Laryngeal Mass

8/6/2019 Laryngeal Mass

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By Gretchen Remolador

And friends from Ward 3A


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I. INTRODUCTION

y Malignant tumor of the larynx is also known as laryngeal cancer. Cancer of thelarynx accounts for 2% to 3% of all malignancy and presents as malignantulceration with underlying infiltration and is spread by local extension toadjacent structures in the throat and neck, and by the lymphatic system.Laryngeal cancer is classified and treated by its anatomic site. Cancer of thelarynx (voice box) may occur on the glottis ( true vocal cords), the supraglotticstructures ( above the vocal cords) or the subglottic structures (below the vocalcords).

y There are an estimated 10,600 new cases of laryngeal cancer each year, mostoccurring in men and it is thought that older men are more likely to developlaryngeal cancer than women because the two main risk factors for acquiringthe disease are lifetime habits of smoking and alcohol abuse.More men smoke

and drink more than women, and more African-American men are heavysmokers than other men in the United States. However, as smoking becomesmore prevalent among women, it seems likely that more cases of laryngealcancer in females will be seen and the incidence of cancer of the larynx inwomen is increasing. If untreated, cancer of the larynx is inevitably fatal; 90%of untreated people die within 3 years. Like other cancers; however, it ispotentially curable if discovered early enough.


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III. PATIENTS PROFILEy Client C, H is an 80 years old, male, Filipino, and a widower. He was born on April 13, 1930 atMinglanilla Cebu. He is a retired Seaman and his religion is Iglesia ni Christo. The main reason ofseeking health care is that he finds it hard to communicate and disrupting when he talks, and hestated that he wants it to be cured.

y .y Past Illness and hospitalizations.y

y Client had Pediatric illness like chickenpox when he was in grade 3, and mumps whenhe was in grade 5. Client cannot recall the medications given but the illness has relieved. He has notundergone surgeries and stated that he has completed all vaccinations given during childhood.

y

y Allergies: Client is not known to have allergies on food and drugs.y

y

y Family historyy

y Patient was abandoned by his parents when he was 13 and had been living with his grandparents sincethen. Hypertension and asthma can be traced on his maternal side and pneumonia on his fathers.However, both of his parents did not die for such diseases. His mother died of dehydration as acomplication of diarrhea and his fathers cause of death was not clear to him although he was aknown alcoholic.


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y C. Social and Personal history

y

Client is a retired seaman with a daughter who now worksin theMiddle East as a nurse. He admits being an alcoholicconsuming about 5-10 glasses a day when he was still youngaround 17-30 years old. He used to be a smoker consuming10-15 stick per day though he has quitted smoking since1997. Apparently, the group of people he socializes makeshim a 2nd hand-smoker. He often eats vegetables andseldom eats meat. He is now living by himself with hisdogs. He is a very religious man he keeps on praying everymorning, afternoon and evening in his church.


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D. Review of systemsy EENT: Blurring of vision Hoarseness

Sore throaty

y GASTRO-INTESTINAL: Thirst Difficulty swallowingy

y MUSCULO-SKELETAL: Neck pain Back painy Joint pain

y NERVOUS: Headache

Dizziness

y 5. ENDOCRINE: Voice changey

y 6. EMOTIONAL: Depression Anxiety


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History of present illness:y Three months prior to admission client experienced

onset of hoarseness, and does not sought consultation

and no medication taken. About 3 weeks before hisadmission client experienced symptoms like coughand colds, fever and took kamilosan spray. Due topersistence of condition thus prompted thisadmission.


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GENERAL DATAyAssessed client sitting on bed awake, conscious,

coherent, responsive with the following vital signs;

T=37.8 degrees Celsius, P= 74 BPM

, R= 20 CPM

and BPof 120/80 mmhg. Appearance and mental status:Relaxed erect posture; coordinated movement; cleanand neat; no body odor; no distress noted; cooperative;clients affect and mood is appropriate to situation.


