HESI case study - Laryngeal Cancer - Maureen Tanner

Mrs. Tanner has been experiencing hoarseness and a change in her voice, but she did not seek medical help until she began to have difficulty swallowing. After being seen by her healthcare provider (HCP), she is scheduled for outpatient surgery for a direct laryngoscopy to obtain a culture and take a biopsy. Mrs. Tanner arrives at the outpatient surgical department at 6:30 am and is escorted to her room. The admitting registered nurse(RN) begins the assessment of Mrs. Tanner. Which question is most important for the RN to ask Mrs. Tanner?

"Have you had anything to eat or drink since midnight?" Eating and/or drinking places the client at risk for vomiting and aspiration during the procedure. If Mrs. Tanner has had anything to eat or drink, the biopsy will be cancelled.

The ONS has given verbal and written information to Mrs. Tanner, has answered any questions, and is completing the physical assessment. Which question is important for the ONS to ask Mrs. Tanner?

"How much alcohol do you drink a week?" Heavy drinking is a risk factor for laryngeal cancer, but more importantly, if Mrs. Tanner drinks large amounts of alcohol, the potential for withdrawal should be addressed.

Mrs. Tanner is being discharged home tomorrow after 5 days in the hospital. Mr. Tanner stops the RN in the hallway and says that he is really scared about taking his wife home. What is the best response by the RN?

"Let's sit down and discuss what you are worried about." The RN should attempt to find out what Mr. Tanner is scared about and provide factual information, as well as support.

How should the RN respond?

"Tell me more about what you mean by touching your wife." The RN needs to clarify exactly what Mr. Tanner's fears are. If the RN doesn't address his sexual concerns, it is unlikely that they will be addressed by another healthcare professional.

Mrs. Tanner reports that she drinks occasionally, mainly on the weekends with friends. The ONS is more concerned that Mrs. Tanner smokes 1 pack of cigarettes a day. She discusses this issue with Mrs. Tanner, who says, "Don't worry about my smoking. I will never smoke another cigarette again." How should the ONS respond to help Mrs. Tanner in her attempt to stop smoking?

"What steps are you going to take to stop smoking?" The ONS should determine what steps Mrs. Tanner is planning to take to stop smoking and provide smoking cessation information, if needed.

The next time the RN enters Mrs. Tanner's room, Mrs. Tanner writes on the communication board, "Is there something wrong? I heard someone in the hall say something about me receiving the wrong medication." How should the RN respond?

"You were supposed to receive gentamicin, but you received ampicillin." The best response by the RN is to tell the truth.

The admission RN completes the admission assessment and starts an IV of 1000 mL normal saline prescribed to run over 10 hours. The drop factor on the tubing is 10 drops/mL (gtts/mL). At how many drops per minute (gtts/min) should the tubing be regulated to deliver the prescribed solution? 17 (Enter the numerical value only. If rounding is required, round to the whole number.)

17 1000 mL/600 min X 10 gtts = 16.6 rounded to 17 gtts/min

Which nursing intervention is most helpful to Mrs. Tanner?

Ask Mrs. Tanner if she would like to talk to someone who has had this surgery. Mrs. Tanner may feel more comfortable asking questions and expressing her fears to someone who has undergone the same procedure. The International Association of Laryngectomees and the American Cancer Society Visitor Program are two organizations that provide this service. INCORRECT: Refer Mrs. Tanner to a psychologist to discuss her fears about having this surgery. There is a better intervention to meet the client's needs. Tell Mrs. Tanner it is OK to be scared and hold her hand. While this acknowledges her fears and offers support, there is a better intervention to meet the client's needs. Give Mrs. Tanner literature provided by the American Cancer Society. While written information is an important part of teaching, there is a better intervention to meet the client's needs.

The RN is discussing activities of daily living with Mrs. Tanner. Which instruction should the RN include?

Caution Mrs. Tanner to take only tub baths. Because water could enter the stoma site and go directly into the lungs during showers, tub baths should be encouraged. INCORRECT: Explain the need to wear a plastic bib when showering. The stoma site should be protected from water entering the site. Because a plastic bib could block the airway, the client should wear a shower shield if showering. Advise Mrs. Tanner not to wear any type of perfume. Mrs. Tanner may wear perfume, but she should not apply it near the stoma site. Encourage Mrs. Tanner to use aerosol deodorants. Aerosol deodorants should be discouraged since the spray could enter the stoma site.

The night RN is preparing to administer the 12:00 midnight dose of gentamicin, an intravenous aminoglycoside antibiotic that was started when Mrs. Tanner was in the PACU. The RN notices the empty IV antibiotic bag that was administered during the day shift is labeled ampicillin. The nurse checks the Medication Administration Record and realizes the client does not have a prescription for ampicillin. Which action should the night RN implement?

Complete a medication error incident report. The night RN should complete a medication error incident report to document this finding.

