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Disorders and management of patients with diseases of the Upper Respiratory System
A. ALLERGIC RHINITIS (hay fever) - sensitivity to allergens with whitish or clear nasal discharge;
inflammation and irritation of the mucus membranes of the nose
Non allergic: changes in temperature, odors, food
Allergic: exposure to an irritant or an allergen

B. 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.
Nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise
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.

Clinical Manifestations:
nasal congestion
runny nose
sneezing
nasal discharge
nasal itchiness
tearing
watery eyes,
scratchy or sore throat
general malaise
low-grade fever

chills
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.

PHARMA MANAGEMENT:
o Medication therapy for allergic and non-allergic rhinitis focuses on symptom relief.
Antihistamines are administered for sneezing, itching, and rhinorrhea.
Oral decongestant agents are used for nasal obstruction.
intranasal corticosteroids may be used for severe congestion
Ophthalmic agents are used to relieve irritation, itching, and redness of the eyes.

NURSING MANAGEMENT:
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.

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6 VIRUSES KNOWN TO CAUSE RHINITIS:
Rhinovirus
parainfluenza virus
coronavirus,
respiratory syncytial virus
(RSV)
influenza virus

adenovirus


C. SINUSITIS: inflammation of mucus membranes in the sinuses which may be followed by infection with a yellowish-
green discharge

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

Focus of Management:
treatment with antibiotics, decongestants, antihistamines
surgery to drain and open sinuses
antral irrigation (sinus irrigation)

Clinical Manifestations:
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
facial congestion or fullness


PHARMA MANAGEMENT:
o The goals of treatment of acute sinusitis are to treat the infection, shrink the nasal mucosa, and relieve pain.
First-line antibiotics
amoxicillin(Amoxil)
trimethoprim/sulfamethoxazole (Bactrim, Septra)
erythromycin.

Second-line antibiotics
Cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), cefprozil (Cefzil) and amoxicillin
clavulanate (Augmentin).
Macrolides such as azithromycin (Zithromax), and clarithromycin (Biaxin).
Quinolones such as ciprofloxacin (Cipro), levofloxacin (Levaquin) (used with severe penicillin allergy), and
sparfloxacin (Zagam) have also been used.

o The course of treatment is usually 10 to 14 days.

OTHER MEDICATIONS:
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 may be effective for opening blocked passages.
Decongestant agents such as pseudoephedrine (Sudafed, Dimetapp) are effective because of their
vasoconstrictive properties.

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o It is important to administer them with the patients 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.


NURSING MANAGEMENT:
instruct the patient about methods to promote drainage
inhaling steam (steam bath, hot shower, and facial sauna)
increasing fluid intake
Applying local heat (hot wet packs).
Inform the patient about the side effects of nasal sprays and about rebound congestion.
In the case of rebound congestion, the bodys receptors, which have become dependent on the decongestant sprays
to keep the nasal passages open, close and congestion results after the spray is discontinued.

D. 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.

Clinical Manifestations:
impaired mucociliary clearance and ventilation
cough (because the thick discharge constantly drips backward into the nasopharynx)
chronic hoarseness
chronic headaches in the periorbital area
facial pain.
o These symptoms are generally most pronounced on awakening in the morning.
Fatigue and nasal stuffiness are also common.
some patients experience a decrease in smell and taste
fullness in the ears

PHARMA MANAGEMENT:
antimicrobial agents of choice include the following
amoxicillin clavulanate (Augmentin)
ampicillin (Ampicin)
Clarithromycin (Biaxin)
third-generation cephalosporins such as
cefuroxime axetil (Ceftin)
cefpodoxime (Vantin)
cefprozil (Cefzil)
Quiolones such as:
Levofloxacin (Levaquin)
o The course of treatment may be 3 to 4 weeks.
o Decongestant agents, antihistamines, saline sprays, and heated mist are also recommended

Nursing Management:
Because the patient usually performs care measures for sinusitis at home, nursing management consists mainly of patient
teaching.

TEACHING PATIENTS SELF-CARE:
teach the patient how to promote sinus drainage by increasing the environmental humidity (steam bath, hot shower,
and facial sauna)
increasing fluid intake
applying local heat (hot wet packs)
instructs the patient about the importance of following the medication regimen.


