Lippincott Certification Review Medical-Surgical Nursing

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Chapter 18

Box 18-2: Procedures for Glaucoma

Deviated Nasal Septum ●● Description ●● The nasal septum, which bisects the nasal cavity, is made up of cartilage and bone; deviations are common. ●● Although septal deviation typically is asymptomatic, it can cause nasal obstruction and increase the risk of sinusitis and epistaxis. ●● Deviated nasal septum may be congenital or caused by trauma. ●● Signs and symptoms ●● Signs and symptoms of deviated septum include drying, crusting nasal discharge and other mucosal changes, as well as bleeding that can block the sinus opening. ●● The patient may report shortness of breath and difficulty breathing through the nose and may also report sinusitis and headache. ●● Upper respiratory tract infection or nasal trauma can exacerbate symptoms. ●● Diagnosis and treatment ●● Diagnosis is based on visual inspection of the nasal mucosa with a bright light and nasal speculum. ●● Short-term treatment consists of decongestants, antihistamines, and nasal saline rinses to open the nasal airway and analgesics to relieve headache. ●● Long-term treatment may require septoplasty or submucous resection of the septum; in these procedures, the septum is surgically straightened and then stabilized with sutures and packing (consisting of petroleum jelly, iodoform, and soft gauze) for 24 to 48 hours. ●● Indications for surgery include nasal hemorrhage and an inability to pack the nose adequately because of deformity, recurrent sinusitis resulting from blocked sinus openings, and such signs and symptoms as snoring, breathing through the mouth, dry mouth, and shortness of breath. ●● Surgery is performed under local or general anesthesia and is generally an outpatient procedure; its complications include septal hematoma, infection, hemorrhage, septal perforation, anosmia, and cosmetic deformity. ●● Preoperative nursing interventions ●● Determine the severity of the nasal airway obstruction; a patient with a blocked nasal airway needs humidification, oral hygiene, and other comfort measures. ●● Teach the patient about postoperative care to reduce anxiety and promote adherence. Argon laser trabeculoplasty (ALT) is a first-line therapy for different types of glaucoma. It’s used either instead of drug therapy or if drug therapy can’t control the increased intraocular pressure (IOP). Performed as an outpatient procedure, ALT directs 40 to 80 laser beams into the trabecular network, creating holes through which the aqueous humor can return to the venous circulation. For patients who are unresponsive to drug therapy or ALT, or aren’t suitable candidates for these treatments, a trabeculectomy may be performed. In this glaucoma filtration procedure, a flap of sclera is dissected free to expose the trabecular meshwork. This discrete tissue block is then removed, and a surgical hole is made in the periphery of the iris. The opening allows aqueous humor to flow out under the conjunctiva by creating a filtering bleb. Often, drugs such as 5-fluorouracil are applied during or after the procedure to control scarring and reclosure of the hole. Patients for whom trabeculectomy has failed to maintain lower IOP or who are at high risk for failure may need a tube shunt implanted to keep the drainage pathway artificially open. These shunts are surgically kept closed with an absorbable suture to allow healing time. Because of the time required before the shunt is operational and the difficulty of medically controlling IOP after surgery, the patient may undergo a trabeculectomy at the same time. Usually, this site fails about the same time as the shunt is healed, providing for continuous pressure reduction. When other treatments have failed to control IOP, transscleral cyclophotocoagulation may be performed. Between 20 and 40 laser beams are directed into the ciliary body of the eye to decrease its production of aqueous fluid. Laser peripheral iridotomy is used to correct the narrow angle between the iris and the trabecular meshwork that blocks appropriate drainage of aqueous humor in patients with angle-closure glaucoma. A laser beam creates a small hole in the peripheral iris, allowing the fluid to flow to the anterior chamber of the eye, which also results in opening of the angle of the eye.

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