Care of At Risk and Sick Clients with

Alterations and Problems

1. Integrate & apply nursing concepts and
principles in given health situations based
on epidemiologic profile
2. Discuss the pathophysiologic responses to
physiologic alterations
3. Assess and formulate plan of care to
address client problems
4. Implement safe & quality interventions with
health education ensuring multidisciplinary
collaboration
5. Evaluate with the client the health status and
expected outcome of the nurse-client
relationship
 “STUFFY NOSE”
Group of disorder characterized by
inflammation and irritation of the mucous
membranes of the nose.

ACUTE/ CHRONIC
ALLERGIC/ NONALLERGIC
Reaction of a nasal mucosa to a specific
allergen

SEASONAL: spring/ falls d/t pollens

PERENNIAL: environmental allergenc
 “COMMON COLD/ CORYZA”
Infection of the URT caused by 200
different viruses

Rhinovirus
Coxsackievirus
Adenovirus
 CAUSES & CAUSES:
Vasomotor Rhinitis
idiopathic, abuse of nasal decongestants
(rhinitis medicamentosa), psychological
situations, irritants (smoke, pollution,
fumes)

Mechanical Rhinitis
tumor, deviated septum, crusting,
hypertrophied turbinate, foreign body,
CSF leak
 CAUSES & CAUSES:
Chronic Inflammatory
polyps, sarcoidosis, granulomas

Infectious Rhinitis
acute viral infection, acute/ chronic
rhinosinusitis and rare infections

Hormonal Rhinitis
pregnancy, use of oral contraceptives,
hypothyroidism
 CAUSES:
Temperature or humidity
Odors
Infection (bacterial or viral)
Age
Systemic disease
Use of OTC drugs
(decongestants = rhinitis medicamentosa)
Presence of a foreign body (Allergic Rhinitis)
INDOOR ALLERGENS OUTDOOR ALLERGENS
Dust mite feces Trees (oak, elm, ash,
Dog/ cat dander sycamore, maple, walnut)
Cockroach droppings Weeds (ragweed,
Molds sagebrush, Russian thistle)
Grasses (orchard, Bermuda,
redtop, blue grass)
Molds (Alternaria,
Cladosporium, Aspergillus )
S/Sx:
rhinorrheas (runny nose; excess drainage)
nasal congestion
nasal discharge (purulent w/ bacterial)
sneezing
pruritus (nose, roof of mouth, throat, eyes & ears)
headache
Inflammation of the para nasal sinuses

Frequently involves the maxillary and

ethmoid sinuses
 TYPES:

Acute Sinusitis – respiratory symptoms last > 10

days but < 30 days

Subacute Sinusitis – respiratory symptoms > 30

days without improvement

Chronic Sinusitis – respiratory symptoms last

longer than 120 days
S/Sx: rhinitis symptoms + the following:

orbital cellulitis + abscess

meningitis
brain abscess
intractable wheezing in children with asthma
cavernous sinus thrombosis
subdural empyema (pus collection)
ASSESSMENT: History
Physical Examination
(sinus palpation)
Signs & Symptoms

LABORATORY
Allergy Test
Swabbing & culture

DIAGNOSTICS
Nasoscopy, X-ray, CT scan, MRI
**Treat the Cause
PHARMACOLOGIC
Antihistamines
Decongestants (reduce edema)
Leukotriene modifiers: Montelukast
Antihistamine + Decongestant
Brompheniramine/ pseudoephedrine
Leukotriene modifiers: Montelukast
Antibiotics
Anticholinergics: Ipratropium bromide
Corticosteroid or Saline nasal spray
Diet: ↑oral fluid intake

ü Avoid or reduce exposure to allergens

ü Ensure medication education
ü Environmental control (home & work)
ü Hand hygiene
 “SORE THROAT”
Sudden painful inflammation of the
pharynx including the posterior 3rd of the
tongue, soft palate and tonsils
 CAUSES:
Virus
(Adenovirus, Influenza, EBV, Herpes simplex)

Bacterial
(Streptococcus – group A/B/G, N. gonorrhoeae,
Mycoplasma pneumoniae, Arcanobacterium
haemolyticum, HIV)

Fungal (Candida Albicans)

