Care of Patient's with Noninfectious Upper Respiratory Problems

A patient has been diagnosed with vocal nodules. The HCP recommends conservative treatment that includes lifestyle modifications. What does the nurse teach the patient to do? (Select all that apply) a. Give the voice a rest from speaking, including no whispering b. Avoid humid climate conditions c. Use stool softeners to decrease straining d. Limit intake of caffeinated beverages e. Avoid heavy lifting

a c r

The nurse is caring for a patient who had a naseseptoplasty. Which action is the best to delegate to the licensed practical nurse? a. Administer a stool softener to ease bowel movements. b. Assess the patient's airway & breathing after general anesthesia c. Evaluate the patient's emotional reaction to the facial edema & bruising. d. Take vital signs every 4 hours as ordered by the physician

a

Which patient has the highest risk for developing cancer of the larynx & should be alerted about relevant lifestyle modifications to decrease this risk? a. 57 year old male with alcoholism b. 18 year old marijuana smoker c. 28 year old female with diabetes d. 34 year old male who snorts cocaine

a

Which surgical procedure of the neck area poses no risk postop for aspiration? a. Total laryngectomy b. Transoral cordectomy c. Hemilaryngectomy d. Partial laryngectomy

a

To assess for potential vocal cord paralysis in a patient, what does the nurse ask the patient about? (Select all that apply) a. "do you yell & scream at sporting events frequently?" b. "Have you ever experienced any trauma to your vocal cords recently?" c. "Do you have GERD?" d. "Do you have any diseases of the vagus nerve?" e. "Were you recently intubated for a prolonged time period with an endotracheal tube?"

a b d e

A patient is admitted for a posterior nosebleed. Posterior packing is in place & in addition, the patient is on oxygen therapy, antibiotics, & opioid analgesics. What is the priority assessment? a. Tolerance of packing or tubes b. Gag & cough reflexes c. Mouth breathing d. Skin breakdown around the nares

b

A patient suffers from chronic xerostomia related to past radiation therapy treatments. Which intervention does the nurse use to assist the patient with this symptom? a. Offer small frequent meals b. Suggest chewing sugarless gum c. Explain fluid restrictions d. Teach to wash with mild soap & water

b

A patient has been transferred from the ICU to the medical-surgical unit after a laryngectomy. What does the nurse suggest to encourage the patient to participate in self-care?

Suctioning the mouth with a Yankauer suction

Obstructive Sleep Apnea

-A breathing disruption during sleep that lasts at least 10 seconds & occurs a minimum of 5 times in an hour. -Factors: obesity, a large uvula, short neck, smoking, enlarged tonsils or adenoids, & oropharyngeal edema. -During sleep, the muscles relax & the tongue & neck structures are displaced. As a result, the upper airway is obstructed but chest movement is unimpaired. The apnea increases blood carbon dioxide levels & decreases the pH. These blood gas changes stimulate neural centers. The sleeper awakens after 10 seconds or longer of apnea & corrects the obstruction, & respiration resumes. -The person may have excessive daytime sleepiness, an inability to concentrate, & irritability.

Which side effects would a patient with obstructive sleep apnea report?

-Excessive daytime sleepiness -Inability to concentrate

Interventions *Head & Neck Cancer*

-Focus of treatment is to remove or eradicate the cancer while preserving as much normal function as possible. -Treatment- laryngeal cancer- range from radiation therapy (for a small specific area or tumor) to total laryngopharyngectomy with bilateral neck dissections followed by radiation therapy. -Monitor respiratory system by assessing respiratory rate, breath sounds, pulse ox, arterial blood gas values, & results of pulmonary function tests. -Airway obstruction- can occur from tumor growth, edema, or both. -Teach patient to use Fowler's & semi-Fowler's position for best air exchange. -Sitting up right in a reclining chair may promote more comfortable breathing. -Radiation therapy- Small cancers in specific locations has a cure rate of at least 80%. Most patients have hoarseness, dysphagia,skin problems, & dry mouth for a few weeks after radiation therapy. Most patients have sore throat & difficulty swallowing during radiation to the neck. Gargling with saline or sucking ice may decrease discomfort. Mouthwashes & throat sprays containing a local anesthetic agent (lidocaine or diphenhydramine) -Analgesic drugs may be prescribed. -Skin at site of irradiation becomes red & tender & may peel during therapy. Instruct patient to avoid exposing this area to sun, heat, cold, & abrasive treatments such as shaving. -Salivary glands- in the irradiation path- the mouth becomes dry (Xerostomia) -Side effect- long term & may be permanent; Problems from reduced saliva include increased risk for dental carries, oral infections, halitosis, & taste changes. No cure. Heavy fluid intake (water) & humidification can help. Some benefit- artificial saliva (Salivary moisturizing sprays or gels, (MouthKote) or saliva stimulants (Salagen & cevimeline (Cholinergic drugs). Chemotherapy- can be used alone or in addition to surgery or radiation. -Biotherapy in the form of epidermal growth factor receptor (EGFR) blockers may be effective for patients whose cancers over express the receptor. Cetuximab (Erbitux). This drug blocks EGFRs in normal tissues as well as those in the tumor. As a result- severe skin reactions are common. -Very small, early stage tumors may be removed by laser therapy, or photodynamic therapy. -Laryngectomy (total & partial), tracheotomy, & oropharyngeal cancer resections. Major types of surgery for laryngeal cancer include cord stripping, removal of a vocal cord (cordectomy), partial laryngectomy, & total laryngectomy. - If cancer is in the lymph nodes in the neck or if the tumor has a high rate of nodal spread, the surgeon performs a nodal neck dissection along with removal of the primary tumor (radical neck) -To protect the airway, a tracheostomy is needed. -With a partial laryngectomy, the tracheostomy is usually temporary. -With a total laryngectomy the upper airway is separated from the throat & esophagus, the trachea is brought out through the skin in the neck & sutured in place. -Neck dissection includes the removal of lymph nodes, the sternocleidomastoid muscle, the jugular vein, the 11th cranial nerve, & surrounding soft tissue. -Monitor airway patency, vital signs, hemodynamic status, & comfort level. -Monitor for hemorrhage & other general complications of anesthesia & surgery -Take vital signs hourly for the first 24 hours & then every 2 hours or according to agency police until the patient is stable. -Complications after surgery: airway obstruction, hemorrhage, wound breakdown, & tumor recurrence. First priorities- Airway maintenance & ventilation; other priorities are wound, flap, & reconstructive tissue care; pain management nutrition; & psychological adjustment, including speech & language therapy.

Head & Neck Cancer

-Usually squamous cell carcinomas & are slow growing -Cancer begins when the mucosa is chronically irritated & becomes tougher & thicker (squamous metaplasia) often with a keratin layer (keratosis) -At the same time, genes controlling cell growth are damaged, allowing excessive growth of these abnormal cells, which eventually become malignant. These lesions may then be seen as white, patchy, lesions (leukoplakia) or red, velvety patches (erythroplakia). -First spreads (metastasizes) into nearby structures, such as lymph nodes, muscle, and bone. -Risk Factors- Tobacco & alcohol use; voice abuse, chronic laryngitis, exposure to chemicals, dusts, & poor oral hygiene, long-term or severe GERD & infection with HPV.