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GORDONS FUNCTIONAL HEALTH

PATTERNy HEALTH PERCEPTION- HEALTHMANAGEMENT PATTERN

y walay mga sakit-sakit, maayo and lawas as verbalized by the client. Client described his currentcondition as 6 in a scale of 1-10 (as 10 as the highest score). He only sought medical attention whenexperiencing severe illness, not manageable by self medication. His usual over the counter drugs arepain reliever such asMefenamic acid and Paracetamol as for fever. He sometimes used herbal plantslike guava for cleansing of wound and cough remedy as an alternative medicine.

y NUTRITION &METABOLISM PATTERN.

y Client takes 3 full meals per day consisting of rice, vegetables, fish, and sometimes cannedgoods. He likes to eat dried fish and anchovies as an appetizer and he stated that his meal isincomplete without this. He seldom eats pork and beef as a meat due to his religious restrictions. Healso eats fruits like banana, avocado and etc. He doesnt follow any certain type of diet and has nevertaken any vitamin as supplements. He has not experienced problems or difficulty eating foods. Hedrinks water at least 3- 5 glasses everyday. He drinks alcohol beverages about 5-10 glasses consumedin a day when he was still young and stop drinking alcohol around 30 years old due to religiousrestrictions. He was a smoker and consumed 10-15 sticks per day, but he quit smoking since 1997.

y During the present illness patients appetite reduces due of difficulty swallowing and eating largeamount of foods. Client reported that he lost weight about 8-11 pounds.


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ELIMINATION PATTERN

y Clients usual bowel pattern occur everyday, color andconsistency of stools was sometimes dark yellow and darkbrown and moderately soft and watery. He seldomexperiences constipation. He urinate 4-6 x a day with

yellowish urine. He never experience difficulties orproblems upon urination and defecation.

y During hospitalization he only defecate every other andurinates 4-6 times a day without any difficulty.


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ACTIVITY AND EXERCISEThe clients routine exercises include jogging and walking around thebackyard. He used to lift heavy objects when he was still in work. Andnow his activities include reading bible, news paper, watching

television and talking with his friends, he also went to malls, to hisfriends house and to his church.

y 5. CONITIVE AND PERCEPTION

y Senses are intact; able to feel heat and cold weather; able to answer

question appropriately and coherently to the questions given; able toread and write with the use eye glasses. Client is a college graduate; Heis able to speak, English, tagalog and cebuano language fluently. He isable to remember past and recent events that are only significant.This present illness causes him difficulty to express/communicate

verbally to his friends and relatives.


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y 9. ROLES AND RELATIONSHIPy

y Client is living alone. He is responsible to his actions he has a goodrelationship to his daughter and friends.

y

y 10. SEXUALITY AND REPRODUCTIONy

y Client was sexuality active until he became a widower. He has onedaughter.

y

y

y 11. VALUES AND BELIEFSy

y Clients religion is Iglesia ni Christo. He always goes to his churchand attends prayer meetings.


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ANATOMY AND

PH

YSIOLOG

YThe larynx is located where the throat dividesinto the esophagus and the trachea. Theesophagus is the tube that takes food to thestomach. The trachea, or windpipe, takes air tothe lungs. The area where the larynx is located issometimes called the Adam's apple.

The larynx has two main functions. It containsthe vocal cords, cartilage, and small muscles thatmake up the voice box. When a person speaks,small muscles tighten the vocal cords, narrowingthe distance between them. As air is exhaled pastthe tightened vocal cords, it creates sounds thatare formed into speech by the mouth, lips, andtongue.

The second function of the larynx is to allow air toenter the trachea and to keep food, saliva, and

foreign material from entering the lungs. A flap oftissue called the epiglottis covers the tracheaeach time a person swallows. This blocks foreignmaterial from entering the lungs. When notswallowing, the epiglottis retracts, and air flowsinto the trachea. During treatment for cancer ofthe larynx, both of these functions may be lost.


