NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Blood and Lymphatic System

Focus topic: Medical–Surgical Nursing

The circulatory system, a continuous circuit, is the mechanical conveyor of the body constituent called blood. Blood, composed of cells and plasma, circulates through the body and is the means by which oxygen and nutritive materials are transported to the tissues and carbon dioxide and metabolic end products are removed for excretion. The lymphatic system collects toxins from the tissues and carries it to the blood.

Medical–Surgical Nursing: Blood and Blood Factors

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Blood Components

Focus topic: Medical–Surgical Nursing

Plasma
A. Plasma accounts for 55% of the total volume of blood.
B. It is composed of 92% water and 7% proteins.

Solid Particles
A. Solid particles account for 45% of the total blood volume.
B. Blood cells.

  • Erythrocytes (red blood cells).
    a. Normal count in an adult is 4–6 million cells/mm3.
    b. They contain hemoglobin, which carries oxygen to cells, and carbon dioxide from cells to lungs.
    c. Red blood cells (RBCs) originate in bone marrow and are stored in the spleen.
    d. Average life span is 10–120 days.
  • Leukocytes (white blood cells).
    a. Normal count in an adult is 4500 to 11,000/mm3.
    b. Primary defense against infections.
    c. Neutrophils play an active role in the acute inflammatory process and have phagocytic action.
    d. Macrophages—both fixed and wandering cells—act as scavengers and phagocytize foreign bodies, cellular debris, and more resistant organisms (e.g., fungi and Mycobacterium tuberculosis).
    e. Lymphocytes play an important role in immunologic responses.
    f. Monocytes are the largest of the leukocytes and are less phagocytic than macrophages.
  • Platelets (thrombocytes).
    a. About 100,000–400,000/mm3 are needed for clot retraction.
    b. Fewer than 60,000/mm3 may lead to a tendency to bleed.

Blood Component Therapy

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: System Assessment

Focus topic: Medical–Surgical Nursing

A. Assess onset of symptoms, whether insidious or abrupt.
B. Assess for petechiae, ecchymosis.
C. Evaluate bleeding time.
D. Assess for fatigue and general weakness.
E. Assess for chills or fever.
F. Assess for dyspnea.
G. Observe for ulceration of oral mucosa and pharynx.
H. Assess for pruritus.
I. Check skin color—pallor, yellow cast, or reddishpurple hue.
J. Assess for visual disturbances.
K. Palpate for hepatomegaly or splenomegaly.
L. Assess for dietary deficiencies—ask questions about daily intake of foods.
M. Assess for neurological symptoms.

  • Numbness and tingling in the extremities.
  • Personality changes.

N. Evaluate cardiovascular signs and symptoms.

  • Hypotension or hypertension.
  • Character of pulse.
  • Capillary engorgement.
  • Venous thrombosis.

O. Assess for gastric distress and weight loss.

Medical–Surgical Nursing: System Implementation

Focus topic: Medical–Surgical Nursing

A. Prevent infections.

  • Maintain isolation, if indicated, and meticulous medical asepsis.
  • Suggest bed rest.
  • Provide high-protein, high-vitamin, and highcalorie diet.
  • Administer antibiotics as ordered.

B. Promote rest for fatigue and weakness.

  • Conserve client’s strength.
  • Suggest frequent rest periods.
  • Ambulate as tolerated.
  • Decrease disturbing activities and noise.
  • Provide optimal nutrition.

C. Provide care for hemorrhagic tendencies.

  • Provide rest during bleeding episodes.
  • Apply gentle pressure to bleeding sites.
  • Apply cold compresses to bleeding sites when indicated.
  • Do not disturb clots.
  • Use small-gauge needles to administer medications by injection.
  • Support the client during transfusion therapy.
  • Observe for symptoms of internal bleeding.
  • Have tracheostomy set available for client who is bleeding from mouth or throat.

