Understanding the Problem

Bleeding can be very upsetting. It can happen at different times but especially when a person is receiving treatments for cancer. Chemotherapy decreases the number of platelets which clot the blood. When this happens, the person is at a higher risk of bleeding, especially from the mouth, the nose, and in the long gastrointestinal (GI) tract. Family caregivers should know when to sound the alarm and to catch bleeding in its early stages.

Your goals are to:

• call for help when it is needed
• to control bleeding if it starts
• to prevent future bleeding

When To Get Professional Help

The first question you should ask is whether or not the young person with a bleeding problem needs help from medical professionals.

You should call the doctor or nurse if any of the following are true.

• Any unusual bleeding that last more than 10 minutes, such as bleeding from the nose, gums, or skin.
  
• Vomiting of blood or coffee ground material.
  
• Blood in the urine. Look for red, pink or dark brown urine.
  
• Blood in the stools. Look for red, dark red or black colored stools.
  
• Little red or purple spots underneath the skin or in the mouth or on the trunk, stomach, or back, which appear within a few hours.
  
• More bruises on different parts of the body, such as on the chest, waist, abdomen, or head rather than the more normal places, such as elbows and knees.
  
• Severe headaches that happens suddenly.
  
• Very sleepy or unable to wake up.
  
• Your child is injured, especially if he bumps his head hard.

When you call you will need the following facts to answer questions which the doctor or nurse may ask you.

1. When did this sign of bleeding start?
   
2. How long did it last?
   
3. How much was there?
   
4. What do you think caused it to happen?
   
5. Has the person coughed up blood?
   
6. For menstruating females: Is there vaginal bleeding? How heavy is the flow?
   
7. What medications were taken recently?
   • Aspirin
   • Ibuprofen-Motrin, Advil
   • Iron
   • Any suppositories
   • Chemotherapy (when)
     
8. Is the person receiving radiation therapy? If yes, where on the body?

Here's an example of what someone might say when calling:

"I am Jane Smith, the mother of John Smith. My child sees Dr. Jones at the oncology clinic for neuroblastoma. The homecare plan on bleeding says to call if he had bleeding from the gums. He just ate some cereal and started bleeding around the front teeth. He also just started chemotherapy two weeks ago and I was worried that this caused the bleeding."

What You Can Do To Help

If you decide that the bleeding problem is not an emergency at this time, here are two things you can do on your own to control bleeding if it happens.

Control Bleeding

Platelets are the elements in the blood that clot the blood. When these are low, blood does not clot and bleeding does not stop by itself.

Low platelet counts mean that bleeding can happen more easily and last longer than normal usually. Some chemotherapies cause platelet counts to drop. Therefore, when a person is receiving chemotherapy, you should be on the lookout for any bleeding or rapid bruising. Stop it if you can, and report it to the physician or nurse early.

When bleeding starts, it often flows from tiny capillaries that are very near the skin surface, such as from the nose or gums. These capillaries open easily but they also close easily.

• Press on areas of bleeding skin. Pressing on the skin gives the blood in the little blood vessels more time to clot up. Apply pressure for about five minutes to the skin site to maintain the pressure. If you can get an ice-filled cloth or very cold cloth, do so, but don't let go of pressing the skin. Ice helps the bleeding to stop. If the bleeding doesn't stop completely, do this again for 10 minutes.
  
• Apply a cold cloth or ice pack to the area of bleeding. Again, pressing helps stop the bleeding. For a nose bleed, pinch the nose with a handkerchief or put ice wrapped in a soft cloth over the bridge of the nose and pinch for several minutes.

If bleeding is from the nose:

• Put a cold cloth on the nose and pinch the nose.
  
• Do not lie down. Lying down keeps blood flowing more easily to the head. If the young person sits up or stands, then blood does not flow quite as quickly and the bleeding is more likely to stop.
  
• Tilt the head forward. This prevents blood from dripping in the back of the throat, which can cause gagging and be very uncomfortable.

Prevent bleeding in the future

There are many ways to prevent bleeding and bruising if the platelet count is low.

• Do not use ibuprofen, which is the same as Motrin or Advil or Nuprin, among others. Ibuprofen decreases the blood's ability to clot. Avoid giving these at all times.
  
• Do not use aspirin or aspirin-containing products. At the drug store, read the fine print on the label of any analgesic or pain relief pill. It will list aspirin or "acetyl salicylic acid" as part of the ingredients. This means the pill has aspirin in it. Aspirin makes one bleed more easily, especially if platelets are low.
  
• Use a very soft toothbrush or a sponge-type toothbrush. Gums bleed easily when irritated or scraped. A soft toothbrush treats the gums much more gently, and they are less likely to bleed.
  
