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Nursing Concepts > Sensory > Flashcards

Sensory Flashcards

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1
Q

Risks of impaired vision and hearing

A

falls
unable to take medication properly
cannot hear proper instructions

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2
Q

myopia

A

nearsightedness

can see near

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3
Q

hyperopia

A

farsightedness

can see far

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4
Q

Nursing considerations: Home safety

A

Eliminate tripping hazards for room safety
lower bed
teach proper use and care of hearing aids
explain tray set up
good lighting

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5
Q

Conjunctivitis

A 
Infections
bacterial, viral, allergen exposure
teach eye from administration
prevent spread of infection
pain relief: heat and cold pack, analgesics
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6
Q

Tx: Bacterial eye diseases

A

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

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7
Q

Tx: Viral eye diseases

A

comfort care, topical corticosteroids
associated with pink eye
red, itchy watery, can affect both eyes, highly contagious

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8
Q

Tx: Allergic eye diseases

A 
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
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9
Q

Detached retina

A

separation of the sensory retina and the underlying pigment epithelium with the fluid accumulation between the 2 layers caused by retina break/tear

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10
Q

Detached retina risk factors

A 
age
myopia
trauma
cataracts surgery 
family hx
teaching: visual activity screening, exam with slit lamp
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11
Q

Detached retina s/s

A

photopsia: light flashes
cobwebs
curtain across field of vision: corresponds with area of detachment

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12
Q

Detached retina Tx

A

restrict head and eye movement
no reading or writing
surgery: post op, bedrest, specific positioning, activity modifications
eye drops: anti-inflammatory, dilating agents, antibiotics

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13
Q

Mydriatic Drops

A

phenylephrine: pupil dilation

can cause systemic anticholinergic affects: dry mouth, constipation

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14
Q

Cycloplegic agents

A

paralyzes ciliary muscles
inhibits accommodation
ex: atropine

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15
Q

Glaucoma

A

eye disease
intraocular pressure is elevated, measured with tonometery
progressive vision loss

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16
Q

Normal IOP

A

10-21mmHg

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17
Q

open angle glaucoma

A

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

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18
Q

Acute angle closure glaucoma

A 
>50mmHg
painful, sudden onset
optic nere atrophy
peripheral visual field loss
2nd leaving cause of blindness, many are unaware
preventable
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19
Q

Miotics, Oral/IV hyperosmotics

A

lower IOP for acute angle closure glaucoma

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20
Q

Cholinergic agents (miotic meds)

A

constrict pupil

improve circulation

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21
Q

adrenergic agonists

A

limits production of aqueous humor and dilates pupil
all end in ‘ine’
teaching: wear sunglasses

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22
Q

betablockers

A

first line therapy
reduces aqueous humor production
teaching: can be absorbed systemically causing bronchoconstricton, bradycardia

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23
Q

Timolol

A

beta blocker
can interfere with the aqueous humor production which will reduce pressure
can have systemic affect

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24
Q

Eye med teaching

A

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

25
Q

Post-op eye teaching

A

avoid activities that increase IOP
lift nothing over 10lb for over 1 week
best vision not expected for 4-6 weeks

26
Q

Gerontologic Considerations

A

tend to special needs of older adults

caution about potential drug interactions that occur with systemic illnesses and their treatments

27
Q

Cataracts

A 
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
28
Q

Cataract causes

A

age, trauma, toxins

29
Q

Cataract RN teaching

A

wear sunglasses and protect eyes during hazardous activities and get annual eye exams done

30
Q

Cataract Tx

A

removal of lens with lens implant

31
Q

Cataract Medications

A

anticholinergics: atropine

- prevents pupil contraction and has a long duration, fast onset

32
Q

Cataract post op care

A

prevent increased IOP, prevent infection, eye drop medication, pain relief, self care, prevent falls/injury, cold compress

33
Q

Otitis Media

A

ear infection

fever, decreased appetite, pulling at ears, sucking aggravates pain

34
Q

Skin health promotion

A

avoid environmental hazards
adequate hygiene and good nutrition
skin self exams
periodic professional exams of hard to see areas

