washing your hands isn't about wetting them with cold water. A good routine should include: jewelers. attention to creases and under nails. It is important to work up a lather to remove any germs.
Dry hands on a clean towel.
Nails have more chance of staying clean if they are kept fairly short.
Oral Hygiene
Attention should be paid to eliminating food particles, dental plaque and ensuring daily gum care, as well as visiting the dentist regularly. Teeth should be brushed after each meal and a minimum of twice a day in an effective manner n, in front, behind and across the top of the teeth, for three minutes.
Rinse.
The principle of not putting objects or fingers in the mouth should also be firmly adhered to. Sugar and sweets also encourage germ proliferation .
Personal Hygiene
A dirty body is a hotbed for developing germs. Dust, sweat and other secretions, and warmth are all factors which encourage germs to multiply.
A shower or bath with effective cleansing products should therefore follow any physical activity.
Everyday secretions occur even without physical effort, and are enough to encourage germs.

.
Clean clothes should be worn and underwear changed daily, yet this is still not obvious to everyone.
Although teeth brushing and shampooing are more or less part of most people's routine, head lice run rife in schools.
Lice لمقلا measure 2-3 mm; the female lays a dozen eggs (nits) a day at root of the hair. The eggs hatch after about a week and the lice become adult in 2 weeks. They can live for 2 months and cause severe itching.
Treatment is applied locally after shampooing. Hair is then gone through with a fine comb طشملا to catch the nits لمقلا ضيب. Bedding, hats and scarves should be washed at 60°C or above if the material is suitable.
How to avoid Lice: three times a week depending on the child's activities).
Avoid sharing hats
ةعبقلا and scarves.
Change bedding at least once a week.
Nasal Hygiene
When talking of self or airborne contamination, the nose should automatically spring to mind. Nasal secretions are highly contaminating, and a runny nose or sneezing are an important source of germ dissemination.
The solution is simple and within easy reach: disposable paper tissues.
Frequent nose blowing clears the nostrils and limits the spread of germs.
But maybe even this simple act calls for a little education: nger to close it and blow خفنthrough the other one.

-laden tissue.
Take care not to irritate the nose due to repeated blowing. Always do it delicately, with a soft tissue.
Editors: Mills, Elizabeth Jacqueline
Title: Nursing Procedures, 4th Edition
Copyright
© آ
Eye, Ear, and Nose Care



INTRODUCTION
EYE CARE
EYE IRRIGATION


EAR CARE
NOSE CARE
 EMERGENCY
 INTRODUCTION
 Part of "14 - Eye, Ear, and Nose Care"


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 Because the eyes transmit about 70% of the sensory information reaching the brain, visual impairment can severely limit a person's ability to function independently and to perceive and react to his surroundings. Similarly, untreated hearing loss can drastically impair

 communication and social interaction. Inner-ear disorders may disrupt equilibrium and the ability to move freely. Likewise, nasal disorders can interfere with respiration, reduce vitality, and cause marked discomfort.
When caring for a patient with a sensory loss, remember that he's actually experiencing multiple impairments because sensory impairment also impairs perception. The combined loss significantly alters a person's daily activities and threatens his security and selfimage.
Because eye, ear, and nose disorders are as common as they are troublesome, you're likely to perform the procedures presented in this chapter whether you practice in a hospital, clinic, extended-care facility, or other setting. You may be called on to assist with or perform eye, ear, or nose procedures in situations ranging from

emergencies to routine checkups. These procedures call for the utmost care and precision to prevent infection and injury and to
 preserve function.
Overcoming perceptual barriers
 Performing procedures that diagnose, treat, or even briefly cause sensory impairment requires you to give clear, simple instructions

 and explanations. You'll also need to provide ample reassurance to a patient who's certain to feel apprehensive about his ability to care for himself and function independently. In an emergency, effective communication becomes even more important because you'll be dealing with a patient suddenly disoriented by sensory and perceptual impairments.
Providing clear patient teaching
You can make an important contribution to the patient's understanding of eye, ear, and nasal disorders. As you implement various procedures, inform your patient about preventive care measures. Teach him to recognize signs and symptoms of sensory disorders. Urge him to schedule regular examinations to detect problems early. Remind him to use safety equipment at work and, as appropriate, at home.
 Always provide thorough explanations. A simple fact or tip that to you seems almost too obvious to mention may actually offer valuable insight to the patient. When the patient leaves you, he should be better able to prevent, cope with, and manage the sensory disorder he has as well as any that could arise in the future.
EYE CARE
Part of "14 - Eye, Ear, and Nose Care"
HOT AND COLD EYE COMPRESSES
 applied hot or cold, eye compresses are soothing and therapeutic.
Hot compresses may be used to relieve discomfort. Because heat increases circulation (which enhances absorption and decreases inflammation), hot compresses may promote drainage of superficial infections.
 cold compresses can reduce swelling or bleeding and relieve itching.
Because cold numbs sensory fibers, cold compresses may be ordered to ease periorbital discomfort between prescribed doses of pain medication. Typically, a hot or cold compress should be applied for
20-minute periods, four to six times per day. Ocular infection calls for the use of sterile technique.

