Head and neck cancer refers to a malignancy that lies above the clavicle but excludes the brain, spinal cord, axial skeleton, and vertebrae. Although head and neck cancer accounts for 5% of all malignant disease, disability is great because of the potential loss of voice, disfigurement, and social consequences. The majority of the laryngeal neoplasms (95%) are squamous cell carcinomas that arise from the oral cavity. When cancer is limited to the vocal cords (intrinsic), spread may be slow. When the cancer involves the epiglottis (extrinsic), metastasis is more common.
Current treatment choices include surgery, radiation, and chemotherapy. Radiation or carbon dioxide laser may be used for early stage disease. This plan of care focuses on nursing care of the patient undergoing radical surgery of the neck, including laryngectomy.
Partial laryngectomy (also called cordotomy): Tumors that are limited to one vocal cord are removed, and a temporary tracheotomy is performed to maintain the airway. After recovery from surgery, the patient will have a voice but it will be hoarse.
Hemilaryngectomy: When there is a possibility the cancer includes one true and one false vocal cord, they are removed along with an arytenoid cartilage and half of the thyroid cartilage. Temporary tracheotomy is performed, and the patient’s voice will be hoarse after surgery.
Supraglottic laryngectomy: When the tumor is located in the epiglottis or false vocal cords, radical neck dissection is done and tracheotomy performed. The patient’s voice remains intact; however, swallowing is more difficult because the epiglottis has been removed.
Total laryngectomy: Advanced cancers that involve a large portion of the larynx require removal of the entire larynx, the hyoid bone, the cricoid cartilage, two or three tracheal rings, and the strap muscles connected to the larynx. A permanent opening is created in the neck into the trachea, and a laryngectomy tube is inserted to keep the stoma open. The lower portion of the posterior pharynx is removed when the tumor extends beyond the epiglottis, with the remaining portion sutured to the esophagus after a nasogastric tube is inserted. The patient must breathe through a permanent tracheostomy, with normal speech no longer possible. Swallowing is not a long-term problem because there is no connection between the esophagus and trachea.
CARE SETTING
Inpatient surgical and possibly subacute units.
RELATED CONCERNS
Cancer
Psychosocial aspects of care
Surgical intervention
Total nutritional support: parenteral/enteral feeding
Patient Assessment Database (Preoperative)
Preoperative data presented here depend on the specific type/location of cancer process and underlying complications.
EGO INTEGRITY
May report: Feelings of fear about loss of voice, dying, occurrence/recurrence of cancer
Concern about how surgery will affect family relationships, ability to work, and finances
May exhibit: Anxiety, depression, anger, and withdrawal
Denial
FOOD/FLUID
May report: Difficulty swallowing (dysphagia)
May exhibit: Difficulty handling oral secretions, chokes easily
Swelling, ulcerations, masses may be noted depending on location of cancer
Oral inflammation/drainage, poor dental hygiene
Leukoplakia, erythroplasia of oral cavity
Halitosis
Swelling of tongue
Altered gag reflex and facial paralysis
HYGIENE
May exhibit: Neglect of dental hygiene
Need for assistance in basic care
NEUROSENSORY
May report: Diplopia (double vision)
Deafness
Tingling, paresthesia of facial muscles
May exhibit: Hemiparalysis of face (parotid and submandibular involvement), persistent hoarseness or loss of voice (dominant and earliest symptom of intrinsic laryngeal cancer)
Difficulty swallowing
Conduction deafness
Disruption of mucous membranes
PAIN/DISCOMFORT
May report: Chronic sore throat, “lump in throat”
Referred pain to ear, facial pain (late stage, probably metastatic)
Pain/burning sensation with swallowing (especially with hot liquids or citrus juices), local pain in oropharynx
(Postoperative) Sore throat or mouth (pain is not usually reported as severe following head and neck surgery, as compared with pain noted before surgery)
May exhibit: Guarding behaviors
Restlessness
Facial mask of pain
Alteration in muscle tone
RESPIRATION
May report: History of smoking (including cigars)/chewing tobacco
Occupation working with hardwood sawdust, toxic chemicals/fumes, heavy metals
History of voice overuse, e.g., professional singer or auctioneer
History of chronic lung disease
Cough with/without sputum
Bloody nasal drainage
May exhibit: Blood-tinged sputum, hemoptysis
Dyspnea (late)
SAFETY
May report: Excessive sun exposure over a period of years or radiation therapy
Visual/hearing changes
May exhibit: Masses/enlarged nodes
SOCIAL INTERACTION
May report: Lack of family/support system (may be result of age group or behaviors, e.g., alcoholism)
Concerns about ability to communicate, engage in social interactions
May exhibit: Persistent hoarseness, change in voice pitch
Muffled/garbled speech, reluctance to speak
Hesitancy/reluctance of significant others to provide care/be involved in rehabilitation
TEACHING/LEARNING
May report: Nonhealing of oral lesions
Concurrent use of alcohol/history of alcohol abuse
Discharge plan
DRG projected mean length of inpatient stay: 5.0–13.0 days
Assistance with wound care, treatments, supplies; transportation, shopping; food
preparation; self-care, homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Direct/indirect laryngoscopy; laryngeal tomography, biopsy, and needle biopsy: Are the most reliable diagnostic indicators for direct visualization or to detect local or regional spread/staging.
