Chapter 25 The Sensory System - Eye
instillation of eye ointment
(may include antibiotics or be used for rough dry eye for more moisture) check med label and be sure which eye is getting med, follow 6 rights of med admin, perform hand hygiene, apply gloves, remove cap and place on table on side or upside down, expose conjunctival sac, apply thin ribbon of ointment along entire length of sac, to end ribbon twist tube with lateral movement of wrist without touching eye, recap tube, ask pt to close eye and roll eyes around under lids to distribute med
functions of the eye structures
-bony orbit: protects eye -eyelashes: trap foreign particles keeping them from landing on the eyeball -eyelids: protect eyes from foreign matter and distribute moisture on eye surface -sebaceous gland: secrete oily fluid that lubricates the lids -eyelid: blinking 6-30x/min stimulates lacrimal glands to produce tears -lacrimal gland: secretes tears that moisten, lubricate and cleanse the surface of the eye, tears contain an enzyme that destroy bacteria and prevent infections -transparent cornea: allow light to hit the lens, assists with bending of light rays (refraction) so rays will hit the retina in the right location for images to be transmitted to the brain -choroid: absorbs excess light rays that could interfere with vision -ciliary processes: secrete aqueous humor that maintains shape of the anterior chamber, nourishes structures in this part of the eye -aqueous humor: assists with refraction of light onto the retina, amount present determines the internal pressure of the eye, reabsorbed by blood vessels located at the junction of the sclera and cornea -iris muscles: control dilation and constriction of pupil -suspensory ligaments: connect to ciliary body and lens, allow light to focus on lens and retina which is necessary for close vision -retinas rods and cones: photoreceptors for light and color -retina nerves: transmits images perceived to brain -optic nerve: conducts nerve impulses from retina to brain -optic disc visualization: provides info about pressure within eye and skull (when ICP rises optic disc appears swollen or choked) -optic nerve: visual impulses travel along here to the optic chiasma anterior to the pituitary gland -optic tract: carry images from medial portion of left and right eye and lateral portion of right and left eye -images are conducted to the visual cortex in the occipital lobe of the brain
structures of the eye
-eyeball: spherical shape (6 muscles attach to the eyeball and allow for movement, muscles comes from bones of the orbit and insert on the outer layer of the eyeball) -sclera: part of wall of eyeball is white and covers posterior 5/6ths of the eyeball -transparent cornea: part of the wall of the eyeball and covers the anterior 1/6th of the eyeball -choroid: part of middle layer of eyeball and is a highly vascular layer containing brown pigment located between the sclera and the retina -ciliary body: part of middle layer and contains fingerlike ciliary processes that produce aqueous humor, helps change eye shape for near and far vision -iris: third part of middle layer, colored portion, doughnut shape with pupil as central opening, contains 2 groups of smooth muscles that constrict and dilate pupil to regulate entrance of light -biconvex & transparent lens: with suspensory ligaments and ciliary body forms a partition that divides the interior of the eyeball into 2 chambers, anterior chamber between lens and cornea is filled with aqueous humor, posterior chamber between lens and retina contains vitreous humor -suspensory ligaments: connect ciliary body to lens -retina: inner layer of tissue of eyeball, found in posterior portion of it, contains several layers, layer with rods and cones acts as the receptor for light images -optic nerve: carries messages from nerve cells in retina to brain -optic disc: formed by axons of ganglion cells of retina -macula lutea: yellow spot lateral to optic disc that allows for visual detail -fovea centralis: area of retina that produces the sharpest image -eyelids: composed of skin, connective tissue and conjunctiva -conjunctiva: thin mucous membrane that lines the eyelid and covers anterior portion of eyeball except for cornea -eyelashes: line edge of eyelid -sebaceous gland: situated with eyelashes -lacrimal glands: in upper outer area above eyes -lacrimal ducts/canals: carry tears from eye to nose
corneal abrasion or ulceration
-s/s: pain and discomfort aggravated by blinking, hx of trauma, foreign body or contact lens wear -tx: change or d/c use of contact lenses, teach pt proper way to insert, remove and care for contacts, caution pt to not moisten lens with saliva, topical antibiotic ointment and cycloplegic drops for pain
vitamins and antioxidants beneficial to vision
-vitamin A: protects against night blindness, slow adaptation to darkness and glare blindness, carotenoids found in vitamin A are in green leafy and yellow veggies (carrots, greens, spinach, OJ, sweet potatoes, cantaloupe) -lutein and zeaxanthin: antioxidants, prevent macular degeneration and cataracts, found in yellow fruits and veggies, red and purple fruits and greens, lutein is high in tomatoes, carrots, broccoli, kale, spinach and romaine lettuce, zeaxanthin high in corn (highest), cornmeal, kale, japanese persimmons and turnip greens
Before eye surgery, a patient is instructed to take stool softeners. When asked about the rationale for taking the stool softener, an appropriate response would be: 1. "The medication reduces the possibility of straining at stool postoperatively." 2. "The medication prevents constipation caused by anesthetic agents." 3. "The medication cleanses the gastrointestinal tract." 4. "The medication enhances surgical recovery."
1. "The medication reduces the possibility of straining at stool postoperatively."
