Epistaxis Nursing Diagnosis and Nursing Care Plan

Epistaxis Nursing Care Plans Diagnosis and Interventions

Epistaxis NCLEX Review and Nursing Care Plans

Epistaxis, often known as a nosebleed and is a frequent complaint. Although it rarely poses a life-threatening hazard, it may still give parents of young children cause for serious concern. Most of the time, epistaxis is harmless, spontaneous, and self-limiting, but others can be chronic.

There are two different types of epistaxis according to the location. When the blood vessels in the front of the nose burst and start to flow, it is called anterior epistaxis, while the back or the deepest section of the nose is where posterior epistaxis occurs.

Blood trickles down the back of the throat in this instance, epistaxis from the back might be harmful.

Although it can be frightening to see blood gushing from the nose, most epistaxis is not severe and can be treated at home.

Types of Epistaxis

  • Anterior epistaxis. Begins on the bottom portion of the wall dividing the two sides of the nose, in the front of the nose called the septum. This front part of the nose has delicate capillaries and tiny blood vessels that are prone to breaking and bleeding. The most typical and often non-serious type of epistaxis is this one. Children are more likely to get this epistaxis, which may typically be managed at home.
  • Posterior epistaxis. Happens deep inside the nose. The larger blood vessels in the back of the nose, close to the throat, are bleeding, which is the source of this epistaxis. Compared to an anterior epistaxis, this one may be more dangerous. It may cause significant bleeding that runs down the back of the throat. For an epistaxis of this nature, immediate medical assistance is required. Adults are more likely to get this kind of epistaxis.

Signs and Symptoms of Epistaxis

Causes of Epistaxis

  • Local Causes. A break in blood vessels in the nose from an injury.
    • Nose picking
    • A foreign body in the nose
    • Face trauma
    • Anatomical abnormalities including a deviated septum
    • Inflammatory reactions
    • Intranasal malignancies
    • Inflammation of the nasal mucosa due to smoking
  • Medications. People who use certain drugs may be more susceptible to epistaxis.
    • Blood thinners. Prevent blood from clotting.
    • Platelet aggregation inhibitors
    • Homeopathic drugs that prolong bleeding
    • Nasal sprays. Used to treat itchy, runny, or stuffy noses. Medications such as antihistamines and decongestants can dry out the nasal membranes.
  • Systemic Causes
    • Vascular abnormalities
    • Cardiovascular diseases
    • Hereditary Hemorrhagic Telangiectasia. The most prevalent type of vascular systemic illness impacts the nasal mucosa. Symptoms typically begin at puberty and get worse over time as people mature.
    • Von Willebrand disease. The most typical irregularity of the clotting factor can cause frequent, ongoing epistaxis.
    • Hemophilia A and B
    • Alcohol. Heavy alcohol consumption can also raise the risk for epistaxis since it interferes with normal blood coagulation processes and enlarges the superficial blood vessels, raising the possibility of a rupture.
  • External Factors
    • Changes in humidity or temperature. The two common environmental factors that contribute to epistaxis, as the nose’s blood vessels are more vulnerable to rupture in dry or chilly conditions.
    • Allergies. Epistaxis risk can be increased by allergies for a variety of causes. In addition to the allergic inflammatory reaction itself, frequent nose blowing and the use of allergy medications such as decongestants and antihistamines that dry up the nasal mucosa can raise the likelihood of experiencing an epistaxis.
    • Chemical irritants. Chemicals in cleaning supplies, and chemical fumes at the workplace with strong odors.

Risk Factors to Epistaxis

  • Age
    • Children between the ages of two and ten. Children are more prone to epistaxis due to dry air, colds, allergies, and inserting fingers and items into their noses.
    • Adults who are 45 to 65 years old. In middle age and older adults, blood clotting times may be longer. They are also more prone to having high blood pressure, atherosclerosis or the hardening of the artery walls, a bleeding condition, and to regularly take blood thinners like aspirin.
  • Pregnancy. Pregnancy causes blood vessels in the nose to swell, which increases pressure on the sensitive blood vessels that line the inside of the nose.
  • Trauma. A fall, a car accident, or a blow to the face are among the accidents that could result in an epistaxis. After-injury epistaxis could be an indication of a broken nose, skull fracture, or internal bleeding.
  • Vascular abnormalities
    • Hereditary Hemorrhagic Telangiectasia. The most prevalent type of vascular systemic illness impacts the nasal mucosa. Symptoms typically begin at puberty and get worse over time as people mature.
    • Von Willebrand disease. The most typical irregularity of the clotting factor can cause frequent, ongoing epistaxis.
    • Granulomatosis with polyangiitis
    • Infections
  • Medications
    • Use of anticoagulants
    • Use of antiplatelet
    • Vitamin C deficiency
    • Use of other medications causing coagulopathy

