UPPER AND LOWER AIRWAY ALTERATIONS FROM CANCER 342021

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UPPER AND LOWER AIRWAY ALTERATIONS FROM CANCER 3/4/2021 1

UPPER AND LOWER AIRWAY ALTERATIONS FROM CANCER 3/4/2021 1

3/4/2021 2

3/4/2021 2

TEACHING CLIENTS ABOUT RISK FACTORS ****Smoking and ETOH air pollution & industrial exposure vocal

TEACHING CLIENTS ABOUT RISK FACTORS ****Smoking and ETOH air pollution & industrial exposure vocal straining/chronic laryngitis 3

ASSESSMENTS If Client has history of following for 3 -4 weeks should suspect laryngeal

ASSESSMENTS If Client has history of following for 3 -4 weeks should suspect laryngeal cancer Hoarseness Lump in mouth, throat, neck Mouth sores that don’t heal 4

Late ASSESSMENTS Dysphagia Foul breath Chronic cough/Hemoptysis Dyspnea Sore throat/sores in throat/burning when drinking

Late ASSESSMENTS Dysphagia Foul breath Chronic cough/Hemoptysis Dyspnea Sore throat/sores in throat/burning when drinking citrus juices or hot liquids Persistent, unilateral ear pain 5

Signs of Metastasis  METASTASIS occurs to local structures first (mucosa, muscle, bone)

Signs of Metastasis METASTASIS occurs to local structures first (mucosa, muscle, bone) LATER METASTASIS: spread by blood and lymph to lung and liver ASSESSMENTS INDICATING METASTASIS: Enlarged cervical lymph nodes Weight loss General debility 6

ASSESSMENTS: Diagnostics Panendoscopy under general anesthesia: (laryngoscopy, nasopharyngoscopy, esophagoscopy, bronchoscopy) MRI/CT/SPECT/PET scans Xrays Biopsy:

ASSESSMENTS: Diagnostics Panendoscopy under general anesthesia: (laryngoscopy, nasopharyngoscopy, esophagoscopy, bronchoscopy) MRI/CT/SPECT/PET scans Xrays Biopsy: squamous cell 7

TREATMENT Varies depending upon location and metastasis • Radiation (may be used to shrink

TREATMENT Varies depending upon location and metastasis • Radiation (may be used to shrink tumor size) • chemotherapy • surgery 8

SURGERY FOR LARYNGEAL CANCER: EFFECT ON VOICE SURGERY TYPE • LASER SURGERY: reduce tumor

SURGERY FOR LARYNGEAL CANCER: EFFECT ON VOICE SURGERY TYPE • LASER SURGERY: reduce tumor • CORDECTOMY: partial removal of one vocal cord • HEMI-LARYNGECTOMY: removal of one vocal cord or part of a cord; temporary tracheostomy VOICE QUALITY Normal, hoarse Normal/hoarse High cure rate Voice is breathy and hoarse 9

SURGERY FOR LARYNGEAL CANCER: EFFECT ON VOICE SURGERY TYPE • Supraglottic partial laryngectomy: Hyoid

SURGERY FOR LARYNGEAL CANCER: EFFECT ON VOICE SURGERY TYPE • Supraglottic partial laryngectomy: Hyoid bone, false cords, epiglottis removed; possible neck dissection if nodes involved high risk for aspiration; temporary tracheostomy VOICE QUALITY • Breathy and hoarse 10

SURGERY FOR LARYNGEAL CANCER: EFFECT ON VOICE • Total laryngectomy: • No natural voice

SURGERY FOR LARYNGEAL CANCER: EFFECT ON VOICE • Total laryngectomy: • No natural voice entire larynx, • Permanent • Pre-epiglottic region is tracheostomy removed • Radical neck dissection if nodes are involved to decrease risk of lymphatic spread 11

POSTOPERATIVELY • NECK DISSECTION: removal of lymph nodes, sternocleidomastoid muscle, jugular vein, 11 th

POSTOPERATIVELY • NECK DISSECTION: removal of lymph nodes, sternocleidomastoid muscle, jugular vein, 11 th cranial nerve and surrounding tissue, part of thyroid and parathyroid glands • Shoulder drop: 11 th cranial nerve cut (spinal accessory nerve): need PT 12

PRIORITY CONCERNS POSTOP • • • ****Respiratory: respiratory distress ****Hemorrhage Wound/flap integrity Nutrition Pain

PRIORITY CONCERNS POSTOP • • • ****Respiratory: respiratory distress ****Hemorrhage Wound/flap integrity Nutrition Pain 13

