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Chapter 52: Nursing Care of Patients With Sensory Disorders: Vision and HearingPART 1: VISIONVision Disorders:Infections and Inflammation:Infections can be bacterial or viral.Bacterial: staphylococcus & streptococcusViral: herpes simplex virus, cytomegalovirus & human adenovirusInflammation causes: allergies to environmental substances, irritation to chemicals in perfumes, makeup, sprays, plants or mechanical irritation (sunburn).Conjunctivitis: Inflammation of conjunctiva.Caused by virus or bacteria, haemophilus influenzae, Chlamydia trachomatis & Neisseria monly transmitted among children and then to family members.Redness & crusting exudate on lids and in corners of eyes, itching and tears can occur.Hand hygiene to prevent spread.Viral:More common.Highly contagious.Transmitted via contaminated eye secretions on a hand that then touches or rubs an eye.Hardy.Lives on dry surfaces for 2 or more weeks.Lasts 2-4 weeks.Treated with eye washes or eye irrigations. Relieves inflammation & pain.Bacterial:PinkeyeDue to staphylococcus or streptococcus bacteria.Highly contagious.Treated with antibiotic eye drops or ointments.Blepharitis: Inflammation of eyelid edges.Chronic inflammatory process.Causes: staphylococcal infection, seborrhea (dandruff), rosacea, chronic skin disease of skin, abnormalities of meibomian glands and lipid secretions.Two types:Seborrheic:Reddened eyelids with scales and flaking at base of eyelashes.Ulcerative:Crusts at eyelash base, reddened eyes, inflamed corneas.Treatment: Long term daily cleaning.Diluted baby shampoo or sterile eyelid cleanser solution are used.Staph may cause eyelids to become thick.Infection: Bactrim/E-Mycin applied to eyelid edges 1-4x/day after eyelids have been cleansed.Keratoconjunctivitis Sicca (Dry Eye Disease):Causes: inadequate lubrication of eye due to reduced quality or amount of tears.> 50 yo (risk)Symptoms: scratchy feeling, excess tearing then dryness, burning, pain, redness & blurred vision.Treatment: smoking cessation, avoid second hand smoke, take eye breaks, use warm compress for Meibomian gland swelling, using tear duct plugs, requesting prescription meds that are non-drying, using OTC Rx eye drops (Restasis/Xiidra)Hordeolum and Chalazion:Hordeolum: Eyelid infection (sty) small staph abscess in the sebaceous gland at base of eyelash. Small, raised & reddened area. Usually heal on their own in a few days.Chalazion: (internal hordeolum) Larger than sty and puts pressure on cornea, causing greater discomfort.May require surgical incision and drainage if they do not drain on their own.Keratitis: Inflammation of the cornea.Patho and Etiology:Acute or chronicSuperficial or deepMay be associated with bacterial conjunctivitis, herpes simplex, corneal ulcer, TB and syphilis.Herpes simplex keratitis: Most common in developed countries.Bacterial fungal infections: Most common in rest of world.Signs and Symptoms:Blepharospasm: Spasm of eyelidsDecreased vision.Photophobia: Sensitivity to light.TearingReddened conjunctivaCloudy corneaDiagnostic Tests:Assessment with sit lamp/handheld lampExamine cornea with light diagonally across cornea. Fluorescein stain: stained area viewed with blue light & disruption shows ical anesthetic used for blepharospasm.Therapeutic Measures:Topical antibioticsTopical corticosteroidsTopical interferonsAntiviral medicationsCycloplegic agentsWarm compressCorneal transplant if needed.Eye plications:Corneal infectionsSusception to perforation if too thin.Permanent scarring of cornea.Permanent loss of vision.Nursing Process for the Pt With Infection and Inflammation of the Eye:Subjective Data: WHAT’S UP? (Table 52.3)Objective Data:Condition of conjunctivaEyelidsEyelashesPresence of exudateTearingVisible abscess on palpebral borderPalpable abscess on eyelidOpacity of corneaVisual acuity testingEvaluation: Successful if:Pain reduced to acceptable ratingVision improvesInjury does not occurInfection doesn’t occur from poor hygienePrescribed treatment is stated or demonstrated correctly.Refractive Errors:Pathophysiology and Etiology:Refraction: bending of light rays as they enter the eye.Emmetropia: normal vision. Light rays bent to focus images precisely on macula of retina.Ametropia: any refractive error. When light rays entering the eye are not refracted to focus on retina. (Largest # of impairment in vision.)4 ametropic disorders:Hyperopia, myopia, astigmatism & presbyopiaHyperopia: (Farsightedness)Light rays focus