Biographic DataName: Carrick HanzelAge: 18 years oldDate of Birth: May 2, 1996Address: Lot 59 Claremont Gardens Old HarbourNext of Kin: Lelieth Williams (mother) Devon Hanzel (father)Health HistoryPresent Complaint and History of Present Complaints:Patient presented to the Operating Theatre with complaints of being unable to breathe through the nose, nasal stuffiness and frontal headaches. The patients nares appear deformed. Patient was seen at the University Hospital of the West Indies with bilateral nasal mass x2years. His mother explains he has had trouble smelling birth. She reports that the polyps have been occurring from the age of 12.Previous Medical History: NilPrevious Surgical History: NilAllergies: No known AllergiesFamily History: Grandmother died from osteocarcinomaHead to Toe Assessment (Pre Operative)Young male patient complains about not being able to breathe through his nose and that he was ugly. Received client lying in supine position alert, conscious and oriented to all three spheres on stretcher. Mucous membranes pink and moist. Nares widened and deviated. Septum intact and correctly aligned. Full bilateral occlusion observed in nares. Upon inspection, smooth surfaced, non erythematic masses felt. Copious amounts of foul smelling purulent drainage noted. Cranial nerve I inhibited, client unable to detect smells. Client observed breathing through his mouth. Lymph nodes palpable, mild pain reported upon palpation. Trachea in alignment. Chest expansion equal and symmetrical. Crackles heard upon auscultation of lung field. Nil signs of respiratory distress noted. S1 and S2 heart sounds heard, nil murmurs detected. Pulse regular and bounding. Capillary refill prompt. IV access in situ to left dorsum with 500 mls Normal saline progressing. Abdomen flat, soft and non tender upon palpation. Nil abnormalities detected to the extremities.(Post Operative )Received young male patient complaining of pain rating 5/10 on the pain scale. Received client lying in supine position grimacing and crying on stretcher. Mucous membranes pink and moist. Dressing noted to nose. Same dry and intact. Client observed breathing through his mouth. Lymph nodes palpable, mild pain reported upon palpation. Trachea in alignment. Chest expansion equal and symmetrical. Crackles heard upon auscultation of lung field. Nil signs of respiratory distress noted. S1 and S2 heart sounds heard, nil murmurs detected. Pulse regular and bounding. Capillary refill prompt. IV access in situ to left dorsum with 500 mls Normal saline progressing. Abdomen flat, soft and non tender upon palpation. Nil abnormalities detected to the extremities.Vital Signs: Temp: 97.9F, Pulse: 88bpm, RR:20 bpm, B/p: 122/73, SpO2: 96%

What are Nasal Polyps?According to Blackwells Nursing Dictionary 2014, nasal polyps are focal hyperplasia of the submucous connective tissue of the nose with accumulation of oedematous fluid. These painless, noncancerous growths result from chronic inflammation due to asthma, recurring infection, allergies, drug sensitivity or certain immune disorders.Pathophysiology of Infected Nasal PolypsThe pathogenesis of nasal polyposis is unknown. Polyp development has been linked to chronic inflammation, autonomic nervous system dysfunction, and genetic predisposition. Most theories consider polyps to be the ultimate manifestation of chronic inflammation; therefore, conditions leading to chronic inflammation in the nasal cavity can lead to nasal polyps. Bernstein derived a theory on the pathogenesis of nasal polyps. Bernstein's theory posits that inflammatory changes first occur in the lateral nasal wall or sinus mucosa as the result of viral or bacterial host interactions. In most cases, polyps originate from contact areas of the middle meatus, especially the narrow clefts in the anterior ethmoid region that create turbulent airflow, and particularly when narrowed by mucosal inflammation. Ulceration or prolapse of the submucosa can occur, with epithelialization and new gland formation. During this process, a polyp can form from the mucosa because the inflammatory process from epithelial cells, vascular endothelial cells, and fibroblasts. This response increases sodium absorption, leading to water retention and polyp formation.The epithelial rupture theory suggests that rupture of the epithelium of the nasal mucosa is caused by increased tissue turgor in illness such as allergies and infections. This rupture leads to prolapse of the lamina propria, resulting in the formation of polyps.Medical ManagementOral and topical nasal steroid administration is the primary medical therapy for nasal polyposis.Antihistamines, decongestants, and cromolyn sodium provide little benefit. Immunotherapy may be useful to treat allergic rhinitis but, when used alone, does not resolve existing polyps. Administer antibiotics for bacterial infections. Oral steroids are the most effective medical treatment for nasal polyposis. In adults, most authors use prednisone (30-60 mg) for 4-7 days and taper the medicine for 1-3 weeks. Dosage varies for children, but the maximum dose is 1 mg/kg/d for 5-7 days, then taper over 1-3 weeks. Responsiveness to corticosteroids appears to depend on the presence or absence of eosinophilia.Some nasal sprays include Fluticasone (Flonase), Flunisolide (Nasarel), and Budesonide (Rhinocort).Surgical ManagementPolypectomy Nasal polypectomy is a surgical procedure to remove polyps located in the nasal passages. Nasal polypectomy is indicated for uncontrolled symptoms or symptoms that fail maximum medical therapy.Endoscopic Sinus SurgeryAnendoscopeis inserted into the nose, providing the doctor with an inside view of thesinuses. Surgical instruments are inserted alongside the endoscope. This allows the doctor to remove small amounts of bone or other material blocking the sinus openings and remove polyps of themucous membrane. In some cases a laser is used to burn away tissue blocking the sinus opening. A small rotating burr that scrapes away tissue may also be used.

