Amy Shurtz, RN
The pediatric strabismus patient in surgery
Strabismus comes from the Greek word strubisnos, which literally translated means “a squinting.” This is somewhat deceptive, because strabismus rarely results in what we commonly think of as squinting-partially closing the eyes to see clearly. Strabismus is a condition in which both eyes can’t look a t an object a t the same time due to discrepancies in the strength, hence coordination, of the extraocular musc1es.l It occurs in 2% of the children in this country and may be caused by a recessive gene that accounts for the deviations from normal in the length, strength, or attachment positions of the extraocular muscles.* Other causes include specific trauma and disease, such as birth injuries or intraorbital tumors.
Amy Shurtz, RN was a nurse clinician in ophthalmology at the University of Iowa Hospitals and Clinics Iowa City. when this article was written She IS a diploma graduate of the Peter Bent Brigham Hospital School of Nursing Boston
There are six extraocular muscles of the eye, which are striated, voluntary skeletal muscles (Fig 1).The medial rectus is primarily responsible for adduction and, along with the inferior oblique, superior, and inferior rectus muscles, is innervated ’by the I11 cranial nerve (oculomotor). The VI cranial nerve (abducens) innervates the lateral rectus, which is involved in abduction. The superior oblique initiates upward motion of the eye arid is innervated by the IV cranial nerve, the t r ~ c h l e a r . ~ Normally, the lines of vision (visual axis) of the eyes are parallel when the object is a t a distance of 20 feet or more. When the object is nearer, the eyes rotate medially so that the visual axes meet the object. This is convergence. Divergence is a shift of visual axes from a nearer to a farther object, and the lines of vision move farther apart.* Accommodation i5; the adjustment of the eye to focus the image on the retina, which consists of’ t h r e e reflexive actions. When accommodating for near vision, the ciliary muscles contract, increasing curvature of the lens. The pupil contracts, and the visual axes converge (Fig 2). For distant vision, the changes are r e ~ e r s e d . ~ Refractive errors are caused by a condition in which parallel rays of light are not focused on the retina for a variety of reasons6 Fusion is the ability of the brain to blend images from each eye and interpret them as one. For this to occur,
AORN Journal, October 1979, Vol30, N o 4
639
both visual axes must be coordinated.7 In strabismus, the visual axis of only one eye goes to the object. Strabismus may be divided into two broad categories: paralytic and nonparalytic. Paralytic strabismus is the inability of the extraocular muscles of the affected eye to coordinate with the unaffected eye. In nonparalytic strabismus, the affected eye moves with the normal eye but maintains a separate visual axis. This is called concomitant strabismus and is due to a n error of refraction. The error may be that the accommodation isn’t accurate when both eyes are able to fix accurately on the object. The child can choose between coordinated fixation with poor vision or accurate accommodation with double vision. The choice resulting in strabismus usually starts to be consistently noticeable between the ages of two and three. Until that time, the retina isn’t developed enough to provide distinctively clear images anyway. There are two general kinds of concomitant strabismus: monocular, when one eye is used constantly for vision and the other eye habitually deviates, and alternating, when either eye is used for vision and the other eye becomes the affected eye.s Strabismus, then, is described by what deviation the eye presents: esotropia (also called convergent strabismus)-inward deviation exotropia (also called divergent strabismus)-outward deviation hypertropia-upward deviation hypotropia-downward deviation (Fig 3).9 The goal of strabismus surgery is to obtain the highest potential for the best possible vision by making fusion possible and to obtain the best appearance. The surgery consists of correcting the basic position of one eye relative to the other. This is done by either lengthening or shortening the involved extraocular muscles. Surgery is indicated when
640
A
INFERIOR^
RECTUS
Fig 1 . A, side view of a right eye 6 . front view of a right eye. Figs 1 through 4 reprinted with permission from C E Windsor, Jane Hurtt, Eye Muscle Problems in Childhood A Manual for Parents. 2nd e d (St Louis C V Mosby Co, 1974)
a child h a s attained maximum improvement with glasses and exercise and when these results have shown fusion is possible. Usually, this is between the ages of three and five. Preferably, surgery is done before the child starts school, not only for optimal vision, but to alleviate taunting by peers during a particularly formative time of a child’s life.l0 Ideally, t h e surgical correction of strabismus can be done on a n outpatient basis, which decreases emotional trauma, reduces the cost of treatment, and lessens the risk of nosocomial infection. The initial decision about the patient’s suitability for outpatient anesthesia is made by the surgeon, and preparation of the parents and child begins
AORN Journal, October 1979, V o l 3 0 , N o 4
CONTRACTED CILIARY MUSCLES- LENS IS SPHERICAL
i
when the surgery is scheduled. Depending on the age and development of the child, the reasons for his surgery and the experiences he will have must be described in a manner appropriate to his level of understanding. Concise, clear written instructions should be made available to the parents concerning the necessary procedures. These should include the consent form, the laboratory tests to be conducted (urinalysis, hemoglobin, and sickle cell, if applicable), the meeting with the anesthesiologist, and the history that will be recorded the day of surgery. Parents should be told to notify the surgeon in advance if the child becomes ill before the scheduled admission date." A child's development between the ages of three and six encompasses massive changes in every aspect. Physically, motor skills a r e increasing. Acquisition of speed, strength, and coordination all combine to heighten mobility, allowing the child to participate more actively in society than during infancy. Intellectually, the child is acquiring language skills, enabling cognitive abilities to develop by provid-
Fig 2. Normal eyes looking at a distant object, A, and at a near object, 6.The ciliary, or focusing, muscle is thin and relaxes when looking at distant objects, as shown in A. This muscle is noticeably thickened in contraction when looking at near objects, as in B. By means of the ciliary muscle, the eye accommodates itself for objects at varying distances. The process is known as accommodation.
