Corneal Transplant

My case study will critically analyse and evaluate a patient I cared for in an ophthalmic day surgery. This case study will be based on an episode of care for a patient with complex care needs during a long day shift. The patient came to the hospital for surgery to the left eye due to trauma caused by a fall in her home.
The operation that performed was Left keratoplasty and penetrating graft. For the purpose of confidentiality and anonymity as part of the NMC Code of Professional Conduct (2008), my chosen patient will be referred to as Mrs Y. A summary of the patient is described in appendix 1. Also attached as an appendix 1, is a signed verification slip by my mentor at the placement area stating that this is a true account of a patient I have participated in caring for.
In this essay, I will discuss the relevant pathophysiology and pharmacology related to the patient??™s condition and the rationale for the given care. This will be done by using relevant supporting literature, government/clinical guidelines and hospital policies. I will also discuss the significance of the roles of the various MDT members that were involved in the care of my chosen patient.
I will then generate an actual care plan that clearly identifies the nursing problems of the patient from which a validated nursing diagnosis will be initiated. This will be followed by goals outlined for each nursing diagnosis consisting of measurable behaviours of my patient. Interventions will then be outlined giving supporting rationale which will be presented for each nursing intervention. This will be attached as Appendix 2.
In the concluding part of the essay, I will evaluate the effectiveness of the care that I gave to my patient by discussing the outcome for the patient with regards to aspects of the care that well and why. I was introduced to Mrs Y who was admitted pre-operatively to gain her consent for me to participate in her care post-operatively. The NMC code of professional conduct states that you are accountable for your own practice (NMC, 2004).Whatever the level of your involvement, you must be satisfied that participants have given informed consent to take part in the research study before you act. Therefore, it was my responsibility as a student nurse to gain the consent of the patient. I explained to her that, it was part of a case study for my assignment. She gave me her consent and was willing to answer any questions I might have to help with manage her care.
Mrs Y came for an emergency procedure for corneal perforation to the left eye. This involved the full-thickness replacement of bottom of the corneal tissue. This is known as Penetrating Keratoplasty. This was as a result of trauma from a fall at her home.
Sometimes the cornea is damaged after a foreign object has penetrated the tissue, such as from a poke in the eye, which is the case of Mrs. Y. According to the National Eye Institute, situations like these can cause painful inflammation and corneal infections called keratitis. The avascular cornea is one of the most sensitive tissues in the body with the highest density of sensory neurons just below the epithelium. (Corbett, Rosen and Bratt 1999).
These infections can reduce visual clarity, produce corneal discharges, and perhaps erode the cornea. Corneal infections can also lead to corneal scarring, which can impair vision and may require a corneal transplant.
According to Denniston and Murray (2009), Keratoplasty is also known as corneal transplant, which is an operation used to remove a damaged cornea and replace it with healthy corneal tissue from the eye of a suitable donor. A corneal transplant can improve sight and relieve pain in a damaged eye as in the case of Mrs Y. This is the commonest of all transplant procedures.
The National Institute for Health and Clinical Excellent (NICE) published its guidelines in July 2007 for corneal transplants. The guide from NICE advocated that the current evidence on the safety and efficacy of corneal transplant appears adequate to support this procedure. However, it also advocated that normal arrangement of consenting, audits and clinical governance must be in place to allow for continuous monitoring for safety and efficacy.
Mrs Y was returned to the recovery room one and half hours after surgery. Caring for my patient post-operatively required for me to use the five steps in the nursing process. The nursing process is ???An organised, systematic and deliberate approach to nursing with the aim of improving standards in nursing care??? (Rush S, Fergy S & Weels D 1996).Nursing knowledge is used throughout the process to formulate changes in approach to the patients changing condition. During the process, nurses use this knowledge to identify problems and changes that are occurring to the patient. Caring for a patient requires the nurse to communicate with the patient to determine how they are feeling and gain the results of implemented care from the patient. Communication is necessary in nursing profession and practice to develop a therapeutic relationship with patient (Hewison 2004).
Throughout this process, I will use the Roper, Logan, Tierney model (1996), Activities of Daily Living which centres on the patient as an individual and his relationship with the five components of the model: Physiological, psychological, sociocultural, politico economicand environmental.