CRITICAL RESCUE

Immediately notify the Rapid Response Team if dyspnea with stridor occurs. -Emergency endotracheal intubation or tracheostomy may be needed.

The nurse is observing a client performing stoma care for a laryngectomy for the first time. Which action does the nurse reinforce? a. Washing the stoma with soap and water b. Covering the stoma with a gauze pad c. Irrigating the stoma with half-strength peroxide d. Making sure any scab around the stoma is removed

ANS: A The client is taught to wash the stoma gently and to prevent anything from getting into the opening. The client should never scrape around the opening because this could cause broken skin, irritation, and infection. Peroxide is not used for irrigation; irrigation of the stoma is not done.

What is the highest priority for the nurse to teach the client who is being discharged after a fixed centric occlusion for a mandibular fracture? a. How to use wire cutters b. Eating six soft or liquid meals each day c. How to irrigate the mouth every 2 hours d. Sleeping in semi-Fowler's position postoperatively

ANS: A The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. Although the client will need to sleep in a semi-Fowler's position to assist in avoiding aspiration if vomiting does occur, this will not be as high a priority as knowing how to cut the wires.

A client has undergone a nasoseptoplasty 2 hours ago. It is a priority for the nurse to assess for which factor? a. Nasal drainage b. Bleeding c. Pain d. Airway patency

ANS: D Assessing and maintaining a patent airway is always the top priority. The other assessments are important but do not take priority over airway.

A patient is unable to speak following a cordectomy. Which action is delegated to the nursing assistant to assist the patient in dealing with communication issues?

Allow extra time to accomplish ADLs because of communication limitations.

The nurse is instructing a patient about a scheduled polysomnography. Which patient statement indicates understanding of the procedure? a. "The test can be done in the doctor's office & will take 2 to 3 hours" b. "I shouldn't eat anything after midnight the night before, & someone must accompany me." c. "The test determines the depth & type of sleep & muscle movement" d. "The test determines the amount of sleep I need for adequate rest"

C

What are the lab assessments of neck & head cancer?

CBC, bleeding times, urinalysis, & blood chemistries, & renal & hepatic function tests.

You are assisting the physician in the examination room with a client who is experiencing a nosebleed. The physician asks you for silver nitrate. You realize the physician plans to use the silver nitrate sticks you provide to do which of the following things?

Cauterize the bleeding vessel or vessels Rationale: Silver nitrate, cocaine .5%, or adrenaline 1:1000 is used to cauterize a bleeding vessel or vessels.

People in which of the following groups are most likely to get benign laryngeal tumors?

Cheerleaders

When the nurse does teaching about the prevention of laryngeal obstruction to a community citizen's group, the nurse will talk about the most common causes of laryngeal obstruction in adults. Which of the following suggestions by the nurse would be most important and most helpful in preventing laryngeal obstruction during a meal?

Chew food into small pieces and avoid or minimize alcohol intake Rationale: The risk factors are not chewing food sufficiently and ingesting large boluses of food, consuming excessive amounts of alcohol, and having dentures.

When a client appears to have manifestations of epiglottitis, the nurse will most need to do which of the following things?

Have equipment for intubation near the bedside Rationale: A naso or oropharyngeal airway must not be inserted, as it can cause spasm and total airway obstruction. The nurse, however, must be prepared for emergency intubation of the client at any time and needs to have the equipment near the bedside. Epiglottitis is frightening, and the client must be monitored for signs of respiratory distress.

When airway obstruction is complete, the __________ maneuver must be performed immediately to clear the obstruction.

Heimlich Rationale: When airway obstruction is complete, the Heimlich maneuver must be performed immediately to clear the obstruction.

A patient is having radiation therapy to the neck & reports a sore throat & difficulty swallowing. Which statement by the nursing student indicates a correct understanding of symptom relief for this patient?

I will help the patient with a saline gargle.

Which statement by the patient indicates understanding about radiation therapy for neck cancer?

My voice will initially be hoarse but should improve over time.

Assessment *Epistaxis* Treatment

Observe the patient for respiratory distress & for tolerance of packing or tubes. -Humidity, oxygen, bed-rest, & antibiotics may be prescribed. -Opioids- assess patients at least hourly for gag & cough reflexes. -Oral care & hydration- important because of mouth breathing. -Use pulse ox to monitor for hypoxemia. -Tubes or packing- usually removed after 1-3 days.

A patient is learning esophageal speech & reports that he feels bloated after a practice session. To assist the patient with this issue, what does the nurse do?

Obtain an order for PRN antacids.

A patient has had surgery for cancer of the neck. Which behavior indicates that the patient understands how to perform self care to prevent aspiration?

Positions self upright before eating or drinking anything.

The nurse will instruct a client who has a fracture of the nose, some leakage of cerebrospinal fluid, and who is at home to do which of the following things?

Rest in bed with head elevated or in a recliner chair Rationale: The client who has a CSF leak is to rest in bed with head elevated or in a recliner chair. Fluids may be restricted and distributed throughout the day. The client is not to strain, blow the nose, sneeze, or cough vigorously. The client is to report stiff neck, headache, and fever, as they are possible signs of infection.

The nurse is assessing a patient who has had a neck dissection with removal of muscle tissue, lymph nodes, & the 11th cranial nerve. Which assessment finding is anticipated because of this surgical procedure?

Should drop with a decreased limitation of movement.

The nurse is caring for several patients who require treatment for laryngeal cancer. Which treatment/procedure requires patient education about aspiration precautions?

Supraglottic laryngectomy

What does the nurse include in the teaching session for a patient who is scheduled to have a partial laryngectomy?

Supraglottic method of swallowing

You are working with a client who has had nasal surgery for a broken nose. The client has some clear drainage from the nose and ears. Which of the following actions would be best on your part?

Test the fluid for glucose using a dextrostrip Rationale Leakage of clear fluid from the nose or ears of a client who has had nasal surgery may indicate leakage of cerebrospinal fluid. The fluid will test positive for glucose if it is cerebrospinal fluid.

The physician orders the discontinuation of the nasogastric tube for a patient with a total laryngectomy. Before discontinuing the tube, which action is performed?

The physician & the nurse will assess the patient's ability to swallow.

What are the diagnostic testing for head & neck cancer?

X-rays, CT, mri, nuclear imaging, bone scans, SPECT scans, & PET scans. Direct & indirect laryngoscopy & biopsy.

