Ophthalmic Nursing

Kai Tiaki : the journal of the nurses of New Zealand, Volume XII, Issue 1, 1 January 1919, Page 25

Ophthalmic Nursing

By C. Gordon MacLeod, M.A., M.D., Ch.M. (Edin.), Hon. Ophthalmic Surgeon, Sydney Hospital ; Hon. Consulting Ophthalmic Surgeon, Royal Alexandra and Coast Hospitals, N.S.W. (Continued from October Issue.)

When a patient is convalescent and dressings discontinued, a shade is often required. This is best met by a piece of stiff broAvn paper folded in two, so that the dimensions of the shade are roughly ten inches broad and six inches deep. Under the fold a double strip of brown paper, an inch wide, is passed, and pinned behind the patient's head. The above costs nothing, and can be renewed daily or oftener.

*7 I now wish to deal with the Ci role of the nurse in the case of a major operation on the eye," such as extraction of senile cataract, where her part is of prime importance before, during, and after operation.

With the general principles involved I need not deal, as these are the same as in other surgical operations. I only wish to emphasise such points as are of special application to ophthalmic work.

When an eyeball has an opening made into the interior for the purpose of restoring vision, the case naturally is much more critical and anxious than those operations where the eyeball is not opened, as for example in operations for ingrowing eyelashes, pterygiuin, or where the eyeball is removed altogether.

Suppuration after many operations in general surgery, though a serious complication, does not necessarily mean that the operation is not to be ultimately successful. Intraocular suppuration in nearly every case spells ruin to the eye as far as useful vision is concerned. How then can we do our best to prevent this calamity ? The answer is, by, before operation, (1) seeing to the patient's general condition, (2) seeing that the condition of the eye itself is as favourable as possible.

(1) It is taken for granted here that the operation is not one of special urgency, and that the time of operating can be selected. (In some conditions, as, for example, acute glaucoma, delay in operating may mean irretrievable loss of sight.) The general health is important as affecting the power of repair, and if feeble and below par ought to be built up as far as possible. Cough is a serious factor, and has

to be carefully inquired into, as it disturbs the healing of the wound. Anything abnormal that comes under the notice of the nurse ought to be brought to the knowledge of the surgeon, especially to anything, even trivial in itself, that causes spa«modic action.

(2) Local precautions. The main thing to see is that there is no discharge about the eye, cither from the conjunctival sac or tear passage. If anything of this nature exists the operation has to be postponed until the condition is treated, and until there is not the slightest trace of crusting round the edge of the lids in the morning. If the nurse notices any trace of gumming together she ought to report without fail.

The nurse can, before operation, do a great deal towards encouraging the patient and teaching him how to behave during the operation. He can be told that pain, if any, will be insignificant, that he must resist any inclination to close the eye unless told to do so, when he must do so gently, as when asleep, and not screw the lids up forcibly. He should also be instructed to practise looking down, which, when the patient is blind, he has often a difficulty in doing. When recumbent, "looking down" means looking in the direction of the feet. The patient before operation is prepared as for a general surgical operation, except that if, as is usually the case, there is not to be general but local anaesthesia, the patient need not be kept fasting.

Before the patient is brought on to the table the parts about the eye should be well washed with ethereal soap — the eyebrows and eyelashes especially (during which great care has to be taken that the eyes are kept closed), afterwards with sterlisea water, then with biniodide or perchloride of mercury lotion (1-5000), and dried. Some then prefer to have a sterile dressing put over the eye until the operation is just about to take place.

With regard to bathing the conjunctival sac itself immediately before operation, any lotion used nowadays is merely for the purpose of gently flushing the parts with a sterile and unirritating fluid, such as warm

saline or boric lotion ; use of a powerful germicidal lotion, such as that of strong perchloride of mercury, causing reaction and irritation of the conjunctival membrane, is

now recognised as more likely to defeat than achieve the end aimed at by reducing the vitality of the parts and their natural resisting powers towards infective organisms. If the appearances suggest that vigorous antiseptic measures are called for, then obviously operation should be postponed. I may say, however, that nowadays some of the modern non-irritating silver preparations are frequently used immediately before operation.

