MULTIDISCIPLINARY CARE

Rhinoplasty may be performed as a day procedure or may require an overnight stay in hospital. Improved techniques include the use of fibreoptic endoscopes, which can reduce hospitalisation time. Nasal tissue may be added or removed and the nose may be lengthened or shortened. Implants are sometimes used to reshape the nose. After surgery, nasal packing may be inserted to apply pressure and prevent bleeding or septal haematoma formation. Nasal septal splints (small pieces of plastic or Silastic) may be inserted to help prevent scar tissue formation between the surgical site and lateral nasal wall. An external plastic splint is moulded to fit the new shape of the nose and applied to support the nose. Adhesive surgical strips such as Steri-strips are placed to hold the skin against the septal cartilage. Typically, nasal packing is removed the day after surgery and the splint is removed in 3–5 days.

NURSING MANAGEMENT: NASAL SURGERY

Examples of nasal surgery include rhinoplasty, nasoseptoplasty and nasal fracture reduction. Before surgery, the patient should be instructed not to take aspirin-containing drugs or non-steroidal anti-inflammatory drugs (NSAIDs) for 2 weeks to reduce the risk of bleeding. Nursing interventions during the immediate postoperative period include assessment of respiratory status, pain management and observation of the surgical site for haemorrhage and oedema. Education is important because the patient must be able to detect early and late complications at home. Depending on the type and extent of surgery, patients may be advised not to blow their nose for a period. There is an interim period as the oedema and ecchymosis resolve before the final cosmetic effect can be achieved.

NURSING AND COLLABORATIVE MANAGEMENT: EPISTAXIS

Simple first aid measures should be used first to control epistaxis. The nurse should: (1) keep the patient quiet; (2) place the patient in a sitting position, leaning forwards or, if not possible, in a high reclining position so that the head and shoulders are elevated; (3) apply direct pressure by pinching the entire soft lower portion of the nose for 10–15 minutes; (4) apply ice compresses to the nose and have the patient suck on ice; (5) partially insert a small gauze pad into the bleeding nostril and apply digital pressure if bleeding continues; and (6) obtain medical assistance if bleeding does not stop.

If first aid is not effective, management involves localisation of the bleeding site and application of a vasoconstrictive agent, cauterisation or anterior packing by a healthcare provider. Vasoconstriction can be achieved using small cotton swabs soaked in 1:1000 adrenaline, oxymetazoline or 4% cocaine; these can be wrapped around the tips of a pair of forceps and applied to the bleeding point.⁵ Anterior packing usually consists of inserting a nasal tampon impregnated with a collagen haemostat and local anaesthetic agent that constricts the bleeding vessels and remains in place for 48–72 hours. The use of diathermy under local anaesthetic, in the emergency department, is becoming more widespread because, if successful, it avoids the complications associated with nasal packing (hypoxia, septicaemia and cardiac arrhythmias) and the cost of admission to hospital.⁶ Alternatively, inflatable balloons may be used as a nasal pack or gauze rolls may be inserted (see Fig 26-1). Strings attached to the packing are brought to the outside and taped to the cheek for ease of removal. A nasal sling (a folded 50 × 50 mm gauze pad) should be taped over the nostrils to absorb drainage.

Figure 26-1 Method for placing posterior nasal pack. A, The catheter is passed through the bleeding side of the nose and pulled out through the mouth with a haemostat. Strings are tied to the catheter and the pack is pulled up behind the soft palate and into the nasopharynx. B, Nasal pack in position in the posterior nasopharynx. A dental roll at the nose helps maintain correct position.

Nasal packing may alter respiratory status, especially in older adults. Some patients experience hypoventilation (decreasing respiratory rate which increases PaCO₂) and hypoxaemia (decrease in PaO₂) sufficient to lead to cardiac arrhythmias or respiratory arrest. The nurse should closely monitor respiratory rate, heart rate and rhythm, oxygen saturation (SpO₂) and level of consciousness, and observe for signs of bleeding and aspiration. Because of the risk of complications, the patient may be admitted to a monitored unit to permit closer observation.

Packing may be painful because sufficient pressure must be applied to stop the bleeding. Nasal packing predisposes to infection from bacteria normally resident in the nasal cavity (e.g. Staphylococcus aureus). The patient should receive analgesics for pain (e.g. paracetamol with codeine) and be considered for antibiotic prophylaxis. Nasal packing is left in place for a minimum of 3 days. Before removal, the patient should be medicated for pain. After removal, the nostrils may be gently cleaned and lubricated with water-soluble jelly.

Failure of posterior packing to control epistaxis indicates the need for surgery or radiological embolisation of the affected artery. The most common surgical procedure involves ligation of the internal maxillary artery performed through an incision under the upper lip to gain access to the artery.

The patient can be discharged after being taught about home care. The patient should be instructed to avoid vigorous nose blowing, strenuous activity, lifting and straining for 4–6 weeks. The patient should be taught to sneeze with the mouth open and to avoid the use of aspirin-containing products or NSAIDs.

CLINICAL MANIFESTATIONS

Manifestations of allergic rhinitis are nasal congestion; sneezing; watery, itchy eyes and nose; altered sense of smell and taste; and thin, watery nasal discharge. The nasal turbinates appear pale, boggy and swollen. The turbinates may fill the air space and press against the nasal septum. The posterior ends of the turbinates can become so enlarged that they obstruct sinus aeration or drainage and result in sinusitis.

With chronic exposure to allergens, the patient’s responses include headache, congestion, pressure, postnasal drip and nasal polyps. The patient may complain of cough, hoarseness or the recurrent need to clear the throat. Congestion may cause snoring.¹⁰

NURSING AND COLLABORATIVE MANAGEMENT: ALLERGIC RHINITIS

Since the range of severity is wide and many sufferers present with severe symptoms, resistance to treatment with usual pharmacotherapy, which includes antihistamines and topical nasal corticosteroids, may occur. For some individuals allergen injection immunotherapy is effective in reducing symptoms and medication requirements.¹¹ Several steps are used in managing allergic rhinitis. The most important step involves identifying and avoiding triggers of allergic reactions (see Box 26-1).

The patient should be instructed to keep a diary of times when the allergic reaction occurs and the activities that precipitate the reaction. Steps can then be taken to avoid these triggers.

The goal of medication therapy is to reduce inflammation associated with allergic rhinitis and reduce nasal symptoms so that the patient has no adverse effects and can sleep well at night to avoid daytime somnolence.¹² This involves the use of antihistamines, intranasal corticosteroids and leukotriene receptor antagonists (LTRA) to manage symptoms (see Table 26-1). Second-generation (non-sedating) antihistamines are preferred over first-generation antihistamines due to their selectivity and non-sedating effects.

