Chapter 26

$Rhinitis and treatment$
- Rhinitis: Inflammation of nasal mucosa, often in response to a specific allergen
- Clinical Manifestations: sneezing, watery, itchy eyes and nose, decreased sense of smell, and thin, watery nasal discharge that can lead to a more sustained mucus production and nasal congestion
- Nasal Turbinates: pale, boggy, swollen
- Headache, stuffy nose, nasal congestion, sinus pressure
- Nursing Care: identify and avoiding triggers of allergic reactions, teach pt to take note when reactions occur
- Goal of drug therapy: reduce inflammation associated with allergic rhinitis, reduce nasal symptoms, minimize associated complications, and maximize quality of life
- Oral: antihistamines (second gen because 1st gen -chlorpheniramine- is sedating), decongestants, LTRA’s
- Intranasal: antihistamine, anticholinergic, corticosteroids
- Immunotherapy: intradermal shots
Drug therapy Table 26-2 focus on nursing actions

Drug	SE	Nursing Action
Anticholinergic: nasal spray- bromide	nasal dryness and irritation, nose-bleeds may occur, does not cx systemic SE	reduce need for other rhinitis medications
Antihistamines: First generation (oral): , chlorpheniramine, diphenhydramine	cx sedation and somnolence, anticholinergic effects (dry mouth, constipation, urinary hesitancy)	warn pt operating machinery (sedating), teach to report palpitations, change in HR, change in bowel/bladder habits, rapid onset of action
Antihistamines: Second Gen (Oral): Zyrtec (Ceterizine), Allegra, Loratadine (Claritin)	minimal sedation, few effects	teach pt to expect few SE, more expensive, rapid onset of action
Antihistamines: Second Gen (Nasal): azelastine, olopatadine	H/a, bitter taste, somnolence, nasal irritation	longer use increased risk for rebound vasodilation, which can increase congestion
Corticosteroids Nasal Spray: budesonide, beclomethasone, flunisolide, fluticasone	systemic SE unlikely, in rare instances: fungal infection	adherance important: teach to use on regular basis (not PRN), teach to clear nasal passage before use, may take 1-2 days, stop use if nasal infection occurs
Decongestant (oral): pseudoephedrine (Sudafed)	CNS stimulation, cx insomnia, headache, irritability, increased blood and ocular pressure, dysuria, tachycardia	Tolerance variable, teach adverse reactions, inform HCP if preexisting cardiovascular dz, HTN, DM, hepatic or renal dz, rebound nasal congestion
Intranasal (Nasal Spray): phenylephrine, oxymetazoline	same as above	should not be used for more than 3 or 4 times/day, rebound nasal congestion may occur
Leukotriene Receptor Antagonists (LTRAs) and Inhibitors: Antagonists (montelukast) singulair, Inhibitors (zileuton)	Well tolerated, May cause h/a, dizziness, rash, GI changes	monitor liver function tests periodically while on therapy, stop if elevated, give on empty stomach
Mast Cell Stabilizer Nasal spray: cromolyn spray	minimal	reinforce that spray prevents symptoms, begin 1 week before pollen season starts and use throughout pollen season

