Haemorrhage (original)

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<ul><li><p>CONTENTSObjectivesIntroductionDefinitionNormal Anatomy of Blood VesselsComposition of BloodPathophysiology Types of HaemorrhageW.H.O GradingClassification of HaemorrhageCausesSigns &amp; SymptomsEmergency ManagementNursing Care PlanSummaryReferences</p></li><li><p>OBJECTIVESAt the end of this presentation, participants willbe able to ;Gain knowledge about haemorrhageDefine haemorrhageDescribe anatomy of blood vessels &amp; composition of bloodDifferentiate different types of haemorrhageElaborate classificationLearn about W.H.O grading of haemorrhageDiscuss causes and signs &amp; symptoms of haemorrhageManage haemorrhage in emergency</p></li><li><p>HAEMORRHAGEINTRODUCTION 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. </p></li><li><p>HAEMORRHAGEDEFINITION The term haemorrhage refers to a large amount of bleeding in a short time. (Thygerson, Gulli &amp; Krohmer 2006; pp:23)</p><p> An escape of blood from a ruptured blood vessel. ( Weller &amp; Wells 1990; pp:217)</p><p> Haemorrhage is the loss of blood from a vessel. (Malcolm R. Colmer 1986 ; pp:98)</p></li><li><p>ANATOMY OF BLOOD VESSELS </p></li><li><p>BLOODPLASMA55%PROTEINS 7%WATER 91.5%PLATELETS1,50,000-400,000OTHER SOLUTES 1.5%WHITE BLOOD CELLSRED BLOOD CELLS 4.8 5.4 millionsALBUMIN 54%GLOBULIN 38%FIBRINOGEN 7%ALL OTHERS 1%ELECTROLYTESNUTRIENTSGASESREGULATORY SUBSTANCESWASTE PRODUCTSNEUTROPHILS60 70%LYMPHOCYTES 20 25%MONOCYTES 3 8%EOSINOPHILS 2 4%BASOPHILS 0.5 1.0%COMPOSITION OF BLOOD</p></li><li><p>CLOTTING MECHANISMDefense mechanism of circulatory system to leakageInvolves complex series of reactionsAdequate amount of calcium and all clotting factors are essentialClotting factors include; thromboplastin, prothrombin, thrombin and fibrinogenClot formed is called fibrinPlatelets and other blood cells also play an important role in clot formation</p></li><li><p>CLOTTING MECHANISM &amp; SITE OF ACTION OF ANTICOAGULANTSPlatelet breakdown Tissue damage</p><p> Oral anticoagulants Sodium citrate </p><p> Heparin THROMBOPLASTINTHROMBINCALCIUMPROTHROMBINFIBRINOGENFIBRIN (CLOT)</p></li><li><p>TYPES OF HAEMORRHAGE</p></li><li><p>TYPES OF HAEMORRHAGECAPILLARYBleeding oozes steadily but slowlyVENOUSflow steadily under less pressure doesn't spurtARTERIALBleeding spurts with each heartbeatDifficult to control due to pressureMost serious type as large amount of blood may be lost in short time </p></li><li><p>TYPES (cont)PRIMARYOccurs immediatelyA cut finger or an operation incisionREACTIONARY(INTERMEDIATE)Occurs in first 24-hrs after operationMore severe the operation, more likely it is to occurOperations on kidney, thyroid and breasts as well as total hysterectomy are more liable to be followed by reactionary haemorrhageSECONDARYIf infection is present, walls of blood vessels may be eroded and may burst, causing what is known as secondary haemorrhage</p></li><li><p>TYPES (cont)REVEALED OR EXTERNALBleeding can be seenFrom an open wound e.g.; abrasion, laceration, avulsion, amputation etc.Through natural opening like mouth, nose, anus, vagina etc.CONCEALED OR INTERNALBleeding cannot be seenOccurs in one of the body cavities such as abdomenCan result from;Blunt trauma or penetrating injuryAcute or chronic medical illness</p></li><li><p>W.H.O GRADING</p></li><li><p>CLASSIFICATION OF HAEMORRHAGE</p><p>CLASS ICLASS IICLASS IIICLASS IVup to 15%(40%(&gt;2000ml) of total blood volume</p><p>CompensationEarly DecompensationLate Decompensation(Early irreversible)Compensation Limited(Irreversible)Normal BP, Pulse, RespirationsUnable to maintain BPTachycardia &amp; tachypneaDecreased pulse strength &amp; narrow pulse pressureBP 70mmhg or below(systolic)Weak , thready rapid pulseNarrowing pulse pressureTachypnea Pulse barely palpableRespirations : rapid, shallow and ineffectiveVasoconstrictionRelease of catecholamine Epinephrine Norepinephrine - Anxiety, slightly pale and clammy skin</p><p>Significant release of catecholamine - Cool, clammy skin and thirst - Increased anxiety and agitation -Normal renal outputAnxiety and restlessnessIncreased LOC &amp; AMSPale, cold and clammy skinDecreased renal