Sensory Disorders-Nclex

Caring for clients with Sensory Disorders- Eyes, ears.

Terms in this set (...)

eye disease in which the lens becomes covered in an opaque film that affects sight, eventually causing total blindness.
Congenital Cataracts
Infants should be able to follow moving objects by 3 months of age- absence of the red reflex.
Symptoms of Cataracts
Blurred-hazy vision, halo around lights, Yellow, white, or gray discoloration of pupil, gradual loss of vision.
Intraoperative Floppy Iris Syndrome
Can occur if taking Flomax (tamsulosin)-used for BPH-during cataract surgery. Stop Flomax before surgery.
Post-operative Care for eye surgery
Maintain semi-fowlers position, Avoid bending, report sharp pain in eye, sign of infection or decrease in vision, flashes of light. Avoid water in eye, Wear eye shield at all times.
Group of diseases that increase intraocular pressure- leading cause of blindness.
Primary Open-angle glaucoma
Effects both eyes, asymptomatic- caused by decrease in aqueous humor. S/S: tired eyes, diminished peripheral vision, halos around lights, hardening of eyeball, increased intraocular pressure.
Acute Glaucoma
Primary Angle-Glaucoma, age related process, sudden decrease in aqueous humor. S/S: aches in eyebrow, pain around eyes, cloudy vision, pupil dilation. Medical Emergency.
Normal Intraocular Pressure Range
10 to 21 mm Hg
Nursing Care for Glaucoma
Reducing pressure- with Miotic eye drops. Avoid Visine and Atropine to prevent intraocular pressure.
Uveitis-Nursing Care
Inflammation of the Iris- causing poor quality of vision. - Wear sunglasses, Cool or warm compresses, nonaspirin medications.
Fundoscopic Examination
diagnostic procedure that employs the use of mydriatic eye drops (such as tropicamide) to dilate or enlarge the pupil in order to obtain a better view of the fundus of the eye- may reveal grayish-yellow patches.
Hypertensive Retinopathy
long history of uncontrolled high blood pressure- cotton wool spots may be seen- may lead to retinal detachment or loss of vision.
Diabetic Retinopathy
disease of the retina in diabetics characterized by capillary leakage, bleeding, and new vessel formation (neovascularization) leading to scarring and loss of vision
Macular Degeneration-Nursing Care
degeneration of the cells of the macula lutea which results in blurred vision and can cause blindness- Atrophic (dry: decrease in central vision. Exudative (wet): sudden decrease in vision due to serous detachment. - Provide Diet high in dark green leafy vegetables and yellow/orange vegetables.
Retinitis Pigmentosa
hereditary, progressive disease marked by night blindness with atrophy and retinal pigment changes- visual acuity declines until blind. No Therapy- may vitamin A.
Retinal Detachment
visual impairment resulting from the retina becoming separated from the choroid in the back of the eye from trauma, fluid accumulation, or age related.
Retinal Detachment Symptoms/ Nursing Care
Blurred Vision, Flashes of Light, Visual Floaters, A veil-like loss of vision.- Place in dependent position. Post-op care: place pt. on abdomen with head turned with operative eye upward for several days until gas/oil is absorbed. Keep head bowed when walking. Avoid activities like reading.
Nearsightedness- correct Concave lens
Farsightedness- correct Convex lens
Lens losses elasticity- unable to focus on close objects- age related
uneven curvature- eye defect which prevents proper focus
Types of eye surgery correction, RK, PRK, LASIK, corneal ring
Hyphema Eye Injury-Nursing Care
Hemorrhage into the anterior chamber of the eye. Both eyes are patched, bed rest, semi-fowlers, no reading.
Contusion Eye Injury-Nursing Care
Bruising of the eyeball- Ice affected eye, elevate head to 30 to 40 degrees.
Foreign bodies Eye Injury- Nursing Care
Objects that irritate eyes- Cover both eyes with cups. ONLY can be removed by Ophthalmologist.
Lacerations and Penetrating Eye Injury-Nursing Care
Medical Emergency- Affects Cornea- IV antibiotics and Surgery.
Ocular Melanoma-Nursing Care
Cancer of the eye- S/S: blurred vision, decreased visual acuity, intraocular pressure, change in iris color, retinal detachment.-Tx: Radiation or enucleation (removal of eyeball).
Otitis Externa- Nursing Care
