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01.04 Nasal Disorders

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Overview

  1. Nasal disorders are conditions that alter the anatomy and functioning of the nose and nasal cavity.
  2. Examples:
    1. Deviated septum
    2. Nasal Polyps
    3. Sinusitis
    4. Epistaxis

Nursing Points

General

  1. Deviated septum
    1. Displacement of nasal septum
    2. Very common
    3. Present at birth or as a result of facial trauma
  2. Nasal polyps
    1. Grapelike clusters of mucous membrane and connective tissue
    2. Benign
    3. Caused by irritation to nasal mucosa, allergies, or infection
  3. Sinusitis
    1. Inflammation of mucous membranes in sinuses
    2. Can lead to infection
  4. Epistaxis
    1. Nosebleed
    2. Common problem
    3. Many causes

Assessment

  1. Symptoms
    1. Deviated septum
      1. Sinus infection
      2. Sleep apnea
      3. Snoring
      4. Epistaxis
      5. Difficulty breathing
      6. Facial pain
      7. Loss of smell
    2. Nasal polyps
      1. Obstructed nasal breathing
      2. Increased discharge
      3. Voice change
    3. Sinusitis
      1. Nasal swelling
      2. Nasal congestion/drainage
      3. Headache
      4. Facial pressure/pain
      5. Low-grade fever
    4. Epistaxis
      1. Nosebleed from one or both nostrils

Therapeutic Management

  1. Deviated septum
    1. Nasal sprays
    2. Septoplasty
      1. Surgical management
      2. Straightens nasal septum
  2. Nasal polyps
    1. Nasal steroids
    2. Polypectomy
      1. Surgical removal
  3. Sinusitis
    1. Diagnosis
      1. Transillumination
      2. Sinus x-ray
      3. CT
    2. Medications
      1. Antibiotics
      2. Analgesics
      3. Decongestants
    3. Functional endoscopic sinus surgery
      1. Remove infected mucosa
      2. Improve nasal drainage
  4. Epistaxis
    1. Manual pressure
    2. Nasal packing
    3. Electrocautery
  5. Other considerations
    1. NG tube placement

Nursing Concepts

  1. Sensory perception
  2. Tissue/skin integrity

Patient Education

  1. Deviated septum
    1. Prevention
    2. Administration of nasal sprays
    3. Post-op care
  2. Nasal polyps
    1. Administration of nasal sprays
    2. Post-op care
    3. Observe for recurrence
  3. Sinusitis
    1. Increase fluids
    2. Medication therapy
    3. Post-op care
  4. Epistaxis
    1. Manual pressure
    2. Other treatments
    3. Lifestyle modifications

Reference Links

Study Tools

Video Transcript

Today we’ll be reviewing a few common nasal disorders. These include deviated septum, nasal polyps, sinusitis, and epistaxis. A nasal disorder is any condition that alters the anatomy and functioning of the nose and nasal cavity. By the end of this lesson, you will understand some of the most common nasal disorders, associated symptoms and treatment, and nursing considerations for patients with these disorders.

So we’ll start off with discussing deviated septum. This is a super common condition. There’s actually a pretty good chance that you may have some degree of septal deviation as it affects a large number of people – like 80% of people. It can either be present at birth or as a result of facial trauma. So really a deviated septum is just a displacement of the nasal septum. It’s considered the most common cause of nasal obstruction. Upon visual examination you may or may not be able to see a visual abnormality when inspecting the nose. So looking at this MRI image you can see here how the septum in the nose is just slightly crooked vs just a straight line. Really only more advanced cases actually cause symptoms such as sinus infections, snoring or sleep apnea, epistaxis, facial pain, loss of smell, and with severe cases, patients can have difficulty breathing. If the patient has symptoms, usually nasal sprays are tried first before surgical management. Different nasal sprays that can be tried include decongestants, antihistamines, and corticosteroids. If nasal sprays are ineffective, sometimes a septoplasty will be performed. This is a surgical procedure that straightens the nasal septum and repositions it in the middle of the nose. Patient education includes prevention, so things like encouraging helmets when indicated in different sports, wearing a seatbelt when riding in a vehicle, etc. As well as nasal spray administration and post-op care if a septoplasty is performed.

