Haemorrhage

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HaemorrhageIntroduction Haemorrhage is the loss of blood from blood vessel. The blood loss is described as extra vasated(outside the vessel) . Blood may be lost from all three types of vessels , the arteries, the veins or capillaries. The type of haemorrhage is named accordingly. Bleeding which occurs as soon as vessel is divided is known as primary haemorrhage. If the patient is collapsed the vessel may not bleed immediately, but as recovery takes place, the blood pressure rises and bleeding occurs. This is known as reactionary or intermediate haemorrhage. Haemorrhage can involve all the blood vessels.Natural arrest of haemorrhage

Adequate amount of calcium is required and all the clotting factors are essential for the natural arrest of haemorrhage. The blood in the circulation is kept fluid by a fine balance between clotting and fibrinolysis.

When a tissue is damaged

Prothrombin is converted into its active form thrombin

(in the presence of calcium)

Fibrinogen then transformed by thrombin to fibrin

Mesh is formed by platelets and other blood cells to form clot

Factors affecting clotting

Calcium calcium helps in the clotting of blood. Calcium can be displaced from the blood by 3.8% solution of sodium citrate, acid citrate dextrose solution, citrate phosphate dextrose solution, ethylenediamine tetra-acetic acid (EDTA) . acid citrate dextrose and acid citrate phosphate solutions are used to prevent clotting of stored blood.Prothrombin - it is formed from vitamin K, a fat soluble vitamin absorbed from small intestine.a patient suffering from obstructive jaundice will not absorb vitamin k and therefore they are liable to bleed if operated upon. For this reason vitamin k injection is given so as to restored the prothrombin level of blood.

Fibrinogen It is the precursor of fibrin. In the absence of fibrinogen severe bleeding may occur, fibrinogen are the substances which dissolve fibrin by a phenomenon known as fibrinolysis. The fibrinolytic activity of blood may be increased:

In complicated obstetric cases associated with haemorrhage. After strenuous activity.

In presence of some malignant growth.

The patient suffering from increased fibrinolysis will show reduced evidence of clotting. They may be treated by neutralization of the fibrinolysis by the administration of fibrinogen.

Types of haemorrhage (according to the vessels involved)1. Arterial haemorrhage

2. Capillary haemorrhage

3. Venous haemorrhage

Arterial haemorrhage When blood loss is from artery is known as arterial haemorrhage. The blood is bright red and spurts with the heart beat. The escape is from both ends of vessels not only from nearer to the heart. Blood loss is more rapid from a vessel of corresponding size.

Capillary haemorrhage The blood oozes over the surface of capillary and is darkish red in color oozing over several hours can result in considerable blood loss.

Venous haemorrhage When the blood loss is from vein then it is known as venous haemorrhage. The blood is dark red in color, ther is no spurting and rate of loss is much less severe than arterial haemorrhage. When there is injury to large vessels then it will be a serious matter. A further danger is that air may be sucked into the damaged vein giving rise to fatal air embolism which the blood and air form foam.(According to the time of wound)

1. Primary haemorrhage

2. Reactionary or intermediate haemorrhage

3. Secondary haemorrhage

Primary haemorrhage It is immediate haemorrhage which occurs when there is damage to any blood vessel and bleeding occurs immediately. E.g cut on a finger or operative incision.

Reactionary or intermediate haemorrhage It occurs in first 24 hours after operation. The more severe the operation the more likely it is to occur especially after the patient has recovered from circulatory collapse, operation on kidney, the thyroid and the breast as well as total hysterectomy are particularly liable to be followed by reactionary or intermediate haemorrhage.Secondary haemorrhage It is due to sloughing of the wall of blood vessel. The commonest cause is bacterial infection, but in the absence of infection it may cause by action of an enzyme e.g. acid pepsin on peptic ulcer. In this type the thinnest vessels burst first and blood may be found on the dressings. This should be reported immediately because larger vessels can also be eroded in another few days.

(Clinical classification of the haemorrhage)

1. Revealed or external

2. Concealed or internal

Revealed haemorrhage it is a type when bleeding can be seen externally.

