Care of the Patient with an Eye Disorder Lesson Plan PDF

**CRM LESSON PLAN REPORT** **Care of the Patient with an Eye Disorder** **NP02L024 ELO A / Version 2.0** **Analysis** **NOV 2023** **Effective Date: N/A** **SCOPE:** This lesson focuses on skills required to complete care for a patient with visual disorders. **Distribution Restriction:** Dis...

**CRM LESSON PLAN REPORT** **Care of the Patient with an Eye Disorder** **NP02L024 ELO A / Version 2.0** **Analysis** **NOV 2023** **Effective Date: N/A** **SCOPE:** This lesson focuses on skills required to complete care for a patient with visual disorders. **Distribution Restriction:** Distribution authorized to the DOD and DOD Contractors only FD review is required prior to release for national disclosure policy (NDP) compliance and the protection of operational data associated with US tactics, techniques, and procedures (TTPs).This determination was made on 3 April 2020. **SECTION I. ADMINISTRATIVE DATA** +---------+---------+---------+---------+---------+---------+---------+ | **All | **[Cour | | | | | | | Courses | se | | | | | | | Includi | Number] | | | | | | | ng | {.under | | | | | | | This | line} | | | | | | | Lesson* | [Versio | | | | | | | * | n]{.und | | | | | | | | erline} | | | | | | | | [Course | | | | | | | | Title]{ | | | | | | | |.underl | | | | | | | | ine}** | | | | | | | | | | | | | | | | 300-68C | | | | | | | | 2023 | | | | | | | | Practic | | | | | | | | al | | | | | | | | Nurse | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | | **POIs* | | | | | | | | * | | | | | | | | | | | | | | | | **[POI | | | | | | | | Number] | | | | | | | | {.under | | | | | | | | line} | | | | | | | | [Versio | | | | | | | | n]{.und | | | | | | | | erline} | | | | | | | | [Title] | | | | | | | | {.under | | | | | | | | line} | | | | | | | | [Phase] | | | | | | | | {.under | | | | | | | | line} | | | | | | | | [Status | | | | | | | 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| | | | | -0057 | | | | | | | | TREAT | | | | | | | | LACERAT | | | | | | | | IONS, | | | | | | | | CONTUSI | | | | | | | | ONS, | | | | | | | | AND | | | | | | | | EXTRUSI | | | | | | | | ONS | | | | | | | | OF THE | | | | | | | | EYE | | | | | | | | | | | | | | | | 081-833 | | | | | | | | -0058 | | | | | | | | TREAT | | | | | | | | BURNS | | | | | | | | OF THE | | | | | | | | EYE | | | | | | | | | | | | | | | | 081-835 | | | | | | | | -3022 | | | | | | | | ADMINIS | | | | | | | | TER | | | | | | | | MEDICAT | | | | | | | | ED | | | | | | | | EYE | | | | | | | | DROPS | | | | | | | | OR | | | | | | | | OINTMEN | | | | | | | | TS | | | | | | | | | | | | | | | | 081-835 | | | | | | | | -3028 | | | | | | | | PERFORM | | | | | | | | A | | | | | | | | NURSING | | | | | | | | ASSESSM | | | | | | | | ENT | | | | | | | | | | | | | | | | 081-835 | | | | | | | | -3098 | | | | | | | | ADMINIS | | | | | | | | TER | | | | | | | | MEDICAT | | | | | | | | ION | | | | | | | | VIA | | | | | | | | MUCOUS | | | | | | | | MEMBRAN | | | | | | | | ES | | | | | | | | | | | | | | | | 081-835 | | | | | | | | -3105 | | | | | | | | PREPARE | | | | | | | | MEDICAT | | | | | | | | ION | | | | | | | | FOR | | | | | | | | ADMINIS | | | | | | | | TRATION | | | | | | | | | | | | | | | | 081-835 | | | | | | | | -3152 | | | | | | | | CONDUCT | | | | | | | | PATIENT | | | | | | | | TEACHIN | | | | | | | | G | | | | | | | | BASED | | | | | | | | ON | | | | | | | | PATIENT | | | | | | | | CARE | | | | | | | | NEEDS | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | **Knowl | ----- | | | | | | | edge** | ------- | | | | | | | | ------- | | | | | | | | ------- | | | | | | | | ------ | | | | | | | | ------- | | | | | | | | ------- | | | | | | | | ------- | | | | | | | | ---- -- | | | | | | | | ------- | | | | | | | | ------- | | | | | | | | ------- | | | | | | | | --- --- | | | | | | | | ------- | | | | | | | | ------- | | | | | | | | ------- | | | | | | | | ---- | | 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INTRODUCTION** +-----------------------+-----------------------+-----------------------+ | **Motivator** | The eye constantly | | | | gathers information | | | | through