Care of Patients with Noninfectious Upper Respiratory Problems

Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Chapter 31

Care of Patients with Noninfectious Upper Respiratory Problems

A patient with synchronous primary cancers of the larynx and floor of the mouth treated by laryngectomy, excision of

the floor of the mouth, and skin grafting.

Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Chapter 31 Care of Patients with Noninfectious Upper Respiratory Problems Learning Outcomes

1. Assess the patient for risk factors for head and neck cancer.2. Teach people how to avoid common risk factors for head and neck cancer.3. Use an appropriate nonverbal form of communication for a patient with a laryngectomy.4. Perform a focused upper respiratory assessment and re-assessment to determine adequacy of oxygenation and tissue perfusion.5. Prioritize nursing care needs of a patient after a nasoseptoplasty.


Chapter 31 Care of Patients with Noninfectious Upper Respiratory Problems Learning Outcomes (Continued)

6. Recognize manifestations and care needs of a patient with an anterior nosebleed and of a patient with a posterior nosebleed.7. Prioritize nursing care needs of a patient with facial trauma.8. Describe the pathophysiology and the potential complications of sleep apnea.9. Apply knowledge of anatomy to prevent aspiration in a patient with a tracheostomy.10. Teach the patient and family about home management of a laryngectomy.11. Describe patients with Noninfectious Upper Respiratory Problems and the related nursing interventions and rationales.


Chapter 31 Care of Patients with Noninfectious Upper

Respiratory Problems

Disorders of the nose and sinuses Fracture of the noseEpistaxisNasal PolypsCancer of the nose and sinusesFacial trauma

Obstructive sleep apnea


Chapter 31 Care of Patients with Noninfectious Upper Respiratory Problems (Continued)

Disorders of the larynxVocal cord paralysisVocal cord nodules and polypsLaryngeal trauma

Other upper airway disorders

Upper airway obstructionNeck trauma*Head and neck cancer*


Nursing Priority

• Promote oxygenation by ensuring a patent airway!


Anatomy of the Nose & Sinuses


Fracture of the Nose

• Displacement of bone or cartilage can cause airway obstruction or cosmetic deformity; potential source of infection

• CSF may indicate skull fracture

• Interventions– Closed reduction– Rhinoplasty– Nasoseptoplasty


Rhinoplasty

Immediate postoperative appearance of a patient who has undergone rhinoplasty. Note the splint and gauze drip pad (moustache dressing).


Postoperative Careafter Rhinoplasty

• Observe for edema and bleeding

• Check vital signs every 4 hours

• Change drip pad as needed


Epistaxis

• Nosebleed is common problem• Cauterization of affected capillaries may be

needed; nose is packed• Posterior nasal bleeding is an emergency!• Assess for respiratory distress, tolerance of

packing or tubes• Humidification, oxygen, bedrest, antibiotics,

pain medications


Epistaxis (cont’d)


Nasal Polyps

• Benign, grapelike clusters of mucous membranes and connective tissue

• Large polyps may obstruct nasal airway• Manifestations:

– Obstructed nasal breathing– Increased nasal discharge– Change in voice quality

• Managed with inhaled steroids and thenpolypectomy


Nasal Polyps (cont’d)


Cancer of the Nose & Sinuses

• Tumors rare, can be benign or malignant• Seen with exposure to dust from wood,

textiles, leather, as well as flour, nickel, chromium mustard gas, radium

• Slow onset, manifestations resemble sinusitis


Cancer of the Nose & Sinuses (cont’d)

• Local lymph enlargement often occurs on side with tumor mass

• Surgical removal is main treatment; may be combined with radiation (IMRT)


Facial Trauma

• Priority action is airway assessment!• Manifestations:

– Stridor– Shortness of breath/dyspnea– Anxiety/restlessness– Hypoxia and hypercarbia– Decreased oxygen saturation– Cyanosis, loss of consciousness


Le Fort Fracture

• I — nasoethmoid complex fracture

• II — maxillary and nasoethmoid complex fracture


Le Fort Fracture (cont’d)

• III — combination of I & II plus orbital-zygoma fracture; often called craniofacial disjunction


