1. Introduction and definition
2. Histamine: source, receptors, and actions
3. Classification of antihistamines
   • H1 receptor antagonists
   • First-generation (sedating) H1 antihistamines
   • Second-generation (less-sedating) H1 antihistamines
   • H2 receptor antagonists
4. Mechanism of action
5. Pharmacological actions
6. Therapeutic uses
7. Adverse effects
8. Contraindications and precautions
9. Drug interactions
10. Important drugs
    • Chlorpheniramine
    • Diphenhydramine
    • Promethazine
    • Hydroxyzine
    • Cetirizine
    • Loratadine
    • Fexofenadine
    • Famotidine
11. Nursing responsibilities and patient education
12. Short-note and viva questions

Brief overview

Dyspeptic Syndrome

Definition

Main Symptoms

• Epigastric pain or burning
• Post-meal fullness or heaviness
• Early satiety: feeling full after eating a small quantity of food
• Abdominal bloating
• Belching
• Nausea, sometimes vomiting
• Heartburn may coexist, but repeated heartburn/regurgitation suggests GERD

Causes

1. Organic dyspepsia

• Peptic ulcer disease
• Gastritis
• Gastro-oesophageal reflux disease (GERD)
• Helicobacter pylori infection
• Drug-induced irritation, especially NSAIDs such as aspirin, ibuprofen, and diclofenac
• Gastric cancer, rarely but important to exclude in warning signs
• Pancreatic or biliary disease in selected patients

2. Functional dyspepsia

• Abnormal gastric motility or delayed gastric emptying
• Visceral hypersensitivity
• Stress, anxiety, or depression
• Diet and lifestyle factors

1. Postprandial distress syndrome (PDS)
   • Post-meal fullness
   • Early satiety
2. Epigastric pain syndrome (EPS)
   • Epigastric pain
   • Epigastric burning

Risk Factors / Aggravating Factors

• Spicy or fatty foods
• Excess tea, coffee, alcohol, or smoking
• Large meals or irregular meals
• Stress and lack of sleep
• NSAIDs and corticosteroids
• H. pylori infection
• Obesity, especially if reflux symptoms are present

Assessment and Investigations

• H. pylori testing: urea breath test, stool antigen test, or biopsy
• Upper GI endoscopy
• Complete blood count if anemia or bleeding is suspected
• Stool test for occult blood where appropriate
• Ultrasound or other tests only if symptoms suggest gallbladder, liver, or pancreatic disease

Alarm Features

• Unexplained weight loss
• Gastrointestinal bleeding, black stool, or vomiting blood
• Persistent vomiting
• Difficulty or pain while swallowing
• Anemia, weakness, or pallor
• Abdominal mass
• New persistent symptoms in an older adult
• Family history of upper GI cancer

Management

Non-pharmacological management

• Eat small, frequent meals.
• Avoid heavy, fatty, spicy foods if these trigger symptoms.
• Avoid excess tea, coffee, alcohol, and smoking.
• Do not lie down immediately after eating.
• Avoid unnecessary NSAIDs.
• Reduce stress and maintain adequate sleep.
• Maintain healthy body weight.

Drug treatment

• Antacids for temporary relief of acidity.
• H2 blockers: famotidine.
• Proton-pump inhibitors (PPIs): omeprazole, pantoprazole, esomeprazole, especially when acid-related disease or GERD is suspected.
• Prokinetics: metoclopramide or domperidone in selected patients with fullness, nausea, or delayed gastric emptying. Use only under medical advice because of adverse effects.
• H. pylori eradication therapy: PPI plus prescribed antibiotics if infection is confirmed.
• Stop or change irritating drugs such as NSAIDs when possible, under prescriber guidance.

Nursing Responsibilities

• Assess location, duration, severity, and relation of pain to meals.
• Ask about nausea, vomiting, appetite, weight change, stool color, and bleeding.
• Check use of aspirin, ibuprofen, diclofenac, steroids, alcohol, and tobacco.
• Administer prescribed medicines correctly, often PPIs before meals as ordered.
• Observe and report alarm symptoms immediately.
• Teach dietary modification and avoidance of self-medication with NSAIDs.
• Encourage compliance with the full H. pylori eradication regimen if prescribed.
• Explain that persistent symptoms need follow-up, even if antacids give temporary relief.

