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Haemorrhage
Introduction Haemorrhage is the loss of blood from blood vessel. The blood loss is described
extra vasated(outside the vessel) .
Blood may be lost from all three types of vessels , the arteries, the veins or capillaries. The type
haemorrhage is named accordingly. Bleeding which occurs as soon as vessel is divided is known
primary haemorrhage. If the patient is collapsed the vessel may not bleed immediately, but
recovery takes place, the blood pressure rises and bleeding occurs. This is known as reactionary
intermediate haemorrhage. Haemorrhage can involve all the blood vessels.
as
of
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Types of haemorrhage
(according to the vessels involved)
1. Arterial haemorrhage
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2. Capillary haemorrhage
3. Venous haemorrhage
Arterial haemorrhage When blood loss is from artery is known as arterial haemorrhage. The blood
is bright red and spurts with the heart beat. The escape is from both ends of vessels not only from
nearer to the heart. Blood loss is more rapid from a vessel of corresponding size.
Capillary haemorrhage The blood oozes over the surface of capillary and is darkish red in color
oozing over several hours can result in considerable blood loss.
Venous haemorrhage When the blood loss is from vein then it is known as venous haemorrhage.
The blood is dark red in color, ther is no spurting and rate of loss is much less severe than arterial
haemorrhage. When there is injury to large vessels then it will be a serious matter. A further danger is
that air may be sucked into the damaged vein giving rise to fatal air embolism which the blood and air
form foam.
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Signs and symptoms after severe haemorrhage
Extreme pallor (face will be ashen,white and clammy with cold sweat)
Coldness (temp. 97degree farenhiet)
Air hunger ( patient literally gasps for breaths and respirations will be rapid)
Rapid thready pulse
Extremely low blood pressure
Extreme thirst
Diminished urine volume(acute renal failure )
Blindness , tinnitus and coma occurs prior to death
Effects of haemorrhage
Cardiac cycle- cardiac cycle is the repetitive pumping action that produces pressure changes that
circulates blood throughout the body. It will get disturbed i.e. it pumps less amount of blood to
different organs.
Cardiac output normal cardiac output is 5-6 lt/min
The total amount of blood separately pumped by each ventricles per minute usually expressed in lt per
minute. It can be increases upto 30 lt/ min. in the time of exercise. It is determined by multiplying the
heart rate by volume of blood ejected by each ventricle during each beat.
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Styptics these are also used to control bleeding and they act as astringents. Such as snake
venom or adrenaline may be used locally in certain cases.trombin and gel foam can be used in
some cases such as in low pressure bleeding from venules and capillaries.
Lay the casuality down with head low , raise his legs by use of pillow.
Keep him calm and relaxed. Reassure him.
Donot allow him to move.
Keep up the body heat with thin blankets or coat.
Do not give anything to eat or drink aspiration may occurs.
Do not apply ice bags or hot water bottles to chest or abdomen.
Take him to the hospital as early as possible.
Transport gently.
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2. to prevent shock in operations where blood loss is considerable such as rectal resection ,
hysterectomy and arterial surgery.
3. in severe burns to make up for blood lost by burning but only after plasma and electrolyte have
been replaced.
4. to correct severe anaemia from cancer , marrow aplasia and similar condition and from slow
continuous haemorrhage. In blood transfusion as in all intravenous injections, the tubing and
other portion of the delivery apparatus must be free from air.
Shock
Introduction : shock is the life threatening condition. It is characterized by inadequate tissue
perfusion that if untreated results in cell death. The supply of oxygen to tissues is essential in the
maintainence of life and this can be ensured when circulatory system is functioning normally.
Historical background : In 1923 Walter and Cannor first worked for all conditions of shock.
Definition : Shock can be defined as a condition in which systemic blood pressure is inadequate to
deliver oxygen and nutrient to supply to vital organs and cellular functions.
Shock is defined as a failure of circulation to supply adequate oxygen to the tissues.
Significance of shock: shock affects all the body systems. It may develop slowly or rapidly
depending upon the underlying causes. During shock body struggles to survive, calling on all its
haemostatic mechanism to restore blood flow and tissue perfusion. Therefore any patient with any
disease sate may be at risk of developing shock.
Nursing care of patient with shock requires ongoing systemic assessment. Many interventions
required in caring for the patient with shock call for close collaboration with other members of
health care team and a physicians order. The nurse must anticipated such orders because need to be
executed with speed and accuracy.
