Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx. It is a frequent emergency department (ED) complaint and often causes significant anxiety in patients and clinicians. However, the vast majority of patients who present to the ED with epistaxis (likely more than 90%) may be successfully treated by an emergency physician.
1. Risk for Bleeding
Goal: minimize bleeding
Expected Outomes: No bleeding, vital signs within normal limits, no anemis.
Interventions:
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.
Independent
Collaboration
3. Acute pain
Goal: pain diminished or disappeared
Expected Outcomes:
Interventions:
Source : http://nursing-care-plan.blogspot.com/2011/12/3-nursing-diagnosis-for-epistaxis-with.html
Nursing Diagnosis for Epistaxis with Interventions and Rational
1. Risk for Bleeding
Goal: minimize bleeding
Expected Outomes: No bleeding, vital signs within normal limits, no anemis.
Interventions:
- 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.
Independent
- 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.
Collaboration
- 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
Expected Outcomes:
- Clients express the pain diminished or disappeared
- Clients do not grimace in pain
Interventions:
- 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
