1. Priority Questions 2. Neck Cancer - assessment, interventions, and education related to treatment a. Starts on page 548 in book b. Assessment i. Leukoplakia - patchy lesions in mouth ii. Erythroplakia - red velvety lesions in mouth iii. 2 most important risk factors include alcohol and tobacco use iv. History 1. Difficulty speaking, SOB, tumor bulk, tobacco/alcohol use, acute or chronic laryngitis/pharyngitis, oral sores, difficulty swallowing, lumps in neck, exposure to HPV v. Lab assessment 1. CBC, bleeding time, urinalysis, blood chemistries, HPV test vi. Scans 1. SPECT 2. CT PET 3. Panendoscopy - examination of the upper aerodigestive tract (pharynx, larynx, upper trachea and oesophagus) c. Interventions i. Priority is to remove or eradicate the cancer while preserving function ii. Monitor gas exchange by assessing resp rate, breath sounds, pulse ox, and arterial blood gas values 1. Airway obstruction can occur from tumor growth, edema, or both iii. Teach pt to use the fowler’s or semi fowler's position for best gas exchange iv. d. Education related to treatment i. Radiation therapy 1. After radiation therapy, pt might experience hoarseness, dysphagia, skin problems, impaired taste, dry mouth, sore throat, difficulty swallowing 2. Voice hoarseness usually improves 4-6 weeks after completion of radiation therapy 2 3. For those with sore throat and difficulty swallowing, gargling with saline or sucking on ice may decrease discomfort. Throat sprays with local anesthetic agents such as lidocaine or diphenhydramine may prove temporary relief 4. Skin may become red and tender and may peel during therapy a. Instruct pt to avoid exposure to sun, heat, cold, and abrasive actions such as shaving b. Wear protective clothing made of soft cotton and wash area gently with a mild soap such as Dove c. Use prescribed skin care products 5. If salivary glands are in the path of radiation, the mouth may become dry (xerostomia). This is usually long-term and may be permanent a. If this happens, educate on increased need for oral care to reduce risk of caries, bad breath, and oral infections b. Heavy fluid intake and humidifiers can help, artificial saliva or saliva stimulant may help ii. Concurrent radiation therapy with chemotherapy 1. Intensifies discomfort of radiation alone 2. Educate not to take breaks as this will affect treatment outcome iii. Biotherapy with epidermal growth factor receptor inhibitors 1. Severe skin reactions are common 3. Peritonsillar abscess – treatment (pg 611) a. Rare complication of acute tonsillitis b. Infection spreads from tonsils to surrounding tissue and forms an abscess c. Most common cause is beta-hemolytic step d. Treatment i. Most pts can be treated as outpatients with antibiotics but antibiotics alone are often ineffective ii. Pt may need steroids to reduce swelling iii. Pt may need drainage of abscess iv. Pain control is important 1. Drugs may include topical analgesics, opioids v. Pt may need liquid drugs due to inability to swallow vi. Tonsillectomy may be performed e. Stress adherence of treatment f. Stress coming to the ER if signs of obstruction (drooling and stridor) appear 4. Laryngectomy - pre and post-operative care a. Voice conservation procedures are only used if they do not risk incomplete removal of the tumor (pg 550) b. Entire larynx, hyoid bone, strap muscles, one or two tracheal rings removed 3 c. Partial laryngectomy - some voice may be left, tracheostomy is temporary d. Full laryngectomy - no natural voice is left, upper airway is separated from the throat and esophagus and a permanent laryngectomy stoma is created in the neck e. Pre-op care (pg 551) i. Teach patient and family about tumor ii. Surgeon explains procedure and informed consent iii. Discuss and interpret implications of consent iv. Explain about self-management of the airway, suctioning, pain control methods, the critical care environment (including ventilators and critical care routines), nutritional support, feeding tubes, and plans for discharge. Patient will need to learn new method of speech during the time that mechanical ventilation is used, and depending on surgery type possibly forever 1. Phrase questions in a yes/no format for those who cannot speak f. Post-op care i. Monitor Airway patency, Vital Signs, hemodynamic status, and comfort level. Monitor for Hemorrhage and other General complications of anesthesia and surgery. Take Vital Signs hourly for the first 24 hours and then according to agency policy. ii. complications after surgery include Airway obstruction, Hemorrhage, wound breakdown, tumor recurrence iii. The first priorities after head and neck surgery are airway management and gas exchange. 1. Patients may require ventilator assistance. a. Most are easily weaned from ventilator using a tracheostomy collar and humidified oxygen to help move mucus secretions b. Secretions may remainted blood tinged for 1 to 2 days after c. Report any increased bleed to surgeon d. Laryngectomy tube is used for patients who have undergone a total laryngectomy. These can be changed daily if needed iv. Other priorities include wound, flap, and reconstructive tissue care; pain management; nutrition; psychological adjustment including speech and language therapy v. Surgeon may place a closed surgical drain in neck to collect blood and drainage vi. Coughing and deep breathing is usually effective in clearing/moving mucus vii. Suction away from the surgical site viii. Perform suture care every 1-2 hours 4 ix. Speech for total laryngectomy 1. Esophageal speech (burping speech) may be attempted 2. Electrolarynx (battery powered device) os placed against neck or speech g. Home care (pg 555) i. Avoid swimming, use care when showering and shaving ii. Lean slightly forward and cover stoma when coughing or sneezing iii. Wear stoma guard or loose clothing over stomga iv. Clean stoma with mild soap, lubricate with non-oil based ointment v. Humidify stoma with saline, humidify house vi. Wear a medical alert bracelet 5. Therapeutic communication 6. xoplasty – post-op education (pg 557) a. Surgical reconstruction of the nose b. Pts return from surgery with packing in both nostrils. This is used to prevent bleeding and provide support. i. Because of packing, Pt cannot breathe through the nose c. Observe for edema and bleeding, check vitals every 4 hours until pt is discharged d. If there are no complications, pt can be discharged day-of e. Priority: Assess how often the pt is swallowing after nasal surgery bc repeated swallowing bay indicate posterior nasal bleeding i. Notify surgeon if bleeding is present f. Soft foods can be eaten as soon as gag reflex has returned and pt is alert g. Pt education i. Instruct patient to stay in semi-fowler's position and move slowly ii. Use cool compresses on the nose, eyes, and face to reduce swelling and bruising iii. Get lots of rest iv. To prevent bleeding - first few days after packing is removed 1. Limit valsalva maneuvers (limit forceful coughing and straining during bowel movement) 2. Do not sniff upwards 3. Do not blow nose 4. Do not sneeze with mouth closed 5. Avoid aspirin, NSAIDS 6. Use a humidifier v. Edema lasts for weeks and final surgical result may take 6-12 months 7. Nasal Fractures- assessment, interventions, causes (pg 557) a. Assessment