exam 2 Flashcards
cholecystitis
inflammation of the gallbladder, calculous cholecystitis
pain, tenderness, rigidity of the Rt upper abdomen, N/V
cholelithiasis
calculi or gallstones risk factors: 5 Fs female fat forty years old fluctuation in weight fertile (estrogen)
clinical manifestations:
Biliary colic (sharp pain)
Episodic, vague, right upper abdomen. May radiate to back, right scapula and shoulder
Severe, steady
Begins suddenly after a meal (high-fat)- may last 5 hours
Accompanied by N/V, dyspepsia, eructation, flatulence, feeling of fullness
assessment/diagnostic findings:
Ultrasonography of RUQ - study of choice, accurate
Endoscopic Retrograde- looks at liver, bile, pancreatic duct, NPO, Sedation - ride home
Cholangiopancreatography (ERCP)- know this
prevention:
medical management:
Asymptomatic:
Nutritional and supportive therapy
Pharmacologic therapy- 6-12 months to dissolve stones
With symptoms:
Nonsurgical removal of gallstones- Extracorporeal shock wave lithotripsy
Surgical management- open or laparoscopic cholecystectomy
Gerontologic consideration-high mortality rate
Nursing Management:
Nutritional Modification - low fat diet
During acute pain episode: Low fat liquids
Advance as tolerated:
cooked fruits, rice, lean meats, mashed potatoes, non-gas forming veggies, bread, coffee with low-fat milk or tea (not black tea)
Avoid:
eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming veggies, alcohol & refined, fatty, and fried foods (can cause episodes)
risk factors:
Cystic fibrosis
Diabetes
Frequent changes in weight
Ileal resection or disease
Low-dose estrogen therapy—carries a small increase in the risk of gallstones
Obesity
Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic disease)
Treatment with high-dose estrogen (e.g., in prostate cancer)
Women, especially those who have had multiple pregnancies or who are of Native American or U.S. southwestern Hispanic ethnicity
Laparoscopic Cholecystectomy
Nursing Process-
Assessment: focus on the patient’s respiratory status
a history of smoking, previous respiratory problems, shallow respirations, a persistent or ineffective cough, and the presence of adventitious breath sounds
Nutritional status
previously obtained laboratory results to obtain information about the patient’s nutritional status.
Nursing Diagnosis: Acute pain Impaired gas exchange Skin integrity & drainage Risk for infection Imbalanced nutrition
Planning and Goals:
relief of pain, adequate ventilation, intact skin and improved biliary drainage, optimal nutritional intake, absence of complications, and understanding of self-care routines.
Nursing Interventions: low-fowlers position IV fluids and NG suction soft diet after bowel sounds return Patient Education: Managing Pain: Sitting upright or use a heating pad Take analgesic meds as needed Resuming Activity: Begin walking immediately Take shower or bath 1 to 2 days after Drive car 3-4 days after Avoid lifting heavy objects Resume sexual activity when desired Caring for the Wound Check for infection Wash puncture site with mild soap and water Allow special adhesive strips to puncture site to fall off Resume normal diet Managing follow-up care
Complications: bleeding & GI symptoms Obstruction of the bile duct: Ischemia Gangrene Rupture of the gallbladder wall- abscess or peritonitis (rigid, board-like abdomen, guarding) Bile peritonitis Postcholecystectomy syndrome
Acute Pancreatitis
clinical manifestations: -Abdominal pain! Severe (“knife-like”), unrelenting, Sudden onset Mid-epigastric area or LUQ May occur 24-48 hrs. after heavy meal or alcohol ingestion May be diffuse or radiate to back, left flank, left shoulder Acutely ill. Guarding. May be relieved by fetal position, sitting up & leaning forward Persists for days to weeks -Postural hypotension -Tachycardia -N/V -Abd. distention, rigidity -Absent or decreased bowel sounds -Fever -Mild to generalized jaundice -Retroperitoneal bleeding \+ Cullen’s sign: bruising on abd \+ Turner’s sign: bruising on flank area
risk factors: Gallstone Ethanol (alcohol) Trauma Steroids Mumps Autoimmune Scorpion bite Hyperlipidemia Ercp Drugs
assessment:
SAMPLE
Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake, Event prior
OPQRST
Onset, Provocation/Palliation/Position, Quality, Region/Radiation, Severity, Time
Labs:
Serum amylase & lipase (within 2-12 hrs.)
Urine amylase
Serum glucose, potassium, magnesium, & calcium
Serum bilirubin
Liver enzymes: AST, ALP
WBC
Hemoglobin & hematocrit
(hemorrhagic pancreatitis)
Nursing Diagnosis:
Acute Pain: Sit and lean forward
Fluid/electrolyte disturbances: Give IV fluids
Imbalanced Nutrition: They can’t eat because of pain. Keep patient NPO first, then help with nutrition. Diet high in protein and low in fat. Avoid heavy meals and alcohol.
prevention:
medical management:
NPO
NG feedings ok; start early.
TPN
Acute pain management: IV
Narcotics: morphine, fentanyl, hydromorphone (Dilaudid)
Chronic pain control:
NSAIDs (Toradol)
Avoid narcotics to prevent dependence
Antibiotics if infection is present
Pancreatic enzymes:
Pancrelipase (Lipancreatin)
Exogenous source of protease, amylase & lipase
For acute & chronic pancreatitis & pancreatic cancer
Enhances digestion of starches, fats
Promotes nutrition & decrease number of BMs
Do not chew capsule contents.
Wipe lips (to prevent skin breakdown or irritation).
complications: Fluid and Electrolytes Disturbances: CV Renal- acute renal failure Hypovolemic shock- Up to 6 L of fluid can be third‑spaced; caused by retroperitoneal loss of protein‑rich fluid from proteolytic digestion Pancreatic Necrosis an inflammatory mass that may be infected. May lead to multiple organ failure, shock. Most common cause of death
gerontologic considerations that influence acute pancreatitis
Mortality rate increases with aging
The incidence of multiple organ dysfunction syndrome (MODS) increases r/t progressive decrease in physiologic function of major organs with increasing age.
Close monitoring of major organ function and aggressive treatment of necessary to reduce mortality.
Chronic Pancreatitis
Manifestations:
Pain:
Recurrent episodes of severe, deep, epigastric and LUQ abdomen, may radiate to back.
Burning, gnawing, nagging, constant pain with periods of acute exacerbation
Accompanied by vomiting, may last for days to weeks
As disease progresses, interval between episodes of pain becomes shorter
GI/GU:
Weight loss, anorexia, N/V, malnutrition and muscle wasting, steatorrhea, flatulence, constipation
Jaundice and dark urine.
Risk Factors:
Alcohol and Malnutrition
DIagnostic findings: ERCP: Provides details about the anatomy of the pancreas and the pancreatic and biliary ducts. It is also helpful in obtaining tissue. CT, MRI Glucose tolerance test Increase serum amylase, serum lipase
Medical Management:
Nonsurgical: pain control, do not want to use narcotics.
