thrombocytopenia and thrombocytopenic purpurathrombocytopenia and thrombocytopenic purpura elisabeth...
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Thrombocytopenia And
Thrombocytopenic Purpura
Elisabeth Sosa, MSN, ARNP, AOCNP
Elisabeth Sosa, MSN, ARNP, AOCNP is a certified adult oncology nurse practitioner. She
practices within a large private-practice hematology/medical oncology group in Central
Florida. She has previously been published in the Clinical Journal of Oncology Nursing
(CJON).
ABSTRACT
Thrombocytopenia can occur for a number of different reasons. These
include congenital disorders, bone marrow disorders, infectious causes, drug
effect, and immunologic causes. The purpose of this course is to provide a
brief review of thrombocytopenia, with a focus on idiopathic
thrombocytopenic purpura (ITP). The course will discuss the definition of
thrombocytopenia, as well as grading the severity. This course will also
review complications of thrombocytopenia, including bleeding. Readers are
provided with an understanding of how thrombocytopenia and ITP are
treated and knowledge of bleeding precautions. Bleeding precautions
increase patient safety when the platelet count is dangerously low. It is
important that health care personnel have an understanding of
thrombocytopenia so that patients can be treated appropriately and
complications can be avoided.
KEYWORDS: thrombocytopenia, platelets, hematology, idiopathic
thrombocytopenic purpura
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 2 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Pharmacology content is 0.5 hours (30 minutes).
Statement of Learning Need
Nurses are required to be knowledgeable about how thrombocytopenia
occurs. ITP, idiopathic thrombocytopenia, is a cause of thrombocytopenia that
nurses need to understand and be able to educate patients about in terms of
bleeding risk and disease management.
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Course Purpose
To help nurses develop an understanding of the treatment of
thrombocytopenia, specifically idiopathic thrombocytopenic purpura (ITP), as
well as the bleeding precautions in patients with thrombocytopenia.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Elisabeth Sosa, MSN, ARNP, AOCNP, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC –
all have no disclosures.
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC.
Release Date: 1/1/2016 Termination Date: 7/14/2017
Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.
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1. Your patient has a platelet count of 7,000. What grade is the
thrombocytopenia?
a) Grade I
b) Grade II
c) Grade III
d) Grade IV
2. Which of the following medications is NOT known to cause
thrombocytopenia?
a) Heparin
b) Lisinopril
c) Penicillin
d) Valproic acid
3. How is ITP diagnosed?
a) Using a special blood test that is sent to a reference lab
b) Bone marrow biopsy
c) It is a diagnosis of exclusion
d) Ultrasound of the abdomen
4. Which of the following is a complication of thrombocytopenia?
a) Intracranial bleeding
b) Anemia
c) GI bleed
d) All of the above
5. Which of the following is NOT known to cause thrombocytopenia?
a) Bone marrow disorder
b) Vitamin D deficiency
c) HIV
d) Rheumatoid arthritis
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Introduction
The following case study may be seen in the outpatient primary care setting.
The objective of this case study is to illustrate how some patients with
thrombocytopenia, specifically idiopathic thrombocytopenic purpura (ITP),
may present. Suggestions will be made later in this course on how the
patient should be treated, including appropriate diagnostic testing,
pharmacological treatment, and supportive care.
Case Study: Mary
Mary is a 45-year-old female with no significant medical history. She
develops symptoms including urinary frequency and pain when urinating.
She presents to her primary care physician (PCP) and is diagnosed with a
urinary tract infection. After verifying her allergies, the physician
prescribes a course of Bactrim for the patient. After several days, Mary’s
urinary symptoms resolve. However, she begins to notice bruising on her
arms and legs. She has not experienced any trauma to these areas. Mary
also has several nosebleeds.
Mary returns to her PCP to discuss her new symptoms. A complete blood
count (CBC) is drawn and notes a normal white blood cell count (WBC) of
5.4 and normal hemoglobin of 13.1. However, the platelet count is
abnormal at 45,000. Mary’s medical records do not show evidence of
thrombocytopenia in the past. Mary’s PCP refers her to a hematologist
right away for further evaluation of thrombocytopenia.
