Adult Health Chapter 18: Management of Patients with Upper Respiratory Tract Disorders
Aphonia is
impaired ability to use one's voice due to distress or injury to the larynx.
Nuchal rigidity is
stiffness of the neck or inability to bend the neck.
The voice is spared with the
supraglottic laryngectomy.
Upper Respiratory Tract: Peritonsillar Abscess Assessment and Diagnostic Findings
- Aspiration - Ultrasound exam
Acute Pharyngitis Medical Management
- If bacterial ➔ antibiotics - If viral ➔ supportive measures
Tonsillitis and Adenoiditis
- lymphatic tissue -Often site of infection
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?
A face mask
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:
A permanent tracheal stoma would be necessary.
The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs?
Initiate enteral feedings. -Postoperatively, the client may not be permitted to eat or drink for at least 7 days. Alternative sources of nutrition and hydration include IV fluids, enteral feedings through a nasogastric or gastrostomy tube, and parenteral nutrition. Once the client is permitted to resume oral feedings, thick liquids are offered; sweet foods are avoided because they cause increased salivation and decrease the client's appetite. The client's taste sensations are altered for a while after surgery because inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. In time, however, the client usually accommodates to this change and olfactory sensation adapts; thus, seasoning is based on personal preferences.
The nurse is performing preoperative teaching with a client who has cancer of the larynx. After explaining the most important information, what is the nurse's best action?
Provide the client with audiovisual materials about the surgery.
Normal Breath Sounds: Bronchial (tubular)
heard only over trachea, high pitch; loud and long expirations, sometimes a bit longer than inspiration.
Repetitive apneic events result in
hypoxia and hypercapnia, which triggers a sympathetic response (increased heart rate and decreased tone and contractility of smooth muscle).
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?
impaired verbal communication - Loss of the ability to speak normally is a devastating consequence of laryngeal surgery and is certain with a total laryngectomy.
Positive-pressure ventilators require
intubation and are used for clients who are under general anesthesia. - They are also used for clients with acute respiratory failure, primary lung disease, or who are comatose.
As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that:
laryngeal cancer is one of the most preventable types of cancer.
With esophageal speech, the client forms words with the
lips. - Esophageal speech causes the voice quality to be lower pitched and gruff sounding.
Clients receiving endotracheal intubation for the purpose of general anesthesia should not require
long-term placement of the ET tube.
bronchovesicular breath sounds
medium-pitched and quieter sounds normally heard over the mainstem bronchi - over main bronchus
Clients with obstructive sleep apnea may experience a
morning headache.
An endotracheal tube is inserted through the
mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own.
Chest pain can occur with
pneumonia, pulmonary infarction, pleurisy, carcinoma
Chest Pain may be
pulmonary, cardiac, gastrointestinal, or musculoskeletal cause
During a total laryngectomy, a complete
removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.
The nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing
sinus infection.
Clients with nasotracheal and nasogastric tubes in place are at risk for developing
sinus infections.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward. -Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood.
TEP requires a
surgical opening in the posterior wall of the trachea, followed by the insertion of a prosthesis such as a Blom-Singer device.
Fractures of the Nose Assessment & Diagnostic Findings
- Accurate diagnosis only after swelling subsides - Clear fluid drainage from nostril may mean fracture of cribiform plate with leakage of cerebrospinal fluid - xRay
Obstructive Sleep Apnea Nursing Management
- Explain disorder - Correct use of therapies - Risks of untreated OSA
Respiratory Physical Assessment: Chest Configuration
Normal ratio of anteroposterior diameter to lateral diameter is 1:2
Removal of a portion of the vocal cord occurs with a
hemilaryngectomy.
A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?
a feeling of swelling at the back of the throat -After an initial hoarseness lasting longer than a month, clients with laryngeal cancer will feel a sensation of swelling or a lump in the throat or in the neck. Weight loss often occurs later in the progression of laryngeal cancer due to reduced calorie intake as a result of impaired swallowing and pain. Clients with laryngeal cancer may report burning in the throat when swallowing hot or citrus liquids.
