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Trach and laryngeal CA

Terms in this set (65)

•Tracheotomy:
•Surgical incision into the trachea to establish an airway
•Tracheostomy:
•Stoma that results from the tracheotomy
tracheostomy
Slide note
On ventilator for a period of time, weening from a mechanical vent may be hard so need a trach
Surgical procedure-made in neck in cricroid cartilage
Percutaneous insertion-percutaneous incision into trachea at bedside, or by tracheologist
Patients can pull a percutaneous insetion out easier ! MAJOR Concern
Indications for a Tracheostomy
Tumor

Stenosis: subglottic, tracheomalacia

•Broncho Pulmonary Dysplasia

•Chronic pulmonary disease

•Chest wall injury

•Bypass upper airway obstruction
-Face trauma-get tracehsotomy due to largngeal edema


Facilitate removal of secretions


Long-term mechanical ventilation
-Neuro unit-c2 c3 spinal cord injruy (quadrelgic who are trached on vent)

Neuromuscular diseases, paralysis or weakening chest muscles and diaphragm


Aspiration related to muscle or sensory problems in the throat
notes
ALS, Gullian Barre, Myanthia Gravis on trach-because they loose resp musculature and need long term resp management

Parkinsons, Cerebro Ball Palsy with swalloing deficits get trach

Pts who had significant strokes get trach

Long term intubation not going anywhere get trach (decreases risk of VAP, comfortable)

CF, pulonary hyperplasia in pedi get trach

SIZE MATTERS-how they get air in and out of lungs, mobilize secretions, sunctionSize 6-8 most common for adults ; you ARE NARROWING AIRWAY pt needs more inspirtory voice for this airway
Advantages of Tracheostomy
•Less risk of long-term damage to airway
•Comfort increased
•Patient can eat as tube enters lower airway
•Increased mobility
Tracheostomy Tube with Inflated Cuff
Cuff infaltes to seal around the trachea-delivering air under pressure (take path of least resitance) -then comes out of trach tube , SO CUFF is essential to keep oxygenated tube down into rhonchi

Inner cannula

Obturator-used once trach Is put in
obturator and trach
•Care involves:
____ the airway to remove secretions

cleaning around _____ with ____

Changing ____

Inner ____ ___
sunctioning

stoma NS and H2O2 (half and half)

collar

innercannula care
When is suctioning indicated?_
•Coughing , visible secretions, high pressure alarm, rhonchi sounds
•Nursing judgement based on patients need


Could be once every couple of hours , tend to have lot more secretions cuz it bypasses upper oral
Cleaning stoma
•Know baseline of stoma-infection
•Pivot stoma and spin Q-tip around without moving trach itself
Inner cannula care
•Inside trach; locks in place, counter clockwise to unlock
•Lots of secretions they get dirty
•When in hosptial STERILE procedure, at home CLEAN
Adjust collar to patients neck -snug but don't want to occlude carotid -
helps hold trach in place
•Inner cannula care
Inner cannula-needs to be cleaned with speed,
Disposable more $ but take 5 seconds
Tube with inflated cuff is used for


should not exceed
risk of aspiration or in mechanical ventilation

Inflate cuff with minimum volume to create an airway seal
Should not exceed 20 mm Hg or 25 cm H2O
Note
Dressing help deal with secretions, draw away from skin, change this as many times as you want to keep this area
Trach care normally once a shift maybe once
3 times in 24 hrs?
PART OF THIS PROCESS- check cuff pressure; pressure causes breakdown; cause breakdown to tracheal walls (35 mm Hg) so not higher than 25 cm H20)
Disonnect bulb and you can measure pressure
Deflation

performed to _______

patient should _____

suction mouth and tube
remove secretions accumulating above the cuff

cough up secretions prior to deflation
Deflation notes
May do this as routine care (cuff integrity) , is there a leak??? Cuff not functioning no SEAL gotta replace
Cuff not sealed-air can come up vocal cords and patient can speak
Sunction oral pharynx-oral secretions, salivia in pt mouth at back of throat pull back trach-can possibly fall into lungs! (pneumonia!)
•Precautions in tube replacement

Tubes of _____ is kept at ____


Tapes are not changed for at lease ____ after insertion

First tube change is performed by ___ no sooner than __
•Tube of equal or smaller size is kept at bedside for emergency reinsertion - KEY !!!!!

