PNP Review: Blood Disorders

Anemia

• Anemia: a deficiency of erythrocytes or hemoglobin
• Causes: blood loss, inadequate erythrocyte production, destruction of formed RBCs
• Assessment Findings:
  • Inadequate RBC volume: orthostatic hypotension, thready pulses, oliguria, heart murmur
  • Compensatory mechanisms for lost RBC function: tachycardia, tachypnea, cool, clammy skin, amenorrhea
  • Decreased RBC function: dyspnea, chest discomfort, acidosis, headache, vertigo, pallor

Hypovolemic Anemia

• Causes: sudden loss of large volume, chronic loss of small amounts of blood
• Assessment Findings:
  • Extreme pallor, tachycardia, hypotension, reduced urine output, altered consciousness, fatigue, chills, rapid respiratory rate
• Medical Management:
  • Blood transfusions: treating underlying condition or chronic blood loss
  • Administration of oral, IV, or IM iron: restore hemoglobin

Iron Deficiency Anemia

• Iron Deficiency Anemia: insufficient iron to produce hemoglobin
• Assessment Findings:
  • Reduced energy, feel cold all the time, fatigue and dyspnea with minor physical exertion, rapid heart rate even at rest, decreased hemoglobin, hematocrit, and serum iron levels
• Medical Management:
  • Foods high in iron, Blood transfusion
• Nursing Management:
  • Increase iron intake, collaborate with dietitian, administer iron supplement (IM Z-track)

Sickle Cell Anemia

• Sickle Cell Anemia: Hemoglobin A is replaced by Hemoglobin S; sickle- or crescent-shaped erythrocytes from inadequate oxygen supply to blood
• Hereditary; sickle cell crisis
• Chronic hemolytic anemia
• Assessment Findings:
  • Jaundice, tachycardia, dyspnea, cardiomegaly, and dysrhythmias; stroke, acute chest syndrome
• Diagnostic Findings:
  • Sickledex test; hemoglobin electrophoresis
• Medical Management:
  • Supportive treatment: regular blood transfusions; bone marrow transplantation; prophylactic antibiotic therapy
  • Sickle cell crisis: narcotic analgesia, O2, bed rest, IV fluids, meds

Other Anemias

• Hemolytic Anemia: Chronic premature erythrocyte destruction
• Assessment Findings:
  • Jaundice, enlarged spleen, shock
• Medical Management:
  • Removing the cause; corticosteroids; blood transfusions
• Surgical Management:
  • Splenectomy
• Nursing Management:
  • Health history, supportive care, medication, teaching measures of self-care, arrange follow-up evaluations

Thalassemias

• Thalassemias: hereditary hemolytic anemia
• Types: alpha-thalassemias, beta-thalassemias
• Assessment Findings:
  • Cooley's anemia: bronzing of the skin
• Medical Management:
  • Symptomatic, frequent transfusions, iron chelation therapy
• Nursing Management:
  • Bed rest, protect from infection, closely monitor blood transfusion

Pernicious Anemia

• Pernicious Anemia: lack of intrinsic factor necessary for absorption of vitamin B12
• Degenerative changes in nervous system
• Secondary to surgical removal of stomach or small bowel resection
• Assessment Findings:
  • Stomatitis, glossitis, digestive disturbances; diarrhea; dyspnea with minimal exertion, jaundice, irritability, confusion, depression, numbness and tingling in arms and legs, ataxia
• Diagnostic Findings:
  • Blood and bone marrow studies; Schilling test, blood smear
• Medical Management:
  • IM vitamin B12
  • Physical therapy for permanent neurologic deficits
• Nursing Management:
  • Glossitis and stomatitis: soft, bland diet; small, frequent meals; oral care
  • Permanent neurologic deficit: encourage and assist with ambulation, supervision
  • Teaching: administration of vitamin B12; diet

Folic Acid Deficiency Anemia

• Folic Acid Deficiency Anemia: immature erythrocytes; insufficient dietary intake of foods rich in folic acid
• Assessment Findings:
  • Severe fatigue, sore and beefy-red tongue, dyspnea, nausea, anorexia, headaches, weakness, light-headedness
• Diagnostic Findings:
  • Schilling test
• Medical Management:
  • Folic acid supplements; balanced diet
• Nursing Management:
  • Teaching: diet, oral hygiene, rest promotion

