Exam 20 - Upper Airway Disorders

Epistaxis (Nosebleed)

• Nasal membrane congestion leads to capillary rupture
• Injury is a frequent cause
• Can be primary or secondary to other conditions
• Related to menstrual flow in women
• Hypertension, irritation of nasal mucosa, dryness, chronic infection, nose picking, vigorous nose blowing, and prolonged aspirin or NSAID use can contribute
• Bright red blood drains from one or both nostrils
• Severe hemorrhage can lead to losing up to one liter of blood per hour in adults

Epistaxis Assessment

• Subjective data includes duration and severity of bleeding, as well as precipitating factors
• Objective data includes bleeding from one or both nostrils (anterior or posterior), vital signs, and signs of hypovolemic shock, with hypotension as a late sign

Epistaxis Diagnostic Tests

• Hemoglobin and Hematocrit.
• Coagulation studies (PT, PTT, INR) are performed
• Rhinoscopy helps locate the bleeding site

Epistaxis Medical Management

• Involves nasal packing with epinephrine-soaked cotton
• Cautery (electrical or chemical) can be used
• Possible posterior packing
• Balloon tampon using a Foley-like catheter
• Antibiotics minimize infection risk after bleeding is controlled

Epistaxis Nursing Interventions and Teaching

• Keep the patient calm
• Position the patient sitting and leaning forward, or reclining with head and shoulders elevated, keep an emesis basin available
• Apply direct pressure to the soft part of the nose for 10-15 minutes
• Apply ice compresses to the nose
• Monitor for signs of hypovolemic shock
• Instruct the patient and family to avoid nose picking, vigorous nose blowing, scratching, or placing foreign objects in the nose
• Encourage keeping nasal mucous membranes moist
• Advise against aspirin and NSAIDs

Patient Teaching for Epistaxis

• Teach the patient to sneeze with their mouth open
• Compromised blood flow: Assess vital signs and level of consciousness every 15 minutes, and document blood loss
• To avoid aspiration elevate the head of the bed, encourage the patient to let blood drain, pinch nostrils, have patient breathe through the mouth, apply ice, assist in clearing secretions, and instruct the patient to expectorate rather than swallow blood

Deviated Septum & Nasal Polyps

• Deviated Septum: Congenital abnormality or injury causes deviation from midline
• Nasal Polyps: Tissue growths from prolonged sinus inflammation, often linked to allergies

Deviated Septum & Nasal Polyps Manifestations

• Clinical manifestations include stertorous respirations (strenuous, snoring sound), dyspnea, and postnasal drip.
• Assess history of injuries, infections, allergies, sinus congestion, dyspnea

Deviated Septum & Nasal Polyps Objective Data During Assessment

• Identify the condition and location and assess rate and character of respirations
• Diagnostic tests include sinus radiographic studies and visual examination

Deviated Septum & Nasal Polyps Managment

• Surgical correction is needed
• Nasoseptoplasty straightens the septum
• Nasal polypectomy removes polyps
• Packing controls bleeding for 24 hours
• Hydrate nasal mucosa with irrigation or petroleum
• Medications reduce inflammation, congestion, and prevent infection includes corticosteroids, antihistamines, antibiotics, and analgesics

Deviated Septum & Nasal Polyps Interventions and Patient Teaching

• Maintain airway patency and prevent infection
• Monitor for infection or hemorrhage postoperatively
• Contact physician for bleeding or infection
• Exercise caution against nasal sprays and drops due to rebound effect
• Avoid nose blowing, vigorous coughing, or Valsalva maneuver for 2 days post-op
• Expect ecchymosis and edema for several days

Deviated Septum & Nasal Polyps Problems

• Inability to Clear Airway: Document ability to clear secretions and respiratory status, elevate the head of the bed, apply ice to decrease edema, change nasal drip pad, and document exudate
• Potential for Injury: Assess and report exudates; instruct patient against blowing nose postoperatively

Allergic Rhinitis and Allergic Conjunctivitis

• Atopic condition results from antigen-antibody reactions in nasal membranes, nasopharynx, and conjunctiva
• Common allergens include trees, grass, weeds, mold, fungi, dust, mites, animal dander, foods, drugs, and insect stings

Allergic Rhinitis and Allergic Conjunctivitis Manifestations

• Acute ocular symptoms are edema, photophobia, excessive tearing, blurred vision, pruritus
• Rhinitis leads to excessive secretions and inability to breathe through the nose
• Can lead to otitis media
• Chronic: Headache, severe nasal congestion, postnasal drip, cough
• If Untreated: Otitis media, bronchitis, sinusitis, pneumonia

