unit 1 powerpoint

Slide 1Primary Care: The Art and Science of Advanced Practice Nursing, 3rd Edition
Copyright © 2011 F.A. Davis Company
Chapter 8
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd Edition
Common Complaints
Dry eye
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Common Complaints (cont’d)
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Lid Pathology: Blepharitis
Occasionally seen in those with trisomy 21
Tends to affect people with psoriasis, seborrhea, eczema, allergies, and lice infestations
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Blepharitis (cont’d)
Ulcerative form
Involves the lash follicle and the meibomian glands of the eyelid
May be pustules at the base of the hair follicles that may crust and bleed
Lashes become thin and break easily
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Hordeolum
Hordeolum (stye): an acutely presenting, erythematous, tender lump within the eyelid
External hordeolum: inflammation/infection of the eyelid margin affecting the hair follicles of the eyelashes
Internal hordeolum: inflammation/infection of the meibomian glands
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Chalazion
A granulomatous infection of a meibomian gland, presenting in the form of painless swelling on the eyelid
Initially may be tender and erythematous before evolving into a nontender lump
Blepharitis is frequently associated with chalazia
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Dry Eye
Sjögren’s syndrome
May reflect a more local infectious process, as in some forms of conjunctivitis
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Dye Eye (cont’d)
Certain medications: anticholinergic agents, beta-adrenergic blockers, and antihistamines
Aging, especially women during menopause
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Treatment for Dry Eye
Elimination of offending systemic medications
Use of artificial tear substitutes, lubricants, gels, and ointments
Possibly eyelid therapy
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Treatment for Dry Eye (cont’d)
Level 2 treatment (if prior level not effective)
Ocular lubricants, nonpreserved artificial tear substitutes, and anti-inflammatory agents such as topical cyclosporine A, topical corticosteroids, or topical/systemic omega-3 fatty acids
Cyclosporine ophthalmic emulsion (RESTASIS®) for chronic dry eye
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Treatment for Dry Eye (cont’d)
Level 3 treatment (when levels 1 and 2 fail)
Autologous serum, special contact lenses, and permanent punctual occlusion
Level 4
Grafting of mucous membranes
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Red Eye/Conjunctivitis
Conjunctivitis: inflammation of the conjunctiva covering the front of the eye
Common causes
Sexual transmission and ophthalmia neonatorium
Herpes simplex (HSV) I
Allergy
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Conjunctivitis: Diagnostic Tests
Dilated pupil exam for proptosis, optic nerve dysfunction, decreased visual acuity, diplopia, or anterior chamber inflammation
Fluorescein staining to rule out corneal involvement or keratitis
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Cataracts
Other causes of cataracts: congenital, metabolic, and traumatic etiologies
Excessive exposure to sunlight (ultraviolet B rays) without protective lenses over time
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Glaucoma
Glaucoma: progressive damage to the optic nerve, resulting in optic nerve atrophy and blindness, most typically associated with elevated intraocular pressure
Open-angle
Angle-closure (closed-angle, or narrow-angle glaucoma)
Primary or secondary (associated with an ocular condition or a systemic process)
Also a congenital form
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Glaucoma Treatment
Open-angle glaucoma
Laser or surgical treatment if not controlled by medication
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Glaucoma Treatment (cont’d)
Acetazolamide (Diamox)
Laser iridotomy or peripheral iridectomy
Bedrest should be maintained until the attack is broken

