Nursing care
Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis
Tratamiento local de un faringostoma secundario a osteorradionecrosis
Olga González-Antolín
Servicio de Digestivo y Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
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"documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Enferm Clin. 2017;27:186-92" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Knowledge and attitudes of primary care nurses about the management of patients with insomnia" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "186" "paginaFinal" => "192" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Conocimientos y actitudes de las enfermeras de Atención Primaria sobre el manejo del paciente con insomnio" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "María Clara Vidal-Thomàs, Beatriz Yañez-Amoros, Isabel Torrens, Elena Torres-Solera, Magdalena Esteva" "autores" => array:5 [ 0 => array:2 [ "nombre" => "María Clara" "apellidos" => "Vidal-Thomàs" ] 1 => array:2 [ "nombre" => "Beatriz" "apellidos" => "Yañez-Amoros" ] 2 => array:2 [ "nombre" => "Isabel" "apellidos" => "Torrens" ] 3 => array:2 [ "nombre" => "Elena" "apellidos" => "Torres-Solera" ] 4 => array:2 [ "nombre" => "Magdalena" "apellidos" => "Esteva" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1130862116301693" "doi" => "10.1016/j.enfcli.2016.11.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130862116301693?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445147917300140?idApp=UINPBA00004N" "url" => "/24451479/0000002700000003/v2_201706121007/S2445147917300140/v2_201706121007/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Nursing care</span>" "titulo" => "Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "193" "paginaFinal" => "202" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Olga González-Antolín" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Olga" "apellidos" => "González-Antolín" "email" => array:1 [ 0 => "olgonzalez@humv.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Digestivo y Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento local de un faringostoma secundario a osteorradionecrosis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 557 "Ancho" => 990 "Tamanyo" => 123484 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Day 22. Insertion of the silver alginate dressing (Biatain Alginate AG<span class="elsevierStyleSup">®</span>) in the bed of the lesion after cleaning with saline.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Osteoradionecrosis and chondronecrosis are amongst the complications that can appear after radiotherapy in the treatment of head and neck tumours, they are characterised by their late onset and difficulty in treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">These complications originate essentially because radiation affects all cells in the field of treatment, especially the endothelium of small and medium-sized blood vessels, causing their obliteration, atrophy and fibrosis, resulting in tissue hypoxia, hypocellularity and hypovascularity and consequent necrosis. The incidence of osteoradionecrosis in patients with head and neck tumours is from 3% to 14%.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The jawbone is the most-affected bone, since it is most frequently exposed to radiation. The hyoid bone, clavicles, temporal bone, and base of skull can also be affected, the latter in the treatment of nasopharyngeal cancers.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Adverse reactions to radiotherapy depend on the volume and surface that is being irradiated, the total number of doses and their fractionation, and the age and condition of the patient. These effects can be divided into three phases:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0025" class="elsevierStylePara elsevierViewall">The acute effects that occur during treatment.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0030" class="elsevierStylePara elsevierViewall">The delayed early effects that appear between a few weeks and up to 2–3 months after completing treatment, which are usually reversible.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0035" class="elsevierStylePara elsevierViewall">The delayed late effects that appear after between 3 months and 12 years following radiotherapy. These are generally irreversible and result in a worsened quality of life of the patient, causing permanent disabilities of varying intensity.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a></p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">These effects involve the cutaneous mucosa and can range in severity from a simple erythema to tissue necrosis, processes of hyperpigmentation, alopecia and mucositis are common. Fibrosis of the cervico-facial muscles can also occur and its consequent impact on chewing and swallowing and cervical mobility. Likewise, involvement of the salivary glands is also common with consequent xerostomia, which in turn increases the risk of dental caries and can encourage mucosal candidiasis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Complications secondary to radiotherapy, bearing in mind that these are tumours usually originate in the oral cavity, pharynx and/or larynx, and sometimes even with previous surgical sequelae, often cause these patients swallowing difficulties. In fact up to 50% of head and neck cancer patients suffer some degree of malnutrition, which is severe in a third of these patients.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Osteoradionecrosis is one of the most feared lesions that can occur after exposure to radiation. This complication results in ischaemic bone necrosis which causes pain and loss of bone structure which can occur spontaneously or, more usually, after trauma (generally teeth extractions). In patients with head and neck tumours who have undergone radiotherapy, the jawbone is most affected as it is poorly vascularised and very dense; therefore it is very sensitive to the effects of radiation. In 95% of cases soft tissue necrosis and bone exposure are also associated. These radio induced lesions are the most common indication for hyperbaric oxygen treatment, to reduce hypoxia and oedema, and to improve the host's response to infection and ischaemia.