PH 19 Drugs for Ear and Eye Problems.pdf

18 Drugs for Ear and Eye Problems LEARNING OUTCOMES 1. Explain what types of drugs are used topically to manage ear problems. 2. Describe the proper technique to give drugs to the ear. 3. Explain what types of drugs are used topically to manage eye problems. 4. Describe the proper technique to give...

18 Drugs for Ear and Eye Problems LEARNING OUTCOMES 1. Explain what types of drugs are used topically to manage ear problems. 2. Describe the proper technique to give drugs to the ear. 3. Explain what types of drugs are used topically to manage eye problems. 4. Describe the proper technique to give eye drops and eye ointments. 5. List the names, actions, possible side effects, and adverse effects of drugs for glaucoma. 6. Explain what to teach patients and families about different drug categories to manage glaucoma. 7. Describe lifespan considerations for drugs for glaucoma. KEY TERMS alpha-adrenergic agonists (ăd-rěn-ĚRJ-ĭk ĂG-ō-nĭsts, p. 340) These drugs bind to receptor sites in the eye and reduce the amount of aqueous humor produced. beta-adrenergic antagonists (BĔ-tă ăd-rěn-ĚRJ-ĭk, p. 336) Drugs that inhibit adrenergic receptor sites in the eye and decrease production of aqueous humor. carbonic anhydrase inhibitors (CAIs) (kăr-BŎN-ĭk ăn-HĪ-drāz ĭn-HĬB-ĭ-tŏr, p. 342) A type of diuretic that also can lower intraocular pressure by decreasing production of aqueous humor by 50-60%. cerumenolytics (sě-RŪ-mĭ-nō-LĬ-tĭk, p. 331) Drugs that soften earwax. cholinergic drugs (kō-lĭn-ĚRJ-ĭk, p. 341) Drugs that increase the availability of acetylcholine to activate specific receptors. This leads to decreased production of aqueous humor and improving outflow of aqueous humor to decrease intraocular pressure. ophthalmic drugs (ŏf-THĂL-mĭk, p. 331) Liquid or ointment drugs prepared to place on the eye or the conjunctiva. otic drugs (Ō-tĭk, p. 330) Drugs prepared for delivery into the external ear canal. prostaglandin agonists (prŏ-stă-GLĂN-dĭn ĂG-ō-nĭsts, p. 335) Drugs that bind to specific prostaglandin receptor sites in the eye causing an increase outflow of aqueous humor. 608 Ear Problems Ear Structure and Function The ear, along with the brain, is the organ that allows hearing. It has three parts that are important to hearing: the external ear, the middle ear, and the inner ear. The external ear is known as the pinna (Fig. 18.1). It is made of cartilage covered by skin and attached to the side of the head. The external ear extends from the pinna through the external ear canal to the tympanic membrane (eardrum) (Fig. 18.2). The ear canal is an S-shaped tube open to the outside that ends at the eardrum. This canal is lined with hair cells and cells that produce cerumen (also called “earwax”) and oil. Cerumen helps protect and lubricate the ear canal. In adults, the ear canal tilts downward and is slightly curved in an S-shape that is about 1 to inches (2.5–3.75 cm) long. In children the canal is shorter and straighter. FIG. 18.1 The external ear (pinna). (From Ignatavicius D, Workman ML, Rebar C: Medical-surgical nursing, ed 9, St. Louis, 2018, Saunders.) 609 FIG. 18.2 Anatomy of the middle and inner ear. (From Ignatavicius D, Workman ML, Rebar C: Medical-surgical nursing, ed 9, St. Louis, 2018, Saunders.) The middle ear is a small compartment that extends from the eardrum to the oval and round windows of the wall separating it from the inner ear. It contains the top opening of the eustachian tube and three small bones known as the bony ossicles, which are the malleus (hammer), the incus (anvil), and the stapes (stirrup) (see Fig. 18.2). The bony ossicles are joined loosely, which allows them to move and “jiggle” with vibrations created when sound waves hit the eardrum. The eustachian tube extends from the floor of the middle ear to the back of the throat. This allows pressure on both sides of the eardrum to equalize. (You may have felt this as a “popping” sensation when you swallow or yawn, especially when traveling in a car up and down steep hills.) The eustachian tube normally allows secretions to drain from the middle ear into the throat. This opening from the throat to the middle ear also allows organisms in the throat to move upward (ascend) into the middle ear and cause otitis media (middle ear infection). The inner ear is on the other side of the oval window and contains the semicircular canals, the cochlea, the vestibule, and the end of the eighth cranial nerve (see Fig. 18.2). The semicircular canals are tubes that contain fluid and hair cells and are connected to the eighth cranial nerve. The fluid and hair cells within the canals help maintain the sense of balance. The cochlea is the fluid-filled organ with hair cells that detect vibration from sound and stimulate the eighth cranial nerve. Hearing is the main function of the ear and occurs when sound waves are moved through the air to the external ear canal. These waves then hit the movable eardrum, creating vibrations that are transferred to the bones (ossicles) of the middle ear. The vibrations move the three small, loose bones in the middle ear, which then allows the vibrations to be transmitted to the cochlea of the inner ear. In the cochlea, the vibrations stimulate the nerve of hearing (the eighth cranial nerve), which carries the impulse to the areas of the brain that allow the nerve impulses to be “heard” and interpreted as sounds. 610 Drugs to Manage Ear Problems The most common ear problems are infection and inflammation that occur in the external ear and in the middle ear. When these problems occur in the middle ear, antimicrobials and anti-inflammatories are given systemically, most often by the oral route. The actions, side effects, and nursing implications of systemic antimicrobials are discussed in Chapter 5. The actions, side effects, and nursing implications of systemic anti-inflammatories are discussed in Chapter 12. Infections and inflammation of the pinna and the ear canal are most often managed by topical drug application because the external ear can be reached from the outside. The actions of topical antimicrobial drugs and anti-inflammatories are the same as those given systemically and are discussed in Chapters 5 and 12. Drugs that are prepared to apply into the external ear canal are otic drugs. Box 18.1 presents the techniques involved in giving (instilling) eardrops into the ear canal. Fig. 18.3 shows the correct techniques for instilling eardrops into adults (see Fig. 18.3A) and children younger than 3 years (see Fig. 18.3B). Box 18.1 Technique for Instilling Eardrops Into a Patient's Ear • Make sure that the patient's eardrum is intact. This may require assessment by the RN or other healthcare provider. Never give an ear drug if there is damage to the eardrum. • Read the label of the drug carefully to ensure that it is “for otic use.” Never put any solution in the ear that is not labeled specifically for use in ears. • Verify the drug using the 9 Rights of Drug Administration. • Wash your hands and don a pair of clean gloves. • Warm the eardrops to room temperature. • Ask the patient to lie down with the head turned so that the affected ear is turned upward; if the patient is sitting in a chair, tilt the patient's head so the affected ear is up. • For a young child (younger than 3 years), gently pull the pinna down and back. • For an older child or adult, pull the pinna up and back. • Using the applicator, place only the prescribed number of drops into the patient's ear. Aim the drops onto the side of the ear canal and let them run into the ear. • Insert a cotton ball into the opening of the ear canal to keep the drops from rolling out of the ear. • Remind the patient to keep his or her head in this position for 2 to 5 minutes as directed to allow the drops to flow. • Remove your gloves and wash your hands. 