26 CHAPTER VIII: EVALUATION A.

Discharge Planning Instruction/ Out-patient Instruction

The client will be instructed about the proper procedure for taking medications based on drug study made on all of her take home medications, and correlating understanding will be discussed with the patient until complete understanding measured by patient being able to explain and repeat in detail all of the relevant information with emphasis on dosage and side effects of the drugs/medications given to the client. A light sedative may be prescribed to help induce sleep. During the first week, a friend or relative should stay with the patient. Take the patient to the hospital back if there are any difficulties.

The Medications are as follows: MEDICATION Mydriatics: Autonomic drugs used to ensure maximal pupillary dilation preoperatively, which is essential for a successful lens extraction. Short-acting mydriatics often are used. Most commonly used mydriatics are phenylephrine hydrochloride and tropicamide. Phenylephrine HCl (Neo-Synephrine) o Direct-acting adrenergic agent available in 2.5% and 10% concentrations. and Acts locally by as potent vasoconstrictor mydriatic constricting

ophthalmic blood vessels and radial muscles of the iris. Favorably used by many ophthalmologists because of rapid onset and moderately prolonged action, as well as the fact that it does not produce compensatory vasodilation. Most ophthalmologists prefer 2.5% to 10% concentration because of fewer risks of severe adverse systemic effects. Onset of

27 action is within 30-60 min lasting for 3-5 h. Corticosteroids: Help decrease and control inflammatory response following cataract surgery especially in the immediate postoperative period. The most commonly used ophthalmic steroid is prednisolone acetate 1%. Dexamethasone 0.1% ophthalmic solution sometimes is used as an alternative. Forte) o Prednisolone acetate 1% (AK-Pred, Pred Topical anti-inflammatory agent for

ophthalmic use. A good glucocorticoid that, on the basis of weight, has 3-5 times anti-inflammatory potency of hydrocortisone. Glucocorticoids inhibit edema, fibrin deposition, capillary dilation, and phagocytic migration of acute inflammatory response as well as capillary proliferation, deposition of collagen, and scar formation. Indicated for treatment of steroid-responsive inflammation of palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe. o inflammation by polymorphonuclear capillary permeability. Antibiotics: Broad-spectrum antibiotic ophthalmic solutions often are used prophylactically in immediate postoperative period. A number of topical antibiotics are used depending on surgeon's preference, but, generally, medications are active against both gramDexamethasone (Ocu-Dex) Decreases suppressing leukocytes migration and of reducing

28 positive and gram-negative organisms. (Ciloxan) o Ciprofloxacin Active

against a broad spectrum of gram-positive and gramnegative organisms. Bactericidal action results from interference with enzyme DNA gyrase needed for bacterial DNA synthesis. In vitro and clinical studies have shown it to be active against following organisms: gram-positive (ie, Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus viridans) and gram-negative (ie, Haemophilus influenzae, Pseudomonas aeruginosa, Serratia marcescens). Other organisms have been found to be susceptible in vitro but have yet to be established firmly by clinical studies. Nonsteroidal anti-inflammatory ophthalmics: Used for pain and inflammation associated with cataract surgery. epafenac ophthalmic (Nevanac) o Nonsteroidal anti-inflammatory prodrug for ophthalmic use. Following administration, converted by ocular tissue hydrolases to amfenac, an NSAID. Inhibits prostaglandin H synthase (cyclooxygenase), an enzyme required for prostaglandin production. Indicated for treatment of pain and inflammation associated with cataract surgery. EXERCISE N

Since the patient is Status Post Extra Capsular Cataract Extraction with Posterior Chamber Intraocular Lens (ECCE

29 with PCIOL). His/her home environment will be assessed in order to address any concerns or hazards which may adversely affect the patients condition. Ongoing assessment will be made assuming that changes in the environment of the patient are also occurring. The nurse should plan a progressive activity schedule that focuses on the increasing activity tolerance and muscle strength. Exercises are strictly forbidden. Stooping and any activity which results in the patient having to bend forwards are discouraged to prevent dislodgement or removal of implanted artificial lenses in place. Patients should be clearly instructed NOT to do any household work until instructed by the surgeon. One week is the usual complete rest period.

