Upper Respiratory Problems

  1. Where are disorders of the upper respiratory system
    • nose
    • sinuses
    • pharynx
    • larynx
  2. Nose and paranasal sinus problems
    • deviated septum
    • nasal fracture
    • rhinoplasty
    • epistaxis
    • allergic rhinitis
    • acute viral rhinitis
    • influenza
    • sinustitis
    • obstruction of nose and sinuses
  3. Structural and traumatic disorders
    • deviated septum
    • nasal fracture
    • rhinoplasty- including septoplasty and nasal fracture reduction
  4. Deviated septum
    • the nasal septum is normally straight. In a deviated septum, it is deflected, usually severely shifted in those diagnosed
    • most common cause: trauma to nose at birth or later in life
    • symptoms: minor cases may be asymptomatic. obstruction to nasal breathing, nasal congestion, frequent sinus infections, epistaxis and facial pain
  5. Medical management of deviated septum
    • if minor focus on symptom control of nasal inflammation and congestion
    • use saline rinses and decongestants to clear nasal passages
    • severe- nasal septoplasty
  6. Nasal fracture
    • most common cause: blunt trauma
    • Complications: airway obstruction, epistaxis, meningeal tears causing CSF leakage
    • Symptoms: localized pain, crepitus (grinding, crunching etc) on palpation, swelling, difficulty breathing through nose, epistaxis, ecchymosis (bruising), cosmetic deformity
    • can be simple or complex
  7. simple nasal fracture
    • are unilateral or bilateral
    • typically produces little or no displacement
    • often reduced with manual manipulation
  8. complex nasal fracture
    • may also involve subsequent damage to adjacent facial structures (teeth or eyes for example)
    • powerful frontal blows can cause these
    • evaluate pt for possible injury to the cervical spine or orbital or mandibular bones
    • there is often considerable swelling of soft tissue and you may need to wait 5-10 days for edema to subside to repair. you can do septoplasty or rhinoplasty
  9. Sign of CSF leak after nasal fracture
    • clear, pink-tinged or persistant drainage after control of epistaxis
    • send a sample to the lab to confirm its CSF
  10. Nursing treatment of nasal fracture
    • maintain airway by keeping pt sitting upright
    • ippy ice to reduce edema and bleeding
    • administer analgesia as ordered
    • nasal decongestants for stuffiness
    • no hot showers or alcohol for 48 hrs to prevent swelling
    • ask pt to quit or decrease smoking to facilitate tissue healing
  11. Rhinoplasty
    • surgical reconstruction of the nose
    • performed to improve airway function when trauma or deformities cause nasal obstruction or for cosmetic reasons
    • often performed as an outpatient procedure
    • nasal tissue is added or removed, and the nose may be lengthened or shortened
    • incisions are usually hidden inside the nose
    • plastic implants may be used to reshape the nose
  12. Sonic rhinoplasty
    rhinoplasty that incorporates the use of ultrasonic devices to gently aspirate bone, enabling a refined cosmetic result
  13. Nursing Responsibilities in nasal surgery
    • instruct PT to tell dr about any meds they take at home
    • no asprin or nsaids for 5 days to 2 weeks perioperatively to reduce bleeding risk
    • encourage smoking cessation to promote faster healing
    • maintain airway and assess respiratory status
    • manage pain
    • observe surgical site for bleeding, infection, edema
    • teach patient to detect complications at home
    • cold compresses at home and elevation to minimize swelling and discomfort
    • subtle swelling may resolve slow and full cosmetic result can take up to a year
  14. Epistaxis
    • nosebleed
    • most often occurs in adults over 50
  15. Possible causes of epistaxis
    • trauma
    • hypertension
    • low humidity
    • upper respiratory tract infections
    • allergies
    • sinusitis
    • foreign bodies
    • chemical irritants (ie street drugs)
    • overuse of decongestant nasal sprays
    • facial or nasal surgery
    • anatomic malformation
    • tumors
    • conditions that prolong bleeding or alter platelet counts increase risk
    • NSAIDS, wafarin or other anticoagulants may prolong bleeding
  16. anterior vs posterior epistaxis
    • anterior: 90% of nosebleeds happen in anterior nasal cavity. easily seen. can be self treated and usually stops spontaneously