Mrs Y presented with some obstructive disorder upon arrival into recovery. It was observed that, she appeared to have cyanosis, dyspnoea with the use of accessory muscles when breathing and a productive cough. Checking her vital signs presented a respiratory rate of 24bpm. From further nursing assessment, it was found out that Mrs Y has a past medical history of asthma. This is generally considered to be a chronic obstructive airway disease because it causes resistance or obstruction to exhaled air. Asthma is a chronic disorder of airway inflammation and bronchial hyperactivity characterised symptomatically by cough, chest tightness, shortness of breath, increased sputum production and wheezing as a result of decreased airflow. (Jual, L. 2009. Pp. 118).
There are two types of asthma; Intrinsic and extrinsic. Mrs Y. was diagnosed to have the intrinsic type which according to Galbraith, Bullock, Manias, Hunt and Richards (1999), unlike the extrinsic type, is not triggered by allergens but is more related to an alteration in autonomic nervous system function. Just like Mrs Y who developed asthma 25 years ago, it is more common in people who develop asthma later in life. In intrinsic asthma, the airways are considered hyperactive as the parasympathetic stimulation dominates causing bronchoconstriction and various mucus production. Her current medications included inhaled corticosteroids- beclomethasone and beta 2-agonist salbutamol.
This is an anti-inflammatory drug which isthe most effective and commonly used long-term control medications for asthma. They reduce swelling and tightening in the airways.Corticosteroids do not generally cause serious side effects. When they do occur, side effects can include mouth and throat irritation and oral yeast infections. (www.mayoclinic.com). It was very clear to us from the pre-operative notes that, Mrs Y voiced out anxiety and stress about the surgery which could have been a cause of her current condition.
Salbutamol, an inhaled short-acting beta-2 agonist was administered to Mrs Y via the use of a nebuliser. Salbutamol works by acting on receptors in the lungs called beta 2 receptors. When salbutamol stimulates these receptors it causes the muscles in the airways to relax. This allows the airways to open. (www.netdoctor.co.uk). Salbutamol is most commonly taken using an inhaler device. Inhaling the medicine allows it to act directly in the lungs where it is needed most. It also reduces the potential for side effects occurring in other parts of the body, as the amount absorbed into the blood through the lungs is lower than if it is taken by mouth.
When administering the inhalation therapy, we ensured that Mrs Y was sitting upright. This position aids the expansion of the lungs and provides greater surface area of lung tissue where the therapy can act. We also provided Mrs Y with respiratory therapy by posture drainage and percussing. These technique help to loosen and mobilise secretions.
The effect of the medication administered was monitored as well as her vital signs. This was to determine amount and characteristics of bronchial secretions immediately following therapy. Tachycardia is an adverse effect of beta 2-agonists therefore we monitored her pulse rate as per regime. Being a student nurse, all pharmacological and therapeutic interventions I carried out was under the supervision of my mentor and/or trained staff as per NMC Code of Professional Conduct (2006) as well as the trust policy.
Each registered nurse is accountable for his/her practice. This practice includes preparing, checking and administering medications, updating knowledge of medications, monitoring the effectiveness of treatment, reporting adverse drug reactions and teaching patients about the drugs that they receive (OShea 1999).
Mrs Y was provided with adequate hydration to decrease the thickness of bronchial secretions. Because Mrs Y has a past medical history of type 2 diabetes, we monitored her blood glucose levels as bronchodilators can produce hyperglycaemia.Oxygen therapy was administered through nasal cannula ( to prevent feeling of suffocation) as prescribed to treat her hypoxia with regular oxygen saturation checks until she was able to maintain an oxygen saturation between 95-100% on room air.
As anxiety and fear can aggravate the condition, we provided a calm atmosphere and reassuring attitude throughout Mrs Y??™s care. After nearly two hours of nursing intervention, our goal was met through maintenance of airway patency and reduction in congestion. Mrs Y was instructed on the importance of stress management to prevent this condition from resurfacing in the future.
In accordance with the British Thoracic Society, the long term aims in asthma management involves abolishing the symptoms, maintaining the best lung function, preventing the development of permanent lung impairment and avoiding unnecessary drug side effects. After an initial assessment, the person with asthma must maintain regular contact with a skilled health professional for follow up, support and education. Therefore, upon discharge, a referral was made to the specialist respiratory district nurse to visit Mrs Y for support and education.Apart from the nurses, the other MDT members associated with Mrs Y??™s care were; consultant surgeon, anaesthetist and pharmacist.
