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Chapter 53
Nose Sinus, and Throat Disorders
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Learning Objectives
• Describe the nursing assessment of the nose, sinuses,and throat.
• Identify nursing responsibilities for patients undergoingtests or procedures to diagnose disorders of the nose,sinuses, or throat.
• Describe the nurse’s role when the following commontherapeutic measures are instituted: administration oftopical medications, irrigations, humidification, suctioning,tracheostomy care, and surgery.
• Explain the pathophysiology, signs and symptoms, complications,and medical or surgical treatment of selecteddisorders of the nose, sinuses, and throat.
• Assist in developing nursing care plans for patients withdisorders of the nose, sinuses, or throat.
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Anatomy and Physiology of the Nose, Sinuses, and Throat
• Nose• External nose• Internal nose
• Sinuses• Maxillary, frontal, ethmoid, and sphenoid
• Throat
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Figure 53-1
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Figure 53-2
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Health History
• Chief complaint and history of present illness • Obtain detailed description of the patient’s
complaints
• Past medical history • Previous streptococcal infections; sinus infections;
surgery on the nose, sinuses, or throat; known allergies; and current and recent medications
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Health History
• Review of systems • Presence of nasal discharge (amount, color),
obstruction, bleeding, sneezing, snoring, throat pain or soreness, hoarseness, aphonia (loss of voice), and earache
• An altered sense of smell or facial pain should be noted
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Physical Examination
• External nose examined for size, shape, color, and lesions
• If drainage, note amount, color, and consistency
• Examiner listens for abnormal breath sounds and notes whether the patient is breathing through the nose or the mouth
• Patency of the nostrils determined by gently closing one naris at a time and instructing the patient to breathe through the other naris
• The sinuses are assessed indirectly
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Physical Examination
• Examiner palpates over the frontal and maxillary sinuses for tenderness or pain
• Inspect throat at the back of the oral cavity• Mucous membranes and tonsils inspected for
redness, swelling, drainage, lesions • Inspection and palpation of the neck may
reveal enlarged lymph nodes
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Age-Related Changes in the Nose, Sinuses, and Throat
• Nasal obstruction more common because of the softening of the cartilage of the external nose
• Mucous membrane thinner; produces less mucus • Epistaxis (nosebleed) more common in older people• Decline in the sense of smell as people age • Tissues of larynx are drier and less elastic in older
adult • Weakened esophageal sphincter allows gastric
contents to flow back into the throat when the patient lies down
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Diagnostic Tests and Procedures
• Throat culture• Isolate and identify infective organisms
• Laryngoscopy • Inspection of the larynx to aid in diagnosis of
abnormalities or to remove foreign bodies
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Figure 53-3
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Therapeutic Measures
• Nose drops• Nasal and throat irrigations• Humidification• Suctioning• Tracheostomy care• Nasal surgery
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Care of the Patient Having Nasal Surgery
• Assessment• Pain, pressure, anxiety, and dyspnea • Monitor vital signs to detect signs of excessive
blood loss • Number of dressings saturated and the frequency of
changes • Bleeding from the nasal cavity may flow into throat
and be swallowed although the dressing remains dry
• Check back of throat for bleeding; be alert for frequent swallowing
• Inspect vomitus and stool for blood (bright red or “coffee ground” emesis and red, maroon, or black stools)
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Care of the Patient Having Nasal Surgery
• Interventions• Decreased Cardiac Output • Acute Pain • Impaired Gas Exchange • Disturbed Body Image
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Disorders of the Nose, Sinuses, Throat, and Larynx
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Sinusitis
• Inflammation of the sinuses, most often the maxillary and frontal sinuses
• Most common organisms are Staphylococcus pneumoniae, Haemophilus influenzae, Diplococcus, and Bacteroides
• Signs and symptoms • Pain or a feeling of heaviness over the affected area • Purulent drainage from the nose • When maxillary sinuses affected, pain may seem like a toothache • Headache is common, especially in the morning • Fever may be present; white blood cell count may be elevated
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Sinusitis
• Complications • Chronic sinusitis, meningitis, brain abscess, osteomyelitis, and
orbital cellulitis
• Medical diagnosis and treatment • Diagnosis
• Sinus radiographs, CT; sinus aspiration or nasal endoscopy
• Treatment• Antibiotics, decongestants, nasal corticosteroids, analgesics, and
antipyretics• Twice-daily hot showers, increased fluid intake, humidifier • Functional endoscopic sinus surgery (FESS); Caldwell-Luc
procedure
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Care of the Patient Having Sinus Surgery
• After FESS, able to return to work in 4-5 days • Saline nasal sprays ordered to prevent crusting
and promote healing • After the Caldwell-Luc procedure, the semi-
Fowler’s position is recommended to prevent swelling and promote drainage
• Apply cold compresses as ordered during the first 24 hours
