Presentation on theme: "Isabel Quinn Clinical Nurse Specialist in Head and Neck July 2009"— Presentation transcript:
1Isabel Quinn Clinical Nurse Specialist in Head and Neck July 2009 Head and Neck CancerIsabel QuinnClinical Nurse Specialist in Head and NeckJuly 2009
2Head and Neck Cancers Over 30 specific tumour sites Includes cancers ofmouth, throat, nose, ear, larynx, tongue, floor of mouthsalivary glands, thyroid.• Each site relatively uncommon, 3 most common – mouth, larynx and pharynx.• Generally arise from surface layers upper aero digestive tract (squamous epithelium)
3Incidence 8,000 cases and 2,700 deaths per year in England &Wales 6th most common cancer worldwideMarked regional variations: per 100,000 Thames & Oxford per 100,000 Wales & North West.UHMB cases:125 on database73 new since July 08
4Mouth & pharyngeal cancers 20% last 30 years, particularly < 65 yrs Laryngeal cancer very slightly.Incidence and mortality higher in disadvantaged social groups.Survival rates much the same as 30 years ago. (Nice 2004)
5PrognosisEarly cancers T1, T2 single modality treatment. (78-91% survival at 5yrs)Advanced cancers T3, T4 multi-modality treatment (42-67% survival at 5yrs)But nodal disease ↓ survival all cancers (46% at 5 yrs) (Feber 2000)29-35% present at T448 -51% present with nodal disease.(LSCC Network)
10Free forearm flap grafts To repair defect of tumour excision of tongue / mouth / pharynx.Tissue transferred from forearm – micro-vascular techniques.Flap failureIssues of speaking and swallowingExtensive rehab
18Effects for patients Pain (neuropathic) often difficult to resolve Facial / mouth weakness (disfigurement / poor tongue control – swallowing issues)Inabilty to raise arm above headInability to use shoulder effectively (lifting etc)
19Radiotherapy For T1 or T2 tumours may be first line treatment. May have post op dependant upon histology.Palliative – short course to control local symptoms.4 – 6 weeks Monday to FridayPlanning
25DefinitionsTracheostomy - artificial opening into trachea which is kept open with a tracheostomy tube (can be temporary or permanent.) Connection between mouth, throat and lungs remains.Laryngectomy – Larynx has been removed and trachea is then brought out to form a stoma at the front of the neck (this is permanent.) There is now NO connection between mouth throat and lungs - neck breather. Often there will be no tube to keep stoma open.
26Tracheostomy – Nursing Aims Maintain patent airwayPrevent aspiration and chest infectionsMaintain adequate humidificationPrevent tracheal traumaDevelop alternative communication strategiesHelp adjust to altered body imageEducate patient / carers
27Maintain patent airway Tube obstruction 3rd most common cause of death in patients with tracheostomies. (El Kilany 1980)Feel with hand for good flow of air on expiration.Check O2 sats.Remove, clean and replace inner tube as required, but a good rule of thumb is at start of each shift and then prn.Encourage patient to cough and self expectorate.Suction as required.
28Prevent aspiration and chest infections Check swallow / cough reflex - cuffed tube if necessary. SALT assessmentSuction to mouth, pharynx prior to deflating cuff.Encourage self expectoration of secretions, involve physio if required.One use equipment / closed humidification units.Sterile suction technique.Rigorous stoma care - clean tapes / dressings daily, and as required.
29Maintain adequate humidification HUMIDIFICATION AT ALL TIMES. Bibs, Swedish nose.Diminished warming, moistening effects, leading to drying and crusting and potential blocking of tube.If oxygen required it MUST be humidified.Nebulise saline or steam inhalation if secretions are very thick and difficult to expectorate. N.b note fluid intake.
30Develop alternative communication strategies Speaking valve attachments and speaking tubes. (n.b. not to be used at night and unable to use with cuffed tubes unless fenestrated.)Call bell, pen and pad, picture boards, magic slate, Magnadoodle etc.Coping strategies - extra time and patience required to ‘listen.’Educate and encourage visitors / carers.
31Altered body imageEncourage continued self care of tube / self suctioning if possible.Encourage patient (carers) to look at / touch tube.Remain professional, don’t show displeasure / disgust.
