Upper airway infections are common conditions that affect most people on occasion. Some infections are acute, with symptoms that last several days; others are chronic, with symptoms that last a long time or recur. Patients with these conditions seldom require hospitalization. However, nurses working in community settings or long-term care facilities may encounter patients who have these infections. Thus, it is important for the nurse to recognize the signs and symptoms and to provide appropriate care.
Rhinitis is a group of disorders characterized by inﬂammation and irritation of the mucous membranes of the nose. It may be classiﬁed as nonallergic or allergic. It is estimated that 10% to 15% of the population of the United States has allergic rhinitis (Middleton et al., 1998). Rhinitis may be an acute or chronic condition.
Nonallergic rhinitis may be caused by a variety of factors, including environmental factors such as changes in temperature or humidity, odors, or foods; infection; age; systemic disease; drugs (cocaine) or prescribed medications; or the presence of a foreign body. Drug-induced rhinitis is associated with use of antihypertensive agents and oral contraceptives and chronic use of nasal decongestants. Rhinitis also may be a manifestation of an allergy (see Chap. 53), in which case it is referred to as allergic rhinitis. Figure 22-1 shows the pathological processes involved in rhinitis and sinusitis.
The signs and symptoms of rhinitis include rhinorrhea (excessive nasal drainage, runny nose), nasal congestion, nasal discharge (purulent with bacterial rhinitis), nasal itchiness, and sneezing. Headache may occur, particularly if sinusitis is also present.
The management of rhinitis depends on the cause, which may be identiﬁed in the history and physical examination. The examiner asks the patient about recent symptoms as well as possible exposure to allergens in the home, environment, or workplace. If viral rhinitis is the cause, medications are given to relieve the symptoms. In allergic rhinitis, tests may be performed to identify possible allergens. Depending on the severity of the allergy, desensitizing immunizations and corticosteroids may be required. If symptoms suggest a bacterial infection, an antimicrobial agent will be used (see “Medical Management of Sinusitis”).
Medication therapy for allergic and nonallergic rhinitis focuses on symptom relief. Antihistamines are administered for sneezing, itching, and rhinorrhea. Oral decongestant agents are used for nasal obstruction. In addition, intranasal corticosteroids may be used for severe congestion, and ophthalmic agents are used to relieve irritation, itching, and redness of the eyes.
TEACHING PATIENTS SELF-CARE
The nurse instructs the patient with allergic rhinitis to avoid or reduce exposure to allergens and irritants, such as dusts, molds, animals, fumes, odors, powders, sprays, and tobacco smoke. The patient is instructed about the importance of controlling the environment at home and work. Saline nasal or aerosol sprays may be helpful in soothing mucous membranes, softening crusted secretions, and removing irritants. The nurse instructs the patient in the proper use of and technique for administrating nasal medications. To achieve maximal relief, the patient is instructed to blow the nose before applying any medication into the nasal cavity. In the case of infectious rhinitis, the nurse reviews with the patient hand hygiene technique as a measure to prevent transmission of organisms. The nurse teaches methods to treat symptoms of the viral rhinitis. In the elderly and other high-risk populations, the nurse reviews the value of receiving a vaccination in the fall in order to achieve immunity prior to the beginning of the “ﬂu season.”
FIGURE 22-1 Pathophysiologic processes in rhinitis and sinusitis. Although pathophysiologic processes are similar in rhinitis and sinusitis, they affect different structures. In rhinitis (A), the mucous membranes lining the nasal passages become inﬂamed, congested, and edematous. The swollen nasal conchae block the sinus openings, and mucus is discharged from the nostrils. Sinusitis (B) is also marked by inﬂammation and congestion, with thickened mucous secretions ﬁlling the sinus cavities and occluding the openings.
VIRAL RHINITIS (COMMON COLD)
The term “common cold” often is used when referring to an upper respiratory tract infection that is self-limited and caused by a virus (viral rhinitis). Nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise characterize it. Speciﬁcally, the term “cold” refers to an afebrile, infectious, acute inﬂammation of the mucous membranes of the nasal cavity. More broadly, the term refers to an acute upper respiratory tract infection, whereas terms such as “rhinitis,” “pharyngitis,” and “laryngitis” distinguish the sites of the symptoms. It can also be used when the causative virus is inﬂuenza (“the ﬂu”). Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the ﬁrst part of the symptomatic phase. It is estimated that adults in the United States average two to four colds each year. The common cold is the most common cause of absenteeism from work and school (Mandell, Bennett, & Dolin, 2000).
The six viruses known to produce the signs and symptoms of the viral rhinitis are rhinovirus, parainﬂuenza virus, coronavirus, respiratory syncytial virus (RSV), inﬂuenza virus, and adenovirus. Each virus may have multiple strains. For example, there are over 100 strains of rhinovirus, which accounts for 50% of all colds. The incidence of viral rhinitis follows a speciﬁc pattern during the year, depending on the causative agent. Even though viral rhinitis can occur at any time of the year, three waves account for the epidemics in the United States:
• In September, just after the opening of school
• In late January
• Toward the end of April Immunity after recovery is variable and depends on many fac-
tors, including a person’s natural host resistance and the speciﬁc virus that caused the cold.