D. Give care for ulcerative lesions of the tongue, gums, and/or mucous membranes.

  • Provide nonirritating foods and beverages.
  • Give frequent oral hygiene with mild, cool mouthwash and solutions.
  • Use applicators or soft-bristled toothbrush.
  • Lubricate lips.
  • Give mouth care both before and after meals.

E. Monitor and treat oxygen deficit.

  • Elevate head of the bed.
  • Support client in the orthopneic position.
  • Administer oxygen when indicated.
  • Prevent unnecessary exertion.

F. Provide measures to alleviate bone and joint pain.

  • Use cradle to relieve pressure of bedding.
  • Apply hot or cold compresses as ordered.
  • Immobilize joints when ordered.

G. Apply cool sponges if fever present.
H. Administer antipyretic drugs as ordered.
I. Encourage fluid intake unless contraindicated.
J. Provide care for pruritus and/or skin eruptions.

  • Keep client’s fingernails short.
  • Use soap sparingly, if at all.
  • Apply emollient lotions for skin care.

K. Attempt to decrease client’s anxiety.

  • Explain nature, discomforts, and limitations of activity associated with diagnostic procedures and treatments.
  • Listen to client.
  • Treat client as an individual.
  • Allow family to participate in client’s care.
  • Encourage family to visit with client; provide privacy for family and client.

Medical–Surgical Nursing: Transfusion Administration

Focus topic: Medical–Surgical Nursing

Implementation
A. Follow agency policy and guidelines for preventing transfusion reaction.

  • Check physician’s orders—type and number of units.
  • Identify client and blood bag. Check:

a. Client’s room number; check that ID band number matches transfusion record number. Use agency method of client identification (usually name and date of birth).
b. Name spelled correctly on transfusion record and consent form is signed.
c. Patency of IV.
d. Blood type matches on transfusion record and blood bag (A, B, O, and Rh).

B. Observe blood bag for bubbles, cloudiness, dark color, or black sediment—indicative of bacterial invasion.
C. Check blood with another RN before infusing. Sign transfusion form with another RN according to hospital policy.
D. Ask client about allergy history and report any previous blood reactions.
E. Start infusion with normal saline and appropriate blood tubing. Start blood within 30 minutes from time it is removed from refrigeration. (Blood should not remain at room temperature for long period of time.)
F. Do not allow duration of blood infusion to exceed 4 hours.

G. Use blood filter to prevent fibrin and other materials from entering the bloodstream.
H. Maintain aseptic technique during procedure.
I. Start transfusion slowly at 20–25 drops per minute and observe for transfusion reaction—usually occurs during the first 5–15 minutes.
J. Take baseline vital signs at start of transfusion and again 5 minutes later.
K. Complete the transfusion in no less than 2 hours unless hypovolemic.

  • After initial slow rate, infuse at a rate of 60–80 drops/min. (Administration set—10 gtt/mL.)
  • Hypovolemic client.
    a. Administer blood at the rate of 500 mL in 10 minutes by use of a blood pump or as ordered.
    b. Observe for pulmonary edema and hypervolemia.

Summary of Abo Blood Grouping

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Transfusion Reactions

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Hemolytic or Incompatibility Reaction

Focus topic: Medical–Surgical Nursing

Characteristics
A. Most severe complication.
B. Caused by mismatched blood.
C. The reaction is caused by agglutination of the donor’s red cells.

  • The antibodies in the recipient’s plasma react with the antigens in the donor’s red cells.
  • The clumping blocks off capillaries and, therefore, obstructs the flow of blood and oxygen to cells.

Assessment
A. Assess for increased temperature.
B. Evaluate for decreased blood pressure.
C. Observe for pain across chest and at site of needle insertion.
D. Assess for chills.
E. Observe for hematuria.

F. Evaluate if backache in the kidney region is present.
G. Assess dyspnea and cyanosis.
H. Observe for jaundice in severe cases.

Transfusion Reactions

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Implementation
A. Stop transfusion immediately upon appearance of symptoms.
B. Return remaining blood and client’s blood sample to the laboratory for type and cross-match.
C. Keep IV patent after changing blood tubing with either normal saline or D5W, as ordered.
D. Take vital signs every 15 minutes.
E. Get a urine sample for red blood cells and an accurate output record.
F. Check for oliguria.
G. Administer medications such as vasopressors if indicated.
H. Administer oxygen as necessary.

