29
Upper Respiratory Problems
Janice A. Sarasnick
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cellular Regulation Infection
Functional Ability Sensory Perception
Gas Exchange
LEARNING OUTCOMES
1. Describe the clinical manifestations and nursing and 4. Describe the clinical manifestations and nursing and
interprofessional management of problems of the nose. interprofessional management of problems of the pharynx
2. Discuss the clinical manifestations and nursing and and larynx.
interprofessional management of problems of the paranasal 5. Outline the risk factors for and clinical manifestations of
sinuses. head and neck cancer.
3. Describe the clinical manifestations, nursing, and 6. Discuss the nursing and interprofessional management of
interprofessional management of an upper respiratory patients undergoing surgery for head and neck cancer.
infection. 7. Explain essential components of discharge teaching for the
patient going home with a permanent tracheostomy after
total laryngectomy for cancer.
KEY TERMS
acute laryngitis laryngectomy, Table 29.7
airway obstruction pharyngitis
allergic rhinitis rhinoplasty
epistaxis sinusitis
influenza upper respiratory infections
This chapter discusses problems of the upper respiratory system, 80% of adults may have septa that are slightly off-center. The
which includes the nose, sinuses, pharynx, and larynx, and the diagnosis of a deviated septum is generally reserved for those
care of those undergoing surgery for head and neck cancers. The whose septa are severely shifted.1 A deviated septum can inter-
primary concern with upper respiratory problems is the impact fere with both airflow and sinus drainage due to the narrowed
on ventilation and oxygen (O2) availability. They can negatively passageway.
affect sleep and impair the ability to obtain and maintain nutri- Symptoms vary depending on the degree of deviation. Minor
tion. Sinus and upper respiratory tract infections, allergies, and septal deviations can range from asymptomatic to nasal con-
oral problems can change the senses of both smell and taste. gestion and frequent sinus infections. Manifestations of severe
The patient with head and neck cancer often has depression, septal deviation include facial pain, nosebleeds (epistaxis), and
changes in body image, and impaired sexuality. obstruction to nasal breathing.
The diagnosis is made during examination with a nasal
speculum. The medical management of minor septal deviation
NASAL AND PARANASAL SINUS PROBLEMS focuses on symptom control. For nasal inflammation and con-
gestion, use saline rinses and decongestants to clear nasal pas-
DEVIATED SEPTUM sages and analgesics for pain relief. For severe septal deviation, a
Deviated septum is a deflection of the normally straight nasal nasal septoplasty reconstructs and properly aligns the deviated
septum. The cause is usually from trauma or is genetic. Up to septum.
577
,578 SECTION 6 Problems of Oxygenation: Ventilation
Surgical options include septoplasty and rhinoplasty.
NASAL FRACTURE Septoplasty is done to correct a deviated septum. Patients have
Nasal fracture is the most common facial fracture and the third rhinoplasty for several reasons. Both procedures help maintain
most common fracture of any bone.2 They often occur from a patent airway, restore function of the nose, and help reestab-
blunt trauma, including fights, automobile accidents, falls, and lish the patient’s cosmetic appearance. The presence of septal
sports injuries. Using protective sports equipment and safe- hematoma increases the patient’s risk for deformity and infec-
guarding against falls can prevent many nasal fractures. tion, which may require drainage and antibiotic therapy.
There is no universally accepted classification system for
nasal fractures. We can classify nasal fractures by their fracture
pattern (e.g., impacted, comminuted) or the direction of injury
RHINOPLASTY
(e.g., lateral, frontal). Simple fractures may be unilateral or bilat- Rhinoplasty is the surgical reconstruction of the nose. It is done
eral. They typically have little or no displacement. Powerful for cosmetic reasons or to improve airway function when trauma
frontal blows can cause complex fractures, which may involve or developmental deformities result in nasal obstruction.
damage to adjacent facial structures, such as the teeth or eyes. Most rhinoplasty is an outpatient procedure using regional
Patients with nasal fractures from blunt force trauma should be or general anesthesia. Nasal tissue is added or removed, and
evaluated for injury to the cervical spine, orbital sockets, and the nose may be lengthened or shortened. Plastic implants are
mandible. Complications include airway obstruction, nose- sometimes used to reshape the nose. Incisions are typically
bleeds, meningeal tears causing cerebrospinal fluid (CSF) leak- inside the nose and hidden. Sonic rhinoplasty employs an ultra-
age, septal hematoma, and cosmetic deformity. sonic device to gently aspirate bone, enabling a refined cosmetic
Diagnosis of a nasal fracture is based on health history and result.4
physical assessment. Although facial deformity with a nasal Before surgery, assess the patient’s expectations of the sur-
fracture is common, a nosebleed may be the only manifesta- gery. Actual or perceived changes in body image (e.g., deformed
tion. Other manifestations include localized pain, crepitus on or enlarged nose) can affect self-esteem and interactions with
palpation, swelling, difficulty breathing out of the nostrils, and others. The HCP can use digital photographs to show patients
bruising. their projected appearance after surgery. These images can help
Assess the patient’s ability to breathe through each side of patients decide whether to undergo rhinoplasty.
