A 55-year-old patient has been diagnosed with ocular melanoma in the right eye. The oncologist has recommended enucleation as the treatment of choice. Which nursing intervention is most appropriate when preparing this patient for surgery?
1Instruct the patient to avoid all eye movements for 24 hours before surgery
2Provide emotional support and discuss postoperative prosthetic eye options✓ 정답
3Apply bilateral eye patches to prevent light exposure
4Administer prophylactic antibiotics to both eyes
해설
Enucleation causes permanent vision loss and body image changes, making emotional support and education about prosthetic options the priority. Other interventions are either incorrect or less critical preoperatively.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a patient undergoing enucleation (surgical removal of the eye) for ocular melanoma. The core theme is psychosocial preparation and patient education for a procedure that results in permanent vision loss and significant alteration in body image. Preoperative care must address the profound emotional and psychological impact alongside physical preparation.
Answer Rationale: Key Point! The most appropriate intervention is Providing emotional support and discussing postoperative prosthetic eye options. Enucleation is a life-altering surgery. The nurse's role is to help the patient cope with the impending loss, manage anxiety, and prepare for the future. Discussing the availability and care of a prosthetic eye (ocular prosthesis) provides hope, helps normalize the postoperative appearance, and is a crucial part of informed consent and preoperative teaching.
Distractor Analysis:
Watch out for confusion! Option ①: "Instruct the patient to avoid all eye movements..." is incorrect and physiologically impossible. The nurse might instruct the patient to avoid rubbing the eye, but voluntary eye movement cannot be completely stopped.
Option ③: "Apply bilateral eye patches..." is incorrect. Preoperatively, there is no medical indication to patch the unaffected eye. Postoperatively, only the surgical site will be patched or covered with a shield.
Option ④: "Administer prophylactic antibiotics to both eyes..." is incorrect. Prophylactic antibiotics, if ordered, would typically be administered systemically (IV or oral) to prevent surgical site infection, not as topical drops to the non-surgical eye. This action is not a standard or priority preoperative intervention.
Related Concepts: This scenario integrates surgical nursing, oncological nursing, and psychosocial nursing. Key related areas include grief and loss, body image disturbance, patient education for major surgery, and postoperative care for ocular procedures (e.g., preventing increased intraocular pressure, infection control).
Concept Summary
Concept
Key Points
Enucleation
Surgical removal of the eyeball, leaving eye muscles and orbital contents intact. Indicated for intraocular tumors (melanoma), severe trauma, or painful blind eye.
Ocular Melanoma
The most common primary intraocular cancer in adults. Treatment depends on size/location and may include radiation, laser, or enucleation.
Psychosocial Preparation
Priority for procedures causing permanent disability or disfigurement. Involves active listening, validating feelings, providing realistic information, and fostering hope.
Ocular Prosthesis
Custom-made artificial eye. Fitted weeks after surgery once swelling subsides. Patient education includes insertion, removal, and cleaning procedures.
Side-by-Side Comparison!
Procedure
Definition
Nursing Focus
Enucleation
Removal of the entire eyeball.
Psychosocial support, body image, prosthetic eye care, monitoring for infection/hemorrhage.
Evisceration
Removal of the eye's contents, leaving the scleral shell.
Similar psychosocial support. May have a lower risk of infection spread and allows for a motility implant.
Exenteration
Removal of the eyeball and all orbital contents (muscles, fat, etc.).
Extensive wound care, major body image disturbance, potential for skin grafting, long-term rehabilitation.
Anatomy, Physiology & Pharmacology Points
Orbital Anatomy: The orbit contains the eyeball, extraocular muscles, optic nerve, blood vessels, and fat. Enucleation involves severing the optic nerve and extraocular muscles.
Body Image: The eyes are central to facial identity and non-verbal communication. Loss can profoundly impact self-esteem and social interaction.
Post-op Care: Key goals are to prevent infection, manage pain, and prevent complications like orbital hemorrhage (which can cause pain and proptosis of the prosthesis).
Memory Tips
Acronym: S.E.E. for Enucleation Nursing Priorities: Support (psychosocial), Educate (prosthesis, procedure), Evaluate (for complications post-op).