One-line exam answer

Anemia: Topic Map for BSc Nursing

1. Definition and hemoglobin values
2. Causes and classification
3. Signs and symptoms
4. Diagnostic investigations
5. Iron-deficiency anemia
6. Megaloblastic anemia: vitamin B12 and folate deficiency
7. Hemolytic anemia
8. Aplastic anemia
9. Sickle-cell anemia and thalassemia
10. Treatment and prevention
11. Blood transfusion basics
12. Nursing management and health education

Brief overview

Anemia - Complete Notes for BSc Nursing

Definition

Common hemoglobin cutoffs

Hemoglobin values must always be interpreted using the patient’s age, sex, pregnancy status, altitude, clinical condition, and laboratory reference range.

Normal Functions of RBCs and Hemoglobin

• RBCs carry oxygen from lungs to tissues.
• Hemoglobin binds and transports oxygen.
• RBCs are produced in bone marrow.
• Normal RBC life span is approximately 120 days.
• Old RBCs are removed mainly by the spleen and liver.
• Iron is recycled and used for new hemoglobin production.
  Guyton and Hall Textbook of Medical Physiology describes the RBC life span as about 120 days.

Classification of Anemia

A. According to RBC size: Morphological classification

B. According to cause: Etiological classification

1. Decreased RBC production

• Iron-deficiency anemia
• Vitamin B12 deficiency anemia
• Folate deficiency anemia
• Anemia of chronic inflammation or chronic disease
• Chronic kidney disease due to reduced erythropoietin
• Aplastic anemia
• Bone marrow infiltration by malignancy

2. Blood loss

• Acute hemorrhage: trauma, surgery, postpartum hemorrhage
• Chronic hemorrhage: heavy menstruation, peptic ulcer, piles, gastrointestinal malignancy, hookworm infestation

3. Increased RBC destruction: Hemolytic anemia

• Sickle-cell anemia
• Thalassemia
• Malaria
• G6PD deficiency
• Autoimmune hemolytic anemia
• Incompatible blood transfusion

Causes of Anemia

• Poor dietary intake of iron, vitamin B12, or folate
• Chronic blood loss
• Heavy menstrual bleeding
• Pregnancy and repeated pregnancies
• Hookworm infestation
• Malaria
• Peptic ulcer or gastrointestinal bleeding
• Malabsorption disorders
• Chronic infections, inflammatory disorders, cancer
• Renal disease
• Bone marrow failure
• Hereditary disorders such as thalassemia and sickle-cell disease
• Drugs, toxins, radiation, or chemotherapy

Signs and Symptoms

General symptoms

• Weakness and fatigue
• Easy tiredness
• Dizziness or fainting
• Headache
• Reduced concentration
• Breathlessness on exertion
• Palpitations
• Cold intolerance

Physical signs

• Pallor of conjunctiva, tongue, nail beds, and palms
• Tachycardia
• Heart murmur in severe anemia
• Shortness of breath
• Glossitis: smooth, painful tongue
• Angular stomatitis
• Brittle or spoon-shaped nails, called koilonychia, commonly in iron deficiency
• Jaundice in hemolytic anemia
• Hepatosplenomegaly in some hemolytic disorders
• Petechiae, bleeding, and infection may occur in aplastic anemia because all blood cell lines can be reduced.

Diagnostic Investigations

1. Complete Blood Count: CBC

• Hemoglobin
• RBC count
• Hematocrit or PCV
• MCV
• MCH and MCHC
• White blood cell count
• Platelet count

2. Peripheral blood smear

• Microcytic hypochromic cells: iron deficiency
• Macro-ovalocytes and hypersegmented neutrophils: B12 or folate deficiency
• Sickle cells: sickle-cell disease
• Target cells: thalassemia
• Spherocytes: hemolytic anemia

3. Reticulocyte count

• High reticulocyte count: blood loss or hemolysis, indicating marrow response.
• Low reticulocyte count: decreased RBC production, such as nutritional deficiency or marrow failure.

