CA larynx

Case Presentation in Geriatric Ward

“CANCER OF THE

LARYNX”

Submitted by:Group A1 PCHS BANDONG, James CERCADO, Michelle CILLO, Rudyard DIAZ, Karen DUASO, Byron FONACIER, Butchic GUTIERREZ, Maria Christina LACANILAO, Adrian PAULITE, Zenneth SEVILLENO, Rachelle YAP, Josef

Submitted To:

Marlyn Lugtu RN, MAN

GERIATRIC AREAWard 12, VMMC

INTRODUCTION AND

BACKGROUND

LEARNING OBJECTIVES: To gain better comprehension about the

disease process of cancer of the larynx To have a basis or guideline in caring

for a client Post-Operative Laryngectomy

To relate knowledge and skills with actual practice in the clinical area

© 2007 Thomson Higher Education

CARCINOMA OF THE LARYNX

malignant tumor (carcinoma)

85-95% of laryngeal tumors are squamous cell carcinoma

three areas of the larynx: 1 - glottic area (2/3 cases)2 - supraglottic area 3 - subglottis

Characteristics of squamous cell carcinoma of the larynx:

epithelial nests surrounded by inflammatory stroma with

keratin pearls being pathognomonic

ETIOLOGY:

Primary factors: prolonged tobacco useprolonged alcohol consumption

90% of patients have a history of both

INCIDENCE: World Population: male - 137,197 cases (86%)

female - 22,114 cases (14%)

ages < 65 male-87%, female- 13% ages >= 65male-85%, female- 15%

INCIDENCE: Philippine Population: male - 577 cases(73%)

female - 209 cases(27%)

ages < 65 male-77%, female- 23% ages >= 65male-68%, female- 32%

OUTCOME: 5 year survival for laryngeal cancer is better than that of other neck cancers

2/3rds of cases are Glottic carcinomas with a low rate of spread

Five year survival for:Stage I is >95% Stage II 85-90%Stage III 70-80%Stage IV 50-60%

PATIENTPROFILE

NURSING HEALTH HISTORYA. DEMOGRAPHIC DATA

Patient’s Name : Patient LBRank : N/AGender : MaleAge : 63Birthday : April 27, 1947Marital Status : MarriedNationality : FilipinoReligion : CatholicAddress : Sta. Maria, BulacanWard : Ward 12

B. CHIEF COMPLAINTHoarseness of voice

NURSING HEALTH HISTORYC. HISTORY OF PRESENT ILLNESS

ｷ 5 months prior to admission, patient experienced hoarseness that was not relieved by medicationsｷ 4 months prior to admission, patient experienced a choking feeling when swallowing. Patient claimed to have lost weightｷ 2 months PTA, patient experienced occasional dyspnea. Patient went to an ENT specialist and was initially diagnosed to have a laryngeal mass. Patient was advised to undergo biopsy and tracheostomy tube insertion, but did not comply.ｷ 1 month PTA, patient went to E-Ward of VMMC and complained difficulty of breathing. Biopsy revealed Squamous Cell Carcinoma of the Larynx Stage II. Patient was advised to undergo surgery and to have a CT scan of the neck.

NURSING HEALTH HISTORYD. PAST MEDICAL HISTORY

ｧ Pediatric/Childhood/Adult Illnesses(+) measles, (+) chicken pox

ｧ Operations1967: Appendectomy at QCMC

ｧ Immunizations - Unrecalled

ｧ Allergies - No known allergies

ｧ Vices – Smoking, Drinking alcohol

Family History(+) Hypertension – siblings, parents(+) Cancer – liver ( 2 siblings)

PHYSICAL ASSESSMENT

A. GENERAL APPEARANCE

The patient’s appearance is good. Grooming is properly done and managed. Post-operative wounds are dry with no signs of infection. Patient is not in cardio respiratory distress.

B. MENTAL STATUS

The patient was cooperative, answered queries relevantly with good eye contact. Patient would reply by writing on a writing board or by sign language. There are no perceptual disturbances and no hallucinating behavior was observed. Thought process is goal directed. Cognition is intact.

PHYSICAL ASSESSMENT

BODY PART AND MODALITIES

NORMAL FINDINGS RESULT INTERPRETATION AND ANALYSIS

GENERAL APPEARANCE Observe body built, height and weight Observe posture and gait Observe overall hygiene and grooming SKIN Inspect color and uniformity of skin

Inspect and assess for edema

Inspect and palpate for skin lesions

Proportionate, varies with lifestyle Relaxed, erect; coordinated movement Clean, neat Color varies depending on race; generally uniform except in areas exposed to sun

No edema

Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions

Medium-framed, appropriate to body size.Weight: not obtainedHeight: 5’7 Coordinated movements Patient is neat, wears clean clothes, and hair is groomed

Has light brown complexion ,darker on upper extremities

No edema

Presence of wrinkles on the face, neck, and arms , presence of surgical incision(stoma) on the neck area

Normal Normal Patient is conscious and able to take care of himself and with the help of his wife

Normal. Racial color varies in each individual

Normal

Due to aging, the skin decreases subcutaneous fat, moisture is reduced, along with elasticity, resulting to wrinkles.

