Chapter 26: Concepts of Care for Patients With Noninfectious Upper Respiratory Problems Flashcards
Exam 2 (Dr. Lyons)
nosebleed
epistaxis
oxygen transport to the cells and carbon dioxide transport away from cells through ventilations and diffusion
gas exchange
lower than normal respiratory rate and depth insufficient for gas exchange
hypopnea
thickly crusted oral and nasopharyngeal secretions that can cause an upper airway obstruction aka: mucoid impaction
inspissated secretions
an adult who has had a laryngectomy
laryngectomee
a breathing disruption during sleep that lasts at least 10 sec and occurs a minimum of five times in an hour
obstructive sleep apnea (OSA)
a formal and definitive overnight sleep study with direct observation of the patient while he or she wears a variety of monitoring equipment to evaluate depth of sleep, type of sleep, respiratory effort, oxygen saturation, carbon dioxide exhalation, and muscle movement
polysomnography
surgical reconstruction of the nose
rhinoplasty
The upper respiratory system includes….
nose, sinuses,oropharynx, larynx, and trachea
What kind of issues disrupt airflow and gas exchange for the upper respiratory system?
any issue that blocks any of these passages (nose, sinuses, oropharynx, larynx, and trachea)
What is the primary nursing focus for patients with upper respiratory tract disorders?
is to support gas exchange by maintaining a clear and open airway
How does an upper airway obstruction occur?
when airflow through the nose, mouth, pharynx, or larynx is blocked
Why is early detection crucial when it comes to gas exchange impairment?
can prevent serious complications such as respiratory arrest and death; it can be life-threatening
Common causes of upper airway obstruction can encompass a variety of conditions and incidents, such as what?
tongue swelling resulting from surgery, trauma, or allergic reactions such as angioedema
How do tongue blockages occur?
due to loss of the gag reflex, diminished muscle tone, unconsciousness, or coma
How does laryngeal swelling often occur?
inhalation of smoke, toxins, inflammation, allergic reactions, or anaphylaxis
Some other causes of obstructions
peritonsillar and pharyngeal abscesses, head and neck cancers, and thick secretions
Conditions that may contribute to obstructions
stroke and cerebral edema; trauma or burns to the face, trachea, or larynx; foreign-body aspiration
What can critically impact airway patency and require prompt attention?
Obstructions
A preventable cause of airway obstruction
thickly crusted oral and nasopharyngeal secretions
Who is most at risk for this preventable asphyxiation risk (thickly crusted oral and nasopharyngeal secretions)?
those with altered mental status or consciousness, dehydrated, communication difficulties, ineffective coughing, or who are prone to aspiration
What can be done to prevent this issue (thickly crusted oral and nasopharyngeal secretions)?
provide regular oral care
Airway obstruction demands immediate attention to prevent what?
a partial obstruction from escalating to a complete blockage
What are the symptoms of a partial obstruction?
- sweating
- rapid heartbeat
- anxiety
- elevated blood pressure
What are some diagnostic tools to diagnose a partial obstruction?
- chest or neck xray
- laryngoscopy
- CT scans
What should you monitor for in a patient with a partial obstruction?
signs of hypoxia, hypercarbia, restlessness, increasing anxiety, sternal retractions,”seesaw” chest movements, abnormal breathing, or a sense of impending doom due to difficulty breathing
What equipment should be used for monitoring in patients with partial obstructions?
pulse ox, end-tidal carbon dioxide for continuous gas exchange monitoring
What should be reguarly be check for in patients with partial obstructions?
stridor, cyanosis, changes in the patient’s level of consciousness
To guide appropriate intervention of a airway obstruction what should be determined?
the cause
If the obstruction is due to the tongue falling back or excessive secretions, what are some interventions?
extend the patient’s head and neck and insert a nasal or oral airway; suction to remove any obstructing secretions
What are some interventions for obstructions caused by a foreign body that cannot be manually cleared from the oral cavity?
perform abdominal thrusts
What interventions would you do for an unconscious patient with a known obstruction and palpable pulse?
abdominal thrusts are used instead of chest compressions
What interventions would you do for an unconscious patient with no obstruction is evident?
chest compressions are preferred due to the higher likelihood of cardiac issues over airway obstruction in these cases
What emergency procedures may be necessary to restore gas exchange if the obstruction cannot be quickly resolved?
cricothyroidotomy or a tracheotomy
When an obstruction is not due to a foreign object what intervention may be required?
endotracheal intubation
What can help identify the obstruction’s cause or assist in removing foreign bodies?
laryngoscopy
An emergency procedure that involves making an incision through the cricothyroid membrane between the thyroid and cricoid cartilage?
cricothyroidotomy
What can be used to insert through the incision to keep the airway open until a tracheotomy is performed?
any hollow tube, preferably a tracheostomy tube (this method is used when no other means can secure the airway)
An emergency technique involving inserting a ____ or a very small endotracheal tube directly into the cricoid space to allow airflow.
14-gauge needle
Is done by inserting a tube into the trachea via the nose or mouth
endotracheal intubation
What procedure is done when pharyngeal or laryngeal edema is anticipated to prevent complications from severe swelling?
endotracheal intubation
A surgical procedure typically performed in the operating room with local or general anesthesia, though it can be done at the bedside.
tracheotomy
The use of a local anesthesia for a tracheotomy is when ?
there is a risk of losing the airway during the anesthesia induction
Tracheotomys are reserved for cases where what is not feasible?
intubation with an endotracheal tube
What emergency procedure can be preformed in 2 minutes?
tracheotomy
When might a patient on long-term mechanical ventilation for upper airway obstruction or respiratory failure need a tracheotomy?
after 7 days or more days of continuous endotracheal intubation to prevent laryngeal injury and preserve tissue integrity
What condition can arise from various pathological mechanisms including issues with central nervous system control of ventilation, inadequate circulaions and oxygenation, and airway obstruction?