35
Q

Skin Environmental hazards

A 
sun exposure
UVA-tanning
UVB-burning from sun
high altitudes
tanning booths
allergens
radiation
nutrition (vitamin deficiency)
36
Q

Nonmelanoma Skin Cancers

A

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

37
Q

Dysplastic Nevus Syndrome

A

individual is at increased risk of developing melanoma

atypical moles larger than 5mm across

38
Q

Malignant Melanoma

A

majority of skin cancer deaths from environmental and genetic factors

39
Q

Malignant Melanoma Risk factors

A 
red/blonde hair
light colored eyes
fair skin that freckles
chronic sun exposure
family hx
40
Q

ABCDE Rule

A 
Typically for diagnosing melanoma
Asymmetry
Border irregularity
Color change
Diameter >6mm
Evolving appearance
41
Q

Allergic Dermatologic Problems

A

Associated with allergies and hypersensitivity reactions
family Hx and exposure
patch testing
avoid causative agent

42
Q

Diagnostic and surgical therapies for dermatologic issues

A 
skin scraping
curettage
punch biopsy 
cryosurgery
excisions biopsy
incisional biopsy
43
Q

Control of Pruiritus

A 
break the itch/scratch cycle
cool environment
hydration
wet compress
moisturizer
topical drugs
prevent spread
44
Q

Skin viral infections

A

hard to treat, typically a lesion develops

ex: herpes and warts

45
Q

Skin bacterial infections

A

occurs when a balance between host and microorganisms is altered

46
Q

primary skin infection

A

occurs after there is a break in the skin

Staphylococcus is a common bacteria

47
Q

secondary skin infection

A

already damaged skin or as a result to a systemic disease

Staphylococcus is a common bacteria

48
Q

further investigation of mismatched socks

A

color blindness

problems dressing himself

49
Q

importance of seeing a ophthalmologist

A

prevention
eye changes like potential blindness
aging can be a factor in vision change

50
Q

nursing teaching for resistance to see provider

A

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

51
Q

Hypertension, T2 diabetes, hyperlipidemia in response to Glaucoma

A

some medications for these diseases can cause increased IOP
T2 diabetes can caused blindness
Hyperlipidemia: limited blood flow

52
Q

The nurse provides post instructions for an adult patient after cataract surgery. which written statement if provided by the nurse would be most appropriate?

  1. to avoid contamination of the eye use aseptic technique when applying eyedrops
  2. conjunctivitis may result if the eye is contaminated with wet or dirty eye patches
  3. to prevent infection in the eye wash your hands before changing the eye patch of using eyedrops
  4. coughing and bending over can cause increased IOP resulting in retinal damage or displacement of the intraocular lens
A
  1. To prevent infection in the eye wash your hands before changing the eye patch or using eyedrops
53
Q

The nurse instructs a patient with primary open angle glaucoma about the disorder. which statement is most appropriate?

  1. the retinal nerve is damaged by an abnormal increase in the production of aqueous humor
  2. aqueous humor cannot drain from the eye causing pressure damage to the optic nerve
  3. as the lens enlarges with aging it pushes the iris forward covering the outflow channel of they eye
  4. the lens blocks the pupillary opening preventing the flow of aqueous humor into the anterior chamber
A
  1. aqueous humor cannot drain from the eye causing pressure damage to the optic nerve
54
Q

etiology of blurred vision

A

etiology of blurred vision: refractive errors, corneal opacity, cataracts, migraines ora, retinal changes/retinal detachment/macular degeneration

55
Q

etiology of diplopia

A

abnormal extra ocular muscle action related to muscle or cranial nerve pathologic condition

56
Q

etiology of dryness

A

decreases tear formation or changes in tear composition due to aging or systematic diseases

57
Q

etiology of pain

A

superficial corneal erosion or abrasion

can result from contact wear or trauma, conjunctival or foreign body

58
Q

etiology of photophobia

A

inflammation or infection of cornea or anterior uveal track consists of your ciliary and iris body

59
Q

etiology of spots/floaters

A

most common cause from vitreous liquefaction, benign phenomenon, hemorrage into virtuous humor, retinal holes or tears

Nursing Concepts (1 decks)

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