Care of Clients With Alterations in Cognitive-perceptual Patterns

CARE OF CLIENTS WITH ALTERATIONS

IN COGNITIVE-PERCEPTUAL PATTERNS:

CLIENTS WITH VISUAL DISORDERS

REVIEW OF ANATOMY AND PHYSIOLOGY

•ORBIT •EYEBALL▫SCLERA▫CHOROID▫RETINA

•MUSCLES OF THE EYE•CONJUNCTIVA•LACRIMAL APPARATUS

REVIEW OF ANATOMY AND PHYSIOLOGY

TESTING VISION•Snellen chart•Ophthalmoscope•Biomicroscope or slit lamp•Tonometer•Perimeter•Bjerrum’s tangent screen•Ishihara color plate test•Gonioscopy

SNELLEN CHART

OPHTHALMOSCOPE

BIOMICROSCOPE/ SLIT LAMP

TONOMETER

PERIMETER

BJERRUM’S TANGENT SCREEN

ISHIHARA COLOR PLATE TEST

GONIOSCOPY

PLANNING FOR HEALTH PROMOTION

•CARE OF THE EYES▫Use of medications▫Eye fatigue▫Illumination▫Use of dark glasses▫Danger signals of eye problem

•EYE SPECIALISTS▫Optometrist▫Optician▫Ophthalmologists▫Orthoptist▫Ocularist

PLANNING FOR HEALTH PROMOTION

PLANNING FOR HEALTH MAINTENANCE AND

RESTORATION•NURSING MANAGEMENT

▫Installation of eye drops▫Installation of eye ointments▫Glasses▫Hot compresses▫Cold compress▫Eye irrigations▫Massage of the eyeball▫Contact lenses

•COMMON OCULAR MEDICATIONS▫Local anesthetic▫Parasympathomimetic drugs Grp. 1 (cholinergic drugs) Grp. 2 (cholinesterase inhibitors)

▫Parasympatholytic druds (anticholinergic drugs) Mydriatics cyclopegics

PLANNING FOR HEALTH MAINTENANCE AND

RESTORATION

▫Symphatomimetic drugs (adrenergic drugs)

▫Antibiotics▫Sulfonamide▫Adrenal corticosteroids▫Carbonic anhydrase inhibitors

PLANNING FOR HEALTH MAINTENANCE AND RESTORATION

▫Common ophthalmic symbols:ODOSOUEOMGtt(s)IOP

PLANNING FOR HEALTH MAINTENANCE AND RESTORATION

VISUAL IMPAIRMENT•VARIATIONS

▫The individual who is considered partially sighted may have a visual acuity ranging from 20/70 to 20/200

▫An individual with a visual acuity of 20/70 generally requires special services because of the impairment in vision

▫An individual whose vision is 20/200 or less in the better eye with corrective lenses is considered legally blind

▫An individual who has totally lost his ability to see is considered blind. (congenital/acquired)

•FACTORS▫Age▫Suddenness of onset

•GRIEF PROCESS▫Stage: Shock depression

VISUAL IMPAIRMENT

•NURSING CARE▫Support systems▫Give ample time to work through the client’s feelings

▫Provide opportunities for the client to verbalize his/her thoughts, fears and inadequacies

▫Assist for rehabilitation

VISUAL IMPAIRMENT

ASSESSMENT•Neonate’s eyes are anatomically larger in comparison with body size▫Eyes function immaturely▫Pupils: constricted and unequal (until the 1st week of life)

▫Cornea: larger and flatter than adults

▫Eyelids: edematous; eye movements are uncoordinated

▫Lacrimal glands: don’t function until 2 wks of age

•INFANT’S EYES ARE SMALLER THAN AT BIRTH▫Tears may flow in response to emotions (3

months)▫I month: focuses on stationary objects▫2 months: able to follow moving object▫3 months: focuses on objects within easy

reach; active blink reflex▫4-6 months: 20/200 visual acuity; recognizes

strangers; develops eye-hand coordination▫5-7 months: preference for bright(light)colors▫9 months: pick up tiny objects▫1 y/0: visual acuity 20/100; mature eye

muscles

ASSESSMENT

•TODDLER▫Visual acuity 20/60 (2 y/o)▫3 y/o visual acuity 20/30▫Attention span increased to one mnute

•PRE-SCHOOL▫20/30 visual acuity; readiness for reading

▫Lacrimal glands are fully developed

▫5 y/o: color recognition established

ASSESSMENT

•SCHOOL AGE▫Visual acuity 20/20▫Attention span increased to 20 minutes

•ADOLESCENT▫Emmetropia is well established▫Eyeball attains adult size

•ADULT▫Increased lens elasticity▫Ability to focus upon near objects▫42-45 y/o: gradual loss of accommodation