An endotracheal tube provides a
patent airway for clients who cannot maintain an adequate airway on their own.
A total laryngectomy will result in a
permanent stoma and total loss of voice.
Acute Rhinosinusitis
- Acute bacterial rhinosinusitis (ABRS) or - Acute viral rhinosinusitis (AVRS)
Tonsillitis and Adenoiditis Assessment & Diagnostic Findings
- Primarily clinical diagnosis - Culture
A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube?
"The ET tube will maintain your airway while you're under anesthesia."
Respiratory Physical Assessment:Auscultation Voice sounds
- "99" (bronchophony) or "eee" (egophony) - Vibrations in the larynx pass through bronchi and alveolar tissue to the chest wall. Pathology: increased lung density (pneumonia and pulmonary edema) - Bronchophony + more intense and clearer than normal (should be indistinct) - Egophony + distortion of voice sounds - E to A
fractures of the nose
- Complications include hematoma, infection, abscess, avascular or septic necrosis. - Serious complications do not generally occur
Cancer of the Larynx Clinical Manifestations
- Hoarse for > 2 weeks - Persistent cough or sore throa - Pain & burning in throat - Lump in neck - Later: dysphagia, dyspnea, nasal obstruction/discharge, foul breath, cervical lymph adenopathy, unintended weight loss, pain radiating to ear
Upper Respiratory Tract: Laryngitis Clinical Manifestations
- Hoarseness - Aphonia (loss of voice) - Severe cough - Throat worse in morning, improves when indoors in warmer climate - May have dry cough and dry sore throat that worsens in evening. - "tickle" in throat
Medical Management of Epistaxis
- Identify cause and location - Pinch soft portion of nose for 5 to 10 minutes, patient sits upright - Phenylephrine spray, vasoconstriction - Cauterize with silver nitrate or electrocautery - Gauze packing (tampon) or balloon-inflated catheter inserted into nasal cavity for 3 to 4 days - Antibiotic therapy possible.
Acute Rhinosinusitis Medical Management
- If bacterial ➔ antibiotics - Nasal saline sprays - Topical decongestants for 3-4 days - Antihistamines / oral decongestants Intranasal corticsteroids
Biot's
- Irregular periods of apnea, - Interspersed with cycles of normal rate and depth. - Caused by brain damage due to stroke, trauma, brain herniation
Acute Pharyngitis Nursing
- Liquid or soft diet during acute phase. 2-3L/day - Cool beverages, warm liquids, flavored frozen desserts (ice pops) - If severe, IV fluids may be needed. - Educate about danger signs: dyspnea, drooling, inability to swallow, inability to fully open the mouth - Infection control procedures - Warm saline gargles, ice collar, mouth care - Take full course of antibiotics - Preventative measures - No alcohol, tobacco, avoid secondhand smoke, pollutants
Biopsies
- Lung or lymph node biopsies - Mediastinoscopy Endoscopic exam of mediastinum Investigate pulmonary malignancy, obtain tissue for other diagnosis Nursing: monitor for oxygenation, bleeding, pain relief.
Endoscopic procedures Thorascopy
- Pleural cavity examined with endoscope - Fluid and tissues can be obtained - OR with anesthesia - Pleural effusions, pleural disease, tumor staging - Video assisted thorascopy (VATS) - NPO, may have chest tube post op
Nursing Interventions for the Patient Undergoing Laryngectomy
- Preoperative teaching - Reduce anxiety - Maintain patent airway, control secretions - Support alternative communication - Promote adequate nutrition and hydration - Promote positive body image, self-esteem - Monitor for potential complications Self-care management; homecare
Obstructive Sleep Apnea
- Recurrent episodes of upper airway obstruction with reduction in ventilation. - Apnea = cessation of breathing. - Risk: obese*, larger neck circumference, male, postmenopausal women, advanced age, hypertension
Hemoptysis
- The expectoration of blood from respiratory tract. - Onset usually sudden, can be intermittent or continuous.
Tonsils & Adenoids Part of Lymph System
Protects body from invasion of organisms
Most cases of acute pharyngitis are caused by which of the following?