About an hour after Mrs Y was returned to the ward from recovery post-operatively, she complained of pain in and around the operated eye.With the help of my mentor, we performed a comprehensive assessment of pain to gain an accurate picture of Mrs Y??™s pain experience, which included; direct observation to assess body language, using the pain assessment tool 0-3 where 3 is severe pain, 2 is moderate pain, 1 is mild pain and 0 is no pain, interviewing Mrs Y discussing her interpretation of the cause of pain, exacerbating factors and their coping strategies. These approaches should not be used in isolation but should not be holistic, a ???combination of coordination, communication and liaison??™. (Munafo & Trim 2000).
Pain is a subjective experience and must be described by the patient in order to plan effective treatment.Mrs Y described her pain as sharp in the eye and a throbbing pain in the left temple, and scored the pain a 2. We obtained her vital signs; Bp- 145/87, pulse- 91, temp.- 36.7 degree celsius in order to compare with the subsequent observations.
We noticed that she was tachycardic but the other vital signs were within her normal range, and recorded the information. We then assessed the condition of the eye to check if there is any bleeding from the wound site or any abnormal swelling or inflammation. Everything was normal in accordance to the type of surgery performed.
The first nursing intervention was to help Mrs Y to identify effective pain-relief measures suitable for her. This is because the patient has the most intimate knowledge of his or her pain and the effectiveness of pain measures e.g. relaxation, distraction or medication.
Mrs Y wanted pharmacological intervention for the pain so we ensured that the appropriate medication had been prescribed on the drug chart and also, the post-operative medications such as the eye drops had been dispensed by the pharmacy.
We administered the medication as prescribed and in accordance with the trust policy and procedures. According to Galbraith, et al (1999), a nurse must practice within the policies and procedures of the hospital or community trust, as well as follow the legal framework of government legislations.
According to the NMC (2006), the administration of medicine is an important aspect of the professional practice of persons whose names are on the council??™s register. It is not solely a mechanistic task to be performed in strict compliance with the written prescription of a medical practitioner. It requires thought and the exercise of professional judgement.
She had been prescribed 1gram of paracetamolorally PRN as stated on the drug chart. Paracetamol works as a painkiller by affecting chemicals in the body called prostaglandins. Prostaglandins are substances released in response to illness or injury. Paracetamol blocks the production of prostaglandins, making the body less aware of the pain. (NHS Choices). According to the BNF (2010), the side effects of paracetamol are rear, but rashes, blood disorders, including thrombocytopenia have been reported. Pharmacologic therapy, such as mild analgesic, maybe needed to provide adequate pain relief.
The most common reason for unrelieved pain is failure to routinely assess pain and pain relief. Many clients silently tolerate pain if not specifically asked about it. We evaluate the effectiveness of analgesic at regular, frequent intervals after each administration and especially after the initial doses, also observing for any signs and symptoms of untoward effects such as drowsiness. The analgesic dose may not be adequate to raise the patient??™s pain threshold or may be causing intolerable or dangerous side effects or both. On-going evaluation will assist in making necessary adjustments for effective pain management.
Upon evaluation after half an hour of administering the prescribed analgesia, Mrs Y described her pain as ???completely gone???. Her vital signs when checked again were within her normal range and her pulse rate was down to 62bpm. Therefore no referrals had to be made to the pain team or the anaesthetist.
On the contrary to the actual problems elaborated above, the next nursing care I will elaborate on is a potential problem of risk for infection related to increased susceptibility to surgical site post-op.The nursing goal that was developed was that Mrs Y will exhibit healing of surgical site with no symptoms of infection.
Because of the fact that Mrs Y is elderly and diabetic, it is important to promote wound healing by encouraging a well-balanced diet and adequate fluid intake. Optimal nutrition and hydration improves overall good health and this promotes the healing of any surgical wound. According to Shaw, Lee and Stollery (2010, p151), with a keratoplasty surgery, the first post-operative care dressing must be carried out by the nurse. We must ensure that the graft is in place, the sutures intact and the anterior chamber is formed. Aqueous humour may have leaked through the suture line, causing a flat anterior chamber. Instil antibiotic, steroid and mydriatic eye drops as prescribed. I participated in doing these for Mrs Y under supervision of my mentor.
The healing process is highly dependent on specific communication and precise interaction between various cell types such as epidermal cells. (Cherry, Hughes, Ferguson and Leaper 2001). The ophthalmic patient may have other diseases such as diabetes or arthritis as present in Mrs Y as these conditions have ocular manifestations.
