Nursing Intervention in Eyes Disorders and Infections

Eyes Disorders and Infections
Nursing Assessment
History (subjective data):
–    Change in vision
–    Pain, itching, burning
–    Excessive watering
–    Blurred vision, double vision (diplopia)
–    Loss in field of vision, blind spots, floating spots
–    Difficulty with vision at night
–    Pain in bright light
–    Frontal headache
–    Halos around lights
–    Frequent reddening of eye – conjunctivitis
–    Discharge, eye crusted on awakening
–    Eyes feel dry-    Wearing contact lenses, glasses
–    Regular medication
–    History of glaucoma in family
–    History of diabetes, hypertension
–    Date of last eye exam
Physical assessment (objective data):
–    Observe for redness of conjunctiva, swelling, secretions, excessive tearing
–    Change in visual acuity
–    Note any squinting, tilting head
–    Note ability to move eyebrows, eyes
Nursing Diagnosis
•    Anxiety/fear related to loss of vision
•    High risk for infection related to interruption of body surface
•    High risk for injury related to visual limitations and unfamiliar environment
•    Self care deficit related to post operative
•    Knowledge deficit related to post-operative management, medications, and follow up care
Interventions
General interventions for visually impaired

–    Speak as you enter the room and before touching patient
–    Tell the patient when you are leaving
–    Keep door open or closed NOT ajar
–    Do not move objects without asking patient
–    Give special orientation to room on admission
–    Set up meal tray and orient patient to food
Pre-Op:
–    Describe procedure – Local anesthetic
–    Discharge teaching – eye drops, activity restrictions
–    Start stool softeners to prevent constipation/straining
–    Wash face well with surgical soap
–    Instill eye drops as order
Post-Op:
–    Be gentle- no jarring movement
–    Treat nausea immediately with antiemetics
–    Monitor for pain or visual changes ( sign of bleeding)
–    Eye patch with non-allergic tape
–    Patch both eye if restricting movement of eye
–    Metal eye shield at night for extra protection
–    Physician orders for positioningInstilling Eye Drops
–    Verify order (OS, OD, OU)
–    Wash hands, give patient tissue
–    Remove eye patch, gently cleanse with wet gauze
–    Patient supine or head lilted up, look up
–    Pull lower lid down
–    Squeeze gtts into conjunctiva sac
–    Do not touch dropper to patient’s eye
–    Put pressure with finger over lacrimal duct to decrease systemic absorption
–    Ask pt to close eye gently and rotate eyeball to distribute medication. Do not squeeze eye shunt
–    Apply new patch with non-allergic tape

Diagnostic tests for the eye
Ophthalmoscopy:
examination of the fundus or interior of the eye done with the ophthalmoscope. (lens, retina, retinal blood vessels, optic disc)
Retinoscopy: determine focusing power of each eye
Tonometry: measures the intraocular pressure (IOP)
Normal IOP = 10-20 mmHG
Visual field examination: measures peripheral vision
Slit lamp examination: binocular microscope magnifies the surface of the eye – iritis, cataract.

Ultrasonography: determine pathologic changes – opaque lens, cloudy cornea, blood vitreous
Retinal imaging: produced high resolution image of the entire retina – diabetic retinopathy
Retinal angiography: detects vascular changes and blood flow through retinal vessels. Water soluble dye used. Special camera used to detect appearance and distribution of dye in the retinal arteries, capillaries and veins.

Infections of the eye
–    Conjunctivitis: inflammation of the conjunctiva “pink eye” highly contagious. Antibiotic or antiviral ointment or drops, warm soaks or sterile saline irrigation to remove purulent drainage, decrease swelling, relieve pain or itching.
–    Uveitis: inflammation of the uveal tract – iris, ciliary body and choroid. Oral or topical corticosteroids, mydriatic (dilating) eye drops – atropine, antibiotics, analgesics, sunglasses, to reduce photophobia.
–   Keratitis: inflammation of the cornea.
–    Cornea ulcer: erosion in corneal tissue. Topical anesthetics, mydriatrics, local and systemic antibiotics.
–    Blepharitis: inflammation of the lid margins
–   Hordeolum or sty: inflammation or infection of the Zeis or Moll gland. Warm soak, topical antibiotic
–    Chalazion: a cyst of one or more in meibomian glands (sebaceous glands of inner surface of eyelids at the junction of conjunctiva and lid margins). Apply warm soaks, if the cyst is firm – surgically excised.
Cataract
Lens becomes cloudy and opaque
Most often as a result of aging (over 50 yrs)
Assessment of Cataract:
–    Blurred vision, double vision (diplopia)
–    Distortion when looking at distant objects (nearsightedness)
–     Painless but intolerant to light (photophobia)
–     Difficulty with night vision, c/o glare
–    Needs more light for reading
–    Colors fading
–    Lens becomes cloudy, milky white, progressing to yellow and brown
Treatment and nursing care of Cataract
–    Surgery when loss of vision greatly affects quality of life.
–    Remove lens and implant new one – local anesthetic
–    Monitor for hemorrhage, increased intraocular pressure (IOP), infection
– Increased eye pain, decreasing vision, frontal HA, purulent
drainage, fever and chills
–    Do not lie on affected side
–    Stool softeners
–    Avoid rapid movements, bending from waist
–    Assistance with ambulation