Viral infection
Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the
postoperative period following a tracheostomy.
Nursing Management of Epistaxis
- Airway, breathing, circulation - Vital signs, possible cardiac monitoring and pulse oximetry - Reduce anxiety - Patient teaching: - Avoid nasal trauma, nose picking, forceful blowing, spicy foods, tobacco, exercise -Adequate humidification to prevent dryness - Pinch nose to stop bleeding; if bleeding does not stop in 15 minutes, seek medical attention
Pigeon Chest (Pectus Carinatum)
- Anterior displacement of sternum, increases anteroposterior diameter - May occur with rickets, Marfan syndrome, severe kyphoscoliosis
Upper Respiratory Tract: Peritonsillar Abscess Medical Management
- Antibiotics, corticosteroids - Needle aspiration - Incision & drainage - May need hospitalization for IV abx
Endoscopic procedures Thoracentesis
- Aspiration of pleural fluid and air - Diagnostic or therapeutic - Nursing: monitor for complications, shortness of breath, bleeding, infection
Respiratory Diagnostics Arterial blood gases - MOST ACCURATE ASSESSMENT
- Assess ability of lungs to provide adequate oxygen and remove carbon dioxide - And ability of kidneys to reabsorb or excrete bicarbonate ions to maintain normal pH - Arterial puncture at radial, brachial or femoral artery or through arterial catheter
(T/F) The term "common cold" refers to an infectious, chronic inflammation of the mucous membranes of the nasal cavity requiring hospitalization and treatment with IV antibiotics.
False Rationale: The "common cold" is acute inflammation of the nasal cavity that is typically self‐limiting with nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise. The term is used with acute URIs such as rhinitis, pharyngitis, and laryngitis and often when the causative agent is the influenza virus.
Hemilaryngectomy is done by
splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor.
Wheezing
- High pitched, continuous musical sound - Bronchoconstriction, airway narrowing Asthma - Generally heard on expiration Bronchitis - Generally heard on inspiration
Tracheostomy tubes are inserted into a
surgical opening in the trachea, called a tracheotomy.
Kyphoscoliosis
- Elevation of scapula and S shaped spine. - Limits lung expansion - May occur with osteoporosis, other skeletal disorders.
Funnel Chest (Pectus Excavatum)
- Depression in lower portion of sternum - May compress heart and vessels, resulting in murmurs - May occur with rickets or Marfan syndrome
You are caring for a client who is 42-years-old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?
Edema of the upper airway -An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, post operative bleeding, or a plugged tracheostomy tube.
The nurse advises a patient who sustained a fractured nose during an automobile accident that surgery will be necessary. Due to significant facial edema, surgery would be scheduled:
Within 1 week. -Surgical reduction of a fracture should occur immediately. However, with significant edema present, surgery can be delayed up to 7 days to allow time for the fluid to resolve. After 1 week, if the fracture is misaligned, rhinoplasty will be necessary to reshape the external appearance of the nose.
Rhinitis and Rhinosinusitis Pathophysiology
- Changes in temp or humidity - Odors - Infection - Age, systemic disease - Use of OTC and prescribed nasal decongestants - Allergens - food - Common cold - Drug induced.
Upper Respiratory Tract: Peritonsillar Abscess
- Complication of sore throat - Can spread to neck and chest, intracranial abscess - Edema can cause airway obstruction - life threatening
Computed tomography (CT scan)
- Cross sectional view of chest - Contrast agents useful (not if compromised kidney function, allergy, pregnant, severe obesity, claustrophobic) METFORMIN - hold dose the day of the est to prevent lactic acidosis
Upper Respiratory Tract Infections - URIs Rhinitis and Rhinosinusitis Medical Management
- Depends on cause - Ask about allergens & symptoms - If Viral: medications for symptom relief - If Allergic: allergy testing - If Bacterial: antibiotic - May refer to Ear, Nose, Throat specialist
A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to
Check the clear fluid for glucose.
Rhinitis and Rhinosinusitis Nursing
- Avoid, reduce exposure to allergens / irritants - Saline nasal spray - Hand hygiene - Influenza vaccine for older adults or if high risk.
