Case Presentation

in Geriatric Ward

“CANCER
OF THE
LARYNX”
Submitted by: Submitted To:
Group A1 PCHS
 BANDONG, James
Marlyn Lugtu RN, MAN
 CERCADO, Michelle
 CILLO, Rudyard
GERIATRIC AREA
 DIAZ, Karen
Ward 12, VMMC
 DUASO, Byron
 FONACIER, Butchic
 GUTIERREZ, Maria Christina
 LACANILAO, Adrian
 PAULITE, Zenneth
 SEVILLENO, Rachelle
 YAP, Josef
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
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
© 2007 Thomson Higher Education
 Characteristics of squamous cell carcinoma of
the larynx:
epithelial nests surrounded by
inflammatory stroma with keratin pearls being
pathognomonic
ETIOLOGY:

 Primary factors:
prolonged tobacco use
prolonged 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 >= 65 male-85%, female- 15%
INCIDENCE:
 Philippine Population: male - 577 cases(73%)
female - 209 cases(27%)
 ages < 65 male-77%, female- 23%
 ages >= 65 male-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%
PATIENT
PROFILE
NURSING HEALTH HISTORY
A. DEMOGRAPHIC DATA

Patient’s Name : Patient LB

Rank : N/A
Gender : Male
Age : 63
Birthday : April 27, 1947
Marital Status : Married
Nationality : Filipino
Religion : Catholic
Address : Sta. Maria, Bulacan
Ward : Ward 12

B. CHIEF COMPLAINT
Hoarseness of voice
NURSING HEALTH HISTORY
C. 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 HISTORY
D. PAST MEDICAL HISTORY

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

ｧ Operations
1967: 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 NORMAL FINDINGS RESULT INTERPRETATION AND
MODALITIES ANALYSIS
GENERAL APPEARANCE Medium-framed,  
  appropriate to body size. Normal
Observe body built, height Proportionate, varies with Weight: not obtained  
and weight lifestyle Height: 5’7  
       
 Observe posture and gait  Relaxed, erect; coordinated  Coordinated movements  Normal
  movement    
       
       
Observe overall hygiene Clean, neat Patient is neat, wears clean Patient is conscious and
and grooming   clothes, and hair is able to take care of himself
    groomed and with the help of his wife
       
SKIN      
     
Inspect color and uniformity Color varies depending on Normal. Racial color varies
of skin race; generally uniform Has light brown in each individual
except in areas exposed to complexion ,darker on
sun upper extremities

Inspect and assess No edema Normal

for edema    
No edema
Inspect and palpate for skin Freckles, some birthmarks,   Due to aging, the skin
lesions some flat and raised nevi; decreases subcutaneous
no abrasions or other Presence of wrinkles on the fat, moisture is reduced,
lesions face, neck, and arms , along with elasticity,
presence of surgical resulting to wrinkles.
incision(stoma) on the neck
area
Observe and palpate skin Moisture in skin folds and Dry face and skin  Normal
moisture axilla varies    
       
Palpate skin temperature Uniform with normal range Within normal range: Due to aging, the skin loses it
    elasticity, decreasing the skin’s
turgor, along the factor of
decreased fluid in the
circulation.
 
Observe and palpate skin When pinched, skin springs Decreased skin turgor. Normal
turgor back to previous state Fine lines appear when
    pinched
HAIR   Thickness or thinness of hair
Inspect evenness of growth Hair evenly distributed Hair is unevenly may be determined genetically
over scalp Thick hair, resilient distributed thin hair. A or the nutritional status of
mix of black and white patients. Some adults, due to
Inspect thickness of hair color of hair aging their hair becomes thin
  and changes its color to white
with the loss of protein in the
hair.
 
Inspect presence of No infestations or infections No infestations or Normal. Presence of such may
infestations or infection infections indicate deficient hygiene
    practices.
   
