N 126 Sensory System CALLIE WHITTINGTON MSN RN

N 126 Sensory System CALLIE WHITTINGTON, MSN, RN SPRING 2017

Chapter 51 SENSORY SYSTEM FUNCTION, ASSESSMENT, AND THERAPEUTIC MEASURES: VISION AND HEARING

�Describe the normal anatomy of the sensory LEARNING OUTCOMES system. �Explain the normal function of the sensory system. �List data to collect when caring for a patient with a disorder of the sensory system. �Identify diagnostic tests commonly performed to diagnose disorders of the sensory system. �Plan nursing care for patients undergoing diagnostic tests for sensory disorders. �Describe therapeutic measures for patients with disorders of the sensory system.

Key terms � Accommodation-a reflex action of the eye for focusing � Arcus senilus-A benign white or gray opaque ring in the corneal margin of the eye � Cochlear implant-A device consisting of a microphone, signal processor external transmitter, and implanted receiver to aid hearing � Consensual response-Reaction of both pupils when one eye is exposed to greater intensity of light than the other � Electroretinography-Measurement of the electrical response of the retina to light stimulation � Esotropia-Strabismus in which there is deviation of the visual axis of one eye toward that of the other eye, resulting in diplopia. Also, called cross-eyed � Exotropia-Abnormal turning outward of one or both eyes; divergent strabismus � Hearing aid-An instrument to amplify sounds for those with hearing loss

Key terms (cont. ) � Hypotropia-Downward deviation o the eye away from the visual axis � Nystagmus-Involuntary, cyclical, rapid movement of the eyes in response to vertical, horizontal, or rotary movement. � Ophthalmologist-A physician who specializes in the treatment of disorders of the eye � Ophthalmoscope-An instrument used for examining the interior of the eye, especially the retina � Optician-One who specializes in filling prescriptions for corrective lenses for eyeglasses and contact lenses � Optometrist-A doctor of optometry who diagnoses and treats conditions and diseases of the eye per state laws � Otalgia-Pain in the ear � Otorrhea-Inflammation of the ear with purulent discharge

Key terms (cont. ) �Ototoxic-Having a detrimental effect on the eighth cranial nerve or the organs of hearing �Ptosis-Drooping of eyelid �Rinne test-A test of hearing made with tuning forks �Romberg’s test-A test to determine if a person has the ability to maintain body balance when the eyes are shut and the feet are close together �Snellen’s chart-A chart imprinted with lines of black letters graduating in size from smallest on the bottom to largest on top; used for testing visual acuity �Tropia-A manifest deviation of and eye from the normal position when both eyes are open and uncovered �Weber test-A test for unilateral deafness

Vision �External Eyebrow, eyelids, eyelashes, Conjunctiva, palpebral fissure, Tarsal glands �Lacrimal gland, lacrimal punctum, nasolacrimal duct �Eyeball Sclera, cornea, iris, ciliary body, choroid, retina, optic nerve

Physiology of Vision �Involves the focusing of light rays on the retina and the transmission of the subsequent nerve impulses to the visual areas of the cerebral cortex �Refractive structures in order are the cornea, aqueous humor, lens, and vitreous humor �Lens is the only adjustable part of the focusing system �When the shift of focus becomes closer, accommodation occurs �The visual areas are in the occipital lobes of the cerebral cortex.

Aging and the eye �Most common changes in the aging eye are those in the lens �With age, the lens can become opaque, partially or totally �Peripheral vision decreases �Depth perception decreases and glare intensifies �Safety is impacted �Normal changes: Yellowing of the lens Decreased lacrimal secretions Distorted depth perception

Nursing Assessment �Subjective data, observation, testing, and physical examination �Health History Family history-glaucoma, diabetes, blindness, and cataracts General health and diseases Medication Review Any changes in visual acuity or abnormal symptoms �Physical Examination Visual acuity-Snellen’s chart, E chart, or a Rosenbaum’s card (near and far) Should be done with both eyes, one eye at a time, with correction, and without correction.

Snellen’s chart �Examiner measures 20 feet from the chart �Lowest line indicates visual acuity �Normal vision is 20/20 (patient can read at 20 feet what the normal eye can read at 20 feet �Low vision is at 20/70 �Legal blindness is at 20/200 or less in the best eye

E Chart �Used for patients with literacy issues �Patient asked to indicate the direction of the E-shaped figure

Handheld Visual Acuity Chart �Patient holds card approximately 14 inches from the eyes �Conducted and documented in the same way as the Snellen’s and E chart examinations

Nursing Assessment (cont. ) �Physical Examination (cont. ) Also test peripheral vision utilizing confrontation � How do you do this? Muscle balance and eye movement � Extraocular muscle balance � Cranial nerve function � Can the patient follow your finger with their eye without moving their head? � Is there nystagmus? � Corneal light reflex (check for reaction symmetry, muscle weakness) Pupillary reflexes � Pupils should be round, symmetrical, and reactive to light, accomodation (PERRLA)

Nursing Assessment (cont. ) �Inspection and palpation of external structures Eyebrows-symmetry, hair texture, size, and extension of the brow Orbital area-edema, lesions, puffiness, and tenderness Eyelids-symmetry, presence of eyelashes, eyelash position, tremors, flakiness, redness, and swelling. Open and close eyelids-are the distance between top lid and bottom lid the same. Ptosis-drooping of the eyelid Exudate or nodules Conjunctiva and sclera

Nursing Assessment (cont. ) �Internal eye examination Done by an advanced practitioner LPN/LVN should be able to educate the patient about the examine Ophthalmoscope and a slit lamp �Intraocular pressure Tonometer Puff of air to eye to make an indentation in the cornea to measure intraocular pressure Usually test performed for glaucoma �Review Table 51. 1 and 51. 2 on page 1218 for Subjective and Objective data collection

Gerentological Issues �Presbyopia �Narrowing of the visual field �More difficulty with peripheral vision �Difficult in dim light �Decreased pupil size and responsiveness to light �Increased opacity of the lens (sensitivity) �Yellowing of the lens (color determination) �Distorted depth perception and difficulty correctly judging curbs/step �Decreased secretions

Diagnostic Tests for the Eye �Eye Culture �Digital imaging �Optical Coherence Tomography-takes a picture of the retina �Fluorescein or Indocyanine Green Angiography �Electroretinography �Ultrasonagraphy �Imaging-X-ray, CT, MRI

Therapeutic Measures for the Eye and Vision �Screening and educating individuals, families, and the community �Regular eye examinations-annual exams �Eye hygiene �Nutrition-vitamin A and vitamin B �Eye safety and prevention of injury �Eye irrigation-foreign bodies or chemical substances (Box 51 -1, pg 1223) �Guide dogs for the blind and visually impaired �Medication administration (Box 51 -2 & 51 -3, pg 1223 -1224) �Eye patching �Review Table 51. 3 on Page 1222 Eye safety and injury prevention

Hearing �Outer ear-auricle and the auditory canal �Middle ear-air-filled cavity in the temporal bone, the stapes. Much of what happens here is vibration in order to transmit sound �Inner ear-also called the bony labyrinth, lined with membranes called the membranous labyrinth. Semicircular canals, vestibule, and cochlea (look at figure 51. 12, 51. 13, and 51. 14 on page 1225 -1226) �Hearing involves transmission of vibrations and generation of nerve impulses (involves tympanic membrane, malleus, incus, stapes, oval window of the inner ear, perilymph and endolymph within the cochlea, and hair cells of the organ corti. �Auditory areas are in the temporal lobes of the cerebral cortex

