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Theme 1 week 1NURSING CARE OF DISORDERS OF THE
SKIN/INTEGUMENTARY/EYE, EAR,
NOSE AND THROATSYSTEM
Presenter
Mrs. S Ayub1/8/11
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Objectives
At the end of the session thestudent should be able to :
Define key terms
Demonstrate the knowledge and skills in theassessment of medical / surgical conditions
affecting the Skin, EENT .
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Objectives Cont
Demonstrate nursing knowledge and skills to care
for the patient with Skin and EENT problems
using the Nursing process model as a framework.
Prepare and assist patients undergoing
diagnostic, therapeutic, corrective surgery andrehabilitative procedures.
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Assessment of the skin
Equipment needed: good lighting
Small centimeter ruler
Penlight Gloves
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Skin
Examination is correlated with information
obtained in the history
Inspection : observe for color
Skin color, pigmentation, lesions, jaundice,
cyanosis, scars, moisture, edema, color of the
mucous membrane, hair distribution, nails.
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Palpation Examine the skin for:
Temperature, texture, elasticity, turgor.
Skin findings:
Normally warm, slightly moist Smooth and returns quickly to original shape
when picked up by two fingers when released.
Characteristic hair distribution over body,
Nails present, smooth and care for.
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Physical examination
Focus on skin, hair and nails,
Ask patient skin are of concern
Examine the skin surface under good light Compare right and left side of the body
Note the distribution and configuration of
skin lesions Note shape, boarder, texture and surface of
lesion.
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Palpate lesions for texture, warmth andtenderness
Use metric ruler to determine size of lesion-
serve as a baseline for comparison withsequent measurements
Examine scalp, nails and oral mucous for dark
skinned individuals Look for black, purple or grey lesions palpate
carefully- determine if rashes are present.
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Skin disorders
Skin disorders are the major cause of disability,
disfiguration and discomfort.
Skin is integral to self image. As the largest and
most visible organ of the body, skin is involved inrelating to others.
Facial expressions and temporary changes in skin
color reflect emotion and contribute to nonverbalcommunication. One's image is altered by
changes in and styling of hair and nails.
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Tinea
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Tinea (dhani)
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Psoriasis
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Skin also provides a sensitive form of
communication touch. Appearance is often
important
Undesirable skin changes may not only create
visual abnormalities but also may make a
person feel less perfect.
Skin comprises of 15 % of body weight.
Three layers: epidermal, dermal, and
subcutaneous.
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Diagnostic procedures.
Explain any procedure to the patient and
significant others.
Allow them to ask questions and express
concerns
Teach them appropriate wound care and
indications of possible side effects and
complications that should be reported.
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Skin biopsy
Removes a skin tissue specimen for
histological assessment.
Three types: shave, dermal punch and surgical
excision.
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Shave biopsy
Obtain tissue for analysis from possibly
malignant epidermal growths.
Dermal punch biopsy: a circular instrument
with a sharp cutting edge to remove a
specimen of skin that includes the epidermal,
dermal and the subcutaneous layer.
Surgical Excision Biopsy: used when necessary
to totally incise a lesion
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Inflammatory skin conditions
Atopic dermatitis(atopic and flexural Eczema)
eczematous dermatoses (eczema, nummular,
dyshydrotic, and hand eczema,
neurodermitisis)
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Atopic dermatitis/atopic eczema :
Medical intervention
Control of pruritis, symptom relieve, and
prevention of secondary infection are most
important.
Protect the skin from scratching
Avoid excessive washing or bathing because
soap and water may aggravate the problem.
Clean the skin with bath oils.
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Atopic dermatitis/atopic eczema :
Nursing diagnosis:
Impaired skin integrity due to inflammation:
Nursing intervention: use prescribedtreatment baths to rehydrate skin and relieve
pruritis. Apply emollients frequently
Reapply when the skin feels dry.
Hold medication and notify the physician ifburning, discomfort, or increased pruritisoccurs.
