Care of Clients with Problems In Inflammatory & Immunologic Response, Perception & Coordination (NCM104) Patients With Special

Senses Alterations I and II

LOOKY HERE

Special Senses
We have 5 Special Senses
Smell Taste Sight Hearing Balance (Common Sense)

WEH LOL

They have highly localized receptors that provide specific information about the environment They also transmit external stimuli to the brain so it can interpret it They act also as a protective mechanism

Topics Discussed Here Are: 1. Special Senses Anatomy and Physiology a. Anatomy and Physiology of the Eye b. Hearing and Balance (Anaphy of Ear) 2. Assessment of Eyes and Ears a. Eyes b. Ears c. Diagnostic Tests 3. Disorders of the Eye a. Impaired Vision b. Infection and Inflammatory Conditions of the Eye c. Disorders of the Cornea d. Retinitis Disorders e. Macular Degeneration f. Glaucoma g. Cataract h. Rehabilitation of a Blind Person 4. Disorders of the Ears and Balance a. Wax b. Foreign Bodies c. Otitis Externa d. Otitis Media e. Cholesteatoma f. Otosclerosis g. Meniere's Disease

Olfaction
Sense of smell Response to airborne molecules, called odorants entering the nasal cavity At least 7 (Perhaps 50) primary odors exist o Olfaction neurons have very low thresholds and accommodate rapidly OLFACTION EPITHELIUM and BULB - Olfactory neurons in the olfactory epithelium are bipolar neurons o Distal ends have olfactory hairs - Olfactory hairs have receptors that respond to dissolved substances - Receptors activate G Protein which results in ion channels opening and depolarization NEURONAL PATHWAYS for OLFACTION - Axons from the olfactory neurons extend as olfaction nerves to the olfactory bulbs where they synapse with interneurons - Axons from interneurons from the olfactory tract which connect to the olfactory cortex - Olfactory bulbs and cortex accommodate to odors

Taste
Sensory structures that detect taste stimuli are taste buds Most taste buds are located in the epithelium of papillae Taste buds are found on the o Tongue MORE! o Palate o Lips o Throat HISTOLOGY of TASTE BUDS - Taste buds consists of : o Taste Cells (50)

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Have hairs that extend into taste pores Basilar Cells Supporting Cells

FUNCTIONS of TASTE - Receptors on the hairs detect dissolved FIVE basic types of taste exist: o Salty Sodium Ions o Sour Acids o Sweet Sugar, some other carbohydrates and some protein o Bitter Alkaloids (Base) o Umami Elicited by the amino acid glutamate and related compounds - All taste buds sense FIVE primary tastes, but tend to be more sensitive to ONE o Sensory to bitter substances in the highest (Poisonous) - Taste is strongly influenced by olfactory sensation o Nasal congestion can damper the taste sensation - Tongue can detect other stimuli besides taste o Temperature o Texture NEURONAL PATHWAY for TASTE - The FACIAL NERVE carries taste sensation from the ANTERIOR 2/3 of the tongue - The GLOSSOPHARYNGEAL NERVE carries taste sensation from the POSTERIOR 1/3 of the tongue - The VAGUS NERVE carry taste sensations from the EPIGLOTTIS - The neural pathway for taste extends from the Medulla Oblongata to the Thalamus and to the Cerebral Cortex

Visual System
Consists of: o Eye Eye Ball Optic Nerve Accessory Structures Eyebrows, eyelids, conjunctiva, lacrimal apparatus and extrinsic eye muscles Sensory Neurons

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ACCESSORY STRUCTURES - Eye Brows o Prevent perspiration from entering the eyes and help shade the eyes - Eyelids o Consists of 5 tissue layers o Protect the eyes from foreign objects o Help lubricate the eyes by spreading tears over their surface Lubricating glands associated with the eyelids Meibomian Glands and sebaceous glands Ciliary Glands lie between the hair follicles - Eyelashes o Project from the free margin of each eyelid o Initiate blinking reflex - Conjunctiva o Covers the inner eyelid and the anterior part of the eye - Lacrimal Apparatus o Consists of the lacrimal glands, lacrimal canaliculi and a nasolacrimal duct o Lacrimal Glands secrete TEARS Tears

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Extrinsic Eye Muscles Six strap-like muscles Enables the eye to follow moving objects Maintains the shape of the eyeball FOUR Rectus muscles originates from the annular ring TWO Oblique muscles move the eye in the vertical plane

Contains mostly water and with some salts, mucus, and lysozymes Enter the eye via superolateral excretory ducts Exit the eye

Anatomy of the Eye

~ ~ A slightly irregular hollow sphere with anterior and posterior poles The eyeball is composed of 3 layers o Fibrous Layer Sclera Cornea o Vascular Layer Choroid Ciliary Body Iris o Nervous Layer Retina The internal cavity is filled with fluid called humors FIBROUS LAYER Sclera o Posterior 4/5th of the eye o White Connection: Tissue that maintains the shape of the eyeball o Provide a site for muscle attachments Cornea o Anterior 1/5th o Transparent and refracts light that enters the eye VASCULAR LAYER Choroid o A vascular network o May contain melanin-containing pigmented cells o Appears black in color o Prevents the reflection of light inside the eye Ciliary Body o Ciliary Ring A thickened ring of tissue surrounding the lens Composed of smooth muscle bundles (Ciliary Muscles) Anchors the suprasensory ligaments that holds the lens in place Changes the shape of the lens o Ciliary Process Produces AQUEOUS HUMOR Iris o Smooth muscle regulated by autonomic venous system Sphincter Pupillae Close vision and bright light: pupils CONSTRICT Dilator Pupillae Distant vision and dim light: pupils DILATE

