Breathless Laryngeal Cancer Case Study

• Breathless is the title we came up for this
case because as we all know laryngeal
cancer is a cancer of the respiratory
system. In this disease tumors grow in a
location wherein it compromises the
airway of our client’s. We chose this title
because one of the most common
complaints of patient’s who are suffering
from this illness is DOB or what we nurses
call difficulty of breathing.

Our voice gives us the ability to speak
what we want to say, to verbalize our
feelings in order to communicate well.
Imagine your respiratory system without
the larynx which houses the glottis or the
so called “vocal cords” in order for the
sound to be produced and the one that
bridges the gap between the external
environment and the lungs that supplies
oxygen throughout our body; do you think
you can still function holistically, when a
part of you is impaired or damaged?

• Most of the time people neglect the
relevance on managing their own lifestyle;
how it would help in improving one’s
health and how it will contribute to a
disease; plus the fact that most people
seek medical consultation when the
condition is severe.

• Laryngeal cancer may also be called cancer of
the larynx or laryngeal carcinoma. Most
laryngeal cancers are squamous cell
carcinomas, reflecting their origin from the
squamous cells which form the majority of the
laryngeal epithelium. Cancer can develop in any
part of the larynx, but the cure rate is affected by
the location of the tumor. For the purposes of
tumour staging, the larynx is divided into three
anatomical regions: the glottis (true vocal cords,
anterior and posterior commissures); the
supraglottis (epiglottis, arytenoids and
aryepiglottic folds, and false cords); and the
subglottis.

• Considering that laryngeal cancer one of
the most common type of cancer in the
respiratory system and evidently has a
devastating impact in a man’s health. Our
group, Group 1 BSN level 3 of Dr. Carlos
S. Lanting College, has regarded this case
significant to the fields of nursing education,
practice and research because the completion of
this study does not only comply for
dissemination information purposes, but for
sensible learning as well.

Theory of Comfort by
Katherine Kolcaba
• “Comfort is defined as the state that is
experienced by recipient/patient and is a
holistic experience of being strengthened
through having the needs met for three
types of comfort (relief, ease and
transcendence). We nurses are designed
to address specific comfort needs of the
patient including physiological, physical,
psychological, environment, social and
spiritual.

• In the case of our patient, we provided
nursing care physiologically by performing
Daily tracheostomy Care, nebulization and
suctioniong. We also explained the
Procedures and the importance of the
procedure that our patient will de undergo
to decrease his anxiety. Environmetally.
By decreasing the factor that may irritate
our patient.

Dorothea Orem's Self-Care Model
• The focus of Orem's model of nursing is to enhance the
patient's ability for self-care and extend this ability to
care for their dependents (Orem, 2005). A person's self-
care deficits are a result of their environment. Three
systems exist within the professional nursing model: the
compensatory system, in which the nurse provides total
care; the partial compensatory system, in which the
nurse and the patients share responsibilities for care;
and the educative-development system, in which the
patient has the primary responsibility for personal health,
with the nurse acting as a consultant.

• The basic premise of Orem's model is that
individuals can take responsibility for their
health and the health of others, and in a
general sense, individuals have the
capacity to care for themselves and their
dependents.

• We used the supportive educative theory
of Orem. We explained to our patient the
risk of excessive smoking and too much
consumption of alcohol. The importance of
taking care of his own health and made
him realized the consequences of getting
sick. We all did this through Health
Teaching.

Theory of Lydia Hall
“Core, Care, Cure Model”
• The “core”- (Person)- social sciences,
therapeutic use of self aspects of nursing.
• The “care”- (Body)- natural, and biological
sciences, intimate body care
• The “cure”- (Disease)- pathological and
therapeutic sciences.

• Nurse, educated in communication skills, could
be the best to facilitate these health teachings.
Healing may be hastened by helping people
move in the direction of self-awareness, that
refers to the state of being that nurses endeavor
to help their patients achieve their goal. The
more self-awareness that person has, the more
control they have on their behavior. health
teaching on Proper Deep Breathing Exercise,
Proper Cleaning of Tracheostomy tube and
good oral and body hygiene are the nursing
interventions we’ve done in order for us to
deliver this theory to our patient.

General information
• Name : Mr. Larynx
• Address : Brgy. Holy Spirit Quezon City
• Age : 47
• Birthday : Dec. 27, 1962
• Gender : Male
• Race : Filipino

• Civil Status : Married
• Occupation : Helper in a Fishing Company
• Religion : Catholic
• DOA: Jan. 12, 2010
• Time: 7pm

• Admitting diagnosis: “Laryngeal mass t/c
malignancy”
• Chief complaint : Difficulty of Breathing
• Final Diagnosis: Laryngeal Cancer

History of present illness:
• > 4yrs. PTA pt. experienced hoarseness of voice
and easy fatigability. No medication was given.
No consultation done.
• > 3yrs PTA experienced persistent hoarseness
of voice. No medication given. No consultation
done.
• > 2yrs. PTA patient experienced slight difficulty
of breathing when he is smoking and
nebulization was done to manage the DOB as
advised by the nearby Health Center.

• > 1yr. PTA pt. noted a palpable mass on the
right side of the neck. It was described as big as
a grapes size. No medication given. No
consultation done.
• > 9mths. PTA pt.experienced difficulty of
producing sound and shortness of breath that
patient cannot tolerate anymore and was
rushed to the Lung center and there, an
emergency tracheostomy tube was inserted and
subsequently admitted. He was confined at the
lung center for 1 month Where he undergone
biopsy with a result that is not detected

• > 8mths. PTA pt. was referred to East
avenue medical center but pt. did not
comply with the referral due to financial
problem and pt. decided to stay on their
house to manage his sickness.
• > 6months PTA pt. experienced difficulty
of breathing due to accumulation of
secretions on the trache tube. Suctioning
was done to relieve the DOB.

• >3mths. PTA pt. seek consultation at east
avenue medical center due to inflammation,
redness, and itching on the tracheostomy site.
Management was done. Antibiotics was given
and advised to stay at the hospital but pt.
refused again due to financial problem.
• > 2mths. PTA pt. noted that the mass on the
right side of the neck was enlarged. There were
no pain and tenderness noted.
• > One day PTA pt. experienced difficulty of
breathing due to accumulation of secretions on
the tracheostomy tube and rushed to EAMC and
subsequently admitted

Past medical history
• >Patient had an on and off asthma
attacked in the yr. 2008 and nebulization
was done to manage the asthma attack.

Personal and Social History
• Smoker at the age of 17: for 30yrs. 1 pack
per day and 30pack yrs.
• Alcoholic drinker for 30 yrs. He is fond of
drinking hard drinks like Gin. Average
consumption of 80ml a day.
• Pt. was a helper in a fishing Company for
20yrs.

