Handling Epistaxis in an 11-year-old boy
answer:
Differential Diagnoses:
Diagnosis:
- Allergic Rhinitis (J30.9): This is an inflammation of the interior side of the nose due to physical or biological issues.
- Nasal Foreign body (T17.0XXA): These are benign that are identified to possibly be the cause of bleeding in the sensitive membrane, mucosal damage, and infections.
- NSAID Toxicity (T39.391A): NSAIDs are medicines believed to reduce inflammation and ease the pain. Toxicity of NSAIDs stems from overdosing, thus, causing nausea, dizziness, and headaches among other side effects.
Handling Epistaxis
Plan
Therapeutic modalities for Nose Bleed:
Therapeutic approaches to the management of epistaxis include both medical and behavioral strategies. Nosebleeds usually directly respond to the hemostasis process of cauterization and nasal packing (Svider et al, 2018). An individual can pinch the nose right above the nostrils while sitting down for approximately ten minutes. Comprehensive therapy should be used to manage the common cases involved with anterior epistaxis. Medical treatments should follow and if the case is severe and recurrent, surgical treatment is administered.
Health Promotion/Patient Education Nose Bleed:
A humidifier should be used in living and workspaces to combat the issue of dry hot air. It increases the amount of moisture in the air. A nasal spray, saline in nature, may also be applied to make the nose moist and prevent nosebleeds. Physical injuries to the inner side of the nose can be avoided by not picking or itching the inner side of the nose (Svider et al, 2018). Understanding the types of medication that increase the risk of nose bleeding should also be achieved to prevent the chances of nosebleeds.
Disposition/follow-up instructions for nose bleed:
One should sit down and hold their head forward, pinch the soft part of the nose above the nostrils waits for ten minutes without releasing the pinch. One should then contact or visit a medical doctor.
Nurse Practitioner Intervention:
- Before any type of procedure, you have the mother sign an informed consent for a procedure. What are the three major areas you must discuss when doing any type of procedure?
Patients get to be asked about their willingness to undergo a procedure and if they well understand the surgical procedure that is to be carried out. Nurses need to obtain valid informed consent from the patient before carrying out any surgical procedure on them. This shows the incorporation of nursing ethics in actual practice and ensures the patient’s dignity and respect are upheld. The three major elements that make up an informed consent are disclosure of information, the patient’s ability to make a medical decision, and the voluntary nature of the decision (Svider et al, 2018).
- Nosebleeds can be divided into three groups. What are they?
Nosebleeds occur when one bleeds from their nose. They can be scary or worrying if occurring in children or patients admitted to a health facility. It is crucial that nurses acquire a clear understanding of their causes and how to manage them. The causes of epistaxis lie between three categories; idiopathic, local, and systemic. Local causes are common and may include septal abnormalities, a dry state of the interior side of the nose, or physical injury to the nose (Yan & Goldman, 2021). Systemic causes are more technical and include issues in one’s blood any medications that may lead to blood thinning. Nosebleeds may stem from unknown and unidentified issues. Such causes are considered to be idiopathic.
- 90% of nosebleeds fall into which group?
Nosebleeds are either categorized as anterior or posterior. Anterior nosebleeds are described as those that stem from the blood vessels that flow in the walls dividing the nostrils, while, posterior nosebleeds are those that stem from the artery sullying blood to the nose. Anterior nosebleeds are the most common and account for approximately 90% of all nosebleeds (Yan & Goldman, 2021).
- Name 4 indications for intervention by a provider for a nosebleed.
According to Svider et al (2018), interventions can be undertaken if the individual has had recurrent nosebleeds, one is seriously injured around the nose area, the bleeding has not stopped even after initial first aid, or when the patient complains of drowsiness and nausea.
- You note that the bleeding is coming from an area on the septum. You know that the next step is to apply a vasoconstrictive solution to the nose. What are two ways you can deliver the vasoconstrictive solution?
Blood collection in the septum is referred to as Septal Hematoma. It is usually caused by the existence of an injury in the septum from local causes (Baugh & Chang, 2018). The vasoconstrictive solution is delivered through intranasal administration or administering solubilized medication. Intranasal administration is an easy and non-invasive strategy and is also painless. Drugs in this approach are insufflated through a systemic or local mode of administration. Administration of medicine in liquid form involves the introduction of medicine in drips through the nasal openings and letting it move down the nasal mucosa (Yan & Goldman, 2021). The doctor may also opt to numb the nose and insert an electronic device to close a blood vessel.
