chapter 22 upper respiratory disorder

8/3/2019 Chapter 22 Upper Respiratory Disorder

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Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Management of Patients

With

Upper RespiratoryTract Disorders




Nursing Care of Patients withUpper Airway Disorders

• Upper airway disorders may be minor,treated outside health care setting

– Or may be severe, life threatening

• Require good assessment skills,

understanding of variety of disorders thataffect upper airway, impact those disordersmay have on patient

• Patient teaching is important aspect of care




Specific Disorders

• Rhinitis

• Sinusitis: acute, chronic

• Pharyngitis: acute, chronic

• Tonsillitis, adenoiditis

• Peritonisillar abscess

• Laryngitis




Rhinitis

andSinusitis




RHINITIS characterized by inflammation

and irritation of the mucus membranes of the

nose

TYPES:

1. ACUTE OR CHRONIC - duration

2. NON-ALLERGIC OR ALLERGIC – causative

3. VIRAL OR BACTERIAL


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CAUSATIVE:• CHANGES IN TEMPERATURE / HUMIDITY

• EXPOSURE TO ALLERGENS

• OTC, ANTI HPN, ANTI LIPID, ANTI DEPRESSANT

DRUGS

• SYSTEMIC DISEASES



CLINICAL MANIFESTATION:

• RHINORRHEA

• NASAL CONGESTION

• NASAL DISCHARGE

• SNEEZING

• PRURITUS OF THE NOSE

• HEADACHE



RHINOSINUSITIS

• inflammation of the paranasal sinuses and nasal cavity

• ACUTE RECURRENT CHRONIC: ABRS or AVRS



UNRESOLVE VIRAL OR BACTERIAL RHINITIS

BLOCK NORMAL FLOW OF SINUS SECRETIONS

CONTINUOUS EXPOSURE ENVIRONMENTAL HAZARDS

STEPTOCOCCUS PNEUMONIAE HAEMOPHILUS INFLUENZAE

STAPHYLOCCOCUS AUREUS

MORAXELLA CATARRHALIS

CHLAMYDIA PNEUMONIAE STREPTOCOCCUS PYROGENES

VIRUSES AND FUNGI



ACTIVATION OF IMMUNE RESPONSE

VASCULAR CHANGES

VasodilationCapillary permeability

Tissue congestion

CELLULAR CHANGES

Phagocytic immune responseHumoral immune responseCellular immune response

NASAL DRAINAGE = NASAL OBSTRUCTION FACIAL PAIN-PRESSURE-FULLNESS



ABRS –

10 days ormore

AVRS – less than10 days

RECURRENT CHRONIC = 12

weeks or longer




• PERIORBITAL EDEMA

• SORE THROAT

• ADENOIDAL HYPERTHROPHY• FATIGUE

• DECREASE IN SMELL AND TASTE

• SENSE OF FULLNESS IN THE EAR EAR PAIN




DIAGNOSIS:•HEALTH HISTORY

•PHYSICAL ASSESSMENT•IMAGING STUDIES: XRAY,SINOSCOPY OR NASAL

ENDOSCOPY, ULTRASOUND, CTOR MRI

• DRAINAGE ASPIRATE – C/S




HEALTH HISTORY• RISK FACTORS

SMOKING

PERSONAL/FAMILY HISTORY

OCCUPATIONAL EXPOSURE

ALLERGEN AND ENVIRONMENTAL POLLUTANTS

HEALTH PERCEPTION/PRACTICES

AGE & DEVELOPMENT

PAST HEALTH HISTORY

COUGH




COUGH

ONSET Sudden or gradual, how long ago

NATURE Dry, moist, barking, hacking,productive, non-productive

PATTERNContinuous, occasional, related totime of the day, position or activity,weather

ASSOCIATED

SYMPTOMSPain, shortness of breath, wheezing

ALLEVIATINGFACTORS

Vaporizers, OTC medications

SPUTUM




SPUTUM

AMOUNT Scanty, moderate, or copious

COLOR

Normal – clear sputumMucoid – tracheobronchitis or asthmaYellow/Green – bacterial infectionRusty or blood tinged – pneumonia or TBBlack – Chronic lung diseases