ing the tools with which to react to, form, and interpret perceptions. There is much psychological activity in a child of five years, and certain areas have proved more important than others at this stage. The child begins to experience aggression, frustration, anxiety, fear, and the beginning of the dependence versus independence struggle. Socially, the child is becoming more involved in reciprocal play with others and is aware of this relationship with peers, although egocentrism is characteristic of this age. 'The child is simply unaware of points-of-view other than his own. Developments during these ages are truly formative. As Erik Erikson p i n t s out, the acquisition of these skills and the relationship between them allows a child to become a member of his culture. l2 With this overall awareness, it is essential for the nurse to realize what threats surgery poses to a child of this age and how he is likely to respond. Parental influence plays an important role but it varies with individual families. Nurses must learn to deal with a child's specific behavior in a short time, as-
AORN Journal, October 1979, Val 30, N o 4
641
sisted by a working awareness of the child's developmental stage. In addition to basic circulating duties, adaptations are necessary for the care of the pediatric patient. For a sample nursing care guide, see Table 1. The child's entry into the operating room suite separates him from parents and introduces him into an alien environment. Children should receive preoperative sedation early enough so that it is fully effective. This will allay anxiety and fear and enhance induction. The circulator should be organized so he or she is able to stay with the child through induction. The nurse must present a calm, listening approach and try to establish trust and rapport in the short time prior to induction. Children around the ages of three to five are able to assimilate only one threatening factor at a time, so the nurse should be patient when a child repeats a question. Quietly repeating the answers to his questions reinforces a caring approach. The nurse should be free to hold the patient during induction instead of placing restraints on an awake child, which heighten fear. Staying with a child at this time enhances his security. Too rapid an induction in a child may cause bradycardia. The nurse must be alert for this complication and ready to provide an anticholinergic drug, if requested, understanding its use. Fluid balance in a child is more precarious than in an adult because of his smaller volume. An appropriate size of intravenous bag (500 milliliter) with a mini-dropper administration set should be provided for accurate calibration and to prevent overload errors. Temperature maintenance of a child is important due to his metabolic demands. The room should be between 68 F and 70 F with 50% humidity, then warmed or cooled appropriately according to the patient's needs. A warming blanket may be placed on the bed, if indicated.
642
Fig 3 Types of crossed eyes A esotropia (right eye turned in toward nose) 6 , exotropia (right eye turned out toward the temple) C, hypertropia (right eye turned upward) D, hypotropia (right eye turned downward) ~
~
Every child should have a temperature probe inserted. Warm blankets should be available to place on the child at the end of the procedure for the transfer to the recovery room. Malignant hyperpyrexia is rare, but it is most likely to occur in a child undergoing general anesthesia for the first time. The nurse must know how to obtain equipment for the treatment (ice, tub, and plastic bags) immediately. Positioning of the pediatric strabismus patient follows the basic guidelines of maintaining good body alignment that does not compromise nerves, circulation, skin and soft tissue integrity, or respiration. Also, the anesthesiologist should have free access to the patient. The safety strap should be padded and placed above the knees to prevent
AORN Journal, October 1979,Vol30, No 4
peroneal nerve damage. At the University of Iowa Hospitals and Clinics, draping procedures are as follows. After induction, a stockinet cap is placed on the patient’s head to cover the hair and ears. The cap isolates contaminants from the field and prevents the skin preparation solution from entering the ear canal. The anesthesiologist needs to be aware when the nurse is manipulating the head so he may guard the endotracheal tubes and respiration when the head is flexed. The patient’s skin is prepared with the solution the surgeon prefers. A disposable drape is spread lengthwise over the child‘s body. This is followed by a cloth drape with the proximal end cuffed and folded on the chest until the eyes are draped. A head drape is then applied. This is a folded, disposable sheet with a n unfolded towel centered on the fold of the sheet. Again, anesthesia personnel must be aware when the patient’s head is flexed so the head drape may be slipped under the head. The towel is wrapped turban style around the head, making sure the ears lie flat. The towel is secured with a towel clip through the towel only. A folded towel is placed over the forehead. The rest of the cloth body sheet may be brought up to the middle of the bridge of the nose. Folded towels are placed laterally and medially to the operative eye, and a small towel drape is placed over these. The Mayo stand is set up with the necessary instrumentation. The table is placed on the side of the head which is not being operated on. The procedure is begun. The muscles operated on depend on the patient’s specific problem. Sometimes both eyes are operated on even though only one eye is affected because both eyes act as a team. Bilateral correction will enhance coordination. Two approaches are the most common. Resection strengthens a muscle by remov-
RIGHT EYE
RIGHT EYE
LEFT EYE
LEFT EYE
Fig 4. A, esotropia with left eye turned inward. B, bimedial recession of the medial rectus muscles.
