Chapter 29- Quiz #2 & Lecture Material
Which statement by a client with a laryngectomy indicates a need for further discharge teaching? A. "I must avoid swimming." B. "I can clean the stoma with soap and water." C. "I can project mucus when I laugh or cough." D. "I can't put anything over my stoma to cover it."
D. "I can't put anything over my stoma to cover it."
A client's mother asks what is the most important thing she will need to know to care for her son, who is having an inner maxillary fixation for a mandibular fracture. Which of these does the nurse communicate as the priority? A. "Make sure he gets enough calories each day." B. "He can only consume milk and ice cream until the wires come off." C. "He must brush his teeth every 2 hours." D. "Make sure he always carries the wire cutters with him."
D. "Make sure he always carries the wire cutters with him."
Obstructive Sleep Apnea (OSA) Treatment: Surgical
(used only if all other measures fail) and may either be UPPP/UP3 or GAHM which are the two most common procedures
Laryngectomy Post-Operative Care: Aspiration Risk
if the patient is experiencing copious amount of secretions (may have a laryngectomy tube with a TL which is shorter & wider than a trach)
Laryngeal Trauma
imperative to watch for INCREASING EDEMA as swelling can happen quickly, causing an obstructed airway
Diagnostics
includes a CBC/peripheral blood profile (PBP), bleeding times, urinary analysis (UA), metabolic panel (BMP), liver function test (LFT), kidney function, x-ray, CT , MRI, SPECT, and a laryngoscopy or nasopharyngoscopy
Emergency Airways for an Upper Airway Obstruction
includes a nasal or oral airway if caused by the tongue or excessive secretions, abdominal thrusts if caused by a foreign body, or an emergency procedure (ex. Cricoidthyroidotomy, intubation, or tracheotomy)
Obstructive Sleep Apnea (OSA) Treatment
includes adjusting sleeping position, cessation of alcohol consumption, use of a CPAP, or a UPPP & GAHM surgery if conservative treatment doesn't work
Communication after a Laryngectomy
includes burping/esophageal speech and an electronic device; homecare information involves stoma care, suctioning, communication, humidifier (for total), and cleaning the humidifier in order to prevention a potential INFECTION SOURCE (ex. mold)
Laryngectomy Home-Care Assessment: Nutritional Status
includes changes in muscle mass, lackluster nails/sparse hair, > 10% recent weight loss, impaired oral intake, difficulty swallowing, and generalized edema
Obstructive Sleep Apnea (OSA) Signs & Symptoms
includes frequent nighttime arousals, insomnia, difficulty concentration, daytime sleepiness, and morning headaches
Upper Non-Infectious Respiratory Problems
includes head & neck cancer, laryngectomy, airway obstruction, aspiration, trauma, nose & sinus disorders such as epistaxis, and OSA (obstructive sleep apnea)
Head & Neck Cancer: Early Signs
includes hoarseness > two weeks, change in voice quality or the fit of dentures, and oral ulcers which won't heal
Laryngectomy Home-Care Assessment: Illness Understanding & Treatment Adherence
includes manifestations to report to the provider, correct timing & dose according to the medication plan, ambulation/positioning schedule, dressing changes, skin care, diet modifications (24 hour recall), and skill with their tracheostomy or dressing care
Laryngectomy Post-Operative Care: Corcectomies (laryngeal surgeries)
includes stripping of the vocal cords, partial/total laryngectomy, and a "radical neck" is included if lymph nodes are involved
Head & Neck Cancer: Interprofessional Team
includes the oncologist, surgeon, RN, dietician, SLP, dentist, RT, social work, wound care, clergy, PT/OT, psychosocial counselors, etc. (ALL is involved in care); speech & communication issues, eating disruption, and self-esteem barriers require the need of an entire team for the patient's care
Head & Neck Cancer: Etiology
includes tobacco & alcohol use, voice abuse, chronic laryngitis, exposure to chemicals & dusts (ex. assess for occupation type), poor oral hygiene, long term GERD, and HPV
Causes of Upper Airway Obstruction
includes tongue edema, tongue occlusion, laryngeal edema, peritonsillar or pharyngeal abscess, head & neck cancer, thick secretions, stroke & cerebral edema, smoke inhalation edema, trauma, foreign-body aspiration, burns of the head or neck, anaphylaxis, and inspissation
Nose & Sinus Disorders
includes trauma/fractures and facial trauma
Laryngectomy Post-Operative Care
includes wound/flap/tissue reconstructive care, hemorrhage, basic hemodynamic monitoring, stoma care, wound breakdown, pain management, nutrition, and speech & language rehabilitation
Total Laryngectomy & Aspiration Risk
initially worried about aspiration due to the presence of an artificial airway which requires maintenance & suctioning, but later on post-op we are NOT worried as the patient is NO longer at risk for aspiration and are able to eat
What are interventions for a patient going through cancer treatment and is experiencing a sore throat?
