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The case of the bloody nose.

Brian received an allogeneic hematopoietic stem cell transplant for acute myelogenous leukemia seven weeks ago. His treatment was complicated by sepsis and mild hepatic graft-versus-host disease (GVHD) requiring more frequent platelet infusions. He is readmitted because of severe epistaxis and blood oozing from his tunneled central venous catheter exit site. He has a low-grade fever. His absolute neutrophil count is 980/[mm.sup.3] and platelet count is 9,000/[mm.sup.3], which is decreased from a count of 11,000/[mm.sup.3] four days prior.

What Would You Do?

Hemostasis is a complex interaction between platelets and clotting factors, all of which must be sufficiently present to stop bleeding. The potential for severe bleeding increases once platelet count is less than 10,000/[mm.sup.3] (Eisenberg, 2010). Brian's neutrophil count and low-grade fever may suggest infection, particularly given his recent stem cell transplantation. His history of hepatic GVHD might cause clotting factor deficiency. The increased need for platelets may indicate he is becoming refractory from human leukocyte antigen (HLA) alloimmunization (Eisenberg, 2010).

Nursing care first involves stopping Brian's epistaxis by placing him in a high Fowler position. Direct pressure should be applied to the nostrils just below the bridge of the nose. Topical thrombin or epinephrine with or without packing may be ordered if pressure is unsuccessful. Brian should be transfused with an irradiated, ABO-compatible platelet product. HLA-matched platelets may be ordered if refractoriness is suspected. Institutional policies vary, but nurses may anticipate an order to keep his platelet count between 20,000/[mm.sup.3] and 50,000/[mm.sup.3] (Eaton & Tipton, 2009). If his prothrombin time and partial thromboplastin time are abnormal, fresh frozen plasma may help correct a clotting factor deficiency. Finally, nurses should instruct Brian not to blow or otherwise traumatize his nose.

Eaton, L.H., & Tipton, J.M. (Eds.). (2009). Prevention of bleeding. In Putting Evidence Into Practice: Improving Oncology Patient Outcomes (pp. 253-265). Pittsburgh, PA: Oncology Nursing Society.

Eisenberg, S. (2010). Refractory response to platelet transfusion therapy. Journal of Infusion Nursing, 33(2), 89-97.

[By Seth Eisenberg, RN, OCN[R], Contributing Editor]
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Title Annotation:what would you do?
Author:Eisenberg, Seth
Publication:ONS Connect
Geographic Code:1USA
Date:Mar 1, 2011
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