Management of Sensory

Disorders
Dean Jane L. Olid
 SKIN
• Largest organ of the
body
• Functions:
– Protection
– Sensation
– Fluid balance
– Temperature
regulation
– Vitamin D production
– Immune response
 Primary Skin Lesions
Macule Papule
• Flat, circumscribed area An elevated, firm. Circumscribed area
that is a change in color less than 1 cm in diameter e.g.Wart
of the skin; less than 1 cm (verruca), elevated moles, lichen
planus, cherry angioma, skin tag
in diameter
e.g.
 Primary Skin Lesions
PLAQUE
• Elevated, firm, and
rough lesion with flat
top surface greater
than 1 cm in diameter
e.g.Psoriasis, seborrheic
and actinic keratoses,
eczema
 Primary Skin Lesions
WHEAL
• Elevated irregular-
shaped area of
cutaneous edema;
solid, transient,
variable diameter
• Ex. Insect bite, urticaria,
allergic reaction
 Primary Skin Lesions
NODULE
• Elevated, firm,
circumscribed lesion;
deeper in dermis than a
papule; 1 to 2 cm in
diameter
• Ex. Dermatolfibroma,
erythema nodosum,
lipomas, melanoma,
hemangioma,
neurofibroma
 Primary Skin Lesions
TUMOR
• Elevated and solid
lesion; may or may not
be clearly demarcated;
deeper in dermis;
greater than 2 cm in
diameter
• Ex. Neoplasma, lipoma,
hemangioma
 Primary Skin Lesions
VESICLE
• Elevated,
circumscribed,
superficial, not into
dermis; filled with
serous fluid; less than
1 cm in diameter
• Ex. Varicella
(chickenpox, herpes
zoster, impetigo,
acute eczema
BULLA
• Vesicle greater than 1
cm in diameter
• Ex. Blister, lupus,
impetigo, drug reaction
PUSTULE
• Elevated, superficial
lesion; similar to a
vesicle but filled with
purulent fluid
• Ex. Impetigo, acne,
folliculitis, herpes
simplex
CYST
• Elevated,
circumscribed,
encapsulated lesion; in
dermis or
subcutaneous layer;
filled with liquid or
semisolid material
• Ex. Sebaceous cyst,
cystic acne
SKIN CONFIGURATIONS
 Secondary Skin Lesions
SCALE
• Heaped-up keratinized
cells; flaky skin;
irregular; thick or
thin; dry or oily;
variation in size
• Ex. Seborrheic
dermatitis following
scarlet fever
 Secondary Skin Lesions
LICHENIFICATION
• Rough, thickened
epidermis
secondary to
persistent rubbing,
itching or skin
irritation; often
involves flexor
surface of extremity
 Secondary Skin Lesions
SCAR
• Thin to thick fibrous
tissue that replaces
normal skin
following injury or
laceration to the
dermis
 Secondary Skin Lesions
KELOID
• Irregular-shaped
elevated,
progressively
enlarging scar,
grows beyond the
boundaries of the
wound; caused by
excessive collagen
formation during
healing
EXCORIATION
• Loss of the epidermis
linear hollowed-out
crusted area
• Ex. Abrasion or scratch
scabies
FISSURE
• Linear crack or break
from the epidermis to
the dermis, may be
moist or dry
• Ex. Athlete’s foot,
cracks at the corner of
the mouth, eczema
EROSION
• Loss of part of the
epidermis; depressed,
moist, glistening;
follows rupture of a
vesicle or bulla
• Ex. Varicella, variola
after rupture,
candidiasis, herpes
simplex
ULCER
• Loss of epidermis and
dermis, concave;
varies in size
• Ex. Decubiti, stasis
ulcers, syphillis
chancre
ATROPHY
• Thinning of the skin
surface and loss of
skin markings; skin
appears translucent
and paperlike
• Ex. Aged skin, striae,
discoid lupus
erythematosus
 Vascular Skin Lesions
• TELANGIECTASIA
• Fine, irregular red
lines produced by
capillary dilation
• Ex. Vascular spider,
lupus erythematosus
 Vascular Skin Lesions
CHERRY ANGIOMA
• Small, slightly raised,
bright red areas that
appear on the face,
neck and trunk of the
body. These increase
in size and number
with advanced age.
 Vascular Skin Lesions
• Petechiae Spider Angioma
• Ecchymoses
 Anatomic Distribution of Common
Skin Disorders—Contact Dermatitis
 Anatomic Distribution of Common Skin
Disorders—Seborrheic Dermatitis and
Acne
Anatomic Distribution of Common Skin
Disorders—Scabies and Herpes Zoster
 Skin Appearance
CYANOSIS JAUNDICE
 Normal Aging Changes
• Thinning of skin
• Uneven pigmentation
• Wrinkling, skin folds, and
decreased elasticity
• Dry skin
• Diminished hair
• Increased fragility and
increased potential for
injury
• Reduced healing ability
•
Assessment
Prepare the patient: explain the
of the Skin
purpose and provide privacy and
coverings
MALE PATTERN BALDNESS
• Ask assessment questions
• Inspect the patient’s entire body
including mucosa, scalp, hair, and
nails
• Wear gloves
• Assess any lesions; palpate and
measure them
• Note hair distribution
• Photographs may be used to document
nature and extent of skin conditions
and to document progress resulting
from treatment; they may also be used
to track moles
 Diagnostic Procedures
• Skin biopsy • Skin scrapings

