COMPETENCY APPRAISAL I Case Scenario 2: You are making a nursing visit to an older woman in a retirement hospital.

She was recently discharged from the hospital after treatment for gastric ulcer that resulted from pain medications she was taking for arthritis. During your initial conversation, as you inquire about her health, you notice that the client appears distracted and seems to have difficulty following questions and giving answers. When you ask about the current medications, her responses indicated that she is unsure about what they are for and how to take them. When you ask her to show you the medications, she produces a large brown paper bag with the following bottles: 1. Two bottles of diuretic labeled take two tablets twice a day 2. Three bottles of KCl labeled take five tablets a day in divided doses 3. One bottle of histamine blocker labeled take one capsule a day 4. One bottle of analgesic with oxycodone labeled prn for arthritis 5. One bottle extra strength Acetaminophen prn 6. One bottle of stool softener to take as needed 7. One bottle of Codeine labeled every 4 hours prn As you inquire again about which medications she takes and when, you learn that she has age-related macular degeneration and is legally blind. What competencies are needed to take care of this woman?

I.

Overview

What you should know about age-related macular degeneration What is AMD? AMD is a common eye condition among people age 50 and older. It is a leading cause of vision loss in older adults. It gradually destroys the macula, the part of the eye that provides sharp, central vision needed for seeing objects clearly. In some people, AMD advances so slowly that vision loss does not occur for a long time. In others, the disorder progresses faster and may lead to a loss of vision in one or both eyes. The vision loss makes it difficult to recognize faces, drive a car, read, print, or do close work, such as sewing or fixing things around the house. Despite the limited vision, AMD does not cause complete blindness. You will be able to see using your side (peripheral) vision. The Macula The macula is made up of millions of light-sensing cells that provide sharp, detailed central vision. It is the most sensitive part of the retina, which is located at the back of the eye. The retina quickly turns light into electrical signals and then sends these electrical signals to the brain through the optic nerve. Next, the brain translates the electrical signals into images we see. If the macula is damaged, fine points in these images are not clear. The picture is there, but the fine points are lost.

Who is at risk? AMD usually occurs in people who are age 50 and older. As people get older, the risk increases. Other risk factors include the following: Smoking. Smoking tobacco increases the risk of AMD by two to three times that of someone who has never smoked, and may be the most important modifiable factor in its prevention. Race. Caucasians are much more likely to get AMD than people of African descent. Family history. People with a family history of AMD are at higher risk. Cholesterol. Elevated cholesterol may increase the risk of AMD. Obesity. Abdominal obesity is a risk factor, especially among men. Fat intake. Consuming high amounts of certain fats likely contributes to AMD, while monounsaturated fats are potentially protective. Exposure to sunlight. especially blue light: Evidence is conflicting as to whether exposure to sunlight contributes to the development of macular degeneration. Other research, however, has shown high-energy visible light may contribute to AMD. Hypertension.

Does lifestyle make a difference? Some lifestyle choices, like smoking, are linked to AMD although it remains unknown if altering any of these would alter the impact of AMD on an individual. Nevertheless, the following choices may have an impact on AMD and certainly promote healthy living, including the following:

Avoiding smoking Exercising Maintaining normal blood pressure and cholesterol levels Eating a healthy diet rich in green, leafy vegetables and fish

How is AMD detected? The early and intermediate stages of AMD usually start without symptoms. Only a comprehensive dilated eye exam can detect AMD. The eye exam may include the following:

Visual acuity test. This eye chart measures how well you see at distances. Dilated eye exam. Your eye care professional places drops in your eyes to widen or dilate the pupils. This gives him or her a better view of the back of your eye. Using a special magnifying lens, he or she then looks at your retina and optic nerve for signs of AMD and other eye problems.

Amsler grid. Your eye care professional also may ask you to look at an Amsler grid. Changes in your central vision may cause the lines in the grid to disappear or appear wavy, a sign of AMD.

Fluorescein angiogram. Your eye care professional may suggest you see an ophthalmologist to perform a fluorescein angiogram. With this test, your doctor injects a dye into your arm. Pictures are taken as the dye passes through the blood vessels in your eye. The test allows your doctor to identify leaking blood vessels and decide the best treatment.

