Download Lecture 7 Handout: Sensory System

Sensory System Handout
I.
Charting abbreviations
a. Left eye: ______________
b. Right eye: _____________
c. Both eyes: _____________
d. Drop/s: _______________
II.
Conjunctivitis
a. Inflammation of the ___________________: AKA “_________ eye”
b. Caused by: ____________________ or ________________
c. Spread by: _______________________________
d. S&S (mild)
i. __________________
ii. Itching - _____________________
iii. Tearing & __________________
e. Diagnosis
i. Hx
ii. ____________ exam
iii. Conjunctival Scraping  _____________________
f. Medications
i. _____________________route ______________
g. Nursing Assessment
i. Symptoms: _______________________________
ii. Effects of __________________________
iii. Assoc. symptoms: __________________________
iv. Date of last ____________________
v. Corrective _________________
vi. Past Medical history:___________________________
vii. Vision test:
1. _______________eye chart
2. ____________________ chart
viii. Inspect eye
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ix. Check Pupils: PERRLA
1. P__________________
2. E__________________
3. R__________________
4. R__________________
5. L__________________
6. A__________________
h. Nrs DX: Risk for disturbed sensory perception (visual)
i. Instruct to _____________________
ii. Instruct to avoid _______________________
iii. Emphasize proper ___________________ care
i. Nrs DX: Acute pain
i. Admin ___________________________
ii. Patch _________ eyes
iii. Apply ___________ compress for _____ minutes ____X day
iv. Wear ________________ glasses
v. Avoid excessive _____________________
j. Nrs DX: Knowledge deficit
i. Teach
1. _______________________
2. Correct ___________ care
3. Do not share: ______________________________
4. Do not use _____________ make-up
5. Cleansing technique for _________________
III.
Eye trauma
a. Types
i. Foreign ____________
ii. __________________ & lacerations
iii. __________________
b. Corneal Abrasion: AKA ________________________
i. S&S
1. _____________
2. _____________________________
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3. Tearing
ii. Prognosis
1. Usually heal ______________ scarring
c. Burns
i. Types
1. Chemical burns: e.g._______________________
2. Thermal burns: e.g. _______________________
3. UV burns: e.g. ___________________________
ii. S&S
1. _______________
2. Affects _________________
3. Swollen ____________________
4. Conjunctiva ____________ & edematous: ______________
5. Cornea cloudy or _______________
d. Perforated eye
i. Metal flakes, ____________ shards, ________________
ii. S&S
1. ___________________
2. Partial or complete loss of ___________
3. ________________
4. Loss of ____________ content
e. Blunt eye trauma
i. Causes: ___________________________
ii. Minor
1. Ecchymosis: AKA: _________________________
2. Subconjunctival _______________________
f. Eye trauma Assessment
i. Eye _____________
1. _____________________
2. _____________________ (unless peretrating object)
3. _____________________ : foreign bodies, lacerations
a. ________________ anesthetic
g. Eye trauma diagnostic tests
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i. Fluorescein staining: ____________________________________
ii. Ophthalmoscopic exam
iii. X-ray & CT-Scan: Orbital _______________ & Foreign bodies
h. Treatment: Irrigation
i. _____________ foreign bodies: sterile ______________________
ii. Chemical burns: ___________________ amounts of fluid
iii. Procedure
1. From inner ______________ of the eye to outer
2. Head tipped to ______________ side
i. Eye trauma Tx: Removing loose foreign bodies
i. Use a: ______________, Sterile, ___________-tipped applicator
j. Treatment severe or penetrating injury
i. _________ rest
ii. _______________ eye:______________ pad over _____________ eye
k. Post treatment care
i. Eye-drops / ________________ per order
ii. Eye __________/shield per order
iii. Avoid wearing _____________ until cornea has healed completely
l. Nursing Acute Care Eye trauma
i. Prevention: Eye ___________________, ________ belts
ii. ________________ eyes immediately if chemical splash
iii. Abrasion/penetrating:
1. Loosely cover with a sterile _______________
2. Do not _______________ penetrating objects
3. _________________ both eyes
m. Nursing Care: after injury
i. Reinforce ________________________ care
ii. Discuss ______________& application
iii. Teach how to apply _____________________________
iv. Do not ___________________ or scratch the eye
v. Avoid activities the ________________ intraocular pressure
1. _________________, straining, _____________ over
SMALL GROUP QUESTIONS
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1. Define the following abbreviations: OS, OD, UO, gtts
