NURSING PROCESS: THE PATIENT UNDERGOING LARYNGECTOMY
The nurse assesses the patient for the following symptoms: hoarseness, sore throat, dyspnea, dysphagia, or pain and burning in the throat. The neck is palpated for swelling.
If treatment includes surgery, the nurse must know the nature of the surgery to plan appropriate care. If the patient is expected to have no voice, a preoperative evaluation by the speech thera-pist is indicated. The patient’s ability to hear, see, read, and write is assessed. Visual impairment and functional illiteracy may cre-ate additional problems with communication and require creative approaches to ensure that the patient is able to communicate any needs.
In addition, the nurse determines the psychological readiness of the patient and family. The idea of cancer is terrifying to most people. Fear is compounded by the possibility of permanently losing one’s voice and, in some cases, of having some degree of disfigurement. The nurse evaluates the patient’s and family’s cop-ing methods to support them effectively both preoperatively and postoperatively.
Based on all the assessment data, major nursing diagnoses may include the following:
• Deficient knowledge about the surgical procedure and post-operative course
• Anxiety and depression related to the diagnosis of cancer and impending surgery
• Ineffective airway clearance related to excess mucus pro-duction secondary to surgical alterations in the airway
• Impaired verbal communication related to anatomic deficit secondary to removal of the larynx and to edema
• Imbalanced nutrition: less than body requirements, related to inability to ingest food secondary to swallowing difficulties
• Disturbed body image and low self-esteem secondary to major neck surgery, change in the structure and function of the larynx
• Self-care deficit related to pain, weakness, fatigue, muscu-loskeletal impairment related to surgical procedure and post-operative course
Based on assessment data, potential complications that may de-velop include:
· Respiratory distress (hypoxia, airway obstruction, tracheal edema)
· Wound breakdown
The major goals for the patient may include attainment of an ad-equate level of knowledge, reduction in anxiety, maintenance of a patent airway (patient is able to handle own secretions), effective use of alternative means of communication, attainment of optimal levels of nutrition and hydration, improvement in body image and self-esteem, improved self-care management, and ab-sence of complications.
The diagnosis of laryngeal cancer is associated with misconcep-tions and fears. Many people assume that loss of speech and dis-figurement are inevitable with this condition. Once the physician explains the diagnosis to the patient, the nurse clarifies any mis-conceptions by identifying the location of the larynx, its function, the nature of the surgical procedure, and its effect on speech. In-formational materials (written and audiovisual) about the surgery are given to the patient and family for review and reinforcement.
If a complete laryngectomy is planned, the patient should know that the natural voice will be lost, but that special training can provide a means for communicating. However, the ability to sing, laugh, or whistle will be lost. Until this training is initiated, the patient needs to know that communication will be possible by using the call light or special communication board and by writing. The nurse answers questions about the nature of the surgery and reinforces the physician’s explanation that the patient will lose the ability to vocalize, but that a rehabilitation program is available. The multidisciplinary team conducts an initial as-sessment of the patient and family. The team might include the nurse, physician, respiratory therapist, speech therapist, clinical nurse specialist, social worker, dietitian, and home care nurse.
Next, the nurse reviews equipment and treatments for post-operative care with the patient and family, teaches important coughing and deep-breathing exercises, and assists the patient to perform a return demonstration. The nurse clarifies the patient’s role in the postoperative and rehabilitation periods.
Because surgery of the larynx is performed most commonly for a malignant tumor, the patient may have many questions: Will the surgeon be able to remove all of the tumor? Is it cancer? Will I die? Will I choke? Will I suffocate? Will I ever speak again? What will I look like? The psychological preparation of the patient is as important as the physical preparation.
Any patient undergoing surgery may have many fears. In la-ryngeal surgery, these fears may relate to the diagnosis of cancer and may be compounded by the possibility of permanent loss of the voice and disfigurement. The nurse provides the patient and family with opportunities to ask questions, verbalize feelings, and discuss perceptions. It is important to address any questions and misconceptions the patient and family have. During the pre-operative or postoperative period, a visit from someone who has had a laryngectomy may reassure the patient that people are avail-able to help and that rehabilitation is possible.
