HAEMORRHAGE

DISEASE CONDITION:

 INTRODUCTION:

Bleeding, technically known as hemorrhage (American English),

haemorrhage (British English), or hæmorrhage, is the loss of blood from the
circulatory system.Bleeding is a common reason for the application of first measures
and can be Internal or External. The principle difference is whether the blood leaves
the body –External bleeding can be SEEN, whereas in Internal bleeding NO bleeding
can be SEEN.

The complete loss of blood is referred to as Exsanguination, and

Desanguination is a massive blood loss from the circulatory system.

Hemorrhage generally becomes dangerous, or even fatal, when it causes

hypovolemia (low blood volume) or hypotension (low blood pressure). In these
scenarios various mechanisms come into play to maintain the body's homeostasis.
These include the "retro-stress-relaxation" mechanism of cardiac muscle, the
baroreceptor reflex and renal and endocrine responses such as the renin - angiotensin -
aldosterone system (RAAS).

Certain diseases or medical conditions, such as haemophilia and low platelet

count (thrombocytopenia) may increase the risk of bleeding or may allow otherwise
minor bleeds to become health or life threatening. Anticoagulant medications, such as
warfarin can mimic the effects of haemophilia, preventing clotting, and allowing free
blood flow.

Death from hemorrhage can generally occur surprisingly quickly. This is

because of 'positive feedback'. An example of this is 'cardiac repression', when poor
heart contraction depletes blood flow to the heart, causing even poorer heart
contraction. This kind of effect causes death to occur more quickly than expected.
  DEFINITION:

Haemorrhage or Bleeding is termed as loss of blood from the circulatory

system.[1] Bleeding can occur internally, where blood leaks from blood vessels inside
the body or externally, either through a natural opening such as the vagina, mouth or
anus, or through a break in the skin.

 INCIDENCE:

- Both sex are common

- Children and old age group are common
- Annually 25,000 people are affected with mild to massive haemorrhage in
various conditions.

 ETIOLOGY:
 Traumatic:

Traumatic bleeding is caused by some type of injury. There are different

types of wounds which may cause traumatic bleeding. These include:

 Abrasion ; Also called a graze, this is caused by transverse action of a

foreign object against the skin, and usually does not penetrate below
the epidermis
 Excoriation : In common with Abrasion, this is caused by mechanical
destruction of the skin, although it usually has an underlying medical
cause
 Hematoma : (also called a blood tumour) - caused by damage to a
blood vessel that in turn causes blood to collect under the skin.
 Laceration : Irregular wound caused by blunt impact to soft tissue
overlying hard tissue or tearing such as in childbirth. In some
instances, this can also be used to describe an incision.
 Incision :A cut into a body tissue or organ, such as by a scalpel, made
during surgery.
 Puncture Wound : Caused by an object that penetrated the skin and
underlying layers, such as a nail, needle or knife
 Contusion : Also known as a bruise, this is a blunt trauma damaging
tissue under the surface of the skin
 Crushing Injuries : caused by a great or extreme amount of force
applied over a long period of time. The extent of a crushing injury may
not immediately present itself.
 Gunshot wounds :Caused by a projectile weapon, this may include
two external wounds (entry and exit) and a contiguous wound between
the two
 - Penetrating trauma follows the course of the injurious device. As the energy
is applied in a more focused fashion, it requires less energy to cause significant
injury. Any body organ, including bone and brain, can be injured and bleed.

- Haemorrhage may not be readily apparent; internal organs such as the liver,
kidney and spleen may bleed into the abdominal cavity.(Internal Haemorrhage).

 DUE TO UNDERLYING MEDICAL CONDITIONS:

- ANATOMIC DEFORMITIES:

1) Weakness in blood vessels(Aneurysm or Dissection)

2) Ateriovenous malformation
3) Ulceration
4) Tissue death
5) Cancer
6) Infection
7) Deficiency in Vitamin-K production in gut
8) Hemophilla B or Christmas disease (Factor IX)
9) Hemophilla (Factor VIII)
10) NSAID Drugs
11) Condition affecting the “Hemostastic” system include Platelets and
Coagulation System.

