Noninfectious problems of the upper respiratory tract.
Interventions for clients with noninfectious problems of the upper respiratory tract
The number of clients with chronic respiratory problems is increasing. Respiratory disorders are common and rank as the fifth leading cause of death in the
ANATOMY AND PHYSIOLOGY REVIEW
The two purposes of the respiratory system are to provide a source of oxygen for tissue metabolism and to remove carbon dioxide, the major waste product of metabolism. The respiratory system also influences the following functions:
• Acid-base balance
• Speech
• Sense of smell
• Fluid balance
• Thermoregulation
Upper Respiratory Tract
The upper airways consist of the nose, the sinuses, the pharynx (throat), and the larynx (“voice box”).
NOSE AND SINUSES
The nose is the organ of smell, with receptors from cranial nerve I (olfactory) located in the upper areas. This organ is a rigid structure that contains two passages separated in the middle by the septum. The upper one third of the nose is composed of bone; the lower two thirds is composed of cartilage, which allows limited movement. The septum and interior walls of the nasal cavity are lined with mucous membranes that have a rich blood supply. The anterior nares (nostrils or external openings into the nasal cavities) are lined with skin and hair follicles, which help keep foreign particles or organisms from entering the lungs. The posterior nares are openings from the nasal cavity into the nasopharynx.
Three bony projections (turbinates) protrude into the nasal cavities from the walls of the internal portion of the nose. Turbinates increase the total surface area for filtering, heating, and humidifying inspired air before it passes into the nasopharynx. Inspired air entering the nose is first filtered by vibrissae in the nares. Particles not filtered out in the nares are trapped in the mucous layer of the turbinates. These particles are moved by cilia (hairlike projections) to the oropharynx, where they are either swallowed or expectorated. Inspired air is humidified by contact with the mucous membrane and is warmed by exposure to heat from the vascular network.
The paranasal sinuses are air-filled cavities within the bones that surround the nasal passages. Lined with ciliated epithelium, the purposes of the sinuses are to provide resonance during speech and to decrease the weight of the skull.
PHARYNX
The pharynx, or throat, serves as a passageway for both the respiratory and digestive tracts and is located behind the oral and nasal cavities. It is divided into the nasopharynx, the oropharynx, and the laryngopharynx.
The nasopharynx is located behind the nose, above the soft palate. It contains the adenoids and the distal opening of the eustachian tube. The adenoids (pharyngeal tonsils) are an important defense, trapping organisms that enter the nose or mouth. The eustachian tube connects the nasopharynx with the middle ear and opens during swallowing to equalize pressure within the middle ear.
The oropharynx is located behind the mouth, below the nasopharynx. It extends from the soft palate to the base of the tongue and is a shared passageway for breathing and swallowing. The palatine tonsils (also known as faucial tonsils) are located on the lateral borders of the oropharynx. These tonsils also guard the body against invading organisms.
The laryngopharynx is located behind the larynx and extends from the base of the tongue to the esophagus. The laryngopharynx is the critical dividing point where solid foods and fluids are separated from air. At this point, the passageway divides into the larynx and the esophagus.
LARYNX
The larynx is located above the trachea, just below the pharynx at the base of the tongue. It is innervated by the recurrent laryngeal nerves. The larynx is composed of several cartilages. The thyroid cartilage is the largest and is commonly referred to as the Adam’s apple. The cricoid cartilage, which contains the vocal cords, lies below the thyroid cartilage. The cricothyroid membrane is located below the level of the vocal cords and joins the thyroid and cricoid cartilages. This site is used in an emergency for access to the lower airways. In this procedure, called a cricothyroidotomy (or cricothyrotomy), an opening is made between the thyroid and cricoid cartilage and results in a tracheostomy. The two arytenoid cartilages, which attach at the posterior ends of the vocal cords, are used together with the thyroid cartilage in vocal cord movement.
Inside the larynx are two pairs of vocal cords: the false vocal cords and the true vocal cords. The opening between the true vocal cords is the glottis. The epiglottis is a leaf-shaped, elastic structure that is attached along one edge to the top of the larynx. Its hinge-like action prevents food from entering the tracheobronchial tree (aspiration) by closing over the glottis during swallowing. The epiglottis opens during breathing and coughing.
Lower Respiratory Tract
The lower airways consist of the trachea; two mainstem bronchi; lobar, segmental, and subsegmental bronchi; bronchioles; alveolar ducts; and alveoli. The tracheobronchial tree is an inverted treelike structure consisting of muscular, cartilaginous, and elastic tissues. This system of continually branching tubes, which decrease in size from the trachea to the respiratory bronchioles, allows gases to move to and from the pulmonary parenchyma. Gas exchange takes place in the pulmonary parenchyma between the alveoli and the pulmonary capillaries.
TRACHEA
The trachea (windpipe) is located in front of (anterior to) the esophagus. It begins at the lower edge of the cricoid cartilage of the larynx and extends to the level of the fourth or fifth thoracic vertebra. The trachea branches into the right and left mainstem bronchi at the carina.
The trachea is composed of 6 to 10 C-shaped cartilaginous rings. The open portion of the С is the back portion of the trachea and contains smooth muscle that is shared with the esophagus. Low pressure must be maintained in endotracheal and tracheostomy tube cuffs to avoid causing erosion of this posterior wall and to avoid creating a tracheoesophageal fistula (abnormal connection between the trachea and the esophagus).
MAINSTEM BRONCHI
The mainstem, or primary, bronchi begin at the carina. The bronchus is similar in structure to the trachea. The right bronchus is slightly wider, shorter, and more vertical than the left bronchus. Because of the more vertical line of the right bronchus, it can be accidentally intubated when an endotracheal tube is passed. Similarly, when a foreign object is aspirated from the throat, it most often enters the right bronchus.
LOBAR, SEGMENTAL, AND SUBSEGMENTAL BRONCHI
The mainstem bronchi further branch into the five secondary (lobar) bronchi that enter each of the five lobes of the lung. Each lobar bronchus is surrounded by connective tissue, blood vessels, nerves, and lymphatics, and each branches into segmental and subsegmental divisions. The cartilage of these lobar bronchi is ringlike and resists collapse. The bronchi are lined with ciliated, mucus-secreting epithelium. The cilia propel mucus up and away from the lower airway to the trachea, where the mucus is either expectorated or swallowed.
BRONCHIOLES
The bronchioles branch from the secondary bronchi and subdivide into smaller and smaller tubes: the terminal and respiratory bronchioles. These terminal and respiratory tubes are less than 1 mm in diameter. They have no cartilage and therefore depend entirely on the elastic recoil of the lung to remain open (patent). The terminal bronchioles do not participate in gas exchange.
ALVEOLAR DUCTS AND ALVEOLI
Alveolar ducts, which resemble a bunch of grapes, branch from the respiratory bronchioles. Alveolar sacs arise from these ducts. The alveolar sacs contain clusters of alveoli, which are the basic units of gas exchange. A pair of healthy adult lungs contains approximately 300 million alveoli, which are surrounded by pulmonary capillaries. Because these small alveoli are so numerous and share common walls, the surface area for gas exchange in the lungs is extensive. In a healthy adult, this surface area is approximately the size of a tennis court. Acinus is a term used to indicate the structural unit consisting of a respiratory bronchiole, an alveolar duct, and an alveolar sac.
In the walls of the alveoli, specific cells (type II pneumocytes) secrete surfactant, a fatty protein that reduces surface tension in the alveoli. Without sufficient surfactant, atelectasis (collapse of the alveoli) ultimately occurs. In atelectasis, gas exchange is reduced because the alveolar surface area is reduced.
LUNGS
The lungs are sponge-like, elastic, cone-shaped organs located in the pleural cavity in the thorax. The apex (top) of each lung extends above the clavicle; the base (bottom) of each lung lies just above the diaphragm (the major muscle of inspiration). The lungs are composed of millions of alveoli and their related ducts, bronchioles, and bronchi. The right lung, which is larger than the left, is divided into three lobes: upper, middle, and lower. The left lung, which is somewhat narrower than the right lung to make room for the heart, is divided into two lobes.
The hilum is the point at which the primary bronchus, pulmonary blood vessels, nerves, and lymphatics enter each lung. Innervation of the chest wall is via the phrenic (pleura) and intercostal (diaphragm, ribs, and muscles) nerves. Innervation of the bronchi is via the vagus nerve.
The pleura is a continuous smooth membrane composed of two surfaces that totally enclose the lung. The parietal pleura lines the inside of the thoracic cavity and the upper surface of the diaphragm. The visceral pleura covers the lung surfaces, including the major fissures between the lobes. These two surfaces are lubricated by a thin fluid that is produced by the cells lining the pleura. This lubrication allows the surfaces to glide smoothly and painlessly during respirations.
Blood flow through the lungs occurs via two separate systems: bronchial and pulmonary. The bronchial system carries the blood necessary to meet the metabolic demands of the lungs. The bronchial arteries, which arise from the thoracic aorta, are part of the systemic circulation and do not participate in gas exchange.
The pulmonary circulation is composed of a highly vascular capillary network. Oxygen-depleted blood travels from the right ventricle of the heart into the pulmonary artery, which eventually branches into arterioles that form the capillary networks. The capillaries are enmeshed around and through the alveoli, the site of gas exchange. Freshly oxygenated blood travels from the capillaries and through the venules to the pulmonary veins and then to the left atrium. From the left atrium, oxygenated blood flows into the left ventricle, where it is pumped throughout the systemic circulation.
Accessory Muscles of Respiration
Breathing occurs through changes in the size of and pressure within the thoracic cavity. Contraction and relaxation of specific skeletal muscles (and the diaphragm) cause changes in the size and pressure of the thoracic cavity. Accessory muscles of respiration include the scalene muscles, which elevate the first two ribs; the sternocleidomastoid muscles, which raise the sternum; and the trapezius and pectoralis muscles, which fix the shoulders. In addition, various back and abdominal muscles are used when the work of breathing is increased.
Respiratory Changes Associated with Aging
Many changes associated with older clients result from heredity and a lifetime of exposure to environmental stimuli (e.g., cigarette smoke, bacteria, air pollutants, and industrial fumes and irritants). Table 27-1 shows the age-related changes in the partial pressure of arterial oxygen (Pao2).
Respiratory disease is a major cause of acute illness and chronic disability in older clients. Although respiratory functioormally declines with age, there is usually little difficulty with the demands of ordinary activity. However, the sedentary older adult often reports feeling breathless during exercise.
It is difficult to determine which respiratory changes in older adults are related to normal aging and which changes are pathologic and associated with respiratory disease or exposure to pollutants. In addition, age-related disorders of the neuromuscular and cardiovascular systems may cause abnormal respiration, even if the lungs are normal.
ASSESSMENT TECHNIQUES
History
Obtaining accurate information from the client is important in determining the type and severity of pulmonary problems.
DEMOGRAPHIC DATA
Age, gender, and race can affect the physical and diagnostic findings related to respiratory function. Many of the diagnostic studies relevant to respiratory disorders (e.g., pulmonary function tests) use these demographic data for determining predicted normal values.
PERSONAL AND FAMILY HISTORY
Medical History
The nurse asks clients about their own respiratory history and that of their family members. The family history is obtained to consider respiratory disorders with a genetic component, such as cystic fibrosis, some lung cancers, and alpha,-antitrypsin deficiency (one risk factor for emphysema). Clients with asthma often have a family history of allergic symptoms and reactive airways. The nurse assesses for a history of infectious disease, such as tuberculosis, and considers that family members may have similar environmental or occupational exposures.
Smoking History
The nurse questions the client about the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances, and he or she notes whether the client has passive exposure to smoke in the home or workplace. If the client smokes, the nurse asks for how long, how many packs a day, and whether the client has quit smoking (and how long ago). The smoking history is documented in pack-years (number of packs smoked per day multiplied by number of years). Because the client may have guilt or denial about this habit, the nurse assumes a nonjudgmental attitude during the interview.
Smoking induces anatomic changes in the large and peripheral airways, and these changes lead to varying degrees of airway obstruction. Men who continue to smoke experience a more rapid decline in their pulmonary function than do non-smokers. The pulmonary function of clients who have quit smoking for 2 or more years appears to decline less rapidly than in clients who continue to smoke.
Medication Use
The nurse asks about medications taken for breathing problems and about drugs taken for other conditions. For example, a cough can be a side effect of the angiotensin-converting enzyme (ACE) inhibitors. The nurse determines which over-the-counter medications (e.g., cough syrups, antihistamines, decongestants, inhalants, and nasal sprays) the client is using.
The use of home remedies also is assessed. The client is asked about past medication use and the reason for its discontinuation. For example, he or she may have used numerous bronchodilator metered dose inhalers but may prefer one particular drug for relieving breathlessness. In addition, some medications for other conditions can cause permanent changes in pulmonary function. For example, clients may have residual pulmonary fibrosis if they received bleomycin (Blenoxane) as chemotherapy for cancer or amiodarone (Cordarone) for cardiac problems.
Allergies
Information about allergies is important to the respiratory history. The nurse determines whether the client has any known allergies to environmental substances such as foods, dust, molds, pollen, bee stings, trees, grass, animal dander and saliva, or medications. The client is asked to explain a specific allergic response. For example, does he or she wheeze, have trouble breathing, cough, sneeze, or experience rhinitis after exposure to the allergen? Has he or she ever been treated for an allergic response? If the client has received treatment for allergies, the nurse asks about the circumstances leading up to the need for treatment, the type of treatment, and the response to treatment.
Travel and Area of Residence
Travel and area of residence may be relevant for a history of exposure to certain diseases. For example, histoplasmosis, a fungal disease caused by inhalation of contaminated dust, is found in the central
DIET HISTORY
An evaluation of the client’s diet history may reveal allergic reactions to certain foods or preservatives. Signs and symptoms range from rhinitis, chest tightness, weakness, shortness of breath, urticaria, and severe wheezing to loss of consciousness. The nurse documents in a prominent location of the client’s record any known allergies and the specific type of allergic response experienced. The client is asked about his or her usual food intake and whether any symptoms occur with eating. Malnutrition may occur if he or she has difficulty breathing during eating or the food preparation process.
