Ophthalmic Nursing

Mary E. Shaw, Agnes Lee, Rosalind Stollery, Mary E. Shaw, Agnes Lee, Rosalind Stollery

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118697733
• Edition: 4
• Topic: Medicine
• Subtopic: Clinical Medicine

There have been many changes in the arena of ophthalmic care since the last edition of this book was published. This fourth edition has been fully updated and revised to reflect these recent advances in care, and incorporates new information on patient care, contexts of care, and expanded roles.

It includes a greater emphasis on the primary care setting, more information on issues such as new treatments, infection control, and use of technology, greater detail on theatre, anaesthetics and recovery, and new information on the role of other healthcare professionals involved in ophthalmic care. Now with colour illustrations throughout, this accessible text also includes evidence-based procedure guidelines and reflective practice exercises that enable the reader to apply the learning in practice.

Written by highly regarded authors based at The University of Manchester and Manchester Royal Eye Hospital, Ophthalmic Nursing is a must-have for every eye department.

Chapter 1

The Ophthalmic Patient

This chapter looks at the nature of the patients seen in ophthalmic or in primary care settings.

Introduction

The ophthalmic patient may be of any age and from any background. Ophthalmic conditions affect all age groups – ranging from a few days to more than 100 years old – although, in most ophthalmic settings, the majority of patients seen are elderly.

Infants and children will have parents or guardians who wish to be involved in their child’s care. The infant or child whose parents or guardians are either unable or unwilling to become involved will need the extra care and attention of a nurse to reassure him in unfamiliar and possibly frightening surroundings.

The ophthalmic patient may have other diseases such as diabetes mellitus (Type 1 or Type 2), ankylosing spondylitis or arthritis, as these conditions have ocular manifestations. He may also suffer from unrelated diseases. Patients with co-morbidity can be challenging for the ophthalmic nurse who will have to make decisions about care and management based on need.

Many people with learning disabilities are known to have ocular problems, including: visual impairment, refractive errors, squint, keratoconus, nystagmus, cataract and glaucoma. They face more problems than most members of society, including having difficulty accessing services when disease is detected, and few ophthalmic nurses have training specifically designed to meet the needs of these people.

The ophthalmic patient will arrive at the eye hospital or unit either as a referral to the outpatient department or as a casualty, where many are self-referred and may not be ‘emergencies’ as such. They will present with a variety of conditions, from a lump on the lid to sudden visual loss or severe ocular trauma. In addition, the ophthalmic patient may access care via walk-in centres, NHS direct, the high street optometrist or GP services, including the practice nurse. The Darzi report (Department of Health, 2008a) is driving the agenda for an increasing amount of care in the community, and the author insists that the care should be of a high quality. There is also an emphasis on patient wellbeing and preventive care.

Most people will be anxious on a first visit to a hospital or other health care setting. Even for the elderly but otherwise fit person, it might be his first experience of a hospital. Those arriving following trauma will be in varying degrees of shock depending on the nature and type of accident and they, and their relatives, may be very anxious. Something that seems fairly minor to the nurse with ophthalmic knowledge may, to the layman, appear serious and be thought to threaten sight.

Many people have a fear of their eyes being touched, making examination difficult. Some feel faint – or do faint – while certain procedures, such as removal of a foreign body, are being performed.

There are some old wives’ tales about the eye. One of the most common is that the eye can be removed from the socket for examination and treatment, and be replaced afterwards. This kind of false information does not help the patient’s frame of mind.

Each person will arrive at the hospital with his own individual personality and past experience to influence any attitude towards the eye condition. Some will be stoical, others extremely agitated. Those with chronic or recurrent eye conditions may become more accustomed to visiting the eye hospital. Most patients having ophthalmic surgery are outpatients, day cases or overnight-stay patients. This means they have a very short time to adjust to the hospital setting and have little time to ask the questions that may be initially forgotten in the midst of all the activity. They may feel reluctant to express minor concerns when there appears to be little contact time with nurses.