• Immunofluorescence • Tzanck smear

• Patch testing • Wood’s light

examination
 Management of Patients with Burn
Injury
Causes: • Goals Related to Burns
1. dry heat - fire, • Prevention
2. moist heat - steam or hot
liquids, • Institution of life-saving measures for
3. Radiation the severely burned person
4. friction • Prevention of disability and
5. heated objects, disfigurement through early
6. the sun, specialized and individualized care
7. Electricity • Rehabilitation through reconstructive
8. or  chemicals. surgery and rehabilitation programs
• Thermal burns are the most
common type.
• Most burns occur in the home.
• Young children and the elderly are at
high risk for burn injuries.
 Classification of Burns
• Superficial partial- • First-degree burns
thickness (1ST DEGREE affect only the outer
BURN)
layer of the skin
epidermis.
Manifestation:
• minor pain,
• redness (erythema)
• Mild swelling.
• cause:
e.g.sunburn
 First-degree burns
Management:
• Remove jewelry or tight
clothing from the burned area
before it begins to swell.
• Flush the burn with cool
running water or apply cold-
water compresses (a wet towel
or handkerchief) until the pain
lessens. Do not use ice or ice
water, which can cause more
damage to the tissues.
• Cover the burn with a clean
(sterile, if possible), dry,
nonfluffy bandage such as a
gauze pad. Do not put tape on
the burn.
 Classification of Burns
• 2nd degree burn • affect both the outer
and underlying layer of
skin. They cause pain,
redness, swelling, and
blistering.
Causes:
deep sunburn
exposure to flames
contact with hot liquids
burning gasoline or
kerosene
contact with chemicals.
 2 degree burn
nd

Manifestations:
• skin is bright red and
blotchy
• blisters. It usually
looks wet because of
the loss of fluid
through the damaged
skin.
• very painful.
 3rd Degree Burn
CAUSES: • Third-degree burns can
• contact with: also damage fat,
• corrosive chemicals, muscle, and bone
• flames,
• electricity, or extremely
hot objects;
• immersion of the body in
extremely hot water,
• clothing that catches
fire.
• Skin with a third-degree burn
may appear white or black
and leathery on the surface.
• Because the nerve endings in
the skin are destroyed, the
burned area may not be painful,
but the area around the burn
may be extremely painful.
• Pain causes the breathing rate
and pulse to increase.
• Some areas of the burn may
appear bright red, or may
blister.
• .
 3rd Degree Burn
• Electrical burns damage the deep tissues.
Often only the area of the skin where the
electricity entered the body looks black and
charred. Electrical shocks can make a person
stop breathing and interrupt the rhythm of the
heart.
• Shock occurs when loss of fluids causes the
blood pressure to become so low that not
enough blood reaches the brain and other
major organs.
 3 Degree Burn
rd

The symptoms of shock :

• fainting, general weakness, nausea and
vomiting, rapid pulse and breathing, a blue tinge
to the lips and finger nails, and pale, cold, moist
skin.
• If the victim has been burned in a fire and has
been exposed to large amounts of smoke, he or
she may also have chest pain, red and burning
eyes, and a cough.
• All third-degree burns require emergency
medical treatment.
 Estimation of Total Body Surface
Area (TBSA) Burned
• Rule of Nines
 Pathophysiology of Burns
• Burns are caused by a transfer of energy
from a heat source to the body.
• Thermal (includes electrical)
• Radiation
• Chemical
 Physiologic Changes
• Burns less than 25% TBSA produce a primarily
local response.
• Burns more than 25% may produce a local and
systemic response and are considered major
burns.
• Systemic response includes release of cytokines
and other mediators into the systemic
circulation.
• Fluid shifts and shock result in tissue
hypoperfusion and organ hypofunction.
 Effects of Major Burn Injury
• Fluid and electrolyte shifts
• Cardiovascular effects
• Pulmonary injury
– Upper airway
– Inhalation below the glottis
– Carbon monoxide poisoning
– Restrictive defects
• Renal and GI alterations
• Immunologic alterations
• Effect upon thermoregulation
Nomenclat Tradition Depth Clinical findings
ure al
nomencl
ature

Superficial First- Epidermis involvement Erythema, minor pain, lack of

thickness degree blisters

Partial Second- Superficial (papillary) Blisters, clear fluid, and pain

thickness degree dermis
—
superficial

Partial Second- Deep (reticular) dermis Whiter appearance, with

thickness degree decreased pain. Difficult to
— deep distinguish from full thickness