OCCUPATIONAL HISTORY AND SOCIOECONOMIC STATUS
The nurse considers the home, community, and workplace for environmental factors that could cause or contribute to lung disease. Occupational pulmonary diseases include pneumoconiosis, which results from the inhalation of dust (e.g., coal dust, stone dust, silicone dust); toxic lung injury; and hypersensitivity disease (e.g., hypersensitivity to latex). The occupational history includes the exact dates of employment and a brief job description. Exposure to industrial dusts of any type or to the noxious chemicals found in smoke and fumes may cause respiratory disease. Coal miners, stone masons, cotton handlers, welders, potters, plastic and rubber manufacturers, printers, farm workers, and steel foundry workers are among the most susceptible.
The nurse obtains information about the home and living conditions, such as the type of heat used (e.g., gas heater, wood-burning stove, fireplace, and kerosene heater) and exposure to environmental irritants (e.g., noxious fumes, chemicals, animals, birds, and air pollutants). The client is asked about hobbies and leisure activities. Pastimes such as painting, working with ceramics, model airplane building, furniture refinishing, or woodworking may have exposed the client to harmful chemical irritants.
CURRENT HEALTH PROBLEMS
Whether the pulmonary problem is acute or chronic, the chief complaint is likely to include cough, sputum production, chest pain, and shortness of breath at rest or on exertion. During the interview, the nurse explores the history of the present illness, preferably in chronologic order. This analysis of the problem(s) includes the following:
• Onset
• Duration
• Location
• Frequency
• Progressing and radiating patterns
• Quality and number of symptoms
• Aggravating and relieving factors
• Associated signs and symptoms
• Treatments
Cough
Cough is the cardinal sign of respiratory disease. The nurse asks the client how long the cough has persisted (e.g., 1 week, 3 months) and whether it occurs at a specific time of day (e.g., on awakening in the morning, which is common in smokers) or in relation to any physical activity. The nurse determines whether the cough is productive or nonproductive, congested, dry, tickling, or hacking.
Sputum Production
Sputum production is an important symptom associated with coughing. The nurse notes the duration, color, consistency, odor, and amount of sputum. Sputum may be clear, white, tan, gray or, if infection is present, yellow or green.
The nurse describes the consistency of sputum as thin, thick, watery, or frothy. Smokers with chronic bronchitis have mucoid sputum because of chronic stimulation and hypertrophy of the bronchial glands. Voluminous, pink, frothy sputum is characteristic of pulmonary edema. Pneumococcal pneumonia is often associated with rust-colored sputum, and foul-smelling sputum is often found in anaerobic infections such as a lung abscess. Blood in the sputum (hemoptysis) is most commonly noted in clients with chronic bronchitis or bronchogenic carcinoma. Clients with tuberculosis, pulmonary infarction, bronchial adenoma, or lung abscess may expectorate grossly bloody sputum.
Sputum can be quantified by describing its production in terms of measurements such as teaspoon, tablespoon, and cups or fractions of cups. Normally, the tracheobronchial tree can produce up to 3 ounces (90 mL) of sputum per day. The nurse determines whether sputum production is increasing, possibly from external stimuli (e.g., an irritant in the work setting) or an internal cause (e.g., chronic bronchitis or a pulmonary abscess).
Chest Pain
A detailed description of chest pain helps the nurse differentiate pleural, musculoskeletal, cardiac, and gastrointestinal pain. Because the perception of pain is subjective, pain is analyzed in relation to the characteristics described in the history of the present illness. Coughing, deep breathing, or swallowing usually worsens chest wall pain.
Dyspnea
The perception of dyspnea (difficulty in breathing or breathlessness) is subjective and varies among clients. A client’s perception may not be consistent with the severity of the presenting problem. Therefore the nurse determines the type of onset (slow or abrupt), the duration (number of hours, time of day), relieving factors (changes of position, medication use, activity cessation), and evidence of audible sounds (wheezing, crackles, stridor).
The nurse tries to quantify dyspnea by asking whether this symptom interferes with activities of daily living (ADLs) and, if so, how severely. For example, is the client breathless while dressing, showering, shaving, or eating? Does dyspnea on exertion occur after walking one block or climbing one flight of stairs?
The nurse asks about paroxysmal nocturnal dyspnea (PND), which involves intermittent dyspnea during sleep, and about orthopnea, which is demonstrated by a shortness of breath that occurs when lying down but is relieved by sitting up. These two conditions are commonly associated with chronic pulmonary disease and left ventricular failure. In PND, the client has a sudden onset of breathing difficulty that is severe enough to awaken the client from sleep.
Physical Assessment
ASSESSMENT OF THE NOSE AND SINUSES
The nurse inspects the client’s external nose for deformities or tumors and inspects the nostrils for symmetry of size and shape. Nasal flaring may indicate an increased respiratory effort. To observe the interior nose, the nurse asks the client to tilt the head back for a penlight examination. The nurse may use a nasal speculum and nasopharyngeal mirror for a more thorough examination of the nasal cavity.
The nurse inspects for color, swelling, drainage, and bleeding. The mucous membrane of the nose normally appears redder than the oral mucosa, but it may appear pale, engorged, and bluish gray in clients with allergic rhinitis. The nasal septum is checked for evidence of bleeding, perforation, or deviation. Some degree of septal deviation is common in most adults and appears as an S shape, inclining toward one side or the other. A perforated septum is noted if the light shines through the perforation into the opposite nostril; this condition is often found in cocaine users. Nasal polyps, a common cause of obstruction, appear as pale, shiny, gelatinous structures attached to the turbinates.
The nurse occludes one nare at a time to check whether air moves through the nonoccluded side easily. The nose and paranasal sinuses are palpated to detect tenderness or swelling. Only the frontal and maxillary sinuses are readily accessible to clinical examination because the ethmoid and sphenoid sinuses lie deep within the skull. Using the thumbs, the nurse checks for sinus tenderness by pressing upward on the frontal and maxillary areas; both sides are assessed simultaneously. Tenderness in these areas suggests inflammation or acute sinusitis. Tenderness in response to tapping a finger over these areas also indicates inflammation.
Transillumination of the sinuses may be used to detect sinusitis. In a darkened room, the nurse places the bulb of a penlight on the client’s cheek (just under the corner of the eye) and observes for light penetration through the roof of the mouth. Normally, a faint glow of light through the bone outlines the sinus. Transillumination is absent or decreased in sinusitis. However, this test is not conclusive for sinusitis.
ASSESSMENT OF THE PHARYNX, TRACHEA, AND LARYNX
Examination of the pharynx begins with inspection of the external structures of the mouth. To examine the structures of the posterior pharynx, the nurse uses a tongue depressor to press down one side of the tongue at a time (to avoid stimulating the gag reflex). As the client says “ah,” the nurse notes the rise and fall of the soft palate and uvula and observes for color and symmetry, evidence of discharge (postnasal drainage), edema or ulceration, and tonsillar enlargement or inflammation.
The neck is inspected for symmetry, alignment, masses, swelling, bruises, and the use of accessory neck muscles in breathing. Lymph nodes are palpated for size, shape, mobility, consistency, and tenderness. Tender nodes are usually movable and suggest inflammation. Malignant nodes are often hard and are fixed to the surrounding tissue.
The nurse gently palpates the trachea for deviation, mobility, tenderness, and masses. Firm palpation may elicit coughing or gagging. The space on either side of the trachea should be equal. Many pulmonary disorders cause the trachea to deviate from the midline. Tension pneumothorax, large pleural effusion, mediastinal mass, and neck tumors push the trachea away from the affected area, whereas pneumonectomy, fibrosis, and atelectasis cause a pull toward the affected area. Decreased tracheal mobility may occur with carcinoma or fibro-sis of the mediastinum.
The larynx is usually examined by a specialist with a laryngoscope. The nurse may observe an abnormal voice, especially hoarseness, when there are abnormalities of the larynx.
ASSESSMENT OF THE LUNGS AND THORAX
Inspection
Inspection of the chest begins with an assessment of the anterior and posterior thorax. If possible, the client is in a sitting position during the assessment. He or she should be undressed to the waist and draped for privacy and warmth. The chest is observed by comparing one side with the other. The nurse works from the top (apex) and moves downward toward the base while inspecting for discoloration, scars, lesions, masses, and spinal deformities such as kyphosis, scoliosis, and lordosis.
The nurse observes the rate, rhythm, and depth of inspirations as well as the symmetry of chest movement. An impaired movement or unequal expansion may indicate an underlying disease of the lung or the pleura. The nurse observes the type of breathing (e.g., pursed-lip or diaphragmatic breathing) and the use of accessory muscles. In observing respiration, the nurse documents the duration of the inspiratory (I) and expiratory (E) phases. The ratio of these phases (the I/E ratio) is normally 1:2. A prolonged expiratory phase indicates an obstruction of air outflow and is often seen in clients with asthma or chronic obstructive pulmonary disease (COPD).
The nurse examines the shape of the client’s chest and compares the anteroposterior (AP) diameter with the lateral diameter. This ratio normally ranges from 1:2 to approximately 5:7, depending on body build. The ratio increases to 1:1 in clients with emphysema, which results in the typical barrel chest appearance.
Normally, the ribs slope downward. However, clients with air trapping in the lungs caused by chronic asthma or emphysema have little or no slope to the ribs (i.e., the ribs are more horizontal).
The nurse also checks for abnormal retractions of the intercostal spaces during inspiration, which indicate airflow obstruction. These retractions may be due to fibrosis of the underlying lung, severe acute asthma, emphysema, or tracheal or laryngeal obstruction.
Palpation
Palpation of the chest occurs after inspection. Palpation allows the nurse to assess respiratory movement symmetry and observable abnormalities, to identify areas of tenderness, and to elicit vocal or tactile fremitus (vibration).
The nurse assesses thoracic expansion by placing the thumbs posteriorly on the spine at the level of the ninth ribs and extending the fingers laterally around the rib cage. As the client inhales, both sides of the chest should move upward and outward together in one symmetric movement, and the nurse’s thumbs move apart. On exhalation, the thumbs should come back together as they return to the midline. Decreased movement on one side (unilateral or unequal expansion) may be a result of pain, trauma, or pneumothorax (air in the pleural cavity). Respiratory lag or slowed movement on one side may indicate the presence of a pulmonary mass, pleural fibrosis, atelectasis, pneumonia, or a lung abscess.
The nurse palpates any abnormalities found on inspection (e.g., masses, lesions, bruises, and swelling). The nurse also palpates for tenderness, particularly if the client has reported pain. Crepitus (subcutaneous emphysema) is felt as a crackling sensation beneath the fingertips and should be documented, especially if it occurs around a wound site or if a pneumothorax is suspected. Crepitus indicates that air is trapped within the tissues.
Tactile (vocal) fremitus is a vibration of the chest wall produced when the client speaks. This vibration can be palpated on the chest wall. To elicit tactile fremitus, the nurse places the palm or the base of the fingers against the client’s chest wall and instructs him or her to say the number 99. Using the same hand and moving from the apices to the bases, the nurse compares vibrations from one side of the chest with those from the other side. Palpable vibrations are transmitted from the tracheobronchial tree, along the solid surface of chest wall, and to the nurse’s hand.
The nurse notes the symmetry of the vibrations and areas of enhanced, diminished, or absent fremitus. Fremitus is decreased if the transmission of sound waves from the larynx to the chest wall is slowed. This situation can occur when the pleural space is filled with air (pneumothorax) or fluid (pleural effusion) or when the bronchus is obstructed. Fremitus is increased over large bronchi because of their proximity to the chest wall. Disease processes such as pneumonia and abscesses increase the density of the thorax and enhance transmission of the vibrations.
Percussion
The nurse uses percussion to assess for pulmonary resonance, the boundaries of organs, and diaphragmatic excursion. Percussion involves tapping the chest wall, which sets the underlying tissues into motion and produces audible sounds. The nurse places the distal joint of the middle finger of the less dominant hand firmly over the intercostal space to be percussed. No other part of the nurse’s hand touches the client’s chest wall because doing so absorbs the vibrations. The middle finger of the dominant hand then delivers quick, sharp strikes to the distal joint of the positioned finger. The nurse maintains a loose, relaxed wrist while delivering the taps with the tip of the finger, not the finger pad. This technique is repeated two or three times to determine the intensity, pitch, quality, and duration of the sound produced. Long fingernails limit the ability to percuss.
Percussion produces five distinguishable notes. These sounds assist the nurse in determining the density of the underlying structures (i.e., whether the lung tissue contains air or fluid or is solid). Percussion of the thorax is performed over the intercostal spaces because percussing the sternum, ribs, or scapulae yields sound indicating solid bone. Percussion penetrates only 2 to 3 inches (5 to 7 cm), and therefore deeper lesions are not detected with this technique.
Percussion begins with the client sitting in an upright position. The nurse assesses the posterior thorax first and proceeds systematically, beginning at the apex and working toward the base. The apex of the lung extends anteriorly approximately ¾ to 1 ½ inches (2 to 4 cm) above the clavicle. Posteriorly, there is approximately a 2-inch (5-cm) width of lung tissue at the apex.
The nurse assesses diaphragmatic excursion by instructing the client to “take a deep breath and hold it” while percussing downward until dullness is noted at the lower border of the lung. Normal resonance of the lung stops at the diaphragm, where the sound becomes dull; this site is marked. The nurse repeats the process after instructing the client to “let out all your breath and hold.” The difference between the two markings or sounds is the diaphragmatic excursion, which may range from 1 to 2 inches (3 to 5 cm). The diaphragm is normally higher on the right because of the location of the liver. Diaphragmatic excursion may be decreased or absent in clients with pleurisy, diaphragm paralysis, or emphysema.
The nurse continues to assess the thorax with percussion of the anterior and lateral chest. The percussioote changes from resonance of the normal lung to dullness at the borders of the heart and liver. The presence of fluid or solid material is indicated by a dull percussion note over lung tissue (as occurs with pneumonia, pleural effusion, fibrosis, atelectasis, and tumors).