the nose. Note the presence of edema, bleeding, or hematoma. Obtain a medication history. Aspirin-containing drugs and
Periorbital bruising involving both eyes is called raccoon eyes. It NSAIDs may need to be stopped for 5 days to 2 weeks before
suggests a basilar skull fracture. It increases the chance of CSF surgery to reduce the risk of bleeding. Encourage smoking ces-
leaking into the nasal cavities. Inspect the nose internally for sation to promote postoperative wound healing.
evidence of septal deviation, clear drainage, edema, or bleeding. During the immediate postoperative period, nursing inter-
Clear or pink-tinged persistent drainage after control of bleed- ventions include (1) ensuring patency of the airway, (2) contin-
ing suggests a possible CSF leak. If needed, send a specimen to uous assessment of respiratory status, (3) monitoring for airway
the laboratory to determine the fluid type. obstruction, (4) pain management, and (5) observation of the
Goals of nursing care are to maintain a patent airway, reduce surgical site for edema, bleeding, and infection.
edema and pain, prevent complications, and provide emotional After surgery, nasal packing may be inserted to apply pres-
support. The best way to maintain the airway is to keep the sure and prevent bleeding or septal hematoma formation. An
patient sitting upright. Apply ice to the face and nose in 10- to external plastic splint protects and supports the new shape of
20-minute intervals to help reduce edema and bleeding. Tell the the nose during the healing process. If present, nasal packing is
patient not to blow their nose once bleeding has stopped so they usually removed 1 or 2 days after surgery. The splint may be left
do not disrupt the clot or cause further trauma. Give analge- in place for 1 to 2 weeks.
sia as ordered to control pain. Acetaminophen is preferred over Teaching is important because the patient must be able to
nonsteroidal antiinflammatory drugs (NSAIDs) or aspirin for detect complications at home. The patient typically has tempo-
the first 48 hours to avoid prolonging clotting time and increas- rary nasal and/or facial edema and bruising. Cold compresses
ing the risk for bleeding. Nasal stuffiness may be relieved with and elevating the head can help minimize swelling and dis-
nasal decongestants, saline nasal sprays, and a humidifier. The comfort. Teach about activity restrictions aimed at preventing
patient should avoid hot showers and alcohol for the first 48 bleeding and injury (no nose blowing, swimming, heavy lifting,
hours to prevent an increase in swelling. Encourage the patient strenuous exercise). Sometimes swelling may be slow to resolve,
to quit or decrease smoking to help tissue healing. delaying the achievement of a full cosmetic result for up to 1
When a fracture is confirmed, the goals are to realign the year.
fractured bones using either manual manipulation or surgery.3
Simple fractures are often reduced with manual manipulation.
With complex nasal fractures, considerable swelling of soft
EPISTAXIS
tissues occurs. It may be necessary to wait to repair the frac- Epistaxis (nosebleed) most often occurs in adults over age 50.
ture until after the edema subsides. This may be 5 to 10 days. Nosebleeds can be caused by trauma, low humidity, upper respi-
Antibiotics should be considered for any nasal fracture with dis- ratory tract infections, allergies, sinusitis, foreign bodies, chem-
ruption to the mucosa. ical irritants (e.g., street drugs), overuse of decongestant nasal
, CHAPTER 29 Upper Respiratory Problems 579
A B
C D
Fig. 29.1 (A) Epistaxis balloon. The balloon is inflated after insertion. (B) Epistaxis balloon properly position
in nares. (C) Method for placing posterior nasal pack. A catheter is passed through the bleeding side of the
nose and pulled out through the mouth with a hemostat. Strings are tied to the catheter. The pack is pulled
up behind the soft palate and into the nasopharynx. (D) Nasal pack in position in the posterior nasopharynx.
Dental roll at the nose helps maintain the correct position. (A, Courtesy Boston Medical, Westborough, MA.
