Focus on Glaucoma Relates to Chapter 22 Nursing

Focus on Glaucoma (Relates to Chapter 22, “Nursing Management: Visual and Auditory Problems, ” in the textbook) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc.

Glaucoma • A group of disorders characterized by § Increased IOP and consequences of elevated pressure § Optic nerve atrophy § Peripheral visual field loss Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 2

Glaucoma • Second leading cause of blindness • Leading cause of blindness in African Americans Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 3

Etiology and Pathophysiology • Balance between aqueous production and reabsorption needed for normal level of IOP • Glaucoma related to elevation of IOP Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 4

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Etiology and Pathophysiology • Primary open-angle glaucoma (POAG) § Most common type of glaucoma § Outflow of aqueous humor is ↓ in trabecular meshwork Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 6

Etiology and Pathophysiology • Primary angle-closure glaucoma (PACG) § Angle closure ↓ the flow of aqueous humor § Caused by age, pupil dilation § Possibly drug induced Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 7

Etiology and Pathophysiology • Secondary glaucoma § Results from other ocular or systemic conditions that block outflow § Associated with inflammatory processes Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 8

Clinical Manifestations • POAG § Develops slowly § No symptoms § Unnoticed until all peripheral vision is lost Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 9

Clinical Manifestations • Acute angle-closure glaucoma § Sudden excruciating pain around eyes § Nausea and vomiting § Seeing colored halos around lights § Blurred vision § Ocular redness § Corneal edema Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 10

Clinical Manifestations • IOP elevated in glaucoma • Normal IOP 10 to 21 mm Hg • Open-angle glaucoma 22 to 32 mm Hg • Acute angle-closure glaucoma >49 mm Hg Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 11

Diagnostic Studies • Gonioscopy • Peripheral and central vision test • Ophthalmoscopy Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 12

Ophthalmoscopy Fig. 22 -8. A, In the normal eye, the optic cup is pink with little cupping. B, In glaucoma, the optic disc is bleached and optic cupping is present. (Note the appearance of the retinal vessels, which travel over the edge of the optic cup and appear to dip into it. ) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 13

Collaborative Care • Chronic open-angle glaucoma § Drug therapy § Argon laser trabeculoplasty Therapeutic option to lower IOP Laser stimulates scarring and contraction of trabecular meshwork Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 14

Collaborative Care • Chronic open-angle glaucoma (cont'd) § Trabeculectomy Removal of part of iris and trabecular meshwork Aqueous humor percolates out area of missing iris Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 15

Collaborative Care • Chronic open-angle glaucoma (cont’d) § Implant § Reserved for patients in whom filtration surgery has failed § Permanent surgical placement of small drainage tube and reservoir Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 16

Collaborative Care • Acute angle-closure glaucoma § Miotics § Oral/IV hyperosmotic § Laser peripheral iridotomy § Surgical iridectomy Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 17

Collaborative Care • Secondary glaucoma § Managed by treating underlying problems § Antiglaucoma medication Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 18

Nursing Management Nursing Assessment • Assess patient’s ability to understand comply with treatment. • Assess patient’s psychologic reaction to sight-threatening disorder. • Assess family for patient care. • Assess visual acuity, visual fields, IOP. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 19

Nursing Management Nursing Diagnoses • Risk for injury • Self-care deficits • Acute pain • Noncompliance Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 20

Nursing Management Planning Expected Goals § No progression of visual loss § Understanding of disease process and rationale § Compliance with all aspects of therapy § No postoperative complications Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 21

Nursing Management Nursing Implementation Health Promotion § Teach patient and family risks of glaucoma. § Stress importance of early detection. § Provide ophthalmologic examination. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 22

Nursing Management Nursing Implementation Acute Intervention § Administer medication to lower IOP. § Darken the environment. § Apply cool compresses. § Provide quiet space. § For surgical patients Provide postop instructions. Relieve discomfort. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 23

Nursing Management Nursing Implementation Ambulatory and Home Care § Encourage patient to follow therapy. § Educate on disease process and treatments. § Discuss follow-up appointments. § Provide verbal and written instructions. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 24

Nursing Management Evaluation Expected Outcomes § No further loss of vision § Compliance with recommended therapy § Safe functioning in the environment § No pain from disease and surgery Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 25

Audience Response Question When teaching a patient with primary open-angle glaucoma about the disorder, the nurse explains that: 1. The retinal nerve is damaged by an abnormal increase in the production of aqueous humor. 2. Aqueous humor cannot drain from the eye, causing pressure damage to the optic nerve. 3. As the lens enlarges with aging, it pushes the iris forward, covering the outflow channels of the eye. 4. The lens blocks the pupillary opening, preventing the flow of aqueous humor into the anterior chamber. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 26

Case Study 27 Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc.

Case Study • 67 -year-old woman comes to a community health screening complaining of “tunnel vision. ” • Sometimes she has very bad shooting pain in her eyes. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 28

Case Study • She has a history of hypertension, type 2 diabetes, and hyperlipidemia. • You insist that she see an ophthalmologist, but she insists that she sees “just fine” if she turns her head a lot. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 29

Discussion Questions 1. What can you teach the patient about the importance of seeing an ophthalmologist? 2. What other factors may influence her decision to seek treatment? Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 30

Discussion Questions 3. If she is diagnosed with glaucoma, what can you tell her about possible treatments? Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 31