NCLEX: Ear, nose, and throat disorders

Ear, nose, and throat disorders: Nursing diagnoses

Focus topic: Ear, nose, and throat disorders

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.

Ear, nose, and throat disorders: Common ENT disorders

Focus topic: Ear, nose, and throat 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.

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

Focus topic: Ear, nose, and throat disorders

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.

What’s that ringing?

Focus topic: Ear, nose, and throat disorders

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 audio logic examination usually provide ample evidence of hearing loss and suggest possible causes or predisposing factors.
  • Weber and Rinne tests as well as specialized audio logic 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.

Deafness and decibels

Focus topic: Ear, nose, and throat disorders

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.

Seeing clues

Focus topic: Ear, nose, and throat disorders

  • 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.
  • 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.

Ear, nose, and throat disorders: 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.

Ear, nose, and throat disorders: Otitis externa

Focus topic: Ear, nose, and throat disorders

Otitis externa, or inflammation of the external ear canal skin and auricle, may be acute or chronic. It usually occurs in hot, humid summer weather and is also called swimmer’s ear. With treatment, the acute form usually subsides within 7 days, although it may become chronic. Severe chronic otitis externa may reflect underlying diabetes mellitus, hypothyroidism, or nephritis.

What causes it

Causes may include:

  • bacteria, such as Pseudomonas, Proteus vulgaris, streptococci, and Staphylococcus aureus
  • fungi, such as Aspergillus niger and Candida albicans
  • dermatologic conditions, such as seborrhea or psoriasis.

Pathophysiology

Otitis externa usually results when a traumatic injury or an excessively moist ear canal predisposes the area to infection.

What to look for

Acute otitis externa is characterized by moderate to severe pain. The pain increases when manipulating the auricle or tragus, clenching the teeth, opening the mouth, or chewing. If palpating the tragus or auricle causes pain, the problem is otitis externa, not otitis media. Fungal otitis externa may be asymptomatic. However, A. niger produces a black or gray, blotting, paper like growth in the ear canal.

And now for more

Focus topic: Ear, nose, and throat disorders

Other signs and symptoms of acute infection include:

  • fever
  • foul-smelling aural discharge
  • regional cellulitis
  • partial hearing loss
  • scaling, itching, inflammation, or tenderness
  • a swollen external ear canal and auricle, which can be seen on otoscopy
  • periauricular lymphadenopathy (tender nodes in front of the tragus, behind the ear, or in the upper neck).

What tests tell you

  • Otoscopic examination can determine the need for microscopic ex amination.
  • Culture and sensitivity tests can identify the causative organism and help determine the appropriate antibiotic treatment.

How it’s treated

Treatment for acute otitis externa consists of:

  • heat application to the periauricular region (warm, damp compresses)
  • drug therapy, including topical analgesics, such as otic antipyrine and benzocaine; antibiotic eardrops (with or without hydrocortisone) that are instilled after the ear is cleaned and debris removed; and, if fever persists or regional cellulitis develops, a systemic antibiotic
  • careful ear cleaning (especially in fungal otitis externa), including application of a keratolytic or 2% salicylic acid in cream containing nystatin (for candidal organisms) or instillation of slightly acidic eardrops such as 0.5% neomycin (for most fungi and Pseudomonas organisms); performed only if the tympanic membrane is intact
  • repeated cleaning of the ear canal with baby oil

The tonic for chronic

Focus topic: Ear, nose, and throat disorders

External ear infections are painful, and the patient with chronic otitis externa may require analgesia. Other treatments include:

  • cleaning the ear and removing debris with antibiotic irrigations (primary)
  • instilling antibiotic eardrops and applying antibiotic ointment or cream, such as neomycin, bacitracin, or polymyxin B, possibly combined with hydrocortisone (supplemental)
  • for mild chronic otitis externa, instilling antibiotic ear drops once or twice weekly and wearing specially fitted earplugs while showering, shampooing, and swimming.

