Week No.

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PRIORITIZED NURSING PROBLEM FOR EPISTAXIS

Nursing Diagnosis Nursing Intervention Rationale
1. INEFFECTIVE Independent
BREATHING
PATTERN Place patient with proper body A sitting position permits
alignment for maximum maximum lung excursion and
breathing pattern. chest expansion.
Encourage sustained deep These techniques promotes deep
breaths by: inspiration, which increases
- Using demonstration: oxygenation and prevents
highlighting slow inhalation, atelectasis. Controlled breathing
holding end inspiration for a methods may also aid slow
few seconds, and passive respirations in patients who are
exhalation tachypneic. Prolonged
- Utilizing incentive spirometer expiration prevents air trapping
- Requiring the patient to yawn This method relaxes muscles
Encourage diaphragmatic and increases the patient’s
breathing for patients with oxygen level.
chronic disease. This training improves
Evaluate the appropriateness of conscious control of respiratory
inspiratory muscle training. muscles and inspiratory muscle
Provide respiratory strength.
medications and oxygen, per Beta-adrenergic agonist
doctor’s orders. medications relax airway
Avoid high concentration of smooth muscles and cause
oxygen in patients with COPD. bronchodilation to open air
Maintain a clear airway by passages
encouraging patient to mobilize Hypoxia triggers the drive to
own secretions with successful breathe in the chronic CO2
coughing. retainer patient. When
Suction secretions, as administering oxygen, close
necessary. monitoring is very important to
Stay with the patient during avoid uncertain risings in the
acute episodes of respiratory patient’s PaO2, which could
distress. lead to apnea.
Ambulate patient as tolerated This facilitates adequate
with doctor’s order three times clearance of secretions.
daily This is to clear blockage in
Encourage frequent rest periods airway.
and teach patient to pace This will reduce the patient’s
activity. anxiety, thereby reducing
Consult dietitian for dietary oxygen demand.
modifications. Ambulation can further break up
Encourage small frequent and move secretions that block
meals. the airways.
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Help patient with ADLs, as Extra activity can worsen

necessary. shortness of breath. Ensure the
Avail a fan in the room. patient rests between strenuous
Encourage social interactions activities.
with others that have medical COPD may cause malnutrition
diagnoses of ineffective which can affect breathing
breathing pattern. pattern. Good nutrition can
Educate patient or significant strengthen the functionality of
other proper breathing, respiratory muscles.
coughing, and splinting This prevents crowding of the
methods diaphragm.
Educate patient about This conserves energy and
medications: indications, avoids overexertion and fatigue.
dosage, frequency, and possible Moving air can decrease
side effects. Incorporate review feelings of air hunger.
of metered-dose inhaler and Talking to others with similar
nebulizer treatments, as conditions can help to ease
needed. anxiety and increase coping
Teach patient about: skills.
- pursed-lip breathing These allow sufficient
- abdominal breathing mobilization of secretions.
- performing relaxation This information promotes safe
techniques and effective medication
- performing relaxation administration.
techniques These measures allow patient to
- taking prescribed medications participate in maintaining health
(ensuring accuracy of dose and status and improve ventilation.
frequency and monitoring Exercise promotes conditioning
adverse effects) of respiratory muscles and
- scheduling activities to avoid patient’s sense of well-being.
fatigue and provide for rest
periods
Refer patient for evaluation of
exercise potential and
development of individualized
exercise program.

Teach the patient the proper The most convenient way to

2. INEFFICIENT ways of coughing and remove most secretions is
AIRWAY breathing. (e.g., take a deep coughing. So it is necessary to
CLEARANCE breath, hold for 2 seconds, and assist the patient during this
cough two or three times in activity. Deep breathing, on the
succession) other hand, promotes
Educate the patient in the oxygenation before
following: The proper sitting position and
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- Optimal positioning (sitting splinting of the abdomen

position) promote effective coughing by
- Use of pillow or hand splints increasing abdominal pressure
when coughing and upward diaphragmatic
- Use of abdominal muscles for movement. Controlled coughing
more forceful cough methods help mobilize
- Use of quad and huff secretions from smaller airways
techniques to larger airways because the
- Use of incentive spirometry coughing is done at varying
- Importance of ambulation and times. Ambulation promotes
frequent position changes lung expansion, mobilizes
Position the patient upright if secretions, and lessens
tolerated. Regularly check the atelectasis.
patient’s position to prevent Upright position limits
sliding down in bed. abdominal contents from
Perform nasotracheal pushing upward and inhibiting
suctioning as necessary, lung expansion. This position
especially if cough is promotes better lung expansion
ineffective. and improved air exchange.
Explain procedure to patient Suctioning is needed when
Use well-lubricated soft patients are unable to cough out
catheters secretions properly due to
Use curved-tip catheters and weakness, thick mucus plugs, or
head positioning (if not excessive or tenacious mucus
contraindicated). production.
Instruct the patient to take This procedure can also
several deep breaths before and stimulate a cough. Frequency of
after nasotracheal suctioning suctioning should be based on
procedure and use patient’s present condition, not
supplemental oxygen, as on preset routine, such as every
appropriate. 2 hours. Over suctioning can
Stop suctioning and provide cause hypoxia and injury to
supplemental oxygen if the bronchial and lung tissue.
patient experiences Using well-lubricated catheters
bradycardia, an increase in reduces irritation and prevents
ventricular ectopy, and/or trauma to mucous membranes.
significant desaturation. These facilitates secretion
- Use universal precautions: removal; from a specific side of
gloves, goggles, and mask, as the lung (left or right).
appropriate. Hyperoxygenation before,
Maintain humidified oxygen as during, and after suctioning
prescribed. prevents hypoxia.
Encourage patient to increase Oxygen therapy is
fluid intake to 3 liters per day recommended to improve
within the limits of cardiac oxygen saturation and reduce
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reserve and renal function. possible complications

