Cataract Surgery Care Pathway - N2 Surgical · Cataract Surgery Care Pathway PATIENT ADDRESSOGRAPH: ... Indication for second eye cataract surgery 1) Patient has cataract in the second

Cataract Surgery Care Pathway

PATIENT ADDRESSOGRAPH:

PATIENT Telephone No: ............................................

CONSULTANT: ..............................................................

PROPOSED PROCEDURE:

RIGHT/LEFT Cataract Extraction and Intraocular Lens Implant (Local Anaesthetic)

1ST EYETCI DATE: ............................ TIME: .............................

NEXT OF KIN:

....................................................................................... Relationship:

....................................................................................... Address:

.......................................................................................

.......................................................................................

Telephone No:............................................................

PRE-ASSESSMENT CLINICIAN:

....................................................................................... PRE-ASSESSMENT PERSON:

.......................................................................................

2ND EYETCI DATE: ............................ TIME: .............................

MEDICAL HISTORY YES NO COMMENTS

Will you:

1. Have someone to take you home? Who?

2. Have someone to call on in an emergency?

Have you ever suffered from?

1. Chest pain, Angina?

2. Breathlessness, chest disease?

3. A heart attack or heart problems?

4. Hypertension?

5. Fainting easily?

6. Epilepsy?

7. Arthritis?

8. Diabetes?

9. Any other operations/illnesses?

B/P: P: Urinalysis:

MEDICATION: Warfarin: YES / NO (If ‘yes’ needs 1/52 pre-op INR check)

Tamsulosin: YES / NO Clopidogrel: YES / NO

ALLERGIES: (Write in Red)

Is patient a previous known MRSA carrier: YES / NO

Head Tremor?: NO - Head Tremor YES - Head Tremor Noted - Surgeon Informed

Mobility: Ability to Lie Flat:

Hearing Problems: YES / NO Language Interpreter Needed: YES / NO

1

Indication for first eye cataract surgery

Visual acuity is 6/12 or worse in the first eye?

Visual acuity is 6/12 or better but applies for exception criteria

A) Posterior sub capsular cataract and glare

B) Cortical cataracts and glare

C) Good acuity essential to maintain daily living skills

State reason: ........................................................................................................................

D) Good acuity essential to ability to work

State job: ...............................................................................................................................

E) Driving affected by significant glare

F) Occupational requirement to drive at night and glare

State job: ...............................................................................................................................

G) Borderline visual field defects for driving who would expect a significantly improved visual field with surgery

H) Glaucoma and requires cataract surgery to reduce intraocular pressure

I) Diabetic and clear retina view required for retinopathy screening

J) Other retinal pathology needs clear view to investigate and treat

Clinician signature: ............................................................................... Date: ........ /........ /........

2

The following information has been given to the patient

Detailed explanation of a cataract

Explanation of the Operation (including benefits)

Explanation regarding the routine on the day of surgery, including:

• Information regarding diet and fluids• Information regarding current medication• Advised pre operative bath/shower

Expected symptoms following cataract surgery, including:

• Blurred vision • Diplopia • Hazy vision / glare • Gritty sensation / watery eye

Restrictions following surgery, including:

• Heavy lifting • Prolonged bending• Rubbing the eye• Driving

Need for spectacles following surgery

Possible complications following cataract surgery, including:• Bruising• Infection• Capsular tear, resulting in anterior chamber lens implant +/- Vitrectomy• Raised intraocular pressure• Posterior Capsular thickening• Cystoid Macular Oedema• Refractive surprise• Allergy• Dropped nucleus• Haemorrhage• Corneal decompensation• Detached retina• Dislocation of implant

The above information has been given to the patient by:

Signature: ......................................................................... Date: ........ /........ /........

Print Name: ....................................................................... Job Title: .......................................................................

PATIENT PRE-ASSESSED AS PER PROTOCOL

The above information has been given to the patient.

The patients own questions have been addressed and answered, as detailed below:

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Patient Signature: ................................................................................ Date: ........ /........ /........

Practitioners Signature: ................................................................................................. (Sign & Print)

Optometrists Signature: ................................................................................................. (Sign & Print)

3

Patient Advised:

Transport

3 Hour Stay

Maxitrol Drop Regime 4 Weeks

(Circle as appropriate)

Glaucoma Patients advised to use fresh

supply of prescribed Glaucoma drops

post - operatively.

Post - Op drops to be instilled by:

Patient/Other (Tuition Given - if applicable)

Doctor / Clinician Clerking

OCULAR EXAMINATION RIGHT EYE LEFT EYE

VISION: UNAIDED

AIDED

PIN HOLE

INTRA-OCULAR PRESSURE

LIDS

CONJUNCTIVA

CORNEA

ANTERIOR CHAMBER

PUPIL

LENS

FUNDUS

DISC

4

R L

Tropicamide 1% Left Eye: Right Eye: Both Eyes:

Lot No: ....................................

