chapter 26: Upper respiratory tract stuff

Question 1

Areas of concern

Answer 1

nose, sinuses, pharynx, larynx, and surgery for head and neck cancer

Question 2

Deviated septum

Answer 2

• 80% of ppl have this a little, but diagnosis is for when it’s severe
  -usually bc of trauma
  -fucks with airflow and sinus drainage

Mild:
-nasal congestion and frequent sinus infections
-use saline rinses, decongestants, and analgesics

Severe:
-facial pain, nosebleeds, obstruction to nose breathing
-nasal sptoplasty might be necessary

Question 3

Nasal fracture

Answer 3

-most common facial fracture
-simple fractures are usually uni- or bi-lateral and typically have little to no displacement

-complex fractures usually involve fucking up the rest of your face bones or your spine –> can cause meningeal tearing which leaks CSF –> may manifest as clear/pink drainage after management of bleeding

other signs are crepitus on palpation and difficulty breathing

Question 4

Nursing management of nasal fracture

Answer 4

Maintain airway!
-keep the patient sitting upright

Reduce edema!
-apply ice to face for 10-20 min intervals

Control pain!
-give ordered analgesics (acetominophen or aspirin are goo NSAIDs for first 48 hrs)

Relieve stuffieness!
-nasal decongestants, saline nasal sprays, and a humidifier

Avoid complications
-no hot showers, alc, or smoking for first 48 hrs

Question 5

Doctor management of nasal fractures

Answer 5

simple ones can be manually reset

complex ones –> you gotta wait 5-10 days for the swelling to go down
(maybe antibiotics if mucosa was disrupted)

septoplasty or rhinoplasty to reestablish airways and cosmetics

CAUTION: SEPTAL HEMATOMA ^^^ RISK FOR DEFORMITY AND INFECTION

Question 6

Rhinoplasty

Answer 6

-surgery to improve airway func or for cosmetics
-patient will likely be concerned ab body image
-incisions are inside nose –> sonic rhinoplasty uses ultrasonic device to aspirate bone
-pack (1-2 days) and cast (1-2 weeks) the new nose

Question 7

Special precautions before and after nasal surgery

Answer 7

Before
-Stop aspirin and NSAIDs 5-14 days before to reduce bleeding
-Stop smoking for a bit to encourage healing

After
-monitor pain, surgical site, and airway patency
-teach ab activity restriction: no nose blowing, swimming, heavy lifting, hard core workouts

***sometimes cosmetic endgoal takes a year

Question 8

Epistaxis
who gets them?
why do they happen?
which ones are harder to treat?

Answer 8

ppl over 50

HTN, trauam, low humidity, URT infections, allergies, sinusitis, foreign bodies, chem irritants, anatomic malformations, tumors

posterior ones are harder to treat bc they’re far back and its hard to see how much blood is lost –> happens more in older adults

Question 9

How to treat nose bleeds

Answer 9

-sit up, lean forward, hold nose for 5-15 mins, dont panic, get help if still bleeding

Anterior
-shove tampon with anesthetics or vasoconstrictive agents up there
-can also shove absorbent stuff up there –> “gelatin” stuff
-silver nitrate or thermal caterization

Posterior
-shove stuff deeper –> sponges, epistaxis balloons, 10-14F foley catheter w/ balloon
-2-3 days
-it hurts! give analgesics
-antibiotics bc of impaired mucosa
-nasal sling under nares

Question 10

Post nose bleed care

Answer 10

cleanse and lube with water-soluble jelly
-teach ab saline nasal spray and humidifier
-caution agains aspirin and NSAIDs and nose blowing/extreme exercise for 4-6 weeks

Question 11

Allergic rhinitis
-seasonal
-perennial
episodic
intermittent
-persistant

Answer 11

inflammation of nasal mucosa in response to allergen

-Seasonal = spring and fall from pollen and plants
-Perennial = year round

-episodic = sporadic exposure to allergen–> not part of every day life
-intermittent = symptoms are there less than 4 days a week or 4 weeks a year
-persistent = more than 4 days a week or 4 weeks a year

Question 12

science behind allergic rhiitis

Answer 12

-after initial exposure to allergen, the body makes IgE against it
-at subsequent exposures, mast cells and basophils make histamie, cytokines, PGs, and leukotriens
-4 to 8 hrs later, inflammatory cells go to nasal tissue causing and miantainig allergic reponse

some ppl think its a recurrent cold

Question 13

manifestations of allergic rhinitis

Answer 13

-sneezing, watery/itchy eyes/nose, poor smell, thin/watery nasal drainage
-nasal turbinates are pale, boggy, and swollen
-turbinates fill and press against nasal septum –> can obstruct sinus drainage (sinusitis)
-nasal polyps and post nasal drips = cough

Question 14

Allergic rhinitis treatment

Answer 14

identify and avoid allergen

nasal corticosteroid sprays!!!

oral meds: H1 antihistamies, decongestants, leukotriene receptor antagonists

intranasal meds: anitihistamines, anticholinergics, corticosteroids, cromolyn, and decongestants

immunotherapy (allergy shots) if specific, unavoidable allergen can’t be effectively treated

Question 15

which antihistamines are better?

