CHARNJEET KAUR SANDHU

1. CHARNJEET KAUR
M.SC MEDICAL SURGICAL NURSING

2. Sinusitis
 Sinus :- mucus membrane lined cavities filled with air
that normally drain into nose .
 Sinusitis is infection and inflammation of the para-
nasal sinus. It develop as a result of upper respiratory
infections.


3. Anatomy

4. Risk factors
 Age
 Current history of systematic infections
 Previous history of sinusitis
 Immunosuppressive therapy

5. Etiology
 Bacteria:- streptococcus pneumonae
haemophilus influenza
 Dental infections

6. Pathophysiology
 due to risk factor and etiological factors
 Inflammation and edema
 Nasal congestion
 Obstruction of nasal sinus
 Provide medium for bacterial growth
 Symptoms and signs will appear

7. Clinical manifestations
 Facial pain
 Pressure over affected sinus
 Nasal obstruction
 Fatigue
 Purulent nasal discharge
 Fever
 Headache
 Ear pain
 Dental pain

8. Contd…….
 Cough
 Decreased sense of smell
 Sore throat
 Eyelid edema
 Facial congestion due fullness

9. Diagnostic evaluation
 History taking
 Physical examination( affected areas will be trans
luminated)
 Sinus x- rays ( to detect, sinus opacity, mucosal
thickness and bone distruction)
 Computer tomography:- to rule out local or systematic
defects

10. Complications
 Meningitis
 Brain abscess
 Osteomyelitis
 Orbital cellulitis
 ischemic infarction

11. Management
 Goals
1. To treat infection
2. To shrink nasal mucus membrane inflammation
3. To relieve pain
Note :- choice of medication should be made after
identification of micro-organism

12. Pharmacological therapy
 First line antibiotics (e.g. amoxicillin, trimethoprim,
erythromycin)
 Second line antibiotics( e.g.:- cephalosporin, ceprozil,
amoxicilline clavulanate{augmentin)
 Broad spectrum antibiotics(macrolides, azithromycin)
 Quinolones such as ciprofloxin, levofloxin( used if patient is
severely allergic to penicillin.
 Treatment course will be 10-14days
 Oral and topical decongestant(oxymetazolin) can be used to
reduce swelling
 Heated saline irrigation
 Mucolytic agents may be effective in reducing nasal congestion
 Antihistamines such as diphenylhydramine, cetrizine if allergic
component is suspected

13. Nursing management
 Teach the patient about methods of drainage such as
steam inhalation.
 Instruct regarding increased fluid intake.
 Demonstrate the medication administration.
 Must be taught regarding side effects of nasal sprays
and rebound congestion..
 Nurses must stressed on recommended regimen of
antibiotics

14. 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.
 CAUSES
 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 results in stagnant secretions, an ideal medium for infection. The
organisms that cause chronic sinusitis are the same as those implicated in
acute sinusitis.
 Immunocompromised patients, however, are at increased risk for
developing fungal sinusitis.(Aspergillus fumigatus)

15. CLINICAL MANIFESTATION
 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.
 These symptoms are generally most pronounced on
awakening in the morning.
 Fatigue
 nasal stuffiness
 In addition, some patients experience a decrease in smell
and taste and a fullness in the ears.

16. Assessment and Diagnostic Findings
 History taking
 Physical examination
 CT
 MRI
 Nasal endoscopy may be indicated to rule out underlying
diseases such as tumors and sinus mycetomas (fungus
balls).
 The fungus ball is usually a brown or greenish-black
material with the consistency of peanut butter or cottage
cheese.
 Nasal/ sinus culture
 Allergy test

17. COMPLICATION
 Orbital cellulitis
 Sub-periosteal abscess
 Thrombosis
 Meningitis
 Encephalitis
 ischemic infarction.

18. MEDICAL MANAGEMENT
 The antimicrobial agents of choice include amoxicillin
clavulanate (Augmentin) or ampicillin (Ampicin).
Clarithromycin (Biaxin)
 third-generation cephalosporins such as cefuroxime
axetil (Ceftin), cefpodoxime (Vantin), and cefprozil
(Cefzil) have also been effective.
 Levofloxacin (Levaquin), a quinolone, 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.

