Nursing Care for Seniors with Eye Diseases

Introduction

Ageing, an irreversible process, affects all structures of the human body, including the eye. Age-related changes are observed in all ocular structures (eyelids, lacrimal gland, conjunctiva, cornea, iris, lens, vitreous body). Included in these changes are narrowing of the iridocorneal angle, increased intraocular pressure, sclerosis of vessels, optic nerve degeneration, reduced visual acuity, reduced light adaptation, narrowing of the field of view, and so on (Černák et al., 2013; Silva, 2016). A challenge in care is to distinguish between changes caused by age and pathological states. Most often both factors are present together in the clinical picture (Kalvach et al., 2004; Hegyi, Krajčík, 2015). After age 65, the incidence of degenerative eye diseases increases, as does the incidence of eye diseases in general. One of three seniors over 65 has some visual disturbance (Martinková, 2016). In old age (after 75 years), there is a significant increase in severe visual impairment (Anton, 2009).

Among the most common eye diseases that primarily affect the older population are: cataract, age-related macular degeneration (VPDM), diabetic retinopathy (DR), glaucoma, retinal vascular diseases, dry eye syndrome, presbyopia, and basal cell carcinoma of the eyelids. The most serious complication of these diseases is blindness. Visual impairment is severe in older people because it reduces active life and the ability to care for oneself. With visual impairment, the senior loses orientation ability and recognition of the surrounding world. Vision loss limits self-realization, causes social isolation, worsens orientation, increases demands during hospitalization and rehabilitation. It is a serious personal tragedy (Bartošovič, 2014, Kinski, Milewski, 2002). In addressing problems related to eye diseases or vision loss, family members help most, but healthcare and social workers also support. Family members are irreplaceable in performing self-care activities in a home environment, help with activities outside the home, or substitute for the senior in some activities (e.g., dispensing and prescribing medications, purchasing aids, food, etc.), and they collaborate in the treatment process. Healthcare workers—physicians, specialist doctors, and nurses at various stages of senior care—have an important role in preventing and treating vision disorders.

Healthcare in ophthalmology is provided in both outpatient and inpatient healthcare facilities. Within this care, basic, specialized, and follow-up care are provided. Basic ophthalmic care is provided by general adult physicians. Specialized ophthalmic care is provided in specialized ophthalmology clinics, which are part of polyclinics or clinics. In outpatient ophthalmic surgery units, surgical procedures are performed where patient care does not exceed 24 hours. In inpatient ophthalmic units, which consist of inpatient ophthalmology wards or clinics, continuous care of the patient is required during hospitalization. A special facility is eye tissue banks, which provide material for transplant purposes in ophthalmology. In Slovakia, they were established by the Ministry of Health of the Slovak Republic in Bratislava, Banská Bystrica, and Košice. Follow-up care continues outpatient and inpatient care (Schmidtová et al., 2008).

Specifics of nursing care in ophthalmology

Nursing care as part of healthcare is provided as outpatient, inpatient, and home care. Nursing interventions are focused on basic and specialized care (interventions derived from diagnosed disease and medical orders), education, and counseling. It also includes meeting the biopsychosocial-spiritual needs of the patient, depending on the extent of impairment and advanced age. Assessment of the patient’s health and vision is also very important. In assessment, we focus on pain, eyelid condition, eye movements, facial expression, use of compensatory aids, and other symptoms typical of specific diseases or complications. The nurse is an important person for vision screening. During screening, she can use simple tests—for example, the senior reads a text, reads some words in different font sizes, or identifies current vision problems and their effect on daily activities, hobbies, and social life (Martinková, 2016).

The nurse’s tasks also include identifying and addressing problems associated with changes or diseases of vision. Most often, the nurse helps the patient cope with impairment, find access to information, adapt to the environment, communicate with others, and build interpersonal relationships while practicing self-care.

Outpatient nursing care in ophthalmology

An ophthalmology clinic provides treatment and diagnosis of basic acute and chronic eye diseases and eye injuries. The facility layout must be barrier-free so that even disabled patients have unproblematic access. Outpatient care is needed by patients who require examination or treatment that does not require hospitalization (Haškovcová, Pavlicová, 2013).

A senior comes to an eye clinic on referral from a general practitioner. Because the majority of patients come with vision problems (only a small percentage come for preventive check-ups), it is very important that the nurse helps the patient primarily with orientation in the clinic areas.