What are the forms of AMD that can cause vision loss? There are two forms of AMD: dry and wet. Either form can advance and cause severe vision loss. Later sections of this booklet describe the different types in greater detail. The following is a brief description of each:

The dry form is more common and has three stages-early, intermediate, and advanced. It happens when the light-sensitive cells in the macula slowly break down, gradually blurring central vision in the affected eye.

The wet form is considered advanced AMD and can be more severe. It happens when new blood vessels under the macula leak blood and fluid. Damage to the macula can occur rapidly.

All people who have the wet form had the dry form first.

Dry AMD What is dry AMD? Dry AMD is the most common form of AMD in its early or intermediate stages. It occurs in about 90 percent of the people with the condition. Dry AMD happens when the light-sensitive cells in the macula slowly break down, gradually blurring central vision in the affected eye. As dry AMD progresses, you may see a blurred spot in the center of your vision. Your eye care professional may call this "geographic atrophy." Over time, central vision in the affected eye can be slowly lost as less of the macula works. What are the symptoms? Dry AMD has few symptoms in the early stages. It is important to have your eyes examined regularly before the disease progresses. In the later stages, blurred vision is the most common symptom of dry AMD. Objects also may not appear to be as bright as they used to be.

As a result, you may have trouble recognizing faces. You may need more light for reading and doing other tasks. Both eyes can have dry AMD or one eye can be affected first.

What are drusen? Drusen are another early sign of dry AMD. They are yellow deposits under the retina. They can be small or large in size. Your eye care professional can see drusen when he or she examines the retina during a comprehensive dilated eye exam. Drusen alone do not usually cause vision loss. But people with large drusen are at risk of developing a more severe form of AMD, which results in severe vision loss.

Three stages of dry AMD Dry AMD has three stages, all occurring in one or both eyes. These stages are defined in part by the size and number of drusen under the retina:

Early AMD. People with early AMD have either small drusen or a few mediumsized drusen. At this stage, you may not have any symptoms or vision loss.

Intermediate AMD. People with this stage of AMD have either many mediumsized drusen or one or more large drusen. Many people will have no symptoms, so dont wait for symptoms to determine if you have an intermediate stage of AMD. Some people see a blurred spot in the center of their vision. They often need more light to read and to do other tasks.

Advanced dry AMD. In addition to drusen, people with advanced dry AMD have a breakdown of light-sensitive cells supporting tissue in the macula. This breakdown can cause a blurred spot in the center of your vision, often called geographic atrophy. Over time, the blurred spot may get bigger and dark, taking away a larger area of your straight-ahead vision.

Vision loss and dry AMD If you have vision loss from dry AMD in one eye only, you may not notice any changes in your overall vision. With the other eye seeing clearly, you still can drive, read, and see fine details. You may notice changes in your vision if dry AMD affects both eyes or if you develop the wet form of the disease. In any case, see an eye care professional for a comprehensive dilated eye exam if blurring occurs in your vision. Can the dry form turn into the wet form? All people who have the wet form had the intermediate stage of the dry form first. The dry form also can suddenly turn into the wet form, even during early stage AMD.

Eye care professionals have no way to tell if the dry form will turn into the more severe wet form. Dry AMD can turn into wet AMD at any time. You should get an Amsler grid from your eye care professional to check your vision for signs of wet AMD.

Diet might help Studies have shown that people who eat a diet rich in green, leafy vegetables and fish have a lower risk of developing AMD. While there is no definitive proof that changing your diet will reduce your risk of developing AMD or having it progress, to maintain good health in general, there is no reason not to eat a healthy diet, exercise, avoid smoking, and see your healthcare professional regularly. Wet AMD What is wet AMD? Wet AMD affects about 10 percent of all people with AMD. This type, however, is more severe than the early and intermediate stages of the dry form. Wet AMD happens when abnormal blood vessels behind the retina start to grow under the macula. These new blood vessels can be fragile and leak blood and fluid. The

blood and fluid cause the macula to swell and damage occurs rapidly. The damage may also cause scarring of the retina. Although loss of central vision can happen quickly, eye care professionals can slow down or stop the progression of wet AMD if it is detected before severe vision loss occurs.

What are the symptoms? During the early stages of wet AMD straight lines may appear wavy. People with wet AMD also may develop a blind spot, which results in the loss of central vision. If you notice these or other changes to your vision, contact your eye care professional at once. Again, eye care professionals may be able to treat the condition before severe vision loss occurs. Advanced AMD What is advanced AMD? Both the wet form and the advanced dry form are considered advanced AMD. It can occur in the same eye or an eye may have just one form or the other. In most cases, only advanced AMD can cause vision loss. Additional risk

People who have advanced AMD in one eye are at especially high risk of developing advanced AMD in the other eye. However, research has shown that high doses of vitamins and mineral supplements may slow the progression of intermediate AMD to the more advanced stage.

