E
Risk for electrolyte Imbalance
NANDA-I
Risk Factors
Diarrhea; endocrine dysfunction; fluid imbalance (e.g., dehydration, water intoxication); impaired regulatory mechanisms (e.g., diabetes insipidus, syndrome of inappropriate secretion of antidiuretic hormone); renal dysfunction; treatment-related side effects (e.g., medications, drains); vomiting
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Electrolyte Monitoring, Electrolyte Management: Hypokalemia, Hyperkalemia, Hypocalcemia, Hypercalcemia, Hypernatremia, Hypophosphatemia, and Hyperphosphatemia, Electrolyte Management: Hyponatremia, Fluid/Electrolyte Management, Laboratory Data Interpretation
Nursing Interventions and Rationales
Monitor vital signs at least three times a day, or more frequently as needed. Notify provider of significant deviation from baseline. Electrolyte imbalance can lead to clinical manifestations such as respiratory failure, arrhythmias, edema, muscle weakness, and altered mental status (Buckley, LeBlanc, & Cawley, 2010).
Monitor cardiac rate and rhythm. Report changes to provider. Hyperkalemia can result in ECG changes that can lead to cardiac arrest, and ventricular dysrhythmias (Lee, 2010). Magnesium imbalances also can cause cardiac arrhythmias (Buckley, LeBlanc, & Cawley, 2010). Low serum magnesium (≤2 mEq/L) is associated with hypokalemia and ECG changes (Metheny, 2009).
• Monitor intake and output and daily weights. Weight gain is a sensitive and consistent sign of fluid volume excess (Metheny, 2009).
• Monitor for abdominal distention and discomfort. Gastric emptying rate is generally accelerated by the total volume of fluids consumed (Popkin, D’Anci, & Rosenberg, 2010).
• Monitor the client’s respiratory status and muscle strength. Phosphorus is an essential element in cell structure, metabolism and maintenance of acid-base processes. Consequences of hypophosphatemia include cardiac and respiratory failure (Geerse et al, 2010).
• Assess cardiac status and neurological alterations. Hypophosphatemia can cause myocardial dysfunction, hematological dysfunction, and neurological changes. Causes of neurological changes are not well documented. Hyperphosphatemia is associated with hypocalcemia, causing tetany, muscle spasms, and cardiac arrhythmias (Geerse et al, 2010).
Review laboratory data as ordered and report deviations to provider. Laboratory studies may include serum electrolytes: potassium, chloride, sodium, bicarbonate, magnesium, phosphate, calcium; serum pH; comprehensive metabolic panel; and blood gases.
• Review the client’s medical and surgical history for possible causes of altered electrolytes. Periods of excess fluid loss can lead to dehydration and resulting loss of electrolytes; fluid can be lost through gastrointestinal illness, renal failure, hyperthermia, blood loss, and perspiration due to strenuous exercise (Popkin, D’Anci, & Rosenberg, 2010). Additional causes of electrolyte imbalances include burns, trauma, sepsis, diabetic ketoacidosis, extensive surgeries, and changes in acid-base balance (Yee, 2010).
Complete pain assessment. Assess and document the onset, intensity, character, location, duration, aggravating factors, and relieving factors. Notify the provider for any increase in pain or discomfort or if comfort measures are not effective. Symptoms of electrolyte imbalance and dehydration can include muscle cramps, paresthesias, abdominal cramps, skin manifestations, cardiac arrhythmias, and tetany (Lee, 2010).
Monitor the effects of ordered medications such as diuretics and heart medications. Medications can have adverse effects on electrolyte balance, particularly chemotherapeutic agents, amphotericin B, aminoglycosides, phosphate ingestion loop diuretics, and vitamin D (Buckley, LeBlanc, & Cawley, 2010).
Administer parenteral fluids as ordered and monitor their effects. Rapid resuscitation with fluids can cause adverse effects such as water retention and electrolyte imbalance. Administration of fluids should be done in order to impact the plasma electrolytes and pH in a predictable fashion to prevent adverse consequences (Kaplan & Kellum, 2010).
