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

Nursing Management of Nursing Management of Clients with Stressors of Clients with Stressors of

Sensory FunctionSensory Function

NUR133NUR133

Lecture # 14Lecture # 14

K. Burger, MSEd, MSN, RN, CNEK. Burger, MSEd, MSN, RN, CNE

Eye DisordersEye DisordersNursing AssessmentNursing Assessment

HistoryHistory: : Acuity changes, blurring, diplopia, Acuity changes, blurring, diplopia, photophobia, pain, use of gtts or other photophobia, pain, use of gtts or other eye meds, hx of trauma, familial eye eye meds, hx of trauma, familial eye disease, occupational risksdisease, occupational risks

Risk Factors for Eye DisordersRisk Factors for Eye Disorders::Aging process, DM, HTN, HIV, ++Aging process, DM, HTN, HIV, +++others, Medications, Gender, +others, Medications, Gender, Nutritional deficienciesNutritional deficiencies

Eye DisordersEye DisordersNursing AssessmentNursing Assessment

Visual testingVisual testing: distance, near, : distance, near, peripheral, colorperipheral, color

External examinationExternal examination: lids, : lids, conjunctivae, sclerae, pupils, conjunctivae, sclerae, pupils, extraocular musclesextraocular muscles

Internal examinationInternal examination: : opthalmoscopy to observe- lens opthalmoscopy to observe- lens clarity, red reflex, fundus clarity, red reflex, fundus

Sample Eye Assessment NoteSample Eye Assessment NoteNear vision 20/40 each eye uncorrected, corrected to Near vision 20/40 each eye uncorrected, corrected to

20/20 with glasses. Distant vision 20/20 by Snellen. 20/20 with glasses. Distant vision 20/20 by Snellen. Color vision intact. Visual fields full by confrontation. Color vision intact. Visual fields full by confrontation. Extraocular movements intact and full, no nystagmus. Extraocular movements intact and full, no nystagmus. Corneal light reflex equal.Corneal light reflex equal.

Lids and globes symmetric. No ptosis, edema, or lesionsLids and globes symmetric. No ptosis, edema, or lesionsConjuntivae pink, sclerae white. No discharge evident. Conjuntivae pink, sclerae white. No discharge evident.

Cornea clear, corneal reflex intact. Irides brown; Cornea clear, corneal reflex intact. Irides brown; PERRLAPERRLA

Opthalmoscopic exam reveals red reflex. Discs cream Opthalmoscopic exam reveals red reflex. Discs cream colored, borders well-defined. Maculae yellow OU colored, borders well-defined. Maculae yellow OU

No venous pulsations, hemorrhages, exudates, Drusen No venous pulsations, hemorrhages, exudates, Drusen bodies. bodies.

Eye DisordersEye DisordersDiagnostic AssessmentsDiagnostic Assessments

TonometryTonometry – IOP testing – IOP testing ((normal = 10-21mmHg )normal = 10-21mmHg )

Slit lampSlit lamp – close examination of specific – close examination of specific area of eye area of eye

Corneal stainingCorneal staining – detects corneal defects – detects corneal defectsAngiographyAngiography – detects circulatory defects – detects circulatory defectsElectroretinographyElectroretinography – retinal light – retinal light

responseresponse

GlaucomaGlaucomaEtiology/ Incidence / PrevalenceEtiology/ Incidence / Prevalence

Increased ocular pressure resulting from:Increased ocular pressure resulting from:inadequate drainage of aqueous inadequate drainage of aqueous

humorhumoroverproduction of aqueous humoroverproduction of aqueous humor

Pressure leads to damage of retina and Pressure leads to damage of retina and optic nerveoptic nerve

Primary – Secondary – AssociatedPrimary – Secondary – Associated Increased incidence in African-AmericansIncreased incidence in African-Americans Increased incidence with agingIncreased incidence with aging

