Thrombocytopenia is characterized by a low platelet count, measuring below 150,000/mm³ (150 – 400 x10⁹/L). A normal platelet count is 150,000 – 400,000/mm³ for adults. Platelets are blood cells that aid in coagulation efforts for normal blood clotting. Low platelet counts increase the risk of bleeding.
Thrombocytopenia occurs when the bone marrow doesn’t make enough platelets, such as with leukemia or other blood cancers. Some disease processes may also destroy platelets. The spleen may play a role in thrombocytopenia, as this organ stores one-third of the body’s platelets. It may become enlarged if too many platelets become trapped, reducing the number of platelets in circulation.
In this article:
- Types and Causes
- Signs and Symptoms
- Nursing Process
- Nursing Care Plans
- Ineffective Protection
- Ineffective Tissue Perfusion
- Risk for Bleeding
- Risk for Deficient Fluid Volume
Types and Causes
Thrombocytopenia can be divided further into specific disease processes:
- Immune thrombocytopenia (ITP) is the most common acquired thrombocytopenia and is characterized by the irregular destruction of platelets, often related to autoimmune diseases that cause the body to destroy its own platelets.
- Thrombotic thrombocytopenic purpura (TTP) is a rare condition characterized by thrombocytopenia, hemolytic anemia, fever (in the absence of infection), and neurologic and renal abnormalities. This condition causes microthrombi to deposit in the capillaries and arterioles, using up large amounts of platelets.
- Heparin-induced thrombocytopenia (HIT) is characterized by the development of thrombocytopenia 2 to 10 days after the initiation of heparin therapy. This condition causes platelet destruction and vascular endothelial injury due to an immune response to heparin.
Other causes of thrombocytopenia may include:
- Pregnancy
- Bacteremia
- Aplastic anemia
- Viral infections
- Exposure to toxins
- Excessive alcohol consumption
- Chemotherapy
Signs and Symptoms
In most cases, thrombocytopenia is asymptomatic. But, the most common clinical manifestation is bleeding in the mucosal or cutaneous membranes. Bleeding can manifest as nosebleeds, gingival bleeding, and bleeding into the skin in the form of petechiae, purpura, and superficial ecchymoses. Severe drops in platelets below 10,000/mm³ can result in internal hemorrhaging, which is life-threatening.
Thrombocytopenia is confirmed with a regular blood test. The patient’s medical history and clinical examination can help determine the cause of thrombocytopenia.
Nursing Process
Interprofessional and nursing care for patients diagnosed with thrombocytopenia will mainly depend on the cause of the condition. In some cases, treating the underlying disorder may be sufficient to manage low platelets. Nurses are primarily responsible for preventing bleeding, the early recognition of signs of bleeding, and prompt intervention for its management. Patient education regarding their disease process, prompt reporting of complications, and how to reduce the risk of bleeding is essential.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for thrombocytopenia, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for thrombocytopenia.
Deficient Knowledge
Patient education is an integral part of the management of thrombocytopenia. Lifestyle modifications are needed to prevent bleeding. A thorough understanding of the disease process is key to adherence to the treatment regimen.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Misinformation
- Inadequate information
- Inadequate commitment to learning
- Inadequate interest in learning
- Inadequate participation in care planning
As evidenced by:
- Incorrect verbalization of the disease process
- Inaccurate follow-through of instructions
- Inadequate adherence to lab testing
- Development of severe bleeding
Expected outcomes:
- Patient will verbalize understanding of the disease process, prognosis, and treatment recommendations.
- Patient will implement two strategies to prevent bleeding.
Assessment:
1. Assess the patient’s knowledge about thrombocytopenia.
Determining the patient’s knowledge about the condition can help determine interventions for care and additional information needed for patient education.
2. Determine learning methods.
Information will be successfully received if presented in the way the patient learns best, such as through written, visual, or auditory forms.
Interventions:
1. Educate the patient on bleeding precautions.
- Use caution with sharp objects
- Only use electric razors
- Brush the teeth gently
- Avoid aspirin-containing medications
The patient should also not strain with bowel movements or insert anything rectally to prevent damaging the mucosal lining and causing internal bleeding.
2. Encourage lifestyle modifications.
Lifestyle modifications, including avoidance of risk-taking behaviors such as dangerous sports that may lead to injury, can help lower the risk of bleeding complications.
3. Educate the patient about signs of possible thrombocytopenic complications.
Early detection of signs and symptoms like easy bruising, sudden bleeding with unknown cause, blood in the urine or stool, bleeding in the gums and nose, and neurologic symptoms can indicate complications and progression of the disease. These signs and symptoms must be reported for prompt management.
