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Visual and Auditory Problems

Zoya Minasyan, RN, MSN-Edu

STRUCTURES AND FUNCTIONS OF VISUAL

SYSTEM

ASSESSMENT OF VISUAL SYSTEMS

Magnified view of retina through the ophthalmoscope.

STRUCTURES AND FUNCTIONS OF VISUAL

SYSTEMExternal eye and lacrimal apparatus. Tears produced in the lacrimal gland pass over the surface of theeye and enter the lacrimal canal. From there the tears are carried through the nasolacrimal duct to the nasal cavity.

STRUCTURES AND FUNCTIONS OF VISUAL

SYSTEM

External Structures and Functions, continuedConjunctivaScleraCorneaLacrimal apparatus Extraocular muscles

Internal Structures and FunctionsIrisLensCiliary bodyChoroidRetina

GERONTOLOGIC CONSIDERATIONS:

EFFECTS OF AGING ON VISUAL SYSTEMSArcus senilis. Age-related degeneration of the cornea.

Cataract

• Opacity within lens– The patient may have a cataract in one or both

eyes. • Leading cause of blindness• Most common surgical procedure for those

aged over 65

Etiology and Pathophysiology• Influencing factors– Age – Blunt trauma– Congenital factors– Radiation/UV light exposure– Long-term corticosteroid use– Ocular inflammation

• Senile cataract– Most common type – Altered metabolic processes cause

• Accumulation of water• Altered lens fiber structure

Clinical Manifestations

• Decrease in vision• Abnormal color perception• Glaring of vision– Glare is due to light scatter caused by lens

opacities, and it may be significantly worse at night when the pupil dilates.

• Secondary glaucoma can also occur if the enlarging lens causes increased intraocular pressure (IOP).

Diagnostic Studies

• History and physical examination• Visual acuity measurement• Ophthalmoscopy• Glare testing

Collaborative Care

• Nonsurgical therapy•The patient may be willing to adjust his or her lifestyle to accommodate for visual decline. For example, if glare makes it difficult to drive at night, a patient may elect to drive only during daylight hours or to have a family member drive at night. •Visual aids (palliative)

• Changing eyewear prescription• Reading glasses• Magnifiers • Increased lighting

Surgical Therapy

• Preoperative phase– History and physical assessment– Antibiotic eyedrops– Dilating eyedrops

• Surgical Therapy• The patient’s occupational needs and lifestyle changes are

factors affecting the decision to have surgery. • Preoperative Phase

• local anesthesia,• most cataract patients are older adults and may have several

medical problems that should be evaluated and controlled before surgery.

• Almost all patients with cataracts are admitted to a surgical facility on an outpatient basis.

• Dilating drops and a nonsteroidal antiinflammatory eyedrop are used to reduce inflammation and to help maintain pupil dilation.

• for dilation -mydriatic, an α-adrenergic agonist that produces pupillary dilation by contraction of the iris dilator muscle.

• Another type of drug is a cycloplegic, an anticholinergic agent that produces paralysis of accommodation (cycloplegia) by blocking the effect of acetylcholine on the ciliary body muscles.

Surgical Therapy

• Intraoperative phase– Corneoscleral incision– Cataract extracted and sutured– Cortex irrigated and aspirated– Corticosteroid ointment applied with protective

shield

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Surgical Therapy•Cataract extraction is an intraocular procedure. Rarely, intracapsular extraction is performed, in which the entire lens is removed with the capsule intact (this procedure may be necessary in instances of trauma). More commonly, extracapsular extraction is done, in which the anterior capsule is opened and the lens nucleus and cortex are removed, leaving the remaining capsular bag intact.

• In extracapsular extraction, the surgeon can remove the lens nucleus by “scooping” it out with a lens loop, or by phacoemulsification, in which the nucleus is fragmented by ultrasonic vibration and is aspirated from inside the capsular bag.

• In either case, the remaining cortex is aspirated with an irrigation and aspiration instrument. Placement and type of incision vary among surgeons.

•At the end of the procedure, additional medications such as antibiotics and corticosteroids may be administered.16 Depending on the type of anesthesia, the patient’s eye may be covered with a patch or protective shield. If used, the patch/protective shield usually is worn overnight and is removed during the first postoperative visit.

Implementation of Intraocular Lens

Intraocular lens implant after cataract surgery. Almost all patients now have an intraocular lens implanted at the time of cataract extraction surgery. Because most patients have an extracapsular procedure, the lens of choice is a posterior chamber lens that is implanted in the capsular bag behind the iris.