ASSESSMENT

PLANNING/IMPLEMENTATION

The goal of care is to help each client to lead a

normal life as much as possible

•DEVELOPMENTAL CONSIDERATIONS▫Physical maturation▫Motor development▫Neuromuscular coordination

PLANNING/IMPLEMENTATION

•GUIDELINES FOR COMMUNICATION WITH A BLIND PERSON▫Talk in a normal tone of voice▫Do not try to avoid common phrases in

speech, such as “see what I mean”▫Introduce yourself with each contact. If in a

hospital, knock on the door before entering▫Explain any activity occurring in the room or

what you will be doing▫Announce when you are leaving the room so

the person is not placed in a position of talking to someone who is no longer there

PLANNING/IMPLEMENTATION

•GUIDELINES FOR FACILITATING INDEPENDENCE IN ADL’S FOR BLIND PERSONS▫Place clothing in specific locations in drawers and closets

▫Place food and cooking utensils in specific locations in cupboards and/or refrigerator

▫Encourage use of cane when walking▫Keep furniture and household objects in specific places

PLANNING/IMPLEMENTATION

▫When assisting a blind person in walking, let the person take your arm

▫Provide description of foods on the plate using clock placement of client’s food

▫Always permit blind client to pull out their own seat and chairs themselves

PLANNING/IMPLEMENTATION

•VISUAL IMPAIRMENT AIDS▫For the blindCaneSeeing eye dog or guide dog

▫For the partially blindBooks and newspapers in larger prints

PLANNING/IMPLEMENTATION

•RECREATION▫Leisure time activities; special toys, such as

soft ball should be available▫Special checkers and checkerboards, chess,

scrabble, and Braille cards▫Blind people may also engage in arts and

crafts▫Films, plays and lectures are great sources

of stimulation▫Fishing is an excellent outdoor sport▫Young clients should be encouraged to

engage in physical sports to relieve aggression and hostility

PLANNING/IMPLEMENTATION

•EDUCATION▫Instruct families about an educational setting

▫Resources such as braille books, talking book tapes, recorded lectures, and other services are provided for legally blind

PLANNING/IMPLEMENTATION

•THE HOSPITALIZED CLIENT▫Client should always be oriented to the environment

▫The nurse should encourage the use of tactile senses

▫The client should stand behind the nurse who is guiding him or her

▫The nurse should walk in a straight line

PLANNING/IMPLEMENTATION

▫When leading up and down the stairs, the nurse should pause for a brief moment and then inform the client

▫If handrails are available, the client should be encouraged to use them

▫Doors must never be left partially open

COMMONLY RELATED DISORDERS

•Injuries and trauma•Infections•Cataract•Glaucoma•Detachment of retina•Refractive errors of the eye

Eye Disorders

•Age Related Vision Changes▫flatting of the cornea▫pupillary constriction▫decrease in lens elasticity▫loss of sensory cells

•Physical changes▫inversion, eversion of lid, decreased tear

secretion, “hollowed-eyed”

Conjunctivitis-red, pain, itchy, sticky drainage

Eye Disorders

•Inflammatory Disorders▫conjunctivitis

inflammation of the conjunctiva bacterial or viral

•Treatment▫topical anti-infectives▫anti-inflammatories

Eye Disorders

•Corneal Infections/Inflammations▫corneal scarring and ulcerations are a

major cause of world-wide blindness•Treatment

▫Corneal Transplant

The Client with Eye Trauma

•Corneal Abrasion•Burns•Penetrating Trauma•Blunt Trauma•Treatment

▫topical anesthesia▫facial X-rays or C-T Scans

The Client with Eye Trauma

•Foreign body removal▫sterile saline irrigation

•Eye irrigation▫chemical burn

•Surgery▫penetrating wound

MANAGEMENT•General rule:

▫“Treat the patient but leave the eye alone”

▫Exception: when a chemical injury has occurred and the eye needs to be immediately flushed with water

▫Removing foreign objects: DO NOT TOUCH THE CORNEA

▫IRRIGATION: done for at least 15 minutes before stopping to move the patient or get a doctor

▫No water? – use beer or carbonated beverages

▫Inflammation of cornea▫From infection, irritation, injury, allergy

▫Symptoms: severe eye pain, red watery eye, photophobia

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Keratitis

▫May cause reduced vision, rash

▫Treatment: anesthetics, mydriatics, dark glasses, antibiotics

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•pustular inflammation of eyelash follicle or sebaceous gland on lid margin

