Thrombocytopenia and Bleeding Disorders

• Describe the four steps of hemostasis:

  • Blood vessel constriction
  • Platelet activation and formation of the platelet plug (primary hemostasis)
  • Activation of the clotting cascade which makes fibrin to reinforce the platelet plug (secondary hemostasis)
  • Fibrinolysis and clot dissolution
• Thrombocytopenia:

  • A decrease in the number of circulating platelets
  • Less than 150,000 = thrombocytopenia
• Prolonged Bleeding with Minor Trauma:

  • 50,000
• Spontaneous Hemorrhage:

  • 10,000
• Clinical Manifestations of Thrombocytopenia:

  • Petechia and Ecchymosis
  • Gingival bleeding
  • Epistaxis
  • Heavy menstrual bleeding
  • Hematuria
• Nursing Diagnosis for Thrombocytopenia:

  • Impaired production of platelets
  • Accelerated destruction of platelets
• Impaired Production of Platelets can be caused by:

  • Aplastic anemia
  • Myelodysplastic syndromes
  • Leukemia and other cancers
  • Chemotherapy and radiation
  • HIV, Hep C, CMV
  • Alcohol consumption
• Accelerated Destruction of Platelets can be caused by:

  • Immune thrombocytopenia
  • Heparin
  • Sulfa-containing antibiotics and other drugs
  • Splenomegaly
• Prothrombin Time (PT):

  • Measures the time it takes for plasma to clot after tissue factor is added to it
  • Evaluates the EXTRINSIC and final common pathways of coagulation
• International Normalization Ratios (INR):

  • A standardized system of reporting prothrombin time (PT)
  • Used to monitor and dose warfarin therapy
• Activated Partial Thromboplastin (aPTT):

  • Measures the time it takes for plasma to clot after a reagent is added
  • Evaluates the INTRINSIC and final common pathways of the coagulation cascade
• Immune Thrombocytopenia:

  • The body makes antibodies against its own platelets
  • Platelets coated in antibodies are then destroyed in the spleen or liver
• Clinical Manifestations of Immune Thrombocytopenia:

  • Petechia
  • Ecchymosis
  • Gingival bleeding
  • Epistaxis
  • Heavy menstrual bleeding
  • Hematuria
• Diagnostic Findings of Immune Thrombocytopenia:

  • Hemoglobin = Normal or low depending on amount of blood loss
  • Platelet count = significantly low
  • PT and aPTT = Normal
• Heparin-Induced Thrombocytopenia:

  • Caused by the formation of antibodies against Heparin
  • These antibodies bind to platelets which accelerates platelet destruction in the spleen - this causes bleeding
  • These antibodies induce platelet activation which can initiate the coagulation cascade - results in clotting
• Clinical Manifestations of Heparin-Induced Thrombocytopenia:

  • NO signs and symptoms at first
  • Acute systemic reactions including chills, fever, dyspnea, chest pain and flushing
  • DVT and/or pulmonary embolism
  • Spontaneous bleeding is rare
• Diagnostic Findings of Heparin-Induced Thrombocytopenia:

  • Platelet count: Decreases 4-14 days after heparin is started
  • PT and INR: Normal
  • aPTT: should be prolonged due to the therapeutic effects of heparin
  • Hgb/Hct: normal
  • HIT antibody test: POSITIVE
• Collaborative Management of Heparin-Induced Thrombocytopenia:

  • Discontinue and avoid all heparin products immediately
  • Avoid platelet transfusions
• Disseminated Intravascular Coagulation (DIC):

  • A syndrome characterized by widespread activation of the clotting cascade
  • The increase in clotting depletes platelets and clotting factors
• Diagnostic Findings of Disseminated Intravascular Coagulation (DIC):

  • PT: Often prolonged
  • aPTT: often prolonged
  • Platelet count: Decrased
  • Fibrinogen: Usually decreased
• Collaborative Management of Disseminated Intravascular Coagulation (DIC):

  • Treat the underlying cause
  • Monitor vital signs, I/Os, neuro status, skin, circulation
  • Monitor CBC-P and coagulation labs
  • Prevent patient from trauma to prevent bleeding
  • With serious bleeding administer blood products
  • Heparin might be infused
• Hemophilia A:

  • A dysfunction of deficiency in clotting factors (VIII and IV)
• Clinical Manifestations of Mild Hemophilia:

  • Bruising, heavy menstrual periods
  • Slow persistent prolonged bleeding after trauma, dental or surgical procedures
• Clinical Manifestations of Moderate/Severe Hemophilia:

  • May also have spontaneous bleeding episodes (often in joints and muscles)
• Collaborative Management for Hemophilia:

  • Genetic counseling
  • Replacement of deficient clotting factors ASAP after the start of a bleeding episode
• Collaborative Management for Mild Hemophilia:

  • Desmopressin Acetate (DDAVP) can temporally control minor bleeding
  • Replace deficient clotting factors prophylactically before surgery or dental care
• Collaborative Management for Severe Hemophilia:

  • Replace clotting factors weekly
  • Some patients develop antibodies that inhibit clotting
• People with Thrombocytopenia are at risk for bleeding
• Pathophysiology for von Willebrand Disease:

  • Deficiency in von Willebrand coagulation protein
  • This causes incomplete platelet plugs so the bleeding continues
• Collaborative Management of von Willebrand Disease:

  • Preventative care
  • Replacement therapy during acute bleeding episodes and as prophylaxis
  • Treat any complications
• Pathophysiology of Hemophilia A:

  • X-linked recessive genetic disorder caused by deficient coagulation factor
  • Female parent is ALWAYS the carrier