Full Third- or Dermis and underlying Hard, leather-like eschar, purple

thickness fourth- tissue and possibly fascia, fluid, no sensation (insensate
degree bone, or muscle
 FOR MAJOR BURNS: Initial Care
• Make sure that the person is no longer in contact with smoldering materials.
However, DO NOT remove burnt clothing that is stuck to the skin.
• If breathing has stopped, or if the person's airway is blocked, open the airway. If
necessary, begin CPR.
• Cover the burn area with a cool, moist sterile bandage (if available) or clean cloth.
A sheet will do if the burned area is large. DO NOT apply any ointments. Avoid
breaking burn blisters.
• If fingers or toes have been burned, separate them with dry, sterile, non-adhesive
dressings.
• Elevate the body part that is burned above the level of the heart. Protect the burnt
area from pressure and friction.
• Take steps to prevent shock. Lay the person flat, elevate the feet about 12 inches,
and cover him or her with a coat or blanket. However, DO NOT place the person in
this shock position if a head, neck, back, or leg injury is suspected or if it makes the
person uncomfortable.
 Phases of Burn Injury
• Emergent or resuscitative phase
– Onset of injury to completion of fluid
resuscitation
• Acute or intermediate phase
– From beginning of diuresis to wound closure
• Rehabilitation phase
– From wound closure to return to optimal
physical and psychosocial adjustment
Emergent or Resuscitative Phase:
On-the-Scene Care
• Prevent injury to rescuer.
• Stop injury: extinguish flames, cool the burn, irrigate
chemical burns.
• ABCs: Establish airway, breathing, and circulation.
• Start oxygen and large-bore IVs.
• Remove restrictive objects and cover the wound.
• Do assessment, surveying all body systems, and obtain
a history of the incident and pertinent patient history.
• Note: Treat patients with falls and electrical injuries as for
potential cervical spine injury.
 Emergent or Resuscitative Phase
• Patient is transported to emergency department.
• Fluid resuscitation is begun.
• Foley catheter is inserted.
• Patients with burns exceeding 20-25% should have an
NG tube inserted and placed to suction.
• Patient is stabilized and condition is continually
monitored.
• Patients with electrical burns should have an ECG.
• Address pain; only IV medication should be
administered.
• Psychosocial consideration and emotional support
should be given to patient and family.
 Acute or Intermediate Phase
• 48-72 hours after injury
• Continue assessment and maintain
respiratory and circulatory support.
• Prevention of infection, wound care, pain
management, and nutritional support are
priorities in this stage.
 Rehabilitation Phase
• Rehabilitation is begun as early as possible in
the emergent phase and extends for a long
period after the injury.
• Focus is upon wound healing, psychosocial
support, self-image, lifestyle, and restoring
maximal functional abilities so the patient can
have the best-quality life, both personally and
socially.
• The patient may need reconstructive surgery to
improve function and appearance.
• Vocational counseling and support groups may
assist the patient.
 Management of Shock: Fluid
Resuscitation
• Maintain BP above 100 mm Hg systolic and
urine output of 30-50 mL/hr. Maintain serum
sodium at near-normal levels.
• Consensus formula
• Evans formula
• Brooke Army formula
• Parkland Baxter formula
• Hypertonic saline formula
• Note: Adjust formulas to reflect initiation of fluids
at the time of injury.
 Fluid and Electrotype Shifts:
Emergent Phase
• Generalized dehydration
• Reduced blood volume and hemoconcentration
• Decreased urine output
• Trauma causes release of potassium into
extracellaur fluid: hyperkalemia.
• Sodium traps in edema fluid and shifts into cells
as potassium is released: hyponatremia.
• Metabolic acidosis
 Fluid and Electrolyte Shifts: Acute
Phase
• Fluid re-enters the vascular space from the
interstitial space.
• Hemodilution
• Increased urinary output
• Sodium is lost with diuresis and due to dilution
as fluid enters vascular space: hyponatremia.
• Potassium shifts from extracellular fluid into
cells: potential hypokalemia.
• Metabolic acidosis
 Burn Wound Care
• Wound cleaning
– Hydrotherapy
• Use of topical agents
Wound débridement
– Natural débridement
– Mechanical débridement
– Surgical débridement
• Wound dressing, dressing changes, and skin
grafting
• Use of Biobrane
Dressing
Comparison of Integra Template
and Split-Thickness Autograft
 Pain Management
• Analgesics • Decrease/avoid sleep
– IV use during deprivation
emergent and acute • Nonpharmacologic
phases
measures
– Morphine
– Fentanyl
– Other
• Decrease level of
anxiety
 Nutritional Support
• Goal of nutritional • Enteral route is
support is to promote preferred. Jejunal
a state of nitrogen feedings are
balance and match frequently used to
nutrient utilization. maintain nutritional
• Nutritional support is status with lower risk
based on patient’s of aspiration in a
preburn status and % patient with poor
of TBSA burned. appetite, weakness,
or other problems.
 Other Major Care Issues
• Pulmonary care
• Psychological support of patient and family
• Patient and family education
• Restoration of function
 Nursing Process: Care of the Patient in the
Emergent Phase of Burn Care:
Diagnosis Potential
• Impaired gas exchange Complications/Collaborat
• Ineffective airway ive Problems
clearance • Acute respiratory failure
• Fluid volume deficit • Distributive shock
• Hypothermia • Acute renal failure
• Acute pain • Compartment syndrome
• Anxiety • Paralytic ileus
• Curling’s ulcer
 Nursing Process: Care of the Patient in the Acute
Phase of Burn Care: Diagnosis