4. Iron studies

5. Other tests

• Serum vitamin B12 level
• Serum folate level
• Stool examination for occult blood and worms
• Stool test or other evaluation for GI bleeding
• Bone marrow examination, when indicated
• Hemoglobin electrophoresis for thalassemia or sickle-cell disease
• Renal function tests
• Tests for malaria where clinically suspected

Types of Anemia

1. Iron-Deficiency Anemia

Definition

Causes

• Poor iron intake
• Heavy menstrual bleeding
• Pregnancy
• Repeated childbirth or short interval between pregnancies
• Chronic blood loss from gastrointestinal tract
• Hookworm infestation
• Malabsorption
• Increased requirement during childhood and adolescence

Clinical features

• Pallor, fatigue, weakness
• Breathlessness and palpitations
• Koilonychia
• Brittle hair and nails
• Glossitis and angular stomatitis
• Pica: craving for non-food items such as clay, chalk, or ice

Diagnosis

• Low Hb
• Low MCV and MCHC
• Microcytic hypochromic RBCs on smear
• Low serum ferritin and serum iron
• Raised TIBC

Management

• Find and treat the cause of blood loss.
• Provide iron-rich diet.
• Give prescribed oral or intravenous iron preparations.
• Treat hookworm and infections when present.
• Treat severe anemia urgently as per medical order, possibly including blood transfusion.

2. Megaloblastic Anemia

Definition

Features

• Weakness, pallor, glossitis
• Macrocytosis
• Macro-ovalocytes
• Hypersegmented neutrophils
• May cause leukopenia and thrombocytopenia in severe cases

Vitamin B12 Deficiency

• Poor dietary intake, especially strict vegan diet without supplementation
• Pernicious anemia due to lack of intrinsic factor
• Malabsorption
• Gastric surgery
• Ileal disease or resection

• Tingling and numbness of hands and feet
• Reduced vibration and position sensation
• Difficulty in walking
• Memory or mood changes

Folate Deficiency

• Poor nutrition
• Alcohol use
• Pregnancy
• Malabsorption
• Certain drugs

3. Hemolytic Anemia

Definition

Causes

• Hereditary: sickle-cell disease, thalassemia, G6PD deficiency, hereditary spherocytosis
• Acquired: malaria, autoimmune disease, incompatible blood transfusion, drugs, burns

Features

• Pallor and fatigue
• Jaundice due to increased bilirubin
• Dark urine in some conditions
• Splenomegaly
• Raised reticulocyte count

Management

• Treat the underlying cause.
• Folic acid supplementation may be prescribed.
• Blood transfusion may be required.
• Disease-specific therapy is needed for sickle-cell disease, malaria, autoimmune hemolysis, etc.

4. Aplastic Anemia

Definition

Causes

• Often idiopathic
• Drugs and chemotherapy
• Radiation
• Toxic chemicals such as benzene
• Viral infections
• Autoimmune marrow suppression
• Inherited disorders

Features

• Anemia: pallor, fatigue, dyspnea
• Neutropenia: recurrent infection and fever
• Thrombocytopenia: bruising, petechiae, gum bleeding, epistaxis

Management

• Remove the causative agent, if known.
• Infection prevention and prompt treatment.
• Blood and platelet transfusion when indicated.
• Immunosuppressive therapy or hematopoietic stem-cell transplantation according to specialist advice.

5. Anemia of Chronic Disease / Chronic Inflammation

Mechanism

Laboratory pattern

• Low serum iron
• Low or normal TIBC
• Normal or raised ferritin, unlike iron-deficiency anemia

6. Sickle-Cell Anemia

Features

• Chronic hemolytic anemia
• Painful vaso-occlusive crises
• Jaundice
• Recurrent infection
• Splenic and organ complications

Basic management

• Adequate hydration
• Oxygen if needed
• Pain management
• Infection prevention and vaccination
• Folic acid
• Specialist-directed therapy and transfusion in selected situations

7. Thalassemia

Features

• Microcytic anemia
• Pallor and weakness
• Bone deformities and enlarged spleen in severe disease
• Growth retardation in severe cases

Management

• Regular transfusion in severe thalassemia
• Iron chelation in patients receiving repeated transfusions
• Folic acid supplementation where prescribed
• Genetic counseling

Iron should not be given automatically to every microcytic anemia patient. Thalassemia should be considered, and iron deficiency should be confirmed.

Treatment Principles of Anemia

1. Identify and treat the cause.
2. Correct nutritional deficiencies:
   • Iron for proven iron deficiency
   • Vitamin B12 for B12 deficiency
   • Folic acid for folate deficiency
3. Control blood loss.
4. Treat infections, hookworm, malaria, renal disease, or chronic disease.
5. Use erythropoiesis-stimulating agents in selected conditions, such as chronic kidney disease, under medical supervision.
6. Give blood transfusion only when clinically indicated.
7. Refer patients with severe, unexplained, hereditary, aplastic, or hemolytic anemia.

