Most surgical procedures for the eye are performed on an outpatient basis. However, some procedures (e.g., retinal surgery, high-risk patients, cardiac surgery) are still performed in the hospital. This chapter highlights those patients who are admitted. Chapter 34 covers ambulatory or outpatient surgery.
Bedside ophthalmic assistant
One of our most important senses is that of sight. A blind or partially sighted individual is considerably impaired in the ability to move about freely, perform work, and function effectively. Daily living is seriously jeopardized. Consequently, any threat of loss or impairment of these abilities is a threat to an individual’s independence.
Without sight, no longer can drivers drive their cars, pilots fly their planes, or surgeons perform their work. Because of the consequences of blindness and the fear associated with this threat, the nursing care of patients with eye disorders demands extraordinary skill.
The background for ophthalmic nursing requires a good understanding of people and their management. Psychologic problems induced by the emotional havoc created by the threat of losing one’s vision must be dealt with effectively. Ophthalmic assistants interested in eye nursing will become involved in these emotional reactions.
General nurses are expected to increase their knowledge of the eye and eye disorders. They must become familiar with the terminology and acquainted with various diagnostic tests and surgical procedures. They also must become aware of the relationship between disease of the eye and disease of the body. A gentle touch and fine dexterity are prerequisites in caring for patients, particularly when administering eye medications and treating eyes that have undergone recent surgery. Nurses must move about quietly in the rooms of such patients, not dash into the room, bump into beds or chairs, or in any way startle patients who could become alarmed because they cannot see anyone’s movements. Ophthalmic nursing is essentially “quiet” nursing. The successful restoration or, indeed, improvement in eyesight often provides a stimulating and rewarding experience for ophthalmic nurses.
Visually impaired patient
Blindness is considered to be a total lack of vision or vision insufficient to conduct the ordinary activities of life. It is defined as a central visual acuity of 20/200 or less in the better eye with corrective glasses or a field defect in which the peripheral field is contracted to such an extent that the widest diameter of the visual field subtends an angle not greater than 20 degrees.
With both these limitations, a person is economically blind. A vast majority of the blind are in the group just below this threshold. Some are able to read newspaper headlines and some can identify distant objects. They may see light in various directions—in the corridors and the windows and in the streets. Only in the most severe form is the blind person completely devoid of any light sensation.
Some blind patients live in false hope of a possible cure and refuse to adjust to their decrease in vision. Others withdraw from society and lean heavily on their visual defect. They no longer face the normal problems of daily living and become dependent on others to relieve them of their responsibilities. These blind individuals may find comfort because they do not encounter failures and disappointments and are freed from judgment and condemnation by others. Others again recognize that their visual impairment imposes limitations on their way of life. They have difficulty in accepting their disability and become aggressive and angry in their behavior, and this anger is often reflected toward others. Some adjust realistically; they measure what assets they have and use their resources positively, thereby maintaining a degree of independence. They constantly work toward making life worthwhile for themselves and those with whom they are in contact.
When a patient with poor vision arrives in the hospital, the nurse must evaluate the patient’s degree of acceptance of visual impairment in terms of physical ability and psychologic dependence. The patient who denies existence of the disability and withdraws from society needs to be brought back to reality and to develop meaningful relationships with others. Gradual motivation can be instilled so that the patient eventually will assume a degree of responsibility for self-care. When confronting a patient who is aggressive and hostile because of the impairment, the nurse should establish communication so that the patient feels free to voice negative feelings about his or her limitations.
When a partially sighted or blind patient has to be admitted to a hospital or surgicenter, there should be a structured system of orienting the patient to the environment. The nurse should greet the patient warmly, addressing the person by name, and rapidly clarify the nurse’s position in the hospital setting. It is important that patients know to whom they are talking, who will take care of them, and what hospital personnel will do for them. Often shaking the patient’s hand and touching an arm provide a feeling of welcome. The ophthalmic nurse should observe the patient’s movements to decide what type of help the individual requires. Patients who walk slowly and hesitantly, with body bent forward and arms extended to find certain guiding objects, may require a great deal of assistance and orientation.
Patients with normal vision in one eye but impaired vision in the other eye have little difficulty adjusting to the hospital environment and need little orientation. Partially sighted people with impaired vision are usually aided by bright lights, such as corridor and window lights. Consequently, rooms and corridors should be kept well lit before eye surgery, and hospital design should allow for this level of increased illumination.