Family History:
• (+)Asthma- PATERNAL side
• (+)COPD- PATERNAL side
• (+)Cancer History-MATERNAL side
• (-) HPN
• (-) Kidney Disease
• (-) Heart Disease
• (-) DM

Grand Mother Grand Father Grand Mother Grand Father
Mother Father
Mr. Larynx
affected
Carrier

• SKIN
(-) Night sweats
(-) Change in color
(-) Pruritus
(-) Bruising
• HEAD
(-) Tenderness
(-) Injury

• EYES
(-) Inflamation
(-) Discharge
(-) Excessive tearing
• EARS
(-) Change in hearing
(-) Tinnitus
(-) Pain

• NOSE
(-)Sinus Problem
(-)Sneezing
(-) Discharge
(-) Obstruction
(-) Allergies
(-) Epistaxis

• THROAT/NECK
(+)Pain on the trache site
(+) Itching
• NEURO
(-)Blurring of vision
(-)Headache
(-)Loss of consciousness

• CARDIO
(+) Easy Fatigability
(-) Palpitations
(-) Chest pain
(-)Pressure
(-) Tightness
• RESPIRATORY
(+)Dyspnea
(+) Cough

• GASTROINTESTINAL
(+) loss of appetite
(-) Diarrhea
(-) Constipation
(-) Nausea and vomiting
• MUSCULO-SKELETAL
(+) Muscle pain
(-)Muscle spasm
(+) Muscle weakness

• Date of assessment: January 28, 2010
General Survey: Mr. Larynx, a medium built man
apparently ill and in distress. Received lying on bed
conscious and coherent
Vital Signs
BP: 110/70 mmHg
PR: 83bpm
RR: 29cpm
Temp: 40.5 C
Pain: 5/10
Anthropometric Measurements
Weight: 39kg.
Height: 5’5’’

• SKIN:
– Patient’s skin is warm to touch, Poor skin turgor and
Dry
– Has no lesions and bruises
• Head:
– Skull size and Shape
• Proportionate to the body size, rounded
– Scalp
• Moist, whitish
– Hair Condition
• Evenly distributed, whitish hair
– Facial features / movement
• Symmetrical

• Eyes and Vision
– Eyebrows / Eyelashes hair distribution
• Evenly distributed Lids close symmetrically
– Sclera
• pale
– Pupil
• PERRLA
– Visual acuity
• Able to read news print
– Six ocular movements & alignment
• Both eyes move in different directions

• Ears and Hearing :
• Auricles
– Color
• Same color with the entire skin
– Symmetry & size
• Equal on both sides
– texture & elasticity
• dry and poor skin turgor
• pinna
– recoils when fold
• external canal/ hearing acuity
– normal hearing

• Nose and sinuses :
– external appearance
• symmetrical and straight
– septum
• midline septum
– nasal cavity
• clear without secretions
– facial sinuses
• not tender

• Mouth:
– lips
• dry
– teeth and gums
• teeth appears yellowish, dark gums
– tongue color, position movements
• moves freely without tenderness
– palates & uvula color shape, position &
movement
• pale pink uvula, midline
– gag reflex
• present

• Neck :
– Neck muscles / head measurements
• with visible palpable mass on the right side
of the neck.
– Muscle strength
• limited ROM unable to flex and extend neck
– Lymph nodes
• Palpable and distended

• Tracheostomy site
–pus formation above tracheostomy site.
–Redness
–Swelling
–Multiple lesions are observed on the
tracheostomy site.

• Upper Extremities :
–Skin color, temperature, moisture,
texture turgor
• appropriate to race,
• warm to touch, dry, rough and elastic
–Nail’s color, condition, capillary refill
• Pale, capillary refill >3 secs..
–Muscle size, contractures, tone
• poor muscle tone
• small for his body

– Muscle strength
• Equal strength
– Joints ROM
• Able to flex and extend
– Brachial & radial pulses
• palpable
– Sensation
• Responds when skin is pinched

• Chest and Lungs:
– spinal alignment
• Vertically aligned
– Tactile fremitus
• Symmetrical
– Breathing Sounds
• crackles on RML &RLL of the lungs.

• Abdomen :
–skin integrity
• Dry
–contour symmetry
• Equally rounded
–abdominal movements
• normal
–bowel sounds
• Audible bowel sound

• femoral pulses
– palpable
• palpation
– abdomen
– no enlargement
– bladder
– no enlargement
– liver
– no enlargement

• Lower Extremities :
– skin and toenails
• dry skin and pale toenails
– muscle strength
• Poor muscle strength
– Popliteal, Posterior tibial. Dorsalis pedis
pulses
• palpable pulses

LAB AND DIAGNOSTIC
EXAMINATION

Test Name Result Ref.
Interval
Units Nursing
Interpret
ation
Nursing
consideratio
n
Blood Urea Neutrogen 3.2 2.5-61 mmol/L NORMAL
Creatinine 111 53-115 umol/L NORMAL
Total Protein 69.4 64.0-82.0 g/L NORMAL
Globulin 47.3 30.0-32.0 g/L High Globulin
may
signify
that the
patient is
suffering
from an
Inflamma
tory
condition.
>monitor test
and notify
the
physician of
any
abnormal
values.
Sample Fluid: Serum 01/13/2010

Albumin 22.1 34.0-50.0 g/L Low
Albumin
may signify
Malnutrition
and Cancer
to the
patient.
>intravenous
fluids may alter
results of the test.
> monitor test
and notify the
physician of any
abnormal values.
Albumin/Globulin
ratio
0.5 1.1-1.6 Low
Albumin/Gl
obulin ratio
may signify
that the
patient is
suffering
from an
Infection.
> Prolonged
application of a
tourniquet during
blood collection
can result in a
blood sample that
has a higher
protein
concentration
than the rest of
the circulation.
Total Bilirubin 5.18 0.00-17.10 umol/L NORMAL

Test Name Result Ref. Interval Units Nursing
Interpret
ation
Nursing
consideration
GLU Glucose 4.4 3.9-6.1 mmol/L NORMAL
TP Total protein 67.2 64.0-82.0 g/L NORMAL
CHOL N
Cholesterol
2.8 0.0-5.2 mmol/L NORMAL
LDL Low Density
Lipoprotein -
Cholesterol
1.9 LO 2.6-4.1 mmol/L Low LDL
signifies
that the
patient is
malnouris
hed.
Health Promotion
(Encourage patients
between ages of
45 to 65 years
old to have their
cholesterol level
checked every 5
years.
Sample Fluid: Serum 01/13/2010 9:34 a.m.
Triglycerides 1.13 0.40-1.70 mmol/L NORMAL

High Density
Lipoprotein -
Cholesterol
0.37 LO 0.91-1.56 mmol/L Low HDL signifies
that the patient
has malabsorption
and
malnourishment.
Health
Promotion
Conjugated
Bilirubin
2.69 0.00-5.00 umol/L NORMAL
Indirect Bilirubin 2.49 0.00-12.10 umol/L
Sodium 126 135-148 mmol/L Low sodium may
signify that
the patient is
suffering from
Hyponatremia.
>measure daily
input and
output of
fluids.