Medical–Surgical Nursing: Allergic Reactions

Focus topic: Medical–Surgical Nursing

Characteristics
A. Allergic response to any type of allergen in the donor’s blood.
B. Common reaction, usually mild in nature.

Assessment
A. Assess for hives.
B. Assess for urticaria.
C. Observe for wheezing.
D. Check for laryngeal edema.

Implementation
A. Administer an antihistamine like Benadryl (diphenhydramine) to control itching and to relieve edema.
B. Slow infusion rate, evaluate, and, if reaction is severe, discontinue the transfusion immediately and keep vein open with normal saline.

Medical–Surgical Nursing: Bacterial Contamination

Focus topic: Medical–Surgical Nursing

Assessment
A. Check blood to see if it is cloudy or discolored or appears to have bubbles present.
B. Assess for sudden increase in temperature.
C. Check for dry, flushed skin.
D. Assess for abdominal or lumbar pain.
E. Assess for hypotension.
F. Assess for headache and sudden chills.

Implementation
A. If transfusion has been started, discontinue immediately.
B. Send remaining blood to laboratory for culture and sensitivity. It is usually advisable to send client’s blood sample as well, if transfusion has been started.
C. Change IV tubing and keep line patent.
D. Check vital signs, including temperature, every 15 minutes.
E. Insert Foley catheter for accurate output and urine specimen as ordered.
F. Control hyperthermia, if present, with antipyretics, cooling blankets, or sponge baths.
G. Draw blood cultures before antibiotics started.

Transmission of Aids

A. Blood donations are now screened for the acquired immune deficiency syndrome (AIDS) virus.
B. AIDS antibody test keeps potentially infectious blood and blood products out of the U.S. blood supply.

  • AIDS antibody is a protein naturally produced in body in response to presence of the AIDS virus.
  • Positive test indicates the AIDS antibody is in blood.
  • Blood that tests positive will not be accepted (even if result may be a false positive).

C. Based on the AIDS antibody test for all blood and blood products, transfusion-related AIDS is now extremely rare.

Medical–Surgical Nursing: Transmission of Viral Hepatitis

Focus topic: Medical–Surgical Nursing

Characteristics
A. Donors are screened to prevent transmission.

  • If blood shows positive for hepatitis B surface antigen (formerly Australian antigen), donor is rejected.
  • If donor has had jaundice or hepatitis, donor is rejected permanently.

B. Hepatitis transmitted through blood is usually not fatal.
C. Nursing management is related to the care of clients with hepatitis, based on the seriousness of the condition.

Medical–Surgical Nursing: Circulatory Overload

Focus topic: Medical–Surgical Nursing

Characteristics
A. Transfusion is administered too rapidly.
B. Quantity is in excess of the amount the circulatory system can accommodate.
C. Usually occurs when transfusion is administered to debilitated clients, elderly or young clients, or clients with cardiac or pulmonary disease.

Assessment
A. Observe CVP for increased reading.
B. Assess for tachycardia, sudden increase in blood pressure.
C. Evaluate for respiratory difficulty (e.g., dyspnea, shortness of breath, cough, rales, rhonchi).
D. Assess for hemoptysis and/or pink frothy sputum.
E. Evaluate edema, especially pulmonary edema.

Implementation
A. Discontinue transfusion.
B. Provide for patent airway and adequate ventilation.

  • Administer oxygen at 2 L/min/nasal cannula.
  • Intubate as needed.

C. Place client in semi- to high-Fowler’s position to facilitate respiration.
D. Give diuretics (Lasix [furosemide]) as ordered.

  • Drugs will help to decrease blood volume.
  • Reduces effects of hypervolemia on the heart.

E. If client is in congestive heart failure, may need to digitalize.
F. Be prepared for electrocardiogram (ECG) and chest x-ray.