    • posterior: more common in older adults secondary to other health problems (ie hypertension). occur closer to the throat, making it difficult to know how much blood loss has occured. may require medical treatment
  17. Nursing care for epistaxis
    • calm and quiet environment
    • sit pt leaning forward with head and shoulders elevated
    • pinch entire soft portion of the nose for 10-15 min to apply pressure
    • apply ice compresses and have them suck on ice
    • packing for post. bleeds with nasal sponges or epistaxis balloons
    • seek medical assistance
  18. Medical management for anterior bleed
    • a pledget (nasal tampon) with lidocaine (anathetic solution) and/or vasoconstrictive agents like epinepherine may be placed into the nasal cavity
    • absorbable materials like oxidized cellulose, gelatin foam, or a gelatin-thrombin comination may be used
    • packing can stay in place for 48-72hrs
    • silver nitrate can be sued for chemical cauterization of an identified bleeding point
    • thermal cauterization is for more severe bleeding and may require the use of local or general anesthesia
  19. Medical management for posterior bleed
    • may be much more difficult to identify its location
    • often require packing with epistaxis balloons or compressed nasal sponges
    • if packing fails to stop bleeding, arterial embolization (small piece of gelatin sponge or other material is put in a cathetor to clog the blood vessel)
  20. If first aid not effective for epistaxis
    • identify bleeding site and apply vasoconstrictive agent
    • localize bleeding
    • cauterization (chemical is less invasive than thermal)
    • anterior packaging (pledgets)
  21. pledgets
    • nasal tampons
    • used for packing anterior epistaxis
    • predisposes pt to infection
    • remains in about 3 days
    • if it fails- ligaion of internal maxillary artery (suture tied around blood vessel to shut it off)
  22. how to avoid epistaxis from reoccurring
    avoid vigourse nose blowing, strenuous activity, lifting or straining for 4-6 weeks
  23. Nasal packing and breathing
    • nasal sponges, packing and balloons may impair respiratory status
    • monitor consciousness, heart rate and rhythm, respiratory rate, spo2, and observe for difficulty breathing or swallowing
    • nasal packing is painful bc suffiecient pressure must be applied to stop bleeding. give mild opiod analgesic (ie acetaminophen with codeine) abx may be prescribed too against staphlyococci
  24. allergic rhinitis
    • inflammation of the nasal mucosa in response to a specific allergen
    • 14% of population is affected
    • 3.4 billion- cost to manage
  25. ways to classify allergic rhinitis
    • by the causative allergen: seasonal or perennial (long lasting)
    • by the frequency of symptoms: episodic, intermittent, or persistant
    • both seasonal and perennial rhinitis can be episodic, intermittent, or persistant
  26. episodic allergic rhinitis
    symptoms related to sporadic exposure to allergens not typically encountered in the patients normal environment, such as exposure to animal dander when visiting a friends house
  27. intermittent allergic rhinitis
    the symptoms are present less than 4 days a week or less than 4 weeks per year
  28. persistent allergic rhinitis
    symptoms are present more than 4 days a week and more than 4 weeks per year
  29. seasonal allergic rhinitis
    • usually occurs in spring and fall
    • caused by allergy to pollens
    • typical attack lasts several weeks when pollen counts are high, then dissappears and comes back the same time next year
  30. perennial allergic rhinitis
    • occurs year round from exposure to environmental allergens 
    • both seasonal and perennial rhinitis can be episodic, intermittent, or persistant
  31. allergic rhinitis common triggers
    • animal dander
    • dust mites
    • cockroaches
    • fungi 
    • molds
  32. allergen sensitization
    • occurs with initial allergen exposure which results in production of antigen specific immunoglobin E IgE
    • after exposure, mast cells and basophils release histamine, cytokines, prostaglandins and leukotrienes which cause early symptoms
    • for 8 hours after exposure, inflammatory cells infiltrate the nasal tissues
  33. symptoms of allergic rhinitis
    • sneezing
    • itching