Equipment
For hot compresses: Gloves • prescribed solution, usually sterile water or normal saline solution • sterile bowl • sterile 4″ pads • towel.
4 — أ ″ gauze
For cold compresses: Small plastic bag (such as a sandwich bag) or glove
• ice chips • آ½â€³ (1.3 cm) hypoallergenic tape • towel • sterile
4″ 4 — أ ″ gauze pads • sterile water, normal saline solution, or prescribed ophthalmic irrigant • gloves.
Preparation of equipment
For hot compresses: Place a capped bottle of sterile water or normal saline solution in a bowl of hot water or under a stream of hot tap water. Allow the solution to become warm, not hot (no higher than 120آ° F [48.9آ° C]).
Pour the warm water or saline solution into a sterile bowl, filling the bowl about halfway. Place some sterile gauze pads in the bowl.
For cold compresses: Place ice chips in a plastic bag (or a glove if necessary) to make an ice pack. Keep the ice pack small to avoid excessive pressure on the eye. Remove excess air from the bag or glove, and knot the open end. Cut a piece of hypoallergenic tape to secure the ice pack. Place all equipment on the bedside stand near the patient.
Implementation


Explain the procedure to the patient, make him comfortable, and provide privacy.
 When applying hot compresses, have the patient sit if possible. When applying cold compresses, have the patient lie supine. Support his head with a pillow, and turn his head slightly to the unaffected side.
This position will help hold the compress in place.
 If the patient has an eye patch, remove it.
Drape a towel around the patient's shoulders to catch any spills.
Wash your hands and put on gloves.
P.694
APPLYING AN EYE PATCH ةدامكلا
With a physician's order, you may apply an eye patch for various reasons: to protect the eye after injury or surgery, to prevent accidental damage to an anesthetized eye, to promote healing, to absorb secretions, or to prevent the patient from touching or rubbing his eye.

A thicker patch, called a pressure patch, may be used to help corneal abrasions heal, compress postoperative edema, or control hemorrhage from traumatic injury. Application requires an ophthalmologist's prescription and supervision.
To apply a patch, choose a gauze pad of appropriate size for the patient's face, place it gently over the closed eye (as shown), and secure it with two or three strips of tape. Extend the tape from midforehead across the eye to below the earlobe.
A pressure patch, which is markedly thicker than a single-thickness gauze patch, exerts extra tension against the closed eye. After placing the initial gauze pad, build it up with additional gauze pieces. Tape it firmly so that the patch exerts even pressure against the closed eye (as shown).
For increased protection of an injured eye , place a plastic or metal shield (as shown) on top of the gauze pads and apply tape over the shield.
Occasionally, you may use a head dressing to secure a pressure patch.
The dressing applies additional pressure or, in burn patients, holds the patch in place without tape.
P.695
Applying hot compresses

Take two 4″ 4 — أ ″ gauze pads from the basin. Squeeze out the
 excess solution.
Instruct the patient to close his eyes. Gently apply the pads—one on top of the other—to the affected eye. (If the patient complains that the compress feels too hot, remove it immediately.)
 Change the compress every few minutes, as necessary, for the prescribed length of time. After removing each compress, check the patient's skin for signs that the compress solution is too hot.
Applying cold compresses
 Moisten the middle of one of the sterile 4″
4 — أ ″ gauze pads with the sterile water, normal saline solution, or ophthalmic irrigating

 solution. This helps to conduct the cold from the ice pack. Keep the edges dry so that they can absorb excess moisture.
 Tell the patient to close his eyes; then place the moist gauze pad over the affected eye.
 Place the ice pack on top of the gauze pad, and tape it in place. If the patient complains of pain, remove the ice pack. Some patients may have an adverse reaction to cold.
After 15 to 20 minutes, remove the tape, ice pack, and gauze pad and discard them.
Concluding the procedure


Use the remaining sterile 4″ 4 — أ ″ gauze pads to clean and dry the patient's face.
If ordered, apply ophthalmic ointment or an eye patch. (See
Applying an eye patch.)
Special considerations


When applying hot compresses, change the prescribed solution as frequently as necessary to maintain a constant temperature.
If ordered to apply moist, cold compresses directly to the patient's eyelid, fill a bowl with ice and water and soak the 4″
4 — أ ″ gauze pads in it. Place a compress directly on the lid; change compresses every 2 to 3 minutes. Cold compresses are contraindicated in treating eye inflammation, such as keratitis and iritis, because the capillary constriction inhibits delivery of nutrients to the cornea.
Home care
When teaching a patient to apply warm compresses at home, explain that he can substitute a clean bowl and washcloth for the sterile equipment. If both eyes are infected, emphasize the importance of using separate equipment for each eye. Inform the patient that this will keep him from passing infection back and forth between the eyes. Direct him to wash his hands thoroughly before and after treating each eye.
Documentation
Record the time and duration of the procedure. Describe the eye's appearance before and after treatment. Note any ointments (and amounts)