Signs and symptoms of viral rhinitis are nasal congestion, runny nose, sneezing, nasal discharge, nasal itchiness, tearing watery eyes, “scratchy” or sore throat, general malaise, low-grade fever, chills, and often headache and muscle aches. As the illness progresses, cough usually appears. In some people, viral rhinitis exacerbates the herpes simplex, commonly called a cold sore.
The symptoms last from 1 to 2 weeks. If there is signiﬁcant fever or more severe systemic respiratory symptoms, it is no longer viral rhinitis but one of the other acute upper respiratory tract infections. Allergic conditions can also affect the nose, mimicking the symptoms of a cold.
There is no speciﬁc treatment for the common cold or inﬂuenza. Management consists of symptomatic therapy. Some measures include providing adequate ﬂuid intake, encouraging rest, preventing chilling, increasing intake of vitamin C, and using expectorants as needed. Warm salt-water gargles soothe the sore throat and nonsteroidal anti-inﬂammatory agents (NSAIDs) such as aspirin or ibuprofen relieve the aches, pains, and fever in adults. Antihistamines are used to relieve sneezing, rhinorrhea, and nasal congestion. Topical (nasal) decongestant agents may relieve nasal congestion; however, if they are overused they may create a rebound congestion that may be worse than the original symptoms. Some research suggests that zinc lozenges may reduce the duration of cold symptoms if taken within the ﬁrst 24 hours of onset (Prasad, Fitzgerald, & Bao, 2000). Amantadine (Symmetrel) or rimantadine (Flumadine) may be prescribed prophylactically to decrease the signs and symptoms as well. Antimicrobial agents (antibiotics) should not be used because they do not affect the virus or reduce the incidence of bacterial complications.
TEACHING PATIENTS SELF-CARE Most viruses can be transmitted in several ways: direct contact with infected secretions; inhalation of large particles that land on a mucosal surface from coughing or sneezing; or inhalation of small particles (aerosol) that may be suspended in the air for up to an hour. It is important to teach the patient how to break the chain of infection. Hand washing remains the most effective measure to prevent transmission of organisms. The nurse teaches methods to treat symptoms of the common cold and preventive measures (Chart 22-2).
The sinuses, mucus-lined cavities ﬁlled with air that drain normally into the nose, are involved in a high proportion of upper respiratory tract infections. If their openings into the nasal passages are clear, the infections resolve promptly. However, if their drainage is obstructed by a deviated septum or by hypertrophied turbinates, spurs, or nasal polyps or tumors, sinus infection may persist as a smoldering secondary infection or progress to an acute suppurative process (causing purulent discharge). Sinusitis affects over 14% of the population and accounts for billions of dollars in direct health care costs (Tierney, McPhee, & Papadakis, 2001). Some individuals are more prone to sinusitis because of their occupations. For example, continuous exposure to environmental hazards such as paint, sawdust, and chemicals may result in chronic inﬂammation of the nasal passages.
Acute sinusitis is an infection of the paranasal sinuses. It frequently develops as a result of an upper respiratory infection, such as an unresolved viral or bacterial infection, or an exacerbation of allergic rhinitis. Nasal congestion, caused by inﬂammation, edema, and transudation of ﬂuid, leads to obstruction of the sinus cavities (see Fig. 22-1). This provides an excellent medium for bacterial growth. Bacterial organisms account for more than 60% of the cases of acute sinusitis, namely Streptococcus pneumoniae, Haemophilus inﬂuenzae, and Moraxella catarrhalis (Murray & Nadel, 2001). Dental infections also have been associated with acute sinusitis.
Symptoms of acute sinusitis may include facial pain or pressure over the affected sinus area, nasal obstruction, fatigue, purulent nasal discharge, fever, headache, ear pain and fullness, dental pain, cough, a decreased sense of smell, sore throat, eyelid edema, or facial congestion or fullness. Acute sinusitis can be difficult to differentiate from an upper respiratory infection or allergic rhinitis.
Assessment and Diagnostic Findings
A careful history and physical examination are performed. The head and neck, particularly the nose, ears, teeth, sinuses, pharynx, and chest, are examined. There may be tenderness to palpation over the infected sinus area. The sinuses are percussed using the index ﬁnger, tapping lightly to determine if the patient experiences pain. The affected area is also transilluminated; with sinusitis, there is a decrease in the transmission of light (see Chap. 21, Fig. 21-8). Sinus x-rays may be performed to detect sinus opacity, mucosal thickening, bone destruction, and air–ﬂuid levels. Computed tomography scanning of the sinuses is the most effective diagnostic tool. It is also used to rule out other local or systemic disorders, such as tumor, ﬁstula, and allergy.
Acute sinusitis, if left untreated, may lead to severe and occasionally life-threatening complications such as meningitis, brain abscess, ischemic infarction, and osteomyelitis. Other complications of sinusitis, although uncommon, include severe orbital cellulitis, subperiosteal abscess, and cavernous sinus thrombosis.