What to do

  • Monitor vital signs, particularly temperature. Watch for and record
    the type and amount of aural drainage.
  • Remove debris and gently clean the ear canal with 0.5% neomycin or polymyxin B. Place a wisp of cotton soaked with solution into the patient’s ear, and apply a saturated compress directly to the auricle. Afterward, dry the ear gently but thoroughly. (If the patient has severe otitis externa, such cleaning may be delayed until after initial treatment with antibiotic ear drops.)

Traveling in the canal

Focus topic: Ear, nose, and throat disorders

  • To instill ear drops in an adult, pull the pinna back to straighten the canal. To ensure that the drops reach the epithelium, insert a wisp of cotton moistened with ear drops, or have the patient lie on his side with the affected ear up for 15 minutes after instilling drops.
  • If the patient has chronic otitis externa, clean the ear thoroughly. Use wet soaks intermittently on oozing or infected skin. If the patient has a chronic fungal infection, clean the ear canal well, and then apply an exfoliative ointment.
  • Evaluate the patient. Make sure the patient is a febrile and pain free, can administer his ear drops properly, and knows which risk factors to avoid.

Ear, nose, and throat disorders

Ear, nose, and throat disorders: Otitis media

Focus topic: Ear, nose, and throat disorders

Otitis media, or inflammation of the middle ear, may be acute, chronic, or serous. The infection appears suddenly and typically lasts only a short time. Its incidence rises during the winter months, paralleling the seasonal rise in bacterial respiratory tract infections. It results from disruption of eustachian tube patency.

What causes it

Acute otitis media occurs as a result of pneumococci, betahemolytic streptococci, staphylococci, and gram-negative bacteria such as Haemophilus influenzae. Chronic otitis media results from inadequate treatment of acute infection as well as infection by resistant strains of bacteria.

Serious about serous

Focus topic: Ear, nose, and throat disorders

Serous otitis media occurs as a result of:

  • viral upper respiratory tract infection, allergy, or residual otitis media
  • enlarged lymphoid tissue
  • barotrauma (pressure injury caused by an inability to equalize pressures between the environment and the middle ear).
    The causes of chronic serous otitis media are:
  • adenoidal tissue overgrowth that obstructs the eustachian tube
  • edema resulting from allergic rhinitis or chronic sinus infection
  • inadequate treatment of acute suppurative otitis media.

Pathophysiology

With the acute form of otitis media, respiratory tract infection, allergic reaction, or positional changes (such as holding an infant in the supine position during feeding) allow re flux of nasopharyngeal flora through the eustachian tube and colonization in the middle ear.
With prompt treatment, the prognosis for acute otitis media is excellent; however, prolonged accumulation of fluid within the middle ear cavity causes chronic otitis media.
With serous otitis media, obstruction of the eustachian tube results in negative pressure in the middle ear that promotes transudation of sterile serous fluid from blood vessels in the membrane of the middle ear.

Ear, nose, and throat disorders

What to look for

Although the patient with acute otitis media may be asymptomatic, typical signs and symptoms include:

  • severe, deep, throbbing pain
  • upper respiratory tract infection with a mild to high fever
  • hearing loss, usually mild and conductive
  • lack of response or inattention to spoken word
  • sensation of blockage in the ear, dizziness, nausea, and vomiting
  • obscured or distorted bony landmarks of the tympanic membrane (evident on otoscopy)
  • bulging of the tympanic membrane with concomitant erythema
  • purulent drainage in the ear canal from tympanic membrane rupture.

Serous symptoms

Focus topic: Ear, nose, and throat disorders

Many patients with serous otitis media are asymptomatic but end up developing severe conductive hearing loss ranging from 15 to 35 dB, depending on the thickness and amount of fluid in the middle ear cavity. Other signs and symptoms include:

  • a sensation of fullness in the ear or hearing an echo when speaking
  • popping, crackling, and clicking sounds with swallowing and jaw movement
  • experiencing a vague feeling of top-heaviness
  • tympanic membrane retraction, which causes the bony landmarks to appear more prominent (seen on otoscopy)
  • clear or amber fluid behind the tympanic membrane (seen on otoscopy) with possible presence of an air bubble
  • blue-black tympanic membrane (seen on otoscopy) if hemorrhage into the middle ear has occurred.

