PRESENTED BY -YOGESH DENGALE

1ST M.SC NURSING

 Introduction
 Definition
 Natural arrest of hemorrhage
 Factors affecting hemorrhage
 Types & causes
 Signs & symptoms
 Effects of hemorrhage
 Control of external hemorrhage
 First aid treatment of external hemorrhage
 Control of internal hemorrhage
 First aid treatment of internal hemorrhage
 Special sites of hemorrhage
 Hemorrhage is the loss of blood vessel.The blood loss
is described as extra vasculated(outside the vessel).it
may lie on the surface of body, on patients clothing or
on the floor. Blood may be lost from all three types of
vesseles, the arteries , the vein or capillaries
 The term hemorrhage refers to excess loss of blood due to
rupture of blood vessel.
Or
 Lose blood from the body as a result of injury or illness
Or
 Hemorrhage means the loss of blood from the vascular
system associated with an absolute reduction in the
circulating blood volume
 Adequate amount of calcium is required & all the clotting
factors are essential for the natural arrest of hemorrhage.
The blood in the circulation is kept fluid by a fine balance
between clotting & fibrinolysis.
 When a tissue is damaged

 Prothrombin is converted in to its active from thrombin(in

to presence of calcium)

 Fibrinogen then transformed by thrombin to fibrin

 Mesh is formed by platelets & other blood to form clot

Calcium

Prothrombin

Fibrinogen
 There are many causes of bleeding but few of the most
commonest are discussed here in this presentation and they are
as follows:
1.WOUNDS
A break in the continuity of skin, is termed as wound. Various
types of wounds are as follows:-
a) Incised wound
b) laceration
c) Abrasion
d) Contusion
e) Punctured wound
f) Gunshot Wound
2. FRACTURE OF LARGE BONES
3. INTRAOPERATIVE PERIOD
4. ROAD TRAFFIC ACCIDENT
5. BLUNT TRAUMATIC INJURY
6. INVASSIVE DIAGNOSTIC PROCEDURES
7. ANATOMICAL DEFECTS
8. CANINE BITE
9. CRUSH INJURY
10.VARICOSE BLEEDING
Classification-

World health organization

 Grade0-no bleeding
 Grade1-petechial bleeding
 Grade2-mild blood loss(clinically significant)
 Grade3-gross blood loss, requires transfusion
 Grade4-debilitating blood loss, retinal or cerebral
associated with fatality.
 Hemorrhaging is broken down into four
classes by the American College of
Surgeons' advanced trauma life
support (ATLS).

 Class I Hemorrhage involves up to 15% of blood volume..

 Class II Hemorrhage involves 15-30% of total blood
volume.
 Class III Hemorrhage involves loss of 30-40% of
circulating blood volume.
 Class IV Hemorrhage involves loss of >40% of circulating
blood volume.
According to situation-

1) Aterial hemorrhage

2) Capillary hemorrhage

3) Venous hemorrhage
According to the time of wound;
1.Primary hemorrhage
2.Reactionary or intermediate hemorrhage
3.Secondary hemorrhage

1.Primary hemorrhage-
2.Reactionary hemorrhage-
3.Secondary hemorrhage-

Clinical classification of the hemorrhage;

1.Revealed or External
2.Concealed or Internal
4.Accidental hemorrhage –

Accidental hemorrhage is of two types;

 A. Primary hemorrhage
 B. Secondary hemorrhage

5.Post-partum hemorrhage-excess bleeding that occurs

immediately after labor( delivery of baby) is called post partum
hemorrhage.

6. Hemorrhage due to premature detachment of placenta -in

some cases the placenta is detached from the uterus of mother
before the due to date of delivery causing severe hemorrhage.
Early signs & symptoms-
 Restlessness & anxiety
 Feeling faint
 Coldness( temp.slightly subnormal)
 Pallor
 Patient feels thirsty
 Signs & symptoms after severe hemorrhage-
 Extreme pallor
 Child sensation
 Air hunger
 Rapid thredy pulse
 Extremely low blood pressure
 Extreme thirst
 Dminished urine output
 Blindness tinnitus & coma occur prior death
On cardiovascular system-
 Reduced blood after hemorrhage decreases venous return,
ventricular filling & cardiac output.

