Transcript Sensory/Perceptual Alterations - NACCNursing

Sensory/Perceptual Alterations
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Module A
Eye Terminology/ Pathophysiology
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Refractive errors
Blindness
Infection/ inflammation
Cataracts
Retinal detachment
Retinopathy
Eye Terminology/ Pathophysiology
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Macular degeneration
Glaucoma
Enucleation
Trauma
Refractive Errors of the Eye
• Most common visual problem
• Refraction is the bending of light rays
• Prevents light rays from converging into a
single focus on retina
• Non-surgical correction
– corrective glasses
– contacts
– corneal molding to treat astigmatism
Refractive Errors of the Eye
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Surgical Correction
LASIK
PRK
Myopia
Near sightedness- can see up close, but not objects
in the distance
– Most common refractive error
– Images are bent & fall in front of retina, not on the
retina
Refractive Errors of the Eye
• Hyperopia
– Farsightedness
– Images are focused behind retina, not on retina
• Presbyopia
– Loss of accommodation for near vision
– Lens loses its elasticity
– Age 30’s to 40’s
– Has difficulty with close reading without backing
away from the material
Refractive Errors of the Eye
• Astigmatism
– Irregular corneal curvature
– Incoming light rays are bent unequally
– Can occur with other refractive errors
– Treated with corneal molding
Blindness
• Visual acuity is measured with the Snellen Chart.
Visual acuity is measured as a fraction. The top
number is the distance to the chart. The bottom
number is the distance at which a “normal eye”
can read the line.
• Definition of Legal Blindness- visual acuity of
20/200 or < with corrective lenses or visual field
no > 20 degrees
Blindness
• Nursing Diagnoses
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Altered sensory perception R/T blindness
Risk for injury R/T inability to see potential dangers
Self-care deficit R/T visual impairment
Fear R/T inability to accurately interpret environment
Blindness
• Goal: Make a successful adjustment to the
impairment
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Orient client physically & verbally to the environment
Encourage self-care activities
Encourage independence
Use sight-guided technique when assisting with
walking
– Encourage use of touch
– Establish routine placement for tableware
– Take the person’s hand & guide to find personal care
items
Blindness
• Goal: Verbalize feelings R/T loss
– Allow expression of fears and feelings of anger
– Help to identify coping strategies
• Goal: Use of appropriate coping strategies
– Provide emotional support
– Provide diversion activities- radio, audio books
– Referral to agencies: ex. American Foundation for
the Blind, Social & Rehabilitative Services
Eye Infections & Inflammation
• Hordeolum
– Also called “sty”
– Infection of sebaceous gland or an eyelash follicle
in the lid margin
– Red, swollen, tender, painful area on skin surface
of eyelid. May have purulent drainage
– Warm, moist compresses & anti-infective
ointment
Eye Infections & Inflammation
• Chalazion
– Sterile inflammation of a sebaceous gland in the
eyelid
– Painless swelling
– Surgical excision if it interferes with vision
Eye Infections & Inflammation
• Blepharitis
– Common chronic bilateral inflammation of lid
margins
– Lids are red rimmed with scales or crusts
– Treatment: warm, moist compresses, gentle
cleansing with baby shampoo, anti-infective
ointment
Eye Infections & Inflammation
• Conjunctivitis- infection or inflammation of
conjunctiva
– Bacterial conjunctivitis- “pink eye”. Occurs most
commonly in children. Contagious. Present with
tearing, redness, mucopurulent drainage, itching.
Treat with antibiotic drops. Teach good handwashing,
isolate linens, keep out of school or day-care. Teach to
discard opened contact lens care products and eye
make-up.
– Viral conjunctivitis- may treat with corticosteroid
drops
– Inflammatory conjunctivitis- not contagious
Cataracts
• Opacity of the lens
• Cataract removal is the most common surgical
procedure for older Americans
• Risk factors
– Aging
– Trauma
– Toxins
– Long term use of corticosteroids
– UV light exposure
– Smoking
Cataracts
• Assessment findings
– Dimmed vision, blurred vision, loss of visual acuity
– Abnormal color perception
– Sensitivity to glare
– Pupil may appear white, gray, or opaque
– Loss of red reflex
Cataracts
• Preoperative nursing care
– Antibiotic drops if ordered
– Mydriatic eye drops to dilate the pupils
– Preoperative teaching: Avoid rubbing eyes after
surgery. Eye patch will be applied on affected eye
& will be removed the following day at the postop
appointment. Teach that surgery is done under
local anesthesia with sedation to keep
comfortable.
Cataracts
• Postoperative care:
– Antibiotic drops to prevent infection,
corticosteroid drops to decrease inflammation.
– Avoid activities that increase IOP such as lifting,
stooping, straining
– Wear eye shield as instructed
– Glasses can only be prescribed when healing
process is complete, usually 6-8 weeks
– Teach to look through central portion of lens
implant.
