Acetazolomide her right eye 4 months earlier; unfortunately

Acetazolomide Case Study


The following Case Study will
focus on a routine Cataract patient admitted within our Hospital, It will
explore the benefits of initial assessment between the patient and the nurse
care plans developed. It
will discuss the use of Acetazolomide tablet in Cataract surgery and if this
indeed is beneficial to the patient. This paper will use evidence based
information to evaluate the use of Acetazolomide tablets and weather they help
in cataract surgery to establish good practice with good holistic patient
centred care at the foremost. For the purpose of this Case Study and to
protect the patient’s confidentiality all names and places will be changed in
accordance with the Nursing Midwifery Council (NMC2008.)  And data protection act (DOH 1998).

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Cataract Surgery although not
inclusive is primarily performed on older patients who may have other core
morbidities which can include arthritis and poor mobility along with limited
movement of limbs this could impact on the patient administering necessary
drops, they may also have social issues which can include living on their own
and 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 a
complete picture of the patient and how they can be helped. An effective
assessment will provide the nurse with information on the patient’s background,
lifestyle, family history and the presence of illness or injury “.During
assessment it is as important to be integrating discharge planning for the
patient to ensure patients return home into the community with the appropriate
care and support (RCN 2004) Good nursing holistic assessment is central to a
good discharge (Atwal 2002), it needs to be centred around the patient within a
lifestyle specific manner this will include the ability to be able to continue
their compliance of  self care once they
have left the hospital setting.



Mrs Smith is an 83 year old patient who is being
admitted to the Hospital for Cataract Surgery to her left eye. Mrs Smith has
previously undergone cataract surgery to her right eye 4 months earlier;
unfortunately for Mrs Smith her original surgery had encountered post surgery
complications, although in accordance with (NHS Choices,2016) The risk of serious complications developing as a
result of cataract surgery is very low. Most common complications are treatable
and don’t have a long-term impact on your vision. For Mrs Smith this has left
her feeling very vulnerable and frightened for her forthcoming surgery.
Although vision is now improving with her right eye it has been a very
stressful time. A study by (Wetsch et al., 2010) underpinned
the reality of day case surgery stress within a group of patients. And in
relation to post procedure complications after her prior surgery it is understandable
the anxiety and stress Mrs Smith will be feeling.



As previously stated Mrs Smith is
an 83 year old lady attending the hospital for Cataract Surgery she is in
relatively good health apart from Hypertension which is being treated with
medication, border line for Diabetes 2 which Mrs Smith is managing to control
with a good diet she also suffers with poor mobility due to Arthritis. However
Mrs Smith is suffering with extreme anxiety and stress for her up and coming
surgery as previously stated this is due to complications suffered from her
previous cataract surgery on her right eye, the results of which had left her
with a build up of intraocular pressure and the fear of losing her sight. For
admission of Mrs Smith I shall be using nursing model Roper et al (2000) based
on the Daily Activities of living I feel this is a appropriate model of nursing
as it takes a Holistic approach to nursing care and will be the care plan
followed throughout the stay of Mrs Smith.


 My initial assessment starts with good
communication, (Kitson, 2004) states the nurses need
good communication skills to be able to engage with patients efficiently to
promote a therapeutic relationship. Whereas (Morris and Morris 2010) argue that
it is a complex dynamic as the quality of the relationship between the nurse
and patient will be influenced by each party’s ability to communicate. However
there still remains much debate about the effectiveness of using these models
with arguments that individualized care can be compromised by fitting patients
into a set structure (Kearney 2001, McCrae 2012). With this in mind it is
important nurses take a pragmatic approach when assessing a patient and utilize
frameworks appropriate for the area of practice. Good Assessment is a
fundamental part of the nursing process According
to (Heaven & McGuire, 1996) “it is a systematic, deliberate and interactive
process that underpins every aspect of nursing care it is the process by which
the nurse and patient together identify needs and concerns and is seen as the
cornerstone of individualized care”.  It is the collecting; validating and
clustering of information it is paramount to enable the planning,
implementation and evaluation of a patients care. After performing the original
assessment you are able to establish the patient’s baseline and start to
diagnose and develop a care plan. Assessment decreases the
potential for, or the severity of, chronic conditions and helps the individual
to gain control over their health through self-care (RCN 2004).This is especially
paramount in today’s rapidly changing healthcare system, as nurses take on more
advanced roles, working across boundaries and setting up new services to meet
patients needs (DH2006a).


