Case Study Upper Resp
Mr. Davidson is a 24-year old boxer. He had a boxing game and received with a nose injury. Due to
heavy nosebleed, he was transferred to ER.
Health Assessment and Physical Exam:
Diagnostic Test:
Deviated septum is observed. X-ray is done to confirm the diagnosis.
Patient is alert and oriented. He didn't lose his consciousness. The patient reports severe nose pain. No
other symptoms.
Nursing Care:
What should be your highest priority when you plan the care of this patient?
o Vent airway, BCs
Which position should you assist the patient to and why?
o Up right position, head slightly forward
How do you differentiate between anterior nasal bleeding and posterior nasal bleeding?
o Posterior: secondary to hypertension, older people, coughing, more dangerous, back of throat
o Anterior: stops spontaneously, not life threatening, able to see
What are some of the nursing interventions that can help control the bleeding of this patient? Provide
rationale.
o High fowlers, pinch nose, head tilt forward, acetaminophen, nasal sponges, nasal packing,
medication for pain, Tylenol (no NSAIDS)
What is the appropriate way to apply pressure to stop the epistaxis? How and for how long?
o Pinch nose against septum 10-15 mins, up right, lean forward, ice
Would you insert gauze into the bleeding nostril in this case? Why?
o NO because patient has a fx. If stops in 10-15 mins then no gauze
Considering the bleeding, what medications would be contraindicated?
o NSAIDS, (aleve, advil, ibuprofen) anticoagulants (warfarin, heparin, Lovenox)
Heparin-IV, SC Lab: aPPT Need: sulfate
, Coumocin- PO Lab: PT, INR Need: vit K
Lovenox-
If you notice a clear liquid draining from the patient's left ear, what should you do next?
o Worried about CSF from skull fx, check fluid for glucose, send to lab
What do you expect the vital signs of this patient to be? Explain.
o Increased HR, high RR, increase BP patient is in distress and anxious
The ENT specialist applies nasal ointment that includes topical Lidocaine and epinephrine. What are
the indications and desired outcomes of these two agents?
o Lidocaine pain, epi is vasoconstrictor
The bleeding continues, so the ENT decides to use a Pledget (nasal tampon) impregnated with
cocaine. Why cocaine?
o Cocaine- potent anesthetic and vasoconstrictor
How long should the pledgets remain in the nose?
o 2-3 days
o Need ENT to place and remove pladget
While the pledgets inside the nose, the patient needs to sneeze, what should tell the patient?
o Sneeze with mouth open
Remember the pre-op management (consent, precautions (bleeding and infection), etc).
o Consent- patientneeds to consent unless unconscious
o Precautions- know about bleeding and risk infection
Formulate a nursing diagnosis with highest priority post-op.
o Airway clearance effective
o Edema
Sulfamethoxazole/Trimethoprim (Bactrim) antibiotic was prescribed for the patient to take for 2
weeks. What teaching should you provide regarding the indication and the administration of this
antibiotic?
o Finish antibiotic in entirety
o Bactrim is for MRSA or staph infection
, During the rhinoplasty, packing is inserted and left for few days. What teaching should you provide
regarding the packing?
o No nose blowing, swimming, heavy lifting, strenuous activity
# 2: Allergic Rhinitis
Mrs. Jones is a 32-year old who has a history of persistent allergic rhinitis.
What is the difference between intermittent and persistent allergic rhinitis?
o Intermittent- >4 days a week or 4 months per year
o Persistent-symptoms present more than four days a week and for more than four weeks per year
What seasons of the year do allergies flare up? Why?
o Spring and fall
What immunoglobulin rises when Mrs. Jones exposes to allergens?
o IgE
What are the major chemical mediators that are released during exposure to allergens? What are the
major changes these mediators cause? How do these changes explain the symptoms of sneezing, itching,
and congestion?
o Prostaglandins, leukotrienes, histamines
Release mediators,
Nursing Care:
The best and most important step management of allergic rhinitis is to avoid allergens. Teach the patient
how to identify allergens. (Table 26-4)
Mrs. Jones says "I want something to cure this allergy". How should you respond?
o We can manage symptoms, but not cure allergies
Identify the connection between the chemical mediators that result from the allergic reaction and the
commonly prescribed medications.
o Histamine- antihistamines (counteract histamines released)
What is the indication, mechanism of action, desired outcome, side-effects, and adverse effects of 1st-
generation antihistamines? What is the major advantage of 2nd-generation antihistamines compared
with 1st-generation antihistamine? Mention one 1st-generation antihistamine agent and 2nd-
generationantihistamine agent.
