Sensory Perception/Tissue Integrity

Glaucoma, Macular Degeneration, Cataract, Meniere's, PI

glaucoma definition

group of eye disorders resulting in increased intraocular pressure (IOP)

glaucoma patho

Compression of retinal blood flow = ischemia = non-reversible vision loss

Starts peripherally & gradually moves toward the fovea.

untreated can lead to complete loss of vision

types of glaucoma

• open-angle glaucoma (OAG)

• angle-closure glaucoma (ACUTE)

open-angle glaucoma (OAG)

_{^{most common}}

• usually affects both eyes

• no s/s in early stages

• late stages: seeing halos around lights, losing peripheral vision

angle-closure glaucoma (ACUTE)

sudden onset of decreased vision, painful.

_{^{medical emergency!}}

glaucoma risk factors

• Hispanic/Latino > 60

• African American > 40

• family hx

glaucoma prevention

eye exams w/ glaucoma checks

_{tonometry— measures IOP}

ophthalmoscopic exam for glaucoma shows—

cupping & atrophy of the optic disc

_{becomes wider and deeper and turns white or gray.}

_{moderately dilated, non-reactive pupil.}

diagnostic assessment for glaucoma

visual field testing by perimetry

optic nerve imaging

normal range for IOP ((glaucoma))

8-21 mmHg

open-angle glaucoma IOP range

22-32 mmHg

angle-closure IOP range ((glaucoma))

30 mmHg or higher

loss of visual sensory perception can be prevented by:

early detection, lifelong treatment, close monitoring

patient teaching for eye drop administration

• When more than 1 drop is prescribed, teach the patient to wait 5-10 mins between drug installations to prevent one drug from diluting another.

• good handwashing

• keep the eyedrop container tip clean

• avoid contact of the tip to any part of the eye

• teach punctual occlusion

technique of punctual occlusion

placing pressure on the corner of the eye near the nose immediately after eyedrop installation to prevent systemic absorption of the drug

prostaglandin agonist eye drops

Bimatoprost, Latanoprost, Travoprost

• help drain fluid from the eye, which lowers eye pressure

prostaglandin eye drop teaching

_{Teach to check the cornea for abrasions or trauma. Drugs should not be used when the cornea is not intact.}

_{Teach that eye color may darken, and eyelashes elongate, over time in the eye receiving one of these drugs. Knowing the side effects in advance reassures the patient that their presence is expected and normal.}

_{If only one eye is to be treated, teach not to place drops in the other eye to try to make the eye colors similar. Using the drug in an eye with normal IOP can cause a lower-than-normal IOP, which reduces vision.}

_{Caution that using more drops than prescribed can reduce drug effectiveness. Drug action is based on blocking receptors, which can increase in number when the drug is overused.}

Alpha-Adrenergic Agonist eye drops

Brimonidine, Timolol

• lower the amount of aqueous humor the eye makes

Alpha-Adrenergic eye drops teaching

^{Ask whether the patient is taking any antidepressants from the MAOI class. These enzyme inhibitors increase blood pressure, as do the adrenergic agonists. When these agents are taken together, the patient may experience hypertensive crisis.}

^{Teach the patient to wear dark glasses outdoors and to avoid too much sunlight exposure. This type of drug can cause the eyes to become sensitive to light.}

^{Teach the patient not to use the eyedrops with contact lenses in place and to wait 15 minutes after using the drug to put in contact lenses, if worn. These drugs are absorbed by the contact lens, which can become discolored or cloudy.}

^{Ask whether the patient has moderate-to-severe asthma or COPD. If these drugs are absorbed systemically, they constrict pulmonary smooth muscle and narrow airways.}

^{Teach patients with diabetes to check their blood glucose levels more often when taking these drugs. These drugs induce hypoglycemia and can mask the hypoglycemic symptoms.}

^{Teach patients who also take oral beta blockers to check their pulse at least twice per day and to notify the primary health care and eye care providers if the pulse is consistently below 60 beats/min. These drugs potentiate the effects of systemic beta blockers and can cause an unsafe decrease in heart rate and blood pressure.}

surgical management for glaucoma

laser trabeculoplasty

surgical post-op teaching for glaucoma

• avoid coughing, sneezing or straining which may cause choroidal detachment & hemorrhage.

