Surgery and Surgical Nursing II.pdf

Surgery and Surgical Nursing II Non-infectious Problems of the Upper Respiratory Tract Presentation By Vincentia Sarfo-Brobbey 1  Facial Trauma Facial trauma...

Surgery and Surgical Nursing II Non-infectious Problems of the Upper Respiratory Tract Presentation By Vincentia Sarfo-Brobbey 1  Facial Trauma Facial trauma is an injury to the face and it ranges from simple soft tissue injuries to the life threatening situation Caused by massive tissue loss and airway compromise Facial trauma can result in permanent disfigurement and disability. 2 Nasal Fracture 3  Fracture of the Nose The location of the nose makes it susceptible to injury Nasal fracture is more common than any other bone in the body Results from a direct assault on the nose, sports injuries and road traffic accidents Nasal fracture leads to deformity that may give rise to obstruction of the nasal air passages and facial disfigurement 4  Patterns of Nasal Fractures Class 1: A blow to the anterior nose, causing depression or displacement of the distal portion of the nasal bone A fracture of the cartilaginous septum, running from the dorsum towards the bony septum may also occur (Chevallet fracture) Class 2: Lateral trauma to the nose, resulting in lateral deviation of the bony nasal pyramid 5  Patterns of Nasal Fractures Class 3: A high-energy injury to the nose, which leads to a complex fracture which extends into the ethmoid bone Clinical Manifestations Bleeding from the nose externally and internally into the pharynx Swelling and bruising of the soft tissues adjacent to the nose Change in appearance of the nose 6  Clinical Manifestations Difficulty in breathing Loss of sense of smell Change in vision Watery rhinorrhoea Diagnostic Investigations Plain X-ray of the head CT Scan of the head 7  Management As a rule, bleeding is controlled with the use of cold compresses The nose is assessed for symmetry either before swelling has occurred or after it has subsided The patient is referred to a specialist, usually 3 to 5 days after the injury, to evaluate the need to realign the bones Nasal fractures are surgically reduced 7 to 10 days after the injury 8  Nasal Fracture Nursing Interventions - Refer to the lecture notes Complications of Nasal Fracture Epistaxis Cerebrospinal fluid leakage Septal haematoma Traumatic anosmia 9 Nasal Polyps 10  Nasal Polyps Nasal polyps are grape like swellings or outpouchings of mucous membrane lining the nose or paranasal sinuses, especially the ethmoids and occur as solitary or multiple lesions They cause nasal obstruction, sometimes with a ball-valve effect, nasal discharge, and they are usually bilateral They have a tendency to recur and they are caused by infections 11  Management Nasal polyps may shrink with topical steroid therapy but will not usually disappear Short course of steroids are useful in severe cases. Endoscopic ethmoidectomy may be required for recalcitrant cases Nasal polypectomy is performed under local or general anaesthetic. A sinare-like instrument is used to remove the polyps and the bleeding site cauterised 12  Nasal Polyps Nursing Interventions - Refer to lecture notes Complications of Nasal Polyps Acute or chronic sinusitis Obstructive sleep apnoae Can lead to nasal cancer 13  Head and Neck Cancer The head and neck comprises of six regions: Nasopharynx, oral cavity (including the lips, floor of the mouth, tongue, cheeks, gums and hard palate) Oropharynx (base of the tongue, the tonsillar region, the palate and pharyngeal walls) Hypopharynx (the lower throat) 14  Head and Neck Cancer The head and neck comprises of six regions: Larynx (including the vocal cords and both supraglottis and subglottis) Nasal cavity (the ethmoid and maxillary sinuses and the parotid, submandibular and minor salivary glands). 15  General Causes of Head and Neck Cancer Tobacco Smoking Alcohol Sexually transmitted Virus (HPV 16) Environmental factors Hereditary 16  Cancer of the Nose and Sinuses The nose and paranasal sinuses can be the site of both benign and malignant neoplasms The variety of tissue types that constitute the nose and sinuses results in a wide range of histological tumour types Tumours can arise from epithelial tissue, bone, cartilage and neurological, vascular and lymphoid tissue and muscle 17  Cancer of the Nose and Sinuses Tumours will be benign or malignant in their behaviour. Malignant tumours of the nose and paranasal sinuses are rare 18  Aetiology of Cancer the Nose and Sinuses Inhalation of carcinogens