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

2. 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

3. 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

4. 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”)

5. 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.”

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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.”

19. 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.

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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