Timby/Smith: Introductory Medical-Surgical Nursing, 11/e Chapter 20: Caring for Clients With Upper Respiratory Disorders

Infectious and Inflammatory Disorders Rhinitis Pathophysiology and Etiology Inflammation of the nasal mucous membranes; acute, chronic, or allergic Assessment Findings: sneezing, nasal congestion, rhinorrhea, sore throat, watery eyes, cough, low-grade fever, headache, aching muscles, and malaise Medical Management: antipyretics, decongestants, antitussives, saline gargles, saline spray, antihistamines Nurse Management: prevention and minimizing potential complications; handwashing

Infectious and Inflammatory Disorders—(cont.) Sinusitis Pathophysiology and Etiology: inflammation of the sinuses; maxillary sinus Assessment Findings: headache, fever, pain over affected sinus, nasal congestion, pressure around eyes Medical Management: saline irrigation, antibiotic therapy, vasoconstrictors, nasal corticosteroids Surgical: Caldwell-Luc procedure, external sphenoethmoidectomy Nursing Management: mouthwashes, humidification, increased fluid intake, nasal decongestants, antihistamines

Sinus Surgery Nursing Postoperative Care Observe for repeated swallowing: hemorrhage Optic nerve function assessment Temperature every 4 hours; pain over involved sinuses Administer analgesics as indicated, ice compresses Nasal packing and dressing under nares (“moustache” or drop pad”)

Question Which of the following statements made by a client with sinusitis would indicate to the nurse that further teaching is required? A) “I use a warm mist humidifier at night.” B) “I take my decongestants when the doctor ordered.” C) “I will call the physician if my fever comes back.” D) “I will put ice packs on my nose three times each day.”

Answer D) “I will put ice packs on my nose three times each day.” Rationale: Application of ice packs is not a standard treatment for sinusitis; this statement needs clarification for the client.

Infectious and Inflammatory Disorders—(cont.) Pharyngitis Pathophysiology and Etiology Inflammation of throat; rhinitis and other URIs Group A streptococci: strep throat Complications: endocarditis, rheumatic fever, glomerulonephritis Highly contagious: inhalation or direct contamination with droplets

Infectious and Inflammatory Disorders—(cont.) Pharyngitis—(cont.) Assessment Findings: sore throat, dysphagia, fever, headache, white or exudate patch over tonsillar area, swollen glands Medical Management Throat culture Antibiotic treatment: erythromycin

Infectious and Inflammatory Disorders—(cont.) Tonsillitis and Adenoiditis Pathophysiology and Etiology: primary or secondary Chronic tonsillar infection: partial upper airway obstruction; chronic adenoidal infection: otitis media Assessment Findings: sore throat, difficult or pain on swallowing, fever, malaise, enlarged adenoids: nasal obstruction, snoring Medical Management: antibiotic therapy, analgesics, saline gargles Surgical Management: tonsillectomy and adenoidectomy

Infectious and Inflammatory Disorders—(cont.) Tonsillitis and Adenoiditis—(cont.) Nursing Management: precare/postcare: lab results: hematocrit, platelet count, clotting time, aspirin use, NSAIDs Nursing Diagnosis Risk for Aspiration Risk for Impaired Tissue Integrity Acute Pain

Question After a client undergoes surgery to the upper respiratory tract, the nurse should monitor the client for: A) Infection B) Patent airway C) Bleeding tendencies D) Septicemia

Answer B) Patent airway Rationale: Airway is always the primary assessment to be made after surgery.

Infectious and Inflammatory Disorders—(cont.) Peritonsillar Abscess Pathophysiology and Etiology: develops in connective tissue between tonsil and pharynx Streptococcal or staphylococcal tonsillar infection Assessment Findings: difficulty and pain with swallowing, fever, malaise, ear pain, and difficulty talking Diagnostic Findings: sensitivity studies and culture

Infectious and Inflammatory Disorders—(cont.) Peritonsillar Abscess—(cont.) Medical Management: antibiotic therapy Surgical Management: needle aspiration, surgical incision, and drainage Nursing Management Semi-Fowler’s position; prevent aspiration Ice collar, topical anesthetics, throat irrigations, drink fluids, cool or room temperature Observe for respiratory obstruction—dyspnea, restlessness, or cyanosis—or excessive bleeding

Infectious and Inflammatory Disorders—(cont.) Laryngitis Pathophysiology and Etiology: inflammation and swelling of the mucous membrane Causes: URI, excessive use of voice, allergies, smoking Assessment Findings: cannot speak above a whisper; aphonia; throat irritation; dry, nonproductive cough Hoarseness longer than 2 weeks: laryngoscopy Persistent hoarseness: sign of laryngeal cancer Medical Management Voice rest, treatment or removal of cause, antibiotic therapy if bacterial Smoking cessation

Structural Disorders Epistaxis Pathophysiology and Etiology: rupture of tiny capillaries in the nasal mucous membrane Risk factors: trauma, systemic infections (rheumatic fever), local infections, dry nasal mucosa, hypertension, aspirin, nasal tumors, and blood dyscrasias; cocaine abuse/inhaled drugs Assessment Findings: nasal speculum and tongue blade reveals bleeding