Auscultation
Auscultation includes listening for normal breath sounds, adventitious sounds, and voice sounds. Auscultation provides information about the flow of air through the tracheo-bronchial tree and helps the listener to identify fluid, mucus, or obstruction in the respiratory system. The diaphragm of the stethoscope is designed to detect high-pitched sounds.
Auscultation begins with the client sitting in an upright position. With the stethoscope pressed firmly against the client’s chest wall (clothing can distort or muffle sounds), the nurse instructs him or her to breathe slowly and deeply through an open mouth. (Breathing through the nose would set up turbulent sounds that are transmitted to the lungs.) A systematic approach is used, beginning at the apices and moving down through the intercostal spaces to the bases. Listening over bony structures is avoided while auscultating the thorax posteriorly, laterally, and anteriorly. The nurse listens to a full respiratory cycle, noting the quality and intensity of the breath sounds. The client is observed for signs of lightheadedness or dizziness caused by hyperventilation during auscultation. If these symptoms occur, the client is told to breathe normally for a few minutes.
NORMAL BREATH SOUNDS
Normal breath sounds are produced as air vibrates while passing through the respiratory passages from the larynx to the alveoli. Breath sounds are identified by their location, intensity, pitch, and duration within the respiratory cycle (e.g., early or late inspiration and expiration). Normal breath sounds are known as bronchial or tubular (harsh hollow sounds heard over the trachea and mainstem bronchi), bronchovesicular (heard over the branching bronchi), and vesicular (a soft rustling sound heard in the periphery over small bronchioles). The nurse describes these sounds as normal, increased, decreased (diminished), or absent.
When bronchial breath sounds are heard peripherally, they are abnormal. This increased sound occurs when centrally generated bronchial sounds are transmitted to an area of increased density, such as in clients with atelectasis, tumor, or pneumonia. When audible in an abnormal location, bronchovesicular breath sounds may indicate normal aging or an abnormality such as pulmonary consolidation and chronic airway disease.
ADVENTITIOUS BREATH SOUNDS
Adventitious sounds are additional breath sounds superimposed oormal sounds, and they indicate pathologic changes in the tracheobronchial tree. Table 27-6 classifies and describes adventitious sounds: crackle, wheeze, rhonchus, and pleural friction rub. Adventitious sounds vary in pitch, intensity, duration, and the phase of the respiratory cycle in which they occur. The nurse documents exactly what is heard on auscultation.
VOICE SOUNDS
If the nurse discovers abnormalities during the physical assessment of the lungs and thorax, the client is assessed for vocal resonance. Auscultation of voice sounds through the normally air-filled lung produces a muffled, unclear sound because sound vibrations travel poorly through air. Vocal resonance is increased when the sound must travel through a solid or liquid medium, as it does in clients with a consolidated area of the lung, pneumonia, atelectasis, pleural effusion, tumor, or abscess.
BRONCHOPHONY. Bronchophony is the abnormally loud and clear transmission of voice sounds through an area of increased density. For assessment of bronchophony, the client repeats the number 99 while the nurse systematically auscultates the thorax.
WHISPERED PECTORILOQUY. Whispered pectoriloquy is the enhanced voice heard through the chest wall. It is much more sensitive than bronchophony and is perceived by having the client whisper the number sequence one, two, three. Whispered words normally sound faint and indistinct. If they are heard loudly and distinctly, the nurse suspects consolidation of lung tissue.
EGOPHONY. Egophony is another form of abnormally enhanced vocal resonance and has a high-pitched, bleating, nasal quality. The nurse auscultates the thorax while the client repeats the letter E. Egophony exists when this letter is heard as a flat, nasal sound of A through the stethoscope. This abnormal sound indicates an area of consolidation, pleural effusion, or abscess.
OTHER INDICATORS OF RESPIRATORY ADEQUACY
The nurse evaluates additional indicators of respiratory adequacy because gas exchange affects all body systems. Some indicators (e.g., cyanosis) indicate immediate oxygenation problems. Other changes (e.g., clubbing, weight loss, unevenly developed muscles) reflect a more long-standing oxygenation problem.
Skin and Mucous Membranes
The skin and mucous membranes are assessed for the presence of pallor or cyanosis, which could indicate inadequate ventilation. Areas to assess include the nail beds and the mucous membranes of the oral cavity. The fingers are examined for clubbing, which would indicate hypoxia of long duration.
General Appearance
The nurse observes the client for muscle development and general body build. Long-term respiratory problems are often associated with an inability to maintain body weight and a loss of general muscle mass. Arms and legs may appear thin or poorly muscled. The muscles of the neck and chest may be hypertrophied, especially in the client with chronic obstructive pulmonary disease (COPD).
Endurance
The nurse observes how easily the client moves and whether he or she is short of breath while resting or becomes short of breath when walking 10 to 20 steps. As the client speaks, the nurse observes how often he or she pauses for breath between words.
Psychosocial Assessment
The nurse assesses aspects of the client’s lifestyle that may significantly affect respiratory function. Some respiratory conditions may be worsened by stress. The nurse asks about present life stresses and usual coping mechanisms.
Chronic respiratory illnesses may cause changes in family roles and relationships, social isolation, financial problems, and unemployment or disability. By discussing coping mechanisms, the nurse assesses the client’s reaction to these psychosocial stressors and discovers strengths and ineffective behaviors. For example, the client may react to stress with dependence on family members, withdrawal, or noncompliance with interventions. After completing the psychosocial assessment, the nurse assists the client in determining the support systems available to help cope with respiratory impairment.
Diagnostic Assessment
I LABORATORY TESTS
Blood Tests
A red blood cell count provides data regarding the transport of oxygen from the lungs. A hemoglobin deficiency directly affects tissue oxygenation because hemoglobin transports oxygen to the cells and could cause hypoxemia.
Arterial blood gas (ABG) analysis assesses oxygenation (partial pressure of arterial oxygen [Pao2]), alveolar ventilation (partial pressure of arterial carbon dioxide [Paco2]), and acid-base balance. Blood gas studies provide valuable information for monitoring treatment results, adjusting oxygen therapy, and evaluating the client’s responses to treatment and therapy, such as during weaning from mechanical ventilation.
Sputum Tests
Sputum specimens obtained by expectoration or tracheal suctioning assist in the identification of pathogenic organisms or abnormal cells, such as in a malignancy or a hypersensitivity state. Sputum culture and sensitivity analyses identify bacterial infection with either gram-negative or gram-positive organisms and determine the vulnerability to specific antibiotics. Cytologic examination is performed on sputum to help diagnose malignant lesions by identifying cancer cells. Benign conditions, such as a hypersensitivity state, may also be identified by cytologic testing. Eosinophils and Curschmann’s spirals (a mucous form) are often found by cytologic study in clients with allergic asthma.
RADIOGRAPHIC EXAMINATIONS
Standard Radiography
Chest x-ray examinations are performed for clients with respiratory tract disorders to evaluate the present status of the chest and to provide a baseline for comparison with future changes. Standard chest x-ray examinations are performed from posteroanterior (PA; back to front) and left lateral (LL) projections. Portable chest x-ray studies (taken anteroposterior [AP], front to back) cost more, and the films produced are of lower quality and are more difficult for the radiologist to interpret. Consecutive, 10-mm cross-sectional views of the thorax and produces a three-dimensional assessment of the lungs and thorax.
Fat, cystic, and solid tissue can be distinguished with CT. By adding an intravenously injected contrast agent, vessels and other soft tissue structures can be identified. CT is especially valuable in studying the mediastinum, hilar region, and pleural space. The newer high-resolution CT (HRCT) uses 1.5- to 2-mm “slices” to assist in assessing bronchial abnormalities, interstitial disease, and emphysema. Nursing interventions for the client undergoing CT include education about the procedure and determination of the client’s sensitivity to the contrast medium (very important for anaphylaxis prevention).
Ventilation and Perfusion Scanning
A ventilation and perfusion scan (V/Q scan) identifies the areas of the lung being ventilated and the distribution of pulmonary blood. It is used primarily to support or rule out a diagnosis of pulmonary embolism.
To perform the study, the physician first injects a radionuclide with the client in a supine position and then takes six perfusion views: anterior, posterior, right and left lateral, and two obliques. If the perfusion scan is normal, there is no reason to continue with the ventilation scan. Otherwise, the client inhales a radioactive gas or radioaerosol, and the lung is scanned continuously—as the gas makes its way into the lungs (the “wash-in” phase), once the gas has reached equilibrium within the lungs, and then while the gas is leaving the lungs (the “wash-out” phase).
The nurse teaches the client about the procedure and explains that the radioactive substance clears from the body in approximately 8 hours.
OTHER NONINVASIVE DIAGNOSTIC TESTS
Pulse Oximetry
Pulse oximetry identifies hemoglobin saturation. Usually hemoglobin is almost 100% saturated with oxygen. The pulse oximeter uses a wave of infrared light and a sensor placed on the client’s finger, toe, nose, earlobe, or forehead. Ideal normal pulse oximetry values are 95% to 100%; values may be a little lower in older clients and in clients with dark skin. To avoid confusion with the Pao2 values from arterial blood gases, pulse oximetry readings are recorded as the Sao2 (arterial oxygen saturation), or Spo2.
A pulse oximetry reading can alert the nurse to desaturation before clinical signs occur (e.g., dusky skin, pale mucosa, and nail beds). The nurse considers client movement, hypothermia, decreased peripheral blood flow, ambient light (sunlight, infrared lamps), decreased hemoglobin, edema, and fingernail polish as possible causes for low readings. Covering the sensor or changing its positioning could yield better accuracy if too much ambient light is present.
Results lower than 91% (and certainly below 86%) constitute an emergency and necessitate immediate treatment. When the Sao2 is below 85%, the tissues of the body have a difficult time becoming oxygenated. An Sao2 of less than 70% is usually life threatening, but in some cases values below 80% may be life threatening. Pulse oximetry is less accurate at lower values.
Pulmonary Function Tests
Pulmonary function tests (PFTs) evaluate lung function and dysfunction and include studies such as lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation. The physician interprets the results by comparing the client’s data with normal findings predicted according to age, gender, race, height, weight, and smoking status.
PFTs are useful in screening clients for pulmonary disease even before the onset of signs or symptoms. Serial testing provides objective data that may be used as a guide to treatment (e.g., changes in pulmonary function can support a decision to continue, change, or discontinue a specific therapy). Preoperative evaluation with PFTs may identify the client at risk for postoperative pulmonary complications. One of the most common reasons for performing such tests is to determine the cause of dyspnea. When performed while the client exercises, PFTs help to determine whether dyspnea is caused by pulmonary or cardiac dysfunction or by muscle deconditioning. These tests are also useful for determining the effect of the client’s occupation on pulmonary function and for evaluating any related disability for legal purposes.
CLIENT PREPARATION. The nurse prepares the client for PFTs by explaining the purpose of the tests for planning care. He or she is advised not to smoke for 6 to 8 hours before testing. According to institutional policy and procedure, bronchodilator medication is withheld for 4 to 6 hours before the test. The client with respiratory impairment often fears further breathlessness and is usually anxious before these “breathing” tests. The nurse helps to reduce apprehension by describing what will be experienced during and after the testing.
PROCEDURE. PFTs can be performed at the bedside or in the respiratory laboratory. The client is asked to breathe through the mouth only. A nose clip may be used to prevent air from escaping. The client performs different breathing maneuvers while measurements are obtained.
FOLLOW-UP CARE. Because numerous breathing maneuvers are performed during PFTs, the nurse observes for increased dyspnea or bronchospasm after such studies. The nurse documents whether bronchodilator medication was administered during testing and alters the client’s medication schedule as indicated.
Exercise Testing
Exercise, or activity in general, increases metabolism and gas transport as energy is generated. These tests are performed on a treadmill or bicycle or by a self-paced 12-minute walking test. The normal client’s exercise is limited by hemodynamic factors, whereas the pulmonary client is limited by ventilatory capacity, pulmonary gas exchange compromise, or both. The nurse explains exercise testing and assures the client of close monitoring by trained professionals throughout the test.
Skin Tests
Skin tests are used in combination with other diagnostic data to identify various infectious diseases (e.g., tuberculosis), viral diseases (e.g., mononucleosis and mumps), and fungal diseases (e.g., coccidioidomycosis and histoplasmosis). The presence of allergic hypersensitivity and the status of the immune system can be demonstrated through skin testing. Exposure to the allergen or organism used in testing produces a specific reaction (delayed hypersensitivity reaction) of the client’s immune system.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is used in the diagnosis of respiratory system disorders to provide information about the type and condition of the tissues being imaged along any plane inside the body: vertically, horizontally, and diagonally. This costly procedure requires little client preparation other than the removal of all metal objects. Because of the powerful magnets used in MRI, clients with pacemakers, aneurysm clips, inner-ear implants, cardiac valves, or any other metallic foreign objects in the body are not candidates for MRI.
The nurse informs the client of possible claustrophobia and discomfort from lying on a hard, cool table inside the magnet’s small cylinder. The nurse instructs the client in the use of relaxation techniques and imagery to help decrease these sensations. Sedation may be necessary in some cases. The nurse explains that the noises heard during the examination are the natural, rhythmic sounds of radiofrequency pulses. These noises may range from barely audible to noticeable.
OTHER INVASIVE DIAGNOSTIC TESTS
Endoscopic Examinations
Endoscopic diagnostic studies to assess respiratory disorders include bronchoscopy, laryngoscopy, and mediastinoscopy. The most common complications are those related to the medications and bleeding.
Thoracentesis
Thoracentesis is used for diagnosis or treatment and involves the aspiration of pleural fluid or air from the pleural space. Microscopic examination of the pleural fluid helps in making a diagnosis. Pleural fluid may be drained to relieve pulmonary compression and the resultant respiratory distress caused by cancer, empyema, pleurisy, or tuberculosis. Thoracentesis is often followed by pleural biopsy to assist in further assessment of the parietal pleura. Thoracentesis also allows the instillation of medications into the pleural space.