A patient has had a radical neck dissection surgery with a reconstructive flap over the carotid artery. Which intervention is appropriate for the flap care? a. Evaluate the flap every hour for the first 72 hours. b. Monitor the flap by gently placing a Doppler on the flap c. Position the patient so that the flap is in the dependent position d. Apply a wet-to-dry dressing to the flap

a

After being treated in the ED for posterior nosebleed, the patient is admitted to the hospital. The nasal packing is in place & vital signs are stable. The patient has an IV of normal saline at 125 mL/hr. What is the priority for nursing care? a. Airway management b. Managing potential dehydration c. Managing potential decreased cardiac output d. Monitoring for potential infection

a

The nurse is assessing a patient's skin at the site of radiation therapy to the neck. Which skin condition is expected in relation to the radiation treatments? a. red, tender, & peeling b. shiny, pale, & tight c. puffy & edematous d. pale, dry, & cool

a

A patient had a rhinoplasty & is preparing for discharge home. A family member is instructed by the nurse to monitor the patient for postnasal drip by using a flashlight to look in the back of the throat. If bleeding is noted, what does the nurse tell the family members to do? a. Place ice packs on the back of the neck and apply pressure to the nose. b. Hyperextend the neck & apply pressure & ice packs as needed. c. Seek immediate medical attention for the bleeding. d. Monitor for 24 hours if the bleeding appears to be a small amount

c

A patient returns from surgery following a rhinoplasty. The nursing assistant places the patient in a supine position to encourage rest & sleep. Which action should the nurse take first? a. Teach the patient how to use the bed controls to position herself b. Explain the purpose of the semi-Fowler's position to the nursing assistant. c. Place the patient in a semi-Fowler's position & assess for aspiration d. Post a notice at the head of the bed to remind personnel about positioning

c

The nurse is caring for a patient who has just returned from rhinoplasty surgery. Which assessment finding warrants additional assessment & concern? a. Bilateral packing of both nares in place b. Moustache pad in place c. Demonstrated repeated swallowing d. Traces of bruising around the eyes.

c

The nurse is assessing a patient who reports being struck in the face & head several times. During the assessment, a pink-tinged drainage from the nares is observed. Which nursing action provides relevant assessment data? a. Have the patient gently blow the nose & observe for bloody mucus b. Test the drainage with a reagent to check the pH c. Ask the patient to describe the appearance of the face before the incident d. Place a drop of the drainage on a filter paper & look for a yellow ring

d

The nurse identifies the priority problem of reduced self-concept related to perceived disfigurement created by tracheostomy for a young female patient. What does the nurse recommend for this patient?

-Assist the patient to identify realistic goals. -Have the patient talk with someone who has adapted to having a tracheostomy.

Wound, Flap, & Reconstructive Tissue Care

-Flaps are skin, subcutaneous tissue & sometimes muscle, taken from other body areas that may be used for reconstruction after head & neck resection. -After neck dissection, the surgeon places a split-thickness skin graft (STSG) over the exposed carotid artery before covering it with skin flaps or reconstructive flaps. -The first 24 hours after surgery are critical. -Evaluate all grafts & flaps hourly for the first 72 hours. -Monitor capillary refill, color, drainage, & Doppler activity of the major feeding vessel. -Report changes to the surgeon immediately because surgical intervention may be needed. -Position the patient so that the side of the head & neck with the flaps is not dependent.

Assessment *Obstructive Sleep Apnea

-Patients often unaware they have. -Should be suspected for any person who has persistent daytime sleepiness or "waking up tired" -Irritability & personality changes. -Most accurate test- polysomnography (PSG) performed during an overnight sleep study.

Interventions*Vocal*Cord*Paralysis*

-Securing an airway- main intervention -Place patient in high-fowler's position to aid in breathing & proper alignment of airway structures. -Assess for airway obstruction. -Simple procedure- open vocal cords paresis involves injecting polytef (Teflon) into affected cord so it enlarges toward unaffected cord -The patient with open cord paralysis is at risk for aspiration because the airway is open during swallowing. Teach patient to hold breath during swallowing to allow the larynx to rise, close, & push food to esophagus. -Indications of aspiration include immediate coughing on swallowing of liquids or solids, a "wet" sounding voice, & "tearing up" or water eyes on swallowing.

Hemorrhage

-A possible complication after any surgery but its uncommon with laryngectomy. -The surgeon often places a closed surgical drain in the neck area to collect blood & drainage for about 72 hours after surgery. The drain also helps maintain the position of the reconstructed skin flaps. Any drain obstruction or equipment malfunction may cause a buildup of blood or serum under the flaps. -Monitor drainage, & record its amount & character- check the patency & functioning of the drainage system. Report any drain malfunction or change in flap appearance to the surgeon.

NASAL POLYPS

-Are benign, grapelike clusters of mucous membrane & connective tissue. -Often occur bilaterally & are caused by irritation to the nasal mucosa or sinuses, allergies, or infection (chronic sinusitis). -Large polyps- may obstruct airway. -Manifestations: obstructed nasal breathing, increased nasal discharge, & change in voice quality. -Managed with nasally inhaled steroids followed by surgical removal (polypectomy) with standard or laser surgery, under local or general anesthesia. -Observe patient for bleeding after surgery. -Nostrils are usually packed with gauze for 24 hours after surgery.

Interventions *Upper Airway Obstruction

-Assess for cause of obstruction -Obstruction is due to tongue falling back or excessive secretions, slightly extend the patients head & neck & insert a nasal or oral airway. -Suction to remove obstructing secretions -Foreign body, perform abdominal thrusts -May require emergency procedures such as cricothyroidotomy, endotracheal intubation or tracheotomy. -Cricothyroidotomy- an emergency procedure often performed outside the hospital by emergency medical personnel. It's a stab wound at the cricothyroid membrane between thyroid cartilage & cricord cartilage. Used when it's the only way to secure airway. -Endotracheal intubation- performed by inserting a tube into the trachea via the nose (nasotracheal) or mouth (orotracheal) by a physician, anesthesia provider. -Tracheotomy- s surgical procedure 5-10 minutes to perform -Tracheotomy- reserved for the patient who can't be easily intubated with an endotracheal tube. -Patients receiving mechanical ventilation for upper airway obstruction or respiratory failure- may require a tracheostomy after 7 or more days of continuous intubation.

Intervention *Laryngeal trauma

-Assessing airway & monitoring vital signs (including respiratory status & pulse ox) every 15-30 minutes. -MAINTAIN PATENT AIRWAY -Apply oxygen & humidification as prescribed to maintain adequate oxygen saturation. -Manifestations of respiratory difficulty: tachypnea, nasal flaring, anxiety, sternal retraction, SOB, restlessness, decreased oxygen saturation, decreased level of consciousness, & stridor. -Surgical intervention- needed for lacerations of mucous membranes, cartilage exposure, & cord paralysis. -Laryngeal repair- performed ASAP to prevent laryngeal stenosis & to cover any exposed cartilage -Artificial airway may be needed.

