Nursing of Sensory Perception

Retinopathy of Prematurity

BY 3RD GROUP

Marissa Ulkhair

1311311089

Mery Sepriani

1311311092

M. Angga Mahalta

1311312003

Suci Nilam Sari

1311312004

Hasnatul Fikryah

1311311009

Sonia Mestika Hernandes

1311311053

Cindy Kurnia Nengcy

1311311093

Pratiwi Wulandari

1311311051

Sindy Rahmawati

1311311004

Vhira Nadiandra Pratiwi

1311311008

Nurul Arvina

1311311015

UNDERGRADUATE PROGRAM
FACULTY OF NURSING
ANDALAS UNIVERSITY
2014/2015

FOREWORD
Praise 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 Prematurity
The 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 I
Introduction
1. Background
Retinopathy 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. Purpose
To explore about Retinopathy of Prematurity and Nursing Care Plans for this disorder

Chapter II
Literature Review
A. Definition of retinopathy of prematurity

Retinopathy 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 ROP

During 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. Pathogenesis
Beginning 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 ROP
1. 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 use
Oxygen 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 ROP
3. 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 infants
4. The other risk factors
Use of some kind of medicine, ROP has also been associated with intraventricular haemorrhage, and others.
E. Classification
The 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 from
avascular 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. Treatment
The 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.

Timing
When 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 therapy
Laser 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.
Cryotherapy
Cryotherapy 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 surgery
Scleral 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 PLAN

1. Assessment
a. Assess the patient identity
b. Assess the patients health history
c. Assess the familys health history
d. 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 Interventions
Nursing Diagnosis
1. Disturb

Expected outcome
NOC Suggested

Intervention
NIC Priority

Sensory

Outcome :

Intervention :

Perceptual

Vision compensation

Cognitive

related to

behaviour :

stimulation

integration

Personal actions to

: promotion of

resulting from

compensate for visual

awarness and

retinopathy

impairment

comprehension of

of prematurity

Rationale

surronding by
utilization of planned
The child demonstrates

stimuli
Provide kinesthetic,

Because visual

minimal signs

tactile, and auditory

sensory input is not

of sensory deprivation.

stimulation during

present, the child

play and in daily care

needs input from all

(e.g., talking and

other senses to

playing). Provide

compensate and

music while bathing

provide adequate

an infant using bells

sensory

and other noises on

stimulation.

each side of infant.

Verbally describe to a

child all actions being

2. Risk for Injury

NOC Suggested

carried out by adult.

NIC Priority

related to

Outcome: Risk

Intervention:

impaired vision

Control: Personal

Fall Prevention.

actions to understand,

Instituting special

prevent, eliminate, or

precautions with

reduce modifieble

patients at risk for

reduce modifiable

injury from falling.

health threats.
Evaluate environment

The child may be at

for potential safety

risk for injury

hazards based on age

related both to

of child and degree of

developmental stage

impairment. Be

and inability to

particularly alert to

visualize hazards.

objects that give

visual cues to their
dangers (e.g., stoves,
fireplaces, candles).
Eliminate safety
hazards and
protect the child from
exposure. Take the
child on a four of new
rooms, explaining
safety hazards
(e.g., schools, hotel
3. Delay Growth

NOC Suggested

room, hospital room).

NIC Priority

and Development

Outcome: Child

Intervention:

related to

Development:

Developmental

impaired vision

Milestones of

Enhancement:

developmental

Child :

progression.

Facilitating or
teaching parents
caregives to facilitate
optional growth &
development of
children.

Help parents plan

impaired child

early, regular

benefits

social activities

developmentally

with other

from contact

children.
Provide

with other

opportunities and

The visually

children.
To obtain

encourage self-

adequate

feeding activities.
Provide an

nutrients, the

environment rich

feel comfortable

in sensory input.
Assess growth and
development

feeding self.
Sensory input is

during regular

normal

examinations to

development to

child needs to

identify the childs

strengths and
needs.

needed for

occur.
Regular
examinations aid
in early
identification of
growth problems
or
developmental
delays, so that
appropriate
interventions can

be planned.
4. Disabled

NOC Suggested

NIC Priority

Family Coping

Outcome: Family

Intervention: Family

related to childs

Coping: capasity of the

Mobilization:

prolonged

family to manage the

Utilization of family

disability from

stressors that tax family

strengths to influence

sensory

resources

childs health in a

impairment

positive direction.
The family successfully Provide
copes

with

the

explanation

experience of having a
visually impaired child.

The parents may

of

feel guilt about

visual impairment

the childs visual

as appropriate.
Refer parents to

impairment,

organizations,

allayed

early intervention

knowledge of the

programs,

other parents of

cause.
The parents will

visually impaired

receive

children.
Assist parents to

information and

plan for meeting

others.
The child may

and

educational,

and

needs

their

of

visually

impaired

can

support

developmental
safety

which

child.

be
by

needed
from

require
enhanced
environment
developmental

changing

progress.

environment
assist

to

visually

impaired child.

3. Evaluation
- The child demonstrates minimal signs of sensory deprivation

in

order to faster

Offer resources for

home

an

The family successfully copes with the experience of having a visually

impaired child

Chapter III
Conclusion
Retinopathy 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.

References
Hatfield, N.T. (2008). Broadribbs Introductory Pediatric Nursing 7th Edition. China:
Lippincott Williams & Wilkins.
Ackley, B.J. (2011). Nursing Diagnosis Handbook 9th edition.USA: Mosby Elsevier
Bulecheck, G.M. (2013). Nursing Interventions Classification (NIC) 6th Edition. USA :
Elsevier
Moorhead, S. (2013). Nursing Outcome Classification (NOC) 5th Edition. USA: Elsevier
Richard E., Md. Behrman (2003). Nelson Textbook of Pediatric 17th Edition. Philadelphia :
W.B Saunders
Marilyn J Hockenberry, David Wilson (2008). Wongs Nursing Care of Infants and Children.
National Council : NCLEX
M. Elizabeth Hartnett, M.D., and John S. Penn, Ph.D. Mechanisms and Management of
Retinopathy of Prematurity. The new England journal of medicine.
Smeltzer, Suzanne.C & team.(2010).Brunner and Suddarth Text Book Of Medical Surgical
Nursing 12th Edition.China: Walters Kluwer
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Edition. Philadelphia : Davis Company