    • rhinorrhea (nasal cavity filled with significant nasal fluid)
    • congestion
    • watery/itchy eyes and/or nose
    • altered smell, thin watery discharge
    • nasal turbinates (shell shaped networks of bones, tissues and vessels) that are pale, boggy or swollen
    • chronic headache (H/A)
    • congestion
    • pressure
    • post nasal drip
    • cough
    • hoarsness
    • recurrent need to clear throat
    • snoring
  34. nursing management of allergic rhinitis
    • most important: identify and avoid triggers of allergic reactions (commonly dust mites, mold spores, pollens, pet allergens, smoke)
    • instruct pt to keep a diary and note times of rxn. pt will be more aware of intermittant rxn (ie pets) than persistant (ie dust mites or mold)
    • drug therapy: nasal corticosteroid sprays, oral h1-antihistamines, decongestants and leukotriene receptor antagonists
  35. are second or first generation antihistimines better for allergic rhinitis
    • second generation are preferred because of their non sedating effects
    • remind patients to drink fluids to reduce adverse symptoms
  36. naso-corticosteroids
    • sprays are used to decrease inflammation locally
    • little absorption into systemic circulation
    • therefore, systemic side effects ar rare
  37. combination drug therapy for allergic rhinitis
    • you can do this if one medication isnt relieving symptoms
    • ie an oral h1-antihistimine with an intranasal corticosteroid
    • of course check for drug-drug interactions
  38. immunotherapy for allergic rhinitis
    • allergy shots
    • may be used when a specific, unavoidable allergen is identified and drugs are not tollerated or are ineffective
    • controlled exposure to small amounts of the known allergen through frequent (often weekly at least) injections with the goal of decreasing sensitivity
    • sublingual or intranasal administration of allergen immuno therapy may be appropriate for certain patiients
  39. summary of medications for allergic rhinitis
    • OTC Meds: antihistamines, decongestants, eye drops
    • Prescribed: Nasonex, zyrtec, claritin
  40. acute viral rhinitis
    • aka the common cold or acute coryza
    • most prevalent infectious disease
    • inflammation of the upper respiratory tract that can be caused by over 200 different viruses
    • transmitted by airborne droplet spray
    • virus can survive on inanimate objects up to 3 days
    • symptoms can range from mild to more severe
  41. nursing management of acute viral rhinitis
    • aim interventions at reliving symptoms
    • rest
    • fluids
    • proper diet
    • antipyretics (anti-fever)
    • analgesics
    • patroleum jelly for sore nose
    • remember: antibiotics wont work here
  42. when do symptoms of acute viral rhinitis usually begin
    • 2-3 days after infection
    • symptoms may last 2-14 days with typical recovery in 7-10 days
  43. what increases susceptibility to acute viral rhinitis
    • winter months- ppl overcrowd indoors
    • fatigue
    • physical and emotional stress
    • allergies affecting nose and throat
    • compromised immune function
    • lack of exercise
  44. complications of acute viral rhinits
    • pharyngitis
    • sinusitis
    • otitis media
    • tonsillitis
    • lung infection
    • secondary bacterial infection (fever over 103F is a sign)
  45. influenza
    • a highly contageous respiratory illness that causes significant morbidity and mortality
    • millions, 5-20% of usa contract it each year
    • Season: Sept-April, peaking in November-March
  46. influenza death
    • most deaths in people > 60, those with heart or lung disease
    • can be prevented with vaccination of high risk groups
  47. influenza serotypes
    • a,b and c
    • only a and b cause significant illness in humans
  48. Influenza A
    • subtyped based on if it has hemagglutinin (H) and neuraminidase (N) surface proteins
    • most common and most virulent type
    • mostly found in birds, pigs, horses, seals and dogs
    • Type A H1N1 (swine flu) of 2009- never had been seen in humans before but it mutated and a worldwide pandemic (spreading around the globe) resulted
  49. H and N antigens in flu
    • H (hemgglutinin) antigens: allow virus to enter the cell 
    • N (neuraminidase) antigens: facilitate cell to cell transmission
  50. Influenza b and c
    • both only infect humans and dont have subtypes like A
