NeuroMuscular/Skeletal/Sensory FA23

Glaucoma

- increased intraocular pressure with progressive loss of peripheral vision

- second leading cause of blindness

- Usually painless and pt may not even be aware of vision loss

Glaucoma pathophysiology

Intraocular pressure compresses the retinal blood vessels and the photoreceptors and their synapsis nerve fibers --> Results in poorly oxygenated photoreceptors and nerve fibers --> Sensitive nerve tissue becomes ischemic and dies

Glaucoma risk factors

- older than 60

- African American (6-8x more incidents)

- Family hx of glaucoma

- CV disease

- DM

- HTN

- Obesity

- Severe myopia (nearsightedness)

Is there a cure for glaucoma?

There is NO CURE

- Medications and surgery may decrease continued loss of vision

open angle glaucoma

the most common form of glaucoma, where the trabecular meshwork gradually becomes blocked, causing a buildup of pressure

Open angle glaucoma risk factors

age and family hx

Closed angle glaucoma

Sudden onset of the narrowing/closing of the chamber angle between the iris and the cornea

IT IS AN EMERGENCY

primary glaucoma

hereditary and bilateral

associated glaucoma

related to another disease process

- DM

- HTN

- Retinal detachment

secondary glaucoma

Glaucoma that occurs secondary to another primary disease

Ex: - uveitis (uvea inflammation)

- Iritis (iris inflammation)

-Trauma (including eye surgeries)

Open angle glaucoma clinical manifestations

- no symptoms until late

- Increased IOP

- GRADUAL vision loss

- Optic Nerve atrophy

- loss of peripheral vision

Closed angle glaucoma clinical manifestations

- sudden onset

- blurred vision

- severe, sharp PAIN

- headache, nausea, vomiting

- colored halos around lights

What is the most important thing to have for glaucoma?

Always need to have MEDICATIONS

Childhood glaucoma

- congenital

- enlarged eyes

- cloudiness of the cornea

- photosensitivity

assessment of glaucoma

- family hx

- eye exams (every 2 years >40y; annual >65y)

- tonometry

- visualization of optic cup

- field of vision testing

- Gonioscopy

tonometry

the measurement of intraocular pressure

gonioscopy

evaluates the drainage angle of the anterior chamber

miotic

constricts pupil and increase outflow of aqueous humor

Ex: pilocarpine, physostigmine

mydriatics

dilate the pupils

Ex: atropine, scopolamine

glaucoma pharmacotherapy

- slow progression or prevent further damage

- beta blockers (timolol)

- alpha adrenergic agents

- cholinergic agents (miotic)

- carbonic anhydrase inhibitors (hyperosmotic agents)

- hyperosmotic agents

Cholinergic medication effect on eyes

- miotic

- increased intraocular fluid drainage

- CAUTION: diminished vision in dimly lit areas

Beta adrenergic medication effect on eyes

- decrease aqueous humor production

- increase outflow of aqueous humor

- teach about punctal occlusion -> systemic effects

- can cause eye redness and burning

beta blockers medication effect on eyes

- decrease aqueous humor production

- teach punctal occlusion -> systemic effects

- Contraindications: asthma, COPD, 3rd degree heart block, bradycardia, cardiac failure

alpha adrenergic agonists medication effect on eyes

- decrease aqueous humor production

- teach punctal occlusion -> systemic effects

- side effects include eye redness, dry mouth, and nasal passages

carbonic anhydrase inhibitors effect on eyes

- decrease aqueous humor production

- DO NOT administer to pts with sulfa allergies

-Monitor electrolytes

- HYPOKALEMIA is more likely to occur when given w/ steroids & diuretics

Prostaglandin analogs effect on eyes

- increases uveoscleral outflow

- can result in darkening of iris, conjunctival redness

- can result in URIs and headaches

- single dose lowers IOP for 20-24 hours

glaucoma surgical interventions

- Argon Laser Trabeculoplasty (ALT)

- Laser Peripheral Iridotomy

- Surgical Iridectomy

- Shunt drainage device

Argon Laser Trabeculoplasty (ALT)

a laser beam opens the fluid channels of the eye, helping the drainage system to work better

Laser Peripheral Iridotomy (LPI)

a small hole is made in the iris to allow it to fall back from the fluid channel and help the fluid drain

- Preferred for closed angle glaucoma

- Contraindicated in CORNEAL EDEMA

surgical iridectomy

Surgical removal of part of the iris

frequently performed in treating closed angle glaucoma

Shunt drainage devices

small devices implanted into the eye to drain excess fluid

Potential complications of glaucoma surgery

- burns cornea, lens, and retina

- transient intraocular pressure

- blurring of vision

Complications of eye surgical procedures

- hemorrhage

- low or elevated IOP

- uveitis

-Cataracts

Endophtlamitis

- Complication of laser iridotomy

- Serious interocular inflammatory disorder that results from an infection of the vitreous cavity

Nursing Management: Pre-Op Eye Surgeries

- SIGNED CONSENT

- Answer any questions/concerns

- Does patient have a ride home?

