SESSION 4

CHECK FOR UNDERSTANDING (60 minutes) You will answer and rationalize this by yourself. This will be
recorded as your quiz. One (1) point will be given to correct answer and another one (1) point for the
correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You are given 60 minutes
for this activity:

Case Study: Read and examine the case thoroughly.

Patient Profile: F.N. is a 28-year-old male patient who sustained bilateral fractures of the nose, three rib
fractures, and a comminute fracture of the tibia in an automobile crash 5 days ago. An open reduction
and internal fixation of the tibia were performed the day of the trauma. F.N. is now scheduled for a
rhinoplasty to reestablish an adequate airway and improve cosmetic appearance.

Subjective Data

 Reports facial pain at a level of 6 on a 10-point scale

 Expresses concern about his facial appearance
 Complains of dry mouth

Objective Data
 RR 24
 HR 68 bpm
 Bilateral ecchymosis of eyes (raccoon eyes)
 Periorbital edema and edema of face reduced by about half since second hospital day
 Has been NPO since midnight in preparation for surgery

Discussion Questions
1. When F.N. was admitted, examination of his nose revealed clear drainage. What is the significance of
the drainage? What testing is indicated?
Answer: Possible CSF leakage from basilar skull fracture
2. What is the reason for delaying repair of F.N.’s nose for several days after the trauma?
Answer: waiting until edema subsides
3. What measures should be taken to maintain F.N.’s airway before and after surgery?
Answer:  HOB elevated, cold compresses to reduce edema, activity restrictions (no hot showers, no
strenuous exercise, no smoking or alcohol first 48 hrs, no blowing nose, no heavy lifting, no NSAIDs or
aspirin)
4. Priority Decision: When F.N. arrives in the post anesthesia care unit (PACU) following surgery, what
priority assessments should the nurse make in the immediate postoperative period?
Answer: respiratory status, vitals, surgical incision
5. Priority Decision: F.N.’s nasal packing is removed in 24 hours and he is to be discharged. What priority
predischarge teaching should the nurse provide?
Answer: report any bleeds lasting >15 mins or new bright red bleeds, no aspirin or NSAIDs, activity
restrictions

6. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses?
Are there any collaborative problems?
Answer:

Case Study
1. Clear drainage in the nose after facial trauma may be
cerebrospinal fluid (CSF) that is leaking from the central
nervous system following fractures of the face. Testing at the
bedside or in the laboratory with strips that indicate glucose
can differentiate CSF from mucus.
2. The vascularity of the face may cause excessive edema
following facial trauma and surgery to repair fractures may
need to be delayed until the edema subsides.
3. Airway can be maintained best by keeping F.N. in an upright
position and controlling edema of the upper airway. After
surgery, cold compresses and head elevation may help to
decrease edema, reduce dyspnea, and minimize discomfort.
F.N. may have PO fluids when awake and cold fluids will
help to decrease the swelling. Activity restriction to prevent
bleeding and injury include no nose blowing, swimming,
heavy lifting, strenuous exercise, or large facial movements.
4. Respiratory status—rate, depth, and rhythm—should be
assessed frequently to note respiratory distress. Vital signs
should be taken and observation of the surgical site for
hemorrhage and edema should also be done often.
5. F.N. needs to be taught how to clean the nose and nares
with cotton swabs and water or hydrogen peroxide and to
apply water-soluble jelly to the nares; to continue using the
external plastic splint as ordered; to report any continued
drainage of serosanguineous fluid from the nose after
24 hours or any fresh bleeding; and to not use aspirin or
aspirin-containing products for pain relief. F.N. should also
be educated about symptoms of postoperative infection.
Activity restriction to prevent bleeding and injury will be
decreased as the rhinoplasty heals.
6. Nursing diagnoses:
• Disturbed body image related to postoperative edema and
changed facial appearance
• Acute pain related to incisional edema
• Risk for ineffective breathing pattern related to presence
of packing and nasal edema
Collaborative problems:
Potential complications: nasal hemorrhage, nasal hematoma,
infection