Nursing Management (Pre Operative) Perform Physical Assessment Taking Vital signs as baseline data Ensure patient file contains blood report, CT scans etc. Ensure complete understanding of impending procedure, clear up any misconceptions about the procedure. Ensure the consent form is signed Shave the Op site if necessary. In this case, if the patient has a moustache Ensure the patient refrain from taking medications that may cause bleeding such as aspirin. Suctioning of patients nasopharynx and oropharynx. Maintain on NPO status at least 6-8 hours before the surgery. Administer pre-op medications such as antibiotics for the infection process and pethidine for impending surgical pain as ordered by the physician.Intra Operative Management Setting up and preparation of the theatre room and instruments for procedure (bed, lighting, endoscopic tools,etc) Gown the patient-go through surgical checklist to ensure adherence Re-check vitals to ensure normalcy Position patient correctly on the theatre bed. Suctioning of nasopharynx and oropharynx Ensure patient safety throughout procedure Enforce the importance of maintaining sterility( proper handwashing and scrubbing technique of the staff)Post Operative Management Monitor patient in the recovery area until stable to return to ward in keeping with the hospital policy. Monitor vital signs for post-surgical complications. Place client in semi or high fowlers position to ensure adequate ling expansion due to compromised breathing abilities. Suctioning or the nasopharynx and oropharynx Assess patient condition for signs of change (signs of infection,post surgical complications) Assess the operation site for drainage.(bleeding,pus etc.) Change op site dressing if needed. Assess pain level and administer analgesics as ordered. Do discharge teachings.

Discharge Teachings Advise patient to be compliant with his medications. Educate him on the importance of completing all medication therapies especially the antibiotic therapy. Encourage client to keep his appointments for follow up and review. Encourage client to avoid irritants such as dust, fur etc. to prevent the reoccurrence of polyps. Discourage digging, picking, rubbing and blowing of the nose as this may lead to post-surgical complication such as bleeding and infections as well as delayed healing. Educate on the importance of proper hand washing to prevent infection.

Strengths and Weaknesses of Nursing ManagementStrengths The theatre room and instruments were sterilized and prepared according to the standards in keeping with the policy manual of the unit for the institution. Sterility was maintained by the staff.Weaknesses The patient was not placed in semi or high fowlers position based on his compromised breathing abilities as stated in the Fundamentals of Nursing,2013. The client was not being maintained on antibiotic therapy as prescribed. According to Kozier and Erb,2013, completion of antibiotic therapy reduces the risk of antibiotic resistance. The consent form was not signed beforehand but at the time when the patient arrived at the theatre. According to the Theatre Policy Manual, all consent forms should be signed at least 24hours before surgery.

CARE PLANNeeds and DiagnosesOxygen Ineffective airway clearance related to retained mucous secretions secondary to nasal congestion as evidenced by crackles heard upon auscultation of lung field, client excessive need for suctioning and inability to breathe through the nose. Risk for Aspiration related to retained mucous secretions secondary to infected nasal polyps.Safety and Security Impaired sensory perception: olfactory is retired and as such replaced by Impaired environmental interpretation syndrome related to inability to receive and transmit external stimuli secondary to infected nasal polyps as evidenced by loss in sense of smell, and bilateral blockage of nares.Rest,Comfort and Activity Pain related to soft tissue trauma secondary to invasive surgical procedure as evidenced by patient verbalization of pain after surgery of 5/10, crying and grimacing.Psychosocial Disturbed body image related to nasal blockage by mass secondary to infected nasal polyps as evidenced by patients verbalization of being ugly, and deformed nares.