behind retina.See more clearly far away than up close.Globe or eyeball is too short from front to back.Myopia: (Nearsightedness)Light rays focus on front of retina.Eyeball elongated.Light rays don’t reach retina.Distant vision is blurred.Close items are clear.Astigmatism: Unequal curvatures in shape of cornea.Irregular cornea causes light rays to be refracted in two different points.Can cause myopic or hyperopic astigmatism.Blurred vision with distortion.Caused by inflammation, injury, corneal surgery or inherited autosomal dominant trait.Presbyopia: (Age-related condition)Len’s gradually lose elasticity.Difficult for lens to change shape.Less able to focus light onto retina to see close objects.People compensate for it by holding objects farther away.Eyestrain and mild frontal headache may occur.Signs and Symptoms:Difficulty reading or seeing objects.Eyestrain & headacheDiagnostic Tests:Snellen ChartRetinoscopic examCycloplegic drug dilates pupilTherapeutic Measures:Treated with either eyeglasses or contact lenses.Bend the parallel lightLASIKPRKReshape corneaBlindness: (complete or almost complete absence of sense of sight)Prefer to be called visually impaired.Patho and Etiology:Blindness caused by cataracts, glaucoma, diabetes, hypertension and trauma.Permanent or transient.Partial or complete.Only in darkness is night blindness.Signs and Symptoms:Total vision lossBlurred, distorted or absent in specific areas of visual field, cataracts, diabetic retinopathy or refractive errors.Glaucoma or retinitis pigmentosa: objects may appear dark.Diabetic retinopathy: center of visual field may be dark.Hemianopia: half of visual field may be impaired.Can occur with stroke.Diagnostic Tests:Visual field examTonometrySit lamp microscope examRetinal angiographyUltrasonographyTherapeutic Measures:MedicationsSurgical interventionsCorrective eyewearReferral to supportive servicesBionic eyeNursing Process for the Patient with Visual Impairment:Subjective Data: WHAT’S UP? (Table 52.3)Objective Data: squinting, rubbing eyes, compensatory measures, withdrawn or socially isolated, low self-esteem, poor coping mechanisms or poor interpersonal skills.Nursing Diagnoses, Planning, and Implementation/Nursing Care Plan for the Patient With Visual Impairment:Interventions:Perform ADLs.Assist with grooming and dressing.Provide assistance with prepping food and feeding as required.Provide for optimal care of assistive appliances such as eyeglasses.Structure environment to compensate for visual loss by adding color and contrast.Use of large-print directional signs and arrow, well lit areas, traffic areas free of clutter.Assistive devices such as handheld magnifying glasses, tableside magnifiers, TV magnifiers, talking watches, phones, and alarm clocks.Refer to ophthalmologist or OT.Evaluation: Groom, dress and feed self independently?Groom and self dress?Eat as desired?Glasses fit properly? Clean? Current RX?Environment have clearly delineated walkways, sitting areas, and doorways?Identify locations?Aware of assistive devices?Know what resources are available?Interacting With a Patient Who Has a Visual Impairment?Identify yourself.Normal tone of voice.Speak directly to patient.Don’t play with service dog.Explain location of items in room. Keep same place at all times if possible.Ask what their needs are.Explain procedures before beginning them.Explain activity occurring in room or within patient’s auditory range.Explain location of items on tray by position on a clock.Diabetic Retinopathy: Vascular changes occur in retinal blood vessels.Patho and Etiology:Most common in diabetes.Related to excess glucose, changes in retinal capillary walls, formation of microaneurysms, constriction of retinal blood vessels.Three stages:Background: Microaneurysms form on retinal capillary walls.May leak blood into central retina or macula.EdemaDecrease in color discrimination and visual acuity.Preproliferative retinopathy:Swollen and irregularly dilated veins.Sluggish or blocked blood flow.No symptoms.Proliferative retinopathy:Formation of new blood vessels.Grow into retinal and optic disc area to increase the blood supply to retina.Leak blood into vitreous and retina.Causes retinal detachment.Signs and Symptoms:Reduction in central visual acuity or color due to macular edema.Visual loss at last stage can’t be plications:Existing visual loss cannot be reversed.Pts with diabetes should have comprehensive eye exam through dilated pupils at least once a year.Diagnostic Tests:Only be