MS CH 52: Nursing Care of Patients With Sensory Disorders PDF

4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1236 52 Nursing Care of Patients With Sensory Disorders: Vision and Hearing KEY TERMS...

4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1236 52 Nursing Care of Patients With Sensory Disorders: Vision and Hearing KEY TERMS LAZETTE V. NOWICKI astigmatism (uh-STIG-mah-TIZM) blepharitis (BLEF-uh-RIGH-tis) blindness (BLYND-ness) LEARNING OUTCOMES carbuncle (KAR-bung-kull) 1. Explain the pathophysiology of each of the disorders of cataract (KAT-uh-rakt) chalazion (kah-LAY-zee-on) the sensory system. conductive hearing loss (kon-DUK-tiv HEER-ing LOSS) 2. Define blindness and the refractive errors of vision. conjunctivitis (kon-JUNK-ti-VIGH-tis) 3. Explain the etiologies, signs, and symptoms of each enucleation (ee-NEW-klee-AY-shun) external otitis (eks-TER-nuhl oh-TIGH-tis) sensory disorder. furuncle (FYOOR-ung-kull) 4. Plan nursing care for patients undergoing tests for glaucoma (glaw-KOH-mah) sensory disorders. hordeolum (hor-DEE-oh-lum) hyperopia (HIGH-per-OH-pee-ah) 5. Identify therapeutic measures for each sensory disorder. macular (MAK-yoo-lar) 6. Identify medications contraindicated for patients with Ménière’s disease (ma-NEARS di-ZEEZ) acute angle-closure glaucoma. miotics (my-AH-tiks) myopia (my-OH-pee-ah) 7. List three ototoxic drugs. myringoplasty (mir-IN-goh-PLASS-tee) 8. List data to collect when caring for patients with disorders myringotomy (MIR-in-GOT-uh-mee) of the sensory system. otosclerosis (OH-toh-skle-ROH-sis) photophobia (FOH-toh-FOH-bee-ah) 9. Plan nursing care for patients with disorders of the eye presbycusis (PREZ-by-KYOO-sis) or ear. presbyopia (PREZ-by-OH-pee-ah) retinopathy (ret-i-NAH-puh-thee) 10. Plan nursing care interventions for the patient with a sensorineural (SEN-suh-ree-NEW-ruhl) hearing impairment. stapedectomy (stuh-puh-DEK-tuh-mee) 11. Discuss how to know if nursing interventions for sensory disorders have been effective. 1236 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1237 Chapter 52 Nursing Care of Patients With Sensory Nervous System Disorders: Vision and Hearing 1237 Conjunctivitis VISION DISORDERS Conjunctivitis is inflammation of the conjuncti va caused Early detection of visual problems can reduce their impact. by either a virus or a bacterium. Viral conjunctivitis occurs Nurses play an important role in assisting the patient with visual more commonly than bacterial conjunctivitis and is highly problems (Table 52.1). contagious. The virus is usually transmitted via contami- nated eye secretions on the hand that then touches or rubs Infections and Inflammation an eye, infecting that eye. The virus is hardy and may li ve Infections and inflammation of the e ye and surrounding on dry surfaces for 2 weeks or more. Viral conjunctivitis structures can be bacterial or viral in origin. The eye may lasts 2 to 4 weeks. Bacterial conjuncti vitis (commonly become aggravated by allergens, chemical substances, or called pinkeye) usually is due to staphylococcal or strepto- mechanical irritation, leading to infection by microor gan- coccal bacteria and is also highly contagious. Conjunctivitis isms. Mechanical irritation may be caused by sunb urn or can also be caused by the organisms Haemophilus influen- bacterial infection. Inflammation results from aller gies to zae, Chlamydia trachomatis, and Neisseria gonorrhoeae. environmental substances or by irritation of chemical irri- Conjunctivitis is commonly transmitted among children and tants found in perfumes, mak eup, sprays, or plants. Viral then to family members. Signs and symptoms of conjunc- agents that cause infection include herpes simple x virus, tivitis include conjunctival redness and crusting e xudate cytomegalovirus, and human adeno virus. Bacterial agents that infect the eye include Staphylococcus and Streptococcus WORD BUILDING (“Cultural Considerations”). conjunctivitis: conjunctive—joining membrane + itis—inflammation TABLE 52.1 EYE DISORDER SUMMARY Signs and Symptoms Visual disturbances Pain Redness, secretions, itchiness Sensation of pressure in eyes Diagnostic Tests and Findings Visual acuity Ophthalmoscopic examination of internal and external eye Amsler grid (identifies visual field disturbances) Slit-lamp examination (identifies abnormalities on cornea and sclera) Tonometry (identifies intraocular pressure) Therapeutic Measures Medications: reduce intraocular pressure, treat infections, anesthetize the eye Surgery Complications Worsening vision or loss of vision Acute pain Priority Nursing Diagnoses Anxiety related to visual-sensory deficit Risk for Injury Deficient Knowledge Cultural Considerations Vision Trachoma, a form of conjunctivitis, is a common, chronic disease that affects millions of people worldwide. It is primarily seen among low-income persons in the Mediterranean, Africa, Brazil, and the Far East. Trachoma is caused by a viral strain of Chlamydia trachomatis that is highly contagious. Following the acute conjunctivitis phase, the eyelids shrink as a result of scarring. The shrinking tends to pull the eyelashes inward (entropion), which may scratch the cornea. In addition, granulations form on the inner eyelids. This painful condition may eventually lead to corneal ulceration and blindness. Trachoma is medically treated with topical and oral erythromycin or tetracycline. 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1238 1238 UNIT FOURTEEN Understanding the Sensory System on the lids and in the corners of the eyes, itching, pain, and Blepharitis excessive tearing. Blepharitis, an inflammation of the eyelid margins, is a chronic Viral conjunctivitis is treated by supporti ve measures, inflammatory process. The cause may include staphylococcal which seek to keep the patient comfortable until the infec- infection, seborrhea (dandruff), rosacea (a chronic disease of tion resolves on its own. Treatment includes eyewashes or the skin usually affecting middle-aged and older adults), dry eye irrigations, which cleanse the conjunctivas and relieve eye, or abnormalities of the meibomian glands and their lipid the inflammation and pain. Bacterial conjuncti vitis is secretions. There are tw o types of blepharitis: seborrheic treated with antibiotic eye drops or ointments (Table 52.2). blepharitis and ulcerative blepharitis. Seborrheic blepharitis is Adults generally prefer eye drops because they do not im- characterized by reddened eyelids with scales and flaking at the pair vision. Ointments are commonly used when the eye is base of the lashes. Ulcerati ve blepharitis produces crusts at resting (at night) or in children, who may squeeze their eyelashes, reddened eyes, and inflamed corneas. Eyelids chron- eyes shut and cry when ocular medications are applied, ically infected with Staphylococcus may become thickened, and thus expelling the medication. With either type of conjunc- eyelashes may be lost. Treatment requires a commitment to tivitis, hand hygiene is the best means of pre venting the long-term daily cleansing with cotton-tipped sw abs dipped in spread of the disease. TABLE 52.2 OPHTHALMIC MEDICATIONS Medication Class/Action Examples Nursing Implications Diagnostic Aids Fluorescein Sodium Staining of eye. fluorescein (AK-Fluor) Stain needs to be irrigated out of eye Lesions of foreign objects pick when examination is complete. up bright yellow-orange stain Stain is colorfast, so caution should be so abnormality can be detected. used when irrigating. Topical Anesthetics Provide local anesthesia to area, tetracaine (Pontocaine) Eye must be protected because blink making examination painless. reflex is temporarily lost. Also used to reduce pain of injury. Lid should be kept closed to keep eye moist after examination and treatment. Antiangiogenetics Antivascular Endothelial Growth Factor Inhibits growth of new blood pegaptanib (Macugen) Monitor for 1 week after to detect vessels and slows progression infection early. of wet age-related macular degeneration Eye Allergy Symptom Relief Relieves red, itchy eyes caused by nedocromil (Alocril) See Box 51-4. allergies azelastine (Astelin) Caution patient not to wear soft contact naphazoline (Naphcon) lenses while eyes are red. olopatadine (Patanol) Anti-Infectives Antibiotics Treat bacterial eye infections. ciloxan (Cipro) Give on an empty stomach. Encourage fluids. Urge patient to take with full glass of water. gatifloxacin (Zymar) See Boxes 51-4 and 51-5. 