Pink – pulmonary edema

CHARACTERS

Watery – thin usually clearViscous – very thick, firm, and staystogetherSemi-liquid (N) – thicker than watery

sputum but not as thick as viscous sputumFrothy sputum – foam-like and containsmany small air bubbles

ODOR Normal sputum has little or no odorAbnormal sputum may have sweaty smell or

foul and offensive smell

SHORTNESS OF BREATH




SHORTNESS OF BREATH

ONSET

Sudden or gradual, how long ago

NATUREPrecipitating factorDescription of respiration effort

PATTERN Associated with activity or positionContinuous or intermittent

ASSOCIATEDSYMPTOMS

Pain, cough, diaphoresis

ALLEVIATINGFACTORS

Positioning and home remedies

PAIN




PAIN

ONSET Sudden or gradual, how long ago

NATURE Stabbing, burning, squeezing,crushing

PATTERNLocation and radiationActivity, pain, variable

ASSOCIATED

SYMPTOMS

Dizziness, nausea, diaphoresis or

palpitations

ALLEVIATING and AGGRAVATING FACTORS

Massage, Rest, OTC medications, Environment,warm/cold temperature




PHYSICAL ASSESSMENT

• ERYTHEMA, PALLOR, ATROPHY, EDEMA, CRUSTING,DISCHARGE, POLYPS, EROSIONS AND SEPTAL

PERFORATION OR DEVIATION

• CERVIAL NODE ADENOPATHY AND SINUS TENDERNESS– percussion

• TRANSILLUMINATION




INCREASE ILLUMINATION = SINUS FILLED WITH AIR

DECREASE ILLUMINATION = SINUS FILLED WITH FLUID




MANAGEMENT

• SALINE LAVAGE/STEAM INHALATION

• ANTIBACTERIAL / ANTIVIRAL

• DECONGESTANT

• ANTI HISTAMINE

• CORTICOSTEROIDS

(BUDESONIDES/BECLOMETHASONE)

• MUCOLYTIC, EXPECTORANT AND ANTITUSSIVE

• CORRECTIVE SURGICAL REPAIR




NURSING DIAGNOSIS

• INEFFECTIVE AIRWAY CLEARANCE – inability toclear secretions or obstructions from therespiratory tract to maintain clear airway

• INEFFECTIVE BREATHING PATTERN –

inspiration and expiration that does not provideadequate ventilation

• IMPAIRED GAS EXCHANGE – excess or deficitin oxygenation and/or carbon dioxideelimination at the alveolar capillary membrane

• ACTIVITY INTOLERANCE – insufficientphysiological or psychological energy to endure

or complete required or desired daily activities




CORRELATED NURSING DIAGNOSIS

• ANXIETY

• FATIGUE

• FEAR

• POWERLESSNESS

• INSOMNIA

• SOCIAL ISOLATION




PLANNING

• MAINTAIN PATENT AIRWAY• IMPROVE COMFORT AND EASE OF BREATHING

• MAINTAIN AND IMPROVE PULMONARY

VENTILATION AND OXYGENATION• IMPROVE ABILITY TO PARTICIPATE IN

PHYSICAL ACTIVITIES

• PREVENT RISK ASSOCIATED WITHOXYGENATION PROBLEMS SUCH AS SKIN ANDTISSUE BREAKDOWN, SYNCOPE, ACID – BASEIMBALANCES AND FEELINGS OF

HOPELESSNESS AND SOCIAL ISOLATIONS




NURSING INTERVENTION

FOR CLIENTWITHPULMONARY PROBLEM




INTERVENTIONIncludes:

1. Positioning the client to allow maximum chest expansion.

2. Encouraging and providing frequent changes in position.

3. Encouraging ambulation

4. Implementing measures that promote comfort

• Encouraging deep breathing and coughing

• Ensuring adequate hydration

• Health teaching




Achieve efficient and controlled ventilation > breathingretraining Good gas exchange Prevent exhaustion

Prevent atelectasis and other respiratory complications




• Pursed lip + abdominal breathing

– Improves ventilation

– Releases trapped air in the lungs

– Keeps the airways open longer and decreases the work of breathing

– Prolongs exhalation to slow the breathing rate

– Improves breathing patterns by moving old air out of the lungsand allowing for new air to enter the lungs

– Relieves shortness of breath

– Causes general relaxation




Breathing Into a Paper Bag

help to control carbon dioxide levels in your bloodstream.