millions of | | | | receptors. What would | | | | it be like if a | | | | person could not see? | | | | How would it impact | | | | their lives? This | | | | lesson discusses | | | | several important | | | | terms, disease | | | | processes, and | | | | surgical treatments | | | | for the eye. | | | | | | | | As a 68C Practical | | | | Nursing Specialist, | | | | you will be assigned | | | | to a variety of areas | | | | where you will be | | | | required to perform | | | | duties such as | | | | providing emergent, | | | | acute and long-term | | | | nursing care for | | | | patients during | | | | peacetime or wartime | | | | in medical surgical | | | | and critical care | | | | areas; alternatively, | | | | in operational | | | | conditions requiring | | | | the efficient use of | | | | field medical | | | | equipment. | | | | | | | | The requirements of | | | | providing nursing | | | | care for patients who | | | | are critically ill or | | | | with traumatic | | | | injuries or chronic | | | | conditions will | | | | require the 68C | | | | Soldier to apply | | | | lessons learned along | | | | with practitioner | | | | knowledge and | | | | abilities to perform | | | | their skills | | | | effectively. The 68C | | | | Soldier's ability to | | | | perform these skills | | | | proficiently will | | | | have a direct impact | | | | on patient outcomes | | | | no matter the setting | | | | or environment where | | | | the patient encounter | | | | occurs. | | +-----------------------+-----------------------+-----------------------+ | | **NOTE:** Inform the | | | | students of the | | | | following Terminal | | | | Learning Objective | | | | requirements. | | | | | | | | At the completion of | | | | this lesson, you | | | | \[the student\] will: | | +-----------------------+-----------------------+-----------------------+ | | **Action:** | Determine approaches | | | | for safe and | | | | effective patient | | | | care | +-----------------------+-----------------------+-----------------------+ | | **Conditions:** | Given a patient with | | | | a disorder of the eye | +-----------------------+-----------------------+-----------------------+ | | **Standards:** | By correctly | | | | responding to | | | | written, oral, and | | | | experiential | | | | assessment measures. | +-----------------------+-----------------------+-----------------------+ | | | | +-----------------------+-----------------------+-----------------------+ | **Safety | None | | | Requirements** | | | +-----------------------+-----------------------+-----------------------+ | **Risk Assessment | Low | | | Level** | | | +-----------------------+-----------------------+-----------------------+ | **Environmental | **NOTE:** It is the | | | Considerations** | responsibility of all | | | | Soldiers and DA | | | | civilians to protect | | | | the environment from | | | | damage. | | | | | | | | None | | +-----------------------+-----------------------+-----------------------+ | **Evaluation** | | | +-----------------------+-----------------------+-----------------------+ | **Instructional | | | | Lead-In** | | | +-----------------------+-----------------------+-----------------------+ **SECTION III. PRESENTATION** **NOTE:** Inform the students of the Enabling Learning Objective requirements. **Nursing Considerations for Care of the Patient with Common Eye Complications** 1 Learning Step / Activity 1 Nursing Considerations for Care of the patient with Common Eye Complications --- ------------------------------ ------------------------------------------------------------------------------ Method of Instruction: Large group discussion Instructor to Student Ratio: 1:30 Time of Instruction: 15 mins Media: Large group discussion Activity 1. Terms. Note Have discussion and review about anatomy, structure, and chamber of eye. (Review from Phase I pgs. 1816-1818) (refresh from phase I) Assessment Note Review Table 53.1 Normal Finding of the Adult Eye p. 1818 a\. Physiology of Vision -- (sequence) Light must travel through the cornea, ➡️ aqueous humor ➡️ pupil ➡️crystalline lens ➡️vitreous humor to reach the rods and cones of the retina. Once this has taken place, the image is transported via the optic nerve to the visual center of the cerebral cortex in the brain. b\. Assess the individual for the following items: 1. Verbal review of body systems 2. Eye pain, pruritus, photophobia, excessive tearing, dryness, floaters (dark to semitransparent spots in the visual field), light flashes, scotomas (diminished vision in a defined area of the visual field), halos around lights, diplopia (double vision), discharge, visual changes such as depth perception and peripheral vision changes, blind spots or fading color vision. 