Nursing Process: The Patient With Upper Airway Infection

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, diffi-culty in swallowing, cough, hoarseness, fever, stuffiness, and gen-eralized discomfort and fatigue. Determining when the symptoms began, what precipitated them, what if anything re-lieves them, and what aggravates them is part of the assessment. It also is important to determine any history of allergy or the ex-istence 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 ten-derness, 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, ulcera-tion, 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

NURSING DIAGNOSES

 Based on the assessment data, the patient’s major nursing diag-noses may include the following:

• Ineffective airway clearance related to excessive mucus pro-duction 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 sec-ondary to diaphoresis associated with a fever

• Deficient knowledge regarding prevention of upper respi-ratory infections, treatment regimen, surgical procedure, or postoperative care

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Based on assessment data, potential complications may include:

• Sepsis

• Meningitis

• Peritonsillar abscess

• Otitis media

• Sinusitis

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

An accumulation of secretions can block the airway in patients with an upper airway infection. As a result, changes in the respi-ratory pattern occur, and the work of breathing required to get beyond the blockage increases. The nurse can implement several measures to loosen thick secretions or to keep the secretions moist so that they can be easily expectorated. Increasing fluid intake helps thin the mucus. Use of room vaporizers or steam inhalation also loosens secretions and reduces inflammation of the mucous membranes. To enhance drainage from the sinuses, the nurse in-structs the patient about the best position to assume; this depends on the location of the infection or inflammation. For example, drainage for sinusitis or rhinitis is achieved in the upright posi-tion. In some conditions, topical or systemic medications, when prescribed, help to relieve nasal or throat congestion.

PROMOTING COMFORT

Upper respiratory tract infections usually produce localized dis-comfort. In sinusitis, pain may occur in the area of the sinuses or  may produce a general headache. In pharyngitis, laryngitis, or tonsillitis, a sore throat occurs. The nurse encourages the patient to take analgesics, such as acetaminophen with codeine, as pre-scribed, which will help relieve this discomfort. Other helpful measures include topical anesthetic agents for symptomatic relief of herpes simplex blisters (see Chart 22-1) and sore throats, hot packs to relieve the congestion of sinusitis and promote drainage, and warm water gargles or irrigations to relieve the pain of a sore throat. The nurse encourages rest to relieve the generalized dis-comfort and fever that accompany many upper airway conditions (especially rhinitis, pharyngitis, and laryngitis). The nurse in-structs the patient in general hygiene techniques to prevent the spread of infection. For postoperative care following tonsillec-tomy and adenoidectomy, an ice collar may reduce swelling and decrease bleeding.

PROMOTING COMMUNICATION

Upper airway infections may result in hoarseness or loss of speech. The nurse instructs the patient to refrain from speaking as much as possible and to communicate in writing instead, if possible. Additional strain on the vocal cords may delay full return of the voice.

ENCOURAGING FLUID INTAKE

In upper airway infections, the work of breathing and the respi-ratory rate increase as inflammation and secretions develop. This, in turn, may increase insensible fluid loss. Fever further increases the metabolic rate, diaphoresis, and fluid loss.

Sore throat, malaise, and fever may interfere with a patient’s willingness to eat. The nurse encourages the patient to drink 2 to 3 L of fluid per day during the acute stage of airway infection, un-less contraindicated, to thin secretions and promote drainage. Liquids (hot or cold) may be soothing, depending on the illness.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

Prevention of most upper airway infections is difficult because of the many potential causes. However, most upper respiratory in-fections are transmitted by hand-to-hand contact. Therefore, it is important to teach the patient and family how to minimize the spread of infection to others. Other preventive strategies are iden-tified in Chart 22-2. The nurse advises the patient to avoid ex-posure to others at risk for serious illness if respiratory infection is transmitted. Those at risk include elderly adults, immuno-suppressed people, and those with chronic health problems.

