Chapter 26
Upper Respiratory Problems
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Problems of the Nose
and Paranasal Sinuses
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2
Deviated Septum

Deflection or shift of the nasal septa



Trauma
Interferes with airflow and drainage
Symptoms
• Minor: none, congestion, frequent infections
• Severe: facial pain, nosebleeds, obstruction


Diagnoses—speculum exam
Treatment: decongestants, analgesia, nasal
septoplasty (severe)
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3
Nasal Fracture (1 of 4)

Trauma

Complications—obstruction, nosebleeds, meningeal
tears with CSF leak, septal hematoma, deformity

Simple—little displacement

Complex—damage to adjacent structures; evaluate
for injury of cervical spine, orbital bone, or mandible
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4
Nasal Fracture (2 of 4)

Manifestations: deformity, nosebleed, pain, crepitus,
swelling, difficulty breathing through nose,
ecchymosis
• Periorbital ecchymosis—“raccoon eyes” evaluate for
basilar skull fracture
• CSF leak—clear or pink persistent drainage; lab
confirmation more accurate than bedside glucose test
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5
Nasal Fracture (3 of 4)

Nursing care

Patent airway; prevent complications; emotional
support
• Bleeding; edema, pain—sit upright, ice,
acetaminophen, decongestants, nasal spray, humidifier
• Avoid hot showers, alcohol, and smoking

Realignment


Closed reduction
Open reduction—septoplasty and rhinoplasty
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6
Nasal Fracture (4 of 4)

Septoplasty

Rhinoplasty



Body image considerations
Digital photos—projected appearance
Postop: nasal packing and splint
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7
Nasal Surgery (1 of 2)

Nursing management

Preoperative:
• Avoid Aspirin and NSAIDs 5 days to 2 weeks
• Smoking cessation

Postoperative:
•
•
•
•
Maintain patent airway
Monitor respiratory status/airway obstruction
Pain management
Observe for edema, bleeding, infection
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8
Nasal Surgery (2 of 2)

Patient teaching:

Manage edema, bruising, and pain: Cold compresses
and elevate HOB


Prevent bleeding and injury:
No: nose blowing, swimming,
heavy lifting, or strenuous exercise

May take a year for full cosmetic result

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9
Epistaxis (1 of 2)

Nosebleed


Many causes; often resolve spontaneously
First aid:
• Sitting position, lean forward, with head tilted forward;
direct pressure/squeeze lower part of nose for 5 to 15
minutes

Medical management
• Pledget with anesthetic or vasoconstrictor
• Absorbable packing/sponges; balloon (Fig. 26-1)
• Chemical or thermal cauterization; embolization
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10
Epistaxis Balloon (Fig. 26-1)
(Courtesy Boston Medical, Westborough, Mass.)
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11
Epistaxis (2 of 2)




Monitor respiratory status, LOC, VS, pulse ox,
dyspnea, and dysphagia
Administer analgesia and antibiotics
Premedicate before removal of packing
Patient education:
•
•
•
•
Humidifier or nasal spray
Sneeze with mouth open
Avoid aspirin and NSAIDs
Avoid vigorous nose blowing, strenuous activity, lifting
or straining for 4 to 6 weeks
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12
Allergic Rhinitis (1 of 3)



Inflammation of nasal mucosa
Cause: seasonal (pollen) or perennial (environmental)
allergen
Frequency of symptoms
• Episodic—sporadic exposure
• Intermittent—less than 4 days/week or less than 4
weeks/year
• Persistent—greater than 4 days/week or greater than 4
weeks/year

Exposure leads to IgE and inflammation (Fig. 13-6)
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13
Allergic Rhinitis (2 of 3)

Manifestations:
Sneezing; watery, itchy eyes and nose;
congestion, decreased smell, thin watery nasal
drainage
 Pale, boggy, swollen turbinates
 Chronic exposure: headache, nasal congestion
and sinus pressure,
 hoarseness; cough due to nasal polyps
 and post nasal drip

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14
Allergic Rhinitis (3 of 3)

Management
• Identify and avoid triggers (Table 26-1)
• Reduce inflammation and symptoms (Table 26-2)



Corticosteroids; nasal and/or oral
Antihistamines; decongestants, LTRAs
Immunotherapy: allergy shots
• Patient education: medications
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15
Acute Viral Rhinopharyngitis (1 of
3)