GlaucomaGlaucomaTypesTypes

Open AngleOpen Angle

Most commonMost common BilateralBilateral Slow onsetSlow onset Usually painlessUsually painless Blurred visionBlurred vision

Closed AngleClosed Angle

Sudden onsetSudden onset EmergencyEmergency Severe pain Severe pain

radiating around radiating around eyes & faceeyes & face

Colored halos Colored halos around lightsaround lights

GlaucomaGlaucomaAssessmentAssessment

Early signsEarly signs = IOP, blurred vision, = IOP, blurred vision, decreased accommodation, difficulty decreased accommodation, difficulty adjusting to darknessadjusting to darkness

Later signsLater signs = loss of peripheral = loss of peripheral vision, decreased acuity vision, decreased acuity (uncorrectable), halos around lights, (uncorrectable), halos around lights, painpain

Glaucoma Glaucoma InterventionsInterventions

Medication RxMedication Rx::-Miotics-Miotics-Sympathomimetic-Sympathomimetic-Beta blockers-Beta blockers-Carbonic anhydrase inhibitors-Carbonic anhydrase inhibitors-Osmotic diuretics-Osmotic diuretics-Prostaglandin agonist-Prostaglandin agonist

Surgical RxSurgical Rx::-Trabeculoplasty-Trabeculoplasty-Iridectomy-Iridectomy

Glaucoma MedicationsGlaucoma Medications

Increase Increase Drainage of Drainage of

Aqueous HumorAqueous HumorMioticsMiotics Pilocarpine Pilocarpine

hydrochloridehydrochloride(Isopto Carpine)(Isopto Carpine)

Osmotic DiureticsOsmotic DiureticsGlycerinGlycerinMannitol ( Osmitrol )Mannitol ( Osmitrol )

Prostaglandin AgonistsProstaglandin AgonistsLatanoprost (Xalatan)Latanoprost (Xalatan)

Decrease Decrease Production of Production of Aqueous HumorAqueous Humor

Beta BlockersBeta BlockersTimolol maleate Timolol maleate (Timoptic)(Timoptic)

CAIsCAIsActetazolamide Actetazolamide (Diamox)(Diamox)

SympathomimeticsSympathomimeticsDipivefrin ( Propine)Dipivefrin ( Propine)

Ophthalmic MedicationOphthalmic MedicationNursing Implications for Pt Nursing Implications for Pt

TeachingTeaching Instill drops into conjunctival sac not Instill drops into conjunctival sac not

directly onto the corneadirectly onto the corneaApply pressure to inner canthus Apply pressure to inner canthus

X30secX30secDo not touch dropper to eyeDo not touch dropper to eyeWait 3-5 minutes between dropsWait 3-5 minutes between dropsClose eyes gently after administrationClose eyes gently after administrationDo not rub eyes; dab gently prnDo not rub eyes; dab gently prn

GlaucomaGlaucomaSurgical InterventionsSurgical Interventions

TrabeculoplastyTrabeculoplasty May be used in May be used in

open-angle open-angle glaucoma if pharm glaucoma if pharm rx ineffective or as rx ineffective or as primary rx primary rx

Laser rx to Laser rx to trabecular meshwork trabecular meshwork increases space increases space between fibers and between fibers and increased outflow of increased outflow of aqueous humor into aqueous humor into conjunctivaeconjunctivae

IridectomyIridectomy

Emergency rx for Emergency rx for acute closed angle acute closed angle glaucomaglaucoma

Section of iris is Section of iris is removed to create removed to create pathway for flow of pathway for flow of aqueous humoraqueous humor

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

CataractsCataractsEtiology / Incidence / PrevalenceEtiology / Incidence / Prevalence