The nurse promotes a patent airway by positioning the patient in the semi-Fowler’s or Fowler’s position after recovery from anes-thesia. Observing the patient for restlessness, labored breathing, apprehension, and increased pulse rate helps the nurse identify possible respiratory or circulatory problems. Medications that de-press respiration, particularly opioids, should be used cautiously. As with other surgical patients, the nurse encourages the laryn-gectomy patient to turn, cough, and take deep breaths. If neces-sary, suctioning may be performed to remove secretions. The nurse also encourages and assists the patient with early ambula-tion to prevent atelectasis and pneumonia.
If a total laryngectomy was performed, a laryngectomy tube will most likely be in place. (In some instances a laryngectomy tube is not used; in others it is used temporarily, and in many it is used permanently.) The laryngectomy tube, which is shorter than a tracheostomy tube but has a larger diameter, is the pa-tient’s only airway. The care of this tube is the same as for a tra-cheostomy tube. The nurse cleans the stoma daily with saline solution or another prescribed solution. If a non–oil-based antibiotic ointment is prescribed, the nurse applies it around the stoma and suture line. If crusting appears around the stoma, the nurse removes the crusts with sterile tweezers and ap-plies additional ointment.
Wound drains may be in place to assist in removal of fluid and air from the surgical site. Suction also may be used, but cautiously, to avoid trauma to the surgical site and incision. The nurse ob-serves, measures, and records drainage. When drainage is less than 50 to 60 mL/day, the physician usually removes the drains.
Frequently, the patient coughs up large amounts of mucus through this opening. Because air passes directly into the trachea without being warmed and moistened by the upper respiratory mucosa, the tracheobronchial tree compensates by secreting ex-cessive amounts of mucus. Therefore, the patient will have fre-quent coughing episodes and may develop a brassy-sounding, mucus-producing cough. The nurse should reassure the patient that these problems will diminish in time as the tracheobronchial mucosa adapts to the altered physiology.
After the patient coughs, the tracheostomy opening must be wiped clean and clear of mucus. A simple gauze dressing, wash-cloth, or even paper towel (because of its size and absorbency) worn below the tracheostomy may serve as a barrier to protect the clothing from the copious mucus that the patient may expel initially.
One of the most important factors in decreasing cough, mucus production, and crusting around the stoma is adequate humidi-fication of the environment. Mechanical humidifiers and aerosol generators (nebulizers) increase the humidity and are important for the patient’s comfort.
The laryngectomy tube may be removed when the stoma is well healed, within 3 to 6 weeks after surgery. The nurse can teach the patient how to clean and change the tube and remove secretions.
Understanding the patient’s postoperative needs is critical. Alter-native means of communication are established and used consis-tently by all personnel who come in contact with the patient—for example, a call bell or hand bell may be placed within easy reach of the patient. Because a Magic Slate often is used for communi-cation, the nurse should document which hand the patient uses for writing so that the opposite arm can be used for intravenous infusions. (The nurse should discard any old notes used for com-munication to ensure the patient’s privacy.) If the patient cannot write, a picture-word-phrase board or hand signals can be used. Preoperatively, the nurse reviews the system of communication to be used postoperatively with the patient.
Because it is very time-consuming to have to write everything or communicate through gestures, the inability to speak can be very frustrating. The patient may become impatient and angry when not understood. In such cases, other staff members need to be alert to the problem and also recognize that the patient will be unable to use the intercom system.The return of communication is generally the ultimate goal in the rehabilitation of the laryngectomy patient. The nurse works with the patient, speech therapist, and family to encourage use of alternative communication methods.
Postoperatively, the patient may not be permitted to eat or drink for 10 to 14 days. Alternative sources of nutrition and hydration include intravenous fluids, enteral feedings through a nasogastric tube, and parenteral nutrition.
Once the patient is ready to start oral feedings, the nurse ex-plains that thick liquids will be used first because they are easy to swallow. The nurse instructs the patient to avoid sweet foods, which increase salivation and suppress the appetite. Solid foods are introduced as tolerated. The nurse instructs the patient to rinse the mouth with warm water or mouthwash and to brush the teeth frequently.