The goals of treatment of acute sinusitis are to treat the infection, shrink the nasal mucosa, and relieve pain. There is a growing concern over the inappropriate use of antibiotics for viral upper respiratory infections; such overuse has resulted in antibiotics being less effective (more resistant) in treating bacterial infections such as sinusitis. As a result, careful consideration is given to the potential pathogen before antimicrobial agents are prescribed.
The antimicrobial agents of choice for a bacterial infection vary in clinical practice. First-line antibiotics include amoxicillin (Amoxil), trimethoprim/sulfamethoxazole (Bactrim, Septra), and erythromycin. Second-line antibiotics include cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), and cefprozil (Cefzil) and amoxicillin clavulanate (Augmentin). Newer and more expensive antibiotics with a broader spectrum include macrolides, azithromycin (Zithromax), and clarithromycin (Biaxin). Quinolones such as ciproﬂoxacin (Cipro), levoﬂoxacin (Levaquin) (used with severe penicillin allergy), and sparﬂoxacin (Zagam) have also been used. The course of treatment is usually 10 to 14 days. A recent report found little difference in clinical outcomes between ﬁrst-line and second-line antibiotics; however, costs were greater when newer second-line antibiotics were used (Piccirillo, Mager, Frisse et al., 2001).
Use of oral and topical decongestant agents may decrease mucosal swelling of nasal polyps, thereby improving drainage of the sinuses. Heated mist and saline irrigation also may be effective for opening blocked passages. Decongestant agents such as pseudoephedrine (Sudafed, Dimetapp) have proven effective because of their vasoconstrictive properties. Topical decongestant agents such as oxymetazoline (Afrin) may be used for up to 72 hours. It is important to administer them with the patient’s head tilted back to promote maximal dispersion of the medication. Guaifenesin (Robitussin, Anti-Tuss), a mucolytic agent, may also be effective in reducing nasal congestion.
In 2000, the U.S. Food and Drug Administration issued a public health advisory concerning phenylpropanolamine, which previously had been commonly used in oral decongestants and diet pills. The voluntary recall of products containing this ingredient was based on a study linking its use with hemorrhagic stroke in women. Men may also be at risk (Kernan et al., 2000).
Antihistamines such as diphenhydramine (Benadryl), cetirizine (Zyrtec), and fexofenadine (Allegra) may be used if an allergic component is suspected. If the patient continues to have symptoms after 7 to 10 days, the sinuses may need to be irrigated and hospitalization may be required.
TEACHING PATIENTS SELF-CARE
Patient teaching is an important aspect of nursing care for the patient with acute sinusitis. The nurse instructs the patient about methods to promote drainage such as inhaling steam (steam bath, hot shower, and facial sauna), increasing ﬂuid intake, and applying local heat (hot wet packs). The nurse also informs the patient about the side effects of nasal sprays and about rebound congestion. In the case of rebound congestion, the body’s receptors, which have become dependent on the decongestant sprays to keep the nasal passages open, close and congestion results after the spray is discontinued.
The nurse stresses the importance of following the recommended antibiotic regimen, because a consistent blood level of the medication is critical to treat the infection. The nurse teaches the patient the early signs of a sinus infection and recommends preventive measures such as following healthy practices and avoiding contact with people who have upper respiratory infections (see Chart 22-2).
The nurse should explain to the patient that fever, severe headache, and nuchal rigidity are signs of potential complications. If fever persists despite antibiotic therapy, the patient should seek additional care.
Chronic sinusitis is an inﬂammation of the sinuses that persists for more than 3 weeks in an adult and 2 weeks in a child. It is estimated that 32 million people a year develop chronic sinusitis.
A narrowing or obstruction in the ostia of the frontal, maxillary, and anterior ethmoid sinuses usually causes chronic sinusitis, preventing adequate drainage to the nasal passages. This combined area is known as the osteomeatal complex. Blockage that persists for greater than 3 weeks in an adult may occur because of infection, allergy, or structural abnormalities. This results in stagnant secretions, an ideal medium for infection. The organisms that cause chronic sinusitis are the same as those implicated in acute sinusitis. Immunocompromised patients, however, are at increased risk for developing fungal sinusitis. Aspergillus fumigatus is the most common organism associated with fungal sinusitis.
Clinical manifestations of chronic sinusitis include impaired mucociliary clearance and ventilation, cough (because the thick discharge constantly drips backward into the nasopharynx), chronic hoarseness, chronic headaches in the periorbital area, and facial pain. These symptoms are generally most pronounced on awakening in the morning. Fatigue and nasal stufﬁness are also common. In addition, some patients experience a decrease in smell and taste and a fullness in the ears.
Assessment and Diagnostic Findings
A careful history and diagnostic assessment, including a computed tomography scan of the sinuses or magnetic resonance imaging (if fungal sinusitis is suspected), are performed to rule out other local or systemic disorders, such as tumor, ﬁstula, and allergy. Nasal endoscopy may be indicated to rule out underlying diseases such as tumors and sinus mycetomas (fungus balls). The fungus ball is usually a brown or greenish-black material with the consistency of peanut butter or cottage cheese.
