Nursing Care Plan Radical Neck Surgery Laryngectomy Post Operative

RADICAL NECK SURGERY: LARYNGECTOMY
(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.

Nursing Care Plan Lung Cancer Postoperative Care

LUNG CANCER: POSTOPERATIVE CARE

I. Pathophysiology
a. Usually develops within the wall or epithelium of the
bronchial tree
b. Prolonged exposure to cancer-promoting agents causes
damage to ciliated cells and mucus-producing cells, leading
to genetic mutations and development of dysplastic cells.
II. Classification (Memorial Sloan-Kettering Cancer Center,
2008; National Cancer Institute, 2008)
a. Small cell lung cancers (SCLCs), or oat cell lung cancer
i. Represent about 15% to 25% of lung cancer cases
(Elias & Baldini, 2008)
ii. Occur almost exclusively in smokers
iii. Aggressive and fast growing with surgery seldom a
treatment option
b. Non–small cell lung cancers (NSCLCs)
i. Most common type of lung cancer (75% to 85%, Elias
& Baldini, 2008)
ii. Include adenocarcinoma, squamous cell, and large cell
carcinomas
iii. Frequently associated with metastases, but are generally
slow growing
III. Staging (National Cancer Institute, 2008)
a. Stage 0—cancer cells only found in the innermost lining of
the lung
b. Stage IA—tumor has grown through the innermost lining
of the lung into deeper lung tissue, but does not invade the
bronchus; no cancer cells found in nearby lymph nodes
c. Stage IB—tumor is larger, may be more than 3 cm across;
may have grown into the main bronchus; may have grown
into the pleura, but no cancer cells found in nearby lymph
nodes
d. Stage IIB—tumor has invaded the chest wall, diaphragm,
pleura, main bronchus, or tissue that surrounds the heart;
cancer cells found in nearby lymph nodes
e. Stage IIIA—tumor may be any size; cancer cells found in
the lymph nodes near the lungs and bronchi and between
the lungs on the same side of the chest as the tumor
f. Stage IIIB—tumor may be any size; cancer cells found on
the opposite side of the chest from the tumor, with possible
invasion into nearby organs
g. Stage IV—malignant growths may be found in more than
one lobe or may have metastasized to other organs

IV. Etiology (American Cancer Society, 2008)
a. Risk factors include cigarette smoking or being exposed to
secondhand smoke; radon, asbestos, other occupational
exposures, including radioactive ores such as uranium,
inhaled chemicals or minerals, such as nickel compounds,
silica, coal dust, and cromates, or diesel exhaust; high
levels of arsenic in drinking water; and family history of
lung cancer.
b. Chronic obstructive pulmonary disease (COPD) and
pulmonary fibrosis may increase susceptibility.
V. Statistics
a. Morbidity: Second most commonly diagnosed cancer
accounting for 13% of all cases (American Association
for Cancer Research, 2005) with new cases of lung
and bronchus cancer estimated at 172,570 for 2005
(Jemal et al, 2005).
b. Mortality: Number one cause of death in cancer patients;
in 2004, death rates for men and women were 89,575 and
68,431, respectively; results in more deaths than breast
cancer, prostate cancer, and colon cancer combined
(U.S. Cancer Statistics Worling Group, 2007).
c. Cost: $9.6 billion was spent for treatment in 2004.
VI. Treatment Options
a. Depends upon staging—generally the lower the stage, the
more favorable the prognosis
i. Surgery is primary treatment for NSCLC stage I and
stage II tumors.
ii. Selected stage III carcinomas may be operable if the
tumor is resectable.
b. Surgical procedures for operable tumors of the lung
include:
i. Pneumonectomy—performed for lesions originating in
the main stem bronchus or lobar bronchus
ii. Lobectomy—preferred for peripheral carcinoma localized
in a lobe
iii.Wedge or segmental resection—performed for lesions
that are small and well contained within one segment
iv. Endoscopic laser resection—may be done on peripheral
tumors to reduce the necessity of cutting through ribs
v. Photodynamic therapy—reduces symptoms such as
bleeding or may be used to treat very small tumors

Care Setting
Client is treated in inpatient surgical and possibly subacute
units.

Nursing Priorities
1. Maintain or improve respiratory function.
2. Control or alleviate pain.
3. Support efforts to cope with diagnosis and situation.
4. Provide information about disease process, prognosis,
and therapeutic regimen.