Common cold—greater than 200 viruses;
coronavirus
Contagious: airborne droplets or contact
Frequent in winter months—close contact
• Worsened by fatigue, stress, allergies, and altered
immune status


Symptoms—2 to 3 days after infection
Usual recovery 7 to 10 days
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16
Acute Viral Rhinopharyngitis (2 of
3)
 Management
• Symptom relief: rest, fluids, antipyretics, analgesia,
saline spray, gargle, lozenges, antihistamines,
decongestant (no more than 3 days to prevent
rebound), cough suppressants
• Vitamin C, Echinacea, Zinc (Complementary and
Alternative Therapies)
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17
Acute Viral Rhinopharyngitis (3 of
3)

Management
• No antibiotics unless complications (bacterial)
• Monitor/teach to report secondary infection or
worsening symptoms
• Chronic disease—report: sputum changes, short of
breath, chest tightness
• Teach to avoid crowds/sick people and use good
hand hygiene
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18
Influenza (1 of 3)



Highly contagious; increased morbidity and mortality
Peak season: December to February
Classified by serotypes (A, B, C, D)
• A subtypes: H and N antigens (e.g., H1 N1)

Influenza A—most common and virulent
• Mutated viruses —no immunity
• Pandemics (worldwide spread)
• Epidemics (localized outbreaks)

Transmission: infected droplets
• 1 day before onset symptoms—5 to 7 days
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19
Influenza (2 of 3)
 Manifestations
(Table 26-3)
• Abrupt onset—~ 7 days: chills, fever, myalgia,
headache, cough, sore throat, fatigue
• Complications: pneumonia, ear or sinus infections;
Older adults—weak and lethargic
 Diagnostic
Studies
• H and P, prevalence in community
• Viral cultures
• Rapid influenza diagnostic tests (RIDTs)
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20
Influenza (3 of 3)

Management

Prevention: Vaccine
•
•
•
•


Inactivated or live attenuated (Table 26-4)
Need annual vaccine
Takes 2 weeks for antibody production
Advocate vaccine for those greater than 6 months and
high risk (e.g., HCW and long term care residents)
Symptom relief and prevent secondary infection: rest,
fluid, antipyretic, analgesia
Antivirals: shorten duration of symptoms and reduce
risk of complications
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21
Sinusitis (1 of 2)

Inflammation of sinus mucosa results in blockage and
accumulated secretions (Fig. 26-2)

Risk for viral, bacterial, or fungal infection
 Classified as: acute, subacute, or chronic
 Manifestations:
• Acute: pain/tenderness, purulent drainage, congestion, fever,
malaise, headaches, halitosis
• Chronic: facial or dental pain, congestion, increased drainage

Diagnostic studies:
• X-ray, CT scan, nasal endoscopy
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22
Sinusitis (2 of 2)

Management

Symptom relief:
• Decongestants, corticosteroids, analgesia, saline spray
or irrigation; antibiotics if symptoms worse or greater
than 1 week

Patient/caregiver education—Table 26-5
• Rest, hydration, humidifier, warm compresses, HOB ,
meds as prescribed; No smoking
• Reduce exposure to allergens

Chronic, persistent, or recurrent sinusitis
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23
Obstruction of Nose and Sinuses
 Nasal
polyps—benign growths related to chronic
inflammation
• Large polyps—obstruction, discharge, and speech
distortion
• Treatment: corticosteroids or endoscopic or laser
surgery
 Foreign
bodies—inorganic or organic
• Pain, bleeding, difficulty breathing
• Treatment: removal
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24
Problems of the Pharynx
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25
Acute Pharyngitis (1 of 2)

Inflammation of pharyngeal walls; tonsils, palate,
uvula

Causes: Viral (90%), bacterial (strep throat), fungal
(candidiasis)
• Other: dry air, smoking, GERD, allergy, postnasal drip,
ETT, chemicals, cancer

Manifestations: sore throat, red, swollen pharynx
• Classic bacterial: fever greater than 38° C, cervical
lymph node enlargement, pharyngeal exudate, absent
cough
• Fungal: white patches
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26
Acute Pharyngitis (2 of 2)

Goals: infection control, symptom relief, prevent
complications
• Viral—no antibiotics
• Bacterial—antibiotics; PCN for strep
• Candida—antifungal (swish and swallow)

