TOPRANK NURSING

PERIOPERATIVE NURSING, PAIN MANAGEMENT AND SPECIAL SENSES

PATRICK MIGEL MERCADO,RN

 When the decision to have surgery is
PREOPERTAIVE made and ends when the client is
transferred to the operating table

PERIOPERATIVE When the client is transferred to the

INTRAOPERATIVE operating table and ends when the client
NURSING is admitted in the PACU

POSTOPERATVE When the client is admitted to the PACU

and ends when the healing is complete
 OBSTRUCTION
Impairment to the flow of vital fluids

PERFORATION
4 MAJOR TYPES
Rupture of an organ
OF PATHOLOGIC
PROCESS
REQUIRING EROSION
SURGERY Wearing off of a surface or membrane

TUMORS
Abnormal new growths
 TYPES OF SURGERY
ACCORDING TO:

PURPOSE DEGREE OF DEGREE OF EXTENT OF

URGENCY RISK SURGERY
q Diagnostic
q Exploratory q Elective
q Curative q Major q Radical
q Urgent q Minor q Simple
q Palliative q Emergency q Minimally
q Optional Invasive
q Day
 TYPES OF SURGERY
ACCORDING TO PURPOSE
DIAGNOSTIC – Confirms and establishes diagnosis (Biopsy)
PALLIATIVE – Relieves or reduces pain or symptom of a
disease; it does not cure
EXPLORATORY – To determine the extent of the disease
condition such as exploratory laparatomy
 TYPES OF SURGERY
ACCORDING TO PURPOSE
CURATIVE – To treat the disease condition
q ABLATIVE – Removes as diseased body part
q CONSTRUCTIVE –Restores function or appearance that
has been lost or reduced
q RECONSTRUCTIVE –involves repair of damaged organ
 TYPES OF SURGERY
ACCORDING TO URGENCY
EMERGENCY – Performed immediately to preserve function
or life; indications: without delay
q To control hemorrhage
q Fracture repair
q Extensive burns
q Bladder or intestinal obstruction
q Gunshot or stab wounds
 TYPES OF SURGERY
ACCORDING TO URGENCY
URGENT/IMPERATIVE – requires prompt attention
q Indications: within 24-30 hours
q Acute gallbladder infection
q Kidney/Ureteral Stones
 TYPES OF SURGERY
ACCORDING TO URGENCY
REQUIRED – Needs to have surgery
q Indications: Plan within few weeks or months
q Prostatic hyperplasia without bladder obstruction
q Thyroid disorder
q Cataracts
 TYPES OF SURGERY
ACCORDING TO URGENCY
ELECTIVE – should have surgery
q Indications: failure to have surgery not catastrophic
q Repair of scars
q Simple Hernia
q Vaginal Repair
 TYPES OF SURGERY
ACCORDING TO URGENCY
OPTIONAL – decision rest with client
q Indications: Personal preference
q Example: Cosmetic surgery
DAY/AMBULATORY – done as outpatient basis
 TYPES OF SURGERY
ACCORDING TO RISK
MAJOR SURGERY MINOR SURGERY
q High risk q Few complications anticipated
q Complicated q Day surgery
q Prolonged q Ambulatory surgery centers
q Large blood loss
q More possible complication

q Eg: Open heart surgery, removal

of kidney; organ transplant
SUPRA ABOVE; BEYOND CYSTO BLADDER

ORTHO JOINT ENCEPHALO BRAIN

CHOLE BILE OR GALL ENTERO INTESTINE

HYSTERO UTERUS MYO MUSCLES

MAST BREAST NEPHRO KIDNEY

MENINGO MEMBRANE/MENINGES NEURO NERVE

OOPHOR OVARY THORACO CHEST

PNEUMO VISCERO ORGAN ESPECIALLY IN

LUNGS THE ABDOMEN

SALPHINGO FALLOPIAN TUBE

-OMA TUMOR/SWELLING -SCOPY LOOKING INTO

-ECTOMY REMOVAL OF AN -OSTOMY MAKING AN OPENING

ORGAN OR GLAND OR STOMA

-RHAPY SUTURING OR STITCHING -OTOMY CUTTING INTO

-PLASTY TO REPAIR OR RESTORE -CELE TUMOR; SWELLING;
HERNIA

-ITIS inflammation
“Extends from the time the client is admitted in the surgical unit, to the time
he/she is prepared physically, psychosocially, spiritually and legally for the
surgical procedure, until he is transported into the operating room” – Josie
Udan

PRE-OPERATIVE PHASE
 PREOPERATIVE PERIOD
Refers to the time interval that begins when the decision for surgical intervention is
made until the client is transported to the OR

GOAL:
FOCUS: The patient to be in
Preparation of the the best possible
patient physical and emotion
condition for surgery
 PREOPERATIVE PERIOD
INFORMED CONSENT
Prior to any surgical procedure, informed consent is required from the client or
legal guardian.

