Chapter 13 Care of the Patient with a

Chapter 13 Care of the Patient with a Visual or Auditory Disorder Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc.

Overview of Anatomy and Physiology • Anatomy of the eye § Accessory structures of the eye • • Eyebrows Eyelashes Eyelids Lacrimal apparatus Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 2

Figure 13 -1 (From Thibodeau, G. A. , Patton, K. T. [2007]. Anatomy and physiology. [6 th ed. ]. St. Louis: Mosby. ) Lacrimal apparatus. Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 3

Overview of Anatomy and Physiology • Anatomy of the eye (continued) § Structures of the eyeball • • Sclera Cornea Choroid Ciliary body Iris Pupil Retina Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 4

Overview of Anatomy and Physiology • Anatomy of the eye (continued) § Chambers of the eye • Anterior chamber § Aqueous humor • Posterior chamber § Vitreous humor Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 5

Figure 13 -2 (From Thibodeau, G. A. , Patton, K. T. [2008]. Structure and function of the body. [13 th ed. ]. St. Louis: Mosby. ) Horizontal section through the left eyeball. The eye is viewed from above. Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 6

Overview of Anatomy and Physiology • Anatomy of the ear § External ear • Auricle • External auditory canal • Tympanic membrane § Middle ear • • Eustachian tube Malleus Incus Stapes Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 7

Figure 13 -3 (From Thibodeau, G. A. , Patton, K. T. [2008]. Structure and function of the body. [13 th ed. ]. St. Louis: Mosby. ) The ear. External, middle, and inner ear. (Not to scale. ) Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 8

Overview of Anatomy and Physiology • Anatomy of the ear (continued) § Inner ear • Labyrinth § § Bony labyrinth—filled with perilymph o Semicircular canals o Vestibule o Cochlea—organ of Corti Membranous labyrinth—filled with endolymph Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 9

Figure 13 -4 (From Thibodeau, G. A. , Patton, K. T. [2005]. The human body in health and disease. [4 th ed. ]. St. Louis: Mosby. ) The inner ear. Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 10

Overview of Anatomy and Physiology • Other special senses § Taste and smell • Taste buds: salty, sweet, sour, bitter • Olfactory receptors: sense of smell § Touch • Tactile receptors § Position/movement • Proprioceptors Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 11

Laboratory and Diagnostic Examinations • Diagnostic eye tests § § § § Snellen test Color vision Refraction Ophthalmoscopy Tonometry Amster grid test Schirmer’s tear test Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 12

Disorders of the Eye • Blindness and near-blindness § Etiology/pathophysiology • Loss of visual acuity • Congenital or acquired • Legal blindness § § 20/200 with corrective eyewear (normal 20/20) Visual field less than 20 degrees (normal 180) Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 13

Disorders of the Eye • Blindness and near-blindness (continued) § Clinical manifestations/assessment • • Diplopia Pain Floaters and light flashes Pruritus; burning of the eyes Loss of peripheral vision Halos Orbital pressure Bulging of the eyes Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 14

Disorders of the Eye • Blindness and near-blindness (continued) § Medical management/nursing interventions • • • Corrective eyewear Canes Seeing-eye dogs Magnifying systems Surgical procedures Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 15

Disorders of the Eye • Refractory errors § Etiology/pathophysiology • Astigmatism—unequal curve in the shape of the cornea or lens • Strabismus—inability of the eyes to focus in one direction; cross-eyed • Myopia—nearsightedness; eyeball is too long • Hyperopia—farsightedness; eyeball is too short Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 16

Disorders of the Eye • Refractory errors (continued) § Clinical manifestations/assessment • Diminished or blurred vision § Medical management/nursing interventions • Corrective lenses • Surgical correction § § § Radial keratotomy (RK) Photorefractive keratectomy (PRK) Laser-assisted in-situ keratomileusis (LASIK) Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 17

Disorders of the Eye • Conjunctivitis § Etiology/pathophysiology • • • Inflammation of the conjunctiva Bacterial or viral infection Allergy Environmental factors Commonly called pink eye Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 18