Positive-pressure ventilators require intubation and are used for clients who are under
general anesthesia. - They are also used for clients with acute respiratory failure, primary lung disease, or who are comatose.
Wheezes -
musical, continuous sounds rhonchi - lower pitched, continuous, partial airway obstruction
Barrel Chest:
occurs due to overinflation of lungs. - Occurs with aging - Hallmark sign of emphysema and COPD - Ribs more widely-spaced, intercostal spaces tend to bulge on expiration
Obstructive sleep apnea occurs usually in men, especially men who are
older and overweight.
Respiratory Diagnostics Venous blood gas studies
- Balance between the amount of oxygen used b tissues/organs and the amount of oxygen returning to the right side of the heart in the blood. - Done when cannot obtain ABG
Acute Rhinosinusitis Nursing
- Education about danger signs - Periorbital edema - Severe pain on palpation - Humidify air - Use of warm compresses - Avoid swimming, diving, air travel - Stop smoking
Assessment of the Patient Undergoing Laryngectomy
- Health history - Physical, psychosocial, and spiritual assessment - Nutrition, BMI, albumin, glucose, electrolytes - Literacy, hearing, and vision; may impact communication after surgery - Coping skills and available support systems for patient and family after surgery
Obstructive Sleep Apnea Medical Management
- Weight loss - Avoid alcohol - Positional therapy (avoid sleeping on back) - Oral appliances - CPAP - continuous positive airway pressure. Prevents airway collapse - BiPAP - bilevel positive airway pressure. Makes breathing easier
Upper Respiratory Tract Infections - URIs Rhinitis and Rhinosinusitis
- Bacterial or viral - Inflammation & irritation of nasal mucous membranes - Viral rhinitis aka common cold - Acute or chronic - Allergic or nonallergic Allergic: Exposure to dust, dander, plant pollens
A tracheoesophageal puncture is the method where a client speaks with the assistance of a
surgically implanted valve that diverts air through the esophagus through a surgical opening in the posterior wall of the trachea with the assistance of a voice prosthesis.
A client undergoes a laryngectomy to treat laryngeal cancer. What instruction should the nurse include in the teaching about the neck stoma?
"Keep the stoma moist." -The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of non-oil based ointment around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities.
A client reports periodic sneezing, runny nose, and itchy eyes throughout the year. Which instruction(s) will the nurse include when teaching the client about these signs and symptoms? Select all that apply.
- Avoid powders and scented products." - "Stay away from all tobacco smoke." - "Blow the nose before using a nasal spray." - "Clean the nasal spray container after each use."
Endoscopic procedures Bronchoscopy
- Direct inspection of larynx, trachea, bronchi - Flexible fiberoptic bronchoscope usually - Purpose: remove foreign bodies/secretions, control bleeding, treat postop atelectasis, destroy or excise lesions, provide brachytherapy (radiation) - NPO 4-8 hours, informed consent, remove oral appliances - After procedure - NPO until cough reflex returns
A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?
Applying nasal packing -A nasal fracture very often produces bleeding from the nasal passage. As a rule, bleeding is controlled with the use of packing.
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Noisy breathing -Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice.
Late symptoms of laryngeal cancer include which of the following. Select all that apply.