Informed consent implies that the client has been informed and involved in
decisions affecting his or her health.

THE HEALTHCARE PROVIDER WHO WILL DO THE PROCEDURE SHOULD

OBTAIN THE CONSENT.
 PREOPERATIVE PERIOD
INFORMED CONSENT
Before obtaining the informed consent, the surgeon/HCP should provide
the following information the client.

q The nature of and the reason for the surgery

q All available options and the risks associated with each option
q The risks of the surgical procedure and its potential outcomes
q Name and qualifications of the surgeon performing the procedure
q The right to refuse consent or later withdraw the consent
 PREOPERATIVE PERIOD
INFORMED CONSENT
ROLE OF THE NURSE
q Witness the client’s signature on the consent
q Discusses and reviews advanced directive document
q Ensures that the patient signed the document
voluntarily
q Ensures that the patient is competent to sign the
document
PREOPERATIVE PERIOD
INFORMED CONSENT
 PREOPERATIVE PERIOD
ASSESSMENT
PHYSICAL DIAGNOSTICS EDUCATIONAL OTHERS
ASSESSMENT ASSESSMENT q Use of
q CBC q Previous
q Height medication
q Na, K, Crea, experience
q Weight q Educational q Presence of
FBS
q Vital signs q CXR level trauma
q Mental Status q Urinalysis q Sensory q Allergies
Examination q Coagulation impairments q Contraptions
studies q Expectations
q ECG
 PREOPERATIVE PERIOD
DIAGNOSIS
Deficient Knowledge related to lack of education about the perioperative
process

Anxiety related to effects of surgery on ability to function in usual roles

Grieving related to perceived loss of body part associated with planned surgery

Ineffective Coping related to lack of clear outcomes of surgery

 PREOPERATIVE PERIOD
PLANNING/IMPLEMENTATION
DIAGNOSTICS BOWEL PREP SKIN PREP

MEDICATIONS CONTRAPTIONS ANESTHESIA

PREOPERATIVE
TEACHING
JEWELRIES EXERCISES SPIROMETRY

POST OP
PAIN DIET
RESTRICTIONS
INCENTIVE SPIROMETRY
1. Instruct the client to assume
sitting or upright position
2. Instruct the client to place the
mouth tightly around the
mouthpiece
3. Instruct client to inhale slowly to
raise & maintain the flow rate
indicator between 600-900
4. Instruct client to hold the breath
for 5 seconds and then to
exhale through pursed lips
5. Instruct client to repeat this
process 10 times every hour
 PREOPERATIVE PERIOD
PLANNING/IMPLEMENTATION
MOVING LEG EXERCISES DEEP
BREATHING
q To promote
q To promote AND
venous return
q To enhance lung
venous return, COUGHING
expansion and thereby q To enhance
mobilize preventing lung expansion
secretions thrombophlebit and mobilize
q To stimulate GI is and secretions
motility thrombus thereby
q To facilitate early preventing
formation
ambulation atelectasis.
 PHYSICAL PREPARATION
Consumption of clear liquids up to 2 hours
before elective surgery

Consumption of breast milk 4 hours before

NPO after Midnight surgery

A light breakfast 6 hours before the

procedure

A heavier meal 8 hours before surgery

 PHYSICAL PREPARATION
Enemas before surgery are no longer routine but cleansing enema may be order
if bowel surgery is planned.

Clients are asked to bath or shower the evening or morning of surgery to reduce
risk of wound infection.

Pre-medications can be given depending to the anesthesiologist such as

sedatives, narcotics, anticholinergics, antiemetic, antihistamines and analgesics

Removal of valuables, nail polish, prosthesis, dentures, etc.

 “Extends from the time the client is admitted to the operating room, to the
time of administration of anesthesia, surgical procedure is done, until he/she
is transported to the recovery room/post anesthesia care unit” – Josie Udan