interventions include gargling with saline, sucking on ice, and use of a prescribed, numbing benadryl/lidocaine mouthwash
Obstructive Sleep Apnea (OSA) Treatment: Surgical Genioglossal Advancement & Hyoid Myotomy Procedure (GAHM)
involves advancing the attachment of the muscular part of the tongue on the mandible and depending on the obstruction site, symptoms are relieved in up to 80% of OSA patients (typically performed when UPPP/UP3 is performed too)
Obstructive Sleep Apnea (OSA) Treatment: Surgical Uvulopalatopharyngoplasty Procedure (UPPP/UP3)
involves excision of the tonsillar pillars, uvula, and posterior soft palate in order to remove the obstructive tissue (typically performed when GAHM is performed too)
Nose & Sinus Disorders: Facial Trauma
involves fixed occlusion for a fractured jaw and a #3 classification which includes cranial dysfunction (mid face and skull do NOT connect = WORST CLASSIFICATION)
Nose & Sinus Disorders: Trauma/Fractures
involves fractures, epistaxis, and cancer
A patient with which two allergies need to have a CT without contrast?
iodine and shellfish (also know kidney function to remove contrast from body)
Laryngectomy Post-Operative Care: Single Modality Radiation Therapy/Surgery
less complex treatment than when compared to radical surgery with chemotherapy & radiation, typically complex treatment is required though as this cancer type is found in later stages
Shoulder drop occurs after a procedure when a patient has what removed?
lymph nodes; extensive surgery lasting up to eight hours and the patient will NOT have the ability to move their shoulder
Advanced Head & Neck Cancer
may be accompanied by difficulty swallowing or breathing
Nose & Sinus Disorders: Trauma/Fractures (Epistaxis)
may be caused by HTN, dry mucous membranes, trauma, blood disorders (ex. thrombocytopenia) and we need to assess for a headache
Positive Airway Pressure
may be delivered ONLY to the nasal airway, opening of mouth may air leakage which decreases regimen efficacy, direction into nares = minimal headgear, or full face (nose & mouth) based on breath-to-breath partitioning of airflow
Causes of Upper Airway Obstruction: Trauma
may be facial, tracheal, or laryngeal trauma
Cancer Treatment
may either be surgical or non-surgical
Cancer patients with which type of treatment need to be educated on avoiding sun exposure, shaving, sticking to the use of a mild soap (ex. Dove), and lotion recommendations from their treatment department?
radiology (follow radiology/oncology recommendations), they'll follow protocols based on the type of radiology received
Erythroplakia
red, velvety patches in the mouth which indicate abnormal cell growth (as well as leukoplakia)
General Assessment Components
remember physical, psychosocial (including LITERACY, UNDERSTANDING, & OCCUPATION), laboratory, and imaging studies all in treating your patient
Laryngectomy Home-Care Assessment: Wound Condition & Tissue Integrity
remove dressings (note condition), cleanse wound, and compare with previous notations of the wound condition (include exudate, cellulitis, & odor)
Nose & Sinus Disorders: Trauma/Fractures (Cancer)
resembles sinusitis with bloody drainage, pain after treatment, and lymph enlargement; biopsy needs to be performed of tumor to determine if it's benign or malignant and inquire about patient's occupation (exposure to dust/textiles)
If tolerable, what is the best patient position to promote gas exchange?
semi or high-fowler's (sitting the patient up); toleration is determined by assessing an adequate BP, vitals, and slowly raising the head of the bed progressively
Laryngectomy Post-Operative Care: Secretions
should be blood-tinged for a couple of days, but continuous oozing needs to be reported (stoma care is the same for a trach)
Why would we perform a BMP on a patient?
shows the patient's electrolyte status, especially as we need to monitor potassium (could stop a surgery from occurring as well as high bleeding times = high PTT & INR)
Why would we perform a SPECT on a patient?
single photon emission CT which helps locate additional tumor site
Head & Neck Cancer: Incidence
statistics of this diagnosed pathology is increasing, affects men 2x > women, and is most common within adults older than 60
Obstructive Sleep Apnea (OSA) Assessment
1. OBTAIN a comprehensive medical & sleep history. 2. Perform a Polysomnography (PSG) "sleep study"; monitors EEG, ECG, & EMG = electromyograph to diagnose OSA. 3. Epworth Sleepiness Scale; commonly used sleep assessment tool. We can also ask our patient about sleep patterns, daytime naps, and sleep aids they may use.
