- Anxiety related to unfamiliarity with the medical condition and its first aid as evidenced by expresses anxiety and distress
- Deficient Fluid Volume related to excessive bleeding and Use of anticoagulants as evidenced by excess blood loss and decreased blood pressure
- Deficient Knowledge related to inadequate knowledge of first aid and Unfamiliarity with nosebleeds as evidenced by Inaccurate statements about epistaxis and inappropriate first-aid measures performed
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Feeling nervous -Verbalizing a sense of impending danger -Difficulty controlling one’s worrying Objective data: -Restlessness and tense appearance -Tachycardia -Tachypnea -Hyperventilation -Diaphoresis -Trembling/tremors -Weakness or tiredness -Difficulty concentrating -Difficulty sleeping -GI distress | Anxiety related to unfamiliarity with the medical condition and its first aid as evidenced by expresses anxiety and distress | Patient will verbalize feelings and concerns about the current condition. Patient will demonstrate effective coping strategies that can help alleviate anxiety. | 1. Encourage the patient to express feelings and concerns freely. Verbalization of perceived threats can help reduce the patient’s anxiety and encourage a trusting relationship. The nurse can then provide reassurance and dispel any unwarranted concerns. 2. Encourage breathing exercises. Encourage the patient to continue breathing through their nose in slow breaths to help reduce stress and keep them calm during an epistaxis episode. 3. Educate the patient regarding epistaxis first aid measures. Proper education on how to initially manage epistaxis can help the patient remain calm and composed during an episode. Knowing what to do will help reduce stress and anxiety. 4. Explain all interventions. Especially for young children, the nurse should show the patient supplies or instruments they are using, and how they work so the child will be less frightened and more willing to cooperate. | Patient verbalized feelings and concerns about the current condition. Patient demonstrated effective coping strategies that can help alleviate anxiety. |
| Subjective data: Verbal reports from the patient Objective data: -Excess blood loss -Decreased blood pressure -Weakness -Increase heart rate -Pallor -Fatigue | Deficient Fluid Volume related to excessive bleeding and Use of anticoagulants as evidenced by excess blood loss and decreased blood pressure | Patient will maintain airway and circulation within expected parameters. Patient will demonstrate interventions to prevent bleeding and reduce fluid volume loss | 1. Ensure hemodynamic stability. At all times, the nurse should closely monitor airway patency and circulation. Oxygen should be applied if necessary, and an IV line should be started to transfuse crystalloids. 2. Administer intravenous fluid or blood product replacement. Excessive blood loss occurring with posterior epistaxis may require blood transfusion and intravenous fluid replacement. 3. Teach the patient when to seek medical help during an epistaxis episode. If nasal bleeding has not stopped after 20 minutes of applying first aid measures, there is excessive blood loss or respiratory distress, immediate medical support must be sought. 4. Ensure follow-up with a specialist. Patients who have an underlying coagulopathy should follow-up with a haematologist. Recurrent epistaxis should be addressed by an ENT. | Patient maintained airway and circulation within expected parameters. Patient demonstrated interventions to prevent bleeding and reduce fluid volume loss |
| Subjective data: -Verbalizes poor understanding -Seeks additional information Objective data: -Inaccurate demonstration or teach-back of instructions -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment or worsening medical condition -Avoiding eye contact or remaining silent during teaching | Deficient Knowledge related to inadequate knowledge of first aid and Unfamiliarity with nosebleeds as evidenced by Inaccurate statements about epistaxis and inappropriate first-aid measures performed | Patient will verbalize understanding of the current condition and appropriate first aid measures Patient will demonstrate effective ways of preventing nasal bleeding. | 1. Educate children on preventing nosebleeds. Children often pick their noses and may insert foreign objects into their noses. Instruct them against doing this and keep their fingernails cut short to reduce irritation. 2. Educate the patient about actions that can trigger nasal bleeding. Nasal bleeding can be caused by blowing the nose too hard, nose picking, colds or sinusitis, and excessive use of nasal sprays. 3. Educate the patient about first-aid measures to stop nasal bleeding. Sit up straight with the head slightly leaning forward. Pinch the soft tissue of the nostrils for at least 5-10 minutes. If bleeding persists after 20 minutes, seek additional support. 4. Offer interventions if nosebleeds are frequent. Keep nasal passages moist with a saline solution during winter months or when sick with a respiratory infection. Use a humidifier indoors to keep the air moist. Do not smoke, as smoking dries out and irritates the nose. | Patient verbalized understanding of the current condition and appropriate first aid measures Patient demonstrated effective ways of preventing nasal bleeding. |