Answer 15

second generation –> they don’t cause sedation

Question 16

Acute viral rhinopharyngitis

Answer 16

common cold / nasopharyngitis
-most prevalent infectious disease –> ppl get 1-3 per year

usually coronavirus, RSV, or enterovirus
-droplet (and kinda contact) spread –> worse with overcrowding
-symptoms start 2-3 days aft infection and last up to 2 weeks

risk factors = fatigue, stress, allergies, immunocomprimise

Question 17

How to treat acute viral rhinopharyngitis

Answer 17

-rest, fluids, antipyretics, analgesics

for sore throat
-warm salt gargles, ice chips, lozenges, or sprays

for cough
-antihistamie and decongestant therapy reduce postnasal drip
-dont use decongestant spray more than 3 days –> rebound congestion

vit C, echinacea, and zinc aren’t proven to help

Teach patients to recognize signs of secondary bacterial infections

Question 18

complications of acute viral rhinopharyngitis

Answer 18

acute bronchitis
sinusitis
otis media
tonsilitis
pneumonia

Go to HCP if symptoms last over 2 weeks

Question 19

Influenza

Answer 19

Super contagious rep illness that kills ppl –> GET VACCINATED

4 serotypes: A, B, C, and D

droplet spread

incubation = 1-4 days (peak contagiousness on day 3)
symptoms last 5- 7 days

Question 20

Influenza A

Answer 20

most common
has 2 surface proteins: H helps enter cell; N helps w/ cell-to-cell transmission
infects a lot of animals

mutates to affect humans –> causes pandemic or epidemic bc ppl’s immune systems aren’t used to it

Question 21

Influenza B and C

Answer 21

B and C only affects humans
No subtypes
B sometimes causes epidemics, but milder than A
C causes mild symptoms, but not epidemics

D only affects animals

Question 22

Influenza manifestations: complicated and uncomplicated

Answer 22

uncomplicated:
-similar to a cold
- abrupt onset
-headache, cough, sore throat fatigue
-normal breath sounds and chest ascultation

complicated:
-pneumonia from primary influenza or secondary bacterial infection (and ear/sinus infection)
-dyspnea and crackles
-if bacterial pneumonia, influenza gets better, but cough and purulent sputum gets worse

Question 23

diagnosing influenza

Answer 23

-not using viral cultures as much

Rapid influenza diagnostic tests (RIDTs)
-can detect influenza from resp secretions in 5 mins
-best if done w/in 48 hrs of symptoms onset
-sometimes inaccurate

Question 24

contraindictions to influenza vaccine

Answer 24

severe allergic reactions to past ones

egg allergy –> there’s alternatives for ppl like this though

Question 25

anitviral meds for influeza

Answer 25

Neuraminidase inhibitors preventing spread to other cells Zanamivir (Relenza) --> inhaler Oseltamivir (Tamiflu) --> capsule Peramivir (Rapivab) --> IV New drug baloxavir marboxil (Xofluza) --> PA endonuclease inhibitor that stops viral replication --> oral

Question 26

Sinusitis

Answer 26

Affects 1/7 adults --> inflammation blocks ostia to sinuses -build up of fluid in sinuses promotes bacterial infections -often follows URT infection where ciliary action is decreased If symptoms worsen after 3-5 days or last longer than 10 days, secondary bacterial infection is probably present (5-10% of the time) --> streptococcus pneumonia, moraxella, haemophilus influenzae

Question 27

Sinusitis -acute subacute -chronic

Answer 27

Acute = starts within 1 week or URT infection and lasts less than 4 weeks Subacute = lasts 4-12 weeks Chronic = longer than 12 weeks --> usually associated with allergies and nasal polyps --> happens after a bunch of acute ones permanently fuck up cilia

Question 28

Acute sinusitis manifestations

Answer 28

pain over sinus purulent drainage nasal obstruction congestion fever malaise headaches halitosis

Question 29

chronic sinusitis manifestations -also risk factors/correlations

Answer 29

nonspecific rarely febrile facial pain, nasal congestion, increased drainage --> not severe pain or purulent shit nasal endoscopy, xray, CT scan confirm Asthma, GERD, smoking

