Deviated septum is a deflection of the normally straight nasal septum. Although up to 80% of the adult population may have septums that are slightly off center, the diagnosis of deviated septum is generally reserved for those that are severely shifted.¹ Trauma to the nose, either at birth or later in life, is the most common cause of deviated septum.² Deviation from midline can interfere with airflow and sinus drainage through the narrowed passageway. Symptoms vary depending on the degree of deviation. Minor septal deviations may be asymptomatic. Common manifestations of septal deviation include obstruction to nasal breathing, nasal congestion, frequent sinus infections and nosebleeds (epistaxis), and facial pain.

Medical management of deviated septum is focused on symptom control of nasal inflammation and congestion (see Table 27-2). For recurrent or severe symptoms, a nasal septoplasty is performed to reconstruct and properly align the deviated septum.

eNursing Care Plan 27-1 Patient With a Tracheostomy

Nursing Diagnosis*

Ineffective airway clearance related to presence of artificial airway and excessive mucus as evidenced by adventitious breath sounds, retained secretions, ineffective cough, dyspnea, and/or restlessness

Patient Goals

1. Demonstrates effective coughing and secretion clearance

2. Maintains normal breath sounds

Outcomes (NOC)	Interventions (NIC) and Rationales
Respiratory Status: Airway Patency • Respiratory rate _____ • Respiratory rhythm _____ • Depth of inspiration _____ • Ability to clear secretions _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range • Adventitious breath sounds _____ • Dyspnea at rest _____ • Accumulation of sputum _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Airway Management • Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds to evaluate airway status. • Remove secretions by encouraging coughing or by suctioning to clear airway. • Encourage slow deep breathing, turning, and coughing to assist in mobilizing secretions. • Position to alleviate dyspnea (e.g., head of bed elevated 30-40 degrees) to allow maximum lung expansion and a more forceful cough. • Monitor respiratory and oxygenation status to determine effectiveness of interventions. Artificial Airway Management • Provide 100% humidification of inspired gas/air because normal upper airway humidification not present. • Provide adequate systemic hydration via oral or intravenous fluid administration to liquefy secretions. • Tape a second tracheostomy tube (same type and size) and forceps to head of bed to replace tube to maintain airway in case of accidental decannulation. • Provide trachea care every 4 to 8 hours as appropriate: clean the inner cannula, clean and dry the area around the stoma, and change tracheostomy ties to maintain patency of the tracheostomy tube and reduce host pathogens. • Maintain inflation of endotracheal/tracheostomy cuff at 15-20 mm Hg during mechanical ventilation and during and after feeding to minimize pressure on trachea.

Outcomes (NOC)

Interventions (NIC) and Rationales

Respiratory Status: Airway Patency

• Respiratory rate _____

• Respiratory rhythm _____

• Depth of inspiration _____

• Ability to clear secretions _____

Measurement Scale

1 = Severe deviation from normal range

2 = Substantial deviation from normal range

3 = Moderate deviation from normal range

4 = Mild deviation from normal range

5 = No deviation from normal range

• Adventitious breath sounds _____

• Dyspnea at rest _____

• Accumulation of sputum _____

• Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds to evaluate airway status.

• Remove secretions by encouraging coughing or by suctioning to clear airway.

• Encourage slow deep breathing, turning, and coughing to assist in mobilizing secretions.

• Position to alleviate dyspnea (e.g., head of bed elevated 30-40 degrees) to allow maximum lung expansion and a more forceful cough.

• Monitor respiratory and oxygenation status to determine effectiveness of interventions.

Artificial Airway Management

• Provide 100% humidification of inspired gas/air because normal upper airway humidification not present.

• Provide adequate systemic hydration via oral or intravenous fluid administration to liquefy secretions.

• Tape a second tracheostomy tube (same type and size) and forceps to head of bed to replace tube to maintain airway in case of accidental decannulation.

• Provide trachea care every 4 to 8 hours as appropriate: clean the inner cannula, clean and dry the area around the stoma, and change tracheostomy ties to maintain patency of the tracheostomy tube and reduce host pathogens.

• Maintain inflation of endotracheal/tracheostomy cuff at 15-20 mm Hg during mechanical ventilation and during and after feeding to minimize pressure on trachea.

Nursing Diagnosis

Risk for aspiration related to presence of tracheostomy tube and impaired swallowing

Patient Goals

1. Demonstrates ability to swallow oral foods without aspiration

2. Uses protective measures to prevent aspiration

Outcomes (NOC)	Interventions (NIC) and Rationales
Aspiration Prevention • Identifies risk factors _____ • Positions self upright for eating and drinking _____ • Remains upright for 30 minutes after eating _____ • Selects foods according to swallowing ability _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Aspiration Precautions • Monitor level of consciousness, cough reflex, gag reflex, and swallowing ability. • Monitor pulmonary status to detect signs and symptoms of aspiration. • Position upright 90 degrees or as far as possible to prevent aspiration from esophagus. • Keep head of bed elevated 30 to 45 minutes after feeding to promote gastric emptying and prevent aspiration. • Keep tracheal cuff inflated to prevent aspiration of oral food and fluids. • Keep suction set-up available to remove secretions that could be aspirated. • Suction oropharynx and secretions from top of tube cuff before deflating cuff to prevent aspiration of upper airway secretions.
Swallowing Status • Handles oral secretions _____ • Ability to clear oral cavity _____ • Timely swallow reflex _____ • Swallow study findings _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Swallowing Therapy • Determine patient’s ability to focus attention on learning/performing eating and swallowing tasks to evaluate patient’s potential for oral intake. • Provide/monitor consistency of food/liquid based on findings of swallowing study to ease swallowing and minimize aspiration. • Assist patient to position head in forward flexion in preparation for swallowing. • Monitor for signs and symptoms of aspiration that indicate swallowing dysfunction. • Monitor body weight to determine need for enteral feedings to maintain nutrition.

