Epistaxis: Understanding and Managing Nosebleeds

Epistaxis (Nosebleed)

• Nasal membrane congestion causes capillary rupture.
• Injury may cause nosebleeds.
• Nosebleeds can be primary or secondary.
• Menstrual flow can cause nosebleeds in women.
• Hypertension may contribute to nosebleeds.
• Irritation of nasal mucosa, dryness, chronic infection, or nose picking can cause nosebleeds.
• Vigorous nose blowing can cause nosebleeds.
• Aspirin or NSAID use can lead to prolonged bleeding.
• Bright red blood can drain from one or both nostrils.
• Severe hemorrhage can lead to a loss of up to one liter of blood per hour in adults.
• Assessment includes duration, severity, precipitating factors, bleeding from one or both nostrils, anterior or posterior bleeding, vital signs, and signs of hypovolemic shock.
• Hypotension is a late sign of hypovolemic shock.
• Diagnostic tests include hemoglobin and hematocrit, coagulation studies, and rhinoscopy.
• Medical management includes nasal packing with epinephrine-soaked cotton, cautery, posterior packing, balloon tampon, and antibiotics.
• Nursing interventions include keeping the patient calm, positioning the patient, applying direct pressure to the soft part of the nose for 10-15 minutes, applying ice, monitoring for signs of hypovolemic shock, instructing the patient and family to avoid nose picking, and encouraging keeping nasal mucous membranes moist.
• The patient should avoid aspirin and NSAIDs.
• Patient should sneeze with their mouth open.
• For compromised blood flow, assess vital signs and consciousness every 15 minutes and document blood loss.
• For potential aspiration, elevate the head of the bed, encourage the patient to let blood drain, pinch nostrils, have patient breathe through mouth, apply ice, assist in clearing secretions, and instruct the patient to expectorate rather than swallow blood.

Deviated Septum & Nasal Polyps

• Etiology includes congenital abnormality or injury causing deviation from midline.
• Nasal polyps are tissue growths caused by prolonged sinus inflammation, often due to allergies.
• Clinical manifestations include stertorous respirations, dyspnea, and postnasal drip.
• Assessment includes subjective data on injuries, infections, allergies, sinus congestion, and dyspnea and objective data on the condition and location and respiratory rate and character.
• Diagnostic tests include sinus radiographic studies and visual examination.
• Medical management includes surgical correction, nasoseptoplasty, nasal polypectomy, nasal packing for 24 hours, nasal mucosa hydration, medications, corticosteroids, antihistamines, antibiotics, and analgesics.
• Nursing interventions include maintaining airway patency, preventing infection, monitoring for infection or hemorrhage, contacting a physician for bleeding or infection, cautioning against nasal sprays and drops, avoiding nose blowing, and expecting ecchymosis and edema.
• Inability to clear the airway requires documenting the ability to clear secretions and respiratory status, elevating the head of the bed, applying ice, changing nasal drip pad, and documenting exudate.
• Potential for injury requires assessing and reporting exudates and instructing the patient against blowing their nose postoperatively.

Allergic Rhinitis and Allergic Conjunctivitis

• Etiology includes atopic condition resulting from antigen-antibody reactions in nasal membranes, nasopharynx, and conjunctiva.
• May be seasonal or perennial.
• Common allergens include trees, grass, weeds, mold, fungi, dust, mites, animal dander, foods, drugs, and insect stings.
• Clinical manifestations include acute ocular symptoms (edema, photophobia, tearing, blurred vision, pruritus), rhinitis (secretions, inability to breathe), otitis media, and chronic symptoms (headache, nasal congestion, postnasal drip, cough).
• Assessment includes initial complaints (sneezing, congestion, pruritus, lacrimation), chronic signs (headache, nasal congestion, postnasal drip, cough), and physical exam findings.
• Diagnostic tests include skin testing and serum radioallergosorbent test.
• Medical management includes relieving signs and symptoms, preventing infections, antihistamines, decongestants, lodoxamide for conjunctivitis, and topical or nasal corticosteroids.
• Flunisolide, fluticasone and budesonide are medications used to treat these conditions.
• Nursing interventions include health promotion, teaching ways to avoid allergens, teaching self-care management through symptom control, and teaching medication action and usage.

Obstructive Sleep Apnea

• Partial or complete upper airway obstruction during sleep is the main etiology.
• Relaxation of tongue and soft palate obstructs the pharynx.
• More common in men; incidence increases with age and weight gain.
• Structural anomalies of the nares and/or pharynx are possible causes.
• The apneic period happens with severe hypoxemia and hypercapnia.
• Startle response, snorts, and gasps act as ventilatory stimulants.
• Apnea and arousal cycles happen 200-400 times during sleep.
• Causes morning headache, personality changes, hypertension, cardiac dysrhythmias, frequent awakening at night/insomnia and excessive daytime sleepiness.
• Witnessing of apneic episodes by others.
• Polysomnography is needed for diagnosis.
• There must be diagnosis after repeated episodes of apnea or diminished respiratory effort (30-50%).
• Mild Apnea: Avoid sedatives and alcohol before sleep, weight loss, oral appliance, and support group.
• Moderate to Severe Apnea: Nasal continuous positive airway pressure (nCPAP).
• Nasal mask attached to high-flow blower.
• Provides positive pressure to prevent airway collapse.
• Bi-level positive airway pressure (BiPAP)
• Higher pressure during inspiration; lower during expiration.

