A nurse is caring for a client who underwent enucleation of the right eye 24 hours ago. Which nursing intervention is most important for preventing complications?
1Apply warm compresses to the surgical site every 2 hours
2Encourage the client to cough and deep breathe vigorously
3Monitor for signs of bleeding and maintain pressure dressing✓ 정답
4Position the client in Trendelenburg position
해설
Monitoring for bleeding and maintaining the pressure dressing is critical to prevent hemorrhage, the most serious immediate complication after enucleation. Other options are either contraindicated (warm compresses, Trendelenburg) or less priority (coughing).
Understanding Enucleation and Immediate Postoperative Risks
Enucleation is the surgical removal of the entire globe of the eye, leaving the orbital structures, including muscles, fat, and connective tissue, intact. In the first 24 hours postoperatively, the most critical complication is hemorrhage into the orbital socket. The surgical disruption of the ophthalmic artery and its branches creates a significant risk for a retrobulbar hematoma, which can compromise the integrity of the wound and the orbital tissues. The case report on enucleation due to an ocular abscess highlights that even in a controlled surgical setting, managing the highly vascular retrobulbar space is paramount, and postoperative care focuses on maintaining hemostasis to prevent a life-threatening or wound-dehiscence-causing bleed [1]. Therefore, vigilant monitoring for bleeding and the secure maintenance of a pressure dressing are the cornerstones of immediate nursing care. The pressure dressing provides direct compression to the socket, tamponading small vessels and minimizing the accumulation of blood and serous fluid, which directly prevents hematoma formation and promotes wound healing.
Analysis of Incorrect Options
The other options represent interventions that are either contraindicated or of lower priority in this specific postoperative phase.
- Option 1: Apply warm compresses to the surgical site every 2 hours. This is contraindicated. Heat application causes vasodilation, which would increase blood flow to the already vulnerable surgical site, drastically elevating the risk of hemorrhage and increasing local edema. The priority is vasoconstriction and clot stabilization, which is achieved by the pressure dressing and, if needed, cool compresses to reduce swelling, not heat.
- Option 2: Encourage the client to cough and deep breathe vigorously. While pulmonary hygiene is important post-anesthesia, vigorous coughing and deep breathing are specifically contraindicated after ocular surgery. These actions perform a Valsalva maneuver, which causes a sudden, sharp increase in intraocular and intracranial venous pressure. This spike in pressure can easily rupture newly formed clots in the orbital vessels, leading to severe hemorrhage and potential extrusion of the orbital implant.
- Option 4: Position the client in Trendelenburg position. The Trendelenburg position (head lower than feet) is absolutely contraindicated. This position increases venous pressure in the head and neck, which directly promotes orbital edema and bleeding. The correct postoperative positioning to prevent complications is elevating the head of the bed to 30 to 45 degrees to promote venous drainage from the surgical site and reduce edema formation.
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 Hemorrhage PreventionImmediate Nursing Priorities in the First 24 Hours
The highest priority is preventing a retrobulbar hematoma. Maintain the pressure dressing securely to provide direct compression and tamponade vessels.
Monitor vital signs and the surgical site for signs of active bleeding such as bright red drainage on the dressing or sudden proptosis of the implant.
Caution
Do not apply warm compresses as heat causes vasodilation. Avoid maneuvers that increase orbital pressure, such as vigorous coughing or the Trendelenburg position.
Enucleation — Surgical removal of the entire globe of the eye, leaving orbital muscles and surrounding tissues intact.
Retrobulbar Hematoma — A collection of blood behind the globe within the orbital socket, a critical complication that can compromise the wound and vision.
Pressure Dressing — A firm bandage applied to provide direct compression, tamponading small vessels to minimize bleeding and promote hemostasis.