Exam 2 Flashcards
Cognition
Integration of mental processes and intellectual function
Cognition is necessary for…
Reasoning, learning, memory, personality
S/S of Impaired Cognition
Loss of short/long term memory
Disorientation to person, place, time, and/or situation
Impaired reasoning/decision making
Impaired language skills
Emotionally labile
Delusions and hallucinations
Risk Factors for Impaired Cognition
Advanced age Brain trauma, disorder, or disease Toxins Substance use disorder Genetic diseases Depression Fluid/Electrolyte imbalances Opioids, steroids, psychoactive drugs, and general anesthesia
Health History for Impaired Cognition
Onset, signs/symptoms
Comorbidities such as diabetes, cardiovascular disease, hypertension, cancer, post-op, pain, hypothyroidism, end of life
Mini-Mental Status Examination
Delirium
An acute confused state, may become fearful or anxious, often secondary to another problem
May be caused by lack of sensory stimulation, alcohol withdrawal, dehydration, lack of environmental cues
Dementia
A chronic confused state
Onset is subtle
Slowly progressive and organic
Problems with confusion and disorientation, personality changes, impaired judgment
Delayed Intellectual Functions
Have more to do with children
Amnesia
Occurs as a result of a head trauma
Primary Prevention of Impaired Cognition
Avoid substance use
Safety measures such as helmets, prevention of head injuries, monitoring for lead in the water
Stimulate intellect
Nursing Interventions for Impaired Cognition
Focus on safety
Communication aids such as eye glasses, hearing aides
Orientation on a regular basis
Identify and treat causes
Nursing Interventions for the Prevention of Delirium
Provide therapeutic activities
Early mobilization
Control pain
Minimize use of psychoactive drugs
Prevent sleep deprivation
Maintain oxygen levels and fluid/electrolyte balance
Nursing Interventions for Delirium
Identify and treat cause
Safety
Nonessential medications should be stopped (with a Doctor’s order)
Nutrition and fluid should be supervised
Environment should be quiet and calm, contain familiar environmental cues, encourage visits from family and friends
Most Common Types of Dementia
Alzheimer’s Disease
Vascular or Multi-Infarct Dementia
Alzheimer’s Disease
Chronic, progressive, irreversible disease process
Caused by the degeneration of the brain that leads to impaired intellectual function
Plaques in the cortex, neurofibril tangles
Risk Reduction for Alzheimer’s Disease
Engage in activity, change diet, exercise
Diagnostics for Alzheimer’s Disease
CT scan would show smaller brain
Acetylcholine levels
Early Stage of Alzheimer’s Disease
Mild memory lapses, difficulty in work or social activities
Able to compensate for loss and function independently
Further Progression of Alzheimer’s Disease
Obvious memory lapses, confabulating
Problem to recognize familiar faces, word finding problems
May get lost in familiar places
Sundowning, wandering
Speaking skills deteriorate, ADL problems
Disorientation with delusions and hallucinations
Apraxia, Visual Agnosia, Dysgraphia
Apraxia
Inability to carry out sequential movements on command
Visual Agnosia
Inability to recognize objects by sight
Dysgraphia
Difficulty writing
Terminal Stage of Alzheimer’s Disease
Severe mental and physical deterioration
Alzheimer’s Disease Treatments
Goal is to manage cognitive and behavioral symptoms
Aricept and Namenda used to enhance acetylcholine uptake into the brain, which enables patient to maintain memory over time
Ativan to help with anxiety and stress
HALOPERIDOL–antipsychotic
Anti-depressants
Nursing Interventions for Alzheimer’s Disease
Support cognitive function by cuing, guidance, providing a calm predictable environment, clear simple explanations, memory aids
Safety measures such as removing all hazards, putting in hand rails, providing adequate lighting, prohibiting driving, smoking only with supervision, avoiding restraints
Vascular Dementia
Associated with cerebrovascular disease, same risk factors as cardiovascular disease
Abrupt onset, caused by clot in a small vessel, multiple infarcts or strokes
Uneven, stepwise downward decline
Impairments dependent on what area of the brain is affected
Associated with HTN, CVD, hypercholesterolemia, smoking, diabetes
Opthalmologist
Physician that specializes in diagnosing and treating eye diseases and prescribes lenses
Optometrist
Professional in eye assessment, vision and vision problems
Does not treat eye diseases
Optician
