About
Nose Bleed.
Assess
Duration and frequency of nosebleeds, trauma, nasal dryness, history of allergies.
Complications
Hypoxemia- monitor pulse oximetry, administer oxygen, encourage mouth breathing.
Hemorrhage- monitor vital signs, seek emergent physician intervention.
Respiratory distress- monitor respiratory status; monitor for patent airway; monitor pulse oximetry.
Diagnosis
- Knowledge deficit related to care of frequent nosebleeds, prevention
- Fear related to appearance of large amounts of blood
Goals
- Client will have no active nasal bleeding.
- Client will state three interventions to prevent reoccurrence of nasal bleeding.
- Client will state criteria for when to seek additional medical assistance.
Interventions
- Position the client upright, apply pressure laterally to the nose and hold for 5 minutes.
- Monitor for aspiration of blood contents.
- Apply ice or cool compresses to area.
- Teach client to avoid blowing nose for at least the day to prevent re-opening clots.
- Insert nasal packing loosely if above strategies do not stop bleeding.
- If bleeding continues, seek emergent medical attention, may require surgical intervention, posterior nasal packing, or pressure catheters inserted by a physician.
- If surgical intervention, monitor patient frequently, hydrate with plenty of fluids, encourage mouth breathing, monitor for gag reflexes, assess pulse ox for signs of hypoxemia.
- Administer analgesics as ordered.
- Monitor for signs/ symptoms of complications.
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