1. Medical-Surgical Nursing: Concepts & Practice
3rd edition
Chapter 13
Care of Patients with Disorders of the Upper Respiratory System
Copyright © 2017, Elsevier Inc. All rights reserved.

2. Theory Objectives
Recognize symptoms of disorders of the sinuses, pharynx, and larynx.
Describe the postoperative care for the patient undergoing a rhinoplasty.
List emergency measures for the patient with an airway obstruction.
Review a nursing care plan for the patient who had a laryngectomy.
Analyze safety factors to be considered when caring for the patient with a tracheostomy.

3. Clinical Practice Objectives
Institute measures to stop epistaxis.
Provide tracheostomy care.
Devise interventions for the psychosocial care of the patient who has undergone a laryngectomy.
Visit a patient who has a permanent tracheostomy and ask her to share some of her successful coping strategies.

4. Disorders of the Nose and Sinuses
Upper respiratory infection (the common cold) and rhinitis
A major goal in the care of a common cold is to prevention of a secondary bacterial infection.
A person with a cold is contagious for about 3 days after symptoms first appear.
Colds are spread by droplet infection.

5. Common Cold – Non productive cough
Acute viral rhinitis – many different strains so vaccine not possible
Virus- airborne droplet can live on surfaces for a long period
Usually no fever – if there is it’s low grade 99. which is common with viral infections

6. Older Adult Care Points
Immune function in older adults is decreased, and they are therefore more at risk for contracting a cold or upper respiratory infection. They should be encouraged to stay away from people who have such infections.
If a cold develops, an older person is more likely to develop a secondary infection. Encourage increased fluid intake and lots of rest until the cold symptoms are completely cleared.

7. Commonly Prescribed Drugs for Allergic Rhinitis and Sinusitis
Antihistamines
1st generation – drowsiness (Benadryl)
2nd generation – non-drowsy (Claritin)
Corticosteroid sprays – inhibit inflammatory response - Flonas
Mast cell stabilizer- inhibit inflammatory mast cells (Nasalcrom)
Decongestants-promote vasoconstriction (Sudafed)

8. Common Cold (cont)
A bacterial infection is likely present when a cold persists for more than a week to 10 days without improvement, or if the patient begins to feel worse, has a temperature of 101 and develops chest pains or coughs up purulent sputum (productive cough)

9. Caution with Aspirin
Aspirin should not be given to children younger than 19 years of age because aspirin has an association with Reye’s syndrome.
Adults taking anticoagulants or nonsteroidal anti-inflammatory drugs should not take aspirin because aspirin will further prolong the clotting time.

10. Sinusitis
Sinusitis is an inflammation of the mucosal lining of the sinuses.
Causes include infection that has spread from the nasal passages to the sinuses and blockage of normal sinus drainage routes.
Pneumococci, streptococci, or Haemophilus influenzae are usually the infecting organisms.

11. Sinusitis (Cont.)
A deviated septum or nasal polyps can contribute to blockage of the nasal passages.
People with a deviated nasal septum or allergy problems tend to have recurrent sinusitis.
As exudate accumulates in the sinuses, pressure builds up, causing considerable pain.

12. Symptoms Symptoms include Headache Fever Tenderness over the sinuses
Malaise
Purulent drainage from the nose
Sometimes a nonproductive cough
The upper teeth may become painful.

13. Treatment
Relieve pain, promote sinus drainage, control infection, and prevent recurrence.
Hot, moist packs over the sinus area can be helpful.
Inhaling moist steam thins secretions and helps to promote drainage.
Kits for sinus irrigation are available at drugstores and seem to help.

14. Treatment (Cont.)
Medications are prescribed to promote vasoconstriction, reduce swelling, and promote drainage.
Decongestants also may be used.
Infection may be treated with an antibiotic or anti-infective agent, often for at least 10 days.

15. Treatment (Cont.)
Rest, reduced stress, a balanced diet, and control of allergies can help prevent recurrence.
Analgesics are given for pain.
Fluid intake should be increased and dairy product intake lowered to decrease the thickness of secretions.

16. Epistaxis (Nosebleed)
Causes –decreased humidity, excessive nose blowing, allergy with inflammation, nose picking, medical condition (prolonged bleeding time), trauma, hypertension, blood DO, pt on anti-coagulant/anti-platelet increased risk
Bleeding is the only sign.
Management
Minimal bleeding – pressure, patient sit forward
Persistent bleeding – ER to cauterize bleeding vessel

17. Stopping a Nosebleed
See Figure 13-1 on p. 276.

18. Epistaxis
Cold compresses or ice may be applied to the nose to help constrict the blood vessels.
If there is still bleeding minutes, repeat process
If persistent ER – cauterize, pack or insert a small balloon device to stop the bleeding
**instruct patient to spit blood into a basin or tissue..accumulation of blood in the stomach will eventually cause N & V

19. Pharyngitis
Pharyngitis (inflammation of the pharynx), usually called a sore throat
The inflammation may be caused by a virus, bacteria, or fungus; usually viral.
Acute follicular pharyngitis (“strep throat”) is caused by beta-hemolytic streptococcal infection.
Fungal pharyngitis occurs with long-term use of antibiotics or inhaled corticosteroids, or in patients with immunosuppression, such as occurs with HIV or AIDS or during cancer treatment.

20. Pharyngitis (Cont.)
Laryngitis (inflammation of the larynx with diminished voice or hoarseness) may occur if the infection progresses into the larynx.
If the inflammation extends to the epiglottis, epiglottitis occurs.
More common in children

21. Signs, Symptoms, and Diagnosis
Symptoms include
Dry, “scratchy” feeling in the back of the throat
Mild fever
Headache
Malaise
Throat, tonsils, palate, and uvula may be involved and will be reddened
Dysphagia is also present with discomfort when swallowing one’s own saliva.

