MANAGEMENT OF

PATIENTS WITH UPPER

RESPIRATORY TRACT
DISORDERS
 LEARNING OBJECTIVES
1. Describe nursing management of
patients with upper airway disorders.
2. Compare and contrast the upper
respiratory tract infections with regard to
cause, incidence, clinical manifestations,
management, and the significance of
preventive health care.
3. Use the nursing process as a framework for
care of patients with upper airway infection.
4. Describe nursing management of the patient
with epistaxis.
5. Use the nursing process as a framework for
care of patients undergoing laryngectomy.
UPPER AIRWAY INFECTION
– Rhinitis
– Sinusitis
– Pharyngitis
– Tonsilitis
RHINITIS
 Rhinitis
• Rhinitis is a group of disorders characterized
by inflammation and irritation of the mucous
membranes of the nose.
• It may be classified as
– nonallergic or
– allergic.
• Rhinitis may be an acute or chronic
condition.
 Pathophysiology
• Nonallergic rhinitis may be caused by a
variety of factors, including environmental
factors such as changes in temperature or
humidity, odors, or foods; infection; age;
systemic disease; drugs (cocaine) or
prescribed medications; or the presence of a
foreign body.
 CLINICAL MANIFESTATIONS
• rhinorrhea (excessive nasal drainage, runny nose),
• nasal congestion,
• nasal discharge (purulent with bacterial rhinitis),
• nasal itchiness, and
• sneezing.
• Headache may occur, particularly if sinusitis is also
present.
 Medical Management
• Medication therapy for allergic and nonallergic
rhinitis focuses on symptom relief.
• Antihistamines are administered for sneezing,
itching, and rhinorrhea.
• Oral decongestant agents are used for nasal
obstruction.
• intranasal corticosteroids may be used for severe
congestion, and
• ophthalmic agents are used to relieve irritation,
itching, and redness of the eyes.
Nursing Management
TEACHING PATIENTS SELF-CARE
• The nurse instructs the patient with allergic
rhinitis to avoid or reduce exposure to
allergens and irritants, such as dusts, molds,
animals, fumes, odors, powders, sprays, and
tobacco smoke.
• Saline nasal or aerosol sprays may be
helpful in soothing mucous membranes,
softening crusted secretions, and removing
irritants.
• In the case of infectious rhinitis, the nurse
reviews with the patient hand hygiene
technique as a measure to prevent
transmission of organisms.
 VIRAL RHINITIS
(COMMON COLD)
• The term “common cold” often is used when
referring to an upper respiratory tract infection
that is self-limited and caused by a virus (viral
rhinitis).
• Nasal congestion, rhinorrhea, sneezing, sore
throat, and general malaise characterize it.
The six viruses known to produce the signs
and symptoms of the viral rhinitis are
1. rhinovirus,
2. parainfluenza virus,
3. coronavirus,
4. respiratory syncytial virus (RSV),
5. influenza virus, and
6. adenovirus.
 Clinical Manifestations
• nasal congestion,
• Runny nose,
• sneezing,
• nasal discharge,
• nasal itchiness,
• tearing watery eyes,
• “scratchy” or sore throat,
• general malaise,
• low-grade fever,
• chills,
• headache and
• muscle aches
• The symptoms last from 1 to 2 weeks.
• If there is significant fever or more severe
systemic respiratory symptoms, it is no longer
viral rhinitis but one of the other acute upper
respiratory tract infections.
 Medical Management
• Management consists of symptomatic therapy
• adequate fluid intake,
• encouraging rest,
• Preventing chilling,
• increasing intake of vitamin C, and
• using expectorants as needed.
• Warm salt-water gargles soothe the sore
throat and
• nonsteroidal anti-inflammatory agents
(NSAIDs) such as aspirin or ibuprofen relieve
the aches, pains, and fever in adults.
• Antihistamines are used to relieve sneezing,
rhinorrhea, and nasal congestion.
Nursing Management
 TEACHING PATIENTS SELF-
CARE
• Most viruses can be transmitted in several
ways:
– direct contact with infected secretions; inhalation of
large particles that land on a mucosal surface from
coughing or sneezing; or
– inhalation of small particles (aerosol) that may be
suspended in the air for up to an hour.
• It is important to teach the patient how to
break the chain of infection. Hand washing
remains the most effective measure to
prevent transmission of organisms.
• The nurse teaches methods to treat
symptoms of the common cold and preventive
measures
 ACUTE
SINUSITIS
 Acute sinusitis
• Acute sinusitis is an infection of the
paranasal sinuses
• It frequently develops as a result of an upper
respiratory infection, such as an
– unresolved viral or bacterial infection, or
– an exacerbation of allergic rhinitis.
 CLASSIFICATION
1. ACUTE SINUSITIS
– Lasts from 1 day to 3 weeks