Inspect amount of body hair Variable Variable Normal
       
NAILS      
 
Inspect nail plate shape and Convex curvature; angle of Convex curvature; Normal
texture nail plate is about 160 o with angle is less than
smooth texture 160o with smooth
texture
Inspect, palpate, and Prompt return of usual pink Capillary refilled within 3 Normal
perform blanch test capillary color within 2-3 seconds seconds  
refill      
       
FACE    
   
 Inspect skull size, shape Rounded shape, Round shape and Normal
and symmetry normocephalic and symmetric  
  symmetric    
   
Inspect facial features Symmetric Symmetric Normal
       
   
Inspect edema and No edema or hollowness No edema or Normal
hollowness in the eyes Symmetrical facial hollowness  
Inspect symmetry of facial movements Unable to assess since  
movements   patient is unconscious  
       
       
EYES      
       
Inspect eyebrows, Hair on eyebrows is evenly Hair on eyebrows is Normal
eyelashes, and eyelids distributed with intact skin, evenly distributed with Patient is wearing eyeglasses,
symmetrically aligned and intact skin,  
moves symmetrically. symmetrically aligned.
Hair on eyelashes is equally Hair on eyelashes is
distributed, slightly curled equally distributed,
outward. slightly curled outward.
Eyelids closed Eyelids do closed
symmetrically without symmetrically, and
discharges without discharges
   
Inspect palpebral and bulbar Bulbar conjunctiva appears Bulbar conjunctiva appears Paleness on the
conjuctiva transparent with evident transparent with evident conjunctiva may be
  capillaries. Sclera is white. capillaries. Sclera is pale. indicative of decreased
  Palpebral conjuctiva Palpebral conjunctiva blood supply to the area.
  appears shiny, smooth and appears dull and pale  
  pink    
Inspect and palpate lacrimal   No edema or tenderness Normal
gland No edema or tenderness    
 
Inspect and palpate lacrimal No edema Normal
sac No edema  

Insect and palpate No discharges or Normal

nasolacrimal duct No discharges or tenderness  
Inspect and perform cornea tenderness With bilateral blinking  
sensitivity reflex test Bilateral when cornea is    
  touched    
Inspect pupils for color,   Color is black, round and Normal.
shape and symmetry Color is black, varies with symmetrical  
  race; 3-7mm in diameter,    
  round and symmetrical    
Inspect pupils for direct and   Patient’s pupils constricted Normal
consensual reaction to light Pupils constrict when when illuminated and  
  illuminated and dilated non- dilated non-illuminated  
  illuminated    
    Patient was able to see Normal
Inspect peripheral visual   object on the periphery  
fields Sees objects on the    
  periphery
EARS  
 
Inspect auricle for color, Color same as facial skin, Normal
symmetry, size and position symmetrical, auricles  
Color same as facial skin, aligned with outer canthus
symmetrical, auricles
aligned with outer canthus
Palpate auricles for texture, Recoils when folded, pliable, Recoils when folded, pliable, not Normal
elasticity and areas of not tender tender  
tenderness  
 
Inspect external ear canal Dry cerumen may be present Presence of cerumen  
for cerumen, skin lesions,      
pus and blood      
       
NOSE      
       
Inspect external nose for Symmetric and straight, no Symmetric and straight, no Patient has NGT to aid in
shape, size or color, flaring discharge or flaring uniform discharge or flaring. Patient has administration of food
or discharge color NGT tube taped on his nose. and medications.
       
Palpate and assess for No tenderness or masses No tenderness or masses Normal
tenderness or masses      
     
Palpate for patency of both Air moves freely with Air moves freely with inhalation Normal
nasal cavities inhalation and exhalation and exhalation  
    Intact and in the middle  
MOUTH AND      
OROPHARYNX      
     
Inspect lips for symmetry of Uniform pink color, soft and Symmetrical contour. Slightly Dark colored lips is due
contours, color and texture moist with smooth texture; dark and dry lips to long term smoking
  symmetrical contour    
       
Inspect teeth and gums 32 adult teeth, smooth white Incomplete set of teeth, has Missing/incomplete set of
shiny tooth enamel, pink, dental caries. teeth in older adult is
moist and firm gums. common because of
decreased calcium in the
teeth. Dental caries
indicates poor hygiene.
Inspect tongue for position, Pink, rough and is positioned in the Dark red, rough and is Normal
color and texture center positioned at the center  
       
Inspect for tongue movement Moves freely Moves Freely Normal
     
Inspect base of tongue, mouth Smooth tongue base with prominent Not assessed
floor and frenulum veins  
     