– Avoid lying on operative side
Retinal Detachment
• Separation of the sensory retina & the
underlying pigmented epithelium, with fluid
accumulation between the two layers
• Risk factors
– Eye Trauma
– Increasing age
– Diabetic Retinopathy
– Personal or family history
Retinal Detachment
• Clinical manifestations
– Impending retinal detachment- light flashes,
floaters, cobweb or hairnet appearance
– Complete retinal detachment- painless loss of
vision “like a curtain” coming across field of vision
Retinal Detachment
Surgical Interventions
-- Laser photocoagulation-uses intense focused light
beam which causes a scar. This seals the edges of the
tear preventing fluid from accumulating.
-- Cryopexy- Uses extreme cold to produce scarring
-- Scleral Buckling- Uses a silicon implant, may also use
encircling band to indent the globe of the eye. See
picture Lewis, p 431
-- Pneumatic retinopexy- Injection of a gas to form a
temporary bubble that helps close the retinal break.
Retinal Detachment
• Postoperative care
– Topical antibiotics
– Topical corticosteroids
– Analgesics
– Mydriatics to dilate the pupil
– Special positioning may be prescribed by surgeon
depending on the extent & the area of
detachment. May be on bedrest. May have to
keep head positioned so that the bubble is in
contact with the retinal break
Retinopathy
• Diabetic retinopathy is the leading cause of visual
disability & blindness in persons with
uncontrolled DM
• Hypertensive retinopathy is caused by high blood
pressure which creates blockages in the small
vessels of the retinal.
• Papilledema is swelling of the optic disc & nerve
due to sustained, severe hypertension. This is a
medical emergency. Treatment focuses on
lowering the BP.
Macular Degeneration
• Most common cause of irreversible central
vision loss in persons over 60.
• Family Hx is a major risk factor.
• 2 types: wet & dry
• Nutritional supplements have shown to slow
the progression
Primary open-angle Glaucoma
• Characterized by
– Increased intra-ocular pressure (IOP)
– Optic nerve atrophy
– Peripheral visual field loss
– Tonometry measures IOP. IOP > 22 mmHG
Much more common in African- Americans
Primary open-angle glaucoma accounts for 90% of
cases
• Obstruction of the flow of aqeuous humor
resulting in build up of pressure (IOP)
Primary open-angle Glaucoma
• Pathophysiology
• Imbalance between rate of secretion of
aqueous humor & rate of absorption of
aqueous humor
Increased IOP
Decreased peripheral vision Edema
Blindness
Acute closed angle glaucoma
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Rare
Medical Emergency
Requires surgery
Complete closure of the angle
Subjective assessment
Severe pain in & around eye
Headache
Rainbow halos around light
N&V
Glaucoma
• Medications are primary treatment
– Beta adrenergic blockers- ex. Betoptic,
Timoptic, Betagan
– Alpha adrenergic agonists- ex. Dipivefrin (
Propine), Alphagan, Lopidine, Xalatan
– Miotics- ex. carbachol, pilocarpine
– Carbonic anhydrase inhibitors- ex. Azopt, Trusopt
eyedrops. Medication taken by mouthNeptazane, Diamox
All 4 classes of drugs decrease aqueous humor
production
Glaucoma
– The nurse should stress the importance of
compliance with medications & follow-up
appointments to treat, monitor, & prevent loss of
vision. Life-long medications will most likely be
required
– Beta blocker eye drops used to treat glaucoma can
cause an additive effect if systemic beta blockers
(ex. Tenormin, lopressor, toprol, corgard) are also
prescribed. Some eye drops to lower IOP are
contraindicated in patients with COPD.
Glaucoma Medications
• Goal of medical intervention is to decrease
IOP.
• Avoid use of antihistamines or
sympathomimetic drugs found in cold
medicines. These cause mydriasis or dilation
of the pupil. The opposite goal of treatment
Enucleation
• Removal of the eye
• Primary indication is a blind, painful eye, some
malignancies.
• Emotional support
• 6 weeks may be fitted for eye prosthesis
Eye Trauma
• Types of injuries
– Blunt injury
– Penetrating injury
– Chemical injury
– Foreign bodies
90% of all eye injuries can be prevented by using
proper eye protection when participating in
sports, woodworking, yard work. Comply with eye
wear recommendations at place of employment
Types of Ophthalmic Drugs
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Topical anesthetics- for pain
Topical antibiotics
Steroids- decrease inflammation
Mydriatics- dilate the pupil for eye exam
Miotics- contract the pupil permitting better
drainage of intraocular fluid in glaucoma
• Carbonic anhydrase inhibitors
• Beta blockers
Ear Terminology/ Pathophysiology
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Hearing Loss/ Deafness
Trauma
External otitis
Impacted cerumen
Otitis Media
Otosclerosis
Meniere’s Disease
Symptoms of Hearing Loss
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Frequently asking people to repeat statements
Loud volume on T.V. or radio
Withdrawal from social interactions
Better understanding in small groups
Using loud speaking voice
Turning head/ leaning forward to favor one
ear.
Auditory Assessment
• The unit for measuring loudness is the decibel.
