Introduction Facial trauma, also called maxillofacial trauma, is any physical trauma to the face.

Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and fractures of the jaw, as well as trauma such as eye injuries. Symptoms are specific to the type of injury; for example, fractures may involve pain, swelling, loss of function, or changes in the shape of facial structures. Facial injuries have the potential to cause disfigurement and loss of function; for example, blindness or difficulty moving the jaw can result. Although it is seldom life-threatening, facial trauma can also be deadly, because it can cause severe bleeding or interference with the airway; thus a primary concern in treatment is ensuring that the airway is open and not threatened so that the patient can breathe. Depending on the type of facial injury, treatment may include bandaging and suturing of open wounds, administration of ice, antibiotics and pain killers, moving bones back into place, and surgery. When fractures are suspected, radiography is used for diagnosis. Treatment may also be necessary for other injuries such as traumatic brain injury, which commonly accompany facial trauma. In developed countries, the leading cause of facial trauma used to be motor vehicle accidents, but this mechanism has been replaced by interpersonal violence; however auto accidents still predominate as the cause in developing countries and are still a major cause elsewhere. Thus prevention efforts include awareness campaigns to educate the public about safety measures such as seat belts and motorcycle helmets, and laws to prevent drunk and unsafe driving. Other causes of facial trauma include falls, industrial accidents, and sports injuries. An immediate need in treatment is to ensure that the airway is open and not threatened (for example by tissues or foreign objects), because airway compromise can occur rapidly and insidiously, and is potentially deadly. Material in the mouth that threatens the airway can be removed manually or using a suction tool for that purpose, and supplemental oxygen can be provided. Facial fractures that threaten to interfere with the airway can be reduced by moving the bones back into place; this both reduces bleeding and moves the bone out of the way of the airway. Tracheal intubation (inserting a tube into the airway to assist breathing) may be difficult or impossible due to swelling. Nasal intubation, inserting an endotracheal tube through the nose, may be contraindicated in the presence of facial trauma because if there is an undiscovered fracture at the base of the skull, the tube could be forced through it and into the brain. If facial injuries prevent orotracheal or nasotracheal intubation, a surgical airway can be placed to provide an adequate airway. Although cricothyrotomy and tracheostomy can secure an airway when other methods fail, they are used only as a last resort because of potential complications and the difficulty of the procedures. Traditionally, tracheostomy has been provided for trauma patients who required endotracheal intubation for a prolonged period of time. In 1989, the American College of Chest Physicians' Consensus Conference on Artificial Airways in Patients Receiving Mechanical Ventilation recommended that tracheostomy should be considered in patients anticipated to require endotracheal intubation for more than 21 days. It also recommended, however, that if tracheostomy is indicated, it should be done early to minimize the duration of translaryngeal intubation and lower the incidence of associated complications. Recently, there has been an increasing trend towards converting endotracheal intubation to tracheostomy at an earlier stage as more evidence supports the benefits of early tracheostomy. Whited conducted a prospective study involving 200 medical and surgical intensive care unit (ICU) patients to assess the effect of duration of intubation on airway pathology. Before starting the study, they divided patients into three groups based on arbitrary thresholds of duration of endotracheal intubation: 2 to 5 days, 6 to 10 days and more than 10 days. The authors concluded that the risk of serious and irreversible airway complications increased after the 10th day of translaryngeal intubation. In those who were intubated for 10 days, the incidence of chronic airway stenosis was 5% compared to 12% in those who were intubated for more than 10 days. The controversy regarding the ideal timing of tracheostomy in trauma patients continues, however, because of the absence of large-scale, well-designed prospective randomized trials. The purpose of this article is to review the available data related to the advantages and disadvantages of early tracheostomy in critically ill trauma patients.

