7.-Respiratory-Disorder-part-1.pdf

CARE OF THE PATIENTS WITH RESPIRATORY DISORDERS SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLID...

CARE OF THE PATIENTS WITH RESPIRATORY DISORDERS SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO SLIDESMANIA.CO  ASSESSMENT OF PATIENT WITH RESPIRATORY DISORDER History ✓ Biographic Data ✓ Chief complaint ▪ Hemoptysis ▪ Dyspnea ▪ Wheezing ▪ Cough ▪ Stridor ▪ Sputum production ▪ Chest pain ✓ Past Medical History ▪ Childhood/Infectious disease ▪ Respiratory Immunization ▪ Major illnesses/ Hospitalization SLIDESMANIA.CO ▪ Medication ▪ Allergies  ✓ Family History ✓ Psychosocial History and Lifestyle ▪ Occupational or environmental exposure ▪ Geographic Location ▪ Personal Habits (year of smoking x packs/day = pack years 15 years of smoking X 2 Packs/day = 30 packs years) Physical Examination ✓ Inspection ▪ Signs and Symptoms of respiratory distress ▪ I: E (Inhalation: Expiration) ratio (1:2) ▪ Speech pattern ▪ Chest wall configuration ▪ Chest movement SLIDESMANIA.CO ▪ Finger and toes  ✓Palpitation ▪ Trachea ▪ Chest wall ▪ Thoracic excursion ▪ Tactile fremitus ✓Percussion ▪ Resonance ▪ Hyperresonance ▪ Dullness ✓Auscultation ▪ Breath Sound SLIDESMANIA.CO  Best Practices: When auscultating the lung field: 1. Use the diaphragm of the stethoscope. Breath sounds are considered high-pitched sounds. 2. Auscultate the posterior chest, then proceed to the anterior chest. 3. Listen for lung sounds from the top to the bottom of the chest (lung apices to the lung bases) 4. Auscultate from side to side of the chest. 5. Auscultate the anterior chest starting above the clavicle to listen to the apices of the lungs. 6. When auscultating the anterior chest, once in the nipple line, move out along side the chest to the mid-axillary line. 7. Place the diaphragm at the intercostal spaces. SLIDESMANIA.CO  ▪ Voice Sounds a. Egophony b. Whispered Pectoriloquy c. Bronchophony ▪ Altered Breathing Patterns a. Cheyne – Stokes Breathing ⁻ Marked rhythmic, waxing, and waning respirations from very deep or very shallow breathing and temporary apnea. b. Kussmaul’s breathing ⁻ (hyperventilation) increased rate and depth c. Hypoventilation ⁻ Slow, shallow respirations d. Biot’s breathing ⁻ Shallow breaths interrupted by apnea; “irregular irregularity.” e. Apneustic breathing SLIDESMANIA.CO ⁻ Prolonged, gasping inspiration followed by a very short, inefficient expiration.  Normal Findings 1. General appearance ✓ Appear relaxed; breathing is quiet and easy without apparent effort; facial expressions and limb movements are relaxed. 2. Breathing pattern ✓ Smoothing and regular; may have occasional sighing respirations; breathing is quiet and passive with symmetric chest expansion; abdomen bulges slightly with inhalation. 3. Respiratory rate ✓ 12 to 20 respirations per minute SLIDESMANIA.CO (adults).  3. Skin ✓ Oral mucous membranes are pink; no cyanosis or pallor present. ✓ Palpitations of skin and chest wall reveal smooth skin and a stable chest wall; no crepitation, masses, or painful areas. 4. Nails ✓ Angulation between the base of nail and finger; no thickening of distal finger width, no clubbing. 5. Chest wall configuration ✓ Symmetric, bilateral muscle development; straight spinal processes; downward and equal slope of ribs. 6. Tracheal position ✓ Midline and straight; directly above the SLIDESMANIA.CO suprasternal notch.  8. Vocal/ Tactile Fremitus ✓ The sensation of sound vibrations produced when the patient speaks ✓ The examiner may feel for these vibrations by placing the extended hand gently on the chest wall. The spoken voice produces low–frequency vibrations through the vocal cords, the airways, and the pleura. These vibrations are felt and compared bilaterally. ✓ The examiner instructs the patient to say “one-two-three’ or “how-now- brown-cow.” as these words are spoken, the examiner feels for the vibrations. 9. Abnormal Responses ✓ Increased fremitus ▪ An increase in vibratory sensation is felt when there is consolidation of the lung caused by fluid-filled or solid structures, which would transmit the vibrations better than air-filled lungs. ✓ Decreased fremitus SLIDESMANIA.CO ▪ A decrease in the vibratory sensation is felt when more air than normal is blocked or trapped in the lungs or pleural space; vibrations of the spoken voice are decreased.  ✓ Percussion Tones 1. Resonant – heard over normal lung tissue. 2. Flat – heard over airless tissue. 3. Dull – occurs over dense lung tissues such as a tumor or consolidation. 4. Tympanic – indicates a large tension pneumothorax. 