2. BLEEDING: Hemorrhage or sever bleeding is the major cause of shock “Hypoperfusion” means extravasation of blood This condition involves losing blood. This can occur internally (when blood leaks from blood vessels inside the body), externally through a natural opening (such as the vagina, mouth, or rectum), or externally through a break in the skin. Blood loss; Open injury bleeding

3. External bleeding: There are three types of external bleeding 1- Arterial bleeding : Usually bright red in color because of O 2 In this type bleeding is more because it has hight blood pressure. It is the most difficult to control the bleeding Blood loss is rapid and profuse o The color of blood is bright red o Blood spurts as the heart beats 2- Venous bleeding: Usually dark red because it has CO 2 and waste product It is easy to control bleeding except large vein like neck vein. Blood loss is a steady flow o The color of blood is dark 3- Capillary bleeding: o Blood flow is slow o The color of blood is red but less bright Usually slow because of the small size and pressure easily can be contaminated

4. 3- Capillary bleeding: o Blood flow is slow o The color of blood is red but less bright Usually slow because of the small size and pressure easily can be contaminated

5. Severity of External bleeding:- Depend on blood loss according to age and physical size of patent Adult more 1000cc Child more 500cc Infant more 150cc

6. Controlling of External Bleeding: It is the most important in management of shock Control blood loss mean increase in perfusion Guid line of controlling external bleeding 1- Direct pressure The most common and effective way direct press to wound “ pressure dressing Always check distal pulse to make sure dressing is not light

7. 2- Elevation On injured extremity may be used at the some time of pressure dressing It should be above the heart level gravity reduce blood pressure in extremity ->>>> slow bleeding Pressure point: *Brachial artery *Femoral artery 3- splinting Stabilizing fractures reduce injuries to tissues and vessels

8. 4- Cold application Ice – cold packs  reduce swelling cause constriction of blood vessels of blood vessels  minimize bleeding “Never apply ice directly to skin”

9. 5- Tourniquet Or blood pressure cuff should be last choice Only in life threatening emergency Apply above the joint 5cm above wound

10. Internal Bleeding Not seen, that cause internal bleeding very serious also it can be large a wound in short time. C auses of internal hemorrhage: Deep chest or abdominal wound Any cut into muscle or fracturing of bone Fracture Ruptured aneurysm Crush injuries Bleeding ulcers

11. Signs of internal bleeding: 1- injuries to the surface of the body. 2-Bruising,swelling, pain over vital signs. 3- Painful, swollen or deformed extremities. 4- Bleeding from mouth, rectum, vaginal. 5- Tender, rigid, distended abdomen 6- vomiting  bright red vomits 7- Dark,tarry stool or bright red in stool(malena) 8- Mechanism of injury.

12. - Detecting internal bleeding: assume internal bleeding whenever the following are present o Wound that have penetrated the skull § Blood in the ear § Vomiting or coughing up blood(hemoptysis) Wound that have penetrated the chest or abdomen § Large areas of bruised abdomen § Abdominal tenderness, rigidity, or spasm § Blood in urine (Hematouria) § Rectal bleeding § Bone fractures mainly the long bone of the arm or thigh.

13. Nursing care for internal bleeding Maintain ABC provide support Administer high concentrated O2 Control any external bleeding