NURSING CARE OF A PATIENT WITH CATARACT PRESENTED BY NASALLAH ABUBAKAR

1. NURSING CARE OF A PATIENT WITH CATARACT PRESENTED BY NASALLAH ABUBAKAR MSc. Nursing (UNN), BNSc. (ABU), RNT, Regtd.Ophthalmic Nurse, RN. AT THE NONA ANNUAL SCIENTIFIC CONFERENCE HELD AT GOMBE 2ND OCTOBER, 2017

2. INTRODUCTION • A cataract is opacity of the lens that distorts image projected onto the retina and that can progress to blindness. • The lens opacity reduces visual acuity. In that, the lens loses water and increases in size and density, causing compression of lens fibers. • A cataract then forms as oxygen uptake is reduced, water content decreases, calcium content increases, and soluble protein becomes insoluble. • Over time, compression of lens fibers causes a painless, progressive loss of transparency that is often bilateral. • Surgical removal of the opacified lens is the only cure for cataracts. • Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or adversely affects lifestyle.

3. OBJECTIVES • This Paper seeks to: • Define Cataract • Explain the causes of Cataract • Highlight on the clinical manifestations of Cataract • Briefly explain the Medical/Surgical Management of Cataract and • Discuss the Nursing Care of a Patient with Cataract.

4. Definition of Cataract • A cataract is a lens opacity or cloudiness. • On visual inspection, the lens appears gray or milky and it is one of the most common eye disorders. • According to the World Health Organization, cataract is the leading cause of blindness in the world. • Almost one in five people between the ages of 65 and 74 develop cataract severe enough to reduce vision.

5. CAUSES Cataracts have several causes and may be: • Age-related, the most common cataract (senile cataract). • Present at birth (hereditary), • Trauma (develops after a foreign body injures the lens). • Complicated cataracts develop as secondary effects in patients with metabolic disorders (e.g., diabetes mellitus), • Radiation damage (x-ray or sunlight), • Eye inflammation or disease (e.g., glaucoma, retinitis pigmentosa, detached retina, recurrent uveitis).

6. CAUSES Cont. • Exposure to a toxic substance e.g from drug e.g steroids or chemical toxicity. • Congenital cataract due to maternal infection (e.g., German measles, mumps, hepatitis) during the first trimester of pregnancy. • Lifestyle. Factors that increase the risk of cataracts include cigarette smoking, obesity, high-triglyceride levels in men e.t.c. • Low socio-economic status: Recent studies have linked cataract risk to lower income and educational level.

7. Clinical Manifestations • Opaque or cloudy white pupil • Gradual loss of vision • Blurred vision • Decreased color perception: increasing density of the lens tissue results in its yellowing, and this can lead to loss of some colour perception - objects appear more yellow and less blue than they did. • Vision that is better in dim light with pupil dilation

8. Clinical Manifestations Cont. • ‘Ghosting’ of images (where one distinct image is seen with the shadow of another next to it) and the patient may interpret this as ‘double’ vision. • Photophobia • Absence of the red reflex • Glare: Glare refers to the pain felt when the patient looks directly into the light. • Halos: Halos are formed when the patient looks at a bright light and there is still the vision of the light after looking away.

9. Assessment and Diagnostic Findings • Diagnosis is made by: • History, • Visual acuity test, and • Direct ophthalmoscope or • Slit lamp examination: Ophthalmoscope or slit lamp examination allows detailed visualization of anterior segment of the eye to identify lens opacities and other eye abnormalities.

10. Assessment and Diagnostic Findings Cont. • Tests include: • History and Physical Examination • Snellen’s visual acuity test:  measures the degree of visual acuity in the patient. • Ophthalmoscope: is used to view the extent of cataract. • Slit-lamp biomicroscopicexamination:  is used to establish the degree of cataract formation.

11. Medical Management • There is no medical treatment for cataracts, although use of vitamin C and E and beta-carotene is being investigated. • Glasses or contact, bifocal, or magnifying lenses may improve vision. • Mydriaticscan be used short term, but glare is increased. • In fact no nonsurgical treatment cures cataracts or prevents age-related cataracts.

12. Surgical Management • Surgical removal of the opacified lens is the only cure for cataracts. Cataracts occur bilaterally, the more advanced cataract is removed first. • Extracapsular cataract extraction: the most common procedure, removes the anterior lens capsule and cortex, leaving the posterior capsule intact. • A posterior chamber intraocular lens is implanted where the patient’s own lens used to be. • Intracapsular cataract extraction: removes the entire lens within the intact capsule. • An intraocular lens is implanted in either the anterior or the posterior chamber, or the visual deficit is corrected with contact lenses or cataract glasses.