sleep apnea
is characterized by disruptions in breathing during sleep that last for at least 10 seconds and occurs at least 5 times per hour.
obstructive sleep apnea
:shallow breathing with insufficient airflow for effective gas exchange
hypopnea
Obstructive sleep apnea typically involves what?
hypopnea
Etiology of obstructive sleep apnea
during sleep, the relaxation of head and neck muscles allows the tongue, soft palate, and other throat structures to collapse and obstructthe upper airway, while neural control of chest movement remains unaffected; this obstruction impairs gas exchange, increasing carbon dioxide levels and decreasing blood pH; these changes stimulate neural centers, causing the sleeper to awaken after 10 seconds or more of apnea, correct the obstruction and resume breathing; the cycle can repeat as frequently as every 5 minutes, disrupting sleep and preventing the deep sleep necessary for optimal physiological restoration
Can cause arterial blood oxygen saturation to drop significantly below 80%
apnea episodes
Individuals with what condition often experience chronic daytime sleepiness, difficulty concentrating, morning headaches, and irritability
Obstructive Sleep Apnea (OSA)
What are some long-term consequences of chronic OSA?
a higher risk of hypertension, stroke, cognitive impairments, weight gain, diabetes, and cardiovascular and pulmonary diseases
Disruptions in hormonal energy balance from OSA can lead to what that can adversely impact the patient’s health?
severe metabolic problems
What is the primary cause of OSA?
a blockage of the upper airway by the soft palate or tongue
What some contributing factors (etiology and genetic risk) of OSA?
obesity, a large uvula, a short neck, smoking, enlarged tonsils or adenoids and swelling in the oropharyngeal area
Many patients with what are unaware of their condition?
sleep apnea
What disorder should be expected in adults who experience persistent daytime sleepiness or report feeling tired upon waking, especially if they also snore heavily?
sleep apnea
Sample questions to ask a patient who is at risk for sleep apnea:
- Inquire about daytime drowsiness or episodes of falling asleep during activities such as using a computer, reading, or driving
- ask if the patient has ever been awakened by their own snoring and whether family members have noticed loud snoring
- Inquire about the frequency of nightmares, which can be associated with OSA
- Inquire if family members have observed disturbed breathing patterns during sleep
- Ask of the patient has tried to enhance sleep with OTC sleep aids or increased alcohol consumption
In sever cases of sleep apnea what are some things you should ask your patient in their assessment?
Have you fallen asleep while eating, or any time they sit down?
What is a typical breathing pattern for a patient with sleep apnea?
involves increasingly spaced breaths followed by periods of no breathing, which are then followed by gasping and snorrting as the patient partially awakens to correct the obstruction
What condition does a patient with OSA develop?
GERD
If a patient with OSA frequently experiences “heartburn”, regurgitation, or a burning, choking sensation with coughing upon waking what might they have developed?
GERD
What should be assessed in patient at risk for OSA?
- overall appearance including height and weight (many adult with OSA are overweight)
- examine the jaw, chin, and neck (as OSA is often associated with retracted lower jaw, small chin and a short neck)
- inspect the oral cavity and throat for the size and shape of the pharynx, uvula, and tongue
- check for swelling or enlargement of these structures: tonsils, adenoids, pillars, and soft palate
Chronic OSA is linked to what issues which may not respond well to standard treatments?
cardiovascular issues, particularly hypertension
What should you measure in OSA patients suspected of cardiovascular issues?
blood pressure, heart rate, and rhythm, and use pulse oximetry
If a patient with OSA is being treated for hypertension what should be reviewed?
the medication and dosages used
If hypertension is detected but not previously managed in a patient with OSA, what should you do during their assessment/ office visit?
recheck the blood pressure later in the examination and document any persistent elevations
What are common behaviors in individuals with chronic OSA?
personality changes, depression, general loss of interest in social activities
Who can provide valuable insight into the psychosocial changes of the patient who has OSA?
family members
What are some more questions you can ask your OSA patient during their psychosocial assessment?
Have you had difficulty with memory, concentration, perceived energy levels and abioity to stay focused on tasks while working or studying?
A questionnaire that evaluates perceived sleep quality and daytime sleepiness?
STOP-Bang Questionnaire
If the results of the STOP-Bang questionnaire suggest the presence of OSA, what is the next step a patient may be recommended to followup with?
complete a less invasive home sleep study
What is a home sleep study?
the patient sleeps in their own bed while their respiratory rate, heart rate, chest movement, eye movements, and other muscle activity are electronically monitored.
If the at-home study indicates a sleep apnea issue, the patient is referred to have a what?
a more comprehensive overnight sleep study, known as polysomnography
During what study does the patient get monitored throughout the entire sleep period with a range of equipment to assess sleep depth and type, respiratory effort, oxygen saturation, carbon dioxide levels, and muscle activity?
polysomnography
What types of monitoring techniques are used in a polysomnography test?
EEG, ECG, pulse oximetry, and EMG
The main concern for the patient with moderate-to-severe OSA is what?
poor gas exchange and hypoxia caused by disrupted sleep patterns
Management of OSA depends on the severity of the condition and what?
the patient’s willingness to participate in treatment
What is the main goal in the treatment of OSA?
to reduce airway obstruction and enhance both the depth and duration of restorative sleep
What are some ways to correct OSA and improve gas exchange for mild cases?
changing sleep positions; losing weight
Devices that prevent tongue subluxation may reduce what?
obstruction
How can an oral appliance improve airflow for someone with OSA?
by holding the lower jaw forward
Some devices prevent the tongue from slipping back during sleep, what is a couple drawbacks to these devices?
they may be bulky and uncomfortable; increase risk of oral mucosal damage
CPAP
continuous positive airway pressure
What is the most common nonsurgical therapy treatment for OSA?
