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== MEDICAL SURGICAL NURSING ==

Introduction:

           Sinusitis is a common infection that may occur in any of the paranasal sinuses it is a common medical condition that affects as estimated 35 million people in rear in USA. Rhinitis is the inflammation of the nasal cavities, and it is a most common disorder to affect the nose and accessory nasal sinuses. The signs and symptoms of these are headache, fever

chills and purulent discharge form the nose.

Sinusitis : Definition:

           It is the inflammation of the mucous membranes of one or more sinuses. 

Anatomy and physiology:

The paranasal sinuses are sterile air felled cavities located within the bones of the skull . They consist of the maxillary sinus( in the checks) the ethmoid sinuses (between the eyes) the frontal sinuses (above the eyebrows) and  the sphenoid sinus (behind the eyes and ethmoid sinus) the paranasal sinuses are normally kept sterile by maxillary transport.

Arterial supply:

          Supra orbital artery intraorbital artery , internal caratid artery 

Nerve supply:

         Supra orbital nerve , infra orbital nerve and anterior middle and  posterior superior anterior nerve, posterior ethmoidal nerve

Physiology: Functions of the sinus:  To give resonance to the voice  To lighten the bones of the face and cranium , making PE earsier for the eract to balance on cop of the vertebra column Incidence:

           Sinusitis is a common medical condition that affects an estimated 35 million people a year in USA people with a deviated nasal septum or allergy problem tend to have recurrent sinusitis. 

Types :

           Sinusitis can be bacterial, viral or fugal in origin and may be classified as acute or chronic 

Bacterial sinusitis:

          It is most commonly associated with streptococcus pneumonia, haemophilus influenza.

Viral sinusitis:

          It is believed to follow an upper respiratory infection in which the virus penetrates the normal mucus membrane, decreasing ciliary transport. 

Fungal sinusitis:

          It is uncommon and is found more often in patients who are immune compromised or in a debilited state, such as patients with uncontrolled diabetes or patients who are immune suppressed because of chemotherapy or organ transplantation. The most common types of fungal sinusitis are aspergillosis, candidiasis, histoplasmosis etc. The organisms that normally are focused in the soil . They enter the respiratory tract through inhalation and in a person with a normal immune system are promptly eliminated

According to the sevearity is may be acute and chronic sinusitis

Acute sinusitis: Definition:

          Acute sinusitis is an inflammation of the sinus for fever than 8 weeks in a child. It is frequently associated with the common cold. 

Etiology:  Upper respiratory tract infection  Tooth infection  Nasal congestion (abnormal accumulation of blood any part)  Exacerbation (1st in the sevearity of disease) of allergic rhinitis. Pathophysiology:

           Acute sinusitis frequently develops as a result of an upper respiratory tract infection or an exacerabation of allergic rhinitis. Nasal congestion caused by inflammation, oedema and transudation of fluid, leads to obstruction of the sinus cavities, leads  to obstruction of the sinus cavities. This provides an excellent medium for bacterial growth. 

Clinical features:  Pain over the sinus  Purulent nasal secretions  Pressure Diagnostic evaluation:  Ct scan of the sinuses , is performed to rule out other local or systemic disorders, such as tumor, fistula and allergy.

Chronic sinusitis: Definition:

          Chronic sinusitis is an inflammation of the sinus that persises for more than 8 weeks in an adult or 2 week in a child. 

Etiology:  Narrowing or obstruction of ostia of the frontal, maxillary and anterior ethmoid sinuses.  Infection  Allergy  Structural abnormalities. Pathophysiology:

          Chronic sinusitis is usually caused by a narrowing or obstruction of the ostia of  the frontal, maxillary and anterior ethmoid sinuses, which drawn in to the middle meatus. This combined area is known as the osteomeatal complex. The blockage may occur because of infection , allergy or structural abnormalities . This results in stagnant secretions an ideal median for infection. 

Clinical manifestations:  Impaired mucociliary clearance and ventilation  Cough  Chronic headache in periorbital area  Facial pain  Fatigue and nasal stuffiness  Decrease in smell and taste  Feeling of fullness in the ears Assessment and diagnostic evaluations:  Ct scan  Magnetic resonance imaging  Nasal endoscopy Complication:  Chronic sinusitis  Severe orbital cellulitis  Sub periosteal abscess  Cavernous sinus thrombosis  Meningitis  Direct infection of the brain  Osteomyelitis  Ischemic infarction Management : Medical management :  Use of appropriate antibiotic to manage the bacterial infection  De congestants to reduce nasal oedema  Corticosteroid nasal sprays to reduce mucosal inflammation  Humidification by use of normal saline solution irrigations or a vaporizer or humidifier to prevent nasal crusting and to moisten secretions  In the case of chronic sinusitis antimicrobial agents are administered for 21 days  Cefuroxime anelil  Ceflixime (suprax)  Cefprozil Surgical management :  Sinus tap and irrigation for acute  Sinusitis : insertion of catheter through sinus ostia to irrigate sinus  Functional endoscopic sinus surgery use of sinus endoscopes to enter sinus, remove diseased mucosa and open sinus ostia.  Frontal sinusectomy with or without obliteration for chronic sinusitis. Removal of frontal sinus mucosa to remove disease Nursing management:  The nurse instructs the patient about methods to promote sinus drainage such as inhaling steam , increasing fluid intake and applying local heat.  The nurse also informs the patient about the side effects of nasal decongestant spreads  The nurse teaches the early signs and symptoms  If fever persists despite antibiotic therapy the patient should seek additional care . Nursing diagnosis: 1)Ineffective airway clearance related to nasal obstruction  Increase humidification  Increase fluid intake , use nasal saline sprays.  Administer medications as order  Elevate head end of the bed 2)High risk for infection related to sinusitis  Assess amount and characteristic s of nasal drainage  Monitor temperature  Obtain or assist with obtaining culture of drainage  Observe patients for orbital complications  Monitor patients for decrease in pulse rate  Administer antibiotics or antifungal agents 3)Altered sensory perception related to usual oedema  Instruct the patient to make appropriate adaptations In his living environment 4)Pain related to sinus infection  Assess amount of pain  Administer and evaluate effectiveness of analgesics every 4 hours  Instruct patient to avoid bending lifting , stooping  Apply warm, most compresses to sinus area 5)Knowledge deficit regarding treatment and follow up care  Assess the knowledge of the patient  Teach about the disease  Increase humidification

