Post-operative Care

Upon the child’s return from the operating room, initial nursing actions are critical for a smooth recovery.

Immediate Post-Operative Actions:

• Initial Assessment and Report: On arrival to collect the child from surgery, nurses must first assess the child’s vital signs immediately. Obtain a comprehensive report from the surgical team in theatre detailing the procedure performed, any significant intra-operative events, and specific post-operative instructions. This detailed handover is essential for ensuring consistent and informed care.

• Positioning for Recovery: Transport the child back to the pediatric surgical ward using a post-operative bed. Position the child in the bed according to the surgeon’s specific orders, which is often in a face-down (prone) position immediately post-surgery. This precise positioning is crucial for promoting optimal healing and minimizing potential complications based on the surgical procedure.

Post-Operative Care Procedures in the Ward:

• Initial Care and Positioning:

  • Initial Vital Signs Monitoring: On arrival in the ward, promptly and regularly monitor vital signs including heart rate, blood pressure, respiratory rate, and oxygen saturation.

  • Positioning and Support: Position the child in bed precisely as directed by the surgeon, frequently face down, to support optimal healing and prevent complications. If instructed, use sandbags to carefully immobilize the head to limit movement.

  • Safety Precautions: Ensure side rails of the bed are raised if both eyes are covered to prevent accidental falls. Place the call bell within easy reach to enable the child to easily summon assistance if needed.

  • Rest and Recovery: Allow the child to rest comfortably in the ward to recover from anesthesia effects. Continuously monitor bed positioning to adhere to surgical guidelines.

• Ongoing Observations:

  • Monitoring for Bleeding: Closely observe for any signs of bleeding from the surgical site. Note the amount and nature of any discharge.

  • Dressing Integrity: Regularly check eye dressings to confirm they remain securely in place, dry, and clean. Immediately report and address any signs of dressing becoming loose, wet, or showing signs of discharge or infection.

• Welcoming and Assessing the Child:

  • Gentle Reassurance: Greet the child gently as they awaken from anesthesia, offering comforting words and reassurance to reduce any anxiety or confusion upon waking.

  • Initial Eye Assessment: Before any cleansing or medication, perform an initial assessment of the eyes and surrounding tissue, after donning non-sterile gloves. Carefully remove any old eye dressings, patches, or shields, discarding them appropriately. If dressings are adhered to the eyelid or lashes, gently soften them with gauze moistened with sterile 0.9% saline solution before removal.

Detailed Eye Assessment Checklist:

Assess each eye and surrounding tissues for:

1. Redness: Note any unusual redness or inflammation.

2. Swelling: Observe for any edema or puffiness around the eye and eyelids.

3. Abrasions: Check for any signs of scratches or abrasions on the skin around the eye.

4. Irritation: Assess for signs of irritation reported by the child (if conscious and able to communicate), such as itching, stinging, or burning sensations.

5. Discharge: Document any eye discharge, noting its color, odor, and volume.

6. Eyelid Position: Observe eyelid closure – is it partial or full? Note the presence of a blink reflex if possible to assess.

7. Conjunctival Assessment (if possible): If the child is cooperative, ask them to look upwards. If not cooperative, with parental help, gently restrain the child and carefully pull down the lower eyelid to partially open the eye.

8. Eyelid Encrustation: Check for any dried discharge or encrustation on the eyelids and eyelashes. If present, soften with sterile gauze dampened with 0.9% saline.

9. Need for Swabbing: If discharge is observed, perform an eye swab for culture before proceeding with eye cleansing.

Procedures:

• Performing Eye Swabbing (for Suspected Infection):

  • Using a sterile cotton swab, gently roll it across the conjunctival sac inside the lower eyelid to collect a specimen.

  • Place the swab immediately into the appropriate transport medium.

  • Ensure prompt delivery of the specimen to the laboratory for analysis.

  • For suspected Chlamydia infection, always perform the eye swab after eye cleansing has been completed to ensure accurate sample collection.

• Performing Eye Cleansing:

  • Prepare sterile 0.9% saline or sterile water in a sterile container.

  • Moisten sterile gauze with the chosen solution.

  • Wipe the eye gently from the inner aspect (near the nose) to the outer aspect, using a fresh gauze square for each wiping stroke to prevent re-contamination.

  • Always cleanse the non-infected eye first if only one eye is affected to avoid cross-contamination.

  • Perform hand decontamination again after cleansing is complete and before proceeding with other eye care measures.