What advice may you give to an aging adult to help prevent macular degeneration? (Select all that apply.) 1. Do not smoke or quit if you do smoke. 2. Maintain a healthy weight; especially do not carry weight around the waist. 3. Avoid bending or heavy lifting. 4. Drink with a straw.
1. Do not smoke or quit if you do smoke. 2. Maintain a healthy weight; especially do not carry weight around the waist
People with diabetes may face several eye problems and diseases as a complication of their illness. Which of the following can cause severe vision loss or blindness in a person with diabetes? (Select all that apply.) 1. Glaucoma 2. Retinopathy 3. Presbyopia 4. Cataracts
1. Glaucoma 2. Retinopathy 4. Cataracts
Which nursing action(s) demonstrate(s) appropriate care of a patient who is visually impaired? (Select all that apply.) 1. Introduce self before touching. 2. Speak slowly with a loud voice. 3. Keep the door ajar. 4. Ensure ready access to the call button for assistance. 5. Assist with feeding using the clock method.
1. Introduce self before touching. 4. Ensure ready access to the call button for assistance. 5. Assist with feeding using the clock method.
After eye surgery, a patient is instructed to avoid movements that increase the venous pressure in the head, neck, and eyes. Which movement(s) increase(s) venous pressure? (Select all that apply.) 1. Straining 2. Bending over 3. Keeping the head up 4. Sudden head movements 5. Strenuous exercises
1. Straining 2. Bending over 5. Strenuous exercises
A male patient was informed that he would need to wear a pair of corrective lenses for astigmatism. When asked about the condition, the patient demonstrates understanding when he states that: 1. "Astigmatism is hardening of the ciliary muscles." 2. "Astigmatism is an irregular curvature of the cornea." 3. "Astigmatism enables focusing of light in front of the retina." 4. "Astigmatism is an increased opacity of the lens."
2. "Astigmatism is an irregular curvature of the cornea."
A nurse evaluates the visual acuity of a patient using the Snellen chart. Which statement is true regarding the use of the Snellen chart? 1. The chart is placed 40 feet away from the patient. 2. The patient reads the letters using one eye at a time. 3. The numerator (top number) indicates the smallest line that the patient could read. 4. The denominator (bottom number) refers to the patient's distance from the chart.
2. The patient reads the letters using one eye at a time.
Which instruction must be included in the discharge teaching of a patient who has undergone corneal transplant? 1. Increase physical activity. 2. Wear an eye shield when in close contact with children or pets. 3. Remove the pressure dressing as needed. 4. Lie only on the operative side.
2. Wear an eye shield when in close contact with children or pets.
An older adult is admitted for cataract extraction. Which sign or symptom is associated with this condition? 1. Increased tearing 2. Increasing farsightedness 3. Increasing complaints about glare 4. Bluish discolorations
3. Increasing complaints about glare
While looking at a card with a geometric grid of identical squares, a patient is asked to focus on a central dot and to describe any distortions of the surrounding boxes. Which patient statement indicates a need for further diagnostic testing? 1. "I get dizzy staring at these boxes for so long." 2. "I am beginning to see color differences in the squares." 3. "I can see all the boxes surrounding the dot." 4. "There are wavy lines around the central dot."
4. "There are wavy lines around the central dot."
A woman complains of eye itching, tearing, halos around lights, and decreased central vision. Which symptom most clearly relates to macular degeneration? 1. Eye itching 2. Tearing 3. Halos around lights 4. Decreased central vision
4. Decreased central vision
During a health care provider visit, a 65-year-old man complains of pain in his right eye associated with excessive tearing. You note that the eye is red with lashes rubbing against the cornea. A likely condition would be: 1. ptosis. 2. ectropion. 3. hordeolum. 4. entropion.
4. entropion.
