Nursing Care of at Risk

and Sick adult Clients

with Problems in
Oxygenation
Oxygenation- Ventilation
Learning objectives:
 Identify the pathophysiology of some of the upper respiratory disorders.
 Identify the assessment components and approaches and procedures for
each case
 Identify the required diagnostics and laboratory procedures for each
case/condition
 Identify the various medical (pharmacologic) and nursing care modalities
 Identify any surgical and special procedures, its indications, purposes
and the nursing responsibilities associated with it.
Review of Anatomy and Physiology of
Respiratory system
 Asynchronous approach
Clients with Upper Respiratory Disorder

Rhinitisand sinusitis
Influenza
Pneumonias
Rhinitis
Overview
 Rhinitisis an inflammation of the nasal mucosa and often the
mucosa in the sinuses that can be caused by infection (viral or
bacterial) or allergens.
 The common cold (coryza) is caused by viruses spread from
person to person in droplets from sneezing and coughing, or by
direct contact.
 This disorder often coexists with other disorders, such as
asthma and allergies, and may be acute or chronic, nonallergic
or allergic (seasonal or perennial).
 The presence of an allergen causes histamine release and other
mediators from WBCs in the nasal mucosa. The mediators bind
to blood vessel receptors causing capillary leakage, which
leads to local edema and swelling.
Types of Rhinitis
 -Sudden change in temperature, humidity
A. Non-allergic rhinitis- -Response not necessary due to allergic reaction but to sudden change in the environmental
condition which hindi kayang sabayan ng system natin ng biglaan . (e.g init-lamig)
-food: maanghang
Infection: viral, bacterial, fungal

 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. Doesn’t involve the immune system. Fragrances,
cigarette smoke, and windy or cold weather are just a few causes
Wear and tear process- thinning of passage way; the membrane

Sub types:
tissues thinning + cause dryness
 https://www.medicalnewstoday.com/articles/177085#types Dryness – trigger and welcome of infection; scaling (bad breath)
Dental/Upper respi problems
Thinning = scaling = halitosis
 Infectious rhinitis- viral rhinitis, is caused by an infection, such as the common cold or flu. The lining of
the nose and throat become inflamed when a virus attacks the area.
 Atrophic rhinitis- happens when the membranes inside the nose, called turbinate tissue, become thinner
and harder, causing the nasal passages to widen and become drier.
 Rhinitis medicamentosa-is caused by the use of drugs. This can be the overuse of nasal
decongestants, beta blockers, aspirin or cocaine. Nasal decongestants reduce the swelling of the blood
vessels inside the nose. If used for more than a week, they can cause the nose to become inflamed again,
even if the original problem, say, a cold, has gone. A side effect of certain medications, or as a rebound effect
from using nasal decongestant sprays.
Medication caused rebound effect = use of decongestants (vix inhaler has decongestants (4-5 days limitation of use) because of decongestants
Rebound effect = nasal congestion
Sub types of Non allergic rhinitis https://www.medicalnewstoday.com/articles/177085#types

• Occupational rhinitis: Occurs in people who have exposures at work to things

like wood dust, chemicals, or other airborne particles. Ex. Construction worker, teachers (chalk)

• Pregnancy rhinitis: Occurs in pregnant women as a response to hormonal

changes.
• Gustatory rhinitis: A response to eating certain foods, especially hot and/or spicy
food. Symptoms can also occur when drinking alcohol.
• Vasomotor rhinitis: This type of rhinitis can have different causes depending on
the person: weather changes, fragrances, cigarette smoke are some common
examples.
-because of vasoconstriction, vasodilation
- Temporary
- Blood vessels
 B. Allergic Rhinitis

 Allergic rhinitis, or hay fever, is an allergic response to specific

allergens. occurs when the immune system treats a normally
Pollen / from pet dander / dust mites

harmless substance as an invader. When an allergen is inhaled,

allergy cells in the lining of the airway set off a series of signals
that eventually lead to the release of a chemical called
histamine. Histamine is responsible for symptoms like sneezing
and itching. Other chemicals released by the body lead to nasal
congestion and stuffiness.
 Subtypes
 Perennial Allergic Rhinitis- allergies can occur year round, or at any time during the year
in response to indoor substances, like dust mites and pet dander.
 Seasonal Allergic Rhinitis- allergies occur during the summer and flowering season and
are typically in response to outdoor allergens like pollen.
 Assessment
 Subjective data
 Excessive nasal drainage, runny nose (rhinorrhea) and nasal congestion Because nag sswolllen, passageway lumiliit