POSTOPERATIVELY: AIRWAY • Pt has a tracheostomy • Temporary: partial laryngectomy • Permanent: total

POSTOPERATIVELY: AIRWAY • Pt has a tracheostomy • Temporary: partial laryngectomy • Permanent: total laryngectomy – Upper airway separated from the pharynx and esophagus – Trachea is brought out to skin in neck and sutured in place creating a stoma – Called laryngectromy stoma 14

POSTOP: AIRWAY Ventilator to tracheostomy collar Oxygen Humidification: thins mucus, prevents obstruction Some MD

POSTOP: AIRWAY Ventilator to tracheostomy collar Oxygen Humidification: thins mucus, prevents obstruction Some MD have 5 -10 ml of sterile saline into airway q 2 hr (CONTROVERSIAL) • Secretions blood tinged 1 -2 days • Suction • • 15

AIRWAY CONTINUED FOR TOTAL LARYNGECTOMY PT Laryngectomy tube (p 575) • Like a tracheostomy

AIRWAY CONTINUED FOR TOTAL LARYNGECTOMY PT Laryngectomy tube (p 575) • Like a tracheostomy tube, but shorter, fatter, larger lumen • Prevents scar tissue contracture • Care like tracheostomy tube care (see chapter 31) Laryngectomy button: • Like a laryngectomy tube, but made of Silastic, has single lumen very short • Comfortable, easily removed for cleaning, custom fit 16

AIRWAY CONTINUED • Coughing and deep breathing clear secretions • Oral secretions: suction by

AIRWAY CONTINUED • Coughing and deep breathing clear secretions • Oral secretions: suction by client with Yankauer 17

STOMA CARE FOLLOWING TOTAL LARYNGECTOMY • Use flashlight to assess • Clean suture line

STOMA CARE FOLLOWING TOTAL LARYNGECTOMY • Use flashlight to assess • Clean suture line with ½ strength hydrogen peroxide: prevent secretions from forming crusts and obstructing airway • Suture line care q 1 -2 hours during the first few days after surgery then q 4 hours • Assess stoma for bright/shiny color (should look like the oral mucosa) 18

WOUND/FLAP/ RECONSTRUCTIVE CARE • Use to close wound • Use other muscles to reconstruct

WOUND/FLAP/ RECONSTRUCTIVE CARE • Use to close wound • Use other muscles to reconstruct head and neck resection • Assess every hour for 72 hours • Cap refill, color, Doppler activity of major vessel • Any changes call surgeon 19

POSTOP HEMORRHAGE • Drain in neck for 72 hours postop • Want to drain

POSTOP HEMORRHAGE • Drain in neck for 72 hours postop • Want to drain freely. Do not want accumulation under flaps (impairs blood flow to and from flap) • Report sudden stoppage (clot obstructing drain) 20

WOUND BREAKDOWN • Common • Due to poor nutrition, alcohol use, wound contamination, radiation

WOUND BREAKDOWN • Common • Due to poor nutrition, alcohol use, wound contamination, radiation therapy • Packing • Could have carotid artery rupture: IMMEDIATE PRESSURE, TO OR IMMEDIATELY for carotid resection – Risk of stroke and death 21

POSTOP: PAIN • Morphine (statex) IV bolus and PCA for several days postop •

POSTOP: PAIN • Morphine (statex) IV bolus and PCA for several days postop • Progress to acetaminophen with codeine (Tylenol # ___: #1: 7. 5 mg Codeine, #2: 15 mg Codeine, #3: 30 mg Codeine, #4: 60 mg Codeine) • Oral medication after pt tolerates oral nutrition • Supplemented with NSAIDS – very effective • Amitriptyline (Elavil): use for nerve root pain 22

POSTOP: NUTRITION • All clients receive IV fluids ONE OF THREE OPTIONS AFTER HEAD

POSTOP: NUTRITION • All clients receive IV fluids ONE OF THREE OPTIONS AFTER HEAD AND NECK SURGERY to achieve the following goal: 35 -40 kcal/kg of body wgt: • NGT: most common, used 7 -10 days postop; pt must be able to swallow • Gastrostomy • Or jejunostomy POSTOP TOTAL LARYNGECTOMY: no aspiration can occur because airway and esophagus are separated 23

POSTOP COMMUNICATION • POSTOP TOTAL LARYNGECTOMY: pt has no voice • Communication initially through

POSTOP COMMUNICATION • POSTOP TOTAL LARYNGECTOMY: pt has no voice • Communication initially through writing/picture board • Then artificial larynx, then esophageal speech • Need support from laryngectomee (person who has had larynx removed and is in support group) 24

