OXY-MID.pdf1.pdf

○ Facilitate inhalation 1. Inspection ○ Bronchovesicular: soft-medium pitched sound RESPIRATORY SYSTEM...

○ Facilitate inhalation 1. Inspection ○ Bronchovesicular: soft-medium pitched sound RESPIRATORY SYSTEM ○ Regulate intensity of respiration Central cyanosis (lips), peripheral cyanosis (nail beds) heard anterior to the right or left of the Pneumotaxic center Labored breathing sternum Group of organs and tissues that help you breathe ○ Prevent overdistention of the lungs Respiratory rate, depth, and pattem ○ Maintain current lung inspiration and Chest deformities (barrel chest, funnel chest) and scar expiration (previous operation) ○ 16-20 cycles per minute Chest expansion Clubbing of fingers PROTECTIVE MECHANISM FOR NORMAL RESPIRATIONS 1. Cilia Microscopic, hair-like projections that protect the airway by rapid, coordinated, FUNCTIONS OF THE RESPIRATORY SYSTEM unidirectional beating Abnormal/Adventitious Breath Sounds Function: propels the sheet of mucus upward Primary Functions toward the oropharynx Crackles/crepitus 1. Provides oxygen Cilia action is impaired by hypoxia, ○ Dry or wet crackling sounds simulated by 2. Removes carbon dioxide dehydration, drying, anesthesia, and rolling a lock of hair near the ear Secondary Functions pollutants (smoke) ○ Best heard on inspiration 1. Facilitates sense of smell 2. Palpation ○ Causes: fluid accumulation/alveoli collapse 2. Produces speech Palpation of the chest includes evaluation of thoracic 3. Maintain acid-base balance expansion, percussion, and evaluation of Wheezes diaphragmatic excursion ○ Due to bronchoconstriction ○ High-pitched and musical in nature ○ Best heard on expiration Rhonchi/gurgles ○ Loud, sonorous sound that is heard at the upper lungs 2. Cough ○ Best heard on expiration Response to an irritant ○ Cause: narrowed airways PULMONARY VENTILATION (BREATHING) Not a normal part of respiration Occurs when the capabilities of the mucus 3. Percussion Stridor Ventilation - movement of air in and out of the lungs blanket and cilia are exceeded Resonance: normal ○ Loud, gurgling sound heard during inspiration Inspiration - moves air in to the lungs If cough has mucus and secretions, then it Dull/flat: suggests firm mass, atelectasis (collapse of ○ May indicate partial obstruction of the airway Expiration (exhalation) - moves air out of the lungs indicates an infection in the respiratory tract lungs) Hyper resonance: increased trapped air Pleural friction rub PROCESS OF GAS EXCHANGE 3. Reflex Bronchoconstriction (pneumothorax) ○ Harsh, crackling sound like rubbing 2 leather This protects the distal lung structures pieces together 1. Ventilation - movement of air between atmosphere Occurs in response to excessive irritants (dust, ○ Heard during inspiration and expiration and alveoli cold environment, temperatures) ○ Caused by loss or decreases pleural fluid 2. Diffusion - movement of air from an area of high concentration to lesser concentration LUNG ASSESSMENT Bronchial breath sounds are associated with egophony, 3. Perfusion - linking of blood system to the alveoli bronchophony, and whispered pectoriloquy 4. Transport - oxygen delivery to the tissues 1. Inspection Assess the respiratory rate, rhythm, depth Egophony REGULATION OF BREATHING Assess skin color, appearance of chest, if ○ Describes voice sounds that are distorted client is using accessory muscles (trapezius ○ How to illicit? During auscultation, the patient Respiratory Control Center muscle, diaphragm) 4. Auscultation is asked to say or repeat the letter “E” a. Medulla Normal lung sounds: ○ Positive: the sound heard is A rather than E Generates the basic rhythm 2. Palpation ○ Bronchial high pitch tubular sounds, normal ○ Indication: lung consolidation (when the air in Inspiratory and expiratory center To determine the movement of the chest over large airways the small airways of the lungs is replaced with b. Pons e.g. if there is tactile fremitus ○ Vesicular: low pitched sounds heard over a fluid, solid, or other material such as pus, Apneustic center most of the lung field and bases blood, water, stomach contents, or cells)  c. Biot’s respiration therapy Bluish coloring of the sin and the very late indicator of Bronchophony Also called ataxic breathing; ○ No smoking (systematic desensitization) hypoxia ○ Describes vocal resonance that is more associated with complete ○ Oral hygiene, wise selection of foods Determined by the amount of unoxygenated intense and clearer than normal irregularity hemoglobin in the blood ○ How to illicit? During auscultation, ask the Associated with respiratory Dyspnea ○ Check: patient to say "99" depression resulting from Due to decreased lung compliance or