Nursing Management Conjunctivitis by upp16792

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									Assessment and Management of
  Patients with Eye and Vision
           Disorders
          Chapter 58
 Assessment and Evaluation of Vision
• Ocular history
   – Chart 58-1, p. 2048
• Visual acuity
   – Snellen chart
      • Record each eye
      • What does 20/20 mean?
• Finger count or hand
  motion
Examination of External Structures
• Note any evidence of irritation, inflammation,
  discharge, etc.
• Assess eyelids and sclera
• Assess pupils and pupillary response in a
  darkened room
• Note gaze and position of eyes
• Assess extraocular movements
• Note ptosis
• Note nystagmus
           Diagnostic Evaluation
•   Opthalmoscopy
•   Slit-lamp examination
•   Color vision testing
•   Amsler grid
•   Ultrasonography
•   Fluorescein and indocyanine grean
    angiography
    Diagnostic Evaluations (cont.)
• Tonometry
  – Measures intraocular pressure
• Gonioscopy
  – Visualizes the angle of the anterior chamber
• Perimetry testing
  – Evaluates field of vision
  – Helpful in detection of central scotomas
              Impaired Vision
• Identify the term for normal vision
• Describe refractive errors
• Discuss the following refractive errors
  – Myopia
  – Hyperopia
  – Astigmatism
Eyeball Shape Determines Visual
   Acuity in Refractive Errors
          Terms to Understand
• Best Corrected Visual Acuity (BCVA)
• No light perception (NLP)

• Compare and Contrast:
  – Low vision
  – Blindness
  – Legal blindness
  Nursing Management of Low Vision
• Support coping strategies, grief processes, and
  acceptance of visual loss
• Strategies for adaptation to the environment
   – Item placement in room
   – Clock method for meal tray
• Communication strategies
• Collaboration with low vision specialist, OT, or other
  resources
• Braille or other methods for reading/communication
• Service animals
                   Glaucoma
• Discuss the pathophysiology of glaucoma

• Identify the risk factors

• What is the most serious implication of this
  condition?

• When does the incidence of this condition
  increase?
                  Question
A normal intraocular pressure is:
a) 8 mm Hg
b) 15 mm Hg
c) 22 mm Hg
d) 25 mm Hg
                    Answer
A normal intraocular pressure is:
a) 8 mm Hg
b) 15 mm Hg 
c) 22 mm Hg
d) 25 mm Hg

Rationale: When aqueous fluid production and
   outflow are in balanced, the IOP is between 10
   and 21 mm Hg.
            Types of Glaucoma
• Open-angle
  – Chronic open-angle glaucoma
  – Normal-tension glaucoma
  – Ocular hypertension
• Angle-closure
  – Acute angle-closure
  – Subacute angle-closure
  – Chronic angle-closure
• Congential
• Glaucoma secondary to other condiditons
          Clinical Manifestations
• Insidious until significant vision loss:
   – Peripheral vision loss
   – Blurring halos
   – Difficulty focusing
   – Difficulty adjusting eyes to low light
• May experience aching or discomfort around
  the eye or a headache
                 Diagnositics
Discuss the expected   Progression of visual field
  findings--             defects:
• Tonometry
• Gonioscopy
• Perimetry testing
                 Treatment

• Describe the goals of glaucoma treatment

• Identify treatment modalities to achieve these
  goals.
         Nursing Managment
• What is a key teaching point regarding
  treatment?
• What is the focus of management?
• What aspects of management should be
  emphasized?
• What areas of management should be
  included in teaching?
• What is a key psychosocial nursing
  intervention?
                   Cataracts

•   Describe the appearance of a Cataract.
•   When are cataracts most likely to occur?
•   Discuss the associated concerns?
•   Identify risk factors
           Clinical Manifestations
•   Painless, blurry vision
•   Sensitivity to glare
•   Reduced visual acuity
•   Other effects:
    – Myopic shift, astigmatism, diplopia, color shifts
      including brunescent
• Diagnostic findings:
    – Decreased visual acuity and opacity of the lens by
      opthalmoscope, slit-lamp, or inspection
             Cataract Surgery
• Indicated when decreased vision interferes
  with normal activities
• Outpatient procedure with local anesthesia
  – 1 hour
  – Discharge soon after procedure
  – Need thorough teaching prior to discharge
• Complications are rare but significant if
  present (Table 58-5, p. 2062)
        Types of Cataract Surgery
•   Intracapsular cataract extraction (ICCE)
•   Extracapsular cataract extraction (ECCE)
•   Phacoemulsification
•   Lens replacement
    – Intraocular lens implant (IOL)


Compare and Contrast these surgical procedures
            Nursing Managment

•   Describe pre-operative preparation
•   Describe post-operative care
•   Discuss post-operative teaching needs
•   Identify the most important aspect of post-
    operative teaching.
                  Question
Which of the following diagnostics is used to
  establish the degree of cataract formation?
a) Perimetry
b) Tonometry
c) Slit lamp biomicroscopic examination
d) Goniscopy
                    Answer
Which of the following diagnostics is used to
  establish the degree of cataract formation?
a) Perimetry
b) Tonometry
c) Slit lamp biomicroscopic examination 
d) Goniscopy

