SENSORY/PERCEPTUAL FUNCTIONS

  1. Laryngectomy with radical neck dissection: removal of entire larynx, lymph nodes, submandibular salivary gland, sternomastoid muscle, spinal accessory nerves, and jugular vein for cancer of the larynx that extends beyond the vocal cords. Permanent tracheostomy; new methods of speech will have to be learned.

    Partial laryngectomy: removal of lesion on larynx. Patient will be able to speak after operation, but quality of voice may be altered.

    1. Assessment:
      1. Subjective data:
        1. Feeling of lump in throat.
        2. Pain: Adam’s apple; may radiate to ear.
        3. Dysphagia.
      2. Objective data:
        1. Hoarseness: persistent (longer than 2 weeks), progressive.
        2. Lymphadenopathy: cervical.
        3. Breath odor: foul.
    2. Analysis/nursing diagnosis:
      1. Impaired verbal communication related to removal of larynx.
      2. Body image disturbance related to radical neck dissection.
      3. Ineffective airway clearance related to copious amounts of mucus.
      4. Fear related to diagnosis of cancer.
      5. Impaired swallowing related to edema.
      6. Impaired social interaction related to altered speech.
    3. Nursing care pian/implementation:
      1. Preoperative care:
        1. Goal: provide emotional support and optimal physical preparation.
          1. Encourage verbalization of fears; answer all questions honestly, particularly about having no voice after surgery.
          2. Visit from person with laryngectomy (contact New Voice Club, Lost Chord, or International Association of Laryngectomees).
        2. Goal: health teaching.
          1. Prepare for tracheostomy.
          2. Other means to speak (esophageal “burp” speech, tracheoesophageal prosthesis or electronic artificial larynx).
      2. Postoperative care:
        1. Goal: maintain patent airway and prevent aspiration.
          1. Position: semi-Fowler’s (elevate 30-45 degrees), preventing forward flexion of neck to reduce edema and keep airway open.
          2. Observe for hypoxia:
            1. Early signs: increased respiratory and pulse rates, apprehension, restlessness.
            2. Late signs: dyspnea, cyanosis; swallowing difficulties-patient should chew food well and swallow with water.
          3. Laryngectomy tube care:
            1. Observe for stridor (coarse, high-pitched inspiratory sound)-report immediately.
            2. Have extra laryngectomy tube at bedside.
            3. Suction with sterile equipment; 2-3 mL of sterile saline into stoma may be used to loosen secretions.
        2. Goal: promote optimal physical and psychological function.
          1. Frequent mouth care.
          2. Wound: exposed site; note color and amount of drainage.
          3. Tubes: closed drainage system (Hemovac, fackson-Pratt);expect <100 up to 300 mL of serosanguineous drainage first postoperative day; drainage should decrease daily; observe patency.
          4. Post-drainage system removal-observe: skin flaps down, adherent to underlying tissue.
          5. Use surgical asepsis.
          6. Answer call bell immediately; use preestablished means of communication.
          7. Reexplain all procedures while giving care.
          8. Support head when lifting.
        3. Goal: health teaching.
          1. Speech rehabilitation as soon as esophageal suture is healed.
            1. Information on laryngeal speech (International Association of Laryngectomees, American Cancer Society, American Speech and Hearing Association).
            2. Esophageal speech best learned in speech clinic-learn to burp column of air needed for speech; new voice sounds are natural but hoarse.
          2. Stoma care:
            1. Cover with scarf or shirt made of a porous material (material substitutes for nasal passage-warms and filters out particles).
            2. Use source of humidification (“mister” or commercial humidifier).
            3. Caution while bathing or showering, to decrease likelihood of aspiration.
            4. Swimming not recommended.
            5. Procedure for suctioning if cough ineffective.
          3. Simple ROM of neck; how to support head.
          4. Possible contraindications: use of talcum powder, tissues.
    4. Evaluation/outcome criteria:
      1. No surgical complications (airway obstruction, infection, hemorrhage).
      2. Learns alternative speech 30-60 days after surgery.
      3. Demonstrates proper stoma care.
      4. Resumes productive lifestyle (work, family).
      5. Normal response to change in body image (anger, grief, denial).