Bleeding from inside the nose is called epistaxis Fairly common and is seen in all age groups. “Epistaxis refers to nose bleed or hemorrhage from the nose”. It‘s mostly commonly originates in the anterior portion of the nasal cavity. A hemorrhage from the nose, referred to as epistaxis, is caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nose. Most commonly, the site is the anterior septum, where three major blood vessels enter the nasal cavity: (1) the anterior ethmoidal artery on the forward part of the roof (Kesselbach’s plexus) (2) the sphenopalatine artery in the posterosuperior region, and (3) the internal maxillary branches (the plexus of veins located at the back of the lateral wall under the inferior turbinate).

1. EPISTAXIS ( Nose
bleeding)
Mr. ANILKUMAR B R (Assistant
Professor)
Medical-surgical Nursing

2. EPISTAXIS ( Nose
bleeding)

3. Introduction
•Bleeding from inside the nose is called epistaxis
•Fairly common and is seen in all age groups.
“Epistaxis refers to nose bleed or hemorrhage from the
nose”.
• It‘s mostly commonly originates in the anterior portion
of the nasal cavity.

4. Definition
•A hemorrhage from the nose, referred to as
epistaxis, is caused by the rupture of tiny,
distended vessels in the mucous membrane of
any area of the nose.

5. •Most commonly, the site is the anterior septum, where
three major blood vessels enter the nasal cavity:
(1) the anterior ethmoidal artery on the forward part of
the roof (Kesselbach’s plexus)
(2) the sphenopalatine artery in the posterosuperior
region, and
(3) the internal maxillary branches (the plexus of veins
located at the back of the lateral wall under the
inferior turbinate).

7. Types of Epistaxis
1. ANTERIOR EPISTAXIX (Most common and less
severe and easy to control)
2. POSTERIOR EPISTAXIX ( Less common more severe
and difficult to control)

8. Anterior VS Posterior Epistaxis

9. Classification
• Anterior epistaxis
More common
Mostly from Little’s area or
anterior part of lateral wall
Mostly occurs in children or
young adults
Mostly trauma
Usually mild, can be easily
controlled by local pressure or
anterior pack
• Posterior epistaxis
Less common
Mostly from poster
superior part of nasal cavity
After 40 years of age
Spontaneous; often due to
hypertension or
arteriosclerosis
Bleeding is severe, requires
hospitalization; postnasal
pack often required

10. Anterior VS Posterior Epistaxis

12. Causes of Epistaxis
•There are a variety of causes associated with
epistaxis, including: trauma, infection, inhalation of
illicit drugs, cardiovascular diseases, blood
dyscrasias, nasal tumors, low humidity, a foreign
body in the nose, and a deviated nasal septum.
•Additionally, vigorous nose blowing and nose picking
have been associated with epistaxis.

13. Pathophysiology and Etiology
1. Local causes:
a) Dryness leading to crust formation-bleeding occurs
with removal of crusts by nose picking, rubbing, or
blowing.
b) Trauma – direct blows
c) Infections (Acute: viral rhinitis, nasal diphtheria, acute
sinusitis.)
d) Foreign bodies (Non-living: any neglected foreign
body)

14. Pathophysiology and Etiology
5. Atmospheric changes. High altitudes, sudden
decompression (Caisson’s disease).
6. Deviated nasal septum (DNS).

15. Pathophysiology and Etiology
2. Systemic causes are less common :
a)Hypertension
b) arteriosclerosis
c) renal disease
d) Bleeding disorders
e) Idiopathic
f) Liver disease- hepatic cirrhosis
g) Disorders of blood and blood vessels- Aplastic anemia,
leukemia, thrombocytopenic and vascular purpura,
hemophilia, Christmas disease, scurvy, vitamin K
deficiency.