Expiry Date: ........ /........ /........

Oxybuprocaine 0.4% Left Eye: Right Eye: Both Eyes:

Lot No: ....................................

Expiry Date: ........ /........ /........

Past Ocular History:

Symtoms:

ADVICE:............................................................................................................................................................

............................................................................................................................................................

5

N2S Cataract Clinic at St Stephens Gate Medical Practice

55 Wessex Street Norwich NR2 2TJ

t: 01603 229617 f: 01603 229614

www.n2surgical.co.uk

I, ..........................................................................................................................................................................................

Consent to the operation of:

Cataract extraction and lens implant in eye

Or minor eye surgery as detailed below:

......................................................................................................................................................................................

.....................................................................................................................................................................................

.....................................................................................................................................................................................

The nature and purpose of which have been explained to me by:

..............................................................................................................................................

I confirm that I am informed of the risks and benefits of the procedure.

I also consent to any other measures and anaesthetics which may become necessary during the procedure and

consent for any complication to be dealt with as the surgeon sees appropriate.

Signed: ...................................................................................... Date: ........ /........ /........

I confirm that I have explained the procedure to the above patient as well as the other appropriate options,

which are available, and the possible risks involved. The explanation I have given is in my judgement, suited

to the understanding of the patient.

Signed: ...................................................................................... Date: ........ /........ /........

Consent to Operate or Procedure

Norwich and Norfolk Surgical Ltd. (N2S) Registered address: St Stephens Gate Medical Practice, 55 Wessex Street, Norwich NR2 2TJ Company No: 10615484 registered in England and Wales.

Medication Prescribing and Record Sheet - 1st Eye

6

DATE: ALLERGIES:

DRUG

G Cyclopentolate 1% minims

G Phenylephrine 2.5% minims

G Oxybuprocaine 0.4% minims

Chloramphenicol 0.5% minims

PRE-OPERATIVE AND ‘ONCE ONLY’ DRUGS

DOSE EYE L or R

PRESCRIBED BY

GIVEN BY

TIME 1st 2nd 3rd

DRUG

G Maxitrol Drops

T.T.A.

FREQUENCY

As per eye drop diary

SIGNATURE DATE PHARMACY

Pre-Operative Checklist

Please tick box Must be checked and signed by two members of staff

Identity band correct and sited securely

Consent form corresponds to patient’s understanding

Consent form is signed

Operation site marked

Pupil Dilated?

Dentures?

Prosthesis/ Hearing Aid?

ALLERGIES? (RED wrist band in situ?)

Patient advised to keep still and to squeeze handholder’s hand before moving or speaking etc.

YES NO COMMENTS

Comments

Patient prepared for surgery

Signed: ...................................................................................... Date: ........ /........ /........

Signed: ...................................................................................... Date: ........ /........ /........

W.H.O. Check List

Oxygen via ‘L’Bar

Rubens Pillow/ Gel Head Support

Pillow Under the knees

Patient SpO2: %

Signature:

Please Tick Box / Record Reading

Litres

Patient Heart Rate: BPM

Date:

Intra - Operative Care Pathway

7

Date: ........ /........ /........ 1st Eye Cataract Operation Note

8

OPERATION RIGHT / LEFT Cataract Extraction and Intraocular Lens Implant

IOL Power ....................................... Target refraction: .........................................

SURGEON (Name and Signature)

SCRUB PERSON

CIRCULATING PERSON

SKIN PREP USED

LOCAL ANAESTHETIC

IOL STICKER

SIGNATURE

Aqueous Iodinated Povidone Aqueous Chlorhexidine

Topical (0.4% Oxybuprocaine / 0.5% Proxymetacaine)

Intra-Cameral (1% lidocaine)

Sub–Tenon Injection (2% Xylocaine +Adrenaline 1:200,000 & Hyalase)

INCISION

Limbal Corneal

CCC, Hydrodissection, Phaco, I/A

IOL: Bag Sulcus AC Wounds: Secure .......... x ................. stitches

Intra-cameral Moxifloxacin

Dosage: 500µg / 0.1ml

Lot No: ........................................

Expiry Date: ......... /......... /..........

DRESSINGS: Eye shield

Phenylepherine

Dosage: 2.5%

Lot No: ........................................

Expiry Date: ......... /......... /..........

Chloramphenicol Ointment

Lot No: ........................................

Expiry Date: ......... /......... /..........