- You note that the area that is the source of the bleeding is about 3 mm in diameter. You decide to use a silver nitrate stick. How long should you apply pressure with the stick? (Paraphrase and use references)
Cauterization with the chemical substance, silver nitrate, is used as an intervention to treat epistaxis that can be identified as continuously recurring (Svider et al, 2018). It is used in the treatment of minor recurrent epistaxis as the remains after sealing a blood vessel. Silver nitrates sticks, when used to treat nosebleeds, should be used for an approximate period of two minutes. The degree of the resultant caustic action is directly determined by the amount of time the cauterization process was carried out.
- Why is it important not to use the silver nitrate over that time frame?
An eschar is formed at the contact point between the silver nitrate and blood vessels due to the free silver ions delivered. Th contact with the moist environment of the nose is the catalyst to this process. Excess-free silver ions due to prolonged exposure may bring about coagulation of the blood; a fatal situation as the blood vessel would be blocked.
- After hemostasis is obtained, what are three types of treatment methods that can be used to protect the cauterization site?
Nose care, regulated activity, and treatment medicines are critical and necessary to help protect the cauterization site (Yan & Goldman, 2021). Hemostasis helps manage the problem. Maintaining the cauterization site and preventing it from destruction requires extreme care and caution. The treated part of the nose should not be touched or blown for a week or two. Heavy activity or exercise should be avoided for the first 24 hours after the treatment. Blood-thinning medication should be avoided for a few days after the treatment (Yan & Goldman, 2021).
- After placing the nasal sponge/tampon, the patient should be closely monitored for 3-5 minutes. Why is that?
The patient should be closely monitored to ensure the hemostasis process is completed and proper cauterization is achieved. Removing it too soon may prevent the blood vessel from being mended properly (Baugh & Chang, 2018).
- If a sponge/tampon is used, it is not necessary to use antibiotics.
Antibiotics are necessary for nasal packing as they help prevent the development of sinusitis and block the possibility of the development of Staphylococcus aureus; which causes a toxic shock syndrome (Yan & Goldman, 2021). Antibiotics are a necessity.
- If it is necessary to pack the nose, it may be advisable to give the patient a narcotic or sedative medication (unless a contraindication exists). Why?
The narcotic or sedative medication helps numb the area or immobilize the patient momentarily to reduce the degree of movement during the treatment (Yan & Goldman, 2021). This helps in limiting the possibility of a problem in treatment. It also allows for lower blood pressure if the patient’s pressure is high.
- Name 5 complications of the above procedures
1. Hemorrhagic shock: this is a form of shock to the blood vessel where the extreme loss of blood leads to lower levels of oxygen delivered to the cells.
- Septic shock: this is when the blood pressure goes extremely low due to an infection acquired after hemostasis. There should be appropriate and quick procedures to ensure minimum blood loss.
3. Pneumocephalus: this is the presence of air molecules in the internal environment of the brain. This may be brought about from a poor local or systemic process.
- Sinusitis Septal: this is an inflammation of the sinus that affects the septum and may be due to an injury or infection in the septum.
- Pressure necrosis: This is when a high degree of pressure causes pressure ulcers, hence, an injury into the deep tissues.
- After the procedure, you tell the patient and his mother that he can take acetaminophen for any pain/discomfort. Why is it important not to have him take ibuprofen?
NSAIDs such as ibuprofen can cause discomfort and increase the probability of a nosebleed, thus, one should not take NSAIDs for pain relief after hemostatic treatment for epistaxis (Baugh & Chang, 2018).
- What is the leading cause of nosebleeds in adolescents?
Nosebleed in adults is mainly caused by dry and hot air due to climate and environmental changes (Baugh & Chang, 2018). This hot and dry air caused strain and irritation in the nasal membranes, thus, making them weaker and more vulnerable to rapture. Flu and common colds may also cause rapture on the inner membrane.
- What is the definition of this above code?
30901- Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method (Waguespack & Simon, 2019).
30903 – Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method (Waguespack & Simon, 2019).
30905 – Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial (Waguespack & Simon, 2019).
