1. Chapter 27 Nursing Management Upper Respiratory Problems Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

2. Structural and Traumatic Disorders of the Nose  Deviated septum  Nasal fracture  40% of bone injuries in facial trauma  Obstruction, epistaxis, meningeal tears What might clear nasal drainage indicate? What might clear nasal drainage indicate?  Rhinoplasty  Surgical reconstruction of the nose

3. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Epistaxis  Causes  Trauma  Foreign bodies  Drugs  Steroids  Tumors  Location  Anterior (80%) – Kiesselbach plexus  Posterior – posterior branch sphenopalatine artery

4. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Care for Nosebleed  Sit forward or high Fowler’s position  Direct pressure for 10 – 15 minutes  Vasoconstrictive medications Cocaine, neosynephrine (Afrin nasal spray) Cocaine, neosynephrine (Afrin nasal spray)  Cauterization  Nasal packing  Patient teaching  Avoid blowing nose, strenuous activity, lifiting, sneeze with mouth open, avoid ASA & NSAIDs

5. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

6. Fig. 27-1

7. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Inflammation and Infection of the Nose and Paranasal Sinuses

8. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Allergic Rhinitis  Clinical manifestations  Sneezing  Watery eyes  Watery nasal draingage or congestion  Pale, boggy turbinates  Cough (post-nasal drip)  Management: Allergic rhinitis  Indentify causative agent  Antihistamines What are the side effects? What are the side effects?  Nasal corticosteroids  Immunotherapy

9. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Viral Rhinitis  AKA the common cold or acute coryza  Most prevalent infectious disease  Spread by droplet transmission  Management: Acute viral rhinitis  Rest  Fluids  Antipyretics  Observe for secondary bacterial infection Fever >100.4, mucopurulent discharge, swollen & tender nodes, pharyngeal erythema Fever >100.4, mucopurulent discharge, swollen & tender nodes, pharyngeal erythema

10. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Influenza  Causes 36,000 deaths annually in the U.S.  Usually in people > 60 years  Clinical manifestations  Fever  Aches  Chills  Tiredness  Sudden symptoms Runny nose and GI symptoms are more common in children Runny nose and GI symptoms are more common in children Most common complication is pneumonia Most common complication is pneumonia

11. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Influenza  Management: Influenza  Identify high-risk individuals and recommend vaccination (attenuated live virus or inactivated) Age > 50, health care workers, chronic respiratory illness Age > 50, health care workers, chronic respiratory illness Most effective when given in the fall Most effective when given in the fall Contraidications – egg allergy or Hx of Guillain-Barré syndrome Contraidications – egg allergy or Hx of Guillain-Barré syndrome  Symptom management Fluids, rest, antipyretics (no ASA in children – Reye’s syndrome) Fluids, rest, antipyretics (no ASA in children – Reye’s syndrome)  Antiviral medications Must be started within 48 hrs of illness onset Must be started within 48 hrs of illness onset May be prescribed for prophylaxis May be prescribed for prophylaxis

12. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Sinusitis  Ostia of one or more of the sinuses becomes blocked by swollen or inflamed nasal mucosa  May be viral, bacterial, or fungal (rare)  Acute is usually related to URI, allergic rhinitis, swimming, or dental manipulation  Chronic > 3 weeks duration; linked with allergies & nasal polyps  Clinical manifestations  Pain over the affected sinus, fever, malaise, HA, congestion, purulent nasal discharge  Chronic presentation is nonspecific

13. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 27-3

14. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Sinusitis  Management: Sinusitis  Antibiotics if symptoms last > 7 days Due to difficulty with treating the infection courses may last from 10 days to several weeks Due to difficulty with treating the infection courses may last from 10 days to several weeks  Decongestant sprays Do not use for more than 72 hours – rebound effect Do not use for more than 72 hours – rebound effect  Topical steroids  Antihistamines Avoid usage Avoid usage  Saline nasal lavage Neti pot, bulb syringe Neti pot, bulb syringe

15. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Obstruction of the Nose and Paranasal Sinuses  Polyps  Benign masses that develop in response to repeated inflammation  Foreign bodies  Inorganic May produce no symptoms May produce no symptoms  Organic Cause local reaction Cause local reaction Purulent, foul smelling drainage Purulent, foul smelling drainage  Sneezing or blow nose  Do not irrigate

16. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Problems Related to the Pharynx  Acute pharyngitis  Viral  Bacterial Strep throat Strep throat  What complication(s) can arise untreated strep throat?  Candida albicans  Thrush Opportunistic infections may indicate? Opportunistic infections may indicate?  Diphtheria  What population(s) would you expect to have diphtheria? to have diphtheria?

17. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Pharyngitis  Clinical manifestations  Fever, pharyngeal erythema, pain, N/V, tonsillar exudates, cough (not with strep throat)  Management: Acute pharyngitis  Rapid strep  Supportive care Fluids, rest, antipyretics, Fluids, rest, antipyretics, analgesia analgesia  Antibiotics Penicillin – drug of choice Penicillin – drug of choice  Immunization – diphtheria

18. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Obstructive Sleep Apnea  Clinical manifestations and diagnostic studies  Frequent awakening at night (as many as 200- 400), insomnia, excessive daytime sleepiness, witnessed apenic episodes, snoring, irritability, morning HA (hypercapnia dilates cerebral vessels)  Polysmnography  Management: Sleep apnea  Avoid sedatives & alcohol before sleep, weight loss, oral appliances, CPAP, BiPAP, surgery

19. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Obstructive Sleep Apnea  Uvulopalatopharyngoplasty  UPPP or UP3  Geniglossal advancement & advancement & hyoid myotomy hyoid myotomy  GAHM

20. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 27-5

21. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Problems Related to the Trachea and Larynx

22. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Airway Obstruction  Medical emergency  May be partial or complete Aspiration, foreign bodies, CNS depression, laryngeal spasms, edema, allergic reaction Aspiration, foreign bodies, CNS depression, laryngeal spasms, edema, allergic reaction  Clinical manifestations  Stridor, wheezes, retractions, cyanosis, restlessness, tachcardia, snoring How do you assess for airway patentcy? How do you assess for airway patentcy?  Management: Airway obstruction  Reversal agents, CPAP, BIPAP, intubation, OPA, NPA, surgically created airways

23. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tracheostomy

24. Tracheostomy  What is a tracheostomy?  Surgically created airway entering the trachea  Indications  Bypass upper airway obstruction  Facilitate removal of secretions  Long-term mechanical ventilation Permit oral intake and speech Permit oral intake and speech Increased comfort Increased comfort Less risk of damage to airway Less risk of damage to airway Increased mobility Increased mobility

25. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

26. Fig. 27-6

27. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Tracheostomy  Providing tracheostomy care  What structures are bypassed with a trach? What is the client at risk for?  What interventions do you anticipate?  Swallowing dysfunction  How is the airway protected with a trach?  How is swallowing assessed?  Speech with a tracheostomy tube  Cuffed vs. fenstrated tubes  Decannulation

28. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 27-7

29. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 27-8.

30. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 27-10

31. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Head and Neck Cancer  Clinical manifestations  Early signs Painless growth Painless growth Sore that does not heal Sore that does not heal Change in fit of dentures Change in fit of dentures Persistent sore throat, lump, unilateral ear pain, or hoarseness Persistent sore throat, lump, unilateral ear pain, or hoarseness  Late signs Pain Pain Dysphagia Dysphagia ↓ tongue mobility ↓ tongue mobility Airway obstruction Airway obstruction

32. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Head and Neck Cancer  Diagnostic studies  CT scan, MRI, PET scan, biopsy  Collaborative care  Stage & grade  What are the treatment options?  What structures can be affected?  Nutritional therapy How does radical neck dissection or supraglottic larygectomy impact nutrition? How does radical neck dissection or supraglottic larygectomy impact nutrition?

33. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 27-12

34. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 27-14

35. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Head and Neck Cancer  Nursing assessment  Nursing diagnoses  Planning  Nursing implementation  Health promotion What places a person at risk? What places a person at risk?

36. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 27-15