Prevention of Aspiration During Swallowing

-Avoid serving meals when patient is fatigued. -Smaller & more frequent meals. -Adequate time; do not hurry patient -Close supervision if patient is self-feeding -Emergency suctioning equipment close at hand -Avoid water & other thin liquids -Thicken liquids -Avoid foods that generate thin liquids -Patient in most upright position possible. -When possible, completely (or @ least partially) deflate the tube cuff during meals -Suction after initial cuff deflation to clear the airway & allow maximum comfort during meal. -Each bite slowly -Encourage "dry swallow" -Avoid consecutive swallows by cup or straw

Interventions *Obstructive Sleep Apnea

-Change in sleeping position or weight loss may reduce or correct. -Position-fixing devices- may prevent subluxation of the tongue & neck structures & reduce obstruction. -Severe sleep apnea- requires nonsurgical or surgical methods -Noninvasive positive-pressure ventilation (NPPV) to hold open the upper airways. -Bi level positive airway pressure (BiPAP)- nasal mask or full mask delivery system- autotitrating positive airway pressure (APAP), Nasal continuous positive airway pressure (CPAP). -BiPAP- machine delivers a set inspiratory positive airway pressure at the beginning of each breath. -APAP- machine adjusts continuously, resecting the pressure throughout the breathing cycle to meet patients needs. -CPAP- delivers a set positive airway pressure continuously during each cycle of inhalation & exhalation. -One drug approved to help manage daytime sleepiness associated with sleep apnea: Modafinil (Attenace, Provigil)-helpful for patients who have narcolepsy (uncontrolled day time sleep) from sleep apnea by promoting daytime wakefulness. -Surgical intervention- may involve a simple adenoidectomy, uvulectomy, or remodeling of the entire posterior oropharynx (uvulopalatopharyngoplasty [UPP}) -A tracheostomy may be needed for very severe sleep apnea- not relieved by more moderate interventions

Wound Breakdown

-Common complication caused by poor nutrition, a long smoking history, alcohol use, wound contamination, & previous radiation therapy. -Manage wound breakdown with packing & local care as prescribed to keep the wound clean & to stimulate the growth of healthy granulation tissue. -When the carotid artery ruptures, large amounts of bright red blood spurt quickly. It's also possible for the carotid artery to have a small leak, with continuous oozing of bright red blood. -Usually a small leak leads to a complete rupture within a short time.

Surgical Procedures for Other Head & Neck Cancers

-Composite resections- a combination of surgical procedures, including partial or total glossectomies, partial mandibulectomies, & if needed, nodal neck dissections. -Tracheostomy- may be planned to provide an adequate airway -Tracheotomy- a surgical incision into the trachea for the purpose of establishing an airway (tracheostomy)

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 -Nasal fractures often result from injuries received during falls, sports activities, car crashes, or physical assaults. -Blood or clear fluid (cerebrospinal fluid {CSF}) rarely drains from one or both nares as a result of a simple nasal fracture & if present, indicates a more serious injury (skull fracture). -CSF can be differentiated from normal nasal secretions because CSF contains glucose that will test positive with a dipstick. -When CSF dries on a piece of filter paper, a yellow "halo" appears

Airway Maintenance & Ventilation

-During weaning, the patient usually uses a tracheostomy collar (over the artificial airway or open stoma) with oxygen & humidity to help move mucous secretions. -Humidity helps remove crusts & prevents obstruction of the tube with secretions. -Some surgeons prescribe instillation of 5-10 mL of sterile saline or sodium bicarbonate into the airway every 2 hours -A laryngectomy tube- used for patients who have undergone a total laryngectomy & need an appliance to prevent scar tissue shrinkage of the skin- tracheal border. -Coughing, deep breathing & saline instillation (when this intervention is prescribed) are usually effective in clearing secretions. -Instruct the patient how to cough & deep breathe to clear secretions. -Oral secretions can be suctioned by the alert patient using a Yankauer or tonsillar suction or a soft red latex catheter. -Inspect the stoma with a flashlight. -Clean suture line with sterile saline (or whatever solution has been prescribed) to prevent secretions from forming crusts & obstructing the airway. -Perform suture line care every 1-2 hours during the first few days after surgery and then every 4 hours thereafter.

CRITICAL RESCUE

-If a carotid artery leak is suspected, call the Rapid Response Team & do not touch the area because additional pressure could cause an immediate rupture. -If carotid artery ruptures because of drying or infection, immediately place constant pressure over the site & secure the airway. -Maintain direct manual, continuous pressure on the carotid artery & immediately transport the patient to the operating room for carotid resection. -Do not leave the patient. Carotid artery rupture has a high risk for stroke & death.

Upper Airway Obstruction

-Life-threatening emergency, in which airflow is interrupted through the nose, mouth, pharynx, or larynx. -Causes: Tongue edema (surgery, trauma, angioedema as an allergic response to a drug), tongue occlusion (loss of gag reflex, loss of muscle tone, unconsciousness, coma) laryngeal edema, peritonsillar & pharyngeal abscess, head & neck cancer, thick secretions, stroke & cerebral edema, etc. -One preventable cause of airway obstruction leading to asphyxiation is inspissated oral & nasopharyngeal secretions. -HIGHEST RISKS- nursing home patients who have altered mental status, & LOC, are dehydrated, unable to communicate, unable to cough effectively.

Emergency Care of Patient with Anterior Nosebleed

-Maintain Standard Precautions or Body Substance Pre-cautions. -Position patient upright & leaning forward to prevent blood from entering stomach & possible aspiration. -Reassure patient & attempt to keep patient quiet to reduce anxiety & BP. -Apply direct lateral pressure to nose for 10 minutes & apply ice or cool compresses to nose & face. -If nasal packing is necessary, loosely pack both nares with gauze or nasal tampons. -To prevent rebleeding from dislodging clots, instruct patient to not blow nose for 24 hours after bleeding stops. -Seek medical attention if ineffective.

A patient has demonstrated anxiety since a diagnosis of neck cancer. The surgery & radiation therapy are completed. Which behavior indicates that the patient's anxiety is decreasing?

-Makes a plan to contact the American Cancer Society Visitor Program

FACIAL TRAUMA

-Mandibular (lower jaw) fractures: can occur at any point on the jaw & common facial fractures -Le Fort I- nasoethmoid complex fracture -Le Fort II- maxillary & nasoethmoid complex fracture -Le Fort III- combines I & II, plus an orbital-zygoma fracture, called craniofacial disjunction, because the midface has no connection to the skull.

Neck Trauma

-May be caused by knife, gunshot, or traumatic accident -May have more than one injury, including cardiovascular, respiratory, intestinal, or neurologic damage.

Vocal Cord Paralysis

-May result from injury, trauma, or diseases that affect the larynx, laryngeal nerves, or vagus nerve. -Prolonged intubation with an endotracheal tube may cause temporary or permanent paralysis. -Paralysis may occur in patients with neurologic disorders. Damage to vagus nerve (by chest injury), brain or brainstem may lead to nerve dysfunction. -Paralysis of both vocal cords may result from direct injury, stoke involving the brainstem, or total thyroidectomy. -One vocal cord is involved (most common) the airway remains patent but voice is affected. -Manifestions: (open bilateral vocal cord paralysis) hoarseness; a breathy weak voice; & aspiration of food. -Bilateral closed vocal cord paralysis causes airway obstruction & is an EMERGENCY if the symptoms are severe & patient can't compensate. STRIDOR= major manifestation

Pain Management

-Morphine (Statex) often given IV by a patient-controlled analgesia (PCA) pump for the first 1-2 days after surgery. -As the patient progresses, liquid opioid analgesics can be given by feeding tube. Oral drugs for pain & discomfort are started only after the patient can tolerate oral intake. -After discharge, the patient still requires pain management, esp. if he or she is receiving radiation therapy. -An adjunct to the pain regiment may be liquid NSAIDs. These drugs provide excellent pain relief & can be used along with opioid analgesics. -Amitriptyline (Elavil)- or other tricyclic antidepressants may also be used for the lancinating pain of nerve-root involvement.