Concealed haemorrhage it is that type when bleeding cannot be seen externally. The bleeding occurs into one of the body cavities such as the abdomen, into the lumen of hollow organ such as intestine or into the tissues. It may later become obvious e.g. by being vomited or per rectum or by bruising and swelling on the surface of the body. Since it must be diagnosed on the presence of symptoms and signs alone.Signs and symptoms of haemorrhage

Early signs and symptoms:

Restlessness and anxiety

Faintness

Coldness (temp.slightly subnormal-98degree farenhiet)

Slightly increased pulse

Pallor

Patient feel thirsty

Signs and symptoms after severe haemorrhage

Extreme pallor (face will be ashen,white and clammy with cold sweat)

Coldness (temp. 97degree farenhiet)

Air hunger ( patient literally gasps for breaths and respirations will be rapid)

Rapid thready pulse

Extremely low blood pressure

Extreme thirst

Diminished urine volume(acute renal failure )

Blindness , tinnitus and coma occurs prior to death

Effects of haemorrhage

Cardiac cycle- cardiac cycle is the repetitive pumping action that produces pressure changes that circulates blood throughout the body. It will get disturbed i.e. it pumps less amount of blood to different organs.

Cardiac output normal cardiac output is 5-6 lt/min

The total amount of blood separately pumped by each ventricles per minute usually expressed in lt per minute. It can be increases upto 30 lt/ min. in the time of exercise. It is determined by multiplying the heart rate by volume of blood ejected by each ventricle during each beat.

Control of external haemorrhage:

Pressure will control all types of external haemorrhages. According to its severity ther is a choice of methods.

Pad and bandage this is the simple method of applying direct pressure to a bleeding wound and is applicable to vast majority of cases. It is effective and causes no damage.

Digital pressure it is the pressure applied on the point of artery supplying blood to the area of wound. This will control haemorrhage temporarily and is called indirect pressure. It is particularly valuable in the neck where other methods are not applicable.

Elevation of the limb it will control venous haemorrhage. This is a classical method of dealing with a sudden haemorrhage from a ruptured varicose vein of leg.

Application of tourniquet this is rarely required except for control of a torrential haemorrhage from the limb. A temporary tourniquet may have to be devised in sudden emergency. It should be 3-4 inches wide. It can be a hancerchief, scarf or a tie.The great danger of tourniquet is that if it is left on for more than 30 minutes then gangrene of the limb may occur. The time of application and removal of tourniquet should be recorded. The limb on which tourniquet is applied should be kept elevated afterwards to control edema which may result from venous congestion.

Surgical ligation it is necessary if the bleeding is persistent.

Coagulation it is the coagulation of bleeding point with the electrocautry. It can be used to coagulate the blood from small blood vessels. Pack it will temporarily control severe haemorrhage. This method is used in operation theatre to control temporary or sudden haemorrhage. The theatre nurse should always have a pack readily available for this emergency.

Styptics these are also used to control bleeding and they act as astringents. Such as snake venom or adrenaline may be used locally in certain cases.trombin and gel foam can be used in some cases such as in low pressure bleeding from venules and capillaries.First aid treatment in case of severe external bleeding:

Bring the sides of wound together and press firmly.

Press on the pressure point for 10-15 min.

Place the causality in comfortable position and raise the injured part and reassure him.

Apply a clean pad larger then 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.

Bandage it but not too tightly.

Control of internal haemorrhage:

The following methods can be used to control bleeding. The organ is emptied of blood cloy if possible: in case of severe bleeding from bladder, a catheter is passed and bladder is emptied.

The vessels are encouraged to contract: a lot of saline or sodium bicarbonate to which a few drops of adrenaline solution have been added ,is of great value in washing the organ. This can be repeated every two hourly. The use of ergometrine after the birth of placenta is an example of stimulating the vessel to contract. Pittosin i/v may be effective in control of bleeding from esophageal varices.

Packing: it can be done with gauze soaked in adrenaline is effective. Surgical ligature: surgical ligation can be done in case of ruptured spleen.

Internal pressure: this may be applied by the balloon of triluminal tube in bleeding esophageal varices or by the balloon of foleys catheter in the prostatectomy cavity.

First aid treatment in case of internal bleeding

Lay the casuality down with head low , raise his legs by use of pillow.

Keep him calm and relaxed. Reassure him.

Donot allow him to move.

Keep up the body heat with thin blankets or coat.

Do not give anything to eat or drink aspiration may occurs. Do not apply ice bags or hot water bottles to chest or abdomen.

Take him to the hospital as early as possible.

Transport gently.

Restoration of blood volume

Blood volume can be restored by blood transfusion. Indications for blood transfusion are:

1. to counteract the effect of severe haemorrhage and replace blood loss.