Potassium 3.0 3.5-5.3 mmol/L Low
potassium
may signify
that the
patient is
suffering from
hypokalemia.
>monitor test and
notify the physician
of any abnormal
values.
>v/s should be
monitored routinely.
>monitor and
document input and
output of fluids.
Aspartate
Aminotransfe
rase
15 15-37 u/L NORMAL
Alanine
Aminotransfe
rase
24 30-65 u/L Low Alanine
Aminotransfe
rase may
signify that
the patient is
suffering from
liver problem.
>document any
known allergies of
the patient.
> monitor test and
notify the physician
of any abnormal
values.
Result Unit Normal Value Nursing
Interpretatio
n
Sodium 138 mmol/L 136-148 NORMAL
Potassium 4.4 mnol/L 3.60-5.20 NORMAL
Sample Type: Serum 01/18/2010

Components Resul
t
Normal values Units Nursing
Interpretation
Nursing Consideration
White Blood
Cells count
8.9 Adults(5-10)
Neonates(9-10)
X10^g
/L
NORMAL
Hemoglobin 103 Males(140-170)
Females(120-
140)
Neonates(187-
201)
gm/L Low
hemoglobin
may signify
that the patient
is considered to
be anemic.
>arrange for prompt transport
of the specimen to the
laboratory.
>Assess for abnormal physical
responses.
>monitor H&H values for
anticipated beneficial
purposes.
Hematocrit 0.28 Males(0.40-0.50)
Female(0.38-
0.48)
Neonates(0.49-
0.55)
% Low hematocrit
may signify
that the patient
is considered to
be anemic.
>monitor lab results.
>measure and record v/s at
regular and interval times.
>carry out medical treatment
protocol.
Neutrophil 0.72 Adults(0.45-
0.65)
Neonates(0.40-
0.50)
% High
Neutrophil
levels may
signify that the
patient is
suffering from
bacterial
infection and
Cancer.
>instruct the physically active
patient to avoid strenuous
activity for 24 hours.
>arrange for prompt transport
of blood to the laboratory.
HEMATOLOGY 01/23/2010

Lymphocyte 0.11 Adults(0.15-
0.25)
Neonates(0.31-
0.60)
% Low
Lymphocyte
may signify
that the patient
is suffering
from miliary
pulmonary
tuberculosis.
>same as to the Nx
considerations on Neutrophil
Monocyte 0.06 0.02-0.06 % NORMAL
Eosinophils 0.02 0.02-0.04 % NORMAL
Basophils 0.01 0.00-0.01 % NORMAL
Platelet count 35.4 150-450 X10^g
/L
Low platelet
count may
signify that the
patient is
suffering from
an infection
and iron
deficiency
anemia.
>instruct patient on how to
avoid bruising or bleeding.
>instruct the patient to avoid
aspirin.

Mean
corpuscular
volume
81.0 80-100 FL NORMAL
Mean
corpuscular
hemoglobin
29.1 27-31 pg NORMAL
Mean
corpuscular
hemoglobin
concentration
359 320-360 g/L NORMAL
Red blood cell
distribution
width
14.7 11.6-14.6 % Increased RDW
is may signify
that the patient
is suffering
from
anisocytosis.
>ensure that the sample is not
taken from the hand/arm that
has an IV line.
>assess the puncture for signs
of bleeding or ecchymosis of
skin.
>to promote clotting, use
sterile gauze and apply
pressure to the site, or raise
the arm above the head while
maintaining pressure on the
site.

Result Normal values Nursing
Interpretation
Nursing
consideration
Clotting time 4 minutes & 30
seconds
3-7 minutes NORMAL
Bleeding time 2 minutes 1-4 minutes NORMAL
BIOPSY RESULT:
LARYNGEAL CANCER specifically on the Supraglottic Area
HEMATOLOGY

• Laryngeal cancer is a disease in which
malignant (cancer) cells form in the tissues
of the larynx.
• The larynx (voice box) is located just
below the pharynx (throat) in the neck.
The larynx 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.
• Most laryngeal cancers form in squamous
cells, the thin, flat cells lining the inside of
the larynx.

• 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).

• Use of tobacco products and drinking too
much alcohol can affect the risk of
developing laryngeal cancer.
• Possible signs of laryngeal cancer include
a sore throat and ear pain.
• These and other symptoms may be
caused by laryngeal cancer or by other
conditions. A doctor should be consulted if
any of the following problems occur:

• A sore throat or cough that does not go
away.
• Trouble or pain when swallowing.
• Ear pain.
• A lump in the neck or throat.
• A change or hoarseness in the voice.

• Tests that examine the throat and neck
are used to help detect (find), diagnose,
and stage laryngeal cancer.
• The following tests and procedures may
be used:

• Physical exam of the throat and neck: An
examination in which the doctor feels for swollen
lymph nodes in the neck and looks down the
throat with a small, long-handled mirror to check
for abnormal areas.
• Laryngoscopy: A procedure in which the doctor
examines the larynx (voice box) with a mirror or
with a laryngoscope (a thin, lighted tube).
• Endoscopy: A procedure to look at organs and
tissues inside the body to check for abnormal
areas. An endoscope (a thin, lighted tube) is
inserted through an incision (cut) in the skin or
opening in the body, such as the mouth. Tissue
samples and lymph nodes may be taken for
biopsy.

• CT scan (CAT scan): A procedure that makes a
series of detailed pictures of areas inside the
body, taken from different angles. The pictures
are made by a computer linked to an x-ray
machine. A dye may be injected into a vein or
swallowed to help the organs or tissues show up
more clearly. This procedure is also called
computed tomography, computerized
tomography, or computerized axial tomography.
• MRI (magnetic resonance imaging): A
procedure that uses a magnet, radio waves, and
a computer to make a series of detailed pictures
of areas inside the body. This procedure is also
called nuclear magnetic resonance imaging
(NMRI).

• Biopsy: The removal of cells or tissues so
they can be viewed under a microscope to
check for signs of cancer.
• Barium swallow: A series of x-rays of the
esophagus and stomach. The patient
drinks a liquid that contains barium (a
silver-white metallic compound). The liquid
coats the esophagus and stomach, and x-
rays are taken. This procedure is also
called an upper GI series.

Certain factors affect prognosis
(chance of recovery) and
treatment options.
• Prognosis (chance of recovery) depends
on the following:
• The stage of the disease.
• The location and size of the tumor.
• The grade of the tumor.
• The patient's age, gender, and general
health, including whether the patient is
anemic.

• Treatment options depend on the
following:
• The stage of the disease.
• The location and size of the tumor.
• Keeping the patient's ability to talk, eat,
and breathe as normal as possible.
• Whether the cancer has come back
(recurred).

• Smoking tobacco and drinking alcohol
decrease the effectiveness of treatment for
laryngeal cancer. Patients with laryngeal
cancer who continue to smoke and drink
are less likely to be cured and more likely
to develop a second tumor. After treatment
for laryngeal cancer, frequent and careful
follow-up is important.

• Stages of Laryngeal Cancer
• After laryngeal cancer has been diagnosed,
tests are done to find out if cancer cells have
spread within the larynx or to other parts of the
body.
• The process used to find out if cancer has
spread within the larynx or to other parts of the
body is called staging. The information gathered
from the staging process determines the stage
of the disease. It is important to know the stage
of the disease in order to plan treatment. The
results of some of the tests used to diagnose
laryngeal cancer are often also used to stage
the disease.

• There are three ways that cancer spreads in the
body.
• The three ways that cancer spreads in the body
are:
• Through tissue. Cancer invades the surrounding
normal tissue.
• Through the lymph system. Cancer invades the
lymph system and travels through the lymph
vessels to other places in the body.
• Through the blood. Cancer invades the veins
and capillaries and travels through the blood to
other places in the body.

• When cancer cells break away from the
primary (original) tumor and travel through
the lymph or blood to other places in the
body, another (secondary) tumor may
form. This process is called metastasis.
The secondary (metastatic) tumor is the
same type of cancer as the primary tumor.
For example, if breast cancer spreads to
the bones, the cancer cells in the bones
are actually breast cancer cells. The
disease is metastatic breast cancer, not
bone cancer.

