NURSING PORCESS

PATIENT WITH UPPER AIRWAYS INFECTION

ASSESSMENT
S/S Headache Sore throat Pain around the eyes Difficulty in swallowing

What relieves them What aggravates History of any allergy Existence of concommittant illnesses

DIAGNOSIS
Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammations Acute pain related to upper airway irritation secondary to infection Impaired verbal communication related to physiologic changes and upper airway irritation secondary to infection or swelling

Sepsis Meningitis Peritonsillar abscess Otitis media Sinusitis

COLLABORATIVE PROLBEMS/POTENTIAL COMPLICATIONS

PLANNING/GOALS
Relief of pain Maintenance of effective means of communication Normal hydration Knowledge of how to prevent upper airway infections Absence of complications

NURSING INTERVENTION
Maintaining of Patent Airway Breathing increases to compensate for the blockage Increasing fluid intake Use of room vaporizers or steam inhalation Drainage sinusitis and rhinitis upright position

PROMOTING COMFORT
Localized discomfort Nurse encourage analgesics Acetmainophen and codeine Topical anesthetics for herpes simplex Hot packs to relieve congestions of sinusitis Warm water gargles General hygiene technique Postoperative adenoidectomy and tonsillectomy ice collar may reduce swelling an decrease bleeding

PROMOTING COMMUNICATION
Hoarseness and loss of speech Refrain form speaking communicate in writing Use of memo pad or a bell to signal for assistance when needed

ENCOURAGE FLUID INTAKE

Increase as inflammation and secretions develop increase insensible fluid loss Fever further, increases the metabolic rate, diaphoresis and fluid loss Sore throat may interfere with a patients willingness to eat and drink. Provide a list of eaisly ingested food increase caloric intake soups, pudding, yougurt, cheese, high protein drinks, popsicles.

 Drink 2 to 3 L of fluids per day during acute stage of airway infection Liquids may be soothing depending on the disorder.

PROMOTING HOME AND COMMUNITY BASED CARE

Teaching patients self-care Nurse teaches the minimize the spread of infections Handwashing Avoid exposure to people who are risk for serious illness Elderly adults, immunosuppressed people, Increasing humidity level Adequate fluid intake

CONTINUING OF CARE
Referral is rare Consider for annual influenza vaccine elderly Follow-up appointment with the primary care provider

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Families are instructed to monitor s/s Seek immediate care sepsis and meningitis compromised immune system Peritonsillar abscess may develop after an acute infection of the tonsils treatment to drain the abscess and receives antibiotic for infection

 Otitis media and sinusitis may develop with URI

EVALUATION
Expected patient outcomes Maintain a patient airway by managing secretions a. Reports decrease congestion b. Assumes best position to facilitate drainage of secretions c. Uses self-care measures appropriately and consistently to manage secretions during the acute phase of illness

Report relief of pain and discomfort using pain intensity scale a. Uses comfort measures: analgesics, hot packs, gargles, rest

OBSTRUCTION AND TRUAMA OF THE UPPER RESPIRATORY AIRWAYS

OBSTRUCTION DURING SLEEP

SLEEP APNEA SYNDROME defined as cessation of breathing during sleep usually caused by repetitive upper airway obstruction. Prevalent in men especially those who are older and overweight Smoking possible risk factors