sensory eent disorders(2) edited
TRANSCRIPT
Care of Clients with Care of Clients with Sensory ProblemsSensory Problems
Care of Clients with Care of Clients with Sensory ProblemsSensory Problems
Pocholo Santos Chinese General Hospital College of Nursing
NCM 104
Diagnostic AssessmentDiagnostic AssessmentDiagnostic AssessmentDiagnostic Assessment1. Eye
a. Snellen’s Chart To check visual acuity
b. Tonometry To measure intra-ocular pressure N=12-20 mmHg
c. Perimetrya. To check peripheral vision
d. Bjerrum’s tangent screen For central vision
e. Ishihara plate Color vision
Diagnostic AssessmentDiagnostic AssessmentDiagnostic AssessmentDiagnostic Assessment
2. Eara. AudiometryDecibels
Unit of measurement in hearing 70 decibels do not damage the ear
Conductive Hearing Loss Problems with tympanic membrane, middle ear
or mastoid Sensorineural Hearing Loss
Problems of the Cochlea (sensory) and acoustic nerve (neural)
Mixture Hearing Loss Combinatation of conductive and sensorineural
affectation
Diagnostic AssessmentDiagnostic AssessmentDiagnostic AssessmentDiagnostic Assessment
Vestibular function• Diagnostic test for balance and
equilibrium• Oculovestibular reflex or calorie test
• Test 8th cranial nerve• Cold or hot water into external
auditory canal produces nystagmus
Diagnostic AssessmentDiagnostic AssessmentDiagnostic AssessmentDiagnostic Assessment
Tuning forkWeber test
• On patient’s forehead or teethRinnes test
• Shifted between mastoid bone and 2 inches from the ear canal opening
Eyes DisordersEyes Disorders
Anatomy & PhysiologyAnatomy & Physiology[EYES][EYES]
Anatomy & PhysiologyAnatomy & Physiology[EYES][EYES]Outer Protective Layer
Sclera - the white visible portion of the eyeball. The muscles that move the eyeball are attached to the sclera.
Cornea - the clear, dome-shaped surface that covers the front of the eye. Middle Vascular Layer Choroid - the thin, blood-rich membrane that lies between the retina and the
sclera; responsible for supplying blood to the retina. Ciliary body - the part of the eye that produces aqueous humor. Iris - the colored part of the eye. The iris is partly responsible for regulating the
amount of light permitted to enter the eye.Inner Neural Layer Pupil - the opening in the middle of the iris through which light passes to the back
of the eye. Retina - the light-sensitive nerve layer that lines the back of the eye. The retina
senses light and creates impulses that are sent through the optic nerve to the brain.
Anatomy of the EyeAnatomy of the Eye
Anatomy & PhysiologyAnatomy & Physiology[EYES][EYES]
Anatomy & PhysiologyAnatomy & Physiology[EYES][EYES]
Refractive Media Cornea - transparent layer that forms the external coat of the
anterior portion of the eye Aqueous humor - the clear, watery fluid in the front of the
eyeball. Lens (Also called crystalline lens.) - the transparent
structure inside the eye that focuses light rays onto the retina. Vitreous body - a clear, jelly-like substance that fills the back
part of the eye.
GlaucomaGlaucomaGlaucomaGlaucoma increased intraocular pressure which can damage
optic nerve that eventually lead to blindness• Causes:
• Congenital, inherited, trauma
2 TYPES of GLAUCOMA2 TYPES of GLAUCOMA
( Narrow Angle or Close Angle)
Imbalance in the production and excretion of aqueous humor that leads to intraocular tension and displacement of iris against the angle of anterior chamber
( Simple, Wide or Open Angle)
Actual obstruction in the excretion of the aqeuous humor
Slow, gradual development Asymptomatic at first
GLAUCOMA (ACUTE AND CHRONIC)
Risk factors:1. Unknown2. Emotional disturbances3. Hereditary factors4. Allergies
GLAUCOMA (ACUTE AND CHRONIC)
Subjective Data1. Acute (Close-angle)
a. Pain, severe in and around eyesb. Headachec. *Rainbow halos around lightsd. Blurring of visione. Nausea, vomiting
2. Chronic (Open-angle)a. Eyes tire easilyb. *Loss of peripheral vision
GLAUCOMA (ACUTE AND CHRONIC)
Objective Data1. Corneal edema2. *Decreased peripheral vision3. Increased cupping of optic disc4. Tonometry pressures 22 mm. Hg5. Pupils dilated6. Redness of eye
GLAUCOMA (ACUTE AND CHRONIC)
Analysis/Nursing Diagnosis1. Visual sensory/perceptual alterations2. Pain3. Risk for injury
GLAUCOMA (ACUTE AND CHRONIC)
Nursing Care Plan/Implementation1. Goal: reduce intraocular pressure
a. Bed restb. Semi Fowler’sc. Medications:
i. Miotics (pilocarpine, carbachol) ii. Carbonic anhydrase inhibitors (acetazolamide [Diamox]) iii. Anticholinesterase (demecarium bromide [Humorsol]) iv. Ophthalmic (timolol)
GLAUCOMA (ACUTE AND CHRONIC)
2. Goal: health teachinga. Prevent increased IOP by avoiding
i. Anger, excitement, worry ii. Constrictive clothing iii. Heavy lifting iv. *Atropine or other mydriatics, which
cause dilation v. Straining at stool vi. Eye strain
b. Relaxation techniquesc. Prepare for surgical correction if indicated: laser
trabeculoplasty, trabeculectomy
CATARACT
Pathophysiology1. Developmental or degenerative opacification of the
crystalline lens.
