Wound Healing: A Complete Textbook of Medical Surgical Nursing PDF

290 _Juta’s Complete Textbook of Medical Surgical Nursing External factors. External factors are factors in the Nursing management of wounds environment that will impact on wound healing. These The aim of wound care is to promote healing. In assessing include:...

290 _Juta’s Complete Textbook of Medical Surgical Nursing External factors. External factors are factors in the Nursing management of wounds environment that will impact on wound healing. These The aim of wound care is to promote healing. In assessing include: and caring for wounds, nurses must ensure that they do The longer the patient's stay in hospital, the greater is the following: the risk for infection (nosocomial infection). * Identify factors that may interfere with wound healing, Preoperative preparation of the operative area is such as inadequate nutrition, impaired circulation and important. Patients must bathe before surgery to sensation, underlying diseases, prescribed medication, ensure hygiene. An antiseptic soap may be used to obesity, age of the patient, as well as pain experienced decrease the number of micro-organisms on the skin. * Note the anatomical position of the wound and in Maintaining the highest level of aseptic technique describing its size specify the sites and borders (sides). intraoperatively and during wound care decreases the This is important in predicting the duration of the risk of infection. healing process and to guide the choice of wound The wound care method must ensure protection of the dressing materials. For example, healing in areas with wound and encourage healing. good vascularisation is rapid, Unnecessary opening and cleaning of wounds * Classify the wound (acute, chronic, close, open, dirty, increase the risk of infection and delays healing. and clean). * Provide the size, shape and depth of the wound to AC ee eu Met Mattel) monitor the progress of healing. * Observe the wound exudates for amount, colour, Good nutrition, including adequate amounts of odour and consistency. vitamins A, B, C, K; minerals and proteins promote * Observe the wound edges and the skin around the Wound healing because: wound and note swelling, redness, pain and erosion. * Vitamin A is necessary for collagen production and growth of epithelial cells over denuded cells Management includes: Vitamin B complex is necessary for the proper * Cleaning functioning of enzymes * Debridement Vitamin C is necessary for collagen production * Wound closure with sutures, clips or skin closure and the formation of capillaries strips Vitamin K is important in normal clotting * Wound dressings Minerals (iron, copper, zinc) are necessary for © Skin grafting collagen formation * Antibiotics and anti-inflammatory medication. Protein and amino acids are tissue builders vital to the healing process. Wound cleaning Following injury, all wounds must be thoroughly cleaned Adequate rest, including immobilisation of the with plain water, sterile water or sterile sodium chloride affected part, prevents the disruption of the healing 0.9%, to wash away any dirt introduced at the time of process. Rest also allows nutrients and oxygen to injury. be available for healing rather than being used for Antiseptics containing iodine, hydrogen peroxide, energy-related activity. alcohol, hypochlorite, acetic acid and chlorhexidine (eg, Eusol, Povidone-iodine, Savlon®, chlorhexidine in Adequate exercise, either active or passive, is alcohol) should never be used on clean wounds, and important for the promotion of good circulation. should preferably not be used at all, even for dirty, infected Good circulation is essential, because blood contains wounds. Antiseptics remove bacteria from wounds, but all the necessary ingredients for wound healing, such damage fibroblasts, macrophages, capillaries and other ‘as amino acids, vitamins, calcium, phosphorus, etc. It cells found in wounds. The result of this is delayed wound is also responsible for the removal of waste products healing. Only sterile water or 0.9% sodium chloride of inflammation from the wound site. should be used for the care of clean surgical and other trauma wounds. Specific management for contaminated and infected wounds will depend on the state of the A summary of factors that delay wound healing are wound, the extent of contamination, and the severity of Pp resented in Table 16.4. wound infection,  Chapter 16 - Introduction to the disorders associated with cells and tissues 289 angiogenesis, granulation tissue development, and — Thyroxine originating from the thyroid wound contraction. Various cellular mediators cause — Glycogen originating from the pancreas. fibroblasts to migrate to the injured tissue or wound. The fibroblasts are normally found in the connective tissue, Wound healing may occur by one of the following and they are responsible for synthesising collagen. methods: Initially, the collagen that is deposited in the wound is ¢ Healing by first/primary intention occurs in wounds gel-like. It then cross-links to form collagen fibril which with minimal tissue loss and wound edges that are adds tensile strength to the wound. The wound is able to close to one another. This healing takes about 7 days withstand tension, stress and even twisting after about and a very thin scar results. An example of healing 2-3 weeks, by first/primary intention is a clean, surgical incision New tissue grows from surrounding healthy connective where the wound edges are held close together by tissue, The granulation is filled with small, fragile sutures, staples or clips. capillaries and appears red, translucent and granular. It * Healing by secondary intention occurs in wounds is sensitive to damage and bleeds easily. Epithelial cells with extensive tissue loss. Wound edges are usually at the wound margin migrate into the wound and cover far apart and cannot be brought together. The area in it. Wound contraction is noticeable about 7-12 days after the middle gradually fills with granulation and the injury, and is characterised by the edges of the wound wound heals from the edges inward. Healing time is being brought together by the myofibroblasts. Contraction longer and scarring is greater. The wound is also very of the skin is the result of movement of the epithelial cells prone to infection, since there is no epidermal barrier and the surrounding skin towards the centre of the wound to entry of micro-organisms. An example of wound in an attempt to close it. healing by this method is a pressure sore/ulcer. The final stage of wound healing is remodelling and * Healing by third/ertiary intention is also known as maturation, which starts around the 21st day of injury delayed secondary healing. This occurs when closure of and may continue for 2 or more years. The duration of the wound is undesirable due to infection. This type of this phase is dependent on the extent and depth of tissue healing results in wider and deeper scars, since suturing injury. The scar tissue formed undergoes reconstruction is usually delayed until conditions become favourable, by collagen deposition, lysis and debridement of wound for example, when the infection has cleared. edges. Capillaries disappear from the scar, leaving it white because of lack of blood supply. Factors affecting wound healing Internal factors. These are factors within the patient's Activity in the wound during the body that may accelerate or retard the healing of wounds. third phase These factors include: * Blood supply to the area. Adequate blood supply Specialised fibroblasts, the myofibroblasts, cause facilitates healing, while poor blood supply retards contraction that assists in moving the wound edges healing. to the centre of the wound * Immunological factors. Immune deficiency will The wound scar softens and fattens reduce the formation of antibodies and lymphocytes Tensile strength increases, but full tissue strength that are necessary to prevent wound infection. may in some instances never be regained. * Wound healing is delayed in malnourished patients. * Wound healing is delayed in patients with diabetes mellitus or infection and those on cancer therapy. Wound healing * Wound healing in the elderly may be delayed because Healing of wounds depends on: of causes such as atrophy of capillaries in the skin, * The degree of tissue loss decreased growth factors, nutrition deficiencies, etc. * Blood supply to the area * Adipose tissue has limited blood supply, decreasing * Nutritional status of the patient nutritional supply for wound healing, which tends to * Hormones produced. These hormones include: retard wound healing in obese individuals. In obese