• serous detachment involves some degree of vision loss— usually painless.

• hemorrhagic detachment involves immediate loss of vision w/ sudden, excruciating, throbbing pain.

cataracts patho

lens opacity that distorts the image, visual sensory perception is greatly reduced

cataracts risk factors

• age

• trauma

• toxin exposure

• DM, HTN

• smoking

cataracts assessment

• decreased color perception (early)

• increased difficulty seeing at night, esp. while driving

cataracts intervention

surgery is only approach!

surgical interventions for cataracts

• phacoemulsification _{^{(most common)}}

• extracapsular cataract extraction (ECCE)

pre-op care: surgical ((cataracts))

• Teach that care before and after the procedure requires regular self-examination of the eye and possible instillation of different types of eyedrops several times daily for a prescribed period before surgery.

• Ask whether the patient takes any drugs that affect blood clotting, such as aspirin, warfarin, clopidogrel, and dabigatran. Communicate this information to the ophthalmologist because these drugs may need to be discontinued in select patients before cataract surgery. Stop 5-7 days prior to surgery.

• no driving

post-op care: surgical ((cataracts))

• Immediately after surgery, antibiotic and steroid ointments are instilled. The patient is usually discharged very soon following surgery, after stabilization and monitoring, approx. within an hour.

• Remind the patient that mild eye itching is normal, as is a “bloodshot” appearance. The eyelid may be slightly swollen; however, significant swelling or bruising is abnormal.

• Pain early after surgery may indicate increased intraocular pressure (IOP) or hemorrhage. Instruct patients to contact the ophthalmologist if pain occurs with nausea or vomiting.

• Instruct the patient who has had cataract surgery to immediately report any reduction of vision in the eye that just had the cataract removed.

• _{^{Creamy white, dry, crusty drainage on the eyelids and lashes is normal. However, yellow or green drainage indicates infection and must be reported.}}

• _{^{Remind them that final best vision will not occur until 4 to 6 weeks after surgery.}}

care coordination in cataracts following surgery

• usually discharged within an hour or two following cataract surgery

• Ensure that patients have someone who can drive them to this appointment.

• _{^{Some patients are prescribed to wear a light eye patch at night to prevent accidental rubbing. Instruct the patient to avoid getting water in the eye for 3 to 7 days after surgery.}}

• _{follow any other activity restrictions. Cooking and light housekeeping are permitted, but vacuuming should be avoided for several weeks because of the forward flexion involved and the rapid opposing movements required.}

macular degeneration patho

deterioration of the macula (area of central vision)

_{Leading cause of blindness in US individuals > 65}

2 types of macular degeneration

1. wet

2. dry

dry macular degeneration

more common. no cure. gradual blockage of retinal capillaries.

• pigmented residue and photoreceptor waste product in the retina

dry macular degeneration s/s

• central vision declines

• night vision is affected & ability to see clearly when reading is impaired. eventually loses all central vision.

dry macular degeneration risk factors

• faster among smokers

• DM

• HTN

• HLD

• > 55y

• Caucasian

• Family hx

wet macular degeneration

progresses quickly.

detachment of pigment epithelium in the macula. blood vessels invade this injured area & cause fluid and blood to collect under the macula.

wet macular degeneration s/s

sudden decrease in vision

_{progresses quickly}

wet macular degeneration risk factors

can occur at any age

_{only one or both eyes}

macular degeneration risks can be reduced by:

increasing long-term dietary intake of—

• Lutein

• Zeaxthinmacular

macular degeneration assessment tools

• ophthalmoscopy

• Amsler grid test

take action: dry macular degeneration

no cure. management focused on slowing progression.

