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Managing epistaxis

Rushing, Jill MSN, RN

doi: 10.1097/01.CCN.0000394498.04772.d7
Department: Pearls

Follow these steps to stop nasal bleeding.

Jill Rushing is a nursing instructor at the University of Southern Mississippi in Hattiesburg. Adapted and updated from Rushing J. Managing epistaxis. Nursing. 2009;39(6):12.

Epistaxis (nasal bleeding) is relatively common but rarely fatal. Anterior bleeding is usually managed by digital pressure, gentle chemical cauterization, or nasal packing. Posterior bleeding, which is less common, is characterized by massive bleeding that's initially bilateral; this bleeding may be more difficult to control.

Follow these tips to manage epistaxis:

  • Put on protective gear, including gown, gloves, and face shields. Quickly assess the ABCs (airway, breathing, and circulation) and support them as indicated. Reassure the patient.
  • 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. Tell her to breathe through her mouth while she holds firm pressure on the soft flesh of her nose for at least 10 minutes. 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.
  • Ensure bedside suction is functioning properly. Provide an emesis basin and tissues. Tell her to spit blood into the basin if necessary. This helps prevent nausea and vomiting and lets you estimate the amount of bleeding.
  • Obtain vital signs and SpO2 level, and assess her breath sounds. Administer supplemental oxygen via facemask if needed. Continue to monitor vital signs closely.
  • Assess for signs and symptoms of hemodynamic instability, including change in mental status, pallor, diaphoresis, hypotension, tachycardia, and tachypnea.
  • If bleeding is significant, establish vascular access, place the patient on a cardiac monitor, and begin fluid resuscitation with a crystalloid solution, as prescribed. Obtain specimens for blood work, including complete blood cell count and coagulation profile, as prescribed.
  • 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.
  • If bleeding persists, assist in preparing the epistaxis tray and a headlamp. Make sure lighting is adequate. Once the bleeding site is identified, the definitive treatment is cautery (silver nitrate or electrical). If cautery is unsuccessful, nasal packing will be used to apply direct pressure to the bleeding site. During the procedure, reassure the patient, monitor vital signs, and assess for hypoxia.
  • After bleeding is controlled, reassess the patient and provide oral care. Keep the patient's mouth moist while the packing is in place.
  • If packing is used, especially posterior packing, monitor for respiratory compromise. Tell the patient to report signs and symptoms of infection and teach her about any prescribed antibiotics. If she has posterior packing, she'll be admitted to the hospital. A patient with anterior packing will follow up with an ear, nose, and throat specialist as an outpatient.
  • The nasal packing will be left in place for 3 to 5 days. Instruct the patient to avoid exerting herself, forcefully blowing her nose, or bending over. She should also avoid NSAIDs, alcoholic beverages, and smoking for 5 to 7 days. Tell her to apply water-soluble ointment to her lips and nostrils while packing is in place and to use a cool-mist room humidifier. Advise her to take steps to prevent constipation and straining, which increases the risk of bleeding.
  • Don't leave the patient unattended during -epistaxis.
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RESOURCES

Cartwright SJ, Morris JJ, Pinder D. Managing nosebleeds. Student BMJ. 2008;16:212–214.
    . Gluckman W, Barricella R, Quraishi H, Lamba S. Epistaxis. 2008.
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