upper respiratory problems

Overview of the Upper Respiratory System

The upper respiratory system includes:

• Nose

• Paranasal sinuses

• Pharynx

• Larynx

• Head and neck structures

Problems involving the upper respiratory system can affect:

• Ventilation: Movement of air into and out of the lungs.

• Oxygenation: Delivery of oxygen to the blood and tissues.

• Nutrition: Difficulty swallowing, chewing, or breathing while eating.

• Psychosocial status: Changes in appearance, speech, communication, and quality of life.

Nasal Fractures

Definition: A break in the nasal bones. Nasal fractures are the most common type of facial fracture.

Treatment:

• Some fractures require no reduction.

• Closed reduction or surgery may be performed when deformity or impaired function is present.

• Reduction is often delayed until swelling decreases, usually 5–7 days.

Potential complications:

• Airway obstruction

• Nosebleeds

• Meningeal tears

• Hematoma

• Cosmetic deformity

Nursing priorities:

1. Maintain a patent airway.

2. Assess for additional facial or head injuries.

3. Position the patient upright and slightly forward.

4. Monitor for bleeding and respiratory difficulty.

5. Instruct the patient to avoid blowing their nose.

6. Acetaminophen is preferred during the first 48 hours because aspirin and NSAIDs can increase bleeding risk.

If a patient has a nasal fracture and difficulty breathing, airway assessment comes before pain management or cosmetic concerns.

Rhinoplasty

Definition: Surgical reconstruction of the nose.

It may be performed for:

• Cosmetic reasons.

• Improved airway function.

Preoperative considerations:

• Hold aspirin and NSAIDs approximately 5 days to 2 weeks before surgery, according to provider instructions.

• These medications can increase bleeding risk.

Postoperative nursing care:

• Maintain airway patency.

• Assess respiratory status.

• Monitor for airway obstruction.

• Manage pain.

• Monitor for edema, bleeding, and infection.

• Packing or splinting may be used.

• Encourage follow-up appointments.

Patient teaching:

• Avoid blowing the nose.

• Avoid activities that could cause trauma to the nose.

• Keep the head elevated as instructed.

• Report excessive bleeding or signs of infection.

• Follow activity restrictions and postoperative instructions.

NCLEX TIP: After rhinoplasty, airway obstruction and bleeding are major concerns. Never assume that difficulty breathing is simply expected postoperative swelling.

Epistaxis

Definition: A nosebleed.

Epistaxis is classified as either anterior or posterior.

Anterior epistaxis

More common

• Bleeding originates from the front of the nasal cavity.

• Often managed with direct pressure.

• May be treated with medications or absorbent materials.

Possible treatments:

• Afrin (oxymetazoline)

• Lidocaine

• Epinephrine

• Silver nitrate

• Surgifoam

• Gelfoam

• Floseal

Posterior epistaxis

Higher risk

• Bleeding originates farther back in the nasal cavity.

• May be more difficult to control.

• Can require nasal packing or balloon devices.

Possible treatments:

• Merocel nasal sponges

• Rapid Rhino epistaxis balloons

• Foley catheter

Patients with posterior packing should be admitted because of the potential for respiratory compromise.

First aid for a nosebleed

1. Sit upright.

2. Lean slightly forward.

3. Pinch the soft part of the nostrils together.

4. Maintain pressure for 5–15 minutes.

5. If bleeding does not stop, seek medical care.

Why lean forward?

To prevent blood from draining down the throat, which can cause:

• Nausea and vomiting.

• Aspiration.

• Airway complications.

Nursing care for posterior packing:

• Closely monitor airway and respiratory status.

• Monitor for continued bleeding.

• Assess oxygenation.

• Watch for signs of respiratory compromise.

Discharge teaching:

• Do not pick or blow the nose.

• Avoid strenuous activity until cleared.

• Avoid forceful sneezing; sneeze with the mouth open.

• Avoid inserting anything into the nose.

• Follow instructions regarding packing removal and follow-up.

• Report recurrent or uncontrolled bleeding.

NCLEX PEARL: Posterior epistaxis + nasal packing = increased risk for airway compromise.

