PERI OPERATIVE CARE OF MAXILLO FACIAL SURGERY

Report
SUBMITTED BY:
PREETHY FRANCIS
SUBMITTED TO:
RADHAMANI P.C
INTRODUCTION
DEMOGRAPHIC DATA
NAME
:
AGE
:
SEX:
:
MR NO
:
NATIONALITY :
DIAGNOSIS :
XYZ
20 years old
Male
209631
Saudi
Multiple Facial bone fractures.
CHIEF COMPLAINTS
Complaint of Bleeding from nose LOC , swelling around
right eye and eye lids and periorbital area on right side.
NAME OF SURGERY
 1)ORIF OF RIGHT ZYGOMA (Either of a pair of bones
that from the prominent part of the cheeks and
contribute to the orbits)MAXILLARY(Maxillae is the
upper jaw) AND MANDIBLE(lower jaw)
FRACTURE.2)ORIF OF NASAL BONE FRACTURE.
History intended for surgical
procedure
 Sustaining MULTI FACIAL TRAUMA on Zygoma ,
Maxillary ,mandible and Nasal Bone.
 DATE OF ADMISSION: 11/08/13
 DATE OF SURGERY: 12/08/2013
 DATE OF DISCHARGE: 21/08/2013
PHYSICAL ASSESSMENT
 ON ADMISSION IN EMERGENCY ROOM
1.General Appearance
 Patient is Oriented to time, place and person.
 Looks weak and fatigue.
 Unable to mobilize upper and lower face joints.
 Upper teeth fracture
2.Integumentary System
• Skin is warm.
• Abrasions presents on the face.
• Noted abrasion on upper and lower
extremities.
3.Neurological System
•
No spine and cranial bone fracture.
GCS 15/15
Head and Neck
• Hair is equally distributed.
• Abrasions on face.
• Patient’s pinna is same colour as facial skin
aligned with eye level.
• Lips are pink but swollen.
• Upper teeth fracture seen.
• No lymph node enlargement on neck.
Face And Nose
• Right facial hematoma and facial edema.
• Bleeding from nose.
• Nasal bone fracture septum deviated to left.
• Difficulty to take breath through nose.
• Swelling on right eye, eye lids and periorbital
area on right side.
Respiratory System
Thorax
• The thorax is symmetric on inspection.
• Equal air movements.
• Clear breath sound on auscultation.
Cardiovascular System
• Airway Adequate
• Heart sound : s1 and s2 normal
• BP is 120/80mmHg
• Pulse rate-66/mts
• Lungs – Breath sound present, normal &
clear .
Genito urinary system
• With Foleys catheter FG.16present.
Gastrointestinal System
• Patient have soft abdomen, no tenderness.
Musculoskeletal System
• Able to mobilize his upper and lower limb .
• Can perform ADL
• Tenderness at the site of fracture .
• Visible deformity.
PATIENT HISTORY
Past Medical History
 No known History of HTN,DM and Asthma.
Present Medical History
 Patient have some LOC and weakness.
Present Surgical History
He undergone RIGHT ORIF ZYGOMA ,
MAXILLARY and MANDIBLE BONE and
NASAL BONE FRACTURE done under
general anesthesia on 12/08/13.
Past Surgical History
He have no surgical history
VITAL SIGNS
BP- 120/86mmhg
PR- 66 b /mts
Temperature- 36.4C
SPO2- 98%
Pain scroe-8 Assess by Facial numerical
scale
GCS -15/15.
TREATMENT ORDERED BY
FACIOMAXILLARY SURGEON







Haematological Investigations
ABO RH group.
Urine analysis.
Chest X-ray.
Non contrast enhanced CT Brain
Medications
ABO RH Group
A positive blood Group.
 CHEST X-RAY
Chest X-ray shows normal.