Nursing Diagnosis

Impaired verbal communication related to use of cuffed artificial airway/tracheostomy tube as evidenced by inability to speak and signs of frustration

Patient Goal

Uses written and nonverbal techniques to effectively communicate with others

Outcomes (NOC)	Interventions (NIC) and Rationales
Communication • Use of written language _____ • Use of pictures and drawings _____ • Use of nonverbal language _____ • Exchanges messages accurately with others _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Communication Enhancement: Speech Deficit • Listen attentively because patient may be able to whisper or speak if cuff deflated. • Use picture board. • Use hand gestures. • Carry on one-way conversations to prevent isolation of the patient. Teaching: Disease Process • Provide information to patient about condition. • Provide reassurance about patient’s condition to allay fear and frustration. • Instruct patient on measures to control/minimize symptoms (e.g., small cuffless tube, fenestrated tube, speaking valve, speaking tracheostomy tube) to permit speech.

Outcomes (NOC)

Interventions (NIC) and Rationales

Communication

• Use of written language _____

• Use of pictures and drawings _____

• Use of nonverbal language _____

• Exchanges messages accurately with others _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Communication Enhancement: Speech Deficit

• Listen attentively because patient may be able to whisper or speak if cuff deflated.

• Use picture board.

• Use hand gestures.

• Carry on one-way conversations to prevent isolation of the patient.

Teaching: Disease Process

• Provide information to patient about condition.

• Provide reassurance about patient’s condition to allay fear and frustration.

• Instruct patient on measures to control/minimize symptoms (e.g., small cuffless tube, fenestrated tube, speaking valve, speaking tracheostomy tube) to permit speech.

Nursing Diagnosis

Ineffective self-health management related to lack of knowledge about care of tracheostomy at home as evidenced by questioning ability to care for self.

Patient Goals

1. Demonstrates satisfactory tracheostomy care, including suctioning and stoma care

2. Verbalizes key elements of the therapeutic regimen, including knowledge of disease, complications, and treatment plan

Outcomes (NOC)	Interventions (NIC) AND Rationales
Knowledge: Treatment Procedure • Treatment procedure _____ • Steps in procedure ____ • Correct use of equipment _____ • Appropriate action for complications ____ Knowledge: Disease Process • Cause and contributing factors _____ • Effects of disease ____ • Usual course of disease process _____ • Signs and symptoms of disease complications _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge	Teaching: Psychomotor Skill • Demonstrate skill for patient. • Give clear, step-by-step directions so patient can care for self at home. • Provide practice sessions (spaced to avoid fatigue, but often enough to prevent excessive forgetting) to promote manual proficiency. • Provide frequent feedback to patient on what he or she is doing correctly and incorrectly so that bad habits are not formed. • Provide written information/diagrams for reference. • Observe patient return-demonstrate skill to assess skill level and need for additional teaching. Teaching: Disease Process • Appraise the patient’s current level of knowledge related to specific disease process to identify learning needs. • Provide information to the patient about condition to allow patient to plan treatment regimen. • Describe rationale behind management/therapy/treatment recommendations so that patient becomes committed to self-care. • Instruct the patient on which signs and symptoms (e.g., changes in secretion [yellow to green or blood-tinged] and/or elevated body temperature) to report to health care provider as these may be early signs of respiratory infection. • Refer patient to local community agencies/support groups to provide ongoing assistance and support.

Outcomes (NOC)

Interventions (NIC) AND Rationales

Knowledge: Treatment Procedure

• Treatment procedure _____

• Steps in procedure ____

• Correct use of equipment _____

• Appropriate action for complications ____

Knowledge: Disease Process

• Cause and contributing factors _____

• Effects of disease ____

• Usual course of disease process _____

• Signs and symptoms of disease complications _____

Measurement Scale

1 = No knowledge

2 = Limited knowledge

3 = Moderate knowledge

4 = Substantial knowledge

5 = Extensive knowledge

Teaching: Psychomotor Skill

• Demonstrate skill for patient.

• Give clear, step-by-step directions so patient can care for self at home.

• Provide practice sessions (spaced to avoid fatigue, but often enough to prevent excessive forgetting) to promote manual proficiency.

• Provide frequent feedback to patient on what he or she is doing correctly and incorrectly so that bad habits are not formed.

• Provide written information/diagrams for reference.

• Observe patient return-demonstrate skill to assess skill level and need for additional teaching.

Teaching: Disease Process

• Appraise the patient’s current level of knowledge related to specific disease process to identify learning needs.

• Provide information to the patient about condition to allow patient to plan treatment regimen.

• Describe rationale behind management/therapy/treatment recommendations so that patient becomes committed to self-care.

• Instruct the patient on which signs and symptoms (e.g., changes in secretion [yellow to green or blood-tinged] and/or elevated body temperature) to report to health care provider as these may be early signs of respiratory infection.

• Refer patient to local community agencies/support groups to provide ongoing assistance and support.

