Epistaxis or nosebleeds are common and self-limiting, with only about 10% requiring emergent treatment. There are two types of epistaxis:
- Anterior epistaxis: Most epistaxis occurs in the anterior part of the nasal cavity, where blood vessels and capillaries are small and fragile. Anterior bleeding usually stops on its own.
- Posterior epistaxis: Posterior bleeding occurs in the back of the nasal cavity where vessels are larger. These bleeds are often related to hypertension or underlying vascular abnormalities. Bleeding in this area may be heavier and flow down the back of the throat. Medical attention may be needed to stop the bleeding.
Children between the ages of 2-10 may have minor nosebleeds due to picking their noses or sticking objects into their noses. Later in life, patients between the ages of 45-65 have an increased risk of epistaxis due to blood taking longer to clot as well as the use of anticoagulants and aspirin. Older adults are also more likely to suffer from chronic vascular diseases like hypertension and atherosclerosis.
Pregnant women may experience nosebleeds as their vasculature changes and blood vessels in the nose expand, causing increased pressure.
Additional causes of epistaxis include:
- Trauma
- Deviated septum
- Low humidity
- Chronic oxygen use via nasal cannula
- Allergies
- Sinusitis
- Upper respiratory tract infections
- Foreign bodies in the nose
- Chemical irritants
- Tumors
- Cocaine use
- Clotting disorders like hemophilia
Immediate medical treatment should be sought if the nosebleed cannot be stopped after more than 20 minutes, if the bleeding is rapid, accompanied by breathing difficulties, and if bleeding occurred after head trauma or serious injury.
A physical exam can help identify the condition. Further diagnostic studies like CBC or PTT can help assess bleeding disorders, while imaging tests like nasal CT scan, facial x-ray, and nasal endoscopy can help identify injuries like a broken nose, internal bleeding, or skull fracture.
Nursing Process
Priority nursing care for patients with epistaxis involves stopping the bleeding. The airway and circulation must be maintained at all times. Medical management may be required if the bleeding will not stop within 20 minutes of direct pressure. Vasoconstricting foams or gels, nasal packing, and cauterization are interventions that may be employed. Patient education is essential to teach first aid measures to help control nosebleeds at home and avoid recurrence and complications.
Nursing Assessment
The initial evaluation of a patient with epistaxis involves a thorough medical history and physical examination. Key aspects to assess include:
Medical History: Review the patient’s history for risk factors such as recent nasal trauma, history of bleeding disorders, use of anticoagulant or antiplatelet medications, and any previous episodes of epistaxis. Inquire about the duration, frequency, and severity of the nosebleed, as well as any associated symptoms such as dizziness, headache, or visual disturbances.
Physical Examination: Perform a comprehensive physical examination focusing on the nose and nasal cavity to identify the source of bleeding. Inspect the nasal septum for any signs of trauma, ulcers, or deviated septum. Check for signs of active bleeding and assess the patient’s vital signs, including blood pressure and heart rate, to evaluate for any signs of hemodynamic instability.
Laboratory Tests: If the patient has a significant bleeding history or there is a suspicion of an underlying bleeding disorder, obtain laboratory tests, including complete blood count (CBC), coagulation profile (PT, PTT), and blood type and crossmatch if a transfusion is anticipated.
Nursing Interventions
Nursing intervention plays a pivotal role in the effective management of epistaxis. By conducting thorough evaluations, implementing evidence-based interventions, and providing comprehensive patient education, nurses can significantly improve patient outcomes and quality of life. Through their dedication and expertise, nurses ensure that patients receive holistic, compassionate, and person-centered care, ultimately leading to successful management of epistaxis and enhanced well-being.
Immediate Management
The initial management of epistaxis focuses on controlling the bleeding and stabilizing the patient. Key interventions include:
Positioning: Have the patient sit upright and lean forward slightly to prevent blood from flowing down the throat and causing aspiration. Encourage the patient to breathe through their mouth and avoid swallowing blood.
Nasal Compression: Apply direct pressure to the soft part of the nose for at least 10-15 minutes. Instruct the patient to pinch the nostrils together firmly and maintain the pressure continuously without interruption.
Topical Vasoconstrictors: If nasal compression is ineffective, consider the application of topical vasoconstrictors, such as oxymetazoline or phenylephrine, to help constrict the blood vessels and reduce bleeding.
Cauterization: For persistent bleeding, chemical or electrical cauterization may be necessary. This procedure should be performed by a trained healthcare provider.