Complications of chronic sinusitis, although uncommon, include severe orbital cellulitis, subperiosteal abscess, cavernous sinus thrombosis, meningitis, encephalitis, and ischemic infarction.
Medical management of chronic sinusitis is almost the same as for acute sinusitis. The antimicrobial agents of choice include amoxicillin clavulanate (Augmentin) or ampicillin (Ampicin). Clarithromycin (Biaxin) and third-generation cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), and cefprozil (Cefzil) have also been effective. Levoﬂoxacin (Levaquin), a quinolone, may also be used. The course of treatment may be 3 to 4 weeks. Decongestant agents, antihistamines, saline sprays, and heated mist may also provide some symptom relief.
When standard medical therapy fails, surgery, usually endoscopic, may be indicated to correct structural deformities that obstruct the ostia (openings) of the sinus. Excising and cauterizing nasal polyps, correcting a deviated septum, incising and draining the sinuses, aerating the sinuses, and removing tumors are some of the speciﬁc procedures performed. When sinusitis is caused by a fungal infection, surgery is required to excise the fungus ball and necrotic tissue and drain the sinuses. Oral and topical corticosteroids are usually prescribed. Antimicrobial agents are administered before and after surgery. Some patients with severe chronic sinusitis obtain relief only by moving to a dry climate.
Because the patient usually performs care measures for sinusitis at home, nursing management consists mainly of patient teaching.
TEACHING PATIENTS SELF-CARE
The nurse teaches the patient how to promote sinus drainage by increasing the environmental humidity (steam bath, hot shower, and facial sauna), increasing ﬂuid intake, and applying local heat (hot wet packs). The nurse also instructs the patient about the importance of following the medication regimen. Instructions on the early signs of a sinus infection are provided and preventive measures are reviewed.
Acute pharyngitis is an inﬂammation or infection in the throat, usually causing symptoms of a sore throat.
Most cases of acute pharyngitis are caused by viral infection. When group A beta-hemolytic streptococcus, the most common bacterial organism, causes acute pharyngitis, the condition is known as strep throat (Bisno, 2001). The body responds by triggering an inflammatory response in the pharynx. This results in pain, fever, vasodilation, edema, and tissue damage, manifested by redness and swelling in the tonsillar pillars, uvula, and soft palate. A creamy exudate may be present in the tonsillar pillars (Fig. 22-3).
Uncomplicated viral infections usually subside promptly, within 3 to 10 days after the onset. However, pharyngitis caused by more virulent bacteria such as group A beta-hemolytic streptococci is a more severe illness. If left untreated, the complications can be severe and life-threatening. Complications include sinusitis, otitis media, peritonsillar abscess, mastoiditis, and cervical adenitis. In rare cases the infection may lead to bacteremia, pneumonia, meningitis, rheumatic fever, or nephritis.
The signs and symptoms of acute pharyngitis include a ﬁery-red pharyngeal membrane and tonsils, lymphoid follicles that are swollen and ﬂecked with white-purple exudate, and enlarged and tender cervical lymph nodes and no cough. Fever, malaise, and sore throat also may be present.
Assessment and Diagnostic Findings
Rapid screening tests for streptococcal antigens such as the latex agglutination (LA) antigen test and solid-phase enzyme immunoassays (ELISA), optical immunoassay (OIA), streptolysin titers, and throat cultures are used to determine the causative organism, after which appropriate therapy is prescribed. Nasal swabs and blood cultures may also be necessary to identify the organism (Corneli, 2001).
Viral pharyngitis is treated with supportive measures since antibiotics will have no effect on the organism. Bacterial pharyngitis is treated with a variety of antimicrobial agents.
If a bacterial cause is suggested or demonstrated, penicillin is usually the treatment of choice. For patients who are allergic to penicillin or have organisms that are resistant to erythromycin (one ﬁfth of group A beta-hemolytic streptococci and most S. aureus organisms are resistant to penicillin and erythromycin), cephalosporins and macrolides (clarithromycin and azithromycin) may be used. Antibiotics are administered for at least 10 days to eradicate the infection from the oropharynx.
Severe sore throats can also be relieved by analgesic medications, as prescribed. For example, aspirin or acetaminophen (Tylenol) can be taken at 3- to 6-hour intervals; if required, acetaminophen with codeine can be taken three or four times daily. Antitussive medication, in the form of codeine, dextromethorphan (Robitussin DM), or hydrocodone bitartrate (Hycodan), may be required to control the persistent and painful cough that often accompanies acute pharyngitis.
A liquid or soft diet is provided during the acute stage of the disease, depending on the patient’s appetite and the degree of discomfort that occurs with swallowing. Occasionally, the throat is so sore that liquids cannot be taken in adequate amounts by mouth. In severe situations, ﬂuids are administered intravenously. Otherwise, the patient is encouraged to drink as much ﬂuid as possible (at least 2 to 3 L per day).
The nurse instructs the patient to stay in bed during the febrile stage of illness and to rest frequently once up and about. Used tissues should be disposed of properly to prevent the spread of infection. It is important to examine the skin once or twice daily for possible rash, because acute pharyngitis may precede some other communicable diseases (ie, rubella).