Nursing Diagnosis

Risk for infection related to bypass of upper airway defense mechanisms and impaired skin integrity

Patient Goal

Demonstrates no signs or symptoms of infection

Outcomes (NOC)	Interventions (NIC) and Rationales
Infection Severity • Purulent sputum _____ • Fever _____ • Chilling _____ • Malaise _____ • Sputum culture colonization _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None Risk Control: Infectious Process • Acknowledges personal risk for infection _____ • Identifies personal signs and symptoms that indicate potential risk _____ • Maintains a clean environment _____ • Practices infection control strategies _____ • Monitors changes in general health status _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Infection Protection • Monitor for systemic and localized signs and symptoms of infection to promote early detection of infection. • Monitor absolute granulocyte count, white blood cell count, and differential results to promote early detection of infection. • Teach patient and family members how to avoid infections. • Maintain asepsis for patient at risk. Artificial Airway Management • Maintain sterile technique when suctioning and providing tracheostomy care to reduce exposure to pathogens. • Provide trachea care every 4-8 hr as appropriate: clean inner cannula, clean and dry the area around the stoma, and change tracheostomy ties to reduce environmental pathogens. Tube Care • Inspect the area around the tube insertion site for redness and skin breakdown to detect infection. • Change tube routinely, as indicated by agency protocol, to prevent contaminated tubing from being a source of infection.

Outcomes (NOC)

Interventions (NIC) and Rationales

Infection Severity

• Purulent sputum _____

• Fever _____

• Chilling _____

• Malaise _____

• Sputum culture colonization _____

Risk Control: Infectious Process

• Acknowledges personal risk for infection _____

• Identifies personal signs and symptoms that indicate potential risk _____

• Maintains a clean environment _____

• Practices infection control strategies _____

• Monitors changes in general health status _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Infection Protection

• Monitor for systemic and localized signs and symptoms of infection to promote early detection of infection.

• Monitor absolute granulocyte count, white blood cell count, and differential results to promote early detection of infection.

• Teach patient and family members how to avoid infections.

• Maintain asepsis for patient at risk.

Artificial Airway Management

• Maintain sterile technique when suctioning and providing tracheostomy care to reduce exposure to pathogens.

• Provide trachea care every 4-8 hr as appropriate: clean inner cannula, clean and dry the area around the stoma, and change tracheostomy ties to reduce environmental pathogens.

Tube Care

• Inspect the area around the tube insertion site for redness and skin breakdown to detect infection.

• Change tube routinely, as indicated by agency protocol, to prevent contaminated tubing from being a source of infection.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 27-2 Patient Having Total Laryngectomy and/or Radical Neck Surgery

Nursing Diagnosis**

Ineffective airway clearance*

Nursing Diagnosis

Risk for aspiration*

Nursing Diagnosis

Risk for infection*

Nursing Diagnosis

Patient Goals

1. Verbalizes that information provided preoperatively reduced anxiety

2. Demonstrates effective use of relaxation techniques

Outcomes (NOC)	Interventions (NIC) and Rationales
Preprocedure Readiness • Knowledge of procedure _____ • Reported personal preparation for procedure _____ • Discussion of concerns about procedure _____ • Knowledge of postprocedure routines _____ Measurement Scale 1 = Not adequate 2 = Slightly adequate 3 = Moderately adequate 4 = Substantially adequate 5 = Totally adequate Anxiety Self-Control • Seeks information to reduce anxiety _____ • Uses effective coping strategies _____ • Uses relaxation techniques to reduce anxiety _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Teaching: Preoperative • Determine the patient’s previous surgical experiences and level of knowledge related to surgery to evaluate learning needs. • Appraise the patient’s/significant other(s) anxiety relating to surgery to determine effectiveness of interventions. • Describe the postoperative routines/equipment (e.g., medications, respiratory treatments, tubes, machines, support hose, surgical dressing, ambulation, diet, family visitation) and explain their purpose to increase the patient’s sense of control. • Provide time for the patient to ask questions and discuss concerns to help in mental preparation for surgery. • Provide time for the patient to rehearse events that will happen (e.g., methods of communicating postoperatively) to enhance postoperative care. • Instruct the patient to use coping techniques directed at controlling specific aspects of the experience (e.g., relaxation, imagery) to reduce anxiety. Anxiety Reduction • Encourage verbalization of feelings, perceptions, and fears to understand the patient’s perspective of situation, treatment, and prognosis to begin adjustment and acceptance. • Provide factual information concerning diagnosis, treatment, and prognosis to reduce patient’s sense of helplessness and increase sense of control. • Assist patient to articulate a realistic description of upcoming event. • Encourage family to stay with patient to provide caring and support.

Outcomes (NOC)

Interventions (NIC) and Rationales

Preprocedure Readiness

• Knowledge of procedure _____

• Reported personal preparation for procedure _____

• Discussion of concerns about procedure _____

• Knowledge of postprocedure routines _____

Measurement Scale

1 = Not adequate

2 = Slightly adequate

3 = Moderately adequate

4 = Substantially adequate

5 = Totally adequate

Anxiety Self-Control

• Seeks information to reduce anxiety _____

• Uses effective coping strategies _____

• Uses relaxation techniques to reduce anxiety _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Teaching: Preoperative

• Determine the patient’s previous surgical experiences and level of knowledge related to surgery to evaluate learning needs.

• Appraise the patient’s/significant other(s) anxiety relating to surgery to determine effectiveness of interventions.

• Describe the postoperative routines/equipment (e.g., medications, respiratory treatments, tubes, machines, support hose, surgical dressing, ambulation, diet, family visitation) and explain their purpose to increase the patient’s sense of control.

• Provide time for the patient to ask questions and discuss concerns to help in mental preparation for surgery.

• Provide time for the patient to rehearse events that will happen (e.g., methods of communicating postoperatively) to enhance postoperative care.

• Instruct the patient to use coping techniques directed at controlling specific aspects of the experience (e.g., relaxation, imagery) to reduce anxiety.

Anxiety Reduction

• Encourage verbalization of feelings, perceptions, and fears to understand the patient’s perspective of situation, treatment, and prognosis to begin adjustment and acceptance.

