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Respiratory Lecture (Part 1): MedSurg Test 2 Sem 4 Spring 2021
Terms in this set (128)
What are some risk factors for head & neck cancer?
alcohol & tobacco; industrial exposure; sun exposure; HPV; excessive smoked meat ingestion; poor oral hygiene; men >50y.o.; if <50y.o. assoc. w/ HPV
What is important to educate you patient on about head & neck cancer?
most are preventable; abstinence from tobacco/alcohol; good oral hygiene; safe sex
What are SSx of head & neck cancer?
white/red patches in mouth (leuko/erythroplakia); non healing ulcer; change in denture fit; lump in throat; change in voice/hoarseness >2wks; unilateral ear pain; lumps/swelling in neck; sore throat; hemoptysis
what are early Sx of head/neck cancer?
few Sx in early stages (mainly advanced upon Dx); hoarseness >2wks (sign of laryngeal cancer)
what are late Sx of head/neck cancer?
unintentional wt loss; difficulty chewing/swallowing/moving tongue or jaw; difficulty breathing; airway obstruction
How is head/neck cancer Dx?
inspect oral cavity (under tongue/dentures); look for thickened mucosa; bimanually palpate nodes of the neck; leukoplakia & carcinoma in situ may precede invasive carcinoma by yrs
how is head/neck cancer staged?
if lesions are suspected, how do we Dx head/neck cancer?
follow up indirect pharygnoscopy & laryngoscopy to visualize larynx & vocal cords; multiple Bx; CT/MRI (spread); PET
What is the first line Tx option for head/neck cancer?
this kind of surgical Tx for head/neck cancer is where the outer tissue layer of vocal cords are removed but it rarely affects speech
vocal cord stripping
this type of surgical Tx for head/neck cancer is where endoscope laser inserted into the throat to vaporize/remove tumor
this type of surgical Tx for head/neck cancer is where part/all of vocal cords are removed; if partial then could cause hoarseness; if all then speech is impossible
this type of surgical Tx for head/neck cancer is where removal of the tongue is removed can cause speech deficit
this type of surgical Tx for head/neck cancer is where half of the tongue is removed and can cause speech deficit
this type of surgical Tx for head/neck cancer is where part/all of the larynx is removed; total= air now enters thru stoma->need humidifier->normal voice production is impossible; dont use straws
this type of surgical Tx for head/neck cancer is where part/all of throat is removed
this type of surgical Tx for head/neck cancer is where an alternate pathway for breathing via stoma in trachea
this type of surgical Tx for head/neck cancer is where all tissue from mandible to clavicle is removed (including nerves/muscle/glands/blood vessels)
radical neck dissection
this type of surgical Tx for head/neck cancer is where all lymph nodes are removed but less tissue taken out (may spare nerves/blood vessels/muscles)
modified radical neck dissection (most common)
this type of surgical Tx for head/neck cancer is where few lymph nodes are removed w/ muscle/vessels/nerves spared; for pt where cancer hasnt spread far
selective neck dissection
this Tx for head/neck cancer is preferred for pt w/ early stage (no node involvement); used alone or w/ surgery
this Tx for head/neck cancer is combined w/ radiation for stages 3 & 4; cetiximab (Erbitux) is used for late stage to stop cancer cells from growing
how do we Tx malnutrition in a head/neck cancer pt?
prophylactically place gastrostomy tube for high risk pt; monitor wt loss; antiemetics/analgesics before meals; bland foods are easy to tolerate; dry milk added for calories; mild sauces/gravies increase calories & moisten food; elevate HOB; ST swallow study (if low risk then thickened liquids/pureed foods w/ High fowlers); avoid thin/watery fluids; watch for choking & have suction ready
why does a head/neck pt go to PT?
begin immediately post op to maintain strength/movement in shoulders & neck to prevent shoulder drop/weakness
this type of voice restoration for a head/neck cancer pt is a hand held/battery powered device using sound waves to create speech
what are the pros/cons of electrolarynx?
pros: immediately available after surgery; easy to use; little maintenance
cons: mechanical sound quality
this type of voice restoration for a head/neck cancer pt is where a fistula is created in transesophageal wall to divert air across mucosa->phonation when tracheostoma is occluded; one-way valve prosthesis (Blom Singer) to prevent aspiration; pt manually blocks stoma w/ finger to speak
what are the pros of TEP?
