Nursing Process: The Patient Undergoing a Neck Dissection

NURSING PROCESS: THE PATIENT UNDERGOING A NECK DISSECTION

Assessment

Preoperatively, the patient’s physical and psychological prepara-tion for major surgery is assessed, along with his or her knowl-edge of the preoperative and postoperative procedures. Postoperatively, the patient is assessed for complications such as altered respiratory status, wound infection, and hemorrhage. As healing occurs, neck range of motion is assessed to determine whether there has been a decrease in range of motion due to nerve or muscle damage.

Diagnosis

NURSING DIAGNOSES

Based on all the assessment data, major nursing diagnoses may include the following:

•        Deficient knowledge about preoperative and postoperative procedures

•        Ineffective airway clearance related to obstruction by mucus, hemorrhage, or edema

•        Acute pain related to surgical incision

•        Risk for infection related to surgical intervention secondary to decreased nutritional status, or immunosuppression from chemotherapy or radiation therapy

•        Impaired tissue integrity secondary to surgery and grafting

•        Imbalanced nutrition, less than body requirements, related to disease process or treatment

•        Situational low self-esteem related to diagnosis or prognosis

•        Impaired verbal communication secondary to surgical re-section

•        Impaired physical mobility secondary to nerve injury

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Potential postoperative complications that may develop include the following:

1) Hemorrhage

2)  Chyle fistula

3)  Nerve injury

Planning and Goals

The major goals for the patient include participation in the treat-ment plan, maintenance of respiratory status, absence of infec-tion, viability of the graft, maintenance of adequate intake of food and fluids, effective coping strategies, attainment of comfort, effective communication, and absence of complications.

Nursing Interventions

PROVIDING PREOPERATIVE PATIENT EDUCATION

Before surgery, the patient should be informed about the nature and extent of the surgery, and what the postoperative period will be like. The patient is encouraged to ask questions and to express concerns about the upcoming surgery and the expected results. During this exchange, the nurse has an opportunity to assess the patient’s cop-ing abilities, answer questions, and develop a plan for offering assis-tance. A sense of mutual understanding and rapport will make the postoperative experience less traumatic for the patient. The patient’s expressions of concern, anxieties, and fears can guide the nurse in providing support postoperatively.

PROVIDING GENERAL POSTOPERATIVE CARE

For the patient who has had extensive neck surgery, specific postoperative interventions include mainte-nance of a patent airway and continuous assessment of respiratory status, wound care and oral hygiene, maintenance of adequate nutrition, and observation for hemorrhage or nerve injury.

MAINTAINING THE AIRWAY

After the endotracheal tube or airway has been removed and the ef-fects of the anesthesia have worn off, the patient may be placed in Fowler’s position to facilitate breathing and promote comfort. This position also increases lymphatic and venous drainage, facilitates swallowing, and decreases venous pressure on the skin flaps.

In the immediate postoperative period, the nurse assesses for stridor (coarse, high-pitched sound on inspiration) by listening frequently over the trachea with a stethoscope. This finding must be reported immediately because it indicates obstruction of the airway. Signs of respiratory distress, such as dyspnea, cyanosis, changes in mental status, and changes in vital signs, are assessed because they may suggest edema, hemorrhage, inadequate oxy-genation, or inadequate drainage.

Pneumonia may occur in the postoperative phase if pulmonary secretions are not removed. Coughing and deep breathing are en-couraged to aid in the removal of secretions. The patient should assume a sitting position, with the nurse supporting the neck so that the patient can bring up excessive secretions. If this is in-effective, the patient’s respiratory tract may have to be suctioned. Care is taken to protect the suture lines during suctioning. If a tra-cheostomy tube is in place, suctioning is performed through the tube. The patient may also be instructed on use of Yankauer suc-tion (tonsil tip suction) to remove oral secretions. Temperature should not be taken orally.