The partially sighted individual who is being escorted should be permitted to take the assistant’s arm lightly above the elbow. This automatically places the patient a step behind the guide, which provides protection and the ability to feel slight movements and to anticipate directional changes. An individual should never be pushed or steered. Any stairs, ramps, or surface changes should be indicated and described so that footing adjustments can be made. While walking with the patient, the assistant should engage in conversation and give a description of the surroundings. The assistant should also orientate a blind person to the room and the bathroom by having the person move about, touch the furniture and equipment, and become familiar with his or her location. These objects should be kept in a fixed location so that the patient may use them as landmarks.
Many patients and parents of children undergoing surgery will ask the hospital assistant questions they have been hesitant to ask the ophthalmologist. The assistant must be sure to say the right thing with tact and diplomacy and in a quiet authoritative manner, speaking in lay terms that are readily understandable and not shocking. For example, the parents should not be told that their child is crosseyed and requires sight-saving surgery. It is more tactful to state that the child requires the surgery to correct the eyes’ tendency to turn and that surgery offers the best treatment for a permanent correction. It even helps to reassure the parents by telling them that the procedure is simple and painless and requires only a short recuperation period.
Children, in particular, enter the hospital with a fair degree of apprehension. Basically, they want to like and trust the people they meet, but they are afraid of the unknown, the atmosphere, the strange uniforms, the instruments, and the worry about needles. Usually, a sincere smile, a soft voice, and a warm greeting will break the ice.
The ophthalmic assistant
The ophthalmic assistant can play a greater role in helping patients understand the disorder and what should be expected during both minor and major surgery.
Assistants may choose to review pictures or videos. Certification of the assistant becomes of value, not only for professional reasons but also developing greater communication and trust with the patient and a stronger understanding of ocular diseases and disorders.
The assistant can be invaluable in handling calls from pharmacists and opticians on prescriptions. They can provide indigent patients with samples and direct others to more inexpensive quality opticians and pharmacists.
Before surgery, the ophthalmic nurse should review with the patient the type of surgery that is about to be performed and what is expected of the patient to promote the success of the operation. This approach considerably lessens the patient’s anxieties and elicits postoperative cooperation. Even though basic information has been given to the patient by the ophthalmologist, securing the patient’s confidence helps the development of a good nurse–patient relationship, which promotes the patient’s recovery.
For those procedures performed under local anesthesia, the patient should be instructed in deep breathing and movement of the limbs to encourage circulation. Older adults tend to lie rigidly in the same position for prolonged periods, fearful of movement. The voluntary movement of limbs and chest muscles greatly lessens respiratory difficulties postoperatively.
Patients also should be instructed that coughing, sneezing, and squeezing the eyelids may have a detrimental effect on the operation. Bowel evacuants are often used the night before surgery so that abdominal discomfort is relieved and harmful straining after surgery is eliminated.
If the patient has never had eyedrops instilled, it is appropriate for the ophthalmic nurse to provide instructions regarding the procedure and the purpose of medication before surgery so that undue squeezing of the eyes after medication is avoided. Ophthalmic nurses will probably be responsible for administering eye ointments and solutions and it is important that they take extreme care in administering these medications. The eyes are especially sensitive after surgery, and any abrupt manipulation will cause discomfort and squeezing, which endangers the eye. Hands should be washed before instilling drops. The dropper tip should not touch the eyelashes. The head should be tilted back, the patient asked to look up and the lower eyelid pulled down. The drop is then instilled in the lower fornix (see Fig. 4.3 ). Topical anesthetic drops, however, are placed in the eye with the patient looking down and the solution directed to the 12 o’clock area of the sclera near the limbus. This permits the drop to run down over the cornea, where it produces maximal anesthesia.
Patients should be advised that whether they have local or general anesthesia, they will feel little discomfort during or after surgery. Some patients are very concerned that they will see everything during the operation and must be reassured that this is not so.
When the patient has returned from the operating room to the bed or chair, gentleness is of the utmost importance. After intraocular procedures, the patient should exercise caution and avoid rapid head movements. To prevent dislodging the eye dressing or pressing the eye bandage into the pillow and thereby injuring the eye, the patient should avoid lying on the side that has had surgery. The patient must be reminded to refrain from touching or disturbing the eye dressings so as to prevent any self-inflicted injury or infection. With older adults, during sleep, the assistant may put loose restraints on the wrists as a reminder for the sleeping patient not to touch the eye dressing.
