INTRODUCTION

The larynx is a part of the throat, between the base of the tongue and the trachea.
It contains the vocal cords, which vibrate and make sound when air is directed
against them. The sound echoes through the pharynx, mouth, and nose to make a
person's voice.

The larynx and vocal cords have several functions:

1.The larynx produces sound for speaking. The vocal cords move and come
together to change the sound and pitch of your voice.
2.The larynx protects your airway when you swallow. The epiglottis and vocal cords
close tightly when you swallow to keep food and fluids from entering your lungs.
3.The vocal cords open naturally when you breathe so that air can get in and out of
your lungs
There are three main parts of the larynx:
Supraglottis: The upper part of the larynx above the vocal cords, including
the epiglottis.
Glottis: The middle part of the larynx where the vocal cords are located.
Subglottis: The lower part of the larynx between the vocal cords and
the trachea (windpipe).

DEFINITION
Cancer of the larynx is a malignant tumor in an around the larynx (voice box).
ETIOLOGY
There is no causative factors of cancer of the larynx .There are however risk
factors that increases a persons chances of developing laryngeal cancer.
Tobacco and Alcohol Use
The risk for these cancers is much higher in smokers than in nonsmokers. The
more you smoke, the greater the risk. Smoke from cigarettes, pipes, and cigars all
increase your chance of developing laryngeal cancers.A person who smokes one
pack a day is 16 times more likely at risk for laryngeal cancer (DOHA., 2012).
Drinking a lot of alcohol over a long period of time increases a persons risk of
developing laryngeal cancer. People who smoke and drink are many times more
likely to get head and neck cancer than are people with neither habit.
Secondhand Smoke
Some studies have also found that long-term exposure to secondhand smoke
might increase the risk of these cancers, but more research is needed to confirm
this.
Workplace Exposures
Long and intense exposures to wood dust, paint fumes, and certain chemicals used
in the metalworking, petroleum, plastics, and textile industries can also increase
the risk of laryngeal cancer.
Exposure to asbestos (a mineral fiber that was often used as an insulating material
in many products in the past) is an important risk factor for lung
cancer and mesothelioma (cancer that starts in the lining of the chest or
abdomen). Some studies have also found a possible link between asbestos
exposure and laryngeal cancer.
Family history
People who have a first degree relative diagnosed with a head and neck cancer
have double the risk of laryngeal cancer of someone without a family history.
Example: parent, brother, sister or child.
Diet
Poor eating patterns are common in people who are heavy drinkers. A poor diet
may increase the risk of cancer of the larynx. This is due to a lack of vitamins and
minerals.

A diet high in fresh fruit and vegetables seems to reduce the risk of cancer of the
larynx. This may be because these foods contain high levels of the antioxidant
vitamins A, C and E. Vitamins and other substances in fresh foods may help to stop
damage to the lining of the larynx that can lead to cancer.
One research study found that a Western style diet, high in processed, fried and
barbecued meat, gives an increased risk of laryngeal cancer.
Low immunity
Studies have shown that people with HIV or AIDS have a risk of laryngeal cancer
that is 3 times higher than people who do not have HIV or AIDS. People who take
immunosuppressant have a risk of laryngeal cancer that is double that of the
general population.
Acid reflux
Stomach acid can sometimes go back up the esophagus and irritate or damage the
esophagus lining. It can occur when people have conditions such as gastroesophageal reflux disease (GERD). GERD can cause heartburn and increase the
chance of cancer of the esophagus.
Gender
Cancers of the larynx and hypopharynx are about 4 times more common in men
than women. This is likely because the main risk factors smoking and heavy
alcohol use are more common in men. But in recent years, as these habits have
become more common among women, their risks for these cancers have increased
as well.
Age
Cancers of the larynx and hypopharynx usually develop over many years, so they
are not common in young people. Over half of patients with these cancers are 65
or older when the cancers are first found.
Race
Cancers of the larynx and hypopharynx are more common among African
Americans and whites than among Asians and Latinos.