glaucoma pathophysiology
IOP is determined by rate of aqueous humor production and outflow of aqueous humor from eye, imbalance may occur from overproduction by ciliary body or obstruction of outflow, IOP >22 requires evaluation, increased IOP restricts blood flow to optic nerve and retina, ischemia causes these structures to lose their function gradually, vision impairment from damage to optic nerve or retina is permanent
The patient presents to the clinic for a routine exam. Which signs or symptoms, if demonstrated or reported by the patient, indicate a possible eye disorder? Select all that apply. a) Double vision b) Blurred vision c) Flashing lights d) Tear production e) Irises of differing colors
a) Double vision b) Blurred vision c) Flashing lights
When collecting data from a patient concerning past diagnostic testing for an ear disorder, the patient reports that a needle was used to draw a blood specimen. Which test would use this step? a) Fluorescent treponemal antibody absorption (FTA-ABS) test b) Rinne test c) Electronystagmography d) Calorie test
a) Fluorescent treponemal antibody absorption (FTA-ABS) test
A patient wearing corrective lenses has a visual acuity of 20/200. The nurse knows this patient has which characteristic? a) Legally blind b) Age-related presbyopia c) Low night vision due to loss of rods d) Proper correction for astigmatism
a) Legally blind
A patient has been diagnosed with sensorineural hearing loss. The patient questions potential causes of this type of hearing loss. Which are associated with a sensorineural hearing loss? Select all that apply. a) Meningitis b) Use of ibuprofen (Motrin) c) Use of furosemide (Lasix) d) Wax buildup in the ear e) Exposure to loud noises
a) Meningitis b) Use of ibuprofen (Motrin) c) Use of furosemide (Lasix) e) Exposure to loud noises
A patient is being evaluated for a disorder of the ear. Which problem statement/nursing diagnosis is of the highest priority? a) Risk for injury related to alteration in equilibrium b) Deficient knowledge related to disease process c) Disturbed sensory perception related to damage from disorder d) Anxiety related to presence of the disorder
a) Risk for injury related to alteration in equilibrium
When selecting foods that will promote the ability of the eyes to see in darkness, which food should be included? a) Spinach b) Pears c) Apples d) Celery
a) Spinach
When providing care to patients, the nurse must recognize the medications that are considered ototoxic. Which medication has this distinction? a) Amoxicillin b) Gentamicin c) Acetaminophen d) Prednisone
b) Gentamicin
The nurses recognize the importance of testing intraocular pressure in the diagnosis of which disorder? a) Myopia b) Glaucoma c) Hyperopia d) Strabismus
b) Glaucoma
The nurse is reviewing a patient's chart and notes the patient's vision in his left eye is 20/70. The nurse uses this information to make which interpretation of the patient's vision? a) The patient can read the line on the chart labeled 20 at 70 feet. b) The patient can read the line on the chart labeled 70 at 20 feet. c) The patient can see 20/70ths of what a patient of that age can see. d) The patient can see 20/70ths of what a normally sighted person can see.
b) The patient can read the line on the chart labeled 70 at 20 feet.
The nurse is caring for a patient with a hearing disorder who has begun to complain of dizziness and a disorder of the vestibular system is suspected. Which diagnostic test would be most appropriate? a) Rinne test b) Vestibular testing c) Audiometric testing d) Evoked-response audiometry
b) Vestibular testing
eye disorder prevention
basic eye care, vitamins, antioxidants, replacement tears for dry eyes, eye injury
The nurse should recognize that sounds of __________ decibels or greater have reached a level that may begin to have an impact on hearing. a) 60 b) 70 c) 80 d) 90
c) 80
The physician recommends that a patient have diagnostic testing performed to assess for an alteration in vestibular function of the ears. Based on your knowledge, which test do you anticipate will be ordered? a) Weber test b) Evoked-response audiometry testing c) Calorie test d) Rinne test
c) Calorie test
When caring for the patient diagnosed with glaucoma, it important that the nurse's instructions include which statement? a) Patients with glaucoma need to have their condition reevaluated every 3 years. b) Glaucoma is associated with a diet high in fat. c) Glaucoma may be managed with eye drops. d) The vision lost by glaucoma may be corrected with surgery.
c) Glaucoma may be managed with eye drops.
A patient has a caloric test to check for alterations in vestibular function. The patient asks the nurse what the normal test findings will be. The LPN/LVN should explain to the patient that if the test is normal, the patient is likely to experience which symptom? a) No response b) Flushing of the skin c) Nausea and vomiting d) Tingling of the earlobes
c) Nausea and vomiting
A patient complains of tinnitus. Which factor, if present in the patient's history, may be most closely related to the patient's complaint? a) The patient takes zinc supplement. b) The patient is a high school student. c) The patient takes large doses of aspirin. d) The patient is slightly dehydrated from gastroenteritis.
c) The patient takes large doses of aspirin.
A patient has a corneal abrasion. Which factor in the patient's history is most closely related to this problem? a) The patient smokes. b) The patient is 75 years old. c) The patient wears contact lenses. d) The patient has a history of renal disease.
c) The patient wears contact lenses.
The eye structure that contains the rods is known as the a) iris. b) cornea. c) retina. d) optic disc.
c) retina.