Question 30

management of sinusitis

Answer 30

decongestants/ saline nasal spray intranasal corticosteroids analgesics Amoxicilin if bacterial infection -if that doesn't help after 2 weeks, add in clavulanate, fluoroquinolone, or cephalosporin If chronic, broad spectrum antibiotics for 4-6 weeks Surgery and propel implant (dissolves after 30 days) if hypertrophy or septal deviation is the cause

Question 31

Nasal polyps

Answer 31

soft, painless growths from repeat inflammation of sinus or nasal mucosa -yellow, gray, or pink grape-like things If big, can cause nasal obstructio, nasal discharge, and speech distortion --> fix wtih corticosteroids or endoscopic/laser surgery

Question 32

Foreign bodies

Answer 32

inorganic = plastic or metal --> no symptoms organic = food --> inflammation, nasal discharge with bad smell pain, difficulty breathing, nasal bleeding blow it out- don't irrigate bc that'll push it back in

Question 33

Acute pharyngitis

Answer 33

inflammation of pharyngeal walls -may include tonsils, palate, and uvula -can be viral, bacterial, or fungal viral = 90% of the time bacterial = 5-10% ----> strep throat from beta-hemolytic streptococci fungal = after long antibiotic or corticosteroid use --> also immuno supressed ppl Other causes = dry air, smoking, GERD, allergies, intubation, chems, cancer

Question 34

Acute pharyngitis manifestation

Answer 34

-red, swollen throat If bacterial: -fever over 100.4 -anterior cervical lymph node enlargement -tonsillar or pharyngeal exudate -absence of cough white irregular patches = candida albicans

Question 35

caring for acute pharyngitis

Answer 35

if strep throat, pennicilin several times a day for 10 days to prevent rheumatic fever -other antibiotics are ok too: erythromycin, clindamcin, azithromycin -person is still contagious til they've been on meds 24-48 hrs candida is treated with nystatin --> swish around mouth ibuprophin or acetominphen for pain

Question 36

peritonsilar abcess

Answer 36

complication of tonsilitis -usually from strep -pain, swelling, throat blocking fever, chills, leukocytosis, difficulty swallowing, muffled voice treatment = IV antibiotics, needle aspiration, or incision and drainage of abcess --> sometimes emergency tonsillectomy

Question 37

Laryngeal Polyps

Answer 37

develop on vocal cords from vocal abuse or irritation -hoarseness is main thing -treat with voice rest and hydration Big ones cause dysphagia, dyspnea, and stridor --> might need surgery

Question 38

Acute laryngitis

Answer 38

swelling and inflammation of voice box -usually viral, but can also be from overuse of voice or exposure to irritants tingling or burning in back of throat is main thing -also fever, cough, feeling of fullness in throat -symptoms shouldn't last more than 3 weeks

Question 39

treatment of acute aryngitis

Answer 39

dont talk or sing --> kinda impossible --> whispering makes it worse though so idk -acetaminophen, cough suppressants, lozenges, and humidifiers can help -hydration is good; caffeine, smoking, and alc are bad

Question 40

Airway obstruction

Answer 40

manifestations -choking, stridor, use of accessory muscles, intercostal retraction, nostril flaring, wheezing, restlessness, tachycardia, cyanosis, and change in LOC Gotta have an airway w/in 3-5 mins to prevent permanent brain damage Interventions = heimlich, cricothyroidotomy, ET intubation, or tracheostomy

Question 41

Tracheostomy

Answer 41

shorter and wider than ET tube: -lower infection risk, more comfy, less risk of vocal cord damage Similar to cricothyroidotomy, but done in OR rather than emergencies Newer technique = percutaneous tracheostomy where you open the hole progressively to prevent bleeding and other complications

Question 42

pieces of tracheostomy tubing

Answer 42

flange = faceplate obturator = helps insert tube outer cannula = keeps airway patent inner cannula cuffs w/ balloons = ensure airway is open (usually if breathing mechanically) fenestrations in cannulas = allow for spontaneous breathing and talking

Question 43

Nursing prep before tracheostomy

Answer 43

explain procedure make sure all personel and equipment are there -bag-valve-mask, bedside suction, IV take vitals put patient supine give analgesia

Question 44

After tracheostomy

Answer 44

inflate cuff --> confirm w/ auscultaion of chest, end tidal CO2, ad air through suction catheter remove ET tube monitor vitals and ventilator settings chest xray

Question 45

how often to check, clean, and dress tracheostomy

Answer 45

check at least once per shift dress and clean every 12 hrs

Question 46

management of tracheostomy balloon and suction post surgery

Answer 46

check pressure every 8 hrs pressure shouldn't exceed 20-25 --> don't want to damage tracheal mucosa don't do suction during first couple hours -give humidified air to compensate for loss of moisture

Question 47

changing tapes and tubes of tracheostomy

Answer 47

change tape 24 hrs after procedure --> 2 person job HCP can change tubes no sooner than 7 days after tracheostomy -keep tube of equal or lesser size by bed

Question 48

what to do if tracheostomy tube gets dislodged?

