Nursing of Sensory PerceptionRetinopathy of Prematurity

BY 3RD GROUP

Marissa Ulkhair1311311089Mery Sepriani 1311311092M. Angga Mahalta1311312003Suci Nilam Sari1311312004Hasnatul Fikryah1311311009Sonia Mestika Hernandes1311311053Cindy Kurnia Nengcy1311311093Pratiwi Wulandari1311311051Sindy Rahmawati1311311004Vhira Nadiandra Pratiwi1311311008Nurul Arvina1311311015

UNDERGRADUATE PROGRAMFACULTY OF NURSINGANDALAS UNIVERSITY2014/2015

FOREWORDPraise and thankfulness stated to Almighty Allah SWT, has given the great chance and opportunity to the writer team for finishing this paper well. The title of this paper is about Retinopathy of PrematurityThe purpose of this paper to make students understand having a good knowledge and skill. Then, students can practice to the patients at all.The writer team also say thanks to Miss. Nelwati and all of our family had given us many support and contribution for writing this paper.The writer team really realizes this paper not written maximally and perfectly, Therefore the team really hopes some improving suggestions and critics from all the readers, the writer team really appreciate it.

Padang, March 4th 2015

The writer team

Chapter IIntroduction1. BackgroundRetinopathy of prematurity refers to a complication commonly associated with the preterm newborn. It results from the growth of abnormal immature retinal blood vessels. Preterm birth may be a factor contributing to this growth. In addition, the use of high concentrations of oxygen has been identified as a major cause. The immature blood vessels constrict when high levels of oxygen are given, depriving the retinal tissues of adequate nutrition. In addition, in some newborns capillaries increase, leading to scarring and eventually retinal detachment. These events lead to varying degrees of blindness.This retinal vasculopathy occurs almost exclusively in preterm infants.It may be acute (early stages) or chronic (late stages). Clinical manifestations range from mild, usually transient changes of the peripheral retina to severe progressive vasoproliferation, scarring, and potentially blinding retinal detachment. ROP includes all stages of the disease and its sequelae. Retrolental fibroplasia (RLF), the previous name for this disease, described only the cicatricial stages.

2. PurposeTo explore about Retinopathy of Prematurity and Nursing Care Plans for this disorder

Chapter IILiterature ReviewA. Definition of retinopathy of prematurityRetinopathy of prematurity (ROP) is a developmental disorder that occurs in the incompletely vascularized retina of premature infants and is an important cause of blindness in children in both the developed and the developing countries.Retinopathy of prematurity (ROP) is a retinal disorder of low birth weight premature infants. It can be mild with no visual defects, or it may become aggressive with new vessel formation (neovascularisation) and progress to retinal detachment and blindness. The stimulus for the abnormal growth of blood vessels comes from the peripheral immature retina. Early detection and effective management of this condition can prevent blindness.Retinopathy of Prematurity (ROP) is an eye disorder affecting premature infants. This disorder was called Retrolental Fibroplasia in thepast. ROP affects immature blood vessels of the retina. It occurs weeks after birth. Once development of blood vessels is complete, a child is no longer a candidate for this disorder.

B. Etiology of ROPDuring the last 12 weeks of pregnancy, a babys eyes develop quickly. When a babys born, most of the blood vessels in the retina are nearly grown. The retina usually finishes growing in the first few weeks after birth.If a baby is born too early, his blood vessels may stop growing, or they may not grow correctly. These fragile vessels can leak, causing bleeding in the eye. Scar tissue can form, and if the scars shrink, they may pull the retina loose from the back of the eye. This is called retinal detachment. Retinal detachment is the main cause of vision problems and blindness in ROP. Some things make a baby more likely than others to have ROP. These are called risk factors. Having a risk factor doesnt mean for sure that your baby will have ROP. But it may increase his chances. We know that the smallest and sickest babies have more risk factors for ROP than larger, healthier babies. Risk factors for ROP include: Premature birth This is birth that happens too early, before 37 weeks of pregnancy. Apnea. This is when a babys breathing stops for 15 to 20 seconds or more. Anemia. This is when the body doesnt have enough healthy red blood cells to carry oxygen to the rest of the body. Heart disease Infection Trouble breathing or respiratory distress Slow heart rate (also called bradycardia) Problems with the blood, including having blood transfusions. This means having new blood put in the body.

