respiratory

Supraglottic Laryngectomy what does this pt require postoperatively?

, Requires postoperative temporary tracheostomy

Risk factors smoking and tobacco use include ?

- Cigarettes -Cigars, snuff and chew

Risk factors Economic and Social/Cultural Factors include?

- Financial concerns -Crowding/living conditions -Diet

Risk factors Nonmodifiable Factors include?

-Genetics -Age/Development

Total Laryngectomy what does it do?

-Removes the vocal cords, permanently Changed airflow pattern -Patient has a permanent opening in neck for breathing

Trach cuff Excess pressure can cause what?

. Excess pressure- that over capillary pressure- will cause tissue death- much like pressure causing a decubitus ulcer.

1. Which of the following statements is true? A. Intrapleural pressure is always less than atmospheric pressure. B. Intrapleural pressure is always greater than atmospheric pressure. C. Intrapleural pressure is always greater than intrathoracic pressure. D. Intrathoracic pressure is always greater than atmospheric pressure.

1. A

10. The structure which closes the larynx to prevent aspiration is____________.

10. epiglottis

11. The process by which oxygen and carbon dioxide is exchanged across the alveolar membrane is ____________.

11. diffusion

12. The blood in the pulmonary artery is ___________ (oxygenated or unoxygenated?)

12. unoxygenated

2. Contraction of the diaphragm and external intercostals cases thoracic volume to ____________ (increase or decrease?) which causes lung volume to ____________ (increase or decrease?) which causes intrapulmonary pressure to ____________(increase or decrease?).

2. increase, increase, decrease

Trach cuff pressure Under most circumstances cuff pressure should not exceed

25 cm H2O or 20 mm HG

3. True or false- Air is normally in the pleural space.

3. False

2. A patient states that he smokes 1 1⁄2 packs of cigarettes a day and has for the last 20 years. What will the nurse record as his pack year history? __________________________________________________________________________________

30

4. A function of the nose is to: A. Initiate the cough reflex B. Warm and humidify inspired air C. Produce surfactant D. All of the above

4. B

5. As pleural pressure increases lung volume ________(increases or decreases?)

5. decreases

6. If surfactant decreases in the alveoli lung compliance will __________(increase or decrease?)

6. decrease

7. The exchange of gases between blood and cells is called ____

7. respiration

8. Gas exchange occurs in: A. Trachea B. Bronchioles C. Aveoli D. Nose

8. C

9. The primary chemical stimulus for breathing is _______________.

9. carbondioxide

Thoracentesis what is it?

A diagnostic procedure where a needle is inserted into the pleural space to aspirate fluids for testing, to remove fluid to relieve respiratory distress or to instill medication

Blom-Singer Voice Prosthesis

A mechanical sound is produced

what pt will not be able to participate in the test?

A patient in pain or confused

Lung Perfusion Scan what is essential for interpretation?

A recent CXR is essential for interpretation

PET Scan-Positron Emission Tomography what is injected?

A short half-life radionuclide is injected, usually a glucose analog, for this reason the patient should have a fairly normal glucose

Tracheostomy

A surgical incision into the trachea to establish an airway

Esophageal Speech is it easy or difficult for pts? how does the voice sound?

Air is swallowed and the "Burping" of air from the stomach through the mouth allows the person to make sound. This is difficult for many patients. The voice is usually deep and quite changed from normal speech tones.

Tracheostomy Uses:

Airway obstruction Removal of secretions Decreases dead air space severe obstructive sleep apnea Long term mechanical ventilation changes in airway anatomy due to surgery or trauma.

laryngectomy tubes if a cuff is needed for ventilation or for other reasons in a laryngectomy patient what will be used?

An appropriately sized cuffed endotracheal or trach tube

Lung Scan Nursing Care why is encouraging fluid recommended after the test

As with other tests that use some form of dye or other injected substance, to help rid the substance from the body. Of course the nurse must take into account the condition of the patient, some patients may not tolerate excessive fluid or may be on fluid restrictions.