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Changes in emotional state: Pupils dilate when the subject matter is Controls the amount of light entering the pupil Color is detected by the amount of melanin present Large Amount of Melanin: Brown / Black Less Amount of Melanin: Light brown, green, or Gray Even Less Melanin: Blue NERVOUS LAYER Retina Aqueous Humor o The inner layer of the eyeball o Has over 123 million photoreceptors which respond to light Ciliary Macular (Fovea Centralis) Process o Area of greatest sensitivity to light o Highest concentration of photoreceptors Optic Disc Lens o Located through which nerves exit and blood vessels enter the eye o No photoreceptor cells o The Blind Spot of the eye Iridocorneal o o CHAMBERS of The EYE - Composed of 3 Chambers o Anterior Chamber Between the cornea and iris o Posterior Chamber Between the iris and the lens o Vitreous Chamber Much larger than the 2 chambers Posterior to the lens

Flow

Cornea

Trabecular Meshwork Canal of Schlemm

Aqueous Humor

Veins

Fills the Anterior and Posterior chamber Supports, nourishes and removes wastes for the cornea, which has no blood vessels Produced by the CILIARY PROCESS as a blood filtrate Returned to the circulation through the scleral venous sinus

Vitreous Humor
Fills the Vitreous Chamber Contributes to the Intraocular Pressure (IOP) Helps maintain the shape of the EYEBALL Holds the lens and retina in place Functions in the refraction of light in the eye

Aqueous Humor Production Must be EQUAL to the EXCRETION

Lens
A biconvex, transparent, flexible avascular structure that: o Allows precise focusing of light onto the retina o Is composed of epithelium and lens fibers Lens epithelial anterior cells that differentiates into lens fibers Lens fibers: Cell fibers filled with the transparent protein CRYSTALLIN o With age, the lenses become more compact and dense and loses its elasticity (Presbyopia)

Functions of the Complete Eye

Properties of Light o Electromagnetic Spectrum All electrical waves from short gamma rays to long radio waves

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Visual Spectrum Portion of the electromagnetic spectrum that can be detected by the human eye Refraction o Bending of light o Light striking a CONCAVE SURFACE refracts OUTWARD (Divergence) o Light striking a CONVEX SURFACE refracts INWARD (Convergence) o Converging lights rays meet a the focal point and are said to be FOCUSED (***) o

Focusing system of the EYE (Light Refraction) Cornea Person for most of the convergence Aqueous Humor Lens Adjusts the convergence by changing the shape Vitreous Humor Distant and Near Vision Distant Vision: Looking at the object 20 feet or more Near Vision: Looking at the object less than 20 feet from the eye Relaxation of the ciliary muscles causes the lens to FLATTEN, producing the Emmetropic Eye o Normal Resting condition of the lens Far point of vision o Point at which the lens does not have to THICKEN for focusing to occur o Normal: 20 feet / more from the eye Near Point Vision o Closest point an obnject can come to the eye and still be focused (***) When an object is less than 20 feet from the eye, the image falling on the retina is no longer focused Three EVENTS MUST Occur to Bring the Image into FOCUS! 1. Accommodation by the Lens Contraction of the ciliary muscles causes the lens to become more spherical Change in the lens shape enables the eye to focus on objects that are less than 20 feet away 2. Constriction of the pupils To increase the depth of focus 3. Convergence of the Eye Medial rotation of the eye (***)

Structures and Functions of the Retina

Pigmented layer of the retina Provides a black backdrop for increased visual acuity Rods and Cones synapse with Bipolar Cells o Bipolar cells synapse at ganglion cells (***) Rods Responsible for non-color vision and vision with low illuminate (Night Vision) Rod-shaped photo receptive part of the rods contains about 700 doublelayered membrane discriminating (***) RODS: Disc containing Rhodopsin

= DARK = LIGHT

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A Purple pigment consisting of little Protein OPSIN covalently bound to a yellow photosensory pigment called Retinal (Derived from Vitamin A) Exposure to light activates Rhodopsin o Rhodopsin is split by light into retinal and opsin, eventually resulting in an action potential o Light adaptation is caused by a radiation of Rhodopsin o Dark adaptation is caused by Rhodopsin production o Responsible for color vision and visual acuity Three Types (Each with a Different type of Iodopsin Pigment) o Pigments are most sensitive to blue, red and green light Perception of many colors result from mixing the ratio of the different types of cones that are active at a given moment (***) Most visual image are focused on the Fovea Centralis and Macula o Fovea Centralis has many high concentration of cones o In the remaining (***) o Most rods (***) Bipolar and Ganglion cells in the retina can modify information sent