ing a specified amount of muscle to increase its tension. Recession weakens the effect of a muscle by moving back its insertion on the gllobe, keeping the length of the muscle intact. The most common operation probably is a recession of a medial rectus muscle for esotropia (Fig 4)l. Moving back its insertion weakens the medial pull that makes the eye deviate inward, permitting the lateral rectus to act more efficiently in pulling the eye laterally. The technical schema of a recession is: 1. An eyelid speculum is inserted, and the conjunctiva is incised at the border of the muscle to be recessed. 2. A muscle hook is passed under the muscle, and Tenon’s capsule is incised over the muscle insertion. 3. A double-armed suture is passed
AORN Journal, October 1979,Vol30, No 4
643
Table 1
Nursing care guide Patient problem
Nursing activity
Patient outcomes
Anxiety and fear due to impending surgery and unfamiliar environment
Be informed about child's age and level of development Time call for patient to allow maximum effect of preoperative sedation Organize time to be able to stay with patient before induction Respond calmly and patiently to child's behavior Hold child during induction Explain and reinforce that he will be safe and well cared for Don't place restraints on child until after induction
Patient verbalizes fears Patient is calm Patient's body is relaxed Patient verbalizes understanding of events appropriate to his level of development
Potential bradycardia upon induction
Be alert for signs of bradycardia upon induction Provide appropriate anticholinergic drug in room Be familiar with use of drug in this situation
Patient does not exhibit significant change in heart rate
Potential problems regulating fluid balance
Provide 500 ml bag with minidropper administration set
Patient maintains appropriate fluid balance
Potential injuries due to improper positioning under general anesthesia
Place safety strap above knees, over blanket All bony prominences appropriately padded Good alignment of extremities with support as needed Provide free access by anesthesia personnel
Patient's skin integrity is maintained Circulation, nerves, and respiration are not compromised due to positioning
Potential problem for maintaining appropriate temperature according to child's metabolic demands
Warm room if necessary Check for use of heating pad Make sure temperature probe is inserted and connected to temperature monitor Have warm blankets available for recovery room transfer Be alert for malignant hyperpyrexia and ready to take appropriate action
Patient will maintain safe temperature conducive to homeostasis
Potential conjunctival granuloma
After donning, wipe gloves of scrub person and surgeons with moist towel to remove any traces of starch or powder remaining on gloves
Patient will not exhibit signs of conjunctival granuloma postoperatively
644
AORN Journal, October 1979, V o l 3 0 , N o 4
Patient problem
Nursing activity
Patient outcomes
Potential aspiration if child vomits during transfer to recovery room
Transfer patient on cart capable of being placed in Trendelenburg position Patient is positioned securely on side with support if indicated
Patient will not aspirate if he vomits during transfer
Potential injuries during transfer if in postanesthetic excitable stage
Have properly and fully equipped cart available for transfer
Patient will not show signs of injury from transfer
through the muscle at its insertion point, and the muscle is severed distally to this suture. 4. Using a caliper and ruler, the desired distance on the globe behind its previous insertion is found, and the muscle is anchored to the globe at that point. 5 . The conjunctiva is closed. Another approach for correcting esotropia is resection of the lateral redus. The operation chosen depends on the patient’s pathology and the surgeon’s decision regarding the presenting situation. The schema for a resection is: 1. An eyelid speculum is inserted, and the conjunctiva is incised at the insertion of the muscle to be resected. 2. A muscle hook is passed under the muscle at its insertion, and Tenon’s capsule over this area is further incised. 3. A double-armed suture is passed through the muscle belly at the desired position of suturing, and the muscle is incised anterior t o this suture. 4.The stump of the muscle is excised from the insertion, and the muscle is now sutured to the insertion using the preplaced double-armed suture. 5 . The conjunctiva is c10sed.l~ For two reasons, a patient may have to undergo more than one operation to correct strabismus. First, doing a minimal correction is desirable. An overcor-