22. Signs, Symptoms, and Diagnosis (Cont.)
With laryngitis, the voice may become hoarse or absent. The usual course for uncomplicated pharyngitis or laryngitis is 3 to 10 days. The diagnosis of pharyngitis is confirmed by clinical signs and symptoms.
A throat culture is often done to confirm or rule out streptococcal infection.

23. Treatment and Nursing Management
Conservative measures are rest, warm saline gargles (1⁄2 to 1 tsp of table salt to a glass of warm water), throat lozenges (small medicinal tablets that dissolve in the mouth), plenty of fluids, and a mild analgesic for aches and pains
Antiseptic sprays and lozenges help provide relief from discomfort.

24. Treatment and Nursing Management (Cont.)
Bacterial pharyngitis requires antibiotic therapy, particularly if the infecting organism is Streptococcus.
Chronic pharyngitis may require diagnostic procedures to determine the underlying cause and therapeutic measures such as humidification and filtering of environmental air.
Fungal pharyngitis is treated with an agent effective against fungi but may be difficult to control in immunocompromised individuals.

25. Sore throat
*** throat culture is performed before treatment to check for Streptococcus which can cause rheumatic fever or glomerulonephritis if not treated promptly*****

26. Tonsillitis Etiology and pathophysiology
Signs, symptoms, and diagnosis
Treatment
Throat culture (cause streptococci, staphylococci)
Surgery
Nursing management
Preoperative and postoperative care – restrict ASA, NSAIDs prior to surgery. If patent has temp or s/s Uri surgery will usually be postphoned

27. Obstruction and Trauma
Laryngeal edema – allergic reaction, crash injury or foreign object or food that goes down the airway
Upward thrusts to dislodge
The most common cause of obstruction in unconscious adult or child older than 1 year is the tongue.

28. Obstructive Sleep Apnea
Etiology and pathophysiology –muscle relaxing at back of throat, tongue falls back and blocks the airway
Snoring – daytime fatigue, morning headaches
Sleep study – CPAP, oral appliances
Continuous positive airway pressure (CPAP)
Complications
Untreated sleep apnea can contribute to myocardial infarction or stroke.
Constant fatigue
Capnography – Co2 monitoring after surgery

29. Nasal Fracture
Usually from sport injury, motor vehicle accident or physical assault
Diagnosis -
Visual inspection for deformity
Change in nasal breathing
Crepitation—grating sound or feeling of rough surfaces rubbing together upon palpation

30. Nasal Fracture (Cont.) Treatment
If the patient is seen within the first 24 hours after injury, a closed reduction is most often performed using local or general anesthetic.
Pain relief
Ice or cold compresses to reduce swelling
Cosmetic rhinoplasty

31. Audience Response Question 1
Which nursing intervention(s) would be appropriate during the immediate postoperative period for a patient who has undergone rhinoplasty? (Select all that apply.) pg 279
Observe for frequent swallowing.
Monitor amount of drainage.
Position the patient flat on the back.
Apply warm compresses.
Provide humidified oxygen.
Correct Answer: 1 and 5

32. Cancer of the Larynx Etiology and pathophysiology - tumor
Signs and symptoms – page 280 (next slide)
Diagnosis – CT scan MRI and tissue sample
Treatment – radiation 85% effective, laryngectomy, neck dissection (if tumor progressed to surrounding tissues)

33. Signs of Possible Throat Cancer
Hoarseness lasting more than 3 weeks
Sore throat that lasts more than 2 weeks
Consistent pain in or around the ear when swallowing
Difficulty swallowing
Dry, persistent cough for no known reason
Blood in phlegm or saliva lasting more than a few days
Lumps or knots on the neck indicating enlarged cervical lymph nodes

34. Older Adult Care Points
Men in their 60s to 80s with a long history of smoking and heavy alcohol use are most likely to develop laryngeal cancer.
A thorough assessment should be carried out for these individuals.

35. Endotracheal Intubation and Tracheostomy
Endotracheal intubation means that an endotracheal tube is inserted into the trachea via the nose or the mouth with the use of a laryngoscope.
Tracheostomy is a surgical incision into the trachea for the purpose of inserting a tube through which the patient can breathe.
Figure 13-6 on page airflow after laryngectomy

36. Purposes of Tracheostomy
To assist or control ventilation by mechanical means over a prolonged period of time
To facilitate suctioning of secretions in the air passages of patients unable to cough
To prevent aspiration of oral and gastric secretions (as in unconscious or paralyzed patients)

37. Purposes of Tracheostomy (Cont.)
To bypass a constricted or obstructed upper airway (as results, for example, from edema of the larynx, presence of a foreign body or tumor, surgical procedures involving the neck, severe burns, facial trauma, or chest trauma)

38. Audience Response Question 2
The patient’s spouse asks, “What is the purpose of the tracheostomy?” Which comment(s) demonstrate(s) nursing knowledge regarding the procedure? (Select all that apply.)
“It facilitates suctioning of respiratory secretions.”
“It prevents recurrence of respiratory arrest.”
“It prevents aspiration of oral secretions in unconscious patients.”
“It bypasses an obstructed upper airway.”
“It is a temporary airway for face and neck injuries.”
Correct Answer: 1, 3, 4, and 5

39. Nursing Management
Monitor continuously for signs of respiratory distress.
Immediate postoperative care
Psychological support
Communication
Rehabilitation