Aging and the Ear �Damage to the hair cells in the organ of corti usually becomes apparent sometime after the age of 60 �Once damaged, the hairs cannot be replaced �High frequencies hearing is usually lost first (presbycusis) �Low-pitched ranges are usually still adequate �More difficult to filter out background noises, so busy, loud environments make it difficult to hear conversations. �Doesn’t help to talk to patients louder, it makes it more difficult to discriminate sounds �Normal age related findings=presbycusis

Nursing Assessment �Quiet environment, document the patient’s behavior because it will provide key information related to hearing loss �Health history-WHAT’S UP? Where it is? How it feels? Aggravating and alleviating factors? Timing? Severity? Useful data for associated symptoms? Perception of the problem by the patient? Decreased hearing (or loss), otorrhea (discharge), otalgia (ear pain), itching, fullness, tinnitus (ringing, buzzing, or roaring in the ears), or vertigo (dizziness) Medication- Why? Hearing aids or assistive devices, surgeries, treatments, allergies, sodium and alcohol intake, childhood illnesses (mumps, measles, scarlet fever)

Nursing Assessment (cont. ) �Health History (cont. ) Recent illnesses Hospitalizations Injury Swimming Flying or diving Medical diseases History of exposure to loud noises Family history Meniere’s disease Ear care, preventative measures Employment, hobbies, activities

Nursing Assessment (cont. ) �Physical Examination Observe patient behaviors � Talk, speech, words Inspect external structures-size, symmetry, configuration, and angle of attachment Palpate Test auditory acuity Balance testing Advanced practitioner-otoscopic examination Note any abnormalities, deformities, scars Wax Review Table 51. 4 & 51. 5 on pg 1227 -1229 for Subjective and Objective data collection Review Box 51 -4 on pg 1228 for behaviors indicating hearing loss

Nursing Assessment (cont. ) �Auditory acuity testing Whisper voice test Rinne test-tuning fork � Used to differentiate between conductive and sensorineural hearing loss � Air conduction is heard twice as long as bone conduction. � Air conduction is in front of the ear � Bone conduction is at the mastoid process � Abnormal findings indicate conduction or sensorineural problems Weber test-tuning fork � Placed on center of patients forehead or head � Determine if patient hears better in left ear, right ear, or same in both Review Table 51. 6 on pg 1230

Nursing Assessment (cont. ) �Balance testing If patient reports dizziness, nystagmus, or problem with equilibrium Assesses vestibular function Observe the patient’s gait while walking-balance, posture, and movement Romberg’s test-falling test, difficulty maintaining a standing position with only minimal swaying � Could indicate an inner ear problem � Safety is a concern �Otoscopic exam Used to visualize the external ear, ear canal, and tympanic membrane Identify specific disorders or infections, remove wax, or remove foreign bodies Ear canal should be smooth and empty-no redness, scaliness, swelling, drainage, nodules, foreign objects, or excessive wax Eardrum (tympanic membrane) should be shiny, smooth, and pearly gray

Diagnostic tests for the Ear and Hearing � Audiometric testing-determines type and degree of hearing loss � Typanometry-to measure compliance of the tympanic membrane and differentiate problems in the middle ear (can cause vertigo, nausea, or dizziness during test) � Caloric test-to test the function of the eighth cranial nerve and to assess vestibular reflexes of the inner ear that control balance (contraindicated in patients with perforated tympanic membrane) � Electronystagmogram-to diagnose the causes of unilateral hearing loss of unknown origin, vertigo, or ringing in the ears (patient should avoid tranquilizers, alcohol, stimulants (tobacco and caffeine), and antivertigo agents for 1 -5 days prior to test) (contraindicated in patients with pacemakers) � CT and MRI � Lab tests-ear culture, pathology

Therapeutic Measures for the Ear and Hearing �Medications-anti-infectives, anti-inflammatories, anti-histamines, decongestants, cerumenolytics, and diuretics. (Review Box 51 -5 Administration of Eardrops pg 1232) �Ear Health Maintenance �Assistive Hearing Devices-hearing aids, cochlear implants (sensorineural hearing loss) What is important for you to know about these devices? Safety products-visual alarm smoke detectors, flashing light, or alarms that vibrate �Guide dogs �Review Table 51. 8 pg 1233 -1234 for prevention of ear problems

Chapter 52 NURSING CARE OF PATIENTS WITH SENSORY DISORDERS: VISION AND HEARING

LEARNING OUTCOMES � Explain the pathophysiology of each of the disorders of the sensory system. � Define blindness and the refractive errors of vision. � Explain the etiologies, signs, and symptoms of each sensory disorder. � Plan nursing care for patients undergoing tests for sensory disorders. � Identify therapeutic measures for each sensory disorder. � Identify medications contraindicated for patients with acute angle -closure glaucoma. � List three ototoxic drugs. � List data to collect when caring for patients with disorders of the sensory system. � Plan nursing care for patients with disorders of the eye or ear. � Plan nursing care interventions for the patient with a hearing impairment. � Discuss how to know if nursing interventions for sensory disorders have been effective.

Key terms � Astigmatism-An error of refraction in which a ray of light is not sharply focused on the retina but is spread over a more or less diffuse area � Blepharitis-Inflammation of the glands and lash follicles along the margin of the eyelids � Blindness-lack or loss of ability to see � Carbuncle-A necrotizing infection of skin and subcutaneous tissue composed of a cluster of boils � Cataract-Opacity of the lens of the eye � Chalazion-A small eyelid mass resulting from chronic inflammation of a Meibomian gland � Conductive hearing loss-Impaired transmission of sound waves through the external ear canal to the bones of the middle ear � Conjunctivitis-Inflammation of the conjunctiva of the eye

Key terms (cont. ) � Enucleation-Removal of an organ or other mass intact from its supporting tissues, as of the eyeball from the orbit � External otitis-Inflammation of the external ear � Furuncle-An acute circumscribed inflammation of the subcutaneous layers of the skin or of a gland or hair follicle � Glaucoma-A group of eye diseases characterized by increased intraocular pressure � Hordeolum-Sty � Hyperopia-Farsightedness � Macular degeneration- Age-related breakdown of the macular area of the retina of the eye � Meniere’s disease-A recurrent and usually progressive group of symptoms including progressive deafness, ringing in the ears, dizziness, and a sensation of fullness or pressure in the ears � Miotics-An agent that causes the pupil to contract

Key terms (cont. ) � Myopia-The error of refraction in which rays of light entering the eye parallel to the optic axis are brought to a focus in front of the retina; nearsightedness � Myringoplasty-Surgical reconstruction of the tympanic membrane � Myringotomy-Incision of the tympanic membrane, usually performed to relieve pressure and allow for drainage of either serous or purulent fluid in the middle ear behind the tympanic membrane � Otosclerosis-A condition characterized by chronic, progressive deafness, especially for low tones � Photophobia-Abnormal visual intolerance to light � Presbycusis-Progressive, bilaterally summetrical perceptive hearing loss occurring with age; usually occurs after age 50 and is caused by structural changes in the organs of hearing � Presbyopia-Diminution of accommodation of the lens of the eye occurring normally with aging, and usually resulting in hyperopia, or farsightedness � Retinopathy-Disease of the retina of the eye

