15.6 Sinusitis

The term sinusitis, also known as a sinus infection, refers to inflammation of the sinuses. Acute sinusitis means symptoms last 4 weeks or less, and chronic sinusitis lasts 12 weeks or more. Recurrent sinusitis refers to four or more episodes of sinusitis with each episode lasting four weeks or less. The focus of this section will be acute sinusitis.

Acute sinusitis can be caused by viruses, bacteria, or fungi, with viral causes being the most common. Acute bacterial sinusitis is often preceded by a URI. Other risk factors for sinusitis are a deficient immune system, exposure to cigarette smoke, or defects in nasal anatomy (deviated septum or the presence of tumors or polyps in the nose).^[1],[2]

Pathophysiology

The purpose of healthy sinuses is to move any foreign antigens, dust, or pollutants to the nose and throat so they can be swallowed. This is done with the help of cilia (small, hair-like protrusions that move debris). Sinusitis occurs when the sinuses cannot rid the area of pathogens, which leads to inflammation. This often occurs due to edema in these areas as a result of a URI. This edema prevents pathogen clearance, and the infectious agent then begins to multiply in the sinus cavities.^[3] See Figure 15.3^[4] for an illustration of the sinus cavities.

Assessment (Recognizing Cues)

Physical Exam

The cardinal signs and symptoms of sinusitis are purulent nasal discharge, nasal congestion, and facial pain or pressure. Nasal discharge is typically thick and yellow or green in color. Other associated symptoms are cough or fatigue, changes in sense of smell (decreased or no sense of smell), pain in the teeth, fullness in the ear, headache, bad breath, or fever.

Complications can occur when sinusitis spreads to nearby areas, such as the brain or orbit of the eye. Orbital spread can lead to cellulitis or abscess formation. Spread to the brain can lead to hematoma, abscess formation, or inflammation of the meninges.

A diagnosis of acute sinusitis is often a clinical diagnosis that can be made with the presence of two major symptoms or one major symptom plus two or more lesser symptoms. Major symptoms refer to purulent nasal discharge, nasal congestion, facial pain, changes in smell, and fever. Minor symptoms consist of headache, ear fullness/pain, bad breath, pain in the teeth, a cough, fever, and fatigue. Children with bacterial sinusitis often have a fever as well.

To guide appropriate treatment with antibiotics, it is important to distinguish between bacterial and viral causes of sinusitis. With a bacterial cause of sinusitis, symptoms are usually present for greater than ten days, or they initially improve and then worsen. This initial improvement with subsequent worsening of symptoms is known as double worsening.^[5],[6] Antibiotics are not indicated for viral sinusitis because antibiotics are only effective against bacterial infections.

Common Laboratory and Diagnostic Tests

Laboratory tests are not routinely performed for acute sinusitis, but inflammatory markers such as ESR and CRP may be elevated with bacterial causes. Imaging or cultures are not routinely done unless there is a concern for a complication or the sinusitis is chronic or resistant to treatment.^[7],[8]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with acute sinusitis include symptom management and preventing complications from occurring.

Nursing diagnoses for clients with acute sinusitis are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment.

Possible nursing diagnoses for clients with acute sinusitis are as follows^[9]:

• Acute pain r/t disease process
• Impaired breathing pattern r/t nasal congestion
• Risk for impaired skin integrity r/t continual nasal discharge
• Fatigue r/t disease process

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, achievable, realistic, and timebound (SMART) with a set time frame based on the application of appropriate nursing interventions.

Sample expected outcomes for the suggested nursing diagnoses are listed below:

• The client will exhibit a reduction in pain within one hour based on a numeric scale such as FACES or FLACC.
• The client will demonstrate the ability to breathe through their nose within 24 hours.
• The client will exhibit non-reddened, intact skin surrounding the nose within 24 hours.
• The client will display an increase in energy and engage in age-appropriate play within 48 hours.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Treatment for acute bacterial sinusitis consists of antibiotic therapy. First-line treatment recommended by the American Academy of Pediatrics is amoxicillin or amoxicillin with clavulanate. Supportive care is encouraged for clients with acute bacterial or viral sinusitis. Nasal sprays containing steroids or saline can help relieve congestion, acetaminophen or ibuprofen can be used to manage pain, and warm compresses can help reduce sinus pressure.

Clients are referred to an otolaryngologist if a complication is suspected or if initial treatment is ineffective.^[10],[11]

Nursing Interventions

Registered nurses plan interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client.

When caring for a client with acute sinusitis, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching, as described in the following subsections.^[12]

Nursing Assessments

• Assess the color, consistency, and frequency of nasal secretions to determine if improvement is occurring.
• Assess the client’s pain using a number scale, FACES or FLACC, as a decrease in pain could indicate improvement in their condition.
• Assess the condition of the skin around the client’s nose, as excessive nasal discharge can lead to skin irritation and breakdown.
• Monitor the client for changes in neurological status, as this could indicate spread of the infection to the brain.

Nursing Actions

• Encourage the client to sit upright, as this can improve nasal drainage and breathing. Using extra pillows while sleeping can also reduce congestion and improve the quality of sleep.
• Encourage application of warm compresses to manage facial pressure.
• Encourage increased fluid intake to help thin secretions, if not contraindicated.
• Encourage the application of petroleum jelly or a moisturizing cream around the nose to protect the skin from excessive nasal secretions.

Client Teaching

• Educate the client and their caregivers on the reason antibiotics are not effective for viral sinusitis.
• Teach the client and their caregivers about over-the-counter medications (Tylenol, ibuprofen, saline nasal sprays) that can be administered for symptom relief.
• Provide education on antibiotics or steroid nasal sprays if prescribed, including that antibiotics should be completed in their entirety to prevent the development of antibiotic resistance.
• Teach clients and their caregivers about respiratory etiquette and effective handwashing to prevent the spread of disease.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.