Epistaxis [Nosebleed]
A common sign, epistaxis can be spontaneous or induced from the front or back of the nose. Most nosebleeds occur in the anterior-inferior 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 deviations; hematologic, coagulation, renal, and GI disorders; and certain drugs and treatments.
Act Now: If your patient has severe epistaxis, quickly take his vital signs. Be alert for tachypnea, hypotension, and other signs of hypovolemic shock. Insert a large-gauge I.V. line for rapid fluid and blood replacement, and 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 a hypovolemic patient 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 of swallowed blood. If the patient isn’t hypovolemic, have him sit upright and tilt his head forward. Constantly check airway patency. If the patient’s condition is unstable, begin cardiac monitoring and give supplemental oxygen by mask.
Assessment
History
If your patient isn’t in distress, take a history. Does he have a history of recent trauma? How often has he had nosebleeds in the past? Have the nosebleeds been long or unusually severe? Has the patient recently had surgery in the sinus area? Ask about a history of hypertension, bleeding, or liver disorders, and other recent illnesses. Ask if the patient bruises easily. Find out what drugs he uses, especially anti-inflammatories, such as aspirin, and anticoagulants such as warfarin.
Physical examination
Begin the physical examination by inspecting the patient’s skin for other signs of bleeding, such as ecchymoses and petechiae, and noting any jaundice, pallor, or other abnormalities. When examining a trauma patient, look for associated injuries, such as eye trauma or facial fractures. Determine if the epistaxis is unilateral or bilateral. Inspect for blood seeping behind the nasal septum, in the middle ear, and in the corners of the eyes.
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 also cause epistaxis. Rubeola may cause an oozing nosebleed along with the characteristic maculopapular rash. Two other childhood diseases — pertussis and diphtheria — can also cause oozing epistaxis.
Suspect a bleeding disorder if you see excess umbilical cord bleeding at birth or profuse bleeding during circumcision or other procedures. Epistaxis commonly begins at puberty in patients with hereditary hemorrhagic telangiectasia.
Geriatric pointers
Elderly patients are more likely to have posterior nosebleeds.
Medical causes
Angiofibroma (juvenile)
Angiofibroma is a rare disorder that usually occurs in males and is characterized by severe recurrent epistaxis and nasal obstruction.
Aplastic anemia
Aplastic anemia develops insidiously, eventually producing nosebleeds as well as ecchymoses, retinal hemorrhages, menorrhagia, petechiae, bleeding from the mouth, and signs of GI bleeding. Fatigue, dyspnea, headache, tachycardia, and pallor may also occur.
Barotrauma
Commonly seen in airline passengers and scuba divers, barotrauma may cause severe, painful epistaxis when the patient has an upper tract respiratory infection.
Biliary obstruction
Biliary obstruction produces bleeding tendencies, including epistaxis. Typical features are colicky, right-upper-quadrant pain after eating fatty food, nausea, vomiting, fever, flatulence and, possibly, jaundice.
Cirrhosis
With cirrhosis, epistaxis is a late sign that occurs along with other bleeding tendencies (bleeding gums, easy bruising, hematemesis, melena). Other typical late findings include ascites, abdominal pain, shallow respirations, hepatomegaly or splenomegaly, and fever of 101° to 103° F (38.3° to 39.4° C). The patient may also exhibit muscle atrophy, enlarged superficial abdominal veins, severe pruritus, extremely dry skin, poor tissue turgor, abnormal pigmentation, spider angiomas, palmar erythema and, possibly, jaundice and central nervous system disturbances.
Coagulation disorders
Such disorders as hemophilia and thrombocytopenic purpura can cause epistaxis along with ecchymoses, petechiae, and bleeding from the gums, mouth, and I.V. puncture sites. Menorrhagia and signs of GI bleeding, such as melena and hematemesis, can also occur.
Glomerulonephritis (chronic)
Glomerulonephritis produces nosebleeds as well as hypertension, proteinuria, hematuria, headache, edema, oliguria, hemoptysis, nausea, vomiting, pruritus, dyspnea, malaise, and fatigue.
Hepatitis
When hepatitis interferes with the clotting mechanism, epistaxis and abnormal bleeding tendencies can result. Associated signs and symptoms typically include jaundice, clay-colored stools, pruritus, hepatomegaly, dry and flaky skin, abdominal pain, fever, fatigue, weakness, dark amber urine, anorexia, nausea, and vomiting.
Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease)
Rendu-Osler-Weber disease causes frequent, sometimes daily, epistaxis, as well as hemoptysis and GI bleeding. Telangiectases appear as pinpoint, purplish red spots or flat, spiderlike lesions on the mucous membranes of the lips, mouth, tongue, nose, and GI tract. They occasionally appear on the trunk and fingertips.
Hypertension
Severe hypertension can produce extreme epistaxis, usually in the posterior nose, with pulsation above the middle turbinate. It may be accompanied by dizziness, a throbbing headache, anxiety, peripheral edema, nocturia, nausea, vomiting, drowsiness, and mental impairment.
Infectious mononucleosis
In patients with infectious mononucleosis, blood may ooze from the nose. Characteristic features include sore throat, cervical lymphadenopathy, and a fluctuating fever with an evening peak up to 101° to 102° F (38.3° to 38.9° C).
Influenza
When influenza affects the capillaries, a slow, oozing nosebleed results. Other signs and symptoms of influenza include dry cough, chills, fever, malaise, myalgia, sore throat, hoarseness or loss of voice, conjunctivitis, facial flushing, headache, rhinitis, and rhinorrhea.
Leukemia
With acute leukemia, sudden epistaxis is accompanied by a high fever and other types of abnormal bleeding, such as bleeding gums, ecchymoses, petechiae, easy bruising, and prolonged menses. These may follow less-noticeable signs and symptoms, such as weakness, lassitude, pallor, chills, recurrent infections, and low-grade fever. Acute leukemia may also cause dyspnea, fatigue, malaise, tachycardia, palpitations, a systolic ejection murmur, and abdominal or bone pain.
With chronic leukemia, epistaxis is a late sign that may be accompanied by other types of abnormal bleeding, extreme fatigue, weight loss, hepatosplenomegaly, bone tenderness, edema, macular or nodular skin lesions, pallor, weakness, dyspnea, tachycardia, palpitations, and headache.
Maxillofacial injury
With a maxillofacial injury, a pumping arterial bleed usually causes severe epistaxis. Associated signs and symptoms include facial pain, numbness, swelling, asymmetry, open-bite malocclusion or inability to open the mouth, diplopia, conjunctival hemorrhage, lip edema, and buccal, mucosal, and soft-palatal ecchymoses.
Nasal fracture
Unilateral or bilateral epistaxis occurs with nasal swelling, periorbital ecchymoses and edema, pain, nasal deformity, and crepitation of the nasal bones.
Nasal tumor
Blood may ooze from the nose when a tumor disrupts the nasal vasculature. Benign tumors usually bleed when touched, but malignant tumors produce spontaneous unilateral epistaxis, along with a foul discharge, cheek swelling, and — in the late stage — pain.
Orbital floor fracture
Orbital floor fracture is a type of trauma that may damage the maxillary sinus mucosa and, on rare occasions, cause epistaxis. More typical features include periorbital edema and ecchymoses, diplopia, infraorbital numbness, enophthalmos, limited eye movement, and facial asymmetry.
Polycythemia vera
A common sign of polycythemia vera, spontaneous epistaxis may be accompanied by bleeding gums; ecchymoses; ruddy cyanosis of the face, nose, ears, and lips; and congestion of the conjunctiva, retina, and oral mucous membranes. Other signs and symptoms vary according to the affected body system but may include headache, dizziness, tinnitus, vision disturbances, hypertension, chest pain, intermittent claudication, early satiety and fullness, marked splenomegaly, epigastric pain, pruritus, and dyspnea.
Renal failure
Chronic renal failure is more likely than acute renal failure to cause epistaxis and a tendency to bruise easily. More common signs and symptoms are oliguria or anuria, weight loss, anorexia, abdominal pain, diarrhea, nausea, vomiting, tissue wasting, dry mucous membranes, uremic breath, Kussmaul’s respirations, deteriorating mental status, and tachycardia.
Skin changes include pruritus, pallor, yellow-bronze pigmentation, purpura, dry skin, excoriation, uremic frost, and brown arcs under the nail margins. Neurologic signs and symptoms may include muscle twitches, fasciculations, asterixis, paresthesia, and footdrop. Cardiovascular effects include hypertension, arrhythmias, signs of heart failure, signs of pericarditis, and peripheral edema.
Sarcoidosis
Oozing epistaxis may occur in sarcoidosis, along with a nonproductive cough, substernal pain, malaise, and weight loss. Related findings include tachycardia, arrhythmias, parotid enlargement, cervical lymphadenopathy, skin lesions, hepatosplenomegaly, and arthritis in the ankles, knees, and wrists.