2. to prevent shock in operations where blood loss is considerable such as rectal resection , hysterectomy and arterial surgery.

3. in severe burns to make up for blood lost by burning but only after plasma and electrolyte have been replaced.4. to correct severe anaemia from cancer , marrow aplasia and similar condition and from slow continuous haemorrhage. In blood transfusion as in all intravenous injections, the tubing and other portion of the delivery apparatus must be free from air.

Transfusion under increased pressure:In some circumstances usually of large rapid blood loss it my be necessary to transfuse blood more quickly than possible by the simple gravity drip method. Following methods can be used:

Pressure cuff this is an inflateable cuff placed around the bag of blood, when it is inflated it exert external pressure on the bag of blood, thus increasing the flow of blood into the patient.

Pressure pump administration some transfusion giving sets permits either gravity or pressure pump administration of blood.

Precautions during blood transfusion:

patient and transfusion apparatus should be kapt under constant supervision.

Blood must be transfused according to the rate prescribed by the doctor. Approx.25 drops per minute. Is the casual rate of blood transfusion which means that bag is transfused in four hours. Sufferers from cardiac , pulmonary diseases or sever anaemia must be transfused at the slow rate sometimes at 12 drops per minute.

Half an hourly pulse rate and temperature should be recorded.

If blood transfusion is for shock , the blood pressure and pulse rate should be recorded after each unit of blood.

All the patients should be watched for symptoms of transfusion reaction after first few ml of blood from each unit of blood, such as allergic reaction , pyrexia, air embolism , overloading , thrombophlebitis etc.

Haemorrhages from special sites :

The occurrence from special sites is designated by special terms:

Epistaxis : it is the bleeding from nose.

Haemoptysis : it is the expectoration of blood from lungs.

Haematemesis : it is the vomiting of blood.

Malaena : it is the passage of dark blood per rectum from a site high in intestinal tract.

Haematuria : it is the presence of blood in the urine.

Haemothorex : it is the bleeding into the chest. Haemoperitonium : bleeding into the peritoneum.

Menorrhagia : excessive menstruation at normal interval.

Haemopericardium : it is the bleeding into the pericardium.

Hematomyalia : it is the bleeding into the spinal cord.

Shock

Introduction : shock is the life threatening condition. It is characterized by inadequate tissue perfusion that if untreated results in cell death. The supply of oxygen to tissues is essential in the maintainence of life and this can be ensured when circulatory system is functioning normally.Historical background : In 1923 Walter and Cannor first worked for all conditions of shock.

Definition : Shock can be defined as a condition in which systemic blood pressure is inadequate to deliver oxygen and nutrient to supply to vital organs and cellular functions.

Shock is defined as a failure of circulation to supply adequate oxygen to the tissues.

Significance of shock: shock affects all the body systems. It may develop slowly or rapidly depending upon the underlying causes. During shock body struggles to survive, calling on all its haemostatic mechanism to restore blood flow and tissue perfusion. Therefore any patient with any disease sate may be at risk of developing shock.

Nursing care of patient with shock requires ongoing systemic assessment. Many interventions required in caring for the patient with shock call for close collaboration with other members of health care team and a physicians order. The nurse must anticipated such orders because need to be executed with speed and accuracy.Causes of circulation failure: circulation may fail from :

1. Sudden malfunction of heart : this may occur as a result of:-

Coronary artery occlusion with acute myocardial ischemia.

Trauma with structural damage to heart.

Toxemia viral or bacterial

Effects of drugs

2. deficient oxygenation of blood in lungs :- amongst many causes the following are the most important surgically.

Post operative atelectasis

Thoracic injuries particularly of chest , i.e. pneumothorex, crushing and laceration of lung Obstruction of pulmonary artery by an embolus.

Disturbances of lung function following surgery and anaesthesia.

3. reduction in blood volume ( oligaemia and hypovolemia ) : this may occurs from loss of :

whole blood haemorrhage ( internal or external )

plasma this is particularly significant in burns

water and electrolytes which occurs from peritonitis, intestinal obstruction , paralytic ileus , acute dilation of the stomach, severe diarrhoes and vomiting .

4. miscellaneous : there are number of other conditions that may lead to shocked state with low blood pressure.

Faintness

Acute anaphylaxis

Acute adrenal deficiency ( Addisons disease )

Overdosage of drugs e.g analgesics like pethidine

Following therapy with beta blocking agents

Noxious stimuli such as pain, if severe will cause vasodilation particularly of spleenic vessels with pooling of blood in the area. This is the mechanism of primary shock.

