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1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 53 Nose Sinus, and Throat Disorders.

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1 1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 53 Nose Sinus, and Throat Disorders

2 2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Learning Objectives Describe the nursing assessment of the nose, sinuses, and throat. Identify nursing responsibilities for patients undergoing tests or procedures to diagnose disorders of the nose, sinuses, or throat. Describe the nurses role when the following common therapeutic measures are instituted: administration of topical medications, irrigations, humidification, suctioning, tracheostomy care, and surgery. Explain the pathophysiology, signs and symptoms, complications, and medical or surgical treatment of selected disorders of the nose, sinuses, and throat. Assist in developing nursing care plans for patients with disorders of the nose, sinuses, or throat.

3 3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy and Physiology of the Nose, Sinuses, and Throat Nose External nose Internal nose Sinuses Maxillary, frontal, ethmoid, and sphenoid Throat

4 4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 53-1

5 5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 53-2

6 6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Health History Chief complaint and history of present illness Obtain detailed description of the patients complaints Past medical history Previous streptococcal infections; sinus infections; surgery on the nose, sinuses, or throat; known allergies; and current and recent medications

7 7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Health History Review of systems Presence of nasal discharge (amount, color), obstruction, bleeding, sneezing, snoring, throat pain or soreness, hoarseness, aphonia (loss of voice), and earache An altered sense of smell or facial pain should be noted

8 8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Physical Examination External nose examined for size, shape, color, and lesions If drainage, note amount, color, and consistency Examiner listens for abnormal breath sounds and notes whether the patient is breathing through the nose or the mouth Patency of the nostrils determined by gently closing one naris at a time and instructing the patient to breathe through the other naris The sinuses are assessed indirectly

9 9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Physical Examination Examiner palpates over the frontal and maxillary sinuses for tenderness or pain Inspect throat at the back of the oral cavity Mucous membranes and tonsils inspected for redness, swelling, drainage, lesions Inspection and palpation of the neck may reveal enlarged lymph nodes

10 10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Age-Related Changes in the Nose, Sinuses, and Throat Nasal obstruction more common because of the softening of the cartilage of the external nose Mucous membrane thinner; produces less mucus Epistaxis (nosebleed) more common in older people Decline in the sense of smell as people age Tissues of larynx are drier and less elastic in older adult Weakened esophageal sphincter allows gastric contents to flow back into the throat when the patient lies down

11 11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures Throat culture Isolate and identify infective organisms Laryngoscopy Inspection of the larynx to aid in diagnosis of abnormalities or to remove foreign bodies

12 12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 53-3

13 13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Therapeutic Measures Nose drops Nasal and throat irrigations Humidification Suctioning Tracheostomy care Nasal surgery

14 14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having Nasal Surgery Assessment Pain, pressure, anxiety, and dyspnea Monitor vital signs to detect signs of excessive blood loss Number of dressings saturated and the frequency of changes Bleeding from the nasal cavity may flow into throat and be swallowed although the dressing remains dry Check back of throat for bleeding; be alert for frequent swallowing Inspect vomitus and stool for blood (bright red or coffee ground emesis and red, maroon, or black stools)

15 15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having Nasal Surgery Interventions Decreased Cardiac Output Acute Pain Impaired Gas Exchange Disturbed Body Image

16 16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Disorders of the Nose, Sinuses, Throat, and Larynx

17 17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Sinusitis Inflammation of the sinuses, most often the maxillary and frontal sinuses Most common organisms are Staphylococcus pneumoniae, Haemophilus influenzae, Diplococcus, and Bacteroides Signs and symptoms Pain or a feeling of heaviness over the affected area Purulent drainage from the nose When maxillary sinuses affected, pain may seem like a toothache Headache is common, especially in the morning Fever may be present; white blood cell count may be elevated

18 18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Sinusitis Complications Chronic sinusitis, meningitis, brain abscess, osteomyelitis, and orbital cellulitis Medical diagnosis and treatment Diagnosis Sinus radiographs, CT; sinus aspiration or nasal endoscopy Treatment Antibiotics, decongestants, nasal corticosteroids, analgesics, and antipyretics Twice-daily hot showers, increased fluid intake, humidifier Functional endoscopic sinus surgery (FESS); Caldwell-Luc procedure

19 19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having Sinus Surgery After FESS, able to return to work in 4-5 days Saline nasal sprays ordered to prevent crusting and promote healing After the Caldwell-Luc procedure, the semi- Fowlers position is recommended to prevent swelling and promote drainage Apply cold compresses as ordered during the first 24 hours Provide gentle oral care to avoid injury to the incision

