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Sensory/Perceptual Alterations 201/107
Module A
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Eye Terminology/ Pathophysiology
• Refractive errors• Blindness• Infection/ inflammation• Cataracts• Retinal detachment• Retinopathy
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Eye Terminology/ Pathophysiology
• Macular degeneration• Glaucoma• Enucleation• Trauma
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Refractive Errors of the Eye
• Most common visual problem• Refraction is the bending of light rays• Prevents light rays from converging into a
single focus on retina• Non-surgical correction– corrective glasses– contacts– corneal molding to treat astigmatism
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Refractive Errors of the Eye
• Surgical Correction– LASIK– PRK• Myopia– Near sightedness- can see up close, but not objects
in the distance– Most common refractive error– Images are bent & fall in front of retina, not on the
retina
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Refractive Errors of the Eye
• Hyperopia– Farsightedness– Images are focused behind retina, not on retina• Presbyopia– Loss of accommodation for near vision– Lens loses its elasticity– Age 30’s to 40’s– Has difficulty with close reading without backing
away from the material
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Refractive Errors of the Eye
• Astigmatism– Irregular corneal curvature– Incoming light rays are bent unequally– Can occur with other refractive errors– Treated with corneal molding
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Blindness
• Visual acuity is measured with the Snellen Chart. Visual acuity is measured as a fraction. The top number is the distance to the chart. The bottom number is the distance at which a “normal eye” can read the line.
• Definition of Legal Blindness- visual acuity of 20/200 or < with corrective lenses or visual field no > 20 degrees
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Blindness
• Nursing Diagnoses– Altered sensory perception R/T blindness– Risk for injury R/T inability to see potential dangers– Self-care deficit R/T visual impairment– Fear R/T inability to accurately interpret environment
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Blindness• Goal: Make a successful adjustment to the
impairment– Orient client physically & verbally to the environment– Encourage self-care activities– Encourage independence– Use sight-guided technique when assisting with
walking– Encourage use of touch– Establish routine placement for tableware– Take the person’s hand & guide to find personal care
items
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Blindness
• Goal: Verbalize feelings R/T loss– Allow expression of fears and feelings of anger– Help to identify coping strategies• Goal: Use of appropriate coping strategies– Provide emotional support– Provide diversion activities- radio, audio books– Referral to agencies: ex. American Foundation
for the Blind, Social & Rehabilitative Services
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Eye Infections & Inflammation
• Hordeolum– Also called “sty”– Infection of sebaceous gland or an eyelash follicle
in the lid margin– Red, swollen, tender, painful area on skin surface
of eyelid. May have purulent drainage– Warm, moist compresses & anti-infective
ointment
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Eye Infections & Inflammation
• Chalazion– Sterile inflammation of a sebaceous gland in the
eyelid– Painless swelling – Surgical excision if it interferes with vision
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Eye Infections & Inflammation
• Blepharitis– Common chronic bilateral inflammation of lid
margins– Lids are red rimmed with scales or crusts– Treatment: warm, moist compresses, gentle
cleansing with baby shampoo, anti-infective ointment
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Eye Infections & Inflammation• Conjunctivitis- infection or inflammation of
conjunctiva– Bacterial conjunctivitis- “pink eye”. Occurs most
commonly in children. Contagious. Present with tearing, redness, mucopurulent drainage, itching. Treat with antibiotic drops. Teach good handwashing, isolate linens, keep out of school or day-care. Teach to discard opened contact lens care products and eye make-up.
– Viral conjunctivitis- may treat with corticosteroid drops
– Inflammatory conjunctivitis- not contagious
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Cataracts
• Opacity of the lens• Cataract removal is the most common surgical
procedure for older Americans• Risk factors– Aging– Trauma– Toxins– Long term use of corticosteroids– UV light exposure– Smoking
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Cataracts
• Assessment findings– Dimmed vision, blurred vision, loss of visual acuity– Abnormal color perception– Sensitivity to glare– Pupil may appear white, gray, or opaque– Loss of red reflex
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Cataracts
• Preoperative nursing care– Antibiotic drops if ordered– Mydriatic eye drops to dilate the pupils– Preoperative teaching: Avoid rubbing eyes after
surgery. Eye patch will be applied on affected eye & will be removed the following day at the postop appointment. Teach that surgery is done under local anesthesia with sedation to keep comfortable.
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Cataracts• Postoperative care:– Antibiotic drops to prevent infection,
corticosteroid drops to decrease inflammation.– Avoid activities that increase IOP such as lifting,
stooping, straining– Wear eye shield as instructed– Glasses can only be prescribed when healing
process is complete, usually 6-8 weeks– Teach to look through central portion of lens
implant.– Avoid lying on operative side
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Retinal Detachment
• Separation of the sensory retina & the underlying pigmented epithelium, with fluid accumulation between the two layers
• Risk factors– Eye Trauma– Increasing age– Diabetic Retinopathy– Personal or family history
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Retinal Detachment
• Clinical manifestations– Impending retinal detachment- light flashes,
floaters, cobweb or hairnet appearance– Complete retinal detachment- painless loss of
vision “like a curtain” coming across field of vision
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Retinal Detachment
Surgical Interventions-- Laser photocoagulation-uses intense focused light
beam which causes a scar. This seals the edges of the tear preventing fluid from accumulating.