Allergic Rhinitis and Allergic Conjunctivitis Assessment

• Initial complaints are severe sneezing, congestion, pruritus, lacrimation
• Chronic include headache, severe nasal congestion, postnasal drip, cough
• Physical Exam: Pale mucosa of the turbines

Allergic Rhinitis and Allergic Conjunctivitis diagnostics and managment

• Skin testing, serum radioallergosorbent test (RAST)
• Relieve and prevent infections
• Medications: antihistamines, decongestants, lodoxamide for conjunctivitis, topical or nasal corticosteroids, Beclomethasone, Dexamethasone, Flunisolide, Fluticasone, Budesonide

Allergic Rhinitis and Allergic Conjunctivitis Interventions and Teaching

• Focus on health promotion and maintenance
• Educate about ways to avoid allergens
• Teach self-care management through symptom control
• Explain medication action and usage, assess for effectiveness

Obstructive Sleep Apnea Etiology and Pathophysiology

• Partial or complete upper airway obstruction during sleep
• Relaxation of the tongue and soft palate obstructs the pharynx
• More common in men, incidence with age and weight gain
• Structural anomalies of the nares and or pharynx

Obstructive Sleep Apnea Assessment

• Apneic period with severe hypoxemia and hypercapnia
• Startle response, snorts, and gasps as ventilatory stimulants
• Apnea and arousal cycles 200-400 times during sleep
• Morning headache, personality changes, hypertension, cardiac dysrhythmias
• Diagnostics: Polysomnography
• Diagnosis after repeated episodes of apnea or diminished respiratory effort (30-50%)

Obstructive Sleep Apnea Treatment

• Mild Apnea: Avoid sedatives and alcohol before sleep, weight loss, oral appliance, support group
• Moderate to Severe Apnea: Nasal continuous positive airway pressure (nCPAP)

Obstructive Sleep Apnea nCPAP Therapy

• A nasal mask is attached to a high-flow blower, and provides positive pressure to prevent airway collapse
• Bi-level positive airway pressure (BiPAP) has higher pressure during inspiration, lower during expiration

Upper Airway Obstruction Etiology and Pathophysiology

• Recent respiratory incident, trauma, choking, dentures, aspiration, tongue obstruction, laryngeal spasm, laryngeal edema

Upper Airway Obstruction Clinical Manifestations

• Stertorous respirations, altered rate, character, and apneic episodes
• Agitation, changes in level of consciousness, and confusion

Upper Airway Obstruction Assessment

• Subjective: Patient unable to talk
• Objective: Signs of hypoxia, respiratory distress (stertorous respirations, stridor, wheezing), cyanosis, bradycardia, hand over throat

Upper Airway Obstruction Medical Managment

• In cases of upper airway obstruction, the Heimlich maneuver, emergency tracheostomy, and artificial airways (pharyngeal, endotracheal, tracheal) may be necessary
• Prompt assessment will aid in the diagnosis
• Radiographic studies identify foreign bodies

Upper Airway Obstruction Interventions and Patient Teaching

• Nursing interventions include promptly opening the airway and restoring patency
• Patient problem includes the inability to clear airway: Reestablish and maintain airway, administer oxygen, suction as needed, monitor vital signs and breath sounds
• Potential for Aspiration: Monitor respiratory rate, rhythm, and effort; assess ability to swallow secretions; elevate the head of the bed, document breath sounds and secretions, and suction as needed

Laryngeal Cancer Etiology

• Most often in people over age 65
• Prolonged tobacco use
• Chronic laryngitis
• Vocal abuse
• Family history
• Gastroesophageal reflux disease
• Heavy alcohol use

Laryngeal cancer manifestations

• Progressive or persistent hoarseness (early sign) > 2 weeks
• Pain in larynx radiating to ear
• Dysphagia
• Lump in throat
• Enlarged cervical lymph nodes

Laryngeal Cancer

• Assessment: Onset of symptoms, difficulty breathing or swallowing, examine sputum for blood
• Diagnostics: Visual examination with direct laryngoscopy with biopsy, imaging studies (X-Ray, CT, MRI, PET)

Laryngeal cancer medical and nursing interventions

• Medical Management: Radiation therapy if tumor confined to the vocal cord without limitation of movement, surgery: Total or partial laryngectomy, radical neck dissection, chemotherapy
• Nursing Interventions including airway patency, frequent suctioning, and skin integrity monitoring

Acute Rhinitis (Common Cold/Coryza)

• Etiology: The mucous membranes of the nose and sinuses become inflamed, caused by viruses, can be complicated by bacteria
• Symptoms: Productive cough, thin, serous nasal exudate, sore throat, and fever
• Assessment: Subjective- Sore throat, dyspnea, congestion, objective- Erythema, edema, local irritation of the throat, monitor vital signs
• Diagnosis: Throat and sputum cultures determine bacterial
• Medical Management: Analgesia, antipyretics, cough suppressant and expectorant and antibiotics for bacterial infection

Acute Rhinitis Interventions and Patient Teaching

• Patient Teaching: Teach handwashing and proper tissue disposal, limit exposure to others for 48 hours, and check temperature every 4 hours
• Nursing Interventions: Promote comfort
• Patient Problems: Inability to Clear Airway (encourage fluids, use a vaporizer) and willingness for Improved Health Management (monitor respiratory status, assess swallowing, document breath sounds and secretions, elevate the head of the bed, suction as needed

Acute Follicular Tonsillitis

• Etiology/Pathophysiology: Caused by group A beta-hemolytic Streptococcus or air or foodborne bacterial infection, most common in school-age children
• Symptoms: Enlarged cervical lymph nodes, sore throat, fever, chills, malaise, general muscle aching, and enlarged tonsils with purulent exudate
• Assessment: Subjective- severity of throat pain, pain to ears, headache, joint pain, objective- Enlarged erythematous tonsils and increased throat secretions
• Diagnostic Tests: Throat cultures and WBC count
• Medical Management: Antibiotic for active infection
• Interventions: Surgery for recurrent infections, 4-6 weeks after attack subsides or facilitate recovery and prevent secondary infections
• Patient Problems: Discomfort- assess pain and need for analgesics, document effectiveness of meds, offer warm saline gargles, ice chips, and ice collar; maintain airway and position; observe for vomiting, potential for inadequate fluid volume- assess hydration status, encourage ice pops, ice chips, and increased oral intake and potential for aspiration- maintain patent airway; keep patient lying on their side and observe for swallowing and vomiting

Laryngitis Etiology and Pathophysiology

• Secondary to other respiratory disorders, viral or bacterial infections
• Excessive use of voice, inhalation of irritating fumes
• May cause severe respiratory distress in children under five

Laryngitis Clinical Manifestations

• Hoarseness, scratchy and irritated throat, persistent cough
• Assessment: Progressive hoarseness and cough. Evaluate patient's voice quality and sputum through Laryngoscopy
• Medical Management: No antibiotic therapy for viral causes, comfort measures. Antibiotic therapy for bacterial causes
• Assess pain level and offer medication for comfort, use steam inhalation
• Instruct on voice rest; provide other means of communication, anticipate needs

Prognosis And Pharyngitis Etiology

• Laryngitis: Prognosis is good for adults, but can lead to respiratory distress in children
• Pharyngitis: Etiology is acute or chronic, common throat inflammation with viral origin or caused by hemolytic streptococci, staphylococci, or other bacteria. "Strep throat" is contagious for 2-3 days after onset of signs
• Clinical Manifestations: Dry cough, tender tonsils, enlarged lymph glands, erythematous, sore throat
• Assessment: Subjective- pharyngeal discomfort, fever, and difficulty swallowing, objective- Palpate for enlarged, edematous glands, associated tenderness, and elevated temperature
• Diagnostic Tests: Throat cultures

Pharyngitis and Sinusitis

• Pharyngitis Medical Management: Antibiotics (penicillin or erythromycin) and analgesics/antipyretics (Tylenol)
• Patient Problems: Provide warm saline gargles and assess pain, encourage oral fluids, offer oral care, instruct on voice rest, observe and record hydration, monitor intake and output and temp, maintain IV therapy if indicated
• Sinusitis Etiology/Pathophysiology: Chronic or acute, maxillary or frontal, viral or bacterial
• Clinical Manifestations: Constant, severe headache, pain and tenderness in affected area, purulent exudate
• Assessment: Subjective- decreased appetite, nausea, malaise, headache, and pain in the region, objective- vital signs (temperature) and character of drainage

Sinusitis Diagnosis and Managment

• Diagnostic Tests: Sinus x-rays, transillumination, CT scan
• Medical Management: Nasal windows to facilitate drainage, Caldwell-Luc operation to remove diseased tissue, medications- saline nasal irrigation, nasal corticosteroids, oral or injected corticosteroids, decongestants, analgesics, antibiotics (if bacterial)
• Patient Problems: Assess respiratory status, mouth breathing may be necessary; consider neti pots, document comfort level, assess the need for analgesics, elevate HOB, apply warm packs
• Prognosis: Uncomplicated sinusitis has a good prognosis; complications include cavernous sinus thrombosis, spread of infection to bone, brain, meninges, leading to meningitis, osteomyelitis, or septicemia