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NCLEX prep > Sensory > Flashcards

Sensory Flashcards

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1
Q

Normal Intraoccular Pressure

A

10-21

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2
Q

Myopia

A

nearsightedness. refractive ability of eye is too strog

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3
Q

Hyperopia

A

farsightedness. refractive ability of the eye is too weak

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4
Q

Presbyopia

A

loss of lens elasticity due to aging. have trouble focusing eye

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5
Q

Astigmatism

A

irregular curve of the cornea.

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6
Q

Legal Blindness Patho

A

visual acuity WITH corrective lenses in better eye is 20/200 or less. visual field is no greater than 20 degrees

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7
Q

Legal Blindness Care

A

use normal tone when speaking. alert client when approaching. orient client to environment using specific focal point in the room. ensure the pathway is clear. allow pt to touch objects in the room. use clock placement for food. promote independence. provide radios/tv/clocks that give time orally or use braille watch. allow pt to grasp RN’s arm close to body for direction of movement. instruct pt to remain 1 step behind the nurse when ambulating. instruct on use of cane (white with red tip).

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8
Q

Cataracts Patho

A

opacity of lens that distorts image and can lead to blindness.

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9
Q

Cataracts S/S

A

blurred and cloudy vision. starbursts around lights. decreased color perception. diplopia. reduced vision acuity. loss of vision.

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10
Q

Cataracts Care

A

surgery (1 eye at a time). use tylenol for pain

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11
Q

Cataracts Pre Op Care

A

teach handwashing. prevent decreased IOP (bending, coughing, straining, rubbing of eye). teach about need for eye drops for 2-4 weeks. give eye meds (mydriatics and cycloplegic)

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12
Q

Cataracts Post Op Care

A

HOB 30-45. turn to back or nonoperative side. use eye patch. position pt belongings to nonoperative side. use side rails for safety. assist with ambulation. no eye straining. no rubbing or putting pressure on eye. no rapid movements. no lifting heavier than 5 lbs. prevent constipation (stool softeners). wipe excess drainage or tearing with sterile wet cotton ball from inner to out canthus. eye shield at bed. wear glasses at all time if lens is NOT implanted. eye itching and mild discomfort is NORMAL days after. decrease in vision, severe eye pain, increase in redness, increase in eye discharge = REPORT TO MD

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13
Q

Glaucoma Patho

A

ocular disease resulting in increased IOP. leads to damaged optic nerve and can result in blindess.

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14
Q

Types of Glaucoma

A

OPEN: aqueous humor can NOT leave eye resulting in increased IOP. no pain.
CLOSED: sudden onset, n/v and is an emergency

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15
Q

Glaucoma S/S

A

diminished accommodation. increased IOP.
OPEN: tunnel vision. painless. gradual vision changes.
CLOSED: blurred vision. halos around lights. ocular erythema.

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16
Q

Glaucoma Care

A

NO anticholinergics. report eye pain, halos, and changes in vision. surgery can be performed (trabeculectomy). watch for hemorrhage and chorodial detachment.

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17
Q

Glaucoma Meds

A

OPHTHALMIC MEDS: miotics like pilocarpine (meds that constrict pupils). carbonic anhydrase inhibitors (decrease production of aqueous humor). beta blockers end in -olol (decrease aqueous humor and IOP). mannitol (decrease IOP).

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18
Q

Retinal Detachment S/S

A

flashes of light. floaters. blacks spots. blurred vision. curtain drawn over eyes. painless loss of central/peripheral vision

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19
Q

Retinal Detachment Care

A

bed rest. cover both eyes with patched to prevent detachment. speak to client before approaching. position pt head as prescribed. protect from injury. no jerky head movements. minimize eye stress. prepare for surgery.

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20
Q

Retinal Detachment Post Op

A

eye patch. check for hemorrhage. prevent n/v and check for restlessness (can cause hemorrhage). report sudden sharp eye pain. avoid coughing. bed rest. assist w/ ADLs. no sudden head movement. do NOT do anything to increase IOP. limit reading for 3-5 weeks. no squinting, straining, constipation, heavy lifting, bending over. dark glasses in day. eye patch at night.