 Note:

- Platelets are small blood components that form a plug in the blood vessel
wall that stops bleeding. Platelets also produce a variety of substances that
stimulate the production of a blood clot.

- One of the most common causes of increased bleeding risk is exposure to

non-steroidal anti-inflammatory drugs (or "NSAIDs").

- The prototype for these drugs is aspirin, which inhibits the production of
thromboxane. NSAIDs inhibit the activation of platelets, and thereby
increase the risk of bleeding.

- The effect of aspirin is irreversible; therefore, the inhibitory effect of

aspirin is present until the platelets have been replaced (about ten days).

- Other NSAIDs, such as "ibuprofen" (Motrin) and related drugs, are

reversible and therefore, the effect on platelets is not as long-lived.
 TYPES OF HAEMORRHAGE:

- Hemorrhage is broken down into 4 classes by the American College

of Surgeons' Advanced Trauma Life Support (ATLS).

 Class I Haemorrhage:

- Involves up to 15% of blood volume.

- There is typically no change in vital signs
- Fluid resuscitation is not usually necessary.
-

 Class II Haemorrhage:

- Involves 15-30% of total blood volume.

- Tachycardia (rapid heart beat) with a narrowing of the difference between
the systolic and diastolic blood pressures.
- The body attempts to compensate with peripheral vasoconstriction.
- Skin may start to look pale and be cool to the touch.
- Volume resuscitation with crystaloid (Saline solution or Lactated Ringer's
solution) is all that is typically required.
- Blood transfusion is not typically required.

 Class III Haemorrhage:

- Involves loss of 30-40% of circulating blood volume.

- The patient's blood pressure drops
- Heart rate increases,
- Peripheral perfusion, such as capillary refill worsens, and the mental status
worsens.
- Fluid resuscitation with crystaloid
- Blood transfusion are usually necessary.

 Class IV Haemorrhage:

- Involves loss of >40% of circulating blood volume.

- The limit of the body's compensation is reached and aggressive
resuscitation is required to prevent death.
 CLINICAL MANIFESTATION:

- Pain on vital organs

- Disability
- Hypoxia
- Bruising
- Cyanosis
- Skin colour changes
- Delayed capillary refill
- Pale, Cold and Clammy Skin
- Increased Heart rate
- Rising Pulse rate
- Difference between systolic and diastolic
- Falling Blood Pressure
- Stupor
- Confused mental state
- Thirsty
- Shock
- Moist Skin
- Decreased Urine out put

 DIAGNOSTIC STUDIES:

 HISTORY COLLECTION:

- Site of haemorrhage
- Duration of haemorrhage
- Precipating causes
- Surgical history
- Family history
- Systemic illnesses
- Drugs
- WHO BLEEDING SCALE

 SITE OF HAEMORRHAGE:
- Muscle and joint bleeds indicate coagulatory defect,
- Prolonged haemorrhage from nose, epistaxsis, GI haemorrhage
indicate failure of preventing haemostasis due to platlets decreases,
- Recurrent bleeds at a single site suggest a local structural abnormality.

 DURATION OF HISTORY:
- It may be possible to assess whether the patient has a congential or
acquired disorder.

 PRECIPATING CAUSES:
- Haemorrhage arising spontaneously indicates a more severe deficit than
haemorrhage arises only after trauma.
 SURGICAL HISTORY:

- Enquiry about cell operation is useful in particular dental extraction,

Tonsillectomy and Circumsission, as these are all stressful of the
haematics system.
- Haemorrhage starts immediately after surgery indicates defective
Platelets Plug Formation.
- Bleeding comes after several hours is more indicate of failure of
Platelets Plug Stabilization by fibrin due to coagulation defect.

