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NR202 Test 4 Respiratory Trauma


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State the pathophysiology of Laryngeal cancer
Squamous cell carcinoma most common type
a. changes in laryngeal mucosa takes place over time when subjected to noxious irritants (cigarette smoke, alcohol)
b. Leukoplakia: white, patchy precancerous lesions
c. Erythroplakia: red, velvety patches
Signs/Symptoms of Laryngeal cancer
1. Most occur in glottis area of larynx: hoarseness
2. S/S depends on area of larynx affected
3. Hoarseness
4. Change in voice
5. Painful swallowing
6. Dyspnea
7. Foul breath
8. Palpable lump in neck
9. Earache
What diagnostic tests are used to diagnose laryngeal cancer
Direct or indirect laryngoscopy to visualize the larynx
Biopsy usually done under general anesthesia
CT, MRI, Chest X-Ray: Evaluate size of mass, lymph node involvement, determine metastasis
What treatment is used for Laryngeal cancer-
a. What is treatment based on
T=tumor size
N= lymph node involvement
M= presence or absence of metastasis
Stages I-IV with IV being most invasive
What types of therapies are used?
Radiation therapy-Treatment of choice for early cancer. Affects voice and is used along with chemotherapy in advanced cases. For palliative treatment
Chemotherapy is used as primary treatment for some cancers. It is used to treat distant metastases and for palliative treatment
c. What are three types of surgeries
partial laryngectomy
total laryngectomy and Radical neck dissection
Difference between a partial laryngectomy total laryngectomy and Radical neck dissection:
Partial: 1. One half or more of the larynx is removed. 2. Voice preserved but changes
3. Several weeks enteral or parenteral nutrition. 4. Teach swallowing techniques to prevent aspiration
Total laryngectomy: 1. The Larynx, thyroid cartilage, several tracheal rings and the hyoid bone are removed. (Radical or modified neck dissection more extensive removal of tissue) 2. No risk for aspiration. 3. Normal speech is lost. 4. Permanent tracheostomy
Radical Neck dissection: 1. All tissue from lower edge of mandible down to clavicle is removed. Care includes: hemovac drain, skin grafts/flaps. Shoulder drop, difficulty turning and lifting head.
Speech rehabilitation: name 3 types and describe
Tracheoesophageal puncture (TEP)
a. Small fistula created between posterior tracheal wall and anterior esophagus with one way shunt valve.
b. When tracheostomy stoma is occluded, air is forced into the esophagus and hypopharynx to create sound
2. Esophageal Speech
a. Uses swallowed air to create sound and form words
b. Belchlike sound
3. Speech generators
a. Electrolarynx
i. Creates vibration and client forms words using normal muscles of speech.
