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Sensory Disorders: Vision & Hearing. Chapter 27 Cristen Walker, MS, CRNP. Refractive Errors. Refraction = bending of light rays Emmetropia - normal vision Light rays are bent to focus precisely on macula (retina) Ammetropia - refractive error, image not clearly focused on retina

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sensory disorders vision hearing

Sensory Disorders: Vision & Hearing

Chapter 27

Cristen Walker, MS, CRNP

refractive errors
Refractive Errors
  • Refraction = bending of light rays
  • Emmetropia - normal vision
    • Light rays are bent to focus precisely on macula (retina)
  • Ammetropia - refractive error, image not clearly focused on retina
    • Hyperopia – farsighted, light rays focus behind retina, short eyeball
    • Myopia – nearsighted, distance vision blurred, long eyeball
    • Astigmatism - blurred vision w/ distortion, unequal shape of cornea
    • Presbyopia - older age, loss of ability to focus on close objects, lenses lose elasticity
refractive errors1
Refractive errors
  • Signs & Symptoms
    • difficulty reading or seeing objects, headaches
  • Diagnosis: Snellen chart; exam of retina w/ dilation
  • Treatment: corrective lenses; surgical
    • Incisional radial keratectomy – incision on cornea to reshape
    • Photorefractive keratectomy - becoming more common, use of laser to reshape
    • Intrastromal corneal rings (Intacs) – flexible ring to change cornea shape
        • for MYOPIA
lasik
LASIK
  • Laser assisted in-situ keratomileusis
  • Laser used to create thin, circular flap in cornea, folded back, damaged corneal tissue removed, cornea reshaped
  • Allows light to properly focus on retina
  • For near-, farsightedness, and astigmatism
  • Procedure: 5-10 minutes, pt. awake, eye anesthetic used, mild oral sedative, minimal pain
lasik1
LASIK
  • Post-operative teaching:
    • Rest 4-6 hours post procedure
    • No driving same day
    • No exercise for 1 week
    • No eye rubbing
    • Vision corrected to 20/20 – 20/40
    • May still need “reading glasses” (bifocals)
    • Improved vision within 1-3 days
    • Complications: Infection, night glare
disorders of the eye infection
Disorders of the Eye: Infection
  • Conjunctivitis - inflammation of conjunctiva
infection inflammation
Infection & Inflammation
  • Blepharitis -inflammation of the eyelid margins (chronic)
    • Seborrheic
      • Redness & flaking at base of lashes
    • Ulcerative
      • Crusting at lashes, redness of eyes and inflammation of cornea
    • Tx - long-term daily cleansing
        • cu-tips & baby shampoo or special eye cleanser
    • May require antibiotic ointment
    • Usually caused by staph or effect of rosacea
infection inflammation1
Infection & Inflammation
  • Hordeolum - “sty” - external
    • Small abcess at base of eyelash (red, raised)
    • Forms in sebaceous gland
    • Usually resolve spontaneously without treatment
    • Warm compresses
  • Chalazion - internal hordeolum
    • Larger and more problematic
    • More painful
    • May require I & D w/ antibiotics
keratitis
Keratitis
  • Keratitis - inflammation of the cornea.
    • Acute or chronic
    • Caused by infection or irritation
    • Causes – bacterial conjunctivitis, improper contact lens care, herpes virus, tuberculosis, syphilis, inability of eyelid to close properly
    • Symptoms:
      • Pain with eye movement, vision changes, photophobia (sensitivity to light)
    • Diagnosis: during corneal exam
    • Treatment: antibiotics or antivirals, artificial tears
    • If severe, may need corneal transplant (keratoplasty)
      • Corneal tatoo ?
keratitis1
Keratitis
  • Treatment
    • Corneal infections are serious and can result in loss of sight.
    • May be associated w/ contact lens use
    • Overnight wearing of contact lens increases risk – can lead to pseudomonas
    • Must dispose of lenses
blindness
Blindness
  • Complete or almost complete absence of sight.
  • Often referred to as “visually impaired” to avoid negative connotation
  • Legal blindness = 20/200
      • With corrective lenses
blindness1
Blindness