A patient is receiving enteral feedings & a nasogastric tube is in place. In order to prevent aspiration, which precautions are used?

-No bolus feedings are given at night -Check the pH of the secretions -Elevate the HOB during & after feedings -Evaluate the patient's tolerance of the feedings.

Intervention *Vocal Cord Nodules & Polyps

-No smoking & voice rest -Avoid heavy lifting -Stool softeners- used to avoid bearing down during elimination which closes the glottis. -Humidifying the air soothes the cords & prevents overydrying. -If hoarseness not relieved- surgeon may remove nodules or polyps using laryngoscopy. Laser & surgical resection are used to remove the membrane of affected cord. -After surgery- patient must maintain complete voice rest for about 14 days to promote healing.

Vocal Cord Nodules & Polyps

-Nodules- enlarged, fibrous tissues caused by infectious processes or overuse of the voice. Occur where the vocal cords touch during speech. Teachers, coaches, sports fans & singers. -Polyps- edematous masses that occur most often in smokers & people with allergies. -Both= painless -Manifestation: painless hoarseness because of the loss of coordinated vocal cord closure

Epistaxis

-Nosebleed- common problem because of the many capillaries within the nose. -Occur as a result of trauma, HTN, blood dyscrasia (leukemia), inflammation, tumor, decreased humidity, nose blowing, nose picking,chronic cocaine use, & procedures (nasogastric suctioning). -Patient often reports-bleeding started after sneezing or blowing the nose. -Document amount & color of blood & take vital signs. -Ask patient the number, duration, & causes of previous bleeding episodes.

Laryngeal Trauma

-Occurs with crushing or direct blow injury, fracture, or injury induced by prolonged endotracheal intubation. -Manifestations: difficulty breathing (dyspnea) inability to produce sounds (aphonia), hoarseness & subcutaneous emphysema (air present in the subcutaneous tissue) -Bleeding from airway (hemoptysis) may occur, depending on location of the trauma.

Interventions- Nasoseptoplasty

-Or submucous resection (SMR) may be needed to straighten a deviated septum when chronic symptoms (stuffy nose, snoring, sinusitis) or discomfort occurs. -Most adults have a slight nasal septum deviation with NO SYMPTOMS. -Major deviations- may obstruct the nasal passages or interfere with airflow & sinus drainage . The deviated section of the cartilage and bone is removed as an ambulatory surgical procedure. -Nursing care is similar to that for a rhinoplasty.

Warning Signs of Head & Neck Cancer

-Pain -Lump in mouth, throat, or neck -Difficulty swallowing -Color changes in mouth or tongue to red, white, gray, dark brown, or black -Oral lesion or sore that doesn't heal in 2 weeks. -Persistent or unexplained oral bleeding -Numbness of mouth, lips, or face -Change in the fit of dentures -Burning sensation when drinking citrus juices or hot liquids -Persistent, unilateral ear pain -Hoarseness or change in voice quality -Persistent or recurrent sore throat -SOB -Anorexia & weight loss

Assessment *Upper airway obstruction

-Partial obstruction- produces a subtle or general manifestations- diaphoresis, tachycardia, & elevated BP. -Diagnostic procedures- chest & neck xrays, laryngoscopic exam, & CT. -Observe for hypoxia & hypercarbia, restlessness, increasing anxiety, sternal retractions, a "seesawing" chest, abdominal movements, or a feeling of impending doom related to actual air hunger. -Use pulse ox- ongoing monitoring of oxygen saturation. -Assess for stridor, cyanosis, & changes in level of consciousness.

Assessment *Head & Neck Cancer

-Patient may have difficulty speaking because of hoarseness, SOB, tumor bulk, & pain. -With laryngeal cancer- painless hoarseness may occur because of tumor size and an inability for the vocal cords to come together for normal speech (phonation). -Vocal cord lesions-earliest form of laryngeal cancer -Any person with history of hoarseness, mouth sores, or a lump in the neck for 3-4 weeks- be evaluated for laryngeal cancer. -Inspection & palpation of head & neck= important -Diagnostic tests include: CBC count, bleeding times, urinalysis, & blood chemistry. -Patient with chronic alcoholism- may have low protein & albumin levels from poor nutrition -Liver & Kidney function tests- to rule out cancer spread & to evaluate patient's ability to metabolize drugs & chemotherapy agents. -Imaging studies- X rays of skull, sinuses, neck & chest, CT with or without contrast media helps evaluate tumor's exact location. MRI-can help differentiate normal from diseased tissue. -Brain, bone, & liver- evaluated with nuclear imaging, bone scans, single photon emission computerized tomography (SPECT) scans, & PET scans. -Indirect & direct laryngoscopy, tumor mapping, & biopsy.

Interventions *Facial Trauma*

-Primary action-establish & maintain a patent airway -Anticipate the need for emergency intubation, tracheotomy (surgical incision into the trachea to create an airway) or cricothyroidotomy (creation of a temporary airway by making a small opening in the throat between the thyroid cartilage & the cricoid cartilage). -Upon patient arrival, care focuses on establishing an airway, controlling hemorrhage & assessing for the extent of injury. -If shock is present, fluid resuscitation & identification of bleeding sites are started immediately. -Stabilizing the fractured segment of a jaw fracture allows the teeth to heal in proper alignment. This process involves fixed occlusion (wiring the jaws together in the mouth closed position). Patient remains for 6-10 weeks. Antibiotic therapy- may be prescribed because of oral wound contamination. Treatment delay, tooth infection, or poor oral care may cause mandibular bone infection, which may require surgical debridement (removal of dead tissue), IV antibiotic therapy, & longer period with jaws in a fixed position. -More extensive jaw fractures may require open reduction with internal fixation (ORIF) procedures. -Compression plates & reconstruction plates with screws may be applied. -Facial fractures- may be required with microplating surgical systems that involve bone substitutes. These shaping plates hold the bone fragments in place until the new bone growth occurs. -Fixation methods- may use resorbable devices (plates & screws) to hold tissues in place.These devices are made from a plastic-like material that retains its integrity for about 8 weeks & then slowly biodegrades. -Inner maxillary fixation (IMF)- The bones are realigned & then wired in place with the bite closed.

Assessment *Facial Trauma*

-Priority Action- Airway assessment -Manifestations (of airway obstruction): stridor, SOB, dyspnea, anxiety, restlessness, hypoxia, hypercarbia (elevated blood levels of carbon dioxide), decreased oxygen saturation, cyanosis, & loss of consciousness. -After establishing airway, assess site of trauma for bleeding & possible fractures. -Check for soft-tissue edema, facial asymmetry, pain, or leakage of spinal fluid through ears & nose, indicating a temporal bone or basilar skull fracture. -Assess vision & eye movement because orbital & maxillary fractures can entrap the eye. -Check behind the ears (mastoid area) for extensive bruising, known as "battle sign."