Nursing diagnoses and interventions-interventions specific for laryngeal cancer
1. Risk for impaired Airway Clearance
a. risk for edema and airway obstruction
2. Impaired verbal communication
3. Impaired swallowing
4 Impaired nutrition
5. Anticipatory grieving
9. Postoperative care after one of the three types of surgeries to treat laryngeal cancer:
1. Monitor airway closely!
2. Elevate HOB 30-45 degrees
3. Suction prn
4. Trach care
5. NPO until cough and gag reflexes return
6. Ice packs
7. Fluid replacement
8. Communication
9. Nutrition (IV or tube feedings)
10. Speech therapist to teach how to swallow
11. Psychological care
10. Home care after surgery for laryngeal cancer
Tracheostomy care
Adapting to water near stoma
Smoking cessation
Referral to community Laryngectomy club
State some general things about lung cancer:
a. Leading cause of cancer deaths in US
b. Incidence increases with age <50
c. Smoking-- > 80 % related to smoking
d. Exposure to ionizing radiation, inhaled irritants (Asbestos)
e. Usually advanced when diagnosed
f. Most die within one year of diagnosis
g. 5 year survival is 15%
What is the etiology of lung cancer
a. Cigarette smoking-75-85% of the cases
b. Air pollution
c. Occupational pollutants (coal, asbestos)
d. Second hand smoke
What is the pathophysiology of lung cancer
Production of undifferentiated cells which do not function normally
Name the types of lung cancer
Signs and symptoms of lung cancer, Systemic signs and symptoms, and signs and symptoms of metastisis
1. Insidious onset
a. spreads by direct invasion lymphatic and blood borne avenues
2. Chronic cough
3. Hemoptysis
4. Wheezing
5. SOB
6. Dull, aching chest pain--pleuritic pain
7. Hoarseness, Dysphagia (pressure on trachea and esophagus)
Systemic signs and symptoms
1. Weight loss, anorexia, fatigue, weakness
2. Bone pain, tenderness, swellinng
3. Clubbing of fingers and toes
4. S/S or endocrine, cardiovascular function
1. Metastasis of brain: Confusion, personality change, headache, impaired gait and balance
2. Bone metastasis-Bone pain, pathological fractures, spinal cord compression
3. Liver-Jaundice, RUQ pain, anorexia
What is superior vena cava syndrome and the signs and symptoms of it
a. Results from compression of the vena cava by mediastinal tumors
i. Edema of face/neck
ii. H/ A, dizziness, vision, syncope
iii. Dilated veins of upper chest and neck
iv. Cerebral edema symptoms, laryngeal edema
Diagnositc tests for Lung cancer
Sputum cytology - First morning sputum for presence of malignant cells
Chest x-ray- Usually 1st evidence of lung cancer
Bronchoscopy: a. Visualize and obtain tissue for biopsy, b. Bronchial washing if tumor not visualized
a.Evaluate and locate tumors (for needle biopsy)
b. Detect distant metastasis
c. Evaluate tumor response to treatment
Cytologic exam and biopsy
a) Aspiration of fluid from pleural effusion, percutaneous needle biospy and lymph biopsy
CBC, liver enzymes and calcium
a) Evidence of metastasis of paraneoplastic syndromes
Treatments for lung cancer
1. Combination Chemotherapy
a. Treatment of choice for oat cell small cell lung cancer b) Used as adjunct to surgery and radiation therapy
2. Surgery
a)Goal is to remove as much involved tissue as possible and reserve
b) Surgery is treatment of choice for non small cell cancer
c) Most tumors are inoperable or only partially resectable
3. Radiation Therapy
a) Used alone or with surgery b) Goal is cure or symptom relief
c) May be done prior to surgery to debulk tumors
d) May be used to lessen manifestations from bone or brain metastasis or superior vena cava syndrome
e) Nursing interventions
(1) Do not remove markings for radiation treatment
(2) Monitor for side effects: fatigue, skin reactions, esophagitis
Nursing diagnoses and interventions for lung cancer
Ineffective Breathing Pattern
Activity Intolerance
Anticipatory Grieving
Name some disorders of the pleura
1. pleuritis
2. pleural effusion
3. pneumothorax
4. hemothorax
Define pleuritis and give the signs and symptoms
a)Inflammation of the pleura
b) Often results from pneumonia or rib injury
Signs and symptoms
Onset abrupt
Pain unilateral, well localized
Pain is sharp & may be referred to neck or shoulder
Pain aggravated by breathing, coughing, movement
May hear Pleural Friction rub
How is Pleuritis diagnosed
Presence of previous signs and symptoms
Chest x -ray and ECG to rule out other causes of chest pain
What is the treatment of pleuritis