An opacity of lens; distorts imageAn opacity of lens; distorts imageAge related etiology = most commonAge related etiology = most commonAll people >70y.o. have some degreeAll people >70y.o. have some degreeExposure to ultraviolet light increases Exposure to ultraviolet light increases

risk risk Other etiology r/t trauma, congenital Other etiology r/t trauma, congenital

defects, associated diseasesdefects, associated diseases5-10 million affected worldwide each 5-10 million affected worldwide each

yearyear

CataractsCataractsAssessmentAssessment

Blurred visionBlurred visionDecreased color perceptionDecreased color perceptionOpacity of lensOpacity of lensAbsence of red reflexAbsence of red reflexVision better in dim light w/ pupil Vision better in dim light w/ pupil

dilationdilationGradual loss of visionGradual loss of visionPainlessPainless

Cataract InterventionsCataract InterventionsSurgery = Surgery =

only option for Rxonly option for Rx Surgical removal of Surgical removal of

diseased lens and diseased lens and replacement with replacement with silicone prosthetic silicone prosthetic lenslens

Extracapsular Extracapsular procedure = most procedure = most commoncommon

Outpatient surgeryOutpatient surgery

Cataract SurgeryCataract SurgeryNursing ImplicationsNursing Implications

Usually no eye patchUsually no eye patchClient to wear dark sunglasses Client to wear dark sunglasses Antibiotic/steroid eye gttsAntibiotic/steroid eye gtts Instruct client to visit MD following Instruct client to visit MD following

dayday Instruct client in measures to avoid Instruct client in measures to avoid

increasing IOPincreasing IOP

CRITICAL THINKING CHALLENGECRITICAL THINKING CHALLENGEIgnatavicius & Workman Medical-Surgical Nursing 5Ignatavicius & Workman Medical-Surgical Nursing 5thth edition edition

The client is a 62-year-old woman who works as a The client is a 62-year-old woman who works as a stockbroker. She has recently been diagnosed stockbroker. She has recently been diagnosed with bilateral cataracts. She lives in the Denver with bilateral cataracts. She lives in the Denver area and her hobbies include long-distance biking area and her hobbies include long-distance biking and downhill skiing. She has a glass or two of and downhill skiing. She has a glass or two of wine with dinner every night. She smoked when wine with dinner every night. She smoked when she was in college but has not smoked for more she was in college but has not smoked for more than 30 years. She is surprised by her diagnosis than 30 years. She is surprised by her diagnosis because she is a vegetarian and keeps herself because she is a vegetarian and keeps herself physically fit. She also tells you that neither of her physically fit. She also tells you that neither of her parents nor any of her four brothers and sisters parents nor any of her four brothers and sisters have cataracts.have cataracts.

How should you explain the influence of genetics How should you explain the influence of genetics on the development of cataracts?on the development of cataracts?

What factors may have influenced the What factors may have influenced the development of her cataracts? development of her cataracts?

What additional personal and family information What additional personal and family information should you obtain from this client?should you obtain from this client?


Your 62-year-old client with bilateral cataracts is Your 62-year-old client with bilateral cataracts is scheduled to have an extracapsular cataract scheduled to have an extracapsular cataract removal with immediate intraocular lens removal with immediate intraocular lens implantation for her left eye (the one with the implantation for her left eye (the one with the worse vision). She asks why both eyes can't be worse vision). She asks why both eyes can't be done at the same time so that she will not have to done at the same time so that she will not have to go "through all of this rigmarole twice." She also go "through all of this rigmarole twice." She also is concerned about her facial appearance after is concerned about her facial appearance after surgery and whether any bruising will be present.surgery and whether any bruising will be present.

Should both eyes be done at the same time? Why Should both eyes be done at the same time? Why or why not?or why not?

How will her appearance be changed during the How will her appearance be changed during the first week after surgery? first week after surgery?


Your 62-year-old client had the cataract Your 62-year-old client had the cataract removed from her left eye and a multifocal lens removed from her left eye and a multifocal lens implanted on Friday afternoon. She plans to go implanted on Friday afternoon. She plans to go back to work on Monday and does not want her back to work on Monday and does not want her co-workers to know about the surgery. (She co-workers to know about the surgery. (She worries that people will think she is "old" and worries that people will think she is "old" and not on the cutting edge of her profession). not on the cutting edge of her profession).

