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72 Cards in this Set
- Front
- Back
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Cataract
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* opacification (clouding) of the lens of the eye which can interfere with the light transmission to the retina and the ability to perceive images clearly.
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Cataract - s/sx/RF
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*s/sx - visual acuity decreases; complaints of glare, color discrimination is impaired. *RF-congenital, aging, toxicity, accidents, radiation (sunlight), altered metabolism (DM), cigarette
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Cataract - Tx/Meds
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Tx- surgery is only option. No meds available. (lens is removed and an artificial lens is implanted.
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Cataract - NIs
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*HP-wear sunglasses, avoid radiation, antioxidants. *Pre-op-accurate info given, *Post-op-semi-fowler’s or on non-op side, protective shield, eye drops, loss of depth perception, and AVOID ACTIVITIES THAT INCREASE IOP
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Interocular Pressure increases with
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straining, coughing, sneezing
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Glaucoma
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condition characterized by optic neuropathy with gradual loss of peripheral vision and usually, increased intraocular pressure of the eye. Silent killer of vision. Leading cause of blindness worldwide.
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Glaucoma - s/sx
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gradual narrowing of vision field (usually unnoticeable until late)
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Glaucoma - primary
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most common in adults over the age of 60 but may be a congenital condition in infants and children. Two types open-angle (POAG), and angle-closure (PACG)
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Glaucoma - secondary
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develops as a results of infection or inflammation of the eye, cataract, tumor, hemorrhage or eye trauma
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Glaucoma - Open Angle (POAG)
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-accounts for 90% of cases. -trabecular meshwork (drainage tubes) become clogged and fluid doesnt drain causing IOP. -chronic and gradually progressive with no symptoms.
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Glaucoma - Angle Closure (PACG)
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-accounts for 5-10% of cases. -The angle of the iris and anterior chamber narrows, obstructing the outflow of aqueous humor. - aka acute angle closure.
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Glaucoma - Meds/Tx
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-administer cholinergic agonist (miotic), beta blockers, carbonic anhydrase inhibitors. - Surgery - laser trabeculoplasty. - Dx - tonometry (measures intraocular pressure. .
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Glaucoma - ND
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Disturbed sensory perception:Visual, Risk for injury, Anxiety.
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Retinal Detachment
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-separation of the retina from the choroid in the posterior eye. -results from aphakia (cataract removal); diabetic retinopathy, trauma, retinal break.
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Retinal Detachment - assessment
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flashes of light (photopsia), curtain coming down, cobweb, floaters, ring; blurred vision; loss of vision. Dx: visual acuity, ophthalmoscopy.
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Retinal Detachment - Nursing implementations
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-considered a medical emergency. -surgical options- photocoagulation; cryotherapy; laser, scleral buckling
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Retinal Detachment - NDs/NIs
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Ineffective tissue perfusion: retinal-restoring contact between the retinal and the choroid is priority; Anxiety
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Macular Degeneration
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-destructive changes in the maculae due to injury or gradual failure of the outer pigmented layer of the retina, which removes cellular waste products and keeps the retinal attached to the choroid; retinal degenerative process involving the macula varying degrees of central vision loss
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Macular Degeneration - dry/nonexudative
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-gradual process that begins with accumulation of deposits called drusen beneath the pigment epithelium of the retina. Over time, these deposits enlarge and become more numerous causing the epithelium to detach in small areas and become atrophic, interfering with sensory function of the macula.
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Macular Degeneration - wet/exudative
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-formation of new, weak blood vessels in the potential space between the choroid (vascular layer) and the retina (neurosensory layer). These new vessels tend to leak, elevating the retina from the choroid and distorting vision.
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Macular Degeneration - s/sx
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-central vision becomes blurred and distorted, but peripheral vision remains intact. Visual distortion (wavy lines)
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macular Degeneration - tx
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-dry-in early stages can be slowed thru use of high-dose antioxidants and zinc. Also daily administration of Vit C, E, A (beta-carotene), zinc and copper. -wet- treated with laser surgery
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macular degeneration - NI/ND
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significant psychosocial issues related to loss of vision. Nursing focus is on helping hte patient and family members adapt by offering visual aids and other coping strategies.
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Unconsciousness - ND/NI
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Priority ND/NI airway maintenance, skin integrity, contractures, and nutrition. Number 1 being airway patency.
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Triggers for migraines
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Hormonal, Foods (chocolate, wine, aged cheese), weather (barometric pressure. rapid changes in blood glucose levels, stress, emotional excitement, fatigue, alcohol, stimuli like bright lights,
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Types of headaches - Migraine
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migraine-2 types with aura and without aura (visual disturbance prior to onset of migraine. Pain is usually unilateral and throbbing, but can become bilateral as it progresses. Systemic manifestations- n/v, chills, fever, hunger, anorexia, etc.