C. PathogenesisBeginning at 16 wk of gestation, retinal angiogenesis normally proceeds from the optic disc to the periphery, reaching the outer rim of the retina (ora serrata) nasally at about 36 wk and extending temporally by approximately 40 wk. Injury to the process results in various pathologic and clinical changes. The first observation in the acute phase is cessation of vasculogenesis. Rather than a gradual transition from vascularized to avascular retina, there is an abrupt termination of the vessels, marked by a line in the retina. The line may then grow into a ridge composed of mesenchymal and endothelial cells. Cell division and differentiation may later resume, and vascularization of the retina may proceed. Alternatively, there may be progression to an abnormal proliferation of vessels out of the plane of the retina, into the vitreous, and over the surface of the retina. Cicatrization and traction on the retina may follow, leading to detachment.The risk factors associated with ROP are not fully known, but prematurity and the associated retinal immaturity at birth represent the major factors. Hyperoxia is also a major factor, but other problems, such as respiratory distress, apnea, bradycardia, heart disease, infection, hypoxia, hypercarbia, acidosis, anemia, and the need for transfusion are thought by some to be contributory factors. Generally, the lower the birthweight and the sicker the infant, the greater the risk for ROP.The basic pathogenesis of ROP is still unknown. Exposure to the extrauterine environment including the necessarily high inspired oxygen concentrations produces cellular damage, perhaps mediated by free radicals. Later in the course of the disease, peripheral hypoxia develops and vascular endothelial growth factors are produced in the nonvascularized retina. These growth factors stimulate abnormal vasculogenesis, and neovascularization may occur. This may then lead to scarring and vision loss.D. Risk factors of ROP1. Birth weight and gestational age Infants with very low birth weight are at significantly higher risk of developing severe ROP that requires treatment. Similarly, the severity of ROP is inversely proportional to gestational age. Present evidence shows that low birth weight and gestational age are the most predictive risk factors for the development of ROP.2. Oxygen useOxygen therapy has been previously implicated in the etiology of ROP. The use of supplemental oxygen neither caused progression of pre-threshold ROP nor significantly reduced the number of infants requiring peripheral ablative therapy Recent evidence suggests that repeated hypoxic and hyperoxic episodes may be an important factor in the pathogenesis of ROP. Strict management of oxygen delivery without fluctuations and monitoring may be associated with decreased occurrence of ROP .Although the exact relationship between oxygen therapy and ROP is currently not well established, oxygen therapy seemed to play an important role in the pathogenesis of ROP3. Light Exposure There is no evidence that light exposure is a risk factor in the development of ROP, since reduction in ambient light exposure has not reduced the incidence of ROP in high risks infants4. The other risk factorsUse of some kind of medicine, ROP has also been associated with intra-ventricular haemorrhage, and others.

E. ClassificationThe currently used international classification of ROP describes the location, extent, and severity of the disease. To delineate location, the retina is divided into three concentric zones, centered on the optic disc. Zone I, the posterior or inner zone, extends twice the disc-macular distance, or 30 degrees in all directions from the optic disc. Zone II, the middle zone, extends from the outer edge of zone I to the ora serrata nasally and to the anatomic equator temporally. Zone III, the outer zone, is the residual crescent that extends from the outer border of zone II to the ora serrata temporally, this area of the retina being vascularized. The extent of involvement is described by the number of circumferential clock hours involved.The phases and severity of the disease process are classified into five stages:1. Stage 1 is characterized by a demarcation line that separates vascularized fromavascular retina. This line lies within the plane of the retina and appears relatively flat and white. Often noted is abnormal branching or arcading of the retina vessels that lead into the line.2. Stage 2 is characterized by a ridge; the demarcation line has grown, acquiring height, width, and volume and extending up and out of the plane of the retina. It may change from white to pink. Vessels may leave the plane of the retina to enter the ridge.3. Stage 3 is characterized by the presence of a ridge and by the development of extraretinal fibrovascular tissue.4. Stage 4 is characterized by subtotal retinal detachment caused by traction from the proliferating tissue in the vitreous or on the retina. Stage 4 is subdivided into two phases: (1) subtotal retinal detachment not involving the macula and (2) subtotal retinal detachment involving the macula.5. Stage 5 is total retinal detachment.