Erythrocytosis

• Polycythemia vera: increase in circulating erythrocytes and leukocytes
• Rapid proliferation of blood cells produced by the bone marrow; cause is unknown
• Assessment Findings:
  • Reddish-purple face and lips, fatigue, weakness, exertional dyspnea
• Diagnostic Findings:
  • Elevated blood cell count, platelets and WBC counts elevated, abnormal serum K+ and uric acid
• Medical Management:
  • Phlebotomy, radio phosphorus, and radiotherapy

Leukocytosis

• Leukocytosis: proliferation of leukocytes, usually in immature form
• Four types according to dysfunctional bone marrow stem cell line (Acute and Chronic forms of lymphocytic and myelogenous leukemia)
• Precipitating factors: genetic correlation
• Assessment Findings:
  • Severe anemia, infections, fatigue, easy bruising, fever, enlarged spleen and lymph nodes, internal or external bleeding
• Medical Management:
  • Antineoplastic drugs, transfusions, Transplantation: bone marrow; stem cell
• Nursing Process:
  • Assessment: history of symptoms; physical assessment, laboratory results; assess neutrophil
  • Diagnosis and Planning:
    • Risks: infection, hemorrhage, activity intolerance, disturbed body image, anxiety, and fear
  • Interventions:
    • Monitor platelet counts, assess for signs of bruising and petechiae; report hematuria or epistaxis (nosebleed)
    • Acknowledge client's anxieties and fears, reassure PT

Multiple Myeloma

• Multiple Myeloma: malignancy involving plasma cells
• Osteoclasts break down bone cells, resulting in increased blood calcium and pathologic fractures
• Osteolytic tumors: "punched-out" or "honeycombed" appearance in bones
• Assessment Findings:
  • Bone Pain, infection, symptoms of anemia, bruising, nosebleeds, renal calculi
• Diagnostic Findings:
  • Skeletal radiographic studies: bone lesions; increased serum calcium levels, bone marrow aspiration
• Medical Management:
  • Steroids, anticancer drugs, antibiotics
  • Analgesics, blood transfusions
  • Back braces, body casts
  • Surgical Management: transplantation: bone marrow; stem cell
• Nursing Management:
  • Assess pain, signs of infection (increased WBC, Fever), fatigue, bleeding, thrombus formation, urine
  • Analgesics, ambulation (caution-fracture), fluid intake I&O, safety, Prevent infection

Agranulocytosis

• Agranulocytosis: decrease in production of granulocytes
• Neutrophils, Basophils, Eosinophils
• Assessment Findings:
  • Fatigue, fever, chills, headache, opportunistic infections
• Medical Management:
  • Remove cause; drugs: human granulocyte colony-stimulating factor
• Nursing Management:
  • Drug assessment, protective isolation (neutropenic); visitor restriction–NO flowers, fruit

Aplastic Anemia

• Pancytopenia: Aplastic Anemia: pancytopenia: numbers of all cells reduced
• Causes: autoimmune, exposure to toxic chemicals, radiation, drug therapy
• Assessment Findings:
  • Weakness, fatigue, opportunistic infections, Unusual bleeding, petechiae, ecchymosis
  • Enlarged spleen/abdominal pain
• Diagnostic Findings:
  • CBC- blood cell count; bone marrow aspiration
• Medical Management:
  • Withdrawal of causative agent, Transfusions, antibiotics, corticosteroids, Transplantations: bone marrow; autologous stem cell
• Nursing Management:
  • History, physical assessment, symptoms, Infection prevention measures/isolation
  • Nutrition; modify oral hygiene, Monitoring of blood transfusion

Coagulopathies

• Thrombocytopenia: platelet manufacture by bone marrow is decreased or platelet destruction by the spleen is increased (Splenomegaly)
• Causes: leukemia; malignant blood diseases, severe infections
• Assessment Findings:
  • Purpura (purple/reddish), bleeding, internal hemorrhage (GI)
• Medical Management:
  • Eliminate cause; corticosteroids, transfusions
  • Surgical Management: splenectomy
• Nursing Management:
  • Manage/minimize bleeding: Apply pressure/tourniquet, ADR; taper corticosteroid dosage/frequency

Hemophilia

• Hemophilia: clotting factor; inherited: mother to son
• Assessment Findings:
  • Oozing; severe bleeding, bleeding in joints