13. Surgical Management Cont. • Phacoemulsification: has become a preferred technique. • It involves making a small incision (2-3mm) at the limbus into the anterior chamber, or a little further away from the cornea, in the sclera. • Through this, a tunnel is formed, diagonally, into the anterior chamber. • Next, a single continuous circular tear is made in the anterior capsule (capsulorrhexis). • The ‘phaco’ probe is then directed through the incision and the lens nucleus is emulsified and removed from the eye by an irrigation/aspiration technique. • Finally, a small or foldable lens is placed in the remaining capsular ‘bag’ of the lens.

14. NURSING MANAGEMENT • Preoperative Nursing Care of the Patient undergoing Cataract Surgery: • The eye is a delicate and important organ, and its care and protection are of the utmost importance. • The patient with cataract should receive the usual preoperative care for ambulatory surgical patients undergoing eye surgery.

15. Preoperative Nursing Care of the Patient undergoing Cataract Surgery Cont. • Physical Orientation: •  The patient will require a thorough orientation to his immediate hospital environment. • This is done to help the patient during the postoperative period, since he may be temporarily blind as a result of the surgery. • Assist the patient to learn details of his room such as the location of furniture, doors, windows, and so forth. • Familiarize the patient with the voices of those who will care for him after surgery. • Familiarize him with the daily sounds and noises in the environment, since he will be more aware of sound without his vision.

16. Preoperative Nursing Care of the Patient undergoing Cataract Surgery Cont. • Observation: • The patient should be observed for tendencies to cough or sneeze (smoker's cough, allergies, and so forth). • Such observations should be reported to the professional nurse for consideration in the plan of care. • Such violent movements of the head during the postoperative course may cause increased intraocular pressure, leading to hemorrhage or rupture of incisions.

17. Preoperative Nursing Care of the Patient undergoing Cataract Surgery Cont. • PatientEducation: • The patient must receive a thorough education about the postoperative course of events and his responsibilities and restrictions. • During surgery patients need to be able to lie still and must be aware that they cannot move their heads or their eyes. • They also need to be prepared for their faces to be covered, because this can be a very frightening experience initially. • A member of the theatre staff who acts as a liaison between the patient and the surgical team usually supports patients undergoing cataract surgery under local anaesthesia.

18. Preoperative Nursing Care of the Patient undergoing Cataract Surgery Cont. • PatientEducation Cont. • The patient must understand the objective of resting the eyes and avoiding actions that increase intraocular pressure. Thus, • The head must be kept very still. • No reading. • No showers, no shampooing, no tub baths. • No bending over at the waist. • No lifting of heavy objects. • No sleeping on the operative side.

19. Preoperative Nursing Care of the Patient undergoing Cataract Surgery Cont. • Physical Preparations. • A bowel preparation is done the evening prior to surgery to prevent the patient from straining at stool during the immediate post-op period. • Cutting of eyelashes, and shaving of face should be done prior to surgery. • After the patient has been taken to surgery, prepare a post-op bed, ensuring that the bed is equipped with side rails. • Sand bags should be made available for use in immobilizing the head.

20. Preoperative Nursing Care of the Patient undergoing Cataract Surgery Cont. • Family Education: • Often, if the patient must be kept absolutely still or will be temporarily blinded after surgery, a member of the family may be asked to stay with the patient. • If this is the case, the family member should receive the same orientation and education given to the patient.

21. Preoperative Nursing Care of the Patient undergoing Cataract Surgery Cont. • Nursing Assessment before surgery: • The nurse should assess: • Recent medication intake: It is a common practice to withhold any anticoagulant therapy to reduce the risk of retro bulbar hemorrhage. • Medical evaluation includes recording details of current medication and history of any allergy. • Preoperative tests: such as complete blood count, electrocardiogram, and urinalysis are prescribed especially if they are indicated by the patient’s medical history. • Vital signs: Stable vital signs are needed before the patient is subjected to surgery.

22. Nursing Assessment before surgery cont. • Visual acuity test results: Test results from Snellen’s and other visual acuity tests are assessed. • Patient’s medical history: The nurse assesses the patient’s medical history to determine the preoperative tests to be required. • Biometry: involves series of measurements of the eye, including assessment of the corneal curvature and the axial length of the globe so that calculations can be made on the intraocular lens power needed at surgery. • Discussion with patients about their lifestyle will take place at this stage to determine whether near or far vision is more important to them.

23. Nursing Assessment before surgery cont. • Identification of social problems: that may require support, in which case services may be arranged and surgery is not delayed; • Identification and initiation of treatment for any condition: that may increase the risk of severe post-operative infection (e.g endophthalmitis), such as lid and conjunctival infections. • Consent: The benefits and risks must be clear to the patient before it is signed by the patient.

