Lesson plan on

haemorrhage
Submitted to: submitted by:
Mrs. rajbir kaur pooja rani
Lecturer m.sc (n)2 year
nd

s.b.d.s college of nsg s.b.d.s college of nsg

Submitted on:
SPECIFIC OBJECTIVES

At the end of the class student will able to provide the comprehensives care to the patient with hemorrhage.

CONTRIBUTORY OBJECTIVES:

At the end of the class student will be able to:

A. Introduction about haemorrhage.

B. Define haemorrhage.
C. Describe about incidence.
D. Enlist causes of haemorrhage.
E. Explain the pathophysiology of haemorrhage.
F. State the clinical manifestation of haemorrhage .
G. Recognize the diagnostic evaluation of haemorrhage.
H. Describe the management of haemorrhage.
I. Discuss the nursing management of patient with haemorrhage. .
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1. 2min Problem solving
method.

2. 2min Define hemorrhage. Hemorrhage is defined as a loss of blood What is the Loss of blood from PPT Define
from the body is called hemorrhage. definition of the body is called hemorrhage.
hemorrhage? hemorrhage.
3. 2min Explain how the Blood in the fluid form because the balance
hemorrhage occurs. between clotting and fibrinolysis.

When tissue get damaged

Prothrombin converted into its active form

thrombin ( in the presence of calcium)

Fibrinogen then transformed by thrombin to

fibrin

And then blood cells form clot

4. 4min Describe the factor FACTORS AFFECTING CLOTTING What are the factor Prothrombin and PPT Enlist the
affecting the ARE- affect the clotting? fibrinogen. factors
clotting. 1. Calcium affecting blood
2. Prothrombin clotting.
3. Fibrinogen
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1. CALCIUM-
 Calcium helps in clotting of
blood.
 This calcium is displaced
from the body by 3.8%
solution of sodium citrate etc.
2. PROTHROMBIN-
 It is formed from vit. K, a fat
soluble vitamin absorbed
from the small intestine.
 Its help in the clotting factors.
3. FIBRINOGEN-
 In the absence of fibrinogen
severe bleeding may occur.
 Its help in the phenomenon
known as fibrinolysis by
dissolving the fibrin
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5. 3min Enlist the types of A.ACCORDING TO THE VESSELS What are the types These are of three PPT What are the
hemorrhage. INVOLVE- of hemorrhage? types arterial, types of
a) Arterial hemorrhage capillary and hemorrhage?
b) Capillary hemorrhage venous
c) Venous hemorrhage hemorrhage.

a) ARTERIAL HEMORRHAGE-
 Blood loss from the artery is
known as arterial
hemorrhage.
 The blood is bright red.
 Blood loss is more rapid from
a vessel of corresponding.

b) CAPILLARY HEMORRHAGE-
 The blood oozes over the
surface of capillary and is
dark in color.

c) VENOUS HEMORRHAGE-
 The blood is los from vein is
known as venous
hemorrhage.
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 The blood dark in color.
 The rate of loss is much
severe than arterial
hemorrhage.

B) ACCORDING TO THE TIME OF

WOUND
a) Primary hemorrhage
b) Reactionary or intermediate hemorrhage
c) Secondary hemorrhage

a) PRIMARY HEMORRHAGE-
It is immediate hemorrhage which
occurs when there is damage to any
blood vessels and bleeding occurs
immediately.

b) REACTINARY OR
INTERMEDIATE HEMORRHAGE-
 It most occurs in first 24 after
operation.
 The major operation which
may leads to hemorrhage are
kidney operation, thyroid and
breast operation.

c) SECONDARY HEMORRHAGE-
 It is due to sloughing off the
wall of blood vessels.
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 The common cause of bacterial
infection.
 In this type the thinnest vessels
burst first and blood may be found
on the body.

C) ACCORDING TO THE CLINICAL

CLASSIFICATION OF HEMORRHAGE-
a) Revealed or external
b) Concealed or internal

A) REVEALED OR EXTERNAL-
It is a type when bleeding can be seen
externally.