Competency Standards for Nursing Practice A. Safe and Quality Nursing Care

Identify the Problem

Patient is an elderly woman that appears distracted and seems to have difficulty following questions and giving answers.

Patient is unsure about what her medications are and how to take them.

Prioritized Problem

Patient has age-related macular degeneration and is legally blind.

Solutions to Problem

Approach, Ask, Assist.

Approach: if you suspect someone may need a hand, walk up, greet them and identify yourself.

Ask: "Would you like some help?" The person will accept your offer or tell you if they don't require assistance.

Assist: listen to the reply and assist as required. Not all people who are blind or vision impaired will want assistance - don't be offended if your assistance is not required.

Address people who are blind or have low vision by their names so they know you are speaking to them.

Use simple words when explaining what are the medications and how to take them.

Since, patient is legally blind, let family members help/assist in giving right medication on the right time and at the right dosage.

Let the person who is blind or have low vision know that you have entered the room.

Do not walk away from a person who is blind or have low vision without indicating that you are doing so - it is embarrassing and frustrating to talk to thin air.

In dangerous situations say "STOP" rather than "LOOK OUT" Do not relocate objects or furniture without telling the person who is blind or has low vision.

Use ordinary language when directing or describing and be specific. Do not point, or say "over there".

Direct people who are blind or have low vision to their left and right, not yours.

Use words like "look" and "see"; they are part of everyone's vocabulary. Otherwise both you and the person who is who is blind or have low vision will feel awkward.

Describe the surroundings and obstacles in a person's pathway (remember to look up as well as down). Warn of the presence of over-hangs, such as kitchen cupboards, jutting side mirrors of cars, or trees.

Do not leave doors ajar. Close them or open them fully. Be aware that the person who is blind or has low vision will be disadvantaged by not seeing what is going on. Therefore talk about what is happening.

Ask people who are blind or have low vision what they want or need. Do not direct questions through their companion.

If people who are blind or have low vision extend their hands to shake, do so. When seating people who are blind or have low vision, put their hands on the back of the chair and they will then be able to seat themselves.

If the patient is not familiar with the surroundings, ask politely if they would like to be guided; do not be offended if your offer is not accepted

Offer your arm for the person to grip just above the elbow (they may prefer to grip your shoulder)

When guiding someone with sight problems, walk slightly in front, making sure that the pace is not too fast or too slow

If steps or stairs are involved always state whether they go up or down and give warning of approaching ground level

Explain changes in ground surface, such as moving from a tiled floor to carpet

Never guide someone into a seat backwards: instead, describe the chair, place your hand on the back of the chair, and enable the person to orientate themselves into the seat independently

Management of Resources and Environment

Ensure the physical environment suits the needs of people who are blind or have vision impairment.

Do switches and controls for machinery etc have raised markings that identify their purpose?

Are walkways and doorways accessible and appropriately marked (for example, tactile markings)?

Are there appropriate audible substitutions for visual signals? Is the lighting of the appropriate strength and placement to maximise the use the person can make of their sight?

Does the person's work area need modifications for safety or productivity reasons?

Is the lunchroom furniture arranged to be inclusive of everyone in it, to avoid possible social isolation?

Are interview rooms quiet and private, and equipped with required audible or tactile substitutions?

Arrange furniture with open spaces. Ensure no sharp edges protrude.

C. Health Education

Consumption of a diet rich in antioxidants (beta carotene and the mixed carotenoids that are precursors of vitamin A, vitamins C and E, selenium, and zinc), or taking antioxidant nutritional supplements,( may help prevent macular degeneration, particularly if started early in life. )

Good dietary sources of antioxidants include citrus fruits, cauliflower, broccoli, nuts, seeds, orange and yellow vegetables, cherries, blackberries, and blueberries. ( Research has shown that nutritional therapy can prevent ARMD or slow its progression once established..)

Avoiding tobacco smoke and eating a diet low in saturated fat. Encourage repetition of information or new skill. To assist in remembering.

Give information in manageable amounts, using verbal, written and audiovisual modes at level of clients ability.

