Sensory Study Guide Flashcards
Anatomy - EYE
EYE
- EXTERNAL
- SCLERA (“whites”)
- CORNEA (covers front of eyeball)
- MIDDLE
- CHOROID (nerves and blood vessels - nutrients to retina)
- CILIARY BODY (produces aqueous humor)
- IRIS (colored part of eye)
- CHOROID (nerves and blood vessels - nutrients to retina)
- INTERNAL
- RETINA (optic nerve receptors) - lightwaves changed into impulses.
- RODS (peripheral/darks)
- CONES (central/color)
- RETINA (optic nerve receptors) - lightwaves changed into impulses.
Anatomy - EAR
EAR
- EXTERNAL (pinna/auricle —> tympanic membrane)
- MASTOID -CERUMEN
- MIDDLE (medial side of TM)
- 3 BONES –> MALLEUS (hammer), INCUS (anvil), STAPES (saddle)
- INNER (Labyrinth)
- COCHLEA (snail-shaped)
- ORGAN OF CORTI -receptor/organ for hearing
- SEMICIRCULAR CANALS - 3 bony tubes w/ receptors
- VESTIBULE - 2 bony structures w/ receptors
- COCHLEA (snail-shaped)
** (SEMICIRC. & VESTIB. –> EQUILIBRIUM/BALANCE) **
Normal occurrences that take place with aging in the eyes and ears.
EYES
- DECR. lens accommodation (PRESBYOPIA/MYOPIA)
- DECR depth perception (FALL RISK)
- DECR PERIPHERAL VISION (driving risk!)
- DECR ability to react to light/dark
- DECR color perception (blues/greens/violets)
- DECR tear formation (DRY/itchy eyes)
- DECR. fluid circulation (INCR. RISK GLAUCOMA)
EARS
- PRESBYCUSIS
- HIGH-PITCHED sounds go first *
- VERTIGO/dizzoness/TINNITUS
- Equilibrium/BALANCE PROBLEMS
- INCR. CERUMEN
Normal adult vital signs and pulse ox
PULSE: 60-100bpm
RESP: 12-20rpm
PAIN: 0-10 scale (medicate @ 3 or above)
PULSE OX: 95%-100%
* (COPD 88%-92%)
TEMPERATURE
-ORAL: 96.8 - 100.4
-RECT: 97.7 - 101.3
-AXILL: 95.5 - 99.5GLAUCOMA
- cause
- s/s
- tx
GLAUCOMA: increase in IOP
- CAUSE: inability of the aqueous humor to drain
- RISK FACTORS: HTN, DM, Age, Infection
- S/S
- PROGRESSIVE (RAPID - acute glaucoma)
- PERIPHERAL VISION LOSS
- Mild eye pain (PAIN, NAUSEA - acute glaucoma)
- Halos
- TREATMENT
- PYLOCARPINE (MIOTIC drops) –> (vaso)CONSTRICT
- TINOLOL (beta blocker)
- SURGERY
What diagnostic testing would determine the persons risk at developing glaucoma?
VISUAL ASSESSMENT
TONOMETRY - mesures IOP
GONIOSCOPY - determines drainage angle
What normal findings would you expect to see and document during an eye assessment?
P:upils
E:qual - pupils of both eyes should be the same
R:ound
R:eactive to - both pupils should CONSTRICT w/ light
L:ight
A:ccomodation OK - pupils both change b/w near and far vision
C:oordination - reaction same in both eyes
What is peripheral vision?
“side-vision”
-Loss of peripheral vision is called “tunnel-vision”.
What is cerumen?
Earwax.
Produced in EXTERNAL ear.
PROTECT ear from foreign objects.
What types of medication can be used to treat middle and inner ear problems?
MIDDLE EAR PROBLEMS
-Infection -Injury -Dz
INNER EAR PROBLEMS
-Tinnitus -Vertigo
ANTIBIOTICS - for infection
ANTIHISTAMINES - effective in tx of vertigo/nausea
ANTIEMETICS - tx n/v associated with vertigo (Droperidol)
BENZOs - has antivertigo effects (Valium)
What is a cochlear implant?
Pt education imperative for success?
Can they have MRI’s?
