Preoperative Ophthalmic Nursing Care

Preoperative Evaluation

Once the patient has been admitted to the ward for surgery or treatment, as per the instructions in the case sheet, the OA is to do the necessary tests and record them in the case sheet. The following tests are conducted prior to the intra ocular/ cataract surgery.

A.Ocular examination

i. Visual acuity

Vision should be tested with and without glasses and with pinhole. In advanced and mature cataract, perception and projection of light should be tested in the entire four quadrants to rule out retinal problems.

ii. Refraction

Both the eyes should be refracted. If the extent of cataract does not correspond to the visual loss, posterior segment pathology should be ruled out by special tests. In such cases the possibility of poor prognosis is explained to the patient before the surgery.

iii. Intraocular pressure (IOP)

The tension must be normal. If the tension is raised due to glaucoma the tension has to be lowered either by operation or by medication. The IOP has to be normal before cataract surgery. Usually lOP is tested by Schiotz tonometer/non contact tonometer in both eyes. In borderline and raised lOP, differential tonometry and applanation tonometry are done.

iv. Syringing

Patency of nasolacrimal duct should be tested. If the duct is partially free with clear fluid, hourly antibiotic drops are started and conjunctival swab is taken for culture and sensitivity. The operation is performed only after the culture shows no growth. If duct is not free,with mucus or purulent discharge, Dacryocystorhinostomy / Dacryocystectomy is to be done and cataract surgery can be done after one month.

v. A-scan, K-reading prior to cataract surgery

It is essential in case of IOL surgery. It gives the power of planoconvex IOL and +2 is added to this for biconvex IOL. In case of scarred cornea and irregular surface of cornea, the K reading will not be possible. In this case the other eye should be taken into consideration.

vi. Random blood sugar (RBS)

Random blood sugar test is compulsory for all cataract patients to ensure that they are not diabetic. Normal random blood sugar value is below 160mgs. If the patient's blood sugar is raised, additional test (fasting blood sugar and post prandial blood sugar) is done.

B. General examination

Common systemic problems like diabetes, hypertension, and ischemic heart disease should be under control before surgery. Physician fitness is required in such cases prior to surgery.

i. Blood sugar evaluation

In diabetic patients, fasting and post prandial blood sugar evaluation is done. Diabetes should be well under control, and if not controlled, physician's opinion must be taken and treatment added according to the doctor's advice. On the day of operation, anti-diabetic treatment should be avoided to prevent hypoglycemia. (In uncontrolled diabetes, there is a chance of post-operative infection and delayed wound healing and the pupil is difficult to dilate).

ii. Blood pressure recording

In the presence of hypertension, blood pressure must be reduced to systolic 170mm of Hg and diastolic 100 mm of Hg. If surgery is done in uncontrolled hypertension, there is a grave risk of expulsive hemorrhage immediately after the section is made for cataract surgery.

If B.P is not controlled, physician's opinion is taken, important investigations like blood urea, serum creatinine and serum cholesterol may be done and treatment started according to the physician's advice. Cataract surgery can be safely done with diastolic blood pressure under 100 mm Hg. In these patients, phenylephrine and adrenaline should be avoided and pupil dilatation is achieved with cyclopentolate and tropicamide.

iii. Cardiac evaluation

Every cardiac patient should have fresh ECG . Surgery should be performed only after six months of the previous attack of IHD or MI. Here again adrenaline and phenylephrine should be avoided and surgery has to be done with cardiac monitoring.

iv. Asthma

In asthmatic patients, chest auscultation should be done for the presence of rhonchi. Patients should continue the anti asthmatic treatment. An injection of Broncho dilator before surgery can be given to make the patient comfortable on the operation table.

v. Renal failure and renal transplantation

Blood urea and serum creatine tests results are obtained.

vi. Allergic conditions

If the patient has any history of medicinal allergy, a xylocaine test dose has to be given before giving local anaesthesia.Hence it is mandatory to get the information from the patient and record it in the case sheet.

vii. For paediatric patients

Hemoglobin and urine sugar should be tested. The anesthetist's opinion is also needed. If the child has cough or cold the surgery should be postponed.

Hemoglobin, bleeding time, clotting time, blood group should be investigated for the patients with DCR, enucleation and evisceration.

The above mentioned tests are performed and recorded in the case sheet of the patient. The OA in the ward has to meticulously check whether all the necessary tests have been conducted and give instructions to the patient.

C. Assisting the doctor in examining patients

In the ward, the ward OA is to give the doctors all the details about the patients. The doctor checks the patient in the slit lamp and records the findings. The OA assists the doctor in all the procedures. The OA has to adhere to the instructions given by the doctor.

On the day of the surgery the OA has to clean the outside area of the eye with iodine. Ask the patients to relax and inform them of the time they are to be ready for the surgery. Counsel the patients to have no fear about the surgery. Ensure them that the OA will be there to help them at any time. The OA should instil a confidence to face the surgery.

