Chap 53 Care of the patient with sensory disorder
Cataracts clinical manifestations:
painless and Blurred vision, difficulty reading fine print, diplopia, photo sensitivity, glare, abnormal color perception difficulty driving at night
otitis media risk factors
passive smoke daycare, males 6 to 36 month, bottle-feeding chronic health problems sibling with recurrent ear infections Patient usually had upper respiratory infection that ascends via the eustachian tube and involves the lining of the entire middle ear
Menieres disease risk factor
recent viral infection, stress, alcohol use, family history and allergies
keratoplasty (corneal transplant)
removal of the full thickness of the patient cornea followed by surgical implantation Done to replace a damaged cornea resulting from trauma, ulceration or congenital deformations -Corneal is taken 4 h of death -Communicable disease diseases such as Hep, HIV or cancer are not appropriate for transplants -Donor tissue is best used within 5 days after removal
eye safety for corneal injuries
Teach how to apply drops wear goggles, avoid strain
Hyperopia medical management
corrective eyewear (contact or glasses)
Cataracts
crystalline opacity or clouding of the lens Can be -congenital (rubella) -acquired(systemic disease, trauma, toxins -Senile related to age
keratitis diagnostic test
culture and sensitivity test fluorescien-gram staining Gram negative bacteria appears green Gram positive bacteria appears yellow
blindness S/S
diplopia, blurred vision, pain presence of floaters or flashes of light in the visual fields, light sensitivity, burning of the eyes, sense of orbital pressure, bulging eyes,
Diabetic retinopathy
disorder of retinal blood vessel characterized by capillary micro-aneurysms, hemorrhage, exudate and formation of new vessel and connective tissue Can cause retinal detachment
Refraction
eye is able to bend light rays so that the rays fall onto the retina
hyperopia
farsightedness, result from error of refraction in which rays of light entering the eye are brought into focus behind the retina inability to see objects at close range
legal blindness
loss in visual acuity that prevents a person from performing work requiring eyesight; defined as maximal visual acuity of 20/200 with corrective eyewear and / or field sight capacity reduced to 20 degrees
blindness
loss of visual acuity that ranges from partial to total loss of sight
Glaucoma risk factors
middle age and older 1 in 50 whites is affected 1 in 10 a] African a American will have it
open angle glaucoma
more common, 90 % of cases, no pain or blurred vision despite loss of peripheral vision The outflow of aqueous humor is decreased in the trabecular meshwork, the drainage channel is occluded. It slow progressive and result from degenerative changes, can affect both eyes more common in African American and diabetics patients Check nerve damage, decline peripheral vision
Snellen test
most common exam , assess acuity, for children adjust it Patient is at 20 feet from chart and ask to read lines -20/20 means pt has normal vision -20/40 means patient can read at 40 feet what the normal person can read at 20 feet.
myopia
nearsightedness Elongation of the eyeball or an error in refraction so that parallel rays are focused in front of retina S/S inability to see objects at a distance
Menieres disease
CHRONIC disease of the inner ear characterized by recurrent episodes of vertigo, progressive unilateral nerve deafness and tinnitus
A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder?
"Have you had difficulty with peripheral vision?
Glaucoma Diagnostic Tests
- Tonometry is used to measures IOP Normal IOP is 10 to 21, pt will have above 22 usually between 22 and 32 in open angle and 50 and higher in closed angle - visual field test shows decline in peripheral vision
blindness patient teaching
-Assess ability to perform ADLs and provide assistance with ADLs -Allow adequate time to assist in self care -Be aware of services and device available and make referrals -Advise patient to walk slowly, obtain verbal clue from walking companions, touch objects if present with tips of canes, -The companion should precede the patient 1 foot, with hand on the companion elbow -Describe surroundings when assisting in new surroundings
Possible causes of patient's reduce vision?