Anemia

• Anemia: a deficiency of erythrocytes or hemoglobin
• Causes: blood loss, inadequate erythrocyte production, destruction of formed RBCs
• Assessment Findings:
  • Inadequate RBC volume: orthostatic hypotension, thready pulses, oliguria, heart murmur
  • Compensatory mechanisms for lost RBC function: tachycardia, tachypnea, cool, clammy skin, amenorrhea
  • Decreased RBC function: dyspnea, chest discomfort, acidosis, headache, vertigo, pallor

Hypovolemic Anemia

• Causes: sudden loss of large volume, chronic loss of small amounts of blood
• Assessment Findings:
  • Extreme pallor, tachycardia, hypotension, reduced urine output, altered consciousness, fatigue, chills, rapid respiratory rate
• Medical Management:
  • Blood transfusions: treating underlying condition or chronic blood loss
  • Administration of oral, IV, or IM iron: restore hemoglobin

Iron Deficiency Anemia

• Iron Deficiency Anemia: insufficient iron to produce hemoglobin
• Assessment Findings:
  • Reduced energy, feel cold all the time, fatigue and dyspnea with minor physical exertion, rapid heart rate even at rest, decreased hemoglobin, hematocrit, and serum iron levels
• Medical Management:
  • Foods high in iron, Blood transfusion
• Nursing Management:
  • Increase iron intake, collaborate with dietitian, administer iron supplement (IM Z-track)

Sickle Cell Anemia

• Sickle Cell Anemia: Hemoglobin A is replaced by Hemoglobin S; sickle- or crescent-shaped erythrocytes from inadequate oxygen supply to blood
• Hereditary; sickle cell crisis
• Chronic hemolytic anemia
• Assessment Findings:
  • Jaundice, tachycardia, dyspnea, cardiomegaly, and dysrhythmias; stroke, acute chest syndrome
• Diagnostic Findings:
  • Sickledex test; hemoglobin electrophoresis
• Medical Management:
  • Supportive treatment: regular blood transfusions; bone marrow transplantation; prophylactic antibiotic therapy
  • Sickle cell crisis: narcotic analgesia, O2, bed rest, IV fluids, meds

Other Anemias

• Hemolytic Anemia: Chronic premature erythrocyte destruction
• Assessment Findings:
  • Jaundice, enlarged spleen, shock
• Medical Management:
  • Removing the cause; corticosteroids; blood transfusions
• Surgical Management:
  • Splenectomy
• Nursing Management:
  • Health history, supportive care, medication, teaching measures of self-care, arrange follow-up evaluations

Thalassemias

• Thalassemias: hereditary hemolytic anemia
• Types: alpha-thalassemias, beta-thalassemias
• Assessment Findings:
  • Cooley's anemia: bronzing of the skin
• Medical Management:
  • Symptomatic, frequent transfusions, iron chelation therapy
• Nursing Management:
  • Bed rest, protect from infection, closely monitor blood transfusion

Pernicious Anemia

• Pernicious Anemia: lack of intrinsic factor necessary for absorption of vitamin B12
• Degenerative changes in nervous system
• Secondary to surgical removal of stomach or small bowel resection
• Assessment Findings:
  • Stomatitis, glossitis, digestive disturbances; diarrhea; dyspnea with minimal exertion, jaundice, irritability, confusion, depression, numbness and tingling in arms and legs, ataxia
• Diagnostic Findings:
  • Blood and bone marrow studies; Schilling test, blood smear
• Medical Management:
  • IM vitamin B12
  • Physical therapy for permanent neurologic deficits
• Nursing Management:
  • Glossitis and stomatitis: soft, bland diet; small, frequent meals; oral care
  • Permanent neurologic deficit: encourage and assist with ambulation, supervision
  • Teaching: administration of vitamin B12; diet

Folic Acid Deficiency Anemia

• Folic Acid Deficiency Anemia: immature erythrocytes; insufficient dietary intake of foods rich in folic acid
• Assessment Findings:
  • Severe fatigue, sore and beefy-red tongue, dyspnea, nausea, anorexia, headaches, weakness, light-headedness
• Diagnostic Findings:
  • Schilling test
• Medical Management:
  • Folic acid supplements; balanced diet
• Nursing Management:
  • Teaching: diet, oral hygiene, rest promotion