 FAMILY HISTORY:
- Help in the identification of all type of genetically and hereditary
caused bleeding disorder. Example: Hemophilla.

 SYSTEMIC ILLNESSESS:
- Many diseases of haemorrhage is and its treatment is associated with
the significant bleeding.
- But it is particularly important to consider the possibility of hepatisis,
or renal failure, paraprotemanemia, or connective tissue disease.

 DRUGS:

- Almost any medicine can potentially produce bleeding, either by

depressing bone marrow function with consequent to
thrombocytopenia or by interacting with Warfain.
- NSAID inhibits platelets function effect of aspirin may last upto 10
days of single tablets.

 PHYSICAL EXAMINATION:
 OBSERVATION:
- This examination is to identify and diagnosis the type, duration and
characterise of haemorrhage, and its site.
- Helps to assess the type of haemorrhage, massive haemorrhage etc.
Complete physical examination is to mark and to find the
haemorrhage.

 WHO- BLEEDING SCALE:

Grade-0 No Bleeding.
Grade-1 Petechial Bleeding.
Grade-2 Mild Blood Loss (Clinically Significant).
Grade-3 Gross Blood Loss, Requires Transfusion.
Debilitating Blood Loss, Retinal or
Grade-4
Cerebral associated with Fatality.

 Coagulation Screening Test:

 SITIVATION IN WHICH
S.No: INVESTIGATION NORMAL RANGE
TEST MAY BE ABNORMAL
1) Platelet Count 150-400*10/1 - Thrombocytopenia
-

Thrombocytopenia

- Abnormal platelets function

2) Bleeding Time < 8 min
- Deficiency of Von
Willebrand factor vascular
abnormality.

Prothrombin Time - Deficiencies of Factors II, V,

3) 12-15 Sec
(PT) VII, X,

- Deficiencies of Factors II, V,

VII, IX, X, XI, XII

Activated Platelet
4) Thromboplastin 30-40 Sec
Time (APTT) - Antibiotic against clotting
Factor,

- Lumpus Antigen

5) Fibrinogen 1.5-4.0g/l - Hypofibrinogenous

DIFFERTIAL DIAGNOSIS:

 Aneurysm
 Breakthrough bleeding
 Cerebral hemorrhage
 Coagulation
 Exsanguination - death by bleeding
 Hematemesis - vomiting fresh blood
 Hematochezia - rectal blood
 Hematuria - blood in the urine from urinary bleeding
 Hemophage
 Hemophelia
 Hemoptysis - coughing up blood from the lungs
 Intracerebral hemorrhage - bleeding in the brain caused by the rupture of a
blood vessel within the head. See also hemorrhagic stroke.
  Intracranial hemorrhage
 Postpartum hemorrhage
 Subarachnoid hemorrhage (SAH) implies the presence of blood within the
subarachnoid space from some pathologic process. The common medical use
of the term SAH refers to the nontraumatic types of hemorrhages, usually from
rupture of a berry aneurysm or Ateriovenous malformation (AVM). The scope
of this article is limited to these nontraumatic hemorrhages.
 Upper gastrointestinal bleed
 Vaginal bleeding

 COMPLICATION:

- Hypovolemic Shock

- Infection

- Thrombocytopenia

- Shock / Coma

- Death

TREATMENT:

 FIRST AID: (Initial Management)

o MINOR BLEEDING OR HAEMORRHAGE,

o EMERGENCY BLEEDING CONROL

o BLEEDING FROM BODY CAVITIES,(External Bleeding)

o INTERNAL BLEEDING,

o RISK OF BLOOD CONTAMINATION,

- All people who have been injured should receive a thorough

assessment. It should be divided into a primary and secondary survey
and performed in a stepwise fashion, following the "ABCs".

o PRIMARY ASSESSMENT:
o SECONDARY ASSESSMENT:
 - The Primary survey or assessment examines and verifies that the
patient's Airway is intact, that s/he is Breathing and that Circulation is
working. A similar scheme and mnemonic is used as in CPR.