Preoperative counselling

• Depending on the patient's emotional state and their situation counselling should be given.
• Knowledge of the patient should be analyzed to know whether there is an awareness of the surgery.
• The patients should be told about the nature of the disease, the treatment procedure and surgical method, type of anesthesia (retrobulbar, facial, topical).
• Duration of their stay, date and timing of the surgery should be informed.
• Duration of the surgery need not be informed. Sometimes the surgery may take longer time than planned and this may create unnecessary anxiety to the patient and also the attendant.
• Importance of the surgery, the complications and positive results should be explained to the patients.
• If the patient has fear to undergo the surgery, then a role model patient who had successfully completed the surgery can demonstrate or share their positive experience
• The facilities provided by the hospital should be clearly explained

A. Preoperative preparation for retina surgery

• The patient is admitted to the hospital the day before surgery
• Eyelash cutting is done by the OA
• Antibiotic drops are given once an hour, six times prior to surgery
• Patients above 40 years will be tested for blood sugar, blood urea, serum creatine, urine albumin, ECG
• Oral antibiotics should be started for patients with intraocular foreign body and infection
• Physician fitness must be obtained prior to surgery

B. Paediatric preoperative preparation

• Check the case sheet for details regarding completion of investigations and indication of type of surgery, eye to be operated, operating surgeon, time of surgery
• Ensure completion of investigations regarding administration of general anesthesia e.g B.P, urine sugar, hemoglobin percentage, 'A' Scan, keratometry for paediatric cataract.
• In cases of systemic problems it is necessary to get either the Paediatrician or the Physician opinion prior to surgery.
• Note the general condition of the child. Look for upper respiratory tract infection in children Patient should undergo assessment by the anesthetist.
• Confirm the time of surgery and duration of starvation
• Preoperative application of antibiotics on the previous day, dilating drops in cases of cataract on the day of operation is mandatory

i. Preparation of patient and the parents on the day of surgery

• Take them to the operating room at the specified time
• Hand over the case records to the nurse in the preoperative waiting room
• Schedule the patients in cooperation with the nurse according to the list on that day

ii. Paediatric preoperative Counselling

• Depending on the emotional state of the patient's parents' and their situation counselling should be given.
• The patient's parents should be told the nature of the disease, (cataract / squint) the treatment procedure and surgical method.The choice of the lens and the surgery type is totally dependent on the parents decision.
• Duration of their stay, date and timing of the surgery should be told.
• Duration of the surgery should be told.
• The facilities provided by the hospital should be clearly explained.
• Importance of the surgery, the complications and positive results should be explained to the patient's parents.

C. Preoperative counselling for orbit surgery

• Confirm the time of surgery and duration of starvation for the pediatric patients and patient undergoing general anesthesia.
• Bath can be taken. Heavy food should be avoided. In diabetic patients test report of fasting blood sugar is requested.
• Appropriate instructions have to be given to patients with systemic diseases.They have to take their medications as to continue their routine medication for B.P, asthma, diabetes and cardiac diseases. Certain medicines like aspirin should not be taken for two to three days before and after surgery.

Day Care Surgery Procedure

In recent years due to the advancement in medical technology, most of the ophthalmic surgeries are done as day care. In day care surgery the patients need not stay in hospital. All cataract surgeries can not be done as a day care procedure. Patients with systemic diseases like cardiac, hypertension, diabetes, asthma and very elderly patients have to stay in the hospital before and after surgery. Patients from far off places also prefer to stay in the hospital to avoid traveling long distances. Patients without any systemic problem and who reside near the hospital area could utilize day care facilities.

If the patient accepts surgery and if they are from in and around the hospital area and have no systemic problems then check the willingness for daycare. If the patient agrees to it, and then the patient is given all the instructions. If the hospital has a separate counselling department, the counsellors can be given the responsibility of informing the patients about day care procedure. In smaller hospitals the OA has to give the instructions.

Surgery is done in the theatre and adjacent to the theatre, there is a nursing station. The patient is guided to the place. At the nursing station the case sheets are received and prescription slip is given based on surgery type. The patient is directed towards the pharmacy. After purchasing the medicines the patients are given instructions about how to use the preoperative medicines. They are given a day care card and are asked to bring their day care card on surgery day. On the day of surgery, patients are directed to the day care room after verifying their day care card. In the day care room the OA will check whether the eye is properly dilated. If not, dilatation drops are applied. Following that the patient waits for sometime.

The OA will also verify the blood sugar and blood pressure of patients and their fitness certificate. If everything is under control, patients are directed to the operation theatre. Surgery is performed at the scheduled time. After the surgery, patients are led to the daycare room. There the patients are told about postoperative care and are asked to come on the following day for postoperative review. On the day after surgery the patient undergoes final examination and review date will be fixed up in consultation with the patient.

Summary

In this unit we have covered the necessary tests conducted and the relevance of them and how to prepare the patient for surgery.

Key points to remember

1. From the case sheet the OA should find out whether the necessary tests are conducted and, if not, send the patients for the tests and record the results in the case sheet.
2. Consider the patient's willingness as well as the health status of the patient. If the patient is a cardiac patient, they should not be advised for day care.
3. Day care instructions should be given clearly

Student exercise

Say true / false

1. Diabetic person should come for day surgery.
2. Patient's allergy should be listed.
3. Adrenaline and phenylephrine can be used with cardiac patient.
4. Both eyes refraction need not be done.
5. High IOP is contraindication for surgery.

Answer the following

1. Why preoperative instructions are important for the patient?
2. Describe how day care patients are selected
3. Draw the flow chart for day care procedure
4. List the preoperative tests to be completed
5. List the ocular tests to be conducted before cataract surgery