CONTENTS

Objectives Introduction Definition Normal Anatomy of Blood Vessels Composition of Blood Pathophysiology Types of Haemorrhage W.H.O Grading Classification of Haemorrhage Causes Signs & Symptoms Emergency Management Nursing Care Plan Summary References

OBJECTIVES

At the end of this presentation, participants willbe able to ; Gain knowledge about haemorrhage Define haemorrhage Describe anatomy of blood vessels & composition of

blood Differentiate different types of haemorrhage Elaborate classification Learn about W.H.O grading of haemorrhage Discuss causes and signs & symptoms of haemorrhage Manage haemorrhage in emergency

HAEMORRHAGE

INTRODUCTION Haemorrhage is the loss of blood escaping

from the circulatory system. Bleeding can occur internally, where blood leaks from blood vessels inside the body, or externally, either through a natural opening such as mouth, nose, ear, urethra, vagina or anus, or through a break in the skin. Uncontrolled bleeding can rapidly lead to shock and death.

HAEMORRHAGE

DEFINITION The term haemorrhage refers to a large amount of

bleeding in a short time. (Thygerson, Gulli & Krohmer 2006; pp:23)

An escape of blood from a ruptured blood vessel. ( Weller & Wells 1990; pp:217)

Haemorrhage is the loss of blood from a vessel. (Malcolm R. Colmer 1986 ; pp:98)

ANATOMY OF BLOOD VESSELS

BLOOD

PLASMA

55%

PROTEINS 7%

WATER 91.5%

PLATELETS1,50,000-400,000

OTHER SOLUTES 1.5%

WHITE BLOOD CELLS

RED BLOOD CELLS 4.8 – 5.4 millions

ALBUMIN 54%GLOBULIN 38%FIBRINOGEN 7%ALL OTHERS 1%

ELECTROLYTESNUTRIENTSGASESREGULATORY SUBSTANCESWASTE PRODUCTS

NEUTROPHILS60 – 70%

LYMPHOCYTES 20 – 25%

MONOCYTES 3 – 8%

EOSINOPHILS 2 – 4%

BASOPHILS 0.5 – 1.0%

COMPOSITION OF BLOOD

CLOTTING MECHANISM

Defense mechanism of circulatory system to leakage Involves complex series of reactions Adequate amount of calcium and all clotting factors are essential Clotting factors include; thromboplastin, prothrombin, thrombin and

fibrinogen Clot formed is called fibrin Platelets and other blood cells also play an important role in clot

formation

CLOTTING MECHANISM & SITE OF ACTION OF ANTICOAGULANTS

Platelet breakdown Tissue damage

Oral anticoagulants

Sodium citrate

Heparin

THROMBOPLASTIN

THROMBIN

CALCIUM

PROTHROMBIN

FIBRINOGEN

FIBRIN (CLOT)

TYPES OF HAEMORRHAGE

TYPES OF HAEMORRHAGE

CAPILLARY Bleeding oozes steadily but

slowlyVENOUS flow steadily under less

pressure doesn't spurtARTERIAL Bleeding spurts with each

heartbeat Difficult to control due to

pressure Most serious type as large

amount of blood may be lost in short time

TYPES (cont)

PRIMARY Occurs immediately A cut finger or an operation incision

REACTIONARY(INTERMEDIATE) Occurs in first 24-hrs after operation More severe the operation, more likely it is to occur Operations on kidney, thyroid and breasts as well as total

hysterectomy are more liable to be followed by reactionary haemorrhage

SECONDARY If infection is present, walls of blood vessels may be eroded and may

burst, causing what is known as secondary haemorrhage

TYPES (cont)

REVEALED OR EXTERNAL Bleeding can be seen From an open wound e.g.; abrasion, laceration, avulsion,

amputation etc. Through natural opening like mouth, nose, anus, vagina etc.

CONCEALED OR INTERNAL Bleeding cannot be seen Occurs in one of the body cavities such as abdomen Can result from;

Blunt trauma or penetrating injury Acute or chronic medical illness

W.H.O GRADING

CLASSIFICATION OF HAEMORRHAGECLASS I CLASS II CLASS III CLASS IV

up to 15%(<750ml) of total blood volume

15-30%(500-1500ml) of total blood volume

30-40%(2000ml) of total blood volume

>40%(>2000ml) of total blood volume

Compensation Early Decompensation Late Decompensation(Early irreversible)

Compensation Limited(Irreversible)

Normal BP, Pulse, Respirations •Unable to maintain BP•Tachycardia & tachypnea•Decreased pulse strength & narrow pulse pressure

•BP 70mmhg or below(systolic)•Weak , thready rapid pulse•Narrowing pulse pressure•Tachypnea

•Pulse barely palpable•Respirations : rapid, shallow and ineffective

•Vasoconstriction•Release of catecholamine• Epinephrine• Norepinephrine - Anxiety, slightly pale and clammy skin

•Significant release of catecholamine - Cool, clammy skin and thirst - Increased anxiety and agitation -Normal renal output

•Anxiety and restlessness•Increased LOC & AMS•Pale, cold and clammy skin•Decreased renal output

•Lethargic, confused and unresponsive•Extremely pale, cold and clammy skin•Diminished renal output