Causes of circulation failure: circulation may fail from :
1. Sudden malfunction of heart : this may occur as a result of: Coronary artery occlusion with acute myocardial ischemia.
Trauma with structural damage to heart.
Toxemia viral or bacterial
Effects of drugs
2. deficient oxygenation of blood in lungs :- amongst many causes the following are the
most important surgically.
Post operative atelectasis
Thoracic injuries particularly of chest , i.e. pneumothorex, crushing and laceration
of lung
Obstruction of pulmonary artery by an embolus.
Disturbances of lung function following surgery and anaesthesia.
3. reduction in blood volume ( oligaemia and hypovolemia ) : this may occurs from loss of :
whole blood haemorrhage ( internal or external )
plasma this is particularly significant in burns
Low energy yielding from nutrients and produces acidic intracellular environment
Normal cell function affected , cells swells and cell membrane become more permeable,
allowing fluid and electrolytes to move out and into the cells
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Sodium potassium pump impaired due to this
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Neurogenic shock
Anaphylactic shock
Hypovolemic shock : This is the most common type of shock ,due to insufficient circulatory
volume. In hypovolemic shock there is decreased in circulatory volume to level that is
inadequate to meet bodys need for tissue oxygenation. This occurs when there is loss in the
intravascular fluid upto 15% to 25%. This would represents a loss of 750 to 1300 ml of blood in
a 70 kg person. Common causes of shock are : exercise , fluid loss from circulatory system e.g
bleeding , burns , blood loss from G I or severe diarrhea.
Pathophysiology :
Decreased blood volume
Decreased
stroke
volume
and
cardiac output
Pulmonary congestion
decreased tissue perfusion
decreased
coronary artery perfusionvolume
Circulatory shock or distributive shock : In this there is no blood loss but the
shock is due to the dilation of the blood vessels. This displacement of blood
causes a relative hypovolemia because not enough blood returns to heart which
leads to subsequent inadequate tissue perfusion.
The varied mechanisms leading to the initial vasodilation in circulatory
shock is subdivided into septic shock . it is the most common type of circulatory
shock and caused by wide spread infection due to sepsis called by an
overwhelming infection leading vasodilation. E.g. infections by bacteria . they
release toxins which produce adverse biochemical , immunological and
neurological effects. The most common causative organism of septic shock are
gram negative bacteria.
Pathophysiology :
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Vasodilation
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Diagnostic studies: Blood studies reveals overly acidic blood ph with low
circulatory carbondioxide, blood pressure monitoring.
First aid in case of shock :
Principles involved in first aid :
1) Remove the cause of accident from near the causuality. If possible remove
the casuality from danger such as burning house, room with poisonous
gases.
2) Handling the patient with due care and attention to reduce pain and to
prevent worsening of the condition.
3) Constant observation should be provided to the casuality to identify failure
of breathing, bleeding and then to take appropriate measures to treat
problems.
4) Using material available at hand.
5) Clear the crowd around the casuality.
6) Take the help of the bystanders to give first aid.
7) Reassure the casuality.
8) Transport the casuality to the doctor as early as possible.
First aid in shock :
Reassure the casuality.
Lay him down on his back comfortably with head low and turned to
one side except in case of head injury.
Loosen the clothing around the neck, chest and waist.
Keep the casuality warm.
Give him sips of water if he is thirsty. Never give any alcoholic
drinks.
Never use hot water bag or massage the limbs.
Arrest haemorrhage by adequate measures.
Check pulse ,respiration and level of consciousness.
Transport the causality to the hospital immediately.
Treatment of shock : Pharmacological interventions.
Hypovolemic shock
Volume expanders
Desmopression ( in case of diabetes)
Antidiarrheal agents for diarrhea
Cardiogenic shock
Volume expanders
Positive cardiac inotropics
Vasodilators
Vasiactive and antiarrythmia medication
Distributive shock
Volume expanders
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Positive cardiac inotropics
Vasoconstrictors
Obstructive shock
Volume expanders
Septic shock
Broad spectrum antibiotics
Neurogenic shock
Hypoglycemia glucose is rapidly administered.
Management of shock
Administration of intravenous fluids, blood products, and medication. They
are helpful in treating shock. These include :
Crystalloids: these are used for intravenous fluid replacement in
early stages of shock .e.g ringers solution and normal saline most
commonly used..
