Chapter 31

Care of Patients with Noninfectious Upper Respiratory Problems

Mrs. Marion Kreisel MSN, RNNU230 Adult Health 2Fall 2011

Anatomy

Anatomy and Function of the Larynx

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: Post op HOB elevated to decrease swelling and dyspnea• Closed reduction• Rhinoplasty: • Nasoseptoplasty

Rhinoplasty

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. Especially Post op from a Rhinoplasty. Excessive swallowing is seen in the patient. Keep HOB elevated at least 48 hours to decrease swelling

Epistaxis (Cont’d)

• Assess for respiratory distress and for tolerance of packing or tubes.

• Administer humidification, oxygen, bedrest, antibiotics, pain medications.

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 is polypectomy

Nasal Polyps (Cont’d)

Cancer of the Nose and Sinuses

• Tumors 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. 80% cure rate

Facial Trauma: Interventions

• Airway assessment• Anticipate need for emergency intubation• Tracheotomy• Cricothyroidotomy• Fixed occlusion• Débridement• Clear fluid draining from one of the

nares, testing positive for glucose

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—change of sleep position, weight loss, positive-pressure ventilation

• Surgical management—adenoidectomy, uvulectomy or uvulopalatopharyngoplasty

Positive Airway Pressure

Disorders of the Larynx• Vocal cord paralysis• Vocal cord nodules and polyps• Laryngeal trauma• Laryngitis: GERD common cause

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: Interventions

• Interventions include:• Assessment for cause of the

obstruction• Maintenance of patent airway and

ventilation:• Cricothyroidotomy• Endotracheal intubation,

nasotracheal or orotracheal• Tracheostomy

Neck Trauma

• Neck trauma may be caused by a knife, gunshot, or traumatic accident.

• The priority nursing care for a patient with neck trauma is assessing for and maintaining a patent airway.

• Assess for other injuries including cardiovascular, respiratory, intestinal, and neurologic damage.

• Assess carotid artery and esophagus.• Assess for cervical spine injuries, and

prevent excess neck movement.

Head and Neck Cancer

• History • Phonation• Psychosocial assessment• Laboratory assessment• Imaging assessment• Other diagnostic assessment

Head and Neck Cancer: Interventions

• Radiation therapy: Voice will improve within 4 to 6 weeks of completing radiation therapy; this is an expected side effect.

• Chemotherapy• Cordectomy• Laryngectomy: Preop teaching very

important that patient will never speak normally again!

Throat After Laryngectomy

Aspiration cannot occur after a total laryngectomy because the airway and esophagus have been completely separated.

Laryngectomy: Postoperative Care

• The first priorities after head and neck surgery are airway maintenance and ventilation

• Wound, flap, and reconstructive tissue care

• Hemorrhage• Wound breakdown• Pain management• Nutrition• Speech and language rehabilitation

Communication After Laryngectomy

• Esophageal speech

Community-Based Care

• Home care management• Health teaching:

• Stoma care• Communication• Smoking cessation

• Psychosocial preparation • Health care resources

NCLEX TIME

Question 1

What is the percentage of cure rate for radiation treatment of small cancers in specific locations?

A. 30% to 50%B. At least 55%C. 40% to 60%D. At least 80%

Question 2

A patient has been admitted to the emergency department after experiencing a fall while rock climbing. He appears to have several facial fractures. Which

assessment finding, if observed, is most serious?

A. Malaligned nasal bridgeB. Clear fluid draining from one of the nares,

testing positive for glucose C. Clear fluid draining from one of the nares,

testing negative for glucoseD. Crackling of the skin (crepitus) upon

palpation

Question 3

During recovery from a rhinoplasty, the nurse observes that the patient is swallowing repeatedly. This outcome may indicate:

A. Dry mouth because of medicationsB. Oversecretion from the salivary glandsC. Posterior nasal bleedingD. Edema of the surgical site

Question 4The patient receiving radiation therapy for treatment of

head and neck cancer is considering stopping the treatments because the hoarseness of his voice has actually worsened. The nurse should explain that the:

A. Voice will improve within 4 to 6 weeks of completing radiation therapy; this is an expected side effect.

B. Hoarseness will improve if the radiation absorbed dose is decreased from 5000 to 4000 rad;

C. Hoarseness will improve if the treatments are decreased from daily to three times per week; this is an adverse reaction.

D. Voice will improve within 12 to 15 weeks of completing radiation therapy; this is an expected side effect.

Question 5

True or False: Aspiration is still possible after a total laryngectomy.

A. TrueB. False