611 FIG. 18.3 Correct techniques for giving eardrops to an adult (A) and to a child (B). (From Perry A, Potter P, Ostendorf W: Clinical nursing skills & techniques, ed 8, St. Louis, 2014, Mosby.) Top Tip for Safety Apply only drugs and liquids labeled “for otic use” into the ear canal. Lifespan Considerations The length and angle of ear canals differ between young children and adults. In adults the ear canal tilts downward, is longer, and is slightly curved in an S-shape. In children the canal is shorter and straighter. These differences require differences in technique when instilling drugs into the ear canal. • When instilling eardrops into an adult's ear, gently pull the external ear up and back (see Fig. 18.3A). • When instilling eardrops into a child's ear, gently pull the external ear down and back (see Fig. 18.3B). Another problem that can occur in the external ear canal is an excessive buildup of cerumen to such an extent that sound waves are blocked, hearing is reduced, and the patient has ear pain. For this problem, instillation of cerumenolytic drugs (that 612 soften earwax) may be used before irrigation of the ear. (Review ear irrigation in your fundamentals or medical-surgical nursing textbook.) These drugs are available over the counter and most often contain a carbamide peroxide combination (Table 18.1). An important issue to remember and to teach patients about the use of such a product is to never use it in an ear that has drainage or discharge because the eardrum may not be intact and the solution could enter the middle ear, causing an infection. Also, do not instill a cerumenolytic or irrigate an ear canal in a person who is dizzy, because these actions will increase the dizziness. Recent literature suggests that distilled water or saline may be just as effective as oil- or peroxide-based solutions. Carefully review the order and do not hesitate to ask the healthcare provider if you have questions. Table 18.1 Example of Cerumenolytic Cerumenolytics: These agents are typically solvents used to break up or soften earwax so that it can be easily removed. DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS Carbamide peroxide (Debrox, Murine Ear Wax removal • Teach patients that side effects are rare and Adults, adolescents, and children 12 years and older: Instill 5–10 drops twice daily in the affected include redness, itching, or rash. ear(s) for up to 4 days. Keep drops in ear for 5 minutes by keeping head tilted or placing cotton • Do not give drug if patient has any symptoms of in ear. Do not use for more than 4 days. The kit comes with an ear syringe for flushing. infection or any discharge from the ear because this may cause damage to the middle or inner ear. • To avoid dizziness, give the drug while the patient is lying down and the affected ear is turned upward. • Do not insert the tip of the applicator into the ear canal to avoid contamination of the tip or damage to the ear. • Remind the patient to remain lying down for at least 5 minutes after giving the drops for maximum effectiveness. • Make sure that the drug is room temperature. Drugs that are too cold or too warm can cause dizziness, nausea, and even burns to the ear. • To avoid infection, do not share the drug with other patients. • Gently flush the ear with warm water after application of drug with a bulb syringe or the syringe provided by the manufacturer. • Remind patient that they may hear a bubbling sound after they instill the eardrops. Top Tip for Safety Never place a drug into the ear canal or irrigate the ear canal if there is drainage present because it could enter the middle ear and cause an infection. Eye Problems Together the eye and the brain allow sight (vision). Although many problems can affect the eye and vision, those that can be managed with drug therapy are inflammation, infection, and glaucoma. Drugs for these problems are ophthalmic drugs, which come in liquid drops or ointment form. Chapter 12 discusses various types of anti-inflammatory drugs, nearly all of which have an ophthalmic form. Chapter 5 discusses antimicrobial drug therapy. Many antimicrobial and antiinflammatory drugs have an ophthalmic form, and their actions are the same as the systemic form. Follow directions carefully when giving the ophthalmic form to avoid 613 underdosing or overdosing. This chapter focuses on drug therapy to manage the chronic eye disorder of glaucoma, which cannot be cured but can be controlled. Although the actions and uses for these drugs differ, some nursing implications are the same for all of them. In addition, many of the points to teach patients and families about these drugs are the same. Box 18.2 describes these common nursing considerations for ophthalmic drugs, and Box 18.3 describes general patient teaching points. Nursing considerations and patient teaching issues specific to any single drug type are listed with the individual drug categories. Box 18.2 General Nursing Considerations for Ophthalmic Drug Therapy • Always wash your hands before and after giving eye drops (use gloves if available). • Assess the patient's eye for redness, drainage, or open areas. In some cases redness is a side effect of the eye drugs but could also be a sign of infection. If there is any new redness, drainage, or open areas, notify the RN or healthcare provider before giving the eye drugs. • Never touch the tip of the applicator/dropper or the inside of the cap to avoid contamination and reduce the risk for infection. • Always check to make sure that you are giving the correct concentration of the drug and correct number of drops in the correct eye. • Only use drugs that are specifically labeled for ophthalmic use. • Remove contact lenses before giving eye drops and read the drug inserts carefully to see if the patient is able to use his or her contact lenses over the course of the therapy. • If giving more than one type of eye drop, wait at least 5 minutes between instillations to avoid drug interaction. • Teach the patient that his or her vision may be slightly blurry for a few minutes after giving eye drops and slightly longer for eye ointment. Avoid any significant activity until the blurred vision passes to reduce risk for falls. • Always report any sudden eye pain or sudden changes in vision to the healthcare provider immediately because these symptoms may indicate potential for eye injury and even blindness. • Follow the directions in Box 18.4 for instilling eye drops or ointments into a patient's eye. • Fig. 18.10 shows the correct technique for applying eye drops. • After giving eye drops, ask the patient to close his or her eyes for 2 minutes; this reduces the amount of drug absorbed systemically. A second option to reduce systemic absorption of the drug is to apply gentle pressure with the index finger over the tear duct in the inner corner of the eye for about 3 minutes after giving 614 the eye drops (Fig. 18.11). • Fig. 18.12 shows the correct technique for applying eye ointments. FIG. 18.10 Correct technique for instilling eye drops. (From Perry A, Potter P, Ostendorf W: Clinical nursing skills & techniques, ed 9, St. Louis, 2017, Mosby.) FIG. 18.11 Applying digital nasolacrimal occlusion (also called punctal occlusion) to prevent systemic absorption. (From Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier.) FIG. 18.12 Correct technique for instilling ointment into the eye. (From Ignatavicius D, Workman ML, Rebar C: Medical-surgical nursing, ed 9, St. Louis, 2018, Saunders.) 