Week 9

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  1. Erythroplakia
    Difficult to differentiate from an inflammatory or immune response.
  2. Squamous Cell Carcinoma
    Other risk factors: textile workers, plumbers, coal and metal workers. Sun exposure, poor nutritional habits, poor oral hygiene and infection with HPV. Over 34, 000 new cases diagnosed each year, with almost 8,000 deaths (in the US).
  3. Basal Cell Carcinoma
    Pearly: A pale grayish white color, tinted with blue; tooth; Of a pale grayish white color, tinted with blue2nd most common type of oral cancer, but is much less common than squamous cell carcinoma.
  4. Malignant Oral Tumors: Interventions
    Iggy page 1236 Chart 56-3Maintaining an open airway: Position to maximize ventilation, remove secretions by encouraging coughing or suctioning, ausculatate breath sounds, administer humidified air or oxygenOral hygiene routine: ideally every 2 hours for ulcerated lesions, infection, or immediately post-op. soft bristled brush is preferred, The use of toothettes is discouraged because these may not adequately control bacteremia-promoting plaque. Lubricant can be applied to moisten lips and oral mucosa. Teach to avoid commercial mouth washes (contain alcohol) and lemon glycerin swabs (acidic), can cause burning and drying. (See chart 56-2 on page 1233 in Iggy), can use warm saline or baking soda rinse. Radiation therapy: Can be done by external beam (passes through the skin) or interstial implantation. External beam typically given as 5 daily treatments per week over a 6 to 9 week period. Interstitial is used for smaller lesions or to give a boost of radiation to the external beam method. Usually hospitalized for the duration of the treatment and placed on radiation transmission precautions. Chemotherapy: May receive one or more drugs. Surgical management: May remove smaller, noninvasive lesions in ambulatory with local anesthesia. May also be responsive to cryotherapy (extreme cold application)
  5. Postoperative Care
    Patient may have temporary or permanent tracheostomy. Elevate HOB at least 30 degrees to decrease edema by gravity. Collaborate with a speech pathologist for swallowing needs. What type of community needs do you think these people will have? (page 1239 Iggy)
  6. Salivary Gland Tumors
    Assessment to see if the tumor has invaded the hypoglossal nerve.

    žRelatively rare among oral tumorsžOften associated with radiation of the head and neck areasžAssessment—ability to wrinkle brow, raise eyebrows, squeeze eyes shut, wrinkle nose, pucker lips, puff out cheeks, and grimace or smiležTreatment of choice—surgical excision of the parotid gland
  7. Esophageal Tumors
    More than half metastasize, Esophagus is richly supplied with lymph tissue, there is early spread of tumors to the lymph nodes, in most cases the tumor is large and well established when diagnosed. 2 primary causes: tobacco use and heavy alcohol intake. Long term untreated GERD can lead to esophageal adenocarcinoma. For people with Barrett’s esophagus (cell appearance changes), the risk of cancer is greatly increased and ultimately becomes cancerous. odynophagia: painful swallowing.
  8. Esophageal Cancer
    Psychosocial: Diagnosis causes high anxiety, the disease is accompanied by distressing symptoms and is often terminal, the fear of choking, Diagnostic assessment: barium swallow with fluoroscopy usually first diagnostic test for dysphagia, definitive diagnosis is made by EUS, and EGD may also be done to inspect and obtain tissue for biopsy.
  9. Nonsurgical Management
    Nutrition therapy: semisoft foods or thickened liquids are preferred. Record intake. May need boost or ensure, enteral feedings may be needed, possibly gastrostomy tube or jejenostomy tubeSwallow therapy: encourage to suck on a lollipop to strengthen the tongue. Tilt head forward when swallowing, see chart 57-9 page 1258 Iggy. Sitting, preferably in chair to eat, not in bed, Chemotherapy: only moderately effective, usually given in combination with radiation. Chemo given to make the cells more sensitive to the effects of the radiation. Radiation therapy: only moderately effective, can be used palliatively to shrink the tumor. Chemoradiation: done together, chemo at week 1 and week 5, additional drug cycles give after radiation. Newest addition is targeted therapy, which interfere with the cancer cells growth in a variety of ways with less impact on the healthy cells. Photodynamic therapy: apply a light sensitive drug, 2 days after the injection, a fiberoptic probe with a light at the tip is threaded into the esophagus through an endoscope. The light activates the photofrin, destroying only the cancer cells. Esophageal dilation
  10. Surgical Management
    Conventional open surgical techniques are lengthy and are associated with many complications or death. Fistula formation between the trachea and esophagus, abcess and respiratory complications are common.MIE: for patients with early stage cancer a laparoscopic assisted MIE may be performed, most patients require open d/t to size of tumor and mets at the time of diagnosis.
  11. Esophagectomy
    The esophagus presents a difficult surgical challenge due to its location beneath the breastbone (sternum), posterior to the heart and between the lungs. Sometimes a local excision or tumor enucleation may be used for a very small esophageal GIST. However, for larger tumors most of the esophagus is removed in an esophagectomy. The following diagram illustrates how the stomach is brought up through the space formerly occupied by the esophagus.