*Assessment* Neck Trauma

-Priority- Assessing & Maintaining Patent Airway -After airway patency is ensured, assess for bleeding or impending shock. -Perform neurologic assessment for mental status, sensory level, & motor function. -Carotid angiogram may be needed to rule out vascular injuries. -Esophagus injury may occur with neck trauma. -Assess for chest pain & tenderness, oral bleeding & crepitus (crackling sounds when palpating the skin) -Barium or meglumine diatrizoate (Gastrografin) swallow may be needed to rule our an esophageal perforation injury. -Cervical spine injuries often occur at same time as a neck injury. -Health care personnel must take great care not to make these injuries worse by causing neck movement while establishing the airway using the jaw-thrust maneuver.

Interventions- Rhinoplasty

-Surgical reconstruction of the nose -Patient returns from surgery with packing in both nostrils; this packing prevents bleeding & provides support for the reconstructed nose. The gauze packing is treated with an antibiotic to reduce the risk of infection. -After surgery observe for edema & bleeding. Check vital signs every 4 hours until patient is discharged. -Instruct patient to stay in a semi-Fowler's position & to move slowly. Rest & use cool compresses on nose, face, eyes, to help reduce swelling & bruising. -Urge patient to drink at least 2500 mL/day. -To prevent bleeding, teach patient to limit valsalva maneuvers (forceful coughing or straining during a BM), not to sniff upward ot blow the nose & not to sneeze with the mouth closed for the 1st few days after packing is removed. -Laxatives or stool softeners to ease BM. -Avoid aspirin & other NSAIDS to prevent bleeding. -Antibiotics to prevent infection -Final Surgical Result- 6-12 months.

Cancer of the Nose & Sinuses

-Tumors rare, can be benign or malignant. -Asian Americans (higher incidence of nasopharyngeal cancer). More common among people with chronic exposure to wood dusts, dusts from textiles, leather dusts, flour, nickel, & chromium dust, mustard gas, & radium. -Onset of sinus cancer- slow & manifestations resemble sinusitis. -Patient may have advanced disease @ diagnosis. -Manifestations: persistent nasal obstruction, drainage bloody discharge, & pain that persists after treatment of sinusitis. -Lymph node enlargement often occurs on the side with tumor mass. -Tumor location- identified with x-ray, computed tomography (CT), or MRI. -Surgical removal is main treatment; may be combined with radiation (IMRT) -Chemotherapy- may be used in conjunction with surgery & radiation for some tumors. -Most commonly used agents: carboplatin, cisplatin, 5-fluorouracil, docetaxel, paclitaxel -Maintaining a patent airway -Monitoring for hemorrhage -Provide wound care -Assessing nutritional status (essential after surgery) -Perform trach. care (if needed) -Careful mouth & sinus cavity care with saline irrigations using an electronic irrigation system. -Assess for pain & infection

Interventions *Epistaxis*

-Use at home or ED- a special nasal plug that contains an agent to promote blood clotting. The plug expands on contact with blood & compresses mucosal blood vessels. Can be removed in an hour. -Medical attention- needed if nosebleed doesn't respond. The affected capillaries may be cauterized with silver nitrate or electrocautery and nose packed. Anterior packing controls bleeding from the anterior nasal cavity. -Posterior nasal bleeding is an emergency because it can't be easily reached & the patient may lose a lot of blood quickly. -Posterior packing, epistaxis catheters (nasal pressure tubes) or a gel tampon are used to stop bleeding that originates in posterior nasal region. -With packing, HCP positions a large gauze pack in the posterior nasal cavity above the throat, threads the attached string through the nose, & tapes it to patient's cheek to prevent pack movement. -Epistaxis catheter- have an exterior balloon along the tube length in addition to an anchoring balloon on the end. Tubes are inserted into back nares. The anchoring balloon is inflated1st to keep the tubes in place. Then the pressure balloons are inflated carefully for both tubes at the same time to compress bleeding vessels. -INTERVENTIONS AT HOME- -After tubes or packing is removed- petroleum jelly-applied to nares for lubrication & comfort. Avoid strenuous activities such as heavy lifting. Nasal saline sprays & humidification add moisture & prevent rebleeding.

A patient has been diagnosed with sleep apnea. Which assessment findings indicate that the patient is having complications associated with sleep apnea? a. Side effects of hypoxemia, hypercapnia, and sleep deprivation b. Decrease in arterial carbon dioxide levels & sleep deprivation c. Respiratory alkalosis with retention of carbon dioxide d. Irritability, obesity, & enlarged tonsils of adenoids.

A

The nurse is assessing a client who is 6 hours post surgery for a nasal fracture. The client has facial pain (5 out of 10) and nasal packing in place. What actions by the nurse are most appropriate at this time? (Select all that apply.) a. Observe for clear drainage. b. Observe for bleeding. c. Observe the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing. g. Administer pain medication. h. Place the client in Trendelenburg position.

ANS: A, B, C, D, G The nurse should observe for clear drainage because of the risk for cerebrospinal fluid (CSF) leakage. The nurse should note whether the client is swallowing frequently because this could indicate postnasal bleeding. The nurse should also ask the client to open his or her mouth and should observe the back of the throat for bleeding. Pain medication should also be administered. It is too soon to change the packing, which should be changed by the surgeon the first time. A nasal steroid would increase the risk for infection.

The nurse is assessing a client with facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin

ANS: A, D Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis or bruising behind the ear is called "battle sign" and indicates basilar skull fracture.

Which statement made by the client who is prescribed "voice rest" therapy for vocal cord polyps indicates the need for more teaching? a. "I will stay out of rooms and places where people are smoking." b. "When I speak at all, I will whisper rather than use a normal tone of voice." c. "For the next several weeks, I will not lift more than 10 pounds." d. "I will drink at least 3 quarts of water each day and will use stool softeners."

ANS: B Treatment for vocal cord polyps includes not speaking, no lifting, and no smoking. The client has to be educated not to even whisper when resting the voice. It is also appropriate for the client to stay out of rooms where people are smoking, and to stay hydrated and use stool softeners.

Which clinical manifestation in a client with paralysis of one vocal cord alerts the nurse to the possibility of aspiration? a. Oxygen saturation is decreased. b. Voice is weak and tremulous. c. The client coughs immediately after swallowing. d. An audible wheeze is present on exhalation.

ANS: C The client with open vocal cord paralysis is at risk for aspiration because the airway may not close during swallowing. Coughing may indicate that the client's airway is irritated from aspirated contents. Decreased oxygen saturation can occur for a number of reasons. A weak voice may indicate weak muscles, and wheezing may indicate swelling or inflammation in the airways.

While playing football at school, a patient injured his nose resulting in a possible simple fracture. The patient's parents call the nurse seeking advice. What doe the nurse tell the parents to do? a. Ask the school nurse to insert a nasal airway to ensure patency. b. Apply an ice pack & allow the patient to rest in a supine position. c. Seek medical attention within 24 hours to minimize further complications d. Monitor the symptoms for 24 hours & contact the physician if there's bleeding

c

Supraglottic Method of Swallowing

1. Place yourself in upright, preferably out of bed position. 2. Clear your throat. 3. Take a deep breath. 4. Place 1/2-1 teaspoon of food into mouth. 5. Hold breath, or "bear down" (valsalva maneuver) 6. Swallow twice 7. Release breath & clear throat 8. Swallow twice again 9. Breathe normally

A patient has been diagnosed with airway obstruction during sleep. The nurse most likely includes patient education about which device for home use? a. CPAP to deliver a positive airway pressure b. Oxygen via face-mask to prevent hypoxia c. Neck brace to support the head & facilitate breathing d. Nebulizer treatments with bronchodilators

A

A client had a partial laryngectomy and has received instructions on the supraglottic method of swallowing. Which action by the nurse is most appropriate? a. Place a chart in the client's room detailing the steps in the process. b. Order a dynamic swallow study. c. Repeat the instruction each day. d. Have the client demonstrate swallowing.