Intranasal corticosteroid or sodium cromoglycate aerosols are effective for seasonal and perennial rhinitis. Nasal corticosteroid sprays are used to decrease inflammation locally with little absorption in the systemic circulation; therefore, systemic side effects are rare. Relief may require combining a nasal corticosteroid spray and an antihistamine. The patient should begin the intranasal corticosteroid 2–3 weeks prior to the allergy season, if possible. Patients using nasal inhalers need careful instruction about proper use (see Fig 26-2). Nasal decongestant sprays can cause a rebound effect from prolonged use.

Figure 26-2 Method for using an intranasal inhaler.

Omalizumab is a monoclonal antibody to IgE that is now in use for the treatment of allergic rhinitis.¹³ In New Zealand and Australia it is indicated as add-on therapy for adults who have severe allergic asthma. By binding to IgE antibodies, it prevents IgE from attaching to mast cells and thus prevents the release of mediators such as histamine. It blocks the allergic cascade for multiple allergens. (The mechanisms involved in the allergic response are discussed in Ch 13.)

Immunotherapy, which targets a specific antigen, may be used if drugs are not either tolerated or ineffective. Immunotherapy involves controlled exposure to small amounts of a known allergen through frequent (at least weekly) injections, with the goal of decreasing sensitivity.

NURSING AND COLLABORATIVE MANAGEMENT: ACUTE VIRAL RHINITIS

Rest, fluids, proper diet, antipyretics and analgesics are recommended. Complications of acute viral rhinitis include pharyngitis, sinusitis, otitis media, tonsillitis and lung infections. Unless symptoms of complications are present, antibiotic therapy is not indicated. Antibiotics have no effect on viruses and, if taken injudiciously, will produce antibiotic-resistant bacteria. If symptoms remain for at least 7 days with no improvement, acute bacterial sinusitis may be present and require treatment with antibiotics.

During the cold season, the patient with a chronic illness or a compromised immune status should be advised to avoid crowded situations and to consider having a flu vaccination. Frequent hand-washing and avoiding hand-to-face contact will help prevent direct spread.

Interventions are directed towards relieving symptoms. The patient should be encouraged to drink increased amounts of fluids to maintain an adequate level of hydration. Antihistamine or decongestant therapy reduces postnasal drip and significantly decreases the severity of cough, nasal obstruction and nasal discharge. The patient should also be taught to recognise the symptoms of secondary bacterial infection, such as a temperature higher than 38°C; purulent nasal exudate; tender, swollen glands; and a sore, red throat. In the patient with pulmonary disease, signs of infection include a change in consistency, colour or volume of the sputum. Because infection can progress rapidly, the patient with chronic respiratory disease may be taught to begin antibiotics for sputum changes, increased shortness of breath and chest tightness.

CLINICAL MANIFESTATIONS

The onset of flu is typically abrupt with systemic symptoms of cough, fever and myalgia often accompanied by a headache and sore throat. Milder symptoms, similar to those of the common cold, may also occur. Physical findings are usually minimal with normal assessment on chest auscultation. Dyspnoea and diffuse crackles are signs of pulmonary complications. In uncomplicated cases, symptoms subside within 7 days. Some patients, particularly older adults, experience weakness or lassitude that persists for weeks. The convalescent phase may be marked by a hyperactive airway and a chronic cough. Important diagnostic factors include the patient’s health history, clinical findings and the presence of other cases of influenza in the community.

The most common complication of influenza is pneumonia. Patients who develop secondary bacterial pneumonia experience gradual improvement of influenza symptoms, then worsening cough and purulent sputum. Treatment with antibiotics is usually effective if started early.

NURSING AND COLLABORATIVE MANAGEMENT: INFLUENZA

The nurse should advocate influenza vaccination in high-risk patients during routine surgery visits or, if hospitalised, at the time of discharge (see Box 26-2). The vaccine is 70–90% effective in preventing influenza in adults. To be effective, the vaccine must be given in the autumn before exposure occurs. In Australia and New Zealand, routine vaccination is recommended for older persons and those with chronic disease.^17,18 High priority is also given to groups such as healthcare workers who can transmit influenza to high-risk persons. By being vaccinated, healthcare workers can decrease the risk of transmitting influenza to those who have less ability to cope with the effects of this illness. Despite obvious benefits, many people are reluctant to be vaccinated and concerns should be dispelled. Current vaccines are highly purified and reactions are extremely uncommon. Soreness at the injection site is usually the only side effect. The contraindications are a history of Guillain-Barré syndrome and hypersensitivity to eggs because some vaccines are taken from an influenza virus that has been grown in embryonic hens eggs.

The primary goals in management are supportive measures directed towards relief of symptoms and prevention of secondary infection. Unless at high risk or complications develop, the patient with influenza usually requires only symptomatic therapy. Older adults and those with a chronic illness may require hospitalisation. Antivirals can be prescribed for chemoprophylaxis if an influenza outbreak or pandemic occurs. Zanamivir and oseltamivir may be effective against both influenza A and B. These drugs are neuraminidase inhibitors that may prevent the virus from spreading to other cells. For maximum benefit, they should be initiated as soon as possible and ideally within 2 days of the onset of symptoms. They may shorten the course of influenza. Zanamivir is administered using an inhaler. Oseltamivir phosphate is available as an oral capsule. There is some debate regarding the use of both zanamavir and oseltamavir for the reduction of both the symptom duration and severity of influenza.

CLINICAL MANIFESTATIONS

Acute sinusitis causes significant pain over the affected sinus, purulent nasal drainage, nasal obstruction, congestion, fever and malaise. The patient looks and feels sick. Assessment involves inspection of the nasal mucosa and palpation of the sinus points for pain. Findings that indicate acute sinusitis include a hyperaemic and oedematous mucosa, enlarged turbinates and tenderness over the involved sinuses. The patient may have recurrent headaches that change in intensity with position changes or when secretions drain.

Chronic sinusitis is difficult to diagnose because symptoms may be non-specific. The patient is rarely febrile. Although there may be facial pain, nasal congestion and increased drainage, severe pain and purulent drainage are often absent. Symptoms may mimic those seen with allergies. X-rays of the sinuses or a sinus computed tomography (CT) scan may be performed to confirm the diagnosis. CT scans may show the sinuses to be filled with fluid or the mucous membrane to be thickened. Nasal endoscopy with a flexible scope may be used to examine the sinuses, obtain drainage for culture and restore normal drainage.

Many patients with asthma have sinusitis. The link between these diseases is unclear. Sinusitis may trigger asthma by stimulating reflex bronchospasm. Appropriate treatment of sinusitis often causes a reduction in asthma symptoms.²⁰

NURSING AND COLLABORATIVE MANAGEMENT: SINUSITIS

If allergies are the precipitating cause of sinusitis, the patient needs to be instructed (see Box 26-3) in ways to reduce sinus inflammation and infection, including environmental control of allergies and appropriate drug therapy (see p 599).

