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Nursing Diagnosis Nursing Intervention Rationale: Prioritized Nursing Problem For Epistaxis

This document outlines nursing interventions for a patient at risk for epistaxis (nosebleed). It identifies assessing the patient's health history and monitoring vital signs as important to identify risk factors. Checking for occult blood in stool and urine can help determine the source of any bleeding. Education on preventive measures and signs of bleeding to watch for are also prioritized. If abnormal lab values are present, administering prescribed blood products may be needed to replace blood components and clotting factors. Maintaining contact with blood transfusion centers helps ensure availability of blood if transfusions are required.

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Myrshaida Ibrahim
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834 views3 pages

Nursing Diagnosis Nursing Intervention Rationale: Prioritized Nursing Problem For Epistaxis

This document outlines nursing interventions for a patient at risk for epistaxis (nosebleed). It identifies assessing the patient's health history and monitoring vital signs as important to identify risk factors. Checking for occult blood in stool and urine can help determine the source of any bleeding. Education on preventive measures and signs of bleeding to watch for are also prioritized. If abnormal lab values are present, administering prescribed blood products may be needed to replace blood components and clotting factors. Maintaining contact with blood transfusion centers helps ensure availability of blood if transfusions are required.

Uploaded by

Myrshaida Ibrahim
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PRIORITIZED NURSING PROBLEM FOR EPISTAXIS

Nursing Diagnosis Nursing Intervention Rationale


Independent

 Risk for  Determine the patient’s  Early identification of


Bleeding health history for signs possible risks for
that can be associated bleeding provides a
with a risk for bleeding foundation for
such as liver disease, implementing
inflammatory bowel appropriate preventive
disease, or peptic ulcer measures.
disease.

 Monitor patient’s vital  Hypotension and


signs, especially BP and tachycardia are initial
HR. Look for signs of compensatory
orthostatic hypotension. mechanisms usually
noted with bleeding.
Orthostasis (a drip of 20
mm Hg in systolic BP or
10 mm Hg in diastolic
BP when changing from
supine to sitting position)
indicates reduced
circulating fluids.

 Check stool (guaiac) and  These tests are used to


urine (Hemastix) for distinguish bleeding from
occult blood. the gastrointestinal or
urinary tracts that may
not be visible.

 Educate the at-risk  Information about


patient about precautionary measures
precautionary measures lessens the risk for
to prevent tissue trauma bleeding.
or disruption of the
normal clotting
mechanisms.

 Educate the patient and  Early evaluation and


family members about treatment of bleeding by
signs of bleeding that a health care provider
need to be reported to a reduce the risk for
health care provider. complications from blood
loss.
 Let the patient use  These treatments reduce
normal saline nasal drying and cracking of
sprays and emollient lip mucous membranes and
balms. therefore reduce the risk
of bleeding.

 Tell the female patient  Alterations in


to inform the health care coagulation may lead to
provider when there is increased blood loss with
an increase in menstrual regular menstruation.
bleeding as indicated by
an increase in the
number of sanitary pads
used.

Dependent
 Blood product
 When laboratory values transfusions replace
are abnormal, administer blood clotting factors;
blood products as RBCs increase oxygen-
prescribed. carrying capacity; FFP
replaces clotting factors
and inhibitors; platelets
and cryoprecipitate
provide proteins for
coagulations.

 For bleeding linked with  Protamine sulfate


excessive anticoagulant reverses the effect of
use, give appropriate heparin. Vitamin K will
antidotes as prescribed. counteract the action of
warfarin.

Interdependent
 Keep in touch with  This is to assure the
blood transfusion center. availability of blood
when needed.

References:

https://nurseslabs.com/risk-for-
bleeding/

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