Running head: GROUP SIX CASE STUDY TWO 1

Group Six Case Study Two

Tabetha Elie, Maria Marquez, Rose Nyarko, Victoria Stock

University of Florida College of Nursing

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Case Study 2

NS is a 32-year-old female who had been sick with a cold virus for 10 days. She states that she

had flu symptoms of cough, sore throat, and fatigue. It has been 3 weeks since the cold, and she

continues to be fatigued and finds it hard to get enough energy to do things. NS says she has

noted that she has been bruising easily. She hit her arm accidentally on the edge of a counter, and

now she has a large bruise. She has also noted little purple spots all over her hands and chest. On

exam it is noted that she does have a large bruise on her right arm and petechiae and purpura

over her chest and hands. Lab work comes back with a platelet count of 40,000mm3.

1. NS has been diagnosed with idiopathic thrombocytopenic purpura (ITP).

Explain what it is and who can get it.

According to McCance and Huether (2014), Idiopathic thrombocytopenic purpura (ITP)

is a disorder of platelet consumption. In this disorder, platelet destruction exceeds the rate of

platelet production. ITP is caused by antiplatelet antibodies binding to the plasma membrane of

platelets ​(McCance & Huether, 2014)​. This binding leads to the destruction of platelets by

mononuclear phagocytes in the spleen and lymphoid tissue. ITP is prevalent in children.

2. Discuss the four mechanisms of thrombocytopenia.

The four mechanisms of thrombocytopenia are the following: decreased platelet

production, increased destruction, increased platelet consumption, and increased sequestration.

Acquired thrombocytopenia can happen because of decreased platelet production secondary to

drugs, viral infections, thiazides, estrogens, quinine-containing medications, nutritional

deficiencies, bone marrow hypoplasia, chronic renal failure, and radiation therapy ​(McCance &
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Huether, 2014). Overall, bone marrow suppression is the cause of decreased platelet production.

Bone marrow failure can be caused by HIV, EBV, parvovirus, or medications.

According to McCance and Huether (2014), the increased platelet consumption is what

causes the most common forms thrombocytopenia. The most common forms include idiopathic

(immune) thrombocytopenic purpura (ITP), heparin-induced thrombocytopenia (HIT), and

thrombotic thrombocytopenic purpura (TTP). With HIT, the release of platelet factor 4 from

activated thrombin and platelets is what causes an increased platelet consumption. With TTP, the

platelets cause and aggregates occlusion of arterioles and capillaries within the microcirculation

(McCance & Huether, 2014).

Another mechanism of thrombocytopenia is the increase of platelet sequestration. Splenic

sequestering, as well as hypothermia, secondary to hypersplenism induces thrombocytopenia

(McCance & Huether, 2014; ​Veneri et al., 2009). The last mechanism of thrombocytopenia is the

increase of platelet destruction. There are two categories with this mechanism, drug-induced

thrombocytopenia and heparin-induced thrombocytopenia. Drug-induced involves the

destruction of platelets by drug-dependent antibodies. Some of these drugs include low

molecular-weight heparin, quinine, linezolid, rifampin, and naproxen (Shah, Haddad,

Vachharajani, Asif, Agarwal, 2014). Although there is a long list of drugs that induce

thrombocytopenia, quinidine and sulfonamides are the most common ones (Shah et al., 2014).

3. What symptoms would you expect to see in a patient with ITP and which tests would be

used to confirm the diagnosis?

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Idiopathic thrombocytopenic purpura (ITP) may or may not have symptoms. When they

do, symptoms progress from minor bleeding such as easy or excessive bruising (purpura) and

petechiae to major hemorrhage from mucosal sites. The major symptoms include epistaxis,

hematuria, menorrhagia, unusually heavy menstrual flow and bleeding gums (McCance &

Huether, 2014).

Diagnosis of ITP is based on a history of bleeding and associated symptoms such as

fever, weight loss, and headache (McCance & Huether, 2014). A physician may perform a

physical examination and run one or more of the following tests: complete blood count (CBC),

blood smear, and bone marrow exam.

A CBC is used to ascertain the number of blood cells, including platelets in a blood

sample. The white and red blood cell counts are usually within normal range but platelet count is

usually low. The blood smear is used to confirm the number of platelets observed in a complete

blood count. For this test, a microscope is used to observe a sample of blood placed on it to

check the platelets and other blood cells. The bone marrow exam is used to identify the cause of

a low platelet count (Maureen Donahue, 2018). Additionally, a screening will be necessary to

those who are at risk for HIV, hepatitis C, or helicobacter Pylori because there might be a link to

ITP (Maureen Donahue, 2018).

4. What is the treatment for thrombocytopenic purpura?

Treating thrombocytopenic purpura is crucial to the patient’s survival. Without treatment,

the rate of survival is only 10%, whereas with immediate treatment, the patient’s rate of survival

improves to in between 80% and 90% (​McCance & Huether, 2014). There are several ways to
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treat thrombocytopenic purpura, but the first choice of treatment is to replenish the patient’s

plasma until it returns to a regular and functioning state. Replacing the plasma replaces the

enzyme that is responsible for aiding the von Willebrand factor (vWF) bind into smaller

molecules to aid clotting ​(​McCance & Huether, 2014). This enzyme that will be replenished is

known as ADAMTS13. While the plasma is returning to a more regular state, glucocorticoids

will also be administered to the patient ​(​McCance & Huether, 2014).

If the patient does not respond well to plasma replenishment, two other methods of

treatment could be tried. The patient could be given rituximab, which is a genetically made

anti-CD20 monoclonal antibody (Stasi, Pagano, Stipa, & Amadori, 2001). Rituximab is normally

used to treat non-Hodgkin's Lymphoma, but in certain cases with thrombocytopenic purpura, the

antibody works to eliminate B-cell clones (Stasi et al., 2001). If the patient does not respond to

either of the two treatments, the patient potentially could have a splenectomy. This route of

treatment runs an extremely high risk of complications due to issues with the blood not being

able to clot, which further runs the risk of hemorrhaging ​(​McCance & Huether, 2014).

5. What discharge instructions would you give to the patient?

The patient would need to be extremely cautious of excessive bleeding and the risk of not

being able to clot as well. The patient should be aware of signs and symptoms that are consistent

with excessive bleeding: bruising easier than normal, petechiae, purpura, bleeding from the

gums, hematochezia, melena, hematuria, and any trauma the patient could experience in the

future. If the patient experiences any of these signs and symptoms, or her current signs and

symptoms worsen, the patient should return to their healthcare provider for further treatment.
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The patient should also avoid blood thinning medications that could prevent clotting, like Aspirin

or NSAIDS, also known as non-steroidal anti-inflammatory drugs (​McCance & Huether, 2014).

The patient should take precautions for any further injury that could cause bleeding.

References

McCance, K. L., & Huether, S. E. (2014). ​Pathophysiology: The biologic basis for disease in

adults and children.​ St. Louis, MO: Mosby.

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Stasi, R., Pagano, ​A., Stipa, E., Amadori, S., (2001). Rituximab chimeric anti-CD20 monoclonal

antibody treatment for adults with chronic idiopathic thrombocytopenic purpura. ​Blood,

98(4), 952-957. doi: https://doi.org/10.1182/blood.V98.4.952.

Donahue, Maureen. (2018).​ Idiopathic thrombocytopenic purpura diagnosis.​ Retrieved from

http://www.healthline.com/health/idiopathic-thrombocytopenic-purpura-itp