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Cancer of larynx

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neoplasm occurring in the larynx, most commonly squamous cell in origin

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What is directly r/t the development of cancer of the larynx?

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prolonged use of combined effects of alcohol and tobacco

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Other contributing factors to cancer of the larynx

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vocal straining Chronic laryngitis family disposition Industrial exposure to carcinogens Nutritional deficiencies: riboflavin

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Cancer of larynx men are affected

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8 times more often then women

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Diagnosis of cancer of the larynx usually occurs between ages of

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55 and 70

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The earliest sign of cancer of the larynx is

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hoarseness or a change in vocal quality that lasts more than 2 weeks

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Medical management of cancer of larynx

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radiation, often with adjuvant chemo or surgical removal of larynx

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Nursing assessment of cancer of the larynx

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MRI Direct laryngoscopy Assessing for hoarseness of longer than 2 weeks (early changes) Assessing for color changes in mouth or tongue Assessing for dysphagia, dyspnea, cough, hemoptysis, weight loss, neck pain radiating to ear, enlarged cervical nodes, and halitosis Radiographs of head, neck, and chest CT scan of neck and biopsy

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Hint With cancer of the larynx, the tongue and mouth often appear

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white, gray, dark brown, or black and may appear patchy

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Nursing plans and interventions for cancer of larynx

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Provide preop teaching: Allow client and family to observe and handle tracheostomy tubes and suctioning equipment. Explain how and why suctioning will take place after surgery. Plan for acceptable communication methods after surgery. Consider literacy level Refer client to speech pathologist Discuss the planned rehab program

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Post op teaching Cancer of larynx

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Simplify communications Use planned alternative communication methods Keep call bell/light within reach at all times Ask client yes/no questions Promote resp functioning: assess resp rate and characteristsics every 1 -2 hours Keep bed in semi fowler at all times keep laryngeal airway humidified at all times Auscultate lung sounds every 2-4 hours Provide tracheostomy care every 2-4 hours Administer tube feedings as prescribed Encourage ambulation as early as possible Refer for speech rehab with artificial larynx or to learn esophageal speech Humidification of environment

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Tracheostomy care involves

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cleaning inner cannula, suctioning, and applying clean dressings

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Hint Air entering the lungs is humidified along the nasobronchial tree. This natural humidifying pathway is gone for the client who has had a laryngectomy

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If the air is not humidified before entering the lungs, secretions tend to thicken and become crusty

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Hint A laryngectomy tube has a larger lumen and is shorter than the tracheotomy tube

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Observe the client for any signs of bleeding or occlusion, which are the greatest immediate postop risks (first 24 hours)

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Hint Fear of choking is very real for laryngectomy clients They cannot cough as they could earlier because the glottis is gone. Teach the glottal stop technique to remove secretions

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take deep breath, momentarily occlude tracheostomy tube, cough, and simultaneously remove finger from tube

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Pulmonary TB

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communicable lung disease caused by an infection by mycobacerium tb bacteria

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TB transmission is

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airborne After initial exposure, the bacteria encapsulate (they form a Ghon lesion) Bacteria remain dormant until a later time, when clinical symptoms appear

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Nursing assessment of TB

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Often asymptomatic Symptoms: fever with night sweats anorexia, weight loss malaise, fatigue cough, hemoptysis dyspnea, pleuritic chest pain with inspiration Cavitation or calcification as evidenced on chest radiograph Positive sputum culture Repeated upper respiratory infections

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Hint A positive TB skin test in a HEALTHY client is exhibited by an induration

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10 mm or greater in diameter 48-72 hrs after test

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Hint Anyone who has received a bacillus calmette-guerin (BCG) vaccine will have a positive skin test and must be evaluated with an initial chest radiograph

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A health history with s/s form may be filled out annually until s/s arise; then another radiograph is required Chest xrays are required on new employment; employer may require an xray every 5 years

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Nursing plans and interventions TB

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Provide client teaching: cough into tissues and dispose of immediately into special bags Take all prescribed meds daily for 9-12 months Wash hands using proper handwashing technique Report symptoms of deteriorating condition, especially hemorrhage Collect sputum cultures as needed; client may return to work after 3 negative cultures Place client in respiratory isolation while hospitalized Administer TB meds Refer client and high risk persons to local or state health department for testing and prophylactic treatment Promote adequate nutrition

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TB Client may return to work after how many negative sputum cultures?

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3

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Drug therapy for TB

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Isoniazid (INH) Rifampin (Rifadin) Ethambutol (myambutol) Pyrazinamide Rifapentine (priftin)

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Hint Teaching is very important with the client with TB

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Drug therapy is usually long term (6 mo or longer). It is essential that the client take the medications as prescribed for the entire time. Skipping doses or prematurely terminating the drug therapy can result in a public health hazard

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Hint: teaching points Rifampin (4)

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Reduces effectiveness of oral contraceptives Clients should use other birth control methods during treatment Gives body fluids orange tinge Stains soft contact lenses

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Hint: teaching points Isoniazid (INH) (1)

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Increased phenytoin (dilantin) levels)

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Hint: teaching points Ethambutol (myambutol) (2)

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Vision check before starting therapy and monthly thereafter May have to take for 1-2 years

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Hint: teaching points Teach rationale for combination drug therapy to increase compliance. Resistance develops...

