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

 Monitor patient’s vital  Hypotension and

signs, especially BP and
HR. Look for signs of
orthostatic hypotension.
tachycardia are initial
compensatory
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
signs of bleeding that
need to be reported to a
health care provider.
treatment of bleeding by
a health care provider
reduce the risk for
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
are abnormal, administer
blood products as
prescribed.
transfusions replace
blood clotting factors;
RBCs increase oxygen-
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/