N


N




3316


Nasal Irrigation


Definition: Enhancing nasal mucosa functioning using saline lavage


Activities:



• Consider contraindications prior to procedure (e.g., patients with facial trauma not fully healed and patients with neurologic or musculoskeletal problems that increase aspiration risk)


• Prepare irrigating solution, using premade packets or household ingredients


• Mix 1 teaspoon salt and ½ teaspoon baking soda with 1 pint lukewarm, potable water, adjusting salinity and temperature of solution according to institutional guidelines or patient preference, if necessary


• Use salt that does not contain iodine, anticaking agents, or preservatives to avoid irritation to the nasal mucosa (i.e., use kosher, canning, or pickling salt)


• Draw up solution using low positive pressure device (e.g., bulb syringe or spray bottle) or gravity-based pressure device (e.g., neti-pot or other commercial nasal saline rinse product)


• Position patient over sink or basin with head tilted downward and rotated so that one nostril is above the other


• Gently insert applicator tip or spout into uppermost nostril until a comfortable seal is formed while avoiding pressing tip or spout into the septum


• Instill approximately half of prepared solution into nostril


• Instruct patient to breathe normally through mouth


• Monitor evacuation of fluid return from lower nostril (e.g., amount, color, consistency)


• Repeat procedure in other nostril


• Adjust head position as needed to avoid the draining of solution into back of throat or ears


• Encourage patient to blow nose gently


• Irrigate nasal passages 1 to 3 times per day or as prescribed


• Cleanse irrigating device after each use


• Prepare fresh solution daily


• Discontinue if patient experiences pain, nosebleeds, or other problems


• Instruct patient on techniques for self-irrigation


• Administer nasal medication, if necessary


• Provide referral to health care provider


6th edition 2013



1450


Nausea Management


Definition: Prevention and alleviation of nausea


Activities:



• Encourage patient to monitor own nausea experience


• Encourage patient to learn strategies for managing own nausea


• Perform complete assessment of nausea, including frequency, duration, severity, and precipitating factors, using such tools as Self-Care Journal, Visual Analog Scales, Duke Descriptive Scales, and Rhodes Index of Nausea and Vomiting (INV) Form 2


• Observe for nonverbal cues of discomfort, especially for infants, children, and those unable to communicate effectively, such as individuals with Alzheimer’s disease


• Evaluate past experiences with nausea (e.g., pregnancy and car sickness)


• Obtain a complete pretreatment history


• Obtain dietary history containing the person’s likes, dislikes, and cultural food preferences


• Evaluate the impact of nausea experience on quality of life (e.g., appetite, activity, job performance, role responsibility, and sleep)


• Identify factors (e.g., medication and procedures) that may cause or contribute to nausea


• Ensure that effective antiemetic drugs are given to prevent nausea when possible (except for nausea related to pregnancy)


• Control environmental factors that may evoke nausea (e.g., aversive smells, sound, and unpleasant visual stimulation)


• Reduce or eliminate personal factors that precipitate or increase the nausea (anxiety, fear, fatigue, and lack of knowledge)


• Identify strategies that have been successful in relieving nausea


• Demonstrate acceptance of nausea and collaborate with the patient when selecting a nausea control strategy


• Consider the cultural influence on nausea response while implementing intervention


• Encourage patient not to tolerate nausea but to be assertive with health providers in obtaining pharmacological and nonpharmacological relief


• Teach the use of nonpharmacological techniques (e.g., biofeedback, hypnosis, relaxation, guided imagery, music therapy, distraction, acupressure) to manage nausea


• Encourage the use of nonpharmacological techniques before, during, and after chemotherapy, before nausea occurs or increases, and along with other nausea control measures


• Inform other health care professionals and family members of any nonpharmacological strategies being used by the nauseated person


• Promote adequate rest and sleep to facilitate nausea relief


• Use frequent oral hygiene to promote comfort, unless it stimulates nausea


• Encourage eating small amounts of food that are appealing to the nauseated person


• Instruct in high-carbohydrate and low low-fat food, as appropriate


• Give cold, clear liquid, odorless and colorless food, as appropriate


• Monitor recorded intake for nutritional content and calories


• Weigh regularly


• Provide information about the nausea, such as causes of the nausea and how long it will last


• Assist to seek and provide emotional support


• Monitor effects of nausea management throughout


3rd edition 2000



2620


Neurologic Monitoring


Definition: Collection and analysis of patient data to prevent or minimize neurologic complications


Activities:



• Monitor pupillary size, shape, symmetry, and reactivity


• Monitor level of consciousness


• Monitor level of orientation


• Monitor trend of Glasgow Coma Scale


• Monitor recent memory, attention span, past memory, mood, affect, and behaviors


• Monitor vital signs: temperature, blood pressure, pulse, and respirations


• Monitor respiratory status: ABG levels, pulse oximetry, depth, pattern, rate, and effort


• Monitor invasive hemodynamic parameters, as appropriate


• Monitor ICP and CPP


• Monitor corneal reflex


• Monitor cough and gag reflex


• Monitor muscle tone, motor movement, gait, and proprioception


• Monitor for pronator drift


• Monitor grip strength


• Monitor for tremor


• Monitor facial symmetry


• Monitor tongue protrusion


• Monitor for tracking response


• Monitor EOMs and gaze characteristics


• Monitor for visual disturbance: diplopia, nystagmus, visual-field cuts, blurred vision, and visual acuity


• Note complaint of headache


• Monitor speech characteristics: fluency, presence of aphasias, or word-finding difficulty


• Monitor response to stimuli: verbal, tactile, and noxious


• Monitor sharp/dull or hot/cold discrimination


• Monitor for paresthesia: numbness and tingling


• Monitor sense of smell


• Monitor sweating patterns


• Monitor Babinski response


• Monitor for Cushing response


• Monitor craniotomy/laminectomy dressing for drainage


• Monitor response to medications


• Consult with coworkers to confirm data, as appropriate


• Identify emerging patterns in data


• Increase frequency of neurological monitoring, as appropriate


• Avoid activities that increase intracranial pressure


• Space required nursing activities that increase intracranial pressure


• Notify physician of change in patient condition


• Institute emergency protocols, as needed

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Dec 3, 2016 | Posted by in NURSING | Comments Off on N

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