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SHOCK
PRESENTED BY
Sakuntala Giri
SUM Nursing College
Introduction
• Shock is a life threatening condition. lt is
characterized by inadequate tissue perfusion
that if untreated results in cell death. The
supply of oxygen to tissues is essential in the
maintenance of life and this can be ensured
when circulatory system is functioning
normally.
• In 1923 Walter and Canner first worked for all
conditions of shock.
SHOCK
SHOCK
CLASSIFICATIONOF SHOCK
• Hypovolemic shock.
• Cardiogenic shock.
• Circulatory shock or distributive shock
a. Septic shock.
b. Obstructive shock.
c. Neurogenic shock.
d. Anaphylactic shock.
Hypovolemic shock
• This is the most common type of shock, due to
insufficient circulatory volume
• This occurs when there is loss in the
intravascular fluid up to 15% to 25%.
• That is a loss of 750 to 1300 ml of blood in a
70 kg person
ETIOLOGY
PATHOPHYSLOLOGY
Decreased blood volume
Decreased venous return
Decreased cardiac output
Decreased tissue perfusion
Decreased cellular metabolism
CLINICAL MANIFESTATIONS
• Decreased cardiac output
• Hypotension
• Altered tissue perfusion
• Cool and clammy skin
• Cyanosis or PaIe skin color (pallor)
• A rapid, weak, thready pulse
• Thirst and dry mouth, due to fluid depletion
• Fatigue due to inadequate oxygenation
• Anxiety, restlessness, altered mental state
CARDIOGENIC SHOCK
It is caused by the failure of heart to pump
effectively.
 This is due damage of heart muscles, mostly
from myocardial infarction.
ETIOLOGY
•
Decreased cardiac contractility
Decreased stroke volume and cardiac output
Pulmonary congestion
decreased tissue perfusion
decreased coronary artery perfusion
volume
CLINICAL MANIFESTATIONS
• Pulmonary edema
• Increased central venous pressure
• Distended jugular veins due to increased jugular
venous pressure
• Weak or absent Pulse due to tachyarrhythmia
• Shortness of breath
• Chest pain
SEPTIC SHOCK
• It is secondary to infections by micro organisms.
• Septic shock is caused by an overwhelming systemic
infection and inflammation resulting in vasodilation
• Most common gram negative bacteria such as
Escherichia coli, Proteus species, Klebsiella
pneumoniae
• Which release an endotoxin and produce adverse
biochemical,immunological & neurological effects
which are harmful to the body.
SEPTIC SHOCK
Pathophysiology
Severe localize infection of gram –ve bacili
Bacterial invasion into bloodstream(septicemia)
Inflammatory response
Endotoxin release into circulation
Histamine & other chemical mediator release
vasodilation
Increased capillary permeability
Inadequate tissue perfusion to vital organ
Multiple organ failure
I
CLINICAL MANIFESTATION
• Pyrexia due to increased level of cytokines
• Systemic vasodilation resulting in hypotension
• Warm and sweaty skin due to vasodilation
• Reduced contractility of the heart
• Increased levels of neutrophils
• Increased heart rate
• Increased cardiac output
OBSTRUCTIVE SHOCK
ETIOLOGY
Clinical manifestations
• Tachycardia
• Tachypnea
• Hypotension
• Cyanosis
• Oliguria
• Altered mental status
• jugular veins may be distended
• Pulsus paradoxus in case of tamponade
Neurogenic shock
• This is a very uncommon type of shock.
• lt is most often seen in patients who have had
and extensive spinal cord injuries.
• The loss of autonomic and motor reflexes below
level of injury results in loss of sympathetic
control.
• This leads to relaxation of vessels and peripheral
dilation and hypotension.
ETIOLOGY
Pathophysiology
Spinal cord injury
Inhibit the sympathetic nerve stimulation
Arterial & venous dilatation
Arterial / venous blood pooling
Hypotenson
Bradycardia, warm dry flushed skin
Decreased perfusion of vital organ
Multisystem organ failure
CLINICAL FEATURE
• Hypotension
• Altered mental status
• Bradycardia
• Skin that is warm and dry
• Tachycardia and tachypnea
• Cool and clammy skin
• Priapism due to Peripheral nervous system
stimulation
Anaphylactic shock
Anaphylactic shock is caused by severe
reaction to an allergen, antigen, drug or
foreign protein.