Discharge Goals
1. Oxygenation and ventilation adequate to meet individual
activity needs.
2. Pain controlled.
3. Anxiety and fear decreased to manageable level.
4. Free of preventable complications.
5. Disease process, prognosis, and planned therapies
understood.
6. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS: impaired Gas Exchange

May be related to
Removal of lung tissue
Altered oxygen supply—hypoventilation
Decreased oxygen-carrying capacity of blood—blood loss
Possibly evidenced by
Dyspnea
Restlessness
Changes in mentation
Hypoxemia and hypercapnia
Cyanosis
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Demonstrate improved ventilation and adequate oxygenation of tissues by arterial blood gases (ABGs) within client’s normal
range.
Be free of symptoms of respiratory distress.

ACTIONS/INTERVENTIONS
Respiratory Management
Independent
Note respiratory rate, depth, and ease of respirations. Observe
for use of accessory muscles, pursed-lip breathing, or
changes in skin or mucous membrane color, such as pallor
and cyanosis.
Auscultate lungs for air movement and abnormal breath
sounds.
Investigate restlessness and changes in mentation and level of
consciousness.
Assess client response to activity. Encourage rest periods,
limiting activities to client tolerance.
Note development of fever.
Airway Management
Maintain patent airway by positioning, suctioning, and use of
airway adjuncts.
Reposition frequently, placing client in sitting and supine to
side positions.
Avoid positioning client with a pneumonectomy on the operative
side; instead, favor the “good lung down” position.
Encourage and assist with deep-breathing exercises and
pursed-lip breathing, as appropriate.
Tube Care: Chest
Maintain patency of chest drainage system following
lobectomy and segmental wedge resection procedures.
Note changes in amount or type of chest tube drainage.
Observe for presence of bubbling in water-seal chamber.
Airway Management
Collaborative
Administer supplemental oxygen via nasal cannula, partial
rebreathing mask, or high-humidity face mask, as indicated.
Assist with and encourage use of incentive spirometer.
Monitor and graph ABGs and pulse oximetry readings. Note
hemoglobin (Hgb) levels.

RATIONALE
Respirations may be increased as a result of pain or as an
initial compensatory mechanism to accommodate for loss
of lung tissue. However, increased work of breathing and
cyanosis may indicate increasing oxygen consumption and
energy expenditures or reduced respiratory reserve, for
example, in an elderly client or extensive COPD.
Consolidation and lack of air movement on operative side are
normal in the client who has had a pneumonectomy; however,
a client who has had a lobectomy should
demonstrate normal airflow in remaining lobes.
May indicate increased hypoxia or complications such as
mediastinal shift in a client who has had a pneumonectomy
when accompanied by tachypnea, tachycardia, and tracheal
deviation.
Increased oxygen consumption and demand and stress of
surgery may result in increased dyspnea and changes in
vital signs with activity; however, early mobilization is
desired to help prevent pulmonary complications and to
obtain and maintain respiratory and circulatory efficiency.
Adequate rest balanced with activity can prevent
respiratory compromise.
Fever within the first 24 hours after surgery is frequently due
to atelectasis. Temperature elevation within postoperative
day 5 to 10 usually indicates an infection, such as wound
or systemic.
Airway obstruction impedes ventilation, impairing gas
exchange. (Refer to ND: ineffective Airway Clearance.)
Maximizes lung expansion and drainage of secretions.
Research shows that positioning clients following lung surgery
with their “good lung down” maximizes oxygenation by
using gravity to enhance blood flow to the healthy lung,
thus creating the best possible match between ventilation
and perfusion.
Promotes maximal ventilation and oxygenation and reduces
or prevents atelectasis.
Drains fluid from pleural cavity to promote reexpansion of
remaining lung segments.
Bloody drainage should decrease in amount and change to
a more serous composition as recovery progresses.
A sudden increase in amount of bloody drainage or return
to frank bleeding suggests thoracic bleeding or a hemothorax;
sudden cessation suggests blockage of tube, requiring
further evaluation and intervention.
Air leaks appearing immediately postoperatively are not
uncommon, especially following lobectomy or segmental
resection; however, this should diminish as healing
progresses. Prolonged or new leaks require evaluation to
identify problems in client versus a problem in the drainage
system.
Maximizes available oxygen, especially while ventilation is
reduced because of anesthetic, depression, or pain, and
during period of compensatory physiological shift of
circulation to remaining functional alveolar units.
Prevents or reduces atelectasis and promotes reexpansion of
small airways.
Decreasing PaO2 or increasing PaCO2 may indicate need for
ventilatory support. Significant blood loss results in
decreased oxygen-carrying capacity, reducing PaO2.