This document provides an overview of haemorrhage or bleeding. It defines haemorrhage, describes the normal anatomy of blood vessels and composition of blood. It discusses the different types of haemorrhage including capillary, venous, arterial, primary, reactionary, secondary, revealed, and concealed. It also covers the WHO grading of haemorrhage, classification, causes, signs and symptoms. The document outlines the emergency management of haemorrhage including controlling external and internal bleeding. It concludes with discussing nursing care plans and assessments for patients experiencing haemorrhage.

4. CONTENTS
 Objectives
 Introduction
 Definition
 Normal Anatomy of Blood Vessels
 Composition of Blood
 Pathophysiology
 Types of Haemorrhage
 W.H.O Grading
 Classification of Haemorrhage
 Causes
 Signs & Symptoms
 Emergency Management
 Nursing Care Plan
 Summary
 References

5. OBJECTIVES
At the end of this presentation, participants will
be able to ;
 Gain knowledge about haemorrhage
 Define haemorrhage
 Describe anatomy of blood vessels & composition of
blood
 Differentiate different types of haemorrhage
 Elaborate classification
 Learn about W.H.O grading of haemorrhage
 Discuss causes and signs & symptoms of haemorrhage
 Manage haemorrhage in emergency

6. HAEMORRHAGE
INTRODUCTION
Haemorrhage is the loss of blood escaping
from the circulatory system. Bleeding can occur
internally, where blood leaks from blood vessels
inside the body, or externally, either through a natural
opening such as mouth, nose, ear, urethra, vagina or
anus, or through a break in the skin. Uncontrolled
bleeding can rapidly lead to shock and death.

7. HAEMORRHAGE
DEFINITION
The term haemorrhage refers to a large amount of
bleeding in a short time.
(Thygerson, Gulli & Krohmer 2006; pp:23)
An escape of blood from a ruptured blood vessel.
( Weller & Wells 1990; pp:217)
Haemorrhage is the loss of blood from a vessel.
(Malcolm R. Colmer 1986 ; pp:98)

8. ANATOMY OF BLOOD
VESSELS

9. B
L
O
O
D
P
L
A
S
M
A
55%
PROTEINS 7%
WATER 91.5%
PLATELETS
1,50,000-400,000
OTHER SOLUTES 1.5%
WHITE BLOOD
CELLS
RED BLOOD
CELLS
4.8 – 5.4 millions
ALBUMIN 54%
GLOBULIN 38%
FIBRINOGEN 7%
ALL OTHERS 1%
ELECTROLYTES
NUTRIENTS
GASES
REGULATORY SUBSTANCES
WASTE PRODUCTS
NEUTROPHILS
60 – 70%
LYMPHOCYTES 20 – 25%
MONOCYTES 3 – 8%
EOSINOPHILS 2 – 4%
BASOPHILS 0.5 – 1.0%
COMPOSITION OF BLOOD

10. CLOTTING MECHANISM
 Defense mechanism of circulatory system to leakage
 Involves complex series of reactions
 Adequate amount of calcium and all clotting factors are essential
 Clotting factors include; thromboplastin, prothrombin, thrombin and
fibrinogen
 Clot formed is called fibrin
 Platelets and other blood cells also play an important role in clot
formation

11. CLOTTING MECHANISM & SITE OF
ACTION OF ANTICOAGULANTS
Platelet breakdown Tissue damage
Oral anticoagulants
Sodium citrate
Heparin
THROMBOPLASTIN
THROMBIN
CALCIUM
PROTHROMBIN
FIBRINOGEN
FIBRIN (CLOT)

13. TYPES OF HAEMORRHAGE

14. TYPES OF HAEMORRHAGE
CAPILLARY
 Bleeding oozes steadily but
slowly
VENOUS
 flow steadily under less
pressure
doesn't spurt
ARTERIAL
 Bleeding spurts with each
heartbeat
 Difficult to control due to
pressure
 Most serious type as large
amount of blood may be lost in
short time