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Comfort, alteration in, due to
inflammation
Nursing intervention: during the acute phase
try to remove the patient from the
environment or home to prevent from more
itching or environmental and other triggeringfactors that induce itching.
Provide a well ventilated, cool room and light,
loose clothing, avoid irritating fibres such aswools or polyester.
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Protect skin from self injury. ( cut nails short,
use cotton gloves and socks)
Assess possible triggering factors such as
allergens, or irritants, bacterial and viral, or
fungal infection, environmental changes, such
as temperature and humidity changes, or
emotional or physical stress.
Protect from exposure to herpes simplex virus.
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Potential alteration in self concept due
to body image change
Some skin conditions evoke feelings of anxiety,embarrassment, disgust, or repulsion in anaffected patient and others
Nursing intervention: recognize thepsychosocial impact of the skin disorder onthe person and significant others and evaluateyour feelings about the person, the persons
skin condition ways you communicate yourfeelings and the persons perception of them.
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Be aware of your non- verbal communicatione.g. negative body language and expressionsof rejection.
Assess the persons and significant others fornegative reactions to the skin disorder.
Develop rapport
Acknowledge concerns and facilitate theexpression of feelings.
Beware of individuals feelings
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Assess the persons perception of self, the skin
disorder, and its impact.
Use helpful verbal and non- verbal therapeutic
communication skills.
Use physical touch appropriately.
Observe the persons interactions with others
and assess interpersonal relationship.
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Anticipate social isolation, depression andwithdrawal during the acute phase orexacerbation of chronic skin conditions.
Foster self esteem by giving sincerecomplements on the persons activities and
appearances.
Discuss ways of covering the skin disorder ifthe patient wishes e.g. cosmetics to concealscars.
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Recognize that as an individuals condition
improves, the persons perception of self and
others will improve.
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Eczema
In acute phase topical corticosteroids may beprescribed. Apply emollients frequently.
During the acute phase use only lotion bases.
For chronic phases rehydrate the skin withemollient socks and treatment baths.
reapply when skin is dry,
If eczema worsens suspect intolerance to newtopical medication and report this to thephysician
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Eczema in arms
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Alteration in comfort due to pruritis
and pain.
Observe indications of secondary infections
(bacterial, viral, or fungal)
Depending of location of dermatitis assess for
and avoid environmental irritants
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Xerotic eczema/ dry skin
Skin is dehydrated, erythemotous, scaling andfinely cracked. Occurs in patches and mayinvolve any skin surface.
Common in elderly people If severe, skin is tight, it itches and is painful.
In low humidity, excessive water is lost from
the stratum corneum. Water loss causesXerotic chapping, especially in artificiallyheated rooms
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Medical intervention
Preventing dryness and relieving symptoms
Rehydrate the skin by tepid soaks
Emollients impede the fate of water
evaporation from the skin by their residual oil
film.
Avoiding bathing with soap and using a cold-
air humidifier is recommended.
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Xerotic eczema/ dry skin : impaired
skin integrity due to dehydration of
stratum corneum
Correct skin cleaning, use superfatted soap or
bath oil, limit use of soap except in
intertriginous areas, avoid soap during shower
or bath, avoid hot water baths.
Practice proper dry skin care daily, pat rather
than rub, dry.
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Stasis dermatitis
Provide dry skin care
Assess for self- induced injury and a history of
trauma.
Assess for evidence of skin thinning and the
presence of ulceration
Teach person and significant others way of
reducing and relieving pruritis and explain
prescribed medication
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Teach ways to reduce edema (elevating the
legs 30 degrees, wearing professionally fitted
support hose, avoiding standing, crossing the
legs and ankles and wearing shoes andclothing that are constricting).
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Contact dermatitis
Take a thorough health history, including
information about recent exposure to
soap/ detergents, lotions, powders, toilet
items, medications, ( oral, topical, OTC),
solvents, chemicals, plants, new clothing,
cosmetics, and fragrances.