increased Skin color ○ Normal: word is not clearly heard or faint drug overdose and brain airway resistance Central cyanosis (tongue, lips) sounds are heard injury, normally at the level of ○ Check: Peripheral cyanosis (nail bed, ○ Positive: the "99" appears louder and more the medulla Onset earlobes) distinct over certain areas Time ○ Indication: lung consolidation Ease to effort Position PHYSICAL ASSESSMENT a. Dyspnea Interventions: Whispered pectoriloquy Difficult or labored breathing ○ Identify and correct the cause Nose and Sinuses ○ Describes the ability to clearly and distinctly b. Orthopnea ○ High back rest Inspection hear whispered sounds that should not Inability to breath except in ○ Oxygen therapy ○ Mucosa (color, swelling, exudates, bleeding) normally be heard upright or sitting position ○ Septum (deviation — can cause airway ○ How to illicit? During auscultation, ask the Chest Pain obstruction, perforation, bleeding) patient to whisper a sequence of words such ASSESSMENT OF RESPIRATORY STATUS Associated with pulmonary or cardiac disease Palpation as “one-two-three” Pulmonary: sharp, stabbing, intermittent, dull aching, ○ Frontal and maxillary sinuses (tenderness) ○ Abnormal: whispered sounds heard will be Health history and persistent clear and distinct a. Demographic data Pain is felt on the side where the pathologic process is ○ Indicates lung consolidation b. Personal and family history (genetics: asthma, located, but may be referred elsewhere (neck, back, cancer) abdomen) ALTERATIONS IN RESPIRATORY FUNCTIONS c. Smoking history ○ Check: d. History of medication used Quality 1. Altered breathing patterns e. History of allergens Intensity Rate f. Occupational and socioeconomic status Radiation a. Tachypnea g. Environment Precipitating factor b. Bradypnea h. Current health problem Relationship of pain to respiration Pharynx and Mouth c. Apnea i. Status of immunization Interventions: Inspection j. Vital signs ○ NSAIDs, anesthetic block ○ Color, symmetry, presence of exudates, Volume PQRST (precipitating factors, quality, radiation, ulceration, and enlargement a. Hyperventilation PRIMARY INDICATORS OF RESPIRATORY DISORDERS severity, treatment) Excessive amount of air in the COLDSPA (characteristic, onset, location, duration, Chest Configuration lungs Cough severity, pattern, associated factors) Ratio of anteroposterior dm to lateral dm is 1:2 It results from deep rapid Results from irritation of the mucous membranes Barrel Chest respirations anywhere in the respiratory tract Wheezing ○ Occurs as a result of over inflation of the b. Hypoventilation The patient’s chief protection against the Major finding in a patient with bronchoconstriction or lungs Decreased rate and depth of accumulation of secretions in the bronchi and airway narrowing ○ Increase AP dm of the thorax respiration bronchioles Interventions: ○ e.g. emphysema Causes retention of carbon ○ Dry, irritated cough or productive cough with ○ Oral or inhalant bronchodilator Funnel Chest dioxide sputum ○ Occurs when there is depression in the lower ○ Acute or chronic cough Clubbing of Finger portion of the sternum Rhythm Sign of lung disease found in patients with chronic ○ This may compress the heart and great a. Cheyne-stokes Sputum Production hypoxic conditions, chronic lung infections, and vessels resulting in murmurs Marked rhythmic waxing and The reaction of the lungs to any constantly recurring malignancies of the lungs Pigeon Chest waning of respirations from irritant ○ Occurs as a replacement of the sternunn very deep to very shallow It may also be associated with nasal discharge Hemoptysis ○ Increase in the AP diameter breathing and temporary ○ Check: Expectoration of blood from the respiratory tract Kyphoscoliosis apnea Color ○ Check: ○ Characterized by elevation of the scapula and b. Kussmaul’s (hyperventilation) Odor Onset a corresponding S-shaped spine Increased rate and depth of Consistency and amount Amount ○ Limits lung expansion within the thorax respiration, seen in metabolic Interventions: ○ It may occur with osteoporosis and other acidosis and renal failure ○ Increase OFI (oral fluid intake), inhalation Cyanosis skeletal disorders that affects the thorax  ○ Because there is greater accumulation of procedure) administered sputum overnight ○ NPO ○ Instruct the client to void before the ○ Microorganisms are highly virulent ○ Vital signs procedure and to wear loose clothing The nurse can collect sputum after CPT and postural ○ Skin preparation ○ Remove dentures drainage ○ Inform the pt, that a local anesthetic will be ○ Instruct the client to refrain from smoking or A suction machine can be used to collect sputum if given, the procedure takes