Mod 1. Lect 2. Upper Respiratory Disorders (NS2P2)
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**Review of Respiratory System Structures:
Upper-frontal sinus: eyebrow
-Naso-> Oro->Laryngeal pharynx.
Septoplasty, rhinoplasty, fracture reductions
**BEFORE SURGERY: stop Aspirin/NSAIDs for 2 weeks prior to reduce risk of bleeding.
=>Expect:Mouth breathing (swollen, can't breathe out of nose)Moderate swelling and discoloration
- =>Monitor:Vital signs
- Signs of bleeding: Observe for excessive swallowing, nausea (indicate bleeding-blood in stomach), Assess bleeding through nasal drip pad ("tampons")
- Semi-fowler’s position
- Provide adequate pain relief, hydration
- -Tonsillectomy or adnoidectomy: Post-op:; 11-12 days, high risk of bleeding because the scabs that have formed will have fallen, so severe bleeding will happen.
- -TEACH: don't nose blow, swim, heavy liftening or strenous exercise. Use of saline spray or rinse is okay.
surgical reconstruction of the nose: done cosmetically or to improve airway. CT assessed. Outpaitent procedure using regional or general anestheisa. Nasal packing after surgery (note: predisoposes pt to infection from bacteria present in nasal cavity)
Nose bleed; caused by low humidity, allergies, URI, sinusitis, trauma, Hypertension, Aspriin (prolongs bleeding)
-Interventions: Quiet pt, lean head slightly forward, apply dirrect prssure by pinching entire soft lower portion of nose against nasal septum for 10-15 mins.
- -Medical managment: vasoconstruct agent, cauterization, anterior packing, nasal tampon= pledgets impregnanted in lidocaine. Vasoconstrictive agents: cocaine or epinephrine. Silver nitrate to cauterize after epistaxis has stopped. Use of Epistaxis Balloons (Rapid Rhino) to inflate or use of a nasal sling using 2x2 pad.
- -Observe LOC, Pulse ox,
Inflammation and irritation of nasal mucus membranes
- =>Causes include
- Allergic-can be intermittent or perennial, seasonal.
- Nonallergic: trauma, kids sticking things up their nose, hormonal, smoking cocaine/drug use damages nasal mucosa, vasomotor decreased circulation to that area.
=>Allergic rhinitis is an IgE mediated inflammatory disease (can be seasonal or all year long): sensitization
to an allergen occurs with intial allergen exposure, which results in the production of antigen speficic immunoglubulin E. Causes sneezing, itching, rhinnorrhea and congestions.
Seasonal/intermittent vs perennial/persistentUsual triggers include pollen, dust mites, pet dander, molds (there's a mold count in texas...)Usually develops <20 years oldFamilial history
- =>Clinical Manifestations
- Triad of nasal congestion, sneezing, clear rhinorrhea (runny nose)
- Itchy, puffy eyes
- Pale, boggy nasal mucosa
- Enlarged turbinates Mouth breathing
- Allergic shiners (black eye without trauma, mucosa so blocked up that blood pools around tissues in eye causing a black eye.)
- =>Collaborative Care of Allergic Rhinitis
- Identify and eliminate allergens (most important in managing): Keep diary of potential triggers-allergen testing is beneficial for these patients
- -the bedroom should be the most allergic free: hepa filter, wood floors, no pets, clean bedding, run a/c?
- =>Drug therapy when allergen avoidance is ineffective
- Notes: second generation prefffered over first, adqaute fluid intake,
- Oral H1 blockers- loratadine (Claritin), cetirizine (Zyrtec), fexofenadine (Allegra) (second generation of allergen blockers because no sedation occurs ! vs First generation: Benadryl)
- Corticosteroid Nasal Sprays- fluticasone (Flonase), mometasone (Nasonex), triamcinolone (Nasacort) (second line of defense, nasally administered so no systemic side effects despite being corticos, Use REGULARLY, not PRN)
oral phenylephrine (Sudafed-vasoconstriction clears all inflammation, but contraindicated in BP issues, rebound vasodilation/swellling can occur so limit for 2-3 days maybe to one nostril), topical phenylephrine (Neo-
- Synephrine--not as long acting), topical azelastine (Astelin), topical oxymetazolin (Afrin)
- Leukotriene receptor-blockers, mast cell stabilizers
Spread by airborne droplets, frquent during winter (due to indoor crowding), exercise can reduce number of URIs
=> Care of the Patient
=> Types of meds used
=> Collaborative Care
- -inflammed sinuses with excess mucus. Usually frontal and shenoid sinuses.