• Excessive fluid volume Potential

• Risk for infection Complications/Collaborati
• ve Problems
Imbalanced nutrition
• Heart failure and pulmonary
• Acute pain
edema
• Impaired physical mobility
• Sepsis
• Ineffective coping
• Acute respiratory failure
• Interrupted family processes
• Visceral damage (electrical
• Deficient knowledge burns)
 Home Care Instructions
• Mental health
• Skin and wound care
• Exercise and activity
• Nutrition
• Pain management
• Thermoregulation and clothing
• Sexual issues
Assessment and Management of Patients with
Eye and Vision Disorders
Extraocular Muscles
Visual Pathways
Cross-Section of the Eye
Internal Structures of the Eye
 Assessment and Evaluation of
Vision
• Ocular history
• Visual acuity
– Snellen chart
 Record each eye
 20/20 means the patient can read the “20” line at
a distance of 20 feet
• Finger count or hand motion
 Examination of the External
Structures
• Note any evidence of irritation, inflammatory
process, discharge, etc.
• Assess eyelids and sclera
• Assess pupils and pupillary response in a
darkened room
• Note gaze and position of eyes
• Assess extraocular movements
• Ptosis: drooping eyelid
• Nystagmus: oscillating movement of eyeball
 Diagnostic Evaluation
• Ophthalmoscopy
– Direct and indirect
– Examines the cornea, lens, and retina
• Slit-lamp examination
• Color vision testing
• Amsler grid
• Ultrasonography
• Fluorescein and indocyanine green
angiography
• Tonometry
– Measures intraocular pressure
• Gonioscopy
– Visualizes the angle of the anterior chamber
• Perimetry testing
– Evaluates field of vision
– Scotomas: blind areas in the visual field
 Impaired Vision
• Refractive errors
– Can be corrected by lenses that focus light
rays on the retina
• Emmetropia: normal vision
• Myopia: nearsighted
• Hyperopia: farsighted
• Astigmatism: distortion due to irregularity
of the cornea
Eyeball Shape Determines Visual
Acuity in Refractive Errors
 Glaucoma
• A group of ocular conditions
in which damage to the
optic nerve is related to
increased intraocular
pressure (IOP) caused by
congestion of the aqueous
humor
• Open-angle glaucoma
– Chronic open-angle glaucoma
– Normal-tension glaucoma
– Ocular hypertension
• Angle-closure (pupillary block)
glaucoma
– Acute angle-closure
– Subacute angle-closure
– Chronic angle-closure
• Congenital glaucomas and
glaucoma secondary to other
conditions
 Pathophysiology of Glaucoma
• Normal outflow of aqueous
humor
• In glaucoma, aqueous
production and drainage are
not in balance
• When aqueous outflow is
blocked, pressure builds up
in the eye
• Increased IOP causes
irreversible mechanical
and/or ischemic damage
 Clinical Manifestations
• Called the “silent thief,” glaucoma renders the
patient unaware of the condition until there is
significant vision loss, including peripheral
vision loss, blurring, halos, difficulty focusing,
and difficulty adjusting eyes to low lighting

• Patient may also experience aching or

discomfort around the eyes or a headache
 Diagnostic Findings
• Tonometry to
assess IOP

• Gonioscopy to
assess the angle of
the anterior
chamber

• Perimetry to assess
vision loss
• Goal is to prevent further • Maintain IOP within a
optic nerve damage range unlikely to cause
damage
• Pharmacologic therapy:
• Surgery
– Laser trabeculoplasty
– Laser iridotomy
– Filtering procedures
– Trabeculectomy
– Drainage implants or
shunts
 Nursing Management
• Focus on maintaining the
therapeutic regimen for
lifelong control of a chronic
condition
• Emphasize the need for
adherence to therapy and
continued care to prevent
further vision loss
• Provide education regarding
use and effects of
medications
• Medications used for
glaucoma may cause vision
alterations and other side
effects; the action and effects
of medications need to be
explained to promote
compliance
• Provide support and
interventions to aid the
patient in adjusting to vision
loss/potential vision loss
 Cataracts
• An opacity or
cloudiness of the
lens

