Soins du nez

 

Soins du nez

Objectifs

Dégager les voie aérien supérieur

Indication

Impossibilité pour le patient de se moucher, coma, paralysies, personne âgées etc ::

Matériel

  • 1 plateau
  • 1 haricot
  • Compresses stériles
  • Sérum philosophique
  • Mouchoir en papiers
  • Protection (carre d’alèse)
  • Savon liquide et essuie-mains à usage unique
    • Bien humidifier les croûtes.
    • Moucher les narines l’une après l’autre , sinon les mucosités contenant des micro-organismes sont refoulées vers les sinus et les trompes d’eustache, risquant de provoquer des inflammations, lorsque le patient a envie d’éternuer, bien placer le mouchoir devant le nez sans serrer les narines.
    • Ne jamais utiliser d’huile (vaseline..) en présence d’une sonde à oxygène (risque d’explosions).
  •   
 

Technique (ce soin doit être pendant la toilette et hors de la toilette)

 
  • Prévenir le patient
  • Allumer la présence
  • Installer la protection
  • Faire moucher le patient une narine après l’autre, évacuer les secrétions
  • Si le patient a des croûtes dans le nez
    1. 1 appliquer déplier la compresse, la rouler sur elle-même en cône afin de réaliser un mèche
    2. Humidifier le pointe e la compresse avec du sérum physiologique
    3. L’enfoncer doucement dans la narine en tournant sur elle-même.
    4. Retirer doucement la compresses en observant son état : recommencer si nécessaire. Ce geste peut provoquer un éternuement : il contribue au dégagement des voies respiratoires.
    5. Faire de même avec l’autre narine.
      • Remettre tout en ordre.
      • Désinfecter le matériel.
      • Se laver les mains.
 

Transmissions.

·        Transmission orale à l’infirmier ‘écrites sur le dossier de soins

·        Comportement du patient : ses attitudes, son aide, ses paroles.

·        Saignement de nez (épistaxis).

·        Couleur et odeur des mucosités.

·        Si sécheresse importante des mucosités.

·        Présence de croûtes dans le nez.

Important.

 
  • Ce soin ne peut être exécuté que si le patient n’a pas de sonde nasale. dans le cas contraire. Ce soin relève de la compétence infirmière.
Prodiguer ce soin avec douceur, ne pas arracher les croûtes

10 votes. Moyenne 2.80 sur 5.

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