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Fluids & Electrolytes
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, may be more difficult to control.
[black left pointing small triangle] 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.
* Put on protective gear, including gown, gloves, and goggles. Quickly assess the ABCs (airway, breathing, and circulation) and support them as indicated. Reassure the patient.
* 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 ordered. Obtain specimens for blood work, including complete blood cell count and coagulation profile, as ordered.
* Obtain a history about 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. Assist the healthcare provider as needed during the exam and treatment. Reassure the patient, monitor vital signs, and assess for hypoxia.
* After bleeding is controlled, reassess the patient and provide oral care.
* 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.
* Instruct the patient to avoid exerting herself, forcefully blowing her nose, or bending over during the first 24 hours. She should also avoid NSAIDs, alcoholic beverages, and smoking for 5 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 more bleeding.
* Don't leave the patient unattended during epistaxis.
* Don't underestimate the amount of blood that can be lost from epistaxis.
Cartwright SJ, Morris JJ, Pinder D. Managing nosebleeds. Student BMJ. 2008;16:212-214.
Evans JA, Rothenhaus T. Epistaxis. 2007. http://emedicine.medscape.com/article/764719-overview.
Gluckman W, Barricella R, Quraishi H, Lamba S. Epistaxis. 2008. http://emedicine.medscape.com/article/994459-overview.
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