Environmental factors
S/Sx:
“scratchy throat”
firey-red pharyngeal membrane & tonsils w/ petechiae
inflamed lymphoid follicles w/ white-purple exudates
enlarged & tender lymph nodes
fever >38.3 degrees C
headache & malaise
pharyngeal dryness and pain (dysphagia)
nausea & vomiting
bad breath
COMPLICATIONS:
Rhinosinusitis
Otitis Media
Peritonsillar abscess
Mastoiditis
Cervical Adenitis
Rheumatic fever
Acute Nephritis
Meningitis
Septicemia
Persistent inflammation of the pharynx

Common in adults
 CAUSES:
Dusty surroundings
Excess voice use
Chronic cough
Habitual use of alcohol & tobacco
 TYPES:
Hypertrophic – general thickening & congestion
of pharyngeal mucous membrane

Atrophic – late stage of first type w/ thin, whitish,

glistening and wrinkled at times

Chronic granular – swollen lymph follicles of the

pharyngeal wall
S/Sx:
constant sense of irritation or fullness in the throat
mucus collects in throat & expelled by coughing
difficulty swallowing
intermittent postnasal drip
ASSESSMENT: History, Physical Examination
Signs & Symptoms

LABORATORY
Rapid antigen detection test (RADT)
Swabbing & culture
ASO Titer

DIAGNOSTICS
Pharyngoscopy
PHARMACOLOGIC
Antibiotics: Penicillin, Erythromycin
Cephalosphorins, Macrolides
Antifungal: Nystatin
Analgesics: ASA, acetaminophen, NSAIDS

Local: gargles (chlorhexidine, hexetidine)

lozenges
oral sprays (benzydamine HCl,
chamomile)
Diet: liquid or soft diet
cool/ warm liquids
↑oral fluid intake (2-3L/ day)

ü Bed rest (febrile phase)

ü Encourage oral care and warm saline ½ tsp
to 8 oz water gargles (40.6 – 43.3 degrees)
ü Proper waste disposal (tissue etc.)
ü Complete the course of pharmacologic
therapy
ü ⨂ sharing of utensils
ü Environmental disinfection
ü Coughing & sneezing etiquette
ü WOF: dyspnea, drooling, inability to
swallow, inability to fully open mouth
Persistent inflammation of the pharynx

Common in adults
 CAUSES:
Dusty surroundings
Excess voice use
Chronic cough
Habitual use of alcohol & tobacco
S/Sx:
constant sense of irritation or fullness in the throat
mucus collects in throat & expelled by coughing
difficulty swallowing
intermittent postnasal drip
COMPLICATIONS:
Rhinosinusitis
Otitis Media
Peritonsillar abscess
Mastoiditis
Cervical Adenitis
Rheumatic fever
Acute Nephritis
Meningitis
Septicemia
Inflammation of the tonsils & adenoids
TONSILS: behind the faucal pillars
ADENOIDS: posterior wall of the
nasopharynx
 CAUSES:
Pathogens
Group A beta hemolytic streptococcus (GABHS)
Epstein-Barr virus
Cytomegalovirus
S/Sx: Tonsilitis
sore throat
fever
snoring
difficulty swallowing

Adenoiditis
frequent colds, mouth breathing, noisy respiration
earache, draining ears
foul-smelling breath
voice impairment, noisy respiration
COMPLICATIONS:
Acute Otitis Media
Perforated TM
Mastoiditis
Permanent deafness
ASSESSMENT: History, Physical Examination
Signs & Symptoms

LABORATORY
Rapid antigen detection test (RADT)
Swabbing & culture
ASO Titer

DIAGNOSTICS
Pharyngoscopy
PHARMACOLOGIC
Antibiotics: Penicillin, Erythromycin
Cephalosphorins, Macrolides
Analgesics: ASA, acetaminophen, NSAIDS

Local: gargles (chlorhexidine, hexetidine)

lozenges
oral sprays (benzydamine HCl,
chamomile)
SURGICAL
Tonsillectomy & Adenoidectomy
Diet: liquid or soft diet
cool/ warm liquids
↑oral fluid intake (2-3L/ day)
⨂ spicy, hot, acidic or rough foods

ü Bed rest (febrile phase)

