What should the nurse include in discharge teaching for the patient with a total laryngectomy?

Vol. 8 •Issue 7 • Page 35
Caring for Laryngectomy Patients

Nội dung chính

• Which nursing action has the highest priority when caring for a patient with laryngeal trauma?
• What should the nurse include in discharge teaching for the patient with a total laryngectomy?
• Which of the following are the common complications of total laryngectomy?
• What should I expect after a laryngectomy?

For patients hospitalized with a co-morbidity, primary concern is often with care of the laryngectomy site

When patients with laryngectomies are hospitalized they have concerns for their care above and beyond the immediate reason for hospitalization. They need to feel comfortable that their airway needs are going to be competently handled. These patients have undergone a laryngectomy to treat advanced laryngeal cancer.

Airway & Breathing

Ensuring a stable airway with the tracheostomy is of primary importance. Administering oxygen and effective evacuation of mucous plugs are major concerns. Laryngectomy patients should not receive oxygen via a nasal cannula due to the surgical alteration in their respiratory anatomy. Normally, when air is inhaled through the nose, it is warmed and humidified prior to reaching the lungs. In these patients, this mechanism is no longer intact, since their upper and lower airways are no longer attached. Instead, humidified oxygen is administered via a tracheostomy collar. One or more drains may be present in the postoperative period.

The humidification is necessary to keep the mucus thin and easier to suction and helps to protect the stoma site from unnecessary dryness. The nurse must be cautious not to allow condensation collecting in the tracheostomy collar tubing from getting into the trachea site, as this could lead to infection.

Mucous plugs are another challenge. These occur primarily because of the underlying coexisting chronic obstructive pulmonary disease, such as emphysema, and inability to humidify the air. If the patient is able, allow him to cough. Suctioning may be traumatic to the airway and is frightening to the patient.

If the patient is not able to cough, suctioning via the stoma is necessary. A few drops of normal saline or ocean spray nose drops down the stoma may help to facilitate the removal of mucous plugs. When suctioning, remember to do so gently, and with the least amount of suction necessary, so as not to cause trauma to the stoma or trachea. After clearance by speech therapy to take thin liquids by mouth, encourage 6-8 glasses of fluids per day. This also will help keep the mucous membrane secretions thin.

Listen to the lungs frequently to assess for breath sound changes that may indicate pneumonia or pulmonary infections. Other preventive measures include frequent position changes, encouraging deep breathing and monitoring pulse oximetry.

Care of the Stoma

The stoma site (see photo) requires meticulous care to reduce infection and bleeding. It is important to identify how patients have been caring for the stoma at home if they had a tracheostomy placed prior to this procedure. If possible, allow patients to do their own care or collaboratively provide the care with the nurse.

Daily care involves ensuring that the stoma site is clean and the skin surrounding the site is free of infection. Gently wipe with warm water to remove any dried secretions followed by 1 percent hydrocortisone ointment to prevent irritation. Don’t use petroleum-based products, as they can be inhaled and lead to pneumonia.

To compensate for some of the lost function of the upper airway, a patient who has had a laryngectomy needs to wear a stoma covering or a heat moisture exchange adapter. Some patients prefer a 1-inch square foam patch or a gauze cloth dampened with witch hazel, an anti-inflammatory, antiseptic and astringent, to create moisture in the trachea. If the patient prefers, provide a mist bottle to moisten the gauze covering. A room humidifier also helps to keep the environmental relative humidity at 50 percent. The water in it needs to be changed daily to prevent pathogen growth.

Safety Issues

When the patient uses the call system to contact a nurse, it must be answered immediately by going to the room rather than requesting the patient to talk over the intercom. Personnel working on the floor should be made aware of this need; signs may be placed on the door if policy permits. Patients need hand call bells that they can constantly ring if no one answers the light.

Speech & Communication

Without a voice these patients may use esophageal speech, tracheoesophageal puncture (TEP), an electrolarynx,1 and/or writing or communication board to facilitate communication. Nurses caring for the patient should make it a priority to become familiar with the form of communication the patient is most comfortable using.

Esophageal speech forces air through the esophagus and causes vibrations to travel up through the mouth. This speech is sometimes harder to understand and is more difficult to learn (less than 2 percent of laryngectomy patients can master it). When using this type of speech the patient traps air in the esophagus and, as described by one patient, “burps the air forward to make a sound.” Laryngectomy patients who use esophageal speech report that this takes energy and is tiring.

TEP speech is similar to esophageal speech, but requires a commercially made device to redirect air from the trachea into the esophagus. The TEP is often performed at the time of the initial surgery but can be done later. With TEP, the stoma must be occluded either by a finger or with a commercial device such as tracheostoma valve, which acts as a one-way valve opening during inhalation and closing during exhalation. It is very important for nurses to know that in the case of an emergency dealing with the airway, this commercial device must be removed and the patient tracheally intubated.