F. TreatmentThe principle treatment is to remove the stimulus for growth of new blood vesssels by ablating the peripheral vascular retina. This will in turn reduce the incidence of retinal detachment and consequent blindness. TimingWhen indicated, treatment should be carried out as soon as possible, ideally within 2-3 days of the diagnosis. The rational is that the disease can advance rapidly and any delay in treatment will reduce the chances of success. Type if treatment Laser therapyLaser therapy is procedure of choice, being less invasive, less traumatic to the eye and causes less discomfort to he infant. Laser is also simpler to apply in treating located disease. Laser should be applied on the peripheral avascular retina. Ideally laser applications should be spaces one half burn width apart.Complications of laser therapy:May cause burn in cornea and iris. Other inmplications include cataract, and retinal and vitreous haemorrhage.

CryotherapyCryotherapy significantly improves the outcome of severe ROP. Complication of cryotherapy :Can result ocular complications like eyelid edema, laceration of the conjunctiva, and pre retinal and vitreous haemorrhage as well as systemic complications like bradycardia, cyanosis, and respiratory depression.

Vitreoreitnal surgeryScleral buckling is advocated for stage 4B and stage 5 ROP. Lens sparing vitreous surgery can also be carried out, preferably at 38 to 42 weeks of postmenstrual age. Patient with advanced disease or severe ROP should be referred to a tertiary centre for further management.

G. Complication of ROP Myopia occurs in about 80% of infants with ROP Strabismus and amblyopia are also common residual findings. Retinal detachment can occur as early as 6 months up to 31 years from the time of diagnosis, with a mean ageof 13 years in regressed ROP patients. Retinal detachment may even occur in sub threshold ROP Acute angle closure glaucoma can be seen in cicatricial ROP

NURSING CARE PLAN1. Assessmenta. Assess the patient identityb. Assess the patients health historyc. Assess the familys health historyd. Physical examination. Assess for: Skin: Usually thin, translucent to gelatinous with vessels easily seen, becoming loose and wrinkled after a few days. Color: Ranging from pink or dark red (ruddy) to acrocyanosis, a bluish discoloration of the palms of the hands and soles of the feet. (This condition is considered normal immediately after birth but should not persist longer than 48 hours.) Behavior/activity level: Incapable of moving smoothly from one state or level of alertness to another to control his environmental input. Muscle tone: Characteristically weak, leaving a flaccid and open resting position and allowing for increased heat loss of body temperature, as well as an increased inability to control his behavioral state. Breasts: Engorgement rarely seen. Nipples and areola are usually not easily noted. Head: Large in proportion to body size; bones of the skull are soft, with overriding sutures and small fontanels, leaving a narrow, flattened appearance to head and face. Eyes: Small and sometimes fused; eyelids may become edematous after treatment. Ears: Soft, flat, and small with little cartilage, allowing for the pinna to bend and fold, leading to potential injury to ear. Nose: Small with visible milia; breathing predominately through nose; nasal flaring indicative of respiratory distress. Chest: Weak musculoskeletal structure; lung auscultation typically wet and noisy; heart beat rapid and difficult to hear over lung sounds. Abdomen: Full and soft with a weak muscle tone, allowing for visible bowel loops and marked abdominal distention. Genitalia: In female, labia minora and clitoris prominent because the labia majora are underdeveloped; in male, small scrotum and, frequently, undescended testes.2. Nursing diagnosis, Outcome and InterventionsNursing Diagnosis Expected outcomeInterventionRationale

