immune thrombocytopenic purpura /-sī′təpē″nik/ [Gk, thrombos + kytos, cell, penia, poverty; L, purpura, purple] , mucocutaneous bleeding of thrombocytopenia, caused by a platelet membrane-specific autoantibody that shortens the platelet lifespan. It is diagnosed by exclusion of drug effects, inflammatory disorder, thrombotic thrombocytopenic purpura, DIC, or hematologic disorder. It affects middle-aged adults and is more prevalent in women than in men. Acute immune thrombocytopenic purpura is a side effect of viral infection in children 2 to 6 years of age, and although the thrombocytopenia is profound, the disorder resolves spontaneously within a few weeks. Also called autoimmune thrombocytopenic purpura. Compare disseminated intravascular coagulation. Formerly called idiopathic thrombocytopenic purpura. See also hemophilia, hemorrhagic diathesis, thrombasthenia. ▪ OBSERVATIONS: Common manifestations include petechiae and ecchymoses on the skin, particularly the lower extremities; easy bruising; bleeding from the nose and gums; melena in stools; hematemesis; heavy menses and breakthrough bleeding; and hematuria. Jaundice, fever, and decreased levels of consciousness may be seen in thrombotic thrombocytopenic purpura. Diagnosis focuses on obtaining a history of bleeding symptoms and on ruling out other causes of thrombocytopenia, such as medications, ethanol abuse, HIV, or hematologic disorder. Lab findings include decreased platelet count. Bleeding time is prolonged, but coagulation time is normal. Capillary fragility is increased. Bone marrow aspiration shows an abundance of megakaryocytes. In thrombotic thrombocytopenic purpura there is severe anemia, elevated BUN, elevated creatinine, elevated reticulocytes, elevated LDH, decreased haptoglobin, and fragmented RBCs on peripheral smear. Platelet size and morphological appearance may be abnormal in thrombotic thrombocytopenic purpura. Complications include hemorrhage into organs, such as the brain, gastrointestinal tract, or heart, which can be fatal without treatment. ▪ INTERVENTIONS: Medications that may be causing or contributing to the thrombocytopenia are discontinued. Treatment is determined by platelet count and bleeding status. Corticosteroids are used to enhance platelet production and promote capillary integrity. Immunosuppressants are used if the disease does not respond to steroids. Platelet transfusions are used in cases of severe bleeding in idiopathic thrombocytopenic purpura. Plasma exchange or plasmapheresis is the treatment of choice in thrombotic thrombocytopenic purpura. Vincristine may be used in thrombotic thrombocytopenic purpura cases that are refractory to plasmapheresis. Splenectomy may be considered for severe unresponsive thrombocytopenia. Immune globulin is given to prepare severely thrombocytic individuals for surgery. Platelet counts and bleeding episodes are monitored closely. Stool softeners are administered to prevent constipation. ▪ PATIENT CARE CONSIDERATIONS: Nursing goals are aimed at eliminating gross or occult bleeding, maintaining vascular integrity, decreasing risk for injury, and reducing complications. Safety precautions are instituted to prevent bruising (e.g., mouth swabs and soft-bristle toothbrush for oral care; electric razor for shaving; insertion of IV access device for blood draws; padding of bed rails and hard surfaces). Emesis, sputum, stool, urine, and other secretions for occult blood and pad counts during menstruation are frequently assessed and tested. Active bleeding is controlled with ice packs, gentle pressure, or packing. Rest and activity should be carefully balanced to conserve energy. Education is needed on trauma prevention and safety precautions, including the avoidance of contact sports; the avoidance of the Valsalva maneuver; the necessity for gentle coughing, sneezing, and nose blowing; and the necessity for increased fluid intake and balanced periods of rest and exercise. Instruction in infection precautions is given for those taking immunosuppressants. Education includes instruction to avoid anticoagulant over-the-counter medications, such as aspirin or aspirin products and other NSAIDs.