B) CONCEALED HEMORRHAGE-
 It is the type when bleeding cannot
be seen externally.
 These bleeding occur into one of
the body cavities such as the
abdomen, into the lumen of hollow
organ such as intestine or into the
tissues.
 It is later become obvious. E.g. By
being vomited or per rectum.

6. 3min Write down the CLINICAL MANIFESTATION What is the It can be early and PPT List out the
clinical 1. EARLY clinical late pallor, feeling clinical
manifestation of 2. LATE manifestation of faint etc. menifestations
hemorrhage. hemorrhage? of
hemorrhage.
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EARLY CLINICAL MANIFESTATION-
 Restlessness and anxiety
 Feeling faint
 Coldness Slightly increase pulse
 Pallor
 Patient feel thirsty

LATE CLINICAL MANIFESTATION AFTER

SEVERE HEMORRHAGE-
 Extreme pallor
 Cold and clammy skin
 Air hunger
 Rapid thirsty pulse
 Extremely low blood pressure
 Diminished urine volume
 Blindness, tinnitus and coma occur priorto
death.
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7. 10min Describe the MANAGEMENTS- What are the It mainly involves PPT How will you
management of management the first aid manage
hemorrhage. 1. CONTROL OF EXTERNAL strategies for management and hemorrhage?
HEMORRHAGE hemorrhage? varies according
 Pad and bandage- to the types of
This is the simple method of hemorrhage.
applying direct pressure to a
bleeding wound.
 Digital pressure-
It is the pressure applied on the
point of artery supplying blood to
the area of wound.
 Elevation of the limb-
It will control venous hemorrhage.
It helpful in reduce the blood flow
to the area.
 Application of the tourniquet-
This is rarely require.
It should be 3-4 inches wide.
It can be a hanker chief, scarf or a
tie.
It may cause damage to the part
where there is no blood supply and
that can leads to gangrene.
 Surgical ligation-
Under the surgical procedure tying
the vessels where the blood is
coming.
 Coagulation-
It can be use to coagulate the blood.
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 Pack-
This method use in the operation
theatre for temporary or sudden
hemorrhage.
Pack is applied over the
hemorrhage.
 Styptics-
This is also use in bleeding.
It mainly acts as astringents such as
snake venom and adrenaline.
Helps in controlling of bleeding.

FIRST AID TREATMENT IN CASE OF

SEVERE EXTERNAL BLEEDING-
 Bring the sides of the wound together and
press firmly.
 Press on the pressure point for 10-15 min.
 Place the casualty in a comfortable position
and raise the injured part and reassure them.
 Apply the clean pad larger than the wound
and press it firmly with the palm until
bleeding becomes less.
 If bleeding continues do not take off
original dressing but add more pads.

CONTROL OF INTERNAL HEMORRHAGE-

 If the bleeding from the bladder then the
bladder should empty.
 Packing: It can be effective in control
bleeding .
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 Packing can be done with the gauze soaked
in adrenaline is effective.
 Surgical ligature: Surgical ligature can be
done in case of ruptured spleen.
 Internal pressure: This may be applied by
the balloon of triluminal tube in bleeding
esophageal varies or by the balloon of
Foley’s catheter in the prostatectomy cavity.

FIRST AID TREATMENT IN CASE OF

INTERNAL BLEEDING-
 Lay the causality down with head low, raise
his legs by use of pillow.
 Keep him calm and relaxed. Reassure him.
 Do not allow him to move.
 Keep up the body heat with thin blankets or
coat.
 Do not give him any things to eat aspiration
may occur.
 Take him to the hospital as much as
possible.
 Transport gently.