As stated above good assessment is essential to the
nursing process and as a result it is paramount that I enable Mrs Smith to give
me a full account of her previous surgery and her post procedure complications
to give me a greater understanding of how this affected Mrs Smith. It is only
with all this information that I can tailor the care plan to ensure good
holistic care is delivered with Mrs Smith at the centre of all decisions.
Following the initial assessment and completion of care pathway, inclusive of
base line observations, in accordance with the (Nice, 2007) guidelines that give
clear recommendations for observations recorded on admission, and after gathering
a full previous medical history from Mrs Smiths it was apparent that after her
previous surgery she unfortunately developed a build up of intraocular pressure
in her eye.

Although it is normal for cataract surgery to make a
change 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 history
of Diabetes, and the fear of developing glaucoma and losing her sight was very
real. It was important for Mrs Smith that this information played a vital role
in developing a holistic based care plan during her stay within the hospital.


After initial assessment and collection of patient
history it was paramount that before surgery took place, involvement of the
surgeon would be needed to highlight the issues raised to ensure Mrs Smith
receives high quality care. (Kings College, 2008) states this should be
delivered to the patients in order to achieve a good experience within their
care. Nursing advocacy helps play a key role in keeping patients safe whilst in
the hospital setting and is a fundamental part of the nursing and midwifery
code (NMC, 2015).  Acting as my patients
advocate I raised my concerns with the Consultant giving them a full previous
medical history inclusive of previous surgery. Nurses are better placed to act
as the patients advocate because of their continued interaction with the
patient, (Pattillo, 2011). Where (Marquis & Huston ,2009) state that nurses
are the first health care professionals that can recognise situations, and it
is their responsibility to report these situation to the designated person in
order to initiate a change in the patients care.

It was decided by the consultant that prior to
surgery for Mrs Smith it would be beneficial to give my patient an Acetazolomide
tablet prior to commencing cataract surgery.

Acetazolomide is a frequently used medication in
ocular surgery and helps reduce the intraocular pressure in the eye British National
Formulary (BNF 74, 2017-2018). Acetazolomide is an ocular hypotensive drug and
has been used in cataract surgery since 1954; it helps with the reduction of
intraocular pressure within 60 to 90 minutes of surgery with a maximum fall
within 3 to 5 hours. However the exact way in which this happens is not known. (Aggarwal
& Malik 1963)  and can be given pre
or post operatively due to Mrs Smith previous complication with a build up of
pressure behind the eye on her last surgery the consultant deemed pre
operatively was the best line of care for Mrs Smith.

 I spoke with
Mrs Smith regarding our care plan and fully explained the reason this was
decided, 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 increased
self assurance, reduce anxiety have a better understanding of the problem,
contain knowledge about side effects of medication and a greater self
acceptance after surgery which will ensure the patient continues to receive good holistic care
whilst in the hospital.


There has been quite a lot of research in the use of
drugs in cataract surgery to help reduce the intraocular pressure post surgery a
study conducted on 202 patients in 1998 on the use of Acetazolomide before or
after surgery showed that patients that took the medication pre operatively had
a significant reduction in intraocular pressure post surgery. Another study
published in 2017 by Hayashi et al., 2017 describes the benefit of giving
Acetazolomide to patients with Primary Open Angle Glaucoma prior to cataract
surgery to also have a significant effect in the control on intraocular
pressure post surgery however this study also showed that giving Acetazolomide postoperatively
helped reduce the intraocular pressure for 5 hours or more after surgery


Whilst researching the argument for the use
Acetazolomide in cataract surgery the author found that the information they
could gather was linked with other intra ocular reducing pressure medications
although there was a clear indication in the benefits of using Acetazolomide
preoperatively as opposed it to postoperatively it was very difficult to
ascertain the benefits for Acetazolomide on its own. It also came to their attention
that currently,
there are no specific guidelines in this regard resulting in wide variation in
practice across the UK. They then looked at a study which was conducted in 2005
by Zamvar and Dhillon, which focused on the way surgeons dealt with intraocular
pressure for cataract surgery. The study was based solely on surgeons and was
taken up with good results. It looked at the use on medication such as
Acetazolomide for reduction of intraocular pressure; this study also compared
results with surgeons that used no medication for intraocular pressure. This
study had lots of elements and included different pressure relievers, included
the timings of follow up appointments, it unfortunately was not conclusive with
results, and found the use of post surgical pressure medication was more geared
to personal belief rather than conclusive evidence.