Erythrocytosis

• Polycythemia vera: increase in circulating erythrocytes and leukocytes
• Rapid proliferation of blood cells produced by the bone marrow; cause is unknown
• Assessment Findings:
  • Reddish-purple face and lips, fatigue, weakness, exertional dyspnea
• Diagnostic Findings:
  • Elevated blood cell count, platelets and WBC counts elevated, abnormal serum K+ and uric acid
• Medical Management:
  • Phlebotomy, radio phosphorus, and radiotherapy

Leukocytosis

• Leukocytosis: proliferation of leukocytes, usually in immature form
• Four types according to dysfunctional bone marrow stem cell line (Acute and Chronic forms of lymphocytic and myelogenous leukemia)
• Precipitating factors: genetic correlation
• Assessment Findings:
  • Severe anemia, infections, fatigue, easy bruising, fever, enlarged spleen and lymph nodes, internal or external bleeding
• Medical Management:
  • Antineoplastic drugs, transfusions, Transplantation: bone marrow; stem cell
• Nursing Process:
  • Assessment: history of symptoms; physical assessment, laboratory results; assess neutrophil
  • Diagnosis and Planning:
    • Risks: infection, hemorrhage, activity intolerance, disturbed body image, anxiety, and fear
  • Interventions:
    • Monitor platelet counts, assess for signs of bruising and petechiae; report hematuria or epistaxis (nosebleed)
    • Acknowledge client's anxieties and fears, reassure PT

Multiple Myeloma

• Multiple Myeloma: malignancy involving plasma cells
• Osteoclasts break down bone cells, resulting in increased blood calcium and pathologic fractures
• Osteolytic tumors: "punched-out" or "honeycombed" appearance in bones
• Assessment Findings:
  • Bone Pain, infection, symptoms of anemia, bruising, nosebleeds, renal calculi
• Diagnostic Findings:
  • Skeletal radiographic studies: bone lesions; increased serum calcium levels, bone marrow aspiration
• Medical Management:
  • Steroids, anticancer drugs, antibiotics
  • Analgesics, blood transfusions
  • Back braces, body casts
  • Surgical Management: transplantation: bone marrow; stem cell
• Nursing Management:
  • Assess pain, signs of infection (increased WBC, Fever), fatigue, bleeding, thrombus formation, urine
  • Analgesics, ambulation (caution-fracture), fluid intake I&O, safety, Prevent infection

Agranulocytosis

• Agranulocytosis: decrease in production of granulocytes
• Neutrophils, Basophils, Eosinophils
• Assessment Findings:
  • Fatigue, fever, chills, headache, opportunistic infections
• Medical Management:
  • Remove cause; drugs: human granulocyte colony-stimulating factor
• Nursing Management:
  • Drug assessment, protective isolation (neutropenic); visitor restriction–NO flowers, fruit

Aplastic Anemia

• Pancytopenia: Aplastic Anemia: pancytopenia: numbers of all cells reduced
• Causes: autoimmune, exposure to toxic chemicals, radiation, drug therapy
• Assessment Findings:
  • Weakness, fatigue, opportunistic infections, Unusual bleeding, petechiae, ecchymosis
  • Enlarged spleen/abdominal pain
• Diagnostic Findings:
  • CBC- blood cell count; bone marrow aspiration
• Medical Management:
  • Withdrawal of causative agent, Transfusions, antibiotics, corticosteroids, Transplantations: bone marrow; autologous stem cell
• Nursing Management:
  • History, physical assessment, symptoms, Infection prevention measures/isolation
  • Nutrition; modify oral hygiene, Monitoring of blood transfusion

Coagulopathies

• Thrombocytopenia: platelet manufacture by bone marrow is decreased or platelet destruction by the spleen is increased (Splenomegaly)
• Causes: leukemia; malignant blood diseases, severe infections
• Assessment Findings:
  • Purpura (purple/reddish), bleeding, internal hemorrhage (GI)
• Medical Management:
  • Eliminate cause; corticosteroids, transfusions
  • Surgical Management: splenectomy
• Nursing Management:
  • Manage/minimize bleeding: Apply pressure/tourniquet, ADR; taper corticosteroid dosage/frequency

Hemophilia

• Hemophilia: clotting factor; inherited: mother to son
• Assessment Findings:
  • Oozing; severe bleeding, bleeding in joints

