Sensory System
Chapter 40

• Left eye
– OS
• Right eye
– OD
• Both eyes
– OU
• Drop/s
– gtt/ gtts
Eye abbreviations:

Conjunctivitis
• Inflammation of the conjunctiva
• AKA
– “pink eye”

• Caused by
– Bacteria
– Viral
• Spread by
– Direct contact
Conjunctivitis

• S&S (mild)
– Redness
– Itching
• pruritus
– Tearing
– Discharge
Conjunctivitis

Conjunctivitis
• Dx
– History
– Visual examination
– “conjunctival scraping”
• Culture

• Rx
– Antibiotics
• Topical
Conjunctivitis

Nursing assessment
• Symptoms
• Effects on vision
• Associate symptoms
• Date of last eye exam
• Corrective lenses???

Nursing Assessment
• Past medical history
• Test vision
– Snellen eye chart
– Rosenbaum chart

Snellen Eye chart Rosenbaum chart
• Pic from book

Nursing Assessment
• Inspect eye
• Check pupil
– PERRLA

• P upils
• E qual
• R ound
• R eactive to
• L ight
• A ccommodation

Priority Nursing Diagnosis: Risk for
• disturbed sensory perception (visual)
• Instruct to avoid touching or rubbing eyes
• Emphasize proper contact care

NRS DX: Acute pain
• Administer analgesics routinely
• Patch both eyes PRN
• Teach to apply warm compresses for 15 minutes, 3-4 x day

NRS DX: Acute pain
• Wear dark glasses
• Avoid excessive reading

NRS DX: Knowledge deficit
• Teach
– Hand washing
– Correct eye care
– Do not share
• Makeup
• Towels
• Contact lenses
– Do not use old makeup
– Cleaning techniques for contacts

Eye trauma
• Common types of eye injury
– Foreign body
– Abrasion
– Laceration
– Burn

Corneal Abrasion
• AKA
– Scratched cornea

Corneal Abrasion
• S&S
– Pain!
– Photophobia
– Tearing

Corneal Abrasion
• Prognosis
– Usually heal without scarring

• Types of burns
– Chemical burns
– Thermal burns
– UV burns
Burns

• S&S
– Pain
– Affects vision
– Swollen eyelids
– Conjunctiva red & edematous
• Slough
– Cornea cloudy or hazy
Burns

Perforated eye
• Examples of causes
– Metal flakes
– Glass shards
– Weapons

Perforated eye
• S&S
– Pain
– Partial or complete loss of vision
– Bleeding
– Loss of eye contents

Blunt eye trauma
• Common cause
– Sports injuries

Blunt eye trauma
• Minor
– Ecchymosis (lid)
• AKA:
– Black eye
– Subconjunctival hemorrhage

Eye trauma Assessment
• Eye exam
– Vision
– Movement
• Unless penetrating objects
– Inspect
• Foreign objects
• Lacerations

Eye trauma treatment
• Topical anesthetic
– Before inspection

Eye trauma DX Test
• Fluorescein staining
– ID
• Foreign bodies
• Abrasions
• Can you find the abrasion?

Eye trauma DX Test
• Ophthalmoscopic examination

Eye trauma DX Test
• X-ray
• CT scan
– Orbital fx
– Foreign bodies

Eye trauma: Irrigate
• Small foreign bodies
– Irrigate
• sterile saline
• Chemical burns
– Irrigate
• Copious amounts of fluid

Eye trauma: Irrigate
• Procedure
– “from the inner canthus of the eye to the outer”
– Head tipped slightly to the affected side

NOTE!!!
• Immediately irrigate the eye is a chemical burn is suspected. Irrigation to remove the chemical is of higher priority than assessment of the eye

Eye trauma TX
• Remove loose foreign bodies
– Use a
• Moist
• Sterile
• Cotton-tipped applicator

Eye trauma TX
• Severe or penetrating injury
– Bed rest
– Stabilize eye
• Apply eye pad
• Over both eyes

Eye trauma TX
• Post-care
– Eye-drops / ointment
– Eye pad/shield per order
– Avoid wearing contacts until cornea has healed completely

