Hemophilia Nursing Care Plan & Management

Description

Hemophilia is now on the rise among the pediatric population across the world.

• Hemophilia results from mutations at the factor VIII or IX loci on the X chromosome and each occurs in mild, moderate, and severe forms.
• A similar level of deficiency of factor VIII or IX results in clinically indistinguishable disease because the end result is deficient activation of factor X by the factor Xase complex (FVIIIa/FIXa/calcium and phospholipid).
• Hemophilia A is an X-linked, recessive disorder caused by the deficiency of functional plasma clotting factor VIII (FVIII), which may be inherited or arise from spontaneous mutation.
• Hemophilia B, or Christmas disease, is an inherited, X-linked, recessive disorder that results in the deficiency of functional plasma coagulation factor IX.

Pathophysiology

Pathophysiologies for both hemophilia A and B are as follows:

Hemophilia A

• Primary sites of factor VIII (FVIII) production are thought to be the vascular endothelium in the liver and the reticuloendothelial system.
• FVIII deficiency, dysfunctional FVIII, or FVIII inhibitors lead to the disruption of the normal intrinsic coagulation cascade, resulting in excessive hemorrhage in response to trauma and, in severe cases, spontaneous hemorrhage.
• Human synovial cells synthesize high levels of tissue factor pathway inhibitor, resulting in a higher degree of factor Xa (FXa) inhibition, which predisposes hemophilic joints to bleed.
• This effect may also account for the dramatic response of activated factor VII (FVIIa) infusions in patients with acute hemarthroses and FVIII inhibitors.
• Bleeding into a joint may lead to synovial inflammation, which predisposes the joint to further bleeds; a joint that has had repeated bleeds (by one definition, at least 4 bleeds within a 6-month period) is termed a target joint.
• Approximately 30% of patients with severe hemophilia A develop alloantibody inhibitors that can bind FVIII; these inhibitors are typically immunoglobulin G (IgG), predominantly of the IgG4 subclass, that neutralizes the coagulant effects of replacement therapy.

Hemophilia B

• Factor IX deficiency, dysfunctional factor IX, or factor IX inhibitors lead to disruption of the normal intrinsic coagulation cascade, resulting in spontaneous hemorrhage and/or excessive hemorrhage in response to trauma.
• Hemorrhage sites include joints (eg, knee, elbow), muscles, central nervous system (CNS), GI system, genitourinary (GU) system, pulmonary system, and cardiovascular system.
• Factor IX, a vitamin K–dependent single-chain glycoprotein, is synthesized first by the hepatocyte; the precursor protein undergoes extensive posttranslational modification before being secreted into the blood.
• The intrinsic system is initiated when factor XII is activated by contact with damaged endothelium.
• In the extrinsic system, the conversion of factor X to factor Xa involves tissue factor (TF), or thromboplastin; factor VII; and calcium ions.
• FVIII and FIX circulate in an inactive form; when activated, these 2 factors cooperate to cleave and activate factor X, a key enzyme that controls the conversion of fibrinogen to fibrin.
• Therefore, the lack of either of these factors may significantly impair clot formation and, as a consequence, result in clinical bleeding.

Statistics and Incidences

Hemophilia is slowly progressing among pediatric patients in all parts of the globe.

• Hemophilia A is the most common X-linked genetic disease and the second most common factor deficiency after von Willebrand disease (vWD).
• The worldwide incidence of hemophilia A is approximately 1 case per 5000 males, with approximately one-third of affected individuals not having a family history of the disorder.
• In the United States, the prevalence of hemophilia A is 20.6 cases per 100,000 males; in 2016, the number of people in the United States with hemophilia was estimated to be about 20,000.
• Hemophilia A occurs in all races and ethnic groups.
• Because hemophilia is an X-linked, recessive condition, it occurs predominantly in males; females usually are asymptomatic carriers.
• The incidence of hemophilia B is estimated to be approximately 1 case per 25,000-30,000 male births.
• The prevalence of hemophilia B is 5.3 cases per 100,000 male individuals, with 44% of those having severe disease.
• Hemophilia B is much less common than hemophilia A. Of all hemophilia cases, 80-85% are hemophilia A, 14% are hemophilia B, and the remainder are various other clotting abnormalities.
• Hemophilia B occurs in all races and ethnic groups.

Causes

The causes of both hemophilia A and B are apparently from a genetic form.

