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.
In this article:
- Overview
- Nursing Process
- Nursing Care Plans
- Deficient Fluid Volume
- Deficient Knowledge
- Ineffective Airway Clearance
- Risk for Bleeding
Overview
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 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.
Ineffective Airway Clearance
Posterior nosebleeds may cause blood to flow into the throat, which has the possibility of causing airway obstruction. Excessive bleeding, trauma, and foreign objects in the nose or throat may also affect airway clearance.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Excessive blood in the nasal cavity or throat
- Foreign bodies in the airway
- Retained secretions
- Posterior epistaxis
- Aspiration of blood
- Traumatic injury
- Inflammation
As evidenced by:
- Altered respiratory pattern
- Adventitious breath sounds
- Bradypena
- Tachypnea
- Cyanosis
- Difficulty verbalizing
- Ineffective cough
- Dyspnea
- Restlessness
Expected outcomes:
- Patient will exhibit clear breath sounds and a respiratory pattern within normal limits.
- Patient will not report any difficulty breathing or coughing.
Assessment:
1. Assess for injuries or foreign bodies.
Severe nosebleeds from trauma, such as a sports injury or physical assault, should be assessed and monitored closely, as fractures are a common cause of nasal obstruction. Small children may stick objects into their noses that can pass into the oropharynx and be aspirated, causing airway obstruction.
2. Monitor lung sounds and respiratory status.
The nurse must closely monitor the patient’s respiratory rate, depth, and pattern for concerns. Lung sounds should be assessed regularly for adventitious findings.
3. Assess for a posterior bleed.
Bleeding in the back of the nose often causes excessive bleeding as larger arteries are affected. Blood will be observed in the oropharynx, and the patient may spit or cough blood. Bleeding from both nares is also observed.
Interventions:
1. Ensure airway patency.
Maintaining an open airway is a priority. Remove debris, foreign objects, and prepare for intubation if bleeding is excessive or fractures are present.
2. Position the patient upright, with a slight forward lean.
This position optimizes breathing, maximizes lung expansion, and prevents aspirating or swallowing blood.
3. Manage nausea and vomiting.
If the patient is swallowing large amounts of blood, this can lead to nausea and vomiting, which in turn increases the risk of aspiration. Administer antiemetics if necessary to prevent vomiting.
4. Apply an ice pack over the bridge of the nose as indicated.
An ice pack can help with vasoconstriction, which reduces inflammation and slows the bleeding, preventing ineffective airway clearance.
Risk for Bleeding
Epistaxis can occur spontaneously or be triggered by various factors. Some patients may be at an increased risk for nosebleeds, such as those with clotting disorders, sinus issues, or during pregnancy.
Nursing Diagnosis: Risk for Bleeding
Related to:
- Nasal trauma
- Sinus conditions
- Altered clotting
- Pregnancy
- Use of anticoagulants
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain free from nosebleeds.
- Patient will verbalize interventions that help reduce the risk of nosebleeds.
Assessment:
1. Assess causative factors for epistaxis.
Epistaxis may be caused by various factors, including trauma due to the presence of a foreign body, nose picking, or blunt force, conditions affecting the nasal passages, and chronic underlying health issues like atherosclerosis. Properly identifying these factors can help plan appropriate interventions to correct and manage the bleeding.
2. Assess the medication regimen.
Medications like anticoagulants, NSAIDs, and salicylates can increase the patient’s risk for bleeding or epistaxis. Review any use of supplements like St. John’s wort, ginger, garlic, or vitamin E that may increase the risk for bleeding when taken with anticoagulants.
3. Review laboratory values.
Alterations in clotting values, such as platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT), significantly affect the patient’s clotting ability and increase their risk for bleeding.
Interventions:
1. Instruct the patient on the use of nasal medications.
Saline nasal spray or lubricating ointments help keep the inside of the nose moist, prevent cracking of the mucous membranes, and reduce the risk of bleeding.
2. Encourage the use of a humidifier.
Dry nostrils can contribute to epistaxis. A humidifier can help soothe the nostrils and throat. If the patient uses a nasal cannula long-term, connect humidification to the oxygen source to increase the moisture delivered with the oxygen.
3. Instruct the patient to avoid smoking.
Smoking tends to dry up and irritate the nostrils, increasing the risk of bleeding. Children should not be around smoking, as secondhand smoke can also contribute to nosebleeds.
4. Educate the patient taking anticoagulants.
The patient who is taking anticoagulants, specifically warfarin, will need to have their INR (international normalized ratio) levels monitored to ensure they are in a therapeutic range to reduce the risk of bleeding. Patients taking anticoagulants should also avoid grapefruit, as this interaction increases the risk for bleeding.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Epistaxis. Osmosis from Elsevier. 2022. From: https://www.osmosis.org/answers/epistaxis
- Epistaxis. Tabassom A, Cho JJ. [Updated 2022 Sep 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK435997/
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Nosebleed (Epistaxis). Cleveland Clinic. Reviewed: October 23, 2019. From: https://my.clevelandclinic.org/health/diseases/13464-nosebleed-epistaxis
