Epistaxis clinical pathway

Timeline ED Day 1 Day 2 Day 3 Outcomes

Consults o Primary care physician o Patient re- Patient re-evaluated Patient re- Follow up
o Otolaryngologist evaluated by by primary and evaluated by appointments are
o IM/Nephrologist if BP primary and previously involved primary and given by primary
uncontrolled previously involved specialties previously involved and previously
o Cardiologist/Neurologist specialties specialties involved specialties
if patient taking
anticoagulant and is
having coagulopathy
Assessment and o H&P o Patient is admitted o Monitor vitals o Monitor vitals o no active
Intervention o BP if bilateral packing o Assessment for o Assessment for epistaxis
o IV lines was done in ED or active epistaxis active epistaxis
o Ice packs bleeding persisted o Removal of nasal o (sodium
o Digital nasal o Monitor vitals packing fusidate
compression o Assessment for ointment)
o Chemical cauterization active epistaxis
o Nasal Packing
Medications o Antibiotic o Antibiotic o Topical o Topical o Topical
o Pain killer o Pain killer decongestant decongestant decongestant
o Fluid replacement as o Fluid replacement (xylometazoline) (xylometazoline) (xylometazoline)
needed as needed o Local nasal Local nasal Local nasal
o Topical decongestant o Topical lubrication lubrication (sodium lubrication (sodium
(xylometazoline) decongestant (sodium fusidate fusidate ointment) fusidate ointment)
(xylometazoline) ointment)
Activity o Rest, setting up, leaning No limitation No limitation No limitation No limitation
forward

Tests o CBC (Hemoglobin) o CBC (Hemoglobin) o CBC o CBC Diagnostic studies

o Coagulation profile Coagulation profile (Hemoglobin) (Hemoglobin) within normal for
Coagulation profile Coagulation profile this patient
Education o Patient and/or family Reinforcement of the Reinforcement of the Reinforcement of Able to verbalize
educated about the condition and condition and the condition and actions in case of
causes, management management plan management plan management plan recurrent bleeding
plan
Discharge o Able if epistaxis stopped o Able if epistaxis Able if epistaxis Able if epistaxis Able to verbalize
spontaneously with stopped and nasal stopped and nasal stopped and nasal discharge plan
simple techniques, like pack removed, pack removed, pack removed,
applying cold packs, normal BP and normal BP and normal BP and
digital compression, coagulation profile coagulation profile coagulation profile
cauterization or
unilateral nasal packing
with OPD follow up
Appointment
 Clinical pathway for Tonsillectomy and Adenoidectomy
Pre-Operative 1-2 hour pre- Post-Op 30-60 Post-operative 3-4 Outcomes
operative minutes hours
Assessment / o H&P o Preoperative RN o observe for initial o observe for o Vital Signs stable
Evaluation o Consents are assessment bleeding bleeding and within normal
signed o Parent confirms o Vital signs Q15 o Vital signs Q1 limits
o Baseline vital signs procedure, min x 4 with hour x2 o Nausea/vomiting
nothing by assessment absent within 2hrs
mouth. o No nasal or oral
ooze
o Patient
ambulating,
tolerates activity
o Fluid intake
adequate for
weight
o IV discontinued

Investigations o Routine labs o All results Specimens are sent - -

o Viral markers received to lab
o ESR & CRP
o Blood grouping
Blood Reservation Arranged All available Needed/not needed - -

Consults o Nursing asessmemt o Nursing o Nursing o Nursing o OPD follow up

o ORL surgeon asessmemt asessmemt asessmemt appointment with
assessment o ORL surgeon o ORL surgeon o ORL surgeon ORL-HNS
o Anesthesist assessment assessment assessment
assessment o Anesthesist o Anesthesist o Other
assessment assessment specialities
follow up
Medication o Check for allergies Anesthetic agent Pain control and Pain control and Pain control and
antiemetic as antiemetic as antiemetic as needed
needed needed
 o Check for
appropriate
identification band

Diet NPO nothing per oral nothing per oral NPO until awake and Patient/guardian able
(NPO) (NPO) alert then begin to verbalize diet
clear fluid, proceed instructions
to Soft cold diet
gradually as
tolerated
Activity - Bed rest Bed rest, positioned begin raising head of Patient can resume
in lateral recumbent bed; to parents’ lap normal activity
position as tolerated; then up
to chair as tolerated

Education o Diagnosis and Procedure and Stir up regimen o Review Patient/guardian able
management preoperative process begins (deep breath, discharge diet to verbalize discharge
o Post operative are explained to the wake up, orient to instructions plan, diet at home,
expectations parents surroundings) o Review signs OPD appointments,
o Diet at home /symptoms of and when to seek
bleeding medical help
o instructions for
treatment of
nausea and
vomiting
o Pain
management
Teaching