Palpate tongue and mouth Smooth with no palpable nodules Not assessed.
floor for nodules, lumps or Hard palate is lighter pink with more  
excoriation irregular texture.  
Inspect hard and soft palate Soft palate is light pink and smooth  
     
Inspect uvula for position and Midline of soft palate. Moves up when Not assessed.
mobility client talks  
     
Inspect tonsils for color, Pinkish, has no discharge  Not assessed.
discharge and size Present  
     
NECK    
     
Inspect neck for symmetry, Symmetrical with no limitations on Not assessed Patient has
control of movement, pulsation movement. No edema or palpable   presence of surgical
and edema lymph nodes   incision and stoma
      from total
      laryngectomy
Inspect and palpate thyroid Not visible on inspection, ascends Not assessed
gland when client swallows
THORAX AND LUNGS    
   
Inspect shape and symmetry of Anteroposterior to transverse Anteroposterior diameter; Normal
thorax diameter in ratio of 1:2; symmetrical symmetrical  
       
Inspect spinal alignment Spine vertically aligned Spine is vertically aligned Normal
       
Palpate for respiratory excursion Full and symmetric chest expansion Patient has full and Normal
    symmetric chest  
    expansion  
   
Palpate for tactile Fremitus Bilateral symmetry of tactile fremitus Symmetrical tactile Normal
    fremitus  
 
Auscultate chest Vesicular and bronchovesicular Crackles heard Crackles are
  breath sounds   heard when
  secretions block
HEART   the airways.
       
Inspect and palpate pericardium, No pulsations No pulsations Normal
       
VITAL SIGNS    
Temperature 36.7-37.6 oC   Normal
       
Pulse rate 60-100bpm   Normal
       
Blood pressure 90/60-140/90   Normal
  mmHg    
       
Respiratory rate 12-20cpm   Normal
     
ABDOMEN    
    
Inspect skin integrity, Unblemished skin, no Unblemished skin with no Normal
contour and symmetry lesions. Flat, rounded or lesions. Abdomen is flat.  
scaphoid with symmetric  
  contour  
 
Auscultate abdomen for Audible bowel sounds Hypoactive bowel sounds GI may be depressed since
bowel sounds   during introduction of air there is not enough blood
    prior to NGT feedings. supply to the mesenteric
    area, there is decreased
gastric emptying.
 
Palpate abdomen, liver and Abdomen has no No presence of tenderness Normal
spleen tenderness, liver and over the abdomen, liver and  
  bladder not palpable bladder not palpable  
       
MUSCULOSKELETAL    
SYSTEM  
     
Inspect muscles for size and Equal size on both sides Equal size on both sides, Normal
shape with equal strength but with evident weakness  
  of the body,  

Inspect and palpate bones No deformities, edema, or  No deformities or edema Normal
for deformities, presence of tenderness    
edema or tenderness      
       
Inspect and palpate joint for No swelling or tenderness, No swelling but with evident Normal, due to weakness
swelling and tenderness in moves smoothly weakness patient is unable to perform
movement   active ROM exercises.

 
 
NEUROLOGIC SYSTEM    
         
 
Inspect light touch sensation Light tickling on touch Patient was to determine  Normal
  sensation. tickling sensation
   
Inspect pain sensation Able to discriminate sharp Patient able to identify sharp Normal
  from dull sensations from dull object  
   
Inspect temperature Able to discriminate hot from Patient was able to identify Normal
sensation cold temperature hot objects from cold  
       
  Patient was able to  
Inspect position sensation Can readily determine the determine the position of his Normal
  position of fingers and toes fingers and toes  
       
  Able to discern a particular Patient was able to identify Normal
Inspect tactile sensation object placed at hand with the pen when placed on his
eyes closed hand
 GORDON’S
FUNCTIONAL
HEALTH
PATTERNS
 BEFORE HOSPITALIZATION
AND DURING HOSPITALIZATION

Health perception According to the The patient is

Health management patient, health is a hospitalized , he is
pattern freedom from disease now aware of his
or ailment, condition. He rate his
body/mind. He had no health status as 8
health problems, until (10 excellent)
he was experiencing  
pain around his neck.
Tylenol was taken for
his pain reliever.
 BEFORE HOSPITALIZATION
AND DURING HOSPITALIZATION

Nutrition metabolic The patient eats 3 Patient has poor

Pattern times a day with appetite. Less solid
snack every after intake and more on
meal. Good appetite liquid.
and used Centrum for
his vitamin intake.
 

