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Idiopathic Thrombocytopenic Purpura
Pediatric Medicine Rotation (PEDO 8950)
University of Nevada, Las Vegas
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What is Idiopathic Thrombocytopenic
Purpura?
Idiopathic thrombocytopenic purpura (ITP) , also known as primary immune thrombocytopenic purpura and autoimmune thrombocytopenic purpura, is defined as isolated thrombocytopenia with normal bone marrow and in the absence of other causes of thrombocytopenia.
● ITP is a disorder that can lead to easy or excessive bruising and bleeding. ● Children often develop ITP after a viral infection and usually recover fully without treatment.
Pathophysiology
The bleeding results from unusually low levels of platelets — the cells that help blood clot.
● ITP is primarily a disease of increased peripheral platelet destruction, with most patients having antibodies to specific platelet membrane glycoproteins. ● Relative marrow failure may contribute to this condition since studies show that most patients have either normal or diminished platelet production. ● Acute ITP often follows an acute infection and has a spontaneous resolution within 2 months. ● Chronic ITP persists longer than 6 months without a specific cause.
Statistics and Incidences
Incidence rates of idiopathic thrombocytopenic purpura (ITP) are as follows:
● An average estimate of the incidence in children is 50 cases per 1,000,000 per year. ● New cases of chronic refractory ITP comprise approximately 10 cases per 1,000,000 per year ● According to studies in Denmark and England, childhood ITP occurs in approximately 10-40 cases per 1,000,000 per year. ● A prospective, population-based study in Norway indicated an incidence of 53 per 1,000,000 in children younger than 15 years. ● A study in Kuwait reported a higher incidence of 125 cases per 1,000,000 per year. ● The mortality rate from hemorrhage is approximately 1% in children and 5% in adults. ● Spontaneous remission occurs in more than 80% of cases in children. ● Peak prevalence occurs in children aged 2-4 years. ● Approximately 40% of all patients are younger than 10 years.
● Spontaneous bleeding. Spontaneous bleeding occur when platelet count is less than 20,000/mm3.
Assessment and Diagnostic Findings
Diagnosis of idiopathic thrombocytopenic purpura includes:
● Laboratory studies. Isolated thrombocytopenia on a complete blood cell count (CBC) is the key laboratory finding; the white blood cell (WBC) count and hemoglobin level typically are normal, unless severe hemorrhage has occurred; on peripheral smear, truly giant platelets suggest congenital thrombocytopenia. ● Imaging studies. A CT scan of the head is warranted if concern exists regarding intracranial hemorrhage.
Medical Management
Treatment may include a number of approaches, such as medications to boost platelet count or surgery to remove spleen (splenectomy).
● Prehospital care. Prehospital care focuses on the ABCs (airway, breathing, circulation), which include providing oxygen, controlling severe hemorrhage, and initiating intravenous (IV) fluids to maintain hemodynamic stability; airway control may be necessary for a large intracranial hemorrhage. ● Emergency department care. Life-threatening bleeding requires conventional critical care interventions; in the patient with known ITP, high-dose parenteral glucocorticoids and IV immunoglobulin (IVIg), with or without platelet transfusions, are appropriate. ● Consultations. Consult a hematologist for assistance in confirming the diagnosis or, in the patient with known ITP, arranging disposition and follow-up care, if appropriate.
Pharmacologic Management
Glucocorticoids and intravenous immunoglobulin (IVIg) are the mainstays of medical therapy for idiopathic thrombocytopenic purpura (ITP).
● Glucocorticoids. These agents are used to treat idiopathic and acquired autoimmune disorders; they have been shown to increase platelet count in ITP. ● Blood products. Administration of IVIg may temporarily increase platelet counts in some children and adults with ITP; consider IVIg if the situation requires a rapid, temporary rise in platelet count. ● Thrombopoietic. These agents directly stimulate bone marrow platelet production.
Nursing Assessment
Assessment in a child with ITP include the following:
● History. Medications can be a common etiology for inducing thrombocytopenia, and patients should have their medications carefully reviewed; one study used three distinct methods to document drugs that may be associated with drug-induced immune thrombocytopenia (DITP). ● Physical exam. Address risk factors for increased bleeding, such as GI disease, CNS disease, urologic disease, or active lifestyle, as these may determine the aggressiveness of management.
Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses for idiopathic thrombocytopenic purpura are:
● Risk for bleeding related to decreased platelet count. ● Risk for injury related to abnormal blood profile.
● Prevent injury. Thoroughly conform patient to surroundings; put call light within reach and teach how to call for assistance; respond to call light immediately; avoid use of restraints; obtain a physician’s order if restraints are needed; and eliminate or drop all possible hazards in the room such as razors, medications, and matches. ● Prevent infection. Wash hands and teach patient and SO to wash hands before contact with patients and between procedures with the patient; encourage fluid intake of 2,000 to 3,000 mL of water per day, unless contraindicated; recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes; and if infection occurs, teach the patient to take antibiotics as prescribed; instruct patient to take the full course of antibiotics even if symptoms improve or disappear.
Idiopathic Thrombocytopenic Purpura
Course: Pediatric Medicine Rotation (PEDO 8950)
University: University of Nevada, Las Vegas
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