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Until patch testing is completed,
reduce exposure to suspected
environmental allergens/ irritants.Patch testing may worsen the
condition if performed during the
acute stage of the dermatitis.
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Knowledge deficit
Review identified allergens/irritants ,possible
sources of allergen/ irritant contact,
recognition of irritants/ allergens, ways to
avoid and limit contact, and ways to relievepruritis.
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Sunburn
Reduce skin temperature and inflammation
by applying cool tap water soaks or by cool tap
water baths.
Warn the person that it is too dangerous to
become too cool ( hypothermia) is skin intact,
apply an oil- in water moisturizing lotion.
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Assess skin for blistering. Apply cold sterile,
normal saline soaks continuously to blisters.
Apply nonadhering sterile dressing.
Observe for bacterial infections. Soak and cool baths promote comfort.
Provide teaching/ learning opportunities to
view photo protection methods Advise person to avoid sun exposure until
desquamation is resolved.
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Furuncles and carbuncles
Hasten lesion maturation and relieve
discomfort by applying warm compressions
t.i.d.
Prepare for incision when infection becomes
localized and fluctuates when palpated.
Obtain bacterial culture and sensitivity test.
Provide teaching/learning opportunities.
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Knowledge deficit regarding
communicability of bacterial infection.
Teach the patient to change the dressings on
an open draining furuncle/ carbuncle
frequently, to dispose off dressing carefully
and to wash hands
Bath in antibacterial skin cleanser to use
disposable razor and discard after each use.
The persons linen should be washedthoroughly and separately from other linen.
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Nail disorders
Onycholysis: nursing diagnosis: impaired skin
integrity due to inflammation
Intervention: take an appropriate culture of
the nail to detect bacterial, viral or myocotic
infection. Instruct the person about the
prescribed treatment. Assess the persons
history for trauma and / or chemical irritants.
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Knowledge deficit regarding condition
and its management.
Intervention.: provide teaching/ learning
opportunities including(a) method of reducing
trauma, e.g. clipping nails to reduce further
separation (b) avoiding manicuring or selfinduced trauma. (c) limiting chemical irritants
such as soap, cleansers, nail products. (d)
keeping the nail dry, and if rubber gloves areused reduce maceration by lining them with
thin cotton gloves.
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Paronychia
Impaired skin integrity due to inflammationand bacterial and fungal infection.
Intervention: apply warm soaks three times a
day to reduce pressure and pain. Assist inincision and drainage of inflamed sites. Obtainappropriate cultures of purulent material.Teach the person about prescribe topical /or
systemic antibiotic therapy, emphasizing needfor compliance during treatment.
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Unguis Incarnatus
( ingrown toe nails)
Impaired skin integrity due to local
trauma and inflammation
Intervention: warm soaks 20 severaltimes a day. Assess for secondary
bacterial infection.
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Explain postsurgical wound care. if
nail potion is removed or clipped,
keep a white petroleum impregnatedcotton wick under the remaining nail
edge. Teach the person to change
wick daily.
P li d li ki
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Premalignant and malignant skin
conditions
Basal cell epithelioma: impaired skin integrity
due to cutaneous malignancy.
Intervention: encourage prompt treatment to
minimize local tissue destruction. Teach
postoperative wound care.
P i l l i i i d
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Potential alteration in copying due to
fear and malignancy
Intervention: explain that metastases seldom
occur with this condition.
Knowledge deficit regarding condition and its
management
Intervention: assess the history of sun exposure
and evaluate the signs of skin damage. Review
photo protection methods with the personand significant others.
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Actinic Keratosis ( Solar Keratosis)
Potential skin integrity impairment due to
chronic repetitious actinic damage.
Intervention: assess all sun- exposed skin sites
for actinic damage. A shave biopsy may be
used to rule out malignancy in a suspicious
lesion . Explain the treatment plan to the
person and significant others.
K l d d fi it di diti
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Knowledge deficit regarding condition
and its management.
