Transcript eyedisorder
THE EYE DISORDERS PYRAMID POINTS • Nursing interventions for the client who is legally blind • Assessment findings in a client with a cataract • Client education following cataract surgery • Assessment findings in a client with glaucoma • Client education regarding compliance with medical treatments for glaucoma PYRAMID POINTS • Assessment findings in the client with retinal detachment • Interventions for the client with retinal detachment • Emergency interventions for the client with an eye injury • Postoperative interventions following enucleation and exenteration • Nursing interventions related to organ donation LEGALLY BLIND • DESCRIPTION – If the best visual acuity with corrective lenses in the better eye is 20/200 or less, or a visual field of 20 degrees or less in the better eye LEGALLY BLIND • IMPLEMENTATION – When speaking to the client who has limited sight or is blind, the nurse uses a normal tone of voice – Alert the client when approaching – Orient the client to the environment – Use a focal point and provide further orientation to the environment from that focal point LEGALLY BLIND • IMPLEMENTATION – Allow the client to touch objects in the room – Use the clock placement of foods on the meal tray to orient the client – Promote independence as much as possible – Provide radios, TVs, and clocks that give the time audibly, or provide a Braille watch – When ambulating, allow the client to grasp the nurse’s arm at the elbow; the nurse keeps his or her arm close to the body so that the client can detect the direction of movement LEGALLY BLIND • CLIENT EDUCATION – Remain one step behind the nurse when ambulating – Using the cane for the blind client, which is differentiated from other canes by its straight shape and white color with red tip – That the cane is held in the dominant hand several inches off the floor – That the cane sweeps the ground where the client’s foot will be placed next, to determine the presence of obstacles CATARACTS • DESCRIPTION – An opacity of the lens that distorts the image projected onto the retina and which can progress to blindness – Causes include the aging process (senile cataracts), inherited (congenital cataracts), and injury (traumatic cataracts); can also occur as a result of another eye disease (secondary cataracts) – Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or adversely affecting lifestyle CATARACTS • ASSESSMENT – Opaque or cloudy white pupil – Gradual loss of vision – Blurred vision – Decreased color perception – Vision that is better in dim light with pupil dilation – Photophobia – Absence of the red reflex APPEARANCE OF EYE WITH CATARACT From Black JM, Hawks JH, Keene AM: Medical-surgical nursing: clinical management for positive outcomes, 6th ed., Philadelphia, 2001 W.B. Saunders. Courtesy of Ophthalmic Photography, University of Michigan, WK Kellogg Eye Center, Ann Arbor, MI. CATARACTS • IMPLEMENTATION – Surgical removal of the lens, one eye at a time – Intracapsular extraction: the lens is removed within its capsule through a small incision – Extracapsular extraction: the lens is lifted out without removing the lens capsule; may be performed by phacoemulsification in which the lens is broken up by ultrasonic vibrations and extracted CATARACT REMOVAL From Black JM, Matassarin-Jacobs E: Medical-surgical nursing: clinical management for continuity of care (1997), 5th ed., Philadelphia, W.B. Saunders. CATARACTS • IMPLEMENTATION – A partial iridectomy may be performed with the lens extraction to prevent acute secondary glaucoma – A lens implantation may be performed at the time of the surgical procedure CATARACTS • PREOPERATIVE – Instruct the client regarding the postoperative measures to prevent or decrease intraocular pressure – Administer preoperative eye medications including mydriatics and cycloplegics as prescribed CATARACTS • POSTOPERATIVE – Elevate the head of the bed 30 to 45 degrees – Turn the client to the back or unoperative side – Maintain an eye patch; orient the client to the environment – Position the client’s personal belongings to the unoperative side – Use side rails for safety – Assist with ambulation CATARACT SURGERY • CLIENT EDUCATION – Avoid eye straining – Avoid rubbing or placing pressure on the eyes – Avoid rapid movements, straining, sneezing, coughing, bending, vomiting, or lifting objects over 5 pounds – Measures to prevent constipation – Dressing changes and prescribed eye drops and medications CATARACT SURGERY • CLIENT EDUCATION – Wipe excess drainage or tearing with a sterile wet cotton ball from the inner to the outer canthus – Use of an eye shield at bedtime – If a lens implant is not performed, the eye cannot accommodate and glasses must be worn at all times – Cataract glasses act as magnifying glasses and replace central vision only CATARACT SURGERY • CLIENT EDUCATION – Cataract glasses magnify and objects will appear closer; therefore, the client needs to accommodate, judge distance, and climb stairs carefully – Contact lenses provide sharp visual acuity but dexterity is needed to insert them – Contact the physician for any decrease in vision, severe eye pain, or increase in eye discharge GLAUCOMA • DESCRIPTION – Increased intraocular pressure as a result of inadequate drainage of aqueous humor from the canal of Schlemm or overproduction of aqueous humor – The condition damages the optic nerve and can result in blindness TYPES OF GLAUCOMA • ACUTE CLOSED-ANGLE OR NARROW-ANGLE GLAUCOMA – Results from obstruction to outflow of aqueous humor • CHRONIC CLOSED-ANGLE GLAUCOMA – Follows an untreated attack of acute closedangle glaucoma • CHRONIC OPEN-ANGLE GLAUCOMA – Results from overproduction or obstruction to the outflow of aqueous humor OPEN-ANGLE AND CLOSED-ANGLE GLAUCOMA From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby. TYPES OF GLAUCOMA • ACUTE – A rapid onset of intraocular pressure greater than 50 to 70 mmHg • CHRONIC – A slow, progressive, gradual onset of intraocular pressure greater than 30 to 50 mmHg GLAUCOMA • ASSESSMENT – Progressive loss of peripheral vision followed by loss of central vision – Elevated intraocular pressure (normal pressure is 10 to 21 mmHg) – Vision worsening in the evening with difficulty adjusting to dark rooms – Blurred vision – Progressive loss of central vision GLAUCOMA • ASSESSMENT – Halos around white lights – Frontal headaches – Eye pain – Photophobia – Lacrimation OPHTHALMOSCOPIC IMAGE OF OPEN-ANGLE GLAUCOMA From Apple DJ, Rabb MF: Ocular pathology, ed. 5, St. Louis, 1998, Mosby. ACUTE GLAUCOMA • IMPLEMENTATION – Treat as a medical emergency – Administer medications as prescribed to lower intraocular pressure – Prepare the client for peripheral iridectomy, which allows aqueous humor to flow from the posterior to anterior chamber CHRONIC GLAUCOMA • IMPLEMENTATION – Prepare the client for trabeculoplasty as prescribed to facilitate aqueous humor drainage – Prepare the client for trabeculectomy as prescribed, which allows drainage of aqueous humor into the conjunctival spaces by the creation of an opening CHRONIC GLAUCOMA • CLIENT EDUCATION – The importance of medications: miotics to constrict the pupils, carbonic anhydrase inhibitors to decrease the production of aqueous humor, and beta blockers to decrease the production of aqueous humor and intraocular pressure – The need for life-long medication use – Wear a Medic Alert bracelet – Avoid anticholinergic medications CHRONIC GLAUCOMA • CLIENT EDUCATION – To report eye pain, halos around the eyes, and changes in vision to the physician – That when maximal medical therapy has failed to halt the progression of visual field loss and optic nerve damage, surgery will be recommended RETINAL DETACHMENT • DESCRIPTION – Occurs when the layers of the retina separate because of the accumulation of fluid between them, or when both retinal layers elevate away from the choroid as a result of a tumor – Partial separation becomes complete if untreated – When detachment becomes complete, blindness occurs RETINAL DETACHMENT TEAR IN RETINA From Phipps WJ, Sands, J, Marek JF: Medical-surgical nursing: concepts and clinical practice, ed. 6, St. Louis, 1999, Mosby. RETINAL DETACHMENT VIEW OF FUNDUS From Black JM, Hawks JH, Keene AM: Medical-surgical nursing: clinical management for positive outcomes, 6th ed., Philadelphia, 2001 W.B. Saunders. Courtesy