Tracheostomy
Head and Neck
Cancer
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Relate the nursing and interprofessional
management of the patient who has a
tracheostomy.
•
Outline the risk factors for and clinical
manifestations of head and neck cancer.
•
Objectives
Discuss the nursing and interprofessional
management of patients requiring surgery for
head and neck cancer.
•
Explain essential components of discharge
teaching for the patient going home with a
permanent tracheostomy after total
laryngectomy for cancer.
•
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Tracheostomy
Surgically created stoma (opening) to:
• Establish a patent airway
• Bypass an upper airway obstruction
• Facilitate secretion removal
• Permit long-term mechanical ventilation
• Facilitate weaning from mechanical ventilation
May be done emergently (cricothyrotomy),
surgically in OR, or percutaneously at bedside
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Tracheostomy
Advantages of tracheostomy over
endotracheal tube
• Easier to keep clean
• Better oral and bronchial hygiene
• Patient comfort increased
• Less risk of long-term damage to vocal cords
•
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Tracheostomy Tubes
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Tracheostomy tube with cuff and pilot balloon
Fenestrated tracheostomy tube with cuff,
inner cannula, and decannulation plug
Speaking tracheostomy tube with cuff and
two external tubings
Tracheostomy tube with foam-filled cuff
Uncuffed tracheostomy tube—long term
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Tracheostomy
Tube
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reserved.
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•
Tracheostomy
Nursing Management
Acute care
• Explain the purpose of procedure
• Prepare for:
• Surgery in OR
• Bedside insertion
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Tracheostomy
Nursing Management
•
Bedside insertion
• Include respiratory
therapist
• Emergency equipment available
• Bag-valve-mask (BVM)
• Record vital signs and SpO2
• Ensure existing IV is patent
• Assess bedside suction
• Position patient supine
• Administer analgesia and/or
sedation
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Tracheostomy
Nursing
Management
•
Postprocedure care
• Obturator removed (keep at
bedside)
• Cuff (balloon) is inflated
• Confirm placement:
• Auscultate for air entry;
end tidal CO2 capnography;
passage of suction catheter
• Chest x-ray
• Tracheostomy sutured in place
and secured
• Monitor VS, SpO2, and
mechanical ventilator settings
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Tracheostomy
Nursing Management
•
•
•
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Monitor for complications
• *Bleeding, airway obstruction,
infection
Assess site and patency at least every
shift
Monitor cuff inflation pressure: 20 to
25 cm H2O
• Minimal occlusion volume
Suction PRN
Humidified air—thins secretions;
reduces mucous plugs
Tracheostomy care per agency policy
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Closed
Suctioning
• (From Potter PA, Perry AG:
Basic nursing: essentials for
practice, ed 7, St Louis, 2011,
Mosby.)
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Tracheostomy Care

Changing tapes (ties)
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Tracheostomy Management
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•
•
•
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Prevent dislodgement
Chronic care / Teaching
Swallowing dysfunction
Speech
Decannulation
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Fenestrated Tracheostomy Tube
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•
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Air passes from lungs through opening in
tracheostomy into upper airway
Must not be at risk for aspiration
Remove inner cannula, deflate cuff, and place
cap on tube
Assess patient for any respiratory distress
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Speaking Tracheostomy Tube
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Two pigtail tubings
• One connects to cuff for inflation
• Other connects to opening just above cuff
• When second tube is connected to
low-flow air source, this permits speech
Can be used on patients at risk for aspiration
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Speaking Valves
Thin diaphragm that
opens on inspiration
and closes on expiration
Air flows over vocal
cords during exhalation
Cuff must be deflated
or use uncuffed tube
(Courtesy Passy-Muir, Inc, Irvine, Calif.)