CLINICAL MANIFESTATIONS
Early Manifestations
Hoarseness of more than two (2) weeks duration occurs in patients with cancer of
the glottis area because the tumor impedes the action of the vocal cord during
speech.
The voice may sound harsh, raspy, and lower in pitch. Affected voice sounds are
not always signs of subglottic or supraglottical cancer.
The patient may complaint of sore throat and pain and burning in the throat,
especially when consuming of liquids or citrus juices.
A lump may be felt in the neck.
LATE MANIFESTATIONS
Dysphasia
Dyspnea (difficulty breathing)
Unilateral nasal obstruction or discharge
Persistent ulceration
Foul breath
Cervical lymph adeopathy
Unintentional weight loss
General debilitated state,
Pain radiating to the ear may occur with metastasis

DIAGNOSTIC STUDIES
Complete History and Physical Examination of the head and neck.
This assessment should identify risk factors, family history and nay underlying
medical condition. Assessment is carried out to check the mobility of the vocal
cords are carried out- if normal movement is limited the growth may have affected
the muscle, other tissues and even the airway.
The lymph nodes of the neck and the thyroid gland are palpated for enlargement.
Laryngoscopy-is performed under local or general anesthesia to evaluate all
areas of the larynx. In some cases intra-operative examination obtained by direct
microscopic visualization and palpation of the vocal folds may yield a more
accurate diagnosis. Samples are then sent off for analysis.
Fine Needle Aspiration (FNA) biopsy- this is done as an initial screening
procedure to obtain sampled for any enlarged lymph nodes in the neck.
A Barium Swallow may be done if the patient initially presents with a chief
complaint of difficulty in swallowing, to outline any structural anomalies of the
neck that could pinpoint a tumor.
Endoscopy performed to identify the extent of the tumor.
CT or MRI scan are used to assess regional adenopathy and soft tissue and to
stage and determine the extent of a tumor. MRI is also helpful in post treatment
follow up to detect a recurrence.
Positron Emission Tomograpgy (PET)- PET scanning may also be used to
detect recurrence o the laryngeal tumor after treatment.

MEDICAL MANAGEMENT
The goals of laryngeal cancer is geared towards curing; preservation of safe,
effective swallowing; preservation of useful voice; and avoidance of permanent
tracheostoma (Tierney et al., 2012)
Treatment options include surgery, radiation therapy, and adjunctive
chemoradiation therapy.
The treatment plan depends on the location of the tumor and the size, on whether
it as an initial diagnosis or a recurrence.
Early Stage Tumors (Stage I and II)
Patients with early stage tumors and lesions without lymph node involvement,
external beam radiation therapy or conservative surgery (vocal cords striping or
cordectomy) may be effective.
Stage III and IV
Patients with Stage III and IV tumors that are resectable may be advised to have
either total with or without post operative therapy or radiation therapy with
concurrent chemotherapy (with single-agent Cisplatin). If the patient is unsuitable
for two treatments together, they may receive biological therapy alongside
radiotherapy. Patients with late stage tumors that extend through cartilage and
into soft tissues generally are advised to have total laryngectomies with post
operative radiation therapy ( GLibert et al., 2009).
Drugs used in Chemotherapy
Cisplatin
Daxirubusin
Carboplatin
Docetaxel
Paclitaxel
Bleomycin
Methotrzate
Ifofamide

5-FU

Drug Card
Name of Drug: Generic Name
Cisplatin

Brand Name
Platinol

Pregnancy Category: Category D

Therapeutic Class; Antineoplastics
Pharmocologial Class: Alkylating Agents
Indiccations : Metastatics testicular and ovarian carcinoma.
Adavnced bladder cancer
Head and neck cancer
Cervial Cancer
Lung cancer
Other tumors.
Action: Inhibits DNA synthesis by producing cross- linking of parent DNA stands
( cellcycle phasenonsepcific).
Therapeutics Effect: Death of rapidly replicating cells particularly malignant ones.
Route
Iv

