Mar 01, 2012
By Lynn Jensen, BSN, RN

Focusing your care

Working with clients with vision loss

Linda is a 52-year-old with diabetes who was recently admitted to hospital with acute cholecystitis. Linda has experienced a gradual decline in her vision over the last 12 years due to diabetic retinopathy. At present, she is able to read large print at close range, and she uses a white cane for independent travel. She lives with her husband and two teenage children and works full time as a social worker. Linda became increasingly agitated during her hospital stay because of how she was treated by hospital staff: some raised their voices when speaking to her; others talked to Linda’s husband, rather than putting the questions about her care directly to her. When Linda’s dinner tray was delivered, no one told her that it was on her bedside table. Staff entered her room without announcing themselves. Housekeeping staff moved her telephone, talking watch and white cane and did not return them to their original locations.

Linda’s situation is common. She received substandard health-care services because most care providers do not understand vision loss.

How can you provide the best possible care to clients who are blind or partially sighted?

Deliver culturally sensitive care

Each client is different, and it is natural to adjust the care you provide and how you provide it in response to these differences. The easiest way to understand a client’s needs is to simply ask what you can do to be supportive: “How can I help you?” No two people, whether blind, partially sighted or sighted, function the same way, and therefore no two people require identical help.

It is important to maintain and support your clients’ independence. Encourage clients to perform tasks as independently as possible. They may require some assistance until they become familiar with their new surroundings, but do not assume that they cannot help themselves.

Be aware of your own emotional reactions to vision loss and blindness, so that you will not be overwhelmed when your assistance is needed. Refrain from asking repeated questions about how clients lost their vision. It can be very frustrating for them to have to explain their situation over and over again.

Clients with vision loss should be treated with the same respect and dignity as any others.

Demonstrate effective communication skills

When meeting clients, wait for them to extend a hand, since they may not see you extend yours. Do not be afraid to ask, “May I shake your hand?”

Use your natural voice and volume when speaking. Keep in mind that clients may have difficulties hearing you if there is background noise. They may not have the luxury of being able to lip-read. Be sure to speak directly to clients; do not speak through an accompanying friend or family member.

Clients may not be able to identify the faces of people entering or exiting the room, which can result in frustration and anxiety. Remember to identify yourself when you address clients so they know that you are speaking to them, even after they get to know who you are by recognizing your voice. Don’t forget to let them know when you are leaving the room so they do not continue to talk to you.

Some people want to have more information than others. If in doubt, ask. Always explain which medications you are administering. This allows clients to be directly involved in their care and may also prevent medication errors.

Balance can be affected by vision loss. Be cautious when mobilizing your clients. You should never grab, push or pull them. It is very unsettling to be pushed backwards into a wheelchair, and you could be putting clients at risk of serious injury. When you take clients to another location [PDF, 95.2 KB], describe where you are going, to help them orient themselves: “We are going to turn left and enter the radiology department.” If you must walk away for a moment, be sure to leave clients next to a stationary object. Being left in an open space can be uncomfortable.

When helping clients into a seat or wheelchair, bring them close to it and describe its position. You could also place your hand on the back or arm of the chair and allow them to slide a hand down your arm to locate the seat. Describe where your hand is resting: “My hand is on the back of the chair, and the chair is pushed into the table.”

Be as specific as possible when telling clients where objects are. Up to 90 per cent of our normal communication is visual, so remember that clients may not be able to see your facial expression and your gestures. Use everyday language. Don’t worry about using terms such as see and look when talking. People with vision loss use these terms, watch TV and go to the movies, too.

Provide environmental adaptations and accommodations

There are simple actions [PDF, 84.4 KB] you can take to help a client feel more comfortable in a hospital room. If possible, allow clients to move around their rooms to get an understanding of the placement of furniture, providing assistance as needed. Let them know that they have roommates or that the room is co-ed.

Do not move things in clients’ rooms; an item that is even five centimetres out of place can cause a lot of frustration. Keep doors completely open or completely closed to prevent injury — never leave them half open! Likewise, cupboard doors and drawers should always be closed and toilet seats placed down.

Do not assume that clients are unable to perform certain tasks such as signing their names. Provide medication handouts, instructions from a physician and teaching materials in a variety of formats, including large print, braille, audio and electronic text.

Other points to remember

Some people experience significant fluctuations in vision depending on the time of day, stress levels, blood glucose levels or environmental conditions such as lighting and glare. Clients may have problems with depth perception if they have differing levels of vision in each eye. Extra time may be required to allow for their eyes to adjust to changes in light intensity.

Don’t forget that a visual deficit can skew the results of physical and neurological exams such as the Glasgow Coma Scale and Mini-Mental State Examination.

Vision loss is no different from other losses that clients experience. Individuals who have recently lost their vision may be depressed or angry. They may be more sensitive to terms like “I’ll see you later.” However, more important than changing your language is remembering to be empathetic.

