HAEMORRHAGE

ROOM NO: 01-02-05

NO

NAME

MATRIX NO

1
2 3 4 5

NURAIN BT RASHID
MUNIRAH BT AZIZ AIZA RABIATUL AMIRA BT ABD AZIZ RAFEAH BT HAJI MARZUKI FARRINA NOORELINDA BT CHE HUSSAIN

09 DIN0019
09 DIN 0133 09 DIN 0137 09 DIN0017 09 DIN0009

6
7 8 9 10

NURUL SHUHADA BT ZULKAFLI

WAN NURUL SYAHIRAH NURUL SYAZLIN BT MAHADZIR NURUL BAIDURA BT ISMAIL SITI HASMIDA BT MOHAMMED

09 DIN0003
09 DIN0005 09 DIN 0142 09 DIN0018 09 DIN 0139

1. Define haemorrhage

2. State the type of haemorrhage

3. Sign and symptom of haemorrhage 4. Carried out the management of patient

with haemorrhage 5. List the nursing diagnosis of patient 6. Explain the nursing care plan of patient with haemorrhage

An escape of blood from a ruptured blood vessel, externally or internally Arterial hemorrhage involves bright red blood which escapes in rhythmic spurts, corresponding to the beats of the heart.

Venous hemorrhage involves dark- red blood which escapes in an even flow.

Arterial haemorrhage
Venous haemorrhage Primary haemorrhage

Ruptured of an artery

Ruptured of the vein

If bleeding immediately follows an injury

Secondary haemorrhage
Rectionary haemorrhage

Delayed bleeding from sepsis usually about 10 days after injury

Delayed bleeding after injury

Hematuria hemoptysis hematemesis Post-operative haemorrhage Post partum haemorrhage

Secondary post partum haemorrhage

Blood in the urine from urinary bleeding Coughing up blood from the lungs

Bleeding in the stomach

After the surgery Occurs within 12-24 of delivery from the uterus which measures 500ml or more blood loss Excessive bleeding more than 24hour after bleeding

Antepartum haemorrhage Cerebral haemorrhage Intracranial haemorrhage

Occurs before the delivery during stage of labour eg placenta previa

Episode of bleeding into the cerebrum usually stroke

Bleeding within the cranium which may be extradural, subdural, subarachnoid or cerebral
Bleeding beneath the dura meter. It may be due to injury and causes signs of compression. The CSF will be blood stained

Intradural haemorrhage

Loss of conscious

Rapid pulse

Weak pulse

shock

sweating

Sign & symptom

thirstiness

Pale face
Cold& clammy skin

dizziness restlessness

MANAGEMENT OF PATIENT WITH HAEMORRHAGE

1.

Assess patients level of consciousness by performing A= airway, B= breathing, C = circulation , if patient is unconscious :

a) to check for A= airway, - hear the breathing sound through patient mouth. - perform jaw thrust maneuver by one hand is placed on each side are grasped and lifted, displacing the mandible forward. - maintain patients airway by remove any foreign body - intubate patient and maintain the ventilation ( oxygen, ETT )

b ) to check for B = breathing, - ensure that patients respiration is stable > 12 25 bpm. C ) to check for C = circulation, - check the patients pulse usually Systolic BP for radial pulse is 80 mmHg, femoral pulse is 70 mmHg and carotid pulse is 60 mmHg. - also check for capillary refill.

2. Monitor patient vital signs of ( BP, pulse, respiration, temperature ) hourly until patient stable.
R low blood pressure and high pulse rate indicate patient having hemorrhage. 3. Apply direct pressure dressing at the haemorrhage site. R to stop bleeding.

4. Administer Vitamin K through IM if patient have high blood loss eg. Fracture femur.( If bleeding non stop occur.) R to stop bleeding.
5. Administer ATT ( anti tetanus toxoid ) through IM as ordered by doctor. R to prevent Tetanus is patient having a penetrating trauma or severe bleeding.

6. Elevate the site of hemorrhage eg. Bleeding at the upper or lower limb. R - to promote venous return to stop bleeding.

7. Insert intravenous line at the both side of hand. R one IV line for IV therapy another IV line to prepare for blood transfusion.