Onset
Unknown

Peak
18- 23 days

Duration
39 days

Contraindication/ Precautions
Contraindicated in: Hypersensitivity
OB: Lactation: Pregnancy or Lactation
Use cautiously in:Hearing loss
Renal impairment (dosage recommended)
Heart failure

Electrolyte abnormalities
Active infections
Bone marrow depression
Geri: Risk of nephrotoxicity and peripheral neuropathy
Adverse Effects/ Side effects
CNS:REVERSIBLE POSTERIOR LEUKOENCEPHALOPATHY SYNDROME (RPLS),
SEIZURES,Malaise, weakness
EENT: ototoicity, tinnitus
GI: severe nausea, vomiting, diarrhea, hepatoxicity
GU: nephrotoxicity, sterility
DERM: alopecia
F and E: hypoclacemia, hypokalemia, hypomagnesaemia
Hemat: LEUKOPENIA, THROSYTOPENIA, anemia
Local: phlebitis at IV site
Metabolic: hyperuricemia
Neuro: Pheripheral Neuropathy
Misc: Anaphylactios reactions
*CAPITALSletters indicate life-threatening.
Italics indicated most frequent
Nursing Consideration
Assessment

1. Monitor vital signs during administration.

2. Monitor intake and output and specific gravity during therapy.to reduce risk of
nephrotoxicity.
3. Encourage to drink 2000-3000 mL/day of water to promote excretion of uric acid.
4. Assess IV site. It may cause necrosis of tissue if extravasation.
5. Administer parenteral antiemetic agents 30-45 min before the therapy and routinely
around the clock for the next 24hours.
6. Assess for bleeding: petechiae, stools, urine, and emesis. Apply pressure to
venipuncture sites for 10 minutes.
7. Medications may cause ototoxicity and neurotoxicity. Assess patient for dizziness,
numbness and tingling of extremities.
8. Before administering clarify all ambiguous orders, double check single,
daily and course of therapy dose limits.

Name of Drug:
Generic Name
Docetaxel
Docefrez, Taxotere

Trade Name

Pregnancy Category : Category D

Therapeutic Class : Antineoplastics
Pharmacological Class : Taxoids
Indications: - Breast cancer (locally advanced/metastatic breast cancer or with
doxorubicin and
cyclophosphamide as adjuvant treatment of node-positive
disease).
- Nonsmall-cell lung cancer (locally advanced/metastatic) after
failure on platinum
regimen or with platinum as initial therapy).
- Advanced metastatic hormone-refractory prostate cancer (with
prednisone).
- Squamous cell carcinoma of the head and neck (locally advanced)
with cisplatin and
fluorouracil.
- Gastric adenocarcinoma (locally advanced) with Cisplatin and
Fluorouracil.
Action:
- Interferes with normal cellular microtubule function required for
interphase and
mitosis.
Therapeutic Effect: - Death of rapidly replicating cells, particularly malignant
ones.
Route
IV

Onset
Rapid

Contraindication/Precautions
Contraindicated in: - Hypersensitivity;

Peak
5-9 days

Duration
7 days

Hypersensitivity to polysorbate 80;

