Wednesday, March 14, 2012

3 Nursing Diagnosis Interventions for Hemophilia

Nursing Diagnosis and Nursing Interventions for Hemophilia

1. Nursing Diagnosis: Ineffective Tissue Perfusion related to active bleeding
characterized by decreased consciousness, bleeding.

Objectives / Expected outcomes: There was no impairment of consciousness, good capillary refill, bleeding can be resolved

Nursing Interventions
  1. Assess the cause of bleeding
  2. Assess skin color, hematoma, cyanosis
  3. Collaboration in the provision of adequate IVFD
  4. Collaboration in the provision of blood transfusion.

Rational:
  1. By knowing the cause of bleeding it will assist in determining appropriate interventions for patients
  2. Provide information about the degree / adequacy of tissue perfusion and assist in determining appropriate intervention
  3. Maintain fluid and electrolyte balance and maximize contractility / cardiac output so that the circulation becomes inadequate
  4. Repair / menormalakan red blood cell count and enhance oxygen-carrying capacity to be adequate tissue perfusion.

2. Nursing Diagnosis: Deficient Fluid volume related to loss due to bleeding
characterized by: a dry oral mucosa, skin turgor is slow again.

Objectives / Expected outcomes: Indicates repairs fluid balance, moist oral mucosa, skin turgor quickly returned less than 2 seconds

Nursing Interventions:
  1. Monitor vital signs
  2. Monitor output and income
  3. Estimate the wound drainage and the loss of a visible
  4. Collaboration in the provision of adequate fluid

Rational
  1. Changes in vital signs may indicate the direction of abnormal fluid loss due to an increase in bleeding / dehydration
  2. Need to determine kidney function, fluid replacement needs and to help evaluate the fluid status
  3. Provide information about the degree of hypovolemia and help determine intervention
  4. Maintain fluid balance due to bleeding

3. Nursing Diagnosis : Risk for Injury related to weakness of the defense secondary to hemophilia
characterized by frequent injuries

Objectives / 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
  2. Avoid injury, light - weight
  3. Keep an eye on every move that allows the occurrence of injury
  4. Encourage the parents to bring children to the hospital immediately in case of injury
  5. Explain to parents the importance of avoiding injury.

Rational
  1. Fragile tissue and impaired clotting mechanisms boost the risk of bleeding despite the injury / mild trauma
  2. 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. Early identification and treatment can limit the severity of complications
  4. Parents can find out mamfaat of injury prevention / risk of bleeding and avoid injury and complications.
  5. Lower the risk of injury / trauma.

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