B, From Roberts JR, Hedges JR: Clinical procedures in emergency medicine, ed 5, Philadelphia, 2009, Saun-
ders.)
sprays, facial or nasal surgery, anatomic malformation, and 3. If bleeding does not stop within 15 minutes, seek medical
tumors. Conditions that prolong bleeding time or change plate- assistance.
let counts may predispose a patient to nosebleeds.5 Bleeding An anterior bleed may be treated medically by placing a
time may be prolonged if the patient takes aspirin, NSAIDs, pledget (nasal tampon) impregnated with anesthetic solution
warfarin, or other anticoagulant drugs. (lidocaine) and/or vasoconstrictive agents (epinephrine) into
We describe nosebleeds as anterior or posterior. About 90% the nasal cavity. Absorbable materials, such as oxidized cellu-
of nosebleeds occur in the anterior part of the nasal cavity. They lose (surgical), gelatin foam (Gelfoam), or a gelatin-thrombin
are easy to visualize. Anterior bleeding can be self-treated and combination (Floseal), are another option. Packing for ante-
usually stops spontaneously. Posterior bleeding occurs more rior bleeds can stay in place for 48 to 72 hours. Silver nitrate
often with older adults with other health problems. Since poste- may be used to chemically cauterize a specific bleeding point.
rior nosebleeds are closer to the throat, it is often hard to deter- Thermal cauterization is reserved for more severe bleeding. It
mine how much blood loss has occurred. Posterior bleeding may require the use of local or general anesthesia.6
may need medical treatment. It may be harder to find the location of a posterior bleed.
Posterior bleeds often need packing. Packing with compressed
Nursing and Interprofessional Management: nasal sponges (e.g., Merocel) or epistaxis balloons (e.g., Rapid
Epistaxis Rhino) is best because of the ease of placement. Packing is
Use simple first aid measures to control nosebleeds: inserted into the nares and advanced along the floor of the nasal
1. Place the patient in a sitting position, leaning slightly for- cavity. The sponge expands with moisture to fill the nasal cavity
ward with head tilted forward. and tamponade bleeding. An epistaxis balloon inflated with air
2. Apply direct pressure by squeezing the entire soft lower part achieves the same pressure effect (Fig. 29.1). In the absence of
of the nose (nostrils) together for 5 to 15 minutes. a specific nasal device, we may use a size 10F, 12F, or 14F Foley
Upper Respiratory Problems
Janice A. Sarasnick
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cellular Regulation Infection
Functional Ability Sensory Perception
Gas Exchange
LEARNING OUTCOMES
1. Describe the clinical manifestations and nursing and 4. Describe the clinical manifestations and nursing and
interprofessional management of problems of the nose. interprofessional management of problems of the pharynx
2. Discuss the clinical manifestations and nursing and and larynx.
interprofessional management of problems of the paranasal 5. Outline the risk factors for and clinical manifestations of
sinuses. head and neck cancer.
3. Describe the clinical manifestations, nursing, and 6. Discuss the nursing and interprofessional management of
interprofessional management of an upper respiratory patients undergoing surgery for head and neck cancer.
infection. 7. Explain essential components of discharge teaching for the
patient going home with a permanent tracheostomy after
total laryngectomy for cancer.
KEY TERMS
acute laryngitis laryngectomy, Table 29.7
airway obstruction pharyngitis
allergic rhinitis rhinoplasty
epistaxis sinusitis
influenza upper respiratory infections
This chapter discusses problems of the upper respiratory system, 80% of adults may have septa that are slightly off-center. The
which includes the nose, sinuses, pharynx, and larynx, and the diagnosis of a deviated septum is generally reserved for those
care of those undergoing surgery for head and neck cancers. The whose septa are severely shifted.1 A deviated septum can inter-
primary concern with upper respiratory problems is the impact fere with both airflow and sinus drainage due to the narrowed
on ventilation and oxygen (O2) availability. They can negatively passageway.
affect sleep and impair the ability to obtain and maintain nutri- Symptoms vary depending on the degree of deviation. Minor
tion. Sinus and upper respiratory tract infections, allergies, and septal deviations can range from asymptomatic to nasal con-
oral problems can change the senses of both smell and taste. gestion and frequent sinus infections. Manifestations of severe
The patient with head and neck cancer often has depression, septal deviation include facial pain, nosebleeds (epistaxis), and
changes in body image, and impaired sexuality. obstruction to nasal breathing.