retinal detachment etiology
caused by a hole, tear or break in neuronal layer allows vitreous humor to seep between layers, traction, exudative mechanisms, congenital malformations, trauma, metabolic disorders (diabetic or hypertensive retinopathy), common in pts with high degree of myopia, those who have had cataract surgery and who have had direct trauma to eye, incidence increases after age 40, common in between ages 40-70 -primary -secondary
narrow angle/angle closure (acute) glaucoma
caused by position of iris which lies too close to drainage canal and bulges forward against cornea blocking drainage of aqueous humor, relief of situation must be prompt or damage to optic nerve will cause blindness -dx: hx, testing IOP, slit lamp eye exam -s/s: severe pain in eye, appearance of colored halos around lights, blurred vision, pain in and around eye, n/v, sudden rise in IOP to 50-70 -tx: reduce IOP as quick as possible, give eye drops, surgery performed as soon as inflammation subsides to relieve pressure against optic nerve, cyclocryotherapy, topical epinephrine, pilocarpine, IV acetazolamide -nursing management: teach activity precautions during healing, schedule for meds, sx to report, aseptic handling of eyedrops and use of eye shield
instillation of eye drops
check med label and be sure which eye is getting med, follow 6 rights of med admin, perform hand hygiene, apply gloves, remove cap and place on table on side or upside down, have pt sit and recline looking up and tilt head toward eye getting drop, with tissue beneath fingers retract lower lid downward exposing conjunctival sac, drop number of drops directly into sac not on cornea, block lacrimal gland with finger for 30-60secs, replace cap without contaminating dropper tip, ask pt to close eyes for 1min for med absorption
care of artificial eye
clean by hand with gentle soap (mild soap or baby shampoo) and water, scleral shells may need to be removed at night or other products can remain in place for months, use lubricating eye drops to moisten prosthesis and use plunger to put prothesis into the socket, when removing or inserting prosthesis have head over padded surface, lift upper lid and insert eye with notched end toward the nose, after inserted as far as possible under upper lid depress lower lid to allow eye to slip into place
common disorder of the eye: dry eye
common in people older then 40 and women in menopause, caused by deficiency of tears, evaporation from dysfunction of meibomian glands exacerbated by environmental conditions (dust, wind) -s/s: tearing, soreness, gritty feeling in eye -tx: lubricating eye drops (if goes untreated can cause corneal ulcers), treat underlying cause, keep tear layer of eye moist and functional, artificial tears, prescription drops or ointments
The nurse is preparing to administer otic medications to a 2-year-old child. Which step is most correct? a) After the medication is expressed from the dropper, gently force air into the ear canal to promote absorption of the medication. b) To reduce loss of medication, encourage the patient to lie down for 15 to 25 minutes after administration. c) Gently pull the pinna upward and back during administration. d) Gently pull the pinna downward and back during administration.
d) Gently pull the pinna downward and back during administration.
The nurse is reviewing the assessment documentation on an older adult patient made the previous shift. The nurse notes what changes occur in the eye with aging? a) Equal in size, not completely round, and not reactive to light. b) Completely round, pupils bulging, and pupil size enlarges. c) Reactive to light, wider visual field, and ability to see dim light. d) Sunken look, cornea flattens, and cataracts may form.
d) Sunken look, cornea flattens, and cataracts may form.
An older patient questions why he has begun to experience eye dryness as he has gotten older. Which statement provides the most accurate information? a) Aging places the eyes at a greater risk for infection. b) The eyes of older individuals may require oil-based drops. c) Environmental influences impact the ability of aging eyes to remain moist. d) The amount of tears produced is reduced with aging.
d) The amount of tears produced is reduced with aging.
pts at high risk for glaucoma
diabetes, african americans, family hx of glaucoma
ptosis
drooping of upper lid so it partially covers cornea, caused by congenital weakness of muscle or long term presence of foreign body -sx: obvious drooping of eye, if not corrected in infants can cause blindness, pt tilts head back or raises eyebrows to see from under lids -tx: surgery, removal of foreign object
eye disorder dx test and exams
dx tests are performed to test visual acuity, prescribe prescription lenses, inspect interior of eye, check IOP and assess health of retinal blood vessels, dx by computed tomography, optical coherence tomography and MRI,
ectropion
eversion or outward turning of lower lid, caused by aging and laxness of skin and muscle tissues, facial paralysis, edema of conjunctiva lining the lid or contraction of scar tissue -sx: irritation of conjunctiva, spilling of tears down cheeks because of blocked outlet, irritation of skin on cheeks, sx of conjunctivitis -tx: patch eye, surgery
cataract dx
examine dilated pupil with slit lamp, rule out glaucoma, tonometry to determine IOP or fluid pressure within the eye
hordeolum
external stye, infected swelling near lid margin on inside -s/s: sharp pain becoming dull and throbbing, rupture and drainage of pus bring relief, localized redness and swelling of lid -tx: resolves spontaneously, warm compress, tell pt not to squeeze swelling, poor health can cause recurrence
cataract tx
extracapsular extraction (lens is removed in one piece), small incision cataract surgery/phacoemulsification (lens is removed in pieces after being broken up by ultrasound waves), surgery only used when loss of vision greatly affects quality of life, surgical removal of affected lens with clear lens implantation, intraocular lens implanted, can have glasses or contacts after lens insertion, vision improved within 2wks and fully recovered within 3mo, outpatient procedure, use procedural sedation and local anesthesia
muscles of the eye
