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NSG 220 -Sensory Notes Review

NSG 220 -Sensory Notes Review

NSG 220 -Sensory Notes Review

Sensory

  • Refraction: use of the appropriate lens or contact lens
  • Emmetropia: Normal vision
  • Myopia: nearsighted: experiences blurred vision at a distance
  • Hyperopia: farsighted: experiences blurred vision close up
  • Astigmatism: irregular curvature of the cornea causes visual distortion of images near and far.

Blindness: legally blind if visual acuity is less than 20/200 (with corrective lens) or less than 20 degrees of the visual field.

  • Nursing consideration:
    • Address the pt in normal voice of tone – DON’T YELL, Face the client
    • Let the client know you are in the room, what you will be doing.
    • Orient the client of the environment by using clock method
    • During ambulation, allow the client to grab pt’s arm and remain one step behind the nurse.
    • Provide stimulation (TV, radio, music, etc) so they don’t feel isolated, keep other senses stimulated
    • Promote independence as much as possible.
    • THINK OF SAFETY

Glaucoma: Damage of the optic nerve b/c of increase aqueous humor in the eye.

  • One of the leading cause of irreversible blindness.
  • Known as THIEF OF SIGHT
  • More prevalent in >40 yo, Men, Black and Asian.
  • Myopia and Hyperopia, eye injury
  • Co-morbidities (diabetes, migraine headache, poor circulation)
  • IOP ?: Blinking, tight lid squeezing, and upward gazing
  • IOP ?: cold weather, alcohol, fat free diet, heroin, marijuana
  • Normal IOP is 10-21 mm hg
  • IOP more than 50 for 24-48 hrs will cause blindness
  • Assessment:
    • Progressive loss of peripheral vision
    • Elevated IOP
    • Decrease vision especially at night, has difficulty adjusting to light of the room. (FIRST SYMPTOM)
    • Halo around white lights
    • Frontal headache and eye pain
    • Silent thief of sight (more acute, could happen overnight. Could happen with N/V)
  • Diagnostic Test:
    • Tonometry, Goniscopy, Visual field testing
  • Implementation:
    • Treat acute glaucoma as a medical emergency
    • Prepare for the client for a peripheral iridectomy. Helps facilitate drainage from the posterior to anterior chamber.
    • Instruct the patient to avoid anticholinergic medications
    • Instruct the client to notify physician of changes in vision, pain, halos.
    • Medications, if it fails, client will undergo a Trabeculectomy; allows drainage of the aqueous humor into the conjunctival sac by creating an opening.
  • Medications: (ALL IN EYE DROP FORMS)
    • Cholinergic: Miotics (Isotocarpine)
      • Constricts the pupil, promotes drainage
      • Caution the patient about diminished vision in dark areas.
    • Adrenergic Agonist (Epinephrine)
      • Decreases aqueous fluid production and increases outflow
      • can experience increase in BP, headaches, tremors, palpitations and anxiety
    • Beta-Blockers (Timoptic)
      • Decrease aqueous humor production
      • Can cause bradycardia, exacerbation of pulmonary disease, and hypotension.
      • Contraindicated in pt with COPD, Cardiac Hx.
    • Alpha adrenergic agonist (Apraclonide):
      • Decrease aqueous humor production
      • Can cause eye redness, dry mouth and nasal passages
    • Prostaglandin Analog (Xalatan)
      • Increase uveoscleral outflow
      • Can cause conjunctival redness, possible rash
      • Instruct pt to report any side effects
    • Carbonic Anhydrase Inhibitors (Diamox) PO
      • Decrease aqueous humor production
      • Anaphylactic reaction, electrolyte imbalance, depression, lethargy, GI.
      • Do not administer to pt with Sulfa allergies and monitor electrolytes.
      • STRONG DIURETIC CAN CAUSE ELECTROLYTE IMBALANCE
    • Surgical Management:
      • Laser Trabeculoplasty: widens the canal of Schlemm.
        • IOP may occur post procedure
      • Laser Iriodotomy: opening is created to eliminate the blockage.
        • May have burning of the cornea, lens, retina.
      • Filtering procedure: creating opening or fissure to drain the fluid
      • Trabeculectomy
      • Drainage implants
    • Nursing Interventions:
      • Education regarding the medication
      • Punctal occlusion
        • Apply pressure to corner of the eye to absorb well
      • Antihypertensive med with Diamox will double the hypotensive effect
      • Handwashing
      • Post-surgical interventions:
        • Both eyes will have drops post-surgery
        • No eyedrops night before the surgery (affected eye)
        • No straining sports (swimming, jogging, contact sports), No Bending
        • Must check with physician before resuming any activities (2-3 weeks after surgery)