-feeling of fullness at frontal section and runny nose

 Purulent(pus) nasal discharge -Discharges of runny rose: thin and clear one (cases of allergy/viral infection); ibang amoy at kulay (bacterial/fungal)

 Sneezing and pruritus (itch) of the nose, throat and ears -sneezing – normal mechanism of the body (upper respi) to get rid of any particles that come in
contact of mucus membrane ; successive because there is production of mucus and discharges
-pruritis – because of dischargers; some instances in the areas of the throat; there are
 Itchy, watery eyes conditions of periorbital swelling (one of complications)
-teary eyes because of swelling of mucosal lining
 Sore, dry throat -Because eustachian tube = discharges from ears

 Objective Data
 Red, inflamed, swollen nasal mucosa
 Low-grade fever
No fever until presence of infection
 -Determine whether if it is non allergic or allergic rhinitis

Diagnostics -Because management depends on the type of rhinitis

-If allergic- utilize medication that would stop allergic reaction
-Non allergic- infection = antibiotic treatment
-if there’s a need of systemic or localized management

 testing may include allergy tests to identify possible allergens.

 Nonallergic rhinitis is diagnosed based on symptoms and ruling out other causes, especially
allergies. The doctor will perform a physical examination and ask questions about the
appearance of symptoms. -direct visualization: nasal speculum (are we entertaining rhinitis secondary to
inflammation or inflammation because of polyps )

 There are no specific, definite tests used to diagnose nonallergic rhinitis. The doctor is likely to
conclude the symptoms are caused by nonallergic rhinitis if there is nasal congestion, a runny
nose or postnasal drip, and tests for other conditions don't reveal an underlying cause such as
-It would depend on the history
allergies or a sinus problem. -specifically if discharges have colors
-ct scan of frontal sections (polyps, tumor, puss)
-trial and error of medications
 In some cases, the doctor may try a medication and see whether your symptoms improve.
Ruling out allergic rhinitis
 In many cases, rhinitis is caused by an allergic reaction. The only way
to be sure rhinitis isn't caused by allergies is through allergy testing,
which may involve skin or blood tests.
 Skin test. To find out whether the symptoms might be caused by a certain
allergen, the skin is pricked and exposed to small amounts of common airborne
allergens, such as dust mites, mold, pollen, cat and dog dander. If the patient is
allergic to a particular allergen, he/she would likely develop a raised bump
(hive) at the test location on the skin. If not allergic to any of the substances,
the skin looks normal.
-commonly used by dermatologists
-by patch

 Blood test. A blood test can measure the immune system's response to
common allergens by measuring the amount of certain antibodies in the
bloodstream, known as immunoglobulin E (IgE) antibodies. A blood sample is
sent to a medical laboratory, where it can be tested for evidence of sensitivity
to specific allergens.
-IgE (helps us in identifying the invaders in the system) FOR ALLERGIC RESPONSE
-IgM/IgG bacteria/viral)
Ruling out sinus problems
 The doctor will wantto be sure the symptoms aren't caused by a
sinus problem related to a deviated septum or nasal polyps. If the
doctor suspects a sinus problem may be causing the symptoms,
the patient may need an imaging test to view the sinuses.
 Nasal endoscopy. This test involves looking at the inside of the nasal
passages. This is done with a thin, fiber-optic viewing instrument called
an endoscope. The doctor will pass the fiber-optic endoscope through
the nostrils to examine the nasal passages and sinuses.
 Computerized tomography
Direct visualization (CT)endoscope
a
of nasal passageway ; using fiberoptic scan. This procedure
to nostrils-area of soft palate/roof is
in the floor of nasal
cavity; flexible tube ; px under local anesthesia (lidocaine spray)
computerized X-ray technique that produces images of the sinuses that
w/ viewing device

are more detailed than those produced by conventional X-ray exams.

-if any growth is present (at sinuses)

-know the location to percuss sinuses
-identifying contributing factor
-If allergic:
known: check san allergic
If not known: patient undergo spam checking identification of the allergen (swab test)
-dermatologist / EENT do this testing
-this may help to allergic shots
desensitization process: exposure of allergens over the period of time and it triggers the system to diffuse (para magsawa katawan mo)

Managements
 The first step in treating allergic rhinitis is getting an accurate diagnosis.  Allergies can be
treated using a combination of the following:
• Environmental control measures: Make changes to the home environment to help reduce
the exposure to different types of allergens. For example, removing carpeting can reduce
dust exposure. -causes should be avoided