rection (from esotropia to exotropia) is extremely difficult and often impossible to correct. Therefore it is wise to do the most conservative correction initially and then, if indicated, bring the patient back for more repair. The second reason a patient may have another operation is that a critical deviation wasn’t apparent until the horizontal deviation was corrected.I4 The following operations involve the superior and inferior oblique muscles to correct vertical devi,ations. (Myectomy may also be perforimed on the other muscles.) A myectomy is a method of weakening the action of a muscle. The muscle is lengthened by performing a Z-plasty, or the inferior oblique is completely severed. If the inferior oblique is severed laterally, the muscle is weakened without paralyzing it due to its unique anatomy. The schema is: The involved muscle is isolated, as previously described. If the superior oblique is being approached, the muscle sheath is opened, and graded sections of the muscle are excised, according to the patient’s need. A myectomy of the inferior oblique is done in a graded fashion by placing two clamps across the muscle belly lateral to the inferior rectus and excising the isolated strip of muscle. The ends of the muscle are cauterized and released. The conjunctiva is closed.15 A tuck is a method of shortening, thus
AORN Journal, October 1979, Vol30, No 4
645
strengthening, the superior oblique: 1. An incision is made in the conjunctiva medially to the superior rectus. 2. A muscle hook is passed posteriorly into t h e orbit, and the superior oblique muscle is hooked and brought out into the incision. 3. A tucker is placed over the muscle, and a graded doubling of muscle, like looping a rope, is completed. 4. A double-armed suture is passed through the base of the loop, effectively shortening the muscle. 5. The tip of the loop is sutured to the sclera, and the muscle is tucked back laterally to the superior rectus. 6. The conjunctiva is closed.16 On completion of the operation, the nurse should have available a pediatric cart capable of being placed in Trendelenburg position, with an intravenous infusion (IV) pole and four side rails. The recovery room is notified about the patient they are about to receive, including pertinent data that will enhance the consistency of nursing care. The nurse assists in transferring the patient to the cart. The child remains in the recovery room until the risk of immediate complications has passed, and he has sufficiently recovered, as determined by the anesthesiologist. Depending on the institution's policy, parents may be allowed in the recovery room once their child has awakened. At discharge, parents should be given postoperative instructions. They should understand the importance of reestablishing fluid balance by encouraging the child to drink small amounts of noncarbonated beverages frequently. Directions may be included for applying an antibiotic ointment to the eyes. Finally, parents should be given a telephone number to call for further advice or to report complication^.'^ 0
646
Notes 1. Florence G Blake, T Howell Wright, Eugenia H Waechter, Nursing Care of Children, 8th ed (Philadelphia: J B Lippincott Co, 1970) 428. 2. Herbert M Katzin, Geraldine Wilson, Strabismus in Childhood (St Louis: C V Mosby Co, 1968)4. 3. Norma J Kolthoff, Catherine A n t h o n y , Textbook of Anatomy and Physiology (St Louis: C V Mosby Co, 1971) 247. 4. Katzin, Wilson, Strabismus in Childhood, 20. 5. Ibid, 35. 6. Ibid, 82. 7. Ibid, 22. 8. Blake, Wright, Waechter, Nursing Care of Children, 428. 9. Katzin, Wilson, Strabismus in Childhood, 6. 10. Blake, Wright, Waechter, Nursing Care of Children, 829. 11. D J Steward, "Outpatient pediatric anesthesia,"Anesthesiology 43 (August 1975)268-276. 12. Justin Aronfreed, Nancy Bayley, Ursula Bellugi, Developmental Psychology Today (Del Mar, Calif: Communications Research Machines, Inc, 1971) 209. 13. Walter F Ballinger, Jacquelyn C Treybal, Ann B Vose, Alexander's Care of the Patient in Surgery, 5th ed (St Louis: C V Mosby, 1972) 258-259. 14. Katzin, Wilson,Strabismus in Childhood, 75. 15. Ballinger,Treybal, Vose, Alexander's Care of the Patient in Surgery, 259. 16. Ibid, 259. 17. Steward, "Outpatient pediatric anesthesia," 274.
