Sensory Issues Flashcards
Review the anatomy of the Eye
Slide 1
Assessment of the eye:
History External assessment Visual fields, & eye movement Eye position- exophthalmos, enophthalmos Eye lids and lashes Blink response Conjunctivae, sclera Light reflex- accommodation v. light reflex
Fundus
Fundus is normally orange-red color- darker on darker complexion
Normal look to blood vessels
Optic Disc where blood vessels converge is yellowish to pale pink with well defined margins
Macula responsible for central vision- always temporal to optic disc
Age Related Changes
Smaller pupils, do not dilate easily- night vision a problem
Lens less elastic- near object difficult to see
Lens becomes opaque- color perception
Decreased depth perception, peripheral
Eyes recessed in socket- tissue folds on lids
Decreased strength of muscles of eye movement
Conjunctivitis
Conjunctiva covers inner lid and external eye Inflammation from bacteria or virus Extremely contagious- “Pink Eye” Redness and itching, gritty sensation Tearing and discharge Inflamed preauricular nodes Treated with antibiotic drops and pills
Nursing Issues with Eye Infections
Pain Analgesics, warm compresses Protect from sun Visual changes No contact lenses, handwashing, blurring Risk for spread of infection Handwashing, wash eyes separately, may use baby tearless shampoo especially for blepharitis
Cataracts
Likely after age 70 Cumulative exposure to UV (sun) Reduced O2 uptake by lens Dehydration of lens, opacity Immature to “ripe” Immature= some light getting through, useful vision Ripe= poor vision, poor light penetration Tend to be bilateral Trauma or chemical irritation
Symptoms of Cataracts
Blurred vision Photophobia Sensitivity to glare Vision better in low light Cloudy appearance of lens
Pre-op Care for Cataract Surgery
Mydriatic medication pre-operatively to produce mydriasis or dilitation of the eye
Educate patient on need to have someone available as will have limitation in vision due to eyepatch, can’t drive
Need to frequently instill drops after surgery
Nursing Care after Cataract Surgery
Leave eye patch on with shield
For 24 hrs limit activity to sitting, resting in bed or limited walking in house
Do not rub eye
Do not lift more than 5 lbs- why?
Do not strain, or bend over, avoid reading, why?
Eye drops as ordered
No aspirin, take Tylenol for pain
Additional Patient Teaching
Report eye pain not relieved by Tylenol Report headache, nausea, severe itching Report swelling of eye Eye patch should not put pressure on eye Tearing is normal Hazards of monocular vision Unrelieved eye pain and nausea sign of increased intraocular pressure
Case: The nurse is performing an assessment on a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is:
A. Eye Pain
B. Floating spots
C. Blurred vision
D. Diplopia
Glaucoma
Painless increased intraocular pressure Optic nerve atrophy Visual field loss Common preventable cause of blindness 5 times more likely in African Americans than whites
Pathophysiology of Glaucoma
Decreased outflow of aqueous humor
Increased production of aqueous humor
Extra fluid caused increased pressure on retina- which is painless.
Decrease outflow + increased production = increased pressure on retina
Pathophysiology of Glaucoma
Fluid produced in ciliary bodies, travel around the iris from the posterior chamber to the anterior chamber, through Canal of Schlemm and the trabecular mesh, to be absorbed into the vascular supply.