Elimination pattern Patient defecates 1 No changes in

or 2 times a day and elimination pattern.
urinates 3-4 times a
day with normal color
of urine. No reports
on ay elimination
problems.
 BEFORE HOSPITALIZATION
AND DURING HOSPITALIZATION

Activity exercise Activities on a Pre and post

pattern regular days were operation he usually
biking, household walks around the
chores and room.
gardening. His rest
time was smoking a
cigarette. It was his
break time habit. (3
packs/day)
 
Sexuality- According to the They can no longer
Reproductive pattern patient, he is blessed do what a married
with 2 children and a couple usually do.
loving wife.
 BEFORE HOSPITALIZATION
AND DURING HOSPITALIZATION

Sleep -rest pattern The patient can easily Patient is

fall asleep. experiencing sleep
Normal hours of pattern disturbance.
sleep (8hrs) No proper rest, due to
anxiety. ( scared he
might not wake up)

Sensory- perceptual Patient is a high He cannot talk due to

pattern school graduate. his condition, but can
Cognitive pattern Can understand and hear and
  speak English well. communicate well by
He has bee wearing writing down his
eyeglasses for thoughts.
4years. Good hearing.  
 
 BEFORE HOSPITALIZATION
AND DURING HOSPITALIZATION

Role The patient’s Patient feels so

relationship wife is the one blessed to have
pattern that make the his family
  decision in their around all the
family. time.

Self-perception The patient is He can no

Self concept healthy. Can longer perform
pattern perform his daily any of his task,
task very well. now that he is
hospitalized.
 Before hospitalization
and during hospitalization

Coping stress According to the His family is a

tolerance patient, the most big contribution
pattern helpful in talking in facing his
things over is present
his family. condition.

The patient is a
Value- belief Roman Catholic
pattern 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 Tract
The organs are located outside of the thorax or
chest cavity. It consist of the: nose, pharynx and
larynx.
 Lower Respiratory Tract
The 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

STRUCTURE
FUNCTIONS
 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
STRUCTURE
Pharynx 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.
 FUNCTIONS
 Acts as a passageway for air
during breathing

 Produces sound during speech

 Prevents food and other

foreign substances from
entering the breathing
structures.
STRUCTURE OF
THE PHARYNX
 CARTILAGES
 Single Laryngeal
 Paired Laryngeal

MUSCLES
 Intrinsic
Extrinsic
 CARTILAGES
Single 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.
 CARTILAGES
Paired 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.
Intrinsic muscles 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.
Extrinsic muscles
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
STRUCTURE
 Trachea 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
ALVEOLI
STRUCTURE
FUNCTIONS
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 LUNGS
STRUCTURE
FUNCTIONS
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
STRUCTURE
e. 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 lung
b.2) 8 segments in
the left lung
 FUNCTIONS
The lungs have two functions – air
distribution and gas exchange.
THORACIC CAVITY
“chest”
STRUCTURE
FUNCTION
STRUCTURE
The thoracic cavity has three
divisions 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
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 VENTILATION
MECHANISMS

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 VENTILATION
MECHANISMS

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.
RESPIRATORY PHYSIOLOGY

Pulmonary Volumes
The 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 Oxygen
1. 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
 Precipitating Factors:
Eating salt-preserved foods (like fish, eggs,
Predisposing Factors:
leafy vegetables and roots) during early
People who are between 30 and 50 years of
childhood
age
Nutritional deficiency (Riboflavin)
Men are more likely to have laryngeal
Cigarette smoking
cancer than women
Alcohol abuse
Chinese or Asian ancestry
Poor Oral Hygiene
Hereditary
Long Term Sun Exposure
Occupational Exposure (chemicals esp.
asbestos)
Formation of
benign bronchial
epithelium tissue