• Provide factual information concerning diagnosis, treatment, and prognosis to reduce patient’s sense of helplessness and increase sense of control.

• Assist patient to articulate a realistic description of upcoming event.

• Encourage family to stay with patient to provide caring and support.

Nursing Diagnosis

Acute pain related to surgical tissue injury as evidenced by report of discomfort; facial mask of pain; and/or changes in blood pressure, pulse, and respiratory rate

Patient Goals

1. Reports satisfaction with pain relief

2. Uses pain relief techniques effectively

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Control • Uses analgesics appropriately _____ • Uses nonanalgesic relief measures appropriately _____ • Reports pain controlled _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Pain Management • Observe for nonverbal cues of discomfort, especially in patients unable to communicate effectively (e.g., facial expression, reluctance to cough or move) to plan appropriate interventions. • Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity, or severity of pain and precipitating factors to provide adequate pain relief measures. • Teach use of nonpharmacologic techniques (e.g., relaxation, guided imagery, music therapy, distraction, and massage) before, after, and, if possible, during painful activities; before pain occurs or increases; and along with other pain relief measures to manage pain. • Provide the person optimal pain relief with prescribed analgesics to provide consistent therapeutic levels of analgesics. • Use pain control measures before pain becomes severe.

Outcomes (NOC)

Interventions (NIC) and Rationales

Pain Control

• Uses analgesics appropriately _____

• Uses nonanalgesic relief measures appropriately _____

• Reports pain controlled _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Pain Management

• Observe for nonverbal cues of discomfort, especially in patients unable to communicate effectively (e.g., facial expression, reluctance to cough or move) to plan appropriate interventions.

• Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity, or severity of pain and precipitating factors to provide adequate pain relief measures.

• Teach use of nonpharmacologic techniques (e.g., relaxation, guided imagery, music therapy, distraction, and massage) before, after, and, if possible, during painful activities; before pain occurs or increases; and along with other pain relief measures to manage pain.

• Provide the person optimal pain relief with prescribed analgesics to provide consistent therapeutic levels of analgesics.

• Use pain control measures before pain becomes severe.

Nursing Diagnosis

Imbalanced nutrition: less than body requirements related to surgical procedure, edema, and/or dysphagia as evidenced by absence of or inadequate oral intake

Patient Goals

1. Maintains body weight

2. Consumes adequate fluids and nutrients to meet metabolic needs in the postoperative period

Outcomes (NOC)	Interventions (NIC) and Rationales
Nutritional Status • Nutrient intake _____ • Weight/height ratio _____ • Food intake _____ • Fluid intake _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range	Nutrition Therapy • Complete a nutritional assessment. • Administer enteral feedings as needed to provide adequate nutrients while wound heals. • Ensure availability of progressive therapeutic diet to allow patient time to adjust to initiation of oral intake. • Instruct patient and family about prescribed diet to facilitate adequate intake. • Monitor food/fluid ingested and calculate daily caloric intake to evaluate effectiveness of therapy.

Outcomes (NOC)

Interventions (NIC) and Rationales

Nutritional Status

• Nutrient intake _____

• Weight/height ratio _____

• Food intake _____

• Fluid intake _____

Measurement Scale

1 = Severe deviation from normal range

2 = Substantial deviation from normal range

3 = Moderate deviation from normal range

4 = Mild deviation from normal range

5 = No deviation from normal range

Nutrition Therapy

• Complete a nutritional assessment.

• Administer enteral feedings as needed to provide adequate nutrients while wound heals.

• Ensure availability of progressive therapeutic diet to allow patient time to adjust to initiation of oral intake.

• Instruct patient and family about prescribed diet to facilitate adequate intake.

• Monitor food/fluid ingested and calculate daily caloric intake to evaluate effectiveness of therapy.

Nursing Diagnosis

Impaired verbal communication related to removal of vocal cords as evidenced by inability to speak

Patient Goals

1. Uses written and nonverbal communication techniques to communicate with others

2. Explores the use of speech aids to be used in voice rehabilitation

Outcomes (NOC)	Interventions (NIC) and Rationales
Communication • Use of written language _____ • Use of pictures and drawings _____ • Use of nonverbal language _____ • Exchanges messages accurately with others _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Communication Enhancement: Speech Deficit • Instruct patient and family on use of speech aids (e.g., tracheal-esophageal prosthesis and artificial larynx) for voice rehabilitation. • Use picture board with patient to communicate needs. • Teach esophageal speech as a means of communication. • Reinforce need for follow-up with speech pathologist after discharge to learn use of voice prosthesis, electrolarynx, or esophageal speech.

Outcomes (NOC)

Interventions (NIC) and Rationales

Communication

• Use of written language _____

• Use of pictures and drawings _____

• Use of nonverbal language _____

• Exchanges messages accurately with others _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Communication Enhancement: Speech Deficit

• Instruct patient and family on use of speech aids (e.g., tracheal-esophageal prosthesis and artificial larynx) for voice rehabilitation.

• Use picture board with patient to communicate needs.

• Teach esophageal speech as a means of communication.

• Reinforce need for follow-up with speech pathologist after discharge to learn use of voice prosthesis, electrolarynx, or esophageal speech.

