Chapter 13
Care of the Patient with a
Visual or Auditory Disorder
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and
Physiology
• Anatomy of the eye

Accessory structures of the eye
•
•
•
•
Eyebrows
Eyelashes
Eyelids
Lacrimal apparatus
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 2
Figure 13-1
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
Lacrimal apparatus.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 3
Overview of Anatomy and
Physiology
• Anatomy of the eye (continued)

Structures of the eyeball
•
•
•
•
•
•
•
Sclera
Cornea
Choroid
Ciliary body
Iris
Pupil
Retina
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 4
Overview of Anatomy and
Physiology
• Anatomy of the eye (continued)

Chambers of the eye
• Anterior chamber

Aqueous humor
• Posterior chamber

Vitreous humor
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 5
Figure 13-2
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)
Horizontal section through the left eyeball. The eye is viewed from
above.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 6
Overview of Anatomy and
Physiology
• Anatomy of the ear

External ear
• Auricle
• External auditory canal
• Tympanic membrane

Middle ear
•
•
•
•
Eustachian tube
Malleus
Incus
Stapes
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 7
Figure 13-3
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)
The ear. External, middle, and inner ear.
(Not to scale.)
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Slide 8
Overview of Anatomy and
Physiology
• Anatomy of the ear (continued)

Inner ear
• Labyrinth


Bony labyrinth—filled with perilymph
o Semicircular canals
o Vestibule
o Cochlea—organ of Corti
Membranous labyrinth—filled with endolymph
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Slide 9
Figure 13-4
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
The inner ear.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 10
Overview of Anatomy and
Physiology
• Other special senses

Taste and smell
• Taste buds: salty, sweet, sour, bitter
• Olfactory receptors: sense of smell

Touch
• Tactile receptors

Position/movement
• Proprioceptors
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 11
Laboratory and Diagnostic
Examinations
• Diagnostic eye tests

Snellen test
 Color vision
 Refraction
 Ophthalmoscopy
 Tonometry
 Amster grid test
 Schirmer’s tear test
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 12
Disorders of the Eye
• Blindness and near-blindness

Etiology/pathophysiology
• Loss of visual acuity
• Congenital or acquired
• Legal blindness


20/200 with corrective eyewear (normal 20/20)
Visual field less than 20 degrees (normal 180)
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Slide 13
Disorders of the Eye
• Blindness and near-blindness (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Diplopia
Pain
Floaters and light flashes
Pruritus; burning of the eyes
Loss of peripheral vision
Halos
Orbital pressure
Bulging of the eyes
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Slide 14
Disorders of the Eye
• Blindness and near-blindness (continued)

Medical management/nursing interventions
•
•
•
•
•
Corrective eyewear
Canes
Seeing-eye dogs
Magnifying systems
Surgical procedures
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 15
Disorders of the Eye
• Refractory errors

Etiology/pathophysiology
• Astigmatism—unequal curve in the shape of the cornea
or lens
• Strabismus—inability of the eyes to focus in one
direction; cross-eyed
• Myopia—nearsightedness; eyeball is too long
• Hyperopia—farsightedness; eyeball is too short
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 16
Disorders of the Eye
• Refractory errors (continued)

Clinical manifestations/assessment
• Diminished or blurred vision

Medical management/nursing interventions
• Corrective lenses
• Surgical correction



Radial keratotomy (RK)
Photorefractive keratectomy (PRK)
Laser-assisted in-situ keratomileusis (LASIK)
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Slide 17
Disorders of the Eye
• Conjunctivitis

Etiology/pathophysiology
•
•
•
•
•
Inflammation of the conjunctiva
Bacterial or viral infection
Allergy
Environmental factors
Commonly called pink eye
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 18
Disorders of the Eye
• Conjunctivitis (continued)

Clinical manifestations/assessment
• Erythema of the conjunctiva
• Edema of the eyelid; crusting discharge
• Pruritus; burning; excessive tearing

Medical management/nursing interventions
•
•
•
•
Warm compresses
Eye irrigations with normal saline
Antibiotic drops or ointment
Keep free from exudate
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 19
Disorders of the Eye
• Keratitis