from smoke Hardwood exposure in ethmoid adenocarcinoma Other environmental pollutants may have a role in some benign conditions Human papillomavirus (HPV) infection 19  Clinical Manifestations Nasal blockage Rhinorrhoea Epistaxis Facial pain Hyposmia or Anosmia 20  Diagnostic Investigations Nasal endoscopy Orbital examination, including eye movements Cranial nerves, especially the trigeminal nerve (5th Cranial nerve) Intraoral examination, including hard and soft palate, teeth and gingiva 21  Diagnostic Investigations Otoscopy CT scan of the head Biopsy of the lesion Full blood count may be indicated if lymphoma is suspected 22 Management for Malignant Tumour of the Nose and Sinuses Surgical options are: External Approach I. Craniofacial resection (CFR) II. Lateral rhinotomy III. Midfacial degloving IV. Total maxillectomy Endoscopic Approach 23 Management for Malignant Tumour of the Nose and Sinuses Surgical options are: Maxillofacial and plastic surgery collaboration may be required along with colleagues from restorative dentistry and prosthetics 24 Management for Malignant Tumour of the Nose and Sinuses Medical options The use of chemotherapy (Platinum-based, Cisplatin) and Radiotherapy as adjuvant treatments should be fully discussed among the multidisciplinary team and with the patient Patient should be aware of the side effects of these treatment modalities 25  Oropharyngeal Cancer Cancer of the oral cavity and pharynx can occur in any part of the mouth; lips, lateral tongue, floor of mouth most common or throat Risk factors for cancer of the oral cavity and pharynx which include cigarette, cigar, pipe smoking, use of smokeless tobacco and excessive use of alcohol 26  Oropharyngeal Cancer Oral cancers are often associated with the combined use of alcohol and tobacco. Other factors include gender (male), age (older than 50 years) and among the blacks. Malignancies of the oral cavity are usually squamous cell cancers. 27 Clinical Manifestations of Oropharyngeal Cancer Few or no symptoms Painless sore or mass in the mouth that will not heal Painful indurated ulcer or lesion with raised edges As the cancer progresses, patient may complain of tenderness in the throat or mouth Difficulty in chewing, swallowing or speaking 28  Clinical Manifestations of Oropharyngeal Cancer Coughing of blood-tinged sputum Enlarged cervical lymph nodes Diagnostic Investigations Oral examination Assessment of cervical lymph nodes Biopsies of suspicious lesions which is not healed within two week 29  Medical Management of Oropharyngeal Cancer Management varies with I. Nature of the lesion II. Preference of the physician III. Patient choice Resectional surgery, Radiation therapy, Chemotherapy, or a combination may be effective 30  Medical Management of Oropharyngeal Cancer Lip Cancer: Small lesions are excised liberally. Larger lesions may be treated by radiation therapy. Tongue Cancer: Treated aggressively, recurrence rate is high. Radiation and surgery (total resection or hemiglossectomy) are performed. Radical neck dissection for metastases of oral cancer to lymphatic channel in the neck region with reconstructive surgery 31  Oropharyngeal Cancer Nursing Intervention: Refer to Lecture notes 32 Vocal Cord Paralysis 33  Vocal Cord Paralysis Vocal cord paralysis refers to immobility of the ‘true’ vocal cord resulting from disruption of motor innervations to the laryngeal musculature Vocal cord paralysis is commonly happened in otolaryngology practice and is often a manifestation of disease and not a diagnosis in and of itself 34  Vocal Cord Paralysis It may be secondary to injury to either the vagus or the recurrent laryngeal nerve, neoplastic conditions and iatrogenic diseases Vocal cord paralysis can be unilateral or bilateral Paralysis of the left vocal cord is more commonly observed than right vocal cord paralysis owing to the longer and more tortuous course of the left recurrent laryngeal nerve within the mediatsinum 35 Aetiology of Vocal Cord Paralysis (Unilateral and Bilateral) Dysfunction of base of the skull/the brainstem nuclei Injury to the vagus nerve or the recurrent laryngeal nerve supplying the involved side of the larynx Non-laryngeal malignancy Malignancy of the larynx 36  Aetiology of Vocal Cord Paralysis (Unilateral and Bilateral) Surgical trauma such as Thyroidectomy, Parathyroidectomy, Carotid endartectomy, Anterior approach to the cervical spine, Repair Zenker’s diverticulum (Pharyngeal pouch), Cricopharyngeal myotomy Idiopathic Endotracheal