Sensory Alterations Flashcards
Visual fields
Measurement of range of vision (perimetry)
Tonometry
Measures intraocular pressure
Advise not to squint, cough, or hold breath during procedure
Myopia
Nearsightedness
Hyperopia
Farsightedness
Presbyopia
With aging
Commonly occurs after age 35
Agrigmatism
Uneven curvature of cornea causing blurring of Vision
Conjunctivitis
Cause: bacteria, virus, allergies
Nursing considerations (NC) Warm, moist compress, topical antibiotics, hydrocortisone
Sty
Staphylococcal organism
NC- warm compresses, antibiotics, incision and drainage
Chalazion
Inflammatory cyst
Duct obstruction
Incision and drainage
Keratitis
Inflammation of cornea
Virus
Spread of systemic disease
Hot compress, steroids, except with herpes
Uveitis
Inflammation of iris, ciliary body, choroid
Local or systemic infection
Retinopathy of prematurity (ROP)
Assessment: demarcation line forms (separates avascular retina anterior lay with vascularized retina posteriorly)
Ridge forms
Retinal detachment
-can cause blindness in premature infants
High concentration of oxygen cause the premature infants retinal vessels to construct, causing blindness
Sometimes causes when oxygen concentrations are greater then 40% and when used longer than 48-72 hours in infants
Strabismus
Assessment: visible deviation of eye
Diplopia
Child tilts head or squints
Imbalance of extraocular muscles
Plan/implementation
No surgical intervention begins no later than age 6
Occlusion of unaffected eye to strengthen weaker eye
Orthotic exercises
Detached retina
Assessment- Flashes of light Blurred or sooty vision Sensation of particles moving in line of vision A feeling of curtain coming up or down Loss of vision Confusion
Causes:: trauma, aging, diabetes, tumors
Plan: bed rest, do not bend forward, avoid excessive movements.
Affected eye or both eyes must be patched to decrease movement of eye
Avoid strenuous activity for 3 months after surgery( air bubble used to apply pressure to retina)
Cataracts
Objects appear distorted and blurred; decreased color perception.
Annoying glare, double vision
Pupil change from black to gray to milky white
Plan: laser surgery
Complication:: hemorrhage- sudden sharp pain
Increased intraocular pressure
Glaucoma
Cloudy, blurry vision or loss of Visio.
Artificial lights appear to have rainbows or halos around them
Decreased peripheral vision
Pain, headache
Nausea, vomiting
Types:: angle closure- sudden onset, emergency- associated with emotional disturbances, allergy, vasomotor disturbaces
Open-angle (primary glaucoma)
Blockage of aqueous humor flow)- associated with trauma, hemorrhage, iritis, aging
Plan::
Medications:: prostaglandin agonists, adrenergic agonists, beta-adrenergic blockers, cholinergic agonists, carbonic anhdrase inhibitors
To keep angle open
Surgery- laser trabeculoplasty
Avoid use of mydriatics (atropine)- which can close angle
Educate public to 5 danger signs of glaucoma: continues brow arching, halos around light, blurry vision, diminished peripheral vision, headache or eye pain
Hearing loss
Conductive
Conductive loss- assessment
Pain, fever, headache, discharge, altered growth and development, personality changes
Caused:: infection, inflammation, foreign body, trauma, ear wax
Complications- meningitis resulting from initial infection
Diagnostic-
Audiogram (quantitative)-degree
Tuning fork (qualitative)-type
Hearing loss
Perceptive (sensorineural)
Assessment- pain, fever, discharge, altered growth and development, personality changes, depression, suspiciousness, withdraw
Due to disorder of the organ of corti or the auditory nerve
Causes- congenital, infection, trauma, labyrinth dysfunction- menieres disease
Ear drop for adult
Pull upward and backward
Ear drop in child
Pull Downward and backward
Ménière’s disease
Assessment- nausea, vomiting, incapacitating vertigo, tinnitus, feeling of pressure, fullness in ear. Fluctuating, progressive decreased hearing on involved side, nystagmus, headache
Diagnose:: dilation of the membrane of the labyrinth.
Recurrent attacks of vertigo with sensorineural hearing loss
Attacks recur several times a week, periods of remission may last several years.
Diagnostics tests- we ER and rinne test, CT
Drug therapy- antihistamine in acute phase, antiemetics, anti vertigo meds (valium, raglan, tigan) and diuretics.
Low sodium diet, avoid caffine, nicotine, alcohol
Acute otitis media
Infection in middle ear
From pathogenic organisms
Assessment- ringing in ear, fever, headache, head Rolling, crying, ear tugging (kids)
Red bulging tympanic membrane
Plan- administer antibiotics, antihistamines, nasal decongestant
Myringotomy- tympanic meme tame incision to relieve pressure and release purulent fluid
Tympanoplasty- surgical reconstruction of ossicles and tympanic memenrane
Trigeminal neuralgia
Aka tic douloureux
Involves one or more branches of the Fifth cranial nerve causes, infections of sinuses, teeth, mouth, or irritation of nerve pressure.
