Upper Respiratory Disorders 1

Polyps

swollen masses of the sinus or nasal mucosa and connective tissue that extend into the nasal passages.

Sinusitis

inflammation of the sinuses

Rhinosinusitis

a condition characterized by inflammation of the nasal cavity and sinus membranes, often leading to congestion and facial pain.

decongestants

medications used to relieve nasal congestion by reducing swelling in the nasal passages.

triad disease

The triad disease is often characterized by the presence of nasal polyps, asthma, and aspirin sensitivity, commonly referred to as Samter's triad.

Sinusitus SIGNS AND SYMPTOMS

Patients report pain or feeling of heaviness over affected sinus.

May report purulent drainage from the nose

Maxillary sinuses; the pain may seems like a toothache

Headache is MOST COMMON

Fever may be present

WBC count may be elevated

Symptoms of chronic sinusitis are often nonspecific. Patients experience facial or dental pain, nasal congestion, increased drainage. Fever not usually present.

Sinusitis: Complications

Chronic sinusitis may follow acute sinusitis.

Other potential complications are meningitis, brain abscess, osteomyelitis, and orbital cellulitis.

Possibility of brain infection exists.

Suspects neurologic complications if patient has high fever, vomiting, chill, seizures, or blurred vision.

Sinusitis: Medical Diagnosis and Treatment

Confirmed with CT or MRI.

Culture of material obtained by aspiration of sinuses done by specialist.

Medciations: decongestants to promote drainage, intranasal corticosteroids to decrease inflammation, and OTC analgesics to relieve pain.

Warm, moist packs applied to face can promote drainage and reduce pain.

Other measures to promote drainage include: twice-daily hot showers, increase fluid intake, use of humidifier.

After hot shower or use of humidifier, encourage patient to blow nose thoroughly.

Sleep with head of head elevated

Nasal saline sprays of washes.

Irrigating solutions can be prepared at home using saline water ( 1 quart), pickling/canning salt (1 tom 1 ½ heaped teaspoons) and baking soda (1 teaspoon).

DO NOT USE tape water or table salt.

Sinusitis: Surgical Treatment

MOST COMMON surgery is functional endoscopic sinus surgery (FESS). FESS is an outpatient procedure in which specialized instruments are passed into the sinuses through nasal cavity.

Nasal packing may be done to control the bleeding. Removed after a few hours.

Complications of FESS include: nasal bleeding and scarring. Cerebrospinal fluid (CSF) leakage and injury are possible.

Another surgical option: sinus postal dilation (SOD), which uses a balloon to enlarge the openings in the sinuses promote drainage. SOD can be done in outpatient settings.

Less commonly, External sphenoethmoidectomy is done through a small incision on the side of the nose that permits removal of disease sphenoidal or ethmoidal sinus mucosa.

Nursing care of the Patient having Sinus Surgery

After FESS, patient is able to return to work in 4 to 5 days.

Saline nasal sprays may be ordered to prevent crusting and promote healing.

Fowler position is recommended to prevent swelling and promote drainage.

Apply cold compress as ordered during first 24 hours.

Nasal packing usually left in place until first postoperative day.

Antral packing is left in place for 36 to 72 hours.

Caution the patient to avoid plowing nose or straining, which could cause bleeding and tissue damage.

After procedure (3-5 days), nasal sprays order to moisten nasal mucosa.

Nasal Polyps

Small polyps are typically asymptomatic.

Large polyps may grow and eventually obstruct the nasal airways.

Polyps resemble white grapes in size and shape.

Exact cause UNKNOWN, but patients often have Hx of allergic rhinitis or infections.

Size may be reduced by removing allergens or treating the allergic response.

Corticosteroids inhaled nasally may be prescribed.

Surgical removal under local anesthesia often necessary.

Nasal polyps tend to recur.

Nursing Care of the Patient having Nasal Polyps Surgery

Often doen in an outpatient facility.

Advise patient not to take aspirin; it increases the risk of bleeding and some patients are allergic to aspirin.