2. SUBACUTE SINUSITIS
– From 3 weeks to 3 months

3. CHRONIC SINUSITIS
– Lasts longer than 3 months
 PATHOPHYSIOLOGY
• Sinuses are lined with cilia: which facilitate
movement of fluids and microorganisms into
the nasal cavity for exit from the body.
• Viral illness produce inflammation of the sinus
mucosa causing obstruction of the normal
ciliary action: creating an ideal environment
for bacterial growth.
• Following invasion of microorganism into the
sinuses, the inflammatory response increases
swelling and congestion; bacterial growth
continues.
 COMMON ORGANISM
• Streptococcus pyogenes,
• Staphylococcus aureus
• Streptococcus pneumoniea
• Haemophilus influenzae
 Clinical Manifestations
• facial pain or pressure over the affected sinus
area,
• nasal obstruction,
• fatigue,
• Purulent nasal discharge,
• fever,
• headache,
• ear pain and fullness,
• Dental pain,
• cough,
• a decreased sense of smell,
• sore throat,
• eyelid edema, or facial congestion or
fullness
 Assessment and Diagnostic Findings

• history and physical examination

• Sinus x-rays
• Computed tomography scanning of the
sinuses is the most effective diagnostic tool
 Complications
• Acute sinusitis, if left untreated, may lead to
severe and occasionally life-threatening
complications such as
– meningitis,
– brain abscess,
– ischemic infarction, and
– osteomyelitis.
 Medical Management
• The goals of treatment of acute sinusitis are to
treat the infection, shrink the nasal
mucosa, and relieve pain.
• First-line antibiotics include
– amoxicillin (Amoxil),
– trimethoprim/sulfamethoxazole (Bactrim,
Septra), and
– erythromycin.
• Second-line antibiotics include
– cephalosporins such as
• cefuroxime axetil (Ceftin),
• cefpodoxime (Vantin), and
• cefprozil (Cefzil) and
• amoxicillin clavulanate (Augmentin).
• Newer and more expensive antibiotics with a
broader spectrum include
• macrolides,
• azithromycin (Zithromax), and
• clarithromycin (Biaxin).
• Quinolones such as
– ciprofloxacin (Cipro),
– levofloxacin (Levaquin) (used with severe
penicillin allergy), and
– sparfloxacin (Zagam) have also been used
Nursing Management
 TEACHING PATIENTS SELF-
CARE
• The nurse instructs the patient about methods
to promote drainage such as
– inhaling steam (steam bath, hot shower, and
facial sauna),
– increasing fluid intake, and
– applying local heat (hot wet packs).
• The nurse should explain to the patient that
fever, severe headache, and nuchal rigidity
are signs of potential complications.
CHRONIC
SINUSITIS
 Chronic sinusitis
• Chronic sinusitis is an inflammation of the
sinuses that persists for more than 3 weeks in
an adult and 2 weeks in a child.
 Pathophysiology
• A narrowing or obstruction in the ostia of the frontal,
maxillary, and anterior ethmoid sinuses usually
causes chronic sinusitis, preventing adequate
drainage to the nasal passages.
• Blockage that persists for greater than 3 weeks in
an adult may occur because of infection, allergy, or
structural abnormalities. This results in stagnant
secretions, an ideal medium for infection.
 Clinical Manifestations
• impaired mucociliary clearance and
ventilation,
• cough (because the thick discharge constantly
drips backward into the nasopharynx),
• Chronic hoarseness,
• chronic headaches in the periorbital area, and
• Facial pain.
• Fatigue and nasal stuffiness
• decrease in smell and taste and a
fullness in the ears.
Assessment and Diagnostic Findings