Rhinitis : Definition:

         It is the inflammation of the mucous membrane of the nose . It is the most common disorder to affect the nose and accessory nasal sinuses. 

Anatomy and physiology:

          The nose is the organ of smell. The receptors for smell are placed in the upper one third of the nasal cavity. This part is lined by olfactory mucosa . The olfactory mucosa lines the upper one third of the nasal cavity including the roof formed by cribriform plate and the medial ant lateral walls up to the level of the superior chonche The nasal septum is median osseo cartilaginous partition between the two halves of the nasal cavity. 

Arterial supply:

         Anterosuperior part is supplied by the anterior ethmoidal artery , sphenopalatine artery, facial artery , ethmoidal arter

Venous drainage: Facial vein and sphenopalatine vein nerve supply  General sensory neves  Anti ethmoidal nerve  Special sensory nerve Physiology: Functions of the nose:

          The nose is the first of the respiratory passage through which the inspired air passes. The function of the nose is to begin the process by which the air is warmed, moistened and filtered 

Incidence:

          It is the most prevalent infectious disease among people of all ages 

Types:

         Rhinitis can be viruses , bacterial and allergence and it may be classified as acute or chronic. 

Acute rhinitis:

         It may be caused by allergens or a virus. 

It frequently called hay fever, is commonly initiated by sensitivity reactions to allergens , especially plant pollens. Acute viral rhinitis:

          It is caused by one or more of more than 30 viruses. It usually spreads from one person to another person toa another via droplet nuclei from sneezing or coughing and is most contagious in the first 2 to 3 days after symptoms appear. 

Chronic rhinitis:

           It presents intermittently or continuously when an individual is exposed to certain allergens such as dust, animal danger, wool and foods. Rhinitis can also occur after excessive use of nose drops or sprays, as a rebound effect causing nasal congestion

Etiology:  It may be caused by allergens or a virus  It is a interplay of virus bacteria and allergens  Nasal congestion Pathophysiology :

           The rhinitis frequently develops the offending substance causes a release of vasoactive mediators. Eg: histamine, serotonin, bradykinin and prostaglandin, which induces vaso dialation and increased capillary permeability, Edema and swelling of the nasal mucoasa result. Nasal congestion caused by inflammation lead to obstruction in the nasal cavities. This provide sand excellent medium for bacterial and viral growth. 

Clinical features:  Headache  Nasal irrigation and congestion  Sneezing  Watery eyes  Rhinorrhea  Fatique  Low grade fever and chills  Dry throat  Non productive cough Diagnostic evaluations:  History collection  Physical evaluation  Nasal edoscopy  Allergy testing Complications:  Otitis media  Sinusitis  Bronchitis  Pneumonia Management : Medical management:  Use of appropriate antibiotic to manage the viral infection  Aspirin should be given or some other mild non prescription analgesic can help relieve the muscle aches and headache of a cold  Fluid intake should be given  Antihistamines and decongeseants are commonly given but most be used with caution in the elderly because of side effects such as vertigo, hypertension , urinary retention and insomnia  Antipyretics are administered Nursing management:  The nurse should avoid the persons with a cold and conduct with others  A person with a cold is contagious about 3 days after his symptoms fist appear  Fruit juices are recommended , especially citrus juices, because of their vitamin c content.  Nose drops or sprays for the relief of nasal congestion  Adequate fluid intake of at least 2000ml /day  Teach about viral rhinitis Nursing diagnosis: 1)Ineffective airway clearance related to nasal obstruction  Increase humidification  Use nose drops or sprays  Provide proper position  Administer medication as ordered 2)High risk for infection related ot rhinitis  Monitor temperature  Monitor patient for decrease in pulse rate  Administer IV fluids  Administer antipyretics 3)Altered sensory perception related to usual edema  Instruct the patient to make appropriate adaptations In his living environment 4)Pain related to infection  Assess amount of pain  Administer and evaluate effectiveness of analgesics every 4hrs.  Instruct patient to avoid bending, lifting , stooping  Apply warm, moist compresses to nasal area 5)Knowledge deficit regarding treatment and follow up care  Assess the knowledge of the patient  Teach about the disease condition  Increase humidification Conclusion :

          Students are able to tell about sinusitis and rhinitis, its definition , etiology ,types, pathophysiology, clinical manifestation, complication, diagnostic evaluation and management.