    • b: can cause regional epidemics (more localized outbreak than a pandemic), but milder than A
    • C: mild illness and doesnt cause epidemics or pandemics
  51. Influenza symptoms
    • incubation period 1-4 days with highest transmission one day before symptoms
    • typically are abrupt
    • symptoms are systemic- cough, fever, myalgia (muscle pain), headache, sore throat, runny or stuffy nose, aches, vomiting, joint aches, extreme tiredness
  52. label the symptomsImage Upload 1
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  53. influenza diagnosis
    • examination findings are usually minimal
    • crackles are sign of pulmonary complication
    • pneumonia is the most common secondary complication to flu 
    • (starts with improved symptoms then worse cough and purulent sputum)
    • viral cultures are the gest but can take 3-10 days. can tell you flu type which is helpful for making next years vaccine (if the virus only mutates a little many will still have partial immunity)
    • there are also rapid flu tests used within first 48hrs of symptoms to identify flu from other viral or bacterial infections, but it cant tell you the type or give a false positive
  54. nursing management of flu
    • vaccinate high risk groups in the fall before exposure bc it takes 2 weeks for full protection
    • diagnostic tests may delay treatment
    • medication: initiated within 2 days of onset of symptoms. shortens flu course
  55. flu vaccine
    • 2 types: inactivated and live attenuated
    • given with a needle, usually in the arm for those over 6months who are healthy or have chronic medical conditions (except for certain ones)
    • changed yearly based on most likely strains
  56. difference between live attenuated and trivalent inactivated flu vaccine
    • inactivated: injection, for those over 6mo , can be used with chronic medical conditions or nursing home residents, pregnant or immunocompromised
    • live attenuated: nasal spray, healthy ppl between 2 and 49, CANT be used in young children or older adults, preg, immunocompromised, ppl on aspirin or salicyclates, increased risk
  57. how effective is the seasonal flu vaccine
    • effectivenes can vary and partly depends on the match between the viruses in the vaccine and the flu viruses in the commnity
    • if closely matched VE (vaccine effectiveness) is higher
    • if not closely matched, VE reduced
    • best matched years have VE 70-90% in healthy adults
  58. flu mist
    • effective
    • has live weakened flu viruses that dont cause the flu
    • LAIV (flumist)
    • less invasive, but again cant be used in anyone with chronic illness or risk or pregnant
  59. anti-viral flu drugs
    • Oseltamivir (Trade: Tamiflu): comes in oral liquid suspension for children or in capsules at childrens doses
    • Zanamivir (Trade: Relenza) recommended for treatment and prevention of flu. an inhaled powder that comes with a disk inhaler

    peramivir (Rapivab): given IV

    • these antiviral drugs are neuraminidase inhibitors that prevent the virus from spreading to other cells. They shorten duration of flu symptoms and reduce complication risk
    • treat ASAP
  60. Sinusitis
    • develops when inflammation or hypertrophy (enlargement) of the mucosa blocks the ostia (openings) in the sinuses, through which mucous drains into the nose
    • affects 1 in 7 adults
    • provides a medium risk from growth of bacteria, viruses, fungi that can cause infection
  61. Rhinosinusitis
    • concurrent inflammation or infection of the nasal mucosa
    • can accompany sinusitis
  62. types of sinusitis
    • acute sinusitis: usually results from URI (upper respiratory infection, viral sinusitis esp usually follows this), allergic rhinitis, swimming, or dental manipulation. lasts 4 weeks or less
    • subacute sinusitis: symptoms progress from 4 to 8 weeks
    • chronic sinusitis: persistant infection usually associated with allergies and nasal polyps. results in irreversable loss of normal ciliated epithelium that normally line the sinus cavity. lasts longer than 8 weeks
  63. Other things that can affect optimal mucous drainage from the sinuses
    • nasal polyps
    • foreign bodies
    • deviated septum
    • tumors
  64. why is sinusitis risky
    the secretions that accumulate behind the blocked ostia become a rich media for bacterial, viral or fungal growth which may cause infection