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AORN Journal, October 1979, V o l 3 0 , No 4
The pediatric strabismus patient in surgery
Strabismus comes from the Greek word strubisnos, which literally translated means “a squinting.” This is somewhat deceptive, because strabismus rarely results in what we commonly think of as squinting-partially closing the eyes to see clearly. Strabismus is a condition in which both eyes can’t look a t an object a t the same time due to discrepancies in the strength, hence coordination, of the extraocular musc1es.l It occurs in 2% of the children in this country and may be caused by a recessive gene that accounts for the deviations from normal in the length, strength, or attachment positions of the extraocular muscles.* Other causes include specific trauma and disease, such as birth injuries or intraorbital tumors.
Amy Shurtz, RN was a nurse clinician in ophthalmology at the University of Iowa Hospitals and Clinics Iowa City. when this article was written She IS a diploma graduate of the Peter Bent Brigham Hospital School of Nursing Boston
There are six extraocular muscles of the eye, which are striated, voluntary skeletal muscles (Fig 1).The medial rectus is primarily responsible for adduction and, along with the inferior oblique, superior, and inferior rectus muscles, is innervated ’by the I11 cranial nerve (oculomotor). The VI cranial nerve (abducens) innervates the lateral rectus, which is involved in abduction. The superior oblique initiates upward motion of the eye arid is innervated by the IV cranial nerve, the t r ~ c h l e a r . ~ Normally, the lines of vision (visual axis) of the eyes are parallel when the object is a t a distance of 20 feet or more. When the object is nearer, the eyes rotate medially so that the visual axes meet the object. This is convergence. Divergence is a shift of visual axes from a nearer to a farther object, and the lines of vision move farther apart.* Accommodation i5; the adjustment of the eye to focus the image on the retina, which consists of’ t h r e e reflexive actions. When accommodating for near vision, the ciliary muscles contract, increasing curvature of the lens. The pupil contracts, and the visual axes converge (Fig 2). For distant vision, the changes are r e ~ e r s e d . ~ Refractive errors are caused by a condition in which parallel rays of light are not focused on the retina for a variety of reasons6 Fusion is the ability of the brain to blend images from each eye and interpret them as one. For this to occur,
AORN Journal, October 1979, Vol30, N o 4
639
both visual axes must be coordinated.7 In strabismus, the visual axis of only one eye goes to the object. Strabismus may be divided into two broad categories: paralytic and nonparalytic. Paralytic strabismus is the inability of the extraocular muscles of the affected eye to coordinate with the unaffected eye. In nonparalytic strabismus, the affected eye moves with the normal eye but maintains a separate visual axis. This is called concomitant strabismus and is due to a n error of refraction. The error may be that the accommodation isn’t accurate when both eyes are able to fix accurately on the object. The child can choose between coordinated fixation with poor vision or accurate accommodation with double vision. The choice resulting in strabismus usually starts to be consistently noticeable between the ages of two and three. Until that time, the retina isn’t developed enough to provide distinctively clear images anyway. There are two general kinds of concomitant strabismus: monocular, when one eye is used constantly for vision and the other eye habitually deviates, and alternating, when either eye is used for vision and the other eye becomes the affected eye.s Strabismus, then, is described by what deviation the eye presents: esotropia (also called convergent strabismus)-inward deviation exotropia (also called divergent strabismus)-outward deviation hypertropia-upward deviation hypotropia-downward deviation (Fig 3).9 The goal of strabismus surgery is to obtain the highest potential for the best possible vision by making fusion possible and to obtain the best appearance. The surgery consists of correcting the basic position of one eye relative to the other. This is done by either lengthening or shortening the involved extraocular muscles. Surgery is indicated when
640
A
INFERIOR^
RECTUS
Fig 1 . A, side view of a right eye 6 . front view of a right eye. Figs 1 through 4 reprinted with permission from C E Windsor, Jane Hurtt, Eye Muscle Problems in Childhood A Manual for Parents. 2nd e d (St Louis C V Mosby Co, 1974)
a child h a s attained maximum improvement with glasses and exercise and when these results have shown fusion is possible. Usually, this is between the ages of three and five. Preferably, surgery is done before the child starts school, not only for optimal vision, but to alleviate taunting by peers during a particularly formative time of a child’s life.l0 Ideally, t h e surgical correction of strabismus can be done on a n outpatient basis, which decreases emotional trauma, reduces the cost of treatment, and lessens the risk of nosocomial infection. The initial decision about the patient’s suitability for outpatient anesthesia is made by the surgeon, and preparation of the parents and child begins
AORN Journal, October 1979, V o l 3 0 , N o 4
CONTRACTED CILIARY MUSCLES- LENS IS SPHERICAL
i
when the surgery is scheduled. Depending on the age and development of the child, the reasons for his surgery and the experiences he will have must be described in a manner appropriate to his level of understanding. Concise, clear written instructions should be made available to the parents concerning the necessary procedures. These should include the consent form, the laboratory tests to be conducted (urinalysis, hemoglobin, and sickle cell, if applicable), the meeting with the anesthesiologist, and the history that will be recorded the day of surgery. Parents should be told to notify the surgeon in advance if the child becomes ill before the scheduled admission date." A child's development between the ages of three and six encompasses massive changes in every aspect. Physically, motor skills a r e increasing. Acquisition of speed, strength, and coordination all combine to heighten mobility, allowing the child to participate more actively in society than during infancy. Intellectually, the child is acquiring language skills, enabling cognitive abilities to develop by provid-
Fig 2. Normal eyes looking at a distant object, A, and at a near object, 6.The ciliary, or focusing, muscle is thin and relaxes when looking at distant objects, as shown in A. This muscle is noticeably thickened in contraction when looking at near objects, as in B. By means of the ciliary muscle, the eye accommodates itself for objects at varying distances. The process is known as accommodation.
