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Nursing, LPN, Year 2 > x Eye & Ear Take Home > Flashcards

x Eye & Ear Take Home Flashcards

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1
Q

Types of Infectious and Inflam Eye Disorders

A
  • Blepharitis (inflame of eyelid)
  • Hordeolum aka Sty (infect of sebaceous gland, eyelid)
  • Chalazion (cyst of nodule of eyelid)
  • Conjuctivitis (inflame of conjunctiva, common)
  • Keratitis (inflam of cornea)
  • Uveitis (inflam of mid layer of eye)
  • Iritis (inflam of iris only)
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2
Q

Blepharitis

A

Inflammation of eyelid
CAUSE: infection or dermatitis
SS: eyelid irritated, itchy, eyelid margin red, crusted, scaly

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3
Q

Hordeolum

A

aka STY
Infection of sebaceous glands of eyelid
CAUSE: staphyloccos aureus
SS: red, painful, may affect internal or external lid

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4
Q

Chalazion

A

Painless cyst or nodule of eyelid

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5
Q

Conjunctivitis

A

aka Pink Eye
inflammation of conjunctiva, COMMON

CAUSE: viral, bacterial, direct contact
SS: mild, redness, itching, tearing, discharge of eye. (sever infections i.e. gonnorhea and trachoma major cause of blindness in sub saha africa, mid east, asia)

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6
Q

Disorders of Cornea

A

clear cornea transmits and helps focus light and images onto retina. protects internal eye. scarring can lead to blindness. no blood supply

  • Keratitis (inflame of cornea)
  • Corneal Ulcer
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7
Q

Keratitis

A

Inflammation of cornea

CAUSE: infection, lack of tears, trauma
SS: discomfort, tearing, discharge, photophobia, blepharospasm (spasm of eyelid, inability to open eye), sudden severe pain (corneal perf)

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8
Q

Corneal Ulcer

A

MEDICAL EMER
CAUSE: infection (herpes, shingles) , trauma, misuse of contacts
-superficial or deep
-scarring can occur
-if cornea perforated, can lead to infection –> vision loss

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9
Q

-Uveitis/Iritis

A
  • Uveitis (inflam of mid layer of eye)
  • Iritis (inflam of iris only), more common

SS: severe pain, photophobia, blurred vision, constricted pupil, red limbus (where cornea meets conjunctiva)

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10
Q

Eye Disorders: NI/MM

A
  • GOAL: to Preserve Vision, Prevention, Client teaching
  • DX: med Hx, eye exam, Flourescein stain w slit lamp exam (ulcers green at staining), Conjunctival/Ulcer scrapings (exam/culture)
  • MED:
  • prevent further infection, reduce pain, client teaching
  • frequent handwashing, discard old makeup, don’t share facial cosmetics, test vision using Snellen or Rosenberg chart
  • Dry sterile dressing over affected eye, perforation etc.
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11
Q

Corneal Transplant

A

done when cornea is scarred/opaque. taken from cadavors 65/under
MED: Antihistamine, Corticosteroids
-limited blood supply so rare for body to reject
-eye patch 24hrs after
-avoid activities that increase ocular pressure (lifting, BM,

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12
Q

Eye Disorder: Nursing Diagnoses

A

-Risk for disturbed sensory perception
OUTCOME: w remain free from visual deficits

-Acute Pain
OUTCOME: w state pain is absent or at tolerable level

-Risk for Injury
OUTCOME: w remain free from injury

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13
Q

Types of eye trauma

A
  • foreign bodies
  • abrasions
  • lacerations
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14
Q

Corneal Abrasion

A
  • scratch of cornea
  • cause: contact lens, eyelash, small foreign bodies
  • SS: painful, photo phobia, tearing
  • heal rapidly, no scar
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15
Q

Eye Burns

A

-affect outer portion of eye
-chem: ammonia, car battery acid, oven drain cleaners
-thermal burns from explosion
-UV light
SS: pain, affects vision, swollen eyelid, red edematous conjunctiva, may slough. Cornea appears cloudy or hazy

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16
Q

Eye perforation

A
  • cause: metal flakes, glass shards, weapons,

- SS: pain, partial/complete loss of vision, bleeding, possible loss of eye contents

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17
Q

Blunt Eye Trauma

A
  • Cause: sport injuries
  • minor ecchymosis (black eye) or subconjunctival hemmorhage (bleeding into conjunctiva)
  • RX: no treatment needed
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18
Q

Hyphema

A

Bleeding into anterior chamber of eye

-SS: Red tint to vision, visible blood in ant chamber, Diplopia, pain w eye mvmt.

