A nurse is caring for a client who underwent enucleation of the right eye 24 hours ago. Which nursing intervention is most appropriate for this client?
1Encourage the client to lie flat on the back to prevent bleeding
2Apply ice packs directly to the surgical site for 20 minutes every hour
3Remove the eye patch to assess the surgical site every 2 hours
4Elevate the head of the bed 30-45 degrees to reduce swelling✓ 정답
해설
Elevating the head of the bed 30-45 degrees promotes venous drainage and reduces swelling post-enucleation. Other options are incorrect: lying flat may increase swelling, direct ice application can damage tissue, and frequent patch removal increases infection risk.
Understanding Enucleation and Postoperative Priorities
After enucleation (surgical removal of the eye), the immediate postoperative period focuses on maintaining the integrity of the surgical site, controlling edema, and preventing complications such as hemorrhage. The orbit is a highly vascular space, and the formation of a hematoma or excessive swelling can compromise the healing of the implant and surrounding tissues. The most critical nursing intervention in the first 24 hours is to promote venous drainage and minimize fluid accumulation in the dependent tissue.
Analysis of the Correct Answer Option 4: Elevate the head of the bed 30-45 degrees to reduce swelling.
This is the correct intervention. Elevating the head of the bed (HOB) to a semi-Fowler's position (30-45 degrees) utilizes gravity to facilitate venous and lymphatic return from the head and neck. This mechanical reduction in hydrostatic pressure directly decreases the risk of periorbital edema and ecchymosis at the surgical site. The case report by Fuertes-Recuero et al. (2025) on enucleation in a chimpanzee highlights that the primary postoperative complication following this procedure is significant periorbital swelling and inflammation, which necessitates careful management to protect the surgical site [1]. By reducing swelling, this position also indirectly minimizes tension on the suture line, thereby reducing pain and the theoretical risk of wound dehiscence.
Analysis of Incorrect Options Option 1: Encourage the client to lie flat on the back to prevent bleeding.
This position is contraindicated. Lying flat increases venous congestion in the head and orbit, which elevates hydrostatic pressure and can actually promote bleeding and edema at the operative site. Postoperative management aims to avoid any increase in intraorbital pressure, and a flat position works against this goal. The referenced case report describes the use of anti-inflammatory and analgesic therapy to manage the expected postsurgical edema, not a flat position, which would exacerbate the condition [1].
Option 2: Apply ice packs directly to the surgical site for 20 minutes every hour.
Direct application of ice to the surgical site is contraindicated. The pressure from an ice pack can traumatize the delicate suture line, increase intraocular or intraorbital pressure, and potentially cause injury to the implant or surrounding tissues. While cold therapy is used to reduce edema, for an enucleation site, it is applied gently to the surrounding periorbital area, never directly over the eye dressing or with pressure. The surgical site requires a sterile, pressure-free environment to heal, as any trauma could introduce infection into the orbit, a complication the prolonged antimicrobial therapy in the case study was specifically intended to prevent [1].
Option 3: Remove the eye patch to assess the surgical site every 2 hours.
The initial postoperative dressing applied after enucleation, which typically includes a firm pressure bandage, should not be removed frequently. It is usually left in place for the first 24 to 48 hours to provide hemostasis by direct pressure and to protect the wound from contamination. Removing the eye patch every 2 hours would disrupt clot formation, dramatically increase the risk of secondary hemorrhage, and expose the fresh surgical wound to pathogens. The case report describes a chronic infectious process that ultimately necessitated the enucleation; preventing postoperative orbital infection is a paramount nursing concern, and maintaining an intact, sterile pressure dressing is a key component of that prevention [1].
References (research sources)
[1]
Enucleation Due to Ocular Abscess in a Captive Chimpanzee (Pan troglodytes): A Case Report from the Republic of Congo.Case reportFuertes-Recuero M, López-Hernández JL, Ramírez-Lago A, Gutiérrez-Cepeda L, De Pablo-Moreno JA, Morón-Elorza P, Revuelta L, Atencia R. (2025) · DOI: 10.3390/vetsci12090805
Post-Enucleation PositioningReducing Edema in the First 24 Hours
Elevate the head of bed to 30-45 degrees (Semi-Fowler's position) immediately after surgery. This uses gravity to promote venous and lymphatic drainage, directly reducing periorbital edema and ecchymosis.
Maintain the pressure dressing intact for the first 24-48 hours to prevent postoperative hemorrhage and support the conformer. Do not remove it for routine assessment.
Caution
Never position the client flat on their back; this increases venous congestion and the risk of hematoma formation. Apply ice compresses around the dressing, never directly over the surgical site.
Enucleation — Surgical removal of the entire eyeball, leaving the orbital structures and extraocular muscles intact.
Semi-Fowler's Position — A bed position where the head is elevated 30 to 45 degrees, used to promote respiratory function and venous return.
Periorbital Edema — Swelling of the tissues surrounding the eye, a common postoperative complication after eye surgery.