or dressings applied to the eye. Record the patient's tolerance of the procedure.
EYE IRRIGATION
Part of "14 - Eye, Ear, and Nose Care"
Used mainly to flush secretions, chemicals, and foreign objects from the eye, eye irrigation also provides a way to administer medications for corneal and conjunctival disorders. In an emergency, tap water may serve as an irrigant.
The amount of solution needed to irrigate an eye depends on the contaminant. Secretions require a moderate volume; major chemical burns require a copious amount. Usually, an I.V. bottle or bag of normal saline solution (with I.V. tubing attached) supplies enough solution for continuous irrigation of a chemical burn. (See Three devices for eye irrigation, page 696.)
Equipment
Gloves • goggles • towels • eyelid retractor • cotton balls or facial tissues • optional: litmus paper, proparacaine topical anesthetic.
For moderate-volume irrigation: Prescribed sterile ophthalmic irrigant • sterile cotton-tipped applicators.
For copious irrigation: One or more 1,000-ml bottles or bags of normal saline solution • standard I.V. infusion set without needle.
Commercially prepared bottles of sterile ophthalmic irrigant are available.
All solutions should be at body temperature: 98.6آ° F (37آ° C).
Preparation of Equipment
Read the label on the sterile ophthalmic irrigant. Double-check its sterility, strength, and expiration date.
For moderate-volume irrigation: Remove the cap from the irrigant container and place the container within easy reach. (Be sure to keep the tip of the container sterile.)
For copious irrigation: Use sterile technique to set up the I.V. tubing and the bag or bottle of normal saline solution. Hang the container on an I.V. pole, fill the I.V. tubing with the solution, and adjust the drip regulator valve to ensure an adequate but not forceful flow. Place all other equipment within easy reach.
P.696
EQUIPMENT
THREE DEVICES FOR EYE IRRIGATION

Depending on the type and extent of injury, the patient's eye may need to be irrigated using different devices.
Squeeze bottle
For moderate-volume irrigation—to remove eye secretions, for example—apply sterile ophthalmic irrigant to the eye directly from the squeeze bottle container. Direct the stream at the inner canthus, and position the patient so that the stream washes across the cornea and exits at the outer canthus.
I.V. tube
For copious irrigation—to treat chemical burns, for example—set up an I.V. bag and tubing without a needle. Use the procedure described for moderate irrigation to flush the eye for at least 15 minutes.
Morgan lens
Connected to irrigation tubing, a Morgan lens permits continuous lavage and also delivers medication to the eye. Use an adapter to connect the lens to the I.V. tubing and the solution container. Begin the irrigation at the prescribed flow rate. To insert the device, ask the patient to look down as you insert the lens under the upper eyelid.
Then have her look up as you retract and release the lower eyelid over the lens.
Implementation





Wash your hands, put on gloves and goggles, and explain the procedure to the patient. If the patient has a chemical burn, ease his anxiety by explaining that irrigation prevents further damage.
Assist the patient in lying supine. Turn his head slightly toward the affected side to prevent solution flowing over his nose and into the other eye.
Place a towel under the patient's head, and let him hold another towel against his affected side to catch excess solution.
Using the thumb and index finger of your nondominant hand, separate the patient's eyelids.
If ordered, instill proparacaine eyedrops as a comfort measure. Use them only once because repeated use retards healing.
P.697



To irrigate the conjunctival cul-de-sac, continue holding the eyelids apart with your thumb and index finger.
To irrigate the upper eyelid (the superior fornix), use an eyelid retractor. Steady the hand holding the retractor by resting it on the patient's forehead. The retractor prevents the eyelid from closing involuntarily when solution touches the cornea and conjunctiva.
For moderate irrigation


Holding the bottle of sterile ophthalmic irrigant about 1″ (2.5 cm) from the eye, direct a constant, gentle stream at the inner canthus so that the solution flows across the cornea to the outer canthus.
 Evert the lower eyelid and then the upper eyelid to inspect for retained foreign particles.
 Remove any foreign particles by gently touching the conjunctiva with sterile, wet cotton-tipped applicators. Don't touch the cornea.
Resume irrigating the eye until it's clean of all visible foreign particles.
For copious irrigation



Hold the control valve on the I.V. tubing about 1″ above the eye, and direct a constant, gentle stream of normal saline solution at the inner canthus so that the solution flows across the cornea to the outer canthus.
Ask the patient to rotate his eye periodically while you continue the irrigation. This action may dislodge foreign particles.
Evert the lower eyelid and then the upper eyelid to inspect for retained foreign particles. (This inspection is especially important when the patient has caustic lime in his eye.)
Concluding the procedure
 After eye irrigation, gently dry the eyelid with cotton balls or facial tissues, wiping from the inner to the outer canthus. Use a new cotton ball or tissue for each wipe. This reduces the patient's need to rub his
 eye.
Remove and discard your gloves and goggles.

 When indicated, arrange for follow-up care.
 Wash your hands to avoid burning from residual chemical contaminants.
Special considerations
 When irrigating both eyes, have the patient tilt his head toward the side being irrigated to avoid cross-contamination.
 For chemical burns, irrigate each eye for at least 15 minutes with normal saline solution to dilute and wash the harsh chemical. If the patient can't identify the specific chemical, use litmus paper to determine whether the chemical is acidic or alkaline, or to be sure that the eye has been irrigated adequately. (After irrigating for a chemical burn, note the time, date, and chemical for your own reference in case you develop contact dermatitis.)
Documentation
Note the duration of irrigation, the type and amount of solution, and characteristics of the drainage. Record your assessment of the patient's eye before and after irrigation. Note his response to the procedure.
EAR CARE
Part of "14 - Eye, Ear, and Nose Care"
EAR IRRIGATION
Irrigating the ear involves washing the external auditory canal with a stream of solution to clean the canal of discharges, to soften and remove impacted cerumen, or to dislodge a foreign body. Irrigation may also be used to relieve localized inflammation and discomfort. The procedure must be performed carefully to avoid causing patient discomfort or vertigo and to avoid increasing the risk of otitis externa. Because irrigation may contaminate the middle ear if the tympanic membrane is ruptured, an otoscopic examination always precedes ear irrigation.
This procedure is contraindicated when a foreign body (such as a pea) obstructs the auditory canal because a foreign body attracts and absorbs moisture. In contact with an irrigant or other solution, it swells, causing intense pain and complicating removal of the object by irrigation. Ear irrigation is also contraindicated if the patient has a cold, a fever, an ear infection, or an injured or ruptured tympanic membrane. The presence of a hearing aid battery in the ear also contraindicates irrigation because battery acid could leak, and irrigation would spread caustic material throughout the canal.