8.Take blood sampling to test for full blood count of hemoglobin, BUSE, and group cross match. R To monitor for any sign and symptom of hypovolemic shock and blood transfusion if needed.
9.Administer IV Therapy of colloid solution e.g: Hartman and crystalloid e.g: lactated ringers solution. R To maintain plasma electrolyte composition and prevent hypovolemic shock.

10. Administer blood transfusion (whole blood or packed cell) if patients hemoglobin less than 8 g/dL. R To replace blood loss.
11. Administer analgesic medication such as intramuscular (IM) injection pethidine 50mg as ordered by doctor. R to relieve pain.

NURSING CARE PLAN

Nursing diagnosis: alteration in fluid volume deficit ; hypovolemia related to excessive bleeding.

Supporting data Verbal

: patient c/o thirst, lethargy, weakness, decrease urine output. : patient having hypotension, decreased skin turgor, concentrated urine, increased in pulse rate, severe bleeding.

Non- verbal

Expected outcome :

patient experiences adequate fluid volume and electrolyte balance as evidence by urine output > 30ml/hr, normal blood pressure, heart rate , normal skin turgor and less bleeding.

NURSING INTERVENTION:
Assess patient general condition; skin turgor, urine concentration, and patient complains such as thirst, weakness. Obtain patient history the probable cause of the fluid disturbance such as bleeding and trauma. R- as a baseline data to plan appropriate nursing intervention and implementation.
1.

2. Assess patient ; - active fluid loss from wound, and severity of bleeding. R - to maintain in accurate input and output.
- Assess color ( dark yellow, pale yellow, clear,

hematuria) and amount of urine . R- to report urine output less than 30 ml/hr for 2 consecutive hours. Concentrated urine and decreased urine output denotes fluid deficit.
- Assess skin turgor and mucous membrane for sign of

dehydration. R- to detect severity of dehydration.

3. Monitor patients vital sign such as blood pressure for orthostatic changes, pulse rate, respiration , temperature and saturation pulse oximetry oxygen (spo2) every hourly,2 hourly, 4 hourly and when necessary until patient stable.
R- to detect vital sign abnormality. Sinus tachycardia and hypotension may occur when hypovolemic while pulse rate is weak if electrolyte imbalance occur. Temperature is check to detect decreased of body fluid through perspiration and increased respiration.

4. Set Intravenous (IV) Line and administer IV Therapy e.g colloid solution Hartmann while crystalloid solution e.g lactated Ringers , 0.9% normal saline solution to patient as prescribed by doctor. R- parenteral fluid replacement is indicated to prevent shock and maintain hydration. 5. Monitor serum electrolyte and urine osmolality and report abnormal values. (BUSE, BUN, Hb, GXM) as ordered by doctor. R- to detect hypovolemia. Elevated BUN and Hemoglobin test suggest fluid deficit. Urine specific gravity is likewise increased.

Monitor input and output (I/O) chart and daily weight consistently with same scale, same time and same cloth. R- to detect positive or negative balance and for accurate measurement to identify severe weight loss.
6.

Encourage patient to drink if dont have contraindication. Provide a jag of water at patient bedside within easy to reach. R- to replace fluid loss and maintain hydration.
7.

8. Administer blood transfusion if Hb less than 8g/dL such as whole blood, packed cell as ordered by doctor. R- to replace blood loss.

9.Assist the physician with insertion of a central venous line and arterial line as indicated if patient unconscious. R- to allows more effective fluid administration and monitoring.

10. Observe sign and symptom of hypovolemic shock, fluid overload, and mental status every shift. R- as early precaution to prevent any complication.
11. Administered oxygen 3-5 liter via nasal prong if

patient complain of shortness of breath(SOB) and his/her spo2 shows <95%. R- to prevent hypoxia.
12. Inform doctor if patient having any improvement or

deterioration of fluid volume deficit. Such as sign and symptom of dehydration . R- to plan for further intervention.

1) Barbara F. Weller 2005, Baillieres Nursing Dictionary, Twenty-fourth edition page 184. 2) Joyce M. Black,Ester Matassarin 1993 MedicalSurgical Nursing A Psycophysiologic Approach Fourth Edition by W.B Sunders Company.