- -tiny drain holes in sinuses but too thick can cause buildup material, procedures to drill into sinuses to make those holes bigger."Ostia" the opening that swelling block.
- Secondary to Upper Resp Infection, allergic rhinitis, swimming, dental work, Significant pain, congestion, fever, malaise
- Diagnosed via H&P
- -swimming changes pressure in sinus canal and exposes sinuses to unsanitary conditions -chemicals can cause inflammation: bleach.
- -Doctor tapping on face: checking for sinus tenderness and congestness.
- xrays/CT required for diagnosis.
- -50% of asthma have chronic sinusitis: post nasal drip associated with sinusitis may trigger asthama by stimulating brochosconstriction. GERD and smoking also increase.
- Usually secondary to allergies, occupational exposure, or nasal polyps
- Lasts >4 weeks
- Irreversible damage w/ repeated episodes of inflammation.
- May require imaging to diagnose (CT Scan)
- =>Care of the patient with Rhinitis or Sinusitis
- Identify cause (i.e. allergen)
- Keep diary of potential triggers
- Goal of medication is to reduce inflammation
- H1 antihistamines
- Corticosteriods (nasal) To decrease inflammation
- Decongestants: to promote drainage
- Leukotriene receptor-blockers (study more on..)
- analgesics: for pain
- Saline nasal spray: rinse nasal passages.
- =>Collaborative Care of Sinusitis
- Treatment of allergic rhinitis/underlying cause (try to avoid corticosteroids, keep as last resort
- Symptom relief
- Steam inhalations & warm showers (twice daily), bedside humidifiers
- Nasal irrigation/saline spraysWarm compresses
- Patient Teaching: avoiding swimming, air travel (changes sinus pressures) smoking, hard to distinguish between viral and bacterial cuases, most cases of acute resolve w/o complications in 7-10 days.
- Antibiotic therapy -amoxicillin or augmentin (first line), second line: bactrine-use distilled water!-smoke is irritant.
-Acute vs Chronic
- Inflammation of the pharyngeal walls, tonsils, palate, and uvuula
- -90% viral
- -fungal: from inhaled corticosteroids and antibiotics.-
- =>Acute: infections, allergic rhinitis, post-nasal drip, mouth breathing, trauma
- -when viral cause: strept throat is mostly the cause.
rhinitis/sinusitis, dental sepsis, obstructions, mouth breathing (drying of mucosa-increase thickness of secretions), GERD (see asthma, stomach contents being aspirated into lungs causing allergic reaction), chronic irritants such as smoking or occupational exposure
- =>Clinical manifestations
- Red, edematous pharynx Sore throat, "scratchy throat"Pain w/ swallowingTonsillar exudates (swollen tonsils)
- Cervical lymphadenopathy (swollen lymphs)
- Fever, chills
- -Rapid strept test-quick swab.
**Collaborative Care of Pharyngitis: Acute vs. Chronic
- Rapid strep test if suspected
- Supportive measures: OTC, saline, gargle wash, lemon water, tea
- Antibiotic therapy for bacterial infections: penicillins for strept throat
- Treatment of underlying causes (like allergies)
- -candida infections treated with nystatin (Mycosstatin)
- -antifungal antibiotic
- Identify and treat precipitating causes
- Symptom relief
- Laser cautery: if there's increased swelling in the throat, tonsillectomy--decrease for recurrent strept throat.
**Specific Disorders of the Pharynx
: Acute, Bacterial or Viral
- Adenoiditis (pharyngeal tonsillitis)
- -tonsil stones: tonsils get so inflammed and swollen, deep canyons in tissue so exudate gets in there and solidifies.