Facial Trauma Interventions

• Airway assessment• Anticipate need for emergency intubation• Tracheotomy• Cricothyroidotomy• Fixed occlusion• Débridement


Obstructive Sleep Apnea

• Breathing disruption during sleep

• Excessive daytime sleepiness, inability to concentrate, irritability

• Nonsurgical management—change of sleep position, weight loss, positive-pressure ventilation

• Surgical management—adenoidectomy, uvulectomy or uvulopalatopharyngoplasty


Assessment and Medication

• Polysomnography (PSG)– Overnight sleep study– Determines the depth of sleep, respiratory effort,

oxygen saturation and muscle movement

• Modafinil (Attenace, Provigil)


Positive Airway Pressure


Disorders of the Larynx

• Vocal cord paralysis• Vocal cord nodules and polyps• Laryngeal trauma


Disorders of the Larynx (Continued)

• Vocal cord nodules and polyps

• Laryngeal trauma


Upper Airway Obstruction

• Interruption in airflow through nose, mouth, pharynx, or larynx

• Life-threatening emergency

• Early recognition essential in preventing further complications, including respiratory arrest


Interventions for Upper Airway Obstruction

• Assess cause of obstruction

• Maintenance of patent airway and ventilation

– Cricothyroidotomy

– Endotracheal intubation (nasotracheal or orotracheal)

– Tracheotomy


Neck Trauma

• May be caused by knife, gunshot, traumatic accident

• Priority is to assess for and maintain patent airway!

• Assess for other injuries: cardiovascular, respiratory, intestinal, neurologic damage


Head and Neck Cancer

• Usually squamous cell carcinoma and slow growing

• Usually begins with mucous that is chronically irritated, becoming tougher and thicker

• Leukoplakia and erythroplakia lesions


Physical Assessment/Clinical Manifestations of Head and Neck Cancer

• Lumps in mouth, throat, neck• Difficulty swallowing• Color changes in mouth or tongue• Oral lesion or sore that does not heal in 2

weeks• Persistent, unilateral ear pain


Physical Assessment/Clinical Manifestations of Head and Neck Cancer (cont’d)

• Persistent/unexplained oral bleeding• Numbness of mouth, lips, or face• Change in fit of dentures• Burning sensation when drinking citrus or

hot liquids


Physical Assessment/Clinical Manifestations of Head and Neck Cancer (cont’d)

• Hoarseness or change in voice quality• Persistent/recurrent sore throat• Shortness of breath • Anorexia and weight loss


Head and Neck Cancer Interventions

• Radiation therapy

• Chemotherapy

• Cordectomy

• Laryngectomy


Throat after Laryngectomy


Laryngectomy Postoperative Care

• First priorities are airway maintenance and ventilation!

• Wound, flap, reconstructive tissue care

• Hemorrhage


Laryngectomy Postoperative Care (Continued)

• Wound breakdown

• Pain management

• Nutrition

• Speech and language rehabilitation


Communication After Laryngectomy


Communication After Laryngectomy (cont’d)


Community-Based Care

• Home care management• Teaching for self management:

– Stoma care– Communication– Smoking cessation

• Psychosocial preparation • Health care resources


The patient is a 58-year-old woman diagnosed with throat cancer 1 week ago. She has come to the clinic today to discuss surgical options with her health care provider. She is very tearful and appears sad when the nurse calls her back to the examination room.

Based on her diagnosis, which clinical manifestation will the nurse likely observe in the patient?

A. Severe chest painB. HoarsenessC. Low hemoglobin level (anemia)D. Numbness and tingling of the face


• ANS: B• The patient may experience several different

symptoms. The most commonly seen with throat cancer is hoarseness, as well as mouth sores or a lump in the neck. Anemia can result if surgery is performed. Severe pain in the chest can be associated with many different disorders and is not usually linked to throat cancer. Numbness and tingling of the face cannot be observed.


(cont’d)

When the nurse begins taking the patient’s history, she says, “Did you know that I have throat cancer and may not survive?” What is the nurse’s most appropriate response?

A. “I am so sorry to hear this.”B. “My mother had cancer, so I know how you

must be feeling right now.”C. “I know you have been diagnosed with cancer.

Tell me why you think you may not survive.”D. “I am sure that your cancer can be cured if you

follow your doctor’s advice.”