Analgesia, warm salt water gargle, nonirritating liquids,
lozenges, humidifier
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27
Problems of the Larynx and
Trachea
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28
Laryngeal Polyps

Benign growth on vocal cords from vocal abuse or
irritation




Most common: hoarseness
Large: dysphagia, dyspnea, stridor
Treatment: vocal rest and hydration
Surgical removal if large or risk of cancer
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29
Acute Laryngitis (1 of 2)

Inflammation of larynx (voice box)


Causes: *virus, upper respiratory tract infection,
overuse of voice, smoke or chemical
exposure/inhalation
Classic manifestations:
• Tingling or burning back of throat; need to clear throat,
hoarseness, loss of voice
• Other: fever, cough, full feeling in throat
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30
Acute Laryngitis (2 of 2)

Diagnosis: history, presentation, changes in voice

Treatment:




Limit use of voice; no whispering
Acetaminophen, cough suppressants, lozenges,
humidifier, fluids; antibiotics if bacterial
No caffeine, alcohol, or smoking
Last greater than 3 weeks; see HCP
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31
Airway Obstruction (1 of 2)

Medical emergency!



Partial or complete
Manifestations: choking, stridor, use of accessory
muscles, suprasternal and intercostal retractions,
nasal flaring, wheezing, restlessness, tachycardia,
cyanosis, change in LOC
Immediate assessment and treatment—brain damage
or death in 3 to 5 minutes
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32
Airway Obstruction (2 of 2)
 Interventions
•
•
•
•
to establish patent airway
Heimlich maneuver
Cricothyroidectomy
ET intubation
Tracheostomy
• Partial or recurrent symptoms: chest x-ray,
laryngoscopy, or bronchoscopy
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33
Tracheostomy (Fig. 26-3, A)

Surgically created stoma (opening) to:






Establish a patent airway
Bypass an upper airway obstruction
Facilitate secretion removal
Permit long-term mechanical ventilation
Facilitate weaning from mechanical ventilation
May be done emergently (cricothyrotomy), surgically
in OR, or percutaneously at bedside
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34
Tracheostomy
Advantages of tracheostomy over endotracheal tube




Easier to keep clean
Better oral and bronchial hygiene
Patient comfort increased
Less risk of long-term damage to vocal cords
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35
Tracheostomy Tubes
(Table 26-6)





Tracheostomy tube with cuff and pilot balloon
Fenestrated tracheostomy tube with cuff, inner
cannula, and decannulation plug
Speaking tracheostomy tube with cuff and two
external tubings
Tracheostomy tube with foam-filled cuff
Uncuffed tracheostomy tube—long term
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36
Tracheostomy Tube (Fig. 26-3, B)
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37
Tracheostomy
Nursing Management (1 of 4)

Acute care


Explain the purpose of procedure
Prepare for:
• Surgery in OR
• Bedside insertion
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38
Tracheostomy
Nursing Management (2 of 4)

Bedside insertion
• Include respiratory therapist

Emergency equipment available
• Bag-valve-mask (BVM)





Record vital signs and SpO2
Ensure existing IV is patent
Assess bedside suction
Position patient supine
Administer analgesia and/or sedation
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39
Tracheostomy
Nursing Management (3 of 4)

Postprocedure care



Obturator removed (keep at bedside)
Cuff (balloon) is inflated
Confirm placement:
• Auscultate for air entry; end tidal CO2 capnography;
passage of suction catheter
• Chest x-ray

Tracheostomy sutured in place and secured
 Monitor VS, SpO2, and mechanical ventilator settings
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40
Tracheostomy
Nursing Management (4 of 4)



Monitor for complications (Table 26-7)
 *Bleeding, airway obstruction, infection
Assess site and patency at least every shift
Monitor cuff inflation pressure: 20 to 25 cm H2O

Minimal occlusion volume (Table 26-6)
Suction PRN (Fig. 26-4 and Table 26-8)
 Humidified air—thins secretions; reduces mucous plugs
 Tracheostomy care per agency policy
(Table 26-9 and Fig. 26-5)

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41
Closed Suctioning
(From Potter PA, Perry AG: Basic nursing: essentials for practice, ed 7, St Louis, 2011, Mosby.)
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42
Tracheostomy Care

Changing tapes (ties)
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43
Tracheostomy
Nursing Management (1 of 2)

