Nursing Care Plan for Hemophilia
Hemophilia is a rare bleeding disorder in which the blood doesn't clot normally.
People born with hemophilia have little or no clotting factor. Clotting factor is a protein needed for normal blood clotting. There are several types of clotting factors. These proteins work with platelets (PLATE-lets) to help the blood clot.
Platelets are small blood cell fragments that form in the bone marrow—a sponge-like tissue in the bones. Platelets play a major role in blood clotting. When blood vessels are injured, clotting factors help platelets stick together to plug cuts and breaks on the vessels and stop bleeding.
Rarely, hemophilia can be acquired. "Acquired” means you aren't born with the disorder, but you develop it during your lifetime. This can happen if your body forms antibodies (proteins) that attack the clotting factors in your bloodstream. The antibodies can prevent the clotting factors from working.
Nursing Diagnosis and Interventions for Hemophilia
Ineffective Tissue Perfusion
related to : active bleeding
characterized by : decreased consciousness, bleeding.
Expected outcomes: There was no impairment of consciousness, good capillary refill, bleeding can be resolved
Nursing Interventions
1. Assess the cause of bleeding
Rational : By knowing the cause of bleeding it will assist in determining appropriate interventions for patients
2. Assess skin color, hematoma, cyanosis
Rational : Provide information about the degree / adequacy of tissue perfusion and assist in determining appropriate intervention
3. Collaboration in the provision of adequate IVFD
Rational : Maintain fluid and electrolyte balance and maximize contractility / cardiac output so that the circulation becomes inadequate
4. Collaboration in the provision of blood transfusion.
Rational: Repair / menormalakan red blood cell count and enhance oxygen-carrying capacity to be adequate tissue perfusion.
Fluid Volume Deficit
related to : loss due to bleeding
characterized by : a dry oral mucosa, skin turgor is slow again.
Expected outcomes: Indicates repairs fluid balance, moist oral mucosa, skin turgor quickly returned less than 2 seconds
Nursing Interventions:
1. Monitor vital signs
Rational : Changes in vital signs may indicate the direction of abnormal fluid loss due to an increase in bleeding / dehydration
2. Monitor output and income
Rational : Need to determine kidney function, fluid replacement needs and to help evaluate the fluid status
3. Estimate the wound drainage and the loss of a visible
Rational : Provide information about the degree of hypovolemia and help determine intervention
4. Collaboration in the provision of adequate fluid
Rational : Maintain fluid balance due to bleeding
Risk for Injury
related to : weakness of the defense secondary to hemophilia
characterized by : frequent injuries
Expected outcomes: injury and complications can be avoided / did not happen.
Nursing Interventions
1. Maintain security of client's bed, put a safety on the bed
Rational : Fragile tissue and impaired clotting mechanisms boost the risk of bleeding despite the injury / mild trauma
2. Avoid injury, light - weight
Rational : Patients with hemophilia are at risk of spontaneous bleeding was controlled so that the required monitoring every move that allows the occurrence of injury
3. Keep an eye on every move that allows the occurrence of injury
Rational : Early identification and treatment can limit the severity of complications
4. Encourage the parents to bring children to the hospital immediately in case of injury
Rational : Parents can find out mamfaat of injury prevention / risk of bleeding and avoid injury and complications.
5. Explain to parents the importance of avoiding injury.
Rational : Lower the risk of injury / trauma.
Hemophilia is a rare bleeding disorder in which the blood doesn't clot normally.
People born with hemophilia have little or no clotting factor. Clotting factor is a protein needed for normal blood clotting. There are several types of clotting factors. These proteins work with platelets (PLATE-lets) to help the blood clot.
Platelets are small blood cell fragments that form in the bone marrow—a sponge-like tissue in the bones. Platelets play a major role in blood clotting. When blood vessels are injured, clotting factors help platelets stick together to plug cuts and breaks on the vessels and stop bleeding.
Rarely, hemophilia can be acquired. "Acquired” means you aren't born with the disorder, but you develop it during your lifetime. This can happen if your body forms antibodies (proteins) that attack the clotting factors in your bloodstream. The antibodies can prevent the clotting factors from working.
Nursing Diagnosis and Interventions for Hemophilia
Ineffective Tissue Perfusion
related to : active bleeding
characterized by : decreased consciousness, bleeding.
Expected outcomes: There was no impairment of consciousness, good capillary refill, bleeding can be resolved
Nursing Interventions
1. Assess the cause of bleeding
Rational : By knowing the cause of bleeding it will assist in determining appropriate interventions for patients
2. Assess skin color, hematoma, cyanosis
Rational : Provide information about the degree / adequacy of tissue perfusion and assist in determining appropriate intervention
3. Collaboration in the provision of adequate IVFD
Rational : Maintain fluid and electrolyte balance and maximize contractility / cardiac output so that the circulation becomes inadequate
4. Collaboration in the provision of blood transfusion.
Rational: Repair / menormalakan red blood cell count and enhance oxygen-carrying capacity to be adequate tissue perfusion.
Fluid Volume Deficit
related to : loss due to bleeding
characterized by : a dry oral mucosa, skin turgor is slow again.
Expected outcomes: Indicates repairs fluid balance, moist oral mucosa, skin turgor quickly returned less than 2 seconds
Nursing Interventions:
1. Monitor vital signs
Rational : Changes in vital signs may indicate the direction of abnormal fluid loss due to an increase in bleeding / dehydration
2. Monitor output and income
Rational : Need to determine kidney function, fluid replacement needs and to help evaluate the fluid status
3. Estimate the wound drainage and the loss of a visible
Rational : Provide information about the degree of hypovolemia and help determine intervention
4. Collaboration in the provision of adequate fluid
Rational : Maintain fluid balance due to bleeding
Risk for Injury
related to : weakness of the defense secondary to hemophilia
characterized by : frequent injuries
Expected outcomes: injury and complications can be avoided / did not happen.
Nursing Interventions
1. Maintain security of client's bed, put a safety on the bed
Rational : Fragile tissue and impaired clotting mechanisms boost the risk of bleeding despite the injury / mild trauma
2. Avoid injury, light - weight
Rational : Patients with hemophilia are at risk of spontaneous bleeding was controlled so that the required monitoring every move that allows the occurrence of injury
3. Keep an eye on every move that allows the occurrence of injury
Rational : Early identification and treatment can limit the severity of complications
4. Encourage the parents to bring children to the hospital immediately in case of injury
Rational : Parents can find out mamfaat of injury prevention / risk of bleeding and avoid injury and complications.
5. Explain to parents the importance of avoiding injury.
Rational : Lower the risk of injury / trauma.