Investigations:
Investigations
PH
Patient’s Values
7.417
Normal Values
RBS
130
110-140
PCO2
38.7 mmHg
35-45 mmHg
Na
134.8 mmol/L
135 to 145 mEq/L
K
3.68 mmol/L
3.5-5.0mmol/l
Total Bilirubin
10.7µmol/L
1.1-17.1 µmol/L
Direct Bilirubin
12.9
0.04-60 µmol
SGOT
16.6
10-38 µ/L
SGPT
17.8
10-41 µ/L
Alkaline Phosphate
Albumin
Protein
Hb
95.6
25.4
46.2
15.6 gm/dl
35-129 µ/L
34.0-48.0
66-87 g/L
13.7-17.5g/dl
WBC
12.27
4.23-9.07
PLT
358
163-337/ul
7.35-7.45
C T BRAIN STUDY
CT brain
shows
fractures and
some air in
soft tissues
DRUG STUDY
Name of drug :
Inj . Augmentine
Dose
:
1.2gm
Route
:
I.v
Action
: Antibiotic
Indication
Lower Respiratory Tract Infections, Skin
and Skin Structure Infections , other
bacterial infections
Contraindication
When susceptibility test results show
susceptibility to amoxicillin, indicating no
beta-lactamase production, AUGMENTIN
should not be used.
Name of drug : Inj.flagyl
Dose
:
100ml
Route
:
I.v
Action
:
Antibiotic
Indication
:
BACTERIAL SEPTICEMIA, BONE
AND JOINT INFECTIONS
Contraindication : When susceptibility test results show
susceptibility to injection full dose can’t give to patient .
Pregnancy (1st trimester)
Name of drug : Inj . perfaglan
Dose
: 100 mg
Route
:
I.v
Action
: Analgesics
Indication
: Pain
Contraindication : Sensitive patient in
NSAID drugs
Name of drug :
Inj. Hydrocortisone
Dose
:
100mg
Route
:
I.v
Action
:
Anti-inflammatory drug
Indication
:
Corticosteroidresponsive dermatoses.
Contraindication:
Exclude viral disease (e.g, chickenpox, measles).
Name of drug
: Inj . Diclofenac
Dose
: 75mg
Route
: I.v
Action
: Anti-inflammatory drug(NSAID)
Indication
: Pain, Osteoarthritis (OA) or
rheumatoid arthritis (RA) in patients at high risk for
developing NSAID-induced gastric or duodenal ulcers
Contraindication
:Pregnancy ,Aspirin allergy. Coronary
artery bypass graft surgery.
ANATOMY OF FACICAL BONES
The facial skeleton serves to protect the brain;
house and protect the sense organs of smell,
sight, and taste; and provide a frame on which
the soft tissues of the face can act to facilitate
eating, facial expression, breathing, and speech.
The primary bones of the face are the mandible,
maxilla, frontal bone, nasal bones, and zygoma.
Facial bone anatomy is complex, yet elegant, in
its suitability to serve a multitude of functions.
LIST OF FOURTEEN FACIAL BONES.
Inferior nasal concha (2)
Lacrimal bones (2)
Mandible
Maxilla (2)
Nasal bones (2)
Palatine bones (2)
Vomer
Zygomatic bones (2)
The hyoid bone is sometimes included, and
sometimes excluded. The ethmoid bone (or a
part of it) is sometimes included, but
otherwise considered part of
the neurocranium; the same is the case with
the sphenoid bone. Some sources describe
the maxilla's left and right parts as two bones.
Likewise, the palatine bone is also sometimes
described as two bones.
Mandible
The mandible is a U-shaped bone. It is the
only mobile bone of the facial skeleton, and,
since it houses the lower teeth, its motion is
essential for mastication. It is formed by
intramembranous ossification.
The mandible is composed of 2
hemimandibles . The hemimandibles fuse to
form a single bone by age 2 years.
Maxilla
The maxilla has several roles. It houses the
teeth, forms the roof of the oral cavity, forms
the floor of and contributes to the lateral wall
and roof of the nasal cavity, houses the
maxillary sinus, and contributes to the inferior
rim and floor of the orbit. Two maxillary bones
are joined in the midline to form the middle
third of the face.
Function
The alveolar process of the maxillae holds the
upper teeth, and is referred to as the maxillary
arch. Each maxilla attaches laterally to
the zygomatic bones (cheek bones).Each maxilla
assists in forming the boundaries of three
cavities:
• The roof of the mouth
• The floor and lateral wall of the nasal antrum
• The wall of the orbit
Components
Each half of the fused maxillae consists of:
• The body of the maxilla
• Four processes
• The zygomatic process
• The frontal process of maxilla
• The alveolar process
• The palatine process
• Infraorbital foramen
• The maxillary sinus
Articulations
Each maxilla articulates with nine bones:
two of the cranium: The frontal and ethmoid
seven of the face:
The nasal, zygomatic, lacrimal, inferior nasal
concha, palatine, vomer, and the adjacent
fused maxilla.