• Medications: Both over-the-counter and prescription treatments can be effective when used
alone or in combination with one another. Discuss with the doctor the best options and
combinations that would suit patients needs. Neozep: (phenylephrine) decongestants cause dryness (vasoconstrict, decrease edema formation and release of
blood components = reduce moisture) if morethan days (72 hrs til therapeutic effect) = robound congestion
• Allergy shots: Also called immunotherapy, allergy shots help teach the body to become
less allergy to triggers over time.
• Other therapies: Nasal saline rinses (Neti Pot) is a non-medicated rinse that can help flush
out allergens and mucus in the nose.
 Nonallergic rhinitis is treated with medications to relieve the symptoms and doing your best
to avoid the triggers. Treatments like environmental control measures and allergy shots do
not work because allergens are not the culprit.
 Medications
 Antihistamines, such as brompheniramine/pseudoephedrine (Dimetapp); leukotriene
inhibitors, such as montelukast (Singulair); and mast cell stabilizers, such as cromolyn
(Nasalcrom), are used to block the release of chemicals from WBCs that bind with
receptors in nasal tissues, which prevent edema and itching.
-check and review -nasal drainage: (w/use of nasal saline)
-additional medications -salinase
 Nursing Considerations -possible combinations or change of meds -antihistamines (cause vasoconstriction HPN),
dimetapp, pseudoephidrine, phenopropanolamine

 Older adults should be aware of adverse effects such as vertigo, hypertension, and urinary retention.
 Decongestants, such as phenylephrine (Neo-Synephrine), constrict blood vessels and
decrease edema.
 Nursing Considerations
 Encourage clients to use as prescribed for 3 to 4 days to avoid rebound nasal congestion.
 Intranasal glucocorticoid sprays (Flonase) are the most effective for prevention and
treatment of seasonal and perennial rhinitis.
 Antipyretics are used if fever is present.
 Antibiotics are given if a bacterial infection can be identified.
Treatment of nonallergic rhinitis depends on how much it bothers the patient. For mild
cases, home treatment and avoiding triggers may be enough. For more-bothersome
symptoms, certain medications may provide relief, including:

• Saline nasal sprays. Use an over-the-counter nasal saline spray or homemade saltwater solution to flush the nose of
irritants and help thin the mucus and soothe the membranes in your nose. -isotonic solution

• Corticosteroid nasal sprays. If your symptoms aren't easily controlled by decongestants or antihistamines, the
doctor may suggest a nonprescription corticosteroid nasal spray, such as fluticasone (Flonase) or triamcinolone
(Nasacort). Prescription-only corticosteroid nasal sprays are also available.
 Corticosteroid medications help prevent and treat inflammation associated with some types of nonallergic rhinitis. Possible side effects include
nasal dryness, nosebleeds, headaches and throat dryness. -nasal glucocorticoids spray : safety (-) immune responses
Vasoconstriction effect (seasonal/perineal rhinitis)
-small doses
• Antihistamine nasal sprays. Try a prescription antihistamine spray such as azelastine (Astelin, Astepro) and
olopatadine hydrochloride (Patanase). While oral antihistamines don't seem to help nonallergic rhinitis, nasal sprays
containing an Non-allergic:
antihistamine may reduce symptoms of nonallergic rhinitis.
direct to the site, hindi gagana ang systemic, pero localized

• Anti-drip anticholinergic nasal sprays. The prescription drug ipratropium (Atrovent) is often used as an asthma
inhaler medication. But it's now available as a nasal spray and can be helpful if a runny, drippy nose is your main
Vasoconstriction effect
complaint. Side effects may include nosebleeds and drying of the inside of your nose.
-anti postnasal drip/ anti runny nose

• Decongestants. Available over-the-counter or by prescription, examples include pseudoephedrine-containing drugs

(Sudafed) and phenylephrine (Afrin, Neo-Synephrine, others). These medications help narrow the blood vessels,
reducing congestion in the nose. Possible side effects include high blood pressure, heart pounding (palpitations) and
restlessness.
Other treatment
 Immunotherapy Triggers system to build own self defense mechanis

