Transcript 22 L.Interventions for Clients with Noninfectious Problems of the

Fracture of the Nose
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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:
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Rhinoplasty
Nasoseptoplasty
Epistaxis
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Nosebleed is a common problem.
Interventions if nosebleed does not
respond to emergency care:
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Affected capillaries are cauterized with
silver nitrate or electrocautery and the
nose is packed.
Posterior nasal bleeding is an
emergency.
(Continued)
Epistaxis (Continued)
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Assess for respiratory distress and for
tolerance of packing or tubes.
Administer humidification, oxygen,
bedrest, antibiotics, pain medications.
Nasal Polyps
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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
Cancer of the Nose and Sinuses
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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.
Facial Trauma
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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
Facial Trauma Interventions
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Anticipate the need for emergency
intubation, tracheotomy, and
cricothyroidotomy.
Control hemorrhage.
Assess for extent of injury.
Treat shock.
Stabilize the fracture segment.
Obstructive Sleep Apnea
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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
Disorders of the Larynx
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Vocal cord paralysis
Vocal cord nodules and polyps
Laryngeal trauma
Upper Airway Obstruction
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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.
Upper Airway Obstruction
Inverventions
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Interventions include:
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Assessment for cause of the obstruction
Maintenance of patent airway and
ventilation
Cricothyroidotomy
 Endotracheal intubation
 Tracheostomy
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Neck Trauma
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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.
Head and Neck Cancer
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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.
Ineffective Breathing Pattern
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Interventions include:
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Treatment goal: to remove or eradicate
the cancer while preserving as much
normal function as possible
Nonsurgical management
Radiation therapy
Chemotherapy
Surgical Management
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Laryngectomy (total and partial)
Tracheostomy
Oropharyngeal cancer resections
Cordal stripping
Cordectomy
Preoperative Care
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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
Postoperative Care
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Monitor airway patency, vital signs,
hemodynamic status, comfort level.
Monitor for hemorrhage.
Assess for complications:
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Airway obstruction
Hemorrhage
Wound breakdown
Tumor recurrence
Airway Maintenance and
Ventilation
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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
Wound, Flap, and
Reconstructive Tissue Care
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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
Hemorrhage
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Uncommon with laryngectomy
Often, surgical drain placed by
surgeon
Wound Breakdown
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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
Pain Management
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Morphine
Acetaminophen with codeine
Acetaminophen alone
Nonsteroidal anti-inflammatory
drugs
Nutrition
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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
Speech Rehabilitation
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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
Risk for Aspiration
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Interventions include:
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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
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Anxiety Interventions
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Interventions include:
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Team conference
Explore reason for anxiety
Teaching
Antianxiety drugs such as diazepam
administered with caution because of
the possibility of respiratory depression
Lorazepam
Disturbed Body Image
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Interventions include:
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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)
Disturbed Body Image (Continued)
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Advising loose-fitting, high-collar shirts
or sweaters, scarves, jewelry, or
cosmetics to be worn to cover the
laryngectomy stoma
Stoma Care
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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.
Chronic Airflow Limitation
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Chronic lung diseases of chronic
airflow limitation include:
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Asthma
Chronic bronchitis
Pulmonary emphysema
Chronic obstructive pulmonary
disease includes emphysema and
chronic bronchitis characterized by
bronchospasm and dyspnea.
Asthma
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Intermittent and reversible airflow
obstruction affects only the airways,
not the alveoli.
Airway obstruction occurs due to
inflammation and airway
hyperresponsiveness.
Aspirin and Other Nonsteroidal
Anti-Inflammatory Drugs
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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
Collaborative Management
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Assessment
History
Physical assessment and clinical
manifestations:
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No manifestations between attacks
Audible wheeze and increased
respiratory rate
Use of accessory muscles
“Barrel chest” from air trapping
Laboratory Assessment
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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)
Laboratory Assessment
(Continued)
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Atopic asthma with elevated serum
eosinophil count and immunoglobulin
E levels
Sputum with eosinophils and mucous
plugs with shed epithelial cells
Pulmonary Function Tests
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The most accurate measures for
asthma are pulmonary function tests
using spirometry including:
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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
Interventions
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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.
Drug Therapy
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Pharmacologic management of
asthma can involve the use of:
Bronchodilators
Beta2 agonists
Short-acting beta2 agonists
Long-acting beta2 agonists
Cholinergic antagonists
(Continued)
Drug Therapy (Continued)
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Methylxanthines
Anti-inflammatory agents
Corticosteroids
Inhaled anti-inflammatory agents
Mast cell stabilizers
Monoclonal antibodies
Leukotriene agonists
Other Treatments for Asthma
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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.