After retinal detachment operations, the head of the bed is often placed in the position that is most beneficial for securing the reattachment. For some of these patients, a considerable amount of encouragement is necessary, and every effort should be made to ensure that the patient avoids exertion or strain in the immediate postoperative period. For surgery that is not intraocular, such as for strabismus or eyelid repair, limitations seldom are placed on the patient’s activity. For small-incision intraocular surgery, many of these safeguards are being abandoned.
The hospital atmosphere should be quiet and subdued. We recommend blackout drapes in each room so that the drapes may be drawn if the patient is photosensitive, as so often occurs after an eye operation. This is often caused by a low-grade iritis or a dilated pupil. The nurse should be on guard for signs of restlessness or confusion in the patient. Some patients undergo behavioral changes and may even have hallucinations. We are all dependent on sensory input from exposure to the world about us. The patient who suddenly loses the sense of sight because of a bandage often feels isolated from the environment and becomes disoriented. This creates a state of confusion, and disturbing illusions may occur. Any changes of this sort require a watchful nurse who constantly communicates with the patient and tries to effect relaxation and a return to reality. Radios may help in giving the patient this contact with reality through the auditory sense.
If nausea or vomiting occurs in the immediate postoperative period, adequate medication must be given immediately for relief. Often a light, often liquid, diet is ordered for the day of surgery as prevention. Foods should be sufficiently low in residue so that they require only a minimum amount of chewing and are not constipating. The physician’s orders must be carefully followed and order abbreviations must be well known ( Table 33.1 ).
|do not repeat
|twice a day
|c or cum
|four times a day
|three times a day
Sometime before the first eye dressing, the patient should be made aware that removal of the bandage does not immediately result in clear vision. No matter what the surgery, it takes time for the process of healing to occur and for the final vision to be obtained.
Alarming postoperative signs and symptoms
The ophthalmic nurse undertaking the immediate postoperative treatments for eye patients should be on the watch for unusual ocular signs that indicate untoward complications. Any hemorrhage in the anterior chamber should be noted and the attending physician informed. Unusual pain may be accompanied by a prolapse of the iris, in which a knuckle of iris protrudes from the wound incision; this is an alarming sign and requires immediate attention. However, this is rare today with smaller incisions. The presence of a flat anterior chamber that has not re-formed, or one that has suddenly occurred, should be noted.
Any evidence of small amounts of whitish material in the lower portion of the anterior chamber is an ominous sign and should be brought to the attention of the ophthalmologist immediately. It indicates a developing hypopyon, which may arise from an intraocular infection. If accompanied by severe pain, it is even more ominous and should be brought to the immediate attention of the surgeon or doctor on call.
Marked swelling of the eyelids combined with excoriation of the skin should be noted. This is a common sign of allergy to the medication that is being introduced or of an infection that may be starting. Unusual complaints of pain in the immediate postoperative period should be quickly brought to the attention of the ophthalmologist because occasionally, wound rupture or infection does occur, which is marked by severe pain. Evidence of a purulent discharge postoperatively is a warning sign.
Instructions to patient on discharge
When the patient is discharged from the hospital, or even if an outpatient, he or she should be given instructions that will ensure the continuing success of the eye surgery. Eyes that have had surgery require cautious care for the first few weeks after operation ( Box 33.1 ).
Your wound is healing, but it will not be firm enough to stand much pressure. You may feel that something is in your eye. This is because of the stitches or the incision. This feeling will go away. Continue to be careful.
Avoid closing the eyes tightly. One often closes the eyes tightly when laughing, talking, sneezing, coughing or yawning, or if irritated. At these times, you should be particularly careful not to close your eyes tightly. Never rub or touch the eye.
Avoid stooping, straining, lifting, and bending over.
If there is much secretion then wipe off the lids with cotton, but avoid exerting pressure on the eye, particularly the upper lid.
You will be given drops to use in your eye. Please follow these directions carefully. When the drops are gone, fill your prescription and use those drops.
How to instill drops
Wash your hands thoroughly before and after putting in eyedrops and ointments.
Clean the edges of your eyelids, using a clean cotton ball or washcloth that has been moistened with tap water. Do not press on the upper lid.
Pull your lower lid down with one hand, forming a pouch. Look up.
Put one drop of medicine in the pouch. Do not touch the tip of the bottle to your lid, eyelashes, or any other place.
Close your eye for 1 full minute after each drop.
If you find the preceding difficult, lie on the bed and repeat the instructions while looking up at the dropper.