  65. Bacterial sinusitis
    • streptococcus pneumoniae, haemophilus influenzae and moraxella catarrhalis are the most common causes
    • 5%-10% of people with virul sinusitis develop a bacterial infection
  66. what condition is linked to sinusitis
    • asthma
    • 50% of pt with moderate to severe asthma have chronic sinusitis
    • postnasal drip can contribute to asthma by stimulating bronchoconstriction
  67. clinical manifestations of sinusitis
    • significant pain over the affected sinus
    • purulent (containing pus) nasal drainage
    • nasal obstruction, congestion, fever, malaise (discomfort)
    • looks sick
    • hyperemic (increased blood flow to) and edematous (swollen with accumulated fluid) mucosa
    • enlarged turbinates
    • tenderness over involved sinuses
    • recurrent headache that changes with position or drainage
  68. diagnosing sinusitis
    • chronic is more ifficutl to diagnose bc symptoms are often non specific and patient is rarely febirle
    • ct scan
    • sinus xray
    • nasal endoscopy
  69. ct scan in sinusitis
    may show the sinuses to be filled with fluid or a thickened mucous membrane
  70. nasal endoscopy in sinusitis
    • with a flexible scope
    • may be used to examine the sinuses, obtain a specimen for culture, and restore normal drainage
  71. nursing care for sinusitis
    • if they have allergies reduce allergens
    • give medication as prescribed
    • increase fluid intake
    • hot showers
    • irrigate nose with saline to rince nasal passages, facilitate drainage and decrease inflammation
    • possibly surgery

    acute- focus on symptom relief
  72. surgery for sinusitis
    • for some pt medical therapy may not relieve symptoms
    • they may require nasal endoscopic surgery to relive blockage caused by hypertrophy or septal deviation
    • this is usually an outpatient procedure where Propel, a self expanding implant is placed directly at the sinus to maintain post operative patency to the sinus cavity and provide localized corticosteroid delivery directly to the sinus cavity
  73. medications for sinusitis
    • antibiotics: broad spectrum abx may be used since mixed bacterial flora are present and difficult to eliminate in bacterial sinusitis. amoxcillin is the first line drug of choice though but may go to broad spectrum if this doesnt work
    • decongestants
    • corticosteroids
    • mucolytics: acetylcysteine (mucomyst)- contains natural amino acids that lyse mucous to clear it
  74. obstruction of the nose and paranasal sinuses
    • polyps
    • foreign bodies
  75. nasal polyps
    • benign mucous membrane masses form slowly in response to repeated inflammation of sinus or nasal mucosa
    • can exceed the size of a grape
    • causes nasal obstruction, discharge and speech distortion
    • yellow, gray or pink semitransparent projections
    • most common in men over 40
  76. foreign bodies
    • a variety of foreign bodies can lodge in the URT
    • can be inorganic (may cause no symptoms and be incidentally discovered in routine examination) or organic (may produce a local inflammatory rxn and nasal discharge which may become purlulent and foul smelling if object remains in nasal cavity for a while)
    • should be removed from the nose through route of entry. avvoid irrigating the nose or pushing the object backward as these could cause aspiration or further airway obstruction
  77. treatment of obstruction of nose and sinuses
    • removal: edoscopic or laser surgery
    • recurrence is common
    • topical or systemic corticosteroids may slow polyp growth
  78. acute pharyngitis
    • acute inflammation of pharyngeal walls
    • may include tonsils, palate, uvula
    • can be caused by viral, bacterial or fungal infection
    • 70% viral, 15-20% acute follicular pharyngitis (strep throat) beta hemolytic streptococcal
  79. strep throat
    • bacterial pharyngitis
    • usually results from group A beta hemoylytic streptococci
    • 5-10% of cases
  80. fungal pharangitis
    • ie candidiasis
    • can develop with prolonged use of antibiotics or inhaled corticosteroids
    • can also occur in the immunosuppressed
  81. other causes of acute pharyngitis that arent infections
    • dry air
    • smoking
    • GERD
    • allergies and postnasal drip
    • endotracheal (ET) intubation
    • chemicals
    • cancer
