Pharmacologic Highlights

Medication or

Drug Class Dosage Description Rationale

Analgesics Varies with drug Morphine sulfate, fentanyl Relieve pain

Other Drugs: Chemotherapy (usually 5-fluorouracil [5-FU] and cisplatin) may be used in certain circumstances; however, no improvement in overall survival rate has been demonstrated.

Independent

Spend time with the patient preoperatively exploring changes in the patient's body, such as the loss of smell and the inability to whistle, gargle, sip, use a straw, or blow the nose. Explain that the patient may need to breathe through a stoma in the neck, learn esophageal speech, or learn to use mechanical devices to speak. Encourage the expression of feelings about a diagnosis of cancer and offer to contact the appropriate clergy or clinical nurse specialist to counsel the patient.

Postoperatively, assess the patient's level of comfort. Reposition the patient carefully; after a total laryngectomy, support the back of the neck when moving the patient to prevent trauma. Provide frequent mouth care, cleansing the mouth with a soft toothbrush, toothette, or washcloth. After a partial laryngectomy, the patient should not use his or her voice for at least 2 days. The patient should have an alternate means of communication available at all times, and the

556 Laryngotracheobronchitis (Croup)

nurse should encourage its use. After 2 to 3 days, encourage the patient to use a whisper until complete healing takes place. Because the functional impairments and disfigurement that result from this surgery are traumatic, close attention should be paid to the patient's emotional status.

As soon as possible after surgery, the patient with a total laryngectomy should start learning to care for the stoma, suction the airway, care for the incision, and self-administer the tube feedings (if the patient is to have tube feedings after discharge). Assist the patient in obtaining the equipment and supplies for home use. Discuss safety precautions for patients with a permanent stoma. If appropriate, refer the patient to smoking and alcohol cessation counseling.

• Preoperative health and social history, physical assessment, drinking and smoking history

• Postoperative physical status: Incisions and drains, patency of airway, pulmonary secretions, nasogastric feedings, oral intake, integrity of the skin

• Pain: Location, duration, frequency, precipitating factors, response to analgesia

• Preoperative, postoperative, and discharge teaching

• Patient's ability to perform self-care: Secretion removal, laryngectomy tube and stoma care, incision care, tube feedings

Teach the patient the name, purpose, dosage, schedule, common side effects, and importance of taking all medications. Teach the patient signs and symptoms of potential complications and the appropriate actions to be taken. Complications include infection (symptoms: wound drainage, poor wound healing, fever, achiness, chills); airway obstruction and tracheostomy stenosis (symptoms: noisy respirations, difficulty breathing, restlessness, confusion, increased respiratory rate); vocal straining; fistula formation (symptoms: redness, swelling, secretions along a suture line); and ruptured carotid artery (symptoms: bleeding, hypotension).

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.

Laryngotracheobronchitis (LTB) is an inflammation and obstruction of the larynx, trachea, and major bronchi of children. In small children, the air passages in the lungs are smaller than those of adults, making them more susceptible to obstruction by edema and spasm. Because of the respiratory distress it causes, LTB is one of the most frightening acute diseases of childhood and is responsible for over 250,000 emergency department visits each year.

It is sometimes called croup, although croup can be more specifically described as one of three entities: LTB, laryngitis (inflammation of the larynx), or acute spasmodic laryngitis (obstructive narrowing of the larynx because of viral infection, genetic factors, or emotional distress). Acute spasmodic laryngitis is particularly common in children with allergies and those with a family history of croup. Acute LTB usually occurs in the fall or winter and is often mild, self-limiting, and followed by a complete recovery.

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