Disorders of the Eye • Conjunctivitis (continued) § Clinical manifestations/assessment • Erythema of the conjunctiva • Edema of the eyelid; crusting discharge • Pruritus; burning; excessive tearing § Medical management/nursing interventions • • Warm compresses Eye irrigations with normal saline Antibiotic drops or ointment Keep free from exudate Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 19

Disorders of the Eye • Keratitis § Etiology/pathophysiology • Inflammation of the cornea • Injury, irritants, allergies, viral infection, or diseases • Pneumococcus, Staphylococcus, Streptococcus, and Pseudomonas are most common types of bacterial causes • Herpes simplex is most common viral cause Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 20

Disorders of the Eye • Keratitis (continued) § Clinical manifestations/assessment • • • Severe eye pain Photophobia Tearing Edema Visual disturbances Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 21

Disorders of the Eye • Keratitis (continued) § Medical management/nursing interventions • Pharmacological management § § • • Topical and systemic antibiotics Analgesics Pressure dressings Warm or cold compresses Epithelial debridement Keratoplasty Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 22

Disorders of the Eye • Dry eye disorders (keratoconjunctivitis sicca) § Etiology/pathophysiology • Lacrimal gland dysfunction from an autoimmune mechanism § Clinical manifestations/assessment • Complaints of sandy or gritty sensation in the eye § Medical management/nursing interventions • Artificial tear replacement • Punctal plugs or repair if injured Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 23

Disorders of the Eye • Ectropion and entropion § Etiology and pathophysiology • Noninfectious disorders of the eye lid causing abnormal eyelid margins § Clinical manifestations • Abnormal direction of the eyelid • Corneal dryness § Medical management/nursing interventions • Topical medications to reduce conjunctival and corneal drying • Surgery Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 24

Disorders of the Eye • Cataracts § Etiology/pathophysiology • Noninfectious opacity or clouding of the lens • Congenital; acquired; senile § Clinical manifestations/assessment • • • Blurred vision Diplopia Photosensitivity Decreased night vision Opacity in the center portion of lens Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 25

Disorders of the Eye • Cataracts (continued) § Medical management/nursing interventions • Surgical removal § Lens implant or glasses • Postoperative § § § Avoid direct sunlight Bed rest with bathroom privileges (BRPs) Analgesics No bending down or straining Avoid coughing, sneezing, and blowing nose Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 26

Disorders of the Eye • Diabetic retinopathy § Etiology/pathophysiology • Capillary microaneurysms, hemorrhage, exudates, and formation of new vessels and connective tissue in the retina § Clinical manifestations/assessment • Microaneurysms • Progressive loss of vision; “floaters” § Medical management/nursing interventions • Photocoagulation • Vitrectomy Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 27

Disorders of the Eye • Macular degeneration § Etiology/pathophysiology • Slow, progressive loss of central and near vision due to aging retina § Clinical manifestations/assessment • Gradual and variable bilateral loss of vision • Color perception may also be affected § Medical management/nursing interventions • Usually no treatment • May use photocoagulation Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 28

Disorders of the Eye • Retinal detachment § Etiology/pathophysiology • Separation of the retina from the choroid in the posterior area of the eye § Clinical manifestations/assessment • Flashes of light; floating spots • Loss of a specific field of vision § Medical management/nursing interventions • Photocoagulation; cryosurgery; diathermy • Scleral buckling Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 29

Figure 13 -8 (From Lewis, S. M. , Heitkemper, M. M. , Dirksen, S. R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7 th ed. ]. St. Louis: Mosby. ) Retinal break with detachment: surgical repair by scleral buckling technique. Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 30

Disorders of the Eye • Glaucoma § Etiology/pathophysiology • An abnormal condition of elevated pressure within an eye; obstruction of outflow of aqueous humor § § Open-angle Closed-angle Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 31

Figure 13 -9 (From Havener, W. H. [1997]. Synopsis of ophthalmology. St. Louis: Mosby. ) A, Chronic open-angle glaucoma. B, Acute-angle closure glaucoma. Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 32

Disorders of the Eye • Glaucoma (continued) § Clinical manifestations/assessment • Open-angle § § § No signs or symptoms during early stages Tunnel vision Eye pain Difficulty adjusting to darkness Halos around lights Inability to detect colors Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 33