Growth hormone from the pituitary gland. Growth patients the stress on sutured wounds is increased, hormone increases cell permeability for protein. and dehiscence (bursting) is a distinct possibility. The increased protein in cells of the wound area is * Smoking decreases the oxygen supply to the wound used for wound repair and contributes to hyper-coagulation. Cortisol from the adrenal cortex 288 _Juta's Complete Textbook of Medical Surgical Nursing Wound occurs 16.2 The four stages i Uo Cet iia) rg fee eel) ahd Inflammation There are four stages of pressure sores. They happen as follows: Proliferation and angiogenesis © Stage 1: Pressure area is red. This redness remains even after pressure is removed. Skin is intact. Wound remodelling and maturation Stage 2: Skin is broken. Lesion is superficial. Stage 3: Full-thickness skin loss. Subcutaneous Figure 16.2 Wound healing process tissue may be included. Stage 4: Full-thickness skin loss, through muscle, * Small blood vessels dilate and capillary permeability tendon and down to the bone. Various sinuses may increases, This results in the leakage of fluid and other present. molecules into the interstitium. * Neutrophils move into the wound, to. assist in preventing infection by phagocytosis. malnutrition, poor blood circulation to the tissues, use * Monocytes enter the wound and differentiate into of steroids and anti-inflammatory drugs. The aged are macrophages. Their function is to digest necrotic tissue at a higher risk for pressure ulcers, because of loss of and remove debris in the wound. Other functions of subcutaneous fat and decreased skin elasticity, combined the macrophages include inhibiting bacterial growth with poor nutrition and generalised atrophy of the skin. and releasing of growth factors that stimulate wound The thin, underweight patient and the obese patient healing. Macrophages also play a role in the induction are also at high risk for developing pressure ulcers (see of collagen synthesis. Chapter 10). * Platelets, activated by thrombin, release growth factors that stimulate healing. Inspection of pressure areas When inspecting pressure areas on a patient, the following The second phase is the reconstructive (fibroplastic should be noted: proliferative) and angiogenesis phase. Angiogenesis * Skin colour = observe for red mottled skin that does occurs within hours after injury, simultaneously with not return to normal colour when pressure is relieved the inflammatory process, The enzymes produced by * Note blistered or broken skin endothelial cells break down the basement membrane, * Note any exudate in areas where the skin is broken and the new epithelial cells build new vessels. As * Note any actual pressure ulcers = if a pressure ulcer is capillaries grow across the wound, blood flow to the present, observe the size and depth wound is increased, as well as nutrients and oxygen. This * Observe the appearance of the tissue: whether it is enhances tissue repair. healthy, inflamed, swollen, infected or necrotic. Fibroplastic proliferation begins on the third or fourth day following tissue injury, and lasts up to 14-21 days. Physiology of wound healing This phase consists of collagen deposition, continued The wound healing process is the body's normal response when a wound occurs. The process consists of three phases (see Figure 16.2): Lo the wound during the 1. Inflammation Pr Mor) 2. Fibroblastic proliferation and angiogenesis * Rapid growth of epithelial cells, producing a 3. Wound remodelling and maturation. protective covering for the wound * Formation of new capillaries, followed by the The first phase of the healing process is the inflammatory/ defensive phase, which occurs immediately after injury formation of granulation tissue and collagen synthesis and lasts about 3-4 days. It is intended to neutralise and Cross-linking and overlapping of the collagen destroy harmful agents, limit their spread and prepare fibres to increase the tensile strength of the wound the damaged tissue for healing. During this phase the and provide wound integrity following activities occur in the wound: Collagen fibres fill in the gaps in the wound and * Haemostasis — blood, serum proteins and clotting form a scar factors move into the wound. Fibrin enhances clot formation to seal off bleeding points.  Chapter 16 = Introduction to the disorders associated with cells and tissues 285 Table 16.2 General nursing care plan of a patient with disorders of the cells and tissues Pain/Swelling/Poor skin colour Nursing diagnosis * Discomfort and altered pattern of sleep related to pain and oedema secondary to the inflammatory process evidenced by reports of pain by the patient and observable swelling and redness of the skin Expected outcome — *_No pain No swelling Skin colour good Nursing * Put the patient on bed rest (rest aids the healing process by reducing oxygen demands) interventions and * Nursing interventions should be arranged such that unnecessary interruptions of planned rationale rest periods are avoided In order to promote comfort, the inflamed area should not be moved and should, where possible, be supported on a splint or pillow The inflamed extremity could also be elevated to relieve the oedema and pain Apply heat or cold to the inflamed areas to increase circulation and/or minimise oedema respectively Administer prescribed antiinflammatory drugs and analgesics to counteract fever Evaluation Patient comfortable, no complaints of pain Patient able to sleep throughout the night Oedema subsiding Cag Nursing diagnosis * Risk for knowledge deficit about the disease process Expected outcome —*_ Increased knowledge about the disease process Nursing * Explain the disease process and the importance of rest interventions and rationale Evaluation * Patient knowledgeable about the disease process MTT MC ria) Nursing diagnosis * Potential for wound infection secondary to cell injury * Potential for fluid volume deficit secondary to fluid loss through diaphoresis and fever Expected outcome — *_No evidence of infection Vital signs normal Fluid intake adequate Nursing * Apply aseptic technique principles throughout wound care interventions and Prevent transmission of pathogens between patents by washing hands in between patient rationale care Administer prescribed antibiotics Monitor and record vital signs to detect and treat infection early if present Give a diet high in calories, vitamins and minerals to facilitate the healing process fee fluid intake to replace loss through diaphoresis and to eliminate toxins from the 0 ehion and record fluid intake and output Monitor and record vital signs 4-hourly Evaluation Patient taking in fluid adequately Vital signs normal 284. Juta’s Complete Textbook of Medical Surgical Nursing and loss of function. Abnormal cell growth manifests by oxygen deficit to cells and tissues as a result of respi- the presence of tumours. It is important to obtain the ratory or cardiac failure and anaemia (decreased history of the onset, duration and the characteristics of oxygen carrying capacity) the presenting tumours, * Physical injury: trauma, heat or cold injury, irradiation * Injury caused by chemicals such as metals, drugs and Diagnostic studies solvents The following diagnostic studies may be done for the * Damage as a result of autoimmunity and genetic defects purpose of identifying the specific irritant or stressor * Excess or deficiencies in nutritional intake of iron and producing inflammation secondary to cell injury, These vitamins. diagnostic studies are also used to find how well the body's defences are reacting: Cell injury may be reversible or irreversible. Reversible * Haematological studies, such as a full blood count, cell injury is not lethal and it can be corrected by removal blood culture and erythrocyte sedimentation rate of the stimulus, while irreversible injury is lethal and (ESR) are done, These tests can be repeated to monitor cannot be corrected, The death of cells is called necrosis the patient's response to treatment. and it results from disease processes. * A swab specimen of the exudate or body fluids may be sent for microscopic culture and sensitivity test Adaptation of cells to injury to determine the specific micro-organisms causing The cell has the capacity to adapt to injury in order to the infection. This test also helps in choosing the maintain homeostasis and to ensure its viability. This appropriate antibiotics, adaptation occurs when the stimulus is continuous/ * A biopsy of the tumour is done by the physician to persistent or when the cell cannot withstand the stimulus determine if the tumour is benign or malignant. without suffering some form of