INTRAOPERATIVE PHASE
 INTRAOPERATIVE PERIOD

ASEPSIS

HOMEOSTASIS
GOAL

SAFE ADMNISTRATION OF ANESTHESIA

HEMOSTASIS
 INTRAOPERATIVE PERIOD
TYPES OF ANESTHESIA
GENERAL ANESTHESIA REGIONAL ANESTHESIA
q Loss of sensation and consciousness q Temporary interruption of the
q Protective reflexes such as cough & gag transmission of nerve impulses to and
q Analgesia à Amnesia à from a specific area or region of the
Unconsciousness à Loss of reflexes body
and muscle tone
q Chief disadvantage: Respiration and
cardiac depression
 INTRAOPERATIVE PERIOD
REGIONAL ANESTHESIA
SPINAL
LOCAL ANESTHESIA
ANESTHESIA q L2-S1
q Infiltration NERVE q Injected to
TOPICAL q Lidocaine BLOCK subarachnoi EPIDURAL
ANESTHESIA q Injected the d space ANESTHESIA
q Skin area nerve or q Anesthetic
q Lidocaine small nerve agent in
group that epidural
supplies space
small area of
the body
4.) MEDULLARY/STAGE OF
DANGER
Respiratory or Cardiac depression or arrest
INTRAOPERATIVE
3.) SURGICAL
Extends from the loss of lid reflex to the loss of most
PERIOD
reflexes. Surgical procedure is started. STAGES OF
2.) EXCITEMENT/DELIRIUM ANESTHESIA
Extends from the time of loss of consciousness by
the time of loss of lid reflex. It may be characterized
by shouting, struggling of the client

1.) ONSET/INDUCTION
Extends from administration of anesthesia to
the time of loss of consciousness
INTRAOPERATIVE PERIOD
ASSESSMENT
 INTRAOPERATIVE PERIOD
DIAGNOSIS
Risk for Aspiration Risk for Injury

Ineffective Protection Risk for Imbalanced Body Temperature

Impaired Skin Integrity Ineffective Peripheral Tissue Perfusion

Risk for Deficient Fluid Volume

 INTRAOPERATIVE PERIOD
PLANNING AND IMPLEMENTATION
qPosition the client appropriately for surgery
qPerform preoperative skin preparation
qAssist in preparing and maintaining sterile field
qOpen and dispense sterile supplies during surgery
qProvide medications and solutions for the sterile field
qMonitor and maintain a safe, aseptic environment
qManage catheters, tubes, drains and specimens
qPerform sponge, sharp and instrument counts
INTRAOPERATIVE PERIOD
 DORSAL RECUMBENT LITHOTOMY PRONE
q Hernia Repair q Vaginal repairs q Spinal Surgeries
q Mastectomy q D&C q Laminectomy
q Bowel Resection q Rectal Surgery
q Abdominal-perineal resection
INTRAOPERATIVE PERIOD
Operating Surgeon

Surgical Assistant

Anesthesiologist

Circulating Nurse

Scrub Nurse
 INTRAOPERATIVE PERIOD
SURGEON
q Performs the procedure
q Heads the surgical team and is
specially trained and qualified
q Has the ultimate responsibility for
performing the surgery in an
effective and safe manner
ANESTHESIOLOGIST
q Assesses the patient before the
surgery
q Supervises the patient’s condition
throughout the surgical procedure
q Monitors the VS, ECG, Blood
oxygen saturation and body
temperature
 INTRAOPERATIVE PERIOD
CIRCULATING NURSE
q Coordinates all personnel in the OR
q Monitors responsible cost
compliance associated with
operating room procedures
q Ensure all equipment is working
properly
q Guaranteeing sterility of
instruments and supplies
q Assisting with positioning
q Performing surgical skin preparation
q Handling specimens
q Assisting anesthesia personnel
SCRUB NURSE
q Gathering of equipment & supplies
q Prepares all supplies and
instruments using sterile technique
q Maintains sterility during surgery
q Handles supplies & instruments
during surgery
q Performs aftercare
q Keep accurate count of sponges,
sharps and instruments during the
surgery
 INTRAOPERATIVE PERIOD
CIRCULATING NURSE
q Monitors the room and team
members for breaks in sterile
technique
q Coordinating activities with other
departments
q Documenting care provided
q Minimizing conversation and traffic
within the OR suite
 INTRAOPERATIVE PERIOD

UNRESTRICTED ZONE SEMI-RESTRICTED RESTRICTED ZONE

q Can wear street clothes
q Patient reception area and
holding area
ZONE
q Scrub attire (Scrub clothes
and caps) is required
q May include areas where
surgical instruments are
processed
q Scrub clothes, shoe cover
caps and masks are worn
q Operating theater and
sterile core area
 SURGICAL ASEPTIC TECHNIQUE
All materials in contact with surgical wound or used within the sterile filed must be
sterile

Sterile surfaces or articles may touch other sterile surfaces or articles remain sterile

Contact with unsterile objects at any point renders a sterile area contaminated

Gowns of the surgical team are considered sterile in front from the chest to the
level of the sterile field
The sleeves are also considered sterile from 2 inches above the elbow to the
stockinette of the cuff

Sterile drapes are used to create a sterile field.

