Sensory Exam Flashcards
Most common changes in the aging eye are those in the ___.
what happens?
lens partially or totally opaque loses elasticity peripheral vision losses depth perception decreases
what is Snellen’s chart
Used to test visual acuity
what does 20/20 vision mean
the patient can read at 20 feet what the normal eye can read at 20 feet
visual impairment starts at what number/
20/70
how to test intraocular pressure
puff of air
what is the whisper voice test
plug one ear, whisper in the other
what is the Rinne test
differentiates between conductive and sensorineural hearing loss. Place an activated tuning fork to mastoid process and in front of the ear
What is the Weber test
place tuning fork on top of head and see if they can hear the same from both ears
What is Romber’s test
have the patient stand with eyes open and then closed. Observe for swaying. Some swaying is ok!
what is Audiometric testing
When the patient is placed in a sound proof room with head phones and raises hand when sounds are heard
What is tympanometry
Used to measure compliance of the tympanic membrane and determine problems of the middle ear. It determines the amount of pressure in the middle ear.
What is a caloric test
Warm or cold water is irrigated into the ears.
Nystagmus is a normal response. If no nystagmus, it is indicative of Menier’s disease
S/S of any eye disorder
visual disturbances, pain, redness, secretions, itchiness, sensation of pressure in the eyes
possible Nursing Dx for eye disorders
acute pain
anxiety r/t visual-sensory deficit
deficient knowledge
define conjunctivitis
inflammation of conjunctiva due to a virus or bacteria
contagious (whether bacterial or viral)
aka pink eye
s/s of conjunctivitis
redness
crusting exudate
itching
define Blepharitis
chronic inflammation of eyelid margins
2 types seborrheic and ulcerative
define hordeolum
a sty, staph abscess in the sebaceous gland at base of eyelash
define keratitis
inflammation of cornea
s/s of keratitis
Pain inflammation Decreased vision photophobia spasms If untreated, patient may suffer loss of vision
define Hyperopia
farsightedness
light rays focused behind retina
define myopia
nearsightedness
light rays focused in front of the retina
define astigmatism
unequal curvatures in the shape of cornea which causes blurred vision.
define presbyopia
crystalline lenses lose elasticity, causing decrease ability to focus on close objects
s/s of refractive errors
Difficulty reading or seeing objects
Eyestrain causing headaches
Myopia – holding reading material close to eyes
Hyperopia – holding reading materials farther from eyes
Therapeutic interventions for refractive errors
Corrective lenses
Laser assisted in situ keratomileus (LASIK)
Photorefractive keratectomy (PRK) – laser
causes of blindness
Trauma
Complications of diseases (HTN, Diabetes, cataracts, glaucoma, malnutrition, infection)
Caused when the ray of light on their way to the optic nerve is obstructed or by disease of the optic nerve
Dx test for blindness
Visual field exam Tonometry Slit-lamp microscope exam Retinal angiography Ultrasonography
Define diabetic retinopathy
Vascular changes in retinal blood vessels
It’s due to the excess glucose, changes in the retinal walls, and formation of microaneurisms and constriction of blood vessels
define retinal detachment and name s/s
Separation of retina from choroid layer of eye which allows for fluid to enter the space between the layers
Signs & Sx: sudden change in vision, Flashing lights or floaters
Dx test of retinal detachment
indirect ophthalmoscopy
visualization of the retina
complications of retinal detachment
Increased intraoccular pressure and posses threat for further detachments
Define glaucoma
Group of diseases characterized by abnormal pressure within the eyeball
Pressure causes damage to cells of the optic nerve
Types:
Acute angle closure glaucoma
Primary open able glaucoma
s/s of acute angle closure glaucoma
ophthalmic emergency unilateral, rapid onset severe pain blurred vision rainbows around lights eye redness steamy-appearing cornea Photophobia tearing
s/s of primary open able glaucoma
bilateral, gradual onset painless at times mild aching headaches halo around lights frequent visual changes not corrected with eyeglasses
Dx test for glaucoma
tonometry: used to detect increased IOP
Normal IOP – 12 to 20 mm Hg
eye drop treatment for glaucoma
1st line treatment is focused on opening the aqueous flow using cholinergic agents (miotics) which constrict the pupil causing the iris to pull away from the drainage canal, allowing aqueous fluid to flow freely.