Zygoma
The zygoma forms the lateral portion of the
inferior orbital rim, as well as the lateral rim and
lateral wall of the orbit. Additionally, it forms the
anterior zygomatic arch, from which the masseter
muscle is suspended.
The masseter muscle acts to close the mandible for
mastication and speech. On its lateral surface, the
zygomatic bone has 3 processes. Inferiorly, a
concave process projects medially to articulate with
the zygomatic process of the maxilla, forming the
lateral portion of the infraorbital rim.
Frontal Bone
Anterior surface
The frontal bone forms the anterior portion of
the cranium, houses the frontal sinuses, and
forms the roof of the ethmoid sinuses, nose, and
orbit.
Anteriorly, the external surface is convex
superiorly, and it articulates with the parietal
bones posteriorly and the greater wing of the
sphenoid posteroinferiorly.
Nasal Bones
The paired nasal bones form the anterosuperior
bony roof of the nasal cavity. They are
approximately quadrangular. They articulate
with the nasal process of the frontal bone
superiorly, the frontal process of the maxillary
bone laterally, and with one another medially.
Their inferior border is free and forms the
superior margin of the piriform aperture.
FACIAL BONES AND ITS FUCTIONS
SR
NO
Name of bones and
locatons
Function(s) - of specific
bones/features
1
Hyoid
In the neck, below the tongue
2
Lacrimal
Behind and lateral to the nasal Contain foramina for the
bone, also contribute to the
nasolacrimal ducts (tear ducts).
orbits.
(Smallest bones in the face.)
3
Mandible Known as the lower jaw bone.
Bone into which the lower teeth are
attached.
The only moveable facial bone.
4
Maxilla
Bone into which the upper teeth are
attached.
Each maxilla contains a maxillary
sinus that drains fluid into the
Upper jaw bone, which also
forms the lower parts of the
orbits.
Supports the tongue, providing
attachment sites for some tongue
muscles
5
Nasal
Pair of small oblong bones
that form the bridge and roof
of the nose.
6
Palatine
Back of the roof of the .Small
"L-shaped" bones.
7
Turbinator Also known as Turbinate
Bone and Nasal Concha.
Form the nasal cavities.
8
Vomer
Separates the nasal cavities into left
and right sides.
9
Zygomatic Also known
as Zygoma and Malar Bone.
Cheek Bone because it forms
the prominent part of the
cheeks. Also contributes to the
orbits.
Thin roughly triangular plate of
bone on the floor of the nasal
cavity and part of the nasal
septum.
Form the bottom of the orbitals and
nasal cavities, and also the roof of
the mouth.
Articulates with the frontal, maxilla,
sphenoid and temporal bones.
FACIAL MUSCLES
Structure and Actions
The facial muscles are subcutaneous (just under the skin)
muscles that control facial expression. They generally originate
from the surface of the skull bone (rarely the fascia), and insert on
the skin of the face. When they contract, the skin moves.
Innervation
The facial muscles are innervated by facial nerve (cranial nerve
VII), with each nerve serving one side of the face.[ In contrast, the
nearby masticatory muscles are innervated by the mandibular
nerve, a branch of the trigeminal nerve (V) cranial nerve.
Development
The facial muscles are derived from the second
branchial/pharyngeal arch.
List of muscles
The facial muscles include
Occipitofrontalis
Temporoparietalis muscle
Procerus
Nasalis muscle
Depressor septi nasi
Orbicularis oculi
Corrugator supercilii
Zygomaticus major
Zygomaticus minor
FACIAL
NERVE
The motor part of the facial nerve arises from
the facial nerve nucleus in the pons while the
sensory and parasympathetic parts of the facial
nerve arise from the nervus intermedius.
The motor part and sensory part of the facial
nerve enters the petrous temporal bone via
the internal auditory meatus (intimately close to
the inner ear) then runs a tortuous course
(including two tight turns) through the facial
canal, emerges from the stylomastoid
foramen and passes through the parotid gland,
where it divides into five major branches.