Sinusitis
- inflammation or swelling of mucosa blocks the opening in the sinuses, through which mucus drains into the nose
- Viral normally resolve less than 14 days, if last longer than 10 then bacterial infection may be present
- Clinical Manifestations:
- acute: pain over affected sinus, purulent nasal drainage, nasal obstruction, congestion, fever, malaise
  - findings:edematous mucosa, discolored purulent nasal drainage, enlarged turbinates, tenderness over involved frontal and/or maxillary sinuses, halitosis
- chronic: facial or dental pain, nasal congestion, increased drainage
- 50% of pt with asthma have chronic sinusitis
- interprofessional care:
- teach to reduce inflammation and infection, including environmental control of allergens and appropriate drug therapy
- acute: symptom relief, oral or topical decongestants to promote drainage (no longer than 4-5 days), intranasal corticosteroids to decrease inflammation, analgesics to relieve pain, and saline spray
- if symptoms worsen or last longer than 1 week, antibiotic therapy may be prescribed (Amoxicillin)
$Polyps$
- Problems of the Larynx and Trachea
- Laryngeal Polyps
- develop on vocal cords from vocal abuse or irritation
- s/s: hoarseness
- tx: voice rest and adequate hydration
- can cx dysphagia, stridor
- usually benign but could cause cancer
$Tracheostomy- types of tubes, management, complications, suction and care, speech,$ \n $swallowing$
- Surgically created stoma (opening) to:
- Establish a patent airway
- bypass an upper airway obstruction
- Facilitate secretion removal
- Permit long-term mechanical ventilation
- Facilitate weaning from mechanical ventilation
- May be done emergently (cricothyrotomy) surgically in OR, or percutaneously at bedside
- Advantages of tracheostomy over endotracheal tube
- easier to keep clean (shorter in length and wider in diameter)
- better oral and bronchial hygiene
- patient comfort increased (no tube in mouth)
- Less risk of long-term damage to vocal cords
- Tracheostomy Tubes 26-6
- Tracheostomy tube with cuff and pilot balloon
  - minimize pressure on tracheal wall
- fenestrated trachesotomy tube with cuff, inner cannula, and decannulation plug
  - allow patient to speak, fenestrated inner cannula can be used to facilitate cleaning
- Speaking tracheostomy tube with cuff and two external tubings
  - 2 tubes: one leading to cuff and second to opening above cuff
- tracheostomy tube with foam-filled cuff
  - patient cannot speak with this tube
- uncuffed tracheostomy tube -- long term
- nursing considerations:
  - if possible, assess r/f aspiration before removing inner cannula assess for s/s of dyspnea or respiratory distress when fenestrated cannula is first used
  - monitor and record pressure q 8hr
  - report inability to keep cuff inflated
  - before insertion, withdraw all air from cuff
- Closed Suctioning
- avoid suctioning through newly created trach-→ aggravate discomfort and promote bleeding
- each time pt suctioned, note and record amount, color, clarity, and patient tolerance to the procedure
- at first, humification is essential to keep secretions thin and decrease formation of mucous plugs
- Tracheostomy care
- changing tapes (ties)
- Swallowing
- risk for aspiration
- if pt can swallow without aspiration when the cuff is deflated, the cuff may be left deflated or cuff-less tube substituted
$Passy Muir valve$
- thin diaphragm that opens on inspiration and closes on expiration
- air flows over vocal cords during exhalation
- cuff must be deflated or use uncuffed tube
- evaluate patient’s ability to tolerate
$Nursing management with head and neck cancer, education on skin protection, swallowing, etc.$ \n $S/S to watch for following surgery$
- Structures includes: nasal cavity, paranasal sinuses, nasopharynx, oropharynx, larynx, oral cavity, and/or salivary glands
- squamous cells in mucosal surfaces
- Etiology: smoking (85%)
- excess alcohol consumption
- Age: most over age 50, 2x more likely in men
- R/f: HPV, excess alcohol, exposure to: sun, asbestos, industrial carcinogens, marijuana, radiation to head and neck, and poor oral hygiene
- Manifestations: vary with location
- pharyngeal: lump in throat or sore throat that does not get better with tx, white or red patches in mouth, chance in quality of voice
- hoarseness for more than 2 weeks can be symptom of early laryngeal cancer
- ear pain or ringing in ears, swelling or lumps in the neck, constant coughing, coughing up blood, swelling of jaw, unintentional weight loss, difficulty chewing, swallowing, moving tongue or jaw, breathing
- Diagnostic Studies
- Early detection
- physical assessment: mouth, ears, nose, throat, neck
  - thickening of normally soft and pliable oral mucosa, leukoplakia, eryhtroplakia, palpate lymph notdes
- pharyngoscopy and laryngoscopy: visually inspected for lesions and tissue mobility
- CT, MRI, PET scanning
- Interprofessional Care
- Surgery
  - first line tx for head and neck cancers
  - vocal cord stripping: removal of outer layers of tissue on the vocal cords
  - Laser surgery: an endoscope with a laser is inserted down the throat, and tumor can be vaporized and removed
  - Cardectomy: Removal of part or all of the vocal cords
  - may change tone of voice, removal of one lead to hoarse voice, if both are removed than no voice
  - Partial or total Laryngectomy: Removal of part or all the larynx, change airflow and normal voice production will not be possible
- Chemo
- Nutritional therapy: pt are malnourished before tx begins, tx modalities increase risk for malnutrition
  - surgery: pt unable to consume nutrients orally because of swallowing, location of sutures, or difficulty swallowing
  - gastrostomy tube, enteral nutrition, antiemetics or analgesics before meals can reduce nausea and mouth pain
  - when pt can successfully swallow with low or no risk for aspiration, small amounts of thickened liquids or pureed foods may be given with the patient in high-Fowler’s position, avoid thin, water fluids because they are hard to swallow and increase risk for aspiration
- Nursing Management
- Diagnoses
  - impaired airway clearance
  - risk for aspiration
- postoperatively, nursing care priorities include airway management, wound care, nutrition, communication, and psychosocial issues related to body image changes.
- semi-fowler’s to decrease edema and limit tension on suture lines
- Dry mouth
- Stoma Care: cover stoma when coughing and during any activity that may lead to inhalation of foreign materials
- Evaluation:
  - Have effective coughing and secretion clearance
  - Swallow oral foods without aspiration
  - Uses effective coping strategies
  - Use techniques to effectively communicate