Sunday, January 8, 2012

Ineffective Airway Clearance Nursing Care Plan for Epistaxis

Epistaxis is defined as acute bleeding from the nostril, nasal cavity or nasopharynx. Anterior nosebleeds occur when the source of bleeding originates from Kiesselbach's plexus (Little's area) which is present in the anterior part of the nasal canal. Anterior epistaxis usually occurs in children and young adults.

However, posterior nosebleeds originates from the sphenopalatine artery which is present in the posterior part of the nasal canal. Posterior epistaxis usually presents in old individuals.

First-Aid at Home for Epistaxis

  • Remember to stay calm. Most nose bleeds are benign and will stop with simple measures.
  • Sit upright and lean your head forward. Tilting your head backward will cause you to swallow the blood.
  • Pinch your nose for about 10 minutes. This simple application of pressure should stop most bleeds.
  • Once the bleeding has stopped, try to prevent any further irritation to the nose for the next 24 hours. Avoid sneezing, blowing your nose, picking your nose or straining.
  • Avoid prolonged exposure to dry air. Using a humidifier and avoiding air-conditioned environments will help keep the nasal mucosa from drying out and triggering more bleeding.

Nursing Diagnosis Nursing Care Plan for Epistaxis

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.

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