Medical Surgical Nursing Lecture Prelim PDF

Management of Patients with Upper Respiratory Tract Disorders Rhinitis - A group of disorders characterized by inflammation and irritation of the mucous membranes of the nose. - It may be acute or chronic, and allergic or nonallergic. - Allergic rhinitis is further cla...

Management of Patients with Upper Respiratory Tract Disorders Rhinitis - A group of disorders characterized by inflammation and irritation of the mucous membranes of the nose. - It may be acute or chronic, and allergic or nonallergic. - Allergic rhinitis is further classified as seasonal or perennial rhinitis and is commonly associated with exposure to airborne particles such as dust, dander, or plant pollens in people who are allergic to these substances. - Seasonal rhinitis occurs during pollen seasons, and perennial rhinitis occurs throughout the year. - Allergic rhinitis may occur with exposure to allergens such as foods, medications, and particles in the indoor and outdoor environment. The most common cause of nonallergic rhinitis is the common cold. Signs and Symptoms - Rhinorrhea (excessive nasal drainage, runny nose) - Nasal congestion - Nasal discharge (purulent with bacterial rhinitis) - Sneezing - Pruritus of the nose, roof of the mouth, throat, eyes, and ears Medical Management - It depends on the cause, which may be identified through the history and physical examination - If viral rhinitis: medications may be prescribed to relieve the symptoms - In allergic rhinitis: allergy tests may be performed to identify possible allergens - If symptoms suggest a bacterial infection, an antimicrobial agent is used. Pharmacologic Therapy - Medication therapy for allergic and nonallergic rhinitis focuses on symptom relief. - Antihistamines and nasal sprays may be useful - Oral decongestant agents may be used for nasal obstruction - The use of saline nasal spray can act as a mild decongestant and can liquefy mucus to prevent crusting - The choice of medications depends on the symptoms, adverse reactions, adherence factors, risk of drug interactions, and cost to the patient Nursing Management - 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 - To prevent possible drug interactions, the patient is cautioned to read drug labels before taking any OTC medication - The nurse instructs the patient about the importance of controlling the environment at home and at work - The nurse instructs the patient in correct administration of nasal medications o The patient is instructed to blow the nose before applying any medication into the nasal cavity. In addition, the patient is taught to keep the head upright; spray quickly and firmly into each nostril away from the nasal septum; and wait at least 1 minute before administering the second spray. o The container should be cleaned after each use and should never be shared with other people to avoid cross-contamination - In the case of infectious rhinitis, the nurse reviews hand hygiene technique with the patient as a measure to prevent transmission of organisms - In older adults and other high-risk populations, the nurse reviews the importance of receiving an influenza vaccination each year to achieve immunity before the beginning of the flu season Viral Rhinitis (Common Cold) - Medical term is coryza - The most frequent viral infection in the general population - The term common cold often is used when referring to a URI that is self-limited and caused by a virus - Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase - Rhinoviruses and influenza virus are the most likely causative organisms Signs and Symptoms - Low-grade fever - Nasal congestion - Rhinorrhea and nasal discharge - Halitosis - Sneezing  - Tearing watery eyes - “Scratchy” or sore throat - General malaise - Chills - Headache and Muscle aches Medical Management - Management consists of symptomatic therapy that includes adequate fluid intake, rest, prevention of chilling, and the use of expectorants as needed - Warm salt-water gargles soothe the sore throat - Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, relieves aches and pains - Antihistamines are used to relieve sneezing, rhinorrhea, and nasal congestion - Petroleum jelly can soothe irritated, chapped, and raw skin around the nares - Antimicrobial agents (antibiotics) should not be used, because they do not affect the virus or reduce the incidence of bacterial complications - Topical therapy delivers medication directly to the nasal mucosa, and its overuse can produce rhinitis medicamentosa, or rebound rhinitis Nursing Management - Implementation of appropriate hand hygiene measures remains the most effective measure to prevent transmission of organisms - The use of tissues to avoid the spread of the virus with coughing and sneezing, and to cough or sneeze into the upper arm if tissues are not readily available - The nurse instructs the patient about methods to treat symptoms of the common cold and provides both verbal and written information to assist in the prevention and management of URIs Rhinosinusitis - Formerly called sinusitis, is an inflammation of the paranasal sinuses and nasal cavity Acute Rhinosinusitis - Classified as acute bacterial rhinosinusitis (ABRS) or acute viral rhinosinusitis (AVRS) - Acute rhinosinusitis usually follows a viral URI or cold, such as an unresolved viral or bacterial