Rhinitis “Hay Fever”

Classified as intermittent (seasonal) or persistent (perennial).

Considered persistent when symptoms are present for more than 4 days a week for more than 4 weeks per year.

Allergic Rhinitis: Pathophysiology

Follows exposure to a substance that causes an allergic response (allergens).

Fluid leaks from capillaries, causing swelling of nasal mucosa.

Changes are triggered by overuse of decongestant nose drops or sprays.

Intermittent allergic rhinitis is cause by exposure to pollens. Lasts several weeks, resolves, and does not return until the pollen reappears.

Persistent allergic rhinitis is more likely due to allergens that are continuously in the environment, such as dust and animal dander.

allergen

a reaction to the release of the chemicals, including histamine, that causes vasodilation and increased capillary permeability.

Allergic Rhinitis: Signs and Symptoms

Sneezing, watery and itchy eyes, nasal obstruction, clear nasal discharge, frontal headache.

Nasal mucosa is often pale but can be red or bluish.

Allergic Rhinitis: Medical Diagnosis

Disgnosis is based on detailed history.

Which chronic symptoms, patient may be instructed to keep a diary describing all episodes; to identify possible allergens.

Allergic Rhinitis: Medical Treatment

Patient may be referred to Allergist.

Allergist applies solution of common allergens to the skin; to asses patient’s reaction individually.

Immunotherapy (desensitization) advised to decrease the patient’s reaction to allergens. often called “allergy shots"

Drugs used to treat rhinitis are primarily intranasal corticosteroids and oral or intranasal antihistamines Second generation antihistamines (Zyrtec) are preferred over first generation antihistamine (Benadryl) because they are less sedating.

Decongestants help to relieve symptoms.

Medications should be used only on short-term basis.

First generation antihistamines should be used cautiously in older patients because the sedation could lead to falls.

Advise patient to consult with a physician or a pharmacist about appropriate OTC drugs.

Nursing Care of Patient with Allergic Rhinitis

Usually treat as outpatient

Nurse may need to reinforce teaching about immunotherapy and drug therapy.

Patients usually advised to begin intranasal corticosteroids before allergy season.

Coryza

known as the common cold; contagious and spread by droplet infection.

Acute Viral Coryza: SIGNS AND SYMPTOMS

fever, fatigue, nasal discharge, sore throat

Acute Viral Coryza: Complications

Infection usually runs its course in approximately 1 week.

Complications include: otitis media, sinusitis, bronchitis, pneumonia; more common in people with weakened resistance

Acute Viral Coryza: Medical Treatment

Drug therapy includes: antihistamines, decongestants, antitussives, and antipyretics.

If only one symptoms, choose single agent to avoid multiple side effects.

Antibiotics; inform that they are not effective against infections caused by viruses.

Inappropriate use of antibiotics promotes the development of resistant strains of bacteria

Acute Viral Coryza: Prevention

Avoidance of people with colds: Colds are most contagious during first 2 or 3 days after symptoms appear.

The very young, very old, and those with weakened immune systems should be protected from exposure

Nursing Care of the Patient with Acute Viral Coryza

Public education about prevention and drugs prescribed for treatment.

Echinacea is considered safe for short-term use of less than 10 days.

High doses of Vitamin C taken orally may decrease the duration of cold symptoms by a few days.

Encourage patient to rest and drink plenty of fluids.

Tumors; SIGNS AND SYMPTOMS

can be benign or malignant

Risk factors include: smoking, being male, being infected human papillomavirus, certain occupations, notably furniture making, caperntry, leather work, bakery work, exposure to certain chemicals or dust

Primary symptom: nasal obstruction in either one or both sides

Another sign is bloody discharge from one nasal passage.

Cancer of the nasal cavity is rare, compromising only 3% to 5% of cancer diagnosis each year. 4 out of 5 cases occur in people at least 55 years of age.

Tumors: Medical Diagnosis

based on biopsy or removal of entire tumor for examination

when cancer confirmed if highly suspected, CT, MRI, and positron emission tomography (PET) scans done to assess extent of disease.

