NURSING PROCESS: THE PATIENT UNDERGOING MASTOID SURGERY
Although several otologic surgical procedures are performed under moderate sedation, mastoid surgery is performed using general anesthesia.
The health history includes a complete description of the ear problem, including infection, otalgia, otorrhea, hearing loss, and vertigo. Data are collected about the duration and intensity of the problem, its causes, and previous treatments. Information is ob-tained about other health problems and all medications that the patient is taking. Medication allergies and family history of ear disease also should be obtained.
Physical assessment includes observation for erythema, edema, otorrhea, lesions, and characteristics such as odor and color of dis-charge. The results of the audiogram should be reviewed.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
· Anxiety related to surgical procedure, potential loss of hear-ing, potential taste disturbance, and potential loss of facial movement
· Acute pain related to mastoid surgery
· Risk for infection related to mastoidectomy, placement of grafts, prostheses, electrodes, and surgical trauma to sur-rounding tissues and structures
· Disturbed auditory sensory perception related to ear dis-order, surgery, or packing
· Risk for trauma related to balance difficulties or vertigo dur-ing the immediate postoperative period
· Disturbed sensory perception related to potential damage to facial nerve (cranial nerve VII) and chorda tympani nerve
· Impaired skin integrity related to ear surgery, incisions, and graft sites
· Deficient knowledge about mastoid disease, surgical proce-dure, and postoperative care and expectations
The major goals of caring for a patient undergoing mastoidec-tomy include reduction of anxiety; freedom from pain and dis-comfort; prevention of infection; stable or improved hearing and communication; absence of injury from vertigo; absence of or ad-justment to sensory or perceptual alterations; return of skin in-tegrity; and increased knowledge regarding the disease, surgical procedure, and postoperative care.
Information that the otologic surgeon has discussed with the pa-tient, including anesthesia, the location of the incision (post-auricular), and expected surgical results (eg, hearing, balance, taste, facial movement), is reinforced. The patient also is encour-aged to discuss any anxieties and concerns about the surgery.
Although most patients complain very little about incisional pain after mastoid surgery, they do have some ear discomfort. Aural fullness or pressure after surgery is caused by residual blood or fluid in the middle ear. The prescribed analgesic may be taken for the first 24 hours after surgery and then only as needed. The pa-tient is instructed in the use of and side effects of the medication.
A tympanoplasty may also be performed at the time of the mastoidectomy. A wick or external auditory canal packing is used after a tympanoplasty to stabilize the tympanic membrane. Pa-tients should be informed that they may experience intermittent sharp, shooting pains in the ear for 2 to 3 weeks after surgery as the eustachian tube opens and allows air to enter the middle ear.
Measures are initiated to prevent infection in the operated ear. The external auditory canal wick, or packing, may be impreg-nated with an antibiotic solution before instillation. Prophylac-tic antibiotics are administered as prescribed, and the patient is instructed to prevent water from entering the external auditory canal for 6 weeks. A cotton ball or lamb’s wool covered with a water-insoluble substance (eg, petroleum jelly) and placed loosely in the ear canal usually prevents water contamination. The post-auricular incision should be kept dry for 2 days. Signs of infec-tion such as an elevated temperature and purulent drainage are reported. Some serosanguineous drainage from the external audi-tory canal is normal after surgery.
Hearing in the operated ear may be reduced for several weeks be-cause of edema, accumulation of blood and tissue fluid in the mid-dle ear, and dressings or packing. Measures are initiated to improve hearing and communication, such as reducing environ-mental noise, facing the patient when speaking, speaking clearly and distinctly without shouting, providing good lighting if the pa-tient relies on speech reading, and using nonverbal clues (eg, facial expression, pointing, gestures) and other forms of communica-tion. Family members or significant others are instructed about ef-fective ways to communicate with the patient. If the patient uses assistive hearing devices, one can be used in the unaffected ear.
Vertigo may occur after mastoid surgery if the semicircular canals or other areas of the inner ear are traumatized. This symptom is relatively uncommon after this type of ear surgery and usually is temporary. Antiemetics or antivertiginous medica-tions (eg, antihistamines) can be prescribed if a balance distur-bance or vertigo occurs. The patient should be instructed about the expected effects and potential side effects. Safety measures such as assisted ambulation are implemented to prevent falls. Safety measures must also be implemented at home to prevent falls and injury.
Facial nerve injury is a potential, although rare, complication of mastoid surgery. The patient is instructed to report immediately any evidence of facial nerve (cranial nerve VII) weakness, such as drooping of the mouth on the operated side. A more frequent oc-currence is a temporary disturbance in the chorda tympani nerve, a small branch of the facial nerve that runs through the middle ear. Patients experience a taste disturbance and dry mouth on the side of surgery for several months until the nerve regenerates.
The patient is instructed to avoid heavy lifting, straining, exer-tion, and nose blowing for 2 to 3 weeks after surgery to prevent dislodging the tympanic membrane graft or ossicular prosthesis.
The patient is informed about the surgery and operating room environment. Discussing postoperative expectations helps to de-crease anxiety about the unknown. Because postoperative in-structions for mastoid surgery vary among otologic surgeons, it is important for the nurse to be aware of the surgeon’s preferences when teaching the patient.
Patients require instruction about prescribed medication therapy, such as analgesics, antivertiginous agents, and antihistamines pre-scribed for balance disturbance. Teaching includes information about the expected effects and potential side effects of the medica-tion. Patients also need instruction about any activity restrictions. Possible complications such as infection, facial nerve weakness, or taste disturbances, including the signs and symptoms to report immediately, should be addressed (see Chart 59-5).
Some patients, particularly elderly patients, who have had mas-toid surgery may require the services of a home care nurse for a few days after returning home. However, most people find that assistance from a family member or a friend is sufficient. The care-giver and patient are cautioned that the patient may experience some vertigo and will therefore require help with ambulation to avoid falling. Any symptoms of complications are to be reported promptly to the surgeon. The importance of scheduling and keeping follow-up appointments is also stressed.
Expected patient outcomes may include:
1) Demonstrates reduced anxiety about surgical procedure
a) Verbalizes and exhibits less stress, tension, and irritability
b) Verbalizes acceptance of the results of surgery and ad-justment to possible hearing impairment
2) Remains free of discomfort or pain
i) Exhibits no facial grimacing, moaning, or crying, and reports absence of pain
ii) Uses analgesics appropriately
3) Demonstrates no signs or symptoms of infection
i) Has normal vital signs, including temperature
ii) Demonstrates absence of purulent drainage from the external auditory canal
iii) Describes method for preventing water from contami-nating packing
4) Exhibits signs that hearing has stabilized or improved
i) Describes surgical goal for hearing and judges whether the goal has been met
ii) Verbalizes that hearing has improved
5) Remains free of injury and trauma because of vertigo
i) Reports absence of vertigo or balance disturbance
ii) Experiences no injury or fall
iii) Modifies environment to avoid falls (eg, night light, no clutter on stairs)
6) Adjusts to or remains free from altered sensory perception
i) Reports no taste disturbance, mouth dryness, or facial weakness
7) Demonstrates no skin breakdown
i) Lists ways to prevent dislodging graft or prosthesis
8) Is aware of limitations in activities (eg, bathing, lifting, air travel) and for how long Verbalizes the reasons for and methods of care and treatment
a) Shares knowledge with family about treatment protocol
b) Describes treatment and the time frame for the recov-ery phase
c) Discusses the discharge plan formulated with the nurse with regard to rest periods, medication, and activities permitted and restricted
d) Lists symptoms that should be reported to health care personnel
e) Keeps follow-up appointments