During mild hemorrhage-

 during slow or mild hemorrhage when there is loss of a small
amount of blood up to 350-500 ml the blood pressure decreases
slightly & soon it returns back to normal.

During severe hemorrhage-

 when hemorrhge is severe with lost of about 1500 to 2000 ml
of blood , the arterial blood pressure falls to a great extend.
On skin-
 Vasoconstriction
 It increases the deoxygenation of blood.
 It results pallor in color of skin. Sometimes cyanosis develops.

On tissue fluid-
 arteriole constriction decreases the capillary pressure.
 It helps to compensates the blood loss.

On kidney-
 constriction of afferent & efferent arterioles of kidney after
hemorrhage decreases the GFR very much, Therefore, the
urinary output decreases.
On Renin secretion-
 hypoxia produced after blood loss increases secretion of Renin
from kidney & the subsequent formation of Angiotensin 2.
 It also increases release of aldosterone from adrenal cortex.
 Aldosterone causes retention of sodium

On secretion of antidiuretic harmone –

 ADH is released in large quantities immediately after the
hemorrhage.
 It is probably due to increased osmolality of body fluid by
aldosterone induced sodium retention.
On respiration-
 hemorrhage causes stagnant hypoxia because of decreases in
venous return, cardiac output.

On nervous system-

1.on reticular formation-

The catecholamine stimulates the reticular activating system.
it causes restlessness, anxiety and increased motar actvity after
hemorrhage.
2. on brain-
 Through hemorrhage causes vasoconstriction in many organ
of the body, it causes vaso-dilation in brain.

3.Fainting-
 when hemorrhage is severe, cardiac output decreases & blood
pressure falls. So, the blood flow to brain decreases resulting
in unconsciousness.

4.cerebral ischemia-
 when the blood flow to brain is severely affected due to
hypoxia , ischemia of the brain tissue develops within 5
minutes. It causes irreversible damage to brain tissues
1.Pad & Bandage-
 This is the simple method of applying direct pressure to a
bleeding wound & is applicable to vast majority of cases.
 It is effective & causes no damage.
2.Digital pressure-
It is the pressure applied on the point of artery supplying blood
to the area of wound.
This will control hemorrhage temporally & is called indirect
pressure.
3.Elevation of the limb-
It will control venous hemorrhage.
This is a classical method of dealing with a sudden hemorrhage
from a ruptured varicose vein of leg
4.Application of tourniquet-

 A temporary tourniquet may have to be devised in sudden

emergency.
 It should be 3-4 inches wide.
 The great danger of tourniquet is that if it is self on for more
than 30 min then gangrene of the limb may occur.

5.Surgical ligation-
 It is necessary if the bleeding is persistent.
6.coagulation-
 It can be used to coagulate the blood from small blood
vessels.
7
.Pack-
 It will temporarily control severe hemorrhage.
 This method is used in operation theater to control
temporary or sudden hemorrhage.