Nursing Diagnosis

Disturbed body image related to disfiguring surgery and loss of speaking ability as evidenced by withdrawal, depression, isolation, unwillingness to look at self or assist with care, and/or refusal to see visitors

Patient Goals

1. Acknowledges changes in body image

2. Discusses feelings about and the meaning of changes in physical appearance

3. Participates in self-care

Outcomes (NOC)	Interventions (NIC) and Rationales
Body Image • Adjustment to changes in physical appearance _____ • Adjustment to changes in body function _____ • Willingness to use strategies to enhance function _____ Measurement Scale 1 = Never positive 2 = Rarely positive 3 = Sometimes positive 4 = Often positive 5 = Consistently positive	Body Image Enhancement • Use anticipatory guidance to prepare patient for predictable changes in body image to facilitate effective coping mechanisms. • Assist patient to discuss changes caused by illness or surgery. • Identify means of reducing the impact of any disfigurement through clothing or cosmetics to aid in successful adjustment. • Assist patient to separate physical appearance from feelings of personal worth to increase acceptance of altered physical appearance. Socialization Enhancement • Encourage enhanced involvement in already established relationships as acceptance by significant others is a critical factor in patient’s own acceptance. Self-Care Assistance • Encourage patient to perform normal activities of daily living to level of ability as participation in self-care is a sign of successful adjustment.

Outcomes (NOC)

Interventions (NIC) and Rationales

Body Image

• Adjustment to changes in physical appearance _____

• Adjustment to changes in body function _____

• Willingness to use strategies to enhance function _____

Measurement Scale

1 = Never positive

2 = Rarely positive

3 = Sometimes positive

4 = Often positive

5 = Consistently positive

Body Image Enhancement

• Use anticipatory guidance to prepare patient for predictable changes in body image to facilitate effective coping mechanisms.

• Assist patient to discuss changes caused by illness or surgery.

• Identify means of reducing the impact of any disfigurement through clothing or cosmetics to aid in successful adjustment.

• Assist patient to separate physical appearance from feelings of personal worth to increase acceptance of altered physical appearance.

Socialization Enhancement

• Encourage enhanced involvement in already established relationships as acceptance by significant others is a critical factor in patient’s own acceptance.

Self-Care Assistance

• Encourage patient to perform normal activities of daily living to level of ability as participation in self-care is a sign of successful adjustment.

Nursing Diagnosis

Deficient knowledge related to lack of exposure to information and unfamiliarity with informational resources as evidenced by verbalized concern about ability to manage self-care at home

Patient Goals

1. Demonstrates satisfactory care of tubes and incisions

2. Verbalizes key elements of the therapeutic regimen and speech rehabilitation, including knowledge of disease, complications, and treatment plan

Outcomes (NOC)	Interventions (NIC) and Rationales
Discharge Readiness: Independent Living • Obtains needed assistance _____ • Uses personal support system _____ • Describes signs and symptoms to health professional _____ • Describes prescribed treatments _____ • Describes risks for complications _____ • Manages own medications _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Teaching: Psychomotor Skill • Demonstrate skill for patient. • Give clear, step-by-step directions so patient can care for self at home. • Provide practice sessions (spaced to avoid fatigue, but often enough to prevent excessive forgetting) to promote manual proficiency. • Provide frequent feedback to patient on what he or she is doing correctly and incorrectly so that bad habits are not formed. • Observe patient return-demonstrate skill to assess skill level and need for additional teaching. • Provide written information/diagrams as an accurate reference reduces error. Teaching: Disease Process • Instruct patient on which signs and symptoms to report to health care provider to detect possible recurrence of tumor or tracheal stenosis. • Refer patient to local community agencies/support groups for continued support and education.

Outcomes (NOC)

Interventions (NIC) and Rationales

Discharge Readiness: Independent Living

• Obtains needed assistance _____

• Uses personal support system _____

• Describes signs and symptoms to health professional _____

• Describes prescribed treatments _____

• Describes risks for complications _____

• Manages own medications _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Teaching: Psychomotor Skill

• Demonstrate skill for patient.

• Give clear, step-by-step directions so patient can care for self at home.

• Provide practice sessions (spaced to avoid fatigue, but often enough to prevent excessive forgetting) to promote manual proficiency.

• Provide frequent feedback to patient on what he or she is doing correctly and incorrectly so that bad habits are not formed.

• Observe patient return-demonstrate skill to assess skill level and need for additional teaching.

• Provide written information/diagrams as an accurate reference reduces error.

Teaching: Disease Process

• Instruct patient on which signs and symptoms to report to health care provider to detect possible recurrence of tumor or tracheal stenosis.

• Refer patient to local community agencies/support groups for continued support and education.

^*Nursing diagnoses are listed in order of priority.

^**Because a tracheostomy is usually performed for the patient with a total laryngectomy and/or radical neck surgery, see eNCP 27-1 (on the website for this chapter) for these nursing diagnoses.

Nasal Fracture

Nasal fracture is the most common facial fracture and the third most common fracture of any bone. Fracture of the nose occurs as a result of blunt trauma, such as occurs with fights, automobile accidents, falls, and sports injuries. Many cases of facial trauma can be prevented by using protective sports equipment and protecting against falls. Complications associated with nasal fractures include airway obstruction, epistaxis, meningeal tears causing cerebrospinal fluid (CSF) leakage, septal hematoma, and cosmetic deformity.

Nasal fractures can be classified as simple or complex. Simple fractures may be unilateral or bilateral and typically produce little or no displacement.³ Powerful frontal blows can cause complex fractures, which may also involve subsequent damage to adjacent facial structures such as the teeth, eyes, or other facial bones. Orbital fractures may be seen with midfacial trauma.

Diagnosis of a nasal fracture is based on the health history and physical examination. Clinical manifestations suggestive of a nasal fracture include localized pain, crepitus on palpation, swelling, ecchymosis, cosmetic deformity, epistaxis, and difficulty breathing out of the nostrils. Although facial deformity with a nasal fracture is common, often epistaxis may be the only initial sign.

