Chapter 26 Patient with Noninfectious Upper Respiratory Problems

d. Reposition the client to the side and suction the mouth mouth with a large-bore catheter The client is in danger of aspirating the vomitus. Repositioning to side-lying and suctioning the vomitus are the most important first actions for preventing this potentially life-threatening complication. If repositioning and suctioning are not effective, cutting the wires would be appropriate second action.

A client has just come to the floor after an inner maxillary fixation for a mandibular fracture with wiring of the jaws. As the nurse raises the head of the bed, the client starts to vomit a large amount of liquid vomitus. What is the nurse's priority action? A. Administer the prescribed anti-emetic by the intravenous or rectal route. B. Immediately notify the surgeon, the anesthesiologist, or the rapid response team. C. Cut the wires holding his jaws together, and carefully remove them from the mouth. d. Reposition the client to the side and suction the mouth mouth with a large-bore catheter

b. examine the throat for bleeding

What is the nurse's best first action when a postoperative patient with a rhinoplasty repeatedly swallows? a. ask the patient if a sore throat is present b. examine the throat for bleeding c. provide ice chips to reduce pain d. notify the surgeon

d. skull fracture

Which complication of nasal fracture does the nurse suspect when a patient's clear nasal secretions react positively when tested for glucose? a. jaw fracture b. facial fracture c. vertebral fracture d. skull fracture

c. long-term bloody nasal discharge

Which patient symptom suggests the possibility of sinus cancer to the nurse? a. blurred vision b. intermittent nasal obstruction c. long-term bloody nasal discharge d. reduction of nasal mucous production

b. 57-year-old man with chronic alcoholism

Which patient will the nurse educate about relevant lifestyle modifications to decrease the risk for head and neck cancer? a. 64-year-old woman previously treated for breast cancer b. 57-year-old man with chronic alcoholism c. 34-year-old man who snorts cocaine d. 28-year-old woman with diabetes

c. if bleeding recurs, call 911 immediately

Which precaution is most important for the nurse to teach a patient, who is a secretary, and just had nasal tubes removed after a posterior nasal bleed? a. avoid NSAIDs for at least 1 week b. wait 4 weeks before returning to work c. if bleeding recurs, call 911 immediately d. do not blow your nose for at least a month

-history: tobacco and alcohol use and other risk factors -swallowing difficulty -lumps in neck -hoarseness or change in voice quality -mouth sores and lumps

assessment for head and neck cancer

-history of environment -neck assessment (lymph enlargement often occurs on side with tumor mass)

assessments for potential cancer of the nose and sinuses

-trauma -hypertension -blood dyscrasia -after sneezing or blowing nose

common causes of epistaxis

nosebleed

epistaxis

-monitor for CSF (yellow halo, positive for glucose) -maintain patent airway -stop bleeding

nursing interventions for fractures of the nose

-airway -site of trauma -vision and eye movement -behind ears for bruising -spinal and skull trauma

what must the nurse assess in a facial trauma?

a. hoarseness

*A 58-year-old woman who has been diagnosed with throat cancer one week ago comes to the clinic today to discuss surgical options with her health care provider. Based on this diagnosis, which assessment finding does the nurse anticipate?* a. hoarseness b. severe chest pain c. low hemoglobin level (anemia) d. numbness and tingling of the face

for sore throat: -gargle with salt water -suck on ice chips -use throat spray or mouthwash for skin: -avoid exposure to sun, heat, or cold -avoid abrasive treatments, such as shaving -wear protective clothing, such as soft, cotton material -gently wash with mild soap -use only lotions and powders provided by oncologist

*After radiation therapy begins, the patient comes to the clinic for a follow-up visit. She reports having a sore throat and difficulty swallowing, and the skin on her throat is red, tender, and peeling. What patient teaching will the nurse provide?*

d. encourage sitting in a chair for meals

*The nurse is caring for a patient admitted for treatment of neck and throat cancer. Which nursing action is appropriate?* a. provide water hydration b. feed if coughing occurs c. assure that liquid nutrition is thinned d. encourage sitting in a chair for meals

D. Clear glucose positive fluid draining from nares

*The nurse is caring for a patient with facial fractures following a fall. Which assessment finding requires immediate nursing intervention?* A. Malaligned nasal bridge B. Skin crepitus upon palpation C. Blood draining from one nare D. Clear glucose positive fluid draining from nares

a. "At first, the hoarseness may become worse" c. "Gargling with saline may help decrease throat discomfort" d. "Your voice will improve within 4 to 6 weeks after completion of therapy" e. "You should rest your voice and use alternative communication therapy"

*The patient choose to undergo radiation therapy because the lesion is small and the cure rate is 80% or higher. When the patient asks what will happen to her voice, what is the appropriate nursing response? (SATA)* a. "At first, the hoarseness may become worse" b. "The more you use your voice, the quicker it will improve" c. "Gargling with saline may help decrease throat discomfort" d. "Your voice will improve within 4 to 6 weeks after completion of therapy" e. "You should rest your voice and use alternative communication therapy"