Should she go back to work on Monday? Why Should she go back to work on Monday? Why or why not?or why not?

What accommodations will she have to make What accommodations will she have to make at her workplace?at her workplace?

What specific activities will you tell her to What specific activities will you tell her to avoid?avoid?

Macular DegenerationMacular Degeneration Dry (age-related)Dry (age-related)

Most commonMost commonGradualGradual

Wet Wet Sudden onsetSudden onset

Macula = area of Macula = area of central visioncentral vision

Increased risk for Increased risk for smokerssmokers

Antioxidant intake Antioxidant intake decreases risk and decreases risk and slows progressionslows progression


The client is a 75-year-old man who was The client is a 75-year-old man who was diagnosed with age-related "dry" macular diagnosed with age-related "dry" macular degeneration after he was involved in a car degeneration after he was involved in a car accident in which he failed to stop at an accident in which he failed to stop at an intersection and hit another car at a low intersection and hit another car at a low rate of speed. No injuries resulted from the rate of speed. No injuries resulted from the car accident although the client received a car accident although the client received a citation for a moving violation. The client is citation for a moving violation. The client is very upset with the diagnosis. His wife has very upset with the diagnosis. His wife has never driven nor has she managed the never driven nor has she managed the household accounts. He is concerned about household accounts. He is concerned about "going blind" and wants to know if the "going blind" and wants to know if the LASIK procedure would restore his vision. LASIK procedure would restore his vision.


Can the client continue to drive? Why Can the client continue to drive? Why or why not?or why not?

Will a LASIK procedure be helpful for Will a LASIK procedure be helpful for this problem? Why or Why not?this problem? Why or Why not?

How will you address the issue of How will you address the issue of "going blind?""going blind?"


Your client with macular degeneration Your client with macular degeneration (dry) wants to know if continuing to use (dry) wants to know if continuing to use his limited vision will increase the his limited vision will increase the progression of the macular degeneration. progression of the macular degeneration. He also worries that he will "lose his mind" He also worries that he will "lose his mind" if he has to give up all his usual activities.if he has to give up all his usual activities.

How will you address his concerns?How will you address his concerns? How will you proceed to assist the client How will you proceed to assist the client

and his wife in maintaining independence and his wife in maintaining independence and quality of life?and quality of life?

LIGHTHOUSE INTERNATIONALLIGHTHOUSE INTERNATIONAL

RetinopathyRetinopathy

•HypertensiveHypertensive•DiabeticDiabetic

Retinal DetachmentRetinal Detachment

Partial detachmentPartial detachment – –Layers of retina separate because of Layers of retina separate because of fluid accumulation between themfluid accumulation between them

Complete detachmentComplete detachment – – if above left untreated; leads to if above left untreated; leads to blindnessblindness

Retinal DetachmentRetinal DetachmentAssessmentAssessment

Flashes of light Flashes of light ( photopsia)( photopsia)

FloatersFloaters Blurred visionBlurred vision Sense of curtain Sense of curtain

being drawnbeing drawn Loss of portion of Loss of portion of

visual fieldvisual field

Retinal DetachmentRetinal DetachmentInterventions & Nsg ImplicationsInterventions & Nsg Implications

Emergency RXEmergency RX Apply eye patches to both eyesApply eye patches to both eyes Provide bed restProvide bed rest

Surgical RXSurgical RX Gas / OilGas / Oil inserted inside eye to compress inserted inside eye to compress

retina. Postop – position on abdomen, head retina. Postop – position on abdomen, head turned with unaffected eye up X 1 weekturned with unaffected eye up X 1 week

Scleral bucklingScleral buckling – silicone band around eye to – silicone band around eye to hold choroid and retinal layers togetherhold choroid and retinal layers together

Ear DisordersEar DisordersNursing AssessmentNursing Assessment

HistoryHistoryInfections, trauma, exposure to loud Infections, trauma, exposure to loud noises, swimming habits,smoking, noises, swimming habits,smoking, nutritional deficiencies, family hx, nutritional deficiencies, family hx, concurrent diseases (HTN, DM), concurrent diseases (HTN, DM), medications, allergiesmedications, allergies

QuestionsQuestionsAcuity changes? Vertigo? Tinnitus? Acuity changes? Vertigo? Tinnitus? Hyperacusis? Excessive cerumen?Hyperacusis? Excessive cerumen?