Transformation
benign tissue to
neoplastic tissue

Laryngeal cancer

Squamous Cell
Carcinoma
 Glottic Subglottic
Supraglottic

Tend to be In situ •Irregular area of mucosal thickening •Anteriorly: through

nonkeratinizing component •Advanced: exophytic, fungatic, cricothyroid membrane into
endophytic, ulcerated mass thyroid gland superiorly:
Ulcerated, flat, Mitoses and glottis and supraglottis
•More commonly keratinizing, well
exophytic, or necrosis •Inferiorly: trachea posteriorly:
to moderately differentiated
papillary below the cricoid cartilage and
•In situ component
•Invasive component predominantly into the esophagus
infiltrative •Lymphatic drainage: upper
Large, tan-white
and lower jugular chains,
neoplasm in the right
perlaryngeal and paratracheal
supraglottis, •Airway obstruction nodes
extending upward (dyspnea, stridor) •Stomal recurrent tumor
toward epiglottis •Vocal cord fixation
(voice changes)
•Large exophytic •Irregular area of
•Fungating mucosal thickening
•Changes in the • ulcerating •Advanced: exophytic,
quality of voice • endophytic fungatic, endophytic,
•Dysphagia ulcerated mass
•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 normal
Transparency clear normal
albumin (-) (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
Risk for After 3 hours of Assess amount To assess After 3 hours of
OBJECTIVE: aspiration r/t nursing and cause and nursing
nasogastric intervention, the consistency of contributing intervention,
- NGT patent feeding client will be able respiratory factors the client was
and intact secretions and To clear able to
to demonstrate
strength of gag secretions demonstrate
techniques to reflex. To mobilize techniques to
prevent Maintain thickened prevent
aspiration operational secretions that aspiration
suction may interfere
equipment at with
bedside swallowing.
Assist with To determine
postural presence of
drainage secretions or
Auscultate lung silent
sounds aspirations
frequently To assist in
Elevate client correcting
to highest or factors that can
best possible lead to
position for aspiration
eating and
drinking and
during tube
feeding
Assessment Nursing Planning Intervention Rationale Evaluation
Dx

Maintain strict skin hygiene To maintain skin After 3 hours of

OBJECTIVE: Impaired After 3 hours of using mild non detergent integrity at optimal nursing
skin nursing intervention, soap, drying gentle and level. intervention, the
-slight redness integrity r/t the client will be able thoroughly and lubricating   client was able to
around the to presence to demonstrate with lotion or enrollment as   demonstrate
tracheal stoma of tracheal indicated   techniques to
techniques to prevent
- negative stoma   prevent skin
bleeding skin breakdown Change position in bed/chair To promote normal breakdown
- negative on regular schedule. circulation
purulent  
drainage Encourage participation with  To prevent
active and assistive ROM vasoconstriction
exercises. To increase
circulation and alter
excessive tissue
pressure

Emphasize importance of To maintain general

adequate nutritional and fluid good health and skin
intake turgor
ASSESSMENT NURSING DX PLANNING NSG INTERVENTION RATIONALE EVALUATION
Observe for localized signs To assess
OBJECTIVE: Risk for infection After 3 hours of of infection at insertion causative and After 3 hours of
r/t surgical nursing sites of invasive lines, contributing factors nursing
- presence of incision intervention, sutures, surgical incision.   intervention, the
the client will   client was able to
tracheal stoma
be able to Stress proper hand A first-line defense demonstrate
demonstrate washing techniques by all against techniques,
techniques, caregivers between nosocomial lifestyle changes to
lifestyle therapies / client infection promote safe
changes to environment
promote safe Cleanse incision daily and To reduce existing
environment prn with povidone iodine risk factors

Encourage early For mobilization of

ambulation, deep respiratory
breathing, coughing, secretions
position change
DISCHARGE
PLANNING
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 including
maintaining employment as long as possible
Continuous intake of meds as of doctor’s orders,
follow up check-ups, continuous speech therapy.
Provide Safe environment
Established rapport
Provide 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 feeding
Teach to supplement meals with nutritional
supplements
Teach to make food diary
Parenteral Nutrition
Encourage beliefs in religious activities such as
prayers, biblical references aspects etc.