A 7-year-old child with hemophilia A is admitted to the pediatric unit after a fall that resulted in suspected internal bleeding. Which nursing intervention should be the highest priority?
The nurse is caring for a child with hemophilia A who has signs of internal bleeding following a traumatic injury.
1Administer aspirin for pain management to keep the child comfortable
2Encourage active range of motion exercises to prevent joint stiffness
3Monitor vital signs frequently and assess for signs of shock✓ 정답
4Apply heat packs to affected areas to promote circulation
해설
Children with hemophilia are at high risk for severe bleeding complications due to deficient clotting factors. Frequent vital sign monitoring and shock assessment are critical for early detection of hemorrhage progression.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a child with Hemophilia A who has sustained trauma and is suspected of having Internal bleeding. Hemophilia A is a congenital bleeding disorder caused by a deficiency of Factor VIII. The primary pathophysiological concern is uncontrolled hemorrhage, which can lead to Hypovolemic shock and potentially life-threatening complications. The nursing process dictates that the first step is always assessment, especially when a patient's condition is unstable or potentially deteriorating.
Answer Rationale: Key Point! The highest priority is always the patient's Airway, Breathing, and Circulation (ABCs). In this scenario, the threat to circulation (bleeding) is the immediate concern. Frequent vital sign monitoring (e.g., tachycardia, hypotension, tachypnea) and assessment for signs of shock (e.g., pallor, cool clammy skin, delayed capillary refill, altered mental status) are critical for early detection of hemorrhage progression. This allows for timely intervention, such as administering Factor VIII concentrate and initiating fluid resuscitation, to prevent circulatory collapse.
Distractor Analysis:
Watch out for confusion! Option ①, administering aspirin, is contraindicated in bleeding disorders. Aspirin is an antiplatelet agent that inhibits platelet aggregation, which would exacerbate bleeding. For pain in hemophilia, acetaminophen is the preferred analgesic.
Option ②, encouraging active range of motion, is incorrect in the acute phase of a bleeding episode, especially with suspected internal or joint (hemarthrosis) bleeding. Movement can worsen bleeding and increase pain. The correct initial intervention is R.I.C.E. (Rest, Ice, Compression, Elevation) for the affected joint or area.
Option ④, applying heat packs, is also contraindicated in acute bleeding. Heat causes vasodilation, which can increase blood flow to the area and worsen hemorrhage. Cold application (ice) is indicated to promote vasoconstriction and reduce swelling.
Related Concepts: The management of hemophilia revolves around preventing and treating bleeding episodes. This includes prophylactic factor replacement, prompt treatment of bleeds with specific clotting factor concentrates, and meticulous avoidance of medications and activities that increase bleeding risk. Patient and family education on injury prevention, recognizing signs of bleeding, and emergency procedures is a cornerstone of long-term care.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a pediatric unit. A 7-year-old boy with known Hemophilia A is brought in by his anxious parents after he fell off his bike. He complains of abdominal pain and his left knee is swollen and painful. He appears pale and is slightly tachycardic.
Nursing Intervention Strategy:
1Immediate Assessment (ABCs)Quickly assess airway and breathing. Then focus on circulation: Obtain vital signs (BP, HR, RR, SpO2) and establish baseline. A heart rate of 120 bpm in a resting 7-year-old is significant. Assess skin color, temperature, capillary refill (>2 seconds is abnormal), and level of consciousness.
2History & PhysicalAsk about the mechanism of injury and location of pain. Gently palpate the abdomen for tenderness or distension (signs of possible internal bleeding). Assess the affected joint for swelling, warmth, and limited range of motion (signs of Hemarthrosis).
3Collaborative CareNotify the physician/NP immediately. Anticipate orders for STAT labs (Hgb/Hct, PT/PTT) and administration of Factor VIII concentrate. Prepare for IV access if not already established.
4Comfort & SafetyApply an ice pack wrapped in a towel to the swollen knee. Keep the child on bed rest with the limb elevated. Provide age-appropriate distraction and administer prescribed acetaminophen for pain—never NSAIDs or aspirin.
Patient Safety and Precautions: Never administer intramuscular (IM) injections to a patient with hemophilia due to the risk of causing a hematoma. Use the smallest gauge needle possible for blood draws and apply firm pressure for at least 5 minutes. Ensure all healthcare team members are aware of the diagnosis and bleeding precautions.
Nursing Procedure & Medication FlowAdministering Factor VIII Concentrate:
1. Verify the order and the specific product (dose in units/kg).
2. Reconstitute the lyophilized powder with the provided sterile diluent. Gently roll the vial; do not shake vigorously to avoid denaturing the protein.
3. Administer via IV push (bolus) or short IV infusion as per protocol, usually over 5-15 minutes. Monitor the infusion site closely.
4. Monitor for effectiveness (reduction in pain/swelling, stabilization of vital signs) and for potential adverse reactions like allergic symptoms or fever.
A Word from Your Senior Nurse
"In pediatrics, a child with hemophilia who has had a fall is a red flag situation. Your eyes and your assessment skills are your best tools. That subtle increase in heart rate or that slight pallor might be the only early clues to significant internal blood loss before the blood pressure drops. Always think ABCs first. Your priority isn't just to 'do something'—it's to assess first to know what the most critical 'something' is. This clinical reasoning is exactly what the NCLEX tests."
Hemophilia A — An X-linked recessive bleeding disorder caused by a deficiency of clotting Factor VIII, leading to prolonged bleeding, especially into joints and muscles.
Hemarthrosis — Bleeding into a joint space, a common and debilitating complication of hemophilia that causes pain, swelling, and can lead to chronic arthropathy.
Factor VIII Concentrate — The definitive treatment for bleeding episodes in Hemophilia A. It is a lyophilized powder of purified Factor VIII that is reconstituted and administered intravenously.
R.I.C.E. — An acronym for the initial management of acute musculoskeletal injuries or bleeds: Rest, Ice, Compression, Elevation. Used in hemophilia to manage joint bleeds.
Hypovolemic Shock — A life-threatening condition caused by a significant loss of blood or fluids, leading to inadequate perfusion of organs. In hemophilia, it is a risk from uncontrolled internal or external hemorrhage.