Laryngography: May be performed with contrast to study blood vessels and lymph nodes.
Pulmonary function studies, bone scans, or other organ scans: May be indicated if distant metastasis is suspected.
Chest x-ray: Done to establish baseline lung status and/or identify metastases.
CBC: May reveal anemia, which is a common problem.
Immunological surveys: May be done for patients receiving chemotherapy/immunotherapy.
Biochemical profile: Changes may occur in organ function as a result of cancer, metastasis, and therapies.
ABGs/pulse oximetry: May be done to establish baseline/monitor status of lungs (ventilation).
NURSING PRIORITIES
1. Maintain patent airway, adequate ventilation.
2. Assist patient in developing alternative communication methods.
3. Restore/maintain skin integrity.
4. Reestablish/maintain adequate nutrition.
5. Provide emotional support for acceptance of altered body image.
6. Provide information about disease process/prognosis and treatment.
DISCHARGE GOALS
1. Ventilation/oxygenation adequate for individual needs.
2. Communicating effectively.
3. Complications prevented/minimized.
4. Beginning to cope with change in body image.
5. Disease process/prognosis and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.
Current treatment choices include surgery, radiation, and chemotherapy. Radiation or carbon dioxide laser may be used for early stage disease. This plan of care focuses on nursing care of the patient undergoing radical surgery of the neck, including laryngectomy.
Partial laryngectomy (also called cordotomy): Tumors that are limited to one vocal cord are removed, and a temporary tracheotomy is performed to maintain the airway. After recovery from surgery, the patient will have a voice but it will be hoarse.
Hemilaryngectomy: When there is a possibility the cancer includes one true and one false vocal cord, they are removed along with an arytenoid cartilage and half of the thyroid cartilage. Temporary tracheotomy is performed, and the patient’s voice will be hoarse after surgery.
Supraglottic laryngectomy: When the tumor is located in the epiglottis or false vocal cords, radical neck dissection is done and tracheotomy performed. The patient’s voice remains intact; however, swallowing is more difficult because the epiglottis has been removed.
Total laryngectomy: Advanced cancers that involve a large portion of the larynx require removal of the entire larynx, the hyoid bone, the cricoid cartilage, two or three tracheal rings, and the strap muscles connected to the larynx. A permanent opening is created in the neck into the trachea, and a laryngectomy tube is inserted to keep the stoma open. The lower portion of the posterior pharynx is removed when the tumor extends beyond the epiglottis, with the remaining portion sutured to the esophagus after a nasogastric tube is inserted. The patient must breathe through a permanent tracheostomy, with normal speech no longer possible. Swallowing is not a long-term problem because there is no connection between the esophagus and trachea.
CARE SETTING
Inpatient surgical and possibly subacute units.
RELATED CONCERNS
Cancer
Psychosocial aspects of care
Surgical intervention
Total nutritional support: parenteral/enteral feeding
Patient Assessment Database (Preoperative)
Preoperative data presented here depend on the specific type/location of cancer process and underlying complications.