Observe and palpate skin moisture Palpate skin temperature

Observe and palpate skin turgor HAIRInspect evenness of growth over scalp

Inspect thickness of hair

Inspect presence of infestations or infection

Inspect amount of body hair NAILS Inspect nail plate shape and texture

Moisture in skin folds and axilla varies Uniform with normal range

When pinched, skin springs back to previous state

Hair evenly distributedThick hair, resilient

No infestations or infections

Variable

Convex curvature; angle of nail plate is about 160o with smooth texture

Dry face and skin Within normal range:

Decreased skin turgor. Fine lines appear when pinched Hair is unevenly distributed thin hair. A mix of black and white color of hair

No infestations or infections Variable

Convex curvature; angle is less than 160o with smooth texture

Normal Due to aging, the skin loses it elasticity, decreasing the skin’s turgor, along the factor of decreased fluid in the circulation. Normal

Thickness or thinness of hair may be determined genetically or the nutritional status of patients. Some adults, due to aging their hair becomes thin and changes its color to white with the loss of protein in the hair. Normal. Presence of such may indicate deficient hygiene practices. Normal

Normal

Inspect, palpate, and perform blanch test capillary refill FACE

Inspect skull size, shape and symmetry

Inspect facial features

Inspect edema and hollowness in the eyesInspect symmetry of facial movements EYES Inspect eyebrows, eyelashes, and eyelids

Prompt return of usual pink color within 2-3 seconds

Rounded shape, normocephalic and symmetric

Symmetric

No edema or hollownessSymmetrical facial movements Hair on eyebrows is evenly distributed with intact skin, symmetrically aligned and moves symmetrically.Hair on eyelashes is equally distributed, slightly curled outward.Eyelids closed symmetrically without discharges

Capillary refilled within 3 seconds Round shape and symmetric Symmetric No edema or hollownessUnable to assess since patient is unconscious Hair on eyebrows is evenly distributed with intact skin, symmetrically aligned. Hair on eyelashes is equally distributed, slightly curled outward.Eyelids do closed symmetrically, and without discharges

Normal Normal Normal Normal Normal Patient is wearing eyeglasses,

Inspect palpebral and bulbar conjuctiva Inspect and palpate lacrimal gland Inspect and palpate lacrimal sac

Insect and palpate nasolacrimal ductInspect and perform cornea sensitivity reflex test Inspect pupils for color, shape and symmetry Inspect pupils for direct and consensual reaction to light Inspect peripheral visual fields EARS

Inspect auricle for color, symmetry, size and position

Bulbar conjunctiva appears transparent with evident capillaries. Sclera is white.Palpebral conjuctiva appears shiny, smooth and pink No edema or tenderness

No edema

No discharges or tendernessBilateral when cornea is touched Color is black, varies with race; 3-7mm in diameter, round and symmetrical Pupils constrict when illuminated and dilated non-illuminated Sees objects on the periphery

Color same as facial skin, symmetrical, auricles aligned with outer canthus

Bulbar conjunctiva appears transparent with evident capillaries. Sclera is pale.Palpebral conjunctiva appears dull and pale No edema or tenderness

No edema

No discharges or tendernessWith bilateral blinking Color is black, round and symmetrical Patient’s pupils constricted when illuminated and dilated non-illuminated Patient was able to see object on the periphery

Color same as facial skin, symmetrical, auricles aligned with outer canthus

Paleness on the conjunctiva may be indicative of decreased blood supply to the area. Normal

Normal

Normal Normal. Normal Normal

Normal

Palpate auricles for texture, elasticity and areas of tenderness

Inspect external ear canal for cerumen, skin lesions, pus and blood NOSE Inspect external nose for shape, size or color, flaring or discharge Palpate and assess for tenderness or masses Palpate for patency of both nasal cavities MOUTH AND OROPHARYNX Inspect lips for symmetry of contours, color and texture Inspect teeth and gums

Recoils when folded, pliable, not tender

Dry cerumen may be present Symmetric and straight, no discharge or flaring uniform color No tenderness or masses Air moves freely with inhalation and exhalation

Uniform pink color, soft and moist with smooth texture; symmetrical contour 32 adult teeth, smooth white shiny tooth enamel, pink, moist and firm gums.

Recoils when folded, pliable, not tender

Presence of cerumen Symmetric and straight, no discharge or flaring. Patient has NGT tube taped on his nose. No tenderness or masses Air moves freely with inhalation and exhalationIntact and in the middle Symmetrical contour. Slightly dark and dry lips Incomplete set of teeth, has dental caries.

Normal Patient has NGT to aid in administration of food and medications. Normal

Normal Dark colored lips is due to long term smoking Missing/incomplete set of teeth in older adult is common because of decreased calcium in the teeth. Dental caries indicates poor hygiene.

