CAPITOL UNIVERSITY
College of Nursing
Cagayan de Oro City
Name: Chaine M. Agolito
Section/ CN: CN137
NURSING CARE PLAN
SUBJECTIVE
“Nag gamit man gyud kog cotton buds
sa akoang ilong aron makuha ang mga
kalungat, pag tanaw nako naa namay
dugo, wala raman ko. Tapos
ASSESSMENT nakabantay nalang akoang bana nag
tulo na sagunson ang dugo.
Gipasagdaan raman nako pero karon
di naman gaundang gagamit rakog
tissue pangtrapo”
Bleeding of the nose related to the insufficient knowledge of precautions to avoid trauma of
DIAGNOSIS
(P&E/P.E.S
FORMAT)
SHORT TERM
= There will be less of blood from the
nose after 1 hour of nursing
intervention
PLANNING =Patient’s blood pressure will be in
(Goals and normal range after 1 hour
Objective) =Patient will report that the dizziness
and lightheadedness are gone after 4
hours of nursing intervention
=The bleeding stopped after 4 hours of
intervention
INTERVENTION
Independent
1. Assess the location of the
bleeding site through a nasal
speculum, penlight, or
headlight.
2. Perform initial treatments such
as applying direct pressure and
assisting patient in upright
position with head tilted
Intervention
forward.
(With
3. Monitor the patent’s vital
Rationale)
signs, airway, breathing and
assist with control of bleeding.
4. Assure that the patient is calm
during the period of
intervention.
5. Educate the patient to avoid
vigorous exercise, hot spicy
food, tobacco, and to
remember precautionary
management to avoid another
MEDICAL-SURGICAL NURSING NCM 112
NURSING CARE PLAN (NCP) FORMAT
Date: September 13, 2021
NCP #: 1
OBJECTIVE
-Amount of blood in the tissue
-Pallor
-Blood Pressure: 129/70 mmHg
-dizziness and lightheadedness are present
-Pulse Pressure: 115 bpm
the nasal area
LONG TERM
=Client will report no signs of nose bleeding after
48 hours
=Client will apply the precautions and management
for Nosebleed in her everyday lifestyle after being
in the hospital.
RATIONALE
1 This is to identify the site of bleeding in the
nasal cavity. The location is very important
to determine the appropriate interventions
to be done to the client.
2 Applying pressure to the soft outer portion
of the nose to help stop the blood flow and
placing the client in a proper position will
prevent the patient from swallowing and
aspirating blood.
3 Checking the vital signs of the patient is
very important to determine the severity of
the symptoms of the patient. The client
may have lack of understanding of the
initial treatments that should be done even
at bed so assisting with the control
bleeding is very important.
4 Blood loss on clothing and handkerchiefs
can be frightening and nasal treatments
and examination are uncomfortable.
Assure that patient is calm by explaining
Professor: Emman M. Parangue, R.N.
 nose bleed due to trauma. the procedures done to him/her and the
bleeding can be controlled. This will help
reduce the anxiety.
5 There are certain activities tend to cause
vasodilation and increase the risk for
rebleeding and proper discharge education
to prevent epistaxis such as forceful nose
blowing, straining, and nasal trauma

Dependent
1. If instructed by the physician
application of nasal 1. The decongestant nasal spray causes
decongestants such as vasoconstriction which helps stop the
phenylephrine spray may be bleeding, small blood vessels are
done. constricted-temporarily stopping or
Collaborative slowing the blood flow through them.
1. A suction may be used to
remove excess blood and clots 1. Excess blood and clots may cause blockage
from the field of inspection of the area or field of inspection which may
result with difficulty of identifying the
source of bleeding and prevent proper
airway breathing.
The goals are met, there was less blood from the nose after 1 hour of nursing intervention.
The Patient’s blood pressure was in normal range after 1 hour. The dizziness and
lightheadedness were gone and the bleeding stopped after 4 hours. After 48 hours the
patient reported no sign of bleeding from the nose and discharge education about
EVALUATION precautions and management were applied every day.

MEDICAL-SURGICAL NURSING NCM 112

NURSING CARE PLAN (NCP) FORMAT Professor: Emman M. Parangue, R.N.