extrinsic/skeletal muscles -superior rectus: controlled by oculomotor, elevates eye or rolls it superiorly and toward midline -inferior rectus: controlled by oculomotor, depresses eye or rolls it inferiorly and toward midline -medial rectus: controlled by oculomotor, moves eye medially and toward midline -lateral rectus: controlled by abducens, moves eye laterally and away from midline -superior oblique: controlled by trochlear, depresses eye and turns it laterally away from midline -inferior oblique: controlled by oculomotor, elevates eye and turns it laterally away from midline intrinsic/smooth muscles -ciliary: controlled by oculomotor parasympathetic fibers, causes suspensory ligament to relax so lens becomes more convex for close vision -iris circular muscles: controlled by oculomotor parasympathetic fibers, decreases size of pupil to allow less light to enter eye -iris radial muscles: controlled by sympathetic fibers from spinal nerves, increases size of pupil to allow more light to enter eye
danger signals of open angle glaucoma
glasses even new ones that dont clarify vision, blurred or hazy vision that clears up after a while, difficulty adjusting to dark rooms, seeing rainbow colored rings around lights, narrowing of vision at sides of one or both eyes
latinos and eye disease
have high rate of diabetic retinopathy and open angle glaucoma, education level, income and mental health correlate with eye disease knowledge and exposure to health info
cataract s/s
hazy/double/blurred vision, decreased color perception, photophobia, complaints about glare, increasing nearsightedness, colors are faded or appear yellowish or brownish, desire for increased light to read, difficulty with night vision, frequent need for glasses prescription change, progressive loss of vision (possibly caused by secondary glaucoma), as untreated cataract progresses lens of eye is cloudy milky white then turns yellow and eventually brown or black
retinal detachment nursing management/pt teaching
head positioned so area of repair is dependent preventing pull of gravity, monitor IOP for 24hrs, vision improves gradually over several weeks to months, use of eye patches (change once a day), wear eye shield when sleeping, use eye drops and antibiotic ointment, use strict asepsis when giving eye drops and ointment, give acetaminophen for pain, use cold packs for pain for 10-20mins at a time, flashing lights are common for first few weeks and decrease over 2-6mo (if they worsen within several weeks notify surgeon), light sensitivity is common and may cause tearing which lessens after 4-6wks, wear sunglasses outdoors, moderate amount of discharge is normal colored yellowish or pink tinged, notify surgeon if discharge amount increases or accompanied by pain or if its foul smelling and green tinge indicating infection, cleanse eyelid with gauze pad or cotton ball moistened with irrigating solution or tap water (use separate pad for each eye), dont get water in eye when showering, at discharge tell pt to avoid heavy lifting, straining and vigorous activity for several weeks, wear glasses during day for protection and eye shield at night after eye patch is no longer needed
nursing goals to promote good vision
health education to inform the general public about basic eye care, prevention of accidental injury to the eye, prevention of visual loss
blepharitis
infection of glands and lash follicles along lid margin -s/s: itching, burning, photophobia, mucus discharge, scaling, crusted lids, glued shut on awakening, loss of eyelashes -tx: warm compress, scrub lids with baby shampoo, stroke sideways to remove exudate and scales, antibiotic eye drops
conjunctivitis
inflammation of conjunctiva, pink eye caused by chemical irritants, bacteria or virus -s/s: pain, discomfort, increased tearing and mucus production, itching, sensation of foreign body in eye -tx: antibiotic eye drops and ointments, special care when handling infective material
keratitis
inflammation of cornea caused by allergy, microbes, ischemia or decreased lacrimation -s/s: pain, discomfort, photophobia, blurred vision -tx: self healing, antibiotic eye drops or ointment, steroids, encourage pt to use good personal and hand hygiene
corneal disorder: keratitis
inflammation of cornea caused by irritation or infection, pts who had a stroke may develop this because of improper closing of the eye, may occur in coma pt because of improper eye care, can occur in pts with exophthalmos, bacteria infection common in pts who wear contacts causing redness of eye and tearing with feeling of grittiness or pain, discharge from eye may occur -tx: artificial tears, antibiotics, meds given topically, IV or subconjunctivally
common disorder of the eye: uveitis
inflammation of uveal tract (uveal tract consists of iris, ciliary body and choroid), results from medical conditions, systemic immune mediated diseases causing inflammation or drug and allergic reactions, infectious agents, herpes, syphilis, cytomegalovirus, toxoplasmosis, TB and west nile virus -s/s: tearing, blurred vision, photophobia, aching around eye, bloodshot sclera, small nonreactive irregular pupil -tx: rest ciliary body with cycloplegic drug, analgesics, antibiotics, steroids, cool or warm compress, sunglasses, low light indoors
eye disorders causes
injury or disease or disorders for which theres a genetic predisposition, diabetes, htn, stroke, untreated glaucoma, macular degeneration from smoking, cataracts, AIDS
eye disorder assessment/data collection history exam
inspect eyes for redness, discharge nd visual acuity using snellen eye chart, note hx of AIDS, htn, diabetes neurologic disorders, neuromuscular diseases, endocrine disorders, thyroid disease, liver and kidney failure, atherosclerosis (causes retinal changes), acute hyperglycemia (alters shape of lens and causes temporary blurred vision), prolonged hyperglycemia can affect blood vessels of the retina causing dilation and blood flow changes leading to vision loss, note hx of drug use that change color vision and visual acuity and lead to cataracts, retinopathy and glaucoma (ethambutol, tamoxifen, corticosteroids, accutane), note family hx of eye disorders, teach pt to be aware of gradual changes in vision, have had more minor accidents lately, are more easily fatigued and are less interested in doing things that once gave them pleasure such as reading, sewing or other hobbies requiring close vision