Thoracentesis Care what to assess post procedure?

Assess dressing and lung sounds Assess thoracentesis site

Bronchoscopy potential pneumothorax; Post procedure : what needs to be assessed?

Assess for respiratory distress, changes in VS, dysrhythmias, hemoptysis

tracheostomy tube Nursing care: what do you assess on the pt?

Assess that the patient has air exchange through the tube and has bilateral breathe sounds

Bronchoscopy Before feeding pt what needs to happen?

Assess the gag reflex with a sip of water before feeding.

Supraglottic Laryngectomy what is this pt at a high risk for?

Because of the removal of structures, especially the removal of the epiglottis, the patient is at high risk for aspiration and frequently has difficulty swallowing

Thoracentesis Care what is done post procedure on the pt?

CXR There is risk for pneumothorax.

. supraglottic swallow

Clear the throat or cough (gently) Take a breathe Hold the breath (or do a Valsalva maneuver) Swallow a small amount of food/fluid- Swallow twice then cough or clear their throat before breathing again

PET Scan-Positron Emission Tomography what is it?

Combines emissions from the radioactive scan with computerized tomography/ electrons from tissues and form gamma rays which are detected by the scanner

tracheostomy tube Nursing care: how is communication effected by tracheostomy? what should be established with communication?

Communication is directly effected The patient will not be able to speak. A communication method, individualized to the patient, should be established.

Cancer of the Head and Neck, Laryngeal Cancer Surgeries

Cordectomy Hemilaryngectomy Supraglottic Laryngectomy Total Laryngectomy Other surgery- radical neck dissection

Inflating the cuff cuff pressure should be what?

Cuff pressure should be between 14 and 20 mm HG ( 20=28cm H20)- follow your facility guidelines. Inflating the cuff

cuff pressures should be checked how often?

Cuff pressures should be checked at least every shift. Of course, always follow facility policies and procedures.

Cancer of the Head and Neck, Laryngeal Cancer when would other surgeries be deemed necessary?

Depending upon the TMN evaluation and lymph node involvement

PET Scan-Positron Emission Tomography Distinguishes between what?

Distinguishes benign and malignant pulmonary nodules/tissues and to identify presence of cancerous tumors It can detect tumors through out the body but can be especially useful for lung and brain.

PET -Nursing Care what may alter test results?

Drugs that alter glucose metabolism and abnormal glucose levels

jackson laryngectomy tube

Due to the changed anatomy a laryngectomy tube is shorter with a sharper downward curve.

Lung Scan Nursing Care encourage what post test?

Encourage fluids 24-48 hours post-test

PET -Nursing Care what is encouraged post test?

Encourage fluids 24-48 hours post-test

Voice rehabiliatation for patients who have undergone a total laryngectomy include:

Esophageal Speech Electronic Larynx Blom-Singer Voice Prosthesis

Inhalation Scan what does this scan evaluate?

Evaluates regional respiratory function

Patient Care- PFTs what needs to be explained to the patient for preparation ?

Explain the test to the patient. Cooperation is necessary. The patient will be expected to deep breath in and out.

Inflating the cuff how should the volume be?

Follow trach manufacturer recommendations for volumes. Verify with a manometer and record the pressure.

Trach cuff how should the cuff be when you need to suction?

For this reason it is important to suction the patient when the cuff is deflated

what procedures put the pt at risk for aspiration?

Hemilaryngectomy (or Vertical Laryngectomy) and Supraglottic Laryngectomy

Patient Care- PFTs can a patient use bronchodilators?

Hold bronchodilators as instructed by the MD. Patient should take bronchodilators with them as the test can precipitate an asthma attack.

Nursing Interventions R/T Prevention of Complications are all important in preventing complications and in promoting healing.