 Also known as allergy shots. If one have severe allergies, this treatment plan in conjunction with
medications to control symptoms. These shots decrease the immune response to particular
allergens over time. They do require a long-term commitment to a treatment plan.
 An allergy shot regimen begins with a buildup phase. During this phase, the patient must go to
the allergist for a shot one to three times per week for about three to six months to let the body
get used to the allergen in the shot. -done in clinic ; px is asked to stay for 45 minutes after the first shot and
advised to report any reactions (late allergic responses)
 During the maintenance phase, the patient will likely need to see the allergist
-adverse effect is high:for shots
first few every two
days/weeks

to four weeks over the course of three to five years. The changes may not be noticed until over a
year after the maintenance phase begins. Once the patient reach this point, it’s possible that the
allergy symptoms will fade or disappear altogether.
 Some people can experience severe allergic reactions to an allergen in their shot. Many allergists
ask the patient to wait in the office for 30 to 45 minutes after a shot to ensure that he doesn’t have
an intense or life-threatening response to it.
Other treatment cont….
-known allergen turned into tablets
 Sublingual immunotherapy (SLIT) -advantage: rare of anaphylaxis
-problem: local hypersensitivity reaction

 SLIT involves placing a tablet containing a mixture of several allergens under

your tongue. It works similarly to allergy shots but without an injection.
Currently, it is effective for treating rhinitis and asthma allergies caused by grass,
tree pollen, cat dander, dust mites, and ragweed. The patient can take SLIT
treatments, such as Oralair for certain grass allergies, at home after an initial
consultation with the doctor. The first dose of any SLIT will take place in the
doctor’s office. Like allergy shots, the medication is taken frequently over a
period of time determined by the doctor.
 Possible side effects include itching in the mouth or ear and throat irritation. In
rare cases, SLIT treatments can cause anaphylaxis. Talk to the doctor about SLIT
to see if the allergies will respond to this treatment. The doctor will need to direct
your treatment with this method.
Sinusitis
 Types
Acute Sinusitis
Acute sinusitis refers to sinusitis symptoms lasting
less than four weeks. Most cases begin as a
If it is viral, if bacterial -> chronic complication, fungal -> worst

common cold. Symptoms often go away within a -later on could result pamamaga ng periorbital

week to 10 days; but in some people, a bacterial

sections, sides of nose, teary eye, nasal congestion

-nasal/sinus plague- good medium to have

infection develops.
bacterial colony (high protein)

Chronic Sinusitis
Chronic sinusitis, also referred to as chronic
rhinosinusitis, is often diagnosed when symptoms
have gone on for more than 12 weeks, despite -persist despite medical treatment

medical treatment.
Pathophysiology -

 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
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.
Signs and Symptoms
 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.
 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.
 Complications
 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
Management

 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).
Management
 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.
 Oral 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.
Management
 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.
 Nursing Management
 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.
 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
 Chronic sinusitis is an inflammation of the sinuses that
persists for more than 3 weeks in an adult and 2 weeks in
a child.
Pathophysiology
 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. (SHM)
 Immunocompromised patients, however, are at increased risk for
developing fungal sinusitis.
 Aspergillus fumigatus is the most common organism associated with fungal
sinusitis.
Symptoms
 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.
Diagnostic
 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 mycetoma (fungus balls). The fungus ball
is usually a brown or greenish-black material with the consistency
of peanut butter or cottage cheese.
Diagnostic
 Allergy testing performed by an allergist / immunologist can
identify what allergic triggers might be behind your chronic or
reoccurring sinus infections.
 In chronic or severe cases, the doctor may also examine the nasal
passages using a technique called rhinoscopy or nasal endoscopy.
 In this procedure, a thin, flexible instrument is inserted up the nostril to
view the sinus passages and look for blockages.
 The doctor may order a MRI or CT scan to look for abnormalities
in the sinuses – narrow drainage passages, polyps or a deviated
septum.
Complications
 Complications
of chronic sinusitis, although
uncommon, include
 severe orbital cellulitis,
 subperiosteal abscess,
 cavernous sinus thrombosis,
 meningitis,
 encephalitis, and
 ischemic infarction.
Management
Management
 The treatment of sinusitis depends on the cause, severity and duration
of symptoms.
 Chronic sinusitis is typically not caused by a bacterial infection, so
treating the condition with antibiotics usually doesn’t help.
 Avoid activities and places that may aggravate your symptoms—
especially if your symptoms relate to an allergy.
 Intranasal corticosteroid sprays may be appropriate for recurrent
sinusitis, but only under the care of the doctor. If the diagnosis involves
a fungus, the doctor may prescribe an antifungal medication.
Management (3-4 weeks)