COCHLEAR IMPLANT: surgically implanted coil beneath skin behind ear with electrode –> stimulates auditory nerve fibers.
For SENSORINEURAL hearing loss.
PT EDUCATION
- DO NOT GET IT WET
- MRI’s CONTRAINDICATED
- Teach infection prevention
- Device is not turned on immediately after surgery
What is an ear wick used for?
Used to KEEP MEDICATION IN EAR.
- common w/ abx and swimmers ear.
- PREVENTS MED LOSS
- Remove before administering more medication
How does a corticosteroid work in a pt who just had a lens transplant?
ANTIINFLAMMAROTY.
- Keeps inflammation down
(LONG TERM use corticosteroid can lead to INCR. IOP)
Why is it important to assess visual acuity before and after one eye having surgery?
Establishes a BASELINE.
-You’ll be able to see effectiveness/ineffectiveness of surgery.
What does a “consensual pupil response” mean?
When you shine a light in one eye and both eyes do the same thing.
Ex: light shined in (L) eye —> (L) eye AND (R) eye constrict.
Describe HORDEOLUM
- CAUSE
- S/S
- TX
- PT TEACHING
HORDEOLUM: (“STYE”)
CAUSE: inflammation of SEBACEOUS gland
S/S:
- RED
- inflamed/RAISED
- PAIN (w/PUS)
TX:
- WARM COMPRESS to promote drainage
- Topical ABX
TEACHING
- WASH HANDS
- Do NOT share make-up
- Do NOT pop it!
Describe PRESBYOPIA
- CAUSE
- S/S
- TX
- PT TEACHING
PRESBYOPIA: gradual loss of accommodation
CAUSE: AGE-related (lens becomes less elastic)
S/S
-FARSIGHTED
TX
- GLASSES (bifocals if myopia and presbyopia)
TEACHING
-Caution DRIVING AT NIGHT
Describe PRESBYCUSIS
- CAUSE
- S/S
- TX
- PT TEACHING
PRESBYCUSIS: gradual/degeneration of hearing loss
CAUSE: AGE-related (deterioration of cochlear structures)
S/S
-Decreased ability to hear HI-PITCHED sounds
TX
- HEARING AID
TEACHING
- Wash ear piece DAILY with MILD SOAP
- Check batteries regularly.
- Have patience - takes time to get used to.
Describe MYOPIA
- CAUSE
- S/S
- TX
- PT TEACHING
MYOPIA: (NEARSIGHTED) - light rays focus in FRONT of retina
CAUSE: AGE, elongation of eyeball
S/S
- blurred far vision
- DECR accommodation
TX
-GLASSES
TEACHING
-caution DRIVING AT NIGHT
Describe CATARACTS
- CAUSE
- S/S
- TX
- PT TEACHING
CATARACTS: opacity of the lens that impairs vision.
CAUSE
- AGE
- FAMILY HX
- DM
- SMOKING
- injury
S/S
- WHITE PUPIL (cloudiness)
- ABSENT RED REFLEX
- Halos
- DECR. VISUAL ACUITY
TX
-CATARACT SURGERY to remove lens and replace with prosthesis
TEACHING
-REPORT N/V
-AVOID activities that INCREASE IOP
(DON’T WANT IMPLANT COMING OUT!)
Describe EXTERNAL OTITIS
- CAUSE
- S/S
- TX
- PT TEACHING
EXTERNAL OTITIS: (“swimmer’s ear”) - inflammation of the external ear.
CAUSE: chronic external ear inflammation, exposure to water.
S/S
- PAIN
- FLUID in ear
- PURULENT DRAINAGE (sometimes)
TX
- wear EARPLUGS while doing water activities
- prescribed ear drops can be used in prevention
Describe MENIERE’S DISEASE
- CAUSE
- S/S
- TX
- PT TEACHING
MENIERE’S DISEASE: chronic INNER EAR disease (VERTIGO)
CAUSE: increase in endolymph fluid
S/S
- RECURRENT VERTIGO
- N/V
- TINNITUS
- Progressive unilateral hearing loss
TX
- DRAMAMINE
- DIURETICS between attacks
- LOW-SODIUM Diet
TEACHING (when vertigo is present)
- Lie down, dim lights
- NO fast head movements
Describe ACUTE OTITIS MEDIA
- CAUSE
- S/S
- TX
- PT TEACHING
ACUTE OTITIS MEDIA: inflammation/infection of the MIDDLE EAR.