POSTOP COMMUNICATION • ESOPHAGEAL SPEECH • Sound produced by burping air swallowed and shaping

POSTOP COMMUNICATION • ESOPHAGEAL SPEECH • Sound produced by burping air swallowed and shaping words with mouth • Monotone voice, no pitch (vocal cords necessary for 15 consonants, other 10 formed by shaping the mouth) • Need good hearing • Have intestinal bloating - antacids 25

POSTOP COMMUNICATION • MECHANICAL DEVICES • If cannot do esophageal speech can use electrolarynges

POSTOP COMMUNICATION • MECHANICAL DEVICES • If cannot do esophageal speech can use electrolarynges • Battery powered device placed against the side of the neck or check • Air in mouth and throat is vibrated, move mouth and lips and tongue as usual 26

POSTOP COMMUNICATION • TRACHEOESOPHAGEAL FISTULA (see p 577578) • Fistula created between trachea and

POSTOP COMMUNICATION • TRACHEOESOPHAGEAL FISTULA (see p 577578) • Fistula created between trachea and esophagus during surgery or after • Pt covers stoma and opening of the prosthesis; air diverted from lungs • Lip and tongue movement produces speech 27

RISK FOR ASPIRATION • Surgical changes in respiratory tract and altered swallowing mechanisms increase

RISK FOR ASPIRATION • Surgical changes in respiratory tract and altered swallowing mechanisms increase risk for aspiration • NGT in place increases risk – HOB up, check placement before feeding, check residual before bolus feeding or q 4 -6 hours during continuous feedings – If residual greater than 100 ml withhold feeding, call MD – Keep suction available • Altered swallowing due to tracheostomy tube placement • Client who has had subtotal, vertical, or supraglotic laryngectomy MUST be observed for ASPIRATION • Swallowing study helps determine swallowing ability (see p 579, chart 32 -4 on how to swallow) 28

PREVENTION OF ASPIRATION • • Once client taking po Small amounts of food Avoid

PREVENTION OF ASPIRATION • • Once client taking po Small amounts of food Avoid liquids/used thickening agent Cut food into small pieces Meds in elixir form Break or crush pills HOB up 30 -45 minutes after feedding 29

HOME HEALTH TEACHING • Stoma care: mild soap/H 2 O, lubricate stoma with nonoilbased

HOME HEALTH TEACHING • Stoma care: mild soap/H 2 O, lubricate stoma with nonoilbased ointment • Tracheostomy/laryngectomy tube care: increase humidity • Avoid swimming, careful showering or shaving • Lean forward cover stoma when coughing/sneezing • Wear stoma guard to cover stoma, filters air while keeping humidity in airway • Wear Medic. Alert bracelet and emergency care card for life threatening situations (mouth to neck breathing, oxygen to neck opening) 30

PSYCHOSOCIAL • total laryngectomy client cannot produce sounds during laughing and crying • Mucous

PSYCHOSOCIAL • total laryngectomy client cannot produce sounds during laughing and crying • Mucous secretions may appear suddenly, embarrassing, cover stoma with gauze or handkerchief 31

CANCER OF THE LUNG

CANCER OF THE LUNG

GENERAL SUMMARY • Leading cause of death in USA • usually dx late with

GENERAL SUMMARY • Leading cause of death in USA • usually dx late with metastasis already present, Px: good if tumor can be removed • Metastasizes through blood and lymph going to bone liver, brain, adrenal • Occurs result of repeated exposure to inhaled substances that cause chronic tissue irritation or inflammation • Genetic factors

CIGARETTE SMOKING: BIG BAD WOLF MAJOR CAUSE OF LUNG CANCER: • Cigarette smoking –

CIGARETTE SMOKING: BIG BAD WOLF MAJOR CAUSE OF LUNG CANCER: • Cigarette smoking – major factor (85% of all lung Ca deaths) • Risk based on # years, # cigarettes smoked/day • Risk decreases when smoking stops, but ex-smokers may still develop lung ca • non-smokers exposed to passive/secondhand smoke have increase risk of lung ca SECOND CAUSE: industrial chemical and air pollutants

HEALTH PREVENTION • Review Healthy People for 2010 objectives (see page 611) • When

HEALTH PREVENTION • Review Healthy People for 2010 objectives (see page 611) • When do you start teaching? • What can nurses do?

