Fracture of the Nose Displacement of either the bone or cartilage of the nose can cause airway obstruction or cosmetic deformity and is a potential source of infection. Cerebrospinal fluid could indicate skull fracture. Interventions: Rhinoplasty Nasoseptoplasty

Epistaxis Nosebleed is a common problem. Interventions if nosebleed does not respond to emergency care: Affected capillaries are cauterized with silver nitrate or electrocautery and the nose is packed. Posterior nasal bleeding is an emergency. (Continued) S&P

Epistaxis (Continued) Assess for respiratory distress and for tolerance of packing or tubes. Administer humidification, oxygen, bedrest, antibiotics, pain medications. S&P

Nasal Polyps Benign, grapelike clusters of mucous membranes and connective tissue May obstruct nasal breathing, change character of nasal discharge, and change speech quality Surgery: treatment of choice Sentences and phrases

Cancer of the Nose and Sinuses Cancer of the nose and sinuses is rare and can be benign or malignant. Onset is slow and manifestations resemble sinusitis. Local lymph enlargement often occurs on the side with tumor mass. Radiation therapy is the main treatment; surgery is also used. Sentences and phrases

Facial Trauma Le Fort I nasoethmoid complex fracture Le Fort II maxillary and nasoethmoid complex fracture Le Fort III combination of I and II plus an orbital-zygoma fracture, often called craniofacial disjunction First assessment: airway Sentences and phrases

Facial Trauma Interventions Anticipate the need for emergency intubation, tracheotomy, and cricothyroidotomy. Control hemorrhage. Assess for extent of injury. Treat shock. Stabilize the fracture segment.

Obstructive Sleep Apnea Breathing disruption during sleep that lasts at least 10 seconds and occurs a minimum of five times in an hour Excessive daytime sleepiness, inability to concentrate, and irritability Nonsurgical management and change of sleep position Surgical management: uvulopalatopharyngoplasty S&P

Disorders of the Larynx Vocal cord paralysis Vocal cord nodules and polyps Laryngeal trauma

Upper Airway Obstruction Life-threatening emergency in which an interruption in airflow through the nose, mouth, pharynx, or larynx occurs. Early recognition is essential to prevent further complications, including respiratory arrest.

Upper Airway Obstruction Inverventions Interventions include: Assessment for cause of the obstruction Maintenance of patent airway and ventilation Cricothyroidotomy Endotracheal intubation Tracheostomy

Neck Trauma Neck trauma may be caused by a knife, gunshot, or traumatic accident. Assess for other injuries including cardiovascular, respiratory, intestinal, and neurologic damage. Assess for patent airway. Assess carotid artery and esophagus. Assess for cervical spine injuries and prevent excess neck movement. Sentences and phrases

Head and Neck Cancer Head and neck cancers can disrupt breathing, eating, facial appearance, self-image, speech, and communication. In laryngeal cancer, hoarseness may occur because of tumor bulk and inability of the vocal cords to come together for normal phonation. S&P

Ineffective Breathing Pattern Interventions include: Treatment goal: to remove or eradicate the cancer while preserving as much normal function as possible Nonsurgical management Radiation therapy Chemotherapy

Surgical Management Laryngectomy (total and partial) Tracheostomy Oropharyngeal cancer resections Cordal stripping Cordectomy

Preoperative Care Client and family teaching about the tumor Self-care of airway Methods of communication Suctioning Pain control methods Critical care environment Nutritional support Goals for discharge

Postoperative Care Monitor airway patency, vital signs, hemodynamic status, comfort level. Monitor for hemorrhage. Assess for complications: Airway obstruction Hemorrhage Wound breakdown Tumor recurrence

Airway Maintenance and Ventilation Ventilatory assistance and weaning Total laryngectomy appliance to prevent scar tissue Coughing and deep breathing Saline instillations Oral secretions Stoma care, a combination of wound care and airway care S&P