damage. * Radiological studies may be done by the radiologist to The capacity for adaptation and the sensitivity to help determine the location and the extent of inflam- different types of injury varies according to cell type. mation in certain body areas, for instance, inflammation For example, the myocardial cells and neurons are very in the bone tissue, lung tissue or in the veins. sensitive to ischaemic injury, while the liver cells are more sensitive to chemical injury. Nursing diagnoses Cells adapt by performing excess work, replicating, Alter assessment, the nurse may formulate the following. decreasing function or changing their differentiated nursing diagnoses (general nursing care plans for properties. The main adaptations to a persistent stimulus patients with cell and tissue disorders are summarised in may involve cellular hypertrophy, hyperplasia, metaplasia Table 16.2): or atrophy, The meaning of these adaptations are given in * Discomfort related to pain and oedema secondary to Table 16.3. the inflammatory process evidenced by reports of pain by the patient and visible swelling, Wounds * Risk for knowledge deficit about the disease process When the body’s cells or ti are injured, a disruption * Potential for fear of being isolated from the family and in their integrity occurs. This is known as a wound. To of disrupting family relationships related to reverse heal, the injured tissue has to go through a process of barrier nursing (if it becomes necessary, and if visitors recovery, regeneration, and replacement. are limited). The patient's fear or potential depression Recovery occurs when cells that were destroyed are may be due to knowledge deficit of the disease and of able to restore themselves with no evidence of permanent the nursing process. injury. This is known as localisation and resolution. When the injury has led to the death of cells or tissues Specific disorders associated with cells and (necrosis), the affected area will either heal by regeneration, sues or by replacement of the dead cells with new similar cells Cell injury and cell death in structure and function, for instance, grafts. Cells that Cell injury refers to the situation where the integrity of the do not regenerate following injury are the neurons of the cell has been compromised as a result of the following central nervous system and cardiac muscle cells. factors: Replacement of damaged cells by connective tissue is * Infection by viruses, bacteria, parasites, fungi and called scarring, which is a natural result of the process of other organisms tissue repi * Ischaemia (hypoxia): deficient blood supply or direct  Chapter 16 = Introduction to the disorders associated with cells and tissues 283 nutritionist or hospital dietitian should be involved in * creating a safe home environment in order to prevent planning the patient's diet. injuries, Increased fluid intake should also be encouraged, and the patientshould be given fluids high in calories, vitaminC, When the inflammatory response subsides and pus and potassium and protein to replace fluids lost through dead tissues have been removed, tissue repair (healing) diaphoresis (sweating). Increased fluid intake helps begins. The healing process consists of replacing lost cells to dilute and eliminate the toxins from the body. Strict with identical cells (regeneration) or with connective monitoring of intake and output and daily weighing must tissue (scar tissue formation). This is discussed further in be done to monitor the nutrition and fluid status during the section about wound and wound healing. inflammation. Nursing assessment and common findings Assisted bathing, bed baths and showering. These The nurse should obtain focused subjective and objective procedures should be encouraged for hygienic purposes data in order to identify the problems of the patient. and in order to help remove debris (such as dead cells) Always commence the assessment by establishing the from the inflammation, to lower the body temperature presenting complaint and its duration. The final diagnosis (tepid water may be used) and to promote comfort and ually the summary of the subjective and objective self-esteem. data based on the chief complaint. Prevention of cross-infection. Infection delays the healing Subjective data and repair of tissues, therefore all measures to prevent History taking transmission of pathogens between patients and nurses Subjective data collection should include general must be strictly enforced. These measures include hand biographical information, and should focus on the washing, aseptic technique, and isolation precautions presence of the specific risk factors mentioned earlier. The where necessary. The principles of aseptic technique must nurse should obtain the health history, family history and be applied throughout wound care, history of the causes of cell injury, such as exposure to chemicals, radiation and mechanical injury. Medical management Drugs that may be prescribed for management of The presenting symptoms. The presenting complaints, inflammation include the anti-inflammatory drugs, such as pain, redness and swelling, loss of function, analgesics and antibiotics as determined by microscopic abnormal growth or the presence of a wound should culture and sensitivity tests, be accompanied by enquiry into their duration and Depending on the extent of cell injury, there may be location. a need for suturing or debridement to facilitate healing. Where this is done, it is imperative for aseptic techniques Family history. Family history of neoplasms and other to be strictly applied. diseases of the cells and tissues should also be established. Essential health information Previous illnesses and treatment of diseases of the cells The inflammation and infection process must be and tissues. A history of serious or acute infection and explained to the patient to ensure that they understand trauma must be considered because these may alter the the importance of: properties of some cells. Trauma, surgery, radiotherapy * good nutrition to improve resis ance and speed up the or malignancy can result in the interruption of the cell healing process function and growth. * infection control measures such as hand washing, good personal hygiene, maintenance of a healthy Objective data lifestyle and prevention of trauma and infection Physical examination * first aid measures for minor tissue injuries such as A review of all the systems should be done through cuts, bruises and minor burns so that injuries are inspection, palpation, percussion and auscultation, The attended to immediately to prevent complications that physical examination elicits information regarding the may arise presence of systemic signs and symptoms of inflammation, * safe and aseptic application of wound dressings to which include pyrexia, tachycardia, tachypnoea, fatigue, prevent infection general malaise, anorexia, nausea and vomiting. The local signs may be those of hyperaemia, local warmth, swelling, 282 _Juta’'s Complete Textbook of Medical Surgical Nursing The fluid and fibrinogen that leak out through the Signs and symptoms of inflammation walls of the capillaries block the lymphatic vessels, thus Following cell injury, the inflammatory process is initiated delaying the spread of pathogens and other harmful and it is usually confined to a local area, where the patient agents to other parts of the body. will experience pain, swelling, redness, heat, and loss of This is nature's way of containing cell injury by function. localising inflammation, In some cases, local injury can cause systemic The bone marrow is, in the meantime, stimulated to manifestations when the chemical mediators are released increase the rate of production of leukocytes (leukocytosis) into the circulation, The systemic manifestations include such as granulocytes, macrophages and neutrophils. fever, tachycardia, anorexia, malaise, painful, and This ensures that their supply is adequate and available palpable nodes. to engulf and destroy bacteria and foreign particles at the site of inflammation, through a process known as Nursing management of inflammation phagocytocis. Rest. This is when the patient is placed on restricted The debris produced at the site of inflammation activity or bed rest. Rest aids the healing process by consists of tissue fluids and dead cells, as well as their reducing oxygen demand. In order to promote comfort, products, referred to as exudate. The type, nature and the inflamed area specifically should not be moved. The quantity of exudates depend on the type and severity of importance of rest should be explained to the patient and cell injury. rest periods planned. Nursing