NCLEX RN Practice Question # 459

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Retinal detachment

Description

• 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.

Assessment

• 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

Immediate interventions

• 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.

Surgical procedures

• 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.

Postoperative interventions

• 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.