NCM1128

Care of Clients with Problems in Oxygenation, Fluid and

Electrolytes, Infectious, inflammatory and Immunologic
Response, Cellular Aberrations, Acute and Chronic
Management of
Patients With Upper
Respiratory Tract
Disorders
 • Describe nursing management of
patients with upper airway disorders.
• Compare and contrast the upper
respiratory tract infections with regards
to cause, incidence, clinical
Management of manifestations, management,and the
significance of preventive health care.
Patients With Upper • Use the nursing process as a framework
Respiratory Tract for care of patients with upper airway
infection and the significance of
Disorders preventive health care.
• Use the nursing process as a framework
for care of patients with upper airway
infection.
 • Most common reason for seeking
healthcare
• May be minor, acute, chronic, severe,
Management of or life threatening
Patients With • Treated in community settings: doctor
Upper offices, urgent care clinics, long-term
Respiratory care facilities, or self-care at home

Infections (URIs) • Early detection of signs and symptoms

and appropriate interventions can
avoid unnecessary complications
• Patient teaching focus on prevention
and health promotion
 Rhinitis and rhinosinusitis: acute, chronic

Upper Pharyngitis: acute, chronic

Respiratory
Tract Tonsillitis, adenoiditis
Infections/
URIs Peritonsillar abscess

Laryngitis
Rhinitis

• A group of disorders characterized by

inflammation and irritation of the mucous
membranes of the nose. It may be classified as
nonallergic or allergic.
• Nonallergic rhinitis may be caused by a variety of factors,
including environmental factors such as changes in
temperature or humidity, odors, or foods; infection; age;
systemic disease; drugs (cocaine) or prescribed medications;
or the presence of a foreign body.
• Drug-induced rhinitis is associated with use of
antihypertensive agents and oral contraceptives and chronic
use of nasal decongestants.
• Rhinitis also may be a manifestation of an allergy in which
case it is referred to as allergic rhinitis.
Pathophysiology
 Rhinitis and
Rhinosinusitis
Clinical Manifestations

• The signs and symptoms of rhinitis include

rhinorrhea (excessive nasal drainage, runny
nose), nasal congestion, nasal discharge
(purulent with bacterial rhinitis), nasal itchiness,
and sneezing. Headache may occur, particularly
if sinusitis is also present.
Medical Management
• The management of rhinitis depends on the cause, which may be
identified in the history and physical examination.
• If viral rhinitis is the cause, medications are given to relieve the
symptoms.
• In allergic rhinitis, tests may be performed to identify possible
allergens.
• Desensitizing immunizations and corticosteroids
• If symptoms suggest a bacterial infection, an antimicrobial agent will
be used
Pharmacologic Therapy
• Medication therapy for allergic and nonallergic rhinitis focuses on
symptom relief.
• Antihistamines (Benadryl, Clarinex, Claritin, Zyrtec) are administered for
sneezing, itching, and rhinorrhea.
• Oral decongestant agents (phenylephrine) are used for nasal obstruction.
• Intranasal corticosteroids (Fluticasone) may be used for severe
congestion.
• Ophthalmic agents are used to relieve irritation, itching, and redness of
the eyes.
Nursing Management
• Avoid or reduce exposure to allergens and irritants, such as
dusts, molds, animals, fumes, odors, powders, sprays, and
tobacco smoke.
• Instructed about the importance of controlling the
environment at home and work.
• Saline nasal or aerosol sprays may be helpful in soothing
mucous membranes, softening crusted secretions, and
removing irritants.
 Viral Rhinitis (Common Cold)
• Common cold often is used when referring to an upper respiratory
tract infection that is self-limited and caused by a virus (viral
rhinitis).
• “Cold” refers to an afebrile, infectious, acute inflammation of the
mucous membranes of the nasal cavity.
• More broadly, the term refers to an acute upper respiratory tract
infection, whereas terms such as “rhinitis,” “pharyngitis,” and
“laryngitis” distinguish the sites of the symptoms.
• The six viruses known to produce the signs and symptoms of the
viral rhinitis are rhinovirus, parainfluenza virus, coronavirus,
respiratory syncytial virus (RSV), influenza virus, and adenovirus.
Clinical Manifestations

