Reconstructive procedures on the face are individualized to the patient’s needs and desired outcomes. They are performed to re-pair deformities or restore normal function as much as possible. They may vary from closure of small defects to complicated pro-cedures involving implantation of prosthetic devices to conceal a large defect or reconstruct a lost part of the face (eg, nose, ear, jaw). Each surgical procedure is customized and involves a vari-ety of incisions, flaps, and grafts.
In correcting a primary defect, the surgeon may have to create a secondary defect. Although the procedure may restore some function, such as eating or talking, the cosmetic or aesthetic re-sults may be limited. The original appearance of a patient who has severe damage to soft tissue and bone structure can seldom be restored. Multiple surgical procedures may be required. The process of facial reconstruction is usually slow and tedious.
NURSING PROCESS: CARE OF THE PATIENT WITH FACIAL RECONSTRUCTION
The face is a part of the body that every person desires to keep at its best or improve, because most human interactions involve the face. When the face loses its appearance and function by injury or disease, significant emotional reactions often occur. Changes in appearance frequently cause anxiety and depression. Patients with facial changes frequently mourn for the lost part, suffer a loss of self-esteem because of reactions or rejection by others, and withdraw and isolate themselves. Health care personnel can ac-knowledge that anxiety and depression are appropriate for what the patient is experiencing.
The nurse assesses the patient’s emotional responses and iden-tifies strengths as well as usual coping mechanisms to determine how the patient will handle the surgical procedure. Any area in which the patient and family need extra support is identified.
The preoperative assessment determines the extent of dis-figurement and improvement that can be anticipated, as well as the patient’s understanding and acceptance of these limitations. The nurse is in a better position to reinforce facts and clarify mis-conceptions after the surgeon has fully informed the patient about the procedure, the functional defects that may result, the possible need for a tracheostomy or other prosthesis, and the probability of additional surgery. The nurse instructs the patient about various postoperative measures: intravenous therapy, the use of a nasogastric tube to allow gastric decompression and pre-vent vomiting, and the frequent and lengthy periods that may be required to care for wounds, flaps, and skin grafts and to change dressings. Extra time is needed when presenting this information to anxious patients because they may not hear, concentrate, or comprehend what is being said.
Based on the nursing assessment data, the patient’s major post-operative nursing diagnoses may include the following:
· Ineffective airway clearance related to tracheobronchial se-cretions
· Acute pain related to facial edema and effects of the proce-dure
· Imbalanced nutrition: less than body requirements related to altered physiology of oral cavity, drooling, impaired chewing and swallowing, or excision affecting the tongue
· Impaired verbal communication related to trauma or surgery producing anatomic and physiologic abnormalities of speech
· Disturbed body image related to disfigurement
· Interrupted family processes related to grief reaction and disruption of family life
Based on the assessment data, potential complications that may develop include.
The major goals for the patient may include a patent airway and adequate pulmonary function, increased comfort, adequate nu-tritional status, an effective communication method, positive self-concept, effective family coping, and absence of infection.
The immediate concern after facial reconstruction is maintenance of an adequate airway. If the patient has regained consciousness, mental confusion with combative, anxious behavior is a sign of hypoxia (ie, reduced oxygen supply to tissues). Sedatives or opi-oids are not prescribed in this situation because they may impair oxygenation. If the patient shows signs of restlessness, the airway is carefully inspected to detect laryngeal edema or accumulation of tracheobronchial mucus. Secretions are suctioned as necessary until the patient can manage the secretions without help. If the patient has a tracheostomy, suctioning is performed with sterile technique to prevent infection and cross-contamination.
Facial edema is an uncomfortable but natural consequence of facial reconstructive surgery. The patient’s head and upper torso are kept slightly elevated (if the blood pressure is stable) to help reduce facial edema. Catheters attached to closed drainage may be in place to keep the tissue in close apposition and to remove serous discharge. If extensive reconstruction has been performed, the patient’s head should be properly aligned and supported so that minimal stress is placed on the suture line.
Analgesics are prescribed to relieve pain. If bone grafts have been used for reconstruction, there is usually considerable pain in the donor area. If the patient has head and neck cancer and increasing levels of pain, comprehensive nursing management is required.
Fluids may be offered to the patient after oral and pharyngeal edema diminish, the incisional areas and flaps heal, and the pa-tient can swallow saliva. Gradually, soft foods are added as toler-ated. If the patient cannot meet nutritional needs by the oral route, parenteral nutrition (ie, infusion of nutrients, water, and vitamins into the stomach or proximal small intestine through a tube) is initiated. The formula strength and feeding rate are grad-ually increased until the desired daily caloric level is attained. Patients who have had rad-ical surgery for large, encroaching neoplasms may have difficulty resuming eating. Positive nutrition is reflected in weight gain, and nutritional status is monitored by measuring body weight daily and assessing serum protein and electrolyte levels periodically.