- During the pulse check of C, attempts should also be made to control

bleeding and to assess perfusion, usually by checking capillary refill

- . Additionally a persons mental status should be assessed (Disability) or

either an AVPU scale or via a formal Glasgow Coma Scale.

- The Secondary survey or assessment is performed by removing of the

cloth on case of minor cases. Examining the patient from head to toe for
other injuries.

- Important aspect is that the survey or assessment should not delay

treatment and transportation if non correctable problem is identified.

o MINOR BLEEDING OR HAEMORRHAGE:

- Minor bleeding is bleeding that falls under a Class I hemorrhage and the
bleeding is easily stopped with pressure.

- The largest danger in a minor wound is infection.

- Haemorrhage can be stopped with direct pressure and elevation, and the
wound should be washed well with soap and water.

- A dressing, typically made of gauze, should be applied. Peroxide or

iodine solutions (such as Betadine) can injure the cells that promote
healing and may actually impair proper wound healing and delay closure.

o EMERGENCY BLEEDING CONROL:

- Severe bleeding poses a very real risk of death to the casualty if not
treated quickly. Therefore, preventing major bleeding should take priority
over other conditions.

- Save failure of the heart or lungs. Most protocols advise the use of direct
pressure, rest and elevation of the wound above the heart to control
bleeding.

- The use of a Tourniquet is not advised in most cases, as it can lead to

unnecessary Necrosis or even loss of a limb.

- Tourniquets should rarely be used as it is usually possible to stop

bleeding by the application of manual pressure.

 NOTE: Immediate management for hemorrhage

- REST,
 - ELEVATION,

- DIRECT PRESSURE,

o BLEEDING FROM BODY CAVITIES: (External Bleeding)

 DESCRIPTION:

- External hemorrhage means loss of blood from the circulatory

system which can be SEEN easily or identified.

 ETIOLOGY:

- There are about Six main categories:

 Abrasion - Also called a graze, this is caused by

transverse action of a foreign object against the
skin, and usually does not penetrate below the
epidermis
 Excoriation - In common with Abrasion, this is
caused by mechanical destruction of the skin,
although it usually has an underlying medical
cause.

 Laceration - Irregular wound caused by blunt

impact to soft tissue overlying hard tissue or
tearing such as in childbirth.

 Incision - A clean 'surgical' wound, caused by a

sharp object, such as a knife.

 Puncture Wound - Caused by an object

penetrated the skin and underlying layers, such
as a nail, needle or knife.

 Contusion - Also known as a bruise, this is a

blunt trauma damaging tissue under the surface
of the skin.

 Gunshot wounds - Caused by a projectile

weapon, this may include two external wounds
(entry and exit) and a contiguous wound
between the two.
  RECOGNITION:

- Recognizing external bleeding is usually easy, as the presence of

blood should alert you to it. It should however be remembered that blood
may be underneath or behind a victim.

- It may be difficult to find the source of bleeding, especially with large

wounds or (even quite small) wounds with large amounts of bleeding. If
there is more than 5 cups of bleeding, then the situation is life-threatening.

 TREATMENT:

- In all first aid situations, the priority is to protect yourself, so put on

protective gloves before approaching the victim.

- All external bleeding is treated using three key techniques, which

allow the body's natural repair process to start. These can be remembered
using the acronym mnemonic 'RED', which stands for:

 Rest
 Elevation
 Direct pressure
 Rest:

- In all cases, of hemorrhage resting client in one place is very important

because frequent movement will increase the bleeding or hemorrhage.

 Elevation:

- In case of larger bleeds, it may be necessary to elevate the wound above

the level of the heart (whilst maintaining direct pressure the whole time).

- This decreases the blood flow to the affected area, slowing the blood
flow, and assisting clotting.