Cones

Neuronal Pathway of Vision

Ganglion cell Axons from the optic nerve, optic chiasm and optic tracts o Extend to the Thalamus and SYNAPSE o Then the neurons form the Optic Radiation that project to the visual cortex Depth Perception o o

Hearing and Balance

Three parts of the Ears are: o External Ear Extends from the outside of the head to the Tympanic Membrane o Middle Ear Air-filled chamber, medial to the Tympanic Membrane o Inner Ear Set of fluid filled chambers medial to the Middle Ear The external and Middle ear are involved with hearing The Inner ear functions in both hearing and equilibrium

AUDITORY STRUCTURES and THEIR FUNCTIONS EXTERNAL EAR - Auricle Fleshy part of the external ear - External Acoustic Meatus o Passageway that leads to the tympanic membrane o Finally with hairs and ceruminous glands Ceruminous Glands produce Cerumen (Ear wax) o Tympanic membrane (Ear Drum) Thin connective tissue that vibrates in response to sound Transfer sound electrically to the middle ear Ossicles Bounding between outer and middle ears MIDDLE EAR

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A small, air-filled, mucosa-lined cavity o Flanked laterally by the eardrum o Flanked medially by the oval and round windows Contains 3 small bones (Malleus Incus Stapes) o Transmit vibratory motion of the eardrum to the oval window o Pampered by the Tensor tympani and Stapedius muscles o Auditory Tube (Eustachian Tube) Equalizes the pressure within the ear

INNER EAR - Bony labyrinth o Interconnected, fluid filled tunnel within the temporal bone - Contains: o Vestibule and Semicircular Canals: primarily involved in balance o Cochlear: Involved in hearing - Membranous Labyrinth o Series of membranous sacs with the bony labyrinth o Filled with Potassium (K+) rich filled called Endolymph (Protein) o Space between the bony labyrinth and membranous labyrinth is filled Perilymph - Cochlea o Spiral shaped canal within the temporal bone o Divided into the three compartments by the vestibule and vesicular membranes o Scala Vestibuli and Scala Tympani contains Perilymph o Cochlear Duct contains Endolymph and the spiral organ Spiral organ consists of inner hair cells and outer hair cells with attachments to the tectorial membrane Hair cells have hair-like projections at their apical ends which are very long called Stereocilia AUDITORY FUNCTIONS - Pitch is = Frequency of soundwaves - Volume = Is determined by the amplitude - Timbre is the resonant quality (Overtones) of sound Hearing Involves - Soundwaves funneled by the auricle down the external acoustic meatus causes the tympanic membrane to vibrate - Tympanic membrane vibrations pass along the auditory window of the inner ear (***) - Movement of the stapes in the oval window causes the Perilymph, vestibular membrane and Endolymph to vibrate and produce movement of the basilar membrane - Movement of the basilar membrane causes bending of the Stereocilia (***) - Bending of the Stereocilia pulls on gating spring and opens K+ channels - K+ ions enter the (***) - Depolarization causes the release of glutamate (?), general action potentials in the sensory hemoassociated with hair cells - The round window dissipates soundwaves and protects the inner ear from pressure build up

Neural Pathway Static Balance

Evaluates the position of the head relative to gravity and detects live acceleration and deceleration (***) Vestibule Contains o The Utricle and Saccule in the inner ear

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Contains maculae of hair cells Hairs are embedded in an Otolithic Membrane Consists of a gelatinous mass and crystals called otoliths Moves in response to gravity Evaluates movements of the head Semicircular canals 3 Semicircular canals at right angles to one another are present in the inner ear The Ampulla of each semicircular canal contains the crista ampullaris Has hair cells within hair

Assessment
History Taking (Ocular) o Blurred, double-vision / distorted vision o Pain PQRST o Itching sensation o Any eye discharge Color, consistency, odor RSVP! o Onset of problem R Redness o Duration S Swelling o Any history of trauma / injury o How it affects ADLs V Visual Acuity o Family history of same symptoms P Pain on palpation o History of Chronic Conditions o Genetic abnormalities Eye Examination o Visual acuity o Check for the Following 1) Position of the eyelid 2) Lid and eyelash margin 3) Pupillary response 4) Cardinal Gazes 5) Redness / swelling of the mucous membrane 6) Discharge Watery, purulent Corneal Reflex? Corneal Abrasion? Diagnostic Assessment o Snellens Chart Tests visual acuity Normal result is 20/20 o Ishihara Plate Tests color vision o Tonometry Indirect measurement of intraocular pressure Normal: 10 21 mmHg (or 11 21) ? o Perimetry Measurement of the peripheral visual field o Gonioscopy A biomicroscopic examination that visualizes the anterior chamber angle Diagnostic test of congenital and secondary glaucoma o Bjerrum Tangent Screen Measures central vision o Ophthalmoscopy Examines the fundus of the eye o Slit Lamp Biomicroscopy Assesses the eyes anterior portion under high magnification and in optical section o Amsler Grid