Intubation 37  Aetiology of Vocal Cord Paralysis (Unilateral and Bilateral) Iatrogenic conditions such as Thoracic aneurysm repair, Pneumonectomy, Aortic valve repair, Coronary artery bypass grafting, Oesophageal/tracheal surgery, Mediastinoscopy, Ligation of patent ductus arteriosus. Laryngeal infections such as Herpes zoster, Herpes simplex, Epstein–Barr virus and Cytomegalovirus in the immunocompromised patient Non-surgical trauma 38  Clinical Manifestations of Vocal Cord Paralysis Dysphonia Hoarseness Vocal fatigue and tremor Aphonia Shortness of breath 39  Clinical Manifestations of Vocal Cord Paralysis Difficulties in Swallowing Dyspnoea Stridor in patient with bilateral vocal cord paralysis Dysarthria/Slurred speech 40  Diagnostic Investigations of Vocal Cord Paralysis History of recent surgery involving thyroid, cervical or thoracic procedures Video-stroboscopy to assess the structure and movement of the vocal cords Laryngeal electromyography to determine the underling pathology and treatment option 41  Diagnostic Investigations of Vocal Cord Paralysis CT scan, MRI and X’ray Blood test for culture and sensitivity 42 Conservative/ Non-Surgical Management of Vocal Cord Paralysis Once an underlying neoplastic process has been definitively ruled out, expectant treatment may be indicated Voice therapy is widely recommended prior to restorative surgery and will aid in establishing the severity of the paralysis and evaluate the impact of vocal cord paralysis on the patient’s phonation, articulation, respiration and swallowing 43 Conservative/ Non-Surgical Management of Vocal Cord Paralysis Speech therapy provides an important adjuvant treatment in the management of vocal cord paralysis, focusing on optimising the efficiency of voice production, minimising compensations that are counter productive and educating patients about their underlying voice disorder. 44  Surgical Management of Vocal Cord Paralysis Injection Augmentation The primary aim of injection augmentation is to implant a substance that can fill a space and restore the normal characteristics of vocal cord movement and thereby improve phonation and glottic competence. Examples of the injectable are Alloplastic implants (Silicone, Paraffin, Teflon) and Bio-implants (Autologous collagen, fat, fascia). 45  Surgical Management of Vocal Cord Paralysis Medialization Laryngoplasty The primary aim of medialization laryngoplasty or type I thyroplasty is to improve glottic closure by modifying the position of the vocal cords 46  Surgical Management of Vocal Cord Paralysis Selective Laryngeal Reinnervation The primary aim of selective laryngeal reinnervation is that it has the potential to restore a normal or near normal voice quality without affecting the flexibility of the vocal cord 47 Laryngeal Trauma 48  Laryngeal Trauma Injury to the larynx (voice box) is rare but serious life threatening situation Laryngeal trauma is often divided into two (2) main groups: I. Blunt trauma II. Penetrating trauma 49  Clinical Manifestations of Laryngeal Trauma Mucosal tears of the larynx during operation (Thyroid) Fractures of the bony or cartilaginous structures Avulsions Transections Inhalation of foreign bodies, hot gases 50  Clinical Manifestations of Laryngeal Trauma Swallowing or aspiration of caustic liquids Road traffic accident when the driver’s neck strikes the steering wheel Blow to the neck Strangulation 51  Clinical Manifestations Pain or tenderness over the larynx Dysphonia/Hoarseness Dyspnoea Intercostal muscle retraction Cyanosis in some cases Odynophagia 52  Clinical Manifestations Dysphagia Haemoptysis Ecchymosis of the neck Subcutaneous emphysema Loss of normal thyroid prominence Deviation of larynx 53  Diagnostic Investigations Direct laryngoscopy Esophagoscopy Chest x-ray CT scans of the neck and chest 54  Management of Laryngeal Trauma Management and Nursing intervention- Refers to lecture notes 55 Non-infectious Problems of the Lower Respiratory Tract 56 57 Emphysema 58  Emphysema Emphysema is chronic inflammation which reduces the flexibility or destroy the walls of the alveoli, resulting in over distention of the alveolar walls This causes air to be trapped in the lungs, impeding gas exchange. Smoking is often linked to development of emphysema A less frequent cause is an inherited alpha-antitrypsin deficiency 59  Diagnostic Investigations Chest X’ray Electrocardio Gram (ECG) Pulmonary function test Arterial blood gas analysis 60  Clinical Manifestations Difficulty in breathing due to air trapping which retains carbon dioxide and reduces alveolar gas exchange Barrel chest which develops over time as more air is trapped within the distal airways Use of accessory muscles to breathe as the respiratory effort increases. 