Nasal Fracture
(Complications, Clinical Manifestations, Assessment, Goals of Nursing Management, Treatment)
Complications: airway obstruction, epistaxis, meningeal tears causing CSF leakage, septal hematoma, cosmetic deformity
Diagnosis: H&P
Clinical Manifestations: pain, crepitus on palpation, swelling, difficulty breathing through nostrils, epistaxis, ecchymosis, cosmetic deformity
Assess: ability to breathe through each side of nose, note presence of edema, bleeding, hematoma. Raccoon eyes —> maybe basilar fracture. Inspect for septal deviation, hemorrhage, clear drainage (CSF leak).
Goals of Nursing Management: maintain airway, reduce edema and swelling, reduce pain, prevent complications, provide emotional support.
Nursing treatment: keep upright, apply ice in 10 or 20 minute intervals for edema, administer analgesia (acetaminophen preferred), nasal stuffiness relieved by nasal decongestants, nasal saline sprays, or humidifier. Teach to avoid hot showers and alcohol for 48 hours. Teach to quit smoking to facilitate tissue healing.
Treatment: septoplasty or rhinoplasty
Nursing treatment for nasal surgery: aspirins and nsaids may need to be d/c’d prior to surgery, quit smoking to promote postop healing. Cold compresses and head elevation for swelling. Activity restrictions (no swimming, no nose blowing, no heavy lifting, no strenuous exercise). Full cosmetic improvement can take many months up to 1 year.
Allergic Rhinitis
(Definition, Classification, Clinical Manifestations, Nursing Management)
Definition: inflammation of the nasal mucosa in response to a specific allergen.
Classification: by causative agent (seasonal or perennial) or by frequency of symptoms (episodic, intermittent, or persistent).
Clinical manifestations: early symptoms of sneezing, itching, rhinorrhea, and congestion. Water, itchy eyes. Altered sense of smell. Thin, watery nasal discharge that can lead to more sustained mucus production and nasal congestion. Turbinates appear pale, boggy, swollen, may obstruct passageway and lead to sinusitis. Chronic exposure leads to headache, stuffy nose, pressure.
Nursing Managment:
1. Most important step: identifying and avoiding triggers of reactions. Instruct patient to keep diary of when the reaction occurs and activities that precipitate the reaction.
Possible triggers to avoid: house dust, house dust mites, pet allergens, mold spores, pollens, smoke.
2. Drug therapy (reduce inflammation, reduce nasal symptoms, and minimize complications): nasal corticosteroids are first line and most effective. First-generation Antihistamine alert: drowsiness from sedation, be careful with heavy machinery. Second-generation antihistamines do not produce a sedating effect. Sudafed may produce tachycardia and palpations in patients with heart disease. Other oral meds: antihistamines, decongestants, leukotriene receptor antagonists (LTRAs). Intranasal meds: antihistamines, anticholinergics, corticosteroids, cromolyn, decongestants.
Acute Viral Rhinitis (Cold)
(Definition, Clinical Manifestations, Assessment, Implementation, Treatment, Teaching)
Definition: infection of the upper respiratory tract that can be caused by more than 200 different viruses.
1. Majority are mild and self-limiting. Others, such as coxsackieviruses and adenoviruses, can cause a more severe illness.
2. Acute viral rhinitis is the most prevalent infectious disease, with the average adult contracting 1 to 3 colds per year.
Transmission: spread by airborne droplets. Can live on inanimate objects for up to 3 days, so direct hand contact as well.
Cause/increased susceptibility: overcrowding in winter months, fatigue, stress, allergies, compromised immune status. Exercise may reduce the number of upper respiratory infections.
Clinical Manifestations/Symptoms:
1. Runny nose, watery eyes, nasal congestion, sneezing, cough, sore throat, fever, headache, and fatigue.
2. Typically begin 2-3 days after infection, last 2-14 days, and recovery is in 7-10 days.
Interventions: Directed at relieving symptoms.