Surgical: not often
Gerontologic consideration
Compare and contrast Acute vs Chronic pancreatitis
• Acute Pancreatitis: o Abrupt onset o Often reversible after treatment o May lead to chronic pancreatitis o Acute necrotizing pancreatitis is a life threatening condition • Chronic Pancreatitis: o Continuing inflammatory disease o Irreversible pathology o Relapsing acute pancreatitis o Exocrine pancreatic insufficiency can result o Diabetes mellitus can result o Triaditis can result in cats
cancer of pancreas
Risk Factors: Cigarette smokers (2-3 times more) Obesity Chemical and toxin exposure (petrolem) Diabetes mellitus Chronic pancreatitis African Americans > Caucasians Male greater than female Incidence increases over 45 years old Diet that is high-fat and low in fruits, vegetables Inherited genetic syndromes
Manifestations: S/S APPEAR WHEN DISEASE IS FAR ADVANCED Upper abd. pain. May radiate to middle, upper back Jaundice, icterus Anorexia, unintentional wt. loss Ascites S/S of insulin insufficiency (glycosuria, hyperglycemia) Itching N/V Palpable abd. mass
Assessment & Diagnostic Findings:
Spiral CT (85-90% accurate)
MRI
ERCP
Medical Management: Pancreatoduodenectomy (Whipple procedure or resection)- Treatment options: Surgery Radiation Chemotherapy Pancreatoduodenectomy: Involves: Removal of gallbladder Removal of head of the pancreas Removal of distal 1/3 of stomach + portion of jejunum Removal of duodenum Removal of lower ½ of the common bile duct Reconstruction: Anastomosis of remaining pancreas & stomach to jejunum
Nursing Management: Relieving pain- FIRST Improving breathing pattern Monitor for shock, hemorrhage, hepatorenal failure Manage NG, suction Multiple IV and arterial lines used for fluid & blood replacement, hemodynamic monitoring Nutrition Risk for bleeding Focus on psychological, emotional state
After pancreatic surgery:
Lots of tubes!
Airway is priority and then pain
Slow down dumping syndrome
Do not sit upright after eating - Lower head of bed
Slow down amount of time food moves to stomach , so they can digest better
Sit up to eat and then lower HOB, 45 degrees
No liquids when eating meal – fluid can move food faster
Monitor & manage pt in ICU:
VS, ABGs, oxygenation, lab values, urine output
multiple IV & arterial lines; hemodynamic monitoring
manage mechanical ventilation
Provide comfort. Manage pain.
Promote nutrition. Address malabsorption and diabetes.
Provide psychological & emotional support.
Educate about self-care.
Diet modifications
Meds: analgesics, TPN, pancreatic enzyme replacement
Wound & skin care
Management of drains, stents
Obesity
Clinical manifestations:
Causes: Behavioral Environmental Physiologic Genetic
Associated Disorders: Cancer Type 2 diabetes by tenfold HTN by fourfold Alzheimer's
Secondary Causes: Diseases/disorders- Hypothyroidism Cushing syndrome Medications Weight Gain Medications- Beta blockers: metoprolol Calcium channel blockers: amlodipine Antipsychotics: chlorpromazine; clozapine; olanzapine Antidiabetics: insulins; sulfonylureas Hormones: corticosteroids; medroxyprogesterone Weight Loss AEDs: lamotrigine (Lamictal); topiramate (Topamax) Antidepressants: bupropion (Wellbutrin, Zyban); Antidiabetics: metformin (Glucophage)
Assessment and diagnostic findings:
-Calculate body mass index (BMI): Person’s weight in KG divided by the square of height in meters) May need to convert lbs to kgs and inches to meters.
oBMI classifications:
Below 18.5: Underweight
18.5-24.9: Normal or healthy weight
25.0-29.9: Overweight
30-34.9: Class 1 obesity
35-39.9: Class ll Obesity
Above 40: Class lll obesity (Extreme, severe)
oDiagnostic lab studies:
CV disease: cholesterol and triglycerides
Type 2 diabetes: fasting blood glucose and glycosylated hemoglobin.
Nonalcoholic fatty liver disease: aspartate aminotransferase and alanine aminotransferase.
Medical management:
oLifestyle modification:
Set weight loss goals
Increase physical activity
Improve diet habits: Commercial diets do not work.
Track: Daily food intake and Nutritional value and caloric content
Healthy Diet Components:
Few processed foods, sugars, and trans fats, and heavy in plant-based foods.
Promote healthy sleep habits
Address barriers to change
Self-monitoring and strategizing ongoing lifestyle changes aime at a healthy weight
Healthy eating strategies:
Limit or eliminate: Processed foods, High caloric beverages, Fast foods, Vending machine foods, and Foods high in sugars
Encourage: Reduce portions; use smaller plates and measure foods, Schedule and plan meals and snacks, Eat at home more than out, Eat breakfast, Limit snacks, Eat nutritious foods, Drink water, and Stay within daily caloric intake plan.
Pharmacologic management:
Medications are used if we cannot help with the weight through exercise and diet.
Antiobesity meds are meant to supplement not supplant/replace diet modifications and exercise.
Need to encourage the use of multivitamins with these. If they are taking other meds they need to let the doctor know.
Indications for antiobesity meds:
BMI> 30
BMI> 27 with related concomitant morbidities
Orlistat:
Prevents digestion of fats.
AE’s: Oily discharge, reduced food and vitamin absorption, and decreased bile flow.
Lorcaserin:
Simulates serotonin receptors in the hypothalamus in the brain to curb appetite.
AE’s: HA, dry mouth, fatigue, and nausea
Phentermine/topiramate-ER:
Suppresses the appetite and induces a feeling of satiety
AE: Dry mouth, constipation, nausea, change in taste, dizziness, insomnia, and numbness and tingling of extremities.
Contraindications: hyperthyroidism, glaucoma, MAO inhibitor.
Nonsurgical or surgical interventions:
Minimally-invasive interventions:
Vagal blocking:
Placement of a pacemaker-like device into the SQ tissue in the lateral thoracic cavity.
Blocks vagus nerve via implanted device
Few SE/AE’s
Pt should be educated to recharge the device twice weekly.
Intragastric balloon therapy:
Endoscopic placement of saline-filled balloons into the stomach.
Remains in place for 3-6 months
SE/AE’s: N/V, balloon rupture causing obstruction
oSurgical Management:
Bariatric Surgery
Performed after nonsurgical methods have failed.
Selection Criteria:
BMI of 30 for patients with comorbid conditions
Need counseling before and after: lifestyle
Results: 10-35% body weight within 2-3 years.
Improved comorbidities: DM, HTN, OSA, dyslipidemia
Types:
Roux-en-Y gastric bypass (RYGB)
Gastric Banding
Sleeve gastrectomy
Biliopancreatic diversion with duodenal switch
Nursing Management:
Mechanics of ventilation and circulation
Heart failure and HTN are common
Maintain in low Fowler position
Continuous pulse oximetry- every shift at minimum.
Supplemental oxygen and CPAP
Central and peripheral circulatory compromise
Heart failure and HTN are common
Use appropriate size BP cuff
Monitor for venous thromboembolism (VTE) which places at risk for DVT and PE
Skin Integrity & Body Mechanics
Increased adipose tissue diminishes supply of blood, oxygen & nutrients to peripheral tissues
The presence of more folds in the skin is associated with more skin moisture and increased friction. Immobility. - pressure ulcer risk.
Use specialty bariatric equipment (lifts, transport equipment, commodes)
Turn every 2 hours- prevent pressure ulcers
Implement safe patient handling protocols so nurse does not incur musculoskeletal injury.
