MedicalSurgical Nursing Concepts Practice 3 rd edition Chapter

$Correcting Errors of Refraction Prescription eyeglasses or contact lenses Photorefractive keratectomy (PRK) LASIK (laser$

Normal Vision, Hyperopia, and Myopia Copyright © 2017, Elsevier Inc. All rights reserved. 4

Eye Disorders Uveitis Corneal disorders Ø Ø Keratitis and corneal transplantation (keratoplasty) Corneal ulcer

Keratoplasty and Acute Transplant Rejection Courtesy of Ophthalmic Photography at the University of Michigan,

Postoperative Care Recovery for 1 to 2 hours and then discharged home Pressure dressing

Postoperative Care (Cont. ) Instructions for safety Ø Ø May lie only on the

Eye Trauma Removal of foreign bodies Chemical burns Enucleation Ø Care of the artificial

Applying an Eye Patch Perform hand hygiene, and cleanse the skin of the patient’s

Applying an Eye Patch (Cont. ) Secure the patch by placing strips of tape

Applying an Eye Patch (Cont. ) For a pressure patch Ø Use two eye

Applying Eye Ointment Copyright © 2017, Elsevier Inc. All rights reserved. 13

Cataract Etiology Pathophysiology Signs and symptoms Diagnosis Treatment Ø Ø Extracapsular extraction Intracapsular extraction

Common causes-cataracts Age-related Trauma-penetrating injury Toxicity- long-term use of steroids or betablockers Congenital Diabetes,

Signs and symptoms Blurred vision Diplopia (double vision) Photophobia Visible opacity Absent red reflex

Cloudy Appearance of Eye with Cataract Courtesy of Ophthalmic Photography at the University of

Copyright © 2017, Elsevier Inc. All rights reserved. 1

General Care After Eye Surgery Always wash the hands before instilling medication. Be careful

General Care After Eye Surgery (Cont. ) Instill only the number of drops ordered;

General Care After Eye Surgery (Cont. ) Maintain designated head position and activity restrictions.

General Care After Eye Surgery (Cont. ) Keep the follow-up appointment with the surgeon.

Glaucoma Etiology Pathophysiology Ø Ø Ø Narrow-angle or angle-closure (acute) glaucoma Open-angle (chronic) glaucoma

Pathophysiology of Glaucoma Copyright © 2017, Elsevier Inc. All rights reserved. 24

Comparison of Open-Angle and Narrow -Angle Glaucoma From Lehne RA: Pharmacology for nursing care,

Open-Angle Glaucoma Signs and symptoms Diagnosis Ø Ø High risk for glaucoma Tonometer Treatment

Open- and closed-angle glaucoma Open- most common form Aqueous humor outflow is decreased due

Danger Signals of Glaucoma Glasses, even new ones, that do not seem to clarify

Danger Signals of Glaucoma (Cont. ) Seeing rainbow-colored rings around lights Narrowing of vision

Glaucoma Teaching Plan Signs of IOP include pain in eye, redness, tearing, blurred vision,

Glaucoma Teaching Plan (Cont. ) Need to take prescribed medications and refrain from taking

Glaucoma Teaching Plan (Cont. ) Wear ID tag or bracelet stating “Glaucoma” and carry

Narrow-Angle (Angle-Closure) Glaucoma Signs and symptoms Diagnosis Treatment Nursing management Ø Teaching on activity

Treatment and Nursing Management Emergency treatment Ø Reduce IOP as quickly as possible. During

Retinal Detachment Etiology Ø Ø Primary retinal detachment Secondary retinal detachment Pathophysiology Signs and

Retinal Detachment (Cont. ) Copyright © 2017, Elsevier Inc. All rights reserved. 38

Treatment of Retinal Detachment Laser therapy Cryotherapy Scleral buckling Closed vitrectomy removes the cloudy

Retinopathy Etiology Pathophysiology Ø Proliferative and nonproliferative retinopathy Signs and symptoms Diagnosis Treatment Nursing

Macular Degeneration Etiology Pathophysiology Signs and symptoms Diagnosis Treatment Nursing management Copyright © 2017,

Wet and dry Dry MD: most common form, caused by gradual blockage of retinal

Expected findings Lack of depth perception Objects appear distorted Dark spot in center of

Low-Vision Aids Support group Illumination and magnification of reading material Books with large print

Preoperative Care of the Patient Having Eye Surgery Patient and family teaching Preoperative eyedrops

Postoperative Care of the Patient Having Eye Surgery (Cont. ) The key word is

Patient with Eye Patch Copyright © 2017, Elsevier Inc. All rights reserved. 51

Instilling Eye Drops Copyright © 2017, Elsevier Inc. All rights reserved. 52

Resources for the Vision Impaired Self-care, employment, education, and recreational activities Readers and tape

External Otitis Etiology and pathophysiology Signs and symptoms Diagnosis Treatment Nursing management Copyright ©

Impacted Cerumen and Foreign Bodies Irrigating an ear canal Ø Ø When irrigating an

Otitis Media Etiology Pathophysiology Signs and symptoms Diagnosis Treatment Nursing management Copyright © 2017,

