Diabetic Retinopathy NCLEX Review Care Plans
Nursing Study Guide on Diabetic Retinopathy
Diabetic retinopathy is a medical condition that involves the damage of an important part of the eye called retina. This is a complication of diabetes where in high blood sugar levels may injure the blood vessels of the retina.
If left undiagnosed and/or untreated for years, diabetic retinopathy may result to blindness. Therefore, it is important to encourage the patient to have regular eye check-ups and to promote compliance on performing blood sugar monitoring and administering maintenance medications.
Signs and Symptoms of Diabetic Retinopathy
- Floaters – spots or dark strings floating in the visual field
- Blurry or patchy vision
- Loss of vision in one or both eyes – could be partial or full; could be sudden or gradual
- Fluctuating vision
- Dark or empty areas in the vision
- Eye redness
- Eye pain
Cause of Diabetic Retinopathy
The retina is a crucial part of the eye that is comprised of light-sensitive layer of cells situated at the back of the eye. Its purpose is to convert light to electrical signals that are sent to the brain to be converted into images, creating vision or the sense of sight.
Diabetic retinopathy is caused by persistently high levels of serum glucose that damage the network or tiny blood vessels in the retina. There are three stages of diabetic retinopathy based on the damage caused by high blood sugar levels.
Stages of Diabetic Retinopathy
- Background retinopathy. In this early stage, the blood vessels suffer from persistently high blood sugar levels as evidenced by the formation of tiny bulges in them. There could be a slight bleeding, but the vision is not usually affected.
- Pre-proliferative retinopathy. In the second stage of DR, the damage is found to be more widespread and severe. The bleeding in the eye is significant, and the vision is starting to get affected.
- Proliferative retinopathy. In the retina, new but weak blood vessels develop in order to compensate for the damage in the existing blood vessels. Also, scar tissue from injury can be observed. The blood vessels bleed easily and as a result, the patient may have partial blindness. If left untreated, the patient may have full loss of vision.
Types of Diabetic Retinopathy
- Early Diabetic Retinopathy. Also known as nonproliferative diabetic retinopathy (NPDR), early diabetic retinopathy involves the damage of existing blood vessels, while new blood vessels are not proliferating or growing. NPDR is more common compared to proliferative diabetic retinopathy (PDR). The damage of the retina’s blood vessels can worsen from mild to severe if the blood sugar levels are left uncontrolled. There can be edema (swelling) in the macula or center of the retina as a result of fluid build-up. This can result to a further decline in vision, and requires treatment to prevent permanent blindness.
- Advanced Diabetic Retinopathy. Also known as proliferative diabetic retinopathy (PDR), this type involves the closing of existing damaged blood vessels and the formation of new but weak blood vessels in the retina. These abnormal blood vessels bleed easily. The blood can leak into the vitreous body, a clear and jelly-like substance filling the center of the eye. Scar tissue also forms from the new blood vessels. This can result to retinal detachment and to a possible increase in intra-ocular pressure (IOP). If left untreated, IOP build up can damage the optic nerve, causing glaucoma.
Risk Factors for Diabetic Retinopathy
The following are the risk factors that may increase the likelihood of developing diabetic retinopathy:
- Present medical history of diabetes – either type 1 or type 2
- Having had diabetes for a long period of time
- Uncontrolled diabetes – persistently high blood sugar levels
- Hypertension – persistently high blood pressure levels
- Hypercholesterolemia – persistently high cholesterol levels
- Afro-Caribbean, Hispanic, Native American, or Asian background
- Tobacco use
Complications of Diabetic Retinopathy
- Vitreous hemorrhage. This results from the seeping of blood from the new retinal blood vessels into the vitreous cavity. This complication is evidenced by floaters or dark spots in the visual field, as well as loss of vision.
- Glaucoma. New blood vessels that are fragile may also grow in the iris or the frontal part of the eye, causing an interference in the normal flow of fluid. When this happens, intraocular pressure increases. Persistently high IOP can damage the optic nerve and lead to glaucoma.
- Retinal detachment. The scar tissue that results from the formation of new retinal blood vessels can cause the retina to detach from the back of the eye. Retinal detachment is evidenced by light flashes, floaters, or severe loss of vision.
- Blindness. Complete vision loss may occur due to poorly managed DR and untreated glaucoma or macular edema.
Diagnosis of Diabetic Retinopathy
Annual check-up for diabetic retinopathy is strongly recommended for people with type 1 or type 2 diabetes. Diabetic eye screening is useful in the early diagnosis of DR and loss of vision due to diabetes.
If DR is suspected during the screening appointment, the following diagnostic exams may be ordered:
- Dilated eye exam. This exam involves the use of eye drops to dilate or widen the pupils, allowing the doctor to see the eye structures better.
- Fluoresceine angiography. This is a more comprehensive version of dilated eye exam wherein a dye is injected intravenously in the arm. The dye travels through the blood vessels of the eyes and multiple pictures are taken that can show any broken, leading, or closed retinal blood vessels.
- Optical coherence tomography (OCT). OCT can be used to measure the thickness of the retina through a cross-sectional view. Any leakage into the retinal tissue can also be assessed through OCT. This is also routinely done to monitor the progress of the patient during treatment.