Open Angle Glaucoma
Outflow impaired but still about to get through
Open Angle Glaucoma
Occurs over time Vision changes are often not noticed Loss of peripheral vision Difficulty adapting to dark Halos around lights As pressure increases, acuity decreases
Angle Closure Glaucoma
Angle of Iris blocks drainage of aqueous humor through canal of Schlemm
Requires immediate intervention to prevent damaging increase in ocular pressure
Angle Closure
Narrow angle, closed angle
With dilation of pupil the angle closes completely
This occurs quickly and the increased pressure caused damage to retina and permanent blindness
Happens in darkness, emotional distress which cause pupil dilation
Must avoid mydriatic drugs- atropine, anticholinergics
Symptoms- sudden H/A, red conjunctiva, cloudy cornea, N&V
Angle Closure Glaucoma
Iridectomy often produces a keyhole appearance to the pupil
Treatment of Glaucoma
Meds are not a cure, but can control sx
Cholinergics (miotics)- pilocarpine gtts
Beta-adrenergic blockers- timoptic gtts
Several systemic meds that decrease production of aqueous humor
For Closed Angle- diuretics to bring intraocular pressure down quickly- mannitol (osmotic diuretic)
Timoptic (timolol maleate)
Beta adrenergic antagonist, miotic- drops
Relaxes iris- constricts (miosis)
Reduces production of aqueous humor
Usually given every 12 hrs
Antihypertensive, antianginal, migraines- oral
Adverse effects- bronchospasm (COPD), bradycardia, syncope
NSAIDS antagonize hypotensive effects
Pilocarpine hydochloride
Cholinergic
Contraction of ciliary muscle, increasing outflow of aqueous humor, induces miosis
Apply gentle pressure to nasolacrimal duct for 1-2 minutes after instilling to prevent systemic effects
Usually given 3-4 times per day
Adverse effect- anticholinergic
Bronchospasm (COPD), tachycardia, dry mouth, urinary retention
Nursing Issues with Glaucoma
Loss of vision is permanent- grieving
Treatment prevents further loss of vision
Teach instillation of eye drops- frequent and lifelong
Remember cross-contamination with drops
Issues with diuretics- K loss, dehydration
Case: The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care.
A. Decrease fluid intake to control the intraocular pressure.
B. Avoid over use of eyes.
C. Decrease the amount of salt in the diet.
D. Eye medication will need to be administered lifelong.
Retinal Detachment
Painless separation of retina from choroid (vascular layer between sclera & retina) – dense with blood vessels- deprived of blood supply
More often with advanced age, trauma
Shadow or black area in vision, flashes of light as retina pulls away
Areas of detachment look bluish-gray
Treatment of Retinal Detachment
No medical treatment
Laser Photocoagulation-burns edges and prevents further damage.
Pneumatic Retinopexy-instillation of gas bubble that rises to the location of the tear and puts pressure on the retina to connect to the choroid.
Scleral Buckling-surgical procedure to place retina back in contact with choroid from outside of eye.
Case: The nursing is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of retinal detachment?
A. Complaints of a burst of black spots or floaters.
B. A sudden sharp pain in the eye.
C. Total loss of vision.
D. A reddened conjuctiva.
Diabetic Retinopathy
Leading cause of blindness
Progressive disorder causing microscopic damage to the blood vessels of retina
Microaneurysms of capillaries, dilated & tortuous veins
Aneurysms rupture and cause small areas of scar tissue
Progressive retinal ischemia stimulated new vessels to grow- ineffective
Diabetic Retinopathy
Blot hemorrhages, scar is yellow, Large new blood vessl cover macula , aneurysms in blood vessels of eye , cotton wool spots-scar tissue
Vision with Diabetic Retinopathy
If hemorrhage close to macula, central vision is more damaged
Treatment for Retinopathy
Photocoagulation- stop leaking of fluid onto retina
Vitrectomy- remove bloody vitreous, replace it with normal saline to maintain shape of eye
Nursing Care after laser surgery
Outpatient procedure
Vision blurry for a day, can’t drive
Mild pain, H/A, sensitivity to light for a few days-OTC pain meds, and patch
Spots in vision from laser disappear over time
Minimize increased intraocular pressure
Macular Degeneration
Age-related degeneration of macula
Central vision loss
“Dry”- atrophy of outer retina and underlying tissues
“Wet”- serous fluid from choroid leaks into retina and macula
No known cure
Dietary supplements show some promise
Macular Degeneration
Dry- thinning of retinal tissue with yellowish spots of debris from cell breakdown- scar tissue
Wet- domes of fluid appear on retina causing visual change of distorted lines, with dark, blurry white out in center of vision
Supplements- Vit C + Vit E + Beta-carotene + zinc, and egg yolks (leutene)
No effective treatment or cure
Retinitis Pigmentosa
Progressive, genetic disease Loss of peripheral vision progressing to total blindness Caused by production of unstable protein Loss of night vision in childhood, early No treatment or cure Should have genetic counseling
Corneal Transplant
Keratoplasty- use of donor corneas to improve clarity of vision (cadavers)
Local anesthesia
Visual return is slow, sutures distort the vision
Rejection is a problem
Emergencies of the eye:
- Blunt
- Penetrating
- Chemical
Blunt
Treatment begins immediately
See physician immediately to determine extent of injury
Ice
Visual acuity assessed
Penetrating
Never remove
Notify physician immediately
Visual acuity assessed
Chemical
Irrigate x 10 min immediately
Visual acuity assessed.