Nursing Management of a Patient with Anemia

Assessment

• Assess fatigue, weakness, dizziness, dyspnea, palpitations, and chest pain.
• Observe pallor, tachycardia, jaundice, bruising, and bleeding.
• Monitor vital signs, especially pulse, respiratory rate, blood pressure, and oxygen saturation if indicated.
• Review menstrual history, dietary pattern, pregnancy, drugs, stool color, bleeding, and history of chronic illness.
• Monitor Hb, hematocrit, RBC indices, reticulocyte count, and prescribed investigations.

Nursing interventions

• Provide adequate rest and cluster nursing activities to reduce fatigue.
• Assist with activities of daily living if weakness is severe.
• Encourage gradual activity as tolerated.
• Provide a balanced iron-, protein-, folate-, and B12-rich diet.
• Administer prescribed hematinics correctly.
• Monitor response to therapy through symptoms and laboratory values.
• Prevent falls in patients with dizziness.
• Observe for cardiac overload, especially in severe anemia or during transfusion.
• Maintain infection-prevention measures in aplastic anemia or neutropenia.
• Monitor bleeding in thrombocytopenic patients.

Health education

• Take iron, folate, and B12 supplements exactly as prescribed.
• Do not stop iron just because stools become dark. Dark stools are common with oral iron.
• Oral iron can cause nausea, constipation, abdominal discomfort, and dark stools.
• Keep iron medicines away from children because overdose can be dangerous.
• Take dietary iron with vitamin C-rich foods if advised.
• Avoid tea or coffee near iron intake because they can reduce absorption.
• Seek urgent care for black stool, vomiting blood, severe breathlessness, chest pain, fainting, high fever, or unusual bleeding.

Prevention of Anemia

• Eat a balanced diet containing iron, folate, vitamin B12, and protein.
• Iron and folic acid supplementation during pregnancy as per national program or prescriber advice.
• Regular antenatal checkups.
• Deworming according to local public-health guidance.
• Prevention and early treatment of malaria in endemic regions.
• Early detection and treatment of heavy menstrual bleeding.
• Safe food practices and treatment of chronic infections.
• Genetic counseling for families affected by thalassemia or sickle-cell disease.

Short Exam Answer: Definition

Very Short Viva Questions

1. What is the commonest nutritional anemia?
   Iron-deficiency anemia.
2. What is the normal life span of an RBC?
   About 120 days.
3. What type of anemia is caused by iron deficiency?
   Microcytic hypochromic anemia.
4. Which vitamins cause megaloblastic anemia when deficient?
   Vitamin B12 and folic acid.
5. Which test indicates body iron stores?
   Serum ferritin.
6. What is pancytopenia?
   Decrease in RBCs, WBCs, and platelets.
7. Which anemia has neurological symptoms?
   Vitamin B12 deficiency anemia.
8. Which anemia is associated with jaundice and high reticulocyte count?
   Hemolytic anemia.

Epistaxis (Nosebleed)

Definition

Types of Epistaxis

1. Anterior epistaxis

• Bleeding arises from the front part of the nose.
• Most common type, especially in children and young adults.
• Usually mild and visible from one nostril.
• Often stops by direct pressure.

2. Posterior epistaxis

• Bleeding arises from deeper, posterior nasal vessels.
• More common in older people and those with hypertension or blood-thinning medicines.
• Blood may flow into the throat and may be swallowed.
• Usually heavier and requires urgent medical assessment.

Causes of Epistaxis

Local causes

• Nose picking, especially in children
• Trauma or blow to the nose
• Excessive nose blowing or sneezing
• Dry air, hot weather, or cold weather
• Upper respiratory tract infection, common cold, allergic rhinitis
• Foreign body in nose
• Deviated nasal septum
• Nasal polyps or tumor, rarely
• Nasal surgery
• Use of nasal sprays, especially if used incorrectly or excessively

Systemic causes

• Hypertension
• Bleeding disorders, such as hemophilia or thrombocytopenia
• Severe anemia or leukemia
• Liver disease
• Dengue or other illnesses causing low platelet count
• Drugs: aspirin, clopidogrel, warfarin, heparin, and other anticoagulants
• Alcohol misuse

In children, the most frequent cause is digital trauma, meaning nose picking. Scott-Brown's Otorhinolaryngology Head & Neck Surgery notes that most childhood episodes respond to simple compression.

