Chapter 26: Concepts of Care for Patients With Noninfectious Upper Respiratory Problems Flashcards
Exam 2 (Dr. Lyons) (343 cards)
1
Q
nosebleed
A
epistaxis
2
Q
oxygen transport to the cells and carbon dioxide transport away from cells through ventilations and diffusion
A
gas exchange
3
Q
lower than normal respiratory rate and depth insufficient for gas exchange
A
hypopnea
4
Q
thickly crusted oral and nasopharyngeal secretions that can cause an upper airway obstruction aka: mucoid impaction
A
inspissated secretions
5
Q
an adult who has had a laryngectomy
A
laryngectomee
6
Q
a breathing disruption during sleep that lasts at least 10 sec and occurs a minimum of five times in an hour
A
obstructive sleep apnea (OSA)
7
Q
a formal and definitive overnight sleep study with direct observation of the patient while he or she wears a variety of monitoring equipment to evaluate depth of sleep, type of sleep, respiratory effort, oxygen saturation, carbon dioxide exhalation, and muscle movement
A
polysomnography
8
Q
surgical reconstruction of the nose
A
rhinoplasty
9
Q
The upper respiratory system includes….
A
nose, sinuses,oropharynx, larynx, and trachea
10
Q
What kind of issues disrupt airflow and gas exchange for the upper respiratory system?
A
any issue that blocks any of these passages (nose, sinuses, oropharynx, larynx, and trachea)
11
Q
What is the primary nursing focus for patients with upper respiratory tract disorders?
A
is to support gas exchange by maintaining a clear and open airway
12
Q
How does an upper airway obstruction occur?
A
when airflow through the nose, mouth, pharynx, or larynx is blocked
13
Q
Why is early detection crucial when it comes to gas exchange impairment?
A
can prevent serious complications such as respiratory arrest and death; it can be life-threatening
14
Q
Common causes of upper airway obstruction can encompass a variety of conditions and incidents, such as what?
A
tongue swelling resulting from surgery, trauma, or allergic reactions such as angioedema
15
Q
How do tongue blockages occur?
A
due to loss of the gag reflex, diminished muscle tone, unconsciousness, or coma
16
Q
How does laryngeal swelling often occur?
A
inhalation of smoke, toxins, inflammation, allergic reactions, or anaphylaxis
17
Q
Some other causes of obstructions
A
peritonsillar and pharyngeal abscesses, head and neck cancers, and thick secretions
18
Q
Conditions that may contribute to obstructions
A
stroke and cerebral edema; trauma or burns to the face, trachea, or larynx; foreign-body aspiration
19
Q
What can critically impact airway patency and require prompt attention?
A
Obstructions
20
Q
A preventable cause of airway obstruction
A
thickly crusted oral and nasopharyngeal secretions
21
Q
Who is most at risk for this preventable asphyxiation risk (thickly crusted oral and nasopharyngeal secretions)?
A
those with altered mental status or consciousness, dehydrated, communication difficulties, ineffective coughing, or who are prone to aspiration
22
Q
What can be done to prevent this issue (thickly crusted oral and nasopharyngeal secretions)?
A
provide regular oral care
23
Q
Airway obstruction demands immediate attention to prevent what?
A
a partial obstruction from escalating to a complete blockage
24
Q
What are the symptoms of a partial obstruction?
A
- sweating
- rapid heartbeat
- anxiety
- elevated blood pressure
25
What are some diagnostic tools to diagnose a partial obstruction?
* chest or neck xray
* laryngoscopy
* CT scans
26
What should you monitor for in a patient with a partial obstruction?
signs of hypoxia, hypercarbia, restlessness, increasing anxiety, sternal retractions,"seesaw" chest movements, abnormal breathing, or a sense of impending doom due to difficulty breathing
27
What equipment should be used for monitoring in patients with partial obstructions?
pulse ox, end-tidal carbon dioxide for continuous gas exchange monitoring
28
What should be reguarly be check for in patients with partial obstructions?
stridor, cyanosis, changes in the patient's level of consciousness
29
To guide appropriate intervention of a airway obstruction what should be determined?
the cause
30
If the obstruction is due to the tongue falling back or excessive secretions, what are some interventions?
extend the patient's head and neck and insert a nasal or oral airway; suction to remove any obstructing secretions
31
What are some interventions for obstructions caused by a foreign body that cannot be manually cleared from the oral cavity?
perform abdominal thrusts
32
What interventions would you do for an unconscious patient with a known obstruction and palpable pulse?
abdominal thrusts are used instead of chest compressions
33
What interventions would you do for an unconscious patient with no obstruction is evident?
chest compressions are preferred due to the higher likelihood of cardiac issues over airway obstruction in these cases
34
What emergency procedures may be necessary to restore gas exchange if the obstruction cannot be quickly resolved?
cricothyroidotomy or a tracheotomy
35
When an obstruction is not due to a foreign object what intervention may be required?
endotracheal intubation
36
What can help identify the obstruction's cause or assist in removing foreign bodies?
laryngoscopy
37
An emergency procedure that involves making an incision through the cricothyroid membrane between the thyroid and cricoid cartilage?
cricothyroidotomy
38
What can be used to insert through the incision to keep the airway open until a tracheotomy is performed?
any hollow tube, preferably a tracheostomy tube (this method is used when no other means can secure the airway)
39
An emergency technique involving inserting a ____ or a very small endotracheal tube directly into the cricoid space to allow airflow.