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Diabetic Retinopathy
Ophthalmologist must do yearly retinal eye exam on all diabetics
Three stages
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Diabetic Retinopathy (cont’d)
Microaneurysms, intraretinal hemorrhage, macular edema, and lipid deposits
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Management of Diabetic Retinopathy
First goal for patients at risk for microvascular complications, including diabetic retinopathy, is prevention
The only pharmacologic agent found to slow the progression of diabetic retinopathy is Lisinopril, an angiotensin-converting enzyme (ACE) inhibitor
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Macular Degeneration
“Dry”: a slow progressive atrophy and degeneration of the retina
“Wet”: age-related; new blood vessels develop under the retina in the macula, causing a sudden distortion or loss of central vision
Refer immediately to an ophthalmologist
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Macular Degeneration (cont’d)
If vision is less than 20/20, do “pinhole” test
Vision that corrects with the pinhole test implies an uncorrected refractive error
Funduscopic exam is normal in patients with refractive errors
Yellow round spots (drusen): indicative of early macular degeneration
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Management of
Macular Degeneration
No treatments for the initial stage of early disease
In the intermediate stage of the disease, high-dose antioxidant vitamins and zinc supplements possibly help
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Tinnitus
Risk factors
Hearing loss, labyrinthitis, Ménière’s disease, otitis media or externa, otosclerosis, ear-canal blockage (from ear wax or a foreign body)
History of high or low blood pressure, head trauma, anemia, hypothyroidism, hyperthyroidism, or allergies
Chronic exposure to noise
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Management of Tinnitus
Learning to cope with tinnitus is necessary
Avoidance of risk factors
Protective earplugs
Tinnitus-masking devices
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Otitis Media (OM)
Otitis media with effusion (OME): transudation of plasma from middle ear blood vessels, leading to chronic effusion in the absence of the signs and symptoms of acute infection
Acute otitis media (AOM): suppurative OM or purulent OM
Recurrent OM: the clearance of middle ear effusions between acute episodes of otic inflammation
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OM: Subjective Data
Stuffiness, fullness, and a loss of auditory acuity in the affected ear only
Pain is rare; may describe popping, crackling, or gurgling sounds when chewing, yawning, or blowing the nose
Rare vertigo
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AOM Symptoms
Unilateral hearing loss
Possible dizziness (space disorientation), vertigo, tinnitus (ringing in the ears), vomiting, or nausea
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Chronic OM Symptoms
History of repeated bouts of acute otitis media, followed by a period of continuous or intermittent otorrhea lasting for more than three months
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Objective Signs of OM
OME
Mucous membranes of nasal and oral cavities may be injected or edematous
Eardrum may be dull but usually is not bulging, and eardrum mobility typically decreases on pneumatic otoscopy
AOM
Tympanic membrane may be amber or yellow-orange, or may be injected and pinkish gray to fiery red in color
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Chronic OM
Chronic, foul-smelling otorrhea—anaerobic bacterial infection
Chronic, grayish-yellow suppuration—cholesteatoma from the degenerative products of invasive epithelialization
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Management of OM
Uncomplicated cases of OM: self-limited and require no specific intervention
May need pain relief
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Management of OME
14- to 28-day course of antibiotic such as amoxicillin/clavulanate (Augmentin), cefaclor (Ceclor), or trimethoprim-sulfamethoxazole (Bactrim)
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Nonallergic Rhinitis
Vasomotor
Hormone-related
Atrophic (mostly in geriatric patients)
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Clinical Presentation
of Rhinitis
Viral rhinitis
Allergic rhinitis
Itching in the nasal passages, conjunctivae, and roof of the mouth
Epiphoria (stringy, watery ocular discharge)
Sneezing, coughing, and a sore or burning throat
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Clinical Presentation
Watery rhinorrhea, nasal congestion, “nasal” speech, and forced mouth-breathing
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Management of Rhinitis
Rhinorrhea may be treated with oral decongestants
Topical preparations
Dextromethorphan for persistent coughs
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Treatment for Allergic Rhinitis
Oral antihistamines: short-term treatment
Intranasal corticosteroids: long-term management
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Sinusitis
Acute: abrupt onset of infection and post-therapeutic resolution of symptoms lasting no more than 4 weeks
Subacute: a purulent nasal discharge persists despite therapy, lasting from 4 to 12 weeks
Chronic: episodes of prolonged inflammation with repeated or inadequately treated acute infection lasting greater than 12 consecutive weeks
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Subjective Symptoms of Sinusitis
Gradual onset of symptoms
Recurrent or chronic dull, constant pain over the affected sinuses
Pain increases and becomes characteristically throbbing
Maxillary sinusitis: pain over the cheeks and upper teeth—may worsen when standing erect
Frontal sinusitis: pain over the eyebrows—may worsen with recumbency
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Objective Signs of Sinusitis
A red, swollen nasal mucosa
A swollen pale mucosa with watery secretions, points to allergic sinusitis or rhinitis
Objective
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Objective Signs of Sinusitis (cont’d)
Purulent secretions
Black or necrotic material—mucormycosis-related rhinorrhea in immunocompromised patients
Ethmoid sinus involvement may result in chemosis (eyelid mucous membrane edema), proptosis, conjunctival injection, extraocular muscle palsy, or orbital fixation
Tenderness on palpation over the sinuses
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Management of Sinusitis
Since a vast majority of acute sinusitis cases are caused by viruses, antibiotics are largely unhelpful
Antimicrobial therapy indicated for acute uncomplicated bacterial sinusitis
Saline nasal spray
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Other Sinusitis Treatment
Increase fluid intake
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Medications for Sinusitis
Avoid nonprescription medicated nose drops and sprays
Use prescription nasal sprays for no more than 3 to 4 days at a time
Expectorants such as guaifenesin to liquefy sinus secretions and facilitate drainage
Anti-inflammatory topical steroids in nasal spray preparations
Empiric antibiotic therapy for 7 to 10 days
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Temporomandibular Joint Disease (TMD)
A cluster of related disorders in the masticatory system
The most common presenting symptom is pain in the muscles of mastication, the preauricular area, and/or the temporomandibular joint
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Subjective Symptoms of TMD
Ear symptoms account for 28 percent of clinical presentations
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Management of TMD
Use a multidisciplinary approach
Goals for management: reduction or elimination of pain and restoration of acceptable mandibular function
Adjustment in diet consistency, education, and alteration of oral parafunctional habits
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Other Treatment for TMD
Stress relief, pain control methods such as counseling, hypnosis, biofeedback, and guided imagery
Pharmacotherapy

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