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Reconstruction of the defect after removing all devitalised hard and soft tissue can only be achieved with healthy vascularised tissue. At this point, muscle and myocutaneous flaps, using pectoralis major, sternocleidomastoid, deltoid or trapezius muscle enables volumes of tissue to be moved with excellent vascularisation, and they are particularly indicated for reconstructing defects that reach deep structures. Free flaps are also an alternative in the treatment of these head and neck defects, but are more complex to create.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In this article we present a case that required local treatment of a pharyngostomy secondary to radiotherapy treatment of an epidermoid carcinoma of the right oropharynx, the lesion having appeared two months after completion of treatment. The lesion required surgical reconstruction with a myocutaneuos flap (pectoralis major muscle) to repair the tissue defect.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Lesion bed preparation is essential prior to surgical reconstruction. Because the lesion was located in the neck, the principal problem in debridement of the necrotic tissue lay in the proximity of the damaged tissue to the carotid artery and jugular vein, where surgical debridement with a scalpel would carry a high risk of bleeding and also be painful. Enzyme debridement by collagenase ointments is not indicated either for these types of lesions due to the risk of aspiration through the airway or digestive tract because these are exposed.</p><p id="par0070" class="elsevierStylePara elsevierViewall">For these reasons, an aginate dressing with silver was chosen because it combined the properties required for local treatment of the lesion such as autolytic debridement of the necrotic tissue, promotion of granulation, control of infection and management of exudate.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The references report that pharyngocutaneous fistula is the most common postoperative complication after total laryngectomy.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> Reports agree that there are numerous risk factors for this complication to appear, such as radiotherapy treatment and tracheotomy prior to laryngectomy, the tumour site, diabetes mellitus and, in the postoperative period, haemoglobin levels below 10<span class="elsevierStyleHsp" style=""></span>g/dl and/or prealbumin levels below 17<span class="elsevierStyleHsp" style=""></span>mg/dl.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">As well as surgical reconstruction with myocutaneous and free flaps, negative pressure treatment is another treatment option for pharyngocutaneous fistulas, but its application has numerous limitations (uncontrolled infection of the fistula, the presence of necrotic tissue requiring debridement, non-revascularised arterial disease or exposure of vessels and organs with a high risk of bleeding).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The literature only refers to the use of alginate dressings in treating pharyngocutaneous fistulas for managing salivary exudate.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> However, there are references to the use of silver alginate dressings in the treatment of venous leg ulcers.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case description</span><p id="par0090" class="elsevierStylePara elsevierViewall">A 62-year-old female patient who was transferred to our unit on 12 January 2016, referred by the radiotherapy department where she had been admitted 17 days previously with a diagnosis of right laterocervical abscess.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Her history included:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Smoking and alcohol intake of 60–80<span class="elsevierStyleHsp" style=""></span>g/day.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">Epidermoid carcinoma of the right tonsil (T2N2M0) in 1999 treated with chemotherapy and radiotherapy.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0110" class="elsevierStylePara elsevierViewall">Infiltrating ductal carcinoma of the right breast diagnosed in December 2008, treated by tumorectomy plus chemotherapy and tamoxifen until June 2015.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall">Diagnosis of second epidermoid carcinoma of the right oropharynx (soft palate T2N0M0) in August 2015 for which she received radiotherapy at a dose of 2<span class="elsevierStyleHsp" style=""></span>Gy per day, 5 days a week over 6 weeks. She tolerated the treatment well and had no adverse effects of note.</p></li></ul></p><p id="par0120" class="elsevierStylePara elsevierViewall">Two weeks prior to admission, the patient had started a picture of poorly controlled pain, the presence of a mass in her right laterocervical region progressively growing and subsequently abscessing, developing into a right laterocervical necrosis with gradual destruction of the tissue planes of the skin, muscle (sternocleidomastoid) and right lateral pharyngeal wall. A large pharyngostoma had opened from the lower edge of the jawbone to the height of the hypopharynx.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Initial culture of a sample of exudate from the lesion isolated <span class="elsevierStyleItalic">Staphylococcus aureus</span> and <span class="elsevierStyleItalic">Klebsiella pneumoniae</span>, intravenous antibiotic treatment was started with amoxicillin/clavulanic acid and metronidazole. This antibiotic guideline was changed two weeks after the patient's admission after a further antibiogram that indicated intravenous cloxacillin. On the third day of admission, the nasogastric tube was replaced with a percutaneous gastrostomy by endoscopic approach.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The most relevant finding from imaging studies (cervico-thoracic CT and CT angiography), apart from the major necrosis and loss of tissue, was the complete obliteration of the common carotid artery and its main branches.