-Cataracts -Glaucoma -Retinopathy
total blindness
-Complete lack of form and visual light perception -Clinically recorded as NLP (no light perception)
blindness causes
-Congenital results from birth defects -Acquired from diabetic retinopathy, glaucoma, cataracts, infections, tumors and acute trauma
Blindness medical management
-Corrective eyewear, -Assistive devices : canes, guide dogs, magnifying systems, -surgical correction: laser surgeries provide excellent results, corneal transplants can restore corneal damage
Post op glaucoma surgery
-Elevate HOB to promote eye drainage by gravity, minimize eye swelling and discomfort and reduce eye trauma -An eye patch should be placed on patient and should not be taken at night -Can not be drive back home with eye shield -Instruct patient to avoid bending at waist and lifting ( nothing over5 lbs) will increase IOP and should be avoided to prevent injury to the healing surgery site. -Staining with BM is also avoided ( may have to take stool softeners) -Patient should lie in unaffected side -Instruct patient to wash hands before touching eye, to avoid infection, wash periorbital area each day, cleansing in and outward motion,, avoid dripping water,, no shampooing or water should get into eye, avoid splashing water into eye when showering and bathing
Macular degeneration clinical manifestations:
-Gradual and variable bilateral loss of central vision gradual loss of ability to see objects clearly distorted vision, with object appearing to be the wrong size or shape or straight lines appearing wavy or crooked Gradual loss of color vision scotomas (blind spots in visual field) Dark or empty area appearing in the center of vision Pt have difficulty to distinguish colors
Glaucoma
-Increase intraocular pressure in the anterior chamber because of obstruction of the outflow of aqueous humor -Optic nerve atrophy -progressive loss of peripheral vision
Keratitis
-Inflammation of the cornea May result from Injury, irritants, allergies, bacterial infections (syphilis,) viral infection (HSV and varicella zoster)or diseases -Pneumococcus, staph, strep, pseudomonas are most common types of bacterial causes -Herpes simplex is most common viral cause
Keratitis medical managements:
-Topical and systemic antibiotics -Cycloplegic mydriatic drug paralyze the ocular muscle of accommodation and dilate the pupil - Antiviral therapy Acyclovir -Analgesics to control pain Pressure dressing to relax the eye muscle, in both eyes -Warm or cold compresses 2 or 4 times a day to relieve symptoms -Epithelial debridement my be performed Corticosteroids are contraindicated because they contribute to a longer course, possible deeper ulceration of the cornea, and systemic complications -Surgical management may involve corneal transplant aka keratoplasty
A nurse is reinforcing teaching for a client who has just had a cataract removed from the right eye & an intraocular lens implanted. Which of the ff should the nurse includes?
-Wear sunglasses when outside -Do not engage in sexual intercourse until your provider has verified that your eye has healed -Manage eye pain w/ acetaminophen -Take a stool softener to prevent constipation
what action should the nurse take if client with glaucoma is taking timolol or betaxolol
-assess history for diagnosis of asthma Beta is for beta 1 and beta 2 Betaxolol is for beta 1 only and do not cause bronchospasm. It is preferred drug for asthmatic -Monitor pulse rate for bradycardia and heart block Beta blocker decrease HR, BP should be monitored Use in patient with HF
ARMD diagnostic test
ophthalmoscopy detect opacity, hemorrhage and new blood vessel formation Fluorescein angiography is used to assess presence of leaking blood vessels and confirm diagnosis
hyperopia diagnostic test
ophthalmoscopy, retinoscopy, visual acuity and refraction tests
Otitis media medical managements:
Antibiotics to , analgesics for severe pain, nasal decongestants, local heat, aspiration of fluid from behind eardrum, myringotomy
*Common Refractory Errors*
Astigmatism, hyperopia myopia
Cataracts post op medical managements:
Avoid direct sunlight, bed rest, analgesics, no bending or straining, avoid activities that increase IOP such as bending, stooping, coughing or lifting Eye shield in operate eye at night for protection Report signs of infection, such as yellow or green drainage, BEST VISION is not expected until 4-6 weeks after the surgery Do not bera down Post op meds are antibiotic, corticosteroids drops to prevent infection and decrease postoperative inflammatory response Notify HCP if complication such as pain erythema, drainage or sudden visual changes, sudden pain
Cataract patient teaching
Avoid straining Avoid heavy lifting Avoid use of make up No rubbing eyes Wear sunglasses Proper ways to use eyes drops, apply light pressure to prevent quick absorption Can resume sexual activity within 1 - 2 weeks Can return to work (1 - 4 weeks) Takes 6 - 8 weeks to fully return to normal
keratoplasty preoperative
Before surgery, encourage patient to ask questions and expose concerns Teach about the use of of protective eyeglasses if a dilation causing eye medication is to be used Teach patient deep breath and turning to reduce complications NO COUGHING because it can damage the surgical site Maintain dietary restrictions and administer meds as ordered
Cataract pre-op
Blood thinner need to be stop
A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The nursing instructor asks the student to describe the types of medication that will likely be prescribed for the client to treat the eye disorder. Which drug classification will facilitate the outflow of aqueous humor?
