NSRG 250 QUIZ 8

Laryngectomy

• Surgical removal of the larynx (voice box)

• Nursing Concepts

  • Distal portion of trachea is brought to skin surface, sewn into place

  • Necessitates permanent tracheal artificial airway

  • Speech options post operation:

    • Artificial larynx

    • Tracheoesophageal voice prosthesis

    • Esophageal speech

    • Writing, gestures, mouthing

• Interventions

  • Airway is biggest concern

    • If CPR needed, must be delivered mouth to neck

  • NG tube feeding once bowel sounds return

    • Tissues in the throat can take weeks to heal

    • Thin liquids only after swallow eval

    • Extra nutrition necessary for healing (often malnourished before surgery due to cancer)

  • Increase humidity and saline in stoma as instructed

  • Suctioning

  • Stoma Care

  • Good oral hygiene

  • Humidified O2

  • Sleep with head of bed elevated (secretions)

Obstructive sleep apnea

• A sleep-related breathing disorder with apneic periods that last 10 seconds or more with five or more episodes per hour

• Nursing Concepts

  • Includes partial or complete collapse of airway which interrupts ventilation

  • Results in hypoxia and insomnia

  • Main cause is upper airway obstruction by the soft palate or tongue

  • Decreases gas exchange, increases blood CO levels, decrease pH

  • Risk Factors

    • Obstruction by soft palate or tongue, Obesity, Large uvula, Short neck, Smoking, Large tonsils, or adenoids Oropharyngeal edema

  • Impact on health

    • Systemic hypertension, cardiac arrythmias, heart failure, stroke

    • Motor vehicle accidents due to daytime drowsiness

    • Depression

  • Manifestations

    • Nighttime

      • Snoring

      • Breathing ceases for 10 seconds or longer 

    • Daytime

      • Excessive daytime sleepiness

      • Inability to concentrate, irritability

• Interventions

  • Nonsurgical management

    • Change of sleep position

    • Weight loss

    • Positive-pressure ventilation

  • Surgical management

    • Adenoidectomy, uvulectomy

    • Considered when pt can’t tolerate CPAP or when it doesn’t improve sx

  
  

Chest tube

• a plastic tube that is used to drain fluid or air from the chest

• Nursing Concepts

  • Indications

    • Remove excess air or fluid from the pleural space

  • Drainage System Mechanism

    • Positive Expiratory Pressure, Gravity

    • Water Seal 

    • Suction usually set to -20cm H₂0 

  • Mobile Chest Drains

    • Heimlich (flutter) valve, Pneumostat

  • Tip of tube for air drainage placed near front lung apex

  • Tip of tube for liquid drainage placed on side near base of lung

  • Connected by 6 feet of tubing to collection device placed below chest

    • Gravity drainage

  • When 2 inserted, join them by Y-connector close to patient

• Interventions

  • Check sterility and patency of drainage system hourly

  • Keep sterile gauze at bedside to cover and occlude insertion site immediately if it becomes dislodged

    • Padded clamps as well if drainage system interrupted

  • Check water-seal chamber for unexpected bubbling due to air leak in system

  • Remove when drainage is minimal and lung expansion is stable

Chronic bronchitis

• An inflammation of the bronchi and bronchioles caused by exposure to irritants, especially cigarette smoke

• Nursing Concepts

  • Inflammation, vasodilation, congestion, mucosal edema, and bronchospasm

  • Airway enlargement – loss of recoil

  • Production of large amounts of thick mucus

  • Impairs airflow and gas exchange

    • PaO2 decreases (hypoxemia), arterial carbon dioxide increases (respiratory acidosis)

  • Affect airway

  • Causes more sputum than emphysema

  • Increases work of heart -> cardiac issues

  • Complications

    • Hypoxemia 

    • Acidosis 

    • Respiratory infections

    • Cardiac failure; Cor pulmonale

    • Cardiac dysrhythmias

• Interventions

  • Smoking cessation:

  • Bronchodilators:

  • Steroids: Inhaled or oral corticosteroids

  • Biologic medications: Dupilumab (Dupixent®) and mepolizumab (Nucala®)

  • Ensifentrine (Ohtuvayre®):

  • Roflumilast (Daliresp®):

  • Oxygen therapy:

  • Antibiotics:

  • Pulmonary rehabilitation:

Emphysema

• A destructive problem of lung elastic tissue that reduces its ability to recoil after stretching, leading to hyperinflation of the lung

• Nursing Concepts

  • Result in dyspnea with reduced gas exchange and need for increased respiratory rate

  • Hyperinflation of lungs

  • Loss of elastic recoil

  • Increased airway resistance due to compromised alveolar walls

  • Bullae form due to enlargement of alveoli

  • Air trapping

  • affects alveoli   

  • More likely to cause acidosis & cardiac problems

  • Gas exchange decreased overall

• Interventions

  • Stop smoking

  • getting recommended vaccinations, washing your hands frequently and wearing a mask when you’re around others who could be sick.