Assessment:: stabbing are burning facial pain- excruciating, unpredictable, paraxysmal twitching, grimacing of facial muscles.
Nursing consideration- identify and avoid stimuli that exacerbate the attacks administer medications: carbamazepine (tegretol)- anti-seizure meds, and analgesics
Treatment- tegreto, alcohol injection to nerve, resection of the nerve, mucrocascular decompression
Use warm instead of hot wash clothes, chew on Uneffected side
Bell’s palsy (facial paralysis)
Assessment:: Inability to close eye Decreased corneal reflex Increased lacrimation Speech difficulty Loss of tAste Distortion of one side of face Analysis:: peripheral involvement of the seventh cranial nerve Predisposing factors- vascular ischemia, viral disease, edema, inflammatory reactions.
NS::
Protect head from cold or drafts. Administer analgesics.assist with electric stimulation. Tech isometric exercises for a facial muscles (below and suction from a straw).
Massage, warm packs, provide emotional support for altered body image. Prevent corneal abrasion’s( artificial tears)
Treatment- electrical stimulation, analgesics, steroid therapy, antiviral medications, recovery takes 3 to 5 weeks
Acoustic neuroma
Assessment- deafness, partial, initially twitching, grimacing of facial muscle dizziness
Analysis- benign tumor of the eighth cranial nerves
NS-
Pre-and post operative care for posterior fossa craniotomy
Comfort measures/assist with turning of head and neck. Treatment- surgical surgical excision of tumor
Guillain-Barré syndrome
Assessment- 1)parenthesis pain often occurring in glove-and-stocking distribution; pain
2)Motor losses symmetrical, is a beginning and lower extremities, then extend upward to include trunk, upper chimneys, cranial nerves, and vasomotor function; deep tendon reflexes disappear; respiratory muscle compromise.
3) excessive or inadequate autonomic dysfunction
A. Hypotension, tachycardia
B. Vasomotor flushing
C. Paralytic ileus
D. Profuse sweating
4) progression period- average 10 days, with duration of maxim symptoms of 10 days
5) recovery period- several months to a year, 10% residual disability
Guillain-Barré syndrome
Diagnose
1)Progressive inflammatory autoimmune response occurring in peripheral nervous system, Resulting compression of the nerve roots and peripheral nerves, demyelination occurs slows are alters nerve conduction
2) possible causes
A. Infective, viral
B. Autoimmune response
C. May follow immunizations
3) course
A. Acute, rapidly ascending sensory and motor deficit that may stop at any level of the CNS
B) protracted, develops slowly, regresses slowly
C) prolonged course with phases of deterioration and partial remission
Guillain-Barré syndrome plan/implementation
1) intervention is symptomatic
2) steroids in acute phase
3) plasmapheresis, IV immunoglobuns, adrenocorticotropic hormone, corticosteroids
4) mechanical ventilation, elevate head of bed, suctioning
5) prevent hazards of immobility
6) maintain adequate nutrition, hydration
7) physical therapy, range of motion
8) pain reducing measures
9) eye care
10) ) Prevention of complications– UTI, aspiration, constipation, urinary retention
Can be complete recovery, but depends on how good nursing care was
Meningitis
Assessment
1) headache, fever, photophobia
2) signs of meningeal irritation
A. Nuchal rigidity-stiff neck
B. Kernigs sign- when hip is flexed to 90 degrees, complete extension of the knee is restricted and painful
C. Brudzinski’s sign- attempts to flex the neck will produce flexion at knee and thigh
D. Opisthotonic position- extensor rigidity with legs hyperextended and forming an arc with trunk
3) chances in loc
4) seizures
5) symptoms in infants: refuse feedings,vomiting, diarrhea, bulging fontanalles, vacant stare, high-pitched cry
Meningitis implementation
IV antibiotic therapy- penicillin, cephalosporin, vancomycin
Monitor ABG, arterial pressures, body weight, serum electrolytes, urine volume, specific gravity, osmolality (SIADH can occur)
Droplet precautions
Migraine headache meds
Beta blockers, triptan preparations- activate serotonin receptors
Acetaminophen, NSAIDs,topiramate (topamax), ergotamines- dihydroergotamine (DHE), take at start of headache
Migraine assessments–
Prodromal (indicating onset)- depression, irritability, feeling cold, food cravings, anorexia, change in activity level, increased urination
Aura- light flashes and bright spots, numbness and tingling (lips, face, hands), mild confusion, drowsiness, dizziness, diploplia (double vision)
Huntingtons disease
Assessment- depression and temper outburst
Choreform movements (constant movements)
-slight to severe restlessness
-facial grimacing
-arm movements
Personality changes
Diagnose:: rare, familial progressive, degenerative disease that is passed from generation to generation (dominant inheritance- only one allele is required)
Plan- drug therapy to intend to reduce movement and subdue behavior changes (Librium, haldol, Thorazine)
Supportive, genetic counseling