Key terms (cont. ) �Sensorineural-Hearing loss caused by impairment of a sensory nerve �Stapedectomy-Excision of the stapes to improve hearing, especially in cases of otosclerosis

Anatomy of a normal eye

Vision Disorders �Table 52. 1 pg 1237 Eye disorder Summary Signs and symptoms � Visual disturbances, pain, redness, secretions, itchiness, sensation of pressure in eyes Diagnostic tests and findings � Visual acuity, ophthalmoscopic examination of internal and external eye, Amsler grid (identifies visual field disturbances), Slit-lamp examination (identifies abnormalities on cornea and sclera), tonometry (identifies intraocular pressure) Therapeutic Measures � Medications, Complications � Worsening surgery vision or loss of vision, acute pain Priority Nursing Diagnosis � Anxiety, Risk for Injury, Deficient knowledge

Infections and inflammation �Bacterial or viral �Aggravated by allergens, chemical substances, or mechanical irritation

Infections and inflammation (cont. ) � Conjunctivitis (aka Pinkeye) Contracted through contaminated eye secretions Virus stays alive on surfaces for 2 weeks or more Lasts 2 -4 weeks Commonly transmitted among children and then to family members Redness, crusting exudate, itching, pain, and excessive tearing Treat symptoms, pain, and prevent spread of infection Bacterial-antibiotic eye-drops or ointments used Good hand-hygiene is the best prevention method

Infections and inflammation (cont. ) � Blepharitis Chronic inflammatory process Usually affects middle-aged and older adults Two different types � Seborrheic blepharitis-reddened eyelids with scales and flaking at the base of the lashes � Ulcerative blepharitis-crusts at eyelashes, reddened eyes, and inflamed corneas Eyelids can become thickened and eyelashes can be lost Treatment includes long-term daily cleansing with cotton-tipped swabs dipped in baby shampoo or sterile eyelid cleanser solutions

Infections and inflammation (cont. ) � Hordeolum (stye) In the sebaceous gland at the base of the eyelash Small, raised, reddened Cosmetics contribute � Chalazion (stye) In the connective tissue of the eyelid Larger than hordeolum Puts pressure on cornea=more discomfort May require surgical I&D if they don’t drain spontaneously � Both are painful � May require oral antibiotics � Treated with warm compresses

Infections and inflammation (cont. ) � Keratitis Inflammation of the cornea, acute or chronic May be associated with bacterial conjunctivitis, viral infection (herpes simplex is the most common in developed countries), corneal ulcer, or tuberculosis and syphilis Dry eyes, contact lenses, and poor hygiene practices, decreased corneal sensation, or immunosuppressed are at higher risk Pain that increases with lid movement, decreased vision, photophobia, tearing, and blepharospasm. Reddened conjunctiva and the cornea can appear opaque Topical antibiotics, corticosteroids, interferons, antiviral, cycloplegic agents, and warm compresses Corneal transplant may be needed for severe damage Eye patch to decrease movement This is serious and can threaten eyesight Tissue can become thin and susceptible to perforation Untreated = scarring and permanent loss of vision

Infections and inflammation (cont. ) � Review Table 52. 2 pg 1238 Ophthalmic Medications Fluorescein-staining of the eye, diagnostic aid, lesions of foreign objects pick up bright yellow-orange stain so abnormality can be detected Tetracaine-topical anesthetic, helps to make exam less painful Pegaptanib-Antiangiogenetics, antivascular endothelial, growth factor, inhibits growth of new blood vessels, slows progression of macular degeneration Eye allergy symptom relief to relieve red, itchy eyes caused by allergies-multiple medications listed Anti-infectives, antibiotics-treat bacterial eye infections-Cipro most common Antivirals-treat viral eye infections, trifluridine is the most common Antifungals-treat fungal eye infections Anti-inflammatories- reduce inflammation, can be steroidal or nonsteroidal Lubricants-moisten eyes in healthy and ill persons Miotics-lower intraocular pressure Carbonic anhydrase inhibitors-reduce intraocular pressure, used for glaucoma Osmotics-reduce intraocular pressure in acute open-angle glaucoma Beta-adrenergic blockers- reduce intraocular pressure Mydriatics-dilate pupils for examination or surgical procedures Cycloplegics-paralyze muscles of accommodation for examination or surgical procedures

Infections and inflammation (cont. ) �Nursing process Data collection � Review Table 52. 3 pg 1241 subjective data collection for eye inflammation and infection conditions (WHAT’S UP) � Objective data includes the condition of the conjunctiva, eyelids, and eyelashes Exudate, tearing, any visible abscess, any palpable abscess in the eyelid, opacity of the cornea, and visual acuity abnormal results Nursing diagnoses, planning, and implementation � Acute pain � Risk for injury � Deficient knowledge Evaluation � Relief of symptoms, vision improves, free of injury, no infection present, patient education is effective (disease process, prevention, treatment), proper med administration

Refractive Errors �Refractive is the bending of light rays as they enter the eye Normal vision-light rays are bent to focus images precisely on the macula of the retina Account for the largest number of impairments in vision Hyperopia-farsightedness, light rays focusing behind the retina, see images that are far away more clearly than images that are close, corrected with convex lenses Myopia-nearsightedness, light rays focusing in front of the retina, distance vision is blurred but items close up are clear, corrected with concave lenses Astigmatism-unequal curvatures in the shape of the cornea, parallel light rays enter the eye, the irregular cornea causes the light rays to be refracted to focus on two different points, can be either myopic or hyperopic, blurred vision with distortion, can be caused by injury, inflammation, corneal surgery, or inherited Presbyopia-crystalline lenses lose their elasticity, resulting in a decrease in ability to focus on close objects, causes light rays to focus beyond the retina, resulting in hyperopia, associated with aging, usually occurring after 40. Inability to see objects at close range, hold object to be viewed farther away. Eyestrain and mild frontal headache are common, relieved with eye rest and corrective lenses

Refractive errors (cont. ) �Hyperopia

Refractive errors (cont. ) �Myopia

Refractive errors (cont. ) �Astigmatism

Refractive errors (cont. ) �Presbyopia

Refractive errors (cont. ) � Signs and symptoms Difficulty reading or seeing objects Eyestrain occurs and it causes headaches � Diagnostic tests Roughly diagnosed utilizing Snellen’s chart Definitive diagnosis needs to have a retinoscopic examination (dilatation of the pupil is done prior) Patient education about safety needs to be done prior to this exam because the meds utilized can cause blurry vision. They should also not drive or read until medication has dissipated. � Therapeutic measures Eyeglasses or contact lenses Laser surgeries (LASIK) Photorefractive keratectomy (PRK)

Blindness � The term visually impaired is preferred � Diagnostic tests � Caused by a variety of factors Trauma Complications from disease Visual field examination, tonometry, slit-lamp microscope Retinal angiography for blood flow and vascular changes Ultrasonography for the posterior eye that can’t be seen on an external exam � Therapeutic measures Treating the underlying condition Prevent further impairment Medication Surgical intervention Corrective eyewear Referral to supportive services � HTN, Diabetes, cataracts, glaucoma � Rays of light are obstructed on their way to the optic nerve or tract where the brain connects with vision � Can be permanent or transient, complete or partial, or can occur only in darkness � Signs and symptoms Loss of vision Blurred, distorted, or absent vision in specific areas Objects appear dark or absent in peripheral field Defect in the optic pathways in the brain (often seen in stroke) � � Center of visual field is dark (diabetic retinopathy or macular degeneration) Half the visual field is impaired (hemianopia)