RELIEVING PAIN

Pain and the patient’s fear of pain are assessed and managed. Pa-tients with head and neck cancer often report less pain than patients with other types of cancer; however, the nurse needs to be aware that each person’s pain experience is individual. The nurse admin-isters analgesics as prescribed and assesses their effectiveness.

PROVIDING WOUND CARE

Wound drainage tubes are usually inserted during surgery to pre-vent the collection of fluid subcutaneously. The drainage tubes are connected to portable suction device (eg, Jackson-Pratt), and the container is emptied periodically. Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours. Excessive drainage may be indicative of a chyle fistula or hemor-rhage (see later discussion). If dressings are present, they may need to be reinforced from time to time. Dressings are observed for evidence of hemorrhage and constriction, which impairs res-piration and perfusion of the graft. The graft is assessed for color and temperature, and for the presence of a pulse if applicable, to determine viability. The graft should be pale pink and warm to the touch. The surgical incisions are also assessed for infection, which is reported immediately. Prophylactic antibiotics may be prescribed.

MAINTAINING ADEQUATE NUTRITION

Nutritional status is assessed preoperatively; early intervention to correct nutritional imbalances may decrease the risk of postopera-tive complications. Frequently, nutrition is less than optimal be-cause of inadequate intake, and the patient often requires enteral or parenteral supplements preoperatively to attain a positive nitro-gen balance. This therapy may need to be continued postopera-tively if the patient cannot take enough nutrients by mouth. Supplements (eg, Ensure, Sustacal) that are nutritionally dense may help reestablish a positive nitrogen balance. They may be taken en-terally by mouth, by nasogastric feeding tube, or by gastrostomy feeding tube. (See the Plan of Nursing Care for further discussion.)

The patient who is able to chew may take food by mouth; the level of the patient’s chewing ability will determine whether some diet modification (eg, soft, pureed, or liquid foods) is necessary. Food preferences should also be discussed with the patient. Oral care before eating may enhance the patient’s appetite, and oral care after eating is important to prevent infection and dental caries. Most patients are able to maintain and gain weight.

SUPPORTING COPING MEASURES

Preoperatively, information about the planned surgery is given to the patient and family. The psychological postoperative nursing intervention is aimed at supporting the patient who has had a change in body image or who has major concerns regarding the prognosis. The patient may have difficulty communicating and may be concerned about his or her ability to breathe and swallow normally. The nurse enlists the support of family or friends in en-couraging and reassuring the patient that adjusting to the results of this surgery will take time.

The person who has had extensive neck surgery often is sensi-tive about his or her appearance. This can occur when the oper-ative area is covered by bulky dressings, when the incision line is visible, or later after healing has occurred but the appearance of the neck and possibly the lower face has been significantly altered. If the nurse accepts the patient’s appearance and expresses a pos-itive, optimistic attitude, the patient is more likely to be encour-aged. The patient also needs an opportunity to express concerns regarding the success of the surgery and the prognosis. The Amer-ican Cancer Society may be a resource to provide a volunteer to meet with the patient either preoperatively or postoperatively.

People with cancer of the head and neck frequently have used alcohol or tobacco before surgery; postoperatively, the patient is encouraged to abstain from these substances. Alternative methods of coping need to be explored. A referral to Alcoholics Anonymous may be appropriate.

PROMOTING EFFECTIVE COMMUNICATION

If a laryngectomy was performed, the nurse explores other methods of communicating with the patient and obtains a con-sultation with a speech/language therapist. Alternatives to verbal communication may include use of a pencil and paper or point-ing to needed items on a picture pad. Alternative speech tech-niques, such as an electrolarynx (a mechanical device held against the neck) or esophageal speech, may be taught by a speech/language therapist.

MAINTAINING PHYSICAL MOBILITY

Excision of muscles and nerves results in weakness at the shoulder that can cause shoulder drop, a forward curvature of the shoulder. Many problems can be avoided with a conscientious exercise pro-gram. These exercises are usually begun after the drains have been removed and the neck incision is sufficiently healed. The purpose of the exercises depicted in Figure 35-5 is to promote maximal shoulder function and neck motion after surgery. Physical thera-pists and occupational therapists can assist patients in performing these exercises.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Hemorrhage

Hemorrhage may occur from carotid artery rupture as a result of necrosis of the graft or damage to the artery itself from tumor or infection. The following measures are indicated:

•        Vital signs are assessed. Tachycardia, tachypnea, and hy-potension may indicate hemorrhage and impending hypo-volemic shock.

