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NURS 110 Thrombocytopenia – Assignment Solution

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NURS 110 Thrombocytopenia – Assignment Solution

MS II: Hematology Case Study II Name: Title: Thrombocytopenia Scenario: The nurse is caring for a 30-year-old HIV positive type 1 diabetic male who was admitted into the hospital today for a 4-day history of excessive bruising, frequent nose bleeds, and bleeding gums. His platelet count is 30,000/µL. His admitting diagnosis is immune thrombocytopenia. He is awake and alert and denies any pain or discomfort. Vital signs are temperature 97.2, pulse 96 bpm, respirations 16 per minute, and blood pressure 118/60 mm Hg. He has several areas of purpura on his back and arms. He states his last nosebleed was last night, which lasted 2 hours. He states that even though he uses a soft toothbrush his gums bleed excessively each time he brushes his teeth.   NGN Item Type: Use an X for the nursing actions listed below that are Indicated (necessary), Contraindicated (could be harmful), or Nonessential (not necessary) for the client’s care at this time. Only one selection can be made for each nursing action.
Nursing Action Indicated Contraindicated Nonessential
Apply direct pressure for 5-10 minutes after each insulin injection.
Ask patient to blow nose forcefully to remove old clots.      
Offer the patient a razor blade for shaving.
Closely monitor hemoglobin and hematocrit count.
Encourage the patient to use an incentive spirometer to aid in lung expansion.
Plan to administer aspirin 81 mg each day to prevent blood clots.
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