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1239 Chapter 52 Nursing Care of Patients With Sensory Nervous System Disorders: Vision and Hearing 1239 TABLE 52.2 OPHTHALMIC MEDICATIONS—cont’d Medication Class/Action Examples Nursing Implications polymyxin B and trimethoprim ophthalmic (Polytrim) tobramycin (Tobrex) sulfacetamide (Bleph-10, Isopto Cetamide, Sodium Sulamyd) Antivirals Treat viral eye infections. trifluridine (Viroptic) See Box 51-4. Antifungals Treat fungal eye infections. natamycin (Natacyn) Follow instructions for instillation. Anti-Inflammatories Reduce inflammation of conjunctiva, cornea, or eyelids due to infection, edema, allergic reaction, cataract surgery or burns. Steroidal dexamethasone (Decadron) See Box 51-4. May be combined with antibiotic, as in TobraDex (tobramycin and dexamethasone) Nonsteroidal ketorolac (Acular) See Box 51-4 Use only as prescribed. bromfenac (Xibrom) Reduces ocular inflammation and pain following cataract surgery usually within 2 days of bid treatment. Lubricants Moisten eyes in healthy and ill artificial tears (Lacri-Lube, Tears Explain that ointment distorts vision. persons. Plus) Miotics Lower intraocular pressure pilocarpine (Pilocar) See Box 51-4. by stimulating papillary and physostigmine (Isopto Eserine) Expect to see a smaller than normal ciliary sphincter muscles. pupil with little if any reaction to light. Carbonic Anhydrase Inhibitors Reduce intraocular pressure by acetazolamide (Diamox) Check for sulfa allergy. reducing aqueous humor Instruct patient to avoid excess sun formation. exposure. Used for glaucoma when other miotics have been unsuccessful. Osmotics Reduce intraocular pressure in mannitol (Osmitrol) Monitor for headache, nausea, acute open-angle glaucoma. vomiting, and confusion. Beta-Adrenergic Blockers Reduce intraocular pressure by timolol (Timoptic) See Box 51-4. reducing aqueous humor betaxolol (Betoptic) Monitor for bradycardia, heart block, formation and increasing its and wheezing. outflow. Continued 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1240 1240 UNIT FOURTEEN Understanding the Sensory System TABLE 52.2 OPHTHALMIC MEDICATIONS—cont’d Medication Class/Action Examples Nursing Implications Mydriatics atropine See Box 51-4 Dilate pupils for examination or Dilated pupils cannot protect eye from surgical procedures. bright light, so dark glasses are needed until drug effects have worn off. Monitor for side effects. Cycloplegics Paralyze muscles of accommodation cyclopentolate Contraindicated in patients with for examination or surgical glaucoma because of increase in procedures. intraocular pressure. diluted baby shampoo or sterile eyelid cleanser solutions to pre- with movement of the lid o ver the cornea. Other symptoms of vent infection. If infection occurs, antistaphylococcal antibiotic keratitis include decreased vision, photophobia (sensitivity to ointment (bacitracin, erythromycin) is applied to the lid margins light), tearing, and blepharospasm (spasm of the e yelids). The one to four times a day after the e yelids have been cleansed. conjunctiva often appears reddened. In adv anced cases, the Warm compresses may also be used. cornea may appear opaque (cloudy). Hordeolum and Chalazion DIAGNOSTIC TESTS. Assessment of keratitis or corneal ulcer is made by use of a slit lamp or a handheld light. The cornea is Another type of eyelid infection is a hordeolum. An external examined by shining the light source obliquely (diagonally) hordeolum (sty) is a small staphylococcal abscess in the se- across the cornea to sho w opacity in the cornea. Fluorescein baceous gland at the base of the eyelash (either the glands of stain may also be used to outline the area of involvement. When Zeis or glands of Moll). Styes are small, raised, reddened the stained area is viewed with a blue light, the disruption in the areas. Use of cosmetics on the eyes may contribute to horde- corneal surface shows up clear. If the patient is having pain from olum formation. A second type of abscess, a chalazion (in- blepharospasm (contraction of the orbicularis oculi muscle), the ternal hordeolum), may form in the connecti ve tissue of the examiner may instill a topical ophthalmic anesthetic such as eyelids, specifically in the meibomian glands. A chalazion is proparacaine. larger than an external hordeolum. Styes may be tender; how- ever, a chalazion often puts pressure on the cornea, causing THERAPEUTIC MEASURES. Therapeutic interventions may in- more discomfort. Hordeolums usually form and heal sponta- clude topical antibiotics, topical corticosteroids, topical inter - neously within a fe w days and require no treatment. Cha- ferons, antiviral medications for herpes simple x, cycloplegic lazions may require surgical incision and drainage (I&D) if agents (to keep the iris and ciliary body at rest), and warm com- they do not drain spontaneously. If either type of abscess per- presses. If the cornea is se verely damaged, corneal transplant sists, administration of oral antibiotics may be prescribed may be required. The eye may be patched to decrease the along with application of warm compresses to aid healing. amount of eyelid movement over the cornea during healing. Keratitis COMPLICATIONS. Corneal infections are usually serious and often threaten eyesight. The corneal tissue may become thin and PATHOPHYSIOLOGY AND ETIOLOGY. Keratitis is inflammation susceptible to perforation. Untreated, keratitis can cause perma- of the cornea and may be acute or chronic and superf icial or nent scarring of the cornea, resulting in permanent loss of vision. deep. The depth of keratitis is determined by the layers of the cornea that may be affected. Keratitis may be associated with Nursing Process for the Patient With Inflammation bacterial conjunctivitis, a viral infection such as herpes simplex, and Infection of the Eye a corneal ulcer, or diseases such as tuberculosis and syphilis. DATA COLLECTION. Table 52.3 reviews the subjective data Herpes simplex keratitis is the most common corneal infection that is collected. Objective data collection includes the condition in developed countries, with bacterial and fungal infections of the conjuncti va, eyelids, and e yelashes; the presence of being more prevalent throughout the rest of the w orld. People exudate, tearing, any visible abscess on the palpebral border , who have dry e yes, wear contact lenses and practice poor or a palpable abscess in the e yelid; opacity of the cornea; and contact lens hygiene, have decreased corneal sensation, or are visual acuity testing comparing unaffected and affected eyes. immunosuppressed are at increased risk of keratitis. SIGNS AND SYMPTOMS. The cornea has many pain receptors, WORD BUILDING so any inflammation of the cornea is painful.This pain increases photophobia: photo—light + phobia—fear of 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1241 Chapter 52 Nursing Care of Patients With Sensory Nervous System Disorders: Vision and Hearing 1241 TABLE 52.3 SUBJECTIVE DATA COLLECTION FOR EYE INFLAMMATION AND INFECTION CONDITIONS W What part of the eye is affected? Eyelid, conjunctiva, cornea? Where is it? H Pressure? Itchy? Painful? No pain? Irritated? Spasm? How does it feel? A Is it worse when rubbing eyes or blinking? Is there photosensitivity? Aggravating and alleviating factors T Was there exposure to a pathogen? Previous infection or irritation? Timing How long have symptoms persisted? S Is there visual impairment? Does pain affect activities of daily living? Severity U Is patient infected with lice? Immunosuppression? Do other members Useful data for associated symptoms of the family or peer group have symptoms? Are eyedrops used? Is there