• tearing watery eyes • nasal congestion

• “scratchy” or sore • runny nose
throat
• sneezing
• general malaise
• low-grade fever
• nasal discharge
• Chills • nasal itchiness
• headache and muscle
aches
• As the illness progresses, cough usually appears.
• In some people, viral rhinitis exacerbates the herpes
simplex, commonly called a cold sore.
• The symptoms last from 1 to 2 weeks. If there is significant
fever or more severe systemic respiratory symptoms, it is no
longer viral rhinitis but one of the other acute upper
respiratory tract infections.
• Allergic conditions can also affect the nose, imitating the
symptoms of a cold.
Medical Management
• Symptomatic therapy.
• Provide adequate fluid intake
• Encouraging rest
• Increasing intake of vitamin C and expectorants
• Warm salt-water gargles
• Nonsteroidal anti-inflammatory agents (NSAIDs) such as aspirin or
ibuprofen relieve the aches, pains, and fever.
• Antihistamines are used to relieve sneezing, rhinorrhea, and nasal
congestion.
• Topical (nasal) decongestant agents may relieve nasal
congestion.
• Zinc lozenges for the first 24 hours of onset
• Antimicrobial agents (antibiotics) should not be used
because they do not affect the virus or reduce the incidence
of bacterial complications
Nursing Management
• Most viruses can be transmitted in several ways:
• direct contact with infected secretions;
• inhalation of large particles that land on a mucosal surface from
coughing or sneezing;
• or inhalation of small particles (aerosol) that may be suspended in
the air for up to an hour.

HANDWASHING
 Acute Sinusitis
• The sinuses, mucus-lined cavities filled with air that drain
normally into the nose, are involved in a high proportion of
upper respiratory tract infections.
• An infection of the paranasal sinuses.
• Frequently develops as a result of an upper respiratory infection,
such as an unresolved viral or bacterial infection, or an
exacerbation of allergic rhinitis.
• Nasal congestion, caused by inflammation, edema, and
transudation of fluid, leads to obstruction of the sinus cavities.
• This provides an excellent medium for bacterial
growth. Bacterial organisms account for more
than 60% of the cases of acute sinusitis, namely
Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis.
• Dental infections also have been associated with
acute sinusitis.
Clinical Manifestations
• facial pain or pressure over • Dental pain
the affected sinus area
• Cough
• nasal obstruction
• Fatigue
• a decreased sense of smell
• Purulent nasal discharge • sore throat
• Fever • eyelid edema
• Headache • facial congestion or
• ear pain and fullness fullness.
Assessment and Diagnostic Findings
• A careful history and physical examination are performed.
• The head and neck, particularly the nose, ears, teeth, sinuses, pharynx, and chest,
are examined - tenderness to palpation over the infected sinus area
• The sinuses are percussed using the index finger, tapping lightly to determine if the
patient experiences pain.
• The affected area is also transilluminated; with sinusitis, there is a decrease in the
transmission of light.
• Sinus x-rays may be performed to detect sinus opacity, mucosal thickening, bone
destruction, and air–fluid levels.
• Computed tomography scanning of the sinuses is the most effective diagnostic tool. It is
also used to rule out other local or systemic disorders, such as tumor, fistula, and allergy.
 Chronic Sinusitis
• An inflammation of the sinuses that persists for more than 3
weeks in an adult and 2 weeks in a child.

