Fracture of the Nose

1
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

2
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)

3
Epistaxis (Continued)

• Assess for respiratory distress and for tolerance
  of packing or tubes.
• Administer humidification, oxygen, bedrest,
  antibiotics, pain medications.

4
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

5
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.

6
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

7
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.

8
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 and change of sleep
  position
• Surgical management uvulopalatopharyngoplasty

9
Disorders of the Larynx

• Vocal cord paralysis
• Vocal cord nodules and polyps
• Laryngeal trauma

10
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.

11
Upper Airway Obstruction Inverventions

• Interventions include
• Assessment for cause of the obstruction
• Maintenance of patent airway and ventilation
• Cricothyroidotomy
• Endotracheal intubation
• Tracheostomy

12
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.

13
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.

14
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

15
Surgical Management

• Laryngectomy (total and partial)
• Tracheostomy
• Oropharyngeal cancer resections
• Cordal stripping
• Cordectomy

16
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

17
Postoperative Care

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

18
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

19
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

20
Hemorrhage

• Uncommon with laryngectomy
• Often, surgical drain placed by surgeon

21
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

22
Pain Management

• Morphine
• Acetaminophen with codeine
• Acetaminophen alone
• Nonsteroidal anti-inflammatory drugs

23
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

24
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

25
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

26
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

27
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)

28
Disturbed Body Image (Continued)

• Advising loose-fitting, high-collar shirts or
  sweaters, scarves, jewelry, or cosmetics to be
  worn to cover the laryngectomy stoma

29
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.

30
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.

31
Asthma

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

32
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

33
Collaborative Management

• Assessment
• History
• Physical assessment and clinical manifestations
• No manifestations between attacks
• Audible wheeze and increased respiratory rate
• Use of accessory muscles
• Barrel chest from air trapping

34
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)

35
Laboratory Assessment (Continued)

• Atopic asthma with elevated serum eosinophil
  count and immunoglobulin E levels
• Sputum with eosinophils and mucous plugs with
  shed epithelial cells

36
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

37
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.

38
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)

39
Drug Therapy (Continued)

• Methylxanthines
• Anti-inflammatory agents
• Corticosteroids
• Inhaled anti-inflammatory agents
• Mast cell stabilizers
• Monoclonal antibodies
• Leukotriene agonists

40
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.

41
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.

42
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)

43
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

44
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

45
Complications

• Chronic bronchitis
• Hypoxemia and acidosis
• Respiratory infections
• Cardiac failure, especially cor pulmonale
• Cardiac dysrhythmias

46
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

47
Laboratory Assessment

• Status of arterial blood gas values for abnormal
  oxygenation, ventilation, and acid-base status
• Sputum samples
• Hemoglobin and hematocrit blood tests
• Serum alpha1-antitrypsin levels drawn
• Chest x-ray
• Pulmonary function test

48
Impaired Gas Exchange

• Interventions for chronic obstructive pulmonary
  disease
• Airway management
• Monitoring client at least every 2 hours
• Oxygen therapy
• Energy management

49
Drug Therapy

• Beta-adrenergic agents
• Cholinergic antagonists
• Methylxanthines
• Corticosteroids
• Cromolyn sodium/nedocromil
• Leukotriene modifiers
• Mucolytics

50
Surgical Management

• Lung transplantation for end-stage clients
• Preoperative care and testing
• Operative procedure through a large midline
  incision or a transverse anterior thoracotomy
• Postoperative care and close monitoring for
  complications

51
Ineffective Breathing Pattern

• Interventions for the chronic obstructive
  pulmonary disease client
• Assessment of client
• Assessment of respiratory infection
• Pulmonary rehabilitation therapy
• Specific breathing techniques
• Positioning to help alleviate dyspnea
• Exercise conditioning
• Energy conservation

52
Ineffective Airway Clearance

• Assessment of breath sounds before and after
  interventions
• Interventions for compromised breathing
• Careful use of drugs
• Controlled coughing
• Suctioning
• Hydration via beverage and humidifier
• (Continued)

53
Ineffective Airway Clearance (Continued)

• Postural drainage in sitting position when
  possible
• Tracheostomy

54
Imbalanced Nutrition

• Interventions to achieve and maintain body
  weight
• Prevent protein-calorie malnutrition through
  dietary consultation.
• Monitor weight, skin condition, and serum
  prealbumin levels.
• Address food intolerance, nausea, early satiety,
  loss of appetite, and meal-related dyspnea

55
Anxiety

• Interventions for increased anxiety
• Important to have client understand that anxiety
  will worsen symptoms
• Plan ways to deal with anxiety

56
Health Teaching

• Instruct the client
• Pursed-lip and diaphragmatic breathing
• Support of family and friends
• Relaxation therapy
• Professional counseling access
• Complementary and alternative therapy

57
Activity Intolerance

• Interventions to increase activity level
• Encourage client to pace activities and promote
  self-care.
• Do not rush through morning activities.
• Gradually increase activity.
• Use supplemental oxygen therapy.