• Hearing loss is measured in decibels
• 0-15 dB - normal hearing
• >40-55 dB - moderate hearing loss
• >90 - profound hearing loss
15 dB are generated with shuffling paper in
quiet room. 40dB low conversation. 150 dB jet
plane 100 feet away
Types of Hearing Loss
• Conductive- sound waves are blocked to the
inner ear because of problem in external or
middle ear. Causes- inflammation, obstruction
external or middle ear, tumors, otosclerosis
• Sensorineural- Problem with sensory fibers in
inner ear so the impulse to the brain is
impaired. Often permanent. Causes- cranial
nerve damage, medications, trauma, inherited
disorders, prolonged exposure to loud noise,
aging
Types of Hearing Loss
• Conductive/Sensorineural Hearing Loss- a mix
of both types
Nursing Interventions
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Face the client when speaking
Speak slowly and clearly
Lower the pitch of your voice
Limit other noises when speaking to the
client, close the door, turn off T.V.
Hearing Loss/Deafness
• Hearing Health Promotion
– Increasing rate of hearing loss in young adults as a
result of prolonged amplified sound (I-pods, etc)
– Industrial work environments- use of ear
protection
– Immunizations- encourage MMR immunization
– Ototoxic drugs & chemicals- salicylates, diuretics,
antineoplastic drugs (cisplatin), antibiotics
(gentamycin), chemicals used in industry such as
mercury
Assistive Devices & Techniques
• Hearing Aids
• Lip reading- allows for approx 40%
understanding. Gestures & facial expression
help to clarify the spoken message
• Sign language
• Assistive Listening Devices
• Service dogs for deaf
• Special telephones
• Computer programs
Deafness
• Consult community resources such as National
Assoc. for Deaf
• Teach safety precautions when crossing the
street, driving
Ear Trauma
• Blows to the ear can cause conductive hearing
loss. Foreign objects into the ear canal may
cause perforation
• Head trauma that injures temporal lobe can
affect hearing
• Emergency care of head injury- may find
clear/ bloody drainage in ear canal. Sign of
serious head injury. Fluid may be leaking CSF
External Otitis
• Inflammation or infection of the epithelium of
the auricle and ear canal.
• “Swimmer’s Ear”
• Pain upon movement of the auricle or on
application of pressure to the tragus
• Treatment- antibiotic and/or steroid ear
drops, anagesics
Impacted cerumen
• Treat with irrigation of the ear canal with bulb
syringe or special device used in the healthcare
providers office
• Use warm tap water. Place basin under the ear
with towel around the neck so client does not
get wet
• Lubricating drops may help loosen the earwax,
so irrigation can be done.
Impacted cerumen
• Irrigation is contraindicated if tympanic
membrane is perforated.
• Teach to avoid cotton tipped applicator use in
ear canal. May cause ruptured eardrum or
may cause impaction of cerumen.
Otitis media
• Common childhood disease which often
follows colds, allergies, sore throats, and
blockage of the eustachian tube.
• Treatment – antibiotics (amoxicillin)
• Otitis media with effusion- inflammation of
the middle ear with collection of serous or
purulent drainage. May be chronic
Otitis media
• Surgical therapy– myringotomy with tympanostomy tube placement
– Myringoplasty- surgical repair of TM perforation
– Mastoidectomy- removal of diseased tissue and
infection. Incision behind ear
Otosclerosis
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Autosomal dominant disease
Fixation of the stapes in the oval window
Hearing aids may be effective
Surgical intervention- stapendectomy with
prosthesis insertion
• Progressive gradual hearing loss, may hear
ringing or roaring
Meniere’s Disease
• Inner ear disease
– Episodic vertigo
– Tinnitus
– Fluctuating hearing loss
– May have sudden, severe attacks of vertigo with
N&V
May feel as if they are being pulled to the ground or
feel like they are whirling in space
Meniere’s Disease
• Nursing interventions
-Keep in a quiet, dark room during an acute attack
-Safety measures- siderails up, call for assistance to
get up
Surgical intervention- surgical decompression of the
endolymphatic sac to reduce pressure on cochlear
hair cells and to prevent further damage and hearing
loss
Meniere’s Disease
• Treatmento antihistamines- to decrease tissue edema
o antiemetic- such as phenergan, tigan
o diuretics- such as diamox
Main medication is meclizine (antivert) to
control nausea and vertigo
o -Low salt diet
• Safety
Mastoiditis
• Swelling behind the ear and pain. Cellulitis on
the skin over the mastoid process.
• Fever, malaise, tender and enlarged
postauricular lymph nodes
• Most common treatment is simple/ modified
mastoidectomy with tympanoplasty
Assistive Devices & Techniques
• Cochlear implant- Implanted electronic
hearing device that stimulates the nerves of
the inner ear. Ideal candidate is someone who
became deaf after learning to speak. Extensive
training and rehab are essential. Offers the
profoundly deaf the ability to hear sounds
including speech
Questions
• Which task is appropriate to delegate to an
LPN who is working with the RN?
• Administer eye drops to a child with
conjunctivitis.+
• Review hand washing with a patient who has
an eye infection+
• Show a client how to remove eye exudate+
• Assess nutritional factors with a client with
macular degeneration
Question
• A patient with a history of head trauma is in
need of treatment for adult strabismus. What
treatment would be considered appropriate
for this patient?
• Rational
THE END