The seminar covered haemorrhage, or bleeding, including its definition, types, causes, signs and symptoms, investigations, management, prevention and nursing care. Haemorrhage results from ruptured blood vessels and a reduction in circulating blood volume. It can be arterial, venous, or capillary based on the vessel involved. Common causes include head trauma, high blood pressure, aneurysms and blood disorders. Signs range from restlessness to pallor and loss of consciousness. Investigations may include CT scans, MRI and angiography. Management involves supportive care, surgery, and rehabilitation. Nurses monitor for changes and complications while educating patients on prevention, medications and follow-up.

1. SEMINAR ON
HAEMORRHAGE
PRESENTED TO: PRESENTED BY:
MR.SANTOSH GURJAR SIMRAN
ASSOCIATE PROFESSOR M.Sc.NURSING 1ST
YEAR
ACON, PATIALA ACON, PATIALA

2. INTRODUCTION
The escape of blood from a ruptured ves
sel; it can be either external or internal.
Blood from an artery is bright red in color
and comes inspurts; that from a vein is
dark red and comes in asteady flow

3. DEFINITION
Haemorrhage results in the
reduction of circulating blood
volume. It occurs when a blood
vessel ruptures allowing blood to
leak inside the brain.

4. TYPES OF HAEMORRHAGE
1. According to the vessels involved
Capillary haemorrhage is oozing of blood from
minute vessels.
Arterial haemorrhage is blood loss from artery.
The blood is bright red and spurts with the heart
beat.
Venous haemorrhage is the blood loss from
veins. The blood loss is dark red in color, there is
no spurting and rate of loss is much less severe
than arterial haemorrhage.

6. 2. Clinical classification of the haemorrhage
Concealed haemorrhage is internal
haemorrhage.
Revealed haemorrhage is a type when bleeding
can be seen externally.
Primary haemorrhage that which soon follows an
injury.

7. Intermediate haemorrhage occurs in first 24
hours after operation.
Secondary haemorrhage
occurs following an injury after a considerable l
apse of time.

8. CAUSES OF HAEMORRHAGE
 Head trauma . Injury is the most common cause of
bleeding in the brain for those younger than age 50.
 High blood pressure . This chronic condition can,
over a long period of time, weaken blood vessel walls.
Untreated high blood pressure is a major preventable
cause of brain hemorrhages.
 Aneurysm . This is a weakening in a blood vessel wall
that swells. It can burst and bleed into the brain,
leading to a stroke.

9.  Blood vessel abnormalities. (Arteriovenous
malformations) Weaknesses in the blood vessels in and
around the brain may be present at birth and diagnosed
only if symptoms develop.
 Amyloid angiopathy. This is an abnormality of the blood
vessel walls that sometimes occurs with aging and high
blood pressure. It may cause many small, unnoticed bleeds
before causing a large one.
 Blood or bleeding disorders. Hemophilia and sickle cell
anemia can both contribute to decreased levels of blood
platelets.

10. Liver disease. This condition is associated
with increased bleeding in general.
Brain tumors .

11. PATHOPHYSIOLOGY OF
HAEMORRHAGE
Haemorrhage
Hypovolemic shock
Cellular anaerobic metabolism
Lactic acidosis
Decrease function of coagulase protease
Coagulopathy
Further haemorrhage

12. This hemorrhage is exacerbated by the ischemic endothelial cells
activating anticoagulant pathway .
In compensatory state of the shock blood supply to the muscles is
reduced, which become unable to generate the heat  hypothermia
As coagulation functions poorly at low temp.  further hemorrhage.
Further hypoperfusion and worsening acidosis and hypothermia
 physiological exhaustion  “Death”

13. SIGNS AND SYMPTOMS OF
HAEMORRHAGE
Early signs and symptoms
Restlessness and anxiety
Feeling faint
Coldness
Slightly increased pulse
Pallor
Patient feels thirsty

14. Signs and symptoms after severe haemorrhage
 Extreme pallor( face will be ashen, white and clammy
with cold sweat)
 Chilled sensation( temperature 97degree Fahrenheit)
 Air hunger( patient literally gasps for breaths and
respirations will be rapid)
 Rapid thread pulse
 Extremely low blood pressure
 Extreme thirst
 Diminished urine volume( acute renal failure)
 Blindness, tinnitus and coma occur prior to death

15. INVESTIGATION
A neurological exam or eye exam, which
can show swelling of the optic nerve, may
also be performed.
CT scan, which can reveal internal
bleeding or blood accumulation

17. MRI.
Cerebral angiography can be useful in
determining whether a vascular malformation
or an aneurysm is the cause of ICH
A lumbar puncture (spinal tap) is usually not
performed, as it may be dangerous and make
things worse.

18. Management

19. MANAGEMENT
 Supportive therapy is needed to maintain airway and oxygenation.
 Neurosurgical consultation should be promptly obtained.
 Hydration and fluid and electrolyte balance should be maintained.
 Transfusions of red blood cells may be given if bleeding
compromises heart or lung function or threatens to do so because
of its pace or volume.
 Rehabilitation may include physical therapy, speech therapy, and cou
nselling.

20. MEDICAL MANAGEMENT
 Medical therapy of intracranial hemorrhage is
principally focused on adjunctive measures to
minimize injury and to stabilize individuals in the
perioperative phase.
 Perform endotracheal intubation for patients with
decreased level of consciousness and poor airway
protection.
 Rapidly stabilize vital signs, and simultaneously
acquire emergent CT scan.

21.  Intubate and hyperventilate if intracranial pressure is
increased; initiate administration of mannitol for further
control.
 Maintain euvolemia, using isotonic sodium chloride
solution or lactated Ringer’s solution, to maintain brain
perfusion without exacerbating brain edema.
 Avoid hyperthermia.

22.  Correct any identifiable coagulopathy with fresh frozen
plasma, vitamin K, protamine, or platelet transfusions.
 Initiate anticonvulsant definitely for seizure activity or
lobar hemorrhage, and optionally in other patients.
 Facilitate transfer to the operating room or ICU.

23. SURGICAL CARE
 Consider nonsurgical management for patients with
minimal neurological deficits or with intracerebral
hemorrhage volumes less than 10 mm.
 Consider surgery for patients with cerebellar
hemorrhage greater than 3 cm, for patients with
intracerebral hemorrhage associated with a structural
vascular lesion, and for young patients with lobar
hemorrhage.

24. Other surgical considerations include the
following:
Clinical course and timing
Patient's age
Etiology
Location of the hematoma
Mass effect and drainage patterns

25. SURGICAL APPROACHES
Craniotomy and clot evacuation :
The neurosurgeon removes a portion of the
skull and conducts open surgery to drain the
hematoma and repair the ruptured blood
vessel. This is a major surgical procedure that
is typically used when the hematoma is very
large, or when it’s compressing the brain stem,
where critical functions are controlled.

27. Stereotactic aspiration with thrombolytic
agents:
Stereotactic aspiration uses computed
tomography (CT) to locate the hematoma and a
specially developed suction tool to drain it. The
patient is immobilized in a stereotactic head
frame that allows a greater degree of precision
and accuracy than otherwise possible.

29. Endoscopic evacuation:
Endoscopic evacuation is similar to simple
aspiration in that it involves drilling a hole in
the skull, but instead of traditional surgical
instruments a highly skilled neurosurgeon can
reach and drain the hematoma using an
endoscope (a tiny camera-guided instrument)

30. PREVENTION
 Treat high blood pressure. Studies show that 80% of
cerebral hemorrhage patients have a history of
high blood pressure. The single most important thing
you can do is control yours through diet,exercise, and
medication.
 Don’t smoke.
 Don’t use drugs. Cocaine, for example, can increase
the risk of bleeding in the brain.

31.  Drive carefully, and wear your seat belt.
 If you ride a motorcycle, always wear a helmet.
 Investigate corrective surgery. If you suffer from
abnormalities, such as aneurysms, surgery may help
to prevent future bleeding.
 Be careful with warfarin, follow up regularly with your
doctor to make sure your blood levels are in the
correct range.