</p><p id="par0135" class="elsevierStylePara elsevierViewall">On initial assessment of the lesion, the patient presented a large pharyngostomy through which could be seen the nasogastric tube, base of tongue, larynx, hyoid bone and lower edge of the horizontal branch of the jawbone with edges that were erythematous, inflamed, painful to touch, with abundant necrotic tissue adhering strongly to the underlying structures and the presence of abundant necrotic, purulent and malodorous material (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Up until that moment, local treatment of the lesion had comprised dry dressings with nitrofurantoin ointment- impregnated gauze covered by a polyurethane foam dressing that required changing twice or even three times a day due to abundant purulent drainage.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">For this reason a dressing strategy was implemented with the following objectives:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1.</span><p id="par0145" class="elsevierStylePara elsevierViewall">To remove necrotic tissue in the least traumatic way possible, due to the anatomical area of the lesion and cause the patient the least discomfort possible.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2.</span><p id="par0150" class="elsevierStylePara elsevierViewall">To control of local infection.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">3.</span><p id="par0155" class="elsevierStylePara elsevierViewall">To manage the exudate.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">4.</span><p id="par0160" class="elsevierStylePara elsevierViewall">To schedule dressings every 48<span class="elsevierStyleHsp" style=""></span>h.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">5.</span><p id="par0165" class="elsevierStylePara elsevierViewall">To prepare the surgical bed for subsequent reconstruction.</p></li></ul></p><p id="par0170" class="elsevierStylePara elsevierViewall">A dressing regimen was established with these objectives in mind using a combination of silver alginate dressings (Biatain alginate AG<span class="elsevierStyleSup">®</span>) for local treatment of infection, associated with an activated carbon dressing to reduce the odour and a polyurethane foam dressing with a silicone edge (Biatain Silicone<span class="elsevierStyleSup">®</span>) to manage the exudate and to maintain the damp environment required by the dressing. A spray barrier dressing was applied (Cavilon<span class="elsevierStyleSup">®</span>) to protect against maceration of the skin around the lesion.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Gradually a reduction in the amount of purulent exudate and odour was noticed, performing the dressings every 48<span class="elsevierStyleHsp" style=""></span>h. Fifteen days after starting the dressing regimen with Biatain Alginate AG<span class="elsevierStyleSup">®</span>, the sternocleidomastoid muscle, which was completely necrosed, was debrided (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">The dressing regimen was subsequently changed, the activated carbon dressing was removed as there was no longer any odour, and in its place a low adherence polyurethane foam dressing (Biatain Soft Hold<span class="elsevierStyleSup">®</span>) was placed to retain the exudate and because it was adaptable enough to cover the lesion. A further dressing of polyurethane foam with silicone edge (Biatain Silicone<span class="elsevierStyleSup">®</span>) was placed on top of this dressing as a secondary dressing to ensure that the lesion was properly covered, because if only one polyurethane foam dressing had been placed, when the lower part of the dressing became saturated and due to the action of gravity it would become loose and leave the lesion uncovered. By using this double dressing we prevented this problem with the added advantage of keeping the dressing damp without needing to change it, at least within two days.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Two weeks after implementing this dressing regimen and as a side effect of fentanyl patches, the patient developed a paralytic ileus with profuse vomiting that flowed through the pharyngostomy, therefore parenteral nutrition was commenced to combat nutritional decline. Likewise, it was necessary to change the antibiotic treatment, since the result from a culture taken after the bouts of vomiting was positive for <span class="elsevierStyleItalic">Enterococcus faecalis and Escherichia coli (E. coli)</span>, and I.V. ceftazidime and metronidazole were prescribed. The lesion was less exudative but continued to drain purulent content (<a class="elsevierStyleCrossRefs" href="#fig0020">Figs. 4 and 5</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">Once enteral feeding was resumed through the nasogastric tube, and a month after starting treatment, a significant improvement in healing was observed. The purulent exudate abated, hardly any sloughy tissue remained, and abundant granulation tissue appeared that was well vascularised at the edges of the wound, partially covering the hyoid bone. The dressings were then scheduled every 72<span class="elsevierStyleHsp" style=""></span>h (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">The result of a further culture showed the presence of a multiresistant <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> in addition to the earlier <span class="elsevierStyleItalic">E. coli</span> and <span class="elsevierStyleItalic">E. faecalis</span>, and therefore the patient had to be isolated and the antibiotic treatment changed again (ceftazidime and teicoplanin IV). Despite this setback, the appearance of the lesion continued to improve, with slight progress of the granulation tissue and filling of the cavity from the edges inwards, and the fistula reduced considerably in size (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>).</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">A month and a half after the dressings had been started, when the cultures returned negative and given the lesion's good progress, antibiotic treatment was discontinued (66 days of I.V. treatment) and the patient was taken out of isolation. A cervico-thoracic PET was performed showing no signs of pathological uptake and surgical reconstruction was scheduled two weeks later. In this latter stage, care comprised removing mucous crusts adhering to the bed of the lesion, helped by dampening and applying Vaseline locally, it was then only necessary to cover the lesion with polyurethane foam dressings (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>).