Pathophysiology

Rhinitis, an inflammation of the nasal mucosa, is a common problem of the nose and often also involves the sinuses. It can be caused by infection (viral or bacterial) or contact with allergens. Often an allergic rhinitis will make the mucous membranes more susceptible to invasion, and then infection accompanies the allergy. Regardless of the cause, rhinitis is uncomfortable.

Allergic rhinitis, often called hay fever or allergies, is triggered by hypersensitivity reactions to airborne allergens, especially plant pollens or molds. Some episodes are “seasonal” because they recur at the same time each year and last a few weeks. Perennial rhinitis occurs either intermittently with no seasonal pattern or continuously whenever the person is exposed to an offending allergen such as dust, animal dander, wool, or foods (e.g., seafood). Rhinitis also occurs as a “rebound” nasal congestion from overuse of nose drops or sprays (rhinitis medicamentosa) and chronic nasal inhalation of cocaine.

Acute viral rhinitis (coryza, or the common cold) is caused by any of over 200 viruses. It spreads from person to person by droplets from sneezing or coughing and by direct contact. Colds are most contagious in the first 2 to 3 days after symptoms appear. Colds are self-limiting unless a bacterial infection occurs at the same time. Complications occur most often in immunosuppressed people and older adults, especially if they live or work in crowded conditions or in group settings.

Patient-Centered Collaborative Care

In both acute and chronic allergic rhinitis, the presence of the allergen causes a release of histamine and other mediators from white blood cells (WBCs) in the nasal mucosa. These mediators bind to blood vessel receptors, causing local blood vessel dilation and capillary leak, leading to local edema and swelling. Manifestations include headache, nasal irritation, sneezing, nasal congestion, rhinorrhea (watery drainage from the nose), and itchy, watery eyes.

Viral or bacterial invasion of the nasal passages causes the same local tissue responses as allergic rhinitis. Often the patient also has systemic manifestations, including a sore, dry throat and a low-grade fever.

Management of the patient with any type of rhinitis focuses on symptom relief and patient education. Teach him or her about correct use of the drug therapy prescribed.

Drug therapy, including antihistamines and decongestants, is prescribed but must be used with caution in the older adult because of side effects such as vertigo, hypertension, and urinary retention. Antihistamines, leukotriene inhibitors, and mast cell stabilizers block the chemicals released by WBCs from binding to receptors in nasal tissues or reduce the amount of mediator present, preventing local edema and itching. Decongestants constrict blood vessels and decrease edema. Antipyretics are given if fever is present. Antibiotics are prescribed only when a bacterial infection accompanies rhinitis. Rhinitis caused by overuse of nose drops or sprays is treated by discontinuing the drug. Steroid nasal sprays may be used to decrease the rebound nasal congestion during the first week after discontinuing the drug (Regan, 2009).

Complementary and alternative therapies may be used to decrease the severity of acute viral rhinitis for some people early in the course of the problem. Common agents used for this purpose are echinacea, large doses of vitamin C, and zinc preparations such as COLD-EEZE or Zicam. These products may help increase nonspecific immune function.

Supportive therapy can increase the patient’s comfort and help prevent spread of the infection. Instruct the patient about the importance of rest (8 to 10 hours a day) and fluid intake of at least 2000 mL/day unless other health problems require fluid restriction. Humidifying the air helps relieve congestion. Humidity can be increased with a room humidifier or by breathing steamy air in the bathroom after running hot shower water.

Teach patients to reduce the risk for spreading colds by thoroughly washing hands, especially after nose blowing, sneezing, coughing, rubbing the eyes, or touching the face. Other precautions include staying home from work, school, or places where people gather; covering the mouth and nose with a tissue when sneezing or coughing; disposing properly of used tissues immediately; and avoiding close contact with other people (e.g., kissing, hugging, handshaking). Stress the need to avoid close contact with people who are more susceptible to infection, such as older adults, infants, and anyone who has a chronic respiratory problem. An uncomplicated cold typically subsides within 7 to 10 days.

Pathophysiology

Sinusitis is an inflammation of the mucous membranes of one or more of the sinuses. Swelling can obstruct the flow of secretions from the sinuses, which may then become infected. The disorder often follows rhinitis. Other conditions leading to sinusitis include deviated nasal septum, nasal polyps or tumors, inhaled air pollutants or cocaine, facial trauma, nasal intubation, dental infection, or decreased immune function.