a) Symptomatic treatment
(1) Analgesics (NSAIDS)
(2) Codeine
b) Splint chest while coughing
c) Positioning for comfort
Define pleural effusion
a) Collection of excess fluid in pleural space
(1) Normally contains 10-20 mL serous fluid
b) Occurs with lung cancer, pneumonia, heart failure, liver or renal disease
What is the Pathophysiology of pleural effusion
a) Pleural fluid may be transudate
(1) Formed when capillary pressure is high or plasma proteins are low
b) Pleural fluid may be exudates
(1) Result of increased capillary permeability
c) Collections of specific fluids in the pleural cavity
d) Empyema = pus
e) Hemothorax = blood
f) Hemorrhagic = blood and pleural fluid
signs and symptoms of pleural effusion
a) Dyspnea
(1) Due to lung compression
b) Pleuritic pain
(1) Relieved when effusion forms
c)Decreased breath sounds
d) Dull percussion tone
e) Limited chest wall movement
Diagnostic tests for pleural effusion
a) Chest X-ray: Fluid collects at base of affected lung or lateral wall
b) CT or ultrasounds: May be used to localize and differentiate pleural effusions
c) Thoracentesis
a. Invasive procedure when fluid is removed with needle and analyzed for content including abnormal cells or culture if needed
b. May be done to improve breathing
c. Done under local anesthesia-can be done at bedside
d. Usually only remove 1200-1500 mL at a time
i. Risk of cardiovascular collapse
Treatment of Pleural effusion
a. Depends on the cause
b. If recurrent, may treat with irritant (Talc or Doxycycline)
Definition and pathophysiology of pneumothorax:
a. Definition: Accumulation of air in the pleural space
b. Pathophysiology
i. Air enters the pleural space when either the visceral or parietal pleura is damaged
ii. Lung expansion is impaired and lung collapses
Types of pneumothorax
a. Spontaneous-Fluid around lung: lung shrivels up and there is diminished or no air flow
b. Traumatic: Fluid around lungs expanding to the outside
c. Tension-Puts tension on lungs-moves everything to the side: emergency situation
Signs and symptoms of pneumothorax
a. Dependent in size, extent of lung collapse and underlying lung disease
b. Pleuritic chest pain
c. SOB at rest
d. Increased respiratory and heart rate
e. Asymmetrical chest wall movement
f. Absent lung sounds
g. Hyperresonant lung sounds to percussion
Diagnostic tests for pneumothorax
a. Chest x-ray
b. ABGs
treatment of pneumothorax
i. Purpose is to allow air to move into the lungs for normal inspiration
ii. Chest tubes allow the lung to re-expand and to remove excess air, blood or fluid after an injury or surgery.
iii. As the air and fluid moves out of the pleural space, the pressure in the pleural space becomes more negative
iv. As the negative pressure increases, the lung expands more. This expansion of the lung also pushes out air and fluid
v. Can have one chest tube positioned higher to help with re-expansion and another placed lower to help remove fluid or blood
Types of chest drainage systems-also treatment of pneumothorax
1. Traditional water seal chest drainage system-Most common chest drainage system with 3 chambers. One collects blood or fluid that is draining. One is a water seal chamber, and one is a wet suction control chamber: regulates negative pressure
2. Dry suction water seal chest drainage system-3 chambers as well. Do not fill suction chamber with water
3. Dry suction chest drainage system-Has a one way mechanical valve that allows air to leave the chest and prevents air from moving back in.
Nursing interventions for those who have pneumothorax
1. Assess respiratory status
2. monitor the drainage tubing to be sure it does not kink or looping below the collection system
a. Keep collection system lower than the patient’s chest
3. Monitor the water seal chamber
a. Fluctuation or “tidaling” is normal
b. Continuous bubbling indicates an air leak
4. Monitor drainage in the collection chamber
a. Shows how much and how fast fluid is being lost. Bloody drainage-postop then becoming serous.
b. Assess significant increases or decreases in drainage
i. Report over 70 ml or bright red free flowing blood
5. Do not milk chest tube
6. Position patient for comfort-do not compress the chest tube when in lateral position
a. Fowler’s position
b. Change positions frequently
c. Range of motion exercises
d. Patient can be ambulated
7. Encourage pt to deep breathe
8. Removal of chest tube
How do you remove a chest tube/when?