 SURGICAL ASEPTIC TECHNIQUE
Only the top surface of a draped table is considered sterile.

After a sterile package is opened, the edges are considered unsterile.

The movements of the surgical team are from sterile to sterile areas only.
Sterile areas must be kept in view during movement around the area
Whenever a sterile barrier is breached, the area must be considered contaminated.
A tear or puncture of the drape permitting access to an unsterile surface
underneath renders the area unsterile
Items of doubtful sterility are considered unsterile.
“Extends from the time the client is admitted to the recovery room, to the time
he is transported back into the surgical unit, discharged from the hospital,
until the follow-up care.” – Josie Udan

POSTOPERATIVE PHASE
 POSTOPERATIVE PERIOD
Maintain adequate body Ensure discharge planning
systems function and teaching

Restore homeostasis
GOAL
Prevent postop
complications
Alleviate pain and
discomfort
 POSTOPERATIVE PERIOD
ASSESSMENT
O2 Sats & Ventilation Skin Color

Cardio Status Fluid Status

LOC Postoperative site

AIRWAY
Cough & Gag Reflex Drains

POSITION? Ability to extremities Pain and Safety

 POSTOPERATIVE PERIOD

GENERAL ANESTHESIA
Side lying and Fowler’s

POSITION
SPINAL/EPIDURAL ANESTHESIA
Flat on bed
 POSTOPERATIVE PERIOD
DIAGNOSIS
Acute Pain Ineffective Airway Clearance

Risk for Infection Ineffective Breathing Pattern

Risk for Injury Delayed Surgical Recovery

Risk for Deficient Fluid Volume Disturbed Body Image

 POSTOPERATIVE PERIOD
PLANNING AND IMPLEMENTATION

“POSTOPERATIVE CARE PLANNING AND DISCHARGE

PLANNING BEGIN IN THE PREOPERATIVE PHASE WHEN
PREOPERATIVE TEACHING IS IMPLEMENTED”
 POSTOPERATIVE PERIOD
CRITERIA IN DISCHARGING TO PACU
ACTIVITY à able to obey commands such as deep breathing exercises

RESPIRATION à easy and noiseless breathing

CIRCULATION à BP is within +/- 20 mmHg preop level

CONSCIOUSNESS à responsive

COLORà Pinkish skin and mucus membrane

POSTOPERATIVE PERIOD
Pain Management Hydration

Positioning Urine and GI FXN

IS, DBE & Coughing Diet

Leg Exercises Drains/Suction

Early Ambulation Wound Care

 WOUND CARE
SEQUENTIAL SIGNS OF Appearance
HEALING
1. Absence of bleeding and the Size
appearance of a clot binding
the wound edges Drainage
ASSESSMENT
2. Inflammation at wound
edges for 1 to 3 days Swelling
3. Reduction in inflammation
when the clot diminishes Pain
4. Scar Formation
5. Diminished scar over a Drains/Tubes
period of months or years
 POSTOPERATIVE COMPLICATIONS
ATELECTASIS PNEUMONIA

CAUSE Accumulated secretions Infection, aspiration

or failure of client to and immobility
DBE and ambulate

ONSET 1-2 days after Sx 3-5 days after Sx

Dyspnea and increased respiratory rate, Crackles, Elevated

SIGNS AND SX
body temperature, productive cough and chest pain
 POSTOPERATIVE COMPLICATIONS
WOUND INFECTION
INTERVENTIONS:
ONSET: 3 to 6 days

CAUSES OR RISK q Administer antibiotics

Assessment: q Monitor VS
FACTORS:
q Fever and chills q Assess wound
q Poor aseptic technique
q Contaminated wound q Warm, tender, drainage
prior Sx painful & inflamed q Maintain asepsis,
q Diabetes Mellitus site change dressing &
q Immunocompromised q Edematous site perform from wound
q Elevated WBC irrigation
 POSTOPERATIVE COMPLICATIONS
HEMORRHAGE
Copious escape of blood from the blood vessel

Capillary: Slow and oozing
Venous: Dark in color and
bubble out
Arterial: Spurts and is bright
in color
MANIFESTATIONS
q Apprehension; restlessness; thirst; cold; moist; pale
q Deep, rapid RR; low body temperature
q Low cardiac output
q Low BP and HGB
MANAGEMENT
q Vitamin K, Hemostan
q Ligation of bleeders
q Pressured Dressings
q BT and IV Fluids
WOUND DEHISCENCE