Inspect tongue for position, color and texture Inspect for tongue movement Inspect base of tongue, mouth floor and frenulum Palpate tongue and mouth floor for nodules, lumps or excoriationInspect hard and soft palate Inspect uvula for position and mobility Inspect tonsils for color, discharge and size NECK Inspect neck for symmetry, control of movement, pulsation and edema Inspect and palpate thyroid gland

Pink, rough and is positioned in the center Moves freely Smooth tongue base with prominent veins Smooth with no palpable nodulesHard palate is lighter pink with more irregular texture.Soft palate is light pink and smooth Midline of soft palate. Moves up when client talks Pinkish, has no dischargePresent Symmetrical with no limitations on movement. No edema or palpable lymph nodes Not visible on inspection, ascends when client swallows

Dark red, rough and is positioned at the center Moves Freely Not assessed Not assessed. Not assessed. Not assessed. Not assessed Not assessed

Normal Normal

Patient has presence of surgical incision and stoma from total laryngectomy

THORAX AND LUNGS Inspect shape and symmetry of thorax Inspect spinal alignment Palpate for respiratory excursion

Palpate for tactile Fremitus

Auscultate chest

HEART Inspect and palpate pericardium, VITAL SIGNSTemperature Pulse rate Blood pressure Respiratory rate

Anteroposterior to transverse diameter in ratio of 1:2; symmetrical Spine vertically aligned Full and symmetric chest expansion

Bilateral symmetry of tactile fremitus

Vesicular and bronchovesicular breath sounds

No pulsations 36.7-37.6 oC 60-100bpm 90/60-140/90mmHg 12-20cpm

Anteroposterior diameter; symmetrical Spine is vertically aligned Patient has full and symmetric chest expansion Symmetrical tactile fremitus Crackles heard No pulsations

Normal Normal Normal Normal

Crackles are heard when secretions block the airways. Normal


ABDOMEN Inspect skin integrity, contour and symmetry

Auscultate abdomen for bowel sounds

Palpate abdomen, liver and spleen MUSCULOSKELETAL SYSTEM Inspect muscles for size and shape

Inspect and palpate bones for deformities, presence of edema or tenderness Inspect and palpate joint for swelling and tenderness in movement

Unblemished skin, no lesions. Flat, rounded or scaphoid with symmetric contour Audible bowel sounds

Abdomen has no tenderness, liver and bladder not palpable

Equal size on both sides with equal strength

No deformities, edema, or tenderness No swelling or tenderness, moves smoothly

Unblemished skin with no lesions. Abdomen is flat.

Hypoactive bowel sounds during introduction of air prior to NGT feedings.

No presence of tenderness over the abdomen, liver and bladder not palpable

Equal size on both sides, but with evident weakness of the body,

No deformities or edema No swelling but with evident weakness

Normal

GI may be depressed since there is not enough blood supply to the mesenteric area, there is decreased gastric emptying. Normal Normal

Normal Normal, due to weakness patient is unable to perform active ROM exercises.

NEUROLOGIC SYSTEM

Inspect light touch sensation

Inspect pain sensation

Inspect temperature sensation Inspect position sensation Inspect tactile sensation

Light tickling on touch sensation. Able to discriminate sharp from dull sensations Able to discriminate hot from cold temperature

Can readily determine the position of fingers and toes Able to discern a particular object placed at hand with eyes closed

Patient was to determine tickling sensation

Patient able to identify sharp from dull object

Patient was able to identify hot objects from cold Patient was able to determine the position of his fingers and toes Patient was able to identify the pen when placed on his hand

Normal


GORDON’S FUNCTIONAL

HEALTH PATTERNS

BEFORE HOSPITALIZATION AND DURING HOSPITALIZATION

Health perceptionHealth management pattern

According to the patient, health is a freedom from disease or ailment, body/mind. He had no health problems, until he was experiencing pain around his neck. Tylenol was taken for his pain reliever.

The patient is hospitalized , he is now aware of his condition. He rate his health status as 8 (10 excellent)


Nutrition metabolic Pattern

Elimination pattern

The patient eats 3 times a day with snack every after meal. Good appetite and used Centrum for his vitamin intake.

Patient defecates 1 or 2 times a day and urinates 3-4 times a day with normal color of urine. No reports on ay elimination problems.

Patient has poor appetite. Less solid intake and more on liquid.

No changes in elimination pattern.


Activity exercise pattern

Sexuality- Reproductive pattern

Activities on a regular days were biking, household chores and gardening. His rest time was smoking a cigarette. It was his break time habit. (3 packs/day) According to the patient, he is blessed with 2 children and a loving wife.

Pre and post operation he usually walks around the room.

They can no longer do what a married couple usually do.


Sleep -rest pattern

Sensory- perceptual pattern Cognitive pattern

The patient can easily fall asleep.Normal hours of sleep (8hrs)

Patient is a high school graduate.Can understand and speak English well. He has bee wearing eyeglasses for 4years. Good hearing.