Geriatric:• Monitor electrolyte levels carefully, including sodium levels and potassium levels, with both increased and decreased levels possible. Elderly are prone to electrolyte abnormalities because of failure of regulatory mechanisms associated with heart and kidney disease, a decrease in the ability to reabsorb sodium and a loss of diluting capacity in the kidneys. Many elderly clients are receiving selective serotonin reuptake inhibitors for treatment of depression, which can result in hyponatremia (Schlanger & Bailey, 2010).
Client/Family Teaching and Discharge Planning:
• Teach client/family the signs of low potassium and the risk factors. Signs and symptoms of low potassium include muscle weakness, nausea, vomiting, constipation, and irregular pulse (Lee, 2010).
• Teach client/family signs of high potassium and the risk factors. Signs and symptoms of high potassium include restlessness, muscle weakness, slow heart rate, diarrhea, and cramping (Metheny, 2009).
• Teach client/family the signs of low sodium and the risk factors. Early signs of low sodium include nausea, muscle cramps, disorientation, and confusion and may mimic those of dehydration (Lee, 2010).
• Teach client/family the signs of high sodium and the risk factors. Signs of high sodium include thirst, dry mucous membranes, rapid heartbeat, low blood pressure, and cool extremities. Symptoms can progress to confusion, delirium, and seizures (Lee, 2010).
• Teach client/family the importance of hydration during exercise. Dehydration occurs when the amount of water leaving the body is greater than the amount consumed. The body can lose large amounts of fluid when it tries to cool itself by sweating (Wedro, 2008).
• Teach client/family the warning signs of dehydration. Early signs of dehydration include thirst and decreased urine output. As dehydration increases, symptoms may include dry mouth, muscle cramps, nausea and vomiting, lightheadedness, and orthostatic hypotension. Severe dehydration can cause confusion, weakness, coma, and organ failure (Schwellnus, 2009).
• Teach client about any medications prescribed. Medication teaching includes the drug name, its purpose, administration instructions such as taking it with or without food, and any side effects to be aware of. Diuretic use remains a primary cause of low serum potassium levels (Lee, 2010).
Instruct the client to report any adverse medication side effects to his/her provider. Assessing and instructing clients about medications and focusing on important details can help prevent client medication errors (Buckley, LeBlanc, & Cawley, 2010).
References
Buckley, M.S., LeBlanc, J.M., Cawley, M.J. Electrolyte disturbances associated with commonly prescribed medications in the intensive care unit. Crit Care Med. 2010;38(6):S253–S264.
Geerse, D.A., et al. Treatment of hypophosphatemia in the intensive care unit: a review. Crit Care. 2010;14(4):R147.
Kaplan, L.J., Kellum, J.A. Fluids, pH, ions and electrolytes. Curr Opin Crit Care. 2010;16(4):323–331.
Lee, J.W. Fluid and electrolyte disturbances in critically ill patients. Electrolyte Blood Press. 2010;8(2):72–81.
Metheny, N.M. Fluid and electrolyte balance: nursing considerations. Sudbury, MA: Jones & Bartlett Learning; 2009.
Popkin, B.M., D’Anci, K.E., Rosenberg, I.H. Water, hydration, and health. Nutr Rev. 2010;68(8):439–458.
Schlanger, L.E., Bailey, J.L., Sands, J.M. Electrolytes in the aging. ACKD. 2010;17(4):308–319.
Schwellnus, M.P. Cause of exercise-associated muscle cramps (EAMC)—altered neuromuscular control, dehydration or electrolyte depletion? Br J Sports Med. 2009;43(6):401–408.
Wedro, B., Dehydration, 2008 Retrieved March 24, 2009, from http://www.medicinenet.com/dehydration/article.htm
Yee, A.H. Neurologic presentations of acid-base imbalance, electrolyte abnormalities and endocrine emergencies. Neurol Clin. 2010;28(1):1–16.
