Upper Respiratory Disorders

1. UPPER RESPIRATORY
DISORDERS
BY: MRS. KATHLEEN R. PAREL, RN, MAN

2. PROBLEMS OF THE NOSE AND
SINUSES
RHINITIS
- is an inflammation of the mucous
membrane of the nose, often producing
excessive nasal secretions and obstruction.

3. TYPES:
ALLERGIC - IgE – mediated response causing release of vasoactive substances
from mast cells
INFECTIOUS - viral (common cold) and bacterial (purulent)
DRUG – INDUCED (rebound rhinitis, medicamentosa) – caused by excessive use of
topical nasal decongestants.
NONALLERGIC, NON INFECTIOUS (vasomotor rhinitis) – unexplained autonomic
nasal dysfunction as a result of overactivity of the parasympathetic nerve supply to
the mucous membranes of the nose and paranasal sinuses

4. CLINICAL MANIFESTATIONS:
1. Hypersecretion; wet running/dripping nose or post nasal drip
2. Nasal obstruction symptoms: nasal congestion, pressure, or
stuffiness
3. Headache

5. NURSING ALERT:
Instruct patient as follows:
1. Do not blow nose too frequently or too hard; doing so many
cause infection to spread, sinuses to become infected, and
an eardrum to be perforated.
2. Blow through both nostrils at the same time to equalize
pressure.

6. MANAGEMENT:
1. Treatment of underlying cause (allergy,
infection)

7. PATIENT EDUCATION:
1. Avoid irritating inhalants, especially smoke, aerosols,
noxious fumes.
2.Do not over use topical nasal sprays / drops.
Decongestant nasal sprays / drops should not be
used for more than 3 consecutive days.

8. NASAL OBSTRUCTION
CAUSES:
1. Deviated septum
2. Hypertrophy of turbinate bones
3. Nasal polyps
4. Tumors; scars; adhesions
5. Fractures; foreign bodies
6. Adenoid hypertrophy
7. Overuse of nose drops; drugs (rauwolfia; antithyroid drugs)

9. Related Problems:
Chronic infection of nose
Sinusitis; pain in sinus regions
Recurrent otitis media

10. Management:
Removal of cause, including surgical interventions
Correction of infection

11. Epistaxis
Refers to nose bleed or hemorrhage from the
nose. It most commonly originates in the
anterior portion of the nasal cavity. Posterior
nasal bleeding usually originates from the
turbinates or lateral nasal wall.

12. Causes:
1. Local:
A. Dryness leading to crust formation – bleeding occurs with
removal of crusts by nose picking B.
B. Trauma
2. Systemic: Hypertension, arteriosclerosis, renal and bleeding
disorders

13. Diagnostic Evaluation
1. Inspection with nasal speculum to determine site of
bleeding, important to determine which side bled first.
2. Blood evaluation to exclude blood dyscrasias.

14. Management:
(Depends on severity and source of bleeding in nasal cavity.
1. Patient is placed in an upright posture, leaning forward to reduce
venous pressure and instructed to breathe gently through the mouth
to prevent swallowing of blood.
2. Patient is instructed to compress the soft part of nasal tip with index
finger and thumb for 5 – 10 minutes to maintain pressure on the
nasal septum.

15. 3. A cotton pledget soaked with a vasoconstricting agent may be inserted
into each nostril and pressure applied. After 5 – 10 minutes the cotton is
removed, and the site of bleeding is identified.
4. The blood vessel may be cauterized.
5. If bleeding continues (posterior bleeding), packing may be layered
nasal cavity and the nasopharynx or balloon tamponade may be required
apply pressure over a larger area.
6. Surgical ligation of vessels may be required.

16. Nursing Alert:
 Monitor the patient for a vasovagal episode during insertion
of nasal packing.

17. Complications:
 Rhinitis; maxillary and frontal sinusitis; hemotympanum;
otitis media

18. Nursing Interventions / Patient Education
1. Be aware that packing is uncomfortable and painful.
2. Monitor patient with posterior packing for hypoxia (from aspiration
of blood, sedation, and pre-existing pulmonary dysfunction)
3. Monitor for respiratory difficulty or obstruction - secondary to
slippage of packing or balloon, swelling of palate, relaxation of
tongue.

19. 4. Instruct the patient as follows for self-management of minor bleeding episodes:
a. Sit up and lean forward while compressing the soft part (tip) of nose between
finger and thumb.
b. If bleeding continues, moisten a small piece of cotton with vasoconstricting nose
drops and place inside nose. Press against bleeding site 5-10 minutes.
5. Avoid blowing or picking nose after a nose bleed.
6. After a week or so, apply a lubricant to nasal septum twice daily to reduce dryness.
7. Use a humidifier if environmental air is dry.

20. Sinusitis
 Is an inflammation of the mucous membranes of one or more
paranasal sinuses. It is usually precipitated by congestion from a
viral upper respiratory infection and/or nasal allergy. Obstruction of
the ostia (resulting from mucosal swelling and/or mechanical
obstruction), leads to retention of secretions and is the usual
precursors to sinusitis.

21. Causes:
 The common cold.
 Nasal and seasonal allergies, including allergies to mold.
 Polyps (growths).
 A deviated septum
 A weak immune system from illness or medications.