interventions should be organised so that unnecessary interruptions of planned Types of exudate rest periods are avoided, A sign may be put on the patient's Serous exudate. Serous exudate is seen in the early stages door to remind other staff members not to disturb planned of inflammation. It consists of fluid with small quantities of rest periods, dead cells. Examples of serous exudate include blister: pleural fluid. Inside wounds, exudate has anti-microbial Elevation of the affected part. Elevation of the part properties and therefore serves to clean and protect the relieves the oedema and pain, It also increases the venous wound and provide a moist environment to prevent return, thereby improving circulation. The extremities, dehydration and necrosis thereof. head, and neck are body parts that can be elevated with ease, Care must be taken to ensure that the whole part is Purulent/suppurative exudate. This consists of leukocytes, elevated, for instance, when an inflamed foot is elevated, dead or living micro-organisms, dead cells and debris the entire leg should be elevated higher than the level of This exudate is also known as pus, and is present in the heart. Use pillows, bed elevators, back rests and other abscesses and boils. Purulent exudate may be yellow, positioning devices to achieve thi green or brown depending on the causative organisms. Application of heat. Applying heat to the inflamed area Catarrhal exudate. This type of exudate is found in causes vasodilatation, thereby increasing circulation and inflammation of mucus-producing tissues in the respiratory thus an increased supply of leukocytes to the area. The tract manifested by a runny nose or rhinorrhoea, and is heat also helps in muscle relaxation, thereby relieving common with infections of the respiratory tract. pain. Heat can be applied in both dry and moist forms. Care must be taken not to inflict burns on the patient. Haemorthagic exudate. Haemorrhagic exudate occurs when there is injury and/or necrosis of the walls of blood Application of cold. A cold application decreases vessels. The colour of the exudate is either bright or dark inflammation by constricting the blood vessels, reducing red, indicating arterial or venous bleeding, respectively. blood flow to the area, slows nerve conduction, and relieves pain. Nomenclature relating to inflammation The suffix ‘itis’ is used at the end of the name of an Nutrition. Fever increases the body’s demand for calories organ to indicate inflammation, for example, bronchitis and fluids. For this reason, a patient with an inflammatory is the inflammation of the bronchi; conjunctivitis is condition should be put on a diet that is high in calories, inflammation of the conjunctiva of the eye; and cellulitis vitamins, minerals and proteins. The meals should be is inflammation of the cells or tissues, digestible, and food should be served in small quantities and at frequent intervals to promote appetite. The  Chapter 16 - Introduction to the disorders associated with cells and tissues 281 Classification of the disorders of cells and depends on the voltage, tissue resistance and the tissues pathway of the current as it passes through the body. The classification of the disorders of cells and tissues is * Micro-organisms such as bacterial endotoxins attack done according to the causative factors. The conditions the macrophages and T-cells while the exotoxins. affecting cells and tissues are caused by injury to the cells target specific cells such as the neurotoxins. Viruses and abnormal cell growth. The conditions include cell attack specific receptors on the surface of the injury, cell death, burns, wounds and tumours. Burns are host cells and damage them by depriving them of discussed in Chapter 50. nutrients. The cells die as a result or may transform into a tumour state. In malignancy, there may be Risk factors infiltration into or replacement of the normal cell by Risk factors for injury or death of cells include the the malignant cell, following: * Natural degenerative processes in the elderly cause * Hypoxia or hypoxaemia causes inadequate cellular cells to die. oxygenation. Hypoxia interferes with the cell's ability * Auto-immunity causes the immune system to destroy to function. The length of time various cells and tissues normal cells. can survive without oxygen differs; for example, brain cells can survive for 3-4 minutes, while other vital Pathophysiology organs can survive much longer, provided they are When the cells are Injured)’ they loge theiP'iniegrity-and harvested while the donor (although brain dead) is ability to function; injury: or death of body, cells ‘can be still alive. caused by one or more risk factors stated earlier * Nutritional deficiency or excess of one or more of the essential nutrients such as proteins and vitamins can Cell response to injury cause cell damage. Inadequate glucose or insufficient The inflammatory response oxygen to transform glucose into energy results in an In the event of cell injury, the healthy cells and tissues energy deficit that can cause cell injury. adjacent to the site of injury react defensively, and ¢ Extreme hot temperatures increase metabolic reactions this response is called ‘the inflammatory response or and cause cell damage by coagulating cell proteins. inflammation’. Inflammation is defined as an acute non- This can cause permanent damage and is the case in specific physiological response by the body to tissue burns. Cold temperatures cause vasoconstriction and injury. decrease blood flow to the tissues. It also causes stasis The inflammatory response is intended to neutralise of blood, clot formation with resultant ischaemia and destroy harmful agents, limit their spread to other and necrosis, for instance, in frostbite. The extent tissues, and prepare the damaged cells for healing. The of cell injury depends on the temperature and the damaged cells release chemical mediators, such as duration of exposure to or contact with the untoward histamine, kinins and prostaglandins into the blood for temperature, circulation throughout the body. The chemical mediators * lonising radiation changes cell structure and enzyme serve as messengers to various organs and tissues of the synthesis. Some cells are more sensitive to radiation immune system. than others. Reproductive cells and those in lymph Events involved in the process include changes in nodes and gastro-intestinal tract are highly sensitive. blood flow and vessel permeability, as well as movement * Chemical injury disrupts cell metabolism. The of leukocytes from the vessel into the tissues. Blood damage depends on the toxicity and the strength of vessels at the site of cell injury constrict momentarily the chemical, as well as the susceptibility of the cells and then dilate in response to the release of chemical involved. Arsenic, lead, cyanide, pesticides, carbon mediators from the injured cells. The result is that more monoxide, alcohol and bacterial exotoxins are some blood (hyperaemia) will flow to the damaged area and it of the chemicals that cause injury to cells and tissues. will be flushed or red in colour. * Mechanical injury causes cells and tissues to rupture. The walls of the capillaries become more permeable Abrasions and lacerations are causes of mechanical and allow water and proteins to move out of the blood injury. into the surrounding tissues. This leakage of fluids into * Excessive light and noise can cause damage to the the spaces around the cells produces swelling (oedema), cornea and the ears respectively. which exerts pressure on the nerves, causing pain and * Electrical injury destroys cells by the heat it generates limitation or loss of function of the affected area. and the burns it causes. The extent of the cell injury  280 _Juta’s Complete Textbook of Medical Surgical Nursing The nucleus is a structure in the cell that is surrounded * Carry out specialised functions such as conduction or by a double membrane known as the nuclear envelope. transmission of stimulus from one part of the body to It contains the genetic material of the cell in the form of another. chromatin threads composed of deoxyribonucleic acid (DNA). The DNA in the nucleus cannot pass through Tissues and organs the nuclear envelope into the cytoplasm. Within the The cells that function together are called tissues, and nucleus, one or more nucleoli are found, These contain tissues form organs. The types of cells that form an organ the ribonucleic acid (RNA) which transmits information are as follows: from the DNA to the ribosomes in the cytoplasm, * Epithelial cells are arranged in layers, They form the outside covering of the body and absorptive