Nursing care in an eye clinic primarily includes:

  • guidance and assistance with measuring unaided and corrected visual acuity on Snellen and ETDRS optotypes, refraction testing, and intraocular pressure measurement (most often using a pneumotonograph),
  • assistance during annual eye examination, which focuses on vision and compensatory aid checks,
  • preparation and education before optical coherence tomography, laser procedures, or perimetric testing,
  • application of eye drops, ointments, and solutions into the conjunctival sac (inducing mydriasis, irrigation, treatment after removal of foreign bodies from the eye, after irrigating lacrimal canals),
  • preparation and patient education before fluorescein angiography,
  • administration of intravenous and intramuscular medications, according to physician orders,
  • preoperative, perioperative, and postoperative care for patients in day surgery,
  • education of the patient on following the treatment regimen and administering medications into the conjunctival sac,
  • taking biological samples for microbiological (swab from conjunctival sac), hematological, and biochemical testing.

Inpatient nursing care in ophthalmology

A nurse provides inpatient nursing care to patients hospitalized in eye wards and clinics. At admission, it is very important to familiarize the patient with the spatial setup not only of the ward/clinic, but also of their room, so they can move safely in these spaces.

Nursing care for a patient hospitalized in an eye ward is mainly focused on:

  • short preoperative patient preparation,
  • immediate preoperative patient preparation,
  • postoperative care,
  • care of a patient after eye injury,
  • care of a patient admitted with decompensated glaucoma disease,
  • care of a patient admitted for intravenous vasodilator therapy,
  • preparation and education of the patient before discharge to home treatment,
  • counseling focused on access to and use of suitable corrective low-vision aids.

Home nursing care for a patient with an eye disease

Home nursing care, as a form of outpatient care, is provided not only for patients with chronic conditions but also for acute and short-term illnesses and after day-surgery procedures (Hergyi, Krajčík, 2010).

The ADOS nurse most often performs these interventions:

  • administers medications into the conjunctival sac,
  • takes biological material: blood, a swab from conjunctival sac, wound exudate (after removal of a nevus, blepharochalasia, or sutures after trauma around the eye),
  • treats wounds around the eye sterilely after minor surgical procedures,
  • educates the client and family on medication application into the conjunctival sac, nutrition, eyelid skin hygiene, etc.,
  • conducts training in independence when using eye compensation aids,
  • assesses the client’s social environment,
  • keeps written and, where appropriate, photo documentation of nursing care provided.

Education of seniors with eye diseases

In current ophthalmology practice, nurses are increasingly taking on the role of educator. This role is closely linked to the provision of information from social counseling and social rehabilitation.

Nursing education in ophthalmology is highly specific, especially because educational methods are limited. In educating seniors, different forms of teaching from those used in younger age groups must be selected. The learning process in older adults is most hindered by quick presentation of material, so it is necessary to use various didactic aids, a board, thesis images, and short summaries written in larger font. Spatial conditions and appropriate room atmosphere are also important because the learning process is more sensitive in seniors to external influences (Hudáková, Majerníková, 2010). We provide all information gradually and at a level that allows the senior to understand. It is always best to verify understanding. It is useful to schedule discussions between 9:30–11:30 and 15:30–17:00 and to address important questions always in collaboration with the family. The educational content is shaped by the environment in which it is delivered.

Education of seniors in ophthalmology outpatient care

Patient education is carried out by the outpatient nurse in cooperation with the physician and operating nurse. The purpose of education is to support adherence to treatment and encourage higher activity, as more of health care responsibility is transferred to the senior. The nurse builds and influences patient knowledge, attitudes, behavior, and skills so that the patient develops their own effort to improve their health state (Magerčiaková, 2008).

Main educational focus areas in ophthalmology outpatient care are:

  • teaching the patient about the principle and procedure of slit-lamp examination, refractometer, pneumotonometer, and visual acuity testing,
  • teaching the patient before laser procedures on the eye: the need to induce mydriasis before the procedure, taking a Diluran tablet immediately after the procedure, possible complications afterwards, and the need to monitor intraocular pressure 24 hours after the procedure,
  • demonstration and training in correct application of drops, solutions, and ointments into the conjunctival sac,
  • taking medications and possible adverse effects of medications,
  • comprehensive information as part of long- and short-term preoperative preparation when hospitalization is planned: internal preoperative examination, biological sample collection, anesthesiology examination (only if the procedure will be under general anesthesia), application of antibiotic drops (also in written form),
  • education on the entire perioperative period for patients scheduled for day-case surgery,
  • comprehensive education for the patient and relatives before intravitreal application: primarily antibiotic drops (Vigamox, Oftaquix) for 3 days, 5 times daily before the planned procedure, keeping the appointment, and attending control examinations,
  • educating the patient before perimetric examination: if the patient does not correctly understand the principle of the examination, the physician cannot interpret results properly, often impossible. This test is especially important for patients with glaucoma and seniors undergoing assessment of fitness to drive,
  • adherence to treatment regimen and monitoring disease in patients with hypertension, diabetes mellitus, thyroid disorders, and others,
  • teaching the patient in preparation for minor procedures not included in day-case surgery (removal of chalazion, eyelid skin tag removal, blepharochalasia of upper eyelids, removal of corneal stitches and skin sutures near the eyes): patient position and cooperation during the procedure, medication application after the procedure, eyelid skin hygiene, possible use of analgesics, and follow-up ophthalmologic control.

Education of seniors in day-case surgery

Surgical procedures performed in day-case eye surgery offer many benefits for both patients and society. “The basic principle in day-case surgery is to minimize the patient’s stay in the healthcare facility and move postoperative care and recovery to the home environment” (Valková, Pochybová, 2012, p. 3). This places greater demands on preoperative preparation and strict postoperative care. This should be carried out by the physician and nurse in collaboration with the patient and their family members (Mesárošová, Morovicsová, 2006).

Education in day-case surgery is specific mainly because information provision and acquisition of skills for the entire perioperative period must be included in the preoperative phase (Morovicsová, 2008).

Contents of education during short preoperative preparation:

  • ways to reduce fear and anxiety about the operation: presence of a close support person, high-quality information about care during each phase and the course of the procedure,
  • necessity of preparing the surgical field: trimming eyelashes, applying mydriatics, rinsing tear pathways,
  • information about hygiene regimen: changing into surgical attire, removing jewelry and prostheses, removing facial makeup, removing nail varnish,
  • information and demonstration of reducing unwanted sensations (coughing, sneezing): demonstration of eye movements during surgery, agreeing on a pain signal,
  • information about the immediate postoperative regimen.

Contents of education in the postoperative period:

  • information on postoperative regimen and discharge to home treatment,
  • adherence to protective regimen: avoid bending, do not lift heavy loads, sleep on the non-operated eye side, normal bowel movement, prevention of constipation, avoid dusty environments, wear sunglasses,
  • pharmacotherapy: application of drops and ointments, oral medication use,
  • strict hand hygiene before applying eye medications,
  • overall hygiene and hygiene of the operated eye: showering and hair washing with mildly warm water, avoiding shampoo or soap entering the eye, washing the face with only clean water,
  • subsequent review by ophthalmologist,
  • possible postoperative complications: visual changes, swelling, inflammation of the eye, presence of secretion,
  • provision of telephone contact to the physician in case of acute need for consultation (Valková, Pochybová, 2012).

Education of seniors on the ophthalmology ward/clinic

Patients hospitalized in ophthalmology wards have both acute and chronic eye problems. Most commonly, these are patients who will undergo planned or unplanned surgical procedures, patients with decompensated glaucoma, patients admitted for intravenous vasodilator therapy, and patients after various eye injuries.

Education of a hospitalized patient with chronic eye disease (DR, VPDM, glaucoma):

  • information on treatment regimen for the specific condition,
  • practice of medication application into the conjunctival sac,
  • use of medications and appropriate nutritional supplements, and recognition of adverse medication effects,
  • use of compensatory aids: glasses, magnifiers,
  • attendance at regular controls.

Conclusion Diseases of the sensory organs, including eye diseases, are not an immediate cause of mortality in seniors, but they significantly worsen quality of life. In the home environment, they limit activities of daily life, instrumental activities, and social life. In institutional settings, they increase the risk of iatrogenic trauma. Therefore, it is the role of healthcare workers, especially nurses, to focus on seniors and motivate them to prevention, early diagnosis, and cooperation in treatment of visual disorders, so they can live through the autumn of life in as good health as possible and with minimal dependence on others.

Authors: Mgr. Zdenka Brziaková Očná klinika UVN SNP FN Ružomberok PhDr. Katarína Zrubáková, PhD Fakulta zdravotníctva KU Ružomberok List of references

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