615 Box 18.3 General Teaching Points for Patients and Families During Topical Eye Drug Therapy • Use only drugs that are labeled “for ophthalmic use only.” Never place any solution in the eye that is not properly labeled. • Eye drops are typically clear, thin, liquid drugs that are supplied in a bottle specifically labeled “for ophthalmic use only.” • Eye ointments are thick, often appear “greasy,” and come in a squeezable tube. The ointment remains in contact with the eye for a longer period than the eye drops. • The concentration of the drugs is on the label and must be carefully compared with the drug order. • Use only the prescribed number of eye drops into the eye because too much of the drug can lead to adverse effects. • Never share eye drops or ointments with another person to avoid eye injury and decrease risk for infection. • Wash your hands thoroughly and, if available, put on clean gloves. • Ask the patient to remove glasses or contact lenses before giving the eye drugs (contact lenses can absorb the eye drugs so they must be removed). • Remove the cap of the eye drug and place it upside down on the table to avoid contamination. • Never touch the tip of the eye dropper/applicator with your finger or to the patient's eye. The tip should remain sterile. • Ask the patient to tilt his or her head back slightly to look at the ceiling. With a tissue, gently retract the lower lid to expose the conjunctival sac. • Teach the patient (or family) the proper technique for giving eye drops. Overthe-counter saline drops can be used to practice the technique and avoid waste of the eye drugs. • The patient should never drive or use heavy machinery if having blurred vision after taking the eye drugs. • After giving eye drops, ask the patient to close his or her eyes for 2 minutes; this reduces the amount of drug absorbed systemically. A second option to reduce systemic absorption of the drug is to apply gentle pressure with the index finger over the tear duct in the inner corner of the eye for about 3 minutes after giving the eye drops. • Always report any sudden eye pain or sudden changes in vision to the healthcare provider immediately because these symptoms may indicate potential for eye injury and even blindness. • Teach patients that if there are any new symptoms while taking the drug (whether relating to the eye or general symptoms) to let their healthcare provider know right away. 616 • Should there be any sudden decrease or loss of vision, teach the patient to go to the emergency department or call 911. Drug therapy for any eye problem requires that the drops or ointment be instilled using correct technique to ensure the drug is in contact with the eye and that no harm or infection occurs. Box 18.4 describes the correct technique for instilling opthalmic drugs to a patient, and Box 18.5 describes the correct technique to teach patients how to place drugs into their own eyes. Box 18.4 Technique for Giving Eye Drops or Ointments to a Patient 1. Check the name, strength, expiration date, color, and clarity of the eye drops to be instilled. If the drug is an ointment, be sure that it is an ophthalmic (eye) preparation and not a general topical ointment. 2. Check to see whether only one eye is to have the drug or whether both eyes are to receive the drug. 3. If both eyes are to receive the same drug and one eye is infected, use two separate bottles or tubes and carefully label each with “right” or “left” for the correct eye. 4. Wash your hands and put on gloves. 5. Explain the procedure to the patient. 6. Make sure the patient is not wearing contact lenses; if the patient is, ask him or her to remove them. 7. Have the patient sit in a chair while you stand behind the patient (or alternatively stand in front of the patient who is sitting in a chair or over the patient who is lying in bed). 8. Ask the patient to tilt his or her head backward, with the back of the head resting against you (or the back of the chair), and look up at the ceiling. 9. Gently pull the lower lid down against the patient's cheek, forming a small pocket. 10. Hold the eye-drop bottle or ointment tube (with the cap off) like a pencil, with the tip pointing down. 11. For ointment, squeeze a small amount out onto a tissue (without touching the tip to the tissue) and discard this ointment. 12. For eye drops, gently squeeze the bottle and release the prescribed number of drops into the pocket that you have made with the patient's lower eyelid. Do not touch any part of the eye or lid with the tip of the bottle. For ointment, gently squeeze the tube and release a small amount of ointment into the pocket that you have made with the patient's lower eyelid. Do not touch any part of the eye or lid with the tip of the tube. 13. Gently release the lower eyelid. 14. Ask the patient to close his or her eye gently, without squeezing the lids tightly, and roll the eye under the lid to spread the drug across the eye for 617 about 2 minutes. 15. As an alternative to closing the eyes after giving eye drops, with a gloved finger, gently press and hold the corner of the eye nearest the nose to close off the tear duct for about 3 minutes to prevent the drug from being absorbed systemically. 16. Without pressing on the eyelid, gently blot or wipe away any excess drug or tears with a tissue. 17. Gently release the lower lid. 18. Remove your gloves. 19. Recap the tube or bottle. 20. Wash your hands again. 21. Replace contact lenses as appropriate. 22. Remind patients that their vision will be blurry and not to drive until their vision clears. Adapted from Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier. Box 18.5 Technique for Self-Administration of Eye Drugs 1. Check the name, strength, expiration date, color, and clarity of the eye drops to be instilled. If the drug is an ointment, be sure that it is an ophthalmic (eye) preparation and not a general topical ointment. 2. Check to see whether only one eye is to have the drug or if both of your eyes are to receive the drug. 3. If both eyes are to receive the same drug and one eye is infected, use two separate bottles or tubes and carefully label each with “right” or “left” for the correct eye. 4. Wash your hands. 5. Remove the cap from the bottle or tube, keeping the cap upright to prevent contaminating it. 6. Remove contact lenses if present. 7. Tilt your head backward, open your eyes, and look up at the ceiling. 8. Using your nondominant hand, gently pull the lower lid down against your cheek, forming a small pocket. 9. Hold the eye-drop bottle or ointment tube (with the cap off) like a pencil with the tip pointing down with your dominant hand. 10. For ointment, squeeze a small amount out onto a tissue (without touching the tip to the tissue) and discard this ointment. 