 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.
a quinolone, Levofloxacin (Levaquin), 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.
 SURGICAL MANAGEMENT
 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.
Nursing Management
 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.
Please read about the following other
upper respiratory tract conditions:
 Pharyngitis – viral: Mononucleosis (EBV, CMV) ; bacteria (S.Pyogenes)
Complications: fever, joint pain , heart problems, shaking movements, rash, HPN, hematuria
 Tonsilitis – palatine tonsils “crypts” ; symptoms: exudate (whitish appearance)
Viral: Rhinovirus, Adenovirus, Corona Virus, Influenza ; Bacteria: S.Pyogenes (antibiotics are given)
Complication: Peritonsillar Abscess, Heart, Joints, Nervous system, damage to kidneys
 Adenoiditis – Adenoids “nasal pharyngeal tonsils
 Peritonsillar abscess (Quincy)
S.Pyogenes, Sta.Aureus, Anaerobic organisms
 Laryngitis
NURSING PROCESS: THE PATIENT
WITH UPPER AIRWAY INFECTION
 Assessment
 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.
Assessment
 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.
 Diagnosis
 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
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.
Nursing Interventions
 MAINTAINING A PATENT AIRWAY
 PROMOTING COMFORT
 PROMOTING COMMUNICATION
 ENCOURAGING FLUID INTAKE
 PROMOTING HOME AND COMMUNITY-BASED CARE
 MONITORINGAND MANAGING POTENTIAL
COMPLICATIONS
Influenza (flu)
Overview
 Seasonal influenza or “flu” occurs as an epidemic, usually in the fall and winter months in
the western part of the globe and in the South East Asian region during the rainy season.
Usually during the “BER” months
 ◯ It is a highly contagious acute viral infection that occurs in children and adults of all ages.
 ◯ Influenza may be caused by one of several virus families, and this can vary yearly. Adults are
contagious from 24 hr before manifestations develop and up to 5 days after they begin.
 ● Pandemic influenza refers to a viral infection among animals or birds that has mutated and
is becoming highly infectious to humans. The resulting viral infection has the potential to
spread globally, such as H1N1 (“swine flu”) and H5N1 (“avian flu”) and recently the Covid-19.
Influenza (Flu)
 Influenza (flu) is a contagious respiratory illness caused
by influenza viruses.
 It can cause mild to severe illness.
 Serious outcomes of flu infection can result in hospitalization or
death.
 Some people, such as older people, young children, and people
with certain health conditions, are at high risk of serious flu
complications. 
Types
 There are two main types of influenza (flu) virus: Types A and B.
 The influenza A and B viruses that routinely spread in people
(human influenza viruses) are responsible for seasonal flu epidemics each year.
 Flu Symptoms

 Influenza (flu) can cause mild to severe illness, and at times can lead to death. Flu is
different from a cold. Flu usually comes on suddenly. People who have flu often feel
some or all of these symptoms:
• fever* or feeling feverish/chills
• cough
• sore throat
• runny or stuffy nose
• muscle or body aches
• headaches
• fatigue (tiredness)
• some people may have vomiting and diarrhea, though this is more common in
children than adults.
 *It’s important to note that not everyone with flu will have a fever.
How Flu Spreads
 Most experts believe that flu viruses spread mainly by
tiny droplets made when people with flu cough, sneeze
or talk.
 These droplets can land in the mouths or noses of people who
are nearby.
 Less often, a person might get flu by touching a surface or object
that has flu virus on it and then touching their own mouth, nose
or possibly their eyes.
Period of Contagiousness
 The patient may be able to spread flu to someone else
before they know they are sick, as well as while they are
sick.
• People with flu are most contagious in the first 3-4 days
after their illness begins.
• Some otherwise healthy adults may be able to infect others
beginning 1 day before symptoms develop and up to 5 to 7
days after becoming sick.
• Some people, especially young children and people with
weakened immune systems, might be able to infect others
for an even longer time.
Onset of Symptoms
 The time from when a person is exposed and infected
with flu to when symptoms begin is about 2 days, but
can range from about 1 to 4 days.
Complications of Flu

 Most people who get flu will recover in a few days to less than two weeks, but some
people will develop complications (such as pneumonia) as a result of flu, some of
which can be life-threatening and result in death.
 Sinus and ear infections are examples of moderate complications from flu,
 Pneumonia is a serious flu complication that can result from either influenza virus
infection alone or from co-infection of flu virus and bacteria.
 Other possible serious complications triggered by flu can include
 inflammation of the heart (myocarditis),
 brain (encephalitis) or
 muscle (myositis, rhabdomyolysis) tissues, and
 multi-organ failure (for example, respiratory and kidney failure).
 Flu virus infection of the respiratory tract can trigger an extreme inflammatory
response in the body and can lead to sepsis, the body’s life-threatening response to
infection.
 Flu also can make chronic medical problems worse. For example, people
with asthma may experience asthma attacks while they have flu, and people
with chronic heart disease may experience a worsening of this condition triggered by
flu.
Differentiating cold vs flu
Signs and Symptoms Cold Influenza (Flu)
Symptom onset Gradual Abrupt