5. Hyperresonant – produced by emphysema and pneumothorax ▪ Hyperresonance is abnormal sound heard during percussion in adults. It represents air trapping such as in obstructive lung disease. ▪ Resonance – over lungs ▪ Flat – over heavy muscles and bones ▪ Dullness – heart, liver ▪ Tympany – stomach 6. Breath and Voices Sounds: Normal and Abnormal ▪ Vesicular – heard over most of lung fields – soft and short expirations. ▪ Bronchovesicular – heard over main bronchus area and over SLIDESMANIA.CO upper right posterior lung field – expiration equals inspirations. ▪ Bronchial – heard only over trachea – loud and long expiration.  ▪ Abnormal ⁻ Bronchial when heard over peripheral lung fields. ⁻ Bronchovesicular when heard over peripheral lung fields. ▪ Voice sounds: 1. Bronchophony: Using the diaphragm of the stethoscope, listen to the posterior chest as the patient says “ninety-nine”/”1,2,3” ⁻ Negative response: Muffled “nin-nin” sound heard ⁻ Positive response: Clear, loud “ninety-nine” response heard because lung tissues are consolidated. 2. Whispered pectoriloquy: Listen to posterior chest as patient whispers “one-two-three” ⁻ Negative response: Muffled sound heard. ⁻ Positive response: Clear “one-two-three” is heard because of lung consolidation. 3. Egophony: Listen to posterior chest as the patient says “e-e-e”. ⁻ Negative response: Muffled “e-e-e” sound heard. SLIDESMANIA.CO ⁻ Positive response: Sound of “e” changes to “a-a-a” sound of consolidation.  DIAGNOSTIC STUDIES AND THERAPIES FOR THE Skin Test: Mantoux Test RESPIRATORY SYSTEM ✓ PPD (Purified Protein Derivative) is used. ✓ Route of administration: Intradermal ✓ Read 48 to 72 hours after injection. ✓ (+) Mantoux Test is induration of 10mm or more. ✓ For HIV-positive clients, induration of 5 mm is considered positive. ✓ (+) Mantoux test signifies exposure to Mycobacterium tubercle bacilli. Mantoux test will be positive for clients who have received BCG. (Instead, QFT – QuantiFERRON – TB) may be used in TB screening) Chest X-Ray ✓ Practice the client on how to hold his breath and to do deep breathing. SLIDESMANIA.CO ✓ Instruct the client to remove metal from the chest. Metal are radiopaque and may be mistaken as lesions.  Fluoroscopy Studies the lung and chest in motion. Bronchography/ Bronchogram ✓ A radiopaque medium is instilled directly into the trachea and bronchi and the entire bronchial tree or selected areas may be visualized through X-ray. ✓ Nursing Interventions Before Bronchogram Secure written consent. ▪ Check for allergies to sea foods or iodine or anesthesia. ▪ NPO for 6 to 8 hours. To prevent aspirations during and after the procedure. ▪ Pre-op meds: Atropine SO4 (to keep airways clear from saliva and mucus secretions); valium (to ease anxiety and relax the client); topical anesthesia sprayed into the throat, followed by local anesthetic injected into SLIDESMANIA.CO larynx (to depress the gag reflex and facilitate insertion of the bronchoscope). ▪ Have oxygen and antispasmodic agents ready.  ✓ Nursing Interventions After Bronchogram ▪ Side – lying position. To prevent aspirations ▪ NPO until cough and gag reflex returns. ▪ Cough and deep breathe client. ▪ Low grade fever is common. Bronchoscopy ✓ The direct inspection and observation of the larynx, trachea and bronchi through a bronchoscope. ✓ Diagnostic uses: ▪ To collect secretions. ▪ To determine locations of pathologic process and collect specimens for biopsy. ✓ Therapeutic uses: SLIDESMANIA.CO ▪ To remove aspirated foreign objects. ▪ To excise small lesions.  ✓ Nursing Interventions Before Bronchoscopy ▪ Informed consent/permit needed. It is an invasive procedure. ▪ Atropine and Valium pre-procedure as prescribed; topical anesthesia sprayed into the throat followed by local anesthesia injected into larynx. ▪ NPO for 6 and 8 hours. To prevent aspirations. ▪ Remove dentures, prostheses, contact lenses. To prevent airway obstruction (dentures) and to avoid losses of valuable. ✓ Nursing Interventions After Bronchoscopy ▪ Side-lying position. To promote drainage of secretion from the mouth. ▪ Check for the return of cough and gag reflex before giving fluid per orem. To prevent aspiration. ▪ Watch for cyanosis, hypotension, tachycardia, arrhythmias, SLIDESMANIA.CO hemoptysis, dyspnea. These signs and symptoms indicate perforation of bronchial tree.  