 When a patient who has already produced
antibodies to a foreign substance develops a
systemic antigen antibody reaction.
Antigen antibody provides mast cells to
release vasoactive substance such as
histamine or bradykinin that cause
vasodilatation
PATHOPHYSIOLOGY
• Due to antibody responses
• Release of histamine
• Vasodilatation
• Increased capillary permeability
• Severe broncho constriction
• Decreased oxygen supply and utilization
• Inadequate tissue perfusion.
CLINICAL FEATURE
• Skin eruptions and large bumps
• Localized edema, especially around the face
• Laryngeal edema
• Weak and rapid pulse
• Breathlessness and cough
• Tachycardia and tachypnea
• Hypotension
• Cyanosis
• Urticaria and pruritus
• Severe bronchospasm
DIAGNOSIS OF SHOCK
• Chest x-rays
• CVP Measurement
• Hemoglobin level measurement
• Arterial Blood Gases (ABG) analysis
• Urinalysis
• Complete blood count
• Blood, urine and sputum culture
• Blood chemistry including kidney function tests
• Cardiac catheterization and Coronary
angiography
• Echocardiogram and Electrocardiogram
• Cardiac enzymes (troponin, CKMB) test
• Computed tomography
MANAGEMENT OF SHOCK
MANAGEMENT
Management in all types of shock include the
following:
• Management of airway, breathing and
circulation
• Fluid replacement to restore intravascular
volume
• Vasoactive medications to restore vasomotor
tone and improve cardiac function
• Nutritional support to address metabolic
requirement
The ABCDE approach
A
B
CD
E
Disability due
to neurological
deterioration
Circulation &
shock
management
Breathing &
ventilation
Airway & oxygenation
Exposure &
examination
Airway
• See respiratory pattern
• Head tilt chin lift
• Jaw thrust
• Suction
• Oral airways
• Nasal airways
• Nebulised adrenaline for stridor
• Intubation
• Cricothyroidotomy
– Needle or surgical.
• O2 administer,if airway open
Breathing
Consider ventilation
with AMBU bag.
Position upright if
struggling to breath
Specific treatment
i.e.: β agonist for
wheeze, chest
drain for
pneumothorax
circulation
• Position supine with legs raised
– Left lateral tilt in pregnancy
• IV access
• Fluid challenge
– colloid or crystalloid?
• ECG Monitoring
• Specific treatment
Disability - assessment
• AVPU (or GCS)
– Alert, responds to Voice, responds to Pain,
Unresponsive
• Pupil size/response
• Posture
• BM
• Pain relief
Disability - interventions
• Optimise airway, breathing & circulation
• Treat underlying cause if drug induced
causes.
– i.e.: naloxone for opiate toxicity
• Treat  blood glucosei,e hypoglycemia
– 100ml of 10% dextrose (or 20ml of 50%
dextrose)
• Control seizures
• Seek expert help for CVA or ICP
Exposure & Examine
• Remove clothes and examine head to toe
front and back.
– Haemorrhage, rashes, swelling, sores,
catheter etc
• Keep warm
• Maintain dignity
Complications
• a. ARDS- (acute respiratory distress syndrome)
• b. Multiple Organ Failure
DEFINITION
• Hemorrhage or bleeding is termed as escape
or loss of blood from the circulatory system.
• It may be internally (from blood vessels) and
externally (through natural opening such as
mouth, anus or vagina). It may be termed as
exsanguination (complete loss of blood) and
desanguination (massive blood loss).
ETIOLOGY
Traumatic injury
Hematoma
Incision
Puncture wound
Medical condition
• Intravascular change
• Intramural changes
• Extra vascular changes
Deficiency of coagulation factors
Exposure to NSAIDS
TYPES OF HEMORRHAGE
• According to the vessels involved:-
• Arterial hemorrhage:- It is bleeding from
artery, which is bright red in color and sprouts
as a jet, rises and falls in time with the pulse.
• Capillary hemorrhage:- The blood oozes over
the surface or comes out from capillary and is
darkish red in color.
• Venous hemorrhage:- bleeding from vein and
is dark in color.
• According to time of wound:-
• Primary hemorrhage:- It is immediate
hemorrhage which occurs when there is damage
to any blood vessels and bleeding occur
immediately e.g. cut on finger.
• Reactionary or intermediate hemorrhage:- It
occurs in first 24 hrs. after operation. E.g.
operation of kidney and thyroid etc.