only a few minutes eating a heavy meal for 4 to 6 hours before patient cannot cough (15-20 mins), a small dressing will be placed the test over the puncture site Post-procedure ○ Bring the CXR film for the physician to view ○ Client may resume normal diet and any (for the physician to confirm that it is the bronchodilators and respiratory treatments correct side to puncture) that were hold before the procedure ○ Position the pt. sitting upright with the arms ○ Allow the patient to rest after the procedure and head supported by a table at the bedside, and resume to normal activity if the pt. cannot sit up, assist him to a lying position on the unaffected side with the head of the bed elevated at 45 degrees ○ Instruct the patient to avoid coughing 3. Bronchoscopy During the procedure (physician) Direct visual examination of the larynx, ○ Aseptic condition trachea, and bronchi with a fiberoptic scope ○ Advance the thoracentesis needle with the RISK FACTORS FOR RESPIRATORY DISORDERS A general or local anesthesia spray may be syringe attached. When the pleural space is given before the procedure to prevent reached, suction may be applied with the 1. Allergens gagging syringe 2. Chest injuries The client may also gargle an anesthetic to Post-procedure 3. Crowded living conditions anesthetize the throat ○ Check vital signs and skin color 6. Skin Test/Mantoux Test 4. Exposure to chemicals and environmental pollutants ○ Record total amount of fluid withdrawn Medication used in Mantoux test: PPD 5. Family history of infectious disease Bronchoscopy Nursing Responsibilities: ○ Position to the unaffected side or puncture (purified protein derivative) 6. Frequent respiratory illness Pre-procedure side up Skin test uses an intradermal injection to help 7. Geographic residence and travel to foreign countries ○ NPO post midnight ○ Apply pressure dressing and assess site diagnose various infectious disease 8. Smoking ○ Remove dentures/eyeglasses frequently Mantoux test is used to determine the 9. Surgery ○ Informed consent exposure of the client to tuberculosis ○ Vital signs ○ Will not diagnose mycobaterium DIAGNOSTIC TEST ○ Prepare suction equipment tuberculosis ○ Have emergency resuscitation ready Read after 48-72 hours 1. Chest x-ray Induration of 10mm or > = (+) Provides information regarding the For HIV and immunocompromised 5mm = (+) anatomical location and appearance of the lungs 7. Arterial Blood Gases (ABG) Determines the adequacy of alveolar gas 2. Sputum Examination which is done for: exchange and evaluates the acidity of the Culture and Sensitivity 5. Pulmonary Function Test lungs and kidney to maintain acid-base ○ Identify specific microorganisms and Test used to evaluate lung mechanics, gas balance its drug sensitivities exchange, and acid-base disturbance through Cytology spirometric measurements, lung volumes, ○ Identify origin, structure, function, 4. Thoracentesis NORMAL ABG VALUES and arterial blood gas levels and pathology of cells Needle aspiration of air/fluid from the pleural pH 7.35-7.45 ○ 3 serial collection cavity for the diagnosis and therapeutic PFT Nursing Responsibilities: AFB (Acid Fast Bacillus) purposes (relieve pain, dyspnea) Pre-procedure PaO2 80-100 mmHg ○ Identify mycobacterium tuberculosis The needle is inserted between the 7th and ○ Explain the procedure to the patient ahead of ○ 3 serial collection (collected 3 times 8th intercostal space time and inform him that he will be asked to PaCO2 35-45 mmHg consecutively) breath into a machine and is painless Thoracentesis Nursing Responsibilities: ○ Determine whether an analgesic that may HCO3 22-28 mEq/L Sputum Examination Nursing Responsibilities: Pre-procedure depress the respiratory function is being Collect specimen preferably early in the morning ○ Informed consent (because it is an invasive ABG Nursing Responsibilities Pre-procedure RESPIRATORY TREATMENTS ○ Perform Allen’s test before drawing radial artery specimens BREATHING RETRAINING ○ Have the client rest for 30 minutes before the specimen collection to ensure accurate This includes exercises to decrease the use of measurement of the body oxygenation accessory muscles of breathing to decrease and to ○ Avoid suctioning before drawing the ABG promote carbon dioxide elimination sample Main types: ○ If there is oxygen therapy, discontinue oxygen Pursed lip breathing CHEST PHYSIOTHERAPY 30 minutes before blood extraction Percussion, vibration techniques are performed over Post-procedure the thorax to loosen secretions in the affected area of ○ Place the specimen on ice (to prevent the lungs and move them into more central airways coagulation) Patient should be in orthopneic position ○ Note the client's