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Unit 5 > Sensory Perception Nursing Process > Flashcards

Sensory Perception Nursing Process Flashcards

1
Q

Pathophysiolgy

of

Cataracts (5)

A
  • Opacity of the lense that distorts the image projected into the retina
  • Lens density increases, transparency is lost
  • Both eyes may get it, but rate of progression is different
  • Blindness occurs if left untreated
  • Usually age related (over 65)
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2
Q

Causes of cataracts due to eye trama (5)

A
  • heat
  • blunt force
  • x-rays
  • UV light
  • radiation
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3
Q

Causes of cataracts due to toxicity (4)

A
  • corticosteroids
  • chlorpromazine
  • beta blockers
  • miotic drugs
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4
Q

Causes of cataracts due to other systemic diseases (4)

A

diabetes

hypoparathyroidism

down syndrome

chronic sunlight exposure

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5
Q

Causes of cataracts due to Intraocular Disease (4)

A

retinitis pigmentosa

recurrent uveitis

glaucoma

retinal detachment

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6
Q

Risks associated with cataracts (7)

A

advanced age

diabetes or other systemic diseases

heredity

smoking

exposure to the sun

eye trauma

chronic corticosteroid use

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7
Q

Subjective manifestations of cataracts (5)

A

smudged glasses

Blurred vision

Diplopia – double vision

Glare and light sensitivity – photo sensitivity

Halo around lights

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8
Q

Objective manifestations of Cataracts (5)

A

Progressive and painless loss of vision

decreased color perception

retina opacity

Absent red reflex

Cloudy bluish white pupil (late stage)

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9
Q

Interventions for those with cataracts who have not had surgery (4)

A

Surgery is only “cure”

Procedure: Phacoemulsification and clear plastic lens replacement

Nursing Priorities

  • safety
  • teach them how to make best of existing vision

Check visual acuity using Snellen chart.

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10
Q

Interventions for those with catacts that have not had surgery (2nd group of 4)

A

Check internal/external eye using ophthalmoscope.

Determine functional capacity due to decreased vision.

Increase light in room.

Provide adaptive devices like Magnifying lens, large print books, talking clocks

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11
Q

Pre-Operative Care for cataracts surgery (6)

A

Mydriatic drug dilates pupil

Reinforce info from opthamologist

stress that care after surgery requires instillation of different eye drops, several times a day, for 2-4 weeks.

assess pt’s ability to evaluate eye appearance and take eye drops

if pt is unable to perform, help find options (family)

ask pt. if they are taking aspirin, warfarin, clopidogrel, or dabigatran

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12
Q

Cataract Post OP education (7)

A

teach to:

wear dark glasses outdoors or in bright places until pupil is ready

how to instill eye drops properly and fall prevention

watch for infection of bleeding

avoid water in eye for 3-7 days

avoid driving until vision is not blurry

light ADL’s are ok but NO Vacuuming

Create written schedule for timing/order of eye drops

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13
Q

Cataract Post-Op Interventions and Education (6)

A

suggest use of cool compresses and mild analgesics such as tylenol for discomfort

remind NOT to use Aspirin due to blood clotting

light eyepatch in case of accidental rubbing, NOT COMMON

Teach pt to avoid activities that increase IOP

Teach pt to stand in shower with head AWAY from shower head 1st week post Op.

Wash hair 1-2 days post op, ONLY WITH HEAD TILTED BACK.

