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CHAPTER 20 Caring for Clients With Upper Respiratory Disorders

for gentle gargling. The nurse instructs the client to be up right and to expectorate in a forward direction over a sink or basin. The nurse encourages the client to drink fluids that are cool or at room temperature and observes the client for signs of respiratory obstruction (e.g., dyspnea, restlessness, or cyanosis) or excessive bleeding. Laryngitis Laryngitis is inflammation and swelling of the mucous membrane that lines the larynx. Edema of the vocal cords frequently accompanies laryngeal inflammation. Laryngitis may 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. Hoarseness, inability to speak above a whisper, and/or aphonia (complete loss of voice) are the usual symptoms. Clients also complain of throat irritation and a dry, nonpro ductive cough. 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 in volves voice rest and treatment or removal of the cause. Anti biotic therapy may be used if a bacterial infection is the cause. If smoking is the cause, the nurse encourages smoking ces sation and refers the client to a smoking cessation program. STRUCTURAL DISORDERS Epistaxis Pathophysiology and Etiology Epistaxis , or nosebleed, is a common occurrence. It is usually not serious but can be frightening. Nosebleeds are the rupture of tiny capillaries in the nasal mucous membrane. They occur most commonly in the anterior septum, referred to as Kiessel bach plexus . Risk factors associated with nosebleeds include trauma, systemic infections such as rheumatic fever, local in fections, dry nasal mucosa, hypertension, use of aspirin, nasal tumors, and blood dyscrasias. Epistaxis that results from hy pertension or blood dyscrasias is likely to be severe and dif ficult to control. Those who use cocaine or other inhaled drugs may have frequent nosebleeds. Foreign bodies in the nose and deviated septum contribute to epistaxis, along with forceful nose-blowing and frequent or aggressive nose-picking. Assessment Findings Inspection of the nares using a nasal speculum and light re veals the area of bleeding. The examiner uses a tongue blade to check the back of the throat and a laryngeal mirror to view the area above and behind the uvula. Medical and Surgical Management The severity and location of the bleeding determine the treat ment. One or a combination of the following therapies may be used: • Direct continuous pressure to the nares for 5 to 10 minutes with the client sitting upright with head tilted forward to prevent swallowing and aspiration of blood • Application of ice packs to the nose

Client and FamilyTeaching 20-3 Epistaxis

• Cauterization with silver nitrate, electrocautery, or ap plication of a topical vasoconstrictor such as 1:1,000 epinephrine • Nasal packing with a cotton tampon • Pressure with a balloon-inflated catheter—inserted poste riorly for a minimum of 48 hours Nursing Management The nurse monitors vital signs and assesses for evidence of continued bleeding. The nurse may initiate measures to control bleeding, such as applying pressure and ice packs. Other treatments require a primary provider’s order. The cli ent experiencing epistaxis is usually anxious and requires reassurance. If underlying conditions are the cause, the nurse refers the client for medical follow-up. The nurse may also recommend humidification, use of a nasal lubricant to keep the mucous membranes moist, and avoidance of vigorous nose-blowing and nose-picking or other nose trauma. Client and Family Teaching 20-3 outlines teaching about the treat ment of severe nosebleed. Nasal Obstruction Obstruction of the nasal passage interferes with air passage. Three primary conditions lead to nasal obstruction: a devi ated septum, nasal polyps, and hypertrophied turbinates. Pathophysiology and Etiology A deviated septum is an irregularity in the septum that re sults in nasal obstruction. The deviation may be a deflection from the midline in the form of lumps or sharp projections or a curvature in the shape of an “S.” Marked deviation can result in complete obstruction of one nostril and interference with sinus drainage. A deviated septum may be congenital, but it often results from trauma. Nasal polyps are grapelike swellings that arise from the na sal mucous membranes (Fig. 20-3). They probably result from chronic irritation related to infection or allergic rhinitis. They obstruct nasal breathing and sinus drainage, ultimately leading to sinusitis. Most are benign and tend to recur when removed. • Do not swallow blood; spit out any blood oozing from the area. Do not blow the nose. If blood has been swal lowed, the client may see diarrhea and black, tarry stools for a few days. • Do not attempt to remove nasal packing or to cut the string anchoring the packing. • Take pain medications as ordered. Do not use aspirin or ibuprofen products until bleeding is controlled. • Notify the primary provider if bleeding persists or if any respiratory problems develop. The nurse instructs clients experiencing epistaxis to do the following: • Apply pressure to the nares with two fingers. Breathe through the mouth and sit with the head tipped forward to prevent blood from running down the throat.

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