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HESI: Mr. Russo

Terms in this set (25)

Your shift has just begun and you are informed that Mr. Russo, a 68-year-old male seen in the Emergency Department, has suspected closed angle glaucoma of the right eye. He is being admitted to your unit and requires immediate treatment to prevent permanent loss of vision. The Operating Room is on stand-by for this case. Mr. Russo is accompanied by his son.
Mr. Russo tells you that he is experiencing severe pain in his right eye and you notice that the eye is tearing and is very red. His eyelid is puffy and he complains that his vision is "blurry." He is fearful and in pain. You obtain a set of vital signs and document the initial assessment data.
1. The nurse understands that glaucoma is characterized by peripheral visual field loss due to optic nerve damage. Glaucoma is usually associated with intraocular hypertension also known as:

- increased intraocular pressure
- small retinal hemorrhages
- intraocular inflammation
- opacity of the crystalline lens
- increased intraocular pressure

In persons with glaucoma, an increase in intraocular pressure (from an excess of aqueous humor) is usually responsible for the optic nerve and visual field damage that can occur.
2. In glaucoma, intraocular pressure increases in which part of the eye?

- Anterior chamber
- Posterior chamber
- Lens
- Anterior chamber

In persons with glaucoma, intraocular pressure increases in the anterior chamber, as a result of an increased amount of aqueous humor.
Aqueous humor supplies essential nutrients to the eye. Secreted by the ciliary body, aqueous humor circulates from the posterior chamber through the pupil to the anterior chamber. Outflow of aqueous humor from the anterior chamber occurs through the trabecular meshwork into the canal of Schlemm, and eventually to venous circulation.
Normal intraocular pressure is maintained when aqueous humor is produced and drained in equal amounts.
Mr. Russo has closed angle glaucoma.
The difference between open angle glaucoma and closed angle glaucoma is: Primary open angle glaucoma or POAG is more common than closed angle glaucoma. It is a chronic disease where there is no pain or blurred vision despite the loss of peripheral vision. It is more common in African American clients and individuals with diabetes. Unfortunately, many people are unaware of their condition.
Primary closed angle glaucoma or PCAG presents as an acute eye emergency. It results in sudden closure of the angle resulting in a sudden rise in intraocular pressure. Since the flow of aqueous humor out of the eye is restricted, it is painful. The affected eye is red and tearing. The eyelid is swollen and treatment must begin within 24-48 hours if blindness is to be avoided.
First line medications include topical ophthalmic preparations such as beta blockers, prostaglandin analogs, or alpha 2 adrenergic agonists.
Timolol or betaxolol are often prescribed for persons with glaucoma. These medications decrease production of aqueous humor and also help increase outflow from the anterior chamber.
3. Clients taking timolol or betaxolol are both beta blockers. What actions should the nurse take when a client is prescribed timolol eye drops?

Select all that apply (there are 2 correct answers).

- Assess client history for diagnosis of asthma
- Assess client history for penicillin allergy
- Monitor client's pulse rate for bradycardia and heart block
- Monitor client's potassium level
- Assess client history for diagnosis of asthma
Eye medications can be absorbed systemically and have systemic effects. Timolol and betaxolol are beta-blockers. Timolol is non-selective for beta 1 and beta 2. Betaxolol is selective for beta 1 only and therefore does not cause bronchospasms. This is the preferred drug for asthmatics.

- Monitor client's pulse rate for bradycardia and heart block
Eye medications can be absorbed systemically and have systemic effects. Timolol and betaxolol are beta-blockers. Beta-blockers can decrease the heart rate. Blood pressure should be followed. These drugs should be used with caution in any client with heart failure. Systemic absorption of eye medication can be reduced with occlusion of the nasolacrimal duct (application of slight finger pressure) after the medication is administered.
Glaucoma can result in serious consequences, even blindness, if not detected and treated. Glaucoma is the leading cause of blindness in African Americans and Hispanics. It is a disease of the optic nerve and usually but not always is associated with intraocular hypertension.
Screening with ophthalmoscopy and measurement of intraocular pressure is important.
Intraocular pressure is measured by determining how much pressure is required to flatten the cornea, or make an indentation in the eye. Generally, a pressure over 24 mm Hg indicates a problem, and further testing (such as examination through dilated pupils) is required.
Mr. Russo's intraocular pressure was 50 mm Hg when he was admitted.
4. With acute closed angle glaucoma, proper positioning of Mr. Russo is important. Which position is best for Mr. Russo?