linings of The cytoplasm is composed of mainly water, electrolytes, the body cavities. Examples include the skin, linings of lipids and organic molecules. Electrolytes within blood vessels, mucous membranes. the cytoplasm maintain the pH of the intracellular * Nerve cells are highly specialised, conductive and environment, The common intracellular electrolytes are irritable cells. Examples are neuron and glial cells. potassium, phosphate and magnesium. The cytoplasm is * Muscle cells are responsible for body movement, organised into many subunits known as organelles which because of the ability to contract and relax. Examples carry out cellular functions as indicated in Table 16.1, are smooth, cardiac and skeletal muscles. * Connective cells are supportive to other cells and Functions of the cell tissues. Examples are bone, cartilage, tendons and The cells perform the following functions: blood. * Take in nutrients from food, and convert the nutrients into energy An organ has different tissues where each tissue has a Protect the body from injury, eg epithelial cells specific function to perform, eg the heart has muscle tissue, ee Provide movement to the body, eg muscle cells connective tissue, pericardium, endothelium and many Maintain homeostasis other specialised tissues that work together to complete a function. Tissues are each made up of similar cells. eee Responsible for multiplication/reproduction (growth) Responsible for the elimination of waste products Table 16.1 Cytoplasmic organelles enn nn GN as es AFs I Covers the contents of the cell Separates the intracellular and the extracellular fluid Regulates the movement of substances in and out of the cell Maintains the structure of the cell Lipid and steroid production Bile conjugation Detoxification of unnecessary cell substances Protein synthesis Contains RNA and protein Synthesises polypeptides * Flat membrane sacs which contain and store packages of proteins Sacs of membrane containing enzymes that break down ingested material Membranous sacs that transport and store material Cellular respiration Transforms energy from glucose or lipids into adenosine triphosphate (ATP) Hollow tubes/rod-like structures of protein that give structural support to cells  iy Management of disorders of the ear, nose and throat LEARNING OBJECTIVES On completion of this Chapter, the learner should be able to: describe the causative factors, pathophysiology, clinical manifestations and pharmacological management of medical and surgical disorders of the ear, nose and throat relate the pathophysiology of conditions of the ear, nose and throat to the clinical manifestations accurately assess patients with medical and surgical disorders of the ear, nose and throat accurately interpret assessment findings including results from diagnostic tests done in the diagnosis of medical and surgical disorders of the ear, nose and throat effectively plan and implement appropriate care for patients presenting with medical and surgical disorders of the ear, nose and throat: — carry out a nursing assessment on the patient — specify nursing objectives for the patient — draw up an individualised nursing care plan for the patient — implement nursing care for the patient — evaluate the results of care © effectively manage emergencies and/or complications in patients presenting with medical and surgical disorders of the ear, nose and throat. Pea MOD RLU el kelyf adenoiditis An infection and inflammation of the adenoids. CUE Taritttityas) A hypersensitivity reaction caused by airborne substances such as pollen, dust or UAC Cg moulds. COTE Ce] Loss or absence of the sense of smell. auricle The outer part of the external ear, which is attached to the cranium. It collects and directs sound waves. CT) A yellowish-brown wax-like secretion found in the external auditory canal. Ty Accumulation of cerumen in the external auditory canal. The accumulated cerumen Ta sett) becomes hard and dry. Cie) A cysHike tumour or lesion in the middle ear, inner ear or mastoid air cells. The cyst is lined with squamous epithelium and filled with keratin debris. The tumour can destroy the temporal bone. A condition resulting from any interference with the transmission of sound impulses hearing loss through the external auditory canal, the eardrum and/or the middle ear.  wey Management of disorders of the integumentary system LEARNING OBJECTIVES On completion of this Chapter, the learner should be able to: * describe the impact of skin diseases on individuals * support patients with skin disorders through giving health information on the care, treatment and prognosis of the various skin disorders * discuss the various skin disorders, the risk factors related to these, the causal micro-organisms, the clinical manifestations, the lesion distribution and the nursing interventions thereof. KEY CONCEPTS AND TERMINOLOGY PT lic lCL ey Skin applications or additives to bath water to kill bacteria. antiseptics Skin applications or bath water additives which halt the growth of micro-organisms, allowing for the body to step up its own defence mechanism. Bullous Autoimmune skin disease characterised by blisters on the flexor surfaces of the arms, pemphigus legs, axilla and groin dit) Dry, cracking and inflamed skin at the corners of the mouth, usually associated with poor nutrition. Ty retry Hot or cold applications on an area to facilitate suppuration (hot compresses) or reduce swelling or pain (cold compresses). Thick suspensions of oil in water or emulsions in which medication may be added to treat bacterial or fungal skin infections. Non-greasy, non-staining semi-solid emulsions used to prevent crusting. Oily lotions used to soften the skin. Liquid applications with a water (suspension) or oil base (liniments). A form of cutaneous T-cell lymphoma that generally affects skin, presenting with an itchy rash. PDs Thick oil- or water-based pastes which, when applied, form a layer over the skin. PTeric Medicinal mixture of powders and ointments, which usually sticks to the skin when applied. suspensions Liquid preparations in which powder is suspended in water — these require shaking before use. 1060 Juta’s Complete Textbook of Medical Surgical Nursing Pharmacological management el nas This includes beta-blockers, prostaglandin analogues, adrenergic agonists and carbonic anhydrase inhibitors. Be careful of sulphonamide allergy. Drugs are the first-line therapy. Regular follow-up of IOP is essential, including gonioscopy; OCT of the retinal nerve After 1 hour, 2% Pilocarpine drops must be instilled in fibre layer thickness and optic nerve head analysis; and the eye. If the IOP is still > 35 mmHg, 50% glycerol perimetry to assess the patient's response to treatment. 1 g/kg must be given orally (beware in diabetics). Drug therapy is reviewed as needed. IVI 20% mannitol can be given IVI over 45 minutes if Indications for surgery include the following: glycerol is not tolerated. * Continued elevation of intraocular pressure despite maximum drug therapy An Nd:YAG laser peripheral iridotomy (PI) must be * Visual field loss despite patient compliance and performed as the cornea clears. The laser makes an maximum drug therapy opening through the iris to relieve the pressure in the * Non-compliance with the follow-up and drug therapy. posterior chamber. It creates flow of aqueous from the posterior chamber into the anterior chamber of the Specific procedures include trabeculectomy, visco- eye. A prophylactic YAG PI must also be done in the canalostomy, argon laser trabeculoplasty (elderly patients) other eye to prevent angle closure. and drainage implants (Express, Istent, Ahmed, Baerveltd or Molteno valves) to facilitate drainage of aqueous humour, Trans-scleral cyclophotocoagulation diode laser is critical to control progression of the condition and can be used in refractory glaucoma. prevent further damage of the optic nerve. Complications include transient acute elevation of * Side effects of the medication should be discussed intraocular pressure, iritis, peripheral anterior synechiae with the patient. If there is poor compliance due to and hypotony, blepharitis and, rarely, endophthalmitis. side effects, this should be brought to the doctor's attention to change to a different class of medication. Primary closed-angle glaucoma * Once vision is lost, nothing can bring it back, but with In this condition, the IOP is raised due to closure of the medication the vision that is still present can be saved. angle of filtration. The trabecular meshwork is occluded Patients must not stop the medication if their vision by the itis, which is pushed towards the cornea, thus does not improve, because by