Oxygen Flashcards
Chest tube- lung normal pressure
- Normal breathing mechanisms operate on the principle of negative pressure
- Pressure in chest cavity is normally lower than the atmosphere causing air to move into the lungs during inspiration
- Whenever the chest is opened, there is loss of negative pressure
- Collapsed lung result from opening of chest or collection of air, fluid, or other substances (serous fluid, pus, blood, etc.)
What’s a chest tube
- Surgical incision of the chest wall almost always causes some degree of pneumothorax.
- CT Improves gas exchange and breathing
- Used to re-expand the involved lung to remove exchange
Different chest tube insertion
- Insertion into pleural space restores negative intrathoracic pressure needed for lung re-expansion after surgery or trauma
- Insertion into the mediastinal space (extra pleural space) anteriorly or posteriorly drains blood after surgery
Types of chest tube
●Small-bore and large bore (7-12Fr), have a one-way valve apparatus to prevent air from moving back into the chests.
●Large-bore (range up to 40Fr) are usually connected chest drainage system to collect fluid and air.
●CT positioned after insertion, sutured to the skin, connected to a drainage apparatus to drain fluid and air from pleural or mediastinal space.
Closed drainage system chest tube
- Closed system prevents air from reentering the chest on inhalation
- Three chambers: Suction control chamber, water seal, collection chamber for drainage.
- Comes in wet or dry suction control systems
Nurse’s Role
Chest tube Connected to Closed Drainage System
- Prepare drainage system for use
- Maintain drainage system (on or off suction). Suction control chamber 20 cm (adult), water seal (2 cm).
- Watch for air leak
- Monitor site and dressing
- Monitor respiratory status
- Measure output every shift
- Maintain proper positioning (supine elevated, drain on floor)
Tracheostomy tube nursing responsibility
- Change inner cannula every 8 hours if it is disposable
- If non-disposable is being used clean every 8 hours or more often if needed.
- Provide humidification
- Suction when needed to prevent formation of mucus plugs
- Provide adequate humidification and hydration to thin secretions and prevent crusting.
- Secure tube with ties/straps to prevent dislodgement
- Clean stoma daily with soap and water or prescribed solution using soft cloth or gauze
- Prevent water from entering the stoma
Oral cancer risk factor
- Most occur on the lower lip
* black men after 35
Oral cancer risk factors (modifiable/preventable)
●HPV ●Smoking/tobacco use ●Chronic Alcohol (ETOH) use ●Asbestos ●Marijuana use ●Radiation therapy to head and neck ●Outdoor occupations (prolonged sun exposure) ●Irritation from pipe stem resting on the lip ●Poor oral hygiene ●Recurrent herpetic lesions ●Syphilis ●Ill-fitting prosthesis ●Chemical irritants
Oral cancer prevention
- Discuss risk factors
- Safe sex
- Good oral hygiene
- Smoking cessation
- Avoid tobacco and alcohol
Oral Cancer Manifestations
•Chronic sore throat or mouth or feeling that something is “stuck”
●Voice changes
●Leukoplakia: white patch “smoker’s patch”
- Can lead to hyperkeratosis (becomes hard and leathery)
●Erythroplasia: Red, velvety patch on the mouth or tongue.
●Asymptomatic neck mass
●Indurated, painless ulcer: Lip
●Later signs: difficulty chewing and speaking, earache, dysphagia, toothache, increased salivation, slurred speech, limited tongue movement
Oral Cancer Diagnostics
●H&P exam
●Biopsy
**Oral exfoliative cytology: scrap lesion, spread on slide, examine under microscope
***Toluidine blue test: Apply to stained area. Results in uptake of the agent by the cancer cells.
●CT
●MRI
●PET scans
Oral Cancer Based TNM Staging
looks at the size and depth of the cancer and whether it has spread anywhere else in the body
•Size of the tumor(T) number
●Location of involved lymph nodes (N)
●Extent of metastasis (M)
●Stage 0 is in situ (confined to where it is)
●Is slightly different for each type of cancer
Head & Neck Cancers
Surgery considerations
• age, health, urgency of treatment, cosmetic, functional considerations (ability to talk, swallow or chew), and patient choice
●Type of surgery depends on the location and extent of the tumor
●Minimally invasive robotic-assisted surgery: for small tumors in the mouth and throat
Extensive Surgeries for head and neck
●Hemiglossectomy: Removal of half of the tongue
●Glossectomy: removal of the tongue
•Radical neck dissection: primary lesion with removal of regional lymph nodes, the deeper cervical lymph nodes, and their lymphatic channels.