14-gauge needle
40
Is done by inserting a tube into the trachea via the nose or mouth
endotracheal intubation
41
What procedure is done when pharyngeal or laryngeal edema is anticipated to prevent complications from severe swelling?
endotracheal intubation
42
A surgical procedure typically performed in the operating room with local or general anesthesia, though it can be done at the bedside.
tracheotomy
43
The use of a local anesthesia for a tracheotomy is when ?
there is a risk of losing the airway during the anesthesia induction
44
Tracheotomys are reserved for cases where what is not feasible?
intubation with an endotracheal tube
45
What emergency procedure can be preformed in 2 minutes?
tracheotomy
46
When might a patient on long-term mechanical ventilation for upper airway obstruction or respiratory failure need a tracheotomy?
after 7 days or more days of continuous endotracheal intubation to prevent laryngeal injury and preserve tissue integrity
47
What condition can arise from various pathological mechanisms including issues with central nervous system control of ventilation, inadequate circulaions and oxygenation, and airway obstruction?
sleep apnea
48
is characterized by disruptions in breathing during sleep that last for at least 10 seconds and occurs at least 5 times per hour.
obstructive sleep apnea
49
:shallow breathing with insufficient airflow for effective gas exchange
hypopnea
50
Obstructive sleep apnea typically involves what?
hypopnea
51
Etiology of obstructive sleep apnea
during sleep, the relaxation of head and neck muscles allows the tongue, soft palate, and other throat structures to collapse and obstructthe upper airway, while neural control of chest movement remains unaffected; this obstruction impairs gas exchange, increasing carbon dioxide levels and decreasing blood pH; these changes stimulate neural centers, causing the sleeper to awaken after 10 seconds or more of apnea, correct the obstruction and resume breathing; the cycle can repeat as frequently as every 5 minutes, disrupting sleep and preventing the deep sleep necessary for optimal physiological restoration
52
Can cause arterial blood oxygen saturation to drop significantly below 80%
apnea episodes
53
Individuals with what condition often experience chronic daytime sleepiness, difficulty concentrating, morning headaches, and irritability
Obstructive Sleep Apnea (OSA)
54
What are some long-term consequences of chronic OSA?
a higher risk of hypertension, stroke, cognitive impairments, weight gain, diabetes, and cardiovascular and pulmonary diseases
55
Disruptions in hormonal energy balance from OSA can lead to what that can adversely impact the patient's health?
severe metabolic problems
56
What is the primary cause of OSA?
a blockage of the upper airway by the soft palate or tongue
57
What some contributing factors (etiology and genetic risk) of OSA?
obesity, a large uvula, a short neck, smoking, enlarged tonsils or adenoids and swelling in the oropharyngeal area
58
Many patients with what are unaware of their condition?
sleep apnea
59
What disorder should be expected in adults who experience persistent daytime sleepiness or report feeling tired upon waking, especially if they also snore heavily?
sleep apnea
60
Sample questions to ask a patient who is at risk for sleep apnea:
* Inquire about daytime drowsiness or episodes of falling asleep during activities such as using a computer, reading, or driving
* ask if the patient has ever been awakened by their own snoring and whether family members have noticed loud snoring
* Inquire about the frequency of nightmares, which can be associated with OSA
* Inquire if family members have observed disturbed breathing patterns during sleep
* Ask of the patient has tried to enhance sleep with OTC sleep aids or increased alcohol consumption
61
In sever cases of sleep apnea what are some things you should ask your patient in their assessment?
Have you fallen asleep while eating, or any time they sit down?
62
What is a typical breathing pattern for a patient with sleep apnea?
involves increasingly spaced breaths followed by periods of no breathing, which are then followed by gasping and snorrting as the patient partially awakens to correct the obstruction
63
What condition does a patient with OSA develop?
GERD
64
If a patient with OSA frequently experiences "heartburn", regurgitation, or a burning, choking sensation with coughing upon waking what might they have developed?
GERD
65
What should be assessed in patient at risk for OSA?
* overall appearance including height and weight (many adult with OSA are overweight)
* examine the jaw, chin, and neck (as OSA is often associated with retracted lower jaw, small chin and a short neck)
* inspect the oral cavity and throat for the size and shape of the pharynx, uvula, and tongue
* check for swelling or enlargement of these structures: tonsils, adenoids, pillars, and soft palate
66
Chronic OSA is linked to what issues which may not respond well to standard treatments?
cardiovascular issues, particularly hypertension
67
What should you measure in OSA patients suspected of cardiovascular issues?
blood pressure, heart rate, and rhythm, and use pulse oximetry
68
If a patient with OSA is being treated for hypertension what should be reviewed?
the medication and dosages used
69
If hypertension is detected but not previously managed in a patient with OSA, what should you do during their assessment/ office visit?
recheck the blood pressure later in the examination and document any persistent elevations
70
What are common behaviors in individuals with chronic OSA?
personality changes, depression, general loss of interest in social activities
71
Who can provide valuable insight into the psychosocial changes of the patient who has OSA?
family members
72
What are some more questions you can ask your OSA patient during their psychosocial assessment?
Have you had difficulty with memory, concentration, perceived energy levels and abioity to stay focused on tasks while working or studying?
73
A questionnaire that evaluates perceived sleep quality and daytime sleepiness?
STOP-Bang Questionnaire
74
If the results of the STOP-Bang questionnaire suggest the presence of OSA, what is the next step a patient may be recommended to followup with?
complete a less invasive home sleep study
75
What is a home sleep study?
the patient sleeps in their own bed while their respiratory rate, heart rate, chest movement, eye movements, and other muscle activity are electronically monitored.
76
If the at-home study indicates a sleep apnea issue, the patient is referred to have a what?
a more comprehensive overnight sleep study, known as polysomnography
77
During what study does the patient get monitored throughout the entire sleep period with a range of equipment to assess sleep depth and type, respiratory effort, oxygen saturation, carbon dioxide levels, and muscle activity?
polysomnography
78
What types of monitoring techniques are used in a polysomnography test?
EEG, ECG, pulse oximetry, and EMG
79
The main concern for the patient with moderate-to-severe OSA is what?
poor gas exchange and hypoxia caused by disrupted sleep patterns
80
Management of OSA depends on the severity of the condition and what?
the patient's willingness to participate in treatment
81
What is the main goal in the treatment of OSA?
to reduce airway obstruction and enhance both the depth and duration of restorative sleep
82
What are some ways to correct OSA and improve gas exchange for mild cases?
changing sleep positions; losing weight
83
Devices that prevent tongue subluxation may reduce what?
obstruction
84
How can an oral appliance improve airflow for someone with OSA?
by holding the lower jaw forward
85
Some devices prevent the tongue from slipping back during sleep, what is a couple drawbacks to these devices?
they may be bulky and uncomfortable; increase risk of oral mucosal damage
86
CPAP
continuous positive airway pressure
87
What is the most common nonsurgical therapy treatment for OSA?
