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CHAPTER 20 Caring for Clients With Upper Respiratory Disorders

Pathophysiology and Etiology The tonsils and adenoids are lymphatic tissues and common sites of infection. Primary infection may occur in the ton sils and adenoids, or the infection can be secondary to other URIs. Chronic tonsillar infection leads to enlargement and partial upper airway obstruction. Chronic adenoidal infec tion can result in acute or chronic infection in the middle ear (otitis media). If the causative organism is group A Strepto coccus , prompt treatment is needed to prevent potential car diac and renal complications. Assessment Findings Sore throat, difficulty or pain on swallowing, fever, and mal aise 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 culture and sensitivity test determines the causative microor Antibiotic therapy for bacterial tonsillitis, analgesics such as acetaminophen, and saline gargles may be used to treat the infection and associated discomfort. Chronic tonsilli tis and adenoiditis may require tonsillectomy , operative removal of the tonsils, and adenoidectomy , operative re moval of the adenoids. The criteria for performing these procedures are repeated episodes of tonsillitis (usually more than seven in a year or four to five times a year for 2 years in a row or three times a year for 3 years in a row), sleep disorders related to obstructed breathing, hypertro phy of the tonsils, enlarged obstructive adenoids, repeated purulent otitis media, hearing loss related to serous otitis media associated with enlarged tonsils and adenoids, and other conditions (e.g., asthma, rheumatic fever) exacer bated by tonsillitis. Tonsillectomy and adenoidectomy are generally done as outpatient procedures. Recovery time is generally at least 10 days to 2 weeks or longer, especially for adults. (See the “Nursing Process” section for related nursing care of this client.) Stop,Think, and Respond 20-2 What is the most serious complication of a tonsillec tomy? Why? Concept Mastery Alert Positioning After Tonsillectomy and Adenoidectomy A standard of care to prevent aspiration for clients entering the postanesthesia care unit (PACU) is to place the client lying on either side with an emesis basin to catch drainage. Positioning the client in a semi-Fowler position is not recommended, as this does not provide an easy exit for secretions because the client is recovering from anesthesia. ganism and appropriate antibiotic therapy. Medical and Surgical Management

Client and FamilyTeaching 20-2 Tonsillectomy and Adenoidectomy

The nurse ensures that the client and family members can manage self-care at home by communicating the following points: • Report any signs of bleeding to the primary provider— this is particularly important in the first 12 to 24 hours and then 7 to 10 days after surgery as the throat heals. • Gently gargle with warm saline or an alkaline mouthwash to assist in removing thick mucus. • Maintain a liquid and very soft diet for several days after surgery—avoid spicy foods and rough-textured foods. • Also, avoid milk and milk products if the client does not tolerate them well.

Clinical Scenario Over the past 6 months, a young adult was seen in a clinic with repeated fevers of at least 38.5°C, enlarged and painful lymph nodes in the neck, white patches on the tonsils,

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. Clients with a peritonsillar abscess experience difficulty and pain with swallowing, fever, malaise, ear pain, and difficulty talk ing. On visual examination, the affected side is red and swol len, as is the posterior pharynx. Drainage from the abscess is cultured to identify the microorganism. Sensitivity studies determine the appropriate antibiotic therapy. Immediate treatment of a peritonsillar abscess is recom mended to prevent the spread of the causative microorgan ism to the bloodstream or adjacent structures. Penicillin or another antibiotic is given immediately after a culture is ob tained and before results of the culture and sensitivity tests are known. Needle aspiration (preferred because it is less invasive and less painful) or 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. Re peated episodes may necessitate a tonsillectomy. Nursing management of the client undergoing needle aspiration or incision and drainage of an abscess includes placing the client in a semi-Fowler position to prevent aspi ration. An ice collar may be ordered to reduce swelling and pain. Clients may have topical anesthetic agents and throat irrigations with warm saline or alkaline solutions every 1 to 2 hours. They may also use similar solutions or mouthwash and positive strep tests. The client is scheduled for a tonsillectomy today. What are the essential considerations for the nurse in planning for this client’s postoperative care? See the following Nursing Process section.

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