MDC 1 FINAL EXAM

1. Signs and Symptoms of Visual Impairment

- Blurry vision

Squinting

Closing one eye

Leaning close to screens

2. Nursing Interventions for visual impairment

- Knock and announce entrance and exit

Communication to floor staff that they are visually impaired

Orient them to their environment

Count steps to bathroom with them

don't change the environment

Describe their food placement on the plate in terms of a clock face.

Assess if they need assistance to the bathroom

3. Myopia

- Near sightedness, distance vision is poor

4. Astigmatism

- Irregularity or deformity of the shape of the cornea

Oval shape, should be round

5. Cataracts s/s

- Blurred vision

Clouded vision

Decreased color perception

May think that glasses are smudged

Double vision

Halos around objects

Problems with ADL'S

Affects reading and driving

Impaired night vision

Frequents changes in eyeglass prescription

Without surgical intervention blindness follows

6. Cataract Surgery Post-Op assessment Monitor for

- Observe for increasing eye redness

Decrease in vision

Increase in tears

Photophobia

Floaters

Sharp, or sudden pain in eye

Green or yellow drainage on the lids and lashes

NOTE: Creamy, white, crusty drainage on eye lids and lashes is normal, but stress

importance of handwashing

Antibiotic and steroid ointment are placed in the eye immediately post-op.

Discharged home one hour after surgery

Wear dark glasses and avoid bright sunlight until pupils respond to light.

Do not drive - Will need ride home

Develop a schedule for the administration of post-op eye drops. Be sure client or family

can demonstrate the correct technique for administering the drops.

Be sure the client understands the importance of attending all follow-up appointments.

Itching of the eye is normal.

Eyelid swelling is normal also and can be managed with a cool compress

Discomfort can be managed with Tylenol but aspirin needs to be avoided because it

affects blood clotting.

Uncontrolled pain may indicate hemorrhage or increased intraocular pressure and the

physician should be notified especially if nausea and vomiting accompanies the pain.

Report Worsening Vision

7. Discharge planning after cataract Surgery

- Develop a schedule for the administration of post-op eye drops. Be sure client or

family can demonstrate the correct technique for administering the drops.

Be sure the client understands the importance of attending all follow-up appointments.

Teach them S&S

8. Restrictions after cataract Surgery

- Avoid jarring rapid movements, wear dark sunglasses, no driving themselves home

9. Hearing Impairment Communication

- Face them

Don't yell, speak clearly, slowly

Use whiteboard when necessary

Use interpreter if the patient speaks sign language

10. Risk Factors for Hearing Loss

- Medications

Loud noises over long period (occupational)

11. Tinnitus

- Ringing in the ears

12. Patient Education for installation of eardrops

- place dropper half inch above ear

pull auricle back and out

lay on your side for a couple of minutes to let medication to get into inner ear

13. How Weber Test is performed

- Uses tuning fork

Vibrate tuning fork, first place it on the top of the head and have the patient tell which

side they hear the vibrations more on

14. Normal result of Weber test

- Vibrations should be equal on both sides

15. What is cellulitis?

- infection of the skin

16. Interventions of cellulitis

- Warm compresses

Elevate the affected area

Reposition patient frequently

17. Scleroderma

- hardening of the skin

18. Wound Assessment Documentation

- C: color

O: odor

C: consistency

A: amount

Location

Size

Extent of tissue involvement

19. Exudate

- Slough: refers to the yellow/white material in the wound bed; it is usually wet, but can

be dry. It generally has a soft texture. It can be thick and adhered to the wound bed,

present as a thin coating, or patchy over the surface of the wound

20. Eschar

- Dead tissue that eventually sloughs off healthy skin after an injury. (a scab)