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Introduction ⬇

In the highly vascular nasal mucosa, even seemingly minor injuries can cause major bleeding and blood loss. Initial treatment for nasal bleeding begins with ensuring a secure airway and hemodynamic stability.

Most nasal bleeding originates at a plexus of arterioles and venules in the anteroinferior septum. About 90% of nosebleeds are anterior and can be controlled by pinching the anterior aspect of the nose. 1 Initially, direct pressure is applied for about 20 minutes. When direct pressure alone doesn’t stop bleeding, topical vasoconstrictive drugs such as oxymetazoline or chemical cautery with silver nitrate sticks may be effective. 2 Silver nitrate sticks are rolled over the area for 5 to 10 seconds until a gray eschar forms; then antibiotic ointment is applied to the area. 1

If these steps are unsuccessful, nasal packing is typically the next step for persistent bleeding. 1,2,3 The patient may have to undergo nasal packing to stop anterior bleeding (which runs out of the nose) or posterior bleeding (which runs down the throat).2,3 If blood drains into the nasopharyngeal area or lacrimal ducts, the patient may also appear to bleed from the mouth and eyes. Only about 1 in 10 nosebleeds occurs in the posterior nose, which usually bleeds more heavily than the anterior location. 1 Posterior nasal packing is contraindicated in patients with facial trauma. If the patient can’t protect the airway because of shock, altered mental status, or another condition, the airway should be secured before posterior nasal packing insertion. 3

The nurse typically assists a practitioner with anterior or posterior nasal packing. Commercially available balloons are relatively easy to insert and quite effective for anterior bleeding. Whichever procedure is used, the patient will need ongoing encouragement and support to reduce discomfort and anxiety, as well as ongoing assessment to determine whether the procedure succeeded and to detect possible complications.

Equipment ⬆ ⬇

Equipment

Gowns • mask and goggles or mask with face shield • gloves • drape • emesis basin • nasal speculum • light source (headlamp or fiberoptic nasal endoscope) • suction apparatus • normal saline solution • prescribed anesthetic agent • cotton balls or gauze pad • nasal balloon device or nasal tampon • vital signs monitoring equipment • disinfectant pad • oral care supplies • stethoscope • tape • pulse oximeter and probe • sterile nasal aspirator tip • nasal speculum and tongue blades (may be in a preassembled head and neck examination kit) • vial of 2% lidocaine • sterile normal saline solution (1-g container and 60-mL syringe with Luer-lock tip or 5-mL bullets for moistening nasal tampons) • antibiotic ointment • prescribed medications • Kelly clamp or Bayonet forceps • Optional: epistaxis tray, supplemental humidified oxygen and face mask, arterial blood gas kit, facial tissues, tongue blade, syringe, hemostats, nasal dressing holder, topical nasal vasoconstrictor (such as 0.5% phenylephrine), 20-mL syringe, prescribed sedative, supplies for blood sampling, sterile water, water-soluble lubricant, facial tissues.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility.

Make sure that the light source functions properly, because good lighting is essential.3 Prepare the suction equipment and make sure that it’s functioning properly. Have normal saline solution readily available to flush the suction tubing, as needed.