Wound, Flap, and Reconstructive Tissue Care Pectoralis major myocutaneous flaps Island flaps Rotation flaps Trapezius flaps Split-thickness skin grafts Free flaps with microvascular anastomosis Critical stage: first 24 hr after surgery Sentence and phrases

Hemorrhage Uncommon with laryngectomy Often, surgical drain placed by surgeon Sentence and phrase

Wound Breakdown Common complication caused by poor nutrition, alcohol use, wound contamination, and previous radiation therapy Packing and local care as prescribed to keep wound clean and to stimulate growth of healthy granulation tissue Risk of carotid artery rupture

Pain Management Morphine Acetaminophen with codeine Acetaminophen alone Nonsteroidal anti-inflammatory drugs

Nutrition Nasogastric Gastrostomy Jejunostomy Parenteral nutrition until the gastrointestinal tract recovers from the effects of anesthesia No aspiration after total laryngectomy because the airway and esophagus are completely separated Sentences and phrases

Speech Rehabilitation Writing or using a picture board Artificial larynx Esophageal speech: sound produced by “burping” the air swallowed or injected into the esophageal pharynx and shaping the words in the mouth Mechanical devices (electrolarynges) Tracheoesophageal fistula S&P

Risk for Aspiration Interventions include: Dynamic swallow study Enteral feedings Routine reflux precautions Elevation of the head of bed Strict adherence to tube feeding regimen No bolus feeding at night Checking residual feeding

Anxiety Interventions Interventions include: Team conference Explore reason for anxiety Teaching Antianxiety drugs such as diazepam administered with caution because of the possibility of respiratory depression Lorazepam

Disturbed Body Image Interventions include: Helping client and family set realistic goals Involving client in self-care Teaching alternate communication methods Easing client into a more normal social environment after the hospitalization (Continued) Sentences and phrases

Disturbed Body Image (Continued) Advising loose-fitting, high-collar shirts or sweaters, scarves, jewelry, or cosmetics to be worn to cover the laryngectomy stoma

Stoma Care Apply shield over the tracheostomy tube or laryngectomy stoma when bathing to prevent water from entering the airway. Apply protective stoma cover or guard to protect the stoma during the day. Instruct client how to increase humidity in the home. Sentences and phrases

Chronic Airflow Limitation Chronic lung diseases of chronic airflow limitation include: Asthma Chronic bronchitis Pulmonary emphysema Chronic obstructive pulmonary disease includes emphysema and chronic bronchitis characterized by bronchospasm and dyspnea.

Asthma Intermittent and reversible airflow obstruction affects only the airways, not the alveoli. Airway obstruction occurs due to inflammation and airway hyperresponsiveness.

Aspirin and Other Nonsteroidal Anti-Inflammatory Drugs Incidence of asthma symptoms after taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) However, response not a true allergy Results from increased production of leukotriene when other inflammatory pathways are suppressed Sentences and phrases

Collaborative Management Assessment History Physical assessment and clinical manifestations: No manifestations between attacks Audible wheeze and increased respiratory rate Use of accessory muscles “Barrel chest” from air trapping

Laboratory Assessment Assess arterial blood gas level. Arterial oxygen level may decrease in acute asthma attack. Arterial carbon dioxide level may decrease early in the attack and increase later indicating poor gas exchange. (Continued) S&P

Laboratory Assessment (Continued) Atopic asthma with elevated serum eosinophil count and immunoglobulin E levels Sputum with eosinophils and mucous plugs with shed epithelial cells

Pulmonary Function Tests The most accurate measures for asthma are pulmonary function tests using spirometry including: Forced vital capacity (FVC) Forced expiratory volume in the first second (FEV1) Peak expiratory rate flow (PERF) Chest x-rays to rule out other causes

Interventions Client education: asthma is often an intermittent disease; with guided self-care, clients can co-manage this disease, increasing symptom-free periods and decreasing the number and severity of attacks. Peak flow meter can be used twice daily by client. Drug therapy plan is specific. Sentences and phrases

