Estes Case Study s1

Chev Buljabasic

Background scenario

It is 11 pm on a Saturday evening in late November. Chev is a 22-year-old junior at an urban campus of a major university. He has come into the clinic of the student health center with a towel and ice pack on his nose. There is blood on his shirt and his face. His girlfriend, Mantha, and his roommate, Trevor, accompany him. He moves quickly over to a chair next to the admitting desk. He seems agitated and restless. Trevor seems agitated and restless also. He crosses the room, and jumps up to sit on the counter at the admitting desk. He is dripping blood onto the counter, and onto his forearm, watch, and sleeve, but does not seem to notice.

Interview

"Hey, I'm bleeding!"

"I need help."

"I got it all over my car."

"It started when I sneezed. I sneezed about 5 times and couldn't stop."

Mantha:

"Can't you do something?"

"It's been bleeding a long time. We tried to stop it every way we knew how, but it just starts again.

"I pinched his nose closed, and held it, but it just gushed out when I took my hand away."

Trevor:

"He has had a couple nosebleeds before. It seems to always happen on Saturday night when we go party at his friends house."

"Hey, what are you guys doing around here? Can't you see he is bleeding to death?"

"Nobody hit him, at least nobody I saw!" Examination

Vital signs:

Temperature: 99.4°F Pulse: 120 Respiration rate: 28 Blood pressure: 118/80

Observation:

Skin is pale. Client swallows frequently. Voice sounds "nasally", and wet. Blood is noted on shirt and towel. When client removes towel from nose, blood runs out. Client appears anxious and agitated. His arm and leg movements are sudden and jerky. His attention seems easily distracted, and his gaze wanders around the room. He makes verbal comments about people and objects in the room, but does not appear to be able to prioritize his thoughts or actions in a matter that supports concern over his physical complaint. Pupils are dilated. There is no sign of external trauma to the face.

Palpation:

Normal

Auscultation:

Respirations are shallow and rapid. Lungs are clear. Hyperactive bowel tones are present in all four quadrants of abdomen.

Laboratory reports:

Hematocrit: 44% (Normal male: 41 to 53%) Hemoglobin:15.3 g/dL (Normal male: 13.5 to 17.5 g/dL) Prothrombin time, partial thromboplastin time. Platelet count is normal.

As time passes

Chev admits to snorting cocaine at a party prior to his nosebleed. He admits to regular cocaine use. The physician prepares to pack the nose.

Background education Nosebleeds, known as epistaxis, occur when one or more of the blood vessels in the nose are ruptured, most often due to injury to the nasal membranes covering the blood vessel.

Nosebleeds can be caused by several factors. Primary are factors that dry out or irritate the nasal membranes. These include dry air, viruses, allergies, colds, antihistamines, decongestants, or picking at crusts and itchy spots inside the nose. A second cause of nosebleeds is related to factors external to the nose, primarily an injury or a blow to the outside of the nose, or a foreign body inside the nose, which causes injury to the nasal mucosa.

Finally, some medical conditions can cause frequent nosebleeds, including polyps, blood disorders, coagulation disorders, surgery to the nose area, anticoagulant medications, cancer, immune disorders, or hypertension.

The nose is divided by the nasal septum into two sides. Each side has an anterior area, the anterior nasal septum, and a posterior area. The nasal cavities are supplied with blood from the internal and external carotid arteries. Kiesselbach’s plexus is a very vascular area on the top of the anterior nasal septum is the most common origin of a nosebleed. The mucosa covering this area is very fragile and the area lies tight against underlying cartilage, offering little buffer for trauma.

Most nosebleeds stop by themselves. The first priority in nursing assessment is to check and maintain an adequate airway, for oxygenation, and to prevent aspiration. Then, assessment and intervention to stop the bleed is begun. For nosebleeds that continue beyond three to four minutes, the first approach is to apply simple pressure externally to the nose to stop the bleeding. Calm the client and have them sit quietly, leaning forward. Flex the neck anteriorly, until the chin touches the chest. With thumb and forefinger, have the client pinch the anterior septal area tightly, and press the pinch back toward the bones of the face. The client must hold this pressure for at least five minutes. Repeat at necessarily if bleeding resumes. If the pinch is released prior to the five-minute mark, start over. This maneuver will often stop bleeding which originates in the Kisselback’s plexus area. If the bleeding is posterior to the site of the pressure, this will not stop the bleeding, but blood will spill over into the nasopharynx and can be spit out. Extending the head backward, a traditional response to nosebleeds, actually increases the risk of aspirating or swallowing blood, and should not be done. Laying flat or putting the head lower than the heart is not helpful and may worsen the bleeding. Ice packs to the nose, face, or back of neck are often used with mixed results.

Bleeding which does not stop with these measures needs additional treatment by a physician. This includes diagnosing the exact location of the bleed, using an endoscope or a speculum. The mucosa is anesthetized and interventions to stop the bleeding are undertaken. Interventions can include packing the nose, using commercial nasal packs, or petroleum gauze. Both anterior and posterior nasal packing can be done. Antibiotic ointment is often used on the packs, and/or antibiotic therapy is used when packs are used to reduce the risk of sinus infections. Cauterizing the bleeding vessel with electrocautery or silver nitrate can be used, followed by packing. Vasoconstrictors, including topical oxymetazoline hydrochloride (Afrin), cocaine, or epinephrine can be used. Surgical interventions to ligate the bleeding vessel are a last resort if other methods are ineffective, or if the nosebleed is severe enough to be life threatening.