1. Removal of a chest tube is done when minimal draining is coming out
2. Done when the lung has re-expanded as evidenced by chest x-ray and there is no tidaling in the water seal chamber
3. Usually done within 2-3 days after surgery or pneumothorax
4. May premedicate for pain prior to removal
5. Patient will be instructed to take a deep breath and hold it (sometimes instructed to do mild Valsalva) and chest tube is removed
a. This is to prevent air from entering the pleural space into the space
6. Dressing (gauze or petroleum) with tape is applied to make air tight
7. Pleurodesis-Creation of adhesions B/T parietal and visceral pleura to prevent recurrence. Instill a chemical agent (Doxycycline) to cause inflammation and scarring
8. Surgery-Create adhesions or partially excise parietal pleura
Nursing diagnoses for pneumothorax
1. Impaired gas exchange
2. Risk for injury
3. Ineffective breathing patterns
4. Decreased cardiac output
5. Risk for infection
6. Pain
7. Knowledge deficit
Definition and pathophysiology of hemothorax
a. Blood in pleural space resulting from chest trauma, surgery, diagnostic procedures
a. Blood collection results in impaired ventilation and gas exchange
b. Risk of shock
Signs and symptoms of hemothorax and diagnostic tests
a. Similar to pneumothorax
b. Diminished lung sounds
c. Dull percussion tone
Treatment of hemothorax
a. chest tube to drainage
b. Blood transfusion if significant loss
c. Autotransfusion may be done
Chest and lung trauma
Thoracic injuries-most commonly caused by car collisions or falls
What are some types of chest injuries
1. Rib fractures
2. Flail chest
3. Pulmonary contusion
Diagnostic tests for chest injuries:
1. Chest X-Ray
a. Used to identify most chest wall injuries
2. ABGs and Oxygen saturation
a. Used to identify altered ventilation and gas exchange
Treatment of chest injuries:
1. Rib fracture
a. Adequate analgesia
b. Rib belt, binders, taping
c. Most often treated at home
2. Flail chest and pulmonary contusion
a. Often requires intubation and mechanical ventilation, ICU care
b. Can result in long term insufficiency requiring home health referral
c. Patient education regarding care of chronic respiratory problem
Nursing diagnoses used for chest injuries
1. Acute Pain
2. Ineffective airway clearance
3. impaired gas exchange
Spleen trauma
1. Grade 1-5 assigned based on severity of injury
2. 1 is least severe, 5 completely shattered spleen
3. Blunt or penetrating trauma can lacerate, bruise, compress, or crush the spleen or tear it from its blood supply
4. Why not just remove it?
What happens after a spleen is taken out
1. Living without a spleen increases risk of developing sepsis and dying
a. Patients at increased risk for any kind of infection. Immune system not as effective
2. Should seek medical care for minor infections
3. Overwhelming Postsplenectomy Sepsis syndrome
a. Greatest risk the first year after removal
b. Continues as lifelong threat
Diagnostic tests to determine spleen trauma
1. CT scan of the abdomen
a. Can reveal the spleen’s appearance and the amount of blood present in the abdomen
b. ABGs
i. Critical to detect acidosis
ii. Monitor pH for values less than 7.35
iii. In case of ongoing hypovolemia or hemorrhage, the base deficit will be greater than 2
c. CBC
i. May be done every few hours for the first 24-48 hours then daily
ii. Monitoring for decreasing Hgb-one gram drop or greater from one reading to the next not good
iii. An increase in WBC or the number of bands (immature neutrophils) on the differential may signal an acute infection, such as peritonitis.
Nursing assessment/interventions related to spleen trauma
1. IV Line-fluids
2. Bedrest
3. Intake and Output
4. Vital signs-monitor for shock
5. Level of consciousness
6. Pain
7. Nausea and vomiting
8. Abdominal assessments-measure for abdominal girth for increased bleeding
Nursing diagnoses used for spleen trauma
1. Because it is a very vascular organ, any trauma could result in hemorrhage
2. What nursing diagnosis would you anticipate
3. Risk for fluid imbalance or Fluid Volume deficit
a. How would you assess for the potential of hemorrhage
i. Increasing heart rate and decreasing blood pressure
ii. Thready pulse
iii. Increased respiratory rate/ resp acidosis
iv. Changes in neurologic function: restlessness moving one to lethargy
v. Skin: pale and cool
b. Other nursing interventions used if there was active bleeding
1. Fluid volume replacement
2. Blood transfusion
3. Assessment for shock
4. Risk for infection
a. Patient education about decreasing their risk for infection
i. What would you include?
b. Physician may order vaccines against certain bacteria after removing the spleen
5. Routine postoperative care

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