Epistaxis (Nosebleeds)

Epistaxis is the relatively common occurrence of bleeding (hemorrhage) from the nose, usually noticed when the blood drains out through the nostrils.

A. Type of Epistaxis

There are two types ; Anterior from the nasal septum (Kiesselbach’s plexus) as most common cases. Anterior bleeding may also originate anterior to the inferior turbinate. Posterior from the nasal septum as less common cases. Posterior hemorrhage originates from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx.

Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting.


B. Sign and Symptoms

A common sign, epistaxis can be spontaneous or induced from the front or back of the nose. Bleeding usually occurs from only one nostril. If the bleeding is heavy enough, the blood can fill up the affected nostril and overflow into the nasopharynx (the area inside the nose where the two nostrils converge), causing simultaneous bleeding from the other nostril as well.

Blood can also drip into the back of the throat or down into the stomach, causing a person to spit up or even vomit blood. Signs of excessive blood loss include dizziness, weakness, confusion and fainting. Excessive blood loss from nosebleeds does not often occur.


C. Causes Of Epistaxis

1. Most cases of epistaxis do not have an easily identifiable cause.
2. Local trauma (ie, nose picking) is the most common cause, followed by facial trauma, foreign bodies, nasal or sinus infections, and prolonged inhalation of dry air. A disturbance of normal nasal airflow, as occurs in a deviated nasal septum, may also be a cause of epistaxis.
3. Latrogenic causes include nasogastric and nasotracheal intubation.
4. Children usually present with epistaxis due to local irritation or recent upper respiratory infection (URI).
5. Oral anticoagulants and coagulopathy due to splenomegaly, thrombocytopenia, platelet disorders, or AIDS-related conditions predispose to epistaxis.
6. The relationship between hypertension and epistaxis is implicated. Epistaxis is more common in hypertensive patients, and patients are more likely to be acutely hypertensive during an episode of epistaxis. Hypertension, however, is rarely a direct cause of epistaxis, and therapy should be focused on controlling hemorrhage before blood pressure reduction.
7. Epistaxis is more prevalent in dry climates and during cold weather.

Vascular abnormalities that contribute to epistaxis may include the following:

• Sclerotic vessels
• Hereditary hemorrhagic telangiectasia
• Arteriovenous malformation
• Neoplasm
• Septal perforation, deviation
• Endometriosis

D. Pathophysiology Of Epistaxis

Nosebleeds are due to the rupture of a blood vessel within the richly perfused nasal mucosa. Rupture may be spontaneous or initiated by trauma. Nosebleeds are reported in up to 60% of the population with peak incidences in those under the age of ten and over the age of 50 and appears to occur in males more than females.

An increase in blood pressure (e.g. due to general hypertension) or local blood flow (for example following a cold or infection) will increase the likelihood of a spontaneous nosebleed. Anticoagulant medication and disorders of blood clotting can promote and prolong bleeding. Spontaneous epistaxis is more common in the elderly as the nasal mucosa (lining) becomes dry and thin and blood pressure tends to be higher. The elderly are also more prone to prolonged nose bleeds as their blood vessels are less able to constrict and control the bleeding.


E. Nursing Measures in Epistaxis Cases

1. Place patient in an upright position, leaning forward to reduce venous pressure
2. Avoiding the patient to talk and let to breathe through his mouth
3. Tell the Patient to firmly grasp and pinch his entire nose between the thumb and fingers for at least 10 minutes
4. Compress the soft outer portion of the nose against the midline septum for about 5-10 minutes continuously
5. Keep the head of the bed elevated 30 to 45 degrees for the next 4 hours.
6. Tell to the patient not to blow his/her nose for several hours and to avoid lifting objects or bending at the waist for the next 24 hours.
7. If symptoms persist assist the physician, They will do or order some of following treatments: application of topical anesthetic vasoconstrictor solution, such as a 4% lidocaine and topical epinephrine; topical chemical cauterization with silver nitrate; nasal tampon insertion; or insertion of up to 36 to 72 inches (90 to 180 cm) of ½ inch petroleum gauze packing into the nostril.
8. Care of the gauze packing pack inside the nose and be remove after 24 hours
9. Psychological support to the patient specially if packing is applied as he feels uncomfortable

Image of Netcell Epistaxis Pack and Epistaxis Catheter

F. Nursing Diagnoses

Nursing dianoses on the patient with Epistaxis :

• Risk for Deficient Fluid Volume (If excessive blood loss happened)
• Risk for Ineffective Breathing Pattern or Ineffective Airway Clearance (especially in children, they are going to be scared, so Fear is also another nursing diagnosis to consider).

