Download Nursing Management of Clients with Sensory Function

Nursing Management of
Clients with Stressors of
Sensory Function
NUR133
Lecture # 14
K. Burger, MSEd, MSN, RN, CNE
Eye Disorders
Nursing Assessment

History:
Acuity changes, blurring, diplopia,
photophobia, pain, use of gtts or other
eye meds, hx of trauma, familial eye
disease, occupational risks

Risk Factors for Eye Disorders:
Aging process, DM, HTN, HIV, +++others,
Medications, Gender, Nutritional
deficiencies
Eye Disorders
Nursing Assessment
Visual testing: distance, near, peripheral,
color
 External examination: lids,
conjunctivae, sclerae, pupils, extraocular
muscles
 Internal examination: opthalmoscopy
to observe- lens clarity, red reflex, fundus

Sample Eye Assessment Note
Near vision 20/40 each eye uncorrected, corrected
to 20/20 with glasses. Distant vision 20/20 by
Snellen. Color vision intact. Visual fields full by
confrontation. Extraocular movements intact
and full, no nystagmus. Corneal light reflex
equal.
Lids and globes symmetric. No ptosis, edema, or
lesions
Conjuntivae pink, sclerae white. No discharge
evident. Cornea clear, corneal reflex intact.
Irides brown; PERRLA
Opthalmoscopic exam reveals red reflex. Discs
cream colored, borders well-defined. Maculae
yellow OU
No venous pulsations, hemorrhages, exudates,
Drusen bodies.
Eye Disorders
Diagnostic Assessments
Tonometry – IOP testing
(normal = 10-21mmHg )
 Slit lamp – close examination of specific
area of eye
 Corneal staining – detects corneal defects
 Angiography – detects circulatory defects
 Electroretinography – retinal light
response

Glaucoma
Etiology/ Incidence / Prevalence
Increased ocular pressure resulting from:
inadequate drainage of aqueous humor
overproduction of aqueous humor
 Pressure leads to damage of retina and
optic nerve
 Primary – Secondary – Associated
 Increased incidence in African-Americans
 Increased incidence with aging

Glaucoma
Types
Open Angle





Most common
Bilateral
Slow onset
Usually painless
Blurred vision
Closed Angle
Sudden onset
 Emergency
 Severe pain radiating
around eyes & face
 Colored halos around
lights

Glaucoma
Assessment

Early signs = IOP, blurred vision,
decreased accommodation, difficulty
adjusting to darkness

Later signs = loss of peripheral vision,
decreased acuity (uncorrectable), halos
around lights, pain
Glaucoma
Interventions
Medication Rx:
-Miotics
-Sympathomimetic
-Beta blockers
-Carbonic anhydrase inhibitors
-Osmotic diuretics
-Prostaglandin agonist
 Surgical Rx:
-Trabeculoplasty
-Iridectomy

Glaucoma Medications
Increase
Decrease
Drainage of Aqueous
Production of
Humor
Aqueous Humor
Miotics
Beta Blockers
Pilocarpine hydrochloride Timolol maleate
(Isopto Carpine)
(Timoptic)
Osmotic Diuretics
CAIs
Prostaglandin Agonists
Sympathomimetics
Glycerin
Mannitol ( Osmitrol )
Latanoprost (Xalatan)
Actetazolamide
(Diamox)
Dipivefrin ( Propine)
Ophthalmic Medication
Nursing Implications for Pt Teaching
Instill drops into conjunctival sac not
directly onto the cornea
 Apply pressure to inner canthus X30sec
 Do not touch dropper to eye
 Wait 3-5 minutes between drops
 Close eyes gently after administration
 Do not rub eyes; dab gently prn

Glaucoma
Surgical Interventions
Trabeculoplasty
 May be used in openangle glaucoma if
pharm rx ineffective
or as primary rx
 Laser rx to trabecular
meshwork increases
space between fibers
and increased outflow
of aqueous humor
into conjunctivae
Iridectomy
Emergency rx for
acute closed angle
glaucoma
 Section of iris is
removed to create
pathway for flow of
aqueous humor

http://dmc.org/videolibrary/ek_gla
ucoma.html
Cataracts
Etiology / Incidence / Prevalence
An opacity of lens; distorts image
 Age related etiology = most common
 All people >70y.o. have some degree
 Exposure to ultraviolet light increases risk
 Other etiology r/t trauma, congenital
defects, associated diseases
 5-10 million affected worldwide each year