Rationale: The Snellen visual acuity test,
   opthalmoscopy, and slit lamp biomicroscopic
   examination are used to establish the degree of
   cataract formation.
             Corneal Disorders
• Treatment of diseased corneal tissue
  – Phototherapeutic keratectomy
  – Keratoplasty
  – Donor tissue transplant
     • Contraindications (Chart 58-9, p. 2065)
     • Risk of graft failure
  – Continued follow-up and support
• Refractive surgery
  – Elective procedures: (PRK and LASIK)
  – Pre-procedure counseling
             Retinal Disorders
• Retinal detachment
• Retinal vascular disorders
  – Central retinal vein occlusion
  – Branch retinal vein occlusion
  – Central retinal vein occlusion
  – Macular degeneration
          Retinal Detachment
• Describe a retinal detachment
• Discuss manifestations of a retinal
  detachment
• Identify the diagnostics you would expect to
  be ordered for a patient with suspected retinal
  detachment
             Surgical Treatment
• Scleral buckle
• Pars plana vitrectomy
  – Removal of the vitreous, locating the incisions at the
    pars plana
  – Frequently used in combination with other
    procedures
• Pneumatic retinopexy
  – Injected gas bubble, liquid, or oil used to flatten the
    sensory retina against the RPE
  – Post-operative positioning is crutial
Before and After
          Nursing Managment
• Discuss a key nursing intervention associated
  with retinal surgery.
• Why is this intervention so important?

• Measures to promote patient comfort
• Positioning
  Retinal Artery or Vein Occlusion
• Loss of vision can occur
• May result from:
  • Atherosclerosis, cardiac valvular disease, venous stasis,
    hypertention, and increased blood viscosity
• Associated risk factors:
  – Diabetes mellitus, glaucoma, aging
• Patients may report decreased visual acuity or
  sudden loss of vision
          Macular Degeneration
• Age-related macular degeneration (AMD)
• Most common cause of vision loss in > 60 yrs
• Types
  – Dry
  – Wet

  Compare and Contrast the types of AMD
 Progression of AMD–
Pathways to Vision Loss
          Photodynamic Therapy
• Light-sensitive verteporfin dye injected into
  vessels
   – Laser used to active the dye and shut down vessels
     without damaging retina
• Expected outcome is to slow or stabilize the
  vision loss
• Key teaching point:
   – Patient must avoid sunlight or bright light for 5-7 days
     to prevent activation of dye in superficial vessels
         Nursing Management
• What is the primary focus of nursing
  management of AMD?

• Discuss recommendations the nurse would
  incorporate into her teaching plan.

• Identify an additional concern that must be
  addressed.
                Ocular Trauma
• Prevention is best strategy
  – Chart 58-10, p. 2072
  – Patient and public education
• Must know emergency treatment
  – Flush chemical injuries
  – Do not remove foreign objects
  – Protect using metal shield or paper cup
• Potential exists in some injuries for sympathetic
  opthalmia causing blindness in the uninjured eye
Infectious and Inflammatory Disorders
• Dry eye syndrome
• Conjunctivitis (pink-eye)
  – Classified by cause:
     • Bacterial, viral, fungal, parasitic, allergic, and toxic
  – What is a key teaching consideration regarding
    viral conjunctivitis
• Uveitis
• Orbital cellulitis
• Other (see Table 58-6, p. 2076)
   Ocular Consequences of Systemic
               Disease
• Identify three systemic conditions that can
  lead to visual disturbances/blindness with
  either poor management or progression of the
  disease.
                 Question
Common causes of blindness and visual
  impairment among adults 40 years of age or
  older include which of the following?
a) Diabetic retinopathy
b) Glaucoma
c) Macular degeneration
d) All of the above
                      Answer
Common causes of blindness and visual impairment
  among adults 40 years of age or older include
  which of the following?
a) Diabetic retinopathy
b) Glaucoma
c) Macular degeneration
d) All of the above 

Rationale: The most common causes of blindness and visual
    impairment among adults 40 or older are diabetic
    retinopathy, macular degeneration, glaucoma and
    cataracts.
              Safety and Teaching
• Important measure in regards to disorders
  affecting vision
• Patient teaching is vital
   –   Prevention of eye injuries
   –   Importance of compliance with treatment
   –   Signs of complications
   –   Proper use of medications, patches, and shields
• Safety strategies are essential
   – In hospital as well as at home
   – Binocular vision is lost with patching  increased risk
     for falls
           Ocular Prosthetics
• Care of prothestic eye:
  http://www.carolinaeyeprostheticsinc.com/pr
  osthetic-eye-care.html

• Artificial eye care:
  http://www.articlesbase.com/medicine-
  articles/artificial-eye-care-708004.html

								
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