• Increased incidence
with aging
 Clinical Manifestations
• Painless, blurry vision
• Sensitivity to glare
• Reduced visual acuity
• Other effects include myopic shift, astigmatism,
diplopia (double vision), and color shifts including
brunescent c. (color value shift to yellow-brown)
• Diagnostic findings include decreased visual acuity
and opacity of the lens by ophthalmoscope, slit-lamp,
or inspection
 Surgical Management
• If reduced vision does not interfere with
normal activities, surgery is not needed
• Surgery is performed on an outpatient
basis with local anesthesia
• Surgery usually takes less than 1 hour
and patients are discharged soon
afterward
• Complications are rare
 Types of Cataract Surgery
• Intracapsular cataract extraction (ICCE): removes entire lens; rarely
done today
• Extracapsular cataract extraction (ECCE): maintains the posterior
capsule of the lens, reducing potential postoperative complications
• Phacoemulsification: an ECCE that uses an ultrasonic device to
suction the lens out through a tube; incision is smaller than with
standard ECCE
• Lens replacement: after removal of the lens by ICCE or ECCE, the
surgeon inserts an intraocular lens implant (IOL), which eliminates
the need for aphakic lenses; however, the patient may still require
glasses
 Nursing Management
• Preoperative care
• Usual preoperative care for
ambulatory surgery
• Dilating eye drops or other
medications as ordered
• Postoperative careProvide
written and verbal instructions
• Instruct patient to call
physician immediately if: vision
changes; continuous flashing
lights appear; redness,
swelling, or pain increase; type
and amount of drainage
increases; or significant pain is
not relieved by acetaminophen
 Corneal Disorders
• Treatment of diseased
corneal tissue
– Phototherapeutic
keratectomy
– Keratoplasty
– Use of donor tissue for
transplant: see Chart 58-9
– Need for follow-up and
support
– Potential graft failure; teach
signs and symptoms
• Refractive surgery
– Elective procedures to
recontour corneal tissue
and correct refractive
errors
– Patients need counseling
regarding potential
benefits, risks, and
complications
LASIK
 Retinal Disorders
• Retinal detachment • Retinal vascular
disorders

– Central retina vein

occlusion

– Branch retinal vein

occlusion

– Central retinal vein

occlusion

– Macular degeneration
 Retinal Detachment
• Separation of the sensory retina
and the retinal pigment epithelium
(RPE)
• Manifestations: sensation of a
shade or curtain coming across
the vision of one eye, bright
flashing lights, and sudden onset
of floaters
• Diagnostic findings: assess visual
acuity; assess retina by indirect
ophthalmoscope, slit-lamp, stereo
fundus photography, and
fluroescein angiography;
tomography and ultrasound may
also be used
 Surgical Treatment
• Scleral buckle
• Pars plana vitrectomy
– Removal of the vitreous, locating
the incisions at the pars plana
– Frequently used in combination
with other procedures
• Pneumatic retinopexy
– Injected gas bubble, liquid, or oil
is used to flatten the sensory
retina against the RPE
– Postoperative positioning is
critical
 Nursing Management
• Patient teaching
– Eye surgery is most often done as an outpatient
procedure, so patient education is vital
• Teach the signs and symptoms of complications,
especially increased IOP and infection

• Promote comfort
• Patient may need to lie in a special position
with pneumatic retinopexy
 Retinal Vein or Artery Occlusion
• Loss of vision can occur
from retinal vein or artery
occlusion
• Occlusions may result from
atherosclerosis, cardiac
valvular disease, venous
stasis, hypertension, and
increased blood viscosity;
associated risk factors are
diabetes mellitus,
glaucoma, and aging
• Patients may report
decreased visual acuity or
sudden loss of vision
 Macular Degeneration
• Age-related macular • Types
degeneration (AMD) – Dry or nonexudative type is
• The most common cause of most common, 85%-90%

vision loss in persons older  Slow breakdown of the

layers of the retina with
than age 60 the appearance of drusen
– Wet type
 May have abrupt onset
 Proliferation of abnormal
blood vessels growing
under the retinachoroidal
revascularization (CNV
Vision Loss Associated With
Macular Degeneration
Retina Showing Drusen and AMD
 Nursing Management
• Patient teaching • Recommendations
include improving
• Supportive care lighting, getting
magnification
• Safety promotion devices, and
referring patient to
vision center to
improve/promote
function
 Trauma

• Emergency treatment
– Flush chemical injuries
– Do not remove foreign
objects
– Protect using metal
shield or paper cup
• Potential exists for
sympathetic ophthalmia,
causing blindness in the
uninjured eye with some
injuries
 Infectious and Inflammatory
Disorders
• Dry eye syndrome
• Conjunctivitis (“pink eye”)
– Classified by cause: bacterial, viral, fungal,
parasitic, allergic, and toxic
– Viral conjunctivitis is contagious: see Chart 58-11