Is the separation of the wound edges

at the suture line; it is usually occurs 6
to 8 days after surgery

WOUND EVISCERATION

Is the protrusion of the internal organs

through an incision; it is usually occurs
6 to 8 days after surgery
 WOUND DEHISCENCE WOUND EVISCERATION

qIncreased in drainage qDischarge of serosanguineous

qOpened wound edges fluid from a previously dry wound
qAppearance of underlying tissues qThe appearance of loops of
through the wound bowel or other abdominal
contents through the wound
qClient reports of feeling of
popping sensation after coughing
or turning.
EVISCERATION IS MOST COMMON AMONG OBESE CLIENTS WHO HAVE
HAD ABDOMINAL SURGERY!!!
 EVISCERATION IN A WOUND
1. Call for help; ask that the surgeon be notified and that needed supplies
be brought to the client’s room
2. Stay with client
3. While waiting for supplies to arrive, place the client in a low Fowler’s
position with the knees bent
4. Cover the wound with a sterile normal saline dressing and keep the
dressing moist
5. Take vital signs and monitor the client closely for signs of shock
6. Prepare the client for surgery as necessary
7. Document the occurrence, actions taken and the client’s response.
 FEMORAL PHLEBITIS/ DEEP THROMBOPHLEBITIS
Often occurs after operations on the lower abdomen or during the course of septic
conditions as ruptured ulcers or peritonitis

Assessment: INTERVENTIONS
CAUSES OR RISK
q Pain q Hydration
FACTORS: q Encourage leg exercises and
q Injury: Damage to the q Redness
ambulation
vein q Swelling
q Elevate the affected leg with
q Hemorrhage q Heat/Warmth
pillow support
q Prolonged immobility q (+) Homan’s Sign q Avoid massage on the calf of the
q Obesity/Debilitation leg
q Anticoagulant therapy
 An unpleasant sensory and
emotional experience associated
with, or resembling that
associated with, actual or
potential tissue damage,
5TH VITAL SIGN

ALWAYS SUBJECTIVE
qPain is always a personal experience that is influenced to varying
degrees by biological, psychological, and social factors.
qPain and nociception are different phenomena. Pain cannot be
inferred solely from activity in sensory neurons.
qThrough their life experiences, individuals learn the concept of pain.
qA person’s report of an experience as pain should be respected.
qAlthough pain usually serves an adaptive role, it may have adverse
effects on function and social and psychological well-being.
qVerbal description is only one of several behaviors to express pain;
inability to communicate does not negate the possibility that a human
or a nonhuman animal experiences pain.
FACTORS AFFECTING THE PAIN EXPERIENCE

Ethnic and Cultural Values Previous pain experience

Developmental Stage Meaning of pain

Environment and support

people
 TYPES OF PAIN: LOCATION

REFERRED PAIN --> pain that appears/arise in different areas of the body

VISCERAL PAIN--> pain arising from organs or hollow viscera/ perceived in a

remote area
 TYPES OF PAIN: DURATION

ACUTE PAIN --> last only through the expected recovery period

CHRONIC PAIN --> also known as persistent pain; lasting 3 months

CANCER PAIN --> may result from the direct effects of the diseases and its
treatment (HIV, Burns)
 ACUTE PAIN CHRONIC PAIN
Less then 3 months More than 3 months

Known cause Unpredictable cause

Localized Poorly localized

Physiological Response Physiological Response

q Increased HR, BP, RR , Dec GI q Weight loss, insomnia, loss
Motility of libido

Psychological response
 ASSESSMENT
P What are the factors that precipitated the pain? What are you doing?

Q Crashing? Burning? Throbbing? Tingling?

R Where is the pain? Does it radiate?

S Pain scale

T How long? Intermittent?

 0 NO PAIN
1
2 MILD PAIN
3
4
5 MODERATE PAIN
6
7
8 SEVERE PAIN
9
10
 TYPES OF PAIN: ETIOLOGY
NOCICEPTIVE PAIN--> experienced when an intact, properly functioning nervous
system sends signals that tissues are damaged, requiring attention and proper care

SOMATIC PAIN à originates in the skin, muscles, bone or connective tissue.

NEUROPATHIC PAINà associated with damager or malfunctioning nerves due to

illness, injury or undetermined reasons.

PERIPHERAL NEUROPATHIC PAIN CENTRAL NEUROPATHIC PAIN

(e.g., phantom limb pain, post-herpetic (e.g., spinal cord injury pain, poststroke
neuralgia, carpal tunnelsyndrome) follows pain, multiple sclerosis pain) results from
damage or sensitization of peripheral malfunctioning nerves in The central
nerves. nervous system (CNS).
PAIN THRESHOLD is the least amount of stimuli that is needed for a person to
label a sensation as pain. Pain threshold may vary slightly from person to person,
and may be related to age, gender, or race, but it changes little in the same
individual over time.