Drug Therapy Pharmacologic management of asthma can involve the use of: Bronchodilators Beta2 agonists Short-acting beta2 agonists Long-acting beta2 agonists Cholinergic antagonists (Continued)

Drug Therapy (Continued) Methylxanthines Anti-inflammatory agents Corticosteroids Inhaled anti-inflammatory agents Mast cell stabilizers Monoclonal antibodies Leukotriene agonists

Other Treatments for Asthma Exercise and activity is a recommended therapy that promotes ventilation and perfusion. Oxygen therapy is delivered via mask, nasal cannula, or endotracheal tube in acute asthma attack. Sentence and phrase

Status Asthmaticus Status asthmaticus is a severe, life-threatening acute episode of airway obstruction that intensifies once it begins and often does not respond to common therapy. If the condition is not reversed, the client may develop pneumothorax and cardiac or respiratory arrest. Emergency department treatment is recommended.

Emphysema In pulmonary emphysema, loss of lung elasticity and hyperinflation of the lung Dyspnea and the need for an increased respiratory rate Air trapping, loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into bullae, and collapse of small airways (bronchioles) Sentence and phrases

Classification of Emphysema Panlobular: destruction of the entire alveolus Centrilobular: openings occurring in the bronchioles that allow spaces to develop as tissue walls break down Paraseptal: confined to the alveolar ducts and alveolar sacs

Chronic Bronchitis Inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tobacco smoke Inflammation, vasodilation, congestion, mucosal edema, and bronchospasm Affects only the airways, not the alveoli Production of large amounts of thick mucus

Complications Chronic bronchitis Hypoxemia and acidosis Respiratory infections Cardiac failure, especially cor pulmonale Cardiac dysrhythmias

Physical Assessment and Clinical Manifestations Unplanned weight loss; loss of muscle mass in the extremities; enlarged neck muscles; slow moving, slightly stooped posture; sits with forward-bend Respiratory changes Cardiac changes

Laboratory Assessment Status of arterial blood gas values for abnormal oxygenation, ventilation, and acid-base status Sputum samples Hemoglobin and hematocrit blood tests Serum alpha1-antitrypsin levels drawn Chest x-ray Pulmonary function test

Impaired Gas Exchange Interventions for chronic obstructive pulmonary disease: Airway management Monitoring client at least every 2 hours Oxygen therapy Energy management

Drug Therapy Beta-adrenergic agents Cholinergic antagonists Methylxanthines Corticosteroids Cromolyn sodium/nedocromil Leukotriene modifiers Mucolytics

Surgical Management Lung transplantation for end-stage clients Preoperative care and testing Operative procedure through a large midline incision or a transverse anterior thoracotomy Postoperative care and close monitoring for complications

Ineffective Breathing Pattern Interventions for the chronic obstructive pulmonary disease client: Assessment of client Assessment of respiratory infection Pulmonary rehabilitation therapy Specific breathing techniques Positioning to help alleviate dyspnea Exercise conditioning Energy conservation

Ineffective Airway Clearance Assessment of breath sounds before and after interventions Interventions for compromised breathing: Careful use of drugs Controlled coughing Suctioning Hydration via beverage and humidifier (Continued)

Ineffective Airway Clearance (Continued) Postural drainage in sitting position when possible Tracheostomy

Imbalanced Nutrition Interventions to achieve and maintain body weight: Prevent protein-calorie malnutrition through dietary consultation. Monitor weight, skin condition, and serum prealbumin levels. Address food intolerance, nausea, early satiety, loss of appetite, and meal-related dyspnea

Anxiety Interventions for increased anxiety: Important to have client understand that anxiety will worsen symptoms Plan ways to deal with anxiety

Health Teaching Instruct the client: Pursed-lip and diaphragmatic breathing Support of family and friends Relaxation therapy Professional counseling access Complementary and alternative therapy

Activity Intolerance Interventions to increase activity level: Encourage client to pace activities and promote self-care. Do not rush through morning activities. Gradually increase activity. Use supplemental oxygen therapy. Sentences and phrases