Never use eyedrops that are more than 2 months old. Discard them.
You may watch television and read.
You may go outdoors for a walk or drive. It is not necessary to cover the eye, but it is preferable to shield it from bright sunlight by wearing sunglasses with ultraviolet protection.
You may wash your hair 1 week after surgery, but do not get soapy water in your eye.
Mild pain and discomfort may be relieved by aspirin. If there is more severe pain, please contact us.
You may have the feeling of something in the eye because of the incision, but do not close it tightly. This feeling may persist for a few weeks.
Glasses or contact lens may be prescribed when the eye is fully healed and the prescription is stable.
Each ophthalmologist has specific individual methods of dealing with patients. The physician’s input is most important in giving directions to patients. Typed discharge instructions similar to those in Box 33.1 are helpful.
Operating room assistant
Many ophthalmic assistants working in offices and clinics have the privilege of accompanying the ophthalmologist to the operating room. Here a new challenge awaits.
The drama of the operating room, the exactness, care, and detail required in eye surgery and the satisfaction resulting from a successful procedure instill a sense of accomplishment in the assistant at the end of each operating period. Here, the operating room assistant is expected to fulfill his or her role with the utmost gentleness, care, and attention.
The ophthalmic nurse probably will be responsible for the selection, care, handling, and sterilization of the many ophthalmic instruments required. A meticulous scrub and gown routine must be followed. One should be exceptionally careful that the exact sterile technique in scrubbing, gowning, and draping in the operating room is not broken by any member of the team, lest an infection develop that not only may cause irreparable damage but also result in blindness and even removal of the eye itself ( Fig. 33.1 ).
The use of powderless gloves has been a major help in reducing airborne particles.
The operating room must be quiet except for background music; CD players or tapes are helpful. Sudden loud noises might make the patient move unexpectedly and endanger the eye. All those who assist the ophthalmologist must ensure that the environment is pleasant and quiet from the time the patient is brought into the room until he or she leaves. Personal talk, such as politics, vacation, sports, and other patients should be avoided.
Aseptic technique in the operating room
Although surgery has been practiced since ancient times, the practice of asepsis is recent. As long ago as 3000 bce , Egyptians bored holes in skulls to let evil spirits out. Even in 700 bce , the Hindus performed cataract and eyelid surgery. Those who performed the surgery learned to keep their fingernails short, take daily baths, and wear white clothing. It was only in the 19th century that Joseph Lister introduced modern surgical aseptic techniques. Lister recognized that results of surgery improved 10-fold if microorganisms could be kept out of the wound. Thus many methods of sterilization of instruments and preparations for cleansing and disinfecting the skin came into being, until today’s modern methods were attained. Aseptic technique is discussed in Chapter 30 . Strict adherence to the principles of instrument sterilization, skin disinfection, and eye preparation is essential to eliminate ocular infections, which can be visually devastating ( Box 33.2 ).
Masks and caps
Mask covering only the mouth and not the nose
Mask tied too loosely
Hair permitted to protrude from the cap
Fingernails too long (should not exceed 1 mm)
Allowing the runoff to drip from the hands, thus contaminating them (runoff should be from the elbow)
Too short a scrub time
Failing to develop a systematic scrub routine and thus leaving bare spots
Splashing the clothes, thus contaminating sterile gown later
Using wet section of towel to dry upper arms, thus contaminating dry fingers
Allowing towel to touch unsterile clothing
Allowing gown to become contaminated by the hands or other unsterile objects
Allowing gown to touch unsterile objects by walking about the room
Dispensing powder from the hands into the air
Not carefully cleansing powder from outside of gloves
Touching outer portion of glove
Failing to detect perforations or breaks in the glove
Holding hands against the body while waiting
Believing the manufacturer’s claim for the product; check it out
Relying on aqueous antiseptics
Failing to realize that quaternary ammonium compounds (Zephiran) may be neutralized by even small traces of soap
In applying antiseptics, going back and forth from clean to contaminated areas and back to the clean area again (instead, ever-widening circles should be made, starting from the eyelid margin)
Forgetting to prepare the eyelashes, the eyelid margin, or the eyebrows
Routine procedure for the operating room assistant
Assistants must know the operative procedure well, even if it requires additional reading for them to become familiar with the technique. There should be a regularly updated card or page listing the surgeon’s preferences in instruments, sutures, and preparation of the patient. Assistants should question other operating room personnel who have worked with the surgeon to understand his or her special variations. If all are unfamiliar with the procedure, assistants should not hesitate to contact the surgeon a day or two before surgery to ensure that all necessary equipment is available.