• Instilling Eye Medication (Drops or Ointment):

  • Cleanse the eye(s) as described above before each medication instillation.

  • Verify patient identity by checking the child’s identification band against the medication prescription chart. For adolescents over 16 who are consenting, ensure supervision if the medication may affect vision.

  • Always use new, unopened medication containers for each patient post-surgery to maintain sterility.

  • Position your non-dominant hand gently on the child’s forehead for stability while holding the medication container in your dominant hand.

  • Place a tissue or non-sterile gauze swab under the lower eyelid to catch any excess medication. Gently pull down the lower eyelid to create a small pouch.

  • Instill the prescribed dose of medication into the conjunctival sac, avoiding contact between the medication container tip and the eye surface.

• Applying Eye Padding/Dressings/Shields:

  • Eye Padding: Apply folded sterile gauze gently over the closed eyelid, ensuring it covers the entire area. Secure the padding firmly but comfortably with medical tape.

  • Eye Dressings: Use polyacrylamide hydrogel dressings (e.g., Geliperm®) to cover the closed eyelid for enhanced moisture retention and protection, following manufacturer instructions for application.

  • Eye Shield: For additional protection, particularly at night or for active children, apply a rigid, clear eye shield over the dressed eye and secure it with clear medical tape. Ensure the shield does not apply pressure to the eye.

General Post-operative Precautions:

• Secure Dressings: Ensure all eye dressings are well-secured. Use an eye shield to protect padding or reinforce loose tape to prevent accidental displacement.

• Restraints if Necessary: For younger children or those who are disoriented and at risk of disrupting dressings or injuring their eyes, consider using soft arm restraints as appropriate and prescribed.

• Constant Monitoring of Position: If specific positioning is required (e.g., face down), continuously monitor sleeping patients to ensure they maintain the correct position, especially immediately post-anesthesia.

• Minimize Startling: Avoid jarring the bed or making sudden loud noises to prevent startling the patient, which could lead to involuntary movements that could harm the surgical site.

• Mental Health Monitoring: Be vigilant for signs of depression or suicidal tendencies, particularly in patients who have experienced new vision loss. Provide emotional support and report any concerns to the medical team.

• Check Oral Intake Orders: Always verify physician’s orders regarding oral intake before offering food or drink, to prevent nausea and vomiting, particularly post-anesthesia.

Approach to Patient Communication:

• Verbal Introduction: Always speak to the patient upon entering their personal space and before initiating any physical contact.

• Procedure Explanation: Fully explain each procedure or activity in age-appropriate language before commencing it, even for seemingly simple tasks.

• Orientation Reinforcement: Regularly reinforce the patient’s orientation to their surroundings, especially if vision is impaired or temporarily lost due to dressings.

• Departure Notification: Inform the patient when you are leaving their immediate area, to prevent feelings of abandonment and enhance their sense of security.

Diversional Activities:

• Non-Visual Stimulation: If eye bandages are not in place, provide non-fatiguing activities that do not strain the eyes, such as listening to audiobooks or music.

• Social Interaction: Encourage visitors to chat or read aloud to the patient to provide social and auditory stimulation.

• Audio Entertainment: Utilize a radio or audio player for entertainment and to keep the patient connected to the outside world and informed (e.g., news, stories).

Specific Nursing Care for Patients with Vision Loss (Temporary or Permanent):

• Physical Space Orientation:

  • Provide a detailed verbal description of the room, including the location of furniture and other significant objects.

  • Physically guide the patient around the room initially, allowing them to familiarize themselves with the layout and spatial relationships.

• Maintaining Safety and Consistency:

  • Inform the patient of any changes to the room layout immediately to prevent accidents and maintain spatial awareness.

  • Keep doors either fully open or fully closed to avoid partially open doors that can be a hazard.

  • Ensure toiletries and personal items are consistently placed in the same locations for easy and predictable access.

  • Remove any hazardous items or obstacles from the immediate environment to prevent falls and injuries.

• Assisting the Patient with Mobility:

  • Address the patient by name when initiating interaction to ensure they know you are speaking to them.

  • Inform the patient when you are about to leave their presence, even for a moment.

  • When walking, offer your arm or shoulder to the patient to provide physical guidance and reassurance. Allow the patient to take your arm rather than pulling them.

• Promoting Autonomy:

  • Encourage the patient to be as self-sufficient as safely possible to maintain their independence and self-esteem. Provide assistance only when needed, rather than preemptively doing tasks for them that they can manage themselves.