Upload
lady350z
View
219
Download
0
Embed Size (px)
Citation preview
8/3/2019 Foreign Body in the Nose
1/32
MADAM MURNIWATIENTNUR 3354
8/3/2019 Foreign Body in the Nose
2/32
FAIRUZ BT JANI
ALEESZAH BT ABDULLAH
SITI AISHAHANIS BT SAID RAHMATKAMARULZAMAN B SIDEK
NOR HALIJAH BT AWANG
ATHIFATUL HASANAH MOHD NASIB
8/3/2019 Foreign Body in the Nose
3/32
8/3/2019 Foreign Body in the Nose
4/32
Locations for nasalforeign bodies tolodge
anterior to the middleturbinate or below theinferior turbinate.
Unilateral foreign bodiesaffect the right side
about twice as oftencompared to the left.(due to a right-handedindividuals to insertobjects in their right
naris.)
8/3/2019 Foreign Body in the Nose
5/32
Nasal foreign bodies (NFBs) can occurfrequently in the pediatric setting andadults, especially those with mental
retardation or psychiatric illness.Children's interests to lodging foreign
bodies in their nasal cavities.
8/3/2019 Foreign Body in the Nose
6/32
Nasal foreign bodies - cause damage to thenasal cavity and surrounding structures.
They can produce local inflammation may result pressure necrosis - can causemucosal ulceration and erosion into bloodvessels producing epistaxis.
The swelling - obstruction to sinusdrainage and lead to a secondary sinusitis
difficulty breathing
Button batteries, magnets, and living
foreign bodies can be destructive
8/3/2019 Foreign Body in the Nose
7/32
8/3/2019 Foreign Body in the Nose
8/32
Difficulty breathing through theaffected nostril
Feeling of something in the nose
Foul-smelling
Bloody nasal discharge
Irritability, particularly in infants Irritation or pain in the nose
8/3/2019 Foreign Body in the Nose
9/32
Inorganic materialsplastic or metal common from beads and small
parts from toys.These materials are often asymptomatic and
may be discovered incidentally. Organic foreign bodies
food, rubber, wood, and spongebe more irritating to the nasal mucosa and may
produce earlier symptoms.
8/3/2019 Foreign Body in the Nose
10/32
Medical history
Physical examination.
A special lighted instrument - to lookinside the nostrils
8/3/2019 Foreign Body in the Nose
11/32
Difficulty breathing r/t foreign body inthe nose
Goal to improve the patientbreathing pattern
InterventionsAssess patient level of breathing for nursing
care plan.Advice patient to breathing through mouth to
avoid object in further.Place patient in fowlers position to easy
breathing.Avoid blowing nose too hard or repeatedly to
prevent any injury.Evaluation
8/3/2019 Foreign Body in the Nose
12/32
Self uncomfortability r/t Foul-smelling
Goal - to increase patient comfortablewith self InterventionsAssess patient nose conditions like swelling
for nursing care plan.Strictly patient about important of hygieneand handwashing before and after touchnose to prevent infection.
Advice patient to not rub the nose.
Perform good environment to preventinfections.
Advice patient to wear mask to avoid anyuncomfortable to others
EvaluationPatient will comfort and confident with
8/3/2019 Foreign Body in the Nose
13/32
Bloody nasal discharge r/t pressure ofmaterials inside
Goal decrease the amount of blood in nasaldischarge Interventions
Assess amount and color of blood for nursingplan.
Perform cold compress to stop the blood Advice patient to not rub the nose Advice patient to not wipe the discharge by
using unclean towel. Advice patient to not try remove object that
cannot see or not easy to grasp.EvaluationsDecrease pressure given will decrease the amount
of blood that contain in nasal discharge
8/3/2019 Foreign Body in the Nose
14/32
Inflammation of nasal mucusmembranes.
Release of histamine and otherssubstances can cause vasodilation andedema occur as reactions to allergens(pollen,dust,mold or some food)
May be caused by viral (viral rhinitis)orbacterial infection
8/3/2019 Foreign Body in the Nose
15/32
Rhinitis divided into allergic and non-allergicrhinitis.
Allergic rhinitis
Non-allergic rhinitis, which can be subdividedinto : Infectious Drug-induced Gustatory Hormonal Occupational Vasomotor
Non-allergic rhinitis with eosinophilia syndrome(NARES)
8/3/2019 Foreign Body in the Nose
16/32
8/3/2019 Foreign Body in the Nose
17/32
Nasal congestion
Localized itching
SneezingNasal discharge
Fever or malaise
8/3/2019 Foreign Body in the Nose
18/32
Chronic rhinitis - inflammation or aninfection.Diseases such as tuberculosis, rhinoscleroma
rhinosporidiosis,leishmaniasis, blastomycosis,
histoplasmosis, and leprosyAllergic Rhinitis - caused by a reaction of
the body's immune system to anenvironmental trigger.
Include dust, molds, pollens, grasses, trees,and animals.Acute Viral Rhinitis: Acute viral rhinitis (the
common cold) can be caused by a variety
of viruses.
8/3/2019 Foreign Body in the Nose
19/32
Skin test. To find out whether symptoms might be caused by a certain
allergen.
Blood test. A blood test to measure immune system's response to common
allergens by measuring the amount of certain antibodies inbloodstreem.