2. Describe conjunctivitis, how would you assess for it?
3. What is the common treatment for conjunctivitis?
4. You are fishing with a young child and the line breaks and the fish hook flies into their eye. What
would you do?
5. After the hook is removed, what instructions should be given to the child?
IV.
Cataracts:
a. Definition: ________________ of the ____________  impaired vision
i. Common, __________________, Affects ____________
ii. _____ age  cells become less ________________
iii. Affect _________________ first  spreads towards ___________
iv. Affects ______________ & _______________ vision
v. ______________ obscured
vi. _______________________
vii. Pupil appear: _________________________________
b. Risk factors
i. _________________: Senile cataracts
ii. Sunlight
iii. Smoking & Heavy __________________ consumption
iv. Eye ____________________
v. Diabetes ________________________
c. Diagnosis
i. Hx & __________ exam
d. Treatment
i. ____________________ removal
1. Clouded ___________ removed  Intraocular lens ____________
e. Nursing care: eye surgery
i. Pre-op
1. Assess __________________ of procedure
2. Assess vision of ________________________ eye
3. Reinforce ___________________ teaching
4. Remove all eye __________________________
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5. Administer per-op __________________ per order
ii. Post-op
1. Assess
a. ______________
b. ______________
c. Comfort
d. Status of eye __________________
2. Maintain eye ____________ per MD order
3. Position: _____________________________
4. Approach from ______________________ side
5. Prevent:
a. ________________________ & Straining
b. ________________________ & Sneezing
6. Immediately report: __________________________________
a. _________________ or cloudiness
b. ____________________
c. ________ vision
d. Floaters, flashes ____________________
7. Keep personal items & _________________ within reach
8. Admin __________________ per order
9. Arrange for _____________________
10. Teach
a. How to ________________ eye drops
b. How to ________________ eye patch
c. Avoid __________________
d. Wear _____________ glasses
e. Make & _____________ appointments
V.
Glaucoma
a. Pathophysiology
i. _______ intraocular pressure  _______________ vision loss
ii. Vision loss is _______________
b. S&S: Chronic
i. _____________________
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ii. Difficulty adapting from ________________ to _____________
iii. _______________ vision: halos
iv. Difficulty focusing on _____________ objects
c. S&S acute
i. Severe eye _______________
ii. _______________
iii. Halos, red eyes, cornea clouded
iv. Pupil: ___________________ & _____________________
d. Treatment
i. Tonometry: Measures intraocular ____________________
ii. Visual field testing: Check ____________________ vision
e. Medications
i. Meds to _____________ intraocular pressure
ii. Mydriatics (drugs that ___________________pupils) must be avoided
f. Health promotion
i. Early screening
1. >40 __________________
2. > 60 __________________
g. Nursing assessment
i. Risk factors
ii. ___________ about vision
iii. Fm Hx
iv. ________________ eye
v. Assess ___________________ & ___________________
h. Nursing Diagnosis: Risk for injury
i. Assess ability to provide ______________________
ii. Alert others not to ____________________ items in room
i. Application of eye drops
i. Use __________________technique
ii. Have clients sit ___________ or lie supine with head tilted slightly ___
iii. Rest hand on the client’s____________ , hold the dropper ______cm above
conjunctival __________ and instill the medication into the _____________ of the
sac. Then instruct the client to ___________his eye gently.