Equipment
Ear irrigation syringe (rubber bulb) • otoscope with aural speculum • prescribed irrigant • large basin • linen-saver pad and bath towel • emesis basin • cotton balls or cotton-tipped applicators • 4″ أ— 4″ gauze pad • optional: adjustable light (such as a gooseneck lamp), container for irrigant, tubing, clamp, and syringe with ear tip.
 NURSING ALERT Wear gloves if you expect contact with infected matter.
Preparation of equipment
Select the appropriate syringe, and obtain the prescribed irrigant. Put the container of irrigant into the large basin filled
P.698 with hot water to warm the solution to body temperature (98.6آ° F [37آ°
C]). Avoid extreme temperature changes because they can affect inner ear fluids, causing nausea and dizziness.
HOW TO IRRIGATE THE EAR CANAL
Follow these guidelines for irrigating the ear canal:


Gently pull the auricle up and back to straighten the ear canal. (For a child, pull the ear down and back.)
Have the patient hold an emesis basin beneath the ear to catch returning irrigant. Position the tip of the irrigating syringe at the meatus of the auditory canal (as shown below). Don't block the meatus because you'll impede backflow and raise pressure in the canal.
Figure. No caption available.

 Tilt the patient's head toward you, and point the syringe tip upward and toward the posterior ear canal (as shown below). This angle prevents damage to the tympanic membrane and guards against pushing debris farther into the canal.
Figure. No caption available.
 Direct a steady stream of irrigant against the upper wall of the ear canal, and inspect return fluid for cloudiness, cerumen, blood, or foreign matter.
Test the temperature of the solution by sprinkling a few drops on your inner wrist. Inspect equipment (syringe or catheter tips) for breaks or cracks; inspect all metal tips for roughness.
Implementation
 Explain the procedure to the patient, provide privacy, wash your
 hands, and put on gloves if necessary.
If you haven't already done so, use the otoscope to inspect the
 auditory canal that will be irrigated.
Help the patient to a sitting position. To prevent the solution from running down his neck, tilt his head slightly forward and toward the

 affected side. If he can't sit, have him lie on his back and tilt his head slightly forward and toward the affected ear.
Make sure you have adequate lighting.
If the patient is sitting, place the linen-saver pad (covered with the bath towel) on his shoulder and upper arm, under the affected ear. If he's lying down, cover his pillow and the area under the affected ear.
 Have the patient hold the emesis basin close to his head under the affected ear.

 To avoid getting foreign matter into the ear canal, clean the auricle and the meatus of the auditory canal with a cotton ball or cottontipped applicator moistened with normal saline solution or the prescribed irrigating solution.
 Draw the irrigant into the syringe and expel any air.
 Straighten the auditory canal; then insert the syringe tip and start the
 flow. (See How to irrigate the ear canal.)
During irrigation, observe the patient for signs of pain or dizziness. If he reports either, stop the procedure, recheck the temperature of the irrigant, inspect the patient's ear with the otoscope, and resume irrigation as indicated.
 When the syringe is empty, remove it and inspect the return flow.



Then, refill the syringe, and continue the irrigation until the return flow is clear. Never use more than 500 ml of irrigant during this procedure.
Remove the syringe, and inspect the ear canal for cleanliness with the otoscope.
Dry the patient's auricle and neck.
Remove the bath towel and place a 4″ 4 — أ ″ gauze pad under his ear to promote drainage of residual debris and solution.
Special considerations
 Avoid dropping or squirting irrigant on the tympanic membrane.
This may startle the patient and cause discomfort.
P.699
If you're using an irrigating catheter instead of a syringe, adjust the flow of solution to a steady, comfortable rate with a flow clamp.
Don't raise the container more than 6″ (15.2 cm) above the ear. If the container is higher, the resulting pressure could damage the tympanic membrane.


