Nursing Management of visual impairment ,

primary objective:Student will be able to identify the problems faced by people having low vision/ blindness based on their disease process. Plan and implement care and impart incidental health education to guide people to prevent visual impairment and help people with Low vision to live an independent life through adaptation to changes in visual acuit.
Definition : visual impairement covers folowing terms;
Low vision:
Low vision is a general term describing visual impairment that requires patients to use devices and strategies in addition to corrective lenses to perform visual tasks. Low vision is defined as a best corrected visual acuity(BCVA) OF 20/70 TO 20/200.
Blindness : Blindness is defined as a BCVA that can range from 20/400 to no light perception.
Absolute blindness: The clinical definition of absolute blindness is the absence of light perception.
Legal Blindness: Legal blindness is a condition of impaired vision in which a person has a BCVA that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less.
International Classification of Diseases -10(2010) describes visual impairment into different categories based on visual acuity findings.
causes include all disorders of eye and prevention includes the prevention and treatment of all disorders of eye . the ppt also gives different categories of drugs used to treat eye disorders.
National program of control of blindness(NPCB) goals are also discussed in the PPT.
Rehabilitation strategies discribed in the ppt include emotional adjustment and impact, factors supporting mobility and communication various techniques and strategies used for dealing with low vison, government strategies for blind .
lastly the ppt describes the expected outcome of the core nursing diagnosis and its interventions:
Disturbed Sensory Perception: Vision R/T impaired anatomy and Physiology of eye
Expected outcome: The client will have improved visual perception as evidenced by an improved visual acuity nearing 6/6 or client adaptation to changes in visual acuity and client performing activities of daily living.
Disturbed Sensory Perception: Vision R/T impaired anatomy and Physiology of eye
Expected outcome: The client will have improved visual perception as evidenced by an improved visual acuity nearing 6/6 or client adaptation to changes in visual acuity and client performing activities of daily living.

1. Visual impairment/ blindness and its management PRESENTED BY MRS.SULAKSHA DESSAI DEPT. OF MEDICAL SURGICAL NURSING , INE, BAMBOLIM ,Goa.

2. OBECTIVES FOR THE TOPIC END OF CLASS OBJECTIVE : Student will be able to identify the problems faced by people having low vision/ blindness based on their disease process. Plan and implement care and impart incidental health education to guide people to prevent visual impairment and help people with Low vision to live an independent life through adaptation to changes in visual acuity.

3. OBECTIVES FOR THE TOPIC INSTRUCTIONAL OBJECTIVES: The student will be able to- 1. Review the anatomy and physiology of Eye 2. Define Low vision and Blindness. 3. Classify Low vision and Blindness 4. Describe the etiological factors leading to blindness 5. Discuss about the prevention of blindness. 6. Describe the role of ‘’ National Program for Control of Blindness ‘’ in the management of blindness in India. 7. Estimate the Goals & Objectives of NPCB in the XII Plan 8 .Explain the rehabilitation of a blind person. 9. Enumerate the role of National A ssociation for Blind in Goa. 10. Write the Nursing care plan for the core nursing diagnosis of Blind.

4. Anatomy and physiology

5. Visual impairment/ blindness: A white cane , the international symbol of blindness

6. Visual impairment and blindness KEY NOTES: 285 million people are estimated to be visually impaired worldwide: 39 million are blind and 246 have low vision. About 90% of the world's visually impaired live in low-income settings. 82% of people living with blindness are aged 50 and above. Globally, uncorrected refractive errors are the main cause of moderate and severe visual impairment; cataracts remain the leading cause of blindness in middle- and low-income countries. The number of people visually impaired from infectious diseases has reduced in the last 20 years according to global estimates work. 80% of all visual impairment can be prevented or cured.

