3.10 Thrombocytopenia
Thrombocytopenia is characterized by a decreased number of platelets in the blood. Thrombocytopenia may occur due to many factors affecting platelet production, platelet destruction, or platelet utilization.
Thrombocytopenia is often an acquired condition, such as an immune-mediated response, response to another condition, or a side effect of medication. For example, idiopathic thrombocytopenic purpura (ITP) is an acquired thrombocytopenia caused by the client’s immune system mistakenly destroying its own platelets. Thrombocytopenia may be caused by other hematological disorders, such as aplastic anemia or leukemia. Additionally, medications such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), penicillin, phenothiazines, prednisone, and chemotherapy can cause thrombocytopenia.[1]
Thrombocytopenia can also be inherited due to genetic mutations, resulting in abnormal platelet production and function. Inherited forms of thrombocytopenia are more rare than acquired forms of the disease.[2],[3]
Thrombocytopenia can cause many symptoms related to excessive bleeding, such as easy bruising, petechiae, purpura, ecchymoses, prolonged bleeding from minor cuts or injuries, and excessive bleeding from the nose or gums. Purpura are red or purple spots on the skin that do not blanch when pressure is applied and measure between 4 and 10 millimeters (mm) in diameter. When purpura spots are less than 4 mm in diameter, they are called petechiae.[4] See Figure 3.10[5] for an image of a severe case of petechiae and purpura. In severe cases of thrombocytopenia, internal bleeding can occur, posing life-threatening risks.[6],[7]
Assessment
Physical Examination
Common signs and symptoms of thrombocytopenia are summarized in Table 3.10.
Table 3.10. Clinical Manifestations of Thrombocytopenia[8],[9]
| Body System | Clinical Manifestations |
|---|---|
| Integumentary | Easy bruising or purpura (purple or red spots on skin), petechiae (small red or purple dots on the skin), prolonged bleeding from cuts or injuries, or excessive bleeding from the gums or nose. |
| Musculoskeletal | Joint pain and swelling caused by hemarthrosis (bleeding into joints). |
| Gastrointestinal | Blood in the stool or black, tarry stools. |
| Genitourinary | Blood in the urine or heavy menstrual bleeding. |
| Respiratory | Hemoptysis (coughing up blood). |
| Neurological | Intracranial hemorrhage (rare). |
| Cardiovascular | Tachycardia, hypotension, and weak pulses resulting from blood loss. |
Diagnostic Testing
Thrombocytopenia is diagnosed by decreased platelet counts on a CBC. Bleeding times may be further evaluated by PT, PTT, and INR. Review normal reference ranges for common diagnostic tests in “Appendix A – Normal Reference Ranges.”
The structure of the platelets may also be examined through a test called a peripheral blood smear. If the cause of thrombocytopenia remains uncertain, a bone marrow aspiration and biopsy may be performed to assess the amount of megakaryocytes (platelet-producing cells).[10],[11],[12]
Nursing Diagnoses
Nursing diagnoses for clients with thrombocytopenia are based on their risk for bleeding and the need for health teaching to prevent bleeding.
Nursing diagnoses for clients with thrombocytopenia may include these diagnoses:
- Risk for Bleeding
- Readiness for Enhanced Knowledge
Outcome Identification
Outcome identification includes setting short- and long-term goals and creating specific expected outcome statements for nursing diagnoses identified for the client. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions.
An example of an expected outcome for a client with thrombocytopenia is the following:
- The client will remain free from excessive bleeding.
Interventions
Medical Interventions
Medical interventions for thrombocytopenia address the low platelet counts and prevent bleeding complications. The choice of interventions depends on the underlying cause, the severity of thrombocytopenia, and the client’s individual health status.
Common medical interventions and treatments used to manage thrombocytopenia are as follows:
- Medications: If a prescribed medication is the cause of the thrombocytopenia, it is stopped when possible. Medications like thrombopoietin receptor agonists (e.g., romiplostim) may be prescribed to stimulate the bone marrow to produce more platelets. Corticosteroids are useful to slow the rate of platelet destruction.
- Platelet Transfusions: In severe cases of thrombocytopenia with critically low platelet counts or when the client’s risk of bleeding is high, platelet transfusion may be prescribed. This therapy provides an immediate increase in platelets and can help to stop bleeding.
- Immunosuppressive Therapy: Immunosuppressive medications may be prescribed for immune-mediated thrombocytopenia to suppress the immune system’s attack on platelets.
- Intravenous Immunoglobulin (IVIG): IVIG may be prescribed for immune-mediated thrombocytopenia. It provides antibodies that can temporarily suppress the immune system’s destruction of platelets.
- Splenectomy: In cases of refractory immune thrombocytopenia, where other treatments have been ineffective, surgical removal of the spleen (splenectomy) may be considered. The spleen stores platelets, so its removal helps to increase the number of circulating platelets in the bloodstream.
- Lifestyle Modifications: Health care providers may recommend lifestyle modifications, such as avoiding activities that increase the risk of bleeding.[13],[14]
Nursing Interventions
Nursing interventions for clients with thrombocytopenia focus on preventing bleeding and providing health teaching to support the client’s well-being.
Implementing Bleeding Precautions
Nurses play a significant role in preventing bleeding in clients at risk for bleeding, including those diagnosed with thrombocytopenia. Nursing Interventions Classification (NIC) provides a list of evidence-based nursing interventions categorized as “Bleeding Precautions” that can be implemented for a variety of medical conditions, including thrombocytopenia.[15] See selected nursing interventions related to this category in the following box.