Nursing process for the patient with visual impairment � Data collection Review Table 52. 4 pg 1244 Subjective data collection for visual disorders � WHAT’S UP � Diagnosis, planning, and implementation Objective data � Observing the patient for squinting, rubbing of eyes, using compensatory measures � Review Box 52 -1 pg 1245 Interacting with a patient who has a visual impairment You have to understand how to interact with the patient that has visual impairment Independent or dependent Has the patient recently become visually impaired? Meet self-care needs, remaining safe, grieving process, resources, devices Families should be included � Evaluation Complete ADL’s independently as possible Free of injury

Nursing care plan for the patient with visual impairment �Dressing and feeding self care deficit �Risk for injury �Deficient knowledge

Diabetic Retinopathy �Vascular changes occur in retinal blood vessels �Most common in diabetic patients �Excess glucose, changes in retinal capillary walls, formation of microaneurysms, and constriction of retinal blood vessels �Three stages: Background retinopathy Preproliferative retinopathy Proliferative retinopathy

Diabetic retinopathy (cont. ) � Background retinopathy Earliest stage Microaneurysms form on the retinal capillary walls � Leak blood into the central retina or macula � With leakage, edema so the patient may notice a decrease in color discrimination and visual acuity � Preproliferative retinopathy Second stage Swollen and irregularly dilated veins Sluggish or blocked blood flow Usually, not aware of this stage because there are no symptoms � Proliferative retinopathy The third stage Formation of new blood vessels growing into the retinal and optic disc area in an attempt to increase blood supply to the retina These new blood vessels are fragile and will often leak blood into the vitreous and retina They may grow into the vitreous, causing a traction effect, pulling the vitreous away from the retina and the retina away from the choroid (retinal detachment)

Diabetic retinopathy (cont. )

Diabetic retinopathy (cont. ) � Signs and symptoms Reduction in central visual acuity or color vision (due to macular edema) Many patients have no symptoms until the proliferative stage, where vision is lost This vision loss can usually not be restored � Complications Early treatment can be successful in preventing further vision loss, but the vision that has been lost cannot be restored Comprehensive eye exams at least once a year Diabetes control and management � Diagnostic tests Only on examination of the internal eye Exam conducted with an ophthalmoscope with dilation of the pupil In earlier stages the vessels may appear swollen and tortuous (twisted) � Therapeutic measures Stopping leakage of blood and fluid into the vitreous and retina Lasers can shrink the abnormal blood vessels Vitrectomy, the vitreous humor is drained out of the eye chamber and replaced with saline or silicon oil Careful control of diabetes

Nursing process for the patient with diabetic retinopathy �Data collection Risk factors associated May not have any symptoms Changes in perceptions of visual acuity or color discrimination �Diagnosis, Planning, and Implementation Focus on prevention with early detection and treatment If vision loss has already occurred then use the “nursing care plan for the patient with visual impairment” �Nursing diagnosis Risk for or actual ineffective self health management �Evaluation Able manage therapeutic regimen

Retinal Detachment � Separation of the retina from the choroid layer beneath it � Allowing fluid to enter the space between the layers � Three causes: Hole or tear in the retina that allows fluid to flow between the two layers Fibrous tissue in the vitreous humor that contracts and pulls the retina away Fluid or exudate accumulation in the subretinal space that separates the retinal layers � Signs and symptoms Sudden vision change Seeing flashing lights and then floaters “looking through a veil” or “cobwebs” and finally “like a curtain being lowered over the field of vision” that results in darkness No pain because there are no sensory nerves Peripheral vision loss and acuity in the affected eye � Diagnostic tests Indirect ophthalmoscopy to visualize the retina (appears pale, opaque, and in folds) Slit-lamp examination helps to magnify the lesions

Retinal detachment (cont. ) �Therapeutic measures Immediate medical treatment in order to protect vision Restoration varies and depends on the affected area Laser surgery, cryopexy, scleral buckling, and pneumatic retinopexy �Complications Risk of increase intraocular pressure, tears, and recurrent detachment �Nursing process Data collection � Subjective data-patient observation of the loss of peripheral vision, change in visual acuity, presence of floaters, flashing lights, cobwebs, or veil-like impairment. Absence of pain � Objective data-patient’s visual acuity, visual fields, ability to perform ADLs, level of anxiety Diagnosis, planning, implementation, and evaluation � Same as “Nursing process for the patient having eye surgery” [later in chapter]

Retinal detachment (cont. )

Glaucoma � Group of diseases characterized by damage to the optic nerve (responsible for transmitting visual information from the eye to the brain) � Silent, progressive, and irreversible � Results in loss of peripheral vision, then central vision, then blindness � Abnormal pressure can be what causes the damage � No cure, just prevention of further damage

Glaucoma (cont. ) �Pathophysiology Most common form of glaucoma is primary, which has two different types � Primary Open-Angle Glaucoma (POAG) � Acute Angle-Closure Glaucoma (AACG) Secondary glaucoma-caused by infections, tumors, or injuries. Congenital glaucoma-developmental abnormalities �Primary Open-Angle Glaucoma Drainage system of the eye degenerates and blocks the flow of aqueous humor �Acute Angle-Closure Glaucoma People have anatomically narrowed angle at the junction where the iris meets the cornea Structures protrude into the anterior chamber, angle is occluded (blocking flow of aqueous humor) Medical emergency, resulting in partial or total blindness

Glaucoma (cont. ) � Etiology and prevention AACG-higher incidence in Asians, women older than 45, and nearsighted people POAG-chances increase over age 40, Europeans older than 50, African Americans older than 35, diabetes, family hx of glaucoma, 4 -5 x more common in African American and European Americans Yearly eye exams-glaucoma screenings � Signs and Symptoms AACG-unilateral, rapid onset, severe pain, blurred vision, rainbows around lights, and photophobia, red eyes, steamy appearing cornea, tearing, nausea and vomiting POAG-develops bilaterally, onset is gradual and painless, can have no noticeable symptoms, mild aching in the eyes, headache, halos around lights, frequent visual changes that are not corrected with glasses � Diagnostic tests Measure IOP, identify optic nerve damage and visual loss Tonometry detects IOP (normal 12 -20 mm. Hg) AACG IOP exceeds 50 mm. Hg Laser device is used to detect nerve damage before the patient has symptoms Visual field examination (peripheral vision, distance) Corneal thickness A special lens, gonioscopy, to determin openangle or angle-closure

Glaucoma (cont. ) � Therapeutic measures Medication (miotics are the most common) to open the aqueous flow, cholinergic agents to constrict the pupil. This causes the iris to pull away from the drainage canal so the aqueous fluid can flow freely. Medication to slow the production of aqueous fluid (carbonic anhydrase inhibitors, adrenergic agonists, and beta blockers) helps to decrease IOP Steroid drops reduce inflammation AACG patients given all of these types of medication, mannitol, hyperosmolar agent, analgesics, and complete bed rest Lifelong eye drop medications twice or more daily When there are no symptoms, it can be difficult for patients to adhere to treatment Meds are expensive Difficult to understand the meds Should wear medical I. D. bracelet � Meds and diagnosis in order to prevent administration of meds or treatment that is contraindicated for glaucoma AACG contraindicated meds can result in blindness � Anticholinergics (atropine), antihistamines (Benadryl), hydroxyzine (Vistaril) � ALWAYS CHECK