58
Potential for Pneumonia or Other Respiratory
Infections

• Risk is greater for older clients
• Interventions include
• Avoidance of large crowds
• Pneumonia vaccination
• Yearly influenza vaccine

59
Cystic Fibrosis

• Genetic disease affecting many organs, lethally
  impairing pulmonary function
• Present from birth, first seen in early childhood
  (many clients now live to adulthood)
• Error of chloride transport, producing mucus with
  low water content
• Problems in lungs, pancreas, liver, salivary
  glands, and testes

60
Nonpulmonary Manifestations

• Adults usually smaller and thinner than average
  owing to malnutrition
• Abdominal distention
• Gastroesophageal reflux, rectal prolapse,
  foul-smelling stools, steatorrhea
• Vitamin deficiencies
• Diabetes mellitus

61
Pulmonary Manifestations

• Respiratory infections
• Chest congestion
• Limited exercise tolerance
• Cough and sputum production
• Use of accessory muscles
• Decreased pulmonary function
• Changes in chest x-ray result
• Increased anteroposterior diameter of chest

62
Exacerbation Therapy

• Avoid mechanical ventilation
• Airway clearance
• Increased oxygenation
• Antibiotic therapy
• Heliox (50 oxygen, 50 helium) therapy
• Bronchodilator and mucolytic therapies

63
Surgical Therapy

• Lung and/or pancreatic transplantation do not
  cure the disease the genetic defect in chloride
  transport and the thick, sticky mucus remain.
• Transplantation extends life by 10 to 20 years.
• Single-lung transplant as well as double-lung
  transplantation is possible.

64
Primary Pulmonary Hypertension

• The disorder occurs in the absence of other lung
  disorders, and its cause is unknown although
  exposure to some drugs increases the risk.
• The pathologic problem is blood vessel
  constriction with increasing vascular resistance
  in the lung.
• The heart fails (cor pulmonale).
• Without treatment, death occurs within 2 years.

65
Interventions

• Warfarin therapy
• Calcium channel blockers
• Prostacyclin agents
• Digoxin and diuretics
• Oxygen therapy
• Surgical management

66
Interstitial Pulmonary Disease

• Affects the alveoli, blood vessels, and
  surrounding support tissue of the lungs rather
  than the airways
• Restrictive disease thickened lung tissue,
  reduced gas exchange, stiff lungs that do not
  expand well
• Slow onset of disease
• Dyspnea common

67
Sarcoidosis

• Granulomatous disorder of unknown cause that can
  affect any organ, but the lung is involved most
  often
• Autoimmune responses in which the normally
  protective T-lymphocytes increase and damage lung
  tissue
• Interventions (corticosteroids) lessen symptoms
  and prevent fibrosis

68
Idiopathic Pulmonary Fibrosis

• Common restrictive lung disease
• Example of excessive wound healing
• Inflammation that continues beyond normal healing
  time, causing extensive fibrosis and scarring
• Mainstays of therapy corticosteroids, which slow
  the fibrotic process and manage dyspnea

69
Occupational Pulmonary Disease

• Can be caused by exposure to occupational or
  environmental fumes, dust, vapors, gases,
  bacterial or fungal antigens, or allergens
• Worsened by cigarette smoke
• Interventions special respirators that ensure
  adequate ventilation

70
Lung Cancer

• A leading cause of cancer deaths worldwide
• Metastasizes at late-stage diagnosis
• Paraneoplastic syndromes
• Staged to assess size and extent of disease
• Etiology and genetic risk
• (Continued)

71
Lung Cancer (Continued)

• Incidence and prevalence make lung cancer a major
  health problem.
• Health promotion and illness prevention is
  primarily through education strategies and
  reduced tobacco smoking.

72
Manifestations of Lung Cancer

• Often nonspecific, appearing late in the disease
  process
• Chills, fever, and cough
• Assess sputum
• Breathing pattern
• Palpation
• Percussion
• Auscultation

73
Surgical Management

• Lobectomy
• Pneumonectomy
• Segmentectomy (wedge resection)

74
Chest Tubes

• Placement after thoracotomy
• Drainage system
• Care required
• Monitor hourly to ensure sterility and patency.
• Tape tubing junctions.
• Keep occlusive dressing at insertion site.
• Position correctly to prevent kinks and large
  loops.

75
Interventions for Palliation

• Oxygen therapy
• Drug therapy
• Radiation therapy
• Laser therapy
• Thoracentesis and pleurodesis
• Dyspnea management
• Pain management