NIC Selected Nursing Interventions for Bleeding Precautions[16],[17]
- Identify clients at risk for bleeding by reviewing for specific risk factors related to poor clotting function (i.e., a hematological condition or side effects from a medication).
- Assess skin for petechiae, purpura, ecchymosis, or bleeding from wounds or surgical sites.
- Monitor heart rate, blood pressure, and respiratory rate. Tachycardia, hypotension, and tachypnea are initial compensatory mechanisms associated with bleeding.
- For clients at severe risk of bleeding, monitor for signs and symptoms of internal and external hemorrhage (i.e., distension or swelling of an affected body part, change in the type or amount of drainage from a surgical wound or drain, bloody saturation of dressings, pooling of blood beneath client, hypotension, weak and rapid pulse, cool and clammy skin, rapid breathing, restlessness, reduced urine output).
- Monitor coagulation studies, such as platelets, PT, aPTT, INR, fibrinogen, and fibrin degradation products.
- Administer medications, such as thrombopoietin receptor agonists or immunosuppressive therapy, as prescribed.
- Administer platelets transfusions, as prescribed.
- Protect the client from injury that can cause bleeding (i.e., avoid intramuscular injections, use a soft toothbrush, use an electric razor, and avoid rectal suppositories and straining with constipation).
- Implement fall precautions because there is a high risk of internal bleeding from injuries resulting from falls.
- Avoid medications and supplements that potentially increase bleeding such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, heparin, clopidogrel, ginger, etc., as appropriate.
- Avoid invasive procedures; if they are necessary, monitor closely for bleeding.
- If excessive bleeding occurs, apply pressure or a pressure dressing over the site and immediately notify the health care provider.
- Teach the client and family on signs of bleeding (i.e., easy bruising, nosebleeds, bleeding gums, blood in the urine or stool, or extremely heavy menstrual bleeding) and to notify their health care provider if bleeding occurs.
Health Teaching and Health Promotion
Nurses teach clients and their family members about thrombocytopenia, its causes, and management. They teach about signs of bleeding and when to call the health care provider.
Evaluation
During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.
RN Recap: Thrombocytopenia
View a brief YouTube video overview of thrombocytopenia[18]:
- Medline Plus. (n.d.). Acquired platelet function defect. National Institutes of Health. https://medlineplus.gov/ency/article/000546.htm ↵
- National Heart, Lung, and Blood Institute. (2023). Bleeding disorders: Causes and risk factors. National Institutes of Health. https://www.nhlbi.nih.gov/health/bleeding-disorders/causes ↵
- MedlinePlus. (2020). Platelet disorders. National Library of Medicine. https://medlineplus.gov/plateletdisorders.html ↵
- Medline Plus. (n.d.). Purpura. National Institutes of Health. https://medlineplus.gov/ency/article/003232.htm ↵
- “Purpura.jpg” by User:Hektor is licensed under CC BY-SA 3.0 ↵
- National Heart, Lung, and Blood Institute. (2023). Bleeding disorders: Causes and risk factors. National Institutes of Health. https://www.nhlbi.nih.gov/health/bleeding-disorders/causes ↵
- MedlinePlus. (2020). Platelet disorders. National Library of Medicine. https://medlineplus.gov/plateletdisorders.html ↵
- National Heart, Lung, and Blood Institute. (2023). Bleeding disorders: Causes and risk factors. National Institutes of Health. https://www.nhlbi.nih.gov/health/bleeding-disorders/causes ↵
- MedlinePlus. (2020). Platelet disorders. National Library of Medicine. https://medlineplus.gov/plateletdisorders.html ↵
- National Heart, Lung, and Blood Institute. (2023). Bleeding disorders: Causes and risk factors. National Institutes of Health. https://www.nhlbi.nih.gov/health/bleeding-disorders/causes ↵
- MedlinePlus. (2020). Platelet disorders. National Library of Medicine. https://medlineplus.gov/plateletdisorders.html ↵
- MedlinePlus. (2016). Blood count tests. National Library of Medicine. https://medlineplus.gov/bloodcounttests.html ↵
- National Heart, Lung, and Blood Institute. (2023). Bleeding disorders: Causes and risk factors. National Institutes of Health. https://www.nhlbi.nih.gov/health/bleeding-disorders/causes ↵
- MedlinePlus. (2020). Platelet disorders. National Library of Medicine. https://medlineplus.gov/plateletdisorders.html ↵
- Wagner, C. M., Butcher, H. K., & Clarke, M. F. (2024). Nursing interventions classifications (NIC) (8th ed.). Elsevier. ↵
- Wagner, C. M., Butcher, H. K., & Clarke, M. F. (2024). Nursing interventions classifications (NIC) (8th ed.). Elsevier. ↵
- Makic, M. B., & Martinez-Kratz, M. R. (2023). Ackley and Ladewig’s Nursing diagnosis handbook: An evidence-based guide to planning care (13th ed.). Elsevier ↵
- Open RN Project. (2024, March 24). Health Alterations - Chapter 3 Hematological - Thrombocytopenia [Video]. YouTube. CC BY 4.0 https://www.youtube.com/watch?v=Pt0Y6C2Of3o ↵
A medical condition characterized by a decreased number of platelets in the blood.
Red or purple spots on the skin that do not blanch when pressure is applied and measure between 4 and 10 millimeters (mm) in diameter.
Purpura spots are less than 4 mm in diameter.
Bleeding into joints.
Coughing up blood.
Platelet-producing cells.