nursing care plan for epistaxis nurseslabs

Prepare the patient for splenectomy as indicated. These conditions include: Immune thrombocytopenia. Monitor hemoglobin level and other blood components. (2020). If no improvement, pack the nose with vasoconstrictor-soaked gauze and a heavy coat of petroleum jelly for 10 minutes. St. Louis, MO: Elsevier. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); This is a community of professional nurses gifted with literary skills who share theoretical and clinical knowledge, nursing tidbits, facts, statistics, healthcare information, news, disease data, care plans, drugs and anything under the umbrella of nursing. Educate why exercise is important. Desired Outcome: The patient will actively participate in the treatment plan and will be able to demonstrate behaviors that will help prevent complications. It commonly varies in size, severity, and treatment needed. The patient should be asked about the initial presentation of the bleeding, previous bleeding episodes, and their treatment, comorbid conditions, and current medications, including over the counter medicines and herbal and home remedies. Nurse Salary: How Much Do Registered Nurses Make? Manage tobacco withdrawal symptoms as they appear. Check stool (guaiac) and urine (Hemastix) for occult blood. Weigh the patient daily. Nurses assigned to the patient continuously update the plan as they carry out planned interventions in their respective shifts. Tell her to breathe through her mouth while she holds firm pressure on the soft flesh of her nose for at least 10 minutes. This is commonly referred to as idiopathic thrombocytopenic purpura. Start a food chart. Hypovolemia due to bleeding may lower blood pressure levels and put the patient at risk for hypotensive episodes that lead to shock. Any condition that causes enlargement of the spleen can cause it to trap more platelets than usual, hence affecting the number of platelets in the blood circulation. Commence the patient on fluid balance chart. Example Answers For Questions On Evidence Based Practice. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Hope weve helped you write better nursing care plans! Teach the patient about measures to reduce constipation such as increased fluid intake and dietary fiber. To provide pain relief especially in the affected area. The two types of clotting factor products include plasma-derived concentrates and recombinant factor concentrates. Priority of assessment falls on determining whether the patient has been displaying signs and symptoms of bleeding and whether there is a need to rehydrate the patient or start blood transfusions. The client with epistaxis usually arrives at the emergency room following unsuccessful attempts to stop the bleedingsigns of airway obstruction. Epistaxis. Ask the patient to rate fatigue level (mild, moderate, or severe fatigue). Knowledge , relevance , and definitely good tools for a student to read and comprehend daily. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Nursing Care Plan for Diverticulitis. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. A patient with anterior packing will follow up with an ear, nose, and throat specialist as an outpatient. Most of the time it can be remedied by cold compress. Close monitoring. Medical-surgical nursing: Concepts for interprofessional collaborative care. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). She received her RN license in 1997. Provide an emesis basin and tissues. Refer to the dietitian as needed. St. Louis, MO: Elsevier. We have placed these care plans online so that nursing students (and pre-nursing students) can get an idea of how care plans are created, and what care plans will . Some error has occurred while processing your request. Also known as plasma exchange, this procedure involves the removal of plasma from the body of the patient and replacing it with new plasma fluid. Nursing Care Plan for Atelectasis 1 Nursing Diagnosis: Ineffective Breathing Pattern related to atelectasis as evidenced by shortness of breath, SpO2 level of 85%, respiratory rate of 27, cough, rapid and shallow breathing, chest pain when breathing, cold and clammy skin, and restlessness St. Louis, MO: Elsevier. Hemoglobin carries oxygen to the cells in the body. Includes our easy-to-follow guide on how to create nursing care plans from scratch. Our ultimate goal is to help address the nursing shortage by inspiring aspiring nurses that a career in nursing is an excellent choice, guiding students to become RNs, and for the working nurse helping them achieve success in their careers! It serves as a guide in anticipating the patient's healthcare needs. Perform the blood transfusion if indicated. Support holistic care which involves the whole person including physical, psychological, social and spiritual in relation to management and prevention of the disease. Gluckman W, Barricella R, Quraishi H, Lamba S. Epistaxis. Rationales are scientific principles that explains the reasons for selecting a particular nursing interventions. Wolters Kluwer Health If you continue to use this site we will assume that you are happy with it. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. Medication. Also, advise him/her to avoid forceful nose blowing and straining with bowel movement. Monitoring of the patients neurological status may include measurement of GCS, level of consciousness, pupillary reaction, and muscle strength. HOME NURSING CARE PLANS 9 ASTHMA NURSING CARE PLANS 9 Asthma Nursing Care Plans UPDATED ON JANUARY 3, 2023 BY PAUL MARTIN, BSN, R. ADVERTISEMENTS Menu In this guide are nine (9) NANDA nursing diagnosis for asthma nursing care plans including their nursing assessment and interventions. The nurses signature demonstrates accountability. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Although it rarely poses a life-threatening hazard, it may still give parents of young children cause for serious concern. The endoscopist can diagnose and treat bleeding peptic ulcers while the patient undergoes endoscopy. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. NURSING PROCESS FOCUS Clients Receiving Antidepressant. 2008. http://emedicine.medscape.com/article/994459-overview. Nursing Care Plans and Nursing Diagnosis ? Assess for signs and symptoms of hemodynamic instability, including change in mental status, pallor, diaphoresis, hypotension, tachycardia, and tachypnea. Provides tissues and emesis basin to allow the patient to expectorate any excess blood. Early signs of bleeding include gum bleeding, epistaxis, and unexplained bruises. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. St. Louis, MO: Elsevier. Wolters Kluwer Health, Inc. and/or its subsidiaries. You can download it here: Nursing Care Plan Template. Electrolytes may need to be replaced intravenously. Problems in clotting factors in medical conditions such as hemophilia put the patient at risk for bleeding. However, early detection and treatment can improve the outcome and prevent serious complications from happening. To explore the patients energy levels and how these can affect ADLs. Expected Outcomes: Therefore, our team will give you the ease in finding the correct Nursing Care Plan for Epistaxis. Hair growth often signifies good perfusion while purplish to cyanotic skin is associated with reduced or absent tissue perfusion. A well-written care plan allows nurses to measure the effectiveness of care and to record evidence that the care was given. Nursing Diagnosis: Risk for Bleeding related to anticoagulant therapy. Levels below this range can cause problems in the human body. They are segmented in categories: Miscellaneous nursing care plans examples that dont fit other categories: Care plans that involve surgical intervention. Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Desired Outcome: To prevent any bleeding episode and improve platelet count. Disturbed Visual Sensory Perception. For more information, please refer to our Privacy Policy. Anterior bleeding is usually managed by digital pressure, gentle chemical cauterization, or nasal packing. Austin Health Search. Laryngeal Nanda Care Plan. Desired Outcome: The patient will develop an understanding of the importance of protecting the involved extremity from further injury. In an acute care setting, most goals are short-term since much of the nurses time is spent on the clients immediate needs. St. Louis, MO: Elsevier. Nursing Care Plans for Osteomyelitis Acute Pain r/t infectious process and swelling Expected Outcome: The patient will report an acceptable pain level of 3 or less on a 0 to 10 pain scale, as evidenced by vital signs within normal limits and a relaxing effect and body posture. Tube feeding Biophysical: 1. Most episodes of bleeding from the nose resolve before the patient arrives at the medical care facility, but persistent or recurrent bleeding requires immediate intervention. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Obtain blood samples and monitor platelet counts as well as coagulation levels (INR, PT, and PTT). Provide an emesis basin and tissues. Mental Health Psychiatric Nursing Review Questions with. Low blood pressure, low temperature, and dizziness may result from excessive bleeding. Nursing Care Plan for Depression Thought Self Esteem. This calls for an immediate review of the right dose for the patient. Fracture Nursing Care Plans 11 Nursing Diagnosis - Nurseslabs Nursing study notes for nurses. After assigning priorities for your nursing diagnosis, the nurse and the client set goals for each determined priority. * Put on protective gear, including gown, gloves, and goggles. Heating Boiler Distributor, Tell the patient to report signs and symptoms of infection and teach her about any prescribed antibiotics. Free; Metrics In Brief. 00 Comments Please sign inor registerto post comments. Obtain blood samples to monitor coagulation essays for factors VIII and IX. Commence a fluid balance chart, monitoring the input and output of the patient. Nursing Diagnosis: Ineffective Tissue Perfusion (Renal) related to low levels of cellular components required for oxygen delivery secondary to chronic anemia as evidenced by hemoglobin level of 6.9 g/dL. Managing epistaxis. Sudden changes in the patients symptoms can signify a new stroke or worsening of the condition. Fluid restriction to <1500mL/day until LLQ pain resolves; no caffeine. Explain to a sexually active patient the use water-soluble lubricants during intercourse. Include episodes of vomiting, gastric suctioning, and other gastric losses in the I/O charting. Aslaug And Harbard, Gluckman W, Barricella R, Quraishi H, Lamba S. Epistaxis. Delayed wound healing is very common in patients with peripheral vascular disease. Beneficence is the duty to do no harm and the duty to do good. Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range. Thrombotic thrombocytopenic purpura. Assess the patients energy level and fatiguability, as well as his/her usual activities of daily living (ADLs). The terms goal, outcome, and expected outcome are oftentimes used interchangeably. (Specific Systems) University Wallace Community College Selma Course Nursing Concepts 2 (11193) Academic year2021/2022 Helpful? Desired Outcome: To prevent any bleeding episode and improve platelet count. As an Amazon Associate I earn from qualifying purchases. Factor replacement therapy can be subtherapeutic in decreased levels of factors VIII and IX. Stomach upset due to alcohol, drugs, blood, or iron 5. The nursing diagnosis Impaired Physical Mobility is defined as the limitation in independent, purposeful physical movement of the body. Prolonged wound healing can predispose the broken skin and surrounding area to further infections. Some herbal remedies can affect clotting factors, such as ginseng and gingko biloba. -The nurse will consult with discharge planning on setting up with an agency that provided 24 hour care givers at discharge. Prepare the patient for clotting factor replacement therapy. To enable to patient to have specialized advice on renal diet while incorporating his/her food preferences. The consent submitted will only be used for data processing originating from this website. Nurseslabs.com is an education and nursing lifestyle website geared towards helping student nurses and registered nurses with knowledge for the progression and empowerment of their nursing careers.Since we started in 2010, Nurseslabs has become one of the most trusted nursing sites helping thousands of aspiring nurses achieve their goals. Nursing interventions are directed at prevention. Low blood pressure, low temperature, and dizziness may result from excessive bleeding. 4 Real World Examples of Using Clinical Judgement to. Post-surgery, assess and monitor the patients surgical wound site for any signs of unexpected bleeding. Assuring the patient in a calm, efficient manner that bleeding can be controlled can help reduce anxiety. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Also, they feel dizzy, faint, or are losing color in their face they should go to the ER. Nursing2020 Critical Care6(2):48, March 2011. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. Encourage the patient to follow a low cholesterol, high caloric diet. * If bleeding is significant, establish vascular access, place the patient on a cardiac monitor, and begin fluid resuscitation with a crystalloid solution, as ordered. To assess the fluid volume status of the patient. Assess baseline functions such as the ability of the patient to swallow, speak, and move. Nursing diagnoses handbook: An evidence-based guide to planning care. Please try again soon. In particular,client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic and environmental. All rights reserved. Maintain seizure precautions. Free care plans list: Browse our care plan database for nurses and nursing students below to learn more about how care plans are arranged, organized, and created. Encourage adequate hydration. Posterior bleeding, which is less common, is characterized by massive bleeding that's initially bilateral; this bleeding may be more difficult to control. This helps prevent nausea and vomiting and lets you estimate the amount of bleeding. Early signs of bleeding include gum bleeding, epistaxis, and unexplained bruises. To measure the risk of bleeding by knowing the platelet counts and coagulation levels of the patient. wound cleaning prevent further injury and infection, Thrombophlebitis Nursing Diagnosis and Nursing Care Plans. Maintain skin care change position every hourly to prevent bed sore. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. Vitamin K is currently used for warfarin overdose.Protamine sulfate is currently used for, Decreased quantity or quality of circulating platelets in the blood (such as in, Interference in the genetic expression of clotting factors (such as hemophilia), Increased number of platelets (such as in immune thrombocytopenic purpura or ITP), Reduction of the bone marrows capacity to produce platelets (such as in blood cancers), Liver impairment or other conditions where there is a decreased rate in the synthesis of clotting factors, Gastrointestinal disorders such as peptic ulcer disease (PUD) and inflammatory bowel disease (IBD), Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), systemic anti-cancer therapy agents (SACT) may cause bone marrow suppression, Some herbal remedies that can affect clotting factors, such as ginseng and gingko biloba. Advise the patient to stop the use of non-steroidal anti-inflammatory drugs (NSAIDs), anticoagulants, and certain herbal remedies prior to surgery, as indicated by the physician. to maintaining your privacy and will not share your personal information without I hope to learn more and improve my skills towards nursing. Follow these tips to manage epistaxis: Put on protective gear, including gown, gloves, and face shields. Nursing management Monitor for patient vital signs assists in the control of bleeding. 2204 Intervention with a Suicidal Client Flashcards Quizlet. * Obtain a history about previous nosebleeds, other bleeding episodes, easy bruising, and medication use, especially use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents, warfarin, and herbal products. Nose bleeds are mostly caused by too much heat. To establish baseline data. All rights reserved. Advise patient to use a soft-bristled toothbrush as well as a non-abrasive toothpaste. Obtain baseline vital signs and monitor them regularly. Knowing how valuable nurses are in delivering quality healthcare but limited in number, he wants to educate and inspire nursing students. Teach the patient how to sit on a commode to avoid straining (renal damage). Medication. Nursing Diagnosis: Risk for Bleeding related to invasive surgical procedure. She found a passion in the ER and has stayed in this department for 30 years. Wolters Kluwer Health, Inc. and/or its subsidiaries. You can read the full text of this article if you: You may be trying to access this site from a secured browser on the server. Nursing Assessment Nursing Care Plan for Epistaxis. EPISTAXIS (NASAL BLEEDING) is relatively common but rarely fatal. 1.Goal 2.Related Action 3.Rational 4.Evaluate outcome, Wow God bless plenty Nurseslabs really relieve my burdens . Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Reassure the patient, monitor vital signs, and assess for hypoxia. * If bleeding persists, assist in preparing the epistaxis tray and a headlamp. Nursing Care Plan 2. Desired Outcome: To prevent any bleeding episode during or after the surgical procedure. To treat any unexpected bleeding as early as possible. Peripheral Arterial Disease (As a Complication of Diabetes), Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral) related to delayed peripheral wound healing secondary to peripheral arterial disease as evidenced by an open wound on the right big toe. About a third of the bodys platelets are housed in the spleen. Depending on the presenting signs and symptoms, further tests may be requested to determine the primary cause of thrombocytopenia. Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral) related to decreased peripheral blood flow secondary to Buergers disease, as evidenced by pale, reddish, or bluish hands or feet, pain on the affected area, Raynauds phenomenon (fingers and toes turn pale when exposed to cold), leg numbness and weakness. Cryoprecipitate and monoclonal antibodies are other options in treating hemophilia and reducing the risk for bleeding. Teach the patient or caregiver pinching pressure techniques. Nursing Care Plans Download these FREE nursing care plan examples for different conditions. For them to function, they need oxygen to break down sugar and use it as energy. Reassure the patient. To allow the stomach lining to heal, and to prepare the patient for diagnostic procedure (endoscopy). Get new journal Tables of Contents sent right to your email inbox, http://emedicine.medscape.com/article/994459-overview, Articles in PubMed by Jill Rushing, MSN, RN, Articles in Google Scholar by Jill Rushing, MSN, RN, Other articles in this journal by Jill Rushing, MSN, RN, Caring for hospitalized patients with alcohol withdrawal syndrome, Managing a patient with Acute Respiratory Distress Syndrome PART 2: ARDS, Privacy Policy (Updated December 15, 2022). Nursing Diagnosis: Fluid Volume Deficit related to blood volume loss secondary to bleeding as evidenced by hematemesis, low platelet count, HB of 70, skin pallor, blood pressure level of 85/58, and lightheadedness, Desired Outcome: The patient will have an absence of bleeding, a hemoglobin (HB) level of over 100, blood pressure level within normal range, full level of consciousness, and normal skin color, Nursing Diagnosis: Risk for Injury related to abnormal blood profile. She received her RN license in 1997. Blood transfusion may be required if there is too much blood loss. Good tissue perfusion is often characterized by the presence of good pulses in the femoral, popliteal, posterior tibial, and dorsalis pedis region. Anticipate that the physician my put the patient in an NPO or nothing per orem/ nothing by mouth status as ordered. Nursing interventions can be independent, dependent, or collaborative: When writing nursing interventions, follow these tips: Rationales, also known as scientific explanation, are the underlying reasons for which the nursing intervention was chosen for theNCP. Based on nursing knowledge and experience or knowledge from relevant sciences. For them to function, they need oxygen to break down sugar and use it as energy. Splenectomy or the removal of spleen was the recommended treatment for ITP and steroid-refractory thrombocytopenia; however, the advent of new treatments such as thrombopoietin receptor antagonists renders splenectomy as one of the last resorts for the treatment of ITP. Ineffective airway clearance. Buy on Amazon, Silvestri, L. A. The Nursing Care Plan for Epistaxis is a kind of Information Nursing Care Plan Examples are much sought after on the internet and has linkages with various information Nursing Care Plan other Examples. Desired Outcome: The patient will be able to prevent injury by means doing activities that can be done without spending too much energy, and by modifying environment to adapt to current capacity. This condition can presents as follows: Thrombocytopenia can result from different conditions or as a side effect of medications. [black left pointing small triangle] Have the patient sit upright with her head tilted forward, and instruct her to apply direct external digital pressure to the nares with her index finger and thumb. The following are the early warning signs of reduced tissue perfusion: Numerous conditions can affect the bodys ability to perfuse oxygen to the cells. Prepare the patient for the surgical procedure as indicated. If bleeding persists, cotton pledgets soaked in a vasoconstrictor and anesthetic will be placed in the anterior nasal cavity, and direct pressure should be applied at both sides of the nose. Here are four (4) nursing care plans (NCP) for Hypovolemic Shock: Involve the client in the process to enhance cooperation. Join NursingCenter on Social Media to find out the latest news and special offers. * Obtain vital signs and SpO 2 level, and assess her breath sounds. To prepare for any need to perform blood transfusion as prescribed. Medical-surgical nursing: Concepts for interprofessional collaborative care. Students also viewed Mat Health Chap 16 Objectives Electrolytes may need to be replaced intravenously. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). The signs and symptoms of thrombocytopenia are mostly related to bleeding. Measles Nursing Diagnosis and Nursing Care Plan, Transient Tachypnea Nursing Diagnosis and Nursing Care Plan. Increased blood viscosity is a contributory factor to clotting. Posterior bleeding, which is less common, may be more difficult to control. Obtain a focused health history, including previous nosebleeds, other bleeding episodes, easy bruising, and medication use, especially use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents, warfarin, and herbal products. Here are six (6) nursing care plans (NCP) and nursing diagnosis for patients with sepsis and septicemia: If you would like to change