Laryngectomy Post-Operative Care: Tumor Staging (TNM)
1. T (tumor size) 2. N (nodal involvement) 3. M (metastasis location)
Laryngectomy Patients & Glottal Stop Technique
1. Take a Deep Breath 2. Occlude Tube (momentarily) 3. Cough 4. Remove Finger from Tube (simultaneously)
A client has received packing for a posterior nosebleed. In reviewing the client's prescriptions, which of these does the nurse question? A. "Ibuprofen 800 mg every 8 hours as needed for pain." B. "Elevate the head of the bed 45 to 60 degrees." C. "Provide humidified air." D. "Have suction available at the bedside."
A. "Ibuprofen 800 mg every 8 hours as needed for pain."
Which interventions are most appropriate for the nurse to teach a client with a nasal fracture to reduce bleeding from the injury? Select all that apply. 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 (mustache) dressing as soon as it becomes wet." F. "Use acetaminophen for pain rather than aspirin or other NSAIDS."
A. "Avoid blowing or picking the nose." F. "Use acetaminophen for pain rather than aspirin or other NSAIDS."
A client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? A. "Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe." B. "Because your body isn't getting enough oxygen you wake up and breathe." C. "Your tongue may be blocking your throat, and you wake up because you are choking." D. "You really aren't waking up that often. It just feels that way."
A. "Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe."
With which client does the nurse anticipate complications from obstructive sleep apnea following abdominal surgery? A. 28-year-old who is 80 lbs (36.4 kg) overweight and has a short neck B. 48-year-old who has type 1 diabetes and chronic sinusitis C. 58-year-old who has had gastroesophageal reflux disease for 10 years D. 78-year-old who wears upper and lower dentures and has asthma
A. 28-year-old who is 80 lbs (36.4 kg) overweight and has a short neck
When reviewing discharge care with the client who has had a laryngectomy, the client states the morphine doesn't work well because he still has shooting pain in the incisional area. Which of these does the nurse suggest be prescribed? A. A nonsteroidal anti-inflammatory drug B. Lorazepam C. An increase in the morphine dose D. Acetaminophen
A. A nonsteroidal anti-inflammatory drug
A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit? A. Administering preoperative antibiotics and anxiolytics B. Assessing the client's nutritional status and need for nutrition supplements C. Having the client sign the operative consent form D. Teaching the client about the need for tracheal suctioning after surgery
A. Administering preoperative antibiotics and anxiolytics
The community health nurse is providing education about risk factors for head and neck cancer? Which of these risks will be included in the teaching session? A. Alcohol and smokeless tobacco use B. Chronic laryngitis and voice abuse C. Marijuana use and exposure to industrial chemicals D. Poor oral hygiene and smoking cigarettes
A. Alcohol and smokeless tobacco use
A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? A. Ask the client whether the mask fits tightly over the mouth and nose. B. Discuss the use of autotitrating positive airway pressure (APAP). C. Plan to teach the client about treatment with modafinil (Provigil). D. Suggest that a nasal mask be used instead of a full facemask.
A. Ask the client whether the mask fits tightly over the mouth and nose.
The charge nurse in the emergency department (ED) is making assignments for the team including a new RN who has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse? A. Client on warfarin (Coumadin) with epistaxis with brisk bleeding B. Client with facial burns caused by a mattress fire while sleeping C. Client with possible facial fractures after a motor vehicle collision D. Client with suspected bilateral vocal cord paralysis and stridor
A. Client on warfarin (Coumadin) with epistaxis with brisk bleeding
A client is diagnosed with a tumor of the larynx. The nurse determines that the client is in the late stage of the disease process if the client exhibits which finding? A. Dyspnea B. Hoarseness C. Hemoptysis D. Voice changes
A. Dyspnea
The emergency nurse is preparing to care for a client sustaining facial and neck injuries in a motor vehicle crash. Which of these is the priority at this time? A. Ensure a tracheostomy tray is at the bedside B. Place pressure on areas of hemorrhage C. Assess the mastoid area for battle sign D. Administer isotonic fluid replacement
A. Ensure a tracheostomy tray is at the bedside
The nurse is caring for a client who has just had radical neck surgery and is receiving mechanical ventilation. Which of these assessments takes priority? A. Observing the dressing for bright-red blood B. Monitoring for decreased level of consciousness C. Evaluating the outcome of pain management strategies D. Analyzing trends of urine output since surgery
A. Observing the dressing for bright-red blood
The nurse is supervising a client during mealtime who has had a recent laryngectomy. Which of these is essential to include in the plan of care? A. Swallow twice to clear the airway B. Thicken all foods to a honey consistency C. Elevate the head of the bed to 45 degrees D. Review the results of the radiographic swallowing study
A. Swallow twice to clear the airway
What is ALWAYS the first priority for a post-op patient?