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Definition of Thrombocytopenia
Platelets are a type of blood cell that are produced in the bone marrow by
megakaryocytes. The megakaryocytes inside the bone marrow release
platelets, or fragments of cytoplasm, into the bloodstream. Once in the
bloodstream, the platelets exist for eight to twelve days. Typically,
phagocytes in the spleen remove platelets from the circulation.
Approximately one third of platelets are stored in the spleen (Baldwin,
2003).
Normal platelet count is between 150 and 400. Thrombocytopenia is defined
as a platelet count less than 150 (Lichtman, Kaushansky, Kipps, Prchal, &
Levi, 2011; Winkeljohn, 2013). However, there are varying degrees of
thrombocytopenia. Grading is illustrated in Table 1. Platelets play an
important role in hemostasis, which is the process of a blood clot being
formed from the fluid part of blood. When there is injury to the vessel wall,
platelets create a hemostatic plug to stop the bleeding. If there is a problem
with platelet production or function, or if platelet destruction is occurring,
thrombocytopenia can ensue and lead to significant bleeding complications
(Rodriguez & Gobel, 2011).
Table 1. National Cancer Institute Common Terminology Criteria for Adverse
Events: Thrombocytopenia
Grade 1 2 3 4 5
<LLN-
75,000/mm^3
<75,000-
50,000/mm^3
<50,000-
25,000/mm^3
<25,000/mm^3 -
LLN- lower limit of normal. (National Cancer Institute, 2009)
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Causes of Thrombocytopenia
There are many reasons why a low platelet count may be noted on lab work.
While the focus of this course is ITP, it is important to have an
understanding of other causes of thrombocytopenia, as ITP is a diagnosis of
exclusion. For example, psuedothrombocytopenia may occur. This happens
when platelets clump together and give a falsely low platelet count. The
platelets can clump when they are placed in lavender EDTA
(ethylenediaminetetraacetic acid) tubes. It is important to recollect the sample
in a blue sodium citrate tube to determine if the patient does in fact have
thrombocytopenia. Dilutional thrombocytopenia can occur when a patient
receives a large number of red blood cell transfusions.
Normally, the patient would need to have received more than 15 to 20
transfusions in a 24-hr period for this phenomenon to occur. Distributional
thrombocytopenia occurs when a large percentage of platelets are stored in
the spleen instead of in circulation. This is seen in patients with
splenomegaly, cirrhosis, and portal hypertension. While the actual number of
platelets is normal, the peripheral count is low and this will be noted as
thrombocytopenia on the CBC. Bleeding is uncommon in this case (Baldwin,
2003; Lichtman et al., 2011).
Major Causes Of Thrombocytopenia
The major causes of thrombocytopenia are noted below and will be
discussed in more detail in the following paragraphs.
Reduced platelet production
Increased platelet destruction
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As mentioned previously, platelets are produced in the bone marrow. If
cancer penetrates the bone marrow, such as in leukemia, lymphoma,
metastatic cancer with bone involvement, or multiple myeloma, platelet
production suffers. In oncology patients being treated with radiation therapy
in which the radiation field involves large amounts of bone marrow, platelet
production also diminishes. Certain drugs can also affect platelet production
(see below).
Certain viral infections, such as rubella, mumps, Epstein-Barr,
cytomegalovirus, HIV, and varicella, can also inhibit platelet production. This
can also happen in patients with typhus and Rocky Mountain spotted fever.
Chronic alcohol abuse and illicit drug use also affect platelet production. In
addition, patients with vitamin B12, folate, and/or iron deficiency may also
have thrombocytopenia. These substances are necessary for normal bone
marrow function (Baldwin, 2003; Lichtman et al., 2011).
Increased destruction of platelets can happen for many different reasons,
but can be categorized into immunologic and nonimmunologic reasons.