19. SURGICAL MANAGEMENT
 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 cortico- steroids 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.

20. NURSING MANAGEMENT
NURSING TEACHING :-
 The nurse teaches the patient how to promote sinus
drainage by increasing the environmental humidity
(steam bath, hot shower and facia sauna)
 increasing fluid intake
 applying local heat (hot wet packs).
 The nurse also instructs the patient about the
importance of following the medication regimen.

21. PHARYNGITIS

22. Anatomy of pharynx

23. ACUTE PHARYNGITIS
 Acute pharyngitis is an inflammation or infection
in the throat, usually causing symptoms of a sore
throat.

24. RISK FACTORS
 Immunocompromised
 Young children
 Allergic rhinitis
 Smoking (second hand smokers)
 In GERD
 Indotracheal intubation
 Low immunity

25. Causes
 Viral ( viral usually which cause common cold)
1. Rhinovirus
2. Adenovirus
3. Herpes simplex virus
4. Epstein bar virus
5. HIV infector
 Bacterial
1. e.g. group A beta-hemolytic streptococcus
2. Neisseria gonorrhea
3. Corynebacterium diptheria

26. PATHOPYSIOLOGY
 DUE O EETIOLOGICAL FACTORS BODY TRIGGER
A INFLAMMATORY RESPONSE
 PAIN, FEVER, VASODILATION, EDEMA, AND
TISSUE DAMAGE(SYMPTOMS)
 REDNESS AND SWELLING IN THE TONSILLAR
PILLARS, UVULA, AND SOFT PALATE(SIGNS)
 A CREAMY EXUDATE MAY BE PRESENT IN THE
TONSILLAR PILLARS

27. CLINICAL MANIFESTATION
 The signs and symptoms of acute pharyngitis include
1. a fiery-red pharyngeal membrane and tonsils,
2. lymphoid follicles that are swollen and flecked with
white-purple exudates
3. enlarged and tender cervical lymph nodes
4. no cough.
5. Fever
6. malaise
7. sore throat also may be present.

28. DIAGNOSTIC EVALUATION
 History taking
 Physical examination
 Rapid screening tests for streptococcal antigens such as the latex
agglutination (LA) antigen test and solid-phase enzyme
immunoassays
 (ELISA), optical immunoassay (OIA)
 streptolysin titers,
 throat cultures are used to determine the causative organism,
 Nasal swabs
 blood cultures may also be necessary to identify the organism

29. Management
 Viral pharyngitis is treated with supportive measures since
antibiotics will have no effect on the organism.
 Bacterial pharyngitis is treated with a variety of antimicrobial
agents.
 Antibiotics are used in case of bacterial causes e.g penicillin
 A beta-hemolytic streptococci and most S. aureus organisms are
resistant to penicillin and erythromycin), cephalosporins ,
macrolides (clarithromycin and azithromycin) may be used.
 Antibiotics are administered for at least 10 days to eradicate the
infection from the oropharynx.
 Corticosteroid e.g.:- dexamethasone and prednisone
 Antifungal :- e.g. mycostatin
 Analgesics :- acetaminophen and NSAID’s can be used to relieve
pain

30. NUTRITIONAL THERAPY
 A liquid or soft diet is provided during the acute stage
of the disease.
 Occasionally, the throat is so sore that liquids cannot
be taken in adequate amounts by mouth.
 In severe situations, fluids are administered
intravenously.
 The patient is encouraged to drink as much fluid as
possible.

31. COMPLICATIONS
 Sinusitis,
 Otitis media
 Peritonsillar abscess
 Mastoiditis
 Meningitis, rheumatic fever, or nephritis.

32. NURSING MANAGEMENT
 Provide bed rest to the patient.
 Hot saline solution gargles will be effective
 Ice collar make the patient comfortable
 Mild anasthetics also can be used to decrease local
soreness
 Advise bed rest during febrile stage
 Examine skin daily for dryness and rash because it may
also progress to some communicable diseses such as
rubella.

