SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

S.Y. 2018-2019
Progress Notes

DATE PROBLEM MEDICAL/SURGICAL NURSING OUTCOME

INTERVENTION INTERVENTION
03-15- Adm due to IVF started: PLNSS Monitor Patient
20 bruises and 1L (KVO) at left intake and still have
very low metacarpal vein output bruises and
platelet count Meds started Monitor v/s very low
platelet
count
3-16-19 Very low IVF continued: Same Made Patient
platelet count order comfortable still have
Meds continued and needs bruises and
attended very low
platelet
count
3-17-19 Very low IVF continued with Made Patient
platelet count #2 PLNSS 1L (KVO): comfortable still have
Same order and needs bruises and
Meds continued attended very low
platelet
count
3-18-19 Very low IVF continued: Same Made Patient
platelet count order comfortable still have
Meds continued and needs bruises and
attended very low
platelet
count
3-19-19 Very low IVF continued: Same Made Patient
platelet count order comfortable still have
Meds continued and needs bruises and
2 units of platelet attended platelet
concentrate Observed for count
transfused any lowered from
Peripheral Blood unusualities 10 to 9
Smear and Bone
Marrow Aspiration
Biopsy done
3-20-19 Had fever of IVF continued: Same Made Patient
38 degrees order comfortable still have
Celsius and Meds continued and needs bruises and
platelet attended very low
lowered from platelet
10 to 9 count
Discharged IVF terminated
against Waiver signed by patient’s
medical advice parents
(DAMA)
Discharge Plan

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S.Y. 2018-2019
MEDICATION

The patient was advised to take her medication as ordered by her

doctor.

` Prednisone 10mg/5ml – 5ml TID after meals for 4 weeks then

5ml BID after 1 week for 1 week

Folic Acid 5mg/5ml – 5ml OD

EXERCISE

The patient’s parents were advised to do any kind of exercise

with the patient but they should observe her safety to reduce the risk
of bleeding from her activity.

TREATMENT

The student nurse encouraged the patient’s parents to let the

patient take her medications on time. It was explained that she is at
risk of bleeding and they should be concerned in her health. It was
also encouraged to report to her physician if there are visual
disturbances and headache happening to her because it is a sign of
intracranial bleeding.

In her case, the first treatment that should be done is to take

immunosuppressive/corticosteroid drugs because it can block the
binding receptors on macrophages so that the platelet would not be
destroyed. Another treatment is the blood transfusion (e.g. plasma).
It gives the body additional platelets whenever there is bleeding. The
transfused platelet are rapidly destroyed by the macrophage, hence, it
can compensate the decrease of platelet count. The management is to
undergo splenectomy (after surgery, the patient is at risk in
infection because spleen performs an important role in immunity).

HEALTH TEACHING

Patient’s parents were instructed to avoid the patient having

constipation and valsalva maneuver and flossing her teeth because it
can lead to bleeding. They were also encouraged to let the patient use
soft-bristled toothbrush to prevent gum bleeding. They were also
encouraged to have knowledge regarding her medications.

OUT PATIENT

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S.Y. 2018-2019
The patient’s parents were instructed to have followed up checkup
in the Pedia Hematology after 1 month for further examinations and
evaluation regarding to her health condition.

DIET

The patient’s parents were encouraged to let the patient eat iron
rich food for her blood like fish, liver, milk and poultry products.
We also encouraged her to eat calcium and vitamin D rich food for
supplementation on her bones to make it healthier because every time
there is a decrease of platelets in her body, her bone is tending to
compensate the decrease of platelet. Examples of these foods are salt
water fish, dairy products, eggs and dark green leafy vegetables.

SOCIAL AND SPIRITUAL

It is encouraged to let the patient socialize with other children

despite of other condition. It was also encouraged to let her become a
loving daughter and she should also obey whatever her parents tell her
to do.

Also, they were encouraged to go to the church and pray because

only God can give her the protection and safety that she needs. It can
help her to have positive outlook in her life despite of her
condition.

CHAPTER V

CONCLUSIONS AND RECOMMENDATIONS

Conclusion

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 SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

S.Y. 2018-2019
Idiopathic Thrombocytopenic Purpura is a disease wherein our
immune system is affected because of the medications which an ITP
patient takes. They should know how to protect their selves from
infections. Health care provider doesn’t treat the disease itself.
They prioritized to treat the platelet depletion because it can cause
to severe bleeding. As a health care provider, we should advise ITP
patients to observe a healthy life style. They should avoid all agents
that interferes platelet function.

The primary goal in nursing management is to have the patient a

safe platelet count. Even though that there is decrease of platelet,
blood transfusion is one of the management next to corticosteroid
drugs where in it supplies the body new platelet for it circulation
but it is not advisable because the anti-platelet anti-bodies are all
in the circulation that can bind to the transfused platelet and it
will lead to destruction. The good thing for this is it can provide
our body more platelet and also to help our bone marrow not to have
depression.

Recommendation

It is recommended to the patient’s parents that even if they

leave it all up to GOD for their daughter’s healing, they still need
to seek help from healthcare providers in managing their daughter’s
illness. They should find ways to further supplement their knowledge
about the illness, its managements, possible risks and the likes.

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S.Y. 2018-2019

References

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Guide Diagnosis, Proritized Interventions and Rationales. Edition
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2. Gulanick, Klopp, Galanes, Gradishar, Puzas (1994). Nursing Care

Plans, Nursing Diagnosis and Intervention. Third Edition., Mosby

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S.Y. 2018-2019
3. Berman A., Snyder, S. J. Kozier B., Erb G.(2007). Kozier and
Erb’s Fundamentals of Nursing Concepts Process and Practice. 8th
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6. www.wikipedia.com

7. www.mayoclinic.com

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