Nursing Care of Patients With Upper Respiratory Tract Disorders

Epistaxis

• More commonly known as a nosebleed.

• Can bleed from the anterior or posterior region.

  • Anterior bleeds:

    • More common.

    • Originate from the Kiesselbach plexus.

    • Easier to locate and treat.

  • Posterior bleeds:

    • Can be severe and difficult to control.

    • Blood vessels are larger.

Causes of Epistaxis

• Dry, cracked mucous membranes, trauma, forceful nose blowing, nose picking, and tumors.

• Anything that reduces the blood’s ability to clot:

  • Hemophilia: genetic disorder where clotting factors are missing.

  • Leukemia: affects platelet production.

  • Regular aspirin use.

  • Anticoagulant therapy.

  • Chemotherapy.

• Cocaine use.

Nursing Interventions for Epistaxis

• Instruct patient to sit in a chair and lean forward slightly to avoid aspirating or swallowing blood.

• Apply direct pressure for 5-10 minutes.

• Ice packs to nose/eye area will cause constriction of bleeding vessels.

• Nasal packing with petroleum gauze.

• Nasal balloon catheter such as the Rapid Rhino:

  • Inflated balloon places pressure on the bleeding vessels to stop the bleeding.

• Vasoconstrictive agent like Afrin nasal spray.

• Electrocautery if the bleeding vessel can be located and other measures have not worked.

Nursing Care for the Patient With Epistaxis

• Monitor amount and color of bleeding.

• Monitor vital signs.

• Monitor hemoglobin level.

• Once bleeding is controlled:

  • HCP will remove packing.

  • Caution patient not to blow nose for up to 48 hours.

  • Avoid nose picking.

  • Avoid bending over.

  • Use nasal saline spray or humidifier if bleeding was caused by dryness.

Deviated Septum

• Nasal septum is off center

• Symptoms:

  • Chronically stuffy nose.

  • Blocked sinus drainage.

  • Headaches.

  • Sinus infections.

  • Nosebleeds.

• Treatment:

  • Nasoseptoplasty – involves revising or removing the deviated portion; nasal packing is then placed to reduce bleeding; typically done as an outpatient surgical procedure under local anesthesia.

Nursing Care for the Patient After Nasoseptoplasty

• Monitor Vital Signs/Bleeding

• Report Excess Swallowing

  • Excessive swallowing should alert you to check for blood running down the back of the throat

• Monitor Dressing for Excess Bleeding

  • Patient will have a nasal packing in place and a “mustache dressing” of folded gauze under the nose to catch drainage

• Discharge Teaching:

  • Maintain semi-Fowler’s position at all times

  • Avoid anything that might increase pressure and cause bleeding:

    • Sneezing, coughing, straining for bowel movements

  • Avoid aspirin and related medications

  • Return in 24-48 hrs to have packing removed

  • Read Box 30.1 on page 520 for patient education following nasal surgery

Sinusitis

• Inflammation of Sinus Mucosa

  • Acute or Chronic

  • Chronic sinusitis is diagnosed if symptoms have existed for more than 3 months and are unresponsive to treatment

  • Ethmoid (between the eyes) and maxillary (behind the maxilla) – most commonly affected

  • Can be the result of a bacterial infection caused by Streptococcus pneumonia and H. influenza OR may follow a cold or other viral upper respiratory illness

Sinusitis: Signs and Symptoms

• Pain over region of affected sinuses

• Purulent nasal drainage

• Pain over cheek and upper teeth (maxillary sinus)

• Pain between and behind eyes (ethmoid sinus)

• Pain in the forehead typically indicates frontal sinusitis

• Fever present in acute infection, with or without generalized fatigue and foul breath

Sinusitis: Complications

• Osteomyelitis in surrounding areas

• Cellulitis of the orbit (infection of the soft tissues around the eye)

• Abscess

• Meningitis

• Asthma symptoms

  • The patient who has received inadequate treatment or who has not been compliant with treatment is at risk for these complications

Nursing Interventions for Sinusitis

• Saline Irrigation

• Intranasal Corticosteroids (i.e., Flonase)

• Decongestants

• Warm Moist Packs (1-2 hrs. BID)

• Acetaminophen or Ibuprofen for pain & fever

  • Treatment is aimed at relieving pain and promoting sinus drainage

• Humidification

• Oral Fluids (8-10 glasses/day)

• Positioning (Semi- Fowler’s)

• Antibiotics

• Surgical Drainage if more conservative treatments have been unsuccessful

Obstructive Sleep Apnea

• Apnea During Sleep (most often supine)

• Transient hypoxemia results, and a signal to take a breath causes a sudden, loud inhalation (as many as 100 x hour)

