Elsevier items and derived items © 2006 by Elsevier Inc

Sensory: Eye and Ear

Irene Owens, MSN, ARNP, FNP-BCFall 2010

Elsevier items and derived items © 2006 by Elsevier Inc.

Chapter 49Assessment of the Eye and VisionAssessment of the Eye and Vision

Anatomy and Physiology Review

Layers of the eyeball Refractive structures and media External structures Muscles Nerves Blood vessels


Refraction Emmetropia: the perfect refraction of

the eye Hyperopia: occurs when the eye does

not refract light enough Myopia: occurs when the eye

overrefracts or overbends the light Astigmatism: a refractive error caused

by unevenly curved surfaces on or in the eye, especially of the cornea


Pupillary Constriction

Miosis is pupillary constriction. Mydriasis is pupillary dilation. Accommodation is the process of

maintaining a clear visual image when the gaze is shifted from a distant to a near object.


Age-Related Structural Changes

Decreased eye muscle tone Ectropion and dry eye Arcus senilis Corneal changes Changes in color of sclera Less ability to dilate pupil More light needed for reading


Age-Related Functional Changes

Lens yellows Accommodation is gradually lost Near point of vision increases

(presbyopia) Far point decreases Color perception decreases Intraocular pressure


Physical Assessment

Inspection: exophthalmos, enophthalmos, ptosis, scleral and corneal assessment

Pupillary assessment: anisocoria, consensual response (brisk, sluggish, nonreactive or fixed)

(Continued)


Go to medicalvideos.us eye exam


Physical Assessment (Continued)

Tests for measurement of vision: acuity, near-vision testing, confrontation test Snellen chart and Rosenbaum

Assessment of extraocular muscle function


Diagnostic Tests

Slit-lamp examination Corneal staining Tonometry Ophthalmoscopy Ultrasonography Fluorescein angiography Electroretinography



Chapter 50Interventions for Clients with Eye

and Vision Problems


Blepharitis Inflammation of the eyelid edges Itchy, red, and burning eyes Seborrhea of the eyebrows and eyelids

with greasy scales and mattering Control with eyelid care using warm,

moist compresses followed by gentle scrubbing with diluted baby shampoo

Avoidance of rubbing the eyes

Blepharitis



Entropion

Turning inward of the eyelid causing the lashes to rub against the eye

Caused by eyelid muscle spasms, or result of trauma

Eyelid turned inward; red conjunctiva Surgical correction of eyelid position Instruction in procedure to instill

eyedrops

Entropion



Ectropion

Turning outward and sagging of the eyelid

Caused by relaxation of the orbicular muscle

Reduced washing action of tears, leading to corneal drying and ulceration

Surgery to restore proper lid alignment

Ectropion



Hordeolum

Stye can be external or internal. Treatment is with warm compresses

four times a day and antibacterial ointment, which may blur vision.

To remove ointment, close the eye and gently wipe the closed eyelid from the nasal side of the eye outward.

Hordeolum



Chalazion

Inflammation of sebaceous gland in eyelid.

Most protrude on the inside of eyelid. Eye fatigue, light sensitivity, and

excessive tears result.(Continued)


Chalazion (Continued)

Treatment consists of warm compresses for 15 minutes 4 times per day, followed by instillation of ophthalmic ointment.

Surgery is an option.

Chalazion



Keratoconjunctivitis Sicca

Also called dry eye syndrome, results from changes in tear composition, lacrimal gland malfunction, or altered tear distribution

Artificial tears, lubricating ointment Surgery

Keratoconjunctivitis sicca



Conjunctival Disorders

Hemorrhage Conjunctivitis Trachoma


Corneal Disorders

Keratoconus is the degeneration of the cornea, deposits in the cornea, dystrophies, keratitis, or ulceration of the corneal surface

Reduce symptoms, restore corneal clarity, enhance client’s ability to use remaining vision

Antibiotics, antifungals, antivirals, steroids


Cataract

Clouding of the lens, blurring of the lens distorts the image and color projected onto the retina.

As cataract matures, opacity makes it difficult to see the retina.

Visual acuity is restricted.


Disturbed Sensory Perception: Visual

Interventions include:› Surgery to remove cataract and implant a

small, clear, plastic lens› Enhanced social interaction› Safety issues


Postoperative Care—Cataract

Antibiotics given subconjunctivally. Eye is unpatched. Discharge usually

occurs within 1 hr with dark glasses. Instill antibiotic-steroid eyedrops. -

TobraDex Mild itching is normal. *bloodshot eye* Pain indicates a complication. Reduce IOP - Diamox Prevent infection. Assess for bleeding. *no ASA*


Health Teaching

Report to surgeon: sharp, sudden pain in the eye, bleeding or increased discharge, lid swelling, decreased vision, or flashes of light or floating shapes.

Avoid activities that might increase IOP. Review procedure for use of eyedrops.