Cataracts
Assessment
Blurred vision
 Decreased color perception
 Opacity of lens
 Absence of red reflex
 Vision better in dim light w/ pupil dilation
 Gradual loss of vision
 Painless

Cataract Interventions
Surgery =
only option for Rx
 Surgical removal of
diseased lens and
replacement with
silicone prosthetic
lens
 Extracapsular
procedure = most
common
 Outpatient surgery
Cataract Surgery
Nursing Implications
Usually no eye patch
 Client to wear dark sunglasses
 Antibiotic/steroid eye gtts
 Instruct client to visit MD following day
 Instruct client in measures to avoid
increasing IOP

CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5th edition
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The client is a 62-year-old woman who works as a
stockbroker. She has recently been diagnosed with
bilateral cataracts. She lives in the Denver area and her
hobbies include long-distance biking and downhill skiing.
She has a glass or two of wine with dinner every night.
She smoked when she was in college but has not
smoked for more than 30 years. She is surprised by her
diagnosis because she is a vegetarian and keeps herself
physically fit. She also tells you that neither of her
parents nor any of her four brothers and sisters have
cataracts.
How should you explain the influence of genetics on the
development of cataracts?
What factors may have influenced the development of
her cataracts?
What additional personal and family information should
you obtain from this client?
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5th edition
Your 62-year-old client with bilateral cataracts is
scheduled to have an extracapsular cataract removal
with immediate intraocular lens implantation for her left
eye (the one with the worse vision). She asks why both
eyes can't be done at the same time so that she will not
have to go "through all of this rigmarole twice." She also
is concerned about her facial appearance after surgery
and whether any bruising will be present.
 Should both eyes be done at the same time? Why or
why not?
 How will her appearance be changed during the first
week after surgery?

CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5th edition
Your 62-year-old client had the cataract removed
from her left eye and a multifocal lens implanted
on Friday afternoon. She plans to go back to
work on Monday and does not want her coworkers to know about the surgery. (She worries
that people will think she is "old" and not on the
cutting edge of her profession).
 Should she go back to work on Monday? Why or
why not?
 What accommodations will she have to make at
her workplace?
 What specific activities will you tell her to avoid?

Macular Degeneration



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Dry (age-related)
Most common
Gradual
Wet
Sudden onset
Macula = area of
central vision
Increased risk for
smokers
Antioxidant intake
decreases risk and
slows progression
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5th edition

The client is a 75-year-old man who was
diagnosed with age-related "dry" macular
degeneration after he was involved in a car
accident in which he failed to stop at an
intersection and hit another car at a low rate of
speed. No injuries resulted from the car accident
although the client received a citation for a
moving violation. The client is very upset with
the diagnosis. His wife has never driven nor has
she managed the household accounts. He is
concerned about "going blind" and wants to
know if the LASIK procedure would restore his
vision.
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5th edition
Can the client continue to drive? Why or
why not?
 Will a LASIK procedure be helpful for this
problem? Why or Why not?
 How will you address the issue of "going
blind?"

CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5th edition
Your client with macular degeneration (dry)
wants to know if continuing to use his limited
vision will increase the progression of the
macular degeneration. He also worries that he
will "lose his mind" if he has to give up all his
usual activities.
 How will you address his concerns?
 How will you proceed to assist the client and his
wife in maintaining independence and quality of
life?
 LIGHTHOUSE INTERNATIONAL

Retinopathy
•Hypertensive
•Diabetic
Retinal Detachment

Partial detachment –
Layers of retina separate because of fluid
accumulation between them

Complete detachment –
if above left untreated; leads to blindness
Retinal Detachment
Assessment
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Flashes of light
( photopsia)
Floaters
Blurred vision
Sense of curtain being
drawn
Loss of portion of
visual field
Retinal Detachment
Interventions & Nsg Implications

Emergency RX
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Apply eye patches to both eyes
Provide bed rest
Surgical RX
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Gas / Oil inserted inside eye to compress retina.
Postop – position on abdomen, head turned with
unaffected eye up X 1 week
Scleral buckling – silicone band around eye to hold
choroid and retinal layers together
Ear Disorders
Nursing Assessment
History
Infections, trauma, exposure to loud
noises, swimming habits,smoking,
nutritional deficiencies, family hx,
concurrent diseases (HTN, DM),
medications, allergies
 Questions
Acuity changes? Vertigo? Tinnitus?
Hyperacusis? Excessive cerumen?