- D/C medications (especially blood thinners such as NSAIDs, warfarin, Plavix, etc.)

- Continue home medications

Nursing Management: Post-Op eye surgery

- Monitor VS

- Assess for complications

- Have patient lay on UNAFFECTED side or supine w/ slight elevation

Complications of eye surgery

- Transient IOP (fluctuating)

- Choroidal hemorrhage (SERIOUS)

- Choroidal detachment

post op eye surgery teaching

- DO NOT DRIVE

- Do not do anything that increases IOP (such as bending over)

- no aspirin

- DO NOT LIE ON OPERATIVE SIDE

- report pain, nausea, headache, eye discomfort

discharge teaching for eye surgery

- HANDWASHING

- keep eye drop container tip clean

- Eye drop administration

- Regular eye exams (every 2 - 4 years)

eye drop administration

- apply in conjunctiva

- wait 10-15 min between drops (if there are multiple eye drops prescribed)

- Punctal occlusion

punctal occlusion

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

home safety considerations for eye surgery

- Orient to environment (use the clock position to orientate)

- ambulation assistance (cane/walker)

- Emotional support (acceptance, use positive reinforcement, ONE TASK AT A TIME)

Cataracts

clouding of the lens

causes of cataracts

- Congenital

- Age (older adults)

- Trauma and Inflammation (post intraocular surgeries, uveitis)

- Medication induced (steroids, miotics, amiodarone, phenothiazines)

- metabolic (diabetes, hypocalcemia)

cataracts risk factors

- smoking (>35 y)

- High triglyceride levels

- Systemic diseases (diabetes)

- Sunlight

- Steroid/medications

- Aging (>70 yo)

- Trauma (wounds/chemicals)

early manifestations of cataracts

slightly blurred vision and decreased color perception

painless

progressive manifestations of cataracts

- lens opacity

-reduced vision (clouded, dim, blurred, double)

- Sensitivity to light and glare

-Decreased night vision

- Increased loss of color perception

- Halos around lights

Assessment of cataracts

- Age

- Recent/past trauma of eye

- radioactive exposure

-systemic diseases (DM, down syndrome)

- Prolonged use of corticosteroids, chlorpromazine, miotics

- Intraocular disease (such as uveitis)

What do doctors use to assess for cataracts?

- Snellen chart (vision test)

- Slit lamp w/ eye dilation (Ophthalmoscopy)

- Glare testing (brightness acuity test)

- Keratometry (measure the curvature of the cornea)

Cataracts post-op teaching:

- no strenuous activity or heavy lifting, sex, etc.

- Healing about 6-12 weeks

- Do not touch the eye

- Sunglasses/eye protection

- Contact physician for sharp pain, nausea, vomiting

Cataracts Nursing Management

- reduced visual sensory perception

- safety risk

- Post op care (anxiety, pain, infection, injury, knowledge deficit)

pt teaching cataracts

- cataract surgery increases risk of retinal detachment (notify surgeon STAT)

S/S to look out for: new floaters (dots) in vision, flashing lights, decrease pain, increase in redness

retinal detachment

two layers of the retina separate from each other (curtain vision)

MEDICAL EMERGENCY

clinical manifestations of retinal detachment

- sudden onset and painless

- curtain vision

- flashes, shadows, floaters

retinal detachment assessment

- history (family hx, meds, what were they doing when it happened)

- Visualization of the retina (ophthalmoscope)

- complications: early diagnosis

Nursing management of retinal detachment

- restrict eye movements (no reading/writing, close work, etc.)

- avoid activities that increase IOP

- dim lights NOT indicated

- wear eye patch

- report S/S of infection (redness, pain, drainage)

- maintain follow up appts

macular degeneration

progressive damage to the macula of the retina

loss of central vision

leading cause of severe, irreversible vision loss in people >60y

macular degeneration risk factors

Age

Smoking

HTN

Poor diet

Genetics

Petite/short females

wet macular degeneration

New blood vessels growing beneath the retina leak blood and fluid, damaging the retinal cells.

