Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide

Sinus infections Nosebleeds

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o Problems breathing through the nose o Medications used in the nose o Changes in the sense of smell o Previous injuries to the nose • Assess the external nose. o Normal: Color similar to the rest of the face, symmetrical, and no discharge; no flaring of nostrils, no lesions, and no tenderness with palpation o Deviations from normal: Redness or blueness, asymmetrical or crooked, discharge, flaring of nostrils, lesions, and tenderness with palpation • Assess air flow through the nostrils: Have the patient close his mouth, occlude one nostril and breathe through the other nostril. Repeat for the other side. o Normal: Air moves freely through each nostril o Deviations from normal: Air movement is restricted through one or both nostrils • Assess the nasal cavities using a nasal speculum: Facing the seated client, have the patient tip his head back. Insert the closed nasal speculum into the nostril, avoiding pressure on the nasal septum. Open the speculum and inspect the entire nasal cavity. o Normal: Pink mucosa, clear drainage (if any is present), no lesions, and nasal septum (between the nostrils) is intact andmidline o Deviations from normal: Red or swollen mucosa, purulent or bloody drainage, lesions, and nasal septum (between the nostrils) deviated to one side • Assess the frontal sinuses: Tap gently on each cheekbone. o Normal: No tenderness o Deviations from normal: Tenderness Evaluation It’s important to compare all the findings with previous findings to determine if there are changes to any abnormal nose or sinus findings. Record and report any significant deviations from the normal. 2.7 Mouth/Throat Since the patient's head must be still during the exam, the room should have a bed for the patient to lie on or a chair with a headrest to support the patient's head in one position. Equipment needed for the mouth and throat exam includes a tongue depressor, gauze pads, and a penlight. Information and abnormal findings provided by unlicensed personnel should be verified during this exam. Implementation • Wear gloves and any other appropriate infection control gear (mask, protective eyewear, gown, etc.).

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