Nursing Care
• Teach to prevent eye injuries!
– Eye protection
– Seat belts
• flush eye immediately if chemicals splash

Nursing care
• If an abrasion or penetrating or blunt injury 
– Loosely cover with sterile gauze
– Do not remove penetrating objects
– Patch both eyes

Nursing Care: After injury
• Reinforce follow-up apt
• Discuss meds & application
• Teach how to apply eye patch
• Do not rub or scratch the eye

Nursing Care: After injury
• Teach to avoid activities that h intraocular pressure
– Lifting
– Straining
– Bending over

Small Group Questions
1. Define the following abbreviations: OS, OD, UO, gtts
2. Describe conjunctivitis, how would you assess for it?
3. What is the common treatment for conjunctivitis?
4. You are fishing with a young child and the line breaks and the fish hook flies into their eye.
What would you do?
5. After the hook is removed, what instructions should be given to the child?

Cataracts
• Clouding of the lens  impaired vision
– Common
– >65
– Affects both eyes

Cataracts
• Age 
• Cells become less clear
• Affects edges first 
• Spreads towards center

• Affects
– Near vision
– Far vision
• Details obscured
• Glare
– light / dark
• Pupils appear
– cloudy gray / white
Cataracts

• Risk factors
– Age
• Senile cataracts
– Sunlight
– Cigarette smoke
– Heavy alcohol consumption
– Eye trauma
– Diabetes mellitus
Cataracts

• History
• Eye examination
Cataracts: Dx

Cataracts: Tx
• Surgical removal
• Clouded lens removed
• Intraocular lens is implanted

Nursing Care: Eye surgery
• Pre-op
– Assess understand of procedure
– Assess vision of unaffected eye
– Reinforce post-op teaching
– Remove all eye make-up
– Admin. Pre-op meds per order

Nursing Care: Eye surgery
• Post-op
– Assess
• V/S
• LOC
• Comfort
• Status of eye dressing
– Maintain eye patch / shield per order
– Position
• Semi-Fowlers
• Fowlers

Nursing Care: Eye surgery
• Approach client on unaffected side
• Intervene PRN to prevent
– Vomiting
– Straining
– Coughing
– Sneezing
• Immediately report sudden / sharp pain to
MD

Nursing Care: Eye surgery
• S&S to report to MD
– Redness or cloudiness
– Drainage
– i vision
– Floaters
– Flashes
– Halos

Nursing Care: Eye surgery
• Personal items & call light within reach
• Admin eye-drops and meds per order
• Arrange or referals

Nursing Care: Eye surgery
• Teach
– How to instill eye-drops
– How to apply eye patch
– Avoid rubbing
– Wear sun glasses
– Make & keep apt.

Glaucoma
• Increased intraocular pressure 
– Gradual vision loss
• Vision loss is permanent

Chronic Glaucoma: S&S
• Painless
• Difficulty adapting light to dark
• Blurred vision
• Halos
• Difficulty focusing on near objects

Acute glaucoma: S&S
• Severe eye PAIN
• N&V
• Halos
• Red eye, cornea clouded
• Pupil
– Dilated
– Fixed

Clinical Alert!
• Acute glaucoma is a medical emergency.
Without prompt treatment the affected eye will become blind. Immediately report manifestations of acute glaucoma to the charge nurse or MD

Glaucoma: Dx
• Tonometry
– Measures intraocular pressure
• Visual field testing
– Checks peripheral vision

Glaucoma: Rx
• Meds to i intraocular pressure

Memory alert
• Mydriatics (drugs that dilate pupils) must be avoided with glaucoma.