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19
Q

NI/MM for eye injury

A

DX:

  • eye exam (eye mvmt, abrasions)
  • Fluorescein staining (presence of foreign bodies)
  • opthalmoscopic exam (bleeding/trauma to int chamber)
  • X-ray, CT scan

MM/NI:

  • eye irrigate w saline, copious amt. chem burn,
  • direct to INNER CANTHUS, head tipped lightly to affected side to avoid contam of other eye.
  • Sterile cotton tip applicator to remove foreign bodies.
  • eye patch to keep eye closed for 24 hrs
  • SX for penetrating wounds

MED:

  • topical analgesic (pain, photophobia)
  • topical ABX
  • Narcotics, Sedatives, Antiemetics, Analgesics ( pain, anxiety, prevent vomiting which Inc ocular pressure
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20
Q

Nursing Care, eye injury

A

PROTECTING EYE, PRESERVING VISION

  • asses, record vision each eye (baseline)
  • asses eye for traum
    -STAT irrigation if chem burn. Priority
    -
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21
Q

Refractive Errors

A

change in shape or cornea, lens or eyeball affect focus of light on the retina

  • Myopia
  • Hyperopia
  • Astigmatism
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22
Q

Myopia

A
  • Near sighted. see close objects clear

- DEC w age

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23
Q

Hyperopia

A
  • far sighted. see far objects clear

- INC w age

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24
Q

Presyopia

A

-impaired accommodation d/t age

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25
Q

Astigmatism

A

Irregular curvature of cornea and lens

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26
Q

** Myopia (see clear near) DEC w age

A

Hyperopia (see clear far) INC w age

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27
Q

Refractive Errors: NI and SX

A
  • encourage pt to seek Tx
  • check vision w chart
  • refer to optometrist prn
  • encourage wear glasses
  • teach MED eye drops admin, use as directed

SX:

  • Radial Keratotommy
  • LASIK
  • PRK (photorefractive keratectomy)
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28
Q

Cataracts

A

Clouding of lens

  • affect both eyes
  • EARLY SS: Clouding around edges (IMMATURE)
  • LATE SS: Clouding into center (MATURE), pupil grey/white, red reflex lost
  • SS: diff adjusted btwn light and dark
  • RISK: DM, Smoking, ETOH, Congenital, eye trauma, over -MED (corticosteroids, chlorpromazine), UV
  • DX: Eye exam, Hx
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29
Q

Glaucoma

A

NO CURE

  • UP ocular eye pressure, gradual vision loss (silent thief). Aqueous humor fills space btwn lens and cornea. Produced by ciliary body and flows thru pupil into anterior chamber. Then drains through trabecular mesh into canal of schlemm
  • Leading cause of blindness
  • SS: peripheral vision lost then progress
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30
Q

Normal Inter ocular Eye Pressure

A

12 - 20 mm Hg

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31
Q

Types of Glaucoma

A
  • Open angle

- Closed angle

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32
Q

Open Angle Glaucoma

A

-RSK: Af-Am, Mexican, prior Hx (screen every 2 yrs over 40yrs old)
-aqueous humor drainage thru canal of Schlemm is obstructed.
-Slow buildup of pressure
-damage retinal neurons and optic nerve
SS:
-peripheral vision gradually lost
-visual field narrows
-no pain
-diff adjusting light to dark
-blurred vision
-halo around lights
-diff focusing on near objects

33
Q

Closed Angle Glaucoma

A

-RSK: older adults, Asian, previous closed angle glaucoma
-MED EMERGENCY
-angle between cornea and iris closed
-BLOCKS drainage of aqueous humor
-sudden rapid UP Intraocular Pressure
-damage retina and optic nerve
-One eye affected
-AVOID MEDS that dilate the eye (w reduce angle and make worse)
SS:
-severe sudden eye pain w blurred vision
-N/V
-Halos aroun dlithst
-affected eye RED, cornea clouded
-dilated, fixed, non reactive pupil

34
Q

LOOK Nursing Care Checklist: Eye Sx

A

Box 40-2, Burke pg 1025

35
Q

LOOK Manifestations of Glaucoma

A

Box 40-4, Burke pg 1026

36
Q

MEDS: Mydriatics

A
  • Drugs to dilate pupils (Atropine)
  • MyDriatic, Dilate (pneumonic)
  • NOT FOR CLOSED ANGLE GLAUCOMA
37
Q

