1. 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

2. 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)
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3. Epistaxis (Continued)
Assess for respiratory distress and for tolerance of packing or tubes.
Administer humidification, oxygen, bedrest, antibiotics, pain medications.
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4. 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
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5. 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.
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6. 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
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7. 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.

8. 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
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9. Disorders of the Larynx
Vocal cord paralysis
Vocal cord nodules and polyps
Laryngeal trauma

10. 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.

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

12. 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.
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13. 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.
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14. 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

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

16. 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

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

18. 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
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19. 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
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20. Hemorrhage Uncommon with laryngectomy
Often, surgical drain placed by surgeon
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21. 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

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

23. 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
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24. 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
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25. 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

26. 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

27. 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)
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28. Disturbed Body Image (Continued)
Advising loose-fitting, high-collar shirts or sweaters, scarves, jewelry, or cosmetics to be worn to cover the laryngectomy stoma

29. 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.
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30. 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.

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

32. 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
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33. 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

34. 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)
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35. Laboratory Assessment (Continued)
Atopic asthma with elevated serum eosinophil count and immunoglobulin E levels
Sputum with eosinophils and mucous plugs with shed epithelial cells

36. 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

37. 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.
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38. 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)

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

40. 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.
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41. 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.

42. 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)
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43. 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

44. 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

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

46. 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

47. 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

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

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

50. 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

51. 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

52. 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)

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

54. 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

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

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

57. 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.
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58. Potential for Pneumonia or Other Respiratory Infections
Risk is greater for older clients
Interventions include:
Avoidance of large crowds
Pneumonia vaccination
Yearly influenza vaccine

59. 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
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60. 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

61. 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

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

63. 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.

64. 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.

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

66. 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
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67. 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

68. 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
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69. 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
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70. 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)
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71. 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.

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

73. Surgical Management Lobectomy Pneumonectomy
Segmentectomy (wedge resection)

74. 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.

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