CLIENT PREPARATION. Adequate client preparation is essential before thoracentesis to ensure cooperation during the procedure and to prevent complications. The nurse tells the client to expect a stinging sensation from the local anesthetic agent and a feeling of pressure when the needle is inserted. The nurse reinforces the importance of not moving during the procedure (avoiding coughing, deep breathing, or sudden movement) to avoid puncture of the visceral pleura or lung.
These positions widen the intercostal spaces and permit easy access to the pleural fluid. The nurse properly positions and physically supports the client. Pillows are used to make the client comfortable and to provide physical support.
Before the procedure, the nurse checks the client’s history for hypersensitivity to local anesthetic agents and checks to make sure the client has signed an informed consent. The entire chest or back is exposed, and the aspiration site is shaved if necessary. The actual site depends on the volume and location of the effusion, which are determined by radiography and physical examination procedures such as percussion.
PROCEDURE. Thoracentesis is usually performed at the bedside, although ultrasonography or computed tomography may be used to guide it. After draping the client and cleaning the skin with a germicidal solution, the physician uses aseptic technique and injects a local anesthetic agent into the selected intercostal space. The nurse keeps the client informed of the procedure while observing for shock, pain, nausea, pallor, diaphoresis, cyanosis, tachypnea, and dyspnea.
The physician advances the short 18- to 25-gauge thoracentesis needle (with an attached syringe) into the pleural space. Gentle suction is applied as the fluid in the pleural space is slowly aspirated. A vacuum collection bottle is sometimes necessary to remove larger volumes of fluid. To prevent re-expansion pulmonary edema, usually no more than 1000 mL of fluid is removed at one time. If a pleural biopsy is to be performed, a second, larger needle with a cutting edge and collection chamber is used. After the physician withdraws the needle, pressure is applied to the puncture site, and a small sterile dressing is applied.
FOLLOW-UP CARE. After thoracentesis, the physician orders a chest x-ray study to rule out possible pneumothorax and subsequent mediastinal shift (shift of center thoracic structure toward one side). The nurse monitors the client’s vital signs and auscultates breath sounds while noting absent or diminished sounds on the affected side. The puncture site and dressing are observed for leakage or bleeding. The nurse also assesses for other complications, such as reaccumulation of fluid in the pleural space, subcutaneous emphysema, pyrogenic infection, and tension pneumothorax. The client is encouraged to breathe deeply to promote reexpansion of the lung. The nurse documents the procedure, including the client’s tolerance, the volume and character of the fluid removed, any specimens sent to the laboratory, the location of the puncture site, and respiratory assessment findings before, during, and after the procedure.
Lung Biopsy
A lung biopsy is performed to obtain tissue for histologic analysis, culture, or cytologic examination. The physician uses tissue samples to make a definite diagnosis regarding the type of malignancy, infection, inflammation, or lung disease. Biopsy procedures include transbronchial biopsy (TBB) and transbronchial needle aspiration (TBNA), both of which are performed during bronchoscopy; transthoracic needle aspiration (percutaneous approach for areas not accessible by bronchoscopy); and open lung biopsy (in the operating room).
CLIENT PREPARATION. The client may have predetermined ideas about the outcome of the biopsy and may closely associate the terms biopsy and cancer. Therefore the nurse explains what to expect before and after the procedure and explores the client’s feelings and fears. To reduce discomfort and anxiety, the physician may prescribe an analgesic or sedative before the procedure. The nurse informs the client undergoing percutaneous biopsy that discomfort is minimized with a local anesthetic agent but that a sensation of pressure may be experienced during needle insertion and tissue aspiration. Open lung biopsy is usually performed in the operating room with the client under general anesthesia, and the usual preoperative preparations apply.
PROCEDURE. Percutaneous lung biopsy may be performed in the client’s room or in the radiology department after an informed consent has been obtained. Fluoroscopy, CT, or ultrasonography is often used to better visualize the area undergoing biopsy and to guide the procedure. Positioning of the client is similar to that for thoracentesis. The physician cleans the skin with an antibacterial agent and administers a local anesthetic agent. Under sterile conditions, the physician inserts a spinal-type 18- to 22-gauge needle through the skin into the desired area (e.g., tissue, nodule, or lymph node) and obtains the tissue needed for microscopic examination. The nurse applies a dressing after the procedure.
An open lung biopsy is performed in the operating room. The client undergoes a thoracotomy where lung tissue is exposed. At least two tissue specimens are taken (usually from an upper lobe and a lower lobe site). The surgeon places a chest tube to remove air and fluid so the lung can reinflate and then closes the chest.
FOLLOW-UP CARE. The nurse monitors the client’s vital signs and breath sounds every 4 hours for 24 hours and assesses for signs of respiratory distress (e.g., dyspnea, pallor, diaphoresis, and tachypnea). Pneumothorax is a serious complication of needle biopsy and open lung biopsy, and therefore it is important for the nurse to report untoward signs and symptoms promptly. The nurse also monitors for hemoptysis (which may be scant and transient) or, in rare cases, for frank bleeding from vascular or lung trauma.
The upper airway structures include the nose, sinuses, oropharynx, larynx, and trachea. These structures are vulnerable to specific problems and also may be affected by other common acute and chronic disorders. Clients with upper respiratory problems are found across the health care continuum. The major nursing priority with disorders of the upper respiratory tract is maintaining a patent airway.
NONINFECTIOUS DISORDERS OF THE NOSE AND SINUSES
Fracture of the Nose
OVERVIEW
Nasal fractures commonly result from injuries received during falls, sports activities, motor vehicle accidents, or physical assaults. If the bone or cartilage is not displaced, serious complications usually do not result from the fracture, and treatment may not be necessary. However, displacement of either the bone or cartilage can cause airway obstruction or cosmetic deformity and is a potential source of infection.
COLLABORATIVE MANAGEMENT
Assessment
The nurse documents any nasal problem, including deviation, malaligned nasal bridge, change iasal breathing, crepitus on palpation, midface braising, and pain. Blood or clear (cerebrospinal) fluid rarely drains from one or both nares. The presence of drainage could indicate a skull fracture. Although important in evaluating general facial fractures, radiographic examination is not always useful in the diagnosis of nasal fractures.
Interventions
The physician performs a simple closed reduction of the nasal fracture (using local or general anesthesia) within the first 24 hours after injury. After 24 hours the fracture is more difficult to reduce because of edema and scar formation. Simple closed fractures need not be surgically treated. Treatment focuses on pain relief and local cold compresses to decrease swelling.
RHINOPLASTY. A reduction and surgery may be required for severe fractures or for those that do not heal properly. Rhinoplasty is a surgical reconstruction of the nose for cosmetic purposes and for functional improvement of airflow. The client returns from surgery with packing in both nostrils; this packing prevents bleeding and provides a stent (object that provides support and structure) for the reconstructed nose. The gauze packing is typically treated with an antibiotic ointment, such as bacitracin (Backing) to reduce the risk of infection. A “moustache” dressing (or drip pad), usually a folded 2X2 gauze pad, is usually placed under the nose. A splint or cast may cover the nose for additional alignment and protection. The nurse or client changes the drip pad as necessary.
Postoperatively, the client is observed for edema and bleeding, and vital signs are obtained every 4 hours until discharge. Assessing how often the client swallows is a priority. Repeated swallowing may indicate posterior nasal bleeding. Using a penlight, the nurse examines the pharynx for bleeding and notifies the surgeon if bleeding is present. The client with uncomplicated rhinoplasty with or without related surgical procedures (browlifts, blepharoplasties, face lifts) is usually discharged the day of surgery. The client and family or significant other are instructed in routine care.
The nurse and/or family places the client in a semi-Fowler’s position and instructs him or her to move slowly and to rest as much as possible. Cool compresses are applied to the nose, eyes, or face to reduce swelling and prevent excessive discoloration. If a general anesthetic was used, the client may eat soft foods once the effects of anesthesia have been eliminated (e.g., the client is alert and the gag reflex has returned) and the surgeon has so ordered. An oral fluid intake of at least 2500 mL/day is encouraged.
To prevent bleeding, the client is instructed to limit Val-salva maneuvers (e.g., forceful coughing or straining during a bowel movement) for the first few days after removing the nasal packing. Laxatives or stool softeners may be prescribed to facilitate bowel movement. Aspirin and nonsteroidal anti-inflammatory drugs are avoided during this time to prevent the possibility of bleeding. The surgeon may order prophylactic antibiotics to prevent postoperative infection and pain medication to relieve discomfort. The nurse explains that edema and discoloration usually last for several weeks, with the final surgical result evident in 6 to 12 months.
NASOSEPTOPLASTY. Nasoseptoplasty, or submucous resection (SMR), may be necessary to straighten a deviated septum when chronic symptoms (e.g., a “stuffy” nose) or discomfort occur. A slight deviation of the nasal septum is present in most adults and causes no symptoms. Major deviations, however, may obstruct the nasal passages or interfere with airflow and sinus drainage. The surgeon removes the deviated section of the cartilage and bone. The amount resected depends on the type and degree of deformity.
Nursing care is similar to that for a rhinoplasty. Nasoseptoplasty is usually an outpatient procedure.
Epistaxis
OVERVIEW
Epistaxis (nosebleed) is a common problem because of the rich capillary network within the nose. Nosebleeds may occur as a result of trauma, hypertension, blood dyscrasia (e.g., leukemias), inflammation, tumor, decreased humidity, excessive nose blowing, nose picking, chronic cocaine use, and selected nursing procedures such as nasogastric suctioning. Men are usually affected more often than women, and older adults tend to bleed most often from the posterior portion of the nose.
COLLABORATIVE MANAGEMENT
Assessment
The client will usually report that the bleeding started after sneezing or blowing the nose. The nurse documents the amount and color of the blood and takes the vital signs. The client is asked about the number, duration, and causes of previous bleeding episodes. This information is documented in the client’s medical record.
Interventions
Medical attention is needed if the nosebleed does not respond to these interventions. In such cases the physician cauterizes the affected capillaries with silver nitrate or electrocautery and follows with anterior packing. Anterior packing is very effective in controlling bleeding from the anterior nasal cavity.
The physician uses a posterior pack to stop bleeding that originates in the posterior nasal region. A string is attached to a large gauze pack and then threaded through the nose and out the mouth. The physician positions the pack in the posterior nasal cavity above the pharynx and then tapes the string to the client’s cheek to prevent movement of the pack. This procedure is uncomfortable, and the airway may be obstructed if the pack slips. Most clients who require posterior packing are hospitalized.
The nurse observes the client for respiratory distress and for tolerance of the packing. The physician may prescribe humidification, oxygen, bed rest, and antibiotics. To maintain gag and cough reflexes and an optimal level of consciousness, the client should not receive any sedatives and only limited pain medication. The nurse provides oral care and ensures adequate hydration, which is important because of mouth breathing. Pulse oximetry is used to monitor for hypoxemia. The physician removes the packing after 2 to 5 days.
Petroleum jelly can be applied to the nares for lubrication and comfort. Nasal saline solution and humidification may be helpful to add moisture and prevent crusting and rebleeding. To prevent further crusting and subsequent rebleeding, the client is taught to continue gentle saline irrigations and lubrication to the nasal cavity after discharge. Other instructions include the avoidance of vigorous nose blowing, the use of aspirin or other nonsteroidal anti-inflammatory agents (NSAIDs), and strenuous activities such as lifting.
Nasal Polyps
OVERVIEW
Nasal polyps are benign, grapelike clusters of mucous membrane and loose connective tissue. Polyps usually occur bilaterally and are often caused by irritation to the nasal mucosa or sinuses, allergies, or infection (chronic sinusitis). If polyps become too large, airway obstruction may result.
COLLABORATIVE MANAGEMENT
Assessment
Clinical manifestations of nasal polyps include obstructed nasal breathing, the presence of or a change in the character of nasal discharge, and a change in speech ‘quality. Clients who have had polyps are at risk for recurrence.*
Interventions
Surgery is the treatment of choice for nasal polyps. The extent of the surgery required depends on the type of polyp present.
Benign nasal polyps are treated medically with nasally inhaled steroids and surgical removal (polypectomy). A polypectomy can be performed using either local or general anesthesia. The nurse observes the client for postoperative bleeding. After surgery, the nostrils are usually packed with gauze for 24 hours. Nasal polyps tend to recur if not completely resected.
Inverting papilloma is a rare, benign, space-occupying lesion that erodes nasal and maxillary skeletal structures. Often initially diagnosed as benign polyps, inverting papillomas grow by pressure into adjacent structures. Extensive sinus and nasal surgery is necessary for complete removal. If these papillomas are completely resected, they do not recur.
Juvenile angiofibromas are similar in growth pattern but cellularly different from other polyps. These tumors usually occur in adolescent males and may undergo resolution when the client reaches adulthood. These lesions may be removed by traditional nasal surgery or may require skull base resections for more invasive tumors.
Cancer of the Nose and Sinuses
OVERVIEW
Tumors of the nasal cavities and sinuses are relatively uncommon and may be either benign or malignant. Malignant lesions of these areas can occur at all ages, but the peak incidence is 40 to 45 years of age in males and 60 to 65 years of age in females. Asian Americans have a higher incidence of nasopharyngeal cancer.
COLLABORATIVE MANAGEMENT
Assessment
The onset of sinus cancer is slow, with symptoms resembling sinusitis. Therefore the client may have relatively advanced disease at diagnosis. Nasal or sinus malignancy is suggested by persistent nasal obstruction, drainage, bloody discharge, and pain that does not improve after treatment of sinusitis. Local lymph node enlargement usually occurs on the side with greater tumor mass.
Interventions
Radiation therapy is the primary treatment for nasopharyngeal cancers. Surgical resection may be indicated if radiation therapy is not successful. Chemotherapy has not proved to be effective.
The specific surgical procedure depends on the amount of tumor, its anatomic location, and the degree of tissue invasion. The primary deficit is a change in body image or speech and an alteration iutrition, especially when the maxilla and floor of the nose are involved in the resection. These procedures often cause the client to experience changes in taste and smell.
