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IPL Eye conditions (KEC IPL student led 3-Oct-2022)

Label the diagram-

1. Cornea
2. Anterior chamber
3. Pupil
4. Iris
5. Scleral venous sinus
6. Ciliary zonule (Suspensory Ligament)
7. Lens
8. Ciliary body
9. Sclera
10. Choroid
11. Retina
12. Macula lutea / Fovea centralis
13. Optic nerve (artery and vein)
14. Posterior segment (contains vitreous humor) the cint
15. Blind spot

List the function of each of these structures

1. Protect the structure inside the eye, contributing to the refractive power of the eye, and focusing light rays on the retina with minimum scatter and optical degradation.
2. The anterior is filled with aqueous humour, which is a watery fluid that provides nourishment to the interior eye structure and helps to keep the eyeball inflated.
3. it admits and regulates the flow of light to the retina. Which allows us to perceive images. It opens and closes to control the amount of light that is allowed to enter the eye.
4. It controls your pupil and helps your eye see clearly. It constantly changes how dilated your pupil is without your control. That is called the pupillary light reflex.
5. It also called the canal of Schlemm, is a circular channel in the eye that collects aqueous humor from the anterior chamber and delivers it into the bloodstream via the anterior ciliary veins.
6. Key role in ocular function, centering the lens on the optical axis and transmitting the focus that molds its shape during accommodation.
7. The main function is to transmit and focus the light onto the retina in order to create a clear image of observed objects at various distances. It is also the main structure of the accommodation reflex which is activated when the eye focuses on close objects
8. The ciliary body is found behind the iris and includes the ring-shaped muscle that changes the shape of the lens when the eye focuses. It also makes clear fluid that fills the space between the cornea and the iris.
9. The sclera functions as the supporting wall of the eyeball. It helps maintain the eyeball’s shape and protects it from injury. It is covered by conjunctiva, which is clear mucus membranes that lubricate (moisturise) the eye.
10. The choroid supplies the outer retina with nutrients and maintains the temperature and volume of the eye.
11. The retina is a layer of photoreceptors cells and glial cells with the eye that captures incoming photons and transmits them along the neuronal pathway as both electrical and chemical signals for the brain to perceive a visual picture.
12. Part of the retina is responsible for the shape and detailed central vision (also called visual acuity). The macula lutea, also called the fovea, contains a very high concentration of cones. These are the light-sensitive cells in the retina that give detailed central vision.
13. The optic nerves relay messages from your eyes to the brain to create visual images. It plays a crucial role in the ability to see. There are millions of nerve fibres that make up each optic nerve. (*damage to an optic nerve can lead to vision loss in one or both eyes.
14. To protect the round shape of the ball.

Name 3 common eye conditions that would affect the outer eye and the treatment options…

1. Refractive errors (include myopia (near-sightedness), hyperopia (farsightedness), astigmatism (distorted vision at all distances), and presbyopia)

Treatment option

• can be corrected by eyeglasses, contact lenses, or in some cases, surgery

2. Cataract ( a clouding of the eye’s lens and is the leading cause of blindness worldwide)

Treatment option

• removal of cataract

3. Retinal detachment (Natural ageing process, one or more holes on retain which allows fluid pass underneath, separated from the supporting and nourishing tissues underneath it.)

Treatment option

• Involves surgery. The eye doctor will seal the retinal holes and reattach the retina

Discuss 3 some activities of daily living that would be affected by blindness.

1. Maintaining a safe environment – need time to familiarise the environment, unable to see hidden hazards, especially moving into a new environment.

2. Eating and drinking – unable to cook, may familiarise by regular practice, but hard to ensure the quality and healthy of the food consumed.

3. Woking and playing – may encounter difficulties in getting a sustainable job, unable to participate in certain sports activities.

Q1. Scenario one- Patient is 82 years old. She is blind and has lived alone for the last 8 years after her husband suddenly passed away. She had a fall yesterday and sustained a small wound to her arm, which the nurse is dressing 2 times a week. Lilly has a guide dog and has coped well at home prior to this. What considerations would you make for Lilly? What would you want to check, or what questions would you want to ask? Would you need to refer her to anyone?

Ans: What considerations would you make for Lilly?