Medical–Surgical Nursing: Massive Blood Transfusion Reaction

Focus topic: Medical–Surgical Nursing

Definition: Massive transfusion is a transfusion of a volume of blood greater than or equal to one’s blood volume in 24 hours (e.g., 10 units in a 70-kg (154 lbs) adult). If a client receives stored blood in such large volumes, his or her own blood may be, in effect, “washed out.”

Assessment
A. Hypothermia due to rapid transfusion of large amounts of cold blood.
B. Arrhythmias or cardiac arrest.
C. Liver failure clients may have difficulty metabolizing citrate.
D. Hypocalcemia.

Implementation
A. Hypothermia can be avoided by using a heatexchange device that gently warms blood. All other means of warming blood are contraindicated due to hemolysis.
B. Treatment for hypocalcemia (rarely required) is 10 mL of a 10% solution of calcium gluconate IV diluted in 100 mL D5W given over 10 minutes.
C. Do not transfuse blood stored for longer than 1 week if client has renal failure because client may have elevated K+.

Medical–Surgical Nursing: Transfusion-Related Acute Lung Injury

Focus topic: Medical–Surgical Nursing

Definition: Transfusion-related acute lung injury (TRALI) is a syndrome that includes dyspnea, hypotension, bilateral pulmonary edema, and fever.

Characteristics
A. TRALI has surpassed hemolytic reactions as the leading cause of transfusion-related death. Mortality rate is reported to be 5% to 10%.
B. Sudden development of noncardiogenic pulmonary edema (acute lung injury).
C. Usually occurs within 2–6 hours after transfusion of blood product; can occur up to 48 hours later.
D. As many as one-third of all clients who develop acute lung injury have been exposed to blood products.
E. TRALI may be an important and potentially preventable cause of acute lung injury.

Assessment
A. Clients present with findings similar to those of adult respiratory distress syndrome.
B. Symptoms.

  • Hypotension.
  • Fever.
  • Dyspnea and tachycardia.
  • Noncardiogenic pulmonary edema with diffuse bilateral pulmonary infiltrates on chest radiography is characteristic.

C. Assess for presence of TRALI with transfusions of all types of blood products.

Implementation
A. Generally supportive and similar to that for adult respiratory distress syndrome.
B. Ventilatory and hemodynamic assistance are utilized as required. Most symptoms resolve within 96 hours after ventilatory support.
C. There are no clear indications for the use of corticosteroids, and their use remains controversial in this setting.
D. Additional blood component therapy should not be withheld if clear indications for transfusion exist.

Medical–Surgical Nursing: Disorders of the Blood

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Purpuras

Focus topic: Medical–Surgical Nursing

Definition: The extravasation of blood into the tissues and mucous membranes.

Characteristics
A. Idiopathic thrombocytopenic purpura is characterized by platelet deficiency due to either hypoproliferation, excessive destruction, or excessive pooling of platelets in the spleen.
B. Vascular purpura is characterized by weak, damaged vessels, which rupture easily.

Assessment
A. Observe for petechiae; bruising.
B. Assess postsurgical bleeding.
C. Evaluate increased bleeding time.
D. Evaluate abnormal platelet count (less than 20,000).
E. Assess for ecchymosis.

Implementation
A. Identify underlying cause (medication) if possible.
B. Complete steps to control bleeding.
C. Monitor transfusion of platelets.
D. Monitor administration of corticosteroids.
E. Monitor client with post-surgical splenectomy for idiopathic thrombocytopenia.

Medical–Surgical Nursing: Agranulocytosis

Focus topic: Medical–Surgical Nursing

Definition: An acute, potentially fatal blood disorder characterized by profound neutropenia; most commonly caused by drug toxicity or hypersensitivity.

Assessment
A. Assess for chills and fever.
B. Assess for sore throat.
C. Assess for exhaustion and depletion of energy.
D. Observe for ulceration of oral mucosa and throat.