RESTORATION OF BLOOD VOLUME-

 BLOOD VOLUME CAN RESTORE BY
BLOOD TRANSFUSION-
 INDICATION ARE-
 Severe hemorrhage.
 Under the major case hemorrhage can be
there to replace blood loss need to do blood
transfusion.
 Severe burn.
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SHOCK
DIFINITION:
1. 3min Define the shock. Shock can be defined as a condition in which What is the Shock is defined PPT Define shock.
systemic blood pressure is inadequate to deliver definition of as a inadequate
oxygen and nutrients to supply to vital organ and shock? deliver of the
cellular function. oxygen and
nutrients to the
vital organ.
CAUSES:
2. 3min Enlist the causes of  Sudden malfunction of heart: It is mainly due to PPT List out the
shock.  MI What are the sudden causes of
causes of shock? malfunction of the shock
 Trauma
heart, any injury
 Toxemia- viral or bacterial
or effects of
 Effects of drugs drugs.
 Deficient oxygenation of blood in lungs
 Thoracic injury
 Obstruction in pulmonary artery by an
embolism.
 Reduction in blood volume:
 Internal or external hemorrhage
 Burn
 Peritonitis
 Intestinal obstruction
 Severe diarrhea or vomiting.
 Miscellaneous
 Noxious stimuli such as pain, if
severe will cause vasodilatation and
start pulling the blood over that
area.
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3. 4min Explain the path PATHOPHYSIOLOGY- Describe the path Cell produce Chalk Explain the
physiology of physiology of energy to produce board path
shock. Lack of oxygen supply and nutrient in cells shock. ATP. Low physiology of
energy produces shock.
acidic
Cell produce energy through anaerobic metabolism intracellular
to produce ATP environment.
Normal cell
function affected,
Low energy yielding from nutrients and produces cell swells. Cell
acidic intracellular environment structure damage

Normal cell function affected, cell swells and cells

membrane become more permeable, allowing fluid
and electrolytes to move out and into the cells

Sodium potassium pump impaired due to this

Cell structure damage

Cell death occur

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04. 10min Write down the STAGES OF SHOCK: What are the Stages of shock Chart Explain in
stage of shock. stages involve in are- Initial, detail about
1. Initial stage shock? compensatory, stages of
2. Compensatory stage progressive, shock.
3. Progressive or decompensate refractory stage
4. Refractory or Irreversible

1. INITIAL STAGE-
During this stage Inadequate perfusion

Cellular hypoxia Mitochondria unable to produce

ATP

Due to lack of oxygen and the cell membranes

Will damaged

Leakage to the extracellular fluid Cell perform

anaerobic respiration

Build up a lactic and pyruvic acid Systematic

metabolic acidosis

Multisystem failure and results in shock

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2. COMPENSATORY STAGE-
 The patient blood pressure remains within
normal limits.
 Vasoconstriction, increased heart rate and
increased contractility of the heart
contribute to maintaining adequate cardiac
output.
 This results from stimulation of the
sympathetic nervous system and subsequent
release of catecholamine ( epinephrine and
norepinephrine )
 The body shunts blood from organs such as
the skin, kidneys, and gastrointestinal tract
to the brain and the heart to ensure adequate
blood supply to these vital organs.
 As a result, the patient skin is cold and
clammy, bowel sounds are hypoactive and
urine output decreased.
05. 2 min State the clinical CLINICAL MANIFESTATION –
manifestation of  Normal blood pressure What are the Clinical PPT What are the
shock.  Metabolic acidosis clinical manifestations are clinical
manifestations of metabolic manifestations
 Respiratory alkalosis
compensatory? respiratory of
 Deep rapid respiration
acidosis alkalosis, compensatory?
 Changes in LOC restless etc.
 Restlessness
 Tachycardia
 Dry clammy skin
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06. 4min Explain the MEDICAL MANAGEMENT- What are the Mainly the PPT What are the
medical  The management strategies are: medical medicine and the medical
management of  Fluid replacement: Crystalloids like are management of fluid replacement management
compensatory ringer’s solution and normal saline most this stage? are the of this stage?
stage. common used. management
 Medication therapy: Ionotropic agents ( strategies.
Dopamine, dobutamine, epinephrine )

3. PROGRESSIVE STAGE ( DE-

COMPRESATING)-
 In the progressive stage of shock, the
mechanism that regulates blood pressure
can no longer compensate.
 Blood pressure falls below normal limits
that are less than 90mmHg.
 Overworked heart becomes dysfunction: the
body inability to meet increased oxygen
requirements produce ischemia; and cause
the myocardial depression.
 At this stage the patient prognosis worsens.

