1

/ NAMEOF THECANDIDATE AND ADDRESS / MR. JOBY.M.JOSEPH.
I YEAR M.Sc. NURSING STUDENT,
N.D.R.K. COLLEGE OF NURSING,
B.M. ROAD, HASSAN-573201, KARNATAKA.
2 / NAME OF THE INSTITUTION / N.D.R.K. COLLEGE OF NURSING, B.M. ROAD, HASSAN-573201, KARNATAKA.
3 / COURSE OF STUDY AND SUBJECT / MASTER OF SCIENCE IN NURSING
(CHILD HEALTH NURSING)
4 / DATE OF ADMISSION TO THE COURSE / 11.07.2011
5 / TITLE OF THE TOPIC / “EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING NEONATAL THROMBOCYTOPENIA AMONG 3RD YEAR B.Sc NURSING STUDENTS STUDYING IN SELECTED COLLEGES OF NURSING AT HASSAN DISTRICT, KARNATAKA.”
5.1 / STATEMENT OF THE PROBLEM / ““A “A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING NEONATAL THROMBOCYTOPENIA AMONG 3RD YEAR B.Sc NURSING STUDENTS STUDYING IN SELECTED COLLEGES OF NURSING AT HASSAN DISTRICT,KARNATAKA.’’

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION.

6. BRIEF RESUME OF THE INTENDED WORK:

6.1 INTRODUCTION

“A babe in the house is a well-spring of pleasure, a messenger of peace and love, a resting place for innocence on earth, a link between angels and men”

- Martin Farquhar

Platelets, or thrombocytes from a Greek word θρόμβος, "clot" and κύτος, "cell", are small, irregularly shaped clear cell fragments i.e. cells that do not have a nucleus containing DNA, 2–3µm in diameter which are derived from fragmentation of precursor megakaryocytic which are found in the spongy center of long bones or bone marrow. They are the smallest cell- like structures in the blood. When a blood vessel is punctured or damaged, normal mature platelets have a tendency to aggregate group, together at the site forming a plug that stops bleeding. The average lifespan of a platelet is normally just 5 to 9 days. So the bone marrow of healthy individuals is continually, producing new platelets to replace the old ones. Platelets are a natural source of growth factors. They circulate in the blood of mammals and are involved in homeostasis, leading to the formation of blood clots.1

If the number of platelets is too low, excessive bleeding can occur. However, if the number of platelets is too high, blood clots can form thrombosis, which may obstruct blood vessels and result in such events as a stroke, myocardial infarction, pulmonary embolism or the blockage of blood vessels to other parts of the body, such as the extremities of the arms or legs. An abnormality or disease of the platelets is called a thrombocytopathy, which could be either a low number of platelets thrombocytopenia, a decrease in function of platelets thrombasthenia, or an increase in the number of platelets thrombocytosis. There are disorders that reduce the number of platelets, such as heparin-induced thrombocytopenia or thrombotic thrombocytopenic purpura that typically cause thromboses, or clots, instead of bleeding.1

Thrombocytopenia is one of the most common hematological problems in neonatal intensive care units, with 20-35% of the NICU patients developing this problem before hospital discharge. Thrombocytopenia is a blood disorder characterized by an abnormally low number of circulating platelets thrombocytes in the blood stream. Because platelets play an important role in the process of coagulation blood clotting and in the plugging of damaged blood vessels, persons with decreased platelets bruise easily and can have episodes of excessive bleeding hemorrhage. Thrombocytopenia usually an acquired disorder, but it can also be congenital, as in neonatal rubella or German measles.2

Thrombocytopenia is defined as platelet count less than150×109/L and sometimes indicated as less than 100×109/L. However it is considered severe if the platelet count is below 30×109/Moderate if it is between 30×109/Land 50×10 /L and mild usually asymptomatic if above 50×109/L. While most cases are resolved within 7-14 days with appropriate therapy,2.5%-5% of NICU patients develops severe thrombocytopenia, sometimes lasting for several weeks and requiring>20 platelets transfusions.3

Platelets first appears in the human fetus at five weeks post conception, and increase in number during fetal life reaching a mean of 150×109/L by the end of the 1st trimester of pregnancy and neonatal adult values by 22 weeks of gestation. Since 22weeks is the lowest gestational age at which a newborn infant is considered viable. This means that even the smallest and most immature infants cared for in neonatal intensive care units usually have platelets count between 150 and 450×109/L, although platelet count below150×10/L are found in up to 14% of premature infants. Among infants born at term to mothers with normal platelets levels>98% have platelet count above150×109/L. For these reasons, thrombocytopenia in neonates as in adults, has been traditionally defined as a platelet count <150 ×10/L. 4

