Hemorrhage

Definition

Hemorrhage is the escape of blood from blood vessels, either externally (visible) or internally (often occult). Rapid loss of large volumes produces hypovolemic shock.

Classes of Hemorrhage

• Class I: less than 15% loss. Mild tachycardia
• Class II: 15 to 30%. Tachycardia, narrowed pulse pressure
• Class III: 30 to 40%. Hypotension, confusion, decreased urine output
• Class IV: greater than 40%. Severe shock, life-threatening

Signs and Symptoms

Tachycardia (earliest), hypotension, cool clammy skin, pallor, anxiety/restlessness, oliguria, altered mental status, delayed capillary refill.

Nursing Interventions

Apply direct pressure to external bleeding. Establish 2 large-bore IVs, administer crystalloid and blood products. Elevate legs (Trendelenburg only if no respiratory compromise). Keep patient warm (hypothermia impairs clotting). Identify source, prepare for surgery or interventional radiology. Monitor Hgb/Hct trends.

NCLEX Relevance

Tachycardia is the earliest sign of hemorrhage; hypotension is late.