CATARACT
Risk Factors1. Aging2. Trauma3. Toxins4. Congenital defect
CATARACT
Subjective Data1. Blurring2. Loss of acuity3. Distortion4. Diplopia5. Photophobia
CATARACT
Objective Data1. Blindness (bilateral or unilateral)2. Loss of red reflex3. Gray opacity of lens
CATARACT
Analysis/Nursing Diagnosis1. Visual sensory/perceptual alterations2. Risk for injury3. Social isolation
Nursing ManagementNursing Management
ECCE- extracapsular cataract extraction- anterior portion of the lens capsule plus the capsule contents are removed
ICCE- intracapsular cataract extraction Cryoextraction- use of frozen probes to remove lens Iridectomy - creation of an opening for the flow of aqeous humor
which may be blocked post op; prevention of secondary glaucoma
Phacoemulsification- ultrasonic vibratin to breakup the lens Intraocular lens implant- lens prosthesis Cataract glasses
Nursing ManagementNursing Management
Post op care Eye dressing with Eye shield AAT Eye shield at night for the 1st month Cataract lens (aphakic glasses) - appears 1/4 closer IOL implant - an alternative for better binocular vision
Made of polyethyl methacrylate OOB 1day post op COD OD until 7 -10 days Eye drops as ordered
Retinal DetachmentRetinal Detachment Sensory retina separates from the pigment
epithelium of the retina
Causes: Retinal DetachmentCauses: Retinal Detachment
congenital malformations
trauma (including previous ocular surgery)
vascular disease
choroidal tumors
hemorrhage
high myopia or vitreous disease, or degeneration
Exudates that occur in front or behind the retina
Aphakia (absence of crystalline lens)
Management Eye bandaged Specific positioning prescribed by MD. Head positioned so that retinal tear or hole is at
the lowest point of the eye. Surgical
Both eyes bandagedResume activities in 3-5 weeksCold compresses to decrease edema
Signs and SymptomsSigns and Symptoms
Flashes of lights Floating spots Progressive blurring of vision - visual field deficits - visual
loss Visual curtain Anxiety, confusion, fearDiagnostics Opthalmoscopic exam - gray, opaque retina, with folds,
holes, tears
Nursing ManagementNursing Management
Discuss surgical options Photocoagulation- intense beam of light directed to close the retinal
tear Cryosurgery- subfreezing temperatures applied to the surface of the
sclera in the area of the hole to produce inflammatory reaction Diathermy- needle point electrode applied through sclera Scleral buckling- sclera and corroid are intended or buckled toward the
retinal break Injecting an intraocular gas bubble to promote adhesion
Nursing ManagementNursing Management
Bed rest with eyes covered Place on a dependent position Immediate Surgery - reattach the retina Pre Op care and Mydriatics OU as ordered; eye patches OU Post op care
Affected area should be on the upper position Activities - consulted with the MD Pressure patch over the affected eye Rest the eyes and head immediate post op Avoid increase IOP (coughing, straining, NV) COD OD
UveitisUveitis
inflammation of the eye's uvea
Uveal tract - middle vascular layer of the eye, contributing to the retina’s blood supply
TypesTypes
Anterior uveitis
Intermediate uveitis
Posterior uveitis
Diffuse uveitis
UveitisUveitis
Uveitis Iritis Iridocyclitis Choroiditis Choroiretinitis
Causes: Local/systemic disease Injury Unidentified factors
S/s Pain in the eyeball radiating
to forehead Blurred vision Photophobia Redness of the eyes without
purulent discharge Small pupil lacrimation
Nursing ManagementNursing Management