1. Disturb Sensory Perceptual related to integration resulting from retinopathyof prematurityNOC Suggested Outcome : Vision compensation behaviour :Personal actions to compensate for visual impairment

NIC Priority Intervention : Cognitive stimulation: promotion of awarness and comprehension of surronding by utilization of planned stimuli

The child demonstrates minimal signsof sensory deprivation.Provide kinesthetic, tactile, and auditory stimulation during play and in daily care (e.g., talking and playing). Provide music while bathing an infant using bells and other noises on each side of infant. Verbally describe to a child all actions being carried out by adult.Because visual sensory input is not present, the child needs input from all other senses to compensate andprovide adequate sensorystimulation.

2. Risk for Injury related to impaired visionNOC Suggested Outcome: Risk Control: Personal actions to understand, prevent, eliminate, or reduce modifieble reduce modifiable health threats.NIC Priority Intervention: Fall Prevention. Instituting special precautions with patients at risk for injury from falling.

Evaluate environment for potential safety hazards based on age of child and degree of impairment. Beparticularly alert to objects that give visual cues to their dangers (e.g., stoves, fireplaces, candles). Eliminate safety hazards andprotect the child from exposure. Take the child on a four of new rooms, explaining safety hazards(e.g., schools, hotel room, hospital room).The child may be at risk for injury related both to developmental stage and inability to visualize hazards.

3. Delay Growth and Development related to impaired visionNOC Suggested Outcome: Child Development:Milestones of developmentalprogression.NIC Priority Intervention:Developmental Enhancement: Child :Facilitating or teaching parents caregives to facilitate optional growth & development of children.

Help parents plan early, regular social activities with other children. Provide opportunities and encourage self-feeding activities. Provide an environment rich in sensory input. Assess growth and development during regular examinations to identify the childs strengths and needs. The visually impaired child benefits developmentally from contact with other children. To obtain adequate nutrients, the child needs to feel comfortable feeding self. Sensory input is needed for normal development to occur. Regular examinations aid in early identification of growth problems or developmental delays, so that appropriate interventions can be planned.

4. Disabled Family Coping related to childs prolonged disability from sensory impairmentNOC Suggested Outcome: Family Coping: capasity of the family to manage the stressors that tax family resourcesNIC Priority Intervention: Family Mobilization: Utilization of family strengths to influence childs health in a positive direction.

The family successfully copes with the experience of having a visually impaired child. Provide explanation of visual impairment as appropriate. Refer parents to organizations, early intervention programs, and other parents of visually impaired children. Assist parents to plan for meeting developmental educational, and safety needs of their visually impaired child. Offer resources for changing home environment to assist visually impaired child. The parents may feel guilt about the childs visual impairment, which can be allayed by knowledge of the cause. The parents will receive needed information and support from others. The child may require an enhanced environment in order to faster developmental progress.

3. Evaluation The child demonstrates minimal signs of sensory deprivation The family successfully copes with the experience of having a visually impaired child

Chapter IIIConclusionRetinopathy of prematurity is a retinal disorder of low birth weight premature infants. It can be mild with no visual defects, or it may become aggressive with new vessel formation (neovascularisation) and progress to to retinal detachment and blindness. The stimulus of abnormal growth of blood vessels comes from the peripheral immature retina. Early detection and effective management of this condition can prevent blindness.This retinal vasculopathy occurs almost exclusively in preterm infants.It may be acute (early stages) or chronic (late stages). Clinical manifestations range from mild, usually transient changes of the peripheral retina to severe progressive vasoproliferation, scarring, and potentially blinding retinal detachment. ROP includes all stages of the disease and its sequelae. Retrolental fibroplasia (RLF), the previous name for this disease, described only the cicatricial stages.

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