Traceability Stickers 1st Eye

9

1st Eye Discharge Assessment

10

ALERT, ORIENTATED AND ABLE TO SIT UNAIDED

EYE SHIELD / EYE DRESSINGS

ASSESSED FIT FOR DISCHARGE

ESCORT ARRIVED

PATIENT DISCHARGED AT ................ HOURS

DISCHARGE AS PER PROTOCOL SIGNATURE OF NURSE

..............................................................................

MEDICINES/DROPS ISSUED TO TAKE HOME (DOSAGE EXPLAINED) GP’S LETTER GIVEN TO PATIENT FOLLOW UP APPOINTMENT

GIVEN FOR: ..................................................

VENUE: ......................................................... POST OPERATIVE ADVICE GIVEN

APPROPRIATE CONTACT NUMBERS GIVEN TO PATIENT / CARER

Signature of Discharging Practitioner: .......................................... Print Name: ......................................... Date: ...... /...... /......

PATIENTS REPORTS THAT:

Has patient removed dressings & replaced shield? (if applicable)

Is Patient in pain?

How is the patient’s vision?

Does the patient have any questions?

Any other comments?

YES / NO / COMMENT

First Post - Operative Phone CallDate: ...... /...... /....... Time: ................ Staff Name: .............................................. Signature: .............................................


Has patient removed shield and bathed eye?

Is Patient in pain?


Have they started using Maxitrol as prescribed?


Patient advised of post - op appointment?

YES / NO / COMMENT

Second Post - Operative Phone CallDate: ...... /...... /....... Time: ................ Staff Name: .............................................. Signature: .............................................

1st Eye Post - Operative Review

Right Eye Date: ...... /...... /....... Left Eye

Unaided

PH

GAT

Lids and Lashes

Conjunctiva

Cornea

Iris

Pupil

AC

Wound

IOL

Disc

MACS

Periphery

Administering drops as per regime: YES / NO

Can drive? YES / NO

Discharged to Opticians: YES / NO

Patient advised to:

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

Listed for second eye: YES / NO

Signature: .................................................. Print Name: .................................................. Date: ........ /........ /........

11

Please clearly document any variance, remembering to state: Date, Time and Signature of Clinician/Practitioner

Notes

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13

Indication for second eye cataract surgery

1) Patient has cataract in the second eye with visual acuity of 6/18 or worse

2) Visual acuity on the first eye worse than 6/9

State reason: ....................................................................................................................................

3) Visual acuity on the first eye 6/9 or better but patient needs second eye because:

A. Anisometropia

B. Glaucoma and requires cataract surgery to reduce intraocular pressure

C. Patient still has glare due to cortical cataract

D. Patient still has glare due to posterior sub capsular cataract

E. Good acuity essential to ability to work

State job ...................................................................................................................................

F. Occupational requirement to drive at night and glare

State job ...................................................................................................................................

G. Driving affected by significant glare

H. Borderline visual field defects for driving who would expect a significantly improved visual field with surgery

I. Diabetic and clear retinal view required for retinopathy screening

J. Other retinal pathology needs clear view to investigate and treat

Clinician signature: ................................................................................. Date: ........ /........ /........

14

15

I, ..........................................................................................................................................................................................

Consent to the operation of:

Cataract extraction and lens implant in eye

Or minor eye surgery as detailed below:

......................................................................................................................................................................................

.....................................................................................................................................................................................

.....................................................................................................................................................................................

The nature and purpose of which have been explained to me by:

..............................................................................................................................................

I confirm that I am informed of the risks and benefits of the procedure.

I also consent to any other measures and anaesthetics which may become necessary during the procedure and

consent for any complication to be dealt with as the surgeon sees appropriate.

Signed: ...................................................................................... Date: ........ /........ /........

I confirm that I have explained the procedure to the above patient as well as the other appropriate options,

which are available, and the possible risks involved. The explanation I have given is in my judgement, suited

to the understanding of the patient.

Signed: ...................................................................................... Date: ........ /........ /........

Consent to Operate or Procedure

Norwich and Norfolk Surgical Ltd. (N2S) Registered address: St Stephens Gate Medical Practice, 55 Wessex Street, Norwich NR2 2TJ Company No: 10615484 registered in England and Wales.

N2S Cataract Clinic at St Stephens Gate Medical Practice

55 Wessex Street Norwich NR2 2TJ

t: 01603 229617 f: 01603 229614

www.n2surgical.co.uk

Medication Prescribing and Record Sheet - 2nd Eye

16

DATE: ALLERGIES:

DRUG

G Cyclopentolate 1% minims

G Phenylephrine 2.5% minims

G Oxybuprocaine 0.4% minims

Chloramphenicol 0.5% minims

PRE-OPERATIVE AND ‘ONCE ONLY’ DRUGS

DOSE EYE L or R

PRESCRIBED BY

GIVEN BY

TIME 1st 2nd 3rd

DRUG

G Maxitrol Drops

T.T.A.