• The following stages are used for
laryngeal cancer:
• Stage 0 (Carcinoma in Situ)
• In stage 0, abnormal cells are found in the
lining of the larynx. These abnormal cells
may become cancer and spread into
nearby normal tissue. Stage 0 is also
called carcinoma in situ.

• Stage I
• In stage I, cancer has formed. Stage I
laryngeal cancer depends on where
cancer is found in the larynx:
• Supraglottis: Cancer is in one area of the
supraglottis only and the vocal cords can
move normally.
• Glottis: Cancer is in one or both vocal
cords and the vocal cords can move
normally.
• Subglottis: Cancer is in the subglottis only

• Stage II
• In stage II, cancer is in the larynx only. Stage II
laryngeal cancer depends on where cancer is
found in the larynx:
• Supraglottis: Cancer is in more than one area of
the supraglottis or surrounding tissues.
• Glottis: Cancer has spread to the supraglottis
and/or the subglottis and/or the vocal cords do
not move normally.
• Subglottis: Cancer has spread to one or both
vocal cords, which may not move normally.

Pea, peanut, walnut, and lime show tumor sizes.

• Stage III
• Stage III laryngeal cancer depends on whether cancer
has spread from the supraglottis, glottis, or subglottis.
• In stage III cancer of the supraglottis:
• cancer is in the larynx only and the vocal cords do not
move normally, and/or cancer is in tissues next to the
larynx; cancer may have spread to one lymph node on
the same side of the neck as the original tumor and the
lymph node is smaller than 3 centimeters; or
• cancer is in one area of the supraglottis only and in one
lymph node on the same side of the neck as the original
tumor; the lymph node is smaller than 3 centimeters and
the vocal cords can move normally; or
• cancer is in more than one area of the supraglottis or
surrounding tissues and in one lymph node on the same
side of the neck as the original tumor; the lymph node is
smaller than 3 centimeters and/or the vocal cords do not
move normally.

• In stage III cancer of the glottis:
• cancer is in the larynx only and the vocal cords do not
move normally, and/or cancer is in tissues next to the
larynx; cancer may have spread to one lymph node on
the same side of the neck as the original tumor and the
lymph node is smaller than 3 centimeters; or
• cancer is in one or both vocal cords and in one lymph
node on the same side of the neck as the original tumor;
the lymph node is smaller than 3 centimeters and the
vocal cords can move normally; or
• cancer has spread to the supraglottis and/or the
subglottis and/or the vocal cords do not move normally.
The cancer has also spread to one lymph node on the
same side of the neck as the original tumor and the
lymph node is smaller than 3 centimeters

• In stage III cancer of the subglottis:
• cancer is in the larynx only and the vocal cords
do not move normally; cancer may have spread
to one lymph node on the same side of the neck
as the original tumor and the lymph node is
smaller than 3 centimeters; or
• cancer is in the subglottis only and in one lymph
node on the same side of the neck as the
original tumor; the lymph node is smaller than 3
centimeters; or
• cancer has spread to one or both vocal cords,
which may not move normally, and to one lymph
node on the same side of the neck as the
original tumor; the lymph node is smaller than 3
centimeters.

• Stage IV
• Stage IV is divided into stage IVA,
stage IVB, and stage IVC. Each
substage is the same for cancer in
the supraglottis, glottis, or subglottis.

• In stage IVA:
– cancer has spread through the thyroid
cartilage and/or has spread to tissues beyond
the larynx such as the neck, trachea, thyroid,
or esophagus, and may have spread to one
lymph node on the same side of the neck as
the original tumor; the lymph node is smaller
than 3 centimeters; or
• cancer has spread to one or more lymph nodes
anywhere in the neck and the lymph nodes are
smaller than 6 centimeters; cancer may have
spread to tissues beyond the larynx, such as the
neck, trachea, thyroid, or esophagus. Vocal
cords may not move normally.

• In stage IVB:
– cancer has spread to the space in front of the
spinal column and surrounds the carotid
artery, or has spread to parts of the chest and
may have spread to one or more lymph nodes
anywhere in the neck (the lymph nodes may
be any size); or
– cancer has spread to a lymph node that is
larger than 6 centimeters and may have
spread as far as the space in front of the
spinal column, around the carotid artery or to
parts of the chest. Vocal cords may not move
normally.
• In stage IVC, cancer has spread beyond the
larynx to other parts of the body.

• The larynx , commonly called the "voice box," is a tube
shaped structure comprised of a complex system of
muscle, cartilage, and connective tissue. The larynx is
suspended from the hyoid bone, which is significant in
that it is the only bone in the body that does not
articulate with any other bone. The framework of the
larynx is composed of three unpaired and three paired
cartilages. The thyroid cartilage is the largest of the
unpaired cartilages, and resembles a shield in
shape. The most anterior portion of this cartilage is very
prominent in some men, and is commonly referred to as
an "Adam's apple." The second unpaired cartilage is the
cricoid cartilage, whose shape is often described as a
"signet ring." The third unpaired cartilage is the
epiglottis, which is shaped like a leaf. The attachment of
the epiglottis allows it to invert, an action which helps to
direct food and liquid into the esophagus and to protect
the vocal cords and airway during swallowing.

• The three paired cartilages include the
arytenoid, cuneiform, and corniculate
cartilages. The arytenoids are shaped like
pyramids, and because they are a point of
attachment for the vocal cords, allow the
opening and closing movement of the
vocal cords necessary for respiration and
voice. The cuneiform and corniculate
cartilages are very small, and have no
clear-cut function.

• There are two primary groups of laryngeal
muscles, extrinsic and instrinsic. The extrinsic
muscles are described as such because they
attach to a site within the larynx and to a site
outside of the larynx (such as the hyoid bone,
jaw, etc.). There are eight extrinsic laryngeal
muscles, and they are further divided into the
suprahyoid group (above the hyoid bone) and
the infrahyoid group (below the hyoid
bone). The suprahyoid group includes the
stylohyoid, mylohyoid, geniohyoid, and digastric
muscles. The suprahyoid extrinsic laryngeal
muscles work together to raise the larynx. The
infrahyoid group includes the sternothyroid,
sternohyoid, thyrohyoid, and omohyoid
muscles. The infrahyoid extrinsic laryngeal
muscles work together to lower the hyoid bone
and larynx.

• The intrinsic laryngeal muscles are described as
such because both of their attachments are
within the larynx. The intrinsic muscles include
the interarytenoid, lateral cricoarytenoid,
posterior cricoarytenoid, cricothyroid, and
thyroarytenoid (true vocal cord) muscles. All of
the intrinsic muscles are paired (that is, there is
a right and left muscle) with the exception of the
transverse interarytenoid. All of the intrinsic
laryngeal muscles work together to adduct
(close) the vocal cords with the exception of the
posterior cricoarytenoid, which is the only
muscle that abducts (opens) the vocal cords.

