Neck Dissection

H.AKOUM
 Neck Dissection

• Malignancies of the head and neck include those

of the oral cavity, oropharynx, hypopharynx,
nasopharynx, nasal cavity,paranasal sinus, and
larynx (Fig)
• These cancers account for fewer than 5% of all
cancers. Depending on the location and stage,
treatment may consist of radiation therapy,
chemotherapy, surg or a combination of these
modalities.

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• A radical neck dissection involves removal
of all cervical lymph nodes from the
mandible to the clavicle and removal of the
sternocleidomastoid muscle, internal
jugular vein, and spinal accessory muscle on
one side of the neck.

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 Preoperative management
• Interventions to improve nutritional status
preoperatively include nutritional supplements,
hyperalimentation, alcohol withdrawal, and counseling.
• Patient's general health status is evaluated, and
underlying conditions, such as cirrhosis and
obstructive pulmonary or cardiovascular disease, are
identified and treated, if possible.
• Patient is evaluated for level of understanding of
disease process, treatment regimen, and follow-up
care.
• Emotional preparation for major surgery, long
rehabilitation, and change in body image is provided.
 Postoperative Management
• A major goal of postoperative management is protection of
the airway. After the patient has fully recovered from
anesthesia, the endotracheal tube is removed (unless
respiratory compromise occurs).
• The patient is closely monitored for hemorrhage. Wound
drainage through portable suction should not exceed 120 mL
on the first postoperative day, then decreases.
• Prophylactic antibiotics are given to prevent infection
because of extensive incision, lymph node resection, and
close proximity to oral secretions.
• Oral nutritional supplements, enteral feedings, or
hyperalimentation is provided until oral intake is adequate
and nutritional status is improved.
 Complications
• Surgery: salivary incontinence, malocclusion,
unintelligible speech, difficulty eating or swallowing,
unacceptable deformity
• Radiation
– Early: radiation mucositis, erythema, desquamation,
dysphagia, secondary infection, oral pain
– Long-term: atrophy, fibrosis, salivary dryness,
hoarseness, difficulty swallowing, bone pain,
osteonecrosis, pathologic fractures, limitation of
movement
 Nursing Diagnoses
• Ineffective Breathing Pattern related to laryngeal
edema, secretions, presence of a tracheostomy
• Risk for Infection related to surgery, proximity of
secretions to suture line, radiation
• Imbalanced Nutrition: Less Than Body
Requirements related to anorexia, inability to
swallow, pain on swallowing
• Impaired Verbal Communication related to laryngeal
edema, laryngectomy, tracheostomy
• Disturbed Body Image related to surgical therapy,
radiation changes
 Nursing Interventions
Maintaining Effective Breathing Pattern
• Place the patient in Fowler's position.
• Observe for signs of respiratory
embarrassment, such as dyspnea, cyanosis,
edema, hoarseness, or dysphagia.
• Provide supplemental oxygen by face mask,
if necessary; if tracheostomy is present,
provide oxygen by collar or T-piece,
providing adequate humidification.
• Auscultate for decreased breath sounds, crackles,
wheezes; auscultate over the trachea in the immediate
postoperative period to assess for stridor indicative of
edema.
• Encourage deep breathing and coughing.
• Assist the patient in assuming a sitting position to
bring up secretions (the nurse's hands support the
patient's neck).
• Suction secretions orally or aseptically through a
tracheostomy if patient is unable to cough them up.
Preventing Infection
• Assess vital signs for indication of infection: increased heart rate,
elevation of temperature.
• Inspect wound for hemorrhage, drainage, or tracheal constriction;
reinforce dressings as needed.
• Inspect incision for signs of infection: redness, warmth, swelling,
drainage.
• If portable suction is used, expect approximately 80 to 120 mL of
serosanguineous secretions to be drawn off during the first
postoperative day; this diminishes with each day.
• Aseptically clean skin area around drain exit, using saline or
prescribed solution.
• Make sure that the incision site remains clean and dry; remove
secretions immediately.
Improving Nutritional Status