If malignancy detected and treated early, the better chances of survival.

Carcinomas in the nasopharynx tends to metastasize to the neck, liver and lungs very early; often spread by time they are diagnosed.

A physician should examine any patient with persistent nasal obstruction or bleeding.

Tumors: Medical Treatment

Treatment of nasal malignancies may include: surgery, radiation therapy, chemotherapy, targeted therapy, palliative treatment

Depends on stage of cancer and general health of patient.

Surgeries may be extensive and disfiguring.

Reconstructive surgery or prostheses may be needed.

Benign tumors do not metastasize; likely to require removal because they can obstruct the nasal passages.

Nursing Care of Patient with Nasal Cancer

Patient may be anxious and fearful of disfigurement or even death.

Be supportive and encourage the patient to ask questions and express concerns.

Deviated Nasal Septum

slightly deviated: it is off center

Minor deviations: cause no symptoms and require no treatment

Major deviations: can obstruct the nasal passages and block sinus drainage

Patient complains of headaches, sinusitis, and epistaxis (nosebleeds)

Deviated Nasal Septum:Treatment

Treatment includes: management of nasal allergies, nasal septoplasty (mucosa is repositioned, and the nasal passage is packed with petrolatum gauze; physician removes packing in 24 to 48 hours).

Complications of nasal septoplasty: tears of the septum and saddle deformity (collapse of the bridge of the nose caused b y removal of excessive support tissue or by contraction of the surgical scar)

Epistaxis “Nosebleeds”

Causes: trauma, hypertension, low humidity, allergies, upper respiratory infections, foreign bodies, chemical irritants, overuse of decongestant nasal sprays, nasal surgery, tumors.

Occur in the anterior portion of the nasal cavity and can be self-treated.

Posterior nosebleeds may require medical treatment and occur secondary to health problems, like hypertension.

Epistaxis: First Aid

Sit down and lean forward from the waist.

Keep head elevated but not hyperextended

Direct pressure should be applied for 10 to 15 minutes, unless traumatic face injury; may suggest possible fracture.

Ice pack or cold compress can be applied to nose

Once bleeding stops, advise not to blow nose for several hours; may trigger renewed bleeding.

Epistaxis: Medical Treatment

If bleeding continues, medical attention is needed.

Physician may treat anterior bleeding with topical vasoconstrictor (oxymetazoline nasal prep) or silver nitrate cauterization.

If bleeding not controlled, next step is pressure to the nasal cavity; done by nasal ballon catheter or nasal packing

Epistaxis: Nasal Ballon Catheter

passed through nasal cavity.

inflater too apply pressure to blood vessels.

smaller balloons anchor the catheter in place.

DIfferent types with single and double cuffs including the Rhino, the Epistat, and the Storz T-3100.

Used for both anterior and posterior bleeding.

Epistaxis: Nasal Packing

May pack anterior or posterior nasal cavity or both

Anterior packing uses gauze and an antibacterial ointment

Posterior packing more complicated and requires close monitoring. May be accomplished with nasal sponges, gauze, or nasal tampons.

Posterior packing is inserted into the nares and advanced along the floor of nasal cavity. Packing expands and applies pressure.

Epistaxis: Complications

Related to packing: Impaired breathing, infection, and blockage of Eustachian tube.

If guaze applied to posterior: it can depress the soft palate, causing airway obstruction

Packing left in place for 2 to 3 days.

Nursing Care for patient with Epistaxis: Focused Assessment

Severe Epistaxis: EMERGENCY; only priority data until patient stablized. Priority data is evidence of uncontrolled bleeding and excessive blood loss.

Inspect back of throat and the nose.

Observe for frequent swallowing.

Monitor level of conciousness.

Monitor vital signs to detect signs of hypovolemia (restlessness, tachycardia, tachypnea, hypotension)

Nasal balloon/Nasal packing: Monitor for early signs of infection and airway obstruction (dyspnea, anxiety, tachycardia)

Assess for pain in nose, ear, pharynx.