CLINICAL MANIFESTATION-
 Confusion
 Dilated, sluggish pupil
 Thirst rapid shallow breathing
 Tachycardia
 Cool moist skin
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 Slow capillary refill
 Muscle weakness
 Hypotension

4. REFRACTORY ( IRREVERSIBLE )
 At this stage the vital organs have failed and
the shock can no longer be reversed.
 Brain damage and cell death will occur.
 Death of the person will occur immediately.

CLINICAL MANIFESTATION-
 Unconsciousness
 Absence of reflexes
 Dilated sluggish pupil
 Severe thirst
 Bradycardia
 Cyanosis
 Absence of bowel sounds
 Anuria
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07. 6min Identify the CLASSIFICATION OF SHOCK- What can be the Classification of PPT What can be
classification of classification of shock are the
shock. 1. HYPOVOLEMIC SHOCK shock? hypovolemic classification
2. CARDIOGENIC SHOCK shock, of shock?
3. CIRCULATORY OR DISTRIBUTIVE cardiogenic
SHOCK shock, circulatory
shock
1. HYPOVOIMIC SHOCK-
 This most common type of shock, due
to insufficient circulatory volume.
 In this shock there is decreased in
circulatory volume to level that is
inadequate to meet body’s need tissue
oxygenation.
 CAUSES ARE: Exercise, fluid loss
from the circulatory system by bleeding,
burns or diarrhea.

PATHOPHYSIOLOGY-

Decreased blood volume

Decreased venous return

Decreased cardiac output

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Decreased tissue perfusion

Decreased cellular metabolism

2. CARDIOGENIC SHOCK
 It is caused by the failure of heart to
pump an adequate amount of blood to
vital organs.
 This leads to reduction in cardiac
output.
 It can be result from myocardial
infarction.
 CAUSES- Cardiomyopathy, congestive
heart failure.

PATHIPHYSIOLOGY-

Decreased cardiac contractility

Decreased cardiac output and stroke volume

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Pulmonary congestion decreased tissue perfusion

decreased coronary artery perfusion volume.

3. CIRCULATORY OR DISTRIBUTIVE
SHOCK –
 In this there is no loss of blood from body
but this occurs due to dilatation of blood
vessels.
 There is no enough blood return to the heart
which leads o inadequate tissue perfusion.
 The most common causative organism of
septic shock is gram negative bacteria.
 These infection leads to vasodilatation.
 Vasodilatation leads to circulatory shock.
 It is sub divided into
 A. Septic shock
 B. Obstructive shock
 C. Neurogenic shock
 D. Anaphylactic shock


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a. SEPTIC SHOCK-

Due to infection by micro organism

Vasodilation

Maldistribution of blood volume

Decreased venous return

Decreased stroke volume

Decreased cardiac output

Decreased tissue perfusion

b. OBSTRUCTIVE SHOCK-
Obstruction of blood flow results cardiac
arrest. E.g. Pneumothorax, pulmonary
embolism and aortic stenosis.
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c. NEUROGENIC SHOCK-
 It is most often seen in patient who
have had and extensive spinal cord
injuries.
 The loss of autonomic and motor
reflexes below levels of injury
results in loss of sympathetic
control.
 This leads to dilation and
hypotension, dry skin, Bradycardia.

PATHOPHYSIOLOGY-

Spinal trauma

Inhibit the sympathetic nerve

stimulation

Loss of function below the level of injury

Venous vasodilation

Decreased venous return

Decreased stroke volume

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Decreased cellular oxygen supply

Impaired cellular metabolism

d. ANAPHYACTIC SHOCK-
 Anaphylactic shock is caused by
severe reaction to an allergen,
antigen, drug or foreign body.

