CHAPTER 27 Upper Respiratory Problems

oral hygiene. Explanations and emotional support are of special

significance and should include postoperative measures relating
to communication and feeding. Explain the surgical procedure
to the patient and family, and make sure they understand the
information.
You must tailor teaching to the planned surgical procedure.
For surgeries that involve a laryngectomy, teaching should

539

include information about expected changes in speech. The

nurse or speech pathologist should demonstrate means of communicating other than speaking that the patient can use either
temporarily or permanently. This may include some type of
communication board.
After surgery, maintenance of a patent airway is essential.
The inflammation in the surgical area may compress the trachea.

NURSING CARE PLAN 27-2

Patient Having Total Laryngectomy and/or Radical Neck Surgery
NURSING DIAGNOSIS
NURSING DIAGNOSIS
NURSING DIAGNOSIS
NURSING DIAGNOSIS

Ineffective airway clearance*

Risk for aspiration*
Risk for infection*
Anxiety related to lack of knowledge regarding surgical procedure, pain management, and prevention of complications as
evidenced by questioning about impending surgery, postoperative care, agitation, and restlessness
1. Verbalizes that information provided preoperatively reduced anxiety
2. Demonstrates effective use of relaxation techniques

PATIENT GOALS

OUTCOMES (NOC)
Anxiety Self-Control

INTERVENTIONS (NIC) AND RATIONALES

Anxiety Reduction

Seeks information to reduce anxiety _____

Uses effective coping strategies _____
Uses relaxation techniques to
reduce anxiety _____
Controls anxiety response _____

Encourage verbalization of feelings, perceptions, and fears to understand patients perspective of situation, treatment, and prognosis to begin adjustment and acceptance.
Provide factual information concerning diagnosis, treatment, and prognosis to reduce patients sense
of helplessness and increase sense of control.
Assist patient to articulate a realistic description of upcoming event.
Encourage family to stay with patient to provide caring and support.

Measurement Scale

1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated

NURSING DIAGNOSIS
PATIENT GOALS

Acute pain related to surgical tissue injury as evidenced by report of discomfort; facial mask of pain; changes in blood
pressure, pulse, and respiratory rate
1. Reports satisfaction with pain relief
2. Uses pain relief techniques effectively

OUTCOMES (NOC)
Pain Control

INTERVENTIONS (NIC) AND RATIONALES

Pain Management

Uses analgesics appropriately _____

Uses nonanalgesic relief measures
appropriately _____
Reports pain controlled _____

Observe for nonverbal cues of discomfort, especially in those unable to communicate effectively (e.g.,
facial expression, reluctance to cough or move) to plan appropriate interventions.
Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity, or severity of pain and precipitating factors.
Teach use of nonpharmacologic techniques (e.g., relaxation, guided imagery, music therapy, distraction, and massage) before, after, and, if possible, during painful activities; before pain occurs or
increases; and along with other pain relief measures to manage pain.
Provide the person optimal pain relief with prescribed analgesics to provide consistent therapeutic
levels of analgesics.
Use pain control measures before pain becomes severe.

Measurement Scale

1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated

NURSING DIAGNOSIS
PATIENT GOAL

Imbalanced nutrition: less than body requirements related to surgical procedure, edema, and dysphagia as evidenced by
absence of or inadequate oral intake
1. Maintains body weight
2. Consumes adequate fluids and nutrients to meet metabolic needs in the postoperative period

OUTCOMES (NOC)
Nutritional Status

INTERVENTIONS (NIC) AND RATIONALES

Nutrition Therapy

Complete a nutritional assessment.

Administer enteral feedings to provide adequate nutrients while wound heals.
Ensure availability of progressive therapeutic diet to allow patient time to adjust to initiation of oral
intake.
Instruct patient and family about prescribed diet.
Monitor food/fluid ingested and calculate daily caloric intake to evaluate effectiveness of therapy.