Hearing Loss: 2 types
- Conductive
- Sensioneural
Conductive Hearing Loss
problem with conducting sound waves through outer ear, tympanic membrane, middle ear (ossicles) and the inner ear (oval window/round window). May occur in conjunction with sensorineural hearing loss.
Sensioneural Hearing Loss
cause lies in the vestibuluocochlear nerve (Cranial nerve VIII), the inner ear or central processing centers of the brain.
Conductive Loss
Ear obstruction-cerumen (ear wax) obstruction, foreign body, cotton, insects, toys
Infection-external canal, labrynthitis (infection of the inner ear), chronic otitis media
Otosclerosis-hardening of structures of inner ear (genetic)
Tympanic membrane injury
This hearing loss can be corrected
Dealing with Hearing Loss
Be sure you have patient’s attention Speak directly at patient Don’t turn your back when talking Use more than one word- better for context Lower tone of voice Don’t shout Use a picture board
Sensioneural Loss
Presbycucis-damage to labrynth in older adults- high pitch hearing loss
Noise-induced- repeated acoustic trauma
Tumors of temporal bone
Acoustic neuroma-unable to interpret stuimuli related to position and movement
This hearing loss is not usually able to be treated
Tinnitus-ringing, roaring, chirping in ear
Meniere’s Disease
Affects both vestibular and auditory function
Excess endolymph in labrynth
Hearing loss fluctuates in early stage, but becomes permanent
Vertigo is severe- spinning in nature
Vertigo increases with movement-avoid sudden movement
Encourage slow head movements
Dietary restriction such as salt and fluid reduces the amount of endolymphatic fluid
Decrease ability to hear, may affect some occupations
Signs of Hearing Loss
Failure to respond to verbal communication Inappropriate verbal responses Excessively loud speech Strained facial expressions Tilting of head when listening Constant need for clarification Faulty speech TV/radio too loud Most hearing loss is gradual and goes unnoticed
Hearing Aides
In ear canal
Behind ear
In eyeglasses
Body worn- box carried in shirt pocket
All amplify sound in a controlled manner, but do not change the quality of the sound
Newer aides can select a particular range of sounds to amplify
Vertigo
Balance responsibility of eyes, labyrinth, muscles, joints, cerebellum
Subjective- in motion in a stable environment
Objective- stable in a moving environment
Often accompanied by N&V, nystagmus, salivation, sweating, hypotension
Dizziness is the lack of balance
Lightheadedness, movement within head
Tests for Inner Ear
Electronystagmography-water in ear canal while monitoring for eye motion. Normal response-nystagmus. Absent nystagmus indicates vestibular dysfunction
Weber test (tuning fork on top of head)
If sensorineural loss, lateralize to non-affected
Air conduction normally greater than bone
Rinne test (tuning fork on mastoid
If sensorineural loss, air conduction
Glycerol test-osmotic diuretic to pull fluid from inner ear may improve dizziness or hearing loss.
X-rays, CT- mastoid, middle ear ossicles
Case: A client with Meniere’s disease is experiencing severe vertigo. Which instructions would the nurse give to the client to assist with controlling vertigo?
A. Increase fluid intake to 3000 ml a day.
B. Avoid sudden head movements.
C. Lie still and watch the television.
D. Increase sodium in the diet.