infection, or an exacerbation of allergic rhinitis - Nasal congestion, caused by inflammation, edema, and transudation of fluid secondary to URI, leads to obstruction of the sinus cavities - Typical pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and less commonly Staphylococcus aureus, and Moraxella catarrhalis Signs and Symptoms Symptoms of ABRS - Purulent nasal drainage (anterior and posterior, or both) accompanied by nasal obstruction or a combination of facial pain, pressure, or a sense of fullness (referred to collectively as facial pain-pressure-fullness) - The patient may also report cloudy or colored nasal discharge congestion, blockage, or stuffiness as well as a localized or diffuse headache - Patients with ABRS may present with a high fever (39C [102F] or higher) - The occurrence of symptoms for 10 days or more after the initial onset of upper respiratory symptoms Symptoms of AVRS - The patient does not present with a high fever, not with the same intensity of symptoms, nor with symptoms that persist for as long a period of time - Symptoms of AVRS occur for fewer than 10 days after the onset of upper respiratory symptoms and do not worsen Assessment and Diagnostic Findings - There may be tenderness to palpation over the infected sinus area. The sinuses are percussed using the index finger, tapping lightly to determine whether the patient experiences pain - Diagnostic imaging (x-ray, computed tomography [CT], magnetic resonance imaging [MRI]) is not recommended and generally not needed for the diagnosis of acute rhinosinusitis if the patient meets clinical diagnostic criteria Complications - Local complications include osteomyelitis (inflammation or swelling that occurs in the bone) and mucocele (cyst of the paranasal sinuses)  - Intracranial complications, although rare, include cavernous sinus thrombosis, meningitis, brain abscess, ischemic brain infarction, and severe orbital cellulitis Medical Management - The goals of treatment for acute rhinosinusitis are to shrink the nasal mucosa, relieve pain, and treat infection - Intranasal saline lavage is an effective adjunct therapy to antibiotics in that it may relieve symptoms, reduce inflammation, and help clear the passages of stagnant mucus - Treatment depends on cause; a 5–7-day course of antibiotics is prescribed for bacterial cases Nursing Management - The nurse instructs the patient about symptoms of complications that require immediate follow-up - Referral to the primary provider is indicated if periorbital edema and severe pain on palpation occur - The nurse instructs the patient about methods to promote drainage of the sinuses, including humidification of the air in the home and the use of warm compress to relieve pressure - The nurse also educates the patient about the side effects of prescribed and OTC nasal sprays - The nurse tells patients with recurrent rhinosinusitis to begin decongestants, such as pseudoephedrine, at the first sign of rhinosinusitis. This promotes drainage and decreases the risk of bacterial infection - The nurse stresses the importance of following the recommended antibiotic regimen because a consistent blood level of the medication is critical to treat the infection - The nurse explains to the patient that fever, severe headache, and nuchal rigidity (stiffness of the neck or inability to bend the neck) are signs of potential complications of meningitis (an infection and inflammation of the fluid and membranes surrounding the brain and spinal cord) Chronic Rhinosinusitis and Recurrent Acute Rhinosinusitis - Mechanical obstruction in the ostia of the frontal, maxillary, and anterior ethmoid sinuses (known collectively as the ostiomeatal complex) is the usual cause of CRS and recurrent acute rhinosinusitis. Obstruction prevents adequate drainage of the nasal passages, resulting in accumulation of secretions and an ideal medium for bacterial growth - Both aerobic and anaerobic bacteria have been implicated in CRS and recurrent rhinosinusitis Signs and Symptoms - Impaired mucociliary clearance and ventilation, cough (because the thick discharge constantly drips backward into the nasopharynx), chronic hoarseness, chronic headaches in the periorbital area, periorbital edema, and facial pain - Symptoms are generally most pronounced on awakening in the morning Assessment and Diagnostic Findings - The health assessment focuses on onset and duration of symptoms - In the physical assessment, the external nose is evaluated for any evidence of anatomic abnormality. - A crooked-appearing external nose may imply septal deviation internally - Pain on examination of the teeth, with taping with a tongue blade, suggests tooth infection Complications - Although uncommon, include severe orbital cellulitis, subperiosteal abscess, cavernous sinus thrombosis, meningitis, encephalitis, and ischemic infarction Medical Management - General measures include encouraging adequate hydration and recommending the use of OTC nasal saline sprays, antispasmodic agents such as acetaminophen or NSAIDs, and decongestants such as oxymetazoline and pseudoephedrine - Patients are instructed to sleep with the head of the bed elevated and to avoid exposure to cigarette smoke and fumes - Patients are cautioned to avoid caffeine and alcohol, which can cause dehydration Surgical Management - If the standard medical therapy