Fever Rare Usual; lasts 3-4 days

Aches Slight Usual; often severe

Chills Uncommon Fairly common

Fatigue, weakness Sometimes Usual

Sneezing Common Sometimes

Chest discomfort, cough Mild to moderate; hacking Common; can be severe

cough
Stuffy nose Common Sometimes

Sore throat Common Sometimes

Headache Rare Common

 Both COVID-19 and flu can have varying degrees of signs and symptoms,
ranging from no symptoms (asymptomatic) to severe symptoms.
 Common symptoms that COVID-19 and flu share include:
• Fever or feeling feverish/chills
• Cough
• Shortness of breath or difficulty breathing
• Fatigue (tiredness)
• Sore throat
• Runny or stuffy nose
• Muscle pain or body aches
• Headache
• Some people may have vomiting and diarrhea, though this is more common
in children than adults
Differences between Flu and Covid-19
FLU Covid-19

Spread Contagious More contagious

Loss of taste and smell Absent present

Onset of symptoms 1-4 days from exposure 2-14 days from exposure

Mortality Low High

Treatment Antiviral drug identified Still on process of testing

Vaccination Available Still on process of testing

 Diagnostics
 rapid influenza diagnostic tests (RIDTs)- work by detecting the parts of
the virus (antigens) that stimulate an immune response.
 These tests can provide results within approximately 10-15 minutes but are
not as accurate as other flu tests. Therefore, you could still have flu, even
though your rapid test result is negative.
 rapid molecular assays- detect genetic material of the virus. Rapid
molecular assays produce results in 15-20 minutes and are more
accurate than RIDTs.
Algorithm to assist in the interpretation of
influenza testing results and clinical
decision-making during periods when
influenza viruses are circulating in the
community
Management

 Priority Groups for Antiviral Treatment of Influenza

 Antiviral treatment is recommended as soon as possible for any patient with
suspected or confirmed influenza who:
• is hospitalized;
• has severe, complicated, or progressive illness; or
• is at higher risk for influenza complications.
 Decisions about starting antiviral treatment for patients with suspected influenza
should not wait for laboratory confirmation of influenza virus infection.
 Empiric antiviral treatment should be started as soon as possible in the above
priority groups.
 Clinicians can consider early empiric antiviral treatment of non-high-risk
outpatients with suspected influenza [e.g., influenza-like illness (fever with either
cough or sore throat)] based upon clinical judgement, if treatment can be initiated
within 48 hours of illness onset.
 Antiviral Drug Options
• For hospitalized patients with suspected or confirmed influenza,
initiation of antiviral treatment with oral or enterically-administered
oseltamivir is recommended as soon as possible.
• For outpatients with complications or progressive disease and
suspected or confirmed influenza (e.g., pneumonia, or exacerbation of
underlying chronic medical conditions), initiation of antiviral treatment
with oral oseltamivir is recommended as soon as possible.
• For outpatients with suspected or confirmed uncomplicated
influenza, oral oseltamivir, inhaled zanamivir, intravenous peramivir,
or oral baloxavir may be used for treatment, depending upon approved
age groups and contraindications.
• In one randomized controlled trial, baloxavir had greater efficacy than
oseltamivir in adolescents and adults with influenza B virus infection
(Ison, 2020). (Baloxavir > oseltamivir)
Patient-Centered Care
 ● Nursing Care (hospitalized clients)
 ◯ Maintain airborne and contact precautions for hospitalized
clients with pandemic influenza.
 ◯ Provide saline gargles.
 ◯ Monitor hydration status, intake and output.
 ◯ Administer fluid therapy as prescribed by the provider.
 ◯ Monitor respiratory status.
Client Education
 ◯ Encourage annual influenza vaccination when vaccines become
available.
 ◯ Reduce the risk for spreading viruses by thoroughly washing hands and
following cough etiquette.
 ◯ Avoid places where people gather; avoid close personal contact
(handshaking, kissing and hugging).
 ◯ If flu manifestations develop, increase fluid intake, rest and stay home
from work or school.
 ◯ Avoid travel to areas where pandemic influenza is identified.
 ◯ Be aware of public health announcements and activation of the early
warning system by public health officials in case of pandemic influenza.
PNEUMONIA
PNEUMONIA
 Pneumonia is an inflammation of the lung parenchyma that is
caused by a microbial agent.
 ● Pneumonia is a complication of influenza and affects older
adults and clients who are debilitated or immunocompromised
 Top 4 leading cause of death in the Philippines and among
women (DOH, 2013)
Pneumonia: Pathophysiology
 Bacteria commonly enter the lower airway but do not cause pneumonia in the presence of an
intact host defense mechanism.
 When pneumonia does occur, it is caused by various microorganisms, including bacteria,
mycobacteria, chlamydiae, mycoplasma, fungi, parasites, and viruses. Several systems are
used to classify pneumonias.
 Classically, pneumonia has been categorized into one of four categories:
 bacterial or typical,
 atypical,
 anaerobic/ cavitary, and
 opportunistic.
 However, there is overlap in the microorganisms thought to be responsible for typical and
atypical pneumonias. A more widely used classification scheme categorizes the major
pneumonias as
 community-acquired pneumonia,
 hospital-acquired pneumonia,
 pneumonia in the immunocompromised host, and
 aspiration pneumonia.
 There is overlap in how specific pneumonias are classified because they may occur in differing
settings.
Type of Pneumonia
 Community-acquired pneumonia (CAP) occurs either in the community
setting or within the first 48 hours of hospitalization or
institutionalization. The need for hospitalization for CAP depends on
the severity of the pneumonia.
 The agents that most frequently cause CAP requiring hospitalization are
S. pneumoniae, H. influenzae, Legionella, Pseudomonas aeruginosa, and
other gram-negative rods.
 The specific etiologic agent of CAP is identified in about 50% of the
cases.
 The absence of a responsible caregiver in the home may be another
indication for hospitalization.
 Type of Pneumonia