Treatment of acute sinusitis includes antibiotics to treat the infection if it persists longer than 7 days without treatment. Antibiotic therapy, consisting of amoxycillin as the first-line drug of choice, is continued for 10–14 days to prevent the formation of antibiotic-resistant organisms. If symptoms do not resolve, the antibiotic should be changed to a broader-spectrum agent such as sulfamethoxazole, trimethoprim or erythromycin. With chronic sinusitis, mixed bacterial flora are often present and infections are difficult to eliminate. Broad-spectrum antibiotics may be used for 4–6 weeks. The use of the following ancillary medications can also relieve symptoms: oral or topical decongestants to promote drainage, nasal corticosteroids to decrease inflammation and antihistamines (see Box 26-3). Patients using topical decongestants must be instructed to use the medication for no longer than 3 days to prevent rebound congestion due to vasodilatation. Classic (first-generation) antihistamines increase the viscosity of mucus and promote continued symptoms, so they should be avoided. Non-sedating (second-generation) antihistamines do not cause this problem, but research does not support their use with infectious sinusitis.²¹

The patient should be encouraged to increase fluid intake (6–8 glasses daily) and use nasal cleaning techniques. This may include taking a hot shower in the morning and evening followed by blowing the nose thoroughly. Another intervention to cleanse the nasal passages and promote drainage is steam inhalations.

The patient with persistent or recurrent sinus complaints that are not alleviated by medical therapy may require nasal endoscopic surgery to relieve blockage caused by hypertrophy or septal deviation. This is an outpatient procedure usually performed under local anaesthesia.

CLINICAL MANIFESTATIONS

Symptoms of acute pharyngitis range in severity from complaints of a ‘scratchy throat’ to pain so severe that swallowing is difficult. Both viral and strep infections appear as a red and oedematous pharynx, with or without patchy yellow exudates. Appearance is not always typical. Cultures or a rapid strep antigen test is done to establish the cause and direct appropriate management. Inadequate treatment of acute streptococcal pharyngitis can result in rheumatic heart disease or glomerulonephritis as a sequel to the infection.

White, irregular patches suggest fungal infection with Candida albicans. In diphtheria, a grey–white false membrane, termed a pseudomembrane, is seen covering the oropharynx, nasopharynx and laryngopharynx and sometimes extends to the trachea.

NURSING AND COLLABORATIVE MANAGEMENT: ACUTE PHARYNGITIS

The goals of nursing management are infection control, symptom relief and prevention of secondary complications. The patient with proven strep throat is treated with antibiotics. Candida infections are treated with nystatin, an antifungal agent. The preparation should be swished in the mouth as long as possible before it is swallowed and treatment should continue until symptoms are gone. The patient should be encouraged to increase fluid intake. Cool, bland liquids and jelly will not irritate the pharynx; citrus juices can be irritating.

CLINICAL MANIFESTATIONS AND DIAGNOSTIC STUDIES

Clinical manifestations of sleep apnoea include frequent awakening at night, insomnia, excessive daytime sleepiness and witnessed apnoeic episodes. The patient’s bed partner may complain about the patient’s loud snoring. The snoring may be so disruptive that both partners cannot sleep in the same room. Other symptoms include morning headaches (from hypercapnia, which causes vasodilation of cerebral blood vessels), personality changes and irritability. Complications that can result from untreated sleep apnoea include hypertension, right heart failure from pulmonary hypertension caused by chronic nocturnal hypoxaemia and cardiac dysrhythmias. Symptoms of sleep apnoea alter many aspects of the patient’s lifestyle. Chronic sleep loss predisposes to diminished ability to concentrate, impaired memory, failure to accomplish daily tasks and interpersonal difficulties. Driving accidents are more common in habitually sleepy persons.²⁹ Family life and the patient’s ability to maintain employment are often compromised. As a result, the patient may experience severe depression. Appropriate referral should be made if problems are identified. Cessation of breathing reported by the bed partner is usually a source of great anxiety because of the fear that breathing may not resume.

Diagnosis of sleep apnoea is made by polysomnography. The patient’s chest and abdominal movement, oral airflow, nasal airflow, SpO₂, ocular movement and heart rate and rhythm are monitored. Progression through each sleep stage is determined by monitoring brain waves through electroencephalography (EEG). A diagnosis of sleep apnoea requires documentation of apnoeic events (no airflow with respiratory effort) or hypopnoea (airflow diminished 30–50% with respiratory effort). Generally, more than 10 events an hour with oxygen desaturation below 90% is considered a positive test for OSA. Typically, polysomnography is carried out in a sleep laboratory with sleep technicians monitoring the patient. In some instances, portable sleep studies are conducted in the home setting. Overnight pulse oximetry assessment may be an alternative to determine whether nocturnal oxygen supplementation is indicated.

NURSING AND COLLABORATIVE MANAGEMENT: SLEEP APNOEA

Patients with OSA are treated according to the severity of their symptoms.²⁴ Mild sleep apnoea may respond to simple measures. The patient should be instructed to avoid sedatives and alcoholic drinks for 3–4 hours before sleep. Referral to a weight loss program may help because excessive weight exacerbates symptoms. Symptoms resolve in half of the patients with OSA who use an oral appliance during sleep to prevent airflow obstruction. Oral appliances bring the mandible and tongue forwards to enlarge the airway space, thereby preventing airway occlusion. Some individuals find a support group beneficial, where concerns and feelings can be expressed and strategies discussed for resolving problems.

For patients with more severe symptoms, nasal continuous positive airway pressure (nCPAP) may be used.³⁰ With nCPAP, the patient applies a nasal mask that is attached to a high-flow blower. The blower is adjusted to maintain sufficient positive pressure (5–15 cm H₂O) in the airway during inspiration and expiration to prevent airway collapse. Some patients cannot adjust to exhaling against the high pressure and although nCPAP is highly effective, compliance is poor, even if symptoms of sleep apnoea are relieved.^1,30 Factors that can influence compliance include ongoing education and follow-up care.

A technologically more sophisticated therapy, bi-level positive airway pressure (BiPAP), which is capable of delivering a higher pressure during inspiration (when the airway is most likely to be occluded) and a lower pressure during expiration (when the airway is least likely to be occluded), may be helpful and is better tolerated; however, this should be reserved for patients with respiratory failure (see Fig 26-5). Intra-oral devices are appropriate for mild OSA cases or those who cannot tolerate nCPAP; however, their use must be carefully monitored. Drug therapy is contraindicated as a first-line therapy.

Figure 26-5 Management of sleep apnoea often involves sleeping with a nasal mask in place. The pressure supplied by air coming from the compressor opens the oropharynx and nasopharynx. A REMstar Pro with heater humidifier is shown.

Source: Courtesy of Respironics, Inc. and its affiliates.