Warm saline gargles or irrigations are used depending on the severity of the lesion and the degree of pain. The beneﬁts of this treatment depend on the degree of heat that is applied. The nurse teaches the patient about the recommended temperature of the solution: high enough to be effective and as warm as the patient can tolerate, usually 105°F to 110°F (40.6°C to 43.3°C). Irrigating the throat properly is an effective means of reducing spasm in the pharyngeal muscles and relieving soreness of the throat. Unless the purpose of the procedure and its technique are understood clearly by the patient and family, the results may be less than satisfactory.
An ice collar also can relieve severe sore throats. Mouth care may add greatly to the patient’s comfort and prevent the development of ﬁssures (cracking) of the lips and oral inﬂammation when bacterial infection is present. The nurse instructs the patient to resume activity gradually. A full course of antibiotic therapy is indicated in patients with group A beta-hemolytic streptococcal infection in view of the possible development of complications such as nephritis and rheumatic fever, which may have their onset 2 or 3 weeks after the pharyngitis has subsided. The nurse instructs the patient and family about the importance of taking the full course of therapy and informs them about the symptoms to watch for that may indicate complications.
Chronic pharyngitis is a persistent inﬂammation of the pharynx. It is common in adults who work or live in dusty surroundings, use their voice to excess, suffer from chronic cough, and habitually use alcohol and tobacco.
Three types of chronic pharyngitis are recognized:
• Hypertrophic: characterized by general thickening and congestion of the pharyngeal mucous membrane
• Atrophic: probably a late stage of the ﬁrst type (the membrane is thin, whitish, glistening, and at times wrinkled)
• Chronic granular (“clergyman’s sore throat”): characterized by numerous swollen lymph follicles on the pharyngeal wall
Patients with chronic pharyngitis complain of a constant sense of irritation or fullness in the throat, mucus that collects in the throat and can be expelled by coughing, and difﬁculty swallowing.
Treatment of chronic pharyngitis is based on relieving symptoms, avoiding exposure to irritants, and correcting any upper respiratory, pulmonary, or cardiac condition that might be responsible for a chronic cough.
Nasal congestion may be relieved by short-term use of nasal sprays or medications containing ephedrine sulfate (Kondon’s Nasal) or phenylephrine hydrochloride (Neo-Synephrine). If there is a history of allergy, one of the antihistamine decongestant medications, such as Drixoral or Dimetapp, is taken orally every 4 to 6 hours. Aspirin or acetaminophen is recommended for its antiinﬂammatory and analgesic properties.
TEACHING PATIENTS SELF-CARE
To prevent the infection from spreading, the nurse instructs the patient to avoid contact with others until the fever subsides. Alcohol, tobacco, second-hand smoke, and exposure to cold are avoided, as are environmental or occupational pollutants if possible. The patient may minimize exposure to pollutants by wearing a disposable facemask. The nurse encourages the patient to drink plenty of fluids. Gargling with warm saline solutions may relieve throat discomfort. Lozenges will keep the throat moistened.
TONSILLITIS AND ADENOIDITIS
The tonsils are composed of lymphatic tissue and are situated on each side of the oropharynx. The faucial or palatine tonsils and lingual tonsils are located behind the pillars of fauces and tongue, respectively. They frequently serve as the site of acute infection (tonsillitis). Chronic tonsillitis is less common and may be mistaken for other disorders such as allergy, asthma, and sinusitis.
The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis. Group A beta-streptococcus is the most common organism associated with tonsillitis and adenoiditis.
The symptoms of tonsillitis include sore throat, fever, snoring, and difﬁculty swallowing. Enlarged adenoids may cause mouthbreathing, earache, draining ears, frequent head colds, bronchitis, foul-smelling breath, voice impairment, and noisy respiration. Unusually enlarged adenoids ﬁll the space behind the posterior nares, making it difﬁcult for the air to travel from the nose to the throat and resulting in a nasal obstruction. Infection can extend to the middle ears by way of the auditory (eustachian) tubes and may result in acute otitis media, which can lead to spontaneous rupture of the eardrums and further extension of the infection into the mastoid cells, causing acute mastoiditis. The infection also may reside in the middle ear as a chronic, low-grade, smoldering process that eventually may cause permanent deafness.
Assessment and Diagnostic Findings
A thorough physical examination is performed and a careful history is obtained to rule out related or systemic conditions. The tonsillar site is cultured to determine the presence of bacterial infection. In adenoiditis, if recurrent episodes of suppurative otitis media result in hearing loss, the patient should be given a comprehensive audiometric examination (see Chap. 59).
Tonsillectomy is usually performed for recurrent tonsillitis when medical treatment is unsuccessful and there is severe hypertrophy, asymmetry, or peritonsillar abscess that occludes the pharynx, making swallowing difﬁcult and endangering the airway (particularly during sleep). Enlargement of the tonsils is rarely an indication for their removal; most children normally have large tonsils, which decrease in size with age. Despite the continuing debate over the effectiveness of many tonsillectomies, the operation is still a common surgical procedure in the United States.