Disturbed energy Field
NANDA-I
Disruption of the flow of energy surrounding a person’s being results in disharmony of the body, mind, and/or spirit
Defining Characteristics
Perceptions of changes in patterns of energy flow around the body, such as movement (i.e., tingling, wave, spike, bulge) or lack of movement (i.e., congestion, density, hole, diminished flow); sounds (i.e., tone, words); temperature change (i.e., warmth, coolness); and/or visual changes (i.e., image, color) (revised Wardell, 2011)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Consider using Therapeutic Touch (TT) and/or Healing Touch (HT) for clients with anxiety, tension, pain, or other conditions that indicate a disruption in the flow of energy. EBN: TT and HT, when provided in the clinical setting, promote comfort, calmness, and well-being among hospitalized clients (Danhauer et al, 2008; Jain & Mills, 2011; MacIntyre et al, 2008; Wardell, Rintala, & Tan, 2008). EBN: HT may be effective treatment for relieving pain and improving quality of life in this specific population of persons with intractable central neuropathic itch (Curtis et al, 2011) and fibromyalgia syndrome (Denison, 2004). HT may also decrease length of stay in those undergoing coronary artery bypass surgery (MacIntyre et al, 2008). Cardiovascular disease management may also benefit from biofield interventions (Anderson & Taylor, 2011). TT and HT have been used in a variety of cancer studies showing improved quality of life, decreased pain and anxiety, better symptom management (Aghabati, Mohammadi, & Pour Esmaiel, 2010), and decreased fatigue and nausea (Danhauer et al, 2008). Preservation of immune function has also been suggested during chemoradiation with HT therapy (Lutgendorf et al, 2010). Even so, further study in cancer care is needed before reliable conclusions can be made (Agdal, Hjelmborg, & Johannessen, 2011).
• Consider HT treatments for clients with psychological depression. EBN: HT can be a complementary approach to help in the reconnection process to self and others (Van Aken & Taylor, 2010).
• Administer TT and/or HT as described in the following discussion (may also include Reiki practice). EB: The research relating to therapeutic touch’s effect on pain and anxiety in clients with cancer indicates that the therapy does help reduce pain and anxiety (Jackson et al, 2008). CEB: HT may reduce stress, anxiety, and pain; facilitate healing; have some improvement in biochemical and physiological markers; and give a greater sense of well-being. Nurses may provide safe, noninvasive care to promote healing with HT (Wardell & Weymouth, 2004). HT reduced anxiety in clients undergoing first-time elective coronary artery bypass surgery (MacIntyre et al, 2008) and may be offered in the operative environment (Madrid, Barrett, & Winstead-Fry, 2010).
• Refer to care plans for Anxiety, Acute Pain, and Chronic Pain.
Guidelines for Therapeutic Touch and Healing Touch
• TT and HT may be practiced by anyone with the requisite preparation, desire, and commitment. TT requires completion of a minimum 12-contact hour basic workshop by a TT practitioner who meets Nurse Healers–Professional Associates International, Inc. criteria. HT requires completion of a minimum 17.5-contact-hour level 1 workshop (out of five levels needed for program completion) by a certified HT instructor from either Healing Touch International, Inc. or Healing Touch Program.
• Those who are not licensed health care professionals may practice TT and HT within their families, religious or spiritual community, and with friends.
• Note: Nurses who are not trained in TT or HT should consider spending quiet time with clients listening to their concerns. EBN: Nurses who are not trained in the administration of TT may use quiet time and dialogue to enhance feelings of calmness and relaxation in clients with breast cancer (Kelly et al, 2004).
• TT is conducted according to the standards for its practice developed by Dolores Krieger (1997) and Dora Kuntz (2004). It is used in accordance with guidelines provided by the Nurse Healers–Professional Associates (NH-PAI, 2006).
• HT is conducted according to the code of ethics and standards of practice developed by Healing Touch International, Inc. (Healing Touch International, 2009).
• Administer TT and HT according to the guidelines established by the prospective therapies and programs. A description of HT is found at Healing Touch International at www.HealingTouchInternational.org and for TT at Therapeutic Touch at www.therapeutic-touch.org.
Pediatric:• Consider using TT or HT for pediatric clients with adjunct therapies to decrease stress, anxiety, and pain. EBN: HT and TT are unique touch techniques. They are widely available in pediatric hospitals. Practitioners, as well as clients, may notice improved sense of well-being during and after treatments. These therapies are safe and readily available (Kemper & Kelly, 2004) and may decrease stress and changes in heart rate variability (Kemper et al, 2009).
• Teach that when working with the very young, old, or ill, or in the head area, TT should be gentle and used only for short periods. Exercise caution when using TT with clients who may exhibit an extreme sensitivity to the process (e.g., premature infants, frail elderly, psychotic clients) (Sayer-Adams, 1994). EBN: This study revealed no adverse effects of TT administered for 5 minutes in preterm infants daily for 3 days (Whitley & Rich, 2008).
