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Nursing Care Plan for Laryngeal Cancer
Posted by Lif enurses on February 15, 2011
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Cancer of the larynx is a malignant tumor in the larynx (voice box). It is potentially curable if detected early. It represents less
than 1% of all cancers and occurs about four times more frequently in men than in women, and most commonly in persons
50 to 70 years of age. Squamous cell carcinoma constitutes about 95% of laryngeal cancers. Rare laryngeal cancer forms
adenocarcinoma and sarcoma account for the rest. An intrinsic tumor is on the true vocal cords and tends not to spread
because underlying connective tissues lack lymph nodes. An extrinsic tumor is on some other part of the larynx and tends to
spread easily. Laryngeal cancer is classified by its location:
Supraglottis (false vocal cords)
Glottis (true vocal cords)
Sub glottis (rare downward extension from vocal cords).
Pathophysiology and Etiology of Laryngeal Cancer
Occurs predominantly in men older than age 60. Most patients have a history of smoking; those with Supraglottis laryngeal
cancer frequently have a history of smoking and a high alcohol intake. Other risk factors include vocal straining, chronic
laryngitis, industrial exposure, nutritional deficiency, and family predisposition.
About two-thirds of carcinomas of the larynx arise in the glottis, almost one-third arise in the Supraglottis region, and about
3% arise in the subglottic region of the larynx. When limited to the vocal cords (intrinsic), spread is slow because of
lessened blood supply. When cancer involves the epiglottis (extrinsic), cancer spreads more rapidly because of abundant
supply of blood and lymph and soon involves the lymph nodes of the neck.
A malignant growth may occur in three different areas of the larynx: the glottis area (vocal cords), Supraglottis area (area
above the glottis or vocal cords, including epiglottis and false cords), and sub glottis (area below the glottis or vocal cords to
the cricoid).
Two thirds of laryngeal cancers are in the glottis area. Supraglottis cancers account for approximately one third of the cases,
subglottic tumors for less than 1%. Glottic tumors seldom spread if found early because of the limited lymph vessels found
in the vocal.
Causes for Laryngeal Cancer
The cause of laryngeal cancer is unknown. Major risk factors include smoking and alcoholism. Minor risk factors include
chronic inhalation of noxious fumes and familial disposition.
Nursing Diagnosis for Laryngeal Cancer. An initial assessment includes a complete history and physical examination of
the head and neck. This will include assessment of risk factors, family history, and any underlying medical conditions.
Varied assessment findings in laryngeal cancer depend on the tumors location and its stage. With stage I disease, the
patient may complain of local throat irritation or hoarseness that lasts about 2 weeks. In stages II and III, he usually reports
hoarseness. He may also have a sore throat, and his voice volume may be reduced to a whisper. In stage IV, he typically
reports pain radiating to his ear, dysphagia, and dyspnea. In advanced (stage IV) disease, palpation may detect a neck
mass or enlarged cervical lymph nodes.
Diagnostic tests
The usual workup includes laryngoscopy, xeroradiography, biopsy, laryngeal tomography and computed tomography scans,
and laryngography to visualize and define the tumor and its borders. Chest X-ray findings can help detect metastases.
An indirect laryngoscopy, using a flexible endoscope, is initially performed in the otolaryngologists office to visually evaluate
the pharynx, larynx, and possible tumor. Mobility of the vocal cords is assessed; if normal movement is limited, the growth
may affect muscle, other tissue, and even the airway. The lymph nodes of the neck and the thyroid gland are palpated to
determine spread of the malignancy.
If a tumor of the larynx is suspected on an initial examination, a direct laryngoscopic examination is scheduled. This
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examination is done under local or general anesthesia and allows evaluation of all areas of the larynx. Samples of the
suspicious tissue are obtained for histologic evaluation. The tumor may involve any of the three areas of the larynx and may
vary in appearance.
Computed tomography and magnetic resonance imaging (MRI) are used to assess regional adenopathy and soft tissue
and to help stage and determine the extent of a tumor. MRI is also helpful in post-treatment follow-up in order to detect a
recurrence. Positron emission tomography (PET scan) may also be used to detect recurrence of a laryngeal tumor after
treatment.
Nursing Assessment for Laryngeal Cancer
The nurse assesses the patient for the following symptoms: hoarseness, sore throat, dyspnea, dysphagia, or pain and
burning in the throat. The neck is palpated for swelling. If treatment includes surgery, the nurse must know the nature of the
surgery to plan appropriate care. If the patient is expected to have no voice, a preoperative evaluation by the speech therapist
is indicated. The patients ability to hear, see, read, and write is assessed. Visual impairment and functional illiteracy may
create additional problems with communication and require creative approaches to ensure that the patient is able to
communicate any needs.
