NURSING CARE TO CLIENTS epistaxis

A. Definition
Epistaxis is divided into 2 of the anterior (front) and posterior (rear). Cases of anterior epistaxis is mainly coming from the front of the nose to the origin of bleeding from the plexus kiesselbach. Posterior epistaxis is generally derived from the nasal cavity through the posterior branch a.sfenopalatina.
Anterior epistaxis showed a clear clinical symptoms of bleeding from the nostrils. Posterior epistaxis often show symptoms that are not so obvious such as nausea, vomiting blood, coughing up blood, anemia and posterior epistaxis usually involve large blood vessels so bleeding is more severe.
B. Etiology and Pathophysiology
Epistaxis (nosebleeds) in children is generally derived from Little's area / kiesselbach plexus (Fig. 3) are located on the front wall of the nasal septum.
The two most important factors of epistaxis in children are:
- Trauma minor: the nose, scratching, sneezing, coughing or straining
- Nasal mucosa is fragile: there are upper respiratory tract infection, mucosal drying, use of inhaled steroids through the nose
The cause of epistaxis is the existence of foreign bodies in the nasal cavity, nasal polyps, blood disorders, vascular abnormalities and tumors in the nasopharynx.
C. Review of Nursing
ASSESSMENT:
A. Biodata: Name, age, sex, address, ethnicity, nation, education, employment,
2. History of present illness:
3. The main complaint: the patient normally complain of difficulty breathing, throat.
4. Past medical history:
- The patient had suffered from acute illness or trauma and nose bleeding
- Ever have a history of ENT disease
- Ever menedrita molar pain
5. Family history: Are there any diseases suffered by family members and that may have something to do with the client's current illness.
6. History spikososial
a. Intrapersonal: the perceived feelings of the client (cemas/sedih0
b. Interpersonal: relationships with others.
7. Patterns of health functions
a. Patterns of perception and governance of healthy living
- To reduce the client's usual flu drugs without regard to side effects
b. Patterns of nutrition and metabolism:
- Client's appetite usually decreases due to an interruption in the nose
c. Rest and sleep patterns
- As long as the client feels inditasi can not rest because the client is often a cold
d. Patterns of perception and self-concept
- Clients are constantly cold and smelly cause decreased self-concept
e. The pattern of sensory
- The power of smell impaired clients as a result of clogged nasal continuous cold (both purulent, serous, mucopurulent).
8. Physical examination
a. general health status: general condition, vital signs, consciousness.
b. Physical examination of the data focus on the nose: rinuskopi (red and swollen mucosa).
Subjective data:
- Complaining of weakness
Objective Data
- Bleeding of the nose / pouring a lot of
- Fidget
- Decrease in blood pressure
- Increased pulse
- Anemia
D. Appears Possible Nursing Diagnosis
A. PK: Bleeding
2. Road clearance is ineffective Breath
3. Anxious
4. Acute Pain
E. Nursing Perncanaan
A. PK: Bleeding
Purpose: to minimize bleeding
Criteria: There was no bleeding, normal vital signs, no anemis
INTERVENTION
- Monitor the patient's general condition
- Monitor vital signs
- Monitor the amount of bleeding psien
- Keep an eye on in case of anemia
- Collaboration with the doctor about a problem that occurs with hemorrhage: transfusion, medication
(Diagnosis NANDA, NIC, NOC)
2. Road clearance is ineffective Breath
Purpose: to be effective airway clearance
Criteria: The frequency of normal breathing, no additional breath sounds, do not use additional respiratory muscles, dyspnoea and cyanosis does not occur
No. Rational intervention
1 2 3
1 Independent
• Assess the sound or the depth of breathing and chest movement.
• Note the ability to remove mucous / coughing effectively • Decreased breath sounds may lead to atelectasis, and wheezing Ronchi show accumulation of secretions
• thick or bloody sputum can be bright or lung damage caused by bronchial injury
• Give the Fowler position semi-Fowler or high
• Clean the secretions of the mouth and trachea
• Maintain the entry of fluid at least as much as 250 ml / day unless contraindicated • Positioning helps maximize lung expansion and decrease respiratory effort
• Prevent obstruction / aspiration
• Helps dilution of secretions
1 2 3
2 Collaboration
• Give medication in accordance with the indications mukolitik, expectorants, bronchodilators • Mukolitik to reduce cough, expectorant to help mobilize secretions, bronchodilators reduce bronchial spasms and analgesics are given to reduce discomfort
3. Anxious
Purpose: clients Anxious reduced / lost
Criteria:
- The client will describe the anxiety levels and patterns kopingnya
- The client knows and understands about his illness and its treatment.
No. Rational intervention
1 2 3
1 • Assess client's level of anxiety
• Provide comfort and reassurance to the client:
- Accompany client
- Show empathy (it comes with a touch client)
• Provide a description of the client about her illness slowly, calmly seta sentences using clear, concise easy to understand
• Get rid of excessive stimulation such as:
- Put the client the room a calmer
- Limit contact with others / other clients are likely to experience anxiety
• observation of vital signs.
• If necessary, collaboration with medical teams • Determine the next action
• Facilitate the client's receipt of the information provided
• Increase understanding of the client about the disease and treatment for the disease so that the client more cooperative
• By removing the stimulus that will enhance the peace of the client concerned.
• Know the client early development.
• Drugs can reduce client anxiety levels
4. Acute Pain
Purpose: pain diminished or disappeared
Expected outcomes are:
- Client mengungkapakan the pain diminished or disappeared
- The client does not grimace in pain
No. Rational intervention
1 2 3
1 • Assess client's level of pain
• Explain the causes and effects of pain on the client and family
• Teach relaxation techniques and distractions
• observation of vital signs and client complaints
• Collaboration * with the medical team
- Conservative therapy:
a. Acetaminopen drugs; aspirin, nasal decongestant
• Knowing the client's level of pain in determining further action
• The causes and consequences of pain the client is expected to participate in treatment to reduce pain
• The client knows the distraction and relaxation techniques can be practiced so as if in pain
• Know the general condition and development of the client's condition.
• Eliminate / reduce the client's complaints of pain
REFERENCES
A. Arif, Mansjoer, et al, 1999, Capita Selekta Medicine, 3rd Edition, Volume 1, Aesculapius Media, London ..
2. Hall Publishers. FK. UI. Of 1998. ENT Diseases Textbook. New Style. Jakarta
3. Doengoes, Marilyn, et al, 1999, Nursing Care Plan, EGC, Jakarta
4. Johnson. M. Maas. M. Moorhead. S. Of 2000. Nursing Outcomes Classification (NOC). Mosby. Philadelphia
5. MC. Closky J. and Bulaceck G. Of 2000. Nursing Interventions Classification (NIC). Mosby. Philadelphia.