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more slowly if several anti-TB drugs given, instead of just one drug at a time

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Lung cancer description

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Neoplasm occurring in the lung

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Leading cause of cancer related death in the US

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lung cancer

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_____ is responsible for 80-90% of all lung cancers

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Cigarette smoking

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Exposure to occupational hazards such as ________ and __________ poses significant risk (for lung cancer)

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asbestos and radioactive dust

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Lung cancer tends to appear years after exposure; it is most commonly seen in persons in the ______ or _________ decade of life

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fifth or sixth

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Lung cancer has a poor prognosis; 5 year survival rate is approx

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14%

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Lung cancer nursing assessment

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Dry, hacking cough early, with cough turning productive as disease progresses Hoarseness Dyspnea Hemoptysis; rust colored or purulent sputum Pain in chest area Diminished breath sounds, occasional wheezing Abnormal chest radiograph Positive sputum for cytology and for pleural fluid

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Nursing plans and interventions for lung cancer

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Similar to those implemented for client with COPD Place client in semi fowler position Teach pursed lip breathing to improve gas exchange Teach relaxation techniques; client often becomes anxious about breathing difficulty Administer O2 as indicated by pulse ox or ABGs Take measure to allay anxiety: Keep client and family informed of impending tests and procedures Give client as much control as possible over personal care Encourage client and family to verbalize concerns Decrease pain to manageable level by administering analgesics as needed

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Surgery Lung Cancer Thoracotomy:

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For client who has a resectable tumor unfortunately, detection commonly occurs so late that the tumor is no longer localized and is not amenable to resection

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Surgery Lung Cancer Pneumonectomy

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Removal of entire lung Position client on operative side or back Chest tubes are NOT usually used

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Surgery Lung Cancer Lobectomy and segmental resection

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Position client on back Chest tubes are usually inserted Check to ensure tubing is not kinked or obstructed

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Hint Some tumors are so large that they fill entire lobes of the lung When removed, large spaces are left Chest tubes are not usually used with these clients bc it is helpful if the mediastinal cavity, where the lung used to be, fills up with fluid

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This fluid helps to prevent the shift of the remaining chest organs to fill the empty space

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CHEST TUBES Keep all tubing coiled loosely below _______ with connections tight and taped

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chest level

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CHEST TUBES Keep water seal and suction control chamber at the appropriate water levels

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Monitor the fluid drainage, and mark the time of measurement and the fluid level

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CHEST TUBES Observe for air bubbling in the:

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water seal chamber and fluctuations (tidaling)

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CHEST TUBES Air bubbling should appear in the

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water seal chamber

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CHEST TUBES Do not empty collection container; replace unit when full DO NOT strip or milk chest tubes

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encourage client to breathe deeply periodically maintain dry occlusive dressing

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CHEST TUBES Chest tubes are not clamped routinely If the drainage system breaks, place the distal end of the chest tubing connection in

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a sterile water container at a 2 cm level as an emergency water seal

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Hint If chest tube becomes disconnected, DO NOT CLAMP! Immediately place the end of the tube in a

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container of sterile saline or water until a new drainage system can be connected

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Hint If the chest tube is accidentally removed from the client, the nurse should:

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cover with a dry sterile dressing.

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Hint: chest tube If an air leak is noted, tape the dressing on 3 sides only; this allows air to

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escape and prevents the formation of a tension pneumothorax Notify HCP

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Hint: fluctuations in water seal.... These movements are a good indicator that the system is intact; they should move upward with each inspiration and downward with each expiration. If fluctuations cease: (fluctuations/tidaling in the fluid will occur if there is no external suction....?)

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check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in client's position, bc expanding lung tissue may be occluding the tube opening REMEMBER, WHEN EXTERNAL SUCTION IS APPLIED, THE FLUCTUATIONS CEASE??

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Chemo: administer ______ prior to administration of chemo

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antiemetics Take precautions when administering antineoplastics

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Radiation: Provide skin care according to HCP's request Instruct client NOT TO wash off the lines drawn by radiologist. Instruct client to wear:

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SOFT COTTON GARMENTS only

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Radiation: Avoid use of

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powders and creams on radiation site unless specified by radiologist

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Hint Various pathyphysiologic conditions can be r/t the nursing dx Ineffective breathing patterns.

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inability of air sacs to fill and empty properly (emphysema, cystic fibrosis) Obstruction of the air passages (carcinoma, asthma, chronic bronchitis) Accumulation of fluid in air sacs (pneumonia) Respiratory muscle fatigue (COPD, pneumonia)

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List 4 common symptoms of pneumonia the nurse might note on physical exam

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Tachypnea fever with chills productive cough bronchial breath sounds

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Symptoms of pneumonia in older adult

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confusion, lethargy, anorexia, rapid resp rate

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During mechanical ventilation, what are 3 major nursing interventions

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monitor client's resp status and secure connections establish a communication mechanism with client Keep airway clear by coughing and suctioning

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When examining a client with emphysema, what physical findings is the nurse likely to see?

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barrel chest, dry or productive cough, decreased breath sounds dyspnea, crackles in lung fields

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List four components of teaching for client with TB

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Cough into tissues and dispose of immediately into special bags Long term need for daily meds Good handwashing technique Report symptoms of deterioration e.g. blood in secretions

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