Nursing Process for Bariatric Surgery
Performed only after nonsurgical methods have failed
Selection by multidisciplinary team
Criteria has changed to include BMI of 30 for patients with comorbid conditions
Need counseling before & after re: lifestyle
Typical results: 10-35% of body wt. within 2-3 years
Improved comorbidities (DM, HTN, OSA, dyslipidemia)
Assessment: Preoperative Care: Education and counseling: Surgical risks and benefits Complications Postsurgical outcomes Dietary changes Lifelong follow-up Lab testing Postoperative care: Monitor for leak of anastomosis Assess to ensure goals for recovery are met Assess for absence of complications General assessment
Nursing Diagnoses:
Pain r/t incision/surgery
Planning and Goals:
Nursing management:
Ensuring dietary restrictions: Clear liquid diet 24-48 hours before surgery
Reducing anxiety
Relieving pain
Ensuring fluid volume balance: Iv
Preventing infection
Ensuring adequate nutritional status: After bowel sounds return, six small feedings, 600-800 calories per day. Fluids between meals to prevent dehydration.
Supporting body image changes
Ensuring maintenance of bowel habit
Monitoring and managing potential complications
Collaborative problems and potential complications:
Hemorrhage
Venous thromboembolism
Bile reflux
Dumping Syndrome: Dump the food out of the stomach
Food moving out of the GI too fast. This will cause them to not have enough time to absorb the nutrition. The GI cannot function.
Decreasing the risk:
Do not drink and eat at the same time.
Lower the HOB, not sitting up to eat. Slow down the movement of the food so they can absorb it.
Dysphagia
Bowel or gastric outlet obstruction
Dietary Guidelines:
Eat smaller and more frequent meals containing protein and fiber. Meal should not exceed 1 cup.
High nutrient foods
Consume fat as tolerated
Low carbohydrate intake
Eat two protein snacks daily
Eat slow and chew
Assume a low Fowler position during mealtime and remain there for 20-30 minutes- decreases likelihood of dumping syndrome.
Do not drink fluid with meals
Do drink plenty of water, avoid liquid calories (alcohol, fruit drinks, nondiet sodas
Take dietary supplements of vitamins and medium-chain triglycerides
Follow up monthly injections of vitamin B12 and iron
Walk for 30 min a day.
Neurological assessment
Consciousness and cognition: mental status (Includes multiple functions, each must be assessed and adds to the clinical picture), GCS (glascow coma scale), intellectual function (abilities like counting/math, critical thinking/problem solving, reasoning), thought content, emotional status (affect), language ability (types of aphasia result from injury to different parts of the brain), impact on lifestyle Level of Consciousness—alert, lethargic, stupor, coma GCS: Eye Opening: Spontaneous 4 To sound 3 Pain/pressure 2 None 1 Verbal Response: Oriented 5 Disoriented/Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No response 1 Motor Response: Obeys verbal commands 6 Purposeful/localizes 5 Withdraws to pain 4 Flexion 3 Extension 2 No response 1
Cranial nerves
Motor system: muscle size, muscle tone and strength, coordination and balance, Romberg test
strength: 5 indicates full power of contraction against gravity and resistance or normal muscle strength; 4 indicates fair but not full strength against gravity and a moderate amount of resistance or slight weakness; 3 indicates just sufficient strength to overcome the force of gravity or moderate weakness; 2 indicates the ability to move but not to overcome the force of gravity or severe weakness; 1 indicates minimal contractile power (weak muscle contraction can be palpated but no movement is noted) or very severe weakness; and 0 indicates no movement
Sensory system: tactile sensation, superficial pain, temperature, vibration and position sense (proprioception)
Reflexes: DTRs, biceps, triceps, brachioradialis, patellar Achilles, superficial, pathologic, plantar (Babinski)
Gerontologic considerations: It is important not to attribute abnormality or dysfunction to aging without appropriate investigation. Although mental processing time decreases with age, memory, language, and judgment capacities remain intact.
Nursing interventions for patients having EEG, CT, or MRI
EEG:
To increase the chances of recording seizure activity, it is sometimes recommended that the patient be deprived of sleep the night before the EEG. Anticonvulsant agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG, because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders. Coffee, tea, chocolate, and cola drinks are omitted from the meal before the test because of their stimulating effect. However, the meal itself is not omitted, because an altered blood glucose level can cause changes in brain wave patterns. The patient is informed that the standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours. The patient is assured that the procedure does not cause an electric shock and that the EEG is a diagnostic test, not a form of treatment. An EEG requires the patient to lie quietly during the test. Sedation is not advisable, because it may lower the seizure threshold in patients with a seizure disorder and it alters brain wave activity in all patients. The nurse needs to check the prescription regarding the administration of anticonvulsant medication prior to testing. Routine EEGs use a water-soluble lubricant for electrode contact, which can be wiped off and removed by shampooing later. Sleep EEGs involve the use of collodion glue for electrode contact, which requires acetone for removal.
CT:
preparation for the procedure and patient monitoring
educating the patient about the need to lie quietly throughout the procedure.
Ongoing patient monitoring during sedation is necessary.
If a contrast agent is used, assessed before for an iodine/shellfish allergy, because the contrast agent used may be iodine based. Kidney function must also be evaluated because the contrast material is cleared through the kidneys. A suitable IV line for contrast injection and a period of fasting (usually 4 hours) are required prior to the study. Patients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in kidney function. Fluid intake is also encouraged after IV contrast to facilitate contrast clearance through the kidney.
MRI:
providing education
obtaining an adequate history-Ferromagnetic substances in the body may become dislodged by the magnet, so history of working with metal fragments must be reviewed. The patient is questioned about any implants of any metal objects (e.g., aneurysm clips, orthopedic hardware, pacemakers, artificial heart valves, intrauterine devices). These objects could malfunction, be dislodged, or heat up as they absorb energy. Cochlear implants will be inactivated by MRI; therefore, other imaging procedures are considered. A complete list of metal compatibility may be found on MRI manufacturer Web sites. Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) must be removed. This includes medication patches that have a metal backing and metallic lead wires; these can cause burns if not removed (Fischbach & Dunning, 2015). No metal objects may be brought into the room where the MRI is located; this includes oxygen tanks, IV poles, ventilators, or even stethoscopes. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and literally can be pulled away with such force that they fly like projectiles toward the magnet. There is a risk of severe injury and death. Further, damage to expensive equipment may occur.