Grinds and fits lenses, according to prescriptions
Eye Assessment History
Complaint, pain, discharge, onset/duration/recurrent, precipitating/relieving factors, effects on ADLs, history (diabetes, macular degeneration, surgeries)
Optic Nerve
Cranial Nerve II
Important to realize any damage to this will affect vision
Occipital Lobe
Visual center of the cerebral cortex
Entropion
Eyelid that folds inward
Related to atrophy, congenital conditions, muscle spasms
Need to monitor this, help with any self-care issues, observe for infection/inflammation
Trichiasis
Turning in of the eyelids
Give eyedrops to soothe, monitor for infection/inflammation
Ectropion
Outward position of the eyelid with tearing, corneal dryness, red sclera
Can lead to vision loss, tear loss
Topical meds are prescribed around the clock
Can occur from trauma, laceration/burn, paralysis
Ptosis
Drooping of the eyelid
Related to congenital factors, stroke, neurological trauma
Nystagmus
Involuntary oscillation of eye
Not very common
Caused by drug intoxication, problems with the inner ear
Visual Acuity Tests
Snellen chart
Finger count
Slit Lamp Examination
Magnification that evaluates inflammation and cataracts
Noncontact Tonometry
Looking at intraocular pressure, screening for glaucoma, puff of air in the eye
Goldmann Applanation Tonometry
Cone-shaped device used and placed in the eye to detect pressures
Color Vision Diagnostic Exams
Check for inherited impairments or acquired impairments (use of Digitalis, cataracts)
Amsler Grid
Assesses disturbances in central vision (macular degeneration)
Fluorescein Angiography
Dye is injected to check retinal blood flow
Pre-Procedure: consent, check kidney function, allergies to dye/seafood/iodine, hydration, warn about warmth and metallic taste
Post-Procedure: monitor for N/V, watch for gold hue to the skin, urine may turn orange
Automated Perimetry Test
Identifies flashes of light as they enter the field of vision
What is the correct procedure for performing an ophthalmoscopic exam on the client’s right retina?
From a distance of 8-12 inches and slightly to the side shine a light into the patient’s pupil
Refractory Errors
Problems relating to the bending of light that creates vision in the eye
Signs and Symptoms of Refractory Errors
Diminished or blurred vision
Treatment of Refractory Errors
Corrective lenses
Surgical correction such as LASIK (may cause dry eyes) or Intacs (ring implanted through an incision that reshapes the cornea)
Myopia is the refractive error most commonly corrected by surgery
Myopia
Nearsightedness
Can see near, can’t see far
Hyperopia
Farsightedness
Can see far, can’t see near
Presbyopia
Old-age farsightedness, loss of elasticity of the ciliary muscles
Astigmatism
Unequal curve in the shape of the cornea or lens, leads to problems with focusing
Strabismus
Inability of the eyes to focus in one direction (cross-eyed)
Estropia
One or both eyes turn in the direction of the nose
Extropia
One or both eyes turn away from the nose
Absolute Blindness
No light perception
No usable vision
20/400 or less
Legal Blindness
20/200 with corrective eyewear
Visual field of less than 20 degrees
Cause of Blindness
Birth defects
Acquired problems (diabetic retinopathy, glaucoma, cataracts, infection, tumors, acute trauma)
Signs and Symptoms of Blindness
Diplopia, blurred vision, pain, floaters or flashes of light, light sensitivity, pruritus, halos
Sense of increased orbital pressure, bulging of the eyes, different appearance in eye structure, psychological concerns
Nursing Interventions for Blindness
Assess what they can see, how it affects their ADLs
Make referrals for support groups
Use magnifying systems, seeing-eye animals, make sure glasses are clean
Give verbal clues, walk in front of patient holding their elbow
Knock when entering, introduce yourself
Give them the call light, tell them if you remove something
OD
Right eye
OS
Left eye
OU
Both eyes
Topical Anesthetic Agents for Eyes
Proparacaine, Tetracaine
Give before a diagnostic procedure
Give instructions not to rub their eyes
NOT home medications
Overuse results in softening of the cornea, permanent whitening of the tissue leading to vision loss and scarring
Miotics
Pupil constrictors
Mydriatics
Pupil dilators
Cycloplegic Agents
Paralyze the iris
Contraindications for Eye Medications
Narrow-angles, anti-depressant use
Adverse Effects of Eye Medications
Increased blood pressure, tachycardia, dizziness, ataxia, confusion, disorientation, incoherent speech, hallucinations
Glaucoma Medications
