Thrombocytopenia, DIC & Hemophilia and Nursing Care For Blood Transfusion

Thrombocytopenia,
DIC & Hemophilia
Nursing Care For Blood
Transfusion
Submitted to: Mr. Irfan Ali
By: Maryam Noor
G.BSN 5th semester.
JINNAH COLLEGE OF NURSING
28-feb-2020 Maryam Noor 1

Objectives:
At the end of this presentation learners will be able to:
• Define hemophilia and DIC and thrombocytopenia.
• Describe their pathophysiology.
• Identify their causes and clinical features.
• Discuss their complications.
• Explain their investigation criteria and nursing management .
• Discuss the nursing intervention for the patient receiving blood
transfusion therapy.

Thrombocytopenia
Platelets are tiny blood cells that form clots to stop
bleeding.
• Normal platelet count is 150,000-450,000 / uL.
• Decreased platelet count <150,000 is called
thrombocytopenia.
• Your risk for bleeding develops if a platelet count falls
below 10,000 to 20,000.

Causes of thrombocytopenia:
3. Decreased production:
. Bone marrow diseases
. Idiopathic Thrombocytopenic purpura (ITP)
. Drug-induced thrombocytopenia (DITP)
e.g. chemotherapy
. Pregnancy
1. Increased destruction
. Drugs (heparin)
. Idiopathic
. DIC
2. Sequestration
. Enlarged spleen
. Neonatal
. pregnancy

Signs & Symptoms
Thrombocytopenic symptoms may include:
• Petechiae (superficial tiny areas of bleeding into the skin
resulting in small reddish spots)
• Purpura (easy or excessive bruising)
• Prolonged bleeding cuts
• Fatigue
• Spontaneous bleeding from the gums or nose
• Heavy menstrual bleeding
• Blood in the urine or stools
• Splenomegaly

Investigation test and treatment
Investigation
• CBC
• Physical exam, including a complete medical history.
Treatment
• Treating the underlying cause of thrombocytopenia
• Blood or platelet transfusions
• Plasma exchange
• Surgery
• Medications

Clotting cascade
Factor II
Factor IPT : 11 to 13.5 sec
INR : 0.8 to 1.1
aPTT : 30 to 40 seconds

Hemophilia
• Hemophilia is a severe bleeding disorder resulting from a
congenital deficiency of clotting factor VIII.
• Hemophilia is an X-linked recessive disorder because
genetic information for coagulation factors is located on
the X chromosome.
• Mostly females are carriers and males are affected.

Causes:
• Hemophilia is a genetic disease.
• It occurs when there is a change within the gene that makes
factor VIII or factor IX.
• This gene contains the instructions your body uses to make
certain blood clotting factors.
• For people with hemophilia diagnosis, these clotting
factors aren't made in sufficient quantities.

Cause of hemophilia

Types of hemophilia:
Type of hemophilia Deficient factor
Hemophilia A Deficiency of classical clotting factor VIII.
Most severe.
Hemophilia B Factor IX or Christmas factor.
Hemophilia C Factor XI or plasma thromboplastin.
Parahemophilia Factor V deficiency.

Severity of hemophilia
Severity Factor VIII or IX level characteristics
Normal >50% to <100% Normal
Mild >5% to <40% Few bleeds post
traumatic & post
dental surgery.
Moderate 1% to 5% Few bleeds,
Hemarthrosis, &
traumatic
Severe <1% Spontaneous and
severe bleeding

Pathophysiology.

Symptoms in new born
• Delayed bleeding sometimes hours after bleeding.
• Big cephalohematoma following easy normal delivery.
• Excessive bleeding following circumcision.
• Bleeding during teeth eruption or during the fall of decidual teeth.
• Soft tissues hematoma after injection.
• Bleeding spontaneously or following trauma.
• Bleeding from umblical cord.
• Epistaxis.

Complications
Intracranial
hemorrhage
Development of
acquired circulating
antibody to F VIII.
Hemarthrosis
Therapy related
complication

Investigations
1. Complete blood count (CBC)
2. Activated partial thromboplastin time (APTT) test
 Measures the clotting ability of factors VIII, IX, XI and XII.
 If any of the clotting factors are too low, it takes longer for
the blood to clot.
 Patients with hemophilia A or hemophilia B show a longer
clotting time in this test.
3. Prothrombin time (PT) test
4. Fibrinogen test.(factor I)

Treatment:
• Whole blood transfusion
• Factor replacement therapy
• Other drugs:
Desmopressin; a hormone that increase platelets to stick to an
injured blood vessel.
Antifibrinolytics drugs; Tranexamic acid, Aminocaproic acid.