The prevalence rate of thrombocytopenia at birth slightly below one %among sick neonates, however the incidence is much higher ,ranging from 18-35%of infants admitted to NICU further more the incidence of thrombocytopenia i s inversely proportional to the gestational age of the infants and reaches approximately 70% among the smallest and most premature infants those with birth weight <1000 gm however severe thrombocytopenia described an incidence of 2.4 and 5%among all NICU admissions .most of the neonates with severe thrombocytopenia had major hemorrhage.60% of those hemorrhages were intraventricular .neatly 90%of major hemorrhages in premature neonates bourn at <28 weeks gestation and 87%occured during the first 2 weeks of life .In facts 25-31%of neonates bourn with a weight <1500grams develop an intracranial hemorrhage during the first week of life the high risk period.4

The incidence of thrombocytopenia varies by population .In the well newborn population the incidence is less than 1%.In the neonatal intensive care units, however, the incidence is much higher. Thrombocytopenia develops in 18%-35%of NICU patients and in 73% of extremely low birth weight or ELBW infants.5

Thrombocytopenia in the neonates can be classified according to underlying pathophysiologic cause and sometimes by kinetics mechanism resulting in allows platelet count. On the basis of kinetic mechanism the causes of thrombocytopenia are classified in to decreased platelet count and accelerated platelet destruction or sequestration. On the basis of pathophysiological categories the causes of neonatal thrombocytopenia are classified in to immune mediated, infectious, genetic, drug related, dissiminated intra vascular coagulation and miscellaneous.5

The major mechanism underlying neonatal thrombocytopenia, accounting for about 75% of cases is impaired platelet production .Increased platelet consumption and sequestrations are the chief mechanism in the remainder of cases. In some neonates a combination of mechanisms such as reduced platelet production and accelerated destruction is responsible for the low platelet count. Other main causes of neonatal thrombocytopenia are alloimmune, congenital infections, auto immune, placental insufficiency, prenatal asphyxia, DIC, autoimmune, late-onset sepsis, and NEC etc.5

Treatment is guided by etiology and disease severity. The main concept in treating thrombocytopenia is to eliminate the underlying problem, whether that means discontinuing suspected drugs that cause thrombocytopenia, or treating underlying sepsis Corticosteroids may be used to increase platelet production.Lithium carbonateor foliate may also be used to stimulate the bone marrow production of platelets. Platelet transfusions may be used to stop episodic abnormal bleeding caused by a low platelet count. However, if platelet destruction results from an immune disorder, platelet infusions may have only a minimal effect and may be reserved for life-threatening bleeding.6

A study was conducted at Neonatal Intensive Care Unit of the Pediatric Department, Jinnah Hospital, and Lahore from September 2007 to February 2008.A total of 365 neonates from 0-28 days of age admitted with different clinical problems irrespective of birth weight and gestational age were evaluated for thrombocytopenia. These neonates were categorized into five different groups A-E, which were of neonatal infections, asphyxia neonatorum, preterm and smallness for gestational age, jaundice and miscellaneous respectively. Out of 365 cases, 88 were found to have thrombocytopenia and the platelet counts are < 150,000 per mm3 which was 24.1% of the total. In group A with neonatal infections, out of 152 neonates, 62 had low platelet counts 40.78%. In group B with neonatal asphyxia, out of 90 only 11 had thrombocytopenia 12.2%. In group C with preterm and small for gestational age, out of 60 cases only 9 had thrombocytopenia. In group D with jaundice, all 33 cases had normal platelet counts. In group E with miscellaneous, out of 30 cases only 6 had thrombocytopenia. The percentage of manifest thrombocytopenia cases was 56.8% and of occult thrombocytopenia 43.1%.The leading causes of thrombocytopenia in sick neonates are infections, asphyxia, complicated pre-maturity and smallness for gestational age.7

6.2 NEED FOR THE STUDY

“A baby is God's opinion that life should go on.”

- Carl Sandburg

Thrombocytopenia in healthy infant is rare; only 2% healthy neonates have a platelet count <150×109/L, defined by platelets count <50×109/L. However thrombocytopenia is one of the most common hematological problems in preterm and term neonates admitted to neonatal intensive care units because it affects 8-35% of all admitted patients. It could be demonstrated ,that in premature infants with a birth weight below 1000 the incidence of NNT in nearly 60%.Among thrombocytopenic extremely low birth weight infants almost 40% suffer from severe thrombocytopenia as sufficiency, intra uterine growth restriction and often resulting in small for gestational age infants. Thrombocytopenia occurring after 72hours is known as late-onset thrombocytopenia. In thrombocytopenic neonates platelet count typically decrease over the 1st decades of life and starts to increase at the end of the first week.8

Thrombocytopenia presenting in the first 72 hours of life is usually secondary to placental insufficiency and caused by reduced platelet production, fortunately more episodes are mild or moderate or resolves spontaneously. Thrombocytopenia presenting after 72 hours of age is usually secondary to sepsis or necrotizing enterocolitis and is usually more severe and prolonged. Platelet transfusion remains the only treatment.9