Etiology/pathophysiology
• Inflammation of the cornea
• Injury, irritants, allergies, viral infection, or diseases
• Pneumococcus, Staphylococcus, Streptococcus, and
Pseudomonas are most common types of bacterial
causes
• Herpes simplex is most common viral cause
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 20
Disorders of the Eye
• Keratitis (continued)

Clinical manifestations/assessment
•
•
•
•
•
Severe eye pain
Photophobia
Tearing
Edema
Visual disturbances
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 21
Disorders of the Eye
• Keratitis (continued)

Medical management/nursing interventions
• Pharmacological management


•
•
•
•
Topical and systemic antibiotics
Analgesics
Pressure dressings
Warm or cold compresses
Epithelial debridement
Keratoplasty
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 22
Disorders of the Eye
• Dry eye disorders (keratoconjunctivitis sicca)

Etiology/pathophysiology
• Lacrimal gland dysfunction from an autoimmune
mechanism

Clinical manifestations/assessment
• Complaints of sandy or gritty sensation in the eye

Medical management/nursing interventions
• Artificial tear replacement
• Punctal plugs or repair if injured
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 23
Disorders of the Eye
• Ectropion and entropion

Etiology and pathophysiology
• Noninfectious disorders of the eye lid causing abnormal
eyelid margins

Clinical manifestations
• Abnormal direction of the eyelid
• Corneal dryness

Medical management/nursing interventions
• Topical medications to reduce conjunctival and corneal
drying
• Surgery
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 24
Disorders of the Eye
• Cataracts

Etiology/pathophysiology
• Noninfectious opacity or clouding of the lens
• Congenital; acquired; senile

Clinical manifestations/assessment
•
•
•
•
•
Blurred vision
Diplopia
Photosensitivity
Decreased night vision
Opacity in the center portion of lens
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 25
Disorders of the Eye
• Cataracts (continued)

Medical management/nursing interventions
• Surgical removal

Lens implant or glasses
• Postoperative





Avoid direct sunlight
Bed rest with bathroom privileges (BRPs)
Analgesics
No bending down or straining
Avoid coughing, sneezing, and blowing nose
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 26
Disorders of the Eye
• Diabetic retinopathy

Etiology/pathophysiology
• Capillary microaneurysms, hemorrhage, exudates, and
formation of new vessels and connective tissue in the
retina

Clinical manifestations/assessment
• Microaneurysms
• Progressive loss of vision; “floaters”

Medical management/nursing interventions
• Photocoagulation
• Vitrectomy
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Slide 27
Disorders of the Eye
• Macular degeneration

Etiology/pathophysiology
• Slow, progressive loss of central and near vision due to
aging retina

Clinical manifestations/assessment
• Gradual and variable bilateral loss of vision
• Color perception may also be affected

Medical management/nursing interventions
• Usually no treatment
• May use photocoagulation
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Slide 28
Disorders of the Eye
• Retinal detachment

Etiology/pathophysiology
• Separation of the retina from the choroid in the posterior
area of the eye

Clinical manifestations/assessment
• Flashes of light; floating spots
• Loss of a specific field of vision

Medical management/nursing interventions
• Photocoagulation; cryosurgery; diathermy
• Scleral buckling
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Slide 29
Figure 13-8
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Retinal break with detachment: surgical repair by scleral buckling
technique.
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Slide 30
Disorders of the Eye
• Glaucoma

Etiology/pathophysiology
• An abnormal condition of elevated pressure within an
eye; obstruction of outflow of aqueous humor


Open-angle
Closed-angle
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Slide 31
Figure 13-9
(From Havener, W.H. [1997]. Synopsis of ophthalmology. St. Louis: Mosby.)
A, Chronic open-angle glaucoma.
B, Acute-angle closure glaucoma.
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Slide 32
Disorders of the Eye
• Glaucoma (continued)

Clinical manifestations/assessment
• Open-angle






No signs or symptoms during early stages
Tunnel vision
Eye pain
Difficulty adjusting to darkness
Halos around lights
Inability to detect colors
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Slide 33
Disorders of the Eye
• Glaucoma (continued)