61  Clinical Manifestations Loss of weight as extra calories are needed to maintain respiration. Increased effort of breathing also detracts from eating Patient prefers high folwers position which allows for greater chest expansion 62  Treatment of Emphysema Management & Nursing interventions-Refer to the notes 63 Cystic Fibrosis 64  Cystic Fibrosis Cystic fibrosis is the most common fatal autosomal recessive disease that causes severe damage to mostly the lungs, digestive and reproductive systems but can affect other systems in the body An individual must inherit a defective copy of the cystic fibrosis gene from each parent to have the condition 65  Clinical Manifestations of Cystic Fibrosis The pulmonary Nasal polyps manifestations of this disease Chronic sinusitis include: Haemotypsis Productive cough Wheezing Dyspnoea 66  Clinical Manifestations of Cystic Fibrosis Weight loss Non-pulmonary Clinical Cholestatic jaundice Manifestations Steatorrhoea Gastroesophageal reflux Gastrointestinal Problems Genitourinary Problems Recurrent abdominal pains Male and female infertility Others Failure to thrive in children Digital clubbing Recurrent pancreatitis 67  Diagnostic Investigations Sweat test (Elevated result of a sweat chloride concentration test; values of greater than 60 mEq/L) DNA analysis may also be used in evaluating common genetic mutations of the CF gene. Sputum analysis 68  Treatment Management & Nursing Interventions-Refer to the lecture notes 69  Complications of Cystic Fibrosis Respiratory failure Cor pulmonale Pneumothorax Volvulus Intussusception Bronchiectasis, Bronchitis, Bronchiolitis, Pneumonia 70 Cancer of the Lungs / Bronchogenic Carcinoma 71  Cancer of the Lungs / Bronchogenic Carcinoma Lung cancer is the abnormal, uncontrolled cell growth in lung tissues, resulting in a tumour. A tumour in the lung may be primary when it develops in lung tissue. It may be secondary when the cancer spreads (metastasises) from other areas of the body, such as the liver, brain, or kidneys. 72  Types of Lung Cancer There are two major types of lung cancer; small cell and non- small cell. Small Cell: Oat cell which fast growing and metastasised early. Non-small Cell: Adenocarcinoma (moderate growth rate, early metastasis), Squamous cell (low growing, late metastasis). Large Cell which is fast growing with early metastasis 73  Causes of Lung Cancer The actual cause of lung cancer is unknown. But there are Predisposing causes of this condition. Repetitive exposure to inhaled irritants increases a person’s risk for lung cancer Cigarette smoke Second-hand smoke 74  Causes of Lung Cancer Occupational and environmental exposures to air pollution containing benzo-pyrenes and hydrocarbons and other carcinogens Genetics Dietary factors like diet low in fruits and vegetables 75  Clinical Manifestations of Lung Cancer Coughing due to irritation Weight loss due to the caloric from mass. Presence of needs of the tumour mucous or exudate may not Anorexia be until later in disease Dyspnoea caused by damaged (Sputum production) lung tissue Coughing up blood (haemoptysis) 76  Clinical Manifestations of Lung Cancer Hoarseness Chest or shoulder pains as mass Dysphagia presses on surrounding tissue Head and neck oedema Pleural effusion Fatigue or weakness Finger clubbing may be a late sign of lung cancer 77  Diagnostic Investigations Chest x-ray Biopsy will show cell type CT scan of the lungs Bone scan or CT scans shows Bronchoscopy metastasis of the disease Cancer cells seen in sputum MRI scan Pulmonary function tests 78  Management of Lung Cancer Medical Interventions Treatment is aimed at cure of the tumour if possible. Treatment depends on cell type, stage of the disease and physiologic status. Chemotherapy and radiation are both methods that are used to destroy the cancerous cells. Radiation therapy to decrease tumour size. 79  Cont....Management of Lung Cancer Chemotherapy often with a combination of drugs like Cyclophosphamide, Doxorubicin, Vincristine, Etoposide, Cisplatin. Some patient may still relapse after treatment. Administer anti-emetics (Prochlorperazine) to combat side effects of chemotherapy. Oxygen therapy is used to aid in meeting the current needs of the body, but not all patients will require supplemental oxygen therapy. 