CPAP
88
How does a CPAP work?
it keeps the upper airway open by delivering constant pressure through a nasal-oral facemask, nasal mask, or nasal pillow
89
Why is it necessary to create a proper seal with a CPAP?
a snug fit for effective treatment
90
What led to poor adherence with older CPAP machines?
they were noisy and less comfortable
91
What is different about newer CPAP machines that the old ones?
they are quieter, humidify the air, and often use smaller, more comfortable masks
92
What can the newer CPAP machines monitor/ do that the older ones could not?
patient data and send the information to the patient's smartphone or healthcare provider to track treatment effectiveness
93
What should the patient's be reminded regarding the usage of CPAP machines?
it is crucial to use it daily for at least 6 hrs to reduce OSA-related health risks
94
Many patients adjust well over time and report better sleep and improved well-being which does what?
increases adherence although some believe the equipment to be too intrusive
95
What is vital for therapy success?
patient education
96
What do sleep apnea clinics provide to patients to help ease concerns and promote adherence?
extensive educational resources
97
Does medication have any effect on OSA?
has limited effectiveness
98
What can worsen symptoms of OSA?
sedatives
99
What do stimulants for daytime wakefulness do to patient's with OSA?
often causes side effects without improving restorative sleep
100
What may be considered for patients who cannot tolerate CPAP or for whom it is ineffective?
surgery
101
Before surgery, what is done to identify the problem causing OSA?
thorough endoscopic exam
102
Surgical options may what for OSA patients?
vary depending on cause of OSA
103
Who can benefit from a stimulator implant?
patients with mild-to-moderate OSA
104
Stimulates the hypoglossal nerve to keep the airway open during sleep
a stimulator implant
* (hypoglossal nerve) 12th cranial nerve, and it controls the muscles that move the tongue
105
What are some same-day surgical procedures for patients with a mild case of obstructive sleep apnea?
a stimulator implant, tonsillectomy, adenoidectomy, uvulectomy, or septum repair
106
What are more complex surgeries for patients with obstructive sleep apnea?
uvulopalatopharyngoplasty (UPP); modified uvulopalatopharyngoplasty (modUPP)
107
Most surgical procedures are done same-day unless what?
there is a risk of bleeding or significant airway swelling
108
Uvulopalatopharyngoplasty (UPP) and modified uvulopalatopharyngoplasty (modUPP) are more complex surgeries that involve what?
reconstructing the posterior oropharynx and typically requires a hospital stay of 2 or more days, with a recovery period of 3 to 6 wks
109
Post-surgery care from a UPP or modUPP focuses on what?
maintaining a patent airway, managing pain, and preventing complications
110
Swelling can lead to airway narrowing after UPP or modUPP surgery so what should be monitored?
respiratory effort and gas exchange using pulse oximetry or end-tidal CO2 measurement
111
How often and for what should a patient after UPP or modUPP surgery be evaluated for?
every 2 hrs during the 1st 24hrs for signs of obstruction such as increases respiratory effort, stridor, drooling, changes in voice quality, or reduced oxygen saturation
112
If when monitoring a post-op patient who just underwent UPP or modUPP is having signs of obstruction such as increased respiratory effort, stridor, drooling, changes in voice quality, or reduced oxygen saturation, what should you do?
Notify the Rapid Response Team immediately
113
Why is it essential to control the pain of a patient who just underwent UPP/ modUPP surgery?
the oropharynx is very sensitive
114
In the 1st 24hrs after the more complex surgeries for OSA the patient's pain level is quite high, so what is provided?
intravenous pain medication, with scheduled dosing to provide better relief than the as-needed administration
115
What meds are avoided post-surgery of a OSA patient? Why?
Aspirin and NSAIDS; to reduce the risk of bleeding
116
What is the nursing plan for a post-op OSA patient?
regularly examine the surgical site for bleeding and monitor for signs of increased swallowing or belching- which may indicate blood dripping down the throat; watch for signs of infection- such as purulent exudate, foul breath, or red mucous membranes (report any findings immediately); admin prescribed IV meds for pain; admin prescribed antibiotics
117
Educate the patient that they must not use a toothbrush until they are cleared to resume regular brushing and flossing, why? What should be used in its place?
Infection risk is heightened due to disrupted tissue integrity; oral sponges or mouthwash
118
Proper CPAP compressor and mask/ tubing system maintenance is essential for what?
effective OSA management
119
What is crucial concerning CPAP machines to prevent infection and maintain tissue integrity, especially with humidification, which can increase the risk of fungal infections?
regular equipment cleaning
120
What do most CPAP systems require in the humidifier?
distilled water
121
How often should the mask or nasal pillow be cleaned and how should they be cleaned?
daily; using manufacturer-recommended products
122
Patients with OSA that use a CPAP, should be advised to not share what and why?
their CPAP mask, pillows or tubing; to reduce the risk of infection
123
For patients who have undergone surgery for OSA, what is important to regularly check?
the oropharynx for signs of bleeding, swelling, or infection
124
A small amount of blood in saliva or mucus, particularly after coughing, is normal for a post-op OSA patient. What is not normal and must be immediately reported?
new bleeding, large clots, or bright red blood may signal a serious issue, and the patient should contact their surgeon immediately or visit the ER
125
Patients, who are post-op OSA patients, should be taught to use a mirror for what purpose?
to examine their throat twice daily, noting any changes in size using coin size for comparison. If the throat appears to be narrowing, or if swallowing becomes difficult or painful, especially with drooling, they should seek emergency care as these are signs of swelling that may obstruct the airway.