Labyrinthitis Etiology Pathophysiology Signs and symptoms Diagnosis and treatment Nursing management Copyright © 2017,

Ménière’s Disease (Ménière’s Syndrome) Etiology Pathophysiology Signs and symptoms Diagnosis Treatment Nursing management Copyright

Acoustic Neuroma Rare benign tumor on the eighth cranial nerve, usually unilateral Symptoms are

Otosclerosis and Hearing Loss Etiology and pathophysiology Signs, symptoms, and diagnosis Treatment Ø Ø

Nursing Care of the Patient Having Ear Surgery Preoperative care Postoperative care Home care

An Ear Surgery Dressing Copyright © 2017, Elsevier Inc. All rights reserved. 63

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$Correcting Errors of Refraction Prescription eyeglasses or contact lenses Photorefractive keratectomy (PRK) LASIK (laser$

Correcting Errors of Refraction Prescription eyeglasses or contact lenses Photorefractive keratectomy (PRK) LASIK (laser in situ keratomileusis) Radial keratotomy Copyright © 2017, Elsevier Inc. All rights reserved. 3

Keratoplasty and Acute Transplant Rejection Courtesy of Ophthalmic Photography at the University of Michigan, W. K. Kellogg Eye Center, Ann Arbor, MI. Copyright © 2017, Elsevier Inc. All rights reserved. 6

Postoperative Care Recovery for 1 to 2 hours and then discharged home Pressure dressing and eye shield Nursing actions focus on disturbed sensory perception (visual) Copyright © 2017, Elsevier Inc. All rights reserved. 7

Postoperative Care (Cont. ) Instructions for safety Ø Ø May lie only on the back and nonoperative side postoperatively Graft rejection is a possibility and is heralded by inflammation beginning near the graft edges. It must be reported promptly. If the first transplant fails, the procedure can be redone. Copyright © 2017, Elsevier Inc. All rights reserved. 8

Applying an Eye Patch Perform hand hygiene, and cleanse the skin of the patient’s forehead and cheek with a skin prep solution or pad. Prepare strips of nonallergenic paper or other tape to secure the patch. Ask the patient to close both eyes and position the pad over the lid of the eye to be patched. Copyright © 2017, Elsevier Inc. All rights reserved. 10

Applying an Eye Patch (Cont. ) Secure the patch by placing strips of tape diagonally over the patch from the cheek to the forehead. Use several strips of tape to ensure adhesiveness. After surgery, the shield is used for 2 to 6 weeks, depending on the surgeon’s instructions. Copyright © 2017, Elsevier Inc. All rights reserved. 11

Applying an Eye Patch (Cont. ) For a pressure patch Ø Use two eye patches. Fold the first one in half; place it over the closed eyelid and then place the other patch on top of the folded one. Apply tape as above. For sleeping Ø A plastic or metal eye shield may be placed over the eye and secured to further protect the eye. Often, the patch can be left off when the shield is placed for sleeping. Copyright © 2017, Elsevier Inc. All rights reserved. 12

Cataract Etiology Pathophysiology Signs and symptoms Diagnosis Treatment Ø Ø Extracapsular extraction Intracapsular extraction Nursing management Copyright © 2017, Elsevier Inc. All rights reserved. 14

Common causes-cataracts Age-related Trauma-penetrating injury Toxicity- long-term use of steroids or betablockers Congenital Diabetes, hypoparathyroidism. Down syndrome, chronic sunlight exposure Glaucoma 1

Signs and symptoms Blurred vision Diplopia (double vision) Photophobia Visible opacity Absent red reflex Increased nearsightedness 16

Cloudy Appearance of Eye with Cataract Courtesy of Ophthalmic Photography at the University of Michigan, W. K. Kellogg Eye Center, Ann Arbor, MI. Copyright © 2017, Elsevier Inc. All rights reserved. 17

General Care After Eye Surgery Always wash the hands before instilling medication. Be careful to check the label of the container of the medication to be certain it is the right medication. Do not contaminate the applicator tip of the medication. Copyright © 2017, Elsevier Inc. All rights reserved. 19

General Care After Eye Surgery (Cont. ) Instill only the number of drops ordered; apply pressure at the inner canthus to prevent systemic absorption; close the eye gently (do not squeeze the eye shut). Change the eye patch dressing at least once a day; change as needed to keep the area clean. Follow the medication schedule prescribed by the physician exactly (send home a written schedule). Copyright © 2017, Elsevier Inc. All rights reserved. 20

General Care After Eye Surgery (Cont. ) Maintain designated head position and activity restrictions. Report signs of complications, including sudden, increasing pain in the eye, which can indicate hemorrhage; purulent drainage; decreasing vision; and signs of increased intraocular pressure (IOP), such as brow headache. Copyright © 2017, Elsevier Inc. All rights reserved. 21

General Care After Eye Surgery (Cont. ) Keep the follow-up appointment with the surgeon. Use caution to prevent water in the eye when showering or washing hair. Protect the eye during the day with glasses; use sunglasses for outside wear; wear a protective eye shield at night to protect the eye. Copyright © 2017, Elsevier Inc. All rights reserved. 22