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IV. PATHOPHYSIOLOGYy (open Word document)


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V. COURSE IN THE WARDy 3/8

y Patient was admitted at exactly 7 oclock in the afternoon.

y D- Received pt. trans-in from ER ambulatory with chief

complains of hoarseness of Voicey A - Ushered patient on bed

y Follow-up procurement of pre-operative medication andmaterials

y Scheduled patient for elective surgery as indicated.

y Secured consent

y Secured laboratory exams.

y Reinforce patient status.

y follow-up intern for IV insertion


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y 3/9

y 7 am For ORy D seen patient on bed, awake, with IVF of D5NSS infusing

well, for tracheostomy / local anesthesia and punch biopsy,rigid endoscopy under general anesthesia, wit completematerials and Pre-op medications.

y A referred BP 180/100 to Dr. Gadrinab, started nicardipinedrip 10 mg + 20 cc D5 Water at 6:15am, vital signs taken and

referred to Dr. Antolin, pre operative medications given,ensured NPO is maintained, checked consent, referred to ORNOD for transport

y R transported to OR with the following vital signs: BP=140/80, T= 35.7, P= 80, R= 20


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y 7:30 am For tracheostomyy D received patient from ward per stretcher, conscious,

coherent, and responsive, with consent for operation, with

IVF of D5NSS 800 cc with piggyback of nicardipine drip 75 ccat 20 cc per hour infusing well at left army A identified patient, checked consent, OR rable prepared

aseptically, transferred patient to OR table in supine position,anesthesia inducted by Dr. Vina Lastimosa under generalanesthesia, skin preparation done and draped patient

aseptically, operation started by Dr. Earl Dimerin, anticipatedsurgeons needs, maintained sterility throughut surgery,operation ended, assisted in wound dressing

y R extbated patient, wheeled to PACU, with trachea insertedwell , with IVF infusing well, endorsed to NOD.


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y 9:50 am Post transport PACU notes

y D from OR per stretcher, with IVF of D5NSS 800 cc

with piggyback of nicardipine drip 75 cc at left armclosed, sedated, with tracheo

y A administered O2 inhalation via T piece to tracheatube at 6-8 lpm, provided comfort and safety,maintained on NPO

y R transported to ward, with IVF, awake, conscious,responsive, with trachea to T piece, ward NODinformed, vital signs as follows: BP= 130/80, T= 36.3, P=67, R= 18


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y 3/12 9am Airway patency

y D received patient lying on bed, awake and coherent,

with IVF infusing well at 30 drops per minutes at leftarm, with tracheo, frequent coughing noted, presence ofthick mucoi secretions at trachea tube, vital signs asfollows: BP= 120/80, T= 36.8, P= 95, R= 25

y A monitored respiratory rate, auscultated breath

sounds, elevated head of bed, encouraged effectivecoughing and deep breathing exercises, suctionedsecretions, trachea care done, encouraged ambulation

y R airway patency maintained with RR at 22 bpm


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y 3/15 10 am Impaired verbal

y D received patient sitting on bed, awake, afebrile, no

audible sounds noted, with tracheay A instructed patient to write in a piece of paper if he

has anything to say, needs attended, spoke to patient in aslow and normal tone, suctioned secretions as needed,trachea care done, due meds given, checked and

regulated IVF

y R seen patient cooperating by writing down what hewants to say


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Medications:y Tramadol 50mg IVTT

y IND:Moderate toModerately Severe pain]y CI: hypersensitivity to drug and its component, use cautiously

in patient at risk fro seizure or respiratory distress, withincrease ICP or head injury.y SE: -Diarrhea, nausea, vomiting, urticaria, vaginitisy SC: -determine previous hypersensitivity reactions to

penicillins, and other allergens to therapyy monitor for any signs of hypersensitivity e.g urticaria usually

occurring within few days after start of drug, or fever, dyspneaand report to physician accordingly

y check vital signs accordingly during start of therapy to assesssome allergic reactions manifested