Intervention; discuss the necessity for
reassessment to detect early signs of skin
damage. (b) need to avoid sun exposure, and
(c ) methods of photo protection
S ll i P i kl ll
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Squamous cell carcinoma, Prickle cell
carcinoma
Potential alteration in coping due to fear of
malignancy and disfigurement.
Intervention: discuss the impact of chronicity
or malignancy, exacerbations, social isolation,
depression, and coping mechanisms with the
person and significant others. Feelings of
anger and frustrations may be experiencedand expressed to health professionals
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Help the individual and significant others to
identify and expect realist treatment
outcomes and to set realistic goals.
Provide appropriate realistic goals.
Recognize the complexity of the condition.
Acknowledge expressed fears of reoccurrence
or progressive worsening of the condition.
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Malignant melanoma
Knowledge deficit regarding condition and its
management : intervention: review the
planned surgical procedure, discuss
postoperative wound care, recognize that theextent of surgical intervention depends on the
stage of the lesion.
Additional treatment may includechemotherapy or immunotherapy
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Discuss the need for medical supervision anddemographic assessment every three to sixmonths.
Prevention guidelines include (a) monthly selfassessments scalp, trunk and intertriginous
and genital areas to identify pigmentedlesions, (b) seek medical follow up for any nevichanges, ( c) encourage blood relatedrelatives to obtain demographic assessment
(d) limit sun exposure and (e) perform photoprotection measures.
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The eye structure
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Equipment
Ophthalmoscope, Snellens chart.
Inspection:
Sclera and iris: check for color
Pupils: check for size, shape, symmetry,
reactions to light and accommodation
Eye movement; extra ocular movements. Eye
naturally moves in conjugate fashion.
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Cross visual fields
Confrontation: normally is full medially and
laterally, superiorly and inferiorly in both eyes.
Visual acuity: check with Snellens chart
normal vision: 6/6
Myopia -- near sightedness and
Hyperopia far sightedness.
Common disorders of eye and related
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Common disorders of eye and related
structures.
Normal eyelid function is to(1) protect the
eyes from foreign bodies, external injury,
undue exposure, and excessive light,
and (2) lubricate the eyeballs by distributing
secretions over them, washing away dust and
keeping the corneas moist and transparent.
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Blepharitis (granulated eyelids)
Inflammation of the eyelid margin.
Assessment reveals eyelid irritation, burning
and itching. The eyelid margins appear red-
rimmed and have scales or granulations on
them.
Sometimes the eyelids margins are ulcerated
and the eyelashes fall out.
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Intervention
Removing scales from the eyelids daily with a
damp cotton applicator followed by applying
warm compression
Cleaning the scalp, eyebrows and lid margins,
Applying antibiotic or sulfonamide eye
ointment daily to the lid margins to prevent
buildup of the scales (preferably at night sinceointment blurs vision).
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Hordeolum (Stye)
Is the postular infection of the eyelash follicle or
sebaceous gland on an eyelid margin (typically
staphylococcal in origin).
Assessment reveals a very painful red swelling onthe eyelid margin. The intensity of pain relates to
the amount of swelling. Common in all age
groups.
Begins with local irritation, redness and swelling
and progresses to an acute tender abscess.
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Intervention
Teaching the person not to squeeze at the
lesion since this spreads the infection.
Apply warm, moist compresses to hasten
suppuration
Compresses usually cause a stye to open and
drain without surgery.
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Virus infection
Herpes Zoster involving the eye typically has
an unilateral trigeminal distribution. Skin
lesion are deeper than those of herpes
simplex. They are painful, can become secondarily
infected, and often leave permanent scars.
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Intervention
Ocular treatment is vigorous with mydriatic,
antibiotic, and corticosteroid ointment. Keep
skin lesions clean of infections and crusts by
cleaning and applying antibiotic ointment andhot soaks.
