Nursing Clinical Practice Guide
Clinical Scenario: Mr. Johnson, 68, is post-op day 1 from a right eye enucleation due to a ruptured globe from trauma. He has a firm pressure dressing in place. He mentions he needs to use the bathroom and feels the urge to cough.
Nursing Intervention Strategy:
1. Assessment: Before any action, assess the dressing. Is it intact, dry, and snug? Assess his pain level (using a pain scale) and vital signs. Auscultate his lungs for crackles that might indicate a need to clear secretions.
2. Planning & Implementation:
* Dressing/Bleeding: Reinforce the importance of not touching the dressing. If any bleeding is suspected (e.g., rapid expansion, saturation), notify the surgeon immediately and prepare for possible reinforcement or return to OR.
* Coughing: Teach him to "splint" a cough if absolutely necessary: place a pillow gently against his chest (not face) and give a small, controlled cough. Better yet, encourage deep breathing and use of an incentive spirometer to prevent the need for vigorous coughing.
* Ambulation/Elimination: Assist him out of bed to prevent falls. Caution him against straining during defecation; administer prescribed stool softeners. Ensure call bell is within reach.
* Pain Management: Administer analgesics on a schedule to keep pain controlled, preventing restlessness and hypertension that can contribute to bleeding.
3. Patient Education & Evaluation: Evaluate his understanding of restrictions. Educate that these precautions (no bending, lifting, straining) will be needed for several weeks. Begin discussing the emotional adjustment and future fitting for an ocular prosthesis.
Nursing Procedure & Medication Flow
Pressure Dressing Check:
1. Perform hand hygiene.
2. Visually inspect dressing from the front and back (if accessible) for any drainage, noting color and amount.
3. Do not remove or loosen the dressing unless ordered.
4. Gently palpate around the edges for swelling or tension. Compare to previous assessment.
5. Document findings: "Pressure dressing to right eye intact, dry, and snug. No visible drainage or swelling noted."Medication Caution: Be vigilant with anticoagulants (e.g., warfarin, clopidogrel). Their use may be held peri-operatively, but the nurse must know the patient's medication history and current orders. Administer antiemetics proactively if nausea is present to prevent vomiting and straining.
A Word from Your Senior Nurse
Caring for a patient after enucleation requires a blend of sharp clinical skills and deep empathy. You are guarding against physical complications while supporting a person who has just experienced a profound loss. That pressure dressing is your first line of defense—treat it with respect. In clinical practice and on the NCLEX, always ask yourself: "What is the worst thing that could happen right now?" For this patient in the first 24 hours, it's bleeding. Your priority actions should always flow from that answer. This mindset transforms you from a task-doer into a thinking, protective nurse.