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ASSESSING THE
NOSE ANDSINUSES
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SINUSES
PLANNINGDelegation
Assessment of the nose and sinuses is not
delegated to UAP, However, many aspects are
observed during usual care and may, berecorded by persons other than the nurse.
Abnormal findings must be validated and
interpreted by the nurse.
Equipment
Nasal speculum
Flashlight/penlight
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IMPLEMENTATION
Performance1. Prior to performing the procedure, introduce self and verify
the client's identity using agency protocol. Explain to theclient what you are going to do, why it is necessary, and howhe or she can cooperate, Discuss how the results will be
used in planning further care or treatments.2. Perform hand hygiene and observe appropriate infection
control procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following:allergies, difficulty breathing through the nose, sinusinfections, injuries to nose or face, nosebleeds; medicationstaken; changes in sense of smell.
5. Position the client comfortably, seated if possible.
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ASSESSMENT Nose
6. Inspect the external nosefor any deviationsin shape, size, or color andflaring or discharge fromthe nares.
7. Lightly palpate the
external nose to determineany areas of tenderness,masses, and displacementsof bone and cartilage.8. Determine patency ofbath nasal cavities. Ask theclient to close the
mouth, exert pressure onone naris,and breathe through theoppositeNaris. Repeat the procedureto assesspatency of the oppositenaris.
NORMALFINDINGS
Symmetric and straightNo discharge or flaring
Uniform color
Not tender; no lesions
Air moves freely as theclient breathes through the
nares
DEVIATIONSFROM NORMAL
assymmetricDischarge from naresLocalized areas of rednessor presence ofskin lesions
Tenderness on palpation;
presence ofLesions
Air movement is restrictedin one or both
nares
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9. Inspect the nasal cavities using a flashlight or anasal speculum. Hold the speculum in your right hand to inspect theclient's left nostril and your left hand to inspect the
client's right nostril. Tip the client's head back. Facing the client, insert the tip of the closedspeculum (blades together) about 1cm or up to the pointat which the blade widens. Care mustbe taken to avoid
pressure on the sensitive nasal septum. 1 Stabilize the speculum with your index finger againstthe side of thenose. Use the other hand to position the head and then
to hold the light.
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Open the speculum as much aspossible and inspect the floor of thenose (vestibule), the anterior portion
of the septum, the middle meatus, andthe middle turbinates. The posteriorturbinate is rarely visualized
because of its position, 2 Inspect the lining of the nares andthe integrity and the position of thenasal septum.
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Facial Sinuses
10. Observe for thepresence of redness,swelling, growths, anddischarge.
11. Inspect the nasal septumbetween the nasalchambers.
12. Palpate the maxillary andfrontal sinuses for
tenderness.
13. Document findings in theclient record using forms orchecklists supplementedby narrative notes whenappropriate.
Mucosa pinkClear, waterydischarge
No lesions
Nasal septumintact and inmidline
Not tender
Mucosa red,edematous
Abnormal discharge(e.g., pus)Presence of lesions(e.g., polyps)Septum deviated tothe right or to theleft
Tenderness in one ormore sinuses
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EV ALUATION:
Perform a detailed follow-upexamination of other systems
based on findings that deviated
from expected or normal forthe client. Relate findings to
previous as assessment data if
available. Report significant deviations
from normal to the primary
care provider.
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