Management of pt.s with upper respiratory tract disorder

1. Management of pt.s with upper respiratory tract disorder Mrs. Mahdia Samaha Alkony

2. 1-Rhinitis: Is a group of disorders characterized by inflammation & irritation of the mucous membranes of the nose. It may be classified as: • Non allergic rhinitis may be caused by: • Environmental factors; change temp. Humidity, odors • Foods • Infection • Age • Systemic disease • Drugs (cocaine), or prescribed medication, foreign body.

3. 1-Rhinitis: • Drug-induced rhinitis: is associated with • antihypertensive agents • oral contraceptives • chronic use of nasal decongestants. • Allergic rhinitis

4. 1-Rhinitis: Clinical manifestations: • Rinorrhea (excessive nasal drainage, runny nose) • Nasal congestion • Nasal discharge (purulent with bacterial rhinitis) • Nasal itching • Sneezing • Headache (if sinusitis is also present) . Treatment • Depend on cause if viral, medication given to reduce symptoms. • In allergic rhinitis tests may perform, corticosteroid desensitizing immunization may require.

5. 1-Rhinitis: • If bacterial infection- antimicrobial agent. • Antihistamine for allergy for sneezing, itching, rinorrhea. • Oral decongestant agent. • Intranasal corticosteroids may be used for severe congestion

6. 1-Rhinitis: NSG Management. • Avoid or decrease exposure to allergens & irritants. • Controlling environment. • Technique of administer nasal medication. • Hygiene, blow the nose before medication. • Treat symptom. • In elderly, nurse discusses value of vaccine in the fall to achieve immunity prior the beginning of flu season.

7. 2-Viral rhinitis (common cold). The term “common cold” often is used when referring to an upper respiratory tract infection that is self-limited and caused by a virus (viral rhinitis). Characterized by: • Nasal congestion • Rhinorrhea • sneezing, • sore throat • Tearing watery eyes • General malaise • Specifically, the term “cold” refers to an a febrile, infectious, acute inflammation of the mucous membranes of the nasal cavity. • Cold are highly contagious because virus is shed for about two days before the symptoms appear.

8. 2-Viral rhinitis (common cold). Treatment: • symptomatic therapy • Adequate fluid intake. • Rest • Increase intake of vitamin C • Expectorant. • Warm salt water gargles • NSAID as aspirin, ibuprofen relieves the aches, pain, & fever. • Antibiotic should not be used. • Immunity after recovery is variable and depends on many factors, including a person’s natural host resistance and the specific virus that caused the cold.

9. 3-Acute sinusitis • The sinuses, mucus lined cavities filled with air that drain normally into the nose, are involved in a high proportion of URTI. • If opening to nasal are clear, the infection resolve promptly. • Some individual are more prone to sinusitis because of their occupation as paint, sawdust, and chemicals

10. Path physiology of sinusitis: • Infection of the Para nasal sinuses frequently developed as a result of an URTI. • Nasal congestion caused by inflammation, edema, transudation of fluid, lead to obstruction of the sinus cavity. • This provide an excellent medium for bacterial growth. • Bacterial organism account for 60% of acute sinusitis as streptococcus pneumonia, hemophilus influenza. • Dental infection is associated with acute sinusitis

11. Clinical manifestation • Facial pain • Nasal obstruction • Fatigue • Purulent nasal discharge • Fever • Headache • Facial ear pain & fullness • Dental pain • Cough • Decrease sense of smell • Sore throat • Eyelid edema.

12. Assessment & DX finding • History & physical examination. • Tenderness over the infected sinus area. • Sinus x-ray. (Fluid level, mucosal thickening). • Computed tomography scanning is most effective DX tool. Complication: • Meningitis • Brain abscess • Ischemic infarction • Osteomyelitis • Sever orbital cellulites.

13. Medical Management • Goal to treat infection, shrink the nasal mucosa & relieve pain. • Antimicrobial, amoxicillin, erythromycin. • Mucolytic agent, decease nasal congestion. • Antihistamine • If pt. continues to have symptom 7-10 days, the sinuses may need to be irrigated & hospital may be required.

14. Nursing Management • Teach method to promote drainage as inhaling system, increase fluid intake, local heat. • Inform pt. about S.E of nasal spray. • Teach early sign of a sinus infection & recommended preventive measures as following health practices, avoid contact with people have URTI. • Explain the fever nuchal rigidity, sever headache as sign of potential complication.

15. 4- Acute Pharyngitis • Is an inflammation or infection in the throat usually causing symptoms of a sore throat. Pathophysiology • Most cases are caused by viral infection. • When group A beta-hemolytic streptococcus- most common cause acute pharyngitis the condition know as strep throat. • Body response by triggering an inflammatory response in the pharynx, this results in pain, fever, vasodilation, edema, tissue damage, manifested by redness & swelling in the tonsillar pillars, uvula & soft palate, creamy exudates may be presented in tonsillar pairs.