• Secondary hemorrhage:- It is due to sloughing off
the wall of blood vessel due to bacterial infection
and action of enzyme such as acid pepsin on
peptic ulcer.
• Clinical classification of the hemorrhage:-
• Revealed or external hemorrhage:- Bleeding is
seen externally.
• Concealed or internal hemorrhage:- The
bleeding can not be seen externally. E.g. bleeding
in cavities.
• According to the American College Of Surgeons’ Advanced
Trauma Life Support (ATLS)
• Class I:- It involves upto 15% of blood volume and vital
signs may not change. It does not require fluid
resuscitation.
• Class II:- It involves 15- 30% of total blood volume and
tachycardia and narrowing of systolic & diastolic BP occur.
The skin may look pale and be cool. It is treated by volume
resuscitation with crystalloid (NS or RL) and does not
require blood transfusion.
• Class III:- It involves 30-40% of circulating blood volume.
The patient’s BP will fall, heart rate increases and
peripheral perfusion such as capillary refill worsen and
mental status worsens. It is treated by fluid resuscitation
with crystalloid and blood transfusion.
• Class IV:- It involves loss of >40% of circulating blood
volume. The limit of body’s compensation is reached and
aggressive resuscitation is required to prevent death.
• According to WHO grading of hemorrhage:-
• Grade 0:- No bleeding
• Grade 1:- Petechial bleeding
• Grade 2:- Mild blood loss
• Grade 3:- Gross blood loss requires
transfusion (severe)
• Grade 4:- Debilitating blood loss, retinal or
cerebral fatality
CLINICAL MANIFESTATIONS:-
• Early sign & symptoms
• Pain
• Restlessness and anxiety
• Feeling faint
• Coldness (temperature slightly subnormal)
• Slightly increased pulse
• Pallor
• Thirsty
• Difference between systolic and diastolic pressure
• Sign & symptoms after severe hemorrhage
• Extreme pallor
• Chilled sensation
• Air hunger or hypoxia rapid thread pulse
• Extreme low blood pressure
• Extreme thirst
• Diminished urine volume
• Disability
• Confused mental status
• Bruising
• Blindness, tinnitus and coma occur prior to death
DIAGNOSTIC STUDIES:-
• History collection:-
• Cause and duration of injury
• Sign & symptoms at the time and after bleeding
• Amount of bleeding
• h/o bleeding disorder and taking medications
• quick management of bleeding
• physical examination:-
• vital signs, color of skin, capillary refill, mental
status and skin turgor
• site of bleeding and depth of injury
• Assess sign & symptoms of bleeding.
• Coagulation screening test:-
• Platelet count- 1,50,000- 4,00,000
• Bleeding time- <8 min
• Prothrombin time- 12-15 sec
• Activated platelet thromboplastin time- 30-40
sec
• Fibrinogen- 1.5- 4.0 g/l
COMPLICATIONS:-
• Hypovolemic shock
• Infection
• Thrombocytopenia
• Shock/ coma
• Death
MANAGEMENT
• First aid or immediate measures of external
bleeding:-
• Assess & maintain the victim’s ABCs.
• Rest:- Rest the client in one place because frequent
movement will increase the bleeding.
• Direct pressure:- Apply firm pressure on the wound
to stop the flow of blood.
• Elevation:- Elevate the injured part to stop venous
capillary bleeding above the heart level.
• Dressing:- Once the bleeding is slowed or stopped,
apply firm pressure sterile dressing over the
bleeding site.
• First aid for internal bleeding:-
• Lay down the victim with head low and leg raise.
• Reassure and keep him calm.
• Immobilize and ambulant the patient.
• Maintain the body temperature with thin blanket
or coat.
• Do not give anything to eat or drink to prevent
aspiration.
• Assess the victim’s vital signs and condition of
injured site and measure oxygen and cardiac
function.
• Do not apply ice bags or hot water bottles on
bleeding site.
• Take the victim to the hospital as early as
possible.
• Fluid replacement:-
• Insert IV cannula to provide blood
replacement.
• Withdrawal blood sample for analysis, typing
and cross- matching.
• Fluid replacement with crystalloid solution (RL
& NS) and blood, depends on chemical
estimation and the severity of blood loss.
• Infuse fresh whole blood, platelets and
coagulation factors
• Additional measure:-
• Administer humidified oxygen.