- Elevation only works on the peripheries of the body (limbs and head)
and is not appropriate for body wounds. You should ask the victim to hold
their wound as high as possible.

- You should assist them to do this if necessary, and use furniture or

surrounding items to help support them in this position. If it is the legs
affected, you should lie them on their back (supine), and raise their legs.

 Direct Pressure:

- The most important of these three is direct pressure. This is simply

placing pressure on the wound in order to stem the flow of blood. This is
 best done using a dressing, such as a sterile gauze pad (although in an
emergency, any material is suitable).

- If the blood starts to come through the dressing you are using, add
additional dressings to the top, to a Maximum of Three. If you reach
three dressings, you should remove all but the one in contact with the
wound itself (as this may cause it to reopen) and continue to add pads on
top.

- Repeat this again when you reach three dressings. The reason for not
simply adding more dressings is that it becomes harder to apply the direct
pressure which is clearly needed if this much blood is produced.

- Where an articulate area of the body is wounded (such as the arms or

hands), it is important to consider the position of the area in keeping
pressure on the wound.

 For example:

- If a hand is cut 'across' from the thumb to halfway across the palm,
the would can be closed with direct pressure by simply clasping the
victim's hand shut.

- However, if the hand was wounded from between the two middle
fingers down to the wrist, closing the hand would have the effect of
opening the wound, and so the victim should have their hand kept flat.

- In most cases, during the initial treatment of the bleed, you will apply
Pressure by hand in order to stem the flow of blood. In some cases, a dressing
may help you do this as it can keep pressure consistently on the wound. If you
stop the flow by hand, you should then consider dressing the wound properly.

 Dressing:

- Once the bleeding is slowed or stopped, or in some cases, to assist the

slowing of the blood flow you should consider dressing the wound properly.

- To dress a wound, use a sterile low-adherent pad, which will not stick to the
wound, but will absorb the blood coming from it. Once this is in place, wrap a
crepe or conforming bandage around firmly.

- It should be tight enough to apply some direct pressure, but should not be so
Tight as to Cut blood flow off below the bandage. A simple check for the
bandage being too tight on a limb wound is a Capillary refill check; to do
this,

- Hold the hand or foot (dependent on what limb is injured) above the level of
the heart and firmly pinch the nail. If it takes more than 2 seconds for the pink
color to return under the nail, then the bandage is likely to be too tight.
 - If the blood starts to come through the dressing you have applied, add
another on top, to a maximum of three. If these are all saturated, remove the
top two, leaving the closest dressing to the wound in place. This ensures that
any Blood clots that have formed are not disturbed; otherwise, the wound
would be opened a new.

 Special cases
 Nosebleeds: (Epistaxis)

- If a person has nosebleed, have them Pinch the soft part of the nose firmly
Between thumb and forefinger, just below the end of the bone. If necessary,
do this yourself, but it is preferable to have them do it themselves if they are
able to do it effectively.

- The victim should lean their head slightly forward and breathe through their
mouth. You can also leave the head in a neutral position, but never tilt the
head back. Tilting the head forward ensures that blood isn't ingested (as it can
cause vomiting) or inhaled (choking hazard).

- If you are unsuccessful at stopping the bleeding after 10 minutes of direct

pressure, you should assess the blood flow. If the blood flow is minor, you
could consider using an Ice pack on the Bridge of the nose to help stem the
flow.

- If the nose continues to bleed with a fast flow, you should seek medical
assistance, probably from the ambulance.

 Embedded Objects

- If there is something embedded in the wound, do not remove it. Instead,

apply pressure

- Around the object using sterile gauze as described above. Rolled bandages
are perfect for this. Be careful Not to disturb the object, as moving it may
exacerbate the bleeding. This doesn't apply to superficial splinters and such.

 Stab, puncture or gunshot wounds to the body

- These wounds are life threatening.

