Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse in a pediatric emergency department. A 7-year-old boy with known severe hemophilia A is brought in by his anxious parents after he fell off the monkey bars, hitting his head. He is alert but complaining of a headache and seems more irritable than usual.
Nursing Intervention Strategy:- 1Immediate Action (Simultaneous if possible)• Airway, Breathing, Circulation (ABC) Assessment: Ensure patent airway, adequate breathing, and circulation.
• Activate Emergency Protocol: Notify the physician/hematologist STAT. While waiting for orders, prepare the factor VIII concentrate from the unit's specialized refrigerator. In many centers, a standing protocol allows nurses to initiate factor administration for suspected intracranial hemorrhage (ICH) immediately.
• Brief, Targeted Assessment: Quickly obtain a history (time of injury, loss of consciousness, vomiting) and perform a baseline neurological assessment (Glasgow Coma Scale (GCS), pupil check, limb movement).
- 2Definitive Treatment Administration• Two-Patient Identifiers: Confirm patient identity and allergy status.
• Verify the Product: Check the factor VIII vial against the prescription for dose, route (IV), and expiration. This is a high-alert medication.
• Administer IV: Administer the calculated dose via IV push or short infusion as per protocol. Use a dedicated line if possible. Monitor closely for signs of reaction during infusion.
- 3Concurrent Supportive Care & Monitoring• Neurological Monitoring: After factor administration, institute neurological checks every 15-30 minutes (or as ordered) to monitor for signs of increasing ICP (decreasing GCS, unequal pupils, vomiting, hypertension with bradycardia).
• Environmental Management: Elevate the head of the bed 30 degrees, maintain a quiet, dimly lit environment to minimize stimulation and ICP spikes. Enforce strict bed rest.
• Diagnostic Coordination: Prepare the child for a STAT head CT scan once stable, ensuring he is accompanied by a nurse.
Patient Safety and Precautions:
• Never Delay Factor for Imaging: In suspected ICH, factor is given first. Do not wait for CT confirmation.
• Bleeding Precautions: Avoid unnecessary venipunctures, IM injections, or rectal temps. Use soft toothbrushes.
• Factor VIII Storage & Handling: Store according to manufacturer guidelines (often refrigerated). Do not shake vigorously. Reconstitute carefully using aseptic technique.
Nursing Procedure & Medication Flow
Procedure: Administering Factor VIII Concentrate
1. Obtain order/verify protocol for ICH dose (often 50 units/kg or to achieve 100% factor level).
2. Gather supplies: Factor VIII vial, sterile diluent, syringe, needle, alcohol swabs, IV access supplies.
3. Perform hand hygiene and don gloves.
4. Reconstitute powder with provided diluent, gently rolling vial to mix. Do not shake.
5. Draw up calculated dose into syringe.
6. Perform two-nurse verification (or scan barcode if available) against the MAR and patient ID.
7. Administer via IV push over 1-5 minutes (per product guidelines) through a patent IV line.
8. Monitor vital signs before, during, and after infusion. Watch for tachycardia, flushing, fever, chills (signs of reaction).
9. Document: Lot number, expiration, dose, time, route, site, and patient response.
A Word from Your Senior Nurse
"Nursing a child with hemophilia in crisis requires you to be a calm, swift, and knowledgeable advocate. That moment when you hang that factor VIII bag is the moment you are most directly saving brain function. Your assessments before and after tell the story of your intervention's success. In pediatrics, remember that a child's change in behavior—like new irritability or lethargy—can be the most sensitive sign of rising intracranial pressure. Trust your assessment skills, but never let monitoring delay the life-saving drug. This blend of critical thinking, skilled procedure, and compassionate care is what makes nursing indispensable."