NSG 220 -Sensory Notes Review

Cataracts: Opacity of the lens that leads to blindness

  • One of the leading causes of disability in older population >40 yo.
  • Intervention is required when their visual acuity is reduced to a level that affects their lifestyle
  • Nuclear: by aging, center of the lens affected
  • Cortical: cortex is affected, the cloudiness begins on the outside and extends inward.
  • Subcapsular: inside the posterior capsule.
    • Seen with diabetes and foresightedness and taking high doses of steroids
  • Risk Factors:
    • Age, can be systematic, meds (Aspirin, Corticosteroids), Smoking & Alcohol
    • Positive Fx
    • Thorazine
    • Long-term exposure to sunlight
    • Eye injury or surgery
  • Assessment:
    • PAINLESS
    • Light sensitivity increased
    • Opaque, cloudy white pupil
    • Gradual vision loss
    • Blurred vision
    • Decreased color perception
    • Vision that is better in dim light with pupil dilation
    • Near-sightedness might get worse
  • Surgical Management:
    • Outpatient basis
    • When both eyes have cataracts, one eye must be treated at a time, giving several weeks to months to allow healing, evaluate and if the patient experience complication, another type of procedure is used for the other eye.
    • Intracapsular cataract extraction
    • Extracapsular surgery
    • Lens replacement
      • Intraocular lens is most commonly used, does not require glasses
    • Nursing management:
      • Pre-op care:
        • Anticoagulation is withheld
        • ASA (aspirin) should be withheld 5-7 days
        • NSAID withheld 3-5 days
        • dilating eyedrops are administered q10 min for 4 doses, 1 hr prior to surgery
        • Abx, corticosteroids, and NSAIDS may be administered prophylactically
      • Post-op care:
        • HOB 30-45 (Fowler’s Position)
        • Eye patch: orient the client to the environment (clock method)
        • Position items on the non-operative side
        • SIDE RAILS FOR SAFETY, ASSIST WITH AMBULATION
      • Client Education:
        • Avoid eye straining (reading, cell, computer)
        • Avoid rubbing of the eye
        • Avoid rapid movements, straining, sneezing, coughing, bending, vomiting, lifting heavy objects
        • Prevent constipation
        • Wipe eye with a sterile wet cotton inner to outer
        • Use eye shield at night
        • If the client did not have an IOL then light accommodation is decreased and glasses must be worn
        • Notify MD for decreased vision, pain or Increase drainage

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Retinal Detachment: layer of retina separated because of the accumulation of fluid btw them.

  • Detachment becomes complete if not treated.
  • Complete detachment leads to blindness.
  • THIS IS MEDICAL EMERGENCY
  • Assessment:
    • Early Sign (Slow detachment):
      • Flashes of light
      • Floaters
      • Increase in blurred vision
    • Acute, sudden/extensive Detachment:
      • Sense of a curtain being drawn over the eye MEDICAL EMERGENCY
      • Loss of a portion of the visual field
      • Usually no complaints of pain
    • Implementation:
      • Immediate bed rest
      • Cover the eye to prevent further detachment
        • Decreases workload of the eye
        • Decreases stimuli
      • Position client as ordered by MD
      • Protect!!!! Avoid jerky movements
      • Surgical Procedure is REQUIRED
        • Cryotherapy, Diathermy, Laser Therapy, Scleral buckling (most common), Injection of air
      • Nursing Intervention:
        • Post-op:
          • Maintain eye patch bilaterally (to prevent stimuli)
          • Monitor for hemorrhage
          • Prevent N/V for extra pressure in the eye, can cause hemorrhage
          • Monitor for sudden, sharp pain in the eye (NOTIFY MD)
          • If pt has gas, position pt on abdomen, head turn to the unaffected side
          • Limit reading for 3-5 weeks
          • Avoid squatting, straining, constipation, heavy lifting, bending from waist-down
          • Wear dark glasses during the day and eye patch during night

Macular Degeneration: tiny, yellow spots beneath the retina

  • Most common cause of visual loss in older adults >60 yo
  • CENTRAL VISION is affected.
  • Peripheral vision is unchanged.
  • Client do not experience total blindness.
  • Risk Factor: Age, Hypertension, Tobacco use, Family Hx.
  • Type:
    • Dry: Gradual blurring
    • Wet: abrupt onset, complain of crooked lines. Caused by abnormal blood vessel growing under the retina.
  • Manifestations:
    • Straight lines appear wavy
    • Distance vision decreases
    • Ability to distinguish color decreases
    • Ability to see details (words on paper) is decreased
    • Abnormal black spot may appear in the visual field of one eye.
  • Nursing Intervention:
    • Education about Verteporfin
      • Light activated dye, used in photodynamic therapy)
    • Dark glasses
    • Gloves, wide brim hat
    • Avoid direct exposure to sun or bright light for at least 5 days after treatment
    • Sunlight exposure can lead to severe blistering of the skin and sunburn.
    • Use of Amsler Grid, which can be done at home.

Corneal Surgeries: