Respiratory Problems: Trachea, Larynx, Nose, and Sinus Flashcards

General Hospital Interventions and Airway Management

Universal Interventions for Airway Management: * Head Tilt, Jaw Thrust: Fundamental maneuvers used to open the airway and facilitate breathing in hospital patients. * Pulmonary Functioning Improvements: * Humidified $O_2$ : Provides moisture to the airway to prevent dryness and irritation. * Incentive Spirometry: Encourages deep breathing to expand the lungs. * Early Mobilization: Moving the patient early post-operatively to improve lung expansion and prevent stagnation.

Laryngeal Obstruction

Emergency Classification: Acute airway obstruction is considered a medical emergency.
Clinical Presentation (Signs of Increased Work of Breathing - WOB): * Use of accessory muscles. * Retractions located in the neck and intercostal spaces. * Patient may display significant risk for obstruction even if $SpO_2$ and $PaO_2$ appear normal.
Normal Oxygenation Values: * $SpO_2$ (Oxygen Saturation): Normal range is typically $95\%$ to $100\%$ . Levels below $92\%$ are considered low and indicative of serious issues. * $PaO_2$ (Partial Pressure of Oxygen in Arterial Blood): Normal values range from $10.5 \text{ to } 13.5\,\text{kPa}$ .
Treatment Modalities: * Removal of airway edema or mechanical airway obstruction. * Heimlich Maneuver: Used for foreign body removal. * Intubation: Inserting a tube to secure the airway. * Cricothyroidotomy: Emergency procedure to establish an airway. * Tracheostomy Placement: A surgical opening in the trachea.

Tracheostomy Procedure and Postoperative View

Surgical Specifications: * The incision is made below the $2^{nd}$ tracheal ring. * A $2\,\text{cm}$ transverse incision is made above the sternal notch. * Hemostasis: Electrocautery is employed to control bleeding. * Dilation: A $2\text{-prong}$ tracheostomy dilator is used to expand the opening.
Postoperative Equipment: * Shiley Tracheostomy Tube: A specific type of tube used to maintain the opening. * The tube is carried to the pretracheal tissues.

Head and Neck (H&N) Cancer

Risk Factors: * Tobacco use and Alcohol ( $ETOH$ ) consumption. * Environmental exposure. * Human Papillomavirus ( $HPV$ ). * Demographics: Age greater than $50$ and male gender represent higher risk. * Note on Genetics: There is no known genetic component to head and neck cancer.
Symptomatology ( $Sx$ ): * Hoarseness, cough, or sore throat. * Dysphonia: A change in the sound of the voice. * Dysphagia: Difficulty swallowing. * Dyspnea: Shortness of breath ( $SOB$ ). * Foul Breath: Caused by ulcerations in the larynx.
Diagnostics ( $Dx$ ): * Oral cavity examination. * Pharyngoscopy and Laryngoscopy. * Biopsy: Performed during laryngoscopy. * Imaging: CT scans, MRI, or barium swallow studies.

Surgical Therapy for Head and Neck Cancer

Primary Treatment: Surgery is considered the first-line treatment for H&N cancer.
Surgical Range: Ranges from vocal cord stripping up to radical neck dissection with tracheostomy.
Staging and Surgical Choice: * Stage 1 & 2: Partial laryngectomy. * Stage 3 & 4: Total laryngectomy.
Radical Neck Dissection Components: * Removal of all cervical lymph nodes. * Removal of the sternocleidomastoid muscle. * Removal of the internal jugular vein. * Removal of the spinal accessory muscle.
General Post-op Nursing Considerations: * Maintain respiratory status. * Monitor for hemorrhage. * Manage acute pain. * Provide wound care and monitor for infection.

Post-Laryngectomy Interventions: Airway Clearance

Number One Priority: Maintaining airway patency is the top priority intervention following surgery.
Interventions: * Continuous assessment of $SpO_2$ and frequent vital signs. * Administration of humidified $O_2$ as needed ( $PRN$ ). * Positioning: Semi or High Fowler’s position to decrease laryngeal edema. * Hygiene: Encourage Turning, Coughing, and Deep Breathing ( $TCDB$ ). * Trach Care: Change the tracheostomy inner cannula every $8\,\text{hours}$ , provided the surgeon has approved it.
Addressing Mucus Plugs: Severe "plugs" may require a bronchoscopy (using a scope to visualize and suction secretions).

Monitoring Respiratory Status and Ineffective Airway Clearance

Goals: Reduce upper airway swelling and prevent lower airway complications.
Signs of Worsening Airway Clearance: * Restlessness, labored breathing, and tachycardia. * Worsening crackles on auscultation. * Alveolar "Dead Space": Indicated by diminished breath sounds. * Coarse breath sounds and changes in sputum character. * Infection Risk: Stagnant sputum can lead to pneumonia ( $PNA$ ); monitor for fever and increased White Blood Cell ( $WBC$ ) counts.