Fluid resuscitation is not usually required

-volume resuscitation with crystalloids is all that may be required- Blood transfusion is not usually required

fluid resuscitation with crystalloid-blood transfusions are usually required

-aggressive resuscitation is required to prevent death

CAUSES OF HAEMORRHAGE

Multiple trauma Injury to the highly vascular area involving lungs, liver,

spleen, or prostate Any surgical or obstetric emergency Aneurysms Hypertension Septicemia (Gram negative & Meningococcal) Widespread Carcinomas Bleeding disorders

SIGNS & SYMPTOMS

EARLY SIGNS & SYMPTOMS Restlessness and anxiety Coldness ; temp is slightly subnormal Blood pressure is lowered Pulse rate is slightly increased Pallor Increased thirstSIGNS & SYMPTOMS AFTER SEVERE HAEMORRHAGE Extreme pallor Coldness is profound Air hunger ; respirations are rapid & sighing Pulse rate is very rapid

SIGNS & SYMPTOMS (cont)

Blood pressure is extremely low Thirst is extreme Volume of urine output is diminished

SIGNS & SYMPTOMS OF INTERNAL BLEEDING May appear quickly or take days to appear Bruising Painful, tender area Vomiting or coughing up blood

NURSING MANAGEMENT MEDICAL MANAGEMENT

EVALUATION

INTERVENTION

PLANNING

NURSING DIAGNOSIS

ASSESSMENT

Dependent

Independent

HISTORY

EXAMINATION

INVESTIGATION

TREATMENT

PAST HX

PRESENT HX

INSPECTION

PALPATION

AUSCULTATION

GENERAL

SPECIFIC

GENERAL

SPECIFIC

SYMPTOMATIC

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION

Obvious bleeding risk for deficient fluid volume r/t large amount of blood loss evidenced by trauma

To stop bleeding INDEPENDENT - Apply pressure bandage - Elevation(limbs - Shift the patient to OT (if needed) DEPENDENT - IV coagulation therapy(tranaxemic acid, vit.k, FFP)

Bleeding stopped

Restlessness and anxietySOBLips cyanoticDelayed or absent capillary refillBP below 70mmhg to unobtainable

Ineffective tissue perfusion related to hypotension evidenced by excessive blood loss

To make pt relax and comfortableTo build systolic BP upto above 90mmhgTo get strong peripheral pulses

INDEPENDENT - Counseling & psychotherapy - Attach cardiac monitor -O2 inhalation - Monitor SP02 continuously - Monitor patient for signs of shockDEPENDENT - IV fluid replacement according to blood loss

Patient is relaxedBreathing comfortableStrong peripheral pulsesBP above 90mmhg (systolic)No signs of shock

Cold clammy skinTemp below 35dc

Hypothermia related to ineffective tissue perfusion evidenced by hypotension

To build up body temperatureTo get skin warm

- cover patient with blanket to warm up body _ Monitor skin temperature every 15 mints

Skin warm and dryTemp 37dc or above

INVESTIGATIONS GENERAL All baseline investigations SPECIFIC PT, APTT to check clotting profile ABG’s to check perfusion CBC to review Hb, Hct levels, and platelet count RFT’s to review renal profile when urine output is less or

diminished

CONTROL OF EXTERNAL BLEEDING Place dressing over the wound and apply direct pressure If patient is bleeding from an arm or leg, elevate the injured area

above heart level to reduce blood flow Apply a pressure bandage (if bleeding is not controlled) If bleeding still cannot be controlled, apply pressure at a pressure

point (artery or vein) while keeping pressure on the wound

CONTROL OF INTERNAL BLEEDING For minor internal bleeding (such as bruise on the leg from

bumping into the corner of a table), follow the steps of the RICE procedure:

Rest the injured area Ice or cold pack application over the injury Compression over injured area by applying an elastic bandage Elevation of injured arm or leg, if it is not broken For serious internal bleeding follow these steps Care for shock by raising legs 6 to 12 inches, and cover the patient to

maintain warmth If vomiting occurs, roll the patient onto his/her side to keep airway

clear Monitor breathing Identification and correction of underlying problem

SUMMARY

Haemorrhage is loss of blood from any blood vessel due to some trauma or injury. It may also occur due to some bleeding disorder or tumors. Bleeding may be external or internal. Signs and symptoms depend on extent of blood loss. It is classified into four classes according to blood loss. W.H.O has set a standard grading schedule to assess level of blood loss. Uncontrolled bleeding can lead to hemorrhagic shock and even death. So immediate measures are taken to control bleeding and blood products and fluids are administered to replace fluid volume. Patient is monitored continuously and assessed to check patient’s response to therapy.

REFERENCES

Brunner & Suddhart’s Textbook of Medical Surgical Nursing, vol 2, 12th ed, 2010: pp 2161 – 2163

Colmer ; Moroney’s Surgery for Nurses, 16th ed, 1981 : pp 98 – 106

Howard, Steinmann, Sheehy’s emergency nursing principles & practice, 6th ed, 2003 pp ;

Thygerson, Gulli & Krohmer, First Aid, 5th ed, 2006 : pp 23 – 27

http://www.google.com/bleeding-wikipedia

http://europepmc.org/abstract/MED/6517266