Signs and Symptoms

• Blood coming from one or both nostrils
• Blood trickling into the throat
• Spitting or vomiting swallowed blood
• Anxiety and restlessness
• Dizziness, weakness, pallor, tachycardia, or fainting in severe blood loss

First Aid Management of Nosebleed

Steps

1. Keep the patient sitting upright.
2. Ask the patient to lean forward, not backward.
3. Ask them to breathe through the mouth.
4. Pinch the soft part of the nose, just above the nostrils, firmly with thumb and index finger.
5. Maintain continuous pressure for 10 to 15 minutes. Do not release the pressure repeatedly to check.
6. Apply a cold compress or ice pack wrapped in cloth over the bridge of the nose.
7. Ask the patient to spit out blood that enters the mouth. Do not swallow it.

Do not do these things

• Do not make the patient lie flat.
• Do not tilt the head backward because blood may enter the throat and be swallowed.
• Do not insert cotton, tissue, or sharp objects deep into the nose.
• Do not ask the patient to blow the nose while bleeding continues.

When to Seek Emergency Medical Help

• Bleeding does not stop after 10 to 15 minutes of correct pressure.
• Bleeding is heavy or recurrent.
• The patient feels faint, weak, dizzy, confused, or breathless.
• There is a severe injury to the face or head.
• Blood is flowing continuously into the throat.
• The patient is taking anticoagulants or has a bleeding disorder.
• The patient has very high blood pressure, severe anemia, low platelets, or a serious systemic illness.
• A child has a suspected foreign body in the nose.

Medical Management

• Suction and removal of clots
• Topical vasoconstrictor medicine
• Chemical cauterization, for example silver nitrate, for a visible bleeding point
• Electrical cautery
• Anterior nasal packing
• Posterior nasal packing for posterior epistaxis
• IV fluids or blood transfusion in severe blood loss
• Treatment of the underlying cause, such as hypertension, coagulopathy, infection, or anemia

Nursing Management

Assessment

• Assess amount and duration of bleeding.
• Check whether bleeding is anterior or blood is passing into throat.
• Assess vital signs: pulse, blood pressure, respiration, oxygen saturation.
• Observe for pallor, dizziness, shock, and signs of blood loss.
• Ask about trauma, nose picking, nasal medications, hypertension, fever, and use of anticoagulants.
• Check history of bleeding disorder, liver disease, anemia, or recurrent nosebleed.

Nursing Interventions

• Keep the patient calm and in a sitting, forward-leaning position.
• Apply and maintain direct pressure to the soft nose.
• Provide kidney tray or bowl for blood and tissues.
• Apply cold compress as prescribed.
• Monitor vital signs and level of consciousness.
• Record estimated blood loss and duration of bleeding.
• Prepare equipment for nasal packing if ordered.
• If nasal packing is in place, observe for breathing difficulty, pain, continued bleeding, infection, and displacement of packing.
• Maintain oral hygiene because mouth breathing causes dryness.
• Administer prescribed analgesics, antibiotics, antihypertensives, or IV fluids.
• Teach the patient precautions to prevent rebleeding.

Health Education After a Nosebleed

• Avoid nose blowing and nose picking.
• Avoid strenuous exercise and heavy lifting.
• Avoid hot drinks, alcohol, and smoking.
• Avoid bending forward for a long time.
• Sneeze with the mouth open.
• Keep nails short in children.
• Use saline nasal spray or a small amount of moisturizing nasal ointment only if prescribed for dry nasal mucosa.
• Take blood-thinning medicines only as advised by the prescriber. Do not stop anticoagulants independently.

Short Exam Answer

Viva Questions

1. What is epistaxis?
   Bleeding from the nose.
2. Which area is the most common site of anterior epistaxis?
   Little’s area or Kiesselbach’s plexus.
3. What is the correct position during a nosebleed?
   Sitting upright and leaning forward.
4. For how long should the soft nose be pinched?
   Continuously for 10 to 15 minutes.
5. Why should the head not be tilted backward?
   Blood may flow into the throat, be swallowed, and cause vomiting or aspiration.
6. Which medicines can increase risk of epistaxis?
   Aspirin, clopidogrel, warfarin, heparin, and other anticoagulants.