ing the tools with which to react to, form, and interpret perceptions. There is much psychological activity in a child of five years, and certain areas have proved more important than others at this stage. The child begins to experience aggression, frustration, anxiety, fear, and the beginning of the dependence versus independence struggle. Socially, the child is becoming more involved in reciprocal play with others and is aware of this relationship with peers, although egocentrism is characteristic of this age. 'The child is simply unaware of points-of-view other than his own. Developments during these ages are truly formative. As Erik Erikson p i n t s out, the acquisition of these skills and the relationship between them allows a child to become a member of his culture. l2 With this overall awareness, it is essential for the nurse to realize what threats surgery poses to a child of this age and how he is likely to respond. Parental influence plays an important role but it varies with individual families. Nurses must learn to deal with a child's specific behavior in a short time, as-
AORN Journal, October 1979, Val 30, N o 4
641
sisted by a working awareness of the child's developmental stage. In addition to basic circulating duties, adaptations are necessary for the care of the pediatric patient. For a sample nursing care guide, see Table 1. The child's entry into the operating room suite separates him from parents and introduces him into an alien environment. Children should receive preoperative sedation early enough so that it is fully effective. This will allay anxiety and fear and enhance induction. The circulator should be organized so he or she is able to stay with the child through induction. The nurse must present a calm, listening approach and try to establish trust and rapport in the short time prior to induction. Children around the ages of three to five are able to assimilate only one threatening factor at a time, so the nurse should be patient when a child repeats a question. Quietly repeating the answers to his questions reinforces a caring approach. The nurse should be free to hold the patient during induction instead of placing restraints on an awake child, which heighten fear. Staying with a child at this time enhances his security. Too rapid an induction in a child may cause bradycardia. The nurse must be alert for this complication and ready to provide an anticholinergic drug, if requested, understanding its use. Fluid balance in a child is more precarious than in an adult because of his smaller volume. An appropriate size of intravenous bag (500 milliliter) with a mini-dropper administration set should be provided for accurate calibration and to prevent overload errors. Temperature maintenance of a child is important due to his metabolic demands. The room should be between 68 F and 70 F with 50% humidity, then warmed or cooled appropriately according to the patient's needs. A warming blanket may be placed on the bed, if indicated.
642
Fig 3 Types of crossed eyes A esotropia (right eye turned in toward nose) 6 , exotropia (right eye turned out toward the temple) C, hypertropia (right eye turned upward) D, hypotropia (right eye turned downward) ~
~
Every child should have a temperature probe inserted. Warm blankets should be available to place on the child at the end of the procedure for the transfer to the recovery room. Malignant hyperpyrexia is rare, but it is most likely to occur in a child undergoing general anesthesia for the first time. The nurse must know how to obtain equipment for the treatment (ice, tub, and plastic bags) immediately. Positioning of the pediatric strabismus patient follows the basic guidelines of maintaining good body alignment that does not compromise nerves, circulation, skin and soft tissue integrity, or respiration. Also, the anesthesiologist should have free access to the patient. The safety strap should be padded and placed above the knees to prevent
AORN Journal, October 1979,Vol30, No 4
peroneal nerve damage. At the University of Iowa Hospitals and Clinics, draping procedures are as follows. After induction, a stockinet cap is placed on the patient’s head to cover the hair and ears. The cap isolates contaminants from the field and prevents the skin preparation solution from entering the ear canal. The anesthesiologist needs to be aware when the nurse is manipulating the head so he may guard the endotracheal tubes and respiration when the head is flexed. The patient’s skin is prepared with the solution the surgeon prefers. A disposable drape is spread lengthwise over the child‘s body. This is followed by a cloth drape with the proximal end cuffed and folded on the chest until the eyes are draped. A head drape is then applied. This is a folded, disposable sheet with a n unfolded towel centered on the fold of the sheet. Again, anesthesia personnel must be aware when the patient’s head is flexed so the head drape may be slipped under the head. The towel is wrapped turban style around the head, making sure the ears lie flat. The towel is secured with a towel clip through the towel only. A folded towel is placed over the forehead. The rest of the cloth body sheet may be brought up to the middle of the bridge of the nose. Folded towels are placed laterally and medially to the operative eye, and a small towel drape is placed over these. The Mayo stand is set up with the necessary instrumentation. The table is placed on the side of the head which is not being operated on. The procedure is begun. The muscles operated on depend on the patient’s specific problem. Sometimes both eyes are operated on even though only one eye is affected because both eyes act as a team. Bilateral correction will enhance coordination. Two approaches are the most common. Resection strengthens a muscle by remov-
RIGHT EYE
RIGHT EYE
LEFT EYE
LEFT EYE
Fig 4. A, esotropia with left eye turned inward. B, bimedial recession of the medial rectus muscles.