With regard to the sterilising of instruments, the main point is to remember that these are more delicate than those of general surgery. Those that are all metal ana noncutting can, of course, be sterilised by boiling alone, but cutting instruments, such as knives, and also instruments partly made of wory, are better dealt with by soaking in absolute alcohol in a shallow tray, e.g., a glass pen tray, for twenty minutes, after which they may be dipped for a minute in the steriliser. It is of the utmost importance that the point of the knife should not be damaged during preparation. When in the tray or steriliser cotton wool should be placed under the blade.

After sterilisation the instruments are carefully placed in the rack of a special tray for the purpose.

The patient, when brought on to the table, has a sterile linen cap fitted so as to cover the head, care being taken that no wisps of hair arc exposed. Specially sterilised cocaine (or equivalent) drops are instilled at intervals until the field of operation is anaesthetised. Between the instillations the eyes should be kept closed.

The nurse stands on the side of the eye to be operated on, holding the kidney-shaped tray in position, and the lotion ready for the surgeon's use. Bathing is usually done both before and after the speculum (which keeps the lids apart) is introduced, and the tray is then carefully lowered in the direction of the ear, withdrawn and laid aside, though it is generally required at a later stage at least once again.

A very special caution must here be given with regard to the greatest care being exercised by the nurse not to " joggle " the end of the speculum with the edge of the tray

when applying or withdrawing the latter. At any time this clumsiness is disconcerting both to the surgeon and patient, and in the later stages it may be sufficient to ruin the success of the operation.

After the operation is concluded both eyes are bandaged, and the patient is conveyed to bed with all gentleness and avoidance of all strain and sudden movements. The first twenty-four hours after operation are often vital in determining success or failure. It is important that if possible a sound night's sleep should be secured, with the patient lying on his back and the head and dressing undisturbed, and for attaining this end the services of a good nurse are invaluable.

The chief dangers are violent movements of a spasmodic character likely to disturb the wound. These are coughing, vomiting, sneezing, and hiccough.

Cough should, of course, be ascertained beforehand, and operation postponed till it is better. Sometimes, however, the patient has a chronic cough which cannot be got rid of, and has to be accepted as an additional risk incident to the operation. The head should be supported during the paroxysm. Vomiting may be prevented by sucking ice and the application of a mustard plaster over the stomach, and by fanning the face. Failing this, the head should be steadied by the nurse without pressure on the dressings, while someone else gently withdraws the pillow. If vomiting is inevitable, the head should be supported by the nurse and the patient turned towards the sound side. If the dressings are soiled the surgeon should be informed. Sneezing may be checked by deep inspiration and expiration, and hiccough by sucking ice. Sometimes a hypodermic injection of morphia may be necessary. If prevention of the spasm cannot be attained, support the head.

The patient often finds lying on the back irksome, aud the discomfort may be alleviated by insinuating a pillow under one side, varying this later by doing the same with the other side. Gentle rubbing of the back is also helpful. The head may be kept steady by placing sandbags on each side of it, and a nightcap is useful for keeping the bandage from being displaced by the pillow.

It is hardly necessary to add that the patient must be cautioned against interfering with the dressings. Sometimes, however, a patient does this involuntarily during sleep at a moment when the nurse's back is turned, and to obviate this some surgeons go so far as to have a patient's wrists lightly attached by a bandage fixed to the end of the bed, so that an unconscious attempt to touch the eye at once awakes the patient.

Diet needing little mastication is given, and the bed-pan used for some days, after which restrictions are gradually relaxed. The last matter I wish to deal with is the i( nursing of cases of Purulent Ophthalmia or Conjunctivitis " — ophthalmia simply being an older and less correct name for the latter. Conjunctivitis means an inflammation of the membrane lining the inner surface of the eyelids and reflected over the front — the " white " — of the eyeball. There are various types and grades of conjunctivitis, e.g., the oatarrhal variety, which is differentiated again into subdivisions taking their names from the active bacterial agent present. What is popularly known as 'Sandy Blight" is a form of catarrhal conjunctivitis. Then there is trachoma or " granular lids," which is a form of chronic conjunctivitis, with special characteristics of its own, and which is especially prevalent in the Western districts of the State.