fails and symptoms persist, FESS (Functional Endoscopic Sinus Surgery) may be indicated to correct structural deformities that obstruct the ostia (openings) of the sinuses. FESS is a minimally invasive surgical procedure that is associated with reduced postoperative discomfort and improvement in the patient’s quality of life Nursing Management - Patients usually perform care measures for rhinosinusitis at home; therefore, nursing management consists of good patient education - The patient is instructed to blow the nose gently and to use tissue to remove the nasal drainage - Increasing fluid intake, applying local heat (hot wet packs), and elevating the head of the bed promote drainage of the sinuses - The nurse also instructs the patient about the importance of following the prescribed medication regimen - The nurse instructs the patient about signs and symptoms that require follow-up and provides these instructions verbally and in writing Pharyngitis Acute Pharyngitis - A sudden painful inflammation of the pharynx, the back portion of the throat that includes the posterior third of the tongue, soft palate, and tonsils - Commonly referred to as a sore throat - Group A beta-hemolytic streptococcus (GABHS), which is commonly referred to as group A streptococcus (GAS) or streptococcal pharyngitis Signs and Symptoms - Fiery-red pharyngeal membrane and tonsils, lymphoid follicles that are swollen and flecked with white-purple exudate, enlarged and tender cervical lymph nodes, and no cough - Fever (higher than 38.3C [101F]) and malaise also may be present - Occasionally, patients with GAS pharyngitis exhibit vomiting, anorexia, and a scarlatina-form rash with urticaria known as scarlet fever Assessment and Diagnostic Findings - Rapid Antigen Detection Testing (RADT) - Rapid Strep Test - Strep Culture - Blood Culture Medical Management - Viral pharyngitis is treated with supportive measures because antibiotics have no effect on the causal organism. Bacterial pharyngitis is treated with a variety of antimicrobial agents Pharmacologic Therapy - If the cause of pharyngitis is bacterial, penicillin is usually the treatment of choice - Antimicrobial Agents: penicillin, erythromycin, cephalosporin, analgesic, antitussive Nursing Management - For patients who demonstrate signs of strep throat and have a history of rheumatic fever, who have scarlet fever, or who have symptoms suggesting peritonsillar abscess, nursing care focuses on prompt initiation and correct administration of prescribed antibiotic therapy - The nurse instructs the patient to stay in bed during the febrile stage of illness and to rest frequently once up and about - The nurse (or the patient or family member, if the patient is not hospitalized) should examine the skin once or twice daily for possible rash, because acute pharyngitis may precede some other communicable disease - Warm saline gargles or throat irrigations are used. The benefits of this treatment depend on the degree of heat that is applied. The nurse educates the patient about these procedures and about the recommended temperature of the solution, which should be high enough to be effective and as warm as the patient can tolerate, usually 40.6 to 43.3 degrees Celsius. - Irrigating the throat may reduce spasm in the pharyngeal muscles and relieve soreness of the throat - Mouth care may promote the patient’s comfort and prevent the development of fissures (cracking) of the lips and oral inflammation when bacterial infection is present - The nurse instructs the patient about preventive measures that include not sharing eating utensils, glasses, napkins, food, or towels; cleaning telephones after use; using a tissue to cough or sneeze; disposing of used tissues appropriately; coughing or sneezing into the upper arm if tissues are not readily available; and avoiding exposure to tobacco and secondhand smoke. - The nurse also instructs the patient with pharyngitis, especially streptococcal pharyngitis, to replace their toothbrush with a new one. Chronic Pharyngitis - Is a persistent inflammation of the pharynx - It is common in adults who work in dusty surroundings, use their voice to excess, suffer from chronic cough, or habitually use alcohol and tobacco - There are three types of chronic pharyngitis: o Hypertrophic – characterized by general thickening and congestion of the pharyngeal mucous membrane o Atrophic – probably a late stage of the first type (the membrane is thin, whitish, glistening, and at times wrinkled) o Chronic Granular – characterized by numerous swollen lymph follicles on the pharyngeal wall Signs and Symptoms - Patients 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 - This is often associated with intermittent postnasal drip that causes minor irritation and inflammation of the pharynx Medical Management - Treatment of chronic pharyngitis is based on relieving symptoms; avoiding exposure to irritants; and correcting any upper respiratory, pulmonary, gastrointestinal, or cardiac condition that might be responsible for a chronic cough - Nasal congestion may be relieved by short-term use of nasal sprays or medications Nursing Management - The nurse recommends avoidance of alcohol, tobacco, ENDS use, secondhand smoke, and exposure to cold or to environmental or occupational pollutants - The nurse encourages the patient to drink plenty of