(collection of purulent exudate between the tonsillar capsule and surrounding tissues)
(inflammation of the pharynx): Physical, Chemical
**Nursing Process: Upper Respiratory Infections
- =>Objective/Subjective Data:
- Generalized discomfort
- Allergies: Environmental, Chemical
- Inspection of nose, neck, throat: Palpation of lymph nodes, Swallowing
**Nursing Diagnoses: URIs
- Ineffective Airway Clearance
- Acute Pain
- Impaired Verbal Communication
- Fluid Volume Deficit (pain, swelling--may not want to drink many fluids)
- Knowledge Deficit
**Nursing Considerations: Upper Respiratory Infections
- =>Prevention of upper airway infections
- Avoid crowds
- Use disposable tissues (to avoid spread of infection)
- Proper nutrition and hydration
- Adequate sleep/rest
- Tobacco avoidance
- -Emphasize frequent handwashing with good technique
- -When to contact health care provider
- -Annual influenza vaccines
- =>Provide education regarding antibiotic therapy
- When are antibiotics effective? They're not always necessary. Do I need an antibiotic?What else can I do to get better?What is the harm of taking unnecessary antibiotics?
- =>Provide education to reduce antibiotic resistance
- Take your Rx only
- Don’t skip doses
- Finish the full course of treatment-widespread and inappropriate use of antibiotic will cause antibiotic resistant bacteria.
- -go back to doc if your symptoms persist for more than 7 days. Increased temp >100.4.-dehydration, purulent drainage, worsening cough--> s/s of complications or secondary bacterial infection
**Potential Complications of Upper Airway Diseases
- Peritonsillar abscess
- Otitis media (ear infections)
- Sinusitis also croup.
- tracheotomy: surgical incision into airway, either elective (need for prolonged ventillation) or needed."surgically created stoma (opening) in the treachea to establish an airway. Used to bypass an upper airway obstruction, facilitate removal of secretions or permi long term mechanical ventilation.-Most pts who require mechanical ventilation are intially managed with an endoctracheal tube (ch 6)
- -speaking can be faciltated with deflated cuff, and eating is permitted :)
- -Obturator: used when iserting the tube, placed inside the OUTER cannula with rounded tip protudeing from end of tube to ease insertion then immediately remove obtruator.
- -some trache tubes have disposable inner cannula.
- -HOW TO SUCTION: Table 27-6 (pg 509)
- Prolonged intubation
- Inability of patient to manage secretions
- Upper airway obstruction
- Facilitation of ventilation support
- Adjunct to head/neck surgery or trauma
- Decreased damage to airway
- Increased mobility and comfort (they don't have to sedated on the ventillator)
- Enhanced communication and nutrition (vs et tube)
- More secure airway
- Improved suctioning
- Early transfer of ventilator dependent patients from ICU
-inflated cuff trache:
with high risks of aspiration of oral secretions, protects that airways from secretions draining down the lungs causing secretion aspiration.
- -Uncuffed: allows speaking, allows air to pass through BUT aspiration risk.
- -pilot baloon: prescribed level, if too much pressure you'll degrade the mucosa of trachea and decrease circulation.
- -dont always need a cuffed trache, must uninflate to speak
- -Flangers "Faceplate"-OBTURATOR by bedside.
- => INFLATED CUFF: Used if the patient is at risk for aspiration, the cuff may be deflated to allow talking and easier swallowing. BEFORE deflation, cough up secretions and suction to prevent aspiration during deflation.
- -Takes 5-7 days for stoma to heal: take care not dislodge.
- -Because tube replacement is difficult, several precuations are required:
- 1. Keep a replaccement tube of equal or smaller size at bedside, readily fore emergeyncy reinsertion.
- 2. Do not change trach tapes for at least 24 hours after insertion
- 3. a doctor performs the first tube change no sooners than 7 days within insertion.
=> IF DISLODGED: immediately attemp to replace it, use a hemostat to spread the opening to facilitate replacing tube. Insert the obturator in the replaceent tube, lubricated with saline, and insert the tube into stoma at 45 degree angle to the neck. Then remove obturator for airflow.
=>talking: Deflat cuff first-Fenestrated: opening on surface of outter cannula, only pts who can swallow without risk of aspiration.
**Postop Trach Management
- Keep obturator at bedside
- Humidification of inspired gas (bypassing upper airways!)