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y Acetylcysteine 1 neb every 12 hrsy IND: treatment of respiratory affections characterized by thick and

viscous hypersecrestions acute and chronic bronchitis and itsexacerbation, pulmonary emphysema, mucoviscidosis, and

bronchiectasis.y CI: hypersensitivity to drug, phenylketonuria that contains aspartate.y P: Newborns (Phenylketonuria) and asthmatic patient, and also with

history of peptic ulcer disease.y SE: diarrhea, pyrosis,n/v, urticaria, and bronchospasm.y SC:monitor for S&S of aspiration of excess secretions and for

bronchospasm (unpredictable); with hold drug and notify physicianimmediatelyy Have suction apparatus available, encourage increase fluid intake,

suction secretions may needed to establish and maintain open airwayy Instruct patient/ S.O to report for any signs of respiratory distress


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y Clonidine 150 mg tab SL slowy IND: Hypertension

y CI: Pregnancy, lactation

y SE: -hypotension, postural hypotension, peripheral edema,flushing, drowsiness, headache, fatigue

y SC: -Give last P.O dose immediately before patients sleeps to ensureovernight BP control and to avoid daytime drowsiness

y Instruct patient not to abruptly discontinue drug, abruptwithdrawal may resembles sympathetic stimulation that leads torestlessness and headache 2-3h after miss dose and Hypertensivecrisis 8-18h

y store in tightly closed container at 15 degrees to 30

y check BP after 30 mins. After administering drug to evaluatetherapeutic response and to check for any signs of hypotension


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VI. THEORETICAL

FRAMEWORKKolcabas Comfort Theory

Kolcaba described comfort as existing in 3forms: relief, ease, and transcendence. Also,Kolcaba described 4 contexts in which patientcomfort can occur: physical, psychospiritual,environmental, and sociocultural.

Kolcaba described comfort as existing in 3

forms: relief, ease, and transcendence.If specific comfort needs of a patient are met,for example, the reliefof postoperative pain byadministering prescribed analgesia, theindividual experiences comfort in the reliefsense.

If the patient is in a comfortable state ofcontentment, the person experiences comfort

in the ease sense, for example, how one mightfeel after having issues that are causing anxietyaddressed.

Lastly, transcendence is described as the stateof comfort in which patients are able to riseabovetheir challenges

PSYCHOSPIRITUAL PHYSICAL

ENVIRONMENTAL SOCIOCULTURAL

RELIEF,EASE,TRANSCEDENCE


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VII. NURSING CARE PLANy PROBLEM: Ineffective airway clearance r/t to excessive secretions as evidence by wheezes.

CUESy Subjective: no verbal cuesy Objective : - weakness observed

- ineffective cough with excessive yellowish mucopurulent secretions,

- With tracheostomy attached to t-piece at 4-6 LPM- wheezes upon auscultation.

y ANALYSIS OF THE PROBLEM: The flow of air through a tracheostomy tube may become occludedfor several reasons. The tracheostomy tube may be misaligned so that its opening lies against thetracheal wall, preventing air flow. Cuff over inflation causes the cuff to herniated over the tip of thetube, obstructing air flow. Without adequate airway care, the inner cannula can become occludedwith dried secretions or excessive bronchial secretion.

y STATEMENT OF PATIENT CARE OBJECTIVES:y Short term: Patient will have an effective airway clearance after an hour of intervention.y Long term: Patient will be able to demonstrate behaviors to improve and maintain airway

clearance.


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NURSING ACTIONS RATIONALE EVALUATION

Independent Function:

- Placed patient on moderate high back

rest.-Suction secretion as needed

-Provided chest physiotherapy every after

nebulazation.

-Auscultated lung sound frequently.

-Monitored patency of IV tubings

frequently, regulating IVF at its prescribed

rate.

-Monitored vital signs-provided information about the need to

expectorate secretion versus swallowing

it.

- Instructed patient to cough into paper

tissue and dispose them properly.

- Instructed to performed Deep breathing

exercise

Dependent functions:

-Administered oxygen therapy asindicated.

-Administered medication as prescribed.

Such as acetylcysteine

Interdependent/ collaborative functions:

- Watched out for unusual ties and refer

to physician.