Evaluate patient’s
ability to tolerate
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Head and Neck Cancer
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•
•
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Structures include nasal cavity, paranasal
sinuses, nasopharynx, oropharynx, larynx,
oral cavity, and/or salivary glands
• Squamous cells in mucosal surfaces
Etiology: smoking (85%)
Age: most over age 50
Risk factors: HPV, excess alcohol, exposure to:
sun, asbestos, industrial carcinogens,
marijuana, radiation to head and neck, and
poor oral hygiene
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Head and Neck Cancer
•
Manifestations—vary with location
• Lump in throat or sore throat
(pharyngeal), white or red patches,
change in voice, hoarseness greater than
2 weeks (laryngeal)
• Other: ear pain, ringing in ears, swelling
or lump in neck, constant cough, cough
up blood, swelling in jaw
• Late signs: unintentional weight loss;
difficulty with chewing, swallowing,
moving tongue or jaw, or breathing;
airway obstruction (partial or full)
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Head and Neck
Cancer
•
Diagnostic studies
• Physical assessment: ears, nose,
throat, mouth, and neck
• Check for: thickening of oral
mucosa, lymph nodes,
leukoplakia, or erythroplakia
• Pharyngoscopy and laryngoscopy for
inspection and biopsies
• CT scan, MRI, PET scan
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Head and Neck Cancer
•
•
Staging
• TMN—size of tumor, number and location of
lymph nodes, extent of metastasis
Interprofessional care—many variables considered
to determine therapy
• Surgery: vocal cord stripping, laser, cordectomy,
partial or total laryngectomy, pharyngectomy,
tracheostomy, lymph node removal, neck
dissection (radical, modified, or selective);
reconstructive
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•
Head and
Neck Cancer
Interprofessional care
• Radiation therapy: External beam or internal implants
• Chemotherapy and targeted therapy
• Used in combination with radiation for stages III or IV
• Nutritional therapy:
• Concerns with swallowing after surgery, side effects of
chemotherapy and/or radiation, oral mucositis;
gastrostomy tube and enteral feedings; assess
tolerance, weight, and risk of aspiration
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Head and Neck Cancer
•
Interprofessional care
• Physical therapy
• Strengthen, support, and move upper
extremities, head, and neck to avoid
limited ROM; continue after
discharge
• Speech therapy
• Preoperative: effect of therapy on
voice and potential adaptations or
restoration; support groups
• Postoperative restoration:
electrolarynx, *transesophageal
puncture (Blom-Singer prosthesis,
Fig. 26-9), esophageal speech
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Head and Neck Cancer
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Nursing management
• Assessment:
• Subjective
• Important health information
• Functional health patterns
• Objective
• Respiratory
• Gastrointestinal
• Possible diagnostic findings
• Nursing Priorities (Nursing Diagnoses &
Planning – Goals)
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reserved.
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Head and
Neck Cancer
•
Nursing implementation
• Health promotion
• Avoid tobacco and excess alcohol
• Good oral hygiene
• Safe sex to prevent HPV
• Acute care
• Explain treatment, care required,
and reasons
• Psychological impact: body
changes, external feedings, loss
of voice
• Support systems; loss of
employment
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Head and Neck Cancer
•
Nursing implementation: surgical therapy
• Preoperatively: physical and psychosocial
needs; assess knowledge and
understanding; how to communicate
post-operatively
• Postoperatively: airway management, VS,
bleeding, wound/drain care, skin flaps,
NGT, nutrition, communication,
psychosocial issues, pain control, trach
care and suction, fluids, and hydration
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Head and
Neck Cancer
•
•
•
•
Nursing implementation
Radiation therapy
• Dry Mouth
(xerostomia)
• Oral mucositis
• Skin care
• Fatigue
Stoma care
Psychosocial needs
• Depression, body
image, sexuality
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Head and Neck
Cancer
•
Nursing implementation:
• Ambulatory care: Patient and caregiver
education
• Tracheostomy care and
suctioning, stoma and skin
care, NGT, enteral feedings
• Medic Alert—neck breather
• Safety—smoke and CO
detectors (loss of smell)
• Resume exercise, recreation,
sexual activity, employment
when able
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Head and Neck
Cancer
•
Evaluation: outcomes
• Patient will:
• Have effective coughing and
secretion clearance
• Swallow without aspiration
• Use effective coping strategies
• Communicate effectively with
others: written and nonverbal
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