Acetazolomide Case Study The following Case Study willfocus on a routine Cataract patient admitted within our Hospital, It willexplore the benefits of initial assessment between the patient and the nursesubsequentcare plans developed. Itwill discuss the use of Acetazolomide tablet in Cataract surgery and if thisindeed is beneficial to the patient. This paper will use evidence basedinformation to evaluate the use of Acetazolomide tablets and weather they helpin cataract surgery to establish good practice with good holistic patientcentred care at the foremost. For the purpose of this Case Study and toprotect the patient’s confidentiality all names and places will be changed inaccordance with the Nursing Midwifery Council (NMC2008.) And data protection act (DOH 1998).
Cataract Surgery although notinclusive is primarily performed on older patients who may have other coremorbidities which can include arthritis and poor mobility along with limitedmovement of limbs this could impact on the patient administering necessarydrops, they may also have social issues which can include living on their ownand having no one to help with administration of medication. In accordance with(Crouch and Meurier, 2005) “The purpose of the nursing assessment is to get acomplete picture of the patient and how they can be helped. An effectiveassessment will provide the nurse with information on the patient’s background,lifestyle, family history and the presence of illness or injury “.Duringassessment it is as important to be integrating discharge planning for thepatient to ensure patients return home into the community with the appropriatecare and support (RCN 2004) Good nursing holistic assessment is central to agood discharge (Atwal 2002), it needs to be centred around the patient within alifestyle specific manner this will include the ability to be able to continuetheir compliance of self care once theyhave left the hospital setting. Mrs Smith is an 83 year old patient who is beingadmitted to the Hospital for Cataract Surgery to her left eye. Mrs Smith haspreviously undergone cataract surgery to her right eye 4 months earlier;unfortunately for Mrs Smith her original surgery had encountered post surgerycomplications, although in accordance with (NHS Choices,2016) The risk of serious complications developing as aresult of cataract surgery is very low.
Most common complications are treatableand don’t have a long-term impact on your vision. For Mrs Smith this has lefther feeling very vulnerable and frightened for her forthcoming surgery.Although vision is now improving with her right eye it has been a verystressful time. A study by (Wetsch et al., 2010) underpinnedthe reality of day case surgery stress within a group of patients.
And inrelation to post procedure complications after her prior surgery it is understandablethe anxiety and stress Mrs Smith will be feeling. CaseStudyAs previously stated Mrs Smith isan 83 year old lady attending the hospital for Cataract Surgery she is inrelatively good health apart from Hypertension which is being treated withmedication, border line for Diabetes 2 which Mrs Smith is managing to controlwith a good diet she also suffers with poor mobility due to Arthritis. HoweverMrs Smith is suffering with extreme anxiety and stress for her up and comingsurgery as previously stated this is due to complications suffered from herprevious cataract surgery on her right eye, the results of which had left herwith a build up of intraocular pressure and the fear of losing her sight. Foradmission of Mrs Smith I shall be using nursing model Roper et al (2000) basedon the Daily Activities of living I feel this is a appropriate model of nursingas it takes a Holistic approach to nursing care and will be the care planfollowed throughout the stay of Mrs Smith. My initial assessment starts with goodcommunication, (Kitson, 2004) states the nurses needgood communication skills to be able to engage with patients efficiently topromote a therapeutic relationship. Whereas (Morris and Morris 2010) argue thatit is a complex dynamic as the quality of the relationship between the nurseand patient will be influenced by each party’s ability to communicate. Howeverthere still remains much debate about the effectiveness of using these modelswith arguments that individualized care can be compromised by fitting patientsinto a set structure (Kearney 2001, McCrae 2012).
With this in mind it isimportant nurses take a pragmatic approach when assessing a patient and utilizeframeworks appropriate for the area of practice. Good Assessment is afundamental part of the nursing process Accordingto (Heaven & McGuire, 1996) “it is a systematic, deliberate and interactiveprocess that underpins every aspect of nursing care it is the process by whichthe nurse and patient together identify needs and concerns and is seen as thecornerstone of individualized care”. It is the collecting; validating andclustering of information it is paramount to enable the planning,implementation and evaluation of a patients care.
After performing the originalassessment you are able to establish the patient’s baseline and start todiagnose and develop a care plan. Assessment decreases thepotential for, or the severity of, chronic conditions and helps the individualto gain control over their health through self-care (RCN 2004).This is especiallyparamount in today’s rapidly changing healthcare system, as nurses take on moreadvanced roles, working across boundaries and setting up new services to meetpatients needs (DH2006a).