The actual visual impairment experienced by the patient will vary with the eye condition. With many conditions there is no, or only slight, visual impairment and this may be temporary. Other conditions cause gross visual loss that may have occurred suddenly or gradually over the years. This visual loss may be untreatable and permanent, may be progressive, or sight may be restored. Some patients will have only one eye affected and others both eyes, probably to different degrees. Some will have blurred vision; some will only be able to make out movements. Others will be able to differentiate only between light and dark, or will see nothing at all. Some will have lost their central vision, others their peripheral vision. A number of patients will see better in bright light than dim light, and vice versa. Some degree of visual loss can be very upsetting to the patient and can prove to be a severe impairment to daily living. All patients experiencing severe visual loss will require practical and emotional help in coming to terms with their loss, regardless of the cause and the course it has taken.

Registration for the sight-impaired or severely sight-impaired

Research carried out by the Royal National Institute for the Blind (RNIB) (Bruce et al., 1991) suggested that there are three times more people eligible for registration as sight-impaired or severely sight-impaired than are in fact registered. There is no reason to suppose that this situation has changed. People are reluctant to take the final step as it can appear to be the giving up of any hope that treatment will help. This need not be the case, however: sight-impaired or severely sight-impaired registration can be a much more liberating experience for many as they realise, with help and support, that they can maximise their quality of life. Being registered blind or severely sight-impaired can give access to a variety of benefits, including tax allowance; parking concession (blue badge) and a 50% reduction in TV licence fee.

Severely sight-impaired

The statutory definition for the purpose of registration as a blind person under the National Assistance Act 1948 is that the person ‘is so blind as to be unable to perform any work for which eyesight is essential’. This refers to any form of employment, not only that which the patient formerly followed. It also only takes into account visual impairment, disregarding other bodily or mental infirmities. People with a visual acuity of less than 3/60 on the Snellen (1.0 LogMAR) chart, or with a visual acuity of 6/60 (1.0 LogMAR) but with a marked peripheral field defect, will be eligible for registration.

Sight-impaired

There is no statutory definition of partial sight, although a person who does not qualify to be registered as blind but nevertheless is substantially visually impaired can be registered as partially sighted. Those people with 3/60 to 6/60 (1.0 LogMAR) vision and full peripheral field, those with vision up to 3/60 with moderate visual field contraction, opacities in the media, aphakia and those with 6/18 (10.5 [approximately] LogMAR)or better visual acuity but marked field loss can be included on this register. In England and Wales, a Letter of Vision Impairment (LVI) is obtainable from high street optometrists. In outpatient settings, staff complete the Referral of Vision Impaired Patient (RVI) and, if eligible, patients can take it to their social services department (RNIB 2003).

Assistance and rehabilitation

The National Assistance Act 1948 directed all local authorities to compile a register of blind and partially sighted people residing in their area and to provide advice, guidance and services to enable them and their families to maintain their independence and to live as full a life as possible.

Registration is voluntary. People can choose to register but, if they do so, they can have their names removed from the register at any time should they wish. The local authority has the responsibility of reviewing the register regularly and updating the circumstances of the people on it. Local authorities must offer services to all those identified as visually impaired, whether they choose to register or not. However, registration is necessary to qualify for certain financial benefits and for help from the many voluntary organisations such as the National Library for the Blind. Registration is a good guide as to whether a person is coming to terms with their sight loss.

The process of registration starts with the ophthalmologist certifying on a form. A new system for registering as blind was introduced in England and Wales in November 2003. The Certificate of Visual Impairment (CVI 2003) replaced the old BD8. It is argued that the new system is easier to use and will speed up the process. The BP1 in Scotland and the A655 in Northern Ireland, for which a person is eligible to register as either blind or partially sighted, are still in place. By signing the form, the patient is agreeing for their information to be shared with their local social services, general practitioner and the Department of Population Census, which maintains records of all those opting to share this information.

The Social Services Department has the responsibility for registering people. Some social services departments have delegated this task to their local voluntary organisation that deals with the blind and partially sighted people within their area. The role of the social worker is that of counsellor, providing support and information about the services available. Such services include entitlement to benefits and referral to other statutory bodies involved with retraining, special needs education for those of school and college age, rehabilitation, employment, social, leisure and recreational activities, and introduction to self-help groups.

Voluntary organisations

A number of voluntary organisations work with the visually impaired and most local areas or counties have their own organisations, which were established to provide aids and social contact. Many local authorities have an arrangement with voluntary organisations to provide services to facilitate independent living, ranging from talking or tactile watches and clocks to alarms that sound when rained upon so that the washing can be brought in. Technological developments have resulted, for example, in equipment being available to enlarge print onto a computer screen, to convert the written word into Braille or to use voice synthesisers.