BSN III-HENDERSON; Group 2 | Tracheostomy Secondary to Maxillofacial Trauma

Anatomy and Physiology Respiratory System

The respiratory system is an intricate arrangement of spaces and passageways that conduct air from outside the body into the lungs and finally into the blood as well as expelling waste gasses. This system is responsible for the mechanical process called breathing, with the average adult breathing about 12 to 20 times per minute. When engaged in strenuous activities, the rate and depth of breathing increases in order to handle the increased concentrations of carbon dioxide in the blood. Breathing is typically an involuntary process, but can be consciously stimulated or inhibited as in holding your breath. Nostrils/Nasal Cavities During inhalation, air enters the nostrils and passes into the nasal cavities where foreign bodies are removed, the air is heated and moisturized before it is brought further into the body. It is this part of the body that houses our sense of smell. Sinuses The sinuses are small cavities that are lined with mucous membrane within the bones of the skull. Pharynx The pharynx, or throat carries foods and liquids into the digestive tract and also carries air into the respiratory tract. Larynx The larynx or voice box is located between the pharynx and trachea. It is the location of the Adam's apple, which in reality is the thyroid gland and houses the vocal cords. Trachea The trachea or windpipe is a tube that extends from the lower edge of the larynx to the upper part of the chest and conducts air between the larynx and the lungs. BSN III-HENDERSON; Group 2 | Tracheostomy Secondary to Maxillofacial Trauma 2

Lungs The lungs are the organ in which the exchange of gasses takes place. The lungs are made up of extremely thin and delicate tissues. At the lungs, the bronchi subdivides, becoming progressively smaller as they branch through the lung tissue, until they reach the tiny air sacks of the lungs called the alveoli. It is at the alveoli that gasses enter and leave the blood stream. Bronchi The trachea divides into two parts called the bronchi, which enter the lungs. Bronchioles The bronchi subdivide creating a network of smaller branches, with the smallest one being the bronchioles. There are more than one million bronchioles in each lung. Alveoli The alveoli are tiny air sacks that are enveloped in a network of capillaries. It is here that the air we breathe is diffused into the blood, and waste gasses are returned for elimination.

The skeletal system The human skeleton consists of both fused and individual bones supported and supplemented by ligaments, tendons, muscles and cartilage. It serves as a scaffold which supports organs, anchors muscles, and protects organs such as the brain, lungs and heart. The biggest bone in the body is the femur in the upper leg, and the smallest is the stapes bone in the middle ear. In an adult, the skeleton comprises around 14% of the total body weight, and half of this weight is water. Fused bones include those of the pelvis and the cranium. Not all bones are interconnected directly: There are three bones in each middle ear called the ossicles that articulate only with each other. The hyoid bone, which is located in the neck and serves as the point of attachment for the tongue, does not articulate with any other bones in the body, being supported by muscles and ligaments. Axial skeleton The axial skeleton (80 bones) is formed by the vertebral column (26), the thoracic cage (12 pairs of ribs and the sternum), and the skull (22 bones and 7 associated bones). The axial skeleton transmits the weight from the head, the trunk, and the upper extremities down to the lower extremities at the hip joints, and is therefore responsible for the upright position of the human body. Most of the body weight is located in back of the spinal column which therefore has the erectors spinae muscles and a large amount of ligaments attached to it resulting in the curved shape of the spine. The 366 skeletal muscles acting on the axial skeleton position the spine, allowing for big movements in the thoracic cage for breathing, and the head. Conclusive research cited by the American Society for Bone Mineral Research (ASBMR) demonstrates that weightbearing exercise stimulates bone growth. Only the parts of the skeleton that are directly affected by the exercise will benefit. Non weight-bearing activity, including swimming and cycling, has no effect on bone growth. BSN III-HENDERSON; Group 2 | Tracheostomy Secondary to Maxillofacial Trauma 3

Appendicular skeleton The appendicular skeleton (126 bones) is formed by the pectoral girdles (4), the upper limbs (60), the pelvic girdle (2), and the lower limbs (60). Their functions are to make locomotion possible and to protect the major organs of locomotion, digestion, excretion, and reproduction.