• Genetics. Hemophilia A is caused by an inherited or acquired a genetic mutation that results in dysfunction or deficiency of factor VIII, or by an acquired inhibitor that binds factor VIII; Hemophilia B is an X-linked recessive disease caused by an inherited or acquired mutation in the factor IX gene or by an acquired factor IX inhibitor.

Clinical Manifestations

Hemophilia is suggested by a history of hemorrhage disproportionate to trauma or of spontaneous hemorrhage, or a family history of bleeding problems.

• Spontaneous hemorrhage. Approximately 30-50% of patients with severe hemophilia present with manifestations of neonatal bleeding (eg, after circumcision); other neonates may present with severe hematoma and prolonged bleeding from the cord or umbilical area or at sites of blood draws or immunizations.
• Hematuria. In the genitourinary tract, gross hematuria may occur in as many as 90% of patients.
• General symptoms. Weakness and orthostasis may occur.
• Musculoskeletal. Tingling, cracking, warmth, pain, stiffness, and refusal to use the joint among children are common.
• Central nervous system. Headache, stiff neck, vomiting, lethargy, irritability, and spinal cord syndromes may occur.
• Genitourinary.  Symptoms may be painless; there may be hepatic/splenic tenderness and peritoneal signs.

Assessment and Diagnostic Findings

The diagnosis of hemophilia A and B is established by measuring the following:

• Chromogenic assay. This assay is considered by some to be more accurate, as it measures the level of plasma factor VIII activity but it is less widely available in clinical laboratories in the United States.
• Laboratory studies. Laboratory studies for suspected hemophilia include a complete blood cell count, coagulation studies, and a factor VIII (FVIII) assay.
• CT scans. Head CT scans without contrast are used to assess for spontaneous or traumatic intracranial hemorrhage.
• MRI. Perform magnetic resonance imaging (MRI) on the head and spinal column for further assessment of spontaneous or traumatic hemorrhage; MRI is also useful in the evaluation of the cartilage, synovium, and joint space.
• Ultrasonography. Ultrasonography is useful in the evaluation of joints affected by acute or chronic effusions.
• Testing for inhibitors. Laboratory confirmation of a FVIII inhibitor is clinically important when a bleeding episode is not controlled despite infusion of adequate amounts of factor concentrate.
• Carrier testing. Screening for carrier status can be performed by measuring the ratio of FVIII coagulant activity to the concentration of von Willebrand factor (vWF) antigen; a ratio that is less than 0.7 suggests carrier status.
• Radiography. Radiography for joint assessment is of limited value in acute hemarthrosis; evidence of chronic degenerative joint disease may be visible on radiographs in patients who have been untreated or inadequately treated or in those with recurrent joint hemorrhages.

Medical Management

The treatment of hemophilia may involve prophylaxis, management of bleeding episodes, treatment of factor VIII (FVIII) inhibitors, and treatment and rehabilitation of hemophilia synovitis.