Glaucoma

Group of ocular diseases resulting in increased IOP

Primary open-angle glaucoma Angle-closure glaucoma


Clinical Manifestations

Cupping and atrophy of the optic disc, disc wider and deeper and turns white or gray

Visual field measurement Headache or brow pain, nausea and

vomiting, colored halos around lights, and sudden blurred vision with decreased light perception


Diagnostic Tests

Tonometry Tonography Gonioscopy


Drug Therapy for Glaucoma Pupillary constriction: miotics,

pilocarpine hydrochloride Inhibition of aqueous humor: timolol,

levobunolol, beta blockers, carbonic anhydrase inhibitors

Osmotic drugs part of emergency treatment for rapid reduction of IOP

No epinephrine used in angle-closure glaucoma because it dilates the pupil


Eye Trauma

Hyphema Contusion Foreign bodies Lacerations Penetrating injuries


Reduced Vision

Interventions include:› Communication regarding use of adaptive

items› Safety in familiar settings› Ambulation assisted with care› Self-care and independence promoted› Support for the difficulty of adapting to

loss of sight

Chapter 50Assessment of the Ear and

Hearing

Go to medicalvideos.us examination of the ear.


Normal TM



Anatomy and Physiology

Review of the structure of:› External ear› Middle ear› Inner ear


Ear and Hearing Changes Associated with Aging

Drier, impacted cerumen Loss of tympanic membrane elasticity Decreased bony ossicle movement Degenerative changes of cochlea Disturbed vestibular function Diminished hearing acuity Decreased ability to hear high-

frequency sounds


Assessment Techniques

Thorough history from client Demographic data, gender, age Family history and genetic risk Personal history of past hearing

involvement Socioeconomic status Current health problems


Physical Assessment

External ear and mastoid assessment Otoscopic assessment Cultural considerations, including color

of the lining of the external ear canal and cerumen, which varies according to skin tone


Auditory Assessment

Conductive hearing loss resulting from any physical obstruction of sound wave transmission

Sensorineural hearing loss resulting from a defect in the cochlea, the eighth cranial nerve, or the brain

Mixed conductive-sensorineural hearing loss, a profound hearing loss


Tests

Voice test Watch test Audioscopy Weber tuning fork test Rinne tuning fork test


Diagnostic Assessment

Laboratory tests Computed tomography Magnetic resonance imaging Auditory brainstem-evoked response Electronystagmography Caloric testing Dix-Hallpike test for vertigo


Audiometry

Frequency is the highness or lowness of tones.

Intensity is expressed in decibels. Threshold is the lowest level of

intensity at which pure tones and speech are heard.

Pure tones are generated by an audiometer to determine hearing acuity.


Tests Air conduction test Bone conduction test Speech audiometry Speech reception threshold Speech discrimination Tympanometry

Chapter 51Interventions for Clients with Ear

and Hearing Problems


External Otitis

Painful condition caused when irritating or infective agents come into contact with the skin of the external ear

Commonly called swimmer’s ear Treatment focused on reducing

inflammation, edema, and pain with heat, bedrest, limited head movement, topical antibiotic and steroid therapy, and analgesics


Furuncle

Localized external otitis caused by bacterial infection of a hair follicle

Hearing impaired if the lesion blocks the canal, most commonly cerumen (wax)

Treatment with local and systemic antibiotics, heat application, earwick to relieve pain, and possible incision and drainage

Perichondritis

Infection of the perichondrium, a tough fibrous tissue layer that surrounds the cartilage and gives shape to the pinna.

Goal is to eliminate the infection



Cerumen or Foreign Bodies

Cerumen (wax) is the most common cause of an impacted canal.

Other blockages include vegetables, beads, pencil erasers, insects.

Irrigate canal with a mixture of water and hydrogen peroxide at body temperature for impacted cerumen; Cerumenex softens wax.

Carefully remove foreign object.


Otitis Media

Three types of otitis media include:› Acute otitis media› Chronic otitis media› Serous otitis media


Nonsurgical Management

Quiet environment Bedrest with limited head movement Heat and cold applications Systemic and topical antibiotic therapy Analgesics Antihistamines Decongestants


Surgical Management

Myringotomy is a surgical opening of the pars tensa of the eardrum.

Operative procedure includes grommet (polyethylene tube) placed through the tympanic membrane.

Postoperative care: keep external ear and canal free of other substances while the incision is healing and keep head dry for several days.

Go to entusa.com Mayo clinic ear tubes



Mastoiditis Infection of the mastoid air cells

caused by untreated or inadequately treated otitis media

Nonsurgical management: antibiotics

(Continued)


Mastoiditis (Continued)

Surgical management: simple or modified radical mastoidectomy with tympanoplasty

Complications: damage to cranial nerves, vertigo, meningitis, brain abscess, chronic purulent otitis media, and wound infection

Pediatric Sensory

Conjunctivitus or pink eye is an inflammation of the conjunctival sac

S/S itching, burning, photophobia cratchy eyelids redness edema and thick discharge

Allergiy? Infection? infants could be from blocked lacrimal duct or most common chlamydia May have to use systemic abx. If chlamydia


Conjuncitivis continued..

Treat the cause.. ABX or steroids for severe allergies

Nursing Considerations: No sharing of towels, washcloths correct administration of eye drops never share eye medications prevent injury to the eye no rubbing of the eye throw out eye make-up, do not wear contacts replace if possible.


Pediatric: Strabismus


Amblyopia


External Otitis Media


Serous Otitis Media


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Elsevier items and derived items © 2006 by Elsevier Inc