The Human skull The adult skull is normally made up of 22 bones. Except for the mandible, all of the bones of the skull are joined together by sutures, rigid articulations permitting very little movement. Eight bones including one frontal, two parietals, one occipital bone, one sphenoid, two temporals and one ethmoid form the neurocranium (braincase), a protective vault surrounding the brain. Fourteen bones form the splanchnocranium, the bones supporting the face. Encased within the temporal bones are the six ear ossicles of the middle ears, though these are not part of the skull. The hyoid bone, supporting the tongue, is usually not considered as part of the skull either, as it does not articulate with any other bones. The skull is a protector of the brain. The skull contains the sinus cavities, which are air-filled cavities lined with respiratory epithelium, which also lines the large airways. The exact functions of the sinuses are unclear; they may contribute to decreasing the weight of the skull with a minimal decrease in strength, or they may be important in improving the resonance of the voice. In some animals, such as the elephant, the sinuses are extensive. The elephant skull needs to be very large, to form an attachment for muscles of the neck and trunk, but is also unexpectedly light; the comparatively small brain-case is surrounded by large sinuses which reduce the weight. The meninges, or the system of membranes which envelops the central nervous system, are the three membranes which surround the structures of the nervous system. They are known as the dura mater, the arachnoid mater and the pia mater. Other than being classified together, they have little in common with each other. In humans, the anatomical position for the skull is the Frankfurt plane, where the lower margins of the orbits and the upper borders of the ear canals are all in a horizontal plane. This is the position where the subject is standing and looking directly forward. For comparison, the skulls of other species, notably primates and hominids, may sometimes be studied in the Frankfurt plane. However, this does not always equate to a natural posture in life.

BSN III-HENDERSON; Group 2 | Tracheostomy Secondary to Maxillofacial Trauma

Facial bones The 14 (mainly 7 on each side) facial bones form the framework of the face; provide cavities for the sense organs of smell, taste, and vision; anchor the teeth; form openings for the passage of food, water, and air; and provide attachment points for the muscles that produce facial expressions. Two maxillae form the upper jaw, contain sockets for the 16 upper teeth, and link all other facial bones apart from the mandible (lower jaw). Two zygomatic bones (cheekbones), form the prominences of the cheeks and part of the lateral margins of the orbits. Two lacrimal bones form part of the medial wall of each orbit. Two nasal bones form the bridge of the nose. Two palatine bones from the posterior side walls of the nasal cavity and posterior part of the hard palate. Two inferior nasal conchae form part of the lateral wall of the nasal cavity. The vomer forms part of the nasal septum. The mandible, the only skull bone that is able to move, articulates with the temporal bone allowing the mouth to open and close, and provides anchorage for the 16 lower teeth.

Functions: Support The skeleton provides the framework which supports the body and maintains its shape. The pelvis and associated ligaments and muscles provide a floor for the pelvic structures. Without the ribs, costal cartilages, and the intercostal muscles the lungs would collapse. Movement The joints between bones permit movement, some allowing a wider range of movement than others, e.g. the ball and socket joint allows a greater range of movement than the pivot joint at the neck. Movement is powered by skeletal muscles, which are attached to the skeleton at various sites on bones. Muscles, bones, and joints provide the principal mechanics for movement, all coordinated by the nervous system. Protection The skeleton protects many vital organs:

The skull protects the brain, the eyes, and the middle and inner ears. The vertebrae protect the spinal cord. The rib cage, spine, and sternum protect the lungs, heart and major blood vessels. The clavicle and scapula protect the shoulder. The ilium and spine protect the digestive and urogenital systems and the hip. The patella and the ulna protect the knee and the elbow respectively. The carpals and tarsals protect the wrist and ankle respectively.

BSN III-HENDERSON; Group 2 | Tracheostomy Secondary to Maxillofacial Trauma

Blood cell production The skeleton is the site of hematopoiesis, which takes place in red bone marrow. Marrow is found in the center of long bones. Storage Bone matrix can store calcium and is involved in calcium metabolism, and bone marrow can store iron in ferritin and is involved in iron metabolism. However, bones are not entirely made of calcium, but a mixture of chondroitin sulfate and hydroxyapatite, the latter making up 70% of a bone. Endocrine regulation Bone cells release a hormone called osteocalcin, which contributes to the regulation of blood sugar (glucose) and fat deposition. Osteocalcin increases both the insulin secretion and sensitivity, in addition to boosting the number of insulin-producing cells and reducing stores of fat.