Disorders of the Eye • Glaucoma (continued) § Clinical manifestations/assessment • Closed-angle § § § Severe pain Decreased vision Nausea and vomiting Erythema of the sclera Enlarged and fixed pupil Halos around lights Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 34

Disorders of the Eye • Glaucoma (continued) § Medical management/nursing interventions • Open-angle glaucoma § § § Beta blockers Miotics Carbonic anhydrase inhibitors • Closed-angle § § Osmotic diuretics Iridectomy Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 35

Disorders of the Eye • Corneal injuries § Etiology/pathophysiology • Result from injuries to corneal layers of the eye § Clinical manifestations/assessment • Pain with movement of eye • Excessive tearing; pruritus • Erythema of conjunctiva Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 36

Disorders of the Eye • Corneal injuries (continued) § Medical management/nursing interventions • Flush with normal saline or water • Antibiotic drops or ointment • Penetrating wounds § Do not remove object if present Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 37

Surgeries of the Eye • Enucleation § Surgical removal of the eyeball • Keratoplasty (corneal transplant) § Excision of the corneal tissue, followed by implantation of a cornea from a donor • Photocoagulation § A laser is directed into a small spot on the retina • Vitrectomy § Removal of excess vitreous fluid caused by hemorrhage and replacement with normal saline Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 38

Laboratory and Diagnostic Examinations • Diagnostic ear tests Otoscopy § Tuning fork tests § • Weber’s test • Rinne test Autometric testing § Vestibular testing § • Romberg test • Past-point testing Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 39

Figure 13 -13 (From Seidel, H. M. , Ball, J. W. , Dains, J. E. , Benedict, G. W. [2003]. Mosby’s guide to physical examination. [5 th ed. ]. St. Louis: Mosby. ) Weber tuning fork test. Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 40

Figure 13 -14 (From Seidel, H. M. , Ball, J. W. , Dains, J. E. , Benedict, G. W. [2003]. Mosby’s guide to physical examination. [5 th ed. ]. St. Louis: Mosby. ) Rinne tuning fork test. Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 41

Loss of Hearing (Deafness) • Hearing impairment § Etiology/pathophysiology • Decreased auditory acuity; partial or complete • Affects development of speech • Types § § § Conductive Sensorineural Mixed Congenital Functional Central Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 42

Loss of Hearing (Deafness) • Hearing impairment (continued) § Clinical manifestations/assessment • Requests for repeating information • Nonresponse • Delayed speech development § Medical management/nursing interventions • • According to cause Hearing aids Surgical procedures Cochlear implant Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 43

Inflammatory and Infectious Disorders of the Ear • External otitis § Etiology/pathophysiology • Inflammation or infection of the external canal § Clinical manifestations/assessment • Pain with movement of auricle or chewing • Erythema, scaling, pruritus, edema, watery discharge, and crusting of the external ear § Medical management/nursing interventions • Oral analgesics; corticosteroids • Antibiotic or antifungal ear drops; oral antibiotics Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 44

Inflammatory and Infectious Disorders of the Ear • Otitis media § Etiology/pathophysiology • Inflammation or infection of the middle ear § Clinical manifestations/assessment • • • Fullness in the ear Severe, deep, throbbing pain Hearing loss Tinnitus Fever Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 45

Inflammatory and Infectious Disorders of the Ear • Otitis media (continued) § Medical management/nursing interventions • Pharmacological management § § § Antibiotics Analgesics Nasal decongestants • Local heat • Aspiration of fluid from behind eardrum • Myringotomy Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 46

Inflammatory and Infectious Disorders of the Ear • Labyrinthitis § Etiology/pathophysiology • • • Inflammation of the labyrinthine canals of the inner ear Most common cause of vertigo Viral infection from URI Drugs and food Tobacco and alcohol Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 47

Inflammatory and Infectious Disorders of the Ear • Labyrinthitis (continued) § Clinical manifestations/assessment • • § Severe and sudden vertigo; ataxic gait Nausea and vomiting Nystagmus; photophobia Headache Medical management/nursing interventions • Antibiotics • Dramamine or meclizine for vertigo • IV fluids if nausea and vomiting present Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 48

