Physiological Integrity Q 12
The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80, it will be most important to teach the client and family about:
A. Bleeding precautions
B. Prevention of falls
C. Oxygen therapy
D. Conservation of energy
Correct Answer: A. Bleeding precautions
The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Review laboratory results for coagulation status as appropriate: platelet count, prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), fibrinogen, bleeding time, fibrin degradation products, vitamin K, activated coagulation time (ACT); and educate the at-risk patient and caregivers about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms.
Option B: 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.
Option C: Option C is important, but platelets do not carry oxygen. 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.
Option D: Option D is of lesser priority and is incorrect in this instance. 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 the patient to take the full course of antibiotics even if symptoms improve or disappear.