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Tests client for macular problems Consists of grid of identical squares with a central fixation Ultrasonography Evaluates lesions in the globe or the orbit MRI / CT Scan Optical Coherence Tomography Light is used to evaluate retinal and macular disease Color Fundus Photography Detects and documents retinal lesions Fluorescein Angiography Evaluates macular edema and macular capillary non perfusion and identify retinal and vascular neovascularization Indocyanine Green Angiography Evaluates abnormalities in the choroidal vasculature

History Taking (Ears) o Change in the hearing and balance o Loss of balance o History of accidents o Assess for symptoms of ear disorders o Check for the following 1) External ear 2) Otoscopic Examination 3) Auditory Acuity Whisper, Weber, Rinne o Symptoms of Ear Disorders 1) Deafness Client has hearing loss which may be mild / severe Hearing loss may be conductive, semi-neural / mixed types Otitis media (common cause of deadness among children) Presbycusis (common cause of deafness among adults) 2) Pain Ear ache / Otalgia is a very common complaint Otitis media for children, Otitis externa for adults Pain may arise from the ear itself / from an adjacent site with a shared nerve supply Most common site for referred pain is the throat, where infections of more rarely malignant tumors are responsible 3) Discharge Mucoid, purulent / bloody Cause of discharge is Otitis externa or Otitis media Perforation will be present in the tympanic membrane 4) Vertigo Form of dizziness where the client experiences a spinning sensation Common symptom when balance / vestibular system of the inner ear is diseased Accompanied by nausea and vomiting 5) Tinnitus Common complaint of noise in the ears Its quality varies from high-pitched, whistling to the clanging of bells or recognizable scratching of music

Assessment / Diagnostic Tests

Tuning Fork Tests o Rinnes Test

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Compares air conduction from bone conduction; differentiates conductive and sensorineural hearing loss The vibrating tuning fork is placed against the mastoid bone (Bone conduction) (***) Interpretation of Results: Normal: Air conduction is better than bone conduction (The tone is louder in front of the ear) Conductive hearing loss: Bone conduction is better than air conduction (The tone is louder behind the ear) Weber Test The rounded tip of the handle of the vibrating tuning fork is placed on the clients forehead Interpretation of Results: Normal: Tone heard in center of head / equally in both ears Conductive Hearing Loss: Tone heard better in affected ear; e.g. Otosclerosis Sensorineural Hearing Loss: Tone heard best in unaffected ear The examiner covers one ear with the palm of the hand, then whispers softly from a distance of 1 2 feet from non occluded ear (***) Audiometry It is the single most important diagnostic instrument in detecting hearing loss Types of Audiometry Pure Tone Audiometry o The louder the tone before the client perceives it, the greater the hearing loss Speech Audiometry o Speech word is used to determine the ability to hear and discriminate sounds and words Oculovestibular Test / Caloric Ice Water Test Irrigate the ear with cold water Normal: Lateral Conjugate Nystagmus of the eyes towards the area of stimulation Abnormal: Dysconjugate Nystagmus of the eyes Electronystagmography It helps to diagnose conditions such as Menieres disease and tumor on the internal auditory canal / Posterior Fossa Platform Posturography Used to investigate postural control capabilities such as vertigo Sinusoidal Harmonic Acceleration Rotary Rotation Assess the vestibulocochlear system by analyzing compensatory eye movement Middle ear Endoscopy The ear can be examined by an Endoscopic specialized in otolaryngology

Classifications of Hearing Loss

1. 2. 3. Conductive Hearing Loss Involves interference with conduction of sound impulses through the external auditory canal, the ear drum or the middle ear Sensorineural Hearing Loss *** from the disease or trauma to the inner ear / acoustic nerve Mixed Hearing Loss Involves both conductive and sensorineural loss

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Assessment of Clients with Hearing Loss

Irritable, hostile / hypersensitive in interpersonal relationships Difficulty in following directions Complains about people mumbling Turns up the volume of the Television Asks for frequent repetition Answers questions inappropriately Leans forward to hear better, face looks serious and straight Flat affect Loses sense of humor, becomes grim and lonely Experiences social isolation Develops suspicious attitude Has abnormal articulation Complains of ringing in the ears Has unusually soft / loud voice Dominates conversation

Guidelines for Communicating with Patients with Hearing Impairment

Talk directly to the person facing him/her Speak in clearly enunciated words using normal tone of voice, DONT SHOUT Use gestures with speech Do not whisper to anybody in front of the hearing impaired client Do not avoid conversations with a person who has hearing loss Do not show annoyance by careless facial expressions Move closer to the person or towards the better ear if he/she does not hear you Do not smile, do not chew gum/cover the mouth when talking to the person Encourage the use of hearing aid if the client has