CRANIAL NERVE BRANCHES
Intra cranial
Greater petrosal nerve - provides parasympathetic
innervation to several glands, including the nasal
gland, palatine gland, lacrimal gland, and pharyngeal gland.
It also provides parasympathetic innervation to the sphenoid
sinus, frontal sinus, maxillary sinus, ethmoid sinus and nasal
cavity.
Nerve to stapedius - provides motor innervation
for stapedius muscle in middle ear
Chorda tympani
 Submandibular gland
 Sublingual gland
 Special sensory taste fibers for the anterior 2/3 of the
tongue.
Extra cranial
Distal to stylomastoid foramen, the following
nerves branch off the facial nerve:
Posterior auricular nerve - controls movements of
some of the scalp muscles around the ear
Branch to Posterior belly of Digastric muscle as
well as the Stylohyoid muscle
Five major facial branches
Temporal branch of the facial nerve
Zygomatic branch of the facial nerve
Buccal branch of the facial nerve
Marginal mandibular branch of the facial nerve
Cervical branch of the facial nerve
VEINS, ARTERIES, AND LYMPHATICS
OF THE FACE
Facial artery: This artery stems from the external carotid
artery, follows the inferior border of themandible, and enters
the face. It provides blood to the muscles of the face.
Submental artery: This artery starts from the facial artery
and supplies blood to the tissues under the chin.
Inferior labial artery: Starting from the facial artery at the
angle of the mouth, this artery runsmedially to the lower lip,
where it provides blood flow.
Superior labial artery: This artery starts with the inferior
labial artery, but it runs medially to the upper lip and
provides blood flow there.
Lateral nasal artery: Starting at the facial artery alongside
the nose and running out to the nose ;this artery provides
blood to the skin of the nose.
Angular artery: This last branch of the facial artery passes
to the medial angle of the eye. It provides blood to the
inferior eyelid and the cheek just below.
Occipital artery: This artery branches from the external
carotid artery and passes to the occipital region. It provides
blood flow to the scalp on the back of the head.
Posterior auricular artery: This artery also branches from
the external carotid artery and runs to the areas around the
mastoid process and the ear. It provides blood to the ear
and scalp behind the ear.
Maxillary artery: This artery also starts from the external carotid artery. It runs deep to
the neck of the mandible to supply blood to deeper structures of the face and meninges.
Inferior alveolar artery: This artery branches off the maxillary artery and enters the
mandible to supply the teeth.
Infraorbital artery: This artery branches from the maxillary artery and supplies blood
to the maxilla, teeth, lower eyelid, cheek, and nose.
Superficial temporal artery: Starting at the termination of the external carotid artery
and ascending in front of the ear to the temporal region, this artery supplies blood to the
facial muscles and skin in the frontal and temporal areas.
Zygomaticoorbital artery: This artery branches off the superficial temporal artery and
runs to the orbit (eye socket).
Transverse facial artery: This artery stems from the superficial temporal artery and
crosses the face to just below the zygomatic arch. It supplies blood to the parotid gland
and muscles and skin of the face.
Mental artery: The terminal branch of the inferior alveolar artery, this artery emerges
from the mental foramen, where it supplies blood to the facial muscles and skin of the
chin.
Supraorbital artery: This artery branches from the ophthalmic artery and runs upwards
to supply blood to the muscles and skin of the forehead and scalp.
IMPORTANT VEINS IN THE FACE INCLUDE THE FOLLOWING:
Angular vein: This vein runs obliquely down the side of the nose.
Facial vein: The facial vein drains most of the blood from the face.
It begins at the angular vein in the medial angle of the eye. The deep
facial vein joins the facial vein, which goes on to drain into the
internal jugular vein.
Maxillary vein: This vein accompanies the maxillary artery and
drains blood from the face.
Superficial temporal vein: This vein drains the forehead and scalp.
Retromandibular vein: This vein is formed by the superficial
temporal vein and the maxillary vein. It receives blood from the
region of the temple and the face.
Posterior auricular vein: This vein is joined by a branch of the
retromandibular vein to form the external jugular vein.
Supraorbital and supratrochlear veins: These veins descend from
the scalp to form the angular vein.
