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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Assessment, Physical Examination and Nursing Care Plan for Hemophilia

Hemophilia

Hemophilia is a bleeding disorder caused by deficiency and hereditary factors essential for blood coagulation (Wong, 2003).

Hemophilia is a congenital blood clotting disease caused by deficiency of blood clotting factors, ie factor VIII and factor IX. Factor VIII and factor IX is a plasma protein that is a component needed for blood clotting, these factors are required for fibrin clot formation in the area of ​​trauma. (Hidayat, 2006).

Hemophilia is a congenital coagulation disorders the most frequent and serious. The disorder is associated with a deficiency of factor VIII, IX or XI is determined genetically (Nelson, 1999).

Hemophilia is a hereditary or acquired coagulation disorders are most common, manifest as intermittent episodes of bleeding (Price & Wilson, 2005)

Hemophilia there are 3 kinds:

1. Hemophilia A: Disorders of the factor VIII (Anti - hemophilic factor)
2. Hemophilia B: Disorders of the factor IX (Christmas factor)
3. Van Willebrand disease

Clinical symptoms:
1. Infant (for diagnosis)

• Prolonged bleeding after circumcision
• Subcutaneous ecchymoses over the bumps of bone (at the age of 3-4 months)
• Large hematoma after infection
• Bleeding from the oral mucosa
• Soft tissue bleeding

2. Bleeding episodes (during the life span)

1. Early symptoms, including pain
2. After the pain, the swelling, warmth, and decreased mobility

3. Long-term sequelae

• Prolonged bleeding in the muscle can cause nerve compression and muscle fibrosis.

Pathophysiology of Hemophilia
Bleeding due to clotting disorder usually occurs in such a network that is located in muscles, joints, and other disorders because they can occur in the first, second and third, here the only disturbance will be discussed at the first stage, wherein the first stage is exactly what is the mechanism of interference freezing found in hemophilia A and B. Easy bleeding occurs in hemophilia, due to clotting disorder, at the start when a person is ± 3 months old or moments will begin to crawl the initial bleeding will occur due to minor injuries, followed by subsequent complaints.

Hemophilia can also cause cerebral hemorrhage, and fatal. Rationale is that when bleeding, there is a vascular injury (ie a channel where blood flows through the body) → blood out of the vessel. Blood vessels to shrink / shrank → Platelet (platelets) will close the wound on the vessel → Lack of a specific amount of blood clotting factors, resulting in wound closure webbing is not fully formed blood → did not stop flowing out → bleeding vessels (normal: blood clotting factors work to make webbing (fibrin strands) which will close the wound so that the blood stops flowing vessels).

Assessment and Physical Examination for Hemophilia

1. Assessment

• Family history of bleeding disorder
• Ask an unusual bleeding (bleeding that is difficult to stop a long time)
• Spontaneous bleeding (hemorrhage without trauma)

2. Physical examination
a. Activity
Symptoms: Muscle weakness
Symptoms: fatigue, malaise, inability to perform activities.
b. Circulation
Symptoms: skin, mucous membranes pale, cerebral nerve deficit / signs of cerebral hemorrhage
Symptoms: Palpitations
c. Elimination
Symptoms: Hematuria
d. Ego integrity
Symptoms: Depression, withdrawal, anxiety, anger.
Symptoms: Feelings of hopelessness and helplessness.
e. Nutrition
Symptoms: Anorexia, weight loss.
f. Painful
Mark:. Cautious behavior, anxiety, irritability.
Symptoms: Pain in the bones, joints, central tenderness, muscle cramps
g. Security
Signs: hematoma
Symptoms: mild trauma history.
- There was spontaneous bleeding in joints and muscles over and over accompanied by pain and swelling occurs.
- Recurrent joint bleeding caused by hemophilia Atropati give rise to joint space, bone crest and limited joint movement.
- Usually found in the Gastrointestinal bleeding also, excessive hematuria, and brain hemorrhage.
- There was hematoma at the extremities.
- Limitations and joint pain continued to hemorrhage

3. Psychology
- Assess the patient's self-concept à body image, roles, etc.
- Assess the patient and family understanding about the condition and action
- Assess the impact on lifestyle lung condition

Nursing Care Plan for Hemophilia

Nursing Management for Hemophilia

People with hemophilia should be aware of circumstances that can cause bleeding. They should really pay attention to teeth care to not have to undergo a tooth extraction. Rest of the body where there are injuries. When the leg is bleeding, use a tool such as a cane. Compressed injured body part and the surrounding area with ice or other soft material and frozen / cold. Press and tie, so the bleeding body part can not be moving (immobilization). Use an elastic bandage but keep in mind, do not press too hard and tie. Put these body parts in a higher position than the position of the chest and place it on a soft object like a pillow.

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