HISTORY TAKING, ASSESSMENT OF BLEEDING & EXAMINATION OF PATIENT Nairobi, Kenya June 24, 2013

OBJECTIVES Discuss the importance of history taking Describe the approach to taking a history List important questions to ask when assessing a bleed Examine ways to assess different types of bleeding Distinguish severity of bleeding Identify when and how to treat specific bleeding episodes Explain appropriate follow-up

HISTORY AND ASSESSMENT Accurate and detailed history with assessment of bleeding episodes and trauma in individuals with bleeding disorders is essential for determining appropriate care Use age-appropriate approach Get patient and family history Start general (ROS), get specific History and assessment may be as, or more, important as labs/imaging Listen to the patient and family The process is continuous from first notification of event to follow-up

HISTORY AND ASSESSMENT Careful documentation is essential for each step of the process to ensure appropriate care and follow-up

THE 7 HISTORY AND ASSESSMENT QUESTIONS 1.What are the symptoms? 2.How long have the symptoms been present? 3.What treatment was given, and when? 4.Did an injury happen before the symptoms started? 5.Did a similar problem occur in the past? 6.How was that problem treated? 7.Did that treatment resolve the issue?

ASSESSING POTENTIAL BLEEDING EPISODES Most bleeding episodes do not show blood Look for limb favoring or inability to walk Examine ipsilateral and contralateral extremities Early and appropriate treatment of each episode is critical Replacement of the deficient clotting factor is the single most important step in any intervention For serious bleeds, Treat First – Evaluate Second

EVALUATION OF PATIENT Clinical Scenario Patient comes to clinic/ED with bleed Observe patient ̶ Waiting area ̶ Walking to treatment/evaluation room (does the patient limp?) ̶ Getting onto the exam table Get the details of trauma. Are they consistent with the clinical picture?

WAITING AREA ASSESSMENT

INITIAL ASSESSMENT How does he look as you see him in the waiting room? Does he appear to be in distress? Does he answer questions appropriately? Is his demeanor the same as usual?

ASSESSMENT OF GAIT Is he limping? Do his complaints match his actions? What does he do when he thinks you aren’t watching?

DISCREET ASSESSMENT Does he run? Does he appear in pain? Does he jump up onto the examining table? Does he move his limbs normally?

QUESTIONS TO ASK Ask detailed questions about actions that have been taken at home: Immobilization or rest Ice, Compression, Elevation Treatment Product Dose Frequency Timing

HEAD TRAUMA Treat and evaluate ALL reports of head trauma Lack of bruising or hematoma is NOT reassuring! Questions to ask: How did he bump his head? Did he cry? How far did he fall? (degree of impact) Surface of impact? Headache? Loss of consciousness?

HEAD TRAUMA (CONT’D) Careful assessment for other head trauma complications: Evaluate for possible fractures of orbit, cheek, skull if clinically indicated. Ophthalmologic evaluation if eye is involved. Evaluate social situation if injury appears questionable.

HEAD TRAUMA (CONT’D) Assessment of patient with signs of increased intracranial pressure: Always assume bleeding first, then evaluate for other causes Headache, n/v, lethargy: May be flu Family members may also be symptomatic Treat first to cover to 100% Rule out CNS hemorrhage Then, treat symptoms

NECK OR THROAT BLEEDING Assess airway Treat as a serious bleed Prevention −Factor coverage prior to dental procedures −Avoid mandibular block if possible

GI BLEEDING HISTORY History of nose or mouth bleeding ASA? NSAIDS? Alcohol use? Treatment −Timing −Dose

ASSESSMENT OF GI BLEEDING Signs Coffee ground emesis Black, tarry stools Pallor Decreased hemoglobin

GI BLEEDING Risk of significant blood loss −Careful, serial monitoring of hemoglobin levels important Investigate cause Teach patients signs to observe Follow up blood counts after resolution: Need for iron replacement?