Status Asthmaticus
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Status asthmaticus is a severe, lifethreatening 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.
Emphysema
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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)
Classification of Emphysema
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Panlobular: destruction of the entire
alveolus
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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
Chronic Bronchitis
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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
Complications
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Chronic bronchitis
Hypoxemia and acidosis
Respiratory infections
Cardiac failure, especially cor
pulmonale
Cardiac dysrhythmias
Physical Assessment and
Clinical Manifestations
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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
Laboratory Assessment
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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
Impaired Gas Exchange
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Interventions for chronic obstructive
pulmonary disease:
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Airway management
Monitoring client at least every 2 hours
Oxygen therapy
Energy management
Drug Therapy
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Beta-adrenergic agents
Cholinergic antagonists
Methylxanthines
Corticosteroids
Cromolyn sodium/nedocromil
Leukotriene modifiers
Mucolytics
Surgical Management
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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
Ineffective Breathing Pattern
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Interventions for the chronic
obstructive pulmonary disease client:
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Assessment of client
Assessment of respiratory infection
Pulmonary rehabilitation therapy
Specific breathing techniques
Positioning to help alleviate dyspnea
Exercise conditioning
Energy conservation
Ineffective Airway Clearance
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Assessment of breath sounds before
and after interventions
Interventions for compromised
breathing:
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Careful use of drugs
Controlled coughing
Suctioning
Hydration via beverage and humidifier
(Continued)
Ineffective Airway Clearance
(Continued)
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Postural drainage in sitting position
when possible
Tracheostomy
Imbalanced Nutrition
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Interventions to achieve and
maintain body weight:
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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 mealrelated dyspnea
Anxiety
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Interventions for increased anxiety:
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Important to have client understand
that anxiety will worsen symptoms
Plan ways to deal with anxiety
Health Teaching
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Instruct the client:
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Pursed-lip and diaphragmatic breathing
Support of family and friends
Relaxation therapy
Professional counseling access
Complementary and alternative therapy
Activity Intolerance
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Interventions to increase activity
level:
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Encourage client to pace activities and
promote self-care.
Do not rush through morning activities.
Gradually increase activity.
Use supplemental oxygen therapy.
Potential for Pneumonia or
Other Respiratory Infections
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Risk is greater for older clients
Interventions include:
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Avoidance of large crowds
Pneumonia vaccination
Yearly influenza vaccine
Cystic Fibrosis
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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
Nonpulmonary Manifestations
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Adults: usually smaller and thinner
than average owing to malnutrition
Abdominal distention
Gastroesophageal reflux, rectal
prolapse, foul-smelling stools,
steatorrhea
Vitamin deficiencies
Diabetes mellitus
Pulmonary Manifestations
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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
Exacerbation Therapy
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Avoid mechanical ventilation
Airway clearance
Increased oxygenation
Antibiotic therapy
Heliox (50% oxygen, 50% helium)
therapy
Bronchodilator and mucolytic
therapies
Surgical Therapy
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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.
Primary Pulmonary
Hypertension
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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.
Interventions
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Warfarin therapy
Calcium channel blockers
Prostacyclin agents
Digoxin and diuretics
Oxygen therapy
Surgical management
Interstitial Pulmonary Disease
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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
Sarcoidosis
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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
Idiopathic Pulmonary Fibrosis
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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
Occupational Pulmonary
Disease
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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
Lung Cancer
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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)
Lung Cancer (Continued)
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Incidence and prevalence make lung
cancer a major health problem.
Health promotion and illness
prevention is primarily through
education strategies and reduced
tobacco smoking.
Manifestations of Lung Cancer
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Often nonspecific, appearing late in
the disease process
Chills, fever, and cough
Assess sputum
Breathing pattern
Palpation
Percussion
Auscultation
Surgical Management
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Lobectomy
Pneumonectomy
Segmentectomy (wedge resection)
Chest Tubes
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Placement after thoracotomy
Drainage system
Care required:
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Monitor hourly to ensure sterility and
patency.
Tape tubing junctions.
Keep occlusive dressing at insertion site.
Position correctly to prevent kinks and
large loops.
Interventions for Palliation
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Oxygen therapy
Drug therapy
Radiation therapy
Laser therapy
Thoracentesis and pleurodesis
Dyspnea management
Pain management