Relieve Hiccups, Stop Hyperventilating and Retinal ArteryOcclusion




HYDRATION

• maintain the moisture of the respiratorymucous membrane

– HUMIDIFIERS device that add

water vapor to inspired air

loosen secretions

– NEBULIZERS used to deliver

humidity and medications loosen secretions

– FLUID THERAPY




Humidifier




Therapeutic MeasuresPromote Respiratory Function

• Chest PT

• Incentive spirometry

• Postural drainage

• Medications

• Oxygen therapy

• Artificial airways

• Airway suctioning

• Chest tubes




PERCUSSION AND VIBRATION




Chest Physiotherapy




HFCWO

(High-Frequency Chest Wall Oscillation)




Incentive Spirometry




POSTURAL DRAINAGE

• Postural drainage is drainage by gravity of secretion from various lung segment.




MEDICATIONS• different route can be used > respiratory and intravenous

• ACTIONS: bronchodilation = decreasing resistance inthe respiratory airway + increasing airflow to the lung >better oxygenation

• Short-acting β2-agonists ex: Salbutamol

• Long-acting β2-agonists ex:Salmeterol & Formoterol




BRONCHODILATORS adrenergic, anticholinergic and

methylxanthines

• ADRENERGIC – action like epinephrine

• ANTICHOLINERGICS – long-term COPD ex:ipratropium bromide.

• METHYLXANTHINES – ex: aminophylline andtheophylline

CORTICOSTEROIDS anti-inflammatory properties >steroids (inhibits the synthesis of protein)

Expected Expected




Receptor PrimaryLocation

Effect if Stimulat

ed

Effect if Blocked

Beta 1 Heart

Increase in HR,Conduction Speed

andContractility

Decrease in HR,Conduction Speed

andContractility

Beta 2 Lungs

Broncho-dilatation

Broncho-constriction

Alpha 1

Blood

Vessels

Vasoconstriction Vasodilatation




Medication α Affects β 1 Affects β 2 Affects

Epinephrine

+++ ++ ++

Nor-epinephrine +++ + 0

NEBULIZATION




NEBULIZATION

• solutions/suspensions

intosmall aerosol dropletsthat can be directlyinhaled

• inhaled aerosoldroplets can onlypenetrate into thenarrow branches of thelower airways if theyhave a small diameterof 1-5 micrometers




OXYGEN THERAPY – administration of oxygen at

a concentration greater than that found in theatmosphere

Factors in Transport of O2:

– Cardiac output

– Arterial oxygen content

– Concentration of hemoglobin

– Metabolic requirement




• Often used to treat hypoxia (hypoxemic,circulatory, anemic or histotoxic)

• It is prescribed by the physician who specifiedthe concentration, methods of delivery, andliter flow per minute.

• Patient with COPD require low oxygen

concentration (hypoxic drive)

Oxygen Therapy




SAFETY PRECAUTIONS:

• Avoid smoking or place sign “No Smoking: Oxygen in Use”

• Make sure electric devices are in good working order toprevent short circuit sparks

• Avoid materials that generate static electricity such as

woolen blanket & synthetic fabrics. Cotton blankets andfabrics are advised

• Avoid use of volatile, flammable materials (alcohol,acetone)

• Make know the location of fire extinguisher• Check the level of portable tanks before transporting to

ensure there is enough oxygen in the tank




1. Source of oxygen supply

a. Oxygen tankb. Wall oxygen outlet

2. Flow metera. Mercury ballb. Gauge flow meter

3. Humidifier

4. Delivery system e.g. cannula




Oxygen Therapy




yg py

Oxygen Therapy




Oxygen Therapy

• It is the most commoninexpensive device

• It is easy to apply anddoes not interfere with

clients ability to talk oreat.