</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">Surgical treatment comprised closure of the pharyngostomy by a pedicled flap of the right pectoralis major muscle, as well as a tracheotomy. In the immediate postoperative period (third day), the flap was found to be warm to the touch, with no accumulation of blood and with capillary refill of at least 3 seconds. In the distal area there was a purplish area (venous congestion) which only affected the epidermis (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>).</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Nursing assessment</span><p id="par0210" class="elsevierStylePara elsevierViewall">A nursing assessment was made according to Virginia Henderson's model which showed that the needs for breathing, eating and drinking, eliminating waste, rest and sleep, communication and avoiding dangers were altered. (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">The care plan from the NANDA nursing diagnoses and potential complications (bifocal perspective) with the corresponding criteria from NOC outcomes and NIC interventions are shown on <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">11–13</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0220" class="elsevierStylePara elsevierViewall">The treatment of a lesion caused by radionecrosis involves various aspects from nutrition, control of infection by targeted antibiotic treatment to appropriate wound care, all of which have a significant impact on outcome. Preparation of the lesion bed to the best possible condition, with no signs of infection, free from necrotic tissue and with granulation tissue increases the possibilities for successful surgical reconstruction when this is necessary.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0225" class="elsevierStylePara elsevierViewall">The choice of a silver alginate dressing for local treatment of this type of lesion was very useful and beneficial for the patient because the objectives of removing the necrotic tissue in the least traumatic manner possible and achieving an exudate and infection-free surgical bed were met. Since this is a lesion located in the neck, and due to the vascular structures in the area, there is the added problem that cutting debridement with a scalpel carries a high risk of bleeding, therefore the autolytic debridement provided by alginate is an advantage.</p><p id="par0230" class="elsevierStylePara elsevierViewall">Furthermore, it enabled dressings to be scheduled so as to cause the patient the least discomfort possible, preventing cross contamination or infections as far as was possible and enabling continuity of care.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interests</span><p id="par0235" class="elsevierStylePara elsevierViewall">The author has no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres852148" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec846717" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres852149" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec846718" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case description" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Nursing assessment" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:2 [ "identificador" => "xack285800" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-10-28" "fechaAceptado" => "2017-02-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec846717" "palabras" => array:3 [ 0 => "Osteoradionecrosis" 1 => "Fistula" 2 => "Debridement" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec846718" "palabras" => array:3 [ 0 => "Osteorradionecrosis" 1 => "Fístula" 2 => "Desbridamiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radionecrosis is a late, and difficult to treat, complication of radiotherapy performed on head and neck tumours, and it is difficult to treat. This process causes significant damage, not only in the skin, but also in muscular, nervous, vascular, and bone structures. This, in turn, leads to airway and digestive tract involvement, as well as a functional loss and a cosmetic defect that usually requires reconstructive surgery. Therefore, this process is associated with a significant loss in the quality of life of patients and involves a long hospital stay for treatment, as well as the necessary support measures.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This article describes the local treatment of pharyngocutaneous fistula secondary to radiation therapy of squamous cell carcinoma of the right oropharynx. The lesion appeared two months after completing this treatment and required surgical reconstruction with a myocutaneous flap to repair the tissue defect.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In this context, an alginate wound dressing with silver was used, combined with a medium grip polyurethane foam with a silicone border. Within one month, there was autolytic debridement of all the necrotic tissue and the appearance of granulation tissue. At the same time, the infection was controlled, and a better management of the exudate was obtained, which provided a suitable surgical bed for the reconstruction.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La osteorradionecrosis es una complicación tardía y de difícil manejo que se produce como consecuencia de los tratamientos con radioterapia realizados en los tumores de cabeza y cuello. Ocasiona importantes daños, no solo en la piel sino también en estructuras musculares, nerviosas, vasculares y óseas produciendo una afectación de las vías aérea y digestiva que condicionan una pérdida funcional y un defecto estético que suele precisar de cirugía reconstructiva para su reparación.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Este proceso lleva asociado una importante pérdida en la calidad de vida del paciente y conlleva largos ingresos hospitalarios por los tratamientos y medidas de soporte necesarios.