7. Definition Low vision: Low vision is a general term describing visual impairment that requires patients to use devices and strategies in addition to corrective lenses to perform visual tasks. Low vision is defined as a best corrected visual acuity(BCVA) OF 20/70 TO 20/200. Blindness : Blindness is defined as a BCVA that can range from 20/400 to no light perception. Absolute blindness : The clinical definition of absolute blindness is the absence of light perception. Legal Blindness : Legal blindness is a condition of impaired vision in which a person has a BCVA that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less.

8. International Classification of Diseases - 10(2010) Category Presenting distance visual acuity Worse than: Equal to or better than: 0 Mild or no visual impairment 6/18 20/70 1 Moderate visual impairment 6/18 20/70 6/60 20/200 2 Severe visual impairment 6/60 20/200 3/60 20/400 3 Blindness 3/60 20/400 1/60 * 5/300 (20/1200) 4 Blindness 1/60 * 5/300 (20/1200) light perception 5 Blindness No light perception 9 Undetermined or unspecified * or counts fingers (CF) at 1 metre .

9. CAUSES: uncorrected refractive errors (43%), ] Refractive errors include near sighted, far sighted, presbyopia , and astigmatism cataracts(33 %), glaucoma age related macular degeneration , diabetic retinopathy , corneal clouding , childhood blindness , and a number of infections . cortical visual impairment, Visual impairment can also be caused by problems in the brain due to stroke, prematurity, or trauma among others

10. PREVENTION AND TREATMENT The World Health Organization estimates that 80% of visual loss is either preventable or curable with treatment of the cause. Some of the ophthalmic drugs are listed below to cure and treat visual impairment are:

11. OPHTHALMIC DRUGS 1 MIOTICS I a Α-ADRENERGIC BLOCKER- Dapiprazole II Β-ADRENERGIC BLOCKER a B etaxolol b T imolol III CHOLINERGIC a A cetylcholine b P ilocarpine IV a Α-ADRENERGIC RECEPTOR AGONIST- BRIMONIDINE 2 ANESTHETIC a P roparacaine b T etracaine

12. OPHTHALMIC DRUGS 3) ANTIBIOTICS a C hloramphenicol b C iproflloxacin c G entamycin d T obramycin e M oxifloxacin 4) CARBONIC ANHYDRASE INHIBITORS a B rinzolamide b D orzolamide c A cetazolamide 5) ANTIVIRAL a A cyclovir b Idoxuridine 6) ANTIFUNGAL a A mphotericin b N atamycin

13. OPHTHALMIC DRUGS 7) MYDRIATICS AND CYCLOPLEGICS a A tropine b H omatropine c Cyclopentolate d T ropicamide e P henylephrine 8) CORTICOSTEROID a D examethasone b H ydromethasone

14. OPHTHALMIC DRUGS 9) NSAIDS a N epafenac b Bromfenac c Flurbiprofen 10) OPHTHALMIC DECONGESTANTS a N aphazoline b L odoxamide c O xymetazoline d Otrivin-o 11) a PROSTAGLANDIN ANALOGUES- LATANOPROST 12) MISCELLANEOUS a M ethyllcellulose b H ydroxy propyl methyl cellulose c O phthacare

15. National Program for Control of Blindness National Program for Control of Blindness was launched in the year 1976 as a 100% Centrally Sponsored scheme with the goal to reduce the prevalence of blindness from 1.4% to 0.3%. Various activities/initiatives undertaken during the Five Year Plans under NPCB are targeted towards achieving the goal of reducing the prevalence of blindness to 0.3% by the year 2020. Main causes of blindness are as follows: - Cataract (62.6%) Refractive Error (19.70%) Corneal Blindness (0.90%), Glaucoma (5.80%), Surgical Complication (1.20%) Posterior Capsular Opacification (0.90%) Posterior Segment Disorder (4.70%), Others (4.19%) Estimated National Prevalence of Childhood Blindness /Low Vision is 0.80 per thousand