• Narrowing or obstruction in the ostia of the frontal,

maxillary, and anterior ethmoid sinuses usually causes
chronic sinusitis, preventing adequate drainage to the nasal
passages. – osteomatal complex
Clinical Manifestations
• Impaired mucociliary clearance and ventilation
• Cough (because the thick discharge constantly drips
backward into the nasopharynx)
• Chronic hoarseness
• Chronic headaches in the periorbital area
• Facial pain.
Assessment and Diagnostic Findings
• Computed tomography scan of the sinuses or magnetic resonance
imaging (if fungal sinusitis is suspected), are performed to rule out
other local or systemic disorders, such as tumor, fistula, and allergy.
• Nasal endoscopy may be indicated to rule out underlying diseases
such as tumors and sinus mycetomas (fungus balls). The fungus ball is
usually a brown or greenish-black material with the consistency of
peanut butter or cottage cheese.
Medical Management
• Goals of treatment of acute sinusitis:
• to treat the infection, shrink the nasal mucosa, and relieve pain.

• The antimicrobial agents of choice for a bacterial infection vary in clinical

practice.
• First-line antibiotics include Amoxicillin (Amoxil),
trimethoprim/sulfamethoxazole (Bactrim, Septra), and Erythromycin.
• Second-line antibiotics include Cephalosporins such as cefuroxime axetil
(Ceftin), Cefpodoxime (Vantin), and Cefprozil (Cefzil) and Amoxicillin
clavulanate (Augmentin).
• Newer and more expensive antibiotics with a broader spectrum
include macrolides, Azithromycin (Zithromax), and Clarithromycin
(Biaxin). Quinolones such as Ciprofloxacin (Cipro), Levofloxacin
(Levaquin) (used with severe penicillin allergy), and Sparfloxacin
(Zagam) have also been used.
• The course of treatment is usually 10 to 14 days.
• Use of oral and topical decongestant agents may decrease mucosal
swelling of nasal polyps, thereby improving drainage of the sinuses.
• Heated mist and saline irrigation also may be effective for opening
blocked passages.
Complications
• If left untreated, may lead to severe and occasionally life-threatening
complications such as
• Meningitis
• brain abscess
• ischemic infarction
• osteomyelitis

• Other complications (uncommon):

• severe orbital cellulitis,
• subperiosteal abscess
• cavernous sinus thrombosis.
Nursing Management
• Instructs the patient about methods to promote drainage such as inhaling
steam (steam bath, hot shower, and facial sauna), increasing fluid intake,
and applying local heat (hot wet packs).
• Informs the patient about the side effects of nasal sprays and about
rebound congestion.
• Antibiotic regimen
• Teaches the patient the early signs of a sinus infection and recommends
preventive measures such as following healthy practices and avoiding
contact with people who have upper respiratory infections.
• Explain to the patient that fever, severe headache, and nuchal rigidity are
signs of potential complications. If fever persists despite antibiotic therapy,
the patient should seek additional care.
Is the following
statement true or
false?
Acute pharyngitis of a Question #1
bacterial nature is most
commonly caused by
group A beta-hemolytic
streptococci
Answer to
Question #1

True
Rationale: Acute
pharyngitis of a
bacterial nature is most
commonly caused by
group A beta-hemolytic
streptococci
Pharyngitis
• an inflammation or infection in the throat, usually causing symptoms of a
sore throat.
• Most cases of acute pharyngitis are caused by viral infection.
• Body responds by triggering an inflammatory response in the pharynx.
• Results in pain, fever, vasodilation, edema, and tissue damage, manifested
by redness and swelling in the tonsillar pillars, uvula, and soft palate. A
creamy exudate may be present in the tonsillar pillars
• If left untreated, the complications can be severe and life-threatening.
Complications include sinusitis, otitis media, peritonsillar abscess,
mastoiditis, and cervical adenitis.
• In rare cases the infection may lead to bacteremia, pneumonia, meningitis,
rheumatic fever, or nephritis.
Pathophysiology
Pharyngitis
Diagnostic Findings
• Rapid screening tests for streptococcal antigens, latex agglutination (LA)
antigen test
• enzyme-linked immunoassay (ELISA)
• Optical immunoassay (OIA)
• Streptolysin titer
• Throat cultures
• Nasal swabs
• Blood cultures
Medical Management