The Aging Ear
Cerumen drier
 Tympanic membrane less elastic
 Bony ossicles and cochlea function
diminish
 Changes in vestibular function
 Acuity diminishes

Ear Disorders
Assessment

External Examination:
Swelling, lesions, symmetry, position,
external canal, odor

Internal Examination:
Otoscope exam: assess tympanic
membrane color, intactness, bulging
Assess cerumen
Ear Disorders
Diagnostic Assessment
Hearing Tests
 Whisper
 Weber
 Rinne
 Audiometry
Vertigo Tests
 Caloric
 Dix-Hallpike
 Electronystagmography
Meniere’s Disease
Etiology / Incidence / Prevalence
Etiology unknown
 Possible contributing factors:
infections, allergies, fluid imbalance, stress
 Overproduction or decreased reabsorption
of endolymphatic fluid
 First occurring between ages 20-50
 More prevalent in men

Meniere’s Disease
Assessment
Feeling of fullness in ear
 Tinnitus; low pitched roar/hum
 Vertigo
 Nystagmus
 Nausea / Vomiting
 Severe headache
 Hearing Loss

Meniere’s Disease
Interventions
Protect from injury
 Bedrest
 Avoid rapid head movements
 Sodium and fluid restrictions
 Advise client to stop smoking
 Medications: Nicotinic acid, antiemetics,
antihistamines, sedatives
 Surgery: Endolymphatic decompression,
labyrinthectomy

CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5th edition

The client is a 52-year-old man who is the
conductor of a symphony in a large city.
He is admitted to the emergency
department with severe dizziness and
vomiting. He tells you he was eating
dinner in a restaurant when his symptoms
began suddenly. He has had such
episodes in the past and has been
diagnosed with Ménière's disease. He tells
you he would rather die than lose his
hearing because music is his life.
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5th edition
What vital signs should you take first for
this client? Why?
 What nursing diagnoses are appropriate at
this time for this client?
 What interventions can you initiate for the
symptoms he has before he is seen by a
physician?
 What lifestyle alterations can you suggest
for his chronic condition?

Ear Disorders
Hearing Loss
CONDUCTIVE
 Sound waves blocked
d/t external or middle
ear disorders
 Causes:
inflammatory process
tumors
scar tissue on ossicles
otosclerosis
 Correctable
SENSORINEURAL
 Pathological process
of inner ear or 8th
cranial nerve
 Causes: trauma
ototoxic medications
loud noise exposure
presbycusis
 Permanent and
progressive

Otosclerosis
Etiology



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Bony overgrowth
around ossicles
Fixation of bones
Stapes fixation leads
to conductive loss
Inner ear involvement
leads to sensorineural
loss
Familial tendency
Otosclerosis
Assessment
Slowly progressing conductive loss
 Bilateral ; may be worse in one ear
 Ringing/roaring tinnitus
 Loud sounds when chewing
 Negative Rinne test
 Weber test shows lateralization of sound
to ear with most conductive loss

Otosclerosis
Interventions
Surgical
 Stapedectomy
Fenestration
- removal of stapes
- prosthesis placed
between incus and
stapes footplate
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5th edition
You are the home care nurse for a 74-year-old woman
with diabetes, stasis ulcers, and rheumatoid arthritis who
lives alone at home. She has had a conductive hearing
loss for 10 years and has been using a hearing aid
successfully for that time. She has had a kidney
infection for the past 2 weeks and was seen by her
internist for this problem. At first she was taking Septra
orally (prescribed by her internist) for the infection but
when her symptoms didn't subside, she went to an
urgent care center and was started on streptomycin 8
days ago. The other drugs she takes routinely are
insulin, bumetanide, and ibuprofen. She says her hearing
has decreased during the last 4 days.
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5th edition
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What questions should you ask this client?
Exactly how will you test her hearing in this
setting?
What interventions could you perform
immediately for her change in hearing?
Can you determine whether she has any
sensorineural hearing loss? Why or why not?
What drugs or health factors could be
contributing to her difficulty hearing?