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Sunday, December 18, 2011

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.

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