On inspection, assess the patient’s ability to breathe through each side of the nose and note the presence of edema, bleeding, or hematoma. Ecchymosis may be under one or both eyes. Ecchymosis involving both eyes is often termed raccoon eyes and may suggest an orbital or basilar skull fracture (see Chapter 57). Inspect the nose internally for evidence of septal deviation, hemorrhage, or clear drainage. Clear, pink-tinged, or persistent drainage after control of epistaxis suggests a CSF leak. Perform a quick test at the bedside or send a specimen to the laboratory to determine if glucose is present; the presence of glucose indicates that the fluid is CSF.

Injury of sufficient force to fracture nasal bones results in considerable swelling of soft tissues. With extensive swelling, it may be necessary to wait to repair the fracture until the edema subsides, which may be 5 to 10 days.

Goals of nursing management are to maintain the airway, reduce edema and pain, prevent complications, and provide emotional support. The best way to maintain the airway is to keep the patient in an upright position. Apply ice to the face and nose in 10- to 20-minute intervals to help reduce edema and bleeding. Administer analgesia as ordered to control pain. Acetaminophen is preferred over nonsteroidal antiinflammatory drugs (NSAIDs) or acetylsalicylic acid (ASA; aspirin) for the first 48 hours to avoid prolonging clotting time and increasing the risk for bleeding. Nasal stuffiness may be relieved with nasal decongestants, saline nasal sprays, and a humidifier. Tell the patient to avoid hot showers and alcohol for the first 48 hours to prevent an increase in swelling. Encourage the patient to quit or decrease smoking to maximize tissue healing.

When a fracture is confirmed, the goals are to realign the fracture using closed or open reduction (septoplasty, rhinoplasty) and to ensure that a septal hematoma does not develop, since this increases the patient’s risk for infection. In addition to reestablishing cosmetic appearance, these surgical procedures provide an adequate airway and function of the nose.

Rhinoplasty

Rhinoplasty, the surgical reconstruction of the nose, is performed for cosmetic reasons or to improve airway function when trauma or developmental deformities result in nasal obstruction. When caring for rhinoplasty patients before surgery, assess the patient’s expectations of the surgery. Any actual or perceived alteration in body image (e.g., a deformed or enlarged nose) can affect self-esteem and interactions with others. Computerized photographs can be used to show the patient’s appearance after the surgery. These images often help patients decide whether to undergo rhinoplasty. Explain expected results of surgery frankly and truthfully to avoid disappointment.

Rhinoplasty is performed as an outpatient procedure using regional or general anesthesia. Sometimes nasal tissue is added or removed, and the nose may be lengthened or shortened. Plastic implants are sometimes used to reshape the nose. Incisions are typically inside the nose and are thus hidden. Sonic rhinoplasty incorporates the use of an ultrasonic device to gently aspirate bone, enabling a refined cosmetic result.⁴

After surgery, nasal packing may be inserted to apply pressure and prevent bleeding or septal hematoma formation. An external plastic splint protects and supports the new shape of the nose during the healing process. Nasal packing is usually removed the day after surgery, and the splint is left in place for approximately 1 week.

Nursing Management Nasal Surgery

Examples of nasal surgery include rhinoplasty, septoplasty, and nasal fracture reductions. Before surgery, instruct the patient not to take aspirin-containing drugs or NSAIDs for 2 weeks to reduce the risk of bleeding. Encourage preoperative smoking cessation to promote postoperative wound healing. Nursing interventions during the immediate postoperative period include maintenance of the airway; assessment of respiratory status; pain management; and observation of the surgical site for bleeding, infection, and edema. Teaching is important because the patient must be able to detect early and late complications at home. The patient typically experiences temporary edema and ecchymosis. Cold compresses and elevation of the head can help minimize swelling and discomfort. Teach activity restrictions aimed at preventing bleeding and injury (no nose blowing, swimming, heavy lifting, strenuous exercise).⁵ Subtle swelling may be slow to resolve, delaying the achievement of a full cosmetic result for up to a year.

Epistaxis

Epistaxis (nosebleed) occurs in a bimodal distribution, with children 2 to 10 years of age and adults over age 50 most affected. Epistaxis can be caused by low humidity, allergies, upper respiratory tract infections, sinusitis, trauma, foreign bodies, hypertension, chemical irritants such as street drugs, overuse of decongestant nasal sprays, facial or nasal surgery, anatomic malformation, and tumors.⁶ Any condition that prolongs bleeding time or alters platelet counts will predispose the patient to epistaxis. Bleeding time may also be prolonged if the patient takes aspirin, NSAIDs, warfarin, or other anticoagulant drugs.

Approximately 90% of nosebleeds occur in the anterior portion of the nasal cavity and are easily visualized. Posterior bleeding occurs more commonly with older adults secondary to other health problems. Anterior bleeding usually stops spontaneously or can be self-treated. Posterior bleeding may require medical treatment.

Nursing and Collaborative Management Epistaxis

Use simple first aid measures to control epistaxis: (1) keep the patient quiet; (2) place the patient in a sitting position, leaning slightly forward with head tilted forward; and (3) apply direct pressure by pinching the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes. If bleeding does not stop within 15 to 20 minutes, seek medical assistance.