80  Cont....Management of Lung Cancer Attentions to nutrition such as high protein and high calorie are important to meet the demands of the body. Narcotic pains control is an integral component of care in any type of cancer treatment. Administer analgesics for pain control, drugs like Morphine, Pethidine. Appropriate pain management needs to be individualised for the patient. 81  Management of Lung Cancer Surgical Interventions Surgical management is appropriate for some patients, but not always necessary. Surgical removal of affected area of the lungs: I. Wedge resection II. Segmental resection III. Lobectomy IV. Total lung removal (Pneumonectomy) 82  Management of Lung Cancer Surgical Interventions Serial thoracentesis or chest tube placement is used for recurrent pleural effusions Laser therapy through a bronchoscope is a palliative measure that relieves endobronchial obstructions caused by nonresectable tumours 83  Nursing Interventions Nursing Interventions (Specific Postoperative Care): Refer to lecture notes 84 Infectious Problems of the Respiratory Tract 85 Peritonsillar Abscess (Quinsy) 86  Peritonsillar Abscess (Quinsy) A peritonsillar abscess is a collection of purulent exudate between the tonsillar capsule and the surrounding tissues, including the soft palate. It normally develops after an acute tonsillitis which progresses to a local cellulitis and abscess. 87  Peritonsillar Abscess (Quinsy) This abscess, lateral to the tonsil, which pushes the tonsil towards the mid-line and makes it look enlarged. It is a very painful condition. 88  Clinical Manifestations of Peritonsillar Abscess Raspy voice Odynophagia (Severe sensation of burning, Dysphagia squeezing pain while Otalgia swallowing) Drooling Tender cervical lymph glands Swelling of the soft palate Fever Unilateral tonsillar Tachycardia hypertrophy 89  Diagnostic Investigations Culture and Gram’s stain of the aspirated fluid CT scan is performed when aspiration of the abscess is impossible 90  Medical Management Prescribed antibiotics usually penicillin are extremely effective in controlling the infection in peritonsillar abscess. The abscess may resolve without the need for incision if effective antibiotics are prescribed on time. Surgical Management The abscess may be incised and drained. 91  Nursing Interventions For nursing interventions -refer to the lecture notes 92 Lung Abscess 93  Lung Abscess A lung abscess is necrosis of the pulmonary parenchyma caused by microbial infection; the lesion collapses and forms a cavity. The site of lung abscess is related to gravity and is determined by the patient’s position. For patients in a recumbent position, the posterior segment of an upper lobe and the superior segment of the lower lobe are the most common areas 94  Causes of Lung Abscess Aspiration of anaerobic bacteria such as Staphylococcus aureus and other Gram-negative species Bacterial pneumonia (Klebsiella pneumoniae) Mechanical or functional obstruction of the bronchi 95  Predisposing Factors Patients with impaired cough Drug addiction reflexes Alcoholism Loss of glottal closures or Patients with oesophageal diseases swallowing difficulties may cause aspiration of foreign material Compromised immune function Patients receiving nasogastric Patients with central nervous tube feeding system disorders (Seizure, stroke) Unconscious patients 96  Clinical Manifestations of Lung Abscess The clinical features vary from a Pleurisy or dull chest pains mild productive cough to acute Dyspnoea illness. Absence breath Fever Productive cough of moderate to Body weakness copious amounts of foul- Anorexia and weight loss are smelling sputum often bloody common Leukocytosis may be present 97  Diagnostic Investigations Chest radiograph Sputum culture Fiberoptic bronchoscopy CT scan of the chest 98  Medical Management IV antimicrobial therapy: Clindamycin (Cleocin) is the medication of choice. Large IV doses are required because the antibiotic must penetrate necrotic tissue and abscess fluid. Antibiotics are administered orally instead of intravenously after signs of improvement and the antibiotic therapy may last 4 to 8 weeks. Chest physiotherapy: coughing and postural drainage, percutaneous catheter placement are used for abscess drainage. High protein and high calorie diet is recommended 99  Surgical Interventions Pulmonary resection (lobectomy) though rare, is performed when there is massive haemoptysis or no response to medical management Nursing Interventions - Refer to the lecture notes 100