Adult Health 1 Module 3 Part 1 PDF

LeMone & Burke’s Medical-Surgical Nursing: Clinical Reasoning in Patient Care Seventh Edition Chapter 35 Nursing Care of Patients with Upper Respi...

LeMone & Burke’s Medical-Surgical Nursing: Clinical Reasoning in Patient Care Seventh Edition Chapter 35 Nursing Care of Patients with Upper Respiratory Disorders Slides in this presentation contain hyperlinks. JAWS users should be able to get a list of links by using INSERT+F7 Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Learning Outcomes 35.1 Infectious and Inflammatory Disorders Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. 35.2 Upper Respiratory Trauma or Obstruction Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders. 35.3 Upper Respiratory Tumors Describe the pathophysiology and manifestations of upper respiratory tumors and outline the interprofessional care and nursing care of patients with upper respiratory tumors. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Infectious or Inflammatory Disorders Rhinitis Acute viral rhinitis Allergic rhinitis Vasomotor rhinitis Atrophic rhinitis URI or the common cold Most common respiratory tract infections are highly contagious, with peak incidence in September, late January, and late April Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology of Infectious or Inflammatory Disorders Associated viral strains – Rhinoviruses, adenoviruses, parainfluenza viruses, coronaviruses, and respiratory syncytial virus Usually spreads when the hands and fingers pick it up from contaminated surfaces and carry it to eyes, mucous membranes of the susceptible host Local inflammatory response Swelling of mucous membranes of nasal passages Hyperactivity of mucus-secreting glands Immunity produced only to individual virus Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Manifestations and Complications of Infectious or Inflammatory Disorders Nasal mucus membranes appear red and boggy. Swollen mucous membranes, local vasodilation, and secretions cause nasal congestion. Sneezing, sore throat, and coughing are common. Coryza Infrequent symptoms include low-grade fever, headache, malaise, and muscle aches. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Diagnosis and Treatment of Infectious or Inflammatory Disorders Diagnosis – Possible testing if bacterial infection is suspected Treatments – Medications ▪ Treat symptoms ▪ Experimental vaccines in development – Complementary therapies ▪ Echinacea Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Medications to Treat Infectious or Inflammatory Disorders Medications – Prophylaxis – Treatment to reduce severity ▪ Mild decongestants, antihistamines – Symptom relief includes complementary therapies Complementary therapies – Herbal remedies ▪ Echinacea ▪ Garlic – Dietary supplements ▪ Vitamin C ▪ Zinc – Aromatherapy Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Infectious or Inflammatory Disorders Health promotion – Limit exposure to crowds – Good hand hygiene – General good health/stress reduction activities – Myths of causes – Education Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with Respiratory Syncytial Virus (RSV) Primary cause of respiratory illness in infants and children Common cold in older children and adults Can cause severe illness or death in immunocompromised individuals Transmission same as other URIs Incubation period is 4-6 days Adult manifestations as with URIs In older adults, can present as lower respiratory infection, fever, or pneumonia In infants, can manifest as a URI, but more likely to progress to pneumonia, bronchiolitis, and tracheobronchiolitis in adults Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Treatment of RSV Hydration, mobilization of respiratory secretions Aerosolized ribavirin (Virazole) may be prescribed for older adults and immunocompromised patients with RSV pneumonia. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with RSV Nursing care – Supportive – Teaching for self-care – Identification of complications – Prevention of viral spread Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with Influenza A highly contagious viral respiratory disease that usually occurs in epidemics or pandemics The avian flu has caused a pandemic. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology of Influenza Three major strains – Influenza A, B, and C viruses ▪ Influenza A most common – H1N1 Airborne droplet, direct contact Incubation period of 18-72 hours Virus invades respiratory epithelium, rapidly spreads to neighboring cells Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Manifestations of Influenza Rapid onset – Malaise can develop in minutes Systemic manifestations – Abrupt onset of chills and fever, malaise, muscle aches, and headache Dry, nonproductive cough – Cough can be severe and productive, last for days or several weeks Sore throat Substernal burning Respiratory manifestations – Coryza – Acute symptoms subside in 2-3 days – Fever can last a week Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Complications of Influenza Secondary bacterial infections Sinusitis, otitis media, tracheobronchitis Pneumonia Reye syndrome Older adults – Seasonal influenza – Importance of vaccinations for this population – Optimal time of year to vaccinate is October Uncommon – Myositis – Myocarditis – Encephalitis – Guillain-Barré syndrome Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Goals of Interprofessional Care for the Patient with Influenza Preventing community outbreaks Treatment Prevention Diagnosis Medications Yearly immunization Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Priority Interventions for the Patient with Influenza Prevention – Protecting vulnerable populations – Immunization recommended for: ▪ Those over 65 years ▪ Residents of nursing homes ▪ Those with chronic cardiopulmonary disorders ▪ Those with chronic metabolic diseases ▪ Healthcare workers Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Diagnosis and Treatment of Influenza Diagnosis – History, clinical findings, and knowledge of outbreak in the community Medications – Yearly immunization with influenza vaccine ▪ Severe reactions rare – Amantadine (Symmetrel) or rimantadine (Flumadine) may be used as prophylaxis in unvaccinated people exposed to the virus – OTC drugs such as ASA, acetaminophen – NSAIDs for symptomatic relief – Antitussives can decrease cough – Antibiotics are not indicated Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Influenza Diagnoses, outcomes, and interventions – Ineffective Breathing Pattern – Ineffective Airway Clearance – Disturbed Sleep Pattern – Risk for Infection Continuity of care – Encourage appropriate self-care – Discuss home care Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with Sinusitis Inflammation of mucous membranes of one or more sinuses Physiology review – Air-filled cavities lined with ciliated mucous membranes – Normally sterile Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology of Sinusitis Viruses Streptococci, S. pneumoniae, Haemophilus influenzae, and staphylococci Higher risk to patients with HIV – Common and difficult to treat in patients with AIDS Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Manifestations of Sinusitis Headache, fever, malaise Pain across infected sinuses – Frontal sinusitis ▪ Pain in lower forehead – Maxillary sinusitis ▪ Pain in the cheek – Ethmoid sinusitis ▪ Pain over high lateral aspect of nose and retro-orbital pain – Sphenoid sinusitis ▪ Pain in occiput, vertex, or middle of the head – Acute sinusitis ▪ Pain usually constant and severe – Chronic sinusitis ▪ Pain is usually dull and can be constant or intermittent Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Complications of Sinusitis When infection spreads to surrounding structures Periorbital abscess or cellulitis Cavernous sinus thrombosis Meningitis Brain abscess Sepsis Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Diagnosis and Goal of Care for the Patient with Sinusitis Restoring drainage, controlling infection, relieving pain, and preventing complications Diagnosis – Acute ▪ History and physical exam – Chronic ▪ CT scan or, less frequently, sinus x-rays Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Treatment of Sinusitis Medications – Antibiotics – Topical steroids – Decongestants – Antihistamines – Systemic mucolytic agents – Aerobic exercise to promote mucous flow Surgery – Endoscopic sinus surgery – Antral irrigation – Caldwell-Luc procedure – External sphenoethmoidectomy Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Complimentary Therapies for Sinusitis Complementary therapies – High-volume, low-pressure nasal irrigation ▪ Neti pots – Aromatherapy ▪ Vaporizer, handkerchief – Hot, cold compresses – Steam inhalation – Acupressure Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 35.1 Incision to access ethmoid and frontal sinuses. Resulting scar is nearly invisible in folds of the eye. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Sinusitis Assessment – Healthy history – Physical examination – Diagnostic tests Diagnoses, outcomes, and interventions – Pain Imbalanced Nutrition: Less Than Body Requirements Continuity of care – Following through with appropriate treatment and promoting comfort – Educating patient and family – Postoperative instructions Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with Pharyngitis or Tonsillitis Pharyngitis – An acute inflammation of pharynx – Group A beta-hemolytic streptococcus (GABHS) (strep throat) most common cause Tonsillitis – An acute inflammation of palatine tonsils – Usually due to streptococcal infection Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 35.2 The appearance of the oral pharynx and tonsils in acute pharyngitis and tonsillitis. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology of Pharyngitis or Tonsillitis Pathophysiology and manifestations – Spread by droplet nuclei – Incubation periods of a few hours to several days, depending upon causative organism – Symptoms typically resolve 3-10 days after onset. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Manifestations of Pharyngitis or Tonsillitis Pathophysiology and manifestations – Viral pharyngitis ▪ Gradual onset ▪ Rhinovirus, coronavirus, parainfluenza – Acute pharyngitis ▪ Pain, fever ▪ Scratchy or painfully sore throat – Streptococcal pharyngitis ▪ Abrupt onset, similar symptoms – Tonsillitis ▪ Tonsils bright red, edematous ▪ White exudate ▪ Sore throat, difficulty swallowing ▪ General malaise, fever, otalgia Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Complications of Pharyngitis or Tonsillitis Peritonsilar abscess (quinsy) – GABHS infection extends to surrounding tissue Abnormal immune responses – Acute glomerulonephritis – Rheumatic fever Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Diagnosis of Pharyngitis or Tonsillitis Throat swab – LA or ELISA testing CBC – Severely ill patients – Rules out other causes of pharyngitis Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Medications for Pharyngitis or Tonsillitis Antibiotics for bacterial infections Antipyretics Mild analgesics Peritonsillar abscess – Needle aspiration, incision, and drainage – Topical, local anesthetics Tonsillectomy – Adenoid tissue usually removed Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Pharyngitis or Tonsillitis Risk of significant complications – Encourage patients with enduring systems to seek evaluation, treatment Home care – Acute uncomplicated pharyngitis Following tonsillectomy – Ensure patent airway – Ice collar to reduce swelling, pain – Liquid, semiliquid diet Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with a Laryngeal Infection Epiglottitis – Progressive cellulitis – Base of tongue and epiglottis – Medical emergency; airway could be threatened – Laryngitis – Pathophysiology ▪ Inflammation, swelling pushes epiglottis posteriorly ▪ Possible airway obstruction Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Manifestations of Laryngeal Infection 1- to 2-day history of sore throat Painful swallowing Dyspnea Drooling Stridor Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with a Laryngeal Infection Epiglottitis is frightening; maintain a calm and reassuring manner Focuses on monitoring and maintaining airway patency Monitor oxygen saturation continuously Observe closely for signs of airway obstruction Emergency intubation supplies Patient's impaired ability to speak Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Laryngitis Inflammation of the larynx Occurs alone or with another URI Can be acute or chronic Pathophysiology – Mucous membrane lining of larynx becomes inflamed – Vocal cord edema Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Manifestations of Laryngitis Sore scratchy throat, odynophagia, dyspnea, and possibly drooling and stridor Change in voice quality Dry, harsh cough Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Diagnosis of Laryngitis The epiglottis appears red, swollen, and edematous Nasotracheal intubation may be required to ensure airway patency Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Laryngitis No specific treatment for laryngitis Reducing exposure to precipitating factors Vocal rest Inhalation of steam Spray throat with antiseptic solution Impaired verbal communication Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with Diphtheria Acute, contagious disease caused by Corynebacterium diphtheria Uncommon in the United States Disease spread – Droplet nuclei – Contamination of articles such as eating utensils – Areas where sanitation is poor Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology and Manifestations of Diphtheria Pathophysiology – Tonsils, pharynx common site of infection – Thick, grayish, rubbery pseudomembrane forms over posterior pharynx/trachea Manifestations – Fever – Malaise – Sore throat – Malodorous breath – Lymphadenopathy – Stridor – Cyanosis Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Diagnosis of Diphtheria Diagnosis confirmed by throat