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NUR 2502 / NUR2502 Exam 2: Multidimensional Care III / MDC 3 Exam 2 Blueprint (Latest 2022/2023) Rasmussen
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NUR2502 Multidimensional Care III / MDC 3 Exam 2 Blueprint
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NUR 2502 Exam 2 Blueprint● Head/sinus/neck cancer
o Pathophysiology: squamous cell carcinomas, slow-growing tumors are curable when diagnosed
and treated at early stage, without treatment fatal in 2 years
▪ Most cancers arise from mucous membrane and skin; can start from salivary glands,
thyroid, tonsils
▪ Loss of cellular regulation when mucosa is chronically irritated and becomes tougher and
thicker
● can be irritated by tobacco use, alcohol use, poor hygiene, chronic laryngitis, oral
infections, long-term GERD, chemical exposure, HPV (oral infections)
● Tobacco and alcohol use are two major risk factors, especially in combination
▪ Can disrupt swallowing, breathing, facial appearance, and speech
o Assessment
▪ lumps in mouth, throat, neck-can be palpated
▪ Difficulty swallowing
▪ oral lesions or sore that does not heal in 2 weeks
▪ Persistent, unilateral ear pain
▪ Persistent, unexplained oral bleeding
▪ Change in fit of dentures
▪ other signs/sx include color changes in mouth or tongue, hoarsness, persistent/recurrent
sore throat, SOB, anorexia, weight loss, burning sensation when drinking citrus or hot
liquids, numbness of mouth/lips/face
o Interventions/nursing diagnoses
▪ priority is airway, potential for obstruction
● adequate ventilation/oxygenation: monitor pulse oximetry, ABG levels, oxygen
therapy
▪ Potential for aspiration-put on aspiration precautions, evaluation by speech therapy
▪ Anxiety
▪ Decreased self-esteem
▪ Radiation therapy and chemotherapy—>vomiting very uncomfortable, provide
prescribed anti-emetics
● radiation causes sore throat, skin irritation, voice changes, dry mouth, impaired
taste
, ● Moisturizing sprays, increased water intake, humidification
● Dental consult needed due to increased risk of cavities
▪ Cordectomy-removal of vocal cord
o Laryngectomy
▪ First priorities are airway maintenance and gas exchange
▪ wound, flap, reconstructive tissue care
• Evaluate hourly for first 72 hours-cap refill, color, drainage, doppler activity of
major blood vessel to the area
▪ Hemorrhage-carotid artery may be exposed, causing risk for hemorrhage
▪ wound breakdown with loss of tissue integrity is common complication, especially if
radiation was done before surgery
▪ pain management
▪ nutrition-type of diet identified by speech evaluation
• Usually on NG, PEG, G/J feeding tube until patient can safely swallow
• Aspiration cannot occur with total laryngectomy because airway is completely
separated from esophagus
▪ Speech and language rehab—> grief associated w/losing ability to speak and eat
● Nasal fracture
o Displacement of bone or cartilage can cause airway obstruction or cosmetic deformity, potential
source of infection
o Presence of CSF may indicate skull fracture
o Interventions
▪ closed reduction: moving the bones by palpation to realign them, using local or general
anesthesia within first 24 hours of injury occurrence
▪ Nasoseptoplasty- submucosa resection, deviated section of cartilage and bone is
removed or reshaped to straighten deviated septum
▪ Rhinoplasty post-op care
• surgical reconstruction of the nose to repair fractured nose or change shape of
the nose for improved function and appearance
• Observe for signs of edema and bleeding
• Check vital signs q4hrs
• Change drip pad as needed and monitor it for increased bleeding
• semi-Fowlers, don’t cough/sneeze/strain forcefully
• Pain management: meds, cold compresses
• Facial trauma
o mandibular fractures (lower jaw) are most common
o Le Fort fracture
▪ I-nasoethmoid complex fracture
▪ II fracture is a maxillary and nasoethmoid complex fracture
▪ III combines I and II plus an orbital-zygoma fracture, called craniofacial disjunction
because the mid face has no connection to the skull **high risk of airway blockage
o Assessment
▪ Stridor
▪ SOB, dyspnea
▪ anxiety/restlessness
▪ Hypoxia and hypercarbia
▪ Decreased oxygen saturation
▪ cyanosis, loss of consciousness
, o Interventions
▪ priority action is airway assessment
▪ Anticipate need for emergency intubation
▪ Tracheotomy
▪ Cricothyroidotomy: creation of a temporary airway by making a small opening in the
throat between the thyroid cartilage and the cricoid cartilage
▪ Fixed occlusion: wiring jaws together with the mouth in closed position for 6-10 weeks
▪ Debridement
• Epistaxis
o nose bleed is a common problem due to many capillaries within the nose
o Cauterization of affected capillaries may be needed; nose is packed
o Posterior nasal bleeding is an emergency!—> assess back of throat
▪ Cannot be easily reached and patient may lose blood quickly
▪ Older adults tend to bleed post often from posterior portion of nose
▪ Posterior packing, epistaxis catheters (nasal pressure tubes) or gel tampons are
placed-these can be uncomfortable and may obstruct airway if packing slips
o Assess for respiratory distress, tolerance of packing o tubes
o Humidification, oxygen, bedrest, antibiotics, pain meds
o Nursing care
▪ Manage bleeding
• apply pressure laterally, pinch sides of nose w/gauze for 10 min
• Nasal packing may be used if bleeding does not stop
• Pt should be straight or slightly leaned forward
▪ Monitor BP
▪ don't blow nose for 24 hrs
● Sleep Apnea
o Cessation in breathing while sleeping, must occur a minimum of 5x/hour, can be
hundreds/night, lasts from 10 sec-greater than 1 minute with each episode
o No restorative or regenerative sleep
o Risk factors
▪ Obesity
▪ short neck with recessed chin-short or large neck
▪ Oropharyngeal edema
▪ Family history
▪ Enlarged tonsils, adenoids, uvula
▪ Cigarette smoking and alcohol or sedative use
o Complications
▪ HTN
▪ stroke
▪ Cognitive deficits
▪ Weight gain
▪ diabetes,
▪ pulmonary disease
▪ Cardiovascular disease
▪ Excessive daytime sleepiness, irritability, inability to concentrate
o Assessment
▪ Waking up tired
▪ Loud snoring
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