3. Headaches 4. Nystagmus (involuntary, rhythmic movements of the eyes) 5. History of allergies 6. Current medications, over the counter and prescription 7. Use of visual assistive devices (glasses, contact lenses, magnifying glasses) 8. Personal habits related to care of eyewear 9. Any previous eye injuries or surgeries c\. Laboratory and diagnostic examinations: visual acuity, visual fields, refraction, peripheral vision, and overall health of the eye and supportive structures. (Please refer to referenced pictures as there are many examples) i.e (53.4 shows Amsler Grid) 1. Snellen's test - test for visual acuity. (Fig 53.3) a. Use Snellen's chart; eye patch/cover. b. Person stands 20 feet from chart; covers one eye at a time; asked to read above or below the 20/20 line. c. If findings are abnormal, encourage person to seek further eye testing. 2. Refraction -- bending of light rays as they enter the eye; patient reads chart 20 feet away using a variety of lenses; result will determine the degree of visual disorders including: hyperopia, myopia, astigmatism, and presbyopia 3. Visual field- six visual fields. Identification of loss or deterioration of any field by reviewing the patient's ability to see items as they are moved into the field of vision. *Automated perimetry test*- It places the patient in front of a computer-like device and asks them to stare at a screen and to press a button when flashes of light enter the field of vision. 4. Amsler grid -- assesses for disturbances in central vision, identifying conditions such as macular degeneration. Black grid markings are superimposed on a white background. A centralized black dot is used as the point of reference. The patient is asked to view the grid concentrating on the dot, and report areas of distortion. (Fig. 53.4) 5. Slit-lamp - equipment used to examine the conjunctiva, lens, vitreous humor, iris, and cornea. Dilating drops *(mydriatics)* may be used to evaluate internal surfaces and will cause photosensitivity. 6. Fluorescein angiography- evaluates retinal blood flow. Dye is injected into vessels of the arm or hand. Used for diagnosis of retinal detachment, retinopathy, tumors, and macular degeneration. 7. Tonometry - equipment used to measure intraocular pressure to detect tumors and glaucoma. Puffing air onto the surface of the open eye, the eye pressure is measure by evaluation how the light reflections change as the air hists the eye (Fig 53.5). A more invasive study is *Goldmann tonometry*, in which the eye is numbed and a cone-shaped devices is used to depress the eyeball gently to assess for internal pressure. ----------- ------------------------------------------------------------------ **NOTE:** Conduct a check on learning and summarize the learning activity. ----------- ------------------------------------------------------------------ **[QUESTION]:** What test is used to examine the eye for glaucoma? **[ANSWER]:** Tonometry. Reference: p. 1819. Foundation and Adult Health Nursing 8^th^ ed. 2 Learning Step / Activity Disorders of the Eye --- ------------------------------ ------------------------ Method of Instruction: Large group discussion Instructor to Student Ratio: 1:30 Time of Instruction: 15 mins Media: Large group discussion **Disorders of the Eye** **a.