(From Itano, J., & Taoka, K. [Eds.]. Core curriculum for oncology nursing [4th ed.]. Philadelphia: Elsevier Saunders in collaboration with Oncology Nursing Society.)

1. Assessment

a. Subjective data collection

2) Past medical history

b) Presence of peritoneovenous shunts for ascites fluid containing a number of procoagulant substances

c) Massive blood transfusions, especially those with hemolytic transfusion reactions

d) Transplant rejection

e) Pregnancy and obstetrical complications in female patients of childbearing age

f) Trauma: blunt or penetrating forces

g) Snake bite

h) Respiratory distress syndrome

i) Prolonged extracorporeal circulation

j) Last normal menstrual period: female patients of childbearing age

k) Medications including aspirin, anticoagulants, oral contraceptives, estrogen replacement

l) Allergies

m) Immunization status

b. Objective data collection

2. Analysis: differential nursing diagnoses/collaborative problems

a. Ineffective tissue perfusion: renal, cerebral, peripheral, cardiopulmonary, and gastrointestinal

b. Risk for deficient fluid volume

c. Decreased cardiac output

d. Impaired gas exchange

e. Risk for injury

f. Anxiety/fear

g. Acute pain

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen

c. Establish IV access for administration of crystalloid fluid/blood products/medications

1) Warmed packed red blood cell transfusion: washed cells

2) Platelet concentrates

3) Fresh frozen plasma (FFP)

4) Cryoprecipitate

d. Prepare for/assist with medical interventions

1) Limit number of venipunctures

2) Institute cardiac and pulse oximetry monitoring

3) Apply pressure dressings or sandbags to sites of active bleeding

4) Insert gastric tube and attach to suction

5) Insert indwelling urinary catheter

6) Maintain normothermic body temperature

7) Handle patient gently

8) Assist with hospital admission

e. Administer pharmacologic therapy as ordered

1) Heparin

a) Inhibits thrombin and Xa factor

b) May accelerate bleeding

2) Recombinant human activated protein C (rhAPC)

a) Inhibits factors Va and VIIIa of coagulation cascade

b) Inhibits plasminogen activator inhibitor

3) Aminocaproic acid (Amicar): if heparin-induced bleeding occurs

4) Non-narcotic analgesics

5) Narcotics

4. Evaluation and ongoing monitoring (see Appendix B)

a. Level of consciousness

b. Hemodynamic status

c. Breath sounds and pulse oximetry

d. Cardiac rate and rhythm

e. Intake and output, including overt and covert bleeding

f. Serial laboratory changes: clotting time, platelet count, hematocrit, and hemoglobin

g. Measure abdominal girth every 4 hours if bleeding present

h. Pain relief

B. Hemophilia

Hemophilia is an inherited, sex-linked disorder that occurs most frequently in boys and men. Female family members carry the gene and pass it to their children. There are four types of hemophilia: hemophilia A, hemophilia B, hemophilia C, and von Willebrand’s disease. Hemophilia A (classic hemophilia) is a coagulation disorder caused by a variant form of factor VIII. Severity of the disease is directly related to activity level of factor VIII. Activity level less than 1% is severe and accompanied by spontaneous bleeding. Activity level of 1% to 5% is moderately severe; there is rare spontaneous bleeding but difficulty during surgery or with trauma. Patients with 5% to 10% or greater activity of factor VIII have mild disease with little risk of spontaneous bleeding, but the PTT is prolonged. Bleeding may occur anywhere but characteristically affects joints, deep muscles, urinary tract, and cranial vault (Table 18-1). Immediately following injury, bleeding is usually absent because the initial coagulation step of platelet-plug formation is not affected by hemophilia. Hemophilia B (Christmas disease) results from absence or deficiency of Factor IX. The condition is relatively rare, occurring in 1 in 100,000 persons in the United States, and is clinically indistinguishable from type A, except for treatment. Hemophilia C (Rosenthal’s syndrome) is caused by a deficiency of factor XI. Clinically, it is similar to hemophilia A, but usually has less severe bleeding. Von Willebrand’s disease (angiohemophilia) occurs in male and female patients and is less acute than hemophilia A or B. This type of hemophilia is characterized by defective platelet adherence and decreased factor VIII levels.

Table 18-1 COMMON BLEEDING MANIFESTATIONS IN PATIENTS WITH HEMOPHILIA

Site	Examples
Central nervous system	Intracranial bleeding, most common cause of hemorrhagic death; subdural hematomas occur spontaneously or with minimal trauma
Hemarthroses	Joints, leading to chronic atrophy if not treated aggressively
Hematomas	Soft tissue or muscles, most serious near the neck (airway compromise), extremities (massive blood loss)
Hematuria	Common, but not serious, and source is usually not located
Mucocutaneous tissues	Uncommon, but can be spontaneous from oropharynx, gastrointestinal, epistaxis, or hemoptysis; delayed bleeding after dental extraction can be common
Pseudotumor	Bone cysts that result from unresolved hematomas; usually surgically removed

Modified from Tintinalli, J. E., Kelen, G. D., & Stapczynski, J. S. (2004). Emergency medicine: A comprehensive study guide (6th ed., p 1331). New York: McGraw-Hill.