Local voluntary organisations are often centres of social contact for the visually impaired and their carers. Some voluntary organisations maintain contact through radio stations; Glasgow, for example, has a radio station dedicated entirely to people with visual impairment. Many self-help groups are supported by the voluntary sector; for example, glaucoma or macular disease support groups exist across the UK, with some being facilitated in hospital settings while others are supported in the community.

The needs of people from minority ethnic groups are also catered for by the voluntary sector. Ethnic Enable (http://www.ethnicenable.org.uk), for example, is an organisation set up to assist people with visual impairment who are from specific ethnic groups.

Chapter 2

The Ophthalmic Nurse

This chapter explores the role of the nurse caring for the ophthalmic patient in a variety of settings.

Introduction

It is becoming increasingly common for ophthalmic patients to be cared for in environments other than specialist ophthalmic units. Primary care settings are the focus of many aspects of ophthalmic care, for example in walk-in centres where people attend with a variety of ailments for advice, treatment or referral. In addition, high street optometrists are expanding the range of conditions they diagnose and manage.

The nurse with overall responsibility for the care of the ophthalmic patient should ideally hold a first degree and a specialist ophthalmic qualification. In addition, programmes to prepare others to care for the ophthalmic patient are available at NVQ level 2 or 3. All must have gained applied knowledge and skills whilst practising clinically. Within the wider workforce planning agenda, other clinical roles are being developed such as assistant practitioners and surgical care practitioners.

Ophthalmic nurses will naturally be continuing to expand their practice to include, for example: nurse consent; pre-operative assessment; sub-tenon’s local anaesthesia; and diagnosis and management of ocular emergencies (including telephone triage). As specialist practitioners, ophthalmic nurses will also care for and manage groups of patients linked to ophthalmic sub-specialities: stable glaucoma patients, or those involving oculoplastic procedures, cataracts, corneal conditions, uveitis or emergencies. With any of these expanded roles, the ophthalmic nurse must always be mindful of her professional accountability (Nursing and Midwifery Council, 2008).

The ophthalmic nurse must naturally possess all the qualities required of a nurse working in any speciality or environment. Some characteristics, however, are more important to a nurse specialising in the diseases and conditions of the eye. The eye is very delicate and sensitive, and most of the patients the nurse will attend to will have varying degrees of anxiety about their eye and pain or discomfort in or around the eye. In order to allay any fears the patient may have about his eyes being touched, the ophthalmic nurse must be extremely gentle with her hands and in her manner. The nurse should be aware of her position and work on the patient’s right-hand side when dealing with the right eye and vice versa with the left.

The eye is small, and there is not much room for manoeuvre around it when performing manual nursing procedures. The nurse therefore needs to be manually dexterous, and she also needs to have the best possible vision when performing nursing procedures. There is no place for vanity when dealing with the ophthalmic patient – wearing glasses for close work, should these be required, is essential.

As ophthalmic patients can be from any age group, the nurse needs to be familiar with the special requirements of all ages – those of the very young and the old in particular. However, it is recognised that specialist paediatric nurses should, as a matter of course, care for children. The difficulty here is that there are very few paediatric nurses with an ophthalmic qualification.

The nurse must be thoughtful in her approach to the visually impaired person. She must use a variety of interpersonal skills to their best advantage, including: touching as appropriate to indicate presence or to show concern; introducing herself; indicating when she is leaving; and never shouting. There is a great temptation to assume that a person who is visually impaired is also hard of hearing.

The nurse must always bear in mind that there is an individual human being behind the eyes that are being treated, and should care for each patient as a whole, unique person.

Assessment of patients

Ophthalmic patients receive treatment as outpatients, day cases, and in primary care settings. If hospitalised, they tend to spend a minimum of time actually in hospital. Today’s ophthalmic nurse has a limited amount of time in which to get to know the patient and be able to assess his needs and therefore must employ clear, succinct assessment skills in order to carry out an effective assessment. Many aspects of patient assessment are by necessity delegated to other carers in the team. For example, a clinical support worker may measure visual acuity, take blood or record an electrocardiogram (ECG), and a technician may perform biometry.

