St Thomas University Week 6 Adult Gerontology Acute Discussion Reply

• All replies must be constructive and use literature where possible.

Kelliann Giufurta

To get a comprehensive understanding of the patient’s condition, additional subjective data will need to be conducted before a diagnosis can be achieved. Since the patient is new to Florida and has not yet established care, exploring patient and family history is vital. The advanced practitioner will want to inquire about previous diagnosis of diseases that pose as risk factors such as hypertension and diabetes. Questions regarding changes in night vision, changes in prescription glasses, halo around light, light scattering, double vision, and reduced contrast can assist in achieving a diagnosis. The patient should be asked if the symptoms are worse at certain times during the day such as in the daylight or nighttime. The practitioner should ask about history of steroids, uveitis, and trauma or injury to the eyes. Investigation into social history such as smoking, alcohol use, occupational history, and dietary habits is important. Reduced intake of antioxidants such as vitamin C, glutathione, and protein can induce cataracts (Uphold & Graham, 2018). Relevant family history includes any first-degree relatives who suffered from or is suffering from visual problems or eye disorders, diabetes, hypertension, myotonic dystrophy, type II neurofibromatosis, and galactosemia (Uphold & Graham, 2018).

Objective data obtained during this encounter would include a full set of vital signs including oxygen saturation, pain level, and temperature. Performing a complete physical exam is necessary. An assessment of the eyes will be done by using the Snellen Visual acuity chart, lens opacity, and impaired red reflex. Differential diagnoses to be considered include cataracts, glaucoma, macular degeneration, and trauma. Elderly age, decreased visual acuity, glare sensitivity, inability to identify people from distance (decreased contrast), and reduced functional status due to vision are consistent with the diagnosis of cataract which shall be confirmed by ophthalmoscopic and Slit lamp bio-microscopic examination (Kennedy- Malone et al, 2019). Decreased visual acuity can also be a sign of glaucoma which occurs due to increased intraocular pressure. Trauma is an acute condition and can be ruled out easily as there is neither subjective complaint of injury or trauma nor there is any sign of injury from initial assessment (Uphold & Graham, 2018).

In addition to the laboratory tests listed above, Amsler grid, fluorescein angiogram, Tonometry, fundoscopy, and gonioscopy can be performed. There is no specific radiologic examination for cataracts, however a CT (Computed Tomography) scan and/ or Magnetic Resonance Imaging (MRI) can be used to identify any underlying diseases like Myotonic dystrophy and Type II Neurofibromatosis. Blood glucose and a lipid profile can be used to identify the risk factors that led to development of cataract in the given client.

Treatment for symptomatic management until surgery includes prescription of glasses, contact lens or strong bifocal glasses to improve vision for the time being. Mydriatics such as Atropine, Homatropine, Cyclopentolate, Phenylephrine can be used for short term to improve the vision. Intracapsular cataract extraction, extracapsular surgery, phaco-emulsification, and lens replacement are surgical interventions that can be performed.

Information that should be provided to this patient include education about the short-term use of the above prescriptions and that surgery is necessary. Encouragement of additional intake in foods that are rich in antioxidants such as Vitamin C, beta-carotene, Vitamin E should be provided. Safety education such as walking and reading should be carried out in well-lit areas, and furniture and objects should be placed in convenient places to prevent falling or tipping over (Kennedy-Malone et al., 2019).

Potential complications from the treatment ordered include increased glare sensitivity from mydriatic use. Following cataract surgery, complications such as retrobulbar hemorrhage can occur due to infiltration of local anesthetics used during surgery. Acute bacterial endophthalmitis can occur due to infection of operated eye and chronic endophthalmitis, posterior capsule opacification or malposition of intraocular lens are other complications of cataract surgery (Uphold & Graham, 2018). A surgical Ophthalmologist consult is required for the given client. 

References

Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Advanced Practice Nursing in the Care of Older Adults. (2nd ed.). Philadelphia, PA: F. A. Davis Company. ISBN: 978-0803666610

Uphold, C. R., & Graham, M. V. (2018). Clinical guidelines in family practice. Barmarrae Books.