E. TONSILITIS
1. Inflammation and/or infection of tonsils
2. Acute form is usually bacterial
3. Treat findings; if culture shows bacteria, use antibiotics

Disorders of Lower Respiratory System (LRS): Obstructive
General facts: process in chronic obstructive pulmonary diseases
Block airflow out of lungs
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Trap air, with impairment of gas exchange
Increase the work of breathing

A. Emphysema
Destroys alveoli
Narrows and collapses small airways
Overall lung loses elasticity
Traps air
As alveolar walls die, there is less surface for vital gas exchange


B. Chronic bronchitis
1. Definition
a. inflammatory response in the lung
b. affects few alveoli, mostly airways
2. Findings
a. lungs chronically produce fluids
b. inflammation and mucus narrow the airways


C.Asthma
1. Definition/etiology
a. reversible obstruction of airways
b. inflammation of airways
c. airways hypersensitive to variety of stimuli
d. bronchospasm is a minor component
e. disease waxes and wanes, remissions and exacerbations
2. Findings
a. orthopnea, expiratory wheezing
b. barrel chest, cyanosis, clubbing of fingers
c. distention of neck veins
d. edema of extremities
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e. increased PCO
2
and decreased PO
2

f. polycythemia
3. Diagnostics
a. physical examination with history of findings
b. arterial blood gases
c. chest x-ray
4. Complications
a. hypoxemia
b. hypercapnia
c. variety of respiratory infections
d. cor pulmonale
e. dysrhythmias

Pharmacologic Management for obstructive diseases:
Antibiotics and corticosteroids for infection or chronic inflammation
Bronchodilators
Mucolytics
Expectorants
Respiratory program: postural drainage, exercise, nebulizer, high protein diet

Nursing interventions common to obstructive diseases
Assess client's risk of respiratory failure
Assess for degree of respiratory effort for an increased work of breathing or dyspnea
Assess oxygenation with pulse oximeter if hemoglobin level is within normal limits
Measure arterial blood gases (ABG) to evaluate gas exchange
Administer oxygen as indicated
If risk of respiratory failure, anticipate ventilation
Assist with secretion removal as indicated
Pace client activities to reduce oxygen demand
Teach diaphragmatic breathing and pursed-lip breathing
Position in a high Fowler's to ease breathing effort
Provide for nutritional consults as indicated
Reinforce the plan for small, frequent high carbohydrate meals
Provide referrals for:
a. depression associated with disease
b. pulmonary rehabilitation
c. stop smoking support groups
For asthma, teach clients that aspirin or peanuts may stuimulate an asthma attack

LRS Disorders: Restrictive
In general: these disorders prevent full lung expansion via three mechanisms
Lung stiffening
External compression
Muscle weakness

A.Pulmonary fibrosis- lung stiffening
1. Occupational lung diseases
a. coal worker's pneumoconiosis - risk increases with length of exposure to coal dust (>15 years), intensity of
exposure, and silica content of dust
b. silicosis: workers who will have inhaled silica dust
2. Asbestosis
a. inhalation of asbestos fibers
b. disease may develop 15 to 20 years after exposure

B.Pulmonary sarcoidosis - lung stiffening
1. Etiology
a. unknown origin
b. characterized by formation of tubercles, most often in the lungs
c. may progress to fibrosis
2. Findings
a. dyspnea
b. anxiety
3. Diagnostics
a. chest x-ray
b. biopsy of affected tissue
4. Management
a. antitussives
b. oxygen therapy
c. removal of toxic substances
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Nursing interventions common to all types of pulmonary fibrosis
Prevent infection or exposure to infection
Pace clients' activities to reduce oxygen demands and dyspnea
Reinforce the need for small, frequent meals
Encourage daily activities within pulmonary tolerance
provide referrals for:
depression associated with disease
stop smoking support groups
occupational rehabilitation

Disorders of fluid in pleurae
Pleural fluid disorders - all treated with water seal chest drainage systems