• Prehospital care. Rapid transport to definitive care is the mainstay of prehospital care; prehospital care providers should apply aggressive hemostatic techniques, assist patients capable of self-administered factor therapy, and gather focused historical data if the patient is unable to communicate.
• Emergency department care. Use aggressive hemostatic techniques; correct coagulopathy immediately; include a diagnostic workup for hemorrhage, but never delay indicated coagulation correction pending diagnostic testing; acute joint bleeding and expanding, large hematomas require adequate factor replacement for a prolonged period until the bleed begins to resolve, as evidenced by clinical and/or objective methods; life-threatening bleeding episodes are generally initially treated with FVIII levels of approximately 100%, until the clinical situation warrants a gradual reduction in dosage.
• Factor VIII  and FIX concentrates. Various FVIII and FIX concentrates are available to treat hemophilia A and B; besides improved hemostasis, continuous infusion decreases the amount of factor used, which can result in significant savings; obtain factor level assays daily before each infusion to establish a stable pattern of replacement regarding the dose and frequency of administration.
• Desmopressin. Desmopressin vasopressin analog, or 1-deamino-8-D-arginine vasopressin (DDAVP), is considered the treatment of choice for mild and moderate hemophilia A; DDAVP stimulates a transient increase in plasma FVIII levels; DDAVP may result in sufficient hemostasis to stop a bleeding episode or to prepare patients for dental and minor surgical procedures.
• Management of bleeding. Immobilization of the affected limb and the application of ice packs are helpful in diminishing swelling and pain; early infusion upon the recognition of initial symptoms of a joint bleed may often eliminate the need for a second infusion by preventing the inflammatory reaction in the joint; prompt and adequate replacement therapy is the key to preventing long-term complications.
• Treatment of patients with inhibitors. Inhibitors are antibodies that neutralize factor VIII (FVIII) and can render replacement therapy ineffective; the treatment of patients with inhibitors of FVIII is difficult; assuming no anamnestic response, low-titer inhibitors (ie, concentrations below 5 Bethesda units [BU]) occasionally can be overcome with high doses of factor VIII; there is no established treatment for bleeding episodes in patients with high-titer inhibitors.
• Prophylactic factor infusions. The main goal of prophylactic treatment is to prevent bleeding symptoms and organ damage, in particular to joints; in December 2013, the US Food and Drug Administration (FDA) expanded the indication for anti-inhibitor coagulant complex (Feiba NF) to include routine prophylaxis in patients with hemophilia A or B who have developed inhibitors; approval was based on data from a pivotal phase III study in which a prophylactic regimen resulted in a 72% reduction in median annual bleed rate compared with on-demand treatment.
• Pain management. Hemophilic chronic arthropathy is associated with pain; narcotic agents have been used, but frequent use of these drugs may result in addiction; nonsteroidal anti-inflammatory drugs may be used instead because their effects on platelet function are reversible and because these drugs can be effective in managing acute and chronic arthritic pain; avoid aspirin because of its irreversible effect on platelet function.
• Activity. Generally, individuals with severe hemophilia should avoid high-impact contact sports and other activities with a significant risk of trauma; however, mounting evidence suggests that appropriate physical activity improves overall conditioning, reduces injury rate and severity, and improves psychosocial functioning.
• Gene therapy. With the cloning of FVIII and advances in molecular technologies, the possibility of a cure for hemophilia with gene therapy was conceived; ex vivo gene therapy, in which cells to be transplanted are genetically modified to secrete factor VIII and then are reimplanted into the recipient; in vivo gene therapy, in which a vector (typically a virus altered to include FVIII DNA) is directly injected into the patient; and nonautologous gene therapy, in which cells modified to secrete FVIII are packaged in immunoprotected devices and implanted into recipients.
• Radiosynovectomy. In patients who develop synovitis from joint bleeds, intra-articular injection of radioisotopes to ablate the synovium (radiosynovectomy) can be used to decrease bleeding, slow progression of cartilage and bone damage, and prevent arthropathy.

Pharmacologic Management

Medications of choice for patients with hemophilia are:

• Factor VIII. Factor VIII (FVIII) is the treatment of choice for acute or potential hemorrhage in hemophilia A; recombinant FVIII concentrate is generally the preferred source of factor VIII; prophylactic administration of FVIII is often recommended for pediatric patients with severe disease.
• Antifibrinolytic agents. Antifibrinolytic agents, such as aminocaproic acid and tranexamic acid, are especially useful for oral mucosal bleeds but are contraindicated as initial therapies for hemophilia-related hematuria originating from the upper urinary tract because they can cause obstructive uropathy or anuria.
• Factor IX. Factor IX is the treatment of choice for acute hemorrhage or presumed acute hemorrhage in hemophilia B. Recombinant factor IX is the preferred source for replacement therapy.
• Coagulation factor VIIa. These agents can activate coagulation factor X to factor Xa as well as coagulation factor IX to IXa.
• Coagulation factors. FVIII concentrates replace deficient FVIII in patients with hemophilia A, with the goal of achieving a normal hematologic response to hemorrhage or preventing hemorrhage; recombinant products should be used initially and subsequently in all newly diagnosed cases of hemophilia that require factor replacement; agents that bypass FVIII activity in the clotting cascade (eg, activated FVII) are used in patients with FVIII inhibitors.
• Antihemophilic agents. These agents are used to control bleeding in hemophilia B or FIX deficiency and to prevent and/or control bleeding in patients with hemophilia A and inhibitors to FVIII.
• Monoclonal antibodies. Monoclonal antibodies are used to bind to one specific substance in the body (eg, molecules, antigens); this binding is very versatile and can mimic, block, or cause changes to enact precise mechanisms (eg, bridging molecules, replacing or activating enzymes or cofactors, immune system stimulation).
• Vasopressin-related. Desmopressin transiently increases the FVIII plasma level in patients with mild hemophilia A.