If other measures fail, sleep apnoea may be managed surgically. The two most common surgical procedures are uvulopalatopharyngoplasty (UPPP or UP3) and genioglossal advancement and hyoid myotomy (GAHM). UPPP involves excision of the tonsillar pillars, uvula and posterior soft palate with the goal of removing the obstructing tissue. GAHM involves advancing the attachment of the muscular part of the tongue on the mandible. Laser-assisted uvulopalatoplasty (LAUP) is a surgical procedure than has also been used to treat OSA. Evidence today, however, questions the effectiveness of this type of surgery for people with OSA.³¹ The patient with enlarged tonsils should be referred to an ear, nose and throat surgeon for surgical consideration. Patients with OSA have increased anaesthetic risk.

NURSING MANAGEMENT: TRACHEOSTOMY

Providing tracheostomy care

Before the tracheotomy procedure, the purpose of the procedure should be explained to the patient and family. The nurse should also advise that the patient may not be able to speak, depending on the type of tube used.

A variety of tubes is available to meet individual patient needs (see Table 26-2). All tracheostomy tubes contain a face-plate or flange, which rests on the neck between the clavicles and outer cannula. In addition, all tubes have an obturator, which is used when inserting the tube (see Fig 26-6, C). During insertion of the tube, the obturator is placed inside the outer cannula with its rounded tip protruding from the end of the tube to ease insertion. After insertion, the obturator must be removed immediately so that air can flow through the tube. The obturator should be kept in an easily accessible place at the bedside (e.g. taped to the wall) so that it can be used quickly in case of accidental decannulation.³⁵ Some tracheostomy tubes have an inner cannula, which can be removed for cleaning (see Fig 26-6, B). The cleaning procedure removes mucus from the inside of the tube. If humidification is adequate, mucus may not accumulate and a tube without an inner cannula can be used.

TABLE 26-2 Characteristics and nursing management of tracheostomies

Care of the patient with a tracheostomy involves suctioning the airway to remove secretions³⁵ (see Fig 26-7 and Box 26-4) and cleaning around the stoma. The frequency of suctioning is as determined by direct observation and chest auscultation. In addition, tracheostomy care includes changing tracheostomy ties (see Fig 26-8 and Box 26-5). A two-person technique, one to stabilise the tracheostomy and one to change the ties, is optimal to ensure that the tracheostomy does not become accidentally dislodged during the procedure. If a disposable or non-disposable inner cannula is used, tracheostomy care also involves inner cannula care (see Box 26-5).³⁶

Figure 26-7 Suctioning a tracheostomy. Using aseptic technique, the suction catheter is being withdrawn from the airway while suction is applied. The pilot balloon tubing can be seen lying on the patient’s chest.

BOX 26-4 Procedure for suctioning a tracheostomy tube

1. Assess the need for suctioning 2 hourly. Indications include coarse crackles or rhonchi over large airways, moist cough, an increase in peak inspiratory pressure on mechanical ventilator and restlessness or agitation if accompanied by a decrease in SpO₂ or PaO₂. Do not suction routinely or if the patient is able to clear secretions with cough.

2. If suctioning is indicated, explain the procedure to the patient.

3. Collect the necessary sterile equipment: suction catheter (no larger than half the lumen of the tracheostomy tube), gloves, water, cup and drape. If a closed tracheal suction system is used, the catheter is enclosed in a plastic sleeve and reused. No additional equipment is needed.

4. Check suction source and regulator. Adjust suction pressure until the dial reads –16 to –20 kPa (−120 to –150 mmHg) pressure with tubing occluded.

5. Assess SpO₂, heart rate and rhythm to provide baseline for detecting change during suctioning.

6. Wash hands. Put on goggles and gloves.

7. Use sterile technique to open package, fill cup with water, put on gloves and connect catheter to suction. Designate one hand as contaminated for disconnecting, bagging and operating the suction control. Suction water through the catheter to test the system.

8. Provide preoxygenation by: (1) adjusting the ventilator to deliver 100% O₂; (2) using a reservoir-equipped manual resuscitation bag (MRB) connected to 100% O₂; or (3) asking the patient to take 3–4 deep breaths while administering O₂. The method chosen will depend on the patient’s underlying disease and acuity of illness. The patient who has had a tracheostomy for an extended period of time and is not acutely ill may be able to tolerate suctioning without use of an MRB or the ventilator.

9. Gently insert the catheter without suction to minimise the amount of oxygen removed from the lungs. Insert the catheter the length of the artificial airway. Stop if an obstruction is met.

10. Apply suction intermittently, while withdrawing the catheter in a rotating manner. If secretion volume is large, apply suction continuously.

11. Limit suction time to 10 seconds. Discontinue suctioning if heart rate decreases from baseline by 20 beats/min, increases from baseline by 40 beats/min, an arrhythmia occurs or SpO₂ decreases to less than 90%.

12. After each suction pass, assess for preoxygenation with 3–4 breaths by ventilator, MRB or deep breaths with oxygen.

13. Rinse the catheter with sterile water (if in suction kit).

14. Repeat the procedure with a new catheter until the airway is clear. Limit insertions of suction catheter to as few as needed.

15. Return the oxygen concentration to the prior setting.

16. Rinse the catheter and suction the oropharynx or use mouth suction.

17. Dispose of the catheter by wrapping it around the fingers of a gloved hand and pulling the glove over the catheter. Discard equipment in a proper waste container.

18. Auscultate to assess changes in lung sounds. Record time, amount and character of secretions and response to suctioning.

Figure 26-8 Changing tracheostomy ties. A, A slit is cut about 2.5 cm from the end. The slit end is put into the opening of the cannula. B, A loop is made with the other end of the tape. C, The tapes are tied together with a double knot on the side of the neck.

BOX 26-5 Tracheostomy care

1. Explain the procedure to the patient.

2. Use tracheostomy care kit or collect necessary sterile equipment (e.g. suction catheter, gloves, water, basin, drape, tracheostomy ties, tube brush or pipe cleaners, gauze swabs, sterile water, sodium bicarbonate solution and tracheostomy dressing). Note: Clean rather than sterile technique is used at home.

3. Position the patient in semi-Fowler’s position.

4. Assemble the needed materials on the bedside table next to the patient.

5. Wash hands. Put on goggles and clean gloves.

6. Auscultate chest sounds. If rhonchi or coarse crackles are present, suction the patient if unable to cough up secretions (see Box 26-4). Remove soiled dressing and clean gloves.

7. Open sterile equipment, pour sterile water and hydrogen peroxide in basins and put on sterile gloves.

8. Unlock and remove inner cannula, if present. Many tracheostomy tubes do not have inner cannulae. Care for these tubes includes all steps except for inner cannula care.

