Interventions for Clients with Noninfectious Problems of the Upper and Lower Respiratory Tract

1. Interventions for Clients with Noninfectious Problems of the Upper and Lower Respiratory Tract

2. Fracture of the Nose • Displacement of either the bone or cartilage of the nose can cause airway obstruction or cosmetic deformity and is a potential source of infection. • Cerebrospinal fluid could indicate skull fracture. • Interventions: • Rhinoplasty • Nasoseptoplasty Immediate postoperative appearance of a client who has undergone rhinoplasty. Note the splint and gauze drip pad (moustache dressing).

3. Epistaxis • Nosebleed is a common problem. • Interventions if nosebleed does not respond to emergency care: • Affected capillaries are cauterized with silver nitrate or electrocautery and the nose is packed. • Posterior nasal bleeding is an emergency. (Continued)

4. Epistaxis (Continued) • Assess for respiratory distress and for tolerance of packing or tubes. • Administer humidification, oxygen, bedrest, antibiotics, pain medications. Client with balloon stents in place to control a posterior nasal bleed.

5. Nasal Polyps • Benign, grapelike clusters of mucous membranes and connective tissue • May obstruct nasal breathing, change character of nasal discharge, and change speech quality • Surgery: treatment of choice

6. Cancer of the Nose and Sinuses • Cancer of the nose and sinuses is rare and can be benign or malignant. • Onset is slow and manifestations resemble sinusitis. • Local lymph enlargement often occurs on the side with tumor mass. • Radiation therapy is the main treatment; surgery is also used.

7. Facial Trauma • Le Fort I nasoethmoid complex fracture • Le Fort II maxillary and nasoethmoid complex fracture • Le Fort III combination of I and II plus an orbital-zygoma fracture, often called craniofacial disjunction • First assessment: airway

8. Facial Trauma Interventions • Anticipate the need for emergency intubation, tracheotomy, and cricothyroidotomy. • Control hemorrhage. • Assess for extent of injury. • Treat shock. • Stabilize the fracture segment.

9. Obstructive Sleep Apnea • Breathing disruption during sleep that lasts at least 10 seconds and occurs a minimum of five times in an hour • Excessive daytime sleepiness, inability to concentrate, and irritability • Nonsurgical management • noninvasive positive-pressure ventilation (NPPV) to hold open the upper airways. Essentially, a nasal mask or full-face mask delivery system allows mechanical delivery of either Bi-level positive airway pressure (BiPAP) or nasal continuous positive airway pressure • change of sleep position • Surgical management: uvulopalatopharyngoplasty

10. Disorders of the Larynx • Vocal cord paralysis • Vocal cord nodules and polyps • Laryngeal trauma A hemorrhagic vocal cord polyp Bilateral vocal cord nodules caused by contact and voice abuse, often seen after viral illnesses

11. Upper Airway Obstruction • Life-threatening emergency in which an interruption in airflow through the nose, mouth, pharynx, or larynx occurs. • Early recognition is essential to prevent further complications, including respiratory arrest.

12. Upper Airway Obstruction Inverventions • Interventions include: • Assessment for cause of the obstruction • Maintenance of patent airway and ventilation • Cricothyroidotomy • Endotracheal intubation • Tracheostomy

13. Neck Trauma • Neck trauma may be caused by a knife, gunshot, or traumatic accident. • Assess for other injuries including cardiovascular, respiratory, intestinal, and neurologic damage. • Assess for patent airway. • Assess carotid artery and esophagus. • Assess for cervical spine injuries and prevent excess neck movement.

14. Head and Neck Cancer • Head and neck cancers can disrupt breathing, eating, facial appearance, self-image, speech, and communication. • In laryngeal cancer, hoarseness may occur because of tumor bulk and inability of the vocal cords to come together for normal phonation.

15. Ineffective Breathing Pattern • Interventions include: • Treatment goal: to remove or eradicate the cancer while preserving as much normal function as possible • Nonsurgical management • Radiation therapy • Chemotherapy

16. Surgical Management • Laryngectomy (total and partial) • Tracheostomy • Oropharyngeal cancer resections • Cordal stripping • Cordectomy

17. Preoperative Care • Client and family teaching about the tumor • Self-care of airway • Methods of communication • Suctioning • Pain control methods • Critical care environment • Nutritional support • Goals for discharge

18. Postoperative Care • Monitor airway patency, vital signs, hemodynamic status, comfort level. • Monitor for hemorrhage. • Assess for complications: • Airway obstruction • Hemorrhage • Wound breakdown • Tumor recurrence

19. Airway Maintenance and Ventilation • Ventilatory assistance and weaning • Total laryngectomy appliance to prevent scar tissue • Coughing and deep breathing • Saline instillations • Oral secretions • Stoma care – a combination of wound care and airway care

20. Wound, Flap, and Reconstructive Tissue Care • Pectoralis major myocutaneous flaps • Island flaps • Rotation flaps • Trapezius flaps • Split-thickness skin grafts • Free flaps with microvascular anastomosis • Critical stage: first 24 hr after surgery

21. Hemorrhage • Uncommon with laryngectomy • Often surgical drain placed by surgeon in the neck area to collect blood and drainage for approximately 72 hours postoperatively

22. Wound Breakdown • Common complication caused by poor nutrition, alcohol use, wound contamination, and previous radiation therapy • Packing and local care as prescribed to keep wound clean and to stimulate growth of healthy granulation tissue • Risk of carotid artery rupture

23. Pain Management • Morphine • Acetaminophen with codeine • Acetaminophen alone • Nonsteroidal anti-inflammatory drugs

24. Nutrition • Nasogastric • Gastrostomy • Jejunostomy • Parenteral nutrition until the gastrointestinal tract recovers from the effects of anesthesia • No aspiration after total laryngectomy because the airway and esophagus are completely separated