best speech quality; high satisfaction
this type of voice restoration for a head/neck cancer pt is when air is introduced to esophagus and expelled past pharyngoesophageal segment
what are the cons of esophageal speech?
a lot of time to learn; voice quality reduced
What are possible findings w/ someone who has head/neck cancer?
hoarseness, chronic laryngitis, nasal voice, palpable mass, tracheal deviation, dyspnea, stridor (late Sx), white/red patches, ulceration, asymmetric tongue, exudate in mouth, thickened mucosa, positive Bx
what are the nursing goals when caring for a pt w/ head/neck cancer?
no spread, no complication r/t therapy, nutrition, minimal pain, communication, body image, support system, employment
what is the nursing care pre-op for head/neck cancer Tx?
oral hygiene; develop plan of communication post op
what is the nursing care immediately post-op for head/neck cancer Tx?
airway management; pain (FACES); hemodynamic monitoring (risk of hemorrhage); wound care, nutrition, communication, psych (body image)
How is the nurse supposed to care for a pt post-op for head/neck cancer Tx to keep airway patency in a laryngectomy pt specifically?
frequent suction trtach; after vent weaned & trach removed; stoma healed=laryngectomy removed; reinsert w water soluble lubricant (KY- NOT VASELINE); removed &cleaned daily
How is the nurse supposed to care for a pt post-op for head/neck cancer Tx to keep airway patency?
semi-fowlers; secretions start copious blood tinged->diminish & thicken; adequate fludis/humidification; TCDB
if respiratory distress post-op for a pt w/ head & neck cancer Tx happens, what does the nurse do?
insert trach & connect to AMBU bag/vent; facial O2/oral intubation/nasal intubation=worthless (air will just flow out of stoma)
How is the nurse supposed to care for a pt post-op for head/neck cancer Tx for wound care?
DONT CHANGE DRESSING W/OUT ORDER; skin flaps= no dressing for better visualization (check qh for color/size/edema); doppler for pulses; drains (initially bloody-.serosang->decrease in vol over 24h; check patency q4h; after drains removed monitor for swelling & infection)
How is the nurse supposed to care for a pt post-op for head/neck cancer Tx to maintain proper nutrition?
NGT placed for intermittent suction first 24-48hpost op until peristalsis returns; DO NOT MANIPULATE/MOVE tube
Radiation therapy for head/neck cancer has many SE. how does the nurse care for xerostomia (dry mouth)?
within few wks; pilocarpine hydrochloride (Salagen) to increase saliva production; increase oral fluid; chew sugarless gum/candy; nonalcoholic mouth rinse; artificial saliva; fluoride gels to prevent decay; always carry water bottle
Radiation therapy for head/neck cancer has many SE. how does the nurse care for oral mucositis?
irritation/ulcer/pain; soft toothbrush/floss; prevent radiation scatter w/ bite block/empty fluoride tray/mouth guards; warm/bland rinse (salt & baking soda 4-6x/day); suck on ice chips; avoid commercial mouthwash/hot/spicy/acidic foods
Radiation therapy for head/neck cancer has many SE. how does the nurse care for skin irritation?
reddened/sensitive; use prescribed lotion only; dont use lotion w/in 2h of Tx
Radiation therapy for head/neck cancer has many SE. how does the nurse care for fatigue?
common SE; walk 15-30min/day & complete activities most important to you; rest when energy low; ask for help if needed
Radiation therapy for head/neck cancer has many SE. how does the nurse care for stoma?
teach proper care before DC; wash around stoma daily w/ warm/moist cloth; alkalol (nasal wash spray) q1-2h to keep stoma moist; remove dried secretions w/ tweezers; cover stoma w/ coughing/exercise; cover stoma w/ plastic collar to shower (avoid swimming); humidifier
Laryngectomy: remove entire tube daily & clean same as trach; inner cannula cleaning prn
What should be taught to the pt w/ head/neck cancer in reference to care after DC?