• Viral pharyngitis is treated with supportive measures since

antibiotics will have no effect on the organism.
• Bacterial pharyngitis is treated with a variety of
antimicrobial agents.
Pharmacology
• Penicillin is usually the treatment of choice.
• Cephalosporins and macrolides (clarithromycin and
azithromycin)
• Antibiotics are administered for at least 10 days to eradicate the infection from the
oropharynx.

• Aspirin or Acetaminophen
• Antitussive medication
Clinical Manifestations

• Fiery-red pharyngeal
membrane and tonsils • Fever
• Swollen and flecked • Body malaise
lymphoid follicles with • Sore throat
white-purple exudate
• Large and tender cervical
lymph node
Nursing Management

• Stay in Bed and Rest

• Gargle or Irrigate warm saline
• Ice collar for severe sore throat
• Administer antibiotics
 Tonsillitis

• two oval-shaped pads of

tissue at the back of the
throat
Adenoiditis

• inflammation of the
adenoids caused by infection
Clinical Manifestation
• Sore throat
• Fever
• Snoring
• Difficulty swallowing
• Enlarged adenoids may cause mouth breathing, earache, draining ears,
frequent head colds, bronchitis, foul-smelling breath, voice impairment, and
noisy respiration.
• acute otitis media
• Acute Mastoiditis
Assessment and Diagnostic Findings
• Physical Assessment
• History Taking
• Throat Swab and Culture
• Comprehensive audiometric examination
Medical Management
• Tonsillectomy or adenoidectomy
Pharmacology
• Penicillin is usually the treatment of choice.
• Amoxicillin and Erythromycin
• Antibiotics are administered for 7 days

• Acetaminophen
Nursing Management

• Stay in Bed and Rest

• Gargle or Irrigate warm saline
• Ice collar for severe sore throat
• Administer antibiotics
Peritonsillar Abscess
• collection of purulent exudate
between the tonsillar capsule
and the surrounding tissues,
including the soft palate.
Clinical Manifestation
• Fever
• Dysphagia (Difficulty swallowing)
• Raspy voice
• Odynophagia (a severe sensation of burning, squeezing pain while
swallowing
• Otalgia (pain in the ear)
• Drooling
Assessment and Diagnostic Findings
• Aspiration of purulent material (pus) by needle aspiration
• Culture and Sensitivity; Gram’s stain
• CT-scan (when it is not possible to aspirate the abscess)
Medical Management

• Needle Aspiration
• Incision and Drainage
• Antibiotic Regimen
Nursing Management

• use of topical anesthetic agents

• use of mouthwashes
• Gargles using saline or alkaline solutions at a temperatur at intervals of 1 or 2
hours for 24 to 36 hours
 Laryngitis
• an inflammation of the larynx, often
occurs as a result of voice abuse or
exposure to dust, chemicals, smoke,
and other pollutants
Clinical Manifestation
• hoarseness
• aphonia (complete loss of voice)
• severe cough.
Medical Management

• Antibiotic Regimen
o Topical corticosteroids,
o Beclomethasone dipropionate (Vanceril) inhalation
Nursing Management

• Rest the voice

• Maintain a well-humidified environment
• Advise increase fluid intake
 • Health history
• Signs and symptoms:
headache, cough,
hoarseness, fever,
URI Nursing stuffiness, generalized
Process: discomfort, and fatigue
Assessment • Allergies
• Inspection of nose, neck,
throat, and palpation of
lymph nodes
Complications
• If left untreated, may lead to severe and occasionally life-threatening
complications such as
• Meningitis
• brain abscess
• ischemic infarction
• osteomyelitis

• Other complications (uncommon):

