Ear and Hearing Problems
Disorders
Dr Ibraheem Bashayreh, RN, PhD
11/01/2011
1
Anatomy of the Ear
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External Otitis
• Painful condition caused when irritating or
infective agents come into contact with the
skin of the external ear
• Commonly called swimmer’s ear
• Two most common precipitants are
excessive mositure and trauma to ear
canal.
• 2 most common presenting symptoms are
“otalgia” (ear discomfort) and “otorrhea”
(discharge from external ear canal).
Common symptoms are pain, itching,
tenderness, and temporary loss of hearing.
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External Otitis
• Treatment focused on reducing
inflammation, edema, and pain with
heat, bedrest, limited head
movement, topical antibiotic and
steroid therapy, and analgesics
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Furuncle
• Localized external otitis caused by
bacterial infection of a hair follicle
• Hearing impaired if the lesion blocks
the canal, most commonly cerumen
(wax)
• Treatment with local and systemic
antibiotics, heat application, earwick
to relieve pain, and possible incision
and drainage
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Cerumen or Foreign Bodies
• Cerumen (wax) is the most common cause
of an impacted canal.
Function
• Lubrication,
• Trapping,
• Waterproof barrier,
• Antimicrobial,
• Inhibitory pH
Other blockages include vegetables, beads,
pencil erasers, insects.
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Ear Wax
• Content
• Appearance
• Color
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Treatment
Rx: Irrigate canal with a mixture of water
and hydrogen peroxide at body
temperature for impacted cerumen;
Cerumenex softens wax.
• Carefully remove foreign object.
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Water-clogged ear
• Not the same as Swimmer’s Ear
(Otitis externa)
• Some people are more prone to
retaining water
• Signs and symptoms include feeling
of fullness, wetness, gradual hearing
loss, itching, pain, inflammation, or
infection. So can end up with otitis
externa.
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Treatment
• Tilting the effected ear
• Use of blow dryer
• Isopropyl alcohol 95% in anhydrous
glycerin 5%
• 50:50 mixture of acetic acid 5%
(white vinegar) and isopropyl alcohol
95%
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Otitis Media
* One of the most common childhood
illnesses.
* Approximately $3 billion in
healthcare costs were attributed to >5
million cases in 1995
• Three out of 4 children experience
ear infection (otitis media) by the
time they are 3 years old.
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Otitis Media
• Three types of otitis media include:
– Acute otitis media
– Chronic otitis media
– Serous otitis media
• Most commonly reported
symptoms are cough, rhinitis,
fever, and earache.
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Nonsurgical Management
•
•
•
•
Quiet environment
Bedrest with limited head movement
Heat and cold applications
Systemic and topical antibiotic
therapy
• Analgesics
• Antihistamines
• Decongestants
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Surgical Management
• Myringotomy is a surgical opening of
the pars tensa of the eardrum.
• Operative procedure includes
grommet (polyethylene tube) placed
through the tympanic membrane.
• Postoperative care: keep external
ear and canal free of other
substances while the incision is
healing and keep head dry for
several days.
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Mastoiditis
• Infection of the mastoid air cells caused
by untreated or inadequately treated
otitis media
• Nonsurgical management: antibiotics
(Continued)
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Mastoiditis (Continued)
• Surgical management: simple or
modified radical mastoidectomy with
tympanoplasty
• Complications: damage to cranial
nerves, vertigo, meningitis, brain
abscess, chronic purulent otitis
media, and wound infection
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Trauma
• Trauma and damage to the eardrum
and ossicles may occur by infection,
by direct damage, or through rapid
changes in the middle-ear cavity
pressure.
• Eardrum perforations usually heal
within 24 hours.
• Use preventive measures to protect
the ear from trauma.
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Neoplasms
• Tumors are removed by surgery,
which often destroys hearing in
affected ear.
• Benign lesions are removed
because, with continued growth of
the neoplasm, other structures can
be affected, damaging the facial or
trigeminal nerve.
• When possible, reconstruction of the
middle ear structures is performed.
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Tinnitus
• Continuous ringing or noise perception
is one of the most common problems
with ear or hearing disorders.
• Tinnitis cannot be observed or
confirmed with diagnostic tests.
• When no cause is found, therapy
focuses on masking the tinnitus with
background sound, noisemakers, and
music during sleeping hours.
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Vertigo and Dizziness
• Common manifestations of many ear
disorders
• Advise client to:
– Restrict head motions and move more
slowly.
– Maintain adequate hydration.
– Take antivertiginous drugs.
– Prevent loss-of-balance accidents.