exudate? Are the eyelids stuck together on awakening? Does patient wear contact lenses, soft contact lenses overnight, disposable contact lenses? Does patient have dry eyes? Is patient infected with tuberculosis, syphilis, HIV? What is typical eye hygiene? P What does patient think is wrong? Perception of the problem by the patient HIV = human immunodeficiency virus. NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION. Deficient Knowledge related to eye disease process, prevention, Acute Pain related to inflammation or infection of the eye or and treatment from lack of previous experience surrounding tissues EXPECTED OUTCOME: The patient will be able to explain the EXPECTED OUTCOME: The patient’s pain will be decreased or disease process, prevention, and treatment measures. The absent as evidenced by lower rating on a pain scale. patient will demonstrate the treatment regimen correctly, such as administration of eye drops. Assess the patient for pain. Use of dark glasses, rubbing the eye, squinting, and avoiding light may be indicators of Teach patient prevention, care of the affected eye, pain that should be assessed. medication administration, and safety issues for Administer eye medications (topical anesthetic drops or understanding and adherence to therapeutic plan. ointments, antibiotics, anti-inflammatory agents, or Have patient demonstrate the administration of analgesics) as ordered to relieve eye pain. ointments or drops after teaching has occurred to Apply warm or cool packs as ordered to assist in soothing evaluate understanding. the eye. Teach patient and family how to prevent spreading Patching of the affected eye may help reduce pain by infection if it is contagious. decreasing the movement of the eye across the eyelid. Teach patient proper eye hygiene to prevent further Explore additional methods of pain reduction, such as complications. guided imagery, relaxation techniques, music, or distraction. Teach contact lens hygiene to prevent reinfection of the eye. Risk for Injury related to visual impairment Teach not to wear contact lenses when the eye or surrounding structure is inflamed to prevent irritation. EXPECTED OUTCOME: The patient will not experience injury as a result of visual impairment. EVALUATION. The therapeutic measures ha ve been suc- cessful if pain is reduced to an acceptable rating, vision im- Assess and plan for visual impairments that may be present proves or returns to preillness level, injury does not occur to promote safety. as a result of visual impairment, infection does not occur Advise patient with one eye patched not to drive to prevent as a result of poor eye hygiene or wearing of contact lenses, injury because depth perception is altered. patient explains disease process, pre vention, or treatment Teach caution when ambulating and reaching for things to regimen accurately, or prescribed treatment is stated or prevent injury because inflamed eyes often do not focus demonstrated correctly (e.g., administering e ye drops or well and may have exudate, tearing, or ointment present, ointments). which can interfere with vision. 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1242 1242 UNIT FOURTEEN Understanding the Sensory System Refractive Errors Pathophysiology and Etiology Refraction refers to the bending of light rays as they enter the eye. Emmetropia, or normal vision, means that light rays are bent to focus images precisely on the macula of the retina. Ametropia is a term used to describe an y refractive error. When an image is not clearly focused on the retina, refractive error is present. Ametropia occurs when parallel light rays A entering the e ye are not refracted to focus on the retina. Refractive errors account for the lar gest number of impair - ments in vision. There are four common ametropic disorders: hyperopia, myopia, astigmatism, and presbyopia. HYPEROPIA. Hyperopia (farsightedness) is caused by light rays focusing behind the retina (Fig. 52.1). People who are hyperopic see images that are far away more clearly than images that are close. Physiologically, the globe or eyeball is too short from the front to the back, causing the light rays to focus be yond the Convex lens B retina. Hyperopia is corrected with convex lenses. MYOPIA. Myopia (nearsightedness) is caused by light rays focusing in front of the retina. The eyeball is elongated, and thus the light rays do not reach the retina. Distance vision is blurred but items close up are clear. Myopia is corrected with concave lenses (Fig. 52.1). ASTIGMATISM. Astigmatism results from unequal curvatures in the shape of the cornea. When parallel light rays enter the eye, the irregular cornea causes the light rays to be refracted to C focus on two different points. This can result in either myopic or hyperopic astigmatism. The person with astigmatism has blurred vision with distortion. The corneal irregularities can be caused by injury, inflammation, corneal surgery, or an inherited autosomal dominant trait. PRESBYOPIA. Presbyopia is a condition in which the crystalline lenses lose their elasticity, resulting in a decrease in ability to focus on close objects. The loss of elasticity causes light rays to focus beyond the retina, resulting in hyperopia. This condi- Concave lens tion usually is associated with aging and generally occurs after D age 40. If an individual has preexisting hyperopia, the onset of FIGURE 52.1 Refractive disorders. (A) Hyperopia (farsighted). presbyopia may occur earlier than age 40. Likewise, if a person The eyeball is too short, causing the image to focus beyond has myopia, presbyopia may correct the myopia by projecting the retina. (B) Corrected hyperopia. (C) Myopia (nearsighted). the light rays directly on the retina. Because accommodation A long eyeball causes the image to focus in front of the retina. for close vision is accomplished by lens contraction, people (D) Corrected myopia. with presbyopia exhibit the inability to see objects at close range. They often compensate for blurred close vision by holding objects to be viewed farther away. Reports of eyestrain and mild frontal headache are common. These symptoms are LEARNING TIP relieved with eye rest and corrective lenses. To remember the type of vision a person has, use Signs and Symptoms this saying: You are what you say. For example, if you say you are farsighted, this means that you People with refracti ve errors commonly report dif ficulty have clear vision of far away images, but difficulty reading or seeing objects. Often, the eyestrain that occurs as seeing images that are nearer. If you say you are one attempts to improve visual acuity causes headache. nearsighted, this means that you have clear vision of near images, but difficulty seeing images that WORD BUILDING are farther away. presbyopia: presby—old age + opia—concerning vision 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1243 Chapter 52 Nursing Care of Patients With Sensory Nervous System Disorders: Vision and Hearing 1243 Diagnostic Tests is often seen with strok e. Patients may report that the visual field appears blurry or hazy in corneal visual prob- A refractive error can be roughly estimated by use of lems, cataracts, diabetic retinopathy, or refractive errors Snellen’s chart. For definitive refractive error measure- (Fig. 52.2). ment, a retinoscopic e xamination is needed. Before this examination, a c ycloplegic drug is often instilled Diagnostic Tests (see Table 52.2). A cycloplegic drug dilates the pupil and Diagnostic tests may include a visual f ield examination, temporarily paralyzes the ciliary muscle, thus pre venting tonometry, and slit-lamp microscope e xamination. Retinal accommodation. During the examination, an ophthalmol- angiography is used to follow blood flow through the retinal ogist or optometrist examines the internal and external eye vessels and to detect v ascular changes. Ultrasonography and uses trial lenses via a retinoscope to assess the type of may be used to visualize changes in the posterior e ye that lens best suited to correct the refractive error, which may