Unit 5B - Cataracts

Activities that Increase IOP

• Bending from the waist • Lifting objects weighing more than 10 lbs • Sneezing, coughing • Blowing the nose • Straining to have a bowel movement • Vomiting • Having sexual intercourse • Keeping the head in a dependent position • Wearing tight shirt collars

Diagnostics

• Snellen vision test (visual acuity) • Ophthalmoscope assessment (cloudy lens)

Postoperative Care

• antibiotics and steroids are given • discharged an hour after surgery • teach patient how to instill prescribed eye drops • stress importance: follow-up appointments • give acetaminophen by itself or with oxycodone • do NOT give aspirin (antiplatelet!)

Symptoms

• blurred vision • visual distortion • photophobia (sensitivity to light) • glare • NO PAIN

Cataracts

• lens becomes opaque • distorts images (interferes with transmission of light) • possibly related to aging, trauma, or eye diseases • can be present at birth

Operative Procedures

• lens is extracted by phacoemulsification (image) • new intraocular lens (IOL) is inserted • corrects the cataract AND vision issues • after surgery, some patients have restored 20/20 • vision improvement can occur within a day post-op • best vision will occur 4-6 weeks post-op

Cataracts - Causes

• lens loses water • old lens fibers compress (with aging) • lens becomes more dense • ↑ density = ↑ opacity • an opaque lens scatters light instead of focusing it

Risk Associated with Having Cataracts

• loss of visual sensory perception • loss of ability to complete ADLs • loss of independence • safety risk

Postoperative Patient Teaching - General

• mild eye itching is normal • blood shot appearance is normal • slightly swollen eyelid is normal • use a cool compress to relieve swelling • wear dark glasses in bright environments until pupils respond to light

Preoperative Care

• patient teaching: explain importance of using eyedrops after the procedure for several weeks • assess ability to perform ADLs • most important ADLs: dressing, eating, ambulating • assess appearance of the eye • ask about meds taken that affect blood clotting • discontinue anticoagulants prior to surgery • discontinue aspirin (antiplatelet) prior to surgery • give ophthalmic drugs to dilate pupils/vasoconstrict • give eye drops to induce paralysis • provide a local anesthetic (analgesia and paralysis)

Postoperative Patient Teaching - Restrictions

• restrict activities that increase IOP • cooking and light housekeeping are OK • vacuuming should be avoided (jerky movements) • refrain from driving until vision is clear

Postoperative Patient Teaching - Emergencies

• significant swelling/bruising • sharp pain + N/V occurs (↑ IOP) • signs of infection occur →redness → reduced vision →increased tears →photophobia (extreme light sensitivity) →yellow/green discharge (white is normal) • seeing floaters or halos • reappearance of bloodshot sclera

Non-Surgical Treatments

• stronger glasses • magnifying lens • strong lighting • medication to dilate pupil (↑ sensitivity to glare) • no preventative treatments are available

Scheduling Cataract Surgery

• surgery is performed when ADLs are affected • covered by Medicare (>65 years old) • surgery is the only solution to restore vision

The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? (Select all that apply.) A. "You will need to wear a patch on your eye for several weeks after the surgery." B. "Several different types of eyedrops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." C. "You will receive a medication to help you relax. Then you will receive some different eyedrops to dilate your pupils and paralyze the lens." D. "Bring sunglasses with you on the day of your procedure." E. "You might experience a lot of bruising and swelling around the eye."

***You need to differentiate between pre-op teaching and post-op teaching; what needs to be known beforehand and what can be explained after the procedure? a. A patch is not required for cataract surgery unless there is a risk of injury to the eye b. The patient needs to be aware of the importance of administering their eye drops after the procedure; they need to know ahead of time to know the expectations c. The procedure needs to be explained to the patient d. The patient needs to know ahead of time what to bring the day of surgery e. This is post-op info that can wait until after

The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care? A. Self-care deficit B. Imbalanced nutrition C. Disturbed sensory perception D. Anxiety

a. Although a patient scheduled for cataract surgery has lost their ability to adequately perform ADLs, this is a consequence of largest deficit related to cataracts b. Not related to cataracts c. The largest concern with cataracts is the loss of visual sensory perception d. Not related to cataracts

Cataract surgery results in aphakia. Which of the following statements best describes this term? A. Absence of the crystalline lens B. A "keyhole" pupil C. Loss of accommodation D. Retinal detachment

a. Aphakia means without a lens; cataract surgery removes the lens from the eye b. A keyhole pupil results from iridectomy, which is removal of the part of the iris. This is done for acute closed-angle glaucoma patients c. Loss of accommodation occurs naturally with age d. Retinal detachment is caused by a tearing of the retina from the inner wall of the eye

The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions? A. "I will take Aspirin if I have any discomfort." B. "I will sleep on the side that I was operated on." C. "I will wear my eye shield at night and my glasses during the day." D. "I will not lift anything if it weighs more that 15 pounds."

a. Aspirin is an antiplatelet and can increase the risk of bleeding, so it is not appropriate post-op. Use acetaminophen alone or with oxycodone (Percocet) for discomfort b. Do not sleep on the side of the body where the operation occurred c. Wearing an eye shield at night protect the patient from rubbing his eye in his sleep; glasses are allowed to be worn during the day d. Don't lift anything weighing more than 10 pounds

