References:
- Wong’s Nursing Care of Infants and Children, 11th Edition, ISBN 978-0-323-54939-4, by Marilyn J. Hockenberry, David Wilson, and Cheryl C. Rodgers (pp. 1055–1056)
Idiopathic or immune thrombocytopenic purpura (ITP), the formerly used term because purpura is an infrequent sign at presentation, is now referred to as immune thrombocytopenia. ITP is an acquired hemorrhagic disorder that is characterized by thrombocytopenia, and normal bone marrow with a normal or increased number of immature megakaryocytes and eosinophils. It is the most common thrombocytopenia of childhood and usually presents 1 to 4 weeks after a viral illness, with the majority of cases in children younger than 10 years of age. This disease occurs in one of two forms: an acute, self-limiting course or a chronic course (>12 months’ duration).
Although the causes are not known, it is understood that ITP involves the evolution of antibodies against multiple platelet antigens, leading to reduced platelet survival and impaired platelet production. Clinical symptoms include petechiae, bruising, bleeding from mucous membranes, and prolonged bleeding from abrasions. All signs of failure to clot. However, symptomatic bleeding does not usually occur until the platelet count is lower than 20,000/mm³. Fatal hemorrhages have been reported in less than 1% of all patients.
There is no definitive diagnostic test for ITP. Tests are done to rule out other causes of thrombocytopenia, such as systemic lupus erythematosus, lymphoma, and leukemia.
- Bleeding tests that result abnormal due to ITP are those dependent on platelet function— tourniquet test, bleeding time, and clot retraction time.
Therapeutic Management
The management of ITP is primarily supportive because the disease is self-limiting in the majority of cases. Activity is restricted at the onset while the platelet count is low and while active bleeding or progression of lesions is occurring.
- During acute presentation, treatment is symptomatic: prednisone, IVIG, and anti-D antibody. These are not curative therapies.
- Splenectomy may be used for patients with chronic severe ITP that is not responsive to pharmacologic management and have increased risk of severe hemorrhage. It is the only treatment associated with long-term remission for the majority of children with chronic ITP and therefore removes the risk of hemorrhage.
- This is only done for children older than 5 years of age because of the increased risk of bacterial infection. Vaccinations before splenectomy is recommended if not yet administered. Penicillin prophylaxis is also begun after splenectomy for a minimum of three years. A splenectomy is associated with a lifelong risk for overwhelming infection, increased risk of thrombosis, and the potential development of pulmonary hypertension.
Nursing Care Management
Nursing care is largely supportive and should include teaching regarding the possible side effects of therapy and restriction of contact sports while the child’s platelet count is less than 50,000/mm³ as some experts recommend.
Children with ITP should not participate in any contact sports, bike riding, skateboarding, in-line skating, gymnastics, climbing, or running. Parents are encouraged to engage their children in quiet activities and to prevent any injuries to the child’s head. Instruct the parents to obtain prompt medical evaluation if the child sustains head or abdominal trauma. As with any condition with an uncertain outcome, the family needs emotional support.
Quality Patient Outcomes for Immune Thrombocytopenic Purpura
- Serious bleeding episode prevented
- Activities that increase risk for serious bleeding avoided
- Treatment administered without serious side effects