Medical management involves identifying the bleeding site and applying a vasoconstrictive agent, cauterization, or anterior packing. Pledgets (nasal tampon) impregnated with anesthetic solution (lidocaine) and/or vasoconstrictive agents such as cocaine or epinephrine are placed into the nasal cavity and left in place for 10 to 15 minutes. Silver nitrate may be used to chemically cauterize an identified bleeding point after epistaxis is controlled. Thermal cauterization is reserved for more severe bleeding and requires the use of local or general anesthesia.⁷

If bleeding does not stop, packing may be used. Packing with compressed sponges (e.g., Merocel) or epistaxis balloons (e.g., Rapid Rhino) is preferred over the use of traditional Vaseline ribbon gauze because of the ease of placement. Packing is inserted into the nares and advanced along the floor of the nasal cavity. The sponge expands with moisture to fill the nasal cavity and tamponade bleeding. The balloon is inflated with air to achieve the same pressure effect (Fig. 27-1). Alternatively, absorbable materials such as oxidized cellulose (surgical), gelatin foam (Gelfoam), or a gelatin-thrombin combination (Floseal) may be used as packing for anterior bleeds. In addition to providing pressure to stop bleeding, these materials increase clot formation and protect the nasal mucosa from further trauma.⁷ A nasal sling (a folded 2 × 2-in gauze pad) may be taped under the nares to absorb drainage.

FIG. 27-1 A, Epistaxis balloon. The balloon is inflated after insertion. B, Epistaxis balloon in proper position in nares.

Nasal packing may impair respiratory status, especially in older adults. Closely monitor respiratory rate, heart rate and rhythm, oxygen saturation using pulse oximetry (SpO₂), and level of consciousness, and observe for signs of aspiration. Because of the risk of complications, all patients with posterior packing should be admitted to a monitored unit to permit closer observation.

Packing is painful because sufficient pressure must be applied to stop the bleeding. Nasal packing predisposes patients to infection from bacteria (e.g., Staphylococcus aureus) present in the nasal cavity. The patient should receive a mild opioid analgesic for pain (e.g., acetaminophen with codeine) and an antibiotic effective against staphylococci to protect against infection.

Nasal packing may be left in place for a few days. Before removal, medicate the patient for pain because this procedure is very uncomfortable. After removal, cleanse the nares gently and lubricate them with water-soluble jelly.

Teach the patient about home care before discharge. Instruct the patient to avoid vigorous nose blowing, engaging in strenuous activity, lifting, and straining for 4 to 6 weeks. Teach the patient to use saline nasal spray and/or a humidifier, to sneeze with the mouth open, and to avoid the use of aspirin-containing products or NSAIDs.

Allergic Rhinitis

Allergic rhinitis is the reaction of the nasal mucosa to a specific allergen. Allergic rhinitis can be classified according to the causative allergen (seasonal or perennial) or the frequency of symptoms (episodic, intermittent, or persistent).⁸ Episodic refers to symptoms related to sporadic exposure to allergens that are not typically encountered in the patient’s normal environment, such as exposure to animal dander when visiting another person’s home. Intermittent means that the symptoms are present less than 4 days a week or less than 4 weeks per year. Persistent means that the symptoms are present more than 4 days a week and for more than 4 weeks per year.

Seasonal rhinitis usually occurs in the spring and fall and is caused by allergy to pollens from trees, flowers, or grasses. The typical attack lasts for several weeks during times when pollen counts are high; then it disappears and recurs at the same time the following year. Perennial rhinitis occurs from exposure to environmental allergens, such as animal dander, dust mites, indoor molds, or cockroaches. Both seasonal and perennial rhinitis can be classified as episodic, intermittent, or persistent, depending on the duration and frequency of symptoms.

Sensitization to an allergen occurs with initial allergen exposure, which results in the production of antigen-specific immunoglobulin E (IgE) (see Fig. 14-6). After exposure, mast cells and basophils release histamine, cytokines, prostaglandins, and leukotrienes, which cause the early symptoms of sneezing, itching, rhinorrhea, and congestion. Four to 8 hours after exposure, inflammatory cells infiltrate the nasal tissues, causing and maintaining the inflammatory response. Because symptoms of rhinitis resemble those of the common cold, the patient may believe the condition is a continuous or repeated cold.

Clinical Manifestations

Manifestations of allergic rhinitis are initially sneezing; watery, itchy eyes and nose; altered sense of smell; and thin, watery nasal discharge that can lead to a more sustained mucus production and nasal congestion. The nasal turbinates appear pale, boggy, and swollen. The turbinates may fill the air space and press against the nasal septum. The posterior ends of the turbinates can become so enlarged that they obstruct sinus aeration or drainage and result in sinusitis. With chronic exposure to allergens, the patient’s responses include headache, congestion, pressure, nasal polyps, and postnasal drip as the most common cause of cough. The patient may complain of cough, hoarseness, and the recurrent need to clear the throat. Congestion may cause snoring.

Nursing and Collaborative Management Allergic Rhinitis

The most important step in managing allergic rhinitis is identifying and avoiding triggers of allergic reactions (Table 27-1). Instruct the patient to keep a diary of times when the allergic reaction occurs and the activities that precipitate the reaction. Patients are often more aware of intermittent exposure to an allergen such as pets than they are of a more persistent exposure to allergens such as dust mites, cockroaches, or mold. Identifying such triggers is the first step toward avoiding them.