The diagnosis is made during examination with a nasal
speculum. The medical management of minor septal deviation
NASAL AND PARANASAL SINUS PROBLEMS focuses on symptom control. For nasal inflammation and con-
gestion, use saline rinses and decongestants to clear nasal pas-
DEVIATED SEPTUM sages and analgesics for pain relief. For severe septal deviation, a
Deviated septum is a deflection of the normally straight nasal nasal septoplasty reconstructs and properly aligns the deviated
septum. The cause is usually from trauma or is genetic. Up to septum.
577
,578 SECTION 6 Problems of Oxygenation: Ventilation
Surgical options include septoplasty and rhinoplasty.
NASAL FRACTURE Septoplasty is done to correct a deviated septum. Patients have
Nasal fracture is the most common facial fracture and the third rhinoplasty for several reasons. Both procedures help maintain
most common fracture of any bone.2 They often occur from a patent airway, restore function of the nose, and help reestab-
blunt trauma, including fights, automobile accidents, falls, and lish the patient’s cosmetic appearance. The presence of septal
sports injuries. Using protective sports equipment and safe- hematoma increases the patient’s risk for deformity and infec-
guarding against falls can prevent many nasal fractures. tion, which may require drainage and antibiotic therapy.
There is no universally accepted classification system for
nasal fractures. We can classify nasal fractures by their fracture
pattern (e.g., impacted, comminuted) or the direction of injury
RHINOPLASTY
(e.g., lateral, frontal). Simple fractures may be unilateral or bilat- Rhinoplasty is the surgical reconstruction of the nose. It is done
eral. They typically have little or no displacement. Powerful for cosmetic reasons or to improve airway function when trauma
frontal blows can cause complex fractures, which may involve or developmental deformities result in nasal obstruction.
damage to adjacent facial structures, such as the teeth or eyes. Most rhinoplasty is an outpatient procedure using regional
Patients with nasal fractures from blunt force trauma should be or general anesthesia. Nasal tissue is added or removed, and
evaluated for injury to the cervical spine, orbital sockets, and the nose may be lengthened or shortened. Plastic implants are
mandible. Complications include airway obstruction, nose- sometimes used to reshape the nose. Incisions are typically
bleeds, meningeal tears causing cerebrospinal fluid (CSF) leak- inside the nose and hidden. Sonic rhinoplasty employs an ultra-
age, septal hematoma, and cosmetic deformity. sonic device to gently aspirate bone, enabling a refined cosmetic
Diagnosis of a nasal fracture is based on health history and result.4
physical assessment. Although facial deformity with a nasal Before surgery, assess the patient’s expectations of the sur-
fracture is common, a nosebleed may be the only manifesta- gery. Actual or perceived changes in body image (e.g., deformed
tion. Other manifestations include localized pain, crepitus on or enlarged nose) can affect self-esteem and interactions with
palpation, swelling, difficulty breathing out of the nostrils, and others. The HCP can use digital photographs to show patients
bruising. their projected appearance after surgery. These images can help
Assess the patient’s ability to breathe through each side of patients decide whether to undergo rhinoplasty.
the nose. Note the presence of edema, bleeding, or hematoma. Obtain a medication history. Aspirin-containing drugs and
Periorbital bruising involving both eyes is called raccoon eyes. It NSAIDs may need to be stopped for 5 days to 2 weeks before
suggests a basilar skull fracture. It increases the chance of CSF surgery to reduce the risk of bleeding. Encourage smoking ces-
leaking into the nasal cavities. Inspect the nose internally for sation to promote postoperative wound healing.
evidence of septal deviation, clear drainage, edema, or bleeding. During the immediate postoperative period, nursing inter-
Clear or pink-tinged persistent drainage after control of bleed- ventions include (1) ensuring patency of the airway, (2) contin-
ing suggests a possible CSF leak. If needed, send a specimen to uous assessment of respiratory status, (3) monitoring for airway
the laboratory to determine the fluid type. obstruction, (4) pain management, and (5) observation of the
Goals of nursing care are to maintain a patent airway, reduce surgical site for edema, bleeding, and infection.
edema and pain, prevent complications, and provide emotional After surgery, nasal packing may be inserted to apply pres-
support. The best way to maintain the airway is to keep the sure and prevent bleeding or septal hematoma formation. An
patient sitting upright. Apply ice to the face and nose in 10- to external plastic splint protects and supports the new shape of
20-minute intervals to help reduce edema and bleeding. Tell the the nose during the healing process. If present, nasal packing is
patient not to blow their nose once bleeding has stopped so they usually removed 1 or 2 days after surgery. The splint may be left
do not disrupt the clot or cause further trauma. Give analge- in place for 1 to 2 weeks.