Glaucoma: Population Focus

A
  • Open Angle Glaucoma: Af-Am, Mexican, prior Hx (screen every 2 yrs over 40yrs old)
  • Closed Angle Claucoma: older adults, Asian, previous closed angle glaucoma
38
Q

Glaucoma: Dx Test

A
  • routine eye exam
  • Tonometry (measure IOP_
  • Funduscopy (asses fundus pallor, optic disc cupping)
  • Gonioscopy (mesaures depth of anterior chamber to diff open vs closed angle)
  • Visual Field testing (identify loss of peripheral vision)
39
Q

Glaucoma: MEDS

A

Preserve Vision, Reduce IOP

ACUTE

40
Q

MED: Adrenergic Agonists

A

reduce IOP by REDUCE aqueous humor production, INC it’s absorption

  • Aproclonidine (Lopidine)
  • Brimonidine (Alphagan)

NI:
.NOT in Closed Angle, cardiac arrhythmia, coronary artery disease
.report itching, lid edema, discharge

41
Q

MED: Beta Blockers

A

reduce IOP by RED production of aqueous humor. Does not affect vision

  • Betaxolol (Betoptic)
  • Timolol (Timoptic)

NI:
.report asthma, COPD, heart issues
.HOLD PRESSURE of bridge of nose (1 min) after instilling drops, to prevent systemic absorption. **
.report bradycardia, hypotension, diff breathing

42
Q

MED: Prostoglandin Analog

A

reduces IOP by improving outflow of aqueous humor

-Latanoprost (Xalatan)

NI:
. at bedtime as vision blurry after drops
.1x qhs
.report burning, stinging, redness
.IRIS will darken while using drug (normal)

43
Q

MED: Cabonic Anhydrase Inhibitor

A

reduce IOP by RED prod of aqueous humor (drops, IV)

-Dorzolamide (Trusopt eyedrops)

NI:
instill 10min apart from other opthalmic drugs
.report irritation, hypotension, diff breathing
.may cause eye sting and BITTER taste in mough

44
Q

.

A

.

45
Q

Glaucoma: Sx

A

Lower IOP

Open

46
Q

Glaucoma: NI/MM/Diagnosis

A

-Health promotion
-eye exam q2-4 yrs over 40yrs
-eye exam q1-2yrs if past HX or over 65yrs
-

Diagnoses:
.Reduced ability to provide self care
.increase anxiety
.risk for injury d/t altered peripheral vision

47
Q

How to administer EyeDrops, Ointment

A
  • apply drop in inner canthus
  • hold bridge of nose for beta blocker to prevent systemic absorption (Timolol)
  • Ointment, pull down lower lid, squeeze ointment in pocket, release lid and blink.
48
Q

Glaucoma: Nursing Diagnosis

A

-Deficient Knowledge (Ocular care)
OUTCOME: w verbalize understanding of glaucoma an demonstrate appropriate eye care

-Risk for Injury
OUTCOME: w remain free from injury

-Anxiety
OUTCOME: w report less anxiety

49
Q

Detached Retina

A

MED EMERGENCY

  • retinal contains neurons that allow us to see light and images. Detached, separation of retina from the choroid, the vascular layer of the eye
  • If layers stay separates (retina/choroid), neurons become ischemic and die

CAUSE: spontaneous, trauma, aging (vitreous humor shrink w aging inc risk for detachment)

DX: Eye exam, SS

SS:

  • sudden change in vision
  • no pain
  • veil across vision
  • floaters
  • flashing lights

NI:
-keep detached portion lower that rest of eye. want to keep flaps touching as much as possible

50
Q

Macular Degeneration

A

Macula atrophies or separates from choroid

  • common in OVER 65,
  • leading cause of blindness
SS: 
*.center vision disturbed
*.peripheral intact
.one eye affected
.straight lines appear wavy

NI:
.large print
.bright light

51
Q

Diabetic Retinopathy

A

capillaries dilate, develop micscopic aneurysms, leak, reupture. Cause edema and hemorrhages into retina. New fragile, weaker capillaries form no longer able to transport blood and oxygen to retina

  • 85% of DM pts develop
  • develops 15yrs after Dx w DM 1/2
  • leading cause of new blindness 20-74yrs

NI:
.regular eye exam
.take meds
.control glucose

52
Q

Enucleation

A

removal of an eye

NI: observe for prosthesis when documenting PERRLA

53
Q

Blindness: Promoting indipendence

A
  • notify staff of blind client
  • verbally communicate freely (narrate what you are doing)
  • orient client to room
  • never move furniture without notifying client
  • offer assistance w ADLs
54
Q