126
With a post-op OSA patient- what is expected to decrease gradually, and swallowing should become what over time?
pain; more comfortable
127
What should a post-op OSA patient be educated to drink/ eat after surgery that will help ease discomfort?
drink cool liquids, use a humidifier, gargle with warm salt water, eat soft foods
128
What should a post-op OSA patient report to the surgeon?
any increase in pain or worsening difficulty swallowing
129
Educate the post-op OSA patient on the signs of infection. What are they? What should they do if any of these occur?
increased swelling, pus in the oropharynx, a change in mucous membrane color to bright red, increased pain, fever, taste changes, or bad breath; contact the surgeon
130
Activity restrictions for post-op OSA patients will depend upon what?
the type of surgery that was performed
131
Patients should be educated on the importance of the surgeon's restrictions to avoid what?
complications
132
What are some restrictions that a surgeon may put on a post-op OSA patient?
avoid heavy lifting; avoid doing the Valsalva maneuver
133
Some patients may feel anxious about using a CPAP. What should you provide them as the nurse to help them feel more knowledgable and to help them with the adjustment period?
written & digital instructions; contact information for OSA specialists; CPAP supply resources
134
Post-op OSA patients may worry about the procedure's success, pain, or swallowing difficulties. What is important that nurses reassure them?
that pain & difficulty swallowing is normal post-surgery and should improve within a week; snoring and sleep apnea may persist briefly due to swelling, but this should subside as healing progresses
135
What are the expected outcomes for the patient post-OSA surgery?
maintain normal blood pressure or achieve controlled hypertension with appropriate therapy; patient adheres to prescribed nonsurgical interventions and experiences fewer apnea episodes lasting 10 sec or longer during sleep; improved gas exchange and extended periods of restorative sleep are anticipated leading to reduced daytime sleepiness and increased energy levels; have a smooth, uneventful recovery from any surgical intervention
136
What could occur from a variety of causes, including trauma to the nasal mucosa, hypertension, blood disorders like leukemia, inflammation, tumors, low humidity, nose blowing, nose picking, chronic cocaine use, and procedures like nasogastric suctioning?
epistaxis (nosebleed)
137
When a nosebleed occurs what is important to document?
the amount and color of blood, vital signs should be taken, and inquire about any previous episodes including their frequency, duration, and causes
138
In emergency situations when the nose is bleeding, standard precautions should be followed: what should the nurse do?
position the patient upright, leaning forward to prevent blood from entering the larynx and causing aspiration; reassure the patient to keep them calm, as anxiety and elevated b/p can worsen bleeding; apply direct pressure to the sides of the nose for 10 min. and apply ice or cool compresses to the nose and face (if available); if nasal packing is required: both nostrils can be loosely packed with gauze or nasal tampons- to avoid dislodging clots and causing rebleeding, the patient should avoid blowing their nose for 24 hrs after the bleeding stops.
If these measures are ineffective or nosebleeding occurs frequently, the patient should seek medical attention.
139
Why should a patient not blow their nose within 24hrs of a nose bleed?
to avoid dislodging clots and causing rebleeding
140
If nose bleeding persists, medical intervention may be necessary. Such as what?
cauterization with silver nitrate or electrocautery, along with nasal packing
141
Why are posterior nosebleeds more serious?
they are harder to reach and can result in significant blood loss quickly
142
What interventions would be put in place for a posterior nosebleed?
posterior packing, epistaxis catheter, gel tampons
143
What is the risk if the posterior nose bleed interventions/ packing slips?
obstruction of the airway leading to a reduction of gas exchange
144
Patients with a posterior nose bleed should be closely monitored for what?
respiratory distress and tolerance of devices used for intervention
145
What are some treatments that may be prescribed along with opioids for pain relief for a posterior nosebleed?
humidification, oxygen, bed rest, and antibiotics
146
A patient with a posterior nose bleed who is prescribed opioids for pain relief should be assessed how often and for what?
at least every hour; gag and cough reflexes; pulse oximetry should be used to monitor for hypoxemia
147
When is the nasal packing removed from a patient with a posterior nose bleed?
typically after 1 to 3 days
148
If posterior nose bleed does not stop with packing or tubes more invasive treatments may be needed. What are they?
cauterizing or ligating the blood vessels or embolizing the bleeding artery with interventional radiology
149
What treatment for a posterior nose bleed that persists even after interventions can result in complications like facial pain, tissue necrosis, facial nerve paralysis, or even blindness
embollization
150
After the packing or tubes are removed from a patient who had a posterior nose bleed, what can the patient apply for comfort & keep the nasal passages moist preventing rebleeding?
petroleum jelly; saline nasal sprays
151
What should a patient who had a posterior nose bleed be taught?
to avoid vigorous nose blowing, aspirin, NSAIDS, and strenuous activities like heavy lifting for at least a month
152
Nasal injuries can lead to fractures that what?
compromise tissue integrity and hinder gas exchange
153
Why would treatment not be necessary for a nasal injury that lead to a fracture?
bone or cartilage remained aligned and no complications arose
154
Displacement of the bone or cartilage can result in what complications?
airway obstruction, cosmetic deformities, or risk of infection
155
What should be documented with a nasal fracture?
any nasal issues such as deviation, a misaligned nasal bridge, changes in breathing, crepitus, bruising, pain, and any drainage are important
156
What may drain from one or both nostrils following a nasal fracture- it is rare and suggests what?
blood or clear fluid, possibly cerebrospinal fluid; a serious injury like a skull fracture
157
How can CSF be identifed?
by testing positive for glucose or forming a yellow "halo" on filter paper when it dries
158
If a fracture involves displaced bones what may a healthcare provider perform within 24 hrs of injury using local or general anesthesia?
a simple closed reduction
159
After the initial 24hrs reducing the fracture becomes more challenging due to what and then what can be done?
swelling and scar tissue; any procedure may be postponed until the swelling subsides
160
Treatment after the initial 24hrs after a nasal fracture is focused on what?
typically focused on pain relief and applying cold compresses to reduce swelling
161
A surgical intervention may be required to realign the nose and restore function or appearance in cases of severe fractures or improper healing is called a what?
rhinoplasty
162
After rhinoplasty, the patient returns to the floor with?
packing in both nostrils to control bleeding and support the reconstructed nose
163
While the packing is in place, how must the patient breathe?
through their mouth
164
What is placed under the nose to catch any drainage after a rhinoplasty?