Ok guys, so let’s move on to nasal polyps. So nasal polyps are benign, grapelike clusters of mucous membrane and connective tissue. You can see in this picture this large circular guy right here is a nasal polyp. They can occur in one nostril or can occur bilaterally. Sometimes their cause is unknown, but they can be caused by irritation to the nasal mucosa, allergies, or infection. So these patients could present with obstructed nasal breathing, increased nasal discharge, or a change in voice quality. Depending on the size of the polyp, they could even obstruct the patient’s airway. Management starts with inhaled nasal steroids followed by a polypectomy, which is the surgical removal of the polyps. When educating patients, review nasal spray administration, post-op care such as monitoring for bleeding, and observe for recurrence as they commonly reoccur after treatment.

Ok moving on to sinusitis. So sinusitis is the inflammation of the mucous membranes of one or more of the sinuses. This picture shows the difference between normal sinuses and someone with sinusitis. So you can see these descriptions below: black = air, gray = soft/swollen tissue or thick secretions, white = bone. And the orange arrows show thickening of the mucosa, and the red arrow shows complete blockage of the sinus cavity. So the picture to the left is what normal sinuses look like- see all of the black space vs the picture on the right which shows the thickening of the mucosa here and even complete blockage of this sinus cavity. So with sinusitis, the swelling can obstruct the flow of secretions which can cause infection. Some of the symptoms of sinusitis include nasal swelling, nasal congestion and drainage, headache, facial pressure or pain, and low grade fever. Some of the diagnostic tools include transillumination and various imaging. Transillumination is when a lighted penlight tip is placed in the patient’s mouth and they close their mouth around it in a dark room. Non-swollen sinuses will reflect light and will have a red glow coming through the skin. Swollen sinuses have a reduced or absent glow. Sinus x-rays and CT scans can also be helpful diagnostic tools. Antibiotics are given for bacterial sinusitis, Acetaminophen can be given for analgesia and fever control, and decongestants can be given to help with the sinus pressure. Other helpful treatments include humidification, hot and wet packs over the sinus area, and nasal saline irrigations. Functional endoscopic sinus surgery or FESS is indicated for sinusitis that does not respond to drug therapy. Basically, the infected mucosa is removed, which helps improve the pathway for nasal drainage. Education topics to cover include increasing fluid intake to help thin the secretion, unless contraindicated, medication therapy, and post-op care as applicable such as using saline nasal spray to prevent mucosal crusting.

The last nasal disorder I wanted to cover is epistaxis, or nosebleeds. Nosebleeds are a common problem because of all of the capillaries in the nose. There can be many causes such as trauma, decreased humidity, nose picking, etc. I’m sure you have probably experienced one yourself or have seen someone with a nosebleed before. It is when someone has bleeding from one or both of their nostrils. I still remember my first nosebleed. I was fighting over a toy with my brother and he let go, which caused me to hit myself in the nose with the toy. Toy + nose = trauma. OUCH! My mom helped me apply pressure and all was good. Let’s look at therapeutic management next. Initially, manual pressure is applied to try to stop the bleed. If this is not effective, nasal packing may be needed. If both of these interventions fail, electrocautery of affected capillaries can be utilized. We will be educating our patients on how to apply manual pressure to the bridge of the nose to stop future bleeds, other treatments, and lifestyle modifications like avoiding the use of Aspirin and NSAIDs. Nasal saline spray and humidification can also be helpful to add moisture to the nasal cavity and help prevent future bleeds.

So just something I want you guys to remember is that these different conditions can have an impact on our other nursing care as well. For example, with NG tube placement. It’s super important to ask if the patient has a deviated septum or nasal polyps, as this would impact which nostril we would attempt to place the NG tube in. I have had multiple patients that are not even admitted for problems with their nose, but a NG tube is indicated for their condition and they have either had polyps or a deviated septum, which impacted where I was able to place the NG tube. Another nursing consideration is regarding airway clearance. So if a patient has excessive epistaxis, this can impair their airway. With any of the conditions mentioned earlier, they can also cause the patient to become a mouth breather because their nose is blocked. When patients become mouth breathers, they get super super dry and cracked. Good oral care is super important to help keep the patient’s oral cavity moist.

One nursing concept associated with patients with nasal disorders is an alteration in sensory perception as their sense of smell could be altered due to their condition. Another nursing concept is tissue/skin integrity alteration as with many of these conditions there is an alteration in the nasal mucosa.
The key points to remember include the management for each disorder including the assessment findings and treatment options. We will also emphasize patient education like medications indicated and post-op care if applicable. The last key point is regarding nursing considerations and how these disorders can apply to other patient care such as in NG tube placement.

Okay guys, that’s all on our lesson about nasal disorders. Make sure you check out all the resources attached to this lesson. Now, go out and be your best self today. And, as always, Happy Nursing!

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