Immunologic destruction occurs due to antibodies. Sometimes this happens
because of autoantibodies. This is noted in chronic lymphocytic leukemia,
systemic lupus erythematosus, rheumatoid arthritis, thyroiditis,
inflammatory bowel disease, and autoimmune hemolytic anemia. On the
other hand, thrombocytopenia can take place due to alloantibody-mediated
destruction. This is seen after transfusions and bone marrow/stem cell
transplantation. This is also seen in pregnancy, such as with preeclampsia,
eclampsia, gestational thrombocytopenia, and HELLP syndrome (hemolysis,
elevated liver tests and low platelet count). Immunologic platelet destruction
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is also noted in septic patients. A number of drugs can also lead to platelet
destruction (Baldwin, 2003; Lichtman et al., 2011).
Nonimmunologic causes of platelet destruction also contribute to
thrombocytopenia. This is seen in disseminated intravascular coagulation
(DIC), thrombotic thrombocytopenic purprura (TTP), hemolytic uremic
syndrome, and sepsis. In patients on cardiopulmonary bypass, the machine
may physically damage platelets (Baldwin, 2003).
Drugs That May Cause Thrombocytopenia
Medications that may cause thrombocytopenia are listed below (Baldwin,
2003 and Lichtman et al., 2011):
Drugs affecting platelet production:
Chemotherapy
Estrogen
Anticonvulsants
Thiazide diuretics
Drugs causing platelet destruction:
Heparin (Heparin-Induced Thrombocytopenia HIT)
Barbiturates
Gold salts
H2 blockers
Methyldopa
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Digoxin
Procainamide
Penicillin
Sulfonamides
Quinidine
Quinine
Valproic acid
ITP: What is it?
The list of causes of thrombocytopenia is quite long and exhaustive. ITP is
an acquired condition with no obvious cause of thrombocytopenia and is
therefore diagnosed by excluding other causes of thrombocytopenia. In
adults, ITP usually does not resolve by itself. In patients with ITP, platelets
have a shorter survival time in the bloodstream due to being stored in the
spleen and being destroyed by antibodies. These antibodies may also impair
platelet production. The incidence of ITP is higher in young women than
young men. In older adults, the incidence is equal (Lichtman et al., 2011).
ITP: How is it diagnosed?
In order to diagnose ITP, other causes of thrombocytopenia must be
excluded. This entails a thorough review of medications, as well as a
complete history and physical. Use of herbal products should be discussed.
Specifically, patients should be asked about use of chamomile, ginger,
gingko, and kelp. In addition to asking about alcohol use, usage should be
quantified. Patients should be asked about past surgeries and any bleeding
complications (Baldwin, 2003, Winkeljohn, 2013 and Winkeljohn, 2010).
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Physical examination should focus on ecchymosis, petechiae, and spleen and
liver size. As far as diagnostic tests are concerned, a CBC with manual
differential should be ordered. Viral studies, such as human
immunodeficiency virus (HIV) and hepatitis, should also be done to rule out
infectious causes of thrombocytopenia. The patient should be assessed for
nutritional deficiencies, which include vitamin B12 level, folic acid level, and
iron studies. Coagulation studies should be ordered as well. The presence of
bleeding should be assessed through urinalysis and stool testing for occult
blood. In addition, liver enzymes should be checked. An abdominal
ultrasound is useful in determining the presence of an enlarged spleen. Bone
marrow biopsy is not routinely done, unless the patient is older than 60
years of age (Baldwin, 2003, Winkeljohn, 2013, and Winkeljohn, 2010).
Complications of Thrombocytopenia
Patients usually do not experience symptoms until the platelet count falls
below 20,000. The major complication of thrombocytopenia is bleeding. This
includes spontaneous bleeding from the mouth, nose, and GI tract. Patients
may also have hematuria and hemoptysis. Women may experience
menorrhagia. Two very serious complications, which typically do not occur
unless the platelet count is less than 5,000, are spontaneous intracranial
bleeding and uncontrollable gastrointestinal bleeding. In patients undergoing
surgical procedures, they may experience extended bleeding. Blood loss can
lead to anemia, and may be significant enough to require transfusions of
packed red blood cells (Baldwin, 2003).
Patient Education: Bleeding Precautions
It is very important that nurses educate thrombocytopenic patients about
their risk of bleeding and interventions to minimize the risk. Patients should
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avoid activities that increase the risk of bleeding. For example,
thrombocytopenic patients should use soft toothbrushes and be careful when
flossing to decrease the risk of oral bleeding. Patients should be instructed to
shave with electric razors instead of blades. Also, they should be advised not
to engage in contact sports. Patients should also be assessed for risk of falls.