- Dysphagia - Dyspnea - Persistent hoarseness
Cancer of the Larynx Nursing Management
- Ice - Elevate head - Reassurance - Packing may be uncomfortable - Mouth rinses - Analgesics - Avoid sports x 6 weeks
Tonsillitis and Adenoiditis Nursing
- If surgery, tonsillectomy or adenoidectomy (Fever , Throat pain, Ear pain) - Hemorrhage ** may occur up to 8 days after surgery (Bright red if expectorated, Brown if swallowed, Monitor pulse and temperature, restlessness ) Notify physician
Acute Rhinosinusitis Complications
- If untreated, osteomyelitis, mucocele (cyst of paranasal sinuses), brain abscess
Upper Respiratory Tract: Laryngitis
- Inflammation of larynx - Voice abuse - Exposure to dust, chemicals, smoke, etc - Part of a URI - Isolated infection - GERD
Cancer of the Larynx Assessment & Diagnostic Findings
- Laryngoscopy using flexible endoscope - Diagnostic procedures: fine needle aspiration, barium swallow, endoscopy, CT or MRI scan
Management of Patients With Upper Respiratory Infections (URIs)
- Most common cause for illness, reason for seeking health care and absences from school and work - May be minor, acute, chronic, severe, or life threatening - Treated in community settings: doctor offices, urgent care clinics, long-term care facilities, or self-care at home - Early detection of signs and symptoms and appropriate interventions can avoid unnecessary complications - Patient teaching focus on prevention and health promotion
Acute Pharyngitis Pathophysiology
- Most viral infection - 5-15% can be group A streptococcus (GAS) "strep" throat - Pain, fever, creamy exudate on tonsils - Can be severe & life threatening
Acute Rhinosinusitis (ARS) Clinical Manifestations
- Nasal drainage - Facial pain, pressure, fullness - Nasal discharge, blockage - If symptoms >10 days ➔ bacterial
Magnetic Resonance Imaging (MRI)
- No radiation - Better able to distinguish between normal and abnormal tissue than CT - Contraindicated if: sever obesity, claustrophobia, confusion, agitation, implanted metal or metal support devices considered unsafe. - Gladolinium based contrast agents
Pulse oximetry
- Noninvasive method of continuously monitoring the oxygen saturation of hemoglobin. Fingertip, forehead, earlobe, or bridge of the nose. - Normal >95% - If less than 90% - tissues not receiving enough oxygen - Unreliable if hypothermia, hemodynamic instability, low perfusion states (shock, vasoconstriction, decreased perfusion of limb) Unreliable if dark skin or wearing nail polish - Consider ABG in these situations
Sputum studies
- Obtain early in morning before eating/drinking - Clear nose, throat and rinse mouth first - Then after a few deep breaths, cough deeply, and expectorate sputum - Label and send as soon as possible to the lab
Fractures of the Nose Medical Management
- Pack if bleeding - Cold compresses - Consider C-spine fracture - Specialist referral
Fractures of the Nose Clinical Manifestations
- Pain - Bleeding from the nose externally and internally into the pharynx - Swelling - Periorbital ecchymosis - Nasal obstruction - Deformity
Obstructive Sleep Apnea Surgical Management
- Tonsillectomy - Removal of pharyngeal soft tissue, parts of soft palate & uvula - Nasal septoplasty - Maxillomandibular surgery - Tracheostomy - Pharmacologic therapy
Skin color (cyanosis)
- VERY LATE indicator of hypoxia. - observe color of tongue and lips
Pharyngitis
inflammation of the throat
Nursing Interventions for the Patient with URI
- Elevate head - Ice collar to reduce inflammation and bleeding - Hot packs to reduce congestion - Analgesics for pain - Topical anesthetics - Monitor for severe complications - Gargles for sore throat - Use alternative communication - Encourage liquids and use of room vaporizers or steam inhalation to keep secretions loose and moist for easier expectoration - Rest
Acute Pharyngitis Clinical Manifestations
- Fiery red pharyngeal membrane & tonsils, swollen lymph nodes flecked with white/purple exudates, enlarged & tender cervical lymph nodes, NO cough - Occasionally, vomiting, anorexia, rash with urticaria (scarlet fever)
Upper Respiratory Tract: Peritonsillar Abscess Nursing
- Frequent throat irrigations or mouthwash/ gargle - Must gargle gently with cool or room temp liquids - Observe for complications
epistaxis (nosebleed)
- Hemorrhage from the nose - Anterior septum, most common site - Serious problem, may result in airway compromise or significant blood loss
Upper Respiratory Tract Infections - URIs Clinical Manifestations
- Low grade fever - Nasal congestion - Nasal discharge - Halitosis - Sneezing - Tearing, watery eyes - Scratchy or sore throat - Chills, headache, general malaise, cough
A patient diagnosed 2 weeks ago with acute pharyngitis comes to the clinic stating that the sore throat got better for a couple of days and is now back along with an earache. What complications should the nurse be aware of related to acute pharyngitis? (Select all that apply.)