33. CHRONIC PHARYNGITIS
 Chronic pharyngitis is a persistent inflammation of
the pharynx.
 Risk factors and etiology :-
1. It is common in adults who work or live in dusty
surroundings,
2. use their voice to excess
3. suffer from chronic cough
4. Habitually use alcohol and tobacco.

34. Types
 Hypertrophic: characterized by general thickening and
congestion of the pharyngeal mucous membrane
 Atrophic: probably a late stage of the first type (the
membrane is thin, whitish, glistening, and at times
wrinkled)
 Chronic granular:- (“clergyman’s sore throat”):
characterized by numerous swollen lymph follicles on
the pharyngeal wall

35. CLINICAL MANIFESTATION
 Constant sense of irritation or fullness in the throat,
 Mucus collects in the throat
 Productive cough
 Difficulty swallowing

36. Treatment
 Treatment of chronic pharyngitis is based on relieving
symptoms,
 Avoiding exposure to irritants, and correcting any
upper respiratory, Pulmonary, or cardiac condition
that might be responsible for a chronic cough.

37. PHARMACOLOGICAL TREATMENT
 Nasal congestion may be relieved by short-term use of
nasal sprays or medications containing ephedrine
sulfate (Kondon’s Nasal) or phenylephrine
hydrochloride (Neo-Synephrine).
 If there is a history of allergy, one of the antihistamine
decongestant medications, such as Drixoral ,is taken
orally every 4 to 6 hours.
 Aspirin or acetaminophen is recommended for its
anti-inflammatory and analgesic properties.

38. Nursing management
 To prevent the infection from spreading, the nurse
instructs patient to avoid contact with others until the fever
subsides.
 Alcohol, tobacco, second-hand smoke, and exposure to
cold are avoided, as are environmental or occupational
pollutants if possible.
 The patient may minimize exposure to pollutants by
wearing a disposable facemask.
 The nurse encourages the patient to drink plenty of fluids.
 Gargling with warm saline solutions may relieve throat
discomfort.
 Lozenges will keep the throat moistened.

39. Nursing diagnosis
 Ineffective breathing related to oro-pharyngeal edema
manifested by oropharyngeal examination and
checking vital signs.
 Impaired swallowing related to edema and pain of
pharynx manifested by verbalization
 Pain related to infection of the oropharynx manifested
by verbalization
 Infection related to invasion of bacteria in pharynx

40. DISORDERS OF TONSILS

41.  The tonsils are
composed of
lymphatic tissue
and are situated
on each side of
the oropharynx.
The palatine
tonsils and
lingual tonsils are
located behind
the pillars of
fauces and
tongue
respectively.
ANATOMY OF THE TONSILS

42. TONSILITIS
 It is inflammation of tonsils
Or
It is inflammation of palatine tonsils. The onset is
sudden and common among the childrens

43. Types
 Acute :- can be bacterial or viral in origin
 Recurrent /sub acute :- caused by bacteria.
 Chronic :- which will last for longer period of time.
The cause will be bacterial.

45. CAUSES
 Risk factors :- droplet and direct contact with affected
person is a main risk factor for it .
Etiology :-
1. Group A-beta streptococci
2. Herpes simplex virus
3. Streptococcus pyogenes
4. Epstein bar virus
5. Cytomegalo virus
6. Adeno virus
7. Measles virus

46. PATH- PHYSIOLOGY

47. CLINICAL MANIFESTATION
 The symptoms of tonsillitis include
 sore throat,
 fever,
 snoring,
 difficulty swallowing.
 Pain
 Irritation and discomfort
 Redness
 Fever, chills

48. Contd….
 Otalgia
 Purulent exudate
 Elevated temperature
 Cervical lymph-adenopathy
 Dysphagia, drooling
 Bad breath order, foul taste
 Sensation having foreign object into throat
 White plaque into the pharynx.