Nursing Management

Nursing care for a child with hemophilia include:

Nursing Assessment

Assessment in a child with hemophilia include the following:

• History. For patients in whom hemophilia is suspected, inquire about the history of hemorrhage disproportionate to trauma, history of spontaneous hemorrhage, bleeding disorders in the family, and concomitant illness (especially those associated with acquired hemophilia, such as chronic inflammatory disorders, autoimmune diseases, hematologic malignancies, and allergic drug reactions).
• Physical examination. Assess for joint swelling and ability to move affected limb; Assess for limited ROM, contractures, and bony changes in the joints when bleeding has stopped.

Nursing Diagnoses

Based on the assessment data, the major nursing diagnoses are:

• Acute pain related to traumatic injury to the muscles.
• Impaired physical injury related pain and discomfort with the onset of bleeding episodes.
• Compromised family coping related to incorrect and inadequate information or understanding.
• Risk for bleeding related to decreased concentration of clotting factors circulating in the blood (factor VIII and factor IX).
• Risk for injury related to decreased clotting factor (VIII or IX).

Nursing Interventions

The nursing interventions for a child with hemophilia are:

• Relieve pain. Immobilize joints and apply elastic bandages to the affected joint if indicated; elevate affected and apply a cold compress to active bleeding sites, but must be used cautiously in young children to prevent skin breakdown.
• Maintain optimal physical mobility. Provide gentle, passive ROM exercise when the child’s condition is stable; educate on preventive measures, such as the application of protective gear and the administration of factor products; and refer for physical therapy, occupational therapy, and orthopedic consultations, as required.
• Assist in the coping of the family. Encourage family members to verbalize problem areas and develop solutions on their own; encourage family members to express
  feelings, such as how they deal with the chronic needs of a family member and coping patterns that help or hinder adjustment to the problems.
• Prevent bleeding. Monitor hemoglobin and hematocrit levels; assess for inhibitor antibody to factor VIII; anticipate or instruct in the need for prophylactic treatment before high-risk situations, such as invasive diagnostic or surgical procedures, or dental work; and provide replacement therapy of deficient clotting factors.
• Prevent injury. Utilize appropriate toys (soft, not pointed
  or small sharp objects); for infants, may need to use padded bed rail sides on crib; avoid rectal temperatures; provide appropriate oral hygiene (use of
  a water irrigating device; use of a soft toothbrush or softening the toothbrush with warm water before brushing; use of sponge-tipped toothbrush); and avoid contact sports such as football, soccer, ice hockey, karate.

Evaluation

Goals are met as evidenced by:

• Child experienced decreased pain.
• Child maintained optimal physical mobility as evidenced by normal range of motion (ROM) and activities of daily living within ability.
• Family coped effectively with child’s illness.
• Child’s risk for injury from possible bleeding was decreased through the use of appropriate prophylactic measures.

Documentation Guidelines

Documentation in a child with hemophilia include the following:

• Baseline and subsequent assessment findings to include signs and symptoms.
• Individual cultural or religious restrictions and personal preferences.
• Plan of care and persons involved.
• Teaching plan.
• Client’s responses to teachings, interventions, and actions performed.
• Attainment or progress toward the desired outcome.
• Long-term needs, and who is responsible for actions to be taken.

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Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to

• Hemarthrosis
• Traumatic injury to muscles

Possibly evidenced by

• Verbal complaint of pain/discomfort
• A feeling of stiffness
• Tingling or aching in the affected joint, followed by a decrease in the ability to move a joint
• Guarding behavior
• Irritability, restlessness
• Crying

Desired Outcomes

• Client will experience decreased pain.