Clinical manifestations/assessment
• Closed-angle






Severe pain
Decreased vision
Nausea and vomiting
Erythema of the sclera
Enlarged and fixed pupil
Halos around lights
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Slide 34
Disorders of the Eye
• Glaucoma (continued)

Medical management/nursing interventions
• Open-angle glaucoma



Beta blockers
Miotics
Carbonic anhydrase inhibitors
• Closed-angle


Osmotic diuretics
Iridectomy
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 35
Disorders of the Eye
• Corneal injuries

Etiology/pathophysiology
• Result from injuries to corneal layers of the eye

Clinical manifestations/assessment
• Pain with movement of eye
• Excessive tearing; pruritus
• Erythema of conjunctiva
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 36
Disorders of the Eye
• Corneal injuries (continued)

Medical management/nursing interventions
• Flush with normal saline or water
• Antibiotic drops or ointment
• Penetrating wounds

Do not remove object if present
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Slide 37
Surgeries of the Eye
• Enucleation

Surgical removal of the eyeball
• Keratoplasty (corneal transplant)

Excision of the corneal tissue, followed by
implantation of a cornea from a donor
• Photocoagulation

A laser is directed into a small spot on the retina
• Vitrectomy

Removal of excess vitreous fluid caused by
hemorrhage and replacement with normal saline
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Slide 38
Laboratory and Diagnostic
Examinations
• Diagnostic ear tests


Otoscopy
Tuning fork tests
• Weber’s test
• Rinne test


Autometric testing
Vestibular testing
• Romberg test
• Past-point testing
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Slide 39
Figure 13-13
(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical
examination. [5th ed.]. St. Louis: Mosby.)
Weber tuning fork test.
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Slide 40
Figure 13-14
(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical
examination. [5th ed.]. St. Louis: Mosby.)
Rinne tuning fork test.
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Slide 41
Loss of Hearing (Deafness)
• Hearing impairment

Etiology/pathophysiology
• Decreased auditory acuity; partial or complete
• Affects development of speech
• Types






Conductive
Sensorineural
Mixed
Congenital
Functional
Central
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Slide 42
Loss of Hearing (Deafness)
• Hearing impairment (continued)

Clinical manifestations/assessment
• Requests for repeating information
• Nonresponse
• Delayed speech development

Medical management/nursing interventions
•
•
•
•
According to cause
Hearing aids
Surgical procedures
Cochlear implant
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Slide 43
Inflammatory and Infectious
Disorders of the Ear
• External otitis

Etiology/pathophysiology
• Inflammation or infection of the external canal

Clinical manifestations/assessment
• Pain with movement of auricle or chewing
• Erythema, scaling, pruritus, edema, watery discharge,
and crusting of the external ear

Medical management/nursing interventions
• Oral analgesics; corticosteroids
• Antibiotic or antifungal ear drops; oral antibiotics
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Slide 44
Inflammatory and Infectious
Disorders of the Ear
• Otitis media

Etiology/pathophysiology
• Inflammation or infection of the middle ear

Clinical manifestations/assessment
•
•
•
•
•
Fullness in the ear
Severe, deep, throbbing pain
Hearing loss
Tinnitus
Fever
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 45
Inflammatory and Infectious
Disorders of the Ear
• Otitis media (continued)

Medical management/nursing interventions
• Pharmacological management



Antibiotics
Analgesics
Nasal decongestants
• Local heat
• Aspiration of fluid from behind eardrum
• Myringotomy
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 46
Inflammatory and Infectious
Disorders of the Ear
• Labyrinthitis

Etiology/pathophysiology
•
•
•
•
•
Inflammation of the labyrinthine canals of the inner ear
Most common cause of vertigo
Viral infection from URI
Drugs and food
Tobacco and alcohol
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 47
Inflammatory and Infectious
Disorders of the Ear
• Labyrinthitis (continued)

Clinical manifestations/assessment
•
•
•
•

Severe and sudden vertigo; ataxic gait
Nausea and vomiting
Nystagmus; photophobia
Headache
Medical management/nursing interventions
• Antibiotics
• Dramamine or meclizine for vertigo
• IV fluids if nausea and vomiting present
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 48
Inflammatory and Infectious
Disorders of the Ear
• Obstructions of the ear