49. DIAGNOSTIC EVALUATION
 History taking
 Physical examination
 Tonsillar culture
 Audiometric examination

50. Management
 Lozenges
 Advise to take plenty of fluids orally
 Prescribe warm saline solution for throat irritation
 Administer anti-biotics to control bacterial infection
 Acetylsalicylic acid can administer to relieve pain and
inflammation.
 Apply an ice collar.
 Prescribe liquid diet until sore throat begins to recover
 Advise to take blend diet

51. Contd……………………………
 Pharmacological therapy
1. antibiotics : erythromycin, azithromycin,
ciprofloxin
2. Analgesics eg. Aspirin
3. Others:- corticosteroids can be administer

52. SURGICAL MANAGEMENT
 Tonsillectomy(cold knife {steel} dissection can be
performed, cauterization
Pre-operative care :-
1. Check and perform required investigation
2. Check vital signs every 4 hourly
3. Ensure written formed consent for operation
4. General anesthesia is required for children and local for
adults
5. Mild sedatives can be given to reduce anxiety and to
induce sleep.
6. Patient is sent to OT in clean hospital clothes
accompanied by health personnel

53. Contd…
 Post operative interventions
1. Patient to be received on post-operative bed
2. Place the patient on semi-prone position(head should be
turned to one side.
3. Vital signs must be checked frequently according to
hospital policy.
4. Observe bleeding from the throat if its dark red it will be
normal but in case of fresh bleeding inform to concerned
physician.
5. Regulate the flow of IV fluid and also maintain I/O
charts

54. Routine care
 When consciousness return the shift patient in supine
position
 Encourage client to take cold feeds such as ice cream
 Do not give hot drinks
 Analgesics and antibiotic must be administer acording
to prescription.
 In normal conditions patient can be discharge upto 5
days .

55. Nursing diagnosis
 Pre operative
 Post operative

56. Advise on discharge
 Remain indoor
 Avoid exposure to sun, hard games, vigrous cleaning of
throat, nose blowing.
 Avoid infect with respiratory infection
 Follow the follow up regimen

57. adenoiditis
 adenoids or pharyngeal tonsils consist of lymphatic
tissue near the center of the posterior wall of the
nasopharynx.
 Infection of the adenoids frequently accompanies
acute tonsillitis.
 Group A beta-streptococcus is the most common
organism associated with tonsillitis and adenoiditis

58. Pathophysiology

59. Clinical manifestation
 The symptoms of tonsillitis include :-
1. sore throat
2. Fever
3. snoring,
4. difficulty swallowing
5. Enlarged adenoids may cause mouth-breathing,
6. Earache
7. draining ears
8. frequent head colds
9. bronchitis,

60. Cond…………
1. foul-smelling breath
2. voice impairment
3. noisy respiration.
4. Unusually enlarged adenoids fill the space behind the
posterior nares, making it difficult for the air to travel
from the nose to the throat and resulting in a nasal
obstruction.
5. Infection can extend to the middle ears by way of the
auditory (eustachian) tubes and may result in acute otitis
media, which can lead to spontaneous rupture of the
eardrums
6. extension of the infection into the mastoid cells, causing
acute mastoiditis

61. DIAGNOSTIC EVALUATION
 History taking
 Physical examination
 Tonsillar site is cultured to determine the presence of
bacterial infection.
 Audiometric examination

62. MANAGEMENT

63. SURGICAL MANGEMENT
 Adenoidectomy is indicated only if the patient has had any of the
following problems
1. Hypertrophy of the tonsils and adenoids that could cause
obstruction and obstructive sleep apnea
2. Repeated attacks of purulent otitis media
3. Suspected hearing loss due to serous otitis media that has
occurred in association with enlarged tonsils and adenoids; and
some other conditions, such as an exacerbation of asthma or
rheumatic fever.
4. Appropriate antibiotic therapy is initiated for patients
undergoing tonsillectomy or adenoidectomy.
5. The most common antimicrobial agent is oral penicillin, which
is taken for 7 days. Amoxicillin and erythromycin are
alternatives.

