as dental cleaning, manicure, or
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