• Monitor ECG and sign of cardiac arrest and
shock.
• Use anti- shock garments
• Non- pneumatic anti-shock garments:- It is a
first aid device used to treat hypovolemic
shock and decrease bleeding from the part.
• Pneumatic anti- shock garments:- It is an
inflatable garments used to combat shock,
stabilize fractures, promote hemostasis and
increase peripheral vascular resistance
• MEDICATIONS
• Coagulation:- To coagulate the blood e.g.
vitamin k(phytomenadion), antifibrinolytic
drug( tranexamic acid) and blood products
(factors VIII, IX & fresh frogen plasma).
• Styptics:- To control bleeding and act as
astringent. E.g. adrenaline & thrombin etc.
• Surgical ligation:- It is used for internal
hemorrhage and persistent bleeding.
NURSING MANAGEMENT
• Nursing assessment
• Assess the ABCs , vital signs & ECG of the
patient.
• Assess the site of bleeding and duration &
amount of bleeding.
• Assess the sign & symptoms of patient.
• Take history of bleeding disorders and use of
medicine.
• Perform physical examination of the patient.
• Nursing diagnosis
• Altered tissue perfusion related to bleeding.
• Risk fo fluid volume deficit related to severe
bleeding.
• Ineffective breathing pattern related to
decrease blood flow.
• Hypothermia related to decrease blood
supply.
• Risk of complications: shock, coma & infection
related to excess bleeding and delayed
treatment.
BIBLIOGRAPHY
• Brunner &Suddarth’s, Textbook of Medical- Surgical Nursing, volume-2;
Twelfth edition; New Delhi; Wolters Kluwer pvt. Ltd; 2011; p.p- 2161-
2163.
• BrarNavdeepKaur, Rawat HC, Textbook of Advanced Nursing Practice, First
edition; New Delhi; Jaypee Brothers medical publishers (p) ltd; 2015; p.p-
405-413.
• Basher P. Shebeer and Khan, A concise textbook of Advanced Nursing
Practice, first edition; Bangalore; emeses medical publishers; 2015; p.p-
233-237.
• Clement I, The textbook of first aid and emergency nursing, 6th edition;
New Delhi; Jaypee brothers medical publishers (p) ltd; 2014; p.p- 120,63.
• www.hemorrhage.medline.co.in
• https://en.wikipedia.org/wiki/bleeding
• James H. Approach to the patient in shock,International journal of general
medicine,30 jan 2016;32(4);207-12
Shock

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Shock

  • 2. Introduction • Shock is a life threatening condition. lt is characterized by inadequate tissue perfusion that if untreated results in cell death. The supply of oxygen to tissues is essential in the maintenance of life and this can be ensured when circulatory system is functioning normally. • In 1923 Walter and Canner first worked for all conditions of shock. SHOCK
  • 4. CLASSIFICATIONOF SHOCK • Hypovolemic shock. • Cardiogenic shock. • Circulatory shock or distributive shock a. Septic shock. b. Obstructive shock. c. Neurogenic shock. d. Anaphylactic shock.
  • 5. Hypovolemic shock • This is the most common type of shock, due to insufficient circulatory volume • This occurs when there is loss in the intravascular fluid up to 15% to 25%. • That is a loss of 750 to 1300 ml of blood in a 70 kg person
  • 7. PATHOPHYSLOLOGY Decreased blood volume Decreased venous return Decreased cardiac output Decreased tissue perfusion Decreased cellular metabolism
  • 8. CLINICAL MANIFESTATIONS • Decreased cardiac output • Hypotension • Altered tissue perfusion • Cool and clammy skin • Cyanosis or PaIe skin color (pallor) • A rapid, weak, thready pulse • Thirst and dry mouth, due to fluid depletion • Fatigue due to inadequate oxygenation • Anxiety, restlessness, altered mental state
  • 9. CARDIOGENIC SHOCK It is caused by the failure of heart to pump effectively.  This is due damage of heart muscles, mostly from myocardial infarction.
  • 11.