• It is more comfortablebecause it permits

freedom of movement• It delivers about 24-

45% O2 at flow rate of 2-6 L/min

Nasal Cannula

Simple Face Mask




Simple Face Mask

• Delivers oxygenconcentration fromfrom 40-60% at literflow to a 5-8L/min

• Used whenincreased O2 deliveryis needed for shortperiod




Partial Rebreather mask

• Delivers oxygen

concentration of 60-90% at liters flow of 6-10 L/min

• Reservoir bag allowsthe client to re-breath exhaled air inconjunction withoxygen

• poor fitting andwarm

Non-Rebreather mask




Non-Rebreather mask

• It delivers the highestconcentration of oxygen as possible bymeans other thanmechanical ventilatoror intubation, at litersflow of 10-15 L/min

DIFFERENCE




DIFFERENCE

• Rebreather maskhas a soft plasticreservoir bag attachedat the end that saves

one-third of a person'sexhaled air, while therest of the air gets outvia side ports coveredwith a one-way valve.

• Non-rebreather hasseveral one-way valvesin the side ports. Thistype of mask also has

a reservoir bagattached, but the baghas a one-way valvethat prevents theexhaled carbon dioxidefrom getting into thereservoir.

Venturi mask




Venturi mask

• Delivers oxygenconcentrationprecisely (Fi02)

• used for pts who

are with COPD – appropriate level

• high airflow withcontrolled oxygen

level excess gasleaves throughexhalation port




• Type 1 Respiratory

Failure is low paO2(< 55mmHg) and anormal paCO2(40mmHg)

• hypoxia withouthypercapnia Hypoxemic respiratory failure

• ventilation-perfusion(V/Q) mismatch

• Type 2 Respiratory

Failure is variablepaO2 and a highpaCO2 (>50mmHg)

• build up of carbondioxide Hypercapnic respiratory failure

• neuromuscular

disorders and CNSdepression = bothoxygen and carbondioxide are affected




T-PIECE




T-PIECE

• 8 – 10 L/min (30 -100 FiO2)

• heavy tubing,requires strictchanging 3 days toprevent VAP

• same withtracheostomy collar




TRANSTRACHEAL OXYGENCATHETER directly to the trachea forclient with chronic oxygen therapy need




Transtracheal catheter

Jet ventilation tubing with flow

regulator.




Aerosol mask




Aerosol mask

• 8-10 L/min (30-100% ) havingbetter humidity

FACE TENT




FACE TENT

• 8 -10 L/min (30-

100% FiO2) > goodhumidity and fairlyaccurate O2 delivery

• advantage to be used

for patients with facialtrauma or burns.

• patients are less likely

to feel claustrophobicfor it providescomfort, clear vision,easy for speech




Artificial Airways

• Are inserted to maintain a patent air passage for clientwhose airways has become or may become obstructed.

• It is indicated for client with decrease level of consciousness or airway obstruction and to aid inremoval of tracheobronchial secretion.

• It has four common types:

a. oropharyngeal

b. nasopharyngeal

c. endotracheal

d. tracheostomy




Used for client with alteredLOC. (GA,overdose,headinjury)

It is much easier to insert

Disadvantages:increase oralsecretion, decrease patientcomfort, difficulty withstabilization, inability of patientto communicate.

Tolerated better by alert client.

They are inserted through the naresand terminating in oropharynx.

It is more comfortable to patient

and easier to stabilize. Provide frequent nares and oral

care: reposition the airway in othernares as ordered to preventnecrosis of the mucosa.

Oropharyngeal Airway Nasopharyngeal Airway




The mains risks of its use:

if the person has a gag-reflex they may vomit

when it is too large, it canclose the glottis and thusclose the airway

improper sizing can causebleeding in the airway




• measuring from the middle of the persons

mouth to the angle of the jaw.

• inserted into the persons mouth upside down

– Once contact is made with the back of thethroat, the airway is rotated 180 degrees,allowing for easy insertion, and assuringthat the tongue is secured

– holding the tongue forward with a tonguedepressor and inserting the airway rightside up




NPA or a nasal trumpet




• The correct size airway is chosen by measuring

the device on the patient: the device shouldreach from the patient's nostril to the earlobe orthe angle of the jaw

• outside of the tube lubricated with a water-

based lubricant

• until the flared end rests against the nostril contraindicated in patients with severe head orfacial injuries basilar skull fracture




• c. Nasopharyngeal Insertion Procedures.