8.styptics-
 These are also used to control bleeding & they act as
astringents. Astringents such as snake venom or
adrenaline may be used locally in certain cases.
 Brings the sides of wound together & press firmly.
 Press on the pressure point for 10-15min.
 Place the causality in comfortable position & raise the
injured part & reassure him.
 Apply clean pad larger than the wound & press it firmly
with the palm until bleeding becomes less.
 If bleeding continues do not take off original dressing but
add more pads.
 Bandage, it but not too tightly.
The following methods can be used to control bleeding-
 The organ is emptied of blood clots if possible in case of severe
bleeding from bladder, a catheter is passed & bladder is
emptied.
 The vessels are encouraged to contact a lots of saline or sodium
bicarbonate to which a few drops of adrenaline solution have
been added, is of great value in washing the organ.This can be
repeated every two hourly.
 The use of ergometrine after the birth of placenta is an example
of stimulating the vessel to contact pitosin IV may effective in
control of bleeding from esophageal varies.
 Packing it can be done with gauze soaked in adrenaline is
effective.
 Surgical ligature can be done in case of ruptured spleen.
 Lay the causality down with head low; rise his legs by use
of pillow.
 Keep him clam & relaxed & reassure him
 Do not allow him to move.
 Keep up the body heat with thin blankets or coat.
 Do not give anything to eat or drink aspiration occure.
 Do not apply ice bag or hot water bag to chest & abdomen
 Take him to the hospital as early as possible
 Transport gently
ASSESSMENT:-
◦ Frequent nursing assessment is very important.
◦ Document the progress and response of the patient
◦ Assess blood chemistries, blood gas, oxygen saturation and
electrolytes.
◦ Assess for the air way breathing and the circulation.
◦ Identify the bleeding site, amount of blood loss and nature of
injury.
◦ Assess respiratory tract for the clearance , rate of respiration
and auscultation the respiratory sounds for any abnormality.
 Fluid volume deficit related to bleeding.
 Ineffective tissue perfusion related to bleeding.
 Anxiety / fear related to changes in circumstances or
the threat of death.
 Risk for infection related to bleeding.
 Risk for shock; hypovolemic related to bleeding.
 IMPROVE OXYGENATION:-
 Reassure the patient and make him comfortable.
 Calm down the patient as anxiety may increase heart rate
further causes complications.
 If patient is restless, irritable never give him opiods as it
may further cause hpoxia.
 Clear the air way if it is obstructed with blood clots, blood
or some dust particles.
 Turn head to one side
 Administer oxygen with the help of nasal canulla at the
rate of 4 lit / minutes.
 During hypoxia patient is confused hence explain him the
need of oxygenation and the purpose of nasal cannula.
RESTORE AND MAINTAIN ADEQUATE PERFUSION:-
 Assess the patient for the manifestation of hypoxia.
 Avoid hot application to treat hypothermia as it dilates
peripheral blood vessels and pull away blood from vital
organs.
 Use modified trend burg position for the patient to increase
cardiac output.
 Provide blanket to the patient to prevent hypothermia.
 Check vital signs every 5 minutes specially blood pressure
and pulse.
TEMPERATURE MONITORING:-
 Temperature monitoring is very important in patient with
shock.
 Check temperature by using rectal thermometer avoid axillary
and oral temperature taking.

CARDIAC MONITORING:-
 Monitor blood pressure of the patient every 5 minutes till
patients systolic blood pressure comes to 100 mm of Hg.
 Check the pulse for the rate and rhythm.
 Monitor patients closely on cardiac monitors as patients with
haemmorhagaic shock tend to have arrhythmias due to severe
electrolytes imbalance.
 Measurement of CVP is important in hypovolemic shock as it
helps us to prevent fluid overload.
 BLEEDING CONTROL:-
 Assess the wound for the bleeding.
 Apply direct and firm pressure on the bleeding site.
 Inform the doctor immediately regarding bleeding.
 Prepare the patient for the surgery if required.
 Assist the doctor in ligation and closure of wound .
 Assure aseptic technique throughout the procedure ,
assess that wound is cleaned properly no foreign particles
are left behind in the wound.
 ASSESS PATIENT FOR FLUID OVERLOAD:-
 While treating hypovolemia often rigorous fluid
therapy is given which may cause complication such as
pulmonary edema if not done carefully.
 Be alert for the signs and symptoms of pulmonary
edema
 During fluid therapy assess cardiac as well as
respiratory signs and symptoms which indicate
pulmonary edema. Inform unfavorable changes
immediately.
PSYCHOLOGICAL SUPPORT TO THE PATIENT
AND THE FAMILY:-
 Assure the patient and his family.
 As anxiety increases oxygen demand by increasing the
heart rate hence calm down the patient.
 Keep family members informing about recent updates of
patients condition and his progress.
 Explain use of various equipments to the client.
 Explain each and every procedure prior to doing it
NUTRITION:-
 When patient is in hypovolemia , his BMR is increased
hence there is more need of energy.
 Nutrition supplement is initiated as soon as possible.
BLOOD TRANSFUSION:-
 Check the blood bag for recipients details, group, expiry.
 Tally the name of patient with blood bag.