Glaucoma (cont. ) � Surgical management Happens when medication is not effective or appropriate Goal is to reduce IOP (control the flow of aqueous fluid) Focuses on creating an area where the aqueous humor can flow freely, preventing increased IOP AACG-laser peripheral iridotomy (noninvasive to remove part of the iris) or surgical iridectomy (performed on the other eye to prevent AACG) POAG with trabeculoplasty (noninvasive laser creates opening in trabecular meshwork), Trabeculectomy (part of iris and trabecular meshwork removed), or cyclocryotherapy (cryoprobe destroys part of the ciliary body) � Nursing process Data collection-pain, loss of central and peripheral vision, understanding of disease and adherence to treatment regiment, and ability to perform ADL’s Diagnoses Planning Implementation Evaluation

Cataracts � Pathophysiology Opacity in the lens, causes loss of visual acuity. Vision is diminished due to light rays can’t reach the retina through a cloudy lens. Age, sunlight, diabetes, smoking, steroids, nutritional deficiencies, alcohol consumption, intraocular infections, trauma, and congenital defects � Signs and symptoms Painless, halos around lights, difficulty reading fine print or seeing in bright light, increased sensitivity to glare, double or hazy vison, decreased color vision � Diagnostic tests Eye examination Visual acuity is tested for near and far vision Use of the ophthalmoscope and slit lamp � Surgical management Performed when daily life is impacted One eye treated at a time Outpatient procedure to surgically remove the cloudy lens Implantable lenses Eyeglasses help following surgery for some patients Depending on the kind of surgical intervention (no-stitch or stitch) will drive the post-op teaching � Complications Rare but can be inflammation, increased IOP, macular edema, retinal detachment, vitreous loss, hyphae, endophthalmitis, and expulsive hemorrhage

Cataracts (cont. ) �Nursing process Data collection-home situation is important. Why? Diagnoses Planning Implementation Evaluation �For the patient having eye surgery Read this section on page 1250 -1251 Utilize Table 52. 5 page 1251 for subjective data collection for patients having eye surgery

Macular Degeneration � Pathophysiology Age-related (AMD) leading cause of visual impairment in U. S. residents older than age 50 Deterioration and scarring within the macula (where light rays converge for the sharp, central vision needed for color vision). Dry-atrophic, photoreceptors fail to function and not replaced because of advancing age. Wet-exudative, retinal tissue degenerates so vitreous fluid or blood gets into the subretinal space. New fragile blood vessels form and weaken the macular tissue, leading to subretinal edema. Fibrous scar tissue forms, limiting central vision At risk are those older than 60, family history of macular degeneration, diabetes, smoking, frequently exposed to UV light, and Caucasian. � Prevention Healthy lifestyle Diet with dark green leafy vegetables, and yellow colored fruits and vegetables. Measuring macula pigment optical density (preventative tool) Taking vitamin supplements Can’t repair but it can prevent further progression � Signs and symptoms AMD-dry type is slow progressive loss of central and near vision A condition in both eyes but can progress at different rates AMD wet has the same loss of central and near vision, sudden onset and results in severe vision loss that is described as blurred vision, distortion of straight lines, and a dark or empty spot in the central area of vision Can also have decreased ability to distinguish color

Macular Degeneration (cont. ) � Diagnostic tests Visual acuity for near and far vision Examination of internal eye structures Amsler grid (p. 1252/figure 52. 5) used for central vision distortion and color vision test Digital imaging, optical coherence tomography retinal scan (like a CT scan) and intravenous fluorescein angiography to evaluate blood vessel leakage or abnormalities � Therapeutic measures AMD dry � � � No treatment for dry AMD, so prevention is important AMD dry don’t necessarily become totally blind but they are considered legally blind Low-vision telescopic glasses will help to enhance remaining vision (implanted one for advanced AMD to help with central vision) AMD wet � � � Intermittent injection of antiangiogenesis medication to prevent the formation of new fragile blood vessels that will leak and bleed Laser photocoagulation can seal the leaking blood vessels, but it leaves a small permanent blind spot at the point of laser contact of the macula Currently have clinical trials for other treatment options � Significant visual loss and must adapt to it

Macular Degeneration (cont. ) �Nursing process See “Nursing process for the patient with visual impairment” on page 1243

Trauma � Should be assessed immediately to ensure proper treatment is initiated � Foreign bodies, chemical burns, ultraviolet, direct heat sources, abrasions, lacerations, penetrating (all of these increase risk for infection and blindness) � Signs and symptoms-pain, tearing, conjunctival redness, photosensitivity, decreased visual acuity, erythema, and pruritus � Diagnostic tests Visual acuity, make sure to establish baseline (WHY? ) Patient may resist the visual acuity exam because of discomfort Slit-lamp and ophthamoscope � Therapeutic measures Foreign bodies-flushed with normal saline for irrigation Topical ointment to prevent infection Chemical burns get a 15 -20 minute irrigation with tap water or sterile solution Burns from UV or heat are not irrigated Abrasions and lacerations use anti-infective ointments or drops Eye specialist for penetrating wounds Penetrating wounds-cover both eyes, stabilize object, specialist only to remove

Trauma (cont. ) �Complications If treatment is not successful, eye must be removed. Called enucleation Blindness �Nursing process Data collection and emergency intervention Diagnoses Planning Intervention Evaluation

Tools

Hearing Disorders �Most common disability in the U. S. �Can be acquired or congenital �Impairment ranges from difficulty understanding words or hearing certain sounds to total deafness �Affects communication, social activities, and work activities and can diminish quality of life �Our responsibility to communicate with patients and provide needed information regarding health care �Review Table 52. 6 on page 1254 “Hearing loss summary” �Review Table 52. 7 on page 1255 “Ototoxic Drugs”

Hearing Disorders (cont. ) � Conductive hearing loss A mechanical problem, interference with the conduction of sound impulses through the external auditory canal, the eardrum, or the middle ear to the inner ear Inner ear is not a part of pure conductive hearing loss Causes: cerumen, foreign bodies, infection, perforation of the tympanic membrane, trauma, fluid in the middle ear, cysts, tumor, and otosclerosis Some of these can be corrected Hearing devices can be utilized for those that can’t be corrected

Hearing Disorders (cont. ) � Sensorineural hearing loss Originates in the cochlea Involves the hair cells and nerve endings Neural hearing loss originates in the nerve or brainstem Results from disease or trauma to the sensory or neural components of the ear Causes of nerve deafness: complications of infections (measles, mumps, and meningitis), ototoxic drugs, trauma, noise, neuromas, arteriosclerosis, and the aging process Presbycusis caused by aging due to degeneration of the organ of Corti. � Usually begins in the 5 th decade � Inability to decipher high-frequency sounds � Interferes with the person’s ability to understand what is being said, especially in noisy environments. � Most difficult understanding higher pitched female voices than lower pitched male voices