Implementation
A. Discontinue suspected chemical agents or drugs.
B. Isolate client to reduce exposure to infections.
C. Administer antiviral, antibiotic, and antifungal medications as ordered.

Polycythemia Vera
✦ Definition: A chronic disease of unknown etiology characterized
by overactivity of bone marrow with overproduction
of red cells and hemoglobin. Hematocrit is elevated
(55% of males and 50% of females).
Assessment
✦✦ A. Assess skin.
1. Reddish-purple hue.
2. Pruritus.
B. Diagnosis made by elevated RBC mass, normal O2
saturation level, and enlarged spleen.
✦✦ C. Assess for complications.
1. Increased blood volume.
2. Capillary engorgement.
3. Hemorrhage, nose bleeds.
4. Risk for venous thrombosis.
5. Hypertension.
D. Assess for signs of hypervolemia: visual disturbances,
congestion of conjunctiva, headache, tinnitus,
and vertigo.
E. Assess for gastric distress and weight loss.

Implementation
A. Monitor alkylating agent—Busulfex (busulfan).
B. Assist with phlebotomy to remove 500 to 2000 mL of blood per week until hematocrit reaches 50%; procedure is repeated when hematocrit rises.

  • Monitor blood pressure, pulse, and respirations for tachycardia during procedure and postprocedure.
  • Promote client comfort by positioning in prone position to prevent vertigo and syncope.
  • Instruct clients to avoid iron supplements (especially in multivitamins).
  • Instruct clients to avoid aspirin and aspirincontaining drugs; alters platelet functioning.

C. Monitor for complications (impending cerebrovascular accident [CVA], thrombocytosis).
D. Instruct client to monitor symptoms of iron deficiency.
E. Instruct client to watch common bleeding sites (nose, skin) and report immediately.

Medical–Surgical Nursing: Anemia

Focus topic: Medical–Surgical Nursing

Definition: A condition that occurs when there is a decrease in either quantity or quality of blood. The deficiency may be a decrease in erythrocytes or a lower than normal level of hemoglobin.

Characteristics
A. Common causes of anemia.

  • Acute or chronic blood loss (hemorrhage, bleeding ulcers, malignancy).
  • Destruction of red blood cells (hemolysis).
  • Abnormal bone marrow function—drugs, chemicals, chemotherapy.
  • Decreased erythropoietin due to renal damage.
  • Inadequate maturation of red blood cells.

B. Classifications.

  • Hemolytic anemias—premature destruction of RBCs.
    a. Thalassemia.
    b. Sickle cell disease.
    c. Acquired hemolytic anemia.
  • Hypoproliferative (inadequate production) anemias.
    a. Vitamin B12 deficiency or folic acid deficiency.
    b. Result of marrow damage caused by medications or chemicals.
  • Secondary to blood loss.
    a. Chronic blood loss.
    b. Acute blood loss.

Assessment
A. Assess for signs related to tissue hypoxia.

  • Weakness and fatigue.
  • Need for sleep and rest.
  • Lethargy.
  • Dyspnea.
  • Tachycardia and tachypnea.
  • Pallor.
  • Cold extremities.

B. Assess for signs related to the central nervous system.

  • Vertigo.
  • Irritability.
  • Depression.

C. Evaluate poor wound healing.
D. Assess for dietary deficiencies.

Implementation
A. Provide diet high in protein, iron, and vitamins to increase production of erythrocytes; remember that client is sensitive to hot, cold, and spicy foods.
B. Maintain adequate fluid intake.
C. Protect from infection.
D. Manage fatigue (most common symptom). Provide complete bed rest if necessary.
E. Promote good skin care to prevent pressure ulcers.
F. Protect from falls and injury (due to vertigo).
G. Avoid extremes of heat and cold (due to disturbance in sensory perception).
H. Provide good mouth care with diluted mouthwash and soft toothbrush.
I. Provide emotional support for long-term therapy.

Medical–Surgical Nursing: Iron-Deficiency Anemia

Focus topic: Medical–Surgical Nursing

Definition: The most common type of anemia in the world, slowly progressive, related to a deficiency in iron.

