(POSTOPERATIVE CARE)
I. Pathophysiology
a. Malignancy lies above the clavicle, for instance lip, mouth,
nasal cavity, paranasal sinuses, pharynx, larynx, but excludes
the brain, spinal cord, axial skeleton, and vertebrae.
b. Cancers limited to the vocal cords (intrinsic) tend to
spread slowly, whereas cancers involving the epiglottis
(extrinsic) are more likely to metastasize to lymph nodes
of neck.
c. 90% to 95% of laryngeal neoplasms are squamous cell carcinomas
that arise from the oral cavity (Campbell & de le
Torre, 2008; Oral Cancer Foundation, 2008).
d. Rate of disability is high because of the potential loss of
voice, disfigurement, and social consequences
II. Treatment
a. Radiation alone is the most common treatment for early
stages of some head and neck cancers, such as those
affecting the nasopharynx, larynx, and oropharynx.
b. Combination of radiation and chemotherapy is increasing in
use to preserve structures.
c. Surgery remains mainstay of treatment for advanced-stage
laryngeal cancer, often in combination with radiation.
i. Total laryngectomy (TL), resulting in a permanent tracheostomy,
with normal speech and swallowing no longer
possible
ii. Near total laryngectomy (NTL) or conservation laryngeal
surgery, with swallowing function and some speech
retained
III. Etiology
a. Between 85% to 90% of all head and neck cancers can
be traced to the use of tobacco products or excessive
consumption of alcohol (American Association for Cancer
Research, 2008).
b. Additional risk factors include chronic candidiasis, poor
oral hygiene, ill-fitting dentures, human papillomavirus
(HPV), Epstein-Barr virus (EBV), and acid reflux disease
(Campbell & de la Torre, 2008).
IV. Statistics (National Cancer Institute [NCI], 2007b)
a. Morbidity: Head and neck cancers compose approximately
4% of all cancer cases in the United States, with an
estimated 40,000 men and women diagnosed in 2004.
i. Peak incidence between ages 50 and 60
ii. Male-to-female rates greater than 2:1 (Campbell & de la
Torre, 2008)
b. Mortality: 5-year survival rate is at 50% (Mouth Cancer
Foundation, 2008).
c. Cost: In 2001, lifetime economic burden in the United
States was estimated at $976 billion (Lee et al, n.d.) and the
annual cost for treatment in the United States was approximately
$3.2 billion.
Care Settings
Client is treated in inpatient surgical and possibly subacute
units.
Nursing Priorities
1. Maintain patent airway and adequate ventilation.
2. Assist client in developing alternative communication
methods.
3. Restore or maintain skin integrity.
4. Reestablish or 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 and oxygenation adequate for individual
needs.
2. Communicate effectively.
3. Complications prevented or minimized.
4. Begin to cope with change in body image.
5. Disease process, prognosis, and therapeutic regimen
understood.
6. Plan in place to meet needs after discharge.
NURSING DIAGNOSIS: ineffective Airway Clearance
ACTIONS/INTERVENTIONS
Airway Management
Independent
Monitor respiratory rate and depth; note ease of breathing.
Auscultate breath sounds. Investigate restlessness, dyspnea,
and development of cyanosis.
Elevate head of bed 30 to 45 degrees.
Encourage swallowing, if client is able.
Encourage effective coughing and deep breathing.
Suction laryngectomy and tracheostomy tube and oral and
nasal cavities. Note amount, color, and consistency of
secretions.
Demonstrate and encourage client to begin self-suction
procedures as soon as possible. Educate client in “clean”
techniques.
Maintain proper position of laryngectomy or tracheostomy
tube. Check and adjust ties as indicated.
Observe tissues surrounding tube for bleeding. Change
client’s position to check for pooling of blood behind neck
or on posterior dressings.
Change tube and inner cannula, as indicated. Instruct client in
cleaning procedures.
Collaborative
Provide supplemental humidification, such as compressed air
or oxygen mist collar and increased fluid intake.
Resume oral intake with caution. (Refer to ND: imbalanced
Nutrition: Less than Body Requirements.)
Monitor serial ABGs or pulse oximetry and chest x-ray.
RATIONALE
Changes in respirations, use of accessory muscles, and presence
of crackles or wheezes suggest retention of secretions.
Airway obstruction (even partial) can lead to ineffective
breathing patterns and impaired gas exchange, resulting in
complications, such as pneumonia and respiratory arrest.
Facilitates drainage of secretions, work of breathing, and lung
expansion. Note: Increase elevation when oral intake is
provided.
Prevents pooling of oral secretions, reducing risk of aspiration.
Note: Swallowing is impaired when the epiglottis is
removed and/or significant postoperative edema and pain
are present.
Mobilizes secretions to clear airway and helps prevent respiratory
complications.
Prevents secretions from obstructing airway, especially when
swallowing ability is impaired and client cannot blow nose.
Changes in character of secretions may indicate developing
problems, such as dehydration and infection, and need for
further evaluation and treatment.
Assists client to exercise some control in postoperative care
and prevention of complications. Reduces anxiety associated
with difficulty in breathing or inability to handle secretions
when alone.
As edema develops or subsides, tube can be displaced, compromising
airway. Ties should be snug but not constrictive
to surrounding tissue or major blood vessels.
Small amount of oozing may be present; however, continued
bleeding or sudden eruption of uncontrolled hemorrhage
presents a sudden and real possibility of airway obstruction
and suffocation.
Prevents accumulation of secretions and thick mucous plugs
from obstructing airway. Note: This is a common cause of
respiratory distress and arrest in later postoperative period.
Normal physiological (nasal passages) means of filtering and
humidifying air are bypassed. Supplemental humidity
decreases mucous crusting and facilitates coughing or suctioning
of secretions through stoma.
Changes in muscle mass and strength and nerve innervation
increase likelihood of aspiration.
Pooling of secretions or presence of atelectasis may lead
to pneumonia, requiring more aggressive therapeutic
measures.
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