  12. Postoperative Care
    For patients with traditional open surgery mechanical venitlation is needed for the first 16 to 24 hours. After extubation assessing, TCDB every 1to 2 hours, Incisional support, pain control. Cardiovascular: particularly hypotension during surgery d/t pressure placed on the posterior heart, usually responds well to IV fluid administration, Monitor for fluid volume overload esp. elderly, crackles, edema, increased jugular venous pressure. Observe for A-fib d/t vagus nerve irritation during surgery. Wound management: patient usually has multiple incisions and drains. Provide direct wound support during coughing and deep breathing to prevent dehisences. Wound infection can occur 4 to 5 days after surgery. Leaking from the anastomosis is a dreaded complication that can occur in 2 to 10 days, look for fever, fluid accumulation, early signs of shock (tachycardia, tachypnea, altered mental status). Do not irrigate or reposition and NG tube in patients who have undergone esophageal surgery unless requested by the surgeon. Drainage should change from bloody to yellowish green by the end of the first post op day. Oral nasal care every 2 to 4 hoursStart diet with liquids, advance as tolerated, place in an upright position, and supervise all initial swallowing efforts. The food storage area of the stomach has been radically altered and the only defense against reflux is gravity. Teach importance of 6 to 8 small meals daily, fluids should be taken between meals rather than with meals to prevent diarrhea. Diarrhea can occure 20 minutes to 2 hours after meals and can be managed with immodium before meals. Diarrhea result of vagotomy syndrome, which develops as a result of interrupted vagal fibers to the abdominal organs during surgery.
  13. Tracheostomy
    A vertical tracheal incision for a tracheostomy
  14. Interventions
    Iggy page 580Preoperative care: assess pt./ family knowledge deficits, discuss care communication and speech. Operative procedures: Incision is made, after the trachea is entered the ET tube is removed while the tracheostomy tube is inserted. Trach tube is secured with sutures and trach ties (or velcro holder). A chest xray is obtained to ensure proper placement of the tube. If intubation is not possible the procedure can be done with the patient awake under local anesthesia (yikes!)Postoperative care—ensure patent airway! Possible complications assessment: Tube obstruction: Indicators: difficulty breathing, noisy respirations, difficulty inserting a suction cathether, thick dry secretions, unexplained peak pressures (vent). Assess pt. at least hourly, Prevent obstruction by: helping the pt. C & DB, provide inner cannula care, humidify oxygen source, and suctioning. Tube dislodgment—accidental decannulation: Secure the tube! Tube dislodgement in the first 72 hours is an emergency because the tract has not matured and replacement is difficult. Ensure that tracheostomy tube of the same type and size (or 1 size smaller) is at the bedside.
  15. Other Possible Complications
    Pneumothorax (air in the chest cavity). Subcutaneous emphysema occurs when there is an opening or tear in the trachea and air escapes into fresh tissue planes of the neck. (text book says notify physician immediately)Subcutaneous emphysema Air may escape into the fresh tracheotomy incision, causing subcutaneous emphysema. Usually of no clinical consequence, subcutaneous emphysema may be alarming to the patient and family. The nurse inspects and palpates the neck and upper chest for edema and crepitus. A crackling sensation upon palpations is the hallmark sign of subcutaneous emphysema.1,3 The patient and family are reassured, as needed. Bleeding: small amounts can be expected for the first few days, but constant oozing is abnormal. Infection: Use trach dressing to keep the site clean and dry. If one is not available fold 4X4s and place around the site. Do not cut a 4x4, fragments can be aspirated.
  16. Tracheostomy Tubes
    Cuffed tube is used for patients receiving mechanical ventilation. A non cuffed tube is used for airway maintenance when mechanical ventilation is not required. Because breathing and swallowing move the tube, a cuffed tube does not protect against aspiration. Having a cuffed tube inflated may give a false sense of security that aspiration cannot occur during mouth care and feeding. In addition, the pilot balloon does not reflect whether the correct amount of air is present in the cuff. Tracheostomy tubes come in many varieties, including cuffed, uncuffed and fenestrated. A cuff is a soft balloon around the distal (far) end of the tube that can be inflated to allow for mechanical ventilation in patients with respiratory failure. The cuffs are inflated with air, foam or sterile water. There are several types of cuffs. The low volume cuff is similar to a balloon, a high volume cuff is barrel-shaped. The high volume cuff may be better to avoid complications such as stenosis, because it spreads the pressure out, rather than pushing on one spot in the airway. When the balloon is deflated, the tube allows air around tube for vocalization. In small children, cuffed tubes may not be needed, however, in older children a low-pressure cuff may be needed to achieve an adequate seal. A fenestrated tube can function in many ways. When the inner cannula is in place, the fenestration is covered over (closed) and this works like a double lumen tube. With the inner cannula removed and the plug or red stopper locked in place, air can pass through the fenestration, around the tube and up through the natural airway. The patient can then cough and speak. Always deflate the cuff before capping the tube with the decannulation cap; otherwise the patient has no airway. No MRI for patients with metal trachs, need to change to plastic prior to test.
  17. Possible Complications of Suctioning
    Vagal stimulation results in severe bradycardia, hypotension, heart block, V-tach, asystole, or other dysrhythmias.
  18. Head and Neck Cancer
    Can disrupt breathing, eating, facial appearance, self-image, speech & communication. Metastasize to lymph, muscle & bone nearby and distant sites usually lungs & liver
  19. Head and Neck Cancer
    History: may have had hoarseness, SOB, tumor bulk and pain. Tobacco & alcohol use, lumps in the neck, recurring laryngitis, pharyngitis or oral sores. Environmental and occupational history. PhonationPsychosocial assessment: denial, shame, guilt, blame, Laboratory assessment: CBC, bleeding time, urinalysis, and blood chemistries. Renal and liver function to rule out mets. Imaging assessment: CT, MRI, PET scans Other diagnostic assessment: laryngoscopy, nasopharyngoscopy, esophagoscopy, and bronchoscopy, with biopsies
  20. Head and Neck Cancer: Interventions
    • žRadiation therapy•Hoarseness can worsen•Sore throat, difficulty swallowingžChemotherapyžCordectomyžLaryngectomy
    • Cordectomy: removal of the vocal cordLaryngectomy:
Card Set
Week 9
cancer of neck
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