Less common than dry macular degeneration

dry macular degeneration

caused by a gradual blockage in retinal capillary arteries, which results in the macula becoming ischemic and necrotic due to the lack of retinal cells

Older Caucasian adults more likely to have it

Wet macular degeneration treatment

Ocular injections

Photocoagulation therapy

No cure, just slow the process

Dry macular degeneration treatment

Zinc and antioxidant vitamin

NO CURE, just slowing the process down

retinopathy

any disease of the retina

diabetic retinopathy symptoms

spots, floaters, decrease/loss of vision

Non-proliferative diabetic retinopathy

The blood vessels in the eye become damaged (from diabetes) and develop microaneurysms, which leak and impair the vision

proliferative diabetic retinopathy

changes to the blood vessels of the retina (ineffective perfusion)

diagnostics for retinopathies

examination under ophthalmoscope and fluorescent angiography show signs of "fluffy wool" exudates on retina

treatments for retinopathy

laser photocoagulation therapy

vitrectomy

vitrectomy

the removal of the vitreous humor and its replacement with normal saline

Nursing management of diabetic retinopathy

TEACHING

- diabetic control

-glucose monitoring

- prep/administer medications

- ANNUAL EYE EXAMS

Eye trauma

any injury or insult to any part of the eye

to avoid, use safety goggles

clinical manifestations of eye trauma

corneal injuries (feeling of "something in eye")

Eye pain and burning from solvents or flame or foreign objects

Bleeding from lid/lacerations

"Black eye"

Penetrating injury

Diagnostics for eye trauma

NO MRIs (object could be metal)

Examine eye and ocular structures (Snellen chart)

Sterile fluorescent strips (visualize foreign body)

medical management of burns and chemical eye trauma

flush the eyes for at least 15 minutes

medical management for loose substances in the eye

ophthaine (numbing drops)

eye irrigation (Morgan Lens)

medical management for contact injury to the eye

cool compress

suture if necessary

Medical management of penetrating eye trauma

Protect the eye (stabilize object)

cover other eye to prevent movement

DO NOT REMOVE OBJECT

Do not wipe away tears/drainage (for culture -> antibiotics)

surgery may be indicated

Eye trauma hospitalization nursing management

CURRENT TETANUS IMMUNIZATIONS

Cover eye

Bedrest (decrease IOP)

Safety (side rails up, call bell, low position bed)

Administer meds

Monitor for s/s of infection

strabismus

crossed eyes

esotropia

inward turning of the eye

exotropia

outward turning of the eye

myopia

nearsightedness

hyperopia

farsightedness

astigmatism

defective curvature of the cornea or lens of the eye

presbyopia

age related farsightedness

nystagmus

Involuntary rapid eye movements

retinitis pigmentosa

Genetic disease

Gradual vision loss

Decreased peripheral vision and night vision

NO CURE

Conjunctivitis

inflammation of the conjunctiva

can be bacterial, viral, fungal, or allergies

"pink eye" most common in pediatrics

conjunctivitis treatment

antibiotic eye drops

antiviral eye drops

antihistamines

DEPENDS ON CAUSE

Outer ear

pinna and auditory canal

middle ear

tympanic membrane, malleus, incus, stapes

Inner ear

contains cochlea, semicircular canals, auditory nerve, eustachian tube

What are the main causes of hearing loss?

Infection

Impacted cerumen

Persistent exposure to loud noise

Aging

Trauma/injury

Perforated tympanic membrane

Other causes of hearing loss

congenital defect

ototoxic medications

disease

calcification of ossicles

conductive hearing loss

Result of a problem delivering sound to the cochlea

External or middle ear

Conductive hearing loss causes

- otitis media

- impacted cerumen

- foreign body

- swelling of ear canal

- perforated ear drum

- infection

- tumor

- ossicle malfunction

sensorineural hearing loss

hearing loss caused by damage to the cochlea's receptor cells or to the auditory nerves; also called nerve deafness

inner ear and/or acoustic nerve

sensorineural hearing loss causes

Prolonged exposure to noise

Presbycusis

Ototoxic substance

Ménière's disease

Acoustic neuroma

Diabetes mellitus

Labyrinthitis

Infection

Myxedema

True or False: hearing loss can be both conductive and sensorineural

true; hearing loss can be a result of both conductive and sensorineural problems

Clinical manifestations of conductive hearing loss

Speaks normal and hears best in loud environment