Prevent dislodgement




Watch when turning and repositioning
Keep replacement tube of equal and/or smaller size
at bedside
Do not change tracheostomy tapes (ties) for at least
24 hours after placement
HCP performs first tube change but not sooner than 7
days after placement
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44
Tracheostomy
Nursing Management (2 of 2)

Accidental dislodgement


Call for help; know institution policies and procedures
and your scope of practice
Assess for respiratory distress, if present:
• Insert hemostat in opening and spread; insert obturator
in spare tracheostomy tube, lubricate and insert;
remove obturator; OR
• Insert suction catheter; thread tracheostomy tube over
catheter, then remove suction catheter
• If can’t insert new trach tube; cover stoma with sterile
gauze and ventilate with BVM
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45
Audience Response Question (1 of
2)
Twenty-four hours after a patient had a
tracheostomy, the tube is accidentally dislodged
after a coughing episode. Which action should the
nurse take first?
a. Call the health care provider.
b. Place the obturator in the tracheostomy tube.
c. Position the patient in a semi-Fowler’s position.
d. Grasp the retention sutures to spread the
tracheostomy opening.
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46
Audience Response Question (1 of
2)
Answer: D
Grasp the retention sutures to spread the
tracheostomy opening.
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47
Case Study (1 of 6)


A.M. is a 45-year-old male who had a severe
traumatic brain injury after a motorcycle accident
7 days ago.
He is intubated and mechanically ventilated.
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48
Case Study (2 of 6)


He remains comatose and unable to be weaned
from the ventilator at this point.
He is taken to the OR for insertion of a #8 Shiley
trach with nondisposable inner cannula.
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49
Case Study (3 of 6)
1. What are your priority assessments for A.M. on
his return from the OR?
2. What emergency equipment should you have
available at the bedside?
3. What nursing care will you provide related to
the tracheostomy?
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50
Case Study (4 of 6)
1. For what complications will you monitor A.M.?
2. After initial replacement, how frequently should
you change the tracheostomy tube?
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51
Chronic Care of Tracheostomy

Teach patient/caregiver to:


Observe tracheostomy site for signs and symptoms of
infection
Perform tracheostomy care
• Clean inner cannula
• Suction
• Change tracheostomy tapes

Tube should be changed monthly after 1st tube
change then every 1 to 3 months.
• Clean technique is used at home
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52
Swallowing Dysfunction


Tracheostomy with inflated cuff interferes with
normal function of muscles used to swallow
Speech therapist—clinical assessment for
swallowing and aspiration risk
• Fluroscopy or endoscopy evaluation


If no risk for aspiration, leave cuff deflated or replace
with a uncuffed tube
Thickened liquids or soft foods may be allowed
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53
Speech With a Tracheostomy Tube
(1 of 2)

Provide patient with writing tools if speaking devices
are not used.







Paper and pencil
White board
Cell phone (text)
Magic slate
Picture board
Visual alphabet
Text to speech applications
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54
Speech With a Tracheostomy Tube
(2 of 2)

Techniques to promote speech

Spontaneously breathing patient
• Remove inner cannula, may deflate cuff, and place a
cap on tube; allows exhaled air to flow over vocal cords
(Fig. 26-6)


Fenestrated tracheostomy tubes
Speaking valves
• Passy-Muir (Fig. 26-7)
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55
Fenestrated Tracheostomy Tube
(Fig. 26-6)




Air passes from lungs
through opening in
tracheostomy into upper
airway
Must not be at risk for
aspiration
Remove inner cannula,
deflate cuff, and place
cap on tube
Assess patient for any
respiratory distress
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56
Speaking Tracheostomy Tube (Fig.
26-6)

Two pigtail tubings

One connects to cuff for
inflation
 Other connects to
opening just above cuff
 When second tube is
connected to
low-flow air source, this
permits speech

Can be used on patients
at risk for aspiration
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57
Speaking Valves




Thin diaphragm that
opens on inspiration and
closes on expiration
Air flows over vocal cords
during exhalation
Cuff must be deflated or
use uncuffed tube
Evaluate patient’s ability
to tolerate
(Courtesy Passy-Muir, Inc, Irvine, Calif.)
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58
Case Study (5 of 6)