a "mustache" dressing (often a folded 2x2 gauze pad)
165
What may be applied to the nose for added protection and alignment after a rhinoplasty?
a splint or cast
166
What is important to change as needed/ teach your patient to change as needed after a rhinoplasty?
the drip pad
167
What should be monitored following a rhinoplasty?
swelling and bleeding due to the disruption of tissue integrity
168
Patients who have undergone an uncomplicated rhinoplasty are discharged when?
usually same day
169
What is a key assessment after rhinoplasty surgery?
monitoring how often the patient swallows- as frequent swallowing could indicate posterior nasal bleeding
170
The post-op (rhinoplasty) patient's throat should be assessed using a penlight looking for what?
for any signs of bleeding (if found- notify the surgeon, when nec)
171
The post-op (rhinoplasty) patient should remain in which position?
semi-fowler
172
When the post-op rhinoplasty patient returns to the floor what interventions will the nurse attend to?
patient remains in the semi-fowler position, moves slowly, rests, applies cool compresses to the nose, eyes, and face to minimize swelling and bruising
173
Once the patient's gag reflex (rhinoplasty) returns what should they be encouraged to do?
drink at least 2500 mL of fluid daily
174
To prevent bleeding, in a post-op (rhinoplasty) patient, what education should they be taught?
to avoid forceful coughing and straining during bowel movements and refrain from sniffing or blowing the nose; avoid sneezing with their mouth closed for the 1st few days after removing the nasal packing; avoid taking NSAIDS or aspirin; complete the prescribed antibiotics; due to swelling the final result of surgery may take 6-12 months to become apparent
175
How is facial trauma classified?
based on specific bones (mandibular, maxillary, orbital, nasal) involved and the affected side of the face
176
What are the most common types of facial trauma?
mandibular or lower jaw fractures
177
A Le Fort increases in severity as what increases?
the number increases (Le Fort I,II, & III)
178
Due to the face's rich blood supply, facial trauma often results in what?
significant bleeding, bruising, and loss of tissue integrity
179
What is the primary concern when caring for a patient with facial trauma?
assessing the airway to ensure proper gas exchange (signs of an airway obstruction: stridor, shortness of breath, dyspnea, anxiety, restlessness, hypoxia, reduced oxygen saturation, cyanosis, and loss of consciousness)
180
Once the airway is secured, evaluate the facial trauma site for what?
bleeding and visible fractures; look for soft-tissue swelling, facial asymmetry, pain, or spinal fluid leakage from the ears or nose (which may indicate a skull fracture)
181
What should you assess in a patient with facial trauma?
patient's vision and eye movement, as fractures in the orbital or maxillary regions can trap eye nerves and muscles
182
What should be inspected in a patient with facial trauma?
behind the ears for significant bruising- known as "battle sign" (which is often linked to skull fractures and brain trauma)
183
Since facial trauma may also involve spinal injuries and skull fractures what testing is often performed?
cranial CT scans, facial x-rays, & cervical spine x-rays
184
The top priority in managing head and neck trauma is what?
establishing & maintaining an airway to ensure adequate gas exchange
185
When establishing. maintaining an airway in a patient with a head &/or neck trauma nurses should be prepared for what?
emergency procedures like intubation, tracheotomy, or cricothyroidotomy
186
What is crucial for patients with head/ neck trauma?
rapid stabilization & early intervention by a specialized team can significantly improve recovery outcomes
187
What does stabilizing a fractured jaw involve?
fixing the teeth in proper alignment, often using fixed occlusion or wiring the jaws shut, lasting 6 to 10 wks
188
Delaying treatment for a patient with a fractured jaw could result in what?
tooth infections, or poor oral hygiene- can lead to jawbone infections (which may require surgical removal of dead tissue, intravenous antibiotic therapy, and an extended period with jaw in a fixed position)
189
A severe jaw fraction may need what?
open reduction with internal fixation- where compression or reconstruction plates are used to hold the bone in place
190
Depending on the material, the plates that are used in surgical procedures in severe jaw fractures, may be what?
usually permanent (may not interfere with MRI scans)
191
What is sometimes used to repair facial fractures?
microplating systems with bone grafts or substitutes (these plates may be removed after healing or left in place permanently)
192
What is done for inner maxillary fixation?
the jawbones are realigned and wired in place- keeping the bite closed
193
What type of anesthesia is done for simple fractures of facial bones?
treated with local anesthesia
194
What type of anesthesia is done for more complex fractures of facial bones (involving several facial bones)?
may require general anesthesia
195
Patients with facial fractures where their jaw is wired closed, educate the patient how to perform oral care.
using irrigating devices like a Waterpik or Sonicare
196
Patients with IMK, educate them on what is essential?
self-management and diet- follow a liquid diet
197
Since the patient with IMK cannot open their jaws during vomiting there is a risk for what?
aspiration
198
What should a patient with their mouth wired shut always carry with them and what should they be educated about it?
wire cutters; instructed on how to cut the wires in case of vomiting to maintain airway safety.
*if the wires are cut, they should promptly return to their surgeon
199
Nutrition can be challenging during recovery due to oral fixation, so collaborating with whom is important?
a registered dietitian/ nutritionist for patient education and support
200
What can result from crushing injuries, direct blows, fractures, or prolonged endotracheal intubation?
laryngeal trauma
201
What can laryngeal trauma lead to?
loss of tissue integrity
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Symptoms of loss of tissue integrity due to laryngeal trauma:
difficulty breathing, loss of voice, hoarseness, and subcutaneous emphysema (hemoptysis may occur depending on the injury's location)
203
What is essential to assess the extent of damage due to laryngeal trauma?
direct visual examination of the larynx using laryngoscopy
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Managing laryngeal injuries involve what?
evaluating gas exchange effectiveness and monitoring vital signs; including respiratory status and pulse oximetry- every 15 to 30 min - ensuring a patent airway is crucial; admin oxygen and humidification as prescribed to maintain adequate oxygen levels
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When monitoring a patient with a laryngeal injury respiratory distress may manifest how?