self-care participation; home health will come evaluate; how to manage NGT/trach; pictorial guides; medic alert bracelet; install smoke/carbon monoxide detectors (smell lost); colorful/attractive/nutritious foods (taste semi lost); exercise/sex resumed when pt able; return to work 1-2mo post-op; loss of speech; inability to produce sounds; permanent stoma w/ mucus production; significant other's reaction
this respiratory disorder is characterized by elevated pulm. artery pressure d/t increased resistance to blood flow; MPAP >25 at rest or >30 with exercise; manifests w/ SOB/fatigue; primary or secondary
what is the normal MPAP? (mean pulm. arterial pressure)
this type of pulm. HTN has no apparent cause; aka primary pulm. HTN; progresses rapidly to R sided HF & death; incurable; assoc. w/ CT diseases, cirrhosis, HIV; females
idiopathic PAH (IPAH)
what are the SSx of IPAH?
classics=dyspnea on exertion & fatigue
others: dizziness, syncope, exertional chest pain, S3
Progression->dyspnea at rest, increased RV workload->hypertrophy of RV (cor pulmonale)-> Rsided HF
d/t inability of CO to increase in response to increased O2 demand
How is pulm. HTN diagnsoed?
R-sided cardiac cath is definitive (measures MPAP, CO, pulmonary vascular resistance); work up of EKG/CXR/pulm. function test/echo/CT
What should we teach a pt to report for pulm. HTN?
unexplained SOB, syncope, chest discomfort, edema of feet/ankles
what is included in the drug therapy for pulm. HTN?
CCB (not if already has HF); phosphodiesterase inhibitors (not w/ oral NTG); parenteral vasodilators (dont stop abruptly); inhaled vasodilators (6-9x/day via nebulizer; hold if SBP <85); endothelin receptor antagonists (monitor liver); diuretics; anticoags; O2 (90 or greater)
What is the surgical Tx for IPAH?
atrial septostomy (AS): palliative (no cure) until lung transplant; RtoL shunt to decompress RV
lung transplant for pt w/ severe Rsided HF
recurrence not reported
this type of pulmonary HTN results when a primary condition causes a chronic increase in PAP (sarcoidosis, pulm fibrosis, LV dysfunction, intracardiac shunts, chronic pulm thromboembolism, RA, lupus)
secondary PAH (SPAH)
your pt w/ SPAH presents with these Sx:
dyspnea, fatigue, lethargy, chest pain (specific to SPAH)
RV failure (increased pulmonic sound, S4, peripheral edema, hepatomegaly)
how do we Dx SPAH?
similar to IPAH (right heart cath definitive)
How do we Tx SPAH?
Tx underlying prob; if irreversible damage then IPAH therapy initiated; if d/t thromboembolism then PTE (pulm thromboendarterectomy) may be curative but it's a difficult procedure
this CV/respiratory disorder is RV enlargement d/t primary disorder of resp system; pulm HTN usually preexisting; can happen w/ or without HF; most common cause COPD
your pt w/ cor pulmonale presents with these Sx:
subtle & masked by underlying pulm prob
exertional dyspnea, tachypnea, cough, fatigue (common); RVF hypertrophy on EKG, increased intensity of S2, polycythemia (if 2ndary to COPD), increased blood vol/viscosity; if HF=peripheral edema, wt gain, JVD, bounding pulse, hepatomegaly
how do we Tx cor pulmonale?
treat underlying prob; long term O2 for hypoxemia; correct fluid/lyte & acid/base; diuretics (caution: can worsen heart function); bronchodilators (if COPD); vasodilators, CCB, inotropic agents, Low Na diet
this respiratory disorder is hypoxia resulting from submersion of liquid; kids <5 or males 15-25 y.o.; risk factors include inability to swim, alcohol/drugs, trauma, seizures, hypothermia, stroke, child neglect
submersion in __ water may slow progression of hypoxic brain injury
cold (has better chance of regaining neuro function)
this submersion injury is the process of respiratory impairment after submersion; most victims dont aspirate liquid d/t laryngospasm (if they do->pulm edema->ARDS)
when a person has a submersion injury in __water, water rapidly leaks into capillary bed & circulation-> destroys surfactant & capillary membrane->ARDS. increased risk of infection d/t contaminated water
What might a person w/ a submersion injury present with?
ineffective breathing, coughing frothy/pink sputum, dyspnea, respiratory distress/arrest, rhonchi, crackles, cyanosis, tachy/bradycardia, dysrhythmias, hypotension, cardiac arrest, panic, exhaustion,, coma, MI/c-spine injuries, T abnormalities
What should be the nurse's initial interventions when a pt comes in with a submersion injury/dorwning?