2nd type of medication used to slow production of aqueous fluid
Steroids may also be ordered to decrease inflammation
surgical management of glaucoma
Used when medication not able to control IOP
Focused on creating an area for aqueous humor to flow freely thus preventing increased intraocular pressure
Cataracts are painless
define cataract
Opacity in the lens of the eye that may cause a loss of visual acquity
Vision diminished because light rays are unable to get to retina through clouded lens
factors contributing to cataract development
Age UV radiation Diabetes Smoking Steroids Alcohol Nutrition Intraocular Infections Trauma Congenital Defects
surgical treatment for cataracts
Only treatment
Removal of cloudy lens one eye at a time
complications of cataract surgery
Inflammation Increased IOP Macular edema Retinal detachment Vitreous loss
risk factors for macular degeneration
Older than 60 years old Family history of macular degeneration Diabetes Smoking Frequent exposure to UV light Caucasian
s/s of macular degeneration
Dry type is slow, progressive loss of central & near vision
Usually both eyes, but can be affected differently
Wet type – onset sudden of visual loss Blurred vision Distortion of straight lines Dark or empty spots Decreased ability to distinguish colors
types of macular degeneration
Dry (atrophic)
Wet (exudative)
therapeutic interventions for DRY (ATROPHIC) macular degeneration
No treatment
Most do not lose peripheral vision or become totally blind
Most are classified as legally blind
Special low-vision lenses can enhance remaining vision
therapeutic interventions for WET (EXUDATE) macular degeneration
If diagnosed early – laser photocoagulation can seal the leaking blood vessels, which will slow rate of vision loss
Meds: antiangiogenic – prevents new blood vessels from forming
define each type of eye trauma Foreign body Burns abrasions/lacerations penetrating wounds
Foreign bodies – most common cause of corneal injury (dust in eyes, then rub eyes causing further irritation)
Burns – chemical, UV and direct heat
Abrasions & Lacerations – due to something dragging across the eye
Penetrating wounds – most serious due to eye structures may be permanently damaged
therapeutic intervention for foreign body trauma
NS flush to irrigate object out of eye or to a point where it can be taken out with a swab; topical antibiotic ointment for infection prevention
therapeutic intervention for chemical burn eye trauma
15 to 20 minute irrigation (the sooner the better) of tap water is fine to use at work site; sterile solution used in the hospital; topical antibiotic ointment for infection prevention
therapeutic intervention for abrasions and lacerations to eye
anti-infective ointments or drops after cleansing the eye with NS
therapeutic intervention for penetrating wounds to the eye
eye specialist will treat these; cover both eyes to prevent ocular movement; stabilize any protruding objects; DO NOT REMOVE OBJECT
most common disability in the US
hearing loss
acquired or congenital
define conductive hearing loss
Any interference with the conduction of sound impulses through the external auditory canal, eardrum, or middle ear.