ANS: A The client who is status post partial laryngectomy should be taught alternative methods of swallowing, and a chart should be placed in the client's room to reinforce teaching. A dynamic swallow study is performed to guide rehabilitation for swallowing. Repeating the steps each shift is not as effective as showing the client a chart. Having the client demonstrate swallowing may not verify that he or she correctly understands supraglottic swallowing. A chart in the room will be most effective in helping both client and staff with this method.

After facial trauma, a client has a nasal fracture and is reporting constant nasal drainage, a headache, and difficulty with vision. What is the nurse's first action? a. Collect the nasal drainage on a piece of filter paper. b. Send the client for a facial x-ray. c. Perform a vision test. d. Palpate all facial areas for crepitus.

ANS: A The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebral spinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the client's risk for infection.

The client with which conditions requires immediate nursing intervention? (Select all that apply.) a. Shortness of breath b. Sternal retractions c. Pulse oximetry reading of 95% d. Occasional expiratory wheeze e. Respiratory rate of 8 breaths/min f. Arterial blood gas showing a pH of 7.35 g. Stridor

ANS: A, B, E, G The client with sternal retraction is experiencing serious respiratory difficulty, as is the client with stridor. The client who reports shortness of breath needs immediate assessment, as does the client with a respiratory rate of 8. A pulse oximetry of 95% is within normal limits, as is a pH of 7.35. The client with expiratory wheezes needs to be assessed, but not immediately.

A client has a closed fracture of the nose. Which intervention is best when encouraging self-care for this client? a. Advise the client not to eat or drink for 24 hours after sustaining the fracture. b. Teach the client how to apply cold compresses to the area to reduce swelling. c. Urge the client to sleep without a pillow to hasten resolution of the swelling. d. Reassure the client that his or her appearance will normalize after the swelling is gone.

ANS: B After a closed fracture of the nose, the nurse will encourage rest and the use of cool compresses on the nose, eyes, or face to help reduce swelling and bruising. Avoiding eating or drinking and sleeping without a pillow will not hasten resolution of the swelling. Reassuring the client regarding his or her appearance is not included in self-care.

Which statement indicates that the client needs more teaching regarding rhinoplasty? a. "I will take my temperature twice each day and will report any fever to my doctor." b. "I will wait a few weeks to have my photograph taken, when the swelling is gone." c. "I will take acetaminophen instead of aspirin for pain to avoid excessive bleeding." d. "I will drink at least 3 quarts of liquids a day and will use a stool softener."

ANS: B Explain that edema and bruising may last for weeks, and that the final surgical result will be evident in 6 to 12 months. The client should take his or her temperature and report fever in case of infection. The client should take acetaminophen because risk of bleeding is less than with aspirin. Fluids and stool softeners will decrease the risk of straining.

A client has open vocal cord paralysis. Which technique does the nurse teach the client to do to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Tuck the chin down when swallowing. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.

ANS: B The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration.

Which client does the nurse safely delegate to the LPN/LVN who has been assigned to the unit for the first time? a. Young adult who is 6 hours post radical neck dissection b. Older adult client with esophageal cancer who is awaiting gastric tube placement c. Client who is status post laryngectomy and is awaiting discharge teaching d. Client who is awaiting preoperative teaching for laryngeal cancer

ANS: B The nurse can delegate stable clients to the LPN. The client who is 6 hours post surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching. Teaching cannot be delegated.

A client who has sleep apnea is reporting constant daytime sleepiness. The client has multiple other chronic diseases. What is the nurse's best action? a. Refer the client for surgery. b. Perform a health history. c. Request an order for a sleeping pill. d. Move the client to a private room.

ANS: B The nurse should first assess the client and determine whether he or she has other chronic diseases. If the client's other disorders are not contradictory, the client may be eligible for therapy with modafinil (Attenace) to increase wakefulness during the day. Certain cardiac disorders may prohibit the use of this drug owing to its simulative effects. A sleeping pill would not be an appropriate intervention for a client with sleep apnea. A private room will not help to increase the client's sleep in sleep apnea.

A client develops epistaxis. Which conditions in the client's history could have contributed to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets g. High cholesterol

ANS: B, C, D Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraine, and elevated platelets and cholesterol levels do not cause epistaxis.

Which client is at greatest risk for development of obstructive sleep apnea? a. Woman who is 8 months pregnant b. Middle-aged man with gastroesophageal reflux disease c. Middle-aged woman who is 50 pounds overweight d. Older man with type 2 diabetes and a history of sinus infections

ANS: C The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.

A client states that he is going to relax on the beach between radiation treatments for laryngeal cancer to help his "mental status." What is the nurse's best response? a. "You deserve to do something for yourself." b. "Make sure someone is with you because you shouldn't be alone right now." c. "Your skin can become severely burned, and you should not be out in the sun." d. "You should make sure you use sunscreen that is at least SPF 15."

ANS: C The client should stay out of the sun during treatment because the skin can become severely burned. Sunscreen may or may not help, but an SPF of 15 is low and does not provide adequate prevention.

A high school athlete has suffered a nasal fracture. What is the priority action of the nurse caring for the client? a. Assess for pain. b. Pack the nares to prevent blood loss. c. Assess for bone displacement. d. Assess for airway patency.

ANS: D A patent airway is the priority. The nurse first should make sure that the airway is patent, then should determine whether the client is in pain, and whether bone displacement or blood loss has occurred.

A client reports waking up feeling very tired, even after 8 hours of good sleep. What is the nurse's best action? a. Ask for an order for sleep medication. b. Tell the client not to drink beverages with caffeine. c. Tell the client not to lie flat at night. d. Ask the client whether he or she has ever been evaluated for sleep apnea.

ANS: D Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.

What is the nurse's most important action after a client's gag reflex has returned post rhinoplasty? a. Teach the client to change position every 2 hours. b. Tell the client to put heating pads on the face. c. Instruct the client to lay flat. d. Have the client drink at least 2500 mL/day.

ANS: D Once the gag reflex has returned, the client should drink at least 2 1/2 liters per day. The client should not change position frequently; the best position is semi-Fowler's. Ice rather than heat should be applied. Lying flat is not recommended.

A client develops posterior nasal bleeding and has packing inserted. What is the nurse's priority action? a. Assess the client's pain level. b. Keep the client's head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the client's cheek.

ANS: D The thread is attached to the client's cheek that holds the packing in place. The nurse needs to make sure that this does not move because it can occlude the client's airway. The other options are good interventions, but ensuring that the airway is patent is the priority objective.

The nurse is caring for a patient who had reconstructive neck surgery & observes bright red blood spurting from the tissue flap that's covering the carotid artery.. What is the priority action?