cannot be directly e xamined because of other pathological differ in each e ye. If a c ycloplegic agent has been used, conditions, such as a cloudy cornea, a bloody vitreous, or an patients need to be told that blurred vision might be pres- opaque lens. ent and sunglasses worn until the agent wears of f. In ad- dition, the patient should be instructed that dri ving and Therapeutic Measures reading might not be possible until the effect of the cyclo- Therapeutic interventions for blindness center on treating plegic drug is gone. the underlying condition and pre venting further impair- Therapeutic Measures ment. Treatment may include medications, sur gical inter- Refractive errors are commonly treated with either eyeglasses vention, corrective eyewear, and referral to supporti ve or contact lenses. The corrective lenses bend the parallel light services. rays so that the y converge on the macular portion of the Nursing Process for the Patient With Visual retina. Laser-assisted in situ k eratomileusis (LASIK) and Impairment photorefractive keratectomy (PRK) are sur gical procedures also used to correct refractive error. With LASIK and PRK, What do you think some of the challenges w ould be for a laser energy is applied to reshape the cornea. The cornea is person who is blind? made flatter for indi viduals with myopia and more cone DATA COLLECTION. Table 52.4 re views the collection of shaped for those with hyperopia. subjective data. Collection of objective data involves observ- ing the patient. Is there squinting? Rubbing of e yes? Is the Blindness patient using compensatory measures—magnifying glass, Blindness is the complete or almost complete absence of the sitting close to television, using large-print reading materials, sense of sight. Some people consider the terms blind and avoiding reading, using eyeglasses? partially sighted to be negative and prefer the term visually Psychosocial data are important because a blind person impaired to describe their condition. may be withdrawn or socially isolated, have low self-esteem or poor coping mechanisms, or have poor interpersonal skills Pathophysiology and Etiology as a result of the visual impairment. Blindness in adults is caused by a variety of factors, includ- ing trauma, complications from v arious diseases such as NURSING DIAGNOSES, PLANNING, AND IMPLEMENTA- hypertension and diabetes and conditions such as cataracts TION. Nursing care begins by understanding how to inter- and glaucoma. Blindness is produced when the rays of act with a patient who has a visual impairment (Box 52-1). light on their w ay to the optic nerv e are obstructed, or A patient’s level of independence must be included in the by disease of the optic nerv e or tract of the part of the planning phase. If patients have minimal visual impairment brain connected with vision. Blindness may be permanent or have attended rehabilitation, they may be able to func- or transient, complete or partial, or may occur only in tion independently. If a patient has recently become visu- darkness (night blindness). ally impaired, he or she may be completely dependent until alternative ways of coping with this impairment have been Signs and Symptoms learned. Aside from a general loss of vision, patients may describe Planning focuses on meeting self-care needs, k eeping their visual image as blurred, distorted, or absent in the patient safe from injury , supporting the grie ving specific areas of the visual field. Objects may appear dark process, and helping the patient acquire kno wledge of or absent around the peripheral field in glaucoma or retini- agencies, services, and devices that allow maintenance of tis pigmentosa. Retinitis pigmentosa is a de generation of independence. Families must be included in the planning the pigmented layer of the retina. The center of the visual phase because they need to understand and be supporti ve field may appear dark for indi viduals with diabetic retinopathy or macular degeneration. Half the visual WORD BUILDING field may be impaired in patients with hemianopia. This retinopathy: retino—having to do with the retina + pathy— results from a defect in the optic pathways in the brain and illness, disease, or suffering 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1244 1244 UNIT FOURTEEN Understanding the Sensory System A B C D E FIGURE 52.2 Visual field abnormalities. (A) Normal vision. (B) Diabetic retinopathy. (C) Cataracts. (D) Macular degeneration. (E) Advanced glaucoma. TABLE 52.4 SUBJECTIVE DATA COLLECTION FOR VISUAL DISORDERS W What part of the visual field is affected? If there is vision, what are Where is it? the characteristics of what can be seen? Blurry? Hazy? Dark? Halos around lights? H Is there associated pain with the visual impairment? Headaches? How How does it feel? does it make the patient feel? Fearful? Anxious? Depressed? Help- less? Hopeless? Accepting? A Is it worse when reading? Is it worse when watching TV? Does it affect Aggravating and alleviating factors the patient only at night? Is vision better at distances or close up? T When did the symptoms start? Do they come and go? Is the impair- Timing ment progressively getting worse? Was onset sudden? S Does the impairment affect the patient’s activities of daily living? If Severity so, how severely? Does the patient need assistance to cook, dress, bathe, read mail, pay bills, access health care, obtain transportation, maintain household, shop? U Does the patient have diabetes, hypertension, a family history of re- Useful data for associated symptoms tinitis pigmentosa, a history of eye infection, or eye trauma? Has the patient recently traveled out of the country? P What does the patient think is wrong? How severe does the patient Perception of the problem by the patient perceive the impairment to be? of the self-image and role performance changes that may EVALUATION. The outcomes for a patient with a visual impair- occur (see the “Nursing Care Plan for the P atient With ment are met if the patient demonstrates the ability to complete Visual Impairment”). Referral to or ganizations that en- activities of daily living (ADLs) with increasing independence, hance the independence of people with visual impairments remains free of injury, and demonstrates the ability to assess is helpful. agencies and services for those with visual impairments. 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1245 Chapter 52 Nursing Care of Patients With Sensory Nervous System Disorders: Vision and Hearing 1245 Box 52-1 Interacting With a Patient Who Has a Visual Impairment People entering a room and at each contact with the When walking with the patient, allow the patient to patient should identify themselves. grasp an arm and walk a half step behind. Be aware Post a sign on the door or over the bed that identifies of obstacles on either side when walking. the patient’s visual status so that others can interact When seating a patient, place the patient’s hand on appropriately. the arm of the chair. Remember that the individual is not having hearing Tell the patient when leaving the room or area so the problems, so use a normal tone of voice and do patient does not continue conversation in an empty not yell. room, which may cause embarrassment. Ask patients with visual impairments what their When orienting the patient to the hospital room, needs are; do not assume they need help with explain the location of items the patient may need, everything. such as the water pitcher, call light, bed controls, Talk directly to the patient, not through a companion. urinal, and tissues. Attempt to keep these items in At mealtime, explain the location of items on the the same place at all times. tray by comparing their position to the numbers If the patient has a seeing eye dog, do not play with on a clock (e.g., milk is at 2 o’clock, peas are at the dog, pet it, or feed it without consulting the 7 o’clock). patient—the dog is working! Make sure the patient’s Explain any activity going on in the room or within dog is near the bed, on a mat provided especially for the patient’s