Lewis Ch 26 upper respiratory problem Flashcards
(307 cards)
1
Q
nose, sinuses, pharynx, and larynx
A
upper respiratory system, including
2
Q
is a deflection of the normally straight nasal septum
A
Deviated septum
3
Q
Trauma to the nose, either at birth or later in life, is the
A
most common cause of deviated septum.
4
Q
both airflow and sinus drainage through the narrowed passageway.
A
Deviated septum can interfere with
5
Q
asymptomatic to nasal congestion and frequent sinus infections
A
Minor septal deviations can range from
6
Q
facial pain, nosebleeds (epistaxis), and obstruction to nasal breathing.
A
Manifestations of severe septal deviation include
7
Q
focuses on symptom control.
-nasal inflammation and congestion, use saline rinses and decongestants to clear nasal passages and analgesics for pain relief
A
medical management of minor septal deviation
8
Q
, a nasal septoplasty, done under local or general anesthetic, reconstructs and properly aligns the deviated septum.
A
severe septal deviation medical management
9
Q
is the most common facial fracture and the third most common fracture of any bone
A
Nasal fracture
10
Q
often occur from blunt trauma, including fights, automobile accidents, falls, and sports injuries.
A
cause Nasal fracture
11
Q
(e.g., impacted, comminuted) or based on direction of injury (e.g., lateral, frontal)
A
classify nasal fractures according to the fracture pattern
12
Q
may be unilateral or bilateral and typically have little or no displacement.
A
Simple fractures
13
Q
complex fractures, which may involve damage to adjacent facial structures, such as the teeth or eyes.
A
Powerful frontal blows can cause
14
Q
for injury to the cervical spine, orbital bone, or mandible.
A
Patients with complex nasal fractures should be evaluated
15
Q
Complications include airway obstruction, nosebleeds, meningeal tears causing cerebrospinal fluid (CSF) leakage, septal hematoma, and cosmetic deformity
A
Patients with complex nasal fractures complications
16
Q
nosebleed, localized pain, crepitus on palpation, swelling, difficulty breathing out of the nostrils, and bruising.
A
nasal fractures manifestations
17
Q
Periorbital bruising involving both eyes is called raccoon eyes. It suggests a basilar skull fracture
A
raccoon eyes
18
Q
Clear or pink-tinged persistent drainage after control of bleeding
A
suggests a possible CSF leak
19
Q
Checking this fluid for glucose at the bedside to help confirm the presence of CSF is not recommended because the result is highly unreliable.
A
Glucose on CSF leak (NOT reliable)
20
Q
If needed, send a specimen to the laboratory to determine the fluid type.
A
Determine if its CSF leak
21
Q
maintain a patent airway, reduce edema and pain, prevent complications, and provide emotional support
A
Goals of nursing management are to (nasal fracture)
22
Q
best way to maintain the airway is to keep the patient sitting upright. Apply ice to the face and nose in 10- to 20-minute intervals to help reduce edema and bleeding. Give analgesia as ordered to control pain. Acetaminophen is preferred over nonsteroidal antiinflammatory drugs (NSAIDs) or acetylsalicylic acid (ASA; aspirin) for the first 48 hours to avoid prolonging clotting time and increasing the risk for bleeding. Nasal stuffiness may be relieved with nasal decongestants, saline nasal sprays, and a humidifier. The patient should avoid hot showers and alcohol for the first 48 hours to prevent an increase in swelling. Encourage the patient to quit or decrease smoking to help tissue healing.
A
Medical management for nasal fracture
23
Q
using closed or open reduction
A
fracture is confirmed, the goals are to realign the fracture
24
Q
are often reduced with manual manipulation.
A
Simple fractures (management)
25
, considerable swelling of soft tissues occurs. It may be necessary to wait to repair the fracture until after the edema subsides, which may be 5 to 10 days. Antibiotics should be considered for any nasal fracture with disruption to the mucosa.
With complex nasal fractures (management)
26
include septoplasty and rhinoplasty
Surgical options for nasal fractures
27
is done to correct a deviated septum
Septoplasty (surgery indication)
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improve airway function when trauma or developmental deformities result in nasal obstruction or for cosmetic reasons.
rhinoplasty (surgery indication)
29
Both procedures help maintain a patent airway, restore function of the nose, and help reestablish the patient’s cosmetic appearance. The presence of septal hematoma increases the patient’s risk for deformity and infection, which may require drainage and antibiotic therapy.
septoplasty and rhinoplasty improve
30
, assess the patient’s expectations of the surgery.
rhinoplasty patients before surgery
31
HCP can use digital photographs to show patients their projected appearance after surgery. These images can help patients decide whether to undergo rhinoplasty
rhinoplasty (shown after pic before surgery)
32
is an outpatient procedure using regional or general anesthesia. Nasal tissue is added or removed, and the nose may be lengthened or shortened
Most rhinoplasty (process of surgery)
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Plastic implants are sometimes used to reshape the nose. Incisions are typically inside the nose and hidden.
rhinoplasty (tool w/in surgery)
34
incorporates the use of an ultrasonic device to gently aspirate bone, enabling a refined cosmetic result
Sonic rhinoplasty (sculpts & allows for precision of nose)
35
, nasal packing may be inserted to apply pressure and prevent bleeding or septal hematoma formation.
-An external plastic splint protects and supports the new shape of the nose during the healing process.
-If present, nasal packing is usually removed 1 or 2 days after surgery.
-The splint may be left in place for 1 to 2 weeks.
After rhinoplasty surgery
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Aspirin-containing drugs and NSAIDs may need to be stopped for 5 days to 2 weeks preoperatively to reduce the risk for bleeding. Encourage smoking cessation to promote postoperative wound healing
Before surgery rhinoplasty requirements
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(1) ensuring patency of the airway,
(2) continuous assessment of respiratory status,
(3) monitoring for airway obstruction,
(4) pain management,
(5) observation of the surgical site for edema, bleeding, and signs and symptoms of infection.
During the immediate postoperative period rhinoplasty, nursing interventions include
38
patient typically has temporary nasal and/or facial edema and bruising.
- Cold compresses and elevation of the head can help minimize swelling and discomfort. Teach about activity restrictions aimed at preventing bleeding and injury (no nose blowing, swimming, heavy lifting, strenuous exercise).
-Sometimes swelling may be slow to resolve, delaying the achievement of a full cosmetic result for up to 1 year.
