ENA: EMERGENCY NURSING ORIENTATION

ENA: EMERGENCY NURSING ORIENTATION Lesson Notebook: Dental, Ear, Nose, Throat, and Facial Emergencies • Lesson Outline • Key Resources • Precepto...
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ENA: EMERGENCY NURSING ORIENTATION Lesson Notebook: Dental, Ear, Nose, Throat, and Facial Emergencies •

Lesson Outline



Key Resources



Preceptor Exercises

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.

LESSON OUTLINE Anatomy and Physiology Review • • • • •

Dentition consists of two main structures: the teeth and the periodontium. Primary teeth begin to erupt at age 6 months. Permanent teeth begin to erupt at age 5 to 6 years. Each ear is divided into three sections: external ear (auricle, ear canal, and tympanic membrane), middle ear (ossicles, round and oval windows, and eustachian tube), and internal ear (bony labyrinth). The nose is a mostly cartilaginous structure that warms, filters, and moistens inhaled air, provides a sense of smell, and is the primary passage for air to reach the lungs. The throat (pharynx) is composed of the nasopharynx, oropharynx, and laryngopharynx. The bony structures of the face include the vomer, mandible, and six pairs of bones. Four pairs of sinuses (air-filled pockets) are the ethmoid, frontal, maxillary, and sphenoid sinuses. At the temporomandibular joint, the mandible connects to the temporal bone.

Patient Assessment •

For a patient with a dental, ear, nose, throat, or facial emergency, perform a focused assessment. Use inspection and palpation to examine affected structures, as needed.

Dental Emergencies •











Odontalgia (dental pain) usually results from caries. Affected teeth may be tender on percussion and sensitive to heat, cold, and air. When odontalgia is accompanied by facial or neck swelling, the patient needs prompt assessment and treatment to prevent the spread of infection. Treatment includes antibiotics, topical anesthetics, nerve blocks, and analgesics until the patient receives definitive dental care. Tooth eruption can cause pain, irritability, disrupted sleep, nasal discharge, crying, diarrhea, drooling, dehydration, and low-grade fever. Treatment may include acetaminophen (Tylenol), oral and intravenous fluid administration, saline irrigation, nonopioid analgesics, sparing use of topical anesthetics. Pericoronitis (gum inflammation in the pericoronal flap) results from impacted molars and may cause extreme pain, earache, sore throat, fever, inflamed tissues, submandibular lymphadenopathy, and trismus. Treatment may include warm saline or peroxide irrigation and mouth rinses, incision and drainage, antibiotics, and follow-up with an oral-maxillofacial surgeon. Fractured tooth is the most common dental injury in the emergency department. The Ellis classification system describes different types of fractured teeth and aids in planning their treatment. Because fractured teeth are commonly associated with facial trauma, the priority is to secure the airway, breathing, and circulation. Tooth avulsion occurs when a tooth is torn from its socket. Handle an avulsed tooth by the crown. Ideal treatment is rinsing the tooth and placing it back in the socket as soon as possible. If this is not possible, transport the tooth in Hank solution, milk, or saline solution or under an alert patient’s tongue. Refer the patient to a dentist or oral surgeon. Dental abscesses may be periapical or periodontal. They usually are confined, but some infections can spread to the head and neck, causing different manifestations. Treatment calls for opioids, antipyretics, antibiotics, possibly incision and drainage, and follow-up with an oral surgeon, dentist, or ear, nose, and throat specialist.

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.

LESSON OUTLINE • •

Gingivitis (gum inflammation) is the most common cause of tooth loss. It causes red, swollen gum margins, bleeding, pain, difficulty chewing, and low-grade fever. Topical anesthetics, analgesics, and oral antibiotics are indicated, along with teaching about dental hygiene and referral to a dentist. Ludwig’s angina is the spread of an existing dental infection or cellulitis into three mandibular spaces. It causes swelling in the neck and submandibular tissue (which displaces the tongue superiorly), pain, trismus, muffled voice, dysphagia, drooling, fever or chills, and dyspnea. Priorities in the emergency department include maintaining the airway, breathing, and circulation; relieving pain; and administering intravenous antibiotics.

Ear Emergencies •







Ear inflammations may affect the external, middle, or inner ear. They produce varying manifestations but almost always cause pain. o Otitis externa affects the external ear canal and auricle and usually results from bacterial infection. Signs and symptoms typically include pain, swelling, redness, and purulent drainage of the auricle and ear canal. To treat otitis externa, keep the ear dry, apply heat, and provide analgesics and antibiotics. o Otitis media is the most common infection for which antibacterials are prescribed in pediatric patients. In patients younger than age 3, signs and symptoms include irritability, fever, night waking, poor feeding, balance problems, ear pain, and rubbing or pulling the ears. In older patients, effects include ear pain, hearing loss, ear popping or fullness, and dizziness. Expect to treat otitis media with antipyretics, analgesics, topical anesthetic otic solutions, and either antibacterial agents or observation. o Otitis interna (labyrinthitis) usually results from a viral infection but may have other causes. It produces severe vertigo, nystagmus, dizziness, nausea, vomiting, hearing loss, and tinnitus. Treatment requires bed rest, meclizine (Antivert), antiemetics, fluid, and antibiotics. Mastoiditis (mastoid process inflammation) usually results from untreated acute otitis media. Manifestations include pain in the ear and mastoid area; fever; red, bulging tympanic membrane; red, swollen, tender mastoid area; displaced auricle; and history of otitis media. The patient requires hospitalization for 24 to 38 hours of intravenous antibiotics followed by referral to an ear, nose, and throat specialist. Ruptured tympanic membrane usually results from a bacterial infection but may have other causes. Its signs and symptoms include pain, bloody or purulent ear drainage, hearing loss, vertigo, fever, and a slit-shaped or irregular tympanic membrane on otoscopic examination. Management includes antibiotics, analgesics, and antipyretics. Drainage requires gentle suctioning—not irrigation. Most cases of ruptured tympanic membranes heal spontaneously. A foreign body in the ear is most likely to be cerumen and to affect patients younger than age 5. It may cause earache; purulent, foul-smelling ear drainage; decreased hearing; and a sense of fullness in the ear. Irrigation usually is best for removing impacted cerumen but should not be used for vegetables or other soft materials. Mineral oil or 2% lidocaine (Xylocaine) is used to kill live insects for removal.