Known alcohol intolerance;
Neutrophil count <1500/mm3;
Liver impairment (serum bilirubin > upper limit of normal, ALT and/or AST >1.5
times upper limit of normal, with alkaline phosphatase >2.5 times upper limit
of normal);
OB: Lactation: Pregnancy or lactation.
Use Cautiously in:
OB: Patients with child-bearing potential;
Pedi: Efficacy not established.
Adverse Reactions/Side Effects
CNS: fatigue, weakness
Resp: ACUTE RESPIRATORY DISTRESS SYNDROME, INTERSTITIAL LUNG DISEASE,
PULMONARY FIBROSIS, bronchospasm, dyspnea
CV: ASCITES, CARDIAC TAMPONADE, PERICARDIAL EFFUSION, PULMONARY
EDEMA,peripheral edema
GI: diarrhea, nausea, stomatitis, vomiting
Derm: alopecia, edema, rash, dermatitis, desquamation, erythema, nail disorders
Hemat: anemia, leukopenia, thrombocytopenia, leukemia
Local: injection site reactions
MS: myalgia, arthralgia
Neuro: neurosensory deficits, peripheral neuropathy
Misc: HYPERSENSITIVITY REACTIONS, INCLUDING ANAPHYLAXIS
* CAPITALS indicate life-threatening.
Italics indicate most frequent.
Nursing Consideration:
1. Monitor vital signs before and after administration.
2. Assess infusion site for patency. Docetaxel is not a vesicant. If extravasation
occurs, discontinue docetaxel immediately and aspirate the IV needle. Apply cold
compresses to the site for 24 hr.
3. Monitor for hypersensitivity reactions continuously during infusion. These are
most common after the first and second doses of docetaxel. Reactions may consist
of bronchospasm, hypotension, and/or erythema. Mild to moderate reactions may
be treated symptomatically and infusion slowed or stopped until reaction subsides.
Severe reactions require discontinuation of therapy and symptomatic treatment.
Do not readminister docetaxel to patients with previous severe reactions. Severe
edema may also occur. Weigh patients before each treatment. Fluid accumulation
may result in edema, ascites, and pleural or pericardial effusions. Pretreatment
with corticosteroids (such as dexamethasone 8 mg PO twice daily for 3 days,

starting 1 day before docetaxel) is recommended to minimize edema and

hypersensitivity reactions. PO furosemide may be used to treat edema. For
hormone-refractory metastatic prostate cancer (given with prednisone),
recommended premedication regimen is dexamethasone 8 mg PO, at 12 hr, 3 hr
and 1 hr before docetaxel infusion.
4.Monitor for bone marrow depression. Assess for bleeding (bleeding gums,
bruising, petechiae; guaiac stools, urine, and emesis) and avoid IM injections and
taking rectal temperatures if platelet count is low. Apply pressure to venipuncture
sites for 10 min. Assess for signs of infection during neutropenia. Anemia may
occur. Monitor for increased fatigue, dyspnea, and orthostatic hypotension.
5. Assess for rash. May occur on feet or hands but may also occur on arms, face, or
thorax, usually with pruritus. Rash usually occurs within 1 wk after infusion and
resolves before next infusion.
6. Assess for development of neurosensory deficit (paresthesia, dysesthesia, pain,
burning). May also cause weakness. Pyridoxine (vitamin B 6) may be used to
minimize symptoms. Severe symptoms may require dose reduction or
discontinuation.
7. Assess for arthralgia and myalgia, which are usually relieved by nonopioid
analgesics but may be severe enough to require treatment with opioid analgesics.
8. Assess for diarrhea and stomatitis. If Grade 3 or 4, reduce dose.
9. Monitor CBC and differential before each treatment. Frequently causes
neutropenia (<2000 neutrophils/mm3 ); may require dose adjustment. If the
neutrophil count is less than 1500/mm3, hold dose. Neutropenia is reversible and
not cumulative.
10. Monitor liver function studies (AST, ALT, alkaline phosphatase, bilirubin) before
each cycle.
11.High Alert: Fatalities have occurred with chemotherapeutic agents.
Before administering, clarify all ambiguous orders; double-check single,
daily, and course-of-therapy dose limits; have second practitioner
independently double-check original order, calculations, and infusion
pump settings. Do not confuse Taxotere (docetaxel) with Taxol
(paclitaxel).
12. Solution should be prepared in a biologic cabinet. Wear gloves, gown, and
mask while handling medication. Discard IV equipment in specially designated
containers.

