Debre Brehan University School of Health Science

Program of NursingMedical-Surgical Nursing I

Management of Patients With Upper Respiratory Tract DisordersPrepared by Minlikalew D.

(B.Sc. in Nursing)

On completion of this chapter, the learner will be able to:1. Describe nursing management of patients with upper airway

disorders.2. Compare and contrast the upper respiratory tract infections

withregard to cause, incidence, clinical manifestations,

management, and the significance of preventive health care.3. Use the nursing process as a framework for care of patients

withupper airway infection.4. Describe nursing management of the patient with epistaxis.5. Use the nursing process as a framework for care of patients

undergoing laryngectomy.

LEARNING OBJECTIVES

alaryngeal communication: alternative modes of speaking that do not involve the normal larynx; used by patients whose larynx has been surgically removed

aphonia: impaired ability to use one’s voice due to disease or injury to the larynx

apnea: cessation of breathing dysphagia: difficulties in swallowing epistaxis: hemorrhage from the nose due to rupture of

tiny, distended vessels in the mucous membrane of any area of the nose

herpes simplex: cold sore (cutaneous viral infection with painful vesicles anderosions on the tongue, palate, gingival, buccal membranes, or lips)

Definition of important terms

laryngitis: inflammation of the larynx; may be due to voice abuse, exposure to irritants, or infectious organisms

laryngectomy: removal of all or part of the larynx and surrounding structures

pharyngitis: inflammation of the throat; usually viral or bacterial in origin

rhinitis: inflammation of the mucous membranes of the nose; may be infectious, allergic, or inflammatory in origin

Cont…d

rhinorrhea: drainage of a large amount of fluid from the nose

sinusitis: inflammation of the sinuses; may be acute or chronic; may be viral, bacterial, or fungal in origin

submucous resection: surgical procedure to correct nasal obstruction due to deviated septum; also called septoplasty

tonsillitis: inflammation of the tonsils, usually due to an acute infection

xerostomia: dryness of the mouth from a variety of causes

Cont…d

Upper airway infections are common conditions that affect most people on occasion. Some infections are acute, with symptoms that last several days; others are chronic, with symptoms that last a long time or recur. Patients with these conditions seldom require hospitalization. However, nurses working in community settings or long-term care facilities may encounter patients who have these infections. Thus, it is important for the nurse to recognize the signs and symptoms and to provide appropriate care.

Upper Airway Infections

Cough, Gag, Sneeze ReflexesMucus SecretionsCiliary ActionLot of lymphoid tissueLarge Blood Supply

Upper Airway Defenses

Definition:- It is a group of disorders characterized by

inflammation and irritation of the mucous membranes of the nose.

It may be classified as; a. Non-allergic. b. allergic.It may be; a. an acute or b. chronic condition.

RHINITIS

Causes:-1. Nonallergic;environmental factors (changes in temperature or humidity,

odors, or foods) Infection age systemic disease drugs(cocaine) or prescribed medications (antihypertensive agents, OCP) presence of a foreign body. chronic use of nasal decongestants.2. allergic; any allergic agent (dusts, molds, animals, fumes, odors,

powders, sprays, and tobacco smoke).

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Pathophysiology

Cont…d

Clinical Manifestations; 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.

Cont…d

Medical Management; The management of rhinitis depends on the cause,

which may be identified in the history and physical examination.

If viral rhinitis:-medications are given to relieve the symptoms.

In allergic rhinitis :-desensitizing immunizations, intranasal corticosteroids (Depending on the severity of the allergy) and Antihistamines.

If a bacterial infection:-antimicrobial agent. ophthalmic agents are used to relieve irritation, itching,

and redness of the eyes. Oral decongestant agent.

Cont…d

Nursing Management;instructs the patient with allergic rhinitis to avoid or

reduce exposure to allergens and irritants.Saline nasal or aerosol sprays may be helpful in

soothing mucous membranes, softening crusted secretions, and removing irritants

blow the nose before applying any medication into the nasal cavity.

hand hygiene technique as a measure to prevent transmission of organisms.

reviews the value of receiving a vaccination (elderly and other high-risk Populations)

Cont…d

an upper respiratory tract infection that is self-limited and caused by a virus (viral rhinitis).

Specifically, the term “cold” refers to an a febrile, infectious, acute inflammation of the mucous membranes of the nasal cavity.

It can also be used when the causative virus is influenza (“the flu”).

Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase.

The six viruses known to produce the signs and symptoms of the viral rhinitis are;

- rhinovirus, - respiratory syncytial virus (RSV),

- parainfluenza virus, - influenza virus, and

- coronavirus, - adenovirus. Each virus may have multiple strains. For example, there are over

100 strains of rhinovirus, which accounts for 50% of all colds.