Vision loss can affect her physical health by increasing her risk of falls and her quality of life, and it can also have a big impact on her mental health. Loss of vision is always linked to loneliness, social isolation, and feelings of worry, anxiety, and fear. Depression is common in people with vision loss.

Ans: What would you want to check or what questions would you want to ask?

Did Lily able to maintain a safe environment? Did she encounter difficulties in finding a job? How’re her activities of living affected due to visual impairment?  Did she receive enough support? Did she able to access support from social services? Did she know where to get help and support if needed? Did she receive any information which helps her to cope and manage her disability?

Would you need to refer her to anyone?

Ans: refer to the social workers, inspect her living environment and remove any hidden hazards to minimise harm and hazard may cause. Refer her to the available social network group, so that she won’t feel isolated. Maintain socially active.

Q2. Scenario two- Rob is a plasterer- he has attended the GP surgery with a feeling of something in his eye. His vision is blurred, he is in 8/10 pain, his eye sclera is red, and his eye is watery.

What could have happened to Rob?

• Dirt gets into his eye.
• Chemical burn

List the first aid procedures for a chemical burn.

1. Remove casualty from their working environment if possible.
2. Put on protective gloves if they’re available. Hold the casualty’s eye under gently running water for at least 20 minutes and make sure the outside and inside of the eyelid are washed. Alternatively, flush the eye with 0.9% NS.
3. Make sure the contaminated water does not splash the uninjured eye. (If the casualty is wearing contact lenses, ask them to remove them if they can.)
4. Ask the casualty to hold a clean non-fluffy pad over the injured eye and put a bandage in place.
5. Call 999 or 112. If you know what chemicals might have been involved in the accident, pass this information on to medical professionals.

When do we need to refer Rob on- what would prompt a referral?

If after washing or flushing the affected eye for more than 20 minutes, painfulness and condition remains unchanged or get worse. Should call 999. After being discharged from the hospital, Rob should be referred to an eye clinic or community nurse for a follow-up check-up.

Scenario worksheet

History taking scenario

The patient is 14 years old and is attending today with abdominal pain. The mother calls the GP surgery, concerned re pain.

Let’s take a history:

PC- abdominal pain

HXPC- – lasting 24 hours- hasn’t passed stools. She has been vomiting 4+ times and cannot keep down food. Feels hot.

SOCRATES U

Lower right-hand side of the abdomen- right iliac fossa

24 hours ago

No radiation

No alleviating factors

Constant pain

It makes it worse to lay flat- has to stay in the foetal position

Severity 8/10

She thinks she’s dying

PMH- nil

Surgical history- nil

Medications- nil

Allergies- nil

Family History- father has type two diabetes, the mother has hypertension

Social history- lives at home with mother, father and 3 siblings, attend school, no recent travel, up to date with imms. Lives in a house with no carers.

Would we want to ask about sexual history?

LMP- 2 weeks ago

No UPSI

What is our differential diagnosis?

What else might we want to know?

Question worksheet

Q1. Why is history taking important?

Ans: Medical history is important because when GPs have more information about a patient’s medical history, health care professionals can deliver the most appropriate and effective treatment or support for their concerns. Genetic makeups, environments and lifestyle factors shared by family provide better insight into a medical condition the family may encounter. With the information collected, GPs can also understand patterns of the cause of the diseases or disorders and make a medical diagnosis more likely, which is particularly important in catching something harmful early.

Q2. Do you use any acronyms for history taking?

Ans: SOCRATES

Site (e.g., where, location, area, internal, external, etc.)
Onset (e.g., time of onset. sudden/gradual, etc.)
Character of pain (e.g., dull, sharp, crush, etc.)
Radiation of the pain (e.g., did the pain spread, at particularly sport, etc.)
Associations (e.g., symptoms associated with the pain, vomit, nausea, etc.)
Time course (e.g., any time pattern (morning/evening), duration, etc.)
Exacerbating/Relieving factors (e.g., what makes it worst / what makes it more comfortable.)
Severity (e.g., rate pain score 0 to 10, “zero” no pain, “10” severe pain.)

Top tip- 70% of the time, you will make a diagnosis based on the history taken alone.

Q3. How do you open a consultation?