CAUSE: URI’s, *(Eustachian tube —> throat)
S/S
- PAIN behind eardrum
- FEVER
TX
- NARCOTIC analgesics
- ANTIBIOTICS
TEACHING
- Application of local heat is helpful
- Finish abx
Describe BACTERIAL CONJUNCTIVITIS
- CAUSE
- S/S
- TX
- PT TEACHING
BACTERIAL CONJUNCTIVITIS: (PINK EYE)
CAUSE: allergies, BACTERIA
S/S
- PAIN
- REDNESS
- ITCHING
- THINK PUS (sometimes)
TX
-topical ABX
TEACHING
- WASH HANDS
- Do not share make-up/towels
- NO CONTACTS until infection is gone
Describe KERATITIS
- CAUSE
- S/S
- TX
- PT TEACHING
KERATITIS: inflammation of the CORNEA
CAUSE
- INFECTION
- DUST
- CONTACTS
- Surgery/injury
S/S
- PAIN
- REDNESS of sclera
- “gritty feeling”
- BLURRED VISION
TX
- ANITBIOTICS
- Mydriatics to dilate pupil
What are risk factors that lead to hearing loss?
- LOUD NOISES
- AGE
- GENETICS
- MEDICATION
- DISEASES
- Injury/trauma
- Surgery
What is proper protocol for nurses regarding flushing eyes?
For CHEMICAL burns to the eye:
- IRRIGATE EYE with WATER/SALINE for 15-20 MINUTES to flush chemical out of eye.
When using eye drops is it normal to have blurry vision and/or stinging?
This is a normal response AT FIRST. - advise the pt.
How do you communicate with someone that is hard of hearing?
- FACE PT when speaking
- SPEAK CLEARLY, not shouting
- READ LIPS
- SIGN LANGUAGE
- WRITING on paper/whiteboard
When caring for pts with visual problems, what s/s would you report immediately to physician?
- NAUSEA
- VOMITING
- PAIN
These increase IOP –> physician may need to order antiemetic.
What is the rationale behind why ear drops should be body core temp before administration.
Hot/COLD solutions can cause: DISCOMFORT, DIZZINESS, and NAUSEA
When do pts usually start spiking a fever after surgery?
48-72 HOURS (2-3 days)
SIGN OF INFECTION
What are the steps in performing an ear lavage?
- WARM SOLUTION to body temp.
- Ensure PROPER POSITIONING
- DRAPE PT, and place large EMESIS BASIN under ear.
- Straighten ear canal
- ADULT –> up and back
- CHILD –> down and back
- Draw up irrigation solution (NO AIR)
- INSERT SYRINGE into meatus
- IRRIGATE GENTLY with prescribed solution
- Allow pt to REST ON AFFECTED SIDE –> (allows drainage of excess solution, prevents pressure build up)
- Dry ear canal.
What are bifocals?
BIFOCALS have 2 lenses.
TOP is formulated for a person to see far away
BOTTOM is formulated for a person to see close
TX for presbyopia and myopia.
Post eye surgery, the pt is complaining of a “curtain blocking her vision”, what is your initial action after assessing the eye?
RETINAL DETACHMENT
S/S - “curtain over part of vision”, FLOATIES, blurred vision.
PATCH EYE to prevent further damage.
Why is it important to make sure we are aware of the pts medications along with the reason the pt is on them, before surgery?
NEED TO KNOW WHAT MEDS THEY’RE ON PRIOR TO SURGERY
- contraindications? interactions?
- prevents complications
WHEN WAS LAST DOSE OF MEDS?
Why should a pt cough with mouth open after ear surgery?
INCREASES IOP!
Other things that should be avoided that increase IOP:
- STRAINING movements
- Air travel
- Rapid head movements
- Sneezing/coughing with mouth open
What is tympanoplasty, and pt education?
TYMPANOPLASTY - plastic reconstruction of TM (eardrum) or ossicles with the GOAL –> REPAIR/RESTORE HEARING.