A. Pneumothorax: air between the pleurae



a. open pneumothorax: hole in the chest wall, communicates with the lung
b. closed pneumothorax: hole in lung, chest wall intact
c. tension pneumothorax - a nursing and medical emergency

closed pneumothorax
air is forced into the pleural space with a continued pressure build up
shifts mediastinum away from affected side with results of a compressed heart
treated with chest tube insertion
cardiac and respiratory arrest if not treated
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B. Pleural effusion
fluid (transudate or exudate) in the pleural space
if small, no treatment
if larger, treated with chest tube insertion
Hemothorax
blood in the pleural space
treated with thoracentesis or chest tube
Empyema
purulent drainage in the pleural space
often from a chronic condition such as lung cancer
treated with chest tube inserton
Chylothorax
lymphatic fluid in pleural space
treated with thoracentesis or chest tube


Musculoskeletal diseases associated with difficulty breathing
A. Guillain-Barre syndrome - follows a viral infection
a. ascending paralysis that may affect muscles of respiration as paralysis ascends
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b. muscles so weak that client cannot breathe deeply, a nursing and medical emergency
c. may progress to respiratory failure
d. may require intubation
e. mechanical ventilation
f. course of illness varies from a few months to years

B. Myasthenia gravis
a. sporadic, progressive weakness of skeletal muscle
b. cause: lack of acetylcholine with results of a myoneural junction malfunction
c. may not be able to chew and swallow well
i. may aspirate
ii. may lose protective airway reflexes
d. repeated muscle movements, especially towards days end, can exacerbate acute respiratory failure

C. Poliomyelitis
a. viral infection
b. if disease strikes the respiratory muscles the result may be respiratory failure
c. may not swallow well
i. may aspirate
ii. may lose protective airway reflexes

D. Amyotrophic lateral sclerosis (ALS; Lou Gehrig's Disease)
a. affects motor neurons; autonomic, sensory and mental function unchanged
b. manifests as a chronic, progressive irreversible disorder
c. begins usually in distal ends of upper extremities
d. often leads to respiratory failure within two to five years
e. results in ethical issue
i. whether clients want mechanical ventilation
ii. whether nutritional support is desired
iii. if they would rather die when disease becomes this severe
f. results in clients' inability to communicate or physically move from voluntarily and/or clients lack involuntary
reflexes, such as blinking or gag reflex

E. Muscular dystrophies
a. progressive symmetrical wasting of voluntary muscles with no nerve effect
b. as thoracic muscles weaken, breathing becomes more difficult
c. may not swallow well; risk for aspiration with loss of protective airway reflexes

Interventions common to musculoskeletal disorders
a. monitor carefully for changes in condition
b. assess regular swallowing and ability to protect the upper airway
c. discuss chances of mechanical ventilation or nutritional support: does client wish it?
d. assist with coughing and secretion clearance as indicated
e. prevent infection
f. assess for with appropriate referrals for depression that is often associated with these diseases
g. administer medications specific to the disease condition
h. assist/provide occupational or/and physical rehibilitation as indicated
i. maintain adequate nutrition
j. with terminal disorders, provide for referrals for family

LRS Disorders: Infectious
A. Pneumonia
1. Definition/etiology
a. acute infection of lung parenchyma
b. cause: bacterium, virus, protozoan, mycobacterium, mycoplasma, or rickettsia
c. pneumonia is the leading cause of death from infectious causes
d. may affect only a region of lung: lobar pneumonia, bronchopneumonia
e. may be the result of:
i. primary infection
ii. secondary to other lung damage
iii. aspiration


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2. Risk factors for pneumonia
a. pre-existing pulmonary disease
b. abdominal and thoracic surgery
c. mechanical ventilation
d. advanced age
e. decreased ability to protect airway or cough effectively
f. artificial airway
g. chronic illness and debilitation
h. depressed immune function
i. cancer

3. Diagnostics
a. chest radiograph
b. sputum culture, sensitivity and microscopic analysis, Gram stain, cytology
c. ABG as indicated by clinical condition

4. Management
a. antimicrobials, depending on pathogen
b. antipyretic
c. expectorants
d. antitussives
e. supplemental oxygen, as indicated
f. IV fluids to treat dehydration

5. Nursing interventions
a. monitor finger oximeter if hemoglobin levels within normal limits
b. promote hydration to liquify secretions
c. teach effective coughing techniques to minimize energy expenditure
d. suction if necessary
e. teach the need to continue entire course of antimicrobial therapy which is usually seven to ten days
f. teach that findings are expected to be less within 48 to 72 hours of initial therapy