Nursing Interventions	Rationale
Assess the location, characteristics, and rate of pain (use pain scale).	Hemarthrosis (bleeding into joint) is the main manifestation of the disease. Common sites include the elbows, shoulders, hips, knees, and ankle joints.
Assess for joint swelling and ability to move affected limb.	Bleeding episodes should be managed at the onset of discomfort, which entails a deficient factor replacement.
Immobilize joints and apply elastic bandages to the affected joint if indicated; elevate affected and apply a cold compress to active bleeding sites, but must be used cautiously in young children to prevent skin breakdown.	Immobilization promotes comfort and decreases joint damage; elastic bandage most often avoids musclebleeding; elevation of affected extremity/  joint will minimize swelling; cold  application will promote vasoconstriction.
Provide bed cradle over painful joints and other sites of bleeding.	Prevents pressure of linens on affected sites, especially joints.
Maintain immobilization of the affected extremity during the acute phase (24 to 48 hours); apply a splint or sling to the affected extremity if indicated.	Immobilization of the affected joint helps to decreased bleeding and provide some relief.
Perform range of motion 48 hours after the acute bleeding episode and pain has subsided.	Maintains optimal joint movement.
Administer medications as indicated.	Acetaminophen (Tylenol), propoxyphene, corticosteroids, and codeine are given for pain management; NSAIDs such aspirinare contraindicated since they impair clotting and can cause gastric bleeding.
Administer factor VIII or other prescribed factor component immediately.	Controls the bleeding that is causing the pain.
Educate child about cause of pain and interventions to relieve it; how medications must be administered via per orem, while injections are not advised; to avoid taking aspirin or aspirin product for pain.	Promotes understanding of pain responses and methods to reduce it.
Instruct child to support and protect painful areas and in the importance of immobilization.	Promotes comfort and prevents further bleeding into joints.

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Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.

May be related to

• Pain and discomfort with the onset of bleeding episodes
• Hemarthrosis.

Possibly evidenced by

• Pain in affected joint
• Decreased ability to move the joint
• Immobilized joints (first 24 to 48 hours after a bleeding episode)
• Potential contractures in affected joints

Desired Outcomes

• Child will maintain optimal physical mobility as evidenced by normal range of motion (ROM) and activities of daily living within ability.

Nursing Interventions	Rationale
Assess for limited ROM, contractures, and bony changes in the joints when bleeding has stopped.	Recurrent bleeding of the joints can lead to bone destruction, permanent deformities, and crippling. This data gives the baseline for evaluating further constraints from bleeding.
Provide gentle, passive ROM exercise when the child’s condition is stable.	Clients who are experiencing active bleeding have restricted mobility or splinting. However, later ROM exercise can help maintain optimal muscle and joint movement.
Assist with the progression to active exercise as tolerated.	Non-weight bearing exercise facilitates optimal ROM without stimulating rebleeding. Extra weight should be avoided until swelling has subsided.
Educate on preventive measures, such as the application of protective gear and the administration of factor products.	Avoiding injury and hemarthrosis is essential for maintaining joint and limb mobility and use.
Provide assistive devices when needed.	The chronic joint deformity is a common complaint.
Refer for physical therapy, occupational therapy, and orthopedic consultations, as required.	Electrical stimulation of the muscles around the joints prevents muscle atrophy. Active physiotherapy helps in regaining joint movement and preventing fibrous build up.

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Compromised Family Coping: A usually supportive primary person (family member, significant other, or close friend) insufficient, ineffective, or compromised support, comfort, assistance or encouragement that may be needed by the individual to manage or master adaptive tasks related to his or her health challenge.

May be related to

• Inadequate or incorrect information or understanding
• Prolonged disease or disability progression that exhausts the physical and emotional supportive capacity of caretakers

Possibly evidenced by

• Expression and/or confirmation of concern and inadequate knowledge about long-term care needs, problems, and complications,
• Anxiety and guilt
• Overprotection of child

Desired Outcomes

• Family will cope effectively with child’s illness.

Nursing Interventions	Rationale
Assess family’s coping methods and their effectiveness; family interactions and expectations related to long-term care, developmental level of family; response of siblings; knowledge and use of support systems and resources; presence of guilt and anxiety; overprotection and/or overindulgent behaviors.	Identifies coping methods that work and the need to utilize new coping skills and behaviors, family attitudes; child with special long-term needs either strengthen or distort family relationships and an undue degree of overprotection may be  detrimental to child’s growth and  development such as disallowing school  attendance or peer activities, avoiding  discipline of child, and disallowing child to assume responsibility for ADL.
Encourage family members to verbalize problem areas and develop solutions on their own.	Decreases anxiety and enhances  understanding; provides family an  opportunity to recognize problems and create problem-solving strategies.
Encourage family members to express feelings, such as how they deal with the chronic needs of a family member and coping patterns that help or hinder adjustment to the problems.	Allows for venting of feelings, which relieves guilt and anxiety and helps determine need for information and support.
Assist family in setting short- and long-term goals for the child and integrate child into family activities, include participation of all family.	Promotes involvement and control over situations and maintains the role of family members and parents.
Provide information about long-term care and management.	Enhances family understanding of medical regimen and responsibilities of family members.
Inform family that overprotective behavior may hinder growth and development and that child should be treated as normally as possible.	Promotes understanding of the importance of making child one of the family and the adverse effects of overprotection of the child.
Provide assistance of social worker, counselor, or other as needed.	Gives support to the family faced with long-term care of a child with a serious illness.