Structural Disorders—(cont.) Epistaxis—(cont.) Medical Management: direct continuous pressure, ice packs, topical vasoconstrictor, nasal packing Surgical Management: cauterization, electrocautery, balloon-inflated catheter Nursing Management VS, evidence of continued bleeding Humidification, nasal lubricant, and avoidance of vigorous nose blowing or picking

Question The nurse is teaching first-aid class for parents. The topic is treatment for a nosebleed. One of the parents indicates a need for further teaching with the following statement: A) “Pinch the soft part of the nose firmly.” B) “Flush the nose with warm water.” C) “Apply ice to the back of the neck or to the nose.” D) “Consult a physician as needed.”

Answer B) “Flush the nose with warm water.” Rationale: Warm fluids flushed into the nose should be avoided as it will cause dilatation of the blood vessels and could exacerbate the bleeding.

Trauma and Obstruction of Upper Airway Nasal Obstruction Pathophysiology and Etiology: deviated septum, nasal polyps or grapelike swellings, and hypertrophied turbinates Assessment Findings: hx of sinusitis, difficulty breathing out of one nostril, frequent nosebleeds Medical Management: steroidal nasal spray Surgical Management: submucous surgical resection, septoplasty, rhinoplasty, nose reconstruction Nursing Management: nasal packing, mouth breathing, semi-Fowler’s, VS, oral hygiene

Trauma and Obstruction of Upper Airway—(cont.) Fractures of the Nose Pathophysiology and etiology: trauma Assessment Findings: swelling/edema of soft tissue, external and internal bleeding, nasal deformity, nasal obstruction; CSF—Dextrostix Medical Management: pressure applied, cold compresses Surgical Management: complex fractures Nursing Management: HOB elevated, apply ice, analgesics, assess for airway obstruction, pupillary responses, LOC, and periorbital edema; anxiety

Trauma and Obstruction of Upper Airway—(cont.) Laryngeal Trauma and Obstruction Pathophysiology and Etiology: motor vehicle accidents, blunt trauma in neck region Assessment Findings: neck swelling, bruising, and tenderness; stridor; dysphagia; hoarseness; cyanosis; and hemoptysis Diagnostic Studies: laryngoscopy, x-ray Medical and Surgical Management: patent airway, Heimlich maneuver Nursing Management: LS, respiratory pattern, nasal swelling, bleeding, and laryngeal edema

Sleep Apnea Syndrome Obstructive Sleep Apnea Pathophysiology and Etiology: recurrent and frequent episodes of upper airway obstruction and reduced ventilation Classifications: central, obstructive, mixed Assessment Findings Snore loudly, cessation of breathing for at least 10 seconds, awaken suddenly with loud snort, daytime fatigue, morning headache, inability to concentrate, sore throat, enuresis, and erectile dysfunction

Sleep Apnea Syndrome—(cont.) Obstructive Sleep Apnea—(cont.) Medical Management: lose weight, smoking cessation, eliminate alcohol, and use special pillows Continuous positive airway pressure (CPAP) Bilevel positive airway pressure (BIPAP) Surgical Management: uvulopalatopharyngoplasty and tracheostomy Nursing Management: reassurance, adequate instruction, explanations, self-help groups, counseling

Laryngeal Cancer Pathophysiology and Etiology: causes: carcinogens: tobacco, alcohol, pollutants Assessment Findings: persistent, progressive hoarseness; swelling or lump in throat or neck; dysphagia; weight loss Diagnostic Studies: laryngoscopy, biopsy, CT, MRI, PET Surgical Management: chemotherapy, radiation therapy, laryngectomy Nursing Management Assess for hoarseness, dysphagia, dyspnea, burning in throat, anxiety level, coping strategies, ability to communicate

Alternative Measures of Communication Laryngeal speech used after a laryngectomy Esophageal speech: regurgitation of swallowed air and formation of words with lips Artificial (electric) larynx: throat vibrator held against neck, projects sound into mouth Tracheoesophageal puncture (TEP): surgical insertion of prosthesis; Blom-Singer device Psychosocial issues Nursing Management: social isolation; promote positive self-esteem, encourage social relationships, support services

Tracheotomy and Tracheostomy Tracheotomy: surgical procedure making an opening into the trachea Tracheostomy: surgical opening into the trachea into which a tracheostomy or laryngectomy tube is inserted Temporary or permanent

Tracheotomy and Tracheostomy—(cont.) Nursing Management Risk for Ineffective Airway Clearance: VS, breath sounds, assess skin color, LOC, and mental status; airway patency Risk for Infection: monitor stoma, provide routine tracheostomy care, position Risk for Ineffective Management of Therapeutic Regimen

Endotracheal Intubation and Mechanical Ventilation Uses: respiratory difficulties, comatose clients, general anesthesia Mechanical ventilation: negative pressure, positive pressure Nursing Management: VS, ABGs, SpO2, mental status; confusion, agitation, auscultation, suctioning and humidification, communication