Disorders of the Conjunctiva Sclera
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Disorders of the Conjunctiva, Sclera,
and Cornea
Conjunctivitis is the inflammation of the
conjunctiva.
Generally exogenous and results from
bacterial or viral infection
May result from endogenous inflammation,
allergy, chemical irritations, and fungal or
parasitic infections
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Assessment
Redness, swelling and lacrimation
Pain occurs if cornea is involved.
If conjunctivitis is associated with allergy,
itching occurs
Eye discharge varies in amount and nature
depending on the causative organism.
Ask if eyelids stick together when waking.
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Intervention
With corneal involvement, photophobia may
occur and dark glasses are required.
Specific antibacterial medications (local and
systemic)
Eye irrigations
Hot moist compressions
Eye drops or ointments
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Corticosteroids are contraindicated ininfectious conjunctivitis since they reduce theocular resistance to bacteria.
Eye patches are also contraindicated sincecovering an eye that has surface bacterialinfection promotes bacterial growth.
Allergic conjunctivitis can be treated withtopical decongestants, steroids or non-steroidal agent such as 4 % cromolyn sodium
Trachoma
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Trachoma
a chronic infectious disease of the conjunctiva
and cornea caused by Chlamydia trachomatis.
Is caused by direct contact and is very
communicable
If untreated leads to blindness
Trachoma responds well to local and systemic
sulfonamides or local antibiotics (tetracycline
or erythromycin). Personal cleaniness isessential
Increased intraocular pressure:
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Increased intraocular pressure:
Glaucoma
Assessment reveals red eye, steamy cornea,
shallow interior chamber, turbid aqueous,
greatly elevated IOP and moderately dilated
nonreactive pupil. The person typically experiences blurred
vision, halos around lights, or a rapid loss of
vision.
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Intervention
To control nausea and relieve the intense pain.
The pain tends to subside once the IOP is
reduced.
A peripheral iridectomy is the surgicalprocedure of choice when the acute episode is
relieved.
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Postoperative intervention
Dilation of pupils with cycloplegic drugs to
prevent posterior synechiae and steroid drugs
to decrease inflammation. Immediate
ambulation is usual. Eye patch is not required , though a shield is
used to protect the eye.
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Lens Opacity (cataract)
Cataract surgery is the only available
treatment. The cloudy lens is removed
Disorders of the nose
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Disorders of the nose Epistaxis: assessment: bleeding usually
apparent however person often swallowsblood making assessment of degree of blood
difficult
Nausea secondary to swallowing blood. Hypotension or frank shock if bleeding
prolonged or severe.
Site of bleeding may be anterior or posteriorlocalization of bleeding site may be difficult.
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Intervention
Position patient sitting up unless hypotensive
pinch nostrils together to apply pressure
Obtain postural vital signs
Order hemotocrit or hemoglobin if bleeding issignificant
Locally applied vasoconstrictors e.g. cocaineor epinephrine are often used to control
bleeding , silver nitrate is used occasionally,xylocaine nasal spray
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Cont
Nasal packing with non adherent gauze
Provide mouth care
Provide reassurance
Learning / teaching: techniques for homeostasis
Follow up care
Humidification and application of water soluble
lubricant
Indication of airway obstruction
f
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Disorders of the ear Group A: External ear disorders: deformities,
foreign bodies, impacted cerumen (ear wax) ,external otitis, furunculosis, malignant
tumors, ear drum perforation,
Group b:
Internal ear disorders: otitis media,
otosclerosis,
Aural surgical procedures:
Rehabilitation for hearing impaired people
l d d d
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Nasal and sinus disorders Group c : rhinitis, (common cold), allergic rhinitis,
nasal polyps, epistaxis Group D: sinusitis, assessment and intervention
Group e: swallowing disorders (Dysphagia),
esophageal disorders Group F : achalasia, esophagitis,
Group G: hiatus hernia and esophageal cancer
Group H: tonsillitis, thyroid and parathyroiddisorders
Prepare assessment, nursing diagnosis andintervention for you group work
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