Humidification Turning, Positioning Proper Securement of Tubes Oral and Skin Care Adequate Hydration and Nutrition

Complications of Suctioning

Hypoxia/Bronchospasm Increased Intracranial Pressure Trauma/ Pulmonary bleeding/Mucosal damage and bleeding/ Infection

what is I-PIP

Increased peak inspiratory pressure

tracheostomy tube Complications:

Infections Bleeding Tracheomalacia or tracheal necrosis Tracheal stenosis due to scar formation Tracheoesophageal fistula formation

Trach Cuffs is the cuff inflated or deflated?

Inflate cuff minimal amount needed to prevent pressure on trachea

Cuff Inflation Minimal Occluding Volume

Inflate cuff until no air leak is heard over the trachea at the end of ventilator inspiration or after a deep breath (or after inhalation with a Ambu bag)

Cuff Inflation Minimal Leak Technique

Inflate cuff until no air leak is heard over the trachea at the end of ventilator inspiration or after a deep breath then "Step back" the inflation removing 0.1 ml. of air

PET -Nursing Care post procedure inform pt to do what after flushing the toilet when using the bathroom?

Inform patient to flush toilet and wash hands immediately after voiding, wear gloves and wash hands when handling urine for 24 hours post procedure

tracheostomy tube Nursing care: what should be kept at the pts bedside?

Keep a spare tracheostomy tube and the trach obturator at the bedside.

Cordectomy what does it do?

Lesion is removed by removing all or part of a vocal cord by laryngoscopy

Bronchoscopy what will the pt receive before procedure?

Local anesthesia which reduces cough and gag reflex and antianxiety agents given

Nursing care:

Maintenance of airway Proper tube placement Suctioning Communication Support- emotional/psychosocial Teaching

Thoracentesis Care what to monitor with the pt during and after procedure?

Monitor patient comfort and VS during and after procedure should be taken according to facility policy.

Lung Biopsy what is it?

Obtain tissue for study

what also increases risk for tracheal damage?

Other factors such as improper stabilization of the trach tube and tube movement increase this risk.

Lung Perfusion Scan aides in diagnosing what?

PE Differentiates between PE and other pulmonary diseases such as pneumonia, atelectasis, tumors, COPD

Inhalation Scan aides in the diagnosis of what?

PE Differentiates between PE and other pulmonary diseases such as as pneumonia, atelectasis, tumors, COPD

Patient Care- PFTs how long does the pt have to stop smoking for?

Patient are not to smoke for at least 6 hours.

Thoracentesis during the procedure what must the pt control?

Patient is to control breathing, movement and refrain from coughing during procedure

Thoracentesis Care will the pt be able to get up after the procedure?

Patient may be placed on BR

There is a difference between tracheostomy tube and laryngectomy tube. jakson (metal) trach vs jackson laryngectomy tube

Picture comparison of tracheostomy and laryngectomy tubes

PET Scan- stands for

Positron Emission Tomography sample PET lung cancer image www.rad.kumc.edu/nucmed/clinical.pet_lung.htm - no longer valid site

tracheostomy tube what technique should be used at all times?

Proper aseptic or sterile technique should be used at all times to prevent infections.

tracheostomy tube what is essential and is appropriate of the tracheostomy tube?

Proper suctioning is essential, as is appropriate care of the tracheostomy tube

Inhalation Scan also known as

Radioactive Ventilation Scan, Ventilation Scan, VQ Scan Xenon Lung Scan,

Lung Scan Nursing Care what is eliminated ?

Radioactive nucleotide is eliminated in 6-24 hours

Hemilaryngectomy what does it do?

Removal of one true and one false vocal cord and part of the thyroid cartilage

Supraglottic Laryngectomy what does it do?

Removes the structures above the true vocal cords- the false vocal cords and the epiglottis

Hemilaryngectomy what does this pt require postoperatively?

Requires postoperative temporary tracheostomy

Cordectomy how will the pts voice be?

Retains voice- hoarseness

When assessing the patient you are looking for risks factors as well as for current problems. Many of these risk factors are also assessed a part of the history. Risk factors:

Smoking/Tobacco Use Alcohol Use Industrial and Environmental Exposures Economic and Social/Cultural Factors Nonmodifiable Factors

Thoracentesis what technique is used?

