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Head and Neck Cancer Surgery for Nursing

last modified on: Wed, 09/06/2017 - 11:32

Head and Neck Cancer Surgery

 

  • 1Head and Neck Cancer Surgery
    • 1.1ROUTINE PREOPERATIVE TEACHING OF THE ADULT PATIENT
    • 1.2SURGICAL INTENSIVE CARE UNIT
    • 1.3NUTRITIONAL MANAGEMENT
    • 1.4WOUND MANAGEMENT
    • 1.5SKIN GRAFT DONOR SITE
    • 1.6INTRAVENOUS (IV) SOLUTIONS/MEDICATIONS
    • 1.7URINARY CATHETER
    • 1.8ACTIVITY
    • 1.9PAIN MANAGEMENT
    • 1.10TRACHEOSTOMY
    • 1.11NECK DISSECTION
    • 1.12FREE FLAP
    • 1.13RADIAL FOREARM FREE FLAP
    • 1.14FIBULA FREE FLAP
    • 1.15MAXILLECTOMY
    • 1.16ORBITAL EXENTERATION
    • 1.17SUPPORTIVE SERVICES

 

  1. ROUTINE PREOPERATIVE TEACHING OF THE ADULT PATIENT
    1. Objective:
      1. Patient/family will verbalize understanding of routine preoperative instructions.
    2. Content:
      1. Refer to clinic policy Routine Preoperative Teaching for the Adult Patient.
  2. SURGICAL INTENSIVE CARE UNIT
    1. Objective:
      1. Patient/family will verbalize understanding of progression from operating room and then to SICU or possibly to inpatient unit.
    2. Content:
      1. Patient will be transferred from the operating room either directly to the SICU for intensive monitoring or to the postanesthesia recovery room.
      2. Patient will be transferred from SICU or the recovery room to an adult inpatient unit when condition is stable.
  3. NUTRITIONAL MANAGEMENT
    1. Objective:
      Patient/family will verbalize understanding of nutritional management during postoperative recovery.
    2. Content:
      1. NPO
        1. Usually 7 to 10 days after surgery.
        2. Purpose:
          1. To allow mucosal suture line and surgical sites to heal by preventing stress or pressure during eating or swallowing
          2. Reduce risk of infection
      2. Nasogastric tube feedings
        1. Liquid formula delivered via nasogastric (NG) tube as an alternative way to feed patient.
        2. Duration: until patient is eating by mouth and taking in adequate amounts to meet nutritional requirements.
        3. Feedings administered continuously for at least the first 48 hours, then changed to an every 4 hour interval feeding schedule if patient tolerates.
        4. Bowel status: discuss expected changes in stools with tube feedings to more soft/pasty form.
        5. Instruct patient to report any intolerances/discomforts from tube feedings such as nausea, fullness, bloating, diarrhea. Reinforce that changes may be made in feeding to help decrease/alleviate these problems.
        6. Prior to beginning an oral diet, a swallowing study (cookie swallow) may be done in radiology to assess patient's risk for aspiration or other difficulties with swallowing. The patient may be restricted to a certain consistency of food or require swallowing rehabilitation with a speech pathologist.
        7. When able to swallow, diet will gradually be progressed to consistency patient is able to tolerate. Will not remove NG tube until nutritional needs are met by oral diet alone.
        8. Patients may go home with NG tube feedings if unable to manage oral diet by time of discharge.
  4. WOUND MANAGEMENT
    1. Objective:
      1. Patient/family will verbalize understanding of wound management.
    2. Content:
      1. Describe potential location of incisions.
      2. Wound care 2 to 4 times per day as ordered by physician to keep incisions clean and help prevent infection.
      3. Closed wound drainage.
        1. Drains surgically placed under skin and attached to suction
        2. Purpose: to facilitate healing by preventing fluid accumulation under skin flap
        3. Duration: usually 3 to 5 days, discontinued when drainage decreases
      4. Neck and lower facial edema on operative side is expected.
      5. Oral cares: patient may experience increased oral drainage/secretions or dryness and crusting in the mouth. Oral cares will be initiated as ordered by physician.
        1. Rinses/toothettes
        2. Oral suction
        3. No oral care if intraoral resection until approved by physician
  5. SKIN GRAFT DONOR SITE
    1. Objective:
      1. Patient/family will verbalize understanding of skin graft donor site care.
    2. Content:
      1. Skin graft is usually taken from thigh.
      2. Dressing is placed over donor site for 24 to 48 hours. After removing the outer dressing a transparent dressing will remain in place for 10 to 14 days.
  6. INTRAVENOUS (IV) SOLUTIONS/MEDICATIONS
    1. Objective:
      1. Patient/family will verbalize understanding of IV.
    2. Content:
      1. IV is necessary to administer fluids until oral or NG intake is adequate
      2. IV will be used to administer antibiotics as needed and to provide access for administration of other medications including analgesics.
  7. URINARY CATHETER
    1. Objective:
      1. Patient/family will verbalize understanding of urinary catheter.
    2. Content:
      1. Purpose: to drain urine from bladder intraoperatively and during initial postoperative period until patient is mobile.
      2. Catheter usually removed on postoperative day 1.
      3. Instruct patient to report any difficulty urinating after catheter is removed.
  8. ACTIVITY
    1. Objective:
      1. Patient/family will verbalize understanding of postoperative positioning and activity.
    2. Content:
      1. HOB elevated at all times.
      2. Early and consistent ambulation will be encouraged to improve blood circulation, help keep lungs clear, and build strength.
      3. Encourage compliance with postoperative positioning to ensure proper blood flow to neck or other muscle flaps.
      4. Explain importance of supporting head and back of neck while rising to sitting position or lying down.
  9. PAIN MANAGEMENT
    1. Objective:
      1. Patient/family will verbalize understanding of pain assessment and medication administration.
    2. Content:
      1. Introduce and explain use of pain assessment scales (Simple Descriptive, 0-10 Numeric). Identify patient's preference.
      2. Establish acceptable level of pain.
      3. Reassure that patient will be assessed frequently for pain.
      4. Pain medications will be administered intravenously via PCA pump or on PRN basis while IV access is available.
      5. Pain medications will be administered via NG tube/orally when IV discontinued or when pain level no longer warrants IV medication.
  10. TRACHEOSTOMY
    1. Objective:
      1. Patient/family will verbalize understanding of purpose of tracheostomy and its associated cares/sensory changes.
    2. Content:
      1. Altered airway
        1. Provide diagram and explain purpose of tracheostomy is to bypass narrowed airway caused by postoperative edema. Explain how normal upper airway filtering, moistening, and warming function is bypassed.
        2. Demonstrate tracheostomy tubes (Shiley and Jackson).
        3. Discuss purpose of pulmonary cares: to provide humidity/assist in keeping airway clear.
        4. Describe instillation of saline solution, suctioning, heated nebulizer with mask, frequency of cares determined by patient's secretions/pulmonary status.
      2. Altered communication
        1. Discuss patient's inability to speak until edema decreases.
        2. Determine ability to read and write and discuss appropriate communication methods (ie, writing materials, picture board).
        3. Explain that call light system/intercom at nurses' desk is labeled to indicate patient cannot speak; call light will be answered promptly.
      3. Physical/sensory sensations
        1. Describe air exchange: secretions expelled through tracheostomy tube instead of nose and mouth; cover tube when coughing.
        2. Explain ability to taste and smell will be diminished because upper airway is bypassed.
      4. Patient may go home with tracheostomy tube if unable to tolerate decannulation by time of discharge. Patient/family will be fully instructed on home cares, and a visiting nurse will be arranged to assist patient at home (see Tracheostomy Patient Education Record).
  11. NECK DISSECTION
    1. Objective:
      1. Patient/family will verbalize understanding of assessments and interventions related to postoperative neck dissection care.
    2. Content:
      1. Skin flap will be assessed for adequate circulation.
      2. Avoid constrictive clothing around neck.
      3. Neck may have a sunken or depressed appearance on side of dissection.
      4. Patient may experience loss of sensation to posterior scalp, neck, and shoulder. Reinforce safety measures to protect skin from injury:
        1. Use caution with heat-producing appliances such as hair dryers and hot rollers.
        2. Do not use hot water bottles or heating pads on this area.
        3. Use protective covering in cold weather to prevent frost bite.
        4. Use sunscreen (SPF 15 or greater) and protective covering to prevent sunburn.
        5. Use electric razor to avoid cutting skin.
        6. Patient may experience weakness, discomfort, and limited mobility to affected shoulder. Patient will be assessed during postoperative clinic visits and may be instructed on exercises or referred to physical therapy.