Nurses should discuss tips to prevent falls, such as creating a safe
environment in the home. Patients, especially elderly patients, may need
assistive devices (Winkeljohn, 2013).
Patients with low platelet counts should avoid unnecessary invasive
procedures. These patients should also be instructed on a bowel regimen to
prevent constipation and straining. Thrombocytopenic patients should not
use suppositories or enemas. Other activity to avoid includes sexual activity,
which can increase risk of bleeding. Patients should be advised to use
lubricant when engaging in sexual activity. If the platelet count is severely
decreased, they should abstain. Patients should also be instructed to avoid
certain medications that may affect platelet function, such as ibuprofen and
aspirin (Winkeljohn, 2013).
Bleeding Precautions
Education of patients with thrombocytopenia are highlighted below:
Use soft toothbrush and be careful when flossing
Avoid shaving; if you must shave, use an electric razor
No enemas or suppositories
Use lubrication when engaging in sexual activity
No contact sports
Prevent falls
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Avoid invasive procedures if at all possible
General Treatment of Thrombocytopenia
Treatment of thrombocytopenia varies and is based on cause. For example,
in patients with HIT (heparin-induced thrombocytopenia), all heparin should
be discontinued immediately. Lovenox is also not recommended (Sanofi-
Aventis, 2013). Other forms of anticoagulation should be used instead.
Platelet transfusions are generally not indicated due to risk of clots. In drug-
induced thrombocytopenia, the substance causing thrombocytopenia should
be stopped right away. If the patient is asymptomatic, no further
intervention is required and the platelet count should return to normal in
seven to ten days. Platelet transfusion is only indicated if there is a high risk
of bleeding or the platelet count is less than 5,000 (Baldwin, 2003).
In patients with chemotherapy-induced thrombocytopenia, platelet
transfusions are usually warranted if the platelet count is less than 10,000.
If bleeding is present, such as epistaxis or rectal bleeding, platelet
transfusions should be arranged even if the platelet count is over 10,000. If
patients require an invasive procedure, such as endoscopy or bone marrow
biopsy, the platelet count should be at least 50,000 (Damron et al., 2009).
Treatment of ITP
Corticosteroids
Idiopathic thrombocytopenic purpura is initially treated with corticosteroids,
usually prednisone at a dose of 1mg/kg daily. Once platelets increase,
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prednisone should be tapered. The tapering schedule is based on the platelet
count. The average response time is seven to 28 days. Dexamethasone is
sometimes used as well. The dose is usually 40 mg daily for four days and
may be repeated. Oftentimes, patients with ITP will respond to initial
treatment, but may relapse. If this happens, corticosteroids can be used
again.
Side effects of corticosteroids include increased appetite, weight gain,
difficulty sleeping, and headaches. Prolonged use of steroids can cause
osteoporosis, immunosuppression, and diabetes mellitus (Lichtman et al.,
2011, Winkeljohn, 2010, and Winkeljohn, 2013).
Immunoglobulin (IVIG)
Intravenous immunoglobulin (IVIG) is another treatment option. Platelets
will generally increase quite rapidly, with a response rate of two to seven
days. IVIG is generally infused slowly at first, then titrated as the patient
tolerates. Patients usually receive premedication with acetaminophen and
diphenhydramine to prevent infusion reactions. The large volume of the
infusion can also be a concern.
Side effects include headaches, chest pain/tightness, shortness of breath,
fevers, chills, back pain, and flu-like symptoms. More serious complications
include renal failure, meningitis, anaphylaxis, and thromboembolic events
(Shelton, Griffin, & Goldman, 2006, and Winkeljohn, 2013).
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Anti-Rh (D) immune globulin
Anti-Rh(D) immune globulin is another treatment option that is given
intravenously. The response time is about three to seven days and response
usually lasts for greater than three weeks. This treatment is not indicated for
patients who are Rh negative or who have undergone a splenectomy.