CPAP
How does a CPAP work?
it keeps the upper airway open by delivering constant pressure through a nasal-oral facemask, nasal mask, or nasal pillow
Why is it necessary to create a proper seal with a CPAP?
a snug fit for effective treatment
What led to poor adherence with older CPAP machines?
they were noisy and less comfortable
What is different about newer CPAP machines that the old ones?
they are quieter, humidify the air, and often use smaller, more comfortable masks
What can the newer CPAP machines monitor/ do that the older ones could not?
patient data and send the information to the patient’s smartphone or healthcare provider to track treatment effectiveness
What should the patient’s be reminded regarding the usage of CPAP machines?
it is crucial to use it daily for at least 6 hrs to reduce OSA-related health risks
Many patients adjust well over time and report better sleep and improved well-being which does what?
increases adherence although some believe the equipment to be too intrusive
What is vital for therapy success?
patient education
What do sleep apnea clinics provide to patients to help ease concerns and promote adherence?
extensive educational resources
Does medication have any effect on OSA?
has limited effectiveness
What can worsen symptoms of OSA?
sedatives
What do stimulants for daytime wakefulness do to patient’s with OSA?
often causes side effects without improving restorative sleep
What may be considered for patients who cannot tolerate CPAP or for whom it is ineffective?
surgery
Before surgery, what is done to identify the problem causing OSA?
thorough endoscopic exam
Surgical options may what for OSA patients?
vary depending on cause of OSA
Who can benefit from a stimulator implant?
patients with mild-to-moderate OSA
Stimulates the hypoglossal nerve to keep the airway open during sleep
a stimulator implant
* (hypoglossal nerve) 12th cranial nerve, and it controls the muscles that move the tongue
What are some same-day surgical procedures for patients with a mild case of obstructive sleep apnea?
a stimulator implant, tonsillectomy, adenoidectomy, uvulectomy, or septum repair
What are more complex surgeries for patients with obstructive sleep apnea?
uvulopalatopharyngoplasty (UPP); modified uvulopalatopharyngoplasty (modUPP)
Most surgical procedures are done same-day unless what?
there is a risk of bleeding or significant airway swelling
Uvulopalatopharyngoplasty (UPP) and modified uvulopalatopharyngoplasty (modUPP) are more complex surgeries that involve what?
reconstructing the posterior oropharynx and typically requires a hospital stay of 2 or more days, with a recovery period of 3 to 6 wks
Post-surgery care from a UPP or modUPP focuses on what?
maintaining a patent airway, managing pain, and preventing complications
Swelling can lead to airway narrowing after UPP or modUPP surgery so what should be monitored?
respiratory effort and gas exchange using pulse oximetry or end-tidal CO2 measurement
How often and for what should a patient after UPP or modUPP surgery be evaluated for?
every 2 hrs during the 1st 24hrs for signs of obstruction such as increases respiratory effort, stridor, drooling, changes in voice quality, or reduced oxygen saturation
If when monitoring a post-op patient who just underwent UPP or modUPP is having signs of obstruction such as increased respiratory effort, stridor, drooling, changes in voice quality, or reduced oxygen saturation, what should you do?
Notify the Rapid Response Team immediately
Why is it essential to control the pain of a patient who just underwent UPP/ modUPP surgery?
the oropharynx is very sensitive
In the 1st 24hrs after the more complex surgeries for OSA the patient’s pain level is quite high, so what is provided?
intravenous pain medication, with scheduled dosing to provide better relief than the as-needed administration
What meds are avoided post-surgery of a OSA patient? Why?
Aspirin and NSAIDS; to reduce the risk of bleeding
What is the nursing plan for a post-op OSA patient?
regularly examine the surgical site for bleeding and monitor for signs of increased swallowing or belching- which may indicate blood dripping down the throat; watch for signs of infection- such as purulent exudate, foul breath, or red mucous membranes (report any findings immediately); admin prescribed IV meds for pain; admin prescribed antibiotics
Educate the patient that they must not use a toothbrush until they are cleared to resume regular brushing and flossing, why? What should be used in its place?
Infection risk is heightened due to disrupted tissue integrity; oral sponges or mouthwash
Proper CPAP compressor and mask/ tubing system maintenance is essential for what?
effective OSA management
What is crucial concerning CPAP machines to prevent infection and maintain tissue integrity, especially with humidification, which can increase the risk of fungal infections?
regular equipment cleaning
What do most CPAP systems require in the humidifier?
distilled water
How often should the mask or nasal pillow be cleaned and how should they be cleaned?
daily; using manufacturer-recommended products
Patients with OSA that use a CPAP, should be advised to not share what and why?
their CPAP mask, pillows or tubing; to reduce the risk of infection
For patients who have undergone surgery for OSA, what is important to regularly check?
the oropharynx for signs of bleeding, swelling, or infection
A small amount of blood in saliva or mucus, particularly after coughing, is normal for a post-op OSA patient. What is not normal and must be immediately reported?
new bleeding, large clots, or bright red blood may signal a serious issue, and the patient should contact their surgeon immediately or visit the ER
Patients, who are post-op OSA patients, should be taught to use a mirror for what purpose?
to examine their throat twice daily, noting any changes in size using coin size for comparison. If the throat appears to be narrowing, or if swallowing becomes difficult or painful, especially with drooling, they should seek emergency care as these are signs of swelling that may obstruct the airway.