Apply immediate, direct pressure to the site

The school nurse is teaching a first aid class. Which of the following interventions will the nurse teach as being the best action to take when a person experiences a nose bleed?

Have the person lean forward and pinch the nose upward toward the septum

A patient is experiencing acute anxiety related to hospitalization stress & an inability to accept changes related to laryngeal cancer. The patient wants to leave the hospital, but agrees to try a medication to "help me calm down." For which medication does the nurse obtain a PRN order?

Lorazepam (Ativan)

Preventing Aspiration

Surgical changes in the upper respiratory tract & altered swallowing mechanisms increase the patient's risk for aspiration. -Presence of a nasogastric (NG) feeding tube may further increase potential for aspiration because it keeps the lower esophageal sphincter partially open. -Dynamic swallow study- such as a barium swallow under fluoroscopy- evaluates a patients ability to protect the airway from aspiration & helps determine the appropriate method of swallow rehabilitation. -When an NG tube is in place, help prevent aspiration with the use of routine reflux precautions, including elevating the head of the bed & strictly adhering to tube feeding regimens. -Check residual volume before each bolus feeding (or every 4-6 hours with continuous feeding) & evaluate patient's tolerance of the tube feeling. -If the residual volume is high (above 100 mL for bolus feeding or 2 hours worth of continuous tube feeding) withhold the feeding & notify physician. -Check the pH of pulmonary secretions. -The tracheostomy tube sometimes fixes the larynx in place, resulting in difficulty swallowing. -Patient who has had a partial vertical or supraglottic laryngectomy MUST be observed for aspiration. -Critical to teach the patient to use alternate methods of swallowing without aspirating. -"Supraglottic" method of swallowing- effective after a partial laryngectomy or base-of-tongue resection.

When assessing a client with peritonsillar abscess (quinsy), which of the following manifestations will the nurse observe, in addition to swelling of the tonsils, when visualizing the back of the mouth and throat?

Swelling of the tonsils and deviation of the uvula to one side Rationale: The pus forms behind the tonsil, which causes swelling and deviation of the uvula toward one side.

When writing a care plan for a client with sleep apnea, which of the following goals would be most important in alleviating the manifestations of sleep apnea?

Weight loss of 1-2 pounds per week until within the normal range for height and weight Rationale: Obesity, enlarged tonsils, and using alcohol or sedatives before sleep contribute to sleep apnea. Weight loss is most often the first thing the doctor prescribes, as many people with sleep apnea are overweight. It is also important not to drink alcohol or take hypnotic medication.

A patient with a recent diagnosis of sinus cancer states that he wants another course of antibiotics because he believes he simply has another sinus infection. What is the nurse's best response?

What did the doctor say to you about your condition?

Which factors contribute to sleep apnea? (Select all that apply) a. Smoke b. A short neck c. Athletic lifestyle d. Small uvula e. Enlarged tonsils or adenoids f. Underweight for height & gender

a b e

Following radiation therapy for head & neck cancer, the nurse instructs the patient about which potential side effects? (select all that apply) a. Skin redness & tenderness b. Numbness of the mouth, lips, or face c. Dysphagia d. Hoarseness e. Xerostomia

a c d e

The nurse is interviewing a patient to assess for risk factors related to head & neck cancer. Which questions are appropriate to include? (Select all that apply_ a. "How many servings per day of alcohol would you typically drink?" b. "Have you had frequent episodes of acute or chronic visual problems?" c. "Have you had a problem with sores in your mouth?" d. "When was the last time you saw your dentist?" e. "Do you have recurrent laryngitis or frequent episodes of sore throat?" f."How many packs per day do you smoke & for how many years?"

a c e f

A patient reports noticing a change in the character of nasal discharge & speech quality, & a subjective feeling of blockage in the nasal passages. To gather additional relevant information, which question is the most appropriate to ask this patient? a. "Are you experiencing any soreness or tightness in your throat?" b. "Do you have a history of nasal polyps?" c."Do you take over-the-counter medications on a regular basis?" d. "Do you have a history of frequent nosebleeds?"

b

The nurse is teaching a patient about post-rhinoplasty care. Which patient statement indicates an understanding of the instruction? a. "I will have a very large dressing on my nose" b. "I will have bruising around my eyes, nose, & face" c. "There will be swelling that will cause a loss of sense of smell" d. "My nose will be three times its normal size for 3 weeks"

b

The nurse is caring for a patient with a laryngeal tumor. In order to facilitate comfort & breathing for the patient, which type of position does the nurse use? a. Sims' b. Supine c. Fowler;s d. Prone

c

The nurse is caring for an older adult patient with a history of noncompliance with prescribed metoprolol (Toprol XL) & recurrent nosebleeds. Which assessment finding is the most significant in relation to this patient's risk for repeated nosebleeds? a. Irregular apical pulse of 58 beats/min b. Open-mouth breathing with respiratory rate of 28/min c. Asymptomatic BP of 180/110 mm Hg d. Subjective chills & oral temperature of 97.2 F

c

The nurse is caring for several patients who are at risk because of problems related to the upper airway. What is the priority assessment for these patients? a. Thickness or oral secretions; encourage ingestion of oral fluids. b. Anxiety & pain; provide reassurance & NSAIDs. c. Adequacy of oxygenation; ensure an unobstructed air passageway. d. Evidence of spinal cord injuries; obtain order for x-rays.

c

The nurse observes that a patient is having difficulty swallowing & has initiated aspiration precautions. Which procedure does the nurse expect the physician to order for this patient? a. Chest x-ray of the neck & chest b. CT scan of the head & neck c. Barium swallow under fluoroscopy d. direct & indirect laryngoscopy

c

The nursing student is caring for an older adult patient who sustained a stroke & is confused & having trouble swallowing. Which statement by the nursing student indicates an understanding of aspiration precautions for this patient? a. I will administer pills as whole tablets; they are easier to swallow. b. If the patient coughs, I will discontinue feeding & contact the physician. c. I will keep the head of bed elevated during & after feeding d. I will encourage small amounts of fluids such as water, tea, or juices

c

A patient is at risk for aspiration related to open vocal cord paralysis. What does the nurse teach the patient to do? (select all that apply) a. Raise the chin while swallowing. b. Breathe slowly through an open mouth immediately after swallowing c. Hold the breath during swallowing d. Tilt the head backward during & immediately after swallowing. e. tuck the chin down and tilt the head forward during swallowing.

c e

The nurse is caring for a post op patient who had a radical neck dissection. Which assessment finding is expected? a. Bulky gauze dressing is present that is dry & intact over the site. b. The patient can speak normally, but reports a sore throat c. Permanent gastrostomy tube is present with continuous tube feedings. d. The patient has shoulder muscle weakness & limited range of motion

d

The nursing student is preparing patient teaching materials about head & neck cancer. Which statement is accurate & included in the patient teaching information? a. It metastasizes often to the brain. b. It usually develops over a short time c. It is often seen as red edematous areas. d. It's often seen as white patchy mucosal lesions

d

What type of treatment has the highest cure rate for small cancers of the head and neck? a. Surgery b. Chemotherapy c. Laser surgery d. Radiation therapy

d