  • 12. • Decreased cardiac contractility Decreased stroke volume and cardiac output Pulmonary congestion decreased tissue perfusion decreased coronary artery perfusion volume
  • 13. CLINICAL MANIFESTATIONS • Pulmonary edema • Increased central venous pressure • Distended jugular veins due to increased jugular venous pressure • Weak or absent Pulse due to tachyarrhythmia • Shortness of breath • Chest pain
  • 14. SEPTIC SHOCK • It is secondary to infections by micro organisms. • Septic shock is caused by an overwhelming systemic infection and inflammation resulting in vasodilation • Most common gram negative bacteria such as Escherichia coli, Proteus species, Klebsiella pneumoniae • Which release an endotoxin and produce adverse biochemical,immunological & neurological effects which are harmful to the body.
  • 16. Pathophysiology Severe localize infection of gram –ve bacili Bacterial invasion into bloodstream(septicemia) Inflammatory response Endotoxin release into circulation Histamine & other chemical mediator release vasodilation Increased capillary permeability Inadequate tissue perfusion to vital organ Multiple organ failure I
  • 17. CLINICAL MANIFESTATION • Pyrexia due to increased level of cytokines • Systemic vasodilation resulting in hypotension • Warm and sweaty skin due to vasodilation • Reduced contractility of the heart • Increased levels of neutrophils • Increased heart rate • Increased cardiac output
  • 19. Clinical manifestations • Tachycardia • Tachypnea • Hypotension • Cyanosis • Oliguria • Altered mental status • jugular veins may be distended • Pulsus paradoxus in case of tamponade
  • 20. Neurogenic shock • This is a very uncommon type of shock. • lt is most often seen in patients who have had and extensive spinal cord injuries. • The loss of autonomic and motor reflexes below level of injury results in loss of sympathetic control. • This leads to relaxation of vessels and peripheral dilation and hypotension.
  • 22. Pathophysiology Spinal cord injury Inhibit the sympathetic nerve stimulation Arterial & venous dilatation Arterial / venous blood pooling Hypotenson Bradycardia, warm dry flushed skin Decreased perfusion of vital organ Multisystem organ failure
  • 23. CLINICAL FEATURE • Hypotension • Altered mental status • Bradycardia • Skin that is warm and dry • Tachycardia and tachypnea • Cool and clammy skin • Priapism due to Peripheral nervous system stimulation
  • 24. Anaphylactic shock Anaphylactic shock is caused by severe reaction to an allergen, antigen, drug or foreign protein.  When a patient who has already produced antibodies to a foreign substance develops a systemic antigen antibody reaction. Antigen antibody provides mast cells to release vasoactive substance such as histamine or bradykinin that cause vasodilatation
  • 25.
  • 26. PATHOPHYSIOLOGY • Due to antibody responses • Release of histamine • Vasodilatation • Increased capillary permeability • Severe broncho constriction • Decreased oxygen supply and utilization • Inadequate tissue perfusion.
  • 27. CLINICAL FEATURE • Skin eruptions and large bumps • Localized edema, especially around the face • Laryngeal edema • Weak and rapid pulse • Breathlessness and cough • Tachycardia and tachypnea • Hypotension • Cyanosis • Urticaria and pruritus • Severe bronchospasm
  • 28. DIAGNOSIS OF SHOCK • Chest x-rays • CVP Measurement • Hemoglobin level measurement • Arterial Blood Gases (ABG) analysis • Urinalysis • Complete blood count • Blood, urine and sputum culture • Blood chemistry including kidney function tests • Cardiac catheterization and Coronary angiography • Echocardiogram and Electrocardiogram • Cardiac enzymes (troponin, CKMB) test • Computed tomography
  • 30. MANAGEMENT Management in all types of shock include the following: • Management of airway, breathing and circulation • Fluid replacement to restore intravascular volume • Vasoactive medications to restore vasomotor tone and improve cardiac function • Nutritional support to address metabolic requirement
  • 31. The ABCDE approach A B CD E Disability due to neurological deterioration Circulation & shock management Breathing & ventilation Airway & oxygenation Exposure & examination
  • 32. Airway • See respiratory pattern • Head tilt chin lift • Jaw thrust • Suction • Oral airways • Nasal airways • Nebulised adrenaline for stridor • Intubation • Cricothyroidotomy – Needle or surgical. • O2 administer,if airway open
  • 33. Breathing Consider ventilation with AMBU bag. Position upright if struggling to breath Specific treatment i.e.: β agonist for wheeze, chest drain for pneumothorax
  • 34. circulation • Position supine with legs raised – Left lateral tilt in pregnancy • IV access • Fluid challenge – colloid or crystalloid? • ECG Monitoring • Specific treatment
  • 35. Disability - assessment • AVPU (or GCS) – Alert, responds to Voice, responds to Pain, Unresponsive • Pupil size/response • Posture • BM • Pain relief
  • 36. Disability - interventions • Optimise airway, breathing & circulation • Treat underlying cause if drug induced causes. – i.e.: naloxone for opiate toxicity • Treat  blood glucosei,e hypoglycemia – 100ml of 10% dextrose (or 20ml of 50% dextrose) • Control seizures • Seek expert help for CVA or ICP
  • 37. Exposure & Examine • Remove clothes and examine head to toe front and back. – Haemorrhage, rashes, swelling, sores, catheter etc • Keep warm • Maintain dignity
  • 38.