As stated above good assessment is essential to thenursing process and as a result it is paramount that I enable Mrs Smith to giveme a full account of her previous surgery and her post procedure complicationsto give me a greater understanding of how this affected Mrs Smith. It is onlywith all this information that I can tailor the care plan to ensure goodholistic care is delivered with Mrs Smith at the centre of all decisions.Following the initial assessment and completion of care pathway, inclusive ofbase line observations, in accordance with the (Nice, 2007) guidelines that giveclear recommendations for observations recorded on admission, and after gatheringa full previous medical history from Mrs Smiths it was apparent that after herprevious surgery she unfortunately developed a build up of intraocular pressurein her eye.
Although it is normal for cataract surgery to make achange in the eye pressure it is not possible to predict if this pressure will raise,fall or maintain levels after the surgery (Glaucoma Research Foundation 2017).For Mrs Smith this was a very worrying time with her previous medical historyof Diabetes, and the fear of developing glaucoma and losing her sight was veryreal. It was important for Mrs Smith that this information played a vital rolein developing a holistic based care plan during her stay within the hospital.
After initial assessment and collection of patienthistory it was paramount that before surgery took place, involvement of thesurgeon would be needed to highlight the issues raised to ensure Mrs Smithreceives high quality care. (Kings College, 2008) states this should bedelivered to the patients in order to achieve a good experience within theircare. Nursing advocacy helps play a key role in keeping patients safe whilst inthe hospital setting and is a fundamental part of the nursing and midwiferycode (NMC, 2015). Acting as my patientsadvocate I raised my concerns with the Consultant giving them a full previousmedical history inclusive of previous surgery. Nurses are better placed to actas the patients advocate because of their continued interaction with thepatient, (Pattillo, 2011).
Where (Marquis & Huston ,2009) state that nursesare the first health care professionals that can recognise situations, and itis their responsibility to report these situation to the designated person inorder to initiate a change in the patients care.It was decided by the consultant that prior tosurgery for Mrs Smith it would be beneficial to give my patient an Acetazolomidetablet prior to commencing cataract surgery. Acetazolomide is a frequently used medication inocular surgery and helps reduce the intraocular pressure in the eye British NationalFormulary (BNF 74, 2017-2018). Acetazolomide is an ocular hypotensive drug andhas been used in cataract surgery since 1954; it helps with the reduction ofintraocular pressure within 60 to 90 minutes of surgery with a maximum fallwithin 3 to 5 hours. However the exact way in which this happens is not known. (Aggarwal& Malik 1963) and can be given preor post operatively due to Mrs Smith previous complication with a build up ofpressure behind the eye on her last surgery the consultant deemed preoperatively was the best line of care for Mrs Smith.
I spoke withMrs Smith regarding our care plan and fully explained the reason this wasdecided, good health education requires a high level of engagement from the patient(De Haes, 1982). However De Haes,(1982), also says Patient education should be demonstrable to an increasedself assurance, reduce anxiety have a better understanding of the problem,contain knowledge about side effects of medication and a greater selfacceptance after surgery which will ensure the patient continues to receive good holistic carewhilst in the hospital. There has been quite a lot of research in the use ofdrugs in cataract surgery to help reduce the intraocular pressure post surgery astudy conducted on 202 patients in 1998 on the use of Acetazolomide before orafter surgery showed that patients that took the medication pre operatively hada significant reduction in intraocular pressure post surgery. Another studypublished in 2017 by Hayashi et al.
, 2017 describes the benefit of givingAcetazolomide to patients with Primary Open Angle Glaucoma prior to cataractsurgery to also have a significant effect in the control on intraocularpressure post surgery however this study also showed that giving Acetazolomide postoperativelyhelped reduce the intraocular pressure for 5 hours or more after surgery Whilst researching the argument for the useAcetazolomide in cataract surgery the author found that the information theycould gather was linked with other intra ocular reducing pressure medicationsalthough there was a clear indication in the benefits of using Acetazolomidepreoperatively as opposed it to postoperatively it was very difficult toascertain the benefits for Acetazolomide on its own. It also came to their attentionthat currently,there are no specific guidelines in this regard resulting in wide variation inpractice across the UK. They then looked at a study which was conducted in 2005by Zamvar and Dhillon, which focused on the way surgeons dealt with intraocularpressure for cataract surgery. The study was based solely on surgeons and wastaken up with good results. It looked at the use on medication such asAcetazolomide for reduction of intraocular pressure; this study also comparedresults with surgeons that used no medication for intraocular pressure.