24. Nursing Assessment before surgery cont. • Preoperative medications: Preoperatively, Medications may include: • Dilating drops: administered every 10 minutes for four doses at least 1 hour before surgery. • Antibiotic drugs: may be administered prophylactically to prevent postoperative infection and inflammation. • sedation: may be used to minimize anxiety and discomfort before surgery. • Documentation: all the preoperative care given is recorded for future reference.

25. Postoperative Nursing Care of the Patient undergoing Cataract Surgery • Return from Surgery: • The patient must be lifted off the litter; he is not to move himself. • He should be in recumbent position in bed or as his condition necessitates. • Sandbags should be used where necessary to immobilize the patient's head. • The side rails must be raised at all times to protect the patient in the event he becomes disoriented and attempts to get out of bed. • Place the call bell within easy reach of the patient's head and let the patient know exactly where it is located. • Remind the patient that he should not cough, sneeze, or blow his nose. Instruct him to inform the staff if he feels the urge, since these actions will increase intraocular pressure.

26. Postoperative Nursing Care of the Patient undergoing Cataract Surgery cont. •  Orientation: • Reinforce the physical orientation given during the preoperative period by verbally reviewing the locations of objects in the room. • Orient the patient to other people in the room. • The patient should have an awareness of his surroundings and know what to expect to avoid being startled or frightened.

27. Postoperative Nursing Care of the Patient undergoing Cataract Surgery cont. • Post operative Precautions. • Avoid dislodgement of the eye dressings by securing them with an eye shield or reinforcing loose tape. • Restrain the arms of children and disoriented or uncooperative patients, as appropriate. • A sleeping patient must be watched constantly to ensure that proper positioning is maintained. Often, a family member may be asked to stay with the patient for this purpose. • Avoid jarring or bumping the bed, as this may startle the patient. • If the patient is newly blinded as a result of the surgery, observe for depression and take precautions to reassure and encourage him. • Check the physician's orders before giving anything by mouth. Nausea and vomiting must be avoided. Additionally, the motion of chewing may be contraindicated.

28. Postoperative Nursing Care of the Patient undergoing Cataract Surgery cont. •  Approaching the Patient. • Always speak to the patient upon entering his area and before touching him. • Allay the patient's fears by explaining each procedure or activity fully. • Always let the patient knows when you are leaving his area. • Diversion Activity. • Diversion activities will promote a relaxed atmosphere for convalescence and prevent the patient from dwelling on his situation. • Encourage visitors to chat with the patient or read to him. • Encourage the use of a radio for entertainment and to keep the patient "in touch" with current events since he is unable to read the daily newspaper.

29. Postoperative Nursing Care of the Patient undergoing Cataract Surgery cont. • The ‘First Dressing’: Is done upon the removal of the patient’s eye pad, examining the eye with a pen torch, cleaning the eye, instilling medications as appropriate. • EyeReviewis necessary on the first postoperative day particularly those complex cases that need a prompt and appropriate intervention. • Patients should be given comprehensive, accurate and comprehensible information about what to do if things ‘go wrong’ or if they are worried. • This means they must be given telephone numbers and lists of possible scenarios that should lead to their seeking help. • The minimum advice a patient should receive is about key symptoms of pain, loss of vision and discharge.

30. Postoperative Nursing Care of the Patient undergoing Cataract Surgery cont. • Any activity that causes pain in the operated eye should be avoided. • Once intraocular inflammation has settled and eye medication is no longer being used, patients have their eyes tested to record the final outcome of surgery. • At this time any corrective lenses are prescribed. Patients are likely to be discharged from the eye unit at this stage. • In many places nurses undertake all postoperative care of patients who have had uncomplicated cataract surgery and this may include the modification of medication , supplementary prescribing, auto refraction and final discharge of the patient from the service. • Often, the only time the patient is in contact with an ophthalmologist is in theatre at the time of surgery. This enables the ophthalmic nurses to carry out truly holistic care to the ophthalmic patients.

31. Postoperative Nursing Care of the Patient undergoing Cataract Surgery cont. • Pharmacologic Highlights:Acetazolamidea carbonic anhydrase inhibitor is used to reduce intraocular pressure. • Phenylephrinea Sympathomimetic agent causes abnormal dilation of the pupil constriction of conjunctival arteries. • Other Medications: Postoperatively, medications are prescribed to reduce infection (gentamicin or neomycin) and to reduce inflammation (dexamethasone), taking the form of eye drops. Acetaminophen is prescribed for mild discomfort; tropicamide is prescribed to induce ciliary paralysis.