ABCs; assume c-spine injury present & stabilize; 100% O2 AMBU bag or NRB; prepare for intubation/vent; IV access x2 large bore w/ warmed fluids; 12lead EKG; assess for other injuries; remove wet clothing & apply warm blankets; T & rewarm; c-spine & CXR; insert GT & urinary cath
what should be continuously/closely/often monitored w/ a submersion injury?
ABC, VS, LOC, heart rhythm, T, Sx of acute resp failure (vent & O2 primarily)
what is included in the nursing care for a submersion injury/drowning pt?
correct hypoxia & fluid imbalances; rewarm; if pulm edema present=mech vent w/ PEEP or CPAP; mannitol or furosemide for cerebral edema/decrease free water; constant neuro checks (decreased mental status=cerebral edema, worse hypoxia, profound acidosis); prolonged injuries=altered LOC;; should be observed for minimum 23h
what can the nurse teach to prevent submersion injuries?
water safety, lock pool gates, swimming lessons, life vests, dangers of combining alcohol/drugs and water/swimming
when a person has a submersion injury in __water, the fluid is drawn from vasculature to alveoli->impaired ventilation->hypoxia. the body compensates by shunting more blood to lungs only making PAP worse & hypoxia worse (not well O2 blood)-> cerebral injury edema, brain death. this water destroys surfactant and alveolar-capillary membrane
this type of artificial airway is when a tube is placed in trachea via mouth or nose; more common in ICU; can be done at bedside
endotracheal intubation (ET)
why would someone need to have an ETT?
upper airway obstruction, apnea, high risk aspiration, ineffective secretion clearance, resp distress
what is the difference btwn oral and nasal ET intubations?
oral: preferred, requires laryngoscope/bronchoscope to visualize cords
nasal: blind placement
why is oral ET intubation preferred?
rapid securement of airway, larger diameter->less airway resistance->decreased work of breathing, easier suctioning, allows for bronchoscopy
why would we use a nasal ET intubation?
unstable c-spine injury, dental abscess, epiglottitis
what are the risks of oral intubation?
head/neck mobility limitations make placement difficult; chipped teeth; difficulty swallowing (saliva is increased when placed); oral care (limited space-need peds size); obstruction of tube by biting (place bite block-secure ETT and bite block separately)
What is the nurse to do before an ET intubation?
consent (unless emergent); explain procedure/reason; pt wont be able to speak (other communication methods); mitts to prevent self-extubating; have BVM/AMBU bag attached to O2 (90-95%), suction equipment, IV access; assemble & check equipment (laryngoscope light, ETCO2 detector, ETT stylet w/ 10ml syringe for cuff inflation); remove dentures; sedative them paralytic; oxygenate pt 100% 3-5min; limit intubation attempts to 30sec each; provide breaths btwn attempts
how should a pt be positioned for ET intubation oral & nasally?
oral: supine, head extended, neck flexed (sniffing)
nasal: spray passages w/ local anesthetic & vasoconstrictor (lidocaine w/ epi)
this is the rapid administration of sedative followed by paralytic during emergency; midazolam or etomidate & rapid onset opioid (fentanyl); succinylcholine (paralytic)
rapid sequence intubation (RSI)
what is RSI used for?
decreases risk of aspiration to injury; not used for cardiac arrest or pt known to have difficult airway (dont want them to not be able to breathe on their own); need to monitor SpO2 during procedure
after an ETT is in place, what do you do?
inflate cuff (#1); confirm placement while venting w/ BVM using ETCO2 detector (attached to end of BVM, color/numerical rating, if no CO2 then in esophagus & need to replace); auscultate over epigastrium (shouldnt hear air bolus) then lungs for bilateral/equal breath sounds (if on one side=right mainstem intubation; went too far); watch chest wall for symmetry; SpO2 stable/improved
if findings confirm ETT placement, what should be done next?
