Chapter 14 Care of Patients with Disorders of Upper Respiratory System:

Disorders of the Nose and Sinuses:

-Upper Respiratory Infection(URI), Acute Viral Rhinitis (the common cold), and allergic
rhinitis.
Acute Viral Rhinitis:
-is an inflammation of the nose and upper respiratory tract.
-most prevalent infectious disease among people of all ages.
-pt is contagious for about 3 days after symptoms first appear
-spread by airborne droplet infection
-no cure; but zinc lozenges have proven effective in limiting a cold's duration and
severity for many people
- Fluid intake should be increased. Fruit juices are recommended, especially citrus
juices, because of their vitamin C content.
*Signs Symptoms and Diagnosis:
-starts with a mild sore throat or a hot, dry, prickly sensations in the nose and back of
the throat.
- Within hours after the onset of a cold, the nose becomes congested with increased
secretions, the eyes begin to water, and sneezing, malaise, and an irritating,
nonproductive cough appear.
-muscle aches and headache may occur
-usually no fever or a low grade
-can last 10 to 14 days before all symptoms are gone
Aspirin or another mild nonprescription analgesic can help relieve the muscle aches
and headache of a cold.
-ASPIRIN CAUTION: should not be given to children under 18, has an association with
Reyes syndrome. Adults taking anticoagulants or nonsteriodal anti-inflammatory
drugs should not take aspirin due to further prolong the clotting time.
What is a major goal in care of the common cold is?
-prevention of a secondary bacterial
Allergic Rhinitis:
-no fever
-has same symptoms as the cold except fever
-caused by reaction of the nasal mucosa to an allergen, such as pollen or dust.
*Meds Commonly Prescribed Drugs:
-Antihistamines (Claritin, Allegra, etc.)
-Corticosteroid Spray(Flonase, etc)
-Mast Cell Stabilizer (Nasalcrom)
-Decongestants (Sudafed, Dristan, etc.)
-Second-generation agents
Elder Care Points:
-immune system is decreased and they are therefore more at risk for contracting a
cold or upper respiratory infection. Encourage to stay away from people who have
such infections.
-if cold develops, more likely to develop a secondary infection. Encourage increased
fluid intake and lots of rest until the cold symptoms are completely gone.
Sinusitis:
-an inflammation of the mucosal lining of the sinuses.
-causes include infection that has spread from the nasal passages to the sinuses, and
blockage of normal sinus drainage routes.

-Infecting organisms: Pneumococci, streptococci, or Haemophilus influenzae

-Nasal passages can be blocked by a deviated septum or nasal polyps
(Polyps occur from repeated inflammation of the nasal mucosa and are tissue
growths that obstruct airflow)
-occurs often after colds or other respiratory infections/ during periods of
uncontrolled allergic rhinitis.
-pt with deviated nasal septum or allergy problems tend to have recurrent sinusitis.
- Acute or chronic sinus infection can cause a variety of complications, including
septicemia, meningitis, and brain abscess.
*Signs and Symptoms:
- As exudate accumulates in the sinuses, pressure builds up causing pain
- headache, fever, tenderness over the sinuses, malaise, purulent drainage from the
nose, and sometimes a nonproductive cough. The upper teeth may become painful.
*Treatment:
-relieve pain, promote sinus drainage, control infection, and prevent recurrence.
-hot, moist packs over the sinus area can be helpful
-Inhaling moist steam thins secretions and kits for sinus irrigation available at
drugstores help to promote drainage
-Meds are given to promote decongestion or vasoconstriction and to reduce swelling,
to promote drainage and to relieve pain
-May be treated with antibiotic or anti-infective agent for 10 days.
-Rest, reduced stress, a balanced diet, and control of allergies.
-Fluid intake increase
Epistaxis:
-nosebleed common occurrence and usually results from crusting, cracking, or
irritation of the mucous membrane covering the front of the nasal septum.
-only sign is bleeding
When occurs the patient should sit forward and apply direct pressure by pinching the
soft portion of the nose for the 10 to 15 minutes. This position prevents blood from
running down the back of the throat.
Pharyngitis:
-inflammation of the pharynx SORE THROAT
-can be caused by a virus, bacteria, or fungus; usually viral
-majority cases are viral
-usual course of uncomplicated pharyngitis or laryngitis is 3 to 10 days
-Pharyngitis is confirmed by clinical signs and symptoms.
-Throat culture is often done to confirm Strep
*Acute Follicular Pharyngitis: Strep throat caused by beta-hemolytic
streptococcal infection
*Fungal pharyngitis occurs with long-term use of antibiotics or inhaled
corticosteroids, or in patients with immunosuppression, such as occurs with HIV or
AIDS or during cancer treatment.
*Laryngitis: inflammation of the larynx with diminished voice or hoarseness; may
occur if the infection progresses into the larynx.
*If the inflammation extends to the epiglottis, epiglottitis [A potentially lifethreatening condition that occurs when the tissue protecting the windpipe becomes
inflamed.] occurs; most common in children
Signs and symptoms:
-dry, scratchy feeling in the back of throat
-mild fever
-headache
-Malaise