doing so they might obstructing the outflow of aqueous humour. lose more vision. * All family members over 40 should also be screened Acute closed-angle glaucoma for glaucoma. This is an ophthalmic emergency. The condition has an ¢ In patients with poor vision, time must be spent acute onset with severe nauseating pain in and around to make sure they are able to instil their drops by the eye and rapid loss of vision. The pupil may be mid- themselves, otherwise a caregiver must be taught how dilated or oval shaped. to do it. If not treated adequately and early the patient will become blind. Specific systemic diseases that affect the eye Systemic viral infections Emergency treatment These include measles, mumps, rubella, herpes zoster Patient must lie on their back. Give analgesia and and herpes simplex Clinical manifestations include antiemetic intravenously if possible, and call the conjunctivitis, keratitis, extraocular muscle palsy. The ophthalmologist. treatment is antivirals. Complications, especially in Decrease IOP medically with topical 1OP-lowering congenital rubella, are cataract, glaucoma and squint. drugs (timolol 0.5%) and dexamethasone qid. Systemic carbonic anhydrase inhibitor (acetazolamide) is given in el Tiree un a tablet (500 mg stat) and IVI (500 mg) form. Please note that viral infections such as Patient teaching in glaucoma herpes simplex can get worse if treated with * It is important to discuss the medication programme steroids. with the patient and family because drug therapy is lifelong. Compliance with treatment and follow-up  Chopter 52 - Management of disorders of the eye and vision 1059 * The patient should avoid doing harsh exercise for the — aqueous humour (AH) production and outflow is important first 2 weeks, after which light exercise like walking in understanding the different types of glaucoma. can commence. Normal exercise (running, gym, AH is produced by the ciliary processes in the posterior swimming) can be restarted after 4 weeks, chamber of the eye. It then passes through the pupil, and * If the patient experiences any pain after surgery, they drains through the trabecular meshwork into the canal of must notify the staff as cataract surgery is usually — Schlemm, and then into the episcleral blood vessels. The not painful. Pain on the first day may be due to high angle of the eye refers to the space between the cornea intraocular pressure. Pain on days 7-10, together with and the iris. It is in this space that the trabecular meshwork ared eye with swollen eyelids, may be due to infection. _ is lying 360° around the eye. To visualise this angle, a This should be brought to the ophthalmologist’s gonioscopy lens is place on the eye. By using mirrors and attention immediately because urgent treatment is reflection, the angle can be viewed on the slit lamp. needed to prevent blindness. * The patient must receive the postoperative medication — Glaucoma is classified as the following: prescribed by the doctor and instil it as prescribed, * Primary glaucoma. This may be open or closed angle which is usually 4 times a day for a month after surgery, glaucoma. * Secondary glaucoma. This usually occurs secondary Essential patient education to trauma or pre-existing ocular disease, such as Eye care is usually done by the patient. proliferative diabetic retinopathy. * Itis important for the patient to know the activities that * ~ Congenital glaucoma. In infants, this presents as a big should be avoided, such as those listed above. eye with a watery discharge and cloudy cornea. * A clean and damp soft facecloth should be used to remove discharge that may have dried around the eye, Primary open-angle glaucoma especially upon waking in the morning. The condition is usually bilateral, although it does not * Some redness of the eye and a scratchy feeling are — progress simultaneously in both eyes. The condition normal for the first 3 days, but the patient must not is progressive and insidious. There is an open angle rub the eye. of filtration and the patient is usually unaware of the * On removal of the eye shield, the patient may condition until visual impairment is advanced. The experience blurred vision, intraocular pressure is raised without pain (> 21 mmHg). ¢ Where suturing material was used, there may be — The visual fields are restricted, with loss of peripheral temporary astigmatism. vision. There may be blurring or ‘halos’ around lights, * The patient should consult the doctor ifthey experience _ difficulty in focusing and cupping, and pallor of the optic pain, a decrease in vision, floaters, flashing lights or disc due to longstanding raised intraocular pressure. increased redness. Risk factors Pere UL q These include the following: eG) © Age. This most commonly occurs in people 40 years Any patient experiencingii pain, severe or older. Ge ee uate] dave * Race. The incidence is higher among black African i people. endophthalmitis. If not treated, blindness can occur. * Familial. There is a tendency for this condition to run in families. * Association. There is a higher incidence in nearsighted Glaucoma (myopic) people. The term ‘glaucoma’ refers to a group of conditions that affect the optic nerve, all of which have common Management characteristics: raised intraocular pressure, cupping of the — This may be pharmacological or surgical, and aims at optic disc (head of the optic nerve) and restriction of the preventing further damage to the optic nerve. Screening, peripheral visual field. Normal IOP is between 10 and protocols needs to be in place checking IOP in everybody 21 mmHg. Glaucoma is the second most common cause _ over the age of 40. If the diagnosis is made early, vision of blindness in the world after cataracts. Physiology of loss can be prevented. 1058 _Juto’s Complete Textbook of Medical Surgical Nursing Causes are the following: Surgical removal of the lens can be done manually by * Cataracts may be congenital, hereditary or acquired. extracapsular cataract extraction (6-8 mm_ incision) * Age-related is the most common cause. or by phacoemulsification through a 2-3 mm incision. * Cataracts may follow trauma to the eye. The phaco breaks up the cataract in smaller pieces to * Cataracts may be associated with ocular inflammations be removed through a smaller wound. In actual fact, such as uveitis and metabolic disorders such as the lens content is removed from the capsular bag that diabetes mellitus is left behind for placement of an intraocular lens (IOL). * Risk factors include excessive exposure to sunlight, A new acrylic intraocular lens (IOL) in implanted into the excessive smoking and poor nutrition. capsular bag. Monofocal, multifocal or toric IOLs can be implanted to correct most refractive problems. The lens The onset is usually painless and gradual, but visual strength is determined preoperatively. This will correct the impairment normally progresses at the same rate in refractive error previously present and leave the patient both eyes over time. Changes in colour vision can occur able to see in focus without spectacles. Spectacles for with everything having a yellowish tinge. The patient reading may still be needed, however. experiences increasing difficulty seeing in dim light, and they may also report double vision. The opacity may Nursing management occur in more than one place in the lens so that light Specie preoperative care includes the following: rays may be split (light scattering) and give more than one Explaining the procedure to the patient will help to image (diplopia). A dense cataract can be seen with the calm them. Most cataract surgeries are done under naked eye as a white pearl in the centre of the pupil. local anaesthetic where the patient is awake, but must be able to lie flat on their back for about 30 minutes Assessment and not move their head or talk. They will hear some The most common tests include the Snellen visual acuity sucking noises as the phaco machine removes the test, red reflex test, ophthalmoscopy, and slit lamp lens, but they should not feel any pain. If they do, biomicroscopy. more local anaesthetic can be instilled. * Anticoagulant medication should not be stopped Surgical management prior to surgery, unless asked for specifically by the The anaesthesia used during cataract surgery can be one ophthalmologist. of the following: * Dilating drops are administered every 15 minutes for * Topical anaesthesia. This is done by instilling a local at least an hour before surgery. Usually Cyclomydril anaesthetic drop into the eye, providing pain relief. is used. In this instance the patient can still see and move the * Prophylactic antibiotics, corticosteroids and anti- eye, so good