Lung Scan ✓ Following injections of a radioisotope/radionuclide (e.g., Gallium), scans are taken with a scintillation camera. Measures blood perfusions through the lungs. Confirms pulmonary embolism or other blood-flow abnormalities. Sputum examination ✓ To assess for gross appearance of the sputum. Changes in the gross appearance of the sputum characterize specific disease conditions, e.g., rusty sputum is present in pneumococcal pneumonia; greenish sputum is present in pseudomonas infection, blood-tinged sputum is present in pulmonary tuberculosis (PTB) ✓ Sputum C & S (culture and sensitivity test). This is done to detect the actual microorganisms causing respiratory infection. ✓ AFB staining (Acid-Fast-Bacillus Staining). To detect PTB. ✓ Cytologic examination/Papanicolaou examination. To assess for SLIDESMANIA.CO presence of cancer cells. ✓ Proper collection of sputum specimen:  ▪ Early morning sputum specimen is to be collected. Sputum usually accumulate in the lungs during sleep and it can easily be coughed up in the morning. ▪ Advise the client to rinse mouth with plain water. Do not use mouthwash because its alcohol content may destroy the microorganisms present in the sputum. ▪ Use sterile container. To ensure that the specimen is not contaminated. ▪ Sputum specimen for C and S is collected before the first dose of antimicrobial. To detect accurately the actual microorganisms present in the specimen. ▪ For AFB staining, collect sputum specimen for three consecutive mornings. Biopsy of Lung ✓ Transbronchoscopic biopsy – done during bronchoscopy. ✓ Percutaneous needle biopsy – done with the use of aspiration SLIDESMANIA.CO needle. ✓ Open lung biopsy – done during surgery.  Lymph node biopsy ✓ Scalene or cervicomediastinal ▪ To assess metastasis of lung cancer. Pulmonary function studies ✓ Vital capacity ▪ The maximum volume of air that can be exhaled after a maximum inhalation. ▪ Reduced in COPD ✓ Tidal volume ▪ The volume of air inhaled and exhaled with normal quiet breathing. ✓ Inspiratory reserve volume ▪ The maximum volume that can be inhaled following a normal quiet inhalation. ✓ Expiratory reserve volume SLIDESMANIA.CO ▪ The maximum volume that can be exhaled following a normal quiet exhalation.  ✓ Functional Residual Capacity ▪ The volume of air that remains in the lungs after normal, quiet exhalation. ✓ Residual Volume ▪ The volume of air that remains in the lungs after forceful exhalation. Arterial Blood Gas Studies ✓ Purpose ▪ To assess ventilation and acid-base balance. ✓ Radial artery is the common site for the withdrawal of blood specimens. Allen’s test is done to assess for adequacy of collateral circulation of the hand. It is a test of the ulnar artery. ▪ Allen’s Test 1. Inform patient and explain purpose of the procedure. 2. Apply pressure on the radial and ulnar arteries. 3. Ask patient to close and open hands until the hand become blanched. SLIDESMANIA.CO 4. Release ulnar artery.  5. Assess return of pinkish color on the hands (normal is within 6 seconds) 6. Do documentation. ⁻ If the return of pinkish color on the hand is longer than 6 seconds, there is poor collateral circulation of the hand. Therefore, the radial artery should not be used for blood draw for ABG monitoring. ✓ Use 10 ml. pre-heparinized syringe to draw blood specimen. This is to prevent clotting of the specimen. ✓ Place the specimen in a container with ice. This is to prevent hemolysis. If hemolysis occurs, oxygen and carbon dioxide are released and cannot be measured accurately. ✓ Result is recorded as SAO₂ for oxygen saturation. Pulse Oximetry. ✓ To determine oxygen saturation in the blood. Normal level is 95 to 100% ✓ The pulse oximeter sensor is placed in the index finger, ear lobe or over the nose. ✓ The sensor should be covered with opaque materials. The reading can be affected by sunlight SLIDESMANIA.CO or bright lights. ✓ Remove nail polish. It can affect accuracy of pulse oximeter reading.  Thoracentesis ✓ Aspiration of fluid (pleural effusion) or air (pneumothorax) from the pleural space. ✓ Nursing Interventions Before Thoracentesis ▪ Secure written consent. The procedure is invasive. ▪ Take initial VS. Aspiration of air or fluid from the pleural space may cause hypovolemic shock. ▪ Position: upright, leaning on overbed table (orthopneic position); feet supported on foot stool for comfort. ▪ Instruct client to remain still, avoid coughing during insertion needle. This is to prevent trauma to the lung. ▪ Pressure sensation is felt on insertion of SLIDESMANIA.CO needle. Topical anesthetic is used at the site of needle insertion to numb the area.  ✓ Nursing Interventions After Thoracentesis ▪ Turn the client on the unaffected side to prevent leakage of fluid into the thoracic cavity. ▪ Bed rest until VS are stable. To prevent postural hypotension. ▪ Check for expectoration of blood. This indicates trauma to the lung. Notify the physician. ▪ Monitor VS. To assess for signs and symptoms of internal hemorrhage. Internal hemorrhage is manifested by tachycardia, tachypnea, hypotension, SLIDESMANIA.CO hypothermia (low body temperature).  