Altered level of consciousness
Level of responsiveness and consciousness is the most important indicator of the patient’s condition
LOC is a continuum from normal alertness and full cognition (consciousness) to coma (Table 66-1)
Altered LOC is not the disorder but the result of a pathology
Coma: unconsciousness, unarousable unresponsiveness
Akinetic mutism: unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes
Persistent vegetative state: devoid of cognitive function but has sleep–wake cycles
Locked-in syndrome: inability to move or respond except for eye movements due to a lesion affecting the pons
Assessment:
Level of responsiveness or consciousness
Eye opening; verbal and motor responses; pupils (size, equality, reaction to light)
Pattern of respiration
Respiratory pattern
Cheyne–Stokes respiration
Hyperventilation
Ataxic respiration with irregularity in depth/rate
Eyes
Pupils (size, equality, reaction to light)
Equal, normally reactive pupils
Equal or unequal diameter
Progressive dilation
Fixed dilated pupils
Eye movements
Normally, eyes should move from side to side
Corneal reflex
When cornea is touched with a wisp of clean cotton, blink response is normal
Facial symmetry
Asymmetry (sagging, decrease in wrinkles)
Swallowing reflex
Drooling vs. spontaneous swallowing
Absent in coma
Neck
Stiff neck
Absence of spontaneous neck movement
Response of extremity to noxious stimuli
Firm pressure on a joint of the upper and lower extremity
Observe spontaneous movements
Deep tendon reflexes
Tap patellar and biceps tendons
Pathologic reflexes
Firm pressure with blunt object on sole of foot, moving along lateral margin and crossing to the ball of foot
Abnormal posture
Observation for posturing (spontaneous or in response to noxious stimuli)
Flaccidity with absence of motor response
Decorticate posture (flexion and internal rotation of forearms and hands)
Decerebrate posture (extension and external rotation)
Goals may include: Maintenance of clear airway Protection from injury Attainment of fluid volume balance Maintenance of skin integrity Absence of corneal irritation Effective thermoregulation Accurate perception of environmental stimuli Maintenance of intact family or support system Absence of complications
Priorities: Safety ABC- airway, breathing, circulation Time and effect- something i can do right now without orders and equipment Example- sit patient up who cant breath
Preventing additional injuries, imbalances
Potential complications: Respiratory distress or failure Pneumonia Aspiration Pressure ulcer Venous thromboembolism (VTE) Contractures
Seizures
Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons
Classification of seizures
Focal: originates in one hemisphere
Generalized: occur and engage bilaterally
Unknown: epilepsy spasms
“Provoked” related to acute, reversible condition
Causes: Cerebrovascular disease, Hypoxemia, Fever (childhood), Head injury, Hypertension, Central nervous system infections, Metabolic and toxic conditions, Brain tumor, Drug and alcohol withdrawal, Allergies
Triggers:
Specific time of day or night
Sleep deprivation – overtired, not sleeping well, not getting enough sleep
At times of fevers or other illnesses
Flashing bright lights or patterns
Alcohol or drug use, Use of certain medications
Stress
Associated with menstrual cycle (women) or other hormonal changes
Not eating well, low blood sugar, certain foods
Epilepsies-a group of syndromes characterized by unprovoked, recurring seizures
Classified by specific patterns of clinical features
Age at onset
Family history
Seizure type
Can be primary or secondary
Women:
Increased frequency during menses r/t hormone changes
Effectiveness of contraceptives can be decreased by the use of anticonvulsants
May note a change in pattern of seizure activity during pregnancy, require special care-risk of congenital fetal anomaly is 2-3x higher in women with epilepsy r/t maternal seizures, anticonvulsant medications, and genetic predispositions
Bone loss associated with long term use of some anticonvulsant medications; patient’s should be screened and educated about risks and prevention of osteoporosis
Gerontologic:
High incidence of new onset epilepsy
Cerebrovascular disease is leading cause of seizures of older adults, also increased incidence associated with head injury, dementia, infection, alcoholism, and aging.
Medication absorption, distribution, metabolism, and excretion altered r/t age related changes in liver and renal function. Older adult patients need to be monitored closely for adverse effects, toxicity, and osteoporosis. Cost can be a concern for adherence.
Education:
Take anticonvulsant medications daily as prescribed to keep the drug level constant to prevent seizures. Never discontinue medications, even if there is no seizure activity.
Keep a medication and seizure record (in electronic or paper format), noting when medications are taken and any seizure activity.
Notify the primary provider if unable to take medications due to illness.
Have anticonvulsant medication serum levels checked regularly. When testing is prescribed, report to the laboratory for blood sampling before taking morning medication.
Avoid activities that require alertness and coordination (driving, operating machinery) until after the effects of the medication have been evaluated.
Report signs of toxicity so that dosage can be adjusted. Common signs include drowsiness, lethargy, dizziness, difficulty walking, hyperactivity, confusion, inappropriate sleep, and visual disturbances.
Avoid over-the-counter medications unless approved by the primary provider.
Carry a medical alert bracelet or identification card specifying the name of the anticonvulsant medication and primary provider.
Avoid seizure triggers, such as alcoholic beverages, electrical shocks, stress, caffeine, constipation, fever, hyperventilation, and hypoglycemia.
Take showers rather than tub baths to avoid drowning if seizure occurs; never swim alone.
Exercise in moderation in a temperature-controlled environment to avoid excessive heat.
Develop regular sleep patterns to minimize fatigue and insomnia.
Be aware of and use the Epilepsy Foundation of America (EFA) special services, including help in obtaining medications, vocational rehabilitation, and coping with epilepsy.
Status Epilepticus (acute prolonged seizure activity)
A series of generalized seizures that occur without full recovery of consciousness between attacks
Continuous clinical or electrical seizures lasting at least 30 minutes
Considered a medical emergency
Produces cumulative effects
Vigorous muscle contractions produce heavy metabolic demand
Interference with respirations-venous congestion and hypoxia of the brain
Worry about o2 brain injury if over 5 mins
Stay with patient- call for help
Administer meds within 1-2 minutes if possible!
During a Seizure:
Monitor seizure qualities
Circumstances prior (try to identify a trigger)
Occurrence of an aura
First thing that a patient does with the onset of a seizure (stiffness or gaze, etc)
Movements/presentation of the seizure
Incontinence
Duration
Presentation at end of seizure-cognitive status?
Provide privacy, and protect the patient from curious onlookers.
Ease the patient to the floor, if possible.
Protect the head with a pad to prevent injury (from striking a hard surface).
Loosen constrictive clothing and remove eyeglasses.
Push aside any furniture that may injure the patient during the seizure.
If the patient is in bed, remove pillows and raise side rails.
Do not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything in the mouth during a seizure. Broken teeth and injury to the lips and tongue may result from such an action.
Do not attempt to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.
***If possible, place the patient on one side, which allows the tongue to fall forward and facilitates drainage of saliva and mucus but do not restrain the patient to do so, usually done when seizure is over, maintaining safety/prevention or injury is highest priority during the seizure. If suction is available, use it if necessary to clear secretions (outside the mouth to suction away expelled or ozzing secretions, never insert anything into the mouth during a seizure). After the seizure, may suction out the mouth.
After a seizure:
May be posticatal- maintain privacy, safety,
Assessment- hypoxia, vomiting, post-seizure neuro status and post ictal qualities
Make sure airway is patent
Move patient to a side-lying position to facilitate drainage of oral secretions, prevent aspiration
Bed low locked position with 3 rails up-maybe altered mental status or another seizure.
Headache
Types:
Sinus- pain is behind forehead/checkbones
cluster- pain is in and around one eye
time, and may have a crescendo-decrescendo patturn
May be accompanied by eye watering and nasal congestion
Described as “penetrating”
tension- pain is like a band squeezing head
migraine- pain, nausea & visual changes
Premonitory:
80% of patients
Symptoms hours or days prior
Depression, irritability, cold, food cravings, anorexia, change in activity level, increased urination, diarrhea, or constipation.
Aura:
Focal neurological symptoms, vary per patient, at the onset and/or during the headache phase
May include light flashes or bight spots, numbness or tingling, mild confusion, slight weakness of an extremity, drowsiness, or dizziness.
Headache:
Severe and incapacitating headache
Often associated with photophobia, phonophobia, allodynia, or nausea and vomiting.
Postdrome:
Pain gradually subsides but residual tiredness, weakness, cognitive difficulties, muscle aches/tightness and mood changes can last from hours to days
Cranial arteritis- headache or pain caused inflammation of the arteries/blood vessels.