PATHOPHYSIOLOGY-

Due to antibody response

Release of histamine

vasodilation
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Increased capillary permeability

Severe broncho constriction

Decreased oxygen supply and utilization

Inadequate tissue perfusion

DIAGNOSTIC FINDINDS-
 History taking.
 Assessment of patient symptoms for
shock.
 Conduct head to toe examination
for sig of shock.
 Assess the neurological status for
LOC.
 Assess for the cardiovascular status.
Check for blood pressure.
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 Assess for integumentary status.
Check for skin color, cold and
clammy skin, cyanosis.
 Assess for gastro intestinal status.
Hypoactive bowel sounds.
 Assess for the metabolic status.
 Blood studies reveal acidic blood
PH with low circulatory carbon
dioxide.

FIRST AID IN SHOCK –

 Reassure the causality.
 Lay him down on his back
comfortably with head low and
turned to one side.
 Loosen the clothing around the
neck, chest and waist.
 Give him sips of water if he is
thirsty.
 Check pulse, respiration and level
of consciousness.
 Transport the causality immediately
to hospital.

08. 6min Explain the MANAGEMENT OF SHOCK- What are the Fluid replacement PPT Explain the
management of management and medication management
shock. 1. PHARMACOLOGICAL strategies for require for the of shock.
MANAGEMENT shock? management for
2. NURSING MANAGEMENT shock.
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1. PHARMACOLOGICAL
INTERVENTION-
a. Hypovolemic shock-
 Volume expanders like normal
saline and ringer lactate solution are
used more frequently.
 Anti diarrheal agents for diarrhea
like lopramide.

b. Carcinogenic shock-
 Volume expanders.
 Positive cardiac Ionotropic like
dopamine, dobutamine and
epinephrine.
 Vasodilators- Nitroglycerine,
sodium nitroprusside etc.
 Vasoactive and antiarrythmia
medication- Epinephrine.

c. Distributive shock-
 Volume expanders.
 Positive cardiac Ionotropic

d. Obstructive shock-
 Volume expanders.

e. Septic shock-
 Broad spectrum antibiotics like
taxim etc.
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f. Neurogenic shock-
 Hypoglycemia- glucose is rapidly
administered.

g. Diuretics- These use to treat the oliguria and

increase urine output.
h. Sodium bicarbonate- It is use to treat
metabolic acidosis that occurs as shock
progress.
i. Bronchodilators- Like atophine,
aminophyline, used relieve broncho
constriction in case of anaphylactic.

09. 20min Discuss the NURSING MANAGEMENT- What are the Its include all the PPT What are the
nursing nursing monitoring the nursing
management.  Provide supplemental oxygen therapy to the management vital signs of the management
patient. strategies for patient, ABG strategies for
 Monitor the ABG value to assess the patient shock? analysis, o2 shock?
response to oxygen therapy. administration is
 Continuous monitoring of vital sign should require patient
be done. with the shock.
 Check urine output.
 Maintain nutritional status of the patient.
 Administered prescribed medication to the
patient.
 Follow the 6 rights of administrating the
medication.
 Evaluate the effectiveness of drugs.
 Give psychological support to patient and
relatives.
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NURSING DIAGNOSIS-
1. Fluid volume deficit related to hemorrhage
characterized by oliguria.
Goal: Maintain the normal fluid volume.
 Assess for the sign and symptoms
for bleeding.
 Check the vital sign of the patient.
 Give comfortable position to the
patient.
 Monitor intake and output.
 Administer oxygen as ordered.
 Administered the intravenous fluid
as ordered.

2. Decreased cardiac output related to

ineffective cardiac function characterized by
low blood pressure.
Goal: Maintain normal cardiac output.
 Assess for the vital sign.
 Keep the patient in pulse
oximetery.
 Monitor the intake output of the
patient.
 Provide the comfortable position as
patient require.
 Administered IV fluids as ordered.
 Administered Ionotropic agents like
dopamine.
 Follow the 6 rights of drug
administration.
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 Documentation of the drugs.
 Evaluate the effectiveness of the
drugs.