Characteristics
A. Occurs most often in infants, adolescents, pregnant females, alcoholics, and the elderly.
B. Results from chronic blood loss, inadequate nutritional intake, defective absorption, improper utilization of iron, prolonged drug therapy, or improper cooking of foods.

Assessment
A. Assess for cheilosis—corners of the mouth are cracked, red, and painful.
B. Assess for exertional dyspnea.
C. Check glossitis.
D. Assess for papillae atrophy of tongue (shiny).
E. Check for pica syndrome (abnormal craving for sand, clay, ice).
F. Observe for concave, brittle nails.
G. Assess for fatigue and lack of energy.
H. Observe for signs of anaphylactic shock, particularly with IV iron medications.

Implementation
A. Provide diet high in iron: liver, lean meats, egg yolk, dried fruit, whole-wheat bread, wheat germ, red beans, asparagus, and molasses.
B. Administer iron preparations for 6 to 12 months.

  • Oral.
    a. Administer ferrous sulfate, 300 mg tid.
    b. Give liquid iron with straw to avoid staining of teeth.
    c. Administer oral iron on empty stomach to increase absorption, or, because it is irritating to the GI tract, suggest client take iron after meals.
    d. Give iron with orange juice or vitamin
    C, because iron absorption is aided by vitamin C.
    e. Watch for side effects: epigastric distress, abdominal cramps, nausea, and diarrhea or constipation.
    f. Warn client that stools will be black.
  • Parenteral.
    a. Administer Imferon (iron dextran) IV or intramuscular (IM).
    b. Use Z-track (deep IM) to prevent pain and discoloration.
    C. Monitor fluid and electrolyte balance.
    D. Provide frequent rest periods for intense fatigue.

Medical–Surgical Nursing: Megaloblastic Anemia

Focus topic: Medical–Surgical Nursing

Definition: A group of anemias that have morphologic changes caused by defective DNA synthesis and abnormal RBC maturation.

Characteristics
A. The primary cause is a deficiency of vitamin B12 or folic acid.
B. Sources.

  • Absence of intrinsic factor (pernicious anemia).
  • Surgical resection of the stomach.
  • Atrophy of gastric mucosa.
  • Dietary deficiency—malabsorption disease.
  • Bacterial or parasitic infections.
  • Drugs: Trexall (methotrexate), oral contraceptives, and anticonvulsants.
  • Alcohol abuse and anorexia.

C. Genetic predisposition (especially in northern Europe).

Assessment
A. Assess for neurological disturbance—tingling of extremities, peripheral neuropathy.

  • These symptoms do not occur with folic acid deficiency.
  • Distinction between deficiency in vitamin B12 must be made with deficiency in folic acid.

B. Assess for symptoms of spinal cord degeneration— alterations in gait (loss of balance).
C. Check any loss of finger movement.
D. Evaluate personality and behavioral changes.
E. Assess for glossitis—beefy, red tongue.
F. Assess for anorexia.
G. Assess for fatigue, weakness, pallor.
H. Observe yellow cast to skin.

Implementation
A. Obtain blood work for RBC count and megaloblastic maturation.
B. Prepare client for the following tests.

  • Bone marrow aspiration (assist physician during test).
  • Upper GI series (administer bowel prep).
  • Schilling test (maintain NPO for 12 hours; collect 24-hour urine) for pernicious anemia.
  • Gastric analysis—insertion of nasogastric tube, collection of aspirant, injection of histamine.

C. Administer vitamin B12 deep IM—usually once a month; usual dose of folic acid is 1 mg/day PO or 5 mg/day for malabsorption.
D. Change in diet and oral folic acid if anemia is caused by folic acid deficiency (chronic alcoholism, malabsorption syndrome, or medications).
E. Provide emotional support during bone marrow aspiration.

F. Provide safety measures if a neurological deficiency is present—assist with ambulation.
G. Provide support and explain behavior changes to client and family.