-To take advantage of gravity decreasing

on the diaphragm and enhance drainage.-To clear airway when secretions are

blocking airway.

-To help loosen secretions

- To determine presence of secretion

-To avoid fluid overload and underload.

-To assess changes and notecomplication .

-To examine and report changes in the

color and amount.

-To expectorate and avoid infection .

-To promote respiration

- To reduce hypoxemia

-To thin secretions and promote

respiration.

- To prevent further complication

Patients airway was clear as evidence of

no more noisy respiration sounds.Seen patient following to the instructions

given by coughing with the use of tissue

paper.


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NURSING CARE PLANy Problem: Risk for infection r/t post-operative site secondary to tracheostomy.

y Cues : Intact and patent tracheotomy site.y Excessive yellowish mucopurulent secretions notedy Wheezes noted

y Analysis of data: Tracheostomies increase the risk of bronchopulmonary infectionbecause they bypass upper airway protective mechanism (i.e., filtering, warmingand humidifying) and it decrease mucociliary transport and coughing, thusincreasing retained secretion. Stoma site infection may occur as well.Nosocomial infection is also a potential sterile therefore all solutions andequipment entering the trachea must be sterile.

y STATEMENT OF PATIENT CARE OBJECTIVES:y Short term: Patients tracheostomy site will remain clean and patent after an

hour of intervention.y Long term: Patient will exhibit no indication of infection like absence of fever,

dry and clean tracheostomy site, and clear secretions.


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NURSING ACTIONS RATIONALE EVALUATION

Independent Function:

-Clean the tracheostomy site using

aseptic technique by handwashing,

using sterile gloves and sterile

supplies.

-Changed dressing as needed.

- Inspected the skin around the

stoma for signs of redness,

inflammation and irritations.

-Suction secretion as needed

Dependent functions

-Due medication given on time such

as

1. Co-amoxilav antibiotic.

-Administered medication as

prescribed. Such as acetylcysteine

-Administered O2 as prescribed

Collaborative functions:

- Watched out for unusual ties and

refer to physician.

-To reduce contamination of

microorganism.

-Because Damp or mucus-soaked

dressing constitute a perfect

medium for the growth of

microorganism

-To detect early signs for infection

-To avoid excessive formation of

mucus.

-Drug may inhibit synthesis of

bacterial growth.

-To thin secretions and promote

respiration.

- To prevent further complication.

Tracheostomy site was free from

infection as evidenced by absence

of fever, clean and dry dressing,

clear secretions, and no signs of

inflammation.


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NURSING CARE PLANy PROBLEM: Impaired verbal communication related to the presence of tracheostomy tube.

y CUES:

y Subjective: No audible verbal cues

y Objective: Received patient on lying on bed awake, a febrile and non dyspneic, difficultyproducing speech or sound, facial tension observed upon speaking, active listener, vocalizesinaudible sounds in attempt to communicate, with tracheostomy attached to t-piece at 4-6 LPM.

y ANALYSIS OF THE PROBLEM: Human communication takes many forms. Person usually communicatesverbally through the vocalization of a system of sounds . Humans communicate through touch,written means, sometimes a combination of all the system listed. Communication implies thesending of information as well as the receiving of information . When impairment of means ofcommunication such as the presence of tracheostomy, communication ceases & the messageceases to the sole clarification of the points originally transmitted; resulting from being possiblycompromised.

y

y STATEMENT OF PATIENTCARE OBJECTIVES:

y Short outcome: Patient will be able to use a form of communication to get his need met after an

y hour of communication.

y Long term: After a week of intervention patient will be able to communicate using several

y forms of communication to relate effectively with the people.


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DISCHARGE CARE PLANDate Implemented Time frame Health Teaching based on the Concept of METHODS OUTCOME

M- Instructed patient to take bring home medications. ( Co- amoxiclav625 tab 2x a day) religiously

- Instructed patient and significant other to avoid discontinuation of

the regimen to achieve the optimum effect of the drugs prescribed.

- Explained the rationale for taking the medication as prescribed.