 - And after assessing the ABCs of the victim, you should immediately ummon
an ambulance.

- As always, you should check that you are not in danger when approaching
these victims (from someone with a knife or gun, for instance). As with all
embedded objects, ensure you do not remove the item from the body.

- If possible, you should sit the victim up (as blood in the body will go to the
lowest point, allowing the heart and lungs to work as efficiently as possible).
You should also lean them to the injured side, keeping the healthy side free
from incursion by blood.

- Assess the victim for Open chest wounds or Abdominal injuries, and treat
accordingly

 Amputations

- If a body part has been amputated, immediately summon ambulance

assistance, and treat the bleeding as above. Cover the amputated part with a
moist dressing and get it into a Clean plastic bag.

- And place this bag into a bag of ice and water, sending it with the victim to
the hospital. (label date & time, what body part it is ie:Right finger) .

- You should avoid putting the part in direct contact with ice, as this can cause
irreparable damage, meaning that surgeons are unable to reattach it.

 INTERNAL BLEEDING:

Internal bleeding is bleeding which occurs Inside the body.

Sometimes the blood will leak from inside the body through natural openings.
Other times the blood stays inside the body, causing pain and shock, even
though you cannot see the blood loss.

 ETIOLOGY:

- Internal bleeding can be caused numerous ways. Any time someone

could have internal bleeding, you will do no harm by treating them for
internal bleeding, but not treating the victim could lead to Death.
 Falls
 Car Accidents
 Motorcycle Accidents
 Pedestrians Struck by a Vehicle
 Gun Shot Wounds
 Injures from Explosions
 Impaled Objects
 Stab Wounds
  RECOGITION:

A person may be bleeding internally if one of these things happens:

 Blood comes out of the nose or mouth (occurs from severe head trauma)
 Blood or clear fluid comes out of the ear (occurs from severe head trauma)
 Blood is in the stool
 Blood is in the urine
 Bright red blood, or blood like 'coffee-grounds', is in the vomit
 Blood comes from a woman's birth canal after an injury or during pregnancy
 Bruising over the abdominal or chest area
 Pain over vital organs
 Fractured femur

- But remember, a person may be bleeding inside the body, even though you
cannot see the bleeding. If you see the signs of shock and no apparent injuries,
always suspect internal bleeding. Check the Skin color changes. In cases of
internal bleeding the skin may become Pale and Cold and Cyanosis may be
present.

 FIRST AID TREATMENT:

- Check the victim's ABCs.

- If the victim has ABC complications, treat those first - ABCs always take
Priority.

- Call an ambulance

- Treat for shock

- Assist the victim into the most comfortable position

- Monitor ABCs and vitals until the ambulance arrives

o RISK OF CONTAMINIATION:

- Skin is watertight, there is no immediate risk of Infection to the aide from

contact with blood, provided the exposed area has not been previously
wounded or diseased.

- Before any further activity (especially eating, drinking, touching the eyes, the
mouth or the nose), the skin should be thoroughly cleaned in order to Avoid
cross contamination.

- To avoid any risk, the hands can be prevented from contact with a glove
(mostly latex or nitrile rubber), or an improvised method such as a plastic bag
or a cloth. This is taught as important part of protecting the rescuer in most
first aid protocols.
 - Some rescuers may choose to go to the Emergency department, where Post-
Exposure prophylaxis can be started to Prevent blood-borne infection.

 MANAGEMENT IN EMERGENCY:

 IMMEDIATE MEASURES

 FLUID REPLACEMENT

 MEASURE FOR INTERNAL BLEEDING

 MEASURES FOR OXYGEN AND CARDIAC FUNCTION

IMMEDIATE MEASURES:

- Cut the patient clothing away and carry out a rapid physical examination.

- Apply firm pressure over the bleeding area,

- Apply firm pressure dressing over the bleeding site.

- Elevate the injured part to stop venous capillary bleeding above the heart
level.