LYMPHATIC NODES ARE CATEGORIZED INTO
SEVERAL GROUPS:
Parotid lymph nodes: Receive lymph from the side of
the face and scalp
Submandibular lymph nodes: Get lymph from the
upper lip and part of the lower lip as well as most of the
oral cavity
Submental lymph nodes: Get lymph from the chin
and center of the lower lip
Lymph from these nodes eventually drains into the
deep cervical lymph nodes. The deep cervical lymph
nodes drain into the jugular lymphatic trunk, which
joins the internal jugular vein or brachiocephalic vein
on the right side and thoracic duct on the left side
CASE
PERSENTATION
CASE PERSENTATION
I. INTRODUCTION
A fracture is the (local) separation of an object
or material into two, or more, piece. Fracture is any
break in the continuity of bone. In some cases, a bone
may fracture without visibly breaking. Fractures occur
when the bone is subjected to stress greater than it can
absorb. It can be caused by a direct blow, crushing
force, sudden twisting motion, or even extreme muscle
contraction.
While a variety of treatment options exist for a
fracture that is associated to injury.
PATHOPHYSIOLOGY
Physical trauma due to vehicle accident
Breakage of bone skin and tissue damage
Internal and external bleeding causes swelling
and pain
Hematoma stage:- Hemorrhage and clot
formation.
Inflammatory
stage:- inflammatory cells
appears ,organization and resorption of clot.
Granulation stage:- presence of mesenchymal
cells , fibroblasts and new capillaries.
Soft callus:-callus grows and bridge fracture sites
Hard callus ;callus has sealed bone edges.
Remodeling stage:- reorganization of bone and
orginal cortex restored.
SURGICAL PROCEDURE
OPEN REDUCTIN AND
INTERNAL FIXATION (ORIF)
INTRODUCTION
An open reduction and internal fixation
(ORIF) is a type of surgery used to fix broken
bones. This is a two-part surgery. First, the
broken bone is reduced or put back into place.
Next, an internal fixation device is placed on
the bone; this can be screws, plates, rods, or
pins used to hold the broken bone together
Since broken bones are caused by trauma or an
accident, an ORIF surgery is typically an emergency
procedure. Before your surgery, you may have:
1. Physical exam-to check your blood circulation and
nerves affected by the broken bone.
2. X-ray , CT scan , or MRI scan -tests that take a
picture of your broken bone and surrounding areas
3. Blood tests.
4. We can assess the patient by asking questions such
as: How did you break your bone? How much pain
do you feel? Do you take any blood-thinning
medicines?
5. An anesthesiologist will talk to patient about
anesthesia for your surgery.
Description of Procedure
Each ORIF surgery differs based on the location
and type of fracture. In general, a breathing tube
may be placed to help breathe while sleeping.
Then, the surgeon will wash skin with an
antiseptic and make an incision. Next, the broken
bone will be put back into place. Next, a plate with
screws, a pin, or a rod that goes through the bone
will be attached to the bone to hold the broken
parts together. The incision will be closed with
staples or stitches. A dressing and/or cast will then
be applied.
ORIF OF
MANDIBULAR AND
MAXILLARY
FRACTURE
Mandible and maxillary fractures are a
frequent injury because of the
mandible's and maxilla prominence and
relative lack of support. As with any
facial fracture, consideration must be
given for the need of emergency
treatment to secure the airway or to
obtain hemostasis if necessary before
initiating definitive treatment of the
fracture.
Etiology
Major etiologic factors vary based on
geographic location. Investigators find
out motor vehicle accidents to be the
most common cause , assaults also to be
the other common etiology.
Location of mandibular fractures
Most of the fractures occur in the body
(29%), condyle (26%), and angle (25%) of
the mandible.
Pathophysiology
Classification of mandibular fractures
Simple or closed - Fracture that does not
produce a wound open to the external
environment, whether it be through the
skin, mucosa, or periodontal membrane.
Compound or open - Fracture in which an
external wound, involving skin, mucosa, or
periodontal membrane, communicates with
the break in the bone.
Comminuted - Fracture in which the bone is
splintered or crushed.
Greenstick - Fracture in which one cortex of the bone
is broken and the other cortex is bent
Pathologic - Fracture occurring from mild injury
because of preexisting bone disease.
Multiple - Variety in which two or more lines of
fracture on the same bone are not communicating
with one another.