The most common organisms causing sinus infection are Streptococcus pneumoniae, Haemophilus influenzae, Diplococcus, and Bacteroides. Sinusitis most often develops in the maxillary and frontal sinuses. Complications include cellulitis, abscess, and meningitis.

Diagnosis is made on the basis of the patient’s history and manifestations. Transillumination (reflection of light through tissues) of the affected sinus is decreased. This can be assessed by having the patient place a lighted penlight tip into the mouth and closing the lips around it in a darkened room. Non-swollen sinuses reflect light through the skin as seen as a red glow on the cheek between the eye and the lip. Sinuses that are swollen or filled with secretions have a reduced or absent glow. Other tests for sinusitis include sinus x-rays, endoscopic examination, and computed tomography (CT). Bacterial sinusitis is usually indicated by purulent drainage from one or both nares and lack of response to decongestant therapy.

Patient-Centered Collaborative Care

Assess for manifestations of sinusitis, including nasal swelling and congestion, headache, facial pressure, and pain (usually worse when the head is tilted forward or is in a dependent position). Other manifestations include tenderness to touch over the involved area, low-grade fever, cough, and purulent or bloody nasal drainage.

Pathophysiology

Pharyngitis, or “sore throat,” is a common inflammation of the pharyngeal mucous membranes that often occurs with rhinitis and sinusitis. It accounts for 1.2% of all office visits each year in the United States (Schappert & Rechsteiner, 2008).

Acute pharyngitis can be caused by bacteria, viruses, other organisms, trauma, dehydration, irritants, and tobacco or alcohol use. A common bacterium causing pharyngitis is group A beta-hemolytic Streptococcus, but most adult cases are caused by a virus (Hoyle, 2009).

Patient-Centered Collaborative Care

Pathophysiology

Tonsillitis is an inflammation and infection of the tonsils and lymphatic tissues located on each side of the throat. The tonsils are lymphatic tissue shaped like a small almond. They are covered by mucous membranes and have small valleys (crypts) across their surface. Tonsils filter organisms and protect the respiratory tract from infection (McCance et al., 2010).

Tonsillitis is a contagious airborne infection. Acute or chronic tonsillitis can occur in any age-group, but it is less common in adults. The disease usually lasts 7 to 10 days and often is caused by bacteria, most commonly Streptococcus. Other bacterial causes include Staphylococcus aureus, Haemophilus influenzae, and Pneumococcus. Viruses also cause tonsillitis. Chronic tonsillitis may result from an unresolved acute infection or recurrent infections.

Patient-Centered Collaborative Care

Chart 33-3 lists the manifestations of acute tonsillitis. Diagnostic tests often used to rule out other causes of the sore throat and fever include a rapid antigen test (RAT), CBC, throat culture and sensitivity (C&S) studies, and Monospot test. If respiratory symptoms are present, chest x-rays may be needed. The WBC count usually is elevated in bacterial infections and normal in viral infections.

Antibiotics (usually penicillin or azithromycin) are prescribed for 7 to 10 days. Nursing priorities include teaching the patient about supportive care and stressing the importance of completing antibiotic therapy. Teach him or her to rest, increase fluid intake, humidify the air, use analgesics for pain, gargle several times each day with warm saline, and use throat lozenges.

Surgical intervention for tonsillitis may be needed for recurrent acute infections (especially group A beta-hemolytic streptococcal infections), chronic infections that do not respond to antibiotics, a peritonsillar abscess, and enlarged tonsils or adenoids that obstruct the airway. It is usually performed after the patient has recovered from an acute tonsillitis and no infection is present (except with an acute peritonsillar abscess). The procedure may involve complete tonsil removal (for chronic infection) or a partial tonsil removal for obstruction without infection. A variety of techniques are used to remove tonsils from adults; however, the dissection and snare technique is still the most common. The adenoids may be removed at the same time. When the patient is an adult, a tonsillectomy and adenoidectomy (T&A) is usually performed with him or her under general anesthesia. After surgery, nursing interventions focus on assessing for airway clearance, providing pain relief, and monitoring for excessive bleeding.

Pathophysiology

Seasonal influenza, or “flu,” is a highly contagious acute viral respiratory infection that can occur in adults of all ages. Epidemics are common and lead to complications of pneumonia or death, especially in older adults or debilitated or immunocompromised patients. Between 5% and 20% of the U.S. population develop influenza each year, and more than 36,000 deaths per year are caused by it (Kapustin, 2008). Hospitalization may be required. Influenza may be caused by one of several virus families, referred to as A, B, and C.