Hearing Disorders (cont. ) � Other types of hearing loss Mixed hearing loss is when an individual has both conductive and sensorineural hearing loss � Can be caused be a combination of any of the disorders previously mentioned Central hearing loss is when the central nervous system cannot interpret normal auditory signals � Occurs with cerebrovascular accidents and tumors Functional hearing loss is hearing loss with no organic cause or lesion that can be found. � Also called psychogenic hearing loss and is precipitated by emotional stress � Therapeutic measures Goal is to improve the patient’s hearing Use of hearing aid Surgical intervention for those that don’t have improvement with hearing aids Implantable hearing aids for sound perception in patients with moderate-tosevere sensorineural hearing loss � Cochlear implants can restore up to half of the patient’s hearing

Hearing Disorders (cont. ) �Nursing process Data collection� Subjective data-WHAT’S UP? � Objective data-speak to the patient in a normal tone � Use of the whisper test, Rinne, and Weber tests � Look for underlying cause � Physical examination Diagnoses Planning Implementation Evaluation �Study Box 52 -2 on page 1257 on how to communicate with a person who has a hearing impairment �Study Box 52 -3 Care of Hearing Aids

External Ear �Infections Most common disorder of the external ear (usually external otitis) Exposure to moisture, contamination, or local trauma is an ideal environment for pathological growth When water is left in the ear and washes away protective earwax, allowing growth of bacteria or fungus, is also called swimmer’s ear. Happens more often in summer, but can happen year-round Local infections-ear canal furuncle or abscess is when a hair follicle becomes infected Carbuncle forms when several hair follicles are involved Usually erupt and drain spontaneously Otomycosis an infection caused by fungal growth, usually after topical corticosteroid or antibiotic use � Occurs more in hot weather Auricle infection is called perichondritis-results in necrosis

External Ear (cont. ) �Infections (cont. ) Signs and symptoms � Pain, specifically when gently pulling on pinna, pain when moving the jaw, pain when otoscope is inserted into ear canal, Itching, inflammation, swelling, decreased hearing, redness, drainage, fever � If drainage is present-starts off clear then becomes purulent as infection worsens Diagnostic tests � Labs-CBC (looking at WBC), cultures of discharge (includes sensitivity), Rinne and Weber tests

External Ear (cont. ) � Impacted cerumen The ear is a self-cleaning naturally Wax can become impacted, blocking the ear canal (large amounts of hair, occupations that are dusty or dirty can increase likeliness to have this happen) Improper cleaning contributes Older adult This happens because cerumen production decreases and keratin increases, resulting in drier, harder, and more easily impacted Patients with hearing aids Patients with bony growth � Impacted cerumen (cont. ) Can experience hearing loss Feeling of fullness Blocked ear if cerumen has become impacted Otoscopic examination reveals cerumen blocking the ear canal Audiometric testing reveals conductive hearing loss Hearing loss can be decreased by 45 decibels due to impacted cerumen Whisper voice, Rinne, and Weber tests

External Ear (cont. ) � Masses Benign masses are usually cysts � Others are lipomas, wars, keloids, and infectious polyps � Infections polyps arise from the middle ear and go into the external ear through a hole in the tympanic membrane � Actinic keratosis is precancerous lesions found on the auricle and in older adults � Malignant tumors such as basal cell carcinoma on the pinna and squamous cell in the ear canal may develop and can spread Changes in appearance of the skin occurs with benign and malignant masses Impairs conductive or sensorineural hearing Pain is present and is usually described as deep pain radiating inward on the affected side Ear drainage occurs With progression, facial paralysis may occur Otoscopic exam to visualize the mass Biopsy Imaging studies Audiometric studies

External Ear (cont. ) �Trauma Injuries to the external ear by a blow to the head, automobile accidents, burns, foreign bodies, or cold temperatures � Cotton ball pieces and insects are the most common foreign bodies Lacerations, contusions, hematomas, abrasions, erythema, and blistering seen with thermal or physical trauma Repeated trauma can cause swelling (“cauliflower ear”) Conductive hearing loss if the ear canal is partially or totally blocked Contusions or hematomas-commonly report numbness, pain, and paresthesia of the auricle Foreign bodies-decreased hearing, itching, pain, and infection Take care not to push foreign body in further Imaging studies Audiometric, whisper voice, Rinne, and Weber tests

External Ear (cont. ) � Complications Without treatment, infections can spread, resulting cellulitis, abscesses, middle ear infections, and septicemia Metastasis can occur with untreated malignant tumors Infection, trauma, and malignant tumors can cause temporary or permanent hearing loss, disfigurement, discoloration, and scarring � Therapeutic measures Topical ointments Systemic antibiotics for severe local infections Analgesics for pain Topical or systemic steroids Thorough cleaning prior to any topical treatments Wick insertion for drainage or a swollen shut ear canal � Helps to remove drainage or to aid in administering meds Cerumen removal by trained clinician Perforated tympanic membrane (current or history)-no irrigation Debridement, surgical repair, or application of a protective covering with trauma Surgical management consists of incision and drainage of abscesses. Excision of cysts or cutaneous carcinomas may be required � Nursing process Data collection Diagnoses Planning Implementation Evaluation

External Ear (cont. ) �Review Box 52 -4 Ear Care on page 1261

Middle Ear, Tympanic Membrane, and Mastoid Disorders

Middle Ear, Tympanic Membrane, and Mastoid Disorders (cont. ) � Infections Otitis media-most common disease of middle ear � Inflammation of middle ear, mastoid, and Eustachian tube Mucosa become edematous and discharge is produced Fluid, pus, and air build up in the middle ear impairing ventilation Can be drainage but doesn’t always have drainage Infection lasting longer than 3 months are chronic otitis media Commonly follows an URI Fever, earache, and feeling of fullness in the affected ear Purulent drainage forms causing increasing pain and hearing loss Nausea and vomiting If there is purulent drainage is seen, be concerned about perforated tympanic membrane Mastoid tenderness indicates that infection is in mastoid Otoscopic exam shows a reddened, bulging tympanic membrane. Some patients may only report fullness, bubbling, or crackling in the ear. Allergies, slight conductive hearing loss, or mouth breathing can cause this. � Otoscopic exam will show bulging tympanic membrane but there will be no redness

Middle Ear, Tympanic Membrane, and Mastoid Disorders (cont. ) � Complications Perforation-results in hearing loss, location and size determines the extent of hearing loss Buildup of fluid and pressure can cause spontaneous perforation � Experience relief after pain prior to rupture and Fluid moves the perforation and into the ear canal Damage to ossicles can occur Repeated infections can cause cholesteatoma (a cyst like sac that collects debris, skin, and sebaceous material) that applies pressure on surrounding structures Tympanosclerosis-repeated infections, is deposits of collagen and calcium on the tympanic membrane � Slowly progresses over time, contributing to conductive hearing loss Mastoiditis occurs when otitis media is not treated and spreads to the mastoid area, causing severe pain � Antibiotics have helped to make this condition less common � Frequent ear infections can cause chronic mastoiditis

Middle Ear, Tympanic Membrane, and Mastoid Disorders (cont. ) �Diagnostic tests Elevated WBC Cultures Audiometric studies, Rinne, Weber, Whisper voice tests Imaging studies �Therapeutic measures Topical and systemic antibiotics Steroids Oral Analgesics Politzer ear device “ear popper” to equalize pressure and aid fluid drainage