  82. Clinical manifestations of acute pharyngitis
    • can range from scratchy throat to severe pain
    • red, edematous pharynx with or without patchy yello exudate (viral or bacterial present this way so you cant tell which is which)
    • irregular white patches suggest fungal candida albicans
  83. four classic manifestations of bacterial pharyngitis
    • fever greater than 100.4F or 38C
    • anterior cervical lymph node enlargement
    • tonsillar or pharyngeal exudate (a mass of cells/fluid that has seeped out)
    • absence of cough
    • when 2 or 3 of these are present, do a rapid antigen detection test and/or throat culture to establish the cause for sure
  84. nursing management of acute pharyngitis
    • get a throat culture to confirm cause
    • control infection: strept- abx, cadida- nystatin S&S (antifungal suspension oral). ps needs to swish in mouth for as longs as possible before swallowing
    • infection control, symptom releif, and prevention of secondary infection
  85. acute pharyngitis symptom releif nursing interventions
    • pt can gargle with warm salt water
    • drink warm/cold liquies
    • suck on popsicles, hard candies, throat lozenges
    • cool bland liquids and gelatin wont irritate the pharynx
    • citrus juices irritate- avoid
    • encourage pt to use a cool mist vaporizer or humidifier
  86. drug of choice for bacterial type A b-hemolytic streptococcus
    • penicillin- must be taken several times a day for 10 full days to prevent complications such as rheumatic fever
    • if penicillin allergy- erythromycin or clindamycin are appropriate substitutes
    • other abx- amoxicillin, azithromycin, cephalosporins
    • most ppl contageous until abs for 24-48hrs
  87. Peritonsillar Abscess
    • complication of acute pharyngitis or acute tonsillitis when bacteria invades one or both tonsils
    • most often caused by groupA b-hemolytic strep
    • tonsils can enlarge to threaten airway patency- this is an emergency
  88. symptoms of peritonsillar abscess
    • pain, swelling, blockage of the throat byt he tonsills
    • high fever
    • chills
    • leukocytosis (high wbc)
    • difficulty swallowing
    • muffled voice
  89. peritonsillar abscess treatment
    • IV antibiotic therapy 
    • needle aspiration or incision and drainage of the abscess (I&D)
  90. obstructive sleep apnea
    • partial or complete upper airway obstruction during sleep causing apnea and hypo-apnea (partial stopping of breathing due to partial blockage) lasting 15-90 seconds
    • More common in men, people over 65, the obese
    • 2-10% of the population have it
  91. What happens in obstructive sleep apnea
    you get apnea (cessation of breathing) which causes hypoxemia (low arterial oxygen tension) and hypercapnia (elevated CO2 in blood). this is a respiratory stimulant which causes the person to awake partially and there is a startle response- snorts and gasps- then the tongue and soft palate move forward result in the airway being open
  92. Clinical manifestation of obstructive sleep apnea
    • frequent wakening
    • insomnia
    • excessive daytime sleepiness
    • witnessed the apnea
    • loud snoring
    • morning headache
    • personality changes
  93. Diagnosing obstructive sleep apnea
    • polysomnography
    • aka sleep study- monitors your nighttime sleep patterns including brain waves, blood oxygen, breathing, heart rate, eye and leg movments
  94. treatments for sleep apnea
    • weight loss
    • CPAP
    • BiPAP
    • Surgery
  95. CPAP
    • continuous positive airway pressure machine. uses a hose and mask or nose piece to deliver constant and steady air pressure
    • The air being pushed into the throat prevents the airway from narrowing
  96. BiPAP
    • Bilevel positive airway pressure
    • similar to a CPAP but some people on CPAP find it difficult to exhale with the constant pressure going in, the biPAP adjusts to your breathing pattern and increasing pressure if the time between breaths exceeds its timing limit
    • main difference- bipaps have 2 pressure settings where cpaps have 1. bipaps have lower pressure setting for exhalation
  97. airway obstruction
    there is complete or partial airway obstruction
  98. complete airway obstruction
    • a medical emergency
    • can be caused by allergic reaction, edema, inflammation from infection or burns, peritonsillar or retropharyngeal abscesses, malignancy, laryngeal or tracheal stenosis or trauma