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21
Q

Macular Degeneration Patho

A

loss of central vision

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22
Q

Macular Degeneration S/S

A

decline central vision.blurred vision. distortion

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23
Q

Macular Degeneration Care

A

referrals. laser therapy. photodynamic therapy. goal is to maximize remaining vision.

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24
Q

Instilling Eye Drops

A
  1. hand hygiene
  2. put on gloves
  3. assess eye for redness and drainage
  4. clean with wash cloth and warm water (in to out)
  5. change gloves
  6. verify drop to what eye and check pt ID
  7. waste first drop
  8. pt head back, pull down lower lid, and drop in conjuctival sac
  9. close eye gently
  10. wait 3-5 mins before instilling another

*punctual occulsion with glaucoma (hold inner corner of the eye)

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25
Q

Miosis

A

constricting pupils

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26
Q

Mydriasis

A

dilating pupils

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27
Q

Ocular Melanoma Patho

A

malignant eye tumor

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28
Q

Ocular Melanoma S/S

A

blurred vision. increased IOP. change in iris color.

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29
Q

Ocular Melanoma Care

A

surgery: enucleation

radiation

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30
Q

Enucleation

A

removal of entire eye

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31
Q

Exenteration

A

removal of eye and surrounding bone and tissue

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32
Q

Enucleation and Exenteration Pre Op Care

A

emotional support. encourage client to verbalize feelings. encourage family support.

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33
Q

Enucleation and Exenteration Post Op Care

A

VS. check pressure patch or dressing. report changes in VS or presence of bright red drainage

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34
Q

Hyphema Patho

A

blood in anterior chamber as a result of injury. resolves w/in 5-7 days

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35
Q

Hyphema Care

A

rest in semi fowlers. no suddent eye movements for 3-5 days. cycloplegic eye drops (relax eye). eye shields or eye patch. restrict reading. limit tv.

36
Q

Contusion Patho

A

bleeding into soft tissue as a result of an injury

37
Q

Contusion S/S

A

black eye. pain. photophobia. edema. diplopia

38
Q

Contusion Care

A

ice on the eye asap. eye exam

39
Q

Care for Pt with Foreign Body in Eye

A

have pt look up, expose lower lid, wet cotton tipped applicator with sterile NS, gently twist swab over particle and remove it. if particle can NOT be seen have pt look down, place cotton applicator horizontally on the outer surface of upper eye lid, grasp lashes, and pull upper lid outward and over cotton swab

40
Q

Care for Pt with Penetrating Object

A

NEVER REMOVE THE OBJECT! must be removed by MD. cover eye with cup and tape in place. do NOT allow pt to bend over or lie flat (object may move). do NOT place pressure on eye. NO MRI

41
Q

Care for Pt with Chemical Burn in Eye

A

TREAT ASAP! FLUSH EYES WITH TAP WATER AT LEASE 15-20 MINS AT SCENE AND THEN GO TO ER. if possible obtain sample of chemical.
Priority RN Action: assess client and vision.ask about allergies and type of chemical involved. check pH of eye by placing pH tape on cul-de-sac of eye. irrigate with NS. document.

42
Q

Irrigating the Eye

A

with sterile NS or ocular irrigating solution. position pt supine with head slightly toward affected eye. direct solution across cornea and toward lateral canthus. irrigate for 10 mins (or 1 L). recheck eye pH (should be 6-7)

43
Q

Care for Eye Donor

A

option of eye donation is discussed with family. HOB 30 degrees. instill antibiotic eye drops. close eyes and apply small ice pack.

44
Q

Pre Op Care for Pt Receiving Cornea

A

alleviate anxiety. asses pt eye for infection. report redness, watery/purulent drainage, or edema to MD. abx drops. give fluids and meds IV.

45
Q

Post Op Care for Pt Receiving Cornea

A

patch/shield left on for 1 day. do NOT remove or change dressing w/o HCP orders. check VS and LOC. assess dressing. position pt with head elevated and on nonoperative side to reduce IOP. check for complications (bleeding, wound leaks, infection, rejection). eye shield at night for 1 months and around pets and small kids. no rubbing of eye. avoid activities that increase IOP.

