Rhinosinusitis is an inflammatory disease mucosal lining of the nose and paranasal sinuses. This inflammation often stems from a viral infection, which is due to certain circumstances evolve into a bacterial infection with bacterial pathogens that cause contained in the upper airway. Another cause is a fungal infection, dental infections, and can also occur as a result of fractures and tumors (Benninger and Gottschall, 2006; Soetjipto et al, 2006).
Nursing Diagnosis for Rhinosinusitis : Ineffective Airway Clearance related to excessive mucus.
NOC :
- Respiratory status : Ventilation
- Respiratory status : Airway patency
- Aspiration Control
- Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, was able to breathe easily, no pursed lips).
- Indicates that a patent airway (the client does not feel suffocated, the rhythm of breathing, respiratory frequency in the normal range , no abnormal breath sounds).
- Being able to identify and prevent the factors that can inhibit airway.
NIC :
Airway Management
- Open the airway, use techniques chin lift or jaw thrust if necessary.
- Position the patient to maximize ventilation.
- Identification of the patient's need for installation tools artificial airway.
- Installing mayo if necessary.
- Perform chest physiotherapy if necessary.
- Remove secretions by coughing or suctioning.
- Auscultation of breath sounds, note the presence of additional noise.
- Perform suction on the mayo.
- Give bronchodilators if necessary.
- Give humidifier wet gauze, with NaCl moist.
- Set intake to optimize fluid balance.
- Monitor respiration and O2 status.
- Ensure the needs of oral / tracheal suctioning.
- Auscultation of breath sounds before and after suctioning.
- Inform the client and family about suctioning.
- Ask the client a deep breath before suction done .
- Give O2 by using a nasal, to facilitate nasotracheal suction.
- Use sterile tools every action.
- Instruct the patient to rest and deep breath, after the catheter is removed from the nasotracheal.
- Monitor the status of the patient oxygen.
- Teach the patient's family, how to perform suction.
- Stop suction and administer oxygen if the patient showed bradycardia, increase in O2 saturation, etc.