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Medical-Surgical Nursing:
Concepts & Practice
3rd edition
Chapter 13
Care of Patients with Disorders of the Upper
Respiratory System
Copyright © 2017, Elsevier Inc. All rights reserved.
Theory Objectives
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Recognize symptoms of disorders of the
sinuses, pharynx, and larynx.
Describe the postoperative care for the
patient undergoing a rhinoplasty.
List emergency measures for the patient with
an airway obstruction.
Review a nursing care plan for the patient
who had a laryngectomy.
Analyze safety factors to be considered when
caring for the patient with a tracheostomy.
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Clinical Practice Objectives
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Institute measures to stop epistaxis.
Provide tracheostomy care.
Devise interventions for the psychosocial
care of the patient who has undergone a
laryngectomy.
Visit a patient who has a permanent
tracheostomy and ask her to share some of
her successful coping strategies.
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Disorders of the Nose and Sinuses
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Upper respiratory infection (the common cold)
and rhinitis
A major goal in the care of a common cold is
to prevention of a secondary bacterial
infection.
A person with a cold is contagious for about 3
days after symptoms first appear.
Colds are spread by droplet infection.
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Common Cold – Non productive cough
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Acute viral rhinitis – many different strains so
vaccine not possible
Virus- airborne droplet can live on surfaces
for a long period
Usually no fever – if there is it’s low grade 99.
which is common with viral infections
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Older Adult Care Points
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Immune function in older adults is decreased,
and they are therefore more at risk for
contracting a cold or upper respiratory
infection. They should be encouraged to stay
away from people who have such infections.
If a cold develops, an older person is more
likely to develop a secondary infection.
Encourage increased fluid intake and lots of
rest until the cold symptoms are completely
cleared.
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Commonly Prescribed Drugs for
Allergic Rhinitis and Sinusitis
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Antihistamines
1st generation – drowsiness (Benadryl)
2nd generation – non-drowsy (Claritin)
Corticosteroid sprays – inhibit inflammatory
response - Flonas
Mast cell stabilizer- inhibit inflammatory mast
cells (Nasalcrom)
Decongestants-promote vasoconstriction
(Sudafed)
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Common Cold (cont)
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A bacterial infection is likely present when a
cold persists for more than a week to 10 days
without improvement, or if the patient begins
to feel worse, has a temperature of 101 and
develops chest pains or coughs up purulent
sputum (productive cough)
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Caution with Aspirin
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Aspirin should not be given to children
younger than 19 years of age because aspirin
has an association with Reye’s syndrome.
Adults taking anticoagulants or nonsteroidal
anti-inflammatory drugs should not take
aspirin because aspirin will further prolong
the clotting time.
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Sinusitis
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Sinusitis is an inflammation of the mucosal
lining of the sinuses.
Causes include infection that has spread from
the nasal passages to the sinuses and
blockage of normal sinus drainage routes.
Pneumococci, streptococci, or Haemophilus
influenzae are usually the infecting
organisms.
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Sinusitis (Cont.)
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A deviated septum or nasal polyps can
contribute to blockage of the nasal passages.
People with a deviated nasal septum or
allergy problems tend to have recurrent
sinusitis.
As exudate accumulates in the sinuses,
pressure builds up, causing considerable
pain.
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Symptoms
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Symptoms include
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Headache
Fever
Tenderness over the sinuses
Malaise
Purulent drainage from the nose
Sometimes a nonproductive cough
The upper teeth may become painful.
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Treatment
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Relieve pain, promote sinus drainage, control
infection, and prevent recurrence.
Hot, moist packs over the sinus area can be
helpful.
Inhaling moist steam thins secretions and
helps to promote drainage.
Kits for sinus irrigation are available at
drugstores and seem to help.
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Treatment (Cont.)
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Medications are prescribed to promote
vasoconstriction, reduce swelling, and
promote drainage.
Decongestants also may be used.
Infection may be treated with an antibiotic or
anti-infective agent, often for at least 10 days.
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Treatment (Cont.)
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Rest, reduced stress, a balanced diet, and
control of allergies can help prevent
recurrence.
Analgesics are given for pain.
Fluid intake should be increased and dairy
product intake lowered to decrease the
thickness of secretions.
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Epistaxis (Nosebleed)
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Causes –decreased humidity, excessive nose
blowing, allergy with inflammation, nose picking,
medical condition (prolonged bleeding time),
trauma, hypertension, blood DO, pt on anticoagulant/anti-platelet increased risk
Bleeding is the only sign.
Management
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Minimal bleeding – pressure, patient sit forward
Persistent bleeding – ER to cauterize bleeding vessel
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Stopping a Nosebleed
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Epistaxis
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Cold compresses or ice may be applied to the
nose to help constrict the blood vessels.
If there is still bleeding 10-15 minutes, repeat
process
If persistent ER – cauterize, pack or insert a
small balloon device to stop the bleeding
**instruct patient to spit blood into a basin or
tissue..accumulation of blood in the stomach
will eventually cause N & V
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Pharyngitis
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Pharyngitis (inflammation of the pharynx),
usually called a sore throat
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The inflammation may be caused by a virus,
bacteria, or fungus; usually viral.
Acute follicular pharyngitis (“strep throat”) is
caused by beta-hemolytic streptococcal infection.
Fungal pharyngitis occurs with long-term use of
antibiotics or inhaled corticosteroids, or in patients
with immunosuppression, such as occurs with HIV
or AIDS or during cancer treatment.
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Pharyngitis (Cont.)
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Laryngitis (inflammation of the larynx with
diminished voice or hoarseness) may occur if
the infection progresses into the larynx.
If the inflammation extends to the epiglottis,
epiglottitis occurs.