** Blindness and near blindness: 1. Etiology and Pathophysiology: a. Total blindness is defined as no light perception and no usable vision. b. Functional Blindness is present when the patient has some light perception but no usable vision. c. Legally blind refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. d. Congenital blindness: results from various birth defects e. Acquired blindness: results from diabetic retinopathy, glaucoma, retinal degeneration, and acute trauma, and cataracts 2. Clinical Manifestations: f. Depends on the extent of the disease/trauma. g. Diplopia, pain, presence of floaters, light flashes, burning eyes and loss of peripheral vision; halos (rainbow colors seen around lights); sense of orbital pressures; bulging of eyes; lack of symmetry of an eye structure, such as the pupil. h. A wide variety of emotional symptoms: fear, anxiety, disorientation, depression, helplessness, hopelessness to acceptance 3. Assessment: i. Subjective: i. Early onset may be blurred vision. ii. Determine onset, duration, and severity iii. Determine factors that relieve the symptoms. j. Objective: iv. Note rubbing/squinting. v. Use of compensating measures (squinting, use of magnifying glass) vi. Use of assistive eyewear. 4. Medical Management: k. Corrective eyewear is first method for a partially sighted individual l. Medication for inflammatory disorders if contributing to condition m. Assistive devices; canes, guide dogs, magnifying systems n. Surgical correction: laser surgery or corneal transplants 5. Nursing Interventions and Patient Teaching o. Assistance with ADLs: Primary focus. p. Use protective devices q. Alter surroundings to promote safety r. Arrange objects in room one way and do not rearrange s. Encourage blind person to touch objects t. Adequate time should be provided to allow patient to assist in self- care u. Affects patient and families, be aware of referral services and make appropriate referrals v. Technological advances such as computers with voice recognition enable the patient to read, use the internet, and communicate with others. w. Optical scanners can capture images and, by recognizing the written text, convert the images into identifiable character and words. 1. Guidelines for Communicating with People Who are Visually Impaired: (See Box 53-1: Guidelines for Communicating with Blind People; p1822). a. Talk in normal tone b. Always introduce yourself (unless well known to person c. Describe activities d. Announce when you leave the room e. Do not try to avoid common phrases in speech such as "See what I mean?" 2. Ambulatory Safety: f. Walking slowly g. Use verbal clues from walking companion h. Encourage patient to touch objects or borders i. Walking: i. Companion should precede the person by 1 foot ii. Patients hand should be on companion' s elbow (See Figure 53-6: Sighted-guide technique; p1821) 3. Provide emotional/psychosocial support j. Don't assume patient is in acceptance phase if blindness has been present for years k. May result in physical and emotion problems l. Poor interpersonal skills and coping mechanisms m. Self-care skills may be impaired iii. Malnourished due to diminished self-cooking skills iv. Secondary infections due to poor hygiene practices n. May prefer isolation causing additional physical and emotional difficulties ----------- ------------------------------------------------------------------ **NOTE:** Conduct a check on learning and summarize the learning activity. ----------- ------------------------------------------------------------------ **[QUESTION]:** Name three causes of blindness **[ANSWER]:** Blindness may result from diabetes retinopathy, glaucoma, cataracts, retinal degeneration, and acute trauma. Reference: p. 1820. Foundations and Adult Health. **Refractory Errors** Common Refractory errors (astigmatism, strabismus, myopia, and hyperopia). See Table 53.2: Common Refractory Errors: p1820  a**. Myopia**: nearsightedness. (Difficulty seeing at long distance) 1. Diagnostic Tests: a. Optometrist the patient is assessed for corrective lenses or corrective refractory surgery. 2. Medical Management: b. Prescribed corrective eyeglasses or contact lenses c. Patients who are unable or unwilling to wear corrective eyewear for occupational or cosmetic reasons may elect to seek surgical correction. 