In case bleeding does not stop after 20 minutes, Medical team will think about suspect posterior nasal epistaxis. A relatively serious condition that may require intervention by an otolaryngologist. Treatment may include placement of a double-lumen posterior epistaxis balloon catheter and packing.

Nose bleeding occurs after an injury to the head, this may suggest a skull fracture and x-rays should be taken, the nose may be broken (for example, it is misshapen after a blow or injury).

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Spina Bifida

What is Spina bifida?

Spina bifida is a birth defect in central nervous system. It occurs as a result from neural tube failure to close during embryonic development. The term spina bifida comes from Latin and literally means "split" or "open" spine.

Spina bifida commonly occurs at the end of the first month of pregnancy when the two sides of the embryo's spine fail to join together, leaving an open area. In some cases, the spinal cord or other membranes may push through this opening in the back. The condition usually is detected before a baby is born and treated right away.


Type of Spina Bifida :

1. Spina Bifida Occulta :
Posterior vertebral arches fail to close in the lumbosacral area. Spinal cord remains intact and usually is not visible. Meninges are not exposed on the skin surface and neurological deficit are not usually present. In other word, Most children with this type of defect never have any health problems, and the spinal cord is often unaffected.

2. Spina Bifida Cystica/Manifesta:
The vertebra and neural tube close incomplete resulting in a saclike protrusion in the lumbar or sacral area. The defect includes meningocele, myelomeningocele, lipomeningocel, and lipomeningomyelocele.

Spina Bifida Cystica - Meningocele

The protrusion involves meninges and a saclike cyst that contains CSF in the midline of the back. Spinal cord is not involved and neurological deficits are usually not present.

Spina Bifida Cystica - Myelomeningocel

The protrusion involves meninges, CSF, nerve roots, and spinal cord. The sac is covered by a thin membrane that is prone to leakage or rupture. Neurological deficit are evident.


Signs and Symptoms of Spina Bifida :

Those patients were diagnosed as Spina Bifida, mostly they have sign and symptom bellow :

• Visible spinal defect
• Flaccid paralysis of the legs
• Hip and joint deformities
• Altered bladder and bowel function
• Specific signs and symptoms depend on the spinal cord involvement

Nursing Intervention of Spina Bifida :

• Assess the sac and measure the lesion
• Assess neurological system
• Assess and monitor for increasing ICP
• Measure head circumferences
• Protect the sac, cover with a sterile, moist (normal saline), nonadherent dressing and change the dressing every 2-4 hours
• Place patient in prone position and head to one side
• Use antiseptic technique
• Assess and monitor the sac for redness, clear or purulent drainage, abrasions, irritation, and signs of infection
• Assess for hip and joint deformities
• Administer medication: antibiotics, anticholinergics, and laxatives as prescribed

Treatment of Spina Bifida :

Currently, there is no cure for spina bifida, but there are a number of treatments available to help manage the disease and prevent complications. Initial goals of treatment include reducing neurological damage to your child, minimizing complications such as infections and helping your family learn about and cope with the disorder.

Children with the mildest form of the disease, spina bifida occulta, usually do not require treatment (and often not for meningocele.). The key priorities in the treatment of myelomeningocele are to prevent infection from developing through the exposed nerves and tissue of the defect on the spine and to protect the exposed nerves and structures from additional trauma.

Treatment of the severe form of spina bifida myelomeningocele depends on the specific problems caused by the spinal defect and may include surgery, physical therapy, and the use of braces and other aids.

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