Other structures can be removed depending on the extent of the primary lesion
Radical Neck Dissection
Structures that can be removed
● closely associate muscles ●Mandible ●Salivary gland ●Major blood vessels ●Submaxillary gland ●Part of thyroid and parathyroid glands ●Spinal accessory nerve ***Results in shoulder drop and visible neck depression (poor cosmesis)
After Radical Neck Dissection pt normally has ..
● usually has a tracheostomy
●Drainage tubes inserted into the surgical area connected to suction to remove fluid and blood.
Types of radical neck dissection
•Modified radical neck dissection :
- Most often used.
- ALL lymph nodes are removed. May spare the nerves, blood vessels or muscles.
- May need a flap (uses skin and sub Q tissue)
•Selective neck dissection:
- Can involve fewer lymph nodes removed if cancer has not spread.
- Blood vessels, muscle, and nerves may be spared
Cancer of the Larynx risk factors
- older than 65
- men
- Most are squamous cell carcinomas
- Most present with lymph node.
- Tends to recur within 2-3 years after diagnosis
Cancer of the Larynx
Signs and Sx
- Hoarseness or voice change longer than 2 weeks. Includes low pitch, raspy.
- Persistent sore throat
- Constant cough
- Pain with swallowing
- Ear pain that does not go away
- Difficulty swallowing
- Trouble breathing
- Lump or mass in the neck
- Weight loss due to difficulty eating
Larynx Diagnostic Test
- Indirect laryngoscopy
- Palpation of lymph nodes of the neck and thyroid
- Fine needle aspiration
- Barium swallow
- Endoscopy
- Intraoperative examination
Non surgical therapy for cancer
Radiation:
- can be used to treat small cancers or when lesions cannot be removed
- make tissue become fibrotic and hard to remove surgery is usually done first
- ulceration of oral mucosa, pain, dry mouth, loss of taste, dysphasia, fatigue necrosis and edema
Chemo:
- used in combination with radiation
- shrink lesion before surgery
Palliative:
- When prognosis is poor, cancer is inoperable, patient declined surgery
- placement of GI tube of unable to swallow, suctioning, pain meds
Larynx radiation
Goal:
-eradicate the cancer and preserve function of the larynx
-Can be use preoperative to reduce size of the tumor
Retains a near-normal voice (a benefit)
Complications:
- Chondritis (inflammation of the cartilage)
- stenosis (may require largyngectomy
Larynx Management Goals
- Cure
- Safe & effective swallowing
- Preservation of useful voice
- Avoidance of permanent tracheostomy
Larynx cancer Surgery’s
•Vocal cord stripping (less invasive).
- Removal of the edge of the vocal cord mucosa
•Cordectomy: (less invasive).
- An excision of the vocal cord.
•Laser (Laser microsurgery).
- Method of choice. Shorter recovery, fewer side effects.
•Partial laryngectomy:
- portion of larynx removed with one vocal cord and the tumor.
- Airways remain intact. No expected swallowing problems.
- May change voice quality or hoarseness may result.
- High cure rate.
Total Laryngectomy Effects:
- Permanent voice loss
- Permanent tracheostomy.
- Alternatives to normal speech is required. ( Includes Blom-Singer valve to speak without aspirating).
- Patient has no voice but has normal swallowing.
- Must breathe through a stoma
Larynxectomy planning for Speech
•Speech therapists or pathologists evaluates pre-op
•Plan post op communication strategies and speech therapy
•A system of communication is established
- writing, lip speaking and communication, word boards.
•Long-term postop plan for laryngeal communication is developed
NURSING Assessment BEFORE surgery
For Larynx
•Palpate neck for swelling, nodules, adenopathy •Nutritional status •Review labs •type of Surgery (voice post op?) ## Presence of VISUAL impairment and functional literacy ## Hx of ETOH intake •Psychological readiness •Health Problems
What is Cancer of the Thyroid and risk factor
•Nodule can be benign or malignant
- Benign can grow large enough to obstruct trachea.