1. Rest, oral fluids, antipyretics, analgesics.
2. Sore throat: warm salt water gargles, ice chips, lozenges, sprays.
3. Raw nose: petroleum jelly
4. Nasal congestion: saline nasal spray
5. Reduced post nasal drip, severity of cough, nasal obstruction, and nasal discharge: antihistamine and decongestant therapy (***DO NOT USE topical nasal decongestant for more than 3 days as this will cause REBOUND CONGESTION)
6. Cough: cough suppressants, such as dextromethorphan, and expectorants, such as guaifenesin
7. Antibiotics will do nothing to a virus, but may be used if complications exist.
Complications: pharyngitis, sinusitis, otitis media, tonsillitis, lung infections
Teaching:
1. If symptoms remain with no improvement for 10-14 days, consult HCP
2. Manifestations of secondary bacterial infection: temperature higher than 103F, tender swollen glands, severe sinus or ear pain, significantly worsening symptoms.
3. Green, purulent nasal drainage during the later stages of a cold is not uncommon, and is not always indicative of a bacterial infection.
4. IF pulmonary disease, THEN signs of infection often include change in consistency, color, or volume of sputum. Since infection can progress rapidly, report changes in sputum, increased SOB, and chest tightness
5. IF cold season AND chronic illness/compromised immune system, THEN avoid crowded situations and others with obvious cold symptoms, frequently wash hands and avoid hand to face contact.
Influenza
Definition: highly contagious respiratory illness that causes significant morbidity and mortality.
1. Flu season begins in September and ends in April (most cases between November and March)
2. Vaccination is important to prevent many deaths.
Etiology and pathophysiology:
1. It’s classified into types A, B, and C.
2. A is the most common and virulent and is contagious between humans and animals, and can cause pandemics when it mutates from animals to humans. B&C are only transmitted between humans. Type B can cause regional epidemics, and type C is usually mild.
3. Type A is has subtypes based on presence of two surface proteins, hemagglutinin and neuraminidase. H antigens allow virus to enter the cell, and N antigens facilitate cell to cell transmission. Looks like H3N2.
Transmission: animal to human through direct or indirect contact (animal feces). Human to human through infected droplets and inhalation of aerosolized particles and sometimes through direct contact with contaminated surfaces.
1. Incubation period of 1 to 4 days with peak transmission risk 1 day before onset of symptoms continuing for 5 to 7 days after a person first becomes sick.
Clinical Manifestations/Symptoms:
1. Onset of flu is typically abrupt.
2. Systemic symptoms of chills, fever, and generalized myalgia. Often accompanied by headache, sore throat, cough, and fatigue.
3. Physical examination: normal assessment when auscultating for breath sounds. Dyspnea and diffuse crackles indicate pulmonary complications.
4. Uncomplicated cases: symptoms subside or resolve in 7 days
5. Older adults may experience weakness or lethargy that persists for weeks.
Complications:
1. Pneumonia (common). Can be primary viral infection or secondary bacterial infection. Second bacterial infection victim usually experiences gradual improvement of flu symptoms, then worsening cough and purulent sputum. Treatment with antibiotics is often effective if started early.
2. Ear or sinus infections.
3. Older adults are prone to dehydration.
Diagnostic Studies: commonly diagnosed based on health history, clinical findings, knowledge of other cases of influenza in the community.
1. Gold standard: viral cultures. However, they can take 3-10 days for results. Has advantage of identifying which virus (A, B, or other) is present, and which strains are present. This is useful for next vaccination. Can be obtained from throat swab, nasopharyngeal swab, expectorated sputum, ET tube sample, or bronchoscopy (bronchial wash).
2. Rapid flu tests: may be completed at HCP’s office in less than 30 minutes, or sent to a laboratory, with results available same day. Can help differentiate influenza from other viral and bacterial infections with similar manifestations that may be serious and must be treated differently. Best used within 48 hours of onset of symptoms. Main disadvantage is that it can occasionally yield false positives or it will miss cases. Detects the virus in nasal secretions.
Nursing Management
1. Prevention is the most effective strategy for managing influenza.
2. Vaccinations: there are two types of vaccines, live attenuated and inactivated. Vaccines are changed on a yearly basis. The best time to take it is in September because it takes 2 weeks for full protection to occur. Reactions are extremely rare. Soreness at site is most reported adverse effect. Contraindications: history of severe allergic reaction to previous flu vaccine. If patient experiences anaphylaxis to eggs, he should consult HCP as alternatives for vaccinating patients with egg allergies are now available.