(1) Place pt on a firm surface in the supine position with the

cervical spine stabilized.

(2) Lubricate the NPA with a water-soluble lubricant

(3)Push the tip of the patient's nose slightly upward to exposethe opening in the nostril.

(4)Keeping the head neutral position, insert the tip of the

NPA through the nostril.




• (5) Slowly advance tube along floor of nasal cavity with

bevel pointing toward septum until flange rest firmly againstcasualty's nostril

(a) If resistance is met during insertion, do not continue to

insert.

(b)Stop, remove the adjunct, relubricate, and try the other nostril.

(c)If resistance is still met, check proper size or use alternate

artificial airway method




Artificial Airways




Endotracheal tube




•Are commonly inserted to client who

have had GA and for those in emergencysituation where mechanical ventilation isrequired.

• It is used as short term artificial airwaysto administer mechanical ventilation,relieved upper airway obstruction, protectagainst aspiration or clear secretion

• It is generally removed after 14 days.

Tracheostomy Tube




y

Tracheostomy Tube




Tracheostomy tube in place

Components of tracheostomytube

Tracheostomy




• Inserted to the trachea via the 2nd or 3rd cartilage ring totally bypasses the upperairways.

• It is indicated for client who require long term

oxygen support, wherein an incision is madein the trachea just below the larynx.

• It may be in form of plastic or metal and areavailable in different sizes.

• Patient requiring MV requires a cuffedTracheostomy tube and those that are awakeand alert requires a cuffless tracheostomy




1 - Vocal folds

2 - Thyroid cartilage

3 - Cricoid cartilage

4 - Tracheal rings

5 - Balloon cuff




Nursing Management for Patient with Artificial

Airways.

• Ensure adequate ventilation and oxygenation through theuse of mechanical ventilator, CPAP.

• Clear airway secretion as needed with suctioning.• Use sterile technique in entering AA.

• Elevate the patient on a semi fowlers or sitting position if possible.

• Change position at least every two hours

External tube site care:




Endotracheal tube – provide frequent oral care

if possible, secure the tube at all times

Tracheostomy tube – stoma should be cleanedonce in a shift and tracheostomy ties

changed once a day Have available at all times at the patient

bedside, resuscitation bag, oxygen source,and mask to ventilate the patient in case of

accidental tube removal.

Provide psychological support to thepatient.

SUCTIONING




• It is aspirating secretion through a catheter connected tosuction machine or wall suction outlet.

• It may be an: A. OPEN TIPPED B.WHISTLE TIPPED




• Purpose includes:

- to remove secretion that obstruct theairway.

- to facilitate ventilation.- to obtain secretion for diagnosticpurposes.

- to prevent infection that may result fromaccumulated secretion.




• WHATINTERVENTIONS

ARE APPLICABLETO OUR CLIENT

WITHRHINOSINUSITIS?




COMPLICATIONS

• MAXILLARY RS MASTICATION PROBLEM

• FRONTAL RS OSTEOMYELITIS OF THEFRONTAL BONE

• ETHMOID RS ORBITAL CELLULITIS INTRACRANIAL INFECTION

• SPHENOID RS VASCULAR COMPLICATION

– Infections that involve either of thesestructures may lead to aneurysms orinfected blood clots in the intracranial cavity




• The frontal,

ethmoid andsphenoid sinusesare separated from

the intracranialcavity by a layer of bone




Pharyngitis – inflammation of throat




RISK FACTORS:

• cold & flu seasons

• close contact w/ someone who has sore throat/cold

• smoking exposure• frequent sinus infection

• allergies, viruses and bacteria

• environmental condition

• voice prompt occupation

• chronic cough

• habitual use of alcohol and tobacco

PATHOPHYSIOLOGY




BACTERIA/VIRUSES

TRIGGERS INFLAMMATORY RESPONSE

RELEASING CHEMICAL MEDIATORS

DILATION OF BLOOD VESSEL CAPILLARY PERMEABILITY WBC/MACROPHAGES

INCREASE BLOOD FLOW PLASMA FLUID PHAGOCYTOSIS

Redness SWELLING PAIN release toxins

increased temperature in the area temperature increase

GAS MYCOPLASMA PNEUMONIAE NEISSERIA GONORRHEA




H. INFLUENZA




• ACUTE

– FIERY-REDpharyngealmembrane andtonsils

– swollen lymphoid

follicles with whitepurplish exudates

– enlarged and tendercervical lymph node

– no cough

– fever, malaise, sorethroat

• CHRONIC

– General thickening andcongestion of thepharyngeal mucousmembrane HYPERTHROPIC

– swollen lymphoid follicleson the pharyngeal wall CHRONIC GRANULAR

“ clergyman’s sore throat”

