Student Nurses’ Community
NURSING CARE PLAN – Hemophilia ASSESSMENT Subjective: “Ayaw tumigil ng pagdurugo ng sugat ko” (My
wound won't stop bleeding) as
DIAGNOSIS Ineffective protection related to abnormal blood profile.
INFERENCE
PLANNING After 8 hours of nursing interventions, the patient will display homeostasis as evidenced by absence of bleeding.
INTERVENTION Independent: • Avoid injections, rectal temperatures or rectal tubes. • Maintain a safe environment. Keep all necessary objects within patient’s reach and keep bed in low position Hematest body fluids like urine, stool, and vomitus, for occult blood. •
RATIONALE Protects patient from procedure related causes of bleeding. Reduces accidental injury, which could result in bleeding.
EVALUATION After 8 hours of nursing interventions, the patient was able to display homeostasis as evidenced by absence of bleeding.
verbalized by the patient. Objective: • • • Altered blood clotting. Continuous bleeding. V/S taken as follows: T: 37.1 P: 78 R: 20 BP: 110/80
Hemophilia is a rare, inherited bleeding disorder in which your blood doesn’t clot normally. If you have hemophilia, you may bleed for a longer time than others after an injury. You also may bleed internally, especially in your knees, ankles, and elbows. This bleeding can damage your organs or tissues and, sometimes, be fatal. People born with hemophilia have little to none of a protein needed for normal blood clotting. The protein is called a clotting factor.
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Prompt detection of bleeding or initiation of therapy may prevent critical hemorrhage. Presence of bleeding or hemorrhage may lead to circulatory failure or shock. May reflect cerebral bleeding. These medication reduces platelet
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Monitor for changes in vital signs and skin color like blood pressure, pulse, perspiration, skin pallor or discoloration. Evaluate change in level of consciousness. Avoid use of aspirin products or non steroidal anti-
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Student Nurses’ Community
inflammatory drugs. There are several types of clotting factors, and they work together with platelets to help the blood clot. Platelets are small pieces of blood cells that are formed in the bone marrow. They play a major role in blood clotting. aggregation.