WARNING SIGNALS OF LUNG CANCER • • *Hoarseness *Cough Sputum production Hemoptysis (later finding)

WARNING SIGNALS OF LUNG CANCER • • *Hoarseness *Cough Sputum production Hemoptysis (later finding) Shortness of breath Change in endurance Recurring episodes of pleural effusion, pneumonia, bronchitis

OTHER S&S SEEN: RESULT OF EFFECT ON OTHER SYSTEMS • Muffled heart sounds: tumor/fluid

OTHER S&S SEEN: RESULT OF EFFECT ON OTHER SYSTEMS • Muffled heart sounds: tumor/fluid around heart (cardiac tamponade) • Dysrhythmias: from hypoxemia caused by tumor pressure on heart • Cyanosis/clubbing of fingers: hypoxemia • Bones thin: due to tumor invasion – lead to fx, bone pain • Superior Vena Cava syndrome: comes from tumor pressure

SUPERIOR VENA CAVA SYNDROME • Summarized on p 502 under General Interventions for clients

SUPERIOR VENA CAVA SYNDROME • Summarized on p 502 under General Interventions for clients with Cancer • LIFE THREATENING EMERGENCY • Compression leads to blockage of blood flow in the venous system of the head, neck, upper trunk

SUPERIOR VENA CAVA SYNDROME CONTINUED EARLY S&S: After sleeping see edema of face, tightness

SUPERIOR VENA CAVA SYNDROME CONTINUED EARLY S&S: After sleeping see edema of face, tightness of shirt or blouse WORSENING OF S&S: • Edema arms, hands, dyspnea, erythema of upper body, epistaxis LATE MANIFESTATION: • Hemorrhage, cyanosis, mental status changes from lack of blood to brain, decreased cardiac output and hypotension • LEADS TO DEATH if compression not relieved

OTHER S&S SEEN: RESULT OF EFFECT ON OTHER SYSTEMS • BRAIN METASTASIS: Lethargy, confusion,

OTHER S&S SEEN: RESULT OF EFFECT ON OTHER SYSTEMS • BRAIN METASTASIS: Lethargy, confusion, somnolence • METASTASIS TO SPINE AND SPINAL CORD: Bowel/bladder function altered • GENERAL LATE SYMPTOMS OF LUNG CANCER INCLUDE: fatigue, wgt loss, anorexia, dysphasia, N&V

PSYCHOSOCIAL RESPONSE • Fear/anxiety • Guilt/shame

PSYCHOSOCIAL RESPONSE • Fear/anxiety • Guilt/shame

DIAGNOSTIC TESTS • Chest xray 1 st • Then CT scan • Fiberoptic bronchoscopy

DIAGNOSTIC TESTS • Chest xray 1 st • Then CT scan • Fiberoptic bronchoscopy to see tracheobronical tree and – take specimen – Needle bx done to obtain Ca cells • Thoracoscopy: video assisted thorascope allows entry to chest cavity, small incisions in chest wall: can see lung tissue • Mediastinoscopy: to identify metastasis to mediastinal lymph nodes, small chest incision

DIGNOSTIC TESTS CONTINUED DONE TO SEE SPREAD: • Needle bx of lymph nodes •

DIGNOSTIC TESTS CONTINUED DONE TO SEE SPREAD: • Needle bx of lymph nodes • Direct surgical bx • Thoracentesis with pleural bx • MRI of liver, spleen, brain, bone for met tumors • PFT, ABG: resp status • PET scan is becoming the most THOROUGH test for mets

THORACENTESIS: Aspiration of pleural fluid for dx/tx • Prepare pt for stinging sensation from

THORACENTESIS: Aspiration of pleural fluid for dx/tx • Prepare pt for stinging sensation from local anesthetic and feeling of pressure when needle inserted • Must keep still, no C/DB • P 542 position (over the over bed table; hands over head, 45 degree HOB up) • No more than 1000 ml removed • Chest xray done after procedure to r/o pneumothorax • Listen for absent or reduced breath sounds • Observe puncture site for bleeding, and hemoptysis LUNG BIOPSY: position is similar and complications same 44

TREATMENT • Chemotherapy • Radiation • Surgery • Chemo may be used alone for

TREATMENT • Chemotherapy • Radiation • Surgery • Chemo may be used alone for SCLC • For NSCLC may use chemo alone or in combination with otherapies

SURGERY • MAIN TX: for stage 1 and stage 2 NSCLC • GOAL: remove

SURGERY • MAIN TX: for stage 1 and stage 2 NSCLC • GOAL: remove tumor – hope for cure • TYPES OF SURGERY: depends on location of tumor • TYPES OF INCISIONS: posterolateral, anterolateral, median sternotomy (see fig 3313, p 617 • ALL INCISIONS: long, large, held open with retractors (lots of postop pain)

