# A nurse is caring for a client who underwent emergency retinal detachment repair surgery 6 hours ago. Which assessment finding would require the nurse's immediate intervention?

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> subject: Adult Health

## 문제

A nurse is caring for a client who underwent emergency retinal detachment repair surgery 6 hours ago. Which assessment finding would require the nurse's immediate intervention?

Post-operative retinal detachment repair assessment priorities

## 보기

1. Client reports sudden onset of severe eye pain with nausea and vomiting **✔ 정답**
2. Client has mild drainage from the surgical site with slight redness
3. Client complains of blurred vision in the affected eye
4. Client reports feeling dizzy when changing positions

**정답: 1**

## 해설

Sudden severe eye pain with nausea/vomiting indicates increased intraocular pressure, a serious post-op complication requiring immediate intervention. Mild drainage, blurred vision, and dizziness are less urgent.

## 심화 해설

Understanding the Clinical Priority

The client is in the immediate postoperative period following emergency retinal detachment repair. The nurse's primary focus is monitoring for complications that can threaten vision or indicate a surgical emergency. Among the assessment findings, the ability to distinguish between expected postoperative symptoms and signs of a serious complication is critical.

Analyzing the Correct Answer

The finding that requires immediate intervention is the client's report of sudden onset of severe eye pain with nausea and vomiting. This cluster of symptoms is a classic and alarming presentation for acute angle-closure glaucoma or a significant, rapid rise in intraocular pressure (IOP). In the context of retinal surgery involving silicone oil tamponade, as discussed in the context of complex detachments , a sudden IOP spike is a known and serious complication. The oil can migrate anteriorly, blocking the trabecular meshwork and obstructing aqueous humor outflow. The resulting high pressure can cause intense pain, corneal edema, and a vagal response leading to nausea and vomiting. This constitutes an ocular emergency because sustained elevated IOP can rapidly and permanently damage the optic nerve, leading to irreversible vision loss. The nurse must notify the surgeon immediately for urgent IOP-lowering interventions.

Analyzing the Incorrect Answers

Option 2: Mild drainage and slight redness at the surgical site are common and expected findings 6 hours postoperatively. The inflammatory response to surgical trauma causes some serous or serosanguinous drainage and conjunctival injection. This does not indicate an acute complication requiring immediate intervention, though ongoing monitoring is necessary.

Option 3: A complaint of blurred vision is an anticipated finding after retinal detachment repair. The eye is recovering from significant intraocular manipulation, and the presence of an intraocular gas bubble or silicone oil tamponade will profoundly affect the refractive media, causing severely blurred vision . Postoperative inflammation, corneal edema, and the reattachment process itself also contribute to poor visual acuity in the immediate period. This is not an unexpected emergency.

Option 4: Dizziness upon changing positions is a non-specific symptom that can be related to the lingering effects of anesthesia, preoperative fasting, or vestibular disturbance. While the nurse should implement safety measures to prevent falls, this finding is not directly indicative of a vision-threatening postoperative complication and is a lower priority than symptoms of acute IOP elevation.

Pathophysiology and Clinical Reasoning

The surgical repair of a rhegmatogenous retinal detachment (RRD) aims to close retinal breaks and reattach the neurosensory retina to the retinal pigment epithelium . This often involves pars plana vitrectomy (PPV) with the use of a tamponade agent like gas or silicone oil to hold the retina in place [1,2]. The postoperative period carries risks such as elevated IOP, re-detachment, infection, and proliferative vitreoretinopathy (PVR), a process where cellular membranes contract and re-detach the retina . While PVR is a major cause of late surgical failure, acute IOP elevation is an immediate threat. The nurse's assessment must prioritize the rapid identification of this complication. A sudden, severe pain is the hallmark of a rapid pressure rise, distinguishing it from the mild-to-moderate discomfort expected after surgery. The accompanying nausea and vomiting are a vagal response to the intense pain and high pressure, a key clinical clue that elevates this finding to the highest priority.

## 임상 시나리오

Clinical Scenario

A 62-year-old client is 6 hours post-emergency retinal detachment repair with silicone oil tamponade. The client suddenly reports severe, throbbing right eye pain rated 10/10, accompanied by nausea and vomiting. The eye appears cloudy on gross inspection.

Immediate Nursing Actions

- Notify the surgeon immediately; this is an ocular emergency.

- Keep the client NPO in case urgent surgical intervention is needed.

- Administer prescribed antiemetics to prevent vomiting, which further increases IOP.

- Position the client with the head elevated 30-45 degrees to promote aqueous drainage.

- Avoid any pressure on the affected eye and do not instill any drops without a specific order.

Clinical Pearls

- The triad of severe eye pain, nausea/vomiting, and a cloudy cornea is a hallmark of an acute IOP spike, often from pupillary block by the oil bubble.

- Sustained IOP elevation can cause irreversible optic nerve damage within hours, making timely intervention critical.

- Expected postoperative findings include mild discomfort, slight bloody drainage, and blurred vision, which do not require immediate intervention.

## 핵심 개념

- **Acute Angle-Closure Glaucoma** — A sudden blockage of the eye's drainage system causing a rapid, dangerous increase in intraocular pressure, presenting with severe eye pain, nausea/vomiting, and blurred vision.
- **Intraocular Pressure (IOP)** — The fluid pressure inside the eye; a sudden spike post-retinal surgery can compress the optic nerve and cause irreversible vision loss if not treated immediately.
- **Silicone Oil Tamponade** — A viscous oil injected into the eye during retinal detachment repair to hold the retina in place; it can migrate and block fluid outflow, leading to a pressure spike.

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