Patient assessment remains one of the most important interactions that nurses will have with their patients and, in order to do this thoroughly and efficiently, excellent communication skills are required. The ophthalmic nurse must therefore use verbal and non-verbal skills appropriately. Open-ended questions yield more information than closed questions. For example, asking a patient, ‘Are you managing to put your drops in alright?’ is likely to result in a simple yes or no reply, but had they been asked, ‘How often do you miss putting in your drops?’, they are in effect being given opportunity to admit to missing drops or having difficulty. An appropriate tone and pitch of voice should be employed. The ophthalmic nurse must be aware of the effects of eye contact, facial expression, posture, gestures and touch on the patients, remembering that non-verbal communication apart from touch may not always be immediately appropriate to the visually impaired. However, if the ophthalmic nurse does not utilise her non-verbal communication skills, it could affect her own attitude and behaviour, and the patient or the carer could in turn pick this up. It is also useful to integrate counselling skills such as the use of active listening, silence, and attention and paraphrasing, in order to gain additional understanding of the patient’s needs. The ophthalmic nurse also needs to be very observant. The importance of clear and concise record-keeping cannot be overemphasised.

Patient information and teaching

It is well recognised by nurses that giving information about procedures, for example, relieves anxiety and aids recovery. Not only do patients and carers need to know what is wrong with them and how they will be managed medically or surgically; the majority will also want to know why they are having that particular treatment. Patients and carers have ready access to Internet resources and frequently will have downloaded information about their condition and treatment options. The ophthalmic nurse needs to be aware of this and should be in a position to advise the patient as to the accuracy and reasonableness of information obtained from these resources. Many hospitals and clinics place patient information on their own Web pages as well as such information being available on a range of electronic media. Having an understanding of the rationale behind treatment will aid compliance and will enable the patient to be actively involved in his own care. Patients and carers need information at all stages of management. Patients do benefit from effective pre-operative teaching programmes.

Care systems are based on efficient multidisciplinary team-working. Nurses along side other allied health professionals, such as orthoptists and optometrists, also provide ophthalmic services and are considered key to the provision of quality services and the empowerment of the patient (Department of Health, 2008b).

Voluntary sector organisations, for example Henshaw’s Society for Blind People, the International Glaucoma Association (IGA) and the Royal National Institute for the Blind (RNIB), continue to have a major role in ophthalmic care, and many outpatient departments have resident representatives to assist patients in coming to terms with their lives as people with visual impairment. Nurses are well placed to provide patients with sufficient information about their conditions and treatments. The ophthalmic nurse must, therefore, be in possession of sound knowledge in order to impart accurate information. She also needs time and the ability to use communication skills, mentioned above, appropriately. The nurse needs to assess how much information the patient needs, and in what depth, as well as whether to use lay or professional terminology. The ophthalmic nurse needs to be able to impart information to all age groups. As many of the patients are elderly, she needs a special understanding of the needs this group of individuals. Although the senses are often reduced due to the ageing process, this does not mean that the elderly cannot learn about their health needs. Visually impaired elderly people with a hearing loss are a challenge to the ophthalmic nurse, especially as loss of both of these senses may cause them some confusion.

In addition to providing information on the various conditions and their treatment, the nurse also needs to instruct the patient or carer in practical skills that need to be carried out at home or whilst at work, such as instilling drops, lid hygiene or inserting conformer shells. The patient or carer will need time to practise these skills following instruction from the nurse. It is vital that the nurse assesses their competence, which needs to be satisfactory if compliance is to be achieved. Many reasons exist as to why patients fail to adhere to their treatment plan, including: lack of understanding of the diagnosis; chronic nature of the condition; forgetfulness; lack of motivation; physical problems such as rheumatoid arthritis of the hands; side-effects of the drops; frequency of drop instillation; and multiple pharmacotherapy. Noncompliance may be as high as 95%, if one takes into account late instillation or missed doses. Physical problems such as hand tremor and weakness or arthritis may be overcome by the use of devices to help in the delivery of drops.

Teaching is another area that has been affected by the shortened contact time between nurse and patient. The actual organisation of when and where to carry out teaching is often difficult. Verbal information and instruction must be backed up with the written word - and both must be clear, unambiguous and appropriate for the individual. Written information includes the provision of leaflets in other languages, according to the community served. The patient’s visual acuity and other aspects of vision must be taken into account wh...