1st gen- Benadryl (diamahydramine)
, Side effect: drowsiness –crosses blood brain barrier, sedation effect on brain
Nursing consideration: no driving
2nd Gen- Zyrtec, Claritin, allegra
Pros: non-sedative,
Con: not as strong as 1st
How can the patient manages the dry mouth/mucosa results from antihistamines?
o Ice chips, hydration
Flunisolide spray, an intranasal corticosteroid, is prescribed for Mrs. Jones. For the best results, when
should Mrs. Jones start using Flunisolide?
o Couple weeks before allergy season
o Take every day, no prn
Mrs. Jones says "I should take Flunisolide when I need"? How should you responds?
o False, need a few weeks to kick in
Mrs. Jones says "Flunisolide relieves symptoms within minutes". How should you respond?
o no
Mrs. Jones asks "I usually get a sinus infection once a year, should I continue flunisolide if I get a sinus
infection or quit?" How should you responds?
o Keep taking
In October, Mrs. Jones' symptoms become worse and Singulair (monteLUKAST), a leukotriene receptor
antagonist inhibitor was added. Before Mrs. Jones can start using Singulair, what should the prescriber
check first?
o Liver function- AST and ALT labs
It is safe for Mrs. Jones to use Singulair, what time of the day should she take it?
o evening
Few months after using Singulair, Mrs. Jones calls and reports that her eyes are "turning yellow". What
should you tell her?
o Stop med, liver damage
Due to some life events, Mrs. Jones develops depression. Phenelzine (Nardil), an monoamine oxidase
inhibitor (MAOI), was prescribed for her. How will Nardil affect the allergy medications of Mrs. Jones?
Mr. Davidson is a 24-year old boxer. He had a boxing game and received with a nose injury. Due to
heavy nosebleed, he was transferred to ER.
Health Assessment and Physical Exam:
Diagnostic Test:
Deviated septum is observed. X-ray is done to confirm the diagnosis.
Patient is alert and oriented. He didn't lose his consciousness. The patient reports severe nose pain. No
other symptoms.
Nursing Care:
What should be your highest priority when you plan the care of this patient?
o Vent airway, BCs
Which position should you assist the patient to and why?
o Up right position, head slightly forward
How do you differentiate between anterior nasal bleeding and posterior nasal bleeding?
o Posterior: secondary to hypertension, older people, coughing, more dangerous, back of throat
o Anterior: stops spontaneously, not life threatening, able to see
What are some of the nursing interventions that can help control the bleeding of this patient? Provide
rationale.
o High fowlers, pinch nose, head tilt forward, acetaminophen, nasal sponges, nasal packing,
medication for pain, Tylenol (no NSAIDS)
What is the appropriate way to apply pressure to stop the epistaxis? How and for how long?
o Pinch nose against septum 10-15 mins, up right, lean forward, ice
Would you insert gauze into the bleeding nostril in this case? Why?
o NO because patient has a fx. If stops in 10-15 mins then no gauze
Considering the bleeding, what medications would be contraindicated?
o NSAIDS, (aleve, advil, ibuprofen) anticoagulants (warfarin, heparin, Lovenox)
Heparin-IV, SC Lab: aPPT Need: sulfate
, Coumocin- PO Lab: PT, INR Need: vit K
Lovenox-
If you notice a clear liquid draining from the patient's left ear, what should you do next?
o Worried about CSF from skull fx, check fluid for glucose, send to lab
What do you expect the vital signs of this patient to be? Explain.
o Increased HR, high RR, increase BP patient is in distress and anxious
The ENT specialist applies nasal ointment that includes topical Lidocaine and epinephrine. What are
the indications and desired outcomes of these two agents?