Think: "Eye removal = Emotional storm." The physical prep is standard; the unique, high-priority nursing action is addressing the emotional and educational needs.
High-Frequency NCLEX Topics
The NCLEX frequently tests the nurse's ability to prioritize psychosocial and emotional care for patients undergoing disfiguring surgeries (mastectomy, colostomy, amputation, enucleation). The correct answer often involves support, teaching, and promoting coping strategies, not just technical tasks.
Watch Out for Question Variations!
Postoperative Priority: The question could shift to the first action post-enucleation (e.g., assess pain, check the dressing for bleeding, maintain safety due to monocular vision).
Patient Statement: "Which patient statement indicates effective coping?" (e.g., "I'm sad, but I'm learning how to care for my new artificial eye.").
Complication Identification: Recognizing signs of orbital infection (increased pain, fever, purulent drainage) or hemorrhage (sudden severe pain, bulging dressing).
Nursing Clinical Practice GuideClinical Scenario: Mr. Johnson, 55, is admitted for scheduled right eye enucleation. He is quiet, avoids eye contact, and tells you, "I just want to get this over with. I can't bear the thought of looking in the mirror afterwards."
Nursing Intervention Strategy:
Assessment: Perform a psychosocial assessment. Use open-ended questions: "Tell me what you're most concerned about regarding the surgery." Assess support system, coping mechanisms, and understanding of the procedure and outcomes.
Nursing Diagnosis: Anticipatory Grieving related to impending loss of eye and vision; Disturbed Body Image related to change in appearance secondary to enucleation; Deficient Knowledge regarding postoperative course and prosthetic management.
Planning & Implementation:
Emotional Support: Acknowledge his feelings. "It's completely understandable to feel this way. This is a significant change." Arrange a visit from a peer supporter (someone who has undergone enucleation) if available.
Education: Explain the surgical process simply. Show pictures or models of ocular prostheses. Explain that a temporary conformer will be placed initially, followed by a custom-made prosthesis in 4-8 weeks. Discuss that the artificial eye will have realistic movement.
Collaboration: Involve social work or a clinical psychologist. Ensure the ocularist (prosthesis maker) is scheduled for a postoperative consult.
Evaluation: The patient verbalizes concerns, asks questions about the prosthesis, and identifies one coping strategy. He agrees to speak with a counselor.
Patient Safety and Precautions:
Ensure informed consent is obtained, confirming the patient understands the procedure is irreversible.
Postoperatively, instruct the patient to avoid activities that increase intraocular pressure: bending at the waist, heavy lifting, straining, vomiting (administer antiemetics as needed).
Teach signs of infection to report: increased pain, redness, swelling, fever, or purulent discharge.
Nursing Procedure & Medication FlowPreoperative Care:
1. Administer preoperative medications as ordered (may include systemic antibiotics, sedatives).
2. Verify NPO status.
3. Key Patient Teachings:
- What to expect when waking up (eye patch/shield).
- Importance of not rubbing or putting pressure on the eye.
- Use of prescribed analgesic and antibiotic eye ointments (post-op).
- Safety measures due to loss of depth perception and peripheral vision on that side.
A Word from Your Senior Nurse
"Nursing care for procedures like enucleation truly defines holistic practice. Your technical skills are important, but your ability to provide compassionate, forward-looking emotional support is what the patient will remember. When you educate a patient about a prosthetic eye, you're not just giving information—you're helping them rebuild their sense of self and hope for life after surgery. On the NCLEX and at the bedside, never underestimate the power of psychosocial care. It's always a priority when the intervention changes how a person sees themselves—literally and figuratively."
Enucleation — The surgical removal of an entire eyeball, typically performed for intraocular tumors, severe trauma, or a blind, painful eye.
Ocular Melanoma — The most common primary malignant intraocular tumor in adults, arising from melanocytes in the uvea (choroid, ciliary body, iris).
Ocular Prosthesis — A custom-made artificial eye designed to replace a missing natural eye, fitted after enucleation or evisceration surgery.
Body Image Disturbance — A nursing diagnosis defined as confusion in the mental picture of one's physical self, which can occur after surgeries that alter appearance, such as enucleation.
Anticipatory Grieving — The intellectual and emotional responses exhibited by an individual before an expected significant loss, such as the loss of a body part or function.