Suggest using a medication reminder system. Pill reminder alarm, medication timer Use therapeutic communication skills to assists client problem Teach significant others/folks how to care for patient who is legally blind (in administration of medications)

D. Legal Responsibility Apply the Ten Golden Rules in medication administration: right medication, right patient, right dose, right route, right time, right documentation, right to refuse, right patient education, right approach Document accurately all activities concerning the patient Adhere with RA 9173 or Philippine Nursing Law of 2002 for rendering quality care. Adhere with RA 7277 or the Magna Carta for Disabled Persons Law of 1991 o Section 20 states that The State shall protect and promote the right to health of disabled persons and shall adopt an integrated and comprehensive approach to their health development which shall make essential health services available to them at affordable cost. The National Government shall provide an integrated health service for disabled persons. Adhere with RA 7432 also known as Senior Citizens Act for guidelines on the privileges of senior citizens.

E. Ethico -Moral Responsibility Ethical principles : >Beneficence >Respect for Autonomy. >Justice >Beneficence vs. Non maleficence Records and reports that are gathered should be kept and well organized Check if theres any refusal for treatment. Respect patients decision in refusing to any kind of procedures. Respect the rights and beliefs of the patient as well as the family. Ensure the completeness the patients data on the chart following the hospital protocol (hospital number, name, age, informed consent etc.) and refrain from making errors. Maintain patients privacy and observe confidentiality with her status. Refrain from releasing records and other information without proper authority to ensure privacy and confidentiality in the patients records.

F. Personal and Professional Development Nurses must learn more about the condition of the patient and the proper nursing care needed in order to render appropriate and quality nursing care for the patient.

Nurses must be willing to accept suggestions and recommendations regarding the matters concerned and adapt to change willingly.

Nurses self knowledge and skills should be improved through attending conventions and seminars especially cases related to caring patients with age related macular degeneration. Nurses must be able to improve their level of knowledge and personal skills by surfing the net or reading other books about age related macular degeneration

Nurses must also improve their skills in communicating with clients in order to obtain significant data for enhancement of care.

G. Quality Improvement Nurses must be knowledgeable in the proper way of communicating and caring for patients with impaired vision. Nurses must be able to determine the appropriate safety precautions for elder patients and patients with disabilities. Nurses must be able to document accurately all the procedures, equipments used and attached to the patient and medications given. Nurses must be able to acknowledge patients thoughts and feelings regarding their condition. Nurses must maintain an open communication with the health care team discussing interventions needed by the patient.

Nurses will be able to evaluate patients condition with regards to the treatment regimen and report any progress or obtain referral for further care.

H. Research I. Records Management Ensure the completeness of the patients data on the chart following the hospital protocol (hospital number, name, age, informed consent etc.) and refrain from making errors. Document problems identified with the patient for intervention to takes place. Record patient's status such as vital signs to update patient's condition and provide baseline data. Document all the procedures, equipments used and attached to the patient. Refrain from releasing records and data about patient without proper authority to ensure confidentiality and privacy of patient. Ask permission to proper authority if releasing of records is needed.

J. Communication Communicating effectively with people who are blind or vision impaired

Identify yourselfdo not assume someone will recognize you by your voice; use your full name and indicate your role in their care

Face the person directly and use their name when introducing yourself or directing conversation to them in a group

Speak naturally and clearly: loss of eyesight does not mean loss of hearing

Do not expect eye contact or assume that lack of eye contact means lack of attention to what you are saying

Never channel conversation through a third person In a group setting, introduce the other people present Never leave a conversation without saying so Try to avoid situations where competing background noise may be a problem Ask the patient to describe their level of vision and if they require any help; remember, not all vision impaired patients wear dark glasses or use a guide dog or cane

Continue to use non-verbal body language; this will affect the tone of your voice and adds useful information to someone who is vision impaired

Use everyday languagedo not avoid words like see or look or talking about activities such as watching television

During a consultation, if an examination is needed, explain that physical contact may be required (or that eye drops may be used)

If an interpreter or support worker is involved, ensure the patient is happy with their presence at each stage of the consultation

Ensure the patient knows who is in the consulting room; for example, medical students or nursesask them to introduce themselves, indicate their role, and gain consent to remain

Use accurate and specific language when giving directions. For example, the door is on your left, rather than the door is over there; remember the person is unlikely to see non-verbal cues and gestures or information

Always ask whether help is needed, for example, to be guided to another department