11. Rest your wrist that is holding the bottle or tube against your mouth or upper lip. 12. For eye drops, gently squeeze the bottle and release the prescribed number of drops into the pocket that you have made with your lower lid. Do not touch any part of the eye or lid with the tip of the bottle. For ointment, gently squeeze the tube and release a small amount of ointment into the pocket that 618 you have made with your lower eyelid. Do not touch any part of the eye or lid with the tip of the tube. 13. Gently release your lower eyelid. 14. Close your eye gently (without squeezing the lids tight) and roll your eye under the eyelid to spread the drug across the eye. 15. Keep your eye closed for about 2 minutes. 16. As an alternative to keeping your eye closed for two minutes, gently press and hold the corner of the eye nearest to your nose to close off the punctum for about 3 minutes and prevent the drug from being absorbed systemically. 17. Without pressing on your eyelid, gently blot or wipe away any excess drug or tears with a tissue. 18. Gently release your lower eyelid. 19. Recap the bottle or tube. 20. Replace contact lenses as appropriate. 21. Wash your hands again. 22. Do not drive or operate heavy machinery while your vision is blurry. Adapted from Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier. Eye Structure and Function Vision results from light moving through the eye and meeting the optic nerve, where images are interpreted by the brain. Fig. 18.4 shows the basic anatomy of the eye, as well as the lacrimal gland (tear gland), lacrimal sack (tear sac), and nasolacrimal duct. Fig. 18.5 shows much greater detail of the eye itself. From the side view, you can see the eye is divided into the anterior segment and the posterior segment. Then the anterior segment divides into the anterior chamber and the posterior chamber. The space between the cornea and the lens is filled with a watery fluid called aqueous humor. Aqueous humor is produced by the ciliary body and flows from the posterior chamber to the anterior chamber, where it drains through the trabecular network and is reabsorbed by the body. Normal circulation of the fluid through this space is important in maintaining a normal intraocular pressure (IOP). Normal IOP is between 10 and 20 mm Hg. Maintenance of a normal IOP keeps the eye healthy and helps prevent blindness. This will be important when you learn later in this chapter how drugs work to treat glaucoma. From the side view (Fig. 18.5), you can see that the cornea covers the eye. The clarity of the cornea is important because the cornea allows light to enter the eye. 619 FIG. 18.4 Features of the external eye (front view) along with the tear gland and duct system. (From Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier.) FIG. 18.5 Side view (cutaway) of the internal features of the eye and flow of aqueous humor. (From Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier.) The iris is the muscular ring around the eye (see Figs. 18.4 and 18.5). Pigments in the iris give you the color of your eyes (as determined by your genetic makeup). The muscular iris helps adjust the pupil size to determine how much light enters the eye at any given time. Impulses from the autonomic nervous system cause the muscle to make the adjustment. Constriction of the pupil reduces the amount of light into the eye, and dilation of the pupil increases the light let into the eye (Fig. 18.6). Constriction of the pupil is called miosis; dilation of the pupil is called mydriasis. An easy way to remember this is: “miosis—small word, small pupil; mydriasis—large word, large pupil.” 620 FIG. 18.6 Comparison of pupil size: normal (A), miosis (B), and mydriasis (C). (From Workman ML, LaCharity LA: Understanding pharmacology, ed 2, St. Louis, 2016, Elsevier.) Constriction and dilation of the pupil occur continually as we adjust to varying amounts of light in our environment. For example, when you walk from a dark room into the sunlight, your pupil constricts to reduce the amount of light that gets to the retina (too much light can be very uncomfortable). When you come from the daylight into a dark movie theater, your pupils dilate to let more light in so you can get to your seat (see Fig. 18.6). Memory Jogger Pupil constriction is miosis (small word, small pupil size). Pupil dilation is mydriasis (larger word, larger pupil size). The posterior segment of the eye contains the retina and the optic nerve (see Fig. 18.5). The retina is the lining on the back of the eye. The retina is light sensitive and contains special cells involved in helping to turn light into electrical impulses. The posterior segment is filled with a jelly-like fluid called vitreous humor. The optic nerve in the back of the eye carries messages from the special cells in the retina to the brain, where we then “see” the images. Any increase in pressure in the eye can damage blood vessels in the retina, which then damages the specialized cells in the retina and the optic nerve that carries messages to the brain. 621 Memory Jogger Normal IOP is between 10 and 20 mm Hg. Maintenance of a normal IOP keeps the eye healthy and helps prevent blindness in patients with glaucoma. Bookmark This! The National Eye Institute (https://nei.nih.gov/) has fantastic resources for healthcare professionals, patients, and their families about a wide range of eye disorders. In particular, the National Eye Institute has a great bank of photographs and videos that will help explain what happens in these disorders. Resources are available in English and in Spanish. Glaucoma Glaucoma is a chronic eye disease of increased IOP that causes damage to the optic nerve (Fig. 18.7). If untreated, glaucoma causes loss of peripheral vision and even blindness (Fig. 18.8). The disease is described as a “thief of the night” because the patient typically has no symptoms other than a gradual loss of peripheral side vision. By the time the patient realizes that vision is decreased, he or she has already experienced a degree of permanent vision loss. Those at great risk include African Americans older than 40 years, patients with a family history of glaucoma, and patients older than 60 years, especially Mexican Americans. Although glaucoma typically occurs in adults, eye trauma can cause glaucoma in children. FIG. 18.7 Increased intraocular pressure from too much aqueous humor causing damage to the optic nerve in glaucoma. 622 FIG. 18.8 (A) Scene as viewed by a person with normal vision. (B) Scene as viewed by a person with glaucoma. (Courtesy National Eye Institute, National Institutes of Health.) Glaucoma is an eye disorder that results from too much aqueous humor. As mentioned earlier, aqueous humor is a fluid, similar to plasma, produced by the ciliary body in the eye (see Fig. 18.5). This fluid provides oxygen and nutrients to the cornea, trabecular meshwork, and the lens of the eye. Normally aqueous humor flows freely in the eye, providing nutrition and removing waste products. In the most common type of glaucoma, primary open-angle closure glaucoma, aqueous humor does not drain through the normal pathways. This results in a buildup of fluid and increased IOP in the anterior chamber of the eye (see Fig. 18.7). The fluid increases pressure in the eye leading to damage of the retina and the optic nerve. In rare situations a condition called acute angle closure glaucoma causes a sudden increase in IOP. This leads to severe eye pain, nausea and vomiting, and the patient may report seeing halos around lights. Acute angle closure glaucoma is a medical emergency. Any patient with symptoms of acute