Tonsillectomy or adenoidectomy is indicated only if the patient has had any of the following problems: repeated bouts of tonsillitis; hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive sleep apnea; repeated attacks of purulent otitis media; suspected hearing loss due to serous otitis media that has occurred in association with enlarged tonsils and adenoids; and some other conditions, such as an exacerbation of asthma or rheumatic fever. Appropriate antibiotic therapy is initiated for patients undergoing tonsillectomy or adenoidectomy. The most common antimicrobial agent is oral penicillin, which is taken for 7 days. Amoxicillin and erythromycin are alternatives.
PROVIDING POSTOPERATIVE CARE
Continuous nursing observation is required in the immediate postoperative and recovery period because of the signiﬁcant risk of hemorrhage. In the immediate postoperative period, the most comfortable position is prone with the head turned to the side to allow drainage from the mouth and pharynx. The nurse must not remove the oral airway until the patient’s gag and swallowing reﬂexes have returned. The nurse applies an ice collar to the neck, and a basin and tissues are provided for the expectoration of blood and mucus.
Bleeding may be bright red if the patient expectorates blood before swallowing it Often, however, the patient swallows the blood, which immediately becomes brown because of the action of the acidic gastric juice.
Hemorrhage is a potential complication after a tonsillectomy and adenoidectomy. If the patient vomits large amounts of dark blood or bright-red blood at frequent intervals, or if the pulse rate and temperature rise and the patient is restless, the nurse notiﬁes the surgeon immediately. The nurse should have the following items ready for examination of the surgical site for bleeding: a light, a mirror, gauze, curved hemostats, and a waste basin.
Occasionally, suture or ligation of the bleeding vessel is required. In such cases, the patient is taken to the operating room and given general anesthesia. After ligation, continuous nursing observation and postoperative care are required, as in the initial postoperative period.
If there is no bleeding, water and ice chips may be given to the patient as soon as desired. The patient is instructed to refrain from too much talking and coughing because these activities can produce throat pain.
TEACHING PATIENTS SELF-CARE
Tonsillectomy and adenoidectomy usually do not require hospitalization and are performed as outpatient surgery with a short length of stay. Because the patient will be sent home soon after surgery, the patient and family must understand the signs and symptoms of hemorrhage. Hemorrhage usually occurs in the ﬁrst 12 to 24 hours. The patient is instructed to report frank red bleeding to the physician.
Alkaline mouthwashes and warm saline solutions are useful in coping with the thick mucus and halitosis that may be present after surgery. It is important to explain to the patient that a sore throat, stiff neck, and vomiting may occur in the ﬁrst 24 hours. A liquid or semiliquid diet is given for several days. Sherbet and gelatin are acceptable foods. The patient should avoid spicy, hot, acidic, or rough foods. Milk and milk products (ice cream and yogurt) may be restricted because they may make removal of mucus more difﬁcult.
The nurse explains to the patient that halitosis and some minor ear pain may occur for the ﬁrst few days. The nurse instructs the patient to avoid vigorous tooth brushing or gargling, since these actions could cause bleeding.
A peritonsillar abscess is a collection of purulent exudate between the tonsillar capsule and the surrounding tissues, including the soft palate. It is believed to develop after an acute tonsillar infection, which progresses to a local cellulitis and abscess.
The usual symptoms of an infection are present, together with such local symptoms as a raspy voice, odynophagia (a severe sensation of burning, squeezing pain while swallowing), dysphagia (difﬁculty swallowing), otalgia (pain in the ear), and drooling. An examination shows marked swelling of the soft palate, often occluding almost half of the opening from the mouth into the pharynx, unilateral tonsillar hypertrophy, and dehydration.
Assessment and Diagnostic Findings
Aspiration of purulent material (pus) by needle aspiration is required to make the appropriate diagnosis. The aspirated material is sent for culture and Gram’s stain. A CTscan is performed when it is not possible to aspirate the abscess.
Antibiotics (usually penicillin) are extremely effective in controlling the infection in peritonsillar abscess. If antibiotics are prescribed early in the course of the disease, the abscess may resolve without needing to be incised.
If treatment is delayed, the abscess is evacuated as soon as possible. The mucous membrane over the swelling is ﬁrst sprayed with a topical anesthetic and then injected with a local anesthetic. Single or repeated needle aspirations are performed to decompress the abscess. The abscess may also be incised and drained. These procedures are performed best with the patient in the sitting position to make it easier to expectorate the pus and blood that accumulate in the pharynx. Almost immediate relief is experienced. Approximately 30% of patients with peritonsillar abscess have indications for tonsillectomy (Tierney et al., 2001).
Considerable relief may be obtained by the use of topical anesthetic agents and throat irrigations or the frequent use of mouthwashes or gargles, using saline or alkaline solutions at a temperature of 105°F to 110°F (40.6°C to 43.3°C). The nurse instructs the patient to gargle at intervals of 1 or 2 hours for 24 to 36 hours. Liquids that are cool or at room temperature are usually well tolerated.
Laryngitis, an inﬂammation of the larynx, often occurs as a result of voice abuse or exposure to dust, chemicals, smoke, and other pollutants, or as part of an upper respiratory tract infection.