Treatment: primary goal is relieving symptoms and prevention of secondary infection
1. Unless the patient with flu is at high risk or complications develop, only supportive therapy is necessary. Rest, hydration, analgesics, and antipyretics can provide symptom relief.
2. Three antivirals are used: zanamivir (Relenza) (inhaler), oseltamivir (Tamiflu) (oral capsule), and peramivir (Rapivab) (intravenous IV).
They are neuraminidase inhibitors that prevent the virus from being released and spreading to other cells. They shorten the duration of influenza symptoms and reduce the risk of complications. Treatment should be initiated as soon as possible in patients who are hospitalized with influenza, have severe or complicated illness, or are at high risk for complications. For maximum benefit, therapy should begin within 2 days of onset of symptoms, but may be started later based on clinical judgment.
Influenza Immunization Types
Trivalent Inactivated Influenza Vaccine (TIV)
1. Given by injection
2. Approved in people >= 6 months of age
3. Can be used in people at increased risk including people of any age with chronic medical conditions, residents of nursing homes and long-term care facilities, people who are immunocompromised, pregnant women.
4. Most common side effects: site reactions (pain, redness, swelling)
Live attenuated influenza vaccine (LSIV)
1. Given by nasal spray
2. Approved in healthy people ages 2-49 yr
3. SHOULD NOT BE USED IN: pregnant women, people with known immunodeficiency, children or adolescents receiving aspirin or other salicylates, people who have medical conditions that place them at increased risk for complications from influenza (chronic cardiovascular, pulmonary, or neurological diseases; diabetes mellitus; renal or hepatic dysfunction; hemoglobinopathies), HCPs of high risk patients because of risk of viral transmission from vaccine (should not care for high risk patients for 7 days after vaccination).
4. Most common side effects: runny nose or nasal congestion in all ages, sore throat in adults, fever in patients ages 2-6.
Sinusitis
Definition:
1. Develops when inflammation or hypertrophy (swelling) of the mucosa blocks the openings (Ostia) of the sinuses, through which mucus drains into the nose. Obstruction of mucus drainage can also be caused by nasal polyps, foreign bodies, deviated septa, or tumors. The secretions behind a blocked Ostia are prone to infection.
2. Affects one out of every seven adults
3. Viral sinusitis typically follows an upper respiratory tract infection. Usually this resolves without treatment within 14 days. Only 5-10% of patients with viral sinusitis develop a bacterial infection requiring antibiotic therapy. If symptoms worsen after 3-5 days, or persist longer than 10 days, a secondary bacterial infection may be present.
4. Can be classified as acute, subacute, or chronic. Acute = less than 4 weeks. Subacute= symptoms progress over 4-8 weeks. Chronic = lasts longer than 8 weeks, usually associated with allergies or nasal polyps, GENERALLY RESULTS from repeated episodes of acute sinusitis that result in irreversible loss of normal ciliated epithelium lining the sinus cavity.
Clinical Manifestations:
1. Acute sinusitis: significant pain in affected sinus, purulent nasal drainage, nasal obstruction, congestion, fever, malaise. Assessment involves inspection of the nasal mucosa and palpation of the sinus pressure points for pain. Findings of assessment for acute: edematous mucosa, discolored purulent drainage, enlarged turbinates, tenderness over involves frontal or maxillary sinuses, halitosis (bad breath). Headaches that change in intensity with position changes or when secretions drain are not uncommon.
2. Chronic sinusitis: difficult to diagnose due to nonspecific symptoms. Facial/dental pain, nasal congestion, increased drainage. Symptoms that mimic allergies. CT scans or X-ray may help in diagnosis, showing the sinuses are full of mucus. Also, flexible endoscopy can detect sinusitis, restore normal drainage, and obtain culture specimen. Rarely the patient is febrile. Severe pain and purulent drainage are often absent.