D. "I know you have been diagnosed with cancer. Are you concerned about what the future may hold?"​

*When the nurse begins obtaining a history, the patient asks: "Did you know that I have throat cancer and may not survive?" What is the appropriate nursing response?* A. "Are you having difficulty swallowing?" B. "My mother had cancer, you must feel awful about this" C. "Your cancer can be cured if you follow the health care provider's advice" D. "I know you have been diagnosed with cancer. Are you concerned about what the future may hold?"​

d. Assessing blood flow in the flap using a Doppler device A complete assessment of the area, including Doppler activity of major feeding vessels, needs to be completed before the surgeon is notified. Neither hot nor cold packs nor dressings (nor anything, for that matter) should be applied to the flap site. The site is delicate and should not be massaged.

What is the nurse's best first action when finding that a client's skin flap created after laryngectomy now appears dusky in color? a. Massaging the flap site gently with the palms rather than the fingers b. Notifying the surgeon or the primary health care provider c. Applying moist heat over the flap site and surrounding tissue d. Assessing blood flow in the flap using a Doppler device

d. Notify the primary health care provider. Clear nasal fluid that dries on a piece of filter paper and results in a yellow "halo" appearing as a ring at the dried edge of the fluid indicates leakage of cerebral spinal fluid. This is a rare and critical complication of a nasal fracture and requires immediate intervention. Elevating the head of the bed to 90 degrees could increase the rate of CSF loss. Culturing the sample is not a priority action at this time.

What is the nurse's best first action when the clear fluid draining from the nose of a client with a nasal fracture dries on a piece of filter paper and leaves a yellow "halo" ring at the dried edge of the fluid? a. Culture the sample. b. Elevate the head of the bed to 90 degrees. c. Document the finding as the only action. d. Notify the primary health care provider.

d. "Stop smoking and drink alcohol only in moderation"

What is the nurse's best response when a 62-year-old patient whose brother was just diagnosed with head and neck cancer asks what he could do to reduce his risk for also developing this cancer? a. "Because head and neck cancer has a strong hereditary component, participating in screening twice yearly is critical for you" b. "Always wear sunscreen with a 50% or greater protection factor whenever you are outdoors" c. "Avoid shouting and singing to prevent stress to your vocal chords" d. "Stop smoking and drink alcohol only in moderation"

c. apply immediate, direct pressure to the site

What is the priority action for the nurse to take first to prevent harm for a patient whose tissue flap over the carotid artery after head and neck surgery is spurting bright red blood? a. take the patient's blood pressure b. call the Rapid Response Team c. apply immediate, direct pressure to the site d. apply a bulky sterile dressing and secure the airway

c. Checking gag and cough reflexes Although assessing pain is always important, in this situation safety is the priority. The packing could slip and obstruct the airway. If the client's gag reflex is impaired for any reason, such as opioid therapy, he or she may not be aware of the packing slippage and take no action to protect the airway.

What is the priority assessment the nurse will make for a client with a posterior nosebleed who has posterior packing and is receiving oxygen therapy, antibiotics, and opioid analgesics. What is the priority assessment? a. Determining the degree of mouth dryness b. Examining the skin around the nares for breakdown c. Checking gag and cough reflexes d. Asking about pain relief

c. Applying oxygen The nurse's first priority is to apply oxygen to any client who recently developed restlessness. Restlessness could be a sign of poor gas exchange and partial airway obstruction and requires immediate attention.

Which action has the highest priority for the nurse caring for a client with facial trauma who has new-onset restlessness? a. Preparing the next dose of prescribed pain medication b. Providing ventilation with a manual resuscitation bag c. Applying oxygen d. Assessing for bleeding on the drip moustache dressing

a. have the patient sit upright with the head forward

Which action will the nurse perform first for a patient with an active nosebleed (epistaxis)? a. have the patient sit upright with the head forward b. apply direct lateral pressure to the nose c. apply ice to the back of the patient's neck d. insert nasal packing

c. confused and disoriented, difficulty producing sounds, pulse oximetry 80%

Which assessment finding indicates to the nurse that a patient who sustained laryngeal trauma and is being treated with humidified oxygen that further action is needed urgently? a. respiratory rate 24 breaths/min, PaO2 90-100 mm Hg, no difficulty with communication b. pulse oximetry 96%, anxious, fatigued, blood in sputum, abdominal breathing c. confused and disoriented, difficulty producing sounds, pulse oximetry 80% d. anxious, respiratory rate 30 breaths/min, talking rapidly about the accident, warm to touch

C. Stridor Stridor, representing airway obstruction is the most critical sign/symptom exhibited by the client with laryngeal trauma and must be addressed immediately.