The nurse provides general postoperative care, including maintaining a patent airway, monitoring for hemorrhage, providing wound care, giving strict attention to nutrition, and providing tracheostomy care (if necessary). Meticulous mouth and maxillary cavity care is carried out with saline irrigations using a water pick or a syringe. The client is assessed for alterations in comfort and for infection. Optimal nutrition is essential during the perioperative period for adequate healing to occur.
Facial Trauma
■ OVERVIEW
Facial trauma is defined by the specific bones (e.g., mandibular, maxillary, zygomatic, orbital, or nasal fractures) and the side of the face involved. Mandibular (lower jaw) fractures can occur at any location on the mandible and account for the majority of facial fractures. Le Fort I is a nasoethmoid complex fracture. Le Fort II is a transverse maxillary and nasoethmoid complex fracture. Le Fort III is a combination of I and II plus an orbital-zygoma fracture, often called “cranio-facial disjunction” because it leaves the midface with no connection to the skull. There is often much bleeding with facial trauma because the face is very vascular.
COLLABORATIVE MANAGEMENT
Assessment
The priority in the management of facial trauma is assessment for a patent airway. Signs and symptoms of an upper airway obstruction include stridor, shortness of breath, dyspnea, anxiety, restlessness, hypoxia, hypercarbia, decreased oxygen saturation, cyanosis, and loss of consciousness. After establishing the airway, the nurse assesses the amount and site of soft-tissue trauma, bleeding, and palpable fractures. Additional findings on assessment include edema of soft tissue, asymmetry, pain, or leakage of cerebrospinal fluid through the ears and/or nose, indicating a temporal bone or basilar skull fracture. Because orbital and maxillary fractures can entrap the eye, the nurse assesses vision and extraocular movement (ЕОМ) and also observes for neurologic changes. Because spinal cord trauma and skull fractures often occur in conjunction with facial trauma, cranial computed tomography, facial series, and cervical spine films also are obtained.
Interventions
The priority action is to establish and maintain a patent airway. The nurse must anticipate the need for emergency intubation, tracheotomy, or cricothyroidotomy. When the client arrives at a trauma center, care focuses on establishing an airway, controlling hemorrhage, and assessing for the extent of injury. If signs and symptoms of shock are present, fluid resuscitation and identification of bleeding sites must be initiated immediately.
In head and neck trauma, the nurse must be astute in trauma and critical care nursing. Time is critical in stabilizing the client. Early treatment and response of the appropriate services, including the trauma team, maxillofacial surgeon, general surgeon, otolaryngologist, plastic surgeon, and dentist, optimize the client’s post-trauma recovery.
Stabilization of the fractured segment of a mandibular fracture allows the teeth to heal in proper alignment or occlusion. The client remains in fixed centric occlusion for 6 to 10 weeks. Antibiotic therapy may be prescribed because of oral wound contamination. Delay in treatment, infection of the adjacent tooth, or poor oral care may result in infection in the mandibular bone segment. The client may then require surgical debridement, intravenous (IV) antibiotic therapy, and an extended period in fixation.
Facial fractures often are repaired with microplating surgical systems. These shaping plates fix the bone fragments in place until osteoneogenesis (new bone growth) occurs. Large areas of skull can be replaced with BoneSource. Bone cells grow into the BoneSource and rematrix into a stabilized bone support. In the
If the mandibular fracture is repaired with titanium plates, the nurse teaches the client oral care, soft-diet restrictions, and follow-up care with a dentist. The plates are permanent and do not interfere with magnetic resonance imaging (MRI) studies.
A newer method of fixation is the use of resorbable devices (plates and screws) to hold tissues in alignment. These devices are made from a nonmetallic copolymer that retains its integrity for approximately 8 weeks and then undergoes water-mediated biodegradation. Total degradation of the product requires approximately 15 months (Abernathy et al., 2000). Contraindications for this type of fixation include prior irradiation of the area, smoking, drug or alcohol dependence, uncontrolled diabetes mellitus, immunosuppression, and impaired cardiovascular function.
Inner maxillary fixation (IMF) is another common method of securing a mandibular fracture. The bones are realigned and then wired in place with the bite closed. The physician can repair nondisplaced aligned fractures in a clinic or office using local dental anesthesia. General anesthesia is used to repair displaced or complex fractures or fractures that occur with other facial bone fractures.
Postoperatively, the client is taught about oral care with an irrigating device, such as a Water Рік. If the client is in inner maxillary fixation, the nurse teaches self-care with wires in place, including a dental liquid diet. There is a risk for aspiration if vomiting should occur because of the inability to open the jaws to allow ejection of the emesis. The client is taught the proper method of cutting the wires if emesis occurs. Wire cutters are kept with the client at all times in preparation for this emergency. If the wires are cut, the client is instructed to return to the physician for rewiring as soon as possible to reinstitute fixation.
Nutrition is important for any client with fractures. Because of oral fixation, pain, and surgery, nutritional needs may be ignored. Dietary consultations are important for teaching and support.
NONINFECTIOUS DISORDERS OF THE ORAL PHARYNX AND TONSILS
Obstructive Sleep Apnea
OVERVIEW
Sleep apnea is a breathing disruption during sleep that lasts at least 10 seconds and occurs a minimum of 5 times in an hour. Although sleep apnea can have a neurologic or central origin, the most common form occurs as a result of upper airway obstruction by the soft palate or tongue. Factors that contribute to sleep apnea include obesity, a large uvula, a short neck, smoking, enlarged tonsils or adenoids, and oropharyngeal edema. Men are more commonly affected than women, and the incidence increases with age.
During sleep, the skeletal muscles relax and the tongue and neck structures are displaced. As a result, the upper airway is obstructed even though chest wall movement is unimpaired. The apnea increases the arterial carbon dioxide level and decreases the pH. These blood gas changes stimulate neural activity. The sleeper is aroused spontaneously after 10 or more seconds of apnea and corrects the obstruction, and respiration resumes. The cycle begins again, sometimes as often as every 5 minutes.
This cyclic pattern of disrupted sleep prevents reaching the prolonged state of deep sleep necessary for maximum rest. As a result, the person may experience excessive daytime sleepiness, an inability to concentrate, and irritability.
COLLABORATIVE MANAGEMENT
Assessment
Clients may have sleep apnea if they experience excessive daytime sleepiness or complain of “waking up tired,” particularly if they snore heavily. Other clinical manifestations include irritability and personality changes. In some cases sleep apnea can be diagnosed through the observation of family members while the client sleeps in a supine position. A complete health assessment should be performed when excessive daytime sleepiness is a problem.
The most definitive test for diagnosing sleep apnea is polysomnography (PSG) performed during an overnight sleep study. Overnight sleep studies are preferred because the client is more likely to experience all phases of sleep, including rapid eye movement (REM) sleep and deep sleep. The client is directly observed while wearing a variety of monitoring equipment, including an electroencephalograph (EEG), an electrocardiograph (ECG), a pulse oximeter, and an electromyograph (EMG). Such equipment determines the depth of sleep, type of sleep, respiratory effort, oxygen saturation adequacy, and muscle movement.
Interventions
A change in sleeping position or weight loss may be all that is required to reduce or correct mild sleep apnea. Simple position-fixing devices that prevent subluxation of the tongue and neck structures also may be effective in preventing obstruction. For more severe sleep apnea, nonsurgical or surgical methods to prevent obstruction may be necessary.
A commoonsurgical method to prevent airway collapse is the use of noninvasive positive-pressure ventilation (NPPV) to hold open the upper airways. Essentially, a nasal mask or full-face mask delivery system allows mechanical delivery of either Bi-level positive airway pressure (BiPAP) or nasal continuous positive airway pressure. With BiPAP, a cycling machine delivers a set inspiratory positive airway pressure at the beginning of each inspiration. As the client begins to exhale, the machine delivers a lower set end expiratory pressure. Together these two pressures improve tidal volume and hold open the upper airways.
Nasal continuous positive airway pressure (CPAP) delivers a set positive airway pressure continually throughout each cycle of inhalation and exhalation. For CPAP ventilation through a face mask during sleep, a small electric compressor delivers positive pressure at an individually determined setting. Proper fit of the mask over the nose and mouth is key to successful treatment. Although intrusive, these methods are well accepted by clients after an initial adjustment period.
Surgical intervention for sleep apnea may involve a simple adenoidectomy or uvulectomy or may require remodeling of the entire posterior oropharynx (uvulopalatopharyngoplasty). Both conventional and laser surgeries are used for this purpose. A tracheostomy may be needed for very severe sleep apnea that is not relieved by more moderate interventions.
Oropharyngeal Cancer
Clients with cancer of the mouth, tongue, tonsils, and pharynx present special nursing needs related to airway maintenance, communication, nutrition, and self-image. Chapter 54 provides an in-depth discussion of the collaborative management of clients with oropharyngeal cancer.
NONINFECTIOUS DISORDERS
OF THE LARYNX
Vocal Cord Paralysis
OVERVIEW
Vocal fold (cord) paralysis may result from injury, trauma, or disease that affects the larynx, laryngeal nerves, or vagus nerve. Prolonged intubation with an endotracheal (ET) tube may cause temporary or, rarely, permanent paralysis. Laryngeal paralysis may occur in clients with neurologic disorders. Damage to the vagus nerve (by chest injury) or brainstem may lead to nerve dysfunction. The superior and recurrent laryngeal nerves may be damaged as a result of trauma or disorders that involve the chest, esophagus, or thyroid. Paralysis of both vocal cords may result from direct traumatic injury or bilateral stroke, especially involving the brainstem or following total thyroidectomy.
COLLABORATIVE MANAGEMENT
Assessment
Vocal fold paralysis may be unilateral or bilateral. When only one vocal cord is involved, as is commonly the case, the airway usually remains patent but voice use may be affected. Symptoms of abducted (open) bilateral vocal cord paralysis include hoarseness; a breathy, weak voice; and aspiration of food. Bilateral adducted (closed) vocal cord paralysis causes airway obstruction and dyspnea and is a medical emergency if the symptoms are severe and the client is unable to compensate. Stridor is the major presenting symptom. The client with vocal cord dysfunction is at risk for aspiration because of an inability to protect the airway by normal vocal cord closure.
Interventions
The nurse assesses for symptoms of upper airway obstruction. Securing a patent airway is the primary intervention. The client is placed in a high Fowler’s position to aid in breathing and proper alignment of airway structures. Dyspnea with stridor indicates an inadequate airway, and the nurse immediately notifies the physician. Emergency endotracheal intubation, cricothyroidotomy, or tracheostomy may be necessary.
Many surgical procedures have been used to improve the voice. One procedure for abducted vocal cord paresis involves injecting polytef (Teflon) into the affected cord so it enlarges toward the unaffected cord. This technique improves closure during speaking and eating.
Additional nursing interventions include teaching clients to hold their breath during swallowing. This intervention allows the larynx to elevate, close, and divert the food stream back into the esophagus during swallowing. Another protective technique involves the client tucking his or her chin down and forward during swallowing. The nurse evaluates the client for aspiration of liquids and saliva related to vocal cord dysfunction.
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COLLABORATIVE MANAGEMENT
Both nodules and polyps are painless, but they produce hoarseness because of the loss of coordinated closure of the vocal cords and vocal wave.
Nursing management with vocal cord nodules or polyps is aimed at educating the client and family. The client is instructed about the tobacco use hazards, smoking cessation programs, and the importance of voice rest. Conservative treatment includes not whispering and avoiding heavy lifting. Stool softeners are used to avoid bearing down during elimination (Valsalva maneuvers), which would cause the glottis to close. Humidification of inspired air may soothe the vocal cords and prevent overdrying.
Speech therapy is a primary treatment for behavioral voice changes and helps to reduce the intensity of speech. A conservative approach using speech therapy may make surgery unnecessary.
If hoarseness or another voice disturbance is not relieved by voice rest or speech therapy, the physician may remove the nodules or polyps under direct laryngoscopy. Laser and surgical resection are used to remove the mucous membrane of the affected cord. If both cords are involved, one cord is usually allowed to heal before surgery is performed on the other cord.
After surgery, the client must maintain complete voice rest for approximately 14 days to promote healing. Alternative methods of communication such as a slate board, pen and paper, “magic slate,” or alphabet board are used. A sign is placed on the client’s door, over the bed, and on the intercom system to help implement this important nursing intervention. Education is imperative before the operation and before the client returns home, because these procedures are often performed in an outpatient setting.
Laryngeal Trauma
overview
Laryngeal trauma is a result of a crushing or direct blow injury, fracture, or intrinsic injury such as that induced by prolonged endotracheal intubation.
COLLABORATIVE MANAGEMENT
Symptoms of laryngeal trauma include dyspnea (difficulty breathing), aphonia (inability to produce sound), hoarseness, and subcutaneous emphysema (air present in the subcutaneous tissue). Bleeding from the airway (hemoptysis) may occur depending on the location of the trauma. The physician performs a direct visual examination by laryngoscopy or fiberoptic laryngoscopy of the larynx to determine the nature and extent of the injury.
The management of clients with laryngeal injuries consists of assessing and frequently monitoring vital signs (every 15 to 30 minutes), including respiratory status and pulse oximetry. The nursing priority is to maintain a patent airway. Oxygen and humidification are administered as ordered to maintain adequate oxygen saturation. If the client is experiencing respiratory difficulty, the nurse stays with him or her and instructs other trauma team members to prepare for an emergency cricothyroidotomy (cricothyrotomy) or tracheostomy. Respiratory difficulty is evidenced by signs such as increasing tachypnea, anxiety, sternal retraction, shortness of breath, dyspnea, restlessness, decreased oxygen saturation, decreased level of consciousness, nasal flaring, and stridor (high-pitched, harsh blowing sound heard during breathing).
Surgical intervention is necessary for lacerations of the mucous membranes, cartilage exposure, and paralysis of the cords. Laryngeal repair is performed as soon as possible to prevent laryngeal stenosis and to cover any exposed cartilage. An artificial airway may be indicated. Maintenance of a patent airway is the utmost priority.
