PHYSIOLOGY OF VISION TYPES OF GLAUCOMA

» In order for the vision to occur, 4 physiological process 1) CHRONIC OPEN ANGLE GLAUCOMA (COAG)
are involved: » Most common type of glaucoma
o Refraction of light rays (bending of light rays) » Characterized by obstruction in the flow of aqueous
cornea / lens humor at the trabecular meshwork of the canal of
o Accommodation of the lens Schlemm
o Constriction and dilation of pupil » GRADUAL IN ONSET, BILATERAL
o Convergence of the eyes » IOP = 30 – 50 mmHg

» Normal Refraction / Normal Eye 2) ACUTE CLOSE ANGLE GLAUCOMA (ACAG)

o Emmetropia » Most Dangerous of all type of glaucoma
characterized by forward displacement of the iris to
» Error of Refraction the cornea
o MYOPIA (Nearsightedness) » Could lead to BLINDNESS
• TREATMENT » Sudden / acute onset, UNILATERAL
§ BINCONVE LENS (Curve inwards) » IOP = 50 – 70mmHg
§ They are the thinnest at the center and
thicker at the stage. 3) CHRONIC CLOSE ANGLE GLAUCOMA (CCAG)
» Precipitated by ACAG but with longer duration
o SEVER MYOPIA
• Number 1 cause of RETINAL DETACHMENT
§ Medical emergency, it could lead to SINGS AND SYMPTOMS
permanent blindness. o Tunnel like vision
o Loss of peripheral vision
» Error of Refraction o Halos and rainbows around lights / blurring of vision
o HYPEROPOA (Farsightedness) o Headache
§ Treatment: BICONVEX LENS o Nausea and vomiting
(outward facing lens) o Steamy cornea
o Eye pain / discomfort / red eyes
o ASTIGMATISM (Distorted Vision) o Difficulty of focusing
§ Irregular shape of the cornea o Difficulty in adjusting the eyes in the dark room
(irregularly curved) o If left untreated, could lead to BLINDNESS
§ Treatment: Cylindrical Lens
DIAGNOSTIC PROCEDURE
» PRESBYOPIA (Old Sight)
o Inelasticity of lens due to aging a) TONOMETRY (SCHIOTZ TONOMETER)
o Treatment: » Reveals increase OP
» Painless procedure
DENOMINATOR 20 (Down) à it changes à it indicates the
normal distance by which the person can normally see the letters b) PERIMETRY
in the chart: » Reveals decrease peripheral vision
o OD: 20/20 à OCULIS DEXTER or RIGHT EYE
c) GONIOSCOPY
o OS: 20/20 à OCULI’S SINISTER or LEFT EYE
o OU: 20/20 à OCULI’S UNITA’S or Both EYE » Reveals obstruction in the anterior chamber
o Abnormal Findings: 20 /200 à legally Blind
NURSING PRIORITY / DIAGNOSTIC
GERONTOLGICAL VISION CHANGES
a) Visual Sensory Perception (Disturbed)
a) Decrease visual acuity b) Safety (Risk for Injury)
b) Decrease accommodation of the eyes c) Anxiety
c) Decrease peripheral vision
d) Increase sensitivity to glare NURSING MANAGEMENT:
e) Presbyopia / cataract
» Maintain a comfortable and quiet environment
» Enforce complete bed rest
» Maintain padded rails
» Provide emetic basin
» ADMINISTER MEDICATION AS ORDERED:

a) CHOLINERGIC: MIOTICS
» Constrict the pupil but contracts the ciliary
muscle, to promote increase outflow of aqueous
humor
» E.g., PILOCARPINE / CARBACHOL

J. Marquez | MEDICAL SURGICAL NURSING

 » INCREASE EYE SENSITIVITY TO LIGHT POST – OP NURSING CARE
(problemswith vision in dim especially Punctal » Place the client on the operative side to prevent tension
occlusion during administration on the suture line
» Avoid activities leading to VALSALVA MANEUVER
b) PROSTAGLANDIN ANALOGS: “Prost” » Monitor for signs of increase IOP and notify the physician
» E.g., BIMATOPROTST / HCP:
» It promotes drainage of aqueous humor but it o Head ache
doesn’t systemic diuretics o Eye discomfort
» Common side effects: o Nausea and Vomiting
o Thicke eyelashes and change color of o Tachycardia
Iris to brown o Place eye patch on both eyes