9. If a disposable inner cannula is used, replace with a new cannula. If a non-disposable cannula is used:

a. Immerse the inner cannula in the sodium bicarbonate solution and clean the inside and outside of the cannula using a tube brush or pipe cleaners.

b. Drain the sodium bicarbonate solution from the cannula. Immerse the cannula in sterile water. Remove from sterile water and shake to dry.

c. Insert the inner cannula into the outer cannula with the curved part downwards and lock in place.

10. Remove dried secretions from stoma using gauze soaked in sodium bicarbonate solution. Rinse with another gauze swab soaked in sterile water. Gently pat the area around the stoma dry. Be sure to clean under the tracheostomy face-plate, using cotton swabs to reach this area.

11. Maintain the position of the tracheal retention sutures, if present, by taping above and below the stoma.

12. Change the tracheostomy ties. Use the two-person change technique or secure new ties to flanges before removing the old ones. Tie the tracheostomy ties securely with room for one finger between the ties and skin (see Fig 26-8). To prevent accidental tube removal, secure the tracheostomy tube by gently applying pressure to the flange of the tube during the tie changes. Do not change tracheostomy ties for 24 h after the tracheotomy procedure.

13. As an alternative, some patients prefer tracheostomy ties made of Velcro, which are easier to adjust.

14. If drainage is excessive, place dressing around the tube (see Fig 26-8). A tracheostomy dressing or unlined gauze should be used. Do not cut the gauze because threads may be inhaled or may wrap around the tracheostomy tube. Change the dressing frequently. Wet dressings promote infection and stoma irritation.

15. Repeat care three times a day and as needed.

Both cuffed and uncuffed tracheostomy tubes are available. A tracheostomy tube with an inflated cuff is used if the patient is at risk of aspiration or needs mechanical ventilation. An inflated cuff exerts pressure on tracheal mucosa; it is therefore important to inflate the cuff with the minimum volume of air required to obtain an airway seal. Cuff inflation pressure should not exceed 2.6 kPa (20 mmHg or 25 cm H₂O) because higher pressures will compress tracheal capillaries, limiting blood flow and predisposing tracheal necrosis. Cuff pressure measurement devices are manufactured to facilitate pressure checking. An alternative approach, termed the minimal leak technique (MLT), involves inflating the cuff with the minimum amount of air to obtain a seal and then withdrawing 0.1 mL of air. A disadvantage of MLT is the risk of aspiration from secretions leaking around the cuff. MLT should not be used when the tracheostomy was inserted to bypass an upper airway obstruction—for example, in head and neck surgical patients. Some tracheostomy tubes have cuff pressure release valves to minimise the risk of overinflation.

In some patients, cuff deflation may be performed to remove secretions that accumulate above the cuff. Before deflation, the patient should cough up secretions if possible, and the tracheostomy tube and mouth should then be suctioned (see Fig 26-7 and Box 26-4). This prevents secretions from being aspirated during deflation. In addition, the cuff should be deflated during exhalation because the exhaled gas helps propel secretions into the mouth. The patient should cough or be suctioned after cuff deflation. The cuff should be reinflated during inspiration. The volume of air required to inflate the cuff should be monitored daily because this volume may increase if there is tracheal dilation from cuff pressure. The nurse should assess the patient’s ability to protect the airway from aspiration and remain with the patient when the cuff is initially deflated. When the patient can protect their airway from aspiration and does not require mechanical ventilation, an uncuffed tracheostomy tube should be used.

Retention sutures may be placed in the tracheal cartilage when the tracheostomy is performed. The free ends should be taped to the skin in a place and manner that leaves them accessible if the tube is dislodged. Care should be taken not to dislodge the tracheostomy tube during the first few days when the stoma is not mature (healed). Because tube replacement can be difficult, several precautions are required: (1) a replacement tube of equal or smaller size should be kept at the bedside, readily available for emergency reinsertion; (2) tracheostomy tapes should not be changed for at least 24 hours after the insertion procedure; and (3) the first tube change should be performed, usually by a doctor, no sooner than 5–7 days after the tracheostomy.

If the tube is accidentally dislodged, the nurse should immediately attempt to replace it. The retention sutures (if present) are grasped and the opening is spread. A curved haemostat can also be used to spread the opening to facilitate replacing the tube. The obturator is inserted in the replacement tube, lubricated with saline poured over the tip and the tube is inserted in the stoma at a 45° angle to the neck. If insertion is successful, the obturator is removed immediately so that air can flow through the tube. If the tube cannot be replaced, assess the level of respiratory distress. Minor dyspnoea may be alleviated by placing the patient in a semi-Fowler’s position (supine with the head of the bed raised to approximately 30°) and administering oxygen until assistance arrives. Severe dyspnoea may progress to respiratory arrest. If this situation occurs, the stoma should be covered with a sterile dressing and the patient should be ventilated with bag-mask ventilation until help arrives, unless the patient has experienced a total laryngectomy and has complete separation between the upper airway and the trachea.

Initially, tracheostomy patients should receive humidified air to compensate for the loss of the upper airway to warm and moisturise secretions. After the first tube change, the frequency of tube change depends on the type of tube inserted. Tubes with removable inner tubes should be changed approximately once a month, although the inner tube should be cleaned at least 2–3 times each day to prevent obstruction. When a tracheostomy has been in place for several months, the healed tract will be well formed. The patient can then be taught to change the tube using a clean technique at home (see Fig 26-9). Teaching will vary, depending on the patient’s illness and the device selected.

Figure 26-9 Changing the tracheostomy tube at home. When a tracheostomy has been in place for several months, the tract will be well formed. The patient can then be taught to change the tube using a clean technique at home.

Nursing diagnoses for the patient with a tracheostomy include, but are not limited to, those presented in NCP 26-1.

NURSING CARE PLAN 26-1 The patient with a tracheostomy

Speech with a tracheostomy tube

A number of techniques enable speech in the patient with a tracheostomy. The spontaneously breathing patient may be able to talk by deflating the cuff, which allows exhaled air to flow upwards over the vocal cords. This can be enhanced by the patient occluding the tube. Frequently, a small uncuffed tube is inserted so that exhaled air can pass freely around the tube. If the patient is on mechanical ventilation, speech may be possible by allowing a constant air leak around the cuff. In addition, some tracheostomy tubes and valves have been designed to facilitate speech. The nurse can be an advocate in promoting use of these specialised devices. Their use can provide great psychological benefit and facilitate self-care for the patient with a tracheostomy.

A fenestrated tube has openings on the surface of the outer cannula that permit air from the lungs to flow over the vocal cords (see Fig 26-6, B and Fig 26-10, A). A fenestrated tube allows the patient to breathe spontaneously through the larynx, speak and cough up secretions while the tracheostomy tube remains in place. It can be used by the patient who can swallow without risk of aspiration but requires suctioning for secretion removal. It may also be used by the patient who requires mechanical ventilation for fewer than 24 hours a day (e.g. during sleep).

