Nursing diagnoses

Focus Topic: Eye disorders

When caring for patients with eye disorders, you’ll find that several nursing diagnoses may be used over and over. These diagnoses are listed here, along with nursing interventions and rationales.

Eye disorders: Disturbed sensory perception (visual)

Related to a vision impairment, Disturbed sensory perception (visual) refers to the patient’s deprivation of environmental stimuli. It’s associated with near-sightedness, far-sightedness, diabetes mellitus, cataracts, detached retina, glaucoma, hemianopsia, macular degeneration, optic nerve damage, and blindness.

Expected outcomes

  • Patient performs self-care activities safely and within limits.
  • Patient uses adaptive and assistive devices.

Nursing interventions and rationales

  • Allow the patient to express his feelings about his vision loss. Allowing him to voice his fears helps him to accept vision loss.
  • Remove excess furniture or equipment from the patient’s room, and orient him to his surroundings. If appropriate, allow him to direct the arrangement of the room. This promotes patient safety while allowing him to maintain an optimal level of independence.

Skip the fine print

  • Modify the patient’s environment to maximize any vision the patient may have. Place objects within his visual field, and make sure he’s aware of them. Provide large-print books. Modifying the environment helps the patient meet his self-care needs.
  • Always introduce yourself or announce your presence when entering the patient’s room, and let him know when you’re leaving. Familiarizing the patient with his caregivers helps reality orientation.
  • Provide nonvisual sensory stimulation, such as talking books, audiotapes, and the radio, to help compensate for the patient’s vision loss. Nonvisual sensory stimulation helps the patient adjust to his vision loss.
  • Teach the patient about adaptive devices, such as eyeglasses, magnifying glasses, and contact lenses. A knowledgeable patient will be better able to cope with vision loss.
  • Refer the patient to appropriate support groups, community resources, or organizations such as the American Foundation for the Blind. Post-discharge support will help the patient and his family cope better with vision loss.

Eye disorders: Risk for infection

Related to eye surgery, Risk for infection refers to the patient’s risk of contracting an infection.

Expected outcomes

  • Patient has a normal temperature.
  • Patient develops no infection postoperatively.
  • Patient states that he understands postoperative care and the signs and symptoms of infection.

Nursing interventions and rationales

  • Minimize the patient’s risk of infection by performing hand hygiene before and after providing care and by wearing gloves when providing direct care. Hand hygiene is the single best way to avoid spreading pathogens, and gloves offer protection when handling wound dressings or carrying out various treatments.
  • Monitor the patient’s temperature. Report elevations immediately. An elevated temperature lasting longer than 24 hours after surgery may indicate ocular infection.

Keeping it clean

  • Use strict aseptic technique when suctioning the lower airway, inserting indwelling urinary catheters, providing wound care, and providing I.V. care. This technique helps prevent the spread of pathogens.
  • Teach the patient about good hand hygiene, factors that increase infection risk, and the signs and symptoms of infection. These measures allow the patient to participate in his care and help the patient modify his lifestyle to maintain optimal health.

Common eye disorders

Focus Topic: Eye disorders

Cataracts, glaucoma, retinal detachment, and vascular retinopathies are common eye disorders.

 

Eye disorders: Cataracts

A common cause of vision loss, a cataract is a gradually developing opacity of the lens or lens capsule of the eye. Cataracts commonly occur bilaterally, with each progressing independently. Exceptions are traumatic cataracts, which are usually unilateral, and congenital cataracts, which may remain stationary. Cataracts occur most frequently in patients over age 70. Prognosis is usually good, with surgery improving vision in 95% of cases.

What causes it

  • The cause of a cataract depends on its type:
  • Senile cataracts develop in elderly people, probably because of changes in the chemical state of lens proteins.
  • Congenital cataracts occur in neonates as a result of genetic defects or maternal rubella during the first trimester.
  • Traumatic cataracts develop after a foreign body injures the lens with sufficient force to allow aqueous or vitreous humor to enter the lens capsule.

It gets complicated

  • Complicated cataracts can occur secondary to uveitis, glaucoma, retinitis pigmentosa, or detached retina. They may also occur in the course of a systemic disease (such as diabetes, hypoparathyroid ism, or atopic dermatitis) or can result from ionizing radiation or infrared rays.
  • Toxic cataracts result from drug or chemical toxicity with ergot, naphthalene, phenothiazine and, in patients with galactosemia, from galactose.

Pathophysiology

Pathophysiology may vary with each form of cataract. However, cataract development typically goes through these four stages:

  • immature — partially opaque lens
  • mature — completely opaque lens; significant vision loss
  • tumescent — water-filled lens, which may lead to glaucoma
  • hypermature — deteriorating lens proteins and peptides that leak through the lens capsule, which may develop into glaucoma if intraocular outflow is obstructed.

What to look for

Signs and symptoms of a cataract include:

  • painless, gradual blurring and loss of vision
  • with progression, whitened pupil
  • appearance of halos around lights
  • blinding glare from headlights at night
  • glare and poor vision in bright sunlight.

What tests tell you

  • Ophthalmoscopy or slit-lamp examination confirms the diagnosis by revealing a dark area in the normally homogeneous red reflex.
  • Shining a penlight on the pupil reveals the white area behind it (unnoticeable until the cataract is advanced).

How it’s treated

Treatment consists of surgical extraction of the opaque lens and postoperative correction of vision deficits. The current trend is to perform the surgery as a 1-day procedure.

What to do

  • For patient teaching topics on cataract removal, see Cataract teaching tips.

Cataract teaching tips

  • After surgery, tell the patient to wear sunglasses that filter out ultraviolet rays in bright sunshine.
  • Explain that he should avoid activities that increase intraocular pressure, such as straining with coughing or bowel movements and lifting heavy objects.