• history and diagnostic assessment

• Computed tomography scan of the sinuses
• magnetic resonance imaging (if fungal
sinusitis is suspected),
• Nasal endoscopy may be indicated to rule
out underlying diseases such as tumors and
sinus mycetomas
 Complications
• Complications of chronic sinusitis,
although uncommon, include
– severe orbital cellulitis,
– subperiosteal abscess,
– cavernous sinus thrombosis,
– meningitis,
– encephalitis, and
– ischemic infarction.
 Medical Management
• Medical management of chronic sinusitis is
almost the same as for acute sinusitis.
 The antimicrobial agents of choice
– amoxicillin clavulanate (Augmentin) or
– ampicillin (Ampicin).
– Clarithromycin (Biaxin) and
• third-generation cephalosporins such as
– cefuroxime axetil (Ceftin),
– cefpodoxime (Vantin), and
– cefprozil (Cefzil)
• The course of treatment may be 3 to 4
weeks.
• Decongestant agents,
• antihistamines,
• saline sprays, and
• heated mist may also provide some symptom
relief.
 SURGICAL MANAGEMENT
• When standard medical therapy fails, surgery,
usually endoscopic, may be indicated to
correct structural deformities that obstruct the
ostia (openings) of the sinus.
 SURGICAL MANAGEMENT
• Excising and cauterizing nasal polyps,
• correcting a deviated septum,
• incising and draining the sinuses,
• aerating the sinuses, and
• removing tumors are some of the specific
procedures performed.
Nursing Management
TEACHING PATIENTS SELF-
CARE
• The nurse teaches the patient how to
promote sinus drainage by increasing the
environmental humidity (steam bath, hot
shower, and facial sauna), increasing
fluid intake, and applying local heat (hot
wet packs).
• The nurse also instructs the patient about the
importance of following the medication
regimen.
• Instructions on the early signs of a sinus
infection are provided and preventive
measures are reviewed.
 ACUTE
PHARYNGITIS
• Acute pharyngitis is an inflammation or
infection in the throat, usually causing
symptoms of a sore throat.
 Pathophysiology
• Most cases of acute pharyngitis are
caused by viral infection.
• When group A beta-hemolytic
streptococcus, the most common
bacterial organism, causes acute
pharyngitis, the condition is known as
strep throat
• The body responds by triggering an
inflammatory response in the pharynx.
• This results in pain, fever, vasodilation, edema,
and tissue damage, manifested by redness and
swelling in the tonsillar pillars, uvula, and soft
palate.
• A creamy exudate may be present in the
tonsillar pillars
 Clinical Manifestations

• fiery-red pharyngeal membrane and tonsils,

• lymphoid follicles that are swollen and flecked with
white-purple exudate, and
• enlarged and tender cervical lymph nodes and no
cough.
• Fever,
• malaise, and
• sore throat also may be present.
 COMPLICATIONS
• sinusitis,
• otitis media,
• peritonsillar abscess,
• mastoiditis, and cervical adenitis.
• In rare cases the infection may lead to
– bacteremia, rheumatic fever,
– pneumonia, nephritis.
– meningitis,
Assessment and Diagnostic Findings

• Rapid screening tests for streptococcal

antigens such as the latex agglutination (LA)
antigen test and solid-phase enzyme
immunoassays (ELISA),
• optical immunoassay (OIA),
• and throat cultures are used to determine the
causative organism
• Nasal swabs and blood cultures may also
be necessary to identify the organism
 Medical Management
• Viral pharyngitis is treated with supportive
measures since antibiotics will have no
effect on the organism.