your settings or withdraw consent at any time, the link to do so is in our privacy policy accessible from our home page.. Nursing care plans: Diagnoses, interventions, & outcomes. Quickly assess the ABCs (airway, breathing, and circulation) and support them as indicated. Nursing goals for a child with Kawasaki disease may include increased understanding of the parents and child about the disease condition, medical treatment and planned follow-up care, relief of pain, improved physical mobility, adequate coping, and absence of complications. Risk for bleeding happens with disorders that reduce the quality or quantity of circulating platelets (thrombocytopenia). Here we'll formulate a scenario-based sample AFib nursing care plan.It will include three sample nursing care plans with NANDA nursing diagnosis, nursing assessment, expected outcome, nursing interventions, and rationales.. What is AFib? Nurseslabs. She received her RN license in 1997. Epistaxis (nasal bleeding) is relatively common but rarely fatal. There are several ways for the patient to help his/her wound to heal and improve tissue perfusion. To reduce peripheral edema and to manage obesity, hypertension, fatigue, and weakness. Assess vital signs, particularly blood pressure level. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Nursing diagnoses handbook: An evidence-based guide to planning care. Already a member? Some agencies use a three-column plan wherein goals and evaluation are in the same column. Although the relationship between tobacco use and Buergers disease is unknown, smoking cessation still proves to be the main intervention to manage the disease. Encourage the patient to exercise. Nursing A discussion with the patient regarding risk factors may prevent further injury and promote understanding of the importance of lifestyle modifications to prevent this from happening again. The following are the common goals and expected outcomes for Risk for Bleeding: Assessment is necessary in order to identify potential problems that may have lead to bleeding and also name any event that may happen during nursing care. Although the differential diagnosis should include both local and systemic causes, environmental factors such as humidity and allergens also must be considered. Ineffective Tissue Perfusion Nursing Care Plans Diagnosis and Interventions Ineffective Tissue Perfusion NCLEX Review and Nursing Care Plans The cells are the building blocks of the human body. Desired Outcome: To prevent any bleeding episode while the patient is on anticoagulant therapy. If she has posterior packing, she'll be admitted to the hospital. Tell her to spit blood into the basin if necessary. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. Administer blood or platelet transfusion as prescribed. St. Louis, MO: Elsevier. Anticipate the need for the patient to have whole blood replacements. Obtain Group and Save blood samples from the patient. Note the characteristics of the urine. This mechanism is carried out by the circulatory system in a process known as tissue perfusion. Nursing Interventions: -The nurse will demonstrated 3 techniques to the patient and daughter on how to improve memory.-The nurse will educate the patient about using the call light for help and utilize the bed/chair alarm. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. These anti-fibrinolytics are usually given as prophylaxis for female hemophilia patients with heavy menstrual bleeding, or for those who are schedule for dental work. Dimethyl Maleate And Dimethyl Fumarate, Ashley Furniture Head-foot Model-good King Adjustable Base, Kichler Landscape Lighting Replacement Bulbs, nursing care plan for epistaxis nurseslabs, ING Bank Voice Customer Care Enthusiast program flexibil 4, 6 sau 8 ore. Here are some factors that may be related to Risk for Bleeding: 1. Assess vital signs, particularly blood pressures. Advise the patient to stop or avoid the use of non-steroidal anti-inflammatory drugs (NSAIDs). Their primary function is to stop bleeding by a process known as coagulation, which means clumping together to make a plug and sticking on the source of bleeding. Quickly assess the ABCs (airway, breathing, and circulation) and support them as indicated. She found a passion in the ER and has stayed in this department for 30 years. If cautery is unsuccessful, nasal packing will be used to apply direct pressure to the bleeding site. Nursing Care Plan Orthostatic Hypotension 1 Nausea Nursing Diagnosis: Nausea related to motion sickness and dizziness upon standing secondary to orthostatic hypotension, as evidenced by expression of nausea, increased salivation, and gagging sensation.