3 Nursing Diagnosis for Epistaxis with Interventions and Rational

Nursing Diagnosis

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.

(Diagnosis NANDA, NIC, NOC)


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.

Read More..

Nursing Care Plan for Epistaxis

Definition


Epistaxis is bleeding from the bottom of the nose can be primary or secondary, spontaneous or due to stimulation and is located next to the posterior or anterior.

Care Management

Blood flow will stop after the blood had frozen in the process of blood clotting. A medical opinion says that when the bleeding occurs, it is better if the head is tilted forward position (sitting position) to drain the blood and prevent entry into the esophagus and stomach.

First aid in case of epistaxis is to squeeze the front of your nose for three minutes. During the emphasis should breathe through the mouth. Mild bleeding will usually stop in this way. Do the same thing in case of recurrent bleeding, if it does not stop you should visit a doctor for help.

For chronic nose bleeds due to dryness of the nasal mucosa, is usually prevented by spraying saline in the nose up to three times a day.

If due to pressure, ice packs can be used to shrink blood vessels (vasoconstriction). If it still does not work, can be used nasal tampons. Tampons can stop a bleeding nose and the media is mounted 1-3 days.

Deaths from bleeding nose is something that is rare. However, if it caused damage to the maxillary artery can cause heavy bleeding through the nose and difficult to cure. Action of pressure, vasoconstrictor less effective. Possible healing maksillaris arterial structure (which can damage the facial nerve) is the only solution.

Nursing Care Plan for Epistaxis

Nursing Assessment Nursing Care Plan for Epistaxis

1. Bios: Name, age, gender, address, ethnicity, nation, education, employment.
2. History of present illness
3. The main complaint: the patient normally complain of difficulty breathing, throat.
4. Past history of disease:
   • The patient had suffered from acute illness or trauma and nose bleeding
   • The patient had a history of ENT disease
   • The patient had suffered from toothache molars
5. Family history: Are there any illnesses suffered by family members and that may be something to do with the client's current illness.
6. Psychosocial History
   • Intrapersonal: the perceived feelings of the client (anxious / sad)
   • Interpersonal: relationships with others.
7. Patterns of health functions
   • Pattern perception and management of healthy living
     • To reduce the flu is usually the client taking the drug without regard to side effects
   • Patterns of nutrition and metabolism :
     • Usually the client's appetite is reduced because an interruption in the nose
   • Patterns of Rest and sleep
     • During inditasi client feels unable to rest because the client is often a cold
   • Pattern perception and self-concept
     • The client is often cold and smelled causing continuous self-concept decreased.
       
   • Pattern of sensory
     • The power of smell impaired clients as a result of clogged nasal continuous cold (both purulent, serous, mukopurulen).
8. Physical examination
   • General health status: general condition, vital signs, consciousness.
   • Physical examination data: focus nose.

Subjective Data:

• Complaining of weakness

Objective Data

• Bleeding at the nose / pouring a lot of
• Restlessness
• Decrease in blood pressure
• Increased pulse
• Anemia

Read More..