Common Respiratory Interventions Oxygen Therapy Tracheobronchial Suctioning Suctioning A Tracheostomy Test Bronchial Hygiene Measures Suctioning: oropharyngeal; nasopharyngeal. Steam inhalation. Aerosol inhalation. Medimist inhalation Chest Physiotherapy (CPT) Incentive Spirometry Closed Chest Drainage (Thoracostomy Tube) SLIDESMANIA.CO  Closed Chest Drainage (Thoracostomy Tube) ✓ Purposes ▪ To remove air and/or fluids from the pleural space. ▪ To reestablish negative pressure and re-expand the lungs. Principles Involved in the Mechanism of Closed Chest 1. Drainage by gravity. The bottle/bottles should at least 2 to 3 feet below the level of the chest. Never place the bottle/bottles at the level or above the level of the chest. 2. Displacement Principle. An air vent will expel the air from the bottle as drainage occupies the space in the bottle. The air vent should always be kept open. 3. Suction or negative pressure. It aids in removing the air in the pleural space. ] ▪ Pneumothorax. Is the presence of air in the pleural space. ▪ Pleural effusion. Is the presence of fluid in the pleural space. There are three types of pleural effusion which are as follows: 1. Hydrothorax. Is the presence of water in the pleural space. SLIDESMANIA.CO 2. Hemothorax. Is the presence of blood in the pleural space. 3. Pyothorax (Empyema). Is the presence of pus in the pleural space.  ✓ Types of Closed Chest Damage ▪ One-bottle system ⁻ The bottle serves as drainage/collection bottle and a water-seal bottle. ⁻ Immerse tip of the tube in 2-3 cm. of the sterile NSS to create a water- seal. ⁻ Keep bottle at least 2 to 3 feet below the level of the chest to allow drainage from the pleura by gravity. ⁻ Never raise the bottle above the level of the chest to prevent reflux of air and fluid. ⁻ Assess for patency of the device. o Observe for fluctuation of fluid along the tube. o Observe for intermittent bubbling of fluid; continuous bubbling means presence of air-leak. o As the patient inhales, the fluid along the tube goes up; as he exhales, the fluid goes down and bubbles appear. ⁻ In the absence of fluctuation: o Suspect obstruction of the device – check for kinks along tubing. Avoid milking of tubing to prevent tension pneumothorax. SLIDESMANIA.CO o If there is no obstruction ], consider lung reexpansion; which will be validated by chest x-ray. ⁻ Air vent should be open to air.  ▪ Two-bottle system ⁻ Not connected to the suction apparatus o The first bottle is drainage bottle; the second bottle is water-seal bottle. o Expect continuous bubbling in the suction control bottle ; intermittent bubbling with each respiration. ⁻ Connected to suction apparatus o The first bottle is drainage and water – seal bottle; the sis second bottle is suction control bottle. o Expect continuous bubbling in the suction control bottle; intermittent bubbling and fluctuation in the water-seal. o Immerse tip of the tube in the first bottle in 2 to 3 cm. of sterile NSS; immerse the tube of the suction control bottle in 10 to 20 cm. of sterile NSS to stabilize the normal negative pressure in the lungs. SLIDESMANIA.CO This protects the pleura from trauma if the suction pressure is inadvertently increased.  ▪ Three bottle-system ⁻ The first bottle is drainage bottle; the second bottle is water-seal bottle, the third bottle is suction-control bottle. ⁻ Observe for intermittent bubbling and fluctuation with respiration in water-seal bottle; continuous bubbling the suction control bottle. *Notes: ✓ Encourage to do the following to promote drainage: ▪ Deep breathing and coughing exercises ▪ Turn to sides at regular basis ▪ Ambulate ✓ ROM exercise of arms ✓ Turn to sides at regular basis ✓ Mark the amount of drainage at regular intervals. ✓ Avoid milking and clamping of tube to prevent tension SLIDESMANIA.CO pneumothorax.  ✓ Removal of chest tube – done by physician (when the lungs are reexpanded and fluid drainage has ceased) ▪ Chest x-ray is done to ascertain lung expansion. ▪ Suction is discontinued and the patient is placed on gravity drainage 24 hours before the tube is removed. ▪ Prepare: ⁻ Petroleum jelly ⁻ Suture removal kit ⁻ Sterile gauze ⁻ Adhesive tape ▪ Place client in semi – Fowler’s position ▪ Instruct client to take a deep breath, exhale deeply and do Valsalva maneuver (bear down) as the chest tube is removed. ▪ Chest X-ray may be done after the tube is removed to evaluate for pneumothorax. SLIDESMANIA.CO ▪ Assess for complications: subcutaneous emphysema; respiratory distress.  ✓ If Pleur - evac is used, the first chamber is the drainage or collection chamber, the second (middle) chamber is the water – seal chamber, and the third chamber is the suction – control chamber ▪ The water – seal chamber is filled with 3 cm. of sterile NS. There should be fluctuation of fluid. This indicates patency of the apparatus. ▪ There should be no bubbling in the water – seal chamber. Bubbling indicates air leak. Check connections of tubing. ▪ The suction – control chamber is filled with 20 cm of sterile NS. To stabilize the negative pressure within the lungs. ▪ There should be continuous, gentle bubbling in the suction – control chamber. This ensures drainage of air or fluids from the pleural space. ▪ Absence of bubbling in the suction control chamber indicates that the presence of suction is not enough. There will no SLIDESMANIA.CO drainage. Increase the suction pressure until continuous gentle bubbling is obtained.  ▪ Vigorous bubbling indicates that pressure of the suction is too high. Trauma to pleurae might occur. The suction pressure should be lowered. ▪ Best Practice: ⁻ If the drainage bottle is broken, immerse the tip of the rubber connecting tubing in a bottle of sterile normal saline solution or a glass of water. ⁻ NO CLAMPING, NO MILKING of connecting tube to prevent tension pneumothorax. ⁻ If the chest tube is accidentally dislodged (pulled out), cover the puncture site with thick layers of sterile gauze or non-poruous material. The palm of the hand may be used to cover the puncture site if sterile gauze or non- porous material (plastic wrap) is unavailable. Stay with SLIDESMANIA.CO the patient. Ask a coworker to call the physician.  NONINVASIVE RESPIRATORY THERAPIES Oxygen Therapy the administration of oxygen at a concentration greater than that found in the environmental atmosphere. Indications: ✓ A change in the patient’s respiratory rate or pattern Types of Hypoxia 1. Hypoxemic Hypoxia - is a decreased oxygen level in the blood resulting in decreased oxygen diffusion into the tissues. 2. Circulatory Hypoxia - hypoxia resulting from inadequate capillary circulation. 3. Anemic Hypoxia - a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. 4. Histotoxic Hypoxia - occurs when a toxic substance, such as cyanide, interferes with the ability SLIDESMANIA.CO of tissues to use available oxygen.  Complications Oxygen Toxicity - may occur when too high concentration of oxygen (greater than 50%) is given for an extended period (generally longer than 24 hours). Signs and symptoms: substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays. SLIDESMANIA.CO  Methods of Oxygen Administration SLIDESMANIA.CO  Incentive Spirometry Incentive spirometry is a method of deep breathing that provides visual feedback to encourage the patient to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis. The purpose of an incentive spirometer is to ensure that the volume of air inhaled is increased gradually as the patient takes deeper and deeper breaths. Indications Incentive spirometry is used after surgery, especially thoracic and abdominal surgery, to promote the expansion of the alveoli and to prevent or treat atelectasis. Nursing Management ✓ placing the patient in the proper position: Semi-fowlers position SLIDESMANIA.CO  Small-Volume Nebulizer (Mini-Nebulizer) Therapy The small-volume nebulizer is a handheld apparatus that disperses a moisturizing agent or medication, such as a bronchodilator or mucolytic agent, into microscopic particles and delivers it to the lungs as the patient inhales. Indications Indications for the use of a small-volume nebulizer include difficulty in clearing respiratory secretions, reduced vital capacity with ineffective deep breathing and coughing, and unsuccessful trials of simpler and less costly methods for clearing secretions, delivering aerosol, or expanding the lungs. Nursing Management Instruct the patient to breathe through the mouth, taking slow, deep breaths, and then to hold the breath for a few seconds at the end of inspiration to increase intrapleural pressure and reopen collapsed alveoli, thereby increasing functional residual capacity. SLIDESMANIA.CO  RESPIRATORY DISORDERS Part I. Upper Respiratory Problems Structural and Traumatic Disorder of the Nose A. Deviated Septum. It is a deflection of the normally straight nasal septum. ▪ caused by trauma to the nose or congenital disproportion, a condition in which the size of the septum is not proportional to the size of the nose. ▪ On inspection, the septum is bent to one side, altering the air passage. ▪ The signs and symptoms of deviated nasal septum are as follows: 1. Obstruction to nasal breathing. 2. Nasal edema. 3. Dryness of the nasal mucosa with crusting and bleeding (epistaxis). ▪ The medical management of deviated septum includes the following: SLIDESMANIA.CO 1. Nasal allergy control as in allergic rhinitis. 2. Nasal septoplasty to reconstruct and properly align the deviated septum.  B. Nasal Fracture. This is usually caused by a substantial blow to the middle of the face. ▪ Complications of nasal fracture includes airway obstruction, epistaxis, meningeal tears, septal hematoma, and cosmetic deformity. ▪ Nasal fractures can be classified as unilateral, bilateral or complex. Diagnosis is based on the health history and physical examination. The presenting signs are epistaxis and obvious facial deformity. ▪ On inspection, the nurse should assess the patient’s ability to breathe through each side of the nose and note the presence of edema, bleeding or hematoma. ▪ There may be ecchymosis under one or both eyes. Ecchymosis involving both eyes is also called raccoon eyes. ▪ The nose is inspected internally for evidence of SLIDESMANIA.CO septal deviation, hemorrhage, or clear drainage, which indicates cerebrospinal fluid (CSF) leakage.  ▪ If clear drainage is present, glucose test is done. CSF is positive for glucose. ▪ it may be necessary to wait 5 to 10 days repair the fracture when the edema subsides. ▪ The goals of nursing management of the client with nasal fracture are as follows: 1. Maintain patent airway. 2. Reduce edema. 3. Prevent complications. 4. Provide emotional support. ▪ The appropriate nursing interventions are as follows: 1. Keep the patients in an upright position to maintain airway. 2. Apply ice pack to the face and nose to reduce edema and bleeding. ▪ Medical management of nasal fracture is closed or open reduction (septoplasty, rhinoplasty) to realign the fracture and to SLIDESMANIA.CO assure that a septal hematoma does not develop to prevent infection.  C. Epistaxis. nose bleeding. ▪ Causes ⁻ Trauma ⁻ Hypertension ⁻ Rheumatic Heart Disease ⁻ Cancer ▪ Interprofessional collaborative management for the patients with epistaxis include the following: ⁻ Sit-up, lean forward, head tipped. To prevent aspiration of blood. ⁻ Apply pressure over the soft tissues of the nose for at least 10 to 15 minutes. ⁻ Apply cold compress/ ice pack over the nose. To SLIDESMANIA.CO promote vasoconstriction.  ⁻ The physician may insert nasal pack with neosynephrine (the pack may remain in place for 3 to 5 days), promotes vasoconstriction. ⁻ External nasal pack is removed after 5 days. Blood-soaked packings that remain in place for a long time support proliferation of staphylococcus aureus. ⁻ This may result to toxic shock syndrome (TSS). o Liquid diet, then soft diet. To facilitate swallowing. o Avoid oral – temperature taking. o Do not blow nose for 2 days after removal of the nasal pack. To prevent rebleeding. ⁻ Notify physician if epistaxis is recurrent. This SLIDESMANIA.CO may indicate presence of serious like cancer, RHD, or hypertension.  D. Sinusitis (Acute/Chronic ). Is inflammation of the sinuses. ▪ Causes URTI (upper respiratory tract infection) Cigarette smoking Allergic rhinitis Inflammation Edema of the mucous membrane Hypersecretion of mucus (Rich medium for growth of bacteria, viruses, fungi) Infection SLIDESMANIA.CO  ⁻ Bacteria sinusitis is commonly caused by streptococcus pneumoniae, Hemophilus influenza or Moraxella catarrhalis. ⁻ Viral sinusitis follows an upper respiratory infection in which the virus penetrates the mucous membrane and decreases capillary transport. ⁻ Fungal sinusitis is usually found in patient’s who are debilitated pr immunocompromised. ⁻ Acute sinusitis usually results from an upper respiratory infection, allergic rhinitis, swimming, or dental manipulation which can cause inflammatory changes and retention of secretions. ⁻ Chronic sinusitis (lasting than 3 weeks) is a persistent infection usually associated with allergies and nasal polyps. It usually results from repeated episodes of acute sinusitis that results in irreversible loss of the normal ciliated epithelium lining in the sinus. ⁻ The assessment findings in sinusitis are as follows: ⁻ Pain o Maxillary: check, upper teeth SLIDESMANIA.CO o Frontal: above eyebrows o Ethmoid: in and around the eyes  o Sphenoid: behind eye, occiput, top of the head ⁻ General malaise ⁻ Stuffy nose ⁻ Headache ⁻ Post-nasal drip ⁻ Persistent cough ⁻ Fever ⁻ Halitosis ⁻ X-ray or computed tomography (CT scan) of the sinuses show the sinuses to be filled with fluid or the mucous membrane to be thickened. ⁻ Nasal endoscopy may be used to examine the SLIDESMANIA.CO sinuses, obtain drainage for culture.  Interprofessional Collaborative management for patients with sinusitis are as follows: ⁻ Promote rest. ⁻ Increase fluid intake. To liquefy mucus secretions. ⁻ Apply hot wet packs over the area to liquefy mucus secretions and relieve pain. ⁻ Administer Codeine as prescribed. Avoid ASA. ASA increases the risk of developing nasal polyps among clients with sinusitis ⁻ Codeine (Vicodin) may cause drowsiness and constipation. Advise client to avoid driving and operating electrical machines to prevent accidents. Increase fluid intake to prevent constipation. ⁻ Administer Amoxicillin or other anti-infectives as ordered: (acute infection – 7 to 10 days; chronic infection- 21 days). ⁻ Nasal decongestants e.g. Sudafed, Dimetapp (used for 72 SLIDESMANIA.CO hours). ⁻ Irrigation of maxillary sinuses with warm NSS. To liquefy and drain mucus secretions.  ▪ Surgery for sinusitis: ⁻ Functional Endoscopic Sinus Surgery (FESS). ⁻ Caldwell – Luc Surgery (Radical Antrum Surgery). The incision is between the upper gum and upper lip. This is done in maxillary sinusitis. To prevent trauma on incision: o Do not chew on affected side. o Caution with oral hygiene. o Do not wear dentures for 10 days. o Advise patient not to blow nose for 2 weeks after removal of packing. To prevent bleeding. o Avoid sneezing for 2 weeks after surgery. Open mouth if sneezing is likely to occur. ⁻ Ethmoidectomy SLIDESMANIA.CO ⁻ Sphenoidotomy/Ethmoidotomy ⁻ Osteoplastic flap surgery for frontal sinusitis.  Obstruction of the Nose and Paranasal Sinuses A. Nasal Polyps. These are benign mucous membrane masses that form slowly in response to repeated inflammation of the sinus or nasal mucosa. Polyps which appear as bluish glossy projections in the nares, can exceed the size of a grape. ⁻ The clinical manifestations of nasal polyps are as follows: Nasal obstruction Nasal discharge (usually clear mucus) Speech distortion ⁻ Nasal polyps can be removed with endoscopic or laser surgery, but recurrence is common. Topical or systemic SLIDESMANIA.CO corticosteroid may slow polyp growth.  B. Foreign Bodies. A variety of foreign bodies may lodge in the upper respiratory tract, such as buttons, beads, wood, cotton, beans, peas and paper. ⁻ Local inflammatory reaction and nasal discharge which may become pulurent and foul in odor may be produced. ⁻ Foreign bodies should be removed from the nose. ⁻ Sneezing with the oppposite nostril closed may assist in the removal of foreign bodies. ⁻ If sneezing or blowing the nose or pushing the object, the patient should consult a physician. ⁻ Irrigation of the nose or pushing the object backward should not be done, because either could cause aspirations and airway obstruction. Problems Related to the Pharynx A. Acute Pharyngitis. Is an acute inflammation of the pharyngeal SLIDESMANIA.CO walls. It may include the tonsils, palate, and uvula. ✓ It can be caused a viral, bacterial or fungal infection.  ✓ Viral pharyngitis accounts for 70% of cases. Acute follicular pharyngitis (“strep throat”) accounts for 5% to 15% of episodes in adults. ✓ Fungal pharyngitis, especially candidiasis, can develop with prolonged use of antibiotics or inhaled corticorteriods or among immunosuppresed patients, especially those with human immunoddeficiency virus (HIV). ✓ The clinical manifestations of acute pharyngitis are as follows: ▪ “scartchy throat” ▪ Pain ▪ Swallowing difficutly ▪ Red, edematous pharynx with or without patchy yellow exudates. ▪ White, irregular patches suggest fungal infection with candida albicans. ▪ Cultures or a rapid strep antigens test is done to establish the cause. ✓ Inadequate treatment of acute streptoccal pharyngitis can result in rheumatic heart disease or glomerulonephritis as a sequela to the infection. SLIDESMANIA.CO ✓ Interprofessional collaborative management for patients with acute pharyngitis include the following:  ▪ The goals of nursing management are infection control, symptomatic relief, and prevention of secondary complications. ▪ Antibiotics for “strep throat” ▪ Nystatin (mycostin) for candida infections- swish and swallow ▪ Increase fluid intake ▪ Cool, bland liquids and gelatin (citrus juices can be irritating). B. Peritonsillar Abscess. Is a complication of acute pharyngitis or acute tonsillitis when bacterial infection invades one or both tonsils. ✓ The tonsils may enlarge sufficiently to threaten airway patency. ✓ The clinical manifestation are as follows: ▪ High fever ▪ Leukocytosis SLIDESMANIA.CO ▪ “hot potato voice” ▪ Chills  ✓ Intravenous (IV) antibiotics therapy is given, with needle aspirations or incision and drainage od the abscess. ✓ An emergency tonsillectomy, or an elective tonsillectomy may be done after the infection has subsided. C. Tonsillitis/Adenoiditis ✓ Assessment ▪ Frequent head colds ▪ Soar Throat ▪ Bronchitis ▪ Fever ▪ Foul breath ▪ Snoring ▪ Voice impairment (“hot potato ▪ Dysphagia voice”) ▪ Noisy Respiration ▪ Mouth Breathing ▪ Draining ears SLIDESMANIA.CO ▪ Earache  Interprofessional collaborative management for patients with tonsillitis: ▪ Promote rest. To facilitate recovery. ▪ Increase fluid intake. To excrete microorganism. ▪ Warm saline gargle. To soothe the throat. ▪ Analgesic as ordered. ▪ Surgery: Tonsillectomy and Adenoidectomy (T & A) is indicated if tonsillitis recurs 5 to 6 times a year. Recurrent tonsillitis caused by Group A beta-hemolytic streptococcus (GABHS) may trigger autoimmune disorder like glomerulonephritis and rheumatic heart disease. ▪ Preop Care ⁻ Place the patient in lateral position or prone with a pillow under the chest and head turned to side. To promote drainage from the mouth and prevent aspirations. Once the client is awake, place him in semi