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NUR 611 HUMAN BIOSCIENCES: ALTERED BODY FUNCTIONS DISORDERS OF THE VISUAL AND AUDITORY SYSTEMS compiled by Venina Navuta 23/1/17 DISORDERS OF THE AUDITORY SYSTEM Diagnostic Tests Laboratory tests -routine blood tests -Culture -If clear fluid draining from ear, rule out cerebrospinal fluid Radiological tests - Computed tomography (CT scan) - Magnetic resonance imaging - Arteriography and venography Special Tests Auditory Acuity Tests – whispered voice test, tuning fork tests, Rinne test, Weber test. Audiometric Hearing Tests Balance Testing Inspection and palpation only Inspect mastoid process for redness/swelling External ear: inspected for shape, location of attachment to the head and condition of the visible external canal Otoscope is used to visually see and test the external ear canal Consists of a light, a handle, a magnifying lens and a bulb for injecting air to test eardrum mobility Tympanic Membrane(TM) Observations - color, intactness and shape Characteristics shiny, transparent and opaque/pearly gray slightly concave, movable, & free from lesions Visual Inspection ◦Pinna: swelling, nodules (gout/skin cancer/rheumatoid arthritis) and lesions (malignant skin cancer) Otoscopic Examination ◦Tympanic Membrane: redness, of infection Completed after bilateral external ear and otoscope examination Sound is transmitted by both air conduction and bone conduction Air conduction of sound is normally more sensitive than bone conduction Voice Test Watch Test Tuning Fork Tests: useful, although limited, in differentiating between conductive and sensorineural hearing losses AUDIOMETRY Measurement of hearing acuity Hearing: measured in intensity of sound expressed as decibels Conversational speech is generally around 60 decibels Hearing loss of 45-50 decibels – need a hearing aid Hearing loss of 90 decibels – may not be able to hear speech – even with a hearing aid EAR INSPECTION Normal external ear canal is free from lesions, is dry, clean and not reddened Any deviation from the normal ear shape and attachment is recorded The nurse notes any drainage Outer and Middle Ear Disorders Structural defects due to embryologic malformations Structural changes secondary to infection or trauma Outer Ear Disorders • Microtia and atresia Microtia: abnormal smallness of auricle Atresia: absence of an opening of the external ear • Impacted cerumen: very common cause of temporary conductive HL. Very treatable and preventable. HL that results is flat, conductive, and of varying degree. DISORDERS OF THE EXTERNAL EAR Infections e.g. otitis externa Masses e.g. cysts, malignant tumors Foreign body Impacted cerumen Pruritis Microtia and atresia(congenital) EXTERNAL OTITIS Allergic Reactions Pain Itching Bacterial/fungal Infection Hearing loss Swimming Plugged feeling in ear Trauma Redness and edema TREATMENT Topical antibiotics Corticosteroids Oral analgesics Local heat DISORDERS OF THE MIDDLE EAR Infections e.g. otitis media, mastoiditis Perforated tympanic membrane Otosclerosis OTITIS MEDIA Exudate, pain, Bacterial or viral pressure infection Hearing Fluid accumulation loss/Tinnitus Fever/Malaise Nausea/Vomiting Bulging Tympanic Membrane TREATMENT Systemic antibiotics Analgesics/local heat Antipyretics Antihistamines Decongestants Myringotomy (surgical perforation of eardrum – drains fluid/relieves pain DISORDERS OF THE INNER EAR Acoustic neuroma – benign tumor of the 8th cranial nerve -occurs at any age -Common in women between 30-60 years. MENIERE’S DISEASE Occurs due the imbalance of fluid and electrolytes in the inner ear. S/S – severe tinnitus,feelings of ear fullness, vertigo MENIERE’S DISEASE Consists of three distinct characteristics: 1) Tinnitus 2) Unilateral sensorineural hearing loss 3) Vertigo **Occurs in attacks that can last for several days. Attacks render the client almost totally incapacitated during attack and several days are needed for full recovery MENIERE’S DISEASE Pathologic changes: either overproduction or decreased