With a post-op OSA patient- what is expected to decrease gradually, and swallowing should become what over time?
pain; more comfortable
What should a post-op OSA patient be educated to drink/ eat after surgery that will help ease discomfort?
drink cool liquids, use a humidifier, gargle with warm salt water, eat soft foods
What should a post-op OSA patient report to the surgeon?
any increase in pain or worsening difficulty swallowing
Educate the post-op OSA patient on the signs of infection. What are they? What should they do if any of these occur?
increased swelling, pus in the oropharynx, a change in mucous membrane color to bright red, increased pain, fever, taste changes, or bad breath; contact the surgeon
Activity restrictions for post-op OSA patients will depend upon what?
the type of surgery that was performed
Patients should be educated on the importance of the surgeon’s restrictions to avoid what?
complications
What are some restrictions that a surgeon may put on a post-op OSA patient?
avoid heavy lifting; avoid doing the Valsalva maneuver
Some patients may feel anxious about using a CPAP. What should you provide them as the nurse to help them feel more knowledgable and to help them with the adjustment period?
written & digital instructions; contact information for OSA specialists; CPAP supply resources
Post-op OSA patients may worry about the procedure’s success, pain, or swallowing difficulties. What is important that nurses reassure them?
that pain & difficulty swallowing is normal post-surgery and should improve within a week; snoring and sleep apnea may persist briefly due to swelling, but this should subside as healing progresses
What are the expected outcomes for the patient post-OSA surgery?
maintain normal blood pressure or achieve controlled hypertension with appropriate therapy; patient adheres to prescribed nonsurgical interventions and experiences fewer apnea episodes lasting 10 sec or longer during sleep; improved gas exchange and extended periods of restorative sleep are anticipated leading to reduced daytime sleepiness and increased energy levels; have a smooth, uneventful recovery from any surgical intervention
What could occur from a variety of causes, including trauma to the nasal mucosa, hypertension, blood disorders like leukemia, inflammation, tumors, low humidity, nose blowing, nose picking, chronic cocaine use, and procedures like nasogastric suctioning?
epistaxis (nosebleed)
When a nosebleed occurs what is important to document?
the amount and color of blood, vital signs should be taken, and inquire about any previous episodes including their frequency, duration, and causes
In emergency situations when the nose is bleeding, standard precautions should be followed: what should the nurse do?
position the patient upright, leaning forward to prevent blood from entering the larynx and causing aspiration; reassure the patient to keep them calm, as anxiety and elevated b/p can worsen bleeding; apply direct pressure to the sides of the nose for 10 min. and apply ice or cool compresses to the nose and face (if available); if nasal packing is required: both nostrils can be loosely packed with gauze or nasal tampons- to avoid dislodging clots and causing rebleeding, the patient should avoid blowing their nose for 24 hrs after the bleeding stops.
If these measures are ineffective or nosebleeding occurs frequently, the patient should seek medical attention.
Why should a patient not blow their nose within 24hrs of a nose bleed?
to avoid dislodging clots and causing rebleeding
If nose bleeding persists, medical intervention may be necessary. Such as what?
cauterization with silver nitrate or electrocautery, along with nasal packing
Why are posterior nosebleeds more serious?
they are harder to reach and can result in significant blood loss quickly
What interventions would be put in place for a posterior nosebleed?
posterior packing, epistaxis catheter, gel tampons
What is the risk if the posterior nose bleed interventions/ packing slips?
obstruction of the airway leading to a reduction of gas exchange
Patients with a posterior nose bleed should be closely monitored for what?
respiratory distress and tolerance of devices used for intervention
What are some treatments that may be prescribed along with opioids for pain relief for a posterior nosebleed?
humidification, oxygen, bed rest, and antibiotics
A patient with a posterior nose bleed who is prescribed opioids for pain relief should be assessed how often and for what?
at least every hour; gag and cough reflexes; pulse oximetry should be used to monitor for hypoxemia
When is the nasal packing removed from a patient with a posterior nose bleed?
typically after 1 to 3 days
If posterior nose bleed does not stop with packing or tubes more invasive treatments may be needed. What are they?
cauterizing or ligating the blood vessels or embolizing the bleeding artery with interventional radiology
What treatment for a posterior nose bleed that persists even after interventions can result in complications like facial pain, tissue necrosis, facial nerve paralysis, or even blindness
embollization
After the packing or tubes are removed from a patient who had a posterior nose bleed, what can the patient apply for comfort & keep the nasal passages moist preventing rebleeding?
petroleum jelly; saline nasal sprays
What should a patient who had a posterior nose bleed be taught?
to avoid vigorous nose blowing, aspirin, NSAIDS, and strenuous activities like heavy lifting for at least a month
Nasal injuries can lead to fractures that what?
compromise tissue integrity and hinder gas exchange
Why would treatment not be necessary for a nasal injury that lead to a fracture?
bone or cartilage remained aligned and no complications arose
Displacement of the bone or cartilage can result in what complications?
airway obstruction, cosmetic deformities, or risk of infection
What should be documented with a nasal fracture?
any nasal issues such as deviation, a misaligned nasal bridge, changes in breathing, crepitus, bruising, pain, and any drainage are important
What may drain from one or both nostrils following a nasal fracture- it is rare and suggests what?
blood or clear fluid, possibly cerebrospinal fluid; a serious injury like a skull fracture
How can CSF be identifed?
by testing positive for glucose or forming a yellow “halo” on filter paper when it dries
If a fracture involves displaced bones what may a healthcare provider perform within 24 hrs of injury using local or general anesthesia?
a simple closed reduction
After the initial 24hrs reducing the fracture becomes more challenging due to what and then what can be done?
swelling and scar tissue; any procedure may be postponed until the swelling subsides
Treatment after the initial 24hrs after a nasal fracture is focused on what?
typically focused on pain relief and applying cold compresses to reduce swelling
A surgical intervention may be required to realign the nose and restore function or appearance in cases of severe fractures or improper healing is called a what?
rhinoplasty
After rhinoplasty, the patient returns to the floor with?
packing in both nostrils to control bleeding and support the reconstructed nose
While the packing is in place, how must the patient breathe?
through their mouth
What is placed under the nose to catch any drainage after a rhinoplasty?
a “mustache” dressing (often a folded 2x2 gauze pad)
What may be applied to the nose for added protection and alignment after a rhinoplasty?
a splint or cast
What is important to change as needed/ teach your patient to change as needed after a rhinoplasty?