• The larynx houses the vocal cords, two elastic
bands of tissue (right and left) that form the
entryway into the trachea (airway). Above and
to the sides of the true vocal cords are the false
vocal cords, or ventricular cords. The false
vocal cords do not usually vibrate during voicing,
but are often seen coming together (adducting)
in individuals with muscle tension dysphonia, a
common voice disorder characterized by
excessive muscular tension with voice
production. The true vocal cords open (abduct)
when we are breathing and close (adduct)
during voicing, coughing, and swallowing

Hereditary Cause (maternal side)
+
Risk factors;
Smoker 1pack/day 30 pack years
Alcoholic drinkers
Damage to squamous cells
Metaplasia of the squamous cells
to ciliated squamous cell
producing cancer cells
Tumor growth in Supraglottic area
Hoarseness of voice
Continuous enlargement of tumor
Pressure on the
esophagus
Increased metabolic
rate
Increased burning of
nutrients higher than
is ideal for body
weight

Difficulty of Breathing
Tracheostomy insertion
Difficulty of Breathing
Obstruction of airway
Difficulty of
swallowing
Loss of appetite
Decreased food
intake
Altered nutrition
less than body
requirements
Poor tracheostomy care
Prone to infection
Invasion of pathogen
Increased WBC
FEVER
Accumulation of secretions
Obstruction of airway

• DAY 1
• 01/12/2010
• 5:30 p.m.
• The patient was requested to be admitted
under the service of Dr.
Maluyan/Nieves/Lay/Sy/Labayon. He was put
under DAT diet, with an IVF of 1L PNSS to run
for 12 hours. Therapeutics ordered was as
follows:
• PEN G 3,000,000 units IV every 6 hours ANST
(-)
• CELECOXIB 200g cap every 12hours PRN for
pain PRN

• Diagnostics ordered to the patient includes:
• CBC with APC
• For CT scan of the neck
• BT
• Blood typing w/ Rh typing
• Chest X-ray- PA
• FBS, TSH, FT4
• SGPT, SGT, Alkphos, B1 B2
• Lipid Profile
• TPAG
• BUN, Creatinine
• For liver Ultrasound
• R-L ECG

• The patient was subjected for Direct
Laryngoscopy with Biopsy/GA once CP is
cleared. The physician ordered for the
securing of the consent and for the
database c/o 1st year head and neck
rotation. He was referred to Dental for
Clearance prior to RT, and to IM for CP
Clearance once Labs were in.

• DAY 2
• 01/13/2010
• 7 a.m.
• Pen-G 0-1
• The patient was still for CT scan of the neck
with emphasis of the larynx with contrast. He
was also for liver ultrasonography, R-L ECG,
and CP clearance once Labs were in. The
physician also ordered for the results of the
diagnostic exams done on 01/12/2010.

• 12 p.m.
• The results of CBC, CT, BT, blood typing, FBS, lipid profile,
TPAG, bun & creatinine were received. Patient was referred for CP
clearance, and still for the follow up of Chest X-ray result.
• 5 p.m.
• Patient was still for CT scan of the neck, with emphasis of the
larynx with contrast. Still for the follow up of liver ultrasound result.
Patient was referred for cardiopulmonary clearance. Result of the R-
L ECG was for follow up. The patient was for direct laryngoscopy
with biopsy once CP cleared. Securing of the consent and for OR
materials was ordered. For continuation of the IVF 1L to run for 12
hours and IV antibiotics.

• DAY 3
• 01/14/2010
• 5 p.m.
• CT scan of the neck of the patient with emphasis of the larynx
with contrast was still ordered. The doctor ordered a follow up of the
liver ultrasound that was done on 01/13/2010. The patient was still
for CP clearance, follow up of direct laryngoscopy with biopsy, and
continuation of IVF and IV medicines. Additional orders were given
such as:
• for dental clearance form
• start Moriamin TIV every 8 hours for 8 doses added to PNSS
• 1L PNSS to run for 12 hours

• DAY 4
• 01/15/2010
• 5 p.m.
• Pen G
• 2-3
• UTZ N
• January 26, 2010 was the proposed date for the
ordered CT scan of the neck with emphasis on the larynx
with contrast. Official chest x-ray result was still for follow
up. The official ECG resulted was inserted already. The
patient was for official referral to IM for CP clearance.
The physician requested for the carrying out of dental
notes and the repeat of CBC with APC after 1 week of
Pen G.
• The patient was on a high fiber diet and
maintenance of daily tracheostomy care. For FT4, T8H,
and direct laryngoscopy with biopsy/ General Anesthesia
once cleared.

• 10 p.m.
• The physician ordered for the repeat of
the chest x-ray RA upright.

• DAY 5
• 1/16/2010
• 7:15 a.m.
• For official reading of chest x-ray. The
patient was still for CT scan of the neck with
emphasize of the larynx with contrast, FTH &
TSH, for repeat of CBC after 1 week of Pen G,
and direct laryngoscopy biopsy/ GA once the
patient is CP cleared.

• DAY 6
• 1/17/2010
• 8:45 a.m.
• Pen G
• 4-5
• The patient was still for repeat of CBC with APC
after 1 week.
• The patient was for FT4, TSH, direct laryngoscopy
with biopsy/ GA, and CT scan of the neck with emphasis
of the larynx with contrast. Continuation of the daily
tracheostomy care and Moriamin incorporation was
maintained.

• 5:45 p.m
• The patient was put under NPO at midnight
preoperatively. 1L D5NM to run for 8 hours was started.
Pre-op meds like Nalbuphine 10 mg, Prometacine 50
mg, and Ranitidine 50 mg TIV were prepared and
administrated. Hyponatremia, hypokalemia, and
hypobulemia was still for correction. Nitroabcesion patch
on ACW in the morning was also requested. For pulmo
clearance. Hydrocortisone 100mg TIV was also
requested to be administered as soon as possible.

• 7:05 p.m.
• Anesthesia order was requested to be
carried out. IVF side drips ordered
includes:
• PNSS 1L x 90cc+10 meq KCL x 10 doses
• PNSS 1L to run for 8 hours
• Potassium was also requested to be
repeated.

• DAY 7
• 01/18/2010
• 1:31 a.m.
• Sodium and Potassium was ordered to be
repeated at 3 am.
• 5:35 a.m.
• The patient was for direct laryngoscopy with
biopsy/GA at 8 am and also for ABG. Pulmo
notes was also requested by the physician

• 6:11 p.m.
• The dental and pulmo notes
suggestions were requested to be carried
out. Still for pulmo clearance and for
sputum AFB for 3 days. Nebulization of
2cc PNSS was also started. Patient is still
for CT scan of neck with emphasis of
larynx with contrast.

• DAY 8
• 1/19/2010
• 7 a.m.
• The patient is still for DL with biopsy GA and for pulmo
clearance. Securing of OR materials and consent was also
requested. The IVF and IV meds were continued. Still for sputum
AFB for 3 days. Precise X-ray plates were ordered to be retrieved
and should be placed on bedside. For ultrasound of neck with
emphasis of larynx with contrast.
• 6 p.m.
• Pulmonary suggestions were ordered to be carried out.
Requested for the securing of OR materials and consent.

• DAY 9
• 1/20/2010
• 12:10 p.m.
• The patient was for nebulization of Ipatropiam and Salbutamol,
with an interval of 30 mins of administration, for 3 days. NPO post
midnight ordered.
• 3 p.m.
• The patient was still for direct laryngoscopy with biopsy/GA (1-
21-10) at 10 in the morning. The physician ordered for the securing
of OR materials and consent. Oral and IV meds were still continued.
Still for sputum AFB for three days and CT scan of the neck with
emphasize on larynx with contrast.