reabsorption of endolymphatic fluid, causing a distortion of the entire inner-canal system Distortion leads to decreased hearing from dilation of the cochlear duct, vertigo because of damage to the vestibular system, and tinnitus from unknown cause Usually occurs unilaterally MENIERE’S DISEASE Initial hearing loss is reversible Repeated damage to the cochlea, caused by increased fluid pressure, leads to permanent hearing loss Cause of disease unknown – but is associated with viral or bacterial infections, allergic reactions and biochemical disturbances that increase fluid imbalances MENIERE’S DISEASE Usually occurs between 20-50 years of age – greater prevalence in men and Caucausians Tinnitus is a continuous, low pitched roar or humming sound, worsens just before and during an attack Hearing loss is worse during an attack – permanent hearing loss develops as the attacks increase HEARING LOSS Inability of the ear to detect and perceive sound 3 main types: conductive, sensorineural and mixed CONDUCTIVE HEARING LOSS Can be caused by anything that blocks the external ear. Interference of conduction of sound through the external auditory canal, eardrum or the middle ear SENSORINEURAL LOSS Occurs from a disease or trauma to the inner ear, neural structures or nerve pathways leading to the brainstem. Cochlear Disorders Syndromes and inherited disorders Noise induced hearing loss Other trauma Infections Ototoxicity Infections Congenital ◦Cytomegalovirus ◦HIV ◦Rubella ◦Syphilis ◦Toxoplasmosis Infections Acquired ◦Herpes Zooster Oticus (Chicken Pox) ◦Mumps ◦Syphilis Ototoxicity Some antibiotics that Neomycin are often ototoxic: Amikacin Netilmicin Dihydrostreptomycin Garamycin Gentamicin Kanamycin Streptomycin Tobramycin Viomycin Chemotherapy Carboplatin Cisplatin Drugs that cause reversible hearing loss Quinine Salicylates (aspirin) Loop diuretics Drugs that may be harmful during pregnancy Accutane Dilantin Quinine Thalidomide Central Auditory Disorders VIII Nerve tumors Other diseases of the VIII Nerve Neural disorders Cochlear neuritis Diabetes mellitus Brain Stem disorders Infarcts Gliomas Multiple sclerosis Temporal Lobe disorders DISORDERS OF THE EYE ACCESSORY ORGANS OF EYE Eyebrow Eyelids and eyelashes Lacrimal apparatus NURSING CONSIDERATION preservation of vision prevention of further visual loss in those patients who have already experienced some degree of loss. maximal practical use should be sought for any remaining vision Skilful listening & interviewing are critical tools for the rehabilitation of the distressed patient Common eye diseases seen at the CWMH : -Pterygium -Tarsal cyst -Granuloma -chalazion THEATRE CASES Cataract -evisiation -Enucleation •Corneal perforation repair •iridectomy IMPORTANCE OF CLIENT HISTORY Family history of eye problems (refractive errors, night blindness, colorblindness) Gender – retinal detachments are more common in men and dry-eye symptoms are more common in women Age: incidence of glaucoma/cataract formation increases with aging Presbyopia (inability of the eye to read close up, due to aging of the natural lens of the eye) MEASUREMENT OF VISION Visual acuity tests measure both distance and near vision Snellen Chart: tool to measure distance vision Client stands 20 feet away from the chart, covers one eye and uses other eye for testing.e.g. 20/50 means that client is able to see at 20 feet what a “healthy eye” can see at 50 feet COMMON MEDICATIONS USED Topical anaesthetic Mydriatic Cyclopedic agents Anti-infective Corticosteroids NSAIDS anti-allergy Eye irrigant lubricants Eye Disorders Refractive errors Muscular disorders Disorders of the eyelid Disorders of the globe of the eye Refractive Errors Hyperopia Myopia Astigmatism Presbyopia Hyperopia (Farsightedness) Mechanism ◦object focuses behind the retina ◦able to see only far objects Etiology ◦genetic link SYMPTOMS AND SIGNS ◦blurred vision ◦Squinting ◦eye rubbing ◦headaches DIAGNOSIS ◦Snellen visual acuity test ◦ophthalmoscope TREATMENT ◦Convex lens Myopia (near sightedness) Mechanism ◦object focuses in front of the retina ◦able to see only close objects Etiology ◦genetic link Symptoms and signs ◦blurred vision ◦Squinting ◦eye rubbing Diagnosis ◦Snellen visual acuity test ◦opthalmoscope Treatment ◦concave lens ◦radical keratotomy - shallow incision in the cornea causing it to flatten in desired area (could have significant complications) Astigmatism Mechanism ◦Abnormal shaped cornea (egg shape instead of spherical) ◦object is partially clear & other blurred Etiology ◦genetic link Symptoms and signs oblurred vision oSquinting oeye rubbing oheadaches Diagnosis ◦Snellen visual acuity test ◦opthalmoscope Treatment ◦artificial lens transplant ◦radial keratotomy Presbyopia Mechanism * Rigidity of the lens (old age) * unable to focus Etiology * genetic link Old age (< 40 year) Symptoms and signs * blurred vision * squinting * eye rubbing * headaches Diagnosis ◦* Snellen visual acuity test * opthalmoscope Treatment ◦* lens transplant Muscular Disorders Nystagmus Strabismus Nystagmus Mechanism * repetitive involuntary movements of one or both eyes Etiology * Congenital * Brain tumors * CV lesions * Ear lesions * Alcohol/drug abuse Symptoms and signs * Eye movements *Horizontal, vertical, circular, or combination * blurred vision Diagnosis * viewing of the eyes - involuntary movement * complete neurological tests Treatment * Treat the underlying condition * Congenital stays for life Strabismus Mechanism * Failure of eyes to look in the same direction at the same time * Weakness of muscles of one eye (superior oblique, interior oblique, lateral) Etiology ◦in childhood: associated with amblyopia (decreased vision in one eye) (reversible after 7 years of age) in adults: Usually caused by disease: i.e. diabetes, high blood pressure, brain trauma Symptoms and signs ◦ Types: 1. Esotropia (convergent-cross eye of one eye) 2. Exotropia (divergent- one eye turns outward) 3. Diplopia (adults strabismus) 4. Congenital (no strabismus exists) Diagnosis ◦* complete ophthalmic examination * Diagnose underlying disease Treatment ◦* Treat early * Corrective glasses * orthoptic training * surgery to restore eye muscle balance * treat underlying disorder Nursing Care Goals Environmental management – orientation to the environment anxiety & discomfort; facilitates independance Emotional support Family involvement DISORDERS OF THE EYE Eyelid Abnormalities - ptosis : upper lid hangs down - Ectropian: lower lid hangs down - Trichiasis: eyelashes turn in - Chalazion: eyelid lump PTOSIS is an abnormally low position (drooping) of the upper eyelid. The drooping may be worse at night, when the individual's muscles are tired. ACUTE RED EYE Babies (0-28days)- conjunctivitis of the newborn Children (6/12-6yrs) – vit. A deficiency At any age – conjunctivitis/trachoma, corneal ulcer/foreign body, iritis, acute glaucoma CONJUNCTIVA – DISEASES OF Conjunctivitis – inflammation of the conjunctiva. Causes – viral, bacterial,chemical agents, allergens,physical irritants, radiant energy Acute Bacterial Conjunctivitis Mucopurulant conjunctivitis Caused by: Staph epidermidis and Staph aureus –usually. Strep pneumonae, H influensae and Morexella lucanatae occasionally Symptoms: Acute onset of redness, grittiness, burning and discharge. *Photophobia may be present (corneal involvement) *Stickiness of the eyelids *Usually bilateral disease * Signs: *Conjunctival hyperaema *Mild papillary reaction *Mucopurulant discharge *Lid crusting *No lymphadenopathy. *Normal VA TRACHOMA Chronic relapsing conjunctivitis Cause: chlamydia trachomatis Environmental factors: poor hygiene, personal & social TRANSMISSION IS FAVOURED BY: Crowded living quarters Shortage of water Dirty housing Poor hygiene – animal and human faeces around the house All factors which favour the breeding of FLIES TRACHOMA Also spread by sharing unwashed •Bedding •Clothing •Towels •Face cloths •handkerchiefs MOST AT RISK ARE Children Young mothers CLINICAL MANIFESTATIONS Follicles on underlid Inflammation Scarring Trichiasis Corneal opacity PREVENTION