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">En este artículo se describe el tratamiento local de un faringostoma secundario al tratamiento con radioterapia de un carcinoma epidermoide de orofaringe derecha. La lesión apareció a los dos meses tras finalizar la radioterapia, y precisó reconstrucción quirúrgica con un colgajo miocutáneo para reparar el defecto tisular.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En este contexto, se ha utilizado un apósito de alginato con plata asociado a una espuma de poliuretano de adherencia media con reborde de silicona, consiguiendo en el plazo de un mes el desbridamiento autolítico de todo el tejido necrótico y la aparición de tejido de granulación, a la vez que se controló la infección y se consiguió un mejor manejo del exudado, proporcionando así un lecho quirúrgico adecuado para la reconstrucción.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González-Antolín O. Tratamiento local de un faringostoma secundario a osteorradionecrosis. Enferm Clin. 2017;27:193–202.</p>" ] ] "multimedia" => array:11 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 517 "Ancho" => 990 "Tamanyo" => 83875 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Day 1. Pharyngostomy due to radionecrosis. Exposure of the sternocleidomastoid muscle, visualisation of the pharynx, including the nasogastric tube.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 557 "Ancho" => 990 "Tamanyo" => 113413 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Day 15. Sternocleidomastoid muscle coming away from its point of insertion.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 557 "Ancho" => 990 "Tamanyo" => 96574 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Day 15. The necrosed sternocleidomastoid muscle is cut with a pair of scissors; the hyoid bone is left completely exposed. The base of the tongue, the left lateral wall of the pharynx (from which a drop of saliva is falling) and the entrance to the larynx can be seen.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 557 "Ancho" => 990 "Tamanyo" => 103006 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Day 22. Exposed hyoid bone. The lesion bed shows disperse sloughy tissue and abundant granulation tissue.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 557 "Ancho" => 990 "Tamanyo" => 123484 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Day 22. Insertion of the silver alginate dressing (Biatain Alginate AG<span class="elsevierStyleSup">®</span>) in the bed of the lesion after cleaning with saline.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 557 "Ancho" => 990 "Tamanyo" => 82057 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Day 27. It can be seen that the hyoid bone is completely covered by granulation tissue. Measurements: 7<span class="elsevierStyleHsp" style=""></span>cm long<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm wide<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm deep.</p>" ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 557 "Ancho" => 990 "Tamanyo" => 96492 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Day 47. Good progress, the hyoid bone is not exposed. Measurements: 6<span class="elsevierStyleHsp" style=""></span>cm long<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm wide<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5.5<span class="elsevierStyleHsp" style=""></span>cm deep. Visualisation of the larynx.</p>" ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 557 "Ancho" => 990 "Tamanyo" => 101904 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Day 84. Good progress, with granulation tissue at the left lateral and lower edges. No signs of infection. Only mucous present in the bed of the lesion. Exposure of the right edge of the jawbone. Visualisation of the larynx and the uvula at the back. Measurements: 5.5<span class="elsevierStyleHsp" style=""></span>cm long<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm wide<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5.5<span class="elsevierStyleHsp" style=""></span>cm deep.</p>" ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 1272 "Ancho" => 850 "Tamanyo" => 198296 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Day 93. 3rd postoperative day. Reconstruction of the defect with right pectoralis major muscle and tracheotomy. Superficial haematoma only affecting the epidermis.</p>" ] ] 9 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Need \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Assessment \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breathing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Difficulty in eliminating secretions due to the orocervical communication caused by the pharyngostomy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Eating and drinking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Difficulty in intake and swallowing solid or semi-liquid foods secondary to the pharyngoscomy with the consequent risk of malnutrition. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Elimination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Possible alterations in bowel habit secondary to diet and analgesic treatment (opiates and derivatives). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Need for rest and sleep \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Usual sleep patterns might be altered due to many causes (fear of not being able to breathe properly due to the difficulty in eliminating secretions, pain, discomfort, hospital routines that make sleep difficult…). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Avoiding danger \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">There might be alterations in self-perception (the patient sees herself as inferior to others because of the deformity caused by the lesion), in her pattern of interaction with family and those closest to her and in adapting to change (especially communication difficulties and the change in body image). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Communicating \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The patient has difficulties in communicating due to the pharyngostomy; phonation and correctly articulating words are made difficult. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Need to learn \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">It is important to be aware of her level of knowledge of her state of health and whether or not she finds it difficult to learn new things, which will help independent management of the treatment guidelines. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1438562.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Focussed assessment: list of altered needs.</p>" ] ] 10 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>: Heather Herdman<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a>, Johnson et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> and Bulechek et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p>" "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NANDA nursing diagnosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NOC outcomes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NIC interventions \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">00126 Deficient knowledge: therapy regimen<br><span class="elsevierStyleHsp" style=""></span>Related to:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Lack of exposure.<br><span class="elsevierStyleHsp" style=""></span>Manifested by:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Verbalisation of the problem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1813 Knowledge: therapy regimen<br><span class="elsevierStyleHsp" style=""></span>Indicators:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Prescribed diet<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Prescribed medication<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Prescribed activity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5614. Teaching: prescribed diet<br><span class="elsevierStyleHsp" style=""></span>Activity:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Teach the patient about the prescribed diet<br><br>5616. Teaching: prescribed medication<br><span class="elsevierStyleHsp" style=""></span>Activity:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Teach the patient about administration of medication<br><br>5612. Teaching: prescribed exercise<br><span class="elsevierStyleHsp" style=""></span>Activity:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Teach the patient about the prescribed activity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">00039. Risk for aspiration<br><span class="elsevierStyleHsp" style=""></span>Related to:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>The presence of an enteral tube \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1918. Prevention of aspiration<br><span class="elsevierStyleHsp" style=""></span>Indicator:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Kept in upright position 30 minutes after feed.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Avoid risk factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3200. Precautions to prevent aspiration<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Keep the head of the bed elevated for 30–45<span class="elsevierStyleHsp" style=""></span>min after feed.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Assess the presence of dysphagia, as necessary.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Keep aspiration equipment at hand.<br>1570. Management of vomiting<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Position the patient appropriately to prevent aspiration.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Ensure that effective antiemetics have been given to prevent vomiting.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Assess colour, consistency, presence of blood, duration and volume \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">00118. Disturbed body image<br><span class="elsevierStyleHsp" style=""></span>Related to:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>The cervical lesion<br><span class="elsevierStyleHsp" style=""></span>Manifested by:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Not touching or looking at a body part \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1200. Body image<br><span class="elsevierStyleHsp" style=""></span>Indicators:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Adjustment to body changes due to surgery.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Attitude towards not touching the affected body part \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5220. Body image enhancement<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Observe whether the patient can look at the part of her body that has changed.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Help the patient to identify actions that will enhance her appearance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">00153. Risk for situational low self-esteem<br><span class="elsevierStyleHsp" style=""></span>Related to:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Disturbed body image \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1205. Self-esteem<br><span class="elsevierStyleHsp" style=""></span>Indicators:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Acceptance of own limitations.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Acceptance of constructive criticism.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Maintenance of personal care/hygiene \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5395. Self-efficacy enhancement<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Identify obstacles to a change in behaviour.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Provide an environment for support in knowledge and to learn the skills necessary to perform the health behaviour.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Provide positive reinforcement and emotional support during the learning process \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1438561.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Potential complications \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interventions/NIC \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Airway obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3160. Airway suctioning<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Establish the need for tracheal/oral suctioning.