ing a specified amount of muscle to increase its tension. Recession weakens the effect of a muscle by moving back its insertion on the gllobe, keeping the length of the muscle intact. The most common operation probably is a recession of a medial rectus muscle for esotropia (Fig 4)l. Moving back its insertion weakens the medial pull that makes the eye deviate inward, permitting the lateral rectus to act more efficiently in pulling the eye laterally. The technical schema of a recession is: 1. An eyelid speculum is inserted, and the conjunctiva is incised at the border of the muscle to be recessed. 2. A muscle hook is passed under the muscle, and Tenon’s capsule is incised over the muscle insertion. 3. A double-armed suture is passed
AORN Journal, October 1979,Vol30, No 4
643
Table 1
Nursing care guide Patient problem
Nursing activity
Patient outcomes
Anxiety and fear due to impending surgery and unfamiliar environment
Be informed about child's age and level of development Time call for patient to allow maximum effect of preoperative sedation Organize time to be able to stay with patient before induction Respond calmly and patiently to child's behavior Hold child during induction Explain and reinforce that he will be safe and well cared for Don't place restraints on child until after induction
Patient verbalizes fears Patient is calm Patient's body is relaxed Patient verbalizes understanding of events appropriate to his level of development
Potential bradycardia upon induction
Be alert for signs of bradycardia upon induction Provide appropriate anticholinergic drug in room Be familiar with use of drug in this situation
Patient does not exhibit significant change in heart rate
Potential problems regulating fluid balance
Provide 500 ml bag with minidropper administration set
Patient maintains appropriate fluid balance
Potential injuries due to improper positioning under general anesthesia
Place safety strap above knees, over blanket All bony prominences appropriately padded Good alignment of extremities with support as needed Provide free access by anesthesia personnel
Patient's skin integrity is maintained Circulation, nerves, and respiration are not compromised due to positioning
Potential problem for maintaining appropriate temperature according to child's metabolic demands
Warm room if necessary Check for use of heating pad Make sure temperature probe is inserted and connected to temperature monitor Have warm blankets available for recovery room transfer Be alert for malignant hyperpyrexia and ready to take appropriate action
Patient will maintain safe temperature conducive to homeostasis
Potential conjunctival granuloma
After donning, wipe gloves of scrub person and surgeons with moist towel to remove any traces of starch or powder remaining on gloves
Patient will not exhibit signs of conjunctival granuloma postoperatively
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AORN Journal, October 1979, V o l 3 0 , N o 4
Patient problem
Nursing activity
Patient outcomes
Potential aspiration if child vomits during transfer to recovery room
Transfer patient on cart capable of being placed in Trendelenburg position Patient is positioned securely on side with support if indicated
Patient will not aspirate if he vomits during transfer
Potential injuries during transfer if in postanesthetic excitable stage
Have properly and fully equipped cart available for transfer
Patient will not show signs of injury from transfer
through the muscle at its insertion point, and the muscle is severed distally to this suture. 4. Using a caliper and ruler, the desired distance on the globe behind its previous insertion is found, and the muscle is anchored to the globe at that point. 5 . The conjunctiva is closed. Another approach for correcting esotropia is resection of the lateral redus. The operation chosen depends on the patient’s pathology and the surgeon’s decision regarding the presenting situation. The schema for a resection is: 1. An eyelid speculum is inserted, and the conjunctiva is incised at the insertion of the muscle to be resected. 2. A muscle hook is passed under the muscle at its insertion, and Tenon’s capsule over this area is further incised. 3. A double-armed suture is passed through the muscle belly at the desired position of suturing, and the muscle is incised anterior t o this suture. 4.The stump of the muscle is excised from the insertion, and the muscle is now sutured to the insertion using the preplaced double-armed suture. 5 . The conjunctiva is c10sed.l~ For two reasons, a patient may have to undergo more than one operation to correct strabismus. First, doing a minimal correction is desirable. An overcor-