temperature on the Sequence: laboratory form ○ Percussion ○ Note the oxygen and type of ventilation that ○ Vibration Diaphragmatic breathing the client is receiving in the laboratory form ○ Postural Drainage ○ Apply pressure to the puncture site for 5 to 10 mins or longer if the client is taking Chest Tapping/Clapping/Percussion anticoagulant therapy or has a bleeding Forceful striking of the skin with cupped hands disorder This can dislodge tenacious secretions from the ○ Transport the specimen to the laboratory bronchial walls within 15 minutes Do not perform on the breast, sternum, spine, and kidneys 8. Pulse Oximetry Contraindicated in PTB with active hemoptysis, Non-invasive test that registers the oxygen cardiac problems, pathological rib fractures, saturation of the client's hemoglobin carcinoma The normal value is 98% - 100% AIRWAY CLEARANCE ADJUNCT THERAPIES 1. Autogenic Drainage (“huff cough”) Breathing technique frequently used by patients with Chest Vibration cystic fibrosis and other chronic pulmonary disease Series of vigorous quivering produced by hands that are placed flat against the chest wall 2. Oscillating Positive Expiratory Pressure (PEP) Used after chest percussion to increase turbulence of An oscillating PEP device loosens mucus by producing exhaled air and loosen secretions can be use in PEP and oscillatory vibrations in the airways so that patients with PTB the mucus can be cleared with a cough Postural Drainage Drainage by gravity of secretions from various lung segments A bronchodilator may be given/nebulization may be 3. High Frequency Chest Wall Oscillation rendered before the procedure The patient wears a vest like device that uses air The best time to perform this include before pulses to compress the chest wall, loosening breakfast, before lunch, late afternoon, and before secretions bedtime ○ If the stomach is full, the food could  regurgitate 7. Glucocorticoids/Corticosteroids SIGNS OF HYPOXEMIA Avoid hours after meals INCENTIVE SPIROMETRY Inflammatory agents that reduces edema of the Each position during postural drainage will be Early Signs Late Signs Pediatrics airways assumed by the client for 10-15 minutes. The entire Done to enhance deep inspiration e.g. Budesonide, fluticasone propionate, treatment should last for only 30 minutes Restlessness Extreme Nasal Flaring hydrocortisone Observe gradual change position Decrease PR, RR Restlessness Sternal Contraindicated in head injury spinal injury, increased Disorientation DOB Retractions 8. Decongestants ICP, hemoptysis, geriatric patients Anxiety Stupor Inspiratory Shrinks nasal mucosa membranes and reduces fluid Cyanosis Decrease PR, RR Stridor secretion Cyanosis e.g. Phenylephrine (Neozep), Phenylpropanolamine (Dimetapp), Pseudoephedrine (Sudafed) Simple Face Mask NURSING CARE OF CLIENTS WITH UPPER RESPIRATORY ○ Is used to deliver oxygen concentrations of MEDICATIONS DISORDERS 40% to 60% for short-term oxygen therapy or to deliver oxygen in the emergency 1. Bronchodilators I. Upper Respiratory Infection ○ A minimal flow rate of 5 L/min is needed to Sympathomimetics/adrenergics a. Rhinitis prevent the rebreathing of exhaled air Dilates the airways and relaxes the smooth muscle of b. Viral Rhinitis the bronchi c. Acute sinusitis Partial Rebreather Mask e.g. epinephrine, albuterol (ventolin), isoproterenol d. Chronic Sinusitis ○ Consist of a mask with a reservoir bag that (isuprel), terbutaline sulfate e.-Ñh Acute aryngitis provides an oxygen concentration of 70% to f. Chronic Pharyngitis 90% with flow intes of 6-15 L/min 2. Mucolytics g. Tonsillitis/Adenoiditis ○ The client rebreathes one third of the exhaled Liquefies secretions tidal volume, which is high in oxygen KISS (saturated solution of K iodide) A. RHINITIS (CORYZA) Give with orange juice to mask bitter taste Face Tent Acetylcysteine (Mucomyst) Apical portion of the lungs It is a group of disorders characterized by ○ Fits over the client’s chin, with the top Diphenhydramine (Benadryl) ○ Sitting position inflammation and irritation of the mucous extending half-way across the face ○ 10 - 15 minutes membranes of the nose ○ The oxygen concentration varies but the face 3. Expectorants Middle portion of the lungs Allergic tent is useful instead of a tight-fitting mask for Loosen secretions so that they can be eliminated by ○ Left lateral the client who has facial trauma or burns coughing Pathophysiology of Rhinitis ○ 10 - 15 minutes Used for dry cough and stimulates bronchial Basal portion of the lungs Note: oxygen is colorless, odorless, tasteless, and dry secretions ○ Trendelenburg Precipitating Factors gas that supports combustion Guaifenesin (Robitussin) > Environmental factors ○ 10 - 