After discussing her options with the speech therapist, Mrs. Tanner demonstrates her ability to use esophageal speech. She comments, "I used to hear my son and his friends talk like this. Won't he be surprised!" Two days later, Mrs. Tanner is admitted to the hospital, accompanied by her husband and her two grown children. She is in the preoperative holding area. Which intervention will the RN implement?

Determine if Mrs. Tanner has any problems hearing or writing. A means of communication must be determined prior to surgery since Mrs. Tanner will not be able to speak following her total laryngectomy. An erasable communication board is usually used. If the client has trouble hearing or writing, this situation must be addressed and another means of communication determined.

PACU & ICU Postoperative Nursing Care Following a 7-hour surgery, Mrs. Tanner was first placed in the Post Anesthesia Care Unit (PACU) before being transferred to the Intensive Care Unit (ICU). The RN is completing the shift assessment and notes that Mrs. Tanner has white and dark brown patchy areas on her tongue and oral mucosa. Which action should the nurse implement?

Document this finding and take no action. With cancer of the larynx, the inside of the mouth and the tongue may appear white, gray, or dark brown and may display a patchy pattern.

An unlicensed assistive personnel (UAP) is assisting the surgical floor RN with morning care for Mrs. Tanner. Which task(s) should the RN delegate to the UAP? Select all that apply Which task(s) should the RN delegate to the UAP? Perform the routine tracheostomy care. Clean Mrs. Tanner's bathroom. Empty the Foley catheter and record the output. Change the intravenous bag on the pump. Assist Mrs. Tanner with her bed bath.

Empty the Foley catheter and record the output. This action may be delegated to the UAP. The RN should follow up to assess whether the output is adequate. Assist Mrs. Tanner with her bed bath. This action may be delegated to the UAP. The RN should follow up to assess if there were any problems or concerns noted during the bed bath.

Which intervention has highest priority prior to discharge?

Ensure that Mrs. Tanner carries a special identification card. The card is available from the International Association of Laryngectomees and instructs the reader in providing an emergency airway or resuscitating someone with a stoma. Life-sustaining issues always have the highest priority.

Mrs. Tanner is concerned about singing in the country and western club and asks the ONS, "How long do you think it will before I can sing with my band again?" How should the ONS respond?

Explain that Mrs. Tanner's vocal cords will be removed and that she will not be able to sing. Mrs. Tanner needs the correct information prior to having a total laryngectomy.

Mrs. Tanner uses her erasable board to communicate to the staff that foods taste funny and that she cannot smell anything. She is worried that something is wrong. What action should the RN take regarding Mrs. Tanner's concern?

Explain to the client that this is normal following this type of surgery. This is a common, expected occurrence in clients with a total laryngectomy because a laryngectomy alters airflow, decreasing taste and smell perception. This information should be included in preoperative teaching, and it may need to be reinforced postoperatively as well.

The RN also calls the nurse's station and requests a complete blood count (CBC) stat. In which case is the laboratory result consistent with blood loss through hemorrhaging?

Hemoglobin 11.3 g/dl. Normal hemoglobin for a female is 12.0 g/dl-15.0 g/dl. Therefore, 11.3 g/dl is consistent with blood loss through hemorrhaging.

Which explanation should the RN provide?

Humidified air will keep the mucous membranes and secretions moist. With a tracheostomy, humidification of inspired air in the upper airway is lost. Humidifying the air helps maintain moist mucous membranes and secretions, which promotes secretion removal by coughing or suctioning.

Of the nursing diagnoses included in Mrs. Tanner's care plan, which one has the highest priority?

Ineffective airway clearance. One week following surgery, some local tissue edema may remain and may interfere with airway patency; therefore, impaired airway clearance is the priority. In addition, secretions that may be difficult to remove may also affect airway patency. Remember Maslow's Hierarchy of Needs.

The charge RN notices that the primary nurse caring for Mrs. Tanner is cutting a 4 × 4 gauze to use as a tracheostomy dressing. Which action should the charge nurse implement?

Instruct the primary nurse not to cut gauze for the tracheostomy dressing. Small strings from the gauze can be aspirated through the stoma into the lungs. Folding the gauze into a V-shape and placing it under the tracheostomy tube is an acceptable technique, but cutting the gauze is not.

Which intervention will the PACU RN implement first?

Obtain Mrs. Tanner's vital signs. Vital signs should be assessed first to establish a baseline for the post-anesthesia period.

The RN's assessment reveals a small amount of old blood behind Mrs. Tanner's neck. Since her hemoglobin is 11.3 g/dl the surgeon prescribes an IV fluid bolus. Mrs. Tanner responds positively, and no further bleeding occurs. The RN's anticipation of potential complications and quick response averts further problems. The remainder of Mrs. Tanner's post-anesthesia recovery progresses well, and she is transferred to the surgical unit. Mrs. Tanner's gag reflex has returned, and she is preparing to eat her first meal. Which action should the RN implement?