angle closure glaucoma should receive emergency treatment to avoid blindness. Memory Jogger Glaucoma is a chronic disease with no cure. Drug therapy can prevent further damage and blindness, and must continue for rest of the patient's life. Drug therapy for patients with glaucoma involves reducing the amount of aqueous humor produced by the ciliary body or improving drainage and reabsorption of the aqueous humor. This decreases fluid pressure in the eye and relieves pressure on the retina and the optic nerve. Drugs for glaucoma are typically given as eye drops to the affected eye(s). In emergency cases of acute angle closure glaucoma, drugs may be given orally or intravenously to rapidly reduce IOP. Healthcare providers may recommend select drugs from five classes to manage glaucoma: prostaglandin agonists (sometimes called prostaglandin analogs), betaadrenergic antagonists (blockers), alpha-adrenergic agonists, cholinergic drugs, and carbonic anhydrase inhibitors (CAIs). Memory Jogger 623 The five classes of drugs to treat glaucoma are: • prostaglandin agonists (sometimes called prostaglandin analogs) • beta-adrenergic antagonists (blockers) • alpha-adrenergic agonists • cholinergic drugs • CAIs Prostaglandin Agonists Action and Uses Prostaglandin agonists help to control glaucoma by binding to prostaglandin receptor sites in the eye and relaxing eye blood vessel smooth muscles, which allows these blood vessels to dilate and absorb aqueous humor. As a result, more aqueous fluid enters the blood and less is present in the eye, lowering the IOP. For many people, the prostaglandin agonists are very effective at controlling IOP. They are used only once a day and have fewer systemic side effects than other drugs. Names, usual adult dosages, and nursing implications of these drugs are listed in Table 18.2. Be sure to consult a drug reference book for more information about specific prostaglandin agonists. Table 18.2 Examples of Prostaglandin Agonist and Beta-Adrenergic Antagonist Drugs Prostaglandins agonists: help control glaucoma by binding to prostaglandin receptor sites in the eye and relax eye blood vessel smooth muscles, which allows these blood vessels to dilate and absorb aqueous humor DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS bimatoprost (Lumigan) 1 drop of a 0.01% solution in the • Check the eye carefully for any scratches or signs of trauma. If so, hold the drug and contact affected eye or eyes daily in the evening the registered nurse or healthcare provider because these drugs should not be given if there latanoprost (Xalatan 0.005%) 1 drop (1.5 mcg) in affected are any breaks in the tissue. eye or eyes daily in the evening • Teach patients that they may notice changes in the color of the affected eye (usually travoprost (Travatan 0.004%, Travatan Z 0.004%) 1 drop becomes darker). Patients may notice a slightly darker color on the eyelid. These color in affected eye or eyes daily in the evening changes may be permanent. • Eyelashes on the affected eye may grow longer and thicker. Do not attempt to use the drops in the unaffected eye to make the eyelashes match because the drug may be dangerous if used inappropriately. Beta-adrenergic antagonists: reduce the amount of aqueous humor by binding to beta-adrenergic receptors in the ciliary body of the eye DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS betaxolol hydrochloride (Betoptic, Kerlone) 1–2 drops • To reduce the risk for systemic absorption, perform digital nasolacrimal occlusion on the (0.5% solution) in affected eye every 12 hours affected eye or remind the patient to keep the eye closed for 2–3 minutes. carteolol (Cartrol, Ocupress) 1 drop (1% solution) in • Check vital signs every 4–8 hours while the patient is receiving these drugs to assess for any affected eye every 12 hours decreases in heart rate or blood pressure, or note any increased respiratory effects because levobunolol (Ak-Beta, Betagan) 1–2 drops (0.25% these can be signs of systemic absorption. solution) in affected eye every 12 hours; 1–2 drops (0.5% • Recheck the blood sugar in patients with diabetes regularly because beta blockers can mask solution) in affected eye once daily the symptoms of hypoglycemia. metipranolol (OptiPranolol) 1 drop (0.3% solution) in affected eye every 12 hours timolol (Betimol, Istalol, Timoptic) 1 drop (0.25% solution or 0.5% solution) in affected eye once or twice daily timolol GFS (gel-forming solution) (Timoptic-XE) 1 drop (0.25% solution or 0.5% solution) in affected eye once or twice daily Expected Side Effects The most common side effects of prostaglandin agonists are eye itching and eye redness when they are first applied. In some cases, patients have a foreign body sensation (feels like something is in their eye). Over time patients who take prostaglandin agonists may develop changes in the 624 color of the iris from lighter colors to brown (Fig. 18.9). This is a gradual change and is permanent. The color change is most common in people who have brown pigment in their eyes. The drug also causes thickening and lengthening of the eyelashes and darkening of the skin on the eyelids. FIG. 18.9 Changes in iris color associated with prostaglandin agonist drug therapy for glaucoma. (A) Before treatment. (B) After treatment. (From Yanoff M, Duker J: Ophthalmology, ed 4, St. Louis, 2014, Mosby.) Adverse Effects In rare cases patients who are taking prostaglandin agonists can experience systemic effects including infection, asthma, and corneal erosion (damage to the cornea). Nursing Implications and Patient Teaching Assessment. In addition to the general nursing considerations related to eye drug therapy listed in Box 18.2, make sure to assess the patient's understanding that glaucoma is a chronic disease and will require adherence to drug therapy to prevent decreased vision and even blindness. For all patients who are taking prostaglandin agonists, it is important to check the affected eye for any scratches (corneal abrasion) or other signs of trauma. Never give these drugs if there is any damage to the eye surface. Top Tip for Safety Never instill prostaglandin agonists into an eye that has been scratched or has an infection. Contact the healthcare provider for instructions about continuing glaucoma therapy and managing the corneal problem. Patient and family teaching. In addition to the general teaching points listed in Box 18.3, tell the patient and the 625 family the following: • Avoid using higher than prescribed doses because higher doses can reduce the effectiveness of the drug in controlling glaucoma. • If you have lighter eyes, your eye and eyelid color can change over time, and the lashes can become thicker and longer. If only one eye has glaucoma, the color and lash changes will occur only in that eye. • If you have glaucoma only in one eye, do not place the drops in the unaffected eye even though the colors of your eyes may now be different. Beta-Adrenergic Antagonists Actions Beta-adrenergic antagonists (also called beta blockers) reduce the amount of aqueous humor produced from the ciliary body of the eye. They do this by binding to betaadrenergic receptors in the ciliary body of the eye. Normally cells in the ciliary body produce aqueous humor, so blocking the action of these cells reduces the production of aqueous humor. Common beta blockers for glaucoma, dosages, and nursing implications are listed in Table 18.2. Be sure to consult