15 minutes - Changes to temperature Predisposing Factors - Age - Humidity - Systemic disease Oxygen Therapy: Nursing Implication 4. Antitussives - Odor - Food Postural Drainage Nursing Responsibilities Since oxygen is colorless, odorless, tasteless gas, Cough suppressants Pre-procedure leakage cannot be detected Can cause respiratory depression ○ Check VS as baseline data Since oxygen is a dry gas, it can irritate mucous e.g. Butamirate citrate (Sinecod), codeine sulfate ○ Adjust sessions with the patients membrane of the airways reaction/condition Since oxygen supports combustion, it can cause fire Release of Histamine and other substances 5. Leukotriene Inhibitors ○ If the patient is receiving a tube feeding, stop Used in prophylaxis and treatment of chronic asthma the feeding and aspirate the residual before Oxygen Therapy: Nursing Planning, Intervention, and Not used for acute asthma attacks beginning the CPT Evaluation in Administering Oxygen Inhibits bronchoconstriction, reduces airway edema Post-procedure Assess signs and symptoms of hypoxemia Montelukast, Siluton Vasodilation and edema (conchae) ○ Evaluate vital signs Check doctor's order ○ Evaluate breath sounds Position: semi-fowler’s 6. Antihistamine/H1 Blockers ○ Document secretions expectorated Open source of oxygen before insertion of oxygen Decrease nasopharyngeal secretions and nasal itching ○ Provide oral care device that causes sneezing Signs and symptoms Regulate oxygen flow accurately e.g. Cetirizine (Zyrtec), diphenhydramine (Benadryl), OXYGEN THERAPY Place a “no smoking” sign at the bedside loratidine (Clarinase) Indicated for hypoxemia Avoid use of oil, greases, alcohol and ether near the The patient may feel asleep or get drowsy client receiving oxygen  ○ Nonsteroidal anti-inflammatory agents Physical Examination (head and neck, particularly the (NSAIDs) such as aspirin or ibuprofen relieve nose, ears, teeth, sinuses, pharynx, and chest) Pathophysiology Clinical Manifestations the aches, pains, and fever in adults Percussion (sinuses) URTI Transillumination (sinuses): appearance should be Bacteria: S. pneumoniae, H. influenzae Nasal congestion C. ACUTE SINUSITIS clear Localized itching Sinus x-ray Sneezing Infection of the paranasal sinuses CT scan Narrowing or obstruction in the ostia of the frontal, Nasal discharge Causes: maxillary, and anterior ethmoid sinus ○ Frequent respiratory infection Complications Management/Treatment ○ Nasal congestion No adequate drainage at the nasal passage ○ Bacteria: S. pneumoniae, H. influenzae Meningitis Pharmacologic Treatment ○ Virus: Rhinovirus Brain abscess ○ Antihistamines Ischemic infarction Chronic sinusitis ○ Oral decongestants Osteomyelitis ○ Corticosteroids Clinical Manifestations Nursing Management Medical Management ○ Avoid exposure to allergens and irritants Headache ○ Saline nasal or aerosol First-line antibiotics: amoxicillin (Amoxil), Ear pain and fullness ○ Immunization trimethoprim/sulfamethoxazole (Bactrim, Septra), Dental pain and erythromycin Cough B. VIRAL RHINITIS (COMMON COLD) Second-line antibiotics: cephalosporins such as Decreased sense of smell Pathophysiology cefuroxime axetil (Ceftin), cefpodoxime (Vantin), and Sore throat It is an upper respiratory tract infection that is cefprozil (Cefzil), and amoxicillin clavulanate Eyelid edema, or facial congestion or fullness self-limited and caused by a virus URTI (Augmentin) Slow onset of signs and symptoms Broad Spectrum: macrolides, azithromycin Assessment and Diagnostic Findings (Zithromax), and clarithromycin (Biaxin) 6 Viruses Known to Produce the Signs and Symptoms of the Cigarette Smoking Oral and topical decongestant agents may decrease CT scan Viral Rhinitis mucosal swelling of nasal polyps Nasal endoscopy Allergic Rhinitis Heated mist and saline irrigation 1. Rhinovirus Decongestant agents such as pseudoephedrine Complications 2. Parainfluenza virus (Sudafed, Dimetapp) Inflammation 3. Coronavirus Antihistamine such as diphenhydramine Severe orbital cellulitis, subperiosteal abscess 4. Respiratory Syncytial Virus (RSV) Cavernous sinus thrombosis 5. Influenza Virus Edema of the mucous membrane Nursing Management Meningitis 6. Adenovirus Encephalitis and 1. Inhaling steam (steam bath, hot shower, and facial Ischemic infarction Clinical Manifestations Hypersecretion of the mucus sauna) 2. Increasing fluid intake and applying local heat (hot Medical Management Nasal congestion wet packs) Rhinorrhea Infection 3. Informs the patient about the side effects of nasal 1. Antimicrobial Agents Sneezing sprays and about rebound congestion Amoxicillin clavulanate (Augmentin) or ampicillin Sore throat Manifestations 4. Teach the patient about the early