About
Any trauma involving the facial area which can lead to excessive tissue swelling, bleeding, and impaired airway.
Assess
Priority is to monitor for a patent airway. Secure a patent airway if s/s of obstructed airway and impaired breathing including anxiety, restlessness, loss of consciousness, dyspnea, stridor, decreased pulse-ox, and bluish coloring ( cyanosis) of lips.
Assess tissue damage, swelling, presence of bruising. Rule-out head or neck involvement. Make sure client is maintained immobile until neck injury can be ruled-out by physician. Assess ability of client to see with eyes and move eyes symmetrically.
Check nose and ears for presence of cerebrospinal fluid drainage, notify physician immediately if present.
Complications
Aspiration- keep head-of-bed up, wire cutters post-surgical at bedside, suction prn. Airway obstruction- prepare to intubate. Head and neck trauma- immobilize client until ruled-out, monitor for neurological changes and cerebrospinal fluid drainage.
Diagnosis
- Pain related to soft tissue swelling and fracture
- Impaired gas exchange related to obstructed airway
- Pain related to tissue inflammation and injury
- Body image disturbance related to facial injuries and changes
- Impaired skin integrity related to injury
Goals
- Client will maintain a patent airway
- Client will state a decrease in pain
Interventions
- Assess client frequently for changes in breathing and neurological changes.
- Monitor for a gag reflex before administering fluids and or food.
- Administer medications, as prescribed, for pain.
- Apply cool compresses to minimize swelling as ordered.
- Prepare client for x-rays and other radiography tests.
- Prepare client for surgery as indicated.
- Elevate head of bed semi-fowlers to minimize swelling.
- Post-operatively, teach client measures to maintain safety. Keep wire-cutters at bedside if mouth wires in place, in case of aspiration or vomiting. Teach client how to cut wires if emesis occurs.
- Encourage frequent mouth care with adaptive techniques.
- Teach client adequate hydration and protein supplements to maintain nutritional status to help with healing.
- Monitor for signs/ symptoms of complications.
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