Patient is experiencing sleep pattern disturbance. No proper rest, due to anxiety. ( scared he might not wake up)

He cannot talk due to his condition, but can hear and communicate well by writing down his thoughts.


Role relationship pattern

Self-perceptionSelf concept pattern

The patient’s wife is the one that make the decision in their family.

The patient is healthy. Can perform his daily task very well.

Patient feels so blessed to have his family around all the time.

He can no longer perform any of his task, now that he is hospitalized.

Before hospitalization and during hospitalization

Coping stress tolerance pattern

Value- belief pattern

According to the patient, the most helpful in talking things over is his family.

The patient is a Roman Catholic

His family is a big contribution in facing his present condition.

Faith in God is what helps him stay strong.

ANATOMY AND PHYSIOLOGY of

the RESPIRATORY

SYSTEM

FUNCTIONS As an air distributor and a gas exchanger so

that oxygen may be supplied to and carbon dioxide and be removed from the body’s cell.

It effectively filters, warms and humidifies the air we breathe.

Respiratory organs also influence sound production, including speech used in communicating oral language.

Specialized epithelium in the respiratory tract make the sense of smell (olfaction) possible.

It also assists in the regulation, or homeostasis, of pH in the body.

STRUCTURAL PLAN

Upper Respiratory TractThe organs are located outside of the thorax or chest cavity. It consist of the: nose, pharynx and larynx.

Lower Respiratory TractThe organs are located within the thorax. It consist of the trachea, all segments of the bronchial tree and the lungs.

!The respiratory system also includes several accessory structures, including the oral cavity, rib cage, and diaphragm. Together these structures constitute the lifeline, the air supply line of the body.

THE NOSE

STRUCTUREFUNCTIONS

STRUCTURE The external portion of

the nose consist of a bony and cartilaginous frame covered by skin containing sebaceous glands—the two nasal bones meet and are surrounded by the frontal bone to form the root; the nose is surrounded by the maxilla.

The internal nose (nasal cavity) lies over the roof of the mouth, separated by the palatine bones.

STRUCTURE Septum – separates the

nasal cavity into a right and left cavity; it contains of four structures: The perpendicular

plate of the ethmoid bone

The vomer bone The vomernasal

cartilages Septal nasal cartilages

Each nasal cavity is divided into three passageways: superior, middle and inferior meati.

STRUCTURE Anterior nares – external

openings to the nasal cavities, open into the vestibule.

The sequence of air through the nose into the pharynx – anterior nares to vestibule to all three meati simultaneously to poasterior nares.

STRUCTURE Nasal mucosa – a mucous

membrane that air passes over; it contains a rich blood supply. Olfactory epithelium -

specialized membrane containing many olfactory nerve cells and a rich lymphatic plexus.

Paranasal sinuses – four pairs of air containing spaces that open or drain into nasal cavity and each is lined with respiratory mucosa.

FUNCTIONS• It serves as a passageway

for air traveling to and from the lungs.

• Filters the air• Aids speech• Makes possible the sense of

smell.

THE PHARYNX“throat”

STRUCTURE FUNCTION

STRUCTUREPharynx is a tube like structure about 12.5 cm. (5inches) long that extends from the base of the skull to the esophagus and lies just anterior to the cervical vertebrae.

Nasopharynx – posterior to nasal cavity; is air passageway only; epithelium produces mucus; houses the pharyngeal tonsils

Oropharynx – posterior to and continuous with oral cavity; is both air and food passageway; epithelium changes to deal with abrasive food; houses palatine & lingual tonsils.

Laryngopharynx – posterior to epiglottis and extends to larynx; continuous with esophagus.

FUNCTIONS The pharynx serves as a common

pathway for the respiratory and digestive tract. Since both air and food must pass through this structure before reaching the appropriate tubes.

It also affects phonation (speech production).e.g. only by the pharynx changing its shape can the different vowel sounds be formed.

THE LARYNX“voice box”

STRUCTURE FUNCTIONS

STRUCTURE The thyroid cartilage is the largest portion of the larynx, consisting of a tough hyaline cartilage protruding in the front of the neck. This structure is larger in men and is often referred to as the Adam's apple.

The epiglottis is another portion of the larynx, located at the top. It is composed of elastic cartilage and extends from the larynx toward the tongue. It acts as a flap to keep food and liquid from entering the larynx.

STRUCTURE The vocal cords are contained within the larynx. They consist of folds of tissue made up of muscle and elastic ligaments covered by a mucous membrane and stretch across the upper part of the larynx. The glottis is the space between the vocal cords. There are two types of vocal cords:

False vocal cords do not produce sound. Instead, these muscle fibers help to close the airway during swallowing.

True vocal cords produce sound when air, flowing from the lungs, causes them to vibrate.

FUNCTIONSActs as a passageway for air

during breathingProduces sound during

speechPrevents food and other

foreign substances from entering the breathing structures.