a drug reference book for more information about specific beta-blocking agents to control glaucoma. Expected Side Effects Expected side effects for beta-adrenergic antagonists often occur within a few minutes of instilling the drops in the eye. These include temporary blurring of vision, slight burning or stinging, and tearing of the eye. Later the patient may notice less tear production and dry, itchy, or red eyes. Beta blockers constrict the pupil (i.e., cause miosis). It is important for patients to understand that their pupils do not dilate as easily when they go into a dark room. Memory Jogger To determine whether a drug is a beta blocker, look for the suffix (word ending) olol. Adverse Effects The greatest risk of problems from beta-blocker ophthalmic drugs occurs when they are unintentionally absorbed systemically. This can occur if drops are absorbed through the conjunctiva, the tear ducts, the nose, or other eye tissues. If absorbed systemically, beta blockers can cause the same effects you would see if you gave 626 them orally, as discussed in Chapter 8. Patients could experience decreased heart rate, decreased blood pressure, and even heart failure. Systemic absorption of beta blockers can also cause bronchoconstriction and asthma symptoms. Nursing Implications and Patient Teaching Assessment. In addition to the general nursing considerations related to eye drug therapy listed in Box 18.2, determine the patient's baseline vital signs. Watch for changes in heart rate and blood pressure. If the patient has any respiratory problems such as asthma or chronic obstructive pulmonary disease (COPD), make sure to monitor for any shortness of breath or changes in pulse oximetry. Assess carefully to determine whether the patient is also taking oral beta blockers (see Chapter 8) to control blood pressure or other heart dysrhythmia. If so, notify the healthcare provider to make sure he or she is aware of the oral drug before giving the eye drops. Ophthalmic beta blockers may increase the risk for expected side effects and adverse effects of the oral beta blocker. Planning and intervention. Never touch the tip of the eye dropper or touch the tip directly to the patient's eye, to avoid contaminating the tip. To decrease systemic absorption of eye drops, use only the prescribed amount of the eye drops. After giving the drops, ask the patient to close his or her eyes for 2 minutes. Closing the eyes for 2 minutes reduces the amount of drug absorbed systemically. Another option to reduce systemic absorption of the drug is digital nasolacrimal occlusion (this technique has also been called punctal occlusion). Simply speaking, this means putting gentle pressure with the index finger over the tear duct in the inner corner of the eye for about 3 minutes after giving the eye drops. A word of caution: Even with the techniques to decrease systemic absorption of the eye drops, you will still need to carefully monitor for adverse effects of the drug. Top Tip for Safety To reduce systemic absorption of eye drops, give only the prescribed number of eye drops; then ask the patient to close his or her eyes for 2 minutes or place a gloved finger over the tear duct and apply gentle pressure for about 3 minutes. Evaluation. Monitor the patient for expected side effects and adverse effects. Report any significant change in vital signs, particularly blood pressure below 90/60 mm Hg or heart rate less than 60. Watch for any changes in respiratory status including shortness of breath or wheezing, or decreased pulse oximetry below 92%. Top Tip for Safety 627 To avoid contamination, never touch the tip of the applicator with your finger or directly on the patient's eye. Patient and family teaching. In addition to the general teaching points listed in Box 18.3, tell the patient and family the following: • Do not increase the dose or use the drug more often because excessive use increases the risk for heart and breathing problems, especially if you have asthma, COPD, or other respiratory problems. • Use good lighting when reading and use caution in darker rooms because the eye pupil will not dilate to let in more light, and it may be harder to see objects in dim light. This problem can increase your risk for falls. • Avoid driving at night as your vision will be reduced. • If you have diabetes, check your blood glucose more often because these drugs can mask the symptoms of hypoglycemia if the drug is absorbed systemically. Lifespan Considerations Beta-Adrenergic Blocking Agents for Older Adults Before giving beta-blocker eye drops to patients, make sure they are not taking any oral beta-blocker drugs for a cardiac condition. If so, notify the healthcare provider. Older adults are more likely to have cardiac and respiratory problems from systemic absorption of eye drops. Alpha-Adrenergic Agonists Action and Uses In patients with glaucoma, alpha-adrenergic agonists act to reduce the amount of aqueous humor produced in the eye. In addition, alpha-adrenergic agonists improve the flow of aqueous humor out of the anterior chamber of the eye. These actions reduce the IOP in the eye. Common alpha-adrenergic agonists for glaucoma, dosages, and nursing implications are listed in Table 18.3. Be sure to consult a drug reference book for more information about specific alpha-adrenergic agonists to control glaucoma. Table 18.3 628 Examples of Common Alpha-Adrenergic Agonists and Cholinergic Drugs for Glaucoma Alpha-adrenergic agonists: These drugs act to reduce the amount of aqueous humor produced in the eye. In addition, alpha-adrenergic agonists improve the flow of aqueous humor out of the anterior chamber of the eye. These actions reduce the intraocular pressure in the eye. DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS apraclonidine (Iopidine) 1–2 drops (0.5% solution) in affected eye every 8 hours • Remind patients that these drops can sometimes make dipivefrin hydrochloride (AK-Pro, Propine) 1 drop (0.1% solution) in affected eye every 12 them feel they have something in their eye, so do not rub hours the eyelid. • Monitor vital signs regularly because these drugs can cause increased or decreased blood pressure if absorbed systemically. • Report upper respiratory symptoms such as cough, shortness of breath, sore throat, or runny nose because these can be adverse effects of the alpha-adrenergic agonists. • These drugs may be used for short-term reduction of intraocular pressure or in addition to other types of drugs for patients who do not respond to other drugs. • Wait at least 5 minutes before using other types of eye drops. Cholinergic drugs: These drugs increase availability of acetylcholine to activate specific receptors. This leads to decreased production of aqueous humor and improving outflow of aqueous humor to decrease intraocular pressure. DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS carbachol (Isopto Carbachol) 2 drops (1.5% solution or 3% solution) in affected eye every 8 • Remind patients that vision may be decreased at night, hours so patients may need to avoid night driving. pilocarpine (Isopto Carpine, Pilopine) 1–2 drops (1% solution or 2% solution) in affected eye • Teach patients to wear protective sunglasses in bright every 6–8 hours, depending on strength of solution and patient response to the drug. Also lights because these drugs can cause photophobia. available as gel and as an ocular insert, follow administration