A patient receiving chemotherapy has a platelet count of 15,000 mm (15 x 10 L). Based on this laboratory results, which form of precautions should the nurse implement?

Question

Question

This question was previously asked in

SGPGI Staff Nurse Official Paper (Held On: 28 Feb, 2024 Shift 1)

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Answer 1

Correct Answer: Bleeding Precautions

Rationale:

A platelet count of 15,000/mm³ (15 x 10³/mm³) is critically low, placing the patient at a high risk for spontaneous bleeding. Platelets play a vital role in blood clotting, and a severe deficiency can lead to serious complications like internal bleeding or hemorrhage.
Bleeding precautions involve specific measures to reduce the risk of injury and bleeding for patients with low platelet counts. These include avoiding invasive procedures, using soft toothbrushes, avoiding razor blades (use electric shavers instead), and minimizing activities that could result in trauma or falls.
The nurse should also monitor for signs of bleeding, such as bruising, petechiae (small red or purple spots on the skin), hematuria (blood in urine), or bleeding gums. Immediate interventions should be implemented if any signs of bleeding are observed.
Patients with platelet counts this low may require platelet transfusions to prevent life-threatening bleeding episodes. Collaboration with the healthcare team is essential to manage the patient’s condition effectively.

Explanation of Other Options:

Contact Precautions

Rationale: Contact precautions are used to prevent the spread of infections that are transmitted through direct contact with the patient or their environment. Common conditions requiring contact precautions include multidrug-resistant organisms (e.g., MRSA), Clostridioides difficile, or infectious skin conditions.
Since the question does not mention an infectious condition, contact precautions are not relevant in this scenario.

Respiratory Precautions

Rationale: Respiratory precautions are implemented to prevent the transmission of airborne pathogens, such as tuberculosis, measles, or chickenpox. They involve measures like wearing N95 masks and isolating the patient in a negative-pressure room.
The patient in this scenario is not described as having any respiratory infections, so respiratory precautions are unnecessary.

Neutropenic Precautions

Rationale: Neutropenic precautions are used for patients with a low neutrophil count (neutropenia) to protect them from infections due to weakened immunity. These precautions include strict hand hygiene, avoiding fresh flowers or fruits, and minimizing exposure to sick individuals.
Although chemotherapy can cause neutropenia, this scenario specifically highlights a critically low platelet count, which warrants bleeding precautions rather than neutropenic precautions.

Conclusion:

Given the patient’s platelet count of 15,000/mm³, bleeding precautions are the most appropriate nursing intervention to minimize the risk of bleeding and ensure patient safety. The other options are unrelated to the patient’s immediate clinical concern and do not address the risks associated with thrombocytopenia.