II.Nursing Diagnosis
• Ineffective breathing pattern
• Risk for injury
• Acute pain
• Deficient knowledge
• Anxiety
III.Planning and Outcome Identification
• The major goals for the client diagnosed with a nose, sinus or other disorder may include maintenance of a patent airway; absence of injury; pain relief; knowledge of the disorder, treatment, and preventive measures; and a decrease in anxiety level.
IV.Implementation
Promote measures that maintain a patent airway.
• Humidify the environment with room vaporizers or inhaling stesam.
• Keep the client in semi-Fowler’s position.
• Increased fluid to help thin secretions.
Promote measures that help prevent injury.
• Instruct the client to eat thickened fluids to help prevent choking.
• Encourage the client to wear protective face gear when engaging in physical activities that may traumatize the nose.
• Instruct the client not to put any foreign objects in his mouth.
• Instruct the client to chew food completely before swallowing.
Promote pain relief measures.
• Administer and encourage the client to take analgesics to help relief discomfort..
• Encourage the client to avoid, hot, cold or spicy foods.
Provide verbal and written instructions on the course of disease, its treatment, and preventive measures to help prevent recurrence.
Minimize anxiety. Encourage the client to ventilate feelings and identify ways to effectively deal with anxiety.
V.Outcome Identification
• The client maintains a patent airway.
• The client reports no further upper respiratory system injury.
• The client reports adequate relief of pain and discomfort.
• The client verbalizes an understanding of the course of illness, its treatment, medication used to treat the illness and signs and symptoms to report to the health care provider.
• The client remains calm and exhibit decreased anxiety.