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Types of headaches - Cluster
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extremely severe, unilateral, burning pain located behind or around the eyes. Usually male 20-40, occurs in groups. Typically occurs 2-3 hours after sleeping and awakens person. same side of head is involved.
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Treatment for headaches
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Beta blockers - propranolol/Inderol®; tricyclic antidepressants (amitriptyline/Endep®); ergo®)talkaloids (methysergide/Sansert), SSRIs (paroxetine/Paxil®) and calcium channel antagonists (verapamil/Canlan®); Sumatriptan/Imitrex®-rapidly effective; Zolmitriptan/Zomig®; sometimes Demerol/codeine once headache is in progress.
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Stroke, CVA, brain attack
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sudden decrease in blood flow to localized areas of the brain. characterized by a gradual or rapid onset of neurologic deficits b/c dec. blood flow. b/c the motor pathways cross @ junction of the medulla and spinal cord, strokes lead to loss of impairment of sensorimotor functions on the side of the body opposite the side of the brain that is damaged..known as contralateral deficit. rt hemisphere --> deficits left side of body.
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contralateral deficit
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a stroke in the right hemisphere of the brain is manifested by deficits in left side of the body and vice versa.
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Types of CVAs - Hemorrhagic
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*Hemorrhagic - when blood vessel ruptures, spilling blood into spaces surrounding neurons. manifestation depend on location but incl. vomiting, headache, seizures, hemiplegia and loss of conciousness.
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Types of CVAs - Ischemic
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*Ischemic - blockage may result from a blood clot (either as a thrombus or a emoli, or from stenosis of a vessel resulting from a buildup of plaque. Accounts for 87% of all strokes.
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Types of CVAs - TIAs
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TIA-transient ischemic attack. aka “mini-stroke”, brief period of localized cerebral ischemia that causes neurologic deficits lasting for less than 24 hours. TIAs are often the warning signals of an ischemic thrombotic stroke. Reversible ischemic neurologic deficit (RIND). s/sx diplopia, garbled speech, numbness
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Doppler Studies
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carotid duplex study. evaluates the velocity of the blood flow thru the carotid arteris and identifes occlusive disease. Sound waves produced an image. Also listening for bruits.
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Carotid Endarterectomy
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an occluded area in an artery is clamped off and an incision is made in the artery. Plaque is removed from the inner layer of the artery, the artery is sutured or a graft is completed.
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Thrombotic Stroke
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cause by occlusion of a large cerebral vessel by a thrombus (blood clot). most often occur in older adults who are resting or sleeping.
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Embolic stroke
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a blood clot from atrial fibrillation, ventricular thrombi, MI, CHD, or atherosclerotic plaque and other sources enters the circ sys.and then becomes lodged in a vessel to narrow.
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Priority interventions for Stroke
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Airway patency, preventing aspiration, communication, self esteem
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Remember...
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depression is not a nursing diagnosis
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tPA
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Fibrinolytic therapy using a plasminogen activator is used to treat ischemic stroke. The drug converts plasminogen to plasmin, resulting in fibrinolysis of the clot. to be effective, it must be given IV w/in 3 hours of the onset of manifestations, after confirming (w/CT scan), that pt has not had a hemorrhagic stroke.
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Anticoagulant drug therapy
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may be ordered for an ischemic stroke. Coumadin, heparin, lovenox. Never to be given to a patient with a hemorrhagic stroke.
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How to prevent aspiration with a person who has had a stroke
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-position upright sitting position with neck slightly flexed. -order pureed or soft food and liquids should be thickened (like honey), assess for coughing with eating or drinking.
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types of seizures - simple partial seizure
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partial seizures, which involve the activation of only a restricted part of one cerebral hemisphere, in which consciousness is not altered. Jacksonian/twitching
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types of seizures - complex partial seizure
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partial seizure in which consciousness is impaired. occurs in temporal lobe/altered behavior.
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types of seizures - generalized
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involves both hemispheres; tonic/clonic (grand mal) or absence (petit mal) seizures.
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grand mal seizures
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most common type of seizures in adults. A warning aura may precede seiz. Auras may be a vague sense of uneasiness or an abnormal gustatory, visual, auditory or visceral sensation. (metallic taste, smell of burning rubber or seeing a bright light). Tonic (muscles rigid)/Clonic (muscles relaxed) cycle.
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Petit mal seizures
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sudden brief cessation of all motor activity accompanied by a blank stare and unresponsiveness.
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ALS
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Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease) - loss of motor neurons; death 2-6/3-10 years; patient remains cognitive; death 2-5 years due to resp failure. No cure. muscle wasting.