Scleroma
With scleroma, oozing epistaxis occurs with a watery nasal discharge that becomes foul-smelling and crusty. Progressive anosmia and turbinate atrophy may also occur.
Sinusitis (acute)
With sinusitis, a bloody or blood-tinged nasal discharge may become purulent and copious after 24 to 48 hours. Associated signs and symptoms include nasal congestion, pain, tenderness, malaise, headache, low-grade fever, and red, edematous nasal mucosa.
Skull fracture
Depending on the type of fracture, epistaxis can be direct (when blood flows directly down the nares) or indirect (when blood drains through the eustachian tube and into the nose). Abrasions, contusions, lacerations, or avulsions are common. A severe skull fracture may cause severe headache, decreased level of consciousness, hemiparesis, dizziness, seizures, projectile vomiting, and decreased pulse and respiratory rates.
A basilar fracture may also cause bleeding from the pharynx, ears, and conjunctiva as well as raccoon eyes and Battle’s sign. Cerebrospinal fluid or even brain tissue may leak from the nose or ears. A sphenoid fracture may also cause blindness, whereas a temporal fracture may also cause unilateral deafness or facial paralysis.
Syphilis
Epistaxis is most common in patients with tertiary syphilis, as posterior septum ulcerations produce a foul, bloody nasal discharge. It may be accompanied by a painful nasal obstruction and nasal deformity. Occasionally, primary syphilis causes painful nasal crusting and bleeding accompanied by the characteristic chancre sores.
Systemic lupus erythematosus (SLE)
Usually affecting females younger than age 50, SLE causes oozing epistaxis. More characteristic signs and symptoms include butterfly rash, lymphadenopathy, joint pain and stiffness, anorexia, nausea, vomiting, myalgia, and weight loss.
Typhoid fever
Oozing epistaxis and dry cough are common. Typhoid fever may also cause abrupt onset of chills and high fever, vomiting, abdominal distention, constipation or diarrhea, splenomegaly, hepatomegaly, “rose-spot” rash, jaundice, anorexia, weight loss, and profound fatigue.
Other causes
Chemical irritants
Some chemicals — including phosphorus, sulfuric acid, hypochlorite, ammonia, printer’s ink, and chromates — irritate the nasal mucosa, producing epistaxis.
Drugs
Anticoagulants, such as warfarin, and anti-inflammatories, such as aspirin, can cause epistaxis. Cocaine use, especially if frequent, can also cause epistaxis.
Environment
Dry environments, as occurs during winter use of heaters without humidity, may cause nosebleeds.
Surgery and procedures
Rarely, epistaxis results from facial and nasal surgery, including septoplasty, rhinoplasty, antrostomy, endoscopic sinus procedures, orbital decompression, and dental extraction.
Vigorous nose blowing
Vigorous nose blowing may rupture superficial blood vessels, especially in elderly people and young people, and cause nosebleeds.
Nursing considerations
Until the bleeding is completely under control, continue to monitor the patient for signs of hypovolemic shock, such as tachycardia and clammy skin. If external pressure doesn’t control the bleeding, insert cotton that has been impregnated with a vasoconstrictor and local anesthetic into the patient’s nose.
If bleeding persists, expect to insert anterior or posterior nasal packing. (See Types of nasal packing, page 135.) Administer humidified oxygen by facemask to a patient with posterior packing.
A complete blood count may be ordered to evaluate blood loss and detect anemia. Clotting studies, such as prothrombin time and activated partial thromboplastin time, may be required to test coagulation time. Prepare the patient for X-rays if he has had a recent trauma.
Patient teaching
Advise the patient about proper pinching pressure techniques. For prevention, tell him to apply liberal amounts of petroleum jelly to nostrils to prevent drying, cracking, and avoid picking and to avoid bending and lifting. Instruct the patient to sneeze with his mouth open. Use of a humidifier at night and trimming fingernails are also recommended. Emphasize the need for follow-up care and periodic blood studies after an episode of epistaxis. Advise the patient to seek prompt medical treatment for nasal infections or irritation.
Pictures
![Epistaxis [Nosebleed] - 4932.png](/bookimages/13/4932.png)
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Stuffed nose
Read excerpts from these other book chapters related to Stuffed nose:
Medical Books Excerpts
- Nosebleed
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
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