- Supine
- Side-lying
- Prone
- Fowler's
- Fowler's

The Fowler's position (45 degrees or higher) is preferred for clients with acute closed angle glaucoma. It promotes drainage by gravity and should help control intraocular pressure.
You perform a more comprehensive assessment of Mr. Russo, realizing that acute closed angle glaucoma is an emergency situation.
...
You perform a more comprehensive assessment of Mr. Russo, realizing that acute closed angle glaucoma is an emergency situation.

5. Mr. Russo has a red, painful eye. Which signs and symptoms commonly occur with acute closed angle glaucoma?
Select all that apply (there are 4 correct answers).

- Nausea
- Vertigo
- Blurred vision
- Profuse tearing
- Seeing halos around bright lights
- Nausea
The pain experienced by clients with acute closed angle glaucoma often precipitates nausea and vomiting. It is important that vomiting be prevented, since vomiting increases intraocular pressure.

- Blurred vision
Increased intraocular pressure interferes with proper focusing of the lens, resulting in loss of peripheral vision and blurring of vision.

- Profuse tearing
Besides eye redness, profuse tearing (lacrimation) may occur with acute closed angle glaucoma.

- Seeing halos around bright lights
Seeing halos around lights is a classic symptom of acute closed angle glaucoma.
6. Mr. Russo's eyes are examined. Which of the following do you expect?

- Greyish color of the pupil
- Protrusion of the eyeball
- Nonreactive pupil
- Purulent drainage from the eye
- Nonreactive pupil

In clients with acute closed angle glaucoma, greatly increased intraocular pressure around the iris prevents normal pupil response to light.
It becomes clear to you, as you talk with Mr. Russo, that his recent activities or medications may have precipitated the acute development of closed angle glaucoma.

7. Which event most likely precipitated this acute episode of closed angle glaucoma in Mr. Russo?

- Drinking four cups of coffee with caffeine this morning
- Walking four miles this morning
- Taking over-the-counter antihistamines this morning
- Forgetting to take his diuretic medication
- Taking over-the-counter antihistamines this morning

Acute closed angle glaucoma occurs as a consequence of increased fluid pressure in the eye. Antihistamines/anticholinergic can increase intraocular pressure and precipitate an attack of acute closed angle glaucoma by relaxing the iris sphincter, inducing closure of the filtration angle in people whose eyes already have a narrow angle.
Mr. Russo's primary healthcare provider arrives and writes a prescription for medications to reduce the intraocular pressure as much as possible, until the Operating Room (OR) is available for Mr. Russo's corrective surgery.

8. You anticipate that the HCP will prescribe a combination of eye drops. Which classification of medication do you anticipate to administer?

- mydriatics
- miotics
- cycloplegics
- miotics

Miotics constrict the pupil. This response pulls the iris away from the canal of Schlemm and permits increased drainage of intraocular fluid. Subsequently, intraocular pressure should decrease with administration of a miotic.
9. The HCP has prescribed two different ophthalmic medications to be administered to Mr. Russo. The prescription is as follows: Administer pilocarpine eye drops and acetazolamide intravenously stat. What action should the nurse take first?

- Administer pilocarpine eye drops immediately
- Administer acetazolamide IV before Pilocarpine eye drops
- Insert IV catheter immediately
-Monitor for blurred vision and pupillary dilation
- Administer pilocarpine eye drops immediately

The pilocarpine eye drops can be given quickly and should promptly cause a decrease in Mr. Russo's intraocular pressure. Acetazolamide is also important, but an IV must be started first.
10. In evaluating for the expected effect of the pilocarpine drops, you observe Mr. Russo for what condition?

- constriction of the pupil
- dilation of the pupil
- Ocular stinging, puffy eye lids
- Bitter taste, conjunctivitis
- constriction of the pupil

Pilocarpine is a cholinergic drug or muscarinic agonist. It has a miotic effect on the pupil of the eye. Miotics constrict the pupil. This response pulls the iris away from the canal of Schlemm and permits increased drainage of intraocular fluid. Subsequently, intraocular pressure should decrease with administration of a miotic.
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