Co-morbidities:
1. As many as 50% of moderate/severe asthma patients have chronic sinusitis. GERD and smoking may increase the chance of someone with asthma to develop sinusitis
Treatment:
1. IF allergies are the cause THEN instruct removal of environmental triggers to allergies and drug therapy associated with allergic rhinitis
2. Initial treatment for ACUTE: SYMPTOM RELIEF!! DRAINAGE: oral or topical decongestants; INFLAMMATION: intranasal corticosteroids PAIN: analgesics; CONGESTION: saline nasal spray, available OTC, helps with facilitating drainage and inflammation and rinsing nasal passages CLINICAL RESPONSE SHOULD BE OBSERVED IN 72 HOURS. Topical decongestants: rebound congestion! Do NOT use for more than 4-5 days!
3. IF acute persistent >1 week THEN antibiotic therapy. Amoxicillin is first-line drug of choice and only used for 10-14 days to prevent creation of resistant organisms. IF symptoms do not resolve with amoxicillin THEN fluoroquinolone or broader-spectrum cephalosporin antibiotic.
4. CHRONIC sinusitis: there’s mixed flora so infections are more difficult to eliminate. Broad-spectrum antibiotics may be used 4-6 weeks.
5. Medical therapy may not relieve persistent, recurrent, or chronic illnesses.
6. Endoscopic surgery: available as an outpatient procedure with local anesthesia. This may relieve the blockage. Also, propel, a self-expanding implant, can be placed directly in the sinus during surgery. This helps maintain postoperative potency to sinus cavity and provides localized corticosteroid delivery directly to the sinus lining before dissolving after 30 days.
Patient Teaching:
1. Get plenty of rest to fight infection/promote recovery
2. Keep well hydrated by drinking 6-8 glasses of water to loosen secretions
3. Take hot showers twice daily. Use steam inhaler (15 minutes vaporization of boiling water), bedside humidifier, or nasal saline spray to promote secretion drainage.
4. Apply warm, damp towels around nose, cheeks, and eyes to ease facial pain.
5. Sleep with head elevated to promote drainage and reduce congestion.
6. Report a temperature of 100.4F or greater, which indicated infection.
7. Follow prescribed medication regimen: take analgesics to relieve pain, take decongestants/expectorants to decrease swelling, take antibiotics as prescribed for infection. Be sure to take entire prescription and report continued symptoms or a change in symptoms. Administer topical decongestants appropriately.
8. Perform nasal saline washes once or twice a day to wash sinuses.
9. Do not smoke, and avoid exposure to smoke. Smoke is an irritant and will worsen symptoms.
10. If allergies predispose to sinusitis, follow instructions regarding environmental control, drug therapy, and immunotherapy to reduce the inflammation and prevent sinus infection.
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Obstruction of Nose and Sinuses (Nasal Polyps and Foreign Bodies)
Nasal Polyps
Definition:
1. Soft, painless, noncancerous growths that form slowly in response to repeated inflammation of the sinus or nasal mucosa. May be yellow, grey, or pink semitransparent projections in the naris, and can exceed the size of a grape.
2. Most Common in adults over 40 and are more likely to occur in men than women.
Clinical Manifestations
1. Smaller ones are often asymptomatic.
2. Larger ones cause nasal obstruction, nasal discharge (usually clear), and speech distortion.
Treatment:
1. Topical/systemic corticosteroids are primary medical therapy to shrink them.
2. Endoscopic or laser surgery can remove polyps, but recurrence is common.
Foreign Bodies
Definition:
1. Rare. Can be organic or inorganic. Occur mostly in trauma situations or patients with severe mental illness or probably children.
Symptoms:
1. If It’s organic, it can be foul smelling and produce an inflammatory response if it has been there a long time. May be purulent.
2. Pain, difficulty breathing, bleeding.
Treatment:
1. Do not irrigate the nose, it could cause aspiration.
2. Sneezing or blowing the nose may work. If it doesn’t, consult HCP.
Acute Pharyngitis
Definition: an acute inflammation of the pharyngeal walls.
1. May include tonsils, palate, and uvula.
2. Can be caused by viral, bacterial, or fungal infection.
3. Viral accounts for 90% of cases. Bacterial (strep throat) usually results from group A beta-hemolytic streptococci (5-10%)
4. Fungal (candidiasis) can develop from prolonged use of antibiotics or corticosteroid inhalers, or in immunosuppressed patients (HIV).