Diagnosis for Epistaxis

  • Physical exam. The healthcare provider will do a physical exam to identify the cause or look for evidence of a foreign object in the nose. The medical background and current medications will also be discussed.It is important to check the vital signs for indicators of significant hypertension and intravascular volume depletion such as tachycardia, hypotension.
  • Past medical history. It should include any family history of recognized bleeding disorders, as well as any illnesses known to cause platelet or coagulation deficiencies, such as cancer, cirrhosis, HIV, and pregnancy.
  • Blood test
    • Complete blood count (CBC).  A blood test to assess for blood disorders.
    • Partial thromboplastin time (PTT). Measures how long it takes for the blood to clot.
  • Imaging. After-injury epistaxis could be an indication of a broken nose, skull fracture, or internal bleeding, these can be identified by doing imaging studies.
    • nasal CT scan
    • face and nose X-ray
    • nasal endoscopy

Complications of Epistaxis

Most epistaxis is not serious. However, frequent or severe epistaxis may be a sign of more significant health issues and should be investigated, including high blood pressure or a disease of blood coagulation. Anemia, for instance, might develop as a result of excessive bleeding over a long period of time.

Prevention of Epistaxis

  • Maintain moisture inside the nose. Rhinitis can be brought on by dryness. Apply a small layer of petroleum jelly to the nose using a cotton swab three times per day, especially right before bed.
  • Utilize a saline nasal spray. It keeps the inside of the nose wet by spraying it in the nostrils.
  • Use a humidifier. The dry air at home may be the reason for dry nostrils.
  • Avoid smoking. Smoking can dry up and irritate the inside of your nose.
  • Keep the nostrils clean.
  • Avoid blowing or rubbing the nose vigorously.
  • Keep the children’s fingernails short.
  • Avoid overusing antihistamines and allergy medicines as these could make the nose dry.

First Aid Management for Epistaxis

  • Encourage the person, especially children, to stop crying as it increases blood flow.
  • Position the person upright with the head slightly forward.
  • Apply finger and thumb pressure on the soft area of nostrils beneath the bridge of the nose for at least 10 minutes.
  • Pinch the nostrils and encourage the person to breathe through the mouth.
  • Adjust tight clothing to a looser fit around the neck.
  • Place a cold compress or cloth over the person’s forehead and another one around the neck, particularly the sides.
  • Release the pressure on the nostrils after 10 minutes, and then check to see if the bleeding has stopped.
  • If bleeding continues, get medical attention.
  • Inform the person to refrain from sniffing, blowing the nose, and picking the nose for the remainder of the day.

Treatment for Epistaxis

  • Medical treatment. An evaluation will be done at the hospital to determine how bad the condition is and what’s likely to have caused it. This may involve looking inside the nose, checking the blood pressure and pulse, performing blood tests, and inquiring about any further symptoms.
  • Antibiotic ointment. The healthcare provider may prescribe an antibiotic ointment. Squeeze a pea-sized amount of this onto the front of the nasal septum to apply it, this can lessen the severity and frequency of epistaxis as well as the inflammation and crusting in the nose. Children benefit most from antibiotic ointment.
  • Cautery. The healthcare provider might perform a quick treatment to cauterize or burn the bleeding artery in order to seal it off, if they can pinpoint where the bleeding is coming from. A substance called silver nitrate is used for this. The nose will be sprayed with local anesthetic to make it comfortable, and the silver nitrate stick will be applied to the bleeding point for up to 10 seconds.
  • Nasal packing. The healthcare provider may advise packing the nose with gauze or special nasal sponges to halt the flow of blood by applying pressure to the site of the bleeding if cautery is ineffective or if they are unable to locate a specific bleeding spot.
  • Other therapies.
    • Electrocautery. The blood vessel where the bleeding is coming from is cauterized using electrocautery, which uses an electric current flowing through a wire.
    • Packing under anesthesia. When the person is unconscious from general anesthesia, the nose is properly packed with gauze.
    • Ligation. A procedure that ties off bleeding blood veins in the back of the nose with the help of small instruments.

Nursing Diagnosis for Epistaxis

Nursing Care plan For Epistaxis 1

Risk for Bleeding

Nursing Diagnosis: Risk for Bleeding related to epistaxis secondary to hemophilia.

Desired Outcome: The patient’s threat of injury from potential bleeding is reduced by using suitable prophylactic procedures.