-Throat, tonsils, palate, and uvula may be involved and will be reddened.
-Dysphagia is also present with discomfort when swallowing ones own saliva.
*Laryngitis: the voice may become hoarse or absent.
Treatment:
-conservative measures as rest, warm saline gargles, throat lozenges, plenty of fluids,
and a mild analgesic for aches and pains.
-antiseptic sprays and lozenges help provide relief from discomfort.
-bacterial pharyngitis requires antibiotic therapy esp with Strep
-chronic pharyngitis may require diagnostic procedures to determine the underlying
cause and therapeutic measures such as humidification and filtering of
environmental air
-Fungal pharyngitis is treated with an agent effective against fungi, but may be
difficult to control in immune compromised individuals.
Tonsillitis:
-an infection with inflammation of the tonsils is usually caused by streptococci,
staphylococci, or H. influenzae and is different from pharyngitis;
- Acute tonsillitis may occur repeatedly, especially in those who have a low resistance
to infection.
*Signs, Symptoms, and Diagnosis:
-frequently in young children
-high fever
-sore throat
-general malaise
-pain referred to the ears
-chills
-inspection of the throat reveals redness and swelling of the tonsils and surrounding
tissues with patches of yellow exudate.
-WBC elevated
- Chronic tonsillitis usually produces an enlargement of tonsillar tissue and adenoidal
tissue. Chronic infection produces less dramatic symptoms than acute tonsillitis but
discomfort still occurs. A person with chronic tonsillitis and enlarged adenoids has
frequent colds and appears to be in poor health.
*Treatment:
-A throat culture is done before treatment to check for the presence
of Streptococcus, which can cause rheumatic fever or glomerulonephritis if
not treated promptly.
-warm saline throat gargles and the administration of specific antibiotics(usually
penicillin) to destroy the pathogen.
-bed rest, fever management, and a liquid diet to minimize trauma to the tissues.
-After 24 hours on antibiotics, the patient is no longer contagious
-Surgery is used to treat tonsillitis when it is recurrent or when enlargement of the
tonsils and adenoids obstructs airways. ( seven episodes per year)
Preoperative Care:
-outpatient, same-day surgery
-preliminary lab testing and pt education begins before admitted
-NPO midnight before surgery (6 to 8 hours)
-Any temp or URI should be reported
Postoperative Care:

-usually recover rapidly and rarely suffer complications, the nurse is vigilant
for signs of hemorrhage.
-Vitals checked frequently and the patient is observed for frequent swallowing,
which may indicate bleeding in the throat. Restlessness can be another clue to
excessive bleeding.
-sneezing, vomiting, and coughing can cause bleeding
-can place ice collar on neck to reduce swelling.
-Cold items in diet NOTHING RED! First 24 hours
-Do not use straws!
If the airway is obstructed for an extended period, the heart may stop due to?
-Hypoxia
Obstructive Sleep Apnea:
-condition in which the person stops breathing during sleep for 10 seconds or
more, until there is a reflex gasp for air.
-Muscle relaxation at the back of the throat is the most common cause.
-Snoring is frequent
-Sleep study done to diagnose. Capnography done measures exhaled Carbon
dioxide, apneic events, and respiratory rates.
*Treatment:
-with continuous positive airway pressure (CPAP) applied with a mask or nasal
prongs.
-If left untreated can contribute to Myocardial infarction or stroke. Also
constant fatigue.
Nasal Fracture:
-often results from sports injuries, motor vehicle accidents, or physical assault.
-if the cartilage or bone is not displaced, complications are unlikely and no
treatment is needed.
-displacement can interfere with airflow, cause deformity of the nose and
become a potential spot for infection.
-Crepitation: grating sound or feeling of rough surfaces rubbing together upon
palpation.
-if fracture is severe Rhinoplasty(surgical reconstruction of the nose) can be
done to improve airflow and cosmetic appearance
-observe for frequent swallowing can indicate posterior nasal
bleeding, vital signs are monitored closely, amount of drainage,
cool compresses to decrease swelling, and provide humidified
oxygen.
Which nursing intervention(s) would be appropriate during the immediate
postoperative period for a patient who has undergone rhinoplasty? (Select all that
apply.)
1. Observe for frequent swallowing.
2. Monitor amount of drainage.
3. Position patient flat on the back.
4. Apply warm compresses.
5. Provide humidified oxygen.
Cancer of the Larynx:
-approx 90% of all pts who are diagnosed early and treated with radiation
and/or surgery are cured.