The multiple medication regimen that the patient must follow can be quite complex. Understanding the medications, schedule, side effects is very important. The patient must understand that: He/She will need to undergo further follow-up treatment & check-ups to prevent any untoward outcome and to achieve the desired goal. TREATMENT It will take time before He/She can fully see again (especially if the patient was just recently operated and released). Due to the Surgery done to Him/Her (ECCE with PCIOL), the patient is at risk for post operative complications such as infection of the operated part etc On the first postoperative day, visual acuity should be consistent with the refractive state of the eye, the clarity of the cornea and media, and the visual potential of the retina

30 and optic nerve. Mild edema of the eyelid may be evident, as well as some conjunctival injection. The cornea is normally clear with minimal edema and striae. The anterior chamber should be deep with mild cellular reaction. It is important to check whether the posterior capsule is intact and whether the IOL is positioned properly. The red reflex must be strong and clear and the intraocular pressures should be within normal limits. Transient intraocular pressure elevations may be observed and attributed to retained viscoelastic. Significant improvement of these initial findings is to be expected in subsequent postoperative evaluation as the ocular inflammation subsides typically within 2 weeks. Topical steroids and antibiotics are tapered accordingly. Refraction is believed to be stable at the sixth to eighth postoperative week, at which time corrective lenses can be prescribed. Significant postoperative astigmatism can be addressed by suture removal by the sixth week as guided by keratometry or corneal topography. The client will be taught to utilize all the methods discussed in the NCP (Nursing Care Plan) and will be guided so that self reliance is prevalent. The nurse/ health care provider will carefully instruct the client : HEALTH TEACHING Cough should be controlled. It is good practice not to drive or operate machinery for two to three weeks. Consumption of alcohol is discouraged because it results in higher risks behavior. Follow all the post operative and discharge instructions made by not only the doctor but the nurse/health care provider as well. The client will be referred to community facilities and schedules of guided workout programs will be provided in

31 order to enhance client's motivation and increase chances for success of the attached nursing care plans. The nurse plays a vital role in caring for a Cataract & Post ECCE with PCIOL patient, mainly because it does not only entail the physical caring but the emotional aspects as well. These plans of care may be geared toward a favorable outcome not only for the patient but for the nurse/ health care provider as well. The client may be referred to community groups; facilities etc which may further help the recovery of the client. OUT-PATIENT REFERRAL The surgeon will see the patient after the procedure and again by agreement. This is generally one week after the extraction. If there are no complications, the next appointment will be a month later. At this time it is important for the patient to ask any specific questions he may have. The surgeon often sends a report to the patients general practitioner by mail or fax depending upon local policies and procedures. A list of medications is often sent. A nutritional plan that allows for small, frequent meals may be required. Liquid nutritional supplements may assist in meeting basic caloric requirements. High calorie nutritional supplements may be suggested for increasing dietary intake DIET using food products normally found at home. The patient may be placed on a bland diet or other food restrictions for the first seven to ten days. The patient is instructed to see his GP or specialist if there are complications. ALL REFERENCES: A. Book(s) Medical & Surgical Nursing, by: Brunner & Suddharts

32 Essentials of Nursing Practice, Susan Scott Ricci Fundamentals of Nursing, C. Taylor Fundamentals of Nursing, Kozier & Erb Fundamentals of Nursing, Potter-Perry http://healthmad.com/conditions-and-diseases/cataract-extraction-all-youneed-to-know/#ixzz16Vj7rntD http://healthmad.com/conditions-and-diseases/cataract-extraction-all-youneed-to-know/#ixzz16Vk8j9oH http://healthmad.com/conditions-and-diseases/cataract-extraction-all-youneed-to-know/#ixzz16VkjhHcT http://healthmad.com/conditions-and-diseases/cataract-extraction-all-youneed-to-know/#ixzz16VlNdeXb http://emedicine.medscape.com/article/1210914-overview http://emedicine.medscape.com/article/1210914-treatment http://emedicine.medscape.com/article/1210914-diagnosis http://emedicine.medscape.com/article/1210914-followup http://www.ijo.in/article.asp?issn=03014738;year=2002;volume=50;issue=1;spage=25;epage=28;aulast=Das http://nursingcrib.com/nursing-notes-reviewer/medical-surgicalnursing/cataract/ http://www.emedicinehealth.com/cataracts/article_em.htm http://www.nlm.nih.gov/medlineplus/ency/article/001001.htm http://nihseniorhealth.gov/cataract/whatisacataract/01.html Cataract - Wikipedia, the free encyclopedia.mht

B. Website(s)