• Uveitis
• Orbital cellulitis
Hyperemia in Viral Conjunctivitis
Ocular Consequences of Systemic
Disease
• Diabetic retinopathy

– Diabetes is a leading cause of blindness in people

age 20 to 74

• Ophthalmic complications associated with

AIDS

• Eye changes associated with hypertension

•
Ophthalmic
Ability of the eye to absorb
Medications
• Topical anesthetics
medication is limited

• Barriers to absorption include the • Mydriatics (dilate) and

size of the conjunctival sac; cycloplegics (paralyze):
corneal membrane barriers;
blood–ocular barriers; and tearing,
• Contraindicated with narrow
blinking, and drainage angles or shallow anterior
chambers and for inpatients
• Intraocular injection or systemic
on monoamine oxidase
medication may be needed to treat
some eye structures or to provide
inhibitors or tricyclic
high concentrations of medication antidepressants
• Topical medications (drops and – May cause CNS
ointments) are most frequently symptoms and increased
used because they are least BP especially in children
invasive, have fewest side effects, and the elderly
and permit self-administration
• Anti-infective medications • Anti-inflammatory drugs;
– Antibiotic, antifungal, and
corticosteroid suspensions
antiviral products – Side effects of long-term
• Medications used for glaucoma topical steroids include
glaucoma, cataracts, and
– Increase aqueous outflow or
increased risk of infection;
decrease aqueous
to avoid these effects, oral
production
NSAID therapy may be
– May constrict the pupil and used as an alternate to
affect ability to focus the lens steroid use
of the eye; affects vision
– May also may produce
systemic effects
 Low Vision and Blindness
• Low vision
– Visional impairment that
requires devices and
strategies in addition to
corrective lenses
– Best corrected visual acuity
(BCVA) of 20/70 to 20/200
• Blindness
– BCVA of 20/400 to no light
perception
– Legal blindness is BCVA
that does not exceed
20/200 in better eye, or
widest field of vision is 20
degrees or less
• Impaired vision often is
accompanied by
functional impairment
 Assessment of Low Vision

• History

• Examination of distance and near visual acuity, visual field,

contrast sensitivity, glare, color perception, and refraction

• Special charts may be used for low vision

• Nursing assessment must include assessment of functional

ability and coping and adaptation in emotional, physical, and
social areas
 Management
• Support coping strategies, grief processes, and
acceptance of visual loss
• Strategies for adaptation to the environment
– Placement of items in room
– “Clock method” for trays
• Communication strategies: see Chart 58-3
• Collaboration with low vision specialist, occupational
therapy, or other resources
• Braille or other methods for reading/communication
• Use of service animals
 Guidelines for Instilling Eye
Medications
• Shake suspensions or “milky” solutions to
obtain the desired medication level.
• Wash hands thoroughly before and after
the procedure.
• Ensure adequate lighting.
• Read the label of the eye medication to
make sure it is the correct medication.
• Assume a comfortable position.
• Do not touch the tip of the medication
container to any part of eye or face.
• Hold the lower lid down; do not press on
the eye-ball. Apply gentle pressure to the
cheek bone to anchor the finger holding
the lid
• Instill eye drops before applying
ointments.
• Apply a ½-inch ribbon of ointment to the
lower conjunctival sac.
 Guidelines for Instilling Eye Medications

• Instill eye drops before applying

ointments.
• Apply a ½-inch ribbon of ointment to
the lower conjunctival sac.
• Keep the eyelids closed, and apply
gentle pressure on the inner canthus
(punctal occlusion) near the bridge of
the nose for 1 or 2 minutes
immediately after instilling eyedrops.
• Using a clean tissue, gently pat skin
to absorb excess eyedrops that run
onto the cheeks.
• Wait 5 to 10 minutes before instilling
another eye medication.
Assessment and Management of
Patients with Hearing and
Balance Disorders
Anatomy of the Ear
Anatomy of the Inner Ear
Bone Conduction Compared to Air Conduction
 Assessment
• Inspection of the
external ear

• Otoscopic examination

• Gross auditory acuity

• Whisper test

• Weber test

• Rinne test
 Assessment
• Otoscope • Weber test
Rinne Test
Speech Discrimination
 Diagnostic Evaluation
• Audiometry
• Tympanogram
• Auditory brain stem response
• Electronystagmography
• Platform posturography
• Sinusoidal harmonic acceleration
• Middle ear endoscopy
 Hearing Loss
• Increased incidence with age:
presbycusis
• Risk factors include exposure to
excessive noise levels:
• Types
– Conductive: due to external middle
ear problem
– Sensorineural: due to damage to
the cochlea or vestibulocochlear
nerve
– Mixed: both conductive and
sensorineural
– Functional (psychogenic): due to
emotional problem
Manifestations:
• Early symptoms include:
– Tinnitus: perception of sound; often
“ringing in the ears”
– Increased inability to hear in a
group
– Turning up the volume on the TV
• Impairment may be gradual and
not recognized by the person
experiencing the loss
• As hearing loss increases, patients
may experience deterioration of
speech, fatigue, indifference,
social isolation, or withdrawal; for
other symptoms see
– Hearing impairment: Mild, moderate, severe,
or profound