3. Altered peripheral tissue perfusion related to

vasoconstriction characterized by edema.
Goal: Reduce the edema.
 Assess for extent of fluid retention.
 Monitor daily weight of the patient.
 Monitor the intake output strictly.
 Keep the patient in pulse oximetery.
 Elevate the limb.
 Give the diuretics as ordered.
 Administered the drug.
 Follow the 6 right of drug
administration.
 Document the drug.
 Evaluate the effectiveness of drug.

4. Alteration in nutritional pattern less than

body requirement related to illness
characterized by decreased oral intake.
Goal: Patient will have adequate nutrional
pattern.
 Assess the nutritional status of the
patient.
 Monitor daily weight and identify
weight loss.
 Ask for patient likes and dislikes.
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 Provide the food in attractive
manner.
 Ask for any allergy to any food
products.
 Document the food allergy.
 Consult the dietician for food
recommended for the patient.

5. Risk for infection related to invasive

procedure characterized by interruption of
skin integrity.
Goal: Patient will be prevented from
infection.
 Assess for the skin integrity.
 Take precaution to prevent
nosocominal infection.
 Wash hand frequently.
 Use aseptic techniques.
 Monitor for site of infection for sign
of infection.
 Change the intravenous catheter
every three days.
 Provide indwelling catheter care
frequently.
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10. 2min Summarize the Shock can be defined as a condition in which
topic hemorrhage systemic blood pressure is inadequate to deliver the
and shock. oxygen and nutrients to supply to vital sign.
It is classified into three. That are hypovolemic
shock
Cardiogenic shock, circulatory shock. Management
for the shock is replacement of the fluid,
ionotropics, diuretics, sodium bicarbonate,
vasodilators.

ASSIGNMENT-
Write down the complication of shock?

CONCLUSION-
At the end of my teaching I would like to give
thanks to Mam Mrs.Rajbir, Lecturer for her
guidance throughout the study and my class mates
for their support.
BIBLIOGRAPHY

 Bhasker Shebeer P., A concise text book of advanced nursing practice,4th edition,
2012, EMMESS Medical Publisher,Pg. no.230-241
 Chintamani, Lewis's Medical Surgical nursing,7 edition, 2011, Published by
Elsevier,Pg no.109-135
 Manik Sharon, Lewis Medical Surgical nursing,4th edition, Mosby, 1996, Pg no. 85-
115
 M J Black, Medical surgical nursing,5th edition,1998, Harcourt brace and company
Asia Pvt LTD,Pg no. 678
 Suddarth’s and Brunner, Text book of medical surgical, 10th edition, 2004,
Lippincott Williams welkin, Pg no. 2153-2154,1392
 htt://en.wikipedia.org/wiki/pain
BIBLIOGRAPHY

 Bhasker Shebeer P., A concise text book of advanced nursing practice,4th edition,
2012, EMMESS Medical Publisher,Pg. no.230-241
 Chintamani, Lewis's Medical Surgical nursing,7 edition, 2011, Published by
Elsevier,Pg no.109-135
 Manik Sharon, Lewis Medical Surgical nursing,4th edition, Mosby, 1996, Pg no. 85-
115
 M J Black, Medical surgical nursing,5th edition,1998, Harcourt brace and company
Asia Pvt LTD,Pg no. 678
 Suddarth’s and Brunner, Text book of medical surgical, 10th edition, 2004,
Lippincott Williams welkin, Pg no. 2153-2154,1392
 htt://en.wikipedia.org/wiki/pain
 Lesson plan on
shock
Submitted to: submitted by:
Mrs. rajbir kaur pooja rani
Lecturer m.sc (n)2 year
nd

s.b.d.s college of nsg s.b.d.s college of nsg

Submitted on:
SPECIFIC OBJECTIVES

At the end of the class student will able to provide the comprehensives care to the patient with shock.

CONTRIBUTORY OBJECTIVES:

At the end of the class student will be able to:

A. Introduction about shock .

B. Define shock .
C. Describe about incidence.
D. Enlist causes of shock .
E. Explain the pathophysiology of shock .
F. State the clinical manifestation of shock .
G. Recognize the diagnostic evaluation of shock.
H. Describe the management of shock .
I. Discuss the nursing management of patient with shock . .