Ear Disorders

A

-External Otitis

55
Q

External Otitis

A 
inflammation of the ear canal
RSK: 
-Swimmers ear
-Hearing Aid
-Earplugs
CAUSE:
-bacteria
SS:
-ear pain
-drainage
-canal swollen
56
Q

External Otitis: Teach/NI

A

Pt TEACH:

  • out of water 7-10days
  • use earplugs to swim
  • hair dryer on low setting to dry ear canal after swim
  • NO cotton swabs or other objects in ear canal

NI:

  • hand-washing
  • warm drops by holding bottle in hand or pocket for 5 min
  • place client on unaffected side or tilt head toward unaffected side
  • partially fill ear dropper w MED
  • use non-dominant hand, straighten ear canal by pulling pinna UP an BACK
  • instill RX #of drops
  • keep client on side about 5 min after apply drops
  • loose cotton ball in opening of ear canal for 15-20min
57
Q

Impacted Cerumen/Foreign Bodies

A
  • common in older adults (cerumen drier and harder w age)
  • interferes w sound conduction and hearing
  • pt c/o fullness and tinnitus
  • visualized using otoscope

TX:
FOCUS: clearing canal
-irrigation
-removed using ear curet, forceps etc (wax/foreign bodies)
-Mineral oil or topical lidocaine used to immobilize or kill insects before removal
-**never use water to items such as beans, insects, as it may cause object to swell

58
Q

Otitis Media

A
  • inflammation or infection of Middle Ear
  • most common ME disorder
  • Infants/Young Children usually
  • eardrum protects mid ear from envt. Eustachian tube connects it with the nasopharynx .
  • Organisms can enter ME from nose/throat thru eustachian tube

RSK:

  • URI
  • eustachian tube dysfunction

DX:

  • med HX
  • SS
  • pneumatic otoscope exam (puff air blowin into ear canal. causes slight mvmt of eardrum. less mvmt indicates OM)
  • impedance audiometry (assess mvmt of eardrum and ME structures)
59
Q

Ottitis Media: Serous

A

SEROUS Otitis Media

CAUSE:
-Eustachian tube obstructed for a long time. Air in ME gradually absorbed, causing NEG pressure in ME. Neg press draws serous fluid from capillaries in the space

SS:
.DEC hearing
.snapping/popping sensation in ears
.eardrum moves less free and may bulge
.fluid bubble can be seen behind drum
.changes in atmos press can cause; acute pain, bleeding into ME, rupture of drum, or rupture of round window
60
Q

Ottitis Media: Acute

A

CAUSE

  • usually follows URI
  • swelling of Eustachian tube impairs drainage of ME
  • Mucus, serous fluid collect in ME, bacteria enter from nasopharynx, growing, multiply in fluid.
  • infection causes immune response, pus forms in ME. Pus INC pressure in ME and can rupture the eardrum.
SS:
-severe pain in affected ear
-F
-hearing loss
dizzineess
-vertigo
-tinnitus
-eardrum red, inflamed OR dull, bulging
-purulent drainage
-can lead to Acute Mastoiditis
61
Q

Acute Mastoiditis

A

CAUSE:
-UnRx Acute Mastoiditis

PATHOS:

  • pus fills air cells of mastoid process of temporal bone, next to ME
  • destroys the air cells

SS:

  • earache
  • hearing loss on affected side
  • mastoid process tender, swollen, red, inflamed
  • tinitus
  • HA
  • F
  • may lead to meningitis (rare)
62
Q

Ottitis Media: Chronic

A

permanent performation of the eardrum. recurrent ME infections, destroy the ear drum

SS:

  • recurrent ME infections
  • severe conductive hearing loss
63
Q

Ottitis Media: MEDS/SX

A

MEDS:

  • Decongestants
  • mild analgesics
  • Abx (5-10days, if acute)

SX:
to relieve press in ME
-Tympanocentesis (needle thru ear drum, draw fluid and pus out of ME
-Myringotomy (surgical drainage of ME
-Ventilation (typanostomy) tubes (allows ventilation and drainage of ME during healing)
-Mastoidectomy (removal of infected cells, bone, pus)

ALTERNATIVE:

  • 1 drop lavendar oil on cotton in ear canal
  • warm cloth or chammomile tea bag steeped in warm water, apply heat to side of face or ear, reducing pain
  • pulsatilla, belladonna, aconite
64
Q

Ear Sx: Nursing Care Checklist

A

(Burke, pg1036, Box 40-8)

PRE-OP

  • assess hearing
  • discuss post-op communication strategies
  • avoid blowing nose, coughing, sneezing. instruct to leave mouth open to relieve pressure during.