Lower the intraocular pressure, will be taken the rest of their lives
Ocular Irrigants/Lubricants
Used to clean, maintain a normal pH of the eye related to chemical burns, eliminate debris
DO NOT IRRIGATE if the ocular surface is not intact
Nursing Interventions for Eye Medications
Educate the patient
Use hand hygiene before and after any medication administration
Eye dropper should never touch any part of the eye
Recap immediately after each use
Glaucoma
Increased ocular pressure resulting in optic nerve atrophy, causing loss of peripheral vision
Big cause of blindness
Risk Factors for Glaucoma
Family history Migraines Elderly Thin cornea African American Diabetes/Cardiovascular issues Myopia/Eye trauma/Long term steroids
Open Angle Glaucoma
Optic nerve damage
Possible ocular pain, headache
Halos
Usually bilateral
Can be treated with medications
90% of people with glaucoma have this type
Angle Closure Glaucoma
Rapidly progressive visual impairment
Ocular emergency
Pain with nausea/vomiting and bradycardia
Halos
Pupil vertically oval, fixed, semi-dilated
Conjunctival hyperemia and congestion
Treatment for Open Angle Glaucoma
Beta blockers
Miotics
Diamox
Treatment for Angle Closure Glaucoma
ATROPINE AND MYDRIATICS ARE CONTRAINDICATED
Osmotic diuretics
Iridectomy
Patient Education for Glaucoma
Do not drive for 1-2 hours after eye drops
Press lacrimal duct for 1 minute after meds
Keep extra drops at home
Avoid any valsalva maneuvers
Medical supervision on eye medications long term
Cataracts
Noninfectious opacity that blocks light from reaching the retina
Cause is either congenital or acquired (smoking, tanning, trauma, aging, steroid use, heavy drinking)
Signs and Symptoms of Cataracts
Painless
Blurring-loss of sight
Different eyes develop at different rates
Diplopia
Decrease in night vision
Treatment for Cataracts
Surgery is safer with decreased IOP
INTRAOCULAR LENS IMPLANT (IOLI)
Mydriatics, cycloplegics, local anesthetics, diamox, antibiotic drops
IOLI Post-Op
Sleep on unaffected side for 3-4 weeks
Avoid anything that will increase intraocular pressure
Protect the eye by limiting reading/television, wearing glasses, avoiding direct sunlight, no showers/shampoos for 1-14 days
Expect slight redness, mild watering, irritation, slight prosis
Notify with pain, redness, drainage, sudden vision changes
Keratitis
Inflammation of the cornea caused by irritants, allergies, viral/bacterial infections, herpes simplex
Risk is swimming with contacts in
Signs and Symptoms of Keratitis
Blepharospasm, visual disturbances/vision loss, eye pain, itching, bloodshot eyes, photophobia, tearing, edema
Treatment of Keratitis
Keratoplasty (corneal transplant)
Irrigation
Topical antibiotics, avoid steroids
Corneal Injuries
Results from injuries to corneal layers of the eye
Pain with movement of the eye, excessive tearing, pruritus, erythema of the conjunctiva
Splash Corneal Injuries
Flush with normal saline/water
Antibiotic drops or ointment
Ruptured Globe Corneal Injuries
Parenteral antibiotics
Tetanus/analgesics
Penetrating Wounds Corneal Injuries
Do not remove object if present
Enucleation
Removal of the eyeball
Caused by injury, disease, tumor
Pressure dressing post-op
Heals within 2-4 weeks, then shell prosthesis
Lose depth perception with only one eye
Photocoagulation
Laser is directed into a small spot on the retina
Vitrectomy
Intraocular procedure, incision into the eye allows removal of foreign body, sources of opacity
Retinal Detachment
Separation of the retina from the choroid
Complete detachment leads to blindness
Flashes of light, floating spots, gaps in vision, loss of a specific field of vision, no pain
Retinal Detachment Treatment
Scleral Buckle (compresses sclera to indent scleral wall from outside of the eye)
Vitrectomy
Pneumatic retinoplexy (gas bubble injected to help push retina back into place; prone position to keep in place)
Macular Degeneration
Central Vision Loss
Most common cause of central vision loss in people older than 55
Caused by genetics, longterm exposure to UV light, smoking, light colored eyes, nutrition
Usually no treatment, encourage dietary supplements
Signs and Symptoms of Macular Degeneration
Gradual and variable bilateral loss of vision
Distorted vision, straight lines appearing as curvy lines
Problems with color perception
Dry Eye Disorders
Variety of disorders that have the characteristic of decreased tear secretion
Caused by keratoconjunctivitis sclera, Sjogren syndrome
Treated with artificial tears, cyclosporin, plug in the lacrimal duct