Disorders of the Eye

Impaired Vision o Refractive Errors Vision is impaired because of a shortening / elongated eyeball prevents light from focusing sharply on the retina Can be corrected by wearing corrective eye glasses (***) Myopia: Near sightedness Hyperopia: Far sightedness Astigmatism: Irregularity in the curve of the cornea Presbyopia: Due to aging, inability to accommodate / adjust Vision Protection and General Eye Care - Regular ocular exam and physical examinations - Avoid dangerous items - Early identification and treatment of strabismus in children - Routine eye assessment programs in schools - Early treatment when eye symptoms occur - Routine instillation of appropriate drops in the eyes of every newborn - Blood test during pregnancy to identify syphilis - Inoculation against rubella - Regulation of O2 concentration administered to premature infants - Avoid habitual rubbing of the eyes - Have adequate lighting when reading - Periodically rest eyes during prolonged periods of close works, reading / watching television - Use glasses and wear protective goggles - Keep eye glasses clean, protected from scratching and breakage and properly aligned

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Do not use eye masks or any medications in the eyes unless prescribed by a doctor Do not use soiled clothes for rubbing the glasses / eyes Use care when using aerosol spray Maintain a state of good healthy and eat a well balanced diet with adequate Vitamin A, B, C and E Use care when using solvents, lye solutions , ammonia, caustive solutions to avoid splashing or spilling into eyes

Common Ocular Medications - Local anesthetics - Parasympathomimetic Drugs o Used as MIOTICS Pilocarpine HCl 0.5 10% Carbachol 1.5 3% Acetylcholine Cl 1% - Parasympatholytic Drugs o Used as Mydriatics NeoSynephrine 2.5 / 10% Atropine SO4 0.5, 1.4% Schophonium Hydrobromide 0.25% MALI ._. Cyclopentolate HCl (Cyclogyl) 1% - 2% Tropicamide (Mydriacyl) 0.5 1% - Antibiotic Agents o Gentamicin 0.3% o Neosporin o Chloroptic Eye Drops - Steroids - Carbonic Anhydrase Inhibitors Reduce aqueous humor production o (Diamox) Acetazolamide - Beta Blockers Also used to reduce aqueous humor production o Timolol Maleate (Timoptic)

Infection and Inflammatory Conditions of the Eye

Conjunctivitis o Inflammation which results from bacterial / viral infections o Redness, swelling, Lacrimation, pain, itching, discharge from the eye Types of Conjunctivitis - Bacterial Purulent discharge - Viral Tearing - Allergic Allergies to pollen - Toxic Due to toxic agents MEDICAL MANAGEMENT 1. For Trachoma Broad spectrum antibiotic Surgical Management for correcting Trichiasis to prevent conjunctival scarring 2. Antibiotic for 1 week 3. Vasoconstricting Agents 4. Saline irrigation for toxic conjunctivitis ASSESSMENT 1. Evaluate for type of discharge 2. Conjunctival reaction 3. Presence of Lymphadenopathy 4. Burning sensation

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Itching Photophobia Unilateral, bilateral Health teaching on ways on how to prevent the spread of infection Hand hygiene Avoid sharing of towels, face towels, clothing, eye drops Application of cold compress as ordered Application of antibiotic as orders

Uveitis o Inflammation of the uveal tract o Uveal Tract Middle vascular layer of the eye, contributing to the retinas blood supply o It is composed of the iris, ciliary body, and choroid Uveitis Can AFFECT - Iritis Inflammation of the iris - Iridicylitis Inflammation of the iris and the ciliary body - Choroiditis Inflammation of the choroid - Chorioretinitis Inflammation of the choroid and the retina Causes: - Local / Systemic disease - Injury - Unidentified case MEDICAL MANAGEMENT - Collaborative Management o Mydriatics (Atropine SO4 1% or 0.25%, Scopolamine) o To dilate the pupils o To prevent adhesion between anterior capsule of the lens and the iris o To relieve pain and photophobia o To reduce congestion o To rest the iris and the ciliary body Steroids (Local / systemic) Dark glasses (To relieve photophobia) Analgesics (Aspirin, Acetaminophen) Enucleation (Removal of the EYEBALL) Done if with perforation of sclera and ciliary body NURSING RESPONSIBILITY Assessment - Pain in the eyeball radiating to the forehead and temple - Blurred vision - Photophobia - Redness of eyes without purulent discharge - Small pupil - Lacrimation - Complete physical examination - Complete history - Review diagnostic tests like CBC, ESR - Review client history for repeated Uveitis - Inflammation of the injured / previously operated eye (Exciting eye) followed by the other eye (Sympathizing eye) - Photophobia - Blurring of vision

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Disorders of the Cornea

Corneal Ulcerations - Medical Emergency - May result to corneal perforation, scarring or intraocular infection, permanent impairment of vision Causes: Trauma Exposure to toxic agents Allergy Vitamin deficiency Lowered resistance Bacterial, viral, fungal infections Corneal Opacity - Lack of corneal transparency due to inflammation, ulceration or injury MEDICAL MANAGEMENT - Treatment o Trifluridine (Viroptic), Idoxuridine (IDU), Adenine Arabinoside (Vira-A) o Mechincal Chemical Debridement - Corneal Transplantation (Keratoplasty) o To repair corneal opacity, perforation of the corneal ulcer o Ideally a donated eye is transplanted immediately or is removed from the body within 2 4 hours of death o Corneal may still be viable within 12 hours, after death if the body has been refrigerated; may be transplanted up to 48 hours after death if it is kept in a sterile container on a piece of gauze soaked in NSS at 4C o Clear vision will appear after 6 12 months of surgery) NURSING RESPONSIBILITY - For corneal surgery o Position the client in supine for 1 hour and remain supine until the 1st post op day o Teach the client signs graft failure (RSVP) 1) Blurring of vision 2) Discomfort 3) Tearing 4) Redness of the EYE o Medications Post Op Pain medications Corticosteroids