24 hours

physician

7 days
Teach takes
Takes 4-5 days for stoma to become secure
•Accidental dislodging

Immediately ___

retention sutures grasped and opening spread
replace the tube

•Retention sutures placed in tracheal cartilage during tracheostomy
Notes
"Stay" sutures through skin and trachea so they can be pulled on with trach dislodged to put a new one in!
Think about it neck moves
After first tube change, it should be changed once a
MONTH
When tube has been placed for several months, healed tract will be
•well formed
Patient can be taught to change tube using
•clean technique at home
Notes
Percutaneous-no "stay" sutures
Clean procedure!!
Speaking Tracheostomy Tubes -
Fenestrated
Fenestrated tracheostomy tube
allows the patient to speak, breathe, or clear secretions from the upper airway.
Speaking Tracheostomy Tubes
Weaning off ventialtor-as able to support own ventialte oxygenation
Tracheostomy tubes and valves have been designed to facilitate speech -
•fenestrated trachs
-•Promote use to provide psychologic benefit and self-care
•Spontaneous breathing patient may be able to talk by deflating cuff, allowing exhaled air to flow over vocal cords
•Use of a Passy-Muir valve to cap the trach
Decannulation when
•When patient can adequately exchange air and expectorate
Stoma closed with __ and covered with ___
tape
occlusive dressing
Instruct patient to splint stoma with fingers when
coughing swallowing or speaking
Tissue forms in
•24 to 48 hours
Opening will close
in several days
Note
Deflated and eating and any concern of airway issue -ASPIRATE
most of time pt should have cuff inflated when eating
Week or two for stoma to be solid !
Head and Neck Cancer

arise ____

___ year old , men>women

___,___,____,____
•Arise from squamous cells
•50 - 60 year old, men > women
Tobacco, excessive alcohol, exposure to carcinogens, HPV
Early Manifestations

Ca larynx-hoarseness lating >__-

Lump in throat

____

___
2 weeks

change in voive

sore throat
Late signs
dysphagia, weight loss, pain
•Diagnostic Studies
•Larygnoscopy-observing larygngeal structure and biopsy gold standard!
•Biopsy
•CT, MRI
Note
Laryngeal cancer on the rise
Related to risk factors like smoking , carcinogens , Etoh ingestion
Primary risk factor HPV
Middle age caucasian men
High risk HPV testing on all oral or laryngeal issues

Know Sexual History and practices-oppurtunity for practices

Vocalized symptoms is a fairly bad sign and later stage tumor
Treatment based on
•on location of tumor, disease stage (I - IV), patient age and health, functional considerations (talking, chewing swallowing) and patient choice
Stage I & II
•radiation - external beam or brachytherapy (implanted iridium seeds)
Stage III & IV
•surgery, radiation and chemotherapy
Funcional considerations
Functional-eating
Pt can talk or eat again - G tube
•Surgical procedures
•Cordectomy

•Hemilarygectomy

•Supraglottic laryngectomy

•Supracriciod laryngectomy
surgical considerations
•Risk for aspiration

•Temporary trach

•Voice preserved - change in qulaity
Notes
Different procedures depending on lcoation, you are not taking everything out YOU ARE LEAVING SOME OF IT IN THERE, (little bit of crocoid) leaving some of the Larynx, icnreases risk of aspiration, trach for short time while surgical site heals, pt will have voice!
Partial procedures-that is the biggest concern is that they can speak, quality can chagne
•Total laryngectomy
•Larynx and preepiglottic region (take out)
•NO VOICE
Radical neck dissection
•- wide excision of lymph nodes and channels, may include SCM muscle, mandible
Modified neck dissection
•spare structures to avoid disfigurement, target cervical lymph channels
•Leave some of jaw stick to lymph nodes
Chemotherapy - with radiation for stages
3 and 4
•Cisplatin, docetaxel, 5-U
Problems
•Permanent trach
Loss of voice
•Nutritional issues•
•50% patients malnourished before treatment
•Enteral - PEG tube and tube feedings
•
Oral - Moist foods high in calories and protein
ONLY When epiglottis functions permanently , stoma healed


aspiration preautions

supraglottic swallow-take a deep breath then swallow then breath out
Notes
Stage 4 - lateral neck disessection of lymph nodes and cervical changes and sternoclastoid muscle part of jaw (radical neck resection)

Body image disturbance
•Nursing Assessment
•CC
•HPI
•PM/SH, including risk factors
•ROS
•Nursing Diagnoses
•Ineffective airway
clearance
•Risk for aspiration
•Anxiety
•Pain
•Impaired verbal
communication
•Altered body image
Planning
Goals
•Nursing Implementation
Health Promotion
•Tobacco, alcohol
•Oral hygiene, safe sex
•-Dental dams
•Acute intervention
...
•Radiation
•Dry mouth
•Mucositis-cnaker sores-lidocaine
•Fatigue
•Surgery
•Pre and post op planning and teaching
•
Communication
• Voice rehab
• Electrolarynx, hands free devices
• Esophageal speech-talking when burp
• Transesophageal puncture-for air to pass through and make some sound
•Stoma care
•Depression, Sexuality
•Self care management
Note
Not a death sentence
They don't have a voice whats more important AIRWAY trump impaired verbal
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