•Staphylococcal organism

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Stye or hordeolum

•Symptoms: pain, redness, swelling

•Treatment: warm compress; topical antibiotic

•May need I&D if severe

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▫Cyst of meibomian glands▫Hard, filled with fatty material

▫Painless▫Develops over weeks▫Treatment: surgical excision if infected, interferes with sight

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Chalazion

▫Inflammatory condition of lash follicles meibomian glands of eyelids

▫Swelling, redness, crusts

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Blepharitis

Uveitis•Inflammation of the iris with inflammation of the ciliary body and choroid

Pterygium •A triangular fold of membrane which forms in the conjunctiva which tends from the white of the eye to the cornea

Diabetic Retinopathy•Leading cause of new blindness between ages of 20-74

•84% of diabetics will develop some form ▫depends of length of time you have diabetes

•Vascular disorder that affects the retina▫capillaries become sclerotic

Diabetic Retinopathy•Management

▫Yearly ophthalmologic exams

▫Laser photocoagulation▫Focus is educationalvision changes -blurredblack spots (Floaters)flashing lights sudden loss of vision

Diabetic Retinopathy - vision

The Client with Cataract•Cataract▫a clouding of the lens of the eye

▫interferes with light transmission and the ability to perceive images clearly

▫Significant cause of visional problems in the elderly (50-70%)

Signs and symptoms

•Dimness of visual acuity•Rapid and marked changes of refraction error

CLASSIFICATIONS

•Primary or Senile Cataracts▫Begins first with one eye then the other eye from 45 years on

▫It is rare that this becomes unilateral

▫Occurs with other degenerative changes as person ages

•Secondary or Traumatic▫Due to some disease or injury to the eye

▫Traumatic cataract due to a direct blow or exposure to intense light

•Congenital▫Not seen at the time of birth, but when defective vision becomes evident during childhood. It is associated with attack of German measles in the mother during the 1st trimester of pregnancy

MANAGEMENT•INTRACAPSULAR EXTRACTION▫Lens is removed within its capsule

•EXTRACAPSULAR EXTRACTION▫Lens capsule is excised and the lens is expressed by pressure in the eye from below with a metal spoon

•CRYOEXTRACTION▫Cataract is lifted from the eye by a small probe that has been cooled to a temperature below zero to the wet surface of cataract. All these procedures usually preceded by an iridectomy that is performed to create an opening for the flow of aqueous humor which may become blocked post op when te vitreous humor moves forward

•PHACOEMULSIFICATION▫Requires an incision just large enough to insert a needle probe that vibrates 40,000 times per second to break up the lens and flush it out in tiny suction units

•ENZYMATIC ZONUMOLYSIS▫A technique that involves injecting alpha-chymotrypsin into the anterior chamber.

▫This enzyme frees the attachment of the lens capsule and thereby facilitates removal of the lens without tearing the lens in the process of removing it

•INTRAOCULAR LENS▫Implantation of a synthetic lens designed for distance vision.

▫Pt wears prescribed glasses for reading and near vision.

▫An alternative to sight correction with glasses or contact lenses for the aphasic client

Pre-operative nursing care•Orient the patient•Begin rehab soon after admission-deep breathing exercises, closing eyes without squeezing the lids

•Reduce conjunctival count: antibiotics

•Prepare affected eye for surgery: mydriatics as ordered

▫Re-orient pt▫Prevent IIOP and stress on suture line

▫Promote comfort of the pt▫eye patch▫semi-folwer’s

Post-operative Nursing Care

▫Observe and treat complicationsN/V-anti-emetics, cold compressHemorrhage-notify physician if pt complains of sudden eye pain

Prolapse of the iris-most common post-op complication and can precipitate glaucoma

▫Promote rehabilitation of the patient-encourage independence

▫Health teachings:Dark glassess- 1-4 wks after surgery

Temporary corrective lenses- 1-4 wks after surgery

Permanent lenses 6-8 wks after surgery- eye adjustment in 6 mo; power of accommodation is lost- bifocal lens

Pt should know that it will take time to judge distances, climb stairs and do other simple things

Color of objects seen have slight changes

Ambulatory pts should have slip-on footwear to avoid bending and stooping

Peripheral vision is decreased- turn the head and utilize central vision

Post-operative Nursing Care•Avoid coughing, sneezing straining

▫these increase intraocular pressure•Assess for post-op pain•Assess for surgical complications•Approach from unaffected side•Teach Home Care

▫meds., symptoms to report, photophobia

Glaucoma•Characterized by increased intraocular pressure and gradual loss of vision

•“Silent” thief of vision•Narrowing of visual fields•Cause: obstruction of the circulation of aqueous humor through the meshwork at the angle of the anterior chamber of the eye where the peripheral iris and cornea meet

TYPES OF GLAUCOMA

•Chronic simple or wide or open-angle glaucoma▫Cause: hereditary predisposition to the thickening of the meshwork

•S/S: loss of peripheral vision (tunnel vision) before central vision; frequent changes of glasses; difficulty in adjusting to darkness; failure to detect changes in color; tearing; misty vision; headache; pain behind the eyeball; nausea; vomiting; halos

▫Tx: miotics to constrict the pupil and to draw the smooth muscle of the iris away from the canal of schlema to permit aqueous humor to drain out.