32. NURSING MANAGEMENT
 Any significant change in the patient's neurological
exam (e.g., decline, worsening deficit in mental status)
requires an emergent CT scan to reassess size of the
hemorrhage. In patients with elevated ICP, therapies to
reduce ICP would be instituted.
 Adequacy of oxygenation is monitored; oxygen
saturation, arterial blood gases, and end-tidal CO2
levels are measured and supplemental oxygen
supplied .

33.  Blood glucose must be tightly controlled.
 Patients receiving hyperosmolar therapy with either
mannitol or hypertonic saline must have their electrolytes
monitored frequently (at least every 6 hours) to maintain
adequate electrolyte balance and prevent complications.
 Convulsive and nonconvulsive seizures occur in 28% of
patients following ICH. Nursing responsibilities center on
monitoring for clinical seizure activity in patients with or
without continuous electroencephalography recording and
administering and monitoring of antiepileptic drugs.

34.  Nurses are involved in the assessment of discharge
needs of the patient, which is initiated on admission.
Early needs assessment helps facilitate initial
rehabilitation planning with the interdisciplinary team.
 Other basic nursing responsibilities require the
prevention of pressure ulcers, nosocomial infections,
and deep vein thrombosis and collaboration with the
nutritionist while monitoring the patient's nutritional
intake.

35.  important aspect of a nurse's responsibility is to attend
to the patient's and family's psychosocial and spiritual
needs.
 Ask if the patient has had a sudden brief loss of
consciousness followed by a severe headache; this
sign has been reported by 45% of patients who survive
subarachnoid haemorrhage.Establish any recent
history of vomiting, stiff neck, photophobia, seizure, or
partial paralysis. Establish any history of cerebral
aneurysms.

36. Observe the patient for signs and symptoms of
cranial nerve deficits, especially cranial nerves
III, IV, and VI. Meningeal irritation may lead to
nausea, vomiting, stiff neck, pain in the neck
and back, and possible blurred vision or
photophobia.
Examine for symptoms of stroke syndrome,
such as hemiparesis, hemiplegia, aphasia, and
cognitive deficits. Cerebral edema, increased
ICPs, and seizures may also occur.

37. Provide emotional support for the patient and
family. Encourage the patient to verbalize his
or her fears of death, disability, dependency,
and becoming a burden. Answer the patient’s
and family’s questions, and involve both the
patient and the family or the significant others
in all aspects of planning care.

38. HEALTH
EDUCATION

39. HEALTH EDUCATION
 Prepare the patient and family for the possible need for
rehabilitation after the acute care phase of
hospitalization.
 Instruct the patient to report any deterioration
in neurological status to the physician. Teach the
patient signs and symptoms of deterioration
in neurological status.
 Stress the importance of follow-up visits with the
physician.

40. If the patient has had surgery, teach the patient
or caregiver to notify the physician for any
signs of wound infection or poor incisional
healing.
Be sure the patient understands all
medications, including dosage, route, action,
adverse effects, and the need for routine
laboratory monitoring for anticonvulsants

41. CONCLUSION
At the end of teaching this can be concluded that
haemorrhage means escape of blood outside its
containing vessel. Whenever a patient is hemorrhaging –
whether externally or internally – a loss of circulating
blood results in a fluid volume deficit and decreased
cardiac output. It results in the reduction of circulating
blood volume is a primary cause of shock. Fluid
replacement is imperative to maintain circulation.

42. BIBLIOGRAPHY
 Hinkle L Janice. Bare G Brenda. Smeltzer C Suzzane.Cheever K.H.
Textbook of Medical-Surgical Nursing . 12th Edition. Philadelphia.
Lippincott Williams & Wilkins. 2010; Pp.2061-2063
 Silvestri Anne Linda. Comprehensive review for the NCLEX-RN
Examination.1st Edition. New Delhi.Elsevier.2015;Pp.928
 www.slideshare.net
 www.wikipedia.org`

43. THANKS