rection (from esotropia to exotropia) is extremely difficult and often impossible to correct. Therefore it is wise to do the most conservative correction initially and then, if indicated, bring the patient back for more repair. The second reason a patient may have another operation is that a critical deviation wasn’t apparent until the horizontal deviation was corrected.I4 The following operations involve the superior and inferior oblique muscles to correct vertical devi,ations. (Myectomy may also be perforimed on the other muscles.) A myectomy is a method of weakening the action of a muscle. The muscle is lengthened by performing a Z-plasty, or the inferior oblique is completely severed. If the inferior oblique is severed laterally, the muscle is weakened without paralyzing it due to its unique anatomy. The schema is: The involved muscle is isolated, as previously described. If the superior oblique is being approached, the muscle sheath is opened, and graded sections of the muscle are excised, according to the patient’s need. A myectomy of the inferior oblique is done in a graded fashion by placing two clamps across the muscle belly lateral to the inferior rectus and excising the isolated strip of muscle. The ends of the muscle are cauterized and released. The conjunctiva is closed.15 A tuck is a method of shortening, thus
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strengthening, the superior oblique: 1. An incision is made in the conjunctiva medially to the superior rectus. 2. A muscle hook is passed posteriorly into t h e orbit, and the superior oblique muscle is hooked and brought out into the incision. 3. A tucker is placed over the muscle, and a graded doubling of muscle, like looping a rope, is completed. 4. A double-armed suture is passed through the base of the loop, effectively shortening the muscle. 5. The tip of the loop is sutured to the sclera, and the muscle is tucked back laterally to the superior rectus. 6. The conjunctiva is closed.16 On completion of the operation, the nurse should have available a pediatric cart capable of being placed in Trendelenburg position, with an intravenous infusion (IV) pole and four side rails. The recovery room is notified about the patient they are about to receive, including pertinent data that will enhance the consistency of nursing care. The nurse assists in transferring the patient to the cart. The child remains in the recovery room until the risk of immediate complications has passed, and he has sufficiently recovered, as determined by the anesthesiologist. Depending on the institution's policy, parents may be allowed in the recovery room once their child has awakened. At discharge, parents should be given postoperative instructions. They should understand the importance of reestablishing fluid balance by encouraging the child to drink small amounts of noncarbonated beverages frequently. Directions may be included for applying an antibiotic ointment to the eyes. Finally, parents should be given a telephone number to call for further advice or to report complication^.'^ 0
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Notes 1. Florence G Blake, T Howell Wright, Eugenia H Waechter, Nursing Care of Children, 8th ed (Philadelphia: J B Lippincott Co, 1970) 428. 2. Herbert M Katzin, Geraldine Wilson, Strabismus in Childhood (St Louis: C V Mosby Co, 1968)4. 3. Norma J Kolthoff, Catherine A n t h o n y , Textbook of Anatomy and Physiology (St Louis: C V Mosby Co, 1971) 247. 4. Katzin, Wilson, Strabismus in Childhood, 20. 5. Ibid, 35. 6. Ibid, 82. 7. Ibid, 22. 8. Blake, Wright, Waechter, Nursing Care of Children, 428. 9. Katzin, Wilson, Strabismus in Childhood, 6. 10. Blake, Wright, Waechter, Nursing Care of Children, 829. 11. D J Steward, "Outpatient pediatric anesthesia,"Anesthesiology 43 (August 1975)268-276. 12. Justin Aronfreed, Nancy Bayley, Ursula Bellugi, Developmental Psychology Today (Del Mar, Calif: Communications Research Machines, Inc, 1971) 209. 13. Walter F Ballinger, Jacquelyn C Treybal, Ann B Vose, Alexander's Care of the Patient in Surgery, 5th ed (St Louis: C V Mosby, 1972) 258-259. 14. Katzin, Wilson,Strabismus in Childhood, 75. 15. Ballinger,Treybal, Vose, Alexander's Care of the Patient in Surgery, 259. 16. Ibid, 259. 17. Steward, "Outpatient pediatric anesthesia," 274.
Congress deadline dates Nov 6-Up-to-date local membership roster information to be in at Headquarters Nov 19-Membership computer printout and delegateforms mailed from Headquartersto chapter treasurers Jan 19-Postmark deadline for Congress advance registrations and pre-Congress seminar advance registrations Jan 25-Postmark deadline for forms listing delegates and alternates to be sent to Headquarters Feb 8-Written change of delegate status to be received at Headquarters Feb. 15-Letters outlining duties mailed from Headquarters to delegates and alternate delegates March 28-Postmark deadline for written request for refund of registration fee.
AORN Journal, October 1979, V o l 3 0 , No 4