Diagnosis of Dry Eye Disorders
Schirmer’s test: using filter paper and placing in the lower eyelid of the eye, evaluate after 5 minutes to see how much fluid is on it
Signs and Symptoms of Dry Eye Disorders
Redness, stringy mucus production, eye fatigue, blurry vision, sandy or gritty sensation
Conjunctivitis
Inflammation of the conjunctiva
Caused by hands touching the eyes, allergies, environmental factors
Signs and Symptoms of Conjunctivitis
Redness, swelling, mucopurulent drainage and crusty discharge, itching, burning
Treatment of Conjunctivitis
Chemical splash
Warm compress
Diabetic Retinopathy
Disorder of the retina, microaneurisms in the eye that lead to hemorrhages and scarring and decreased vision
Signs and Symptoms of Diabetic Retinopathy
Visual problems, progressive loss of vision, floaters
Treatment of Diabetic Retinopathy
Photocoagulation
Vitrectomy
Eye Changes with Aging
Visual acuity declines, loss of night vision, pupils decrease in size
Arcus Senilis
Hazy gray ring around the cornea
Hordeolum (Stye)
Acute infection of the eyelid
Chalazion
Inflammatory cyst
Blepharitis
Inflammation of the eyelid margin
Electronystagmography
Electrical activity of the extraocular muscles
Ear Health
With a URI, blow nose with both nostrils open
Do not swim in stagnant waters
Do not use outdated ear drops
Ear Changes with Aging
Tympanic membrane becomes atrophies and sclerotic
Cochlea cells degenerate
Cerumen becomes harder and drier
50% of elderly have a hearing impairment
Presbycusis
Ototoxic Medications
Aminoglycosides
Aspirin
Loop diuretics
Platinum-based antineoplastic medications
Quinine
Nursing Interventions for Hearing Impairment
Face the patient
Speak clearly in a normal tone
Repeat with different words
Move closer, write things down
Encourage hearing aids
Use gestures, do not appear annoyed
Otalgia
Feeling of fullness and pain in the ear, with or without hearing loss
How to Help a Cerumen Impaction
If TM is intact:
Warmed glycerin, mineral oil, or 1/2 strength hydrogen peroxide before irrigation
Irrigate with warm water on low pressure
Direct visual mechanical removal
Otitis Externa
Swimmer’s ear caused by water in the ear canal, trauma of the skin, systemic problem
Signs and Symptoms of Otitis Externa
Pain with movement of auricle or chewing
Erythema, scaling, pruritus, edema, watery discharge, and crusting of the external ear
Treatment for Otitis Externa
Oral analgesics, corticosteroids
Antibiotic or antifungal ear drops, oral antibiotics
Otitis Media
Inflammation or infection of the middle ear caused by microbes/bacteria in the eustachian tube or a cholesteatoma (tumor of the inner eardrum)
Acute, Serous, or Chronic
Signs and Symptoms of Otitis Media
Tympanic membrane is red and bulgy
Edema decreases hearing
Fullness in the ear, hearing loss
Severe, deep, throbbing pain
Tinnitus, sensitivity to noise
Fever
Treatment of Otitis Media
Antibiotics, analgesics, nasal decongestants
Local heat
Aspiration of fluid from behind the eardrum
Myringotomy
Myringotomy
Surgical incision of the tympanic membrane
Drainage to decrease pressure
Tubes may be inserted for 6 months to several years
Take antibiotics until they are gone
Otosclerosis
Ossification of stapes against the oval window
Soft low tones
Gradual, progressive conductive hearing loss
Tinnitus, dizziness to vertigo
Treatment of Otosclerosis
Stepedectomy: removal of the stapes and replacement with a prosthesis
Air conduction hearing aid
Nursing Interventions for Post-Op Stapedectomy
Reinforce dressing, call if dressing dislodges
Bedrest for 48 hours, HOB elevated to 30 degrees
No bending or lifting, blowing nose, sneezing
No shampoo for a week
Meniere’s Disease
Disorder of inner ear fluid balance
Chronic disease of the inner ear
Episodic vertigo, tinnitus, fluctuating sensorineural hearing loss
Treatment of Meniere’s Disease
Decrease fluid pressure, low-salt diet
Antihistamines, tranquilizers, antiemetics, diuretics
Surgery to relieve pressure (endolymphatic shunt, vestibular nerve section)
Nursing Interventions for Meniere’s Disease
Avoid sudden movements
Take measures to prevent falls
Stop driving
Sit down
Keep medications available
Low salt diets, diuretics
Don’t smoke, avoid aspirin
Labyrinthitis
Inflammation of the labyrinth canals of the inner ear
Most common cause of vertigo
Viral or bacterial
Severe and sudden vertigo, ataxic gait
Hearing loss, tinnitus
Treatment of Labyrinthitis
Antibiotics
Dramamine or meclizine for vertigo
IV fluids if nausea and vomiting are present
