Question

The nurse is caring for an adult with hemophilia. Which clinical manifestation causes the nurse the most concern? A. Hemarthrosis of the elbow B. Bruise of the ankle C. Oozing of blood at the IV site D. Unilateral numbness and lack of movement of arm

Short answer

Answer: D. Unilateral numbness and lack of movement of arm

Step-by-step solution

Understand each option

We need to understand each option and the potential risks associated with each clinical manifestation to make an informed decision: A. Hemarthrosis of the elbow: Hemarthrosis is bleeding into a joint space, which can cause pain, swelling, and difficulty moving the joint. B. Bruise of the ankle: A bruise is the damaged blood vessels under the skin, and although this can be painful, it is often not as concerning as other symptoms. C. Oozing of blood at the IV site: Continuous oozing of blood from the IV site could indicate a problem with clotting, which could be problematic. D. Unilateral numbness and lack of movement of arm: This symptom might suggest nerve injury or a more serious condition, like a stroke.

Analyze the potential risks

Now, we will analyze the risks associated with each symptom: A. Hemarthrosis can cause long-term joint damage, pain, and mobility issues. B. A bruise is usually a minor problem and is not the most concerning symptom. C. Oozing of blood at an IV site can lead to blood loss and may require intervention to stop the bleeding. However, it can also be relatively easily managed. D. Unilateral numbness and lack of movement in the arm could be an indicator of nerve injury or a more serious neurological condition, like a stroke, which can have severe consequences if not acted upon promptly.

Determine the most concerning symptom

Based on the potential risks and consequences analyzed in step 2, the most concerning clinical manifestation for the nurse is: D. Unilateral numbness and lack of movement of arm This is the most concerning symptom because it might indicate a neurological issue or stroke, which requires immediate attention and could have severe consequences if left untreated.

Key concepts

Nursing Assessment

Nursing assessment is a critical skill every nurse must master. It's the foundation of caregiving and involves gathering essential data about a patient's health to guide care plans and interventions. When assessing a patient, understanding their symptoms and how they present is key. Nurses must be keen observers, noting any changes or abnormalities in the patient’s condition.
For patients with conditions like hemophilia, it's particularly important to recognize symptoms that deviate from the norm. Hemophilia can result in unusual bleeding and bruising due to the body’s inability to clot blood properly. Thus, recognizing symptoms such as hemarthrosis, bruises, or continuous bleeding is vital.

• Start by observing the patient overall – assess their skin for unusual bruises or rashes.
• Conduct a head-to-toe examination and use clinical equipment as necessary.
• Ask the patient about any unusual feelings, like numbness or tingling sensations.
• Record all findings meticulously – this helps in formulating an accurate care plan.

Good assessment directly impacts the patient's treatment and recovery process. It helps in the early detection of complications and tailoring interventions that can prevent further deterioration.

Clinical Manifestations

Clinical manifestations refer to the signs and symptoms that are associated with a specific disease or condition. They provide valuable clues about what is happening inside the body. For nurses, understanding these manifestations is crucial because it can help in prioritizing care and responding appropriately to a patient's needs.
In the case of hemophilia, typical clinical manifestations include:

• Hemarthrosis: This is bleeding into the joints, often seen in the elbows and knees. It can lead to joint pain, swelling, and eventually permanent joint damage if not treated promptly.
• Bruising: Patients may experience extensive bruising due to minor bumps or injuries, caused by low clotting ability.
• Oozing at the IV Site: This continuous bleeding can be a sign of the body's struggle to clot.
• Neurological Symptoms: Signs like unilateral numbness could be indicative of nerve injury or a stroke, which is potentially life-threatening and requires immediate action.

Recognizing these clinical manifestations helps prioritize interventions that address the most dangerous symptoms first, ensuring patient safety and effective management.

Patient Care

Patient care is the comprehensive approach of attending to the physical and emotional needs of a person receiving medical treatment. For a nurse, this means more than just addressing symptoms; it's about supporting the whole person through their health journey.
Effective patient care relies on the early recognition of clinical manifestations and tailored interventions.

• Monitor Regularly: Keep a close watch on vital signs and any changes in symptoms.
• Prioritize Immediate Concerns: In cases like hemophilia, signs of neurological problems should trigger quick action due to their severity.
• Educate and Communicate: Talk to patients about their condition and symptoms, explaining both the importance of each manifestation and how to manage them.
• Support Emotional Well-Being: Encourage open dialogue about fears and concerns, and provide resources for further psychological support if necessary.
• Coordinate Care: Work alongside other healthcare professionals to ensure consistency and quality in the care plan.

Implementing these strategies not only helps manage the current condition but also fosters resilience and promotes better long-term health outcomes for the patient.