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
- Assess the cause of bleeding
- Assess skin color, hematoma, cyanosis
- Collaboration in the provision of adequate IVFD
- Collaboration in the provision of blood transfusion.
Rational:
- By knowing the cause of bleeding it will assist in determining appropriate interventions for patients
- Provide information about the degree / adequacy of tissue perfusion and assist in determining appropriate intervention
- Maintain fluid and electrolyte balance and maximize contractility / cardiac output so that the circulation becomes inadequate
- 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:
- Monitor vital signs
- Monitor output and income
- Estimate the wound drainage and the loss of a visible
- Collaboration in the provision of adequate fluid
Rational
- Changes in vital signs may indicate the direction of abnormal fluid loss due to an increase in bleeding / dehydration
- Need to determine kidney function, fluid replacement needs and to help evaluate the fluid status
- Provide information about the degree of hypovolemia and help determine intervention
- 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
- Maintain security of client's bed, put a safety on the bed
- Avoid injury, light - weight
- Keep an eye on every move that allows the occurrence of injury
- Encourage the parents to bring children to the hospital immediately in case of injury
- Explain to parents the importance of avoiding injury.
Rational
- Fragile tissue and impaired clotting mechanisms boost the risk of bleeding despite the injury / mild trauma
- Patients with hemophilia are at risk of spontaneous bleeding was controlled so that the required monitoring every move that allows the occurrence of injury
- Early identification and treatment can limit the severity of complications
- Parents can find out mamfaat of injury prevention / risk of bleeding and avoid injury and complications.
- Lower the risk of injury / trauma.