Sterile technique

tracheostomy tube Nursing care: when do you suction?

Suctioning, as needed, using proper technique is an important part of care.

Lung Perfusion Scan what is injected?

Technium is injected IV

Trach Cuffs how is the cuff beneficial?

The cuff will prevent secretions form above the cuff from going into the lower airway.

tracheostomy tube Nursing care: what is important for aspect of care?

The emotional and psychosocial support of the patient and teaching

supraglottic swallow how should the pt be positioned ?

The patient needs to be sitting up, relaxed and able to understand and follow the procedure.

Supraglottic Laryngectomy what voice will the pt have?

The patient will have a changed, but understandable, voice.

Cordectomy used on what lesions?

This procedure is for "in situ" lesions that are found early in the disease process and has a high cure rate.

Supraglottic Laryngectomy how long does the risk for aspiration last?

This risk remains even after recovery and special swallowing techniques may be required for life.

tracheostomy tube Nursing care: when should communication be discussed with the pt?

This should be discussed prior to surgery if possible

Laryngectomy patients tissues should not be used near what?

Tissues should not be used near/on the stoma as they may tear/shred and particles could go into the stoma.

what is a major risk factor for respiratory system disorders?

Tobacco Be sure to also assess other forms of tobacco use and all other drugs also

is the laryngectomy tubes cuffed?

Typically are not cuffed. There is no reason to cuff a laryngectomy as there is no risk of aspiration due to changed anatomy.

Thoracentesis Care what is the Suggested amount of pleural fluid drained

Typically not more than one liter of fluid is drained, however more may be drained depending upon the patient condition and decision of the physician.

what type of patients are they used for trach cuffs?

Used for patients are risk of aspiration or for mechanical ventilation

risk for aspiration Hemilaryngectomy (or Vertical Laryngectomy) and Supraglottic Laryngectomy pts undergoing these procedures how will you instruct them to eat or drink?

When eating or drinking always have the patient sitting up, take small bites, do not talk while eating Some patients may have trouble with thin liquids and thickened liquids may be required.

Hemilaryngectomy how will the pts voice be?

Will have a changed, hoarse, but understandable voice

PET Scan-Positron Emission Tomography translates this information into what?

a three dimensional image

Lung Perfusion Scan the scan produced what image?

a visual image of pulmonary blood flow

Bronchoscopy what is this?

are done to Biopsy, assess, remove mucous plugs and foreign objects

CAT scans what type of scans are they?

are frequently spiral (or helical) scans, if available, as these provide greater resolution and better diagnostic results for some lung issues such as pulmonary emboli.

tracheostomies Humidification of inspired air or oxygen why is this important?

as the patient is not using the filtering and humidifying effect of breathing through the nose.

tracheostomy tube Suctioning is an important part of care of the patient with a tracheostomy. Review suctioning technique as necessary. SUCTIONING how often should a pt be assessed with a tracheostomy tube? what pts do you need to assess more frequently?

assessed at least every two hours, more frequently for acute patients or patients with new tracheostomies, those on ventilators or with other issues.

Endoscopic Exams include what?

bronchoscopy and mediastinoscopy

Lung biopsy may be done either by what?

bronchoscopy or as an open thoracotomy procedure.

before a pulmonary function test how should the pt prepare? are the pts sedated? .

by being well rested prior to the test. The patient should not be sedated

Pulmonary function tests

can be tiring especially to a patient with respiratory impairment or illness.

Note: Laryngectomy patients need what type of identification?

carry an ID or identifier that they are a "neck breather" CPR, O2 via Stoma, ID, No Tissue

Inflating the cuff High cuff pressure wil cause what?

cause tracheal damage

Indications for suctioning include: hearing what lung sounds you know you need suctioning?

course crackles or rhonchi,

tracheostomy tube once tracheal damage occurs what will be difficult?

difficult to reverse.