Answer 48

call for help assess patient for resp distress use hemostat to spread opening where tube was isplaced put obturator in replacement tube, lube with saline, and insert into stoma take out obturator OR -stick suction catheter in and thread tracheostomy tube over the catheter -remove suction catheter -only ok to do if stoma is older than a week --> if not, semi fowler's position -cover stoma with dressing and ventilate

Question 49

Tracheostomy long term care -how often to change? -swallowing

Answer 49

change after 1 month the first time, then every 1 to 3 months after that inflated cuff might cause swallowing probs --> assess for aspiration with videofluoroscopy or fiberoptic endoscopy --> leave cuff deflated or use cuffless tube if it helps

Question 50

Passy-Muir valve

Answer 50

-attaches to hub of tracheostomy tube -when cuff's deflated, valve moves air through vocal cords on exhalation -inhalation still happens through tube

Question 51

Decannulation requirements

Answer 51

1. hemodynamic stability 2. have an intact, stable respiratory drive 3. be able to adequately exchange air 4. independantly expectorate secretions

Question 52

steps for decannulation

Answer 52

-suction the tube and make sure there's no oral secretions -loosen or cut tracheostomy tape and remove sutures -MAKE SURE CUFF IS DEFLATED -pull out in one smooth motion, but stop if resistance -apply sterile dressing and moitor for bleeding

Question 53

Head and neck cancer basics

Answer 53

affects nasal cavity, sinuses, pharynx, larynx, oral cavity, and salivary glands --> usually arises from squamous cells lining the mucosa -smoking and alc are big contributors -ppl over 50! (if under 50, assoc w/ HPV)

Question 54

head and neck cancer manifestations

Answer 54

-soar throat -hoarseness lasting more than 2 weeks -ear pain/ ringing in ears -swelling or lumps in neck -constant coughing/ coughing up blood -difficulty chewing, swallowing, moving tongue

Question 55

Nursing diagnosis of head and neck cancer Doctor stuff

Answer 55

inspect ears, nose, throat, mouth -check for thickening of oral mucosa -check for leukoplakia or erythroplakia (preceed invassive carcinoma by many yrs) -check neck lymph nodes Docotrs: pharyngoscopy/laryngoscopy, biopses, CT or MRI, PET

Question 56

TNM staging

Answer 56

-size of tumor -number of lymph nodes involved -extent of metastasis

Question 57

Surgical therapy for head and neck cancer

Answer 57

Vocal cord stripping - doesn't affect voice Laser surgery Cordectomy - part or all of vocal cords --> affects voice Partial or total laryngectomy - affects voice pharyngectomy trachostomy lymph node removal Neck disection surgery -radical = all tissue from mandible to clavicle (muscle, nerve, glands, vessels) -modified radical = lymph nodes and some tissue -selective = fewer lymph nodes

Question 58

radiation therapy for head and neck cancer

Answer 58

-can use external beam therapy or internal implants (brachytherapy) -Brachytherapy = put radioactive seeds in/near the tumor via a needle

Question 59

Chemotherapy

Answer 59

-used with radiation for stages 3 and 4 -Cetuximab (Erbitux) = targeted therapy used with chemo to stop cells from growing

Question 60

nutrition therapy for cancer

Answer 60

-might be painful or difficult to eat -enteral feeding is important -bland foods are more tolerable, but can add mild sauces to add cals and lubricate -try to get as many cals as possible in bc patients are usually malnourished -videofluoroscopic swallowing studies WATERY STUFF LEADS TO ASPIRATION

Question 61

Approaches to restore oral communication

Answer 61

1. electrolarynx 2. tracheoesophageal puncture (TEP) -- Blom-Singer is most common 3. esophageal speech - hard to learn; alters speech

Question 62

Post-laryngectomy

Answer 62

-need frequent suction -secretions change over time (check every hour and then switch to every 4 hrs) -at first, lots of blood-tinged secretions that gradually diminish and thicken -need adequate fluid and humidifiers -deep breathing and coughing are good

Question 63

What helps with xerostema from radiation?

Answer 63

-fluids sugarless gum sugarless candy nonalc mouth rinses artificial saliva fluoride gels help prevent dental deterioration

Question 64

Other considerations for radiation patients

Answer 64

-have block in mouth during treatment -use warm, bland rinses 4-6 times a day -nothing spicy, hot, or acidic -only perscribed lotions -walk 15-30 mins a day

Question 65

stoma care

Answer 65

-clean daily with moist cloth -nasal spray every 1-2 hrs prevents crusting -remove laryngectomy tube and clean it daily along with inner canula -cover it when coughing or doing anything that could let stuff in -no swimming