The patient with influenza often has a severe headache, muscle aches, fever, chills, fatigue, and weakness. Adults are contagious from 24 hours before symptoms occur and up to 5 days after they begin. Patients who are immunosuppressed may be contagious for several weeks. Sore throat, cough, and watery nasal discharge generally follow the initial symptoms for a week or longer. Most patients feel fatigued for 1 to 2 weeks after the acute episode has resolved.

Health Promotion and Maintenance

Vaccinations for the prevention of influenza are widely available. The vaccine is changed every year on the basis of which specific viral strains are most likely to pose a problem during the influenza season (i.e., late fall and winter). Usually, the vaccines contain three antigens for the three expected viral strains (trivalent influenza vaccine [TIV]). Influenza vaccinations can be taken as an IM injection (Fluviron, Fluzone) or as a live attenuated influenza vaccine (LAIV) by intranasal spray (FluMist). An attenuated virus is a live virus that has been altered to reduce its ability to cause an infection. The intranasal vaccine is live, and some people develop influenza symptoms after its use. It is recommended only for healthy people up to 49 years of age. People recommended to be vaccinated yearly include those older than 50 years, people with chronic illness or immune compromise, those living in institutions, people living with or caring for adults with health problems that put them at risk for severe complications of influenza, and health care personnel providing direct care to patients (Centers for Disease Control and Prevention [CDC], 2010c).

Teach the patient who is sick to reduce the risk for spreading the flu by thoroughly washing hands, especially after nose blowing, sneezing, coughing, rubbing the eyes, or touching the face. Other precautions include staying home from work, school, or places where people gather; covering the mouth and nose with a tissue when sneezing or coughing; disposing properly of used tissues immediately; and avoiding close contact with other people (e.g., kissing, hugging, handshaking). Although handwashing is a good method to prevent transmitting the virus in droplets from sneezing or coughing, many people cannot wash their hands as soon as they have coughed or sneezed. The technique recommended by the CDC for controlling flu spread is to sneeze or cough into the upper sleeve rather than into the hand (CDC, 2010a). (Respiratory droplets on the hands can contaminate surfaces and be transmitted to other people.)

Patient-Centered Collaborative Care

Viral infections do not respond to traditional antibiotic therapy. Antiviral agents may be effective for prevention and treatment of some types of influenza. Amantadine (Symmetrel) and rimantadine (Flumadine) have been effective in the prevention and treatment of influenza A, although strains of resistant organisms are increasing. Ribavirin (Virazole) has been used for severe influenza B. Two drugs that may shorten the duration of influenza A and influenza B are zanamivir (Relenza), which is used as an oral inhalant, and oseltamivir (Tamiflu), which is an oral tablet. These drugs prevent viral spread in the respiratory tract by inhibiting a viral enzyme (neuraminidase) that allows the virus to penetrate respiratory cells. To be effective, they must be taken within 24 to 48 hours after the onset of manifestations.

Advise the patient to stay in bed for several days and increase fluid intake unless another problem requires fluid restriction. Saline gargles may ease sore throat pain. Antihistamines may reduce the rhinorrhea. Other supportive measures are the same as those for acute rhinitis.

Pathophysiology

Many viral infections among animals and birds are not usually transmitted to humans. A few notable exceptions have occurred when these animal and bird viruses mutated and became highly infectious to humans. These infections are termed pandemic because they have the potential to spread globally. Such pandemics include the 1918 “Spanish” influenza that resulted in at least 40 million deaths worldwide and perhaps as many as 100 million deaths. This virus, the H1N1 strain, also known as “swine flu,” mutated and became highly infectious to humans. Most recently, the 2009 H1N1 influenza A resulted in a pandemic infection that spread to 215 countries. In the United States, the number of people infected with this virus during the pandemic is estimated at 61 million, resulting in more than 12,000 deaths (CDC, 2010b). A vaccine was developed in 2009 as a single antigen (monovalent) and was administered separately from the seasonal influenza vaccine. For the 2010-2011 influenza season, the trivalent seasonal vaccine contained the H1N1 antigen.

A new avian virus is the H5N1 strain, known as “avian influenza” or “bird flu,” that has infected millions of birds, especially in Asia, and now has started to spread by human-to-human contact. World health officials are concerned that this strain could become a pandemic because humans have essentially no naturally occurring immunity to this virus. Thus the infection could lead to a worldwide pandemic with very high mortality rates.