•        The patient is instructed to avoid the Valsalva maneuver to prevent stress on the graft and carotid artery.

•         Signs of impending rupture, such as high epigastric pain or discomfort, are reported.

•        Dressings and wound drainage are observed for excessive bleeding.

•        If hemorrhage occurs, assistance is summoned immediately.

•        Hemorrhage requires the continuous application of pressure to the bleeding site or major associated vessel.

•        Although some advocate placing the patient in modified Trendelenburg position to maintain blood pressure, others recommend that the head of the patient’s bed be elevated to maintain airway patency and prevent aspiration.

•        A controlled, calm manner will allay the patient’s anxiety.

•        The surgeon is notified immediately, because a vascular or ligature tear requires surgical intervention.

Chyle Fistula

A chyle fistula (milk-like drainage from the thoracic duct into the thoracic cavity) may develop as a result of damage to the tho-racic duct during surgery. The diagnosis is made if there is ex-cess drainage which has a 3% fat content and a specific gravity of 1.012 or greater. Treatment of a small leak (500 mL or less) includes application of a pressure dressing and a diet of medium-chain fatty acids or parenteral nutrition. Surgical intervention to repair the damaged duct is necessary for larger leaks.

Nerve Injury

Nerve injury can occur if the cervical plexus or spinal accessory nerves are severed during surgery. Because lower facial paralysis may occur as a result of injury to the facial nerve, this complica-tion is observed for and reported. Likewise, if the superior laryn-geal nerve is damaged, the patient may have difficulty swallowing liquids and food because of the partial lack of sensation of the glottis. Speech therapy may be indicated to assist with the prob-lems related to nerve injury.

PROMOTING HOME AND COMMUNITY-BASED CARE 

Teaching Patients Self-Care

The patient and care provider will require instructions about management of the wound, the dressing, and any drains that re-main in place. Patients who require oral suctioning or who have a tracheostomy may be very anxious about their care at home; the transition to home can be eased if the care provider is given sev-eral opportunities to demonstrate the ability to meet the patient’s needs (Chart 35-3).

If the patient cannot take food by mouth, detailed instructions and demonstration of enteral or parenteral feedings will be required. Education in techniques of effective oral hygiene is also important.

Continuing Care

A referral for home care nursing may be necessary in the early pe-riod after discharge. The nurse will assess healing, ensure that feedings are being administered properly, and detect any compli-cations. The home care nurse assesses the patient’s adjustment to changes in physical appearance and status, ability to communi-cate, and ability to eat normally. Physical and speech therapy also may be continued at home.

The patient is given information regarding local support groups such as “I Can Cope” or “New Voice Club,” if indicated.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1)    Discusses expected course of treatment

2)    Demonstrates good respiratory exchange

                                                             i.      Lungs are clear to auscultation

                                                           ii.      Breathes easily with no shortness of breath

                                                        iii.      Demonstrates ability to use suction effectively

3)    Remains free of infection

                                                             i.      Maintains normal laboratory values

                                                           ii.      Is afebrile

4)    Graft is pink and warm to touch

5)    Maintains adequate intake of foods and fluids

                                                             i.      Accepts altered route of feeding

                                                           ii.      Is well hydrated

                                                        iii.      Maintains or gains weight

6)    Demonstrates ability to cope

a.     Discusses emotional responses to the diagnosis

b.     Attends support group meetings

7)    Verbalizes comfort

8)    Attains maximal mobility

                                                             i.      Adheres to physical therapy exercises

                                                           ii.      Attains maximal range of motion

The Plan of Nursing Care presents an overview of the care of a patient undergoing a neck dissection.