Question

case study:

K. B. is a 60 year old man admitted to the ER unit on 11/14/2020 at 0800 after experiencing severe bleeding from his gums and nose, blood in stool, severe headaches and a nonhealing wound. K. B also has a history of hypertension, anemia, hepatitis C and hip replacement requiring red cell transfusion. He smokes a quarter of a pack of cigarettes per day and also uses alcohol about once a week. His current vitals are measured to be: RR 26, BP 150/80 mmHg, HR 101, 02 89%, Temp 99.5, and pain 5. A CBC was ordered and revealed the patient to have a platelet count of 40,000 platelets per microliter. Other significant lab values are also seen to be: Hb 8, RBC 3.5, and WBC 1.5L.

(patient is diagnosed with severe thrombocytopenia )

question: explain/describe the clinical significance of the topic and its impact on the patient

Answer 1

Clinical significance refers to those areas where related nursing actions would make a positive and noticeable change in the behaviour/ condition to the patient. In the case of Mr K.B, the clinically significant issues are -

1. Impaired mucus membrane related to low platelet count as evidenced by bleeding from gums and nose, blood in stool (mucosal injury of the gut)

Clinical significance -

- Risk for mucosal and oral infection

- Need to consume non irritating foods (soft, bland and non spicy) - to avoid further damage to oral mucosa

- Need tp use soft brush or even do finger brushing to clean the teeth

- Frequent rinsing of mouth to prevent bacterial colonization

- Need to take plenty of fluids to keep the mouth from drying

2. Severe headache -

Clinical significance -

- Nicotine in tobacco causes vasoconstriction and results in reduced blood supply to the brain, which can trigger a migraine

- Carbon monoxide also present in tobacco, when in high levels in the blood stream can cause migraine

- Allergy to tobacco smoke can also trigger off a migraiine

-It could also be a sign of cerebral hemorrhage

Hence K.B should be advised to gradually reduce cigarette smoking, as cutting off suddenly can also trigger the migraine

Also look out for cigns and symptoms of cerebral hemorrhage - Irritability, nause and vomiting; difficulty in speaking, weakness of limbs; complaints of visual problems; seizures

3. Risk for infection of non-healing wound - Due to low platelet count, there is delayed blood clotting at the site of the wound and this would result in wound infection

The wound should be dressed with sterile precautions, examined for any slough and promptly removed if detected. Also a high calorie, high protein and a Vitamin C rich diet given to speed up wound healing. An appropriate antibiotic to be administered.

3. Risk for further bleeding and hypovolemia related to thrombocytopenia

Clinical significance -

- Alcohol could be a trigger for thrombocytopenia. Other factors that can initiate a fresh bleeding episode are injuty to the skin and mucosl layers. Iintracranial bleeding is another possibility

Advice patient to stop taking alcohol. Platelet transfusions as necessary

Watch out for signs of cerebral hemorrhage

4. Anemia (Hb - 8 gm%) - Further fall in Hb levels may compromise cardiac function due to increased load. Hence vigorous treatment to improve the Hb is needed. RBC transfusion as mentioned.

5. Hepatitis C - Chronic Hepatitis C infection causes liver fibrosis, with resultant portal hypertension, followed by hypersplenism and sequestration of platelets. This leads to reduced production of thrombopoeitin and endothelial dysfunctioin. All this can contribute to thrombocytopenia

6. Hip replacement surgery in patient with thrombocytopenia - It is a risk factor. But research studies state that such a surgery can be successfully performed with with gamma globulin therapy. It also assists in successful wound healing.

7. Hypertension - Drug therapy for hypertension can trigger off an abnormal immune response, especialy the Heparin used for blood thinning (= heparin induced thrombocytopenia). Additionally thiazide diuretics (ethanol and tolbutamide) could cause thrombocytopenia by suppression of megakaryocyte production and also by an immune mediated mechanism.  

Hence the patient's antihypertensie drugs need to be revewed.