- Mastoiditis - Otitis media - Peritonsillar abscess
Chest Xray
- Normal tissue - radiolucent (air and gas) - Densities produced by tumors, foreign bodies, other pathologies seen on xray - Usually two views: PA (posteroanterior) and lateral - Full inspiration - Contraindicated in pregnant women
A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client speaks with the assistance of a surgically implanted device. The nurse is correct to provide teaching on which method?
A tracheoesophageal puncture
A client exhibits a sudden and complete loss of voice and is coughing. The nurse states
"Do not smoke and avoid being around others who are smoking."
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?
"Family members should continue to talk to the client."
A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client?
"Gargle with a warm salt solution." -A warm saline solution will help with removal of thick mucus and halitosis. It will be a gentle gargle, because a vigorous gargle may cause bleeding. A sore throat may be present for 3 to 5 days. Hot foods should be avoided.
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:
"I should become involved in a weight loss program." - Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program.
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?
"I was chewing ice chips all day long."
Fractures of the Nose Nursing Management
- Ice - Elevate head - Reassurance - Packing may be uncomfortable - Mouth rinses - Analgesics - Avoid sports x 6 weeks
Hemoptysis Most common causes
- Pulmonary infection - Lung cancer - Heart or blood vessel abnormalities - Pulmonary artery or vein abnormalities - PE or infarction (PE means pulmonary embolism)
Respiratory Physical Assessment: Breathing Patterns Normal
- Quiet, regular rate, depth, rhythm - Called eupnea. - Changes may be the first clinical sign a patient is deteriorating.
Acute Pharyngitis Assessment & Diagnostic Findings
- Rapid antigen testing for strep - Confirm negative results by throat culture
Cheyne-Stokes
- Regular periods of apnea. - Regular pattern of rate and depth of breathing increasing then decreasing. - Believed to be a result of heart failure
Rhinitis and Rhinosinusitis Clinical Manifestations
- Rhinorrhea - Nasal congestion - Sneezing - Pruritis nose, throat, eyes, ears - Headache
Upper Respiratory Tract Infections - URIs Viral Rhinitis (Common Cold)
- Self limited - Infectious acute - inflammation of mucus membranes - Nasal congestion, rhinorrhea, sneezing, sore throat, general malaise - Highly contagious - virus shed for 2 days before symptoms appear.
Upper Respiratory Tract: Peritonsillar Abscess Clinical Manifestations
- Severe sore throat - Fever - Trismus (inability to open mouth) - Drooling - May have difficulty swallowing saliva due to pain - Dysphagia (difficulty swallowing) - Enlarged cervical lymph nodes
obstructive sleep apnea (OSA) Clinical Manifestations
- Snoring with breathing cessation for 10 seconds or longer - At least 5 episodes per hour - Awakens with a loud snort as blood oxygen levels drop. - Snoring - Sleepiness - Significant other reports
Tonsillitis and Adenoiditis Clinical Manifestations
- Sore throat - Fever - Snoring - Difficulty swallowing - Voice impairment - Earache
Tonsillitis Medical Management
- Supportive measures - Increased fluid intake - Salt water gargles - Rest If bacterial -> antibiotics Tonsillectomy if chronic
Cancer of the Larynx Medical Management
- Surgery - Radiation therapy - Chemoradiation therapy - Surgery ( Vocal cord stripping (remove mucosa at edge of vocal cord) , Cordectomy (excision vocal cord), Laser surgery , Partial laryngectomy, Total laryngectomy)
Viral Rhinitis Medical Management
- Symptomatic treatment - Adequate fluid intake - Rest - Prevent chills - Use of expectorants - Warm salt water gargles - NSAIDS for aches & pains - Steam, humidified air USE TOPICAL NASAL DECONGESANTS WITH CAUTION may cause rebound rhinitis (rhinitis medicamentosa)
Acute Rhinosinusitis Assessment & Diagnostic Findings
- Tenderness to palpation over sinus - Generally no diagnostic imaging - Sinus aspirates may be obtain with endoscope
Cultures
- Throat, nasal, and nasopharyngeal cultures - Ideally, should culture before starting antibiotics - Usually take 48-72 hours
Respiratory Diagnostics Pulmonary function tests
- Tidal volume = the volume of each breath. Measured with spirometer. - Test performed by respiratory therapist.