PT EDUCATION
- TEMP HEARING LOSS IS NORMAL
- AVOID
-flying in AIRPLANES
-POPPING ears
-BENDING/LIFTING
-BLOWING NOSE
(blow one nostril at a time if necessary)
What is a corneal transplant, and pt education?
CORNEAL TRANSPLANT (KERATOPLASTY) - replacement of damaged corneal tissue.
PT EDUCATION
-Limit activities that INCR IOP!
(BENDING/LIFTING/STRAINING)
-NO WATER IN EARS
What is a stapedotomy and pt education?
STAPEDOTOMY - surgical procedure of MIDDLE EAR in which the STAPES IS REMOVED and replaces with a prosthesis.
PT POSITION - supine w/ HOB up
(operating side up decreases vertigo)
STERILE EAR PACKING - 5-6 days
PT EDUCATION
- NO WATER in ears
- AVOID things that INCR. IOP
- Sneeze with mouth open
- Straining, coughing, lifting
What does sensorineural hearing loss have to do with aging?
SENSORINEURAL hearing loss involves a disturbance of organs of the INNER EAR or of transmitting nerve.
ORGAN OF CORTI
COCHLEA
8th CRANIAL NERVE
* Less sensory fibers leading to cerebral cortex *
What is a RINNEs test used for?
RINNEs Test —-> used for HEARING
VIBRATING TUNING FORK
1st –> held against mastoid.
when pt can no longer hear…..
2nd –> place tuning fork inverted near ear canal.
PT SHOULD BE ABLE TO HEAR SOUND STILL
Used with a Weber’s test
What is an otoscope used for?
OTOSCOPE: instrument used to EXAMINE THE EAR
Uses light and magnifying lens to examine EXTERNAL EAR —> (TM/eardrum - malleus)
What is an ophthalmoscope used for?
OPHTHALMOSCOPE: instrument used to EXAMINE THE EYE.
Examines BACK OF EYE via the pupil.
- RETINA
- OPTIC DISC
- MACULA
- BLOOD VESSELS
Provides info about blood vessels, tumors, and condition of optic nerves.
Difference between miotic and mydriatic eye drops an how they work?
MIOTICS
- CONSTRICT * the pupil.
- Tx for glaucoma (reduces IOP)
MYDRIATICS
- DILATE * the pupil
- Used primarily during physical exams of the eye.
What is a SNELLEN test used for?
SNELLEN: used to assess * VISUAL ACUITY *
- Pt positioned 20 feet away from chart.
- 20/20= what you can see at 20ft, a person with normal vision can see at 20ft.
- 20/200= LEGALLY BLIND
- 20/40= minimum requirement to drive.
What are nursing actions and interventions for a pt complaining of SOB.
If pt complains of SOB:
-change position/ SIT PT UP
-Check VS & SPO2
( * maybe administer O2 * )
-Have pt take DEEP BREATHSATROPINE SULFATE
- Class
- Side Effects
- Pt teaching
ATROPINE SULFATE
** ANTIDOTE TO PILOCARPINE **
CLASS: Anticholinergic
SIDE EFFECTS
- XEROSTOMA (DRY mouth)
- XERODERMA (DRY skin)
- Blurred vision
- Photophobia
TEACHING
- CONTRAINDICATED WITH GLAUCOMA
- Report GI UPSET (Constipation / Diarrhea)
MECLIZINE (ANTIVERT)
- Class
- Side Effects
- Pt teaching
MECLIZINE (ANTIVERT)
- TX OF VERTIGO * assoc. w/ INNER EAR problems
CLASS: ANTIVERTIGO / Antiemetic
SIDE EFFECTS
- Drowsiness
- Dryness
- Blurry vision
- Photophobia
TEACHING
-Warn pt of SEDATIVE EFFECTS
(fall risk–> ensure SAFETY!)
-Avoid driving until effects of med is known.
BETAXOLOL (BETOPTIC)
- Class
- Side Effects
- Pt teaching
BETAXOLOL (BETOPTIC)
- TX FOR GLAUCOMA * - LOWERS IOP by decreasing aqueous fluid!!