64. Nursing management
 Post operative interventions for patient who is undergoing
(Tonsillectomy or adenoidectomy)
1. Continuous nursing observation is required in the
immediate postoperative and recovery period because of
the significant risk of hemorrhage.
2. In the immediate postoperative period, the most
comfortable position is prone with the head turned to the
side to allow drainage from the mouth and pharynx.
3. The nurse must not remove the oral airway until the
patient’s gag and swallowing reflexes have returned.
4. The nurse applies an ice collar to the neck, and a basin and
tissues are provided for the expectoration of blood and
mucus.

65. Contd…
 Hemorrhage is a potential complication after a
tonsillectomy and adenoidectomy. If the patient
vomits large amounts of dark blood or bright-red
blood at frequent intervals, or if the pulse rate and
temperature rise and the patient is restless, the nurse
notifies the surgeon immediately.
 suture or ligation of the bleeding vessel is required. In
such cases, the patient is taken to the operating room
and given general anesthesia. After ligation,
continuous nursing observation and postoperative
care are required, as in the initial postoperative period

66. Contd………
 If there is no bleeding, water and ice chips may be
given to the
 patient as soon as desired. The patient is instructed to
refrain
 from too much talking and coughing because these
activities can
 produce throat pain.

67. Nursing diagnosis
 Pre-operative
1. Pain related to inflammation and infection manifested by
verbalization
2. Impaired swelling related to edema and pain
3. Impaired nutritional pattern less than body requirements
related to inability to swallow manifested by intake output
charts or verbalization.
4. Anxiety related to discomfort and treatment modalities
manifested by verbalization.
5. Knowledge deficit related to disease progress and treatment
options manifested by verbalization or questioning .
6. Risk for spread of infection related presence of micro-
organism manifested by examination.

68. Contd…
 Post-operative nursing diagnosis
1. acute pain related to surgical incision
manifested by verbalization.
2. High risk of infection related invasive procedure
manifested by observation.
3. Impaired skin integrity related to invasion to
skin structure/altered fluid level/ altered
nutritional metabolism manifested by
observation
4. Knowledge deficit regarding home care or post
operative care manifested by verbalisation.

69. PERITONSILLAR ABSCESS
 A peritonsillar abscess is a collection of purulent
exudate between the tonsillar capsule and the
surrounding tissues, including the soft palate.
Etiology :-
1. Exact cause is unknown
2. It is believed to develop after an acute tonsillar
infection, which progresses to a local cellulitis and
abscess.

72. CLINICAL MANIFESTATION
 usual symptoms of an infection are present, together with
1. local symptoms as a raspy voice
2. Odynophagia (a severe sensation of burning, squeezing
pain while swallowing),
3. Dysphagia (difficulty swallowing)
4. Otalgia (pain in the ear)
5. Drooling .
6. An examination shows marked swelling of the soft palate,
often occluding almost half of the opening from the
mouth into the pharynx,
7. Unilateral tonsillar hypertrophy
8. Dehydration

73. Diagnostic evaluations
 History taking
 Physical examination
 Aspiration of purulent material (pus) by needle
aspiration is required to make the appropriate
diagnosis. The aspirated material is sent for culture
and Gram’s stain.
 A CT scan is performed when it is not possible to
aspirate the abscess.

74. Management
 Pharmaceutical :- Antibiotics (usually penicillin) are extremely
effective in controlling the infection in peritonsillar abscess.
 Surgical management not required can be controlled with
antibiotic therapy. If treatment is delayed, the abscess is
evacuated as soon as possible.
 The mucous membrane over the swelling is first sprayed with a
topical anesthetic and then injected with a local anesthetic.
Single or repeated needle aspirations are performed to
decompress the abscess. The abscess may also be incised and
drained. These procedures are performed best with the patient in
the sitting position to make it easier to expectorate the pus and
blood that accumulate in the pharynx.

75. Nursing management
 Considerable relief may be obtained by the use of
topical anesthetic agents and throat irrigations or
the frequent use of mouthwashes
 gargles, using saline or alkaline solutions at a
temperature of 105°F to 110°F (40.6°C to 43.3°C).
 The nurse instructs the patient to gargle at intervals
of 1 or 2 hours for 24 to 36 hours.
 Liquids that are cool or at room temperature are
usually well tolerated.