      5. Postoperative pain manifested primarily by headache.
  12. FREE FLAP
    1. Objective:
      1. Patient/family will verbalize understanding of care required when a vascularized free flap is used to reconstruct surgical defect.
    2. Content:
      1. Circulation:
        1. Nurses will do frequent assessment of flap to ensure adequate blood flow.
        2. Explain that Doppler ultrasound will be used frequently to assess for an audible pulse.
      2. Positioning: physician may order special positioning instructions to prevent tension or kinking of blood vessels; nurses will reinforce this with patient after surgery.
      3. Special medications such as dextran will be ordered postoperatively to promote circulation and prevent blood clot formation. Explain that dextran may contribute to edema.
  13. RADIAL FOREARM FREE FLAP
    1. Objective:
      1. Patient/family will verbalize understanding of care required when a radial forearm free flap is the vascularized free flap used to reconstruct the surgical defect.
    2. Content:
      1. A cast will be applied to donor arm, removed after 5 to 7 days, then replaced with a light dressing.
      2. If bone is harvested, the forearm will be casted for approximately 6 weeks with frequent cast changes in outpatient clinic after discharge from hospital.
      3. Arm will be elevated on 2 pillows.
      4. Drain will be placed in upper arm and discontinued when drainage decreases.
      5. Skin graft will be transferred from upper thigh to forearm. Dressing will be applied to donor site.
  14. FIBULA FREE FLAP
    1. Objective:
      1. Patient/family will verbalize understanding of care required when a fibula free flap is the vascularized free flap used to reconstruct the surgical defect.
    2. Content:
      1. Ace wrap dressing is applied to donor leg for 5 days.
      2. Wound care is given to suture line after dressing removed.
      3. Leg will be elevated on 2 pillows while in bed until discharge to home.
      4. Physical therapist will begin working with patient 2 to 3 days after surgery to improve walking and activity; no weight bearing until physical therapy begins.
  15. MAXILLECTOMY
    1. Objective:
      1. Patient/family will verbalize understanding of wound/hygiene care associated with maxillectomy.
    2. Content:
      1. Surgical defect will be lined with a split thickness skin graft; gauze packing is placed over skin graft, and then the palatal prosthesis will be secured into place with a screw and wires.
      2. Palatal packing and prosthesis will be removed approximately postoperative day 6 and a temporary obturator will be placed. Due to gradual decrease in swelling, the obturator will be ill fitting and require frequent adjustments.
      3. Oral rinses will be ordered after meals and at bedtime.
      4. Prosthodontist will instruct patient on the proper routine for cleaning the prosthesis at home.
      5. Explain that during the first 1 to 2 weeks after surgery, eating and drinking may be a difficult and frustrating process until swelling decreases and obturator is better fitting. Nursing and speech pathologist will offer suggestions to improve eating and swallowing (use of a syringe or catheter, trying various food consistencies).
  16. ORBITAL EXENTERATION
    1. Objective:
      1. Patient/family will verbalize understanding of care and body image changes associated with orbital exenteration.
    2. Content:
      1. A bolster sponge or packing is usually placed in orbital cavity until approximately postoperative day 5, then removed.
      2. Dressing or eye patch will be placed over cavity.
      3. The orbital cavity will be prone to crusting/dryness. Humidification techniques will be used to help alleviate this problem (irrigations, saline solution atomizer, bedside humidity).
      4. Nursing will be available to support and assist patient in adjusting to change in appearance.
  17. SUPPORTIVE SERVICES
    1. Objective:
      1. Patient/family will verbalize understanding of supportive service providers who are available as part of health care team.
    2. Content:
      1. Social worker provides suggestions for assistance with financial, travel, and housing needs. Assists nurses and physicians with discharge planning and arranges supplies and equipment for home setting.
      2. Dietitian evaluates and makes recommendations to optimize patient's nutritional status postoperatively.
      3. Speech pathologist evaluates and instructs patients according to speech and/or swallowing rehabilitative needs.
      4. Home health nurse acts as support and resource person, providing nursing care in patient's home after discharge.