Please enable JavaScript.

Coggle requires JavaScript to display documents.

Obstructive Sleep Apnea, Accounts for approximately half of all head and…

Accounts for approximately half of all head and neck cancers. Almost all malignant tumors of the larynx arise from the surface epithelium and are classified as squamous cell carcinoma. patients with laryngeal cancer present with involved lymph nodes at the time of diagnosis, with bilateral lesions present.

Pharmacologic Therapy:

Patients with stage III and IV tumors that are resectable may be advised to have either total laryngectomies with or without postoperative radiation therapy or radiation therapy with concurrent adjuvant chemotherapy (with single-agent cisplatin) and surgical resection aimed at preserving some of the larynx (i.e., organ preservation surgery).

Patients with late-stage tumors that extend through cartilage and into soft tissues are generally advised to have total laryngectomies with postoperative radiation therapy.

For patients with early-stage tumors (i.e., stages I and II) and lesions without lymph node involvement, external-beam radiation therapy or conservation surgery (i.e., less invasive surgery, such as vocal cord stripping or cordectomy) may be effective.

Nursing Management: The goals of treatment of laryngeal cancer include cure; preservation of safe, effective swallowing; preservation of useful voice; and avoidance of permanent tracheostoma.

Treatment options include surgery, radiation therapy, and adjuvant chemoradiation therapy. The prognosis depends on the tumor location (i.e., supraglottic, glottis, and subglottic), as well as the tumor grade and stage. The treatment plan also depends on whether the cancer is an initial diagnosis or a recurrence. In addition, before treatment begins, a complete dental examination is performed to rule out any oral disease. A consultation with a dental oncologist may be warranted. Any dental problems are resolved, if possible, before surgery and radiotherapy.

Patients should be educated so that they carefully consider the various side effects and complications associated with the different treatment modalities. The presence of lymph node involvement in the neck can affect the outcome. Supraglottic tumors metastasize early and bilaterally even when there appears to be no lymph node involvement at the time of diagnosis. When the neck lymph nodes are involved, the treatment includes surgery, chemoradiation, or both.

Disorder characterized by recurrent episodes of upper airway obstruction and a reduction in ventilation. It is defined as cessation of breathing (apnea) during sleep usually caused by repetitive upper airway obstruction.

Pharmacologic Therapy:

Modafinil (Provigil) has been used to reduce daytime sleepiness.

Protriptyline (Triptil) given at bedtime may increase the respiratory drive and improve upper airway muscle tone.

Medroxyprogesterone acetate (Provera) and acetazolamide (Diamox) have been used for sleep apnea associated with chronic alveolar hypoventilation; however, their benefits have not been well established.

The patient must understand that these medications are not a substitute for CPAP, BiPAP, or MAD. Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea.

Nursing Management:

The nurse explains the disorder in terms that are understandable to the patient and relates symptoms (daytime sleepiness) to the underlying disorder.

The nurse also instructs the patient and family about treatments, including the correct and safe use of CPAP, BiPAP, MAD, and oxygen therapy, if prescribed.

Weight loss, avoidance of alcohol, positional therapy (using devices that prevent patients from sleeping on their backs), and oral appliances such as mandibular advancement devices (MADs) are the first steps. When applied correctly, an MAD advances the mandible so that it is slightly anterior to the upper front teeth, preventing airway obstruction by the tongue and soft tissue during sleep.

The nurse educates the patient about the risk of untreated OSA and the benefits of treatment approaches.

Epistaxis or Nosebleed

Pharmacologic Therapy:

Application of nasal decongestants (phenylephrine, one or two sprays) to act as vasoconstrictors may be necessary.

Antibiotics may be prescribed because of the risk of iatrogenic rhinosinusitis and sepsis.

Nursing Management:

Monitor the patient’s vital signs, assists in the control of bleeding, and provides tissues and an emesis basin to allow the patient to expectorate any excess blood.

Assure the patient in a calm, efficient manner that bleeding can be controlled can help reduce anxiety.

If the origin of the bleeding cannot be identified, the nose may be packed with gauze impregnated with petrolatum jelly or antibiotic ointment; a topical anesthetic spray and decongestant agent may be used before the gauze packing is inserted, or a balloon-inflated catheter may be used. Alternatively, a compressed nasal sponge may be used.

Instruct the patient to avoid vigorous exercise for several days and to avoid hot or spicy foods and tobacco.

If measures and other interventions are unsuccessful in stopping the bleeding, the nose must be examined using good illumination and suction to determine the site of bleeding. Visible bleeding sites may be cauterized with silver nitrate or electrocautery (high-frequency electrical current). A supplemental patch of Surgicel or Gelfoam may be used. Alternatively, a cotton tampon may be used to try to stop the bleeding. Suction may be used to remove excess blood and clots from the field of inspection.

Educate patient before discharge. The nurse explains how to apply direct pressure to the nose with the thumb and the index finger for 15 minutes in the case of a recurrent nosebleed. If recurrent bleeding cannot be stopped, the patient is instructed to seek additional medical attention.

The patient sits upright with the head tilted forward to prevent swallowing and aspiration of blood and is directed to pinch the soft outer portion of the nose against the midline septum for 5 or 10 minutes continuously.

