Nursing Management of Clients with Stressors of Sensory Function

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

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. Glaucoma Interventions • Medication Rx:-Miotics-Sympathomimetic-Beta blockers-Carbonic anhydrase inhibitors-Osmotic diuretics-Prostaglandin agonist • Surgical Rx:-Trabeculoplasty-Iridectomy

10. 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

11. 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

12. 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

13. 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

14. 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

15. Cataract Interventions Surgery = only option for Rx • Surgical removal of diseased lens and replacement with silicone prosthetic lens • Extracapsular procedure = most common • Outpatient surgery

16. 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

17. 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?

18. 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?

19. 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?

20. 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

21. 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.

22. 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?"

23. 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

24. Retinopathy • Hypertensive • Diabetic

25. Retinal Detachment • Partial detachment –Layers of retina separate because of fluid accumulation between them • Complete detachment – if above left untreated; leads to blindness

26. Retinal DetachmentAssessment • Flashes of light ( photopsia) • Floaters • Blurred vision • Sense of curtain being drawn • Loss of portion of visual field

27. 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

28. 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?

29. The Aging Ear • Cerumen drier • Tympanic membrane less elastic • Bony ossicles and cochlea function diminish • Changes in vestibular function • Acuity diminishes

30. Ear DisordersAssessment • External Examination:Swelling, lesions, symmetry, position, external canal, odor • Internal Examination:Otoscope exam: assess tympanic membrane color, intactness, bulgingAssess cerumen

31. Ear DisordersDiagnostic Assessment Hearing Tests • Whisper • Weber • Rinne • Audiometry Vertigo Tests • Caloric • Dix-Hallpike • Electronystagmography

32. 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

33. Meniere’s DiseaseAssessment • Feeling of fullness in ear • Tinnitus; low pitched roar/hum • Vertigo • Nystagmus • Nausea / Vomiting • Severe headache • Hearing Loss

34. 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

35. 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.

36. 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?

37. 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

38. Bony overgrowth around ossicles Fixation of bones Stapes fixation leads to conductive loss Inner ear involvement leads to sensorineural loss Familial tendency OtosclerosisEtiology

39. 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

40. OtosclerosisInterventions Surgical • Stapedectomy Fenestration - removal of stapes - prosthesis placed between incus and stapes footplate

41. 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.

42. 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?