• 7:45 p.m.
• The physician rerquested for an Anesthesia
pre-op order. The patient was put under NPO
post midnight. Once NPO, 1L D5LR to run for 8
hours was requested to be given to the patient.
Pre-op Medicines like Nalbuphine 10 mg, and
Promethazine 50 mg was ordered. He was also
for Salbutamol Nebulization with 2 nebules 30
mins. prior to OR. Still for correction of
Hyponutremia, hypokalemia, and
hypoalbuminemia ratio

• DAY 10
• 1/21/2010
• 7:50 a.m.
• The patient was scheduled for OR.
Moriamin was started and incorporated 1
amp to IVF every 8 hours for 8 doses. 1L
D5LR to run for 8 hours x 3 doses was
continued.

• After OR, the patient was put immediately under
Anesthesia Post-op order and requested to be sent to
PACU. Oxygen was also administrated to the patient at
the rate of 2.3 cpm via T-piece. Patient’s vital signs were
monitored every 15 mins and kept recorded until he’s
physically stable, was put under Cold, soft diet.
Regulation of the present IVF D5LR x 30 gtts/min must
be observed. Post-op drugs include:
• Nalbuphine 10mg TIV every 4 hours x 6 doses
• Ketorolac 30 mg TIV every 6 hours x 4 doses ANST (-)
• Continue PEN G 3,000,000 units TIV every 6 hours

• The patient was positioned to moderate
high back rest, encouraged deep
breathing exercises, and kept comfortable.

• DAY 11
• 1/22/2010
• 7 a.m.
• Pen G
• 8-9
• IVF was still continued (D5LR 1L x 12hours).
Positioned the patient to moderate high back rest and
encouraged deep breathing exercises.
• The patient was kept on a high fiber diet. Still for the
follow up for the biopsy result c/o Gutpitch Laboratory.
He was also referred to dietician for nutritional build up.

• 6 p.m.
• IV meds were still continued. The
patient was advised to be positioned at
moderate high back rest. Biopsy result
was still for follow up, and he was also put
to nutritional build-up and protein diet.

• Day 12
• 1/23/2010
• 7:00 a.m.
• IVF D5LR 1L x 12 hours and IV meds
were still continued. Biopsy result was still
for follow up. Protein was referred to the
patient.

• Day 13
• 1/24/2010
• 8:00 a.m.
• Pen G
• 11-12
•
• IVF and IV meds, as well as protein diet
were still continued. Biopsy result was still for
follow up. The patient was for Barium swallow,
and dental consultation.

• 30 p.m.
• The patient was given Paracetamol 300
mg IV for every 8 hours because of the
sudden onset of hyperthermia as
manifested by the temperature of 37.8
degrees Celsius.

• Day 14
• 1/25/2010
• 7 a.m.
• The patient was still for dental consultation and
Barium swallow. IVF of D5LR 1L to run for 12 hours for 2
doses, high protein diet, and daily trache care was
continued. Biopsy result was still for follow-up.
• 5 p.m.
• The patient was still for dental consultation and
dental clearance and still for barium swallow. IV meds
was still continued. Biopsy result was still for follow up.

• Day 15
• 1/26/2010
• 7:30 a.m.
• Pen G
• 13-14
• Dental consult and clearance was for follow up. The
patient was still for CT scan of the neck with contrast and
emphasis on the larynx. Still for Barium swallow and for
follow up of Biopsy results. IVF was ordered to be
followed by D5LR 1L x 12 hours. IV meds and high
protein diet was still continued, as well as daily trache
care

• 5:30 p.m.
• The patient was still going to undergo
CT scan. For follow up of both dental
clearance and biopsy results. Still for
dental clearance and Barium swallow.

• Day 16
• 1/27/2010
• 7:15 a.m.
• The patient was still for Barium swallow and CT scan of the
neck with contrast and emphasis on the larynx. For follow up of
dental consultation and biopsy result. IVF and IV meds was ordered
to be continued, as well as High protein diet. The patient was
ordered that he maybe transfused with 2 units of albumin 25%
• 2:50 p.m.
• The doctor ordered Paracetamol 300mg TIV for every 4 hours
to the patient due to its Increase in temperature.

• 5 p.m.
• The patient was still for barium
swallow. The doctor ordered a secured CT
scan of the neck with emphasis on the
larynx with contrast. IVF, IV meds, and
high protein diet was still continued. For
referral to IM for reclearance for
Laryngectomy.

• Day 17
• 1/28/2010
• 7 a.m.
• The patient was still for barium swallow, neck CT
scan, and referral to IM for reclearance prior to
Laryngectomy. IVF and IV meds were still continued.
• 5 p.m.
• The patient was still for barium swallow, for neck CT
scan, and IM clearance prior to Laryngectomy. For FT4
TSH and for referral to IM pulmo findings.

• Day 18
• 1/29/2010
• 7 a.m.
• The patient was still for barium swallow and Neck CT scan.
IVF, IV meds, and high protein diet was still continued. He was still
for referral to IM for CP clearance.
• Day 19
• 1/30/2010
• 7 a.m.
• Pen G
• The patient was still for barium swallow; for CT scan of the
neck with emphasis on the larynx with contrast; for Cardio-
pulmonary evaluation and clearance; for Free Thyroxine (FT4) and
Thyroid Stimulating Hormone (TSH). Intravenous fluids were still
continued (D5LR 1L to run for 12 hours for 2 doses). Patient was
also referred to the dietary for nutritional buildup.

• 12:45 p.m.
• Patient was belonged to RCRI with
intermediate risk of developing
perioperative complication. He was also
for adequate hydration, analgesia, and
anesthesia. The doctor ordered
Hydrocortisone 100g Intravenously 30
minutes prior to operating Room.

• Day 20
• 1/31/2010
• Pen G 3/14
• The patient was diagnosed to have risk for
stratification and risk for developing perioperative
complication. He was still for Barium Swallow; CT scan
of the neck with emphasis on the larynx with contrast; for
Free Thyroxine (FT4) and Thyroid-stimulating Hormone
(TSH). D5LR 1L to run for 12 hours for 2 doses was still
continued. The patient was referred to the dietary for
nutritional buildup. IV meds were also continued.

• Day 21
• 02/01/2010
• 7 a.m.
• The patient was still for barium swallow; CT scan of
the neck with emphasis on the larynx with contrast; for
follow up of biopsy result; still for Free Thyroxine (FT4)
and Thyroid-stimulating hormone (TSH). The doctor
ordered for the continuation of intravenous fluids and
medicines, daily tracheostomy care, and nebulization
2cc PNSS every 8 hours for the patient. Also kept for
high protein diet.

• 5 p.m.
• The patient was still for barium swallow
and CT scan of the neck with emphasis on
the neck with contrast. The doctor ordered
for the biopsy and FT4 & TSH result. He
also ordered IVF, IV meds, and
nebulization to continue. High protein diet
was also ordered for the patient.

• Day 22
• 02/02/2010
• Pen G 6-15
• The patient was still for barium swallow and CT scan. Biopsy
result and FT4/TSH results were still ordered to be followed up. IVF
and IV meds were still continued. Orders such as daily tracheostomy
care, nebulization, and high protein diet was still continued.
• 4 p.m.
• FNAB result was still for follow up. The patient was still for
barium swallow and CT scan. Results of biopsy result and FT4/TSH
was still ordered to be followed up. IVF and IV medicines were still
continued. Daily trache care, nebulization, and high protein diet was
still ordered.