• Consider TT and HT for agitated clients with Alzheimer’s disease. EBN: TT and HT may be effective techniques to alleviate agitation in people with Alzheimer’s disease (Hawranik, Johnston, & Deatrich, 2008; Wang & Hermann, 2006).
• Consider TT for elderly with postsurgical pain. EB: The elderly clients in this study who received TT demonstrated a statistically significant decrease in pain intensity scores, pretreatment and posttreatment (McCormack, 2009). Use of therapeutic touch for older adults with diabetic neuropathy can improve quality of life. EBN: Several clinical trials and double blind studies have indicated that further research is needed to determine the use of therapeutic touch to reduce pain in clients with diabetic neuropathy. The study indicates that using therapeutic touch can improve quality of life as well as improve ability to perform activities of daily living and the ability to walk (Gillespie, 2007).
• Assess for the influence of cultural beliefs, norms, and values on the client’s sense of disharmony of mind and spirit. EBN: The client’s sense of disharmony may have cultural roots (Giger & Davidhizar, 2004). Nurses can increase their knowledge about other health systems through assessment and incorporate these into the plan of care for clients as needed (Snyder & Niska, 2003).
• Assess for the presence of specific culture-bound syndromes that may manifest as disturbances in energy or spirit. EBN: Voodoo death, evil eye, and trance dissociation are some of the culture-bound syndromes that have symptoms of disharmony of mind and spirit (Arnault, 1998).
• Validate the client’s feelings and concerns related to sense of disharmony or energy disturbance. EBN: Validation lets family members know that the nurse has heard and understood what was said, and it promotes the relationship between nurse and family members (Spiers, 2002).
Home Care:• See Guidelines for TT and HT.
• Help the client and family accept TT and HT as healing interventions. CEB: Consultation and collaboration with a specialist may be the best approach to nursing care. Numerous studies have reported positive outcomes of HT as a noninvasive complementary therapy (Umbreit, 2000). HT has been used in the home care setting for chronic pain clients and for hospice care (Wardell et al, 2006; Ziembroski et al, 2004).
• Assist the family with providing an appropriate space in which TT and/or HT can be administered.
Consider complementary therapies such as Therapeutic Touch for clients in community mental health programs. A meta-analysis of 11 clinical trials of TT in a community mental health center suggested that TT improves mood. Outcomes observed in this meta-analysis included reductions in tension, confusion, anxiety, and pain and increases in vigor and quality of life or general well-being (Collinge, Wentworth, & Sabo, 2005).
In the presence of a psychiatric disorder, refer for psychiatric home health care services for client reassurance and implementation of therapeutic regimen. EBN: Psychiatric home visit nursing provides an important role in community care for people with mental disorders. Several reports indicated that home visits were associated with rate reduction of readmission to psychiatric wards and reduced hospital stays (Setoya et al, 2008).
Client/Family Teaching and Discharge Planning:
• Teach the TT and/or specific HT technique to clients and family members. EBN: Helping clients while using touch therapy related to Ki (a Korean type of energy therapy) was found to be a dynamic process with each participant actively engaged in increasing the activating, potential power of the human being (Chang, 2003). HT was taught to caregivers of veterans experiencing chronic pain from spinal cord injury (Wardell et al, 2006).
• Teach that when working with the very young, old, or ill, or in the head area, TT should be gentle and used only for short periods. Exercise caution when using TT with clients who may exhibit an extreme sensitivity to the process (e.g., premature infants, frail elderly, psychotic clients) (Sayer-Adams, 1994).
• Teach the client how to use guided imagery. EBN: Imagery is harmless, is time- and cost-effective, and creates a healing partnership between the nurse and client (Reed, 2007).
• Consider the use of progressive muscle relaxation, autogenic training, relaxation response, biofeedback, emotional freedom technique, guided imagery, diaphragmatic breathing, transcendental meditation, cognitive-behavioral therapy, mindfulness-based stress reduction and emotional freedom technique. EB: These are all evidence-based techniques, easy to learn and practice, with good results in individuals with good health or with a disease (Varvogli & Darviri, 2011).