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iv. Apply gentle pressure with your finger and a clean tissue on the nasolacrimal
______________ for 30 to 60 seconds to prevent systemic
Small Group Questions
1. Differentiate between cataracts and glaucoma
2. What is the common treatment for cataracts?
3. What would you teach a patient who had/ was having cataracts surgery?
4. What is the common treatment for glaucoma?
5. What is the prognosis for glaucoma?
6. Describe how to put in eye drops
VI.
Otitis Media
a. Pathophysiology
i. Inflammation of the _______________ear
1. Ear _____________:Protects middle
ear from environment
2. Eustachian ____________:Connects with nasopharynx
ii. Risk factors:
1. ____________, _________________ Eustachian tube dysfunction
b. Serous Otitis media
i. Eustachian tube is ______________  __________ gradually absorbed 
_________________ pressure  Serous ______________ drawn in
ii. S&S
1. _________ hearing
2. ___________________ or popping
3. ___________________ or sunken ear drum
4. Change in atmospheric pressure  ___________________
c. URI  Eustachian tube _________________ Impairs ___________ from middle ear 
______________ grows in fluid  Inflammatory process  ________ increases pressure
 Ear drum ___________
d. S&S
i. _________
ii. Fever
iii. _______________ or Vertigo
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iv. Eardrum: _____________, Inflamed, Dull, Bulging
e. Diagnostic exam
i. Hx and physical exam: ______________________
f. Medications
i. _________________________________
ii. Antibiotics:
iii. ____________ analgesics: __________________________
g. Complementary therapies
i. Drop of ______________oil: Into ear canal
ii. _____________ cloth: To side of face
h. Surgery
i. Tympanocentesis: ___________through eardrum  _______ fluid & pus
ii. Myringotomy: Surgical ________________ of the middle ear
iii. Ventilation (tympanostomy) tubes: Ventilation and _______________ of middle
ear during healing
i. Nursing Care Ear surgery: Pre-op
i. _______________ hearing
ii. Discuss post-op hearing ____________________
iii. Explain post-op restrictions
1. Bowing _________________
2. _______________________ or sneezing
j. Nursing Care eat surgery: post-op
i. Assess
1. Bleeding: _____________________________
2. Nausea: Admin ________________________
3. ________________ / dizziness
4. Hearing
ii. HOB: _______________________________
iii. Stand on _____________________ side to communicate
iv. Remind to _______________ coughing, sneezing, blowing nose
v. Instruction for home care
1. Avoid ________________ until MD OKs
2. Keep ear _______________ clean and change prn
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3. Do not remove inner ear _______________ until MD OKs
4. No________________ , drive or travel by air until MD-OK
5. Anti ____________ & Anti_________________ per MD order
vi. Notify MD if
a. Fever, bleeding, _______ drainage, ______ dizziness, _____ hearing
k. Nursing Assessment Otitis Media
i. _______________: Onset / duration
ii. S&S
iii. Hx ___________________
iv. Move auricle / _________________
v. Inspect ________________ & ______________canal/drum
vi. V/S: Temperature
vii. Assess ___________________
viii. Palpate __________________ process
l. Nursing Diagnosis: Pain
i. _____________analgesics: Q________hour PRN
ii. ______________ to affected side of face & head
iii. Instruct to report abrupt pain _________________
iv. ___________ antibiotics
v. S/E of antibiotics
1. Diarrhea, ____________________ & Trush
2. Eat 8oz ____________________ daily
m. Nursing Diagnosis: Knowledge deficit
i. Instruct pt w/ tubes No…Swimming, ________________, Submerging _______
while bathing, ________ travel
ii. Enc___________, ________ fluid intake & Nutritious ________
Small Group Questions
1. What are the S&S of otitis media
2. What is the pathophysiology of otitis media
3. What medications are prescribed to a client with otitis media?
4. What client teaching would you give in regards to the above medications?
5. A 2 year old is having tubes placed in their ear bilaterally. The mother is confused about the
procedure and what to expect. What would you teach her?
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