The Aging EarThe Aging Ear

Cerumen drierCerumen drierTympanic membrane less elasticTympanic membrane less elasticBony ossicles and cochlea function Bony ossicles and cochlea function

diminishdiminishChanges in vestibular functionChanges in vestibular functionAcuity diminishesAcuity diminishes

Ear DisordersEar DisordersAssessmentAssessment

External Examination:External Examination:Swelling, lesions, symmetry, position, Swelling, lesions, symmetry, position, external canal, odorexternal canal, odor

Internal Examination:Internal Examination:Otoscope exam: assess tympanic Otoscope exam: assess tympanic membrane color, intactness, bulgingmembrane color, intactness, bulgingAssess cerumenAssess cerumen

Ear DisordersEar DisordersDiagnostic AssessmentDiagnostic Assessment

Hearing TestsHearing TestsWhisperWhisperWeberWeberRinneRinneAudiometryAudiometryVertigo TestsVertigo TestsCaloricCaloricDix-HallpikeDix-HallpikeElectronystagmographyElectronystagmography

Meniere’s DiseaseMeniere’s DiseaseEtiology / Incidence / PrevalenceEtiology / Incidence / Prevalence

Etiology unknownEtiology unknownPossible contributing factors:Possible contributing factors:

infections, allergies, fluid imbalance, infections, allergies, fluid imbalance, stressstress

Overproduction or decreased Overproduction or decreased reabsorption of endolymphatic fluidreabsorption of endolymphatic fluid

First occurring between ages 20-50First occurring between ages 20-50More prevalent in menMore prevalent in men

Meniere’s DiseaseMeniere’s DiseaseAssessmentAssessment

Feeling of fullness in earFeeling of fullness in earTinnitus; low pitched roar/humTinnitus; low pitched roar/humVertigoVertigoNystagmusNystagmusNausea / VomitingNausea / VomitingSevere headacheSevere headacheHearing LossHearing Loss

Meniere’s DiseaseMeniere’s DiseaseInterventionsInterventions

Protect from injuryProtect from injuryBedrestBedrestAvoid rapid head movementsAvoid rapid head movementsSodium and fluid restrictionsSodium and fluid restrictionsAdvise client to stop smokingAdvise client to stop smokingMedications: Nicotinic acid, Medications: Nicotinic acid,

antiemetics, antihistamines, sedativesantiemetics, antihistamines, sedativesSurgery: Endolymphatic Surgery: Endolymphatic

decompression, labyrinthectomydecompression, labyrinthectomy


The client is a 52-year-old man who The client is a 52-year-old man who is the conductor of a symphony in a is the conductor of a symphony in a large city. He is admitted to the large city. He is admitted to the emergency department with severe emergency department with severe dizziness and vomiting. He tells you dizziness and vomiting. He tells you he was eating dinner in a restaurant he was eating dinner in a restaurant when his symptoms began suddenly. when his symptoms began suddenly. He has had such episodes in the past He has had such episodes in the past and has been diagnosed with and has been diagnosed with Ménière's disease. He tells you he Ménière's disease. He tells you he would rather die than lose his would rather die than lose his hearing because music is his life.hearing because music is his life.

CRITICAL THINKING CRITICAL THINKING CHALLENGECHALLENGE

Ignatavicius & Workman Medical-Surgical Nursing 5Ignatavicius & Workman Medical-Surgical Nursing 5thth edition edition

What vital signs should you take first What vital signs should you take first for this client? Why?for this client? Why?

