Chapter 27 Laryngeal Cancer & Tracheaostomy Care

42. When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection, what would the nurse expect to find? a. A closed-wound drainage system b. A nasal endotracheal tube in place c. A nasogastric tube with orders for tube feeding d. A tracheostomy tube and mechanical ventilation

ANS: A Following a radical neck dissection, drainage tubes are often used to prevent fluid accumulation in the wound as well as possible pressure on the trachea. The patient has placement of a nasogastric tube to suction immediately after surgery, which will later be used to administer tube feeding until swallowing can be accomplished. A tracheostomy tube is in place but mechanical ventilation is usually not indicated.

11. The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a."I must keep the stoma covered with an occlusive dressing at all times." b."I can participate in most of my prior fitness activities except swimming." c."I should wear a Medic-Alert bracelet that identifies me as a neck breather." d."I need to be sure that I have smoke and carbon monoxide detectors installed."

ANS: A The stoma may be covered with clothing or a loose dressing, but this is not essential. An occlusive dressing will completely block the patient's airway. The other patient comments are all accurate and indicate that the teaching has been effective.

5. A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a.Leave the tracheostomy inner cannula inserted at all times. b.Place the decannulation cap in the tube before cuff deflation. c.Assess the ability to swallow before using the fenestrated tube. d.Inflate the tracheostomy cuff during use of the fenestrated tube.

ANS: C Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.

13. A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? a.Monitor for bleeding. b.Maintain adequate IV fluid intake. c.Suction tracheostomy every eight hours. d.Keep the patient in semi-Fowler's position.

ANS: D The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube.

45. What is the most normal functioning method of speech restoration in the patient with a total laryngectomy? a. Esophageal speech b. A transesophageal puncture c. An electrolarynx held to the neck d. An electrolarynx palced in the mouth

ANS: B Transesophageal puncture provides the most normal voice reproduction but requires a surgical fistula made between the esophagus and the trachea and possibly a valve prosthesis. Esophageal speech involves trapping air in the esophagus and releasing it to form sound but only 10% of patients can develop fluent speech with this method. The electrolarynx, whether placed in the mouth or held to the neck, allows speech that has a metallic or robotic sound.

38. A patients tracheostomy tube becomes dislodged with vigorous coughing. What should be the nurses first action? a. Attempt to replace the tube b. Notify the health care provider c. Place the patient in high Fowler position d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives

ANS: A If a tracheostomy tube is dislodged, the nurse should immediately attempt to replace the tube by grasping the retention sutures (if available) and spreading the opening. The obturator is inserted in the replacement tube, water-soluble lubricant is applied to the tip, and the tube is inserted in the stoma as a 45-degree angle tot eh neck. The obturator is immediately removed to provide an airway. If the tube cannot be reinserted, the health care provider should be notified and the patient should be assessed for the level of respiratory distress, positioned in semi-Fowler position, and ventilated with a manual resuscitation bag (MRB) only if necessary until assistance arrives.

40. The patient has been diagnosed with an early vocal cord malignancy. The nurse explains that usual treatment includes? a. Radiation therapy that preserves the quality of the voice b. a hemilaryngectomy that prevents the need for a tracheostomy c. a radical neck dissection that removes possible sites of metastasis d. a total laryngectomy yo prevent development of second primary cancers

ANS: A If laryngeal tumors are small, radiation is the treatment of chronic because it can be curative and can preserve voice quality. Surgical procedures are used if radiation treatment is not successful or if larger or advanced lesions are present.

6. The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? a.Use a manometer to ensure cuff pressure is at an appropriate level. b.Check the amount of cuff pressure ordered by the health care provider. c.Suction the patient first with a fenestrated inner cannula to clear secretions. d.Insert the decannulation plug before the nonfenestrated inner cannula is removed.

ANS: A Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient's airway is occluded. A health care provider's order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings.

8. A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask? a."How much alcohol do you drink in an average week?" b."Do you have a family history of head or neck cancer?" c."Have you had frequent streptococcal throat infections?" d."Do you use antihistamines for upper airway congestion?"

ANS: A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.

41. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? a. The postoperative use of of nonverbal communicate techniques b. Techniques that will be used to alleviate a dry mouth and prevent stomatitis c. The need for frequent, vigorous coughing in the first 24 hours postoperativity d. Self-help groups and community resources for parties with cancer of the larynx

ANS: A With removal of the larynx, the patient will not be able to communicate verbally and it is important to arrange with the patient a method of communication before surgery so that postoperative communication can take place. Dry mouth and stomatitis result from radiation therapy. Vigerious coughing is not encouraged immediately postoperatively and information related to community resources is usually introduced during the postoperative period.

7. Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx? a."I will need to buy a water bottle to carry with me." b."I should not use any lotions on my neck and throat." c."Until the radiation is complete, I may have diarrhea." d."Alcohol-based mouthwashes will help clean oral ulcers."

ANS: A Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.

31. While the nurse is feeding a patient, the patient appears to choke on the food. Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? a. stridor b. Cyanosis c. Wheezing d. Bradycardia e. Rapid respiratory rate

ANS: A,B,C With partial airway obstruction, choking, stridor, use of accessory muscles, suprasternal and intercostals retraction, flaring nostrils, wheezing, restlessness, tachycardia, cyanosis, and change in level of consciousness may occur. Partial airway obstruction may progress to complete obstruction without prompt assessment and treatment.

34. During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. To Care for the tracheostomy appropriately, what should the nurse do? a. Deflate the cuff, then remove and suction the inner cannula b. Remove the inner cannula and replace it per institutional guidelines c. Remove the inner cannula if the patient shows signs of airway obstruction d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube

ANS: B An inner cannula is a second tubing that fits inside the outer tracheostomy tube. Disposable inner cannulas are frequently used but non disposable ones can be removed and cleaned of mucus that has accumulated on the inside of the tube. Many tracheostomy tubes do not have inner cannulas because when humidification is adequate, accumulation of mucus should not occur.

37. What is included in the nursing care of the patient with a cuffed tracheostomy tube? a. Change the tube 3 days b. Monitor cuff pressure every 8 hours c. Perform mouth care every 12 hours d. assess arterial blood gases every 8 hours

ANS: B Cuff pressure should be monitored every 8 hours to ensure an air leak around the cuff does not occur and that the pressure is not to high to allow adequate tracheal capillary perfusion. Respiratory therapists in some institutions will record the cuff pressure and identify if there is a problem maintaining cuff pressure. Tracheostomy tubes are not usually changed sooner than 7 days after a tracheostomy. Mouth care should be performed a minimum of every 8 hours and more often as needed to remove dried secretions. ABGs are not routinely assessed with tracheostomy tube placement unless symptoms of respiratory distress continue.

44. What should the nurse include in discharge teaching for the patient with a total laryngectomy? a. How to use esophageal speech to communicate b. How to use a mirror to suction the techeaostomy c. The necessity of never covering the laaryngectomy stoma d. The need to use baths instead of showers for personal hygiene

ANS: B Suctioning of the tracheostomy with the use of a mirror is a self-care activity taught to the patient before discharge. Voice rehabilitation is usually managed by a speech therapist or speech pathologist but the nurse should discuss the various types of voice rehabilitation and the advantages and disadvantages of each options. The laryngectomy stoma should be covered with a shield during showering and covered with light scarves or fabric when aspiration of foreign materials is likely.

14. Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a.Cover stoma with sterile gauze and ventilate through stoma. b.Attempt to reinsert the tracheostomy tube with the obturator in place. c.Assess the patient's oxygen saturation and notify the health care provider. d.Ventilate the patient with a manual bag and face mask until the health care provider arrives.

ANS: B The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.

39. When Obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report? a. Long-term denture use b. Heavy tobacco and/or alcohol use c. Persistent swelling of the neck and face d. Chronic herpes simplex infections of the mouth and lips

ANS: B The primary risk factor associated with head and neck cancers are heavy tobacco and alcohol use and family history. Chronic infections are not known to be risk factors, although cancers in patients younger than age 50 have been associated with human papillomavirus (HPV) infection. oral cancer may cause a change in the fit of dentures but denture use is not a risk factor for oral cancer.

10. A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving? a.The patient lets the spouse provide tracheostomy care. b.The patient allows the nurse to suction the tracheostomy. c.The patient asks how to clean the tracheostomy stoma and tube. d.The patient uses a communication board to request "No Visitors."

ANS: C Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

43. Following a supraglottic laryngectomy, the patient is taught how to use the supraglottic swallow to minimize the risk of aspiration. In teaching the patient about this technique, what should the nurse instruct the patient to do? a. Perform Valsalva maneuver immediately after swallowing b. Breath between each Valsalva maneuver and cough sequence c. Cough after swallowing to remove food from the top of the vocal cords. d. Practice swallowing thin, watery fluids before attempting to swallow solid foods

ANS: C Supraglottic laryngectomy involves removal of the epiglottis and false vocal cords and the removal of the epiglottis allows food to enter to trachea. Supraglottic swallowing protects the trachea from aspiration by taking a deep breath, putting the food or fluid in the mouth, swallowing while holding the breath, coughing immediately after swallowing to remove the food from the top of the vocal cord, swallowing again, then breathing. Super-supraglottis swallowing requires performance of the Valsalva maneuver before placing food in the mouth and swallowing.

4. A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a.Encourage increased incentive spirometer use. b.Encourage the patient to increase oral fluid intake. c.Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.

ANS: C This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.

32. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? a. A tracheostomy is safer to perform in an emergency. b. An ET tube has a higher risk of tracheal pressure necrosis c. A tracheostomy tube allows for more comfort and mobility d. An ET tube is more likely to lead to lower respiratory tract infection

ANS: C With a tracheostomy, patient comfort is increased because there is n tube in the mouth. Because the tube is more secure, mobility is improved. The ET tube is more easily inserted in an emergency situation, It is perforable to perform a tracheostomy in an operating room because it requires careful dissection but it can be performed with local anesthetic in the intensive care unit or in and emergency. With a cuff, tracheal pressure necrosis is as much a risk with a tracheostomy tube as with an ET tube and infection is also as likely to occur because the defenses of the upper airway are bypassed.

9. A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the best response by the nurse? a."You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b."You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c."You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally." d."You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration."

ANS: D Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.

35. Which actions prevent the dislodgment of a tracheostomy (select all that apply)? a. Provide tracheostomy care every 24 hours b. Keep the patient in the semi-Fowler position at all times c. Keep a same size or larger replacement tube at the bedside d. Tracheostomy ties are not changed for 24 hours after tracheostomy produce e. Suction the tracheostomy tube when there is a moist cough or a decreased SpO2 f. A physician performs the first tube change, no sooner than 7 days after the tracheostomy

ANS: D, E, F Changing the tracheostomy tapes or the tube to soon will be irritating to the trachea and could contribute to dislodgment of the tracheostomy tube. Suctioning should be done when increased secretions are evident in the tube to prevent the patient from severe coughing, which could cause tube dislodgment. Tracheostomy care is done every 8 hours. Keeping the patient in a semi-Fowler position will not prevent dislodgment. Keeping and extra tube at the bedside will speed reinsertion if the tracheotomy tube is dislodged but it will not prevent dislodgment.

33. What are the characteristics of a fenestrated tracheostomy tube(select all that apply)? a. The cuff passively fills with air b. Cuff pressure monitoring is not required c. It has two tubings with one opening just above the cuff d. Patient can squeak with an attached air source with the cuff inflated e. Airway obstruction is likely if the exact steps are not followed to produce speech f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted

ANS: E,F The fenestrated tracheostomy tube has openings on the outer cannula to allow air to pass over the vocal cords to allow speaking. If the steps of using the fenestrated tracheostomy tube are not completed in the correct order, severe respiratory distress may result. The cuff of the tracheostomy tube with a foam-filled cuff passively fills with air and does require pressure monitoring, although cuff integrity must be assessed daily. The speaking tracheostomy tube has two tubes attached. One tube allows air to pass over the vocal cords to enable the person to speak with the cuff inflated.