Mydriatics (AtSO4, Scopolamine) To dilate pupils To prevent adhesion between ant capsule of
the lens and iris To relieve pain and photophobia To reduce congestion To rest the iris and ciliary body
Steroids Dark glasses Analgesics
Refraction errors:Refraction errors:Refraction errors:Refraction errors:HyperopiaFarsightedness (convex lens)
MyopiaNearsightedness (concave lens)
AstigmatismDistorted vision
PresbyopiaOld sight
Eye SurgeriesEye SurgeriesEye SurgeriesEye SurgeriesEnucleation-removal of eyeballEvisceration- removal of the contents of the
eye with retention of the scleraExenteration- removal of the entire eye and all
other soft tissues in the boney orbit
Care of Patientsundergoing Eye Surgery
Care of Patientsundergoing Eye Surgery
If OU are covered post op, pt needs to be oriented to hospital set up and staff
Pediatric clients need to practice covering the eyes pre op to allay anxiety, restlessness and fear post op
Call light / bell should always be within reach Prep on the eyes on the day of surgery - dilate pupils
using mydriatics
Care of Patientsundergoing Eye Surgery
Care of Patientsundergoing Eye Surgery
Post op care Prevent increase IOP Prevent stress in the suture
line Prevent hemorrhage Prevent infection Keep the head still Position on the unoperative
side or supine Burning sensation - wearing off
of anesthesia Avoid lifting of head, hips,
straining, squeezing eyelids
Open mouth when sneezing, coughing
Open eyes when vomiting Avoid bending forward to prevent
tension at suture line Gradual mobility/positional
changes Side rails up Bedside table at unoperative side Assistance in ambulation Help them learn to feed
themselves
Care of Patientsundergoing Eye Surgery
Care of Patientsundergoing Eye Surgery
Cont… Post op dressing should not be loosened or removed Minimal bleeding is normal Edema of eyelids will subside 3-4 days post op Feeling of something in the eye 4-5 days due to
sutures Sensation of pressure within the eye/ sharp pain may
indicate bleeding - report to MD ASAP
Rehabilitation of a Blind Person
Rehabilitation of a Blind Person
Referrals Orient to the environment. Set up and location of things. Promote independence in ADL May have guide dog, use of cane for direction Talk before touching when approaching Assist in ambulation. Held the client in your arm so you are
one step ahead of him Talk to him frequently so he wont feel neglected Be relaxed and unhurried. Tell procedure before performing
Rehabilitation of a Blind Person
Rehabilitation of a Blind Person
Do not change the environment without describing the change
Promote safety Do not rush up and offer help unless it is clear that
the person wants help Choice of gifts to blind person: gifts that appeal to
senses other than vision
Ear DisordersEar Disorders
Anatomy & PhysiologyAnatomy & PhysiologyAnatomy & PhysiologyAnatomy & Physiology
Anatomy & PhysiologyAnatomy & Physiology
External or outer ear pinna or auricle - the outside part of the
ear. external auditory canal or tube - the
tube that connects the outer ear to the inside or middle ear.
tympanic membrane - also called the eardrum. The tympanic membrane divides the external ear from the middle ear.
Anatomy & PhysiologyAnatomy & Physiology
Middle ear (tympanic cavity) ossicles - three small bones that are connected and transmit the sound waves to
the inner ear malleus incus stapes
eustachian tube - a canal that links the middle ear with the throat area helps to equalize the pressure between the outer ear and the middle ear.