Patient/Family Teaching
1.Instruct patient to report symptoms of hypersensitivity reactions (trouble
breathing; sudden swelling of face, lips, tongue, throat; trouble swallowing; hives;
rash; redness all over body) to health care professional immediately.
2. Advise patient to notify health care professional if fever >101F; chills; sore
throat; signs of infection; bleeding gums; bruising; petechiae; or blood in urine,
stool, or emesis occur. Caution patient to avoid crowds and persons with known
infections. Instruct patient to use soft toothbrush and electric razor.
3. Patient should be cautioned not to drink alcoholic beverages or take products
containing aspirin or NSAIDs.
4. Fatigue is a frequent side effect of docetaxel. Advise patient that frequent rest
periods and pacing of activities may minimize fatigue.
5. Instruct patient to notify health care professional if signs of fluid retention
(peripheral edema in the lower extremities, weight gain, dyspnea), abdominal pain,
yellow skin, weakness, paresthesia, gait disturbances, swelling of the feet, or joint
or muscle aches occur.
6. Instruct patient to inspect oral mucosa for redness and ulceration. If mouth sores
occur, advise patient to use sponge brush and rinse mouth with water after eating
and drinking.
7.Instruct patient to notify health care professional of all Rx or OTC medications,
vitamins, or herbal products being taken and consult health care professional
before taking any new medications.
8. Discuss with patient the possibility of hair loss. Complete hair loss usually begins
after 1 or 2 treatments and is reversible after discontinuation of therapy. Explore
coping strategies.
9. Instruct patient not to receive any vaccinations without advice of health care
professional.
10. Advise female patients to use effective contraception during therapy and to
notify health care professional if pregnancy is planned or suspected or if breast
feeding.
11. Emphasize the need for periodic lab tests to monitor for side effects.

SURGICAL

MANAGEMENT

The overall goal for the patient undergoing surgical treatment includes minimizing
the effects of surgery on speech, swallowing, and breathing while maximizing the
cure of the cancer.
Surgical options include; vocal cord stripping, cordectomy, laser surgery, partial
laryngectomy or total laryngectomy ( De Vita et al., 2011).
Vocal Cord stripping
Stripping of the vocal cord is used to treat dysplasia, hyperkeratosis, and
leukoplakia. The procedure involves removal of the muscosa of the edge of the
vocal cord, using an operative microscope. Early vocal cord lesions are initially
treated with radiation therapy.
Cordectomy
This is an excision of the vocal cord performed by a transoral laser. This procedure
is used for lesions limited to the middle third of the vocal cord.
Laser Surgery

The carbon dioxide laser can be used for the treatment of many laryngeal tumors.
The treatment and recovery are shorter with very few side effects .
Partial Laryngectomy
A partial laryngectomy ( laryngofissure-thyrotomy) is often used for patients in the
early stages of cancer in the glottis area when only one vocal cord is involved. This
type of surgery is associated with very high cure rate. It is also performed for
recurrence when radiation therapy has failed. In this procedure a portion of the
larynx is removed, along with one vocal cord and the tumor. All other structures
remain intact; the airways and the patient is expected to have no difficulty
swallowing. The voice quality may change or the patient may sound hoarse.
Total Laryngectomy
This involves complete removal of the larynx and it provides a cure in the most
advanced of laryngeal cancer and recurrence.
In this procedure the laryngeal structures are removed, including the hyoid bone,
epiglottis, cricoids cartilage and two or three rings of the trachea. The tongue,
pharyngeal walls and most of the trachea are preserved. A total laryngectomy
results in permanent loss of voice and a change in the airway. This requires the use
of a permanent tracheostomy because the larynx which provides the protective
sphincter is no longer present. The tracheal stoma prevents the aspiration of food
and fluid into the lower respiratory tract. The patient has no voice but normal
swallowing.
Tracheostomy
A tracheostomy is a surgical procedure in which an opening is made into the
trachea. The indwelling tube inserted into the trachea is called a tracheostomy
tube.

Categories of Tracheotomy
A temporary tracheostomy can be formed when patients require long term
respiratory support or are unable to protect their own airways
A permanent tracheostomy is created where the trachea is brought out to the
surface of the skin and sutured to the neck wall. This stoma is kept open by the
rigidity of the tracheal cartilage. The patient will breathe through this stoma for the
remainder of his/her life. As a result, there is no connection between the nasal
passages and the trachea.