Causes

  • Obstruction to ray of light to optic nerve
    • HTN, diabetes, glaucoma
  • Disease of optic nerve
  • Injury/Trauma to occipital lobe (area of sight)
    • stroke, tumor
  • Rarely occurs at birth
blindness2
Blindness
  • Nursing Interventions
    • Use normal tone of voice
    • Alert client when approaching
    • Orient client to environment
    • Use a focal point
    • Allow client to touch objects in room
    • Promote independence
    • Provide TV, radio, clocks (oral time)
    • Assist w/ ambulation – client should walk 1 step behind
        • Pg. 1258 Textbook: Care of Pt. w/ visual impairment
cataracts
Cataracts
  • Opacity (cloudiness) of the lens - may cause loss of vision
    • Light rays unable to get through
  • Causes:
    • Age (>50), sunlight, diabetes, smoking, steroids, alcohol use, infections, congenital defects (rubella), chemical toxins
  • Painless
  • Symptoms:
    • Halos around lights, trouble reading fine print (newspaper), increased sensitivity to glare (sun, car lights), hazy vision, decreased color vision, poor night vision
    • Looking through a “sheet of falling water”
cataracts2
Cataracts
  • Surgical removal of cloudy lens, very common procedure
  • Rare complications – increased ICP, hemorrhage, retinal detachment
  • Pre-op
    • Teaching – takes 5-10 minutes, pt. awake (light sedation may be used), eye anesthesia used
    • Post-op expectations – same day surgery, clear vision within 2 days
    • Mydriatics may be given pre-op
cataracts3
Cataracts
  • Post-op care and education
    • Avoid eye rubbing and straining
    • Avoid rapid movements; sneezing/vomiting/coughing
    • Avoid bending, lifting objects >5 lb
    • Avoid constipation
    • Use eye drops as prescribed, 2-4 weeks
    • Use eye shield at bedtime
    • Contact MD for decrease in vision, severe eye pain, increase in eye discharge
retinopathy
Retinopathy
  • 2 causes
  • 1. Diabetes – assoc. w/ excess glucose, constriction of blood vessels & microaneurysms (swell, rupture & hemorrhage)
  • 2. HTN – retinal vasoconstriction decreases blood supply to retina
  • Sx: blurred vision, red/black lines or spots, missing areas in field of vision (may be central)
  • Dx: requires exam of internal eye – annually !
retinopathy1
Retinopathy
  • Tx: Control glucose & BP; prevent further leakage of blood/fluid into retina
    • Laser surgery
    • Vitrectomy (vitreous fluid drained & replaced w/ saline)
  • Cannot reverse vision loss that has occurred, not a cure, may progress
  • Can progress to retinal detachment and/or blindness
retinal detachment
Retinal Detachment
  • Separation of the retina from the choroid layer allowing fluid to enter the space between the layers.
  • Caused by:
    • Hole or tear in the retina
      • either from degenerative changes or trauma
    • Fibrous tissue pulling on retina
      • related to diabetic or hypertensive retinopathy
    • Accumulation of fluid in the space
      • from conditions such as HTN, eclampsia, or tumors.
retinal detachment1
Retinal Detachment
  • Symptoms:
    • Gradual or sudden change in vision
    • loss of peripheral vision or central vision
      • Depends of portion of retinal involved
    • flashing lights (colored lights)
    • floaters or black spots – caused by small hemorrhages
    • “looking through a veil or cobweb” or “curtain over eyes”
  • NO PAIN (retina w/o sensory nerves)
  • Requires prompt referral for treatment (laser reattachment, cryosurgery)
  • Ages 40-70, increased in Jewish descent (r/t to higher incidence of myopia)
retinal detachment2
Retinal Detachment
  • Post op care
    • Eye patch
    • Eye shield during sleep to prevent injury
    • Improvement of vision weeks to months
      • Flashing lights common for few weeks post op
    • Antibiotic eyedrops/ointment post op
    • Pain meds may be prescribed
    • Wear sunglasses to decrease light sensitivity
    • No water in affected eye (showers not recommended)
    • Light activity/rest for several days post op
      • No sports 3-4 mos.
    • No driving until 20/40 vision restored
slide37

Which finding would the nurse expect while caring for a patient with a detached retina ?