sia as ordered to control pain. Acetaminophen is preferred over Teaching is important because the patient must be able to
nonsteroidal antiinflammatory drugs (NSAIDs) or aspirin for detect complications at home. The patient typically has tempo-
the first 48 hours to avoid prolonging clotting time and increas- rary nasal and/or facial edema and bruising. Cold compresses
ing the risk for bleeding. Nasal stuffiness may be relieved with and elevating the head can help minimize swelling and dis-
nasal decongestants, saline nasal sprays, and a humidifier. The comfort. Teach about activity restrictions aimed at preventing
patient should avoid hot showers and alcohol for the first 48 bleeding and injury (no nose blowing, swimming, heavy lifting,
hours to prevent an increase in swelling. Encourage the patient strenuous exercise). Sometimes swelling may be slow to resolve,
to quit or decrease smoking to help tissue healing. delaying the achievement of a full cosmetic result for up to 1
When a fracture is confirmed, the goals are to realign the year.
fractured bones using either manual manipulation or surgery.3
Simple fractures are often reduced with manual manipulation.
With complex nasal fractures, considerable swelling of soft
EPISTAXIS
tissues occurs. It may be necessary to wait to repair the frac- Epistaxis (nosebleed) most often occurs in adults over age 50.
ture until after the edema subsides. This may be 5 to 10 days. Nosebleeds can be caused by trauma, low humidity, upper respi-
Antibiotics should be considered for any nasal fracture with dis- ratory tract infections, allergies, sinusitis, foreign bodies, chem-
ruption to the mucosa. ical irritants (e.g., street drugs), overuse of decongestant nasal
, CHAPTER 29 Upper Respiratory Problems 579
A B
C D
Fig. 29.1 (A) Epistaxis balloon. The balloon is inflated after insertion. (B) Epistaxis balloon properly position
in nares. (C) Method for placing posterior nasal pack. A catheter is passed through the bleeding side of the
nose and pulled out through the mouth with a hemostat. Strings are tied to the catheter. The pack is pulled
up behind the soft palate and into the nasopharynx. (D) Nasal pack in position in the posterior nasopharynx.
Dental roll at the nose helps maintain the correct position. (A, Courtesy Boston Medical, Westborough, MA.
B, From Roberts JR, Hedges JR: Clinical procedures in emergency medicine, ed 5, Philadelphia, 2009, Saun-
ders.)
sprays, facial or nasal surgery, anatomic malformation, and 3. If bleeding does not stop within 15 minutes, seek medical
tumors. Conditions that prolong bleeding time or change plate- assistance.
let counts may predispose a patient to nosebleeds.5 Bleeding An anterior bleed may be treated medically by placing a
time may be prolonged if the patient takes aspirin, NSAIDs, pledget (nasal tampon) impregnated with anesthetic solution
warfarin, or other anticoagulant drugs. (lidocaine) and/or vasoconstrictive agents (epinephrine) into
We describe nosebleeds as anterior or posterior. About 90% the nasal cavity. Absorbable materials, such as oxidized cellu-
of nosebleeds occur in the anterior part of the nasal cavity. They lose (surgical), gelatin foam (Gelfoam), or a gelatin-thrombin
are easy to visualize. Anterior bleeding can be self-treated and combination (Floseal), are another option. Packing for ante-
usually stops spontaneously. Posterior bleeding occurs more rior bleeds can stay in place for 48 to 72 hours. Silver nitrate
often with older adults with other health problems. Since poste- may be used to chemically cauterize a specific bleeding point.
rior nosebleeds are closer to the throat, it is often hard to deter- Thermal cauterization is reserved for more severe bleeding. It
mine how much blood loss has occurred. Posterior bleeding may require the use of local or general anesthesia.6
may need medical treatment. It may be harder to find the location of a posterior bleed.
Posterior bleeds often need packing. Packing with compressed
Nursing and Interprofessional Management: nasal sponges (e.g., Merocel) or epistaxis balloons (e.g., Rapid
Epistaxis Rhino) is best because of the ease of placement. Packing is
Use simple first aid measures to control nosebleeds: inserted into the nares and advanced along the floor of the nasal
1. Place the patient in a sitting position, leaning slightly for- cavity. The sponge expands with moisture to fill the nasal cavity
ward with head tilted forward. and tamponade bleeding. An epistaxis balloon inflated with air
2. Apply direct pressure by squeezing the entire soft lower part achieves the same pressure effect (Fig. 29.1). In the absence of
of the nose (nostrils) together for 5 to 15 minutes. a specific nasal device, we may use a size 10F, 12F, or 14F Foley
