Laryngeal Cancer (Ch. 27 p. 519) 1. What information in the assessment suggests that M.R. is at risk for cancer of the larynx? Cancer of the larynx is strongly associated with prolonged use of tobacco and alcohol, which are both risk factors for M.R. 2. What are your priority teaching strategies for M.R. before and after laryngectomy? Preoperative teaching for M.R. should include i nclude information about the surgery and the expected changes in speech resulting from laryngectomy. Demonstrate other means of communicating that can be used temporarily or permanently following surgery. Explain that after surgery he will be placed in an upright position with a tube in his throat that he will breathe through. The presence of tubes and drains for wound management and gastrointestinal suctioning must be described to M.R. Explain that after the tube is removed, the opening, or stoma, will be his hi s permanent airway. Answer questions M.R. might have about breathing. Teach M.R. the importance of adequate nutrition for wound healing. Explain that enteral feeding is used preoperatively to help improve his nutritional status and will continue postoperatively until he is able to swallow and/or completes any planned radiation therapy. General preoperative teaching should also include incl ude deep breathing, coughing, and pain management. Postoperative teaching that should be planned includes an exercise program to maintain strength and mobility of the affected shoulder and neck, care for the laryngectomy stoma (including laryngectomy laryngectomy tube care and suctioning), and administration of tube feedings if he will be discharged with the gastrostomy tube in place. He should be encouraged to obtain a Medic Alert bracelet that identifies him as a neck breather in an emergency situation. 3. Discuss methods used to restore speech after laryngectomy. There are several methods for speech restoration. Transesophageal puncture, the most common voice rehabilitation method, offers the best speech quality with the highest patient satisfaction. A transesophageal puncture creates a surgical fistula or tract between the esophagus and trachea. The puncture may be created at the same time as the total laryngectomy surgery, or afterward if postoperative radiation is planned. A red rubber catheter is placed in the tracheoesophageal puncture as a stent. Several days later, the catheter is removed and a one-way valved prosthesis is placed in the tract. The prosthesis allows for one-way movement of air from the lungs to the esophagus. Speech is produced by manually blocking the stoma with the finger, causing air to move from the lungs, through the prosthesis, into the esophagus, and out the mouth. The air vibrates against the esophagus and is formed into words by moving the tongue and lips. Another method of voice restoration is the electrolarynx, a handheld, battery-powered device that creates speech with the use of sound waves. The two most common types of el ectrolarynx devices are classified as neck and intraoral. The neck type is placed against the neck, under the ch in, or on the cheek. The patient moves the lips to articulate sound that is conducted into the oropharynx. This option allows for speech immediately after surgery, is easy to learn, l earn, and requires little maintenance. Intraoral devices are used for patients who cannot achieve adequate sound conduction on the skin. The intraoral electrolarynx uses a plastic tube placed in the corner of the roof of the mouth to create vibrations. A hands-free device, using an electromyograph (EMG) transducer transducer in the strap muscles of the neck, is also available. With all devices, voice pitch is low and the sound is mechanical. Esophageal speech involves swallowing air, trapping it in the esophagus, and releasing it to create sound. The air causes vibration of the pharyngoesophageal segment and sound (which initially is similar to a belch). With practice, many patients develop some speech skills, but few develop fluent speech. 4. Is there anything in his history that may affect wound healing after surgery?
M.R.’s history of diabetes and smoking may affect wound healing after surgery. If M.R.’s weight loss is enough to cause a nutritional deficiency, this could also affect wound healing. 5. While in the recovery room, M.R. develops shortness of breath. What are your priority nursing interventions? M.R. is experiencing shortness of breath after surgery. Ensuring a patent airway is critical. First, you should assess for proper tube placement and for any tube obstruction. The HOB should be elevated 30 to 40 degrees. Assess M.R. for the need to be suctioned. Humidified oxygen should be administered. Monitoring M.R.’s color, respirations, and oxygen saturation and intervening as needed should also be nursing priorities. 6. What teaching is required to assist this patient to assume self-care after his surgery? What precautions should the patient take because of his stoma? Self-care requires that the patient learn to care for the laryngectomy stoma and, if necessary, administer tube feedings. Stoma care involves cleansing the skin around the stoma, removing and cleaning both the inner cannula and the entire laryngectomy tube if it is in place, and suctioning the laryngectomy tube if necessary. M.R. should be taught to use a bedside humidifier to keep secretions liquefied. Precautions that the patient should take with the stoma include covering the stoma before shaving or applying makeup to avoid inhalation of foreign materials, using scarves or clothing to shield the stoma, and using a plastic collar to prevent water from entering the sto ma while showering. Because the stoma is a direct route to the lungs, swimming is contraindicated. The patient should be taught to compensate for the loss of smell by using smoke alarms and attractively served food. 7. While on the medical surgical unit, M.R. is tearful and is staring toward the wall. What should you do? Discuss with M.R. that many of the physical changes are reversible as the edema subsides and the tracheostomy tube is removed. Encourage verbalization of feelings and expression of emotions. Convey acceptance to help the patient regain an acceptable self-concept. 8. Based on the assessment data presented, what are your priority nursing diagnoses? Are there any collaborative problems? Nursing diagnoses: anxiety, imbalanced nutrition: less than body requirements, impaired verbal communication, acute pain, impaired swallowing, risk for aspiration Collaborative problems: depression, obstructed airway 9. What role can unlicensed assistive personnel have in relationship to the tracheostomy? The UAP can provide oral care for the person with a tracheostomy and suction the oropharynx if properly trained. 10. How could you best meet M.R.’s communication needs during the first few postoperative days? Magic slate, alphabet boards, writing materials, pictorial guides, or hand signals are useful methods for communicating. However, programmable speech-generating devices allow for use of recorded messages that are matched with a graphic representing each message. Integration of this technology into patient care enhances the patient’s ability to communicate basic needs postoperatively.