Side effects of treatment include hemolysis, headaches, fever, chills, nausea,
vomiting, and allergic reactions (Lichtman et al., 2011, and Winkeljohn,
2013).
Rituximab
Rituximab can be used if the other options listed above were not effective.
This medication is an infusion given weekly for four weeks. Response is
usually seen in about a week. This medication can be quite costly. Side
effects include infusion reactions, including anaphylactic-type reactions.
Fevers, chills, rigors, and headaches may also occur (Winkeljohn, 2013).
Splenectomy
Another option, if previous treatments are deemed ineffective, is removal of
the spleen (splenectomy). However, this treatment is usually not done until
at least six months after diagnosis. Increase in platelets is usually noted
several days after splenectomy.
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Complications include infection, abscess, adhesions, and hernia. Patients
should receive the haemophilus influenzae type B, meningococcal, and
pneumococcal vaccines at least two weeks before splenectomy.
Patients without a spleen are also at increased risk of infection for the rest of
their lives and should be properly educated (Lichtman et al., 2011, and
Winkeljohn, 2013).
Eltrombopag
Eltrombopag is a newer oral medication for ITP. This medication is taken
daily. If discontinued, the platelet count will decrease. Response is noted in
seven to 28 days. The medication is usually well tolerated.
Side effects include bone marrow fibrosis and changes in liver function tests.
Patients should be monitored for thrombotic and thromboembolic
complications (Winkeljohn, 2013).
Romiplostim
Another fairly new medication is romiplostim, which is given subcutaneously
once a week. Patients remain on this medication indefinitely. If discontinued,
the platelet count will decrease.
Response is seen in seven to ten days. Side effects are similar to those seen
in eltrombopag (Winkeljohn, 2013).
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On Reflection: Mary (case study at the beginning of the course)
Mary’s platelet count is 45,000, which is consistent with Grade III
thrombocytopenia. She presents to the hematologist immediately for further
evaluation. The hematologist performs a thorough history, including review
of medications she is currently taking, as well as medications she has taken
recently. The hematologist is concerned about recent exposure to Bactrim
and advises Mary to avoid this medication in the future. The rest of her
history does not reveal any significant findings.
The hematologist performs a physical exam and notes scattered bruises. He
does not appreciate hepatosplenomegaly. The physician proceeds with
further workup to include complete blood count (CBC), peripheral smear,
complete metabolic panel including liver function tests, and abdominal
ultrasound. He also asks the phlebotomist to collect a CBC in a blue tube. He
also checks HIV, hepatitis, CMV, and EBV. In addition, he orders iron
studies, as well as B12 and folic acid levels.
The office nurse educates Mary on signs and symptoms to report
immediately. She also discusses bleeding precautions with the patient. Mary
has no evidence of bleeding and therefore does not require treatment at this
time. Mary is advised to return to the office in one week to discuss results
and repeat the CBC.
At Mary’s next visit, her workup is overall negative. Repeat CBC now shows
an improved platelet count of 100,000. It is determined that Mary likely
experienced drug-induced thrombocytopenia due to Bactrim. However, the
doctor brings Mary back for another CBC in two weeks. Platelets are now
back to normal and bruising has resolved.
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Summary
Thrombocytopenia can occur for many different reasons. It is important that
the cause of thrombocytopenia is determined promptly so that patients can
be treated appropriately. Thrombocytopenia can lead to bleeding
complications, including severe and life-threatening gastrointestinal bleeding
and intracranial bleeding. Patients may require platelet transfusions. If blood
loss is severe, patients may even require transfusions of packed cells. ITP is
a diagnosis of exclusion when other causes of thrombocytopenia are ruled
out.
Nurses play an integral role in caring for these patients and keeping them
safe. Teaching patients and their families about bleeding precautions often
becomes the responsibility of the nurse. Following bleeding precautions and
preventing falls can help prevent further harm. As part of the health care
team, nurses are in an excellent place to improve patient outcomes.
Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course requirement.