OF ACUTE TRACHOMA Encourage hand & face washing with clean water Clean up environment to Eradicate flies Intervention Surgery for trichiasis. Antibiotics . Facial cleanliness to prevent transmission. Environmental change to prevent transmission. Disorders of the Globe of the Eye Keratitis Corneal abrasion or ulcer Scleritis Cataract Glaucoma Macular degeneration Diabetic retinopathy Retinal detachment Uveitis DISORDERS OF THE CORNEA Corneal edema – caused by damage to the epithelium and endothelium of the cornea. Keratitis – inflammation of the cornea. Divided into 2 types -Nonulcerative – epithelium affected and still remains intact -ulcerative – epithelium, stroma or both are destroyed AQUEOUS HUMOR & INTRAOCULAR PRESSURE Glaucoma – group of conditions that cause an elevation of the intraocular pressure. -closed-angle glaucoma -Open-angle glaucoma * Congenital or infantile glaucoma CLINICAL MANIFESTATIONS Sudden, excruciating pain around eyes; headache; nausea/vomiting; halos around lights and sudden blurred vision DIAGNOSTIC TEST/TREATMENT Tonometry, non-contact Puff test Medications: ◦Miotics (which constrict the pupil allowing better circulation-blurs vision (Pilocarpine) ◦Beta Blockers (which inhibit aqueous humor production (Timoptic/Betagan) ◦Surgery – last resort when medication fails DISEASES OF ACCOMMODATION Develops when patient cannot accommodate changes from far to near vision Cataracts – opacity of the lens and interferes with the transmission of light into the retina COMMON CAUSE OF CATARACT AGE – over half are genetically determined Other causes – drugs, diseases, damage PATHOLOGY OF CATARACT Precipitation of transparent protein in the lens – becomes opaque Like frying an egg DISEASES Eye disease – iritis, glaucoma General diseases – diabetes, arthritis, syphilis, leprosy, Down’s syndrome. DAMAGE Contusion injury Perforation Acids and alkalis Sunlight Smoking/alcohol DIFFERENT CAUSES Congenital •Genetic •Hereditary •Rubella •Other viruses TYPES OF CATARACT Immature Mature Intumescent hypermature CATARACTS Risk factors: age, trauma, toxic agents, disease, chronic sunlight exposure and glaucoma or retinal detachment No pain or eye redness is associated with agerelated cataracts Visual acuity is very reduced – without surgery, visual impairment can progress to blindness TREATMENT the only treatment is surgery CATARACTS Surgical approaches to lens removal for cataracts Replacement lenses are inserted – some clients have distant vision restored to 20/20 and may only need glasses for reading or close work Major complication: increased Intraocular Pressure and/or Hemmorhage Another complication: Infection DISORDERS OF THE RETINA Blood Supply and Vascular Lesions – can give rise to papilledema Retinopathies – involve change in structure RETINAL DETACHMENT Involves separation of the sensory retina from the pigment epithelium with fluid accumulation between the two layers. Macular Degeneration - loss of central vision, usually in both eyes. DIABETIC RETINOPATHY The cells of the retinal vessels die and fluid leaks into the eye Fluid is absorbed; thick yellow-white hard exudates are formed Capillaries lose their ability to transport needed oxygen and nutrients Microaneurysms form in capillary walls. Capillaries become fragile – bleed easily and cause retinal ischemia or macular edema reducing visual acuity DIABETIC RETINOPATHY Treatment: depends on the severity of retinal damage Laser therapy can seal microaneurysms and decrease bleeding Scattering of laser burns across the retinal can decrease the retina’s need for oxygen and control the growth of new blood vessels A vitrectomy can be performed if frequent bleeding into the vitreous occurs and fibrin bands threaten to detach the retina REFERENCES Brown, D., & Edwards, H (2012). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems (3rd ed.).Sydney. Elservier Dempsey, Maureen Farrell and J. S meltzer & Bare's Textbook of Medical Surgical Nursing, 3rd Edition. Lippincott Williams & Wilkins, 10/2013. VitalBook file