Teaching/ expectations after rhinoplasty
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most often occurs in adults over age 50
Epistaxis (nosebleed)
40
by trauma, hypertension, low humidity, upper respiratory tract infections, allergies, sinusitis, foreign bodies, chemical irritants (e.g., street drugs), overuse of decongestant nasal sprays, facial or nasal surgery, anatomic malformation, and tumors
Nosebleeds can be caused
41
if the patient takes aspirin, NSAIDs, warfarin, or other anticoagulant drugs.
enhancement of Bleeding caused by
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in the anterior part of the nasal cavity and are easily visualized.
- Anterior bleeding can be self-treated and usually stops spontaneously.
About 90% of nosebleeds (location and management)
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more often with older adults secondary to other health problems (e.g., hypertension). Since posterior nosebleeds are closer to the throat, it is often hard to determine how much blood loss has occurred. Posterior bleeding may need medical treatment.
Posterior bleeding occurs
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(1) place the patient in a sitting position, leaning slightly forward with head tilted forward;
(2) apply direct pressure by squeezing the entire soft lower part of the nose (nostrils) together for 5 to 15 minutes; and
(3) reassure and calm the patient. If bleeding does not stop within 15 minutes, seek medical assistance.
simple first aid measures to control nosebleeds
45
,a pledget (nasal tampon) impregnated with anesthetic solution (lidocaine) and/or vasoconstrictive agents (epinephrine) may be placed into the nasal cavity.
- Absorbable materials, such as oxidized cellulose (surgical), gelatin foam (Gelfoam), or a gelatin-thrombin combination (Floseal), are another option.
-Packing for anterior bleeds can stay in place for 48 to 72 hours.
-Silver nitrate may be used to chemically cauterize a specific bleeding point.
-Thermal cauterization is reserved for more severe bleeding and may require the use of local or general anesthesia
anterior bleeds medical management
46
often need packing. Packing with compressed nasal sponges (e.g., Merocel) or epistaxis balloons (e.g., Rapid Rhino) is preferred over the use of traditional Vaseline ribbon gauze because of the ease of placement.
-Packing is inserted into the nares and advanced along the floor of the nasal cavity. The sponge expands with moisture to fill the nasal cavity and tamponade bleeding.
-The epistaxis balloon is inflated with air to achieve the same pressure effect
- In the absence of a specific nasal device, a size 10F, 12F, or 14F Foley catheter with a 30-mL balloon may be used.
-A nasal sling (folded 2 × 2–inch gauze pad) may be gently taped under the nares to absorb drainage. If packing does not stop the bleeding, arterial embolization may be needed.
Posterior bleeds medical management
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can impair respiratory status
-Closely monitor the level of consciousness, heart rate and rhythm, respiratory rate, and O2 saturation (SpO2) using pulse oximetry. Observe for any signs of difficulty breathing or swallowing
Nasal sponges, packing, and balloons ALERT
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Nasal packing is painful because sufficient pressure must be applied to stop the bleeding. The patient should receive appropriate analgesia. Nasal packing predisposes patients to infection from bacteria (e.g., Staphylococcus aureus) present in the nasal cavity. Antibiotics effective against staphylococci may be prescribed.
Nasal packing for posterior bleeds may be left in place for 2 to 3 days. Before removal, pre-medicate the patient for pain because this procedure is uncomfortable. After packing removal, cleanse the nares gently and lubricate them with water-soluble jelly.
Downside of Nasal packing
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Review how to use saline nasal spray and/or a humidifier.
-Have the patient sneeze with the mouth open and avoid the use of aspirin-containing products or NSAIDs.
-Teach the patient to avoid vigorous nose blowing, engaging in strenuous activity, and lifting and straining for 4 to 6 weeks.
Teaching before discharge for person with posterior bleeding
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is inflammation of the nasal mucosa, often in response to a specific allergen
Allergic rhinitis
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can be classified according to the causative allergen (seasonal or perennial/ last long time) or the frequency of symptoms (episodic, intermittent, or persistent).
classification of Allergic rhinitis
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refers to symptoms related to sporadic exposure to allergens not typically encountered in the patient’s normal environment, such as exposure to animal dander when visiting another person’s home.
Episodic (allergens)
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means that the symptoms are present less than 4 days a week or less than 4 weeks per year.
Intermittent (allergens)
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means that symptoms are present more than 4 days a week and for more than 4 weeks per year.
Persistent (allergens)
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usually occurs in the spring and fall
Seasonal rhinitis (timing/ocurs)
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It is caused by allergy to pollens from trees, flowers, grasses, or weeds
causes of Seasonal rhinitis
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Attacks may last for several weeks during times when pollen counts are high; then it disappears and often recurs at the same time the next year
Seasonal rhinitis (duration)
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occurs year-round from exposure to environmental allergens, such as animal dander, dust mites, cockroaches, fungi, and molds. Both seasonal and perennial rhinitis can be classified as episodic, intermittent, or persistent, depending on the duration and frequency of symptoms.
Perennial rhinitis
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as episodic, intermittent, or persistent, depending on the duration and frequency of symptoms
Both seasonal and perennial rhinitis can be classified
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with initial allergen exposure, which results in the production of antigen-specific immunoglobulin E (IgE)
Sensitization to an allergen occurs
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mast cells and basophils release histamine, cytokines, prostaglandins, and leukotrienes.
After exposure (process/ pathophysiology)
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cause the early symptoms of sneezing, itching, rhinorrhea, and congestion 4 to 8 hours after exposure, inflammatory cells infiltrate the nasal tissues, causing and maintaining the inflammatory response. Because symptoms of rhinitis are like those of the common cold, the patient may think the condition is a continuous or repeated cold.
After exposure (process/ pathophysiology)
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are sneezing; watery, itchy eyes and nose; decreased sense of smell; and thin, watery nasal discharge that can lead to a more sustained mucus production and nasal congestion.
-Nasal turbinates appear pale, boggy, and swollen.
Manifestations of allergic rhinitis
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appear pale, boggy, and swollen. The turbinates may fill the air space and press against the nasal septum. The posterior ends of the turbinates can become so enlarged that they obstruct sinus aeration or drainage and result in sinusitis.
Nasal turbinates (effect of allergic rhinitis)
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, the patient may develop a headache, stuffy nose, nasal congestion, and sinus pressure
chronic exposure to allergens
66
are the most common causes of cough. The patient may report hoarseness and the need to frequently clear the throat
Nasal polyps and postnasal drip
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are the first-line and most effective treatment for allergic rhinitis.