EGO INTEGRITY
May report: Feelings of fear about loss of voice, dying, occurrence/recurrence of cancer
Concern about how surgery will affect family relationships, ability to work, and finances
May exhibit: Anxiety, depression, anger, and withdrawal
Denial
FOOD/FLUID
May report: Difficulty swallowing (dysphagia)
May exhibit: Difficulty handling oral secretions, chokes easily
Swelling, ulcerations, masses may be noted depending on location of cancer
Oral inflammation/drainage, poor dental hygiene
Leukoplakia, erythroplasia of oral cavity
Halitosis
Swelling of tongue
Altered gag reflex and facial paralysis
HYGIENE
May exhibit: Neglect of dental hygiene
Need for assistance in basic care
NEUROSENSORY
May report: Diplopia (double vision)
Deafness
Tingling, paresthesia of facial muscles
May exhibit: Hemiparalysis of face (parotid and submandibular involvement), persistent hoarseness or loss of voice (dominant and earliest symptom of intrinsic laryngeal cancer)
Difficulty swallowing
Conduction deafness
Disruption of mucous membranes
PAIN/DISCOMFORT
May report: Chronic sore throat, “lump in throat”
Referred pain to ear, facial pain (late stage, probably metastatic)
Pain/burning sensation with swallowing (especially with hot liquids or citrus juices), local pain in oropharynx
(Postoperative) Sore throat or mouth (pain is not usually reported as severe following head and neck surgery, as compared with pain noted before surgery)
May exhibit: Guarding behaviors
Restlessness
Facial mask of pain
Alteration in muscle tone
RESPIRATION
May report: History of smoking (including cigars)/chewing tobacco
Occupation working with hardwood sawdust, toxic chemicals/fumes, heavy metals
History of voice overuse, e.g., professional singer or auctioneer
History of chronic lung disease
Cough with/without sputum
Bloody nasal drainage
May exhibit: Blood-tinged sputum, hemoptysis
Dyspnea (late)
SAFETY
May report: Excessive sun exposure over a period of years or radiation therapy
Visual/hearing changes
May exhibit: Masses/enlarged nodes
SOCIAL INTERACTION
May report: Lack of family/support system (may be result of age group or behaviors, e.g., alcoholism)
Concerns about ability to communicate, engage in social interactions
May exhibit: Persistent hoarseness, change in voice pitch
Muffled/garbled speech, reluctance to speak
Hesitancy/reluctance of significant others to provide care/be involved in rehabilitation
TEACHING/LEARNING
May report: Nonhealing of oral lesions
Concurrent use of alcohol/history of alcohol abuse
Discharge plan
DRG projected mean length of inpatient stay: 5.0–13.0 days
Assistance with wound care, treatments, supplies; transportation, shopping; food
preparation; self-care, homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Direct/indirect laryngoscopy; laryngeal tomography, biopsy, and needle biopsy: Are the most reliable diagnostic indicators for direct visualization or to detect local or regional spread/staging.
Laryngography: May be performed with contrast to study blood vessels and lymph nodes.
Pulmonary function studies, bone scans, or other organ scans: May be indicated if distant metastasis is suspected.
Chest x-ray: Done to establish baseline lung status and/or identify metastases.
CBC: May reveal anemia, which is a common problem.
Immunological surveys: May be done for patients receiving chemotherapy/immunotherapy.
Biochemical profile: Changes may occur in organ function as a result of cancer, metastasis, and therapies.
ABGs/pulse oximetry: May be done to establish baseline/monitor status of lungs (ventilation).
NURSING PRIORITIES
1. Maintain patent airway, adequate ventilation.
2. Assist patient in developing alternative communication methods.
3. Restore/maintain skin integrity.
4. Reestablish/maintain adequate nutrition.
5. Provide emotional support for acceptance of altered body image.
6. Provide information about disease process/prognosis and treatment.
DISCHARGE GOALS
1. Ventilation/oxygenation adequate for individual needs.
2. Communicating effectively.
3. Complications prevented/minimized.
4. Beginning to cope with change in body image.
5. Disease process/prognosis and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.
Chinese
French
German
Italian
Japanese
Korean
Russian
Spanish