Glaucoma
–    Increased intraocular pressure (IOP)
– many causes (genetic, trauma, other diseases)
–    Damage to optic disc causing atrophy and loss of peripheral vision
–    Onset slow or rapid
–    IOP determined by aqueous humor
– Excessive production (wide angle glaucoma)
– Decreased outflow (narrow angle)
–    Increased IOP restricts blood flow to optic nerve and retina causing ischemia
–    If IOP is greater than 23mmHg – evaluate

Closed angle Glaucoma (Acute)
–    Sever pain, colored halos around lights, blurred vision, nausea and vomiting
–    Causes – iris lies too close to drainage canal blocking drainage of aqueous humor
–    IOP rises suddenly (50-70 mmHg)
–    Emergency treatment to prevent damage to optic nerve blindness
– Pilocarpine, topical epinephrine
– surgery
Open Angle Glaucoma (chronic)
–    More common (over 90% of glaucoma)
–    Often inherited, degenerative changes in aqueous humor outflow, usually bilateral
–    Symptoms mild until vision is seriously impaired:
–    Glasses no longer working
–    Blurry vision that clears up
–    Trouble adjusting to dark rooms
–    Rainbow colored rings around lights
–    Narrowing of vision at sides of eyes
Treatment – Drugs of Cataract
–    Miotics (pilocarpine) constricts pupil, promotes outflow of aqueous humor. Side effects of blurred vision for 2 hrs, difficult adjustment to dark rooms
–    Beta-adrenergic blocking agents (Xalatan, Timpotic)
–    Carbonic anhydrase inhibitors (acetazolaminde), given orally to decrease aqueous humor production
–    Sympathominetics (epinephrine) increases aqueous humor outflow
–    Must be taken regularly without interruption
–    Will prevent further vision loss but cannot restore vision
–    Surgery
–    Laser used to create openings so excess fluid can escape, done under conscious sedation
–    Post-op: mild headache, blurred vision for 24 hrs.
–    Nursing care post-op:
–    Monitor for increased IOP – increased pain, HA
–    Prevent increased venous pressure in head
–    Avoid straining, bending over
–    Head of bed elevated, even while sleeping
–    No sudden movements
Causes of Ear Damage
–    Sensorineural (damage to nerve)
–    Heredity
–    Degenerative changes with aging
–    Infections (measles, mumps, meningitis, rebella)
–    Exposure to loud noises
–    Ototoxic drug (antibiotics, lasix, ASA, chemotherapy)
–    Head or ear trauma, tumor
–    Conductive loss (impulse transmission)
–    Congenital malformations of ear
–    Perforated ear durm, foreign object in ear
–    Recurrent Otitis Media
–    Otoscleroisis

Nursing Assessment
–    History (subjective data)
–    Pain in ear, recent temperature, allergies, frequent URTI, exposure to loud noises, head trauma, ringing in ears (tinnitus), buzzing, decreased hearing ability, history of hearing loss in family, regular meds, dizziness, vertigo, loss of balance
–    Physical exam (objective data)
–    Symmetry of pinna, drainage (otorrhea), check hearing (whisper test), observe gait, steadiness, response to questions inappropriate, speaks in louder voice that necessary
Nursing Diagnoses
–    Impaired verbal communication related to inability to receive messages
–    Risk for injury related to inability to hear or loss of equilibrium
–    Social isolation related to difficulty in communication
–    Pain related …
Nursing Care
–    Post-op
–    Position as ordered (usually flat with head supported)
–    Monitor for signs of injury to facial nerve (assess eye, forehead and lip movements)
–    Assistance with ambulation, side-rails up
–    Inspect dressing for drainage
–   Instilling ear drops:
–    Supine lateral position with affected ear up
–    Drops at room temperature
–    Straighten ear canal (pull pinna up and back)
–    Insert tip into external canal, instill drops
–    Put cotton ball in external meatus
–    Remain in lateral position for 2-5 min

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