In addition, the nurse determines the psychological readiness of the patient and family. The idea of cancer is terrifying to
most people. Fear is compounded by the possibility of permanently losing voice and, in some cases, of having some
degree of disfigurement. The nurse evaluates the patients and familys coping methods to support them effectively both
preoperatively and postoperatively.
Nursing Diagnosis For Laryngeal Cancer
Common Nursing Diagnosis found in patient with Laryngeal Cancer
Ineffective airway clearance
Impaired verbal communication
Impaired skin/tissue integrity
Impaired oral mucous membrane
Acute pain
Imbalanced nutrition: less than body requirements
Disturbed body image/ineffective role performance deficient knowledge [learning need] regarding prognosis, treatment,
self-care, and discharge needs
Impaired swallowing
Risk for infection
Nursing Care plan for Laryngeal Cancer. Common nursing diagnosis found in Nursing Care plan for Laryngeal Cancer:
Ineffective airway clearance, Impaired verbal communication, Impaired skin/tissue integrity, Impaired oral mucous
membrane, Acute pain, Imbalanced nutrition: less than body requirements, Disturbed body image/ineffective role
performance deficient knowledge [learning need] regarding prognosis, treatment, self-care, and discharge needs, Impaired
swallowing, Risk for infection
Nursing interventions and rationale Nursing Care plan for Laryngeal Cancer
Nursing Diagnosis Ineffective Airway Clearance May be related to:
Partial or total removal of the glottis, altering ability to breathe, cough, and swallow
Temporary or permanent change to neck breathing dependent on patent stoma
Edema formation surgical manipulation and lymphatic accumulation
Copious and thick secretions
Nursing Outcomes Evaluation Criteria, Client Will:
Respiratory Status: Airway Patency
Maintain patent airway with breath sounds clear or clearing.
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Clear secretions and be free of aspiration.
Nursing Intervention and Rationale Nursing Diagnosis Ineffective Airway Clearance:
Monitor vital sign respiratory rate and depth note ease of breathing. Auscultate breath sounds. Investigate restlessness,
Dyspnea, and development of cyanosis. Rationale Changes in respirations, use of accessory muscles, and presence
of crackles or wheezes suggest retention of secretions. Airway obstruction can lead to ineffective breathing patterns
even partial Airway obstruction and impaired gas exchange, resulting in complications, such as pneumonia and
respiratory arrest.
Elevate head of bed 30 to 45 degrees. Rationale Facilitates drainage of secretions, work of breathing, and lung
expansion.
Encourage swallowing, if client is able. Rationale reducing risk of aspiration with Prevents pooling of oral secretions
Encourage and teach effective coughing and deep breathing. Rationale Mobilizes secretions to clear airway and helps
prevent respiratory complications.
Suction laryngectomy and tracheostomy tube and oral and nasal cavities. Note amount, color, and consistency of
secretions. Rationale Changes in character of secretions may indicate developing problems, such as dehydration and
infection, and need for further evaluation and treatment. Prevents secretions from obstructing airway, especially when
swallowing ability is impaired.
Teach and encourage client to begin self suction procedures as soon as possible. Educate client in clean
techniques. Rationale Reduces anxiety associated with difficulty in breathing or inability to handle secretions when
alone.
Maintain proper position of laryngectomy or tracheostomy tube. Check and adjust ties as indicated.Rationale As edema
develops or subsides, tube can be displaced, compromising airway. Ties should be snug but not constrictive to
surrounding tissue or major blood vessels.
Observe tissues surrounding tube for bleeding. Change clients position to check for pooling of blood behind neck or on
posterior dressings. Rationale bleeding or sudden eruption of uncontrolled hemorrhage presents a sudden and real
possibility of airway obstruction and suffocation.
Provide supplemental humidification Rationale: Normal physiological on nasal passages means of filtering and
humidifying air are bypassed. Supplemental humidity decreases mucous crusting and facilitates coughing or suctioning
of secretions through stoma.
Resume oral intake with caution Rationale Changes in muscle mass and strength and nerve innervations increase
likelihood of aspiration.
Monitor serial ABGs or pulse oximetry and chest x-ray. Rationale Pooling of secretions or presence of atelectasis may
lead to pneumonia, requiring more aggressive therapeutic measures.
Nursing Diagnosis Impaired Verbal Communication related to:
1. Anatomical deficit removal of vocal cords
2. Physical barrier tracheostomy tube
3. Required voice rest
Nursing Outcomes Evaluation Criteria Client Will:
Communication Enhancement: Speech Deficit Independent
Communicate needs in an effective manner.