Clinical Manifestations:
1. Symptoms: pain can be mild, scratchy, or severe with difficulty swallowing. Viral and bacterial look similar, with red/edematous pharynx with or without patchy exudates.
2. Four classic manifestations in bacterial: fever > 100.4F; anterior cervical lymph node enlargement; tonsillar or pharyngeal exudate; no cough. When 2-3 of above criteria is present, a rapid antigen detection test and/or throat culture is done to determine cause/treatment.
3. White, irregular patches on the oropharynx suggest fungal infection Candida albicans.
Nursing Management: goals are infection control, symptom relief, and prevention of secondary complications.
1. Symptom relief: gargle warm salt water; drink warm/cold liquids; suck on popsicles, hard candies, or lozenges; drink cool, bland liquids or gelatins, avoid citrus as this is often irritating. Use a cool mist vaporizer or humidifier.
2. Viral pharyngitis: no antibiotics. Use ibuprofen or acetaminophen for pain, increase fluid intake.
3. Bacterial pharyngitis: penicillin is the drug of choice for strep throat. Must be taken several times a day for 10 days to prevent complications such as rheumatic fever. IF allergic to penicillin THEN clindamycin or erythromycin. Other antibiotics may be used. Teach on looking for allergic reaction to penicillin. Most people with strep throat are contagious until they’ve been on an antibiotic for 24-48 hours.
4. Candida/fungal infection: nystatin is used. Swish preparation in mouth for as long as possible before swallowing it. Treatment should continue until symptoms are gone. Patients taking an inhaled corticosteroid should rinse their mouth with water afterwards in order to prevent infection from candida.
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Peritonsillar Abscess
Definition: a complication of tonsillitis and is most often caused by group A beta-hemolytic streptococci (the bacteria that causes strep throat).
Symptoms:
1. Pain, swelling, blockage of the throat (when severe), threatening airway patency. Also, high fever, chills, leukocytosis, difficulty swallowing, muffled voice.
Treatment:
1. IV antibiotic therapy
2. Needle aspiration or an I&D (incision and drainage) of the abscess
3. Emergency tonsillectomy may be performed, or an elective tonsillectomy after the infection has subsided.
Airway Obstruction
Definition:
1. MEDICAL EMERGENCY: may be partial or complete
2. Causes: aspiration of food or foreign object, allergic reactions, edema, inflammation caused by infections or burns, peritonsillar or retro pharyngeal abscesses, malignancy, laryngeal or tracheal stenosis, and trauma.
Clinical Manifestations:
1. Clinical presentation depends upon cause/location of blockage. IF larynx, THEN possible voice hoarseness or complete obstruction. IF tracheal THEN possible wheezing. IF lower respiratory (bronchus) THEN cough or decreased air entry on affected side.
2. Manifestations: choking, stridor, use of accessory muscles, suprasternal and intercostal retractions, flaring nostrils, wheezing, restlessness, tachycardia, cyanosis, change in LOC.
Assessment:
1. Prompt assessment and treatment is essential to prevent partial obstructions turning into complete obstructions. Complete obstructions can result in permanent brain damage/death in 3-5 minutes.
Treatment:
1. Immediate priority is to ensure the airway.
2. Interventions: Heimlich maneuver (see Appendix A), cricothyroidotomy, ET intubation, tracheostomy. Cricothyroidotomy is often used when intubation isn’t possible, and is preferred over tracheostomy.
3. Unexplained partial obstructions or recurrent symptoms indicate a need for additional tests such as chest x-ray, laryngoscopy, and rigid bronchoscopy.
Laryngeal Polyps
Cause: develop on vocal cords from vocal abuse or irritation (singing, talking too much, intubation, smoking). These are usually benign, but may be removed because they can become malignant.
Symptom:
1. most common symptom is hoarseness
2. Larger polyps may cause dysphagia, dyspnea, or stridor
Treatment:
1. Conservatively, with rest and adequate hydration.
2. Larger polyps may need surgical removal.