  • Blurred vision
  • Pain in the affected eye
  • Yellow discoloration of the sclera
  • A sense of a curtain falling across the field of vision
glaucoma
Glaucoma
  • Abnormal pressure within eyeball
    • Increased intraocular pressure
    • Restricts blood flow to retina & optic nerve
  • Damages optic disc & optic nerve
  • Damage is usually silent and irreversible
  • 2nd leading cause of blindness
  • Sx: loss peripheral vision, reduction in central vision, possible blindness
  • Can occur at any age
    • May be genetically predisposed
glaucoma1
Glaucoma
  • Requires lifelong treatment
  • 3 common types:
    • AACG – acute angle-closure glaucoma
        • refers to angle width between cornea & iris
    • POAG – Primary open-angle glaucoma
        • chronic
        • 90%
        • often inherited
    • Associated (secondary) glaucoma
        • w/ DM, HTN, retinal detachment, extreme myopia
glaucoma2
Glaucoma
  • Primary open-angle
    • Most common
    • Aqueous fluid behind iris does not flow properly into anterior chamber
    • No symptoms ??
    • Hazy vision, rainbow colored rings around lights, gradual loss peripheral vision, tunnel vision advanced stages
    • Treatment
      • Eye drops **
      • Laser surgery
      • Microsurgery – to unblock drainage canals
glaucoma3
Glaucoma
  • Acute angle closure (narrow angle)
    • Iris pushes against drainage channels of anterior chamber
    • Drainage canals blocked
    • Increased intraocular pressure – rises suddenly
    • Symptoms = severe
      • Intense eye pain, N/V, sudden vision loss, halos around lights
    • Medical emergency – prompt treatment
    • Treatment: laser or surgical iridectomy, to relieve pressure
        • Failure to treat immediately may cause blindness
glaucoma4
Glaucoma
  • At risk (AACG):
    • People w/ hyperopia
    • Asian
    • Woman >45AACG
    • AACG:
      • Requires strict bedrest
      • Strict avoidance of anticholinergic meds
        • Mydriatics – dilate pupil
glaucoma5
Glaucoma

Nursing Interventions:

1. instruct client to wear medic-alert bracelet

2. instruct client to avoid anticholinergic meds

3. Educate re: symptoms

*pain in eye, blurred vision, halo w/ lights

4. inform pt. of AACG symptoms – emergency

5. Discuss importance of medication compliance

6. Prevention: low sodium diet, limit caffeine,

prevent constipation, decrease stress

slide45

A teaching plan for the client with glaucoma should include:

  • Decrease amount of salt in diet
  • Decrease fluid intake to control IOP
  • Avoid reading the newspaper and watching TV
  • Eye medications will need to be administered for the rest of your life
macular degeneration
Macular Degeneration
  • Leading cause of visual impairment in U.S.
    • >50.
  • Deterioration in macula
    • center of retina
    • light rays converge, color vision occurs
  • 2 types
    • Dry – age related, more common, formation of yellow

deposits (drusen), causes drying/thinning

    • Wet – leaky blood vessels, swelling; more severe
  • High risk:
    • >60 yrs, family history of MD, diabetes, smoking, exposure to UV light, caucasian, female, obese, high BP,

high cholesterol

macular degeneration1
Macular Degeneration
  • Symptoms
    • blurred vision, distortion straight lines, dark spot in central vision, loss can be progressive (dry) or sudden (wet)
  • Treatment
    • Antioxidants/Zinc – may slow progression
      • Vit. C, Vit. E, Beta Carotene (Vit. A)
    • Possible laser surgery to seal leaking blood vessels
      • Not highly effective
    • Telescopic lens implant
ocular melanoma
Ocular Melanoma
  • Malignant eye tumor
  • Adults
  • May change color of iris
  • Diagnosis: routine exam, ultrasound
  • Treatment: enucleation

radiation therapy

eye trauma
Eye Trauma
  • Foreign body most common cause of corneal injury (worsened by rubbing eyes)
  • Corneal abrasions/lacerations from nails or clothing
  • Chemical burns
    • Immediate flushing necessary
    • Water or saline, 15-20 minutes
  • Penetrating wounds = most serious
disorders of the ear
Disorders of the Ear
  • Hearing Loss
  • External disorders
  • Middle Disorders
  • Internal Disorders.
hearing loss
Hearing Loss
  • Conductive – interference w/ conduction of sound impulses through external canal & eardrum
    • Causes – cerumen, foreign body, trauma, fluid, tumor, otosclerosis
        • Otosclerosis: middle ear bones harden & fuse
    • Hearing devices most effective for this type *
    • Can affect speech, language development, academic achievement, behavior
  • Sensorineural - originates in cochlea, involves hair cells & nerves, may also originate in brainstem
    • Caused by disease, trauma, infections, ototoxic drugs, aging
hearing loss1
Hearing Loss
  • Most common disability in the US
  • Ranges from difficulty to total deafness
  • Can be mixture of both types of hearing loss
    • conductive + sensorineural
  • Management is to improve hearing
  • Hearing aids may be necessary
  • Presbycusis
    • hearing loss caused by aging process, degenerative changes to organ of corti (hair cells), over 50, high-pitch frequency decreases
hearing loss2
Hearing Loss

