DISTURBANCE IN SENSORY
PERCEPTION:
NCM 114 GERIA
CATARACT
A cataract is a lens opacity or cloudiness.
On visual inspection, the lens appear gray or milky.
CLASSIFICATION
Nuclear cataract. A nuclear cataract is caused by central opacity
in the lens and has a substantial genetic component.
Cortical cataract. A cortical cataract involves the anterior,
posterior, or equatorial cortex of the lens.
Posterior subcapsular cataracts. Posterior subcapsular cataracts
occur in front of the posterior capsule.
PATHOPHYSIOLOGY
CATARACTS CAN DEVELOP IN ONE OR BOTH EYES AT ANY AGE
AS A RESULT OF A VARIETY OF CAUSES.
PATHOPHYSIOLOGY
Lifestyle. Factors that increase the risk of cataracts are cigarette smoking,
long-term use of corticosteroids, sunlight and ionizing radiation, diabetes,
obesity, and eye injuries.
Research. Recent studies have linked cataract risk to lower income and
educational level, smoking for 35 or more pack-years, and high-triglyceride
levels in men.
Myopia. Nuclear cataract is associated with myopia, which worsens when
the cataract progresses.
Density. If dense, the cataract severely blurs vision.
Cataract in the periphery. A cataract in the equator or periphery of the
cortex does not interfere with the passage of light through the center of
the lens.
STATISTICS AND INCIDENCES
Cataract ranks behind only arthritis and heart disease as a leading
cause of disability in older adults.
Cataracts affect nearly 20.5 million Americans who are 40 years of
age or older, or about one in six people in this age range.
By 80 years of age, more than half of all Americans have cataracts.
According to the World Health Organization, cataract is the leading
cause of blindness in the world.
Almost one in five people between the ages of 65 and 74 develop
cataract severe enough to reduce vision.
CAUSES
Cataracts usually develop without any apparent cause; however
they can result from:
Degenerative changes. Senile cataracts develop in elderly
patients, probably because of the degenerative changes in the
chemical state of lens proteins.
Genetic defects. Congenital cataracts occur in neonates s
genetic defects or as a sequela of maternal infections during the
first trimester
Foreign body injury. Traumatic cataracts occur after a foreign body
injures the lens with sufficient force to allow aqueous or vitreous
humor to enter the lens capsule and also dislocate the lens.
Secondary effects. Complicated cataracts occur as secondary effects
in patients with uveitis, glaucoma, or retinitis pigmentosa, or in the
course of a systemic disease, such as diabetes, hypoparathyroidism,
or atopic dermatitis.
Drug or chemical toxicity. Toxic cataracts result from drug or
chemical toxicity with prednisone, ergot alkaloids, dinitrophenol,
naphthalene, phenothiazines, or pilocarpine, or from extended
exposure to ultraviolet rays
CLINICAL MANIFESTATION
Because all light entering the eye passes through the lens, any
clouding of the lens can cause poor vision.
Blurred vision. Blurred vision is usually the first symptom of cataracts.
Glare. Glare refers to the pain felt when the patient looks directly into
the light.
Halos. Halos are formed when the patient looks at a bright light and
there is still the vision of the light after looking away.
Double vision. Double vision is also one of the early symptoms of
cataract.
PREVENTION
The nurse should instruct the patient to:
Quit smoking. The patient should avoid smoking because it is
one of the greatest contributing factors to cataract.
Wear sunglasses. Wearing of sunglasses shields the eye from too
much exposure to UV rays that predisposes to cataract.
COMPLICATION
Potential complications following cataract surgery include:
Retrobulbar hemorrhage. Retrobulbar hemorrhage can result from
retrobulbar infiltration of anesthetic agents if the short ciliary artery
is located by the injection.
Acute bacterial endophthalmitis. Devastating complication that
occurs in about 1 in 1000 cases.
Toxic anterior segment syndrome. Non-infection inflammation that
is a complication of anterior chamber surgery.
ASSESSMENT & DIAGNOSTIC FINDINGS
Decreased visual acuity is directly proportional to cataract
density.
Snellen visual acuity test. The Snellen visual acuity test
measures the degree of visual acuity in the patient.
Ophthalmoscopy. Ophthalmoscopy is used to view the extent of
cataract.
Slit-lamp biomicroscopic examination. This procedure is used to
establish the degree of cataract formation.
MEDICAL MANAGEMENT
No nonsurgical treatment cures cataracts or prevent age-related
cataracts.
PHARMACOLOGIC THERAPY
Medications administered pre and postoperatively are:
Dilating drops. Dilating drops are administered every 10 minutes
for four doses at least 1 hour before surgery.
Antibiotic drugs. Antibiotic drugs may be administered
prophylactically to prevent postoperative infection and
inflammation.
Intravenous sedation. Sedation may be used to minimize
anxiety and discomfort before surgery.