Thisstudy had lots of elements and included different pressure relievers, includedthe timings of follow up appointments, it unfortunately was not conclusive withresults, and found the use of post surgical pressure medication was more gearedto personal belief rather than conclusive evidence. Following this information a short study wasdone within the hospital on 2 ophthalmic Consultants one who used Acetazolomidepre operatively and one who used no medication for intra ocular pressure beforeor after surgery. This study was carried out on a group of 10 patients ofdiffering age and ethnicity with differing co morbidities between the age of 55and 75. (Appendix 1). This study purely looked at a patient’s perspective postsurgery regarding intraocular pressure, and was not based on a clinical viewand did not contain any post operative follow up appointments. The author isaware this would need to be done to get a more substantive study, but for this shortstudy they were only focusing on the patient’s perspective.
From this study the author found that patientswere having a better post operative experience and had less problems with intraocular pressure postoperatively in the patients that had received theAcetazolomide preoperatively, however what this study is not able to assess isthe compliancy and accuracy of the administration of the antibiotic drop givenpost surgery and if this played a role in any post surgery complications. Mrs Smith agreedto take the Acetazolomide preoperatively after she had been given all theinformation regarding the side effects and was consented for surgery. (Royalcollege of Surgeons, 2015) state that ‘Patientshave a fundamental legal and ethical right to decide what happens to theirbodies. It is therefore essential that patients have given valid consent forall treatments and investigations. For the purpose of this document, consentrefers to the right of patients to decide what, if any, clinical care they areto receive and the duty of surgeons to ensure that patients have given theirpermission prior to any treatment. Mrs Smith was feeling less anxious andstressed now following the care she had received and although she was stillanxious about post operative complications felt we had put in place measures tohelp alleviate these. Once surgery had finished Mrs Smith was bought back tothe ward area and the Scrub nurse handed over there care to me. It is important that thehandover of a patient from theatre contains all relevant clinical informationas this is of great importance to the continuity and safety of care.
Ifclinically and relevant information does not get shared accurately and within atimely manner it could lead to an adverse event, delay in treatment and anomission of care. During this handover it was bought to my attention that thesurgeon would like to see the patient at an earlier date to ensure they couldkeep a close eye on her postoperatively so they could assess if there were anycomplications or any intraocular pressure. I assured Mrs Smith was feeling welland proceeded to provide her with refreshments in accordance with the hospitalprotocols. I arranged all the discharge information for Mrs Smith thisis inclusive of post operative appointment, medication post surgery informationeffective discharge planning is crucial in the continuity of care. The principle of dischargingpatients from hospital has not changed for many years. (Department of Health,2003) however the process and the pace of which we discharge plan have changedbeyond any recognition. And With an increasing ageing population and morecomplex needs we need to adapt accordingly.
(Glaeconomics ,2008) with this isin mind the NHS Institute for Innovation and Improvement, (2009), offers a10-step process for planning the discharge or transfer of patients. It givesguidance for simple discharges that are carried out at ward level should bestandardised throughout an entire hospital, this is the key to making anyprocess work consistently in an organisation. It is always helpful to involvepatients and their families when discharging patients. Because of previous intraocular pressureincluded in Mrs Smith discharge medication was a topical steroid drop asrecommended with the Nice Guidelines (Cataracts in Adults 2017) along with thenormal post operative antibiotic drug.
Eye shield and post operative literatureinclusive of VTE advice and frequently asked questions, as a day hospital withno service available after 8pm it became apparent that some patients could beleft for a long time worrying about a relatively normal post procedure concern.With this in mind we have devised this leaflet within our hospital to helpalleviate some fears patients may have when they get home (appendix 2). MrsSmith was to attend the hospital 3 days later for her follow up appointmentwith the consultant to assess how she was responding post operatively. MrsSmith was feeling very reassured following her surgery and was happy to bedischarged out of our care.
The following morning I telephoned Mrs Smithas is the protocol within our hospital that patients receive a post optelephone call within 24 hours to assess how the eye is settling, how they aremanaging with drops and how the vision is progressing. Postoperative phone call follow-up can be aneffective tool, having nurses contact same day surgical patients early in thepatients recovery process can help guide recovery and highlight early anyproblems that might arise, however there are no guidelines in place as to thebest time to make these call. (Aorn J, 2009) But within our practice we aim tomake the post op phone call within 24 hours of surgery (Aorn, 2009) also statethat the best time to make post operative phone calls is between 12 and 24hours.
