NCP Laryngectomy/Neck Dissection

Nursing Care Plan (NCP) for laryngectomy with a nursing diagnoses of ineffective airway clearance related to trachibronchial secretions or obstruction caused by increased and drying of secretions, inability to cough, aspiration of secretions, or tracheostomy/laryngectomy tube dislodgment or displacement. Ineffective breathing pattern related to decreased lung expansion caused by incisional pain. High risk for aspiration related to presence of tracheostomy, nasogastric tube resulting in the absence of normal protective mechanisms caused by laryngectomy and/or neck surgery.

Laryngectomy is the surgical removal of the larynx done to treat larynx malignancy. It may be partial, supraglottic, vertical, or total depending on extent of tumor and may or may not involve loss of violence and tracheostomy. Radial neck dissection may be done with supraglottic and total laryngectomy to remove cervical lymph nodes, muscle, and vessels on the tumor side. It is also done to treat oral malignancy and is usually accompanied by a tracheostomy.

Expected Outcome for this Nursing Care Plan (NCP): Adequate ventilation with airway/tracheostomy patency evidenced by respirations within normal baseline limits for rate, depth, and ease, effective removal of secretions by cough or suction and absence of aspiration.

Nursing Intervention and rationale:
I. Assess for:
  1. Respiratory rate, ease, and depth changes, decreased or diminished breath sounds, viscosity of secretions and amount, chest expansion symmetry. Changes indicate possible lung complications or obstruction of airways.
  2. . Type of tracheostomy tube, presence of laryngeotomy tube, tube placement, and patency. Tube may be cuffed or not cuffed, fenestrated speaking tube, and provides temporary airway that bypasses surgical areas.
II. Monitor, describe, record:
  1. Respiration date, depth, and ease, breath sounds every two to four hours. This indicates any change in status and possible adventitious sounds or decreased breath sounds indicating mucus accumulation or aspiration.
III. Perform/Provide:
  1. Positions of comfort, semi-Fowler's, sitting as tolerated; side-lying or in supine with head turned to one side. Facilitates chest expansion and drainage of secretions.
  2. Coughing and deep breathing through tracheostomy/laryngectomy tube every three hours; support head and neck when performing these exercises. Prevents accumulation of secretions by removing them.
  3. Suction mouth and nose and ostomy tube using sterile technique as often as needed; provide oxygen if needed between suction passes. Removes secretions in nose and mouth as may have difficulty blowing nose or swallowing.
  4. Instill 1-3 mL NS into tube and suction immediately. Done to remove thick, tenacious secretions.
  5. Air humidification or moist, thin gauze bandage over stoma. Liquefies secretions.
  6. Cleanse tube, inner cannula if present, with hydrogen peroxide and pipe cleners every 2 to 4 hours; change tube according to agency policy. Removes accumulated secretions and crusting that causes tube obstruction and narrowed airway.
  7. Tie tube in place securely with tapes using square knot; change when needed with same type and size tube. Maintains position of tube and prevents dislodgement.
  8. Have ventilator bag at bed-side. Provides ventilation in an emergency and during tube change.
  9. Suction oropharyngeal area before the deflation. Prevents aspiration of fluid or secretions that accumulate above cuff.
  10. Basin and tissues within reach. Provides for wiping away saliva and secretions.
IV. Teach patient/family:
  1. Avoid hard coughing, aerosols. powders, water in ostomy/stoma; cover with light shield when using shower or getting hair cut. Might cause tube dislodgement or mucosal irritation or suffocation.
  2. Care of tube, stoma, suctioning with use of mirror. Promotes self-care and independence.
  3. Humidification of air by shower in room, boiling water to provide steam; fluid intake of 2L/day. Assists to remove secretions that become thick and tenacious.
  4. Inform that will not be able to hold breath. Protective mechanism removed when tracheostomy performed.
  5. Wear emergency alert identification or card in wallet with information. Informs emergency personnel of presence of stoma.

0 comments:

Post a Comment

 
Copyright © 2012. HealthWise - Posts · Comments
Theme Template by BTDesigner · Powered by Blogger