Nursing 211

N211: Health Differences Across the Lifespan I Risk for injury related to abnormal bleeding • Pain related to bleeding into tissues and diagnostic procedures Nursing Diagnosis • Nursing I terventi ns Monitor client for bleeding, PT/INR. Maintain bedrest and transfusion with fresh frozen plasma, platelets, and packed RBCs. Protect client from injury and bleeding. Provide gentle oral care with mouth swabs. Minimize needle sticks; use smallest gauge possible. Apply pressure to injection sites for at least 10 minutes to prevent hemorrhage. Weigh the patient daily to monitor for fluid volume excess. Measure abdominal girth every 4 hours to detect intra-abdominal bleeding. Turn client frequently to eliminate pressure points. Use gentle suction to prevent trauma to mucosa. Provide emotional support to decrease anxiety. Administer IV Heparin during first phase to inhibit coagulation. 1.32 Hemophilia Hemophilia is a hereditary bleeding disorder affecting only males. Transmitted by an x-linked recessive chromosome (mother is carrier, her sons may express the disease). A normal individual has between a 50-200% factor activity in blood; the hemophiliac has from 0-25% activity. The affected individual usually is missing either factor VIII (classic, 75% of cases) or factor IX. Nursing Assessments Male child, first red flag may be prolonged bleeding at the spontaneous or severe bleeding after minor trauma (excessive bleeding at circumcision), subcutaneous and intramuscular hematomas, prolonged bleeding after major trauma/surgery (up to 8 days), hematuria, joint tenderness, pain and swelling in a weight-bearing joint (hip, knee or ankle), tarry stools. Lab values will show that the PTT is prolonged, and the factor VIII assays are less than 25% of the normal factor VIII. Nursing Diagnosis • Risk for trauma related to… • Deficient knowledge related to… Nursing Interventions Include administration of cryoprecipitate of fresh plasma, fresh Frozen plasma or lyophilized (freeze dried) concentrate. Analgesics to control joint pain. Do not give aspirin. Follow blood precautions due to the risk of hepatitis. Teach the patient and family to recognize the early signs of bleeding into the joints; local treatment for minor bleeds (pressure and splinting); administration of factor replacement; discuss dental hygiene and the use of soft toothbrushes. Provide protective care by giving the child soft toys, use padded side rails. Have the


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