The patient can expect to have a diminished sense of taste and smell for a period of time after surgery. Inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. Because taste and smell are so closely connected, taste sensations are altered. In time, however, the patient usually accommodates to this problem and olfactory sensation adapts, often with return of interest in eating. The nurse observes the patient for any diffi-culty swallowing, particularly when eating resumes, and reports its occurrence to the physician.
Disfiguring surgery and an altered communication pattern are a threat to a patient’s body image and self-esteem. The reaction of family members and friends is a major concern for the patient. The nurse encourages the patient to express any feelings about the changes brought about by surgery, particularly those related to fear, anger, depression, and isolation.
A positive approach is important when caring for the patient. Promoting self-care activities is part of this approach. It is im-portant for the patient and family to begin participating in self-care activities as soon as possible. The nurse needs to be a good listener and a support to the family, especially when explaining the tubes, dressings, and drains that are in place postoperatively. Referral to a support group, such as Lost Chord or New Voice clubs (through the International Association of Laryngectomees) and I Can Cope (through the American Cancer Society), may help the patient and family deal with the changes in their lives. Groups such as Lost Chord and New Voice promote and support the re-habilitation of people who have had a laryngectomy by providing an opportunity for exchanging ideas and sharing information.
The immediate potential complications after laryngectomy in-clude respiratory distress and hypoxia, hemorrhage, infection, and wound breakdown.
The nurse monitors the patient for signs and symptoms of respi-ratory distress and hypoxia, particularly restlessness, irritation, agitation, confusion, tachypnea, use of accessory muscles, and de-creased oxygen saturation on pulse oximetry (SpO2). Any change in the respiratory status requires immediate intervention. Ob-struction needs to be ruled out immediately by suctioning and having the patient cough and breathe deeply. Hypoxia and air-way obstruction, if not immediately treated, are life-threatening.
The nurse contacts the physician immediately if nursing measures do not improve the patient’s respiratory status.
Bleeding at the surgical site from the drains or with tracheal suc-tioning may signal the occurrence of hemorrhage. The nurse should notify the surgeon of any active bleeding immediately. Bleeding may occur at a variety of sites, including the surgical site, drains, or trachea. Rupture of the carotid artery is especially dan-gerous. Should this occur, the nurse should apply direct pressure over the artery, summon assistance, and provide emotional sup-port to the patient until the vessel can be ligated. It is important to monitor vital signs for changes, particularly increased pulse rate, decreased blood pressure, and rapid deep respirations. Cold, clammy, pale skin may indicate active bleeding.
The nurse observes for postoperative infection. Early signs of in-fection include an increase in temperature and pulse, a change in the type of wound drainage, or increased areas of redness or ten-derness at the surgical site. Other signs include purulent drainage, odor, and increased wound drainage. The nurse reports any sig-nificant change to the surgeon.
Wound breakdown due to infection, poor wound healing, or de-velopment of a fistula or as a result of radiation therapy or tumor growth can create a life-threatening emergency. The carotid artery, which is close to the stoma, may rupture from erosion if the wound does not heal properly. The nurse observes the stoma area for wound breakdown, hematoma, and bleeding and reports any significant changes to the surgeon. If wound breakdown oc-curs, the patient must be monitored carefully and identified as being at high risk for carotid hemorrhage.
The nurse has an important role in the recovery and rehabilita-tion of the laryngectomy patient. In an effort to facilitate the pa-tient’s ability to manage self-care, discharge instruction begins as soon as the patient is able to participate. Nursing care and patient teaching in the hospital, outpatient setting, and rehabilitation or long-term care facility must take into consideration the many emotions, physical changes, and lifestyle changes experienced by the patient. In preparing the patient to go home, the nurse as-sesses the patient’s readiness to learn and the level of knowledge about self-care management. The nurse also reassures the patient and family that most self-care management strategies can be mas-tered. The patient will need to learn a variety of self-care behav-iors, including tracheostomy and stoma care, wound care, and oral hygiene. In addition, the nurse instructs the patient about the need for safe hygiene and recreational activities.
The nurse provides specific in-structions to the patient and family about what to expect from the tracheostomy and its management. The nurse teaches the pa-tient and family caregiver to perform suctioning and emergency measures and tracheostomy and stoma care. The nurse stresses the importance of humidification at home and instructs the fam-ily to set up a humidification system before the patient returns home. In addition, the nurse cautions the patient and family that air-conditioned air may be too cool or too dry, and thus too irri-tating, for the patient with a new laryngectomy.