VIRAL RHINITIS (COMMON COLD)

Clinical Manifestations;The symptoms last from 1 to 2 weeks. It includes; - nasal congestion, - runny nose, - sneezing, - nasal

discharge, - nasal itchiness, - tearing watery

eyes, - “scratchy” or sore throat, - general

malaise, - low-grade fever, - chills, - headache, - muscle aches. In some people, viral rhinitis exacerbates the herpes simplex,

commonly called a cold sore

Cont…d

Medical Management; Adequate fluid intake. Encouraging rest. Preventing chilling. Increasing intake of vitamin C. Using expectorants as needed. Warm salt-water gargles soothe the sore throat. Nonsteroidal anti-inflammatory agents (NSAIDs) such as aspirin or ibuprofen. Antihistamines (chlorpheniramine maleate , diphenhydramine

(Benadryl) Topical (nasal) decongestant ( e.g. oxymetazoline maleate (Afrin),

phenylephrine (Neo-synephrine), pseudoephedrine (Sudafed) orally. Zinc lozenges may reduce the duration of cold symptoms if taken within

the first 24 hours of onset. Amantadine (Symmetrel) or rimantadine (Flumadine) may be prescribed

prophylactically. Antimicrobial agents (antibiotics) should not be used because they do not

affect the virus or reduce the incidence of bacterial complications.

Cont…d

Nursing Management; Perform hand hygiene often. Use disposable tissues. Avoid crowds during the flu season. Avoid individuals with colds or respiratory

infections. Obtain influenza vaccination, if

recommended (especially if elderly or diagnosed with a chronic illness)

Cont…d

It is an Inflammation of mucous membranes of sinuses. Sinuses are air-filled cavities in facial bones Lined with ciliated mucous membranes Help move fluid & microorganisms out of sinuses into nasal cavity. Normally sterile environment

Frontal and maxillary sinuses commonly involved in adults.

It can be;1. Acute.2. Chronic.

SINUSITIS

1. ACUTE SINUSITISan infection of the paranasal sinuses.

Causes; Often following viral/bacterial upper respiratory infection. An exacerbation of allergic rhinitis. Dental infections Bacterial organisms account for more than 60% of the cases

of acute sinusitis, namely; ◦ Streptococcus pneumoniae.

◦Haemophilus influenzae.◦ Staphylococci

Some individuals are more prone to sinusitis because of their occupations. For example, continuous exposure to environmental hazards such as paint, sawdust, and chemicals may result in chronic inflammation of the nasal passages.

Cont…d

Pathophysiology; Inflammation of mucous membranes

Obstruction (other Nasal polyps, Deviated septum, Rhinitis, Tooth abscess, Swimming or diving trauma, Prolonged nasotracheal intubation

Impaired drainage

Mucus secretions collect in sinus cavity (Medium for bacterial growth)

Cont…d

Inflammatory response (Serum & leukocytes invade area to combat infection)

Increase in swelling & pressure

Cont…d

Clinical Manifestations; facial pain or pressure over the affected sinus area, nasal obstruction, fatigue, purulent nasal discharge, fever, headache, ear pain and fullness, dental pain, cough, a decreased sense of smell, sore throat, eyelid edema, facial congestion or fullness.

Cont…d

Assessment and Diagnostic Findings Hx and P/E. Sinus X-rays. CT scan. Magnetic resonance imaging (MRI).

Rule out malignancy of sinus

Cont…d

Complications;Common Meningitis , Brain abscess, ischemic infarction, and Osteomyelitis.Uncommon Severe orbital cellulitis, Subperiosteal abscess, and Cavernous sinus thrombosis.

Cont…d

Medical Management;The goals of treatment of acute sinusitis are to; - treat the infection, - shrink the nasal mucosa, and - relieve pain. Medications

◦ Antibiotics (orally) for two weeks. Longer if needed to prevent relapse

e.g.- amoxicillin, 1st line - cothrimoxazole (Bactrim) as - cephalosporins, 2nd line

- amoxicillin clavulanate (Augmentin) as -ciprofloxacin

o Antibiotics IV in hospital if no response to oral treatment.

Cont…d

o decongestant agents - oral e.g. pseudoephedrine - Topical e.g. oxymetazoline (Afrin) up to 72

hours.o a mucolytic agent e.g. Guaifenesin.o Heated moist and saline irrigation.o Antihistamines such as diphenhydramine

(Benadryl), cetirizine (Zyrtec), and fexofenadine (Allegra).

Cont…d

Nursing Management; Inhaling steam (steam bath, hot shower,

and facial sauna), Increasing fluid intake, and Applying local heat (hot wet packs). Avoiding contact with people who have

upper respiratory infections. Teach about the s/s of sinusitis

complication. Teach about the side effects of drug.

Cont…d

2. CHRONIC SINUSITIS Chronic sinusitis is an inflammation of the

sinuses that persists for more than 3 weeks in an adult and 2 weeks in a child.

It is estimated that 32 million people a year develop chronic sinusitis.

Cont…d

Cause and Pathophysiology;A 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. This combined area is known as the osteomeatal complex. Blockage that persists for greater than 3 weeks in an adult may occur because of infection, allergy, or structural abnormalities stagnant secretions, an ideal medium for infection.

Immunocompromised patients, however, are at increased risk for developing fungal sinusitis. Aspergillus fumigatus is the most common organism associated with fungal sinusitis.

Cont…d

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, and Facial pain. These symptoms are generally most pronounced on

awakening in the morning. Fatigue and nasal stuffiness, a decrease in smell and taste, and a fullness in the ears.

