Sensory Flashcards
Risks of impaired vision and hearing
falls
unable to take medication properly
cannot hear proper instructions
myopia
nearsightedness
can see near
hyperopia
farsightedness
can see far
Nursing considerations: Home safety
Eliminate tripping hazards for room safety
lower bed
teach proper use and care of hearing aids
explain tray set up
good lighting
Conjunctivitis
Infections bacterial, viral, allergen exposure teach eye from administration prevent spread of infection pain relief: heat and cold pack, analgesics
Tx: Bacterial eye diseases
antibiotic ointment
sticky yellow/green discard, eyelids might be stuck together upon waking, can effect both eyes, direct contact
hand hygiene
avoid contact with other infected people
Important teaching: discard 1st bead of ointment after each use
Tx: Viral eye diseases
comfort care, topical corticosteroids
associated with pink eye
red, itchy watery, can affect both eyes, highly contagious
Tx: Allergic eye diseases
artificial tears (may need teaching) avoid allergens accompanied with nasal congestion, sneezing, eyelid swelling, sensitivity to light, both eyes are affected, not contagious antihistamines corticosteroids
Detached retina
separation of the sensory retina and the underlying pigment epithelium with the fluid accumulation between the 2 layers caused by retina break/tear
Detached retina risk factors
age myopia trauma cataracts surgery family hx teaching: visual activity screening, exam with slit lamp
Detached retina s/s
photopsia: light flashes
cobwebs
curtain across field of vision: corresponds with area of detachment
Detached retina Tx
restrict head and eye movement
no reading or writing
surgery: post op, bedrest, specific positioning, activity modifications
eye drops: anti-inflammatory, dilating agents, antibiotics
Mydriatic Drops
phenylephrine: pupil dilation
can cause systemic anticholinergic affects: dry mouth, constipation
Cycloplegic agents
paralyzes ciliary muscles
inhibits accommodation
ex: atropine
Glaucoma
eye disease
intraocular pressure is elevated, measured with tonometery
progressive vision loss
Normal IOP
10-21mmHg
open angle glaucoma
22-32mmHg
painless, most common, no symptoms outflow of aqueous humor is decreased in trabecular meshwork
gradual loss of peripheral vision, develops slowly
blindless if untreated
decreased visual acuity
3 P’s: preventable, painless, permanent
Acute angle closure glaucoma
>50mmHg painful, sudden onset optic nere atrophy peripheral visual field loss 2nd leaving cause of blindness, many are unaware preventable
Miotics, Oral/IV hyperosmotics
lower IOP for acute angle closure glaucoma
Cholinergic agents (miotic meds)
constrict pupil
improve circulation
adrenergic agonists
limits production of aqueous humor and dilates pupil
all end in ‘ine’
teaching: wear sunglasses
betablockers
first line therapy
reduces aqueous humor production
teaching: can be absorbed systemically causing bronchoconstricton, bradycardia
Timolol
beta blocker
can interfere with the aqueous humor production which will reduce pressure
can have systemic affect
Eye med teaching
use as prescribed
wait 5-10 min between eye drop meds
don’t tough tip of application bottle to eye
wash hands before/after med admin
put pressure on corner of eye after eye drop instiled
Post-op eye teaching
avoid activities that increase IOP
lift nothing over 10lb for over 1 week
best vision not expected for 4-6 weeks
Gerontologic Considerations
tend to special needs of older adults
caution about potential drug interactions that occur with systemic illnesses and their treatments
Cataracts
opacity in lens that impair vision glare due to light scatter on lens occurs gradually, lower night vision no pain decreases V/A, blurred vision, double vision, absent red reflex, trouble seeing colors
Cataract causes
age, trauma, toxins
Cataract RN teaching
wear sunglasses and protect eyes during hazardous activities and get annual eye exams done
Cataract Tx
removal of lens with lens implant
Cataract Medications
anticholinergics: atropine
- prevents pupil contraction and has a long duration, fast onset
Cataract post op care
prevent increased IOP, prevent infection, eye drop medication, pain relief, self care, prevent falls/injury, cold compress
Otitis Media
ear infection
fever, decreased appetite, pulling at ears, sucking aggravates pain
Skin health promotion
avoid environmental hazards
adequate hygiene and good nutrition