Long-term liability

Focus topic: Ear, nose, and throat disorders

Chronic otitis media usually begins in childhood and persists into adulthood. Its effects include:

  • decreased or absent tympanic membrane mobility (tympanosclerosis)
  • cystlike mass in the middle ear (cholesteatoma)
  • erythema and perforation of the eardrum
  • painless, purulent discharge (otorrhea)
  • conductive hearing loss that varies with the size and type of tympanic membrane perforation and ossicular destruction
  • thickening and possible scarring of the tympanic membrane (seen on otoscopy).

What tests tell you

  • Otoscopic examination can determine the need for microscopic examination.
  • Computed tomography scanning can reveal effects on structures of the middle ear.
  • Culture and sensitivity testing can determine the causative organism.
  • Pneumatoscopy can show decreased tympanic membrane mobility. However, this procedure is painful because of the bulging, erythematous tympanic membrane that occurs in acute otitis media.
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How it’s treated
For acute secretory otitis media, the only treatment required may be inflation of the eustachian tube several times per day using Valsalva’s maneuver. Otherwise, nasopharyngeal decongestant therapy may be helpful.

Ear, nose, and throat disorders

Tube time

Focus topic: Ear, nose, and throat disorders

If decongestant therapy fails, myringotomy and aspiration of middle ear fluid, followed by insertion of a polyethylene tube into the tympanic membrane, provide immediate and prolonged equalization of pressure. The tube falls out spontaneously after 9 to 12 months.
Broad-spectrum antibiotics may be used to help prevent acute otitis media in high-risk patients. In patients with recurring otitis media, antibiotics must be used sparingly and with discretion to prevent development of resistant strains of bacteria.
Other treatments for acute otitis media include:

  • antibiotic therapy with ampicillin (Principen), amoxicillin ( Dispermox), or cefaclor (Raniclor) or sulfamethoxazole/trimethoprim (Bactrim) for those who are allergic to penicillin derivatives
  • acetaminophen (Tylenol) or ibuprofen (Motrin) to help control pain and fever
  • myringotomy for severe, painful bulging of the tympanic membrane.

When it goes on and on

Focus topic: Ear, nose, and throat disorders

For chronic otitis media, therapy includes:

  • antibiotics for exacerbations of acute infection
  • elimination of eustachian tube obstruction
  • myringoplasty (tympanic membrane graft)
  • tympanoplasty to reconstruct middle ear structures when thickening and scarring are present, and, possibly, mastoidectomy
  • excision of cholesteatoma, if present.

What to do

  • After myringotomy, maintain drainage flow. Don’t place cotton or plugs deep in the ear canal. Instead, place sterile cotton loosely in the external ear to absorb drainage.
  • To prevent infection after the procedure, change the cotton whenever it gets damp and wash your hands before and after providing ear care.
  • Watch for and report headache, fever, severe pain, or disorientation. Tympano treatment
  • After tympanoplasty, reinforce dressings, and observe for excessive bleeding from the ear canal. Administer an analgesic, if needed.
  • After completing therapy for otitis media, evaluate the patient. Make sure the patient is free from pain and fever, his hearing is completely restored, he understands the importance of completing his antibiotic therapy, and he understands how to prevent recurrence.Sinusitis

The prognosis is good for all types of sinusitis. The types include:

  • acute, which usually results from the common cold and lingers in subacute form in only about 10% of patients
  • chronic, which follows persistent bacterial infection
  • allergic, which accompanies allergic rhinitis
  • hyperplastic, which is a combination of purulent acute sinusitis and allergic sinusitis or rhinitis
  • viral, which follows an upper respiratory tract infection in which the virus penetrates the normal mucous membrane
  • fungal, which is generally uncommon but is more common in immunosuppressed or debilitated patients.