Communicating w/ child or adult:

  • DON’T SCREAM
  • Face patient, eye level
  • Talk slowly and clearly
  • Lower your voice (avoid high-pitch)
  • Use nonverbal cues
  • Allow time don’t rush
  • Don’t avoid speaking to the patient
  • Write it down if needed

Pg. 1271, textbook: Communicating w/ Person who has a hearing impairment

hearing aids
HEARING AIDS
  • Amplify sounds
    • Microphone hearing aids
    • Digital hearing aids (more $$)
    • Inside-ear fit or behind-the-ear fit (most common)
    • Remove battery when not in use
    • Clean weekly w/ dry or damp cloth
  • Cochlear Implant
    • Electrode for cochlear implant is surgically placed
    • Used for profoundly deaf
hearing aids video
Hearing aids Video
  • http://youtu.be/yQ17csWENEo
  • Right click, open hyperlink
external ear disorders
External ear disorders

Infection – most common disorder.

  • Localized abscess from hair follicle– furuncle
  • If involves several hair follicles – carbuncle
  • Usually open and drain spontaneously
  • Otitis Externa = most common infection
  • Bacterial or fungal
  • “swimmer’s ear”
external otitis
External Otitis
  • Most common complaint is PAIN
    • especially when pulling the pinna or moving the jaw
  • Symptoms: ear canal (outer) swollen and red, possible fever
  • Treatment: topical and/or systemic antibiotics
    • May treat with combination meds (steroid + antibiotic) Cortisporin, Floxin (otic drops)
    • Warm compresses
external ear disorders1
External Ear Disorders
  • Impacted cerumen
    • work in dirty areas or improper cleaning
    • prevalent with hearing aids
    • s/s – hearing loss, “blocked ear”
    • Treatment:
      • cerumen softeners (Debrox)
      • ear flushing (NOT used with a perforated TM)
external ear disorders2
External Ear Disorders
  • Insects
    • Mineral oil or diluted alcohol instilled
    • Will suffocate insect
    • Removal with ear forceps
  • Trauma – blunt trauma to head, auto accident, burns, foreign bodies
    • Lacerations, contusions, abrasions, blistering, hematoma
    • Repeated trauma can result in cauliflower ear (swelling, scarring) or hearing loss
middle ear disorders
Middle Ear Disorders
  • Otitis media
    • Inflammation of the middle ear—mastoid—eustachian tube
    • May be bacterial or viral
      • Haemophilus influenzae, strep pneumoniae
    • TM appears red, swollen on exam
    • Acute or chronic (>3 months)
    • w/ or w/o effusion (fluid)
  • Cause
    • inflammation of the nasopharynx, causing build up of fluid or pus
    • Eustachian tube become blocked
    • Infants/young children more prone
otitis media
Otitis Media
  • Signs & Symptoms
    • Fever
    • Earache
    • Fullness in ear
    • Purulent drainage is possible
    • If mastoid involvement will have pain in the mastoid area
    • Infants/children: rubbing/pulling at ear, rolling head side to side, loud/problematic speech, inattentive behavior
otitis media1
Otitis Media

Complications:

  • Perforation – ruptured TM – pain before & relief afterwards - hearing loss may result
  • Cholesteatoma – cyst that spreads through a perforation, resulting in permanent damage & conductive hearing loss
  • Tympanosclerosis – calcification of TM, deposits of collagen, chalky white plaques, lead to conductive hearing loss
  • Mastoiditis– severe infection of mastoid process if OM left untreated, can usually treat w/ antibiotics - may require mastoidectomy
otitis media2
Otitis Media
  • Treatment:
    • Antibiotics – Amoxicillin, Penicillin,