<br>3140. Airway management<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Administer air or humidified oxygen.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Position the patient so as to relieve dyspnoea.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Teach how to cough effectively \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1400. Pain management<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Perform a thorough pain assessment (location, onset, duration, frequency...).<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Monitor the patient's satisfaction level with pain control \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6540. Infection control<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Teach the patient/family about the signs and symptoms of infection and when they should be reported to carers.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Ensure aseptic handling of IV lines.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Ensure appropriate wound care technique.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4. Put universal precautions into practice.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5. Apply Zero Tolerance Protocol.<br>3440. Incision site care<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Inspect the incision site for reddening, inflammation and or signs and symptoms of infection.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Clean the area around the incision with an antiseptic from the cleanest to the least clean area applying an appropriate bandage or dressing<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Teach the patient how to care for the incision while \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Bleeding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4020. Bleeding reduction<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Teach the patient/family about the signs of bleeding and appropriate measures to be taken (report to nursing staff).<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Establish the amount and nature of blood loss.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Maintain a permeable I.V. line.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4. Teach the patient about restrictions in activities, as appropriate.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5. Place the patient in the semi-Fowler position.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>6. Apply manual pressure on the area of bleeding or potential bleeding<br><br>4140. Fluid resuscitation<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Obtain samples for crossmatching.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Administer I.V. fluids as prescribed.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Administer blood products as prescribed.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4. Monitor haemodynamic response \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Insomnia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1850. Sleep enhancement<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Adapt the patient's environment to enhance sleep.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Check the patient's sleep hygiene.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Administer prescribed medication according to route and assess therapeutic and adverse effects \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Malnutrition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1160. Nutritional monitoring<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Weigh the patient at regular intervals and monitor progress.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Monitor calories and food intake.<br>1100. Nutrition management<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Teach the patient about dietary requirements according to their condition.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Monitor tendencies for weight gain or weight loss \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7. Constipation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0450. Constipation/Impaction Management<br><span class="elsevierStyleHsp" style=""></span>Activities:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1. Monitor the appearance of signs and symptoms of constipation.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2. Identify possible causative, contributory factors (medication, diet…).<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3. Encourage increased fluid intake.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4. Instruct the patient/family about a fibre-rich diet \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1438563.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Care plan according to NANDA-NOC-NIC taxonomies.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <span class="elsevierStyleInterRef" id="intr0010" href="http://www-rayos.medicina.uma.es/rmf/radiobiologia/revista/radiobiolog%26iacute;a.htm">http://www-rayos.medicina.uma.es/rmf/radiobiologia/revista/radiobiología.htm</span> [accessed 28.02.16]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radionecrosis de hueso y cartílago en el tratamiento de tumores de cabeza y cuello" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.S. 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I also want to thank all my colleagues from the 6<span class="elsevierStyleSup">th</span> floor of <span class="elsevierStyleItalic">Pabell</span>ó<span class="elsevierStyleItalic">n 2 Noviembre</span> and the ENT department of the University Hospital <span class="elsevierStyleItalic">Marqués de Valdecilla</span> for their excellent work and collaboration, and José Luis Cobo Sánchez, Research, Development and Innovation Support Unit nurse, for his advice.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/24451479/0000002700000003/v2_201706121007/S2445147917300346/v2_201706121007/en/main.assets" "Apartado" => array:4 [ "identificador" => "63168" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Nursing care" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24451479/0000002700000003/v2_201706121007/S2445147917300346/v2_201706121007/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445147917300346?idApp=UINPBA00004N" ]