Compensatory MechanismWhatever the cause of sudden collapse there are certain compensatory physiological mechanism which occur.

Posture : A patient in acute circulatory failure falls down , he should be lie flat on the floor or better in head down position so that circulation can be improve towards heart.

Contraction of skin vessels : Contraction of arterioles and venules of the skin is usual so as to conserve the blood supply to the more vital organs. The application of heat dilates the skin vessels thereby aggravating the condition and should not be used.

Insensitivity : A very collapsed patient usually have little pain . large quantities of pain relieving drugs are unnecessary and in case are ineffective because they cannot be absorbed unless given by intravenous route.

Urinary secretions : These are diminished to conserve fluid in the body but it is also a sign that tissue perfusion is inadequate.

Heart rate accelerates : It occurs in most forms of circulatory failure with the important exception of faint. It is an attempt to ensure that remaining fluid is circulated as rapidly as possible thereby providing sufficient oxygen to tissues. Subnormal temperature :This reduces the requirements of the tissues for the diminishing amount of oxygen available. The core temperature actually be rising. The difference between the two is a measure of the degree of shock.

All these compensatory mechanisms are temporary in their beneficial effects and if the condition of circulation is restored to normal without delay irreversible changes set in.

Pathophysiology

Lack of oxygen supply and nutrient in cells

Cells produce energy through anaerobic metabolism to produce ATP

Low energy yielding from nutrients and produces acidic intracellular environment

Normal cell function affected , cells swells and cell membrane become more permeable, allowing fluid and electrolytes to move out and into the cellsSodium potassium pump impaired due to this

Cell structure damage

Ultimately death of cells

Stages of shock : There are three stages of shock that are commonly identified.

1) Compensatory stage, Non progressive stage, Early stage2) Progressive or Intermediate stage

3) Irreversible or Late stage

Compensatory stage : In this stage , the patients blood pressure remains within normal limits, increased heart rate to maintain the cardiac output and this results from the stimulation of sympathetic nervous system with the subsequent release of epinephrine and norepinephrine. The body shunts blood from skin , kidneys and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result the patients skin will be cold and clammy, bowel will be hypoactive and urine output will decreased in response to release of aldosterone and ADH.

Signs and symptoms : Changes in the level of consciousness, increased depth of respiration, irritability ,anxiety ,restless ,decreased urine output , dilated pupils , thirst , rapid respirations , sepsis , tachycardia, cold skin , decreased cardiac output.

Progressive stage: It is the second stage of shock, the mechanism that regulates the blood pressure can no longer compensate, systolic blood pressure falls and diastolic pressure rises ,decreasing blood flow to myocardium. Another effect on oxygen requirement is bodys ability to meet increased oxygen requirement is bodys inability to meet increased oxygen requirement produce ischemia oxygen deprivation to brain causes the patient to become confused and disoriented. Organs especially lungs , heart and kidneys deteriorate.

Signs and symptoms : decreased response to pain , dilated and sluggish pupils , increased thirst, rapid and shallow breathing , tachycardia, cool moist skin , possible cyanosis , lowered body temperature , muscle weakness and lowered urine output.Irreversible stage: The irreversible stage of shock represents the point along the shock continuum at which organ damage is so severe that patient does not respond to treatment and cannot survive. Multisystem failure develops. Cells in organs and tissues throughout the body damaged and dying. It is the end point of shock that is the patients death is sure.

Signs and symptoms : Unconsciousness, absence of all reflexes , dilated pupils , severe thirst , bradycardia , cardiac arrhythmias, cold clammy skin, immune system collapse, renal failure, shallow respiration.Classification of shock :

Shock can be classified according to the etiology and can be described as :

Hypovlemic shock Cardiogenic shock

Circulatory shock

Septic shock

Obstructive shock

Neurogenic shock

Anaphylactic shock

Hypovolemic shock : This is the most common type of shock ,due to insufficient circulatory volume. In hypovolemic shock there is decreased in circulatory volume to level that is inadequate to meet bodys need for tissue oxygenation. This occurs when there is loss in the intravascular fluid upto 15% to 25%. This would represents a loss of 750 to 1300 ml of blood in a 70 kg person. Common causes of shock are : exercise , fluid loss from circulatory system e.g bleeding , burns , blood loss from G I or severe diarrhea.Pathophysiology :

Decreased blood volume

Decreased venous return

Decreased cardiac output

Decreased tissue perfusion

Decreased cellular metabolism

Cardiogenic shock : It is caused by the failure of heart to pump an adequate amount of blood to vital organs. this will lead to reduction in cardiac output. After due damage of heart muscles, hearts ability to contract and pump blood is impaired and the supply of oxygen is inadequate for the heart and muscles. It can be the result of myocardial infarction. Other causes include arrythmias , cardiomyopathy, congestive heart failure, and cardiac valve problems.