Bringing the patient to surgery
The patient should be as relaxed as possible. A cheerful but quiet manner will provide an atmosphere of relaxation. Assistants should try to instill optimism and confidence in patients and should be particular to point out that everything will go well. They should always express confidence in the skill of the surgeon. It has been our habit to play soft music in the operating room throughout the procedure to ensure relaxation. Coming to the operating room for surgery is a unique and often terrifying experience for the patient. Each patient should be treated as if he or she were the only one and not one of many who pass through each day.
Cutting the eyelashes is not routinely performed for all procedures and may be abandoned by many surgeons since the advent of newer draping techniques. However, when it is necessary, the eyelashes should be cut before skin preparation. A thin film of ointment is placed on the cutting edge of an eyelash scissors so that the free lashes will adhere to the blades and be prevented from falling into the eye. The patient should be reassured that the lashes will rapidly regrow.
Assistants should carefully clean the area under their nails with a nail file or orangewood stick before scrubbing. The water should be at a comfortable temperature. Many sinks have elbow, knee, or foot controls so that adjustments can be made during the scrub technique. Assistants should adhere to the required time and the antiseptics used in any given hospital. They must be sure to follow a definite scrub routine so that no bare areas or blind spots occur on the sides of fingers, back of hands, or back of arms ( Fig. 33.2 ). There should be at least 20 to 30 brush strokes for every portion of skin. The water and the debris should always be allowed to run down from the elbows into the sink and never to run back down over the hands, which have been scrubbed first.
The gown must be folded so that the scrub assistant can unfold and put the gown on without touching the outer side with the bare hands. A towel placed on top of the gown should be used for careful drying of the hands before taking up the gown.
Gowns should be of sufficient thickness to provide protection from contamination by underclothing. Each sleeve should have a fitting wristlet. Many gowns now have wraparound backs to prevent the back area from contaminating instrument tables. Many doctors use disposable paper gowns that require no laundering and have no lint particles.
Several techniques are available for putting on gloves under sterile operating room conditions. The closed gloving technique represents perhaps the best method available for the scrub assistant. Some advantages of the closed gloving technique are reduction of possible contamination of the gloves from the hands and free glove powder, which scatters in an operating room.
In the closed gloving technique ( Fig. 33.3 ), the scrub assistant puts on the gown but slides his or her hands into the sleeves only until the sleeve cuff seams can be grasped between the fingers and thumbs. The hands do not protrude beyond the seam of the gown. The gloves are then laid out with the gown-covered hand. The glove is placed in the sleeve thumb down, with the fingers pointing toward the shoulder, and the wrist edge of the glove is level with the sleeve cuff seam. The cuff of the glove is then grasped against the sleeve with the thumb and forefinger, which are inside the sleeve. The upper edge of the glove cuff is grasped with the sleeve-covered fingers of the opposite hand and the glove opening is pulled down completely over the gown cuff of the hand being gloved. If the glove is being placed on the left hand, the glove cuff and the stockinette cuff are grasped with the right hand and both the cuff and the glove are pulled on at the same time. With the gloved hand, the other glove is now picked up and the same procedure is followed for gloving the other hand. Using this technique, the gloves are never touched with the bare hands.
Arranging the preparation table
A small table should be arranged to provide all the necessary solutions and supplies for preparing the skin and giving local anesthetic. These include antiseptic solutions, irrigation solutions, applicators, gauze, and local anesthetic solutions, as well as suitable syringes and needles. It is desirable that the sterile table be kept separate from the main instrument table and be removed once the eye and eyelid have been prepared.
Arranging the back table
The back table should be laid out in a definite order of use to provide necessary towels, gowns, and gloves for the surgeons, as well as drapes for the patient. Supplies, such as gauze and applicators should be placed here. The back table should include basins for solutions and basins for waste, in addition to required syringes for mixing and drawing up special solutions. Care must always be taken that solutions are never mixed or confused. Instruments are placed on the back of the table, leaving work space in front. Additional instruments that are seldom used but occasionally required may remain on the back table and not be transferred to the instrument, or Mayo, stand.
Arranging the instrument stand
The instrument, or Mayo, stand should be arranged according to a consistent pattern. Forceps are placed in one area, scissors in another, and needle drivers in another. Irrigating solutions, applicators, gauze, and so on have their own place on the instrument stand ( Fig. 33.4 ).