    • can result in permanent brain damage if not corrected in 3-5 min
  99. partial airway obstruction
    • can be caused by aspiration of food or foreign body
    • laryngeal edems, laryngeal or tracheal stenosis, CNS depression or allergic reaction can cause partial to
  100. Sounds with airway obstruction (partial)
    • objects lodge in the larynx may produce voice hoarseness 
    • tracheal obstruction may produce wheezing
    • objects in LRT such as bronchus may produce a cough or decreased air entry on that side
  101. manifestations of airway obstruction
    • choking
    • stridor (high pitched wheezing)
    • use of accessory muscles
    • suprasternal and intercostal retractions
    • flaring nostrils
    • wheezing
    • restlessness
    • tachycardia
    • cyanosis
    • change in consciousness

    assess and treat quickly so it doesnt become a complete obstruction
  102. Treatment of airway obstruction
    • obstructed airway maneuver (Heimlich)
    • critcothyroidotomy: procedure that involves placing a tube through an incision in the cricothyroid membrane under throat to establish an airway for oxygenation and ventilation.
    • endotracheal intubation
    • tracheostomy
  103. endotracheal intubation
    • tube is placed into trachea through mouth and nose to allow ventilation and oxygenation
    • keeps airway open
  104. tracheostomy
    • surgical incision in the trachea to establish airway
    • stoma (artificial opening to a hollow organ, esp one through the body surface) results
  105. why might a tracheostomy be done
    • to establish a patent airway
    • to bypass an upper airway obstruction
    • to facilitate removal of secretions
    • to permit long-term mechanical ventilation
    • to facilitate weaning off of mechanical ventilation
    • to permit oral intake and speech with long term mechanical ventilation
  106. differences between a tracheostomy and a enndotracheal intubation
    • tracheostomy goes through trachea by neck, ET tube goes in usually through mouth, sometimes through nose
    • trach tube shorter in length and slightly wider than ET tube in diameter- makes it eeasier to keep the tube clean and facilitate better oral and brhonchial hygene
    • trach increases patient comfort bc nothing in the mouth
    • less risk of long term damage to vocal cords with trach tubes
  107. parts of a tracheostomy tube
    • flange: faceplate that rests on the neck
    • obturator: used to help insert the tube
    • outer cannula: keeps the airway patent (aka unobstructed)
    • inner cannula: can be disposable or not and removed for cleaning
  108. cuffed vs uncuffed tracheostomy tubes
    • cuffed: has an inflated cuff (Balloon). most commonly used, esp if patient needs mechanical ventilation or is an aspiration risk. the cuff is inflated via the balloon inflation port on the trach tube, and healps keep the tube in place
    • cuffless: primarily used in patients with long term tracheostomy, making eating and talking possible
  109. fenestrated
    • the outer and/or inner cannula of a trach tube may be fenestrated or non fenestrated
    • fenestrated tube: allows the PT to breathe spontaneously (ie a cuff fenestrated tube, when the fucc is deflated and the inner cannula removed, air can pass from lungs up through the opening through the larynx into the upper airway and out the mouth and nose. This permits patient to speak with the tube in place. but when cuff reinflated and inner cannula reinserted, air cant pass to nose and mouth anymore making talking impossible
  110. Care of tracheostomy
    • care for diff types
    • know if you have one tube or an inner and outer cannula
    • know if its fenestrated or non fenestrated
    • make sure its sutured
    • check if tube is dislodged and out- immediately call for help if so, if needed obtaina  hemostat to spread the opening where the tube was displaced
    • suctioning mucous/sputum
    • daily care
    • swallowing disfunction
    • decannulation
  111. nursing diagnoses for tracheostomy
    • ineffective airway clearance: Related to presence of artificial airway en excessive sputum. adventitious breath sounds AEB restlessness, ineffective cough, dyspnea
    • risk for aspiration: R/T presence of tracheotomy, impaired swallowing
    • impaired verbal communication: use of cuffed artificial airway, AEB inability to speak and sign of frustration
