STUDY - Technical - New Dacian's Medicine
Epistaxis
(Classical / Allopathic Medicine)
Epistaxis
(nosebleed) is a common sign that can be spontaneous or
induced from the front or back of the nose. Most nosebleeds
occur in the anterior nasal septum (Kiesselbach's plexus), but
they may also occur at the point where the inferior turbinates
meet the nasopharynx. Usually unilateral, they seem bilateral
when blood runs from the bleeding side behind the nasal septum
and out the opposite side. Epistaxis ranges from mild oozing
to severe - possibly life-threatening - blood loss.
A rich supply of
fragile blood vessels makes the nose particularly vulnerable
to bleeding. Air moving through the nose can dry and irritate
the mucous membranes, forming crusts that bleed when they're
removed; dry mucous membranes are also more susceptible to
infections, which can produce epistaxis as well. Trauma is
another common cause of epistaxis. Additional causes include
septal deviation; hematologic, coagulation, renal, and GI
disorders; and certain drugs and treatments.
ALERT:
If the patient has severe epistaxis:
- quickly take his vital signs (Be alert for tachypnea, hypotension, and other signs of hypovolemic shock.)
attempt to control bleeding by pinching the nares closed (However, if you suspect a nasal fracture, don't pinch the nares. Instead, place gauze under the patient's nose to absorb the blood.)
- have him sit upright and tilt his head forward (If the patient has hypovolemia, have him lie down and turn his head to the side to prevent blood from draining down the back of his throat, which could cause aspiration or vomiting.)
- monitor airway patency
- initiates emergency measures, if necessary.
If the patient's condition permits, perform a focused assessment.
If the patient has severe epistaxis:
- quickly take his vital signs (Be alert for tachypnea, hypotension, and other signs of hypovolemic shock.)
attempt to control bleeding by pinching the nares closed (However, if you suspect a nasal fracture, don't pinch the nares. Instead, place gauze under the patient's nose to absorb the blood.)
- have him sit upright and tilt his head forward (If the patient has hypovolemia, have him lie down and turn his head to the side to prevent blood from draining down the back of his throat, which could cause aspiration or vomiting.)
- monitor airway patency
- initiates emergency measures, if necessary.
If the patient's condition permits, perform a focused assessment.
HISTORY:
Ask the patient about recent trauma. Also, ask if he recently had surgery in the sinus area.
Ask the patient about the frequency of his nosebleeds. Have they been long or unusually severe?
Review the patient's medical history, noting especially hypertension, bleeding or liver disorders, and other recent illnesses. Also, ask the patient if he bruises easily.
Obtain a drug history, including prescription and over-the-counter drugs (paying particular attention to his use of anti-inflammatories, such as aspirin, and anticoagulants such as warfarin), herbal remedies, and recreational drugs. Question the patient about cocaine or other illicit drug use nasally. Also, ask the patient about alcohol intake.
Ask the patient about recent trauma. Also, ask if he recently had surgery in the sinus area.
Ask the patient about the frequency of his nosebleeds. Have they been long or unusually severe?
Review the patient's medical history, noting especially hypertension, bleeding or liver disorders, and other recent illnesses. Also, ask the patient if he bruises easily.
Obtain a drug history, including prescription and over-the-counter drugs (paying particular attention to his use of anti-inflammatories, such as aspirin, and anticoagulants such as warfarin), herbal remedies, and recreational drugs. Question the patient about cocaine or other illicit drug use nasally. Also, ask the patient about alcohol intake.
PHYSICAL
ASSESSMENT:
Inspect the patient's skin for other signs of bleeding, such as ecchymoses and petechiae, noting jaundice, pallor, or other abnormalities.
If the patient has suffered a trauma, look for associated injuries, such as eye trauma or facial fractures.
Inspect the patient's skin for other signs of bleeding, such as ecchymoses and petechiae, noting jaundice, pallor, or other abnormalities.
If the patient has suffered a trauma, look for associated injuries, such as eye trauma or facial fractures.
SPECIAL
CONSIDERATIONS:
If external pressure doesn't control epistaxis, insert cotton impregnated with a vasoconstrictor and local anesthetic into the patient's nose. If bleeding persists, anterior or posterior nasal packing may be inserted.
If external pressure doesn't control epistaxis, insert cotton impregnated with a vasoconstrictor and local anesthetic into the patient's nose. If bleeding persists, anterior or posterior nasal packing may be inserted.
PEDIATRIC
POINTERS:
Children are more likely to experience anterior nosebleeds, usually the result of nose-picking or allergic rhinitis.
Biliary atresia, cystic fibrosis, hereditary afibrinogenemia, and nasal trauma due to a foreign body can cause epistaxis.
Rubeola may cause an oozing nosebleed along with the characteristic maculopapular rash.
Epistaxis commonly begins at puberty in hereditary hemorrhagic telangiectasia.
Children are more likely to experience anterior nosebleeds, usually the result of nose-picking or allergic rhinitis.
Biliary atresia, cystic fibrosis, hereditary afibrinogenemia, and nasal trauma due to a foreign body can cause epistaxis.
Rubeola may cause an oozing nosebleed along with the characteristic maculopapular rash.
Epistaxis commonly begins at puberty in hereditary hemorrhagic telangiectasia.
AGING ISSUES:
Older patients are more likely to have posterior nosebleeds.
Older patients are more likely to have posterior nosebleeds.
PATIENT
COUNSELING:
Instruct the patient about proper pinching pressure techniques. For prevention, tell him to apply petroleum jelly to his nostrils to prevent drying and cracking.
Instruct the patient about proper pinching pressure techniques. For prevention, tell him to apply petroleum jelly to his nostrils to prevent drying and cracking.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common
symptoms, Edition V, McGraw - Hill, 2002.
Dorin,
Merticaru (2010)