A.M. is improving neurologically
and has been off the ventilator for 2 weeks.
He is ready to have the tracheostomy removed.
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59
Case Study (6 of 6)
1. What will you assess prior to removing the
tracheostomy?
2. How will you care for the stoma after the
tracheostomy tube is removed?
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60
Decannulation (1 of 2)

Removal of tracheostomy tube from trachea


Epithelial tissue forms in 24 to 48 hours; opening
closes in 4 to 5 days
Criteria for patient:




Hemodynamically stable
Stable intact respiratory drive
Adequately exchanges air
Independently expectorates
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61
Decannulation (2 of 2)
Prior to:







After removal:
Explain procedure
Monitor VS
Suction tracheostomy and
mouth
Remove tapes/ties
Remove sutures
Deflate cuff
Remove in smooth motion





Apply sterile occlusive
dressing
Monitor for bleeding
Monitor respiratory status
Apply alternate O2 device
Patient education: splint
stoma with coughing,
swallowing, or speaking
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62
Head and Neck Cancer (1 of 13)

Structures includes: nasal cavity, paranasal sinuses,
nasopharynx, oropharynx, larynx, oral cavity, and/or
salivary glands




Squamous cells in mucosal surfaces
Etiology: smoking (85%)
Age: most over age 50
Risk factors: HPV, excess alcohol, exposure to: sun,
asbestos, industrial carcinogens, marijuana, radiation to
head and neck, and poor oral hygiene
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63
Head and Neck Cancer (2 of 13)

Manifestations—vary with location



Lump in throat or sore throat (pharyngeal), white or
red patches, change in voice, hoarseness greater
than 2 weeks (laryngeal)
Other: ear pain, ringing in ears, swelling or lump in
neck, constant cough, cough up blood, swelling in jaw
Late signs: unintentional weight loss; difficulty with
chewing, swallowing, moving tongue or jaw, or
breathing; airway obstruction (partial or full)
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64
Head and Neck Cancer (3 of 13)

Diagnostic studies

Physical assessment: ears, nose, throat, mouth, and
neck
• Check for: thickening of oral mucosa, lymph nodes,
leukoplakia, or erythroplakia


Pharyngoscopy and laryngoscopy for inspection and
biopsies
CT scan, MRI, PET scan
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65
Head and Neck Cancer (4 of 13)

Staging


TMN—size of tumor, number and location of lymph
nodes, extent of metastasis
Interprofessional care—many variables considered
to determine therapy

Surgery: vocal cord stripping, laser, cordectomy,
partial or total laryngectomy, pharyngectomy,
tracheostomy, lymph node removal, neck dissection
(radical, modified, or selective); reconstructive
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66
Head and Neck Cancer (5 of 13)

Interprofessional care


Radiation therapy: External beam or internal implants
Chemotherapy and targeted therapy
• Used in combination with radiation for stages III or IV

Nutritional therapy:
• Concerns with swallowing after surgery, side effects of
chemotherapy and/or radiation, oral mucositis;
gastrostomy tube and enteral feedings; assess
tolerance, weight, and risk of aspiration
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67
Head and Neck Cancer (6 of 13)

Interprofessional care

Physical therapy
• Strengthen, support, and move upper extremities,
head, and neck to avoid limited ROM; continue after
discharge

Speech therapy
• Preoperative: effect of therapy on voice and potential
adaptations or restoration; support groups
• Postoperative restoration: electrolarynx,
*transesophageal puncture (Blom-Singer prosthesis,
Fig. 26-9), esophageal speech
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68
Head and Neck Cancer (7 of 13)

Nursing management


Assessment: See Table 26-11
Subjective
• Important health information
• Functional health patterns

Objective
• Respiratory
• Gastrointestinal

Possible diagnostic findings
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69
Head and Neck Cancer (8 of 13)

Nursing diagnoses





Impaired airway clearance
Risk for aspiration
Difficulty coping
Impaired communication
Planning—goals

Patent airway, no spread of cancer, no complications
from therapy; adequate nutritional intake, minimal to
no pain, able to communicate, acceptable body image
Copyright © 2020 by Elsevier, Inc. All rights reserved.
70
Head and Neck Cancer (9 of 13)

Nursing implementation

Health promotion
• Avoid tobacco and excess alcohol
• Good oral hygiene
• Safe sex to prevent HPV