auditory range. the dog, preferably on the side of the bed that is less Explain procedures before beginning them. Speak to likely to be used by staff. Instruct staff and visitors the patient before touching. about the seeing eye dog. NURSING CARE PLAN for the Patient With Visual Impairment Nursing Diagnosis: Dressing and Feeding Self Care Deficit related to altered vision. Expected Outcome: The patient will demonstrate ability to perform ADLs, with assistance if necessary. Evaluation of Outcome: Patient is able to perform ADLs as independently as possible. Intervention Identify patient’s ability to perform activities of daily living such as dressing and feeding. Rationale Determines patient’s ability to adequately dress and feed self. Evaluation Can patient dress and feed self independently? If not, what level of assistance is required? Intervention Provide assistance with dressing and grooming as required such as pre-matching coordinated clothing for easy selection or selecting and laying coordinated clothing out for patient to dress. Rationale Ensures patient’s dressing and grooming needs are met. Evaluation Is patient able to dress and groom self adequately? Intervention Provide assistance with preparing food and feeding as required such as for severe vision loss use the face of a clock for referencing location of foods on a plate. Rationale Ensures patient’s feeding needs are met. Evaluation Is patient able to eat as desired? Nursing Diagnosis: Risk for Injury related to altered vision Expected Outcome: The patient will remain safe from injury. Evaluation of Outcome: The patient remains injury free. Continued 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1246 1246 UNIT FOURTEEN Understanding the Sensory System NURSING CARE PLAN for the Patient With Visual Impairment—cont’d Intervention Provide for optimal care of assistive appliances such as eyeglasses, including maintenance of proper prescription, fit, and cleaning. Rationale Improperly fitting or dirty eyeglasses may impair vision even further. Older adults should have their eyeglass prescription checked yearly. Evaluation Do eyeglasses fit properly? Are lenses clean? Is prescription current? Intervention Structure environment to compensate for visual loss by adding color and contrast (e.g., chairs and carpeting should be in contrasting colors, bright tape or paint on stairs, medicine bottles color coded with colored dot stickers). Rationale Makes the environment easier to visualize and interpret and assists in depth perception and identifying medications. Evaluation Does the environment have clearly delineated walkways, sitting areas, and doorways? Are areas with changes in elevation clearly identified using contrasting tape or paint? Is there a way for patient to safely self-administer medications? Intervention Structure environment to compensate for visual loss by use of large-print directional signs and arrows, well-lit areas, nonglare surfaces, consistent placement of objects, traffic areas free of clutter. Rationale Large direc- tional signs assist the patient in maintaining orientation. Shiny floors or areas with bright window glass can impair vision. Traffic areas free of clutter assist in preventing injury. Evaluation Can the patient identify locations such as bathroom, dining room, and office areas? Can the patient ambulate freely without safety hazards? Intervention Introduce other assistive devices such as handheld magnifying glasses, tableside magnifiers, television magnifiers, large-print items, and phone dial covers with large numbers, talking watches, alarm clocks, and calcula- tors. Rationale Patients may not be aware of assistive devices that could help them adapt to vision loss and continue previous activities, such as watching TV or reading letters and magazines. Allows people to rely on hearing rather than vision. Evaluation Is patient aware of assistive devices that allow participation in previously enjoyed activities such as TV or reading? Is the patient able to pay bills? Read mail? Communicate on the telephone? Nursing Diagnosis: Deficient Knowledge Expected Outcome: The patient will understand resources that will allow maintenance of independence. Evaluation of Outcome: The patient will identify resources that can be used to support independence. Intervention Refer to specialized clinician such as ophthalmologist or occupational therapist or to specialized resources such as American Federation for the Blind or Prevent Blindness America. Rationale Specialized clinicians can provide detailed examination and treatment for the disorder. Specialized resource groups have networks in place to assist people in coping with loss and assisting with maximizing abilities. Evaluation Does patient know who to call for detailed examination and treatment of problems? Does patient know that there are specialized clinicians and resource groups to help with the visual impairment? Does patient know how to access these specialists? macula. If the leakage causes edema, the patient may notice Diabetic Retinopathy a decrease in color discrimination and visual acuity. Pathophysiology and Etiology The second stage, preproliferative retinopathy, is charac- Retinopathy is a disorder in which vascular changes occur in terized by swollen and irregularly dilated veins, which results the retinal blood vessels. It is most common in persons with in sluggish or blocked blood flow. Patients generally are not diabetes. The pathological changes in diabetic retinopathy are aware of this stage because there are no symptoms. related to excess glucose, changes in the retinal capillary Proliferative retinopathy, the third stage, is characterized walls, formation of microaneurysms, and constriction of reti- by the formation of new blood vessels growing into the retinal nal blood vessels. Three stages of diabetic retinopathy ha ve and optic disc area in an attempt to increase the blood supply been identified: background retinopathy , preproliferative to the retina. The newly formed blood vessels are fragile and retinopathy, and proliferative retinopathy. often leak blood into the vitreous and retina. In addition Background retinopathy is the earliest stage, in which to leaking, the ne wer vessels may grow into the vitreous, microaneurysms form on the retinal capillary walls. These which causes a traction effect, pulling the vitreous away from microaneurysms may leak blood into the central retina or the retina and subsequently pulling the retina a way from 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1247 Chapter 52 Nursing Care of Patients With Sensory Nervous System Disorders: Vision and Hearing 1247 the choroid. This condition is called retinal detachment goal, and intervention for diabetic retinopathy include but is (discussed later). not limited to the following: Signs and Symptoms Risk for or Actual Ineffective Self Health Management EXPECTED OUTCOME: The patient will state ability to man- There may be a reduction in central visual acuity or color age therapeutic regimen. vision as a result of macular edema (see Fig. 52.2). Man y patients with diabetic retinopathy have no symptoms until the Determine whether the patient with a visual impairment who proliferative stage, at which point vision is lost. Visual loss is diabetic can monitor blood glucose and draw up and ad- at the last stage usually cannot be restored. minister the correct amount of insulin. Specialty devices are available that can be preset to draw up the correct amounts Complications of insulin. Family members may have to assist the patient. Early treatment for diabetic retinopathy is highly success- Teach patient the importance of yearly comprehensive eye ful in pre venting further visual loss; ho wever, existing examinations to detect visual changes for treatment. visual loss cannot be re versed. For this reason, it is v ery EVALUATION. Patient goals are met if the patient is able to important for patients with diabetes to have a comprehen- manage the therapeutic regimen. sive eye examination through dilated pupils at least once each year or as