- First trach tube change day 5-7 by MD
- May change to uncuffed tube if PPV no longer required
- Assess for need for suctioning PRN: Secretions upon exam, Suspected aspiration, Tachypnea, sustained cough, respiratory distress (NEVEER scheduled)
- Document: color, consistency. s/s aspiration (tachypnea, cough, respirations)
- =>Routine tracheostomy care
- Stoma care daily or BIDChange ties (one side at a time)
**Weaning from Trach
Demonstrates stability (02 stats, no resp disress, or SOB) for 24-48 hours after discontinuing mechanical ventilation
Cuff is deflated and tube capped (so air no longer going through trache, using mouth breathing)
After decannulation, stoma covered with occlusive dressing
Stoma will close within 48-72 hours (2-3 days)
- Damage to the trachea
- Pneumothorax (collapsed lung)
- Misplacement or displacement of tracheostomy tube
- Tracheosophageal fistula: hole caused when erosions b/w trachea and essophagus, cuff with too much pressure erodes back wall of that trachea. (biggest one)
- Mucus plugs: thick, tenacious clog of sputum that can impede the airway. Respiratory distress
**Cancer of the Larynx
- Over 12,000 new cases annually
- More than 3500 deaths annuallymore common in Men>women
- Most common age of diagnosis 50-70 years
- African Americans>Caucasian Americans
- =>Risk factors
- Tobacco use (highest)
- HPV infection
- Poor nutrition
- Occupational exposure
- Wood dust, paint fumes, chemicals used in textile, petroleum, plastic industries
- TWO TYPES OF LARYNGEAL CANCER: =>Supraglottic: false vocal cords above the vocal cords (35% of cases); if that gets removed, they can usually talk
- -95% are squamous cells and <5% is adenocarcinoma or sarcoma.
- => Glottic: true vocal cords (60% of cases)
- Remainder of cases are either subglottic or too difficult to determine
**Symptoms of Laryngeal Cancer
- Persistent cough
- Sore throat or pain and burning in the throat
- Lump in the neck
Dysphagia, dyspnea, unilateral nasal obstruction, persistent hoarseness, persistent ulceration, foul breath
Weight loss, debilitation, lymphadenopathy (swollen lymphs), and radiation of pain to the ear
**Diagnosis of Laryngeal Cancer
- H&P: Ask about Substance use, Occupational exposure
- Laryngoscopic exam and biopsy: Tumors are staged and classified (TNM)
- -T (Tumor Size)
- N: (number and location of involved nodes) M: (extent of metastasis)
- CT, MRI-used to stage cancer
**Treatment of Laryngeal Cancer
Radiation therapy and/or chemotherapy (stage 1-2)
Partial laryngectomy (stage 1-2)
Supraglottic laryngectomy (voice sparing): false and epiglottis)Removes structures above the TRUE vocal cords (the Temporary trach
- Temporary trach (longer in place than above)
- Partial voice control
- Swallowing intact
- =>Total laryngectomy (Radical neck dissection-accompanied by total laryngectomy: take out lymph nodes, muscle, glands, LOTS of tissues- so perm loss of voice and voice prostesis needed. )
- Permanent trach
- No voice (may need TEP-Trans Esophageal Puncture-)- is a surgically created hole between the trachea (windpipe) and the esophagus (the tubal pathway between the throat and the stomach) in a person who has had a total laryngectomy, a surgery where the larynx (voice box) is removed. The purpose of the puncture is to restore a person’s ability to speak after the vocal cords have been removed. This involves creation of a fistula between trachea and oesophagus, puncturing the short segment of tissue or “common wall” that typically separates these two structures. A voice prosthesis is inserted into this puncture. The prosthesis keeps food out of the trachea but lets air into the esophagus for oesophageal speech.
- Swallowing intact
- May need temporary g-tube
**Changes in Airflow with Total Laryngectomy and Interventions
- -speech: occurs with air coming out of nose and mouth
- -surgical tie off of trachea
- -TEP voice Prostesis: (trachea esophageal prostesis) placed by surgeon after vocal cords have been removed, some require stoma to be covered and some don't ("hands free); vibrating sounds
- -esophageal speech: swallow air and force it through their mouth like burping.