If the physician directs you to place a cotton pledget in the ear canal to retain some of the solution, pack the cotton loosely. Instruct the patient not to remove it.
If irrigation doesn't dislodge impacted cerumen, the physician may order you to instill several drops of glycerin, carbamide peroxide

(Debrox), or a similar preparation two to three times daily for 2 to 3 days, and then to irrigate the ear again.
Complications
Possible complications include vertigo, nausea, otitis externa, and otitis media (if the patient has a perforated or ruptured tympanic membrane).
Forceful instillation of irrigant can rupture the tympanic membrane.
Documentation
Record the date and time of irrigation. Note which ear you irrigated. Also note the volume and the solution used, the appearance of the canal before and after irrigation, the appearance of the return flow, the patient's tolerance of the procedure, and any comments he made about his condition, especially related to his hearing acuity.
NOSE CARE
Part of "14 - Eye, Ear, and Nose Care"
NASAL IRRIGATION
Irrigation of the nasal passages soothes irritated mucous membranes and washes away crusted mucus, secretions, and foreign matter. Left unattended, these deposits may impede sinus drainage and nasal airflow and cause headaches, infections, and unpleasant odors. Irrigation may be done with a bulb syringe or an electronic oral irrigating device.
Nasal irrigation benefits patients with either acute or chronic nasal conditions, including sinusitis, rhinitis, Wegener's granulomatosis, and
Sjأ¶gren's syndrome. In addition, the procedure may help people who regularly inhale toxins or allergens—paint fumes, sawdust, pesticides, or coal dust, for example. Nasal irrigation is routinely recommended after some nasal surgeries to enhance healing by removal of postoperative eschar and to aid remucosolization of the sinus cavities and ostia.
Contraindications for nasal irrigation may include advanced destruction of the sinuses, frequent nosebleeds, and foreign bodies in the nasal passages
(which could be driven farther into the passages by the irrigant). However, some patients with these conditions may benefit from irrigation.
Equipment
Bulb syringe or an oral irrigating device (such as a Water Pik) • rigid or flexible disposable irrigation tips (for one-patient use) • hypertonic saline solution • bath basin • gloves.
Preparation of equipment
Warm the saline solution to about 105آ° F (40.6آ° C). If you'll be irrigating with a bulb syringe, draw some irrigant into the bulb and then expel it.

This will rinse any residual solution from the previous irrigation and warm the bulb.
If you're using an oral irrigating device, plug the instrument into an electrical outlet in an area near the patient. Then run about 1 cup (236.5 ml) of saline solution through the tubing to rinse residual solution from the lines and warm the tubing. Next, fill the reservoir of the device with warm saline solution.
Implementation
 Wash your hands, and put on gloves.
 Explain the procedure to the patient.
 Have the patient sit comfortably near the equipment in a position that allows the bulb or catheter tip to enter his nose and the returning irrigant to flow into the bath basin or sink. (See Positioning the patient for nasal irrigation, page 700.)
 Remind the patient to keep his mouth open and to breathe

 rhythmically during irrigation. This causes the soft palate to seal the throat, allowing the irrigant to stream out the opposite nostril and carry discharge with it.
Instruct the patient not to speak or swallow during the irrigation to avoid forcing infectious material into the sinuses or eustachian tubes.
To avoid injuring the nasal mucosa, remove the irrigating tip from the patient's nostril if he reports the need to sneeze or cough.
Using a bulb syringe


Fill the bulb syringe with saline solution and insert the tip about
آ½â€³ (1.3 cm) into the patient's nostril.
Squeeze the bulb until a gentle stream of warm irrigant washes through the nose. Avoid forceful squeezing, which may drive debris from the nasal passages into the sinuses or eustachian tubes and introduce infection. Alternate the nostrils until the return irrigant runs clear.
P.700
POSITIONING THE PATIENT FOR NASAL IRRIGATION
Whether you're teaching a patient to perform nasal irrigation with a bulb syringe or an oral irrigating device, the irrigation will progress more easily

when the patient learns how to hold her head for optimal safety, comfort, and effectiveness.
Help the patient to sit upright with her head bent forward over the basin or sink and flexed on her chest. Her nose and ear should be on the same vertical plane.
Figure. No caption available.
Explain that she's less likely to breathe in the irrigant when holding her head in this position. This position should also keep the irrigant from entering the eustachian tubes, which will now lie above the level of the irrigation stream.
Using an oral irrigating device
 Insert the irrigation tip into the nostril about آ½â€³ to 1″ (1.5 to 2.5 cm) and turn on the irrigating device. Begin with a low pressure setting (increasing the pressure as needed) to obtain a gentle stream of irrigant. Again, be careful not to drive material from the nose into the sinuses or eustachian tubes. Irrigate both nostrils.
 Inspect returning irrigant. Changes in color, viscosity, or volume may signal an infection and should be reported to the physician. Also report blood or necrotic material.

Concluding the procedure
 After irrigation, have the patient wait a few minutes before blowing excess fluid from both nostrils at once. Gentle blowing through both nostrils prevents fluid or pressure buildup in the sinuses. This action also helps to loosen and expel crusted secretions and mucus.
 Clean the bulb syringe or irrigating device with soap and water, and then disinfect as recommended. Rinse and dry.
Special considerations
 Expect fluid to drain from the patient's nose for a brief time after the irrigation and before he blows his nose.
 Be sure to insert the irrigation tip far enough to ensure that the irrigant cleans the nasal membranes before draining out. A typical amount of irrigant is 500 to 1,000 ml.
Home care
To continue nasal irrigations at home, teach the patient how to prepare saline solution. Tell him to fill a clean 1-L plastic bottle with bottled or distilled water (4 cups + 2 tablespoons [1 oz] = 1 L), add 1 tsp of canning salt, and shake the solution until the salt dissolves. Teach him how to disinfect used irrigating devices.
Documentation
Write down the time and duration of the procedure and the amount of irrigant used. Describe the appearance of the returned solution. Record your assessment of the patient's comfort level and breathing ease before and after the procedure. Document patient-teaching content.
NASAL PACKING
In the highly vascular nasal mucosa, even seemingly minor injuries can cause major bleeding and blood loss. When routine therapeutic measures, such as direct pressure, cautery, and vasoconstrictive drugs fail to control epistaxis (nosebleed), the patient's nose may have to be packed to stop anterior bleeding (which runs out of the nose) or posterior bleeding (which runs down the throat). If blood drains into the nasopharyngeal area or lacrimal ducts, the patient may also appear to bleed from the mouth and eyes.
Most nasal bleeding originates at a plexus of arterioles and venules in the anteroinferior septum. Only about 1 in
P.701

