# A nurse is caring for a client who underwent a total laryngectomy 48 hours ago for laryngeal cancer. Which nursing intervention is most important to implement at this time?

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> subject: Adult Health

## 문제

A nurse is caring for a client who underwent a total laryngectomy 48 hours ago for laryngeal cancer. Which nursing intervention is most important to implement at this time?

## 보기

1. Encourage the client to practice speaking with an electrolarynx device
2. Provide written materials about support groups for laryngectomy patients
3. Monitor for signs of respiratory distress and maintain patent airway **✔ 정답**
4. Teach the client how to perform tracheostomy care independently

**정답: 3**

## 해설

Maintaining airway patency and monitoring for respiratory distress is the highest priority in the immediate postoperative period after total laryngectomy. Other interventions are important but secondary to ensuring physiological stability.

## 심화 해설

Understanding the Postoperative Priority

In the early postoperative period following a total laryngectomy, the client has a permanent tracheostomy stoma. This represents a complete anatomical separation of the upper and lower airways; the client no longer breathes through the nose or mouth. The immediate and ongoing priority is always airway management. The surgical site is susceptible to edema, thick secretions, and crusting, which can rapidly lead to airway obstruction. Evidence indicates that airway compromise and respiratory distress are among the most critical early complications, with risk factors including excessive secretions and improper stoma care .

Why Airway Maintenance is the Most Important Intervention

The stoma is the client's sole source of ventilation. During the first 48 hours, the airway is particularly vulnerable to obstruction from mucus plugs or tissue edema. Monitoring for signs of respiratory distress—such as tachypnea, use of accessory muscles, decreased oxygen saturation, and restlessness—and ensuring the airway remains patent through sterile suctioning and humidification is a lifesaving nursing action. A scoping review on the transport of patients with surgical airways reinforces that the primary risk during any care period is airway compromise, emphasizing that maintaining a secure, patent airway is the foundational principle of care . Without a patent airway, all other interventions are futile.

Analysis of Other Options

- Option 1: Encouraging the client to practice speaking with an electrolarynx is an important part of rehabilitation but is premature at 48 hours postoperatively. The client is still in the acute recovery phase, where pain, edema, and energy conservation take precedence over speech rehabilitation.

- Option 2: Providing written materials about support groups addresses the psychosocial need of altered body image and lifestyle changes. While valuable for long-term coping, this intervention is not the physiological priority in the immediate postoperative period when life-threatening airway complications are most likely to occur.

- Option 4: Teaching the client how to perform tracheostomy care independently is a critical step in discharge planning. However, at 48 hours post-surgery, the client is unlikely to have the physical stamina or emotional readiness to learn and perform this complex skill independently. The focus must first be on stabilization and preventing complications, with education introduced gradually as the client recovers.

Clinical Reasoning and Evidence-Based Rationale

The highest priority is derived from the physiological risk profile of the procedure. A retrospective analysis of post-laryngectomy complications confirms that respiratory complications, including airway obstruction and pulmonary infection, are significant early adverse events . The nursing intervention that directly mitigates this risk is continuous assessment and maintenance of a patent airway. Furthermore, best-practice evidence for preventing and managing tracheostomy complications highlights the necessity of vigilant airway monitoring, effective suctioning, and stoma care to prevent mucous plugging and respiratory deterioration . This physiological need aligns with the foundational nursing principle of airway, breathing, and circulation (ABCs), where airway patency is the unequivocal first step. The specialized nature of the laryngectomy stoma, which requires specific troubleshooting skills to manage obstruction, makes this nursing action the most critical at this time .

## 임상 시나리오

Post-Laryngectomy Airway ManagementImmediate Priorities in the First 48 Hours
After a total laryngectomy, the patient breathes solely through a permanent tracheostomy stoma. The highest priority is maintaining a patent airway because the stoma is vulnerable to obstruction from mucus plugs, crusting, or edema.

Perform sterile suctioning as needed and provide humidified air to keep secretions thin. Continuously monitor for signs of respiratory distress: tachypnea, use of accessory muscles, decreased O2 saturation, and restlessness.

CautionNever occlude the stoma for a patient with a total laryngectomy; they cannot breathe through the mouth or nose. Airway compromise is a life-threatening emergency requiring immediate intervention.

## 핵심 개념

- **Total Laryngectomy** — Surgical removal of the larynx, creating a permanent tracheostomy stoma that separates the upper and lower airways.
- **Tracheostomy Stoma** — A permanent surgical opening in the neck into the trachea, serving as the sole airway for ventilation after total laryngectomy.
- **Airway Obstruction** — Blockage of the airway, which can occur post-laryngectomy due to mucus plugs, crusting, or tissue edema, leading to respiratory distress.
- **Respiratory Distress** — A life-threatening condition characterized by signs such as tachypnea, accessory muscle use, decreased oxygen saturation, and restlessness.
- **Sterile Suctioning** — A technique using sterile equipment to remove secretions from the tracheostomy to maintain a patent airway and prevent infection.

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