Nasal Packing

Definition

Nasal packing is gauze, foam, or cotton that has been packed into the nasal chambers. The term nasal packing may refer to individual gauze strips or cotton pledgets that are packed as they are inserted into the nose to form a plug or may refer to a preshaped pack of foam, gauze, or cotton that is inserted into the nose as a unit. Nasal packing may be coated with petrolatum, antibiotics, or agents that aid in clot formation. Some types of nasal packing have tails made of sutures or ties, which remain outside the nose to assist in repositioning or removing the nasal packing. Preformed nasal packs may include small tubes in the center of the pack to allow some air exchange while the packing is in place.

Purpose

Nasal packing is inserted into the nose by a physician to control severe nosebleeds. The purpose of the packing is to apply direct pressure onto the blood vessels located in the nasal membranes. Nasal packing may be used after nasal surgery to provide support to the nasal septum, control bleeding, and absorb drainage.

Precautions

Nasal packing prevents air exchange through the nose. If both sides of the nose are packed, the client must breathe through his mouth while the packs are in place. Clients with nasal packing should be placed with the head of the bed elevated 30 degrees and observed for respiratory distress. Continued bleeding may not be apparent on the external end of nasal packing. Check the posterior oropharynx area regularly to see if blood is trickling into the back of the throat. Nasal packing can slip back or out with movement or sneezing. Check the positioning of the nasal pack routinely both at the external opening of the nose and by examining the oropharynx.

Description

When assisting the physician with nasal packing insertion, tilt the client back into a semi-reclining position to allow visualization into the nose. Monitor the client's respiratory status and anxiety during the procedure. Assist them to keep their hands down out of the way during the procedure if necessary. Assist the physician with positioning of the client, the light, suction, and the instruments as instructed.

Local packing is a procedure used when only a small part of the nose must be packed. Typically, this occurs when one blood vessel is prone to bleeding, and there is no need to block breathing through the nose. Local packing is used when the pack can remain in place by itself. This situation can be found at the turbinates. Turbinates are folds of tissue on the insides of the nose. The folds are sufficiently firm to support packing. A small piece of gauze or cotton is wedged in between the turbinates where the blood vessel being treated is located. Local packing is left in place for up to 48 hours and then removed. The main advantage to this type of packing is that it enables the patient to breathe through his or her nose. Local packing is also more comfortable than complete packing, although the patient will still experience a sensation that something is in the nasal cavity.

A postnasal pack is used to treat bleeding in the postnasal area. This is a difficult area to pack. Packs used in this area are preformed or made from cotton balls or gauze that have been tied into a tubular shape with heavy gauge suture or umbilical tape. Long lengths of suture or tape are left free. The lengths of suture or tape are used to help position the pack during installation and to remove it. After being tied, the pack is soaked with an antibiotic ointment. Generally, packs are formed larger than needed, so that they completely block the nasal passage. A catheter is passed through the nose and pulled out through the mouth. Strings from one end of the pack are tied to the catheter and the pack is pulled into place by passing through the mouth and up the back of the nasal cavity. The pack is removed in a similar manner. The end of the nose may be taped to keep the packing in place or to prevent the patient from pulling it out. More often a gauze 4×4 is folded and taped across the entrance to the nose to collect excess drainage and remind the client not to interfere with or probe the packing while it is in place.

In patients who are chronic nose pickers, frequent bleeding is common and ulceration of nasal tissue is possible. To promote healing and to prevent nose picking, both sides of the nose are packed with cotton that contains antibiotics. The nose is taped shut with surgical tape to prevent the packing from being removed. The packing is left in the nose for seven to10 days. If the wound is high up in the nasal cavity, gauze strips treated with petrolatum and antibiotics are used. The strips are placed into the nose one layer at a time, folding one layer on top of the other until the area is completely packed.

Modern preformed nasal packs are lubricated with water-soluble lubricant and easily inserted as a unit in a compressed state. They are moistened after insertion by squirting them with saline or nasal medication, which causes them to expand to fill the nose. Newer polymer nasal packs are designed with a nonstick coating and absorbent core to enhance absorption but avoid re-opening the vessels when the pack is removed.

Preparation

When nasal packing is to be inserted in the clinic or emergency room setting, the nurse should wash the hands and put on gloves and a disposable gown. The client should be placed in a sitting position with the nose tilted forward and slightly upward until the physician is ready to insert the packing. The patient should be given 4×4 gauze pads or a washcloth to hold below the nose to catch the blood with one hand, and he or she should apply pressure to the bridge of the nose with the thumb and forefinger of the other hand, while the nurse prepares the equipment. A drape or towel should be placed around the client's neck and shoulders. The nurse should prepare an instrument tray, which includes nasal speculum, hands free light, flash light, nasal packing material, nasal instruments, tongue blades, suction apparatus, sterile saline, lubricant, and medications as requested by the physician. The nurse should explain the procedure to the client, instructing him or her to keep the hands down during the procedure and breathe through the mouth. The patient may feel discomfort while the nose is being packed such as a feeling of congestion or pressure. If he or she has to sneeze, the patient should warn the staff and to sneeze with the mouth open. Medical personnel should wear gowns, gloves, masks and goggles during the insertion of nasal packing because of the potential for blood spraying if the client sneezes.