Epistaxis: Interventions

Decreased Cardiac Output:

Monitor for signs of continued and excessive blood loss.

Immediately report signs of hypovolemia (increased pulse, restlessness, decreased urine output) to physician.

Epistaxis: Interventions

Anxiety:

Support patient and assist the physician during placement of device.

Give reassurance to help remain calm.

Milde sedative may be ordered.

Epistaxis: Interventions

Potential for Injury and Infection:

Check respiratory status frequently.

Constant monitoring for nasal packing in place.

Monitor temperature for elevation, may indicate infection of nasopharynx.

Inspect oral cavity.

Posterior gauze should not be visible. If visible, physician should be contacted to adjust position

Assist with packing removal by supporting patient in sitting position and provide an emesis basin. Drape patient to protect clothing.

Pharyngitis

Inflammation of the mucous membranes of the throat or pharynx.

Can be viral, bacterial, or fungal infection; Most cases are VIRAL; Bacterial infections occurs 5 to 10%; Fungal infections developed with prolonged antibiotic use or inhaled corticosteroids.

Pharyngitis: Signs and Symptoms

Dryness, pain, dysphagia (difficulty swallowing), fever.

Throat appears red and the tonsils may be enlarged.

bacterial pharyngitis has abrupt onset and is characterized by fever, enlarged lymph nodes, tonsillar exudate (drainage), absence of cough.

Pharyngitis: Complications

bacterial pharyngitis is more likely to have serious complications which include acute glomerulonephritis and rheumatic fever.

Pharyngitis: Medical Diagnosis

Based on patient history and physical examination.

Diagnosis of viral or bacterial pharyngitis made after results of a rapid antigen detection test and/or throat culture and complete blood count (CBC).

Pharyngitis: Medical Treatment

Treated with rest, fluids, anagelsics, throat gargles or irrigations.

Intravenous fluid may be ordered; if oral intake is low.

Soft or liquid diet may be ordered due to painful swallowing.

cool-mist vaporizer or humidifier may be order; to increase moisture in the room air.

Viral pharyngitis: focuses on symptom management

Bacterial pharyngitis: treated with antibiotics; Penicillin: given for 10 days; to prevent complications of rheumatic fever.

Fungal infections: treated with nystatin

Pharyngitis: Prevention

Weakened resistance should avoid other with upper respiratory infections.

to help maintain resistance: good nutrition, adequate rest, and avoidance of inhaled irritants.

Pharyngitis is contagious in early stages; avoid contact with susceptible people.

Nursing Care of Patient with Pharyngitis: Focused Assessment

Mild pharyngitis: treated outpatient; unless difficulty breathing.

Nursing interventions are limited.

Relevant data: throat pain, dysphagia, muscle and joint pain, nausea, vomiting, rash.

Take temperature and inspect throat for redness and enlarged tonsils.

Nursing Care of Patient with Pharyngitis: Patient Problems, Goals, Outcomes

Ineffective self-care; lack of understanding of treatment and importance of follow-up care

Goal: appropriate self-care by patient

Criteria for goal: patient correctly describing self-care measures, drug therapy and symptoms to report, and making and keeping follow-up appointments.

Pharyngitis: Interventions

Reinforce the physician’s directions for drug therapy.

Stress the importance of completing prescribed antibiotics.

Encourage to take 2000 to 3000 mL of fluids daily unless contraindicated.

Fluids must be increased cautiously to avoid sudden changes in blood volume.

Advise patients that they are contagious at first; avoid people with poor resistance.

Tonsillitis

Inflammation of the tonsils and other lymphatic tissue in the throat.

Most common in children.

Tonsillitis: Causes

Cause by a virus; can be caused b y bacteria.

Not contagious; viruses and bacteria that cause it ARE contagious.

Frequent handwashing to help prevent spread.

May have repeated infections that respond to treatment; may have chronic infection.

Tonsillitis: Signs and Symptoms

Sore throat, difficulty swallowing, fever, bad breath, sometimes chills.

If swollen tissue block Eustachian tube, pain felt in the ears.

Tonsils are enlarged and red.