SURGICAL MANAGEMENT
Phacoemulsification
COMMON SURGICAL PROCEDURES DONE
TO CORRECT CATARACTS:
Lens replacement. There are three lens replacement options:
Phacoemulsification. A portion of the anterior capsule is removed, allowing extraction
of the lens nucleus and cortex while the posterior capsule and zonular support are left
intact.
Aphakic glasses. In aphakic glasses, objects are magnified by 25%, making them
appear closer than they actually are.
Contact lenses. Contact lenses provide patients with almost normal vision, but
because contact lenses need to be removed occasionally, the patient also needs a pair
pf aphakic glasses.
IOL implants. The most common IOL is the single focus lens or monofocal IOL that
cannot alter the visual shape; multifocal IOLs reduce the need for eyeglasses;
accommodative IOLS mimic the accommodative response of the youthful, phakic eye.
Extracapsular cataract extraction (ECCE). ECCE removes the
anterior lens and cortex, leaving the posterior capsule intact.
Intracapsular cataract extraction. This procedure removes the
entire lens within the intact capsule.
NURSING MANAGEMENT
The patient with cataract should receive the usual preoperative
care for ambulatory surgical patients undergoing eye surgery.
NURSING ASSESSMENT
The nurse should assess:
Recent medication intake. It is a common practice to withhold any
anticoagulant therapy to reduce the risk of retrobulbar hemorrhage.
Preoperative tests. The standard battery of preoperative tests such as
complete blood count, electrocardiogram, and urinalysis are prescribed
only if they are indicated by the patient’s medical history.
Vital signs. Stable vital signs are needed before the patient is subjected to
surgery.
Visual acuity test results. Test results from Snellen’s and other visual acuity
tests are assessed.
Patient’s medical history. The nurse assesses the patient’s medical history
to determine the preoperative tests to be required.
NURSING DIAGNOSIS
Based on assessment data, the nursing diagnoses for the patient
include:
Disturbed visual sensory perception related to altered sensory
reception or status pf sense organs.
Risk for trauma related to poor vision and reduces hand-eye
coordination.
Anxiety related to threat of permanent loss of vision/independence.
Deficient knowledge regarding ways of coping with altered abilities
related to lack of exposure or recall, misinterpretation, or cognitive
limitations.
NURSING CARE PLANNING & GOALS
The major goals for the patient include:
Regaining of usual level of cognition.
Recognizing awareness of sensory needs.
Be free of injury.
Identifying potential risk factors in the environment.
Appearing relaxed and reporting anxiety is reduced at manageable
level.
Verbalizing feelings of anxiety.
Identifying healthy ways to deal with and express anxiety.
NURSING INTERVENTION
Care for a patient with cataract includes:
Providing preoperative care. Use of anticoagulants is withheld
to reduce the risk of retrobulbar hemorrhage.
Providing postoperative care. Before discharge, the patient
receives verbal and written instructions about how to protect
the eye, administer medications, recognize signs of
complications, and obtain emergency care.
EVALUATION
Evaluation of the patient may include:
Regained usual level of cognition.
Recognized awareness of sensory needs.
Free of injury.
Identified potential risk factors in the environment.
Appeared relaxed and reporting anxiety is reduced ti a
manageable level.
Verbalized feelings of anxiety.
Identified healthy ways to deal with and express anxiety.
DISCHARGE AND HOME CARE GUIDELINES
THE NURSE TEACHES THE PATIENT SELF-CARE
BEFORE DISCHARGE:
The nurse teaches the patient self-care before discharge:
Activities. Activities to be avoided are instructed by the nurse.
Protective eye patch. To prevent accidental rubbing or poking of the eye, the patient
wears a protective eye patch for 24 hours after surgery, followed by eyeglasses worn
during the day and a metal shield worn at night for 1 to 4 weeks.
Expected side effects. Slight morning discharge, sone redness, and a scratchy feeling
may be expected for a few days, and a clean, damp washcloth may be used to remove
slight morning eye discharge.
Notify the physician. Because cataract surgery increases the risk of retinal detachment,
the patient must know to notify the surgeon if new floaters in vision, flashing lights,
decrease in vision, pain, or increase in redness occurs.
DOCUMENTATION GUIDELINES
THE FOCUS OF DOCUMENTATION IN A PATIENT
INCLUDE:
Individual findings, noting specific deficit and associated
symptoms, perceptions of client/SOs.
Assistive devices needs.
Use of safety equipment or procedures.
Environmental concerns, safety issues.
Level of anxiety and precipitating/aggravating factors.
Description of feelings.
Awareness and ability to recognize and express feelings.
Plan of care.
Teaching plan.
Client involvement and response to interventions, teaching, and
actions performed.
Attainment or progress toward desired outcomes.
Modifications to plan of care.
Long term needs.
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GLAUCOMA
DEFINITION
Is a condition marked by high intraocular pressure (IOP) that
damages the optic nerve.
TYPES
Chronic open-angle glaucoma
Results from the gradual deterioration of the trabecular network
that, as in the acute form, blocks drainage of aqueous humor
and causes IOP to increase.
If untreated, may result in degeneration of the optic nerve and
visual field loss.