Caused by the interference with the sound wave ability to reach the inner ear
This is a mechanical problem
correction for conductive hearing loss
Infection, foreign bodies and impacted cerumen can be corrected
Hearing devices may improve hearing loss if cause cannot be corrected
define sensory hearing loss
originates in the cochlea & involves hair cells & nerve endings
define sensorineural hearing loss
Results from disease or trauma to the sensory or neural components of the inner ear
define presbycusis hearing loss
hearing loss caused by the aging process
causes of sensorineural hearing loss
Complications of infections (measles, mumps, meningitis) Ototoxic drugs Trauma Noise Neuromas Arteriosclerosis Aging process
define external otitis and its cause
Caused due to exposure to moisture, contamination or trauma
Perfect environment for pathological growth
Staphylococci most common causative organism
most common infection
define ear infection
Localized infection
ear canal furuncle or abscess due to hair follicle infected
Carbuncle forms when several hair follicles involved in forming the abscess
Most furuncles and carbuncles erupt and drain spontaneously
s/s of ear infection
Ear pain (early indication if pain with gentle pull on pinna) – pain may occur with jaw movement or otoscope insertion Pruritus Inflammation present Redness Drainage Fever is a possibility
Dx test of ear infection
CBC (WBC elevation)
Cultures of drainage
Rinne’s test and weber’s test to detect hearing loss
therapeutic interventions for ear infection
Topical (drops/ointment) or systemic antibiotics
Topical or systemic steroids
Thoroughly cleanse ear before topical treatment
risk factors for impacted cerumen
Large amounts of ear hair Work in dusty or dirty environments Improper cleaning Older age Hearing aids
s/s of impacted cerumen
Hearing loss
Feeling of fullness
Feeling of blocked ear
Otoscopic exam shows cerumen blocking ear canal
Dx test for impacted cerumen
Otoscopy Audiometric testing conductive loss in affected ear Whisper voice Rinne’s test conductive loss in affected ear Weber test conductive loss in affected ear
makes found in the ear
Benign masses are usually Sebaceous gland cysts
Malignant tumors such as basal cell carcinoma on the pinna and squamous cell in the ear anal may develop and spread
s/s of masses in the ear
Changes in appearance of skin Impaired conductive or sensorineural hearing loss Pain Ear drainage Facial paralysis (progressed) Visualization of mass during otoscopy
Dx studies for masses in ear
Otoscopy Biopsy Imaging Audiometric studies Demonstrates hearing impairment
s/s of trauma to ear
Lacerations Contusions Hematomas Abrasions Erythema Blistering Itching Decreased hearing Pain Swelling
Dx studies for trauma to the ear
Otoscopic examination – use caution not to push foreign object farther in Imaging studies – to determine extent Evaluate conductive hearing loss: Audiometric test Whisper voice test Rinne’s test Weber’s test
therapeutic interventions for trauma to the ear
debridement, surgical repair, or application of protective covering
Therapeutic measures for external ear disorders
Topical or systemic antibiotics
Analgesics are used to control pain
Steroids are used to treat inflammation
Make sure the ear is thoroughly cleaned prior to topical treatment
Cerumen may be removed with installations or irrigation
Do not irrigate if patient has history of perforated eardrum
define otis media
Most common disease of middle ear
General term for inflammation of middle ear, mastoid, & Eustachian tube
Commonly follows URI
Nasopharyngeal mucosa becomes edematous & discharge produced
Fluid, pus, or air builds up in the middle ear and the Eustachian tube becomes blocked which impairs middle ear ventilation
s/s of otis media
Fever Earache Feeling of fullness in ear Purulent drainage Pain Conductive hearing loss N/V Redness on otoscopic exam
Dx tests for otis media
CBC (elevated WBC) Ear cultures Imaging studies Conductive hearing loss present on Audiometric studies Rinne’s test Weber’s test Whisper test
complications of otis media
Spontaneous perforation of tympanic membrane
Pain with perforation
Hearing loss
Cholesteatoma, Tympanosclerosis, and Mastoiditis
Due to Repeated infections
therapeutic interventions for otis media
Antibiotics Oral analgesics Ear drops (for pain) Surgical Myringotomy – with tubes Myringoplasty – reconstruction of perforated tympanic membrane
define Otosclerosis
Hardening of the ear
Due to formation of new bone along the stapes
Causes the stapes to become immobile and causes conductive hearing loss