Cont…d

Assessment and Diagnostic Findings;-history and P/E, computed tomography scan 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.

Cont…d

Complications; severe orbital cellulitis, subperiosteal abscess, cavernous sinus thrombosis, meningitis, encephalitis, and ischemic infarction.

Cont…d

Medical Management; Medical management of chronic sinusitis is almost the same as

for acute sinusitis. The course of treatment may be 3 to 4 weeks. SurgeryEndoscopic sinus surgery

◦ Antral irrigation Saline solution instilled via 16-gauge needle. Patient seated with head forward & mouth open to allow

drainage of purulent irrigating solution.◦ Caldwell-Luc procedure

If endoscopic surgery unsuccessful. Creates an opening between maxillary sinus & lateral nasal wall.

◦ External sphenoethmoidectomy

Cont…d

Post-op Nursing Care◦ Gauze packing 24-48 hours post-op.◦ Upper lip & teeth numbness for several months.◦ Impaired chewing on affected side.◦ Liquids only first 24 hours post-op.

Followed by soft diet◦ Avoid for 2 weeks after removal of packing

Dentures Valsalva maneuver

Cont…d

General Nursing care;◦Generally no packing required◦Frequent nasal cleaning & irrigation

Sterile normal saline◦Teach

Open mouth sneezing Avoid blowing noseAvoid lifting or straining

increasing fluid intake, and applying local heat (hot wet packs).

Semi-Fowler’s position.◦ Relieves pain.

Cont…d

1. ACUTE PHARYNGITIS Acute pharyngitis is an inflammation or infection in the

throat, usually causing symptoms of a sore throat.Cause and Pathophysiology Most cases of acute pharyngitis are caused by viral infection. When group A beta-hemolytic streptococcus, the most

common bacterial organism, causes acute pharyngitis, the condition is known as strep throat.

The body responds by triggering an inflammatory response in the pharynx.

This 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.

PHARYNGITIS

Cont…d

Clinical Manifestations; a fiery-red pharyngeal membrane and

tonsils, lymphoid follicles that are swollen and

flecked with white-purple exudate, and enlarged,

tender cervical lymph nodes, Fever, malaise, and sore throat also

may be present.

Cont…d

Cont…d

Assessment and Diagnostic Findings; the latex agglutination (LA) antigen test solid-phase enzyme immunoassays (ELISA), optical immunoassay (OIA), streptolysin titers, and throat cultures. Nasal swabs and blood cultures may also

be necessary to identify the organism.

Cont…d

Medical Management;Supportive measures for Viral pharyngitis.Antimicrobial agents (penicillin) for Bacterial

pharyngitis at least 10 days.Analgesic agent e.g. aspirin or

acetaminophen (Tylenol) can be taken at 3- to 6-hour intervals.

A liquid or soft diet.Antitussive medication e.g. codeine,

dextromethorphan (Robitussin DM), or hydrocodone bitartrate (Hycodan).

Cont…d

Nursing Management; Bed rest. Proper tissue disposal. Warm saline gargles or irrigations with a

temperature of 105°F to 110°F (40.6°C to 43.3°C) An ice collar. Teach about the complication.

Cont…d

Complications; sinusitis, otitis media, peritonsillar abscess, mastoiditis, and cervical adenitis. In rare cases the infection may lead to

bacteremia, pneumonia, meningitis, rheumatic fever, or nephritis.

Cont…d

2. CHRONIC PHARYNGITISIt is a persistent inflammation of the pharynx.It is common in adults who work or live in dusty surroundings, use their voice to excess, suffer from chronic cough, an habitually use alcohol and tobacco.Three types of chronic pharyngitis are recognized:

• Hypertrophic:-general thickening and congestion of the pharyngeal mucous membrane

• Atrophic: probably a late stage of the first type (the membrane is thin, whitish, glistening, and at times wrinkled)

• Chronic granular (“clergyman’s sore throat”): characterized by numerous swollen lymph follicles on the pharyngeal wall.

Cont…d

Clinical Manifestations;-a constant sense of irritation or fullness in the throat, mucus that collects in the throat and can be expelled by coughing, and difficulty swallowing.Medical Management; is based on -relieving symptoms, - avoiding exposure to irritants, and - correcting any upper respiratory, pulmonary, or cardiac

condition that might be responsible for a chronic cough. Nasal sprays or medications containing ephedrine sulfate (Kondon’s

Nasal) or phenylephrine hydrochloride (Neo-Synephrine). Antihistamine decongestant medications, such as Drixoral or Dimetapp,

is taken orally every 4 to 6 hours. Antiinflammatory and analgesic agent like Aspirin or acetaminophen.

Cont…d

Nursing Management; avoid contact with others until the fever

subsides. Alcohol, tobacco, second-hand smoke, and

exposure to cold are avoided. The patient may minimize exposure to

pollutants by wearing a disposable facemask. drink plenty of fluids. Gargling with warm saline solutions Lozenges will keep the throat moistened.

Cont…d

TONSILLITIS AND ADENOIDITIS