• severe orbital cellulitis,
• subperiosteal abscess
• cavernous sinus thrombosis.
 • Airway obstruction
• Hemorrhage
• Sepsis
• Meningitis or brain abscess
• Nuchal rigidity (Neck Stiffness)
• Medicamentosa (chronic nasal
URI Potential congestion)
• Acute otitis media
Complications • Trismus (Lock Jaw)
• Dysphagia (difficulty of
Swallowing)
• Aphonia (loss of ability to speak or
damage to the pharynx or mouth)
• Cellulitis
 What should the nurse
Question #2 palpate when assessing
for an upper respiratory
tract infection?
A. Neck lymph nodes
B. Nasal mucosa
C. Tracheal mucosa
D. All of the above
Answer to Question
#2
A. Neck lymph nodes
Rationale: The nurse should palpate
the neck lymph nodes along with the
trachea and the frontal and maxillary
sinuses when assessing for an upper
respiratory tract infection
The nurse should inspect the nasal and
tracheal mucosa when assessing for an
upper respiratory tract infection
 Ineffective Airway Clearance

Acute Pain

URI Nursing
Process: Impaired Verbal Communication
Diagnoses
Fluid Volume Deficit

Knowledge Deficit related to prevention,

treatment, surgical procedure, postoperative
care
 Airway management, reduce risk of aspiration

Pain management

URI Nursing Effective communication strategy

Process:
Planning Increase hydration

Patient teaching: self-care, prevention, and

health promotion

Home care, if indicated

URI Nursing Process: Interventions

• Elevate head
• Ice collar to reduce inflammation and bleeding
• Hot packs to reduce congestion
• Analgesics for pain
• Gargles for sore throat
• Use alternative communication
• Encourage liquids; at least 2 to 3 L/day
• Soft bland diet
• Rest
 Maintenance of patent airway

Expresses relief of pain

URI Nursing
Process: Able to communicate needs
Evaluation
Evidence of positive hydration

Absence of complications
 • Prevention of upper
airway infections
• Emphasize frequent
hand washing
• When to contact
Patient health care provider
Education • Need to complete
antibiotic treatment
regimen
• Annual influenza
vaccine for those at
risk
 • Obstructive sleep apnea—S/S:
Chart 22-3 snoring, Insomia,
morning headache; Tx: CPAP,
BiPAP, oxygen therapy, surgery
• Epistaxis
Obstruction and • Nasal obstruction—S/S:
deviated septum, turbinate
Trauma of the hypertrophy, polyps
Upper Respiratory • Fractures of the nose—S/S:
traumatic obstruction; Tx:
Airway reduction of fracture, control
epistaxis and edema
• Laryngeal obstruction—S/S:
edema, Table 22-3; Tx:
subcutaneous epinephrine,
tracheotomy
Obstructive Sleeping Apnea
• defined as cessation of breathing
(apnea) during sleep.

❑ Obstructive—lack of air flow due to

pharyngeal occlusion
❑ Central—simultaneous cessation of
both air flow and respiratory
movements
❑ Mixed—a combination of central
and obstructive apnea within one
apneic episode
Clinical Manifestation
• Excessive daytime sleepiness
• Frequent nocturnal awakening
• Insomnia
• Loud snoring
• Morning headaches
• Intellectual deterioration
• Personality changes, irritability
• Systemic hypertension
Medical Management

• BiPAP; CPAP
• Uvulopalatopharyngoplasty
Pharmacology
• Protriptyline (Triptil) given at bedtime is thought to increase the respiratory
drive and improve upper airway muscle tone.
• Medroxyprogesterone acetate (Provera)
• Acetazolamide (Diamox) have been recommended for sleep apnea associated
with chronic alveolar hypoventilation
Nursing Management