PAIN TOLERANCE is the maximum amount of painful stimuli that a person is

willing to withstand without seeking avoidance of the pain or relief. Pain tolerance
varies considerably from person to person, even within the same person at
different times and in different circumstances.
 IMPLEMENTATION
Acknowledging and Reducing misconceptions
accepting client’s pain about pain

Assisting support people Reducing Fear and Anxiety

Preventing pain
 PATIENT CONTROLLED ANALGESIA
It allows patient to control the administration of their own medication within
predetermined safety limits.
It permits the patient to administer continuous infusion of medication (BASAL
RATES) safely and to administer extra medication (BOLUS DOSES) with episodes
of increased pain or painful activities.

The pump delivers a preset amount of medication.

A PCA pump is electronically controlled by a timing device.

The timer can be programmed to prevent additional doses from being

administered until a specified time period has elapsed (Lock-out time).
PATIENT CONTROLLED ANALGESIA
Even if the patient pushes the button multiple times in a rapid succession, no
additional doses are released.

ALWAYS WATCH OUT FOR RESPIRATORY DEPRESSION!!!

 WHO ANALGESIC LADDER
The three main principles of WHO Analgesic Ladder – BY THE CLOCK, BY THE
MOUTH AND BY THE LADDER

BY THE CLOCK BY THE MOUTH BY THE LADDER

q Drugs should be given q The oral route is the q Non-opoiods

“by the clock” or preferred route for q Mild opoiods
”around the clock: ease of use. q Strong opoiods
rather than PRN. q IM is not
recommended.
q Least invasive as much
as possible.
First step. Mild pain: non-opioid analgesics
such as nonsteroidal anti-inflammatory drugs
(NSAIDs) or acetaminophen with or without
adjuvants
Second step. Moderate pain: weak opioids
(hydrocodone, codeine, tramadol) with or
without non-opioid analgesics, and with or
without adjuvants
Third step. Severe and persistent pain: potent opioids
(morphine, methadone, fentanyl, oxycodone,
buprenorphine, tapentadol, hydromorphone,
oxymorphone) with or without non-opioid analgesics,
and with or without adjuvants
 Cornea – dense transparent outer layer

Sclera – white of the eye

Iris – colored portion of the eye; located in front of

the lens

Pupil – Controls the amount of light

Retina – a thin, delicate structure in which the

fibers of the optic nerve are distributed; visual
receptive

Vitreous Body– contains a gelatinous substance

that occupies the vitreous chamber
 Rods – peripheral vision

Cones – color vision and central vision

Canal of Schlemm – Controls the IOP

Lens – bends the rays of light so that the light falls

in the retina
Conjunctiva – thin, transparent mucous
membranes of the eyes that line the posterior
surface of each eyelid

Lacrimal gland – produces tears

 DIAGNOSTICS
Snellen’s Chart – tests the visual acuity; Normal: 20/20; Legal Blindness: 20/200

Ishihara Plate – Tests color vision

Retinoscopy – determines the refractive error of an eye

Cover and uncover eye– differentiates various types of strabismus

Tonometry– indirect measure of IOP; Normal: 11—21 mmHg

Gonioscopy– a biomicroscopic examination that visualizes the anterior chamber

angle; diagnoses congenital and secondary glaucoma
 COMMON OCULAR MEDICATIONS
MIOTICS ANTIMICROBIALS
Pilocarpine Gentamycin
Carbachol Neosporin
Acetylcholine Chloroptic eye drops

MYDRIATICS
Neo-Synephrine REDUCES AQUEOUS
Atropine HUMEOR PRODUCTION
Scopolamine Acetazolamide
Cyclopentolate Timolol
Tropicamide
 GENERAL CARE FOR EYE SURGERIES
PREOPERATIVE CARE
If both eyes are to be covered after surgery, the patient needs to be oriented to the
staff and the physical environment prior to surgery.

The preparation of the eyes on the day of the surgery may include the instillation of
combination of drugs into the eye at various intervals to DILATE the pupil.
 GENERAL CARE FOR EYE SURGERIES
POSTOPERATIVE CARE
The patient must keep the head still and try to avoid coughing, vomiting, sneezing
or moving suddenly.
Patient should lie on the unoperated side down to prevent pressure on the
operated eye and to prevent possible contamination of the dressing with vomit.

Patient should lie on the back or unoperated side not on stomach.