of Opthalmic Photography, University of Michigan, WK Kellogg Eye Center, Ann Arbor, MI. RETINAL DETACHMENT • ASSESSMENT – Flashes of light – Floaters – Increase in blurred vision – Sense of a curtain being drawn – Loss of a portion of the visual field RETINAL DETACHMENT • IMMEDIATE IMPLEMENTATION – Provide bed rest – Cover both eyes with patches to prevent further detachment – Speak to the client before approaching – Position the client’s head as prescribed – Protect the client from injury – Avoid jerky head movements – Minimize eye stress – Prepare the client for the surgical procedure as prescribed RETINAL DETACHMENT SURGICAL PROCEDURES • Draining fluid from the subretinal space so that the retina can return to the normal position • Sealing retinal breaks by cryosurgery, a cold probe applied to the sclera, to stimulate an inflammatory response leading to adhesions • Diathermy, the use of an electrode needle and heat through the sclera, to stimulate an inflammatory response RETINAL DETACHMENT SURGICAL PROCEDURES • Laser therapy, which stimulates an inflammatory response to seal small retinal tears before the detachment occurs • Scleral buckling, to hold the choroid and retina together with a splint until scar tissue forms closing the tear • Insertion of gas or silicone oil to encourage attachment because these agents have a specific gravity less than vitreous or air, and can float against the retina SCLERAL BUCKLING From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders. RETINAL DETACHMENT SURGICAL PROCEDURES • POSTOPERATIVE – Maintain eye patches bilaterally as prescribed – Monitor for hemorrhage – Prevent nausea and vomiting and monitor for restlessness, which can cause hemorrhage – Monitor for sudden, sharp eye pain (notify the physician) – Encourage deep breathing but avoid coughing – Provide bed rest for 1 to 2 days as prescribed RETINAL DETACHMENT SURGICAL PROCEDURES • POSTOPERATIVE – Position the client as prescribed – If gas has been inserted, position as prescribed on the abdomen and turn the head so unaffected eye is down – Administer eye medications as prescribed – Assist the client with activities of daily living – Avoid sudden head movements or anything that increases intraocular pressure RETINAL DETACHMENT SURGICAL PROCEDURES • POSTOPERATIVE – Instruct the client to limit reading for 3 to 5 weeks – Instruct the client to avoid squinting, straining and constipation, lifting heavy objects, and bending from the waist – Instruct the client to wear dark glasses during the day and an eye patch at night – Encourage follow-up care because of the danger of recurrence or occurrence in the other eye HYPHEMA • DESCRIPTION – The presence of blood in the anterior chamber – Occurs as a result of an injury – The condition usually resolves in 5 to 7 days HYPHEMA From Zitelli BJ, Davis HW: Atlas of Pediatric Physical Diagnosis, ed. 3, St. Louis, 1997, Mosby. HYPHEMA • IMPLEMENTATION – Encourage rest with the client in semi-Fowler’s position – Avoid sudden eye movements for 3 to 5 days to decrease the likelihood of bleeding – Administer cycloplegic eye drops as prescribed to place the eye at rest – Instruct the client in the use of eye shields or eye patches as prescribed – Instruct the client to restrict reading and watching television CONTUSIONS • DESCRIPTION – Bleeding into the soft tissue as a result of an injury – Causes a black eye and the discoloration disappears in approximately 10 days – Pain, photophobia, edema, and diplopia may occur • IMPLEMENTATION – Place ice on the eye immediately – Instruct the client to receive an eye examination FOREIGN BODIES OF THE EYE • DESCRIPTION – An object such as dust that enters the eye FOREIGN BODIES OF THE EYE • IMPLEMENTATION – Have the client look upward, expose the lower lid, wet a cotton-tipped applicator with sterile normal saline, and gently twist the swab over the particle and remove it – If the particle cannot be seen, have the client look downward, place a cotton applicator horizontally on the outer surface of the upper eye lid, grasp the lashes, and pull the upper lid outward and over the cotton applicator; if the particle is seen, gently twist swab