Nasal corticosteroid sprays
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H1-antihistamines, decongestants, and leukotriene receptor antagonists (LTRAs)
oral medication ( allergic rhinitis.)
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Blocks nasal cholinergic receptors, reducing nasal secretions in the common cold and nonallergic rhinitis.
Nasal Spray/ anticholinergic
ipratropium bromide (Atrovent)
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Nasal dryness and irritation, nosebleeds may occur. Does not cause systemic side effects.
-May reduce the need for other rhinitis medications.
Nasal Spray/ anticholinergic
ipratropium bromide (Atrovent)-side effect
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brompheniramine
chlorpheniramine (Chlor-Trimeton)
clemastine (Tavist)
dexchlorpheniramine
diphenhydramine (Benadryl)
First-Generation Agents (Oral)/ Anti-histamine
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Cross blood-brain barrier, often causing sedation and somnolence.
Can cause paradoxic stimulation (restlessness, nervousness, insomnia).
Anticholinergic side effects (e.g., palpitations, dry mouth, constipation, urinary hesitancy).
First-Generation Agents (Oral)/ Anti-histamine side effect
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Warn patient that operating machinery and driving may be dangerous because of sedative effect.
• Teach patient to report palpitations, change in heart rate, change in bowel or bladder habits.
• Teach patient not to use alcohol with antihistamines because of additive depressant effect.
• Rapid onset of action, no drug tolerance with prolonged use.
First-Generation Agents (Oral)/ Anti-histamine Considerations
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cetirizine (Zyrtec)
desloratadine (Clarinex)
fexofenadine (Allegra)
levocetirizine (Xyzal)
loratadine (Claritin)
Second-Generation Agents (Oral)/ Anti-histamine
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Limited affinity for brain H1 receptors. Cause minimal sedation, few effects on psychomotor activities or bladder function.
Second-Generation Agents (Oral)/ Anti-histamine Side effect
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• Teach patient to expect few, if any, side effects.
• More expensive than traditional antihistamines.
• Rapid onset of action, no drug tolerance with prolonged use.
Second-Generation Agents (Oral)/ Anti-histamine consideration
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azelastine (Astelin)
olopatadine (Patanase)
Second-Generation Agents (Intranasal)/Anti-histamine
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Headache, bitter taste, somnolence, nasal irritation.
- Longer use increases risk for rebound vasodilation, which can increase congestion
Second-Generation Agents (Intranasal)/Anti-histamine side effects
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• Tolerance variable.
• Advise patient of adverse reactions.
• Patient to inform HCP if preexisting cardiovascular disease, hypertension, diabetes, glaucoma, benign prostatic hyperplasia, hepatic or renal disease present before starting therapy.
• Rebound nasal congestion may occur with chronic overusage.
Decongestants (Oral)
pseudoephedrine (Sudafed) Nursing actions
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before first-generation antihistamines because of their nonsedating effects
Second-generation antihistamines are used
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such as an oral H1-antihistamine and an intranasal corticosteroid, may be helpful.
If monotherapy does not relieve symptoms, a 2-drug combination,
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drowsiness and sedation.
• Warn patients that operating machinery and driving may be dangerous because of the sedative effect.
First-generation antihistamines (e.g., chlorpheniramine [Chlor-Trimeton]) can cause
83
Large doses may cause tachycardia and palpitations, especially in patients with heart disease.
• Overdose in those over 60 years of age may result in central nervous system depression, seizures, and hallucinations.
Pseudoephedrine (Sudafed)/ DRUG ALERT
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may be used when a specific, unavoidable allergen is identified, and drugs are not tolerated or are ineffective in controlling symptoms.
Immunotherapy (allergy shots)
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controlled exposure to small amounts of the known allergen through frequent (at least weekly) injections with the goal of decreasing sensitivity.
Immunotherapy involves
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may an option for select patients.
Sublingual or intranasal administration of allergen immunotherapy
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is an infection of the upper respiratory tract.
- most prevalent infectious disease
Acute viral rhinopharyngitis (nasopharyngitis, common cold)
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the coronavirus and are mild and self-limiting. Other viruses, such as human respiratory syncytial virus (RSV) and enterovirus, can cause a common cold.
common cold caused by
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viruses are contagious. They spread by airborne droplets emitted by the infected person while breathing, talking, sneezing, or coughing
Acute viral rhinopharyngitis / common cold
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can survive on inanimate objects for up to 3 days, transmission also occurs by direct hand contact. Frequency of the infection increases in winter months when people stay indoors and overcrowding is more common. Other factors that increase susceptibility include fatigue, physical and emotional stress, allergies affecting the nose and throat, and a compromised immune status.
cautious/ causes of common cold viruses
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Exercise
reduce the number of upper respiratory tract infections
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typically begin 2 or 3 days after infection. They may include runny nose, watery eyes, nasal congestion, sneezing, cough, sore throat, fever, headache, and fatigue. Patients are contagious 1 to 2 days before symptom onset and remain contagious until symptoms have subsided. Symptoms may last 2 to 14 days, with typical recovery in 7 to 10 days
Symptoms Acute viral rhinopharyngitis / common cold
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may slightly reduce the incidence of the common cold.
-does not appear to reduce the duration of a common cold.
-used on a short-term basis in recommended doses
- Caution patients with autoimmune disorders or a tendency toward allergic reactions about using this herb.
Echinacea
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oral zinc (e.g., lozenges, tablets, syrup) and intranasal zinc (e.g., swabs, gels).
-given within 24 hrs of onset of symptoms, zinc lozenges may reduce the duration of cold symptoms
Zinc is available in 2 forms:
95
Rest, oral fluids, antipyretics, and analgesics
interventions to relieve common cold symptoms
96
Warm salt water gargles, ice chips, lozenges, or sprays may help ease a sore throat. Petroleum jelly soothes a raw nose.
Saline nasal spray reduces nasal congestion.
interventions to relieve common cold symptoms
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reduce postnasal drip and decreases the severity of cough, nasal obstruction, and nasal discharge.
Antihistamine and decongestant therapy
98
Saline nasal spray
reduces nasal congestion.
99
Petroleum jelly
soothes a raw nose
100
for no more than 3 days to prevent rebound congestion from occurring.
Caution patients to use intranasal decongestant sprays
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include acute bronchitis, sinusitis, otitis media, tonsillitis, and pneumonia
Complications of Acute viral rhinopharyngitis
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They are an option only if complications are present. Refer to an HCP if there is no improvement in symptoms within 10 to 14 days.