Allergic Rhinitis

Definition: Inflammation of the nasal mucosa in response to an allergen.

Common symptoms:

• Sneezing

• Watery, itchy eyes

• Itchy nose

• Thin, watery nasal drainage

• Nasal congestion

• Decreased sense of smell

Type	Description
Episodic	Exposure to an allergen not typically encountered in the patient's environment
Intermittent	Symptoms less than 4 days per week or less than 4 weeks per year
Persistent	Symptoms more than 4 days per week or more than 4 weeks per year
Seasonal	Occurs during specific seasons, commonly spring and fall
Perennial	Occurs throughout the year

treatment allergic rhinitis

Medication	Purpose / Nursing Considerations
Second-generation antihistamines	Reduce allergy symptoms; generally less sedating
Intranasal corticosteroids	Decrease nasal inflammation
Decongestants	Reduce nasal congestion
Anticholinergic nasal sprays	Reduce nasal secretions
Leukotriene modifiers	Help control allergic symptoms
Immunotherapy	Used when symptoms remain uncontrolled or allergen exposure cannot be avoided

Important medication reminders:

• Intranasal corticosteroids may take several days to 1–2 weeks to achieve maximum benefit.

• First-generation antihistamines, such as diphenhydramine (Benadryl), can cause sedation, hypotension, and falls.

• Older adults are especially vulnerable to these adverse effects.

NCLEX TIP: A patient taking diphenhydramine who is elderly and dizzy is at increased risk for falls.

Upper Respiratory Infections (URIs)

Most upper respiratory infections are viral.

Common problems include:

• Acute viral rhinopharyngitis (common cold)

• Influenza

• COVID-19

• Sinusitis

Acute Viral Rhinopharyngitis (Common Cold)

Definition: Viral infection involving the nose and pharynx.

Symptoms:

• Runny nose

• Watery eyes

• Nasal congestion

• Sneezing

• Cough

• Sore throat

• Fever

• Headache

• Fatigue

Contagious period:

• Contagious approximately 1–2 days before symptoms begin.

• Symptoms generally develop 2–3 days after infection.

• May remain contagious until symptoms resolve, typically around 7–10 days.

Treatment:

• Symptom management.

• Rest and hydration.

• Monitor for complications.

Possible complications:

• Bronchitis

• Pneumonia

• Ear infection

Nursing interventions and patient teaching:

• Encourage hand hygiene.

• Teach respiratory hygiene and cough etiquette.

• Encourage staying home while acutely ill.

• Follow pathogen-specific and facility-specific precautions.

• Droplet/contact precautions are commonly used in hospital settings, depending on the pathogen and policy.

VERY IMPORTANT:

• Antibiotics do NOT treat viral infections.

• Green or purulent nasal drainage does NOT automatically mean bacterial infection.

• Intranasal decongestant sprays should not be used longer than 5 days because of rebound congestion.

• Follow up if symptoms do not improve within 10–14 days.

NCLEX PEARL

Green mucus does not automatically mean the patient needs antibiotics!

Influenza

Definition: A highly contagious respiratory illness associated with significant morbidity and mortality.

Flu season:

• Typically September through April.

• Peaks between December and February.

Influenza types:

Type	Important Information
Influenza A	Causes significant human illness; can also infect animals
Influenza B	Causes significant human illness
Influenza C	Generally causes milder illness
Influenza D	Primarily affects animals

Influenza A is classified using two surface proteins:

• Hemagglutinin (H): Helps the virus enter the host cell.

• Neuraminidase (N): Helps with viral release and spread to other cells.

Think: H = Helps enter; N = New viruses spread

influenza transmission and s&s

Transmission:

• Respiratory droplets.

• Inhalation of infectious particles.

• Direct contact with contaminated surfaces or secretions.

Contagious period:

• Transmission can begin approximately 1 day before symptoms.

• Usually remains contagious for 5–7 days after symptom onset.

Signs and symptoms:

Influenza typically has an abrupt onset.