Nurses/Staff
• The practice of Healing Touch, both in the giving and the receiving, can improve well-being. EBN: Mind-body training provided nurses the perceived benefits of greater spiritual well-being, serenity, better mood, more compassion, and improved sleep (Kemper et al, 2011). Additionally, nurse leaders trained in level 1 of Healing Touch experienced improved stress relief, relaxation, and well-being; decreased depression and anxiety; and improved sleep (Tang et al, 2010).
References
Aghabati, N., Mohammadi, E., Pour Esmaiel, Z. The effect of therapeutic touch on pain and fatigue of cancer patients undergoing chemotherapy. Evid Based Complem Altern Med. 2010;7(3):375–381.
Agdal, R., Hjelmborg, J.V.B., Johannessen, H. Energy healing for cancer: a critical review. Forsch Komplementarmed. 2011;18(3):146–154.
Anderson, J.G., Taylor, A.G. Biofield therapies in cardiovascular disease management: a brief review. Holist Nurs Pract. 2011;25(4):199–204.
Arnault, D.S. Framework for culturally relevant psychiatric nursing. In Varcarolis E.M., ed.: Foundations of psychiatric mental health nursing, ed 3, Philadelphia: WB Saunders, 1998.
Chang, S.O. The nature of touch therapy related to Ki: practitioners’ perspective. Nurs Health Sci. 2003;5(2):103–114.
Collinge, W., Wentworth, R., Sabo, S. Integrating complementary therapies into community mental health practice: an exploration. J Altern Complement Med. 2005;11(3):569–574.
Curtis, A.R., et al. Holistic approach to treatment of intractable central neuropathic itch. J Am Acad Dermatol. 2011;64(5):955–959.
Danhauer, S.C., et al. Healing touch as a supportive intervention for adult acute leukemia patients: a pilot investigation of effects on distress and symptoms. J Soc Integr Oncol. 2008;6(3):89–97.
Denison, B. Touch the pain away: new research on therapeutic touch and persons with fibromyalgia syndrome. Holist Nurs Pract. 2004;18(3):142–151.
Giger, J.N., Davidhizar, R.E. Transcultural nursing: assessment and intervention, ed 4. St Louis: Mosby; 2004.
Gillespie, E.A., et al. Painful diabetic neuropathy: impact of an alternative approach. Diabetes Care. 30(4), 2007. [999-101].
Hawranik, P., Johnston, P., Deatrich, J. Therapeutic touch and agitation in individuals with Alzheimer’s disease. West J Nurs Res. 2008;30(4):417–434.
Healing Touch International, Inc. Retrieved November 2, 2009, from http://www.healingtouchinternational.org.
Jackson, E., et al. Does therapeutic touch help reduce pain and anxiety in patients with cancer? Clin J Oncol Nurs. 2008;12(1):113–120.
Jain, S., Mills, P.F. Biofield therapies: helpful or full of hype? A best evidence synthesis [corrected article]. Int J Behav Med. 2011;18(1):79–82.
Kelly, A.E., et al. Therapeutic touch, quiet time, and dialogue: perceptions of women with breast cancer. Oncol Nurs Forum. 2004;31(3):625–631.
Kemper, K., et al. Impact of healing touch on pediatric oncology outpatients: pilot study. J Soc Integr Oncol. 2009;7(1):12–18.
Kemper, K., et al. Nurses’ experiences, expectations, and preferences for mind-body practices to reduce stress. BMC Complement Altern Med. 2011;11:26.
Kemper, K.J., Kelly, E.A. Treating children with therapeutic and healing touch. Pediatr Ann. 2004;33(4):248–252.
Krieger, D. Therapeutic touch inner workbook. Santa Fe, NM: Bear and Company; 1997.
Kuntz, D., Krieger, D. The spiritual dimension of therapeutic work. Inner Traditions International, Limited; 2004.
Lutgendorf, S.K., et al. Preservation of immune function in cervical cancer patients during chemoradiation using a novel integrative approach. Brain Behav Immun. 2010;24:1231–1240.
MacIntyre, B., et al. The efficacy of healing touch in coronary artery bypass surgery recovery: a randomized clinical trial. Altern Ther Healing Med. 2008;14(4):24–32.