Teach patients to recognize the manifestations of a secondary bacterial infection, such as a temperature higher than 103° F (39.4° C); tender, swollen glands; severe sinus or ear pain; or significantly worsening symptoms. Green, purulent nasal drainage during the later stages of a cold is not uncommon and not always indicative of bacterial infection.
Antibiotics have no effect on viruses.
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is a highly contagious respiratory illness that causes significant morbidity and mortality.
Influenza (flu)
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begins in September and continues through April of each year, peaking between December to February.
Influenza (flu)
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(A, B, C, D). Only A and B cause significant illness in humans.
classify influenza viruses into 4 serotypes
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is subtyped based on the presence of 2 surface proteins: hemagglutinin (H) and neuraminidase (N).
Influenza A (2 surface proteins)
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The H antigens enable the virus to enter the cell, and the N antigens facilitate cell-to-cell transmission. As a result, we name influenza A viruses according to their H and N type (e.g., H3N2).
Influenza A (pathophysiology)
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is the most common and most virulent flu virus
Influenza A
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are found in birds (avian flu), pigs (swine flu), horses, seals, and dogs.
influenza A in animals
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virus mutates (changes), this allows it to infect different species. When a new viral strain reaches humans, people do not have immunity and the virus can spread quickly around the globe, causing a pandemic
pathology of how influenza transmitted to humans
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are more localized outbreaks, often occurring yearly, caused by variants of already circulating strains of the influenza virus.
Epidemics (influenza)
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Influenza B and C viruses only infect humans
influenza virus that only infect humans
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regional epidemics, but the disease it produces is milder than that caused by influenza A
Outbreaks of influenza B can cause
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mild illness and does not cause epidemics or pandemics.
Influenza C causes
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only occurs in animals.
Influenza D
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is communicable between humans primarily through infected droplets, inhalation of aerosolized particles, and, to a lesser extent, through direct contact with contaminated surfaces.
Influenza (transmission)
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virus incubation period of 1 to 4 days, with peak transmission risk starting 1 day before onset of symptoms and continuing for 5 to 7 days after a person first becomes sick
Influenza (duration)
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onset of flu is abrupt. There may be chills, fever, and generalized myalgia, often accompanied by a headache, cough, sore throat, and fatigue. Assessment findings are usually minimal, with normal breath sounds on chest auscultation. In uncomplicated cases, symptoms often subside within 7 days.
Influenza signs &symptoms
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pneumonia, which can be either primary influenza [viral] pneumonia or secondary bacterial pneumonia, and ear or sinus infections. Dyspnea and diffuse crackles are signs of pulmonary complications. Some patients, especially older adults, have weakness or lethargy that may last for weeks.
Common complications Influenza include
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usually has gradual improvement of influenza symptoms, then worsening cough and purulent sputum. Treatment with antibiotics is usually effective if started early.
secondary bacterial pneumonia (complication of influenza)
121
Viral cultures, once considered the
gold standard for diagnosing influenza
122
a throat swab, nasopharyngeal swab, expectorated sputum, ET tube sample, or bronchoscopy (bronchial wash).
obtain a viral culture from
123
which virus (A, B, or another respiratory virus) and which viral strains are present.
viral culture can identify
124
can help in the diagnosis by detecting the virus in secretions from the respiratory tract
Rapid influenza diagnostic tests (RIDTs)
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with results available in as little as 5 minutes. The test can help distinguish influenza from other viral and bacterial infections with similar manifestations that may be serious but are treated differently.
Rapid influenza diagnostic tests (RIDTs) test may be completed in the HCP’s office
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within the first 48 hours of the onset of symptoms. The main disadvantages of the rapid flu test are that it will miss some cases or occasionally be positive when a person does not actually have the flu
RIDTs are best used
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is prevention. Two types of flu vaccines are available: inactivated and live attenuated
best way to managing influenza
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inactivated and live attenuated
Two types of flu vaccines are available:
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is in September or October (before flu exposure) because it takes 2 weeks for full protection to occur. However, the vaccine can be given at any time during the flu season.
best time to receive the flu vaccine
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older than 6 months of age, especially those at high risk (e.g., health care workers, residents of long-term care facilities).
• Give high priority to groups, such as health care workers, who can transmit influenza to high-risk persons.
ALERT Advocate for flu vaccination of all people
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are a history of severe allergic reactions to previous flu vaccine. Patients with anaphylactic hypersensitivity to eggs should discuss the vaccine with their HCP, as alternatives for vaccinating patients with egg allergies are now available.
Contraindications flu vaccination
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Rest, hydration, analgesics, and antipyretics can provide symptom relief
influenza intervents/medical management
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treat shorten the duration of influenza symptoms and reduce the risk for complications.
Zanamivir (Relenza), oseltamivir (Tamiflu), and peramivir (Rapivab) are neuraminidase inhibitors that prevent the virus from being released and spreading to other cells
134
develops when inflammation or swelling of the mucosa blocks the openings (ostia) in the sinuses, through which mucus drains into the nose
Sinusitis
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which may accompany sinusitis, is concurrent inflammation or infection of the nasal mucosa. Nasal polyps, foreign bodies, deviated septa, or tumors can cause obstruction of mucus drainage
Rhinosinusitis,
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may follow an upper respiratory tract infection in which the virus penetrates the mucous membrane and decreases ciliary function
Viral sinusitis
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resolve without treatment in less than 14 days. If symptoms worsen after 3 to 5 days or last for longer than 10 days, a secondary bacterial infection may be present. Only 5% to 10% of patients with viral sinusitis develop a bacterial infection and need antibiotic therapy.
Viral sinusitis treatment
138
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the
most common causes of bacterial sinusitis
139
Fungal sinusitis is uncommon. It usually occurs in patients who are debilitated or immunocompromised.
most common causes of bacterial sinusitis
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can be classified as acute, subacute, or chronic
Sinusitis
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typically begins within 1 week of an upper respiratory tract infection and lasts less than 4 weeks
Acute sinusitis (duration)
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is present when symptoms progress over 4 to 12 weeks
Subacute sinusitis
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(lasting longer than 12 weeks) is a persistent infection usually associated with allergies and nasal polyps.
Chronic sinusitis
144
generally results from repeated episodes of acute sinusitis that result in irreversible loss of the normal ciliated epithelium lining the sinus cavity.
Chronic sinusitis
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significant pain over the affected sinus, purulent nasal drainage, nasal obstruction, congestion, fever, and malaise.