Epistaxis (Nosebleed)

1. Definition

2. Etiology / Causes

A. Local causes

• Nose picking, especially in children
• Trauma to nose or facial injury
• Forceful nose blowing or repeated sneezing
• Dry and irritated nasal mucosa due to dry weather, air-conditioning, or heating
• Upper respiratory tract infection, sinusitis, allergic rhinitis
• Deviated nasal septum
• Foreign body in nose
• Nasal surgery or nasal instrumentation
• Excessive or incorrect use of intranasal sprays
• Nasal polyps, hemangioma, or nasal tumor

B. Systemic causes / diseases

• Bleeding disorders: hemophilia, von Willebrand disease
• Thrombocytopenia, for example dengue, immune thrombocytopenia, leukemia
• Liver disease causing reduced clotting-factor production
• Renal failure, which can impair platelet function
• Severe anemia or hematological malignancy
• Hypertension may be present, although it is not always a direct cause
• Use of anticoagulant or antiplatelet drugs:
  • Warfarin
  • Heparin
  • Apixaban, rivaroxaban, etc.
  • Aspirin
  • Clopidogrel
• Alcohol misuse

Hypertension is commonly found during an acute nosebleed because pain, fear, and anxiety can temporarily raise blood pressure. It may make bleeding harder to control, but a direct cause-and-effect relationship is not always established.

3. Hormonal Causes

• Pregnancy: Increased blood volume, vascular congestion, and hormonal effects on nasal mucosa may cause nasal blockage and epistaxis.
• Puberty: Hormonal changes may contribute indirectly by increasing vascularity.
• Hormonal rhinitis: Nasal congestion and mucosal swelling associated with pregnancy or hormonal changes can make small nasal vessels more fragile.

4. Risk Factors

• Children with frequent nose picking
• Older adults
• Dry climate or winter season
• Recurrent upper respiratory infection or allergic rhinitis
• Hypertension or poorly controlled blood pressure
• Anticoagulant or antiplatelet therapy
• Bleeding disorders and low platelet count
• Liver disease, kidney disease, leukemia
• Alcohol use
• Recent nasal surgery or trauma
• Use of intranasal steroids without proper technique
• Previous episodes of epistaxis

5. Pathophysiology

1. Nasal mucosa has a rich blood supply and contains superficial, fragile blood vessels.
2. Minor trauma, dryness, inflammation, or systemic bleeding tendency damages the nasal mucosa.
3. A small vessel ruptures, commonly in Little's area on the anterior nasal septum.
4. Blood flows from one or both nostrils.
5. If bleeding is posterior, blood may flow backward into the pharynx and be swallowed.
6. Severe or prolonged bleeding can lead to:
   • Tachycardia
   • Hypotension
   • Pallor
   • Dizziness
   • Hypovolemic shock
   • Anemia

Types by site

6. Clinical Manifestations

• Bleeding from one or both nostrils
• Blood trickling into the throat
• Metallic taste in mouth
• Spitting blood or vomiting swallowed blood
• Anxiety and restlessness
• Nasal pain or blockage
• Pallor
• Tachycardia
• Dizziness, weakness, syncope
• Hypotension and shock in severe blood loss

7. Diagnostic Evaluation

History

• Onset, duration, frequency, and amount of bleeding
• Recent trauma, nose picking, cold, allergy, or surgery
• Drug history: aspirin, clopidogrel, warfarin, heparin, NSAIDs
• Personal or family history of bleeding disorder
• Hypertension, liver disease, renal disease, leukemia, dengue
• Previous similar episodes

Physical examination

• Check airway, breathing, circulation
• Measure pulse, respiratory rate, blood pressure, oxygen saturation
• Look for active bleeding point
• Assess whether blood is flowing into the throat
• Examine for trauma, foreign body, nasal mass, crusting, or septal abnormality
• Look for pallor, bruising, petechiae, and signs of shock

Investigations

• Complete blood count: Hb, WBC, platelet count
• Blood grouping and cross-matching if severe bleeding
• Prothrombin time, INR, aPTT
• Liver function tests
• Renal function tests
• Blood pressure monitoring
• Nasal endoscopy to find the bleeding site
• CT scan if trauma, tumor, or sinus disease is suspected

8. Management

Immediate First Aid Management

1. Reassure the patient and keep them calm.
2. Make the patient sit upright.
3. Ask the patient to lean forward slightly.
4. Tell the patient to breathe through the mouth.
5. Pinch the soft part of the nose firmly, just above the nostrils.
6. Maintain uninterrupted pressure for 10 to 15 minutes.
7. Apply an ice pack wrapped in cloth to the bridge of the nose.
8. Ask the patient to spit out blood entering the mouth. Do not swallow it.