AIRWAY & MAINTENANCE
A patient has oral cancer and has received oral radiation therapy for treatment. When do they need to have dental examinations?
AT LEAST every six months (we educate on appointment scheduling)
A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure? A. "I hope I can learn esophageal speech." B. "I will have to take special care not to aspirate while eating." C. "I won't be able to breathe through my nose anymore." D. "It is hard to believe that I will never hear my own voice again."
B. "I will have to take special care not to aspirate while eating."
The standard perioperative laryngectomy plan of care includes these interventions. Which intervention will be most important for the nurse to accomplish preoperatively? A. Educate the client about ways to avoid aspiration when swallowing after the surgery. B. Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. C. Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery. D. Teach the client and significant others about how to suction and perform wound care of the stoma.
B. Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board.
The nurse is caring for the client who has had an open reduction and internal fixation (ORIF) with titanium plates to repair a LeFort III fracture. Which of these activities will the nurse include in the teaching plan? A. Individuals with a titanium plate should not have an MRI and should carry a wallet card stating this. B. It is important to have good oral hygiene using an irrigating device such as Waterpik. C. Let the health care team know if you are experiencing any pain. D. We will be checking behind your ear for any bruising to assess for additional trauma.
B. It is important to have good oral hygiene using an irrigating device such as Waterpik.
A client about to undergo radiation therapy for head and neck cancer (pharyngeal) asks what side effects are expected from this therapy. Which side effects does the nurse teach the client to expect? Select all that apply. A. Scalp and eyebrow alopecia B. Taste sensation loss or changes C. Increased risk for sinus infections D. Increased risk for skin breakdown E. Moderate weight gain F. Increased risk for cavities
B. Taste sensation loss or changes D. Increased risk for skin breakdown F. Increased risk for cavities
A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action? A. Place the client in supine position. B. Apply an ice collar around the client's neck. C. Assist the client to a sitting position with the head tilted forward. D. Instruct the client to swallow the blood until the bleeding can be controlled.
C. Assist the client to a sitting position with the head tilted forward.
The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse? A. Ecchymosis B. Edema C. Excessive swallowing D. Sore throat
C. Excessive swallowing
A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder? A. Thyroid cancer B. Acute laryngitis C. Laryngeal cancer D. Bronchogenic cancer
C. Laryngeal cancer
The nurse in the radiation therapy department is teaching the client about use of fluoride gel trays during radiation treatments. How will the nurse explain the purpose of wearing fluoride gel trays during radiation therapy of the mouth? A. They will keep the mouth moist during treatments. B. They prevent yellow teeth after treatment. C. They prevent radiation scatter from metal in the mouth. D. They will protect the taste buds on the tongue.
C. They prevent radiation scatter from metal in the mouth.
The nurse is planning care for the non-English-speaking client who is on complete voice rest after head and neck surgery. The nurse must verify the client's allergies prior to medication administration. What alternative method of communication is best for the nurse to use? A. Alphabet board B. Picture board C. Translation phone service D. Word board
C. Translation phone service
The nurse is caring for a client with facial trauma who has recently developed restlessness. Which of these is the nurse's first priority? A. Assess for bleeding on the drip moustache dressing. B. Provide ventilation with a manual resuscitation bag. C. Perform the abdominal thrust maneuver. D. Apply oxygen.
D. Apply oxygen.
The nurse assesses that the flap created after laryngectomy in the immediate post-operative period appears dusky in color. What is the nurse's first action? A. Apply moist heat over the flap site. B. Massage the flap site vigorously. C. Place a tight dressing over the flap. D. Assess flow to the area using a Doppler device.
D. Assess flow to the area using a Doppler device.
The nurse enters the room while the client is eating breakfast and recognizes that the client has an upper airway obstruction with signs of hypoxemia. What is the nurse's first action? A. Attempt to remove the obstruction. B. Call the Rapid Response Team (RRT). C. Apply oxygen by non-rebreathing mask. D. Perform the abdominal thrust maneuver.