Middle Ear, Tympanic Membrane, and Mastoid Disorders (cont. ) � Therapeutic measures (cont. ) Surgical intervention-paracentesis with a needle and syringe (tympanic membrane is punctured with the needle, and fluid is drained from the middle ear) Myringotomy-incision is made in the tympanic membrane and fluid is allowed to drain out or is suctioned out � Laser can vaporize the tympanic membrane � Tubes are placed to keep opening open (usually spontaneously come out in 3 -12 months) Myringoplasty-reconstructive repair of perforated tympanic membrane � Gelfoam placed over the perforation � Graft from temporal muscle is placed over the Gelfoam � Gelfoam is absorbed, graft repairs the perforation Mastoidectomy-involves incision, drainage, and surgical removal of the mastoid process

Middle Ear, Tympanic Membrane, and Mastoid Disorders (cont. ) �Otosclerosis Hardening of the ear-formation of new bone along the stapes Stapes becomes immobile causing conductive hearing loss Begins in adolescence or early adulthood and progresses slowlyhearing loss is most apparent after the 4 th decade More common in women than men Affects both ears commonly Cause unknown but familial history is common (possibly hereditary) Primary symptom is progressive hearing loss Bilateral conductive hearing loss (particularly with soft, low tones) Usually seeks medical treatment after hearing loss interferes with daily function May experience tinnitus Otoscopic exam-pinkish orange tympanic membrane due to vascular and bony changes in the middle ear

Middle Ear, Tympanic Membrane, and Mastoid Disorders (cont. ) � Otosclerosis (cont. ) Diagnostic Tests � Audiometric testing to understand type and extent of hearing loss � Imaging studies for location and extent of bony growth � Whisper voice and normal conversation to test decreased hearing � Rinne test usually produces the best hearing for the patient but has more difficulty with the Weber test Therapeutic measures � No cure � Hearing aids can help to improve hearing � Reconstruction of necrotic ossicles to restore some hearing � Surgeries are not always successful � Ossiculoplasty (reconstruction of the ossicles) with prostheses made of plastic, ceramic, or human bone. Can be total or partial � Stapedectomy-treatment of choice Goal to restore vibration and allow sound transmission Improvement immediately for some, others after the swelling has receded

Middle Ear, Tympanic Membrane, and Mastoid Disorders (cont. ) � Otosclerosis (cont. ) Nursing Care � Operative ear is positioned upward when lying in bed � An earplug assists in keep aseptic area � Proximity to brain makes preventing infection VERY important � Antiemetics are important � Patient safety � Patient shouldn’t cough, sneeze, blow their nose, vomit, fly in an airplane, lift heavy objects, or shower � Trauma We all know what trauma is but also consider the impact of blast injuries, baro -trauma, blunt trauma, and pressure Pain and hearing loss Fullness of the ears, vertigo, nausea, disorientation, edema of the affected area, and hemorrhage in the external or middle ear. Barotrauma-drowning or cerebral air embolism Otoscopic exam- retracted, reddened, and edematous tympanic membrane Audiometric studies, imaging studies help to determine extent of middle and inner ear damage

Middle Ear, Tympanic Membrane, and Mastoid Disorders (cont. ) �Nursing Process Data Collection � WHAT’S UP? � Objective assessment Diagnoses Planning Implementation Evaluation �Review Box 52 -5, Page 1265 -1266

Inner Ear � Labyrinthitis Inflammation or infection of the inner ear Can be caused by viral or bacterial pathogens Serous labyrinthitis follows drug intoxication or overindulgence in alcohol � Vertigo-the vestibular structures are involved � Tinnitus-infection is located in the cochlea � Sensorineural hearing loss-infections in the cochlea or vestibular structures � Nystagmus-on affected side � Pain, fever, ataxia, nausea, vomiting, and beginning nerve deafness � Can also be caused by allergy Diffuse suppurative labyrinthitis-acute or chronic otitis media spreads into the inner ear or after middle ear or mastoid surgery Destruction of soft tissue structures from the infection cause permanent hearing loss Signs and symptoms Diagnostic tests � Therapeutic measures � CBC, hearing evaluation, Rinne, Weber tests Antibiotics for bacterial, Viral runs its course, Mild sedation, antihistamines, bed rest Nursing care � Manage symptoms and self-care, education, safety

Inner Ear (cont. ) � Neoplastic Disorders Inner ear tumors (benign or malignant) Acoustic neuroma-8 th cranial nerve is the most common benign � Progressive unilateral sensorineural hearing loss of high-pitched soungs, unilateral tinnitus, and intermittent vertigo � Headache, pain, and balance disorders � Tumor growth = progressive symptoms � Malignant tumors grow quickly � Slow growing, any age, unilaterally � Compresses the nerve and adjacent structures Malignant tumors-rare in the inner ear � Squamous and basal carcinomas arise from epidermal lining of the inner ear Signs and symptoms Diagnostic tests � Neurologic, audiometric, and vestibular testing. Auditory brainstem evoked response and electronystagmography. Examination of CSF (increased protein). CT and MRI to determine tumor size and location

Inner Ear (cont. ) � Neoplastic Disorders (cont. ) Therapeutic Measures � Surgical removal of tumors-preferred method � Labyrinth is destroyed-resulting in permanent hearing loss � Steroids and radiation to decrease the size of the tumor or for inoperable tumors Nursing care � Focuses on preparing the patient for surgery and adjusting to the diagnosis and the resulting hearing loss � Meniere’s Disease Balance disorder-cause unknown Dilation of the membranous labyrinthdisturbance in the fluid physiology of the endolymphatic system. Thought to stem from hypersecretion, hypoabsorption, deficit membrane permeability, allergy, viral infection, hormonal imbalance, or mental stress Develops between ages 40 -60 Symptoms range from vague to severe and debilitating

Inner Ear (cont. ) � Meniere’s Disease (cont. ) Signs and symptoms Symptomatic treatment for acute attacks � Tranquilizers and vagal blockers � Salt-restricted diets, diuretics, antihistamines, and vasodilators for prophylactic treatment � Avoid alcohol, caffeine, and tobacco use � Best rest during acute attacks � Goal of treatments are to preserve hearing and reduce symptoms � Methotrexate for those that don’t respond to other treatment � Surgical management only when medical management fails. � Labyrinthectomy � Shunt from inner ear to subarachnoid space to drain fluid and prevent future hearing loss � Triad of symptoms-vertigo, hearing loss, and tinnitus � Recurring episodic bouts � Nausea and vomiting � Can occur suddenly or can have warning symptoms (headache, fullness in the ears) � Lasts 2 -4 hours � Safety concerns � Irritability, depression, and withdrawal � Weeks for symptoms to resolve � 2 -3 times annually � Diagnostic tests � Therapeutic measures Audiometric studies, neurologic testing and radiographic studies, caloric stimulation test Nursing care-symptoms, safety, emotional support, resources

Canalith Repositioning Maneuvers

Inner Ear (cont. ) �Nursing process Data collection � WHAT’S UP? � Objective Diagnoses Planning Implementation Evaluation

Chapter 19 IMPACT OF COGNITIVE OR SENSORY IMPAIRMENT ON THE CHILD AND FAMILY All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc.