A
B
C
Figure 1.A. Patient with a tracheostomy tube. B. Fenestrated tube, which allows the
patient to talk. C. Double-cuffed tube, inflating the two cuffs alternately can help prevent
tracheal damage.

Uses
1.
2.
3.
4.
5.

of tracheostomy
To bypass an upper airway obstruction
To allow the removal of tacheobronchial secretions
To permit the long term use of mechanical ventilation
To prevent aspirations of oral or gastric secretions
To replace an endotracheal tube

Procedure
It is performed in the operating room or in the ICU, where the patients ventilation
can be well controlled and aseptic technique can be maintained. A surgical opening
is made between the second and third tracheal rings. After the trachea is exposed,
a cuffed tracheostomy tube of an appropriate size is inserted. The cuff is inflated to
occlude the space between the tracheal walls and the tube, to maintain effective
mechanical ventilation and minimized the risk of aspiration. It is held in place
around the patients neck by tape. Usually, a square of sterile gauze is placed
between the tube and the skin to absorb drainage and reduce the risk of infection.

COMPLICATIONS
Early and late complications may occur during the course of tracheostomy tube
management. It can occur a number of years later after the tube has been
removed.
Tube dislodgement leading to loss of airway
When patient is being moved ONE person must be designated solely to support the
tracheostomy tube. Whilst holding the tracheostomy tube, pressure must be

applied to the patients torso by the butt of the hand. This enables a firm hold on
the tracheostomy particularly if the patient coughs or moves unexpectedly. If tube
becomes dislodged never blindly reinsert tube, re-establish airway with an endotracheal tube. If in the ward, call a MET. Initial dressing and tapes remain intact for
at least 24hours
Hemorrhage
Adequate haemostasis at the time of formulation.
Blocked Tracheostomy
Air is usually moistened and warmed in the upper airways. It is also cleaned by the
action of cilia. Inserting a tracheostomy tube bypasses these natural mechanisms,
which means the lungs will receive cool, dry air. Dry air entering the lungs may
reduce the motility of the secretions within the lungs and may reduce the function
of the cilia. In addition the patient may not be able to cough and/or clear the
secretions from their airways through the tracheostomy. This may cause the
tracheostomy to become blocked by these thick or dry secretions. This may be
prevented by careful humidification, tracheal suction and inner tube care. However
it is necessary to keep emergency equipment at hand at all times as a blocked
tube may lead to increasing difficulty breathing and even death.
Displaced Tracheostomy Tube
The tracheostomy tube can be displaced completely and come out of the stoma or
out of the trachea into the soft tissue of the neck.
In order to keep tracheostomy tubes in position they must be secured with tapes.
Tapes that are well secured should allow two fingers to pass freely around the
inside of the tapes. Ensure tapes are not too tight as this has the potential to cause
pressure areas around patients neck. If unsure whether the tube is in the trachea,
listen to the chest bilaterally.
Pneumonia
A build up of secretions may also lead to consolidation and lung collapse, and this
may lead to pneumonia. This may also be prevented by careful humidification,
good physiotherapy, tracheal suction and inner tube care. Aspiration of gastric
contents may also lead to pneumonia. This can occur with patients who are unable
to swallow safely.
Site Infection
There is a risk of site infection caused by introduction of organisms from the
sputum. Careful observation and dressing of the site will reduce this.
Tracheal Damage
Damage to the trachea may be caused by poor tracheal suctioning techniques.
An inner tube should always be inserted to a nonfenestrated tube prior to
performing tracheal suction to ensure the suction catheter does not pass through
the fenestration causing tracheal damage. There is also a potential for a cuffed

tube to damage the trachea. This is due to pressure from the cuff causing necrosis
of the tracheal tissue. All tracheostomy tubes now have low-pressure cuffs,
however overinflation should still be avoided. The pressure in the cuff should be
just adequate to prevent air leakage