20 20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having Sinus Surgery Nasal packing is usually left in place until the first postoperative day Antral packing is left in place for 36 to 72 hours Caution the patient to avoid blowing the nose or straining, which could cause bleeding and tissue damage Three to 5 days after the Caldwell-Luc procedure, nasal saline sprays may be ordered to moisten the nasal mucosa

21 21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nasal Polyps Swollen masses of sinus or nasal mucosa and connective tissue that extend into the nasal passages Exact cause is unknown, but patients often have a history of allergic rhinitis or infections The size of the polyps may be reduced by removing allergens or treating the allergic response Corticosteroids inhaled nasally may be prescribed Surgical removal under local anesthesia, however, is often necessary Nasal polyps tend to recur

22 22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having Nasal Polyp Surgery Often in an outpatient surgical facility, so patient teaching before discharge is especially important Advise patient not to take aspirin because it increases the risk of bleeding and because some patients are allergic to aspirin

23 23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Allergic Rhinitis Hay fever: acute (seasonal) or chronic (perennial) Follows exposure to a substance (allergen) that causes an allergic response A reaction to the release of chemicals, including histamine, that cause vasodilation and increased capillary permeability Fluid leaks from capillaries; causes swelling of nasal mucosa Occasionally these changes are triggered by overuse of decongestant nose drops or sprays Acute allergic rhinitis often from exposure to pollens The chronic form is more likely due to allergens that are continuously in the environment

24 24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Allergic Rhinitis Signs and symptoms Nasal obstruction; sneezing; clear nasal discharge; frontal headache; and itchy, watery eyes Nasal mucosa is often pale, but it can be red or bluish Medical diagnosis Made on the basis of a detailed history With chronic symptoms, the patient may be instructed to keep a diary describing all episodes This can help identify possible allergens

25 25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Allergic Rhinitis Medical treatment Desensitizing injections may be advised to decrease the patients reaction to the offending allergens The drugs used to treat allergic rhinitis are primarily antihistamines and decongestants Nursing care Patients with allergic rhinitis are usually outpatients The nurse who works in a clinic or physicians office may need to reinforce teaching about desensitization and drug therapy

26 26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Viral Coryza The common cold Can be caused by any of some 30 viruses It is contagious and spread by droplet infection Signs and symptoms Fever, fatigue, nasal discharge, and sore throat Complications Otitis media, sinusitis, bronchitis, and pneumonia

27 27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Acute Viral Coryza Medical treatment Antihistamines, decongestants, and antipyretics Prevention Best accomplished by avoiding people with colds Nursing care Primarily public education about prevention and about drugs prescribed for treatment Encourage patients to rest and to drink plenty of fluids

28 28Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Tumors Signs and symptoms Nasal obstruction Bloody discharge from one nasal passage Lesions on the external nose typically begin as small, painless ulcers that do not heal Medical diagnosis Diagnosed by taking a biopsy of the tumor or removing the entire tumor for examination

29 29Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Tumors Medical treatment Combination of surgery, radiation therapy, and chemotherapy Surgical procedures may be extensive and disfiguring, depending on the site and extent of the cancer Reconstructive surgery or prostheses may be needed Nursing care Patient may be especially anxious and fearful of disfigurement or even death Be supportive and encourage the patient to ask questions and express concerns

30 30Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Deviated Nasal Septum Nose divided into two passages by a cartilaginous wall called the septum In most adults, septum is slightly deviated, meaning it is off center Minor deviations cause no symptoms and require no treatment Major deviations, however, can obstruct the nasal passages and block sinus drainage Headaches, sinusitis, and epistaxis Treatment: submucosal resection/nasal septoplasty

31 31Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Epistaxis Nosebleed; from trauma, clotting disorders, dryness, inflammation, and hypertension First aid The patient should sit down and lean forward Direct pressure should be applied for 3 to 5 minutes Medical treatment Nasal balloon catheter Nasal packing Complications Infection, blockage of the eustachian tube, and airway obstruction

32 32Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 16-7

33 33Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 53-5

34 34Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Epistaxis Assessment Inspect the nose and back of the throat for obvious bleeding and observe for frequent swallowing Level of consciousness and vital signs to detect signs of hypovolemia Document allergies and major illnesses Interventions Decreased Cardiac Output Anxiety Risk for Injury and Infection

35 35Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pharyngitis Inflammation of the mucous membranes of the throat or pharynx Usually is caused by a virus but sometimes by bacteria Also can follow exposure to irritating substances in the environment