Figure 26-10 Speaking tracheostomy tubes. A, Fenestrated tracheostomy tube with cuff deflated, inner cannula removed and tracheostomy tube capped to allow air to pass over the vocal cords. B, Speaking tracheostomy tube. One tubing is used for cuff inflation. The second tubing is connected to a source of compressed air or oxygen. When the port on the second tubing is occluded, air flows up over the vocal cords, allowing speech with an inflated cuff. (See Table 26-2 and NCP 26-1 for related nursing management.)

Before the fenestrated tube is used, the patient’s ability to swallow without aspiration is determined (see Table 26-2 and NCP 26-1). If there is no aspiration: (1) the inner cannula is removed; (2) the cuff is deflated; and (3) the decannulation cap is placed in the tube (see Fig 26-10, A). It is important to perform the steps in order because severe respiratory distress may result if the tube is capped before the inner cannula is removed and the cuff deflated. When a fenestrated cannula is first used, the nurse should frequently assess the patient for signs of respiratory distress. If the patient is not able to tolerate the procedure, the cap should be removed, the inner cannula replaced and the cuff reinflated. A disadvantage of fenestrated tubes is the potential for development of tracheal polyps from tracheal tissue granulating into the fenestrated openings.³⁶

A speaking tracheostomy tube has two pigtail tubings. One tubing connects to the cuff and is used for cuff inflation and the second connects to an opening just above the cuff (see Fig 26-10, B). When the second tubing is connected to a low-flow (4–6 L/min) air source, sufficient air moves up over the vocal cords to permit speech. The patient can then speak, although the cuff is inflated.

When a speaking tracheostomy valve is used, an uncuffed tube must be in place or the cuff deflated to allow exhalation (see Fig 26-11). Ability to tolerate cuff deflation without aspiration or respiratory distress must be evaluated in patients using this device. If there is no aspiration, the cuff is deflated and the valve is placed over the tracheostomy tube opening. The speaking valve contains a thin plastic diaphragm that opens on inspiration and closes on expiration. During inspiration, air flows in through the valve. During expiration, the diaphragm prevents exhalation and air flows upwards over the vocal cords and into the mouth.

Figure 26-11 Passy-Muir speaking tracheostomy valve. The valve is placed over the hub of the tracheostomy tube after the cuff is deflated. Two options are available: a white valve for non-ventilated patients and an aqua valve (shown) for ventilated patients. The valve contains a one-way valve that allows air to enter the lungs during inspiration and redirects air upwards over the vocal cords into the mouth during expiration.

If speaking devices are not used, the patient should be provided with paper and pencil or a magic slate. A word (communication) board can usually be obtained from speech therapy or one can be devised with pictures of common needs and an alphabet for spelling words.

CLINICAL MANIFESTATIONS

Early signs and symptoms of head and neck cancer vary with the tumour location. Cancer of the oral cavity may be a painless growth in the mouth, an ulcer that does not heal or a change in fit of dentures. Pain is a late symptom that may be aggravated by acidic food. Cancers of the oropharynx, hypopharynx and supraglottic larynx rarely produce early symptoms and are usually diagnosed in late stages.³⁹ The patient may complain of persistent unilateral sore throat or otalgia (ear pain). Hoarseness may be a symptom of early laryngeal cancer. If a lump in the neck or hoarseness lasts longer than 2 weeks, a medical evaluation is indicated. Some patients experience what feels like a lump in the throat or a change in voice quality.

Late stages of head and neck cancers have easily detectable signs and symptoms, including pain, dysphasia and decreased mobility of the tongue, airway obstruction and cranial nerve neuropathies. The nurse should thoroughly examine the oral cavity, including the area under the tongue and dentures. The floor of the mouth, tongue and lymph nodes in the neck should be bimanually palpated. There may be thickening of the normally soft and pliable oral mucosa. Leucoplakia (white patch) or erythroplakia (red patch) may be seen and should be noted for later biopsy. Both leucoplakia and carcinoma in situ (localised to a defined area) may precede invasive carcinoma by many years.

DIAGNOSTIC STUDIES

If lesions are suspected, the upper airway may be examined using indirect laryngoscopy, which involves using a laryngeal mirror to visualise the laryngeal area, or a flexible nasopharyngoscope may be used. The larynx and vocal cords are visually inspected for lesions and tissue mobility. A CT scan or magnetic resonance imaging (MRI) may be performed to detect local and regional spread. Neoplastic tissue is identifiable because it contains tissue of greater density or because it distorts, displaces or destroys normal anatomical structures. The use of positron emission tomography (PET) scan along with CT has been successful in diagnosing recurring cases of head and neck cancer.⁴⁰ Typically, multiple biopsy specimens are obtained for cytological examination to determine the extent of the disease.

MULTIDISCIPLINARY CARE

The stage of the disease and its management will be determined based on the tumour size (T), the number and location of involved nodes (N) and the extent of metastasis (M). TNM staging classifies disease as stage I to stage IV and guides treatment. Choice of treatment is based on medical history, the extent of the disease, cosmetic considerations, urgency of treatment and patient choice. Approximately one-third of patients with head and neck cancers have highly confined lesions that are stage I or II at diagnosis. Such patients can undergo radiation therapy or surgery with the goal of cure.

Radiation therapy may be effective in curing early vocal cord lesions. This therapy is usually successful in eliminating the tumour while preserving the quality of the voice. If radiation therapy is not successful or the lesion is too advanced for this therapy, surgery may be performed. A cordectomy (partial removal of one vocal cord) is done when there is a superficial tumour involving one cord (see Fig 26-12). A hemilaryngectomy involves removal of one vocal cord or part of a cord and requires a temporary tracheostomy. A supraglottic laryngectomy involves removing structures above the true cords—the false vocal cords and epiglottis. The patient is left at high risk of aspiration following surgery and requires a temporary tracheostomy. Both hemilaryngectomy and supraglottic laryngectomies allow the voice to be preserved but quality is breathy and hoarse.

Figure 26-12 Excision of laryngeal cancer. This cancer of the right vocal cord meets criteria for resection by transoral cordectomy. The cord is fully mobile and the lesion can be fully exposed. It does not approach or cross the anterior commissure.

Advanced lesions are treated by a total laryngectomy in which the entire larynx and pre-epiglottic region is removed and a permanent tracheostomy performed. Airflow patterns before and after total laryngectomy are shown in Figure 26-13.

Figure 26-13 A, Normal airflow in and out of the lungs. B, Airflow in and out of the lungs after total laryngectomy. Patients using oesophageal speech trap air in the oesophagus and release it to create sound.