Impacted - Fracture in which one fragment is driven
firmly into the other.
Atrophic - Fracture resulting from severe atrophy of
the bone.
Indirect - Fracture at a point distant from the site of
injury.
Complicated or complex - Fracture in which
considerable injury to the adjacent soft tissues or
adjacent parts occurs; may be simple or compound.
Classification by anatomic region
The anatomic regions of the mandible.
Symphysis - Fracture in the region of the central
incisors that runs from the alveolar process
through the inferior border of the mandible.
Parasymphyseal - Fractures occurring within the
boundaries of vertical lines.
Body - From the distal symphysis to a line
coinciding with the alveolar border .
Angle - Triangular region bounded by the anterior
border.
Ramus - Bounded by the superior aspect of the
angle to two lines forming an apex .
sigmoid Condylar process - Area of the condylar
process superior to the ramus region.
Coronoid process - Includes the coronoid process
of the mandible superior to the ramus region
Alveolar process - Region that normally contains
teeth.
sigmoid Condylar process - Area of the condylar
process superior to the ramus region.
Coronoid process - Includes the coronoid process
of the mandible superior to the ramus region
Alveolar process - Region that normally contains
teeth
Condylar fractures are classified as extra capsular,
subcondylar, or intracapsular.
Type I is a fracture of the neck of the condyle with
relatively slight displacement of the head. The angle
between the head and the axis of the ramus varies from 1045°.
Type II fractures produce an angle from 45-90°, resulting
in tearing of the medial portion of the joint capsule.
Type III fractures are those in which the fragments are not
in contact, and the head is displaced medially and
forward.
Type IV fractures of the condylar head articulate on or in a
forward position with regard to the articular eminence.
Type V fractures consist of vertical or oblique fractures
through the head of the condyle.
Indications for closed reduction
a. Nondisplaced favorable fractures.
b.Grossly comminuted fractures.
c. Fractures in children involving the developing
dentition.
d.Coronoid fractures.
e. Treatment of condylar fractures.
Indications for open reduction
Displaced unfavorable fractures through the angle
of the mandible: Often, the proximal segment is
displaced superiorly and medially and requires an
open technique for proper reduction.
Severely atrophic edentulous mandibles.
Complex facial fractures & Condylar fractures.
Absolute indications
a. Displacement of the condyle into the middle
cranial fossa.
b. Inability to obtain adequate occlusion by closed
techniques.
c. Lateral extracapsular dislocation of the condyle.
Relative indications
a. Bilateral condylar fractures in an edentulous
patient when splints are unavailable or impossible
because of severe ridge .
b. Unilateral or bilateral condylar fractures when
splinting is not recommended because of
concomitant medical conditions or when
physiotherapy is not possible.
c. Bilateral fractures associated with comminuted
midfacial fractures.
Contraindications
Contraindications to closed reduction
include the following:
a. Patients with poorly.
controlled seizure history.
b. Patients with compromised pulmonary
c. Patients.
d. with psychiatric or neurologic problems
e. Patients with eating or GI disorders.
Medical Therapy
The use of preoperative and perioperative
antibiotics in the treatment of mandible
fractures, especially in the dentate portion is
well established to reduce the risk of
infection . continuing this antibiotic
regimen into the postoperative period did
not further improve the infection rate.
Surgical Therapy
Closed Reduction of Dentate Patients
1)Erich arch bars
2)Bridle wire.
3)Ivy loops.
1)Wire osteosynthesis
This is rarely used for definitive fixation since the advent of
rigid fixation.]However, it may be useful for help in
alignment of fractured segments prior to rigid fixation.
2)Plate fixation
Plate fixation can be of a "load-bearing" or a "load-sharing"
construct, as follows.
a)In load-bearing osteosynthesis, a rigid plate bears the
forces of function at the fracture site. Indications are the
management of atrophic edentulous fractures,
comminuted fractures, and other complex mandibular
fractures.
2)In load-sharing osteosynthesis, stability at the fracture
site is created by the frictional resistance between the
bone ends and the hardware used for fixation.
Complications
1)Delayed union and nonunion
Delayed union and nonunion occur in approximately 3% of
fractures.
2)Nonunion indicates a lack of bony healing between the
segments.
