1. Caring for Patients With Upper Respiratory Disorders

2. Learning Outcomes 1.Describe common disorders affecting the upper respiratory tract, their manifestations, and potential impact on the patient. 2.Safely administer medications and treatments ordered for patients with upper respiratory disorders.

3. Learning Outcomes 3.Plan and provide appropriate individualized nursing care for patients with upper respiratory disorders, showing consideration for expressed values, preferences, and needs. 4.Use technology to identify evidence-based guidelines and document care for patients with upper respiratory system disorders.

4. Learning Outcomes 5.Provide evidence-based teaching and instructions to ensure continuity of care for patients with upper respiratory system disorders.

5. Upper Respiratory Infections and Inflammations Most self-limiting In long-term care facilities can spread rapidly ◦ Control spread Risk for serious problems in older adults

6. Pathophysiology and Manifestations Rhinitis ◦ Inflammation of nasal cavities ◦ Types ◦ Acute viral rhinitis ◦ Allergic rhinitis

7. Pathophysiology and Manifestations Respiratory syncytial virus ◦ Common virus among infants and young children ◦ Usually mild "cold" in adults, unless immunocompromised ◦ Older adults may present with pneumonia.

8. Pathophysiology and Manifestations Influenza ◦ Contagious viral respiratory disease ◦ Mode of transmission ◦ Airborne droplet ◦ Direct contact

9. TABLE 22-1 Manifestations and Course of Rhinitis and Influenza

10. Pathophysiology and Manifestations Sinusitis ◦ Inflammation of mucous membranes of sinuses ◦ Usually caused by bacterial infection ◦ Usually follows URI

11. Pathophysiology and Manifestations Pharyngitis and tonsilitis ◦ Acute inflammation of the throat ◦ Usually viral but may be bacterial ◦ Group A beta-hemolytic Streptococcus (strep throat) most common cause of bacterial form

12. Pathophysiology and Manifestations Pharyngitis and tonsilitis ◦ Tonsillitis ◦ Acute inflammation of the tonsils ◦ May be caused by streptococcal infection ◦ Infectious, may be spread by droplet nuclei ◦ Dysphagia ◦ Difficulty swallowing

13. Pathophysiology and Manifestations Epiglottitis ◦ Medical emergency ◦ Monitor for signs of respiratory distress ◦ Nasal flaring ◦ Restlessness ◦ Stridor ◦ Use of accessory muscles ◦ Oxygen saturation

14. Pathophysiology and Manifestations Epiglottitis ◦ Don't insert nasal or oral airway ◦ May cause spasm and airway obstruction ◦ Nasotracheal intubation may be necessary.

15. Pathophysiology and Manifestations Laryngitis ◦ Inflammation of larynx ◦ Change in voice ◦ Sore, scratchy throat ◦ Dry, harsh cough

16. Collaborative Care Diagnostic tests ◦ Throat swab ◦ CBC ◦ Chest x-ray ◦ Nasal swab ◦ CT scan

17. Collaborative Care Medications ◦ Influenza ◦ Yearly immunization ◦ Bacterial infections ◦ Antibiotic treatment ◦ Use for up to 10 days ◦ Patient no longer contagious after 24 hours of antibiotic therapy ◦ Used up to 2 weeks for sinusitis

18. Collaborative Care Medications ◦ Rhinitis ◦ Decongestants ◦ Antihistamines ◦ Topical nasal steroids ◦ Inhaled steroids

19. Collaborative Care Medications ◦ Sore throat ◦ Warm saltwater gargles ◦ Throat lozenges ◦ Mild analgesics ◦ Cough ◦ Antitussives ◦ Systemic mucolytic agents (guaifenesin)

20. Collaborative Care Complementary therapies ◦ Herbal remedies ◦ Aromatherapy Surgical interventions ◦ Irrigation ◦ Endoscopic sinus surgery ◦ Tonsillectomy

21. Nursing Care Prioritizing nursing care ◦ Maintain airway, breathing, rest Health promotion ◦ Frequent hand washing ◦ Warn of antibiotic misuse

22. Nursing Care Assessing ◦ Determine effect of URI on patient's life ◦ Identify risk factors for complications ◦ Determine whether problem will require medical treatment or self-care appropriate Identifying potential complications ◦ High or continuing fever ◦ Change in mental status, hearing

23. Nursing Care Diagnosing, planning, and implementing ◦ Ineffective breathing pattern ◦ Monitor respiratory rate and pattern ◦ Auscultate lungs ◦ Pace activities ◦ Elevate head of bed

24. Nursing Care Diagnosing, planning, and implementing ◦ Ineffective airway clearance ◦ Monitor effectiveness of cough ◦ Note whether cough is productive or nonproductive ◦ Auscultate lungs

25. Nursing Care Diagnosing, planning, and implementing ◦ Disturbed sleep pattern ◦ Assess sleep pattern ◦ Place in semi-Fowler's or Fowler's position ◦ Provide antipyretics and analgesics ◦ Cough suppressant at night

26. Nursing Care Diagnosing, planning, and implementing ◦ Impaired verbal communication ◦ Encourage patient to rest voice. ◦ Use alternative method to communicate, such as a writing pad. ◦ Comfort measures ◦ Lozenges, gargle, or sprays ◦ Encourage patient to quit smoking.