FREQUENCY

As per eye drop diary

SIGNATURE DATE PHARMACY

Pre-Operative Checklist - 2nd Eye

17

Please tick box Must be checked and signed by two members of staff

Identity band correct and sited securely

Consent form corresponds to patient’s understanding

Consent form is signed

Operation site marked

Pupil Dilated?

Dentures?

Prosthesis/ Hearing Aid?

ALLERGIES? (RED wrist band in situ?)

Patient advised to keep still and to squeeze handholder’s hand before moving or speaking etc.

YES NO COMMENTS

W.H.O. Check List

Oxygen via ‘L’Bar

Rubens Pillow/ Gel Head Support

Pillow Under the knees

Patient SpO2: %

Signature:

Please Tick Box / Record Reading

Litres

Patient Heart Rate: BPM

Date:

Intra - Operative Care Pathway

Comments

Patient prepared for surgery

Signed: ...................................................................................... Date: ........ /........ /........

Signed: ...................................................................................... Date: ........ /........ /........

Date: ........ /........ /........ 2nd Eye Cataract Operation Note

18

OPERATION RIGHT / LEFT Cataract Extraction and Intraocular Lens Implant

IOL Power ....................................... Target refraction: .........................................

SURGEON (Name and Signature)

SCRUB PERSON

CIRCULATING PERSON

SKIN PREP USED

LOCAL ANAESTHETIC

IOL STICKER

SIGNATURE

Aqueous Iodinated Povidone Aqueous Chlorhexidine

Topical (0.4% Oxybuprocaine / 0.5% Proxymetacaine)

Intra-Cameral (1% lidocaine)

Sub–Tenon Injection (2% Xylocaine +Adrenaline 1:200,000 & Hyalase)

INCISION

Limbal Corneal

CCC, Hydrodissection, Phaco, I/A

IOL: Bag Sulcus AC Wounds: Secure .......... x ................. stitches

Intra-cameral Moxifloxacin

Dosage: 500µg / 0.1ml

Lot No: ........................................

Expiry Date: ......... /......... /..........

DRESSINGS: Eye shield

Phenylepherine

Dosage: 2.5%

Lot No: ........................................

Expiry Date: ......... /......... /..........

Chloramphenicol Ointment

Lot No: ........................................

Expiry Date: ......... /......... /..........

Traceability Stickers 2nd Eye

19

2nd Eye Discharge Assessment

20

ALERT, ORIENTATED AND ABLE TO SIT UNAIDED

EYE SHIELD / EYE DRESSINGS

ASSESSED FIT FOR DISCHARGE

ESCORT ARRIVED

PATIENT DISCHARGED AT ................ HOURS

DISCHARGE AS PER PROTOCOL SIGNATURE OF NURSE

..............................................................................

MEDICINES/DROPS ISSUED TO TAKE HOME (DOSAGE EXPLAINED) GP’S LETTER GIVEN TO PATIENT FOLLOW UP APPOINTMENT

GIVEN FOR: ..................................................

VENUE: ......................................................... POST OPERATIVE ADVICE GIVEN

APPROPRIATE CONTACT NUMBERS GIVEN TO PATIENT / CARER

Signature of Discharging Practitioner: .......................................... Print Name: ......................................... Date: ...... /...... /......


Has patient removed dressings & replaced shield? (if applicable)

Is Patient in pain?



Any other comments?

YES / NO / COMMENT

First Post - Operative Phone CallDate: ...... /...... /....... Time: ................ Staff Name: .............................................. Signature: .............................................


Has patient removed shield and bathed eye?

Is Patient in pain?


Have they started using Maxitrol as prescribed?


Patient advised of post - op appointment?

YES / NO / COMMENT

Second Post - Operative Phone CallDate: ...... /...... /....... Time: ................ Staff Name: .............................................. Signature: .............................................

21

2nd Eye Post - Operative Review

Right Eye Date: ...... /...... /....... Left Eye

Unaided

PH

GAT

Lids and Lashes

Conjunctiva

Cornea

Iris

Pupil

AC

Wound

IOL

Disc

MACS

Periphery

Administering drops as per regime: YES / NO

Can drive? YES / NO

Discharged to Opticians: YES / NO

Patient advised to:

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Signature: .................................................. Print Name: .................................................. Date: ........ /........ /........

OCT


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Notes

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DATE: COMMENTS:

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24 Printed April 2017

Documents

Cataract Surgery Care Pathway - N2 Surgical · Cataract Surgery Care Pathway PATIENT ADDRESSOGRAPH: ... Indication for second eye cataract surgery 1) Patient has cataract in the second