- Immobilize the injured part that may be extremity to control blood loss.

FLUID REPLACEMENT:

- Insert intravenous cannula to provide means of blood replacement.

- Withdraw blood sample for analysis, typing, and for cross matching.

- Give fluid replacement, including balanced electrolyte solution (RL

Solution) and blood, depending on chemical estimation of blood loss to correct
intravascular deficit and interstitial fluid space deficit.
 - Fresh whole blood is infused (Blood infusion) is done incase of massive
haemorrhage.

- Additional platelets and coagulation factors are given in large amount of

blood are needed since replacement blood is deficit in clotting factors.

- Warm the blood (Commercial warmer or basin of warm water) massive

blood replacement has a cooling effectiveness causing cardiac arrest.

- Rate of infusion depends on severity of blood loss and chemical evidence of

hypoxia.

MEASURE FOR INTERNAL HAEMORRHAGE:

- suspect internal bleeding in patient with hypovolemic shock with no external

signs of bleeding, rising pulse rate, falling blood pressure, thirst, cool and
-clammy skin moist skin.

- Give whole blood or plasma expanders at the rate of blood loss.

- Prepare the patient immediately for surgical intervention to identity and

control sources bleeding.

- Apply Pneumatic Antishock Garment I available to control internal bleeding

and to facilitate blood flow to vital areas.(Primary use is for hypovolemic
shock secondary to bleeding into lower part of the body.

- Monitor the patient’s Hemodynamic response. Obtain blood gas

determination, establish venous return monitoring as an index of the amount of
replacement fluid to the patient.

- Maintain patient in Supine Position with hemodyamic / Circulatory

parameter begin to improve.

MEASURES FOR OXYGENATION AND CARDIAC FUNCTION:

- Administer humidified oxygen.

- Watch for cardiac arrest, patient who have haemorrhage are candidates for
cardiac arrest caused by hypovolemic with secondary anoxia.

- Assess with ECG monitoring for dysrhthmias.

POST OPERATIVE MANAGEMENT:

- In case of shock, Patient shall be placed in Shock Position.(ie. Lying flat on

back with legs elevated at 20 Degree angle while knees are kept straight).

- Sedatives or analgesic is administered as by prescription order. Wound

should be inspected for any bleeding and apply a sterile dressing should be
done.

- In case of haemorrhage elevated the affected part above the heart level. And
start a transfusion of blood and products and determining the cause of
haemorrhage as the initial therapeutic measure.
NURSING MANAGEMENT:

ASSESSMENT
S.No: CLASS I CLASS II CLASS III CLASS IV

1) Blood Loss 15% 15-30% 30-40% <40%

Percentage of body
2) < 750 ml 1000-1250 ml 1500-1800 ml 2000-2500 ml
weight, Volume

3) Pulse Rate <100 bpm >100 bpm >120 bpm >140 bpm

Normal or Slightly
4) Respiratory per minute Normal Decreased Not Palpable
increased.

5) Pulse Pressure Normal Prolonged Prolonged Prolonged

Cyanotic, Cold,
6) Skin Pale, Cool Pale, Cool Pale, Cool, Moist
Clammy

Level of
7) Slightly Anxious Mild Anxious Anxious Confused Confused
Consciousness(Loc)
8) Urine Output 30ml/hr or more 20-30 ml/hr 5-15/hr Lethargic
 NURSING MANAGEMENT:

-Fluid volume deficit related to massive loss of blood from the

circulatory system.

- Ineffective breathing pattern related to hypoxia.

- Altered systemic tissue perfusion related hypovolemic shock.

- Self care deficit (Partial) related to confused mental state.

- Altered sensory and perceptual activities related to stupor and

secondary to hypoxia.

- Impaired skin intergrity related to bruising of skin.

- Impaired physical motility related to generalized disability and

weakness.

- Fear and anxiety related to disease condition.

- Nutritional status less than body requirement related to G.I.