CLASS: BETA - BLOCKER (antihypertensive)
SIDE EFFECTS
- Dizziness
- Headache
- Arthralgia
- URI / Pharyngitis
- Fatigue
TEACHING
- Monitor BP
- Consult MD before taking OTC meds (sinus/decongestants)
- Avoid driving until effects known.
PILOCARPINE (ISOPTO CARPINE)
- Class
- Side Effects
- Pt teaching
PILOCARPINE (ISOPTO CARPINE)
*TX for GLAUCOMA *
CLASS: CHOLINESTERASE INHIBITOR - produces miosis which increases space aqueous humor can flow —> DECR. IOP
SIDE EFFECTS
- Diaphoresis
- Flushing
- Rhinitis
- Dizziness
- HTN
- Dysphagia
TEACHING
- This is a LIFETIME med. - make sure pt understands
- can cause BURRED VISION/DIFFICULTY FOCUSING –> do not drive!
MEPERIDINE (DEMEROL)
- Class
- Side Effects
- Pt teaching
MEPERIDINE (DEMEROL)
- TX for ACUTE OTITIS MEDIA *
CLASS: NARCOTIC analgesic
SIDE EFFECTS
- Dizziness
- Fatigue/FAINTNESS
- Constipation
- Nausea
- DECR. RR
TEACHING
- DO NOT DRIVE/ TAKE CNS MEDS/ drink ALCOHOL
- Smoke and walk with assistance –> increases N/V and FAINTNESS effects.
- Monitor VS, BP, RR
DROPERIDOL (INAPSINE)
- Class
- Side Effects
- Pt teaching
DROPERIDOL (INAPSINE)
- TX for N/V assoc. w/ VERTIGO *
CLASS: ANTIEMETIC
SIDE EFFECTS
- Drowsiness
- HYPOtension
- Anxiety
- Dizziness
TEACHING
-pt should be aware of HYPOTENSIVE EFFECTS
TIMOLOL (TIMOPTIC)
- Class
- Side Effects
- Pt teaching
TIMOLOL (TIMOPTIC)
- TX for GLAUCOMA * - DECR IOP by reducong aqueous humor production.
CLASS: BETA - BLOCKER (Antihypertensive/Miotic)
SIDE EFFECTS
- LETHARGY
- HYPOGLYCEMIC
- Eye irritation
- Fever
- Hypokalemia
TEACHING
- Do not stop abruptly
- Med can cause DECR HR (learn how to assess pulses)
- Report difficulty breathing.
AMOXICILLIN (AMOXIL)
- Class
- Side Effects
- Pt teaching
AMOXICILLIN (AMOXIL)
- TX for EAR INFECTION *
CLASS: ANTIBIOTIC
SIDE EFFECTS
- GI upset
- N/V
- Pruritis/uticaria
- Conjunctival ecchymosis
TEACHING
- DO NOT MISS A DOSE
- Report diarrhea and s/s superinfection
DIPHENHYDRAMINE (BENADRYL)
- Class
- Side Effects
- Pt teaching
DIPHENHYDRAMINE (BENADRYL)
- TX for VERTIGO * (and N/V assoc. w/ inner ear)
CLASS: ANTIHISTAMINE
SIDE EFFECTS
- Sedative
- Dry mouth
- Incr. HR
- Tinnitus
- Photo-sensitivity
- Urinary retention
TEACHING
- Warn pt of SEDATIVE EFFECTS
- Tell pt DRY MOUTH IS NORMAL
ACYCLOVIR (VALTREX)
- Class
- Side Effects
- Pt teaching
ACYCLOVIR (VALTREX)
CLASS: ANTIVIRAL
SIDE EFFECTS
- Headache
- N/V
- Diarrhea
- Rash/pruritis
TEACHING
- Continue meds until 100%complete
- Monitor s/s hypersensitivity
SCOPOLAMINE (TRANSDERM SCOP)
- Class
- Side Effects
- Pt teaching
SCOPOLAMINE (TRANSDERM SCOP)
- TX for NAUSEA assoc. w/ inner ear problems *
CLASS: ANTICHOLENERGIC
SIDE EFFECTS
- DRY mouth
- Sedation
- Blurred vision
- Urinary retention
- Local irritation
TEACHING
- Place disc on skin site NIGHT BEFORE anticipated motion/trip for best effect.
- WASH HANDS
