Nursing care for a patient with acute hemorrhage

Set of activities performed by the nurse for the decrease or elimination of rapid and excessive blood loss.

Objectives:

– To urgently provide the necessary care to stop the bleeding. – Decrease the anxiety of the patient and family.

Equipment:

– Pressurizer. – Equipment necessary for Oxygen Therapy. – Equipment needed for Bladder Catheterization. – Equipment needed for Peripheral Catheter Insertion Technique. – Equipment necessary for Fluid Therapy Insertion. – Equipment necessary for Venous Blood Sampling. – Sphygmomanometer. – Stethoscope.

Material:

– Non sterile gloves. – Sterile compresses and gauze. – Specific medication. – Necessary material for oxygen therapy. – Material needed for Bladder Catheterization. – Necessary material for Peripheral Catheter Insertion Technique. – Necessary material for Fluid Therapy Insertion. – Material necessary for Venous Blood Sampling. – Nursing records.

Procedure:

– Assess general condition of the patient: skin and mucous membrane coloration, skin characteristics. – Place the patient in bed in a position appropriate to their situation. – Ask for help and notify the physician. – Reassure the patient and family. – Preserve the patient’s privacy. – Observe the amount and nature of blood loss. – Observe for mucous membrane bleeding, hematoma after minimal trauma, presence of petechiae. – Identify cause of bleeding. – Put on disposable gloves – Compress the bleeding site if external. – Take HR, RR and BP. – Administer oxygen in goggles at 2-3 liters per minute.

– Maintain 1-2 thick venous lines, cannulate peripheral line if the patient does not have one. – Draw venous blood for CBC, CBC, coagulation study and crossmatch, if prescribed by physician. – Perfuse the serum prescribed by the physician while awaiting transfusion, if necessary. – Prepare emergency medication while waiting for medical orders. – Inform the patient and family at all times of the procedures being performed in order to alleviate anxiety. – Perform bladder catheterization. – If it is decided to intervene the patient, prepare the transfer according to procedure 1.3. – In case of cardiorespiratory arrest, act according to procedure 12.9. – Identify the tubes with the patient’s data and send them to the laboratory with the analytical report. – Record in the nursing documentation: procedure performed, date and time, incidents, location of bleeding, amount, water balance, cons- tants, medication administered and patient response.