Retinitis Disorders
Retinitis - Often associated with disease of the choroid - Caused by bacteria, fungi, toxoplasmosis, cytomegalovirus - Assess through Ophthalmoscopy MEDICAL MANAGEMENT - Collaborative Management o Rest the eye o Protect the eyes from light o Atropine SO4

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NURSING RESPONSIBILITY Assess - Reduced visual acuity - Changes in the visual field - Alterations in the shape of objects - Discomfort in the eyes - Photophobia

Retinitis Pigementosa - Rods Problem - Night blindness

Retinal Detachment - Separation of the 2 primitive layer of the retina (Outer pigment epithelium and the inner rod and cones layer) - Elevation of both retinal layers away from the choroid because of the presence of a tumor - Related to tumors (Trauma) Causes: -

Myopic degeneration Trauma Aphakia (Absence of crystalline lens) Hemorrhage Exudates that occur in front / behind the retina Sudden, severe physical exertion especially in persons who are debilitated

Assessment: - Floating spots or opacities before the eyes, these are blood and retinal cells that are freed at the time of the tear and cast shadows on the retina as they seem to drift about the eye - Flashes of light the light that enters (***) - Progressive constriction of vision in one area When detachment is extensive and occurs *** there is a sensation that a curtain has been drawn before the eyes or as if looking over a fence - If upper portion is detached, the visual field loss is inferior - On opthalmoscopy, visual field is (***) MEDICAL MANAGEMENT - The head is positioned *** that the retinal hole is in the lowest part of the eye (Dependent position) - Early surgery is required to reattach the retina o Scleral Buckling To produce indentation o Photocoagulation o Cryopexy o Vitrectomy NURSING MANAGEMENT - Keep the client quiet in bed with eyes covered to prevent further detachment RETINAL DETACHMENT PreOp Care o Mydriatics (OU) as ordered PostOp Care o Position dependents on the extent and location of retinal detachment. The area (***) Ambulation and activity will be prescribed by the surgeon Pressure patch over the eye Rest the eyes and head immediately post op Avoid straining, nausea and vomiting, coughing, Valsalva maneuver Change dressing daily Note: Hemorrhage is common complication of the surgery

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Sedentary activity resumed after 3 weeks Activity / Occupation that requires heavy physical exertion may not be prescribed

Macular Degeneration (Age-Related)

Clear vision is the most affected rather than peripheral vision Two Types 1) Dry Outer layer of the retina break down (65 years old) [70%] 2) Wet Proliferation of abnormal blood vessels growing under the retina [30%]

MEDICAL MANAGEMENT - No known cure for dry type if AMD, it can only slow the progression of the disease - Administration of high doses of antioxidants like Vitamin C, E, A and beta carotene, zinc NURSING MANAGEMENT - Encourage client to use Amsler Grid - The client should be encouraged to look at the grids, one eye at a time several times each week - Any changes in the grid must be informed to the physician immediately

Glaucoma
Group of ocular conditions characterized by optic nerve damage There is no cure but can be controlled Acute and chronic Primary and Secondary (Alone / with conditions) Open (Wide) No obstructions; Closed (Narrowed) Secondary to IOP, optic nerve damage, and structural changes in the canal of Schlemm / Trabecular meshwork CLASSIFICATION of Glaucoma - Open Angle - Angle Closed

Acute Glaucoma
Eye disease characterized by suddenly impaired vision due to intraocular tension caused by an imbalance in production and excretion of aqueous humor It is a result of an abnormal displacement of the iris (***)

Chronic Glaucoma
Eye disease characterized by impaired vision due to intraocular tension caused by an actual obstruction in the excretion of aqueous humor It develops slowly, at first no symptoms Vision is lost first before diagnosed with Glaucoma

GLAUCOMA IS IRREVERSIBLE - This is due to the compression and damage of the retina and optic nerve - The blockage to the circulation of the aqueous humor may be secondary to: Infection (Uveitis) (Acute glaucoma) Injury (Acute Glaucoma) - Hereditary NURSING RESPONSIBILTY - Assess Tunnel Vision General discomfort

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Loss of peripheral vision can progress until the person is legally blind Usually begins with one eye, if left untreated, both eyes become affected Persistent dull eye pain in the morning Frequent change of eye glasses, difficulty adjusting to darkness Failure to detect changes in color accurately