Acute care
• Explain treatment, care required, and reasons
• Psychological impact: body changes, external feedings,
loss of voice
• Support systems; loss of employment
Copyright © 2020 by Elsevier, Inc. All rights reserved.
71
Head and Neck Cancer (10 of 13)

Nursing implementation: surgical therapy


Preoperatively: physical and psychosocial needs;
assess knowledge and understanding; how to
communicate post-operatively
Postoperatively: airway management, VS, bleeding,
wound/drain care, skin flaps, NGT, nutrition,
communication, psychosocial issues, pain control,
trach care and suction, fluids, and hydration
Copyright © 2020 by Elsevier, Inc. All rights reserved.
72
Head and Neck Cancer (11 of 13)


Nursing implementation
Radiation therapy






Dry Mouth (xerostomia)
Oral mucositis
Skin care
Fatigue
Stoma care
Psychosocial needs

Depression, body image, sexuality
Copyright © 2020 by Elsevier, Inc. All rights reserved.
73
Head and Neck Cancer (12 of 13)

Nursing implementation:

Ambulatory care: Patient and caregiver education
 Tracheostomy
care and suctioning, stoma and skin
care, NGT, enteral feedings
 Medic Alert—neck breather
 Safety—smoke and CO detectors (loss of smell)
 Resume exercise, recreation, sexual activity,
employment when able
Copyright © 2020 by Elsevier, Inc. All rights reserved.
74
Head and Neck Cancer (13 of 13)

Evaluation: outcomes

Patient will:
•
•
•
•
Have effective coughing and secretion clearance
Swallow without aspiration
Use effective coping strategies
Communicate effectively with others: written and
nonverbal
Copyright © 2020 by Elsevier, Inc. All rights reserved.
75
The patient is a 58-year-old woman diagnosed with throat cancer 1
week ago. She has come to the clinic today to discuss surgical
options with her health care provider. She is very tearful and
appears sad when the nurse calls her back to the examination
room.
Based on her diagnosis, which clinical manifestation will the nurse
likely observe in the patient?
A. Severe chest pain
B. Hoarseness
C. Low hemoglobin level (anemia)
D. Numbness and tingling of the face
(cont’)
When the nurse begins taking the patient’s history, she says, “Did
you know that I have throat cancer and may not survive?” What is
the nurse’s most appropriate response?
A. “I am so sorry to hear this.”
B. “My mother had cancer, so I know how you must be feeling
right now.”
C. “I know you have been diagnosed with cancer. Tell me why
you think you may not survive.” “I am so sorry to hear this.”
D. “I am sure that your cancer can be cured if you follow your
doctor’s advice.”
(cont’d)
The provider discusses radiation therapy with the patient because
her lesion is small and the cure rate is 80% or higher. The patient
asks if her voice will return to normal. What is the nurse’s best
response? (Select all that apply.)
A. “The more you use your voice, the quicker it will improve.”
B. “At first the hoarseness may become worse.”
C. “Your voice will improve within 4 to 6 weeks after completion of
the therapy.”
D. “You should rest your voice and use alternative communication
during the therapy.”
E. “Gargling with saline may help decrease the discomfort in your
throat.”
(cont’d)
After the radiation therapy begins, the patient visits the
clinic stating that her throat is sore, she is having
difficulty swallowing, and the skin on her throat is red,
tender, and peeling.
What strategies does the nurse recommend for these
discomforts?
To prevent aspiration in a patient admitted for treatment
of neck and throat cancer, the nurse’s first step should
be to:
A. Encourage hydration with water and juices.
B. Encourage the patient to eat juicy fruits to address
the sensation of thirst.
C. Stop feeding the patient if coughing occurs.
D. Encourage the patient to sit in a chair for meals.
A patient has been admitted to the ED after
experiencing a fall while rock climbing. He appears to
have several facial fractures. Which observed
assessment finding is most serious?
A. Malaligned nasal bridge
B. Clear fluid draining from one of the nares, testing
positive for glucose
C. Blood draining from one of the nares
D. Crackling of the skin (crepitus) upon palpation
An important nursing intervention to prevent airway
obstruction in an older patient with dementia is:
A. Ensuring the patient is out of bed twice a day
B. Maintaining the head of bed greater than 45 degrees
C. Performing frequent oral hygiene and removing
secretion buildup
D. Teaching the family to use oral suction for excessive
secretions