46
Q

Cornea Rejection

A

occurs at any time. s/s: redness, swelling, decreased vision, pain (RSVP). treat w/ topical corticosteroids.

47
Q

Hearing Loss S/S

A

asking others to repeat statements. straining to hear. turning head or leaning forward. shouting in conversation. ringing in ears. failing to respond when not looking in the direction of the sound. answering questions incorrectly. raising volume of tv. avoiding large groups. withdrawing from social interactions.

48
Q

Facilitating Communication

A

write things down if the pt can read and write. well lit room. get attention before speaking. face client. remove distracting noises. move close to pt and speak slow and clear. keep hands and objects away from mouth. talk with normal volume and lower pitch (high pitch cant be heard). repeat and rephrase. read lips. encourage use of glasses. sign language. telephone amplifiers. flashing lights for the phone and doorbell. disability dogs.

49
Q

Conductive Hearing Loss Patho

A

sound waves are blocked to inner ear fiber. can be corrected

50
Q

Sensorineural Hearing Loss Patho

A

inner ear or sensory fiber damage. permanent.

51
Q

Central Hearing Loss Patho

A

inability to interpret sound and speech due to problem in the brain

52
Q

Cochlear Implant

A

for sensorineural hearing loss. small computer converts sound waves into impulses. electrodes are placed by the internal ear with computer attach to external ear.

53
Q

Hearing Aids

A

for conductive hearing loss. costly and not covered by insurance

54
Q

Hearing Aid Education

A

use slowly to adjust. adjust volume to minimal hearing level to prevent squealing. concentrate on sounds heard and filter out background noise. clean ear mold and cannula. keep dry. turn off before removing. remove battery when not in use. keep extra batteries on hand. keep in safe place. prevent hair products and oils from coming into contact.

55
Q

Presbycusis Patho

A

sensorineural hearing loss associated with aging.

56
Q

Presbycusis S/S

A

gradual hearing loss. bilateral. states they do not have a hearing issue but does not understand what people are saying to them.
*DO NOT USE Q-TIP IN EAR CANAL BECAUSE IT CAN LEAD TO TRAUMA TO CANAL AND PUNCTURE TYMPANIC MEMBRANE**

57
Q

External Otitis Patho

Swimmer’s Ear

A

inflammatory or allergic response involving external auditory canal or auricles. occurs in hot humid environments.

58
Q

External Otitis S/S

Swimmer’s Ear

A

pain. itching. plugged feeling in ear. redness. edema. exudate. hearing loss.

59
Q

External Otitis Care

Swimmer’s Ear

A

apply heat for 20 mins TID. encourage rest. atibiotics. corticosteroids. pain meds. keep ear clean and dry. use ear plugs for swimming. do NOT use hair product or head phones

60
Q

Otitis Media Patho

A

inflammatory disorder caused by infection in middle ear. commonly associated with respiratory infection or flu

61
Q

Otitis Media S/S

A

acute onset of ear pain. crying. irritable. loss of appetite. rolling head sis to side. pulling on ears. purulent drainage. red opaque bulging immobile tympanic membrane. hearing loss.

62
Q

Otitis Media Care

A

increase fluids. avoid chewing. heat/cold therapy. lay down on affected ear. pain and fever meds. antibiotics. myringotomy or tynpanoplasty tubes. chronic otitis media can lead to mastoiditis and mastoidectomy.

63
Q

Myringotomy

A

surgical incision into tympanic membrane to drain fluid

64
Q

Myringotomy Post Op Care

A

keep ear dry. wear ear plugs while in water. no submerging in water. pain and fever meds. do not blow nose for 7-10 days and if you have to blow 1 side at a time. no strenuous activity. no rapid head movements, bouncing, or bending. no drinking through straw. no straining with bowel movement. no flying on plane. no sick people. no getting head wet for 1 wk. keep ball of cotton with petroleum jelly in ear and change daily. report increased ear drainage.

65
Q

Mastoiditis Patho

A

infection of mastoid bone caused by untreated chronic otitis media.

66
Q

Mastoiditis S/S

A

swelling behind ear. pain with head movement. cellulitis on skin or scalp over mastoid process. red dull thick immobile typanic membrane. tender enlarged lymph node. low grade fever.