Pathophysiology

Decreased cardiac contractility

Decreased stroke volume and cardiac output

Pulmonary congestion decreased tissue perfusion decreased coronary artery perfusionvolume

Circulatory shock or distributive shock : In this there is no blood loss but the shock is due to the dilation of the blood vessels. This displacement of blood causes a relative hypovolemia because not enough blood returns to heart which leads to subsequent inadequate tissue perfusion.

The varied mechanisms leading to the initial vasodilation in circulatory shock is subdivided into septic shock . it is the most common type of circulatory shock and caused by wide spread infection due to sepsis called by an overwhelming infection leading vasodilation. E.g. infections by bacteria . they release toxins which produce adverse biochemical , immunological and neurological effects. The most common causative organism of septic shock are gram negative bacteria.Pathophysiology :

Vasodilation

Maldistribution of blood volume

Decreased venous return

Decreased stroke volume

Decreased cardiac output

Decreased tissue perfusion

Obstructive shock : Obstruction of blood flow results from cardiac arrest..e.g cardiac tamponade, pneumothorax, pulmonary embolism , and aortic stenosis .

Neurogenic shock : this is very uncommon type of shock. It 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 result in loss of sympathetic control. This leads to relaxation of vessels and peripheral dilation and hypotension. This is characterized by warm and dry skin, bradycardia , rather than other type of shock.

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 to a foreign subatance develops a systemic antigen antibody reaction. Antigen antibody provides mast cells to release vasoactive substance such as histamine or breadykinin that cause vasodilation.

Risk factors : immunosuppression , invasive procedures and psychological trauma.

Diagnosis of shock : Diagnosis of shock is essential for proper treatment and management. An accurate history and assessment of patient symptoms must be done before commencing yreatment.

Conduct head to toe examination for signs of shock. Assess neurological status of the person by assessing the level of conciousness .

Assess the cardiovascular status. Blood pressure varies with the stages of shock.

Assess for renal status. Anuria and renal failure can occur.

Assess for integumentary status. Check for skin color, cold and clammy skin, cyanosis.

Assess GI status. Hypoactive bowel sounds.

Assess for the metabolic status. Metabolic acidosis will be there.

Diagnostic studies: Blood studies reveals overly acidic blood ph with low circulatory carbondioxide, blood pressure monitoring.

First aid in case of shock :

Principles involved in first aid :

1) Remove the cause of accident from near the causuality. If possible remove the casuality from danger such as burning house, room with poisonous gases.2) Handling the patient with due care and attention to reduce pain and to prevent worsening of the condition.

3) Constant observation should be provided to the casuality to identify failure of breathing, bleeding and then to take appropriate measures to treat problems.

4) Using material available at hand.

5) Clear the crowd around the casuality.

6) Take the help of the bystanders to give first aid.

7) Reassure the casuality.

8) Transport the casuality to the doctor as early as possible.

First aid in shock :

Reassure the casuality.

Lay him down on his back comfortably with head low and turned to one side except in case of head injury.

Loosen the clothing around the neck, chest and waist.

Keep the casuality warm.

Give him sips of water if he is thirsty. Never give any alcoholic drinks. Never use hot water bag or massage the limbs.

Arrest haemorrhage by adequate measures.

Check pulse ,respiration and level of consciousness.

Transport the causality to the hospital immediately.

Treatment of shock : Pharmacological interventions.

Hypovolemic shock

Volume expanders

Desmopression ( in case of diabetes)

Antidiarrheal agents for diarrhea

Cardiogenic shock

Volume expanders

Positive cardiac inotropics

Vasodilators

Vasiactive and antiarrythmia medication

Distributive shock

Volume expanders

Positive cardiac inotropics

Vasoconstrictors

Obstructive shock

Volume expanders

Septic shock

Broad spectrum antibiotics

Neurogenic shock

Hypoglycemia glucose is rapidly administered.

