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
- Objective:
- Patient/family will verbalize understanding of routine preoperative instructions.
- Content:
- Refer to clinic policy Routine Preoperative Teaching for the Adult Patient.
- Speech Pathology pre-laryngectomy counseling: Laryngectomy counseling
SURGICAL INTENSIVE CARE UNIT
- Objective:
- Patient/family will verbalize understanding of progression from operating room to recovery room or SICU to inpatient unit.
- Content:
- Patient will be transferred from the operating room directly to the recovery room or SICU for intensive monitoring.
- Patient will be transferred from the recovery room or SICU to adult inpatient unit when condition stable.
NUTRITIONAL MANAGEMENT
- Objective:
- Patient/family will verbalize understanding of nutritional management during postoperative recovery.
- Content:
- NPO:
- Often 7 to 14 days after surgery
- Purpose:
- To allow suture line and surgical sites to heal by preventing stress or pressure during eating or swallowing
- Reduce risk of infection
- Nasogastric tube feedings:
- Liquid formula delivered via NG tube.
- Duration: until eating by mouth and taking in adequate amounts to meet nutritional requirements.
- Administered continuously for at least the first 48 hours, then changed to every 4 hour schedule if patient tolerates.
- Bowel status: discuss expected changes in stools with tube feedings to more soft, pasty form.
- 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.
- 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.
- Patients may go home with NG tube feedings if unable to manage oral diet by time of discharge.
- NPO:
WOUND MANAGEMENT
- Objective:
- Patient/family will verbalize understanding of wound management.
- Content:
- Describe location of incisions.
- Wound care is 2 to 4 times per day as ordered by physician to keep incisions clean and help prevent infection.
- Closed wound drainage:
- Drains are surgically placed under skin and attached to suction.
- Purpose: to facilitate healing by preventing fluid accumulation under skin flap.
- Duration: usually 3 to 5 days, discontinued when drainage decreases.
- Neck and lower facial edema on operative side is expected.
- Oral care will be initiated as ordered by physician.
SKIN GRAFT DONOR SITE
- Objective:
- Patient/family will verbalize understanding of skin graft donor site care.
- Content:
- Usually taken from thigh.
- 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
- Objective:
- Patient/family will verbalize understanding of IV.
- Content:
- Necessary to administer fluids until oral or NG intake is adequate.
- IV will be used to administer antibiotics as needed and to provide access for administration of other medications including analgesics.
URINARY CATHETER
- Objective:
- Patient/family will verbalize understanding of urinary catheter.
- Content:
- Purpose: to drain urine from bladder intraoperatively and during initial postoperative period until patient is mobile.
- Catheter usually removed on first postoperative day.
- Instruct patient to report any difficulty urinating after catheter is removed.
ALTERED AIRWAY
- Objective:
- Patient/family will verbalize understanding of implications and care of altered airway.
- Content:
- Provide diagram and discuss how upper airway is permanently altered and normal filtering, moistening, and warming functions are bypassed.
- Define stoma as a permanent opening where the trachea is sutured to skin of anterior neck. Describe appearance of stoma.
- Discuss purpose of pulmonary cares; to provide humidity and assist in keeping airway clear of secretions.
- Describe instillation of saline solution, suctioning, heated nebulizer with mask, frequency of cares determined by patient's secretions and pulmonary status.
ALTERED COMMUNICATION
- Objective:
- Patient/family will verbalize understanding of altered communication.
- Content:
- Discuss inability to speak without assistive device.
- Determine ability to read and write and discuss appropriate communication methods (ie, writing materials, picture board).
- Explain that call light system/intercom at nurses' desk is labeled to indicate patient cannot speak; call light will be answered promptly.
- 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
- Objective:
- Patient/family will verbalize understanding of physical/sensory changes.
- Content:
- Describe altered air exchange: secretions expelled through stoma instead of mouth and nose, cover stoma when coughing.
- Explain ability to taste/smell will be diminished because upper airway bypassed.
- Patient may experience increased oral/nasal secretions or dryness and crusting in mouth.
- Explain that patient will be unable to blow nose; will need to wipe secretions away from nose and expectorate oral secretions.
- 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.
- Encourage patient to express feelings regarding body image/sensory changes to nursing staff and other health care providers.
ACTIVITY
- Objective:
- Patient/family will verbalize understanding of postoperative positioning and activity.
- Content:
- HOB is elevated at all times.
- Early and consistent ambulation will be encouraged to improve blood circulation, to help keep lungs clear, and to build strength.
- Encourage compliance with postoperative positioning to ensure proper blood flow to neck or other muscle flaps.
- Explain importance of supporting head and back of neck while rising to sitting position or lying down.
PAIN MANAGEMENT
- Objective:
- Patient/family will verbalize understanding of pain assessment and medication administration.
- Content:
- Introduce and explain use of pain assessment scales (Simple Descriptive, 0-10 Numeric). Identify patient's preference.
- Establish acceptable level of pain.
- Reassure that patient will be assessed frequently for pain.
- Pain medications will be administered intravenously via PCA pump or on PRN basis while IV access is available.
- Pain medications will be administered via NG tube/orally when IV discontinued or when pain level no longer warrants IV medication.
NECK DISSECTION
- Objective:
- Patient/family will verbalize understanding of assessments and interventions related to postoperative neck dissection care.
- Content:
- Skin flap will be assessed for adequate circulation.
- Avoid constrictive clothing around neck.
- Neck may have a sunken or depressed appearance on side of dissection.
- Patient may experience loss of sensation to posterior scalp, neck, and shoulder. Reinforce safety measures to protect skin from injury:
- Use caution with heat-producing appliances, such as hair dryers and hot rollers.
- Do not use hot water bottles or heating pads on this area.
- Use protective covering in cold weather to prevent frost bite.
- Use sunscreen (SPF 15 or greater) and protective covering to prevent sunburn.
- Use electric razor to avoid cutting skin.
- 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.
- Postoperative pain manifested primarily by headache.
SUPPORTIVE SERVICES
- Objective:
- Patient/family will verbalize understanding of supportive service providers who are available as part of health care team.
- Content:
- 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.
- Dietitian evaluates and makes recommendations to optimize patient's nutritional status postoperatively.
- Speech pathologist evaluates and instructs patients according to speech and/or swallowing rehabilitative needs.
- Home health nurse acts as support and resource person, providing nursing care in patient's home after discharge.
HOME CARE INSTRUCTIONS
- Objective:
- Patient/family will verbalize understanding/demonstrate home care instructions.
- Content:
Refer to teaching booklet Laryngectomy Home Care Booklet.- Clean Technique
- Humidification
- Making Saline Solution
- Instilling Saline Solution
- Suctioning
- Care of Suction Equipment
- Care of Airway
- Clean/Insert Stoma Vent
- Precautions
- Emergency Information
- Diet
- International Association of Laryngectomees
- Adverse Signs