Nutrient intake _____

Weight/height ratio _____
Food intake _____
Fluid intake _____

Measurement Scale

1 = Severe deviation from normal range

2 = Substantial deviation from normal range
3 = Moderate deviation from normal range
4 = Mild deviation from normal range
5 = No deviation from normal range

Continued

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SECTION 5 Problems of Oxygenation: Ventilation

NURSING CARE PLAN 27-2contd

Patient Having Total Laryngectomy and/or Radical Neck Surgery

NURSING DIAGNOSIS Impaired verbal communication related to removal of vocal cords as evidenced by inability to speak
PATIENT GOAL Communicates basic needs using written and nonverbal communication techniques
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES
Communication
Communication Enhancement: Speech Deficit

Use of written language _____

Use of pictures and drawings _____
Use of sign language _____
Use of nonverbal language _____
Exchanges messages accurately
with others _____

Instruct patient and family on use of speech aids (e.g., tracheal-esophageal prosthesis and artificial
larynx).
Use picture board.
Listen attentively.
Reinforce need for follow-up with speech pathologist after discharge to learn use of voice prosthesis,
electrolarynx, or esophageal speech.

Measurement Scale

1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised

NURSING DIAGNOSIS
PATIENT GOAL

Disturbed body image related to disfiguring surgery and loss of speaking ability as evidenced by withdrawal, depression,
isolation, unwillingness to look at self or assist with care, and refusal to see visitors
1. Acknowledges changes in body image
2. Discusses feelings about and the meaning of changes in physical appearance
3. Participates in self-care

OUTCOMES (NOC)
Body Image

INTERVENTIONS (NIC) AND RATIONALES

Body Image Enhancement

Adjustment to changes in physical

appearance _____
Adjustment to changes in body
function _____
Willingness to use strategies to enhance
function _____

Use anticipatory guidance to prepare patient for predictable changes in body image to facilitate effective coping mechanisms.
Assist patient to discuss changes caused by illness or surgery.
Identify means of reducing the impact of any disfigurement through clothing or cosmetics to aid in successful adjustment.
Assist patient to separate physical appearance from feelings of personal worth to increase acceptance
of altered physical appearance.

Measurement Scale

Socialization Enhancement

1 = Never positive
2 = Rarely positive
3 = Sometimes positive
4 = Often positive
5 = Consistently positive

Encourage enhanced involvement in already established relationships as acceptance by significant others is a critical factor in patients own acceptance.

Self-Care Assistance
Encourage patient to perform normal activities of daily living to level of ability as participation in selfcare is a sign of successful adjustment.

NURSING DIAGNOSIS
PATIENT GOALS

Deficient knowledge related to lack of exposure to information and unfamiliarity with informational resources as evidenced
by verbalized concern about ability to manage self-care at home
1. Demonstrates satisfactory care of tubes and incisions
2. Verbalizes key elements of the therapeutic regimen and speech rehabilitation, including knowledge of disease, complications, and
treatment plan

OUTCOMES (NOC)
Discharge Readiness: Independent
Living
Seeks assistance appropriately _____
Uses available social support _____
Describes signs and symptoms to health
care professional _____
Describes prescribed treatments _____
Describes risks for complications _____
Manages own medications _____

INTERVENTIONS (NIC) AND RATIONALES

Teaching: Psychomotor Skill
Provide written information/diagrams as an accurate reference reduces error.
Demonstrate skill for the patient.
Observe patient return-demonstrate the skill to ensure correct performance of technique.

Teaching: Disease Process

Instruct patient on which signs and symptoms to report to health care provider to detect possible recurrence of tumor or tracheal stenosis.
Refer patient to local community agencies/support groups.

Measurement Scale

1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
*Because a tracheostomy is usually performed for the patient with a total laryngectomy and/or radical neck surgery, see the related nursing care plan, NCP 27-1, on pp. 532 to 534 for
these nursing diagnoses.