An estimated 2 million babies dies within the first 24hours each year worldwide and these deaths account for about 40% of the under five mortality and two thirds of infant ages up to 12months mortality. Ninety eight percent of neonatal death occurs in developing countries. The limited epidemiological research indicates the main causes of neonatal deaths are infections, birth asphyxia birth injuries, complications of preterm birth and birth defects.10

According to The Annual State of the Worlds Mothers Report the United States has the second worst newborn mortality rate in the developed world. It is also found that higher new born death rates among US minorities and disadvantaged groups. For African Americans, the mortality rate is nearly doubled that of the United States as a whole, with 9.3 deaths per 1000 births.11

Thrombocytopenia develops 22-35% of all babies admitted to NICU and in up to 50% of those admitted to NICU who require intensive care. A considerable population of 20% cases these episodes of thrombocytopenia are severe. This means that 8% of preterm and 6% of all neonates admitted to NICU have severe thrombocytopenia and are at increased risk of hemorrhage, presenting a common management problem.8

The incidence of neonatal thrombocytopenia was varies greatly depending upon the population from <1% in healthy term babies to around one third of the neonates admitted to NICU. Though thrombocytopenia is so prevalent it is often ignored in the surmise that it will resolve spontaneously. However thrombocytopenia if not managed appropriately, it can result in devastating consequences like intracranial hemorrhage and pulmonary hemorrhage particularly in preterm baby.12

The overall prevalence of the neonatal thrombocytopenia was 53.0%.Mild thrombocytopenia in which platelet count is 51-100×109/L. In 39.4% of the neonates, 12.1% had moderate thrombocytopenia and the platelet count is <30-50+10 /L, while severe thrombocytopenia in which platelet count is <30+10/L detected in 1.5% of the neonates. Of these, 84.84% of the cases occurred within 72 hours i.e. early onset. The most common clinical diagnosis among the neonates is severe birth asphyxia(33%),followed by neonatal jaundice(19.7%),neonatal sepsis(16.7%)low birth weight(13.6%), anemia and bleeding(6.1%)and other clinical conditions(10.6%).3

There are certain risk groups like high risk and low risk groups. The high risk groups included babies with obvious bleeding, those with suspected or confirmed sepsis proven on culture, babies having significant birth asphyxia requiring resuscitation for >30 seconds, babies with intrauterine growth restriction or IUGR, extreme low birth or ELBW baby’s birth weight <1000gm born to mothers with a known disorder causing thrombocytopenia due to Rh immunization, pregnancy induced hypertension, platelet disorders in mother or mothers on drugs causing thrombocytopenia, neonates with suspected proven necrotizing enterocolitis(NCC),babies with suspected or proven intrauterine infections , neonates with suspected or proven intrauterine infections and neonates with congenital syndromes associated with associated with thrombocytopenia or Down’s syndrome, Turners syndrome, TAR etc.12

Low risk groups included babies with hyperbilirubinemia unrelated to the above high risk conditions, preterm with a primary diagnosis of respiratory distress syndrome, babies with meconium aspiration syndrome without significant birth asphyxia or IUGR, low birth weight babies weighing between < 1500 and <2500gm and very low birth weight or VLBW neonates weighing >1000gm but <1500gm who were not growth restricted or sick and were admitted only for routine care.12

Because complications of child birth too frequently cause neonatal death, skilled assistance is recommended for all deliveries along with access to the appropriate level of neonatal care when needed. Preconception and antenatal care provide an opportunity to reduce risk factors for neonatal mortality and morbidity. These include detection and treatment of maternal infections; immunization of women of reproductive age against tetanus; and counseling on risks to a healthy pregnancy and birth preparedness, emphasizing the importance of a clean and safe delivery assisted by skilled birth attendant. Clean and safe newborn care prevents and manages neonatal infections and other illness that can otherwise become life threatening. Care givers must be able to recognize signs of illness, and when they appear, promptly seek appropriate medical assistance.10

A study was conducted to evaluate the patterns of thrombocytopenia and thrombocytosis in hospitalized infants 23.8 weeks to term gestation. Neonates were divided in to four gestational age groups and their PLT counts were retrospectively compared for prevalence of thrombocytopenia. According to the results obtained preconception age, post natal age and sepsis among other factors affected platelet count. When counts from non infected appropriately grown infants were evaluated, the risk of thrombocytopenia and thrombocytosis were highest in most preterm infants, and the risks changed with corrected gestational age. Platelet count increased weekly over the first four weeks of life for all but the most preterm infants. Collectively this study high lights the importance of developing epidemiological data distinguishing the smallest or most premature neonates from other population.13