Fatigue, malaise, weight loss, fever
Usually will have inflammation-heat, redness, swelling, tenderness, pain over artery location
Visual problems may be caused ischemia of the involved structures
Management:
Provide individualized care and treatment
Prophylactic medications may be used for recurrent migraines
Migraines and cluster headaches requires abortive medications instituted as soon as possible with onset
Provide medications as prescribed
Provide comfort measures
Quiet, dark room
Massage
Local heat for tension
Nursing management:
Help patient identify triggers and develop a preventive strategies and lifestyle changes for headache prevention
Medication instruction and treatment regimen
Stress reduction techniques
Nonpharmacologic therapies
Follow-up care
Encouragement of healthy lifestyle and health promotion activities
Assessment:
A detailed description of the headache is obtained
Include medication history and use
The types of headaches manifest differently in different persons and symptoms in one individual may also may change over time
Although most headaches do not indicate serious disease, persistent headaches require investigation
Persons undergoing a headache evaluation require a detailed history and physical assessment with neurologic exam to rule out various physical and psychological causes
Diagnostic testing may be used to evaluate underlying cause if there are abnormalities on the neurologic exam
Prevention:
begins by having the patient avoid specific triggers that are known to initiate the headache syndrome
Preventive medical management of migraine involves the daily use of one or more agents that are thought to block the physiologic events leading to an attack. Treatment regimens vary greatly, as do patient responses; therefore, close monitoring is indicated.
Alcohol, nitrites, vasodilators, and histamines may precipitate cluster headaches. Elimination of these factors helps prevent the headaches.
Medical Management Therapy for migraine headache is divided into abortive (symptomatic) and preventive approaches. The abortive approach, best used in those patients who have less frequent attacks, is aimed at relieving or limiting a headache at the onset or while it is in progress.
The preventive approach is used in patients who experience more frequent attacks at regular or predictable intervals and may have a medical condition that precludes the use of abortive therapies
Medical management of migraine during pregnancy and lactation includes nonpharmacologic strategies in addition to safe medication practices
Nonpharmacologic treatments include mainly avoidance of triggers
The triptans, which are serotonin receptor agonists, are the most specific antimigraine agents available. These agents cause vasoconstriction, reduce inflammation, and may reduce pain transmission. The five triptans in routine clinical use include sumatriptan (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), zolmitriptan (Zomig), and almotriptan (Axert) (D’Arcy, 2014). Numerous serotonin receptor agonists are under study. Many of the triptan medications are available in a variety of formulations, such as nasal sprays, inhalers, conventional tablet, disintegrating tablet, suppositories, or injections. The nasal sprays are useful for patients experiencing nausea and vomiting
The triptans are considered first-line treatment of the management of moderate to severe migraine pain. Best results are achieved with early use of triptans; oral dosing takes effect within 20 to 60 minutes of taking the drug and if needed may be repeated in 2 to 4 hours. Triptans are contraindicated in patients with ischemic heart disease. Careful administration and dosing instructions to patients are important to prevent adverse reactions such as increased blood pressure, drowsiness, muscle pain, sweating, and anxiety. The medical management of cranial arteritis consists of early administration of a corticosteroid to prevent the possibility of loss of vision due to vascular occlusion or rupture of the involved artery. The patient is instructed not to stop the medication abruptly, because this can lead to relapse. Analgesic agents are prescribed for comfort.
Nursing care:
during an attack includes comfort measures such as a quiet, dark environment; elevation of the head of the bed to 30 degrees; and symptomatic treatment (i.e., administration of antiemetic medication) (Hickey, 2014).
Symptomatic pain relief for tension headache may be obtained by application of local heat or massage. Additional strategies may include administration of analgesic agents, antidepressant medications, and muscle relaxants.
Education regarding prevention:
Be aware of the definition of migraine headaches along with the characteristics and manifestations.
Recognize triggers of migraine headaches and how to avoid such triggers as:
Foods that contain tyramine, such as chocolate, cheese, coffee, dairy products
Dietary habits that result in long periods between meals
Menstruation and ovulation (caused by hormone fluctuation)
Alcohol (causes vasodilation of blood vessels)
Fatigue and fluctuations in sleep patterns
Develop and use a paper or electronic headache diary.
Implement stress management and lifestyle changes to minimize the frequency of headaches.
Ensure correct pharmacologic management: acute therapy and prophylaxis to include medication regimen and side effects.
Use comfort measures during headache attacks, such as resting in a quiet and dark environment, applying cold compresses to the painful area, and elevating the head.
Seek out resources for education and support, such as the National Headache Foundation.
Trigeminal Neuralgia
A condition of the 5th cranial nerve that is characterized by a sudden attack of pain in the area innervated by any of the 3 branches. Pain ends as abruptly as it starts.
Characterized as a unilateral shooting, stabbing, or burning sensation.
Associated involuntary contraction of the facial muscles can cause sudden closing of the eye or twitching of the mouth.
More common 50s-60s, more common in women and in people with MS (multiple sclerosis)
Pain-free intervals may be measured in terms of minutes, hours, days, or longer. Painful episodes tend to become more frequent and agonizing.
Can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking. A draft of cold air or direct pressure against the nerve trunk may also cause pain. Certain areas are called trigger points because the slightest touch immediately starts a paroxysm or episode. To avoid stimulating these areas, patients with trigeminal neuralgia try not to touch or wash their faces, shave, chew, or do anything else that might cause an attack. These behaviors are a clue to the diagnosis.
Treatment:
Medications:
Anticonvulsants-carbamazepine, gabapentin, phenytoin (reduces transmission of impulses at certain nerve terminals)
Baclophen-muscle relaxant, adjunctive for pain control
Surgical interventions:
May relieve pain for a few years, recurrence is high. Procedures aimed at decompressing the nerve to preserve function or destroying the nerve to keep it from malfunctioning.
Microvascular decompression of the trigeminal nerve
Radiofrequency thermal coagulation-Gamma knife radiosurgery is a noninvasive method of delivering focused radiation to the trigeminal nerve; it requires 6 to 8 weeks of treatment for maximal effect to occur
Percutaneous balloon micro compression
Nursing Management:
Assessment and prevention of pain
Recognizing triggers- prevention is key in pain/symptom control
Providing cotton pads and room temperature water for washing the face, instructing the patient to rinse with mouthwash after eating if tooth brushing causes pain, and performing personal hygiene during pain-free intervals are all effective strategies. The patient is instructed to take food and fluids at room temperature, to chew on the unaffected side, and to ingest soft foods.
Goals:
Give the most nutrition in the smallest amount that you can (ensure, protein cups)
Cluster activities
Pain can go to numbness- pain block – anytime there is numbness, worry about injury
Face has a lot of injury potential
Providing post-operative care:
Postoperative neurologic assessments are conducted to evaluate the patient for facial motor and sensory deficits in each of the three branches of the trigeminal nerve.
If the surgery results in sensory deficits to the affected side of the face, the patient is instructed not to rub the eye because the pain of a resulting injury will not be detected.
The eye is assessed for irritation or redness.
Artificial tears may be prescribed to prevent dryness in the affected eye.
The patient is cautioned not to chew on the affected side until numbness has diminished.
The patient is observed carefully for any difficulty in eating or swallowing foods of different consistencies.
Bell’s Palsy
Facial paralysis is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the affected side.