Transbronchially

done with a bronchoscopy

why would a patient have airway compromise ?

due to a mechanical obstruction or potential for a mechanical obstruction,

tracheostomy tube why may bleeding occur?

due to necrosis or erosion of arteries and is life-threatening emergency.

tracheostomy tube fistula formation or bleeding may be due to what?

excess cuff pressure or pulling, rubbing or traction on the tube that causes trauma.

PET Scan-Positron Emission Tomography is this test expensive or cheap?

expensive test which requires a nearby cyclotron to produce the positron

when a tracheostomy decreases dead air space what does this facilitate?

facilitates air exchange, decreases the work of ventilation, and improves ventilation.

Lung Scan Nursing Care inform the pt to do what after the use the bathroom and flush the toilet?

flush toilet and wash hands immediately after voiding, wear gloves and wash hands when handling urine for 24 hours post procedure

when a pt has an infection with a tach tube what will the pt present with?

however excess secretions can also be seen with complications such as infection.

Indications for suctioning include: if the pt is on a ventilator how do you know if you need to suction?

increased PIP/ the PIP alarm if the patient is on a ventilator.

Suctioning: how should care be with the pt with a tracheostomy tube?

individualized to patient needs.

Inhalation Scan What does the pt have to inhale?

inhales a mix of radioactive gas and distribution of the gas is measured

Mediastinoscopy what is this?

inspects the mediastinum through a small incision near the clavicle.

tracheostomy tube Nursing care: if the tube is dislodged what needs to happen?

it should be replaced gently and quickly with the obturator and the obturator removed.

Inhalation Scan usually performed with what?

lung perfusion scan

Mediastinoscopy what is it commonly used to biopsy?

lymph nodes and is done under general anesthesia.

A number of complications can occur due to a tracheostomy. The nurse is required to do what?

manage patient care to prevent these complications.

Cancer of the Head and Neck, Laryngeal Cancer other surgery example:a radical neck dissection

may be done in conjunction with the hemilaryngectomy or supraglottic laryngectomy

Tracheostomy how long does it stay in?

may be temporary or permanent.

PET Scan-Positron Emission Tomography what is measured?

measure body processes such as glucose metabolism, tissue perfusion or blood flow

Often new tracheostomies have what type of secretions?

more secretions as the body adjusts to the changed anatomy

Hemilaryngectomy (or vertical laryngectomy) and, especially, supraglottic laryngectomy patients are at risk for aspiration , when they eat what is the nurses job?

must be monitored and preventive measures taken to prevent this complication.

Total Laryngectomy how is the pts voice?

no voice

jakson (metal) trach

note the curve near the top of the cannula

Indications for suctioning include: what type of behavioral changes?

o Behavior or mental status Change- indicators of hypoxia like restlessness/anxiety o Respiratory distress

Nursing Interventions R/T Prevention of Complications tracheostomy tube Proper Technique: Before suctioning what needs to happen?

o Hyperoxygenate prior to suctioning

Nursing Interventions R/T Prevention of Complications tracheostomy tube Proper Technique: how long to suction?

o Limitation of time of suctioning

Electronic Larynx

o Several types placed against the neck or a tube into the mouth and the patient then speaks o Mechanical sound is produced

Nursing Interventions R/T Prevention of Complications tracheostomy tube Proper Technique: what technique used and how far to go?

o Sterile technique o Gentle suctioning to proper depth

Risk factors Industrial and Environmental Exposures include?

occupations

Initial nursing care of the patient with a tracheostomy focuses on the maintenance of what? Assuring proper tube placement and preventing what is vital?

of the airway. preventing obstruction by secretions or for other reasons is vital.

Thoracotomy

open thoracic procedure

Bronchoscopy what is important for the pt to do before and after procedure?

patient be NPO prior to the test for the time stated in the facility policy and post procedure until the gag reflex returns.

Total Laryngectomy: Because of the airflow pattern change and the removal of the vocal cords what will happen to the pt?

patient will not be able to speak normally.