ü Encourage oral care and warm saline
gargles (40.6 – 43.3 degrees C)
ü Proper waste disposal (tissue etc.)
ü Complete the course of pharmacologic
therapy
ü ⨂ sharing of utensils
ü Environmental disinfection
ü Coughing & sneezing etiquette
ü ⨂ vigorous brushing or gargling
ü ⨂ smoking
ü WOF: dyspnea, drooling, inability to
swallow, inability to fully open mouth
POSTOPERATIVE CARE
ü Position: prone with head turned to side
ü ⨂ remove oral airway until gag reflex and
swallow reflex have returned
ü Ice collar and basin
ü WOF: bleedinf
Inflammation of the larynx
 CAUSES:
Voice abuse
Exposure to dust, chemical, smoke (pollutants)
GERD
Allergic rhinitis/ pharyngitis

RISK FACTORS:
Temperature changes
Dietary deficiencies
Malnutrition
Immunosuppression
S/Sx:
hoarseness, aphonia (loss of voice)
severe cough
edematous uvula
“tickle” in the throat

* worsen by cold, dry wind

ASSESSMENT: History, Physical Examination
Signs & Symptoms

DIAGNOSTICS
Laryngoscopy
PHARMACOLOGIC
Corticosteroids
Proton-pump inhibitors

Local: gargles (chlorhexidine, hexetidine)

lozenges
oral sprays (benzydamine HCl,
chamomile)
Diet: liquid or soft diet
cool/ warm liquids
↑oral fluid intake (2-3L/ day)
⨂ spicy, hot, acidic or rough foods

ü Voice rest
ü Avoiding irritants (smoking)
ü Adequate rest
ü Cool steam inhalation
ü Well-humidified environment
 Characterized by recurrent episode of
upper airway obstruction and reduction in
ventilation.
Cessation of breathing during sleep
 RISK FACTORS:
Obesity
Male gender
Postmenopausal status
Advanced age
Upper airway & structural changes
Abnormal posterior positioning of one or both
jaws
S/Sx:
frequent and loud snoring
breathing cessation > 10 seconds (5 episodes/ hour)
abrupt awakening with a loud snort (↓blood O2)
= insomnia/ difficulty sleeping, nighttime awakenings, early
morning awakenings, chronic fatigue & hypersomnolence

3 S’s: S – noring
S – leepiness
S – ignificant other report of apnea
COMPLICATIONS:
Rhinosinusitis
Otitis Media
Peritonsillar abscess
Mastoiditis
Cervical Adenitis
Rheumatic fever
Acute Nephritis
Meningitis
Septicemia
ASSESSMENT: History, Physical Examination
Clinical Features

DIAGNOSTICS
Polysomnographic (Sleep study)
Electroencephalogram (EEG)
Electromyogram – chin (EMG)
Thermal sensor/ nasal transducer (airflow)
Inductance plethysmography (breathing)
THERAPIES
Positional therapy devices
Mandibular advancement devices (MAD)
Continuous positive airway pressure (CPAP)
Bilevel positive airway pressure (BiPAP)
SURGICAL
Tonsillectomy
Uvulapalatopharyngoplasty
Nasal septoplasty
Maxillomandibular surgery
Tracheostomy
PHARMACOLOGICAL
Modafinil (Provigil) – stimulant
Protiptyline (Triptil) - ↑respiratory drive
Medoxyprogesterone actetate (Provera)
Acetazolamide (Diamox)
ü Control of daytime sleepiness
ü Education on the use of airway devices
ü Explain the risk of untreated OSA
ü Surgical care for patients
Hemorrhage of the nose d/t rupture of tiny,
distended vessels in the mucous
membrane
 RISK FACTORS:
Local infections (vestibulitis, rhinitis)
Systemic infection (malaria, scarlet fever)
Drying of mucous membranes
Nasal inhalation (corticosteroid, drugs)
Trauma
Arteriosclerosis, Hypertension
Tumor
Thrombocytopenia
ASSESSMENT: History, Physical Examination
Clinical Features
* nasal speculum, pen/headlight

LABORATORY
CBC
Bleeding parameters

DIAGNOSTICS
CT scan
PHARMACOLOGICAL
Nasal decongestants: Phenylephrine
Tranexamic Acid

SURGICAL
Nasal packing: cotton tampon, balloon-
inflated catheter
Cauterized with silver nitrate
Electrocautery
Surgicel or Gelfoam
ü Monitor vital signs, airway and breathing
ü Control bleeding & provide tissue/ emesis
basin
ü Assuring patient in calm, efficient manner
ü Maintain pack in place