76. Anatomy of the larynx

79. Definition
 Laryngitis, an inflammation of the larynx, often
occurs as a result of voice abuse or exposure to dust,
chemicals, smoke, and other pollutants, or as part of
an upper respiratory tract infection

80. Risk factors
 Exposure to sudden temperature changes,
 Dietary deficiencies
 Malnutrition
 Immuno-suppressed state
 Laryngitis is common in the winter and is easily
transmitted.

81. ETIOLOGY
 The cause of infection is almost always a virus.
 Bacterial invasion may be secondary.
 Laryngitis is usually associated with allergic
rhinitis or pharyngitis.

82. CLINICAL MANIFESTATION
 Signs of acute laryngitis include hoarseness or
aphonia (complete loss of voice)
 severe cough
 Chronic laryngitis is marked by persistent hoarseness.
 Laryngitis may be a complication of upper respiratory
infections.

83. MANAGEMENT
 acute laryngitis includes resting the voice
 Avoiding smoking, resting
 inhaling cool steam or an aerosol.
 If the laryngitis is part of a more extensive respiratory
infection due to a bacterial organism or if it is severe,
appropriate antibacterial therapy is instituted.
 The majority of patients recover with conservative
treatment; however, laryngitis tends to be more severe
in elderly patients and may be complicated by
pneumonia

84. CONTD……..
 For chronic laryngitis, the treatment includes resting
the voice, eliminating any primary respiratory tract
infection, eliminating smoking, and avoiding second-
hand smoke.
 Topical corticosteroids, such as beclomethasone
dipropionate (Vanceril) inhalation, may also be used.
 These preparations have no systemic or long-lasting
effects and may reduce local inflammatory reactions.

85. CONTD..
 Reduce intake of caffeine and alcohol intake
 Stopping smoking
 Limiting throat clearance

86. NURSING PROCESS FOR UPPER
RESPIRATORY INFECTIONS
 Assessment (subjective and objective data)
1. 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.
 Determining when the symptoms began, what precipitated
them, what if anything relieves them, and what aggravates
them is part of the assessment.
 Inspection may reveal swelling, lesions, or asymmetry of
the nose as well as bleeding or discharge.
 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.

88. Planning of goals
The major goals for the patient may include
1. Maintenance of a patent airway,
2. Relief of pain
3. Maintenance of effective means of communication
4. Normal hydration
5. Knowledge of how to prevent upper airway
infections
6. Absence of complications.

89. NURSING DIAGNOSIS FOR URTI
 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.

90. Nursing interventions
 Maintaining a patent airway
 Promote comfort
 Promote communication
 Monitoring and managing potential complication
 Encourage fluid intake
 Continue routine care

91. 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
a. Maintains adequate fluid intake

92. Contd…
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
performs self-care adequately
7. Becomes free of signs and symptoms of infection
a. Exhibits normal vital signs (temperature, pulse,
respiratory rate)
b. Absence of purulent drainage
c. Free of pain in ears, sinuses, and throat

93. Upper respiratory obstructions
 OBSTRUCTION DURING SLEEP:-.
Sleep apnea syndrome is defined as cessation of breathing
(apnea) during sleep.
Pathophysiology
 Sleep apnea is classified into three types:
1. Obstructive—lack of air flow due to pharyngeal
occlusion
2. Central—simultaneous cessation of both air flow and
respiratory movements
3. Mixed—a combination of central and obstructive apnea
within one apneic episode.

94. Etiological factors
 mechanical factors a(reduced diameter of the upper
airway)
 Dynamic changes (activity of the tonic dilator muscles of
the upper airway is reduced during sleep. These sleep
related changes may predispose the patient to increased
upper)
 Airway collapse with the small amounts of negative
pressure generated during inspiration.
 Obstructive sleep apnea may be associated with obesity
and with other conditions that reduce pharyngeal muscle
tone (eg, neuromuscular disease, sedative/ hypnotic
medications, acute ingestion of alcohol).