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.

LESSON OUTLINE Nasal Emergencies •





Rhinitis (nasal mucosa inflammation) is characterized by edema of the nasal membranes, vasodilation, discharge, and obstruction. Common effects include nasal congestion, runny nose, sneezing, headache, watery or itchy eyes, throat irritation, malaise, mild fever, and a decreased sense of smell. Management includes antihistamines, nasal corticosteroids, leukotriene modifiers, analgesics, and antipyretics. To prevent rebound nasal congestion, the patient should take nasal decongestants for 2 to 3 days only. Epistaxis (nosebleed) may originate in the anterior or posterior nose. Anterior bleeding is usually acute and comes from Kiesselbach plexus. Posterior bleeding is usually chronic, tends to be more profuse, and commonly affects older patients with hypertension. While observing universal precautions, help the patient sit upright, tilt the head down, and pinch the nares. Once the bleeding site is identified, provide treatment for anterior epistaxis, including topical vasoconstrictors, direct pressure for 5 to 10 minutes, chemical or electrical cautery, or packing (if needed). For posterior epistaxis, insert a posterior nasal pack, if possible, monitor for respiratory obstruction, and give antihypertensives as ordered. A foreign body in the nose usually affects pediatric patients and is discovered when a unilateral, purulent nasal discharge occurs. Other signs and symptoms may include nasal pain and fullness, foulsmelling discharge, epistaxis, sinus pain, fever, and edematous nasal mucosa. Nasal positive-pressure techniques are used first to try to remove the foreign body. If these do not work, a topical anesthetic and vasoconstrictor may be instilled and the object removed with a hooked probe or forceps.

Throat Emergencies •

• •



Pharyngitis (pharynx inflammation) is usually viral, benign, and self-limiting. Signs and symptoms include a bright red throat, swollen tonsils, white or yellow exudate on the tonsils and pharynx, swollen uvula, and enlarged tender cervical and tonsillar nodes. For bacterial pharyngitis, treatment consists of antibiotics, antipyretics, and analgesics, and possibly tonsillectomy. Laryngitis (vocal cord inflammation) may accompany an upper respiratory infection or can occur alone. It may cause voice loss, upper respiratory effects, and dyspnea or stridor. Treatment includes voice rest, steam inhalation, increased fluid intake, and topical anesthetic throat lozenges. Tonsillitis (palatine tonsil inflammation) usually results from a streptococcal infection. Signs and symptoms include a sensation of fullness in the throat, ear pain, jaw or throat tenderness, difficulty speaking or swallowing, white or yellow exudate on the tonsils, and foul breath. Warm saline gargles, topical anesthetic lozenges, analgesics, antipyretics, and antibiotics are indicated. Peritonsillar abscess can result from untreated suppurative tonsillitis. The abscess is unilateral and causes dysphagia, drooling, muffled voice, painful swallowing, trismus, anxiety, fever, malaise, and dehydration. Treatment may require fluids, antipyretics, analgesics, needle aspiration (or surgical incision and drainage), antibiotics, and referral to an eye, ear, and nose specialist.

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.

LESSON OUTLINE Facial Emergencies •



Sinusitis (mucous membrane inflammation in the paranasal sinuses) usually results from an upper respiratory infection or allergic rhinitis. It causes dull, achy pain and tenderness on palpation over the sinus, fever, anorexia, nausea, edematous mucosa, purulent nasal discharge, and reduced transillumination. Nasal decongestant sprays may provide immediate relief but should not be used for more than 3 days. Other treatments include isotonic saline nose drops, increased fluid intake, warm compresses, antibiotics, analgesics, and referral to an ear, nose, and throat specialist. Temporomandibular joint dislocation usually results from opening the mouth too wide, such as when yawning or laughing. The patient reports pain due to muscle spasms and displays chin protrusion, open mouth, and drooling. Treatment is reduction, muscle relaxants, nonsteroidal anti-inflammatory drugs, and a soft diet for 3 to 4 days.

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.

PRECEPTOR EXERCISES Discuss the following questions with your preceptor:

Managing Dental Emergencies 1. What equipment and supplies are available in our department for avulsed teeth or other dental emergencies?

2. What referral resources are available for patients without access to primary dental care?

Ear Irrigation 1. Is ear irrigation a nursing procedure in our department?

2. If so, what is the procedure?

Nasal Packing 1. What devices are used for posterior nasal packing in our department?

2. Is an electrical cautery device available in our department? If so, where is it located and how do I obtain it?

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.

NOTES

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.

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