Nursing Intervention for EpistaxisRationale
Check the patient’s partial thromboplastin time and the factor VIII and IX coagulation assays.PTT is extended due to a clotting system factor deficit. A normal prothrombin time will be achieved. Results that are lower than expected indicate that factor replacement treatments are ineffective.
Examine for any symptoms of bruising or bleeding (observe the extent of bleeding). Check the patient for persistent bleeding after minor injuries.The most common locations for external bleeding include the mouth, which can bleed after a cut, bite, or when a tooth is cut or lost; the nose; significant bleeding from a minor cut; or leaking of blood from a cut that reappears after ceasing for a short period. The frequency or intensity of bleeding is not increased in hemophiliacs. Due to a lack of clotting factor, they instead bleed more extensively. Before clinical symptoms, patients are most often mindful of bleeding. In these cases, the patient’s life can be threatened by bleeding.
Look for any discomfort or swelling throughout the entire body.A cerebral hemorrhage may be suggested by a headache when there has been a history of trauma. Internal bleeding could cause abdominal pain. In most cases, bleeding into a joint is described as a strange tingling sensation that occurs before any pain or swelling is noticed.
Monitor vital signs regularly.Blood loss can result in decreased circulatory volume, which can lead to hypovolemic shock. The following symptoms include tachycardia and hypotension.
Take the following actions to prevent bleeding: If active bleeding is observed, provide manual or mechanical pressure.Dress the wounds with sterile dressings and add pressure.Use topical coagulants such as fibrin foam and thrombin.One of the nurse’s priorities is to control the bleeding. Avoid the use of nasal packing, because removing it could cause further bleeding.

Nursing Care plan For Epistaxis 2

Anxiety

Nursing Diagnosis: Anxiety related to recurrent epistaxis secondary to severe hypertension as evidenced by rapid heart rate, restlessness, nervous appearance, trouble focusing, and difficulty sleeping.

Desired Outcomes:

  • The patient will be able to recognize and discuss his or her thoughts and concerns.
  • The patient will be able to express feelings of anxiousness and suggest recommendations for coping with such feelings.
  • The patient’s vital signs will recover to their normal baseline values.
  • The patient will be able to keep a regular sleep schedule.
Nursing Intervention for EpistaxisRationale
Recognize and assess the existence of anxiousness.It is important to be aware of the patient’s concerns and to inform the patient that these emotions are valid and significant.
Take a detailed look at the bleeding history.  Even though major epistaxis quickly includes both nares, most patients can pinpoint the initial flow to one side, which emphasizes the physical examination. Additionally, the length of the bleeding should be determined, as well as any triggers (such as sneezing, blowing the nose, or picking) and patient attempts to stop the bleeding.
Perform a head-to-toe assessment.    This will enable the nurse to observe any bodily indications or symptoms of anxiety that the patient might not be able to express.
Monitor the patient’s vital signs.    Patient’s vital signs may be irregular if they are anxious. For example, tachycardia or tachypnea may be present.
Explain all activities, processes, and concerns involving the patient; use non-medical words and a gentle, soft voice. When possible, do this ahead of time and confirm the patient’s comprehension.Proper patient education helps them to cope better because they are more prepared and suffer less anxiety and mental distress. Anxiety is exacerbated by uncertainty and unpredictability.
Give hypertension medicine as directed.Antihypertensive drugs are prescribed to patients with a history of hypertension to help lower their blood pressure.
Teach the patient how to regulate their stress and how to relax by doing deep breathing exercises.Cortisol levels are raised over time by stress, and these elevated levels have been associated with hypertension.
Evaluate how the patient copes with anxiety by using effective coping strategies and protective mechanisms.The effectiveness of the patient’s present coping mechanisms can be determined by asking questions that call for detailed responses. By using this strategy, the patient could feel more involved in the treatment process. Reading, keeping a journal, or engaging in physical exercise like walking are all examples of coping mechanisms. People utilize defense mechanisms to keep their egos intact and control their worry.

Nursing Care plan For Epistaxis 3

Fatigue

Nursing Diagnosis: Fatigue related to severe epistaxis secondary to head trauma as evidenced by complaints about a lack of energy, decreased level of consciousness, and increased demand for rest and sleep.