directed by their health care pro vider Retinal Detachment (HCP). Careful control of diabetes during the first 5 years Pathophysiology and Etiology after diagnosis reduces occurrence and delays onset of di- abetic retinopathy. Retinal detachment is a separation of the retina from the choroid layer beneath it (see Fig. 51.1), allowing fluid to enter Diagnostic Tests the space between the layers. The three causes of retinal Diabetic retinopathy, as well as the other retinopathies, can detachment are a hole or tear in the retina that allows fluid to be diagnosed only on examination of the internal eye. The flow between the tw o layers, fibrous tissue in the vitreous examination is conducted with an ophthalmoscope follow- humor that contracts and pulls the retina a way from its ing dilation of the pupil with a c ycloplegic agent. The ex- normal position, or fluid or e xudate accumulation in the amination may be enhanced by use of retinoangiography. subretinal space that separates the retinal layers. In the initial stages, vessels may appear swollen and tortu- Signs and Symptoms ous (twisted). Patients experiencing a retinal detachment report a sudden Therapeutic Measures change in vision. Initially, as the retina is pulled, patients report Treatment of diabetic retinopathy focuses on stopping the seeing flashing lights and then floaters. The flashing lights are leakage of blood and fluid into the vitreous and retina. The caused by vitreous traction on the retina, and floaters are caused leaking microaneurysm is sealed by use of laser photoco- by hemorrhage of vitreous fluid or blood. When the retina de- agulation. Lasers can also be used to shrink the abnormal taches, patients commonly describe it as “looking through a veil” blood vessels. If blood has already leaked into the vitreous, or “cobwebs” and finally “like a curtain being lowered over the a vitrectomy is performed. During a vitrectomy, the vitreous field of vision,” with darkness resulting. There is no pain because humor is drained out of the eye chamber and replaced with the retina does not contain sensory nerv es. On visual examina- saline or silicon oil (oil often remo ved months later). The tion, the patient typically has a loss of peripheral vision when replacement fluid is necessary to support the structures the visual fields are tested and a loss of acuity in the affected eye. of the eyeball until healing can occur. Use of intra vitreal corticosteroids is beneficial. Diagnostic Tests Indirect ophthalmoscopy allows the examiner to visualize the Nursing Process for the Patient With Diabetic retina, which may be pale, opaque, and in folds with retinal Retinopathy detachment to diagnose the type of detachment. If there are DATA COLLECTION. Nursing data collection for diabetic lesions in the e ye, the slit-lamp e xamination allows the retinopathy includes risk factors associated with the incidence examiner to magnify the lesions. of the disease. The patient may not ha ve any symptoms. If people with diabetes do have changes in perceptions of visual Therapeutic Measures acuity or color discrimination, the y should immediately Immediate medical treatment must be sought to help protect contact their HCP. vision. The degree of vision restoration v aries and depends on the af fected area. One or more procedures may be NURSING DIAGNOSIS, PLANNING, AND IMPLEMENTATION. performed to treat retinal tears, or detachment: laser surgery, The planning phase of the nursing process for diabetic cryopexy, scleral buckling, and pneumatic retinopexy. retinopathy focuses on pre vention of visual loss by early detection and treatment. If the patient has entered phase three LASER SURGERY. Laser surgery focuses a laser beam at the and is already visually impaired, the “Nursing Care Plan for the torn area of the retina, causing a controlled burn, which scars Patient With Visual Impairment” is used. Nursing diagnosis, around the tear and reattaches the retina to surrounding tissue. 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1248 1248 UNIT FOURTEEN Understanding the Sensory System CRYOPEXY. Cryopexy is the placement of a supercooled probe Glaucoma on the sclera over the affected area. The probe freezes and scars Glaucoma is a group of diseases characterized by damage to the tear or hole, a principle similar to the laser procedure. the optic nerv e, the structure responsible for transmitting SCLERAL BUCKLING. Scleral buckling is a surgical procedure visual information from the e ye to the brain. The damage for retinal detachment that involves placing a silicon implant is silent, progressive, and irreversible until the end stages, in conjunction with a beltlik e device around the sclera to when loss of peripheral vision occurs, followed by reductions bring the choroid in contact with the retina. Cryosur gery or in central vision and e ventually blindness (see Fig. 52.2). laser surgery is used before the b uckling procedure to seal Sometimes there is abnormal pressure within the e yeball the tear and form a scar that helps adhere the retina and that damages the optic nerve, but not always. Normal tension choroid layers together. Vitrectomy is often done as well. glaucoma is now known to exist. There is no cure for glau- coma, so treatment plans must be followed to prevent further PNEUMATIC RETINOPEXY. Pneumatic retinopexy, done for vision loss. retinal detachment, is a procedure that can be conducted in the health care pro vider’s office but is time-consuming for Pathophysiology the patient. This procedure involves injecting air or gas into The most common form of glaucoma, called primary , con- the chamber to hold the retina in place. The patient must be sists of two types: primary open-angle glaucoma (POAG) and extremely compliant with the treatment re gimen, reclining acute angle-closure glaucoma (AACG). Secondary glaucoma for about 16 hours before the procedure to allow the retina to may be caused by infections, tumors, or injuries. A third fall back toward the choroid. Because air rises, the patient form, congenital glaucoma, is due primarily to developmental must maintain a position that keeps the air bubble against the abnormalities. detached area for up to 8 hours a day for 3 weeks. AACG occurs in people who have an anatomically narrowed Complications angle at the junction where the iris meets the cornea. When nearby eye structures such as the iris protrude into the anterior With any of the retinal procedures there is risk of increased chamber, the angle is occluded, which blocks the flow of aque- intraocular pressure (IOP), tears and recurrent detachment. ous fluid. This is considered a medical emer gency and results Nursing Process for the Patient With Retinal in partial or total blindness if not treated. PO AG occurs when Detachment the drainage system of the e ye, the trabecular meshwork and Schlemm’s canal, degenerate and subsequently block the flow DATA COLLECTION. Subjective data collected include patient of aqueous humor. observation of the loss of peripheral vision, an y change in visual acuity, and the presence of floaters, flashing lights, Etiology and Prevention cobwebs, or veil-like visual impairments. There should be an The incidence of AACG is highest among Asians, women older absence of pain. Objective data collected include the patient’s than age 45, and people who are nearsighted. POAG incidence visual acuity, visual fields, ability to perform ADLs, and level increases in those older than age 40 (over age 50 for European of anxiety. Americans, over age 35 for African Americans), in people with NURSING DIAGNOSES, PLANNING, IMPLEMENTATION, AND diabetes, and in those with a family history of glaucoma, and is EVALUATION. The nursing process for patients with retinal four to five times more prevalent in African Americans than detachment can be found in the “Nursing Process for the European Americans. Those over age 60 or in high-risk groups Patient Having Eye Surgery” section later in this chapter. should have yearly eye examinations for glaucoma detection. Signs and Symptoms CRITICAL THINKING An ophthalmic