B. Pulmonary tuberculosis (PTB)
1. Etiology
a. mycobacterium tuberculosis
b. bacilli lodge in alveoli
c. pulmonary infiltrates
d. can spread throughout body via blood
e. multi-drug resistant PTB is becoming more prevalent
f. PTB incidence is rising with increasing homelessness and AIDS

2. Findings
a. weakness with fatigue
b. anorexia with weight loss
c. night sweats
d. chest pain
e. productive cough

3. Diagnostics
a. sputum and gastric contents, analysis for the presence of acid-fast bacilli
b. chest x-ray for presence of active or calcified lesions, "coin" lesions
c. tuberculin testing
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i. tine, mantoux tests
checked 48 to 72 hours for induration
positive if >10 mm induration in healthy persons
d. establishes if there is an antibody response to the tubercle bacillus
e. if positive, indicates prior exposure to bacillus, not an active disease



4. Management
a. long-term, six to 24 months, antimicrobial therapy with isoniazid (INH) (Hyzyd) or rifampin (Rifadin), with ethambutol
HCL (Etibi) in some cases
b. bed rest or chair rest until findings abate
c. surgical resection of involved lung if medication is not effective
d. high carbohydrate, high protein diet with frequent small meals

5. Nursing interventions
a. with active infection, client must be isolated with airborne precautions when in the hospital
b. teach client
i. proper techniques to prevent spread of infection: hand washing, etc.
ii. to report bloody sputum
iii. not to use over the counter (OTC) medications without health care provider's approval
iv. importance of taking medications as prescribed
adherence to treatment regimen
return at scheduled times for lab testing of liver enzymes
an increase in B
6
to minimize peripheral neuropathies, a common side effect of drug therapy

LRS Disorders: Miscellaneous

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A. Pulmonary embolism
1. Definition/etiology
a. clot blocks blood from the "bed" of arteries that feed the lung
b. client is breathing but gases are not exchanged - ventilation without perfusion
c. hypoxemia results
d. can be mild or immediately fatal, based on the size and location of clot(s)
e. usually clot has traveled from deep veins in the leg or pelvis

2. Diagnostics
a. ventilation/perfusion (V/P) scan, also called V/Q scan
b. ABG
c. EKG

3. Management
a. oxygen via mask
b. anticoagulation - heparin in acute and coumadin for chronic risk
c. thrombolytics
d. filter surgically placed in vena cava for long term care

B. Acute respiratory distress syndrome (ARDS)
1. Definition/etiology
a. alveolar capillary membrane becomes more permeable to fluids
b. increased extravascular lung fluid
c. pulmonary compliance decreases
d. intrapulmonary shunt increases
e. refractory hypoxemia
f. usually seen after lung injury or massive multi-system organ disease

2. Findings
a. restlessness, anxiety
b. dyspnea
c. tachycardia
d. cyanosis
e. intercostal retractions

3. Diagnostics
a. clinical presentation and history of findings
b. hypoxemia on ABG despite increasing inspired oxygen level
c. chest x-ray shows diffuse infiltrates

4. Management
a. optimize oxygenation
i. mechanical ventilation
ii. sedation may be required
iii. paralytic agents may be necessary

b. antibiotics, as indicated
c. corticosteroids

5. Nursing interventions
a. plan for frequent rest periods
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b. monitor trends in oxygenation status, ABGs, respiratory effort
c. observe for behavioral changes and vital signs; confusion and hypertension may indicate cerebral
hypoxia


C. Cor pulmonale
1. Definition/etiology
a. right ventricular hypertrophy and subsequent chronic heart failure
b. cause: heart must pump against great resistance from lung's blood vessels: called increased
pulmonary vascular resistance (PVR)
c. increased PVR results from chronic lung disease
d. may be due to primary pulmonary hypertension as well

2. Diagnostics
a. pulmonary artery pressure readings via a catheter
b. echocardiogram
c. chest radiograph
d. ABG
e. EKG

3. Management
a. administer oxygen as ordered
b. if hemoglobin within normal limits (WNL), monitor oxygenation with finger or pulse oximeter
c. bed rest, as needed
d. monitor effects of medications
i. cardiac glycosides
ii. pulmonary artery vasodilator
iii. diuretics
iv. restricted fluid intake as indicated
e. nursing interventions
i. monitor for changes in oxygenation status
ii. pace activities in clients who tire easily