Supportive Care
In addition to controlling the bleeding, providing supportive care is essential in managing epistaxis and preventing recurrence. Key actions include:
Hydration: Ensure the patient remains hydrated by encouraging adequate fluid intake. This helps maintain mucosal integrity and reduces the risk of recurrent nosebleeds.
Humidification: Advise the use of a humidifier in the patient’s environment to keep the nasal mucosa moist and prevent dryness, which can lead to further bleeding.
Medications: Review the patient’s medications and, if possible, discontinue or adjust any anticoagulants or antiplatelet drugs that may contribute to bleeding. Consult with the prescribing physician before making any changes.
Long-term Management
Preventing recurrent epistaxis requires addressing the underlying causes and educating the patient on preventive measures. Key strategies include:
Lifestyle Modifications: Encourage the patient to avoid activities that may trigger nosebleeds, such as vigorous nose blowing, heavy lifting, or straining. Advise against the use of nasal irritants, such as tobacco smoke and recreational drugs.
Nasal Care: Instruct the patient on proper nasal care, including gentle nasal hygiene and the use of saline nasal sprays to keep the mucosa moist. Recommend the application of a thin layer of petroleum jelly or antibiotic ointment inside the nostrils to prevent dryness and irritation.
Follow-up Care: Schedule follow-up appointments to monitor the patient’s progress and address any recurrent episodes of epistaxis. If the patient experiences frequent or severe nosebleeds, refer them to an otolaryngologist for further evaluation and management.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for epistaxis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for nosebleeds.
Anxiety
Bleeding from the nose is likely to cause anxiety, especially if the bleeding appears severe, if the patient has never had a nosebleed before, and if the patient is young.
Nursing Diagnosis: Anxiety
Related to:
- Unfamiliarity with the medical condition and its first aid
- Threat to health
As evidenced by:
- Expresses anxiety
- Shakiness
- Restlessness
- Expresses distress
- Expresses preoccupation
Expected outcomes:
- Patient will verbalize feelings and concerns about the current condition.
- Patient will demonstrate effective coping strategies that can help alleviate anxiety.
Assessment:
1. Assess the extent of the patient’s anxiety.
Awareness of the patient’s concerns is essential in providing an appropriate plan of care.
2. Assess the patient’s bleeding and medical history.
Obtaining a history can identify the triggers that cause epistaxis, the duration of an episode, and first aid attempts. This information can help plan an appropriate treatment regimen.
Interventions:
1. Encourage the patient to express feelings and concerns freely.
Verbalization of perceived threats can help reduce the patient’s anxiety and encourage a trusting relationship. The nurse can then provide reassurance and dispel any unwarranted concerns.
2. Encourage breathing exercises.
Encourage the patient to continue breathing through their nose in slow breaths to help reduce stress and keep them calm during an epistaxis episode.
3. Educate the patient regarding epistaxis first aid measures.
Proper education on how to initially manage epistaxis can help the patient remain calm and composed during an episode. Knowing what to do will help reduce stress and anxiety.
4. Explain all interventions.
Especially for young children, the nurse should show the patient supplies or instruments they are using, and how they work so the child will be less frightened and more willing to cooperate.
Deficient Fluid Volume
While epistaxis is typically not serious and can be addressed with first aid measures, frequent and heavy nosebleeds can cause deficient fluid volume due to excessive blood loss.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Excessive bleeding
- Use of anticoagulants
- Blood clotting disorder
- Failure to render first aid measures
As evidenced by:
- Excess blood loss
- Decreased blood pressure
- Weakness
- Increase heart rate
- Pallor
- Fatigue
Expected outcomes:
- Patient will maintain airway and circulation within expected parameters.
- Patient will demonstrate interventions to prevent bleeding and reduce fluid volume loss.
Assessment:
1. Assess vital signs.
Changes in vital signs accompanying bleeding and fluid loss include decreased pulse pressure, tachypnea, tachycardia, and an increase or decrease in temperature.
2. Assess lab results.
Monitoring the complete blood count (hemoglobin and hematocrit) along with coagulation labs is necessary to assess the need for transfusions.
3. Assess medication and health history.
Assess if the patient takes anticoagulants or aspirin or has a history of clotting disorders that may provide insight into difficulty controlling bleeding.
Interventions:
1. Ensure hemodynamic stability.
At all times, the nurse should closely monitor airway patency and circulation. Oxygen should be applied if necessary, and an IV line should be started to transfuse crystalloids.
2. Administer intravenous fluid or blood product replacement.
Excessive blood loss occurring with posterior epistaxis may require blood transfusion and intravenous fluid replacement.