– Consequences
• Depends on age and severity
• <3 years: Affects language development;
communication and safety
• Medical Management
– Hearing aids; sign language; speech reading
– Technologic devices (TDDs)
– Use of products to perceive sound: Light-
activated alarms; hearing dogs
• Surgical
Management
– Cochlear implant
– Bone conduction
device
– Semi-implantable
hearing aid
 Guidelines for Communicating
With the Hearing Impaired
• Use a low-tone, normal voice
• Speak slowly and distinctly
• Reduce background noise and distractions
• Face the person and get his attention
• Speak into the less-impaired ear
• Use gestures and facial expressions
• If necessary, write out the information or
use a sign language translator
• Nursing Management
– Observe signs of hearing loss
– Assess speech and communication skills
– Teach client and family
• Use of hearing aids, communication aids, support
services
– Take actions to promote self-care and self
esteem
– Evaluate and follow up client referral
 Conditions of the External Ear
Impacted Cerumen
• Pathophysiology and – Gentle irrigation
Etiology should be used with
– Interferes with sound lowest pressure,
carried on airwaves directing stream
• Assessment Findings behind the
– Otalgia; diminished obstruction
hearing; orange-brown  Glycerin, mineral oil,
accumulation of cerumen half-strength H2O2 or
peroxide in glyceryl
• Medical Management may help soften
– Hydration; irrigation or cerumen
removal with cerumen
spoon
• Nursing Management
– Inspects ear and implements measures to
remove excessive cerumen
– Ear drops; irrigation
• Proper administration and precautions
– Warm ear drops
– Avoid inserting syringe too deeply
– Direct the flow toward the roof of the canal
 Disorders of the External Ear:
Foreign Objects
• Pathophysiology and – Removal may be by irrigation,
Etiology suction, or instrumentation
– Scratched skin – Objects that may swell (such
– Blunt penetration of eardrum as vegetables or insects)
should not be irrigated
– Local inflammation of tissue
– Foreign-body removal can be
• Assessment Findings
dangerous and may require
– Discomfort extraction in the operating
– Diminished hearing room
– Feeling movement
– Buzzing sound
– Inspection with penlight or
otoscope
 Conditions of the External Ear
• External otitis – Therapy is aimed at
• Pathophysiology and reducing discomfort,
Etiology reducing edema, and
– Overgrowth of pathogens treating the infection
– Infected hair follicle – A wick may be inserted
• Assessment Findings into the canal to keep it
open and to facilitate
– Red tissue; swelling
medication administration
– Reduced hearing; fever
– Enlarged lymph nodes
behind ear
– Otoscope examination; C
and S results
• Medical Management
– Warm soaks; analgesics;
antibiotics
 Conditions of the Middle Ear: Otitis
• Pathophysiology and
Media
• Serous otitis media: fluid
Etiology in the middle ear without
– Overgrowth of pathogens evidence of infection
– Infected hair follicle
• Assessment Findings
– Red tissue; swelling
– Reduced hearing; fever
– Enlarged lymph nodes
behind ear
– Otoscope examination; C
and S results
• Medical Management
– Warm soaks; analgesics;
antibiotics
 Conditions of the Middle Ear: Otitis
Media
• Acute otitis media
– Most frequently seen in
children
– Pathogens are most commonly
Streptococcus pneumonia,
Haemophilus influenzae, and
Moraxella catarrhalis
– Manifestations include otalgia
(ear pain), fever, and hearing
loss
– Treatment
 Antibiotic therapy
 Myringotomy or tympanotomy
• Chronic otitis media
– Result of recurrent acute otitis
media
– Chronic infection damages the
tympanic membrane and
ossicle, and involves the
mastoid
– Treatment
 Prevent by treatment of acute
otitis
 Tympanoplasty, ossiculoplasty,
or mastoidectomy
Middle Ear Surgical Procedures
• Tympanoplasty
– Reconstruction of the
tympanic membrane
• Ossiculoplasty
– Reconstruction of the bones of
the middle ear
– Prostheses are used to
reconnect the ossicles to
reestablish sound conduction
• Mastoidectomy
– Removal of diseased bone,
mastoid air cells, and
cholesteatoma to create a
non-infected, healthy ear
– Cholesteatoma: a benign
tumor that is an ingrowth of
skin that causes persistently
high pressure in the middle
ear, causing hearing loss,
neurologic disorders, and
destroying structures
 Disorders of the Middle Ear:
Otosclerosis
• Pathophysiology and Etiology
– Interference: Vibration of stapes; transmission
of sound to inner ear
• Assessment Findings
– Signs and symptoms
• Progressive, bilateral hearing loss; Tinnitus (at
night); pinkish-orange eardrum
– Diagnostic findings
• Audiometric tests; CT scan
• Medical and Surgical Management
– Hearing aid; stapedectomy
• Nursing Management
– Use of selected alternatives for communicating
– Pre- and postoperative teaching: Care of prosthesis
– Postoperative care
• Position client on the nonoperative side
• Monitor for nausea and dizziness
• Assess facial nerve function
 A wire prosthetic stapes is
positioned in the middle ear
Stapedectomy for Otosclerosis
Nursing Process: Client Recovering
From Stapedectomy
• Assessment
– Vital signs; monitoring for complications, drainage
from affected ear, level of discomfort; report
elevation in temperature
• Diagnosis, Planning, and Interventions
– Impaired comfort; risks: Injury; infection
 Interventions
• Reduce anxiety • Prevent injury
– Reinforce information and – Implement safety measures such
patient teaching as assisting with ambulation