connect to vent; secure ETT; suction & bite block; CXR immediately (2-6cm above carina); document & mark position at lip/teeth (21-23 cm); cut extra tubing to remove dead air space; ABGs q15-30min, continuous pulse ox (oxygenation status), ETCO2 (ventilation status)
the RT & nurse share the responsibility of managing the artificial airway. what is the nurse's role?
correct placement, proper cuff inflation, O2 & ventilation, patency, oral care, skin integrity, comfort/communication, assess for complications
how is the nurse going to maintain correct tube placement?
cont. monitor placement (cm; esp after moving pt); watch for symmetric chest mvmt; auscultate breath sounds; failure to reposition a dislodged tube->minimal/no O2 to lungs or right mainstem->pneumothorax
how is the nurse going to maintain cuff inflation?
over inflation=damage to mucosa (measure & monitor cuff pressure (20-25manometer); MOV & MLT techniques
what is the MOV technique for proper cuff inflation of an ETT?
palce stethoscope over trachea and inflate cuff until no air leak heard; pt spontaneously breaths (place stethoscopre over trachea until no sound heard after deep berath/inhalation); manometer=20-25; document (if pressure not maintained/adequate->notify MD)
what is the MLT technique for proper cuff inflation of an ETT?
similar to MOV but remove small amt of air from cuff until slight air leak heard at peak inflation
how does the nurse adequately monitor O2?
what are signs of hypoxemia?
mental status change, anxiety, dusky skin, dysrhythmias
how does the nurse adequately monitor ventilation?
PaCO2, continuous PETCO2
what are signs of hyperventilation?
rapid/deep breaths, circumoral/peripheral numbness & tingling
what are signs of hypoventilation?
slow/shallow breaths, dusky
this method of monitoring ventilation analyzes exhaled gas; continuous assessment of airway patency and presence of breathing; usually 1-5 lower than PaCO2
how is the nurse going to maintain tube patency w/ an ETT?
regularly assess and suction PRN
what are reasons a pt with an ETT would need suctioning?
visible secretions, sudden onset of resp distress, aspiration, increased RR w/ or w/out coughing, sudden decrease in SpO2, increased PAP, adventitious breath sounds over trachea/bronchi
suction systems can be open or closed. what is a closed system?
catheter enclosed to plastic sleeve for sterility and connected directly to vent circuit; O2 & ventilation maintained during suctioning, exposure to secretions and risk of infection reduced
what are potential complications of suctioning w/ an ETT?
hypoxemia (limit suction passes to 10sec each); bronchospasm; increased ICP; dysrhythmias (dont suction if hypoxemic/bradycardic); HTN/hypotension; mucosal damage; pulm bleeding; pain; infection
the pt w/ an ETT isnt tolerating suction. what does the nurse do?
stop; hyperoxygenate pt; reassess until stable
how should the nurse manage thick secretions with an ETT?
hydrate, humidify, dont instill NS unto ETT, ABx (if infection present) turn q2h
how is the nurse going to provide oral care with an ETT?
mouth always open=moisten lips/tongue/gums w/ saline/water swabs; use peds tools for proper care
how is the nurse going to maintain skin integrity w/ an ETT?
reposition and resecure ETT prn
oral: remove bite block->provide oral hygiene->reposition ETT to other side of mouth->replace bit block->confirm placement & cuff inflation->resecure ETT
nasal: dont switch sides=remove tape, clean skin around ETT w/ saline soaked gauze, re-tape
commercially available ETT holders may __ risk of skin breakdown
how is the nurse going to provide comfort/communication w/ an ETT?
picture boards, notepads, whiteboards, keyboards; sedate & analgesia (FACES for pain & sedation scale); music therapy
How should ETT repositioning be done?
limited to RT; 2 staff members; monitor Sx of resp distress
what are 2 major complications of ET intubation?
unplanned extubating & aspiration
this happens when the pt removes/accidental removal or ETT can be catastrophic; watch for migration of cm marking
what does the nurse do to prevent unplanned ETT extubating?
ensure securement, support/observe tube during procedures/repositioning/transfers, sedation/analgesia, soft wrist restrains not an absolute deterrent
what does the nurse do if unplanned extubation occurs?
