Nursing diagnoses

When caring for a patient with an ENT disorder, you’re likely to use several nursing diagnoses repeatedly. These commonly used diagnoses appear here, along with appropriate nursing interventions and rationales.

Impaired swallowing

Focus Topic: Ear, nose, and throat disorders

Related to pain and inflammation, Impaired swallowing may be associated with such conditions as pharyngitis, tonsillitis, and laryngitis.

Expected outcomes

  • Patient can swallow.
  • Patient maintains adequate hydration.
  • Patient exhibits effective airway clearance.

Nursing interventions and rationales

  • Elevate the head of the bed 90 degrees after food or fluid intake and at least 45 degrees at all other times to promote swallowing and prevent aspiration.
  • Position the patient on his side while recumbent to decrease the risk of aspiration. Have suction equipment available in case aspiration occurs.
  • Assess swallowing function frequently, especially before meals, to prevent aspiration.
  • Administer pain medication before meals to enhance swallowing ability.
  • Provide a liquid to soft diet, and consult with the dietitian as necessary to promote less painful swallowing.
  • Provide mouth care frequently to remove secretions and enhance comfort and appetite.
  • If the patient can’t swallow fluids, notify the practitioner and administer I.V. fluids as ordered to maintain hydration.

Disturbed sensory perception (auditory)

Focus Topic: Ear, nose, and throat disorders

Related to altered auditory reception or transmission, Disturbed sensory perception (auditory) may be associated with such conditions as otitis media, mastoiditis, otosclerosis, Ménière’s disease, and labyrinthitis.

Expected outcomes

  • Patient understands that progressive hearing loss is caused by the disease.
  • Patient can communicate.

Nursing interventions and rationales

  • Assess the patient’s degree of hearing impairment, and determine the best way to communicate with him (for example, using gestures, lip reading, or written words) to ensure adequate patient care.
  • When talking to a hearing-impaired person, speak clearly and slowly in a normal to deep voice and offer concise explanations of procedures to include the patient in his own care.
  • Provide sensory stimulation by using tactile and visual stimuli to help compensate for hearing loss.
  • Encourage the patient to express feelings of concern and loss for his hearing deficit, and be available to answer questions. This helps him accept his loss, clears up misconceptions, and reduces anxiety.
  • Encourage the patient to use his hearing aid as directed to enhance auditory function.
  • Upon discharge, teach him to watch for visual cues in the environment, such as traffic lights and flashing lights on emergency vehicles, to avoid injury.

Ineffective airway clearance

Focus Topic: Ear, nose, and throat disorders

Related to nasopharyngeal obstruction, Ineffective airway clearance may be associated with such conditions as nasal papillomas, adenoid hyperplasia, nasal polyps, pharyngitis, and tonsillitis.

Expected outcomes

  • Patient has clear nasal airways.
  • Patient sleeps with normal oxygen saturation.
  • Patient is free from infection.
  • Patient is free from complications.

Nursing interventions and rationales

  • Assess respiratory status (including rate, depth, and stridor) at least every 4 hours to detect early signs of compromise.
  • Position the patient with the head of his bed elevated 45 to 90 degrees to promote drainage of secretions and aid breathing and chest expansion.
  • Suction upper airways as needed to help remove secretions.
  • Have emergency equipment at the bedside in case of airway obstruction.
  • Encourage the patient to cough and deep-breathe every 2 hours to help loosen secretions in his lungs.
  • Encourage the patient to drink at least 3 qt (3 L) of fluid per day to ensure adequate hydration and loosen secretions.

Common ENT disorders

Hearing loss, laryngitis, otitis externa, otitis media, and sinusitis are common ENT disorders.

Hearing loss

Focus Topic: Ear, nose, and throat disorders

Impaired hearing, the most common disability in the United States, results from a mechanical or nervous system impediment to the transmission of sound waves. Hearing loss is further defined as an inability to perceive the range of sounds audible to an individual with normal hearing. Types of hearing loss include congenital hearing loss, sudden deafness, noise-induced hearing loss, and presbycusis (age-related hearing loss).

What causes it

Causes of hearing loss depend on the type. (See Causes of hearing loss.)

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Ear, nose, and throat disorders

 

Pathophysiology

The major forms of hearing loss are classified as:

  • conductive, in which transmission of sound impulses from the external ear to the junction of the stapes and oval window is interrupted
  • sensorineural, in which impaired cochlear or acoustic (CN VIII) nerve function prevents transmission of sound impulses within the inner ear or brain
  • mixed, in which conductive and sensorineural transmission dysfunction combine.

What to look for

Although congenital hearing loss may produce no obvious signs of hearing impairment at birth, deficient response to auditory stimuli usually becomes apparent within 2 to 3 days. As the child grows older, hearing loss impairs speech development.

 

Ear, nose, and throat disorders: Loud and long

Noise-induced hearing loss causes sensorineural damage, the extent of which depends on the duration and intensity of the noise. Initially, the patient loses perception of certain frequencies (around 4,000 Hz) but, with continued exposure, he eventually loses perception of all frequencies.

Ear, nose, and throat disorders: What’s that ringing?

Presbycusis usually produces tinnitus, with progressive decline in overall hearing and the ability to understand the spoken word.

What tests tell you

  • Patient, family, and occupational histories and a complete audiologic examination usually provide ample evidence of hearing loss and suggest possible causes or predisposing factors.
  • Weber and Rinne tests as well as specialized audiologic tests differentiate between conductive and sensorineural hearing loss.
  • Auditory evoked reponses, imaging studies, and electronystagmography help to evaluate disorders, such as vertigo, neuromas, and tinnitus.

