Lippincott Certification Review Medical-Surgical Nursing


Chapter 18

●● Stapedectomy (surgical removal of the stapes) may be done, and the stapes may be replaced by a prosthesis; complications of this procedure, which is typically performed under local anesthesia, include continued hearing loss, granuloma, oval window rupture that causes perilymph fistula, inflammation, infection, prosthesis displacement, and temporary taste changes. ●● Preoperative nursing interventions ●● Use alternative communication methods as needed; a patient with severe hearing loss may need written instructions or a signing oral interpreter. ●● Discuss preoperative tests and postoperative care to reduce anxiety and promote compliance. ●● Encourage the patient to discuss anxieties and expectations; clarify misconceptions, and inform the patient that their hearing won’t improve until 6 weeks after surgery because of edema and packing. ●● Postoperative nursing interventions ●● Elevate the head of the patient’s bed 30 degrees; position the patient according to the practitioner’s orders—on the unaffected side to prevent graft displacement or on the affected side to facilitate drainage. ●● Monitor vital signs, and check dressings for bleeding; attempt to quantify bleeding. ●● Check for headache, stiff neck, fever, and vertigo, which are signs and symptoms of complications. ●● Observe the patient for edema, meningitis, labyrinthitis, and infection. ●● Keep dressings intact; when removed, observe the site for bleeding, redness, drainage, and edema. ●● Clean the suture line as directed; use aseptic technique to prevent infection, and watch for signs of infection. ●● Keep packing intact; it’s absorbable, and it shouldn’t be removed. ●● Assess facial nerve functioning twice daily to detect nerve compromise. ●● Administer pain medications, as needed, to allow the patient to participate in care. ●● Help the patient get out of bed to prevent falls. ●● Remind the patient to avoid rapid head movements, which can cause the dizziness that commonly occurs after surgery. ●● Tell the patient not to blow their nose and to keep their mouth wide open when coughing or sneezing. ●● Discharge nursing interventions ●● Provide written instructions to increase adherence. ●● Tell the patient to avoid strenuous activity for 1 to 3 weeks but to return to work after 1 week as prescribed; strenuous activity can result in perilymph fistula and may dislodge the prosthesis. ●● Instruct the patient to keep the ear dry for 6 weeks; they can shampoo their hair after 1 week; to avoid getting water in the affected ear while bathing, they should plug the ear with a cotton ball coated with petroleum jelly. ●● Tell the patient not to travel by air for 2 to 3 weeks to prevent barotrauma. ●● Tell the patient to avoid people with colds or upper respiratory tract infections for 4 to 6 weeks; these infections can spread to the middle ear by way of the eustachian tube. ●● Instruct the patient to report drainage, fever, otalgia (ear pain), vertigo, redness, and tenderness of the incision site. ●● Tell the patient to change the cotton ball covering the ear canal daily and as needed but not to disturb the packing in the ear canal. ●● Show the patient how to perform daily incision care. Retinal Detachment ●● Description ●● Retinal detachment is the accumulation of subretinal fluid that causes separation of the sensory layers of the retina from the underlying RPE; without treatment, the entire retina may detach, causing severe vision impairment and possible blindness. ●● It may be caused by degenerative changes in the retina or vitreous gel, which result in traction, intraocular inflammation, or mechanical trauma. ●● Rhegmatogenous retinal detachment (RRD) is the most common type and occurs when a tear in the retina leads to subretinal fluid accumulation and separation from the RPE. ●● Risk factors for premature posterior vitreous detachment (that may lead to RRD) include high myopia, prior intraocular surgery, family history, and RRD in the other eye. Some conditions are associated with higher incidence of RRD, including Marfan syndrome, Ehlers–Danlos syndrome, Stickler syndrome, and homocystinuria. Metabolic disease or vascular disease can also predispose to retinal detachment.

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