Implementation ⬆ ⬇

Implementation
  • Gather and prepare the necessary equipment and supplies.
  • Perform hand hygiene. 4,5,6,7,8,9
  • Confirm the patient’s identity using at least two patient identifiers. 10
  • Provide privacy. 11,12,13,14
  • Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.15
  • Raise the patient’s bed to waist level before providing care to prevent caregiver back strain.16
  • Perform hand hygiene. 4,5,6,7,8,9
  • Obtain the patient’s vital signs and observe for hypotension with postural changes. Hypotension and tachycardia suggest significant blood loss.
  • Obtain the patient’s oxygen saturation level using pulse oximetry.
  • Monitor airway patency and provide the patient with an emesis basin, because the patient will be at risk for aspirating or vomiting swallowed blood.
  • Screen for and assess the patient’s pain using facility-defined criteria that are consistent with the patient’s age, condition, and ability to understand. 17
  • Treat the patient’s pain, as needed and ordered, using nonpharmacologic or pharmacologic approaches, or a combination of approaches. Base the treatment plan on evidence-based practices and the patient’s clinical condition, past medical history, and pain management goals. 18 Monitor the patient closely if identified as at high risk for adverse outcomes related to opioid treatment, if opioids are prescribed. 17
  • If ordered, administer a mild sedative, following safe medication administration practices, to reduce the patient’s anxiety and decrease sympathetic stimulation, which can exacerbate a nosebleed.18,19,20,21
  • Perform hand hygiene. 4,5,6,7,8,9
  • Put on gloves, a gown, and a mask and goggles or a mask with face shield to comply with standard precautions.22,23,24
  • Help the patient sit with the head tilted forward to minimize blood drainage into the throat and prevent aspiration.2,3
  • Drape the patient as necessary.
  • At the bedside, create a sterile field using sterile no-touch technique. Open and place all sterile equipment on the sterile field, including the sterile nasal aspirating tip. Label all medications, medication containers, and solutions on and off the sterile field. 25,26 Thoroughly lubricate the posterior packing with antibiotic ointment, as ordered. 3 Alternatively, the practitioner will lubricate the catheters.
  • To inspect the nasal cavity, the practitioner will use a nasal speculum and an external light source such as a headlamp or a fiberoptic nasal endoscope. To remove collected blood and help visualize the bleeding vessel, the practitioner may ask the patient to blow the nose gently, or the practitioner may use suction. 27 The practitioner may treat the nose early with a vasoconstrictor, such as phenylephrine, to slow bleeding and aid visualization.28
  • Instruct the patient to open and breathe normally through the mouth during catheter insertion to minimize gagging as the catheters pass through the nostril.
  • Assist with administering an anesthetic agent, if needed. This step may include administration of a solution containing lidocaine, EPINEPHrine, and tetracaine applied to cotton balls or a gauze pad, which the practitioner will then place in the nostrils for 10 minutes, or the application of lidocaine spray. 3
  • Assist the practitioner with insertion of packing, as directed. (See Inserting posterior nasal packing and Inserting anterior nasal packing.)
  • After insertion, help the patient assume a comfortable position with head elevated 45 to 90 degrees. 3
  • Monitor the patient’s vital signs to detect changes in condition.
  • Monitor the patient’s respiratory status to make sure the airway is patent; monitor oxygen saturation level by pulse oximetry to detect hypoxemia. Make sure that the alarm limits are set appropriately for the patient’s current condition, and that the alarms are turned on, functioning properly, and audible to staff. 31,32,33,34
  • Administer supplemental humidified oxygen by face mask, as needed and ordered.
  • Provide emotional support, because mouth breathing, which is necessary with the packing in place, may cause anxiety and hyperventilation.
  • If severe or recurrent bleeding or an underlying medical condition is present, obtain a blood sample for complete blood count and blood compatibility testing, as ordered. 27 If the patient has renal or hepatic dysfunction, or if the patient was taking an anticoagulant, obtain a specimen for coagulation studies, as ordered. 27 Notify the practitioner of critical test results within your facility’s established timeframe so the patient can receive prompt treatment.35
  • Check the posterior oropharynx frequently to see whether there’s bleeding into the back of the throat or whether the packing has slipped out of position.
  • Maintain the head of the bed at 30 degrees or higher. 27
  • Because a patient with nasal packing must breathe through the mouth, provide frequent oral care. Artificial saliva, room humidification, and ample fluid intake also relieve dryness caused by mouth breathing.
  • As ordered, administer an antiemetic, a decongestant, a sedative, and a prophylactic antibiotic following safe medication administration practices. 18,19,20,21,27,28
  • Reassess and respond to the patient’s pain by evaluating the response to treatment and progress toward pain management goals. Assess for adverse reactions and risk factors for adverse events that may result from treatment. 17
  • Return the patient’s bed to the lowest position to prevent falls and maintain patient safety.36
  • Discard used supplies in the appropriate receptacles. 23
  • Remove and discard your gloves and other personal protective equipment. 22,23
  • Perform hand hygiene. 4,5,6,7,8,9
  • Clean and disinfect your stethoscope using a disinfectant pad. 37,38
  • Perform hand hygiene. 4,5,6,7,8,9
  • Document the procedure. 39,40,41,42

Special Considerations ⬆ ⬇

Special considerations
  • Keep emergency equipment (flashlight, tongue blade, syringe, and hemostat) at the patient’s bedside to expedite packing removal if it becomes displaced and occludes the airway.
  • Avoid administration of aspirin and nonsteroidal anti-inflammatory drugs for a few days to reduce the risk of bleeding.27,28
  • After the packing is in place, compile assessment data carefully to help detect the underlying cause of nosebleeds. Mechanical factors include a deviated septum, injury, and a foreign body. Environmental factors include drying and erosion of the nasal mucosa, which can occur with nasal oxygen delivery or intranasal cocaine use. 2,43 Other possible causes include upper respiratory tract infection, anticoagulant or salicylate therapy, blood dyscrasias, cardiovascular or hepatic disorders, tumors of the nasal cavity or paranasal sinuses, chronic nephritis, human immunodeficiency virus infection, and familial hemorrhagic telangiectasia.
  • The patient should remain on modified bed rest until removal of the pack. 3 The practitioner will usually remove nasal packing in 3 to 4 days. 2,3

Patient Teaching ⬆ ⬇

Patient teaching

Advise the patient to eat soft foods, because nasal packing can impair the ability to eat and swallow. Instruct the patient to drink fluids often or to use artificial saliva to cope with dry mouth. Teach the patient measures to prevent nosebleeds, and instruct the patient to seek medical help if these measures fail to stop bleeding. 2

Complications ⬆ ⬇

Complications

Airway obstruction can occur if an anterior or posterior pack slips backward. 1 The patient may complain of difficulty swallowing, pain, or discomfort. 28 Other possible complications include continued bleeding despite packing, aspiration of blood, hypoxia, infection, intranasal adhesions, and pressure necrosis of nasal structures, especially the septum. 1,2,3 Bradyarrhythmias can develop because of stimulation of the posterior oropharynx related to the packing. 3 Sedation can cause hypotension in a patient with significant blood loss and can also increase the patient’s risk of aspiration and hypoxemia.

Documentation ⬆ ⬇

Documentation

Record the date and time of the procedure and the type of packing used to ensure its removal at the appropriate time. On the intake and output record, document the estimated blood loss and all fluids administered. Note the patient’s vital signs and oxygen saturation level; the results of all laboratory tests; all drugs administered, including topical agents; and the patient’s response to sedation, analgesics, and position changes. Record any complications that occur, interventions taken, and the patient’s response to those interventions. Document teaching provided to the patient and family (if applicable), discharge instructions, and clinical follow-up plans; their understanding of that information; and any need for follow-up teaching.

References ⬆

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