signs of a sinus (Ampicin) General malaise infection Clarithromycin (Biaxin) and Facial pain/congestion or pressure over the affected 5. Recommend preventive measures such as following Third-generation cephalosporins: cefuroxime axetil Management/Treatment sinus area healthy practices and avoiding contact with people (Ceftin), cefpodoxime (Vantin), and cefprozil (Cefzil) Nasal obstruction who have upper respiratory infections There is no specific treatment for the common cold or Fatigue Surgical Management influenza Purulent nasal discharge D. CHRONIC SINUSITIS Management consists of symptomatic therapy Fever 1. Functional Endoscopic Sinus Surgery (FESS) ○ Provide adequate fluid intake Cough decreased sense of smell It is an inflammation of Minimally-invasive approach to the sinus cavities ○ Encourage rest Sore throat the sinuses that persists using endoscopes (telescopes) to view the important ○ Increasing intake of vitamin C for more than 12 weeks structures of the nose and sinuses ○ Warm salt-water gargles soothe the sore Assessment and Diagnostic Findings or longer throat  3 Types of Chronic Pharyngitis results 1. Hypertrophic - characterized by general thickening and congestion of the pharyngeal mucous membrane 2. Atrophic Pharyngitis - probably a late stage of the first type (the membrane is thin, whitish, glistening, and at times wrinkled) 3. Chronic granular (clergyman's sore throat) - 2. Caldwell-Luc Surgery (Radical Antrum Surgery) characterized by numerous swollen lymph follicles on Involves creating an opening into the maxillary the pharyngeal wall Grading of Tonsillar Enlargement antrum through the canine fossa via a sublabial Pathophysiology approach Surgical treatment of the severely diseased maxillary sinus Bacteria, virus, or fungi 0 I - - Inflammation of the pharynx Clinical Manifestations 3. Ethmoidectomy Constant sense of irritation or fullness in the throat Removal of the infected tissue and bone in the S/Sx: Sore throat, fever, dysphagia Mucus that collects in the throat and can be expelled ethmoid sinuses that blocks natural drainage by cough and difficulty swallowing Microdebrider Medical Management 4- Laboratory Test 1. Avoiding exposure to irritants, and correcting any Throat culture and sensitivity test upper respiratory, pulmonary, or cardiac condition that might be responsible for a chronic cough Common Causing Organism: Medical Management 2. Nasal congestion may be relieved by short-term use of nasal sprays or medications containing ephedrine Streptococcus species Antibacterial/antibiotic sulfate (Kondon's Nasal) or phenylephrine Staphylococcus aureus Acetaminophen hydrochloride (Neo-Synephrine) Haemophilus influenzae Throat lozenges 3. Antihistamine Pneumococcus species E. ACUTE PHARYNGITIS 4. Aspirin or acetaminophen Nursing Management Inflammation or infection in the throat, usually causing symptoms of a sore throat Nursing Management Saltwater gargles help reduce swelling Increased fluids (if not contraindicated) Instructs the patient to avoid contact with others until Rest the fever subsides Alcohol, tobacco, second-hand smoke, and exposure F. CHRONIC PHARYNGITIS to cold are avoided, as are environmental or occupational pollutants if possible Persistent inflammation of the pharynx Minimize exposure to pollutants by wearing a Common in adults who work or live in dusty disposable facemask Clinical Manifestations surroundings, use their voice to excess, suffer from Symptoms Increase fluid intake chronic cough, and habitually use alcohol and tobacco Gargle with warm saline solutions may relieve throat Sore throat, fever, chills, and pain on swallowing Sore throat discomfort Generalized symptoms include headache, malaise, Dysphagia and myalgia Throat is red and swollen sometimes with exudate G. TONSILLITIS/ADENOIDITIS Tonsils red and swollen and may have yellow or white Fever exudate Headache Occurs when the function filtering becomes Generalized malaise overwhelmed with a virus or bacteria and infection  manifestations of URTI first so that Avoid colds, crowded or public places ○ Sinus forceps there will be no complications ○ Suction Check prothrombin time H. PERITONSILLAR ABSCESS (QUINSY) ○ Rationale: Concern is bleeding so check for It is a collection of purulent exudate between the clotting time tonsillar capsule and the surrounding tissues, Risk of bleeding so blood should be including the soft palate available on standby If adenoids is involved: ○ Snoring ○ Nasal obstruction Nursing Management ○ And a nasal tone to the voice Throat irrigation Surgical Management Frequent use of mouth gargles, using saline or alkaline solutions at a temperature of 105°F to 110°F Tonsillectomy (Post Op