Nursing care of clients experiencing sensory stressors of the eye and ear

Nursing care of clients experiencing sensory stressors of the eye and ear Lecture notes


Vision stressors
Cataracts
Glaucoma
Retinopathy
Macular degeneration

Cataracts Overview
gradual, progressive thickening of lens
Clouding, blurring of lens distorts image & color projected onto the retina.
As cataract matures, opacity makes it difficult to see the retina & Visual acuity is restricted.
one of the leading causes of blindness in the world today
Increased incidence with age

Etiology of cataracts
Age-Related Cataracts Lens water loss and fiber compaction
Traumatic Cataracts Blunt injury to eye or head • Penetrating eye injury • Intraocular foreign bodies • Radiation exposure, therapy
Toxic Cataracts Corticosteroids • Phenothiazine derivatives Miotic agents
Associated Cataract Diabetes mellitus Hypoparathyroidism • Down syndrome • Chronic sunlight exposure
Complicated Cataracts Retinitis pigmentosa Glaucoma • Retinal detachment

Clinical manifestations
Decreased visual acuity and glare
Photophobia
Decreased color perception
Painless loss of transparency
Diplopia
Absence of red reflex

SURGICAL MANAGEMENT
Intracapsular Cataract Extraction
Extracapsular Cataract Extraction
Intraocular Lens Implantation
Aphakia - absence of lens
Complications:
Secondary Glaucoma
Retinal Detachment

Post procedure complications
PC: ocular inflammation
Administer steroid vs. NSAID drops to affected eye as prescribed
PC: Increased intraocular pressure
Avoid physical activities that may increase pressure
PC:IOL migration
Report visual disturbances once eye is unpatched
Pain
Use Tylenol for pain
PC: surgical site infection
Report fever, drainage or swelling of eye
Risk for injury
Wear eye shield/sunglasses
Discharge instructions

Cataract surgery Do’s
Do use prescribed eye drops, as instructed.
Do wear glasses or eye shield at all times to protect eye from injury, at least for 1 - 2 weeks.
Do wash your eye lid gently with a cotton ball or clean facecloth soaked with luke-warm tap water. Your surgeon will discuss the of sterile water, if necessary.
Do wear eye shield when showering or bathing for one week. Let the water hit your back not your face.
Cataract surgery Do’s
Do ask a family member or friend to help you wash your hair the first time. Do not get operated eye wet.
Gradually increase your activity on the advice of your eye surgeon. Sit in a chair to put on shoes.
Do sleep on back or unoperated side (place a pillow between your knees to help avoid turning over during sleep).

Cataract surgery Don’t’s
Do not rub or bump the operated eye.
Do not get water in the eye.
Do not strain.
Do not get constipated.
Do not lift anything heavier than 20 lbs., for the first week, after surgery.
Do not go swimming until your eye surgeon says you can.
Do not play contact sports.
Do not put your head down below your waist for 2-3 days when bending over.

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 and decreased visual acuity
Primary open-angle glaucoma(POAG)
Most common type, slow to develop
Acute angle-closure glaucoma (AACG) is an ocular emergency

Pathophysiology
compromised drainage of aqueous humor circulation and the subsequent increase in IOP

Etiology of Glaucoma

Primary Glaucoma

• Aging
• Heredity
• Central retinal vein occlusion

Secondary Glaucoma

• Uveitis
• Iritis
• Neovascular disorders
• Trauma
• Ocular tumors
• Degenerative disease
• Eye surgery

Associated Glaucoma

• Diabetes mellitus
• Hypertension
• Severe myopia
• Retinal detachment

Clinical Manifestations
Headache or brow pain, nausea and vomiting, colored halos around lights, and sudden blurred vision with decreased light perception
mid-dilated nonreactive pupil, and a firm globe.
Cupping & atrophy of the optic disc, disc wider, deeper, turns white or gray
Change in Visual field measurement

Diagnostic Tests
Tonometry
IOP>21
tonometry must be performed and must demonstrate increased IOP.
Ophthalmoscopic exam
Cupping and atrophy of optic disc

Drug Therapy
Inhibition of aqueous humor: timolol, levobunolol, beta blockers, carbonic anhydrase inhibitors
Pupillary constriction: miotics, pilocarpine hydrochloride after initial therapy
Pilocarpine must be used with caution
Osmotic drugs part of emergency treatment for rapid reduction of IOP
No epinephrine used in angle-closure glaucoma because it dilates the pupil

Management
Intravenous gamma globulin
High dose of ASA while in hospital
Low dose ASA upon discharge
Base-line echocardiogram to assess coronary artery status

Surgical Management
iridotomy (LPI) performed 24-48 hours after IOP is controlled

Hypertensive Retinopathy
In HTNR, retinal arterioles narrow, take on classic "copper wire" appearance.
Nicking or narrowing of the vessels occurs.
If blood pressure remains elevated, areas of ischemia or "cotton wool" spots, small hemorrhages, headaches, and vertigo occur.