TYPES OF PROCEDURES • SEGMENTECTOMY: lung resection – Includes bronchus, pulmonary artery and vein

TYPES OF PROCEDURES • SEGMENTECTOMY: lung resection – Includes bronchus, pulmonary artery and vein and tissue of the involved lung segment • WEDGE RESECTION: removal of the peripheral portion of small localized areas of disease • LOBECTOMY: removal entire lobe of lung • PNEUMONECTOMY: removal of entire lung including all blood vessels, bronchus is severed and sutured

NURSING CARE: p 618 -622 • Impaired gas exchange – Assessment – Position –

NURSING CARE: p 618 -622 • Impaired gas exchange – Assessment – Position – Treatments

 • Alteration of comfort – Assessment – Pain control methods

• Alteration of comfort – Assessment – Pain control methods

 • Activity Intolerance – Assess – Interventions

• Activity Intolerance – Assess – Interventions

CHEST TUBES AND DRAINAGE PURPOSE: • Restores intrapleural pressure • Allows re-expansion of the

CHEST TUBES AND DRAINAGE PURPOSE: • Restores intrapleural pressure • Allows re-expansion of the lung • Prevents air and fluid from returning to the chest

CHEST TUBES CONTINUED • One two tubes placed – One tube drains fluid –

CHEST TUBES CONTINUED • One two tubes placed – One tube drains fluid – One tube drains air • Puncture sites covered with air tight dressings • Tubes connected via a Y connector to tubing (6 feet long) • Tubing connected to collection device (bottle or selfcontained unit) • Must be kept below the chest to allow for gravity drainage

CHEST TUBES CONTINUED • Uses a water seal mechanism • One-way valve mechanism •

CHEST TUBES CONTINUED • Uses a water seal mechanism • One-way valve mechanism • Prevents air or liquid from moving back into the chest cavity

Chest Tube Placement

Chest Tube Placement

Water Seal Drainage 3 - Bottle System

Water Seal Drainage 3 - Bottle System

Chest Water-Seal Drainage

Chest Water-Seal Drainage

Water Seal Drainage Pleur-evac System

Water Seal Drainage Pleur-evac System

PLEUR-EVAC • Replaces the 3 bottle system with a plastic device • Has 3

PLEUR-EVAC • Replaces the 3 bottle system with a plastic device • Has 3 chambers: – Chamber for drainage – A water seal – Suction control • ADVANTAGES: – – Self-contained Less breakage Less contamination Increased patient mobility

NURSING CARE OF PT WITH PLEUR-EVAC • • Check patency hourly Tape tubing connections

NURSING CARE OF PT WITH PLEUR-EVAC • • Check patency hourly Tape tubing connections Keep occlusive dressing on chest tube insertion site ***Keep emergency sterile gauze to cover insertion site in case chest tube comes out ***Keep padded clamps at bedside in case drainage system is interrupted Avoid kinks, Avoid large loops in tubing (blocks drainage) AVOID VIGOROUS STRIPPING OF CHEST TUBE Book says to use gentle milking of tube to move blood clots and prevent obstruction (somewhat controversial)

ASSESSMENTS OF CLIENT WITH PLEUR-EVAC • • • PRIORITY: assess respiratory status Document amount

ASSESSMENTS OF CLIENT WITH PLEUR-EVAC • • • PRIORITY: assess respiratory status Document amount and type of drainage hourly NOTIFY MD if more than 100 ml/hr occurs AFTER 1 st 24 hours: check drainage q 8 hr Don’t empty drainage collection Mark drainage on collection device with tape

ASSESSMENTS OF CLIENT WITH PLEUR-EVAC • CHECK WATER SEAL CHAMBER for unexpected or CONTINUOUS

ASSESSMENTS OF CLIENT WITH PLEUR-EVAC • CHECK WATER SEAL CHAMBER for unexpected or CONTINUOUS BUBBLING indicating an air leak (call MD) vwater-seal chamber: 2 cm sterile water tidaling of fluid; • NORMAL: to have bubbling during forceful expiration or coughing (comes from air in chest being expelled)

WHERE IS THE AIR LEAK? After reporting Bubbling: MD may instruct nurse to apply

WHERE IS THE AIR LEAK? After reporting Bubbling: MD may instruct nurse to apply a padded clamp on drainage tubing close to occlusive dressing • IF BUBBLING STOPS air leak at CHEST TUBE insertion site or within the chest • IF BUBBLING DOESN’T STOP indicates air leak is between clamp and drainage system