as tachypnea, nasal flaring, anxiety, sternal retraction, shortness of breath, restlessness, decreased oxygen saturation, decreased level of consciousness, or stridor
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If respiratory distress symptoms are present in a patient with a laryngeal injury what should be done?
stay with the patient and alert the trauma team or Rapid Response Team to prepare for emergency intubation or tracheotomy
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When is surgical intervention necessary for a laryngeal injury?
for lacerations of the mucous membranes, exposed cartilage, or vocal cord paralysis
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Why should laryngeal repair be performed promptly?
to prevent laryngeal stenosis and cover any exposed cartilage
*an artificial airway may be required temporarily
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Malignant tumors where are rare but more frequently observed in adults with chronic exposure to wood dust, leather dust, flour, nickel and chromium dust, mustard gas, and radium?
in the sinuses
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The onset of sinus cancer is what?
gradual
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Symptoms of sinus cancer:
similar to sinusitis, including persistent nasal obstruction, drainage, blood discharge, and pain that continues despite treatment for sinusitis; lymph enlargement is often seen in the side of the tumor
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What is often seen on the side that the tumor in the sinus is located?
enlarged lymph nodes
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What diagnostic imaging is used to locate tumors in the sinuses?
x-rays, CT scans, or MRIs
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What is required to confirm a diagnosis of cancer, after a tumor is located in the sinuses?
a biopsy
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What is the primary treatment for nasopharyngeal cancers?
surgical removal of the tumor, either partially or entirely- often combined with radiation therapy, in some cases chemotherapy is used alongside surgery and radiation
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What are some post-surgical issues of tumor removal with cancer of the sinuses?
body image, speech, taste, and smell changes
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Post-op care from tumor removal from sinus cancer involves what?
general management and meticulous care of the mouth and sinus cavities; monitor the patient for pain and signs of infection
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How do you care for post-op patients' sinus cavities and mouth who had tumor removal of their sinuses from cancer?
use saline irrigation with an electronic irrigation system or a syringe
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What types of cancers are relatively common?
head and neck cancers
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Head and neck cancers are relatively common and can have severe what?
impacts on gas exchange, eating, facial appearance, self-image, speech, and communication
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In order to manage the complex needs of a patient with head or neck cancer a coordinated interprofessional team which includes who?
oncologist, surgeon, nurse, registered dietitian nutritionist, speech-language pathologist, dentist, respiratory therapist, social worker, wound care specialist, clergy, occupational and physical therapists, and psychosocial counselors
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Typically head and neck cancers grow slowly and are generally what?
curable if detected and treated early
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The prognosis for advanced cases of head and neck cancers depends on what?
the extent and location of the tumors
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If treatment is not sought, head and neck cancers are often what?
fatal within 2 years of dx
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How can early lesions present with head and neck cancers?
as white, patchy areas known as leukoplakia or red, velvety patches known as erythroplakia
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How does head and neck cancers initially spread? later?
locally to the lymph nodes, muscles, and bones; later to distant sites such as the lungs or liver
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Where do most head and neck cancers originate?
mucous membranes and skin
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Where can head and neck cancers also start besides the mucous membranes and skin?
salivary glands, thyroid, tonsils, or other structures
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What do treatment strategies depend on with head or neck cancers?
depends on the type of tumor cells and the extent of disease at dianosis
230
Primary risk factors for head and neck cancers:
tobacco and alcohol use
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Additional risk factors for head and neck cancers (besides tobacco and alcohol use):
vocal strain, chronic laryngitis, exposure to chemicals or dust, poor oral hygiene, long-term GERD, and oral infections with human papillomavirus (HPV)
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During an assessment, with a patient suspected of having head or neck cancer, what should be asked?
inquire about tobacco and alcohol use; hx of acute or chronic laryngitis, or pharyngitis, oral sores, difficulty swallowing, and any lumps in the neck; patient's smoking hx in pack-years, alcohol consumption- including the number of drinks per day and the duration of use; oral exposure to HPV
233
For laryngeal cancers, what may occur due to the tumor's size and it's impact on vocal cord function?
hoarseness
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If any adult experiences hoarseness, mouth sores, or a lump in the neck for 3-4wks what should they be assessed for?
laryngeal cancer
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What is crucial for evaluating cancer spread and tumor invasion?
imagining studies, such as x-rays of the skull, sinuses, neck, and chest
236
What diagnostic testing may help define the tumor's extent and what performed during this procedure can confirm the dx?
endoscopic examination under anesthesia; biopsies
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A biopsy can confirm a dx and also?
the tumor type, cellular features, location, and stage
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Warning signs of head and neck cancers:
persistent pain, lumps in the mouth, throat, or neck, and difficulty swallowing; changes in the color of the mouth or tongue to red, white, gray, dark brown, or black; oral lesions or sores that do not heal within 2 wks; unexplained oral bleeding; numbness in the mouth, lips, or face; changes in the fit of dentures; a burning sensation when drinking citrus juices or hot liquids; persistent unilateral ear pain; hoarseness or changes in voice quality; persistent or recurrent sore throat; shortness of breath, anorexia, and weight loss are also important signs to watch for
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What is the goal of treatment for head and neck cancers?
to eliminate the cancer while preserving as much function as possible
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What are the treatment options for head and neck cancer?
surgery, radiation, chemotherapy, and biotherapy
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What treatment for head and neck cancer can be used alone or in combination based on the disease stage, the patient's overall health, nutritional status, age, and personal preferences?
biotherapy
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What treatments can be used for laryngeal cancer?
treatment can vary from targeted radiation therapy for small tumors to more extensive procedures like total laryngopharyngectomy with bilateral neck dissections, followed by radiation therapy, depending on the tumor's size and location
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Nursing care for a post-op (head and neck cancer) patient involves what?
preoperative preparation, in-hospital care, discharge planning, and extensive outpatient rehabilitation
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is effective for small cancers and can be used alone or with surgery and chemotherapy for patients with head and/or neck cancers
radiation therapy
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With radiation therapy, patients often experience side effects. What are they?
