Timby/Smith: Introductory
Medical-Surgical Nursing, 11/e
Chapter 20:Caring for Clients With Upper Respiratory
Disorders
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Infectious and Inflammatory Disorders
Rhinitis
• Pathophysiology and Etiology
– Inflammation of the nasal mucous membranes; acute,
chronic, or allergic
• Assessment Findings: sneezing, nasal congestion, rhinorrhea,
sore throat, watery eyes, cough, low-grade fever, headache,
aching muscles, and malaise
• Medical Management: antipyretics, decongestants,
antitussives, saline gargles, saline spray, and antihistamines
• Nursing Management: prevention and minimizing potential
complications; handwashing
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Infectious and Inflammatory Disorders—
(cont.)
Sinusitis
• Pathophysiology and Etiology: inflammation of the sinuses;
maxillary sinus
– Complications: infection of middle ear or brain
• Assessment Findings: headache, fever, pain over affected
sinus, nasal congestion, pain, pressure around eyes, malaise
• Medical and Surgical Management: saline irrigation, antibiotic
therapy, vasoconstrictors, nasal corticosteroids
– Caldwell-Luc procedure, external sphenoethmoidectomy
• Nursing Management: mouthwashes, humidification, increased
fluid intake, nasal decongestants, antihistamines
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Sinus Surgery
• Nursing Postoperative Care
– Observe for repeated swallowing: hemorrhage
– Optic nerve function assessment
– Temperature every 4 hours; pain over involved
sinuses
– Administer analgesics as indicated; ice compresses
– Nasal packing and dressing under nares
(“moustache” dressing or “drip pad”)
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NCLEX
Of the following instructions, which is most important for
the nurse to teach the client to help loosen secretions
and increase comfort during medical treatment for
sinusitis?
A) Blow the nose frequently.
B) Elevate the head of the bed by 45°.
C) Engage in normal activity.
D) Increase fluid intake.
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NCLEX
Answer:
D) Increase fluid intake.
Rationale: If the client is receiving medical treatment, the
nurse informs the client to use mouthwashes and
humidification, as well as increased fluid intake, which may
loosen secretions and increase comfort.
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Infectious and Inflammatory Disorders—
(cont.)
Pharyngitis
• Pathophysiology and Etiology
– Inflammation of throat; rhinitis and other URIs
– Group A streptococci: strep throat
– Complications: endocarditis, rheumatic fever,
glomerulonephritis
– Highly contagious: inhalation or direct contamination
with droplets
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Infectious and Inflammatory Disorders—
(cont.)
Pharyngitis—(cont.)
• Assessment Findings: sore
throat with dysphagia, fever,
chills, headache, white or
exudates patch over tonsillar
area, swollen glands
• Medical Management
–
Throat culture
–
Antibiotic treatment:
assess allergy to penicillin;
erythromycin
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Infectious and Inflammatory Disorders—
(cont.)
Tonsillitis and Adenoiditis
• Pathophysiology and Etiology
–
Primary or secondary
–
Chronic tonsillar infection: partial upper airway obstruction; chronic
adenoidal infection: otitis media
• Assessment Findings: sore throat, difficult or pain on swallowing, fever,
malaise, enlarged adenoids: nasal obstruction, snoring
• Medical and Surgical Management: antibiotic therapy, analgesics, saline
gargles, tonsillectomy, and adenoidectomy
• Nursing Management: precare/postcare: lab results: hematocrit, platelet
count, clotting time, aspirin use, NSAIDs
–
Risk for Aspiration, Risk for Impaired Tissue Integrity, and Acute Pain.
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NCLEX
The nurse is providing postoperative care for a client who
has undergone tonsillectomy. In which position will the
nurse place the head of the bed when the client is fully
awake?
A) Flat with the head elevated on a pillow
B) Slightly raised at a 15° angle
C) Raised at a 45° angle
D) Raised at a 90° sitting position
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NCLEX
Answer:
C) Raised at a 45° angle
Rationale: Elevate head of bed 45° when client is fully
awake. This position decreases surgical edema and
increases lung expansion.