Acute sinusitis causes
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edematous mucosa, discolored purulent nasal drainage, enlarged turbinates, tenderness over the involved frontal and/or maxillary sinuses, and halitosis (bad breath)
-Recurrent headaches are common and may change in intensity with position changes or when secretions drain.
acute sinusitis signs and symptoms include
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are often nonspecific. The patient is rarely febrile. The patient may have facial or dental pain, nasal congestion, and increased drainage. Severe pain and purulent drainage are often absent. Some symptoms mimic those seen with allergies.
symptoms of chronic sinusitis
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X-rays or CT scan of the sinuses may help confirm the diagnosis. CT scans may show the sinuses are filled with fluid or a thickened mucous membrane.
-Nasal endoscopy with a flexible scope may be used to examine the sinuses, obtain a specimen for culture, and restore normal drainage.
diagnosis chronic sinusitis
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may trigger asthma by stimulating bronchoconstriction.
- Gastroesophageal reflux disease (GERD) and smoking may increase the risk for a person with asthma developing sinusitis. Appropriate treatment of sinusitis often causes a reduction in asthma symptoms.
Postnasal drip associated with sinusitis
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oral or topical decongestants to promote drainage, intranasal corticosteroids to decrease inflammation, analgesics to relieve pain, and saline nasal spray to relieve congestion
Medications include sinusitis
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can rinse nasal passages, promote drainage, and decrease inflammation. Saline nasal spray is available over the counter
Saline irrigation of the nasal cavity
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is the first-line drug of choice. It is taken for 10 to 14 days to prevent the formation of antibiotic-resistant organisms
Amoxicillin (acute sinusitis symptoms not relieved > 1 week)
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, the antibiotic should be changed to amoxicillin with clavulanate, a fluoroquinolone, or a 2nd or 3rd generation cephalosporin.
If symptoms do not resolve w/ Amoxicillin
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may be used for 4 to 6 weeks. for chronic sinusitis
Broad-spectrum antibiotics
155
nasal endoscopic surgery to relieve blockage caused by hypertrophy or septal deviation.
-usually done as an outpatient procedure using local anesthesia.
chronic sinus cant work with meds so surgery needed
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, a self-expanding implant, can be placed directly in the sinus during surgery. Propel helps maintain patency to the sinus cavity after surgery and provide local corticosteroid delivery directly to the sinus lining before dissolving after 30 days.
Propel in nasal endoscopic surgery
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are soft, painless, benign (noncancerous) growths that form slowly in response to repeated inflammation of the sinus or nasal mucosa.
Nasal polyps
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most common in adults over age 40 and are twice as likely to occur in men than women
Nasal polyps common in
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, which appear as chronic yellow, gray, or pink semitransparent projections in the naris, can exceed the size of a grape.
Polyps (description)
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nasal obstruction, nasal discharge (usually clear mucus), and speech distortion.
larger polyps include
161
Topical and systemic corticosteroids are primary therapies used to shrink nasal polyps. Endoscopic or laser surgery can remove nasal polyps, but recurrence is common
larger polyps treatment
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such as plastic or metal objects, may cause no symptoms and be incidentally discovered on routine examination.
Inorganic foreign bodies,
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such as food, may cause a local inflammatory reaction and nasal discharge, which may become purulent and foul smelling if the object stays in the nasal cavity for an extended time. Foreign bodies can cause pain, difficulty breathing, and nasal bleeding.
Organic foreign bodies,
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Foreign bodies should be removed from the nose through the route of entry. Sneezing or blowing the nose with the opposite nostril closed may be effective in removing the foreign object. Avoid irrigating the nose or pushing the object backward, since these could cause aspiration and airway obstruction. If sneezing or blowing the nose does not remove the object, consult an HCP.
removal of Foreign bodies
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is an acute inflammation of the pharyngeal walls. It may include the tonsils, palate, and uvula. It can be caused by a viral, bacterial, or fungal infection.
Acute pharyngitis
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accounts for about 90% of cases.
Viral pharyngitis
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usually results from group A β-hemolytic streptococci and accounts for 5% to 10% of cases.
Bacterial pharyngitis (“strep throat”)
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such as candidiasis, can develop with the prolonged use of antibiotics or inhaled corticosteroid
Fungal pharyngitis,
169
can also occur in immunosuppressed patients, especially those with human immunodeficiency virus (HIV) infection. Other causes of pharyngitis include dry air, smoking, GERD, allergy and postnasal drip, ET intubation, chemical fumes, and cancer.
Risk of Fungal pharyngitis,
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range in severity from a “scratchy” throat to pain so severe that swallowing is difficult. Because both viral and streptococcal infections appear as a red and edematous pharynx (with or without patchy exudates)
Symptoms of acute pharyngitis
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(1) fever greater than 100.4° F (38° C); (2) anterior cervical lymph node enlargement; (3) tonsillar or pharyngeal exudate; and (4) absence of cough
-When 2 or 3 of these criteria are present, a rapid antigen detection test and/or a throat culture can help establish the cause and direct treatment.
Four classic manifestations present in bacterial pharyngitis include:
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White, irregular patches on the oropharynx suggest
fungal infection with Candida albicans.
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, antibiotics are not recommended.
viral pharyngitis treatment
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, penicillin is the drug of choice
For bacterial pharyngitis caused by group A β-hemolytic streptococci treatment
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, erythromycin and clindamycin are appropriate substitutes
-Other antibiotics, such as azithromycin (Zithromax) or a 1st generation cephalosporin, are options.
patients allergic to penicillin use
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they have been on antibiotics for 24 to 48 hours.
Most people with streptococcal infections are contagious until
177
with nystatin, an antifungal antibiotic
Candida infections are treated
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Teach patients to swish the preparation in their mouths for as long as possible before swallowing it. Treatment should continue until symptoms are gone
Candida infections med teaching
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for infection with Candida organisms. Thoroughly rinsing the mouth with water after using corticosteroids can prevent this infection.
Patients taking inhaled corticosteroids are at risk
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Teach patients to use ibuprofen or acetaminophen for pain relief. Encourage the patient to increase fluid intake. For symptom relief, have patients to gargle with warm salt water (½ tsp of salt in 8 oz of water); drink warm or cold liquids; and suck on popsicles, hard candies, or throat lozenges. Cool, bland liquids and gelatin will not irritate the pharynx. Citrus juices are often irritating. Encourage the patient to use a cool mist vaporizer or humidifier.
treatment for acute pharyngitis
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is a complication of tonsillitis.