Surgical Therapy

• Postoperative phase– Outpatient procedure unless complications occur– Antibiotic and corticosteroid eyedrops • to prevent infection and to decrease the postoperative

inflammatory response. – Limiting activities • avoid activities that increase the IOP, such as bending

or stooping, coughing, or lifting. – Follow-up visits • The ophthalmologist usually will see the patient 2 to 3

times throughout the 6 to 8 weeks following surgery

Nursing ManagementAssessment

• Visual acuity • Psychosocial impact of visual disability• Level of knowledge of disease• Comfort and ability to comply with postop

treatment

Nursing ManagementNursing Diagnoses

• Self-care deficits• Anxiety

Nursing Management Planning

• Preoperative goals– Make informed decisions regarding therapeutic

options.– Experience minimal anxiety.

• Postoperative goals– Understand and comply with postoperative

therapy.– Maintain level of comfort.– Remain free of infection and other complications.

Nursing Management Implementation

• Health promotion– Wear sunglasses.– Avoid unnecessary radiation.– Adequate antioxidant vitamins (e.g., vitamins C

and E)– Ensure good nutrition.

Nursing Management Implementation

• Acute intervention– Educate about disease process and treatment options.

• the patient needs to know that without surgery, some degree of visual disability will occur. Be available to give the patient and the family information to help them make an informed decision about appropriate treatment.

– Administer medication. • Photophobia is common; therefore decreasing the room lighting is helpful. These

medications produce transient stinging and burning. – Inform those with patch that they will not have depth perception until their

patch is removed. • This necessitates special considerations to avoid possible falls or other injuries. The

patient with significant visual impairment in the un-operated eye requires more assistance while the operative eye is patched. Once the patch is removed (usually within 24 hours), most patients with visual impairment in the un-operated eye will have adequate vision for necessary activities

– Ensure little to no pain.– Teach signs and symptoms of infection.

• of increased or purulent drainage, increased redness, or any decrease in visual acuity.

Nursing Management Implementation

• Ambulatory and home care– Activity restrictions– Medications– Follow-up visits– Signs and symptoms of possible complications– Educate on postoperative visual acuity.– Instruct family to modify activities and

environment.• Remove area rugs.• Prepare frozen meals.• Provide audio books.

Nursing Management Evaluation

• Expected outcomes– Improved vision– Ability to care for self– Minimal to no pain– Optimistic expectations

Glaucoma

• A group of disorders characterized by– Increased IOP and consequences of elevated

pressure– Optic nerve atrophy – Peripheral visual field loss

Etiology and Pathophysiology

• Balance between aqueous production and reabsorption needed for normal level of IOP

• Glaucoma related to elevation of IOP

Etiology and Pathophysiology

• Primary open-angle glaucoma (POAG)– Most common type of glaucoma– Outflow of aqueous humor is ↓, the drainage

channels become clogged, like a clogged kitchen sink. Damage to the optic nerve can then result.

Etiology and Pathophysiology• Primary angle-closure glaucoma (PACG)– Angle closure ↓ the flow of aqueous humor – Caused by age, pupil dilation(it causes peripheral iris

bulging forward and blocking the outflow channels– Possibly drug induced

•An acute attack may be precipitated by situations in which the pupil remains in a partially dilated state long enough to cause an acute and significant rise in IOP. This may occur because of drug-induced mydriasis (dilation), emotional excitement, or darkness. •Check drug records and documentation before administering medications to the patient, and instruct the patient not to take any mydriatic-producing medications.

Etiology and Pathophysiology

• Secondary glaucoma– Results from other ocular or systemic conditions

that block outflow– Associated with inflammatory processes

Clinical Manifestations

• POAG– Develops slowly– No symptoms– Unnoticed until all peripheral vision is lost“tunnel

vision,” in which only a small center field can be seen and all peripheral vision is absent.

Clinical Manifestations

• Acute angle-closure glaucoma – Sudden excruciating pain around eyes– Nausea and vomiting– Seeing colored halos around lights– Blurred vision– Ocular redness– Corneal edema– IOP elevated in glaucoma

• Normal IOP 10 to 21 mm Hg• Open-angle glaucoma 22 to 32 mm Hg• Acute angle-closure glaucoma >49 mm Hg

Diagnostic Studies

• Gonioscopy (allows better visualization of the anterior chamber angle)

• Peripheral and central vision test• Ophthalmoscopy (The optic disc becomes

wider, deeper, and paler (light gray or white). This is visible with direct or indirect ophthalmoscopy)

Ophthalmoscopy

In the normal eye, the optic cup is pink with little cupping. B, In glaucoma, the optic disc is bleached and optic cupping is present. (Note the appearance of the retinal vessels, which travel over theedge of the optic cup and appear to dip into it.)