• ANS: C• The nurse should realize that the patient may

need some psychosocial support. This is the only appropriate therapeutic response. The nurse cannot give her false reassurance, and the nurse should never compare feelings. Head and neck cancer is curable when treated early.


The provider discusses radiation therapy with the patient because her lesion is small and the cure rate is 80% or higher. The patient asks if her voice will return to normal. What is the nurse’s best response? (Select all that apply.)

A. “The more you use your voice, the quicker it will improve.”B. “At first the hoarseness may become worse.”C. “Your voice will improve within 4 to 6 weeks after completion of the

therapy.”D. “You should rest your voice and use alternative communication

during the therapy.”E. “Gargling with saline may help decrease the discomfort in your

throat.”

(cont’d)


• ANS: B, C, D, E• The patient should be taught not to use her

voice more than necessary during and after therapy, and to work with family to determine alternative forms of communication until after the radiation therapy.


After the radiation therapy begins, the patient visits the clinic stating that her throat is sore, she is having difficulty swallowing, and the skin on her throat is red, tender, and peeling.

What strategies does the nurse recommend for these discomforts?For temporary relief of the patient’s sore throat and swallowing difficulty, suggest that she gargle with saline; suck on ice chips, use mouthwash or a throat spray with local anesthetics such as lidocaine. For her red, tender, peeling skin, have her avoid exposure to sun, heat, cold, or abrasive treatments such as shaving; wear protective clothing of soft cotton; wash gently with mild soap; and use only lotions or powders prescribed by the radiation oncologist until the area has healed.

(cont’d)


• For temporary relief of the patient’s sore throat and swallowing difficulty, suggest that she gargle with saline; suck on ice chips, use mouthwash or a throat spray with local anesthetics such as lidocaine. For her red, tender, peeling skin, have her avoid exposure to sun, heat, cold, or abrasive treatments such as shaving; wear protective clothing of soft cotton; wash gently with mild soap; and use only lotions or powders prescribed by the radiation oncologist until the area has healed.


Question 1

To prevent aspiration in a patient admitted for treatment of neck and throat cancer, the nurse’s first step should be to:

A. Encourage hydration with water and juices.B. Encourage the patient to eat juicy fruits to address the

sensation of thirst.C. Stop feeding the patient if coughing occurs.D. Encourage the patient to sit in a chair for meals.


• Answer: D• Rationale: Several interventions are necessary to

reduce the risk of aspiration. Having the patient sit upright to eat is an important initial step to reduce aspiration. Other interventions include encouraging liquids that are “thick.” Avoiding thin liquids like juice, water, and fruits that produce juice are important strategies to reduce aspiration risks. Coughing may be a sign of difficulty with swallowing or aspiration and requires additional assessment.


Question 2

A patient has been admitted to the ED after experiencing a fall while rock climbing. He appears to have several facial fractures. Which observed assessment finding is most serious?

A. Malaligned nasal bridgeB. Clear fluid draining from one of the nares, testing positive

for glucose C. Blood draining from one of the naresD. Crackling of the skin (crepitus) upon palpation


• Answer: B• Rationale: Blood or clear fluid (cerebrospinal

fluid, or CSF) may drain from one or both nares. However, the presence of glucose in the clear drainage indicates that CSF is draining, which could be caused by a skull fracture, a serious complication. A malaligned nasal bridge and crepitus may be observed when evaluating general facial fractures.


Question 3

An important nursing intervention to prevent airway obstruction in an older patient with dementia is:

A. Ensuring the patient is out of bed twice a dayB. Maintaining the head of bed greater than 45 degreesC. Performing daily oral hygiene and removing secretion

buildup D. Teaching the family to use oral suction for excessive

secretions


• Answer: C• Rationale: One preventable cause of airway obstruction

leading to asphyxiation is inspissated oral and nasopharyngeal secretions (Prahlow et al., 2009). In this condition, poor oral hygiene leads to thickening and hardening of secretions that can completely block the airway and lead to death. Patients at highest risk have an altered mental status and level of consciousness, are dehydrated, are unable to communicate, are unable to cough effectively, or have any other risk factors for aspiration.

Care of Patients with Noninfectious Upper Respiratory Problems

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