Chapter 53 Care of the Patient with a

Chapter 53 Care of the Patient with a Visual or Auditory Disorder Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 2

Figure 53 -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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 5

Figure 53 -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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 7

Figure 53 -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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 9

Figure 53 -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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 29

Figure 53 -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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 31

Figure 53 -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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 39

Figure 53 -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, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 40

Figure 53 -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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 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, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 54