    Other treatment options could include:

    • Bronchodilators

    • Inhaled corticosteroids

    • Oral corticosteroids

    • Antibiotics

    • Oxygen therapy

    • Lung volume reduction surgery (LVRS)

    • Bronchoscopic lung volume reduction

Hypercapnia

• Higher than normal blood carbon dioxide levels.

• Nursing Concepts

  • AKA hypercarbia

  • can be chronic (long-lasting)

  • Symptoms: Shortness of breath. Headaches. Persistent tiredness or sluggishness during the day. Disorientation. Confusion or altered mental state. Paranoia. Depression. Seizures.

  • Chronic obstructive pulmonary disease (COPD) and sleep apnea are two common conditions that sometimes lead to this

  • Other causes include:

    • stroke, sedative overdose, obesity hypoventilation syndrome and hypothyroidism, multiple sclerosis (MS), nerve or spinal cord injuries, amyotrophic lateral sclerosis (ALS) muscular dystrophy, flail chest and ankylosing spondylitis, tetanus and botulism, Pulmonary embolism, Vascular disease.

  • Using medications that sedate you (like opioids or benzodiazepines) can cause you to breathe more shallowly or less frequently, increasing risk

  • Complications: Respiratory acidosis, Respiratory failure, Cardiac arrest, Coma.

• Interventions

  • Non-invasive ventilation.

    • Examples include continuous positive airway pressure (CPAP) or bilevel positive airway pressure (often known under the trade name BiPAP®).

  • Oxygen therapy.

  • Medication to reverse overdoses.

    • EX: Nalaxone for opioids

  • Mechanical ventilation.

  • Tests to look at:

    • Pulse oximetry.

    • Arterial blood gas test.

    • a complete blood count, toxicology screen, CO2 blood test and thyroid function tests.

    • chest X-rays or CT scans of your chest or head

    • Pulmonary function tests.

Consolidation

• An abnormal solidification with lack of air spaces in a segment of the lung

• Nursing Concepts

  • May occur with lobar pneumonia in a segment or entire lobe of lung

    • must be present to diagnose pneumonia

  • occurs through accumulation of inflammatory cellular exudate in the alveoli and adjoining ducts

    • liquid can be pulmonary edema, inflammatory exudate, pus, inhaled water, or blood

  • Signs include:

    • Expansion of the thorax on inspiration is reduced on the affected side

    • Vocal fremitus is increased on the affected side

    • Percussion note is impaired in the affected area

    • Breath sounds are bronchial

    • Possible medium, late, or pan-inspiratory crackles

    • Vocal resonance is increased. Here, the patient's voice (or whisper, as in whispered pectoriloquy) can be heard more clearly when there is consolidation, as opposed to the healthy lung where speech sounds muffled.

    • A pleural rub may be present

    • A lower P_AO₂ than calculated in the alveolar gas equation

• Interventions

  • Tests include: Blood tests. Sputum culture. CT scan. Bronchoscopy

  • antibiotics, antivirals, or antifungals

    • medication to control your cough, chest pain, or fever.

  • medication to remove the extra fluid, lower the pressure in your blood vessels, or make your heart pump better.

  • steroids and immunosuppressants for vasculitis

  • Detect cancer early and Removing the tumor with surgery

Induration

• Localized swelling with hardness of soft tissue

• Nursing Concepts

  • Indicates exposure to and posible infection with TB

  • Some causes include:

    • Cysts infected by microorganisms

    • Cancer like skin, inflammatory breast, lymphoma

    • Scarring

  • Raised areas that look smoother and shinier than rest of skin due to fibrotic tissue