c) RHO KINASE INHIBITORS PRE – OP CARE

» E.g., NETRSUDIL » Eye patch on stronger eye to force the weaker eye to be
» It promotes drainage of aqueous humor stronger.
» Common side effects:
o Conjunctival Hyperemia (Red Eyes)

d) EPINEPHRINE EYEDROPS
» Decrease formation and secretion of aqueous
humor
*** NOTE: DO NOT GIIVE ATROPINE SO4 TO
EYDROPS IT COULD LEAD TO INCREASE
IOP**

e) CARBONIC ANHYDRASE INIHIBITOR

» ACETAZOLAMIDE (DIAMOX) – Oral or by
drops
» Promotes increase outflow humor for drainage /
diuretic that inhibits carbonic production
» Assess for a sulfonamide allergy

f) BETA – BLOCKERS
» TIMOLOL MALASIE (TIMOPTICS)
» Decrease production of aqueous humor
» Systemic effects: Punctal Occlusion

g) OSMOTIC AGENTS
» Decrease IOP
» Glycerin OPO
» Mannitol IV For GLAUCOMA CRISI ACAG
» ALPHA AGONIST “Idine”
» E.g., Brimonidine
» It decrease aqueous humor production
(Constricting ciliary body) and promotes
drainage of aqueous humor
» Systemic effects: Punctal Occlusion

ASSIST SURGICAL PROCEDURE:

INVASIVE
a) TRABECULECTOMY (EYE TREPHINING)
» Removal of trabecular of canal Schlemm to
promote drainage

b) PERIPHERAL IRIDECTOMY
» A portion of the iris is excised to promote
drainage

NON – INVASIVE
a) SELECTIVE LASER TRABECULOPTASTY
» It lowers IOP by using lasers to target certain
parts if the drainage angle tissue, thereby allow
extra fluid to drain out of the eye. IOP is lowered
over several months but not permanent.

J. Marquez | MEDICAL SURGICAL NURSING

CATARACT PRE – OP NURSING CARE
» Possibly cut eyelashes
» OPD » Face scrub
» Partial or Complete opacity of the lens
I. EXTERNAL / EXTRINSIC / ACCESSORY
A. PREDISPOSING FACTORS STRUCTURE
» High risk group:
o 60 years old above a) EYELIDS
o Degenerative or Senile Cataract
» Normal: 10mm vertically .30mm horizontally
» Congenital (due to STD)
» Contains the MEIBOMEAN GLANDS à
» Secondary Cataract secrets an oil that lubricates the eyelashes
o DM, Prolonged used of steroids
o Diabetes Retinopathy
» STY / STYE or HORDEOLUM
o Acute localized swelling / infection
» Prolonged exposure to UV rays and heat from smoking of the MEIBOMEAN GLAND of
» Eye Trauma / Injury the eyelid usually caused by
STAPHYLOCOCEUS AUREUS à
B. SIGNS AND SYMPTOMS last for 3 – 5 days.
o Hazy Vision
o Loss of Central Vision
» If more than 5 days, administer CEFALEXIN
o (+) milky white appearance at the center of the pupil (KEFLEX) if allergic to Penicillin or
o Painless CEPHALOSPORINS,
o Decrease in color perception
o Better vision in dim light
o Difficulty in focusing » ADMINISTER PRE – OP MEDS:
o Sensitivity to light and glare
o Increase nearsightedness requiring frequent changes a) MYDRIATIC
of eye glasses o Dilates the Pupil
o Distortion or ghost images o MYDRIACYL
o Can lead to Blindness if left untreated
b) CYCTOPEGICS
C. DIAGNOSTIC PROCEDURES o Paralyzes the ciliary muscle
a) OPTHALMOSCOPY o CYCLOGYL
» Reveals opacity of the lens
POST – OP NURSING CARE
b) SLIT LAMP EXAM
» Reveals opacity of the lens » Wear metal or plastic shield at night, glasses during the
day
c) EYE ULTRASOUNDS » Avoid rubbing or placing pressure in the eyes
» Avoid activities leading to VALSALVA MANEUVER
D. NURSING PRIORITY DIAGNOSIS
» Visual Sensory perception (disturbed) » NOTIFY PHYSICIAN FOR THE FF:
» Safter (Risk for injury) o Severe persistent eye pain that is not relieved by
» Knowledge deficit meds
o Decrease or loss of vision
E. NURSING MANAGEMENT o Increase eye discharger
» Re – Orient the client to environment o Nausea, vomiting or excessive coughing
» Maintain padded rails o Injury to the eye
o Place the client on the un–operative side 3 -4
ASSIST IN SURGICAL PROCEDURE weeks / a month to prevent on the suture line
o Don’t squeeze the eye shut
a) ECCLE – EXTRA CAPSULAR CATARACT o Do not place soap or water
LENTS EXTRACTION o Place one patch (Operative Eye)
o Partial removal of cataract
» MONITOR SIGNS OF COMPLICATIONS:
b) ICCLE – INTRA- CAPSULAR CATARACT o Through rarely occurs serious complication
LENS EXTRACTION might arise following: Lens Extraction
o Total removal of lens together with its o Retinal Detachment
surroundings capsule. o Vision Loss / Blindness
o Retrobulbar Hemorrhage
c) KHELMA PHACO EMULSIFICATION o ENDOPHTHALMITIS
o The use of high frequency sound waves to § Inflammation of the VITREOUS
liquify the contents of the lens which can HUMOR / BODY
then be safety remove from the eye using
suction through a 3mm incision.