Do not

• Do not tilt the head backward.
• Do not lie the patient flat.
• Do not blow the nose.
• Do not insert tissue, cotton, or fingers deep into the nostrils.
• Do not repeatedly release pressure to check for bleeding.

Urgent referral is needed when

• Bleeding continues after correct pressure for 15 to 20 minutes.
• Bleeding is profuse or posterior.
• There is severe facial or head trauma.
• The patient is pale, weak, dizzy, confused, hypotensive, or breathless.
• The patient has a bleeding disorder or uses anticoagulants.
• There is recurrent unexplained epistaxis or suspected nasal mass.

9. Medical Management

• Direct pressure and cold compress
• Suction to remove clots and allow visualization
• Topical vasoconstrictor, such as oxymetazoline, as prescribed
• Local anesthetic with vasoconstrictor, if required before cautery
• Chemical cautery using silver nitrate for a visible anterior bleeding point
• Topical antiseptic or moisturizing nasal preparation after bleeding stops, where prescribed
• Anterior nasal packing if cautery is unsuccessful or bleeding point is not visible
• Posterior nasal packing for posterior bleeding
• Intravenous fluids in significant blood loss
• Blood transfusion if severe blood loss causes hemodynamic instability or significant anemia
• Correction of underlying problem:
  • Treat thrombocytopenia or coagulopathy
  • Correct anticoagulation only under medical supervision
  • Manage uncontrolled hypertension
  • Treat rhinitis, infection, or nasal dryness

Do not stop aspirin, clopidogrel, warfarin, or other blood-thinning medication without the prescriber's advice.

10. Surgical Management

• Electrical cautery of the bleeding vessel
• Endoscopic cauterization
• Endoscopic sphenopalatine artery ligation, commonly used for uncontrolled posterior epistaxis
• Ligation of other supplying arteries in selected cases
• Arterial embolization by interventional radiology when surgery is unsuitable or unsuccessful
• Removal of nasal foreign body, polyp, or tumor if it is the cause

11. Nursing Management

Assessment

• Assess site, amount, color, and duration of bleeding.
• Check if blood is entering the throat.
• Monitor pulse, BP, respiratory rate, oxygen saturation, and consciousness.
• Assess pallor, dizziness, weakness, anxiety, and signs of hypovolemic shock.
• Ask about anticoagulant therapy, trauma, nasal sprays, hypertension, and bleeding disorders.
• Review laboratory results: Hb, platelets, coagulation profile.

Nursing Interventions

• Maintain sitting and forward-leaning position.
• Apply continuous pressure to the soft nose.
• Keep kidney tray, gauze, suction, and emergency equipment available.
• Apply cold compress.
• Encourage the patient to spit out blood rather than swallow it.
• Provide emotional support and reduce anxiety.
• Maintain airway and administer oxygen if prescribed.
• Establish IV access and prepare IV fluids or blood products if ordered.
• Assist the doctor during cautery, nasal packing, or endoscopy.
• Observe for continued bleeding, aspiration, nausea, vomiting, shock, or airway obstruction.
• If nasal packing is present:
  • Check that the pack remains in place.
  • Observe for bleeding around or through the pack.
  • Provide oral care because mouth breathing causes dryness.
  • Monitor for pain, fever, foul smell, or infection.
  • Give analgesics and antibiotics if prescribed.
• Document time of onset, estimated blood loss, interventions, vital signs, and response.

Patient Education

• Do not blow or pick the nose.
• Avoid heavy lifting, strenuous activity, bending down, smoking, alcohol, and hot drinks.
• Sneeze with mouth open.
• Keep fingernails short, especially in children.
• Avoid forceful nose blowing.
• Keep nasal mucosa moist with saline spray or prescribed ointment.
• Attend follow-up if nosebleeds recur.

12. Nursing Diagnoses

1. Risk for deficient fluid volume related to active blood loss.
2. Risk for ineffective airway clearance related to blood in the nasal cavity and pharynx.
3. Anxiety related to sudden bleeding and fear of blood loss.
4. Acute pain related to nasal trauma, pressure, cautery, or nasal packing.
5. Risk for infection related to nasal packing or damaged nasal mucosa.
6. Deficient knowledge related to lack of information about prevention of recurrent epistaxis.
7. Risk for injury related to dizziness, weakness, or syncope due to blood loss.

Short Exam Answer