chalazion
internal stye, infection of meibomian gland -s/s: astigmatism, distorted vision, small hard tumor on lid -tx: surgery, antibiotics
entropion
inversion of lid margin, eyelids turned inward toward eye so lashes rub against eye, caused by scarring and contraction of skin near eyelid -sx: pain, tearing, redness, corneal ulceration -tx: splinting lid with pressure patch or taping lid into everted position, surgery -cicatricial: aging of skin with laxness of tissues supporting lid -spastic: contraction of orbicularis muscle
removal of foreign bodies form eye
irrigation if not deeply embedded by clear lukewarm water at home or sterile water or saline if foreign body is sticking to the cornea, continuous irrigation can be done with small tubing and a bottle of solution or irrigating syringe, dont touch eye with tip of irrigating device, for a speck of foreign matter use moistened sterile cotton swab having pt tilt head back holding lids open to prevent blinking, if a foreign body s sticking out of the eye dont attempt to remove it and patch both eyes to prevent further eye movement and transfer pt to ED or ophthalmologist, if pt continues to complain of pain or sensation of foreign body is still in the eye after irrigation refer them to provider because there may be corneal abrasion (provider applies stain to eye to assess if cornea is abraded and if there is abrasion ointment will be given and eye will be patched, ointment may blur vision), corneal abrasion is painful and pt may be given nonsteroidal antiinflammatory
small incision lenticule extraction/SMILE
laser procedure in which cornea is reshaped by excision of small piece of corneal tissue
photorefractive keratectomy/PRK
laser removes thin layer of tissue from cornea correcting excessive curvature of cornea, prep takes 30mins, procedure takes less then 1min, visual improvement seen within 3-5 days
retinal detachment tx
laser therapy, cryotherapy, photocoagulator, closed vitrectomy, scleral buckling, closed vitrectomy (stabilizes retina against choroid and removes cloudy vitreous humor)
corneal disorder: corneal ulcer
may occur from irritation, infection or injury, ulcer is cultured to determine whether theres a causative organism when theres no hx of injury -tx: antibiotics, scarring or severe infection treated with keratoplasty
laser assisted in situ keratomileusis/LASIK
middle layer of cornea is reshaped with laser after thin outer layer of cornea is peeled back, outer layer is replaced, postop is rapid with little discomfort, procedure takes 10-15mins per eye
errors of refraction
most common visual defect, light rays entering eye arent bent at correct angle and dont focus on retina, if severe eyes will tire easily and pt will have defective vision because the eyes cant change shape of lens enough to compensate for abnormality, may be caused by: -farsightedness/hyperopia (distance between lens and retina is too short so light rays focus behind retina, difficulty seeing close) -nearsightedness/myopia (if eye is too elongated light rays will converge and focus infront of retina and have difficulty seeing far) -accommodation (adjustment of light rays, light rays from distant objects dont enter eye at same angle as light rays from near objects, when looking into distance then quickly looking down the eyes have to adjust to the different light rays entering the eye) -presbyopia (hardening of ciliary muscles, bifocal glasses given to allow 2 sets of lenses in one pair of glasses one for viewing far and one for seeing close) -astigmatism (warped lens or irregular curvature of cornea, prevents horizontal and vertical rays from focusing at same point on retina, if slight eye can accommodate for its imperfection by changing shape of lens)
open angle (chronic) glaucoma
no angle closure, more insidious and common, often inherited that causes degenerative changes in aqueous humor outflow tracts, caused by overproduction of aqueous humor and anatomic problems within the eye, usually bilateral, can progress to complete blindness without producing acute attack, sx are mild and pts usually not aware anything is wrong until vision is seriously impaired -dx: people at normal risk should be screened every 2-4yrs before age 40, every 1-3yrs ages 40-54, every 1-2yrs ages 55-64 and every 6-12mo after age 65, people with high risk should be screened every 1-2yrs after age 35, measure IOP with air tonometer, verification of dx use applanation tonometer -tx: meds to enhance aqueous humor outflow or decrease its production so IOP is decreased, surgery (trabeculoplasty, laser surgery), cyclocryotherapy, miotic eye drops, microsurgery filtering, pilocarpine with disk, diuretics, marijuana (continue meds on an uninterrupted basis and tell pts meds prevent further vision loss but dont restore vision)
eye disorder assessment/data collection physical exam
observe for eye redness of conjunctiva, swollen eyelids or in periorbital space, excessive tearing, changes in visual acuity, secretions and encrustations on eyelids, abnormal position of eyelid, exophthalmos (protrusion of eye), abnormalities of eyelid position, xanthelasma (soft raised yellow areas on eyelid), assess visual impairment noting pts head, hand and eye movements, tilting head to one side to improve vision may indicate pt has double vision or one eye is stronger then other, squinting could mean poor vision, shading eyes with hands may indicate increased sensitivity to light (photophobia), observe for pt ability to move eyebrows and eyes to detect for nerve damage, movement of eyeball is controlled by 6 muscles which are controlled by 3 cranial nerves (oculomotor 3rd, trochlear 4th, abducens 6th)
eye trauma
occurs from accidents and from debris in the air, caused by not using safety eyewear when operating machinery, being struck in the eye by an object that doesnt cause penetration such as a baseball, penetrating injuries require prompt attention
retinal detachment s/s
onset gradual or sudden, flashes of colored light accompanied by showers of floaters (black spots), feel as a curtain has been drawn over a portion of visual field/loss of visual field, cloudy vision, loss of central vision, severe cases complete loss of vision
