Epiglottitis is a potentially life-threatening condition characterized by inflammation and swelling of the epiglottis, which can rapidly lead to airway obstruction. This nursing diagnosis focuses on identifying symptoms, managing the acute airway emergency, and preventing complications.
Causes (Related to)
Epiglottitis can develop due to various factors that contribute to its severity and progression:
- Bacterial infection (most commonly Haemophilus influenzae type b)
- Viral infections
- Medical conditions such as:
- Burns or trauma to the throat
- Allergic reactions
- Autoimmune disorders
- Risk factors including:
- Young age (typically 2-7 years old)
- Unvaccinated status
- Compromised immune system
- Recent upper respiratory infection
Signs and Symptoms (As evidenced by)
Epiglottitis presents with distinctive signs and symptoms that require immediate recognition and intervention.
Subjective: (Patient reports)
- Severe sore throat
- Difficulty and pain when swallowing
- Voice changes
- Drooling
- Preference for sitting upright and leaning forward
- Anxiety and restlessness
- A feeling of throat tightness
Objective: (Nurse assesses)
- Tripod positioning
- Muffled or “hot potato” voice
- Stridor
- Tachypnea
- Tachycardia
- Fever (usually >38.5°C/101.3°F)
- Cyanosis (in severe cases)
- Drooling
- Respiratory distress
Expected Outcomes
The following outcomes indicate successful management of epiglottitis:
- The patient will maintain a patent airway
- The patient will demonstrate normal vital signs
- The patient will show improved respiratory status
- The patient will remain free from complications
- The patient will demonstrate an understanding of prevention measures
- The patient will recover without sequelae
- The patient will maintain adequate hydration and nutrition
Nursing Assessment
Monitor Airway Status
- Assess breathing patterns
- Monitor for stridor
- Observe positioning
- Note voice changes
- Check oxygen saturation
Evaluate Vital Signs
- Monitor respiratory rate
- Check heart rate
- Measure temperature
- Assess blood pressure
- Monitor oxygen levels
Assess Hydration Status
- Check oral mucosa
- Monitor fluid intake
- Assess skin turgor
- Monitor urine output
- Note the presence of drooling
Monitor for Complications
- Watch for signs of airway obstruction
- Assess for respiratory failure
- Monitor for sepsis
- Check for aspiration
- Observe for anxiety
Review Risk Factors
- Check vaccination history
- Assess immune status
- Review medical history
- Document recent illnesses
- Note age-related risks
Nursing Care Plans
Nursing Care Plan 1: Ineffective Breathing Pattern
Nursing Diagnosis Statement:
Ineffective Breathing Pattern related to airway inflammation and edema as evidenced by tachypnea, stridor, and use of accessory muscles.
Related Factors:
- Inflammation of epiglottis
- Airway edema
- Anxiety
- Respiratory distress
Nursing Interventions and Rationales:
- Position the patient upright and leaning forward
Rationale: Maximizes airway patency and reduces work of breathing - Monitor respiratory status continuously
Rationale: Allows early detection of deterioration - Prepare for emergency intubation
Rationale: Ensures immediate response to airway compromise
Desired Outcomes:
- The patient will maintain a patent airway
- The patient will demonstrate an improved breathing pattern
- The patient will maintain oxygen saturation >95%
Nursing Care Plan 2: Hyperthermia
Nursing Diagnosis Statement:
Hyperthermia related to inflammatory response to infection as evidenced by elevated temperature and warm, flushed skin.
Related Factors:
- Bacterial infection
- Inflammatory response
- Increased metabolic rate
- Dehydration
Nursing Interventions and Rationales:
- Monitor temperature frequently
Rationale: Allows tracking of disease progression and treatment response - Administer antipyretics as ordered
Rationale: Helps reduce fever and associated discomfort - Provide cooling measures as appropriate
Rationale: Assists in temperature regulation
Desired Outcomes:
- The patient will maintain a normal temperature
- The patient will show reduced signs of infection
- The patient will remain comfortable
Nursing Care Plan 3: Risk for Deficient Fluid Volume
Nursing Diagnosis Statement:
Risk for Deficient Fluid Volume related to decreased oral intake and increased fluid loss as evidenced by decreased fluid intake and excessive drooling.
Related Factors:
- Difficulty swallowing
- Excessive drooling
- Fever
- Decreased oral intake
Nursing Interventions and Rationales:
- Monitor intake and output strictly
Rationale: Ensures early detection of fluid imbalance - Assess for signs of dehydration
Rationale: Allows prompt intervention - Maintain IV access and fluids as ordered
Rationale: Ensures adequate hydration when oral intake is compromised
Desired Outcomes:
- The patient will maintain adequate hydration
- The patient will demonstrate normal fluid balance
- The patient will show improved swallowing ability
Nursing Care Plan 4: Anxiety
Nursing Diagnosis Statement:
Anxiety related to acute respiratory distress as evidenced by restlessness, increased heart rate, and verbalized fear.
Related Factors:
- Difficulty breathing
- Fear of suffocation
- Unfamiliar environment
- Separation from family
Nursing Interventions and Rationales:
- Maintain calm environment
Rationale: Reduces anxiety and work of breathing - Provide clear, age-appropriate explanations
Rationale: Increases understanding and cooperation - Allow family presence when appropriate
Rationale: Provides emotional support and comfort
Desired Outcomes:
- The patient will demonstrate decreased anxiety
- The patient will maintain an optimal breathing pattern
- Patient will show an improved comfort level
Nursing Care Plan 5: Risk for Infection Transmission
Nursing Diagnosis Statement:
Risk for Infection Transmission related to bacterial infection as evidenced by the presence of infectious organisms.
Related Factors:
- Presence of infectious agent
- Close contact with others
- Limited knowledge of prevention measures
- Compromised immune status
Nursing Interventions and Rationales:
- Implement appropriate isolation precautions
Rationale: Prevents spread of infection - Educate family about infection control
Rationale: Ensures consistent prevention measures - Monitor close contacts for symptoms
Rationale: Allows early intervention if needed
Desired Outcomes:
- The patient will remain free from secondary infections
- Contact individuals will remain uninfected
- The family will demonstrate an understanding of prevention measures
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Baiu I, Melendez E. Epiglottitis. JAMA. 2019 May 21;321(19):1946. doi: 10.1001/jama.2019.3468. PMID: 31112260.
- Booth, A. W., Pungsornruk, K., Llewellyn, S., Sturgess, D., & Vidhani, K. (2024). Airway management of adult epiglottitis: A systematic review and meta-analysis. BJA Open, 9, 100250. https://doi.org/10.1016/j.bjao.2023.100250
- Dowdy RAE, Cornelius BW. Medical Management of Epiglottitis. Anesth Prog. 2020 Jun 1;67(2):90-97. doi: 10.2344/anpr-66-04-08. PMID: 32633776; PMCID: PMC7342809.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