Inotripoic agents: like dopamine , dobutamine and epinephrine to
improve myocardial contractility , adequate cardiac output and
improve tissue perfusion.
Vasodilators : nitroglycerine , sodium nitroprusside used to dllate the
coronary arteries.
Diuretics : these are used to treat oliguria and increase urine output.
Antibiotics : used to treat septic shock because they are bactericidal.
Antihistamines : epinephrine used in anaphylactic shock.
Steroids : used to decrease fluid shifts out of vasculature by
stabilizing capillary walls .
Sodium bicarbonate :it is used to treat metabolic acidosis that occurs
as shock progress.
Broncodilators : like atropine , aminophyline, used to relieve
broncoconstriction in case of anaphylactic shock.
Nursing management in case of shock :
Maintain ABC of the patient.
Provide supplemental oxygen therapy to the patient.
Donot deliever more than 2 lt. of oxygen per minute if person
has history of chronic pulmonary diseases.
Monitor for ABG value to assess the patient response to oxygen
therapy.
Continuous monitoring of vital signs should be done.
Check for urine output of the client.
Maintain nutritional status of the patient. Administer
prescribed medication to the patient.
Give psychological support to the patient and the relatives.
Nursing diagnosis in case of shock :
1. fluid volume deficiet related to haemorrhage.
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Nursing interventions
monitor the signs and symptoms of internal bleeding.
Check for blood pressure.
Give comfortable position.
Keep the patient warm and monitor temperature hourly.
Administer intravenous fluids as ordered.
Monitor urine output.
Administer oxygen as ordered.
2. decreased cardiac output related to ineffective cardiac function .
Nursing interventions
administer IV fluids
monitor urine output.
Monitor blood pressure and pulse rate.
Administer inotropic agents to correct ventricular function.
3. risk for infection related to interruption of skin integrity from
invasive procedures.
Nursing interventions
take precautions to prevent nosocomial infections.
a) Wash hands frequently.
b) Use aseptic techniques.
c) Monitor sites of insertion for signs of infection.
d) Change the intravenous cath every three days.
e) Provide indwelling catheter care frequently.
f) Monitor for whit blood cell count for elevation greater than
10,000 per mm3.
4. altered nutrition lesss than body requirement related to decreased
oral intake.
Nursing interventions
monitor daily weight and identify weight loss.
Consult nutritionist for recommendations about diet.
Check for gastric residuals every 4 hourly , notify the physician
if it is greater than 100 ml.
Monitor for hematocrit, haemoglobin to assess the adequacy of
nutritional replacement.
5. altered peripheral tissue perfusion related to edema from stasis of
blood in the capillaries and vasoconstriction.
Nursing interventions
monitor the extent of fluid retention.
Monitor daily weight of the patient.
Determine the severity of edema.
Watch for elevation in central venous pressure .
Check signs and symptoms of fluid overload.
Prevention of shock :
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Preoperative measures :circulatory collapse should be assessed by strenuous
measures if at all possible. Preoperatively the patient should be as fit as possible
and from the point of view from circulatory system.
His blood should be adequate in quantity and volume.
His tissues should be adequately hydrated.
He should be mobile so that there should be no stagnation in the
circulatory system.
Patient should be kept warm on his journey from ward to theatre.
Post operatively :
Fluid and electrolyte replacement should be done with normal saline,
dextrose 5%, plasma and rest and relief from the pain continues.
Gentle handling by nursing staff wi help in prevention of shock.
Diuretics like mannitol an osmotic diuretic which is neither absorbed in
the renal tubules nor metabolized. If oliguria persists frusemide can be
given.dopamine can be given to improve blood pressure.
Bibliography :
Saunders Manual of Nursing Practice, edition 1st , published by W.B
Saunders, printed in 1997, pp 364-380
Brunner and Suddarths Textbook of Medical Surgical Nursing edition 13 th
published by Lippincott publishers, printed in 2009, pp 216-234
Joyee M Black and Hawks J.H. Medical Surgical Nursing clinical
managemen for positive outcomes, edition 7 th , printed in 2009, pp 24432477.
American Academy of Orthopedic Surgeons, Emergency , Care and
Transportation of the Sick and Injured, Published by Jones and Barlett,7 th
edition , printed in 1998,pp 541 550.
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