s/s of otosclerosis
Progressive hearing loss
Bilateral conductive hearing loss (soft, low tones)
Tinnitus
Otoscopic exam – pinkish/orange tympanic membrane
Dx studies for otosclerosis
Audiometric testing Imaging studies Whisper voice test Rinne’s test Weber’s test
therapeutic interventions for otosclerosis
No cure Hearing aids Ossiculoplasty Total or partial ossicular replacement (prosthesis) Stapedectomy
nursing management for otosclerosis
Operative ear upward when lying in bed Ear plug (keep area aseptic) Activity as ordered Use caution d/t dizziness Instruct not to cough, sneeze, blow nose, vomit, fly in plane, lift heavy objects or shower
Nursing Dx for Middle Ear, Tympanic Membrane & Mastoid Disorders
Risk for infection r/t broken skin, pressure necrosis, chronic disease, or surgical procedure
Acute pain r/t fluid accumulation, inflammation, or infection
Fear r/t hearing loss
define Labyrinthitis
Inflammation or infection of inner ear
Caused by Viral or bacterial pathogens
s/s of labyrinthitis
Vertigo Tinnitus Sensorineural hearing loss Pain Fever N/V
nursing management of labyrinthitis
Symptom management
Safety education while on sedatives and bedrest
Avoid turning head quickly
define Meniere’s Disease
Balance disorder
Cause unknown
disturbance in fluid physiology of the endolymphatic system
s/s of Meniere’s Disease
Triad of Symptoms: Vertigo Hearing loss Tinnitus can also have n/v
Dx test for Meniere’s Disease
audiometric, neurological, radiographs
therapeutic interventions for Meniere’s disease
symptomatic management and prophyloactic treatment between attacks
Salt restriction, Avoid caffeine, alcohol & tobacco
Surgical Treatment – only when medical management has failed
Name the proper sequence as they are involved in the process of producing a visual image from beginning to end
cornea aqueous humor lens vitreous humor retina optic nerve occipital lobe
name the proper sequence in the process of hearing when sound waves enter the ear canal
eardrum malleus incus stapes oval window fluid in the cochlea hair cells in the organ or court eighth cranial nerve temporal lobes
define nystagmus
constant involuntary cyclical eyeball movement
define tropia
deviation of the eye away from the visual axis
define accommodation
adjustment of the eye for distance to focus the image on the retina by changing lens curvature
define ptosis
drooping of the upper eyelid as a resolute of paralysis
define arcus senilus
opaque white ring around the periphery of the cornea in aged persons from deposits of fat
Name purpose of test and normal test results
Snellen chart
visual acuity
20/20 for both eyes
Name purpose of test and normal test results
visual fields
peripheral vision
equal to examiner’s
Name purpose of test and normal test results
cardinal fields of gaze
extraocular movement
follows in all fields without nystagmus
Name purpose of test and normal test results
accommodation
pupillary response to near and far distance
eyes turn inward and pupils constrict when focusing on a near object
Name purpose of test and normal test results
Rinne
differentiate between conductive and sensorineural hearing loss
air conductive greater than bone conduction
Name purpose of test and normal test results
Weber
hearing acuity
heard equally
Name purpose of test and normal test results
Romberg’s
balance/vestibular function
able to maintain standing position without loss of balance
Which of the following would indicate that the patient has a normal corneal light reflex?
- the eye focuses the image in the center of the pupil
- the eyes converge to focus on the light
- constriction of both pupils occurs in response to bright light
- light is reflected at the same spot in both eyes
-light is reflected at the same spot in both eyes
symmetrical eye muscle strength keeps the eyes in the same position, and the light is reflected in exactly the same place
When testing visual fields, the nurse examines which of the following parts of vision?
- peripheral vision
- near vision
- distance vision
- central vision
peripheral vision
Which of the following terms would indicate to the nurse that a substance is toxic to the ear?
- otoplasty
- otalgia
- ototoxic
- tinnitus
ototoxic
otoplasty is ear repair
otalgia is ear pain
tinnitus is ringing in the ears
Which of the following tests would the nurse use as an initial screening test to determine hearing loss?
- Romberg’s test
- Otoscopic examination
- Caloric test
- Whisper voice test
Whisper voice test
Which of the following would the nurse use to document a finding that the patient’s ear is draining?