culture, Gram-stain, or immunofluorescent antibody stains Strict patient isolation procedures All contacts screened, immunized Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Medications for Diphtheria Antitoxin – After a skin test for sensitivity Antibiotics Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Diphtheria Intensive Bed rest, monitor closely for airway obstruction, cardiac manifestations, and CNS complications Equipment for suction, emergency intubation, and tracheostomy kept at bedside Nutrition and fluid balance Prevent transmission Treat infection Neutralize toxins Provide respiratory support Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with Pertussis Whooping cough Highly contagious Bordetella pertussis Aggressive immunization of infants but still occurs in North America Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology of Pertussis Acute upper respiratory infection caused by Bordetella pertussis Effects of pertussis are not due to the infection, but to toxins produced by the bacteria Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Manifestations of Pertussis Follow predictable pattern Begin with typical URI symptoms 1-2 weeks cough becomes more frequent Paroxysms of coughing occur frequently Vomiting commonly follows coughing episode Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Diagnosis and Treatment of Pertussis Active immunization Diagnosis – Culture of nasopharyngeal secretions – Blood tests may be necessary – Lymphocytosis may be present Medication – Erythromycin – Respiratory isolation for 5 days after start of antibiotic therapy Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Pertussis Education Immunization Control of respiratory secretions Maintenance of nutrition and fluid balance Medication administration Safely alert – Report all suspected and confirmed cases of pertussis to local health department and the Centers for Disease Control and Prevention Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with Epistaxis A nosebleed May be idiopathic Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology and Manifestations of Epistaxis (1 of 2) Trauma Drying of nasal mucous membranes Infection Substance abuse (e.g., cocaine) Arteriosclerosis, or hypertension May indicate a bleeding disorder related to acute leukemia, thrombocytopenia, aplastic anemia, or severe liver disease Obvious bleeding from nares Bleeding into posterior nasal and oral pharynx – Nausea and vomiting can occur from swallowing blood Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology and Manifestations of Epistaxis (2 of 2) Posterior bleeding might be less apparent, with blood draining into posterior nasopharynx Commonly associated with disorders such as blood dyscrasias, hypertension, or diabetes – Posterior nosebleeds are more severe, more common in adults Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Medications for Epistaxis Topical vasoconstrictors Chemical agents for cauterization Topical anesthetics, if packing is required Prophylactic antibiotic therapy Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Treatment of Epistaxis Nasal packing – Nasal tampon ▪ Soft balloon filled with air – Direct pressure to bleeding vessel, nasal cavity – Posterior more difficult to control ▪ Both anterior, posterior packing ▪ Hypoxemia common ▪ Foley catheter an alternative Surgery – Chemical or surgical cautery to sclerose involved vessels – Ligation or embolization of internal maxillary artery Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 35.3 Posterior nasal packing. A) A rubber catheter is inserted through the nose and out the mouth and attached to the packing. B) The catheter is withdrawn through the nose to position the packing in the posterior nasopharynx. Ties exiting through the nose and mouth are used to stabilize the packing in position and remove it when it is no longer needed. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Epistaxis Assessment – Health history – Physical exam – Laboratory data ▪ Organ function tests Diagnoses, outcomes, and interventions – Anxiety – Risk of Aspiration – Safety Alert Continuity of care – Teach for home care – Advise things for patient to avoid – Advise when to seek evaluation Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with Nasal Trauma or Surgery Nose most commonly broken facial bone Deviation of the septum Potential complications Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology and Manifestations Nasal Trauma Unilateral fracture involves one side of the nose; causes little displacement or cosmetic deformity Bilateral fractures are more common – Depression or displacement of both nasal bones to