16. Goals & Objectives of NPCB in the XII Plan To reduce the backlog of blindness through identification and treatment of blind at primary, secondary and tertiary levels based on assessment of the overall burden of visual impairment in the country. Develop and strengthen the strategy of NPCB for “Eye Health” and prevention of visual impairment; through provision of comprehensive eye care services and quality service delivery. Strengthening and upgradation of RIOs ( Regional Institute of Ophthalmology) to become centre of excellence in various sub- specialities of ophthalmology Strengthening the existing and developing additional human resources and infrastructure facilities for providing high quality comprehensive Eye Care in all Districts of the country; To enhance community awareness on eye care and lay stress on preventive measures; Increase and expand research for prevention of blindness and visual impairment   To secure participation of Voluntary Organizations/Private Practitioners in eye Care

17. REHABILITATION OF BLIND : EMOTIONAL ACCEPTANCE ; Coping with blindness involves three types of adaptation: emotional, physical and social. Emotional adjustment of blindness determines the success of physical and social adjustments of patient. Effective coping may not occur until the patient recognizes the permanence of low vision / blindness. A patient and the family members of a low vision/ blind undergo various steps of Grieving: denial and shock, anger and protest, restitution, loss resolution and acceptance. This ultimately influence the rehabilitation of the patient who is blind.

18. REHABILITATION OF BLIND : EMOTIONAL ACCEPTANCE ; Most people, once they have been visually impaired for long enough, devise their own adaptive strategies in all areas of personal and professional management . Emotional acceptance go a long way to help a person to adapt to day today activities of life

19. REHABILITATION OF BLIND : Mobility Many people with serious visual impairments can travel independently, using a wide range of tools and techniques . Orientation and mobility : Becoming familiar with an environment or route can make it much easier for a blind person to navigate successfully. Orientation and mobility specialists teach people with visual impairments how to travel safely, confidently, and independently in the home and the community .

20. REHABILITATION OF BLIND : AIDS FOR MOBILITY Tools such as the white cane with a red tip – the international symbol of blindness – may also be used to improve mobility. A long cane is used to extend the user's range of touch sensation . A small number of people employ guide dogs to assist in mobility Folded long cane A blind man is assisted by a guide dog

21. REHABILITATION OF BLIND : GOVERNMENT FACILITIES : Government actions are sometimes taken to make public places more accessible to blind people. Public transportation is freely available to the blind in many cities. Tactile paving and audible traffic signals can make it easier and safer for visually impaired pedestrians to cross streets. In addition to making rules about who can and cannot use a cane, some governments mandate the right-of-way be given to users of white canes or guide dogs. Financial assistance to start a business is another example. Fig. Tactile paving

22. REHABILITATION OF BLIND : Reading and magnification Most visually impaired people who are not totally blind read print, either of a regular size or enlarged by magnification devices or by improving the brightness of the room. Low vision people can make use of large-print reading materials as well as e-book readers that provide large font sizes . Blind people use Braille or talking books and readers or reading machines , which convert printed text to speech or Braille . They can use computers with special hardware such as scanners and refreshable Braille display s as well as software written specifically for the blind, such as optical character recognition applications and screen readers

23. REHABILITATION OF BLIND : Reading and magnification There are also over 100 radio reading services throughout the world that provide people with vision impairments with readings from periodicals over the radio. Blind people may use talking equipment such as thermometers , watches, clocks, scales , calculators , and compasses .

24. Communication Visual impairment can have profound effects on the development of infant and child communication due to their inability to see the world around them Due to delays in a child's communication development, they may appear to be disinterested in social activity with peers, non-communicative and un-education on how to communicate with other people. This may cause the child to be avoided by peers and consequently over protected by family members . REHABILITATION OF BLIND :

25. Communication The blind or visually impaired rely largely on their other senses such as hearing, touch, and smell in order to understand their surroundings . Sound is one of the most important senses that the blind or visually impaired use in order to locate objects in their surroundings. A form of echolocation is used, similar to that of a bat. Echolocation from a person's perspective is when the person uses sound waves generated from speech or other forms of noise such as cane tapping, which reflect off of objects and bounce back at the person giving them a rough idea of where the object is.