27. Nursing Care Managing nursing care ◦ Reminding patient to cough, deep breathe. Evaluating ◦ Ability to manage symptoms Documenting ◦ Assessments, understanding of teaching

28. Nursing Care Continuity of care ◦ Encourage rest ◦ Adequate hydration ◦ Hand washing after coughing ◦ Avoid exposure to crowds ◦ Avoid physical or psychologic stress ◦ Prevention for influenza ◦ Vaccine for high-risk groups

29. Nursing Care Continuity of care ◦ Discuss OTC medications for relief of symptoms ◦ Assist patient to identify possible allergens for allergic rhinitis ◦ Stress importance of completing entire course if on antibiotics ◦ Teach complications of influenza and URIs

30. Pertussis Whooping cough Acute, highly contagious

31. Pathophysiology and Manifestations Infection with Bordetella pertussis Symptoms of URI 7–10 days after exposure ◦ Followed by disruptive cough that may end with audible whoop Adults may present with simple, prolonged cough or typical pattern.

32. Collaborative Care Nasopharyngeal secretions culture Blood tests for antibodies Prevention ◦ Immunization Erythromycin ◦ Traditional antibiotic of choice

33. Nursing Care Education Respiratory isolation measures ◦ Prophylactic antibiotic therapy for all household contacts Reportable disease

34. Upper Respiratory Trauma or Obstruction

35. Epistaxis Nosebleed May be caused by: ◦ Trauma ◦ Drying of membranes ◦ Infection ◦ Substance abuse

36. Pathophysiology and Manifestations Ninety percent arise from vascular area in anterior nasal septum Posterior nosebleed ◦ Hypertension ◦ Diabetes

37. Collaborative Care Pinch toward septum for 5–10 minutes Instruct patient to spit out blood If pressure doesn't control bleeding, further interventions may be necessary. Medications and nasal packing ◦ Topical vasoconstrictors ◦ Anterior packing left in place 24–72 hours

38. Collaborative Care Medications and nasal packing ◦ Posterior packing left in place up to 5 days ◦ Uncomfortable ◦ Supplemental oxygen given with posterior packing Surgery ◦ Cautery procedures ◦ Scab must be left undisturbed.

39. Nursing Care Prioritizing nursing care ◦ Reduce anxiety and maintain airway Health promotion ◦ Reduce incidence ◦ Management of simple nosebleeds Assessing ◦ Simultaneous with implementing interventions

40. Nursing Care Diagnosing, planning, and implementing ◦ Anxiety ◦ Risk for aspiration Evaluating ◦ Additional bleeding Documenting ◦ Time, measures required to control bleeding

41. Nursing Care Continuity of care ◦ Avoid strenuous exercise for days or weeks ◦ Do not blow the nose forcefully ◦ No heavy lifting ◦ Sneeze with mouth open ◦ Lubricate nares with petroleum jelly or bacitracin. ◦ Use humidifier

42. Nasal Polyps Benign growths on mucous lining inside nose Usually bilateral May be asymptomatic or resolve spontaneously Large polyps may cause obstruction, rhinorrhea, loss of smell

43. Nasal Polyps Treatment ◦ Topical corticosteroid nasal sprays ◦ Surgery ◦ Polypectomy

44. Nursing Care Postoperative care instructions ◦ Measures to reduce risk of bleeding ◦ Ice, cold compresses ◦ Avoid blowing nose for 24–48 hours after removal of packing. ◦ Avoid straining, coughing, strenuous exercise. ◦ Manifestations and possible bleeding

45. Nasal Trauma or Deviated Septum Fracture (broken nose) Most commonly broken bone of the face

46. Pathophysiology and Manifestations One or both sides of nose Swelling can obstruct airway. Soft tissue damage nearly always accompanies nasal fracture. Deviated nasal septum ◦ Septal cartilage bulges to one side

47. Collaborative Care Maintain patent airway and prevent deformity. If CSF leak suspected, CT scan performed More complex fractures may need surgery.