**Nursing Process: The Care of a Patient with a Laryngectomy
=> Physical Assessment
- Health history
- History of alcohol abuse
- History of Chemical abuse
- Current occupation
- Learning needs
- Patient and family coping and support systems
- =>Physical assessment
- Lung sounds
- Mucous membranes
- Nutritional status (good nutrition to heal from surgery)
- Hearing ability
- Visual acuity
- Communication techniques
**Collaborative Care- Total Laryngectomy
- =>Tracheostomy care
- Frequent respiratory assessment
- -go to ICU first then stable-> Med surge floor. High risk for pulm complications
- NPO/NGT initially then --> swallow in 5-7 days
- Speech-language pathologist, dietary consults: muscle exercise, compensatory stategies to tuck chin to close off trachea when swallowing to open up esophagus to get less aspiration risk.
- -May be on soft diet in the beginning.
- WhiteboardSpeech therapy consult:
**Nursing Process: The Care of a Patient with a LaryngectomyND's:
Knowledge deficit with post op, Anxiety/Depression (rate it), Alteration in communication, Ineffective Airway Clearance, Imbalanced Nutritions (monitor weights), Self care deficit with traches, Body image disturbance (affects diet and communication-join therapy groups)
**Potential Collaborative Problems
- Respiratory distress
- Wound breakdown
**Discharge Teaching (stoma care)
Stoma care: Stoma should be clean, moist, glistening
- =>Stoma precautions-they can shower, but MUST cover trache.
- No swimming/bathing or contact sportsShower guardsAvoid inhalation of foreign bodies
- Constipation ( cover stoma IF they bear down.)
- Mouth hygiene (altered smell senses, altered nerves)
- can't smell smoke! (smoke detectors) avoid lifting, strainging pos op. Mucous, gagging, check if clean.
- Psychosocial concerns
- Safety concerns: Medi-Alert bracelet
**Mr. K is being discharged on the post op day #7, s/p hemi-larygectomy. His wife was taught care of the trach. Which statement reflects further teaching is required for long-term trach care and management?
“Mr. K can take a shower daily.”
“Mr. K should drink 8-10 glasses of water a day.”
“Mr. K can resume all of his sport activities.”
“Mr. K should have a yearly flu shot.”
“Mr. K can resume all of his sport activities.” (THIS because he must avoid contact sports and no swimming)
=> Nasal fractures:
Either simple or complex
-clinical manifestations: localized pain, creptius on palpation, swelling, ecchymosis (racoon eyes), epistaix or idfficulty breathing. Clear, pink tinged drainage AFTER control of eipstaxis (nose bleed) means CSF leak. Do a test for glucose, if present= csf liquid /:
-Interventions: Priority (maintain airway) by reducing edema, and reduce pain. Keep pt upright, apply ice to the face and nose in 10-20 min intervals, administer analgesia as prescribed (tylenol prefered fover NSAIDS or ASA's. Nasal stuffiness may be relieved with nasal decongestant, nasal saline spray. Quit smoking to maximize tissue healing.
-septoplasty or rhintoplasty (closed or open reductions) and to avoid septal hematomas.
-Onset: Chills, fever, anorexia, malaise, generalized myalgia, headache, cough, rhinorrhea and sore throat.
-most common complication: pneumonia (viral-influenza) or secondary bacterial.
-viral cultures: gold standard: 3-10 days for result.
-Prevention is most effective.
-antiviral medications: Relenza and tamiflu
CH 26 Reading notes:
-Primary purpose of Respiratory system: gas exchange b/w atmosphere and blood.
Nose, mouth, pharynx, epiglottis, larynx, and trachea
-R lung easier to aspiration due to the mainstem bronchhus shorter, wider and straighter.
: lipoprotien that lowrs surface tension and less likely to collapse.
- -LUNGS: Pulmonary artery receives deoxygenated blood from riight ventricle of the heart and delivers in to pulmonary capilatires that are connected with alveoli. Here gas exchanebe occurs so that pulmonary veins return oxygenated blood back to the left atrium.VENOUS blood is collected from capillary netrworks of the body and returned to right atrium by way of the veae cavae.
- -> Bronchial ciruclation: starts with the bronchial arterials which arise from the thoracic aorta. Bronchial circulation provides oxygen to the bronchi and other pulmonary tissues.
-Parietal pleura: irritation causes pain; has sensory fibers unlike visceral
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