Upper Airway Obstruction
OVERVIEW
Upper airway obstruction is a life-threatening emergency. It is defined as any significant interruption in airflow through the nose, mouth, pharynx, or larynx. Early recognition is essential to prevent further complications, including respiratory arrest. The following are some potential causes of upper airway obstruction:
• Tongue edema (surgery, trauma)
• Occlusion by the tongue (e.g., with loss of protective reflexes, loss of pharyngeal muscle tone, unconsciousness, and coma)
• Laryngeal edema
• Peritonsillar and pharyngeal abscess
• Head and neck carcinoma
• Thick secretions in the airway
• Cerebral disorders (i.e., stroke)
• Smoke inhalation edema
• Facial, tracheal, and/or laryngeal trauma
• Foreign body aspiration
• Burns of the head and/or neck area
• Anaphylaxis
COLLABORATIVE MANAGEMENT
Assessment
Upper airway obstruction can be a frightening experience for the client and family. Prompt nursing and medical care are essential to prevent a partial airway obstruction from progressing to a complete obstruction. A client with a partial obstruction (e.g., caused by limited edema or a small foreign body) may have few symptoms or only subtle and general symptoms such as diaphoresis, tachycardia, and elevated blood pressure. Unexplained or persistent recurrent symptoms warrant evaluation even though the symptoms are vague. To rule out any potentially life-threatening condition (e.g., tumor, foreign body, or infection), the physician orders diagnostic procedures, such as a chest x-ray study, lateral neck films, direct laryngoscopic examination, and computed tomography.
The nurse observes for signs of hypoxia and hypercapnia, restlessness, increasing anxiety, sternal retractions, a “seesawing” chest, abdominal movements, or a feeling of impending doom related to actual air hunger. Pulse oximetry is used for the ongoing monitoring of oxygen saturation. The client is continually assessed for stridor, cyanosis, and changes in level of consciousness.
Interventions
The nurse assesses for the cause of the obstruction. When the obstruction is due to the tongue falling back or the accumulation of secretions, the client’s head and neck are placed in a slightly extended position, an oral airway is inserted, and suction may be used to remove obstructing secretions. If the airway obstruction results from a foreign body, abdominal thrusts are performed.
Upper airway obstruction may require emergency procedures such as a cricothyroidotomy, an endotracheal intubation, or a tracheostomy. These procedures are often preceded or followed by direct laryngoscopy to evaluate the cause of obstruction. The physician uses direct laryngoscopy in a controlled situation as the treatment of choice for the removal of foreign bodies.
CRICOTHYROIDOTOMY. Cricothyroidotomy is a life-saving emergency procedure and is usually performed outside the hospital by emergency medical personnel or in the emergency department by a physician. A cricothyroidotomy is a stab wound at the cricothyroid membrane between the thyroid cartilage and the cricoid cartilage ring. Any hollow tube—but preferably a tracheostomy tube—can be placed through this opening to keep the new airway open until a formal tracheotomy can be performed. This procedure is warranted when it is the only way to secure an airway for the client. Alternatively, the physician can make an incision by inserting a 14-gauge needle immediately into the cricoid space to allow air into and out of the lungs, thus bypassing the obstruction.
ENDOTRACHEAL INTUBATION. To accomplish endo-tracheal intubation, a tube is inserted into the trachea via the nose (nasotracheal) or mouth (orotracheal) by a physician, nurse anesthetist, or other specially trained nurse.
TRACHEOSTOMY. A tracheostomy is usually an elective procedure that takes approximately 5 to 10 minutes to perform. The procedure takes place in the operating room (preferably) with the client under local or general anesthesia, or it can be performed at the bedside. Infrequently, an awake tracheostomy with local anesthesia is performed if there is concern that the airway will be lost during the induction of anesthesia. An emergency tracheostomy is reserved for the client who cannot be immediately intubated with an oral or nasal endotracheal tube. The airway can be established in less than 2 minutes in an emergency situation.
Clients receiving mechanical ventilation as part of the treatment for upper airway obstruction or respiratory failure may require an elective tracheostomy after 7 or more days of continuous oral or nasal intubation. In such cases the procedure is performed to prevent laryngeal injury by the endotracheal tube.
Neck Trauma
OVERVIEW
Neck injuries are most often caused by a knife, gunshot, or traumatic accident. The client with neck trauma may have multiple injuries, including cardiovascular, respiratory, gastrointestinal, and neurologic damage. The final outcome of this type of injury depends on the initial assessment and management
COLLABORATIVE MANAGEMENT
Assessment
The priority in the management of neck trauma is assessment for a patent airway. The cardiovascular system is then assessed for signs of internal or external bleeding or impending shock.
The nurse performs a baseline neurologic assessment for mental status, sensory level, and motor function. Injury to the carotid artery may result in death, stroke, or paralysis related to the interruption of blood to the brain. The physician may order a carotid angiogram to rule out vascular injuries.
Injuries involving the esophagus may also occur with neck trauma. The nurse assesses for chest pain and tenderness, oral bleeding, and crepitus (crackling sounds). The physician may order a barium or meglumine diatrizoate (Gastrografin) swallow to rale out an esophageal perforation injury.
Interventions
Cervical spine injuries often occur at the same time as a neck injury. Health care personnel must take great care not to exacerbate these injuries by causing neck movement while establishing the airway. The nurse prepares to assist in emergency intubation, cricothyrotomy, or tracheostomy to establish a patent airway.
Head and Neck Cancer
overview
Head and neck cancer interferes with breathing, eating, facial appearance, self-image, speech, and communication. This form of cancer can be devastating, even when treated successfully. The nurse is challenged in caring for clients with these complex problems. The client can receive appropriate care only through accurate identification of the location and size of the original tumor. An interdisciplinary approach by the health care team is essential to addressing the entire spec-tram of needs for these clients.
Head and neck cancer can be curable when treated early. The prognosis for those who have more advanced disease at diagnosis depends on the extent and location of the tumor. Untreated cancer of the head and neck is a fatal disease, with untreated clients usually dying within 2 years of diagnosis.
Pathophysiology
Most head and neck cancers (80%) are squamous cell (mucosal epithelial) carcinomas that usually require several years to develop. Many head and neck tumors first present as malignant ulcerations with underlying infiltration.
Initially, the mucosa is subjected to an irritating substance and transforms itself into a tougher mucosa (squamous metaplasia) by increasing the mucosal thickness (acanthosis or hyperplasia) or by developing a keratin layer (keratosis). At the same time, cellular gene changes lead to the growth of abnormal epithelial cells that eventually become malignant. These lesions may then take the form of white, patchy lesions or red, velvety patches. Head and neck carcinoma is often diagnosed on the basis of white, patchy mucosal lesions (leukoplakia) or red patches (erythroplasia).
The growth and spread (metastasis) of head and neck cancer depends on the site of the primary tumor. Spread usually occurs in adjacent anatomic areas such as mucosa, muscle, and bone. Systemic spread through the blood and lymphatic systems may also occur. When metastasis occurs, it is most commonly to the lungs or liver.
The histologic description of squamous cell cancers includes carcinoma in situ, well-differentiated carcinoma, moderately differentiated carcinoma, or poorly differentiated carcinoma. Most head and neck cancers are of squamous origin, but they also can be of salivary gland or thyroid origin. Less commonly, tumors can be epidermoid, adenoid cystic, malignant melanoma, or adenocarcinoma. These tumors are treated by various methods depending on the type of tumor and its known response to therapies.
Etiology
Numerous risk factors have been identified as contributing to the development of head and neck cancer, but the actual cause is unknown. The two most important risk factors are tobacco and alcohol use, especially in combination. Other risk factors include chewing tobacco, pipe smoking, marijuana, voice abuse, chronic laryngitis, exposure to industrial chemicals or hardwood dust, and complete neglect of oral hygiene.
Incidence/Prevalence
The frequency of occurrence of head and neck carcinoma is increasing. The American Cancer Society (ACS) estimates 43,000 newly diagnosed cases of oral and laryngeal cancers per year, which accounts for more than 4% of all carcinomas and more than 11,000 deaths per year (ACS, 2000). Approximately three times more males than females are affected, and most head and neck cancers occur in people over 60 years of age.
COLLABORATIVE MANAGEMENT
Assessment
HISTORY
The client with head and neck cancer may have difficulty speaking because of hoarseness, shortness of breath, tumor bulk, and pain. The nurse is sensitive to these difficulties during the interview.
The client is asked about tobacco and alcohol use, history of recurrent acute or chronic laryngitis or pharyngitis, oral sores, and lumps in the neck. The client’s smoking history is calculated in pack-years (the number of packs smoked per day times the number of years the client has smoked). The nurse asks about alcohol intake (how many drinks per day and for how many years). Questions of this nature may be uncomfortable for both the client and the nurse but are an important part of the history. The nurse also asks about exposure to any environmental or occupational pollutants.
Problems related to risk factors are assessed. For example, nutrition may be poor because of alcohol intake and impaired liver function. The nurse assesses dietary habits and any reported weight loss. A history of chronic lung disease, which has an impact on the client’s breathing pattern, is an important operative risk factor.
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
With laryngeal cancer, hoarseness may occur because of tumor bulk and a lack of ability to approximate the vocal cords in a normal fashion during phonation. Lesions of the true vocal cords are the earliest form of laryngeal cancer. A careful evaluation is important for anyone who has a history of hoarseness, mouth sores, or a lump in the neck for 3 to 4 weeks or longer.
Inspection and palpation of the head and neck are important parts of the physical examination. A specially trained nurse may perform a laryngeal examination, which includes the use of the laryngeal mirror or fiberoptic laryngoscope. Lesions may be visible on direct inspection, and the nurse palpates the neck for tumor nodal involvement.
PSYCHOSOCIAL ASSESSMENT
The typical client with head and neck carcinoma has a longstanding history of cigarette and/or alcohol use. The client or family may experience denial, guilt, blame, or shame once the diagnosis is suspected. The nurse assesses the availability and adequacy of support systems and coping mechanisms. Because the client often requires extensive assistance at home following treatment, assessment and documentation of social and family support are essential. The social worker is consulted for assistance as needed. Because of the importance of preoperative and postoperative teaching, cognitive functioning and the level of education and literacy of the client and family are evaluated.
The nurse notes any family history of cancer as well as the client’s age, gender, occupation, interests, and ability to perform the activities of daily living. The client is asked whether his or her occupation requires continual oral communication. Retraining in other vocational areas may be needed if speech has been affected.
LABORATORY ASSESSMENT
Routine diagnostic laboratory tests include a complete blood count, bleeding times, urinalysis, and SMA-20. Decreased protein and albumin levels indicate a loss of protein stores and define the nutritional risks often seen in clients with alcoholism. Renal and liver function tests are performed to rule out metastatic disease and to evaluate the client’s ability to metabolize medications and chemotherapeutic agents.
RADIOGRAPHIC ASSESSMENT
Many types of radiographic studies, including x-ray studies of the skull, sinuses, neck, and chest, are useful in diagnosing metastases, second primary tumors, and the extent of tumor invasion. Computed tomography (CT) of the head and neck, with or without contrast media, helps to evaluate the tumor’s exact location.
OTHER DIAGNOSTIC ASSESSMENT
Magnetic resonance imaging (MRI) can differentiate normal from diseased tissue. An MRI is more sensitive than a CT in defining the extent of soft-tissue invasion.
The brain, bone, and liver may also be evaluated with nuclear imaging, bone scans, SPECT (single photon emission computerized tomography) scans, and PET (positron emission tomography) scans. These tests help in locating additional tumor sites.
Other diagnostic tests include direct and indirect laryngoscopy, tumor mapping, and biopsy. Panendoscopy is performed with general anesthesia to define the extent of the tumor. This procedure includes laryngoscopy, nasopharyngoscopy, esophagoscopy, and bronchoscopy. Anatomic tumor mapping uses biopsy to outline and identify tumor location. At the time of the panendoscopy, the biopsy confirms the diagnosis and determines the tumor type, cellular characteristics, and location. Tumor staging by the TNM (tumor, nodes, metastasis) classification is performed at this time.
COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
The primary collaborative problem for clients with head and neck carcinomas is Risk for Ineffective Breathing Pattern related to impaired airway from the disease process (i.e., tumor invasion or obstruction, edema, and chronic lung disease).
The following are priority nursing diagnoses for these clients:
1. Risk for Aspiration related to edema, anatomic changes,
or alteration of protective oropharyngeal reflexes
2. Anxiety related to fear of the unknown
3. Disturbed Body Image related to tumor and treatment
modalities
ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
In addition to the commoursing diagnoses and collaborative problems, clients with head and neck carcinomas may have one or more of the following:
• Acute Pain or Chronic Pain related to tumor invasion of tissues and nerves and surgical intervention
• Imbalanced Nutrition: Less Than Body Requirements related to dysphagia, anxiety, tumor process, surgical resection, or chronic alcohol intake
• Impaired Verbal Communication related to tumor invasion, associated aphonia, hoarseness, pain, and/or surgical resection
• Impaired Tissue Integrity related to altered circulation, nutritional deficit, tumor invasion, radiation, chemical factors (body secretions or substances), or surgical wound
• Impaired Skin Integrity related to altered circulation, nutritional deficit, tumor invasion, radiation, chemical factors (body secretions or substances), or surgical
wound
• Ineffective Coping related to altered body image, communication method, and/or ineffective social support
• Impaired Social Interaction related to body image disturbance and lifestyle practices
• Impaired Adjustment related to self-care of the tracheostomy and nasogastric tubes, alternative communication methods, and body image disturbance
• Deficient Knowledge related to treatment regimen and unfamiliarity with information resources
Planning and Implementation
INEFFECTIVE BREATHING PATTERN
PLANNING: EXPECTED OUTCOMES. The client with head and neck carcinomas is expected to attain and/or maintain adequate ventilation and oxygenation as evidenced by the partial pressure of arterial oxygen (Pao2), partial pressure of arterial carbon dioxide (Paco2), and Spo2 all being withiormal limits (WNL).
INTERVENTIONS. The goal of treatment is to remove or eradicate the cancer while preserving as much normal function as possible. The physician presents the available treatment options. Modalities of surgery, radiation, or chemotherapy may be used alone or in combination. When planning treatment options, the physician considers the client’s general physical condition, nutritional status, and age; the effects of the tumor on body function; and most important, the client’s personal choice. Before recommending extensive surgery, the physician considers the client’s ability to manage his or her own care postoperatively.