  • 39.
  • 40.
  • 41.
  • 42.
  • 43.
  • 44. Complications • a. ARDS- (acute respiratory distress syndrome) • b. Multiple Organ Failure
  • 45. DEFINITION • Hemorrhage or bleeding is termed as escape or loss of blood from the circulatory system. • It may be internally (from blood vessels) and externally (through natural opening such as mouth, anus or vagina). It may be termed as exsanguination (complete loss of blood) and desanguination (massive blood loss).
  • 46. ETIOLOGY Traumatic injury Hematoma Incision Puncture wound Medical condition • Intravascular change • Intramural changes • Extra vascular changes Deficiency of coagulation factors Exposure to NSAIDS
  • 47. TYPES OF HEMORRHAGE • According to the vessels involved:- • Arterial hemorrhage:- It is bleeding from artery, which is bright red in color and sprouts as a jet, rises and falls in time with the pulse. • Capillary hemorrhage:- The blood oozes over the surface or comes out from capillary and is darkish red in color. • Venous hemorrhage:- bleeding from vein and is dark in color.
  • 48. • According to time of wound:- • Primary hemorrhage:- It is immediate hemorrhage which occurs when there is damage to any blood vessels and bleeding occur immediately e.g. cut on finger. • Reactionary or intermediate hemorrhage:- It occurs in first 24 hrs. after operation. E.g. operation of kidney and thyroid etc. • Secondary hemorrhage:- It is due to sloughing off the wall of blood vessel due to bacterial infection and action of enzyme such as acid pepsin on peptic ulcer.
  • 49. • Clinical classification of the hemorrhage:- • Revealed or external hemorrhage:- Bleeding is seen externally. • Concealed or internal hemorrhage:- The bleeding can not be seen externally. E.g. bleeding in cavities.
  • 50. • According to the American College Of Surgeons’ Advanced Trauma Life Support (ATLS) • Class I:- It involves upto 15% of blood volume and vital signs may not change. It does not require fluid resuscitation. • Class II:- It involves 15- 30% of total blood volume and tachycardia and narrowing of systolic & diastolic BP occur. The skin may look pale and be cool. It is treated by volume resuscitation with crystalloid (NS or RL) and does not require blood transfusion. • Class III:- It involves 30-40% of circulating blood volume. The patient’s BP will fall, heart rate increases and peripheral perfusion such as capillary refill worsen and mental status worsens. It is treated by fluid resuscitation with crystalloid and blood transfusion. • Class IV:- It involves loss of >40% of circulating blood volume. The limit of body’s compensation is reached and aggressive resuscitation is required to prevent death.
  • 51. • According to WHO grading of hemorrhage:- • Grade 0:- No bleeding • Grade 1:- Petechial bleeding • Grade 2:- Mild blood loss • Grade 3:- Gross blood loss requires transfusion (severe) • Grade 4:- Debilitating blood loss, retinal or cerebral fatality
  • 52. CLINICAL MANIFESTATIONS:- • Early sign & symptoms • Pain • Restlessness and anxiety • Feeling faint • Coldness (temperature slightly subnormal) • Slightly increased pulse • Pallor • Thirsty • Difference between systolic and diastolic pressure
  • 53. • Sign & symptoms after severe hemorrhage • Extreme pallor • Chilled sensation • Air hunger or hypoxia rapid thread pulse • Extreme low blood pressure • Extreme thirst • Diminished urine volume • Disability • Confused mental status • Bruising • Blindness, tinnitus and coma occur prior to death
  • 54. DIAGNOSTIC STUDIES:- • History collection:- • Cause and duration of injury • Sign & symptoms at the time and after bleeding • Amount of bleeding • h/o bleeding disorder and taking medications • quick management of bleeding • physical examination:- • vital signs, color of skin, capillary refill, mental status and skin turgor • site of bleeding and depth of injury • Assess sign & symptoms of bleeding.