What causes it

Sinusitis may result from:

  • an upper respiratory tract infection, allergies, or rhinitis
  • nasal polyps
  • bacterial, viral, or fungal infection (possibly due to swimming in contaminated water or dental manipulation, for example).

Pathophysiology

Ordinarily, bacteria are swept from the sinuses through mucociliary clearance. When the ostia (openings to the sinuses) become obstructed by inflammation or mucus, however, these bacteria remain in the sinus cavity and multiply. The mucous membrane inside the cavity becomes swollen and inflamed, and the cavity fills with secretions.

What to look for

Signs and symptoms associated with sinusitis include:

  • nasal congestion and pressure
  • pain over the cheeks and upper teeth (in maxillary sinusitis)
  • pain over the eyes (in ethmoid sinusitis)
  • pain over the eyebrows (in frontal sinusitis)
  • rarely, pain behind the eyes (in sphenoid sinusitis)
  • edematous nasal mucosa and edema of the face and periorbital area
  • fever (in acute sinusitis)
  • nasal discharge (possibly purulent in acute and sub acute sinusitis, continuous in chronic sinusitis, and watery in allergic sinusitis)
  • nasal stuffiness and possible inflammation and pus on nasal examination.

What tests tell you

  • Sinus X-rays may reveal cloudiness in the affected sinus, air fluid levels, or thickened mucosal lining.
  • Antral puncture promotes drainage and removal of purulent material and may provide a specimen for culture and sensitivity identification of the infecting organism (rarely performed).
  • Trans illumination allows inspection of the sinus cavities by shining a light through them; however, purulent drainage prevents passage of light.

How it’s treated

The primary treatment for acute sinusitis is antibiotic therapy. Other appropriate measures include:

  • a vasoconstrictor such as phenylephrine (Afrin) to decrease nasal secretions
  • an analgesic to help relieve pain
  • steam inhalation to promote vasoconstriction and encourage drainage
  • local application of heat to relieve pain and congestion
  • an antibiotic or anti fungal agent (for persistent infection).
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Antibiotics, take two

Focus topic: Ear, nose, and throat disorders

Antibiotic therapy is also the primary treatment for subacute sinusitis. A vasoconstrictor may reduce the amount of nasal secretions.

Allergic sinusitis? Treat rhinitis.

Focus topic: Ear, nose, and throat disorders

Treatment of allergic sinusitis involves treatment of allergic rhinitis, which includes:

  • administration of an antihistamine
  • identification of allergens by skin testing and desensitization by immunotherapy
  • corticosteroids and epinephrine for severe allergic symptoms.

If all else fails…

Focus topic: Ear, nose, and throat disorders

For chronic and hyper plastic sinusitis, an antihistamine, an antibiotic, and a steroid nasal spray may relieve pain and congestion. If irrigation fails to relieve symptoms, one or more sinuses may require surgery. Surgeries include:

  • sinus tap and irrigation for acute sinusitis
  • functional endoscopic sinus surgery
  • external ethmoidectomy or sphenoethmoidectomy
  • frontal sinusotomy for chronic sinusitis.

What to do

  • Enforce bed rest with the head of the bed elevated.
  • Encourage the patient to drink plenty of fluids to promote drainage.
  • Use a humidifier and nasal saline sprays to decrease dryness.
  • Monitor temperature to detect infection. Perform sinus irrigations as ordered.
  • To relieve pain and promote drainage, apply warm compresses continuously or four times daily for 2-hour intervals.
  • Watch for and report complications, such as vomiting, chills, fever, edema of the forehead or eyelids, blurred or double vision, and personality changes.
  • Evaluate the patient. Make sure the patient is free from pain, congestion, headaches, and fever; maintains humidification and drainage of his sinuses; understands the importance of complying with antibiotic therapy; and is able to distinguish common smells.
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