The nurse instructs the patientand family about safety precautions needed because of the struc-tural changes resulting from the surgery. Special precautions are needed in the shower to prevent water from entering the stoma. Wearing a loose-fitting plastic bib over the tracheostomy or sim-ply holding the hand over the opening is effective. Swimming is not recommended, however, because people with a laryngectomy can drown without getting their face wet. Barbers and beauticians need to be alerted so that hair sprays, loose hair, and powder do not get near the stoma, because they can block or irritate the tra-chea and possibly cause infection. These self-care points are sum-marized in Chart 22-8.
Recreation and exercise are important, and all but very strenu-ous exercise can be enjoyed safely. Avoidance of strenuous exercise and fatigue is important because, when tired, the patient has more difficulty speaking, which can be discouraging. Additional safety points to address include the need for the patient to wear or carry medical identification, such as a bracelet or card, to alert medical personnel to the special requirements for resuscitation should this need arise. When resuscitation is needed, direct mouth-to-stoma ventilation should be performed. For home emergency situations, prerecorded emergency messages for police, the fire department, or other rescue services can be kept near the phone to be used quickly.
The nurse instructs and encourages the patient to perform oral care on a regular basis to prevent halitosis and infection. If the pa-tient is receiving radiation therapy, there will be a decrease in saliva, and synthetic saliva may be required. The nurse instructs the patient to drink water or sugar-free liquids throughout the day and to use a humidifier at home. Brushing the teeth or den-tures and rinsing the mouth several times a day will assist in main-taining proper oral hygiene.
Referral for home care is an important aspect of postoperative care for the patient who has had a laryngectomy and will assist the patient and family in the transition to the home. The home care nurse assesses the patient’s general health status and the ability of the patient and family to care for the stoma and tracheostomy.The nurse assesses the surgical incisions, nutritional and respira-tory status, and adequacy of pain management. The nurse assesses not only for signs and symptoms of complications but also for the patient’s and family’s knowledge of which signs and symptoms to report to the physician. During the home visit, the nurse iden-tifies and addresses other learning needs of the patient and family, such as adaptation to physical, lifestyle, and functional changes. It is important to assess the patient’s psychological status as well. The home care nurse reinforces previous teaching and provides reassurance and support to the patient and family as needed.
The nurse encourages the person who has had a laryngectomy to have regular physical examinations and to seek advice con-cerning any problems related to recovery and rehabilitation. The patient is also reminded to participate in health promotion activ-ities and health screening and about the importance of keeping scheduled appointments with the physician, speech therapist, and other health care providers.
Expected patient outcomes may include:
1. Acquires an adequate level of knowledge, verbalizing an understanding of the surgical procedure and performing self-care adequately
2. Demonstrates less anxiety and depression
a. Expresses a sense of hope
b. Is aware of available community organizations and agen-cies such as the Lost Chord or New Voice groups
c. Participates in support group, such as I Can Cope
3. Maintains a clear airway and handles own secretions; also demonstrates practical, safe, and correct technique for clean-ing and changing the laryngectomy tube
4. Acquires effective communication techniques
a. Uses assistive devices and strategies for communication (Magic Slate, call bell, picture board, sign language, lip reading, computer aids)
b. Follows the recommendations of the speech therapist
5. Maintains balanced nutrition and adequate fluid intake
6. Exhibits improved body image, self-esteem, and self-concept
a. Expresses feelings and concerns
b. Participates in self-care and decision making
c. Accepts information about support group
7. Exhibits no complications
a. Vital signs (blood pressure, temperature, pulse, respira-tory rate) normal
b. No redness, tenderness, or purulent drainage at surgical site
c. Demonstrates a patent airway and appropriate respira-tions
d. No bleeding from surgical site and minimal bleeding from drains
e. No wound breakdown
8. Adheres to rehabilitation and home care program
a. Practices recommended speech therapy
b. Demonstrates proper methods for caring for stoma and laryngectomy tube (if present)
c. Verbalizes understanding of symptoms that require medical attention
d. States safety measures to take in emergencies
e. Performs oral hygiene as prescribed