3. Teach the patient when to seek medical help during an epistaxis episode.
If nasal bleeding has not stopped after 20 minutes of applying first aid measures, there is excessive blood loss or respiratory distress, immediate medical support must be sought.
4. Ensure follow-up with a specialist.
Patients who have an underlying coagulopathy should follow-up with a hematologist. Recurrent epistaxis should be addressed by an ENT.
Deficient Knowledge
Nosebleeds can be easily managed if patients are educated on first-aid precautions.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Misinformation
- Inadequate knowledge of first aid
- Inaccurate instructions
- Inadequate participation in care
- Unfamiliarity with nosebleeds
As evidenced by:
- Inaccurate follow-through of instructions
- Inaccurate statements about epistaxis
- Inappropriate first-aid measures performed
Expected outcomes:
- Patient will verbalize understanding of the current condition and appropriate first aid measures
- Patient will demonstrate effective ways of preventing nasal bleeding.
Assessment:
1. Assess the patient’s knowledge about epistaxis.
Understanding what the patient knows about preventing and treating epistaxis can determine gaps in knowledge and plan education.
2. Assess the patient’s ability to learn.
A young child may or may not be able to perform first aid to stop their nosebleed. If not, direct instructions to a parent or guardian.
Interventions:
1. Educate children on preventing nosebleeds.
Children often pick their noses and may insert foreign objects into their noses. Instruct them against doing this and keep their fingernails cut short to reduce irritation.
2. Educate the patient about actions that can trigger nasal bleeding.
Nasal bleeding can be caused by blowing the nose too hard, nose picking, colds or sinusitis, and excessive use of nasal sprays.
3. Educate the patient about first-aid measures to stop nasal bleeding.
- Sit up straight with the head slightly leaning forward.
- Pinch the soft tissue of the nostrils for at least 5-10 minutes.
- If bleeding persists after 20 minutes, seek additional support.
4. Offer interventions if nosebleeds are frequent.
Keep nasal passages moist with a saline solution during winter months or when sick with a respiratory infection. Use a humidifier indoors to keep the air moist. Do not smoke, as smoking dries out and irritates the nose.
Nursing Diagnoses and Rationales for Epistaxis
1. Risk for Bleeding
Rationale: Epistaxis involves active bleeding from the nasal mucosa, which can be triggered by various factors such as trauma, environmental dryness, hypertension, or anticoagulant therapy. Assessing the patient’s bleeding history, monitoring vital signs, and maintaining a humidified environment can help reduce the risk of recurrent nosebleeds.
2. Anxiety
Rationale: Experiencing a nosebleed can cause significant anxiety and distress for patients. Providing reassurance, explaining the causes and management of epistaxis, and teaching relaxation techniques can help alleviate anxiety. Ensuring a calm environment and offering emotional support are also crucial.
3. Impaired Tissue Integrity
Rationale: Frequent or severe nosebleeds can damage the nasal mucosa and surrounding tissues. Assessing the nasal passages, applying appropriate interventions such as nasal packing or cauterization, and promoting nasal hygiene can aid in tissue healing and prevent further damage.
4. Risk for Infection
Rationale: Nasal packing or other interventions to control bleeding may increase the risk of infection. Monitoring for signs of infection, educating the patient on proper nasal care, and ensuring aseptic techniques during nasal interventions are essential to prevent infections.
5. Ineffective Airway Clearance
Rationale: Blood clots or nasal packing can obstruct the nasal passages, impairing airway clearance. Assessing the patient’s respiratory status, encouraging gentle blowing of the nose, and providing interventions such as suctioning or humidified oxygen can help maintain airway patency.
6. Knowledge Deficit
Rationale: Patients may lack knowledge about the causes, prevention, and management of epistaxis. Educating patients and their families about factors that contribute to nosebleeds, such as dry air or nose picking, and teaching appropriate first aid measures can empower them to manage and prevent future episodes.
7. Pain
Rationale: Nosebleeds can cause discomfort and pain, particularly if nasal packing or cauterization is required. Assessing the patient’s pain level, providing analgesics as needed, and offering non-pharmacological pain relief measures, such as ice packs or saline nasal sprays, can enhance patient comfort.
8. Risk for Aspiration
Rationale: Blood from a nosebleed can be swallowed or aspirated, leading to potential respiratory complications. Positioning the patient upright, instructing them to spit out blood instead of swallowing, and closely monitoring for signs of aspiration are critical nursing interventions.
REFERENCES
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