– Irritation or fullness in thethroat

– with cough

– difficulty swallowing




Question

• Tell whether the following statement is true or false:

• Acute pharyngitis of a bacterial nature is most commonly

caused by group A, beta-hemolytic streptococci.




Answer

• True.

• Rationale: Acute pharyngitis of a bacterial nature is most

commonly caused by group A, beta-hemolyticstreptococci.




Potential Complications

• Sepsis

• Meningitis

• Tonsillitis and Adenoiditis

• Peritonsillar abscess

• Otitis media

• Sinusitis

• TONSILLITIS/ADENOIDITIS




– composed lympathic tissue

– fever, snoring , difficultyswallowing, mouthbreathing, earache, nasalobstruction

– throat culture affirmativediagnosis of the causativeagent + physicalexamination

– Supportive treatment,antibiotic, analgesics, andsurgery




Severe sore throatFever




TrismusDroolingPain

Odynophagia/dysphagiaCervical lymph node enlargement




CLINICAL SYMPTOMS




• Hoarseness of voice

• Dry cough worsen in the evening

• Tickling sensation on the throat

– MANAGEMENT:

• SUPPORTIVE




OBSTRUCTION DURING SLEEP (OSA)

• reduction of ventilation during sleep

– obesity

– male gender

– post-menapausal status

– advanced age

snoring, snorting, gasping, choking, apneic episodes,fatigue4 and hypersomnolence

polysomnographic test

CPAP




Nursing Process: Care of Patients with

Upper Respiratory Infections -Assessment

• Health history

• Signs and symptoms: headache, cough, hoarseness,fever, stuffiness, generalized discomfort and fatigue

• Allergies

• Inspection of nose, neck, throat

– Include palpation of lymph nodes




Question

• What should the nurse palpate when assessing for anupper respiratory tract infection?

A. Neck lymph nodesB. Nasal mucosa

C. Tracheal mucosa

D. All of the above




Answer

• A. Neck lymph nodes

• Rationale: The nurse should palpate the neck lymph

nodes along with the trachea and the frontal andmaxillary sinuses when assessing for an upperrespiratory tract infection. The nurse should inspect thenasal and tracheal mucosa when assessing for an upperrespiratory tract infection.





Upper Respiratory Infections - Diagnosis

• Ineffective airway clearance

• Acute pain

• Impaired verbal communication

• Deficient fluid volume

• Deficit of knowledge related to prevention, treatment,surgical procedure, postoperative care





Upper Respiratory Infections - Planning

• Maintenance of patent airway

• Relief of pain

• Maintenance of effective communication

• Normal hydration

• Knowledge to how to prevent upper airway infections

• Absence of complications




Interventions

• Interventions to maintain patent airway

• Promote comfort

– Analgesics

– Gargles for sore throat

– Use of hot packs for sinus congestion or ice collar toreduce swelling, bleeding post tonsillectomy and

adenoidectomy




Interventions (cont’d)

• Rest

• Refrain from speaking, use alternative communication

• Encourage liquids; 2 to 3 L a day, appropriate foods




Patient Education

• Prevention of upper airway infections

• Emphasize frequent hand washing

• When to contact health care provider

• Need to complete antibiotic treatment regimen

• Annual influenza vaccine for those at risk




Epistaxis

• Hemorrhage from nose

• Risk factors

• Sites of bleeding

– Most common: anterior septum

• Can be serious problem resulting is significant blood lossor airway compromise




Treatment of Epistaxis

• Topical vasoconstrictors

– Adrenaline

– Cocaine

– Phenylephrine

• Packing of nasal cavity or balloon catheter




Control of Epistaxis




Nursing Care of Patients with Epistaxis

• Assessment of bleeding

• Monitor airway, breathing

• Vital signs

• Reduce anxiety

• Patient teaching

– Avoid nasal trauma, nose picking, nose blowing

– Air humidification

– Pressure on nose to stop bleeding; if bleeding doesnot stop in 15 minutes, seek medical attention