take action: wet macular degeneration

• laser therapy

• ocular injections w/ vascular endothelial growth factor inhibitors

  • Ranibizumab

Meniere Disease patho

^progressive

• excess of endolymphatic fluid that builds up

• episodes aka “attacks”

  • can last several days, some report ongoing symptoms of varying intensity

Meniere Disease Classic 3 Trio

1. episodic vertigo

2. tinnitus

3. hearing loss

Meniere Disease Prioritizing Hypothesis

FALL RISK

Meniere Disease: Take Action

• diet: avoid high salt intake, caffeine

• safety: avoid ladders, driving, fall precautions, VRT (vestibular rehab therapy)

• decrease stimulation: dim the lights, lie down in a safe place, turn off the TV, avoid reading.

Meniere Disease: drug therapy

• diuretics

• antiemetics— promethazine

• antihistamines— meclizine

  _{intratympanic gentamicin or steroids.}

Meniere Disease: other treatment if drug therapy not effective-

• decompression or shunting of the endolymphatic sac

• labyrinthectomy ((in extreme cases))

Pressure Injury: Stage 1

Nonblanchable erythema/hyperpigmentation of intact skin usually over bony prominences

• Color (not purple or maroon)

• Light skin: Nonblanchable redness

• Dark skin: May not have visible blanching; color of pressure injury site will differ from surrounding tissue

• May be preceded by changes in sensation, temperature, or firmness

Pressure Injury: Stage 2

Partial-thickness loss with exposed dermis

• Color:

• Light skin: Wound bed is viable, pink or red, and moist

• Dark skin: Wound bed may be red or pink without slough, or area may be shiny without slough or bruising

• May look like intact or ruptured serum-filled blister

• Adipose (fat), granulation tissue, slough, and eschar are not visible

Pressure Injury: Stage 3

Full-thickness skin loss

• Adipose (fat) visible in the ulcer

• Granulation tissue and rolled wound edges are often present

• Slough and/or eschar may be present

• Undermining and tunneling may be present

• Fascia, muscle, tendon, ligament, cartilage, or bone are not exposed

Pressure Injury: Stage 4

Full-thickness loss of skin and tissue

• Full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone

• May have slough or eschar

• Rolled edges, undermining, or tunneling are often present

Pressure Injury: Unstageable

Obscured full-thickness skin and tissue loss

• Full-thickness skin and tissue loss

• Extent of damage cannot be confirmed due to being obscured by eschar or slough

Pressure Injury: Deep Tissue

Persistent non-blanchable deep red, maroon, or purple discoloration

• May initially present as a stage 1 pressure injury, resemble other stages as it develops, and progress to full-thickness injury

• Intact or nonintact skin

• Localized area of persistent non-blanchable deep red, maroon, or purple discoloration (discoloration may appear differently in skin with dark pigmentation)

• Epidermal separation reveals a dark wound bed or blood-filled blister

Pressure Injury: Mucosal Membrane

• Found on mucous membranes where a medical device has been or is in use

• These are unstageable ulcers

Pressure Injury Risk Factors

• Prolonged bed rest and/or immobility

• Incontinence

• Diabetes mellitus and/or peripheral vascular disease

• Undernutrition

• Decreased sensory perception or cognitive problems

Pressure Injury: Assessment (body)

inspect—

• entire body, including back of the head

• bony prominences

• areas with excessive moisture

• places where medical devices are present

• under braces, splints, casts, masks, straps, collars, urinary cath tubing

Pressure Injury: Wound Assessment

document—

• location

• size

• color

• extent of tissue involvement

• cell types in the wound base & margins

• exudate

• condition of surrounding tissue

• presence of foreign bodies

Pressure Injury: Wound Measurement

L x W x D ((using mm or cm))

Pressure Injury: Tunneling

“hidden” wounds that extend from the primary wound into surrounding tissues