MEDICAL MANAGEMENT - Objectives: To reduce intraocular pressure and keep it at a safe level Pharmacologic - Miotics - Acetazolamide (Diamox) - Avoid fatigue / stress - Avoid drinking large quantities of fluids Surgery - Sclerotomy, Vitrectomy, Iridencleisis, Trabeculectomy - In some cases, the production of aqueous fluid may be decreased by destroying part of the ciliary body NURSING RESPONSIBILITY (Ulit) - Steamy appearance of the cornea, and further blurring of vision - Tearing, misty vision, blurred appearance of the iris (Which becomes fixed and dilated) Headache, pain behind the eye ball, nausea and vomiting - Rainbow / Halos resembles streetlights seen through a steamy windshield may be seen around lights Nursing Responsibility (Acute Glaucoma) - Assess P (***) - Maintain in bed rest in a quiet darkened room, elevate head 30 - Monitor vital signs - Administer miotic eyedrops as ordered (q 2-4 hours) - Administer Acetazolamide, glycerol orally as ordered - Provide emotional support - Assess clients ability to see - Assist according to degree of visual impairment - Prepare for eye examination as ordered Tonometry ( IOP is 25 mmHg and above) - Avoid Atropine preparation and other Mydriatics - Administer anti-emetics for nausea - Provide Diet as Tolerated - Prepare for surgery if ordered

Cataract
Etiology Cloudy / opacity of the lens that lead to blurring of vision and eventual loss of sight The opacity of the lens is caused by chemical changes in the protein of the lens because of slow degenerative changes of age, injury, poisons / intraocular infections Photochemicals as protein changes in the lens (Na, K, Ca) Cataracts occur so often in the aged at 80 years of age, about 85% of all people have some clouding of the lens

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CLASSIFICATION of CATARACT - Senile Aging - Traumatic Accidents / Post-Surgery - Congenital - Secondary RISK Factors to Consider Systemic Disease o Diabetes o Disorders related to liquid metals o Renal disorders Toxic Factors o Cigarette smoking o Long term use of corticosteroids Physical Factors o Trauma o Ultraviolet Radiation o Sunlight and Ionizing Radiation MEDICAL MANAGEMENT Surgery - Intracapsular Cataract Extraction (ICCE) - Extracapsular Cataract Extraction (ECCE) - Cryoextraction - Iridectomy - Phacoemulsification NURSING MANAGEMENT - Provide PreOp Care 1. Withhold anticoagulant 5 7 days before surgery 2. Administer dilating drugs 10 minutes before surgery 3. Administer antibiotics, corticosteroids, anti-inflammatory drugs, drops may be administered prophylactically - Administer mild analgesics PostOp - Administration of antibiotics, corticosteroids, anti-inflammatory drops may be administered PostOp - Provide written instructions for discharge 1. Wear glasses / metal eye shields at all times 2. Wash before and after touching the eyes 3. Wipe the closed eyes with a single gesture from the inner to outer canthus 4. Avoid lying on the affected side 5. Keep activities light 6. Avoid bending / lifting, pushing heavier than 15 lbs REMEMBER: - Cataract Glasses (Aphakic Glasses) magnify, so that everything appears about closer than it is - Use of contact lenses improves visual correction and better comments appearance

Nutritional Status o Obesity o Poor nutrition o Reduced level of antioxidant Aging Ocular Conditions o Retinitis o Myopia o Infection o Retinal detachment and retinal surgery

Intraocular Lens Implant

Alteration to cataract glasses and contact lenses

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Made from polymethylmethacrylate, is implanted at the time of cataract extraction into the capsular sac Main advantage of the implanted lens is better binocular vision

Tumors of the Eye And Related Disorders

Benign Malignancy Displaced Eyeball, interference with vision Retinoblastoma (Children), Malignant Melanomas (Adult) Most common primary intraocular tumors Collaborative Management Enucleation Brachytherapy

Eye Surgery
Enucleation Removal of the eyeball Evisceration Removal of the entire eyeball contents and cornea, except the sclera Exenteration Removal of the eyelid, eye ball and orbital contents

GENERAL Care for EYE SURGERY

PreOp Care If both eyes are to be covered after surgery, client needs to be oriented to the stuff and physical environment prior to surgery Call light should be placed within the clients reach Preparation of eye on the day of surgery may include instillation of combination of drugs into the eye at various intervals to dilate the pupil PostOp Care General Goals To prevent IOP Stress on suture line Hemorrhage into the anterior chamber (Hyphema) Infection Interventions Immediately after operation, client must keep the head still and try to avoid coughing, vomiting, sneezing *** suddenly Client should lie with the unoperated side down Client may lie on the back on unoperated side but (***) A burning sensation of about 1 hours after surgery usually signifies the wearing off of anesthesia Client is instructed to avoid lifting the head / hip, straining at stool / squeezing the eyes Client should avoid bending forward Side rails are placed on the bed immediately postop and are kept on whild both eyes are covered as long as necessary for protection The bed side (***) Care is taken that the dressing is not loosened or removed Supervision and assistance should be given by the nurse Client is advised not to bend, stoop/light objects several weeks postop Clients who are to have visual limitations must be helped to learn to feed themselves After surgery, clients should keep appointments!

