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2.10 METODOLOGÍA PARA LA IMPLEMENTACIÓN DE UN SGC
1.0 Introduction 2.0 Objectives 3.0 Main Content
3.1 Rhinitis 3.2 Sinusitis 3.3 Pharyngitis
3.4 Tonsillitis and Adenoiditis 3.5 Peritonsillar Abscess 3.6 Laryngitis
4.0 Conclusion 5.0 Summary
6.0 Tutor-Marked Assignment
1.0 INTRODUCTION
The most common upper airway illnesses are infectious and inflammatory disorders. The average person experiences three to five upper respiratory infections (URIs) each year. For some individuals, URIs develop into bronchitis or pneumonia, which involves more serious symptoms and may require antibiotics or other treatments.
2.0 OBJECTIVES
At the end of this unit you will be able to:
• Compare and contrast upper airway infections with regard to etiology, signs and symptoms, clinical manifestations, nursing management, and prevention.
• Apply the nursing process as a framework for developing a nursing care plan for patients with upper airway infection.
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3.0 MAIN CONTENT 3.1 Rhinitis
Rhinitis is inflammation of the nasal mucous membranes. It also is referred to as the common cold, or coryza. Rhinitis may be acute, chronic, or allergic, depending on the cause. The most common cause is the rhinovirus, of which more than 100 strains exist. Colds are rapidly spread by inhalation of droplets and direct contact with contaminated articles (e.g., telephone receivers, doorknobs). Allergic rhinitis is a hypersensitive reaction to allergens, such as pollen, dust, animal dander, or food. Rhinitis is usually not a serious condition; however, it may lead to pneumonia and other more serious illnesses for debilitated, immuno-suppressed, or older clients.
Symptoms associated with rhinitis include sneezing, nasal congestion, rhinorrhea (clear nasal discharge), sore throat, watery eyes, cough, low-grade fever, headache, aching muscles, and malaise. With the common cold, these symptoms continue for 5 to 14 days. A sustained elevated temperature suggests a bacterial infection or infection in the sinuses or ears.
Symptoms of allergic rhinitis will persist as long as the client is exposed to the specific allergen.
Treatment
For most clients, treatment for rhinitis is minimal. Unless specific bacteria are identified as the cause of the infection, antibiotics are not used. Clients may be advised to use antipyretics, such as acetaminophen or non-steroidal analgesics, for fever. Decongestants such as pseudoephedrine may be recommended for severe nasal congestion. For clients experiencing a prolonged cough, anti tussives may be ordered. Saline gargles are useful for a sore throat, as is saline spray for nasal congestion and prevention of crusting. For allergic rhinitis, antihistamines are often used. An example of a first-generation antihistamine is diphenhydramine (Benadryl). Newer antihistamines include loratadine (Claritin), fexofenadine (Allegra), and cetirizine (Zyrtec). Combination decongestants and antihistamines may also
be helpful. An example of this is
brompheniramine/pseudoephedrine(Dimetapp). Medications that desensitize or suppress immune responses, such as cromolyn (Nasalcrom) or intranasal glucocorticosteroids, such as fluticasone (Flonase) may also be prescribed for allergic rhinitis.
Mechanism of Action Side Effects Nursing Considerations
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3.2 Sinusitis
Sinusitis is inflammation of the sinuses. The maxillary sinus is affected most often. Sinusitis can lead to serious complications, such as infection of the middle ear or brain.
Pathophysiology and Etiology
The principal causes are the spread of an infection from the nasal passages to the sinuses and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis because trapped secretions readily become infected. Impaired sinus drainage may result from allergies (which cause edema of the nasal mucous membranes), nasal polyps, or a deviated septum. Measures that help reduce the incidence or severity of sinusitis include eating a well-balanced diet, getting plenty of rest, engaging in moderate exercise, avoiding allergens, and seeking medical attention promptly if a cold persists longer than 10 days or nasal discharge is green or dark yellow and foul smelling.
Sign and symptoms
Signs and symptoms depend on which sinus is infected. They include headache, fever, pain over the affected sinus. Nasal congestion and discharge, pain and pressure around the eyes and malaise.
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Diagnosis
A nasal smear or material obtained from irrigation of the sinus for culture and sensitivity testing identifies the infectious microorganism and appropriate antibiotic therapy. Transillumination and radiographs of the
27 sinuses may show a change in the shape of or fluid in the sinus cavity. A thorough history, including an allergy history, usually confirms the diagnosis.
Medical and Surgical Management
Acute sinusitis frequently responds to conservative treatment designed to help overcome the infection. Saline irrigation of the maxillary sinus may be done to remove accumulated exudate and promote drainage. Such irrigation is accomplished by insertion of a catheter through the normal opening under the middle concha. Antibiotic therapy is necessary for severe infections. Vasoconstrictors, such as phenylephrine nose drops, may be recommended for short-term use to relieve nasal congestion and aid in sinus drainage. Surgery is often indicated for chronic sinusitis. Endoscopic sinus surgery helps provide an opening in the inferior meatus to promote drainage. More radical procedures, such as the Caldwell-Luc procedure and external sphenoethmoidectomy, are done to remove diseased tissue and provide an opening into the inferior meatus of the nose for adequate drainage.