Running Head: INFECTED NASAL POLYPS

Priority Need: OxygenASSESSMENTDIAGNOSISPATIENT OUTCOMEINTERVENTIONSRATIONALESEVALUATION

Subjective Data:Patient verbalize that he could not breathe through his nose.

Objective Data:Temp.97.9 FPulse: 88 bpmRR: 20 bpmB/P: 122/73SpO2: 96%

Masses observed in nares.Patient breathing through mouth.Crackles heard upon auscultation of lung field.

Ineffective airway clearance related to retained mucous secretions secondary to nasal congestion as evidenced by crackles heard upon auscultation of lung field, client excessive need for suctioning and inability to breathe through the nose.

At the end of 30 minutes following nursing and collaborative interventions patient will maintain a patent airway with decreased crackles.Monitor patients vital signs especially respiratory rate and SpO2.

To ascertain baseline and to note any changes.Goal partially met: Crackles still heard upon auscultation of lung fields.

Establish and maintain airwayTo ensure airway patency and facilitate lung expansion.

Place patient in semi or high fowlers position.To facilitate adequate lung expansion and to aid in the movement of mucous.

Suction patients nasopharynx and oropharynx.To remove excess mucous from the airway.

Ascultate lung field for breath sounds.To note the present of adventitious breath sounds and decrease air entry to the lung.

Encourage coughing and deep breathing exercises.To facilitate adequate lung expansion and to clear the airway of secretions that may be blocking the airway.

Administer corticosteroids (prednisone) and or bronchodilators (ventolin) as ordered.To dilate bronchioles and reduce inflammation, to facilitate adequate gaseous exchange.

Encourage patient to increase fluid intake of up to 1200mls per day.

To moisten and loosen secretions.

Reassess vital signsTo note effectiveness of interventions.

Priority Need: Rest, Comfort and ActivityASSESSMENTDIAGNOSISPATIENT OUTCOMEINTERVENTIONSRATIONALESEVALUATION

Subjective Data:Patient verbalize that he is feeling pain of 5/10 post-surgical intervention.

Objective Data:Temp. 97.9FPulse: 88 bpmRR: 20 bpmB/P: 122/73SpO2: 96%Facial grimacing and crying observed.

Pain related to soft tissue trauma secondary to invasive surgical procedure as evidenced by patient verbalization of pain after surgery of 5/10, crying and grimacing.

At the end of 30 minutes through nursing and collaborative management, patient will have a decrease in pain from 5/10 to at least 1/10.Monitor vital signs.To ascertain baseline and to note any changes.Goal met: At the end of thirty minutes, patients pain level decreased to 1/10.

Engage patient in diversional therapyTo help in the distraction of the patient from the pain.

Place patient in the most comfortable position.To help alleviate pain and promote comfort.

Administer analgesics as ordered.(e.g. Voltaren)Blocks pain receptors to prevent pain.

Reassess pain level.To determine if interventions were effective.

ReferencesBeers,M.H.,& Fletcher, A. (2004). Merck Manual of Medical Information: second Home edition.New York: merck & co. Inc.Gosnell,K., & Cooper, K.(2012). Foundations and Adult health Nursing (8th ed.) Missouri:Elsiever Mosby.Hazard,J. (2013, May 18). Reassurance in Nursing. Retrieved from Sheffield Hallman University Research Archive: http://shura.shu.ac.uk/id/eprint/3233Smeltzer,S.C., Bare, B. G., Hinkle,J.L., & Cheever,K.H. (2013). Brunner and Suddarths textbook of medical and Surgical Nursing (13th ed.) Philadelphia: Lippincott Williams & Wilkins.The Spanish Town Hospital (2014). Policy Manual: Revised edition. Retrieved January 28,2015.Kozier,B., & Erb, G. (2013).Fundamentals of Nursing: Concepts,process and Practice (9th ed.) United Kingdon:Prenticehall Publishing.

UNIVERSITY OF TECHNOLOGY,JAMAICACARIBBEAN SCHOOL OF NURSINGCOLLEGE OF HEALTH SCIENCE

A project submitted in partial fulfillment of the the requirement for the Bachelor of Science degree in Nursing.

Practicum 4Module Code: NURS4004Submitted: February 20,2015

Name: Amanda GibbsID#: 1100178