hoarseness, sore throat, dysphagia, skin irritation, impaired taste, and dry mouth; skin at the radiation site may become red, tender, and may peel, requiring gentle care with mild soap and protective clothing
246
dry mouth
xerostomia
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What long-term side effect is the result of irradiating the salivary glands, increasing the risk for cavities and necessitating a dental consult, and may be permanent?
xerostomia
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What are some alleviating measures that can help the discomfort of xerostomia?
moisturizing sprays, increased water intake, and humidification
249
Chemotherapy maybe used alone or in conjunction with what therapy?
radiation
250
Surgical options head and neck cancers depend on what factors?
the tumor's size, node involvement, and metastasis
251
How can early-stage tumors (head and neck cancers) be treated?
laser therapy or photodynamic therapy
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For more advanced cases of tumors (head and neck cancers) what may be required?
extensive surgery such as laryngectomy, tracheostomy, or oropharyngeal resections
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Major surgical interventions for laryngeal cancer include what?
cord stripping, cordectomy, partial laryngectomy, and a total laryngectomy
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What surgical interventions are for cancers involving the lymph nodes?
neck dissection may be performed alongside a tumor removal
255
Post-surgical patients (head and neck cancer/ laryngeal cancer) may be educated on what?
airway management, suctioning, pain control, critical care procedures, nutrition support, and feeding tube care
256
What will post-op patients (head and neck cancers/ laryngeal cancer) need to adapt?
new methods of speech, especially if mechanical ventilation is used if a total laryngectomy necessitates permanent changes to communication
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Following a partial or total laryngectomy, what is required? Will it be permanent?
a tracheostomy: partial laryngectomy- temporarily; total laryngectomy- permanently with a stoma
258
What may occur following an extensive surgery?
shoulder drop
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How long does a head and neck surgery last?
>8hrs
260
Where does a patient go after having surgery on their head and neck (cancer) for the immediate postoperative period?
ICU
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In the ICU during the immediate postoperative period, what should be closely monitored for a cancer patient (head and neck)?
airway patency, vital signs, hemodynamic status, and the patient's comfort
262
What nursing actions are taken for the 1st 24hrs post-op for a (head and neck cancer) patient?
take vital signs, check for signs of hemorrhaging; other complications from anesthesia & surgery hourly, then continue according to agency policy until the patient stabilizes
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What are some post-surgical complications that can occur for a patient who underwent head and neck cancer surgery?
airway obstruction, hemorrhage, wound breakdown, and tumor reoccurrence
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What is the primary focus immediately after surgery (head and neck cancer surgery)?
maintaining airway and ensuring adequate gas exchange
265
What may the patient require if airway cannot be maintained or adequate gas exchange ensured?
mechanical ventilation
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During the weaning process of mechanical ventilation, what may the patient have to use to help manage mucous secretions?
a tracheostomy collar with oxygen & humidity
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What kind of secretions may the patient with a trach collar that is being weaned off mechanical ventilation have? How long will it last?
blood-tinged secretions; 1 to 2 days
268
What should be used for patients who are experiencing blood-tinged mucous? and if bleeding increases what should be done?
Standard Precautions; report to the surgeon
269
What is a laryngectomy tube used for?
to prevent scar tissue shrinkage for patients who have undergone a total laryngectomy
270
The laryngectomy tube is similar to a trach tube but is what?
shorter and wider, requires care akin to trach tube care, with the added possibility of daily or as-needed changes
271
What is a laryngectomy button?
a softer and shorter alternative with a single-lumen
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A patient will need alternative communication methods due to their inability to speak with what procedure/ equipment?
total laryngectomy; laryngectomy button or tube
273
Stoma care post-laryngectomy involves what?
a combination of wound and airway care
274
Inspect the stoma and clean the suture line with what?
sterile saline or prescribed solution to prevent crust formation and airway obstruction
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How often should suture line care occur?
every 1 to 2 hrs initially, then every 4 hrs
276
What color should the stoma and trachea mucosa be?
bright pink and free of crust
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What may improve appearance of the stoma?
tissue flaps used for reconstruction
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The first 24 hrs post-surgery are what?
critical
279
What should be evaluated hourly for the first 72 hrs post-surgery (laryngectomy/ stoma)?
all grafts and flaps
280
What should be monitored hourly for the 1st 72 hrs post-surgery (laryngectomy/ stoma)/ flaps/ grafts?
color, drainage, and Doppler activity of the major blood vessels
281
What should be reported within the 1st 72 hrs post-op (laryngectomy/ stoma/ flaps/ grafts)?
any changes, as surgical intervention may be necessary
282
Position patient, to prevent dependence on what after surgery (laryngectomy/ stoma/ flaps/ grafts)?
dependence of surgical flaps
283
What is a common complication, especially if radiation therapy preceded the surgery?
wound breakdown
284
How should wound breakdown be managed?
with packing and local care as prescribed to maintain cleanliness and promote healthy granulation tissue growth
285
The patient should be assessed hourly for signs of what post-operatively after a (head and neck cancer/ laryngectomy) and what should you do if it is found?
signs of a carotid artery leak and if suspected, initiate the Rapid Response Team and avoid touching the area to prevent rupture
286
In case of a ruptured carotid artery:
apply constant pressure to the site, secure the airway, and transport the patient to surgery immediately
287
What poses a high risk of stroke and death?
a carotid artery rupture
288
What is typically administered via a PCA pump for the 1st 1 to 2 days post-surgery (head and neck cancers)?
morphine
289
When should the patient be introduced to liquid opioid
analgesics that may be given through a feeding tube with oral pain medications (after morphine is stopped)?
as the patient progresses and once the patient can tolerate oral intake
290
What are patients who undergo treatment for head and neck cancer at risk for?
malnutrition due to oral fixation
291
What may be placed for nutritional support and removed when the patient can safely swallow (oral fixation)?
a NG, gastrostomy, or jejunostomy tube
292
What is not a concern as the airway is separated from the esophagus after a total laryngectomy?
aspiration
293
294
Patients will experience voice quality and speech changes post-surgery which can significantly impact what?
social interactions, employment, and quality of life
295
Collaborate with a speech-language pathologist to develop and practice what?