The face is distorted from paralysis of the facial muscles; decreased lacrimation (tearing) occurs; and the patient experiences painful sensations in the face, behind the ear, and in the eye. The patient may also experience speech difficulties and may be unable to eat on the affected side because of weakness or paralysis of the facial muscles.
Most common in adults under 45
Majority of patients recover completely and Bell palsy rarely recurs
cause is unknown, theories include vascular ischemia, viral disease (herpes simplex, herpes zoster), autoimmune disease, or a combination of all of these factors
One sided face paralysis
Less tearing, ability to control blinking (dryness, injury)
Last weeks to months and then goes away
Treatment:
focus is to maintain the muscle tone of the face and to prevent or minimize denervation. The patient should be reassured that no stroke has occurred and that spontaneous recovery occurs within 3 to 5 weeks in most patients.
Medications
Corticosteroids- prednisone- reduce inflammation and edema
Reduces pain and prevents or minimizes denervation
Analgesics- reduces pain
Electrical stimulation- prevents muscle atrophy
Surgical exploration- indicated if tumor suspected for decompression of the nerve.
Nursing management:
While paralysis is present, nursing care involves protection of the eye from injury. The eyelid does not close completely and the blink reflex is diminished, so the eye is vulnerable to injury from dust and foreign particles. Corneal irritation and ulceration may occur.
To prevent injury, the eye should be covered with a protective shield at night/eye patch
Moisturizing eye drops during the day and eye ointment at bedtime may help prevent injury
The patient can be educated to close the paralyzed eyelid manually before going to sleep.
Wraparound sunglasses or goggles may be worn during the day to decrease evaporation from the eye.
After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.
Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy.
Exposure of the face to cold and drafts is avoided.
Peripheral Neuropathy
A disorder affecting the peripheral motor and sensory nerves, usually beginning in the feet and hands, characterized by bilateral and symmetric disturbance of function.
Most common cause of peripheral neuropathy is diabetes with poor glycemic control
Major symptoms: loss of sensation muscle atrophy Weakness diminished reflexes Pain paresthesia of the extremities
Diagnosed by history, physical examination, and electrodiagnostic studies such as EEG or EMG.
Treatment:
No specific treatment, treatment focuses on prevention and slowing progression of disease through control of causative factors like maintaining good glycemic control in diabetic patients.
Nursing Management
Education!!!
Patients with peripheral neuropathy are at risk for falls, thermal injuries, and skin breakdown.
Inspection of the lower extremities for skin breakdown, foot care and follow up!
Assistive devices such as a walker or cane may decrease the risk of falls.
Bathwater temperature is checked to avoid thermal injury.
Footwear should be accurately sized.
Driving may be limited or eliminated, thereby disrupting the patient’s sense of independence.
Preventing injury-
Wear shoes all the time
Check feet daily- hard time with wound healing
See provider/Pediatrist every 3 months- follow progression (EMG)
Parkinson DIsease
Slow, progressive neurologic movement disorder associated with decreased levels of dopamine
Manifestations:
Cardinal: tremor (rolling, resting), rigidity, bradykinesia/akinesia, postural instability
Autonomic: sweating, drooling, flushing, orthostatic hypotension, gastric and urinary retention
Dysphagia
Psychiatric changes: depression, anxiety, dementia, delirium, hallucinations
affects about 1 million patients who are hospitalized in the United States each year
affects men more often than women
Symptoms usually first appear in the 50s; however, cases have been diagnosed as early as 30 years of age.
the cause of most cases is unknown, research suggests a multifactorial combination of age, environment, and heredity
associated with decreased levels of dopamine resulting from degeneration of dopamine storage cells in the basal ganglia region of the brain
the neurotransmitters acetylcholine (excitatory) and dopamine (inhibitory), striatal neurons relay messages to the higher motor centers that control and refine motor movements. The loss of dopamine stores in this area of the brain results in more excitatory neurotransmitters than inhibitory neurotransmitters, leading to an imbalance that affects voluntary movement
Clinical symptoms do not appear until 60% of the pigmented neurons are lost and the striatal dopamine level is decreased by 80%.
Fifteen percent of early PD cases are associated with multiple genetic mutations Ongoing research includes recognition of biomarkers and development of individualized treatment options
Management:
Treatment directed toward controlling symptoms and maintaining functional independence.
Pharmacologic treatment
Levadopa
Surgical procedures
Stereotactic Procedures; thalamotomy, pallidotomy
Neural transplantation
Ongoing research
Thalamotomy and pallidotomy are ablative procedures that were formerly used to relieve symptoms of PD. However, these procedures permanently destroy brain tissue and are rarely used today.
Deep Brain Stimulation (DBS) involves surgical implantation of an electrode into the brain in either the globus pallidus or subthalamic nucleus. Stimulation of these areas may increase dopamine release or block anticholinergic release, thereby improving tremor and rigidity. Levodopa medication dose may be able to be reduced, thus improving dyskinesias.
Patients eligible for DBS are those who have responded to levodopa but are impaired by dyskinesias, have had the disease for at least 5 years, and are disabled by tremor. Patients with dementia and atypical PD are usually not considered for surgical procedures. PD rating scales and specific neurologic tests are used to identify patients who are eligible. Surgical treatment typically occurs 10 to 13 years after diagnosis.
Major care Goals:
Improved functional ability
Maintaining independence in ADLs
Achieving adequate bowel elimination
Attaining and maintaining acceptable nutritional status
Achieving effective communication
Developing positive individual and family coping skills
Nursing Diagnosis: Impaired physical mobility and risk for activity intolerance Disturbed thought processes Self-care deficits Imbalanced nutrition Constipation Impaired verbal communication Ineffective coping and compromised family coping Deficient knowledge Risk for injury Interventions Daily program of exercise ROM exercises Postural exercises Consultation with physical therapy Walking techniques for safety and balance Frequent rest periods Proper shoes Use of assistive devices
Enhancing self-care ability
Encourage, educate, and support independence
Environmental modifications
Use of assistive and adaptive devices
Consultation with occupational therapy
Support of coping
Set achievable, realistic goals
Encourage socialization, recreation, and independence
Planned programs of activity
Support groups and referral to supportive services: counselors, social workers, home care
Testing for the eyes
Most of these are outpatient
Ophthalmoscope- can be inpatient
Direct Ophthalmoscopy: a handheld instrument with various plus and minus lenses. The lenses can be rotated into place, enabling the examiner to bring the cornea, lens, and retina into focus sequentially. The examiner holds the ophthalmoscope in the right hand and uses the right eye to examine the patient’s right eye. The examiner switches to the left hand and left eye when examining the patient’s left eye. the room should be darkened, and the patient’s eye should be on the same level as the examiner’s eye.
both should be comfortable, and both should breathe normally.
The patient is given a target to gaze at and is encouraged to keep both eyes open and steady.
Indirect Ophthalmoscopy: an instrument commonly used by the ophthalmologist to see larger areas of the retina, although in an unmagnified state. It produces a bright and intense light.
Slit-Lamp Examination: is a binocular microscope mounted on a table. This instrument enables the user to examine the eye with magnification of 10 to 40 times the real image.