Under supervision, I instructed Mrs Y to keep a patch over the affected eye until the first eye drops are started 4-6 hours after surgery. Wearing an eye patch promotes healing by decreasing the irritative force of the eyelid against the suture line. Use aseptic technique to instil eye drops such as; teach patient the importance of hand washing before eye care; hold dropper slightly away from the eye so as not to touch the eye lashes; when instilling, avoid contact between the eye, the drop and the dropper and teach the technique to the client and the family members.
Aseptic technique minimises the introduction of microorganisms and reduces the risk of infection as hand washing is the most effective method of preventing infection. Education of Mrs Y must also include having a clear knowledge of the symptoms of graft rejection such as reduced vision, red eye and pain, and an understanding of relevance of seeking prompt treatment.
Also, because of the short hospitalisation, we must teach Mrs Y and her relatives to assess for signs and symptoms of infection such as reddened, oedematous eyelids; prominent blood vessels; drainage on eyelid and eyelashes; elevated temperature (pyrexia) and decreased visual acuity
Early detection of infection enables prompt treatment.
Provide patient with instructions and education on: Medication storage e.g. antibiotic eye drops must be kept in fridge, dosage and frequency, cleaning the affected eye correctly. Correct usage and storage of medication as well as proper eye care helps to minimise or prevent the risk of infection.
I can conclude that, all my aspects of care that I demonstrated went well and each one of my sets set in the care plan was met. Mrs Y was able to maintenance of airway patency and reduction in congestion within two hours of nursing intervention after experiencing airway obstruction. She was also pain-free and comfortable within 30 minutes of complaining of pain. A referral was made to the district nurses upon Mrs Y??™s discharge to help with distilling her eye drops as well as health education on eye care. REFERENCES
British Medical Association (2010) British National Formulary. London, BMA and Royal Pharmaceutical Society of Great Britain.Cherry, G.W., Hughes, M.A., Ferguson, M.W.J. and Leaper, D.J (2001). Wound Healing In: Morris, P.J. and Woods, W.C. (eds) Oxford Textbook of Surgery. Vol.2. Oxford University Press: Oxford.Corbett, M.C., Rosen, E.S. and O??™Bratt, D.P.S. (1999) Corneal Topography: Principles and Applications. BMJ Books: London.Denniston, A., Murray, P. (2009) Oxford Handbook of Ophthalmology. (2ndedn) Oxford University Press: Oxford.Galbraith, A., Bullock, S., Manias, E., Hunt, B. and Richards, A. (1999) Fundamentals of Pharmacology: A text for Nurses and Health Professionals. Addison Wesley Longman.Hewison, A. (2004) Management for nurses and health professional: theory into practice. Oxford. Blackwell science.Lynda, J. and Moyet, C. (2009). Nursing Care Plans and Documentation: Nursing Diagnosis and Collaborative Problems. (5thedn) Lippincott: Williams and Wilkins.Munafo, M. And Trim, J. (2000). Chronic Pain: A Handbook for Health Care Professionals. Butterworth Heinmann: Oxford.NMC.[Homepage of the UK Nursing and Midwifery Council].[Online] 2006. Available from http://www.nmc-uk.org [Assessed 10/10/2010]Nursing & Midwifery Council, (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. NMC: London.NMC. [Homepage of Nursing and Midwifery Council]. [Online] 2004. Accountability. Available from http://www.nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Accountability/. [Assessed 06/10/2010]NHS [Homepage of the National Health Service]. [Online] 2009.Available from http://www.nhs.uk/conditions/Painkillers-paracetamol/Pages/Introduction.aspx. [Assessed on 04/10/10]NEI. [Homepage of National Eye Institute]. [Online].Available from http://www.nei.nih.gov/health/cornealdisease/#3.[Assessed on 03/11/2010].O??™Shea E (1999) Factors Contributing to Medication Errors: A Literature Review.Journal of Clinical Nursing. 8, 5,496-503.Roper, N., Logan, W.W., Tierney, A.J. (1996)The Elements of Nursing: A model for nursing based on a modelfor living. (4thedn). London: Churchill LivingstoneShaw, M., Lee, A. and Stollery, R. (2010) Ophthalmic Nursing. (4thedn). BlackwellThe Nursing Process.[Online]. (2008). Available from www.thenursingprocess.com. [Assessed on 02/10/2010]The Mayo Clinic [Online] (2008).Available from http://www.mayoclinic.com/health/asthma-medications/AP00008. [Assessed on 11/10/2010].

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