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, and antihistamines
Nursing Management: prevention and minimizing potential complications; handwashing

3. Infectious and Inflammatory Disorders—(cont.)
Sinusitis
Pathophysiology and Etiology: inflammation of the sinuses; maxillary sinus
Complications: infection of middle ear or brain
Assessment Findings: headache, fever, pain over affected sinus, nasal congestion, pain, pressure around eyes, malaise
Medical and Surgical Management: saline irrigation, antibiotic therapy, vasoconstrictors, nasal corticosteroids
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” dressing or “drip pad”)

5. NCLEX
Of the following instructions, which is most important for the nurse to teach the client to help loosen secretions and increase comfort during medical treatment for sinusitis?
A) Blow the nose frequently.
B) Elevate the head of the bed by 45°.
C) Engage in normal activity.
D) Increase fluid intake.

6. NCLEX
Answer: D) Increase fluid intake. Rationale: If the client is receiving medical treatment, the nurse informs the client to use mouthwashes and humidification, as well as increased fluid intake, which may loosen secretions and increase comfort.

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 with dysphagia, fever, chills, headache, white or exudates patch over tonsillar area, swollen glands
Medical Management
Throat culture
Antibiotic treatment: assess allergy to penicillin; 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 and Surgical Management: antibiotic therapy, analgesics, saline gargles, tonsillectomy, and adenoidectomy
Nursing Management: precare/postcare: lab results: hematocrit, platelet count, clotting time, aspirin use, NSAIDs
Risk for Aspiration, Risk for Impaired Tissue Integrity, and Acute Pain.

10. NCLEX
The nurse is providing postoperative care for a client who has undergone tonsillectomy. In which position will the nurse place the head of the bed when the client is fully awake?
A) Flat with the head elevated on a pillow
B) Slightly raised at a 15° angle
C) Raised at a 45° angle
D) Raised at a 90° sitting position

11. NCLEX
Answer: C) Raised at a 45° angle Rationale: Elevate head of bed 45° when client is fully awake. This position decreases surgical edema and increases lung expansion.

12. 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

13. Infectious and Inflammatory Disorders—(cont.)
Peritonsillar Abscess—(cont.)
Medical and Surgical Management: antibiotic therapy, 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

14. Infectious and Inflammatory Disorders—(cont.)
Laryngitis
Pathophysiology and Etiology
Inflammation and swelling of the mucous membrane that lines larynx
Causes: URI, excessive/improper 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

15. 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/inhale drugs
Assessment Findings: nasal speculum and tongue blade reveals bleeding

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

17. NCLEX
A client was seen in the emergency room with severe epistaxis. After the physician places a nasal packing, the bleeding is controlled. What should the nurse include as part of the discharge instructions? Select all that apply.
A) Call physician if bleeding persists or becomes worse.
B) Continue taking baby aspirin as ordered.
C) Do not blow the nose.
D) Keep nasal packing in place until seen for follow-up appointment.

18. NCLEX
Answers: A) Call physician if bleeding persists or becomes worse. C) Do not blow the nose. D) Keep nasal packing in place until seen for follow-up appointment. Rationale: The nurse assesses for signs of continued bleeding and educates the clients on measure to prevent bleeding.

19. Structural Disorders—(cont.)
Nasal Obstruction
Pathophysiology and Etiology
Primary conditions: deviated septum, nasal polyps or grapelike swellings, and hypertrophied turbinates
Assessment Findings: hx of sinusitis, difficulty breathing out of one nostril, frequent nosebleeds
Medical and Surgical Management: submucous surgical resection or septoplasty, rhinoplasty or reconstruction of the nose, steroidal nasal spray
Nursing Management: nasal packing, mouth breathing, semi- Fowler’s, VS, oral hygiene

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

21. Trauma and Obstruction of the 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-rays, oxygenation studies
Medical and Surgical Management: patent airway, Heimlich maneuver
Nursing Management: LS, respiratory pattern, nasal swelling, bleeding, and laryngeal edema

22. Trauma and Obstruction of the Upper Airway—(cont.)
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 secs, awaken suddenly with loud snort
Daytime fatigue, morning headache, inability to concentrate, sore throat, enuresis, and erectile dysfunction

23. Trauma and Obstruction of the Upper Airway—(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

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

25. Alternative Measures of Communication
Methods of laryngeal speech used after a laryngectomy includes the following:
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

26. Treatment Modalities for Airway Obstruction or Airway Maintenance
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

27. Treatment Modalities for Airway Obstruction or Airway Maintenance—(cont.)
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

28. Treatment Modalities for Airway Obstruction or Airway Maintenance—(cont.)
Endotracheal Intubation and Mechanical Ventilation
Uses: respiratory difficulties, comatose clients, general anesthesia
Mechanical ventilation: negative pressure, positive pressure
Nursing Management: vital signs; blood gas studies; pulse oximetry; evaluate mental status, confusion, agitation; lung auscultation; suctioning and humidification; communication; “magic slate”; wipe board