32Prevent tracheal trauma Staff awareness, training and competency.Selection of appropriate tubes.Correct suctioning techniques.Cuff pressure.Use of fenestrated tubes (suctioning).Change whole tube regularly as per manufacturers instructions.
33Risk to airway Showering / bathing / swimming – use of aids. Inhalation dust / foreign bodies etc – use of bib / scarf.Emergency situations – neck breathers.Encourage expectoration of secretions.Suction if required
35Indications for Laryngectomy As curative surgical treatment of carcinoma of larynx.To overcome an incompetent larynxe.g. after radiotherapy, radio – necrosis.
36Post Laryngectomy Communication issues. Risk to airway. Maintain humidification.Altered body image.Usual ‘cancer’ issues
37Unable to speak conventionally Communication issuesUnable to speak conventionallySuitability for surgical voice restoration – speaking valves.Care of valves.Electronic speaking aids.Oesophageal speech.Pad and paperInvolvement with SALT.
38Risk to airway Showering / bathing / swimming – use of aids. Inhalation dust / foreign bodies etc – use of bib / scarf.Emergency situations – neck breathers.Encourage expectoration of secretions.Suction if required
40Valve and stoma careCleaning at least once a day, remove crusting from around stoma (forceps)Regular tube cleaning (if worn) – observe size of stomaUse of valve brush / pipette / cotton budsCheck valve position.Valve replacement ?Coughing when drinkingObserve test drinkLoss of ‘voice’Candida
41Indications for tracheal suctioning Each patient should be individually assessed for the need and frequency of suction - amount and consistency of secretions.Patients ability to cough and clear own secretions.Respiratory rate.Oxygen saturation.Presence of infection.
42Suction catheter selection Use appropriate size - no more than half internal diameter of trachy tube. (see chart)Too large - tracheal damage, hypoxia.Too small - inadequate clearing of secretions requiring repeated attempts which may cause tracheal damage.Multi - eyed catheters.
43Equipment requiredFunctional suction apparatus - suction pressure mmHg recommended for adults.Sterile bowl with water for flushing tube.Protective eye wear, mask and plastic apron.Appropriately sized suction catheters.Sterile plastic gloves.Yellow disposal bag.Inner tube if fenestrated tube in situ.Vacuum breaker (finger tip control)
44Nursing Intervention Explain procedure to patient. Prepare equipment. Observe patient throughout (hypoxia, bronchospasm or vagal stimulation - bradycardia.)Switch on suction, connect vacuum breaker and catheter.Gently introduce catheter just beyond end of trachy tube, apply suction and smoothly withdraw catheter. Do not suction for more than 15 secs at a time, or whilst introducing catheter.
45Note tenacity, colour and quantity of secretions. Infected - Note tenacity, colour and quantity of secretions. Infected - ? specimen for c&s.Remove glove and catheter and dispose.Assess patient - is further suction required. Repeat with new catheter and glove if necessary.Flush suction tubing. Switch off suction.Make patient comfortable.Document procedure.
46Suction Technique Do’s Insert and withdraw catheter gently Use low suction pressure <120mmHgUse multi hole suction catheter.Use vacuum breaker.Involve physiotherapists.Don'tsDo not perform suction routinely - only when necessary.Do not instil saline prior to suctioning.Do not apply suction for more than 15 seconds.Do not apply suction when inserting catheter.
47Changing tapes / dressings • The tapes and dressings will need to be changed at least every 24 hours to enable assessment of the tracheostomy site.Change more frequently if soiled to maintain dry skin and reduce risk of infection.Adjust and fasten tapes if they become loose.Use keyhole tracheostomy dressings.
48Care of tubesMost tracheostomy tubes have inner tubes which must be cleaned to prevent blockage.Frequency of cleaning varies widely - assess individually, but a good rule of thumb is to check the inner tube at the beginning of each shift.No evidence for the best solution for cleaning inner tube - sterile or tap water.Mouth care sponges, tracheostomy tube swabs / cotton buds for plastic tubes.
49Care of tubes (cont)Silver inner tubes can be cleaned gently with brushes and under running water.Do not leave tubes soaking, dry thoroughly and replace or store spares in a covered container.Do not leave patient without an inner tube, other than for cleaning and weaning. Absence of an inner tube results in a build up of secretions and could lead to blocking of airway.