Nurse Jairuz Roy is carrying out his preoperative teachings for an older client who will have cataract surgery on the right eye. The nurse concludes that the client needs further understanding about the teachings if he says: A. "I will sleep on my left side after the surgery." B. "I will wipe my nose gently if it is congested after surgery." C. "I will call my physician if I have sharp and sudden pain or a fever after surgery." D. "I will bend below my waist frequently to increase circulation after surgery."

a. Correct; you want to sleep on the opposite of the operation side b. You do not want to violently blow your nose, since this can increase IOP and cause hemorrhaging c. This can indicate an infection d. Avoid any activities that can increase IOP, such as bending over and increases cranial pressure; always bend with the knees

In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physicians orders, expecting which type of eye drops to be instilled? A. An osmotic diuretic B. A miotic agent C. A mydriatic medication D. A thiazide diuretic

a. Decreases intra-ocular pressure (IOP) b. Constricts the pupil c. Mydriatic drops dilate the pupil and cause vasoconstriction; this minimizes bleeding during surgery d. Quickly reduces IOP; used for patients with acute closed-angle glaucoma, not cataracts

The client is scheduled for right-eye cataract removal surgery in 5 days. Which prep instruction should be discussed with the client? A. Administer dilating drops to both eyes for 72 hours prior to surgery. B. Prior to surgery, do not lift or push any objects heavier than 15 pounds. C. Make arrangements for being in the hospital for at least 3 days. D. Avoid taking any type of medication which may cause bleeding, such as aspirin.

a. Dilation drops are given by the doctor just before surgery, not days in advance. b. Lifting heavy objects can increase IOP, which can be an issue for a surgical incision. Lifting should be avoided after surgery, not before. c. Patients who get cataract surgery tend to be sent home within an hour of the procedure. d. Aspirin is an antiplatelet and will increase bleeding risk with eye surgery.

A client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the health care provider?A. Increased tearing B. Itching of the eye C. Reduction in vision D. Swollen eyelid

a. Expected after cataract surgery b. Expected after cataract surgery c. Vision should never become worse after cataract surgery d. Expected after cataract surgery

The 65 yr old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has? A. Conjunctivitis B. Cataracts C. Corneal abrasion D. Open angle glaucoma

a. Infection of the conjunctiva; causes inflammation and pain. b. Cataracts are painless and leads to blurry vision. c. Corneal abrasions can cause blurred vision, but they are usually painful. d. Chronic glaucoma does not cause eye pain, but it manifests as loss of peripheral (tunnel) vision, not blurred vision.

During the early postoperative period, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: A. Call the physician B. Administer the ordered pain medication and antiemetic C. Reassure the client that this is normal D. Turn the client on his or her operative side

a. Severe eye pain soon after cataract surgery indicates increased IOP and possible hemorrhaging; this is an emergency b. This may be appropriate after contacting the physician, but not before c. Severe pain/nausea after surgery is NOT normal d. This will not help the problem

The client who had cataract surgery with a lens implant 1 week ago remarks to the home care nurse that after his daughter left to go to her home in another state yesterday, he combined all of his prescribed eye drops together in one container so he had fewer drops to administer. What is the nurse's best response? A. "This is not a good idea because not all of the drugs are on the same schedule." B. "That is a good idea; just remember to not touch the dropper to your eye when giving yourself the drops." C. "Call your surgeon immediately and get new prescriptions because together these drugs can lower your blood pressure." D. "Call your surgeon immediately and get new prescriptions to use one at a time because these drugs cannot be mixed together."

a. The drugs may be on the same schedule (i.e. take twice a day, before bed, etc.) b. Incorrect; if these drugs could be mixed together, they would be given that way for ease of use c. We don't know what drugs they are on, so we don't know if mixing them together can drop BP d. You reduce the drug concentrations and effectiveness by mixing them together. Each drug should be administered 5 to 10 minutes apart from each other to ensure adequate absorption.

A male client has just had a cataract operation without a lens implant. In discharge teaching, the nurse will instruct the client's wife to: A. Feed him soft foods for several days to prevent facial movement B. Keep the eye dressing on for one week C. Have her husband remain in bed for 3 days D. Allow him to walk upstairs only with assistance

a. This is not necessary to prevent an increase in IOP b. Eye dressings are not needed with cataract surgery unless a risk for injury is present, such as scratching at it or occupational hazards c. Cataract surgery does not require remaining in bed; the patient just needs to keep activity light to prevent increasing the IOP d. The eye cannot accommodate without a lens (changes shape to focus objects at differing distances) and will need assistance with tasks in which he can injury himself

The nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is: A. Eye pain B. Floating spots C. Blurred vision D. Diplopia

a. This may be caused by eye trauma, infection, acute closed-angle glaucoma, etc. Cataracts do not cause pain b. Seeing floating spots is a sign of a detaching retina c. Cataracts initially manifest as blurred central vision and slightly decreased color perception d. Double vision; this is a symptom of strabismus