the drip pad
What should be monitored following a rhinoplasty?
swelling and bleeding due to the disruption of tissue integrity
Patients who have undergone an uncomplicated rhinoplasty are discharged when?
usually same day
What is a key assessment after rhinoplasty surgery?
monitoring how often the patient swallows- as frequent swallowing could indicate posterior nasal bleeding
The post-op (rhinoplasty) patient’s throat should be assessed using a penlight looking for what?
for any signs of bleeding (if found- notify the surgeon, when nec)
The post-op (rhinoplasty) patient should remain in which position?
semi-fowler
When the post-op rhinoplasty patient returns to the floor what interventions will the nurse attend to?
patient remains in the semi-fowler position, moves slowly, rests, applies cool compresses to the nose, eyes, and face to minimize swelling and bruising
Once the patient’s gag reflex (rhinoplasty) returns what should they be encouraged to do?
drink at least 2500 mL of fluid daily
To prevent bleeding, in a post-op (rhinoplasty) patient, what education should they be taught?
to avoid forceful coughing and straining during bowel movements and refrain from sniffing or blowing the nose; avoid sneezing with their mouth closed for the 1st few days after removing the nasal packing; avoid taking NSAIDS or aspirin; complete the prescribed antibiotics; due to swelling the final result of surgery may take 6-12 months to become apparent
How is facial trauma classified?
based on specific bones (mandibular, maxillary, orbital, nasal) involved and the affected side of the face
What are the most common types of facial trauma?
mandibular or lower jaw fractures
A Le Fort increases in severity as what increases?
the number increases (Le Fort I,II, & III)
Due to the face’s rich blood supply, facial trauma often results in what?
significant bleeding, bruising, and loss of tissue integrity
What is the primary concern when caring for a patient with facial trauma?
assessing the airway to ensure proper gas exchange (signs of an airway obstruction: stridor, shortness of breath, dyspnea, anxiety, restlessness, hypoxia, reduced oxygen saturation, cyanosis, and loss of consciousness)
Once the airway is secured, evaluate the facial trauma site for what?
bleeding and visible fractures; look for soft-tissue swelling, facial asymmetry, pain, or spinal fluid leakage from the ears or nose (which may indicate a skull fracture)
What should you assess in a patient with facial trauma?
patient’s vision and eye movement, as fractures in the orbital or maxillary regions can trap eye nerves and muscles
What should be inspected in a patient with facial trauma?
behind the ears for significant bruising- known as “battle sign” (which is often linked to skull fractures and brain trauma)
Since facial trauma may also involve spinal injuries and skull fractures what testing is often performed?
cranial CT scans, facial x-rays, & cervical spine x-rays
The top priority in managing head and neck trauma is what?
establishing & maintaining an airway to ensure adequate gas exchange
When establishing. maintaining an airway in a patient with a head &/or neck trauma nurses should be prepared for what?
emergency procedures like intubation, tracheotomy, or cricothyroidotomy
What is crucial for patients with head/ neck trauma?
rapid stabilization & early intervention by a specialized team can significantly improve recovery outcomes
What does stabilizing a fractured jaw involve?
fixing the teeth in proper alignment, often using fixed occlusion or wiring the jaws shut, lasting 6 to 10 wks
Delaying treatment for a patient with a fractured jaw could result in what?
tooth infections, or poor oral hygiene- can lead to jawbone infections (which may require surgical removal of dead tissue, intravenous antibiotic therapy, and an extended period with jaw in a fixed position)
A severe jaw fraction may need what?
open reduction with internal fixation- where compression or reconstruction plates are used to hold the bone in place
Depending on the material, the plates that are used in surgical procedures in severe jaw fractures, may be what?
usually permanent (may not interfere with MRI scans)
What is sometimes used to repair facial fractures?
microplating systems with bone grafts or substitutes (these plates may be removed after healing or left in place permanently)
What is done for inner maxillary fixation?
the jawbones are realigned and wired in place- keeping the bite closed
What type of anesthesia is done for simple fractures of facial bones?
treated with local anesthesia
What type of anesthesia is done for more complex fractures of facial bones (involving several facial bones)?
may require general anesthesia
Patients with facial fractures where their jaw is wired closed, educate the patient how to perform oral care.
using irrigating devices like a Waterpik or Sonicare
Patients with IMK, educate them on what is essential?
self-management and diet- follow a liquid diet
Since the patient with IMK cannot open their jaws during vomiting there is a risk for what?
aspiration
What should a patient with their mouth wired shut always carry with them and what should they be educated about it?
wire cutters; instructed on how to cut the wires in case of vomiting to maintain airway safety.
*if the wires are cut, they should promptly return to their surgeon
Nutrition can be challenging during recovery due to oral fixation, so collaborating with whom is important?
a registered dietitian/ nutritionist for patient education and support
What can result from crushing injuries, direct blows, fractures, or prolonged endotracheal intubation?
laryngeal trauma
What can laryngeal trauma lead to?
loss of tissue integrity
Symptoms of loss of tissue integrity due to laryngeal trauma:
difficulty breathing, loss of voice, hoarseness, and subcutaneous emphysema (hemoptysis may occur depending on the injury’s location)
What is essential to assess the extent of damage due to laryngeal trauma?
direct visual examination of the larynx using laryngoscopy
Managing laryngeal injuries involve what?
evaluating gas exchange effectiveness and monitoring vital signs; including respiratory status and pulse oximetry- every 15 to 30 min - ensuring a patent airway is crucial; admin oxygen and humidification as prescribed to maintain adequate oxygen levels
When monitoring a patient with a laryngeal injury respiratory distress may manifest how?
as tachypnea, nasal flaring, anxiety, sternal retraction, shortness of breath, restlessness, decreased oxygen saturation, decreased level of consciousness, or stridor
If respiratory distress symptoms are present in a patient with a laryngeal injury what should be done?