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More common in children
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Signs, Symptoms, and Diagnosis
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Symptoms include
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Dry, “scratchy” feeling in the back of the throat
Mild fever
Headache
Malaise
Throat, tonsils, palate, and uvula may be involved
and will be reddened
Dysphagia is also present with discomfort
when swallowing one’s own saliva.
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Signs, Symptoms, and Diagnosis
(Cont.)
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With laryngitis, the voice may become hoarse
or absent. The usual course for uncomplicated
pharyngitis or laryngitis is 3 to 10 days. The
diagnosis of pharyngitis is confirmed by clinical
signs and symptoms.
A throat culture is often done to confirm or rule
out streptococcal infection.
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Treatment and Nursing Management
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Conservative measures are rest, warm saline
gargles (1⁄2 to 1 tsp of table salt to a glass of
warm water), throat lozenges (small
medicinal tablets that dissolve in the mouth),
plenty of fluids, and a mild analgesic for
aches and pains
Antiseptic sprays and lozenges help provide
relief from discomfort.
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Treatment and Nursing Management
(Cont.)
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Bacterial pharyngitis requires antibiotic
therapy, particularly if the infecting organism
is Streptococcus.
Chronic pharyngitis may require diagnostic
procedures to determine the underlying
cause and therapeutic measures such as
humidification and filtering of environmental
air.
Fungal pharyngitis is treated with an agent
effective against fungi but may be difficult to
control in immunocompromised individuals.
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Sore throat
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*** throat culture is performed before
treatment to check for Streptococcus which
can cause rheumatic fever or
glomerulonephritis if not treated promptly*****
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Tonsillitis
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Etiology and pathophysiology
Signs, symptoms, and diagnosis
Treatment
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Throat culture (cause streptococci, staphylococci)
Surgery
Nursing management
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Preoperative and postoperative care – restrict
ASA, NSAIDs prior to surgery. If patent has temp
or s/s Uri surgery will usually be postphoned
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Obstruction and Trauma
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Laryngeal edema – allergic reaction, crash
injury or foreign object or food that goes down
the airway
Upward thrusts to dislodge
The most common cause of obstruction in
unconscious adult or child older than 1 year is
the tongue.
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Obstructive Sleep Apnea
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Etiology and pathophysiology –muscle
relaxing at back of throat, tongue falls back
and blocks the airway
Snoring – daytime fatigue, morning
headaches
Sleep study – CPAP, oral appliances
Continuous positive airway pressure (CPAP)
Complications
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Untreated sleep apnea can contribute to
myocardial infarction or stroke.
Constant fatigue
Capnography – Co2 monitoring after surgery
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Nasal Fracture
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Usually from sport injury, motor vehicle
accident or physical assault
Diagnosis 
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Visual inspection for deformity
Change in nasal breathing
Crepitation—grating sound or feeling of rough
surfaces rubbing together upon palpation
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Nasal Fracture (Cont.)
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Treatment
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If the patient is seen within the first 24 hours after
injury, a closed reduction is most often performed
using local or general anesthetic.
Pain relief
Ice or cold compresses to reduce swelling
Cosmetic rhinoplasty
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Audience Response Question 1
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Which nursing intervention(s) would be
appropriate during the immediate
postoperative period for a patient who has
undergone rhinoplasty? (Select all that
apply.) pg 279
1.
2.
3.
4.
5.
Observe for frequent swallowing.
Monitor amount of drainage.
Position the patient flat on the back.
Apply warm compresses.
Provide humidified oxygen.
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Cancer of the Larynx
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Etiology and pathophysiology - tumor
Signs and symptoms – page 280 (next slide)
Diagnosis – CT scan MRI and tissue sample
Treatment – radiation 85% effective,
laryngectomy, neck dissection (if tumor
progressed to surrounding tissues)
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Signs of Possible Throat Cancer
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Hoarseness lasting more than 3 weeks
Sore throat that lasts more than 2 weeks
Consistent pain in or around the ear when
swallowing
Difficulty swallowing
Dry, persistent cough for no known reason
Blood in phlegm or saliva lasting more than a
few days
Lumps or knots on the neck indicating
enlarged cervical lymph nodes
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Older Adult Care Points
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Men in their 60s to 80s with a long history of
smoking and heavy alcohol use are most
likely to develop laryngeal cancer.
A thorough assessment should be carried out
for these individuals.
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Endotracheal Intubation and
Tracheostomy
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Endotracheal intubation means that an
endotracheal tube is inserted into the trachea
via the nose or the mouth with the use of a
laryngoscope.
Tracheostomy is a surgical incision into the
trachea for the purpose of inserting a tube
through which the patient can breathe.
Figure 13-6 on page 281 0 airflow after
laryngectomy
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Purposes of Tracheostomy
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To assist or control ventilation by mechanical
means over a prolonged period of time
To facilitate suctioning of secretions in the air
passages of patients unable to cough
To prevent aspiration of oral and gastric
secretions (as in unconscious or paralyzed
patients)
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Purposes of Tracheostomy (Cont.)
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To bypass a constricted or obstructed upper
airway (as results, for example, from edema
of the larynx, presence of a foreign body or
tumor, surgical procedures involving the
neck, severe burns, facial trauma, or chest
trauma)
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Audience Response Question 2
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The patient’s spouse asks, “What is the
purpose of the tracheostomy?” Which
comment(s) demonstrate(s) nursing
knowledge regarding the procedure? (Select
all that apply.)
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5.
“It facilitates suctioning of respiratory secretions.”
“It prevents recurrence of respiratory arrest.”
“It prevents aspiration of oral secretions in
unconscious patients.”
“It bypasses an obstructed upper airway.”
“It is a temporary airway for face and neck
injuries.”
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Nursing Management
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Monitor continuously for signs of respiratory
distress.
Immediate postoperative care
Psychological support
Communication
Rehabilitation
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