Etiology/pathophysiology
• Impaction of cerumen in canal; foreign bodies

Clinical manifestations/assessment
• Tinnitus and pain in the ear
• Slight hearing loss; tugging at ear

Medical management/nursing interventions
• Removal of cerumen by irrigation
• Foreign objects are removed with forceps
• Carbamide peroxide to soften cerumen
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Slide 49
Noninfectious Disorders of the Ear
• Otosclerosis

Etiology/pathophysiology
• Chronic, progressive deafness due to formation of
spongy bone, especially around the oval window

Clinical manifestations/assessment
• Slowly progressive conductive hearing loss
• Tinnitus; dizziness to vertigo

Medical management/nursing interventions
• Stapedectomy
• Air conduction hearing aid
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 50
Noninfectious Disorders of the Ear
• Ménière’s disease

Etiology/pathophysiology
• Chronic disease of the inner ear
• Increase in endolymph fluid

Clinical manifestations/assessment
•
•
•
•
•
Vertigo
Nausea and vomiting
Hearing loss; tinnitus
Diaphoresis
Nystagmus
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 51
Noninfectious Disorders of the Ear
• Ménière’s disease (continued)

Medical management/nursing interventions
• No specific treatment
• Decrease fluid pressure

Fluid restriction; diuretics; low-salt diet
• Dramamine, meclizine, and Benadryl
• Surgery




Destruction of labyrinth
Endolymphatic shunt
Cryosurgery
Vestibular nerve section
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Slide 52
Surgeries of the Ear
• Stapedectomy

Removal of the stapes of the middle ear
• Tympanoplasty

Operative procedures on the eardrum or ossicles of
the middle ear to restore hearing
• Myringotomy

Surgical incision of the eardrum
• Cochlear implant

Surgical implantation of a hearing device for the
profoundly deaf
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 53
Nursing Process
• Nursing diagnoses










Health maintenance, ineffective
Anxiety
Self-care deficit
Fear
Impaired environmental interpretation syndrome
Impaired home maintenance
Impaired social interaction
Risk for injury
Risk for loneliness
Sensory perception, disturbed: auditory or visual
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 54
Ophthalmic Drugs
Categories
 Local anesthetics


Antiseptic ointments


Used in procedures such as tonometry, gonioscopy,
cataract surgery, and removal of foreign objects from
the cornea
Prevent gonorrheal ophthalmia neonatorum in
newborn infants, used to treat common eye
infections, germicidal and astringent action
Ophthalmic antiinfectives

Treat eye infections caused by bacteria, fungi, or
viruses
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
55
Ophthalmic Drugs (cont.)
Artificial tears
 Other preparations
 Antiglaucoma agents
Uses
 To control acute narrow-angle glaucoma before
surgery
 Wide-angle glaucoma
 Secondary glaucoma
 Congenital glaucoma before surgery

Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
56
Glaucoma
Three Major Forms
 Primary glaucoma

Narrow-angle: person has a shallow anterior eye
chamber, may be genetic; requires surgery
 Wide-angle glaucoma: gradual onset, controlled
with medications

Secondary glaucoma


Result of other eye problems, treated with
medications
Congenital glaucoma

Birth defect requiring surgical correction
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
57
Antiglaucoma Medications

Sympathomimetics


Beta blockers


Produce vasoconstriction and decrease intraocular
pressure in open-angle glaucoma
Reduce intraocular pressure by reducing the
formation of aqueous humor
Miotics, direct-acting

Cholinergic agonists
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
58
Antiglaucoma Medications (cont.)

Miotics, cholinesterase inhibitors


Inactivates acetylcholinesterase
Carbonic anhydrase inhibitors

Blocks action of an enzyme in the ciliary body,
causing a decrease in aqueous humor secretion
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
59
Antiglaucoma Medications (cont.)

Mydriatic-Cycloplegics


Block the action of acetylcholine
Mydriatics
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
60
Otic Preparations

Control superficial infections of the ear



Action is bacteriostatic or bactericidal
Prophylaxis for infections in swimmers
Removing cerumen
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
61