4. Educate on the need for splenectomy.
The removal of the spleen may be required for immune thrombocytopenia (ITP) or when other treatments have failed. The spleen plays a role in immune function, so the patient will need to take extra precautions to prevent infections.
Ineffective Protection
Ineffective protection is associated with thrombocytopenia due to the risk of bleeding.
Nursing Diagnosis: Ineffective Protection
Related to:
- Low platelets
- Abnormal bleeding
- Cancer
- Chemotherapy
As evidenced by:
- Increased risk for bleeding
- Altered clotting
- Prolonged bleeding time
Expected outcomes:
- Patient will demonstrate a platelet count within normal limits.
- Patient will not experience prolonged bleeding.
- Patient will implement strategies to prevent injury and bleeding.
Assessment:
1. Determine the patient’s bleeding risk.
Determine if the patient presents with an increased risk for bleeding, such as:
- An autoimmune condition that destroys platelets (ITP, rheumatoid arthritis, lupus)
- Pregnancy
- The presence of infection (bacteria that attacks platelets)
- Conditions affecting platelets (TTP and hemolytic uremic syndrome)
- Certain cancers and cancer treatments
- Conditions affecting the liver (i.e., hepatitis) or spleen
- Viruses like HIV
2. Assess for symptoms of bleeding.
Immune thrombocytopenia (ITP) may have no symptoms. When symptoms appear, they may consist of:
- Bruising
- Petechiae
- Larger rashes (purpura)
- Gum bleeding
- Nose bleeding (epistaxis)
- Blood in the urine (hematuria)
- Blood in the stool
3. Review the patient’s medications.
Review the medications that the patient is taking to identify those that may affect clotting, such as:
- Antiplatelets
- Anticoagulants
- Antiseizure drugs (valproic acid)
- Chemotherapy drugs
- NSAIDs
- Statin drugs
- Antibiotics (penicillin and linezolid)
Interventions:
1. Ensure safety.
Emphasize the importance of safety. Implement safety precautions and fall prevention, as injuries can lead to excessive blood loss with thrombocytopenia.
2. Implement bleeding precautions.
Advise the patient of the following:
- Avoid straining when defecating
- Blow the nose gently
- Use an electric razor
- Avoid rectal temperatures, enemas, or suppositories
- Use a soft-bristled toothbrush
3. Control the bleeding.
For bleeding gums, apply pressure to the gums with gauze soaked in ice water. With nosebleeds, pinch the bridge of the nose and keep the head tilted forward until the bleeding stops.
4. Apply pressure after injections or IV site removal.
After venipunctures, IM injections, or removal of IV lines, apply pressure for as long as necessary to stop bleeding, which may take 10-15 minutes.
Ineffective Tissue Perfusion
Normally, platelets clump and form clots to stop bleeding. However, thrombocytopenia (low platelets) may cause continuous bleeding in injured tissues or vessels, which can lead to hemorrhage and poor perfusion.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Hypovolemia
- Presence of infection
- Bleeding disorders
- Certain medications
As evidenced by:
- Prolonged bleeding
- Blood in urine or stool
- Heavy menstrual bleeding
- Lightheadedness or dizziness
- Fatigue
- Change in mentation
- Skin pallor
- Cool and clammy skin
- Chest pain
- Tachycardia
- Hypotension
- Prolonged capillary refill time
- Shortness of breath
- Tachypnea
- Enlarged spleen (splenomegaly)
Expected outcomes:
- Patient will demonstrate a platelet count > 150,000/mm³.
- Patient will not experience bleeding.
- Patient will demonstrate strong peripheral pulses with CRT < 3 seconds.
Assessment:
1. Monitor for signs of significant blood loss.
Monitor for signs of hemorrhage affecting perfusion, such as hypotension, tachycardia, a distended abdomen, blood in the stool or urine, and changes in mental status.
2. Assess the skin for poor perfusion.
The skin may be pale or cyanotic and feel cool to the touch with altered sensations like numbness or tingling. Monitor for large areas of bruising or petechiae.
Interventions:
1. Address the underlying condition.
Manage the condition that is causing the low platelets. This may include discontinuing medications like heparin, treating infections or viruses, or managing autoimmune diseases.
2. Anticipate blood or platelet transfusions.
Transfuse packed red blood cells (PRBC) or platelets as ordered. PRBC replaces blood lost from bleeding and aids in perfusing organs and tissues. At the same time, platelets supplement the low platelet count.
3. Prepare for a possible plasma exchange.
Thrombotic thrombocytopenic purpura (TTP) causes clots to block blood flow to organs, preventing proper perfusion. Therapeutic plasma exchange (TPE) is a solution that replaces the plasma with a plasma substitute to prevent unnecessary clotting in the vessels.
