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Running head: EPISTAXIS

Epistaxis Management
By
Ellenor Chance

Coppin State University: Nursing 600-Dr. Murray

Epistaxis Management

Introduction
A 16 year old male present to the nurse practitioners office is complaining of
spontaneous nose bleeds. The male reports that he does not recall any recent trauma to the face;
however, he does play football for his local high school team. The patient reports that at times he
will practice football with friends at home without wearing proper protective equipment. The
nurse practitioner is aware that epistaxis is a common problem experienced by most individuals
with 60% of the general population reporting having had at least one nose bleed in their lifetime
(Buttaro, Trybulski, Bailey, & Cook, 2008). Most epistaxis episodes are generally caused by
trauma; however, it may be an indication of more severe problems such as infection, systemic
disease, and bleeding disorders (Andersen, Kjeldsen, & Nepper-Rasmussen, 2005). This
condition requires the nurse practitioner to perform prompt and accurate assessment to determine
the acuity of the visit and proper treatment modalities.
Assessment
Subjective
The nurse practitioner would begin the visit by first gathering subjective information
from the patient regarding the chief complaint. Information should be gathered to determine the
history of the present illness and what prompted the patient to seek medical attention. The nurse
practitioner may use direct quotes at this time, to gain clarity and fully understand the patients
reason for seeking care (Seidel, Dains, Flynn, Solomon, & Stewart, 2011). Questions should be
asked concerning the site, frequency, duration, and amount of bleeding experienced. The nurse
practitioner should also assess the patient for upper respiratory infection, nose picking, forceful

Epistaxis Management

blowing, trauma, allergies, and dry climate because these conditions are known to be
predisposing factors to epistaxis (Seidel et al., 2011). In this scenario, the patient admits to past
trauma of the nose and face through contact sports.
The past medical history will include a detailed assessment of the patients medical
history. The practitioner should further assess the patients history of trauma to the face and
nose, while also assessing the patients incidence of infection, tumors, and bleeding disorders
(Buttaro et al., 2008). The nurse practitioner is aware that epistaxis incidence is increased with
the use of anticoagulants such as coumadin and aspirin, chronic steroid use, blood dyscrasias,
aneurysms, and nasal neoplasms (Young & Hall, 2010). Therefore, assessment for these
conditions must be included in the past medical history. The patient or parents should be asked
about current medications. During the assessment of the family history, the nurse practitioner
should determine whether the patient has a family history of hereditary genetic disorder to
promote such as bleeding hemorrhagic telangiectas and vonWillebrand disease (Ragsdale, 2007;
James 2012). The nurse practitioner should gather the medical history of both biological parents
and siblings to determine trends. The social history should assess for chronic alcohol use and
recreational drugs via the nasal route since these too are contributory factors to epistaxis (Young
& Hall, 2012).
Objective
After obtaining subjective assessment data from the client, the nurse practitioner would
then complete a focused physical examination. Before beginning the exam, airway patency
should be established. After airway patency is confirmed and bleeding is stopped, the nurse
practitioner will inspect the nose for symmetry, shape, skin lesions, or signs of infection. The

Epistaxis Management

external nose should be palpated for tenderness and swelling. The internal nose should be
inspected using a nasal speculum only if nasal bleeding has stopped. A nasal decongestant may
be used to aid this process (Buttaro et al., 2008). The practitioner should inspect the mucosa,
internal turbinates, middle meatus, and middles turbinates noting the color, presence of edema,
and foreign bodies. The position of the nasal septum is noted as well. After inspecting the nose
internally and externally, the nurse practitioner would then palpate and percuss the sinuses to
determine the presence of pain. Trans illumination is completed when sinus infection is
indicated or to illuminate areas of bleeding (Barbarito & DAmico, 2012). In this scenario, the
clients nose is symmetrical, with no skin lesions, the internal mucosa is pink in the left nare, and
there is no blood present. The practitioner noted the presence of blood in the right nare, the
mucosa is dark, and the septum is midline. The left nare is noted to be more patent than the
right. No tumors are noted during assessment. In addition, the frontal and maxillary sinuses are
non- tender.
Differential Diagnosis
After gathering all assessment data from both the subjective and objective information,
the nurse practitioner would then come up with a series of differential diagnoses. These would
include conditions that precipitate episodes of recurrent epistaxis such as hereditary hemorrhagic
telangiectasia, nasal tumors, allergies, cold or other infectious process, septal perforation,
vascular abnormality, Osler- Weber- Rendu disease, and hypertension (Buttaro et al., 2008). After
reviewing the subjective and objective data, the nurse practitioner makes the diagnosis of
epistaxis related to nasal trauma. This diagnosis would be made because the client has a history
of playing contact sports with multiple facial injuries, and nasal trauma is the most common
cause of epistaxis (Buttaro et al., 2008).