over it to remove PENETRATING OBJECTS • DESCRIPTION – An injury that occurs to the eye in which an object penetrates the eye PENETRATING OBJECTS • IMPLEMENTATION – Never remove the object because it may be holding ocular structures in place; the object must be removed by the physician – Cover the object with a cup – Do not allow the client to bend – Do not place pressure on eye – Client is to be seen by a physician immediately CHEMICAL BURNS • DESCRIPTION – An eye injury in which a caustic substance enters the eye CHEMICAL BURNS • IMPLEMENTATION – Treatment should begin immediately – Flush the eyes at the site of injury with water for at least 15 to 20 minutes – At the scene of the injury, obtain a sample of the chemical involved CHEMICAL BURNS • IMPLEMENTATION – At the emergency room, the eye is irrigated with normal saline solution or an ophthalmic irrigation solution – The solution is directed across the cornea and toward the lateral canthus – Prepare for visual acuity assessment – Apply an antibiotic ointment as prescribed – Cover the eye with a patch as prescribed ENUCLEATION AND EXENTERATION • DESCRIPTION – Enucleation: removal of the entire eyeball – Exenteration: removal of the eyeball and surrounding tissues and bone – Performed for the removal of ocular tumors – After the eye is removed, a ball implant is inserted to provide a firm base for socket prosthesis and to facilitate the best cosmetic result – A prosthesis is fitted approximately 1 month after surgery ENUCLEATION AND EXENTERATION • PREOPERATIVE – Provide emotional support to the client – Encourage the client to verbalize feelings related to loss • POSTOPERATIVE – Monitor vital signs – Assess pressure patch or dressing – Report changes in vital signs or the presence of bright red drainage on the pressure patch or dressing ORGAN DONATION • DONOR EYES – Obtained from cadavers – Must be enucleated soon after death because of rapid endothelial cell death – Must be stored in a preserving solution – Storage, handling, and coordination of donor tissue with surgeons is provided by a network of state eye bank associations across the country ORGAN DONATION • CARE TO THE DECEASED CLIENT AS A POTENTIAL EYE DONOR – Discuss the option of eye donation with the physician and family – Raise the head of the bed 30 degrees – Instill antibiotic eye drops as prescribed – Close the eyes and apply a small ice pack to the closed eyes PREOPERATIVE: THE RECIPIENT • Recipient may be told of the tissue availability only several hours to 1 day before the surgery • Assist in alleviating client anxiety • Assess eye for signs of infection • Report the presence of any redness, watery or purulent drainage, or edema around the eye to the physician • Instill antibiotic drops into the eye as prescribed to reduce the number of microorganisms present • Administer IV fluids and medications as prescribed CORNEAL TRANSPLANTATION KERATOPLASTY From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders. APPEARANCE OF EYE AFTER KERATOPLASTY From Black JM, Hawks JH, Keene AM: Medical-surgical nursing: clinical management for positive outcomes (2001), 6th ed., Philadelphia, W.B. Saunders. Courtesy of Opthalmic Photography, University of Michigan, WK Kellogg Eye Center, Ann Arbor, MI. POSTOPERATIVE: THE RECIPIENT • Eye is covered with a pressure patch and protective shield that is left in place until the next day • Do not remove or change the dressing without a physician’s order • Monitor vital signs • Monitor level of consciousness • Assess dressing POSTOPERATIVE: THE RECIPIENT • Position the client on the nonoperative side to reduce intraocular pressure • Orient the client frequently • Monitor for complications of bleeding, wound leakage, infection, and graft rejection • Instruct the client how to apply a patch and eye shield • Instruct the client to wear the eye shield at night for 1 month and whenever around small children or pets • Advise the client not to rub the eye POSTOPERATIVE: THE RECIPIENT • GRAFT REJECTION – Can occur at any time – Inform the client of the signs of rejection – Signs include redness, swelling, decreased vision, and pain (RSVP) – Treated with topical corticosteroids