Common findings:

• High fever

• Severe muscle aches (myalgia)

• Headache

• Fatigue

• Cough

Diagnostic testing:

• Rapid diagnostic tests may use nasopharyngeal specimens.

• Testing is most useful when performed early, ideally within the first 48 hours.

management influenza

Treatment: Antivirals

Medication	Administration / Important Information
Baloxavir	Single-dose medication taken with water
Oseltamivir (Tamiflu)	Twice daily for 5 days

Important antiviral teaching:

• Start antiviral treatment as soon as possible.

• Maximum benefit occurs when started within 48 hours.

• Do not delay treatment in hospitalized, severely ill, or high-risk patients just because 48 hours have passed.

Nursing interventions:

• Encourage rest.

• Encourage hydration.

• Manage fever and symptoms.

• Monitor respiratory status.

• Teach annual influenza vaccination.

Vaccination reminder: The flu vaccine does not provide full protection immediately. The PowerPoint emphasizes that protection takes approximately 2 weeks to develop.

NCLEX PEARL: Influenza often presents with sudden fever, severe body aches, headache, and fatigue. The common cold generally has milder symptoms and a more gradual onset.

COVID-19

Definition: Respiratory illness caused by SARS-CoV-2.

Pathophysiology:

• SARS-CoV-2 is an enveloped RNA virus.

• It contains spike proteins.

• Spike proteins bind to ACE2 receptors on host cells.

• Cells in the upper respiratory tract are commonly infected.

• Conjunctival and gastrointestinal entry may also occur.

Transmission:

• Primarily through respiratory particles.

• Incubation may be up to 14 days.

• Patients may transmit the virus while asymptomatic or presymptomatic.

Signs and symptoms:

• Cough

• Fever

• Dyspnea

• Fatigue

• Headache

• Muscle aches

• Sore throat

• Runny nose

• Nasal congestion

• Nausea and vomiting

• Diarrhea

• Loss of taste or smell

• Sputum production

• Mental status changes in some patients

covid-19 Severity categories

Severity categories:

Category	Description
Asymptomatic/presymptomatic	Positive viral test without symptoms
Mild	Flu-like symptoms; often managed at home
Moderate	More significant respiratory illness, including pneumonia
Severe	SpO₂ below 94% on room air, RR above 30/min, or lung infiltrates above 50%; may involve sepsis
Critical	ARDS, septic shock, or cardiac, liver, renal, CNS, or thrombotic complications

Patients at increased risk for severe disease:

• Adults 65 years and older.

• Cancer.

• Kidney, heart, lung, liver, neurologic, or immune disorders.

• Diabetes.

• Obesity or overweight.

• Pregnancy or recent pregnancy.

• Smoking.

• Organ transplantation.

• Sickle cell disease.

• Thalassemia.

• Tuberculosis.

• Substance use disorders.

covid complications and diagnostics

Complications:

• Pneumonia

• Respiratory failure

• ARDS

• Sepsis

• Septic shock

• Multiple organ dysfunction syndrome (MODS)

• Cardiac complications

• Liver and kidney injury

• CNS complications

• Thrombotic problems

Post-COVID conditions:

Symptoms that persist beyond 4 weeks after the initial infection.

Possible symptoms:

• Persistent fatigue.

• Dyspnea.

• Loss of taste or smell.

• Cardiac problems.

• Cognitive changes.

• Psychological issues.

Diagnostic tests:

• Respiratory or oral-pharyngeal specimens.

• Antibody testing may indicate past infection or vaccination response.

• Chest CT may show diffuse opacities.

Possible laboratory findings:

• Lymphopenia.

• Elevated liver enzymes.

• Low albumin.

• Low platelets.

• Elevated CRP.

• Elevated ferritin.

• Elevated ESR.

• Elevated D-dimer.

• Elevated LDH.

covid interventions, meds, vaccines

Nursing interventions:

1. Monitor respiratory status closely.

2. Monitor oxygen saturation and hemodynamics.

3. Recognize rapid deterioration.

4. Escalate oxygen and respiratory support as needed.

5. Assess for sepsis, ARDS, thrombotic complications, and MODS.

6. Follow facility isolation and transmission-based precautions.

7. Support nutrition, skin integrity, and psychosocial well-being.

8. Provide symptom relief, such as acetaminophen for fever.

9. Collaborate with the interprofessional team.

Isolation: Follow current facility policy and pathogen-specific precautions. The lecture describes droplet, airborne, and contact precautions in acute care.