Care) Clinical Manifestations (40.6°C to 43.3° C) Liquids that are cool or at room temperature are 1. Place patient in lateral position or prone position with Raspy voice usually well tolerated head turned to side. Once the client is awake, place Odynophagia (a severe sensation of burning, him in a semi-fowler's position (this position aids squeezing pain while swallowing) I. LARYNGITIS drainage and prevents aspiration) Dysphagia (difficulty swallowing) 2. Keep oral airway until swallowing reflex returns Otalgia (pain in the ear) It is an inflammation of the larynx, often occurs as a 3. Monitor for hemorrhage Drooling result of voice abuse or exposure to dust, chemicals, Frequent swallowing smoke, and other pollutants, or as part of an upper Bright red vomitus Assessment and Diagnostic Findings respiratory tract infection Tachycardia Common during winter 4. Promote comfort Aspiration of purulent material (pus) by needle Place ice collar over the neck aspiration Administer acetaminophen Culture and Gram's stain acid Avoid administer of ASA → acetyl salicylic CT Scan 5. Foods and fluids Provide ice cold fluids Provide bland foods (avoid irritation) Avoid red or dark colored beverages (to know if there is bleeding) Causes Avoid citrus fruits Primary: Virus Client Education for Tonsillectomy Secondary: Bacteria Avoid clearing of throat Clinical Manifestations Avoid coughing, sneezing, blowing nose for 1-2 weeks Medical Management ○ Instruct the client to open the mouth when Hoarseness or aphonia (loss of voice) and severe Tonsillectomy (Pre Op Care) he/she wants to cough or sneeze Antibiotics (usually penicillin) cough Provide 2-3L of fluids until mouth odor disappears Sudden onset made worse by cold dry wind Assess for URTI Avoid hard/scratchy foods until throat is healed Surgical Management ○ Rationale: Report signs and symptoms of bleeding Medical Management Bleeding on postoperative site Throat discomfort between 4th and 8th post op day is Incision and drainage of abscess If manifestations of URTI are present expected ○ At the point of maximum bulge above the Antibiotic therapy such as cough or sneezing, then the Stool black/dark for few days upper pole of tonsil Topical corticosteroids, such as beclomethasone operation must be postponed. Treat Plenty of rest for 2 weeks ○ Guarded knife - incision dipropionate (Vanceril) inhalation  Instruct the patient to rest the voice ○ For post op care after surgery, ice collar can CT Scan Resting be reduce swelling and decrease bleeding MRI Avoid smoking Promoting communication Inhaling cool steam or an aerosol ○ Instructs the patient to refrain from speaking Medical Management as much as possible and, if possible, to Nursing Process: The Patient with Upper Airway Infection communicate in writing instead Surgery ○ Encourages the patient and family to use Radiation therapy and chemotherapy Assessment alternative forms of communication Speech therapy Encouraging fluid intake History of taking ○ Provides a list of easily ingested foods to Surgical Management Physical examination increase caloric intake ○ Encourages the patient to drink 2 to 3 L of Areas where malignant growth occur: 1. Partial laryngectomy Nursing Diagnosis fluid per day ○ Glottic area (vocal cords) 2. Supraglottic laryngectomy ○ Liquids (hot or cold) may be soothing ○ Supraglottic area (area above the glottis or 3. Hemilaryngectomy Ineffective airway clearance related to excessive vocal cords, including epiglottis) 4. Total laryngectomy mucus production secondary to retained secretions Evaluation: Expected Patient Outcomes ○ Subglottis (area below the glottis or vocal and inflammation cords to the cricoid) Partial Laryngectomy Acute pain related to upper airway irritation 1. Maintains a patent airway by managing secretions secondary to an infection Reports decreased congestion Pathophysiology Recommended in the early stages of cancer in the Impaired verbal communication related to physiologic Assumes best position to facilitate drainage of glottic area when only one vocal cord is involved changes and upper airway irritation secondary to secretions Portion of the larynx is removed, along with one vocal infection or swelling 2. Reports feeling more comfortable: cord and the tumor Deficient fluid volume related to increased fluid loss Uses comfort measures: analgesics, hot secondary to diaphoresis associated with a fever packs, gargles, rest Deficient knowledge regarding prevention of upper Demonstrates adequate oral hygiene. respiratory infections, treatment regimen, surgical 3. Demonstrates ability to communicate needs, wants, procedure, or postoperative care level of comfort 4. Maintains adequate fluid intake Planning and Goals 