10 nosebleeds occurs in the posterior nose, which usually bleeds more heavily than the anterior location.
A nurse typically assists a physician with anterior or posterior nasal packing. (See Types of nasal packing, page 702.) She may also assist with nasal balloon catheterization, a procedure that applies pressure to a posterior bleeding site. (See Nasal balloon catheters, page 703.)
Whichever procedure the patient undergoes, you should provide ongoing encouragement and support to reduce his discomfort and anxiety. You should also perform ongoing assessment to determine the procedure's success and to detect possible complications.
Equipment
For anterior and posterior packing: Gowns • goggles • masks • sterile gloves • emesis basin • facial tissues • patient drape (towels, incontinence pads, or gown) • nasal speculum and tongue depressors
(may be in preassembled head and neck examination kit) • directed illumination source (such as headlamp or strong flashlight) or fiber-optic nasal endoscope, light cables, and light source • suction apparatus with sterile suction-connecting tubing and sterile nasal aspirator tip • sterile bowl and sterile saline solution for flushing out suction apparatus • sterile tray or sterile towels • sterile cotton-tipped applicators • local anesthetic spray (topical 4% lidocaine) or vial of local anesthetic solution
(such as 2% lidocaine or 1% to 2% lidocaine with epinephrine 1:100,000)
• sterile cotton balls or cotton pledgets • 10-ml syringe with 22G 1آ½ needle • silver nitrate sticks • electrocautery device with grounding plate and small tip • topical nasal decongestant (such as 0.5% phenylephrine) • absorbable hemostatic (such as Gelfoam, Avitene,
Surgicel, or thrombin) • sterile normal saline solution (1-g container and
60-ml syringe with luer-lock tip, or 5-ml bullets for moistening nasal tampons) • hypoallergenic tape • antibiotic ointment • equipment for measuring vital signs • equipment for drawing blood.
For anterior packing: Two packages of 1
3.8
( ½ آ
-cm) petroleum strip gauze
(3″ to 4″ [0.9 to 1.2 m]) • bayonet forceps or two nasal tampons.
For posterior packing: Two #14 or #16 French catheters with 30-cc balloon or two single- or double-chamber nasal balloon catheters • marking pen.
For assessment and bedside use: Tongue depressors • flashlight • long hemostats or sponge forceps • 60-ml syringe for deflating balloons
(if applicable) • if nasal tampons are in place: saline bullets for applying

moisture and small flexible catheters for suctioning central breathing tube
• drip pad or moustache dressing supplies • mouth care supplies • water or artificial saliva • external humidification.
Preparation of equipment
Wash your hands. Assemble all equipment at the patient's bedside. Make sure the headlamp works. Plug in the suction apparatus, and connect the tubing from the collection bottle to the suction source. Test the suction equipment to make sure it works properly. At the bedside, create a sterile field. (Use the sterile towels or the sterile tray.) Using sterile technique, place all sterile equipment on the sterile field.
If the physician will inject a local anesthetic rather than spray it into the nose, place the 22G 1آ½â€³ needle attached to the 10-ml syringe on the sterile field. When the physician readies the syringe, clean the stopper on the anesthetic vial, and hold the vial so he can withdraw the anesthetic.
This practice allows the physician to avoid touching his sterile gloves to the nonsterile vial.
Open the packages containing the sterile suction-connecting tubing and aspirating tip, and place them on the sterile field. Fill the sterile bowl with normal saline solution so that the suction tubing can be flushed as necessary. Thoroughly lubricate the anterior or posterior packing with antibiotic ointment.
If the patient needs a nasal balloon catheter, test the balloon for leaks by inflating the catheter with normal saline solution. Remove the solution before insertion.
Implementation
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Ensure that all people caring for the patient wear gowns, gloves, and goggles during insertion of packing to prevent possible contamination from splattered blood.
Check the patient's vital signs, and observe for hypotension with postural changes. Hypotension suggests significant blood loss. Also
 monitor airway patency because the patient will be at risk for aspirating or vomiting swallowed blood.
Explain the procedure to the patient, and offer reassurance to reduce his anxiety and promote cooperation.
 If ordered, administer a sedative or tranquilizer to reduce the patient's anxiety and decrease sympathetic stimulation, which can exacerbate a nosebleed.