Introduce myself, show empathy and confirm patient identity (e.g., DOF, Address, NHS no.). Observe any abnormalities (e.g., physical – severe external bleeding, disabilities, etc. Psychological and emotional distress, etc.)

Q4. A patient profile- What do you want to know that’s non-medical?

Ans: Any lifestyle change, allergy, disabilities, family medical history, and any family members who had presented similar symptoms. Any use of substances (e.g., alcohol, drugs).

Q5. How would you ask the patient for the chief complaint?

Ans: Ask an open question (e.g., what can I do for you? / What brings you here, how may I help you.) and allow the patient to express their concerns and needs. Active listening and with an open posture, acknowledge and ask for clarification if needed.

Q6. Do you want to ask open-ended, closed, or leading questions? Are these appropriate?

Ans: Most of the time, ask open-ended questions as medical diagnoses need to be evidence-based, collection of information and diagnosed with critical thinking skills. A closed question limits the information collected from the patient. However, it may be used sometimes, e.g., asking for any SOB – shortness of breath, cough, etc. Try to avoid the leading question, as they may mislead the patient and cause misdiagnoses.

Q7. What does SOCRATES stand for?

Ans: Site, Onset, Character of pain, Radiation of the pain, Associations, Time, Exacerbating/Relieving factors, Severity

Q8a. How would you determine the severity of the pain?

Ans: Plain scale “zero” to “10”. “Zero”, no pain and “10” sever pain.

Q8b. What about with a child?

Ans: Pain scales, behavioural (how the child behaves), physiological (how the child’s body responds) indicators assessment tools and the child’s pain history. Some tools are listed below:

• Visual analogue scales (Marked, indicate pain intensity by children)
• Numerical analogue scales (Marked, indicate pain intensity by children)
• Face Pain Scale (Visual)
• Drawings
• Faces, Legs, Activity, Cry, Consolability (FLACC) (behavioural indicators to assess pain
• Premature Infant Pain Profile (PIPP) Stevens B, Johnston C, Petryshen P, Taddio A. The premature infant pain profile: Development and initial validation. The Clinical Journal of Pain.1996;12(1):13-22.
• Non-Communicating Children’s Pain Checklist
• Obtain pain history from parents

Reference available at: https://www.mygp.com/why-is-medical-history-important/

Q9. Map out your history-taking process…

1. Chief complaints / Presenting complaint (PC)
2. SOCRATES
3. History of presenting complaints (HxPC)
4. Past Medical History
5. Personal / Social History (e.g., sexual orientation, occupation, etc.)
6. Family History
7. Drug / Treatment History

Q10. Make a list of each system- what would you assess?

For example- Respiratory- SOB, Cough, Sputum production, Chest pain, Haemoptysis, Wheeze, sputum colour, and thickness time of when sputum is produced.

Ans:

• Integumentary System
  • Condition of the skin (dry, wet, warm, cold)
  • Temperature (Hypothermia/Hyperthermia)
  • Speech (fluency, incomplete, confuse)
• Skeletal System
  • Fracture (Open/close), posture abnormalities
• Muscular System
  • Contract/extend difficulties
• Nervous System
  • Voluntary/involuntary reflexes
• Endocrine System
  • Sputum production (thickness, colour), any indication of infection
• Cardiovascular System
  • Pulse Rate (Rapid, strong, weak, regular or irregular)
  • Blood pressure (Hypotension/Hypertension)
  • Circulation (capillary refill)
  • Chest pain (crush, frequency, intensity, radiation), any indication of MI/cardio disease
• Lymphatic System
  • Submandibular Nodes (any enlargement, infection indicator)
• Respiratory System
  • Respiration Rate (SOB/hyperventilation)
  • Airway (wheeze), any indication of bronchoconstriction, asthma
  • Cough (Haemoptysis) indication of problems related to respiratory organs/tissues
• Digestive System
  • Vomit or diarrhoea (GI tract infection)
• Urinary System
  • Bowl/urinary retention
• Reproductive System
  • Difficulty/Disability

Date: 28/09/2022

Introduction

This essay aims to reflect on suicide awareness. Office of National Statistics defines suicide as “death given an undergoing cause of intentional self-harm or an injury or poisoning of undetermined intent”. By understanding the factors and causes of suicide thought, awareness of the suicidal signpost, taking proper interventions, providing postvention support, and tackling suicide with high-quality training for the health care professional and the communities, suicide is preventable.