Nursing Management
Nursing Intervention
Oxygenation

Suctioning the Tracheostomy Tube

1. Assess vital signs and the need for
suctioning.

Rationale
1.Routine unnecessary
suctioning causes mucosal
damage, bleeding, and
bronchospasm. Suctioning is

2. Suction patient through the artificial

airway, nose and mouth..no longer than
15 seconds.
3. Assess for signs of hypoxia (increased
heartrate and blood pressure,
oxygenation desaturation, cyanosis,
restlessness, anxiety, cardiac
dysrhythmias).
4. Use a catheter of the correct size.
(standard size is 12 Fr. Or 14 Fr).
Maintaining a Patent Airway
5.Place patient in semi Fowlers
position.
6. Encourage and implement the
patient to turn, cough anddeep
breathing techniques (positioning,
incentive spirometer , frequent position
changes every 1 to 2 hours ,splinting of
chest)
7. Assess lung sounds.
8. Monitor oxygenation saturation.
9. Encourage and assist the patient with
early ambulation.
Air Warming and Humidification
10. Assess for adequate humidification
of the environment.

needed when audible or noisy

secretion, crackles, wheezes are
heard upon auscultation,
increase pulse and respiration
rates or mucus in is present in
the artificial airway.
2. Prolonged suctioning can
cause alveolar collapse.
3. Hypoxia may occur if
suctioning is prolonged, there is
ineffective oxygenation before,
during and after suctioning, to
frequent suctioning.
4. Correct catheter size allows
efficient removal of secretion
without causing hypoxemia.
5. This facilitates ventilation,
promote drainage, minimize
edema, and prevent strain on
the suture lines.
6. Promotes alveolar expansion
and alveolar collapse.
7. Assessment is done to
identify impending
complications.
8. Used for the measurement of
arterial oxygen
saturation (SaO2,) of
hemoglobin.

11. Humidify the air as prescribed.

9. prevents atelectasis,
pneumonia, and deep vein
thrombosis.

12. Assess for fine mist emerging from

the tracheostomy collar or T-piece
during inspiration and expiration.

10. Decreasescough, mucus

production and crusting around
the stoma.

13. Place warming device to

humidification source.

11. Thick, dry secretions can

occlude the airways.

Bronchial and Oral Hygiene

12. Assessment identifies if

humidification is adequate.

14. Implement coughing and deep

breathing combined chest percussion,

vibration and postural drainage.

13. Increases the amount of

humidity delivered.

15. Implement proper oral care.

16. Avoid using glycerin swabs or
mouthwash that contain alcohol to
clean the mouth.

Temperature

17. Assess for cool , pale, diaphoretic

skin.

14. This promotes pulmonary

care by reducing the risk of
respiratory complications such
as lung collapse and pneumonia.
15. Oral hygiene is important to
keep airway patent. To prevent
bacterial overgrowth and dental
caries.
16. These products dry the
mouth.
17. Suggest ineffective
circulation due to hypovolemia .

Nutrition
1. Ensure adequate hydration.
2. keep NPO as ordered by physician.
3. Monitoring intake and output and
noting signs of
dehydration/malnutrition.
3. Administer parenteral fluids as
prescribed by physician.

1. Helps liquefy secretions.

2. the patient may not be able
to eat or drink for atleast 7 days.
3. Parenteral fluids are
necessary to restore volume.
Ringer lactate is usually the fluid
of choice due to its isotonic
properties and close
resemblance to electrolyte
composition .

Elimination
1.Measure and record and drainage.

1.To identify accumulation of

fluid or secretions.

2. Asses the color and amount of

urine. Concentrated urine and
output <30cc for 2 consecutive
hours.

2. To determine if hydration if
adequate.

Rest and activity

1. Assess and implement activities
that promote feelings of comfort
example, listening to music; reading.

1. This promotes relaxation

and reduces anxiety.

Safety and Security

1.Hand washing- wash hands and
teach others to wash hands before
and after patient care,

1. Hand washing reduces the

transmitting of pathogens
from one area of the body to
another

2.Use individual suction catheters

when suctioning the patient.

