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.