 Hospital-acquired pneumonia (HAP) also known as nosocomial pneumonia, is

defined as the onset of pneumonia symptoms more than 48 hours after
admission to the hospital.
 HAP accounts for approximately 15% of hospital-acquired infections but is the most
lethal nosocomial infection. It is estimated to occur in 0.5% to 1% of all hospitalized
patients and in 15% to 20% of intensive care patients.
 Ventilator-associated pneumonia can be considered a type of nosocomial pneumonia
that is associated with endotracheal intubation and mechanical ventilation.
 The common organisms responsible for HAP include the pathogens Enterobacter
species, Escherichia coli, Klebsiella species, Proteus, Serratia marcescens, P.
aeruginosa, and methicillin-sensitive or methicillin-resistant Staphylococcus aureus.
 These respiratory infections occur when at least one of three conditions exists:
 host defenses are impaired,
 an inoculum of organisms reaches the patient’s lower respiratory tract and overwhelms
the host’s defenses, or
 a highly virulent organism is present.
Assessment
 Subjective Data
 Anxiety
 Fatigue
 Weakness
 Chest discomfort due to coughing
 Confusion from hypoxia is the most common manifestation of
pneumonia in older adult clients.
Assessment
 Objective Data
 Physical Assessment Findings
 Fever
 Chills
 Flushed face
 Diaphoresis / excessive sweating
 Shortness of breath or difficulty breathing
 Tachypnea
 Pleuritic chest pain (sharp)
 Sputum production (yellow-tinged)
 Crackles and wheezes
 Coughing
 Dull chest percussion over areas of consolidation
 Decreased oxygen saturation levels (expected reference range is 95% to
100%)
 Purulent, blood-tinged or rust-colored sputum, which may not always be
present
Laboratory Tests
 Sputum culture and sensitivity
 Obtain specimen before starting antibiotic therapy.
 Obtain specimen by suctioning if the client is unable to cough.
 The responsible organism is identified about 50% of the time.
 Older adult clients have a weak cough reflex and decreased
muscle strength. Therefore, older adult clients have trouble
expectorating, which can lead to difficulty in breathing and make
specimen retrieval more difficult.
 CBC – Elevated WBC count (may not be present in older adult
clients)
 ABGs – Hypoxemia (decreased PaO2 less than 80 mm Hg)
 Blood culture – To rule out organisms in the blood
 Serum electrolytes – To identify causes of dehydration
Diagnostic Procedures
 Chest x-ray
 A chest x-ray will show consolidation (solidification, density) of
lung tissue.
 Chest x-ray may not indicate pneumonia for a few days after
manifestations. (6 weeks daw?)
 A chest x-ray is an important diagnostic tool because the early
manifestations of pneumonia are often vague in older adult
clients.
 Pulse Oximetry – Clients who have pneumonia usually have
oximetry levels less than the expected reference range of
95% to 100%.
 Patient-Centered Care
 ● Nursing Care
 Position the client to maximize ventilation (high-Fowler’s = 90%) unless contraindicated.
 Encourage coughing or suction to remove secretions.
 Administer breathing treatments and medications as prescribed.
 Administer oxygen therapy as prescribed.
 Monitor for skin breakdown around the nose and mouth from the oxygen device.
 Encourage deep breathing with an incentive spirometer to PREVENT alveolar collapse.
 Determine the client’s physical limitations and structure activity to include periods of
rest.
 Promote adequate nutrition and fluid intake.
 The increased work of breathing requires additional calories.
 Proper nutrition aids in the prevention of secondary respiratory infections.
 Encourage fluid intake of 2 to 3 L/day to promote hydration and thinning of secretions, unless
contraindicated due to another condition.
 Provide rest periods for clients who have dyspnea.
 Reassure the client who is experiencing respiratory distress.
 Medications
 Antibiotics