Be aware that changing light levels can affect vision: bright sunlight may be a greater problem than dark corridors

Explain where things are placed; for example, your cup of tea is on the table directly in front of youor use the clockface method; for example, its on the plate at 3 oclock

Offer to read any written materials aloud; identify exactly where signatures are required

If providing information for later reference, ensure it is in an accessible format and ask about preferred format; for example, large print, audio, or electronic

K. Collaboration and Teamwork Coordinate with other health team member in providing care for the patient - staff nurse - attending physician - pharmacologist - ophthalmologist / optometrist Maintain a good interpersonal relationship with the patient and other support system. Respect the roles of other healthcare team. Maintain a good relationship with the members of the health team. Discuss information concerning the patient to the health care team involve.

Nurses and other health care personnel should participate actively in patient care and management for the improvement of patients condition. Work hand in hand in providing care for the patient.

Always do what is best for the patient through collaboration and teamwork. If there would be any abnormalities noted, urgent reporting to the physicians should be done and if possible recommend appropriate intervention to improve patient care.

Contributes to decision making regarding patients needs. Recommend appropriate intervention to improve patient care.

Levels of Care PREVENTIVE Don't smoke. Cigarette smoke and its component tar trigger the formation of deposits and thickening in the retina that cause age-related macular degeneration, Eat plenty of dark, leafy green vegetables, such as raw spinach. Just a half cup of raw spinach three times a week is good.

Eat fish or take a fish oil supplement. It is recommend to take at least two enteric-coated fish oil capsules every day on days you don't eat fish. Why enteric-coated? Because it's designed to help the capsule pass through your stomach unaltered until it finally breaks apart in the intestines; that way, you won't belch up that fishy taste!

Exercise regularly, and stay at a healthy weight . This exercise achieves its key benefit for heart disease by keeping arteries larger and more open. The entire pattern of factors that affect risk of macular degeneration appears to parallel with few exceptions their effect on heart disease.

Eat fruit and nuts daily. The link between a healthy diet and decreased vision loss from AMD seems to be the antioxidant properties of certain carotenoids, vitamins and minerals. Reduced disease progression was found in the study of National Eye Institute who took a daily supplement containing vitamin C , vitamin E , beta-carotene ,zinc and copper

Reduce refined carbohydrates (high-glycemic index foods). High GI foods are digested and metabolized more quickly, causing a rapid rise in blood glucose levels. This creates a dramatic spike in levels of the hormone insulin, which works to remove sugar from the blood. These responses can lead to an overproduction of insulin, contributing to weight gain.

Keep your blood pressure and cholesterol under control. Regular exercise and weight control can help manage your blood pressure and cholesterol. Those with hypertension typically will have about a twice higher than usual risk of macular degeneration.

Wear appropriate sunglasses outdoors to block UV and blue light that may cause eye damage.

Have regular eye exams. Checking the medication to be administered.

PROMOTIVE Helping patient to focus on activities and relationships that gives meaning and purpose to his life. Advocacy and disability employment , being to assist and encourage people with disability to be self determining, know their rights, be treated equally, be informed and make choices. Promote positive social interaction or psychosocial support. Include a variety of colorful fruits and vegetables in your diet. The antioxidant vitamins in fruits and vegetables contribute to eye health. Eating a variety of colors ensures that you're getting a variety of vitamins. Eating kale, spinach, broccoli, peas and other vegetables, which have high levels of antioxidants, including lutein and zeaxanthin, may also benefit people with macular degeneration. Choose healthy fats. Healthy unsaturated fats, such as the fats found in olive oil, may help protect your vision. Choose these healthy fats over saturated fats, such as butter and trans fats, and partially hydrogenated oils found in packaged foods.

Choose whole grains over refined grains. Choose whole grains, such as whole-wheat bread, over refined grains, such as white bread.

Add fish to your diet. Fish, such as salmon, sardines and tuna, contain omega3 fatty acids that may help reduce the risk of vision loss related to macular degeneration. Omega-3 fatty acids also can be found in supplements and nuts, such as walnuts.

Curative Anti-angiogenic drugs. Low vision aids Thermal Laser Treatment Laser photocoagulation Photodynamic Therapy (PDT) Okuvision therapy

Rehabilitative Encourage follow-up check-ups to the physician Early provision of advice and support will encourage independence and minimize the socio economic isolation that AMD causes. Training and coping strategies