• Day 23
• 02/03/2010
• 7 a.m.
• The patient was still for barium swallow and CT scan. Biopsy
result and FT4/TSH results were still ordered to be followed up. IVF
and IV meds were still continued. Orders such as daily tracheostomy
care, nebulization, and high protein diet was still continued.
• 5 p.m.
• FNAB result was still for follow up. The patient was still for
barium swallow and CT scan. Results of biopsy result and FT4/TSH
was still ordered to be followed up. IVF and IV medicines were still
continued. Daily trache care, nebulization, and high protein diet was
still ordered.

• Day 24
• 02/04/2010
• Official OR-PA result was still for follow up. All
medicines noted in the chart were ordered to be carried
out. The patient was still for barium swallow and CT
scan. Biopsy result and FT4/TSH results were still
ordered to be followed up. IVF and IV meds were still
continued. Orders such as daily tracheostomy care,
nebulization, and high protein diet was still continued.
The patient was referred to the dietary for nutritional
buildup.

Generic or
brand
name
Dosage/frequency/route Action Indication Nursing Responsibilities
Nalbuphine
(Nubain)
Jan 17- Feb
2
10mgTIV q4X6 Doses Binds to oopiate
receptor in the
CNS
Alters the
perception of
the response
to painful
stimuli while
producing
generalized
CNS
depression
> acts as an
agonist at
specific opiod
receptors in
the CNS to
produce
analgesic and
sedation but
also acts to
cause
hallucination
and is an
antagonist at
receptors
>Moderate to
severe
pain.Also
provides:
analgesiag
,sedation,and
supplement to
balanced
anesthesia
>Assess type location and
intensity of pain before
and one hour after IM or
30 minutes(peak) after Iv
administration.
>Assess BP, pulse, and
respiration before and
periodically during
administration

Generic/
Brand
Name
Dosage/
Frequency/Route
Action Indication Nursing Responsibility
Ranitidine
Hydrochlo
ride
50mg TIVq8 hrs. >competitively
inhibits the
action of
histamine
at the H2
receptors of
the parietal
cells of the
stomach,
inhibiting
basal
gastric acid
secretion
and gastric
acid that is
stimulated
by food,
insulin,
histamine,
cholinergic
agonist,
gastrin and
pentagastri
n.
>short term
treatment of
active
duodenal
ulcer.
>maintenance
therapy
duodenal
ulcer at
reduced
dosage.
>short term
treatment of
active,
benign
gastric
ulcer.
>treatment for
heartburn,
acid
indigestion,
sour
stomach.
>Assess patient for epigastric or
abdominal pain and frank or
occult blood in the stool, emesis,
or gastric aspirate.
> Inform patient that it may cause
drowsiness or dizziness.
> Inform patient that increased
fluid and fiber intake may
minimize constipation.
> Advise patient to report onset of
black, tarry stools; fever, sore
throat; diarrhea; dizziness; rash;
confusion; or hallucinations to
health car professional promptly
.> Inform patient that medication may
temporarily cause stools and
tongue to appear gray black.

GENERIC/BRAND
NAME
DOSAGE/FREQUENCY
/
ROUTE
ACTION INDICATION NURSING
RESPONSIBILITIES
MORIAMIN 1amp TIV every 8
hours for 8
doses added to
1L PNSS to run
for 12hrs.
Multivitamins and
minerals
>malnutrition,
protein and
vitamin
deficiencies
>anemia,
convalescence
,restoration
and
maintenance
of body
resistance
> Assess patient for the
sign of vitamins
deficiency.
>Assess nutritional
status through 24
hours
.
> Determine frequency of
consumption vitamin
rich food.

GENERIC/BRAND
NAME
DOSAGE/FREQUENC
Y
ROUTE
RESPONSIBILITIES
ALBUTEROL
(salbutamol)
2amp through
nebulization 30
mins prior to O.R
>Reduced chemical
mediators
release from
pulmonary
mast cells and
improved ability
of cilia to clear
mucus.
>Relieved
bronchospasm
associated with
acute or chronic
asthma.
>Bronchitis of
reversible
obstructive
airway disease.
>To treat exercise-
induced
bronchospasm.
>Monitor for sign and
symptoms of
toxicity

GENERIC/BRAND
NAME
DOSAGE/
FREQUENCY
ROUTE
RESPONSIBILITIE
S
Acetaminophen
(PARACETAMOL)
300mg PRN TIV for
temp. of 37.8
and above.
>Reduce fever by
direct action on
hypothalamus
heat regulating
center.
>Common cold, flu
other viral and
bacterial
infections or
pain and fever.
> Give drug with food if
GI upsets occurs.
> Assess for
hypersensitivity
reaction.
>Reduced dosage with
hepatic
impairment

Generic/Br
and
name
Dosage/frequ
ency/rou
te
Action Indication Nursing responsibilities
HYDROCORTI
SONE(A-
hydrocort,
cortef,hyd
rocortone,
solocorter
)
1000q TIV > in pharmacologic
doses, all agents
suppress
inflammatio
normal immune
response.
>All agents have
numerous intense
metabolic effects
>enters target cell and
binds to
cytoplasmic
receptors; initiates
many complex
reaction that are
responsible for its
anti inflammatory,
immuno
suppressive and
salt retaining a
ctions.
>management of
adreno cottical
insuffiency: in
choric use in
other situation
is limited
because of
mineralocortic
oid activity
> hyper calcemia
associated by
cancer
> to relieve
inflammation
> these drugs are indicated for
many conditions. Assess
the involved systems before
and periodically during
theraphy.
> assess patient for sings of
adrenal insuffiency (
hypotension, wt.loss,
weakness, nausea,
vomiting, anorexia,
lethargy, confusion,
restlessness)
> monitor intake and output
ratios and daily wt

GENERIC/
BRAND
NAME
DOSAGE/
FREQUENC
Y/
ROUTE
RESPONSIBILITIES
PEN-G
Benzathine
3,000,000 units
TIV every 6
hours
> Inhibits
synthesis of
cell wall of
sensitive
organism
causing cell
death.
>URI caused by
sensitive
streptococci.
> Severe infections
caused by
sensitive
organism
> Assess for any
allergies to
penicillin’s and
cephalosporins.
>Assess for any skin
rashes and lesions.
>Monitor serum and
electrolyte and
cardiac status.
>Report unusual
bleeding.

GENERIC/
BRAND
NAME
DOSAGE/
FREQUENCY/
ROUTE
RESPONSIBILIT
IES
KETOROLAC
(TROMETHAMINE)
Ketorolac 30 mg TIV
every 6 hours x 4
doses ANST (-)
> Anti-
inflammatory
and analgesics
activity/
> Inhibits
prostaglandin
and leukotriene
synthesis.
> Short term
management
for pain( up to
5 days)
>Patients who have
asthma, aspirin-
induced allergy,
and nasal polyps
are at increased
risk for developing
hypersensitivity
reactions. Assess
for rhinitis,
asthma, and
urticaria.
> Assess pain (note
type, location, and
intensity) prior to
and 1-2 hr
following
administration.
> - Caution patient to
avoid concurrent
use of alcohol,
aspirin, NSAIDs,
acetaminophen, or
other OTC
medications
without consulting
health care
professional.