emergency, AACG typically has a unilateral, rapid onset. The patient may report severe pain over the affected Mr. Samuel eye, blurred vision, rainbows around lights, and photophobia Mr. Samuel, age 65, is w orking in the yard when a and have eye redness, a steamy-appearing cornea, and tearing. branch strikes his right eye. He sees flashes of light and Increased IOP can cause nausea and vomiting. then a short time later a dark shadow out of the right eye. POAG develops bilaterally. The onset is usually gradual and painless, so the patient may have no noticeable symptoms 1. What should Mr. Samuel do? or, after time, may e xperience mild aching in the e yes, 2. After having a scleral buckling procedure, Mr. headache, halos around lights, or frequent visual changes that Samuel reports nausea. What action should the are not corrected with eyeglasses. nurse take? 3. Ondansetron (Zofran) 4 mg intramuscular (IM) now Diagnostic Tests is ordered. Available is ondansetron 2 mg/mL in 2 Measuring IOP and identifying optic nerv e damage and mL/vial. How many milliliters should be given? visual loss are done to diagnose glaucoma. Tonometry Suggested answers are at the end of the chapter. detects increased IOP (normal: 12–20 mm Hg), which may be present in about 50% of glaucoma cases. InAACG, IOP 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1249 Chapter 52 Nursing Care of Patients With Sensory Nervous System Disorders: Vision and Hearing 1249 may exceed 50 mm Hg. The GDx Access, a laser de vice, detects nerve damage long before the patient has symptoms LEARNING TIP of glaucoma. Additionally, a visual field examination looks for loss of peripheral vision, distance vision is assessed, Mydriatic medications are contraindicated and corneal thickness is measured. With gonioscopy, a in acute angle-closure glaucoma because special lens is used to determine if glaucoma is open-angle they can cause an acute episode of or angle-closure. increased IOP by dilating the pupil and pushing the iris back, blocking the outflow Therapeutic Measures of aqueous humor. The first-line treatment for glaucoma focuses on opening the Miotic medications constrict the pupil and aqueous flow by administering cholinergic agents (miotics) so may be given to patients with acute such as carbachol (Isopto) or pilocarpine (Pilocar) to constrict angle-closure glaucoma. the pupil. When the pupil is constricted, the iris pulls a way To remember what miotic medications and from the drainage canal so the aqueous fluid can flow freely. mydriatic medications do, so that the A second medication may be given to slow the production of appropriate medication is given and aqueous fluid that includes carbonic anhydrase inhibitors contraindicated ones are never given, such as acetazolamide (Diamox), adrener gic agonists such remember the following: as dipivefrin (Propine), and beta block ers such as timolol D = dilate = mydriatic = do not give. (Timoptic). Slowing the production of aqueous fluid helps No D = constricts = miotic = okay to give. decrease IOP. Additionally, steroid eyedrops may be ordered to reduce inflammation. The patient experiencing an acute attack of AACG is gi ven these types of medications and mannitol, a hyperosmolar agent, to rapidly reduce IOP , as Nursing Process for the Patient With Glaucoma well as analgesics, and is on complete bed rest. DATA COLLECTION. The patient should be monitored for Patients with glaucoma need lifelong use of e ye drop pain, loss of central and peripheral vision, understanding of medications twice or more daily. In the absence of symptoms, disease and adherence to treatment re gimen, and ability to adherence to treatment is often an issue. Other f actors that conduct ADLs. contribute to nonadherence to treatment include the patient’ s NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION. age, inability to afford the medication, and lack of understand- The goal of nursing care for the patient with glaucoma is to ing of the disease process. P atients should carry medical alert prevent further visual loss and to promote comfort if the identification for their glaucoma and medications. This can help patient is experiencing pain with acute glaucoma. See the prevent administration of medications in emergency situations “Nursing Process for the Patient With Visual Impairment and that are contraindicated for glaucoma. Nursing Process for the Patient Having Eye Surgery” sections There are medications, regardless of their route, that are con- for additional nursing diagnoses. traindicated in AACG that can result in blindness if gi ven to a Pain related to increased intraocular pressure patient with AACG. These medications include anticholinergics EXPECTED OUTCOME: The patient will report that pain is such as atropine, antihistamines such as diphenhydramine relieved. (Benadryl), or hydroxyzine (Vistaril) because they are mydri- atics. Before a medication is given, the nurse should determine Give analgesics as needed for acute glaucoma to relieve that it is not contraindicated inAACG, to prevent blindness from pain. occurring. Surgical Management When medication is no longer able to control the flo w of Cornea aqueous humor or reduce the IOP , surgical intervention Surgical drainage may become necessary. Surgery focuses on creating an area opening where the aqueous humor can flow freely, thus preventing increased IOP (Fig. 52.3). F or AACG, laser peripheral Conjunctiva iridotomy or surgical iridectomy is performed. Laser irido- tomy is a noninvasive procedure using a laser to remove a portion of the iris, thus allo wing aqueous fluid to flo w Sclera Lens through the area. Prophylactic iridotomy may be performed on the other e ye to prevent AACG. POAG is treated with laser trabeculoplasty (noninvasive laser beam creates open- ings in trabecular meshwork), trabeculectomy (part of iris and trabecular meshwork removed), or cyclocryotherapy FIGURE 52.3 Flow of aqueous humor after trabeculoplasty (cryoprobe destroys part of ciliary body). (arrows). 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1250 1250 UNIT FOURTEEN Understanding the Sensory System Self-Care Deficit related to decreased vision Factors that contribute to cataract development may include EXPECTED OUTCOME: The patient will be able to care for self age, ultraviolet radiation (sunlight), diabetes, smoking, steroids, with assistance if needed. nutritional deficiencies, alcohol consumption, intraocular infections, trauma, and congenital defects. Assist with self-care as needed to ensure ADLs are met. Anxiety related to partial or total visual loss Signs and Symptoms EXPECTED OUTCOME: The patient will state that anxiety is Cataracts are painless. Symptoms of cataract formation may reduced. include halos around lights, dif ficulty reading fine print or seeing in bright light, increased sensiti vity to glare such as Encourage patient to verbalize concerns about glaucoma when driving at night, double or hazy vision, and decreased to allow questions to be answered. color vision. Risk for Injury related to decreased vision EXPECTED OUTCOME: The patient will not suffer injury as a Diagnostic Tests result of the visual impairment. Cataracts are diagnosed with an e ye examination. Visual acuity is tested for near and far vision. The direct ophthalmo- Refer patient to support services that provide adaptive scope and slit-lamp microscope are used to examine the lens visual devices. and other internal structures. Teach patient and family not to rearrange furniture without patient knowledge to prevent falls or injury. Surgical Management Deficient Knowledge related to medical regimen, disease When cataracts begin to interfere with daily living and quality process due to no prior experience of life, treatment is recommended. One eye is treated at a time EXPECTED OUTCOME: The patient will demonstrate correct with outpatient sur gical removal of the cloudy lens. Im- instillation of eye medications and be able to verbalize plantable lenses, which come in v arious types, are typically understanding of condition and treatment. inserted