copyright © 2014 wolters kluwer health | lippincott williams & wilkins timby/smith:...

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Timby/Smith: Introductory Medical-Surgical Nursing, 11/e

Timby/Smith: Introductory Medical-Surgical Nursing, 11/e

Chapter 20:Caring for Clients With Upper Respiratory Disorders


Infectious and Inflammatory DisordersInfectious 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


Infectious and Inflammatory Disorders—(cont.)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


Sinus SurgerySinus 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”)


NCLEXNCLEX

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.


NCLEXNCLEX

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.



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



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



Tonsillitis and Adenoiditis


– 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.


NCLEXNCLEX

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


NCLEXNCLEX

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.



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



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


Infectious and Inflammatory Disorders—(cont.)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


Structural DisordersStructural 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


Structural Disorders—(cont.)Structural Disorders—(cont.)

Epistaxis—(cont.)• Medical and Surgical Management: direct continuous

pressure, ice packs, cauterization, electrocautery, topical vasoconstrictor, nasal packing, balloon-inflated catheter


– VS, evidence of continued bleeding

– Humidification, nasal lubricant, and avoidance of vigorous nose blowing or picking


NCLEXNCLEX

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.


NCLEXNCLEX

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.


Structural Disorders—(cont.)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, semi-Fowler’s, VS, oral hygiene


Trauma and Obstruction of the Upper AirwayTrauma 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


Trauma and Obstruction of the Upper Airway—(cont.)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



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



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


Laryngeal CancerLaryngeal Cancer


– 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


– Assess for hoarseness, dysphagia, dyspnea, pain, burning in throat, anxiety level, coping strategies, ability to communicate


Alternative Measures of Communication 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


Treatment Modalities for Airway Obstruction or Airway MaintenanceTreatment 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


Treatment Modalities for Airway Obstruction or Airway Maintenance—(cont.)

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


Treatment Modalities for Airway Obstruction or Airway Maintenance—(cont.)

Treatment Modalities for Airway Obstruction or Airway Maintenance—(cont.)Endotracheal Intubation and Mechanical VentilationUses: 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

copyright © 2014 wolters kluwer health | lippincott williams & wilkins timby/smith:...

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