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14
Q

activities increasing IOP (5)

A

bending from the waist

lifting more than 10 pounds

sneezing, coughing

blowing nose

bowel movement strain

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15
Q

Activities that increase IOP (4)

A

vomiting

sexual intercourse

avoid hyperflexed position

wearing tight shirt collars

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16
Q

cataract surgery complications of concern (5)

A

significant swelling

bruising

bloodshot eye after initial has cleared

pain with nausea or vomiting

increased eye redness

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17
Q

cataract surgery complications of concern (2nd set of 5)

A

decreased visual acuity (infection)

increased tears (infection)

photophobia

yellow or green drainage (infection)

flashes of light or floating tracers after initial surgery (infection)

sharp sudden pain in affected eye

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18
Q

Normal or Expected Post Op Manifestations of Cataract Surgery (4)

A

mild itching

bloodshot appearance (initially)

slightly swollen eyelid

creamy white, dry, crusty drainage on eye lids and lashes

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19
Q

Side Effects for Pilocarpine

A

blurred vision.

headache

flushing

increased saliva

sweating

harder to see things in dim light

dizziness

chills

Brow ache,

corneal toxicity,

conjunctival inflammation,

transient myopia,

Retinal detachment

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20
Q

Drugs used for glaucoma

A

Prostaglandin agonists (prost)

  • Travoprost
  • Latanoprost

Adrenergic Agonists(ine)

-Brimonidine

Beta-Adrenergic Agonists (olol)

  • Levobunolol
  • Timolol

Cholinergic Agonists- (pine)

-Pilocarpine

21
Q

Pathophysiology of Glaucoma (6)

A

Disturbance of functional/structural integrity of optic nerve due to high IOP

Decreased fluid drainage or increased fluid secretion increases IOP,presses on nerve fibers and photoreceptors depleting their oxygen ending in necrosis (blindness)

Vision loss is gradual and painless starting from outsidel without pt knowing

1mL aqueous fluid always present but constantly produced & reabsorbed 5mL per day

Expected IOP range = 10 - 21 mm/Hg.

22
Q

3 types of Glaucoma

A

Primary (most common)

  • Open angle
  • angle closure

Associated

Secondary

23
Q

Describe open angle glaucoma (POAG)

(4)

A

both eyes affected w/ no manifestations in early stages

gradual onset

Open-angle refers to the angle between the iris and sclera.

aqueous humor outflow is decreased due to blockages in the eye’s drainage system (Canal of Schlemm and trabecular meshwork)

24
Q

Causes of Primary glaucoma

A

Aging

Heredity

Visual Retinal vein occlusion

25
Q

Describe Primary Angle Closure Glaucoma (PACG)

(4)

A

considered an emergency

less common form of glaucoma.

IOP rises suddenly. sudden onset

angle between the iris and the sclera suddenly closes

26
Q

Causes of secondary glaucoma (6)

A

uveitis

iritis

trauma

Eye surgery or tumors

neovascular disorders

degenerative disease

27
Q

Causes of associated glaucoma (4)

A

Diabetes

hypertension

Severe myopia

retinal detachment

28
Q

Risks associated with glaucoma (6)

A

Age

Infection

Tumors

Diabetes mellitus

Genetic predisposition

Hypertension

29
Q

Late POAG manifestations (7)

A

cupping/atrophy of optic disk

optic disk gets wider and turns grey or white

Peripheral vision loss

decreased visual acuity not correctable w/glasses

double vision

Halos around lights

IOP tonometry reading between 22-32

30
Q

Acute Angle Closure (PACG) subjective data

A

sudden, severe pain around the eyes that radiates over the face.

Headache or brow pain,

nausea and vomiting

halos around lights

blurred vision

decreased light perception

31
Q

PACG objective data (6)

A

reddened sclera

foggy cornea

shallow anterior chamber

cloudy aqueous humor

moderately dilated, nonreactive pupil.

IOP tonometry reading 30+!!!

32
Q

Non-Surgical Interventions for glaucoma (4)

A

Safety Priority: teach about correct technique for eyedrop instillation

Punctal Occlusion- place pressure on corner of eye near nose immediately after administration to prevent systemic absorption

Stress importance of instilling drops on time and no skipped doses

when taking multiple drugs, wait 10-15 min. between next drug to prevent “wash out”

Stress good hygiene: washing hands, cleaning container tips, no touching tip to eye

33
Q

Surgical Procedures for Glaucoma and how they work (2)

A

Laser Trabeculoplasty

  • Burns trabecular meshwork, shrinking fibers making more spaces for aqueous humor to flow out.