Potential for Pneumonia or Other Respiratory Infections Risk is greater for older clients Interventions include: Avoidance of large crowds Pneumonia vaccination Yearly influenza vaccine

Cystic Fibrosis Genetic disease affecting many organs, lethally impairing pulmonary function Present from birth, first seen in early childhood (many clients now live to adulthood) Error of chloride transport, producing mucus with low water content Problems in lungs, pancreas, liver, salivary glands, and testes Sentence and phrases

Nonpulmonary Manifestations Adults: usually smaller and thinner than average owing to malnutrition Abdominal distention Gastroesophageal reflux, rectal prolapse, foul-smelling stools, steatorrhea Vitamin deficiencies Diabetes mellitus

Pulmonary Manifestations Respiratory infections Chest congestion Limited exercise tolerance Cough and sputum production Use of accessory muscles Decreased pulmonary function Changes in chest x-ray result Increased anteroposterior diameter of chest

Exacerbation Therapy Avoid mechanical ventilation Airway clearance Increased oxygenation Antibiotic therapy Heliox (50% oxygen, 50% helium) therapy Bronchodilator and mucolytic therapies

Surgical Therapy Lung and/or pancreatic transplantation do not cure the disease; the genetic defect in chloride transport and the thick, sticky mucus remain. Transplantation extends life by 10 to 20 years. Single-lung transplant as well as double-lung transplantation is possible.

Primary Pulmonary Hypertension The disorder occurs in the absence of other lung disorders, and its cause is unknown although exposure to some drugs increases the risk. The pathologic problem is blood vessel constriction with increasing vascular resistance in the lung. The heart fails (cor pulmonale). Without treatment, death occurs within 2 years.

Interventions Warfarin therapy Calcium channel blockers Prostacyclin agents Digoxin and diuretics Oxygen therapy Surgical management

Interstitial Pulmonary Disease Affects the alveoli, blood vessels, and surrounding support tissue of the lungs rather than the airways Restrictive disease: thickened lung tissue, reduced gas exchange, “stiff” lungs that do not expand well Slow onset of disease Dyspnea common Sentences and phrases

Sarcoidosis Granulomatous disorder of unknown cause that can affect any organ, but the lung is involved most often Autoimmune responses in which the normally protective T-lymphocytes increase and damage lung tissue Interventions (corticosteroids): lessen symptoms and prevent fibrosis

Idiopathic Pulmonary Fibrosis Common restrictive lung disease Example of excessive wound healing Inflammation that continues beyond normal healing time, causing extensive fibrosis and scarring Mainstays of therapy: corticosteroids, which slow the fibrotic process and manage dyspnea Sentences and phrases

Occupational Pulmonary Disease Can be caused by exposure to occupational or environmental fumes, dust, vapors, gases, bacterial or fungal antigens, or allergens Worsened by cigarette smoke Interventions: special respirators that ensure adequate ventilation Sentences and phrases

Lung Cancer A leading cause of cancer deaths worldwide Metastasizes at late-stage diagnosis Paraneoplastic syndromes Staged to assess size and extent of disease Etiology and genetic risk (Continued) S&P

Lung Cancer (Continued) Incidence and prevalence make lung cancer a major health problem. Health promotion and illness prevention is primarily through education strategies and reduced tobacco smoking.

Manifestations of Lung Cancer Often nonspecific, appearing late in the disease process Chills, fever, and cough Assess sputum Breathing pattern Palpation Percussion Auscultation

Surgical Management Lobectomy Pneumonectomy Segmentectomy (wedge resection)

Chest Tubes Placement after thoracotomy Drainage system Care required: Monitor hourly to ensure sterility and patency. Tape tubing junctions. Keep occlusive dressing at insertion site. Position correctly to prevent kinks and large loops.

Interventions for Palliation Oxygen therapy Drug therapy Radiation therapy Laser therapy Thoracentesis and pleurodesis Dyspnea management Pain management