PENETRATING EYE INJURIES

Surgery (Repair / Enucleation)

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Bed rest with bathroom privileges for 1 2 days Observe for sympathetic opthalmia Intraocular (***)

Rehabilitation of a Blind Person

Refer blind person to available facilities Orient to the environment, describe the surroundings and location of things Promote independence ADLs May have a guide dog or use of a cane for direction When approaching, talk before touching When assisting in ambulation, have the client hold your forearm so that you are a step ahead of him Talk the client frequently, so he / she doesnt feel neglected Be relaxed and unhurried when performing nursing procedures. Explain to the client what is being done and what is to be done next Do not change location of objects in the room or in they environment without describing the change Promote safety in the environment Do not rush up and offer help to blind person unless it is clear that the person wants help If significant others ask advise, give with sense of touch

Disorders of The Ears and Balance

Wax (Impacted Cerumen) Otitis Externa Boils Tumors Serous Acute / Chronic Otitis Media

Wax (Impacted Cerumen) Ear wax remains in the ear canal which obstructs the canal and would cause deafness Olive oil / liquid paraffin ear drops or Hydrogen Peroxide will soften impacted wax which is then removed by irrigation Water in the syringe for irrigation should be at body temperature Direct jet of water to the wall of the ear canal to wash out the wax, Ear must be dried gently after irrigating and should be examined by a doctor For Boils Insect in the ear can be treated by application of Lidocaine, mineral oil Not H2O to kill the insect Do not use warm water, vegetable seed if stuck in the ear it can cause swelling and difficult to remove Otitis Externa Infection of the outer ear which is lined by skin Condition is usually bilaterally and symptoms start with itching Client scratches the ear which becomes infected, painful and sometimes blocked by a thin mucopurulent discharge Any precipitating cause is removed and a swab is taken for C&S Ear canal is cleaned gently, thoroughly and frequently using a wisp of cotton on the tip of a suitable probe Drops are instilled directly or used to impregnate a small *** of a ribbon gauze which is left in the ear for 1 2 days Drops may be disinfectants or combinations of topical antibiotics and steroids

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Serous (Secretory) Otitis Media Seen most in children with immature mucosa Hearing loss / deafness is the most common complication Whisper test / Audiogram will confirm the presence of hearing loss Most children outgrow the condition In severe cases, a hole is made in the tympanic membrane (Myringotomy) and a hole is prevented from healing by inserting a small plastic tube (Grommet, dottle / stopple) Acute Otitis Media Client should be confined to bed with analgesics A covered hot water bottle is applied to the ear, it is helpful and warm olive oil drops will help soothe the inflamed membrane If client is seen before perforation occurs, penicillin is given C&S Chronic Otitis Media Persistence of middle ear infection Permanent damage is done to the tympanic membrane, the ossicles may be damaged (very deaf)

Surgical repair of perforation may be done as long as ear has been dry for several months Myringoplasty o A graft (Taken from fascia of the temporalis muscle) is laid on the inner / outer surface of the tympanic membrane Tympanoplasty o Repositioning or replacing a damaged ossicle with a piece of bone Cholesteatoma Cyst lined by squamous epithelium and filled with layers of epithelium scales Forms from an in-pouching of the increased segment of the tympanic membrane and infection of the middle ear canal Extent is (***) Client complains of deafness and offensive scanty discharge Examination of the ear will reveal preventive perforation with white epithelium scales protruding Treatment is surgery and some form of radical mastoidectomy Otosclerosis Abnormal, spongy, highly vascular bone grows across the margins of the oval window ti the foot plate of the stapes which can no longer vibrate Begins in early adulthood and deafness progressively worsens Causes conductive hearing loss Rinnes Test indicates bone conduction is better than air conduction Stapedectomy Staphyloplasty Treatment is achieved better in hearing aid and surgery (Stapedectomy) o Stapedectomy Mobile part of the stapes is removed and a hole is made in the fixed position

Diseases of the Inner Ear

Any disease affecting the inner ear causes damage to the delicate nerve endings responds

Menieres Disease (Endolymphatic Hydrops)

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Characterized by accumulation of Endolymph in the inner ear Chronic with remission and exacerbation Causes: - Unknown - Viral - Emotional Stress Assessment: Vertigo Unilateral / bilateral gradual hearing loss Tinnitus Nausea / Vomiting Webers Test shows that tone later*** MEDICAL-SURGICAL NURSING MANAGEMENT - Bed rest during exacerbation - Decrease Na diet (To prevent retention) - Avoid drinking large amounts of liquid - Avoid reading during vertigo - Avoid alcohol, caffeine, or tobacco - Stress therapy - Medications: Tranquilizer, Vagal blockers (atropine), antihistamine, vasodilators, diuretics - Ossiculoplasty Involves ossicular reconstruction - Labyrinthectomy Removal of the membranous labyrinth through the oval window / mastoid bone PreOp Care - Assess URTI - Shampoo the hair - Inform general anesthesia PostOp Care - Lie on unoperated side - Blow the nose gently one side at a time, sneezing/coughing with mouth open for 1 week after surgery - Avoid physical activity for 1 week - Change cotton balls in the ear daily - Keep ear dry for 6 weeks postop Do not shampoo hair for 1 week Protect (***) - Avoid airplane flight for 1 week - Report any discharge - Avoid reading, watching TV/fast moving objects for 1 week post op - Seek for supervision when ambulating for the first time, secure safety

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