67
Q

Mastoiditis Care

A

surgical removal of infection. then reconstruction of ossicles and tympanic membrane to restore hearing.

68
Q

Mastoiditis Post Op Care

A

check for meningitis (stiff neck and vomiting). change wound dressing 24 hrs post op. check for infection. position pt flat NOT on operative side. bed rest for 24 hrs. assist with getting out of bed.

69
Q

Otosclerosis Patho

A

bony growth of tissue surrounding ossicles. bilateral.

70
Q

Otosclerosis S/S

A

slow progressive conductive hearing loss. bilateral hearing loss. ringing or roaring constant tinnitus. loud sounds hear when chewing. Schwartze’s sign (pink discoloration). negative rinne test.

71
Q

Otosclerosis Care

A

surgery to remove bony growth. stapedectomy with prosthesis (fenestration)

72
Q

Fenestration

A

removal of stapes in middle ear

73
Q

Fenestration Pre Op Care

A

prevent ear infections. avoid excessive nose blowing

74
Q

Fenestration Post Op Care

A

hearing worse at 1st because of swelling and there may not be improvement for up to 6 wks. gelfoam ear packing is used to decrease bleeding. ambulate 1-2 days post op. antibiotics. pain meds. check facial nerve damage and changes in taste. avoid people with respiratory infections. avoid showering. avoid getting hair or wound wet. avoid rapid changes in pressure (quick head movement, sneezing, nose blowing, straining, changes in altitude).

75
Q

Meniere’s Syndrome Patho

A

tinnitus, hearing loss, and vertigo all at once due to build up of endolymphatic fluid in ear

76
Q

Meniere’s Syndrome S/S

A

fullness in ear. tinnitus. hearing loss. vertigo. n/v. nystagmus. headaches.

77
Q

Meniere’s Syndrome Care

A

SAFTEY IS PRIORITY!! bed rest. quiet environment. assist with walking. move head slowing to prevent worsening of vertigo. sodium and fluid restrictions.no smoking. avoid tv with flickering lights.

78
Q

Meniere’s Syndrome Meds

A

nicotinic acid. antihistamines. antiemetics. tranquilizers and sedative. diuretic.

79
Q

Meniere’s Syndrome Surgery

A

drain fluids and inset shunt. resection of vestibular nerve

80
Q

Meniere’s Syndrome Post Op

A

check dressing on ear. speak to pt on unaffected ear. neuro checks. SAFETY!! assis with ambulating. encourage bedside commode. give antivertiginous meds and antiemetics

81
Q

Acoustic Neuroma Patho

A

benign tumor of vestibular or acoustic nerve

82
Q

Acoustic Neuroma S/S

A

hearing damage. decreased facial movement and sensation. tinnitus.

83
Q

Acoustic Neuroma Care

A

surgical removal via craniotomy. think of craniotomy concerns for post op care.

84
Q

Ear Trauma

A

can be caused by foreign object, blowing nose too hard, rapid changes in pressure, basal skull injury. tympanic membrane can heal within 24 hrs. may need surgery

85
Q

Cerumen (ear wax) Removal

A

done by irrigation. irrigation is contraindicated in pts with tympanic membrane perforation or otitis media. glycerin hydrogen peroxide, or mineral oil is placed in ear at bed time to soften wax. MAXIMUM AMOUNT OF SOLUTION USED FOR IRRIGATION IS 50-70 ML! never use ear candles

86
Q

Foreign Object Removal From Ear

A

vegetables expand with hydration so irrigate with caution. insects are killed before removal unless they can be coaxed out by a flashlight or noise. lidocaine is used for pain. mineral oil or diluted alcohol is instilled to suffocate insect then is removed with foreceps. use small ear forceps to remove object avoid pushing object father into canal.

87
Q

Instilling Ear Drops

A

gather solution
check labels for dose and time
wear glove to remove packing
wash hands
otoscopic exam (check ear before inserting. pt move head during exam)
irrigate ear if ear drum is intact
warm eardrops in bowl of warm water for 5 mins
til head to opposite side and place drops in ear
move head back and forth
insert cotton ball
wash hands

*Children < 3 is down and back

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