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Risk for Bleeding: At risk for a decrease in blood volume that may compromise health.

May be related to

• Decreased concentration of clotting factors circulating in the blood (factor VIII and factor IX)

Possibly evidenced by

• [not applicable]

Desired Outcomes

• Child’s risk for injury from possible bleeding is decreased through the use of appropriate prophylactic measures.

Nursing Interventions	Rationale
Monitor the coagulation assays for factor VIII AND IX.	Decreased value indicate that factor replacement therapy is subtherapeutic.
Monitor the partial thromboplastin time (PTT).	PTT is prolonged because of a deficiency in the clotting system factors. The prothrombin time will be normal.
Assess for any signs of bruising and bleeding (note the extent of bleeding). Assess for prolonged bleeding after minor injuries.	Usual sites of external bleeding may include the bleeding in the mouth from a cut, bite, or from cutting or losing a tooth; nosebleeds for no obvious reasons; heavy bleeding from a minor cut, or bleeding from a cut that resumes after stopping for a short time. Hemophiliacs do not bleed faster or more frequently. Instead, they bleed longer due to a deficiency of clotting factor. Clients are often aware of bleeding before clinical manifestation. Bleeding can be life-threatening to these clients.
Assess for any pain and swelling over the entire body.	A headache, in the presence of a trauma history, may suggest intracranial hemorrhage. Abdominal pain may indicate an internal bleeding. Bleeding into a joint is usually reported as a peculiar tingling sensation felt well before pain or swelling is detected.
If spontaneous or traumatic bleeding is evident, monitor vital signs.	Hypovolemic shock can happen due to decreased circulatory volume with blood loss. Signs include hypotension and tachycardia.
Monitor hemoglobin and hematocrit levels.	Hgb and Hct are monitored as indicators of blood loss.
Assess for inhibitor antibody to factor VIII.	Clients who require frequent transfusions may develop inhibitor antibody and require a subsequent change in coagulation therapy to factor VIIa.
Anticipate or instruct in the need for prophylactic treatment before high-risk situations, such as invasive diagnostic or surgical procedures, or dental work.	Treatment may include cryoprecipitate, which contains factor VIII and fibrinogen, and factor VIII concentrate, or it may include desmopressin (DDAVP) for treating mild to moderate hemophilia A.
Perform the following measures to control bleeding: Apply manual or mechanical pressure if active bleeding is noted. Apply sterile dressings to wounds, and apply pressure. Apply topical coagulants, such as fibrin foam and thrombin.	Controlling bleeding is a nursing priority. Nasal packing should be avoided, because the subsequent removal of the packing may precipitate further bleeding.
If bleeding is in a joint (hemarthrosis), elevate and immobilize the affected limb. Apply ice packs to control bleeding.	Repeated hemarthrosis can result in severe and crippling deformity.
Provide replacement therapy of deficient clotting factors.	Replacement of factors is the primary treatment for bleeding. Treatment includes factor VIII, which is an essential clotting factor needed to convert prothrombin to thrombin. This treatment can also be provided in the home. DDAVP is the treatment of choice for mild hemophilia. It is an analogue of vasopressin and is available intravenously and intranasally. Recombinant DNA factors are available. Because they are not produced from humans, they should reduce the risk for infectious transmission.
Administer plasma-derived factor VIIa for clients with antibodies against factor VIII.	Antibodies (inhibitors) to the clotting factors can destroy it before it is able to work and defeat the effect of replacement therapy. New therapies are available to neutralize the antibodies.
Administer tranexamic acid or epsilon aminocaproic acid as indicated.	These are second-line antifibrinolytic drugs that do not actually form clots but help hold clots in place by stopping plasmin activity. They do not replace factor therapy. They are commonly used before dental work, during bleeding episodes, and, in the rare case of a woman with hemophilia, during heavy menstrual bleeding.
Anticipate the need for blood replacements.	Volume expanders and O-negative blood should be immediately available in the event of life-threatening hemorrhage.

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Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

May be related to

• Decreased clotting factor (VIII or IX)

Possibly evidenced by

• [not applicable]

Desired Outcomes

• Client will not experience injury.

