1. Risk for Bleeding
Goal: minimize bleeding
Expected Outomes: No bleeding, vital signs within normal limits, no anemis.
- Monitor the patient's general condition
- Monitor vital signs
- Monitor the amount of bleeding patients
- Monitor the event of anemia
- Collaboration with the doctor about the problems that occur with bleeding: transfusion, medication.
2. Ineffective airway clearance
Goal: to be effective airway clearance
Expected Outcomes: Frequency of normal breathing, no additional breath sounds, do not use additional respiratory muscles, dyspnoea and cyanosis does not occur.
- Assess the sound or the depth of breathing and chest movement.
Rational: Decreased breath sounds may lead to atelectasis, Ronchi, and wheezing showed accumulation of secretions.
- Note the ability to remove mucous / coughing effectively
Rational: bright lumpy or bloody sputum may result from damage to lungs or bronchial injury.
- Give Fowler's or semi-Fowler position.
Rational: Positioning helps maximize lung expansion and reduce respiratory effort.
- Clean secretions from the mouth and trachea
Rational: To prevent obstruction / aspiration.
- Maintain a fluid inclusion at least as much as 250 ml / day unless contraindicated.
Rational: Helping dilution of secretions.
- Give medication in accordance with the indications mucolytic, expectorant, bronchodilator.
Rational: Mucolytic to reduce cough, expectorant to help mobilize secretions, bronchodilators reduce bronchial spasms and analgesics are given to reduce discomfort.
3. Acute pain
Goal: pain diminished or disappeared
- Clients express the pain diminished or disappeared
- Clients do not grimace in pain
- Assess client's level of pain
Rational: Knowing the client's level of pain in determining further action.
- Explain the causes and consequences of pain to the client and his family.
Rational: The causes and consequences of pain the client is expected to participate in treatment to reduce pain.
- Teach relaxation and distraction techniques.
Rational: The client knows the distraction, and relaxation techniques can be practiced so as if in pain.
- Observation of vital signs and client complaints.
Rational: Knowing the prevailing circumstances and conditions of client development.
Source : http://nursing-care-plan.blogspot.com/2011/12/3-nursing-diagnosis-for-epistaxis-with.html