Trach Cuffs pressure on the trachea can cause what to potentially happen?

potential tracheal necrosis or malacia

Lung Scan Nursing Care Observe patient for what after scan?

potential anaphlactic reaction for 60 minutes after study

Bronchoscopy During and post procedure there is a risk for what?

potential pneumothorax; the procedure could cause a puncture wound,

tracheostomies Turning and positioning are important why?

prevention of stasis of secretions in the lungs and for skin care. prevent strain on surgical sites and obstruction of the airway.

Nursing interventions to reduce the risk of complications of tracheostomies include the use of what type of technique?

proper technique at all times when dealing with the tracheostomy and when suctioning.

Thoracentesis Care with removal of large amounts of fluid pt has potential for or greater the likelihood of complications such as

pulmonary edema and shock

Lung Perfusion Scan Also known as what?

radioactive perfusion scan, perfusion ventilation scan, VQ scan lung scintiscan,

Inflating the cuff Patients on high positive pressure, what will the need to maintain a seal for ventilation?

rarely, may need higher pressure to maintain a seal

. Complications of tracheostomies are frequently related to what?

related to the cuff.

PET -Nursing Care how should diabetics use their insulin?

should take insulin as usual the day of the procedure, have a meal 4 hours before the test then be NPO or follow facility protocol

what is the VQ scan?

the Perfusion Scan combined with the Inhalation Scan

supraglottic swallow what may be utilized to assure the vocal cords are closed?

the Valsalva maneuver

Cuff Inflation Techniques include what?

the minimal occluding volume and the minimal leak technique.

. Recorded in the pts history is Tobacco pack/years means what?

the number of packs per day that an individual smokes times the numbers of years he/she has smoked.

This slide shows a Blom-Singer prosthesis and a picture of how the prosthesis is used. how does it work?

the patient occludes the stoma with a finger and the one way valve shunts air from the lungs up through the mouth so the patient can speak.

tracheostomy tube Nursing care: The nurse needs to be aware of what?

the potential complications and take appropriate measures to prevent these.

tracheostomy tube if the tracheostomy tube moves with the pulse what does this mean?

the trach maybe resting against an artery. Notify the physician immediately.

tracheostomy tube Nursing care: what does the tracheostomy effect? how does a tracheostomy effect speech ? how does tracheostomy effect the person?

the very basic act of breathing and also impairs speech and effects the patient's image to themselves and to others.

tracheostomy tube Nursing care: If the patient is having respiratory distress what is this considered?

this is an emergency.

fluid removed from the pleural cavity with a needle is called what?

thoracentesis.

Cancer of the Head and Neck, Laryngeal Cancer surgeries: how are these procedures usually modified?

to allow the patient to maintain as much function and reduce deformity as possible.

when is supraglottic swallow technique used?

to reduce risk of aspiration in patients who have had a supraglottic laryngectomy or who are at risk for aspiration due to other issues.

why is a trach cuff needed for mechanical ventilation?

to seal the airway. Picture of tracheostomy tube with cuff inflated in patient This picture shows placement of a tracheostomy tube with an inflated cuff.

Voice rehabiliatation for patients who have what?

undergone a total laryngectomy

PET -Nursing Care what to avoid for 24 hrs pretest?

use of caffeine, alcohol, and tobacco

. supraglottic swallow technique varies how?

vary slightly and should be adapted to the patient.

tracheostomy tube Nursing care: what will happen with A new tracheostomy stoma?

will close and reinsertion of the tube will be difficult if the tracheostomy is recent, this is a medical emergency and a tracheostomy tray should also be at the bedside.

Lung Perfusion Scan Evaluate perfusion changes associated with what?

with CHF and pulmonary hypertension

Lung Perfusion Scan usually done with what?

with a inhalation scan

Cuff Inflation: Minimal Leak Technique how should the pressure be checked ?

with a manometer. Record the pressure and the volume used.

Thoracentesis how is the procedure done and how is the pt positioned ?

with local anesthesia and with the patient sitting on the edge of the bed arms supported on the bedside stand