A radical neck dissection frequently accompanies total laryngectomy to decrease the risk of lymphatic spread. Depending on the extent of involvement, extensive dissection and reconstruction may be performed. This procedure involves wide excision of the lymph nodes and their lymphatic channels (see Fig 26-14). The following structures may also be removed or transected: sternocleidomastoid muscle and other closely associated muscles, internal jugular vein, mandible, submaxillary gland, part of the thyroid and parathyroid glands, and the spinal accessory nerve.

Figure 26-14 Radical neck incision with suction tubing in place.

A modified neck dissection is performed whenever possible as an alternative to a radical neck dissection. The dissection is modified by sparing as many structures as possible to limit disfigurement and functional loss. A modified neck dissection usually involves dissection of the major cervical lymphatic vessels and lateral cervical space with preservation of nerves and vessels, including the sympathetic and vagus nerves, spinal accessory nerves and internal jugular vein. Neck dissection with vocal cord cancer usually involves one side of the neck. However, if the lesion is midline, a bilateral neck dissection may be performed. When a bilateral neck dissection is performed, it is always modified on at least one side to minimise structural and functional deficits.

The patient may refuse surgical intervention for advanced lesions because of the extent of the procedure or may be judged to be at too great a medical risk to undergo the procedure. In this situation, external radiation therapy may be used as the sole treatment or in combination with chemotherapy.

Brachytherapy, a concentrated and localised method of delivering radiation that involves placing a radioactive source into or near the tumour, may be used to treat head and neck cancer. The goal is to deliver high doses of radiation to the target area while limiting the exposure of surrounding tissues. Thin, hollow, plastic needles are inserted into the tumour area and radioactive iridium seeds are placed in the needles. The seeds emit continuous radiation. Brachytherapy can be used alone or combined with external radiation or surgical intervention. (Radiation therapy and brachytherapy are discussed in Ch 15.)

NURSING MANAGEMENT: HEAD AND NECK CANCER

Nursing assessment

Subjective and objective data that should be obtained from the patient with head and neck cancer are presented in Table 26-3.

TABLE 26-3 Head and neck cancer

NURSING ASSESSMENT

Nursing implementation

Health promotion

Development of head and neck cancer is closely related to personal habits, primarily tobacco use, including the use of cigarettes and cigars. Long-term cigar smokers are at increased risk of oral cancer. Prolonged alcohol use has also been implicated as a potentiating factor in head and neck cancer.

Nurses should include information about risk factors in their health teaching. If cancer has been diagnosed, tobacco cessation is still important. Patients with head and neck cancer who continue to smoke during radiation therapy have a lower rate of response and survival than patients who do not smoke during radiation therapy. Additionally, risk of a second primary cancer is significantly increased in patients who continue to smoke.

Acute intervention

The patient and family must be well informed regarding the type of therapy to be performed and the anticipated implications for all. Assessment of concerns is integral to the plan of care. The patient and family will be confronted by the psychological impact of the diagnosis of cancer, alteration of physical appearance and the possible need for altered methods of communication. The care plan should include assessment of the patient’s support system. The patient may not have someone to provide assistance after discharge, may not be employed or may be employed in a job that cannot be continued.

Radiation therapy

The nurse can suggest interventions to reduce side effects of radiation therapy. Dry mouth (xerostomia), the most frequent and annoying problem, typically begins within a few weeks of treatment. The patient’s saliva decreases in volume and becomes thick. The change may be temporary or permanent. Pilocarpine can be effective in increasing saliva production and should be started before the initiation of radiation therapy and continued for 90 days. Symptom relief can also be obtained by increasing fluid intake, chewing sugarless gum or sugarless sweets, using non-alcoholic mouth rinses and using artificial saliva. Patients should be instructed to always carry a water bottle.

Fatigue is one of the most common side effects of radiation therapy and usually begins a few weeks into therapy. Patients should be encouraged to take frequent rest periods during the day. Also, light regular exercise such as walking may help to give the patient more energy.

The patient may also complain of stomatitis, especially if the oral cavity is in the field of therapy. Irritation, ulceration and pain are common complaints. Patients should be encouraged to eat soft, bland foods during this time. Frequent rinses with water or sucking on ice chips can help with the pain. Commercial mouthwashes containing alcohol and hot or spicy foods should be avoided because they are irritating. If the pain is severe, it can be relieved by using local anaesthetics such as benzydamine hydrochloride, choline salicylate gel or lignocaine. These may be used in the form of a mouthwash, a spray, a jelly or an ointment. Local anaesthetics need to be used with care: if the back of the tongue or the throat is made numb this can result in choking when swallowing food or drink.

Skin over the irradiated area often becomes reddened and sensitive to touch. Patients should be instructed to only use prescribed lotions and skin products while undergoing radiation therapy and to not use any lotions 2 hours prior to treatment. If a moist skin reaction occurs, the healthcare provider should be notified immediately. All exposure to the sun should be avoided to reduce discomfort.

Surgical therapy

Preoperative care for the patient who is to have a radical neck dissection involves holistic consideration of their individual needs. Physical preparation is the same as for any major surgery but with a special emphasis on oral hygiene. Explanations and emotional support are of special significance and should include postoperative measures relating to communication and feeding. The surgical procedure should be explained to the patient and family and the nurse should make sure that the information is understood.

Teaching must relate to both the surgical procedure and the individual needs of the patient and their family. For surgeries that involve a laryngectomy, teaching should include information about expected changes in speech.

After surgery, maintenance of a patent airway is essential. The inflammation in the surgical area may compress the trachea. A tracheostomy tube may be in place. The patient will be placed in a semi-recumbent position to decrease oedema and limit tension on the suture lines. Vital signs should be monitored frequently because of the risk of haemorrhage and respiratory compromise. Pressure dressings, packing or drainage tubes may be used for wound management, depending on the type of surgical procedure. When a radical neck dissection is performed, wound suction using a portable system, such as a Haemovac, may be used. If skin flaps are employed, dressings are typically not used, since clear visualisation of the incision is needed and excessive pressure on tissue should be minimised (see Fig 26-14). The drainage should be serosanguineous and gradually decrease in volume over 24 hours. Patency of drainage tubes should be monitored every 4 hours to ensure that they are properly removing serous drainage and for the amount and character of drainage. If the tubing becomes obstructed, fluid will accumulate under the skin flap and predispose to impaired wound healing and infection. After drainage tubes are removed, the area should be closely monitored for swelling. If fluid continues to accumulate, aspiration may be necessary.

Immediately after surgery, the patient who has had a laryngectomy requires frequent suctioning via the laryngectomy tube. Secretions typically change in amount and consistency over time. The patient may initially have copious blood-tinged secretions that diminish and thicken. Normal saline bolus via the laryngectomy tube is not recommended to assist with removal of thickened secretions as this causes hypoxia and damage to the epithelial cells.³⁶ However, the patient will benefit from the use of a humidifier while hospitalised and at home.