    • Sensitive to touch

  • Skin may feel thicker and firmer

• Interventions

  • Abscess can resolve promptly

  • Antibiotics

  • Immunosuppressants

  • topical steroid cream

  • Diabetes Mellitus treatment

Community Acquired Pneumonia

• An acute infection acquired within the community

• Nursing Concepts

  • Most commonly caused by Streptococcus Pneumoniae, influenza, and COVID-19

  • Risk factors

    • Older adult

    • Never gotten pneumococcal vaccination or got it more than 5 years ago

    • No flu vaccine within past year

    • No COVID-19 vaccine series

    • Chronic health problem or coexisting condition reducing immunity

    • Recently exposed to respiratory viral or influenza vaccine

    • Uses tobacco, alcohol, or exposed to secondhand smoke

• Interventions

  • Antibiotics are often empirical based on multiple patient and environmental factors

  • 5 days of treatment

  • Antibiotics should be given immediately in ED setting

    • within 4 hours

Hospital Acquired Pneumonia

• Onset/diagnosis of pneumonia 48 hours or more after admission to hospital

• Nursing Concepts

  • Categorized under nosocomial pneumonia

  • Risk factors

    • Older adult

    • chronic lung disease

    • Has presence of gram-negative colonization of mouth, throat, and stomach

    • altered level of concsiousness

    • recent aspiration event

    • endotracheal or NG tube or tracheostomy

    • Poor nutrition

    • reduced immunity

    • Drug usage that increase gastric pH or alkaline tube feeding

    • Using mechanical ventilation

• Interventions

  • Encourage pulmonary hygiene and progressive ambulation

  • Hydrate

  • Assess risk for aspiration using evidence-based tool

  • Monitor for sepsis

  • Hand hygiene

  • Vigorous oral care

Ventilator Associated Pneumonia

• Onset/diagnosis of pneumonia 48 hours or more after endotracheal intubation

• Nursing Concepts

  • Presence of ET tube increases risk of Pneumonia by bypassing protective airway mechanism and allows aspiration of secretion from oropharynx and stomach

  • Dental plaque increases risk

  • Categorized under nosocomial pneumonia

  • Risk factors

    • Older adult

    • chronic lung disease

    • Has presence of gram-negative colonization of mouth, throat, and stomach

    • altered level of concsiousness

    • recent aspiration event

    • endotracheal or NG tube or tracheostomy

    • Poor nutrition

    • reduced immunity

    • Drug usage that increase gastric pH or alkaline tube feeding

    • Using mechanical ventilation

• Interventions

  • Initiate ventilator bundle order set

  • Elevate HOB at least 30 degrees

  • Daily weaning assessment

  • DVT prophylaxis

  • Oral care regimen

  • Stress ulcer prophylaxis

  • Suctioning, either as needed or continuous sub glottal suction

  • Hand hygiene

Tuberculosis

• A highly communicable disease caused by infection with Mycobacterium [INSERT]

• Nursing Concepts

  • Close contact with an infectious person

  • Opportunistic infection common with HIV/AIDS

  • Multidrug-resistant version exists

  • Resistant: difficult, costly to treat; can be fatal

  • Slow onset and latent until disease advanced

  • Early manifestations:

    • Progressive fatigue Lethargy Nausea, anorexia, and weight loss Low-grade fever Cough with mucopurulent sputum, blood streaks Dull aching chest pain Dyspnea Sleep disturbances

  • Advanced symptoms

    • Activity intolerance Low-grade fever, Night sweats Cough -- sputum occasionally streaked with blood Dullness with percussion over involved parenchymal areas Bronchial breath sounds, increased transmission of spoken or whispered sounds

  • Induration is present

• Interventions

  • Drug therapy as ordered by health care provider

  • Negative pressure room with respiratory airborne isolation

  • Maintain isolation until three consecutive sputum cultures test negative

  • Pt Teaching: pain management, handling fatigue, importance of good nutrition, adherence to medication

  • Combination drug therapy

    • May include: isoniazid, rifampin, pyrazinamide, ethambutol

  • May take antimemetics or small snack of simple carbs if medications cause nausea

  • Strict adherence to medication regimen

Hemothorax

• Bleeding into chest cavity

• Nursing Concepts

  • Occurs with pneumothorax

  • Simple - less than 1000 mL blood loss

  • Massive - more than 1000 mL blood loss

  • Symptoms include: Shortness of breath (dyspnea). Rapid breathing (hyperventilation). Rapid heart rate. Chest pain. Low blood pressure (hypotension). Feelings of restlessness. Anxiety. Fever.

  • A major injury, chest trauma and surgery are the most common causes

    • Risk factors include: chest surgery and repeated chest injuries

  • Complications: respiratory failure, Hypovolemic shock. Empyema. Scarring in your pleural tissue or lung tissue.

• Interventions

  • Testing

    • Chest X-ray, Computed tomography (CT) scan, Thoracentesis.