• Men affected more than women

• Risk Factors:

  • Obesity The muscles of the throat relax, the tongue and soft tissues fall back to obstruct the airway

  • High Palate

  • Receded Mandible

  • Smoking

Obstructive Sleep Apnea

• OSA increases the risk for:

  • Heart Disease

  • Hypertension

  • Stroke

  • Diabetes

• Signs & Symptoms:

  • Loud snoring followed by periods of total silence

  • Daytime Sleepiness

  • Headache

  • Memory and Attention Problems

Diagnosis of Obstructive Sleep Apnea

• Nocturnal Polysomnography aka Sleep Study

  • During a sleep study, the patient is hooked up to an EEG, EKG, EMG, oxygen saturation, and eye movement monitors and then observed while sleeping

Treatment for Obstructive Sleep Apnea

• Avoid alcohol and HS sedatives (these can worsen apnea by increasing relaxation of the muscles in the pharynx)

• Lose Weight and Smoking Cessation

• Nasal Patch (Provent)-holds airways open during exhalation

• CPAP or BiPAP machines

• Use of a mandibular advancement device

  • Mandibular advancement device is a mouthpiece to pull the mandible forward so the tongue doesn’t fall back obstructing the airway

Infectious Disorders of the Upper Respiratory Tract

• Viral Rhinitis/Common Cold

• Pharyngitis

• Laryngitis

• Tonsillitis/Adenoiditis

• Influenza (flu) and Coronavirus (COVID-19)

Viral Rhinitis/Common Cold

• Inflammation of the nasal mucous membranes most commonly caused by the rhinovirus

• Release of histamine and other substances causes vasodilation and edema

• May occur as a reaction to allergens (pollen, dust, molds, some foods)

Viral Rhinitis: Signs and Symptoms

• Nasal congestion

• Localized itching

• Sneezing

• Sore throat

• Nasal discharge

• May see fever and generalized fatigue

  • BUT…is an antibiotic needed??

Nursing Interventions for Viral Rhinitis

• Treatment is symptomatic

• Antibiotics are ineffective because the cause is viral

• Acetaminophen for generalized discomfort

• Decongestants to relieve nasal congestion

• Rest and fluids are the most effective treatment

Pharyngitis

• Inflammation of the pharynx

• Caused by bacterial or viral infection

• 5-15% of cases are caused by beta-hemolytic streptococci (strep throat)

• This type of infection MUST be treated with antibiotics, or it can lead to rheumatic fever, glomerulonephritis, or other serious complications

Pharyngitis: Signs and Symptoms

• Sore throat

• Dysphagia

• Throat appears red and swollen

• Exudate may be present

  • This usually signals bacterial infection and may be accompanied by fever, chills, headache, generalized fatigue, vomiting

Pharyngitis: Diagnostic Tests

• Rapid streptococcal antigen test OR

• Throat culture and sensitivity test to identify the causative organism and determine which antibiotic will be effective

Nursing Interventions for Pharyngitis

• If the cause is bacterial – antibiotics ordered

  • Penicillin most commonly prescribed

• Acetaminophen or throat lozenges may be used to relieve discomfort

• Saltwater gargles (teaspoon of salt in a glass of warm water) or honey and lemon mixed with warm water help soothe inflamed tissues

• Increase fluid intake

• REST – stay home from work and school

Laryngitis

• Inflammation of the mucous membrane lining the larynx (voice box)

• Can be caused by irritation from smoking, alcohol, chemical exposure, GERD, or a viral, fungal, or bacterial infection

• Often follows an upper respiratory infection

• Most common symptom in hoarseness

Nursing Interventions for Laryngitis

• Rest

• Fluids

• Humidified air

• Acetaminophen

• Antibiotics are used if bacterial infection is present

• Meds to control acid reflux if GERD is the cause

• Avoid speaking to rest the voice

Tonsillitis/Adenoiditis

• Tonsils are lymphatic tissue and their job is to filter microorganisms to protect the lungs from infection

• Tonsillitis occurs when the filtering function becomes overwhelmed with a virus or bacteria and infection results

Tonsillitis/Adenoiditis: Signs and Symptoms

• Usually begins suddenly with a sore throat, fever, chills, and pain on swallowing

• Generalized symptoms include headache, malaise, and myalgia

• Tonsils appear red and swollen & may have yellow or white exudate on them

• If adenoids are involved, patient may snore, report nasal obstruction, and have a nasal tone to their voice

• Bad breath is also very common

Tonsillitis/Adenoiditis: Diagnostic Tests

• Throat culture is done to discover the causative organism and determine effective treatment