Identify and plan for appropriate alternative speech methods after healing.
Nursing Intervention and Rationale Nursing Diagnosis Impaired Verbal Communication:
Review preoperative instructions and discussion of why speech and breathing are altered, RationaleReinforces
teaching at a time when fear of surviving surgery is past.
Determine whether client has other communication impairments, such as hearing, vision, and
literacy.Rationale Presence of other problems influences plan for alternative communication.
Provide immediate and continual means to summon nurse Prearrange signals for obtaining immediate
help Rationale Client needs assurance that nurse is vigilant and will respond to summons. May decrease clients
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anxiety about inability to speak.
Allow sufficient time for communication. Rationale Loss of speech and stress of alternative communication can cause
frustration and block expression, especially when caregivers seem too busy or preoccupied.
Encourage ongoing communication with outside world, such as newspapers, television, radio, calendar, and
clock. Rationale Maintains contact with normal lifestyle and continued communication through other avenues.
Caution client not to use voice until physician gives permission. Rationale Promotes healing of vocal cord and limits
potential for permanent cord dysfunction.
Consult or refer with appropriate healthcare team members, therapists, speech pathologist, and social services. Refer
to hospital-based rehabilitation, and community resources, such as Lost Chord or New Voice Club, International
Association of Laryngectomees, and American Cancer Society. RationaleAbility to use alternative voice and speech
methods, such as electrolarynx, TEP, voice prosthesis, and esophageal speech. Rehabilitation time may be lengthy and
require a number of agencies and resources to facilitate or support learning process.
Nursing diagnosis Impaired Skin/Tissue Integrity related to:
Surgical removal of tissues and grafting
Radiation or chemotherapeutic agents
Altered circulation or reduced blood supply
Compromised nutritional status
Edema formation
Pooling or continuous drainage of secretions oral, lymph, or chyle
Nursing Outcomes Evaluation Criteria Client Will:
Wound Healing: Primary Intention
Display timely wound healing without complications.
Demonstrate techniques to promote healing and prevent complications.
Nursing Intervention and Rationale Nursing Diagnosis Impaired Verbal Communication:
Assess skin color, temperature, and capillary refill in operative and skin graft areas. RationaleCyanosis and slow refill
may indicate venous congestion, which can lead to tissue ischemia and necrosis.
Protect skin flaps and suture lines from tension or pressure. Provide pillow or rolls and instruct client to support head
and neck during activity. Rationale Pressure from tubing and tracheostomy tapes or tension on suture lines can alter
circulation and cause tissue injury.
Monitor bloody drainage from surgical sites, suture lines, and drains Rationale Bloody drainage usually declines
steadily after first 24 hours. Steady oozing or frank bleeding indicates problem requiring medical attention.
Note and report any milky-appearing drainage. Rationale Milky drainage may indicate thoracic lymph duct leakage,
which can result in depletion of body fluids and electrolytes. Such a leak may heal spontaneously or require surgical
closure.
Change dressings, as indicated. Rationale Damp dressings increase risk of tissue damage and infection.
Cleanse thoroughly around stoma and neck tubes (if in place), avoiding soap or alcohol. Show client how to do self-care
of stoma and tube with clean water and peroxide, using soft, lint-free cloth, not tissue or cotton. Rationale Keeping area
clean promotes healing and comfort. Soap and other drying agents can lead to stomal irritation and possible
inflammation. Materials other than cloth may leave fibers in stoma that can irritate or be inhaled into lungs.
Monitor all sites for signs of wound infection, such as unusual redness; increasing edema, pain, exudates; and
temperature elevation. Rationale Impedes healing, which may already be slow because of changes induced by cancer,
cancer therapies, or malnutrition.
Administer oral, IV, and topical antibiotics, as indicated. Rationale Prevents or controls infection.
Nursing Diagnosis Impaired Oral Mucous Membrane related to
Dehydration or absence of oral intake, decreased saliva production secondary to radiation or surgical procedure
Poor or inadequate oral hygiene
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Pathological condition oral cancer, mechanical trauma oral surgery
Difficulty swallowing and pooling of secretions and drooling
Nutritional deficits
Nursing Outcomes and Evaluation Criteria Client Will:
Tissue Integrity: Skin and Mucous Membranes
Report or demonstrate a decrease in symptoms.
Identify specific interventions to promote healthy oral mucosa.
Demonstrate techniques to restore and maintain mucosal integrity.
