Chapter 20: Bleeding Disorders
Thrombocytopenia: low platelet level
oDecreased production of platelets with bone marrow, increased destruction of platelets or
increased consumption of platelets
oMalignancy, infection, medications and DIC
oAspirin reduce normal platelet aggregation
Prolonged bleeding time lasts for several days after aspirin ingestion
oClinical Manifestations and Assessment
Bleeding and petechial usually do not occur with platelet counts greater than 50,000
<20,000: petechial can appear, nasal and gingival bleeding, excessive menstrual bleeding
and excessive bleeding after surgery or dental extractions
<10,000: spontaneous, potentially fatal CNS or GI hemorrhage can occur
if platelets are dysfunctional due to disease or medications: risk for bleeding may appear
much greater even when actual platelet count is not significantly reduced
oMedical Management
If platelet production is impaired, platelet transfusions may increase platelet count and
stop bleeding or prevent hemorrhage
Immune thrombocyte-Penic Purpura
oITP: most common autoimmune blood disorder; affects all ages
oAcute: usually after a viral illness
oChronic: diagnosed by exclusion of other causes of thrombocytopenia
oPathophysiology
Platelet count is decreased by combination of autoantibody mediated platelet
destruction and impaired platelet production secondary to autoantibody effects
Decreased risk in serum thrombopoietin: hormone that stimulates platelet production
Normally in low platelet count; rises to stimulate platelet production
Viral infections can precede the disease
Medications can induce ITP
Systemic lupus or pregnancy can induce ITP
oClinical Manifestations and Assessment
Many have no symptoms
Low platelet count is an incidental finding
Easy bruising, heavy menses, and petechial on extremities and trunk
“wet purpura” bleeding from mucosal surfaces
Have a greater risk for intracranial bleeding than dry purpura
Treatment may not be initiated unless bleeding becomes severe or life-threatening,
platelet count is extremely low or those at risk for bleeding
oMedical Management
“safe” platelet count
Treatment should be based on platelet count, lifestyle and activity level
Immunosuppressive agents
Block receptors on macrophages; platelets are not destroyed
Prednisone
Splenectomy
Platelet transfusions are usually avoided
Patient’s antiplatelet antibodies bind with transfused platelets; destroyed
oNursing Management
Assessment of patient’s lifestyle; determine risk for bleeding
Medication history: be alert for sulfa-containing medications
Assess for recent viral illness; and risk factors for HIV and hepatitis
Reports of headache or visual disturbances should be reported immediately!!!!
Sign of intracranial bleeding
All injections, rectal medications and temperature should be avoided
Teach patients to address signs of exacerbation
Petechial, ecchymosis
Avoid constipation
Use electric razors
Soft-bristled tooth brush
Refrain from sex with counts <30,000
Von Willebrand’s Disease
oMost common inherited bleeding disorder
oResult of deficiency, dysfunction or absence of vWF
Necessary factory and is essential for platelet adhesion at the site of injury
oClinical Manifestations and Assessment
As about bleeding following procedures (like dental procedures), need for blood
transfusions following surgery/childbirth, history of heavy menses and easy bruising
Commonly have nosebleeds and prolonged bleeding from cuts
Lab tests show normal platelet count but prolonged bleeding time and normal or slightly
prolonged PTT
oMedical Management
Replace deficient protein at time of spontaneous bleeding or prior to invasive procedure
Synthetic form of vasopressin: desmopressin (DDAVP)
Causes release of vWF stored within endothelium, results in temporary increase
Administered intranasal or intravenously
Contraindicated in: unstable coronary artery disease (induce platelet aggregation
and cause a MI)
oSide effects: headache, facial flushing, tachycardia, hyponatremia and
seizures
Splenectomy
oEnlarged spleen: may be the site of excessive destruction of blood cells
Autoimmune hemolytic anemia and ITP
oSome patients with grossly enlarged spleen develop severe thrombocytopenia: platelets
sequestered in the spleen
oMost common complications: infection, thrombosis and bleeding
Transfusion
oNursing Management
1 unit of blood should increase hemoglobin by 1g/deciliter
Most people with chronic conditions will get a transfusion once hemoglobin is 8
Example: if patient starts with a hemoglobin of 7 and we give 1unit of blood
there hemoglobin should go to 8
Pretransfusion Assessment
History
oAny previous reactions with transfusions
Reaction, manifestations, interventions required and whether any
preventive measures were used
oAssess # of pregnancies
Higher number can increase risk for reaction due to development
of antibodies from fetal circulation
oOther health problems especially: cardiac, pulmonary and vascular
disease
oSystemic physical assessment
oBaseline vitals
oRespiratory system: auscultation of the lungs; use of accessory muscles
oCardiac: edema or other signs of cardiac failure
oSkin: rashes, petechial and ecchymosis
oSclera
Patient Teaching
S/S of transfusion
oFever, chills, itching, hives, respiratory distress, low back pain, nausea,
pain at IV site or anything “unusual”
Monitoring and Managing Potential Complications
Patients must be informed that the supply of blood is not completely risk-free
Prevent complications, promptly recognize complications if they develop,
promptly initiate measures to control complications
If reaction occurs: immediately stop the transfusion and infuse NS at a rate of 20-
30/hour (KVO: KEEP VEIN OPEN)
Then call the doctor
When giving plasma we don’t type/cross: give plasma to increase blood volume
Surgery, burns, cuts
Albumin (protein): draws in water to CV system
Give for hypovolemic patients; diuresis patient
Significant edema: low albumin, pre-albumin
Low albumin, pre-albumin: malnourishment; give protein
Common
Complications
Resulting
From
Long-Term
Packed
Red
Blood
Cell
(PRBC)
Transfusion
Therapy
Infection
Iron
overload
Transfusion
reaction
Manifestation
Hepatitis
(B,C)
Cytomegalovirus
(CMV)
Heart
failure
Endocrine
failure
(diabetes,
hypothyroidism,
hypoparathyroidism,
hypogonadism)
Sensitization
Febrile
reactions
Management
May
immunize
against
hepatitis
B;
give
alpha-interferon
for
hepatitis
C;
monitor
hepatic
function
WBC
filters
to
protect against
CMV
Prevent
by
chelation
therapy
Diminish
by
RBC
phenotyping,
using
WBC-filtered,
leukocyte
reduced
products
Diminish
by
using
WBC-filtered,
leukocyte
reduced
products
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