Treatment for laryngeal cancer may range from radiation therapy (for a small specific area or tumor) to total laryngopharyngectomy, with bilateral neck dissections followed by radiation therapy. The specific treatment depends on the extent and location of the lesion. Voice conservation procedures are elected only if they can be accomplished without risking incomplete removal of the tumor. The nurse focuses on the client’s total needs, including preoperative preparation, competent in-hospital care, discharge planning and teaching, and extensive outpatient rehabilitation.
NONSURGICAL MANAGEMENT. The nurse monitors the respiratory system by assessing respiratory rate, breath sounds, pulse oximetry, arterial blood gas values, and the results of pulmonary function tests. Signs of respiratory distress may indicate narrowing of the airway related to tumor growth, edema, or both. The client is positioned for optimal air exchange. The nurse educates the client and family about the use of Fowler’s and semi-Fowler’s positions. Sitting upright in a reclining chair may promote more comfortable breathing.
RADIATION THERAPY. Radiation treatment of small cancers in specific locations offers a cure rate of at least 80%. The cure rate for larger cancers is lower when radiation is used as a single-modality therapy. Standard therapy uses 5000 to 7500 rad (radiation absorbed dose), usually over 6 weeks and in daily or twice-daily doses. The physician may recommend radiation alone or in combination with surgery. Because radiation therapy causes alterations in tissue healing, it might not be recommended preoperatively. Radiation therapy is commonly an outpatient procedure. Most clients experience uncomfortable side effects during and for a few weeks following radiation therapy.
Hoarseness may become worse. The nurse reassures the client and family that vocalization will improve to at least pre-treatment levels within 4 to 6 weeks after completion of radiation therapy. The client is encouraged to use voice rest and alternative means of communication until the effects of radiation therapy have subsided.
Most clients have a sore throat and difficulty swallowing while undergoing radiation therapy. Gargling with saline or sucking ice may decrease discomfort. Mouthwashes and throat sprays containing a local anesthetic agent such as diphenhydramine or lidocaine can provide temporary relief. Pain medication is ordered as needed.
The skin at the site of irradiation becomes red and tender and may peel during therapy. The client must avoid exposing this area to sun, heat, cold, and abrasive treatments such as shaving. The nurse instructs the client to wear protective clothing made of soft cotton and to wash this area gently with a mild soap, such as Dove. Only the lotions or powders prescribed by the radiologist should be used until the area has healed.
If the salivary glands are in the path of irradiation, the client will have a dry mouth. This side effect is long term and may be permanent. Heavy fluid intake, particularly water, and a humidified atmosphere can help relieve the discomfort. Some clients benefit from the use of artificial saliva, such as Salivart. Additional interventions for dry mouth include chewing gum and sucking hard candy.
CHEMOTHERAPY. Chemotherapy is not usually used alone for cancers of the head and neck. At times, it is adjuvant (additional) to surgery or radiation.
SURGICAL MANAGEMENT. Tumor size and location (TNM classification) defines the extent of surgical intervention for cancer of the head and neck. The method of reconstruction is also determined by the tumor size and amount of tissue to be resected and reconstructed. Surgical procedures for head and neck cancers include laryngectomy (total and partial), tracheostomy, and oropharyngeal cancer resections.
LARYNGECTOMY AND RELATED SURGICAL PROCEDURES. The major types of resections for laryngeal cancer include cordal stripping, cordectomy (excision of a vocal
cord), partial laryngectomy, and total laryngectomy. If lymph nodes in the neck are involved or if it is known that the tumor has a high rate of nodal spread, the surgeon performs a nodal neck dissection in conjunction with removal of the primary tumor. A pathologist evaluates the resected lymph nodes for tumor invasion.
Preoperative Care. As the client advocate, the nurse teaches the client and family about the tumor. The physician explains the surgical procedure and obtains informed consent. The nurse discusses and interprets the implications of such consent.
The nurse explains about self-care of the airway, compensatory methods of communication, suctioning, pain control methods, the critical care environment (including ventilators and critical care routines), nutritional support, feeding tubes, and goals for discharge. The client will need to learew methods of speech. He or she is prepared for this change through preoperative teaching and the establishment of an alternative form of communication (e.g., pen and pencil, “magic slate,” picture or alphabet board) before surgery.
The explanations of routines and outcomes of care are very important because these discussions are used to plan the hospitalization and rehabilitation. Multidisciplinary teams of nurses, physicians, speech pathologists, social workers, dietitians, and occupational and physical therapists are vitally important in the preoperative evaluation and preparation of clients with cancer.
Operative Procedures. Hemilaryngectomy (vertical or horizontal) and supraglottic laryngectomy are types of partial voice conservation laryngectomies.
To protect the airway, a temporary or permanent tracheostomy is usually performed with a partial laryngectomy. With a total laryngectomy, the upper airway is separated from the pharynx and esophagus, and the trachea is brought out through the skin in the neck and sutured in place, creating a stoma. This airway opening is always permanent and is referred to as a laryngectomy stoma.
Neck dissection includes the removal of tumor-involved lymph nodes, the sternocleidomastoid muscle, the jugular vein, the eleventh cranial nerve, and surrounding involved soft tissue. Because the eleventh cranial nerve (spinal accessory nerve) is resected during the nodal dissection, shoulder drop will be present after surgery. Physical therapy exercises are imperative and help the client ease the shoulder drop by increasing the use of other muscle groups.
Postoperative Care. Head and neck surgical procedures often last 8 hours or longer. Because of the duration of anesthesia and the amount of resection and reconstruction, the client may spend the immediate postoperative period in the surgical intensive care unit. The nurse monitors the client’s airway patency, vital signs, hemodynamic status, and comfort level. Manifestations of postoperative hemorrhage and other general complications of anesthesia and surgery are closely. Vital signs are monitored every hour for the first 24 hours and then every 2 hours until the client is stable. After the client is transferred from the critical care unit, the vital signs can be monitored every 4 hours or according to agency policy. The client is generally out of bed by the second postoperative day.
Complications after a head and neck cancer resection include airway obstruction, hemorrhage, wound breakdown, and tumor recurrence. The priorities in postoperative head and neck cancer care include airway maintenance and ventilation; wound, flap, and reconstructive tissue care; pain management; nutrition; and psychologic adjustment, including speech therapy.
Airway Maintenance and Ventilation. In the immediate postoperative period, the client may need ventilatory assistance because of a long-term smoking history, chronic lung disease, and a long duration of anesthesia. Most clients wean easily from the ventilator after this type of surgery because the thoracic and abdominal cavities are not entered. When weaned from the ventilator, the client usually uses a traceostomy collar, with oxygen and humidification to help mobilize musus secretions. Secretions may remain blood-tinged for 1-2 days.
Coughing, deep breathing, and saline instillation are usually effective in clearing secretions. The lack of a surgical incision in the chest or abdomen improves the ability to cough. The nurse instructs the client in the proper techniques for coughing and deep breathing to clear secretions.
Oral secretions can be suctioned with a Yankauer or tonsillar suction or with a soft red latex catheter. The nurse teaches clients to suction away from the side of an oral cavity cancer resection to prevent wound opening immediately after surgery. Clients can participate in their own care by using a table mirror for visibility. The nurse provides a clean environment for the catheter.
Stoma care following a total laryngectomy is a combination of wound care and airway care. Careful inspection of the stoma with a flashlight is routine. The suture line is cleaned with half-strength hydrogen peroxide to prevent secretions from forming crusts and obstructing the airway. Suture line care is performed every 1 to 2 hours initially, advancing to every 4 hours by the fifth postoperative day. The mucosa of the stoma and trachea should be bright and shiny and without crusts, similar to the appearance of the oral mucosa.
Wound, Flap, and Reconstructive Tissue Care. Tissue “flaps” may be used to close the wound and provide a cosmetically acceptable appearance. Commonly used reconstructive flaps are pectoralis major myocutaneous flaps, island flaps, rotation flaps, trapezius flaps, split-thickness skin grafts (STSGs), and free flaps with microvascular anastomosis (scapula, fibula, or radial forearm free flaps). These flaps may be used for reconstruction after any type of head and neck resection. After neck dissection, the surgeon places an STSG over the exposed carotid artery before covering it with skin flaps or reconstructive flaps.
The first 24 hours are critical. The nurse evaluates all flaps every hour for the first 72 hours and monitors capillary refill, color, and Doppler activity of the major feeding vessel. Any changes are reported to the surgeon immediately because surgical intervention may be indicated. The client is positioned to protect the blood supply of the reconstructed flaps.
Hemorrhage. Hemorrhage is a possible postoperative complication for all clients undergoing surgery, but it is uncommon with laryngectomy. The physician often places a closed surgical drain in the neck area to collect blood and drainage for approximately 72 hours postoperatively. The drain also helps to maintain the position of the reconstructed skin flaps. Any drain obstruction or equipment malfunction may cause a buildup of blood or serum under the flaps. This accumulation jeopardizes the blood supply of the flaps by interfering with both arterial supply and venous drainage. Malfunctioning drains may require surgery to remove accumulated clots. Nursing responsibilities for drain management include monitoring and reporting the amount and character of drainage; emptying the drainage container; and milking the drainage tube as directed by the physician.
Wound Breakdown. Wound breakdown is a common complication because of poor nutrition in these clients, wound contamination from the oral cavity, and previous radiation therapy. A history of alcohol use further complicates the nutritional status.
The nurse treats such wound breakdown with packing and local care as ordered to keep the wound clean and to stimulate the growth of healthy granulation tissue. Wounds may be extensive, and the carotid artery may be exposed. At the initial surgical resection, split-thickness skin grafts are placed over the carotid artery for protection in the event of wound dehiscence. As the wound heals, granulation tissue covers the artery and prevents rapture. If granulation is slow and the carotid artery is at risk, another surgical flap may be made to cover the carotid artery and close the wound.
If the carotid artery ruptures because of drying or infection, the nurse places immediate constant pressure over the site and secures the airway. With direct manual pressure maintained on the carotid artery, the client is immediately transported to the operating room for carotid resection. Carotid artery rupture has a high risk of stroke and death. An immediate nursing response can save the client’s life.
Pain Management. After cancer surgery, pain should be controlled and the client should still be able to participate in care. Morphine often is given by IV bolus and continuously for the first days after surgery. As the client progresses, acetaminophen with codeine, then acetaminophen alone, can be given by feeding tube. Oral medications for pain and discomfort are started only after the client can tolerate oral nutrition. After discharge, the client still requires pain medication, especially if he or she is receiving radiation therapy. An adjunct to the pain regimen may be liquid non-steroidal anti-inflammatory drugs (NSAIDs). These drugs provide excellent pain relief and can be used in conjunction with opioid analgesics. Amitriptyline (Elavil) or other tricyclic antidepressants may also be used as an adjunct to pain medication for the lancinating pain of nerve root involvement.
Nutrition. A nasogastric, gastrostomy, or jejunostomy tube is placed intraoperatively for nutritional support while the aerodigestive tract heals. Initially the client receives IV fluids or parenteral nutrition until the gastrointestinal tract has recovered from the effects of anesthesia. After that, nutrients may be administered via the feeding tube. The nutritional support team or dietitian assesses the client preoperatively and is available for consultations after surgery. A standard postoperative therapeutic goal is 35 to 40 kcal/kg of body weight. Replacement of protein and insensible water loss must also be calculated very carefully.
The nasogastric tube (the most commonly used type of tube) usually remains in place for approximately 10 days after surgery. Before removing the tube, the nurse assesses the client’s ability to swallow if nutrition is to be given by mouth. Aspiration cannot occur following an uncomplicated total laryngectomy because the airway and esophagus have been completely separated. The nurse reassures the client that aspiration will not occur and stays with him or her during the first few swallowing attempts. Swallowing may be uncomfortable at first, and analgesics are administered as ordered.
Speech Rehabilitation. Because the voice and speech can be expected to be altered after surgery, the speech pathologist and nurse discuss the principles of speech therapy with the client and family early in the course of the treatment plan. Voice and speech differences depend on the type of surgical resection. Speech production varies with client practice, amount of resection, and radiation effects, but the speech can be very understandable.
The speech rehabilitation plan for clients undergoing a total laryngectomy consists initially of writing, then using an artificial larynx, then learning esophageal speech. The client needs support and encouragement from the speech pathologist, hospital team, and family while relearning to speak. This process can be time-consuming and requires concentration each time the client speaks. Having a laryngectomee (person who has had a laryngectomy) from one of the local self-help organizations visit the client and family is often beneficial.
Common means of speech communication after laryngectomy include esophageal speech, the use of mechanical devices, and the use of a tracheoesophageal fistula (TEF).
• Esophageal speech. Most total laryngectomees attempt
esophageal speech. Clients produce esophageal speech
by “burping” the air swallowed or injected through the
pharyngoesophageal (P-E) segment and articulate words
in the mouth. The voice produced is a monotone; it can
not be raised or lowered and carries no pitch. In the Eng
lish language, the vocal cords are necessary for 15 con
sonants; the remaining 10 consonants can be formed by
shaping the mouth. Clients must have adequate hearing
or esophageal speech will be difficult, because they will
use their mouth to shape the words as they hear them.
Hearing-impaired clients may require hearing aids.
Initially, gastrointestinal bloating occurs as a result of swallowing air for esophageal speech. Antacids may help to reduce bloating sensations. Esophageal speech also helps to strengthen the respiratory and abdominal musculature, which aids in clearing secretions and in breathing.
• Mechanical devices. The client who cannot attain esophageal speech can use mechanical devices called electro-larynges. Most are battery powered devices placed against the side of the neck or cheek. The air inside the mouth and pharynx is vibrated, and the client moves his or her lips and tongue as usual. Another external device (Cooper-Rand), also battery powered, consists of a plastic tube that is placed within the client’s mouth and vibrates during speech. The quality of speech generated with these devices is robot-like and does notsound natural.