COVID-19 medications:

Medication	When / Why Used	Nursing Considerations
Nirmatrelvir/ritonavir (Paxlovid)	First-line option for eligible mild-to-moderate cases without supplemental oxygen; start within 5 days	Review eGFR and drug interactions
Molnupiravir	Alternative when Paxlovid cannot be used	Used in selected patients
Remdesivir (Veklury)	IV treatment for selected hospitalized patients needing conventional oxygen	Monitor nausea and liver function
Dexamethasone	Hospitalized patients needing high-flow nasal cannula, mechanical ventilation, or ECMO	Monitor response and adverse effects
Tocilizumab	Selected patients with rapid respiratory deterioration while receiving dexamethasone	Monitor for adverse effects and infection
Baricitinib	Selected patients with rapid respiratory deterioration while receiving dexamethasone	Monitor for adverse effects and infection

COVID-19 vaccines:

Types include:

• mRNA vaccines.

• Protein subunit vaccines.

• Viral vector vaccines.

Important teaching:

• mRNA vaccines give immune cells instructions to produce a spike protein.

• mRNA does not enter the nucleus or change a person's genes.

• Protein subunit and viral vector vaccines stimulate an immune response against the spike protein.

• Protein subunit vaccines cannot cause COVID-19 infection.

Common side effects:

• Injection-site reaction.

• Fatigue.

• Fever.

• Muscle pain.

NCLEX PEARL

For a patient with COVID-19, worsening oxygenation and increasing respiratory effort require prompt escalation. Watch for respiratory failure, ARDS, sepsis, and thrombotic complications.

Sinusitis

Definition: Inflammation of the sinus mucosa that causes swelling and obstruction of sinus openings.

Usually occurs with an infection.

Causes:

• Most commonly viral.

• Bacterial infection may be suspected when symptoms worsen after 3–5 days or persist longer than 10 days.

• Only approximately 5–10% of cases are bacterial, according to the lecture.

Types of sinusitis:

Type	Duration / Description
Acute	Begins within 1 week of URI and lasts less than 4 weeks
Subacute	Symptoms progress over 4–12 weeks
Recurrent acute	4 or more infections per year, lasting 7–10 days each
Chronic	Lasts longer than 12 weeks; often associated with allergies or nasal polyps

Symptoms:

• Significant pain over the affected sinus.

• Purulent nasal drainage.

• Nasal congestion.

• Fever.

• Malaise.

Risk factors and associations:

• Moderate to severe asthma.

• GERD.

• Smoking.

• Allergies.

• Nasal polyps.

Nursing interventions:

• Identify the likely cause.

• Treat symptoms.

• Monitor duration and progression.

• Teach the patient when to seek follow-up care.

NCLEX TIP: A patient whose sinus symptoms persist beyond 10 days or worsen after initial improvement may have a secondary bacterial infection.

Nasal Polyps

• Soft, painless, benign growths.

• Develop in response to repeated mucosal inflammation.

• Can obstruct nasal passages.

• May be associated with chronic sinusitis and allergies.

Foreign Bodies

A foreign object can obstruct the nasal passage or airway.

Patient and caregiver teaching:

• Do not push an object farther into the nose.

• Avoid blind attempts to remove an object.

• Seek appropriate medical assistance.

Acute Airway Obstruction

complete airway obstruction is a medical emergency.

Signs may include:

• Inability to speak.

• Inability to cough effectively.

• Difficulty breathing.

• Cyanosis.

• Decreased level of consciousness.

Foreign-body airway obstruction interventions

Patient	Intervention
Responsive adult or child with severe obstruction	Alternate 5 back blows and 5 abdominal thrusts
Infant	Alternate 5 back blows and 5 chest thrusts

Important:

• Do NOT perform a blind finger sweep.