D. Perform the abdominal thrust maneuver.
The nurse is caring for a client with laryngeal trauma. Which sign/symptom does the nurse determine is most critical to report to the provider? A. Aphonia B. Hoarseness C. Loud snoring D. Stridor
D. Stridor
The nurse manager at a long-term-care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks is appropriate to delegate to a nursing assistant? A. Administering throat-numbing lozenges B. Assessing the mouth for inflammation and infection C. Teaching about skin care while receiving radiation D. Washing the skin with plain soap and water
D. Washing the skin with plain soap and water
Psychosocial Concerns in Cancer Treatment
Does the patient have family members or friends to support them at home? Involve social work to obtain all possible resources that can be available for the patient's use.
Which lab value indicates that a blood transfusion is needed before or after surgery? Which value shows us that a patient is at a higher risk for hemorrhage?
Hgb and a higher PTT/INR indicates high hemorrhage risk
Obstructive Sleep Apnea (OSA) Medications
Modafinil (Provigil) is prescribed to promote daytime wakefulness for clients with narcolepsy related to sleep apnea (uncontrollable daytime sleep)
What happens if Obstructive Sleep Apnea (OSA) is left untreated?
OSA may lead to heart failure, severe cognitive problems, and interpersonal issues
What is the first step when an airway obstruction is suspected?
OXYGENATION, then we can establish an airway and call rapid response
Why would we perform a urinalysis on a patient?
a UTI could lead to a systemic infection, catheterization requires knowledge if the patient has a prior history or current UTI
How does a laryngectomy tube differ from a tracheostomy tube?
a laryngectomy tube is shorter, wider, and changed daily
Which lab value indicates an active infection with the patient?
high WBC
Laryngectomy Humidification
air entering the lungs is humidified along the nasobronchial tree as their natural pathway is GONE due to removal of their larynx; if air is NOT humidified before entering the lungs, secretions tend to become thick & crusty
Airway Obstruction: What does obstruction look like? Assess cause of obstruction and provide an emergency airway.
airway maintenance and ventilation is ALWAYS the priority for our patients
Obstructive Sleep Apnea (OSA) Treatment: Surgical Complications
airway obstruction or hemorrhage occur most often in the immediate post-op period
Laryngectomy Tube v. Tracheostomy Tube
an LT has a larger lumen and is short than a TT, so make sure to observe the client for any signs of bleeding or occlusion (will be the greatest immediate risk 24 hours post-op)
Laryngectomy Post-Operative Care: Carotid Rupture
apply pressure, monitor airway, call the doctor, prepare for patient transport to emergency surgery 1. APPLY PRESSURE 2. CALL RAPID RESPONSE
Laryngectomy Home-Care Assessment: Psychosocial Status
ask about passing time, visitors, trips outside of the home, observe personal ability to communicate (or if a family member does it for them), observe interactions with family members, determine the selected communication method & the patient's skill using it, observe the clothing (pajamas v. street clothes), and take the temperature at each visit
What safety issues might be associated with a full face PAP mask? aspiration
aspiration
Head & Neck Cancer: Assessment Questions
assess alcohol & tobacco use, HPV exposure, difficulty eating, recent weight loss, and any liver abnormalities (does the patient look jaundice or is dark urine present)
Upper Airway Obstruction ACTION ALERT
assess the oral care needs of the patient with risk factors for inspissated (thickly crusted) secretions daily, ensuring that whoever provides oral care understands the importance AND correct techniques for preventing secretion buildup & airway obstruction
Laryngeal Trauma CRITICAL RESCUE
assess the patient to recognize signs of respiratory difficulty including tachypnea, nasal flaring, anxiety, sternal retraction, SOB, restlessness, decreased oxygen saturation, decreased LOC, and stridor; if any signs are present, respond by staying with the patient and instructing other trauma team members or the RRT to prepare for an emergency intubation or tracheotomy
Communication after a Laryngectomy (cont.)