Acute Rhinosinusitis (ARS) Pathophysiology
- Usually follows a viral URI/cold - If sinus drainage is obstructed, infection may occur
What is the normal respiratory rate?
12-20 breaths per minute
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to 12 days.
A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub?
20 mL or less
Recurrent ABRS = more than
4 acute episodes per year.
Amoxicillin-clavulanic acid (Augmentin) is the antibiotic of choice to treat
ABRS. - For patients who are allergic to penicillin, doxycycline (Vibramycin) or respiratory quinolones such as levofloxacin (Levaquin) or moxifloxacin (Avelox) can be used.
Adventitious sounds
Abnormal lung sounds heard with auscultation.
The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?
Administer an over-the-counter decongestant.
A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority?
Administer one intramuscular injection of penicillin.
The nurse is assessing a patient who smokes 2 packs of cigarettes per day and has a strong family history of cancer. What early sign of cancer of the larynx does the nurse look for in this patient?
Affected voice sounds
The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?
Apply an ice pack.
The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client?
Avoid sports activities for 6 weeks
A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to
Blow the nose before applying medication into the nares. -The nurse instructs the client to blow the nose before administering the nasal medication. The client should keep the head upright, not tilted back. The client should wait at least 1 minute before administering the second spray and clean the container after each use.
Clubbing of the fingers
Chronic hypoxia, chronic lung infection, malignancy, congenital heart disease, chronic infection or inflammation
Rhinorrhea
Clear nasal discharge, "runny nose"
What is a priority education component for a patient scheduled for a total laryngectomy? A) Clarify misconceptions after the patient speaks with the provider B) Discuss the effect of surgery on speech postoperatively C) Explain methods for communication postoperatively D) All of the above
D. All of the above Rationale: Patients may experience severe anxiety at the thought of waking up from surgery and not being able to speak. Preoperatively, the nurse must clarify any misconceptions regarding the procedure and outcomes, discuss alternative strategies for communication after surgery, and reinforcement of teaching with patient and family that the patient's natural voice will be lost.
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?
Develop an alternate method of communication.
Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?
Drainage is <30 mL/day for 2 consecutive days.
Clients receiving endotracheal intubation for the purpose of general anesthesia should not require long-term placement of the
ET tube.
A client stops breathing during sleep as a result of repetitive upper airway obstruction. To help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to:
Eliminate alcohol ingestion.
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?
Emotional support
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?
Ensure mouth breathing
The nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is
Epistaxis
(T/F) Sputum samples are best collected immediately before bed.
False - Rationale: Sputum samples are used to diagnose infectious processes and evidence of malignant cells. The ideal time to obtain a sputum specimen is early in the morning before the patient has had anything to eat or drink. The patient should clear the nose and throat, then rinse the mouth to avoid contamination of the sample. The patient should be instructed to take a few deep breaths, cough, and expectorate sputum into a sterile container
A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes
Gastroesophageal reflux disease (GERD) -The nurse should ask whether the client has a medical history of GERD. Laryngitis is common in older adults and may be secondary to GERD.
A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?
Group A, beta-hemolytic streptococci
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?
Hoarseness for 2 weeks
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?
Hypercapnia
A client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist with mucus. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. What is a prioritynursing concern?
Ineffective airway clearance -All may be appropriate nursing diagnoses for this client. The nurse would follow Maslow's hierarchy of needs and ABCs (airway, breathing, circulation) to determine the highest priority.
A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is
Ineffective airway clearance related to excess mucus production
The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)?
It requires the insertion of a prosthesis into the trachea.
Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?
Laryngeal cancer -Later, the client notes a sensation of swelling or a lump in the throat, followed by dysphagia and pain when talking.