Filtering microsurgery

  • Creates drainage hole between post. and anter. chambers
34
Q

Most serious complications after Glaucoma surgery (2)

A

Choroidal Hemorrhage

  • acute pain deep in the eye
  • decreased vision
  • vital sign changes

Choroidal Detachment

35
Q

Pathophysiology of Macular Degeneration (5)

A

Dry and Wet Macular Degeneration

central loss of vision affecting macula of the eye.

no cure

age related or result of exudate

Mild blurring and distortion at first, followed by complete central vision loss

36
Q

Describe Dry Macular degeneration (2)

A

most common

caused by a gradual blockage in retinal capillary arteries, resulting in macula becoming ischemic and necrotic due lack of retinal cells.

37
Q

Describe Wet Macular Degeneration (4)

A

sudden decrease in vision after a detachment of pigment epithelium in the macula.

caused by new growth of blood vessels having thin walls allowing blood and fluid to leak from them.

can occur in only one eye or both

can occur at any age

38
Q

Risks associated with macular degeneration (6)

A

Smokers

female

short stature

hypertension

family history

diet lacking carotene,vitamin A,b12, antioxidants

39
Q

Interventions for macular degeneration

(3) subjective
(2) objective

A

Subjective Data

  • lack of depth perception
  • distorted objects
  • blurred vision

Objective data

  • loss of central vision
  • blindness
40
Q

Interventions for Dry macular degeneration (4)

A

No cure

focus on slowing progression and utilizing existing sight

prevention: eat foods high in antioxidants, vitamin B12, and the carotenoids lutein and zeaxanthin.

suggest assistive devices such as magnifying glass, lg print books, and talking clocks

41
Q

Interventions for wet macular degeneration

A

focus on slowing progression & ID further changes in sight

Laser therapy can limit damage

VEGFI’s injected monthly can slow progression

Photodynamic therapy may seal leaking vessels

42
Q

Retinal detachment pathophysiology (2)

A

separation of the retina from the epithelium

emergency

43
Q

subjective manifestations of retinal detachment (4)

A

sudden, painless onset

flashes of light (photopsia)

floating dark spots (associated with blood)

curtain pulled over visual field

44
Q

Objective manifestations of retinal detachment (2)

A

Observations through opthamoscope:

  • gray bulges or folds in retina that quiver
  • sight of a hole or tear at edge of detachment
45
Q

Interventions for retinal detachment

A

If caught while it is a hole or tear, it may be sealed by:

  • photocoagulation
  • freezing probe

Spontaneous reattachment of fully separated retina is rare

For a full detachment, surgery is needed:

  • procedure called a scleral buckling
46
Q

Preoperative care for retinal detachment

A

reassure pt. to allay fears of permanent vision loss

teach pt. to restrict activity/head movement before surgery

apply an eye patch over affected eye to reduce eye movement

Administer prescribed topical drugs to inhibit pupil constriction and accommodation

47
Q

Postoperative care for retinal detachment (4)

A

Apply eye patch and shield

monitor vitals & asses eyepatch for drainage

position pt. as prescribed to promote reattachment if gas or oil is used

administer prescribed analgesics & antiemetics

48
Q

Postoperative care for retinal detachment (2nd group of 4)

A

Instruct pt. to report pain or pain with nausea

Remind pt. to avoid activities contributing to IOP

Remind Pt. to avoid activities w/ REM like reading, writing, sewing, etc…

Report s/s of infections like sudden reduced acuity, eye pain, pupil not constrict to light

49
Q

Uses and considerations of Latanaprost (4)

A

Constricts Pupil

Decreases IOP in open-angle glaucoma; maybe narrow-angle glaucoma with more studies

Not recommended for pts with torn or absent lens or eye trauma.

NO contact lenses for 15 minutes after administration.

Unit 5 (8 decks)

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