    • ineffective self-health management: R/T lack of knowledge about care of tracheostomy, AEB questioning about care, agitation and restlessness
  112. actions to prevent dislodging of a tracheostomy tube
    • keep a replacement tube of equal or smaller size at the bedside, readily available for emergency inserition
    • do not change tracheostomy tapes for at least 24 hours asfter the insertion procedure
    • if necessary a HCP performs the first tube change no sooner than 7 days after the tracheostomy
  113. decannulation
    • removal of the tracheostomy from the trachea
    • to do so, patient must be: 
    • resolved from need for tracheostomy, hemodynamically stable, have a stable intact respiratory drive and be able to adequatly exchange air and expectorate secretions
  114. laryngeal polyps
    develop on vocal cords from vocal cord abuse (excessive talking, singing) or irritation (intubation, cigarette smoking)
  115. most common symptom of laryngeal polyps
  116. treatment of laryngeal polyps
    • treated conservatevly with voice rest and adequate hydration
    • surgical removal may be indicated for large polyps, which may cause dysphagia, dyspnea, and stridor
    • usually are begnin but may be removed bc they can become malignant
  117. head and neck cancer
    • arise from mucosal surfaces and typically are squamous cell in origin
    • not common, but causes great disability because of potential loss of voice, disfigurement
    • chances increase 90% in those over 50 with tobacco and alcohol use that are male
    • classified according to the area where cancer occurs
  118. Affected areas of head and neck cancers
    • brain
    • sinuses
    • nasal cavity
    • nasopharynx, oropharynx, larynx, oral cavity, salivary glands, trachea esophagus, hard palate, lips, tongue
  119. what causes 85% of head and neck cancers
    • tobacco (including smokeless tobacco)
    • excessive alcohol consumption is also a major risk factor
    • HPV gives a large risk
  120. Other risk factors of head and neck cancer
    • sun exposure
    • radiationtherapy to the head and neck
    • exposure to asbestos and other carcinogens
    • poor oral hygene
  121. clinical manifestations of head and neck cancer
    • early manifestations vary based on tumor location
    • may be a painless growth in the mouth
    • ulcer that doesnt heal
    • sore throat that doesnt get better
    • change in denture fit
    • pain is a late symptom
    • persistent unilateral sore in the throat/otalgia (ear ache)
    • hoarseness or neck lump lasting longer than 2 weeks
    • couging up blood

    • unitnentional wieght loss
    • difficulty chewing, swallowing, moving tounge and jaw, or bereathing
    • partially or fully obstructed airway
  122. Diagnostic studies for head and neck cancer
    • early detection is key to survival
    • physical assessment: examine oral cavity for thickening of the pliable oral mucosa. bimanually palpate lymph nodes 
    • upper airways may be examined if lesions are suspected using indirect pharyngoscopy and laryngoscopy (which uses a laryngeal mirror). you can visualize larynx and vocal cords for lesions and tissue mobility and take biopsies
    • CT scan or MRI can detect local and regional spred
    • Positron emisson tomography (PET) scanning is also used
  123. leukoplakia and erythoplakia
    • leukoplakia: white patch
    • erythroplakia: fiery red patch

    these may be found when examining the neck in head and neck cancer
  124. Staging of head and neck cancer
    • head and neck cancer is staged based on ...
    • Size of the tumor (T)
    • Number and location of involved lymph nodes (N)
    • Extent of metastasis (M)
    • this is called TNM staging
    • stages go from Stage 0 (carinoma in situ) through stage IV (spread to distant organs and tissues)
  125. treatment of head and neck cancer
    • based on  medical history, extent of disease, cosmetic consideration, urgency of treatment, patient choice
    • radiation
    • surgery
    • chemotherapy
    • brachytherapy (internal radiation)
  126. nursing management related to head and neck cancer
    • nutrition
    • care related to radiation therapy, surgical therapy, voice rehab (electrolarynx or esophageal speech), stoma care, depression, sexuality
Card Set
Upper Respiratory Problems
Exam of 9/23/19