outputLethargic, confused and unresponsiveExtremely pale, cold and clammy skinDiminished renal outputFluid resuscitation is not usually required-volume resuscitation with crystalloids is all that may be required- Blood transfusion is not usually requiredfluid resuscitation with crystalloid-blood transfusions are usually required-aggressive resuscitation is required to prevent death</p></li><li><p>CAUSES OF HAEMORRHAGEMultiple traumaInjury to the highly vascular area involving lungs, liver, spleen, or prostateAny surgical or obstetric emergencyAneurysmsHypertensionSepticemia (Gram negative &amp; Meningococcal)Widespread CarcinomasBleeding disorders</p></li><li><p>SIGNS &amp; SYMPTOMSEARLY SIGNS &amp; SYMPTOMSRestlessness and anxietyColdness ; temp is slightly subnormalBlood pressure is loweredPulse rate is slightly increasedPallorIncreased thirstSIGNS &amp; SYMPTOMS AFTER SEVERE HAEMORRHAGEExtreme pallorColdness is profoundAir hunger ; respirations are rapid &amp; sighingPulse rate is very rapid</p></li><li><p>SIGNS &amp; SYMPTOMS (cont)Blood pressure is extremely lowThirst is extremeVolume of urine output is diminishedSIGNS &amp; SYMPTOMS OF INTERNAL BLEEDINGMay appear quickly or take days to appearBruisingPainful, tender areaVomiting or coughing up blood</p></li><li><p>NURSING MANAGEMENTMEDICAL MANAGEMENTEVALUATION INTERVENTION PLANNING NURSING DIAGNOSIS ASSESSMENT Dependent Independent HISTORYEXAMINATIONINVESTIGATIONTREATMENTPAST HXPRESENT HXINSPECTIONPALPATIONAUSCULTATIONGENERALSPECIFICGENERALSPECIFICSYMPTOMATIC</p></li><li><p>ASSESSMENTNURSING DIAGNOSISPLANNINGINTERVENTIONEVALUATIONObvious bleedingrisk for deficient fluid volume r/t large amount of blood loss evidenced by traumaTo stop bleedingINDEPENDENT - 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 unobtainableIneffective tissue perfusion related to hypotension evidenced by excessive blood lossTo make pt relax and comfortableTo build systolic BP upto above 90mmhgTo get strong peripheral pulsesINDEPENDENT - Counseling &amp; psychotherapy - Attach cardiac monitor -O2 inhalation - Monitor SP02 continuously - Monitor patient for signs of shockDEPENDENT - IV fluid replacement according to blood lossPatient is relaxedBreathing comfortableStrong peripheral pulsesBP above 90mmhg (systolic)No signs of shockCold clammy skinTemp below 35dcHypothermia related to ineffective tissue perfusion evidenced by hypotensionTo build up body temperatureTo get skin warm - cover patient with blanket to warm up body _ Monitor skin temperature every 15 mintsSkin warm and dryTemp 37dc or above</p></li><li><p>INVESTIGATIONS GENERAL All baseline investigations SPECIFIC PT, APTT to check clotting profile ABGs to check perfusion CBC to review Hb, Hct levels, and platelet count RFTs to review renal profile when urine output is less or diminished</p></li><li><p>CONTROL OF EXTERNAL BLEEDINGPlace dressing over the wound and apply direct pressureIf patient is bleeding from an arm or leg, elevate the injured area above heart level to reduce blood flowApply 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</p></li><li><p>CONTROL OF INTERNAL BLEEDINGFor 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 areaIce or cold pack application over the injuryCompression over injured area by applying an elastic bandageElevation of injured arm or leg, if it is not brokenFor serious internal bleeding follow these stepsCare for shock by raising legs 6 to 12 inches, and cover the patient to maintain warmthIf vomiting occurs, roll the patient onto his/her side to keep airway clearMonitor breathingIdentification and correction of underlying problem</p></li><li><p>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 patients response to therapy. </p></li><li><p>REFERENCES Brunner &amp; Suddharts Textbook of Medical Surgical Nursing, vol 2, 12th ed, 2010: pp 2161 2163 Colmer ; Moroneys Surgery for Nurses, 16th ed, 1981 : pp 98 106 Howard, Steinmann, Sheehys emergency nursing principles &amp; practice, 6th ed, 2003 pp ; Thygerson, Gulli &amp; Krohmer, First Aid, 5th ed, 2006 : pp 23 27 http://www.google.com/bleeding-wikipedia http://europepmc.org/abstract/MED/6517266 </p></li><li><p>**</p></li></ul>