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Infectious and Inflammatory Disorders—
(cont.)
Peritonsillar Abscess
• Pathophysiology and Etiology: develops in connective
tissue between tonsil and pharynx
– Streptococcal or staphylococcal tonsillar infection
• Assessment Findings: difficulty and pain with swallowing,
fever, malaise, ear pain, and difficulty talking
• Diagnostic Findings: sensitivity studies and culture
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Infectious and Inflammatory Disorders—
(cont.)
Peritonsillar Abscess—(cont.)
• Medical and Surgical Management: antibiotic therapy,
needle aspiration, surgical incision, and drainage
• Nursing Management
– Semi-Fowler’s position; prevent aspiration
– Ice collar, topical anesthetics, throat irrigations, drink
fluids, cool or room temperature
– Observe for respiratory obstruction—dyspnea,
restlessness, or cyanosis—or excessive bleeding
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Infectious and Inflammatory Disorders—
(cont.)
Laryngitis
• Pathophysiology and Etiology
–
Inflammation and swelling of the mucous membrane that lines
larynx
–
Causes: URI, excessive/improper use of voice, allergies, smoking
• Assessment Findings: cannot speak above a whisper; aphonia; throat
irritation; dry, nonproductive cough
–
Hoarseness longer than 2 weeks: laryngoscopy
–
Persistent hoarseness: sign of laryngeal cancer
• Medical Management
–
Voice rest; treatment or removal of cause
–
Antibiotic therapy if bacterial
–
Smoking cessation
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Structural Disorders
Epistaxis
• Pathophysiology and Etiology: rupture of tiny capillaries in the
nasal mucous membrane
– Risk factors: trauma, systemic infections (rheumatic
fever), local infections, dry nasal mucosa, hypertension,
aspirin, nasal tumors, and blood dyscrasias; cocaine
abuse/inhale drugs
• Assessment Findings: nasal speculum and tongue blade reveals
bleeding
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Structural Disorders—(cont.)
Epistaxis—(cont.)
• Medical and Surgical Management: direct continuous
pressure, ice packs, cauterization, electrocautery, topical
vasoconstrictor, nasal packing, balloon-inflated catheter
• Nursing Management
– VS, evidence of continued bleeding
– Humidification, nasal lubricant, and avoidance of
vigorous nose blowing or picking
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NCLEX
A client was seen in the emergency room with severe
epistaxis. After the physician places a nasal packing, the
bleeding is controlled. What should the nurse include as
part of the discharge instructions? Select all that apply.
A) Call physician if bleeding persists or becomes worse.
B) Continue taking baby aspirin as ordered.
C) Do not blow the nose.
D) Keep nasal packing in place until seen for follow-up
appointment.
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NCLEX
Answers:
A) Call physician if bleeding persists or becomes worse.
C) Do not blow the nose.
D) Keep nasal packing in place until seen for follow-up
appointment.
Rationale: The nurse assesses for signs of continued
bleeding and educates the clients on measure to prevent
bleeding.
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Structural Disorders—(cont.)
Nasal Obstruction
• Pathophysiology and Etiology
– Primary conditions: deviated septum, nasal polyps or
grapelike swellings, and hypertrophied turbinates
• Assessment Findings: hx of sinusitis, difficulty breathing out of
one nostril, frequent nosebleeds
• Medical and Surgical Management: submucous surgical
resection or septoplasty, rhinoplasty or reconstruction of the
nose, steroidal nasal spray
• Nursing Management: nasal packing, mouth breathing, semiFowler’s, VS, oral hygiene
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Trauma and Obstruction of the Upper
Airway
Fractures of the Nose
• Pathophysiology and Etiology: trauma
• Assessment Findings: swelling and edema of soft tissue, external and
internal bleeding, nasal deformity, nasal obstruction
–
CSF—Dextrostix
• Medical and Surgical Management
–
Lateral displacement: pressure applied; cold compresses;
complex fracture: surgery
• Nursing Management: HOB elevated, apply ice, analgesics, assess for
airway obstruction, pupillary responses, LOC, and periorbital edema;
anxiety
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Trauma and Obstruction of the Upper
Airway—(cont.)