Azithromycin (Zithromax), Cefaclor (Ceclor), Bactrim

    • Oral analgesics – Aspirin, Tylenol, Ibuprofen
    • Eardrops – to relieve pain ??
    • Heating pad
myringotomy
Myringotomy
  • Incision made in TM
  • Fluid drained
  • Tube placed to prevent further accumulation of fluid & to aerate the middle ear
    • Tympanostomy tubes, myringotomy tubes
  • Tubes eventually fall out at 3-12 months post-op
middle ear disorders1
Middle ear disorders
  • Otosclerosis
    • Hardening of ear, from formation of bone along the stapes
    • Stapes becomes fixed to oval window, unable to vibrate
    • Causes conductive hearing loss
  • Cause
    • unknown but may be hereditary; 0.5% population
  • Symptoms
    • hearing loss, usually bilateral
  • Treatment:
    • Hearing aid
    • Stapedectomy – removal w/ prosthetic implant
    • Beethoven
inner ear disorders
Inner Ear Disorders
  • Vertigo
    • Illusion of motion
    • Loss of balance
    • Causes: cold virus, trauma, menieres disease
    • Medications: antihistamines
        • Meclizine (Antivert), Diphenydramine (Benadryl)
    • Benign Positional Vertigo = vertigo symptoms w/ change of position

*standing to sitting/lying to sitting

*Treatment: Epley maneuver (to adjust particles inj

semicircular canals

inner ear disorders1
Inner Ear Disorders

Labrynthitis – inflammation or infection of the inner ear

*can be viral or bacterial

*can last 6 months

* may occur following complicated OM

  • Signs/Symptoms
    • Vertigo
    • Tinnitus
    • Sensorineural hearing loss
    • Ear pain, fever, nausea, vomiting
    • Nystagmus on affected side
labrynthitis
Labrynthitis

Treatment

  • Antibiotics if infected
  • Antihistamines – for relief of dizziness, may or may not help ?
    • Meclizine (Antivert)
  • Antiemetics
  • Pt. may need bedrest (dark room)
  • Avoid abrupt head turning, to avoid vertigo
inner ear disorders2
Inner Ear Disorders

Acoustic neuroma

  • Most common
  • Benign tumor of 8th cranial nerve
  • Grows slow
  • Occurs at any age
  • Compresses nerve & adjacent structures
acoustic neuroma
Acoustic Neuroma

Signs/Symptoms:

  • Progressive unilateral hearing loss
  • Usually loss of high-pitch sounds
  • Unilateral tinnitus
  • headache
  • balance disorders (vertigo)
  • Treatment
    • Surgical removal of tumor
    • Steroids, radiation possible
inner ear disorders3
Inner Ear Disorders

Meniere’s disease – balance disorder with unknown cause, overproduction of lymphatic fluid

  • 40-60 yrs.
  • mild or severe.
  • Triad of symptoms
    • Vertigo—hearing loss—tinnitus
      • Sensorineural hearing loss
    • May include nausea & vomiting
    • Symptoms may be severe & incapacitating
    • May take weeks for symptoms to resolve
    • May be chronic
meniere s disease
Meniere’s Disease
  • Acute episodes can last for 2-4 hours
  • Warning signs of headache and unsteadiness may be present
  • Occurs 2-3 times per year
  • Safety is main concern
  • Treatment
    • symptomatic and prophylactic.
meinere s disease
Meinere’s Disease
  • Symptomatic treatment
    • Tranquilizers (antianxiety meds) during acute attacks
    • Meclizine (Antivert)
    • antiemetics
    • bedrest
    • fall prevention
  • Prophylactic treatment
    • salt-restricted diet
    • fluid restriction
    • diuretics
    • avoid alcohol
    • stop smoking
cochlear implantation
Cochlear Implantation
  • Surgically implanted device
      • External transmitter w/ magnet
      • Internal receiver w/ magnet
  • For severe to profound hearing loss (nerve deafness)
      • Sensorineural hearing loss
  • Goal = to produce hearing sensation
  • Hearing may improve immediately post-op or within 3 months
  • Sound is DISTORTED, “mechanical”, “static”, difficult to hear TV, radio, phone, music
  • Covered by 90% insurances, very $$$
cochlear implant
Cochlear Implant
  • Complications
    • Meningitis
    • Infection
    • Injury to facial nerve
    • CSF leakage from inner ear
    • Taste disturbance (nerve injury during surgery)
    • Numbness around ear
    • Tinnitus
    • **may set off metal detectors
cochlear implant video
Cochlear Implant Video
  • http://youtu.be/SmNpP2fr57A
  • Right click, open hyperlink
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