• CBC with differential can also help identify whether the infection is viral or bacterial

• Chest x-ray may be done if respiratory symptoms are present

Interventions for Tonsillitis/Adenoiditis

• Antibiotics are prescribed for bacterial infection

• Acetaminophen, lozenges, and saline gargles

• Tonsillectomy/adenoidectomy may be considered if tonsillitis becomes chronic or if breathing or swallowing is affected

Influenza (Flu) and Coronavirus (COVID-19)

• Viral infections of the respiratory tract

• Easily transmitted via droplets from coughs and sneezes of infected people

• Young children, chronically ill patients, and older adults with comorbidities such as obesity, hypertension, cardiovascular disease, and diabetes are at increased risk for complications and even death

Influenza (Flu) and Coronavirus (COVID-19)

• Incubation period for the flu from time of exposure to onset of symptoms is 1 to 3 days

• Incubation period for COVID-19 from time of exposure to onset of symptoms is 2 to 14 days

• Person is HIGHLY contagious even in these incubation periods

Respiratory Virus Prevention

• Yearly flu vaccine for anyone over 6 months of age

• Current recommendations for the COVID-19 vaccine include anyone older than 5

• Educate people that they will NOT get the flu or COVID from the shot, because it does not contain any live virus

• Once the vaccines are administered, it takes about 2 weeks for antibodies to develop, then it is effective for about 4 months

Respiratory Virus Prevention

• Other important preventive measures include:

  • Hand hygiene

  • Mask wearing

  • Keeping hands away from the mouth, nose, and eyes

  • Avoiding people with the flu or COVID-19

  • Avoiding crowds when cases are prevalent

Influenza and COVID-19

• Symptoms of Flu (Abrupt Onset):

  • Fever

  • Chills

  • Myalgia

  • Sore Throat

  • Cough

  • General Malaise

  • Headache

    • Flu can last 2-5 days with malaise lasting up to several weeks

• Symptoms of COVID:

  • Cough

  • Myalgia

  • Headache

  • Changes in sense of smell or taste

    • Recovery from COVID varies from 2 weeks to 3-4 months for those with more severe disease

Influenza and COVID-19

• Most common complication of the flu is pneumonia

  • Should be suspected if the patient has persistent fever and shortness of breath or if the lungs develop crackles or wheezes

• Most deaths from COVID-19 occur as the result of respiratory failure

Influenza and COVID-19: Diagnostic Tests

• Viral cultures of throat or nasal swabbing can be done to identify flu, but results may take 3-10 days

• Rapid tests can identify the flu virus in less than 15 minutes, but are less reliable than cultures

• Nasal swabbing is also used for COVID-19 testing

Interventions for Influenza and COVID-19

• Interventions are primarily symptomatic

• Acetaminophen for fever, headache, and myalgia

• Rest and fluids are essentials

• Antibiotics are only used if a secondary bacterial infection is present

• Antiviral agents, such as zanamivir (Relenza) or oseltamivir (Tamiflu) reduces the severity and duration of symptoms if given within 48 hours of onset of symptoms

Cancer of the Larynx (Voice Box)

• Most often a primary cancer and can spread to the lungs, liver, or lymph notes

• Prognosis is good with early diagnosis, but is poor when diagnosis and treatment are delayed

• Causes:

  • History of alcohol and tobacco use

  • Exposure to industrial chemicals or hardwood dust

  • Chronic overuse of the voice

  • Exposure to human papilloma virus (HPV)

Cancer of the Larynx (Voice Box): Signs and Symptoms

• Most common symptom is persistent hoarseness

• Throat or ear pain

• Shortness of breath

• Chronic cough

• Difficulty swallowing

• Stridor may indicate a tumor obstructing the airway

• Late signs include weight loss and halitosis (foul breath)

Cancer of the Larynx (Voice Box): Diagnostic Tests

• Laryngoscopic exam and biopsy are used to diagnose and determine the stage of cancer

• CT scan and MRI can determine presence or extent of metastasis

Interventions for Cancer of the Larynx (Voice Box)

• If diagnosed early, treatment will consist of radiation therapy (this can preserve the patient’s voice)

• Chemotherapy may be used with radiation or surgery, but is not usually used alone

• Larynx will be either partially or completely removed

• If cancer has spread beyond the larynx, a radical neck dissection, which removes adjacent muscle, lymph nodes, and tissue, may be done

Interventions for Cancer of the Larynx (Voice Box)

• After a partial laryngectomy, the patient may have a permanently hoarse voice

• With a total laryngectomy, the patient will have a permanent tracheostomy tube in place with no voice

  • The patient will need to learn alternative methods of communication