36 36Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pharyngitis Signs and symptoms Dryness, pain, dysphagia (difficulty swallowing), and fever The throat appears red, and the tonsils may be enlarged Compared with viral pharyngitis, bacterial pharyngitis has abrupt onset; characterized by abnormal blood cell counts, fever greater than 101° F, and muscle and joint pain

37 37Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pharyngitis Complications Acute glomerulonephritis and rheumatic fever Medical diagnosis Throat culture and a complete blood count

38 38Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pharyngitis Medical treatment Rest, fluids, analgesics, throat gargles or irrigations Bed rest as long as patient has a fever If oral intake is low, intravenous fluids Soft/liquid diet because of painful swallowing Humidifier to increase moisture in the room air Antibiotics, usually penicillin or erythromycin, while awaiting the results of the throat culture

39 39Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pharyngitis Prevention People with poor resistance should avoid others with upper respiratory infections Good nutrition, adequate rest, avoidance of chilling, and avoidance of inhaled irritants People who have pharyngitis are contagious in the early stages and should avoid contact with susceptible people

40 40Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pharyngitis Assessment Throat pain, dysphagia, muscle and joint pain, nausea and vomiting, and rash Take the patients temperature, and inspect the throat for redness and enlarged tonsils

41 41Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pharyngitis Interventions Reinforce physicians directions for drug therapy Stress importance of completing prescribed antibiotics 2000-3000 mL fluids daily unless contraindicated Advise patients that they are contagious at first and should not be exposed to people with poor resistance

42 42Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Tonsillitis Inflammation of tonsils/other throat lymphatic tissue Common in children but more severe in adults Causes Usually bacterial, but sometimes caused by a virus Causative organisms: streptococci, staphylococci, H. influenzae, and pneumococci The infection is contagious; spread by food or airborne routes Most cases run their course in 7 to 10 days May have repeated infections that respond to treatment or may have a chronic infection

43 43Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Tonsillitis Signs and symptoms Sore throat, difficulty swallowing, fever, chills, muscle aches, and headache If swollen tissue blocks eustachian tubes, ear pain Offensive breath odor often with chronic infection The tonsils typically are enlarged and red Purulent drainage/yellowish or white patches on tonsils Lymph nodes in the neck may be tender and enlarged

44 44Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Tonsillitis Medical diagnosis Complete blood count, throat culture and sensitivity, and a test for infectious mononucleosis

45 45Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Tonsillitis Medical treatment Antibiotic therapy for 7 to 10 days Analgesics and anesthetic lozenges for pain and antipyretics for fever Warm saline gargles or irrigations to decrease swelling and remove drainage Rest and adequate fluids promote recovery and decrease the risk of complications

46 46Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Tonsillitis Complications Peritonsillar abscess Surgical treatment Tonsillectomy and adenoidectomy

47 47Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having a Tonsillectomy Assessment Frequently monitor responsiveness/vital signs Inspect drainage from the mouth or vomited fluid for blood Excessive swallowing may indicate bleeding Monitor respiratory effort and skin color to evaluate oxygenation Evaluate pain and dysphagia

48 48Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having a Tonsillectomy Interventions Decreased Cardiac Output Ineffective Airway Clearance Acute Pain Ineffective Therapeutic Regimen Management

49 49Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Obstructive Sleep Apnea Airway obstruction during sleep The tongue and soft palate fall backward partially or completely blocking the airway, causing apnea and hypopnea (abnormally slow, shallow breathing) Blood oxygen level falls; carbon dioxide level rises Stimulate ventilation; cause the patient to arouse Patient startles, snorts, and gasps causing the tongue and soft palate to move forward so the airway is open

50 50Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 53-6

51 51Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Obstructive Sleep Apnea Symptoms related to disrupted sleep pattern Patient often irritable and sleepy during the day Sleeping partner may report loud snoring or episodes of apnea Symptoms can affect many aspects of life Concentration and memory may be impaired Hypertension and cardiac dysrhythmias Diagnosis confirmed by polysomnography

52 52Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Obstructive Sleep Apnea Conservative treatment: weight loss if obese, avoidance of sedatives and alcohol for 3-4 hours before bedtime Oral appliance that shifts mandible and tongue forward may be effective Serious symptoms are treated with nasal continuous positive airway pressure (CPAP) Surgical procedures: uvulopalatopharyngoplasty (UPPP or UP3), genioglossal advancement and hyoid myotomy (GAHM), and laser-assisted uvulopalatoplasty (LAUP)

