Indezine Template

Chapter 49
Care of Patients with Eye and Vision Problems
Mrs. Marion Kreisel MSN, RN Nu230 Adult Health 2Fall 2011

Blepharitis
Inflammation of the eyelid edgesItchy, red, and burning eyesSeborrhea (dermatitis presents with scaly, flaky, itchy, red skin.) of the eyebrows and eyelids with greasy scales and matteringControl with eyelid care using warm, moist compresses followed by gentle scrubbing with diluted baby shampooAvoid rubbing the eyes

Entropion
Turning inward of the eyelid causing the lashes to rub against the cornea of the eyeCaused by eyelid muscle spasms or traumaEyelid turned inward; red conjunctiva Surgical correction of eyelid positionInstruction in procedure to instill eyedrops

Ophthalmic Ointment

Ectropion
Turning outward and sagging of the eyelidCaused by relaxation of the orbicular muscleReduced washing action of tears, leading to corneal drying and ulcerationSurgery to restore proper lid alignment

Hordeolum
Stye can be external or internal.Treatment is with warm compresses four times a day and antibacterial ointment, which may blur vision.To remove ointment, close the eye and gently wipe the closed eyelid from the nasal side of the eye outward.

Hordeolum (Contd)

Chalazion
Inflammation of sebaceous gland in eyelid.Most protrude on the inside of eyelid.Eye fatigue, light sensitivity, and excessive tears result.Treatment consists of warm compresses for 15 minutes 4 times per day, followed by instillation of ophthalmic ointment.Surgery is an option.

Chalazion (Contd)

Keratoconjunctivitis Sicca
Also called dry eye syndrome, results from changes in tear composition, lacrimal gland malfunction, or altered tear distributionArtificial tears, lubricating ointmentSurgery

Conjunctival Hemorrhage
Small, well-defined area of hemorrhage that is bright red under the conjunctivaNo painNo visual impairmentResolves in 14 days without treatment

Conjunctivitis

Trachoma
Chronic, bilateral scarring form of conjunctivitis caused by Chlamydia trachomatisChief cause of preventable blindness in the worldInfection control

Corneal Disorders
Keratoconus is the degeneration of the cornea, deposits in the cornea, dystrophies, keratitis, or ulceration of the corneal surface.Reduce symptoms, restore corneal clarity, enhance patients ability to use remaining vision.Antibiotics, antifungals, antivirals, steroids.

Keratoconum

Keratoplasty
Surgical removal of diseased corneal tissue and replacement with tissue from a human donor cornea (transplant)Regional anesthesiaPostoperative caresubconjunctival antibiotic injection, antibiotic ointment, pressure patch and protective shield to cover eye. Watch for S&S of rejection such as vision problems

Corneal Transplantation

Eye Donation
Corneal tissue from donors free of infectious disease or cancer at the time of their deaths.Care of potential eye donors at death:Raise head of bed 30 degrees.Apply antibiotic eyedrops.Close the eyelids, and apply small ice pack.Discuss donation with family and physician.

Cataract
Clouding and blurring of the lens distort the image and color projected onto the retina.As cataract matures, opacity makes it difficult to see the retina.Visual acuity is restricted.No pain or eye redness is associated with age-related cataracts.

Cataract (Contd)

Cataract Surgery

Cataract Surgery: Collaborative Management
PreoperativeIntraoperativePostoperative

Cataract: Postoperative Care
Antibiotics are given subconjunctivally.Eye is unpatched. Discharge usually occurs within 1 hr with dark glasses.Instill antibiotic-steroid eyedrops.Mild itching is normal.Pain indicates a complication.Reduce IOP.Prevent infection.Assess for bleeding.

Cataract: Community-Based Care
Home care managementHealth teachingHealth care resources

Health Teaching
Report to surgeonsharp, sudden pain in the eye, bleeding or increased discharge, lid swelling, decreased vision, or flashes of light or floating shapes.Avoid activities that might increase IOP.Review procedure for use of eyedrops.

Glaucoma
Group of ocular diseases resulting in increased IOP Normal IOP is 10-21 mm HgPrimary open-angle glaucoma: The most common form of glaucoma, usually affects both eyes, asymptomatic in early stages outflow of aqueous humor through the chamber angle is reduced. Going in more than out-> IOPAngle-closure glaucoma: Less common, sudden onset and emergency. Displacement of the iris and go blind.

Clinical Manifestations
Cupping and atrophy of the optic disc; disc wider and deeper and turns white or grayVisual field measurementHeadache or brow pain, nausea and vomiting, colored halos around lights, and sudden blurred vision with decreased light perception

Diagnostic Tests
Cut down on the prevalance by assessment of the optic nerve, tonometry, annual eye exams/Perimetry: Test to screen visual fields, perpherial vision Gonioscopy: Determines if open angle or closed angle glaucoma is present by IOP levelsOptic nerve imaging: used for ocular HTN who are at risk for eye problems

Measurement of Ocular Tension

Glaucoma Drug Therapy
Constrict the pupilReduce production or increase absorption of aqueous humorProstaglandin agonistsAdrenergic agonistsBeta-adrenergic blockersCholinergic agonists: Pilocarpine gtts: PAGE 1099Carbonic anhydrase inhibitors

Glaucoma Surgical Treatment

Other Disorders
Vitreous hemorrhageUveitis: Uveal tract has 3 related parts: iris, the ciliary body, & the choroid are inflamed.