Which assessment finding is most important for the nurse caring for a client with laryngeal trauma to report immediately to health care provider to prevent harm? a. Productive cough b. Aphonia c. Stridor d. Hoarseness

d. restlessness with high-pitched respirations

Which assessment finding on a patient with significant and obvious facial trauma after being struck repeatedly in the face does the nurse recognize as a priority for immediate action? a. asymmetry of the mandible b. swollen lips and missing teeth c. pain upon palpation over the nasal bridge d. restlessness with high-pitched respirations

c. Positions self upright before eating or drinking anything. Remaining upright while eating and drinking reduces the risk for aspiration by preventing substances from pooling in the pharynx. Drinking thin liquids and using a straw can result in excessive liquids entering the mouth more quickly than the client can swallow, which increases aspiration risk. Eating frequent meals that include a variety of textures and nutrients does not help prevent aspiration.

Which behavior indicates to the nurse that a client preparing for discharge after surgery understands how to perform self-care to prevent harm from aspiration? a. Eats small frequent meals that include a variety of textures and nutrients. b. Uses a straw when drinking liquid nutrition supplements. c. Positions self upright before eating or drinking anything. d. Chooses thin liquids that cause coughing but knows to take small sips.

b. lump in mouth, neck, or throat c. change in fit of dentures d. difficulty swallowing f. numbness in the mouth, lips, or face

Which changes does the nurse teach adults to be aware of as warning signs of head and neck cancer? (SATA) a. weight gain b. lump in mouth, neck, or throat c. change in fit of dentures d. difficulty swallowing e. intermittent bilateral ear pain f. numbness in the mouth, lips, or face

a. limit or avoid straining during bowel movements (Vasalva maneuver) b. do not sniff upwards or blow your nose e. avoid aspirin-containing products or NSAIDs f. use a humidifier to prevent mucosal drying

Which instructions will the nurse give to a patient after rhinoplasty to prevent harm from bleeding? (SATA) a. limit or avoid straining during bowel movements (Vasalva maneuver) b. do not sniff upwards or blow your nose c. sneeze with your mouth close for a few days after packing is removed d. cough forcefully twice daily to keep your airways clear e. avoid aspirin-containing products or NSAIDs f. use a humidifier to prevent mucosal drying

a. "Avoid blowing or picking the nose" f. "Use acetaminophen for pain rather than aspirin or other NSAIDs"

Which interventions are most appropriate for the nurse to teach a patient with a nasal fracture to reduce bleeding from the injury? (SATA) a. "Avoid blowing or picking the nose" b. "Drink at least 2000 mL of fluid daily" c. "Take the antibiotics for as long as they are prescribed" d. "Take in only liquids and eat no solid food for at least a week" e. "Change the drip (moustache) dressing as soon as it becomes wet" f. "Use acetaminophen for pain rather than aspirin or other NSAIDs"

a. Chronic exposure to wood dust and cigarette smoking Cancer of the sinuses is most common among adults with chronic exposure to wood dusts, dusts from textiles, leather dusts, flour, nickel and chromium dust, mustard gas, and radium. Cigarette smoking along with these exposures increases the risk. None of the other factors listed are associated with development of cancer of the sinuses.

Which personal factors or health problems will the nurse suspect as possible causes of a client's diagnosis of cancer of the sinuses? a. Chronic exposure to wood dust and cigarette smoking b. Yearly colds leading to development of sinus infections c. Heavy sun exposure and use of antihistamine nasal spray d. Swimming in the ocean and heating the home with a forced-air furnace

d. Take ibuprofen 800 mg every 8 hours as needed for pain. The nurse must question the prescription for ibuprofen. Ibuprofen is contraindicated in a client with a nosebleed because NSAIDs inhibit clotting and increase the risk for bleeding.

Which primary health care provider's instruction will the nurse question for a client being discharged with nasal packing in place after a posterior nosebleed? a. Sleep in a recliner or with the head in an elevated position. b. Go to the nearest emergency room if bleeding recurs. c. Use a home humidifier for at least 5 days. d. Take ibuprofen 800 mg every 8 hours as needed for pain.

b. "Do you have recurrent laryngitis or frequent episodes of sore throat?" d. "How many packs per day do you smoke and for how many years?" e. "Have you had a problem with sores in your mouth?" f. "How many servings per day of alcohol do you typically drink?"

Which questions are most relevant for the nurse to ask a client when assessing for risk factors and indications for head and neck cancer? (Select all that apply.) a. "When was the last time you saw your dentist?" b. "Do you have recurrent laryngitis or frequent episodes of sore throat?" c. "Have you had frequent episodes of acute or chronic visual problems?" d. "How many packs per day do you smoke and for how many years?" e. "Have you had a problem with sores in your mouth?" f. "How many servings per day of alcohol do you typically drink?"

