nose and sinuses

8/3/2019 Nose and Sinuses

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ASSESSING THE

NOSE ANDSINUSES



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



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.



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



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.



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.



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



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.

nose and sinuses

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