Glaucoma Nursing Care Plan Notes

 

Definition

• Is a condition marked by high intraocular pressure (IOP) that damages the optic nerve.

TYPES:

Chronic open-angle glaucoma

• Results from the gradual deterioration of the trabecular network that, as in the acute form, blocks drainage of aqueous  humor and causes IOP to increase.
• If untreated, may result in degeneration of the optic nerve and visual field loss.
• It is the most common form of glaucoma, and its incidence increases with age.
• Genetics and conditions, such as diabetes and hypertension, also play a role.

Acute closed-angle (or narrow-angle) glaucoma

• Results when the angle between the iris and the cornea becomes narrowed, restricting or blocking the drainage of aqueous humor through the trabecular network and the canal of Schlemn. This causes IOP to increase suddenly.
• It may result from trauma, stress, or any process that pushes the iris forward against the inside of the cornea when there is already an anatomically shallow anterior or chamber.
• It is an acute, painful condition that can cause permanent eye damage within several hours.

Risk Factors

• Congenital
• Inherited
• Trauma

Pathophysiology

In chronic open-angle glaucoma

• Obstruction to outflow of aqueous humor through the trabecular meshwork into Schlemm’s canal leads to increased IOP. It usually is bilateral. Increased IOP eventually destroys optic nerve function causing blindness.

In acute closed-angle glaucoma

• Results in increased IOP because of obstructed outflow of aqueous humor. However, acute closed-angle glaucoma typically involves sudden, complete, unilateral closure with pupil dilation stimulated by a dark environment, emotional stress, or mydriatic drugs.

Assessment/Clinical Manifestations/Signs and Symptoms

Chronic open-angle glaucoma

• No early symptoms
• Insidious visual impairment, blurring
• Diminished accommodation
• Gradual loss of peripheral vision (tunnel vision)
• Mildly aching eyes
• Halos around lights later with elevated IOP

Acute closed-angle glaucoma

• Transitory attacks of diminished visual acuity
• Colored halos around lights
• Reddened eye with excruciating pain
• Headache
• Nausea and vomiting

Laboratory and diagnostic study findings

• Tonometry detects elevated IOP (>10 to 20 mmHg)
• Slit-lamp examination reveals abnormalities in the anterior vitreous humor.

Medical Management

1. Objective of treatment is to prevent optic nerve damage by lowering the IOP to a level consistent with retaining vision. Treatment is almost always lifelong. Treatment also focuses on achieving the greatest benefit at the least risk, cost and inconvenience to the patient.
2. Pharmacologic therapy is the initial and principal treatment for glaucoma. Acute angle-closure glaucoma is treated with medication (including miotics) to reduce IOP before laser or incisional iridectomy. Commonly used agents include:
   • Beta-adrenergic blockers/antagonists are the most widely used hypotensive agents. They are effective in many types of glaucoma.
   • Cholinergic agents (topical) are miotics (cause papillary constriction) and are used in short-term management of glaucoma with papillary block.
   • Alpha-2-adrenergic agonists(topical) reduce IOP by increasing aqueous humor outflow.
   • Carbonic anhydrase inhibitors (systemic) and prostaglandins lower IOP by reducing aqueous humor formation.
   • Osmotic diuretics reduce IOP by increasing the osmolality of the plasma to draw water from the eye into the vascular circulation.

Surgical Management

• Ophthalmic laser surgery is indicated as the primary treatment for glaucoma or is required when medication therapy is poorly tolerated or ineffective in lowering IOP.
• Conventional surgery procedures are performed when laser techniques are unsuccessful or when patient is not a good candidate for laser surgery (eg. Patient cannot sit still or follow instructions)
• Filtering procedures: an opening or a fistula in the trabecular meshwork (trabeculectomy) is made to allow drainage implant or shunt surgery may be performed.

Nursing Diagnosis

• Anxiety related to possible vision loss
• Disturbed sensory perception related to visual impairment
• Ineffective health maintenance related to knowledge deficit
• Risk for injury related to impaired vision
• Self-care deficit related to impaired vision

Nursing Management

1. Provide information regarding management of glaucoma
   • Discuss preoperative and postoperative teaching for immediate surgical opening of the eye chamber.
   • Prepare to administer carbonic anhydrase inhibitors IV or IM, to restrict production of aqueous humor.
   • Prepare to administer osmotic agents.
   • Discuss and prepare the client for surgical or laser peripheral iridectomy after the acute episode is relieved.
2. Provide information about laser trabeculoplasty, if medication therapy proves ineffective.
3. Teach the client about specific safety precautions.
   • Instruct the client to avoid mydriatics such as atropine, which may precipitate acute glaucoma in a client with closed-angle glaucoma.
   • Instruct the client to carry prescribed medications at all times.
   • Instruct the client to carry a medical identification card or wear a bracelet stating his type of glaucoma and need for medication.
   • Instruct the client to take extra precautions at night (e.g. use of handrails, provide extra lighting to compensate for impaired pupil dilation from miotic use).