# 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? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541590 > language: ko > subject: Adult Health ## 문제 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? ## 보기 1. Apply ice packs directly to the surgical site for 20 minutes every hour 2. Encourage the client to lie flat on the affected side to promote drainage 3. Teach the client to avoid bending over or performing Valsalva maneuvers **✔ 정답** 4. Remove the pressure dressing to assess the surgical site every 2 hours **정답: 3** ## 해설 Teaching to avoid bending or Valsalva maneuvers is most appropriate to prevent increased intraocular pressure and protect the surgical site after enucleation. Other options are harmful (ice packs, lying on affected side) or contraindicated (removing dressing). ## 심화 해설 Understanding the Rationale Following enucleation, the primary nursing goal is to prevent complications that could disrupt the surgical site, particularly increased intraocular pressure (IOP) and bleeding. The surgical site is a fresh wound, and any sudden increase in pressure within the orbit can compromise the suture line and lead to hemorrhage or extrusion of the orbital implant. Why the Correct Answer is Option 3 Teaching the client to avoid bending over or performing Valsalva maneuvers is the most appropriate intervention. Both actions cause a rapid and significant spike in intraocular pressure (IOP). A systematic review on the acute effects of resistance exercise, which often involves breath-holding similar to a Valsalva maneuver, confirms that IOP fluctuates and can increase dramatically during such activities [1]. This transient but sharp rise in pressure can stress the fresh surgical wound, potentially causing a wound dehiscence or a retrobulbar hemorrhage. Similarly, bending over increases venous pressure in the head and neck, which is directly transmitted to the orbital vasculature, raising IOP. Educating the client on these restrictions is a critical, evidence-based safety measure. Analysis of Incorrect Options - **Apply ice packs directly to the surgical site for 20 minutes every hour:** While cold application can reduce edema and pain, applying an ice pack *directly* to the surgical site is contraindicated. Direct pressure from the ice pack's weight can increase IOP and disrupt the wound. Any cold therapy would be applied gently and indirectly, but the primary concern 24 hours post-operatively is protecting the site from any pressure, making this option unsafe. - **Encourage the client to lie flat on the affected side to promote drainage:** This position is harmful. Lying flat can increase orbital venous congestion and IOP. More critically, positioning the client on the affected side places direct external pressure on the surgical site, which can cause pain, increase IOP, and disrupt the wound. The standard post-operative instruction is to keep the head elevated to promote venous drainage and reduce edema, and to avoid any pressure on the operative side. - **Remove the pressure dressing to assess the surgical site every 2 hours:** This is a dangerous intervention. The pressure dressing applied after enucleation is a physician-ordered device designed to maintain hemostasis, minimize edema, and support the tissue contours for prosthetic fitting. Removing it prematurely and frequently would disrupt clot formation, dramatically increasing the risk of bleeding and infection. The dressing is typically left undisturbed and is only removed by the surgeon at the designated post-operative visit. Connecting the Evidence to Clinical Practice The rationale for avoiding Valsalva and bending is deeply rooted in the physiology of IOP management. While the systematic review on lifestyle modifications in glaucoma highlights the long-term importance of controlling IOP to prevent optic nerve damage, the same principle applies acutely after surgery . Any activity that spikes IOP threatens the structural integrity of the healing eye socket. The body of perioperative nursing research, such as studies on corneal surgery, reinforces that meticulous attention to preventing pressure on the operative site and educating the patient on activity restrictions are core components of successful post-operative outcomes . The nurse's role is to translate this understanding into clear, actionable teaching: the client must be instructed to avoid lifting heavy objects, straining during bowel movements, coughing forcefully, sneezing with a closed mouth, and bending at the waist. These are all forms of a Valsalva maneuver that can generate a dangerous spike in IOP, as demonstrated in resistance exercise studies where IOP fluctuates with exertion [1].References (research sources) - [1]Acute Effects of Resistance Exercise on Intraocular Pressure in Healthy Adults: A Systematic Review.Meta-analysis/systematic reviewHackett DA, Li J, Wang B, Way KL, Cross T, Tran DL. (2024) · DOI: 10.1519/jsc.0000000000004668 ## 임상 시나리오 Post-Enucleation Safety MeasuresPreventing Intraocular Pressure Spikes Following enucleation, the primary goal is to protect the surgical wound from increased intraocular pressure (IOP) and bleeding. Any sudden pressure surge can cause wound dehiscence or retrobulbar hemorrhage. Instruct the client to strictly avoid bending over at the waist and performing Valsalva maneuvers (e.g., straining during bowel movements, coughing forcefully, lifting heavy objects). These actions cause a rapid, significant IOP spike. CautionNever apply direct pressure to the orbit, including ice packs. Do not remove the surgeon's pressure dressing, which is typically maintained for 24 to 48 hours. Position the client on their back or non-operative side. ## 핵심 개념 - **Enucleation** — Surgical removal of the entire eyeball, leaving the orbital muscles and surrounding tissues intact. - **Valsalva Maneuver** — A forceful attempted exhalation against a closed airway, which significantly increases intrathoracic and intraocular pressure. - **Intraocular Pressure (IOP)** — The fluid pressure inside the eye; a sudden spike can compromise a fresh surgical wound and cause hemorrhage. - **Retrobulbar Hemorrhage** — Bleeding in the space behind the eye, a serious postoperative complication that can compress the optic nerve. - **Wound Dehiscence** — Partial or complete separation of the layers of a surgical wound. ## 같은 주제 문제 - [A nurse is caring for a client who underwent enucleation of the right eye 24 hours ago. 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