assess the patient's reading skills & cognition, fluent language, SLP collaboration, enhancing devices in required, techniques (ex. writing or hand signals), use of a normal tone unless hearing is a PRE-EXISTING problem, make noises if requiring immediate attention, and use yes/no formatted questions
Laryngectomy Post-Operative Care: Nutrition
assists in wound care and healing, most patients will have a post-op tube feeding (ex. NG Tube) as they transition back to a regular diet; may also experience taste changes in the process
Aspiration Prevention
avoid serving meals when the patient is tired, provide small & frequent meals, provide adequate eating time, provide close supervision when patient is eating by self, emergency suction equipment close & turned on, avoid water + other thin liquids, avoid food which generates thin liquids (ex. fruit), maintain an upright position, deflate cuff, take slow bites, "dry swallow" or swallow twice, use small volumes of liquids (use a spoon), chin tuck, encourage patient to indicate when ready for next bite, stop feeding until airway is cleared in case of coughing, and continuously monitor tolerance of intake (assess RR, ease, pulse)
Obstructive Sleep Apnea (OSA) Complications
awakening cycle disrupts deep sleep needed for rest and increases the risk for HTN, stroke, cognitive deficits, weight gain, DM, pulmonary disease, and CVD
Obstructive Sleep Apnea (OSA)
breathing disruption which lasts at least 10 seconds and a minimum of 5x per hour most commonly caused by an obstruction of the soft palate or tongue; decreases gas exchange, increases blood CO2 levels, decreases pH, and then progresses to a neural center stimulation to awaken the patient to correct the imbalance
Battle Signs
bruising behind the ears after facial trauma which causes concern for a Basilar Skull Fracture, so the patient needs to have a CT ASAP (assess respiratory & neuro)
Why do we need to inquire a patient about their occupation?
cancer treatment may include a total laryngectomy, so we need to inform the patient about communicating with their employer in regard to their new needs (ex. retraining) when they are able to work again
How do we assess perfusion?
capillary refill, skin color (will be dusky), or the use of a Doppler (ex. pulse)
Airway Obstruction
characterized by stridor, dyspnea, anxiety, restlessness, hypoxia (low O2 sat), hypercarbia, and the possibility of cyanosis
Laryngectomy Post-Operative Care: Wound Breakdown
contributed to by poor nutrition (why we see some sort of tube feeding post-op), dehydration, smoking, and alcohol use
Laryngectomy Post-Operative Care: Split-Thickness Graft
covers the carotid and two wound flaps; assess for perfusion
Nose & Sinus Disorders: Trauma/Fractures (POSTERIOR Epistaxis)
determined by a patient that's continuously swallowing so we need to assess the throat to notice bleeding, may be a medical emergency (fast bleeding), call rapid response for packing, catheters can be used to stop the bleeding (assess toleration), assess patient EVERY HOURS for respiratory status, antibiotic or oxygen need, packing removed in 1-3 days, nasal saline sprays, and then educating a discharged patient to avoid strenuous activity (ex. blowing nose) AND not buying NSAIDS, Advil, aspirin, ibuprofen, etc. which promotes anticoagulation
Laryngectomy Pre-Operative Care
discuss management of airway with the patient (trach or laryngeal tube) in order to protect their airway, get the patient involved, inform about suctioning & pain, assist with pain control, environment will be critical care, may be on a ventilator, requires tube feedings, and establish a preferred form of communication for after the procedure (ex. paper & pen, alphabet board, picture board
A patient with which condition needs to have an SLP incorporated in their care?
dysphagia (difficulty swallowing)
"Burping Speech" is also known as?
esophageal speech
Why do we need to communicate with PACU for our post-operative laryngectomy patient?
even though the patient may have a PCA, they can still overdose or have a bolus so we need to see what they were given when in PACU's care
Total Laryngectomy v. Trach Post-Op
everything is similar including a new stoma, secretions, and mucous plugs EXCEPT as the patient moves through the healing process with their laryngectomy tube, we no longer have to worry about aspiration from secretions + mouth eating (different manipulated parts in surgery)
-scopy Diagnostic Testing
examination under general anesthetic which allows a healthcare provider to explore a patient on the inside and is invasive in nature so it requires consent
How can we assist an RT when our patient is newly prescribed PPV (ex. OSA patient)?
exposure the patient to the equipment and educate them on what it does (why we need to understand the differences between a CPAP & BiPAP)
Laryngectomy Patients
fear of choking is a real fear for most of these individuals since they are unable to cough as they previously were able (removal of glottis); TEACH THE GLOTTAL STOP TECHNIQUE in order to remove secretions and help alleviate their fear
Nose & Sinus Disorders: Trauma/Fractures (Nasal Fracture Nasoseptoplasty)
fixing a deviated septum, but still has the same nursing care, concerns, and considerations as a Rhinoplasty
Diagnostic CT
gives a tumor evaluation in its location and also helps determine the patient's body geography
Positive Airway Pressure: BiPAP
has DUAL pressure settings, allowing the patient to get MORE AIR in & out of their lungs more easily; common therapy when CPAP is NOT successful in reducing OSA episodes
Diagnostic MRI
helps to differentiate tissue (normal v. diseased) and also helps determine the patient's body geography
Laryngectomy Post-Operative Care: Hemorrhage Risk (JP Drain)
may have a JP for 72 hours which is managed by squeezing it with the cap open to empty it, press for mild suction, and re-cap with gloves, eyewear, and a gown as PPE; assess for drain patency and early or sudden filling, making sure to consider the possibility of an obstruction of the vein (ex. from a clot) which would lead to further blood flow impairment = FAILED FLAP = CALL DOCTOR
Nose & Sinus Disorders: Trauma/Fractures (Nasal Fracture)
may interfere with breathing if swollen or maligned and assess for CSF (clear glucose with halo/ring when dry) which is typically indicative of a skull fracture, risking our patient of cerebral infection (provided another way for microorganisms to enter); treatment is a Closed Reduction which needs to be performed within the first 24 hours to avoid excessive edema preventing the procedure from happening OR may also have a Rhinoplasty/Nasoseptoplasty
Causes of Upper Airway Obstruction: Tongue Edema
may result from surgery, trauma, or angioedema as an allergic response to a drug)
Causes of Upper Airway Obstruction: Tongue Occlusion
may result from the loss of the patient's gag reflex, muscle tone, unconsciousness, or if they're in a coma
A CT Scan requires which medication to me withheld for 24 hours beforehand?