Provide Mrs. Tanner with soft foods when she is eating for the first time after surgery. Soft foods are easier to swallow initially. INCORRECT: Remind Mrs. Tanner to place the food on the front of the tongue and to flex her head backward to swallow. Food should be placed on the back of the tongue with the head flexed forward. Ensure that Mrs. Tanner has a variety of thin liquids to drink. Because liquids often cause the client to choke, all thin liquids should be thickened slightly. Place cold packs around Mrs. Tanner neck prior to eating. Cold packs can decrease edema and constrict blood flow, but they are not helpful with swallowing or eating.

Mrs. Tanner shares with the RN that she is worried that no one will help her if she needs help and that she will not be able to talk to anyone. Which intervention should the RN implement?

Provide a bell that Mrs. Tanner can ring as another means of communication. A bell provides a means of empowerment for the client. It can be used to ring into the call light, or the phone or to ring in the room to inform someone she needs something. It can also be used to answer questions: 1 ring for no or 2 rings for yes. The RN should remember to ask Mrs. Tanner "yes/no" questions (rather than open-ended) when she speaks to Mrs. Tanner over the call light intercom.

Mrs. Tanner has a tracheostomy that has an inner cannula. The RN is performing routine tracheostomy care. Which action should the RN implement first?

Remove the tracheostomy dressing with clean disposable gloves. The RN should remove the dressing first, set up sterile supplies, clean the stoma site and outer cannula, and then remove and clean the inner cannula before replacing it.

Because of the cancer, Mrs. Tanner is at risk for potential complications, such as neck wound fistula and a carotid artery blowout. When anticipating these possible complications, the RN should place which equipment at Mrs. Tanner's bedside?

Several packages of sterile 4×4 gauze. If a carotid artery blowout occurred, the RN would need to apply direct pressure to stem the bleeding.

While assessing Mrs. Tanner, the RN notices that Mrs. Tanner's blood pressure is 92/60 and that her pulse is 112. Mrs. Tanner reports feeling very tired. What action should the RN implement first?

Slip a gloved hand under the client's neck. Since Mrs. Tanner's vital signs indicate possible hemorrhage, the RN should assess for bleeding. A common site for blood to pool following any type of throat surgery is behind the client's neck. INCORRECT: Suction Mrs. Tanner's tracheostomy. This would be the first intervention if the client was exhibiting signs of ineffective airway clearance, but another intervention is warranted here. Check Mrs. Tanner's previous vital signs. Since the client's vital signs reflect hypovolemic shock, another intervention has more immediacy than checking the former vital signs. Administer oxygen via nasal cannula. Because Mrs. Tanner does not breathe through her nose anymore, if oxygen is needed, a mask would be placed over the stoma site.

Mrs. Tanner discusses the surgery with her family and with a woman from a laryngectomy support group. Mrs. Tanner decides to go ahead and have the total laryngectomy. A referral to which member of the interdisciplinary team will be most important for Mrs. Tanner prior to surgery?

Speech therapist. Mrs. Tanner will need to learn a new method of speech, which is taught by the speech therapist.

Which nursing intervention should the ICU RN implement?

Support the client's head when moving the client in bed. Head support reduces the strain on tissues in the operative area. INCORRECT: Discourage coughing for the first 24 hours. Coughing should be encouraged to help remove secretions. Place Mrs. Tanner in the supine position with the bed flat. The head of the bed should be elevated to promote effective breathing. Remove the tracheostomy tube every shift to assess the stoma site. The tracheostomy tube must be left in place until the stoma site has healed.

The speech therapist discusses with Mrs. Tanner, alternative techniques for restoring her speech after the surgery. Selection of the best technique varies from person to person, depending on the person's age and personal preferences. Esophageal speech is popular among laryngectomees because it costs less and can provide a more normal sounding voice than some of the other options. Which statement describes esophageal speech?

Swallowed air is used to create sound and words in a controlled belch. This describes esophageal speech where clients "burp" swallowed air to form sounds into words using the palate, tongue, lips, and teeth.

Which instructions should the RN provide to Mrs. Tanner?

Take a deep breath, occlude the tracheostomy with your finger, cough, and remove your finger. This technique is called "glottal stop," which helps remove secretions.

What should the RN do before reinserting the inner cannula?

Tap or shake the inner cannula to remove excess moisture. This will help remove excess saline prior to inserting the cannula into the stoma in order to reduce the risk of fluid entering the lungs. Some sources recommend drying the inner cannula with sterile pipe cleaners, although this may damage the inner cannula. Follow the organization's policy and procedure. INCORRECT: Dry the outside of the inner cannula with non-sterile gauze. When cleaning the inner cannula, sterility must be maintained. Clean it with hydrogen peroxide. The inner cannula should be rinsed thoroughly with normal saline before being reinserted into the outer cannula. Remove the outer cannula, reinsert the inner cannula, and then place back into stoma. The outer cannula should never be removed from the stoma site by the RN.