Madrid, M.M., Barrett, E.A., Winstead-Fry, P. A study of the feasibility of introducing therapeutic touch into the operative environment with patients undergoing cerebral angiography. J Holist Nurs. 2010;28(3):168–174.
McCormack, G.L. Using non-contact therapeutic touch to manage post-surgical pain in the elderly. Occup Ther Int. 2009;16(1):44–56.
Nurse Healers-Professional Associates International. Guidelines of recommended standards and scope of practice for therapeutic touch. Retrieved March 15, 2006, from http://www.therapeutic-touch.org/content/guidelines.asp.
Reed, T. Imagery in the clinical setting: a tool for healing. Nurs Clin North Am. 2007;42(2):261–277.
Sayer-Adams, J. Complementary therapies: therapeutic touch nursing function. Nurs Stand. 1994;8:25.
Setoya, N., et al. Nursing interventions provided by psychiatric home visit nurses in Japan. J Japan Acad Nurs Sci. 2008;28(1):41–51.
Snyder, M., Niska, K. Cultural related complementary therapies: their use in critical care units. Crit Care Nurs Clin North Am. 2003;15(3):341–346.
Spiers, J. The interpersonal contexts of negotiating care in home care nurse-patient interactions. Qual Health Res. 2002;12(8):1033–1057.
Tang, R., et al. Improving the well-being of nursing leaders through healing touch training. J Altern Complement Med. 2010;16(8):837–841.
Umbreit, A.W. Healing touch: applications in the acute care setting. AACN Clin Issues. 2000;11(1):105.
Van Aken, R., Taylor, B. Emerging from depression: the experiential process of Healing Touch explored through grounded theory and case study. Complement Ther Clin Pract. 2010;16(3):132–137.
Varvogli, L., Darviri, C. Stress management techniques: evidence-based procedures that reduce stress and promote health. Health Sci J. 2011;5(2):74–89.
Wang, K., Hermann, C. Pilot study to test the effectiveness of healing touch on agitation levels in people with dementia. Geriatr Nurs. 2006;27(1):34–40.
Wardell, D., et al. Pilot study of healing touch and progressive relaxation for chronic neuropathic pain in persons with spinal cord injury. J Holist Nurs. 2006;24(4):231–240.
Wardell, D., Rintala, D., Tan, G. Study description of Healing Touch with veterans experiencing chronic neuropathic pain from spinal cord injury. J Explore. 2008;4(3):187–195.
Wardell, D.W., Weymouth, K.F. Review of studies of healing touch. J Nurs Scholarsh. 2004;36(2):147–154.
Whitley, J.A., Rich, B.L. A double-blind randomized controlled pilot trial examining the safety and efficacy of therapeutic touch in premature infants. Adv Neonat Care. 2008;8(6):315–333.
Ziembroski, J., et al. Healing touch and hospice care: examining outcomes at the end of life. Altern Complement Ther. 2004;9(3):146–151.
Impaired environmental Interpretation Syndrome
NANDA-I
Consistent lack of orientation to person, place, time, or circumstances over more than 3 to 6 months, necessitating a protective environment
Risk for dry eye
NANDA-I
At risk for eye discomfort or damage to the cornea and conjunctiva due to reduced quantity or quality of tears to moisten the eye
Risk Factors
Aging; autoimmune diseases (rheumatoid arthritis, diabetes mellitus, thyroid disease, gout, osteoporosis, etc.); contact lenses; environmental factors (air conditioning, excessive wind, sunlight exposure, air pollution, low humidity); female gender; history of allergy; hormones; lifestyle (e.g., smoking, caffeine use, prolonged reading); mechanical ventilation therapy; neurological lesions with sensory or motor reflex loss (lagophthalmos, lack of spontaneous blink reflex due to decreased consciousness and other medical conditions); ocular surface damage; place of living; treatment-related side effects (e.g., pharmaceutical agents such as angiotensin-converting enzyme inhibitors, antihistamines, diuretics, steroids, antidepressants, tranquilizers, analgesics, sedatives, neuromuscular blockage agents; surgical operations); vitamin A deficiency
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Watch for symptoms of dry eyes, which include blurring of vision, heaviness of eyelids, irritation and gritty sensation, light sensitivity, pain, decreased vision, redness of eyes, reflex tears, stinging and ocular discomfort (Seewoodhary & Watkinson, 2009).