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Labyrinthitis
• Infection of the labyrinth
• Meningitis a common complication of
labyrinthitis
• Treatment with systemic antibiotics,
bedrest in a darkened room,
antiemetics, antivertiginous
medications, psychosocial support
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Meniere’s Disease
• Affects 200/100,000 people
• Inner chronic ear Disorder
• A typical Acute Attack causes vertigo,
tinnitus, feeling of fullness and
pressure in ear, fluctuating hearing
loss, nausea and vomiting.
• Average acute attack lasts 2-4 hours
and leaves patient exhausted. Patient
tends to sleep for hours after acute
attacks
• Is there a Cure??
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Ménière's Disease Rx
• Nonsurgical management includes slow
head movements, salt and fluid
restrictions, cessation of smoking, mild
diuretics, nicotinic acid, antihistamines,
antiemetics, diazepam.
• Surgical management is a last resort and
consists of labyrinthectomy (Excision of
the labyrinth of the ear) or endolymphatic
decompression with drainage and shunt.
• Hearing in the affected ear is often
sacrificed.
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Acoustic Neuroma
• Benign tumor of eighth cranial nerve
• Surgical removal via craniotomy
• Extreme care taken to preserve the
function of the facial nerve
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Hearing Loss
• One of the most common physical
handicaps in North America.
• Common causes of conductive hearing
loss: any inflammation process or
obstruction of the external or middle ear
by cerumen or foreign objects.
(Continued)
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Hearing Loss (Continued)
• Common causes of sensorineural
hearing loss: loud noise, drugs,
atherosclerosis, hypertension,
prolonged fever, Ménière's disease,
diabetes mellitus, and ear surgery.
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Assessments
•
•
•
•
•
•
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Tuning fork tests
Otoscopic examination
Psychosocial assessment
Laboratory tests
Radiographic assessment
Other diagnostic assessments such as
audiogram
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Treatment of Hearing Loss
•
•
•
•
Drug therapy
Assistive devices
Hearing aids
Cochlear implants
(Continued)
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Treatment of Hearing Loss
(Continued)
• Tympanoplasty
– Postoperative care includes antisepticsoaked gauze packed in the ear canal,
clean dressing, client flat with head turned
to the side and the operative ear facing up
for at least 12 hours after surgery,
prescribed antibiotics, activity restrictions.
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Stapedectomy
• A partial or complete stapedectomy with
a prosthesis corrects hearing loss and is
most effective for hearing loss related to
otosclerosis.
• Hearing improvement may not occur
until 6 weeks after surgery.
(Continued)
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Stapedectomy (Continued)
• Damage to cranial nerves, vertigo, and
nausea and vomiting are common after
surgery.
• Pain medications and antibiotics are
often used.
• Safety measures and antivertiginous
drugs should be applied.
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Nose & Sinus Disorders
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Epistaxsis
•Precipitating factors
–Trauma
•Picking
–Blunt contact
–Drying of nasal
mucous membranes
–Infection
–Substance abuse
–Arteriosclerosis
–Hypertension
–Bleeding disorders
–Anticoagulant therapy
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Epistaxsis
•Clinical Manifestations
–90% anterior nasal
septum
•Trauma
•Drying
•Infection
–Posterior secondary to
•Blood dyscrasias
•Hypertension
•Diabetes
•Tends to be more severe
•Occurs more frequently in
older adult
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Epistaxsis
•Management
–Anterior
•Simple first aid
–Apply pressure for 5-10
minutes
–Apply ice packs to nose &
forehead
–Sitting position leaning
forward
–Discourage swallowing
blood
•Medications
–Topical vasoconstrictors
»Cocaine
»Neo-Synephrine
»Adrenaline
–Nasal spray or on cotton
swab held against bleeding
site
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Epistaxsis
• Medications cont’d
– Chemical cauterization
• Silver nitrate
• Gelfoam
– Topical anesthetic (pre packing)
• Tetracaine
• Lidocaine
• Cocaine
• Nasal Packing ~ Anterior
– Petroleum gauze
– 24-72 hours commonly
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Epistaxsis
• Nasal Packing ~ Posterior
– Pack both anterior & posterior
– 2-5 days
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Epistaxsis
• Posterior Packing cont’d
– Monitor for hypoxemia
– Administer oxygen as ordered
– Frequent oral hygiene
– Administer narcotic analgesics as
ordered
– Monitor for complications
• Toxic shock syndrome
• Otitis media
• Sinusitis
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Epistaxsis
• Endoscopic Surgery
– Cauterizing bleeding vessel
– Ligation of internal maxillary artery