3. Surgical Management d. Refractory surgery, such as reshaping the corneal curvature is effective in treating the underlying complications causing visual problems. e. Patients are selected by the degree of myopia, the shape of the cornea, and the absence of medical conditions such as sever diabetes, glaucoma, and pregnancy. f. Radial keratotomy (RK) partial-thickness radial incision in the patient's cornea, leaving an uncut optical zone in the center. g. Photorefractive keratectomy (PRK)- uses an excimer laser (ultraviolet laser) to reshape the central corneal surface. h. Laser-assisted in situ keratomileusis (LASIK) is a procedure in which first a corneal flap is folded back and then an excimer laser removes some of the internal layers of the cornea. The flap is returned to its normal position and allowed to heal in place. i. Intracorneal implants, known as Intacs, are microthin rings implanted through incisions in the side of the cornea (Fig 53.7) Used for the patient who has keratoconus, a progressive disease in which the cornea thins. 4. Nursing Interventions and Patient Teaching j. If surgery is involved: patient teaching is required. k. Preoperative: stop wearing contacts 2 days before; rest one day before l. Postoperative: i. Eye patch used on operative sight overnight, removed by doctor next day. ii. Analgesics for pain; if pain persists after one day contact the doctor. iii. Follow up as ordered. iv. Goal is improved vision. Maybe not 20/20 vision, improved vision while operating a vehicle during the day. May experience halos while driving at night requiring glasses. **b. Hyperopia**: farsightedness (difficulty seeing objects at close range) 1. Diagnostic Tests: ophthalmoscopy, retinoscopy, visual acuity tests, and refraction tests. 2. Medical Management: i. Eyeglasses or contacts. ii. Some individuals may choose to self-treat with over the counter (readers) 3. Nursing Interventions and Patient Teaching iii. Assist patient with care and maintenance of eyewear: wash glasses each day ensure screws are secure; contact lenses are cared for according to manufacturers' directions. (See Health Promotion Box Contact Lens Care p.1824 and below) iv. Encourage person to see optometrist/ophthalmologist yearly. v. Nursing diagnosis: risk r/t injuries. Orient person to surroundings; arrange objects in a room in a certain way and do not move. -- -- ----------- ------------------------------------------------------------------ **NOTE:** Conduct a check on learning and summarize the learning activity. ----------- ------------------------------------------------------------------ **[QUESTION]:** Is a person whose eyes are asymmetrical diagnosed with myopia, strabismus, or hyperopia? **[ANSWER]:** Strabismus is the ability of the eyes to focus symmetrically. Reference: p. 1820 Table 53.2, Foundations and Adult Health Nursing 3 Learning Step / Activity Care of the Patient with Infectious disorders of the eye --- ------------------------------ ---------------------------------------------------------- Method of Instruction: Large group discussion Instructor to Student Ratio: 1:30 Time of Instruction: 15 mins Media: Large group discussion **Disorders of the eyelid:** Hordeolum, Chalazion, and Blepharitis 1. Hordeolum (stye): Acute infection of eyelid margins or sebaceous glands of the eyelashes. a. Etiology: Staphylococcus organism. b. Clinical manifestations: i. Abscess at base of eyelashes ii. edema of lid. a. Assessment: 1. Subjective: tenderness; pain with edema. 2. Objective: raised, red area, pustule with exudate. 2. Chalazion: inflammatory cyst on the meibomian gland at the eyelid margin a. Clinical Manifestations: 1. Discomfort 2. Mass on eyelid 3. Edema 4. Visual disturbances b. Assessment 5. Subjective: 1. c/o pressure felt as eyelid closes over cornea 2. visual changes 6. Objective: 3. Cyst formation 4. Eyelid edema 3. Blepharitis: inflammation of eyelid margins c. Etiology: 7. Ulcerative: bacterial infection; usually staphylococcal organisms. 8. Non-ulcerative: caused by psoriasis, seborrhea, or allergic reaction. d. Clinical Manifestations: 9. Pruritis 10. erythema of eyelid 11. eye pain 12. photophobia. 