Retinal Disorders
Macular degeneration: degeneration of the macula (the area of central vision)Retinal holeRetinal tearRetinal detachment

Macular Degeneration
The maculathe area of central visiondeteriorates.Degeneration can be atrophic age-related (dry) or exudative (wet).Rod and cone photoreceptors die.Central vision declines; patient describes mild blurring and distortion.

Retinal Detachment

Hypersensitive Retinopathy
As blood pressure increases, retinal arterioles narrow and take on a classic copper wire appearance.Nicking or narrowing of the vessels occurs.If blood pressure remains elevated, areas of ischemia or cotton wool spots, small hemorrhages, headaches, and vertigo occur.

Diabetic Retinopathy
Retinal blood vessel complicationRetinopathy worsened with poor glucose controlBackground diabetic retinopathyMicroaneurysmsProliferative diabetic retinopathyLaser therapyVitrectomy performed if frequent bleeding into the vitreous occurs

Refractory Errors
MyopianearsightednessHyperopiafarsightednessPresbyopiaage-related problem in which lens loses its elasticityAstigmatismcurve of the cornea is uneven

Surgery for Treatment of Refractive Errors
Laser in-situ keratomileusis (LASIK)Intact corneal ring

Eye Trauma
Hyphema: Hemorrhage in the anterior chamber Force to eye and blood vessels breakContusionForeign bodiesLacerationsPenetrating injuries

Ocular Melanoma
Most common malignant eye tumor in adultsManifestations not readily apparentEnucleationsurgical removal of the entire eyeballRadiation therapy

Reduced Vision
Interventions include:Communication regarding use of adaptive itemsSafety in familiar settingsAmbulation assisted with careSelf-care and independence promotedSupport for the difficulty of adapting to loss of sight

Chapter 48
NCLEX TIME

Question 1
Which circumstance places the patient at the greatest risk for developing vision disturbances?

History of working with computerAdvanced ageHistory of diabetes mellitus Previous employment as a road construction worker

Question 2
What characteristic would the nurse expect to see with age-related changes in an older patients eyes?

Yellowing of the sclera Retinal atrophyColor blindnessEarly-onset glaucoma

Question 3
Which is a priority nursing intervention when providing care to an older patient who has problems with vision?

Review the medication administration record for artificial tearsReview medications before administrationEnsure adequate, nonglare lighting in the patients room Provide written and verbal instruction for nursing education interventions

Question 4
In performing a psychosocial assessment of a patient who has recently experienced vision changes, the nurse should:

Provide the patient with a list of services for the visually impaired.Meet with family members or significant others to determine if the patient can still perform his ADLs.Ask the patient how he feels about the changes in his vision and the effectiveness of his coping methods. Ask the patient if he has made appropriate adjustments in his lifestyle to accommodate his vision changes.

Question 5
What is an appropriate expected outcome for the patient who has undergone an examination of the eye using fluorescein angiography?

Administering mydriatic eye drops for 1 week Drinking fluids to eliminate the dye Appearance of bright redcolored urine until the dye is excreted Staining of the skin for up to 1 week after the test

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Answer: CRationale: Certain systemic diseases increase the risk for developing visual problems. Diabetes mellitus and hypertension can have serious adverse effects on vision. Working with a computer can cause eye strain. Working outside can result in too much exposure to ultraviolet rays if proper eye protection is not worn. Advanced age also influences vision, but environmental factors and diseases impact vision changes associated with advanced age.
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Answer: ARationale: Fatty deposits cause the sclera to develop a yellowish tinge. Retinal atrophy, color blindness, and early-onset glaucoma are not expected age-related changes in the eyes.
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Answer: CRationale: Several changes in the eye that occur with aging alter vision, increasing the risk for tripping or falling. Good lighting is necessary for best vision. Color discrimination can be difficult for older patients, so medication education should include names and indications of medications, but use caution when instructing on color. Verbal and written education provide reinforcement for new information. With aging, the eye dries and artificial tears or normal saline drops can help relieve eye irritation.
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Answer: CRationale: A patient who has experienced changes in visual perception may be anxious or fearful about a possible loss of vision. Visual impairment services are probably not necessary at this early stage. The patients ability to perform ADLs should be assessed first, and directly from the patient (not family members).
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Answer: BRationale: After the test, encourage the patient to drink fluids to help eliminate the dye. Emphasize that any yellow or green staining of the skin will disappear in a few hours. After the test, the urine will be bright green until the dye is excreted. Instruct the patient to avoid direct sunlight until pupils are no longer dilated