Nursing assessment for a nosebleed includes gathering information about the client's history of nosebleed and looking for possible causes. Intervention includes blood pressure, emergency interventions to locate and treat the source of the bleeding, lab work, and radiographs as ordered by the physician. Nursing interventions for severe nosebleeds may include assisting the physician with suction, lighting, or the packing procedure.

Chev’s blood must be treated as if it is infected. Universal precautions must be followed at all times. Universal precautions is a protocol that assumes that all human blood and bodily fluids are infected with blood borne pathogens that can be transmitted to the caregiver. Barrier protection is used at all times to prevent skin and mucous membranes of caregivers from coming in contact with contaminated materials. The extent of barrier protection must be appropriate to the type of exposure anticipated. With Chev’s nosebleed, contaminated blood can be dripped, splashed, or cover items or surfaces in the environment. Precautions include blood containment, protective gloves, gown, eyewear, and surgical masks. Hands or other skin surfaces must be washed immediately if contaminated, or immediately after removing gloves.

Client education includes advising the client to avoid activities that might cause bleeding to resume, including vigorous exercise, eating hot or spicy food, drinking alcohol, or tobacco use. Picking or blowing the nose or sneezing with the mouth closed is to be avoided. The client is advised to apply topical medications, petroleum jelly or nasal sprays as ordered and to take oral antibiotics as prescribed. A follow-up visit to remove the packing and assess the nasal mucosa will be scheduled.

Other interventions might include remedies to lower blood pressure, discontinuation of anticoagulant medications, or further assessment to rule out causes of the nosebleed.

Drug use and nosebleed

Users inhale cocaine powder through the nose. The cocaine is absorbed into the mucous membrane of the nose and into the blood stream. Cocaine is a central nervous system stimulant. It causes increased pulse, respirations, and body temperature, dilated pupils, increased inability to sit still, headache, dizziness, difficulty concentrating, listlessness, and time distortion is common.

Cocaine, when snorted into the nose, is irritating to the epithelium of the nasal passages and causes itching and crusting. It also acts as a vasoconstrictor. Repeated use causes a cycle of ischemia, inflammation, micronecrosis, and infection leading to macronecrosis. With extended abuse, septal perforation is common.

List your findings and conclusions: Nosebleed due to nasal irritation from snorting cocaine

Nursing diagnoses:

00004 Risk for infection 00028 Risk for deficient fluid volume 00140 Risk for injury 00146 Anxiety 00079 Noncompliance. 00044 Impaired tissue integrity 00099 Ineffective health maintenance 00122 Disturbed sensory perception 00130 Disturbed thought processes 00069 Ineffective coping

1. Nosebleeds occur when one or more of the blood vessels in the nose are ruptured. This is most often due to a. Drug use or medications b. Injury to the nasal membranes c. Hypertension d. Blood disorders

2. Bleeding that does not stop with standard measures requires additional treatment by a physician. What is a last resort when treating a nosebleed? a. Surgical ligation b. Calm the client. c. Pack the nose. d. Apply ice packs to the face or nose.

3. Extending the head backward, a traditional response to nosebleeds, actually increases the risk of aspirating or swallowing blood, and should not be done. What intervention may actually make the nosebleed worse? a. Applying external pressure to the nose b. Placing the head lower than the heart c. Packing the nose d. Applying ice packs

4. Mr. Buljabasic was diagnosed with nosebleed due to nasal irritation from snorting cocaine. What is not a nursing diagnosis related to nosebleeds? a. Risk for injury b. Risk for deficient fluid volume c. Impaired verbal communication d. Anxiety

5. Client education includes advising the client to avoid activities that might cause bleeding to resume. The nurse tells the client to avoid a. Taking hypertension medication b. Applying nasal sprays c. Vigorous nose blowing or coughing d. Bending from the waist

6. Cocaine is absorbed into the mucous membrane of the nose and into the blood stream. It is a central nervous system stimulant. Cocaine, when snorted into the nose, can produce all but which of the following symptoms? a. Constricted blood vessels in the nose b. Headaches c. Dizziness d. Decreased pulse and respirations

7. Client education includes advising the client of factors than can cause bleeding to resume. What is a factor that can dry out or irritate the nasal membranes? a. Picking at crusts and itchy spots inside the nose b. Viruses or allergies c. Colds d. All of the above

8. The nose is divided by the nasal septum, into two sides. Each side has an anterior area, the anterior nasal septum, and a posterior area. What is the source of blood supply to the nasal cavities? a. Internal and external carotid arteries b. Dural sinuses c. Common carotid arteries d. External jugular vein

9. Some medical conditions can cause frequent nosebleeds. What disorder is among the list that can cause frequent nosebleeds? a. Tuberculosis b. Cancer or immune disorders c. Acrophobia d. Pneumonia 10. Kiesselbach’s plexus is a very vascular area on the top of the anterior nasal septum is the most common origin of a nosebleed. For nosebleeds that originate in the Kisselback’s plexus area, what intervention is least likely to stop the bleeding? a. Apply external pressure to the nose. b. Calm the client, and have them sit quietly, leaning forward. c. Apply ice packs to the face and nose area. d. Pinch the anterior septal area tightly, and press the pinch back toward the bones of the face for at least five minutes.