Inflammatory and Infectious Disorders of the Ear • Obstructions of the ear § Etiology/pathophysiology • Impaction of cerumen in canal; foreign bodies § Clinical manifestations/assessment • Tinnitus and pain in the ear • Slight hearing loss; tugging at ear § Medical management/nursing interventions • Removal of cerumen by irrigation • Foreign objects are removed with forceps • Carbamide peroxide to soften cerumen Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 49

Noninfectious Disorders of the Ear • Otosclerosis § Etiology/pathophysiology • Chronic, progressive deafness due to formation of spongy bone, especially around the oval window § Clinical manifestations/assessment • Slowly progressive conductive hearing loss • Tinnitus; dizziness to vertigo § Medical management/nursing interventions • Stapedectomy • Air conduction hearing aid Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 50

Noninfectious Disorders of the Ear • Ménière’s disease § Etiology/pathophysiology • Chronic disease of the inner ear • Increase in endolymph fluid § Clinical manifestations/assessment • • • Vertigo Nausea and vomiting Hearing loss; tinnitus Diaphoresis Nystagmus Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 51

Noninfectious Disorders of the Ear • Ménière’s disease (continued) § Medical management/nursing interventions • No specific treatment • Decrease fluid pressure § Fluid restriction; diuretics; low-salt diet • Dramamine, meclizine, and Benadryl • Surgery § § Destruction of labyrinth Endolymphatic shunt Cryosurgery Vestibular nerve section Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 52

Surgeries of the Ear • Stapedectomy § Removal of the stapes of the middle ear • Tympanoplasty § Operative procedures on the eardrum or ossicles of the middle ear to restore hearing • Myringotomy § Surgical incision of the eardrum • Cochlear implant § Surgical implantation of a hearing device for the profoundly deaf Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 53

Nursing Process • Nursing diagnoses § § § § § Health maintenance, ineffective Anxiety Self-care deficit Fear Impaired environmental interpretation syndrome Impaired home maintenance Impaired social interaction Risk for injury Risk for loneliness Sensory perception, disturbed: auditory or visual Mosby items and derived items © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 54

Ophthalmic Drugs Categories Local anesthetics Ø Antiseptic ointments Ø Used in procedures such as tonometry, gonioscopy, cataract surgery, and removal of foreign objects from the cornea Prevent gonorrheal ophthalmia neonatorum in newborn infants, used to treat common eye infections, germicidal and astringent action Ophthalmic antiinfectives Ø Treat eye infections caused by bacteria, fungi, or viruses Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 55

Ophthalmic Drugs (cont. ) Artificial tears Other preparations Antiglaucoma agents Uses To control acute narrow-angle glaucoma before surgery Wide-angle glaucoma Secondary glaucoma Congenital glaucoma before surgery Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 56

Glaucoma Three Major Forms Primary glaucoma Narrow-angle: person has a shallow anterior eye chamber, may be genetic; requires surgery Ø Wide-angle glaucoma: gradual onset, controlled with medications Ø Secondary glaucoma Ø Result of other eye problems, treated with medications Congenital glaucoma Ø Birth defect requiring surgical correction Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 57

Antiglaucoma Medications Sympathomimetics Ø Beta blockers Ø Produce vasoconstriction and decrease intraocular pressure in open-angle glaucoma Reduce intraocular pressure by reducing the formation of aqueous humor Miotics, direct-acting Ø Cholinergic agonists Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 58

Antiglaucoma Medications (cont. ) Miotics, cholinesterase inhibitors Ø Inactivates acetylcholinesterase Carbonic anhydrase inhibitors Ø Blocks action of an enzyme in the ciliary body, causing a decrease in aqueous humor secretion Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 59

Antiglaucoma Medications (cont. ) Mydriatic-Cycloplegics Ø Block the action of acetylcholine Mydriatics Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 60

Otic Preparations Control superficial infections of the ear Ø Action is bacteriostatic or bactericidal Prophylaxis for infections in swimmers Removing cerumen Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 61