A patient has had myocutaneous flap reconstruction for the defect caused by a neck tumor resection
What nursing interventions are indicated for care of this flap? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Keep the patient in the supine position for at least 24 hours after surgery.
2. Regularly assess the flap for capillary refill.
3. Use tracheostomy ties to help keep the flap in place.
4. Keep the patient's head turned slightly toward the operative side.
5. Keep the patient on strict bed rest until flap healing is established.
2,4
Rationale 1: The head of the bed should be elevated to at least 30 degrees to facilitate drainage of fluid and to prevent edema.
Rationale 2: The capillary refill should be brisk and less than or equal to 2 seconds.
Rationale 3: Tracheostomy ties should be positioned away from the graft to prevent pressure on the area.
Rationale 4: Positioning the patient's head toward the operative side will help prevent tension on the flap.
Rationale 5: There is no reason the patient must be on bed rest while the flap heals.
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