POST-OP

  • assess for bleeding, drainage from affected ear
  • asses for N, admin antiemetics
  • elevate hob and position on unaffected side
  • assess for vertigo, dizziness
  • assess hearing
  • stand on unaffected side to communicate, use other comm strategies such as writing etc.
  • avoid coughing, blowing nose, sneezing
  • provide home care instructions (avoid showers until approved by MD)
65
Q

Mid Ear Disorder: Diagnoses

A
  • Acute Pain

- Deficient Knowledge

66
Q

Inner Ear Disorders

A

-Labrinthitis
-Meneiere’s Disease
NO CURE

hearing loss

NI/MM
GOALS: manage symptoms, prevent hearing 
-Bed rest
-dark room
-DEC stimuli
-min mvmt

DX:

  • electronystagmography (ass involun eye mvmt)
  • Xray/CT scan
  • Glycerol Test (oral glycerol to DEC press in Inner Ear)

MED:

  • Diuretic: Hydrochlorothiazine ( Diuretic, DEC IE press)
  • Vertigo/Nausea: Meclizine (Antivert), Prcholrparazine (Compazine), hydroxyzine (Vistaril):
67
Q

Vertigo

A

sensation of whirling or mvmt when there is none

Vertigo is a disorder of equilibrium. Can be disabling, causing falls, injury, diff walking.

Dizziness, however, is a feeling of unsteadiness, lack of balance, light headedness or mvmt within the head. Not as severe.

68
Q

Labrynthititis

A

inflammation of inner ear. Uncommon

CAUSE:
bacteria or viruses

SS:

  • severe vertigo
  • hearing loss
  • nystagmus (rapid involuntary eye mvmts)
  • N/V
69
Q

Meniere’s Disease

A

chronic inner ear disorder caused by excess fluid and pressure in the labrynth of the inner ear

Onset: sudden or gradual

SS:

  • recurring vertigo w tinnitus (sudden, min-hours)
  • gradual hearing loss (usually one ear)

NI:

  • lo Na diet (reduce attacks)
  • no smoking, ETOH
70
Q

Inner Ear: Home Care

A

reduce risk for injury and promote normal sleep patterns

  • change position slowly
  • turn whole body, not just head
  • don’t walk alone
71
Q

Hearing Loss

A

class: conductive, sensorineural or mixed. hearing deficit can be partial or total, congenital or acquired. one or both ears.

72
Q

Conductive Hearing Loss

A

anything that affecrs sound transmission from external opening of ear to inner ear.

(i.e.) obstruction of ear canal (cerumen, perf eardrum, damage to ossicles in mid ear, fluid, scarring, tumors of mid ear.

Sound Amplification devices are effective (hearing aids)

73
Q

Sensorineural Hearing Loss

A
  • affect inner ear or auditory pathways of brain
  • affects ability to hear hi-freq sounds and understanding of consonants (t,p or s)

Hearing Aid may not be effective

CAUSE:

  • Trauma
  • infection
  • disease (Menier’s)
  • ototoxic meds (asa, Lasix, vancomycin, streptomycin, aminoglycoside abx, antimalarial, chemo)
  • renatoal exp to rubella
  • noise (most comm in US)
74
Q

Presbycusis

A
  • progressive hearing loss d/t aging, hair cells of cochlea degenerate
  • sensorineural

SS:
loss of hi pitch, conversation

Hearing Aids useful
Talking louder DOES NOT help

75
Q

Rinne/Weber Tests

A

to determine whether hearing loss is conductive or sensory
RINNE Test
tuning fork on mast bone, wen stop hearing sound, put to ear. If you still hear it, air conduction is better than bone conduction

WEBER Tests
Tuning fork on top of head. Should hear equally in both ears.

76
Q

Amplification

A

.

77
Q

Hearing Aids

A 
devices that amplify sounds making it easier for clients to hear.  Rx only
IN EAR
-discreet, head dexterity
OVER EAR
louder, easier to handle
POCKET TALKER
cheaper, no Rx
MICROPHONE/AMP
for profound hearing loss
78
Q

Hearing Loss: NI

A
  • wear hearing aids
  • cleon our cerumen
  • DEC background noise when speaking to pt

Nursing, LPN, Year 2 (27 decks)

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