Anemia

• Anemia: a deficiency of erythrocytes or hemoglobin
• Causes: blood loss, inadequate erythrocyte production, destruction of formed RBCs
• Assessment Findings:
  • Inadequate RBC volume: orthostatic hypotension, thready pulses, oliguria, heart murmur
  • Compensatory mechanisms for lost RBC function: tachycardia, tachypnea, cool, clammy skin, amenorrhea
  • Decreased RBC function: dyspnea, chest discomfort, acidosis, headache, vertigo, pallor

Hypovolemic Anemia

• Causes: sudden loss of large volume, chronic loss of small amounts of blood
• Assessment Findings:
  • Extreme pallor, tachycardia, hypotension, reduced urine output, altered consciousness, fatigue, chills, rapid respiratory rate
• Medical Management:
  • Blood transfusions: treating underlying condition or chronic blood loss
  • Administration of oral, IV, or IM iron: restore hemoglobin

Iron Deficiency Anemia

• Iron Deficiency Anemia: insufficient iron to produce hemoglobin
• Assessment Findings:
  • Reduced energy, feel cold all the time, fatigue and dyspnea with minor physical exertion, rapid heart rate even at rest, decreased hemoglobin, hematocrit, and serum iron levels
• Medical Management:
  • Foods high in iron, Blood transfusion
• Nursing Management:
  • Increase iron intake, collaborate with dietitian, administer iron supplement (IM Z-track)

Sickle Cell Anemia

• Sickle Cell Anemia: Hemoglobin A is replaced by Hemoglobin S; sickle- or crescent-shaped erythrocytes from inadequate oxygen supply to blood
• Hereditary; sickle cell crisis
• Chronic hemolytic anemia
• Assessment Findings:
  • Jaundice, tachycardia, dyspnea, cardiomegaly, and dysrhythmias; stroke, acute chest syndrome
• Diagnostic Findings:
  • Sickledex test; hemoglobin electrophoresis
• Medical Management:
  • Supportive treatment: regular blood transfusions; bone marrow transplantation; prophylactic antibiotic therapy
  • Sickle cell crisis: narcotic analgesia, O2, bed rest, IV fluids, meds

Other Anemias

• Hemolytic Anemia: Chronic premature erythrocyte destruction
• Assessment Findings:
  • Jaundice, enlarged spleen, shock
• Medical Management:
  • Removing the cause; corticosteroids; blood transfusions
• Surgical Management:
  • Splenectomy
• Nursing Management:
  • Health history, supportive care, medication, teaching measures of self-care, arrange follow-up evaluations

Thalassemias

• Thalassemias: hereditary hemolytic anemia
• Types: alpha-thalassemias, beta-thalassemias
• Assessment Findings:
  • Cooley's anemia: bronzing of the skin
• Medical Management:
  • Symptomatic, frequent transfusions, iron chelation therapy
• Nursing Management:
  • Bed rest, protect from infection, closely monitor blood transfusion

Pernicious Anemia

• Pernicious Anemia: lack of intrinsic factor necessary for absorption of vitamin B12
• Degenerative changes in nervous system
• Secondary to surgical removal of stomach or small bowel resection
• Assessment Findings:
  • Stomatitis, glossitis, digestive disturbances; diarrhea; dyspnea with minimal exertion, jaundice, irritability, confusion, depression, numbness and tingling in arms and legs, ataxia
• Diagnostic Findings:
  • Blood and bone marrow studies; Schilling test, blood smear
• Medical Management:
  • IM vitamin B12
  • Physical therapy for permanent neurologic deficits
• Nursing Management:
  • Glossitis and stomatitis: soft, bland diet; small, frequent meals; oral care
  • Permanent neurologic deficit: encourage and assist with ambulation, supervision
  • Teaching: administration of vitamin B12; diet

Folic Acid Deficiency Anemia

• Folic Acid Deficiency Anemia: immature erythrocytes; insufficient dietary intake of foods rich in folic acid
• Assessment Findings:
  • Severe fatigue, sore and beefy-red tongue, dyspnea, nausea, anorexia, headaches, weakness, light-headedness
• Diagnostic Findings:
  • Schilling test
• Medical Management:
  • Folic acid supplements; balanced diet
• Nursing Management:
  • Teaching: diet, oral hygiene, rest promotion