•White women at risk
Cancer of the Thyroid
Risk Factors
- Hx of head & neck radiation therapy during childhood
- Exposed to radioactive fallout
- Have personal or family history of goiter
Thyroid
Clinical Manifestations
- Enlarged thyroid gland with painless, palpable nodules
- Firm, palpable, cervical masses suggest lymph node metastasis
- Difficulty swallowing or breathing bc of the invasion of the trachea or esophagus
Thyroid diagnostic
- Palpation of enlarged thyroid or mass
- Ultrasound, CT scan, MRI, PET
- Ultrasound-guided fine-needle aspiration
•Thyroid scan:
- “Hot” tumors take up radioactive iodine and are ALWAYS benign. - If nodule does not take up radioactive iodine it’s “cold” and higher risk of cancer
• Test:
- Serum Calcitonin
- Serum thyro-globulin
Thyroid Cancer treatment
- Surgical procedures: Unilateral total or near-total thyroidectomy
- Removal of lymph nodes to determine if cancer has spread
- Radiation therapy to destroy any remaining cancer cells. Improves survival rate.
- Thyroid hormone for TSH dependent thyroid cancers
- Chemotherapy
Thyroid postop 3 most important assessments
frequent post op assessment for:
- airway obstruction
- bleeding
- tetany (intermittent muscular spasms) bc parathyroid gland may have been removed ( low levels of calcium)
Preop meds/ teaching Subtotal thyroidectomy
- Antithyroid drugs
- Iodine (decreases vascularization of the thyroid, reduces the risk for hemorrhage)
- Beta-adrenergic blockers (euthyroid state)
●Teach
- support the head manually while turning in bed
- neck range-of-motion exercises
- Talking likely to be difficult for a short time post op
- Leg exercises
Fowler position to promote oxygen/airway post-op
- Facilitate breathing
- Promote comfort
- Increases lymphatic and venous drainage
- Facilitates swallowing
- Decreases venous pressure on the skin flaps
- Prevents regurgitation and aspiration of stomach contents
How to promote oxygen/airway postop head or neck surgery
•AVOID ORAL TEMP
•Monitor for respiratory distress
-Endotracheal intubation may be needed
•Encourage C&DB
•Support neck
•Suction frequently
•Humidified air or oxygen via tracheostomy
•Maintain adequate fluidSigns of impaired oxygen/ airway
- Restlessness
- Apprehension(anxiety/fear)
- Increased pulse
- Dyspnea
- Cyanosis
- Labored breathing
- Decreased O2 sats
- Changes in mental status
- Changes in vital signs (suggest edema, hemorrhage, inadequate drainage or oxygenation)
- Stridor (Must report immediately)
- Watch for signs of Pneumonia
Post-op complications after neck surgery
- Hemorrhage
- Chyle Fistula- leakage of lymphatic fluid due to damage to the thoracic duct during surgery). Milk-like drainage from the thoracic duct.
- Nerve Injury (Can cause lower facial paralysis and difficulty swallowing)
- Pain
- wound
- Respiratory distress
- Nutrition
- Coping
- Communication
- Mobility
What to do for Post-op pain
- Pain meds
- Monitor verbal and nonverbal signs
- verbally rate pain
- Monitor vital signs
- Teach nonpharmacological strategies for pain
Head & Neck Cancers
Nutrition assessment & interventions to improve nutrition
•Assess for
- Neck swelling - location of sutures - difficulty swallowing - stomatitis from chemo / radiation
- May need GI-TUBE
- monitor for weight loss
- antiemetics before meals
- Expect video swallowing studies.
- Bland foods easier to tolerate when risk of aspiration.
- Increase caloric intake:
- Can add dry milk to food
- Oral supplements
- thick liquids
Head & Neck Cancers
Nutrition NG tube
- inserted during surgery to remove gastric contents via intermittent suction until peristalsis returns.
- Do not manipulate or move the tube
- Start enteral feedings slowly when bowel sounds return and advance to meet nutritional needs
What to do/ teach for Xerostomia (Dry Mouth)
- Pilocarpine hydrochloride (SALAGEN) is often effective in increasing saliva.