metformin
Nose & Sinus Disorders: Trauma/Fractures (Cancer Complications)
monitor airway, hemorrhage possibility, and nutrition alteration due to change in smell
Priorities for Patients with Head & Neck Cancer
monitor for potential airway obstruction due to edema or a tumor, aspiration risk because of edema again or anatomic changes (ex. altered protective reflexes), anxiety due to possibility of death, changes in personal role/family status, changes in economic status, treatment side effects, and any signs of decreased self-esteem due to diagnosis; also provide humidification & warmth on oxygen in order to prevent discomfort and thick secretions (may occult airway), and perform trach care/suctioning AS NEEDED
Cancer Treatment: Radiation
monitor patient for hoarseness, sore throat, dysphagia, skin problems on the radiated area (assess redness or pain), changes or lack of taste, xerostomia, and ensure improvement within 4-6 weeks of completing therapy to educate the patient
Laryngectomy Post-Operative Care: Laryngectomy Tube
needs to be humidified & warmed, patient is deep breathing & coughing, encourage independence & self-care, teach to suction with a younker AWAY from the surgical site in order to prevent wound re-opening, provide a mirror if a patient is A&O, monitor cleanliness of the catheter (store it behind the patient's pillow), and clean the suture line with saline (directed by surgeon)
"Radical Neck"
nodal neck dissection along with tumor removal if lymph node involvement occurs; removal of lymph nodes will involve the Sternocleidomastoid Muscle, 11th CN (turning head against resistance), and surrounding tissue = SHOULDER DROP
Which factors may contribute to sleep apnea?
obesity, large uvula, short neck, smoking, enlarged tonsils, men > women, and an increased risk with age
Nose & Sinus Disorders: Trauma/Fractures (Nasal Fracture Rhinoplasty)
observe patient for edema, bleeding, drainage (color or CSF halo), vital signs EVERY FOUR HOURS, changing of drip pad PRN; both nostrils will be occluded with packing so the patient will be unable to breathe through their nose + mustache dressing
Laryngectomy Home-Care Assessment: Respiratory Status & Gas Exchange Effectiveness
observe rate & depth of respiration, auscultate lungs, check airway patency, examine tracheostomy for drainage (include characteristics if any is present), examine nail beds and mucous membranes for cyanotic signs, and obtain pulse oximetry readings
Table 29.1 Warning Signs of Head & Neck Cancer
pain, lump in mouth/throat or neck, difficulty swallowing, color changes in the mouth/tongue (red/white/gray/dark brown/black), oral lesion or sore that doesn't heal > two weeks, persistent or unexplained oral bleeding, mouth/lips/face numbness (ex. unilateral ear pain & numbness), change in denture fit, burning sensation when drinking citrus juices or hot liquids, hoarseness or change in voice quality, lymphadenopathy (ex. palpate lymph nodes as they'll more than likely be larger) persistent or recurrent sore throat, SOB, or anorexia/weight loss
Laryngectomy Post-Operative Care: PCA
patient are typically on this continuous or patient-pushed device to prevent them from overdosing, but respiratory arrest can still occur from a family member or friend pushing the medication (even when locked out) = PROVIDE FAMILY EDUCATION; two RNs need to make sure of accurate dosage from the prescription and patients will also be scored in documentation based on their vitals, response to medications, and then a possible red flag
Nose & Sinus Disorders: Facial Trauma (Jaw Fracture)
patients will typically be treated through fixed occlusion (6-10 weeks) with jaw wired shut, MAKE SURE the patient has wire cutters in case of emesis that can lead to choking/aspiration; patients also need a waterpik instrument for oral care and a liquid diet placement
Obstructive Sleep Apnea (OSA) Treatment: Post-Op Patient Education
patients will usually be discharged within one day after the surgical procedure, but need to be taught what to expect such as a sore throat, foul odored breath (rinse with diluted mouthwash & salt water), temporary inflammation may still cause snoring, follow-up is important after surgery, and a Polysomnography (PSG) "sleep study" will be performed about 3-4 months after
Emergency Airways for an Upper Airway Obstruction: Cricoidthyroidotomy
performed by a provider through the cricoid cartilage in order to establish an airway
Nose & Sinus Disorders: Trauma/Fractures (Nasal Fracture Rhinoplasty)- Patient Education
prevent post-op bleeding by avoiding blowing the nose, bearing down, implementation of fluids & stool softeners to prevent constipation, raising head of bed slowly, avoiding NSAIDS & aspirin, and applying cool compresses to the face for reduction of swelling & pain
When assessing a patient, you observe stridor. What is the FIRST action you will take in order to respond to the situation?