Oral Health Restoration
Nursing Intervention and Rationale Nursing Diagnosis Impaired Oral Mucous Membrane:
Inspect oral cavity, Tongue, Lips Teeth and gums and Mucous membranes note changes in: SalivaRationale Surgery or
Damage to salivary glands Tongue, Lips Teeth and gums and Mucous membranes may decrease production of saliva,
resulting in dry mouth. Pooling and drooling of saliva may occur because of compromised swallowing capability or pain
in throat and mouth.
Suction oral cavity frequently. Have client perform self-suctioning when possible or use gauze wick to drain secretions.
Rationale Saliva contains digestive enzymes that may be erosive to exposed tissues.
Show client how to brush inside of mouth, palate, tongue, and teeth. Rationale Frequent oral care reduces bacteria and
risk of infection and promotes tissue healing and comfort.
Apply lubrication to lips; provide oral irrigations as indicated. Rationale Counteracts drying effects of therapeutic
measures and negates erosive nature of secretions.
Avoid alcohol based mouthwashes. Rationale: Alcohol can be drying and irritating.
Nursing Diagnosis Acute Pain related to:
Surgical incisions
Tissue swelling
Presence of nasogastric or orogastric feeding tube
Nursing Outcomes and Evaluation Criteria Client Will:
Report pain is relieved or controlled.
Demonstrate relief of pain and discomfort by reduced tension and relaxed manner.
Nursing Intervention and Rationale Nursing Diagnosis Acute Pain:
Evaluate pain level frequently. Rationale : Pain is a major concern for clients undergoing laryngectomy and it is believed
as many as 32% still suffer severe distress, with the administered dosing less than needed to obtain optimal pain relief
Investigate changes in characteristics of pain. Check mouth and throat suture lines for fresh trauma. Rationale May
reflect developing complications requiring further evaluation or intervention.
Provide comfort measures, such as back rub and position change, and Diversional activities, such as television, visiting,
and reading. Rationale Promotes relaxation and helps client refocus attention on something beside pain.
Schedule care activities to balance with adequate periods of sleep or rest. Rationale Prevents fatigue or exhaustion and
may enhance coping with stress or discomfort.
Administer analgesics such as on a scheduled basis or via patient-controlled analgesia; adjust dosages according to
pain level per protocols. Rationale Degree of pain is related to extent and psychological impact of surgery as well as
general body condition.
Patient Teaching Discharge and Home Healthcare Guidelines for Patient with Laryngeal Cancer
Patient Teaching Discharge and Home Healthcare Guidelines for Patient with Laryngeal Cancer. Teach the patient signs
and symptoms of potential complications and the appropriate actions to be taken. Complications include infection (wound
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drainage, poor wound healing, fever, achiness, chills), airway obstruction and tracheostomy stenosis (noisy respirations,
difficulty breathing, restlessness, confusion, increased respiratory rate), vocal straining; fistula formation (redness, swelling,
secretions along a suture line), and ruptured carotid artery (bleeding, hypotension).Teach the patient the name, purpose,
dosage, schedule, common side effects, and importance of taking all medications.
Teach the patient the appropriate devices and techniques to ensure a patent airway and prevent complications. Explore
methods of communication that work effectively. Encourage the patient to wear a Medic Alert bracelet or necklace, which
identifies her or him as a mouth breather. Provide the patient with a list of referrals and support groups, such as visiting
nurses, American Cancer Society, American Speech-Learning-Hearing Association, International Association of
Laryngectomees, and the Lost Cord Club
Patient Teaching Discharge and Home Healthcare Guidelines for Patient with Laryngeal Cancer:
Before partial or total laryngectomy, instruct the patient in good oral hygiene practices. If appropriate, instruct a male
patient to shave off his beard to facilitate postoperative care.
Explain postoperative procedures, such as suctioning, NG tube feeding, and laryngectomy tube care. Carefully discuss
the effects of these procedures (breathing through the neck and speech alteration, for example).
After surgery Teach and encourage client to begin self suction procedures as soon as possible. Educate client in
clean techniques. To Reduces anxiety associated with difficulty in breathing or inability to handle secretions when
alone.
Also, prepare the patient for other functional losses. Forewarn him that he wont be able to smell aromas, blow his
nose, whistle, gargle, sip, or suck on a straw.
Reassure the patient that speech rehabilitation measures (including laryngeal speech, esophageal speech, an artificial
larynx, and various mechanical devices) may help him communicate again.
Encourage the patient to take advantage of services and information offered by the American Speech-Language-Hearing
Association, the International Association of Laryngectomees, the American Cancer Society, or the local chapter of the
Lost Chord Club.