16. Complications • Sinusitis • Otitis media • Peritonsillar abscess • Mastoiditis • Cervical adenitis. • In rare cases may lead to bacteremia, pneumonia, meningitis, rheumatic fever, or nephritis

17. Signs and symptoms • A fiery-red pharyngeal membrane and tonsils • Lymphoid follicles are swollen and flecked with white-purple exudate • Enlarged and tender cervical lymph nodes • No cough. • Fever • Malaise • Sore throat.

18. Assessment & DX. • Latex agglutination (LA) / strep antigen • Throat culture • Nasal swab & blood culture Medical Management • Viral; supportive measures • Bacterial; penicillin, erythromycin, cephalosporin (10 day). • Analgesia, aspirin, acamol. • Antitussive med. Codian • Nutritional therapy; liquid, soft, in sever case IV

19. NSG Management • Bed rest during febrile stage. • Used tissue should be disposed to decrease spread of infection. • Examine skin for rash, because pharyngitis may precede some communicable disease as rubella. • Warm saline gargles. • Ice collar can relieve sever sore throats. • Mouth care. • Full course of antibiotics, A beta-hemolytic strep. • Nurse must instruct the importance of taking full course of med.)

20. TONSILLITIS AND ADENOIDITIS • The tonsils are composed of lymphatic tissue & are situated on each side of oropharynx. • Group A beta streptococcus is the most common organism associated with tonsillitis & adenoiditis.

21. Clinical manifestation: • Sore throat, fever, snoring, difficulty of swallowing. • Mouth breathing, earache, draining ears • Bronchitis, foul smelling breath • Noisy respiration voice impairment. • Acute otitis media, which can lead to spontaneous rupture of the eardrums and further extension of the infection into the mastoid cells, causing acute mastoiditis. • Infection may reside in middle ear cause permanent deafness.

22. Assessment and Diagnostic Findings • Physical examination • Careful history • Culture swab. • If recurrent episodes of suppurative otitis media result in hearing loss, the patient should be given a comprehensive audiometric examination

23. Tonsillectomy or adenoidectomy Indications: • Repeated attack of tonsillitis • Hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive sleep apnea • Repeated attacks of purulent otitis media • Suspected hearing loss due to serous otitis media • An exacerbation of asthma or rheumatic fever. • Appropriate antibiotic therapy is initiated for patients undergoing tonsillectomy or adenoidectomy. • The most common antimicrobial agent is oral penicillin, which is taken for 7 days. Amoxicillin and erythromycin are alternatives.

24. POSTOPERATIVE CARE • Comfortable position; prone with the head turned to the side . • Must not remove the oral airway until the patient’s gag and swallowing reflexes have returned. • Apply an ice collar to the neck, • Bleeding may be bright red if the patient expectorates blood before swallowing it • Notify the surgeon immediately if: • The patient vomits large amounts of dark blood or bright-red blood at frequent intervals • If the pulse rate and temperature rise and the patient is restless • If no bleeding water, ice chips are given to pt • Instruct pt. to refrain coughing & talking because may produce throat pain.

25. PERITONSILLAR ABSCESS • A peritonsillar abscess is a collection of purulent exudate between the tonsillar capsule and the surrounding tissues, including the soft palate. • It is believed to develop after an acute tonsillar infection, which progresses to a local cellulitis and abscess.

26. Clinical Manifestations • A raspy voice • Odynophagia (a severe sensation of burning, squeezing pain while swallowing) • Dysphagia (difficulty swallowing) • Otalgia (pain in the ear) • Drooling. • An examination shows marked swelling of the soft palate, often occluding almost half of the opening from the mouth into the pharynx, unilateral tonsillar hypertrophy, and dehydration

27. Assessment and Diagnostic Findings • Aspiration of purulent material (pus) by needle aspiration is required • The aspirated material is sent for culture and Gram’s stain. • A CT scan is performed when it is not possible to aspirate the abscess

28. Medical Management • Antibiotics (usually penicillin) are extremely effective . • If antibiotics are prescribed early in the course of the disease, the abscess may resolve without needing to be incised. • 30% of pt. with aspiration with periorpital abscess have indication for tonsillectomy.

29. Nursing Management • Use topical anesthetic agents. Throat irrigation, mouth wash Q 1-2 hr / 24-36 hr. • Liquids that are cool or at room temperature are usually well tolerated

30. Laryngitis • An inflammation of the larynx often occurs at dust, chemicals, smoke or other pollutions, or as part of an URTI • May be caused by isolated infection involving only vocal cord. • Cause always virus, bacterial may be secondary. Laryngitis is usually associated with pharyngitis or allergic rhinitis. • Common in winter • Onset exposure sudden temp. change, immuno suppressed, dietary deficiencies, malnutrition.

31. Signs and symptoms • Persistence hoarseness or aphonia (complete loss of voice). • Sever cough. Management: • Avoid smoking • Complete voice rest • Inhaling humidified air promotes moisture of the upper airway, helping to clear secretions and exudate • Antibiotics (if cause bacteria) • In elderly may lead to pneumonia.