Eye disorders: Glaucoma

The term glaucoma refers to a group of disorders characterized by abnormally high IOP that can damage the optic nerve. It occurs in three primary forms: open-angle (primary), acute angle-closure, and congenital. It may also be secondary to other causes. In the United States, glaucoma affects 2% of the population over age 40 and accounts for 12.5% of all new cases of blindness. Its incidence is highest among blacks. Prognosis is good with early treatment.

What causes it

Risk factors for chronic open-angle glaucoma include genetics, hypertension, diabetes mellitus, aging, race (blacks are at increased risk), and severe myopia. Precipitating risk factors for acute angle-closure glaucoma include drug-induced mydriasis (extreme dilation of the pupil) and excitement or stress, which can lead to hypertension. Secondary glaucoma may result from uveitis, trauma, steroids, diabetes, infections, or surgery.

Pathophysiology

Chronic open-angle glaucoma results from overproduction of aqueous humor or obstruction of its outflow through the trabecular meshwork or Schlemm’s canal, causing increased IOP and damage to the optic nerve. (See How aqueous humor normally flows.) In secondary glaucoma, such conditions as trauma and surgery increase the risk of intraocular fluid obstruction caused by edema or other abnormal processes.

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Eye disorders

 

Pressure’s rising

Acute angle-closure glaucoma, also called narrow-angle glaucoma, results from obstruction to the outflow of aqueous humor from anatomically narrow angles between the anterior iris and the posterior corneal surface. It also results from shallow anterior chambers, a thickened iris that causes angle closure on pupil dilation, or a bulging iris that presses on the trabeculae, closing the angle (peripheral anterior synechiae). Any of these conditions may cause IOP to increase suddenly.

What to look for

Patients with IOP within the normal range of 8 to 21 mm Hg can develop signs and symptoms of glaucoma, and patients who have abnormally high IOP may have no clinical effects. Nonetheless, each type of glaucoma has specific signs and symptoms.

Slow but steady

Chronic open-angle glaucoma is usually bilateral and slowly progressive. Symptoms don’t appear until late in the disease. These symptoms include:

  • mild aching in the eyes
  • gradual loss of peripheral vision
  • seeing halos around lights
  • reduced visual acuity, especially at night, that’s uncorrectable with glasses.

Rapid reaction

The onset of acute angle-closure glaucoma is typically rapid, constituting an ophthalmic emergency. Unless treated promptly, this glaucoma produces permanent loss of or decreased vision in the affected eye. Signs and symptoms include:

  • unilateral inflammation and pain
  • pressure over the eye
  • moderate pupil dilation that’s nonreactive to light
  • cloudy cornea and blurring and decreased visual acuity
  • photophobia and seeing halos around lights
  • nausea and vomiting.

What tests tell you

  • Tonometry (using an applanation, Schiøtz’, or pneumatic tonometer) measures the IOP and provides a reference baseline.
  • Slit-lamp examination is used to assess the anterior structures of the eye, including the cornea, iris, and lens.
  • Gonioscopy determines the angle of the eye’s anterior chamber, enabling differentiation between chronic open-angle glaucoma and acute angle-closure glaucoma. The angle is normal in chronic open-angle glaucoma; however, in older patients with chronic open-angle glaucoma, partial closure of the angle may also occur, so the two forms of glaucoma coexist.
  • Ophthalmoscopy shows the fundus, where cupping and atrophy of the optic disk are apparent in chronic open-angle glaucoma. A pale disk appears in acute angle-closure glaucoma.
  • Perimetry establishes peripheral vision loss in chronic open-angle glaucoma. Fundus photography recordings are used to monitor the optic disk for changes.

How it’s treated

For open-angle glaucoma, patients initially receive a betaadrenergic blocker (such as timolol [Timoptic] or betaxolol [Betoptic]), epinephrine, or a carbonic anhydrase inhibitor (such as acetazolamide) to decrease IOP. Drug treatment also includes miotic eyedrops, such as pilocarpine, to promote the outflow of aqueous humor.

Plan B

Patients who don’t respond to drug therapy may be candidates for argon laser trabeculoplasty or a surgical filtering procedure called trabeculectomy, which creates an opening for aqueous outflow.

Emergency action

For acute angle-closure glaucoma — an ophthalmic emergency — drug therapy may lower IOP. When pressure decreases, the patient undergoes laser iridotomy or surgical peripheral iridectomy to maintain aqueous flow from the posterior to the anterior chamber. Iridectomy relieves pressure by excising part of the iris to reestablish aqueous humor outflow. The patient typically undergoes prophylactic iridectomy a few days later on the normal eye.

Medical emergency drug therapy includes acetazolamide to lower IOP; pilocarpine to constrict the pupil, forcing the iris away from the trabeculae and allowing fluid to escape; and I.V. mannitol (20%) or oral glycerin (50%) to force fluid from the eye by making the blood hypertonic. The patient with severe pain may need a opioid analgesic.

What to do

  • For the patient with acute angle-closure glaucoma, give medications, as ordered, and prepare him psychologically for laser iridotomy or surgery.
  • Evaluate the patient. Make sure he follows the treatment regimen and obtains frequent IOP tests. Teach him how to recognize the signs and symptoms of elevated IOP and when to seek immediate medical attention. (See Glaucoma teaching tips.)

Glaucoma teaching tips

  • Stress the importance of meticulous compliance with prescribed drug therapy to prevent increased intraocular pressure, which can lead to disk changes and vision loss.
  • Tell him that vision he’s already lost won’t return, but treatment may prevent further loss.
  • Explain the importance of glaucoma screening for early detection and prevention. Remind him that all persons over age 35, especially those with a family history of glaucoma, should have an annual tonometric examination.
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