How it’s treated

To treat sudden deafness, the underlying cause must be promptly identified. Educating patients and health care professionals about the many causes of sudden deafness can greatly reduce the incidence of this problem.

Ear, nose, and throat disorders: Deafness and decibels

For individuals whose hearing loss was induced by noise levels greater than 90 dB for several hours, treatment includes:

  • overnight rest, which usually restores normal hearing unless the patient was repeatedly exposed to such noise
  • speech and hearing rehabilitation as the patient’s hearing deteriorates, because hearing aids are rarely helpful.

What to do

  • When talking to a patient with hearing loss who can read lips, stand directly in front of him, with the light on your face, and speak slowly and distinctly.
  • Assess the degree of hearing impairment without shouting.
  • Approach the patient within his visual range, and get his attention by raising your arm or waving; touching him may unnecessarily startle him.
  • Write instructions on a tablet, if necessary, to make sure the patient understands.
  • If the patient is learning to use a hearing aid, provide emotional support and encouragement.
  • Inform other staff members and hospital personnel of the patient’s disability and his established method of communication.

Ear, nose, and throat disorders: Seeing clues

  • Make sure the patient is in an area where he can observe unit activities and persons approaching, because a patient with hearing loss depends on visual clues.
  • Evaluate the patient. Make sure he expresses that his hearing loss has resolved or stabilized, is able to maintain communication with others, and exhibits decreased anxiety.
  • Make sure the patient and his family understand the importance of wearing protective devices while in a noisy environment. (See Hearing loss teaching tips.)
  • To prevent noise-induced hearing loss, the public must be educated about the dangers of noise exposure and come to insist on the use, as mandated by law, of protective devices, such as earplugs, during occupational exposure to noise.
  • To help prevent congenital hearing loss, pregnant women need to understand the dangers of exposure to drugs, chemicals, and infection — especially rubella — during pregnancy.

Hearing loss teaching tips

  • Explain the cause of hearing loss and the medical or surgical treatment options.
  • Teach the patient who just received a hearing aid how it works and how to maintain it.
  • Emphasize the danger of excessive exposure to noise, and encourage the use of protective devices in a noisy environment.

Laryngitis

Focus Topic: Ear, nose, and throat disorders

Laryngitis is an inflammation of the vocal cords. Acute laryngitis may occur as an isolated infection or as part of a generalized bacterial or viral upper respiratory tract infection. Repeated attacks of acute laryngitis cause inflammatory changes associated with chronic laryngitis.

What causes it

Acute laryngitis results from infection, excessive use of the voice, inhalation of smoke or fumes, or aspiration of caustic chemicals. Chronic laryngitis results from upper respiratory tract disorders (such as sinusitis, bronchitis, nasal polyps, or allergy), mouth breathing, smoking, gastroesophageal reflux, constant exposure to dust or other irritants, alcohol abuse, or cancer of the larynx.

Pathophysiology

Edema of the vocal cords caused by irritation (from an infection, lesion, or overuse of the voice or other cause) impairs the normal mobility of the vocal cords, causing an abnormal sound.

What to look for

Signs and symptoms of laryngitis include:

  • hoarseness (persistent hoarseness in chronic laryngitis)
  • changes in the character of the voice
  • pain (especially when swallowing or speaking)
  • a dry cough, fever, malaise, dyspnea, throat clearing, restlessness, or laryngeal edema.

What tests tell you

  • Indirect laryngoscopy confirms the diagnosis by revealing exudate and red, inflamed, and occasionally hemorrhagic vocal cords, with rounded (not sharp) edges. Bilateral swelling that restricts movement but doesn’t cause paralysis also may be apparent.
  • Videostroboscopy shows the movement of the vocal cords.

How it’s treated

Treatment of laryngitis includes:

  • resting the voice (primary treatment)
  • symptomatic care, such as an analgesic and throat lozenges (for viral infection)
  • antibiotic therapy (bacterial infection), usually with cefuroxime (Ceftin)
  • identification and elimination of underlying cause (chronic laryngitis)
  • possible hospitalization (in severe acute laryngitis)
  • possible tracheotomy if laryngeal edema results in airway obstruction
  • drug therapy, which may include antacids, histamine-2 blockers, antibiotics, and systemic steroids.

What to do

  • Tell the patient to refrain from talking to avoid straining the vocal cords and allow vocal cord inflammation to decrease.
  • If the patient is hospitalized, place a sign over his bed to remind others of talking restrictions and mark the intercom panel so other hospital personnel are aware that the patient can’t answer.
  • Provide a pad and pencil or a slate for communication.
  • Provide an ice collar, a throat irrigant, and cold fluids for comfort.
  • Evaluate the patient. Make sure he isn’t hoarse or in pain; doesn’t have a fever; doesn’t need a tracheotomy; understands the need to stop smoking, maintain humidification, and complete his antibiotic therapy; and modifies his environment appropriately to prevent recurrence. (See Laryngitis teaching tips.)

Laryngitis teaching tips

  • Suggest that the patient maintain adequate humidification by using a vaporizer or humidifier during the winter, avoiding air conditioning during the summer (because it dehumidifies), using medicated throat lozenges, and avoiding smoking and smoky environments.
  • Teach the patient about prescribed medication, including dosage, frequency, and adverse effects.
  • Instruct the patient to complete prescribed antibiotic therapy.
  • If the patient has chronic laryngitis, obtain a detailed patient history to help determine the cause.
  • Encourage modification of habits that can cause the disorder.
  • Advise the patient to avoid crowds and people with upper respiratory tract infections.
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