return to: Patient Teaching and Education Information Nursing Protocols or Laryngectomy Counseling

or surgical protocol: Total Laryngectomy

see also: Laryngectomy Home Care Booklet

restricted access (to U of Iowa): Total Laryngectomy Home Care Teaching Video

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. Speech Pathology pre-laryngectomy counseling: Laryngectomy counseling

SURGICAL INTENSIVE CARE UNIT

1. Objective:
   1. Patient/family will verbalize understanding of progression from operating room to recovery room or SICU to inpatient unit.
2. Content:
   1. Patient will be transferred from the operating room directly to the recovery room or SICU for intensive monitoring.
   2. Patient will be transferred from the recovery room or SICU to adult inpatient unit when condition stable.

NUTRITIONAL MANAGEMENT

1. Objective:
   1. Patient/family will verbalize understanding of nutritional management during postoperative recovery.
2. Content:
   1. NPO:
      1. Often 7 to 14 days after surgery
      2. Purpose:
         1. To allow 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 NG tube.
      2. Duration: until eating by mouth and taking in adequate amounts to meet nutritional requirements.
      3. Administered continuously for at least the first 48 hours, then changed to every 4 hour 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 intolerance/discomfort from tube feedings such as nausea, fullness, bloating, diarrhea. Reinforce that changes may be made in formula feeding schedule to help decrease or alleviate these problems.
      6. Patient gradually progresses to regular diet as tolerated when able to swallow. Will not remove NG tube until nutritional needs are met by oral diet alone.
      7. Patients may go home with NG tube feedings if unable to manage oral diet by time of discharge.

WOUND MANAGEMENT

1. Objective:
   1. Patient/family will verbalize understanding of wound management.
2. Content:
   1. Describe location of incisions.
   2. Wound care is 2 to 4 times per day as ordered by physician to keep incisions clean and help prevent infection.
   3. Closed wound drainage:
      1. Drains are 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 care will be initiated as ordered by physician.

SKIN GRAFT DONOR SITE

1. Objective:
   1. Patient/family will verbalize understanding of skin graft donor site care.
2. Content:
   1. Usually taken from thigh.
   2. Dressing is placed over donor site for 24 to 48 hours. After removing the dressing, a transparent dressing will remain in place for 10 to 14 days.

INTRAVENOUS (IV) SOLUTIONS/MEDICATIONS

1. Objective:
   1. Patient/family will verbalize understanding of IV.
2. Content:
   1. 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.

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 first postoperative day.
   3. Instruct patient to report any difficulty urinating after catheter is removed.

ALTERED AIRWAY

1. Objective:
   1. Patient/family will verbalize understanding of implications and care of altered airway.
2. Content:
   1. Provide diagram and discuss how upper airway is permanently altered and normal filtering, moistening, and warming functions are bypassed.
   2. Define stoma as a permanent opening where the trachea is sutured to skin of anterior neck. Describe appearance of stoma.
   3. Discuss purpose of pulmonary cares; to provide humidity and assist in keeping airway clear of secretions.
   4. Describe instillation of saline solution, suctioning, heated nebulizer with mask, frequency of cares determined by patient's secretions and pulmonary status.

ALTERED COMMUNICATION

1. Objective:
   1. Patient/family will verbalize understanding of altered communication.
2. Content:
   1. Discuss inability to speak without assistive device.
   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.
   4. Explain that a speech therapist will begin helping patient learn alternate methods of speaking within 2 to 4 days after surgery.

BODY IMAGE/PHYSICAL/SENSORY SENSATION

1. Objective:
   1. Patient/family will verbalize understanding of physical/sensory changes.
2. Content:
   1. Describe altered air exchange: secretions expelled through stoma instead of mouth and nose, cover stoma when coughing.
   2. Explain ability to taste/smell will be diminished because upper airway bypassed.
   3. Patient may experience increased oral/nasal secretions or dryness and crusting in mouth.
   4. Explain that patient will be unable to blow nose; will need to wipe secretions away from nose and expectorate oral secretions.
   5. Explain that patient will be unable to perform Valsalva maneuver or bear down as when having a bowel movement. May need to take stool softeners.
   6. Encourage patient to express feelings regarding body image/sensory changes to nursing staff and other health care providers.

ACTIVITY

1. Objective:
   1. Patient/family will verbalize understanding of postoperative positioning and activity.
2. Content:
   1. HOB is elevated at all times.
   2. Early and consistent ambulation will be encouraged to improve blood circulation, to help keep lungs clear, and to 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.

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.

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.
   5. 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.
   6. Postoperative pain manifested primarily by headache.

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.

HOME CARE INSTRUCTIONS

1. Objective:
   1. Patient/family will verbalize understanding/demonstrate home care instructions.
2. Content:
   Refer to teaching booklet Laryngectomy Home Care Booklet.
   1. Clean Technique
   2. Humidification
   3. Making Saline Solution
   4. Instilling Saline Solution
   5. Suctioning
   6. Care of Suction Equipment
   7. Care of Airway
   8. Clean/Insert Stoma Vent
   9. Precautions
   10. Emergency Information
   11. Diet
   12. International Association of Laryngectomees
   13. Adverse Signs