Nursing Management
If the client is receiving medical treatment, the nurse informs him or her that use of mouthwashes and humidification, as well as increased fluid intake, may loosen secretions andincrease comfort. He or she instructs the client to take nasal decongestants and antihistamines as ordered. If the client has had sinus surgery, the nurse institutes standards for postoperative care. He or she observes the client for repeated swallowing, a finding that suggests possible hemorrhage. One risk of sinus surgery is damage to the optic nerve. Thus, the nurse assesses postoperative visual acuity by asking the client to identify the number of fingers displayed. The nurse monitors the client’s temperature at least every 4 hours. He or she assesses for pain over the involved sinuses, a finding that may indicate postoperative infection or impaired drainage. The nurse administers analgesics as indicated and applies ice compresses to involved sinuses to reduce pain and edema.
The postsurgical client will have nasal packing and a dressing under the nares (‘‘moustache’’ dressing or ‘‘drip pad’’). Because nasal packing forces the client to breathe through the mouth, the nurse encourages oral hygiene and gives ice chips or small sips of fluids frequently. Such measures alleviate the dryness caused by mouth breathing. The nurse changes the drip pad as needed and reports excessive drainage. Postoperative client and family teaching includes telling the client not to blow the nose, lift heavy objects, or do the Valsalva maneuver for 10 to 14 days postoperatively. The
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nurse urges the client to remain in a warm environment and to avoid smoky or poorly ventilated areas.
3.3 Pharyngitis
Pharyngitis, inflammation of the throat, is often associated with rhinitis and other URIs. Viruses and bacteria cause pharyngitis. The most serious bacteria are the group A streptococci, which cause a condition commonly referred to as strep throat. Strep throat can lead to dangerous cardiac complications (endocarditis and rheumatic fever) and harmful renal complications (glomerulonephritis). Pharyngitis is highly contagious and spreads via inhalation of or direct contamination with droplets. The incubation period for pharyngitis is 2 to 4 days.
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Signs and symptoms
The first symptom is a sore throat, sometimes severe, with accompanying dysphagia (difficulty swallowing), fever, chills, headache, and malaise.
Some clients exhibit a white or exudate patch over the tonsillar area and swollen glands.
Diagnosis
A throat culture reveals the specific causative bacteria. Rapid identification methods, such as the Biostar or the Strep A optical immunoassay (OIA), are available to diagnose group Astreptococcal infections. These tests are done in clinics and physician offices. Standard 24-hour throat culture and sensitivity tests identify other organisms.
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Early antibiotic treatment is the best choice for pharyngitis to treat the infection and help prevent potential complications. Penicillin or its derivatives are generally the antibiotics of choice. Clients sensitive to penicillin receive erythromycin. The antibiotic regimen is 7 to 14 days.
SELF-ASSESSMENT EXERCISE
1. Write short note on the following upper airway infections a) Rhinitis,
b) Sinusitis, c) Tonsillitis, d) Peritonsillar
e) Abscess and Laryngitis.
2. Identify 3 nursing diagnoses of a patient with Tonsilitis and draw a nursing care plan to solve the problems of that patient.
3.4 Tonsillitis and Adenoiditis
Tonsillitis is inflammation of the tonsils, and adenoiditis is inflammation of the adenoids. These conditions generally occur together—the common diagnosis is tonsillitis.
Although both disorders are more common in children, they also may be seen in adults.
Pathophysiology and Etiology
The tonsils and adenoids are lymphatic tissues and common sites of infection. Primary infection may occur in the tonsils and adenoids, or the infection can be secondary to other URIs. Chronic tonsillar infection leads to enlargement and partial upper airway obstruction. Chronic adenoidal infection can result in acute or chronic infection in the middle ear (otitis media). If the causative organism is group A streptococcus, prompt treatment is needed to prevent potential cardiac and renal complications.
Signs and symptoms
Sore throat, difficulty or pain on swallowing, fever, and malaise are the most common symptoms. Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice.
Visual examination reveals enlarged and reddened tonsils. White patches may appear on the tonsils if group A streptococci are the cause. A throat
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culture and sensitivity test determines the causative microorganism and appropriate antibiotic therapy.