Common causes of vision loss

According to CNIB, one in 34 Canadians is living with significant vision loss that cannot be corrected with ordinary lenses. The four leading causes of vision loss in Canada are macular degeneration, glaucoma, diabetic retinopathy and cataracts. Keep in mind that clients can have more than one eye condition at a time.

Macular degeneration (MD) is the loss of central vision; central vision allows us to detect colour and detail. Individuals with MD may be able to see somebody approach them but unable to see the person’s face. In most cases, peripheral vision — the “travelling vision” — remains intact. Individuals with MD may be able to get around quite well, but they may not be able to see curbs, stairs, uneven pavement or obstacles on the floor; some choose to use a white identification cane. People with MD may be able to see a pin on the floor (when it reflects the light) in their peripheral vision, but they can’t read the newspaper.

Glaucoma results in tunnel vision. Imagine holding two toilet paper rolls up to your eyes. You can see something far off in the distance, but if somebody approaches you, you may only be able to see a small portion of the person’s form. This loss of peripheral vision means that people may bump into obstacles in their path. They will also experience night blindness. They may need a white cane or a guide dog to help them travel, but they can read the newspaper by using their central vision. Another eye condition that results in loss of peripheral vision is retinitis pigmentosa (RP). Advanced glaucoma and RP can result in complete vision loss.

Diabetic retinopathy, caused by diabetes, can result in blotchy vision and can eventually lead to complete blindness.

Cataracts result in cloudy or foggy vision. As the cataract becomes more advanced, vision decreases. Contrast sensitivity is also lost, so contours, shadows and colours are less vivid.

Visual enhancement techniques

Visual enhancement techniques are methods of altering the environment to enable clients to see better:

Contrast: An object is more likely to be seen when it is on a background of contrasting colour. Examples are a black mug on a white bedside table and a signature made using a black felt-tipped pen.

Colour: Some people can see certain colours better than they can see others. The colours that cause the most confusion are black, navy blue and brown. Red and yellow tend to be the colours that people see best. Placing a red piece of electrical tape on the call bell and light cord helps clients locate these items.

Lighting: Some people are able to see better under certain lighting conditions (e.g., halogen, incandescent or full spectrum). Light should be directed over the client’s shoulder to minimize shadows or glare. Bedside curtains or window blinds can be drawn to reduce glare. People with photophobia may experience extreme pain when they are exposed to light. Wearing dark glasses minimizes photosensitivity. Assigning clients who are photosensitive to beds away from the window may be helpful.

Figure-ground: Imagine a penny placed on a plaid tablecloth. A person with perfect vision may not see it. On a medium-toned, solid-coloured tablecloth, light and dark objects have more contrast. Keep bedside tables uncluttered.

Eccentric viewing: People with loss of central vision may turn their heads to the side to maximize their peripheral vision. Those with central vision may scan the environment to look for objects in the distance. When you are speaking to clients or showing them objects, position yourself and the objects carefully. People who are hard of hearing may rely on their remaining vision to lip-read.

What “legally blind” means

Most people with vision loss have some functional vision; about 90 per cent of CNIB’s clients have some vision. Partial vision can range from the ability to read large print to being able to detect only whether a light is on or off.

Legally blind is an often misunderstood term. Imagine vision as a continuum with no vision at all at one extreme and perfect vision (20/20 vision and 180 degrees of vision) at the other end. Someone who is legally blind has vision of 20/200 or worse or less than 20 degrees of vision in the horizontal plane; 20/200 refers to visual acuities and 20 degrees refers to visual fields. The number in the denominator increases (e.g., 20/400, 20/800) with decreased vision. It is important to note that these measurements take into account best correction (i.e., prescription lenses) in the eye with best vision. Someone with 20/200 vision needs to be 20 feet away from an object that a person with perfect vision can see from 200 feet away. If you can see only the E at the top of the Snellen eye chart, you have 20/200 vision.

Charles Bonnet syndrome

Charles Bonnet syndrome (CBS) refers to symptoms of visual hallucinations experienced by people with vision loss. People with CBS may experience a wide variety of hallucinations, including lines, light flashes, geometric shapes or more complex patterns or images of people, animals or scenes (e.g., cartoon images). The hallucinations will often disappear if they close their eyes and look away, change position or make a change to their environment (e.g., turning lights on). Studies indicate that approximately 10 per cent of people with significant vision loss have such symptoms. The percentage may actually be higher; people may be reluctant to report them for fear that they will be diagnosed with a psychiatric illness. Before you conclude that your clients are confused, consider whether they might have CBS.

Guide dog etiquette

When a client is accompanied by a guide dog, it is important to refrain from interacting with the animal. A guide dog in harness is working. You must not talk to, feed, pet or make eye contact with a working dog, which can distract the animal and put the client at risk of injury. A person does not have to be completely blind to have a guide dog. If in doubt, ask clients whether they have any vision.

Lynn Jensen, BSN, RN, Certified Vision Rehabilitation Therapist at CNIB in Vancouver, B.C.
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