• Provide gentle oral care to avoid injury to the incision
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Care of the Patient Having Sinus Surgery
• Nasal packing is usually left in place until the first postoperative day
• Antral packing is left in place for 36 to 72 hours • Caution the patient to avoid blowing the nose
or straining, which could cause bleeding and tissue damage
• Three to 5 days after the Caldwell-Luc procedure, nasal saline sprays may be ordered to moisten the nasal mucosa
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Nasal Polyps
• Swollen masses of sinus or nasal mucosa and connective tissue that extend into the nasal passages
• Exact cause is unknown, but patients often have a history of allergic rhinitis or infections
• The size of the polyps may be reduced by removing allergens or treating the allergic response
• Corticosteroids inhaled nasally may be prescribed • Surgical removal under local anesthesia, however, is
often necessary • Nasal polyps tend to recur
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Care of the Patient Having Nasal Polyp Surgery
• Often in an outpatient surgical facility, so patient teaching before discharge is especially important
• Advise patient not to take aspirin because it increases the risk of bleeding and because some patients are allergic to aspirin
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Allergic Rhinitis
• “Hay fever”: acute (seasonal) or chronic (perennial) • Follows exposure to a substance (allergen) that causes
an allergic response • A reaction to the release of chemicals, including histamine,
that cause vasodilation and increased capillary permeability
• Fluid leaks from capillaries; causes swelling of nasal mucosa
• Occasionally these changes are triggered by overuse of decongestant nose drops or sprays
• Acute allergic rhinitis often from exposure to pollens • The chronic form is more likely due to allergens that
are continuously in the environment
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Allergic Rhinitis
• Signs and symptoms
• Nasal obstruction; sneezing; clear nasal discharge; frontal headache; and itchy, watery eyes
• Nasal mucosa is often pale, but it can be red or bluish
• Medical diagnosis
• Made on the basis of a detailed history • With chronic symptoms, the patient may be
instructed to keep a diary describing all episodes
• This can help identify possible allergens
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Allergic Rhinitis
• Medical treatment • Desensitizing injections may be advised to decrease
the patient’s reaction to the offending allergens • The drugs used to treat allergic rhinitis are primarily
antihistamines and decongestants
• Nursing care• Patients with allergic rhinitis are usually outpatients • The nurse who works in a clinic or physician’s office
may need to reinforce teaching about desensitization and drug therapy
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Acute Viral Coryza
• The common cold• Can be caused by any of some 30 viruses • It is contagious and spread by droplet infection • Signs and symptoms
• Fever, fatigue, nasal discharge, and sore throat
• Complications• Otitis media, sinusitis, bronchitis, and pneumonia
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Acute Viral Coryza
• Medical treatment • Antihistamines, decongestants, and antipyretics
• Prevention • Best accomplished by avoiding people with colds
• Nursing care• Primarily public education about prevention and
about drugs prescribed for treatment • Encourage patients to rest and to drink plenty of
fluids
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Tumors
• Signs and symptoms • Nasal obstruction • Bloody discharge from one nasal passage • Lesions on the external nose typically begin as
small, painless ulcers that do not heal
• Medical diagnosis• Diagnosed by taking a biopsy of the tumor or
removing the entire tumor for examination
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Tumors
• Medical treatment • Combination of surgery, radiation therapy, and chemotherapy • Surgical procedures may be extensive and disfiguring,
depending on the site and extent of the cancer • Reconstructive surgery or prostheses may be needed
• Nursing care• Patient may be especially anxious and fearful of disfigurement
or even death • Be supportive and encourage the patient to ask questions and
express concerns
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Deviated Nasal Septum
• Nose divided into two passages by a cartilaginous wall called the septum
• In most adults, septum is slightly deviated, meaning it is off center
• Minor deviations cause no symptoms and require no treatment
• Major deviations, however, can obstruct the nasal passages and block sinus drainage
• Headaches, sinusitis, and epistaxis• Treatment: submucosal resection/nasal septoplasty
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Epistaxis
• Nosebleed; from trauma, clotting disorders, dryness, inflammation, and hypertension
• First aid • The patient should sit down and lean forward • Direct pressure should be applied for 3 to 5 minutes
• Medical treatment • Nasal balloon catheter • Nasal packing • Complications
• Infection, blockage of the eustachian tube, and airway obstruction
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Figure 16-7
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Figure 53-5
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Epistaxis
• Assessment • Inspect the nose and back of the throat for obvious
bleeding and observe for frequent swallowing • Level of consciousness and vital signs to detect
signs of hypovolemia• Document allergies and major illnesses
• Interventions
• Decreased Cardiac Output • Anxiety • Risk for Injury and Infection
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Pharyngitis
• Inflammation of the mucous membranes of the throat or pharynx
• Usually is caused by a virus but sometimes by bacteria
