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Neurological 9

  1. Less common type of glaucoma: acute closed-angle (shallow, narrow-angle, primary, or congested glaucoma) - iris bulges and blocks trabecular network.
    1. etiology /epidemiology
      1. a medical and nursing emergency
      2. iris lies near drainage channel (canal of Schlemm) and bulges forward against cornea, blocking the trabecular network and increasing IOP
      3. affects more women; usually after age 45
    2. findings
      1. sudden onset of blurred vision, halos or colored rings around white lights, frontal headache
      2. sudden severe eye pain, reddening of the eye, nausea, vomiting
      3. followed by progression of findings as pressure increases:
        • profuse lacrimation
        • mildly dilated, nonreactive pupil
        • nausea/vomiting
        • cornea appears hazy
      4. blindness may result in two to five days if left untreated
    1. management
      1. expected outcome: to prevent or minimize the damaging effects of acute closed-angle glaucoma
      2. emergency pharmacologic treatment to decrease IOC
        • intravenous osmotic agents
        • mioticeye drops
        • includes carbonic anhydrase inhibitors
        • systemic analgesics
      3. surgery
    2. nursing interventions
      1. monitor for effectiveness of medications as ordered
      2. post-op eyepatch or sunglasses for photophobia
      3. tell client that vision will be blurred for one to two days postsurgery
      4. stress importance of routine yearly or more frequent eye examinations
      5. teach clients to avoid activities that increase IOP
  2. Cataract - maybe unilateral or bilateral
  3. Etiology/epidemiology
    1. clouding of lens - one of the most common eye disorders
    2. first type: senile cataract - result of aging process
    3. second type: traumatic
      1. develops within months of eye trauma
      2. painless but progressive loss of sight in one or both eyes
  4. Expected outcome: correction of visual field defect
  5. Treatment: only surgical
    1. cataract extraction: removal of cloudy lens
      1. most commonly done as outpatient procedure
      2. usually done on one eye at a time
      3. types of cataract extraction
        • extracapsular cataract extraction (ECCE)
        • Phacoemulsification- ultrasound fragments the lens contents
        • intracapsular cataract extraction (ICCE)
          • removes lens contents and lens capsule
          • eye becomes hypermetropic
    2. intraocular lens implant usually performed at time of extraction
    3. peripheral iridectomyusually performed as part of ECCE or ICCE
  6. Potential complications of surgery
    1. hyphema(blood in anterior chamber of the eye)
      1. may require bed rest and patching
      2. observe for increased IOP - complaints of severe pain
      3. may prescribe mioticsor cycloplegics
    2. vitreous prolapse
      1. allows vitreous humorto fall forward into wound
      2. may result in pupil block
      3. may lead to retinal detachment
      4. vitrectomy may be performed
    3. intraocular infection
      1. complaints of throbbing or in eye pain, drainage from eye
      2. antibiotics (ophthalmic and/or systemic)
  7. Nursing interventions
    1. teach client to avoid causes of IOP
    2. observe client's ability to instill eyedrops correctly; provide referrals if unable to
    3. provide written list of complications for the client to report
    4. inform clients that an expected feeling after surgery is one that "sand" is in the eye for six to eight weeks afterwards
  8. Retinal detachment (illustration)
  9. Etiology/epidemiology
    1. holes or breaks (tears) in retina
    2. fluid, blood or a mass separates the retina's sensory layer from the pigmented epithelium (pigment cells)
    3. common causes are inflammation, trauma, hemorrhage, and tumors
    4. retinal detachment often begins in periphery and spreads posteriorly
  10. Findings
    1. a rapid separation gives feeling of a curtain being pulled over eye so that client has partial vision in affected eye
    2. slow separation may be asymptomatic
    3. ophthalmic exam reveals detached area as gray bulge, ripple or fold
  11. Management
    1. expected outcome: correction of and/or prevention of further vision loss: 90% are successfully repaired
    2. laser surgery
      1. photocoagulation: laser beam is directed through dilated pupil
      2. effect is to seal localized breaks or rips in retina
    3. cryotherapy: extreme cold freezes rips in retina
    4. diathermy: heat applied with ultrasonic probe to repair rips
    5. scleral buckle
    6. pharmacotherapy:
      1. adrenergic-mydriatic agents
      2. cycloplegicagents
      3. antibiotics
  12. Nursing interventions
    1. maintain bed or chair rest as ordered
    2. post-op eye patch to rest eye (or both eyes)
    3. dark glasses for photophobia
    4. administer medications as ordered
    5. prevent increases in IOP
  13. Visual impairment and blindness
  14. Legal blindness: a maximum visual acuity of 20/200 (with optimum correction) and/or a visual field that is reduced to a range of 20 degrees (normal range: 180 degrees)
  15. Chief causes: retinal degeneration, glaucoma, cataract, amblyopia, macular degeneration - called "central" loss of vision
  16. Nursing interventions
    1. speak to client upon entering room
    2. safety measures based on how client accommodates sight loss
    3. orient client to new surroundings; use numbers on traditional clock for placement of furniture or food on plate
    4. assist with activities of daily living as required
    5. for walking, do not take client's arm to lead. offer the client your arm so that the blind person holds the arm at the elbow of the lead person who walks a little in front of the blind person