13. Tearing may occur in nonulcerative type. e. Assessment: 14. Subjective: 5. pruritis of the eye 6. lids adhere together during sleep. 15. Objective: 7. Erythema 8. patient rubs eyes 9. light sensitivity 10. tear spillage 4. Diagnostic tests for Hordeolum, Blepharitis and Chalazion: a. Examine the eyelid margins. b. Culture and sensitivity. 5. Medical Management for Hordeolum, Blepharitis and Chalazion: a. Anti-infective agents are prescribed. (cephalexin and erythromycin) b. A localized incision and drainage of a cyst or stye may take place with the patient under local anesthesia c. NS compresses 10-20 minutes, 2-4 a day d. No more tears shampoo to cleanse lids. 6. Nursing Interventions and Patient Teaching: Care so infection is not spread. a. Good hand washing. b. Teach patient use of compresses. c. Keep hands away from eyes. d. No eye make-up until all inflammation subsides e. Eye make-up should be replaced after an eye infection and every 3-6 months thereafter, because of the potential for the make-up to harbor bacteria. 7. Prognosis: Some cases resolve without treatment in 1-2 weeks, some may need antibiotics and rarely need surgical incision and drainage. a. **Inflammation of the Conjunctiva- Conjunctivitis** \(1) Etiology: Common disorder; causes may be viral or bacterial, allergies or environmental factors. (Can spread to unaffected eye) reiterate teaching to patients. 2\) Hands are the most common transmitter. \(a) Redness (erythema) of conjunctiva and edema of the lid. \(b) Crusty discharge on lid and cornea. \(3) Assessment: \(a) Subjective: patient reports itching, burning and excessive tearing. 6. Nursing intervention focuses on prevention of spreading the infection. \(1) Same nursing care as for the patient with Hordeolum and Blepharitis. \(2) Additionally instruct family to use individual wash cloth and towels. \(3) When allergies are present, cold NS compresses to reduce edema. \(4) Topical antibiotics/adrenocortical administered as ordered. 7. Prognosis: Successfully treated with topical antimicrobials. Although highly contagious, the disease is self-limiting, leaving no chance of visual impairment unless a chronic condition develops. **c. Inflammation of the cornea- Keratitis** 1. Etiology and Pathophysiology a. resulting from injury; irritants; allergies; viral infections; congenital syphilis, or smallpox; dirty contact lens b. It may be superficial, involving only the epithelial layer or it may invade the sub epithelial layer and endothelial membrane. c. Very painful when inflammation is present. d. Ulcers may form and result in scarring of the corneal surface. e. Most common viral agent is herpes simplex virus (HSV) 2. Clinical Manifestations: f. Severe eye pain is the most common and differentiates this disease from other inflammatory diseases. g. Also includes photophobia, tearing, edema, or visual disturbances h. If uncontrolled may result in blepharospasms and vision loss. \(3) Assessment: \(b) Objective: facial grimacing, lacrimation, and photophobia. 6. Nursing Interventions and Patient Teaching a. Care so infection is not spread; good hand washing; teach patient use of compresses; keep hands away from eyes; no make-up 3-6 months; instruct family to use individual wash cloth and towels. b. When allergies are present, cold NS compresses to reduce edema. ----------- ------------------------------------------------------------------ **NOTE:** Conduct a check on learning and summarize the learning activity. ----------- ------------------------------------------------------------------ **[QUESTION]:** What diagnostic tests are performed to diagnose a hordeolum (stye)? **[ANSWER]:** The eyelid margins are examined. Culture and sensitivity tests of any drainage may be ordered. Reference: p. 1825. Foundation and Adult Health Nursing. 4 Learning Step / Activity 4 Noninfectious Disorders of the Eye --- ------------------------------ ------------------------------------ Method of Instruction: Large group discussion Instructor to Student Ratio: 1:30 Time of Instruction: 20 mins Media: Large group discussion a. **Dry Eye Disorders** 1. Etiology and Pathology: Dry eyes are caused by a variety of ocular disorders chara