cataract etiology and pathophysiology
opacity of the lens that produces an affect similar to a person would see if looking through a sheet of falling water, lens which is normally transparent becomes cloudy and opaque, congenital cataracts commonly caused by maternal infection with rubella or toxoplasma gondii, typically occurs as a result of aging in people older then 50, traumatic cataracts results from physical blow, extreme heat or chemical toxins, smoking, heavy alcohol use and chronic use of corticosteroids increases risk,
arcus senilis
opaque ring outlining cornea resulting from deposition of fatty globules
retinal detachment dx
ophthalmoscope, ultrasound
glaucoma etiology
optic neuropathy that damages the optic disc causing atrophy and loss of vision, atrophy caused by increased IOP, comes on slowly and cause irreversible vision loss without presenting noticeable sx, may appear abruptly and produce blindness in a matter of hours, can be present at birth or develop at any age, caused by genetic predisposition, trauma or another disorder of the eye, blindness is preventable if treated early, commonly a manifestation of diseases and pathologies in other body systems, may be secondary to eye infection, trauma, eye surgery or ocular tumor, secondary glaucoma can occur from diabetes, htn, extreme myopia or after retinal detachment
danger signals of eye disease
persistent redness (infections and inflammation that arent treated can cause scars or vision loss), continuing pain or discomfort especially after injury, disturbance of vision (floating spots, double vision, blurred vision, loss of side vision), colored light flashes or feeling that curtain has been pulled across the line of vision or shade has been pulled down (can indicate retinal detachment), crossing of eyes especially in children, growths on the eye or eyelids or opacities visible in normal transparent portion of eye, continuing discharge, crusting or tearing of eye, unequal pupil size or distorted shape
planning for visually impaired pt
plan extra time to assist with personal care, allow pt to perform as much self care as possible, teach administration of meds and self care instructions
correcting errors of refraction
prescription glasses or contacts, nearsighted/myopic pts can go through 3 procedures (LASIK, PRK, SMILE), radial keratotomy
expected outcomes for eye problems
pt will compensate for decreased visual acuity and not experience sensory deprivation, not experience injury, verbalize decreased fear as tx begins to help condition, seek assistance with home maintenance within 7 days, explore other means of diversion then reading and watching tv, demonstrate proper instillation of eye drops and will verbalize schedule for eye drops
enucleation
removal of eye if eye is too damaged by trauma to be salvaged or irreparably damaged by disease or tumor, implant sutured to muscle structures, permanent prothesis placed about 6wks after surgery, postop observe for excessive bleeding, swelling, increased pain, elevated temp or displacement of implant, support pt and understand emotional effects of losing an eye
prevention of vision loss
retinopathy associated with diabetes and htn so encourage control over these diseases, encourage pts who have had an accident causing corneal abrasion or infections causing corneal scarring and vision loss to seek tx promptly, seek tx if eye is inflamed, secreting purulent discharge or is sore in tx of infection to prevent residual vision loss, assess pts for cataracts and recommend periodic eye exams, cataracts removal can improve vision, screen for glaucoma to reduce blindness, use handheld tonometer to check IOP for identifying glaucoma,
retinal detachment pathophysiology
separation of sensory layers of retina from pigmented epithelial layer (choroid), causes vitreous fluid to leak under the retina separating a portion of it from vascular wall depriving retina of blood supply
glaucoma teaching plan
signs of elevated IOP (pain in eye, redness, tearing, blurred vision, halos around lights, frequent need for changes in glasses), measures to prevent increases in IOP (low sodium/furstenberg diet, little caffeine intake, prevent constipation and valsalva maneuver, decrease stress), take meds and refrain from taking OTCs and other meds without consulting with provider, meds taken regularly for life, use aseptic technique when instilling eye meds, wear ID tag or bracelet stating you have glaucoma and carry a card in wallet stating what meds youre taking, keep extra bottle of eye meds on hand and carry eye drops, maintain follow up appts, practice safety habits (avoid night driving),
xanthelasma
soft raised yellow areas appearing on eyelid after age 50
aging related eye changes
subcutaneous fat and tissue elasticity decrease and eyes appear sunken, arcus senilis (opaque ring outlining cornea) sometimes results from deposition of fatty globules, cornea flattens and develops irregular curvature after age 65 causing astigmatism or makes existing astigmatism worse making vision blurred, cornea transparency decreases, sclera develops yellowish tinge from fatty deposits and thinning of sclera may cause bluish tinge, iris dilation decreases causing difficulty for older person from going to a bright area to a dark area, lens of eye changes after age 40 gradually losing water and becoming harder causing cataracts to form, ciliary muscles has less ability to allow eye to accommodate (presbyopia) usually begins at age 40, farthest point at which an object can be identified decreases and visual field narrows, pupil size becomes smaller reducing ability to see in dim light, color discrimination decreases, moisture secretion decreases which is common after age 70 (keratitis inflammation of cornea may compromise vision and can lead to vision loss), eversion of lower lid (ectropion) occurs because of loss of muscle tone and elasticity, decreased elasticity and muscle tone may cause drooping of upper lid interfering with vision (ptosis), suffer from dry eye as a result of decreased tear production but can be treated with replacement tears
nursing management after eye surgery