-- Cryopexy- Uses extreme cold to produce scarring-- Scleral Buckling- Uses a silicon implant, may also use
encircling band to indent the globe of the eye. See picture Lewis, p 431
-- Pneumatic retinopexy- Injection of a gas to form a temporary bubble that helps close the retinal break.
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Retinal Detachment
• Postoperative care– Topical antibiotics– Topical corticosteroids– Analgesics– Mydriatics to dilate the pupil– Special positioning may be prescribed by surgeon
depending on the extent & the area of detachment. May be on bedrest. May have to keep head positioned so that the bubble is in contact with the retinal break
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Retinopathy
• Diabetic retinopathy is the leading cause of visual disability & blindness in persons with uncontrolled DM
• Hypertensive retinopathy is caused by high blood pressure which creates blockages in the small vessels of the retinal.
• Papilledema is swelling of the optic disc & nerve due to sustained, severe hypertension. This is a medical emergency. Treatment focuses on lowering the BP.
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Macular Degeneration
• Most common cause of irreversible central vision loss in persons over 60.
• Family Hx is a major risk factor.• 2 types: wet & dry• Nutritional supplements have shown to slow
the progression
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Primary open-angle Glaucoma• Characterized by – Increased intra-ocular pressure (IOP)– Optic nerve atrophy– Peripheral visual field loss– Tonometry measures IOP. IOP > 22 mmHGMuch more common in African- AmericansPrimary open-angle glaucoma accounts for 90% of
cases• Obstruction of the flow of aqeuous humor resulting
in build up of pressure (IOP)
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Primary open-angle Glaucoma
• Pathophysiology• Imbalance between rate of secretion of
aqueous humor & rate of absorption of aqueous humor Increased IOPDecreased peripheral vision EdemaBlindness
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Acute closed angle glaucoma• Rare• Medical Emergency• Requires surgery• Complete closure of the angle • Subjective assessment
Severe pain in & around eyeHeadacheRainbow halos around lightN & V
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Glaucoma• Medications are primary treatment– Beta adrenergic blockers- ex. Betoptic,
Timoptic, Betagan– Alpha adrenergic agonists- ex. Dipivefrin ( Propine),
Alphagan, Lopidine, Xalatan– Miotics- ex. carbachol, pilocarpine– Carbonic anhydrase inhibitors- ex. Azopt, Trusopt
eyedrops. Medication taken by mouth- Neptazane, Diamox
All 4 classes of drugs decrease aqueous humor production
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Glaucoma
– The nurse should stress the importance of compliance with medications & follow-up appointments to treat, monitor, & prevent loss of vision. Life-long medications will most likely be required
– Beta blocker eye drops used to treat glaucoma can cause an additive effect if systemic beta blockers (ex. Tenormin, lopressor, toprol, corgard) are also prescribed. Some eye drops to lower IOP are contraindicated in patients with COPD.
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Glaucoma Medications
• Goal of medical intervention is to decrease IOP.
• Avoid use of antihistamines or sympathomimetic drugs found in cold medicines. These cause mydriasis or dilation of the pupil. The opposite goal of treatment
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Enucleation
• Removal of the eye• Primary indication is a blind, painful eye, some
malignancies.• Emotional support• 6 weeks may be fitted for eye prosthesis
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Eye Trauma
• Types of injuries– Blunt injury– Penetrating injury– Chemical injury– Foreign bodies90% of all eye injuries can be prevented by using
proper eye protection when participating in sports, woodworking, yard work. Comply with eye wear recommendations at place of employment
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Types of Ophthalmic Drugs
• Topical anesthetics- for pain• Topical antibiotics• Steroids- decrease inflammation• Mydriatics- dilate the pupil for eye exam• Miotics- contract the pupil permitting better
drainage of intraocular fluid in glaucoma• Carbonic anhydrase inhibitors• Beta blockers
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Ear Terminology/ Pathophysiology
• Hearing Loss/ Deafness• Trauma• External otitis• Impacted cerumen• Otitis Media• Otosclerosis• Meniere’s Disease
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Symptoms of Hearing Loss
• Frequently asking people to repeat statements
• Loud volume on T.V. or radio• Withdrawal from social interactions• Better understanding in small groups• Using loud speaking voice• Turning head/ leaning forward to favor one
ear.