Medical–Surgical Nursing: Aplastic Anemia

Focus topic: Medical–Surgical Nursing

Definition: Deficiency of marrow stem cells resulting from bone marrow suppression. Pancytopenia frequently accompanies RBC deficiency.

Characteristics
A. Etiology.

  • Toxic action of drugs: Chloromycetin (chloramphenicol), sulfonamides, Dilantin (phenytoin), alkylating agents, antimetabolites, and anticonvulsants (Mesantoin [mephenytoin]).
  • Chemicals: DDT, benzene.
  • Exposure to radiation.
  • Diseases that suppress bone marrow activity (leukemia and metastatic cancer).

B. Treatment.

  • Removal of causative agent.
  • Hematopoietic stem cell transplant (HSCT).
  • Bone marrow or stem cell transplant is treatment of choice for clients younger than age 40.
  • Immunosuppressive therapy.
    a. Antithymocyte globulin (ATG).
    b. Restasis (cyclosporine).
    c. High-dose Cytoxan (cyclophosphamide).
    d. Steroids.

Assessment
A. Exposure to chemicals and/or drugs.
B. Assess for increased fatigue.
C. Assess for ability to complete activities of daily living.
D. Assess for dyspnea, fatigue.
E. Evaluate blood for low platelet and leukocyte count.
F. Assess for infection.

Implementation
A. Avoid use of toxic chemical agents—DDT, carbon tetrachloride, etc.
B. Administer androgens and/or corticosteroids—now not commonly used due to toxic side effects.
C. Monitor transfusion of fresh platelets (RBC transfusion may be introduced also).
D. Protect from infections—avoid contact with others who have infection; provide meticulous hygiene, clean environment.

  • Administer antibiotics when infection occurs.
  • Place client in private room.

E. Prevent fatigue—provide for adequate rest periods. Avoid activities that are stressful.
F. Observe for complications.
G. Provide physical comfort measures.
H. Provide emotional support for client and family.
I. Educate client how to protect from infection and excessive bleeding.
J. Educate public in use of toxic pesticides and chemicals.

Medical–Surgical Nursing: Thrombocytopenia

Focus topic: Medical–Surgical Nursing

Definition: Condition that is a lower than normal number of circulating platelets.

Characteristics
A. Normal platelet count is 150,000 to 400,000/mm3. A count lower than 100,000 leads to this condition; lower than 60,000 may result in tendency to bleed.
B. Condition results from decreased platelet production, destruction of platelets (most common), decreased platelet survival, or sequestration of blood in the spleen.
C. Common causes of platelet destruction.

  • Idiopathic thrombocytopenic purpura— production of an antibody that works against platelet antigen.
  • Heparin induced—may develop with client’s receiving heparin for more than 5 days. (Use of low-molecular-weight heparin may prevent this complication.)
  • Certain drugs (alcohol, aspirin, chemotherapeutic agents, gold salts, sulfonamides, thiazides, penicillin, etc.) induce this condition, which usually resolves in 1–2 weeks after drug is withdrawn.

Assessment
A. Assess skin signs: petechiae (occurring only in platelet disorders), ecchymoses, and purpura.
B. Assess for history of menorrhagia, epistaxis.
C. Check low platelet count, bleeding time, and bone marrow examination.

Implementation
A. Monitor corticosteroid therapy—decreases antibody production. Inform client not to stop medication suddenly.
B. Administer care following a splenectomy—removal of the organ responsible for destruction of antibody- coated platelets.
C. Monitor use of immunosuppressive drugs.
D. Monitor platelet transfusion—may be done for certain clients, especially for thrombocytopenic bleeding.
E. Constantly monitor for bleeding tendency—when platelet count is less than 60,000, avoid

  • Injections.
  • Rectal temperature.

F. Apply pressure to venipuncture sites for 5 minutes.
G. Educate client on how to recognize signs and measures to prevent injury.

  • Avoid trauma and contact sports.
  • Use soft toothbrush—avoid trauma to gums.
  • Use electric shaver.
  • Avoid drugs that thin blood (aspirin).

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