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Question 1 of 1
The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which of the following is associated with this eye disorder?Correct
Answer & Rationale:
Option 4 is Correct
Rationale: A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.Incorrect
Answer & Rationale:
Option 4 is Correct
Rationale: A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.
- Detachment or separation of the retina from the epithelium
- Retinal detachment occurs when the layers of the retina separate because of the accumulation of fluid between them, or when both retinal layers elevate away from the choroid as a result of a tumor.
- Partial detachment becomes complete if untreated.
- When detachment becomes complete, blindness occurs.
- Flashes of light
- Floaters or black spots (signs of bleeding)
- Increase in blurred vision
- Sense of a curtain being drawn over the eye
- Loss of a portion of the visual field; painless loss of central or peripheral vision
- Provide bedrest.
- Cover both eyes with patches as prescribed to
- prevent further detachment.
- Speak to the client before approaching.
- Position the client’s head as prescribed.
- Protect the client from injury.
- Avoid jerky head movements.
- Minimize eye stress.
- Prepare the client for a surgical procedure as prescribed.
- Draining fluid from the subretinal space so that the retina can return to the normal position
- Sealing retinal breaks by cryosurgery, a cold probe applied to the sclera, to stimulate an inflammatory response leading to adhesions
- Diathermy, the use of an electrode needle and heat through the sclera, to stimulate an inflammatory response
- Laser therapy, to stimulate an inflammatory response and seal small retinal tears before the detachment occurs
- Scleral buckling, to hold the choroid and retina together with a splint until scar tissue forms, closing the tear
- Insertion of gas or silicone oil to promote reattachment; these agents float against the retina to hold it in place until healing occurs.
- Maintain eye patches as prescribed.
- Monitor for hemorrhage.
- Prevent nausea and vomiting and monitor for restlessness, which can cause hemorrhage.
- Monitor for sudden, sharp eye pain (notify the physician).
- Encourage deep breathing but avoid coughing.
- Provide bedrest for 1 to 2 days as prescribed.
- Position the client as prescribed (positioning depends on the location of the detachment).
- Administer eye medications as prescribed.
- Assist the client with activities of daily living.
- Avoid sudden head movements or anything that increases intraocular pressure.
- Instruct the client to limit reading for 3 to 5 weeks.
- Instruct the client to avoid squinting, straining and constipation, lifting heavy objects, and bending from the waist.
- Instruct the client to wear dark glasses during the day and an eye patch at night.
- Encourage follow-up care because of the danger of recurrence or occurrence in the other eye.