stay with the patient and alert the trauma team or Rapid Response Team to prepare for emergency intubation or tracheotomy
When is surgical intervention necessary for a laryngeal injury?
for lacerations of the mucous membranes, exposed cartilage, or vocal cord paralysis
Why should laryngeal repair be performed promptly?
to prevent laryngeal stenosis and cover any exposed cartilage
*an artificial airway may be required temporarily
Malignant tumors where are rare but more frequently observed in adults with chronic exposure to wood dust, leather dust, flour, nickel and chromium dust, mustard gas, and radium?
in the sinuses
The onset of sinus cancer is what?
gradual
Symptoms of sinus cancer:
similar to sinusitis, including persistent nasal obstruction, drainage, blood discharge, and pain that continues despite treatment for sinusitis; lymph enlargement is often seen in the side of the tumor
What is often seen on the side that the tumor in the sinus is located?
enlarged lymph nodes
What diagnostic imaging is used to locate tumors in the sinuses?
x-rays, CT scans, or MRIs
What is required to confirm a diagnosis of cancer, after a tumor is located in the sinuses?
a biopsy
What is the primary treatment for nasopharyngeal cancers?
surgical removal of the tumor, either partially or entirely- often combined with radiation therapy, in some cases chemotherapy is used alongside surgery and radiation
What are some post-surgical issues of tumor removal with cancer of the sinuses?
body image, speech, taste, and smell changes
Post-op care from tumor removal from sinus cancer involves what?
general management and meticulous care of the mouth and sinus cavities; monitor the patient for pain and signs of infection
How do you care for post-op patients’ sinus cavities and mouth who had tumor removal of their sinuses from cancer?
use saline irrigation with an electronic irrigation system or a syringe
What types of cancers are relatively common?
head and neck cancers
Head and neck cancers are relatively common and can have severe what?
impacts on gas exchange, eating, facial appearance, self-image, speech, and communication
In order to manage the complex needs of a patient with head or neck cancer a coordinated interprofessional team which includes who?
oncologist, surgeon, nurse, registered dietitian nutritionist, speech-language pathologist, dentist, respiratory therapist, social worker, wound care specialist, clergy, occupational and physical therapists, and psychosocial counselors
Typically head and neck cancers grow slowly and are generally what?
curable if detected and treated early
The prognosis for advanced cases of head and neck cancers depends on what?
the extent and location of the tumors
If treatment is not sought, head and neck cancers are often what?
fatal within 2 years of dx
How can early lesions present with head and neck cancers?
as white, patchy areas known as leukoplakia or red, velvety patches known as erythroplakia
How does head and neck cancers initially spread? later?
locally to the lymph nodes, muscles, and bones; later to distant sites such as the lungs or liver
Where do most head and neck cancers originate?
mucous membranes and skin
Where can head and neck cancers also start besides the mucous membranes and skin?
salivary glands, thyroid, tonsils, or other structures
What do treatment strategies depend on with head or neck cancers?
depends on the type of tumor cells and the extent of disease at dianosis
Primary risk factors for head and neck cancers:
tobacco and alcohol use
Additional risk factors for head and neck cancers (besides tobacco and alcohol use):
vocal strain, chronic laryngitis, exposure to chemicals or dust, poor oral hygiene, long-term GERD, and oral infections with human papillomavirus (HPV)
During an assessment, with a patient suspected of having head or neck cancer, what should be asked?
inquire about tobacco and alcohol use; hx of acute or chronic laryngitis, or pharyngitis, oral sores, difficulty swallowing, and any lumps in the neck; patient’s smoking hx in pack-years, alcohol consumption- including the number of drinks per day and the duration of use; oral exposure to HPV
For laryngeal cancers, what may occur due to the tumor’s size and it’s impact on vocal cord function?
hoarseness
If any adult experiences hoarseness, mouth sores, or a lump in the neck for 3-4wks what should they be assessed for?
laryngeal cancer
What is crucial for evaluating cancer spread and tumor invasion?
imagining studies, such as x-rays of the skull, sinuses, neck, and chest
What diagnostic testing may help define the tumor’s extent and what performed during this procedure can confirm the dx?
endoscopic examination under anesthesia; biopsies
A biopsy can confirm a dx and also?
the tumor type, cellular features, location, and stage
Warning signs of head and neck cancers:
persistent pain, lumps in the mouth, throat, or neck, and difficulty swallowing; changes in the color of the mouth or tongue to red, white, gray, dark brown, or black; oral lesions or sores that do not heal within 2 wks; unexplained oral bleeding; numbness in the mouth, lips, or face; changes in the fit of dentures; a burning sensation when drinking citrus juices or hot liquids; persistent unilateral ear pain; hoarseness or changes in voice quality; persistent or recurrent sore throat; shortness of breath, anorexia, and weight loss are also important signs to watch for
What is the goal of treatment for head and neck cancers?
to eliminate the cancer while preserving as much function as possible
What are the treatment options for head and neck cancer?
surgery, radiation, chemotherapy, and biotherapy
What treatment for head and neck cancer can be used alone or in combination based on the disease stage, the patient’s overall health, nutritional status, age, and personal preferences?
biotherapy
What treatments can be used for laryngeal cancer?
treatment can vary from targeted radiation therapy for small tumors to more extensive procedures like total laryngopharyngectomy with bilateral neck dissections, followed by radiation therapy, depending on the tumor’s size and location
Nursing care for a post-op (head and neck cancer) patient involves what?
preoperative preparation, in-hospital care, discharge planning, and extensive outpatient rehabilitation
is effective for small cancers and can be used alone or with surgery and chemotherapy for patients with head and/or neck cancers
radiation therapy
With radiation therapy, patients often experience side effects. What are they?
