Whilst the trend is towards day surgery for the majority of surgical cases, there will be some patients who require inpatient treatment, for example when there are co-existing medical problems or where the treatment centre is some distance from the patient’s home.
Patients in the ophthalmic day case unit or ward will require pre- and post- operative care, as the majority are admitted for surgery, e.g. cataract extrac- tion, squint surgery, repair of retinal detachment, drainage surgery for chronic glaucoma or following trauma. There may, however, be patients admitted for rest following trauma, for intensive treatment of a severe infection or for treatment of post-operative complications. The specific nursing care for each ophthalmic condition is detailed in the relevant chapters. However, a general note on nursing care is given here.
Pre-assessment
Patients having day case or inpatient surgery tend to be pre-assessed a few weeks prior to the operation. This assessment is carried out in order to estab- lish the needs of the individual patient so that his short period in hospital can be planned, and also to give the necessary information regarding the surgery and to establish a post-operative care plan with the patient and carers.
Post-operative care will normally involve instillation of drops which, in the majority of cases, will be performed by the patient himself or his carer. Ideally, teaching drop instillation should be instituted at pre-assessment as there is little time for this during admission to hospital. Advising patients to purchase artificial tear drops and to practise at home following instruction is one way of overcoming the lack of time to teach this procedure and to observe the patient’s performance.
The nurse has only limited time in which to assess the needs of the patients and must apply all her assessment skills appropriately.
As well as giving the usual pre-operative information to the patient, the nurse may carry out the following procedures and record results and act on findings:
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Testing distance visual acuity;r
Tonometry;r
Biometry;r
ECG;r
Focimetry;r
Slit lamp examination.Information leaflets regarding the surgery and hospital stay should be given to the patient to support the verbal information and instructions that the nurse will give. These can be translated into languages other than English if
necessary. This, together with answering any queries that the patient or carer may have, will help allay fears. Clinical governance requires that patients are actively involved in the production of patient information of any type.
Pre-operative care
In addition to routine pre-operative care for surgery being performed under either local or general anaesthesia, the nurse may be required to carry out the following procedures, depending on the personal preferences of the oph- thalmic surgeon:
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Instilling mydriatic drops prior to cataract extraction or retinal detachment surgery as the pupil needs to be dilated for such surgery to be performed;r
Instilling miotic drops prior to trabeculectomy and keratoplasty;r
Instilling local anaesthetic drops such as G. oxybuprocaine 0.4%, if the operation is to be performed under a local anaesthetic.These drops are usually administered against a prescription or patient group direction.
Post-operative care
In addition to the normal post-operative care required by any patient after surgery, the ophthalmic nurse will need to follow a routine such as that de- scribed here, although this will vary to some extent according to hospital practice.
Eye care
Post-operative eye care involves dressings, cleaning the eye or skin wound, inspection of the eye, instillation of drops and protection of the eye.
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Dressings – eye pads are used but also cartella shields, with or without a pad, may be in place following surgery. If indicated, as in some types of minor lid surgery, the pad is removed before the patient leaves the unit.r
Cleaning the eye or skin wound – the eye or skin will usually only be cleaned on the day following surgery; subsequent cleaning is usually performed once a day or more frequently if indicated. In the case of some oculoplastic procedures, the pad and bandage will remain untouched for between 5 and 7 days.r
Inspection of the eye and surrounding structures will be undertaken post-operatively.r
Instillation of drops – if prescribed, given accordingly; ointment, if pre- scribed, may be applied at night. It should be noted that ointment may be prescribed for structures other than the eye, for example suture lines on the lids.r
Protection of the eye – eye pads or cartella shields may be worn on the first post-operative day; cartella shields are usually worn only at night for 1 or 2 weeks following surgery.Discharge
All patients should be given instructions about care and follow-up:
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Eye drops or ointment – the patient or carer’s ability to instil drops or apply ointment should be determined. Ideally, this process will have commenced at pre-assessment. Names of drops or ointment and times of instillation/application must be given verbally as well as written down.
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Cleaning the eye – if the eye is sticky in the mornings, it should be cleaned using cooled, boiled water in a clean receptacle and using cotton wool or gauze. Advise patients to avoid using dry cotton wool near the eye, as fibres can get into the eye.r
General instructions – patients should avoid stooping down too low in case they lose their balance. If appropriate, the patient should be advised to avoid anything causing increased exertion that will raise the intra-ocular pressure, such as lifting anything heavy. Patients should take care when they wash their hair to avoid getting soap or water into the eye as this would cause irritation that could result in rubbing behaviour. These restrictions should be heeded for 2 weeks initially, but are becoming increasingly less necessary with small incision surgery. Patients must take particular care not to knock or rub the eye, which could cause haemorrhage or cause the iris to prolapse through the wound.r
Outpatient appointment – ensure that the patient has an appointment, usu- ally at 1 or 2 weeks following discharge. Transport may need to be arranged for the day.r
Primary care – the nurse may need to arrange for a community nurse to assist with drop instillation, or may need to organize for the social worker to assess the need for home help or meals on wheels for the patient, prior to discharge.r
Convalescence – not used often, but in some areas recuperation in a con- valescent, residential or nursing home can be arranged for patients before they return to their own homes.r
Specialist procedures such as vitrectomy may require a patient to ‘posture’in certain positions to ensure a satisfactory surgical outcome. To ensure that the patient complies with the posturing instructions, especially if they live alone, it may be necessary to involve other agencies such as those provided by social services and primary care.
It is helpful if all the above information and instructions are written down as well as given verbally, as there is often much detail to absorb in the excitement of going home.
Nursing procedures
The ophthalmic nurse working on the ward and in day case needs to be able to assess the patients and plan their care on an individual basis. She must under- stand the pre- and post-operative care required for each type of ophthalmic operation. She needs to be able to carry out certain ophthalmic procedures competently and knowledgeably. The nurse must also plan the patient’s dis- charge in advance, ensuring that all relevant agencies are involved. She must be knowledgeable in all ophthalmic aspects in order to discuss relevant points with the patient and relatives so that the hospital stay can be made as easy and as pleasant as possible for all concerned.