A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included on the nursing care plan?
A. Monitor for fever every 4 hours.
B. Require visitors to wear respiratory masks and protective clothing.
C. Consider transfusion of packed red blood cells.
D. Check for signs of bleeding, including examination of urine and stool for blood.
Correct Answer: D. Check for signs of bleeding, including examination of urine and stool for blood.
A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the initiation of bleeding precautions, including monitoring urine and stool for evidence of 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).
Option A: Educate the at-risk patient and caregivers about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms. Thoroughly conform the patient to surroundings; put call light within reach and teach how to call for assistance; respond to call light immediately.
Option B: Monitoring for fever and requiring protective clothing are indicated to prevent infection if white blood cells are decreased. 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 C: Transfusion of red cells is indicated for severe anemia. Prehospital care focuses on the ABCs (airway, breathing, circulation), which include providing oxygen, controlling severe hemorrhage, and initiating intravenous (IV) fluids to maintain hemodynamic stability; airway control may be necessary for a large intracranial hemorrhage.