A burning sensation about one hour after surgery usually means that the anesthetic
is wearing off.
 GENERAL CARE FOR EYE SURGERIES
POSTOPERATIVE CARE
Side rails up at all times while both eyes are covered

The bedside table should be placed on the side of unoperated eyes so that the
patient can see it without excessive movement of the head.
Sensation of pressure within the eye and sharp pain are quickly reported to the
surgeon à indicates bleeding
Avoid lifting the head or hips, straining at stool, squeezing the eyelid, bending
forward
 REFRACTIVE ERRORS
MYOPIA (NEARSIGHTEDNESS) à refractive ability of the eyes is too strong for
eye length

HYPEROPIA (FARSIGHTEDNESS) à refractive ability of the eyes is too weak,

images are focused behind the retina

PRESBYOPIA à loss of lens elasticity because of aging; less able to focus the eye
for close work and images fall behind the retina

ASTIGMATISMà occurs because of the irregular curvature of the cornea, image

focuses at 2 different points.
 REFRACTIVE ERRORS
LEGAL BLINDNESS à the best visual acuity with corrective lenses in the better
eyes is 20/200 or less, or the visual field is no greater than 20 degrees in it is widest
diameter in the better eye
INTERVENTIONS INTERVENTIONS
q Speak in normal tone of voice q Instruct the client to remain 1 step
q Alert the client when approaching behind the nurse when
q Orient the client in the ambulating
environment q Instruct the client in the use of the
q Ensure that the client has clear cane in the dominant hand
pathway several inches
q Use the clock placement of foods
on the meal tray
 CATARACTS
Is an opacity of the lens that distorts the image projected onto the retina and that
can progress to blindness.

CAUSES MANIFESTATIONS
q Senile Cataract q Blurred vision and decreased color
q Congenital Cataract perception -- EARLY
q Traumatic Cataract q Diplopia, reduced visual acuity,
q Secondary Cataract absence of red reflex and while pupil
q DM, Rubella, Myopia, UV, – LATE
Steroids q Pain – age related cataract formation
q Loss of vision
 CATARACTS
PREOPERATIVE INTERVENTIONS
q Instruct client on the
postoperative measures
q Stress to the client the installation
of eye drops for 2-4 weeks
q Administer eye medication
preoperatively – MYDRIATICS and
CYCLOPLEGICS
POSTOPERATIVE INTERVENTIONS
q Elevate HOB 30-45
q Turn the client to the back or
nonoperative side
q Maintain an eye patch as prescribed;
orient the client to the environment
q Position the client’s personal
belongings to the nonoperative side
q Use side rails
q Assist with ambulation
 GLAUCOMA
A group of ocular diseases resulting in increased IP due to inadequate drainage of
aqueous humor from the canal of Schlemm or overproduction of aqueos humor.

PRIMARY OPEN ANGLE PRIMARY CLOSE ANGLE

q Results from obstruction to
outflow of aqueous humor and it’s
the most common type of
glaucoma
q Results from blocking the outflow of
aqueous humor into the trabecular
meshwork; causes include lens or
pupil dilation from medication or
sympathetic stimulation
 INTERVENTIONS
PRIMARY OPEN ANGLE
q Painless q Treat ACUTE CLOSURE GLAUCOMA
q Vision changes slow – MEDICAL EMERGENCY
q Tunnel vision q Administer medication to decrease
IOP
q Avoid anticholinergic and OTP
medications
PRIMARY CLOSE ANGLE q Instruct the client to report eye pain,
q Blurred vision halos around eyes and changes in
q Halos around the lights vision to the HCP.
q Ocular Erythema q Prepare the client to trabeculectomy
 RETINAL DETACHMENT
Detachment or separation of the retina from the epithelium; when detachment
becomes complete, blindness occurs.

MANIFESTATIONS
q Flashes of light
q Floaters or black spots
q Increased in blurred vision
q Sense of curtain being drawn
over the eye
q Loss of a portion of the visual
field; painless loss of central or
peripheral vision
INTERVENTIONS
q Bed rest
q Cover both eyes with patches
q Protect the client from injury
q Avoid jerky head movements
q Minimize eye stress
 RETINAL DETACHMENT

SURGERY INTERVENTIONS
q Draining of fluid from the q Maintain eye patches as prescribed
subretinal space so the retina can q Monitor hemorrhage
return to the normal position q Monitor for sudden, sharp eye pain
q Crysurgery q Provide bed rest
q Diathermy q Limit reading for 3-5 weeks
q Laser Therapy q Avoid squinting, straining and
q Scleral Buckling constipation, lifting heavy objects
q Insertion of gas or silicone oil and bending from the waist
 MACULAR DEGENERATION
A deterioration of the macula, the area of central vision; can be atrophic or
exudative