22. Pathophysiology:
Acute infection –----- destroys normal ciliated epithelium ------
impairs drainages from sinuses ---------------pooling and
stagnation of secretions -----------persistence of infection ----------
mucosal changes – loss of cilia – edema – polyp formation -------
leads to SINUSITIS

23. Clinical Manifestations:
1. Pain, stabbing or aching, over the infected sinus .
a. Frontal sinusitis – pain in forehead intensified by bending
forward
b. Maxillary sinusitis – aching pain in facial region and from inner
canthus of the eye to the teeth
c. Ethmoid sinusitis – frontal or orbital headache
d. Sphenoid sinusitis – headache referred to top of head and deep to
the eyes

24. 2. Nasal congestion and discharge; may or may not be present
3. Anosmia (lack of smell): inspires or expired air cannot reach
the olfactory groove.
4. Red and edematous nasal mucosa

25. Diagnostic Evaluation
1. Clinical presentation and physical examination
2. Sinus radiographs
3. Antral puncture and lavage – provides culture material; also a
therapeutic modality to clear sinus of bacteria, fluid, and
inflammatory cells

26. Management
GOAL: To improve ostial patency
 Topical decongestant spray or drops for mucosal shrinkage to encourage
drainage from sinus. This should be limited to no more than 3 successive days of
use.
 Topical decongestant maybe combined with oral decongestant.
 Antibiotics – (amoxicillin, cefaclor, etc..)r for purulent sinusitis
 Analgesics – pain may be significant
 Warm compresses, cool vapor humidity for comfort

27. Complications:
(Depend on anatomic location of sinus involved)
1. Extension of infection to the orbital contents and eyelids
NOTE: Watch for lid edema, edema of ocular conjunctiva, drooping lid, limitation of
extraocular motion, visual loss
2. Bone infection (osteomyelitis) may spread by direct extension or via blood
vessels . Frontal bone commonly affected.
3. Central nervous system complications include meningitis, subdural and epidural
purulent drainage, brain abscess, cavernous sinus thrombosis ( acute
thrombophlebitis originating from an infection in an area having venous drainage
to cavernous sinus)

28. Patient Education
 Acute sinus infection may lead to chronic sinus disease,
 Swimming/diving may cause contaminated water to be
forced into the sinus, usually the frontal sinus.

29. Chronic Sinusitis
Is a suppurative inflammation of the sinuses
with chronic irreversible change in the mucosa
and sinus bony area.

30. Causes:
Common causes of chronic sinusitis include:
 Nasal polyps. These tissue growths can block the nasal passages or sinuses.
 Deviated nasal septum. A crooked septum — the wall between the nostrils — may restrict
or block sinus passages, making the symptoms of sinusitis worse.
 Other medical conditions. The complications of conditions such as cystic fibrosis, HIV and
other immune system-related diseases can lead to nasal blockage.
 Respiratory tract infections. Infections in your respiratory tract — most commonly colds —
can inflame and thicken your sinus membranes and block mucus drainage. These infections
can be caused by viruses or bacteria.
 Allergies such as hay fever. Inflammation that occurs with allergies can block your sinuses.

31. Clinical Manifestations:
Common signs and symptoms of chronic sinusitis include:
 Persistent nasal obstruction; chronic nasal discharge
 Thick, discolored discharge from the nose (runny nose)
 Drainage down the back of the throat (postnasal drainage)
 Blocked or stuffy (congested) nose causing difficulty breathing through your nose
 Pain, tenderness and swelling around your eyes, cheeks, nose or forehead
 Reduced sense of smell and taste

32. Other signs and symptoms can include:
 Ear pain
 Headache
 Aching in your upper jaw and teeth
 Cough or throat clearing
 Sore throat
 Bad breath
 Fatigue

33.  Chronic sinusitis and acute sinusitis have similar signs and symptoms. But acute
sinusitis is a temporary infection of the sinuses often associated with a cold. The
signs and symptoms of chronic sinusitis last at least 12 weeks, but you may have
several episodes of acute sinusitis before developing chronic sinusitis. Fever isn't a
common sign of chronic sinusitis, but you might have one with acute sinusitis.

34. Diagnostic Evaluation:
Sinus roentgenograms
Endoscopy of nose with computed tomographic
imaging – reveals mucosal changes

35. Management
1. Vasoconstricting drugs to promote drainage.
NOTE: RECOGNIZE DANGER OF PROLONGED USE OF
DECONGESTANTS which may lead to rebound rhinitis ( rhinitis
medicamentosa), a recurring cycle of nasal congestion, use of
decongestants, rebound nasodilatation,nasal congestion,more
decongestants, etc.
2. Antibiotic for infections
3. Nasal corticosteroids

36. 4. Surgical interventions ( when conservative treatment is unsuccessful)
A. Endoscopic sinus surgery – endoscopic removal of diseased tissue
from affected sinus; used to treat chronic sinusitis of maxillary,
ethmoid, and frontal sinuses.
B. Nasal antrostomy (nasal – antral window) – surgical placement of an
opening under inferior turbinate to provide aeration of the antrum and
to permit exit for purulent materials

37. C. Caldwell – Luc operation – procedure provides for removal of
diseased mucosal lining of maxillary sinus combined with development
of nasal-antral window. Incision made along upper upper gumline
above canine teeth.
D. Surgical interventions for repair of structural abnormalities, deviated
septum, polyps, etc.

38. Nursing Interventions / Patient Education
1. Instruct patient about using careful oral hygiene. Use mouthwash with aid of
flexible straw.
2. Avoid trauma to the nose
3. Avoid smoke in the environment
4. After Caldwell – luc procedure:
A. Provide cold compress over lip to help reduce swelling.
B. Advise patient that numbness in operative area may be present for several
weeks to months.
C. Instruct the patient to refrain from blowing nose after removal of packing, to
avoid forcing nasal secretions back into maxillary sinus.

39. Assignment:
Nursing Interventions for Nasal Surgery:
A.Endoscopic Sinus surgery
B.Nasal antrostomy
C.Caldwell –Luc operation