chapter 52: nursing care of patients with sensory disorders - vision and hearing Flashcards
conjunctivitis
- inflammation of the conjunctiva
blepharitis
inflammation of the eyelid margins
keratoconjunctivitis sicca
dry eye disease
hordeolum
- staphylococcal abscess in sebaceous gland
chalazion
- abscess in tarsal (meibomian) glands
keratitis
inflammation of the cornea
nursing diagnoses for eye infections and inflammation
- acute pain
- risk for injury
- deficient knowledge
refractive disorders
emmetropia
hyperopia
myopia
astigmatism
presbyopia
emmetropia
normal vision
hyperopia
farsightedness
myopia
nearsightedness
astigmatism
unequal curvatures in cornea
presbyopia
loss of lens elasticity
blindness
- obstacle to rays of light
- disease of optic nerve or tract of brain connected w/ vision
nursing diagnoses for refractive disorders
- self care deficit (bathing, dressing, feeding)
- risk for injury
- deficient knowledge
diabetic retinopathy
- vascular changes in retinal blood vessels
types of diabetic retinopathy
- microaneurysms
- preproliferative retinopathy
therapeutic interventions of diabetic retinopathy
- laser photocoagulation
- vitrectomy
nursing diagnosis for diabetic retinopathy
- ineffective health management
retinal detachment
separation of retina from choroid layer of eye
signs and symptoms of retinal detachment
- sudden change in vision
- flashing lights, floaters
- looking through a veil
- curtain being lowered over vision
- no pain
therapeutic interventions for retinal detachment
- laser surgery
- cryoplexy
- pneumatic retinopexy
- scleral buckling
glaucoma
- group of diseases
- most have elevated pressure within eye
- damage is silent, progressive, irreversible
- optic nerve is damaged
- can lead to blindness
- lifelong treatment needed
- no cure
primary open angle glaucoma (POAG)
- degeneration of drainage system blocks aqueous fluid
- increased intraocular pressure >20 mms of mercury
- gradual and painless
signs and symptoms of glaucoma
- mild eye aching
- headache
- halos around lights
- frequent visual changes
angle closre glaucoma (ACG)
- narrowed angle blocks aqueous fluid
- medical emergency
- increased intraocular pressure may be >50 mm of mercury
signs and symptoms of angle closure glaucoma
- severe eye pain
0 blurred vision - halos around light
- eye redness, cloudy conea
- nausea and vomiting
medications for glaucoma
- miotics
- agents to decrease production of aqueous fluid
miotics
- physostigmine (isopto eserine)
- pilocarpine (pilocar)
agents to decrease production of aqueous fluid
- betaxolol (betoptic)
- timolol (timoptic)
***contraindicated in ACG
- mydriatics
- dilate pupil, which leads to increased ocular pressure
***medications contraindicated in ACG (can cause blindness)
- atropine
- diphenhydramine
- hydroxyzine
surgery for glaucoma
- laser trabeculoplasty
- trabeculectomy
- glaucoma drainage devices (shunts)
- laser peripheral iridotomy
- surgical refectory
nursing diagnoses for glaucoma
- acute pain
- self care deficit (bathing, dressing, feeding, toileting)
- risk for injury
- deficient knowledge
cataracts
- opacity in eye lens
- loss of visual acuity
- difficulty with night vision
- difficulty reading fine print
- sensitivity to glare
- increase in nearsightedness
surgica management for cataracts
- no stitch surgical removal of lens
- laser removal
- lens implant
nursing diagnoses for eye surgery
- risk for injury
- deficient knowledge
- anxiety
macular degeneration
- deterioration in macula: wet or dry
- common over age 64 yeras
- slow, progressive loss of central/near vision
- daily screening: Amsler grid
therapeutic interventions for dry macular degeneration
none
therapeutic interventions for wet macular degeneration
- antiangiogenesis medication
- ranibizumab (lucentis) —> monoclonal antibodies
- aflibercept (eylea)
nursing diagnoses for macular degeneration
- self care deficit (bathing, dressing, feeding)
- risk for injury
- deficient knowledge
eye trauma: emergencies
- foreign bodies
- burns
- abrasions
- lacerations
- penetrating wounds
therapeutic measures and nursing care for foreign object in eye
- irrigate w/ normal salie
therapeutic measures and nursing care for chemical eye trauma
15-20 minute irrigation
therapeutic measures and nursing care for penetrating object in the eye
do not remove
therapeutic measures and nursing care
- antibiotic ointment
- surgery
0 enucleation
enucleation
entire eyeball removal
hearing loss
- conductive hearing loss
- sensorineural hearing los
conductive hearing loss
interference w/ sound conduction to external auditory canal, eardrum, middle ear
sensorineural hearing loss
involves hair cells and nerve endings
presbycusis
normal part of aging process
- degeneration of organ of corti
- inability to decipher high frequency sounds
therapeutic measures for hearing loss
- hearing aid(not usually covered by insurance)
- cochlear implants
nursing diagnosis for hearing loss
impaired verbal communication
external ear infections
external otitis
ear canal furuncle
otomycosis
perichondritis
masses
trauma
impacted cerumen
- normally ear self cleaning
- older adults at risk
- hearing loss
- feeling of fullness
therapeutic interventions for external ear
- topical antibiotics
- irrigations
- analgesics
- incision and drainage
nursing diagnoses for external ear
- acute pain
- risk for injury
- deficient knowledge
otitis media (middle ear infection)
- fever, earache, and feeling of fullness
- antibiotics
- myringotomy
otosclerosis
- new bone along stapes
- conductive hearing loss
- more common in women than in men
- both ears
- hereditary disease
- no cure
therapeutic interventions for otosclerosis
- ossiculoplasty
- stapedectomy
nursing care for otosclerosis
- operative ear is upward when lying
- insert earplug to protect
- promote safety
nursing care for otosclerosis: teach not to
- cough, sneeze
- blow nose
- vomit
- fly
- lift heavy objects
- shower
ear trauma
tympanic membrane perforation
middle ear ossicle fracture
nursing diagnoses for middle ear, tympanic membrane and mastoid disorders
- risk for infection
- acute pain
- deficient knowledge
labyrinthitis
- inflammation or infection of inner ear
- vertigo, tinnitus, sensorineural hearing loss
- antibiotics
- sedation
- besdrest
neoplastic disorders: acoustic neuroma
- tumor of the 8th cranial nerve
- benign or malignant
meniere’s disease
- balance disorder due to fluid disturbance
- triad of symptoms
- episodic bouts 2-3 times of a year
acute treatment for Meniere’s Disease
- tranquilizers
- vagal blockers
- bed rest
prophylactic treatment for Meniere’s Disease
- salt restricted diet
- diuretics
- antihistamines
- vasodilators
- avoid alcohol, caffeine, tobacco
nursing diagnoses for inner ear disorders
- anxiety
- risk for injury
- imbalanced nutrition: less than body requirements