STRUCTURE OF THE PHARYNX

CARTILAGES Single Laryngeal Paired Laryngeal

MUSCLES IntrinsicExtrinsic

CARTILAGESSingle Laryngeal Cartilages

Thyroid cartilage (Adam’s apple) It is the largest cartilage of the larynx and is the one that gives

the characteristics. The one that gives the characteristic triangular shape to its

anterior wall. It is usually larger in man than in woman and has less of a fat pad

lying over it—two reasons why a man’s thyroid cartilage protrudes more than a woman’s.

Epiglottis It is a small leaf-shaped cartilage that projects upward behind the

tongue and hyoid bone. It is attached below to the thyroid cartilage, but it is free superior

border can move up and down during swallowing to prevent food or liquids from entering the trachea.

Cricoid or signet ring cartilage So called because its shape resembles a signet ring. It is the most inferiorly places of the nine cartilages.

CARTILAGESPaired Laryngeal Cartilages

Arytenoids cartilages pyramid-shaped Are the most important paired laryngeal cartilages. The base of each cartilage articulates with the superior border of

the cricoid cartilage. The anterior angles of these of these cartilages serve as points of

attachment for the vocal cords.

Corniculate cartilages Are small and conical in shape.

Cuneiform cartilage Are rod-shaped structures located near the base of the epiglottis.

They closely related to the arytenoids cartilages.

MUSCLESIntrinsic muscles

Cricothyroid muscles lengthen and stretch the vocal folds.

Posterior cricoarytenoid muscles abduct and externally rotate the arytenoid cartilages, resulting in abducted vocal cords.

Lateral cricoarytenoid muscles adduct and internally rotate the arytenoid cartilages, which can result in adducted vocal folds.

Transverse arytenoid muscle adducts the arytenoid cartilages, resulting in adducted vocal cords.

Oblique arytenoid muscles narrow the laryngeal inlet by constricting the distance between the arytenoid cartilages and epiglottis.

Vocalis muscles adjust tension in vocal folds.

Thyroarytenoid muscles sphincter of vestibule, narrowing the laryngeal inlet.

MUSCLESExtrinsic muscles

There are three pairs of extrinsic muscles of the larynx. All of them attach to the oblique line of thyroid cartilage.

Thyrohyoid muscles Sternothyroid muscles Inferior constrictor muscles

LOWER RESPIRATORY TRACT

THE TRACHEA“wind pipe”

STRUCTURE FUNCTION

STRUCTURE It is a tube about 10-12.5 cm long (4-5 inches) and about 2.5 cm wide (1 inch). It extends from the lower edge of the larynx downward into the thoracic cavity, where it splits into right and left bronchi.

cartilage rings (C rings) – between outermost layer of connective tissue; reinforces connective tissue to prevent tracheal collapse

STRUCTURE tracheal wall layers: (internal to external)

– mucosa – goblet cell containing pseudostratified epithelium; cilia propel mucus to pharynx

– submucosa – connective tissue layer deep to mucosa; contains seromucus glands that produce

– mucus sheets– cartilage layer – 16-20 C-

ring hyaline cartilages; fused to adventitia layer; keeps trachea

– from collapsing; final ring is expanded

– adventitia – connective tissue layer

STRUCTURETrachea is lined

with the type of pseudostratified ciliated columnar epithelium typical of the respiratory tract as a whole.

FUNCTION

It furnishes part of the open air to the lungs—obstruction causes

death.

THE BRONCHI AND

ALVEOLISTRUCTUREFUNCTIONS

STRUCTURE The lower end of the trachea

divides into two primary bronchi, one on the right and one on the left, which enters the lung and divides into secondary bronchi that branch into bronchioles, which eventually divide into alveolar ducts.

The alveoli are the primary gas exchange structures. The respiratory membrane –

the barrier between which gases are exchanged by the alveolar air and he blood.

The respiratory membrane consists of the alveolar epithelium, the capillary endothelium and their joined basement membrane.

FUNCTION

The bronchi and alveoli distribute air to the

lung’s interior.

THE LUNGSSTRUCTUREFUNCTIONS

STRUCTURE The lungs are cone-shaped

organs extending from the diaphragm to above the clavicles.a.The hilum – slit on

lung’s medial surface where the primary bronchi and pulmonary blood vessels enter.

b.The base – the inferior surface of the lung that rest on the diaphragm.

c.The apex – pointed upper margin.

d.The coastal surface - lies against the ribs

STRUCTUREe. The left lung is divided into two lobes – superior and inferior.

f. The right lung is divided into three lobes – superior, middle and inferior.

g. The lobes are further divided into functional units-bronchopulmonary segments.a.1)10 segments in

the right lungb.2) 8 segments in

the left lung

FUNCTIONSThe lungs have two functions –

air distribution and gas exchange.