cooperation is needed. This is preferred in inflammatory drops are prescribed to prevent most cases, especially for patients on anticoagulants. postoperative infection. * Local anaesthesia. This is done by peribulbar block * The patient should be orientated to the environment, (PBB). A needle is inserted though the lower lid, and and excess furniture should be removed to prevent a local anaesthetic drug is injected under the eyeball the patient from bumping into it and/or falling to numb the eye, which will cause the vision and eye postoperatively, because the operated eye will be movements to decrease temporarily. Complications patched after surgery. include retrobulbar haemorrhage. * Retrobulbar block (RBB). A longer needle is used to Specific postoperative care inject a local anaesthetic drug behind the eyeball to * The patient should not lift their head suddenly. numb the eye’s vision and movement temporarily. * The patient should avoid straining and_ stooping, * Sub-Tenon's block. A small opening is made through lifting, or pushing or pulling as these may increase the the conjunctiva. A local anaesthetic drug is injected intraocular pressure. witha specifically curved needle under the conjunctiva * A stool softener may also be recommended to avoid to reach the posterior part of the eyeball. Vision and straining when going to the toilet. eye movements are temporarily blocked. * A cotton eye pad during the day and a hard plastic * General anaesthetic. The patient is anaesthetised shield during the night should be placed on the eye in during the surgery. This is usually done in children the first 24 hours to protect it from accidental rubbing. because they cannot lie still In time, the shield can be replaced with spectacles,  Chapter 52 - Management of disorders of the eye and vision 1057 Activity of the condition may cease spontaneously at Types of squint any stage so that some vision is retained. Prophylaxis is 1. Esotropia. Inward turning of the eye important. High concentrations of arterial oxygen should 2. Exotropia. Outward turning of the eye be avoided. It is important to check blood saturation in 3. Hypertropia. Upward turning of the eye premature infants regularly. It should be around 91% and 4. Hypotropia. Downward turning of the eye. not 100%. Monitoring the peripheral retina with an indirect ophthalmoscope should be performed from 4 weeks. If The clinical manifestations of squint include the following: signs of retinopathy are present, the examination should * Adeviated eye be repeated weekly or at 2-weekly intervals to detect * Decreased vision and amblyopia (lazy eye), or progression. If progression is noted, photocoagulation or diplopia cryotherapy of abnormal vessels should be carried out. If * Turning of the head to try to compensate for diplopia. left untreated, the baby can go blind. In children, a poor self-image may result. Squint Deviation (not looking straight) can occur in one or both Treatment is directed at improving vision: eyes. The development of normal binocular (3D) vision * Spectacles if a refractive error is present depends on two eyes looking at one object to decide how * Amblyopic eye management by occlusion of the better far it is. Ina child with a squint, depth perception is very eye to encourage the use of the lazy one poor, and the earlier the squint is treated, the better are the * Surgery of the extraocular muscles to straighten the chances of improving this. A squint can be due to a motor eye(s). imbalance (inherited) or visual impairment (refractive errors, cataract, retinoblastoma, etc). (See Figure 52.5.) Regular and long-term follow-up of such a child is Ae — essential with a multidisciplinary team, which comprises an orthoptist, ophthalmologist, optometrist, ophthalmic ce Ss + Etotropia nurse and parent/family of the child. Aa a Aids and the eye LS - Exotropia Aids is manifested in the eye by the occurrence of Kaposi's sarcoma or opportunistic infections, the most common being herpes zoster ophthalmicus, cytomegalovirus. Figure 52.5 Squints - One visual axis is directed toward retinitis, and squamous cell carcinoma of the conjunctiva. a fixed object while the other deviates from the point Ocular complications occur in about 75% of Aids patients. Kaposi’s sarcoma is seen as a bright red mass and is found mainly on the lower eyelids. Squamous cell carcinoma oT uc presents as a growth on the conjunctiva that looks like Itis never too early to refer a child with a a pterygium. Where HIV/Aids infection is prevalent, squint to an ophthalmologist. Retinoblastoma all lesions such as uveitis, herpes zoster with pain and can also present with a squint. Every child with a typical vesicular rash should be suspected of being a squint should have a dilated fundoscopy and a secondary to it. Vitritis is common with cytomegalovirus retinitis. refraction test. Management Kaposi’s sarcoma is treated with radiation, Herpes zoster is treated with local and systemic antiviral drugs pe Ue out like acyclovir and not with steroids. Cytomegalovirus is Administration of oxygen must be carefully treated with intravitreal ganciclovir, monitored in premature babies and kept at 91%, not 100%. This is a serious medicolegal Cataract condition that if the condition is not screened for The term ‘cataract’ denotes clouding or opacity of the and treated, all medical personnel involved with the crystalline lens. The World Health Organization lists caring of the baby could be sued for negligence. cataract as one of the leading cause of treatable blindness. in the world. 1056 _Juta’s Complete Textbook of Medical Surgical Nursing Perot removal with auto Conjunctiva * Removing the diseased Pterygium g conjunctiva and transplanting a healthy piece from the superior part onto the area that was removed * The graft is fixed with either sutures or fibrin glue Pe ora Diabetic retinopathy can be divided into the following three categories: All diabetic patients should have their eyes 1. Background retinopathy. Microaneursyms, hard checked yearly by an ophthalmologist. exudates, dot and blot haemorrhages 2, Preproliferative retinopathy. Cotton-wool spots, intra-retinal microvascular abnormalities (IRMA) Miscellaneous eye conditions 3. Proliferative retinopathy. Neovascularisation in the Retinopathy retina due to ischaemia The retinopathies are a group of conditions that affect the retina and are a combination of inflammation, Complications include diabetic macular oedema, vitreous degeneration and neovascularisation. haemorrhage, traction retinal detachment, rubeotic or neovascular glaucoma and blindness. Hypertensive retinopathy This disease affects the blood vessels in the retina due to Management high blood pressure. Hypertensive retinopathy is graded This includes controlling the diabetes mellitus and doing as follows: panretinal photo coagulation to eliminate abnormal * Grade 1 (mild retinopathy). Arteriolar narrowing blood vessels. The patient may need vitreoretinal surgery (generalised and focal), AV nicking, and/or arteriolar to treat vitreous haemorrhages and retinal detachment. wall opacity. * Grade 2 (moderate retinopathy). Retinal Retinopathy of prematurity (ROP) haemorrhages, micro-aneurysms, cotton-wool spots, This is a proliferative retinopathy typically affecting and/or hard exudates. premature infants exposed to high ambient oxygen * Grade 3 (malignant retinopathy). Moderate retinopathy concentrations. The condition occurs most frequently plus optic disc swelling, usually also blurred vision. in infants who weigh less than 1 500 g at birth or were Management entails treating the hypertension. In grade born before 32 weeks of gestation. It is usually bilateral, 3 with disc swelling, the patient should be referred to and the severity of involvement of the eyes may be an emergency department due to the imminent risk of asymmetrical. The remaining blood vessels dilate and brain swelling and loss of consciousness. No treatment become torturous, and the capillaries proliferate and is given specifically for the eyes. grow into the vitreous. The retina can detach. Retinal and vitreous haemorrhages can be seen. In the most severe Diabetic retinopathy form, the retrolental space is filled with fibrous tissue This is one of the leading causes of blindness in the world. (hence the older name: retrolental fibroplasia). Formation Most diabetics develops some blood vessel involvement of a retrolental membrane may occur. after 10 years of diagnosis. Blindness will develop if left untreated. However, the condition is never seen before Staging puberty in Type | (insulin-dependent) diabetes mellitus. * Stage 1: a demarcation line is present Retinal blood vessel disturbance can be due to the * Stage 2: a ridge develops destruction of pericytes and endothelial cells leading * Stage 3: extraretinal fibrovascular proliferation occurs to leakage of large molecules. Microvascular occlusion © Stage 4: partial retinal detachment occurs, which will consequently lead to abnormal new ¢ Stage 5: total retinal detachment. vessel growth (neovascularisation).  