# A nurse is caring for a 58-year-old male client who underwent a total laryngectomy for laryngeal cancer 72 hours ago. The client appears anxious and is attempting to communicate by writing notes. His tracheostomy site has minimal clear drainage, vital signs are stable, and oxygen saturation is 95% on room air through the tracheostomy. Which nursing intervention should be the priority at this time?

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## 문제

A nurse is caring for a 58-year-old male client who underwent a total laryngectomy for laryngeal cancer 72 hours ago. The client appears anxious and is attempting to communicate by writing notes. His tracheostomy site has minimal clear drainage, vital signs are stable, and oxygen saturation is 95% on room air through the tracheostomy. Which nursing intervention should be the priority at this time?

## 보기

1. Encourage the client to practice esophageal speech techniques
2. Assess the patency and security of the tracheostomy tube **✔ 정답**
3. Provide emotional support for the loss of natural speech
4. Teach the client alternative communication methods

**정답: 2**

## 해설

Assessing tracheostomy tube patency and security is the priority to maintain the only airway after total laryngectomy. Emotional support and communication methods are important but secondary to physiological stability.

## 심화 해설

Clinical Context & Priority-Setting Rationale

The client is 72 hours post-total laryngectomy, a critical juncture where the surgical airway is maturing but remains highly vulnerable. While communication loss and anxiety are significant psychosocial needs, the physiological principle of the ABC (Airway, Breathing, Circulation) framework dictates that maintaining a patent airway is the absolute priority. A total laryngectomy permanently separates the trachea from the pharynx, meaning the tracheostomy is the client's only airway. Any compromise to its patency or security is immediately life-threatening. Evidence-based guidelines for preventing and managing postoperative tracheostomy complications emphasize that early, systematic assessment of the tube is foundational to safe care [1].

Analysis of Priority Intervention

The correct intervention is to assess the patency and security of the tracheostomy tube. This is not merely a routine check; it is a critical safety assessment driven by the high-risk period of postoperative days 1-5. During this time, the stoma is not yet mature, and risks such as mucous plugging, tube displacement, or accidental decannulation are highest [1]. A thorough assessment includes verifying bilateral breath sounds, checking for subcutaneous emphysema, confirming the security of the tracheostomy ties (allowing one finger's breadth of slack), and ensuring that emergency equipment (a spare tracheostomy tube and obturator of the same size and one size smaller) is immediately visible at the bedside. The presence of minimal clear drainage is a normal finding, but the nurse must remain vigilant for changes that could signal impending obstruction.

Why Other Options Are Deferred

- Option 1 (Esophageal speech): This is an advanced, long-term rehabilitation technique. It is physiologically inappropriate at 72 hours postoperatively when the surgical site is acutely inflamed and healing. Initiating this prematurely could strain suture lines and is not an immediate nursing priority over airway safety.

- Option 3 (Emotional support): While the loss of natural voice is a profound emotional event, psychosocial support, though essential, is a secondary priority to physiological stability. The nurse can provide therapeutic presence and support concurrently with, but never before, ensuring the airway is secure.

- Option 4 (Alternative communication): Preoperative education on communication methods has been shown to improve postoperative outcomes, but this teaching should ideally occur before surgery . At 72 hours post-op, the priority shifts from initial teaching to reinforcing established methods and, most critically, maintaining the airway. The client is already effectively using a basic method (writing notes), so formal teaching of new methods is not the most urgent need.

Integration of Evidence

The systematic review on preoperative education highlights that setting expectations for the postoperative period, including the temporary loss of voice and the presence of a tracheostomy, can reduce anxiety . This explains why the client's current anxiety, while needing acknowledgment, is not an unexpected finding that overrides airway assessment. The evidence synthesis on tracheostomy complications provides the direct clinical rationale: a structured, evidence-based protocol for tracheostomy care, beginning with a focused respiratory and tube assessment, is the cornerstone of preventing life-threatening events like tube obstruction or accidental decannulation in the immediate postoperative phase [1]. The nurse's clinical judgment must integrate this evidence by recognizing that a stable oxygen saturation of 95% on room air does not guarantee continued airway patency; it is a snapshot in time, and the dynamic risk of mucus plugging requires continuous vigilance through regular, hands-on assessment.References (research sources)

- [1]Summary of the best evidence for the prevention and management of postoperative tracheostomy complications in laryngeal cancer patients.Research articleXing R, Zheng L, Chen X, Qing S, Shi Q, Xiao H. (2026) · DOI: 10.3389/fonc.2026.1764483

## 임상 시나리오

Post-Laryngectomy Airway SafetyPriority assessment in the first 72 hours
After a total laryngectomy, the trachea is permanently separated from the pharynx. The tracheostomy is the only airway, making its patency a life-or-death priority over all other needs.

The highest risk period for mucous plugging, tube displacement, or accidental decannulation is postoperative days 1-5. Assess tube patency by checking bilateral breath sounds and looking for subcutaneous emphysema.

CautionAlways keep emergency equipment at the bedside: a spare tracheostomy tube and obturator of the same size and one size smaller. Secure ties with a one-finger breadth slack to prevent skin breakdown while maintaining security.

## 핵심 개념

- **Total Laryngectomy** — Surgical removal of the larynx, permanently separating the trachea from the pharynx, making the tracheostomy the sole airway.
- **Tracheostomy Patency** — The state of the tracheostomy tube being open and free from obstruction, such as mucous plugging, which is critical for ventilation.
- **ABC Priority Framework** — A clinical decision-making tool that prioritizes Airway, Breathing, and Circulation as the most immediate physiological needs.
- **Stoma Maturity** — The healing process of a surgical opening; a tracheostoma is immature and at high risk for stenosis or accidental closure in the first 5-7 days post-op.
- **Esophageal Speech** — A long-term alaryngeal communication method involving swallowing air and releasing it to vibrate the esophagus, taught after initial surgical recovery.

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