5. Identifies strategies to prevent upper airway infections and allergic reactions: The major goals for the patient may include Demonstrates hand hygiene technique Supraglottic Laryngectomy maintenance of a patent airway, relief of pain, Identifies the value of the influenza vaccine maintenance of effective of means communication, 6. Demonstrates an adequate level of knowledge and Indicated in the management of early (stage 1) normal hydration, knowledge of how to prevent performs self-care adequately supraglottic and stage Il lesions upper airway infections, and absence of 7. Becomes free of signs and symptoms of infection. Hyoid bone, glottis, and false cords are removed complications Exhibits normal vital signs (temperature, Clinical Manifestations The true vocal cords, cricoid cartilage, and trachea pulse, respiratory rate) remain intact Nursing Interventions Absence of purulent drainage Hoarse voice Free of pain in ears, sinuses, and throat Excessive coughing Maintaining a patent airway Frequently choking on food ○ Increasing fluid intake LARYNGEAL OBSTRUCTION Ear pain ○ Use of room vaporizers or steam inhalation Neck swelling ○ Instructs the patient about positioning Caused by foreign bodies/object Dysphonia Promoting comfort Intervention: Heimlich maneuver Breathing difficulties ○ Encourages the patient to take antispasmodic agents, such as acetaminophen with codeine, CANCER OF THE LARYNX Assessment as prescribed Advantage: ○ Pain intensity rating scale to assess effectivity It is a malignant tumor in the larynx (voice box) Complete history and physical examination of the ○ Preserves the voice, even though the quality of pain relief measures It is usually a primary cancer and can spread to the head and neck (assessment of risk factors, family of the voice may change ○ Topical anesthetic agents lungs, liver, or lymph nodes history, and any underlying medical conditions) Major problem: ○ Hot packs to relieve the congestion ○ High risk for recurrence of the cancer ○ Warm water gargles or irrigations to relieve Diagnostic Test pain Hemilaryngectomy ○ Encourages rest Laryngoscopy examination and biopsy  Performed when the tumor extends beyond the vocal B. Internal Radiation Therapy oral cavity 1. Acute pain related to surgical procedure cord but is less than 1 cm in size and is limited to the Place the client in a private room When the mouth forms words (articulated), the 2. Impaired verbal communication related to loss of subglottic area Limit visits to 10 to 30 minutes, and have visitors sit at sounds from the electric larynx become audible vocal cords least 6 feet from the client. words 3. Risk for imbalanced nutrition, less than body Total Laryngectomy Monitor for side effects such as burning sensations, requirements related to absence of oral excessive perspiration, chills and fever, nausea and 4. Impaired swallowing related to edema or Performed in the most advanced stage IV laryngeal. vomiting, or diarrhea laryngectomy tube cancer, when the tumor extends beyond the vocal Assess for fistulas or necrosis of adjacent tissues 5. Grieving related to loss of voice cords, or for recurrent or persistent cancer following While a temporary implant is in place, stay in bed and 6. Disturbed body image related to change in body radiation therapy rest quietly to avoid dislodging the implant structure and function The laryngeal structures are removed, including the For outpatient treatments, avoid close contact with hyoid bone, epiglottis, cricoid cartilage, and two or others until treatment has been discontinued three rings of the trachea If the radiologist indicates the need for such measures The tongue, pharyngeal walls, and trachea are dispose of excretory materials in special containers or preserved in a toilet not used by others Tracheoesophageal Puncture Radiation Therapy Internal Radiation Therapy (Client and Family Teaching) Carry out daily activities as able; get extra rest if A valve is placed in the tracheal stoma to divert air To eradicate the cancer and preserve the function of feeling fatigued into the esophagus and out of the mouth the larynx Eat a balanced diet; frequent, small meals often are Once the puncture is surgically created and has Stage I and II better tolerated healed, a voice prosthesis (Blom-Singer) is fitted over the puncture site Nursing Responsibilities: Radiation Therapy Speech Therapy A. External Radiation Therapy Writing Monitor for adverse effects: skin changes, such as Lip speaking blanching, erythema, desquamation, sloughing, or Communication or word boards hemorrhage; ulcerations of mucous membranes; nausea and vomiting, diarrhea, or gastrointestinal Speech Therapy (Postoperative Communica