Tonometry: an essential part of a diagnostic evaluation; it measures IOP (intra ocular pressure) to screen for and manage glaucoma. The device used for measuring IOP is an accurately calibrated applanation tonometer, which measures the pressure needed to flatten the cornea. Because the probe or prism touches the highly sensitive cornea, a topical anesthetic is given prior to measurement
Nursing Interventions
Providing patient education prior to tonometry helps avoid possible errors in IOP measurement. Patients are cautioned to avoid squeezing the eyelids, holding their breath, or performing a Valsalva maneuver, because these may result in abnormally increased IOP.
Protection from injury while eye is under anesthetic
Color Vision Testing: The ability to differentiate colors has a dramatic effect on the activities of daily living (ADLs). For example, the inability to differentiate between red and green can compromise traffic safety. For example, red–green color deficiencies are inherited in an X-linked manner, affecting approximately 8% of men and 0.5% of women Acquired color vision losses may be caused by medications (e.g., digitalis) or pathology (e.g., cataracts).
Because alteration in color vision sometimes indicates conditions of the optic nerve, color vision testing is often performed in a neuro-ophthalmologic workup. The most common color vision test is performed using Ishihara polychromatic plates. These plates are bound together in a booklet. On each plate of this booklet are dots of primary colors that are integrated into a background of secondary colors. The dots are arranged in simple patterns, such as numbers or geometric shapes. Patients with diminished color vision may be unable to identify the hidden shapes. Patients with central vision conditions (e.g., macular degeneration) have more difficulty identifying colors than those with peripheral vision conditions (e.g., glaucoma) because central vision identifies color.
Amsler Grid: a test often used for patients with macular problems, such as macular degeneration. It consists of a geometric grid of identical squares with a central fixation point. The grid should be viewed by the patient wearing normal reading glasses. Each eye is tested separately. The patient is instructed to stare at the central fixation spot on the grid and report any distortion in the squares of the grid itself. For patients with macular problems, some of the squares may look faded, or the lines may be wavy. Patients with age-related macular degeneration (AMD) are commonly given these Amsler grids to take home. The patient is encouraged to check the grids frequently, as often as daily, to monitor macular function for early detection of changes requiring immediate attention
Ultrasonography: Lesions in the globe or the orbit may not be directly visible and are evaluated by ultrasonography. Ultrasonography is a valuable diagnostic technique, especially when the view of the retina is obscured by opaque media such as cataract or hemorrhage. An ultrasonography B-scan identifies pathology such as orbital tumors, retinal detachment, and vitreous hemorrhage. Ultrasonography A-scans are used to measure the axial length for implants prior to cataract surgery
Optical Coherence Tomography: a technology that involves low-coherence interferometry (Boyd, 2015; Gerstenblith & Rabinowitz, 2017). Light is used to evaluate retinal and macular diseases as well as anterior segment conditions. This method is noninvasive and involves no physical contact with the eye.
Fundus Photography: used to detect and document retinal lesions. The patient’s pupils are usually widely dilated before the procedure. The resulting fundus photographs can be viewed stereoscopically so that elevations such as macular edema can be identified.
Laser Scanning: Various scanning techniques use laser light in the diagnostic evaluation of eye disorders. Confocal laser scanning ophthalmoscopy provides a three-dimensional image of the optic nerve topography and is used alone or in conjunction with fundus photography to provide comparative data for suspected optic nerve disease such as glaucoma and papilledema (swelling of the optic disc due to increased intracranial pressure) (Gerstenblith & Rabinowitz, 2017). Laser scanning polarimetry is used to measure nerve fiber layer thickness and is an important indicator of glaucoma progression.
Angiography: done using fluorescein or indocyanine green as contrast agents. Fluorescein angiography is used to evaluate clinically significant macular edema, document macular capillary nonperfusion, and identify retinal and choroidal neovascularization (growth of abnormal new blood vessels). It is an invasive procedure in which fluorescein dye is injected, usually into an antecubital vein. Within 10 to 15 seconds, this dye can be seen coursing through the retinal vessels. Over a 10-minute period, serial black-and-white photographs are taken of the retinal vasculature.
Indocyanine green angiography is used to evaluate abnormalities in the choroidal vasculature, which often are seen in macular degeneration. Indocyanine green dye is injected intravenously (IV), and multiple images are captured using digital video angiography over a period of 30 seconds to 20 minutes.
Nursing Interventions:
Prior to the angiography, the patient’s blood urea nitrogen and creatinine should be checked to ensure that the kidneys will excrete the contrast agent (Fischbach & Dunning, 2015). The patient should be well hydrated, and clear liquids are usually permitted up to the time of the test. The patient is instructed to remain immobile during the angiogram process and is told to expect a brief feeling of warmth in the face, behind the eyes, or in the jaw, teeth, tongue, and lips, and a metallic taste when the contrast agent is injected.
Nursing care after angiography: includes observation of the injection site (usually the antecubital vein) for bleeding or hematoma formation (a localized collection of blood). Fluorescein may impart a gold tone to the skin in some patients, and urine may turn deep yellow or orange. This discoloration usually disappears in 24 hours. Indocyanine green dye is generally well tolerated, but some patients experience nausea and vomiting. Allergic reactions are rare; however, indocyanine green angiography is contraindicated in patients with a history of iodide reactions. Fluids are encouraged following the procedure to facilitate excretion of the contrast agent
Perimetry Testing: evaluates the field of vision. Visual field testing (i.e., perimetry) helps identify which parts of the patient’s central and peripheral visual fields have useful vision. It is most helpful in detecting centralscotomas (blind or partially blind areas in the visual field) in macular degeneration and the peripheral field defects in glaucoma and retinitis pigmentosa. Visual field evaluation and optic nerve assessment are major components of monitoring and detecting glaucoma progression.
Impaired Vision
Refractive errors: Can be corrected by lenses that focus light rays on the retina
Emmetropia: normal vision
Myopia: nearsighted
Hyperopia: farsighted
Astigmatism: distortion caused by irregularity of the cornea
Low vision:
Visional impairment that requires devices and strategies in addition to corrective lenses
Best corrected visual acuity (BCVA) of 20/70 to 20/200
Blindness:
BCVA 20/400 to no light perception
Legal blindness is BCVA that does not exceed 20/200 in better eye or widest field of vision is 20 degrees or less
Impaired vision often is accompanied by functional impairment
Assessment of low vision:
History
Examination of distance and near visual acuity, visual field, contrast sensitivity, glare, color perception, and refraction
Special charts may be used for low vision
Nursing assessment must include assessment of functional ability and coping and adaptation in emotional, physical, and social areas
Management:
Support coping strategies, grief processes, and acceptance of visual loss
Strategies for adaptation to the environment;
Placement of items in room
“Clock method” for trays
Communication strategies
Collaboration with low-vision specialist, occupational therapist, or other resources
Braille or other methods for reading and communication
Service animals
Ocular Medication administration
Ability of the eye to absorb medication is limited
Barriers to absorption include the size of the conjunctival sac; corneal membrane barriers, blood–ocular barriers; and tearing, blinking, and drainage
Intraocular injection or systemic medication may be needed to treat some eye structures or to provide high concentrations of medication
Topical medications (drops and ointments) are most frequently used because they are least invasive, have fewest side effects, and permit self-administration
Topical anesthetics
Mydriatics (dilate) and cycloplegics (paralyze): Contraindicated with narrow angles or shallow anterior chambers and inpatients on monoamine oxidase inhibitors or tricyclic antidepressant
May cause CNS symptoms and increased BP, especially in children or older adults
Anti-infective medications:
Antibiotic, antifungal, or antiviral products
Medications used for glaucoma:
Increase aqueous outflow or decrease aqueous production
May constrict the pupil and may affect ability to focus the lens of the eye; affects vision
May also may produce systemic effects
Anti-inflammatory drugs; corticosteroid suspensions:
Side effects of long-term topical steroids include glaucoma, cataracts, and increased risk of infection. To avoid these effects, oral NSAID therapy may be used as an alternate to steroid use
Prostaglandin Analogs: eye color change, darkening of eyelid skin, eyelash growth, droopy eyelids, sunken eyes, stinging, eye redness, and itching
Beta Blockers: low blood pressure, reduced pulse rate, fatigue, shortness of breath; rarely: reduced libido, depression—Systemic side effects of beta blockers can be minimized by closing the eyes following application or using a technique called punctal occlusion that prevents the drug from entering the tear drainage duct and systemic circulation.