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Help the patient sit with his head tilted forward to minimize blood drainage into the throat and prevent aspiration.
Turn on the suction apparatus and attach the connecting tubing so the physician can aspirate the nasal cavity to remove clots before locating the bleeding source.
To inspect the nasal cavity, the physician will use a nasal speculum and an external light source or a fiber-optic nasal endoscope. To remove collected blood and help visualize the bleeding vessel, he will use suction or cotton-tipped applicators. The nose may be treated early with a topical vasoconstrictor such as phenylephrine to slow bleeding and aid visualization.
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EQUIPMENT
TYPES OF NASAL PACKING
Nosebleeds may be controlled with anteior or posteror nasal packing.
Anterior nasal packing
The physician may treat an anterior nosebleed by packing the anterior nasal cavity with a 3″ to 4″ (0.9- to 1.2-m) strip of antibioticimpregnated petroleum gauze (shown below) or with a nasal tampon.
Figure. No caption available.
A nasal tampon is made of tightly compressed absorbent material with or without a central breathing tube. The physician inserts a lubricated tampon along the floor of the nose and, with the patient's head tilted backward, instills 5 to 10 ml of antibiotic or normal saline solution. This causes the tampon to expand, stopping the bleeding. The tampon should be moistened periodically, and the central breathing tube should be suctioned regularly.

In a child or a patient with blood dyscrasias, the physician may fashion an absorbable pack by moistening a gauzelike, regenerated cellulose material with a vasoconstrictor. Applied to a visible bleeding point, this substance will swell to form a clot. The packing is absorbable and doesn't need removal.
Posterior nasal packing
Posterior packing consists of a gauze roll shaped and secured by three sutures (one suture at each end and one in the middle) or a balloon-type catheter. To insert the packing, the physician advances one or two soft catheters into the patient's nostrils (shown at top of next column). When the catheter tips appear in the nasopharynx, the physician grasps them with a Kelly clamp or bayonet forceps and pulls them forward through the mouth. He secures the two end sutures to the catheter tip and draws the catheter back through the nostrils.
Figure. No caption available.
This step brings the packing into place with the end sutures hanging from the patient's nostril. (The middle suture emerges from the patient's mouth to free the packing, when needed.)
The physician may weight the nose sutures with a clamp. Then he will pull the packing securely into place behind the soft palate and against the posterior end of the septum (nasal choana).
After he examines the patient's throat (to ensure that the uvula hasn't been forced under the packing), he inserts anterior packing and secures the whole apparatus by tying the posterior pack strings around rolled gauze or a dental roll at the nostrils (shown below).

Figure. No caption available.
P.703
EQUIPMENT
NASAL BALLOON CATHETERS
To control epistaxis, the physician may use a balloon catheter instead of nasal packing. Self-retaining and disposable, the catheter may have a single or double balloon to apply pressure to bleeding nasal tissues. If bleeding is still uncontrolled, the physician may choose to use arterial ligation, cryotherapy, or arterial embolization.
When inserted and inflated, the single-balloon catheter (shown below) compresses the blood vessels while a soft, collapsible external bulb prevents the catheter from dislodging posteriorly.
Single-balloon catheter
The double-balloon catheter (shown below) is used for simultaneous anterior and posterior nasal packing. The posterior balloon compresses the posterior vessels serving the nose, including the bleeding vessels; the anterior balloon compresses bleeding intranasal vessels. This catheter contains a central airway for breathing comfort.

Double-balloon catheter
Assisting with insertion
To assist with inserting a single- or double-balloon catheter, prepare the patient as you would for nasal packing. Be sure to discuss the procedure thoroughly to alleviate the patient's anxiety and promote his cooperation.
Explain that the catheter tip will be lubricated with an antibiotic or a water-soluble lubricant to ease passage and prevent infection.
Providing routine care
The tip of the single-balloon catheter will be inserted in the nostrils until it reaches the posterior pharynx. Then the balloon will be inflated with normal saline solution, pulled gently into the posterior nasopharynx, and secured at the nostrils with the collapsible bulb. With a double-balloon catheter, the posterior balloon is inflated with normal saline solution; then the anterior balloon is inflated.
To check catheter placement, mark the catheter at the nasal vestibule; then inspect for that mark and observe the oropharynx for the posteriorly placed balloon. Assess the nostrils for irritation or erosion. Remove secretions by gently suctioning the airway of a double-balloon catheter or by dabbing away crusted external secretions if the patient has a catheter with no airway.
To prevent damage to nasal tissue, the physician may order the balloon deflated for 10 minutes every 24 hours. If bleeding recurs or remains uncontrolled, reinflate the balloon and contact the physician, who may add packing.
Recognizing complications
The patient may report difficulty breathing, swallowing, or eating, and the nasal mucosa may sustain damage from pressure. Balloon deflation may dislodge clots and nasal debris into the oropharynx, which could prompt coughing, gagging, or vomiting.
For anterior nasal packing

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Help the physician apply topical vasoconstricting agents to control bleeding or to use chemical cautery with silver nitrate sticks.
To enhance the vasoconstrictor's action, apply manual pressure to the nose for about 10 minutes.
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If bleeding persists, you may help insert an absorbable nasal pack directly on the bleeding site. The pack swells to form an artificial clot.
If these methods fail, prepare to assist with electrocautery or insertion of anterior nasal packing. (Even if only one side is bleeding, both sides may require packing to control bleeding.)
While the anterior pack is in place, use the cotton-tipped applicators to apply petroleum jelly to the patient's lips and nostrils to prevent drying and cracking.
HOME CARE
PREVENTING RECURRENT NOSEBLEEDS
Review these self-care guidelines with your patient to reduce his risk of developing recurrent nosebleeds:
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Because nosebleeds can result from dry mucous membranes, suggest that the patient use a cool mist vaporizer or humidifier, as needed, especially in dry environments.
Teach the patient how to minimize pressure on nasal passages.
Advise him, for instance, to avoid constipation and consequent straining during defecation. Recommend a fiber-rich diet and adequate fluid intake, and warn him to avoid extreme physical exertion for 24 hours after the nosebleed stops. Caution him to avoid aspirin (which has anticoagulant properties), alcoholic beverages, and tobacco for at least 5 days.
If the patient gets a nosebleed despite these precautions, tell him to keep his head higher than his heart and, using his thumb and forefinger, to press the soft portion of the nostrils together and against the facial bones. (Recommend against direct pressure if he has a facial injury or nasal fracture.) Tell him to maintain pressure