It is the most common form of glaucoma, and its incidence
increases with age.
Genetics and conditions, such as diabetes and hypertension,
also play a role.
TYPES
Acute closed-angle (or narrow-angle) glaucoma
Results when the angle between the iris and the cornea
becomes narrowed, restricting or blocking the drainage of
aqueous humor through the trabecular network and the canal of
Schlemn. This causes IOP to increase suddenly.
It may result from trauma, stress, or any process that pushes the
iris forward against the inside of the cornea when there is
already an anatomically shallow anterior or chamber.
It is an acute, painful condition that can cause permanent eye
damage within several hours.
RISK FACTORS
Congenital
Inherited
Trauma
PATHOPHYSIOLOGY
In chronic open-angle glaucoma
Obstruction to outflow of aqueous humor through the
trabecular meshwork into Schlemm’s canal leads to increased
IOP. It usually is bilateral. Increased IOP eventually destroys
optic nerve function causing blindness.
PATHOPHYSIOLOGY
In acute closed-angle glaucoma
Results in increased IOP because of obstructed outflow of
aqueous humor. However, acute closed-angle glaucoma
typically involves sudden, complete, unilateral closure with pupil
dilation stimulated by a dark environment, emotional stress, or
mydriatic drugs.
ASSESSMENT/CLINICAL
MANIFESTATIONS/SIGNS AND SYMPTOMS
Chronic open-angle glaucoma
No early symptoms
Insidious visual impairment, blurring
Diminished accommodation
Gradual loss of peripheral vision (tunnel vision)
Mildly aching eyes
Halos around lights later with elevated IOP
ASSESSMENT/CLINICAL
MANIFESTATIONS/SIGNS AND SYMPTOMS
Acute closed-angle glaucoma
Transitory attacks of diminished visual acuity
Colored halos around lights
Reddened eye with excruciating pain
Headache
Nausea and vomiting
LABORATORY AND DIAGNOSTIC STUDY
FINDINGS
Tonometry detects elevated IOP (>10 to 20 mmHg)
Slit-lamp examination reveals abnormalities in the anterior
vitreous humor.
MEDICAL MANAGEMENT
Objective of treatment is to prevent optic nerve damage by
lowering the IOP to a level consistent with retaining vision.
Treatment is almost always lifelong. Treatment also focuses on
achieving the greatest benefit at the least risk, cost and
inconvenience to the patient.
MEDICAL MANAGEMENT
Pharmacologic therapy is the initial and principal treatment for
glaucoma. Acute angle-closure glaucoma is treated with
medication (including miotics) to reduce IOP before laser or
incisional iridectomy.
COMMONLY USED AGENTS INCLUDE:
Beta-adrenergic blockers/antagonists are the most widely used
hypotensive agents. They are effective in many types of glaucoma.
Cholinergic agents (topical) are miotics (cause papillary constriction) and
are used in short-term management of glaucoma with papillary block.
Alpha-2-adrenergic agonists(topical) reduce IOP by increasing aqueous
humor outflow.
Carbonic anhydrase inhibitors (systemic) and prostaglandins lower IOP by
reducing aqueous humor formation.
Osmotic diuretics reduce IOP by increasing the osmolality of the plasma to
draw water from the eye into the vascular circulation.
SURGICAL MANAGEMENT
Ophthalmic laser surgery is indicated as the primary treatment
for glaucoma or is required when medication therapy is poorly
tolerated or ineffective in lowering IOP.
Conventional surgery procedures are performed when laser
techniques are unsuccessful or when patient is not a good
candidate for laser surgery (eg. Patient cannot sit still or follow
instructions)
Filtering procedures: an opening or a fistula in the trabecular
meshwork (trabeculectomy) is made to allow drainage implant
or shunt surgery may be performed.
NURSING DIAGNOSIS
Anxiety related to possible vision loss
Disturbed sensory perception related to visual impairment
Ineffective health maintenance related to knowledge deficit
Risk for injury related to impaired vision
Self-care deficit related to impaired vision
NURSING MANAGEMENT
1. Provide information regarding management of glaucoma
Discuss preoperative and postoperative teaching for immediate
surgical opening of the eye chamber.
Prepare to administer carbonic anhydrase inhibitors IV or IM, to
restrict production of aqueous humor.
Prepare to administer osmotic agents.
Discuss and prepare the client for surgical or laser peripheral
iridectomy after the acute episode is relieved.
NURSING MANAGEMENT
2. Provide information about laser trabeculoplasty, if medication
therapy proves ineffective.
NURSING MANAGEMENT
3. Teach the client about specific safety precautions.
Instruct the client to avoid mydriatics such as atropine, which
may precipitate acute glaucoma in a client with closed-angle
glaucoma.
Instruct the client to carry prescribed medications at all times.
Instruct the client to carry a medical identification card or wear
a bracelet stating his type of glaucoma and need for medication.
Instruct the client to take extra precautions at night (e.g. use of
handrails, provide extra lighting to compensate for impaired
pupil dilation from miotic use).
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