Fowler’s. To promote respiratory function. ⁻ Keep oral airway in place until swallowing reflex returns. ⁻ Monitor for hemorrhage. Observe the following signs and symptoms: SLIDESMANIA.CO o Frequent swallowing o Bright red vomitus o Increased PR (tachycardia)  ⁻ Promote Comfort o Place ice collar over the neck. o Administer Acetaminophen to relieve pain. o Avoid administration of ASA. It causes bleeding. ⁻ Food and Fluids o Provide ice – cold fluids, e.g. popsicle. To prevent bleeding. Milk is contraindicated after tonsillectomy, including ice cream. This triggers clearing of the throat and coughing. o Provide bland foods. To prevent irritation od the throat. o Avoid red or dark – colored beverages, e.g., cola, chocolate milk, grape juice. These may conceal signs of bleeding. o Avoid citrus fruit juices. These are irritating to the throat. ▪ Critical to Remember: After tonsillectomy, avoid the following: ⁻ Red or dark-colored beverages. ⁻ Irritating food and beverages. ⁻ Hard and scratchy foods. SLIDESMANIA.CO ⁻ Milk and milk products (e.g. ice cream ⁻ Use of drinking straw.  ✓ Client Education After T & A ▪ Avoid clearing of throat. To prevent bleeding. ▪ Avoid coughing, sneezing, blowing of nose for 1 to 2 weeks. To prevent bleeding. ▪ Provide 2 to 3 L of fluids/day until mouth odor disappears. ▪ Avoid hard/scratchy foods until throat is healed, e.g., popcorn, pretzels, chips. ▪ Report signs and symptoms of bleeding. ▪ Throat discomfort between 4th and 8th postop day is expected. This is due to sloughing off to mucous membrane at the operative site. ▪ Stools: black/dark for few days due to swallowed blood. Reassure client that this is expected. ▪ Plenty of rest for 2 weeks. To regain energy and enhance resistance to infection. ▪ Avoid colds, overcrowded or public places. Coughing and SLIDESMANIA.CO sneezing due to upper respiratory tract infections may cause bleeding.  D. Cancer of the Larynx ✓ Predisposing factors are as follows: ▪ Cigarette Smoking ▪ Alcohol abuse ▪ Voice abuse (Straining the voice) ▪ Environmental pollutants (mustard dust, wood dust, cement dust). ▪ Chronic laryngitis ▪ (+) Family history ▪ Exposure to asbestos. ▪ Tar products, leather, metals ▪ Nutritional deficiencies ✓ The assessment findings in cancer of the larynx are as follows: ▪ Persistent hoarseness of voice. This is the usual initial manifestations. ▪ Mass on anterior neck. ▪ Dyspnea. ▪ Dysphagia. ▪ Chronic laryngitis SLIDESMANIA.CO  ▪ Burning sensation with hot/acidic beverages like citrus juices. ▪ Halitosis ▪ Cervical lymphadenopathy. ▪ Pain radiating to the ear (due to metastasis). ▪ Hemoptysis. ▪ Severe anorexia. ▪ Severe anemia. ▪ Severe weight loss ✓ Interprofessional Collaborative management for the patients with cancer of the larynx including the following: ▪ Surgery: Subtotal/ Total Laryngectomy ▪ Subtotal thyroidectomy – the client retains his voice. ▪ Total thyroidectomy – the client experience absolute loss of voice. SLIDESMANIA.CO ▪ Preop Care: ⁻ Provide psychosocial support  o Effects of Total Laryngectomy Loss of voice Permanent tracheostomy Loss of sense of smell Inability to: Blow Blow of nose Sip soup Sip through straw Whistle Gargle Do Vasalva maneuver: ⁻ Unable lift heavy objects ⁻ Constipation ⁻ Establish means of communication to used SLIDESMANIA.CO postop. The humanness of an individual depends on his ability to communicate.  ▪ Postop Care o Care of the Patient with Tracheostomy o Establish patent airway. Suction as necessary. Use sterile technique. Semi – Fowler’s position Use sterile NSS to lubricate suction catheter tip. Apply suction during withdrawal of suction catheter. Apply suction for 5 – 10 seconds (maximum 15 secs). Insert 3 to 5” of the suction catheter. Instill 2 to 5 mls. Of sterile NSS to liquefy mucous secretions. o Prevent infection. Cleanse stoma and tracheostomy at regular basis. Change dressings and ties as necessary. o Establish means of communication. Use picture board initially. o Provide psychosocial support. SLIDESMANIA.CO o Assist during speech therapy.  ✓ Patient teachings after total laryngectomy: ▪ Cover tracheostomy with porous material. To prevent entry of foreign bodies. ▪ Avoid swimming. To prevent entry of water into the tracheostomy. ▪ Avoid use of powder, spray, or aerosol near tracheostomy. To prevent chemical irritation of the airway. ▪ Prevent follow-up care. ▪ Adverse reaction to radiation therapy for cancer of the larynx: Xerostomia (dry mouth). The patient’s saliva decreases in volume and becomes thick. o Intervention of Xerostomia: 1. Pilocarpine HCI (Salagen) to increase saliva production. 2. Increase fluid intake. 3. Chewing sugarless gum and sugarless candy. 4. Nonalcoholic mouth rinses (baking soda or glycerin SLIDESMANIA.CO solutions) 5. Artificial saliva SLIDESMANIA.CO