JOINT BLEEDING: HISTORY Known injury? Trauma? −May need imaging to rule out fracture/other orthopedic injury Duration of symptoms? Recent bleeding in joint? Recent activities? Target joint? Previous treatment? Prophylaxis? −Breakthrough bleeding may indicate inhibitor or inadequate dose/regimen

JOINT BLEEDING: ASSESSMENT Difficult to assess in young children Observe activities −Unwillingness to use arm or leg? −Eating with opposite hand? −Reaching for toys with one hand? −Crawling instead of walking? −Unwilling to wear shoes?

JOINT BLEEDING: ASSESSMENT (CONT’) Visual exam Measure joint and contralateral joint Range of motion Tenderness Bruising? Pain? Scale of 1-10 Color scale Faces N-PASS

JOINT BLEEDING: EVALUATION Serial measurements to assess progress of treatment Measure in same place Use contralateral joint for comparison

JOINT BLEEDING: EVALUATION (CONT’D)

MUSCLE BLEEDING History: Traumatic injury? Timing of injury? Duration of symptoms? Worsening or improving? Treatment? Pallor, s/s anemia Condition of skin

MUSCLE BLEEDING: ASSESSMENT OF LARGE BLEEDS Careful, serial monitoring of Hgb levels Danger of significant blood loss in large muscle −Quadriceps −Iliopsoas

MUSCLE BLEEDING: ILIOPSOAS Ask patient to lie flat, extend hip and knee Characteristic posturing Decreased ROM hip Palpate for mass in abdomen Observe carefully for parasthesias in thigh Imaging can be helpful −Hip vs. iliopsoas

MUSCLE BLEEDING: ASSESSMENT OF BLEEDING IN SMALL MUSCLES Closed spaces Perform neurovascular checks Calf bleeding: −Observe capillary refill −Careful monitoring of ability to use all toes −Question carefully about numbness/tingling

MUSCLE BLEEDING: OTHER CONSIDERATIONS Helpful to have baseline measurements of arms and legs Dominant limb may be larger May be smaller if on limb with chronic joint bleeding −Can lead to uncertainty when assessing acute hemorrhage

MOUTH BLEEDING Blood loss can be insidious −Monitor Hgb levels Careful history and assessment Observe for: −Pallor, lethargy −Nausea, vomiting −Abdominal pain

SOFT TISSUE BLEEDING Painful to sit or walk? Interferes with activities of daily living? Often not treated

TREATMENT OF SERIOUS BLEEDING Administer factor VIII or IX to achieve high level (70%- 100%) Treat ASAP, before diagnostic evaluation Maintain factor VIII or IX levels above 30% until hemostasis is achieved Additional coverage for invasive procedures Treatment Replace factor as soon as possible Follow local protocols Supportive measures are important

ASSESSMENT OF TREATMENT Maintain communication with patient/family for optimal follow-up Resolution of bleeding as expected? No? −Check weight, dose, frequency −Evaluate for adherence to treatment plan −Evaluate for inhibitor development

SUMMARY History and physical examination are vital to assessment of bleeding Consider age-associated bleeding symptoms Early and adequate treatment is essential Follow-up is key Remember: −Life-threatening bleeding episodes are rare −When identified early and treated appropriately most bleeds can be adequately treated without long-term consequences

ADDITIONAL WFH RESOURCES Hemophilia in Pictures Educator’s Guide Guidelines for the Management of Hemophilia, 2 nd edition Assessment and Management of Pain in Hemophilia Patients Visit the Publications Library at for free copies

JIM MUNN, R.N., M.S. Program Nurse Coordinator University of Michigan HTC, Ann Arbor, MI, USA Chair – WFH Nursing Committee Original author: Regina Butler, RN Hemophilia Nurse Coordinator Clinical Manager, Division of Hematology Children’s Hospital of Philadelphia (CHOP) MERGER AVEC SLIDE 1