Aftercare

The patient should be placed in a semi-reclining position with the head elevated at least 30 degrees and should be allowed to rest. Old blood on the face, neck, and hands should be cleaned away with a warm wet wash cloth, and the soiled linens discarded in a contaminated linen bag. Instruments should be handled according to the contaminated instrument policy of the medical setting. Soiled gowns, gloves, gauze 4×4s, and disposable equipment should be placed in a trash bag that can be sealed and discarded. The nurse should wash the hands again.

The staff should check the nasal drip pad and the oropharynx for bleeding every 15-30 minutes, and notify the physician if the patient drains through four drip pads in an hour or if frank bleeding is observed in the oropharynx. Mouth breathing will cause the patient to have a dry mouth. The patient should be offered ice chips or mouthwash to moisten the mouth. The use of a room humidifier will also help keep the mouth moist. The patient should sneeze with their mouth open to avoid increased pressure in the nose. He or she should not "snuff" drainage in their throat, but spit secretions out into a basin or the sink rather than swallow them. The patient should have tissues on hand for secretions and/or sneezing, and be monitored for respiratory distress, especially for the first hour after packing and during sleep. The patient should know that analgesics can be given if they experience a headache after the procedure. The nurse should monitor the patient for nausea or vomiting of old or fresh blood and warn the client to avoid spicy food and smoking while the packing is in place. The patient may smell a foul odor as the nasal pack ages over the next 48 hours. He or she may also develop bruising or swelling of the eyelids secondary to nasal packing. The patient should not pick at the packing or rub the nose while the packing is in place.

KEY TERMS

Asphyxiation— Smothering. A severe decrease in oxygen concentration in the body, leading to death.

Cautery— Intentional destruction of tissue cells to remove abnormal tissue or form a scar to stop bleeding. Cautery is performed with chemical agents, laser instruments or electrical instruments that burn the tissue.

Oropharynx— An area of the throat visible through the open mouth located between the epiglottis and the soft palate.

Pledget— A small compressed cotton pad that is flat and absorbent.

Turbinate— Ridgeshaped cartilage or soft bony tissue inside the nose.

Ulcer— A sore on the skin or mucous tissue that produces pus and in which tissue is destroyed.

Complications

Because of the complications of using nasal packing, physicians will attempt other methods to control nasal bleeding, such as external pressure, cold packs, cautery or topical medicine application before the use of nasal packing. The most common complication of nasal packing is that the removal of the packing dislodges healing tissue and causes the nose to bleed again. Nasal packing can cause a lack of oxygen in those who have difficulty breathing through their mouths such as elderly clients or those with chronic obstructive pulmonary disease (COPD). Nasal packing can lead to a drop in the blood oxygen content and an increase in blood carbon dioxide levels (CO2). This, in turn, can cause respiratory and cardiac complications, including a racing pulse. Airway obstruction and asphyxiation can occur if the nasal packing slips back into the airway, particularly during sleep. Complications may occur if a pack compresses the eustachian tube, causing ear problems. Infections can develop in the nose, sinus or middle ear after nasal packing insertion. These infections are not common but can lead to septic shock.

Results

Nasal packing is usually an effective method to stop nasal bleeding. In cases of nasal surgery, packing is frequently removed within 24-48 hours following surgery. In the case of nosebleeds, packing may be left in for extended periods of time to promote healing and to prevent the patient from removing scar tissue which might reopen the wound.

Health care team roles

Nasal packing is inserted by a physician. A licensed nurse will routinely assess a client with nasal packing for signs of bleeding, respiratory distress, or infection while they are in the health care setting. Nasal packing is usually removed by the physician but may be removed by a licensed nurse as ordered by the physician. Clients and care providers can be instructed in the care of a client with nasal packing in the home setting but the client must return to the health care setting for removal of the nasal packing.

Resources

BOOKS

Bluestone, C. D., S. E. Stool, and M. A. Kenna. Pediatric Otolaryngology. Philadelphia: W.B. Saunders Company, 1996.

Cohen, M., and R.M. Goldwyn. Mastery of Plastic and Reconstructive Surgery. Boston: Little, Brown and Company, 1994.

Schuller, D.E., and A.J. Schleuning II. DeWeese and Saunder's Otolaryngology-Head and Neck Surgery. St. Louis: Mosby, 1994.

OTHER

Graber, Mark, M.D., and Laura, Beaty, M.D. "Otolaryngology: Nose." University of Iowa Family Practice Handbook. Virtual Hospital Online, July 1999. 〈http://www.vh.org/Providers/ClinRef/FPHandbook/Chapter19/03-19.html〉.

Moses, Scott, M.D. "Epistaxis." Family Practice Notebook Online, March 2001. 〈http://www.fpnotebook.com/ENT171.htm〉.

PACU A/P Septoplasty Protocol. Department of Nursing. UNC Hospitals Online, May 2000. 〈http://www.med.unc.edu/nursing/manuals/protocol/SEPTOPLA.pdf〉.

Shippert, Ron, M.D. "The History of Nasal Packing." Shippert Library Online, November 2000. 〈http://www.shippertmedical.com/〉.