16. Diagnostic Evaluation
1. History : including amount of blood loss, duration of
blood loss medications history ,Side of nose from
where bleeding is occurring and any known bleeding
tendency in the patient or family.
2. Care full inspection with nasal speculum to
determine site of bleeding ( its very important to
determine which site of bled first.)
3. Laboratory investigations to exclude blood dyscrasias
and coagulopathy.

17. Medical Management client with
epistaxis
Management of epistaxis depends on the location of
the bleeding site.
A nasal speculum or headlight may be used to
determine the site of bleeding in the nasal cavity.
Most nosebleeds originate from the anterior
portion of the nose.
Initial treatment may include applying direct
pressure.

18. First aid
•Little’s area- pinching the nose with thumb and index
finger for about 5 minutes- compression of vessels.
•Trotter’s method- patient is made to sit, leaning a
little forward over a basin to spit any blood, and
breathe quietly from mouth- cold compresses should
be applied to nose to cause reflex vasoconstriction.

20. Trotter’s method

21. Anterior nasal pressure with joined
tongue depressors.

22. • If this measure is unsuccessful, additional treatment is
indicated. In anterior nosebleeds, the area may be
treated with a silver nitrate applicator and Gelfoam, or
by electrocautery.
• Topical vasoconstrictors, such as adrenaline or cocaine
(0.5%), and phenylephrine may be prescribed. If bleeding
is occurring from the posterior regions, cotton pledgets
soaked in a vasoconstricting solution may be inserted
into the nose to reduce the blood flow and improve the
examiner’s view of the bleeding site.

23. silver nitrate applicator

24. Gelfoam

25. cotton pledgets

26. Alternatively, a cotton tampon may be used to try to
stop the bleeding. Suction may be used to remove
excess blood and clots from the field of inspection.

27. Cotton tampon

28. Nasal packing with bayonet forceps
and ribbon gauze.

29. •When the origin of the bleeding cannot be identified, the
nose may be packed with gauze impregnated with
petrolatum jelly or antibiotic ointment; a topical
anesthetic spray and decongestant agent may be used
prior to inserting the gauze packing, or a balloon-inflated
catheter may be used.

30. •The packing may remain in place for 48 hours or up to
5 or 6 days if necessary to control bleeding.
•Antibiotics may be prescribed because of the risk of
iatrogenic sinusitis and toxic shock syndrome.

32. Anterior nasal packing
Anterior nasal packing

33. Posterior nasal packing

34. Complications of epistaxis and treatment include the
following:
• Hemorrhagic shock
• Septic shock
• Pneumocephalus (is the presence of air or gas within the
cranial cavity. )
• Sinusitis
• Septal pressure necrosis
• Neurogenic syncope during packing (also called: vasovagal
syncope. It is a sudden drop in heart rate and blood pressure
leading to fainting, often in reaction to a stressful trigger.)
• Epiphora ( is an overflow of tears onto the face).

35. Nursing Management
1. The nurse monitors the vital signs, assists in the control
of bleeding, and provides tissues and an emesis basin to
allow the patient to expectorate any excess blood. It is not
uncommon for patients to be anxious in response to a
nosebleed.
2. Monitor vital sings & assist with control of bleeding.
Assess for changes in BP and pulse indicative of
hypovolemia.

36. Nursing Management
3. Assuring the patient in a calm, efficient manner that
bleeding can be controlled can help reduce anxiety.
4. Instructs to the client to avoid blowing or picking nose
after a nose bleed.
5. Discharge teaching includes reviewing ways to prevent
epistaxis: avoiding forceful nose blowing, straining, high
altitudes, and nasal trauma (including nose picking).
6. Monitor the client with posterior packing for hypoxia.

37. Nursing Management
6. Adequate humidification may prevent drying of the
nasal passages.
7. The nurse instructs the patient how to apply direct
pressure to the nose with the thumb and the index finger
for 15 minutes in the case of a recurrent nosebleed.
If recurrent bleeding cannot be stopped, the patient is
instructed to seek additional medical attention.