Peritonsillar abscess
182
caused by group A β-hemolytic streptococci. T
Peritonsillar abscess
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abscess causes pain, swelling, and blockage of the throat (when severe), threatening airway patency. The patient may have a high fever, chills, leukocytosis, difficulty swallowing, and a muffled voice.
causes Peritonsillar abscess
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consists of IV antibiotic therapy and needle aspiration or incision and drainage of the abscess. In some cases an emergency tonsillectomy is done or an elective tonsillectomy is scheduled after the infection has subsided.
Treatment of Peritonsillar abscess
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develop on the vocal cords from vocal abuse (e.g., excessive talking, singing) or irritation (e.g., intubation, cigarette smoking).
Laryngeal polyps
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is swelling and inflammation of the voice box (larynx)
Acute laryngitis
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virus (e.g., flu, common cold) is the
most common cause Acute laryngitis
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causes include inflammatory or infectious conditions of the upper respiratory tract (e.g., tonsillitis, acute bronchitis), overuse of one’s voice (e.g., yelling loudly at a concert or a sporting event), exposure to smoke-filled environments, or chemical inhalation.
other causes Acute laryngitis
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include a tingling or burning sensation at the back of the throat, a persistent need to clear the throat, and hoarseness, which may be accompanied by complete loss of voice
classic hallmark signs of acute laryngitis
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low-grade fever, persistent cough, or feeling of fullness in the throat. Symptoms will appear suddenly, increase in severity over 2 to 3 days, then gradually subside over the next 7 to 10 days as the condition improves. It usually resolves within 21 days
acute laryngitis symptoms and duration
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is made based on the history, clinical presentation, and changes in voice
Diagnosis of acute laryngitis
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is supportive. The patient is strongly encouraged to limit use of the larynx. This includes no talking or singing, which realistically is almost impossible to do. Patients will want to whisper when communicating but whispering places increased strain on the vocal cords that may worsen the pain. Acetaminophen, cough suppressants, throat lozenges, and use of a humidifier are helpful for throat discomfort.
Treatment for acute laryngitis
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patient increase fluid intake. They should avoid caffeine and alcohol, which may worsen a sore throat. Encourage smoking cessation. If a bacterial cause is known, such as acute bronchitis or tonsillitis, antibiotics should help resolve the condition. If symptoms last longer than 3 weeks, patients should return to their HCP for further investigation and treatment.
teach pts with acute laryngitis
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by aspiration of food or a foreign body, allergic reactions, edema and inflammation caused by infections or burns, peritonsillar or retropharyngeal abscesses, cancer, laryngeal or tracheal stenosis, and trauma.
Airway obstruction (medical emergency) can be caused
195
may be partial or complete
Airway obstruction can be either
196
often depends on the cause of the obstruction and/or location of the blockage.
presentation of an airway obstruction depends
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voice hoarseness or complete airway obstruction.
objects lodged within the larynx may cause
198
wheezing.
Tracheal obstruction may produce
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a cough or decreased air entry on the affected side
Objects lodged within the lower respiratory system (e.g., bronchus) may produce
200
include choking, stridor, use of accessory muscles, suprasternal and intercostal retractions, flaring nostrils, wheezing, restlessness, tachycardia, cyanosis, and change in level of consciousness
Manifestations airway obstruction
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in permanent brain damage or death if not corrected within 3 to 5 minutes.
Complete airway obstruction can result
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the obstructed airway (Heimlich) maneuver cricothyroidotomy, ET intubation, or tracheostomy
- including a chest x-ray, laryngoscopy, and rigid bronchoscopy.
Interventions to reestablish a patent airway include
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is a surgically created stoma (opening) in the anterior part of the trachea
tracheostomy
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(1) establish a patent airway,
(2) bypass an upper airway obstruction,
(3) facilitate removal of secretions,
(4) permit long-term mechanical ventilation, (5) assist with weaning from mechanical ventilation
tracheostomy may be done to
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is shorter in length and slightly wider in diameter than an ET tube.
tracheostomy tube vs ET tube
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, or flange, which rests against the neck,
All tracheostomy tubes have a faceplate
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which is used to help insert the tube
obturator, (tracheostomy )
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(which keeps the airway patent), and an
Many tracheostomy tubes have an outer cannula
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(which can be disposable or nondisposable and removed for cleaning
inner cannula (tracheastomy)
210
is used the most, especially if the patient needs mechanical ventilation.
-helps decrease the risk for aspiration
tracheostomy tube with an inflated cuff (balloon)
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are primarily used for patients with longer term tracheostomies, when mechanical ventilation is not required and the risk for aspiration has decreased. They make talking and eating easier.
Cuffless tubes (tracheostomy tube )
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has an opening (a hole) on the dorsal surface of the tube
- promotes spontaneous breathing
fenestrated tube
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, because we can quickly insert one an emergency.
Most patients who need mechanical ventilation first have an ET tube
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When swelling, trauma, or upper airway obstruction prevents ET intubation, an emergent surgical cricothyroidotomy (also known as a cricothyrotomy) is needed
-can be completed in minutes, involves making an incision through the skin
cricothyrotomy
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, because we can quickly insert one an emergency.
Most patients who need mechanical ventilation first have an ET tube
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. Involves inflating the cuff to minimal occlusion pressure and then withdrawing 0.1–0.5 mL of air. No longer recommended due to risk for silent aspiration.
Minimal leak technique (MLT)
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approaches have less risk for bleeding and fewer postoperative complications
Percutaneous tracheostomy
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tracheal dilation at the cuff site or a crack or slow leak in the housing of the 1-way inflation valve. If the leak is due to tracheal dilation, the HCP may cannulate the patient with a larger tube.
Potential causes include (tracheostomy balloon with cuff
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Never insert decannulation plug in tracheostomy tube until cuff is deflated and nonfenestrated inner cannula removed. Otherwise, patient will be prevented from breathing (no air inflow). This will precipitate a respiratory arrest
-Fenestrated tracheostomy tube (Shiley, Portex) with cuff, inner cannula, and decannulation plug
220
tracheal dilation at the cuff site or a crack or slow leak in the housing of the 1-way inflation valve. If the leak is due to tracheal dilation, the HCP may cannulate the patient with a larger tube.