Cholinergic miotic agents
Cataracts medical management:
Surgery is the only definitive method -Intracapsular extraction, removal of the lens and its entire capsule -Extracapsular extraction the anterior capsule is opened and the lens nucleus and cortex are removed, leaving the remaining capsular bag intact. Healing id rapid
Meniere's disease medical managements:
Destruction of the labyrinth, Endolymphatic shunt, Cryosurgery, Vestibular nerve section
A nurse is caring for a client in an extended care facility who has macular degeneration. What ADL will the client require the greatest amount of assistance?
EATING
hyperopia patient teaching
Emphasize proper care of contact Eyeglasses fit properly the bridge of nose to eliminate slippage
keratoplasty post operative
Ensure correct post op positioning is maintained. Pt on the back or non operative site Use safe measures adequate lightning, clear path orientation to unfamiliar surroundings until patient able to do so Prevent injuries by providing safety devices and orienting patient Announce presence Pt should avoid bond, lift and strain for 1 month to prevent IOP Report severe pain to surgeon , any complaints of erythema, loss of vision photophobia that will occur with corneal rejection Give meds as prescribed, maintain strict surgical asepsis wash hand before contact with eye area, No use of irritants, fragrant powders, perfumes, or eye make up that can cause irritation, sneezing, or coughing Do not rub eyes Reading is limited, TV is ok iF eye patch , show how to use it, if metal eye shield, use at to protect from trauma
ARMD risk factors
Family history of ARMD Advanced age Female gender, light color eye long term exposure to UV light, hyperopia Smoking, obesity, race, Vit A,E, C, copper, zinc slow the progression
closed angle glaucoma
Flow of aqueous humor out of the eye is restricted, , it is painful Affected eye is red, and tearing, eyelid is swollen' Treatment should start within 24 to 48 h to avoid blindness
Corneal injuries medical managements:
Flush w/ normal saline or water - antibiotic drops or ointment- penetrating wounds- Do not remove object if present
Otitis media clinical manifestations:
Fullness in the ear, severe, deep throbbing pain behind tympanic membrane, hearing loss, tinnitus, ringing or tinkling sound in the ear , fever The severe pain may disappear if tympanic membrane rupture
Otitis media
Inflammation or infection of the middle ear Most common ear disorder caused by Haemophilus influence or strept Only one side is affected
A client arrives in the emergency department with an eye injury caused by metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse plan to assist with first?
Irrigate the eye with sterile saline.
A client sustains a chemical eye injury from a splash of a battery acid. The nurse should prepare the client for which immediate measure?
Irrigating the eye with sterile normal saline
open angle glaucoma medical management
Keep IOP low to prevent development Open angle is treated by =beta blockers such as betaxolol reduces IOP, -=latanoprost prostaglandins, 1 drop in eye in PM =miotics like pilocarpine constrict pupil and draw the iris away from cornea allowing aqueous to drain -carbonic anhydrase inhibitors such as acetazolamide decrease production of aqueous humor, which lower IOP
meniere disease patient teaching
Maintain low salt, administered drugs as ordered Minimize vertigo and provide safety keep patient in quiet, dark room in comfortable position Have emesis basin close Avoid fluorescent light or TV watching because this exacerbate Symptoms
Glaucoma Patient Teaching
Matter of control - no cure, importance of meds rest of life, Teach patient proper techniques to to administer eyes drops **Avoid antihistamines, sympathomimetic drugs, no anticholinergics (atropine)**
mydriatics drops
May be used to evaluate internal surface and will cause photosensitivity for a few hours after the exam They dilate the pupils, used in conditions like cataracts, corneal injury, macular degeneration,, disorders of retina, detachment, vessel occlusion and retinitis pigmentosa Don't use in patients with glaucoma (build up IOP)
Diabetic retinopathy clinical manifestations:
Micro-aneurysms identified by ophthalmoscopy in initial phase 'In advanced phase patient has progressive vision loss and the presence of "floaters"
intervention diabetic retinopathy
Monitor for hemorrhage
Menieres disease pharmacotherapeutic:
NO SPECIFIC TREATMENT -fluid restriction, diuretics, low salt diet to decrease fluid pressure Advise patient to avoid caffeine, nicotine Dimenhydrinate, meclizine, diapam, diphenhydramine and fentanyl ordered to use between attacks to reduce vertigo -antivertigo med ( Meclizine)- contraindicated on pt. w/ closed angle glaucoma SURGERY ( preserve hearing in 60 to 90 5 of patients) destruction of labyrinth, insertion of drainage tubes into the subarachnoid space, dissection of cranial nerve VIII Post op Bed rest 1 to 2 weeks, implement safety precautions to avoid falls related to dizziness
Macular degeneration medical managements:
NO TX FOR ARMD New growth can be stopped with meds Bevacizumab and pegaptanib are injected into eye Antibiotic drops accompany injection to prevent infection -photodynamic therapy is used to treat wet ARMD , cause deconstruction of abnormal vessel without causing damage to retinal pigment and photoreceptors After therapy, patient should avoid direct sunlight and others forms of light for 5 days
pre op glaucoma surgery
Take antibiotic eye drops 3 days before surgery If in anticoagulants, need to be stop Optimal vision will not occur for several weeks after surgery Reading glasses will be needed after surgery You must lie still during surgery You can hear the doctors and nurses talking during surgery
Corneal injuries pharmacological management:
Opthalmic antibiotic and steroid: Tobramycin-Dexamethasone(Tobradex) Opthalmic steroids: Prednisone( Ocu pred) Diuretics: Furosemide
Corneal injuries clinical manifestations:
Pain w/ eye movement- excessive tearing- pruritus- erythema of conjunctiva
Diabetic retinopathy medical managements:
Photocoagulation to destroy new blood vessels, seal leaking vessels and prevent retinal edema Vitrectomy or cryotherapy is used when photocoagulation is not possible
Tympanoplasty nursing actions:
Post op bed rest until next morning elevate HOB 40 degrees keep operative side facing upward Monitor temperature, bleeding and report amount, color and constancy of drainage Note complaint of vertigo if patient getting out of bed with sudden movements, nausea, -
Latanoprost (Xalatan)
Prostaglandin analogues (Antiglaucoma) EFFECTS Brown pigmentation of the iris; darkening of the eyelid, blurred vision, itching, excessive tearing; length and thickness in eyelashes. NURSE INTER Close observations during the first dose of med administration.Assess: obtain a thorough medical history- allergies and herbal preparations.Assess: vital signs, baseline ,visual acuity, pulmonary crackles and wheezes. TEACHING Take full course of medication as prescribed; never stop medication suddenly without Dr. approval; instruct client to avoid drugs with potential to increase IOP; inform the client to expect brown pigmentation of iris, darkening eyelids, and excessive tearing; teach client how to administer eye drops.
Menieres disease other clinical manifestations:
Recent episode of vertigo associated with Nausea, vomiting, diaphoresis, tinnitus and nystagmus, tinnitus A sense of fullness in the ear and hearing loss may be present
Corneal injuries
Result from injuries to corneal layers of the eye Cause : laceration, abrasion foreign object in eye, chemical in eye,
ARMD TEACHING
SAFETY, NUTRITION WITH VITAMINS Vit A,E, C, copper, zinc HELP lower progression, diet with dark leafy vegetables spinach , kale, watch light For children eat vit A rich food,
Keratitis clinical manifestations:
Severe eye pain, photophobia, tearing, edema, visual disturbances May lead to blepharospasm (involuntary blinking or spasms of eyelid) and vision loss)
Aged-related macular degeneration (ARMD)
Slow, progressive loss of central and near vision due to aging retina. Most common cause of loos of vision in people older than 60
communicate with a blind person
announce your presence talk in normal tone of voice introduce your self with each contact Do not avoid common phrases like see what I mean explain any activity occurring in the room Announce when you are leaving
Tympanoplasty
any procedure of the eardrum or ossicles of the middle ear to restore or improve hearing in patients with conductive hearing loss Used to repair a perforated eardrum, for otosclerosis, for dislocation or necrosis of a small bone in yhe middle ear
open angle glaucoma S/S
blurred vision, diplopia, loss of peripheral vision, eye pain, difficulty adjusting to dark, halos around light, inability to detect colors IOP is elevated
Keratitis nursing intervention and patient teaching
control pain, safety and prevent complications is essential Provide info about self care of corneal abrasion Teach patient to wash hands before instilling meds to prevent infection and avoid rubbing the eyes Instruct patient to note any changes in discharge or increase pain and to notify HCP stat