BSN III-HENDERSON; Group 2 | Tracheostomy Secondary to Maxillofacial Trauma

Modifiable Factors -Nutritional Status -Activity/ Stress -Occupation

BOOK-BASED
Trauma /Accident

Non-modifiable Factors -Age -Gender

Break in the continuity of the bone Destruction of organic & inorganic matters
Nerve function at the site of the fracture temporarily lost

Numbness

Surrounding muscles become flaccid Outcome if surgery is not performed Continuous bleeding Shock
Maxillofacial Fracture

Fractured bone reduced Muscle spasm & contractions of the surrounding muscles

Facial Pain

Death Poor Circulation

Outcome upon Surgery

Loss of blood to the bone Bone tissue dies Bone will collapse

Cyanosis Pallor

Signs & Symptoms: -Epistaxis -Facial Pain -Facial swelling -Loss of facial sensation

-Maxillary Fracture will be manage -Bone put back into place -Internal fixation device helps to hold bone together

Bone Necrosis

Diagnostic Exam. -CT Scan of the Facial Bones -X-ray -Blood test (CBC)

Management: Surgery ORIF- Open Reduction & Internal Fixation

BSN III-HENDERSON; Group 2 | Tracheostomy Secondary to Maxillofacial Trauma

PATIENT-BASED

Motorcycle Accident

Maxillofacial & Nasal Bone Trauma

Frontal Bone Trauma

L - Ulnar Bone Trauma

R Radial Bone Trauma

L- Femur Bone Trauma

Destructio n of airway

Break in the continuity of the bone Destruction of organic & inorganic matters
Nerve function at the site of the fracture temporarily lost

Impaired ventilation
Decreased Oxygen supply

Numbness

Surrounding muscles become flaccid Muscle spasm & contractions of the surrounding muscles Pain

Cyanosis SOB Restlessness Cyanosis Tachypnea

Impaired physical mobility

Pallor

Tracheostomy

BSN III-HENDERSON; Group 2 | Tracheostomy Secondary to Maxillofacial Trauma

Statement of the Problem

The study aims to describe the nursing assessment, nursing management and medical management for a client with tracheostomy. Specifically, it seeks to answer the following questions:

1. What is the nursing history of the client in terms of: 1.1 Demographic 1.2 Chief Complaint 1.3 History of Present Illness 1.4 Social History 1.5 Psychological Data 1.6 Review of Systems 2. What are the physical assessment findings? 3. What are the medical interventions in the management of the client with tracheostomy? 4. How the different nursing strategies were used in managing the client with tracheostomy?

Method The descriptive research method is employed in the study. The study describes the nursing assessment, nursing and medical management that was given to the client with tracheostomy. The subject of the study is a client from Bamban, Tarlac with tracheostomy. Secondary data on clients profile, nursing management and medical interventions were all taken with due permission from hospital authorities and all other documents pertaining to the subject are treated with confidentiality.

BSN III-HENDERSON; Group 2 | Tracheostomy Secondary to Maxillofacial Trauma

Findings and discussion

Health history of a client with tracheostomy secondary to Maxillofacial Trauma (motorcycle accident) The following discussions describe comprehensively the nursing health history findings of the client with tracheostomy secondary to motorcycle accident. Included in this discussion are demographic data, chief complaints, history of present and past illnesses, social and developmental history, and review of systems of the client.

Demographic Data Table 1 describes the profile of the client with tracheostomy related to maxiloofacial trauma secondary to motorcycle accident. The client is a 19- year old boy, Filipino, Roman Catholic, and was born on September 20, 1992 in Sta. Cruz, Porac. He wasnt able to finished secondary education, he only attained 1st year high school in Bamban National High School. He is currently working as a NCO worker, working in a call center agency and he is the 2nd eldest to the 4 children of Mr. and Mrs. X.The family lives in their own house in Bamban, Tarlac.

Table 1 Demographic Profile of Client with Tracheostomy Related to Maxillofacial Trauma Secondary to Motorcycle Accident Age Date of birth Place of birth Gender Marital status Religion Educational Background Address Informant Date Admitted Admitting Diagnosis 19 years old September 20, 1992 Sta. Cruz, Porac Male Single Roman Catholic 1st year high school Bamban, Tarlac Mother June 27,2012 Multiple fractures due to motorcycle accident

Chief Complaint On January 27, 2012 the patient was admitted to JBLdue to motor accident.

History of Present Illness No history of present illness.

BSN III-HENDERSON; Group 2 | Tracheostomy Secondary to Maxillofacial Trauma

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History of Past Illness The patient has completed all his childhood immunization. He also doesnt have any allergies in food, medication and environment.

BSN III-HENDERSON; Group 2 | Tracheostomy Secondary to Maxillofacial Trauma

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