• Also can follow exposure to irritating substances in the environment
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Pharyngitis
• Signs and symptoms • Dryness, pain, dysphagia (difficulty swallowing), and
fever • The throat appears red, and the tonsils may be
enlarged• Compared with viral pharyngitis, bacterial
pharyngitis has abrupt onset; characterized by abnormal blood cell counts, fever greater than
101° F, and muscle and joint pain
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Pharyngitis
• Complications • Acute glomerulonephritis and rheumatic fever
• Medical diagnosis • Throat culture and a complete blood count
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Pharyngitis
• Medical treatment • Rest, fluids, analgesics, throat gargles or irrigations • Bed rest as long as patient has a fever • If oral intake is low, intravenous fluids• Soft/liquid diet because of painful swallowing • Humidifier to increase moisture in the room air • Antibiotics, usually penicillin or erythromycin, while
awaiting the results of the throat culture
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Pharyngitis
• Prevention• People with poor resistance should avoid others
with upper respiratory infections • Good nutrition, adequate rest, avoidance of chilling,
and avoidance of inhaled irritants • People who have pharyngitis are contagious in the
early stages and should avoid contact with susceptible people
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Pharyngitis
• Assessment • Throat pain, dysphagia, muscle and joint pain,
nausea and vomiting, and rash • Take the patient’s temperature, and inspect the
throat for redness and enlarged tonsils
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Pharyngitis
• Interventions • Reinforce physician’s directions for drug therapy • Stress importance of completing prescribed
antibiotics • 2000-3000 mL fluids daily unless contraindicated • Advise patients that they are contagious at first and
should not be exposed to people with poor resistance
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Tonsillitis
• Inflammation of tonsils/other throat lymphatic tissue
• Common in children but more severe in adults • Causes
• Usually bacterial, but sometimes caused by a virus • Causative organisms: streptococci, staphylococci,
H. influenzae, and pneumococci • The infection is contagious; spread by food or
airborne routes • Most cases run their course in 7 to 10 days • May have repeated infections that respond to
treatment or may have a chronic infection
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Tonsillitis
• Signs and symptoms
• Sore throat, difficulty swallowing, fever, chills, muscle aches, and headache
• If swollen tissue blocks eustachian tubes, ear pain • Offensive breath odor often with chronic infection • The tonsils typically are enlarged and red • Purulent drainage/yellowish or white patches on
tonsils • Lymph nodes in the neck may be tender and
enlarged
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Tonsillitis
• Medical diagnosis • Complete blood count, throat culture and sensitivity,
and a test for infectious mononucleosis
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Tonsillitis
• Medical treatment • Antibiotic therapy for 7 to 10 days • Analgesics and anesthetic lozenges for pain and
antipyretics for fever • Warm saline gargles or irrigations to decrease
swelling and remove drainage • Rest and adequate fluids promote recovery and
decrease the risk of complications
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Tonsillitis
• Complications• Peritonsillar abscess
• Surgical treatment • Tonsillectomy and adenoidectomy
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Care of the Patient Having a Tonsillectomy
• Assessment• Frequently monitor responsiveness/vital signs • Inspect drainage from the mouth or vomited fluid for
blood • Excessive swallowing may indicate bleeding • Monitor respiratory effort and skin color to evaluate
oxygenation • Evaluate pain and dysphagia
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Care of the Patient Having a Tonsillectomy
• Interventions• Decreased Cardiac Output• Ineffective Airway Clearance • Acute Pain • Ineffective Therapeutic Regimen Management
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Obstructive Sleep Apnea
• Airway obstruction during sleep • The tongue and soft palate fall backward partially or
completely blocking the airway, causing apnea and hypopnea (abnormally slow, shallow breathing)
• Blood oxygen level falls; carbon dioxide level rises • Stimulate ventilation; cause the patient to arouse • Patient startles, snorts, and gasps causing the tongue
and soft palate to move forward so the airway is open
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Figure 53-6
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Obstructive Sleep Apnea
• Symptoms related to disrupted sleep pattern • Patient often irritable and sleepy during the day
• Sleeping partner may report loud snoring or
episodes of apnea • Symptoms can affect many aspects of life • Concentration and memory may be impaired • Hypertension and cardiac dysrhythmias • Diagnosis confirmed by polysomnography
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Obstructive Sleep Apnea
• Conservative treatment: weight loss if obese, avoidance of sedatives and alcohol for 3-4 hours before bedtime
• Oral appliance that shifts mandible and tongue forward may be effective
• Serious symptoms are treated with nasal continuous positive airway pressure (CPAP)
• Surgical procedures: uvulopalatopharyngoplasty (UPPP or UP3), genioglossal advancement and hyoid myotomy (GAHM), and laser-assisted uvulopalatoplasty (LAUP)
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Figure 53-7
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Laryngitis
• Inflammation of the larynx • Causes: upper respiratory infections, voice
strain, smoking, alcohol ingestion, and inhalation of irritating fumes