one side Complex fractures can involve the septum, ascending processes of the maxilla, and frontal bones of face Hematomas Bony crepitus Bilateral fractures – Flattened appearance to the nose – An S or C configuration from deviation Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Complications of Nasal Trauma or Surgery Septal hematomas Abscess formation Septal perforation or deviation Cerebrospinal fluid leakage – Fractures in nasoethmoidal or frontal region can disrupt the dura, causing CSF leakage or rhinorrhea Cerebrospinal fluid leakage – CSF rhinorrhea suspected by watery nasal drainage that tests positive for glucose – Can cause obstruction Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Manifestations of Nasal Fracture Epistaxis Deformity or displacement to one side Crepitus Periorbital edema and ecchymosis Nasal bridge instability Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Diagnosis and Treatment of Nasal Trauma Diagnosis – Head and facial x-rays – Intranasal cavity exam Treatment and Surgery – Reduction and external splint application – Ice used to control edema and bleeding – Nasal packing might be necessary to control epistaxis – Rhinoplasty ▪ Surgical reconstruction of the nose – Correct deviated septum ▪ Septoplasty ▪ Submucous resection Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Nasal Trauma Health promotion – Helmets – Facial protection – Seat belts with shoulder harnesses – Airbags Diagnoses, outcomes, and interventions – Ineffective Airway Clearance – Risk for Infection Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with Laryngeal Obstruction or Trauma The narrowest portion of upper airway Frequent location of airway obstruction Laryngeal obstruction is a life-threatening emergency Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology of Laryngeal Obstruction Laryngeal obstruction – Aspirated food or foreign objects – Laryngospasm or edema due to inflammation, injury, anaphylaxis – Tumor Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Manifestations of Laryngeal Obstruction Subcutaneous emphysema or crepitus Voice changes Dysphagia Pain with swallowing Inspiratory stridor Hemoptysis Cough Signs of asphyxia – Coughing, choking, gagging, obvious difficulty breathing with use of accessory muscles, and inspiratory stridor Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology and Manifestations of Laryngeal Trauma Trauma may fracture thyroid and/or cricoid cartilage, resulting in loss of airway patency Soft-tissue injuries can cause swelling that further impairs the airway Manifestations – May include subcutaneous emphysema or crepitus, voice change, dysphagia and pain with swallowing, inspiratory stridor, hemoptysis, and cough Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Interprofessional Care of the Patient with Laryngeal Trauma Treatment goal – Maintain an open airway Rapidity of intervention depends upon extent of obstruction Heimlich maneuver CT scan to identify laryngeal fractures but emergency treatment often prior to diagnosis Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Laryngeal Trauma The priority of nursing care – Restore a patent airway to prevent cerebral anoxia, death Measures to prevent food aspiration CPR teaching Measures to identify/provide rapid intervention for anaphylaxis Heimlich maneuver Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 35.4a Administering abdominal thrusts (the Heimlich maneuver) to a conscious victim. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 35.4b Administering abdominal thrusts (the Heimlich maneuver) to an unconscious victim. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with Obstructive Sleep Apnea Most frequent type of sleep apnea Respiratory drive remains intact but airflow ceases due to occlusion of airway Central sleep apnea rare – Caused by a neurological disorder Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology of Obstructive Sleep Apnea Loss of normal pharyngeal muscle tone Pharynx collapses during inspiration Tongue pulls against posterior pharyngeal wall Obstruction causes O2 sat, PO2, and pH to fall, PCO2 to rise Asphyxia causes brief arousal from sleep – Restores airway patency and airflow – Episodes can occur hundreds of times a night Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Manifestations of Obstructive Sleep Apnea Loud, cyclic snoring, and restless sleep Excessive daytime sleepiness Irritability Gasping or choking during sleep Morning headache Depression, intellectual impairment, and impotence Hypertension Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Complications of Obstructive Sleep Apnea Secondary physiologic effects Sleep