3)Infection : In some studies, particularly those without
antibiotics, infection may occur in more than 50% of
patients.
4)Malunion : It is defined as improper alignment of the
healed bony segments.
5)Ankylosis : Abnormal fibrosis and ultimately ankylosis.
6)Nerve injury : The inferior alveolar nerve and its
branches are the most commonly injured nerves.
Outcome and Prognosis
A higher prognosis is achieved with removal of
grossly carious and periodontally involved teeth.
Treatment should occur as soon as possible for
patient comfort. Prolonged delay in treatment
may contribute to technical complications.
Immobilization of the fracture segments is
perhaps the most important aspect in avoiding
delayed union, nonunion, and infection.
Perioperative Tasks and
Responsibilities of the
Nurse
SCRUB NURSE
Pre-operative Responsibilities
1. Assist with the preparation of the room for the
designated surgical procedure, including gathering
supplies for the procedure.
.2. Scrub, dry hands, gown, and glove
.3. Assist person scrubbed in first position with:
a. Setting up back table, mayo, and basins
b. Arrangement of instruments
c. Preparation of suture and needles.
4. Preparation and counting sponges.
5. Arrangement and preparation of other
necessary itself.
6. Gowning and gloving surgeon and assistants.
7. Assist with draping.
8. Arrangement of sterile field
Intra-operative Responsibilities
1. During the procedure, progress from doublescrubbed position. Train self to keep eyes on field,
and learn steps of procedure.
2. Begin developing methods of anticipating
needs of surgeon and assistant
.3. After closing the skin
a. Assist with care of instruments and counts
if necessary
b. Care of specimen
c. Assist with dressing of wound
Post-operative Responsibilities
1. After the completion of the Procedure:
a. Assist with the gathering of all materials used
during the procedure
b. Discard items as necessary being careful to
discard sharp items in designated places
c. Return all items to respective area.
d. Assist with cleaning of room.
e . Clean the materials used properly and
arrange them after drying
2. Perform any duties which will speed up the
surgical procedure to follow in that room
CIRCULATING NURSE
Pre-operative Responsibilities
Care for the patient before surgery by:
a. Greeting patient and assist nurse with identification
b. Checking patient's chart, preparation, etc.
Prepare the room by:
a. Obtaining instruments, supplies, and equipment for the
designated operative procedure
b. Opening unsterile supplies
c. Assisting in gowning
d. Observing breaks in sterile technique.
e. Assisting anesthesiologist as necessary
f. Assisting with skin preparation and positioning
g . Assisting with forming of the sterile field
h. Count the instruments, sharps and sponges before the procedure
and confirm with scrub nurse.
Intra-operative Responsibilities
During the Procedure
a. Remain in room and dispense materials as necessary
b. Observe procedure as closely as possible
c. Begin establishing method of anticipating needs of
surgical team
d. Care of specimen as indicated.
e. Care of operative records as indicated
2. Before the closing of the organ or peritoneum, count all
instruments, sharps and sponges and confirm with scrub nurse.
3. Inform the surgeon and assistant surgeon of a report of the
instruments.
Post-operative Responsibilities
Properly document all the necessary information on the patient’s
chart
Assist in the cleaning of the Operation Room as necessary.
Prior to operation:
1)A careful history and physical examination are performed to exclude the
possibility of other gastrointestinal diseases that may mimic biliary colic,
such as peptic ulcer disease or reflux esophagitis.
2)When the diagnosis of acute cholecystitis is suspected the patient should
receive nothing by mouth; however, nasogastric suction usually can be
reserved for patients who are vomiting or have ileus and abdominal
distention
3)Intravenous fluids are given to correct volume depletion and any
electrolyte imbalances are measured and corrected. Monitor and regulate
IVF’s
4)The nurse instructs the patient about the need to avoid smoking to
enhance pulmonary recovery postoperatively and avoid respiratory
complications. It is also important to instruct the patient to avoid the use of
aspirin and other agents that can alter coagulation and other biochemical
process
5)On of the most important responsibility of the nurse is to let the patient
sign an informed consent regarding the surgery.
The patient is given anaesthesia prior to surgery and the patient is under
NPO.
During the operation
1. Monitoring the vital signs of the patient is one of the
responsibilities of the nurse during the surgery.