hoarseness, sore throat, dysphagia, skin irritation, impaired taste, and dry mouth; skin at the radiation site may become red, tender, and may peel, requiring gentle care with mild soap and protective clothing
dry mouth
xerostomia
What long-term side effect is the result of irradiating the salivary glands, increasing the risk for cavities and necessitating a dental consult, and may be permanent?
xerostomia
What are some alleviating measures that can help the discomfort of xerostomia?
moisturizing sprays, increased water intake, and humidification
Chemotherapy maybe used alone or in conjunction with what therapy?
radiation
Surgical options head and neck cancers depend on what factors?
the tumor’s size, node involvement, and metastasis
How can early-stage tumors (head and neck cancers) be treated?
laser therapy or photodynamic therapy
For more advanced cases of tumors (head and neck cancers) what may be required?
extensive surgery such as laryngectomy, tracheostomy, or oropharyngeal resections
Major surgical interventions for laryngeal cancer include what?
cord stripping, cordectomy, partial laryngectomy, and a total laryngectomy
What surgical interventions are for cancers involving the lymph nodes?
neck dissection may be performed alongside a tumor removal
Post-surgical patients (head and neck cancer/ laryngeal cancer) may be educated on what?
airway management, suctioning, pain control, critical care procedures, nutrition support, and feeding tube care
What will post-op patients (head and neck cancers/ laryngeal cancer) need to adapt?
new methods of speech, especially if mechanical ventilation is used if a total laryngectomy necessitates permanent changes to communication
Following a partial or total laryngectomy, what is required? Will it be permanent?
a tracheostomy: partial laryngectomy- temporarily; total laryngectomy- permanently with a stoma
What may occur following an extensive surgery?
shoulder drop
How long does a head and neck surgery last?
> 8hrs
Where does a patient go after having surgery on their head and neck (cancer) for the immediate postoperative period?
ICU
In the ICU during the immediate postoperative period, what should be closely monitored for a cancer patient (head and neck)?
airway patency, vital signs, hemodynamic status, and the patient’s comfort
What nursing actions are taken for the 1st 24hrs post-op for a (head and neck cancer) patient?
take vital signs, check for signs of hemorrhaging; other complications from anesthesia & surgery hourly, then continue according to agency policy until the patient stabilizes
What are some post-surgical complications that can occur for a patient who underwent head and neck cancer surgery?
airway obstruction, hemorrhage, wound breakdown, and tumor reoccurrence
What is the primary focus immediately after surgery (head and neck cancer surgery)?
maintaining airway and ensuring adequate gas exchange
What may the patient require if airway cannot be maintained or adequate gas exchange ensured?
mechanical ventilation
During the weaning process of mechanical ventilation, what may the patient have to use to help manage mucous secretions?
a tracheostomy collar with oxygen & humidity
What kind of secretions may the patient with a trach collar that is being weaned off mechanical ventilation have? How long will it last?
blood-tinged secretions; 1 to 2 days
What should be used for patients who are experiencing blood-tinged mucous? and if bleeding increases what should be done?
Standard Precautions; report to the surgeon
What is a laryngectomy tube used for?
to prevent scar tissue shrinkage for patients who have undergone a total laryngectomy
The laryngectomy tube is similar to a trach tube but is what?
shorter and wider, requires care akin to trach tube care, with the added possibility of daily or as-needed changes
What is a laryngectomy button?
a softer and shorter alternative with a single-lumen
A patient will need alternative communication methods due to their inability to speak with what procedure/ equipment?
total laryngectomy; laryngectomy button or tube
Stoma care post-laryngectomy involves what?
a combination of wound and airway care
Inspect the stoma and clean the suture line with what?
sterile saline or prescribed solution to prevent crust formation and airway obstruction
How often should suture line care occur?
every 1 to 2 hrs initially, then every 4 hrs
What color should the stoma and trachea mucosa be?
bright pink and free of crust
What may improve appearance of the stoma?
tissue flaps used for reconstruction
The first 24 hrs post-surgery are what?
critical
What should be evaluated hourly for the first 72 hrs post-surgery (laryngectomy/ stoma)?
all grafts and flaps
What should be monitored hourly for the 1st 72 hrs post-surgery (laryngectomy/ stoma)/ flaps/ grafts?
color, drainage, and Doppler activity of the major blood vessels
What should be reported within the 1st 72 hrs post-op (laryngectomy/ stoma/ flaps/ grafts)?
any changes, as surgical intervention may be necessary
Position patient, to prevent dependence on what after surgery (laryngectomy/ stoma/ flaps/ grafts)?
dependence of surgical flaps
What is a common complication, especially if radiation therapy preceded the surgery?
wound breakdown
How should wound breakdown be managed?
with packing and local care as prescribed to maintain cleanliness and promote healthy granulation tissue growth
The patient should be assessed hourly for signs of what post-operatively after a (head and neck cancer/ laryngectomy) and what should you do if it is found?
signs of a carotid artery leak and if suspected, initiate the Rapid Response Team and avoid touching the area to prevent rupture
In case of a ruptured carotid artery:
apply constant pressure to the site, secure the airway, and transport the patient to surgery immediately
What poses a high risk of stroke and death?
a carotid artery rupture
What is typically administered via a PCA pump for the 1st 1 to 2 days post-surgery (head and neck cancers)?
morphine
When should the patient be introduced to liquid opioid
analgesics that may be given through a feeding tube with oral pain medications (after morphine is stopped)?
as the patient progresses and once the patient can tolerate oral intake
What are patients who undergo treatment for head and neck cancer at risk for?
malnutrition due to oral fixation
What may be placed for nutritional support and removed when the patient can safely swallow (oral fixation)?
a NG, gastrostomy, or jejunostomy tube
What is not a concern as the airway is separated from the esophagus after a total laryngectomy?
aspiration
Patients will experience voice quality and speech changes post-surgery which can significantly impact what?
social interactions, employment, and quality of life
Collaborate with a speech-language pathologist to develop and practice what?