fragmentation Loss of slow-wave sleep Dysrhythmias – Sudden cardiac death Pulmonary hypertension Common in those who are morbidly obese Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Risk Factors for Sleep Apnea Male gender Increasing age Obesity Large neck circumference Use of alcohol and CNS depressants Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Diagnosis of Sleep Apnea Overnight sleep study – Electroencephalogram – Measurements of ocular activity and muscle tone – Ventilatory activity and airflow – Continuous arterial oxygen saturation – Heart rate – Transcutaneous arterial PCO2 Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Treatment of Sleep Apnea Mild-to-moderate apnea – Weight reduction – Abstaining from alcohol – Improving nasal patency – Avoiding supine sleeping position – Nasal continuous positive airway pressure (CPAP) is the treatment of choice for sleep apnea – BiPAP ventilator provides less resistance to exhaling Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Surgical Intervention for Sleep Apnea Tonsillectomy Adenoidectomy Uvulopalatopharyngoplasty (UPPP) Tracheostomy Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 35.5 A patient using a nasal mask and CPAP to treat sleep apnea. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Sleep Apnea (1 of 2) Obstructive sleep apnea is often treated in the home Education of patient and family – Equipment use – Strategies to decrease contributing factors Diagnoses, outcomes, and interventions – Disturbed Sleep Pattern – Fatigue – Ineffective Breathing Pattern – Impaired Gas Exchange – Risk for Injury – Risk for Sexual Dysfunction Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Sleep Apnea (2 of 2) Continuity of care – Education ▪ Relationship between obesity and sleep apnea ▪ How to operate a CPAP – Support groups Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with Nasal Polyps Benign, grapelike growths of lining of nose that interfere with air movement Can obstruct openings, leading to sinusitis Usually affect people with chronic allergic rhinitis or asthma Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology and Manifestations of Nasal Polyps Chronic irritation and swelling of mucus membranes Areas of dependent mucous membrane Bilateral with stemlike base May be asymptomatic Can cause nasal obstruction, rhinorrhea, and loss of sense of smell Sinusitis may develop Voice may have nasal tone Asthmatics who have nasal polyps may have an associated aspirin allergy of which they are not aware Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Treatment of Nasal Polyps Medication – Topical corticosteroid nasal sprays – Low-dose oral corticosteroids Surgery – Polypectomy ▪ Wire snare ▪ Laser removal – Repeated surgery may be necessary Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with Nasal Polyps Teach home care – Apply ice pack – Increase fluid intake – Clean mouth frequently – Avoid blowing nose, straining at stool, vigorous coughing, and strenuous exercise Discuss manifestations of possible bleeding Preoperative and postoperative care of polypectomy patient Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved The Patient with a Laryngeal Tumor Benign or malignant Chronic shouting, projecting, or vocalizing Cigarette smoking and chronic irritation from industrial pollutants Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Benign Tumors Benign tumors – Papillomas – Nodules – Polyps Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology and Manifestations of Laryngeal Tumors (1 of 2) Laryngeal cancer – Most common malignancy is squamous-cell carcinoma – Leukoplakia ▪ White, patchy, and precancerous lesions – Erythroplakia – Red, velvety patches thought to represent a later stage – Initial cancerous lesion, carcinoma in situ (CIS), will develop into squamous-cell cancer if untreated – Laryngeal cancer can develop in glottis, supraglottis, and subglottis Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Pathophysiology and Manifestations of Laryngeal Tumors (2 of 2) Pathophysiology and manifestations – Laryngeal cancer ▪ Cancers of the vocal cords or glottis tend to be well-differentiated, slow-growing ▪ Metastasis occurs late in illness ▪ Manifestations – Hoarseness – Change in voice quality ▪ Cancer of supraglottis (epiglottis, aryepiglottic folds, arytenoid muscles, cartilage, and false vocal cords) – Invades locally, metastasizes early ▪ Subglottic tumors (below vocal cords) – Often asymptomatic until enlarging tumor obstructs airway Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Risk Factors for Laryngeal Tumors Tobacco use Alcohol consumption Poor nutrition Human papillomavirus infection Exposure to asbestos Race – More common in African Americans Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 35.6 Laryngoscopy showing a polyp on the right vocal cord. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 35.7 Cancer of the larynx and epiglottis. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Interprofessional Care of the Patient with a Laryngeal Tumor Benign tumors may resolve with correction of underlying issue Early detection of malignant tumors is critical to survival Diagnosis – Direct or indirect laryngoscopy when cancer is suspected – Biopsy – CT scan, MRI, chest x-ray, PET Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Table 35.1 Staging of Laryngeal Tumors Stage Description Stage 0 Carcinoma in situ No lymph node involvement or metastasis Stage one I Tumor confined to site of origin with normal vocal cord mobility No lymph node involvement or metastasis Stage two II Tumor involves adjacent tissues No lymph node involvement or metastasis Stage three III Tumor confined to larynx with fixation of vocal cords; immediately surrounding supraglottic tissues may be involved No lymph node involvement or a single positive node on the side of the tumor No metastasis Stage four IV Massive tumor that extends beyond boundaries of larynx to involve surrounding tissues Single or multiple lymph nodes may be involved Distant metastasis may be present Source: Based on AJCC Cancer Staging Manual, 7th Edition (2010) published by Springer Science and Business Media LLC, www.springerlink.com; American Cancer Society. (2017). Laryngeal cancer stages. Retrieved from https://www.cancer.org/cancer/laryngeal-and-hypopharyngeal-cancer/detection- diagnosis-staging/staging.html. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Treatment of Laryngeal Tumors Benign vocal cord polyps – Inhaled steroid spray – Some cases call for surgery Radiation therapy – Treatment of choice ▪ Preserves voice – Chemoradiotherapy Chemotherapy – Treats distant metastasis – Palliation when tumor unresectable – Cisplatin and 5-fluorouracil Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Surgical Intervention for Laryngeal Tumors Goals – Remove the malignancy – Maintain airway patency – Achieve optimal cosmetic appearance Laser laryngoscopy Laryngectomy – Partial laryngectomy ▪ Hemilaryngectomy ▪ Vertical partial laryngectomy – Total Radical neck dissection Modified neck dissection Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Post-Surgical Care for the Patient with a Laryngeal Tumor Speech rehabilitation – Necessary if entire larynx is removed – Techniques ▪ Tracheoesophageal puncture with placement of a one-way shunt valve ▪ Esophageal speech ▪ Use of speech generators Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 35.8 Following a total laryngectomy, the patient has a permanent tracheostomy. No connection between the trachea and esophagus remains. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 35.9 The tracheoesophageal prosthesis (TEP) allows diversion of air from the trachea through a one-way valve into the esophagus and oropharynx, producing speech when the tracheostomy stoma is occluded. The one-way valve prevents food from entering the trachea. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Figure 35.10 Speech generators. A) The patient holds the vibrating tip of the speech generator against the throat, using the mouth to form words. B) A plastic handpiece of the generator is held in the corner of the mouth. The audible tone produced by the generator is formed into words. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care of the Patient with a Laryngeal Tumor Emphasize the need for patients with chronic hoarseness to seek treatment Health promotion – Prevent tobacco use in children, adolescents, and young adults – Discourage use of alcohol Diagnoses, outcomes, and interventions – Risk for Impaired Airway Clearance – Impaired Verbal Communication – Impaired Swallowing – Imbalanced Nutrition: Less Than Body Requirements – Anticipatory Grieving Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Nursing Care for the Patient with a Laryngeal Tumor Continuity of care – Benign laryngeal tumor ▪ Teach management of contributing factors – Laryngeal cancer ▪ Teach treatment options ▪ Importance of early intervention ▪ Options for post-operative communication if surgery is necessary – Smoking prevention and cessation activities – Activities to promote abstinence or moderate alcohol use Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved Copyright This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials. Copyright © 2020, 2015, 2011 Pearson Education, Inc. All Rights Reserved