Cancer of the Larynx

• Incidence

• Risk factors

• Categories

– Supraglottic: false vocal cords above vocal cords

– Glottic: true vocal cords

– Subglottic: below vocal cords




Symptoms

• Hoarseness

• Persistent cough

• Sore throat or pain, burning in throat

• Lump in neck

• Later symptoms: dysphagia, dyspnea, unilateral nasalobstruction, persistent hoarseness, persistent ulceration,

foul breath

• Generalized symptoms: weight loss, debilitation,lymphadenopathy, radiation of pain to ear




Question

• Tell whether the following statement is true or false:

• An early sign of cancer of the larynx in the glottic are isenlarged cervical nodes.




Answer

• False.

• Rationale: An early sign of cancer of the larynx in theglottic are is affected voice sounds, not enlarged cervicalnodes.




Medical Diagnosis

• Diagnosis made by history, physical exam, laryngoscopicexam, biopsy

• Tumors staged by TMN classification

• CT, MRI, PET to assess tumor extent and stage, todetermine reoccurrence




Medical Treatment

• Radiation therapy

• Chemotherapy

• Surgery

– Partial laryngectomy

– Supraglottic laryngectomy

– Hemilaryngectomy– Total laryngectomy

Changes in Airflow with Total




Changes in Airflow with Total

Laryngectomy

Nursing Process: Care of a Patient with a





Laryngectomy - Assessment

• Health history

• Assess history of alcohol abuse

• Physical assessment

• Nutritional status

• Assess literacy, hearing, visual ability; may impactcommunication

• Assess learning needs

• Assess patient, family coping, support systems






Laryngectomy - Diagnoses

• Deficit knowledge related to surgical procedure,postoperative course

• Anxiety, depression

• Ineffective airway clearance

• Impaired verbal communication

• Imbalanced nutrition

• Disturbed body image

• Self-care deficit




Potential Collaborative Problems• Respiratory distress

• Hemorrhage

• Infections

• Wound breakdown

• Aspiration






Laryngectomy - Planning• Adequate level of knowledge (patient, family)

• Reduction of anxiety

• Maintenance of patent airway

• Effective means of communication

• Attaining optimum hydration, nutrition

• Improved body image, self-esteem• Self-care management

• Absence of complications




Preoperative Teaching• Instruction regarding type of procedure, resultant

changes (changes in speech, permanent loss of speech,changes in airway)

• Include instruction regarding tubes used postoperatively(drainage tubes, feeding tubes), provide generalpreoperative teaching to prevent postoperativecomplications




Preoperative Teaching (cont’d) • Include planning for postoperative communication, long-

term speech rehabilitation

• Utilize collaborative approach

• Include physician, speech therapy, dietary, social work,clinical nurse specialist, others as required




Anxiety and Depression• Allow asking of questions, provide information

• Permit verbalization of feelings

• Interventions to reduce anxiety, promote comfort

• Reassuring manner

• Stay with patient during episodes of anxiety

• Relaxation techniques




Maintaining a Patent Airway• Semi Fowler’s or high Fowler’s position to decrease

edema

• Monitor for signs, symptoms of respiratory distress

• Tracheostomy or laryngectomy tube assessment, care

• Care of stoma

• Suctioning

• Humidification of air

• Patient teaching




Communication• Plan communication preoperatively

• Immediate postoperative communication

– Magic slate

– Communication board

• Speech rehabilitation

TEP Voice Prosthesis




TEP Voice Prosthesis



Potential for Aspiration• Keep HOB elevated during, after tube feedings

• Check gastric residual when administering tube feedings

• When patient begins oral feeding, maintain upright bedposition during, after feedings

• Swallowing maneuvers to prevent aspiration

• Use of thickened liquids

chapter 22 upper respiratory disorder

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