J. Marquez | MEDICAL SURGICAL NURSING

RETINAL DETACHMENT OTHER EYE DISORDER

» Separation of 2 layers of retina leading to retinal tear. 1. HYPEMA

» Medical Emergency » Presence of blood int the anterior chamber related to
o Time is very critical because it could lead to injury, resolve in 5 – 7 days.
Blindness
NURSING CARE:
A. PREDISPOSING FACTORS » Same as S/P eye surgery.
o Severe Myopia
o Following lens extraction POSITION
o Direct Trauma » Semi – fowler to keep hyphemia away from the optical
o Diabetic Retinopathy center of the cornea

B. SIGNS and SYMPTOMS 2. EYE CONTUSION

o Curtain veil like vision » Bleeding into the soft tissue related to injury, resolves in
o Flashes of lights 10 days (pai, photophobia, edema, diplopia)
o Gradual decrease in central vision
o Headache NURSING CARE:
» Ice on the eye immediately have an eye exam
C. NURSING PRIORITY / DIAGNOSIS
o Visual sensory perception (Disturbed) PENETRATING OBJECTS:
o Safety – Risk for Injury o Never remove these (Done by the MD ASAP)
o Anxiety o Cover the object with the cup (Both eyes)
o Avoid bending and applying pressure on the eye
D. NURSING MANAGEMENT
» Instruct the pt. to be quiet in prescribed (dependent)
position à to keep the detached retina in dependent
position. Avoid jerky head movement

» Patch both eyes to minimize eye stress

» Watch the pt. face with antibacterial solution

» Instruct the pt. not to touch the eyes to avoid

contamination

» ASSIST IN SURGICAL PROCEDURE:

a) DIATHERMY
o Use of an electrode needle and heat through the
sclera.

b) CRYOTHERAPY / CRYOPEXY
o Outpatient surgical procedure that use extreme
cold or freezing to treat retinal tears à creating
a scar tissue that seals the retinal tear.

c) SCLERA BUCKLING
o The most common type of surgery
§ It holds the choroid and Retina together
with the splint.

» POST – OP NURSING CARE:

1) Maintain eye patches bilaterally
2) Prevent nausea and vomiting and monitor for restless
which can cause hemorrhage
3) Monitor for sudden, sharp eye pain (notify HCP /
PHYSICIAN)
4) Provide bed rest for 1 – 2 days
5) Avoid sudden head movement.