On speaking to Mrs Smith she was able to assure me that she was managingto stay compliant with the use of both her eye drops, had used her eye shieldas directed on discharge that her vision had started to improve and that shewas having no issues with any feeling of pressure in the back of her eye andhad not had any post surgery headaches which can be an indication ofintraocular pressure. This was all documented clearly in the patients carepathway, nursing documentation refers to written or electronic clientinformation obtained through the nursing process. (ARNLL 2010). It is essentialfor all good clinical communication provides an accurate reflection ofassessment, changes in condition and care provided and supports themultidisciplinary team in delivering good care.
Mrs Smithdully attended the hospital for her post procedure follow up with theconsultant and clinic nurse this willinclude gathering a post procedure history, a visual acuity test, and athorough examination of the eye. Following their post op appointment and fullassessment Mrs Smith was doing very well post operatively with no signs ofinflammation or further complications. For Mrs Smith she was very relived andpleased at the outcome of her surgery she was also very appreciative of thecare she had received whilst in the care of the hospital.
The hospital althougha very busy specialist ophthalmic is a small unit with a limited number ofnurses and consultants this enables the nurse to be able to follow thepatient’s care offering a great continuity of care. Continuity of care refers to how a patient’s care isconnected over time, it can be argued that effective healthcare organisationshould embody all dimensions of continuity alongside access to good qualitycare and is a paramount reason that the authorworks within the hospital.Reflection isan important process in nursing care. (Mantzoukas & Jasper, 2004) it is anessential attribute for the development of autonomous, critical care, (Chong, 2009) states “Reflective practice should bea continuous cycle in which experience and reflection on experiences are inter-related.A study conducted in 2001 by Hansebo & Kihlgren, proved that nurses who took time to reflecton there working day gained a better understanding of the actions they tookwhich in turn enhanced there professional skills and enabled them to offerbetter care to their patients. Reflection should be used as a professionalmotivator to “move on and do better within practice” with the goal of learningfrom experiences and examining oneself (Bulman, Lathlean, & Gobbi, 2011). It can help aidand promote learning for the purpose of this case study and reflection on thecare offered to Mrs Smith the author will be using the (Gibbs Reflective Cycle 1998)to reflect on their account of the above case study.
On admissionof Mrs Smith it was apparent that they were very anxious regarding theirsurgery due to their previous surgical complications. Anxiety in surgery is verycommon although the symptoms can be very stressful for the patient there is nocure all for anxiety. Pre-surgery anxiety is one of the most commonemotional responses that a patient can experience prior to surgery. With anincrease in minimal stay surgery has reduced the opportunities for nurses tospend time with their patient to discuss anxieties about the procedure theywill undergo to help allay patient anxieties and promote a better recovery fromsurgery by implementing a planned programme of information, giving that nursesspend a considerable amount of time working with patients so it is importantthat they become attuned to signs of anxiety and implement ways to alleviatethem.( Mitchel,l 2012) with this in mind the author feels they was able to helpwith Mrs Smiths anxiety and stress by not only giving them pre and post surgeryinformation but with good multi disciplinary communication the consultant was able to put in place extra measures to help with post surgeryinflammation.
It wasimportant for the author that they followed their concerns for the patient inspeaking with the consultant and acting as the patient advocate. (Patillo, 2011)they felt that they done this effectively and the patient received the bestpossible outcome. With Mrs Smith care being paramount it was necessary that nursehighlighted previous surgical problems to the consultant to ensure that notonly was the consultant fully aware of previous complications but it thenensured that Mrs Smith was indeed offered holistic care which continued fromher time within the hospital as well as her discharge and post procedure followup. For theauthor the care that was given to Mrs Smith within the whole team wasinvaluable and aided in ensuring that not only was the patient reassured onadmission onto the ward which helped with their stress and anxieties prior tosurgery the implementation of medications prior and post surgery also helpedwith the recovery of Mrs Smiths surgery and reduced the chances of any postsurgery complications like she had suffered after their previous surgery. All careoffered to patients needs to be specific to their needs and should be based ontheir needs this should be based on holistic care. The author would not changethe way they offered their care to the patient and would ensure that this levelof care was offered to all patients within the hospital.The authoralso noted from her small study that it is important that patients manage touse the eye drops effective in accordance with the hospitals post operativeregime. The study highlighted that there was some post operative complicationswith patients that had problems with administering eye drops in both sets ofpatients.
This affirmed that good assessment to include discharge is paramountfor cataract surgery as there are many assets in good post operative outcomesfor these patients.