tell pt theres a period of visual adjustment after surgery, may have to use miotic eye drops to constrict pupil and decrease danger of lens dislocation, pt adherence to med schedule is critical to prevent complications and promote healing
basic eye care
to prevent eye strain rest the eye muscles periodically when infront of electronic screens or performing any activity that demands intensive visual effort, if the eyes tire easily, headache, burning, itching or redness get eyes examined, good nutrition, stay active, dont smoke, control weight, BP and cholesterol, accumulations of purulent material or excessive tearing indicate need for eye exam, dry eye in people younger then 60 could be symptomatic of underlying disease, adults with no risk factors should have an eye exam at age 40, every 2-4yrs ages 40-54 and every 1-3yrs from ages 55-64, after age 65 get eye exam every 1-2yrs, important to test for glaucoma because usually its asymptomatic until damage to vision has occurred, people with a family hx of glaucoma should have frequent eye exams to test for increased eye pressure because thats the basic pathology of glaucoma and it tends to be hereditary
chemical burns
treated by lengthy continuous irrigation using IV bag of normal saline or tap water, water should be lukewarm, 30-60mins, see provider asap
corneal disorder: keratoplasty/corneal transplant
used to replace corneas that have been damaged by genetic disorders, trauma, ulcers or keratitis and other diseases, help restore corneal clarity, corneas retrieved from donor cadavers soon after death, use regional anesthesia, procedure may be set up on short notice due to difficulty predicting when a donor will be available, outpatient procedure, takes 1-2wks before improvement seen and improvement will continue for several months, healing is slow and completes in about 1yr, prevent infection, postop observe pt for 1-2hrs then discharge home, apply pressure dressing and eye shield and only removed by provider next day, after shield is worn at night and when around small children or pets for atleast 1mo, instruct pt regarding safety and to lie only on their back and nonoperative side postop, report graft rejection from inflammation, transplant can be redone if failed, nursing actions focused on disturbed visual sensory perception -full thickness keratoplasty/corneal transplant: restores vision in 95% of pts -lamellar keratoplasty: replaces only superficial layer of corneal tissue -DSEK: replaces only inside lining of corneal cells through tiny incision, no sutures, cells held in place for first 24hrs by air bubble, vision improved in matter of weeks, used only when disease is limited to endothelial surface
contact lenses
wash hands before handling, dont sleep with them in, keep water away from them (showering, swimming), clean with disinfecting solution, dont store in water, replace as recommended, clean contact case with lens solution never water, replace lens case every 3mo
care after eye surgery
wash hands before instilling med, check med label, dont contaminate applicator tip of med, instill only number of drops as ordered, apply pressure to inner canthus to prevent systemic absorption, close eye gently, change eye patch once a day and as needed to keep area clean, follow med schedule exactly (send home written schedule), maintain designated head position and activity restrictions, report signs of complications (sudden increasing pain, purulent drainage, decreasing vision, signs of increased IOP such as brow headache), keep follow up appts with surgeon, use caution to prevent water in eye when showering, protect eye with glasses, wear protective eye shield at night, use sunglasses outside
prevention of eye injury
wear protective eyewear when engaging in sports or using machinery and chemicals, cosmetics for eyelids, eyelashes and eyebrows can be s source of infection and should be discarded every 2-4mo to prevent infection, dont use dyes for hair on eyelashes and eyebrows, dont use saliva to moisten eye pencils, eye shadow or mascara because it can cause infection, dont share cosmetics, apply cosmetics with steady hand to prevent scratching cornea and eyelids
cataract prevention
wear sunglasses to protect from UV rays and a hat when outdoors, cumulative exposure to UV light is greatest risk for cataracts
nursing interventions for visually impaired pt
when communicating remember they have a hard time seeing and theyre not deaf, prevent accidents, dont pity, let them feed themselves if preferred or possible, dont interfere or pet guide dog, pt may experience grief, hopelessness and despair, speak normally, speak to pt and identify self as you enter room, dont touch pt until after you speak to them to prevent startling or frightening, ensure pt is oriented to room and can reach call bell, ensure safe environment to prevent falls or bumping into things because they can experience a lack of self confidence and security if movement isnt safe and independent, keep doors closed or or completely open not ajar or, return items to places when working in room, if object needs to be moved ask pt for consent and state new location, tell pt when you leave the room to prevent frustration trying to talk to you and youre not there, when ambulating lead pt holding your arm as they follow, pts prefer help when needed rather then doing thing for them, ask pt amount of assistance needed, dont assume pt is helpless but dont neglect if they need help, when pt is admitted orient to room and surroundings, if pt is blind describe size of room and placement of furniture using bed as focal point, an ambulatory pt can be walked around the room to determine location of bathroom, commode, bath and sink, explain to pt how to locate and use call bell, tv and phone, make sure cane or assistive devices are easily located, set up meal tray and use clock method (open containers of liquids, pour liquids, cut food into bite size pieces unless they can do it, dont give pt straw unless asked, if you have to feed pt be slow and calm and indicate hot or cold foods and ask which food they prefer next, avoid talking too much forcing the pt to stop eating or answer with mouth full, help pt select finger foods, goal is to help pt maintain dignity and self respect while meeting personal needs, dont feed guide dog and make sure its on its own mat or near bed