diagnosed with exam of internal eye.Pupil dilated.Ophthalmoscope used.Retinoangiography.Therapeutic Measures:Stop leakage of blood and fluids.Sealed with laser.Shrink abnormal blood vessels.If blood already leaked into vitreous: vitrectomy performed. (vitreous humor drained out of eye chamber and replaced with saline or silicone oil.)Necessary to support structures of eyeball until healing can occur.Corticosteroids.Nursing Process for Patient with Diabetic Retinopathy:Data collection:Risk factors identified.Nursing Diagnosis, Planning and Implementation:Final state for patient already visually impaired.Determine pt can monitor BG and draw up and admin insulin correctly.Teach importance of yearly comprehensive eye exam.Evaluation:Able to manage therapeutic regimen.Retinal Detachment: Separation of retina from choroid layer.Patho and Etiology:Allows fluid to enter space between the layers.Three causes:Hole or tear in retina that allows fluid to flow between the two layers.Fibrous tissue in vitreous humor that contracts and pulls retina away from its normal position.Fluid or exudate accumulation in subretinal space that separates retinal layers.Signs and Symptoms:Sudden changes in vision.Flashing lights (caused by vitreous traction on retina.)Floaters (caused by bleeding into vitreous humor.)No painLoss of peripheral vision.Diagnostic Tests:Indirect ophthalmoscopyIf lesions: sit-lamp exam to magnify lesions.Therapeutic Measures:Laser Surgery: Causes controlled burn.Forms scars around the tear and reattaches retina to surrounding tissue.Cryopexy:Supercooled probe on sclera.Freezes and scars the tear or hole.Pneumatic Retinopexy:Time consuming.Injecting air or gas into eye chamber to hold retina in place.Reclining about 16 hrs before procedure.Maintain position that keeps the air bubble against detached area for up to 8 hours a day for 3 weeks.Scleral Buckling:Silicon buckle under thin banc of silicon around sclera.Tightened to create indentation.Permanently adhere retina to choroid layers plications:Risk of IOP.Retinal tears.Recurrent retinal detachment.Nursing Process for Patient with Retinal Detachment:Subjective data: loss of peripheral vision, changes in visual acuity, presence of floaters, flashing lights, cobwebs, veil or visual impairment.Objective data: pt’s visual acuity, visual fields, ability to perform ADLs.Nursing Diagnoses, Planning, Implementation and Evaluation:Ambulate with assistance.Teach disease process, preop, postop care and how to admin eye meds.Teach to seek medical care for sudden or worsening pain, watery or bloody discharge or sudden loss of vision.Opportunity to discuss feelings.Should be free of injury, verbalizes pre/post op direction and reports reduced anxiety.Glaucoma: Group of diseases that damage optic nerves. Increased pressure in eye.Damages optic nerve.Silent, progressive and irreversible.Loss of peripheral vision.Followed by reduced central vision and eventually blindness.No cure.Pathophysiology:Most common: PrimaryPrimary open-angle glaucoma (POAG)Acute angle-closure glaucoma (AACG)Secondary caused by infections, tumors & injuries.Third: congenital glaucoma.POAG: Drainage system of eye degenerates and blocks flow of aqueous humor.AACG:Anatomically narrowed angle at junction where iris meets cornea.Blocks flow of aqueous fluid.Considered medical emergency and results in total or partial blindness if not treated.Etiology and Prevention:40 yo and older: POAG increased incident.AACG: Asian women over 45 yo.Signs and Symptoms:POAG:Develops bilaterally.Gradual and painless.No noticeable symptoms.Mild aching in eyes.Headaches, halos around lights & frequent visual changes.AACG:Ophthalmic emergency.UnilateralRapid onsetSevere pain, blurred vision, rainbows around lights, photophobia.Eye redness, steamy-appearing cornea, tearing, nausea and vomiting.Diagnostic Tests:Measuring IOPTonometryGDx AccessVisual field examCorneal thickness measured.Gonioscopy Therapeutic Measures:POAG:Opening aqueous flow.Miotics: Isopto Carbachol, Pilocar.When pupil is constricted, iris pulls away from drainage canal. Allows fluid to flow free.Slow production of aqueous fluid.Adrenergic Agonists: Propine and TimopticAACG:Same meds and placed on bedrest.Pts with glaucoma will need lifelong use of eye drop meds. Factors of nonadherence:AgeInability to afford meds.Lack of understanding.Contraindications: anticholinergics (atropine, antihistamines) (mydriatics)Surgical Managment:Can create area where aqueous humor can flow freely or reduce