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Chapter 13Chapter 13
Care of the Patient with a Visual or Auditory Disorder
Jeanelle Jimenez RN,BSN,CCRN
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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Slide 2Mosby 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
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Slide 3Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 13-1
Lacrimal apparatus.
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
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Slide 4Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and Physiology
• Anatomy of the eye (continued) Structures of the eyeball
• Sclera• Cornea• Choroid• Ciliary body• Iris• Pupil• Retina
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Slide 5Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and Physiology
• Anatomy of the eye (continued) Chambers of the eye
• Anterior chamber Aqueous humor
• Posterior chamber Vitreous humor
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Slide 6Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 13-2
Horizontal section through the left eyeball. The eye is viewed from above.
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)
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Slide 7Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and Physiology
• Anatomy of the ear External ear
• Auricle• External auditory canal• Tympanic membrane
Middle ear• Eustachian tube• Malleus• Incus• Stapes
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Slide 8Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 13-3
The ear. External, middle, and inner ear. (Not to scale.)
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)
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Slide 9Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and Physiology
• Anatomy of the ear (continued) Inner ear
• Labyrinth Bony labyrinth—filled with perilymph
o Semicircular canalso Vestibuleo Cochlea—organ of Corti
Membranous labyrinth—filled with endolymph
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Slide 10Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 13-4
The inner ear.
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Slide 11Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 12Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Laboratory and Diagnostic Examinations
• Diagnostic eye tests Snellen test Color vision Refraction Ophthalmoscopy Tonometry Amster grid test Schirmer’s tear test
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Slide 13Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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)
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Slide 14Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 15Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Disorders of the Eye
• Blindness and near-blindness (continued) Medical management/nursing interventions
• Corrective eyewear• Canes• Seeing-eye dogs• Magnifying systems• Surgical procedures
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Slide 16Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 17Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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)
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Slide 18Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Disorders of the Eye
• Conjunctivitis Etiology/pathophysiology
• Inflammation of the conjunctiva• Bacterial or viral infection• Allergy• Environmental factors• Commonly called pink eye
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Slide 19Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 20Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 21Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Disorders of the Eye
• Keratitis (continued) Clinical manifestations/assessment
• Severe eye pain• Photophobia• Tearing• Edema• Visual disturbances
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Slide 22Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 23Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Worse as day progresses
Medical management/nursing interventions• Artificial tear replacement• Punctal plugs or repair if injured
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Slide 24Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 25Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Ectropion & Entropion
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Slide 26Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 27Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 28Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 29Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 30Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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Slide 31Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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Slide 32Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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• Painless due to lack of retinal sensory nerves
Medical management/nursing interventions• Photocoagulation; cryosurgery; diathermy• Scleral buckling
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Slide 33Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 13-8
Retinal break with detachment: surgical repair by scleral buckling technique.
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.)
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Slide 34Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Disorders of the Eye
• Glaucoma Etiology/pathophysiology
• An abnormal condition of (1) elevated pressure (increased IOP) within an eye due obstruction of outflow of aqueous humor (2) optic nerve atrophy, (3) progressive loss of peripheral vision
Open-angle (more common/slowly progressive)o Aqueous humor outflow decreased due to clogging of
trabecular meshwork; bilateral Closed-angle (less common/acute)
o Sudden obstruction of trabecular meshwork/canals causing rapid vision loss & dramatic symptoms
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Slide 35Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 13-9
A, Chronic open-angle glaucoma. B, Acute-angle closure glaucoma.
(From Havener, W.H. [1997]. Synopsis of ophthalmology. St. Louis: Mosby.)
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Slide 36Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 37Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 38Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Disorders of the Eye
• Glaucoma (continued) Medical management/nursing interventions
• Open-angle glaucoma Beta blockers Miotics Carbonic anhydrase inhibitors Trabeculectomy (removal of corneoscleral tissue if meds
don’t work)• Closed-angle
Osmotic diuretics Iridectomy
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Slide 39Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 40Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 41Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 42Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 43Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 13-13
Weber tuning fork test.
(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)
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Slide 44Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Figure 13-14
Rinne tuning fork test.
(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)
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Slide 45Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 46Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 47Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 48Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 49Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 50Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 51Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 52Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 53Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 54Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Noninfectious Disorders of the Ear
• Ménière’s disease Etiology/pathophysiology
• Unknown• Chronic disease of the inner ear• Increase in endolymph fluid
Clinical manifestations/assessment• Vertigo• Nausea and vomiting• Hearing loss; tinnitus• Diaphoresis• Nystagmus
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Slide 55Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 56Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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
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Slide 57Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
• 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
Nursing Process