Suicide continuum and causes

Patients feeling suicidal include four main steps: thinking, planning, attempting, and completing. Everyone can become suicidal with no specific onset time and place. Causes may include, under stress, feeling extremely distressed, hopeless, helpless, alone, confused, encountering physical chronic pain, having mental issues, e.g., mental disorder or distress, abusing substances, e.g., drugs and alcohol, concerning housing or financing issues, and even cultural, etc. However, the main reason for the cause is that people always try to avoid talking about suicide, with the misconception that discussing more will bring more suicidal thoughts. Acknowledge the importance of prevention, intervention and postvention care can help the patient to manage and minimise suicide significantly.

Prevention, intervention and postvention

As mentioned above, every single person may have suicidal through at any time, no matter where they are. Therefore, non-judgement communication skills are highly required. Actively listening to patients’ needs, directly asking how they feel and what causes them suicidal thoughts, talking openly, acknowledging, addressing promptly and effectively, and providing early support can prevent suicide.

Proper intervention, such as risk assessment, personalised safety planning, and appropriate help and support, helps patients better cope and enhance problem-solving quickly and effectively. Considering individual needs and referring patients to social support, mental health care specialists, trust therapeutic relationships, and faith groups sensibly and appropriately. Referral needs to be able, available, and accessible at all times to maximise support and help whenever, whatever, or whoever is needed.

Maintaining a good therapeutic relationship and building good rapport can beneficial engagement between help care professionals and patients during the postvention stage. Regularly review and communicate with the patient, amend appropriate personalised safety planning, and walk alongside the patients, providing help and support accordingly.

Summary

In conclusion, suicide is preventable. Health care professionals need to be aware and ensure proper prevention, intervention and postvention support care are provided to patients who may have suicidal through. Be sensitive and higher aware that patients do not always have mental health and that there are no specific categories or groups of patients who may plan and attempt suicide.

Date: 26/09/2022

Introduction

This essay aims to reflect on how I should prepare myself to become more confident and competent when handling aggressive patients, rude family members, and patients with psychiatric issues, managing their unmet expectations, needs, wants or demands, and providing holistic personal care for a patient who exhibits anger or aggression simultaneously after watching a few video clips recorded by health care professionals. Understanding anger, acknowledging appropriate interaction, and de-escalation are beneficial and essential for my future nursing pathway.

Understanding anger

Angry or aggressive patients pose a safety threat; their outbursts can cause potential violence or physical harm to health care professionals and other patients. Angry can be verbal or nonverbal, e.g., exaggerated gestures or complete silence, and an agitation continuum with rage and violence moving up the scale. Therefore, nurses need to understand the anger and communicate effectively and compassionately to help patients to control and manage it.

Interacting with angry or aggressive patients

Firstly, maintain some distance from patients. This action prevents health care professionals from being physically harmed cause by patients but also provides personal space for the patient to ease their anxiety. Secondly, help patients to manage their anger. Being empathetic, listening to their needs or demands, and acknowledging and addressing them accordingly. Thirdly, avoiding the use of restraint. Last but not least, avoiding coercive intervention. Treat patients with dignity and respect (NMC, 2018).

De-escalation process

The goal of de-escalation is to ease the patient’s anger in a compassionate, collaborative way and treat them with dignity and respect. Firstly, speak calmly, reassuring the patient’s concerns and needs but firmly with a lower pitch, volume and rate. Secondly, address and respond patient’s want or demand selectively, answer all informational questions and never ignore the patient. Thirdly, ask open-ended questions, empathetically listen to their needs, and show empathy and understanding. Lastly, maintain safety distancing and with arms down, palms facing posture to deliver the message that I am here to help and not to cause any harm.

Summary

In conclusion, understanding anger, effectively communicating and interacting with angry or aggressive patients, and applying the de-escalation process, is essential skills and technique that I need to understand and master throughout my nursing professional development. These skills could minimise the safety threat posed by angry or aggressive patients. They allow me to prioritise people and provide holistic patient care with dignity and respect.

Reference

Nursing and Midwife Council (NMC) (2018) The Code. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf (accessed 26Sep2022)