Epistaxis Management

Plan of Care
It is the nurse practitioners responsibility to provide clients with safe, cost effective care.
Therefore, simple epistaxis management may be controlled at the clinical site. Initially, the nurse
practitioner will establish airway patency and control bleeding from the nares. This is done by
instructing the patient to sit up and tilt his head forward while applying firm pressure to the
effected nares. A nasal decongestant may also be used to cause vasoconstriction and control
bleeding. Nasal cautery with silver nitrate sticks are used to control bleeding as well. Tampons
or xeroform gauze may be packed into the nose either anteriorly or posteriorly depending on the
location of the bleed when all other measures fail. Anterior packing is the most common type of
packing used to control epistaxis (Biswas & Mal, 2009). This is usually done by a skilled
clinician; therefore, if the nurse practitioner is unfamiliar with this technique, emergency referral
may be indicated at this time.
Diagnostic testing is important to assess for any underlying conditions that contribute to
episodes of epistaxis. Complete blood count (CBC) with differential should be obtained to
evaluate blood loss and presence of infection. Prothombin time/ international normalized ratio
(PT/INR) should be obtained if anticoagulation therapy or heredity bleeding disorders are
suspected. When trauma is indicated, an X-ray should be taken of the area to rule out fractures
(Buttaro et al., 2008).
Patients requiring hospitalization for epistaxis are often required to pay costly treatments
such as embolization and are put on bed rest to prevent further bleeding. These patients often
experience complications of immobilization, such as urinary tract infection, constipation, and
pneumonia. These complications drive up health care costs and increase hospital stays

Epistaxis Management

(Kristensen, Neilsen, Gaihede, Boll, & Delmar, 2011). To negate these adverse effects, the nurse
practitioner should provide effective primary and follow up care in the treatment and
management of individuals with epistaxis. In doing so, the nurse practitioner is providing cost
effective care which may decrease the cost burden on the health care industry.
Patient education is also important in the management of epistaxis. It is the nurse
practitioners responsibility to advise the patient to avoid heavy exercise and blood thinning
medication for up to 7 days. The patient is instructed to avoid things that may cause vasodilation
and promote re-bleeding. This includes tobacco and spicy foods. In addition, the patient is told to
keep the nares lubricated to prevent drying and irritation. The patient should be instructed to
avoid activity that may precipitate nasal trauma; therefore, sports, nasal picking, and forceful
nose blowing should be avoided. Including the family in patient education may ensure that
restrictions are adhered to. The nurse practitioner should instruct the family to call the health care
provider if bleeding reoccurs. The patient and family are advised of the importance of following
up care (Buttaro et al., 2008).
To promote health in this client, the nurse practitioner would advise the client to wear
proper protective equipment while playing contact sports to prevent further trauma. The patient
should also maintain adequate hydration status to prevent hypervolemia that may occur with
excessive blood loss. Home humidification may also be warranted to prevent nasal drying and
irritation (Consumer Report on Health, 2010). Lastly, the nurse practitioner should educate the
patient and family on the home management of nose bleeds and when to seek medical care.

Epistaxis Management

Conclusion
In conclusion, when a patient comes into the nurse practitioners office with a
diagnosis of epistaxis, the nurse practitioner must perform a thorough assessment, physical
exam, and diagnosis to accurately treat the disorder. It is imperative to distinguish the
precipitating factors because this will determine the selection of correct diagnostic testing and
the most cost effective interventions. Patient education and health promotion is imperative to
prevent complication. Overall, it is the nurse practitioners responsibilities to ensure that all of
these measures are carried out while providing quality care to the patient.

Epistaxis Management

References
Andersen, P., Kjeldsen, A., & Nepper-Rasmussen, J. (2005). Selective embolization in the
treatment of intractable epistaxis. Acta Oto-Laryngologica, 125(3), 293-297.
Barbarito, C. & D Amico, D. (2007) Health and physical assessment in nursing (pp. 105-107).
UpperSaddle River, NJ: Pearson
Biswas, D., & Mal, R. (2009). Are systemic prophylactic antibiotics indicated with anterior nasal
packing for spontaneous epistaxis?. Acta Oto-Laryngologica, 129(2), 179-181.
doi:10.1080/00016480802043964
Buttaro, T.M., Trybulski, J., Bailey P.P., & Cook, J., S. (2008). Primary care a collaborative
practice (pp. 355-357). St. Louis, MI: Mosby Elsevier
Consumer on health report (2010). Mananging a bloody nose. Retrieved
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James, M. P. (2011) Goodeve, A. C. (2011). von Williebrand disease, Genetics in medicine,
13(5), 365-376
Kristensen, V., Nielsen, A., Gaihede, M., Boll, B., & Delmar, C. (2011). Mobilisation of
epistaxis patients a prospective, randomised study documenting a safe patient care
regime. Journal Of Clinical Nursing, 20(11/12), 1598-1605. doi:10.1111/j.13652702.2010.03560.x
Ragsdale, J. (2007). Hereditary hemorrhagic telangiectasia: from epistaxis to lifethreatening GI bleeding. Gastroenterology Nursing, 30(4), 293-301.
Seidel, H.M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011)
Mosbys guide to physical examination (pp. 304-306). St. Louis, MI: Mosby Elsevier

Young, T., & Hall, R. (2010). The occasional management of epistaxis. Canadian Journal Of
Rural Medicine, 15(2), 70-74.

Epistaxis Management