The electrolarynx, a handheld, battery-operated device, produces electronic vibrations and amplifies the voice when placed over the throat or cheek. It creates a monotone sound from the patient’s vibrations. Because of its small size, care must be taken not to lose it in the linen cart or food tray. The electrolarynx should be labeled with the patient’s name, room number and home phone number.

Gastrointestinal Concerns

Gastrointestinal changes include alterations in eating and elimination2 due to the time it may take (up to 2 weeks) for the tissues in the throat to heal. During this time, patients often require nasogastric feedings as their primary source of nutrition. A speech therapist may be helpful when oral feedings are reinstituted to assess swallowing safety and function. If the swallow mechanism has not been fully reestablished, the patient is at risk for aspiration pneumonitis. Because saliva production may be permanently altered if the patient has had previous radiation therapy, keep a water bottle close.

Normal bowel habits may be altered during hospitalization due to analgesic medication and decreased mobility. It is important to identify the patient’s routine elimination patterns. Patients with a laryngectomy cannot bear down when they are having a bowel movement due to anatomical changes that would occlude the stoma; therefore, patients should have a high fiber diet to keep stools soft or use stool softeners if necessary.

Sleeping & Positioning

When sleeping, laryngectomy patients should have the head of the bed elevated 30 degrees to promote downward drainage of secretions and decrease the risk of aspiration, particularly if the patient has coexisting COPD. Because these patients also may have impaired mobility and range of motion in their neck, propping with extra pillows may be helpful to not occlude the stoma.

Assessing & Monitoring for Complications

Life-threatening complications include infection, carotid artery rupture and the need for CPR due to respiratory failure. Infections may lead to local cellulitis and swelling, further compromising breathing. The nurse must frequently assess the stoma and surrounding skin for increased redness, drainage and pain, and check vital signs and clinical status for signs of infection. WBC assessment can be helpful if infection is suspected.

Postoperative infections may include local infection at the stoma site, tracheitis or pneumonia. If an infection is suspected, a culture of the effluent must be obtained and the patient should be put on appropriate antibiotics as soon as possible. The most frequent stoma infections are Staphylococcus aureus followed by MRSA.3

Carotid artery rupture may result from forceful coughing or erosion from an infection. If this is suspected immediately apply just enough manual pressure being careful not to occlude the airway. In the case of internal airway bleeding, suction should be readily available to prevent large amounts of aspiration of blood and consequent respiratory collapse. A cuffed tracheostomy tube should be kept nearby to help put pressure on the bleeding area and provide a means of suctioning.

In either case, an otolaryngology surgeon should be called immediately to assess the patient and determine the need for emergent surgical repair. A large-bore intravenous line or a central line should be placed in preparation to administer blood transfusions.

If CPR is required the staff must be informed of the patient’s special needs based on the surgical procedure that was performed. For example, if the patient had a total laryngectomy and suffers a respiratory arrest, ventilation to the stoma is required. If the patient had a TEP to facilitate laryngeal speech, there is a fistula between the esophagus and the trachea. Rescue breathing in this case, requires the mouth and nose to be tightly sealed to prevent air from leaking out while ventilation is performed over the stoma.

Know Anatomy & Challenges

As a result of early diagnosis and successful surgical treatment, many laryngectomy patients are survivors. Nurses must be knowledgeable of the anatomy of the larynx, surgical treatment and unique challenges faced by these patients. For an article on these details, go to www.advanceweb.com/nurses.

When laryngectomy patients are hospitalized, they often feel frightened due to the current health situation, loss of control and inability to communicate. Likewise, healthcare providers may feel frightened due to the lack of knowledge on how to holistically care for these patients. Taking the time to get to know your patients may be helpful in easing some of the fear related to caring for them.

Nurse educators should be aware of a valuable resource with teaching students about patients who have undergone laryngectomy. Through local chapters of Nu-Voice Clubs or Lost Cord Clubs you can invite people living with laryngectomy to your classroom. Many patients graciously allow the students to assess their stoma and look down into their trachea. It is a useful way to offer students a hands-on experience and the opportunity to hear the challenges from the patient firsthand.

References

1. Vokes, E.E., & Stenson, K.M. (2003, November). Therapeutic options for laryngeal cancer. The New England Journal of Medicine, 349(22), 2087-2089.

2. Lennie, T.A., Christman, S.K., & Jadack, R.A. (2001, May). Educational needs and altered eating habits following a total laryngectomy. Oncology Nursing Forum, 28(4) 667-674.

3. Wild, D.C., Mehta, D., & Conboy, P.J. (2004, September). Bacterial colonization of laryngectomy stomas. Journal of Laryngology & Otology, 118(9), 710-712.

Lisa Ruth-Sahd is associate professor of nursing at York (PA) College of Pennsylvania and an ICU staff nurse at Lancaster (PA) General Hospital. Kim Miller has been a nurse for 17 years, mostly in cardiothoracic intensive care. Robert Hoover is a laryngectomy patient who speaks to nursing students about his experiences.