after lens removal. Eyeglasses or contact lenses are needed if no lens is reinserted. Eyeglasses may also be needed Teach need for regular eye examinations through with some of the lens implants. With the no-stitch cataract dilated pupils to monitor disease and detect operation, there are no postoperative activity restrictions, and complications. vision improves in about 1 to 2 days. Teach how to administer medications with a return demonstration to ensure that eye drops are administered Complications properly. Complications of cataract sur gery are rare b ut include Teach the patient to rest his or her hand on the forehead inflammation, increased IOP, macular edema, retinal detach- if the patient has trouble keeping the hand steady when ment, vitreous loss, hyphema, endophthalmitis, and expulsive administering eye drops. hemorrhage. Consider large-print labels or audiotaped directions if the patient is unable to see the label on the eye drop Nursing Process for the Patient With Cataracts bottle. DATA COLLECTION. The patient is monitored for visual Consider placing large, multicolored dot stickers on deficits to assist care planning, as well as knowledge needs medication bottles and on corresponding instruction about the disease process, surgical intervention, postopera- cards for patients with multiple medications. tive care, and medical re gimen. The majority of patients Advise family members that they are at increased risk undergoing cataract sur gery have same-day sur gery and of developing glaucoma and should have regular eye then go home. So the home situation, the ability of the examinations because glaucoma can be hereditary. patient or family member to follo w the medical re gimen, EVALUATION. Interventions are successful if the patient and transportation to and from the hospital for the patient maintains an acceptable level of comfort, has no further loss are evaluated. of vision, is able to care for self with assistance, e xpresses NURSING DIAGNOSES, PLANNING, IMPLEMENTATION, AND concerns and anxieties, does not suf fer injury as a result EVALUATION. Preoperative and postoperative nursing care is of the visual impairment, demonstrates correct instillation of the primary nursing responsibility for the patient with eye medications, and is able to v erbalize understanding of cataracts, as discussed next. condition and treatment. Nursing Process for the Patient Having Eye Cataracts Surgery Pathophysiology and Etiology DATA COLLECTION. Table 52.5 reviews subjective data to be A cataract is an opacity in the lens of the eye that may cause collected. Objective data may include visual acuity and a loss of visual acuity (see Fig. 52.2). Vision is diminished peripheral field measurements. Visual acuity should be tested because the light rays are unable to get to the retina through with and without any corrective lenses. Eye tearing, redness, the clouded lens. or swelling is noted. 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1251 Chapter 52 Nursing Care of Patients With Sensory Nervous System Disorders: Vision and Hearing 1251 TABLE 52.5 SUBJECTIVE DATA COLLECTION FOR PATIENTS HAVING EYE SURGERY W Where is the visual disturbance? Is it centrally located? Peripherally? Where is it? Throughout the entire visual field? Unilateral? Bilateral? H How does it feel? Painful? Is there an absence of pain? How does it feel? A Is it worse in bright light or at night? Better when resting eyes or with Aggravating and alleviating factors head of bed elevated? T Was there a sudden onset? Gradual onset? Timing S Does it affect activities of daily living? Does it affect close-up work? Severity U Does the patient suffer from hypertension? Diabetes? Has there been Useful data for associated symptoms trauma? Vascular disease? What is the level of anxiety? Is the pa- tient older than age 50? P Will the visual disturbance impair ability to carry out activities of Perception of the problem by the patient daily living? Ability to comply with medical regimen? Ability to manage home maintenance? Nursing Diagnoses, Planning, and Implementation Macular Degeneration Risk for Injury related to altered visual acuity Pathophysiology and Etiology EXPECTED OUTCOME: The patient will remain free of injury. Age-related macular degeneration (AMD) is the leading Explain that depth perception may be affected by eye cause of visual impairment in U.S. residents older than surgery, which can result in falls, to help prevent injury. age 50. It in volves deterioration and scarring within the Ambulate with assistance and use clearly marked stairs to macula, the area on the retina where light rays con verge prevent injury. for the sharp, central vision needed for reading and seeing At home, beverages can be poured and stored in the small objects. The macula is also responsible for color refrigerator in single-serving glasses to prevent spills vision (Fig. 52.4). There are two types of AMD: dry (at- and slippery floors. rophic) and wet (e xudative). In dry AMD, photoreceptors in the macula fail to function and are not replaced because Deficient Knowledge related to preoperative and postoperative of advancing age. This accounts for 70% to 90% of cases. eye care In the wet form, retinal tissue degenerates, allowing vitreous EXPECTED OUTCOME: The patient will verbalize preoperative fluid or blood into the subretinal space. Ne w fragile blood and postoperative care directions. vessels form (angiogenesis) and compromise the macular Teach disease process, surgical intervention, use of correct tissue, causing subretinal edema. Ev entually, fibrous scar technique for administering eye medications, need to report tissue forms, severely limiting central vision. for medical follow-up as instructed, and need to protect the People at risk of developing macular degeneration include eye from further injury to increase patient knowledge. those older than age 60, those with a family history of macular Patients are told to seek medical treatment if they experience degeneration, persons with diabetes, people who smoke, those sudden, worsening pain, an increase in watery or bloody frequently exposed to ultraviolet (UV) light, and Caucasian discharge, or sudden loss of vision because these are signs people. of hemorrhage or problems. Anxiety related to visual alteration and surgery EXPECTED OUTCOME: The patient will report reduced anxiety. NURSING CARE TIP Give patients the opportunity to discuss their feelings Most damaging exposure to UV light occurs about vision loss and surgery to reduce anxiety. before age 18. So it is important for everyone EVALUATION. The patient goals have been met if the patient of all ages to use adequate UV protective is free of injury, verbalizes preoperative and postoperative di- eyewear. rections, and reports reduced anxiety. 4068_Ch52_1236-1270 15/11/14 2:21 PM Page 1252 1252 UNIT FOURTEEN Understanding the Sensory System Normal layers of macula Nourishing fluids Pigment layer of retina Transparent layer of retina Macula (cones and rods) Macula degeneration Pigment layer tissue breaks down, allowing fluid leakage under the transparent layer. Retinal layers may detach, Retina distorting vision. Later with death of cones and rods, blind spots occur. FIGURE 52.4 Macular degeneration. The macula is a small area of the retina responsible for central and color vision. Prevention changes. If any of the grid lines look crook ed or disappear, the patient should contact the HCP. Digital imaging, optical A healthful lifestyle and a diet that includes dark green leafy coherence tomography retinal scan (similar to a computed vegetables (kale, collard greens, lettuce, spinach), and orange tomography scan) or intravenous fluorescein (dye) angiogra- (peppers) and yellow (corn) color fruits and v egetables is phy can also be used to e valuate blood vessel leakage or important. Measuring macula pigment optical density is an abnormalities in the eye. important preventative tool. Taking the retinal carotenoids lutein and zeaxanthin and zinc supplementation for a lo w Therapeutic Measures macula pigment optical de