• Tracheoesophageal fistula. A tracheoesophageal fistula (TEF) may be used if esophageal speech is insufficient for communication and if the client meets strict criteria. A surgical fistula is created between the trachea and the esophagus either at the time of the laryngectomy or in the postoperative period. The surgeon
places a catheter into the laryngectomy stoma and surgically creates a fistula into the esophagus. The catheter is usually sutured to the neck to prevent accidental dis-
lodgment. After the fistula heals, a silicone prosthesis (e.g., the Blom-Singer prosthesis) is inserted in place of the catheter. The client covers the stoma and the opening of the prosthesis with a finger or opens and closes the opening with a special valve to divert air from the lungs, through the trachea, into the esophagus, and out of the mouth. Lip and tongue movement, not the prosthesis itself, produces speech.
SURGICAL PROCEDURES FOR OTHER HEAD AND NECK CANCERS. The major types of resections, defined by the tumor location of the oropharyngeal cancer, are called composite resections. Composite resections are a combination of surgical procedures that include partial or total glossectomies, partial mandibulectomies and, if required, nodal neck dissections. Tracheostomy may be planned to provide an adequate airway.
TRACHEOSTOMY. A tracheostomy is the (tracheal) stoma, or opening, that results from a tracheotomy. A tracheotomy is a surgical incision into the trachea for the purpose of establishing an airway. It can be performed as an emergency procedure or as a scheduled surgical procedure. A tracheostomy can be temporary or permanent.
RISK FOR ASPIRATION
PLANNING: EXPECTED OUTCOMES. The client with head and neck carcinomas is expected not to aspirate food, gastrointestinal contents, or oral secretions into the lungs.
INTERVENTIONS. Depending on tumor size and location or type of tumor resection, the client may aspirate during eating. This incident can result in life-threatening pneumonia, weight loss, further hospitalization, and increased costs.
Because of anatomic or surgical changes in the upper respiratory tract and altered swallowing mechanisms, the client with head and neck cancer is at risk for aspiration. The presence of a nasogastric (NG) feeding tube may further increase the potential for aspiration because of the incompetent lower esophageal sphincter (LES). The one exception is the client who has undergone a total laryngectomy. In these cases the airway is separated from the esophagus, making aspiration impossible; such a client is not at risk.
A dynamic swallow study, such as a barium swallow under fluoroscopy, evaluates a client’s ability to protect the airway from aspiration and helps to determine the appropriate method of swallow rehabilitation. Bedside clinical assessment of swallowing is important but has a high rate of inaccuracy. In many cases the physician must institute enteral feedings either because of the client’s inability to swallow or because of continued aspiration potential.
Aspiration Precautions: Prevention or minimization of risk factors in the client at risk for aspiration
• Monitor level of consciousness, cough reflex, gag reflex, and swallowing ability.
• Monitor pulmonary status.
• Maintain an airway.
• Position upright 90 degrees or as far as possible.
• Keep suction setup available.
• Feed in small amounts.
• Check NG or gastrostomy placement before feeding.
• Check NG or gastrostomy residual before feeding.
• Avoid liquids or use thickening agent.
• Offer foods or liquids that can be formed into a bolus before swallowing.
• Cut food into small pieces.
• Request medication in elixir form.
• Break or crush pills before administration.
• Keep head of bed elevated 30 to 45 minutes after feeding.
Smoking Cessation Assistance: Helping another to stop smoking
• Give smoker clear, consistent advice to quit smoking.
• Help choose best method for giving up cigarettes, when client is ready to quit.
• Refer to group programs or individual therapists, as appropriate.
• Assist client with any self-help methods.
• Help client plan specific coping strategies and resolve problems that result from quitting.
• Inform client that dry mouth, cough, scratchy throat, and feeling on edge are symptoms that may occur after quitting; the patch or gum may help with cravings.
• Advise client to keep a list of “slips” or near-slips, what causes them, and what client learned from them.
• Advise client to avoid smokeless tobacco, dipping, and chewing.
• Manage nicotine replacement therapy.
• Contact national and local resource organizations for resource materials.
• Follow client for 2 years after quitting, if possible, to provide encouragement.
• Help client deal with any lapses.
• Support client who begins smoking again by helping to identify what has been learned.
• Encourage the relapsed client to try again.
• Serve as a nonsmoking role model.
When an NG tube is in place, the nurse helps to prevent aspiration through routine reflux precautions. These precautions include elevating the head of the bed and strictly adhering to tube feeding regimens, including no bolus feedings at night. Residual feeding amounts are checked before each bolus feeding (or every 4 to 6 hours with continuous feeding), and the client’s tolerance of the tube feeding is evaluated. If the residual volume is too high (above 100 mL or as otherwise prescribed by the physician), the feeding is withheld and the physician notified. The nurse checks the pH of pulmonary secretions. Food coloring is added to the tube feeding, and tracheal secretions are observed. If aspiration occurs, secretions may be the color of the food coloring. Methylene blue is not used today as an additive to tube feedings because it is systemically excreted through the lungs and can appear in pulmonary secretions.
Swallowing can be a major problem for the client who has a tracheostomy tube. Swallowing can be normal if the cranial nerves and anatomical structures are intact. In a normal swallow, the larynx elevates and moves forward to protect itself from the passing stream of food and saliva. Laryngeal elevation also assists in opening the cricopharyngeal muscle, the upper esophageal sphincter. The tracheostomy tube sometimes fixes the larynx in place, making it unable to execute this motion efficiently. The result is difficulty in swallowing.
In addition, the tracheostomy tube cuff can balloon posteriorly when inflated and interfere with the passage of food through the esophagus. The common wall of the posterior trachea (trachealis muscle) and the anterior esophagus is very thin, which allows this pushing phenomenon. The client with head and neck cancer who is cognitively intact may adapt to eating normal food when the tracheostomy tube is small and the cuff is not inflated.
The client who has undergone a subtotal, vertical, or supra-glottic laryngectomy must be observed for aspiration. It is imperative that the nurse and the speech pathologist teach alternate methods of swallowing without aspirating. Especially effective after a partial laryngectomy or base-of-tongue resection is the “supraglottic method” of swallowing. To reinforce teaching and learning, the nurse places a chart in the client’s room detailing the steps. A dynamic swallow study is performed to guide rehabilitation therapy for swallowing and to evaluate the client’s ability to protect the airway.
ANXIETY
PLANNING: EXPECTED OUTCOMES. The client with head and neck carcinomas is expected to verbalize decreased anxiety through increased knowledge and understanding about the specific, individualized treatment plan.
INTERVENTIONS. Multidisciplinary conferences with the physician, clinical nurse specialist, dietitian, speech-language pathologist, physical therapist, psychologist, social worker, discharge-planning nurse, and general nursing staff may be beneficial. The nurse explores the reason for anxiety (e.g., fear of the unknown, lack of preoperative teaching, fear of pain, fear of airway compromise, fear of hospitalization, and loss of control). The client and family often benefit from further information. Before the client is scheduled for surgery (and while still at home), home care nurses or community-sponsored associations (e.g., American Cancer Society) may be able to decrease fears about the disease process and surgical interventions.
• The nurse administers antianxiety agents, such as diazepam (Valium, Meval), with caution because of the possibility of hypercarbia and hypoxia in an already compromised client. The location of the tumor and the presence of any other lung disease may cause some degree of airway obstruction. For anxiety in these clients, the physician prescribes drug therapy judiciously and may choose lorazepam (Ativan, Novo-Lorazem) rather than a solely sedating agent.
DISTURBED BODY IMAGE
PLANNING: EXPECTED OUTCOMES. The client with head and neck carcinomas is expected to state an understanding and, in time, an acceptance of body image changes and return to the previous lifestyle within the limits of the disease.
INTERVENTIONS. The client with head and neck cancer experiences a permanent change in body image because of deformity, the presence of a stoma or artificial airway, speech changes, and a change in the method of eating. The client may be aphonic or have permanent hoarseness or speech deficits. The nurse helps in setting realistic goals, starting with involvement in self-care. Alternative communication methods are taught so the client can functionally communicate in the hospital and after discharge.
The nurse and family must make all attempts to ease the client into a more normal social environment. The nurse provides encouragement and positive reinforcement while demonstrating acceptance and caring behaviors. The family also may benefit from counseling sessions initiated while the client is still in the hospital.
After surgery, the client may feel reserved and socially isolated because of the change in voice and facial appearance. Loose-fitting, high-collar shirts or sweaters (e.g., turtleneck), scarves, and jewelry can be worn to cover the laryngectomy stoma, tracheostomy tube, and postoperative changes related to surgery. Cosmetics may aid in covering any disfigurement. Most surgeons try to place the surgical incisions in the natural skin fold lines if doing so does not pose a risk for cancer recurrence.
Community-Based Care
If no complications occur, the client is usually ready to be discharged home or to an extended care facility within 2 weeks. At the time of discharge, he or she should be able to provide self-care, which may include tracheostomy or stoma care, nutrition, wound care, and methods of communication.
The client and family may feel more secure about discharge if they receive a referral to selected support groups or a community health agency familiar with the care of clients recovering from head and neck cancer. The multidisciplinary team assesses the specific discharge needs and makes the appropriate referrals to home care agencies, including professionals such as nutritionists, nurses, physical therapists, speech pathologists, and social workers. The nurse coordinates the scheduling for chemotherapy or radiation therapy with the client and family.
HEALTH TEACHING
Although education begins during preoperative teaching sessions, most self-care is taught in the hospital. The nurse teaches the client and family how to care for the stoma or tracheostomy or laryngectomy tube, depending on the type of surgery performed. Incision and airway care are reviewed, including cleaning and inspecting for signs of infection.
STOMA CARE. To prevent water from entering the airway, the client is instructed to use a shower shield over the tracheostomy tube or laryngectomy stoma when bathing. To shield the airway during the day, the client may wear a protective cover or stoma guard.
For clients with permanent stomas following laryngectomy or for those with permanent tracheostomies, covering the permanent opening has a double benefit: (1) filtering the air entering the stoma while keeping humidity in the airway, and (2) enhancing esthetic appearance. To protect the airway and increase humidity, the nurse instructs the client to cover the airway with cotton or foam. Attractive coverings are available in the form of cotton scarves, crocheted bibs, and jewelry. Using colored seam binding for tracheostomy ties after the stoma has matured may enhance overall body image. Shirt or dress color can be matched or coordinated with seam bindings of various colors. The client is instructed how to increase humidity in the home. The nurse may teach him or her to instill normal saline into the artificial airway 10 to 15 times a day as ordered.
COMMUNICATION. The client continues the selected method of alternative communication that began in the hospital. He or she wears a medical alert (MedicAlert) bracelet and carries a special identification card. For clients who have undergone a laryngectomy, this card is available from the local chapters of the International Association of Laryngectomees. The card instructs the reader in providing an emergency airway or resuscitating someone who has a stoma.
SMOKING CESSATION. A difficult but important issue after head and neck cancer surgery is smoking cessation. Smoking plays a major role in the development of head and neck cancer. The nurse stresses that smoking cessation can reduce the risk for developing additional malignancies and can increase the rate of healing from surgery.
Smoking cessation is not an easy task, and most clients require continuing support and reinforcement to sustain this action.
PSYCHOSOCIAL PREPARATION
The many physical changes resulting from a laryngectomy influence physical, social, and emotional functioning. Many clients perceive changes in their quality of life. The nurse begins to prepare the client and family for these changes, but another individual who has adjusted to these changes is usually more effective.
The client who is discharged to home with a permanent stoma, tracheostomy tube, nasogastric tube, and wounds experiences an alteration in body image. The nurse stresses the importance of returning to as normal a lifestyle as possible. Approximately half of the clients return to full-time employment, and the rest work part time or apply for disability income. Most clients can resume many of their usual activities within 4 to 6 weeks after surgery or longer after a combination of radiation therapy and surgery. The client may be frustrated at times while trying to adjust to changes in smell, taste, and communication.
The client with a total laryngectomy cannot produce sounds during laughing and crying, and mucous secretions may appear unexpectedly when these emotions or coughing or sneezing occur. The mucus can be embarrassing, and the client needs to be prepared to cover the stoma with a handkerchief or gauze. The client who has undergone composite resections will have difficulty with speech and swallowing.
HEALTH CARE RESOURCES
The home care or hospital nurse informs the client and family of community organizations (e.g., American Cancer Society) and local laryngectomee clubs, which can offer support, accurate information, and friendships. When the client has problems paying for health care services, equipment, and prescriptions, a visiting nurse agency may be helpful in directing him or her to available resources.
In many areas the local unit of the American Cancer Society or Canadian Cancer Society can help provide dressing materials and nutritional supplements to clients ieed. This organization may also provide transportation to and from follow-up visits or radiation therapy.
Evaluation: Outcomes
(The nurse evaluates the care of the client with head and neck carcinomas on the basis of the identified nursing diagnoses and collaborative problems. The expected outcomes are that the client:
• Maintains a patent airway
• Attains or maintains clear lung sounds in all lung fields
• Demonstrates an understanding of head and neck cancer and its treatment
• Performs self-care of the artificial airway and wound
• Performs activities of daily living (ADLs) independently or with minimal assistance
• States that levels of anxiety are reduced
• Resumes as normal a lifestyle as possible through rehabilitation
• States an understanding of and adjusts to changes in physical appearance and body function
• Attains or maintains adequate nutrition
• Does not aspirate gastric contents or food
• Complies with smoking and alcohol cessation
He or she may need to deal with tracheostomy and feeding tubes in public places.
HOME CARE MANAGEMENT
Extensive home care preparation is required after a laryngectomy for cancer. The convalescent period is long, and airway management is complicated. The client or family must be able to take an active role in care.
General cleanliness of the home is assessed. If the client has severe or long-standing respiratory problems, adjustments in the home to allow for one-floor living may be necessary. Increased humidification is needed. A humidifier add-on to a forced-air furnace can be obtained. If the cost of this add-on is not manageable or if the home is heated by radiators, a room humidifier or vaporizer may be appropriate.
A home care nurse is involved with care after discharge and is a very important resource for the client and family. The home care nurse assesses the client and home situation for problems in self-care, complications, adjustment, and adherence to the medical regimen.
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