4. Administer medications as ordered.
The healthcare provider may choose medications to boost the platelet count if the condition affects the immune system. They may prescribe corticosteroids first. If ineffective, immunosuppressants can suppress the immune response. Other medications like eltrombopag or romiplostim are bone marrow stimulants that increase platelet counts.
Risk for Bleeding
Thrombocytopenia is characterized by a low platelet count, increasing the patient’s susceptibility to bleeding and bruising.
Nursing Diagnosis: Risk for Bleeding
Related to:
- Disease process
- Low platelet count
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at the prevention of signs and symptoms.
Expected outcomes:
- Patient will remain free from any signs and symptoms of bleeding.
- Patient’s platelet count will remain within therapeutic limits.
Assessment:
1. Perform a thorough physical examination.
Physical assessment can help detect signs and symptoms of bleeding in patients with thrombocytopenia. Watch for signs of bleeding, including epistaxis, gum bleeding, and bruises.
2. Assess vital signs.
Excessive bleeding can cause hypotension, tachycardia, and mental status changes.
3. Monitor lab values.
A complete blood count should be obtained, and red blood cells, hemoglobin, hematocrit, and platelet counts should be assessed.
Interventions:
1. Continuously monitor coagulation values.
If the patient receives IV heparin therapy, the aPTT and PT values should be monitored per facility guidelines. If these values are out of therapeutic range, bleeding may occur.
2. Provide antidotes as necessary.
Reversal agents such as protamine sulfate for heparin and vitamin K for warfarin may be necessary for excessive bleeding.
3. Review and identify medications that can increase the risk of bleeding.
Medications, including aspirin, NSAIDs, anticoagulants, and other alternative supplements, can increase the risk of bleeding.
4. Provide medications as ordered.
Steroids can increase the platelet count. Immunoglobulins can stop the immune system from destroying platelets, and other medications can help boost platelet production.
5. Prepare and assist in platelet transfusion.
Patients with critically low platelets are often transfused with blood products to boost and correct the platelet count.
6. Use care with invasive procedures.
Patients may still require IV insertion, IM injections, or other invasive procedures. Remember that needles can cause prolonged bleeding and to hold pressure on the area for as long as possible to allow the blood to clot.
Risk for Deficient Fluid Volume
Deficient fluid volume can occur in patients with thrombocytopenia due to bleeding. Patients with low platelet count will have difficulty forming blood clots and are at risk for bleeding.
Nursing Diagnosis: Risk for Deficient Fluid Volume
Related to:
- Excessive bleeding
- Poor coagulation
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at the prevention of signs and symptoms.
Expected outcomes:
- Patient will remain free of signs of bleeding, as evidenced by vital signs within normal limits.
- Patient will exhibit hemoglobin and hematocrit values within therapeutic limits.
Assessment:
1. Assess and monitor vital signs.
Alterations in vital signs like decreased blood pressure can indicate possible bleeding and fluid loss.
2. Assess laboratory values.
Blood test results, specifically low hematocrit and hemoglobin levels, can indicate blood loss.
Interventions:
1. Monitor the patient’s intake and output.
Maintaining accurate records of the patient’s intake and output can help monitor the patient’s fluid volume and hydration status.
2. Administer fluid replacement as indicated.
Fluid replacement promotes better blood circulation and can help replenish fluid loss.
3. Provide blood transfusions as ordered.
Transfusion of blood products, including packed red blood cells, platelets, and plasma, may be indicated for patients with excessive bleeding to increase the intravascular volume.
4. Educate the patient on the signs and symptoms of bleeding.
Fluid loss due to bleeding can occur anytime. Patient education is vital to ensure that the patient is aware of the signs and symptoms of bleeding and possible complications.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Cleveland Clinic. (2022, October 20). Thrombocytopenia: Causes, symptoms & treatment. Retrieved August 2023, from https://my.clevelandclinic.org/health/diseases/14430-thrombocytopenia
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- Mayo Clinic. (2022, April 19). Thrombocytopenia (low platelet count) – Diagnosis and treatment – Mayo Clinic. Retrieved August 2023, from https://www.mayoclinic.org/diseases-conditions/thrombocytopenia/diagnosis-treatment/drc-20378298
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- MedlinePlus. (n.d.). Drug-induced thrombocytopenia. MedlinePlus – Health Information from the National Library of Medicine. Retrieved August 2023, from https://medlineplus.gov/ency/article/000556.htm
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- Thrombocytopenia. Cleveland Clinic. Reviewed: October 20, 2022. From: https://my.clevelandclinic.org/health/diseases/14430-thrombocytopenia
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