Ocular Emergencies

CHAPTER 23 Ocular Emergencies



Ann E. Gerhart, RN, MSN, FNP, APRN, BC, CEN



MAJOR TOPICS



General Strategy


Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Medical Ocular Emergencies


Conjunctivitis

Anterior Uveitis/Iritis

Periorbital/Orbital Cellulitis

Glaucoma

Central Retinal Artery Occlusion


I. GENERAL STRATEGY



A. Assessment




1. Primary and secondary assessment/resuscitation (see Chapter 1)


2. Focused assessment


a. Subjective data collection

1) History of present illness/chief complaint
a) Pain PQRST (see Chapter 9)

b) Abnormal appearance of eye
(1) Eyelid swelling

(2) Redness: lid, sclera, conjunctiva

(3) Change in luster

(4) Asymmetry

c) Changes in visual acuity: normal to blindness
(1) Decreased visual acuity from patient’s “normal”

(2) Decreased visual field from patient’s “normal”

(3) Blurring of vision

(4) Diplopia

(5) Cloudy or smoky vision

(6) Photophobia

(7) Foreign body sensation

d) Tearing

e) Itching

f) Discharge color and consistency

g) Efforts to relieve symptoms
(1) Home remedies

(2) Alternative therapies

(3) Medications
(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history
a) Current or preexisting disease/illness
(1) Diabetes

(2) Cardiovascular: recent cardiac catheterization

(3) Hypertension

(4) Sickle cell

(5) Immunologic diseases, connective tissue disorders

b) Ocular
(1) Corrective lenses
(a) Contact lenses or glasses

(b) Worn at time of injury

(c) Last eye examination/ocular evaluation

(2) Past eye disease, injury, or surgery (cataract or LASIK)

(3) Glaucoma

(4) Chronic eye disease

(5) Family history of eye disease

c) Substance and/or alcohol use/abuse

d) Current medications: medications may cause ocular side effects
(1) Prescription
(a) Eye medication

(b) Steroids

(c) Parasympatholytic drugs

(d) Narcotics

(e) Anticoagulants

(2) Over-the-counter/herbal

e) Allergies

f) Immunization status

3) Psychological, social, environmental factors and risk factors
a) Behavior appropriate for age and developmental stage
(1) School-age children susceptible to conjunctivitis because of close contact and contagious nature of disease

(2) Contact lens wearers at greater risk for corneal abrasions, ulcers, and infections

b) Occupation or profession

c) Hobbies, avocation, recreational activities
(1) Injuries occurring in the garden have increased potential for infection

(2) Swimming may increase potential for ocular infections

d) Possible/actual assault, abuse, or intimate partner violence situations (see Chapter 3)

b. Objective data collection

1) General appearance
a) Level of consciousness

b) Vital signs

c) Hygiene

d) Level of distress/discomfort

2) Inspection: always use contralateral eye for comparison
a) Visual acuity is the vital sign in ophthalmology. It is an essential part of the physical examination process to establish a baseline before treatment as well as for medicolegal reasons; exception to this rule involves patient with chemical injury, in which case irrigation first is mandatory; when possible, patients with glasses or contact lenses should have visual acuity tested with correction. Test each eye separately, then together. If vision is suboptimal, a pinhole testing device can determine whether a problem with acuity is caused by refractory error or another process
(1) Exact assessment by a Snellen chart, a picture chart, or an “E” chart may be necessary for small children, nonverbal patients, or those who cannot read
(a) Ambulatory: tested at distance of 20 feet

(b) Nonambulatory: tested with a hand-held Rosenbaum card at approximately 14 inches

(2) Gross assessment by finger count at 4 feet, if vision is greater than 20/400

(3) Ability to distinguish light or shadows

(4) Visual fields, objects can be seen in the peripheral vision, confrontation

b) Eyelid and adnexa, function, deformity, spasm, erythema, edema

c) Eye/facial surface, to include upper and lower lids for lesions, erythema

d) Tearing

e) Discharge: clear, mucoid, purulent

f) Pupils: should be equal, round, reactive to light and accommodation (PERRLA), measurement of pupil size

g) Extraocular movements (EOMs): intact, limited, or painful

h) Position and alignment of eyes

i) Conjunctiva and sclera for color, inflammation, or edema

j) Blood or white cells in anterior chamber

k) Opaque, gray-white area of cornea

l) Hazy cornea

3) Palpation
a) Intraocular pressure: palpation should not be performed if there is concern regarding integrity of globe; it may result in extrusion of ocular contents and may cause permanent visual loss; the procedure should be reserved for the emergency physician or ophthalmologist in suspected cases of acute glaucoma or central retinal artery occlusion

b) Increased warmth of surrounding tissues/areas

3. Diagnostic procedures


a. Laboratory studies

1) Eye discharge culture

2) Complete blood count (CBC) with differential

3) Erythrocyte sedimentation rate (ESR)

4) C-reactive protein (CRP)

5) Serum glucose

6) Coagulation profile

7) Urinalysis; pregnancy test in female patients of childbearing age if surgery imminent

b. Imaging studies

1) Computed tomography (CT) scan

2) Magnetic resonance imaging (MRI)

3) Soft tissue (orbit films) for foreign body

4) Skull radiographs with Waters’ view, sinus involvement

5) Ocular sonography

c. Other

1) Direct ophthalmoscopic examination

2) Tonometry: intraocular pressure measurement

3) Slit-lamp examination

4) Fluorescein staining: positive Seidel’s test if vitreous humor leakage present


B. Analysis: Differential Nursing Diagnoses/Collaborative Problems




1. Pain


2. Risk for infection


3. Inefficient tissue perfusion: ocular


4. Deficient knowledge


5. Anxiety/fear


6. Disturbed sensory-perception: visual


7. Risk for individual ineffective coping


8. Noncompliance


9. Self-care deficit



C. Planning and Implementation/Interventions




1. Determine priorities of care


a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluid/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Facilitate ophthalmology consultation as appropriate (Box 23-1)

g. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension


3. Allow significant others to remain with patient if supportive


4. Educate patient and significant others



Box 23-1 CONSULTATION CRITERIA


Patients with the following problems should be referred for ophthalmologic consultation:



Penetrating ocular trauma, including impaled objects, embedded foreign bodies, and ruptured globe


Chemical burns of the eye


Severe lid lacerations


Glaucoma


Central retinal artery occlusion


Retinal detachment


Orbital fracture


Hyphema or hypopyon


Preseptal/orbital cellulitis



D. Evaluation and Ongoing Monitoring




1. Continuously monitor and treat as indicated


2. Monitor patient response/outcomes, and modify nursing care plan as appropriate


3. If positive outcomes are not demonstrated, reevaluate assessment and plan of care



E. Documentation of Interventions and Patient Response




F. Age-Related Considerations




1. Pediatric


a. Growth or development related

1) May need to use a picture chart or the “E” chart (patient indicates direction to which “E” points)

2) Delayed presentation may be problematic because children may not notice gradual visual loss

3) Neonatal patients delivered vaginally may develop sexually transmitted diseases with Neisseria gonorrhoeae, Chlamydia trachomatis, and herpes simplex virus. Usually develops within the first month of life

b. “Pearls”

1) Have great patience

2) Infants and small children may need to be restrained in a blanket to reduce number of moving parts and facilitate examination

3) A red eye is not always infectious

4) Consider corneal abrasion as cause of crying in infants

2. Geriatric


a. Aging related

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  4. Cardiovascular Emergencies

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Nov 8, 2016 | Posted by in NURSING | Comments Off on Ocular Emergencies

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