Nursing care and Hemorrhage (post-2)

Nursing care and Hemorrhage

Temperature, pulse ,respiration ,urine ,bowel movement should be observed and measure 6 hourly or according to condition.
Note temperature : 98 .4 °F.; normal: 97 -99.5 /min
Pulse : 60 -90 /minute (Ave:72 /min)
Respiration :10 -18/minute
Urine volume:1200-1800/day
Bowel movement : moved /not
The recording of all this mater are written in a chart called temperature chart.
Bed pans and urinal in bed pan patient. They should be properly cleaned. Before evaluation (B.E) empty the bed pans or urinal : a nurse should observe the volume and color.

Hemorrhage:

Definition:
  1. Abnormal internal or external discharge of blood is called hemorrhage.
  2. Escape of blood out of blood vessels is called hemorrhage.

Type of hemorrhage:

  1. According to nature of vessels:
  1. Arterial –Bright red, spurts as a jet.
  2. Venous –Darker red, escapes as a steady flow.
  3. Capillary –bright red, often rapid ooze.
  1. According to the time of hemorrhage:
  1. Primary –At the time of injury or operation
  2. Reactionary –May follow primary hemorrhage within 24 hours (usually 4-6hours)

Causes Reactionary:

i.                     Rolling /slipping of all ligature
ii.                   Dislodgment of a clot
iii.                  Rise of B.P & refilling of venous system on recovery from stock.
iv.                 Restlessness, coughing & vomiting which raise venous pressure (e.g. reactionary venous hemorrhage within a few hours of thyroidectomy)
  1. Decondary –Occurs after 7-14 days
  1. According to relation with exterior:
1.       Internal (concealed )-as in ruptured spleen or liver fractured femur. Ruptured ectopic gestation or in cerebral hemorrhage
2.       External (revealed )-as in melanin, haematemesis, haemoptysis , haematuria etc,

Sing of acute blood loss:

  1. Increasing pallor & pulse rate .
  2. Restlessness.
  3. Air hunger
  4. Cold &clammy skin
  5. Empty veins
  6. Thirst
  7. Tinnitus
  8. Blindness
  9. Pulse volume low (Thready pulse) as the blood pressure falls.

Principles of management of hemorrhage:

  1. Assessment of blood loss
  2. Replacement of blood loss
  3. Detection of sources or causes of bleeding.
  4. Treatment & control of sources or causes.