directions carefully. • Report symptoms such as sweating, bradycardia, drop in blood pressure, diarrhea, nausea, and vomiting because these may indicate systemic absorption. Expected Side Effects Side effects commonly experienced by patients who are taking alpha-adrenergic agonists for their glaucoma include tearing, redness, blurring of vision, and burning or stinging after giving the eye drops. Some patients may experience a sensation of a foreign body being in their eye. Adverse Effects Adverse effects of adrenergic agonists include bradycardia or tachycardia and a drop in blood pressure. These can result from giving too many drops of the drug, causing systemic absorption. Other adverse effects include allergic reaction, fatigue, and respiratory symptoms. Nursing Implications and Patient Teaching Assessment. In addition to the general nursing considerations related to eye drug therapy listed in Box 18.2, make sure to assess the patient's vital signs, especially heart rate, because the drug can cause either tachycardia or bradycardia. Patients may also experience a drop in blood pressure and/or orthostatic hypotension. Let the prescriber know if the patient is taking antianxiety agents (particularly benzodiazepines), antidepressants, or sedatives because these may increase central nervous system (CNS) effects. Planning and implementation. Carefully monitor the patient's heart rate and blood pressure for changes after giving the eye drops. Make sure to read the label carefully to confirm that you are giving the correct concentration of the drug. Give the exact number of eye drops prescribed by the healthcare provider to the patient to decrease the risk for adverse effects. 629 Make sure to ask the patient to close his or her eyes for 2 minutes or place a gloved finger over the tear duct and apply gentle pressure for about 3 minutes. Always wipe any excess drug that spills on the eyelid or face to avoid systemic absorption. Patient and family teaching. In addition to the general teaching points listed in Box 18.3, tell the patient and family the following: • Make sure to read packaging carefully because some drugs may need to be stored in the refrigerator and protected from light to maintain potency. • Wear dark glasses when you are in the sunlight or other bright light conditions because your pupil will be dilated and your eye will be sensitive to light. • If you have been prescribed to use the drug for a limited time such as 1 week, do not continue the drug beyond that time period. These drugs not only lower elevated IOP, they can also lower normal IOP, which can cause problems. Cholinergic Drugs Action and Uses Cholinergic drugs decrease IOP by reducing the amount of aqueous humor produced and improving its flow. By increasing the amount of acetylcholine, the pupil becomes smaller (miosis). This in turn increases the amount of space between the lens and the iris, allowing the aqueous fluid to flow freely and decreasing IOP. Common cholinergic drugs for glaucoma, dosages, and nursing implications are listed in Table 18.3. Be sure to consult a drug reference book for more information about specific cholinergic drugs to control glaucoma. Expected Side Effects Expected side effects of cholinergic drugs include tearing, stinging, redness of the eye, and blurred vision. Cholinergic drugs cause miosis, so patients may experience difficulty with vision at night and even night blindness. Like other eye drugs we have discussed, systemic side effects are possible and include headache, increased saliva, increased urination, and sweating. Side effects are intensified if patients are prescribed an oral form of cholinergic drugs. Adverse Effects Adverse effects are more common with systemic absorption of the drug. Examples include changes in blood pressure and abnormal heart rhythms. Other adverse 630 effects include double vision and retinal detachment. Nursing Implications and Patient Teaching Assessment. In addition to the general nursing considerations related to eye drug therapy listed in Box 18.2, carefully monitor the patient's vital signs. You will be assessing blood pressure, heart rate, and respiratory rate because they may all be sensitive to changes from cholinergic drugs. Assess the patient for the side effects you might expect from any drug that increases acetylcholine including increased saliva, increased urination, and sweating. Memory Jogger Patients who are taking eye drugs for glaucoma may have unequal pupil size. If there is any question about neurologic status, make sure to contact the registered nurse (RN) or healthcare provider for assessment. Cholinergic drugs should be avoided in people who have breathing problems such as asthma or chronic bronchitis. These drugs should be avoided in patients with gallbladder or liver disease. Always use the right dose and wipe any excess drug off of the patient's skin because it can be absorbed and cause systemic effects. Use digital nasolacrimal occlusion technique or ask the patient to close his or her eyes for at least 2 minutes after giving the drug. Top Tip for Safety To decrease the risk for side effects and adverse effects, make sure to wipe off any excess drug from the skin rather than let it absorb. Never give more drops than are prescribed. Evaluation. Report significant changes in the patient's vital signs including decreased heart rate less than 60 beats per minute or any trouble breathing. Symptoms such as drooling, severe sweating, respiratory failure, and severe neuromuscular weakness indicate cholinergic toxicity. Top Tip for Safety A sudden change in blood pressure, heart rate, or difficulty breathing may be related to cholinergic eye drugs. Notify the healthcare provider immediately. Patient and family teaching. In addition to the general teaching points listed in Box 18.3, tell the patient and 631 family the following: • Use caution in moving from light to dark rooms. Your pupils will not dilate normally so it may be difficult to see. Make sure to use good lighting for reading and other daily activities. • Make sure to remove any excess drug if it spills on skin to avoid absorption. • Report any increase of drooling or sweating, or any difficulty breathing to your healthcare provider immediately because those symptoms may indicate a toxic level of the drug. Carbonic Anhydrase Inhibitors Action and Uses Carbonic anhydrase inhibitors (CAIs) lower IOP by reducing aqueous humor in the anterior chamber of the eye. CAIs are a type of diuretic. They are available in oral forms, as eye drops, and intravenously (for patients who need a rapid decrease in IOP to prevent serious optic nerve damage). Common CAIs for glaucoma, dosages, and nursing implications are listed in Table 18.4. Be sure to consult a drug reference book for more information about specific cholinergic drugs to control glaucoma. Table 18.4 Examples of Carbonic Anhydrase Inhibitors Carbonic anhydrase inhibitors: lower intraocular pressure by reducing aqueous humor in the anterior chamber of the eye DRUG/ADULT DOSAGE RANGE NURSING IMPLICATIONS acetazolamide (Diamox) • Double-check allergies before giving these drugs because some may have cross-sensitivity sustained-release capsules: 250 mg orally one to four with sulfonamide antibiotics. times daily • Report any GI side effects to the healthcare provider because these may be side effects of extended-release capsules: 500 mg by mouth twice carbonic anhydrase