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1. Your patient has a platelet count of 7,000. What grade is the
thrombocytopenia?
a. Grade I
b. Grade II
c. Grade III
d. Grade IV
2. Which of the following medications is NOT known to cause
thrombocytopenia?
a. Heparin
b. Lisinopril
c. Penicillin
d. Valproic acid
3. Which patient would you LEAST expect to develop
a. 67-year-old female with acute leukemia receiving chemotherapy
b. 25 year old male with no past medical history, no history of
infections, and not taking any medications
c. 30 year old female who is 38-weeks pregnant and has proteinuria
d. 55-year-old female with history of chronic alcohol abuse and
cirrhosis
4. How is ITP diagnosed?
a. Using a special blood test that is sent to a reference lab
b. Bone marrow biopsy
c. It is a diagnosis of exclusion
d. Ultrasound of the abdomen
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5. Which of the following is a complication of thrombocytopenia?
a. Intracranial bleeding
b. Anemia
c. GI bleed
d. All of the above
6. What should your female patient with a platelet count of 5,000
avoid?
a. Shaving her legs with a razor
b. Walking
c. Sexual activity
d. Both A & C are correct choices
7. Which of the following is NOT known to cause
thrombocytopenia?
a. Bone marrow disorder
b. Vitamin D deficiency
c. HIV
d. Rheumatoid arthritis
8. In patients with HIT (heparin-induced thrombocytopenia),
what should they avoid?
a. Heparin
b. Lovenox
c. Platelet transfusions
d. All of the above
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9. You are caring for a patient with ITP. What would be the
standard starting dose of prednisone in a patient who weighs
65 kg?
a. 40 mg daily for four days
b. 30 mg twice a day
c. 65 mg daily
d. 65 mg twice a day
10. Your patient with ITP has O negative blood type. Which
treatment is NOT appropriate for this patient?
a. Anti-Rh(D) immune globulin
b. IVIG (intravenous immune globulin)
c. Dexamethasone
d. All of the above treatments are appropriate for the patient
Correct Answers:
1. D. Grade IV
2. B. Lisinopril
3. B. 25 year old male with no past medical history, no history of
infections, and not taking any medications
4. C. It is a diagnosis of exclusion
5. D. All of the above
6. D. Both A & C are correct choices
7. B. Vitamin D deficiency
8. D. All of the above
9. C. 65 mg daily
10. A. Anti-Rh(D) immune globulin
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References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
1. Baldwin, P. D. (2003). Thrombocytopenia. Clinical Journal of Oncology
Nursing, 7(3), 349- 352.
2. Damron, B. H., Brant, J. M., Belansky, H. B., Friend, P. J., Samsonow,
S., & Schaal, A. (2009). Putting evidence into practice: Prevention and
management of bleeding in patients with cancer. Clinical Journal of
Oncology Nursing, 13(5), 573-583.
3. Lichtman, M. A., Kaushansky, K., Kipps, T. J., Prchal, J. T., & Levi, M.
M. (2011). Thrombocytopenia. In J. Shanahan & H. Lebowitz (Eds),
Williams manual of hematology eighth edition (pp.554-574). New
York: McGraw Hill Medical.
4. National Cancer Institute. (2009). Common terminology criteria for
adverse events v4.0 (NIH Publication No. 09-7473). Retrieved from
http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-
14_QuickReference_8.5x11.pdf
5. Rodriguez, A. L. & Gobel, B. H. (2011). Bleeding. In C. Yarbro, D.
Wujcik, & B. Gobel (Eds.), Cancer Nursing (pp. 745-771). Sudbury,
Massachusetts: Jones and Bartlett Publishers.
6. Sanofi-Aventis (2013). Lovenox prescribing information. Retrieved
from http://products.sanofi.us/lovenox/lovenox.html
7. Shelton, B. K., Griffin, J. M., & Goldman, F. D. (2006). Immune
globulin IV therapy: Optimizing care of patients in the oncology
setting. Oncology Nursing Forum, 33(5), 911-921.
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8. Winkeljohn, D. (2010). Idiopathic thrombocytic purpura. Clinical
Journal of Oncology Nursing, 14(4), 411-413.
9. Winkeljohn, D. (2013). Diagnosis, treatment, and management of
immune thrombocytopenia. Clinical Journal of Oncology Nursing,
17(6), 664-666.
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