aqueous humor production.Prevents increased IOP.Laser trabeculoplastyTraditional trabeculectomyShuntsCyclocryotherapyiStent Trabecular Micro-BypassAACG: laser peripheral iridotomySurgical iridectomyProphylactic laser iridotomyNursing Process for the Patient with Glaucoma:Data Collection:Monitored for pain, loss of central and peripheral vision, understanding and ability to conduct ADLs.Nursing Diagnoses, Planning and Implementation: (And Evaluation)Give analgesics as needed for AACG.Identify self-care needs.Refer pt to support services.Teach pt to keep walking areas free of clutter and not to rearrange furniture without pt knowledge.Teach need for regular eye exam.Teach to admin meds and have return demonstration.Teach pt to rest his or her hand on forehead to admin eye drops.Consider large-print labels or audiotaped directions.Consider placing large, multicolored dot stickers on med bottles and on instruction cards.Maintains acceptable level of comfort.No further loss of vision.Able to care for self with assistance.Anxieties relieved.Does not suffer injury.Demonstrates correct instillation of eye meds.Able to verbalize understanding.Cataracts: Opacity in lens of eye that may cause loss of visual acuity.Patho and Etiology:Vision is diminished. Light rays cannot reach retina.Factors: age, UV rays, radiation, diabetes, smoking, steroids, nutritional deficiencies, alcohol consumption, intraocular infections, trauma, congenital defects.Signs and Symptoms:PainlessHalos around lightsDifficulty reading fine print.Seeing bright light.Increased sensitivity to glare while driving at night.Double or hazy vision.Decreased color vision.Diagnostic Tests:Diagnosed with eye exam.Direct ophthalmoscope.Slit-lamp microscope.Surgical Management:Interferes with daily living & quality of life: intraocular lens implant surgery is recommended.LenSx laser to remove cloudy lens.Implantable plications are rare.Nursing Process for the Patient with Cataracts:Monitor for visual deficit.Knowledge needs identified.Pre and post op nursing care is primary responsibility.Nursing Process for the Patient Having Eye Surgery:Ambulate with assistance.Teach disease process, preop, postop care and how to admin eye meds.Teach to seek medical care for sudden or worsening pain, watery or bloody discharge or sudden loss of vision.Opportunity to discuss feelings.Should be free of injury, verbalizes pre/post op direction and reports reduced anxiety.Macular Degeneration: Deterioration and scarring within the macula.Patho and Etiology:AMD: leading cause of permanent impairment of close-up vision or reading. (age >65)Macula is responsible for color vision.Two types:Dry (Atrophic): Photoreceptors in macular fail to function and are not replaced because of advanced age.70-90% of cases.Wet (Exudative):Retinal tissue degenerated, allowing vitreous fluid or blood into subretinal space.Angiogenesis occurs and compromises macular tissue.People at risk: > 60yo, family history, diabetes, smoking, UV light and Caucasians.Prevention:Diet of: dark green leafy veggies, orange and yellow-colored fruits and veggies.Measure: macula pigment optical density.Take: retinal carotenoids lutein, zeaxanthin and zinc supplements.Signs and Symptoms:Dry: Slow, progressive loss of central and near vision.Usually in both eyes.Wet:Loss of central and near vision.Onset is sudden.More severe vision loss.Blurred vision.Distortion of straight lines.Dark or empty spot in central area of vision.Decreased ability to distinguish color.Diagnostic Tests:OphthalmoscopeAmsler gridColor vision testDigital imagingIntravenous fluorescein angiographyTherapeutic Measures:Dry:No treatmentDo not lose peripheral vision or become totally blind.Classified as legally blind.Low-vision telescopic glasses can enhance remaining vision.Telescope implant for end-stage AMD.Wet:Intermittent injection.Drugs that are antiangiogenetic prevent formation of new fragile blood vessels.Laser photocoagulation.Trauma:Emergency and must be immediately treated.Injuries:Foreign bodyChemical burnsUV exposureDirect heat sourcesAbrasionsLacerations from dragging something across eye.Penetrating wounds. (Most serious and increases risk for infection and blindness.Signs and Symptoms:Foreign bodies produce pain.Eye tears excessively to irrigate.Mild to severe pain.Pain sensation might be delayed.Conjunctival rednessPhotosensitivityDecreased visual acuityErythemaPruritusAcute pain and burning. ................
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