Management of shock

Administration of intravenous fluids, blood products, and medication. They are helpful in treating shock. These include : Crystalloids: these are used for intravenous fluid replacement in early stages of shock .e.g ringers solution and normal saline most commonly used..

Inotripoic agents: like dopamine , dobutamine and epinephrine to improve myocardial contractility , adequate cardiac output and improve tissue perfusion.

Vasodilators : nitroglycerine , sodium nitroprusside used to dllate the coronary arteries.

Diuretics : these are used to treat oliguria and increase urine output.

Antibiotics : used to treat septic shock because they are bactericidal.

Antihistamines : epinephrine used in anaphylactic shock.

Steroids : used to decrease fluid shifts out of vasculature by stabilizing capillary walls .

Sodium bicarbonate :it is used to treat metabolic acidosis that occurs as shock progress.

Broncodilators : like atropine , aminophyline, used to relieve broncoconstriction in case of anaphylactic shock.

Nursing management in case of shock :

Maintain ABC of the patient.

Provide supplemental oxygen therapy to the patient.

Donot deliever more than 2 lt. of oxygen per minute if person has history of chronic pulmonary diseases.

Monitor for ABG value to assess the patient response to oxygen therapy.

Continuous monitoring of vital signs should be done.

Check for urine output of the client.

Maintain nutritional status of the patient. Administer prescribed medication to the patient.

Give psychological support to the patient and the relatives.

Nursing diagnosis in case of shock :

1. fluid volume deficiet related to haemorrhage.

Nursing interventions

monitor the signs and symptoms of internal bleeding.

Check for blood pressure.

Give comfortable position.

Keep the patient warm and monitor temperature hourly.

Administer intravenous fluids as ordered.

Monitor urine output.

Administer oxygen as ordered.

2. decreased cardiac output related to ineffective cardiac function .

Nursing interventions

administer IV fluids

monitor urine output.

Monitor blood pressure and pulse rate.

Administer inotropic agents to correct ventricular function.

3. risk for infection related to interruption of skin integrity from invasive procedures.

Nursing interventions

take precautions to prevent nosocomial infections.

a) Wash hands frequently.

b) Use aseptic techniques.

c) Monitor sites of insertion for signs of infection.

d) Change the intravenous cath every three days.

e) Provide indwelling catheter care frequently.

f) Monitor for whit blood cell count for elevation greater than 10,000 per mm3.

4. altered nutrition lesss than body requirement related to decreased oral intake.

Nursing interventions

monitor daily weight and identify weight loss.

Consult nutritionist for recommendations about diet.

Check for gastric residuals every 4 hourly , notify the physician if it is greater than 100 ml. Monitor for hematocrit, haemoglobin to assess the adequacy of nutritional replacement.

5. altered peripheral tissue perfusion related to edema from stasis of blood in the capillaries and vasoconstriction.

Nursing interventions

monitor the extent of fluid retention.

Monitor daily weight of the patient.

Determine the severity of edema.

Watch for elevation in central venous pressure .

Check signs and symptoms of fluid overload.

Prevention of shock :

Preoperative measures :circulatory collapse should be assessed by strenuous measures if at all possible. Preoperatively the patient should be as fit as possible and from the point of view from circulatory system. His blood should be adequate in quantity and volume. His tissues should be adequately hydrated.

He should be mobile so that there should be no stagnation in the circulatory system.

Patient should be kept warm on his journey from ward to theatre.

Post operatively :

Fluid and electrolyte replacement should be done with normal saline, dextrose 5%, plasma and rest and relief from the pain continues.

Gentle handling by nursing staff wi help in prevention of shock.

Diuretics like mannitol an osmotic diuretic which is neither absorbed in the renal tubules nor metabolized. If oliguria persists frusemide can be given.dopamine can be given to improve blood pressure.

Bibliography :

Saunders Manual of Nursing Practice, edition 1st , published by W.B Saunders, printed in 1997, pp 364-380

Brunner and Suddarths Textbook of Medical Surgical Nursing edition 13th published by Lippincott publishers, printed in 2009, pp 216-234 Joyee M Black and Hawks J.H. Medical Surgical Nursing clinical managemen for positive outcomes, edition 7th , printed in 2009, pp 2443-2477.

American Academy of Orthopedic Surgeons, Emergency , Care and Transportation of the Sick and Injured, Published by Jones and Barlett,7th edition , printed in 1998,pp 541 550. www.google .com