  • Steps

    • They’ll first support your breathing by giving you oxygen therapy or, in severe cases, mechanical ventilation.

    • Next, depending on the severity, they’ll either insert a thin needle (thoracentesis) or chest tube (thoracostomy) between your ribs to remove blood from your pleural space

Hypoxia

• Decreased tissue oxygenation

• Nursing Concepts

  • Causes

    • Ineffective oxygenation before, during, and after suctioning

    • Use of a catheter that is too large for the artificial airway

    • Prolonged suctioning time

    • Excessive suction pressure

    • Too frequent suctioning

  • often seen with pneumonia

  • Signs include: increased heart rate and B/P, oxygen saturation, cyanosis, restlessness, anxiety, dysrhythmias

  • Ox sat under 90% indicates it

• Interventions

  • Hyperoxygenate patient with 100% oxygen using manual bag-value-mask attached to an oxygen source

  • Take deep breaths three or four times with existing oxygen deliversy system before suctioning

  • Monitor heart rate, oxygen saturation while suctioning

  • Stop suctioning if it occurs, then reoxygenate until patient’s baseline oxygen saturation level returns

Pneumothorax

• Air in the pleural space causing a loss of negative pressure in the chest cavity, a rise in chest pressure, and a reduction in vital capacity, which can lead to lung collapse

• Nursing Concepts

  • Often caused by blunt chest trauma and may occur with some degree of hemothorax

  • can also occur spontaneously or as a complication of medical procedures

  • can be open or closed

    • open - pleural cavity exposed to outside air

    • closed - EX: chronic obstructive pulmonary disease has spontaneous [INSERT]

  • Tension [INSERT] - life threatening complication where air continues to enter pleural space during inhalation and doesn’t exit during expiration

    • Quickly fatal

  • Signs: Chest pain, dyspnea, tachypnea, hypoxia, reduced or absent breath sounds on affected side, hyper resonance on percussion, asymmetric lung expansion, trachea deviation

    • Also include: extreme respiratory distress, cyanosis, distended neck veins, tachycardia, hemodynamic instability (hypotension, cardiac arrest), respiratory failure

• Interventions

  • Chest x-ray, CT scan, ultrasonography

  • Chest tube therapy is essential

  • Immediate needle decompression witg large bore needle

  • Closely monitor chest tube drainage

  • Serial chest x-ray

  • Pain control, pulmonary hygiene, assess for respiratory failure

  • Open thoracotomy if blood loss is 1000mL or constant bleeding of 150-200 mL/hr over 3-4 hrs

  • Monitor vitals, blood loss, I/O

  • Assess chest tube reaction, infuse IV fluid and blood as ordered

Tracheostomy

• A tracheal stoma (opening) in the neck that results from a tracheotomy

• Nursing Concepts

  • Below thyroid and cricoid cartilage

  • May be temporary or permanent.

  • Consider when:

    • Obstruction of the mouth or throat

    • Breathing difficulty caused by edema (swelling), injury or pulmonary (lung) conditions

    • Airway reconstruction following tracheal or laryngeal surgery

    • Airway protection from secretions or food because of swallowing problems

    • Airway protection after head and neck surgery

    • Long-term need for ventilator (breathing machine) support

• Interventions

  • Air warming and humidification

  • Keep [INSERT] tube secured in place

  • Position patient with head up, slightly extended

  • Bronchial and Oral Hygiene

  • Speech and communication

  • Suctioning only as needed

  • Prevent and treat malnutrition, hemodynamic instability, or hypoxia

  • Check cuff pressure often

    • Cuff pressure should NOT exceed 25-30 cmH2O

Tracheotomy

• A surgical incision into the trachea to create an airway to help maintain gas exchange

• Nursing Concepts

  • takes 5 - 10 minutes

  • Done in OR with local/general anesthesia optimally, but can be done at bedside

  • Use local anesthesia if airway may be lost during anesthesia induction

  • Reserved for patient who can’t be easily intubated with endotracheal tube

• Interventions (Note I literally could not find anything specific to this, so this is just sharing the info with the one that sounds really similar)

  • Air warming and humidification

  • Keep [INSERT] tube secured in place

  • Position patient with head up, slightly extended

  • Bronchial and Oral Hygiene

  • Speech and communication

  • Suctioning only as needed

  • Prevent and treat malnutrition, hemodynamic instability, or hypoxia

  • Check cuff pressure often

    • Cuff pressure should NOT exceed 25-30 cmH2O