Desired Outcomes:

  • The patient will express more energy verbally and will become more involved in daily activities.
  • The patient’s cognitive status will be steady, as demonstrated by a complete level of consciousness.
  • The patient will discuss energy-saving methods.
Nursing Intervention for EpistaxisRationale
Let the patient communicate how they feel about their fatigue.The patient’s perspective can provide useful information on his or her understanding and willingness to reduce fatigue symptoms.
Encourage the patient to have frequent rest breaks, especially before more strenuous activity.Regular rest periods maintain a balance that enables the patient to complete targeted tasks without becoming increasingly exhausted.
Continuously assess the patient’s neurological condition, including the LOC, pupils, and Glasgow coma scale scores.  A decline in status might be indicated by subtle changes including irritation, increasing perplexity, and restlessness. A shift in LOC could indicate an elevated ICP (intracranial pressure).
 Monitor the patient’s vital signs.Vital sign changes could be a marker of elevated brain pressure. The Cushing’s trio, which includes bradycardia, a broadening pulse, and abnormal breathing, is brought on by an elevated ICP.
Determine if there are any signs and symptoms of severe bleeding.    Easy bruising, red or tarry stools; hemoptysis, blood in the urine, excessive bleeding after toothbrushing, phlebotomy, or slight trauma are examples.
Choose energy-saving techniques including sitting and breaking up ADLs into manageable parts. Help with needs for movement or self-care as necessary.Weakness can make it difficult for the patient to do ADLs. The patient is protected from injury during activities by having someone around.

Nursing Care plan For Epistaxis 4

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to the first experience of epistaxis secondary to fragile blood veins as evidenced by the statement of concerns, and providing incorrect information about the condition and treatment.

Desired Outcomes:

  • Patients will accurately communicate information regarding their condition and treatment.
  • The patient will be able to identify potential sources of bleeding.
  • The patient will abide by safety measures to reduce the chance of bleeding.
Nursing Intervention for EpistaxisRationale
Evaluate the patient’s level of learning preparation.The nurse must first determine whether the patient is prepared to learn by evaluating their level of interest, emotional state, and cerebral capacity for learning. The nurse might have to postpone her instruction till a better opportunity.
Include the patient in the development of clear learning objectives by asking them to specify what is most important to understand about their perspective way of living.Encouraging patient participation promotes teaching and learning collaboration and cooperation and enhance adherence to a health regimen.
Instruct patients to refrain from sneezing, coughing, or straining during bowel movements.    These activities can cause additional injury to the mucosal lining.
Instruct the patient instructions to sit up straight and droop their head slightly if the bleeding begins. For at least 10 minutes, put finger and thumb pressure on the soft layer of the nostrils under the nose’s bridge. Advise the patient to use their lips to breathe while their nostrils are being squeezed. Loosen any clothes that are too tight around the neck. Also, include the patient’s family members in giving instructions.  If the patient bleeds, the patient and family need to learn what to do. Hospitalizations might be decreased if people knew what to do in life-or-death situations.
suggested the patient visit a doctor if their nosebleeds persisted.  The reason must be identified and therapy must be started if the bleeding continues. The doctor might recommend medication, for instance, if the reason is persistent nasal mucosa bleeding. Occasionally, a patient bleeds so much that it creates additional health concerns, such as anemia.  

Nursing Care plan For Epistaxis 5

Acute Confusion

Nursing Diagnosis: Acute Confusion related to severe epistaxis secondary to physical trauma as evidenced by changes in psychomotor activity (such as tremors), and misperceptions. cognitive fluctuation and heightened anxiety or irritation.

Desired Outcomes:

  • The patient will regain normal awareness of reality and consciousness.
  • The patient will express understanding of the causes when they are recognized.
  • The patient will exhibit appropriate motor skills.
Nursing Intervention for EpistaxisRationale
Assist the patient with the management of the underlying medical condition.Assisting with the therapy of the underlying condition is essential for optimizing efficiency and preventing future impairment.
Get the family members involved in the reorientation process and provide them with continuous instructions.The patient might not fully comprehend what is going on if they are confused. The patient may feel more comfortable if relatives and close friends are present.
Provide clear instructions. allot the patient enough time to respond, explain, and decide.This kind of communication will lessen anxiety brought on by unfamiliar surroundings.
Regularly monitor the patient’s vital signs.  Blood pressure and heart rate changes could be signs of internal bleeding. An increase in heart rate and lower blood pressure may indicate blood loss in the venous system. Blood loss diminishes vascular volume, resulting in low blood pressure, but an elevated heart rate represents the body’s compensatory effort to pump blood through the system faster than usual to compensate for lost volume.
Regularly evaluate the patient’s neurological condition.  Blood loss lowers the quantity of oxygen-carrying red blood cells, which results in a decrease in the oxygenation of organs, particularly the brain. A decline in brain function could result from these modifications.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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