# Situation: A 60-year-old man who smokes and drinks alcohol daily undergoes total laryngectomy with a permanent tracheostoma for cancer of the larynx. Before discharge, which statement by the client shows that he understands stoma care?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629842  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 60-year-old man who smokes and drinks alcohol daily undergoes total laryngectomy with a permanent tracheostoma for cancer of the larynx.

Before discharge, which statement by the client shows that he understands stoma care?

## 보기

1. "I will cover my stoma with my hand when I cough."
2. "I will leave my stoma uncovered to breathe more easily."
3. "I can swim again once my stoma has fully healed."
4. "I will use a shower guard when I bathe." **✔ 정답**

**정답: 4**

## 해설

After total laryngectomy, water entering the stoma goes directly into the lungs, so a shower guard is used and swimming is not allowed. The client coughs through the open stoma and keeps it covered with a light foam or cloth filter that warms, moistens, and filters the air.

## 심화 해설

Core concept: Permanent tracheostoma after total laryngectomy

After a total laryngectomy, the upper airway and lower airway are permanently separated. The nose and mouth no longer connect to the trachea and lungs. The client breathes exclusively through the permanent tracheostoma in the neck. This changes the normal protective functions of the upper airway: warming, humidifying, and filtering inspired air are lost, and the lower airway is directly exposed to the environment. Any liquid that enters the stoma travels straight down the trachea into the lungs, which can cause aspiration, chemical pneumonitis, or drowning.

The single most important safety rule after total laryngectomy is to keep water out of the stoma. This principle explains why option 4 is correct and why swimming is permanently prohibited.

Analysis of each option

| Option | Statement | Evaluation |
| --- | --- | --- |
| 1 | "I will cover my stoma with my hand when I cough." | Incorrect. The client coughs through the open stoma. Covering the stoma with the hand during coughing can block the airway and force secretions or air into the tissues around the stoma. A tissue or cloth may be held loosely near the stoma to catch secretions, but the hand should not seal the opening. |
| 2 | "I will leave my stoma uncovered to breathe more easily." | Incorrect. The stoma is generally kept covered with a light foam stoma cover, bib, or heat-moisture exchanger (HME). This covering filters particles, preserves moisture, and helps maintain airway humidity. Leaving it uncovered increases drying of the tracheal mucosa, mucus plugging, and irritation. |
| 3 | "I can swim again once my stoma has fully healed." | Incorrect and dangerous. Even a healed stoma remains a direct opening into the trachea. Water entering the stoma during swimming would flow directly into the lungs. Swimming is permanently contraindicated unless the client uses specialized, sealed equipment and has received specific training; routine swimming is not permitted. |
| 4 | "I will use a shower guard when I bathe." | Correct. A shower guard or stoma shield directs water away from the stoma during showering. This allows the client to bathe while protecting the airway from water entry. |

Why a shower guard is essential

The tracheostoma is located on the anterior neck and faces slightly upward and outward. During a shower, water from above can flow directly into the opening. A shower guard is a rigid or semi-rigid plastic shield that is held over the stoma, often with an adjustable strap. It deflects water away from the stoma while still allowing air to move in and out. The client should also avoid directing the shower spray at the neck and should keep the face away from the direct stream.

Key point! A shower guard is for bathing only. It is not a swimming device. The distinction between showering with protection and swimming with immersion is a high-yield test concept.

Stoma covering and humidification

After discharge, the client is taught to wear a stoma cover made of light foam or fabric. This cover serves three purposes: it filters dust and particles, it helps retain heat and moisture from exhaled air, and it reduces drying of the tracheal mucosa. A heat-moisture exchanger (HME) cassette can be placed over the stoma to more effectively preserve humidity and improve pulmonary function. Without a cover or HME, the trachea and bronchi lose moisture rapidly, which thickens secretions and increases the risk of mucus plugging and infection.

Coughing after laryngectomy occurs through the stoma, not the mouth. The client should be taught to lean slightly forward and cover the stoma loosely with a tissue or cloth to catch expelled mucus. The hand should not form a seal over the stoma during a cough because this can create back pressure and force air into the soft tissues of the neck, causing subcutaneous emphysema.

Water safety beyond showering

The prohibition on swimming is permanent and absolute for most clients. Even wading in water deeper than the stoma level is hazardous. Other water precautions include avoiding baths in which the stoma could become submerged, using caution when washing the face, and avoiding the use of aerosol sprays, powders, or fine particles near the stoma. The client should also be cautious in rain and when using a hose or faucet near the neck.

Watch out! A common test error is to assume that once the surgical site heals, normal activities such as swimming can resume. Healing closes the wound but does not restore the upper airway connection. The stoma remains a permanent direct opening into the trachea for life.

Clinical reasoning summary

The correct response demonstrates understanding that the stoma is a permanent, unprotected entry into the lower airway. Using a shower guard shows awareness that water must be kept out during bathing. The incorrect responses reflect misunderstandings about coughing mechanics, the purpose of stoma covers, and the permanent nature of the water restriction. The safest discharge teaching emphasizes three points: keep the stoma covered with a light filter or HME, protect the stoma from water during showers, and never allow the stoma to be submerged in water.

## 임상 시나리오

Tracheostoma Water Safety After Total LaryngectomyKeep water out of the stoma at all times
After total laryngectomy, the upper and lower airways are permanently separated. The client breathes only through the tracheostoma, so any water entering the stoma goes directly into the lungs, causing aspiration or drowning.

Use a shower guard when bathing. Swimming is permanently prohibited. Keep the stoma covered with a light foam filter or HME to warm, moisten, and filter inspired air.

CautionDo not cover the stoma tightly with the hand during coughing. Cough through the open stoma, and hold a tissue loosely nearby to catch secretions.

## 핵심 개념

- **total laryngectomy** — Surgical removal of the larynx, permanently separating the upper and lower airway
- **tracheostoma** — Permanent opening in the neck through which the client breathes exclusively
- **HME** — Heat-moisture exchanger placed over the stoma to warm, humidify, and filter inspired air
- **aspiration** — Entry of fluid or material into the lower airway, a major risk after laryngectomy
- **shower guard** — Protective device used to keep water out of the tracheostoma during bathing

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