Care of the Head and Neck Surgical Patient

Kaokangkue Moua RN, BSN Surgical ICU

CN III Project

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Background of the Project

Head and Neck Surgical patients were inconsistently cared for by SICU and SSDU RN due to lack of knowledge of this patient population

Nurses did not feel confident caring for this patient population and carrying out MD orders per nursing judgement

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Background of the Project

Lack of communication among nurses and physicians have resulted to complications such as: – Bleeding – Failed grafts – Impaired circulation – Obstructive airway

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Indicators for Project

Inconsistent patient care with head and neck surgical patients due to knowledge deficit

Ineffective communication and collaboration among nurses and physicians

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Goal

Improve the delivery of patient care Provide further education regarding head

and neck surgical patients to staff nurses, new hires and new grad nurses

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Components of the Project

Provided a 4 ½ hour education seminar to all SICU and SSDU staff – 98% participation – Another class April 11, 2011

Follow up assessment – Self evaluations – Patient audits – LOS audits

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Outcomes Measures

Improve the delivery of patient care

•No adverse events of airway •Decreased hospitalization, LOS in ICU •Decreased complications

•Rare Carotid Blowout •Unable to assess actual LOS and hospitalization •Longest LOS: 37 Shortest LOS: 1.5weeks •Decreased complications & infection

Provide further education

•Provide on going education as needed •Develop a ENT education resource binder on all SICU and SSDU wings • Consider Educational Tool

•Provide on going in-services as needed •Resource binder on SICU and SSDU units and on PDF Share Point • Annual Educational seminar to new grads, nurses, registry and SPPO staff

Objective Goal Outcome

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Case Study 69 y.o. male with Hx: T2N0 Laryngeal squamous cell

carcinoma s/p RT in 10/07. He had a T4aN0 recurrence in 12/09 and underwent a total laryngectomy. Dysphagia developed and recurrence in the left posterolateral hypopharynx was identified in 06/10.

On 08/24/10, he underwent a left MRND, right neck exploration, total pharyngectomy, esphagectomy, G-tube placement, right ALT free flap with reconstruction of the stoma, pharynx, esophagus, neck skin and soft tissue. Post-operatively, the patient had episodes of hypertension, uncontrolled diabetes and brief episodes of Atrial Fibrillation.

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Case Study

Tachycardia & tachynpea

Reflux Gtube EKG-nonspecific

changes Echo CT r/o PE

Neck dishissence Emesis-laryngectomy

tube, oral cavity & right neck

Right neck exploration I&D Left neck wound

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Case Study POD #28

Copiously bleeding right neck

CODE BLUE Pressure applied Laryngectomy tube

inflated, neck, oral cavity packed

Increase blood loss

OR-innominate vein and artery dissected and clamped

Right neck-large defect Carotid artery and IJ

clamped and ligated SICU-Continue to bleed Care withdrawn:

09/21/2011 @1632

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Suctioning

-20

0

20

40

60

PrePostSelf

Pre 0 1 0 20 40 0

Post 0 0 1 11 49 0

Self 1 0 2 19 39 0

Srongly Disagree

Disagree Neutral Agree Strongly Agree

N/A

How confident do you feel suctioning Head and Neck surgical patients?

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Tracheostomy Care

-100

1020304050

PrePostSelf

Pre 0 0 2 27 32 0

Post 0 1 1 17 42 0

Self 1 0 3 18 39 0

Srongly Disagree

Disagree Neutral Agree Strongly Agree

N/A

How confident do you feel providing trach care to head and neck surgical patients?

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Flap Care and Management

-10

0

10

20

30

40

PrePostSelf

Pre 0 5 15 24 17 0

Post 0 1 1 24 35 0

Self 1 1 7 25 27 0

Srongly Disagree

Disagree Neutral Agree Strongly Agree

N/A

How confident do you feel caring and managing head and neck patients with a flap?

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Patient Education

-100

1020304050

PrePostSelf

Pre 0 2 9 31 19 0

Post 0 0 1 21 39 0

Self 1 1 6 22 31 0

Srongly Disagree

Disagree Neutral Agree Strongly Agree

N/A

How confident do you feel providing head and neck surgical patient education materials with trach care, drain management, surgical wound care and tube

feeds?

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Communication with MD and Chain of Command

-20

0

20

40

60

PrePostSelf

Pre 0 0 7 25 29 0

Post 1 0 0 14 46 0

Self 1 0 4 23 33 0

Srongly Disagree

Disagree Neutral Agree Strongly Agree

N/A

How confident do you feel communicating with the physicians regarding the patient’s plan of care?

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Outcomes: Patient Audits

September 2010-present day: only four major head and neck surgical procedures were done

Avg LOS varies depending on CA diagnosis – SICU: as short as 5 days to as long as several

weeks – SSDU: 4 days to several weeks

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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Outcomes: Patient Audits

Some physicians orders such as tracheal suctioning/care, or stripping JP drains was not being carried out, per flowsheet audit – New grad or traveler nurse

Patient Education: inconsistent, not indicated consistently if patient education on trach care or tube feed administration was done on flowsheet or teaching plan

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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CN III project

Continue to assess, monitor and evaluate patient care and management

Meet with HNS team, collaborate and work together to improve patient outcomes

In-services with SICU/SSDU nursing staff Join SOHN, start California Chapter? Annual Head and Neck Surgical Education

Seminar with HNS physicians

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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References National Cancer Institute. (2005). http://www.cancer.gov/cancertopics/factsheet/Sites-

Types/head-and-neck Rodriguez, C. S., & Blischak , D. M. (2010, May). Communication needs of nonspeaking

hospitalized postoperative patients with head and neck cancer. Applied Nursing Research, 23. Retrieved from http://www.nursingconsult.com/das/journal/view/212977272-2/N/23250713?ec=true&ja=745467&PAGE=1.html&sid=1034181565&source=EM&summaryresults=true&SEQNO=1

Scarpa, R. (2009, August). Surgical Management of Head and Neck Carcinoma. Seminars in Oncology Nursing, 25(3), 172-182.

Shaari, C. M., Buchbinder, D., Costantino, P. D., Lawson, W., Biller, H. F., & Urken, M. L. (1998, April). Complications of Microvascular Head and Neck Surgery in the Elderly . Archieves Otolaryngology Head and Neck Surgery , 124, 407-411.

Thompson, J. M., McFarland, G. K., Hirsch, J. E., & Tucker, S. M. (2002). Cancers of the Head and Neck. In Mosby’s Clinical Nursing. Retrieved from

Thompson, J. M., McFarland, G. K., Hirsch, J. E., & Tucker, S. M. (2002). Ear, Nose and Throat. In Mosby’s Clinical Nursing. Retrieved from http://www.nursingconsult.com/das/book/body/1012316913/1043/137.html?printing=true

Tucker, S. (2000). Laryngectomy: Radical Neck Dissection. In Patient Care Standards: Collaborate Planning and Nursing Interventions. Retrieved from http://www.nursingconsult.com/das/book/212977272-2/view/1337/258.html/4-u1.0-B0-323-00996-4..50019-8--cesec118_5013?sid=1034175261&SEQNO=1&bookft=true&bookftset=1&bbSearchType=single

SE5EOa, Care of the Head and Neck Surgical Patient Education.pdf

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