Open- and closed-angle glaucoma Open- most common form Aqueous humor outflow is decreased due to blockages in the eye’s drainage system, causing a gradual rise in IOP Closed- IOP rises suddenly, onset is sudden and requires immediate treatment Encourage an annual eye exam and good eye health, esp. for those over 40 1

Danger Signals of Glaucoma Glasses, even new ones, that do not seem to clarify vision Blurred or hazy vision that clears up after a while Trouble getting used to darkened rooms, such as in movie theaters Copyright © 2017, Elsevier Inc. All rights reserved. 28

Danger Signals of Glaucoma (Cont. ) Seeing rainbow-colored rings around lights Narrowing of vision at the sides of one or both eyes Encourage a complete eye examination if any of these signs is present. Copyright © 2017, Elsevier Inc. All rights reserved. 29

Glaucoma Teaching Plan Signs of IOP include pain in eye, redness, tearing, blurred vision, halos around lights, and a frequent need for change in eyeglasses. Measures to prevent increases in IOP include ingesting a low-sodium diet and little caffeine, preventing constipation and Valsalva maneuver, and decreasing stress. Copyright © 2017, Elsevier Inc. All rights reserved. 32

Glaucoma Teaching Plan (Cont. ) Need to take prescribed medications and refrain from taking over-the-counter or other medications without physician’s knowledge Glaucoma medication must be taken regularly for life. Use good aseptic technique when instilling eye medication. Copyright © 2017, Elsevier Inc. All rights reserved. 33

Glaucoma Teaching Plan (Cont. ) Wear ID tag or bracelet stating “Glaucoma” and carry card in wallet that states what medications are being taken. Keep extra bottle of eye medication on hand. Carry eyedrops. Maintain close medical follow-up with physician. Practice safety habits; avoid night driving if possible. Copyright © 2017, Elsevier Inc. All rights reserved. 34

Narrow-Angle (Angle-Closure) Glaucoma Signs and symptoms Diagnosis Treatment Nursing management Ø Teaching on activity precautions during healing, schedule for eyedrops, symptoms to report to the surgeon, and aseptic handling of the eyedrops and eye shield Copyright © 2017, Elsevier Inc. All rights reserved. 35

Treatment and Nursing Management Emergency treatment Ø Reduce IOP as quickly as possible. During the attack, use pilocarpine, topical epinephrine, and intravenous acetazolamide. Surgery is performed as soon as inflammation subsides to relieve pressure against the optic nerve endings. Copyright © 2017, Elsevier Inc. All rights reserved. 36

Treatment of Retinal Detachment Laser therapy Cryotherapy Scleral buckling Closed vitrectomy removes the cloudy vitreous humor and stabilizes the retina against the choroid. Nursing management Home care instructions Copyright © 2017, Elsevier Inc. All rights reserved. 39

Wet and dry Dry MD: most common form, caused by gradual blockage of retinal capillary arteries Wet MD: less common, caused by growth of new blood vessels with thin walls that leak blood Risk factors: smoking, diabetes, HTN, female sex, short body structure, family history, diet lacking carotene and vitamin E Wet can occur at any age 1

Expected findings Lack of depth perception Objects appear distorted Dark spot in center of vision Blurred vision Blindness Opthalmoscopy, visual acuity tests, Amsler grid 44

Low-Vision Aids Support group Illumination and magnification of reading material Books with large print Telescopic lenses Head-mounted low-vision enhancement system Watches with large numerals Copyright © 2017, Elsevier Inc. All rights reserved. 48

Postoperative Care of the Patient Having Eye Surgery (Cont. ) The key word is “gentleness. ” Discharge instructions Ø Ø Ø Medications Positioning and level of activity Sexual activity Community resources Copyright © 2017, Elsevier Inc. All rights reserved. 50

Resources for the Vision Impaired Self-care, employment, education, and recreational activities Readers and tape recorders to help with studies Encourage donation of corneas. Copyright © 2017, Elsevier Inc. All rights reserved. 53

Impacted Cerumen and Foreign Bodies Irrigating an ear canal Ø Ø When irrigating an ear canal, the water should be tepid. Cold water and too much irrigation pressure can cause dizziness and nausea as well as pain. Check the temperature of the water each time the syringe or irrigation container is refilled. Drape the patient so that the clothing does not become wet. Copyright © 2017, Elsevier Inc. All rights reserved. 55

Acoustic Neuroma Rare benign tumor on the eighth cranial nerve, usually unilateral Symptoms are gradual hearing loss and tinnitus Usually curable with surgery or stereotactic (Gamma knife, Cyber. Knife) radiotherapy If untreated, it causes deafness. Treatment is surgical. Copyright © 2017, Elsevier Inc. All rights reserved. 60

Otosclerosis and Hearing Loss Etiology and pathophysiology Signs, symptoms, and diagnosis Treatment Ø Ø Ø Hearing aid Microsurgical intervention Tympanoplasty Nursing management Copyright © 2017, Elsevier Inc. All rights reserved. 61