• Signs and symptoms• Hoarseness, cough, and scratchy or painful throat • Aphonia: absence of sound production; “losing” his
or her voice
• Medical diagnosis • Patient’s history and symptoms• Throat culture
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Laryngitis
• Medical treatment • Voice rest is advised, meaning that the patient
should not talk • Removal of the irritant
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Laryngitis
• Assessment• Document severity, how long it has persisted, and
factors that to aggravate or precipitate it • Information about the patient’s occupation and
hobbies may provide clues to the cause of the laryngitis
• Take the patient’s temperature and describe respiratory status to detect possible infection
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Laryngitis
• Interventions• Pad and pencil or Magic Slate for communication • Sign over the bed noting that patient should not
speak • Notice on the intercom at the nurse’s station that the
patient cannot (or should not) speak• Discourage smoking • An environment with a constant temperature• Teach patients that irritants can lead to laryngitis • Recognize irritants in the home and workplace and
know how to protect themselves from harm
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Laryngeal Nodules
• Benign masses of fibrous tissue result primarily from voice overuse but can follow infections
• Singers and public speakers prone to development of nodules
• The only symptom is hoarseness • Nodules are surgically removed under local or
general anesthesia
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Laryngeal Polyps
• Swollen mass of mucous membrane attached to vocal cord
• Can cause continuous or intermittent hoarseness, depending on its location and attachment
• In heavy smokers, masses may develop on both cords
• A procedure called stripping of the vocal cords is necessary to treat this condition
• Unless patient continues smoking, condition usually does not return
• Voice rest prescribed if polyps removed
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Cancer of the Larynx
• Factors: exposure to smoke or other noxious fumes, alcohol consumption, vocal strain, and chronic laryngitis
• Malignant tumors can develop throughout the larynx: above the glottis, on the vocal cords, or below the vocal cords
• Most malignancies are squamous cell carcinomas
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Cancer of the Larynx
• Signs and symptoms • Early symptoms include persistent hoarseness or
sore throat and ear pain • Later signs and symptoms are hemoptysis and
difficulty swallowing or breathing
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Cancer of the Larynx
• Prevention • Stop smoking and drinking alcohol• The public also should be educated to recognize the
signs and symptoms of laryngeal cancer and seek prompt medical attention
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Cancer of the Larynx
• Medical diagnosis • Confirmed by study of a tissue sample obtained
during a laryngoscopy • Radiographs, CT scans, and MRI to define the
extent of the cancer
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Cancer of the Larynx
• Medical treatment • Surgery, radiotherapy, chemotherapy, or a
combination • Surgery: from simple removal of the tumor to
extensive procedures, such as laryngectomy and modified or radical neck dissection
• A laryngectomy can be total or partial • Voice preserved with hemilaryngectomy or
supraglottic laryngectomy; total laryngectomy causes permanent loss of the natural voice
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Figure 53-8
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Care of the Patient Having a Total Laryngectomy
• If patient will lose the ability to speak, information about other means of communication should be available
• Listen compassionately and accept the patient’s expressions of anger or despair
• A total laryngectomy will require that the patient breathe through the trachea
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Care of the Patient Having a Total Laryngectomy
• Complications • Salivary fistula, carotid artery blowout, tracheal
stenosis
• Assessment• Patient’s level of consciousness • Ask about pain and observe for signs of discomfort • Measure vital signs at frequent intervals • Continuous electrocardiogram monitoring and pulse
oximetry to assess oxygenation and circulation • Fluid intake and output, wound drainage
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Care of the Patient Having a Total Laryngectomy
• Interventions• Ineffective Airway Clearance • Anxiety • Decreased Cardiac Output • Acute Pain • Risk for Injury • Imbalanced Nutrition: Less Than Body
Requirements • Impaired Verbal Communication • Ineffective Coping • Risk for Infection • Ineffective Therapeutic Regimen Management
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Figure 53-10
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Care of the Patient Having a Supraglottic Laryngectomy
• Care like that for total laryngectomy except the tracheostomy is temporary, the voice is not lost, and swallowing is more problematic
• Enteral feedings may be needed for a long time, so begin to instruct the patient in self-feeding
• Be alert for signs and symptoms of this complication: increased pulse and respiratory rates, dyspnea, cough, crackles and rhonchi, fever, wheezing, and frothy, pink sputum
• Keep a suction machine readily available
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Care of the Patient Having a Partial Laryngectomy
• Temporary tracheostomy for 2 to 5 days • IV fluids and enteral feedings are ordered at
first • Patients have considerable difficulty
swallowing when oral nourishment is resumed • To prevent aspiration, seat the patient upright,
with the head flexed slightly forward • Semisolids easier to manage than thin liquids • Suction machine should be on hand