communication methods
296
What some ways a patient who underwent a total laryngectomy communicates?
writing, using a picture board, or electronic devices
297
Use of an artificial larynx or learning esophageal speech may be the next step after the patient does what?
progresses after a laryngectomy
298
What is esophageal speech?
where sound is produced by "burping" air into the esophagus and shaping words in the mouth
299
Mechanical devices such as a what, can aid communication by vibrating air in the mouth and throat, though the speech quality can be robotic?
electrolarynges
300
Surgical changes and altered swallowing mechanisms increase the risk for what?
aspiration
301
What can contribute to the risk of aspiration, by keeping the lower esophageal sphincter partially open?
a nasogastric feeding tube
302
Patients with trach tube or those who had partial or supraglottic laryngectomy must be monitored for what?
aspiration
303
What must be taught to patients who have had a supraglottic laryngecromy?
alternative swallowing techniques such as the supraglottic method
304
this method involves sitting upright, clearing the throat, holding the breath, swallowing twice, and repeating process to clear food from the throat:
supraglottic method of swallowing
305
Head and neck cancer surgeries often result in what changes?
to self-concept and self-image due to the presence of a stoma, artificial airway, speech changes, and altered eating methods
306
What are some psychosocial issues that a patient who had/ has head and throat cancer might have?
guilt and regret may arise
307
What should the nurse help the patient do and set for their psychosocial health?
realistic goals, participate in self-care, and use alternative communication methods
308
How should the nurse address social isolation for a patient (head and neck cancer) post-operatively?
suggest loose-fitting clothing, scarves, and cosmetics to cover surgical changes and enhance appearance
309
If no complications arise, the patient is typically discharged home or to an extended-care facility within what timeframe?
2 wks
310
By discharge, what should the patient or a family member be capable of managing?
trach or stoma care; as well as participating in nutrition, wound care, and communication methods
311
What kind of referrals should a patient be given at discharge (who had head and neck cancer/ surgery)?
to support groups, and community health agencies specializing in head and neck cancer recovery
312
Who is often a valuable resource for assessing self-care, potential complications, adjustment issues, and adherence to the medical regimen?
a home care nurse
313
Stoma care includes protection due to what?
anatomical changes from surgery
314
For home laryngectomy care, what should patients be educated on?
avoid swimming and be cautious when showering or shaving; use a shower shield over the tube or stoma during bathing to prevent water from entering the airway; wear a protective stoma cover or stoma guard during the day; when sneezing or coughing- lean slightly forward and cover the stoma to protect it; clean the stoma regularly with mild soap and water and a non-oil-based ointment may be applied as needed to keep the area in good condition; maintain proper humidity, use saline in the stoma, a bedside humidifier, or place pans of water and houseplants around the room; emphasize the need for meticulous cleaning to prevent mold and infection
315
What is important for a patient who underwent head and neck cancer surgery/ stoma wear?
medical alert bracelet and carry an emergency care card to manage any critical situations effectively
316
For patients with severe respiratory issues, what kind of living arrangement changes may be necessary?
modifications for single-floor living
317
A permanent stoma, trach tube, NG, or PEG tube, and wounds can alter what?
body image
318
What should the nurse emphasize to a patient (post-operatively- head and neck cancer)?
the importance of resuming normal activities as much as possible (most patients return to their normal routine usually within 4-6 wks after surgery)
319
Patients with total laryngectomy cannot produce sound while they are doing what?
laughing or crying
320
What may occur during these emotions (laughing or crying) or when coughing or sneezing, which can be embarrassing? What should the patient be prepared to do in such an event?
Unexpected mucous secretions; - the patient should be prepared to cover the stoma with a handkerchief or gauze
321
Patients who have gone through composite resections may face what challenges?
with speech and swallowing; might need to manage trach and feeding tubes in public setting
322
Who should be supervised when assigned or delegated to give care to patients who have risk factors for airway obstruction?
LPNs/ LVNs or AP (CNA)
323
Any direct observations of OBA (obstructive sleep apnea) should be what?
documented
324
What should a patient using a CPAP to manage OSA be instructed to avoid sharing?
the mask device or tubing with others to prevent infections
325
Apply knowledge of anatomy to prevent what from happening in a patient with a trach?
aspiration
326
Teach patients with a CPAP what?
how to correctly use and care of the equipment
327
Remind patients using CPAPs to what daily?
use it whenever they sleep in a bed
328
What should be assessed of any patient who experiences facial or nasal trauma?
airway patency
329
A patient should be assessed for what risk factors?
head and neck cancers
330
Encourage adults who smoke or use tobacco in any way to do what?
quit
331
Teach patients who have had radiation therapy to the oral cavity to have what done at least every 6 months?
dental examination
332
Encourage patients to give prescribed CPAP therapy for OSA how long a trial to adjust to a new and somewhat intrusive sleep routine?
at least 2 wks
333
Who should be taught home management of a laryngectomy stoma or tracheostomy?
patient and family
334
Patients with permanent tracheostomies or laryngectomies should be encouraged to what?
become involved in self-care and to look at the wound and touch the affected area
335
What should be allowed when communicating with a patient with voice loss?
time to communicate
336
What should a nurse teach family members of a patient who cannot speak after surgery for head and neck cancer?
ways to communicate with a patient
337
What should you assess in comatose, cognitively impaired, or non-communicative patients every shift?
the need for oral care to prevent a mucoid impaction
338
Remind patients that their CPAP is only effective when?
the mask is tight enough to prevent air leaks
339
What should be performed to determine adequacy of gas exchange and tissue perfusion?
upper respiratory assessment and reassessment
340
Check the airway and packing of a patient who has posterior nasal packing placed after nasal surgery or posterior epistaxis how often?
at least every hour
341
What should you instruct patient's who have had mandibular immobilization or fixation after a mandibular fracture to keep with them at all times?
wire cutters
342
What should be applied to patients who develop stridor?
oxygen
343
What should a nurse assess the incisions and wounds of a patient who has undergone radical neck surgery for indications of?
loss of tissue integrity, graft perfusion insufficiency, and carotid artery leak or rupture