32. Discharge and Home Care Guidelines • Before discharge: the patient receives verbal and written instructions about how to protect the eye, administer medications, and recognize signs of complications. • Review installation technique of eye drops: into the conjunctival sac. Teach the patient to avoid over-the-counter medications, particularly those with aspirin. • Activities. Activities to be avoided are instructed by the nurse. • Protective eye patch. To prevent accidental rubbing or poking of the eye, the patient wears a protective eye patch for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1 to 4 weeks. • Expected side effects. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days, and a clean, damp washcloth may be used to remove slight morning eye discharge.

33. Discharge and Home Care Guidelines cont. • Notify the physician. Because cataract surgery increases the risk of retinal detachment, the patient must know to notify the surgeon if new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness occurs. • Instruct the patient to report any bleeding, yellow-green drainage, pain, visual losses, nausea, vomiting, tearing, photophobia, or seeing bright flashes of light. • Instruct the patient to avoid activities that increase intraocular pressure such as bending at the waist, sleeping on the operative side, straining with bowel movements, lifting more than 15 pounds, sneezing, coughing, or vomiting. • Instruct the patient to wear a shield over the operative eye at night to prevent accidental injury to the eye during sleep and to wear glasses during the day to prevent accidental injury to the eye while awake.

34. Discharge and Home Care Guidelines cont. • Recommend that the patient avoid reading for some time after surgery to reduce eye strain and unnecessary movement so that maximal healing occurs. • Advise the patient not to shampoo for several days after surgery. • The face should be held away from the shower head with the head tilted back so that water spray and soap avoid contact with the eye. • Vacuuming should be avoided because of the forward flexion and rapid, jerky movement required. • Driving, sports, and machine operation can be resumed when permission is granted by the eye surgeon. • Clients fitted with cataract eyeglasses need information about altered spatial perception. • The eyeglasses should be first used when the patient is seated, until the patient adjusts to the distortion.

35. NURSING CARE PLAN FOR PATIENT WITH CATARACT: • Disturbed visual sensory perceptionrelated to Cataracts or Poor visual acuity or altered sensory perception. • Risk for trauma related to poor vision and reduces hand-eye coordination. • Anxietyrelated to threat of permanent loss of vision/independence. • Deficient knowledge regarding ways of coping with altered abilities related to lack of exposure or recall, misinterpretation, or cognitive limitations. • Acute pain related to trauma to the incision and increased IOP • Risk for infection related to surgery

36. NURSING CARE PLAN FOR PATIENT WITH CATARACT: Disturbed Sensory Perception: (Visual) related to Cataracts or Poor visual acuity: Possibly evidenced by • Visual distortions • Loss of vision • Diminished visual acuity • Changes in usual response to stimuli • Presence of cataract Desired Outcomes • Patient will regain optimal vision possible and will adapt to permanent visual changes • Patient will be able to regain vision to the maximum possible extent with surgical procedure. • Patient will maintain a safe environment with no injury noted. • Patient will be able to use adaptive devices to compensate for visual loss. • Patient will be compliant with instructions given, and will be able to notify physician/nurse for emergency symptoms.

37. NURSING CARE PLAN FOR PATIENT WITH CATARACT: • Nursing Interventions • Assess patient’s ability to see and perform activities. • Encourage patient to see ophthalmologist as ordered . • Provide sufficient lighting for patient to carry out activities. • Provide lighting that avoids glare on surfaces of walls, reading materials, and so forth. Prepare patient for cataract surgery as warranted etc.

38. NURSING CARE PLAN FOR PATIENT WITH CATARACT cont. • Risk for Injury related to Cataracts or Decreased vision • Desired Outcomes • Patient will be free of injury and will be able to perform activities within parameters of sensory limitation. • Patient and/or family will be able to modify environment to ensure patient safety.

39. NURSING CARE PLAN FOR PATIENT WITH CATARACT cont. • Assess patient for degree of visual impairment. • Ensure room environment is safe with adequate lighting and furniture moved toward the walls. Remove all rugs, and objects that could be potentially hazardous. • Keep patient’s glasses and call bell within easy reach. • Instruct patient and/or family regarding need for maintain safe environment. • Instruct patient and/or family regarding safe lighting. Patient should wear sunglasses to reduce glare. • Advise family to use contrasting bright colors in household furnishings.

40. NURSING CARE PLAN FOR PATIENT WITH CATARACT cont. • Nursing Interventions • Assess patient for degree of visual impairment. • Ensure room environment is safe with adequate lighting and furniture moved toward the walls. Remove all rugs, and objects that could be potentially hazardous. • Keep patient’s glasses and call bell within easy reach. • Instruct patient and/or family regarding need for maintain safe environment. • Instruct patient and/or family regarding safe lighting. Patient should wear sunglasses to reduce glare. Advise family to use contrasting bright colors in household furnishings.

41. Thank you for listening