Purulent drainage or yellowish or white patches may be seen on tonsils.

Lymph nodes in neck tender and enlarged.

Tonsillitis: Medical Diagnosis

Physical examination and ask about symptoms and medical history.

Made based on a rapid strep test, throat culture or both.

Culture and sensitivity identify pathogenic organisms present and what antibiotics are needed.

Chest radiograph may be ordered to assess respiratory complications.

Tonsillitis: Medical Treatment

Viral: treatment of symptoms is appropriate.

Bacterial: antibiotics; Analgesics and lozenges for pain; antipyretics for fever.

Children and teenagers should avoid aspirin

Do not give lozenges to children under age of 4.

Warm saline gargles and ice of humidifier: to help decrease swelling.

Rest and adequate fluids; to promote comfort and facilitate recovery.

Tonsillitis: Complications

Peritonsillar access (infection of the tissue surrounding the tonsils) with streptococcal tonsilitis; affected side is very painful, difficulty swallowing, talking, opening mouth

immediate treatment is drainage of the access.

After infection is gone, tonsillectomy is done.

Tonsillitis: Surgical Treatment

Child: strep throat 7 or more times in a year, tonsillectomy suggested. Must sees risk of anesthesia and bleeding as well as missed school days.

Enlarged tonsils causing difficulty breathing or contributing to obstructive sleep apnea (OSA), tonsillectomy suggested.

Elective surgery.

Nursing Care for the Patient Having a Tonsillectomy: Focused Assessment

Frequent monitoring of patient’s responsiveness and vital signs;

Increased pulse rate and restlessness are signs of hypovolemia.

Cyanosis (bluish discoloration of nails bed and lips) late sign of inadequate oxygenation.

Inspect drainage from mouth or vomit fluid for blood. Blood-tinged is normal at first but should decrease.

Excessive bleeding may indicate bleeding.

Monitor respiratory effort and skin color to evaluate oxygenation.

Evaluate pain and dysphagia.

Nursing Patient Having a tonsillectomy: Interventions

Potential Risk for decreased cardia output:

Remind to not cough or clear throat.

Suction very gently to prevent further bleeding.

The patient should not use a straw; Sucking may dislodge the clots that form.

Nursing Patient having a Tonsillectomy: Interventions

Potential for Airway obstruction:

local anesthesia is less of risk for respiratory complications than general anesthesia.

local anesthesia: position patient with head of bed at 45 degrees.

general anesthesia: the bed should be flat and the patient positioned on the side or semiprone; promotes drainage of fluid from mouth to prevent aspiration.

Patient may prefer semi-fowler when awake.

S/S of inadequate oxygenation: increased pulse rate, restlessness, confusion

Nursing Patient Having a Tonsillectomy: Interventions

Acute Pain:

Analgesics ordered for pain.

Ice collars applied to neck; decrease swelling and pain.

Clear liquid diet ordered first.

Cold and frozen liquids are soothing.

Red food and rinks should be avoided; may be confused with blood in sputum or emesis.

Dairy products excluded; causes mucus to be thicker and difficult to expectorate.

Nursing Patient Having a Tonsillectomy: Interventions

Inability to self perform self-care:

Advise patient of measures to promote healing and prevent complications,

Tonsillectomy: Patient Teachings

The diet should be soft and high in protein and calories for the next 10 days.

Avoid strenuous activity and straining for 2 weeks.

Avoid aspirin and other NSAIDs such as ibuprofen, which interfere with blood clotting.

Aspirin should be avoided in children and teenagers.

Avoid smoking, which may disrupt healing.

Drink 8 to 12 8-oz glasses of fluid daily.

Avoid citrus juices, which irritate healing tissues.

Earaches are common and are not cause for alarm.

White patches normally form over the tonsillectomy sites. This tissue will slough off.

Report bleeding to the physician.

Obstructive Sleep Apnea (OSA)

Airway obstruction while sleep caused by narrowing of the airway with relaxation of muscle tone during sleep and/or the tongue and soft palate falling backwards, partially or completely blocking the airway and cessation panes (cessation of breathing) and hypopnea ( abnormally slow, shallow breathing).