stay with pt (#1); call for help, maintain airway, manually ventilate w/ BVM 100%OR (ALWAYS have BVM handy), secure assistance to reintubate, psych support
this happens when the ETT splints the epiglottis open and pt cant protect airway from aspiration b/c the secretions collect above the cuff and enter the lungs when cuff is deflated
what are some contributors to aspiration w/ ETT
improper cuff inflation; pt positioning (HOB should be 30-45); decreased gastric motility and bowel function w/ tube feedings (OGT preferred to reduce risk of sinusistis)
this is a surgically created opening in anterior trachea for est patent airway, bypass upper airway obstruction, facilitate secretion removal, permit long-term mech vent, facilitate weaning from mech vent, and if emergency ET can't be placed
what are the benefits of a tracheostomy?
shorter & wider; easier to clean; better oral/bronchial hygiene; more comfortable (tube not in mouth); less risk of long term cord damage
what are the parts of a tracheostomy?
faceplate (flange); obturator (aids insertion); outer cannula (keeps airway patent); inner cannula (removed for cleaning; disposable or nondisposable)
what is the difference btwn a cuffed & uncuffed tracheostomy?
cuffed: most common; keeps trach in place; if pt needs mech vent/risk of aspiration
uncuffed: allow eating/talking; or pt w/ long-term tracheostomies
the outer cannula on a trach can be fenestrated or nonfenestrated. what is fenestrated?
hole on surface of tube allows pt to breath spontaneously which allows for speaking when tube in place (cuff inflated=no air to vocal cords); for pt with prolonged mech vent; done in OR under general anesthesia or percutaneous trach (newer; but both can be done bedside or OR)
how is a fenestrated trach done?
vertical incision->trach tube inserted->incision sutured->sterile dressing applied
what is the percutaneous tracheostomy (new technique)?
local anesthesia & sedation->video assisted to insert needle into trachea->dilator over needle to open larger and larger->trach inserted; decreased bleeding risk and fewer post-op complications
If done at the bedside, what is the nurse's role with a tracheostomy?
ensure appropriate personnel (RT); have resuscitation equipment available (and BVM); record VS; ensure working IV & suction; assemble & set up equipment; position supine; analgesia & sedation; observe pt tolerance
if assisting with a trach placement, what does the nurse do?
place obturator inside outer cannula w/ rounded tip protruding from end of tube; after insertion immediately remove obturator; keep obturator available in case of accidental removal
immediately after a trach is placed, what is done?
cuff inflated, lung sounds; if ETT present then remove it after trach placement confirmed; suture trach in place & secure ties/Velcro/tape
what are potential complications of trach placement?
airway obstruction, bleeding, infection
what is the nurse's role after a trach is placed?
monitor & document VS (SpO2 should be stable); document vent settings; observe amt of blood at site (notify MD if bleeding persists); CXR; share responsibilities w/ RT; assess site qshift at least (redness/inflammation/edema/ulceration/infection; clean stoma w/ NS; sterile pre-cut dressing qshift); monitor cuff inflation pressure (same as ETT); suction prn (dont suction in first few hr after placement); humidify
what is the care for the inner cannula?
nondisposable=clean qshift at least
how should trach tapes be changed?
after 1st 24h then prn; 2 people; after placement put 2 fingers under tapes to ensure they arent too tight
when repositioning the pt with a trach, it is important to be careful not to dislodge the tube. what are some precautions the nurse should take?
keep replacement tube of smaller size at bedside; dont change tapes for 24h after insertion; HCP performs first tube change no sooner than 7d after trach (if necessary)
there is an accidental dislodgement of a newly inserted trach. what should the nurse do?
stay with pt; immediately call for help (HCP & RT); option A=hemostat->spread opening->insert obturator->lubricate w/ saline->insert tube into stoma->remove obturator immediately;
option B=sterile suction inserted->thread trach over catheter->remove catheter; if tube cant be replaced=monitor pt for resp distress and put in semi-fowlers
if respiratory distress occurs after an accidental dislodgement of newly inserted trach, what should the nurse do?
cover stoma w/ sterile dressing & ventilate BVm over mouth/nose; if pt w/ total laryngectomy=ventilate thru stoma)
how is the nurse to maintain nutritional therapy with a trach?
long term trach may get to eat normal once stoma heals; swallow study/ST; pt tilt head forward slightly to help swallow/prevent aspiration; diet may be soft/thickened liquids (avoid thin/watery fluids)
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