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Auditory Assessment
• The unit for measuring loudness is the decibel.• Hearing loss is measured in decibels• 0-15 dB - normal hearing• >40-55 dB - moderate hearing loss• >90 - profound hearing loss15 dB are generated with shuffling paper in
quiet room. 40dB low conversation. 150 dB jet plane 100 feet away
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Types of Hearing Loss• Conductive- sound waves are blocked to the
inner ear because of problem in external or middle ear. Causes- inflammation, obstruction external or middle ear, tumors, otosclerosis
• Sensorineural- Problem with sensory fibers in inner ear so the impulse to the brain is impaired. Often permanent. Causes- cranial nerve damage, medications, trauma, inherited disorders, prolonged exposure to loud noise, aging
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Types of Hearing Loss
• Conductive/Sensorineural Hearing Loss- a mix of both types
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Nursing Interventions
• Face the client when speaking• Speak slowly and clearly• Lower the pitch of your voice• Limit other noises when speaking to the
client, close the door, turn off T.V.
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Hearing Loss/Deafness• Hearing Health Promotion– Increasing rate of hearing loss in young adults as a
result of prolonged amplified sound (I-pods, etc)– Industrial work environments- use of ear
protection– Immunizations- encourage MMR immunization– Ototoxic drugs & chemicals- salicylates, diuretics,
antineoplastic drugs (cisplatin), antibiotics (gentamycin), chemicals used in industry such as mercury
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Assistive Devices & Techniques
• Hearing Aids• Lip reading- allows for approx 40% understanding.
Gestures & facial expression help to clarify the spoken message
• Sign language• Assistive Listening Devices• Service dogs for deaf• Special telephones• Computer programs
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Deafness
• Consult community resources such as National Assoc. for Deaf
• Teach safety precautions when crossing the street, driving
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Ear Trauma
• Blows to the ear can cause conductive hearing loss. Foreign objects into the ear canal may cause perforation
• Head trauma that injures temporal lobe can affect hearing
• Emergency care of head injury- may find clear/ bloody drainage in ear canal. Sign of serious head injury. Fluid may be leaking CSF
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External Otitis
• Inflammation or infection of the epithelium of the auricle and ear canal.
• “Swimmer’s Ear”• Pain upon movement of the auricle or on
application of pressure to the tragus• Treatment- antibiotic and/or steroid ear
drops, anagesics
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Impacted cerumen• Treat with irrigation of the ear canal with bulb
syringe or special device used in the healthcare providers office
• Use warm tap water. Place basin under the ear with towel around the neck so client does not get wet
• Lubricating drops may help loosen the earwax, so irrigation can be done.
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Impacted cerumen
• Irrigation is contraindicated if tympanic membrane is perforated.
• Teach to avoid cotton tipped applicator use in ear canal. May cause ruptured eardrum or may cause impaction of cerumen.
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Otitis media
• Common childhood disease which often follows colds, allergies, sore throats, and blockage of the eustachian tube.
• Treatment – antibiotics (amoxicillin)• Otitis media with effusion- inflammation of
the middle ear with collection of serous or purulent drainage. May be chronic
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Otitis media
• Surgical therapy- – myringotomy with tympanostomy tube placement– Myringoplasty- surgical repair of TM perforation– Mastoidectomy- removal of diseased tissue and
infection. Incision behind ear
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Otosclerosis
• Autosomal dominant disease• Fixation of the stapes in the oval window• Hearing aids may be effective• Surgical intervention- stapendectomy with
prosthesis insertion• Progressive gradual hearing loss, may hear
ringing or roaring
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Meniere’s Disease
• Inner ear disease– Episodic vertigo– Tinnitus– Fluctuating hearing loss– May have sudden, severe attacks of vertigo with N & VMay feel as if they are being pulled to the ground or
feel like they are whirling in space
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Meniere’s Disease
• Nursing interventions -Keep in a quiet, dark room during an acute attack -Safety measures- siderails up, call for assistance to
get up Surgical intervention- surgical decompression of the
endolymphatic sac to reduce pressure on cochlear hair cells and to prevent further damage and hearing loss
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Meniere’s Disease
• Treatment- o antihistamines- to decrease tissue edemao antiemetic- such as phenergan, tigano diuretics- such as diamox
Main medication is meclizine (antivert) to control nausea and vertigoo -Low salt diet
• Safety
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Mastoiditis
• Swelling behind the ear and pain. Cellulitis on the skin over the mastoid process.
• Fever, malaise, tender and enlarged postauricular lymph nodes
• Most common treatment is simple/ modified mastoidectomy with tympanoplasty
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Assistive Devices & Techniques
• Cochlear implant- Implanted electronic hearing device that stimulates the nerves of the inner ear. Ideal candidate is someone who became deaf after learning to speak. Extensive training and rehab are essential. Offers the profoundly deaf the ability to hear sounds including speech
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Questions• Which task is appropriate to delegate to an
LPN who is working with the RN?• Administer eye drops to a child with
conjunctivitis.+• Review hand washing with a patient who has
an eye infection+• Show a client how to remove eye exudate+• Assess nutritional factors with a client with
macular degeneration
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Question
• A patient with a history of head trauma is in need of treatment for adult strabismus. What treatment would be considered appropriate for this patient?
• Rational
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THE END