Inner ear cochlea (contains the nerves for hearing) vestibule (contains receptors for balance) semicircular canals (contain receptors for balance)
Conductive Hearing LossConductive Hearing LossConductive Hearing LossConductive Hearing Loss
Various problems involving impaired passage of sound from the external ear to inner ear
Causes: Cerumen impaction External otitis media Serous otitis media Suppurative otitis media Otosclerosis
PathophysiologyPathophysiology
Impacted cerumen in the external ear can block sound from reaching the tympanic membrane
External otitis media - inflammation of the external ear with crust and edema
Serous otitis media - involves sterile fluid accumulation in the middle ear
Suppurative otitis media - pus accumulation in the middle ear extending to other structure
Otosclerosis - spongy bone growth over the normal body babyrinth causing the footplate of the stapes to become fixed
Signs and SymptomsSigns and SymptomsSigns and SymptomsSigns and Symptoms Cerumen impaction
Visible impaction in the ear canal
External otitis media Itching Pain Water or purulent discharge
Serous otitis media Plugged feeling in the ear Reverberation of own voice Hearing loss
Suppurative otitis media Throbbing ear pain Fever, NV Hearing loss Feeling of increased pressure in
the ear Bright red, bulging or retracted
tympanic membrane Tympanic membrane rupture with
discharge Otosclerosis
Mixed hearing loss tinnitus
Laboratory & Diagnostic FindingsLaboratory & Diagnostic Findings
Otitis Media 1st stage: tympanic membrane - retracted 2nd stage: tympanic membrane dilate and appear red 3rd stage: tympanic membrane becomes red, thickened,
and bulging with a loss of landmarks 4th stage: perforation, pus and blood drain from the ear
Otosclerosis Reduced air conduction with bone conduction
Nursing ManagementNursing ManagementNursing ManagementNursing Management
Impacted cerumen Soften with instilled peroxide or glycerol preparation Irrigate ear in 2-3 days to remove the wax Keep the otic solution in the ear for 15 mins - tilting head
sideways and putting cotton Notify MD if irritation/inflammation occurs
Nursing ManagementNursing Management
Care of client with tympanic membrane perforation Maintain strict asepsis Do not irrigate the ear Protect from water contamination (use of ear plugs) Recognize the risk for meningitis Use message board if necessary Hearing aid if indicated
Nursing ManagementNursing Management
Treat external otitis media Topical antibiotics, steroids Gentle debridement Acid alcohol solutions to sterilize auditory canal
Prepare in possible myringotomy (serous OM) Incision in the tympanic membrane to relieve pressure and
pus
Nursing ManagementNursing Management
Suppurative OM Systemic antibiotics Nasal decongestants Analgesics
Discuss possible surgery Mastoidectomy Myringoplasty Tympanoplasty
Assist in surgical management for otosclerosis
a. Stapedectomy - replacement of diseased ossicles with prosthesis
b. Fenestration - creation of a new window into the labyrinth to provide new pathway for sound
c. Hearing aidd. Communication techniques
EAR DISORDERSMENIERE’S DISEASE
1. Chronic recurrent disorder of inner ear
2. Attacks of vertigo, tinnitus, and vestibular dysfunction
3. Lasts 30 min. to a full day4. Associated with excessive
dilatation of cochlear duct (unilateral) resulting from overproduction or decreased absorption of endolymph
5. Characterized by progressive sensorineural hearing loss
EAR DISORDERSMENIERE’S DISEASE
Risk factors1. Emotional or endocrine disturbance2. Spasms of internal auditory artery3. Head trauma4. Allergic reaction5. High salt intake6. Smoking7. Ear infections
EAR DISORDERSMENIERE’S DISEASE
Subjective Data1. Tinnitus2. Headache3. True vertigo: sudden attacks, room appears to spin4. Depression, irritability, withdrawal5. Nausea on sudden head motion
EAR DISORDERSMENIERE’S DISEASE
Objective Data1. Impaired hearing, especially low tones2. Change in gait, lack of coordination3. Vomiting with sudden head motion4. Nystagmus—during attacks5. Diagnostic test:
a. Cold caloric may precipitate attackb. Loss of hearing by audiometry
EAR DISORDERSMENIERE’S DISEASE
Analysis/Nursing Diagnosis1. Risk for injury2. Auditory/sensory perceptual alteration3. Risk for activity intolerance
EAR DISORDERSMENIERE’S DISEASE
Nursing Care Plan/Implementation1. Goal: Minimize occurrence of attacks
a. Medications i. Diuretics (clorothiazide [Diuril],
acetazolamide [Diamox]) ii. Antihistamines (dimenhydrinate
[Dramamine], diphenhydramine HCL [Benadryl)
EAR DISORDERSMENIERE’S DISEASE
iii. Vasodilators (nicotinic acid) to control vasospasms
iv. Antiemetics and antivertigo agents (diazepam [Valium], meclizine HCL [Antivert])b. Diet: Low sodium, avoid caffeine, limited
fluidsc. Avoid precipitating stimuli: bright, glaring
lights, noise, sudden jarring, turning head or eyes
2. Goal: health teachinga. No smokingb. Play radio to mask tinnitus particularly at
night
Acoustic NeuromaAcoustic NeuromaAcoustic NeuromaAcoustic Neuroma
a benign tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear
AKA: vestibular schwannoma or neurolemmoma
Acoustic NeuromaAcoustic NeuromaAcoustic NeuromaAcoustic Neuroma
Causes: exposure to loud noise on a consistent basis prior exposure to head and neck radiation history of parathroid adenoma Use of hand held cellular phones (under study)
Diagnostic procedure Audiometry (hearing testing) MRI scanning of the head with contrast.
