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Course: Medical Surgical Nursing

Topic: Epistaxis

The Nurses International Community

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Module Goals

Learners will be able to:

Define epistaxis and list the signs and symptoms.
Discuss the etiology.
Describe the history taking and physical assessment.
Discuss the medical and nursing management.
Describe ways to educating clients about self-care.

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Epistaxis: Definition (Nosebleed)

Bleeding from inside the nose or nasal cavity.

It is one of the most common ear, nose, and throat (ENT) emergencies.

Types

anterior (more common)
posterior (less common, but more likely to require medical attention)

Tabassom & Cho, 2022

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Epistaxis

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Signs and Symptoms

Bleeding from either or both nostrils.
A sensation of flowing liquid at the back of the throat.
The urge to swallow frequently.
Spitting, coughing, or vomiting blood.

Better Health Channel, 2021

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Etiology

Local causes

Digital manipulation
Deviated septum
Trauma
Chronic nasal cannula use

Systemic causes

Alcoholism
Hypertension
Vascular malformations
Coagulopathies (von Willebrand disease, hemophilia)

Tabassom & Cho, 2022

Contact info: info@nursesinternational.org

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Etiology

Environmental factors

Allergies
Environmental dryness (more common in winter months)

Medications

NSAIDs (ibuprofen, naproxen, aspirin)
Anticoagulants (warfarin)
Platelet aggregation inhibitors (clopidogrel)
Topical nasal steroid sprays
Supplement/alternative medications (vitamin E, ginkgo, ginseng)
Illicit drugs (cocaine)

Tabassom & Cho, 2022

Contact info: info@nursesinternational.org

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Critical Thinking Question

Which nursing intervention would be of highest priority for a client with nosebleed who also has a history of heart attack and takes clopidogrel?

Recommend the client to discontinue all nasal sprays
Inform the doctor immediately about client’s order of clopidogrel
Avoid alcohol consumption
Avoid taking NSAIDs

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History Taking

Include:

Duration
Severity
Frequency
Laterality of the bleed
Inciting event, and
Interventions provided prior to seeking care

Inquire about anticoagulant:

Aspirin
NSAID
Topical nasal steroid use

Tabassom & Cho, 2022

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Physical Examination: Equipment

Prepare proper equipment and proper personal protective equipment (PPE) before beginning the physical examination.
Equipment may include:

Nasal speculum
Bayonet forceps
Headlamp
Suction catheter
Packing
Silver nitrate swabs
Cotton pledgets
Topical vasoconstrictors and anesthetic

Tabassom & Cho, 2022

Contact info: info@nursesinternational.org

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Physical Examination (Continued)

Have the client in a seated position in an exam chair in a room with suction available.
Carefully insert the speculum and slowly open the blades to visualize the bleeding site.
A headlight is essential to allow for hands-free illumination.
Clot may need to be suctioned from the nasal cavity to identify the bleeding source.

Tabassom & Cho, 2022

Contact info: info@nursesinternational.org

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Critical Thinking Question

The nurse is preparing the equipment to conduct the physical examination of a client with a nosebleed. Which of the following items should the nurse keep in mind? (Select all that apply).

Nasal speculum
Headlamp
Suction catheter
Packing
Silver nitrate swabs
Cotton pledgets

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Medical Management

Anterior bleeding- apply direct pressure for at least 10 minutes.

Have the client apply constant direct pressure by pinching the nose over the cartilaginous tip (instead of over the bony areas) for a few minutes to try to control the bleed.

If that is ineffective:

Employ vasoconstrictors such as oxymetazoline or thrombogenic foams or gels.

Tabassom & Cho, 2022

Contact info: info@nursesinternational.org

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Medical Management (Continued)

Remove all clots with suction before any attempt at treatment is made.

Rationale:

Clot prevents medication from reaching the vessel.
If packing is necessary, the clot can be pushed into the nasopharynx and aspirated.

Tabassom & Cho, 2022

Contact info: info@nursesinternational.org

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Nursing Management

Instruct the client to:

Avoid nose picking
Blow gently
Use a humidifier to prevent dryness
Apply a small amount of lubricant cream like Vaseline or paw paw ointment inside the nose
Hand hygiene
Drink plenty of fluids
Eat diet rich in fiber to prevent constipation

Healthdirect, 2022

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Critical Thinking Question

A client has been seen at the ER for a nosebleed. Which of the following statements made by the client prompts the need for further assessment?

“Two years ago, a tumor was removed from the right side of my face”
“I drink a lot of fluids regularly”
“When possible, I eat a high-fiber diet”
“I’ve been diagnosed with allergic rhinitis”

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Self-Care: Instructions to the Client

Lean forward and firmly pinch the nose below the bridge for 10 minutes non-stop.
After 10 min, see if the bleeding has stopped.
Don’t tilt the head backwards as the blood may go down the throat into the stomach.
Breathe through the mouth and spit out any blood that enters the mouth.
Place ice packs on the forehead and the back of the neck.

Healthdirect, 2022

Health Essentials, 2023

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Self-Care: How to Pinch the Nose

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Self-Care: Instructions to the Client

Loosen tight clothing around the neck.

When the bleeding has stopped:

Do not pick or blow the nose- this may cause another more bleeding.
Avoid strenuous activity until 24 hours after the bleeding has stopped.
Don’t pack the nostrils with tissues or cotton wool.
If bleeding starts again, repeat the instructions.

Healthdirect, 2022

Contact info: info@nursesinternational.org

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Critical Thinking Question

The nurse is teaching the client about nosebleed. Which of the following interventions should the nurse include in the teaching plan? (Select all that apply).

Tilt the head backwards while applying pressure to the nose
Breathe through the mouth and spit out any blood that enters the mouth
Place ice packs on the forehead and the back of the neck
Pack the nostrils with cotton blood to stop bleeding
Avoid strenuous activities like playing sports

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Red Flags

Considerations for the elderly clients:

Presence of comorbidities such as hypertension and diabetes mellitus cause degenerative changes in blood vessels making them more fragile which bleed easily on abrupt pressure changes such as straining during micturition and defecation.
Excessive coughing in COPD.
Lifting heavy objects.

Parajuli, 2015

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Red Flags

Rhinosinusitis, nasal allergy, temperature changes, and dry heat produce hyperemic nasal mucosa which can bleed while blowing ‘nose or picking’ nose or with trivial trauma leading to anterior epistaxis.

Parajuli, 2015

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Better Health Channel. (2021). Nosebleeds. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/nosebleeds

Healthdirect. (2022). Nosebleed. https://www.healthdirect.gov.au/nosebleed

Contact info: info@nursesinternational.org

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References

Health Essentials. (2023). Stop a Nosebleed in 6 Steps. Cleveland Clinic. https://health.clevelandclinic.org/how-to-stop-a-nosebleed/

Parajuli, R. (2015). Evaluation of Etiology and Treatment Methods for Epistaxis: A Review at a Tertiary Care Hospital in Central Nepal. International Journal of Otolaryngology. https://doi.org/10.1155/2015/283854

Tabassom, A. & Cho, J. (2022). Epistaxis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK435997/#_NBK435997_pubdet_

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