  • 55. • Coagulation screening test:- • Platelet count- 1,50,000- 4,00,000 • Bleeding time- <8 min • Prothrombin time- 12-15 sec • Activated platelet thromboplastin time- 30-40 sec • Fibrinogen- 1.5- 4.0 g/l
  • 56. COMPLICATIONS:- • Hypovolemic shock • Infection • Thrombocytopenia • Shock/ coma • Death
  • 57. MANAGEMENT • First aid or immediate measures of external bleeding:- • Assess & maintain the victim’s ABCs. • Rest:- Rest the client in one place because frequent movement will increase the bleeding. • Direct pressure:- Apply firm pressure on the wound to stop the flow of blood. • Elevation:- Elevate the injured part to stop venous capillary bleeding above the heart level. • Dressing:- Once the bleeding is slowed or stopped, apply firm pressure sterile dressing over the bleeding site.
  • 58. • First aid for internal bleeding:- • Lay down the victim with head low and leg raise. • Reassure and keep him calm. • Immobilize and ambulant the patient. • Maintain the body temperature with thin blanket or coat. • Do not give anything to eat or drink to prevent aspiration. • Assess the victim’s vital signs and condition of injured site and measure oxygen and cardiac function. • Do not apply ice bags or hot water bottles on bleeding site. • Take the victim to the hospital as early as possible.
  • 59. • Fluid replacement:- • Insert IV cannula to provide blood replacement. • Withdrawal blood sample for analysis, typing and cross- matching. • Fluid replacement with crystalloid solution (RL & NS) and blood, depends on chemical estimation and the severity of blood loss. • Infuse fresh whole blood, platelets and coagulation factors
  • 60. • Additional measure:- • Administer humidified oxygen. • Monitor ECG and sign of cardiac arrest and shock. • Use anti- shock garments • Non- pneumatic anti-shock garments:- It is a first aid device used to treat hypovolemic shock and decrease bleeding from the part. • Pneumatic anti- shock garments:- It is an inflatable garments used to combat shock, stabilize fractures, promote hemostasis and increase peripheral vascular resistance
  • 61. • MEDICATIONS • Coagulation:- To coagulate the blood e.g. vitamin k(phytomenadion), antifibrinolytic drug( tranexamic acid) and blood products (factors VIII, IX & fresh frogen plasma). • Styptics:- To control bleeding and act as astringent. E.g. adrenaline & thrombin etc. • Surgical ligation:- It is used for internal hemorrhage and persistent bleeding.
  • 62. NURSING MANAGEMENT • Nursing assessment • Assess the ABCs , vital signs & ECG of the patient. • Assess the site of bleeding and duration & amount of bleeding. • Assess the sign & symptoms of patient. • Take history of bleeding disorders and use of medicine. • Perform physical examination of the patient.
  • 63. • Nursing diagnosis • Altered tissue perfusion related to bleeding. • Risk fo fluid volume deficit related to severe bleeding. • Ineffective breathing pattern related to decrease blood flow. • Hypothermia related to decrease blood supply. • Risk of complications: shock, coma & infection related to excess bleeding and delayed treatment.
  • 64. BIBLIOGRAPHY • Brunner &Suddarth’s, Textbook of Medical- Surgical Nursing, volume-2; Twelfth edition; New Delhi; Wolters Kluwer pvt. Ltd; 2011; p.p- 2161- 2163. • BrarNavdeepKaur, Rawat HC, Textbook of Advanced Nursing Practice, First edition; New Delhi; Jaypee Brothers medical publishers (p) ltd; 2015; p.p- 405-413. • Basher P. Shebeer and Khan, A concise textbook of Advanced Nursing Practice, first edition; Bangalore; emeses medical publishers; 2015; p.p- 233-237. • Clement I, The textbook of first aid and emergency nursing, 6th edition; New Delhi; Jaypee brothers medical publishers (p) ltd; 2014; p.p- 120,63. • www.hemorrhage.medline.co.in • https://en.wikipedia.org/wiki/bleeding • James H. Approach to the patient in shock,International journal of general medicine,30 jan 2016;32(4);207-12