15. TYPES (cont)
PRIMARY
 Occurs immediately
 A cut finger or an operation incision
REACTIONARY(INTERMEDIATE)
 Occurs in first 24-hrs after operation
 More severe the operation, more likely it is to occur
 Operations on kidney, thyroid and breasts as well as total
hysterectomy are more liable to be followed by reactionary
haemorrhage
SECONDARY
 If infection is present, walls of blood vessels may be eroded and may
burst, causing what is known as secondary haemorrhage

16. TYPES (cont)
REVEALED OR EXTERNAL
 Bleeding can be seen
 From an open wound e.g.; abrasion, laceration, avulsion,
amputation etc.
 Through natural opening like mouth, nose, anus, vagina etc.
CONCEALED OR INTERNAL
 Bleeding cannot be seen
 Occurs in one of the body cavities such as abdomen
 Can result from;
 Blunt trauma or penetrating injury
 Acute or chronic medical illness

17. W.H.O GRADING

18. CLASSIFICATION OF HAEMORRHAGE
CLASS I CLASS II CLASS III CLASS IV
up to 15%(<750ml) of total
blood volume
15-30%(500-1500ml) of
total blood volume
30-40%(2000ml) of total
blood volume
>40%(>2000ml) of total
blood volume
Compensation Early Decompensation Late Decompensation
(Early irreversible)
Compensation Limited
(Irreversible)
Normal BP, Pulse, Respirations •Unable to maintain BP
•Tachycardia & tachypnea
•Decreased pulse strength &
narrow pulse pressure
•BP 70mmhg or below(systolic)
•Weak , thready rapid pulse
•Narrowing pulse pressure
•Tachypnea
•Pulse barely palpable
•Respirations : rapid, shallow and
ineffective
•Vasoconstriction
•Release of catecholamine
• Epinephrine
• Norepinephrine
- Anxiety, slightly pale
and clammy skin
•Significant release of
catecholamine
- Cool, clammy skin and thirst
- Increased anxiety and
agitation
-Normal renal output
•Anxiety and restlessness
•Increased LOC & AMS
•Pale, cold and clammy skin
•Decreased renal output
•Lethargic, confused and
unresponsive
•Extremely pale, cold and clammy
skin
•Diminished renal output
Fluid resuscitation is not usually
required
-volume resuscitation with
crystalloids is all that may be
required
- Blood transfusion is not usually
required
fluid resuscitation with crystalloid
-blood transfusions are usually
required
-aggressive resuscitation is
required to prevent death

19. CAUSES OF HAEMORRHAGE
 Multiple trauma
 Injury to the highly vascular area involving lungs, liver,
spleen, or prostate
 Any surgical or obstetric emergency
 Aneurysms
 Hypertension
 Septicemia (Gram negative & Meningococcal)
 Widespread Carcinomas
 Bleeding disorders

20. SIGNS & SYMPTOMS
EARLY SIGNS & SYMPTOMS
 Restlessness and anxiety
 Coldness ; temp is slightly subnormal
 Blood pressure is lowered
 Pulse rate is slightly increased
 Pallor
 Increased thirst
SIGNS & SYMPTOMS AFTER SEVERE HAEMORRHAGE
 Extreme pallor
 Coldness is profound
 Air hunger ; respirations are rapid & sighing
 Pulse rate is very rapid

21. SIGNS & SYMPTOMS (cont)
 Blood pressure is extremely low
 Thirst is extreme
 Volume of urine output is diminished
SIGNS & SYMPTOMS OF INTERNAL BLEEDING
 May appear quickly or take days to appear
 Bruising
 Painful, tender area
 Vomiting or coughing up blood

22. NURSING MANAGEMENT MEDICAL MANAGEMENT
EVALUATION
INTERVENTION
PLANNING
NURSING DIAGNOSIS
ASSESSMENT
Dependent
Independent
HISTORY
EXAMINATION
INVESTIGATION
TREATMENT
PAST HX
PRESENT HX
INSPECTION
PALPATION
AUSCULTATIO
N
GENERAL
SPECIFIC
GENERAL
SPECIFIC
SYMPTOMATIC

23. ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION
Obvious bleeding risk for deficient fluid
volume r/t large amount of
blood loss evidenced by
trauma
To stop bleeding INDEPENDENT
- Apply pressure
bandage
- Elevation(limbs
- Shift the patient to OT
(if needed) DEPENDENT
- IV coagulation
therapy(tranaxemic acid,
vit.k, FFP)
Bleeding stopped
Restlessness and anxiety
SOB
Lips cyanotic
Delayed or absent
capillary refill
BP below 70mmhg to
unobtainable
Ineffective tissue
perfusion related to
hypotension evidenced by
excessive blood loss
To make pt relax and
comfortable
To build systolic BP upto
above 90mmhg
To get strong peripheral
pulses
INDEPENDENT
- Counseling &
psychotherapy
- Attach cardiac monitor
-O2 inhalation
- Monitor SP02
continuously
- Monitor patient for
signs of shock
DEPENDENT
- IV fluid replacement
according to blood loss
Patient is relaxed
Breathing comfortable
Strong peripheral pulses
BP above 90mmhg
(systolic)
No signs of shock
Cold clammy skin
Temp below 35dc
Hypothermia related to
ineffective tissue perfusion
evidenced by hypotension
To build up body
temperature
To get skin warm
- cover patient with
blanket to warm up body
_ Monitor skin
temperature every 15
mints
Skin warm and dry
Temp 37dc or above

24. INVESTIGATIONS
GENERAL
All baseline investigations
SPECIFIC
PT, APTT to check clotting profile
ABG’s to check perfusion
CBC to review Hb, Hct levels, and platelet count
RFT’s to review renal profile when urine output is less or
diminished

25.  CONTROL OF EXTERNAL BLEEDING
 Place dressing over the wound and apply direct pressure
 If patient is bleeding from an arm or leg, elevate the injured area
above heart level to reduce blood flow
 Apply a pressure bandage (if bleeding is not controlled)
 If bleeding still cannot be controlled, apply pressure at a pressure
point (artery or vein) while keeping pressure on the wound

27.  CONTROL OF INTERNAL BLEEDING
 For minor internal bleeding (such as bruise on the leg from
bumping into the corner of a table), follow the steps of the RICE
procedure:
 Rest the injured area
 Ice or cold pack application over the injury
 Compression over injured area by applying an elastic bandage
 Elevation of injured arm or leg, if it is not broken
 For serious internal bleeding follow these steps
 Care for shock by raising legs 6 to 12 inches, and cover the patient to
maintain warmth
 If vomiting occurs, roll the patient onto his/her side to keep airway
clear
 Monitor breathing
 Identification and correction of underlying problem

28. SUMMARY
Haemorrhage is loss of blood from any blood vessel
due to some trauma or injury. It may also occur due to
some bleeding disorder or tumors. Bleeding may be
external or internal. Signs and symptoms depend on extent
of blood loss. It is classified into four classes according to
blood loss. W.H.O has set a standard grading schedule to
assess level of blood loss. Uncontrolled bleeding can lead
to hemorrhagic shock and even death. So immediate
measures are taken to control bleeding and blood products
and fluids are administered to replace fluid volume.
Patient is monitored continuously and assessed to check
patient’s response to therapy.

29. REFERENCES
Brunner & Suddhart’s Textbook of Medical Surgical
Nursing, vol 2, 12th
ed, 2010: pp 2161 – 2163
Colmer ; Moroney’s Surgery for Nurses, 16th
ed, 1981 : pp
98 – 106
Howard, Steinmann, Sheehy’s emergency nursing principles
& practice, 6th
ed, 2003 pp ;
Thygerson, Gulli & Krohmer, First Aid, 5th
ed, 2006 : pp 23
– 27
http://www.google.com/bleeding-wikipedia
http://europepmc.org/abstract/MED/6517266