The nurse teaches patients and their families strategies to re-lieve symptoms of upper respiratory infections. These include in-creasing the humidity level, encouraging adequate fluid intake, getting adequate rest, using warm water gargles or irrigations and topical anesthetic agents to relieve sore throat, and applying hot packs to relieve congestion. The nurse reinforces the need to com-plete the treatment regimen, particularly when antibiotics are prescribed.

Continuing Care

Referral for home care is rare. However, it may be indicated for the person whose health status was compromised before the onset of the respiratory infection and for those who cannot manage self-care without assistance. In such circumstances, the home care nurse assesses the patient’s respiratory status and progress in re-covery. The nurse may advise elderly patients and those who would be at increased risk from a respiratory infection to consider an annual influenza vaccine. A follow-up appointment with the primary care provider may be indicated for patients with com-promised health status to ensure that the respiratory infection has resolved.

MONITORING AND MANAGINGPOTENTIAL COMPLICATIONS

While major complications of upper respiratory infections are rare, the nurse must be aware of them and assess the patient for them. Because most patients with upper respiratory infections are managed at home, patients and their families must be instructed to monitor for signs and symptoms and to seek immediate med-ical care if the patient’s condition does not improve or if the pa-tient’s physical status appears to be worsening.

Sepsis and meningitis may occur in patients with compro-mised immune status or in those with an overwhelming bacterial infection. The patient with an upper respiratory infection and family members are instructed to seek medical care if the patient’s condition fails to improve within several days of the onset of symptoms, if unusual symptoms develop, or if the patient’s con-dition deteriorates. They are instructed about signs and symp-toms that require further attention: persistent or high fever, increasing shortness of breath, confusion, and increasing weak-ness and malaise. The patient with sepsis requires expert care to treat the infection, stabilize vital signs, and prevent or treat sep-ticemia and shock. Deterioration of the patient’s condition ne-cessitates intensive care measures (eg, hemodynamic monitoring and administration of vasoactive medications, intravenous fluids, nutritional support, corticosteroids) to monitor the patient’s sta-tus and to support the patient’s vital signs. High doses of antibi-otics may be administered to treat the causative organism. The nurse’s role is to monitor the patient’s vital signs, hemodynamic status, and laboratory values, administer needed treatment, alle-viate the patient’s physical discomfort, and provide explanations, teaching, and emotional support to the patient and family.

Peritonsillar abscess may develop following an acute infection of the tonsils. The patient requires treatment to drain the abscess and receives antibiotics for infection and topical anesthetic agents and throat irrigations to relieve pain and sore throat. Follow-up is necessary to ensure that the abscess resolves; tonsillectomy may be required. The nurse assists the patient in administering throat irrigations and instructs the patient and family about the impor-tance of adhering to the prescribed treatment regimen and rec-ommended follow-up appointments.

Otitis media and sinusitis may develop with upper respiratory infection. The patient and family are instructed about the signs and symptoms of otitis media and sinusitis and about the impor-tance of follow-up with the primary health care practitioner to ensure adequate evaluation and treatment of these conditions.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1.     Maintains a patent airway by managing secretions

a.     Reports decreased congestion

b.     Assumes best position to facilitate drainage of secretions

2.     Reports feeling more comfortable

a.     Uses comfort measures: analgesics, hot packs, gargles, rest

b.     Demonstrates adequate oral hygiene

3.     Demonstrates ability to communicate needs, wants, level of comfort

4.     Maintains adequate fluid intake

5.     Identifies strategies to prevent upper airway infections and allergic reactions

a.     Demonstrates hand hygiene technique

b.     Identifies the value of the influenza vaccine

6.     Demonstrates an adequate level of knowledge and per-forms self-care adequately

7.     Becomes free of signs and symptoms of infection

a.     Exhibits normal vital signs (temperature, pulse, respira-tory rate)

b.     Absence of purulent drainage

c.      Free of pain in ears, sinuses, and throat