Erythrocytosis

• Polycythemia vera: increase in circulating erythrocytes and leukocytes
• Rapid proliferation of blood cells produced by the bone marrow; cause is unknown
• Assessment Findings:
  • Reddish-purple face and lips, fatigue, weakness, exertional dyspnea
• Diagnostic Findings:
  • Elevated blood cell count, platelets and WBC counts elevated, abnormal serum K+ and uric acid
• Medical Management:
  • Phlebotomy, radio phosphorus, and radiotherapy

Leukocytosis

• Leukocytosis: proliferation of leukocytes, usually in immature form
• Four types according to dysfunctional bone marrow stem cell line (Acute and Chronic forms of lymphocytic and myelogenous leukemia)
• Precipitating factors: genetic correlation
• Assessment Findings:
  • Severe anemia, infections, fatigue, easy bruising, fever, enlarged spleen and lymph nodes, internal or external bleeding
• Medical Management:
  • Antineoplastic drugs, transfusions, Transplantation: bone marrow; stem cell
• Nursing Process:
  • Assessment: history of symptoms; physical assessment, laboratory results; assess neutrophil
  • Diagnosis and Planning:
    • Risks: infection, hemorrhage, activity intolerance, disturbed body image, anxiety, and fear
  • Interventions:
    • Monitor platelet counts, assess for signs of bruising and petechiae; report hematuria or epistaxis (nosebleed)
    • Acknowledge client's anxieties and fears, reassure PT

Multiple Myeloma

• Multiple Myeloma: malignancy involving plasma cells
• Osteoclasts break down bone cells, resulting in increased blood calcium and pathologic fractures
• Osteolytic tumors: "punched-out" or "honeycombed" appearance in bones
• Assessment Findings:
  • Bone Pain, infection, symptoms of anemia, bruising, nosebleeds, renal calculi
• Diagnostic Findings:
  • Skeletal radiographic studies: bone lesions; increased serum calcium levels, bone marrow aspiration
• Medical Management:
  • Steroids, anticancer drugs, antibiotics
  • Analgesics, blood transfusions
  • Back braces, body casts
  • Surgical Management: transplantation: bone marrow; stem cell
• Nursing Management:
  • Assess pain, signs of infection (increased WBC, Fever), fatigue, bleeding, thrombus formation, urine
  • Analgesics, ambulation (caution-fracture), fluid intake I&O, safety, Prevent infection

Agranulocytosis

• Agranulocytosis: decrease in production of granulocytes
• Neutrophils, Basophils, Eosinophils
• Assessment Findings:
  • Fatigue, fever, chills, headache, opportunistic infections
• Medical Management:
  • Remove cause; drugs: human granulocyte colony-stimulating factor
• Nursing Management:
  • Drug assessment, protective isolation (neutropenic); visitor restriction–NO flowers, fruit

Aplastic Anemia

• Pancytopenia: Aplastic Anemia: pancytopenia: numbers of all cells reduced
• Causes: autoimmune, exposure to toxic chemicals, radiation, drug therapy
• Assessment Findings:
  • Weakness, fatigue, opportunistic infections, Unusual bleeding, petechiae, ecchymosis
  • Enlarged spleen/abdominal pain
• Diagnostic Findings:
  • CBC- blood cell count; bone marrow aspiration
• Medical Management:
  • Withdrawal of causative agent, Transfusions, antibiotics, corticosteroids, Transplantations: bone marrow; autologous stem cell
• Nursing Management:
  • History, physical assessment, symptoms, Infection prevention measures/isolation
  • Nutrition; modify oral hygiene, Monitoring of blood transfusion

Coagulopathies

• Thrombocytopenia: platelet manufacture by bone marrow is decreased or platelet destruction by the spleen is increased (Splenomegaly)
• Causes: leukemia; malignant blood diseases, severe infections
• Assessment Findings:
  • Purpura (purple/reddish), bleeding, internal hemorrhage (GI)
• Medical Management:
  • Eliminate cause; corticosteroids, transfusions
  • Surgical Management: splenectomy
• Nursing Management:
  • Manage/minimize bleeding: Apply pressure/tourniquet, ADR; taper corticosteroid dosage/frequency

Hemophilia

• Hemophilia: clotting factor; inherited: mother to son
• Assessment Findings:
  • Oozing; severe bleeding, bleeding in joints