 Antibiotics are given to destroy infectious pathogens; commonly used antibiotics
include penicillins and cephalosporins.
 Antibiotics are often initially given via IV and then switched to an oral form as the
client’s condition improves.
 It is important to obtain any culture specimens prior to giving the first dose of an
antibiotic. Once the specimen has been obtained, the antibiotics can be given while
waiting for the results of the prescribed culture.
 Nursing Considerations
 Observe clients taking cephalosporins for frequent stools.
 Monitor client’s kidney function, especially older adults who are taking penicillins
and cephalosporins.
 Client Education
 Encourage clients to take penicillins and cephalosporins with food.
Some penicillins should be taken 1 hr before meals or 2 hr after.
 Bronchodilators
 Bronchodilators are given to reduce bronchospasms and reduce irritation.
 Short-acting beta2 agonists, such as albuterol, provide rapid relief.
 Cholinergic antagonists (anticholinergic medications), such as ipratropium
(Atrovent), block the parasympathetic nervous system, allowing for increased
bronchodilation and decreased pulmonary secretions.
 Methylxanthines, such as theophylline (Theo-24), require close monitoring of serum
medication levels due to the narrow therapeutic range.
 Nursing Considerations
 Monitor serum medication levels for toxicity for clients taking theophylline.
Adverse effects will include tachycardia, nausea, and diarrhea.
 Watch for tremors and tachycardia for clients taking albuterol.
 Observe for dry mouth in clients taking ipratropium, and monitor heart rate.
Adverse effects can include headache, blurred vision, and palpitations, which may
indicate toxicity.
 Client Education
 Encourage clients to suck on hard candies to help moisten dry
 Encourage increased fluid intake unless contraindicated.
Anti-inflammatories decrease airway inflammation
 Glucocorticosteroids, such as fluticasone (Flovent) and prednisone
(Deltasone), are prescribed to reduce inflammation. Monitor for
immunosuppression, fluid retention, hyperglycemia, hypokalemia, and poor
wound healing.
 Nursing Considerations
 Monitor for decreased immunity function.
 Monitor for hyperglycemia.
 Advise the client to report black, tarry stools.
 Observe for fluid retention and weight gain. This can be common.
 Monitor the client’s throat and mouth for aphthous lesions (canker sores).
 Client Education
 Encourage the client to drink plenty of fluids to promote hydration.
 Encourage the client to take glucocorticosteroids with food.
 Encourage the client to avoid discontinuing glucocorticosteroids without
consulting provider.
Care after Discharge
 Client Education
 Educate the client on the importance of continuing medications
for treatment of pneumonia.
 Encourage rest periods as needed.
 Encourage the client to maintain hand hygiene to prevent
infection.
 Encourage the client to avoid crowded areas to reduce the risk of
infection.
 Remind the client that treatment and recovery from pneumonia
can take time.
 Encourage immunizations for influenza and pneumonia.
 Promote smoking cessation if the client is a smoker.
Complications
 Atelectasis
 Airway inflammation and edema lead to alveolar collapse and increase the risk of
hypoxemia.
 The client reports shortness of breath and exhibits findings of hypoxemia.
 The client has diminished or absent breath sounds over the affected area.
 A chest x-ray shows an area of density.
 Bacteremia (sepsis)
 This occurs if pathogens enter the bloodstream from the infection in the lungs.
 Acute Respiratory Distress Syndrome (ARDS)
 Hypoxemia persists despite oxygen therapy.
 The client’s dyspnea worsens as bilateral pulmonary edema develops that is
noncardiac related.
 A chest x-ray shows an area of density with a “ground glass” appearance.
 Blood gas findings demonstrate high arterial blood levels of carbon dioxide
(hypercarbia) even though pulse oximetry shows decreased saturation.