• Postoperatively provide I.V. fluids and
hyperalimentation, tube feedings through
NG tube or gastrostomy tube, or oral
feedings as soon as swallowing is established.
• Provide mouth care before and after meals.
• Assess for excessive or decreased
salivation, which may impair swallowing.
• Make sure that emergency suctioning and airway equipment
is available at the bedside during meals in the event of
choking or aspiration.
• Position patient in an upright position, supporting shoulders
and neck with pillows, if necessary.
• Ask whether the patient would prefer privacy during meals.
• Provide an environment that is clean and free from
interruptions and odor.
• Assist with oral intake, providing easily chewed foods. Mash
or blenderize meals, if necessary.
Improving Ability to Communicate
• If tracheostomy or laryngectomy has been
performed, provide alternative methods of
communication (letter board, chalk and slate,
paper and pencil). If writing is a problem, it may
be due to denervation of the trapezius muscle.
• Allow adequate time for patient to communicate.
• Place call bell and other articles that patient may
need within easy access.
• Provide support and encouragement during
communication attempts, recognizing that this
patient is often depressed and frustrated even
during limited communication.
• Refer patient to speech-language pathologist, if
indicated.
Strengthening Body Image
• Respect the patient's desire for
privacy during treatments, dressing
changes, and feedings.
• Inform visitors of appearance before
they see patient so their expressions
do not upset patient.
• Provide frequent aeration of the room, and use
deodorants to prevent unpleasant odors.
• Observe for lower facial paralysis; this may indicate
facial nerve injury.
• Watch for shoulder dysfunction, which may follow
resection of spinal accessory nerves.
– Use muscle exercises and muscle reeducation
postoperatively.
– Work with the patient to obtain good functional
range of motion.
• Talk with the surgeon and patient about
decisions about future cosmetic surgery or in
the use of a prosthetic device.
• Encourage the patient to verbalize concerns and
feelings.
– Consult the health care provider to determine
the nature and extent of explanation and
prognosis that has been given to the patient.
– Encourage the patient to seek confirmation of
personal philosophy and religious beliefs because
this may provide answers.
– Accentuate the positive.
– Encourage the patient to participate in the plan of
care.
– Recognize that a great effort has to be made in
behavior modification to change a lifestyle that
included alcohol consumption and cigarette smoking.
It is difficult to do.
 Community and Home Care
Considerations
• If patient has a permanent tracheostomy or
laryngectomy, instruct the patient and family
about:
• Need for increased humidification in home
environment
• Protective stoma cover to help filter air
• Avoiding activities that may cause aspiration (eg,
swimming)
• Referral for speech-language pathologist, social
worker to meet ongoing communication needs
 Patient Education and Health
Maintenance
Exercises
• Instruct the patient and family regarding
exercises to prevent limited range of motion and
discomfort
• Perform exercises morning and evening. Initially,
exercises are done only once; the number is
increased by one each day until each exercise is
done 10 times.
• After each exercise, the patient is instructed to
relax.
• For neck:
– Gently rotate head to each side as far
as possible.
– Tilt head to the right side as far as
possible; repeat for left side.
– Drop chin to chest, and then raise chin
as high as possible.
• For shoulder:
– Standing beside bed, place hand from
unoperated side on bed for support.
– Gradually swing arm on operated side up
and back as far as is comfortable for the
patient.
– Each day, work toward finishing a complete
circle.
 Evaluation: Expected Outcomes

• Maintains adequate breathing pattern; absence of dyspnea,

shortness of breath; is able to handle secretions
• Is free from signs and symptoms of infection; vital signs
stable; incision is clean, dry, without redness or drainage
• Is adequately hydrated, maintains stable nutritional status,
can tolerate diet without choking or aspiration
• Can communicate and make needs known
• Discusses concerns about condition, verbalizes positive
aspects of self