"Swimmers Ear"- caused from hot, humid environment, allergic reaction like hair spray, earrings,or organisms like bacteria/fungi, most infections are from strep.- Do not clean ears, avoid water entering ears.
Otitis Media- Nursing Care
Infection of the middle ear- S/S:fever, pain, vomiting, anorexia. Relief in ear pressure may be a result rupture of tympanic membrane.
How to instill ear drops
Under 3 yrs- Pinna Down and Back/ Over 3 yrs- Pinna Up and Back, gently massage ear.
inflammation of one of the mastoid bones; usually an extension of otitis media characterized by earache, fever, headache, and malaise.
Mastoiditis Nursing Care
IV antibiotics, Mastoidectomy/ Tympanoplasty: Observe for damage to 6th/7th cranial nerve. Notify doctor of facial paralysis or abnormal eye movements, Blow nose one at a time, cough with mouth open, avoid bending, avoid water in ears.
Menieres Disease- Nursing Care
Inner ear- S/S: Vertigo, Tinnitus, decrease ability to hear low tones. Tx: Weber test, Audiogram, "Pikes Peak" pattern, Salt/Fluid restriction, no smoking. -Change position slowly.
Acoustic Neuroma
Benign Tumor involving 8th cranial nerve damaging Cerebellum (regulation and coordination of movement, posture, and balance). S/S: Sensorineural Hearing Loss, Vertigo, Tinnitus. Tx: Craniotomy.
Sensorineural Hearing Loss
damage to inner ear- permanent hearing loss.
hereditary disorder in which hardening of the labyrinth of the inner ear causes tinnitus and eventual deafness- Conductive Hearing Loss.- Weber Test- Tx: Stapedectomy .
Weber Test
Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard.
a graphical representation of a person's auditory sensitivity to sound
Stapedectomy- Nursing Care
Surgical removal of the top portion of the stapes bone and the insertion of a small prosthetic device known as a piston that conducts sound vibrations to the inner ear.- Avoid activities with ear pressure, Avoid crowds, Report abnormal facial sensation, Avoid water in ear.
Presbycusis- Nursing Care
Gradual loss of sensorineural hearing that occurs as the body ages, cant hear high frequencies- Avoid loud sounds, Diet in Vitamin B9/B12, Audiometry Test: measure decibel (Pure-tone= Music stimulus)/ (Speech=spoken words stimulus)
Hear Loss Patient Nursing Care
Stand if front of pt, eliminate background noise, use other communicating techniques like writing board, Try to speak in lower tones. Hearing aid: avoid electrical devices (magnet).
Snellen Chart
display consisting of a printed card with letters and numbers in lines of decreasing size
Ishihara Polychromatic Chart
Color chart to test for color blindness- cannot distinguish red from green or blue from yellow.
Amsler Grid
test to assess central vision and to assist in the diagnosis of age-related macular degeneration
Used to detect glaucoma-test to measure the pressure inside your eyes and a lamp is moved forward until the tip of the tonometer just touches the cornea.
Topical Anesthetics
OcuCaine, Ak-Taine (proparacaine HCL), Pontocaine (tetracaine HCL, cocaine Hcl)- avoid rubbing or touching eye.
Topical Steroids
OcuPred (prednisolone acetate), Dexotic (dexaethasone), Fluor-Op (liquifilim)- reduces swelling/inflammtion-shake before using, assess for corneal ulceration.
Tobrex (tobramycin), Ilotycin (erythromycin), Ocuflox (ofloxacin)- interferes with bacteria- remove exudates from eye before giving.
Alpha 2 Adrenergic Agonist
Alphagan (brimonidine tartrate)- reduced intraocular pressure- do not give with MAOI's, wait 15 minutes before replacing contacts.
Beta Adrenergic Blockers
Betoptic (betaxolol), Ocupress (carteolol Hcl), Timoptic (timolol)- reduced intraocular pressure by decreasing aqueous humor- do not give to pulmonary disease pts, monitor blood glucose.
Miotics (Direct Acting)
Carboptic (carbachol), Isopto Carpine (pilocarpine)- reduces intraocular pressure by constricting pupils- do not give to corneal abrasions pts, do not increase dosages.
Miotics (Cholinesterase Inhibitors)
Humorsol (demecarium bromide), Phospholine (echothiophate iodide)- reduce intraocular pressure by constricting pupils- Asses intraocular pressure frequently
Carbonic Anhydrase Inhibitors
Trusopt (dorzolamide), Azopt (brinzolamide)- decrease aqueous humor to reduce pressure in eye- do not give to pts. Who are sensitive to Sulfonamides, remove contact lens before using for 15 minutes before reinserting.