Health Promotion and Maintenance

The prevention of a worldwide influenza pandemic of any virus is the responsibility of everyone. Health officials have been monitoring the situation with human outbreaks and with testing of both wild and domestic bird species throughout the world. Vaccines currently are available for both H1N1 and H5N1; however, the H5N1 vaccine is stockpiled and not part of general influenza vaccination. The recommended early approach to disease prevention with H5N1 is early recognition of new cases and the implementation of community and personal quarantine and social-distancing behaviors to reduce exposure to the virus.

Plans for prevention and containment in North America have been developed with the cooperation of most levels of government. When a cluster of cases is discovered in an area, the stockpiled vaccine is to be made available for immunizations. Because vaccination with this vaccine is a two-step process with the first IM injection followed 28 days later by a second IM injection, additional prevention measures are needed.

The antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed. These drugs are not likely to prevent the disease but may reduce the severity of the infection and reduce the mortality rate. The infected patients should be cared for in strict isolation. All nonessential public activities in the area should be stopped. These include public gatherings of any type, attendance at schools, religious services, shopping, and many types of employment. People should stay home and use their emergency preparedness supplies (food, water, and drugs) they have stockpiled for at least 2 weeks (see Chapter 12). Travel to and from the affected area should be stopped.

Urge all people to pay attention to public health announcements and early warning systems for disease outbreaks. Teach them the importance of starting prevention behaviors immediately upon notification of an outbreak. Teach all people to have a minimum of a 2-week supply of all their prescribed drugs and at least a 2-week supply of nonperishable food and water for each member of the household. They should also have a battery-powered radio (and batteries) to keep informed of updates in an active prevention situation. See Chapter 12 for more information on items to have ready in the home for disaster preparedness. An influenza pandemic is a disaster, and containing it requires the cooperation of all people.

Patient-Centered Collaborative Care

Care of the patient with avian influenza focuses on supporting the patient and preventing spread of the disease. Both are equally important. The initial manifestations of avian influenza are similar to other respiratory infections—cough, fever, and sore throat. These progress rapidly to shortness of breath and pneumonia. In addition, diarrhea, vomiting, abdominal pain, and bleeding from the nose and gums occur. Ask any patient with these symptoms if he or she has recently (within the past 10 days) traveled to areas of the world affected by H5N1. If such travel has occurred, coordinate with the health care team to place the patient in an airborne isolation room with negative air pressure. These precautions remain until the diagnosis of H5N1 is ruled out or the threat of contagion is over. Diagnosis is made based on clinical manifestations and positive testing. The most rapid test currently approved for testing of H5N1 is the AVantage A/H5N1 Flu Test. It can detect a specific protein (NS1), which indicates the presence of H5N1, from nasal or throat swabs in less than 40 minutes.

When providing care to the patient with avian influenza, personal protective equipment is essential. Coordinate the protection activity by ensuring that anyone entering the patient’s room for any reason wears a fit-tested respirator or a standard surgical mask (“Lessons Learned,” 2010). Use other Airborne Precautions and Contact Precautions as described in Chapter 25. Teach others to self-monitor for disease symptoms, especially of respiratory infection, for at least a week after the last contact with the patient. Use the antiviral drug oseltamivir (Tamiflu) or zanamivir (Relenza) within 48 hours of contact with the infected patient. All health care personnel working with patients suspected of having avian influenza are recommended to receive the vaccine in the recommended two-step process.

No effective treatment for this infection currently exists. Antibiotics and antiviral drugs cannot kill the virus or prevent its replication. Interventions are supportive to allow the patient’s own immune system to fight the infection. Oxygen is given when hypoxia or breathlessness is present. Respiratory treatments to dilate the bronchioles and move respiratory secretions are used. If hypoxemia is not improved with oxygen therapy, intubation and mechanical ventilation may be needed. Antibiotics are used to treat a bacterial pneumonia that may occur with H5N1.

In addition to the need for respiratory support, the patient with H5N1 may have severe diarrhea and need fluid therapy. The Transmission Precautions may prevent the use of a scale to determine fluid needs by weight changes. Monitor the patient’s hydration status, and carefully measure intake and output. The type of fluid therapy varies with the patient’s cardiovascular status and the osmolarity of the blood. The two most important areas to monitor during rehydration are pulse rate and quality and urine output.

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