Laryngeal Trauma and Obstruction
• Pathophysiology and Etiology: motor vehicle accidents, blunt
trauma in neck region
• Assessment Findings: neck swelling, bruising, and tenderness
– Stridor, dysphagia, hoarseness, cyanosis, and hemoptysis
• Diagnostic Studies: laryngoscopy, x-rays, oxygenation studies
• Medical and Surgical Management: patent airway, Heimlich
maneuver
• Nursing Management: LS, respiratory pattern, nasal swelling,
bleeding, and laryngeal edema
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Trauma and Obstruction of the Upper
Airway—(cont.)
Obstructive Sleep Apnea
• Pathophysiology and Etiology: recurrent and frequent episodes
of upper airway obstruction and reduced ventilation
– Classifications: central, obstructive, mixed
• Assessment Findings
– Snore loudly, cessation of breathing for at least 10 secs,
awaken suddenly with loud snort
– Daytime fatigue, morning headache, inability to
concentrate, sore throat, enuresis, and erectile dysfunction
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Trauma and Obstruction of the Upper
Airway—(cont.)
Obstructive Sleep Apnea—(cont.)
• Medical Management: lose weight, smoking cessation,
eliminate alcohol, and use special pillows
– Continuous positive airway pressure (CPAP)
– Bilevel positive airway pressure (BIPAP)
• Surgical Management: uvulopalatopharyngoplasty and
tracheostomy
• Nursing Management: reassurance, adequate instruction,
explanations, self-help groups, counseling
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Laryngeal Cancer
• Pathophysiology and Etiology
–
Causes: carcinogens: tobacco, alcohol, pollutants
• Assessment Findings: persistent, progressive hoarseness; swelling or
lump in throat or neck; dysphagia; pain when talking; weight loss
• Diagnostic Studies: laryngoscopy, biopsy, CT, MRI, and PET
• Medical and Surgical Management: chemotherapy, radiation therapy,
laryngectomy
• Nursing Management
–
Assess for hoarseness, dysphagia, dyspnea, pain, burning in
throat, anxiety level, coping strategies, ability to communicate
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Alternative Measures of Communication
• Methods of laryngeal speech used after a laryngectomy includes the
following:
–
Esophageal speech: regurgitation of swallowed air and formation
of words with lips
–
Artificial (electric) larynx: throat vibrator held against neck,
projects sound into mouth
–
Tracheoesophageal puncture (TEP): surgical insertion of
prosthesis; Blom-Singer device
• Psychosocial issues
•
Nursing Management: social isolation
• Promote positive self-esteem, encourage social relationships,
support services
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Treatment Modalities for Airway
Obstruction or Airway Maintenance
Tracheotomy and
Tracheostomy
• Tracheotomy: surgical
procedure making an opening
into the trachea
• Tracheostomy: surgical
opening into the trachea into
which a tracheostomy or
laryngectomy tube is inserted
– Temporary or permanent
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Treatment Modalities for Airway
Obstruction or Airway Maintenance—
(cont.)
Tracheotomy and Tracheostomy—(cont.)
• Nursing Management
– Risk for Ineffective Airway Clearance: VS, breath
sounds, assess skin color, LOC, and mental status;
airway patency
– Risk for Infection: monitor stoma, provide routine
tracheostomy care, position
– Risk for Ineffective Management of Therapeutic
Regimen
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Treatment Modalities for Airway
Obstruction or Airway Maintenance—
(cont.)
Endotracheal Intubation and
Mechanical Ventilation
Uses: respiratory difficulties,
comatose clients, general anesthesia
• Mechanical ventilation: negative
pressure, positive pressure
• Nursing Management: vital signs;
blood gas studies; pulse oximetry;
evaluate mental status, confusion,
agitation; lung auscultation;
suctioning and humidification;
communication; “magic slate”;
wipe board
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