fluids. Gargling with warm saline solution may relieve throat discomfort. Lozenges keep the throat moistened Tonsillitis and Adenoiditis - 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 infection (tonsillitis) - The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis - Frequently occurring bacterial pathogens include GABHS, the most common organism. The most common viral pathogen is Epstein-Barr virus Signs and Symptoms Symptoms of Tonsillitis - Sore throat, fever, snoring, and difficulty swallowing Symptoms of Adenoiditis - Mouth breathing, earache, draining ears, frequent head colds, bronchitis, foul-smelling breath, voice impairment, and noisy respiration Assessment and Diagnostic Findings - The diagnosis of acute tonsillitis is primarily clinical, with attention given to whether the illness is viral or bacterial in nature - 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, comprehensive audiometric assessment is warranted Medical Management - Tonsillitis is treated with supportive measures that include increase fluid intake, antispasmodic agents, salt-water gargles, and rest. - Bacterial infections are treated with penicillin (first-line therapy) or cephalosporins - Viral tonsillitis is not effectively treated with antibiotic therapy - Tonsillectomy (with or without adenoidectomy) continues to be a commonly performed surgical procedure and remains the treatment of choice for patients with chronic tonsillitis - Tonsillectomy is indicated if the patient has had repeated episodes of tonsillitis despite antibiotic therapy; hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive sleep apnea (OSA);  repeated attacks of purulent otitis media; and suspected hearing loss due to serous otitis media that has occurred in association with enlarged tonsils and adenoids. Indications for adenoidectomy include chronic nasal airway obstruction, chronic rhinorrhea, obstruction of the auditory tube with related ear infections, and abnormal speech Nursing Management - Continues nursing observation is required in the immediate postoperative and recovery periods because of the risk of hemorrhage, which may also compromise the patient’s airway Peritonsillar Abscess - Also called quinsy is the most common major suppurative complication of sore throat Signs and Symptoms - Acutely ill with a severe sore throat, fever, trismus (inability to open the mouth), and drooling - Other symptoms include a raspy voice, odynophagia (a severe sensation of burning, squeezing pain while swallowing), dysphagia (difficulty swallowing), and otalgia (pain in the ear) Assessment and Diagnostic Findings - ED physician decides whether aspiration – an invasive procedure – should be carried out based on the patient’s clinical picture. Intraoral ultrasound and transcutaneous cervical ultrasound are used in the diagnosis of peritonsillar cellulitis and abscesses Medical Management - Antimicrobial agents and corticosteroid therapy are used for the treatment of peritonsillar abscess - However, if the abscess does not resolve, treatment choices include needle aspiration, incision and drainage under local or general anesthesia, and drainage of the abscess with simultaneous tonsillectomy - Patients with complications require hospitalization for IV antibiotics, imaging studies, observation, and proper airway management Nursing Management - The nurse encourages the patient to use prescribed topical anesthetic agents and assists with throat irrigations or the frequent use of mouthwashes or gargles, using saline or alkaline solutions - Gentle gargling after the procedure with a cool normal saline gargle may relieve discomfort. The patient must be upright and clearly expectorate forward - The nurse instructs the patient to gargle gently at intervals of 1 or 2 hours for 24 to 36 hours - Adequate fluids must be provided to treat dehydration and prevent its recurrence - The nurse also observes the patient for complications and instructs the patient about signs and symptoms of complications that require prompt attention by the patient’s primary provider Laryngitis - Inflammation of the larynx, can occur as a result of voice abuse, exposure to dust, chemicals, smoke and other pollutants, or as part of a URI - It can also be associated with gastroesophageal reflux (referred to as reflux laryngitis) - The most common cause is a virus, and laryngitis is often associated with allergic rhinitis or pharyngitis Signs and Symptoms - Signs of acute laryngitis include hoarseness or aphonia (loss of voice) and severe cough - Chronic laryngitis is marked by persistent hoarseness - Other signs of acute laryngitis include sudden onset made worse by cold dry wind Medical Management - Includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool steam or an aerosol. If the laryngitis is part of a more extensive respiratory infection caused by a bacterial organism or if it is severe, appropriate antibacterial therapy is instituted - For chronic laryngitis, the treatment includes resting the voice, eliminating any primary respiratory tract infection, eliminating smoking, and avoiding secondhand smoke - Corticosteroids, such as beclomethasone, may be given - Treatment of reflux laryngitis typically involves use of proton pump inhibitors such as omeprazole given once daily 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 2 to 3 L to thin secretions