It also may be caused by isolated infection involving only the vocal cords.
The cause of infection is almost always a virus. Bacterial invasion may be secondary. Laryngitis is usually associated with allergic rhinitis or pharyngitis. The onset of infection may be associated with exposure to sudden temperature changes, dietary deﬁciencies, malnutrition, and an immunosuppressed state. Laryngitis is common in the winter and is easily transmitted.
Signs of acute laryngitis include hoarseness or aphonia (complete loss of voice) and severe cough. Chronic laryngitis is marked by persistent hoarseness. Laryngitis may be a complication of upper respiratory infections.
Management of acute laryngitis includes resting the voice, avoiding smoking, resting, and inhaling cool steam or an aerosol. If the laryngitis is part of a more extensive respiratory infection due to a bacterial organism or if it is severe, appropriate antibacterial therapy is instituted. The majority of patients recover with conservative treatment; however, laryngitis tends to be more severe in elderly patients and may be complicated by pneumonia.
For chronic laryngitis, the treatment includes resting the voice, eliminating any primary respiratory tract infection, eliminating smoking, and avoiding second-hand smoke. Topical corticosteroids, such as beclomethasone dipropionate (Vanceril) inhalation, may also be used. These preparations have no systemic or long-lasting effects and may reduce local inflammatory reactions.
The nurse instructs the patient to rest the voice and to maintain a well-humidiﬁed environment. If laryngeal secretions are present during acute episodes, expectorant agents are suggested, along with a daily ﬂuid intake of 3 L to thin secretions.
NURSING PROCESS: THE PATIENT WITH UPPER AIRWAY INFECTION
A health history may reveal signs and symptoms of headache, sore throat, pain around the eyes and on either side of the nose, difﬁculty in swallowing, cough, hoarseness, fever, stufﬁness, and generalized discomfort and fatigue. Determining when the symptoms began, what precipitated them, what if anything relieves them, and what aggravates them is part of the assessment. It also is important to determine any history of allergy or the existence of a concomitant illness.
Inspection may reveal swelling, lesions, or asymmetry of the nose as well as bleeding or discharge. The nurse inspects the nasal mucosa for abnormal ﬁndings such as increased redness, swelling, or exudate, and nasal polyps, which may develop in chronic rhinitis.
The nurse palpates the frontal and maxillary sinuses for tenderness, which suggests inﬂammation, and then inspects the throat by having the patient open the mouth wide and take a deep breath. The tonsils and pharynx are inspected for abnormal ﬁndings such as redness, asymmetry, or evidence of drainage, ulceration, or enlargement.
Next the nurse palpates the trachea to determine the midline position in the neck and to detect any masses or deformities. The neck lymph nodes also are palpated for associated enlargement and tenderness.
Based on the assessment data, the patient’s major nursing diagnoses may include the following:
• Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inﬂammation
• Acute pain related to upper airway irritation secondary to an infection
• Impaired verbal communication related to physiologic changes and upper airway irritation secondary to infection or swelling
• Deﬁcient ﬂuid volume related to increased ﬂuid loss secondary to diaphoresis associated with a fever
• Deﬁcient knowledge regarding prevention of upper respiratory infections, treatment regimen, surgical procedure, or postoperative care
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS
Based on assessment data, potential complications may include:
• Peritonsillar abscess
• Otitis media
Planning and Goals
The major goals for the patient may include maintenance of a patent airway, relief of pain, maintenance of effective means of communication, normal hydration, knowledge of how to prevent upper airway infections, and absence of complications.
MAINTAINING A PATENT AIRWAY
An accumulation of secretions can block the airway in patients with an upper airway infection. As a result, changes in the respiratory pattern occur, and the work of breathing required to get beyond the blockage increases. The nurse can implement several measures to loosen thick secretions or to keep the secretions moist so that they can be easily expectorated. Increasing ﬂuid intake helps thin the mucus. Use of room vaporizers or steam inhalation also loosens secretions and reduces inﬂammation of the mucous membranes. To enhance drainage from the sinuses, the nurse instructs the patient about the best position to assume; this depends on the location of the infection or inﬂammation. For example, drainage for sinusitis or rhinitis is achieved in the upright position. In some conditions, topical or systemic medications, when prescribed, help to relieve nasal or throat congestion.
Upper respiratory tract infections usually produce localized discomfort. In sinusitis, pain may occur in the area of the sinuses or may produce a general headache. In pharyngitis, laryngitis, or tonsillitis, a sore throat occurs. The nurse encourages the patient to take analgesics, such as acetaminophen with codeine, as prescribed, which will help relieve this discomfort. Other helpful measures include topical anesthetic agents for symptomatic relief of herpes simplex blisters (see Chart 22-1) and sore throats, hot packs to relieve the congestion of sinusitis and promote drainage, and warm water gargles or irrigations to relieve the pain of a sore throat. The nurse encourages rest to relieve the generalized discomfort and fever that accompany many upper airway conditions (especially rhinitis, pharyngitis, and laryngitis). The nurse instructs the patient in general hygiene techniques to prevent the spread of infection. For postoperative care following tonsillectomy and adenoidectomy, an ice collar may reduce swelling and decrease bleeding.
