Upper Respiratory

Tract
Anatomy and Physiology
Assessment
• Nursing History
– Health History
• assess if client experience:
– dyspnea (shortness of breath)
– pain
– accumulation of mucus
– wheezing
– hemoptysis (blood spit up from the
respiratory tract)
– Edema of the ankles and feet
– Cough
– General fatigue and weakness
–
•
• The nurse tries to determine:
– When the health problems or symptom
started
– How long it lasted
– Was it relieved at any time
– How relief was obtained
• The nurse collects information about:
– Precipitating factors
– Duration
– Severity
– Associated factors or symptoms
– Risk factors and genetic factors that
may contribute to the patients
condition
• The nurse assess the impact of s/sx on
the patient’s :
– ability to perform activities of daily
living
– Ability to participate in usual work and
family activities
• The nurse must assess the following
factors that may affect the patient:
– Anxiety
– Role changes
– Family relationships
– Financial problems
– Employment status
– And the strategies the patient uses to
cope with them

• Family History
– Assess Family history for other family
members with histories of
respiratory impairement
– Assess family history for individuals
with early – onset chronic
pulmonary disease
– Family history of hepatic disease in
infants
– Inquire about family history of cystic
fibrosis
Physical Assessment /
Diagnostics
• Skull X-Ray
–  is a picture of the bones surrounding
the brain, including the facial bones,
the nose, and the sinuses.
• Indirect Laryngoscopy
– utilizes a straight rod-mounted mirror
(laryngeal mirror) that is inserted
into the throat and used to look at
the laryngeal inlet.


• Direct Laryngoscopy
– the laryngoscope is inserted into
the mouth on the right side and
flipped to the left to trap and move
the tongue out of the line of sight,
and, depending on the type of blade
used, inserted either anterior or
posterior to the epiglottis and then
lifted with an upwards and forward
Nursing Diagnosis
• Ineffective Airway Clearance
– Suction naso/tracheal/oral prn to clear
airway when secretions are blocking
airway.
– Elevate head of the bed/change position
every 2 hours and prn to take advantage
of gravity decreasing pressure on the
diaphragm and enhancing drainage
of/ventilation to different lung segments
(pulmonary toilet).
– Give expectorants/bronchodilators as
ordered.
– Increase fluid intake to at least 2000 mL/day
within level of cardiac tolerance (may
require IV) to help liquefy secretions
– Auscultate breath sounds and assess air
• Impaired Verbal Communication
– Note presence of ET
tube/tracheostomy or other physical
blocks to speech
– Individualize techniques using
breathing for relaxation of the vocal
cords, rote tasks (such as counting),
and singing or melodic intonation to
assist aphasic clients in relearning
speech.
– Plan for alternative methods of
communication (e.g., slate board,
letter/picture board, hand/eye
signals, typewriter/computer)
incorporating information about
Nursing Procedures
• Nasal Sprays and Instillations
– instilling a fine mist into the nostril by
action of a hand-
operated pump mechanism.
– a medicine solution prepared for
administration into the nose. Nasal
medicine is given in the form of
nose drops or nasal sprays.