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ALS - NDs
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Risk for disuse syndrome - NIs focus on preventing skin breakdown and infections like UTIs. Ineffective Breathing pattern - as weakness progresses the respiratory muscles are affected - baseline breathing pattern; turn q2; elevate HOB, suction and provide O2; monitor temp and lung sounds.
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Trigeminal Neuralgia
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aka tic douloureux, chronic disease of the trigeminal cranial nerve V that cuases unilateral excruciating facial pain. There are 3 divs of this nerve: ophthalmic, maxillary and mandibular. the max and mand are most affected by this disorder
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Trigeminal Neuralgia - manifestaions
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brief, repetitive episodes of sudden sever facial pain experienced over the surface of the skin. Usually starts near one side of the mouth and rises toward the ear, eye or nostril of same side.
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Trigeminal Neuralgia - NI/ND
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Primary patient concerns are managing pain, maintaining nutrition and preventing injury. Identify factors that trigger attack. Acute Pain, Risk for altered nutr (less);
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what is preferred position for a comatose pt?
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maintain a side lying position with the HOB elevated approx 30degrees. Do not position pt on their back.
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Glasgow coma scale
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used to assess and evaluate 3 responses: eye openings, best verbal response; best motor response. allows same conclusion by all providers. 15 full alert, <8 coma
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Romberg test
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an indication of loss of the sense of position in which the patient loses balance when standing erect, feet together, and eyes closed.
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Postoperative care - eye surgery
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to avoid increasing intraocular pressure - place in semi-F or Fowler’s position on the unaffected side; remind patient to avoid coughing, sneezing or straining as needed. Watching tv, heavy lifting.
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Predisposition for stroke
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HTN, diabetes, sickle cell anemia, ATRIAL FIBRILLATION, hyperlipidemia, sleep apnea, smoking, substance/ETOh abuse, TIA, family hx, obesity, sedentary lifestyle, recent viral/bacterial infection. Women-oral contraception use, pregnancy, childbirth, menopause, migraine headaches w/auras, autoimmune disorders
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unilateral neglect
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stroke complication; form of sensory-perceptual deficit in which the pt cannot integrate and use perceptions from the affected side of the body or from the environment on the affected side and ignores that part.
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TIA meds
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antiplatelet drugs are used to prevent clot formation and blood vessel occlusion incl aspirin (interferes with platelet aggregation), clopidogrel/plavix®, dipyridamole/persantine®, ticlopidine/ticlid®
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Bladder training
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have pt void on schedule, such as q2, rather than in response to the urge to void. Also teach Kegel exercises.
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Phenytoin/Dilantin® teaching
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to avoid gingival hyperplasia maintain good oral hygiene, Use soft toothbrush, massage gums, and floss daily.
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Conjuctivitis - s/sx
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redness and itching of affected are common; also complain of scratchy, burning or gritty sensation; photophobia. Discharge/tearing due to inflammation; discharge can be purulent, water, mucoid. Can have assoc s/sx such as pharygnitis, fever, mailase and swollen preauricular lymph nodes.
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Conjuctivitis - NDs/NIs
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priority ND/NIs include risk for infection and risk for altered vision. Preventing the spread is vital...teach to wash hands before meds and to avoid touching or rubbing eyes. avoid contact lenses.
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presbyopia
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impaired near vision resulting from a loss of elasticity of the lens related to aging. weakened dialator muscles
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Prevention/health promotion - HEARING
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initiating hearing screening and providing infomation about hearing loss and its treatment.
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Aneurysm - Surgical intervention
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tx are performed either to prevent rupture or to isolate the vessel to prevent further bleeding. several methods but the neck of the aneurysm may be clipped with a metal clip to prevent entry of blood into the aneurysm.
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Botulism tx
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Botulism antitoxin must be given. Any toxin the GI tract are removed by cathartics, enemas and gastric lavage.
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botulism NI/NDs
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NIs focus on monitoring for resp. failure and providing ventilatory assistance if neces. Education important.
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Lumbar puncture test
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used to measure CSF pressure and obtain sample. used to dx, IICP from subarachnoid hemorrhage, brain tumor. Place pt on side in fetal position with back bowed, head flexed on the chest, and the knees drawn up to the abdomen. Monitor changes in neuro status (fever, lower numbness, tingling, nonreactive pupils.
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Tetanus - tx
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If contaminated wound/immunization uncertain, passive immun. with tetanus immune globulin is administered. Active immuniz with tetanus toxoid is begun at the same time. Wound carefully debrided and abx given.
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tetanus - tx (cont)
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Penicllin to destroy the ogranism; thorazine®/valium® for muscle spasms and seizures; anticoagulants to prevent dvt. In severe cases, mechanical ventlation
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Tetanus - prevention
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DPT immunization series.
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