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Nursing Management of Clients with Stressors of Sensory Function. NUR133 Lecture # 14 K. Burger, MSEd, MSN, RN, CNE. Eye Disorders Nursing Assessment.

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nursing management of clients with stressors of sensory function

Nursing Management of Clients with Stressors of Sensory Function

NUR133

Lecture # 14

K. Burger, MSEd, MSN, RN, CNE

eye disorders nursing assessment
Eye DisordersNursing 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 assessment1
Eye DisordersNursing 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
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
Eye DisordersDiagnostic 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
GlaucomaEtiology/ 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

GlaucomaTypes
glaucoma assessment
GlaucomaAssessment
  • 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
Glaucoma Interventions
  • Medication Rx:-Miotics-Sympathomimetic-Beta blockers-Carbonic anhydrase inhibitors-Osmotic diuretics-Prostaglandin agonist
  • Surgical Rx:-Trabeculoplasty-Iridectomy
glaucoma medications
Increase

Drainage of Aqueous Humor

Miotics

Pilocarpine hydrochloride

(Isopto Carpine)

Osmotic Diuretics

Glycerin

Mannitol ( Osmitrol )

Prostaglandin Agonists

Latanoprost (Xalatan)

Decrease

Production of Aqueous Humor

Beta Blockers

Timolol maleate

(Timoptic)

CAIs

Actetazolamide

(Diamox)

Sympathomimetics

Dipivefrin ( Propine)

Glaucoma Medications
ophthalmic medication nursing implications for pt teaching
Ophthalmic MedicationNursing 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 open-angle 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

GlaucomaSurgical Interventions

http://dmc.org/videolibrary/ek_glaucoma.html

cataracts etiology incidence prevalence
CataractsEtiology / 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
CataractsAssessment
  • 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
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
Cataract SurgeryNursing 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 5 th edition
CRITICAL THINKING CHALLENGEIgnatavicius & Workman Medical-Surgical Nursing 5th edition
  • 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 5 th edition1
CRITICAL THINKING CHALLENGEIgnatavicius & 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 5 th edition2
CRITICAL THINKING CHALLENGEIgnatavicius & 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 co-workers 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
Macular Degeneration
  • Dry (age-related)Most commonGradual
  • 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 5 th edition3
CRITICAL THINKING CHALLENGEIgnatavicius & 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 5 th edition4
CRITICAL THINKING CHALLENGEIgnatavicius & 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 5 th edition5
CRITICAL THINKING CHALLENGEIgnatavicius & 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
Retinopathy
  • Hypertensive
  • Diabetic
retinal detachment
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
Retinal DetachmentAssessment
  • Flashes of light ( photopsia)
  • Floaters
  • Blurred vision
  • Sense of curtain being drawn
  • Loss of portion of visual field
retinal detachment interventions nsg implications
Retinal DetachmentInterventions & Nsg Implications
  • Emergency RX
    • Apply eye patches to both eyes
    • Provide bed rest
  • Surgical RX
    • 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
Ear DisordersNursing Assessment
  • HistoryInfections, trauma, exposure to loud noises, swimming habits,smoking, nutritional deficiencies, family hx, concurrent diseases (HTN, DM), medications, allergies
  • QuestionsAcuity changes? Vertigo? Tinnitus? Hyperacusis? Excessive cerumen?
the aging ear
The Aging Ear
  • Cerumen drier
  • Tympanic membrane less elastic
  • Bony ossicles and cochlea function diminish
  • Changes in vestibular function
  • Acuity diminishes
ear disorders assessment
Ear DisordersAssessment
  • External Examination:Swelling, lesions, symmetry, position, external canal, odor
  • Internal Examination:Otoscope exam: assess tympanic membrane color, intactness, bulgingAssess cerumen
ear disorders diagnostic assessment
Ear DisordersDiagnostic Assessment

Hearing Tests

  • Whisper
  • Weber
  • Rinne
  • Audiometry

Vertigo Tests

  • Caloric
  • Dix-Hallpike
  • Electronystagmography
meniere s disease etiology incidence prevalence
Meniere’s DiseaseEtiology / 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
Meniere’s DiseaseAssessment
  • Feeling of fullness in ear
  • Tinnitus; low pitched roar/hum
  • Vertigo
  • Nystagmus
  • Nausea / Vomiting
  • Severe headache
  • Hearing Loss
meniere s disease interventions
Meniere’s DiseaseInterventions
  • 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 5 th edition6
CRITICAL THINKING CHALLENGEIgnatavicius & 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 5 th edition7
CRITICAL THINKING CHALLENGEIgnatavicius & 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 processtumorsscar tissue on ossiclesotosclerosis

Correctable

SENSORINEURAL

Pathological process of inner ear or 8th cranial nerve

Causes: traumaototoxic medicationsloud noise exposurepresbycusis

Permanent and progressive

Ear DisordersHearing Loss
otosclerosis etiology
Bony overgrowth around ossicles

Fixation of bones

Stapes fixation leads to conductive loss

Inner ear involvement leads to sensorineural loss

Familial tendency

OtosclerosisEtiology
otosclerosis assessment
OtosclerosisAssessment
  • 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
OtosclerosisInterventions

Surgical

  • Stapedectomy Fenestration

- removal of stapes - prosthesis placed between incus and

stapes footplate

critical thinking challenge ignatavicius workman medical surgical nursing 5 th edition8
CRITICAL THINKING CHALLENGEIgnatavicius & 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 5 th edition9
CRITICAL THINKING CHALLENGEIgnatavicius & Workman Medical-Surgical Nursing 5th edition
  • 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?