  Following this information a short study was
done within the hospital on 2 ophthalmic Consultants one who used Acetazolomide
pre operatively and one who used no medication for intra ocular pressure before
or after surgery. This study was carried out on a group of 10 patients of
differing age and ethnicity with differing co morbidities between the age of 55
and 75. (Appendix 1). This study purely looked at a patient’s perspective post
surgery regarding intraocular pressure, and was not based on a clinical view
and did not contain any post operative follow up appointments. The author is
aware this would need to be done to get a more substantive study, but for this short
study they were only focusing on the patient’s perspective.

 From this study the author found that patients
were having a better post operative experience and had less problems with intra
ocular pressure postoperatively in the patients that had received the
Acetazolomide preoperatively, however what this study is not able to assess is
the compliancy and accuracy of the administration of the antibiotic drop given
post surgery and if this played a role in any post surgery complications.


Mrs Smith agreed
to take the Acetazolomide preoperatively after she had been given all the
information regarding the side effects and was consented for surgery. (Royal
college of Surgeons, 2015) state that ‘Patients
have a fundamental legal and ethical right to decide what happens to their
bodies. It is therefore essential that patients have given valid consent for
all treatments and investigations. For the purpose of this document, consent
refers to the right of patients to decide what, if any, clinical care they are
to receive and the duty of surgeons to ensure that patients have given their
permission prior to any treatment. Mrs Smith was feeling less anxious and
stressed now following the care she had received and although she was still
anxious about post operative complications felt we had put in place measures to
help alleviate these. Once surgery had finished Mrs Smith was bought back to
the ward area and the Scrub nurse handed over there care to me. It is important that the
handover of a patient from theatre contains all relevant clinical information
as this is of great importance to the continuity and safety of care. If
clinically and relevant information does not get shared accurately and within a
timely manner it could lead to an adverse event, delay in treatment and an
omission of care. During this handover it was bought to my attention that the
surgeon would like to see the patient at an earlier date to ensure they could
keep a close eye on her postoperatively so they could assess if there were any
complications or any intraocular pressure. I assured Mrs Smith was feeling well
and proceeded to provide her with refreshments in accordance with the hospital


I arranged all the discharge information for Mrs Smith this
is inclusive of post operative appointment, medication post surgery information
effective discharge planning is crucial in the continuity of care. The principle of discharging
patients from hospital has not changed for many years. (Department of Health,
2003) however the process and the pace of which we discharge plan have changed
beyond any recognition. And With an increasing ageing population and more
complex needs we need to adapt accordingly. (Glaeconomics ,2008) with this is
in mind the NHS Institute for Innovation and Improvement, (2009), offers a
10-step process for planning the discharge or transfer of patients. It gives
guidance for simple discharges that are carried out at ward level should be
standardised throughout an entire hospital, this is the key to making any
process work consistently in an organisation. It is always helpful to involve
patients and their families when discharging patients.

 Because of previous intraocular pressure
included in Mrs Smith discharge medication was a topical steroid drop as
recommended with the Nice Guidelines (Cataracts in Adults 2017) along with the
normal post operative antibiotic drug. Eye shield and post operative literature
inclusive of VTE advice and frequently asked questions, as a day hospital with
no service available after 8pm it became apparent that some patients could be
left 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 help
alleviate some fears patients may have when they get home (appendix 2). Mrs
Smith was to attend the hospital 3 days later for her follow up appointment
with the consultant to assess how she was responding post operatively. Mrs
Smith was feeling very reassured following her surgery and was happy to be
discharged out of our care.