DIC (Disseminated Intravascular Coagulopathy)
• It is an acquired syndrome characterized by hemorrhage
and micro vascular thrombosis.
• It is due to abnormally increased and uncontrolled
generation of thrombin and plasmin formation (leads to
clotting ) and consumption of platelets and coagulation
factors (leads to bleeding ).

Pathophysiology

Causes of DIC
• Infection.
Gram negative bacilli.
Neisseria meningitides.
Streptococcus pneumonia
Falciparam malaria
• Cancers
Lung
Pancreas
Prostate
• Obstetric
Abruptio placenta
Retained dead fetus.
Pre-eclampsia
Amniotic fluid embolism
• Others
Hemolytic transfusion reaction.
Trauma, burn, injury
Liver disease
Snake bite etc..

Symptoms of DIC
• Bleeding
 Bleeding at any site
 Spontaneous bleeding and oozing at
venipuncture sites are clue to diagnosis.
 Purpura & ecchymosis
 Mouth, nose and GIT hemorrhage may
occur.
 Hypotension & shock
• Thrombosis
 Microvascular thrombi may
cause infarction of massive areas
of skin.
 Organ dysfunction.
DIC leads to both bleeding and thrombosis; bleeding is more common than thrombosis.

28-feb-2020 22
Purpura
Ecchymosis
Maryam Noor
PetechiaeBruises

Investigations
• Thrombocytopenia
• Prolonged PT
• APTT may or may not be prolonged
• Low fibrinogen
• Increased level of Fibrin Degradation Products.
• Increased D-Dimers indicating fibrinolysis
• Antithrombin III level may be very low.

ISTH scoring system for DIC
DIC score more
than 5 presents
overt DIC and
requires repeat
scores daily.

Treatment
 Treatment of underline disorder.
 Anticoagulation therapy
 Component replacement
 Antifibrinolytics not given.

Nursing diagnosis
• Risk of bleeding related to depleted coagulated factors.
• Ineffective Tissue Perfusion related to microthrombi.
• Deficient Knowledge related to complexity of disease or
treatment.

Nursing care
• Maintenance of intact skin and oral mucosa.
• Protect toddlers with soft helmets, padding on the knees,
carpets in the homes ad softened and covered corners.
• Avoid intense contact sports such as football, wrestling
etc.
• Drugs such as Aspirin and other NSAIDs are not allowed
because they increase the bleeding risk.
• Observe for signs of orthostatic hypotension.
• Avoid intramuscular injections.

Cont...
• Provide gentle oral care, using saline and water rinses
instead of toothbrushes.
• Use gentle suctioning
• Examine the skin surface for signs of bleeding.
• Assess client’s level of consciousness.

Nursing care for blood transfusion

 Verify physician orders and consent for blood products.
 Obtain a complete set of vital signs including temperature.
 Verify whether there are any orders for pre-medication.
 The transfusion must be started within 30 minutes after the blood has left the
refrigerator.
• The total maximum infusion time is 4 hours including the first 30 minutes.
• Must be started immediately to reduce the risk of infection.
 Ensure the accurate patient identification..
 Always use personal protective equipments including eye shields and gloves,
 Ensure the patient to inform regarding any irritation during transfusion.
Before transfusion:

 Administer the blood products slowly for the first 15 minutes.
 Never infuse any solution other than normal saline through the same catheter.
 Never add any medication to blood.
 Monitor vital signs.
 Monitor for signs and symptoms of adverse reaction.
During transfusion

 Save the transfusion bag for at least 1 hour after transfusion if any adverse
reaction occurs.
 Monitor vital signs.
 According to 2006 American Association of Blood Bank guidelines.
Information to be included in the patient’s medical record must include the
 Transfusion order
 Type of blood product
 The donor unit number
 Date and time of transfusion
After transfusion
Vital signs before and after transfusion
The volume infused
Required signature
Any transfusion adverse effect.

References
• A Parthasarthy (2013) partha's fundamental of pediatrics, 2nd
edn., New delhi: Jaypee brothers medical publishers (p) ltd.
• Hazinki, M.F., (2013) Nursing care of the critically ill child, 3rd
edn., USA: Elsevier.
• https://nurseslabs.com/disseminated-intravascular-coagulation-
nursing-care-plans/
• https://www.medicinenet.com/thrombocytopenia low platelet
count/article htm#thrombocytopenia low platelet count definition
and facts

Your turn!
• 13 years old boy complains the post operative pain.

Thrombocytopenia, DIC & Hemophilia and Nursing Care For Blood Transfusion

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