-cause is unknown, some evidence that predisposing factors include cigarette

smoking, alcohol abuse, diets rich in spicy foods, infection with human
papillomavirus, chronic laryngitis, abuse of the vocal cords, exposure to
radiation, and a familial tendency to cancer.
-most common malignant tumor of the larynx is squamous cell carcinoma.
(grows from the mucous membrane lining the respiratory tract.) Metastasis
may occur to the lung.
**Signs and Symptoms:
-a tumor of the larynx will quickly produce persistent hoarseness that does not
respond to usual methods of treatment.
-hoarseness lasting more than three weeks.
- Sore throat that lasts more than 2 weeks
-Consistent pain in or around the ear when swallowing
-Difficulty swallowing
-Dry, persistent cough for no known reason
-blood in phlegm or saliva lasting more than a few days
-lumps or knots on the neck indicating enlarged cervical lymph nodes.
IF IT SPREADS BEYOND THE VOCAL CORDS:
-the symptoms may include difficulty in swallowing or breathing, halitosis,
blood-tinged sputum, fatigue and weakness, a sensation of having a lump in
the throat, cough, enlarged lymph nodes in the neck, pain in the region of the
Adam's apple or an airway obstruction
Diagnosed by visualizing the larynx via a laryngoscope, by a computed tomography
scan of the larynx and throat, by magnetic resonance imaging, and by microscopic
examination of a sample of tissues taken from the site.
**Treatment:
-once the cancer has spread beyond the vocal cords it is much more difficult
to treat.
-radiation alone is 85% effective in treating early stages; it can be combine
with laser cordectomy for certain types of lesions.
-If tumor is large or not restricted to the vocal cords, the surgeon may perform
a partial laryngectomy (thyroid cartilage is split and only the tumor and
involved portions of larynx and vocal cords are removed)
-Tracheostomy (surgical opening into the trachea) can be done to facilitate
breathing temporarily, but the stoma is eventually closed.
- A total laryngectomy is performed if the tumor has progressed to the point of
paralyzing the vocal cords.
Endotracheal Intubation and Tracheostomy:
-ENDOCTRACHEAL INTUBATION means that an endotracheal tube is inserted
into the trachea via the nose or the month with the use of a laryngoscope.
-TRACHEOSTOMY is a surgical incision into the trachea for the purpose of
inserting a tube through which the patient can breathe. ( no connection
between the nose and mouth and the lower respiratory system.) May need
oxygen therapy or mechanical ventilation following surgery.
Purposes of Tracheostomy:

To assist or control ventilation by mechanical means over a prolonged

period of time.

To facilitate suctioning of secretions in the air passages when the

patient cannot cough.

To prevent aspiration of oral and gastric secretions (as in unconscious

or paralyzed patients).
-To bypass a constricted or obstructed upper airway (e.g., from edema of the
larynx, presence of a foreign body or tumor, surgical procedures involving the
neck, severe burns, facial trauma, or chest trauma).
The patients spouse asks, What is the purpose of the tracheostomy? Which
comment(s) demonstrate(s) nursing knowledge regarding the procedure?
(Select all that apply.)
1. It facilitates suctioning of respiratory secretions.
2. It prevents recurrence of respiratory arrest.
3. It prevents aspiration of oral secretions in unconscious patients.
4. It bypasses an obstructed upper airway.
5. It is a temporary airway for face and neck injuries.
Nursing Management of Tracheostomy:
-requires very specialized nursing care, especially is artificial ventilation
through the tube is required.
-Immediate postoperative care focuses on maintaining a patent airway
and observing for hemorrhage.
-First 24 hours monitor continuously for signs of respiratory distress.
-if pt unable to cough to remove mucus and drainage, tracheal
suctioning is necessary.(needs to be ordered by a HCP) bc if Lumen is
not kept open, the pt will suffocate.
- The lungs should be auscultated (1) before suctioning to assess the
need and (2) afterward to verify that the procedure successfully
cleared the airways. Head-to-toe assessment is done as for any
surgical patient
-Preventing infection: the incision is an open wound with minimal dressings
and is an ideal entryway for infectious organisms. ( if going home teach pt and
family how to properly care for it.)
-Psychological support of the tracheostomy patient and family is essential.
( patient has to learn how to breathe differently and speaking will be different
and might feel sad and depressed.)
-Communication: main (especially laryngectomy patients) will need to be
provided with means of communication such as a pad and pen, a Magic slate,
or a picture board device. Can use speaking tracheostomy valve or may learn
to use esophageal speech as well.
-Rehabilitation: is important in the acceptance of the surgery and the
consequences.
-A speech therapist helps the pt master a new form of speech. Many
people are able to learn esophageal speech:
- first they master the art of swallowing air and then moving it
forcibly back up through the esophagus; then they learn to
coordinate lip and tongue movements with the sound produced
by the air passing over vibrating folds of the esophagus. The
sounds may be somewhat hoarse, but are more natural than
the sounds produced by an artificial larynx.
-Patients who cant master it, a tracheoesophageal prosthesis can be
implanted. Pt places finger over opening of prosthesis and is able to
speak for short period of time.