26. REHABILITATION OF BLIND : Communication Touch is also an important aspect of how blind or visually impaired people perceive the world. Touch gives immense amount of information in the persons immediate surrounding. Feeling anything with detail gives off information on shape, size, texture, temperature, and many other qualities. Touch also helps with communication; braille is a form of communication in which people use their fingers to feel elevated bumps on a surface Certain smells can be associated with specific areas and help a person with vision problems to remember a familiar area. This way there is a better chance of recognizing an areas layout in order to navigate themselves through. The same can be said for people as well.

27. REHABILITATION OF BLIND : Adjusting attitude To avoid the rejected feeling of the visually impaired, people need to treat the blind the same way they would treat anyone else , rather than treating them like they have a disability, and need special attention.

28. National Association for the Blind Goa S tate Branch(St. Cruz) Activities carried for blind Education(Integrated educational Programme ) Vocational Training Multihandicapped projects. Sports Theatre Rehabilitation Employment Marriage Computer training

29. National Association for the Blind Goa State Branch(St. Cruz) Locate & identify the visually handicapped. Provide ID cards and medical certificates Assist in school admissions Provide Educational support Facilitate self employment. Assist in Bank loans, subsidies, schemes Etc.

30. Nursing Management of Blind Disturbed Sensory Perception: Vision R/T impaired anatomy and Physiology of eye Expected outcome : The client will have improved visual perception as evidenced by an improved visual acuity nearing 6/6 or client adaptation to changes in visual acuity and client performing activities of daily living.

31. Nursing Management of Blind Nursing intervention : Assess the causes and level of visual impairment. Assist in the treatment of cause and prevention of visual impairment. Participate in the rehabilitation of visually impaired. Talk with the low vision person as you would talk with any other individual, honestly and without pity. Identify yourself as you approach the person and before you make physical contact. Also introduce other people who accompany you if any. It is often appropriate to touch the persons hand or arm lightly to indicate that you are about to speak.

32. Nursing Management of Blind Nursing intervention : When talking, face the person and speak directly to him or her using a normal tone of voice. Give spatial orientation of his/her environment to the person to help him in locomotion. Be specific when communicating direction. Mention a specific distance or use clock cues when possible. When you offer to assist someone, allow the person to hold on to your arm just above the elbow and to walk a half step behind you . when offering the person a seat, place the persons hand on the back or the arm of the seat. When you are about to go up or down a flight of stairs, tell the person and place his /her hand on the banister. Make sure that the environment is free of obstacles. Remove obstacles that may be in the persons pathway,

33. Nursing Management of Blind Nursing intervention : Offer to read written information, give a live commentary of events whenever required. If you serve food to the person, use clock cues to specify where everything is on the plate. Make sure all objects the person will need are close at hand. Identify the location of objects that the person may need. Do not change the position of any object in the patients room without his/her knowledge. Place all the assistive devices the person uses close at hand. Ask the person, “’How can I help you?’’ Do not offer any help without his permission.

34. R eferences Lyle, T. K. , Cross, A. G., Cook, C. A. G.(1985) May and Worth’s Diseases of the eye(13 th ed.) New Delhi: CBS Publishers & Distributers. Chatterjee, B.M. (2004) Handbook of Ophthalmology(6 th ed.) New Delhi:CBS Publishers & Distributers, Chintamani , Mani, M., Goyal , H., Sharma, A.,US Editors Lewis, S. L., Heitkemper , M. M. ,Dirksen, S. R.,et.al .(2011). Lewis’s Medical Surgical Nursing: Assessment and Management of Clinical Problems; Adapted for South Asian Curriculum . Kundli , Haryana, India: Replika Press (P) Ltd. 415 Smeltzer, S. C., Bare, B.G., Hinkle, J. L., Cheever, K. H. (2010). Brunner & Suddharth’s Textbook of Medical Surgical Nursing . (12 TH ed.) Gurgaon: Wolters Kluwer India Pvt. Ltd. . 1764-1767. https://icd.who.int/browse10/2010/en#!H54