THORACIC CAVITY“chest”STRUCTUREFUNCTION

STRUCTUREThe thoracic cavity has threedivisions divided by pleura

• pleural divisions – the part occupied by the lungs

• Mediastinum – part occupied by the esophagus, trachea, large blood vessels and heart.

Serous membranes (Pleura)• visceral pleura – covers

external lung surface• parietal pleura – covers

thoracic wall and superior surface of diaphragm

• pleural fluid – produced by pleura; lubricating secretion

FUNCTION

Its function is to bring about inspiration and expiration.

RESPIRATORY PHYSIOLOGY


The respiratory system includes pulmonary ventilation, gas exchange in the lungs and

tissues, transport of gases by the blood and regulation of respiration.

PULMONARY VENTILATION

Pulmonary ventilation is a technical term for what most of us call breathing. One phase of it, inspiration, moves air into the lungs and the other phase, expiration, moves air out of the lungs.

• Inspiration – inhalation; moving air into the lungs.

• Expiration – exhalation; moving air out of the lungs.

PULMONARY VENTILATIONMECHANISMS

1. The pulmonary ventilation mechanism must establish two gas pressure gradients

– One which the pressure within the alveoli of the lungs is lower than atmospheric pressure to produce inspiration.

– One which the pressure within the alveoli of the lungs is higher than atmospheric pressure to produce expiration.

2. Pressure gradients are established by changes in the size of the thoracic cavity that are produced by contraction and relaxation of muscles.

3. Boyle’s Law – the volume of the gas varies inversely with the pressure at a constant temperature.

4. Expansion of the thorax results in decreased intrapleural pressure, leading to a decreased alveolar pressure causing air to move into the lungs.

PULMONARY VENTILATIONMECHANISMS

5. Inspiration – contraction of the diaphragm produces inspiration – as it contracts, it makes the thoracic cavity larger.

6. Expiration – a passive process that begins when the inspiratory muscle are relaxed, decreasing the size of the thorax and increasing intrapleural pressure from about – 6 mm Hg to a preinspiration level of – 4 mm Hg.

7. The pressure between parietal and visceral pleura is always less than atmospheric pressure.

8. Elastic recoil – tendency of the pulmonary tissues to return to a smaller size after having been stretched, passively during expiration.


Pulmonary VolumesThe amount of air moved in and

out and remaining and remaining is important in order that a normal exchange of oxygen and carbon dioxide can take place. Spirometer instrument used to measure volume of the air.

PULMONARY GAS EXCHANGE

1. Pressure that is exerted by a gas in a mixture of gases or a liquid.

2. Law of partial pressure (Dalton’s Law) – the partial pressure of the gas in a mixture of gases is directly related to the concentration of that gas in the mixture and to the total pressure of the mixture.

3. Arterial blood PO2 and PCO2 equal alveolar PO2 and PCO2.

HOW BLOOD TRANSPORTS GASES

Transport of Oxygen1. Hemoglobin is made up of four polypeptide chains (two

alpha chains and two beta chains), each with an iron-containing heme group; carbon dioxide can bind to amino acids in the chains and oxygen can bind to iron in the heme group.

2. Oxygenated blood contains about 0.3 ml of dissolved O2 per 100 ml of blood.

3. Hemoglobin increases the oxygen-carrying capacity of blood.

4. Oxygen travels in two forms: as dissolved O2 in plasma and associated with hemoglobin (oxyhemoglobin)

a. Increasing blood PO2 accelerates in hemoglobin association with oxygen.

b. Oxyhemoglobin carries the majority of the total oxygen transported by blood.

HOW BLOOD TRANSPORTS GASES

Transport of Carbon Dioxide

1. A small amount of CO2 dissolves in plasma and is transported as solute (10%)

2. Less than one fourth of blood carbon dioxide combines with NH2 (amine) groups of hemoglobin and other proteins to form carbaminohemoglobin.

3. Carbon dioxide association with hemoglobins is accelerated by increase in blood PCO2.

4. More than two thirds of the carbon dioxide is carried in plasma as bicarbonate ions.

Exchange of gases in tissues takes place between arterial blood flowing through tissue capillaries and cells.

A.RESPIRATORY CONTROL CENTERS - The main integrators that control the

nerves that affect the Inspiratory and Expiratory muscles are located in the brainstem.

1.Medullary Rhythmicity Center

- generates the basic rhythm of the respiratory cycle.

a. 2 interconnected control centers

(1.) INSPIRATORY CYCLE – stimulates inspiration

(2.) EXPIRATORY CYCLE – stimulates expiration

2. The basic breathing rhythm can be altered by different inputs to the medullary rhythmicity center.

a. Input from the apneustic center in the pons stimulates the inspiratory center to increase the length and depth of inspiration.

b. The pneumotaxic center-in the pons-inhibits the apreustic center and inspiratory center to prevent over-inflation of the lungs.

B. Factors that influence breathing-sensors from the nervous system provide feedback to the medullary rhythmicity center.