Upper Airway Obstruction

• Recent respiratory event, trauma, choking, aspiration, tongue obstruction, laryngeal spasm or edema can cause it.
• Stertorous respirations, altered rate, character, and apneic periods.
• Agitation, changes in the level of consciousness, and confusion can occur.
• Patient will be unable to talk.
• Signs of hypoxia, respiratory distress (stertorous respirations, stridor, wheezing), cyanosis, bradycardia and hand over throat can occur.
• Heimlich maneuver, emergency tracheostomy and artificial airways can be used.
• Diagnosis is made with prompt assessment and radiographic studies to identify foreign bodies are needed.
• Nursing interventions include promptly opening airway and restoring patency.
• Inability to Clear Airway- Reestablish and maintain airway, administer oxygen, suction as needed and monitor vital signs and breath sounds.
• Potential for Aspiration: Monitor respiratory rate, rhythm, and effort; assess ability to swallow secretions, elevate head of bed, document breath sounds and secretions, and suction as needed.

Laryngeal Cancer

• Often in people over age 65.
• Prolonged tobacco use, chronic laryngitis, vocal abuse, family history, gastroesophageal reflux disease, and heavy alcohol use can cause it.
• Clinical Manifestations include progressive hoarseness longer than 2 weeks, pain in the larynx radiating to air, dysphagia, lump in the throat and enlarged cervical lymph nodes.
• Patients will present with difficulty breathing or swallowing.
• Examining sputum for blood is needed.
• Diagnostic Tests include visual examination with direct laryngoscopy with biopsy
• Imaging studies (X-Ray, CT, MRI, PET) may be used.
• Medical Management includes radiation therapy if tumor confined to vocal cord without limitation of movement and surgery.
• Surgery includes total or partial laryngectomy, radical neck dissection, or chemotherapy.
• Maintain Airway patency with frequent suctioning.
• Keep monitoring skin integrity, and watch for infection.

Acute Rhinitis (Common Cold)

• Inflammation of the mucous membranes of the nose and sinuses.
• Caused by viruses.
• Bacterial co-infection.
• Clinical manifestations: productive cough, thin, serous nasal exudate, sore throat, and fever.
• Assessment: sore throat, dyspnea, and congestion.
• Objective: Erythema, edema, local irritation of the throat, and monitor vital signs.
• Diagnostic tests: throat and sputum cultures to determine bacterial infection.
• Medical management: analgesia, antipyretics, cough suppressant and expectorant, and antibiotics for bacterial infection.

Acute Follicular Tonsillitis

• Caused by group A beta-hemolytic Streptococcus.
• Air or foodborne bacterial infection, most common in school-age children.
• The patient experiences enlarged cervical lymph nodes, sore throat, fever, chills, malaise, and general muscle aching.
• Clinical manifestations: enlarged tonsils with purulent exudate.
• Severity of throat pain, pain to ears, headache, and joint pain.
• Enlarged erythematous tonsils and increased throat secretions.
• Diagnostic tests: throat cultures and white blood count.
• Antibiotic for active infection.

Laryngitis

• Secondary to other respiratory disorders, viral or bacterial infections.
• Clinical Manifestations include: hoarseness, scratchy throat, irritated throat and persistent cough.
• Assessment: Progressive hoarness and cough.
• Evaluate patient's voice quality and sputum.
• Diagnostic test: Laryngoscopy.
• No antibiotic therapy for viral causes.
• Give antibiotic therapy for bacterial causes.

Pharyngitis

• Acute or chronic, common throat inflammation.
• Viral origin or caused by hemolytic streptococci, staphylococci, or other bacteria.
• Symptoms: Dry cough, tender tonsils, enlarged lymph glands, erythematous throat and sore throat.
• Assessment: Pharyngeal discomfort, fever, difficulty swallowing.
• Diagnostics: throat cultures.
• Medical Management: Antibiotics (penicillin or erythromycin) and analgesics/antipyretics (Tylenol).

Sinusitis

• Chronic or acute, maxillary or frontal, viral or bacterial
• Constant, severe headache, and pain and tenderness in affected area, purulent exudate
• Assessment will show: Decreased appetite, nausea, malaise, headache, and pain in the region.
• Assessment will show: Vital signs (temperature), and character of drainage.
• Sinus x-rays, transillumination, and CT scan.
• Nasal windows needed to facilitate drainage, and Caldwell-Luc operation to remove diseased tissue are needed.
• Medical management: Saline nasal irrigation, nasal corticosteroids, decongestants, analgesics, and antibiotics (if bacterial).
• Nursing Interventions and Patient Teaching will occur.