A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:

1. A

   Activity intolerance

2. B

   Ineffective airway clearance

3. C

   High risk for infection

4. D

   Altered oral mucous membrane

Appeared in: NORCET 6 mains-2024

Explanation

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• According to the Airway, Breathing, Circulation (ABC) framework, maintaining a patent airway is the highest priority in patient care.
• A vertical partial laryngectomy involves surgery on the larynx, which is a critical part of the airway. Postoperative edema, inflammation, and increased mucus production are expected.
• These factors can lead to airway obstruction, a life-threatening emergency that must be addressed immediately.
• The patient's ability to cough and clear secretions is often impaired due to pain and the altered anatomy, making them dependent on nursing interventions to maintain airway patency.

Why Other Options Were Wrong

• Option A: Activity intolerance is a concern related to recovery and rehabilitation, but it is not an immediate life-threatening issue in the early postoperative period.
• Option C: While there is a risk for infection at the surgical site, it is not the most immediate priority. Infections typically develop over hours to days, whereas an airway obstruction can be fatal in minutes.
• Option D: Altered oral mucous membrane is a valid concern related to potential dehydration, NPO status, or trauma from intubation, but it is a comfort and hygiene issue, not a life-threatening priority.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Prioritization of postoperative nursing diagnoses to guide bedside assessment, documentation, and the next nursing action.
• Vigilant airway assessment is a critical nursing responsibility for any patient with head and neck surgery. Early signs of airway compromise include restlessness, agitation, stridor, and increased respiratory effort.
• Nurses must have suction equipment, oxygen, and an emergency tracheostomy kit readily available at the bedside for a post-laryngectomy patient.
• What if? If the question stated the patient was 3 days post-op and had a fever of 101.5°F with purulent drainage from the incision, 'High risk for infection' would become a much higher priority, although airway patency always remains a key assessment.

How to Approach the Question

• First, identify that the question is asking for the 'priority' nursing diagnosis. This signals a prioritization question.
• Recall fundamental prioritization frameworks, such as Maslow's Hierarchy of Needs and the ABCs (Airway, Breathing, Circulation). Physiological needs, especially the ABCs, are always the top priority.
• Analyze the clinical situation: A 'vertical partial laryngectomy' is surgery on the throat, directly impacting the airway.
• Evaluate each option based on the ABC framework. 'Ineffective airway clearance' directly corresponds to 'A' for Airway.
• Compare the immediacy of the threat for each option. Airway obstruction is an immediate, life-threatening event. Infection, activity intolerance, and altered mucous membranes are less acute concerns in the immediate postoperative period.
• Select the option that addresses the most immediate physiological threat to the patient's life.

Concept Tested & Keywords

• Concept Tested: Prioritization of postoperative nursing diagnoses
• Stem keywords: vertical partial laryngectomy, postoperative care, priority nursing diagnosis
• Lead-in keywords: priority
• Clinical cues: The procedure is a vertical partial laryngectomy, which directly involves the airway.

Question ID

QuO5l1C7pQoGRm8fKxVl4K

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 1 pp. 49-51, 50-52