25. Speech Rehabilitation • Writing or using a picture board • Artificial larynx • Esophageal speech: sound produced by “burping” the air swallowed or injected into the esophageal pharynx and shaping the words in the mouth • Mechanical devices (electrolarynges) • Tracheoesophageal fistula

26. Risk for Aspiration • Interventions include: • Dynamic swallow study • Enteral feedings • Routine reflux precautions • Elevation of the head of bed • Strict adherence to tube feeding regimen • No bolus feeding at night • Checking residual feeding

27. Anxiety Interventions • Interventions include: • Team conference • Explore reason for anxiety • Teaching • Antianxiety drugs such as diazepam administered with caution because of the possibility of respiratory depression • Lorazepam

28. Disturbed Body Image • Interventions include: • Helping client and family set realistic goals • Involving client in self-care • Teaching alternate communication methods • Easing client into a more normal social environment after the hospitalization (Continued)

29. Disturbed Body Image (Continued) • Advising loose-fitting, high-collar shirts or sweaters, scarves, jewelry, or cosmetics to be worn to cover the laryngectomy stoma

30. Stoma Care • Apply shield over the tracheostomy tube or laryngectomy stoma when bathing to prevent water from entering the airway. • Apply protective stoma cover or guard to protect the stoma during the day. • Instruct client how to increase humidity in the home.

31. Interventions for Clients with Noninfectious Problems of the Lower Respiratory Tract

32. Chronic Airflow Limitation • Chronic lung diseases of chronic airflow limitation include: • Asthma • Chronic bronchitis • Pulmonary emphysema • Chronic obstructive pulmonary disease includes emphysema and chronic bronchitis characterized by bronchospasm and dyspnea.

34. Asthma • Intermittent and reversible airflow obstruction affects only the airways, not the alveoli. • Airway obstruction occurs due to inflammation and airway hyperresponsiveness.

35. Aspirin and Other NonsteroidalAnti-Inflammatory Drugs • Incidence of asthma symptoms after taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) • However, response not a true allergy • Results from increased production of leukotriene when other inflammatory pathways are suppressed

36. CollaborativeManagement • Assessment • History • (dyspnea), chest tightness, coughing, wheezing, and excessive mucus production • history of such symptoms lasting 4 to 8 weeks following a chest cold or other upper respiratory tract infection • the client with atopic or allergic asthma may also have other allergic symptoms such as rhinitis, skin rash, or pruritus • family members • Physical assessment and clinical manifestations: • No manifestations between attacks • Audible wheeze and increased respiratory rate • Use of accessory muscles • “Barrel chest” from air trapping

37. Laboratory Assessment • Assess arterial blood gas level. • Arterial oxygen level may decrease in acute asthma attack. • Arterial carbon dioxide level may decrease early in the attack and increase later indicating poor gas exchange. (Continued)

38. Laboratory Assessment(Continued) • Atopic asthma with elevated serum eosinophil count and immunoglobulin E levels • Sputum with eosinophils and mucous plugs with shed epithelial cells

39. Pulmonary Function Tests • The most accurate measures for asthma are pulmonary function tests using spirometry including: • Forced vital capacity (FVC) • Forced expiratory volume in the first second (FEV1) • Peak expiratory rate flow (PERF) • Chest x-rays to rule out other causes

40. Interventions • Client education: asthma is often an intermittent disease; with guided self-care, clients can co-manage this disease, increasing symptom-free periods and decreasing the number and severity of attacks. • Peak flow meter can be used twice daily by client. • Drug therapy plan is specific.

41. Drug Therapy • Pharmacologic management of asthma can involve the use of: • Bronchodilators • Beta2 agonists • Short-acting beta2 agonists • Long-acting beta2 agonists • Cholinergic antagonists (Continued)

42. Drug Therapy (Continued) • Methylxanthines • Anti-inflammatory agents • Corticosteroids • Inhaled anti-inflammatory agents • Mast cell stabilizers • Monoclonal antibodies • Leukotriene agonists

43. Other Treatments for Asthma • Exercise and activity is a recommended therapy that promotes ventilation and perfusion. • Oxygen therapy is delivered via mask, nasal cannula, or endotracheal tube in acute asthma attack.

44. Status Asthmaticus • Status asthmaticus is a severe, life-threatening acute episode of airway obstruction that intensifies once it begins and often does not respond to common therapy. • If the condition is not reversed, the client may develop pneumothorax and cardiac or respiratory arrest. • Emergency department treatment is recommended.

45. Emphysema • In pulmonary emphysema, loss of lung elasticity and hyperinflation of the lung • Dyspnea and the need for an increased respiratory rate • Air trapping, loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into bullae, and collapse of small airways (bronchioles)

46. Classification of Emphysema • Panlobular: destruction of the entire alveolus • Centrilobular: openings occurring in the bronchioles that allow spaces to develop as tissue walls break down • Paraseptal: confined to the alveolar ducts and alveolar sacs

47. Chronic Bronchitis • Inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tobacco smoke • Inflammation, vasodilation, congestion, mucosal edema, and bronchospasm • Affects only the airways, not the alveoli • Production of large amounts of thick mucus

48. Complications • Hypoxemia and acidosis • Respiratory infections • Cardiac failure, especially cor pulmonale • Cardiac dysrhythmias

49. Physical Assessment and Clinical Manifestations • Unplanned weight loss; loss of muscle mass in the extremities; enlarged neck muscles; slow moving, slightly stooped posture; sits with forward-bend • Respiratory changes • Cardiac changes