-avoid getting wet: no swimming, keep dry in shower -lean slightly forward and cover stoma when coughing or sneezing -wear stoma guard and loose clothing over stoma -clean stoma with mild soap and water -lubricate stoma with non-oil based ointment as needed -wear medical bracelet

education for patients after surgery for head and neck cancer (laryngectomy)

-semi-Fowler position -cool compress on nose, eyes, face -soft foods -limit Vasalva maneuver -antibiotics -humidifer (mouth breathing=dry throat)

interventions after rhinoplasty for nose fracture

-lean forward (prevents aspiration) -direct lateral pressure for 10 minutes -ice -nasal packing -don't blow nose for 24 hours (will blow clot out) -cauterization if bleeding won't stop

interventions for anterior epistaxis

-maintain airway -manage pain -monitor for hemorrhage and infection -oral care (trach care if applicable)

interventions for cancer of the nose and sinuses

-establish and maintain airway -stabilize jaw fracture (if present) -control hemorrhage -assess for extent of injury -surgery may be necessary

interventions for facial trauma patients

-assess for s/sx of respiratory distress -apply oxygen and humidification -surgical interventions may be necessary (done ASAP to prevent laryngeal stenosis)

interventions for laryngeal trauma

-posterior packing -epistaxis catheter (nasal pressure tubes) -gel tampons -cauterization, ligation, or embolization if bleeding won't stop

interventions for posterior epistaxis

-use petroleum jelly -nasal saline spray -teach about things to avoid

nursing interventions after removal of epistaxis tubes or packing

squamous cell carcinoma: begins with mucosa that is irritated, becoming tougher and thicker which then can metastasize into local lymph nodes, muscle, bone, then distant sites (slow growing)

pathophysiology of head and neck cancer

*-assess hourly for first several days to recognize carotid artery leak: if suspected, call RRT and don't touch; if it actually ruptures, apply pressure* -maintain airway and nutrition -manage wound flap and pain -monitor for hemorrhage -promote communication w/ prostheses -prevent aspiration (supraglottic method of swallowing) -support self-esteem

postoperative care for head and cancer surgery (laryngectomy)

-tobacco and alcohol use -voice abuse -chronic laryngitis -exposure to chemicals or dust -poor oral hygiene -long-term GERD -oral infection with HPV

risk factors for head and neck cancer

1. sit upright, preferably out of bed 2. clear throat 3. take a deep breath 4. place 1/2 to 1 teaspoon of food into mouth 5. hold breath or bear down (Valsalva) 6. swallow twice 7. release breath and clear throat 8 swallow twice again 9. breathe normally

supraglottic method of swallowing for patient's following surgery for head and neck cancer (laryngectomy)

-if no displacement: treatment may not be necessary -if bone or cartilage displaced: may require cast and/or surgery (rhinoplasty or nasoseptoplasty)

treatment for fractures of the nose

radiation therapy (small cancers in specific area) chemotherapy (alone or with radiation/surgery) biotherapy (targeted therapy: blocks growth factors) surgical intervention (determined by size of tumor)

treatment for head and neck cancer

surgical removal may be combined with radiation and chemotherapy

treatment of cancer of the nose and sinuses

false, slow onset

true or false: the onset of cancer of the nose and sinuses is fast

exposure to dust from: -wood -textiles -leather -flour -nickel -chromium -mustard gas -radium -cigarette smoking

what are some causes of nose and sinus cancer?

-crushing or direct-blow injury -fracture -prolonged endotracheal intubation

what are the main causes of laryngeal trauma?

respiratory distress and tolerance of devices

what assessments will the nurse perform after interventions for epistaxis have been implemented?

sinusitis

what can cancer of the nose and sinuses resemble?

nasal trumpet because it may go up into the brain tissue

what intervention is contraindicated in facial traumas?

maintain airway (s/sx of blocked airway: stridor, shortness of breath/dyspnea, anxiety/restlessness, hypoxia, decreased oxygen saturation, cyanosis, loss of consciousness)

what is the priority action for a patient with facial trauma?

maintain patent airway

what is the priority in a laryngeal trauma?

use penlight to assess patient for excessive swallowing, which is indicative of bleeding

what must the nurse assess after a patient has surgery for a fractured nose?

plier cutters in case you need to cut the jaw open to maintain the patient's airway, especially if patient is vomiting (risk of aspiration)

what must you have at a patient's bedside when the patient has their jaw wired shut after a facial trauma?

ask about: -if they have a history of nosebleeds -how often they get nosebleeds -medications (i.e., anticoagulant)

what will the nurse question the patient about when they have epistaxis?

posterior epistaxis because it cannot be easily reached and the patient may lose a lot of blood quickly; also drains into stomach, forms a blood clot

which is a medical emergency: anterior or posterior epistaxis? why?