. > Advise patient to
consult if rash,
itching, visual
disturbances,
tinnitus, weight
gain, edema, black
stools, persistent
headche, or
influenza-like
syndromes
(chills,fever,muscle
s aches, pain)
occur.

PROBLEM LIST
1.) Ineffective Airway Clearance
2.) Elevated Body temperature
3.) Nutrition Less than Body Requirements

ASSESSMENT NURSING
DIAGNOSIS
PLANNING NURSING
INTERVENTION
RATIONALE EVALUATION
Subjective: N/A
Objective:
RR: 29cpm
(Rapid Shallow
Breathing)
Presence of
crackles sound
in the RML and
RLL of the lungs
(+) Restlessness
(+) Clammy skin
Ineffective
Airway
Clearance
related to
increased
mucous
production as
manifested by
increased RR
of 29cpm
After 6hrs of
nursing
intervention
pt. RR will
decreased to
20 and clear
breathing will
be
maintained.
> Positioned the
client in semi-
fowlers position.
> Gave
supplemental
oxygen 2L/min as
ordered.
> Encouraged pt. to
take deep breathing
exercises.
> Nebulized the pt.
as ordered.
> Suctioned the pt.
as ordered.
> Performed daily
trach care.
> Increased oral
fluid intake.
> To facilitate
respiratory function
by use of gravity in
preparation for
suctioning.
> Helps in giving
adequate oxygen to
the pt.
> To promote
chest expansion and
facilitate movement
of the secretions.
> To soften the
secretions for easy
suctioning.
> To remove the
secretions easily.
> To maintain a
clear airway.
> To loosen and
liquefy the
secretions.
Goal Met.
After 6hrs of
nursing
intervention pt.
RR decreased
from 29 to 20
with clear
breathing.

ASSESSMENT NURSING
DIAGNOSI
S
PLANNING NURSING
INTERVEN
TION
RATIONALE EVALUATION
Subjective:
N/A
Objective:
Temp:40.5C
(+) Chilling
(+) Flushing
(+) Warm to
touch
Increased WBC
of 16.5
Elevated
Body
temperatur
e related to
invasion of
pathogens
as
manifested
by
increased
temp. of
40.5C
After 4 hours
of nursing
interventio
n patient
temperatur
e will
decrease
from 40.5C
to 37C
> Provided
extra
blanket
>TSB done.
>Loosened
clothing of
the pt.
>Provided good
ventilation
to the
patient.
>To warmth
the patient
to prevent
chilling.
>Decreases
warmth
and
increases
evaporative
cooling.
> to provide
comfort to
the patient
by
promoting
surface
cooling.
>To promote
clear flow
of air in
the pt.
area
Goal met.
After 4 hours
of nursing
interventio
n, patient
temp
decreased
from 40.5C
to 37C

>Encouraged pt.
to take deep
breathing
exercises.
>Increased fluid
intake
>Paracetamol
given
500mg TIV.
>To promote
chest
expansion
> To promote
surface
cooling
> Helps lowering
body temp.
by inhibiting
prostaglandi
n that is
mediator of
fever and
pain.

Assessment Diagnosis Planning Intervention Rationale evaluation
Subjective:
“wala ako
gana
gumain,
konti
lang.” as
verbaliz
ed by
the
patient
( through lip
reading)
Objective:
>decrease of
weight
from
baseline
of 45kg
to 39kg.
>poor
muscle
tone
Altered
nutrition
less than
body
requirem
ents r/t
difficulty
to ingest
food and
lack of
appetite.
STG:
>after 30mins of
health
teaching
patient will
be able to
understand
the
importance
of good
nutrition.
LTG:
After the 6days
of nursing
intervention
patient will
be able to
gain 5lbs.
STG:
>informed
patient
about the
importan
ce of
good
nutrition.
>enumerated
a list of
foods
with high
nutrition
values to
the
patient.
LTG:
>encouraged
pt. to eat
food rich
in
protein
calcium
and fiber.
STG:
>for the pt. to
know why and
how good
nutrition can
affect his
condition or
well-being.
>for the patient to
know what to
eat.
LTG
> to help pt. gain
the desired
weight.
STG:
> patient was
able to
discuss in
his own
words the
importance
of proper
nutrition and
was able to
enumerate
numerous
kinds of
foods to eat.
LTG:
>pt’s weight
increased
from 39kg. to
41kg.

>provided good
oral
hygiene.
>Monitored
patient’s
weight.
>for the pt. to
become
comfortable
therefore
enhancing the
chances to
increase food
intake
> to monitor any
variations on
the patient’s
weight

• *MEDICATION
• Our patient will undergo total laryngectomy and was given the
following instruction regarding his take-home medications as per his
doctors order:
• Mefenamic acid 500mg for acute pain
• amoxicillin 500mg TID after the operation to prevent infection
• vit.C 500mg TID to boost his immune system
• We have also explained to the client the regimen of his medication
which includes the side-effects, indication proper administration,
time intervals and the importance of adhering strictly to it, as well as
the consequences of failing to complete the course of treatment.

• *ENVIRONMENT AND EXERCISE
• After the operation the patient was expected to have a
stoma the ff. are advised to the patient about proper
caring of the stoma.
• > instructed patient to avoid places that will irritate
the stoma like presence of irritants, dust and pollution.
• > instructed the client not to go out the house
without stoma covering to prevent further infection
• > advised the patient to ambulate as early as he can
to prevent swelling and pneumonia

• *HEALTH TEACHINGS/TREATMENT
• The following health teachings were imparted to
both client and his wife to ensure continuity of
care and his immediate recovery and health
maintenance:
• 1.proper infection control
• 2.enough rest
• 3.proper hygiene (oral and body)
• 4.proper cleaning of stoma with the use of mild
soap and water.

• *OPD (FOLLOW UP CARE)
•
• The client was advised, as per his doctors order
to comeback for his follow up check up, and was
instructed to consult immediately if some signs
of complications occurs.
• *DIET
• Our client will undergo total laryngectomy. The
ff. are advised to the pt. to eat post – operatively.

• Instructed pt. to eat foods rich in protein and calorie like.
• egg
• meat
• potato
• green leafy vegetables
• shrimp
• fish
• avocado
• vit c. rich foods
• mangoes
• oranges
• citrus fruits

• We therefore conclude that smoking is the most important risk factor
for laryngeal mass. Heavy chronic consumption of alcohol,
particularly alcohol spirits, is also significant.
• When combined, these two factors appear to have a synergistic
effect. Some other quoted risk factors, are likely, in part to be related
to prolonged alcohol and tobacco consumption. These include
lacking of nutritional benefits caused by the low socioeconomic
status of our client; most common in male than in female, and within
the bracket of 40-60 years of age. In these factors, hoarseness of
voice is the most common symptom of laryngeal mass. It has been
shown that people who smoke over a prolonged period of time,
whether heavy or relatively light smokers, have the greatest risk for
laryngeal mass

• As smoke passes by the larynx on its way
to the lungs, it can damage the cells there,
so we concluded also that the best way to
prevent this type of disease is by not
smoking. Other measures that can take to
reduce the risk of laryngeal mass is by
avoiding excessive alcohol use and
protecting ourselves from toxic exposures
that have been linked to laryngeal cancer.

Breathless Laryngeal Cancer Case Study

Breathless Laryngeal Cancer Case Study

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