Following a neck dissection, an exercise program should be instituted to maintain strength and movement in the affected shoulder and neck. This is especially important when the spinal accessory nerve and sternocleidomastoid muscles are removed or damaged. Without exercise, the patient will be left with a ‘frozen’ shoulder and limited range of neck motion. This exercise program should be continued following discharge to prevent future functional disabilities. The patient may need neck support to move the head after surgery.

Voice rehabilitation

A speech therapist should meet with the patient following a total laryngectomy to discuss appropriate voice restoration options. These include use of a voice prosthesis, an electrolarynx and oesophageal speech.

The most commonly used voice prosthesis is the Blom-Singer prosthesis (see Fig 26-15). This soft plastic device is inserted into a fistula made between the oesophagus and the trachea. The puncture may be created at the time of surgery or afterwards, depending on the preference of the surgeon. A red rubber catheter is placed in the tracheo-oesophageal puncture and must remain intact until a tract is formed. Once the tract is formed, the speech prosthesis is inserted. This prosthesis allows air from the lungs to enter the oesophagus by way of the tracheal stoma. A one-way valve prevents aspiration of food or saliva from the oesophagus into the tracheostomy. To speak, the patient manually blocks the stoma with the finger. Air moves from the lungs, through the prosthesis, into the oesophagus and out of the mouth. Speech is produced by the air vibrating against the oesophagus and is formed into words by moving the tongue and lips. A valve may also be used with this device. When the valve is in place, the stoma does not need to be closed with the finger to speak. The prosthesis must be cleaned regularly and replaced when it becomes blocked with mucus.

Figure 26-15 Blom-Singer voice prosthesis and tracheostoma valve. With this prosthesis and valve, patients with a laryngectomy can speak normally. Inset shows laryngectomy stoma and voice prosthesis with tracheostoma valve removed.

An electrolarynx is a hand-held, battery-powered device that creates speech with the use of sound waves. One intraoral device uses a plastic tube placed in the corner of the roof of the mouth to create vibrations. To create the most normal sound when using this device, the patient should: (1) avoid trying to use the tongue to hold the tube in place; (2) compress the tone generator for short intervals and speak in phrases, rather than full sentences; (3) speak using large movements of the lips, tongue and jaw, rather than keeping the mouth partially closed; (4) talk face-to-face with the listener; and (5) practise because development of skill takes time. An artificial larynx is placed against the neck rather than in the mouth. This device is used after surgical healing is complete and there is no oedema remaining (see Fig 26-16). With experience the patient can learn to move the lips in ways that create normal-sounding speech. With both devices, voice pitch is low and the sound is mechanical.

Figure 26-16 Artificial larynx. Battery-powered electronic artificial larynx for a patient who has a total laryngectomy.

Oesophageal speech is a method of swallowing air, trapping it in the oesophagus and releasing it to create sound. The air causes vibration of the pharyngo-oesophageal segment and sound (which initially is similar to a belch). With practice, 50% of patients develop some speech skills but only 10% develop fluent speech.

Stoma care

Before discharge the patient should be instructed in the care of the laryngectomy stoma. The area around the stoma should be washed daily with a moist cloth. If a laryngectomy tube is in place, the entire tube must be removed at least daily and cleaned in the same manner as a tracheostomy tube. The inner cannula may need to be removed and cleaned more frequently. A scarf or a loose shirt can be used to shield the stoma.

The patient should cover the stoma when coughing (because mucus may be expectorated) and during any activity (e.g. shaving, applying make-up) that might lead to inhalation of foreign materials. Water can easily enter the stoma; therefore the patient should wear a plastic collar when taking a shower. Swimming is contraindicated. Initially, humidification will be administered via a tracheostomy mask. After discharge, a bedside humidifier can be used. A high oral fluid intake must be maintained, especially in dry weather.

The patient should be told the importance of wearing a medical alert bracelet or other identification that alerts others in an emergency of the use of neck breathing (see Fig 26-17). Because the patient no longer breathes through the nose, the ability to smell smoke and food may be lost. It is important for food to be colourful, attractively prepared and nutritious, because taste may also be diminished secondary to the loss of smell, as well as to radiation therapy. Patients should be advised to install smoke and carbon monoxide detectors in the home.

Figure 26-17 Emergency identification of a neck breather.

Depression

Depression is common following a radical neck dissection. The patient may not be able to speak because of the laryngectomy and cannot control saliva. The neck and shoulders may be numb because of the transected nerves. Their facial appearance may be significantly altered, with swelling, oedema and deformities. The patient must understand that many of the physical changes are reversible as the oedema subsides and the tracheostomy tube is removed. Depression may also be related to concern about the prognosis. The nurse can help the patient through the depression by allowing verbalisation of feelings, conveying acceptance and helping the patient regain an acceptable self-concept. Sometimes it is appropriate to obtain a psychiatric referral for the patient who is experiencing prolonged or severe depression.

Sexuality

Surgery and the presence of foreign attachments such as tracheostomy and gastrostomy tubes may affect body image dramatically. The patient may feel less desirable sexually. The nurse can assist the patient by allowing discussions regarding sexuality and encouraging the patient to discuss this problem with their sexual partner. It may be difficult for the patient to discuss sexual problems orally because of the alteration in communication. The nurse can help the patient plan how to communicate with their sexual partner and offer support and guidance to the sexual partner. Helping the patient to see that sexuality involves much more than appearance may relieve some anxiety.⁴¹

Ambulatory and community care

The patient is often discharged with a tracheostomy tube and a nasogastric or gastrostomy feeding tube. Home healthcare may need to be provided initially to evaluate the family’s or the patient’s ability to perform self-care activities. The patient and family must be taught how to manage tubes and who to call if there are problems.

The patient can resume exercise, recreation and sexual activity when able. Most patients can return to work 1–2 months after surgery. However, many never return to full-time employment. The changes that follow a total laryngectomy can be upsetting. Loss of speech, loss of the ability to taste and smell, inability to produce audible sounds (including laughing and weeping) and the presence of a permanent tracheal stoma that produces undesirable mucus are often overwhelming to the patient. Although changes are discussed before surgery, the patient may not be prepared for the extent of these changes. If the patient has a partner, this person’s reaction to the patient’s altered appearance is important. Acceptance by another person can promote an improved self-image. Encouraging the patient to participate in self-care is another important part of rehabilitation.

Reconstructive surgery may be performed at the time of the initial surgery or soon after the tumour is removed. Various types of flaps and grafts are used. It may be necessary to rebuild the nose or the mandible or to close oral cutaneous openings. Soft prosthetic materials, such as Silastic and Plastigel, are often used to reconstruct deformities.

Despite the use of surgical interventions and radiation therapy, the cure rate is disappointingly low for advanced head and neck cancer. Metastatic cancer is often painful, leaving the affected person in a severely debilitated state. If pain is a problem, a pain control regimen should be identified to provide comfort and referral should be made to a hospice if indicated.