Diagnosis & Assessment of Hemorrhage

Diagnosis & assessment of  hemorrhage

1. History-about predisposing factors, time & mode of onset.
2. General examination –Appearance, pulse, B.P.,respiration.
3. Local examination –Evidence of hemorrhage-concealed, revealed, associated injuries .
4. Investigation-

(a)For assessment of extent of bleeding-

1. Measurement of lost blood ,e.g., clot size of a clenched fist is roughly equal to 500ml.

2. Urinary output

3. CVP

4.Blood TC, DC,Hb% haematocrit , grouping &cross matching , blood urea

(b)For detection of sources of bleeding-

1.       BT,CT

2.       Radiology.

3.       Endoscopy

4.       Surgical exploration.

Treatment:

1. Stoppage (control) of blood loss by-

i.   Pressure & packing

ii.  Position (elevation)& rest with sedation

iii.Operation , lightion ,repair, excision, tourniqued , cauterization(electrical, chemical)

2. Restore blood volume by-

i.   Blood transfusion-

ii.  I/V fluid- 5%DNS ,saline

iii. Plasma, gelatin, dextrin.

Wounds : Decontamination of surface epithelium of skin is known as wound.

Types of wounds:

1. According to  infection-

1. Ascetic wound : One which is not infected by pathogen,
2. Septic wound : one that is infected with pathogen.

2. According to the type of injury-

1.Contused wound: A wound in which skin is unbroken.

2.Incised wound: One made by cutting instrument.

3.Lacerated wound: Where laceration with Massine tissue damage occurs.

4.Penetrating wound : Which pens through the skin into the underline structure usually caused by a sharp blander object.

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.

2. 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)

3. Decondary –Occurs after 7-14 days

3. 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.

Nursing care and Hemorrhage (post-1)

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.

2. 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)

3. Decondary –Occurs after 7-14 days

3. 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.

Hypersensitivity, Oxygen therapy & Unconsciousness

Hypersensitivity

Hypersensitivity:

Hypersensitivity reaction is an inappropriate or excessive immune reaction that occurs in individuals previously sensitize to an antigen with further contact with the same antigen,

Drug reaction (Anaphylactic stock):

It is a type of hypersensitivity reaction which occure ofter administration of some drugs like penicillin, antis era (TIG), hormones.

The drug produce systemic or generalize hypersensitivity reaction like erythematic purities bronchospasm, anaphylactic , layryngeal oedema shock and even death.

Oxygen therapy

Oxygen therapy:

Indication-

1. Shock               
2. Chest injury
3. Severe hemorrhage
4. Toxic haemolysis
5. Gas poisoning
6. Pulmonary embolism.

Procedure of oxygen therapy:

Oxygen is delivered 4-6 liters per minute by a disposable polythene musk or tube or missal peung or with intubation or positive pressure ventilation.

Unconsciousness

 Unconsciousness:

When the function of nervous system gives the trouble then patient felt serious illness

Causes of unconsciousness:

1. Electric shock.
2. Head injury
3. Diabetic coma
4. Major bleeding
5. Sun struck
6. Malignant malaria
7. Pneumonia
8. Carcinogenic shock
9. Central nervous system infections.

Management of unconsciousness:

1. Immediate transferred into the open air place.
2. Lay the patient flat position.
3. Observation the patients
4. Identify the causes of unconsciousness
5. Always avoid gathering
6. Observe bleeding.
7. Immediate measurement of pulse, temperature, respiration and blood pressure .
8. If the patient is asphyxia then immediate started artificial respiration
9. Send to the hospital own his responsibility.

Enemas:

Indication-

1. Before operation of large intestine.
2. Fecal infection

Enemas are………by → soap water

-          Tap water

-          Paraffin oil

-          Suppositories

-          Glycerin