Signs and Symptoms of OSA

Irritable and sleepy during day, loud snoring or episodes of apnea, impaired concentration and memory, Hypertension and cardiac dysrhythmias.

OSA: Medical Diagnosis

Confirmed by polysomnographjy; done in sleep lab or in patient s home.

OSA: Causes and Treatment

No single cause.

Risk factors: obesity and smoking.

Conservative treatment: weight loss if obese, avoidance of sedatives and alcohol for 3 to 4 hours before bed.

advise patient to elevate head of bed and sleep on side.

Oral appliance that shifts the mandible may be effective.

Serious symptoms treated with nasal continuous positive airway pressure (CPAP)

Patient wears mask attached to blower for sleep.

Bilevel positive airway pressure (BiPAP) preferred by some; adjusts to higher pressure during inspiration and lower pressure during expiration.

OSA: Surgical Treatment

Use to reduce obstructing tissues.

Used when other measures not effective.

Not considered a first-line treatment.

Laryngitis

Inflammation of the larynx:

may occur alone, or accompany other upper respiratory infections.

Risk factors: upper respiratory infections, voice strain, smoking, alcohol ingestion, gastroexpohageal reflux disease (GERD), inhalation of irritating fumes; chronic laryngitis cause by exposure to irritants.

Laryngitis: Signs and Symptoms

Hoarseness, cough, scratchy or painful throat; “losing" voice, aphonia (absence of sound production). Voice changes may be permanent after long periods of inflammation.

Laryngitis: Medical Diagnosis

Based on patient history and symptoms.

use of a laryngeal mirror to examine larynx for color, edema, growths (polyps, tumors)

inflamed vocal cords appears read and swollen.

if upper respiratory infection, throat culture may be done to determine pathogen and treatment.

Nursing Care of Patient with Laryngitis: Focused Assessment

Collection of relevant data begins with history of problem

Document severity and duration and any factors that aggravate or precipitate it.

information about occupation and hobbies may give clues to onset.

Take temperature and describe respiratory status to detect infection.

Nursing Care for patient with Laryngitis: Interventions

Explain that voice rest allows larynx to heal; establish other ways to communicate.

Provide pencil and paper for written communication.

Hand signals or pictures for those who can’t read or write.

Place sign over bed to advise staff and visitors that patient should not speak.

Place sign at nurse’s station intercom; alert staff to go to patients room to see what is needed.

Teachings focuses on comfort and avoiding futher episodes.

Discourage smoking.

Advise to remain in environment with consistent temperature.

A room humidifier reduces discomfort of a dry nose and throat.

lozenges containing topical anesthetics may be ordered to sooth irritation.

Chronic Laryngitis: Interventions

Primary treatment goal is to remove irritant.

Advise patient that smoking cessation is likely to improve symptoms.

Changes in voices may be permanent due to inflammation.

Teach patent irritants can lead to laryngitis.

Patient should be able to recognize irritants in home and workplace anyhow rot protect from self from harm.

If incline to stop smoking, provide information about community resources.

American Cancer Society is a good source of information on how to stop smoking.

Laryngeal Nodules

Benign masses of fibrous tissue; over use of voice and can follow infections.

Singers and public speakers prone due to straining of voice.

ONLY symptom: hoarseness

Surgically removed under local or general anesthesia.

Removal is fairly simple but may recur of voice is again misused.

Patient place on voice rest for several days after procedure.

Explain voice rest and emphasize need to avoid strain on voice.

Laryngeal Polyps

Swollen mass of mucous membrane attached to the vocal cord.

Can cause continuous or intermittent hoarseness.

Causes: excessive talking or singing, irritation 9comoonly from smoking)

heavy smokers: flabby mass tissue may develop on vocal cords.

Stripping of the vocal cord is necessary to treat this.

The condition usually doesn’t return unless patient continued to smoke.

Voice rest sis prescribed wh polyps removed.

Cancer of Larynx and Hypopharynx