Nursing Interventions	Rationale
Assess signs and symptoms of bleeding; hemarthrosis (stiffness, tingling, or pain); subcutaneous and intramuscular hemorrhage; oral bleeding; epistaxis (is not a frequent sign); petechiae (are uncommon).	Early detection of bleeding episodes will delay initiation of factor replacement therapy and will minimize complications; oral bleeding is often caused by trauma to the gums; petechiae is caused by low platelet function versus a deficient clotting factor.
Advise adolescents to use an electric shaver versus manual razor devices (with blades).	High risk of bleeding is related to use of razor blades; minimal risk of bleeding is associated with the use of electric shaver.
Utilize appropriate toys (soft, not pointed or small sharp objects); for infants, may need to use padded bed rail sides on crib; avoid rectal temperatures.	All of these recommendations will minimize and/or prevent bleeding episodes due to trauma.
Provide appropriate oral hygiene (use of a water irrigating device; use of a soft toothbrush or softening the toothbrush with warm water before brushing; use of sponge-tipped toothbrush).	Implementation of appropriate oral hygiene will minimize trauma to the gums.
Substitute the subcutaneous route for intramuscular injections; utilize venipuncture blood drawing technique for all required blood testing samples versus the use of a finger or heel puncture.	Both of these measures are associated with less bleeding after implementing subcutaneous injection or venipuncture blood sample.
Recommend non-contact sports activities such as swimming, hiking, or bicycling.	These activities are considered a safe activity by the Hemophilia Foundation.
Avoid contact sports such as football, soccer, ice hockey, karate.	Contact sports will predispose the child to injury and bleeding episodes.
Limit use of helmets and padding of cause joints during participation in contact sports activities.	Daily use of these measures may the child to feel ostracized or may create emotional discomfort.
Maintain close supervision during play time to minimize injuries.	Prevent bleeding related to trauma in the child’s environment.
Institute the following measures to control and halt all bleeding episodes:
Apply manual or mechanical pressure (10 to 15 mins) if active bleeding is observed.	Allows clot formation.
Immobilize and elevate affected extremity above the heart	Decrease blood flow to control bleeding.
Application of cold pack as indicated.	Promote vasoconstriction, but use caution with small children to avoid tissue damage.
Institute factor replacement therapy (based on hospital protocol) and DDAVP (it can be given IV or intranasally)	Control and stop bleeding episode;  Prevent crippling effects from joint bleeding.
Complete bed rest for intramuscular hemorrhage of the lower spine area and non-weight bearing support.	Minimize hemorrhage in muscles of the lower spine.
Assess laboratory values for blood clotting factors (VIII or IX) and vital signs;	These values determine current hemodynamic status and factor replacement therapy guidelines or protocols
Terminate passive range-of-motion exercises after an acute episode of bleeding.	Avoid injury to the affected extremity or joint and to avoid recurrence of bleeding to these.
Educate the family and affected child about signs and symptoms of bleeding, and appropriate interventions to control bleeding at home.	Empowers others with accurate information to identify and manage bleeding episodes.
Instruct parents to include iron-rich foods in diet.	Maintains iron level to prevent anemia.
Advice to wear a medical alert bracelet.	Facilitates accurate diagnosis and treatment in case of an emergency.
Teach parents related to home health maintenance:
The affected child should receive all routine immunizations (use subcutaneous route, recommend pressure and elastic bandage after injections)	Protect the child from childhood communicable diseases.
Reinforce the importance of appropriate dental hygiene program;	Minimize oral trauma.
Reinforce the provision of a safe but normal home environment, such as safety measures that are employed for all children of different ages are recommended; example: for the toddler, gates over stairs but avoid restraining the toddler’s attempt to master motor skills; for the older child, participating in sports activities (use helmets and padding);	Minimize emotional distress during the child’s progression through the different developmental stages.
Provide a home environment free of hazards, including clear pathways, and supervise child during ambulation and play without being overprotective.	Minimize risk of trauma in the home by falls; infants and toddlers frequently fall or sustain injuries.
Instruct parents and child, if age appropriate, to administer factor VIII via IV if signs and symptoms appear, or before dental visits or other possible invasive procedures; instruct in mixing the precipitate, drawing into syringe, venipuncture, and application of pressure following IV, and allow for return demonstration.	Prevents or manages bleeding by factor replacement.
Teach parents and child of possible reactions to IV concentrate administration and that blood is tested for AIDS.	Decreases anxiety caused by risk of  infections such as hepatitis and AIDSfrom replacement products.