• Cricothyroidotomy may be needed when emergency airway access is required.

NCLEX PEARL: Never perform a blind finger sweep because it can push the object farther into the airway.

Acute Pharyngitis

Definition: Acute inflammation of the pharyngeal walls, including the tonsils, palate, and uvula.

Causes:

Cause	Approximate Frequency / Example
Viral	Approximately 90% → symptom management
Bacterial	Group A beta-hemolytic Streptococcus; approximately 5–10%→ PCN
Fungal	Candidiasis (thrush)→ nystatin

Signs and symptoms:

• Scratchy or sore throat.

• Severe throat pain.

• Pharyngeal redness (erythema).

• Edema.

• Possible exudate.

• Fever.

• Enlarged anterior cervical lymph nodes.

Bacterial pharyngitis

Findings suggesting bacterial infection:

Remember:

• Fever.

• Anterior cervical lymphadenopathy.

• Tonsillar/pharyngeal exudate.

• Absence of cough.

These are cardinal findings associated with Group A strep

Diagnostics:

• Rapid antigen detection test.

• Throat culture, based on clinical findings.

—>Rheumatic fever if untreated

Peritonsillar Abscess

Definition: A complication of tonsillitis, typically associated with Group A beta-hemolytic Streptococcus.

Why is it dangerous?

An abscess near the tonsils can cause swelling and potentially obstruct the airway.

Nursing priorities:

1. Monitor airway patency.

2. Assess respiratory status.

3. Monitor for worsening swelling or difficulty swallowing.

4. Prepare for treatment.

Treatment:

• IV antibiotics.

• Needle aspiration or incision and drainage (I&D).

• Emergent tonsillectomy is rare.

• Elective tonsillectomy may be scheduled after the infection resolves.

PRIORITY

Peritonsillar abscess = monitor airway closely because swelling can compromise breathing.

Head and Neck Cancer

Definition: Cancer involving structures of the head and neck. It is classified according to the anatomical area where it develops.

Risk Factors

• Tobacco use.

• Excessive alcohol consumption.

• Age greater than 50.

• Male sex.

• HPV infection.

• Sun exposure.

• Asbestos exposure.

• Industrial carcinogens.

• Marijuana exposure.

• Radiation exposure.

• Poor oral hygiene.

Important: Tobacco and excessive alcohol are major risk factors. HPV is also an important risk factor for certain head and neck cancers.

Manifestations

Early symptoms can be overlooked because patients may assume they have an ordinary upper respiratory infection.

Possible early findings:

• Persistent sore throat.

• Hoarseness.

• Voice changes.

RED FLAG

Hoarseness lasting longer than 2 weeks may indicate early laryngeal cancer.

Late findings:

• Weight loss.

• Dysphagia (difficulty swallowing).

• Impaired tongue movement.

• Impaired jaw movement.

• Dyspnea.

• Partial or complete airway obstruction.

Why is early detection important?

Early detection improves the likelihood of successful treatment and survival.

Health promotion:

• HPV vaccination.

• Safer sexual practices.

• Tobacco avoidance.

• Limiting alcohol exposure.

• Awareness of persistent symptoms.

Cancer Staging: TNM

Cancer staging considers:

Letter	Meaning
T	Tumor size and extent
N	Number and location of involved lymph nodes
M	Presence or extent of distant metastasis

Memory trick:

• T = Tumor

• N = Nodes

• M = Metastasis

head and neck cancer treatment

Treatment depends on the cancer's location, stage, and patient preferences.

Possible treatments:

• Surgery.

• Radiation therapy.

• Chemotherapy.

• Targeted therapy.

• Combination therapy.

Treatment planning must consider the impact on:

• Speech.

• Swallowing.

• Chewing.

• Appearance.

• Communication.

• Quality of life.

management of head and neck cancer

The nurse assesses:

• Health history.

• Current medications.

• Functional health patterns.

• Respiratory system.

• Gastrointestinal system.

• Nutrition and swallowing.

• Pain.

• Communication ability.

• Psychosocial status.