 Monitor the patient throughout for any reaction.

 Insure that informed written consent is obtained.
 Keep eye on vital signs to detect reaction at early stage.
 Use specially designed large bore transfusion set and set the
rate as per order of physician.
 If reaction occurs stop the transfusion notify physician
immediately.
 Do not live client alone during blood transfusion.
 Keep monitoring the patient for any life threatening reaction.
 The occurrence from special sites is designated by special
term;
 Epistaxis-It is bleeding from nose.
 Hemoptysis-It is expectation of bleed from lungs
 Haematemesis-It is the vomiting of bleed
 Malaena-It is the passage of dark blood per rectum from a
site high in intestinal tract.
 Hematuria-It is the presence of blood in the urine.
 Haemothorax-It is the bleeding in to the chest
 Haemoperitonium-Bleeding in to the peritoneum.
 Menorrhagia-Excessive menstruation at normal interval.
 Haemopericardium—It is the bleeding in to the
pericardium
 Hematomyalia-It is the bleeding in to the spinal cord.
 TEXTBOOKS:
 Judith M.Wilkinson,”TEXTBOOK OF FUNDAMENTALS
OF NURSING,”volume -1, jaypee publication, p.p.no.346,
146.
 Erb Bermans Burke,”TEXTBOOK OF FUNDAMENTALS
OF NURSING,”1st edition 2003, pearson
publication,p.p.no.35-37.
 Potter & Perry,” TEXTBOOK OF FUNDAMENTALS OF
NURSING,” 7th edition in 2009, Elsevier publication,
p.p.no.49-50.
 Sanjay N.Pandya, (2003) “ Practical guidelines on fluid
therapy”, first edition, sanjay pandya publishers, New Delhi,
Page No : 13 - 20.
 Luckmann and Sorensen, (1980) “ Medical Surgical
Nursing”, 2nd edition, W.D. Saunders Co, Philadelphia, Page
No : 670, 1221 - 1225, 1604, 1791 – 1795.
 Potter A.Partricia and Anne Griffin Perry, (2005) “
Fundamentals of Nursing”, 6th edition, Moshy Publication,
Missory, Page No : 1143 -1146.
 Brunner and Suddarta’s, (2004), “ Medical and Surgical
Nursing”, 7th edition, J.B.Lippincott Co, Philadelphia, Page No
: 301 – 332.
 William S.Linda and Hopper D. Palua, “Understanding
Medical Nursing”, 2nd edition, F.A. Davis Co, Philadelphia,
Page No : 70 – 79.
 Guidelines for the Management of Spontaneous Intracerebral Hemorrhage
 A Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association
 on behalf of the American Heart Association Stroke Council, Council on
Cardiovascular and Stroke Nursing, and Council on Clinical Cardiology
 Abstract
 Purpose—The aim of this guideline is to present current and comprehensive
recommendations for the diagnosis and treatment of spontaneous intracerebral
hemorrhage.
 Methods—A formal literature search of PubMed was performed through the
end of August 2013. The writing committee met by teleconference to discuss
narrative text and recommendations. Recommendations follow the American
Heart Association/American Stroke Association methods of classifying the
level of certainty of the treatment effect and the class of evidence. Prerelease
review of the draft guideline was performed by 6 expert peer reviewers and by
the members of the Stroke Council Scientific Oversight Committee and Stroke
Council Leadership Committee.
 Results—Evidence-based guidelines are presented for the
care of patients with acute intracerebral hemorrhage. Topics
focused on diagnosis, management of coagulopathy and
blood pressure, prevention and control of secondary brain
injury and intracranial pressure, the role of surgery,
outcome prediction, rehabilitation, secondary prevention,
and future considerations. Results of new phase 3 trials
were incorporated.
 Conclusions—Intracerebral hemorrhage remains a serious
condition for which early aggressive care is warranted.
These guidelines provide a framework for goal-directed
treatment of the patient with intracerebral hemorrhage.
THANK YOU