53 53Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 53-7

54 54Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Laryngitis Inflammation of the larynx Causes: upper respiratory infections, voice strain, smoking, alcohol ingestion, and inhalation of irritating fumes Signs and symptoms Hoarseness, cough, and scratchy or painful throat Aphonia: absence of sound production; losing his or her voice Medical diagnosis Patients history and symptoms Throat culture

55 55Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Laryngitis Medical treatment Voice rest is advised, meaning that the patient should not talk Removal of the irritant

56 56Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Laryngitis Assessment Document severity, how long it has persisted, and factors that to aggravate or precipitate it Information about the patients occupation and hobbies may provide clues to the cause of the laryngitis Take the patients temperature and describe respiratory status to detect possible infection

57 57Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Laryngitis Interventions Pad and pencil or Magic Slate for communication Sign over the bed noting that patient should not speak Notice on the intercom at the nurses station that the patient cannot (or should not) speak Discourage smoking An environment with a constant temperature Teach patients that irritants can lead to laryngitis Recognize irritants in the home and workplace and know how to protect themselves from harm

58 58Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Laryngeal Nodules Benign masses of fibrous tissue result primarily from voice overuse but can follow infections Singers and public speakers prone to development of nodules The only symptom is hoarseness Nodules are surgically removed under local or general anesthesia

59 59Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Laryngeal Polyps Swollen mass of mucous membrane attached to vocal cord Can cause continuous or intermittent hoarseness, depending on its location and attachment In heavy smokers, masses may develop on both cords A procedure called stripping of the vocal cords is necessary to treat this condition Unless patient continues smoking, condition usually does not return Voice rest prescribed if polyps removed

60 60Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cancer of the Larynx Factors: exposure to smoke or other noxious fumes, alcohol consumption, vocal strain, and chronic laryngitis Malignant tumors can develop throughout the larynx: above the glottis, on the vocal cords, or below the vocal cords Most malignancies are squamous cell carcinomas

61 61Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cancer of the Larynx Signs and symptoms Early symptoms include persistent hoarseness or sore throat and ear pain Later signs and symptoms are hemoptysis and difficulty swallowing or breathing

62 62Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cancer of the Larynx Prevention Stop smoking and drinking alcohol The public also should be educated to recognize the signs and symptoms of laryngeal cancer and seek prompt medical attention

63 63Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cancer of the Larynx Medical diagnosis Confirmed by study of a tissue sample obtained during a laryngoscopy Radiographs, CT scans, and MRI to define the extent of the cancer

64 64Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cancer of the Larynx Medical treatment Surgery, radiotherapy, chemotherapy, or a combination Surgery: from simple removal of the tumor to extensive procedures, such as laryngectomy and modified or radical neck dissection A laryngectomy can be total or partial Voice preserved with hemilaryngectomy or supraglottic laryngectomy; total laryngectomy causes permanent loss of the natural voice

65 65Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 53-8

66 66Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having a Total Laryngectomy If patient will lose the ability to speak, information about other means of communication should be available Listen compassionately and accept the patients expressions of anger or despair A total laryngectomy will require that the patient breathe through the trachea

67 67Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having a Total Laryngectomy Complications Salivary fistula, carotid artery blowout, tracheal stenosis Assessment Patients level of consciousness Ask about pain and observe for signs of discomfort Measure vital signs at frequent intervals Continuous electrocardiogram monitoring and pulse oximetry to assess oxygenation and circulation Fluid intake and output, wound drainage

68 68Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having a Total Laryngectomy Interventions Ineffective Airway Clearance Anxiety Decreased Cardiac Output Acute Pain Risk for Injury Imbalanced Nutrition: Less Than Body Requirements Impaired Verbal Communication Ineffective Coping Risk for Infection Ineffective Therapeutic Regimen Management

69 69Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 53-10

70 70Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having a Supraglottic Laryngectomy Care like that for total laryngectomy except the tracheostomy is temporary, the voice is not lost, and swallowing is more problematic Enteral feedings may be needed for a long time, so begin to instruct the patient in self-feeding Be alert for signs and symptoms of this complication: increased pulse and respiratory rates, dyspnea, cough, crackles and rhonchi, fever, wheezing, and frothy, pink sputum Keep a suction machine readily available

71 71Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Care of the Patient Having a Partial Laryngectomy Temporary tracheostomy for 2 to 5 days IV fluids and enteral feedings are ordered at first Patients have considerable difficulty swallowing when oral nourishment is resumed To prevent aspiration, seat the patient upright, with the head flexed slightly forward Semisolids easier to manage than thin liquids Suction machine should be on hand


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