Handling Epistaxis
References
Baugh, T. P., & Chang, C. D. (2018). Epidemiology and management of pediatric epistaxis. Otolaryngology-Head and Neck Surgery, 159(4), 712-716.
Svider, P., Arianpour, K., & Mutchnick, S. (2018). Management of epistaxis in children and adolescents: avoiding a chaotic approach. Pediatric Clinics, 65(3), 607-621.
Waguespack, R. W., & Simon, L. M. (2019). Coding for otolaryngology office procedures. Otolaryngologic Clinics of North America, 52(3), 403-423.
Yan, T., & Goldman, R. D. (2021). Recurrent epistaxis in children. Canadian Family Physician, 67(6), 427-429.
Handling Epistaxis in an 11-year-old boy
question:
Scenario: A mother brings in her 11-year-old son, Branch because he has had a nosebleed. She is concerned about it because they have been applying pressure by pinching it and the nosebleed won’t stop. He has no history of nosebleeds. He has no significant medical history and no known allergies. He is on no medications. Mom and Branch deny trauma to the nose. He says he just woke up with a nosebleed and it won’t stop. He tells you that the left side is the side that is bleeding. Vital signs: Blood Pressure 110/70 Pulse 84 RR 14 Temp. 97.8 oral O2 99%
Differential Diagnoses:
Diagnosis:
- Epistaxis (R04.0) define epitaxis
- Allergic Rhinitis (J30.9) define as allergic rhinitis – common cold
- Nasal Foreign body (T17.0XXA) define the nasal foreign body
- NSAID Toxicity (T39.391A)- define nasal foreign
Handling Epistaxis
Plan.
Therapeutic modalities for Nose Bleed: answer
Health Promotion/Patient Education Nose Bleed: answer question
Disposition/follow-up instructions for nose bleed: answer question
Nurse Practitioner Intervention:
- Before any type of procedure, you have the mother sign an informed consent for a procedure. What are the three major areas you must discuss when doing any type of procedure? (Paraphrase and respond)
As nurses, we need to obtain informed consent before any type of procedure is implemented for the patient. Witnessing the consent indicates that the patient is competent. This also demonstrates that they are voluntarily giving their consent. Therefore, this also indicates that they can understand the information related to the treatment. The major areas that should be discussed when doing any type of procedure include: (1) the disclosure of information, (2) the voluntary nature of the decision, and (3) the competency of the patient (or surrogate) to make a decision.
- Nosebleeds can be divided into three groups. What are they?
Epistaxis or nosebleeds are one of the most common ear, nose, and throat (ENT) emergencies that present to the emergency room or in the primary care office. Epistaxis can be divided into two groups — anterior and posterior. Anterior nosebleeds occur when the blood vessels break and bleed that are located in the front of the nose. Consequently, posterior nosebleeds occur in the deepest part of the nose or the back. In this instance, blood flows towards the back of the throat.
- 90% of nosebleeds fall into which group? (Answer question below not sure correct)
The most common kind of nosebleed is an anterior nosebleed. Approximately 90% of anterior nosebleeds are located within the Kiesselbach’s plexus (also referred to as Little’s area). This is located on the anterior nasal septum.
- Name 4 indications for intervention by a provider for a nosebleed.
- You note that the bleeding is coming from an area on the septum. You know that the next step is to apply a vasoconstrictive solution to the nose. What are two ways you can deliver the vasoconstrictive solution? (Paraphrase answer find additional info and use references)
One way to deliver vasoconstrictive is via intranasal administration. Compared to other ways of administering, the nasal mucosa is easily accessible. This is also a more noninvasive approach and essentially painless which is highly recommended for children. Utilizing this method of administration can be performed easily by patients or by providers in emergencies. Intranasal administration offers a rapid onset of therapeutic effects (local or systemic). Another method of delivering the vasoconstrictive solution is to take the solubilized medication (liquid form) and drip it into the nose a few drops at a time, with a syringe, allowing it to run down onto the nasal mucosa.
- You note that the area that is the source of the bleeding is about 3 mm in diameter. You decide to use a silver nitrate stick. How long should you apply pressure with the stick? (Paraphrase and use references)
Pressure should be applied with the stick for approximately two minutes. This has shown to be usually sufficient, but treatment can vary case by case. When utilizing silver nitrate for cauterization, the length of time that the tip contacts the tissue determines the degree of the resulting caustic action.
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