But the form I wish particularly to deal with just now is Purulent Conjunctivitis, which may occur in both adults and infants, in the latter case being known as Ophthalmia Neonatorum — ophthalmia of the newborn. In the great majority of these cases, and certainly in the most virulent of them, the cause is a definite organism called the gonococcus, which can be recognised microscopically in the discharge. (It has, however, to be remembered that in a small proportion of cases of purulent conjunctivitis in both adults and infants, but more especially so in infants, the cause may not be due to this, but to other organisms.)

In casea of purulent conjunctivitis of gonorrhea] origin the disease is essentially the same in both adults and infants, but is more serious in adults, and the outlook as to the future of the eye, even when early and skilfully treated, is always graver than in the case of infants. In the case of in-

fants, if the proper treatment is commenced in time and faithfully carried out the results are generally good.

In infants the onset generally occurs three days after birth, the infection having occurred during birth, and both eyes are generally affected. In an adult one eye is usually affected in the first instance, and it is of the greatest importance to protect, if possible, the second from becoming also affected. This can best be done by a modification of what is known as Buller'fl Shield. Two square pieces of adhesive plaster have a circular hole cut in them rather smaller than an ordinary watchg asfij A watchglasa is fitted between them, and the two adhesive surfaces brought together. The plaster on the outside surface of the glass is half an inch wider all round its edge than that behind, and this adhesive edging is used for fixing the contrivance on to the forehead, cheeks and side of the nose. By this means the patient's sound eye can remain open and under observation, and ventilation is obtained by the plaster not being fixed down at the lower and outer corner. Flexible collodion can be applied to make the fixing more secure.

It has to be remembered as a general principle that all cases of ophthalmia have to be considered as contagious, the degree of contagion varying according to the amount and character of the discharge, the more purulent this is in character the greater being the contagion, and the gonorrhea type is the most virulent and contagious of all the ophthalmia. The nurse has first of all to take every precaution against accidentally infecting her own eyes, and, a.s a safeguard against the discharge spurting into her own eyes, goggles may be worn. Where only one eye of the patient is affected , any attention to the sound eye required, such as changing or refixing the Buller's Shield and bathing the sound eye, ought to be done before handling the affected one, or if later, not until she has thoroughly cleansed her hands.

The course of the disease is characterised by redness and great swelling of the lids and by a profuse yellow discharge. The main duty of the nurse is to bathe away gently the discharge as often as it collects, and in the acute stage this may require to be done every half hour or every hour during the twenty -four hours. The great dan-

ger is infection of the cornea, leading to its destruction and consequent loss of sight, and therefore every care has to be taken during manipulation to prevent its surface being damaged and so rendered liable to be attacked by the organisms. The particular drops and other applications to be made will, of course, be ordered by the surgeon.

As far as the nurse is concerned, these points cannot be too strongly emphasised : bearing in mind the extreme contagiousness of the case, she ought first of all to take every care against infection of her own eyes or the patient's other eye, if unaffected ; to have everything she may require ready before touching the affected eye ; to turn the head slightly towards the affected side when bathing the eye ; never to use a syringe, and to use the utmost gentleness in all manipulations, lest damage to the cornea may incur loss of the eye ; to burn, boil, or otherwise thoroughly disinfect everything contaminated by the discharge ; and, lastly, to scrupulously cleanse her own hands immediately after dealing with the case.

At one time Ophthalmia Neonatorum accounted for a very large proportion of all cases of blindness. Since the introduction of the method suggested by Crede, and now adopted in all lying-in hospitals, of, immediately after birth, carefully cleansing all infants' eyes and instilling into them a solution of nitrate of silver, the proportion of cases occurring has been enormously reduced. In dealing with a case where the disease is already established, the same practices are observed as with an adult, with attention to the most effective method of holding the child's head previously referred to. It is inadvisable to nurse a child so affected in the arms. As hat already been said, both eyes are usually affected, but in the rare cases where one eye only is affected, the sound eye may be protected by a gauze dressing changed twice daily, the eye being bathed at the time of changing the dressing, and care being taken that this is done with uncontaminated hands. —From the A.T.N.A. Journal.