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Nasal Polyps
• Benign grapelike growth of
mucous membrane
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Nasal Polyps
• Form in areas of dependent
mucous membrane
• Usually bilateral
• Stem-like base makes them
moveable
• May enlarge  nasal obstruction
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Nasal Polyps
• Management
– Topical corticosteroid nasal spray
– Low-dose oral corticosteroids
– Surgery
• Polypectomy under local anesthesia
– Nasal packing to control bleeding
– Avoid blowing nose 24-48 hours post removal of
packing
– Avoid straining at stool, vigorous coughing,
strenuous exercise
– Monitor for bleeding
» Frequent swallowing
» Visible blood at back of throat
• Laser surgery to remove polyps
• May require multiple surgeries as polyps tend to
recur
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Deviated Septum
•May result from trauma
•Causes nasal obstruction
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Deviated Septum
• Surgery
– Septoplasty or submucous resection
• Manipulation of septal cartilage
– Post operatively
• Bilateral nasal packing
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Rhinoplasty
• Surgical reconstruction of the
nose
• Relief of airway obstruction
• Repair visible deformity
• Reshaping of nose by
– Moving
– Rearranging
– Augmenting
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Rhinoplasty
• Post operatively
– Nasal packing for 72 hours
– Temporary plastic splint for 3-5 days
– Swelling subsides within 10-14 days
– Normal sensation returns within
several months
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Sinusitis
• Inflammation of mucous
membranes of sinuses
• Acute or chronic
• Follows upper respiratory
infection
• Organisms
– Streptococci
– Streptococcus pneumoniae
– Haemophilus influenzae
– Staphylococci
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Sinusitis
•Sinuses are airfilled cavities in
facial bones
•Lined with ciliated
mucous
membranes
•Help move fluid &
microorganisms
out of sinuses into
nasal cavity
•Normally sterile
environment
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Sinusitis
•Pathophysiology
–Inflammation of
mucous membranes
•Obstruction 
•Impaired drainage 
•Mucus secretions
collect in sinus cavity
–Medium for
bacterial growth
•Inflammatory
response
–Serum &
leukocytes invade
area to combat
infection
–Increase in
swelling & pressure
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Sinusitis
• Obstruction
– Nasal polyps
– Deviated septum
– Rhinitis
– Tooth abscess
– Swimming or diving trauma
– Prolonged nasotracheal intubation
• Frontal and maxillary sinuses
commonly involved in adults
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Sinusitis
• Complications
– Periorbital abscess
– Cellulitis
– Cavernous sinus thrombosis
– Meningitis
– Brain abscess
– Sepsis
– Hearing loss due to eustachian tube
edema
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Sinusitis
• Clinical Manifestations
– Looks sick
– Pain & tenderness
• Increases when leaning forward
• Worse during first 3-4 hours in
morning
– Headache
– Fever
– Malaise
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Sinusitis
• Clinical Manifestations cont’d
– Nasal congestion
– Purulent nasal discharge
– Bad breath
– Swallowed nasal secretions
• Irritate & inflame the throat
• Nausea or vomiting
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Sinusitis
• Diagnonstics
– Sinus X-rays
– CT scan
– Magnetic resonance imaging (MRI)
• Rule out malignancy of sinus
• Medications
– Antibiotics (orally) for two weeks
• Longer if needed to prevent relapse
– Antibiotics IV in hospital if no response to
oral treatment
– Decongestants
• Oral
• Nasal spray
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Sinusitis
• Surgery
– Endoscopic sinus surgery
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Endoscopic Sinus Surgery
•Nursing care
–Generally no
packing required
–Frequent nasal
cleaning &
irrigation
•Sterile normal
saline
–Teach
•Open mouth
sneezing
•Avoid blowing
nose
•Avoid lifting or
straining
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Sinusitis
• Surgery cont’d
– 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
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Sinusitis
• 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
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Infectious Disorders
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Rhinitis {Common Cold}
• Highly contagious
• Peaks during September and late
January
– When schools open/resume
• 200+ strains of viruses
• Spread by aerosolized droplet
nuclei or direct contact
• Local respiratory inflammatory
response due to antigen-antibody
defense
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Rhinitis
• Clinical Manifestations
– Erythematous & boggy nasal
mucous membranes
– Nasal congestion
– Rhinorrhea
– Sneezing & coughing
– Sore throat
– Fever
– Malaise
– Achy
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Rhinitis
• Diagnostics
– History & physical
• Treat symptoms
