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Radical Neck Surgery_laryngectomy

Radical Neck Surgery_laryngectomy

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Published by: mardsz on Jan 01, 2009
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05/09/2014

 
RADICAL NECK SURGERY: LARYNGECTOMY (POSTOPERATIVECARE)
Head and neck cancer refers to a malignancy that lies above the clavicle but excludes the brain, spinal cord, axialskeleton, 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 usedfor 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 atemporary tracheotomy is performed to maintain the airway. After recovery from surgery, the patient will have avoice but it will be hoarse.
 Hemilaryngectomy:
When there is a possibility the cancer includes one true and one false vocal cord, they areremoved 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 isdone 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 stomaopen. The lower portion of the posterior pharynx is removed when the tumor extends beyond the epiglottis, withthe remaining portion sutured to the esophagus after a nasogastric tube is inserted. The patient must breathethrough 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 careSurgical interventionTotal 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 withdrawalDenial
FOOD/FLUID
May report:
Difficulty swallowing (dysphagia)
May exhibit:
Difficulty handling oral secretions, chokes easilySwelling, ulcerations, masses may be noted depending on location of cancer Oral inflammation/drainage, poor dental hygieneLeukoplakia, erythroplasia of oral cavityHalitosisSwelling 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)DeafnessTingling, 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 swallowingConduction deafnessDisruption 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 behaviorsRestlessnessFacial mask of painAlteration in muscle tone
RESPIRATION
May report:
History of smoking (including cigars)/chewing tobaccoOccupation working with hardwood sawdust, toxic chemicals/fumes, heavy metalsHistory of voice overuse, e.g., professional singer or auctioneer History of chronic lung diseaseCough with/without sputumBloody nasal drainage
May exhibit:
Blood-tinged sputum, hemoptysisDyspnea (late)
SAFETY
May report:
Excessive sun exposure over a period of years or radiation therapyVisual/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 pitchMuffled/garbled speech, reluctance to speak Hesitancy/reluctance of significant others to provide care/be involved in rehabilitation
TEACHING/LEARNING
May report:
 Nonhealing of oral lesionsConcurrent use of alcohol/history of alcohol abuse
Discharge plan
DRG projected mean length of inpatient stay: 5.0–13.0 days
considerations:
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 diagnosticindicators 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.
NURSING DIAGNOSIS: Airway Clearance, ineffective/Aspiration, risk for May be related to
Partial/total removal of the glottis, altering ability to breathe, cough, and swallowTemporary or permanent change to neck breathing (dependent on patent stoma)Edema formation (surgical manipulation and lymphatic accumulation)Copious and thick secretions
Possibly evidenced by (Airway Clearance)
Dyspnea/difficulty breathingChanges in rate/depth of respiration; use of accessory respiratory musclesAbnormal breath soundsCyanosis
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Respiratory Status: Airway Patency (NOC)
Maintain patent airway with breath sounds clear/clearing.Expectorate/clear secretions and be free of aspiration.
Aspiration Control (NOC)
Demonstrate behaviors to improve/maintain airway clearance within level of ability/situation.
ACTIONS/INTERVENTIONS RATIONALE

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