provide oxygen
Positive Airway Pressure: CPAP
provides CONSTANT (continuous) positive pressure to keep the airways open which is necessary for OSA patients
Upper Airway Obstruction: General Symptoms
symptoms include diaphoresis, tachycardia, and elevated BP (we can evaluate vague symptoms which are persistent or unexplained through diagnostic procedures); observe for hypoxia, hypercarbia, restlessness, increasing anxiety, sternal retractions, "seesawing" chest, abdominal movements, or the feeling of impending doom from air hunger
Biotherapy
target therapy which may cause severe skin reactions, including a rash known as EGFR
Home Laryngectomy Care
teach patients to avoid swimming, use care when showering or shaving, lean slightly forward & cover stoma when coughing or sneezing, wear a stoma guard or loose clothing to cover the stoma, clean the stoma with mild soap & water, lubricate the stoma with a non-oil based ointment as needed, increase humidity by using saline in the stoma as instructed (bedside humidified/pans of water/house plants), and obtain a MedicAlert bracelet & care card for life-threatening situations
We assess literacy and understanding of a patient before educating them. How do we make sure that the patient has understood our teaching?
teach-back method
Laryngeal Cancer Signs
the patient's tongue & mouth will often appear white, gray, dark brown, black, and/or patchy
Head & Neck Cancer: Nursing Priority
the priority in this situation is the patient's airway (ABC's)
Causes of Upper Airway Obstruction: Inspissation
thickly crusted oral and nasopharyngeal secretions caused by poor oral hygiene which is common in patients that have an altered mental status or LOC, dehydrated, unable to communicate, are unable to cough effectively, or at risk for aspiration
Combined Chemotherapy AND Radiation
this treatment method intensifies complications and what we need to monitor for in our patients
Use of which two substances are both risk factors for leukoplakia & erythroplakia patches, indicating abnormal cell growth?
tobacco and alcohol
Nose & Sinus Disorders: Trauma/Fractures (ANTERIOR Epistaxis)
treated by packing nostrils, assessing toleration of this newly packed airway, and position the head LATERAL/FORWARD to avoid swallowing blood & prevent aspiration risk
If head and neck cancer is left untreated within a patient, they will die within which next number of years?
two
How do we assess a patient for an upper airway obstruction?
use a pulse oximeter to end-tidal CO2 for ongoing monitoring of gas exchange with contain assessment for stridor, cyanosis, and changes in LOC
Why is a LFT and KFT used as a diagnostic test?
used to rule out metastasis, determine how well the patient can metabolize treatment, and may indicate the patient needing treatment before beginning chemotherapy, a lower dose of chemotherapy, or may not be able to have the option of chemotherapy for treatment due to the inability of their liver or kidney to function in drug clearance
What do we do if we assess a patient with a split-thickness graft after a layngectomy and notice that they are NOT well perfused?
we need to call the doctor and the patient has to go back to surgery, also ensure that the patient is positioning on the NON-surgical site side of their body
Leukoplakia
white, patchy lesions in the mouth which indicate abnormal cell growth (as well as erythroplakia); why cancer patients need to have regular dental check-ups as the dentist will assess the patient's teeth AND mucosa
Diagnostic X-Ray
will purpose to diagnose lesions, metastasis, and the geography of the patient's body
What is a nurse's role in patient consent for a procedure?
witness the signature and make sure that they patient doesn't have any questions; if the patient does have any questions, we need to put them in contact with the provider