Alpha Agonists: burning or stinging, fatigue, headache, drowsiness, dry mouth and nose, relatively higher likelihood of allergic reaction.
Carbonic Anhydrase Inhibitors: in eye drop form: stinging, burning, eye discomfort; in pill form: tingling hands and feet, fatigue, stomach upset, memory problems, frequent urination.
Rho Kinase Inhibitors: eye redness, corneal deposits, stinging, and small bleeds on the white of the eye.
Glaucoma
A group of ocular conditions in which damage to the optic nerve is related to increased intraocular pressure (IOP) caused by congestion of the aqueous humor
Incidence increases with age
Risk factors: African American race Cardiovascular disease Diabetes Family history of glaucoma Migraine syndromes Nearsightedness (myopia) Older age Previous eye trauma Prolonged use of topical or systemic corticosteroids Thin cornea
Types: Wide angle Narrow angle Congenital Associated with other conditions May be primary or secondary
S/S:
“Silent thief”; unaware of the condition until there is significant vision loss; peripheral vision loss, blurring, halos, difficulty focusing, difficulty adjusting eyes to low lighting
May also have aching or discomfort around eyes or headache
Diagnostic Findings:
Tonometry to assess IOP
Opthalmoscopy to inspect the optic nerve disc
Central visual field testing
Management:
Goal is to prevent further optic nerve damage
Maintain IOP within a range unlikely to cause damage
Pharmacologic therapy: miotics, beta blockers, alpha2-agonists, carbonic anhydrase inhibitors, prostaglandins
Laser procedures- Doctors often recommend laser surgery before incisional surgery, unless the eye pressure is very high or the optic nerve is badly damaged. During laser surgery, a focused beam of light is used to treat the eye’s trabecular meshwork (the eye’s drainage system). This helps increase the flow of fluid out of the eye.
Surgery- Incisional Surgery
In contrast, incisional surgery (also called filtering surgery) involves creating a drainage hole with the use of a small surgical tool. This new opening allows the intraocular fluid to bypass the clogged drainage canals and flow out of this new, artificial drainage canal.
When laser surgery does not successfully lower eye pressure, or the pressure begins to rise again, the doctor may recommend incisional surgery. Occasionally, glaucoma surgery may have to be repeated especially if excessive scarring cannot be prevented or after long periods of time.
Nursing Interventions:
Assess for knowledge level and adherence
Education about self-care
Focus on maintaining the therapeutic regimen for lifelong control of a chronic condition
Provide education regarding use and effects of medications
Medications used for glaucoma may cause vision alterations and other side effects. The action and effects of medications need to be explained to promote compliance
Provide support and interventions to aid the patient in adjusting to vision loss or potential vision loss
Cataracts
An opacity or cloudiness of the lens
Increased incidence with aging; by age 80 years, more than half of all Americans have cataracts
A leading cause of disability in the United States
Age: Risk factor
Three types: Traumatic Congenital Senile cataract Can get it congenially or from a trauma but mostly from age Become sensitive to glare
S/S:
Painless, blurry vision, surroundings dimmer
Sensitivity to glare
Reduced visual acuity
Other effects include myopic shift (near-sighted/short-sighted, unable to see unless relatively close); astigmatism (causes blurred vision, occurs when cornea is irregularly shaped or because of the curvature of the lens); diplopia (double vision); and color shifts, including brunescens (color value shift to yellow-brown); Hyperopia (far-sightedness)
Diagnostic findings include decreased visual acuity and opacity of the lens by ophthalmoscope, slit lamp, or inspection
Management:
If reduced vision does not interfere with normal activities, surgery is not needed
Surgery is preformed on an outpatient basis with local anesthesia
Surgery usually takes less than 1 hour, and patients are discharged soon afterward
Complications are rare but may be significant
Phacoemulsification: an ECCE that uses an ultrasonic device to suction the lens out through a tube; incision is smaller than with standard ECCE
Lens replacement: after removal of the lens by ICCE or ECCE, the surgeon inserts an intraocular lens implant (IOL). This eliminates the need for aphakic lenses; however, the patient may still require glasses
Nursing management:
Preoperative care: The patient with cataracts receives the usual preoperative care-standard battery of preoperative tests (e.g., complete blood count, electrocardiogram, and urinalysis) commonly performed for most surgeries as indicated by the patient’s medical history. Alpha-antagonists (particularly tamsulosin [Flomax], which is used for treatment of enlarged prostate) are known to cause a condition called intraoperative floppy iris syndrome. Alpha-antagonists can interfere with pupil dilation during the surgical procedure, resulting in miosis and iris prolapse and leading to complications. Intraoperative floppy iris syndrome can occur even though a patient has stopped taking the drug. The nurse needs to ask patients about a history of taking alpha-antagonists. Surgical team members are then alerted to the risk of this complication (Comerford, 2015). Dilating drops are given prior to surgery. Nurses in the ambulatory surgery setting begin patient education about eye medications (antibiotic, corticosteroid, and anti-inflammatory drops) that will need to be self-administered to prevent postoperative infection and inflammation.
Usual preoperative care for ambulatory surgery
Dilating eye drops or other medications as ordered
Postoperative care
Patient education
Provide written and verbal instructions
Instruct patient to call physician immediately if vision changes; continuous flashing lights appear; redness, swelling, or pain increase; type and amount of drainage increases; or significant pain is not relieved by acetaminophen
Post op instructions: verbal and written education regarding eye protection, administration of medications, recognition of complications, activities to avoid, and obtaining emergency care (see Chart 63-8). An eye shield is usually worn at night for the first week to avoid injury. The nurse also explains that there should be minimal discomfort after surgery and educates the patient about taking a mild analgesic agent, such as acetaminophen, as needed. Antibiotic, anti-inflammatory, and corticosteroid eye drops or ointments are prescribed postoperatively. Patients prescribed anti-inflammatory or corticosteroid eye drops are monitored for possible increases in IOP
If they start seeing flashing lights, redness, swelling or pain CALL
Risk of retinal detachment^^^
Discharge instructions should include:
Avoid lying on the side of the affected eye the night after surgery
Keep activity light (e.g., walking, reading, watching television). Resume the following activities only as directed by the ophthalmologist driving, sexual activity, unusually strenuous activity
Avoid lifting, pushing, or pulling objects heavier than 15 lb
Avoid bending or stooping for an extended period
Be careful when climbing and descending stairs
Sneezing if necessary should not be held in because it would increase IOP. Sneezing should be done with an open mouth to decrease pressure