inhibitors. daily • Monitor electrolytes (particularly sodium and potassium) because these drugs are also brinzolamide (Azopt) 1 drop (1% solution) in affected categorized as diuretics. eye every 8 hours • Monitor for CNS side effects such as drowsiness, fatigue, depression, and irritability. These dorzolamide (Trusopt) 1 drop (2% solution) in affected may require a change in drugs. eye every 8 hours • Notify the healthcare provider if the patient has a history of gout because these drugs may methazolamide (Neptazane, Glauctabs) 50–100 mg increase uric acid level. orally every 8–12 hours Expected Side Effects Eye drops can cause slight burning or stinging with administration. Some patients may experience a bitter or sour taste in the mouth. In rare cases, redness of the conjunctiva can occur. CAIs can cause CNS effects and must be used with caution. Patients may experience drowsiness, fatigue, and headache with oral and intravenous forms. Blood sugar levels may fluctuate when the patient is taking oral CAIs. 632 Adverse Effects Some CAIs are related to sulfonamide drugs and may cause an allergic reaction in patients who are allergic to any sulfa drug. The allergic response can happen even in the eye drops, so make sure to notify the healthcare provider before giving a CAI to a patient with a sulfa allergy. When CAIs are taken orally or intravenously, the patient can experience a wide range of adverse effects, including neurologic effects (i.e., confusion, dizziness, numbness of the hands and feet, and even paralysis), severe skin infections, severe electrolyte imbalances, and liver failure. Nursing Implications and Patient Teaching Assessment. In addition to the general nursing considerations related to eye drug therapy listed in Box 18.2, monitor the patient for side and adverse effects, particularly CNS effects that are more likely with the oral or intravenous drugs. Ask about and report any sulfa allergy to the healthcare provider before giving any CAI. Top Tip for Safety Never give a CAI to a patient who has a sulfa allergy because these drugs are a type of sulfonamide. Evaluation. Assess the patient's response to the drug. Report any severe side effects or adverse effects to the healthcare provider. One side effect, bitter or sour taste in the mouth, may affect the patient's dietary intake, so monitor for this problem carefully. Shortness of breath, dizziness, hives, or itching may be symptoms of an allergic response. Lifespan Considerations Carbonic Anhydrase Inhibitors Pediatric Considerations CAIs should not be given to children because they can slow growth if used long term. Considerations for Pregnancy and Breast-Feeding CAIs should be avoided during pregnancy and breast-feeding. Get Ready for the NCLEX® Examination! Key Points 633 • Apply only drugs and liquids labeled “for otic use” into the ear canal. • When instilling eardrops into an adult's ear, gently pull the external ear up and back. When instilling eardrops into a young child's ear, gently pull the external ear down and back. • Place eardrops or solutions only in the affected ear. • Never give a drug to the ear canal or irrigate the ear canal if there is drainage present, to avoid causing a middle ear infection. • Glaucoma is a chronic disease with no cure; drug therapy can prevent blindness and must continue for the patient's life. • Pupil constriction is miosis (small word, small pupil size). Pupil dilation is mydriasis (larger word, larger pupil size). • Normal IOP is between 10 and 20 mm Hg. Maintenance of a normal IOP keeps the eye healthy and helps prevent blindness in patients with glaucoma. • Never instill prostaglandin agonists into an eye that has been scratched or has an infection. Contact the healthcare provider for instructions about continuing glaucoma therapy and managing the corneal problem. • Prostaglandin agonists can cause a change in the color of the iris of the eye and increase the length of eyelashes. • Before giving beta-blocker eye drops to a patient, make sure he or she is not also taking any oral beta-blocker drugs for any cardiac conditions. • Use digital nasolacrimal occlusion (also called punctal occlusion) to reduce systemic absorption of eye drops. Give only a prescribed number of eye drops; then ask the patient to close his or her eyes for 2 minutes or place a gloved finger over the tear duct and apply gentle pressure for about 3 minutes. • All opthalmic drugs must be labeled specifically for “ophthalmic use.” • Give eye drops or eye ointment in the affected eye only. • Never touch the tip of the bottle or tube to your fingers or directly on the patient's eye to avoid contamination. • Gently pull the lower lid down on the affected eye so that you can place the eye drops or ointment into the conjunctival sac. • Glaucoma drugs are typically available in varying strengths. Make sure to read the label carefully and only give the strength prescribed for the patient. • Adrenergic agonists cause mydriasis. The patient's pupils are dilated, so the eyes are more sensitive to bright lights. Patients may need to wear protective sunglasses in bright conditions. • Beta blockers and cholinergic drugs cause miosis. Patients may have difficulty adjusting to dim lighting because their pupils are smaller. Patients will need to use caution to avoid falls. • Teach patients to report any dizziness or shortness of breath to the healthcare provider because these indicate side effects of the glaucoma drugs. 634 • Advise patients with diabetes that beta blockers can mask the symptoms of low blood sugar. Regular checking of blood sugar will be very important. • Symptoms of too much cholinergic drug include increased saliva, increased urination, and sweating. • Patients who are taking eye drugs for glaucoma may have unequal pupil size. If there is any question about neurologic status, make sure to contact the RN or healthcare provider for assessment. • Cholinergic drugs should be avoided in people who have breathing problems such as asthma or chronic bronchitis. • To decrease the risk for side and adverse effects of any spilled ophthalmic drug, make sure to wipe any excess drug from the skin rather than let it absorb. • CAIs can cause severe neurologic or electrolyte imbalances and must be given with caution. • CAIs are not approved for children because they slow growth. They are not used during pregnancy or breast-feeding because these drugs are known to cause birth defects in animals. Review Questions for the NCLEX® Examination 1. A 78-year-old woman is prescribed 1 drop of 0.25% timolol (Timoptic ophthalmic) to her left eye every day for glaucoma. How does the LPN/VN teach the patient to perform digital nasolacrimal occlusion? 1. Teach the patient to gently press her index finger over the inner corner of her eye over her tear duct for 3 minutes after putting in the eye drop. 2. Teach the patient to press her index finger over the outer portion of her eye (between her eye and her cheek) for 3 minutes after putting in the eye drop. 3. Teach the patient to press her index finger over the inner part of her eye over her tear duct for 10 to 20 seconds after putting in the eye drop. 4. Teach the patient to press her index finger over the outer portion of her eye (between her eye and her cheek) for 10 to 20 seconds after putting in the eye drop. 2. A patient reports slight stinging after applying her eye drops for glaucoma. What is the nurse's best action