Nasal fracture is the most common facial fracture and the most common fracture in the body that usually result from a direct assault. It may affect the ascending process of the maxilla and the septum.

Pharmacologic Therapy:

Uncomplicated nasal fractures may be treated initially with antibiotics, analgesic agents, and a decongestant nasal spray.

The use of analgesic agents such as acetaminophen or NSAIDs (i.e., ibuprofen or naproxen) is encouraged.

Diagnostic Tests:

Intranasal examination is performed in all cases to rule out septal hematoma. Because of the swelling and bleeding that occur with a nasal fracture, an accurate diagnosis can be made only after the swelling subsides.

An x-ray may reveal displacement of the fractured bones and may help rule out extension of the fracture into the skull.

Nursing Management:

Immediately after the fracture, the nurse applies ice and encourages the patient to keep the head elevated.

The nurse instructs the patient to apply ice packs to the nose to decrease swelling. The patient who experiences bleeding from the nose (epistaxis) is usually frightened and anxious and needs reassurance.

Refer patient to a specialist to evaluate the need to realign the bones.

Rinse the mouth to help moisten mucous membranes and avoid becoming dry because of breathing in the mouth, also to reduce the odor and taste of dried blood in the oropharynx and nasopharynx.

To ensure a patent airway and to rule out a cervical spine fracture.

When removing the cotton pledgets, the nurse carefully inspects the mucosa for lacerations or a septal hematoma.

As a rule, bleeding is controlled with the use of packing. Cold compresses are used to prevent or reduce edema.

The nurse instructs the patient to avoid sports activities for 6 weeks.

Cancer of the Larynx

Assessment and Diagnostic Findings:

Mobility of the vocal cords is assessed; if normal movement is limited, the growth may affect muscle, other tissue, and even the airway.

The lymph nodes of the neck and the thyroid gland are palpated for enlargement.

Assessment and Diagnostic Findings:

Fine-needle aspiration (FNA) biopsy (FNA biopsy may be done as an initial screening procedure to obtain samples of any enlarged lymph nodes in the neck), a barium swallow (A barium swallow may be done if the patient initially presents with a chief complaint of difficulty in swallowing, to outline any structural anomalies of the neck that could pinpoint a tumor), endoscopy, CT or MRI scan, and a positron emission tomography (PET) scan.

Intraoperative examination obtained by direct microscopic visualization and palpation of the vocal folds may yield a more accurate diagnosis. Samples of the suspicious tissue are obtained for analysis.

Assessment and Diagnostic Findings:

Complete history and physical examination of the head and neck. This includes identification of risk factors, family history, and any underlying medical conditions.

An indirect laryngoscopy, using a flexible endoscope, is initially performed.

The passage of air through the nostrils is frequently obstructed by a deviation of the nasal septum, hypertrophy of the turbinate bones, or the pressure of nasal polyps.

Pharmacologic treatment:

Antibiotics for the treatment of underlying infection or antihistamines for the management of allergies.

Hypertrophied turbinates may be treated by applying an astringent agent to shrink them.

Nasal corticosteroids as well as oral leukotriene inhibitors, such as montelukast.

Nursing Management:

The treatment of nasal obstruction requires the removal of the obstruction, followed by measures to treat whatever chronic infection exists. In many patients, an underlying allergy also requires treatment. Measures to reduce or alleviate nasal obstruction include nonsurgical as well as surgical techniques.

When a surgical procedure is indicated, most often it is performed on an outpatient basis. The nurse explains the procedure to the patient.

Frequent oral hygiene is encouraged to overcome dryness caused by breathing through the mouth.

Before discharge from the outpatient or same-day surgical unit, the patient is instructed to avoid blowing the nose with force during the postoperative recovery period.

The patient is also instructed about the signs and symptoms of bleeding and infection and when to contact the primary provider.

The patient is provided with written postoperative instructions, including emergency phone numbers.

Fracture of the Nose

Assessment:

Clear fluid draining from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid.

Usually, careful inspection or palpation discloses any deviations of the bone or disruptions of the nasal cartilages.

The nose is examined internally to rule out the possibility that the injury may be complicated by a fracture of the nasal septum and a submucosal septal hematoma.

Nasal Obstruction

Assessment:

Patients with chronic nasal congestion often suffer from sleep deprivation due to difficulty maintaining an adequate airway while lying flat and during sleep.

Persistent nasal obstruction also may lead to chronic infection of the nose and result in frequent episodes of nasopharyngitis.

Chronic nasal congestion forces the patient to breathe through the mouth, thus producing dryness of the oral mucosa and associated problems including persistent dry, cracked lips.

Obstruction of the larynx because of edema is a serious condition that may be fatal without swift, decisive intervention. Swelling of the laryngeal mucous membranes may close off the opening tightly, leading to life-threatening hypoxia or suffocation.

Nursing Management:

If the obstruction is caused by edema resulting from an allergic reaction, treatment may include immediate administration of subcutaneous epinephrine and a corticosteroid.

Ice may be applied to the neck in an effort to reduce edema.

If the airway is obstructed by a foreign body and signs of asphyxia are apparent, immediate treatment is necessary. If all efforts are unsuccessful, an immediate tracheotomy is necessary.

Continuous pulse oximetry is essential in the patient who has experienced acute upper airway obstruction.