• Do not floss your teeth if this causes oozing from the gums. This can cut the gums and bleeding may be hard to stop. Resume flossing when the counts go up again and the doctor or nurse says it's OK to go off of bleeding-type precautions.
  
• Rinse and brush the teeth after eating. Rinsing helps remove any leftover food which can build up and start an abscess or sore and make the gums bleed.
  
• Serve a soft diet, such as soup, mashed potatoes, custards, Jello, or puddings if there is mouth soreness. Avoid foods that are sharp or crunchy or hot, spicy, or acidic foods. Soft foods are the least likely to create a cut or scrape in the mouth. Non-spicy foods also are less likely to cause bleeding. Think back to when you burned the top of your mouth on pizza or a grilled cheese sandwich. The skin tore. When platelets are low, the skin also will bleed if it tears because it was burnt.
  
• Avoid blowing the nose forcefully. Discourage nose-picking or vigorous nose-wiping. There are many tiny blood vessels in and near the nose which can open up if the nose is blown too forcefully.
  
• Apply petroleum jelly or lip balms often.
  
• Avoid straining to move bowels and avoid constipation. Stool should be kept soft so it's easy to have regular bowel movements and go to the bathroom. Straining can break open the delicate tissue near and around the rectal opening and bleeding can start. Constipation can be avoided by drinking water and fluids and by taking a daily stool softener, such as Colace or Senokot. If constipation does occur, offer a mild laxative after checking with the doctor or nurse.
  
• Shave with an electric razor, not razor blades.
  
• Supervise use of sharp objects such as knives, scissors or tools.
  
• Avoid contact sports. Examples of contact sports are football, soccer, basketball, wrestling, and tug of war. Anything that involves rough playing should be discouraged, too.
  
• Avoid heavy lifting and strenuous activities.
  
• Protect the child from injuries such as falling off furniture, down stairs, etc. Use a bed rail and pad it with soft blankets. If you don't want to use a bed rail, push the bed up against a wall and line up chairs on the open side, or place soft pillows on the floor around the bed. Another idea is to take the bed off its frame and place the mattress on the floor. Discourage climbing on furniture, trees, etc.
  
• Supervise outdoor play in order to avoid falls, injuries, etc.
  
• Do not use rectal thermometers, suppositories or enemas. Anything put into the rectum can tear very delicate tissue and bleeding can start easily.
  
• Ask about the blood counts. Ask staff to explain about platelets, what makes them go up and down, and what happens to a person with cancer as platelets rise and fall. Then you can ask what the blood counts are each time they are drawn.

Possible Obstacles

Think about attitudes or ideas that could prevent you from carrying out your plan to control or prevent bleeding.

Here are some obstacles that other people have faced.

1. "When my children have fevers, I always give them Pediaprofen; and it works."
   
   Response: When one is under treatment for cancer and getting chemotherapy, it's important not to take any aspirin or ibuprofen products even though these drugs bring a fever down. The risk of bleeding from these drugs is too great. You also don't want to mask the fever by giving a medicine to lower the temperature before you are told to do so by the doctor or nurse. Mask-ing means that the fever goes down to normal for a short time so you don't think that there's anything really wrong. The doctor and nurse want to know how high the fever is, so call and report it.
   
   
2. "My toddler is always climbing on things and falling down. It's impossible to prevent this."
   
   Response: The key with toddlers is to prevent serious falls (down stairs, off furniture, etc.) and to prevent head injuries.
   
   • Close doors to stairways securely or install a gate.
     
   • Do not leave your child unsupervised, even for a minute, or on a couch, chair, or bed unless there are siderails or the tray table is securely fastened.
     
   • Move furniture with sharp edges or corners from your child's environment. Also move heavy or sharp objects that your child could pull or knock down onto himself.
     
   • Ask about your child's platelet count so that you will know when to monitor very closely (low platelets) and when you can allow more liberal activities (normal platelets).

Carrying Out and Adjusting Your Plan

Go over the goals of this homecare plan and compare the situation now to when you started. Are you able to stop the bleeding on your own whenever it starts? Are the skin and mouth as well cared for and protected as they can be? Are other precautions to prevent bleeding being followed?

If you answer yes to these types of questions, you are meeting your goals and preventing or solving problems with bleeding and bruising. Keep a close eye on this situation in case it changes. However, if you answered no to any of these questions, then you need to continue to attack the problem with bleeding and adjust your plan.

If your plan doesn't work

If problems with bleeding are getting worse, review When to get professional help When calling, tell the doctor or nurse what was done to deal with bleeding and discuss what else could be done. If you don't think that you need to talk with a doctor or nurse about bleeding, then ask yourself if you are doing everything you can to protect the skin against bruises, bumps, or cuts and to encourage good oral hygiene.

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