2. Infection may be
introduced to the lungs from
the mouth.

3.Use sterile technique when

suctioning the patient.
4.Daily stoma care with soap and
water or another prescribed solution
and a gauze. Taking care to prevent
water and soap from entering the
stoma.

3. Reduces the transmission

of microorganisms and
prevents sepsis.
4. Prevents build up of
secretions.
5.

5. Crusting is removed with sterile

tweezes and additional ointment is
applied.

6. To reduce risk of trauma.

6. Keep the cuff pressure between

14 and 20 mm Hg 0r 20 and 28cm
H2O.

7. To keep the pressure at 14

to 20 mmHg or 20 and 28cm
H2O

7. Assess the cuff pressure at least

once during each shift. Especially
with minimal leak technique.

8. To reduce the risk of

aspiration.

8. Keep the head of bed elevated

for at least 30 mins after eating.
9. Keep bed rails up at all times.
10. Use PPE, whenever necessary.
Emotional Safety
1. The nurse should spend with the
patient immediately after
postoperative period.
2. Acknowledge patient frustration
with communication and allow time
for communication.
3.When speaking to the patient, use
a normal tone of voice.

9. To prevent risk of falling

which can cause patient
harm.
10. Prevent the spread of
microorganism.
1. This is focused on building
trust and reducing anxiety.
2. Writing everything can be
very frustrating and time
consuming for the patient.
3. The tracheostomy tube
does not alter hearing or
comprehension.

4.Keep paper and pen or a Magic

Slate and the call light within the
patients reach.
Love and Belonging
1.Clear instructions are given to the
patients family in calm, reassuring
manner.
2.Help the patient set realistic goals,
starting with involvement in selfcare.
3. The nurse discards notes used for
communication by the client.

4. Ensures a mean of
communication.

1. Reassures the patients

family about condition and
well being.
2. Promotes independence.
3. Ensures the patients
privacy.
4. Helps the patient to
respond efficiently.

4. Phrase questions for yes or no

answers.

Self Esteem
1. Place paper towel, gauze or a
cloth may be worn below the
tracheostomy tube.
2. The nurse encourages the patient
to express feelings about changes
brought about by surgery,
particularly feelings related to fear,
anger, depression, and isolation.
3. Provide encouragement and
positive reinforcement while
demonstrating acceptance and
caring behaviours.
4. Assess the family for the need for
counseling.
5. Encourage to wear loose-fitting
shirts, decorative collars or scarves
to cover tracheostomy tube.

1.Serves as a barrier to
protect the clothing from
copious mucus that the
patient may expel.
2. To help the patient with
changes in his/her life.
3. Reassures the patient.
4. Assessment identifies the
need additional emotional
support.
5. This is done because the
patient may feel shy and
socially isolated.
6. Prevent halitosis and dry
mouth.
7. Prevents cracked lips or
skin breakdown and promotes

6. Help the patient wash his/her

mouth every 4 hours while awake or
when he/she desires.
7. Apply lip balm or water soluble
jelly.
8. Offer an opportunity for patient
participation or an family member to
perform cares.

patient comfort.
8.Allows participation in care
and increases slef-esteem.

BIBLIOGRAPHY
Lemone Priscilla, Burke Karen, Bauldoff Gerene. Medica-Surgical Nursing: Critical Thinking
in Pateint Care.Fifth edition. Page 848. United states of America:Pearson Education,
Inc.2011. Lemone Priscilla, Burke Karen, Bauldoff Gerene
Ignatavicius Donn,Workman Linda .Medical Surgical Nursing: Patient centered
Collaborative Care. 6th edition 2010. Saunders Elsevier limited
Laryngeal and Hypopharyngeal: Cancer 2015 American Cancer Society, Inc. Last Medical
Review: 04/08/2014
Last Revised: 03/02/2015

Figure1. Parts of a Tracheostomy Tube