Functional Impairments (at Least 2 of These 10) 102 �Communication �Self-care �Home living �Social skills �Community use �Functional academics �Leisure �Work �Health and safety �Self-direction All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc.

Early Behavioral Signs of Cognitive Impairment 103 �No response to contact, voice, or movement �Irritability �Poor or slow feeding �Poor eye contact during feeding �Diminished spontaneous activity

Causes of Cognitive Impairment 104 �Intrauterine infection and intoxication �Trauma (prenatal, perinatal, or postnatal) �Metabolic or endocrine disorders �Inadequate nutrition �Postnatal brain disease All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc.

Causes of Cognitive Impairment (cont’d) �Chromosomal anomalies �Prematurity, low birth weight, postmaturity �Environmental influences �Unknown prenatal influences �Psychiatric disorders with onset in childhood All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 105

Primary Prevention of Cognitive Impairment �Support for preterm and high-risk infants �Rubella immunization �Genetic counseling �Maternal counseling Use of folic acid supplements Education about fetal alcohol syndrome Education about lead exposure All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 106

Early Intervention 107 �Therapy, exercises, and activities are designed to address developmental delays �Helps children with cognitive impairment achieve full potential All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc.

Down Syndrome �Etiology is unknown, but multiple causes are likely involved �Most common chromosomal abnormality One in 800 to 1, 000 live births �Most common genetic cause of intellectual disability All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 108

Down Syndrome (cont’d) �Maternal age In mothers age 30 years, the incidence is about 1 in 950 In mothers age 40 years, the incidence is about 1 in 110 For 80% of Down syndrome infants, the mother is younger than 35 years �In about 5% of cases, the extra chromosome is from the father All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 109

Manifestations of Down Syndrome 110 All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc.

Hearing Impairment �Ranges from slight to profound Slight to moderately severe hearing loss: Residual hearing is sufficient to process linguistic information through the use of a hearing aid Severe to profound hearing loss: Disability precludes successful processing of linguistic information through hearing with or without a hearing aid All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 111

Causes of Hearing Impairments �Anatomic malformation �Low birth weight �Ototoxic drugs �Chronic ear infections �Perinatal asphyxia �Perinatal infections �Cerebral palsy All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 112

Pathology of Hearing Impairments �Conductive hearing loss (middle ear) �Sensorineural hearing loss (nerve deafness) �Mixed conductive-sensorineural loss may follow recurrent otitis media with complications �Central auditory interception Organic Functional All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 113

Symptom Severity �Measured in decibels (d. B) �Hearing threshold �Effect on speech All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 114

Therapeutic Management of Hearing Impairment �Medical or surgical interventions �Hearing aid �Cochlear implants All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 115

Manifestations of Hearing Impairment in Infancy �Lack of startle reflex �Absence of babbling by age 7 months �General indifference to sound �Lack of response to the spoken word All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 116

Childhood Profound Hearing Impairment �Profound hearing impairment is likely to be diagnosed in infancy �Entry into school �Concerns with speech development All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 117

Promoting Communication �Lip reading �Cued speech �Sign language �Speech language therapy �Socialization �Additional aids All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 118

Care for the Hearing-Impaired Child during Hospitalization �Reassess the understanding of instructions given �Supplement with visual and tactile media �Communication devices Picture board Common words and needs (food, water, toilet) All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 119

Prevention of Hearing Loss �Treatment and management of recurrent otitis media �Prenatal preventive measures �Avoid exposure to noise pollution All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 120

Visual Impairment Classification �Partially sighted Acuity of 20/70 to 20/200 Education is usually in the public school system �Legal blindness Acuity of 20/200 or less Legal as well as medical term All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 121

Etiology of Visual Impairments �Perinatal or postnatal infections Gonorrhea, Chlamydia infection, rubella, syphilis, toxoplasmosis �Retinopathy of prematurity �Perinatal or postnatal trauma �Unknown causes All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 122

Refractive Errors 123 �Refraction is the bending of light rays through the lens of the eye �Myopia �Hyperopia �Strabismus/cross eyed All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc.

Infections �Conjunctivitis Ophthalmic antibiotics Systemic antibiotics in some cases Caution with the use of steroids because they may exacerbate viral infections Infection control concerns All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 124

Nursing Assessment of Vision �Infancy Response to visual stimuli Parental observations and concerns Expect binocularity after age 4 months �Childhood Visual acuity testing All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 125

Promoting Child’s Optimum Development �Play and socialization �Development of independence �Education Braille Audio books and learning materials All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 126

Periodic Recommended Screening �Prenatal �Newborns through preschoolers �Children of all ages All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 127

Emergency Treatment for Eye Injuries 128 �Foreign body �Chemicals �Sunburn �Hematoma �Penetrating injuries All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc.

Deaf and Blind Children �Profound effects on development �Motor milestones are usually achieved �Other developmental achievements are often delayed �Finger spelling �Developing future goals for the child All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 129

Retinoblastoma �Congenital malignant tumor, arising from the retina �In 60% of cases, tumors are nonhereditary and unilateral �In 15%, they are hereditary and unilateral �In 25%, they are hereditary and bilateral All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 130

Diagnostic Evaluation of Retinoblastoma 131 �The most common sign, leucokoria (white reflex), is often reported by the parents as a whitish “glow” in the pupil �Strabismus is the second most common sign �Eye is red and painful; glaucoma is often present �Blindness is a late sign All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc.

Therapeutic Management of Retinoblastoma �Early-stage unilateral tumor Irradiation, cryotherapy Attempt to preserve useful vision in the affected eye �Bilateral disease Attempt to preserve useful vision in the least affected eye �Advanced tumor Enucleation Chemotherapy (there is some controversy about its use) All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 132

Prognosis for Retinoblastoma �Survival rate of nearly 90% �Tumor may spontaneously regress �Concern with development of secondary tumors, especially osteogenic sarcoma All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 133

Nursing Considerations for Retinoblastoma �Elicit parental concerns �Preparation for surgery �Postoperative care �Family support All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 134

Autism Spectrum Disorders (ASDs) �Autism spectrum disorders (ASDs) are complex neurodevelopmental disorders of brain function Autistic disorder Asperger syndrome Pervasive developmental disorder not otherwise specified �Range from mild to severe All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 135

Causes of ASD �The cause of ASD is unknown �Theories A link between hereditary, genetic, and medical problems Immune and environmental factors may increase the incidence �High risk of recurrence in families �No supportive evidence that ASD is caused by the measles–mumps–rubella (MMR) vaccine or vaccines containing thimerosal All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 136

Diagnostic Criteria for ASD �Qualitative impairment in social interaction �Qualitative impairment in communication �Restricted repetitive and stereotyped patterns of behavior, interests, and activities �Delays or abnormal functioning with onset before 3 years of age �American Psychiatric Association DSM-IV-TR All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 137

Nursing Considerations for ASD �Wide variation in the individual client response to treatment efforts �No cure for ASD, but many therapies are used �Most promising results seem to be obtained with the use of highly structured routines and intensive behavior modification programs All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 138

Family Support for ASD �ASD often becomes a “family disease” �Help alleviate parents’ unwarranted feelings of guilt and shame �Stress the importance of family counseling �Autism Society of America (ASA) is a good source of information �Encouraging home care for children; assisting with long-term placement later in life All Elsevier items and derived items © 2013, 2009, Mosby, Inc. , an imprint of Elsevier Inc. 139