• Explain the treatment and procedures to patient and

family
Epistaxis (Nosebleed)
• A hemorrhage from the
nose, caused by the rupture
of tiny, distended vessels in
the mucous membrane of
any area of the nose.
Clinical Manifestation
• Excessive daytime sleepiness
• Frequent nocturnal awakening
• Insomnia
• Loud snoring
• Morning headaches
• Intellectual deterioration
• Personality changes, irritability
• Systemic hypertension
Medical Management

• Pinch soft portion of nose for 5 to 10 minutes

• Phenylephrine spray, vasoconstriction
• Cauterize with silver nitrate or electrocautery
• Gauze packing or balloon-inflated catheter inserted into
nasal cavity for 3 to 4 days
• Antibiotic therapy
Nursing Management

• Airway, breathing, circulation

• Vital signs, possible cardiac monitoring and pulse oximetry
• Reduce anxiety
• Patient teaching:
• Avoid nasal trauma, nose picking, forceful blowing, spicy foods,
tobacco, exercise
• Adequate humidification to prevent dryness
• Pinch nose to stop bleeding; if bleeding does not stop in 15 minutes,
seek medical attention
Nasal Obstruction
• frequently obstructed by a
deviation of the nasal
septum, hypertrophy of the
turbinate bones, or the
pressure of nasal polyps
Medical Management
• requires the removal of the obstruction, followed by measures
to overcome whatever chronic infection exists.
• submucous resection or septoplasty.
Laryngeal Obstruction
• Obstruction due to foreign body
• Edema of the larynx
Medical Management

• Administration of Epinephrine or corticosteroid

• Applying Ice pack on the neck
 • Accounts for approximately
half of all head and neck
cancers
• 13,560 new cases and
3640 deaths annually
• Most common in people
Cancer of over age 65
the Larynx • Four times more common
in men
• Risk factors: smoking,
straining of voice,
nutritional deficiencies,
alcohol use, age (60 years
old up, Gender (Men)
Signs and Symptoms

Early: Later:
• Hoarseness • Dysphagia, dyspnea
• Persistent cough • Nasal obstruction
• Sore throat or pain burning in • Persistent hoarseness
throat • Persistent ulceration
• Raspy voice, lower pitch • Foul breath
• Lump in neck • General debilitation
 Is the following statement
true or false?
An early sign of cancer of
Question #3 the larynx includes
changes in speech, the
voice may sound harsh,
raspy, and lower in pitch
True
Rationale: An early sign of
cancer of the larynx includes
Answer to Question
changes in speech, the voice #3
may sound harsh, raspy, and
lower in pitch
 • History and physical
• Laryngoscopy
• FNA biopsy
Medical • Barium swallow study
Diagnostics • Endoscopy, CT, MRI, PET
scan
• Tumors grade and stage
by TNM system
Medical Management of Laryngeal Cancer

Stages I and II Stages III and IV

• Radiation therapy • Radiation therapy
• Cordectomy • Chemotherapy
• Endoscopic laser • Chemoradiation
excision • Total laryngectomy
• Partial laryngectomy
Changes in Airflow With Total Laryngectomy
 Health history

Physical, psychosocial, and spiritual

assessment

Nursing
Process: Nutrition, BMI, albumin, glucose, electrolytes

Assessment
Literacy, hearing, and vision; may impact
communication after surgery

Coping skills and available support systems for

patient and family after surgery
 Knowledge deficit about surgical procedure

Anxiety relating to diagnosis

Ineffective airway clearance

Nursing
Impaired verbal communication
Process:
Diagnoses Imbalanced nutrition

Disturbed body image

Self-care deficit
 Maintain patent
Postoperative Reduce anxiety airway, control
secretions
Nursing Care
Promote
Support
adequate
alternative
nutrition and
communication
hydration

Promote
positive body Self-care
image, self- management
esteem
 • Respiratory distress
• Hemorrhage
Collaborative • Infection
Problems/Potential • Wound breakdown
Complications
• Aspiration
• Tracheostomal
stenosis