Which type of sleep apnea is characterized by lack of airflow due to pharyngeal occlusion?
Obstructive
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?
Partial laryngectomy
A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved. For what type of surgical intervention will the nurse plan to provide education?
Partial laryngectomy
A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by
Placing the client prone with the head turned to the side
obstructive sleep apnea (OSA) Assessment & Diagnostic Findings
Sleep study, overnight
A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first
Stands behind the worker, who has hands across the neck
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
Sudden restlessness
Acute Pharyngitis
Sudden, painful inflammation of pharynx "sore throat"
When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided?
Swimming
The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45 degrees." This assists in meeting which nursing goal?
The client will have decreased edema. -Elevating the head of the bed 45 degrees when the client is fully awake decreases surgical edema and increases lung expansion.
A patient is being seen in the ED for chest pain, the nurse should ask the patient ... ?
The nurse should ask the patient if the pain occurs on inspiration or expiration. - Assess onset, quality, intensity, and radiation of pain.
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
Total laryngectomy -In more advanced cases, total laryngectomy may be the treatment of choice.
Blood from lung
Usually bright red, frothy, mixed with sputum. Alkaline pH
Blood from stomach
Usually vomited, may be mixed with food, usually darker, called "coffee ground emesis". Acid pH
A client recovering from a total laryngectomy has been receiving enteral nutrition for a week. For which evaluation will the nurse prepare the client before providing oral feedings?
Video fluoroscopy - After surgery, a client recovering from a total laryngectomy will receive an alternative source of nutrition for at least 7 days. Before oral feedings are started, a swallow study through the use of video fluoroscopy is done to evaluate the client's risk of aspiration.
- May last from 1-2 weeks - May exacerbate herpes simplex (cold sore).
Viral Rhinitis
Most cases of acute pharyngitis are caused by viral infection. Responsible viruses include the
adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus.
The long-term and short-term complications of tracheostomy include
airway obstruction. - These are caused by hardened secretions and erosion of the trachea.
A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is
amoxicillin-clavulanic acid.
BiPAP
bilevel positive airway pressure. Makes breathing easier
In central sleep apnea, the client demonstrates simultaneous cessation of
both airflow and respiratory movements.
Mixed sleep apnea is a combination of
central and obstructive apnea, with one apneic episode.
Stridor -
continuous high-pitched musical sound over the neck - EMERGENT Narrowing of upper respiratory tract
CPAP
continuous positive airway pressure. Prevents airway collapse
Dysphagia is
difficulty swallowing.
Xerostomia is
dryness of the mouth from a variety of causes.
Carcinoma -
dull, persistent
A partial laryngectomy (laryngofissure-thyrotomy) is often used for patients in the
early stages of cancer in the glottis area when only one vocal cord is involved.
Normal Breath Sounds: Vesicular
heard over most of the lung fields; low pitch, soft and short expirations.
A sudden and complete loss of voice and cough are symptoms of
laryngitis. -The nurse instructs the client to avoid irritants, such as smoking. Voice rest is indicated. Whispering places stress on the larynx. Inhaling cool steam or aerosol aids in the treatment
In a partial laryngectomy, a portion of the
larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing.
During a supraglottic laryngectomy, a tracheostomy is
left in place until the glottic airway is established.
Friction rubs -
may be either continuous or discontinuous
Crackles -
nonmusical, discontinuous sounds Heart failure
Stiffness of the neck or inability to bend the neck is referred to as
nuchal rigidity.
Esophageal speech occurs from swallowing air and forming words with
the lips.
An artificial larynx is a
throat vibrator held against the neck that projects sound into the mouth.
Tracheostomy tubes are inserted into a surgical opening in the trachea, called a
tracheotomy.
The pleural space, located between the
visceral and parietal pleura, normally contains 20 mL of fluid or less. - The fluid helps lubricate the visceral and parietal pleura.
Peritonsillar Abscess
Collection of pus or fluid around the tonsil
Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?
Continuous positive airway pressure (CPAP)
A partial laryngectomy involves the
removal of one vocal cord.
Pleuritic pain -
sharp, seems to "catch" on inspiration