2. Assisting the anesthesia care provider during induction of
general anesthesia
3. Ensuring adequate oxygenation and hydration
After the operation
1. After recovery, the nurse places the patient in the low fowler’s
position. IV fluids may be given and nasogastric suction may
be given to relieve abdominal distention. Water and other
fluids are given in about 24hours, and soft diet is started when
bowel sounds returned.
2. Placing warm blankets on the patient to enhance comfort and
preserve the patient's body temperature.
3. Assessing the patient's vital signs, oxygen saturation level, level
of consciousness, circulation, pain, IV site, fluid rate, and
hydration status, as well as the status of the surgical site and
dressing and all related monitoring equipment.
4)The nurse helps in relieving the pain by instructing the
patient regarding proper positioning.
The nurse helps in improving the respiratory status by
instructing the patient regarding deep breathing
exercises.
5)The nurse also provides skin care like cleaning the
incision part and providing clean dressing
following a strict aseptic technique.
The nurse instructs the patient about the medications
that are prescribed by the physician.
Discussing recommended follow-up management with
the physician and the surgeon.
PATIENT EDUCATION
Post-procedure Care At the Hospital
1. After surgery, you will be given nutrition through an IV
until you are able to eat and drink.
2. You will be asked to get out of bed and walk 2-3 times a day
to prevent complications.
3. You will begin physical therapy to learn how to move. You
will also be shown exercises to regain muscle strength and
range of motion.
4. You will be asked to cough and breathe deeply to prevent
pneumonia .
5. Your affected part to be immobile to prevent dislocation
At Home
1. When you return home, do the following to help ensure a
smooth recovery:
2. Change your dressing daily or as instructed by your doctor.
3. If the dressing becomes wet or dirty, change it.
4. Once your dressing is removed, keep your incision dry and
clean:
1. Cleanse the incision site with lukewarm water and mild
soap.
2. Use a soft wash cloth to gently wipe the incision area.
5. Get up and walk several times a day.
6. Continue to do exercises prescribed by your physical therapist.
Go to all physical therapy appointments.
7. Be sure to follow your doctor's instructions .
Prioritization Of Nursing Problems
• Acute pain related to surgical incision.
• Imbalanced Nutrition less than body
requirement related to diatery modifications
after surgery.
• Impaired skin integrity related to surgical
incision.
• Deficient fluid volume related to surgical
procedure
• Risk for infection related to surgical incision.
ASSESSMEN
T
Subjective
data
“I have sever
pain while
moving the
face”
verbalized by
patient.
Objective
data


Facial
grimace.
Verbal
report of
pain.
NSG
DIAGNOSIS
Acute pain
related to
fracture and
surgery.
PLANNING
INTERVENTION
After series
of nursing
interventio
ns the
client will
manifest a
decrease in
pain scale
form .
1.Given comfortable
position to the
patient.
2.Maintained
immobilization of
affected part by using
arch bar .
3 .Elevate head end
15 C .
4. Carry out
medication regimen
as per order
5.Sedatives as per
Changes in sleep
pattern
6 .Teach diverting
therapy.
7 .Conform the
reassurance of
intervention
RATIONALE
1.To avoid discomfort
due to un favourable
position.
EVALUATION
After 12 hrs of
nursing
interventions the
goals fully met as
2.Relieves pain and
evidence by :prevent bone
. Decrease in pain
displacement extension scale from 5/10 to
of tissue injury.
0/10.
3 . Elevation promotes
. No pain and
venous return,
discomfort.
decreases edema and
. Verbalize relief
pain .
of pain .
4. To reduce the pain
. Positive response
5.To induce the sleep
pattern.
6 .To divert client
attention from pain.
7. To avoid restlessness.
CONCLUSION
• A case of post RTA polytrauma patient
withComplaint of Bleeding from nose LOC ,
swelling around right eye and eye lids and
periorbital area on right side.
• Initially seen by maxillo facial surgeon.
• Surgical treatment ORIF of mandible
maxillea and nasal bone done.
• Patient is able to move.
• Health education given on home care.
• Patient was discharged.
• Patient was told to come for follow-up after 2
weeks.
BIBLIOGRAPHY
• Lippincott manual of Nursing
Practice 9th edition
• www.localhealth.com
• www.healthtype.com
• www.drugs.com.

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