– Provide support and allow – Provide antiemetics or antivertigo

patient to discuss anxieties medications

• Relieve pain
– Medicate with analgesics for ear
discomfort
– Occasional sharp, shooting pains
may occur as the eustachian
tube opens and allows air into
the middle ear; constant
throbbing pain and fever may
indicate infection
 • Preventing infection
• Improve communication and hearing
– Hearing may be reduced for – Monitor for signs and symptoms
several weeks following surgery of infection
due to edema, accumulation of
– Administer antibiotics as ordered
blood and fluid in the middle ear,
and dressings and packings
– Prevent contamination of ear
– Use measures to improve hearing with water from showers,
and communication as discussed washing hair, etc.
in “Communicating With the
Hearing Impaired”
 Conditions of the Inner Ear
• Dizziness: any altered • Tinnitus
sense of orientation in
space • Labyrinthitis
• Vertigo: the illusion of • Benign positional vertigo
motion or a spinning (BBPV)
sensation
• Nystagmus: involuntary • Ototoxicity:
rhythmic movement of
the eyes associated with • Acoustic neuroma:
vestibular dysfunction tumor of cranial
 Ménière’s Disease
• Abnormal inner ear fluid
balance caused by
malabsorption of the
endolymphatic sac or blockage
of the endolymphatic duct
Manifestations:
• fluctuating, progressive hearing
loss; tinnitus; feeling of
pressure or fullness; and
episodic, incapacitating vertigo
that may be accompanied by
nausea and vomiting
• Pathophysiology and Etiology
– Malabsorption of fluid in the
endolymphatic sac
• Treatment
– Low-sodium diet, 2000 mg a
day
– Meclizine (Antivert),
tranquilizers, antiemetics, and
diuretics
– Surgical management to
eliminate attacks of vertigo;
endolymphatic sac
decompression; middle and
inner ear perfusion; and
vestibular nerve sectioning
 Ménière’s Disease
• Nursing Management
– History: Symptoms; medical; drug; allergy
– Assess gross hearing; Weber and Rinne tests
– Provide emotional support; administer
prescribed drugs; limit movement; promote
safety
– Client teaching: Treatments
 Disorders of the Inner Ear:
Ototoxicity
• Signs and Symptoms
– Tinnitus; sensorineural hearing loss
– Vestibular toxicity; lightheadedness; vertigo; nausea;
vomiting
• Nursing Management
– Client teaching: Ototoxic effects of certain
medications
– Monitor dosage and frequency of drug administration
– Assess changes in hearing
Disorders of the Inner Ear: Acoustic
Neuroma
• Pathophysiology and Etiology
– Cochlear nerve compression; interference with the
blood supply to the nerve and cochlea
• Assessment Findings
– Gradual hearing loss; impaired facial movement
– Altered facial sensation; tinnitus
– Vertigo with or without balance disturbance
– MRI; CSF studies
Disorders of the Inner Ear: Acoustic
Neuroma
• Medical and Surgical Management
– Surgical removal of tumor
– Retain cranial nerve VIII function
– Complications of surgery
• Nursing Management
– Assessment: Evaluating hearing function
– Observing the client’s facial movements
– Testing for facial sensation
– Postoperative care: Continue preoperative
assessment data; monitor for IICP
– Maintain strict asepsis
 Acoustic Neuroma
• Pharmacologic Considerations
– Nonprescription preparations are available for
softening hardened cerumen
• Refer client to a physician if hearing remains
diminished
– Be aware of potentially ototoxic effects of
certain medications
– Monitor the prescribed dosages and the client
for signs of impaired hearing
 General Considerations
• Gerontologic Considerations
– Older clients
• Form drier cerumen; experience an increased
incidence of impaction in the external acoustic
meatus
• Experience disorientation and confusion in strange
surroundings
– Hearing loss is common as adults age
– Assess client’s ability to care for and maintain
hearing aid or other treatments