What nursing diagnoses are What nursing diagnoses are appropriate at this time for this client?appropriate at this time for this client?

What interventions can you initiate for What interventions can you initiate for the symptoms he has before he is the symptoms he has before he is seen by a physician?seen by a physician?

What lifestyle alterations can you What lifestyle alterations can you suggest for his chronic condition?suggest for his chronic condition?

Ear DisordersEar DisordersHearing LossHearing Loss

CONDUCTIVECONDUCTIVE Sound waves blocked Sound waves blocked

d/t external or middle d/t external or middle ear disordersear disorders

Causes:Causes:inflammatory processinflammatory processtumorstumorsscar tissue on ossiclesscar tissue on ossiclesotosclerosisotosclerosis

CorrectableCorrectable

SENSORINEURALSENSORINEURAL Pathological process Pathological process

of inner ear or 8of inner ear or 8thth cranial nervecranial nerve

Causes: traumaCauses: traumaototoxic ototoxic medicationsmedicationsloud noise exposureloud noise exposurepresbycusispresbycusis

Permanent and Permanent and progressiveprogressive

OtosclerosisOtosclerosisEtiologyEtiology

Bony overgrowth Bony overgrowth around ossiclesaround ossicles

Fixation of bonesFixation of bones Stapes fixation leads Stapes fixation leads

to conductive lossto conductive loss Inner ear Inner ear

involvement leads to involvement leads to sensorineural losssensorineural loss

Familial tendencyFamilial tendency

OtosclerosisOtosclerosisAssessmentAssessment

Slowly progressing conductive lossSlowly progressing conductive lossBilateral ; may be worse in one earBilateral ; may be worse in one earRinging/roaring tinnitusRinging/roaring tinnitusLoud sounds when chewingLoud sounds when chewingNegative Rinne testNegative Rinne testWeber test shows lateralization of Weber test shows lateralization of

sound to ear with most conductive sound to ear with most conductive lossloss

OtosclerosisOtosclerosisInterventionsInterventions

SurgicalSurgical Stapedectomy Stapedectomy

FenestrationFenestration

- removal of stapes - removal of stapes

- prosthesis placed - prosthesis placed between incus between incus and and

stapes footplatestapes footplate


You are the home care nurse for a 74-year-old You are the home care nurse for a 74-year-old woman with diabetes, stasis ulcers, and woman with diabetes, stasis ulcers, and rheumatoid arthritis who lives alone at home. She rheumatoid arthritis who lives alone at home. She has had a conductive hearing loss for 10 years has had a conductive hearing loss for 10 years and has been using a hearing aid successfully for and has been using a hearing aid successfully for that time. She has had a kidney that time. She has had a kidney infection for the past 2 weeks and was seen by infection for the past 2 weeks and was seen by her internist for this problem. At first she was her internist for this problem. At first she was taking Septra orally (prescribed by her internist) taking Septra orally (prescribed by her internist) for the infection but when her symptoms didn't for the infection but when her symptoms didn't subside, she went to an urgent care center and subside, she went to an urgent care center and was started on streptomycin 8 days ago. The was started on streptomycin 8 days ago. The other drugs she takes routinely are insulin, other drugs she takes routinely are insulin, bumetanide, and ibuprofen. She says her hearing bumetanide, and ibuprofen. She says her hearing has decreased during the last 4 days.has decreased during the last 4 days.


What questions should you ask this client?What questions should you ask this client? Exactly how will you test her hearing in Exactly how will you test her hearing in

this setting?this setting? What interventions could you perform What interventions could you perform

immediately for her change in hearing?immediately for her change in hearing? Can you determine whether she has any Can you determine whether she has any

sensorineural hearing loss? Why or why sensorineural hearing loss? Why or why not?not?

What drugs or health factors could be What drugs or health factors could be contributing to her difficulty hearing?contributing to her difficulty hearing?

Documents

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