TABLE 27-1

PATIENT & CAREGIVER TEACHING GUIDE
Avoiding Allergens in Allergic Rhinitis

Include the following instructions when teaching a patient or caregiver about allergic rhinitis.
What to Avoid	Specific Approaches
House dust	• Focus on the bedroom. Remove carpeting. Limit furniture. • Put the pillows, mattress, and springs in airtight vinyl bags or containers. • Limit clothing in the bedroom to items used frequently. Place clothing in airtight, zipper-sealed vinyl clothes bags. • Install an air filter. Close the air conditioning vent into the room. Use blinds rather than draperies.
House dust mites	• Wash bedding in hot water (130° F [54° C]) weekly. • Wear a mask when vacuuming. Install a filter on the outlet port of the vacuum cleaner. • Avoid sleeping or lying on upholstered furniture. • Keep house temperature and conditions cool and dry.
Pet allergens	• Remove pets from interior of home. • Clean the living area thoroughly. • Do not expect instant relief. Symptoms usually do not improve significantly for 2 mo after pet removal.
Mold spores	• The three Ds that promote growth of mold spores are darkness, dampness, and drafts. • Ventilate closed rooms and open doors. Consider adding windows to dark rooms. Consider keeping a small light on in closets. • Basement light with a timer that provides light several hours a day may decrease mold growth. • Avoid places where humidity is high (e.g., basements, clothes hampers, greenhouses, barns). Dehumidifiers are rarely helpful.
Pollens	• Stay inside with closed doors and windows during high-pollen season. • Install an air conditioner with a good air filter. Wash filters weekly during high-pollen season. • Put the car air conditioner on “recirculate” when driving. • Avoid having plants, especially in the bedroom.
Smoke	• Presence of a smoker will sabotage the best of all possible symptom reduction programs.

The goal of medications is to reduce inflammation associated with allergic rhinitis, reduce nasal symptoms, minimize associated complications, and maximize quality of life. Appropriate oral medication options include H₁-antihistamines, corticosteroids, decongestants, and leukotriene receptor antagonists (LTRAs). Intranasal medications include antihistamines, anticholinergics, corticosteroids, cromolyn, and decongestants ⁹ (Table 27-2).

TABLE 27-2

DRUG THERAPY
Rhinitis and Sinusitis

Drug	Mechanism of Action	Side Effects	Nursing Actions
Corticosteroids
*Nasal Spray* beclomethasone (Beconase) budesonide (Rhinocort) ciclesonide (Omnaris) flunisolide (Nasalide) fluticasone (Flonase) fluticasone furoate (Veramyst) mometasone (Nasonex) triamcinolone (Nasacort)	Inhibits inflammatory response of allergic rhinitis. At recommended dose, systemic side effects are unlikely because of low systemic absorption. Systemic effects may occur with higher than recommended doses.	Mild transient nasal burning and stinging, mucosal drying. In rare instances, localized fungal infection with Candida albicans.	• Instruct patient to use on regular basis and not PRN. • Instruct patient to clear nasal passages before use. • Reinforce that spray acts to decrease inflammation and it may take several days or weeks to achieve maximum effects. • Discontinue use if nasal infection develops.
Mast Cell Stabilizer
*Nasal Spray* cromolyn spray (NasalCrom)	Suppresses release of histamine and other inflammatory mediators from mast cells.	Minimal side effects. Occasional burning or nasal irritation.	• Reinforce that spray prevents symptoms. • Begin 2 wk before pollen season starts and use throughout pollen season. • If isolated allergy, such as cat, use prophylactically (i.e., 10-15 min before exposure to allergen).
Leukotriene Receptor Antagonists (LTRAs) and Inhibitors
*Antagonists* zafirlukast (Accolate) montelukast (Singulair) *Inhibitors* zileuton (Zyflo)	Suppress leukotriene activity, thereby inhibiting airway edema, bronchoconstriction, mucus production, and inflammation (see Fig. 12-2).	Generally well tolerated. May cause headaches, dizziness, rash, altered liver function tests, GI disturbances. Zafirlukast and zileuton: Monitor PT levels and theophylline levels if patient is taking warfarin or theophylline.	• Monitor liver function tests periodically while on therapy. Discontinue if elevated. • Administer on empty stomach. • Do not discontinue therapy without consulting health care professional. • Not to be used for acute attacks.
Anticholinergic
*Nasal Spray* ipratropium bromide (Atrovent)	Blocks nasal cholinergic receptors, reducing nasal secretions in the common cold and nonallergic rhinitis.	Nasal dryness and irritation may occur. Does not cause systemic side effects.	• Need to prime pump with seven actuations before initial use • May reduce the need for other rhinitis medications.
Antihistamines
*First-Generation Agents (Oral)*
azatadine (Optimine) brompheniramine (Dimetane) chlorpheniramine (Chlor-Trimeton) clemastine (Tavist) dexchlorpheniramine (Polaramine) diphenhydramine (Benadryl) levocetirizine (Xyzal)	Bind with H₁ receptors on target cells, blocking histamine binding. Relieve acute symptoms of allergic response (itching, sneezing, rhinorrhea).	Cross blood-brain barrier, frequently causing sedation and somnolence. Can also cause paradoxical stimulation (restlessness, nervousness, insomnia). Anticholinergic side effects (e.g., palpitations, dry mouth, constipation, urinary hesitancy).	• Warn patient that operating machinery and driving may be dangerous because of sedative effect. • Teach patient to report palpitations, change in heart rate, change in bowel or bladder habits. • Instruct patient not to use alcohol with antihistamines because of additive depressant effect. • Rapid onset of action, no drug tolerance with prolonged use. Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Introduction Nursing Management: Sexually Transmitted Infections Nursing Management: Integumentary Problems Fluid, Electrolyte, and Acid-Base Imbalances Stay updated, free articles. Join our Telegram channel Tags: Medical-Surgical Nursing Assessment and Management of Clinical P Nov 17, 2016 \| Posted by admin in NURSING \| Comments Off on Nursing Management: Upper Respiratory Problems Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access

Problems of Nose and Paranasal Sinuses

Deviated Septum

Nursing and Collaborative Management Epistaxis

Allergic Rhinitis

Clinical Manifestations

Nurse Key

Fastest Nurse Insight Engine

Nursing Management: Upper Respiratory Problems

Nursing Management

Upper Respiratory Problems

Nasal Fracture

Rhinoplasty

Nursing Management Nasal Surgery

Epistaxis

Nursing and Collaborative Management Allergic Rhinitis

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