Coordinate with a respiratory As protection against the blood-
therapist for chest related modes of transmission,
physiotherapy and nebulizer health care workers should use
management as indicated. universal precautions when
Provide postural drainage, coming in contact with the
percussion, and vibration as blood of all patients, or bodily
ordered. fluids containing blood.
Pace activities especially for Increasing humidity of inspired
patients with reduced energy. air will reduce thickness of
Maintain planned rest periods. secretions and aid their removal.
Promote energy-conservation Fluids help minimize mucosal
methods. drying and maximize ciliary
Educate patient on coughing, action to move secretions
deep breathing, and splinting a variety of medications are
techniques. prepared to manage specific
Provide patient understanding problems. Most promote
about the proper use of clearance of airway secretions
prescribed medications and and may reduce airway
inhalers. resistance.
Educate caregivers in hest physical therapy helps
suctioning techniques. Provide mobilize bronchial secretions; it
opportunity for return should be used only when
demonstration. Modify prescribed because it can cause
techniques for home setting. harm if patient has underlying
conditions such as cardiac
disease or increased intracranial
pressure.
Oral care freshens the mouth
after respiratory secretions have
been expectorated.
Patient will understand the
underlying principle and proper
techniques to keep the airway
clear of secretions.
Understanding prescriptions
promote safe and effective
medication administration.
Hydration facilitates easy
elimination of secretions.
This promotes safe and effective
removal of secretions from the
airway.

Urge the patient to drink Oral fluid replacement is

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3. RISK FOR prescribed amount of fluid. indicated for mild fluid deficit
DEFICIENT Oral fluid replacement is and is a cost-effective method
FLUID VOLUME indicated for mild fluid deficit for replacement treatment. Older
and is a cost-effective method patients have a decreased sense
for replacement treatment. of thirst and may need ongoing
Older patients have a decreased reminders to drink. Being
sense of thirst and may need creative in slecting fluid sources
ongoing reminders to drink. (e.g., flavored gelatin, frozen
Being creative in slecting fluid juice bars, sports drink) can
sources (e.g., flavored gelatin, facilitate fluid replacement. Oral
frozen juice bars, sports drink) hydrating solutions (e.g.,
can facilitate fluid replacement. Rehydralyte) can be considered
Oral hydrating solutions (e.g., as needed.
Rehydralyte) can be considered Dehydrated patients may be
as needed. weak and unable to meet
Aid the patient if he or she is prescribed intake independently.
unable to eat without Most elderly patients may have
assistance, and encourage the reduced sense of thirst and may
family or SO to assist with require continuing reminders to
feedings, as necessary. drink.
if patient can tolerate oral Fluid deficit can cause a dry,
fluids, give what oral fluids sticky mouth. Attention to
patient prefers. Provide fluid mouth care promotes interest in
and straw at bedside within drinking and reduces discomfort
easy reach. Provide fresh water of dry mucous membranes.
and a straw. Drop situations where patient
Emphasize importance of oral can experience overheating to
hygiene. prevent further fluid loss.
Provide comfortable Planning conserves patient’s
environment by covering energy.
patient with light sheets. Parenteral fluid replacement is
Plan daily activities indicated to prevent or treat
Insert and IV catheter to have hypovolemic complications.
IV access Fluids are necessary to maintain
Administer parenteral fluids as hydration status. Determination
prescribed. Consider the need of the type and amount of fluid
for an IV fluid challenge with to be replaced and infusion rates
immediate infusion of fluids will vary depending on clinical
for patients with abnormal vital status.
signs. Blood transfusions may be
Administer blood products as required to correct fluid loss
prescribed. from active gastrointestinal
Maintain IV flow rate. Stop or bleeding.
delay the infusion if signs of Most susceptible to fluid
fluid overload transpire, refer overload are elderly patients and
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to physician respectively require immediate attention.

Assist the physician with A central venous line allows
insertion of central venous line fluids to be infused centrally
and arterial line, as indicated. and for monitoring of CVP and
Provide measures to prevent fluid status. An arterial line
excessive electrolyte loss (e.g., allows for the continuous
resting the GI tract, monitoring of BP.
administering antipyretics as Fluid losses from diarrhea
ordered by the physician). should be concomitantly treated
Begin to advance the diet in with antidiarrheal medications,
volume and composition once as prescribed. Antipyretics can
ongoing fluid losses have decrease fever and fluid losses
stopped. from diaphoresis.
Encourage to drink bountiful Addition of fluid-rich foods can
amounts of fluid as tolerated or enhance continued interest in
based on individual needs. eating.
Edducate patient about possible Patient may have restricted oral
cause and effect of fluid losses intake in an attempt to control
or decreased fluid intake. urinary symptoms, reducing
Enumerate interventions to homeostatic reserves and
prevent or minimize future increasing risk of dehydration or
episodes of dehydration. hypovolemia.
Emphasize the relevance of Enough knowledge aids the
maintaining proper nutrition patient to take part in his or her
and hydration. plan of care.
teach family members how to Patient needs to understand the
monitor output in the home. value of drinking extra fluid
Instruct them to monitor both during bouts of diarrhea, fever,
intake and output. and other conditions causing
Refer patient to home health fluid deficits.
nurse or private nurse in able to Increasing the patient’s
assist patient, as appropriate. knowledge level will assist in
Identify an emergency plan, preventing and managing the
including when to ask for help. problem
An accurate measure of fluid
intake and output is an
important indicator of patient’s
fluid status.
Continuity of care is facilitated
through the use of community
resources.
Some complications of deficient
fluid volume cannot be reversed
in the home and are life-
threatening. Patients progressing
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toward hypovolemic shock will

need emergency care