• Bacterial pharyngitis is treated with a

variety of antimicrobial agents.
 PHARMACOLOGIC THERAPY
• If a bacterial cause is suggested or
demonstrated, penicillin is usually the
treatment of choice.
• Severe sore throats can also be relieved by
analgesic medications,
NUTRITIONAL THERAPY
• liquid or soft diet is provided during the
acute stage of the disease, depending on the
patient’s appetite and the degree of
discomfort that occurs with swallowing
 Nursing Management
• The nurse instructs the patient to stay in bed
during the febrile stage of illness and to rest
frequently once up and about.
• Used tissues should be disposed of
properly to prevent the spread of infection.
• Warm saline gargles or irrigations are used
depending on the severity of the lesion and
the degree of pain.
• An ice collar also can relieve severe sore
throats.
• Mouth care may add greatly to the patient’s
comfort and prevent the development of
fissures (cracking) of the lips and oral
inflammation
 CHRONIC
PHARYNGITIS
 Chronic pharyngitis
• Chronic pharyngitis is a persistent
inflammation of the pharynx.
 Three types of chronic pharyngitis are
recognized:
• Hypertrophic: characterized by general thickening
and congestion of the pharyngeal mucous
membrane
• Atrophic: probably a late stage of the first type (the
membrane is thin, whitish, glistening, and at times
wrinkled)
• Chronic granular (“clergyman’s sore throat”):
characterized by numerous swollen lymph follicles
on the pharyngeal wall
 Clinical Manifestations
• Patients with chronic pharyngitis complain of a
– constant sense of irritation or fullness in the
throat,
– mucus that collects in the throat and can be
expelled by coughing, and
– difficulty swallowing.
 Medical Management
• Treatment of chronic pharyngitis is based on
relieving symptoms,
• avoiding exposure to irritants, and
correcting any upper respiratory, pulmonary,
or cardiac condition that might be responsible
for a chronic cough.
• Nasal congestion
• Aspirin or acetaminophen is recommended
for its anti-inflammatory and analgesic
properties.
Nursing Management
 TEACHING PATIENTS SELF-
CARE
• the nurse instructs the patient to avoid
contact with others until the fever subsides.
• Alcohol, tobacco, second-hand smoke, and
exposure to cold are avoided, as are
environmental or occupational pollutants if
possible.
• The patient may minimize exposure to pollutants
by wearing a disposable facemask.
• The nurse encourages the patient to drink plenty
of fluids.
• Gargling with warm saline solutions may relieve
throat discomfort.
• Lozenges will keep the throat moistened.
TONSILITIS
 TONSILITIS
• TONSILITIS is defined a an inflammation of
the tonsils.
• The tonsils are composed of lymphatic tissue
and are situated on each side of the
oropharynx.
• The faucial or palatine tonsils and lingual
tonsils are located behind the pillars of fauces
and tongue, respectively.
• They frequently serve as the site of acute
infection (tonsillitis).
 Clinical Manifestations
• sore throat,
• fever,
• snoring,
• and difficulty swallowing.
• Enlarged adenoids may cause mouth breathing,
– earache, draining ears,
– frequent head colds,
– bronchitis,
– foul-smelling breath,
– voice impairment, and noisy respiration.
Assessment and Diagnostic Findings
• A thorough physical examination is performed and
a careful history is obtained to rule out related or
systemic conditions.
• The tonsillar site is cultured to determine the
presence of bacterial infection.
• In adenoiditis, if recurrent episodes of suppurative
otitis media result in hearing loss, the patient should
be given a comprehensive audiometric
examination
 Surgical Management
• Tonsillectomy is usually performed for
recurrent tonsillitis
Nursing Management
 PROVIDING POSTOPERATIVE
CARE
• Continuous nursing observation is required in the
immediate postoperative and recovery period
because of the significant risk of hemorrhage.
• Bleeding may be bright red if the patient
expectorates blood before swallowing it Often,
however, the patient swallows the blood, which
immediately becomes brown because of the action
of the acidic gastric juice.
 TEACHING PATIENTS SELF-
CARE
• Because the patient will be sent home soon
after surgery, the patient and family must
understand the signs and symptoms of
hemorrhage.
• Hemorrhage usually occurs in the first 12 to
24 hours. The patient is instructed to report
frank red bleeding to the physician.
• The patient should avoid spicy, hot, acidic,
or rough foods.
• Milk and milk products (ice cream and
yogurt) may be restricted because they may
make removal of mucus more difficult
LARYNGITIS
 Laryngitis
• Laryngitis, an inflammation of the larynx,
often occurs as a result of voice abuse or
exposure to dust, chemicals, smoke, and
other pollutants, or as part of an upper
respiratory tract infection.
• Laryngitis is common in the winter and is
easily transmitted.
 Clinical Manifestations
• hoarseness or aphonia (complete loss of voice)
and
• severe cough.
• Chronic laryngitis is marked by persistent
hoarseness.
• Laryngitis may be a complication of upper
respiratory infections
 Medical Management
• resting the voice,
• Avoiding smoking,
• resting, and
• inhaling cool steam or an aerosol.
• If the laryngitis is part of a more extensive
respiratory infection due to a bacterial organism or if
it is severe, appropriate antibacterial therapy is
instituted.
 Nursing Management
• The nurse instructs the patient to rest the
voice and to maintain a well-humidified
environment.
• If laryngeal secretions are present during
acute episodes, expectorant agents are
suggested, along with a daily fluid intake of
3 L to thin secretions.
LARYNGEAL
CANCER