- Sugarless chewing gum or candy
- Non-alcoholic mouth wash rinses(baking soda, glycerin solutions
- Teach patient to always carry a water bottle with them
- Flouride gels or treatments to help prevent dental deterioration
What to do for Mucositis
- Can cause irritation, ulceration, and pain
- Oral care
- Soft toothbrush
- Regular flossing
- Warm bland rinses (salt and baking soda) 4-6 times a day
- Sucking on ice chips (may help reduce pain)
- Avoid commercial mouthwashes and hot spicy or acidic foods
- Empty fluoride gel trays along with bite blocks, athletic guards, or gauze pads can be worn during radiation treatment
Tracheostomy Stoma Care and teaching
- Use only prescribed lotions and skin products while undergoing radiation treatment!!!
- Teach proper stoma care
- Wash area around stoma daily with moist cloth
- Can use nasal wash spray (Alkalol) every 1-2 hour to keep the stoma moist and prevent crusting. Dried secretions can be removed with tweezers
- If Laryngectomy tube is used patient must remove entire tube and clean, then replace it.
- Can wear scarf or loose shirt to hide the stoma
- Cover stoma when coughing
- Cover stoma during any activity that may require inhalation of foreign material (shaving, hair hygiene, applying make up).
- Wear plastic collar when showering
- DO NOT SWIM. Could drown
- Humidification
radiation and chemotherapy Fatigue
- Common
- Walk 15-30 minutes a day
- Do activities most important to them
- Allow rest periods
Head & Neck Cancer
Psychosocial
What it effects, interventions
- Body image
- Inability to speak
- depression
- Involve significant other (acceptance by another person can promote and improved self-image)
- Allow patient and caregiver to express their feelings and emotions
- Provide information about support groups
Head & Neck Cancer
Physical Therapy
- Upper extremities exercises to assist with support / movement of the head
- Begin immediate post op
- Must maintain strength and movement of in the shoulder and neck to avoid ”frozen shoulder”.
- must continue program after discharge to prevent future functional disabilities
Promoting oxygen and airway after surgery
- Coughing and Deep breathing exercise
- Semi-Fowler’s position
- Assess lung sounds / sign of R distress
- Manage pain (causes shallow breathing and ineffective cough)
- Limit medications that depress respirations
- Suction (avoid disrupting the suture line)
- Keep suction setup at bedside. (Instruct the family on use)
- Monitor pulse oximetry (O2 as prescribed)
- Be prepared for possible intubation and mechanical ventilation
- Monitor residual volumes
- Ambulate early
Post op Wound Care for neck surgeries
•May have pressure dressings, packing or drainage tubes
- Do not change unless you have specific orders from HCP - Hemovac, Jackson-Pratt, and Penrose drain may be used
•If skin flaps
- checked hourly for color and change in size or edema.
- doppler may be used for pulse on skin flap.
- Drainage may initially be bloody, then serosanguineous and gradually decrease in volume over 24-48 hours.
- Monitor patency of drainage tubes every hour in the first few hours after surgery then q 4 hours to ensure proper functioning.
- monitor incision for swelling after drainage tubes are removed
Post op home instructions after head or neck surgery
•Wound care instructions
-tracheostomy, NG tube, or G-tube feeding
•Need teaching and home health referral
- Patient and caregiver need teaching. - Encourage patient participation
•Needs to wear Medica Alert bracelet
- alert emergency personnel of possible changes in breathing bc of surgery
- If no longer breathes through nose the ability to smell smoke and taste food is often lost. Will need to install smoke and carbon monoxide detectors
- resume exercise, recreation, and sexual activity when able.
- Most return to work 1-2 months after surgery. Many never return to full-time employment
Complications postop thyroid surgery
• Hypothyroidism/Thyrotoxicosis
•Hypocalcemia
•Injury to laryngeal nerve
*** Vocal cord paralysis
•Infection
•Spastic airway obstruction due to paralysis of both cords
•Respiratory distress due to excess swelling
Nursing care postop thyroid surgery
• VS q15 mins until stable then q30 x24hr
•Monitor respiratory status
•Assess for hemorrhage or tracheal compression
•Trousseau’s sign and Chvostek’s
•Keep IV calcium on hand
•Assess operative site and dressing.
•Semi-Fowler’s position
- Support the head and neck with pillows.
- Avoid neck flexion to prevent tension on the suture line
