Evaluation: The patient has maintained adequate perfusion as evidence by oxygen saturation reading between 95-100% monitored and documented by the nurse in adult observation chart. Patient verbalise understanding of importance of deep breathing, coughing exercise and proper position after surgery. The patient demonstrated normal colour and temperature of skin.
Nursing Diagnosis Priority 2: Risk of bleeding related to tissue trauma as evidence by sanguineous ooze on a nasal bolster Planning: Education Implementations and Evaluation: Plan3:1. The nurse will edify the patient to use preventive measure to avoid tissue trauma. Information about preventative measure reduces the risk for bleeding. 2.The nurse will Instruct the patient do not put anything sharp in your nose. The patient needs to avoid the situations that may cause tissue trauma and increase the risk for bleeding.
3. The nurse will educate the patient about signs of bleeding that need to be informed to nurse. Early detection and treatment of bleeding by a healthcare provider reduce complication by blood loss.