Diabetic Retinopathy
Retinal blood vessel complication
Retinopathy worsened with poor glucose control
Diabetic education is key to minimizing complication
Managed with
Laser therapy
Vitrectomy

Macular Degeneration Overview
The macula—the area of central vision —deteriorates.
Degeneration can be atrophic age-related (dry) or exudative (wet).
Rod and cone photoreceptors die.
Central vision declines; client describes "mild blurring" and "distortion." leading to blindness
Diagnosed with Ophthalmologic exam and angiogram

Risk factors
Smoking, may increase the risk of AMD.
Obesity. Research studies suggest a link between obesity & progression of AMD
Race. Whites are much more likely to lose vision from AMD than African Americans.
Family history. Those with immediate family members who have AMD are at a higher risk of developing the disease.
Gender. Women >men.

Clinical manifestations
For dry AMD: the most common early sign is blurred vision.
-blind spot in the middle of their field of vision.
For wet AMD: the classic early symptom is that straight lines appear crooked.
A small blind spot may also appear in wet AMD, resulting in loss of one's central vision.

Testing
Visual acuity test. This eye chart test measures how well you see at various distances.
Dilated eye exam. Drops are placed in your eyes to dilate the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of AMD and other eye problems. After the exam, your close-up vision may remain blurred for several hours.
Tonometry.

Macular degeneration Management
Laser surgery.
The risk of new blood vessels developing after laser treatment is high. Repeated treatments may be necessary. In some cases, vision loss may progress despite repeated treatments.
Injections.
Wet AMD can now be treated with new drugs that are injected into the eye (anti-VEGF therapy). Avastin (off label use) Macugen, Lucentis.
This drug treatment blocks the effects of the growth factor, impeding choroidal neovascularization (CNV). Source: Mayo Clinic

Macular degeneration Management
Photodynamic therapy.
Injected drug tends to "stick" to the surface of new blood vessels. Next, a light is shined into your eye for about 90 seconds. The light activates the drug. The activated drug destroys the new blood vessels and leads to a slower rate of vision decline.
Photodynamic therapy is relatively painless. It takes about 20 minutes and can be performed in a doctor's office.
Treatment results often are temporary. You may need to be treated again.

Interventions for Clients with Ear and Hearing Problems

Otosclerosis Overview
abnormal growth of bone of the middle ear.
Slowly progressive conductive hearing loss results.
Exact etiology unknown
Increased incidence with Family history
Viruses/measles?
Hormones?
Increased incidence in white middle aged women

Clinical manifestations
Hearing loss
Associated findings (may or may not be present)
Vertigo
Balance problems
Tinnitus
Tuning-fork examination reveals signs of conductive hearing loss.
Weber: lateralizes toward the poor ear
Rinne: BC=AC

Collaborative care
Non surgical management
Hearing aid
Surgical management
stapedectomy
bypasses the diseased bone with a prosthetic device that allows sound waves to be passed to the inner ear.
Complications:
Facial nerve palsy
Vertigo
Taste disturbance
infection

Nursing priorities
Injury, Risk for related to disturbances of balance and impaired ability to detect environmental hazards

Communication, Impaired Verbal related to difficulty understanding others secondary to impaired hearing

Risk for Social Interaction, Impaired related to difficulty in participating in conversations

Social Isolation related to the lack of contact with others secondary to fear and embarrassment of hearing losses

Acute Pain related to inflammation, infection, tinnitus, or vertigo

Therapeutic Regimen Management, Ineffective related to insufficient knowledge of condition, medications, prevention of recurrence, hazards (swimming, air travel, showers), signs and symptoms of complications, and hearing aids


Ménière's Disease Overview
increase in volume and pressure of the inner ear
Increased incidence with positive family history
Multiple episodes of vertigo and hearing loss eventually result in permanent damage to the vestibular and cochlear apparatuses
Falls and accidents are likely to occur

Ménière's Disease
Onset typically occurs in early- to mid-adulthood
fullness or blocked sensation in one ear
Tinnitus, vertigo occur in attacks that can last for several days.
Tuning fork examination reveals one-sided sensorineural hearing loss
Weber:
sound is heard better on the affected side
Rinne:
AC>BC

Collaborative care
Nonsurgical management includes:
slow head movements
Salt, sugar and fluid restrictions
cessation of smoking
Medications
Antihistamines to relive vertigo symptoms
Dramamine to manage nausea/vomiting
Scopolamine for motion sickness
Corticosteroids vs. mild diuretics to relieve pressure
diazepam.

Collaborative care (Continued)
Surgical management
last resort and consists of labyrinthectomy or endolymphatic decompression with drainage and shunt.
Hearing in the affected ear is often sacrificed.

Nursing priorities
PC: hearing loss
Injury, Risk for related to disturbances of balance and impaired ability to detect environmental hazards
Communication, Impaired Verbal related to difficulty understanding others secondary to impaired hearing

Nursing priorities (cont’d)
Risk for Social Interaction, Impaired related to difficulty in participating in conversations
Risk for loneliness related to the lack of contact with others secondary to fear and embarrassment of hearing losses
Therapeutic Regimen Management, Ineffective


Risk for Impaired Verbal Communication
Assistive devices for hearing compensation
Lip reading, sign language
Managing anxiety