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학습 자료 둘러보기 →| Assessment Finding | Pathophysiological Basis | Priority Level |
|---|---|---|
| Signs of respiratory distress and stridor | Direct mechanical obstruction of the upper airway by the expanding pseudomembrane. This is an immediate threat to life [2]. | Highest Priority (Airway) |
| Presence of petechial rash on extremities | Not a typical feature of diphtheria. This is more commonly associated with meningococcemia or other bacterial infections. | Low Priority |
| Complaints of abdominal pain and nausea | Non-specific symptoms that do not represent the most immediate, life-threatening complication of diphtheria. | Low Priority |
| Changes in urinary output and color | Could indicate renal impairment, a late and less common toxin-mediated complication. This does not take precedence over airway management. | Low Priority |
The primary danger in respiratory diphtheria is mechanical upper airway obstruction from the expanding pseudomembrane. Monitor continuously for stridor, a high-pitched inspiratory sound indicating a narrowed airway.
Assess for signs of increased work of breathing: tachypnea, use of accessory muscles (sternal/suprasternal retractions), and nasal flaring. A change in voice or a brassy cough may signal laryngeal involvement.
Do not attempt to remove the pseudomembrane; it is tightly adhered and manipulation can cause bleeding and worsen obstruction. Prepare for emergency airway management and notify the provider immediately if stridor or distress develops.
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