skin self exams
periodic professional exams of hard to see areas
Skin Environmental hazards
sun exposure UVA-tanning UVB-burning from sun high altitudes tanning booths allergens radiation nutrition (vitamin deficiency)
Nonmelanoma Skin Cancers
actinic keratosis: premalignant skin lesions
Basal cell carcinoma: most common type of skin cancer, less deadly
Squamos cell carcinoma: potential to metastasize, smoking, immunosuppression leads to increase in incidents
Dysplastic Nevus Syndrome
individual is at increased risk of developing melanoma
atypical moles larger than 5mm across
Malignant Melanoma
majority of skin cancer deaths from environmental and genetic factors
Malignant Melanoma Risk factors
red/blonde hair light colored eyes fair skin that freckles chronic sun exposure family hx
ABCDE Rule
Typically for diagnosing melanoma Asymmetry Border irregularity Color change Diameter >6mm Evolving appearance
Allergic Dermatologic Problems
Associated with allergies and hypersensitivity reactions
family Hx and exposure
patch testing
avoid causative agent
Diagnostic and surgical therapies for dermatologic issues
skin scraping curettage punch biopsy cryosurgery excisions biopsy incisional biopsy
Control of Pruiritus
break the itch/scratch cycle cool environment hydration wet compress moisturizer topical drugs prevent spread
Skin viral infections
hard to treat, typically a lesion develops
ex: herpes and warts
Skin bacterial infections
occurs when a balance between host and microorganisms is altered
primary skin infection
occurs after there is a break in the skin
Staphylococcus is a common bacteria
secondary skin infection
already damaged skin or as a result to a systemic disease
Staphylococcus is a common bacteria
further investigation of mismatched socks
color blindness
problems dressing himself
importance of seeing a ophthalmologist
prevention
eye changes like potential blindness
aging can be a factor in vision change
nursing teaching for resistance to see provider
eye damage can impact daily activities
Sx can worsen
use active listening skills, why would someone be fearful
-financial burden
-bad experience
gather more information about symptoms
offer to make an appt for her and coordinate care
Hypertension, T2 diabetes, hyperlipidemia in response to Glaucoma
some medications for these diseases can cause increased IOP
T2 diabetes can caused blindness
Hyperlipidemia: limited blood flow
The nurse provides post instructions for an adult patient after cataract surgery. which written statement if provided by the nurse would be most appropriate?
- to avoid contamination of the eye use aseptic technique when applying eyedrops
- conjunctivitis may result if the eye is contaminated with wet or dirty eye patches
- to prevent infection in the eye wash your hands before changing the eye patch of using eyedrops
- coughing and bending over can cause increased IOP resulting in retinal damage or displacement of the intraocular lens
- To prevent infection in the eye wash your hands before changing the eye patch or using eyedrops
The nurse instructs a patient with primary open angle glaucoma about the disorder. which statement is most appropriate?
- the retinal nerve is damaged by an abnormal increase in the production of aqueous humor
- aqueous humor cannot drain from the eye causing pressure damage to the optic nerve
- as the lens enlarges with aging it pushes the iris forward covering the outflow channel of they eye
- the lens blocks the pupillary opening preventing the flow of aqueous humor into the anterior chamber
- aqueous humor cannot drain from the eye causing pressure damage to the optic nerve
etiology of blurred vision
etiology of blurred vision: refractive errors, corneal opacity, cataracts, migraines ora, retinal changes/retinal detachment/macular degeneration
etiology of diplopia
abnormal extra ocular muscle action related to muscle or cranial nerve pathologic condition
etiology of dryness
decreases tear formation or changes in tear composition due to aging or systematic diseases
etiology of pain
superficial corneal erosion or abrasion
can result from contact wear or trauma, conjunctival or foreign body
etiology of photophobia
inflammation or infection of cornea or anterior uveal track consists of your ciliary and iris body
etiology of spots/floaters
most common cause from vitreous liquefaction, benign phenomenon, hemorrage into virtuous humor, retinal holes or tears