1. Change in the PO2 , PCO2 and pH of arterial blood influence the medullary rhythmicity area.

a. PCO2 acts on chemoreceptors in the medulla – if it increases, the result is faster breathing; if it decreases, the result is slower.

b. A decreases in blood pH stimulates chemoreceptors in the carotid and aortic bodies.

c. Arterial blood PO2 presumably has little influence if it stays above a certain level.

2. Arterial blood pressure controls breathing through the respiratory pressoreflex mechanism.

3. Hering Breur reflexes help control respirations by regulating depth of respirations and the volume of tidal air.

4. The cerebral cortex influences breathing by increasing or decreasing the rate and strength of respirations.

PATHO-PHYSIOLOGY

Predisposing Factors:People who are between 30 and 50 years of ageMen are more likely to have laryngeal cancer than womenChinese or Asian ancestryHereditary

Precipitating Factors:Eating salt-preserved foods (like fish, eggs, leafy vegetables and roots) during early childhoodNutritional deficiency (Riboflavin)Cigarette smokingAlcohol abusePoor Oral HygieneLong Term Sun ExposureOccupational Exposure (chemicals esp. asbestos)

Formation of benign

bronchial epithelium

tissueTransformation benign tissue to neoplastic

tissue

Laryngeal cancer

Squamous Cell Carcinoma

SupraglotticGlottic Subglottic

Ulcerated, flat, exophytic,

or papillary

Large, tan-white neoplasm in the

right supraglottis, extending upward toward epiglottis

In situ compone

nt

Tend to be nonkeratinizin

g Mitoses and necrosis

•Airway obstruction (dyspnea, stridor) •Vocal cord fixation (voice changes)•Large exophytic•Fungating• ulcerating• endophytic

•Irregular area of mucosal thickening•Advanced: exophytic, fungatic, endophytic, ulcerated mass

•Irregular area of mucosal thickening•Advanced: exophytic, fungatic, endophytic, ulcerated mass•More commonly keratinizing, well to moderately differentiated•In situ component•Invasive component predominantly infiltrative

•Anteriorly: through cricothyroid membrane into thyroid gland superiorly: glottis and supraglottis •Inferiorly: trachea posteriorly: below the cricoid cartilage and into the esophagus•Lymphatic drainage: upper and lower jugular chains, perlaryngeal and paratracheal nodes•Stomal recurrent tumor

•Changes in the quality of voice•Dysphagia•Odonophagi•Hoarseness•Hemoptisis•Dyspnea

DIAGNOSTIC PROCEDURES AND RESULTS

INDIRECT LARYNGOSCOPE

Initially performed to visually evaluate the pharynx, larynx, and possible tumor

DIRECT LARYNGOSCOPE

Performed under local or general anesthesia

Allows visualization of all areas of the larynx

Biopsy is performed at the same time

CT SCAN

Used to assess regional adenopathy and soft tissue

Used in tumor staging of laryngeal cancer

BIOPSY RESULTS:

Squamous Cell Carcinoma of the Larynx Stage II

LABORATORY RESULTS: Glucose Fasting - 6.0 mmol/L (N.V. 4.1-5.9)

Urinalysis Color l. yellow normalTransparency clear normalalbumin (-) (N.V.

10-100mg/day)sugar (-) (<500mg/day)pH 6.5 (N.V. 4.6-8.0)Specific gravity 1.01 (N.V. 1.003-1.03)

MEDICAL MANAGEMENT

A laryngectomy is a surgical removal of the larynx also called a Voice Box.

Important function of the larynx

Protect airway by ensuring that swallowed food and liquids pass down to the esophagus

Instead to the lungs. Vocal cords is responsible for sound

generation in speech and singing which is located in the larynx

Pre-operative management

Intra operative management

Post operative management

includes informing the patient of the anatomical changes, and expectations regarding swallowing, voice, and the family as a part of the team. The therapist also informs the patient on the different speech options he has after the operations.

Tracheo-Esophageal Speech

Ureta technique

Electrolaryngeal Speech-An electrolarynx is a mechanical device that is used to help produce speech in individuals who have had a laryngectomy, or for some other reason cannot use their larynx

The electrolarynx is a hand-held device about the size of a small electric shaver that has a vibrating plastic diaphragm. In order to speak, the end of the electrolarynx is placed against the neck and a small button in pushed. This causes the diaphragm to vibrate and produces a vibration in the throat that duplicates the vibration of the vocal cords. The speaker than articulates with the tongue, palate, throat and lips as usual.

In esophageal speech, the sound is not produced by the vocal folds but rather by vibrations in the esophagus and pharynx. The technique is that the individual swallows air and then allows it to escape in a controlled fashion.

As the air escapes it causes the walls of the esophagus to vibrate. This produces a sound, which can then be articulated by the mouth an lips to produce speech.

An advantages of esophageal speech is that it requires no additional operations or any special prosthesis. It is also relatively easy to learn.

