Nursing Care Plan Radical Neck Surgery : Laryngectomy (Postoperative Care)

CARE SETTING

Inpatient surgical and possibly subacute units.

RELATED CONCERNS

1. Cancer
2. Psychosocial aspects of care
3. Surgical intervention
4. Total nutritional support: parenteral/enteral feeding
5. Patient Assessment Database (Preoperative)
6. Preoperative data presented here depend on the specific type/location of cancer process and underlying complications.

EGO INTEGRITY

1. May report: Feelings of fear about loss of voice, dying, occurrence/recurrence of cancer
2. Concern about how surgery will affect family relationships, ability to work, and finances
3. May exhibit: Anxiety, depression, anger, and withdrawal
4. Denial

FOOD/FLUID

May report: 
Difficulty swallowing (dysphagia)

May exhibit: 

1. Difficulty handling oral secretions, chokes easily
2. Swelling, ulcerations, masses may be noted depending on location of cancer
3. Oral inflammation/drainage, poor dental hygiene
4. Leukoplakia, erythroplasia of oral cavity
5. Halitosis
6. Swelling of tongue
7. Altered gag reflex and facial paralysis

HYGIENE

May exhibit: 
Neglect of dental hygiene
Need for assistance in basic care

NEUROSENSORY

May report: 

1. Diplopia (double vision)
2. Deafness
3. Tingling, paresthesia of facial muscles

May exhibit: 

1. Hemiparalysis of face (parotid and submandibular involvement), persistent hoarseness or loss of voice (dominant and earliest symptom of intrinsic laryngeal cancer)
2. Difficulty swallowing
3. Conduction deafness
4. Disruption of mucous membranes

PAIN/DISCOMFORT

May report: 

1. Chronic sore throat, “lump in throat”
2. Referred pain to ear, facial pain (late stage, probably metastatic)
3. Pain/burning sensation with swallowing (especially with hot liquids or citrus juices), local pain in oropharynx
4. (Postoperative) Sore throat or mouth (pain is not usually reported as severe following head and neck surgery, as compared with pain noted before surgery)

May exhibit: 

1. Guarding behaviors
2. Restlessness
3. Facial mask of pain
4. Alteration in muscle tone

RESPIRATION

May report: 

1. History of smoking (including cigars)/chewing tobacco
2. Occupation working with hardwood sawdust, toxic chemicals/fumes, heavy metals
3. History of voice overuse, e.g., professional singer or auctioneer
4. History of chronic lung disease
5. Cough with/without sputum
6. Bloody nasal drainage

May exhibit: 

1. Blood-tinged sputum, hemoptysis
2. Dyspnea (late)

SAFETY

May report: 

1. Excessive sun exposure over a period of years or radiation therapy
2. Visual/hearing changes

May exhibit: 
Masses/enlarged nodes

SOCIAL INTERACTION

May report: 

1. Lack of family/support system (may be result of age group or behaviors, e.g., alcoholism)
2. Concerns about ability to communicate, engage in social interactions

May exhibit: 

1. Persistent hoarseness, change in voice pitch
2. Muffled/garbled speech, reluctance to speak
3. Hesitancy/reluctance of significant others to provide care/be involved in rehabilitation

TEACHING/LEARNING

May report: 

1. Nonhealing of oral lesions
2. Concurrent use of alcohol/history of alcohol abuse
3. Discharge plan
4. DRG projected mean length of inpatient stay: 5.0–13.0 days
5. Assistance with wound care, treatments, supplies; transportation, shopping; food
6. preparation; self-care, homemaker/maintenance tasks
7. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

1. Direct/indirect laryngoscopy; laryngeal tomography, biopsy, and needle biopsy: Are the most reliable diagnostic indicators for direct visualization or to detect local or regional spread/staging.
2. Laryngography: May be performed with contrast to study blood vessels and lymph nodes.
3. Pulmonary function studies, bone scans, or other organ scans: May be indicated if distant metastasis is suspected.
4. Chest x-ray: Done to establish baseline lung status and/or identify metastases.
5. CBC: May reveal anemia, which is a common problem.
6. Immunological surveys: May be done for patients receiving chemotherapy/immunotherapy.
7. Biochemical profile: Changes may occur in organ function as a result of cancer, metastasis, and therapies.
8. ABGs/pulse oximetry: May be done to establish baseline/monitor status of lungs (ventilation).

NURSING PRIORITIES

1. Maintain patent airway, adequate ventilation.
2. Assist patient in developing alternative communication methods.
3. Restore/maintain skin integrity.
4. Reestablish/maintain adequate nutrition.
5. Provide emotional support for acceptance of altered body image.
6. Provide information about disease process/prognosis and treatment.

DISCHARGE GOALS

1. Ventilation/oxygenation adequate for individual needs.
2. Communicating effectively.
3. Complications prevented/minimized.
4. Beginning to cope with change in body image.
5. Disease process/prognosis and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.