 The following morning I telephoned Mrs Smith
as is the protocol within our hospital that patients receive a post op
telephone call within 24 hours to assess how the eye is settling, how they are
managing with drops and how the vision is progressing.  Postoperative phone call follow-up can be an
effective tool, having nurses contact same day surgical patients early in the
patients recovery process can help guide recovery and highlight early any
problems that might arise, however there are no guidelines in place as to the
best time to make these call. (Aorn J, 2009) But within our practice we aim to
make the post op phone call within 24 hours of surgery (Aorn, 2009) also state
that the best time to make post operative phone calls is between 12 and 24
hours. On speaking to Mrs Smith she was able to assure me that she was managing
to stay compliant with the use of both her eye drops, had used her eye shield
as directed on discharge that her vision had started to improve and that she
was having no issues with any feeling of pressure in the back of her eye and
had not had any post surgery headaches which can be an indication of
intraocular pressure. This was all documented clearly in the patients care
pathway, nursing documentation refers to written or electronic client
information obtained through the nursing process. (ARNLL 2010). It is essential
for all good clinical communication provides an accurate reflection of
assessment, changes in condition and care provided and supports the
multidisciplinary team in delivering good care.


Mrs Smith
dully attended the hospital for her post procedure follow up with the
consultant and clinic nurse  this will
include gathering a post procedure history, a visual acuity test, and a
thorough examination of the eye. Following their post op appointment and full
assessment Mrs Smith was doing very well post operatively with no signs of
inflammation or further complications. For Mrs Smith she was very relived and
pleased at the outcome of her surgery she was also very appreciative of the
care she had received whilst in the care of the hospital. The hospital although
a very busy specialist ophthalmic is a small unit with a limited number of
nurses and consultants this enables the nurse to be able to follow the
patient’s care offering a great continuity of care. Continuity of care refers to how a patient’s care is
connected over time, it can be argued that effective healthcare organisation
should embody all dimensions of continuity alongside access to good quality
care and is a paramount reason that the author
works within the hospital.

Reflection is
an important process in nursing care. (Mantzoukas & Jasper, 2004) it is an
essential attribute for the development of autonomous, critical care, (Chong, 2009) states “Reflective practice should be
a 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 reflect
on there working day gained a better understanding of the actions they took
which in turn enhanced there professional skills and enabled them to offer
better care to their patients. Reflection should be used as a professional
motivator to “move on and do better within practice” with the goal of learning
from experiences and examining oneself (Bulman, Lathlean, & Gobbi, 2011).  It can help aid
and promote learning for the purpose of this case study and reflection on the
care 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 admission
of Mrs Smith it was apparent that they were very anxious regarding their
surgery due to their previous surgical complications. Anxiety in surgery is very
common although the symptoms can be very stressful for the patient there is no
cure all for anxiety. Pre-surgery anxiety is one of the most common
emotional responses that a patient can experience prior to surgery. With an
increase in minimal stay surgery has reduced the opportunities for nurses to
spend time with their patient to discuss anxieties about the procedure they
will undergo to help allay patient anxieties and promote a better recovery from
surgery by implementing a planned programme of information, giving that nurses
spend a considerable amount of time working with patients so it is important
that they become attuned to signs of anxiety and implement ways to alleviate
them.( Mitchel,l 2012) with this in mind the author feels they was able to help
with Mrs Smiths anxiety and stress by not only giving them pre and post surgery
information but with good multi disciplinary communication  the consultant was able to put in  place extra measures to help with post surgery


It was
important for the author that they followed their concerns for the patient in
speaking with the consultant and acting as the patient advocate. (Patillo, 2011)
they felt that they done this effectively and the patient received the best
possible outcome. With Mrs Smith care being paramount it was necessary that nurse
highlighted previous surgical problems to the consultant to ensure that not
only was the consultant fully aware of previous complications but it then
ensured that Mrs Smith was indeed offered holistic care which continued from
her time within the hospital as well as her discharge and post procedure follow


For the
author the care that was given to Mrs Smith within the whole team was
invaluable and aided in ensuring that not only was the patient reassured on
admission onto the ward which helped with their stress and anxieties prior to
surgery the implementation of medications prior and post surgery also helped
with the recovery of Mrs Smiths surgery and reduced the chances of any post
surgery complications like she had suffered after their previous surgery.

All care
offered to patients needs to be specific to their needs and should be based on
their needs this should be based on holistic care. The author would not change
the way they offered their care to the patient and would ensure that this level
of care was offered to all patients within the hospital.

The author
also noted from her small study that it is important that patients manage to
use the eye drops effective in accordance with the hospitals post operative
regime. The study highlighted that there was some post operative complications
with patients that had problems with administering eye drops in both sets of
patients. This affirmed that good assessment to include discharge is paramount
for cataract surgery as there are many assets in good post operative outcomes
for these patients.