Pulmonary Infection and Wound Management

Pulmonary Complications: * Unchecked secretions lead to $PNA$ . * Monitor for decreased $SpO_2$ and $PaO_2$ , and increased $CO_2$ . * Sputum Findings: Green, thick yellow, or tan sputum with a "funky odor" indicates infection. * Sputum Culture: Can be obtained directly through the tracheostomy.
Wound Infection Indicators: * Purulent, smelly drainage from Jackson-Pratt ( $JP$ ) drains. * Purulent, smelly sputum from suctioning. * Redness and tenderness at the incision site. * Stridor: Can occur due to swelling from infection.
Nursing Actions: * Early notification of signs and symptoms to the physician. * Aseptic technique for wound care and suctioning. * Care for skin flaps and assessment of drains.

Hemorrhage and Carotid Artery Rupture

Risk Factors: Incisions in the neck and oral sites, plus the presence of multiple drains.
Monitoring Goals: * Continuous cardiac monitoring and vitals every $1 \text{ to } 2\,\text{hours}$ . * Serial Labs: Hemoglobin ( $Hgb$ ) and Hematocrit ( $Hct$ ).
Drainage Management: * Expect $80 \text{ to } 120\,\text{mL}$ of drainage from $JP$ drains in the first $24\,\text{hours}$ . * Drains are typically discontinued ( $DC’d$ ) when output drops below $30\,\text{mL/day}$ .
Signs of Developing Hemorrhage: * Excessive drain output (> 120\,\text{mL/day}). * Neck swelling or hematoma at the insertion site. * Decreased Blood Pressure ( $BP$ ) and Central Venous Pressure ( $CVP$ ). * Tachycardia (increased $HR$ ). * Altered Level of Consciousness ( $LOC$ ) and cool, clammy skin.
Valsalva Maneuver: Patients must avoid this as it increases pressure on neck structures.
Carotid Artery Rupture: * A very rare but serious medical emergency. * Action: Apply immediate pressure to the bleed site, notify the MD, and prepare to administer blood products.

Central Venous Pressure (CVP) Analysis

Definition: Measures the amount of blood returning to the Right Atrium.
Volume Relationships: * Decreased CVP: Indicates decreased blood volume (e.g., hemorrhage, dehydration). * Increased CVP: Indicates increased blood volume or blood backing up from the heart.
Normal CVP Readings: * General range: $2 \text{ to } 8\,\text{mmHg}$ . * Physiological normal for most: $2 \text{ to } 6\,\text{mmHg}$ . * Readings of $6 \text{ to } 8\,\text{mmHg}$ suggest slightly increased preload or volume status (dehydration or early fluid overload).
Measurement Conditions: Measured at the end of expiration while the patient is supine.
Respiratory Impact: CVP is lower during inspiration and higher during expiration due to intrathoracic pressure changes.

Long-Term Care and Nutritional Needs

Radiation Post-Care: * Soft toothbrushes and rinsing with saline or baking soda. * Use mild lotions and soap/water; avoid temperature extremes.
Note on Nutrition: Laryngectomy patients cannot eat while a tracheostomy is in place.
Nutrition Interventions: * Maintain IV nutrition or feeding tubes until cleared by speech therapy (swallow studies). * Tube Placement: Confirm with abdominal x-ray ( $KUB$ ) and aspiration of contents. * Aspiration Pneumonia Signs: Sudden decrease in $SpO_2$ and increased Respiratory Rate ( $RR$ ) with coughing after eating. * Swallowing Techniques: Use thickened liquids and the "chin-tuck" maneuver.
Psychosocial Needs: * Address body image and communication needs. * Explain all medical equipment pre-operatively; involve partners in discussion.

Disorders of the Nose and Sinuses

Deviated Septum: * Deflection of nasal septa; most commonly caused by trauma. * Symptoms: Minor (congestion, frequent infection) to Severe (facial pain, nosebleeds, obstruction). * Treatment: Decongestants, analgesia, or nasal septoplasty.
Nasal Fracture: * Manifestations: Deformity, crepitus, ecchymosis, and difficulty breathing. * Periorbital Ecchymosis ("Raccoon Eyes"): Evaluate for basilar skull fracture. * Cerebrospinal Fluid (CSF) Leak: Clear or pink persistent drainage; lab confirmation is required. * Nursing Care: Sit upright, use ice and acetaminophen; avoid hot showers, alcohol, and smoking.
Septoplasty and Rhinoplasty: * Septoplasty corrects the septum; Rhinoplasty reconstructs the nose (outpatient). * Post-op involves nasal packing and splints.
Epistaxis (Nosebleed): * First Aid: Sit, lean forward, tilt head forward, and squeeze the lower nose for $5 \text{ to } 15\, ext{minutes}$ . * Medical Management: Vasoconstrictors (pledget), balloons, or cauterization. * Education: Sneeze with mouth open; avoid aspirin/NSAIDs; avoid nose blowing or heavy lifting for $4 \text{ to } 6\, ext{weeks}$ .
Nasal Polyps and Foreign Bodies: * Polyps: Benign growths from chronic inflammation; treated with corticosteroids or laser surgery. * Foreign Bodies: Can be inorganic or organic; require removal if causing pain or bleeding.