Haemorrhage.

- Sleep pattern disturbance related to hospitalization.

- Risk for wound infection related to susceptibity bacterial

invasion.
 NURSING EXPECTED
S.No: ASSESSMENT GOAL INTERVENTION RATIONAL
DIAGNOSI OUTCOME
1) Subjective Data: - Assess the current fluid - To plan for
volume, intervention,
-
- Fluid volume - To - The clients fluids
- Stop the haemorrhage
- To prevent loss of
immediately,
deficit related to Improve fluid (Blood), volume will be
(Direct Compression)
massive loss of Fluid maintained and
- Start IV fluids - To stabilize the client
blood Volume immediately, and prevent hypovolemic Improved.
(RL,DNS) shock,
Objective Data: from the circulatory
- Put an Input and Output - To calculate the
- The patient is System. Chart, amount of fluid
absorbed,
suffering from massive - Collect blood for
analysis, Cross matching, - To start blood
blood loss or etc. transfusion,

haemorrhage.
- Administer Blood
- To compensate the
transfusion to the patient,
blood loss,

 NURSING PROCESS:
 NURSING EXPECTED
S.No: ASSESSMENT GOAL INTERVENTION RATIONAL
DIAGNOSI OUTCOME
2) Subjective Data: - Assess the current
breathing sounds, and - To monitor trends and
- other respiratory effectiveness of
- Ineffective - To parameters, intervention, - The client
(Respiratory Rate)
breathing pattern Improve Breathing pattern

related to hypoxia. Breathing - Monitor the clients ABC - To check arterial will be improved.
and go for a investigation, oxygen saturation level
Pattern. in the blood,

Objective Data:
- Administer comfortable - To improve lung
- The patient is position and device to expansion to for good
client (Folwer Position) breathing,
suffering from
- Provide humidified
hypoxia, Cyanosis. - To increase oxygen
oxygen to the client,
level in the blood,
- Monitor patient
respiratory distress andd
- To ensure adequate
place patient back on
ventilation,
Ventilator,

S.No: ASSESSMENT NURSING GOAL INTERVENTION RATIONAL EXPECTED

 DIAGNOSI OUTCOME
3) Subjective Data: - Assess for global sign of
infection is change in - To plan for
- colour odour, and interventions,
- Risk for wound - To prevent appearance of the wound,

Infection related Wound

- Clean the wound area
- To prevent wound
To susceptibty Infection with betadin and apply
infection and to enhance
sterile dressing, __
wound healing,
Bacterial invasion. and

Objective Data: Contamination, - Use all type of barrier - To avoid cross

techniques like, Gloving,
contamination,
- The client is hand Washing ,

Susceptible

For bacterial - Administer antibiotics to - To improve resistance

the client as per physicians and prevent infection,
Invasion, order,
 HEALTH EDUCATION:

 Taught all the immediate first aid measures to the client and his/ her
family members.
- Rest,
- Elevation,
- Direct Pressure,

 Encouraged the medical personnel and family member not to touch the
blood without gloves to avoid cross infection,

 Given printed hand notes to family members regarding haemorrhages

sign and symptoms and it complication,

 Advised the patient to clean the wound with betadin regularly with
sterile dressing to improve wound healing,

 Encouraged the client to take good nutrition-c t improve wound

healing,

 CONCLUSION:

 Haemorrhage is a loss of large amount of blood externally or

internally in short period of time. Haemorrhage is caused by slipping
of suture or dislodged clot at incisional site client with coagulation
disorder are at greater risk. In surgical client’s hypovolemic shock is
usually caused by haemorrhage.

 Hypovolemic shock is perfusion of tissues and cell from loss of

circulatory fluid volume, Sign and symptoms hypertension, weak, and
rapid pulse, Cool and clammy skin, rapid breathing, restlessness and
reduced with output haemorrhage or bleeding from wound site in
normal during and immediate after the initial trauma.

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