MANIFESTATIONS INTERVENTIONS
q Initiate strategies to assist in
q A decline in central vision maximizing remaining vision and
q Blurred vision and distortion maintaining independence
q Laser therapy, photodynamic
therapy or other therapies to seal
the leaking blood vessels in or near
the macula
 DIAGNOSTICS
Rinne test – compares air conduction from bone conduction; differentiates
conductive and sensorineural hearing loss

Weber test -- this test is useful to determine cases of unilateral hearing loss

Whisper Voice test – the examiner covers one ear with palm of the hand, then
whispers softly from a distance 1 or 2 feet from the unoccluded ear, and out of
patient’s sight
Pure tone audiometry – the louder the tone before the client perceives it, the
greater the hearing loss
Oculovestibular Test – irrigation the ear with cold water; lateral conjugate
nystagmus of the eyes towards area of stimulation
 SYMPTOMS OF EAR DISEASES
DEAFNESS – hearing loss which can be conductive, sensorineural or mixed types
q Childhood – serous otitis media
q Adult – presbycusis (sensorineural loss)
q Hearing loss predominantly in the higher frequencies

PAIN – Earache or otalgia

DISCHARGE – a discharged from the ear may be mucoid, purulent or bloody

VERTIGO – is a form of dizziness where the patient experiences a spinning

sensation; accompanied by N & V
TINNITUS – noise in the ear; quality varies from a high pitched whistle to clanging
bells or recognizable snatches of music
HEARING LOSS
 HEARING LOSS
CONDUCTIVE HEARING LOSS SENSORINEURAL HEARING LOSS

q Occurs when the sound waves q A pathological process of the inner

are blocked to the inner ear
fibers because of external or
middle ear disorders
q Can be corrected with no
damage to hearing or minimal
permanent hearing loss
ear of sensory fibers that lead to the
cerebral cortex
q Permanent , and measures must be
taken to reduce further damage
 HOW TO COMMUNICATE EFFECTIVELY WITH HEARING
IMPAIRMENT
qTalk directly to the person facing him/her:
qSpeak in clearly enunciated words, using normal tone of voice. Do not shout.
qUse gestures with speech,
qDo not whisper to anybody in front of the hearing - impaired client.
qDo not avoid conversation with a person who has hearing loss.
qDo not show annoyance by careless facial expression.
qMove closer to the person or toward the better ear if he/she does not hear
you.
qDo not smile, do not chew gum or cover the mouth when talking to the
person.
qEncourage the use of hearing aid if the client has one.
 OTITIS MEDIA
An inflammatory disorder usually caused by an infection of the middle ear
occurring as a result of a blocked eustachian tube, which prevents normal
drainage
ASSESSMENT INTERVENTIONS
q Fever q Encourage fluid intake
q Acute onset ear pain q Instruct to avoid chewing -- PAIN
q Loss of appetite q Lie on affected area
q Rolling of head from side to side q Antibiotics, Analgesics and
q Pulling on or rubbing of ear antipyretics
q Purulent discharge
q Red, opaque, bulging, immobile
tympanic membrane
q Signs of hearing loss - CHRONIC
 OTOSCLEROSIS
A genetic disorder of the labyrinthine capsule of the middles ear that results in a
bony overgrowth of the tissue surrounding the ossicles.
ASSESSMENT INTERVENTIONS
q Slowly progressing hearing loss q Hearing aid
q Bilateral hearing loss q Fenestration – removal of the stapes
q Tinnitus
q Loud sound heard in the ear
when chewing
q Pinkish discoloration
q Negative Rinne test
q Weber’s test shows lateralization
 MENIERE’S SYNDROME
A.K.A ENDOLYMPHATIC HYDROPS
It refers to the dilation of the endolymphatic system by overproduction or
decreased reabsorption of endolymphatic fluid

CAUSES ASSESSMENT
q Any factor that increases q Feeling of fullness in the ear
endolymphatic secretion in the q Tinnitus
labyrinth q Hearing loss during an attack
q Viral and bacterial infections q Vertigo – when lying don
q Allergic reactions qN&V
q Biochemical disturbances q Nsystagmus
q Vascular disturbances q Severe headaches
q Long-term stress may be a factor
 MENIERE’S SYNDROME
NONSURGICAL INTERVENTIONS
q Prevent injury during vertigo
q Bed rest in quiet environment
q Provide assistance with walking
q Move the head slowly
q Initiate sodium and fluid
restrictions
q Avoid flickering lights
q Antihistamines ; Tranquilizers
q Mild diuretics
q Avoid Caffeine, alcohol, tobacco
SURGICAL INTERVENTIONS
q Endolymphatic drainage and
insertion of a shunt may be an early
in the course of the disease to assist
in the drainage of excess fluids
q A resection of vestibular nerve or
total removal of the labyrinth may
be performed.