Potential causes include Minimal leak technique (MLT)
221
process whereby a tracheostomy tube is removed once no longer needs it.
decannulation
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process whereby a tracheostomy tube is removed once no longer needs it.
decannulation
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(1) auscultation of the patient’s chest for air entry,
(2) end-tidal CO2 capnography, and
(3) passage of a suction catheter through the tracheostomy tube. After placement is confirmed, the ET tube (if present) is removed
several different methods to confirm tracheostomy tube placement
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should not exceed 20 to 25 cm H2O
Cuff inflation pressure of trachea
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is one way we often use to inflate the tracheostomy cuff
minimal occlusion volume (MOV)
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is essential to keep secretions thin and decrease formation of mucous plugs.
Humidification
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at least every shift.
-Cleaning removes mucus from the inside of the tube to prevent airway obstruction
Clean a nondisposable inner cannula (duartion)
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the first 24 hours and then as needed
Change the tracheostomy tapes after (duration)
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at least every shift.
-Cleaning removes mucus from the inside of the tube to prevent airway obstruction
Clean a nondisposable inner cannula (duartion)
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the first 24 hours and then as needed
Change the tracheostomy tapes after (duration)
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(1) keep a replacement tube of equal or smaller size at the bedside, readily available for emergency reinsertion; (2) do not change tracheostomy tapes for at least 24 hours after the surgical procedure; and (3) if needed, the HCP performs the first tube change usually no sooner than 7 days after the tracheostomy.
Precautions when repositioning pt with tracheostomy
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you can quickly use a hemostat to spread the opening where the tube was displaced. Insert the obturator in the replacement (spare) tracheostomy tube, lubricate with saline, and insert the tube into the stoma.
If respiratory distress is present, in tracheostomy pt
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visible coughing, coarse crackles or wheezes over large airways, moist cough, increase in peak inspiratory pressure on mechanical ventilator, and restlessness or agitation
Assess the need for suctioning hourly. Indications include
234
may not show any signs and/or symptoms of the need to be suctioned, so suctioning once per shift (at minimum) is recommended. Do not suction routinely.
suctioning for Neurologic patients
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(1) connecting and disconnecting the tubing at the suction catheter, (2) using the manual bag-valve-mask (BVM), and (3) operating the suction control. Suction sterile water through the catheter to test the system.
Designate one hand as contaminated for (suctioning for tracheostomy)
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(1) adjusting ventilator to deliver 100% O2 or (2) using a reservoir-equipped BVM connected to 100% O2. The method chosen depends on whether the patient is attached to a mechanical ventilator or has a tracheostomy tube in place
Provide preoxygenation for a minimum of 30 seconds by
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around 1 month after the first tube change and every 1 to 3 months thereafter
tracheostomy tube should be changed
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s often the one who assesses the patient’s ability to swallow
speech therapist ( tracheostomy tube)
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Using different consistencies of thickened fluids, the patient is evaluated for aspiration and/or microaspiration under
videofluoroscopy or with a fiberoptic endoscopy ( tracheostomy tube)
240
may be able to tolerate suctioning without using a BVM
pt long-term chronic tracheostomy and is not acutely ill
241
bradycardic or hypotensive, a dysrhythmia occurs, or SpO2 decreases to less than 90%. A vagal response may have occurred.
Immediately stop suctioning and remove the suction catheter from the patient’s trachea if the patient becomes
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After each suction pass, wait at least 30 seconds before suctioning again. Always hyperoxygenate for at least 30 seconds (via mechanical ventilator or BVM with 5 or 6 breaths) in between each suctioning pass.
during suctioning process
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immediately place the patient in semi-Fowler’s position to decrease dyspnea. Cover the stoma with a sterile dressing and provide ventilation with the BVM over the nose and mouth. If a patient has had a total laryngectomy, there will be complete separation between the upper airway and trachea. Ventilate this patient through the tracheostomy stoma.
If the tube cannot be replaced because of tract immaturity (less than 1 week old) or other circumstances,
244
around 1 month after the first tube change and every 1 to 3 months thereafter
tracheostomy tube should be changed
245
s often the one who assesses the patient’s ability to swallow
speech therapist i
246
Using different consistencies of thickened fluids, the patient is evaluated for aspiration and/or microaspiration under
videofluoroscopy or with a fiberoptic endoscopy
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patient needs mechanical ventilation, provide the patient with a paper and pencil, a white board, or cellular phone for texting. A communication board with pictures of common needs is convenient for patients who may speak other languages. A visual alphabet for spelling words is useful for patients who are weak or have difficulty writing.
techniques to speak pt with tracheostomy patient needs mechanical ventilation
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may be able to talk with a tracheostomy. Several options are available depending upon the type of tracheostomy
techniques to speak pt with tracheostomy
spontaneously breathing patient
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(1) remove the inner cannula (if non-fenestrated), (2) deflate the cuff, and (3) place the cap on the tube
speak pt with tracheostomy
spontaneously breathing patient example if the patient is at low risk for aspiration,
250
Tobacco use
-Excess alcohol consumption is another major risk factor
causes 85% of head and neck cancers
251
may be able to talk with a tracheostomy. Several options are available depending upon the type of tracheostomy
techniques to speak pt with tracheostomy
spontaneously breathing patient
252
(1) remove the inner cannula (if non-fenestrated), (2) deflate the cuff, and (3) place the cap on the tube
speak pt with tracheostomy
spontaneously breathing patient example if the patient is at low risk for aspiration,
253
is a simple device that attaches to the hub of the tracheostomy tub
Passy-Muir valve
254
Removal of the tracheostomy from the trachea is known as
decannulation
255
(1) be hemodynamically stable; (2) have a stable, intact respiratory drive; (3) be able to adequately exchange air, and (4) independently expectorate secretions.
decannulation requirement
256
Teach the patient to splint the stoma with the fingers when coughing, swallowing, or speaking. Epithelial tissue begins to form in 24 to 48 hours, and the opening closes within 4 or 5 days. Surgical intervention to close the tracheostomy is usually not needed.
healing after removing tracheostomy
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according to the area where it occurs.
Head and neck cancer is classified
258
the nasal cavity and paranasal sinuses, nasopharynx, oropharynx, larynx, oral cavity, and/or salivary gland
cancers may involve
259
squamous cells that line the mucosal surfaces of the head and neck
Most head and neck cancers arise from
260
Tobacco use
causes 85% of head and neck cancers
261
human papillomavirus (HPV) infection.