Nursing Care: health promotion
• Early screening
– >40
• q 2-4 years
– > 60
• q 1 – 2 years

Nursing Assessment
• Risk factors
• Ask about vision
• Family Hx
• Inspect eye

Nursing Assessment
• Assess vision
• Assess pupils

NRS DX: Risk for injury
• Assess ability to provide self care
• Alert others not to move items in room

Application of Eye drops
• Use aseptic technique
• Have clients sit upright or lie supine with the head tilted slightly up
• Rest hand on the client’s forehead, hold the dropper 1 to 2 cm above his conjunctival sac and instill the medication into the center of the sac.
Then instruct the client to close his eye gently.
• Apply gentle pressure with your finger and a clean tissue on the nasolacrimal duct for 30 to 60 seconds

Small Group Questions
1. Differentiate between cataracts and glaucoma
2. What is the common treatment for cataracts?
3. What would you teach a patient who had/ was having cataracts surgery?
4. What is the common treatment for glaucoma?
5. What is the prognosis for glaucoma?
6. Describe how to put in eye drops

Otitis Media
• Inflammation of the middle ear
– Ear drum
• Protects middle ear from environment
– Eustachian tube
• Connects with nasopharynx

• Risk factors
– URI
– Allergies
– Eustachian tube dysfunction
Otitis Media

Serous Otitis media
• Eustachian tube is obstructed 
• Air gradually absorbed

• Negative pressure 
• Serous fluid drawn in

Serous Otitis media
• S&S
– i hearing
– Snapping /popping sensation
– Bulging or sunken eardrum
– Change in atmospheric pressure  PAIN!

Acute Otitis media
• URI 
• Eustachian tube swelling 
• Impairs drainage 
• Bacteria grows in fluid 
• Inflammatory process 
• Pus increases pressure 
• Ear drum ruptures

Acute Otitis media
• S&S
– Pain
– Fever
– Dizziness or Vertigo
– Eardrum
• Red
• Inflamed
• Dull
• Bulging

• History
• Physical exam
– Otoscope
Otitis Media: Dx

Otitis Media: Rx
• Decongestants
• Antibiotics
• Mild Analgesics
– Acetaminophen

Complementary therapies
• Pain relief from Otitis
Media
– Drop of lavender oil
– Warm cloth

Otitis Media: Surgery
• Tympanocentesis
– Needle through eardrum

– Extract fluid & pus

Otitis Media: Surgery
• Myringotomy
– Surgical opening of the middle ear

Otitis Media: Surgery
• Ventilation
(tympanostomy) tubes
– Ventilation and drainage of middle ear during healing

Nursing Care: Ear surgery
• Pre-op
– Assess hearing
– Discuss post-op hearing strategies
– Explain post-op restrictions
• Blowing nose
• Coughing
• Sneezing

Nursing Care: Ear surgery
• Post-op
– Assess
• Bleeding
• Nausea
– Admin antiemetics
• Vertigo / dizziness
• Hearing

Nursing Care: Ear surgery
• HOB
– Elevate
– Unaffected side
• Stand on unaffected side to communicate
• Remind to avoid
– Coughing
– Sneezing
– Blowing nose

Nursing Care: Ear surgery
• Instruction for home care
– Avoid showers until MD
OKs
– Keep ear plug clean and change prn
– Do not remove inner ear dressing until MD OKs
– No swim, drive or travel by air until MD-OK
– Antiemetic per MD order
– Antihistamine per MD order

Nursing Care: Ear surgery
• Notify MD if
– Fever
– Bleeding
– h drainage
– h dizziness
– i hearing

Assessment: Otitis Media
• History
– Onset / duration
– S&S
– Hx URI
– Move auricle / pinna
– Inspect throat & ear
– Temperature
– Assess hearing
– Palpate mastoid process

NRS DX: Pain
• Mild analgesics
– Q4hour PRN
• Heat to affected side of face & head
• Instruct to report abrupt pain relief

NRS DX: Knowledge Deficit
• Take All antibiotics
• Discuss S/E of antibiotics
– Diarrhea
– Vaginitis
– Thrush
– Eat 8 oz yogurt q day

NRS DX: Knowledge Deficit
• Instruct pt w/ tubes
– No
• Swimming
• Diving
• Submerging head while bathing
• Air travel
• Enc
– Rest
– h fluid intake
– Nutritious diet

Small Group Questions
1. What are the S&S of otitis media
2. What is the pathophysiology of otitis media
3. What medications are prescribed to a client with otitis media?
4. What client teaching would you give in regards to the above medications?
5. A 2 year old is having tubes placed in their ear bilaterally. The mother is confused about the procedure and what to expect. What would you teach her?