32. Nursing Management • Rest the voice • Well humidified environment. • Expectorant agents for secretion if presented • Fluid intake 3L to thin secretion.

33. Obstruction and Trauma of the Upper Respiratory Airway

34. OBSTRUCTION DURING SLEEP • A variety of respiratory disorders are associated with sleep, the most common is being sleep apnea syndrome. • Sleep apnea syndrome is defined as cessation of breathing (apnea) during sleep.

35. Path physiology Sleep apnea is classified into three types: • Obstructive—lack of air flow due to pharyngeal occlusion • Central—simultaneous cessation of both air flow and respiratory movements • Mixed—a combination of central and obstructive apnea within one apneic episode. The most common type of sleep apnea syndrome, obstructive sleep apnea.

36. Obstructive sleep apnea • Is defined as frequent and loud snoring and breathing cessation for 10 seconds or more for five episodes per hour or more, followed by awakening abruptly with a loud snort as the blood oxygen level drops

37. Clinical features • Excessive day time sleepiness • Frequent nocturnal awakening • Insomnia • Loud snoring • Morning headaches • Intellectual deterioration • Personality changes, irritability • Impotence

38. Clinical features • Systemic hypertension • Dysrhythmias • Pulmonary hypertension, cor pulmonale • Polycythemia • Enuresis

39. Risk factors • Gender: It is more prevalent in men • Age: those who are older • Overweight. • Cigarette smoking

40. Causes • Mechanical factors ; a reduced diameter of the upper airway • Dynamic changes in the upper airway during sleep. • The activity of the tonic dilator muscles of the upper airway is reduced during sleep. These sleep related changes may predispose the patient to increased upper airway collapse with the small amounts of negative pressure generated during inspiration. Obstructive sleep apnea may be associated with obesity and with other conditions that reduce pharyngeal muscle tone (eg, neuromuscular disease, sedative/ hypnotic medications, acute ingestion of alcohol)..

41. Diagnosis • The diagnosis of sleep apnea is made based on clinical features • Polysomnographic findings (sleep test), in which the cardiopulmonary status of the patient is monitored during an episode of sleep

42. Effects of obstructive sleep apnea • Repetitive apneic events result in hypoxia and hypercapnia, which triggers a sympathetic response. • As a consequence, patients have a high prevalence of hypertension • An increased risk of myocardial infarction • Stroke. • In patients with underlying cardiovascular disease, the nocturnal hypoxemia may predispose to dysrhythmias.

43. Medical Management • Seek medical treatment because they experience excessive sleeplessness at inappropriate times or settings (eg, while driving a car). • In mild cases, the patient is advised to avoid alcohol and medications that depress the upper airway and to lose weight. • In more severe cases involving hypoxemia with severe CO2 retention (hypercapnia), the treatment includes continuous positive airway pressure or bilevel positive airway pressure therapy with supplemental oxygen via nasal cannula

44. Medical Management • Surgical procedures (eg, uvulopalatopharyngoplasty) may be performed to correct the obstruction. • As a last resort, a tracheostomy is performed to bypass the obstruction if the potential for respiratory failure or life-threatening dysrhythmias exists.

45. Nursing Management • Explains the disorder in language that is understandable to the patient and relates symptoms (daytime sleepiness) to the underlying disorder. • Instructs the patient and family about treatments, including the correct and safe use of oxygen, if prescribed.

46. EPISTAXIS (NOSEBLEED) A hemorrhage from the nose, caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nose. Causes associated with epistaxis: • Trauma • Infection • Inhalation of illicit drugs • Cardiovascular diseases • Blood disorders • Nasal tumors • low humidity • a foreign body in the nose • a deviated nasal septum. • vigorous nose blowing and nose picking

47. Medical Management • Depend on location of bleeding, most from anterior portion of the nose. If bleeding is from the anterior portion of the nose: • Apply direct pressure; the pt sits upright with head tilled forward to prevent swallowing & aspiration of blood and is directed to pinch the soft outer portion of the nose against the midline septum for 5 or 10 minutes continuously • If unsuccessful silver nitrate applied or electrocautery • Topical vasoconstriction as adrenalin 1:1000, cocain .5%.

48. If bleeding is occurring from the posterior region: • Cotton pledgets soaked in a vasoconstricting solution may be inserted into the nose to reduce the blood flow and improve the examiner’s view of the bleeding site. • A cotton tampon may be used to try to stop the bleeding. • Suction may be used to remove excess blood and clots from the field of inspection. • Only about 60% of the total nasal cavity can actually be seen, however

49. When the origin of the bleeding cannot be identified: • The nose may be packed with gauze soaked with petrolatum jelly or antibiotic ointment; a topical anesthetic spray and decongestant agent • A balloon-inflated catheter may be used. • The packing may remain in place for 48 hours or up to 5 or 6 days if necessary to control bleeding. • Antibiotics may be prescribed because of the risk of iatrogenic sinusitis and toxic shock syndrome.