Collaborative Care• Chronic open-angle glaucoma

– Drug therapy– Argon laser trabeculoplasty

• Therapeutic option to lower IOP– Laser stimulates scarring and contraction of trabecular meshwork – Trabeculectomy

• removal of part of iris and trabecular meshwork– Implant– Reserved for patients in whom filtration surgery has failed– Permanent surgical placement of small drainage tube and reservoir

• General glaucoma•The primary focus of glaucoma therapy is to keep the IOP low enough to prevent the patient from developing optic nerve damage. This damage is manifested by increasing visual field loss and progressive optic disc cupping. Specific therapies vary with the type of glaucoma.

Collaborative Care

• Acute angle-closure glaucoma– Miotics ( constriction of the pupils of the eyes)– Oral/IV hyperosmotic – Laser peripheral iridotomy – Surgical iridectomy• These procedures allow the aqueous humor to flow

through a newly created opening in the iris and into normal outflow channels. One of these procedures may also be performed on the other eye as a precaution, because many patients often experience an acute attack in the other eye.

Collaborative Care

• Secondary glaucoma– Managed by treating underlying problems– Antiglaucoma medication

– If treatment fails, glaucoma can progress to absolute glaucoma, resulting in a hard, sightless, and usually painful eye requiring enucleation (surgical removal of the eye).

Nursing Management Nursing Implementation

Health Promotion– Teach patient and family risks of glaucoma.• Loss of vision due to glaucoma is a preventable

problem. – Stress importance of early detection.• the incidence of glaucoma increases with age

– Provide ophthalmologic examination. • The current recommendation is for an ophthalmologic

examination every 2 to 4 years for persons between ages 40 and 64 years, and every 1 to 2 years for persons age 65 years or older.

Nursing Management Nursing Implementation

Acute Intervention Administer medication to lower IOP. Darken the environment. Apply cool compresses to the patient’s forehead. Provide quiet space. For surgical patients

Provide postop instructions. Relieve discomfort.

Ambulatory and Home Care Encourage patient to follow therapy. Educate on disease process and treatments. Discuss follow-up appointments. Provide verbal and written instructions.

Nursing Management Evaluation

Expected Outcomes No further loss of vision Compliance with recommended therapy Safe functioning in the environment No pain from disease and surgery

Retinal Detachment

• Is a separation of retina and epithelium with fluid accumulation between the two layers.

• Risk factors: increasing age, eye trauma, cataract or glaucoma, family Hx

• Symptoms: photopsia-light flashes, floaters, ring in the field of vision, painless loss of peripheral or central vision, “ like a curtain” coming across the field of vision.

• Care: Surgical therapy

INFLAMMATION AND INFECTION

Hordeolum (sty)Staph aureus- infection of the sebaceous glands in the lid margin

ChalazionInflammation in meibomian (sebaceous) glands in the lid, can be b/c of sty

Blepharitis Scales or crusts on the lid and lashes. Burning, irritation photophobia, caused by staph infections

Conjunctivitis (infection or inflammation)Bacterial infections (pink eye-influenza and pneumonia)Viral infections ( foreign body sensation, redness)Chlamydial infections Allergic conjunctivitis

INFLAMMATION AND INFECTION

Hordeolum (sty) on the upper eyelid caused by staphylococcal infection.

INFLAMMATION AND INFECTION

Keratitis- involved conjunctiva and/or the cornea

Bacterial infectionsViral infectionsOther causes of keratitis Corneal ulcer

INFLAMMATION AND INFECTION

Corneal ulcer. Infection associated with poor contact lens care.

STRABISMUS

Is a condition in which patient cannot focus two eyes simultaneously on the same object.

• Myopia- nearsightness; light rays to be focused in front of the retina (distant objects cannot be seen sharply)

• Hyperopia- farsightness; light rays to be focus behind the retina (difficulty focusing on near objects, and in extreme cases unable to focus on objects at any distance)

• Presbyopia- by aging less elastic lens and decrease eye accomodation (difficulty seeing in dim light, problems focusing on small objects and/or fine print )

• Astigmatism-irregular corneal curvature, blurred vision

STRUCTURES AND FUNCTIONS OF AUDITORY SYSTEM

External, middle, and inner ear.

STRUCTURES AND FUNCTIONS OF

AUDITORY SYSTEM

External EarMiddle EarInner Ear

Transmission of sound

ASSESSMENT OF AUDITORY SYSTEM

Normal Physical Assessment of Auditory System.

ASSESSMENT OF AUDITORY SYSTEM

The tympanic membrane. A, Landmarks of right tympanic membrane. B, Normal-appearingtympanic membrane. C, Perforated tympanic membrane.

• Presbycusis: hearing loss due to aging

• Tinnitus: ringing in the ears- due to aging

• Vertigo: person or objects around the person are moving or spinning or stimulated by the movement of the head