Treatment for Diabetic Retinopathy
- Close monitoring for NPDR. Mild or moderate cases of non-proliferative diabetic retinopathy may not be needed any immediate medical intervention. Instead, controlling blood sugar, blood pressure, and cholesterol levels are incorporated in the treatment plan.
- Medications. Proliferative or advanced DR can benefit from the injection of medications called endothelial growth factor inhibitors into the eyes. These drugs help prevent the new blood vessels from growing and also reduce the fluid build-up and intraocular pressure. Possible side effects of endothelial growth factor inhibitors include mild discomfort, pain, tearing, and burning sensation for about 24 hours post-injection.
- Photocoagulation. This treatment involves the use of laser in the treatment of diabetic retinopathy. The two types of photocoagulation are:
- Focal laser treatment – reduces the rate of blood and fluid leakage from the fragile retinal blood vessels into the vitreous body or other parts of the eye
- Scatter laser treatment – also known as panretinal photocoagulation, scatter laser treatment attempts to shrink the new and weak blood vessels in the retina; possible complications of this treatment are loss of night vision and decrease in peripheral vision.
- Surgery. Vitrectomy is a surgical procedure wherein the blood that leaked into the vitreous of the eye as well as scar tissue in the retina are all removed. This procedure requires the patient to have either local or general anesthesia and can be done as outpatient or day case.
Prevention of Diabetic Retinopathy
The following actions can be advised to a patient with diabetes in order to avoid the development of diabetic retinopathy, or to prevent its worsening if the patient already has this complication:
- Attend their diabetic retinopathy screening. Diabetic patients are invited for an annual eye check-up to assess for the development of diabetic retinopathy.
- Become fully compliant with the diabetes treatment plan, including self-administering diabetes medication/s on time, daily blood sugar monitoring at home, eating a diabetic diet, controlling blood pressure and cholesterol levels, and reporting to the physician for any new symptoms of vision problems.
Nursing Care Plans for Diabetic Retinopathy
Nursing Care Plan 1
Nursing Diagnosis: Disturbed Sensory Perception (Visual) related to the deterioration of macula as evidenced by verbal complaint of vision problems such as blurry or patchy vision, floaters, eye pain and redness
Desired Outcome: The patient will retain optimal vision while preventing permanent loss of vision.
|Assess the vision ability of the patient using an eye chart, and I.V. fluorescein angiography.||To establish a baseline assessment of macular degeneration in terms of vision capacity.|
|Monitor blood sugar levels regularly.||Uncontrolled levels of blood glucose may lead to serious complications such as neuropathy and retinopathy.|
|Encourage the patient to have regular checkups with an ophthalmologist as recommended.||To monitor worsening of vision loss and treat accordingly.|
|Create a daily routine for the patient, as consistent as possible.||To keep the patient in touch with reality and maintain safety.|
|Encourage the patient to promote sufficient lighting at home.||The patient may not be able to perform activities of daily living as normal if he/she cannot see properly. Sufficient lighting also reduces the risk for injury.|
|Administer medications for diabetic retinopathy as prescribed.||Anti-vascular endothelial growth factor (anti-VEGF) or endothelial growth factor inhibitors are used to improve vision in patients with macular edema related to diabetic retinopathy. Taking anti-diabetic drugs as prescribed on a timely manner can help prevent the worsening of diabetic retinopathy.|
|Encourage the patient to use low vision aides.||Lenses or devices that enlarge images are helpful in addressing difficulties such as visual distortions.|
|Prepare the patient for laser therapy if indicated.||Laser therapy involves the use of high intensity light to burn off abnormally growing blood vessels in the eye of patients with advanced diabetic retinopathy.|
|Encourage the patient to add foods containing vitamins C, E, beta-carotene, zinc, and copper in his/her diet in accordance to daily recommended intake.||A study by AREDS shows some benefits if foods containing vitamins C, E, beta-carotene, zinc, and copper are introduced to the patient’s diet.|
|Educate the patient for the need to monitor and report any visual disturbances or other sensory changes.||To facilitate early detection and management of disturbed sensory perception.|
|Encourage the patient to inform the ophthalmologist if there is any worsening of symptoms.||To monitor if diabetic retinopathy is worsening and if there is a need for further investigation and treatment.|
Nursing Care Plan 2
Nursing Diagnosis: Risk for Trauma/Injury related to loss of vision and/or reduced visual acuity secondary to diabetic retinopathy
Desired Outcome: The patient will be able to prevent trauma or injury by means doing activities that can be done within the parameters of visual limitation and by modifying environment to adapt to current vision capacity.
|Assess the patient’s degree of visual impairment.||To establish a baseline of visual acuity and gain useful information before modifying the patient’s environment.|
|Place the bed in the lowest position. Place the call bell within reach (if there’s any), and keep the visual aides and patient’s phone and other devices within reach.||To prevent or minimize injury of the patient.|
|Promote adequate lighting in the patient’s room.||To promote safety measures and support to the patient in doing ADLs optimally.|
|Ensure that the floor is free of objects that can cause the patient to slip or fall.||To promote safety measures and support to the patient in doing ADLs optimally.|
|Advise the patient to wear sunglasses especially when going outdoors.||To reduce glare and help protect the eyes.|
Other possible nursing diagnoses:
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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