Head and neck cancers in those younger than 50 years are often associated with
262
Other risk factors include exposure to the sun, asbestos, industrial carcinogens, marijuana use, radiation therapy to the head and neck, and poor oral hygiene
Head and neck cancers Other risk factors include
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Head and neck cancer is staged based on the size of the tumor (T), number and location of involved lymph nodes (N), and extent of metastasis (M). This is referred to as
TNM staging (cancer)
264
stage 0 is in situ, or confined to where it began, through stage 4, with more advanced disease.
stage 0 vs stage 4
265
a patient’s HPV status
Oral cancer staging considers
266
location of tumor, TNM stage, patient’s age and overall general health, urgency of treatment, cosmetic and functional considerations (e.g., ability to talk, swallow, chew), and patient choice. Treatment options include surgery, radiation therapy, chemotherapy, targeted therapy, or any combination of these modalities.
treatment of cancer
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Surgery
first-line treatment option for head and neck cancers
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Removal of outer layers of tissue on the vocal cords. This approach may be used for a biopsy or to treat some stage 0 cancers confined to the vocal cords. Vocal cord stripping rarely affects speech.
Vocal cord stripping:
269
An endoscope with a laser is inserted down the throat, and the tumor can be vaporized or removed.
Laser surgery:
270
Removal of part or all the vocal cords. There may be changes in tone of voice. Removing part of a vocal cord may lead to a hoarse voice. If both vocal cords are removed, speech will no longer be possible.
• Cordectomy:
271
Removal of part or all the larynx. A total laryngectomy will change airflow in and out of the lungs and normal voice production will not be possible
Partial or total laryngectomy:
272
Removal of part or all the throat.
Pharyngectomy:
273
cisplatin, 5-fluorouracil, carboplatin, docetaxel (Taxotere), paclitaxel, methotrexate, and bleomycin.
Chemotherapy agents currently recommended include
274
, a targeted therapy, is used with chemotherapy to treat patients with late-stage head and neck cancer.
Cetuximab (Erbitux)
275
Selective neck dissection
Modified radical neck dissection:
Radical neck dissection:
Neck dissection surgery: There are 3 main types:
276
Bland foods are easier for patients to tolerate. Patients can increase caloric intake by adding dry milk to foods during preparation, eating foods high in calories, and using oral supplements. It is helpful to add mild sauces and gravy to food. adds calories and moistens food so that it is more easily swallowed.
Cancer pts should eat
277
• This is the most common type of neck dissection for cancer. All lymph nodes are removed. Less neck tissue is taken out than in radical dissection. This surgery may spare the nerves in the neck and, sometimes, the blood vessels or muscle.
Modified radical neck dissection:
278
Selective neck dissection: If cancer has not spread far, fewer lymph nodes are removed. The muscle, nerve, and blood vessels in the neck may be saved.
Selective neck dissection:
279
external-beam therapy or internal implants (brachytherapy).
Radiation therapy can be delivered by either
280
is a concentrated and localized method of delivering radiation that involves placing a radioactive source near or into the tumor
Brachytherapy
281
is often preferred for patients with early head and neck cancer because it offers the patient good results with voice preservation.
Radiation therapy
282
a fistula is created in the tracheoesophageal wall that diverts pulmonary air across the pharyngoesophageal mucosa for phonation when the tracheostoma is occluded
-1-way prosthetic valve is placed in the tract
transesophageal puncture (TEP)
283
cisplatin, 5-fluorouracil, carboplatin, docetaxel (Taxotere), paclitaxel, methotrexate, and bleomycin.29
Chemotherapy agents currently recommended include
284
, a targeted therapy, is used with chemotherapy to treat patients with late-stage head and neck cancer.
Cetuximab (Erbitux)
285
drug targets epidermal growth factor receptor (EGFR), a specific protein within cancer cells, and stops the cells from growing
Cetuximab (Erbitux) pathology
286
Bland foods are easier for patients to tolerate. Patients can increase caloric intake by adding dry milk to foods during preparation, eating foods high in calories, and using oral supplements. It is helpful to add mild sauces and gravy to food.
Cancer pts should eat
287
swallowing studies may be used to evaluate the safety of swallowing postoperatively.
Videofluoroscopic
288
upon air that is introduced into the esophagus and then expelled past the pharyngoesophageal segment, the vibratory source for sound production
Esophageal speech depends
289
(1) electrolarynx, (2) tracheoesophageal puncture (TEP) voice restoration, and (3) esophageal speech.
Three major approaches are used to restore oral communication:
290
is a hand-held, battery-powered device that creates speech with the use of sound waves
- allows for speech immediately after surgery
An electrolarynx
291
is the mechanical sound quality, which many patients find unacceptable.
primary disadvantage of the electrolarynx
292
, a fistula is created in the tracheoesophageal wall that diverts pulmonary air across the pharyngoesophageal mucosa for phonation when the tracheostoma is occluded
transesophageal puncture (TEP)
293
commercial mouthwashes and hot, spicy, or acidic foods because they are irritating.
Patients should avoid. (from radiation/chemo)
294
is made by the air vibrating against the esophagus and is formed into words by moving the tongue and lips.
Speech (created)
295
Air moves from the lungs, through the prosthesis, into the esophagus, and out the mouth
pathophysiology of transesophageal puncture (TEP)
296
common voice prosthesis is the
Blom-Singer prosthesis
297
(because mucus may be expectorated) and during any activity (e.g., shaving, applying makeup) that may lead to inhalation of foreign materials.
-Swimming is contraindicated
cover the stoma when coughing
298
upon air that is introduced into the esophagus and then expelled past the pharyngoesophageal segment, the vibratory source for sound production
Esophageal speech depends
299
of developing esophageal speech are the length of time needed to learn the technique and the reduction in voice quality.
primary disadvantages Esophageal speech depends
300
is often effective in increasing saliva production.
Pilocarpine hydrochloride (Salagen)
301
irritation, ulceration, and pain.
Oral mucositis can cause
302
along with bite blocks, athletic mouth guards, or gauze pads, can be worn during radiation treatments. This prevents radiation scatter to the tongue and cheek from metal work in the mouth
Empty fluoride gel trays,
303
commercial mouthwashes and hot, spicy, or acidic foods because they are irritating.
Patients should avoid
304
Fatigue is a
common side effect of radiation therapy as well as chemotherapy.
305
with a moist cloth. A nasal wash spray (e.g., Alkalol) can be used every 1 to 2 hours to keep the stoma moist and prevent crusting.
patient should wash the area around the stoma daily
306
Dried secretions can be removed with tweezers
stoma (dried secretions)
307
(because mucus may be expectorated) and during any activity (e.g., shaving, applying makeup) that may lead to inhalation of foreign materials.
cover the stoma when coughing
