Macular Degeneration Nursing Care Plan & Management

Definition

• Macular degeneration is largely an age-related disease process whereby central vision gradually deteriorates.

Risk Factors

• Increasing age
• Smoking history
• Hypertension
• Overeight
• Hyperopia
• Familial incidence
•  Wet AMD (more common in Caucasians than African Americans)
• Use of thyroid hormones and hydrochlorthiazies
• Arthritis

image by: www.nlm.nih.gov

Pathophysiology

• Age-related macular degeneration (AMD) is a painless disease where the macular gradually brakes down from the development of fatty, yellow, metabolic waste products, which accumulate in the retina. Drusen (yellowish spots associated with aging) appear in retina.

TYPES:

1. “Dry” or nonneovascular AMD
   • Macular drusen may coalesce, causing gradual decrease in central vision. Missing letters in words, blank spots, geographic atrophy, and retinal pigment epithelial abnormalities may appear.
2. “Wet” or neovascular AMD
   • Characterized by the development of an abnormal choroidal neovascular network beneath the macula. These vessels leak fluid and bleed, causing edema and the development of fibrosis. Visual changes can occur rapidly. Straight lines appear crooked and distorted. The resulting macular disciform scar causes a loss of central vision.

Assessment/Clinical Manifestations/Signs and Symptoms

• Blurred vision
• Blind spot in the middle of the visual field
• Central vision can also be lost as small blind spot may also begin to develop

Laboratory and diagnostic study findings

• Fluorescein angiography and indocyanine green angiography may be used to identify signs of macular degeneration.

Medical Management

Photodynamic therapy (PDT)

• Has been developed in an attempt to ameliorate the choroid neovascularization (CNV) while causing minimal damage to the retina.
• PDT is a two-step process. Verteporfin, a photosensitive dye is infused intravenously over 10 minutes. Fifteen minutes after the start of the infusion, a diode laser is used to treat the abnormal network of vessels.

Nursing Diagnosis

• 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

• Nursing management is primarily educational. Verteporfin is a light-activated dye, and patient education is important preoperatively.
• The patient should instructed to bring dark sunglasses, gloves, a wide-brimmed hat, long-sleeved shirt and slacks to the PDT setting.
• The patient must be cautioned to avoid exposure to direct sunlight or bright light for 5 days after treatment. The dye within the blood vessels near the surface of the skin could become activated with exposure to strong light. This would include bright sunlight, tanning booths, halogen lights and the bright lights used in dental offices and operating rooms.
• Gloves, shoes, socks, sunglasses and a wide-brimmed hat should also be worn if the patient has to go outdoors during daylight hours during this period. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn that may require plastic surgery.

Nursing Diagnosis

Disturbed Sensory Perception: Visual

Related to

• macular degeneration
• presence of drusen
• central vision loss
• age-related ocular changes

Possibly evidenced by

• distortion of central vision
• Straight lines appear distorted
• objects appearing smaller or larger than normal
• Distortion of vision noted on grid
• presence of drusen or yellow deposits under the retina, the light-sensitive tissue at the back of the eye
• legal blindness
• subretinal edema
• retinal bleeding

Desired Outcomes

• Patient will regain optimal vision possible and will adapt to permanent visual changes
• Patient will be able to verbalize understanding of visual loss and diseases of eyes.
• Patient will be able to regain vision to the maximum possible extent with surgical procedure.
• Patient will be able to deal with potential for permanent visual loss.
• Patient will maintain a safe environment with no injury noted.
• Patient will be able to use adaptive devices to compensate for visual loss.
• Patient will be compliant with instructions given, and will be able to notify physician for emergency symptoms.

Nursing Interventions

• Assess patient’s ability to see and perform activities.
  • Rationale: Provides baseline for determination of changes affecting the patient’s visual acuity.
• Assist in diagnostic procedures and provide appropriate information:
  • Indirect ophthalmoscopy
    • Rationale: Fundus examination through a dilated pupil that may reveal gross macular changes.
  • Amsler’s grid
    • Rationale: Used to monitor visual field loss.
  • I.V. fluorescein angiography
    • Rationale: Sequential photographs that may show leaking vessels as fluorescein dye flows into the tissues from the subretinal neovascular net.
• Encourage patient to see ophthalmologist at least yearly.
  • Rationale: Can monitor progressive visual loss or complications. Decreases in visual acuity can increase confusion in the elderly patient.
• Provide sufficient lighting for patient to carry out activities.
  • Rationale: Elderly patients need twice as much light as younger people.
• Provide lighting that avoids glare on surfaces of walls, reading materials, and so forth.
  • Rationale: Elderly patient’s eyes are more sensitive to glare and cataracts diffuse and glare so that patient has more difficulty with vision.
• Provide night light for patient’s room and ensure lighting is adequate for patient’s needs.
  • Rationale: Patient’s eyes may require longer accomodation time to changes in lighting levels. Provision of adequate lighting helps to prevent injury.
• Provide large print objects and visual aids for teaching.
  • Rationale: Assists patient to see larger print, and promotes sense of independence.
• Provide information about laser surgery.
  • Rationale: Laser surgery may be helpful for the wet type of macular degeneration if done early. An approximate of only 20% of patients will have any improvement in visual function if done later.

Nursing Diagnosis

Risk for Injury

May be related to

• macular degeneration
• decreased vision
• aging
• decreased central vision

Risk factors

• Retinal hemorrhage
• Visual distortion
• Confusions
• Presence of drusen
• Decreased visual acuity
• Decreased visual fields
• Decreased central vision

Desired Outcomes

• Patient will be free of injury and will be able to perform activities within parameters of sensory limitation.
• Patient will be able to be free of injury.
• Patient and/or family will be able to modify environment to ensure patient safety.

Nursing Interventions

• Assess patient for degree of visual impairment.
  • Rationale: Increases awareness of problem, and identifies severity to allow for establishment of a plan of care.
• Inform about special devices that can be used.
  • Rationale: Low-vision optical aids are available to improve the quality of life in the patient with good peripheral vision.
• Ensure room environment is safe with adequate lighting and furniture moved toward the walls. Remove all rugs, and objects that could be potentially hazardous.
  • Rationale: Provides a safe environment to reduce potential for injury.
• Keep patient’s glasses and call bell within easy reach.
  • Rationale: Provides for assistance for patient and for optimal visual acuity.
• Instruct patient and/or family regarding need for maintain safe environment.
  • Rationale: Reduced visual acuity puts patient at risk for injury.
• Instruct patient and/or family regarding safe lighting. Patient should wear sunglasses to reduce glare. Advise family to use contrasting bright colors in household furnishings.
  • Rationale: These techniques helps to enhance visual discrimination and reduce potential for injury.

After surgery to extract a cataract:

• Remind patient to attend checkup the following day after surgery.
  • Rationale: Because the patient will be discharged after he recovers from anesthesia post-op. Warn him to avoid activities that increase intraocular pressure.
• Instruct patient to wear a plastic or metal shield over the eye with perforations; a shield or glasses should be worn for protection during the day.
  • Rationale: To protect the eye from accidental injury.
• Teach the patient how to administer antibiotic ointment or drops; including steroids.
  • Rationale: To prevent infection and inflammation.
• Instruct patient to watch out for development of complications, such as sharp pain in the eye uncontrolled by analgesics, or clouding in the anterior chamber.
  • Rationale: This may indicate infection and should be reported immediately.