– Adequate rest
– Increased fluids
– Avoid chills
• Medications
– Decongestants
– Warm saltwater gargles
– Throat lozenges
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Rhinitis
• Complimentary Therapies
– Herbal remedies
• Echinacea
• Garlic
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Rhinitis
• Prevention
– Avoid crowds
– Maintain good general health
– Stress reduction
– HANDWASHING
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Pharyngitis & Tonsillitis
• Viral or bacterial
– Group A beta-hemolytic
streptococcus
• Contagious
– Spread by droplet nuclei
• Complications
– Abscess
– Scarlet fever
– Toxic shock syndrome
– Rheumatic fever
– Post-strept glomerulonephritis
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Pharyngitis & Tonsillitis
• Clinical Manifestations
– Pain
– Fever
– Enlarged & tender lymph
nodes
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Pharyngitis & Tonsillitis
• Usually self-limiting
• Diagnostics
– Throat swab
– Complete blood count
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Pharyngitis & Tonsillitis
• Medications
– Antipyretics
– Mild analgesics
• Acetaminophen
– Antibiotics for 10 days
•
•
•
•
Penicillin drug of choice
Erythromycin
Amoxicillin
Cefuroxime
• Surgery
– Tonsillectomy with adnoidectomy
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Pharyngitis & Tonsillitis
• Post-op Nursing Care
– Monitor for bleeding
• Delayed hemorrhage up to 1 week post
• Avoid use of aspirin
• Observe for excessive swallowing
– Ensure patent airway
• Semi-Fowler’s
• Head turned to side
• Artificial airway until return of gag & swallow
reflexes
–
–
–
–
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Ice collar
Ice chips or sips as desired
Warm saline mouthwashes
Liquid or semi-liquid diet for several days
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Laryngitis
• Inflammation of larynx
• Commonly in conjunction with
URI
• Other causes
– Excessive use of voice
– Sudden change in temperature
– Exposure to irritants
•
•
•
•
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Dust
Fumes
Smoke
Pollutants
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Laryngitis
• Clinical Manifestations
– Change in voice
• Hoarseness
• Complete loss of voice (aphonia)
– Sore throat
– Dry cough
• Treatment
– Rest voice
– Avoid irritants
– Impaired verbal communication
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Influenza
•
•
•
•
AKA: Flu
Highly contagious
Viral
Occurs in epidemics or
pandemics
• Local outbreaks
every 1-3 years
• Global epidemics
every 10-15 years
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Global Epidemics
• Influenza outbreak 2009
– “Swine flu” (H1N1)
• Influenza outbreak 1968
– “Hong Kong flu”
– About 34,000 deaths in U.S.
• Influenza outbreak 1957
– “Asian flu”
– About 70,000 deaths in U.S.
• Influenza outbreak 1918
–
–
–
–
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“Spanish flu”
More than 500,000 deaths in U.S.
Possibly 50 million deaths worldwide
½ of deaths were in young, healthy adults
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Influenza
• Pathophysiology
– Transmitted by airborne droplet &
direct contact
– Three major strains
• Influenza A virus
–
–
–
–
Responsible for most infections
Responsible for most severe outbreaks
Able to alter its surface antigens
Each strain named for strain, geographic
origin, and year
» A/Taiwan/89
• Influenza B virus
• Influenza C virus
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Influenza
• Complications
–
–
–
–
Sinusitis
Otitis media
Tracheobronchitis
Pneumonia
• Especially in elderly or immune suppressed
populations
• Progresses rapidly
• Results in hypoxemia
• Ending in death within a few days
– Reye’s syndrome
• Associated with influenza B virus
• Fatal hepatic failure & encephalopathy develop
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Influenza
• Clinical Manifestations
– Syndromes
• Uncomplicated nasopharyngeal
inflammation
• Viral URI followed by bacterial infection
• Viral pneumonia
– Rapid onset
– Chills and fever
– Malaise, fatigue, weakness
– Muscle aches
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Influenza
• Prevention
– Immunization
• Treatment
– Establish diagnosis
• History & physical
• Knowledge of outbreak in community
– Symptomatic relief
• Amantadine (Symmetrel) or rimantadine
(Flumadine) for prophylaxis if exposed
• Other antivirals may reduce duration & severity
of symptoms
– Zanamivir (Relenza)
– Oseltamivir (Tamiflu)
– Ribavirin (Virazole)
– Prevent complications
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Older Adult
•Respiratory muscles weaken
•Large bronchi & alveoli enlarge
•Available surface area of lungs
decreases
–Reduced ventilation & gas exchange
–Functional cilia decrease in number &
action
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Older Adult
•Cough reflex decreased
•Chest wall compliance decreased
–Osteoporosis
–Calcification of costal cartilage
•Increased risk for aspiration
•Increased risk for infection
•Poor nutrition
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