o Lidocaine pain, epi is vasoconstrictor
The bleeding continues, so the ENT decides to use a Pledget (nasal tampon) impregnated with
cocaine. Why cocaine?
o Cocaine- potent anesthetic and vasoconstrictor
How long should the pledgets remain in the nose?
o 2-3 days
o Need ENT to place and remove pladget
While the pledgets inside the nose, the patient needs to sneeze, what should tell the patient?
o Sneeze with mouth open
Remember the pre-op management (consent, precautions (bleeding and infection), etc).
o Consent- patientneeds to consent unless unconscious
o Precautions- know about bleeding and risk infection
Formulate a nursing diagnosis with highest priority post-op.
o Airway clearance effective
o Edema
Sulfamethoxazole/Trimethoprim (Bactrim) antibiotic was prescribed for the patient to take for 2
weeks. What teaching should you provide regarding the indication and the administration of this
antibiotic?
o Finish antibiotic in entirety
o Bactrim is for MRSA or staph infection
, During the rhinoplasty, packing is inserted and left for few days. What teaching should you provide
regarding the packing?
o No nose blowing, swimming, heavy lifting, strenuous activity
# 2: Allergic Rhinitis
Mrs. Jones is a 32-year old who has a history of persistent allergic rhinitis.
What is the difference between intermittent and persistent allergic rhinitis?
o Intermittent- >4 days a week or 4 months per year
o Persistent-symptoms present more than four days a week and for more than four weeks per year
What seasons of the year do allergies flare up? Why?
o Spring and fall
What immunoglobulin rises when Mrs. Jones exposes to allergens?
o IgE
What are the major chemical mediators that are released during exposure to allergens? What are the
major changes these mediators cause? How do these changes explain the symptoms of sneezing, itching,
and congestion?
o Prostaglandins, leukotrienes, histamines
Release mediators,
Nursing Care:
The best and most important step management of allergic rhinitis is to avoid allergens. Teach the patient
how to identify allergens. (Table 26-4)
Mrs. Jones says "I want something to cure this allergy". How should you respond?
o We can manage symptoms, but not cure allergies
Identify the connection between the chemical mediators that result from the allergic reaction and the
commonly prescribed medications.
o Histamine- antihistamines (counteract histamines released)
What is the indication, mechanism of action, desired outcome, side-effects, and adverse effects of 1st-
generation antihistamines? What is the major advantage of 2nd-generation antihistamines compared
with 1st-generation antihistamine? Mention one 1st-generation antihistamine agent and 2nd-
generationantihistamine agent.
1st gen- Benadryl (diamahydramine)
, Side effect: drowsiness –crosses blood brain barrier, sedation effect on brain
Nursing consideration: no driving
2nd Gen- Zyrtec, Claritin, allegra
Pros: non-sedative,
Con: not as strong as 1st
How can the patient manages the dry mouth/mucosa results from antihistamines?
o Ice chips, hydration
Flunisolide spray, an intranasal corticosteroid, is prescribed for Mrs. Jones. For the best results, when
should Mrs. Jones start using Flunisolide?
o Couple weeks before allergy season
o Take every day, no prn
Mrs. Jones says "I should take Flunisolide when I need"? How should you responds?
o False, need a few weeks to kick in
Mrs. Jones says "Flunisolide relieves symptoms within minutes". How should you respond?
o no
Mrs. Jones asks "I usually get a sinus infection once a year, should I continue flunisolide if I get a sinus
infection or quit?" How should you responds?
o Keep taking
In October, Mrs. Jones' symptoms become worse and Singulair (monteLUKAST), a leukotriene receptor
antagonist inhibitor was added. Before Mrs. Jones can start using Singulair, what should the prescriber
check first?
o Liver function- AST and ALT labs
It is safe for Mrs. Jones to use Singulair, what time of the day should she take it?
o evening
Few months after using Singulair, Mrs. Jones calls and reports that her eyes are "turning yellow". What
should you tell her?
o Stop med, liver damage
Due to some life events, Mrs. Jones develops depression. Phenelzine (Nardil), an monoamine oxidase
inhibitor (MAOI), was prescribed for her. How will Nardil affect the allergy medications of Mrs. Jones?