- Otorrhea
- Otalgia
- Ototoxic
- tinnitus
otorrhea
Which of the following terms indicates that the patient has a hearing loss caused by aging?
- otoplasty
- otalgia
- presbycusis
- tinnitus
presbycusis
which is loss of high pitched sounds due to aging
Which of the following explanations would the nurse give to the patient who had a Snellen chart finding of 20/80?
- You can see at 80 feet what those with normal vision can see at 20 feet.
- You can see at 20 feet what those with normal vision see at 80 feet.
- You can see four times farther than those with normal vision can see
- Your vision is normal
You can see at 20 feet what those with normal vision see at 80 feet
the first distance recorded when conducting the Snellen test is the distance from which the patient can clearly read the alphabetical line on the chart. The second distance recorded is the distance from which a person with normal vision can see the same alphabetical line
In planning safe care for the older adult, which of the following conditions does the nurse recognize would cause visual problems? SATA
- glaucoma
- cataracts
- arcus senilis
- macular degeneration
- estropia
- presbycusis
glaucoma
cataracts
macular degeneration
estropia
In which of the following statements does the nurse understand is true concerning air conduction of sound in the ear?
- it is caused by the vibration of bones in the skull
- it is less efficient than bone conduction
- it is heard longer than bone conduction
- it is caused by transmission of heat through the air
-it is heard longer than bone conduction
Which of the following statements would the nurse understand is true when checking normal auditory acuity using the Rinne test?
- The patient perceives sound equality in both ears
- Air conduction is heard longer than bone conduction in both ears
- Bone conduction is heard longer than bone conduction in both ears
- The patient’s left ear will perceive the sound better than the right ear
Air conduction is heard longer than bone conduction in both ears
Define Carbuncle
several hair follicles forming an abscess
Define Cholesteatoma
epithelial cyst like sac filled with skin and sebaceous material
define mastoiditis
complication of otis media
define barotrauma
pressure in the middle ear caused by atmospheric changes
Which of the following type of eyedrops is given to constrict the pupil, permitting aqueous humor to flow around the lens
- osmotic
- myotic
- mydriatic
- cycloplergic
myotic
mystics lower intraocular pressure by stimulating pupillary and ciliary sphincter muscles
which of the following procedures does the nurse understand is used to correct otosclerosis
- myringotomy
- myringoplasty
- mastoidectomy
- stapedectomy
stapedectomy
involves removing or replacing part of all the stapes with a prothesis
A nurse understands that labyrinthitis is treated primarily with which of the following drug categories
- antihistamines
- antispasmodics
- anti-inflammatories
- antiemetics
antihistamines
Which of the following types of hearing loss does the nurse understand is most improved with the use of a hearing aid?
- conductive
- sensorineural
- mixed
- central
conductive
which of the following would the nurse teach the patient is the most common site for ear infections
- outer ear
- inner ear
- middle ear
- semicircular canal
middle ear
Which of the following would e a symptom the nurse expects to find during examination of a patient with macular degeneration? SATA
- decreased ability to distinguish colors
- sudden loss of vision
- loss of near vision
- loss of central vision
- loss of peripheral vision
- increased periodic dizziness
decreased ability to distinguish colors
oss of near vision
loss of central vision
Which of the following would the nurse explain to the patient is the triad of symptoms associated with Meniere’s disease?
- hearing loss, vertigo, and tinnitus
- nystagmus, headache, and vomiting
- nausea, vomiting, and pain
- nystagmus, vomiting, and pain
hearing loss, vertigo, and tinnitus
Which of the following is usually the first symptom of a cataract that the nurse would expect a patient to report during an examination?
- dry eyes
- eye pain
- blurring of vision
- loss of peripheral vision
blurring of vision
due to clouding of the lens
Which of the following is a symptom that the nurse would expect to find during assessment of a patient experiencing acute angle-closure glaucoma?
- flashing lights
- lens opacity
- halos around lights
- vertigo
halos around lights