The major drawback with esophageal speech is that the sounds have a rough sound, and is often limited to relatively short segments of speech. For many people it is difficult to speak an entire long sentences without taking a break to bring in more air.

Tracheo-Esophageal Speech -The principle in TE speech is that during exhalation, air is diverted into the esophagus. The air eventually flows out the mouth. That air flow causes the esophagus to vibrate, which produces a sound. By moving the lips. tongue,etc, the sound is articulated into speech.

In order to divert air to the esophagus during exhalation, a small opening called a fistula is created between the trachea and the esophagus. A small valved tube is placed into the opening or fistula to keep it open and to prevent swallowed food and liquid from getting down the trachea. This tube is usually called a voice prosthesis.

During this phase of laryngectomy management, the therapist is given an opportunity to help lessen the patient's fears, and depression. He should also help the patient to accept the loss of voice and swallowing difficulties. The motivation of the patient should be increased, so that he can easily learn how to use alternative speech. Social implications are also addressed. Arrangements for voice rehabilitation are also done during the early parts of this phase.

the therapist should confirm if the patient is already medically cleared for therapy. Then he should review the treatment procedure, re-evaluate the patient's swallowing function then give diet recommendations, and create a treatment plan.

NURSING CARE PLAN

Assessment Nursing Dx Planning Intervention Rationale Evaluation

OBJECTIVE:

- NGT patent and intact

Risk for aspiration r/t nasogastric feeding

After 3 hours of nursing intervention, the client will be able to demonstrate techniques to prevent aspiration

Assess amount and consistency of respiratory secretions and strength of gag reflex.Maintain operational suction equipment at bedsideAssist with postural drainage Auscultate lung sounds frequentlyElevate client to highest or best possible position for eating and drinking and during tube feeding

To assess cause and contributing factorsTo clear secretionsTo mobilize thickened secretions that may interfere with swallowing.To determine presence of secretions or silent aspirationsTo assist in correcting factors that can lead to aspiration

After 3 hours of nursing intervention, the client was able to demonstrate techniques to prevent aspiration

Assessment Nursing Dx

Planning Intervention Rationale Evaluation

OBJECTIVE:

-slight redness around the tracheal stoma- negative bleeding- negative purulent drainage

Impaired skin integrity r/t to presence of tracheal stoma

After 3 hours of nursing intervention, the client will be able to demonstrate techniques to prevent skin breakdown

Maintain strict skin hygiene using mild non detergent soap, drying gentle and thoroughly and lubricating with lotion or enrollment as indicated

Change position in bed/chair on regular schedule.

Encourage participation with active and assistive ROM exercises.

Emphasize importance of adequate nutritional and fluid intake

To maintain skin integrity at optimal level. To promote normal circulation To prevent vasoconstrictionTo increase circulation and alter excessive tissue pressure

To maintain general good health and skin turgor

After 3 hours of nursing intervention, the client was able to demonstrate techniques to prevent skin breakdown

ASSESSMENT NURSING DX PLANNING NSG INTERVENTION RATIONALE EVALUATION

OBJECTIVE:

- presence of tracheal stoma

Risk for infection r/t surgical incision

After 3 hours of nursing intervention, the client will be able to demonstrate techniques, lifestyle changes to promote safe environment

Observe for localized signs of infection at insertion sites of invasive lines, sutures, surgical incision.

Stress proper hand washing techniques by all caregivers between therapies / client

Cleanse incision daily and prn with povidone iodine

Encourage early ambulation, deep breathing, coughing, position change

To assess causative and contributing factors A first-line defense against nosocomial infection

To reduce existing risk factors

For mobilization of respiratory secretions

After 3 hours of nursing intervention, the client was able to demonstrate techniques, lifestyle changes to promote safe environment

DISCHARGEPLANNING

tramadol 100 mg. IV, celocoxib 400mg. OD, cefuroxime 500mg. Tablet q8, ca gluc, ca co3 tid, Human Albumin 25% 1 vialx4 OD, clindamycin 300mg q6, diphenhydramine 50mg.

Encourage client to continue taking past activity he enjoys includingmaintaining employment as long as possible

Continuous intake of meds as of doctor’s orders, follow up check-ups, continuous speech therapy.

Provide Safe environmentEstablished rapportProvide alternative methods of communication such as paper and pencils, slate board or letter board,And hand/eye signals.Encourage proper hygiene.Wound care

Followup care is important after treatment for cancer of the larynx. Regular checkups ensure that any changes in health are noted. Problems can be found and treated as soon as possible. The doctor will check closely to be sure that the cancer has not returned. Checkups include exams of the stoma, neck, and throat

Assess current eating pattern.Teach the principles of good nutrition.Manage problem that interfere feedingTeach to supplement meals with nutritional supplementsTeach to make food diaryParenteral Nutrition

Encourage beliefs in religious activities such as prayers, biblical references aspects etc.

CA larynx

Documents

skin normal

neat patient

groomed patient

patient experienced

skin folds

skin springs

wife skin

palpate skin moisture