If symptoms are present, refer client to an ophthalmologist for diagnosis and treatment. Dry eye is not a simple diagnosis; there are various kinds of this frustrating disease, and effective treatments vary depending on the cause of the disease (Gilbard, 2009; Redmond & While, 2008).
Apply warm compresses over the closed eyes if ordered. Warm compresses at 105° F have been shown to decrease symptoms of some kinds of dry eye (Gilbard, 2009).
• Review medications that the client is taking for possible initiation of dry eye. Medications that have been associated with dry eye are antihistamines, beta blockers, selective serotonin reuptake inhibitor antidepressants, and over-the-counter eye drops that contain benzalkonium chloride (Harvard Health Letter, 2010).
Insert ordered eye drops. Hypotonic eye drops helps lower the elevated tear level osmolarity which causes most dry eye symptoms (Gilbard, 2009).
Watch for symptoms of blepharitis including crusting and irritation at the base of the lashes and adjacent redness of the eyelid which may accompany dry eye and refer for treatment as needed. Clients with dry eye also have bacterial overgrowth on the eyelids, from decreased oils in the tear layer which increases inflammation of eye structures (Gilbard, 2009).
• Recognize that symptoms of dry eye are more common in geriatric clients and also can be very debilitating in advanced disease states (Gilbard, 2009). As people age the lubricating glands that surround the eye become less productive. Also the lower eyelids may sag and do not form a good seal over the eye (Harvard Health Letter, 2010).
Critical Care
Provide protection for client’s eyes during use of a ventilator or when unconscious by instilling ordered drops or ointment or using an ordered device to maintain eye moisture (Kocaçal Güler, Eser, & Egrilmez, 2011).
Client/Family Teaching and Discharge Planning:
• Teach clients that the following activities such as watching television, computer use, and driving are associated with decreased blinking that can cause dry eye. Less blinking results in less hydration of the surface of the eye (Harvard Health Letter, 2010).
• Teach clients methods to decrease problems with dry eye including the following:
Avoiding spending long periods of time in dry and windy or hot dry weather
Avoiding spending time in air-conditioned rooms or smoky environments
Protecting eyes from wind and dust
Drinking plenty of water to keep well hydrated
Keeping the environment more humidified, along with good hydration, and avoidance of eye irritants are methods to decrease the distress of dry eye symptoms (Redmond & While, 2008).
Teach client to consult with physician regarding use of omega-3 supplements to decrease dry eye. EB: Systematic reviews found that use of omega-3 supplements was effective in decreasing dry eye symptoms (Cortina & Bazan, 2011; Rand & Asbell, 2011).
• Teach client using eye drops how to self-administer eye drops, and to keep drops in the refrigerator. Keeping the drops in the refrigerator can be helpful because the coldness of the drops increases comfort (Seewoodhary & Watkinson, 2009).
• Warn clients with dry eyes that driving at night can be dangerous. Clients with dry eyes have light sensitivity and decreased refraction (Seewoodhary & Watkinson, 2009).
References
Cortina, M.S., Bazan, H.E. Docosahexaenoic acid, protectins and dry eye. Curr Opin Clin Nutr Metabol Care. 2011;14(2):132–137.
Gilbard, J.P. Dry eye and blepharitis: approaching the patient with chronic eye irritation. Geriatrics. 2009;64(6):22–26.
Harvard Health Letter, When eyes get dry and what you can try, October, 2010 Retrieved from http://harvardpartnersinternational.staywellsolutionsonline.com/HealthNewsLetters/69, L1010c [August 24, 2012].
Kocaçal Güler, E., Eser, I., Egrilmez, S. Effectiveness of polyethylene covers versus carbomer drops. J Clin Nurs. 2011;20(13/14):1916–1922.
Rand, A., Asbell, P. Nutritional supplements for dry eye syndrome. Curr Opin Ophthalmol. 2011;22(4):279–282.
Redmond, N., While, A. Dry eye syndrome (DES) and watering eyes. Br J Commun Nurs. 2008;13(10):471–479.
Seewoodhary, R., Watkinson, S. Treatment and management of ocular conditions in older people. Nurs Stand. 2009;23(35):48–56.