Communication problems may range from minimal difficulty to the loss of oral speech. Some tumors and injuries require extensive surgery involving the larynx, tongue, and mandible. Paper, pen or pencil, and a firm writing surface should be provided. If the patient cannot write, a pictograph board may be used. Referral to a speech therapist may be necessary for the patient who has under-gone structural changes. The family may become frustrated by the patient’s inability to communicate. The patient soon senses this, and both parties may withdraw. Allowing the family to vent their feelings and fears (away from the patient) is important.
Success in rehabilitating the patient undergoing reconstructive surgery depends on the relationships among the patient and the nurse, the physician, and other health care personnel. Mutual trust, respect, and clear lines of communication are essential. Un-hurried care provides emotional reassurance and support.
The kinds of dressings worn, the unusual positions to be maintained, and the temporary incapacity experienced can upset the most stable person. Reinforcement of the patient’s successful coping strategies improves self-esteem. If prosthetic devices are used, the patient is taught how to use and care for them to gain a sense of greater independence. Once involved in self-care activi-ties, the patient may feel some control over what was previously an overwhelming situation.
Patients with severe disfigurement are encouraged to socialize to experience the reactions of others in a more protected envi-ronment. Gradually, they can widen their sphere of contact. Every effort is made to cover or mask defects. Patients may re-quire support by members of the mental health team to accept their changed appearance.
The family is informed about the patient’s appearance after surgery, the supportive equipment, and the ways that the equip-ment aids recovery. It is helpful to join the family for a few min-utes during their first postoperative visit to help them cope with the changes they will see.
A major role of the nurse is to support the family in their de-cision to participate (or not to participate) in the patient’s treat-ment. Nursing interventions also include helping the family members communicate by suggesting ways to reduce anxiety and stress and to promote problem solving and decision making. These activities encourage family members and promote growth.
Secondary infection is a primary concern after reconstructive surgery. The source of infection depends on the location and ex-tent of the procedure, the suture line, and the pedicle flap.
The mouth is inspected to determine the location of sutures (when present) so that they are not accidentally disturbed during the cleaning process. The mouth is cleaned according to protocol several times daily. Loose blood clots may be removed with gen-tle swabbing. The patient is advised not to loosen clots with the tongue because this may cause fresh bleeding. The patient is in-structed not to use fingers to clean or remove blood clots because this may introduce organisms that cause infection.
The suture line remains under stress for several days after sur-gery because of edema, increased drainage, and hematoma for-mation. The nurse assesses the suture line carefully for signs of increased tension and infection (ie, elevated temperature, in-creasing edema, redness, bleeding, and increased pain) with each dressing change. Dressings may need to be changed many times each day until the drainage begins to decrease. Drainage and edema are expected after reconstructive surgery; however, both should decrease, and the process is hastened by using properly placed, functioning suction devices and elevating the head of the bed about 45 degrees. The nurse inspects the suction devices, empties them promptly, and documents the amount and consis-tency of drainage, as well as any unusual odor. When drainage is not removed or if saturated dressings are left unchanged for long periods, infection is likely to occur. Strict asepsis must be main-tained in wound care.
A pedicle flap used in reconstruction may become a source of infection if its circulation becomes compromised. Poor circula-tion may result from a hematoma forming beneath the flap and causing increased pressure on the underlying vasculature. The nurse inspects the flap for changes in color and temperature in-dicative of poor circulation. Signs of necrosis, increased drainage, or an odor may be a warning of an infection and should be re-ported promptly. Reinforcing preoperative teaching about wound healing, the need for strict sterile technique, good per-sonal hygiene, and the need to restrict movement and stress on the operative site is an important part of the nurse’s role in post-operative care and in the prevention of secondary infection.
Expected patient outcomes may include the following:
1) Maintains patent airway
a) Demonstrates respiratory rate within normal limits
b) Exhibits normal breath sounds
c) Demonstrates no signs of choking or aspiration
2) Achieves increasing comfort
a) Reports decreasing pain
b) Follows instructions on proper positioning
c) Avoids movements that stress the operative site
3) Attains adequate nutrition
a) Consumes adequate amounts of food and fluids
b) Maintains weight within normal range or progressively regains weight lost in the early postoperative period
c) Maintains serum protein and electrolyte levels within normal range
4) Communicates effectively
a) Uses appropriate aids to enhance communication
b) Interacts with health care team members, family, and other support people using new communication strategies
5) Develops positive self-image
a) Expresses positive feelings about surgical changes
b) Demonstrates increasing independence in self-care ac-tivities
c) Uses prosthetic devices independently (when appropriate)
d) Verbalizes plans for resuming usual activities (eg, work, recreation)
6) Family members cope with situation
a) Demonstrate decreasing anxiety and conflict
b) Verbalize what to expect
7) Absence of complications
a) Demonstrates vital signs within normal limits
b) Undergoes normal wound healing without signs of infection or sepsis
c) Lists signs of infection that should be reported
d) Understands the need for asepsis (ie, sterile procedures) and good personal hygiene
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