Chapter 49

1. Chapter 49 Care of Patients with Eye and Vision Problems Mrs. Marion Kreisel MSN, RNNu230 Adult Health 2 Fall 2011

2. Blepharitis • Inflammation of the eyelid edges • Itchy, red, and burning eyes • Seborrhea (dermatitis presents with scaly, flaky, itchy, red skin.) of the eyebrows and eyelids with greasy scales and mattering • Control with eyelid care using warm, moist compresses followed by gentle scrubbing with diluted baby shampoo • Avoid rubbing the eyes

3. Entropion • Turning inward of the eyelid causing the lashes to rub against the cornea of the eye • Caused by eyelid muscle spasms or trauma • Eyelid turned inward; red conjunctiva • Surgical correction of eyelid position • Instruction in procedure to instill eyedrops

4. Ophthalmic Ointment

5. Ectropion • Turning outward and sagging of the eyelid • Caused by relaxation of the orbicular muscle • Reduced washing action of tears, leading to corneal drying and ulceration • Surgery to restore proper lid alignment

6. 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.

7. Hordeolum (Cont’d)

8. 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.

9. Chalazion (Cont’d)

10. Keratoconjunctivitis Sicca • Also called dry eye syndrome, results from changes in tear composition, lacrimal gland malfunction, or altered tear distribution • Artificial tears, lubricating ointment • Surgery

11. Conjunctival Hemorrhage • Small, well-defined area of hemorrhage that is bright red under the conjunctiva • No pain • No visual impairment • Resolves in 14 days without treatment

12. Conjunctivitis

13. Trachoma • Chronic, bilateral scarring form of conjunctivitis caused by Chlamydia trachomatis • Chief cause of preventable blindness in the world • Infection control

14. 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 patient’s ability to use remaining vision. • Antibiotics, antifungals, antivirals, steroids.

15. Keratoconum

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

17. Corneal Transplantation

18. 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.

19. 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.

20. Cataract (Cont’d)

21. Cataract Surgery

22. Cataract Surgery: Collaborative Management • Preoperative • Intraoperative • Postoperative

23. 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.

24. Cataract: Community-Based Care • Home care management • Health teaching • Health care resources

25. Health Teaching • Report to surgeon—sharp, 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.

26. Glaucoma • Group of ocular diseases resulting in increased IOP Normal IOP is 10-21 mm Hg • Primary 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-> IOP • Angle-closure glaucoma: Less common, sudden onset and emergency. Displacement of the iris and go blind.

27. Clinical Manifestations • Cupping and atrophy of the optic disc; disc wider and deeper and turns white or gray • Visual field measurement • Headache or brow pain, nausea and vomiting, colored halos around lights, and sudden blurred vision with decreased light perception

28. 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 levels • Optic nerve imaging: used for ocular HTN who are at risk for eye problems

29. Measurement of Ocular Tension

30. Glaucoma Drug Therapy • Constrict the pupil • Reduce production or increase absorption of aqueous humor • Prostaglandin agonists • Adrenergic agonists • Beta-adrenergic blockers • Cholinergic agonists: Pilocarpine gtts: PAGE 1099 • Carbonic anhydrase inhibitors

31. Glaucoma Surgical Treatment

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

33. Retinal Disorders • Macular degeneration: degeneration of the macula (the area of central vision) • Retinal hole • Retinal tear • Retinal detachment

34. Macular Degeneration • The macula—the area of central vision—deteriorates. • Degeneration can be atrophic age-related (dry) or exudative (wet). • Rod and cone photoreceptors die. • Central vision declines; patient describes “mild blurring” and “distortion.”

35. Retinal Detachment

36. 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.

37. Diabetic Retinopathy • Retinal blood vessel complication • Retinopathy worsened with poor glucose control • Background diabetic retinopathy • Microaneurysms • Proliferative diabetic retinopathy • Laser therapy • Vitrectomy performed if frequent bleeding into the vitreous occurs

38. Refractory Errors • Myopia—nearsightedness • Hyperopia—farsightedness • Presbyopia—age-related problem in which lens loses its elasticity • Astigmatism—curve of the cornea is uneven

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

40. Eye Trauma • Hyphema: Hemorrhage in the anterior chamber Force to eye and blood vessels break • Contusion • Foreign bodies • Lacerations • Penetrating injuries

41. Ocular Melanoma • Most common malignant eye tumor in adults • Manifestations not readily apparent • Enucleation—surgical removal of the entire eyeball • Radiation therapy

42. Reduced Vision • Interventions include: • Communication regarding use of adaptive items • Safety in familiar settings • Ambulation assisted with care • Self-care and independence promoted • Support for the difficulty of adapting to loss of sight

43. Chapter 48 NCLEX TIME

44. Question 1 Which circumstance places the patient at the greatest risk for developing vision disturbances? • History of working with computer • Advanced age • History of diabetes mellitus • Previous employment as a road construction worker

45. Question 2 What characteristic would the nurse expect to see with age-related changes in an older patient’s eyes? • Yellowing of the sclera • Retinal atrophy • Color blindness • Early-onset glaucoma

46. 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 tears • Review medications before administration • Ensure adequate, nonglare lighting in the patient’s room • Provide written and verbal instruction for nursing education interventions

47. 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.

48. 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 red–colored urine until the dye is excreted • Staining of the skin for up to 1 week after the test