The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [647]
Each patient will require individually planned, and therefore unique, surgery. Reconstructive surgery of this type often results in altered anatomy, in both appearance and function, which may affect the psychological and physical well-being of the patient. Preoperative patient assessment must be as detailed as possible; this should include information on past and present medical conditions that may delay wound healing. For certain patient groups, for example those with recurrence of head and neck cancer, anatomy may already have been altered, through previous surgery, thereby narrowing down the possible options for reconstruction.
The complexity of the surgery will often require intensive nursing care. Postoperative observation of the wound sites, dressings and drains is crucial as deterioration of a wound can occur suddenly, for example fluid-filled seromas, necessitating the need for prompt nursing action. The main aim following flap reconstruction is to allow easy access for observation and to ensure that circulation and overall care are monitored efficiently during the crucial first 72 hours. Figure 15.6 shows a flap observation chart. These should adhere to medical notes and instructions as per patient. The principles are clarified in the procedure guidelines (e.g. change of wound dressing, removal of drains).
Figure 15.6 Flap observation chart.
Seroma
Following surgery, it is normal for haemoserous fluid to collect postoperatively at the site of excision. Fluid collects where there is a space created by tissue removal and it will continue to do so until the underlying tissues adhere (Harmer 2003).
A seroma is defined as a clinically identifiable collection of serous fluid within any surgical cavity (Woodworth et al. 2000). There appears to be no relationship between seroma formation and the patient’s age, tumour size, grade or Body Mass Index (Woodworth et al. 2000). Seroma formation is a common sequel rather than a complication following breast surgery, particularly when axillary dissection has been undertaken (Agrawal et al. 2006) and the extent of dissection, mastectomy versus breast-conserving surgery and the number of lymph nodes removed have all been shown to influence seroma formation (Cregan 2006). The sentinel lymph node biopsy technique introduced in recent years seems to confer a lower risk of seroma formation (Vitug and Newman 2007).
It is common for serous fluid to collect after removal of the drain. Patients who develop seromas will commonly report a bulging wound and experience pain or discomfort, which may in turn prevent them from performing postoperative exercises, such as arm exercises, which are recommended to restore mobility and minimize the risk of lymphoedema. Seroma formation can also impair the healing process and hinder the patient’s recovery phase due to the risk of wound infection, wound dehiscence, flap necrosis, a delay in commencing further treatment and an increase in the number of postoperative clinic visits required for seroma surveillance (Agrawal et al. 2006). Depending on the amount that has collected, a surgeon or specialist nurse may aspirate this as required. Symptomatic seromas can be drained by simple percutaneous fine needle aspiration according to individual hospital protocol (Warren 2008).
Negative pressure wound therapy
Definition
Negative pressure wound therapy (NPWT) is the application of a uniform negative pressure across the wound bed to promote healing (Ubbink et al. 2008). The benefits of NPWT are improving exudates management, reduction of odour and infection rates and increasing local blood flow to the wound (KCI 2007, NICE 2009, Ubbink et al. 2008).
Evidence-based approaches
Rationale
The advantage of using NPWT is that it stimulates granulation in an enhanced well-vascularized wound bed and promotes wound healing. It creates a moist wound environment and removes exudates and bacteria from the wound (KCI 2007). The interstitial fluid that mechanically compromises healing is gently removed whilst the capillary circulation is increased (Ubbink