48. Collaborative Care Rhinoplasty ◦ Surgical reconstruction of the nose Septoplasty or submucosal resection (SMR) ◦ Corrects deviation

49. Nursing Care Nursing care ◦ Airway management ◦ Control of bleeding, pain and swelling Health promotion ◦ Provide necessary teaching Assessing ◦ Pain, swelling, bleeding, difficulty breathing, deformities, ecchymosis and crepitus

50. Nursing Care Diagnosing, planning, and implementing ◦ Ineffective airway clearance ◦ Risk for infection Evaluating ◦ Position of septum, appearance of nose Documenting ◦ Instructions for follow-up

51. Nursing Care Continuity of care ◦ Ice packs for 20 minutes 4 times/day ◦ Elevate head of bed ◦ Patient with CSF leak ◦ Rest with head elevated and monitor for infection

52. Laryngeal Obstruction or Trauma Life-threatening emergency Narrowest part of upper airway Partial or full obstruction

53. Pathophysiology and Manifestations Obstruction can be caused by: ◦ Laryngospasm ◦ Muscles of the larynx ◦ Laryngeal edema ◦ Aspirated food or foreign object ◦ Trauma to larynx

54. Pathophysiology and Manifestations Manifestations ◦ Coughing ◦ Choking ◦ Gagging ◦ Difficulty breathing ◦ Use of accessory muscles ◦ Stridor

55. Pathophysiology and Manifestations Manifestations ◦ Swelling impairs airway ◦ Subcutaneous emphysema ◦ Change in voice ◦ Dysphagia ◦ Stridor ◦ Hemoptysis ◦ Cough

56. Collaborative Care X-rays, diagnostic tests, or ultrasound to locate obstruction Insertion of endotracheal tube For laryngeal edema due to anaphylaxis, epinephrine given

57. Nursing Care Closely monitor patients at risk for laryngeal obstruction. Suction airway. Be prepared for endotracheal intubation or tracheotomy. Be prepared to initiate CPR. Teach prevention.

58. Obstructive Sleep Apnea Temporary absence of breathing during sleep Risk factors ◦ Obesity ◦ Large neck ◦ Use of alcohol or sedatives

59. Pathophysiology and Manifestations Upper airway obstructed as muscles relax Collapse during inspiration Fall in oxygen saturation Leads to fragmented sleep and disruption of normal sleep cycles

60. Pathophysiology and Manifestations Manifestations ◦ Loud snoring ◦ Frequent nighttime waking ◦ Daytime sleepiness ◦ Headache ◦ Irritability

61. Collaborative Care Diagnosis in sleep laboratory Weight loss prescribed Strict avoidance of alcohol, hypnotic medication

62. Collaborative Care Positive pressure air compressors ◦ CPAP therapy ◦ BiPAP therapy ◦ AutoPAP therapy Surgery ◦ Uvulopalatopharyngoplasty (UPPP)

63. Nursing Care Focus on teaching ◦ Use of respiratory equipment ◦ Avoidance or correction of risk factors

64. Laryngeal Cancer Risk factors ◦ Prolonged use of tobacco and alcohol ◦ Poor nutrition ◦ Occupational exposure Men affected nearly four times more than women

65. Pathophysiology and Manifestations Benign tumors ◦ Common in patients who chronically shout, project, or vocalize in very high or low tone ◦ Hoarseness, breathy voice Malignant tumors ◦ Leukoplakia ◦ Erythroplakia

66. BOX 22-7 Manifestations of Laryngeal Cancer

67. Pathophysiology and Manifestations Malignant tumors ◦ Lesions of true vocal cords, glottis more common ◦ Supraglottic ◦ Change in voice primary manifestation ◦ Tumor prevents complete closure of vocal cords during speech. ◦ Subglottic tumors least common

68. Collaborative Care Diagnostic tests ◦ Laryngoscopy ◦ CT scan ◦ MRI ◦ Needle biopsy ◦ Barium swallow

69. Collaborative Care Radiation ◦ Treatment of choice if localized Chemotherapy ◦ Before surgery or in combination Surgery ◦ Type determined by size, site, and invasiveness of tumor ◦ Carcinoma in situ and vocal polyps treated with laser on outpatient basis

70. Collaborative Care Surgery ◦ Tracheostomy ◦ Total laryngectomy ◦ Entire larynx removed ◦ Normal speech lost ◦ Permanent tracheostomy ◦ Modified or radical neck dissection ◦ If cervical lymph nodes contain cancer cells

71. Nursing Care Prioritizing nursing care ◦ Maintain patent airway Health promotion ◦ Prevent smoking ◦ Early warning signs of laryngeal cancer

72. Nursing Care Assessing ◦ Subjective data from patient vital ◦ Symptoms not until advanced stages Diagnosing, planning, and implementing ◦ Risk for impaired airway clearance ◦ Monitor for airway obstruction ◦ Cold packs as ordered

73. Nursing Care Diagnosing, planning, and implementing ◦ Risk for impaired airway clearance ◦ Withhold food until gag reflex has returned ◦ Impaired verbal communication ◦ Provide alternative ways to communicate ◦ Refer to speech therapist

74. Nursing Care Diagnosing, planning, and implementing ◦ Imbalanced nutrition: less than body requirements ◦ Grieving Managing nursing care ◦ Importance of responding promptly to patient's call, supporting head and neck, and reporting respiratory distress.

75. Nursing Care Evaluating ◦ Effectiveness of interventions Documenting ◦ Note patient's, family's responses Continuity of care ◦ Voice rest for benign tumors ◦ Tracheostomy care ◦ Assessment for discharge