Primary nursing goals:

1. Maintain a patent airway.

2. Promote an acceptable body image.

3. Prevent complications related to treatment.

4. Maintain adequate nutrition.

5. Minimize pain.

6. Promote the ability to communicate.

Common Treatment Complications

• Dry mouth (xerostomia).

• Skin irritation.

• Fatigue.

• Oral mucositis—> monitor intake, oral care, pain mngmnt

High-Yield Comparison: Upper Respiratory Problems

Condition	Hallmark Finding	Priority Nursing Concern
Nasal fracture	Facial trauma, swelling, bleeding	Airway obstruction
Rhinoplasty	Postoperative nasal reconstruction	Airway and bleeding
Anterior epistaxis	Bleeding from front of nose	Direct pressure
Posterior epistaxis	Bleeding farther back in nasal cavity	Airway compromise
Allergic rhinitis	Sneezing, itchy/watery eyes, thin drainage	Trigger avoidance and symptom management
Common cold	Gradual URI symptoms	Hydration, symptom management, infection prevention
Influenza	Abrupt fever, myalgia, fatigue	Early antiviral treatment when indicated
COVID-19	Respiratory symptoms, possible systemic complications	Monitor oxygenation and deterioration
Sinusitis	Sinus pain, congestion, drainage	Identify cause and manage symptoms
Nasal polyps	Soft, painless growths	Airway patency
Acute pharyngitis	Sore throat, erythema	Identify viral vs. bacterial vs. fungal cause
Peritonsillar abscess	Tonsillar infection with abscess	Airway monitoring
Head and neck cancer	Persistent hoarseness, sore throat, dysphagia	Airway, nutrition, communication

Review

• Airway is always the priority with nasal fractures, posterior epistaxis, peritonsillar abscesses, and airway obstruction.

• Nasal fracture: position upright and slightly forward; avoid nose blowing.

• Acetaminophen is preferred during the first 48 hours after nasal fracture because NSAIDs and aspirin increase bleeding risk.

• Rhinoplasty: monitor airway, bleeding, edema, and infection.

• Epistaxis: sit upright, lean forward, and pinch the nostrils for 5–15 minutes.

• Posterior epistaxis: packing can compromise the airway; close monitoring and admission are important.

• Allergic rhinitis: itchy eyes/nose, sneezing, and thin watery drainage.

• Intranasal corticosteroids take several days to 1–2 weeks for maximum benefit.

• Diphenhydramine can cause sedation, hypotension, and falls, especially in older adults.

• Common cold: viral; antibiotics do not treat it.

• Green nasal drainage does not automatically mean bacterial infection.

• Decongestant nasal sprays should not be used longer than 5 days because of rebound congestion.

• Influenza: abrupt onset, high fever, severe myalgia, headache, and fatigue.

• Influenza antivirals work best when started within 48 hours, but do not delay treatment for high-risk or severely ill patients.

• COVID-19 can cause ARDS, sepsis, MODS, and thrombotic complications.

• Paxlovid: check kidney function and drug interactions.

• Sinusitis lasting longer than 10 days or worsening after 3–5 days may suggest bacterial infection.

• Group A strep: fever, anterior cervical lymphadenopathy, exudate, and absence of cough.

• Peritonsillar abscess: IV antibiotics and drainage; monitor airway.

• Hoarseness lasting longer than 2 weeks may indicate laryngeal cancer.

• Head and neck cancer: remember TNM staging.

• Tracheostomy discharge teaching: stoma care, teach-back, emergency supplies, and a spare tube with obturator.

priority concepts

AIRWAY

Recognize obstruction and know when to escalate care.

MEDICATION SAFETY

Know why antibiotics are not used for viral infections, why nasal sprays can cause rebound congestion, and why older adults are at risk with first-generation antihistamines.

RECOGNITION

Differentiate influenza, COVID-19, common cold, allergic rhinitis, and bacterial pharyngitis.

COMPLICATIONS

Recognize posterior epistaxis, peritonsillar abscess, CSF leakage after facial trauma, and respiratory deterioration.

PATIENT EDUCATION

Know rhinoplasty precautions, epistaxis care, infection prevention, and tracheostomy emergency supplies.