▫Drops are prescribed in AM since IOP is usually higher on AM

▫Acetazolamide to reduce formation of aqueous humor

▫Avoid fatigue or stress▫Avoid drinking large quantities of fluid

•Surgery: principle is to improve the drainage of the intraocular fluid or aqueous humor thereby lessening pressure of the eye•Iridecleisis•Corneoscleral trephining (elliot’s operation)

•Langranges operation (sclerectomy)

•Trabeculoctomy and trabeculotomy•Cyclodialysis

•Non-surgical and laser therapy

•Acute angle-closure glaucoma▫Cause: result of an abnormal displacement of iris against the angle of the anterior chamber.

▫Dilation of pupil is caused by darkness, excitement or a mydriatic drug, which may cause blockage of of the outflow mechanism of the eye with narrowed peripheral angle of the anterior chamber

▫S/S: severe eye pain; N/V; abd pain; blurred vision; colored halos around the light; dilated pupils; and IIOP

▫Tx: miotics (diamox); osmotic agents (glycerol)- acts to reduce pressure of acute glaucoma

▫Surgery: iridectomy

•Congenital Glaucoma – rare maybe present at birth

•Secondary glaucoma – because of some other eye conditions such as uveitis or trauma or post op complication

•Absolute glaucoma – end result of uncontrolled glaucoma; enucleation is often necessary

Therapeutic management

•Eye surgery terms▫Enucleation – removal of the eye

▫Exenteration – removal of the eye and its surrounding structures

▫Evisceration – removal of the content of the eye except the sclera

•General nursing care after GLAUCOMA SURGERY▫Pre-op: pt must realize that vision lost cannot be restored but that further loss can usually be prevented; administration of miotics

▫Post-op: Position: flat and quiet for 24 hours Use of narcotics and sedatives Liquid diet until the first dressing Turning on his unoperated side

▫Long term care: No usual restrictions on the use of the eye

Fluid restriction generally is not curtailed and exercise is permitted

Neither darkness or bright lights are harmful to the eyes of the pt.

Medical care for the rest of their lives

Glaucoma - inner eye pressure

Glaucoma Stage 4

DETACHMENT OF THE RETINA•Separation of the two primitive layers of the retina occurs because of the accumulation of fluids between them.

•An elevation of both retinal layers away from the choroid occurs because of the presence of a tumor

•Causes: myopic degeneration, trauma and aphakia

•S/S: floating spots or opacities before the eye due to blood and retinal cells that are freed at the time of the tear and cast shadows on the retina as they seem to drift about the eye; flashes of light and progressive constriction of vision in one eye

MANAGEMENT

•CONSERVATIVE: keep the pat quiet in bed with eyes covered to try to prevent further detachment; head is positioned so that the retinal holes are the lower part of the eye

•NON-SURGICAL METHODS: employed to seal retinal breaks before the retina becomes detached▫Phatocoagulation▫cryotherapy

•SURGICAL METHODS: aimed at sealing the retinal break, reattaching the retina from redetaching ( scleral buckling)

POST OPERATIVE CARE•Eyes are covered to prevent ocular movement

•Position so that the area of detachment is dependent

•Pupils are dilated-mydriatic to facilitate visualization of the retina to decrease movement of the intraocular structures

Discharge Instructions

•Avoid strenous axercise and activity for at least 6 months

•Contact sports are restricted for the remainder of the client’s life

•Client must avoid sudden movement or jarring of the head

REFRACTIVE ERRORS OF THE EYE•TERMS

▫Emmetropia – normal eye▫Ametropia – indicates presence of a refraction error

▫Refraction – bending of the rays of the light as they pass from one medium to another

▫Accommodation – ability of the eye to adjust from near to far objects

▫Adaptation – ability of the eye to see light from darkness

COMMON REFRACTION ERRORS•MYOPIA•HYPEROPIA•PRESBYOPIA•ASTIGMATISM•ANISOMETROPIA•ANISEIKONIA•BLINDNESS