Nasal endoscopy. This test to examine at the inside of nasal passages. This is done
with a thin, fiber-optic viewing instrument called an endoscope.
Computerized tomography (CT) scan. This procedure is a computerized X-ray technique that produces
images of sinuses.
8/3/2019 Foreign Body in the Nose
20/32
Acute pain r/t disease process goal- to decrease patient level of pain and
increase the ability of sleep Interventions
Assess for cause of discomfort,muscles aches,fever fornursing care plan Encourage patient to rest Administer acetaminophen or other analgesics or
antipyretics as doctor order
Administer throat lozenges or salt-water gargles asordered by doctors.EvaluationPatient level of pain decrease and can sleep well
8/3/2019 Foreign Body in the Nose
21/32
Hyperthermia r/t infections Goal to decrease the patient temperature
and no sign and symptoms of dehydration. Interventions
Monitor temperature daily every 4hours ifpatient having fever
Monitor for sign of dehydration such as dryskin,mucus membrane,thirst and weakness.
Advice patient to increase the amount of fluid totreat dehydration.
Administer acetaminophen or other analgesicsor antipyretics as doctor order
Evaluations
Fever controlled in safe levels and patient wellhydrated.
8/3/2019 Foreign Body in the Nose
22/32
Risk for infection r/t poor hygiene Goal to reduce risk of infections
Interventions Assess patient understanding of infections. Advice patient to do handwashing before and
after touch the nose
Advice patient to do hygiene care for reduceinfections Advice patient to covering mouth and nose
when sneezing and coughing Use clean towel to cover the mouth. Perform good environment
Evaluations Risk for infections decrese by evidence patient
follow the nursing interventions well
8/3/2019 Foreign Body in the Nose
23/32
A deviated septum occurs when thethin wall (nasal septum) inside nose isdisplaced to one side. The septum
separates the right and left nasalcavities.
The nasal septum is displaced, making
one nasal passage smaller. If become severe,can block one side of
nose and reduce airflow.
8/3/2019 Foreign Body in the Nose
24/32
8/3/2019 Foreign Body in the Nose
25/32
Obstruction of one or both nostrils - difficult tobreathe through the nostril.
When having a cold (upper respiratory tractinfection) or allergies that cause nasal passagesto swell and narrow.
Nasal congestion - Postnasal drip occurs whenmucus is blocked from flowing out of nose, causingit to drip into and linger in the back of throat.
Nosebleeds -The surface of nasal septumbecome dry, increasing risk of nosebleeds.
Frequent or recurring sinus infections - resultfrom blocked mucus and are often marked byfacial pain and headaches.
Noisy breathing during sleep -This is more
8/3/2019 Foreign Body in the Nose
26/32
8/3/2019 Foreign Body in the Nose
27/32
A condition present at birth.Deviated septum occurs during fetal
development and is apparent at birth.
Injury to the noseCan causes the nasal septum to be knockedout of position.
In infants - injury may occur during the labor
process. In children and adults
accidents may lead to a nose injury and deviatedseptum
from tripping on a step to colliding with another
person on the sidewalk
8/3/2019 Foreign Body in the Nose
28/32
Physical examinationnosebleeds or nasal and ask about had any
trauma to patient nose.
Use bright light and an instrument (nasalspeculum) to spread open nostrils thatexamine by doctor - to diagnose deviatedseptum and determine the seriousness ofcondition.
Refer to an ear, nose and throat specialist(otolaryngologist).
8/3/2019 Foreign Body in the Nose
29/32
Risk for infections r/t blocked mucus Goal to decrease the risk of infections Interventions
Assess patient conditions for nursing care plan
Strictly patient about handwashing before and aftertouch the nose Advice patient about the hygiene care to prevent from
infections. Advice patient to rest in bed because block mucus can
cause headache.
EvaluationRisk for infections have decrease.
8/3/2019 Foreign Body in the Nose
30/32
Sleep disturbance r/t obstructionof airway(breathing)
Goal increase patient ability andcomfort while sleep at night
Interventions
Assess patient patern of sleep likehaving snorr and complain of patient fornursing care plan
Maintain patient in Fowlers position as
much as possibles.Encourage patient to breathing through
mouth.
Evaluation
Patient feel comfort when sleeping
8/3/2019 Foreign Body in the Nose
31/32
Nosebleeds r/t dryness of nasal septum Goal to decrease the amount of bleeding
Interventions Assess patient amount of bleeding and color of blood
and any absent of swelling or bruising for nursing careplan.
Apply ice compress to reduces swelling
Maintain patient in Fowlers position Advice patient to avoid anything that can increase
pressure and bleeding such as sneezing or coughing. Promote good environment.
EvaluationAmount of bleeding decrease caused by nursing
interventions
8/3/2019 Foreign Body in the Nose
32/32
http://www.healthopedia.com/foreign-body-in-nose
http://www.mayoclinic.comWalsh.Crumbie,2007,Clinical Nursing and
Related Science(7th Edition), Philadelphia,Elsevier
Williams.Hopper,2003,UnderstandingMedical Surgical Nursing (3rd Edition),Philadelphia,I Group Press CO.Ltd
http://www.merckmanuals.com
http://www wrongdiagnosis com/r/rhinitis