95. CLINICAL MANIFESTATION
 As per manifestation criteria:- Obstructive sleep apnea is defined
as frequent and loud snoring and breathing cessation for 10
seconds or more for five episodes per hour or more, followed by
awakening abruptly with a loud snort as the blood oxygen level
drops
Other manifestation may include :-
 Excessive daytime sleepiness,
 Morning headache,
 Sore throat,
 Intellectual deterioration,
 Personality changes,
 Behavioral disorders,
 Enuresis,
 Obesity
 Complaints by the partner that the patient snores loudly or is
unusually restless during sleep

96. Clinical manifestation
 Excessive daytime sleepiness
 Frequent nocturnal awakening
 Insomnia
 Loud snoring
 Morning headaches
 Intellectual deterioration
 Personality changes, irritability
 Impotence
 Systemic hypertension
 Dysrhythmias
 Pulmonary hypertension, cor pulmonale
 Polycythemia
 Enuresis

97. DIAGNOSTIC EVALUATION
 The diagnosis of sleep apnea is made based on clinical
features
 History taking
 Physical examination
 Polysomnographic findings (sleep test), in which the
cardiopulmonary status of the patient is monitored
during an episode of sleep.

98. Management
 upplemental oxygen via nasal cannula
 bilevel positive airway pressure therapy(biPAP is similar to
CPAP {Contineous positive airway pressure})
 SURGICAL PROCEDURE:-
 Surgical procedures (eg:-uvulopalatopharyngoplasty
{UPPP}) may be performed to correct the obstruction:-
This is surgical procedure which is used to remove tissues{
tonsils, adenoids) and remodel tissues(uvula, soft palate,
pharynx)
 Tracheostomy :- is performed to bypass the obstruction if
the potential for respiratory failure or life-threatening
dysrhythmias exists.

99. PHARMACOLOGICAL THERAPY
 Protriptyline (Triptil) { non sedative trycyclic
drug}given at bedtime is thought to increase the
respiratory drive and improve upper airway muscle
tone.
Non pharmacological measure
 Administration of low-flow nasal oxygen at night can
 help relieve hypoxemia in some patients but has little
effect on
 the frequency or severity of apnea.

100. Contd……..
 In mild cases, the patient is advised to avoid alcohol
and medications that depress the upper airway and to
lose weight.

101. EPISTAXIS
 A hemorrhage from the nose, referred to as epistaxis,
is caused by the rupture of tiny, distended vessels in
the mucous membrane of any area of the nose. Most
commonly, the site is the anterior septum,

102. ETIOLOGY
 Trauma
 Infection
 inhalation of illicit drugs
 cardiovascular diseases
 nasal tumors
 low humidity
 foreign body in the nose
 deviated nasal septum
 Vigorous nose blowing
 nose picking

103. GENERAL INTERVENTION
 Initial treatment may include applying direct pressure
 The patient sits upright with the head tilted forward to
prevent swallowing and aspiration of blood.
 Advise to pinch the soft outer portion of the nose
against the midline septum for 5 or 10 minute.
 rea may be treated with a silver nitrate applicator or
gelfoam.
 Topical vasoconstrictors such as adrenaline (1:1,000),
cocaine (0.5%), and phenylephrine may be prescribed

104. Contd.
If bleeding is occurring from the posterior regions
 cotton pledgets soaked in a vaso-constricting solution may be inserted into the nose
to reduce the blood flow
 improve the examiner’s view of the bleeding site
 Suction may be used to remove excess blood and clots from the field of inspection
When location not identified :-
 the nose may be packed with gauze impregnated with petrolatum jelly or antibiotic
ointment
 a topical anesthetic spray and decongestant agent may be used prior to inserting the
gauze packing, or a balloon-inflated catheter may be used.
 The packing may remain in place for 48 hours or up to 5 or 6 days if necessary to
control bleeding.
 Antibiotics may be prescribed because of the risk of iatrogenic sinusitis and toxic
shock syndrome(duev to toxic perrduced by staphylococcus aureus .

105. Nursing management
 Nurse monitors the vital signs, assists in the control of
bleeding,
 Provides tissues and an emesis basin to allow the
patient to expectorate any excess blood