communication methods
What some ways a patient who underwent a total laryngectomy communicates?
writing, using a picture board, or electronic devices
Use of an artificial larynx or learning esophageal speech may be the next step after the patient does what?
progresses after a laryngectomy
What is esophageal speech?
where sound is produced by “burping” air into the esophagus and shaping words in the mouth
Mechanical devices such as a what, can aid communication by vibrating air in the mouth and throat, though the speech quality can be robotic?
electrolarynges
Surgical changes and altered swallowing mechanisms increase the risk for what?
aspiration
What can contribute to the risk of aspiration, by keeping the lower esophageal sphincter partially open?
a nasogastric feeding tube
Patients with trach tube or those who had partial or supraglottic laryngectomy must be monitored for what?
aspiration
What must be taught to patients who have had a supraglottic laryngecromy?
alternative swallowing techniques such as the supraglottic method
this method involves sitting upright, clearing the throat, holding the breath, swallowing twice, and repeating process to clear food from the throat:
supraglottic method of swallowing
Head and neck cancer surgeries often result in what changes?
to self-concept and self-image due to the presence of a stoma, artificial airway, speech changes, and altered eating methods
What are some psychosocial issues that a patient who had/ has head and throat cancer might have?
guilt and regret may arise
What should the nurse help the patient do and set for their psychosocial health?
realistic goals, participate in self-care, and use alternative communication methods
How should the nurse address social isolation for a patient (head and neck cancer) post-operatively?
suggest loose-fitting clothing, scarves, and cosmetics to cover surgical changes and enhance appearance
If no complications arise, the patient is typically discharged home or to an extended-care facility within what timeframe?
2 wks
By discharge, what should the patient or a family member be capable of managing?
trach or stoma care; as well as participating in nutrition, wound care, and communication methods
What kind of referrals should a patient be given at discharge (who had head and neck cancer/ surgery)?
to support groups, and community health agencies specializing in head and neck cancer recovery
Who is often a valuable resource for assessing self-care, potential complications, adjustment issues, and adherence to the medical regimen?
a home care nurse
Stoma care includes protection due to what?
anatomical changes from surgery
For home laryngectomy care, what should patients be educated on?
avoid swimming and be cautious when showering or shaving; use a shower shield over the tube or stoma during bathing to prevent water from entering the airway; wear a protective stoma cover or stoma guard during the day; when sneezing or coughing- lean slightly forward and cover the stoma to protect it; clean the stoma regularly with mild soap and water and a non-oil-based ointment may be applied as needed to keep the area in good condition; maintain proper humidity, use saline in the stoma, a bedside humidifier, or place pans of water and houseplants around the room; emphasize the need for meticulous cleaning to prevent mold and infection
What is important for a patient who underwent head and neck cancer surgery/ stoma wear?
medical alert bracelet and carry an emergency care card to manage any critical situations effectively
For patients with severe respiratory issues, what kind of living arrangement changes may be necessary?
modifications for single-floor living
A permanent stoma, trach tube, NG, or PEG tube, and wounds can alter what?
body image
What should the nurse emphasize to a patient (post-operatively- head and neck cancer)?
the importance of resuming normal activities as much as possible (most patients return to their normal routine usually within 4-6 wks after surgery)
Patients with total laryngectomy cannot produce sound while they are doing what?
laughing or crying
What may occur during these emotions (laughing or crying) or when coughing or sneezing, which can be embarrassing? What should the patient be prepared to do in such an event?
Unexpected mucous secretions; - the patient should be prepared to cover the stoma with a handkerchief or gauze
Patients who have gone through composite resections may face what challenges?
with speech and swallowing; might need to manage trach and feeding tubes in public setting
Who should be supervised when assigned or delegated to give care to patients who have risk factors for airway obstruction?
LPNs/ LVNs or AP (CNA)
Any direct observations of OBA (obstructive sleep apnea) should be what?
documented
What should a patient using a CPAP to manage OSA be instructed to avoid sharing?
the mask device or tubing with others to prevent infections
Apply knowledge of anatomy to prevent what from happening in a patient with a trach?
aspiration
Teach patients with a CPAP what?
how to correctly use and care of the equipment
Remind patients using CPAPs to what daily?
use it whenever they sleep in a bed
What should be assessed of any patient who experiences facial or nasal trauma?
airway patency
A patient should be assessed for what risk factors?
head and neck cancers
Encourage adults who smoke or use tobacco in any way to do what?
quit
Teach patients who have had radiation therapy to the oral cavity to have what done at least every 6 months?
dental examination
Encourage patients to give prescribed CPAP therapy for OSA how long a trial to adjust to a new and somewhat intrusive sleep routine?
at least 2 wks
Who should be taught home management of a laryngectomy stoma or tracheostomy?
patient and family
Patients with permanent tracheostomies or laryngectomies should be encouraged to what?
become involved in self-care and to look at the wound and touch the affected area
What should be allowed when communicating with a patient with voice loss?
time to communicate
What should a nurse teach family members of a patient who cannot speak after surgery for head and neck cancer?
ways to communicate with a patient
What should you assess in comatose, cognitively impaired, or non-communicative patients every shift?
the need for oral care to prevent a mucoid impaction
Remind patients that their CPAP is only effective when?
the mask is tight enough to prevent air leaks
What should be performed to determine adequacy of gas exchange and tissue perfusion?
upper respiratory assessment and reassessment
Check the airway and packing of a patient who has posterior nasal packing placed after nasal surgery or posterior epistaxis how often?
at least every hour
What should you instruct patient’s who have had mandibular immobilization or fixation after a mandibular fracture to keep with them at all times?
wire cutters
What should be applied to patients who develop stridor?
oxygen
What should a nurse assess the incisions and wounds of a patient who has undergone radical neck surgery for indications of?
loss of tissue integrity, graft perfusion insufficiency, and carotid artery leak or rupture