 for up to 10 minutes and then to reassess bleeding. If it's uncontrolled, he should reapply pressure for another 10 minutes with ice between the thumb and forefinger.
After a nosebleed or after nasal packing is removed, caution the patient to avoid rubbing or picking his nose, putting a handkerchief or tissue in his nose, or blowing his nose forcefully for at least 48 hours. After this time, he may blow his nose gently and use saltwater nasal spray to clear nasal clots.
For posterior nasal packing
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Wash your hands, and put on sterile gloves.
If the physician identifies the bleeding source in the posterior nasal cavity, lubricate the soft catheters to ease insertion.
Instruct the patient to open his mouth and to breathe normally through his mouth during catheter insertion to minimize gagging as the catheters pass through the nostril.
 Help the physician insert the packing as directed.
 Help the patient assume a comfortable position with his head elevated 45 to 90 degrees. Assess him for airway obstruction or any respiratory changes.
 Monitor the patient's vital signs regularly to detect changes that may indicate hypovolemia or hypoxemia.
Special considerations
 Patients with posterior packing usually are hospitalized for monitoring. If mucosal oozing persists, apply a moustache dressing by securing a folded gauze pad over the nasal vestibules with tape or a commercial nasal dressing holder. Change the pad when soiled.
 Test the patient's call bell to make sure he can summon help if needed. Also keep emergency equipment (flashlight, tongue depressor, syringe, and hemostats) at the patient's bedside to speed packing removal if it becomes displaced and occludes the airway.
 Once the packing is in place, compile assessment data carefully to help detect the underlying cause of nosebleeds. Mechanical factors include a deviated septum, injury, and a foreign body. Environmental factors include drying and erosion of the nasal mucosa. Other possible causes are upper respiratory tract infection, anticoagulant or salicylate therapy, blood dyscrasias, cardiovascular or hepatic

 disorders, tumors of the nasal cavity or paranasal sinuses, chronic nephritis, and familial hemorrhagic telangiectasia.
If significant blood loss occurs or if the underlying cause remains unknown, expect the physician to order a complete blood count and coagulation profile as soon as possible. Blood transfusion may be necessary. After the procedure, the physician may order arterial blood gas analysis to detect any pulmonary complications and arterial oxygen saturation monitoring to assess for hypoxemia. If necessary, prepare to administer supplemental humidified oxygen with a face mask and to give antibiotics and decongestants as ordered.
 Because a patient with nasal packing must breathe through his
 mouth, provide thorough mouth care often. Artificial saliva, room humidification, and ample fluid intake also relieve dryness caused by mouth breathing.
Until the pack is removed, the patient should be on modified bed rest. As ordered, administer moderate doses of nonaspirin analgesics, decongestants, and sedatives along
P.705 with prophylactic antibiotics to prevent sinusitis or related infections.
 Nasal packing is usually removed in 2 to 5 days. After an anterior pack is removed, instruct the patient to avoid rubbing or picking his nose, inserting any object into his nose, and blowing his nose forcefully for 48 hours or as ordered.
Home care
Tell the patient to expect reduced ability to detect smell and taste. Make sure he has a working smoke detector at home. Advise him to eat soft foods because his eating and swallowing abilities will be impaired. Instruct him to drink fluids often or to use artificial saliva to cope with dry mouth.
Teach him measures to prevent nosebleeds, and instruct him to seek medical help if these measures fail to stop bleeding. (See Preventing recurrent nosebleeds.)
Complications
The pressure of a posterior pack on the soft palate may lead to hypoxemia.
Patients with posterior packing are at special risk for aspiration of blood.

Patients with underlying pulmonary conditions, such as chronic obstructive pulmonary disease and asthma, are at special risk for exacerbation of the condition or for hypoxemia while nasal packing is in place. Hypoxemia can be detected with pulse oximetry. Signs and symptoms include tachycardia, confusion, cyanosis, and restlessness.
Airway obstruction may occur if a posterior or anterior nasal pack slips backward. The patient may complain of difficulty swallowing, pain, or discomfort. In patients with posterior packs, otitis media may develop.
Other possible complications include hematotympanum and pressure necrosis of nasal structures, especially the septum.
Sedation may cause hypotension in a patient with significant blood loss and may also increase the patient's risk of aspiration and hypoxemia.
Documentation
Record the type of pack used to ensure its removal at the appropriate time.
On the intake and output record, document the estimated blood loss and all fluid administered. Note the patient's vital signs, his response to sedation or position changes, the results of any laboratory tests, and any drugs administered, including topical agents. Record any complications.
Document discharge instructions and clinical follow-up plans.