Medical and Surgical Management
Antibiotic therapy, analgesics such as acetaminophen, and saline gargles may be used to treat the infection and associated discomfort. Chronic tonsillitis and adenoiditis may require tonsillectomy, operative removal of the tonsils, and adenoidectomy, operative removal of the adenoids. The criteria for performing these procedures are repeated episodesof tonsillitis, hypertrophy of the tonsils, enlarged obstructive adenoids, repeated purulent otitis media, hearing loss related to serous otitis media associated with enlarged tonsils andadenoids, and other conditions (e.g., asthma, rheumatic fever) exacerbated by tonsillitis. Tonsillectomy and adenoidectomy are generally done as outpatient procedures.
3.5 Peritonsillar Abscess
A peritonsillar abscess is an abscess that develops in the connective tissue between the capsule of the tonsil and the constrictor muscle of the pharynx.
It may follow a severe streptococcal or staphylococcal tonsillar infection.
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Signs and symptoms
Clients with a peritonsillar abscess experience difficulty and pain with swallowing, fever, malaise, ear pain, and difficulty talking.
Diagnosis
On visual examination, the affected side is red and swollen, as is the posterior pharynx. Drainage from the abscess is cultured to identify the microorganism. Sensitivity studies determine the appropriate antibiotic therapy.
Treatment
Immediate treatment of a peritonsillar abscess is recommended to prevent the spread of the causative microorganism to the bloodstream or adjacent structures. Penicillin or another antibiotic is given immediately after a culture is obtained and before results of the culture and sensitivity tests are
31 known. Surgical incision and drainage of the abscess are done if the abscess partially blocks the oropharynx. A local anesthetic is sprayed or painted on the surface of the abscess, and the contents are evacuated. Repeated episodes may necessitate a tonsillectomy.
Nursing management
Nursing management of the client undergoing drainage of an abscess includes placing the client in a semi-Fowler’s position to prevent aspiration.
An ice collar may be ordered to reduce swelling and pain. The nurse encourages the client to drink fluids. He or she observes the client for signs of respiratory obstruction (e.g., dyspnea, restlessness, cyanosis) or excessive bleeding.
3.6 Laryngitis
Laryngitis is inflammation and swelling of the mucous membrane that lines the larynx. Edema of the vocal cords frequently accompanies laryngeal inflammation. Laryngitismay follow a URI and results from spread of the infection to the larynx. Other causes include excessive or improper use of the voice, allergies, and smoking.
Signs and symptoms
Hoarseness, inability to speak above a whisper, or aphonia (complete loss of voice) are the usual symptoms. Clients also complain of throat irritation and a dry, nonproductive cough.
Dianosis
The diagnosis is based on the symptoms. If hoarseness persists more than 2 weeks, the larynx is examined (laryngoscopy). Persistent hoarseness is a sign of laryngeal cancer and thus merits prompt investigation.
Treatment
It involves voice rest and treatment or removal of the cause. Antibiotic therapy may be used if a bacterial infection is the cause. If smoking is the cause, the nurse encourages smoking cessation and refers the client to a smoking-cessation program.
4.0 CONCLUSION
Antibiotic therapy is necessary for severe infections. Vasoconstrictors, such as phenylephrine nose drops, may be recommended for short-term use to relieve nasal congestion and aid in sinus drainage. Surgery is often indicated for chronic sinusitis. Endoscopic sinus surgery helps provide an opening in the inferior meatus to promote drainage. More radical procedures, such as the Caldwell-Luc procedure and external
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sphenoethmoidectomy, are done to remove diseased tissue and provide an opening into the inferior meatus of the nose for adequate drainage.
5.0 SUMMARY
In this unit, you have learnt that:
• The most common upper airway illnesses are infectious and inflammatory disorders and they include; Rhinitis, Sinusitis, Pharyngitis, Tonsillitis, Adenoiditis, Peritonsillar Abscess and Laryngitis.
• The upper airway infections can be managed with analgesics, antibiotics and surgical intervention may also be necessary.
6.0 TUTOR-MARKED ASSIGNMENT
Work with preceptors and visit a nearby health facility, identify at least two cases of upper airway infections. Discuss the medical and nursing management of those patients. Send your report to the discussion forum.
7.0 REFERENCES/FURTHER READING
Bullock, B.A., &Henze, R.L. (2000). Focus on pathophysiology.
Philadelphia: Lippincott Williams & Wilkins.
Burke, K.M; Mohn-Brown, E.L &Eby, L (2011). Medical-Surgical Nursing Care. (3rded.). Boston: Pearson Education, Inc.
Nettina, S.M (2010). Lippincott Manual of Nursing Practice (9thed). China:
Wolters Kluwer Health Lippincott Williams & Wilkins.
Rueling, S., & Adams, C. (2003). Close to the vest: a novel way to keep airways clear. Nursing 2003, 33(12), 56–57.
Timby, B.K & Smith, N.E (2010). Introductory Medical-Surgical Nursing (10th ed.).Philadelphia: Wolters Kluwer Health | Lippincott Williams & Wilkins.
Williams, L.S & Hopper, P.D (2003). Understanding Medical-Surgical Nursing. philadelphia: F. A. Davis Company.
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