Upper airway infections may result in hoarseness or loss of speech. The nurse instructs the patient to refrain from speaking as much as possible and to communicate in writing instead, if possible. Additional strain on the vocal cords may delay full return of the voice.
ENCOURAGING FLUID INTAKE
In upper airway infections, the work of breathing and the respiratory rate increase as inﬂammation and secretions develop. This, in turn, may increase insensible ﬂuid loss. Fever further increases the metabolic rate, diaphoresis, and ﬂuid loss.
Sore throat, malaise, and fever may interfere with a patient’s willingness to eat. The nurse encourages the patient to drink 2 to 3 L of ﬂuid per day during the acute stage of airway infection, unless contraindicated, to thin secretions and promote drainage. Liquids (hot or cold) may be soothing, depending on the illness.
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching Patients Self-Care
Prevention of most upper airway infections is difﬁcult because of the many potential causes. However, most upper respiratory infections are transmitted by hand-to-hand contact. Therefore, it is important to teach the patient and family how to minimize the spread of infection to others. Other preventive strategies are identiﬁed in Chart 22-2. The nurse advises the patient to avoid exposure to others at risk for serious illness if respiratory infection is transmitted. Those at risk include elderly adults, immunosuppressed people, and those with chronic health problems.
The nurse teaches patients and their families strategies to relieve symptoms of upper respiratory infections. These include increasing the humidity level, encouraging adequate ﬂuid intake, getting adequate rest, using warm water gargles or irrigations and topical anesthetic agents to relieve sore throat, and applying hot packs to relieve congestion. The nurse reinforces the need to complete the treatment regimen, particularly when antibiotics are prescribed.
Referral for home care is rare. However, it may be indicated for the person whose health status was compromised before the onset of the respiratory infection and for those who cannot manage selfcare without assistance. In such circumstances, the home care nurse assesses the patient’s respiratory status and progress in recovery. The nurse may advise elderly patients and those who would be at increased risk from a respiratory infection to consider
an annual inﬂuenza vaccine. A follow-up appointment with the primary care provider may be indicated for patients with compromised health status to ensure that the respiratory infection has resolved.
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
While major complications of upper respiratory infections are rare, the nurse must be aware of them and assess the patient for them. Because most patients with upper respiratory infections are managed at home, patients and their families must be instructed to monitor for signs and symptoms and to seek immediate medical care if the patient’s condition does not improve or if the patient’s physical status appears to be worsening.
Sepsis and meningitis may occur in patients with compromised immune status or in those with an overwhelming bacterial infection. The patient with an upper respiratory infection and family members are instructed to seek medical care if the patient’s condition fails to improve within several days of the onset of symptoms, if unusual symptoms develop, or if the patient’s condition deteriorates. They are instructed about signs and symptoms that require further attention: persistent or high fever, increasing shortness of breath, confusion, and increasing weakness and malaise. The patient with sepsis requires expert care to treat the infection, stabilize vital signs, and prevent or treat septicemia and shock. Deterioration of the patient’s condition necessitates intensive care measures (eg, hemodynamic monitoring and administration of vasoactive medications, intravenous ﬂuids, nutritional support, corticosteroids) to monitor the patient’s status and to support the patient’s vital signs. High doses of antibiotics may be administered to treat the causative organism. The nurse’s role is to monitor the patient’s vital signs, hemodynamic status, and laboratory values, administer needed treatment, alleviate the patient’s physical discomfort, and provide explanations, teaching, and emotional support to the patient and family.
Peritonsillar abscess may develop following an acute infection of the tonsils. The patient requires treatment to drain the abscess and receives antibiotics for infection and topical anesthetic agents and throat irrigations to relieve pain and sore throat. Follow-up is necessary to ensure that the abscess resolves; tonsillectomy may be required. The nurse assists the patient in administering throat irrigations and instructs the patient and family about the importance of adhering to the prescribed treatment regimen and recommended follow-up appointments.
Otitis media and sinusitis may develop with upper respiratory infection. The patient and family are instructed about the signs and symptoms of otitis media and sinusitis and about the importance of follow-up with the primary health care practitioner to ensure adequate evaluation and treatment of these conditions.
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include:
1. Maintains a patent airway by managing secretions a. Reports decreased congestion b. Assumes best position to facilitate drainage of secretions
2. Reports feeling more comfortable a. Uses comfort measures: analgesics, hot packs, gargles,rest b. Demonstrates adequate oral hygiene
3. Demonstrates ability to communicate needs, wants, level of comfort
4. Maintains adequate ﬂuid intake
5. Identiﬁes strategies to prevent upper airway infections and allergic reactions a. Demonstrates hand hygiene technique b. Identiﬁes the value of the inﬂuenza vaccine
6. Demonstrates an adequate level of knowledge and performs self-care adequately
7. Becomes free of signs and symptoms of infection a. Exhibits normal vital signs (temperature, pulse, respiratory rate) b. Absence of purulent drainage c. Free of pain in ears, sinuses, and throat