E- Home environment should be adequate for care and safely.

- Environmental modification should be done for patients safety.

-The patient is advised to stay in an environment wherein cleanliness is

valued and practiced.

- Significant others are encourage to take in watching the patient in casethe patient needs assistance in some of the ADLs.

- Practice proper sanitary disposal garbage.

T- Referred to Physician for follow-up check-up

- Encourage reinforcement of appropriate and effective coping strategies.

- Instructed significant others to provide patient water for drinking,

bathing and washing clothes free from contamination.

H- Activities of daily living should be modified according to patients

capacity. SOs should render safe techniques to assist patient with self-

care hygiene and feeding.- Emphasized the importance of quality rest.

O- Instructed patient to report different changes like difficulty of

breathing, pain on swallowing, changes in voices

- stressed the importance of continuing on follow-uphealth care plan.

D- Encouraged to eat nutritious foods esp. those are rich in iron and Vit. C

-Instructed patient to eat soft foods to avoid straining or irritating the

throat.

- Promoted the importance of increasing fluid intake, at least 8-10 glasses

of water to avoid constipation.

S- Encouraged patient to keep praying religiously.


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ConclusionThrough this study, we have just known and appreciate the real meaning of having basic knowledge, skills

and positive attitude in the field where we are right now.Knowledge is very important since we will not

only deal with persons alone but also with machines which will be part of saving millions of livers.Asidefrom being skillful and knowledgeable, we nurses must possess positive attitude though we cannot please

all our patients, but still we need to be humble no matter how intense or tough the situation may be . Being

knowledgeable, skillful, and having positive attitude we will be able to gain trust from our patients.

We have realized that attending immediately to the needs of our patients is one effective tool towards

achieving health care goals. We have learned that providing privacy to our patients is an essential part of

patient care.

Providing privacy to our patients is one factor that affects the helping and therapeuticrelationship between the nurse and the patient. By establishing an open communication, trust, confidence

with the patient, nursing therapeutic relationship maintained, thus contributing to the effectiveness of

nursing interventions.Another learning we had regarding patient care is that, patients tend to be

cooperative and gain confidence when they see the angel in us. Patients disease conditions most of the

time have low self esteem, talking to them and doing things for them will be of great help in boosting that

esteem.

As our recommendation, we encourage the StaffNurses to read to broaden knowledge, gather informationand most of all practice what they have learned about all aspects of human life. Since we will be dealing

with different persons with different personalities and preferences, as nurses, we need to be sensitive to

their needs and learn from them.

We encourage them to put not only in their mind what they have learned but also in their hearts. Because

once its in their nobody could steal this from them and this is only weapon to render appropriate and

quality care to our patients.


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Recommendationsy The primary focus of the nursing profession (both nurses and nurses trainees) in this institution (VSMMC) is thequality of health care for all. To this end, I believe that the comprehensive recommendation developed by this casestudy will ensure that VSMMC has a solid foundation of nursing services to meet health needs of the patients in the21st century.

TO THE HOSPITALWhile conducting this case study, Im aware that there may be areas of urgent need. In the short term, I stronglyrecommend that a comprehensive investment in the nursing sector be made across the spectrum of the health caredelivery system to enhance the quality and continuity of health care. This investment for health care consumers will

include.y Reduce hospital admissiony Less frequent emergency room visit sy Reduce stress for those caring for family members at home as well as enhanced accessibility to nursing services.

TO THE STAFF NURSES AND TRAINEESy In general, it is recommended for nurse trainees to know how to perform all their responsibilities with the utmost

accuracy and detail. The primary responsibilities of a nurse usually include knowing and understanding the healthneeds of the patients, performing initial and sometimes frequent evaluations, and performing basic procedures. Nursetrainee should also refine their skills over time. In doing so, their responsibilities may increase. Additionally, to stay

sharp, many nurses participate in continuing education classes to stay informed on new disease, drugs and techniquesfor patient care. By constant practicing and learning, a great nurse develops and displays in her medical knowledge.

Laryngeal Mass

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