J. Marquez | MEDICAL SURGICAL NURSING

 PARTS OF THE EAR III. INNER EAR
(Point of entry, point of exit) a) COCHLEA
» Snail shaped structure that contains the true sense
I. OUTER EAR organ of hearing à ORGAN OF CORTI
(Sensory Loss)
b) MASTOID AIR CELLS
a) PINNAL / AURICLE » Air filled spaces located near the brain
» Mase up of cartilage
» Functions: Passageway of sounds **MASTOIDITIS**

b) EXTERNAL AUDITORY CANAL / MEATUS c) LABYRINTH

» It contains the ceruminous glands à procedure » Membranous
and secretes cerumen or earwax (collects » Bony
irritants, dust, and kills bacteria) o Contains vestibules (which consist of
UTRICLE and SUCCULE located at the
**IMPACTED CERUMEN – Conductive hearing loss** semicircular canal)

c) TYMPANIC MEMBRANE § Fluid in the URICLE and

» In between outer and middle ear, it transmits SUCCULE (ENDOLYMPH and
sound waves from outer to middle ear. PERILYMPH)

II. MIDDLE EAR § SEMICIRCULAR CANAL à

(Hearing loss) controls balance / Kinesthesia /
position sense: movement of the
a) EAR OSSICLES body in space or RIGHTING
REFLEX.
H – hammer / Malleus
d) MENIERE’S DISEASE
A – anvil / Incus
S – stirrups / stapes » Disorder of inner ear characterized by INCREASE
ENDOLYMPH
**OTOSCLEROSIS – immobility / fixation of stapes due to
formation of spongy bone ** MENEIRE’S DISEASE / ENDOLYMPHATIC
HYDROPS
b) EUSTACHIAN TUBE » Inner ear disorder characterized by over dilation of
» Connected to the NASOPHARYNX the endolymphatic system à leading to increase
» CHILDREN: volume of endolymph
o Short » Usually it affects one ear (Unilateral)
o Straight o Nursing Goal: To preserve the remaining
o Widened à Susceptible ear.

» ADULT: » ENDOLYMPH contains water, sodium, potassium

o Slanted chloride and other electrolytes.
o Long
o Narrow A. PREDISPOSING FACTOR
o Idiopathic
» It equalizes pressure ion both ears once it is open o Hereditary
o Allergies
» If it closed such as when going to places with high o Smoking
altitude / ascending or descending of the plane o Ear trauma
o Obesity
» To open the eustachian tube o Hyperlipidemia
o YAWING
o CHEWING » High Risk Group: 40 y/o above
» HPN
c) OVAL WINDOW
» In between middle and inner ears B. SIGNS and SYMPTOMS
» Tinnitus
» Vertigo
» Sensorineural hearing loss
» Nausea and vomiting
» Headache
» Photophobia
» Anxiety
» Palpitation and sweating

J. Marquez | MEDICAL SURGICAL NURSING

C. DIAGNOSTI PROCEDURE SURGICAL PROCEDURE:
» Head CT scan
» Audiometry » Assist in surgical procedure
o Both reveals sensorineural hearing loss » Endolymphatic Sac Decompression
» Labyrinthectomy
o Most common feared complication is:
D. NURSING DIAGNOSIS / PRIORITY Permanent deafness / Hearing loss (Rarely
» Auditory Sensory Perception (Disturbed) Occurs.)
» Fluid Volume Imbalance: Excessive
» Anxiety
» Safety

E. NURSING MANAGEMENT
» Provide a comfortable, quiet and darkened
environment
» Maintain padded rails
» Instruct the client to avoid head movement
» Encourage rest during severe episodes and gradually
increase activity
» During episodic attack, avoid bright lights, to aid
reading which could worsen the symptoms
» Instruct the client to avoid hazardous activities
o Driving
o Operating Machinery
o Mountain climbing
o Other similar activities until 1 week after
symptoms disappear
» Avoid VALSAVA MANEUVER
» Assist in ambulation
»
» ADMINISTER MEDS AS ORDERED:

a) DIURETIC
o HYDROCHLOROTHIAZIDE
o Triamterene

b) ANTI MOTION SICKNESS / ANTI VERTIGO

o Meclizine (Bonamine)
o Dramamine
o Serc

c) ACUTE EPISODE
o ATSO4
o Diazepam
o Fentanyl (patches)
o SE: Constipation

d) ANTI – EMETICS
o Plasil
o Phenergan

e) SEDATIVES AND TRANQUILIZERS

o Phenobarbital (Luminal)

f) ANTI – HISTAMINE
o Dipherihydramine HCL (Benadryl)

» Restrict Fluid and Na (Sodium), avoid caffeine,

smoking.

J. Marquez | MEDICAL SURGICAL NURSING