Acoustic NeuromaAcoustic NeuromaAcoustic NeuromaAcoustic Neuroma
a one-sided, slowly progressive hearing impairment
hearing loss at low frequency Hearing loss Vertigo HA hearing loss at low frequency
OTOSCLEROSIS
Pathophysiology1. Insidious, progressive deafness2. Most common cause of conductive deafness3. Cause unknown4. Formation of new spongy bone in labyrinth5. Results in fixation of stapes6. Leads to prevention of sound transmission through
ossicles to inner ear fluids.
OTOSCLEROSIS
Risk Factors1. Heredity2. Females, puberty to 45 yrs.
OTOSCLEROSIS
Subjective Data1. Tinnitus2. Difficulty hearing; gradual loss in both ears
OTOSCLEROSIS
Objective Data1. Rinne (mastoid)- reduced sound conduction by air
and intensified by bone2. Weber (top of head)- increased sound conduction to
affected ear3. Audiometry—diminished hearing
OTOSCLEROSIS
Analysis/Nursing Diagnosis1. Auditory sensory/perceptual alteration2. Body image disturbance
OTOSCLEROSIS
Nursing Care Plan/Implementation(Discussed in next section: stapedectomy)
STAPEDECTOMY
Pathophysiology1. Removal of the stapes and replacement with a
prosthesis2. Treatment of deafness due to otosclerosis, fixes the
stapes preventing it from oscillating and transmitting vibrations to the fluids in the inner ear
STAPEDECTOMY
Analysis/Nursing Diagnosis1. Sensory perceptual alteration
STAPEDECTOMY
Nursing Care Plan/Implementation1. Pre operative Care: health teaching
a. Keep head in position as orderedb. Avoid sneezing, blowing nose, vomiting,
coughing2. Post operative care
a. Goal: health teaching i. Avoid
1. Washing hair for 2 weeks 2. Swimming for 6 weeks3. Air travel for 6 months4. People with URI5. Heavy lifting or straining
DEAFNESS
Risk Factors1. Conductive hearing losses (transmission deafness)2. Impacted cerumen3. Foreign body4. Defects5. Otosclerosis of ossicles6. Sensorineural hearing losses (perceptive or nerve
deafness)7. Arteriosclerosis8. Infectious diseases (mumps, measles, meningitis)9. Drug toxicities10.Tumors11.Head trauma12.High intensity noises
DEAFNESS
Objective Data1. Inattentive or strained facial expression2. Excessive loudness or softness of speech3. Frequent need to clarify content of conversation4. Tilting of head while listening5. Lack of response
DEAFNESS
Nursing Care Plan/Implementation1. Goal: maximize hearing ability and provide
emotional supporta. Gain person’s attention before speakingb. Provide adequate lightingc. Look at the person when speakingd. Use non verbal cuese. Speak slowly and distinctly. Do NOT shoutf. Use different words if the person does not seem
to understandg. Use alternative communication devices
DEAFNESS
2. Goal: health teachinga. Care of a hearing aid
i. Clean ear mold PRN ii. Keep hearing aid dry iii. Turn hearing aid off at night iv. Store away from pets v. Leave aid in same place
every nightb. Safety precautions: when crossing street, driving
Communicating with a Client with Hearing Impairment
Communicating with a Client with Hearing Impairment
Talk directly to the patient facing her/him Talk in normal tone of voice. Clearly enunciate words Use gestures with speech Do not whisper in front of pt with hearing impairment Do no avoid conversation Do not show annoyance e.g. facial expressions Do not smile, do not chew gum, do not cover mouth Encourage use of hearing aids
Care of Patient undergoing Ear Surgery
Care of Patient undergoing Ear Surgery
Pre-op Assess for URTI Shampoo the hair Inform re local anesthesia but sedated during surgery
Post-op Care Lie on the unoperative side Blow nose gently, one side at a time Sneeze, cough with open mouth 1 week Avoid physical activity x 1week; exercise/sports x 3weeks Cotton ball in the ears daily
Care of Patient undergoing Ear Surgery
Care of Patient undergoing Ear Surgery
Cont… Keep ear dry for 6 weeks post op
Do not shampoo hair x 1 week Protect ears with 2 pieces of cotton balls
Avoid airplane travel 1 week post op Report drainage to MD; slight amount is normal (stain) Avoid reading, watching tv or fast moving objects 1 wk post op Seek supervision when ambulating for the 1st time, dizziness
and light headedness may occur