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Nursing Porcess
Nursing Porcess
ASSESSMENT
S/S Headache Sore throat Pain around the eyes Difficulty in swallowing
What relieves them What aggravates History of any allergy Existence of concommittant illnesses
DIAGNOSIS
Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammations Acute pain related to upper airway irritation secondary to infection Impaired verbal communication related to physiologic changes and upper airway irritation secondary to infection or swelling
PLANNING/GOALS
Relief of pain Maintenance of effective means of communication Normal hydration Knowledge of how to prevent upper airway infections Absence of complications
NURSING INTERVENTION
Maintaining of Patent Airway Breathing increases to compensate for the blockage Increasing fluid intake Use of room vaporizers or steam inhalation Drainage sinusitis and rhinitis upright position
PROMOTING COMFORT
Localized discomfort Nurse encourage analgesics Acetmainophen and codeine Topical anesthetics for herpes simplex Hot packs to relieve congestions of sinusitis Warm water gargles General hygiene technique Postoperative adenoidectomy and tonsillectomy ice collar may reduce swelling an decrease bleeding
PROMOTING COMMUNICATION
Hoarseness and loss of speech Refrain form speaking communicate in writing Use of memo pad or a bell to signal for assistance when needed
Drink 2 to 3 L of fluids per day during acute stage of airway infection Liquids may be soothing depending on the disorder.
CONTINUING OF CARE
Referral is rare Consider for annual influenza vaccine elderly Follow-up appointment with the primary care provider
EVALUATION
Expected patient outcomes Maintain a patient airway by managing secretions a. Reports decrease congestion b. Assumes best position to facilitate drainage of secretions c. Uses self-care measures appropriately and consistently to manage secretions during the acute phase of illness
Report relief of pain and discomfort using pain intensity scale a. Uses comfort measures: analgesics, hot packs, gargles, rest