Chapter 52 - Management of disorders of the eye and vision 1055 a Repair of retinal Retina Reattaching the retina by Rhegmatogenous retinal detachment/scleral buckling indenting the sclera from the detachment (retinal detachment outside with an encircling caused by a retinal tear or silicone band hole) Vitrectomy: pars plana Vitreous Removal of the vitreous gel Rhegmatogenous retinal vitrectomy (PPV) from the posterior segment of detachment, proliferative the eye to release the traction diabetic retinopathy and off the retina and to replace it vitreous haemorrhage with either air, gas or silicone oil Enucleation Eyeball Removal of the entire eyeball Tumours like retinoblastoma or (cornea and sclera) melanoma Evisceration Eyeball Removal of the contents of the © Severe infection, eg eye, leaving the sclera sadephiialiniis © Severe penetrating ocular injuries Exenteration Eyeball and * Removal of the eyeball, Mancedsatanouscall orbital tissue orbital contents (peri-orbital carcinoma or advanced fat and extraocular muscles) retinoblastoma and eyelids © Only the bone of the orbit is left behind Dacryocystorhinostomy Lacrimal Dilating the lacrimal drainage * Epiphoria (watery eye) apparatus passage and inserting a tube * Blockage of lacrimal through the lacrimal passage apparatus into the nose * Nasolacrimal duct obstruction Yag laser capsulotomy Posterior part The Yag laser makes a hole Posterior capsule opacification of the lenticular through an opaque posterior after cataract surgery bag capsule to improve vision Intravitreal injections Vitreous cavity Insertion of a very small needle © Age-related macular through the sclera into the degeneration(AMD): vitreous to inject medication bevacizumab injections (Avastin) or ranibizumab (Lucentis) * Macular oedema: triamcinolone (steroid) Pan retinal laser Retina © The laser burns the retina to During PPV (pars plana photocoagulation (PRP) prevent it from detaching vitrectomy) * Also to stop abnormal blood For proliferative diabetic vessel proliferation in the retinopathy retina To encircle a retinal tear and prevent retinal detachment ” 1054 Juta’s Complete Textbook of Medical Surgical Nursing Table 52.5 Eye surgical procedures and their indications ert a YA) elt la} ATC) lens To remove the lens of the eye Cataract * Removal of the lens without Cataract a a removing the lens capsular ag This is done through a large incision 6 mm or larger Using a phacoemulsification Cataract a a machine to remove the cataract without removing the capsular bag This is done through a small incision (3.2 mm or smaller) Trabecular Drainage procedure to Open-angle glaucoma meshwork direct the Faw of aqueous humour (AH) out of the anterior chamber to under the conjunctiva © The AH under the conjunctiva causes it to al up (this is called a bleb) This is done to lower the intraocular pressure Iris Making an opening through * Acute closed-angle the iris to drain AH from glaucoma posterior chamber of the eye * Narrow angle glaucoma into the anterior chamber (AC) Trabecular Making an opening through Congenital glaucoma meshwork (TM) the TM into the canal of Schlemm, to lower the intraocular pressure Cornea Suturing the cornea to close lacerated cornea after the eye penetrating corneal injury Extraocular Re-implanting the muscles To correct eye deviation (squint muscles backwards onto the eyeball repair) in children or in adults (recession) or shortening the muscles (resection) Extraocular Moving the medial rectus To correct esotropia muscles muscles in both eyes further back on the eyeball Cornea Removal of the diseased host Severe corneal scarring/ cornea in a circular fashion keratoconus and transplanting donated corneal tissue in its place and suturing it together »  Chapter 52 - Management of disorders of the eye and vision 1053 52.2 When to consult an ophthalmolo: Visual acuity must be assessed before commencing treatment, where possible. It is recommended that an ophthalmologist be Blunt-force ocular trauma can cause complete eyelid consulted if one or more of the following signs and swelling, subconjunctival haemorrhage, corneal abrasion, symptoms appear: hyphaema, traumatic anterior uveitis, lens dislocation, * Decreased or sudden loss of vision vitreous haemorrhage, retinal tears detachment or globe * Double vision (seeing two objects when looking at rupture. Penetrating injuries can cause eyelid lacerations, one) conjunctival lacerations, cornea lacerations and scleral Eyes not looking straight (squint or lazy eye) lacerations. Penetrating injuries must be treated surgically. Seeing flashing lights Enucleation may be necessary in severe penetrating Seeing black spots ocular trauma, where the damage is so extensive, to Seeing halos or rainbows around lights avoid chronic bilateral sympathetic uveitis, which will Sensitivity to light ultimately lead to blindness. Additional treatment consists Pain in the eye or forehead, especially if it causes of antibiotics to reduce infection, mydriatics to rest the vomiting eye, and analgesics for pain. An eye shield may be used Redness of the eyes to protect the eye from light and dust. Feeling as if something is in the eye, such as sand Continuous tearing or watering of the eyes Loss of an eye Constant irritation of the eyes Loss of one eye may not cause complete blindness, but this An eyelid that droops is very serious for the patient, as in addition to affecting A-white or yellowish appearance in the pupil area vision, it will have an impact on their appearance and Bluntforce or penetrating eye trauma. self-image. Unless the eye is blind and causing pain, the patient will not accept removal without a great deal of Deep laceration opposition. The nurse will need to carefully explain the / through the reasons for the planned removal, and will need to support Distorted pupil upper lid the patient and their family. Counselling is essential. The \ nurse will need to reassure the patient that an artificial _ ar _/ Penetrating eye will be able to match the existing eye, and therefore “scleral laceration will not impact significantly on appearance. The artificial Base of iris it s eye can be inserted as soon as the socket has healed. Subconjunetival Table 52.5 outlines eye surgical procedures. Eyelid __ haemorrhage lacerati ‘ ~ Hyphaema laceration / Colones Penetrating cornea laceration Discourage the sharing of facecloths and Figure 52.4 Possible eye trauma towels to prevent eye conditions. Specific disorders of the eye Retinoblastoma can kill. All children under the age Congenital ocular conditions of five years visiting a medical facility should have Most congenital ocular conditions occur during the a red reflex test done in both eyes. If positive, refer embryonic stage of development. Ocular structures may immediately to an ophthalmologist. be absent or incomplete at birth. Trauma to the eye eT Uu Prompt care of common eye injuries may prevent visual impairment. Eye injuries are often associated with bodily Do not remove any protruding objects oy) (knives, thorns) from the eye. Always refer trauma, and it is therefore important to prioritise in cases such cases to the ophthalmologist as an emergency. of multiple trauma. The eye is often involved in head trauma, particularly if the orbit is fractured. Any of the Patients with penetrating injuries of the eye and structures of the eye may be involved. Evaluating and booked for theatre must be kept nil per os in treating life-threatening injuries first is paramount, then preparation for the general anaesthesia. the sight-threatening ones.  Chapter 52 - Management of disorders of the eye and vision 1045 Table 52.3 Degenerative ocular conditions Degeneration of the eyelids Entropion This is the turning inward of the lid; the condition may be congenital, due to ageing, or due to scarring following trauma to the eye, Treatment is surgical Ectropion This is eversion of the lower lid, usually bilaterally. The condition may be congenital or age- related, or may follow seventh nerve palsy. Signs and symptoms include watering of the eye, irritation and exposure keratitis. Treatment is surgical Degeneration of the conjunctiva Pinguecula This is a common benign lesion of the conjunctiva consisting of a yellowish white nodule on the bulbar conjunctiva in the area of the palpebral fissur