SENSORY/PERCEPTUAL
EYE ALTERATIONS
REFRACTIVE ERRORS
OVERVIEW
A. THE ABILITY OF THE EYE TO FOCUS ON
THE RETINA DEPENDS ON THE LENGTH OF THE
EYE FROM FRONT TO BACK & THE
REFRACTIVE POWER OF THE LENS SYSTEM
B. REFRACTION IS THE BENDING OF LIGHT
RAYS
C. PROBLEMS IN EITHER EYE LENGTH OR
REFRACTION CAN RESULT IN REFRACTIVE
ERRORS
REFRACTIVE ERRORS
TYPES
STRABISMUS (Eye Deviation)
May lead to Amblyopia
Common test to detect the disorder
• Corneal Light Reflex
• Cover Test
If uncorrected leads to blindness
REFRACTIVE ERRORS
TYPES
MYOPIA
A. ALSO REFERRED TO AS – NEARSIGHTNESS
B. THE REFRACTIVE ABILITY OF THE EYE IS TOO
STRONG FOR THE EYE LENGTH
C. IMAGES ARE BENT & FALL IN FRONT OF, NOT
ON, THE RETINA
REFRACTIVE ERRORS
TYPES
HYPEROPIA
A. ALSO REFERRED TO AS – FARSIGHTEDNESS
B. THE REFRACTIVE ABILITY OF THE EYE IS TOO
WEAK
C. IMAGES ARE FOCUSED BEHIND THE RETINA
D. A SHORTER LENGTH OF THE EYE MAY
CONTRIBUTE TO THE DEVELOPMENT OF
HYPEROPIA
REFRACTIVE ERRORS
TYPES
PRESBYOPIA
A. AS PEOPLE AGE THE CRYSTALLINE LENS
LOSES ITS ELASTICITY & IS LESS ABLE TO
ALTER ITS SHAPE TO FOCUS THE EYE FOR
CLOSE WORK
B. IMAGES FALL BEHIND THE RETINA
C. PRESBYOPIA USUALLY OCCURS IN PEOPLE
IN THEIR 30’s & 40’s
REFRACTIVE ERRORS
TYPES
ASTIGMATISM
A. OCCURS WHEN THE CURVE OF THE CORNEA
IS UNEVEN
B. BECAUSE LIGHT RAYS ARE NOT REFRACTED
EQUALLY IN ALL DIRECTIONS A FOCUS
POINT ON THE RETINA IS NOT ACHIEVED
EYE DISORDERS
BLINDNESS
• LEGALLY DEFINED AS VISION < 20/200 W/ THE
USE OF CORRECTIVE LENSES OR A VISUAL FIELD
OF NO GREATER THAN 20 DEGREES.
• GREATEST INCIDENCE AFTER AGE OF 65
•
RISK FACTORS
A.
GLAUCOMA
B.
CATARACTS
C.
DIABETIC RETINOPATHY
D.
ATHEROSCLEROSIS
E.
TRAUMA
EYE DISORDERS
BLINDNESS
ANALYSIS / NURSING DIAGNOSIS
A. VISUAL SENSORY/PERCEPTUAL
ALTERATION R/T BLINDNESS
B. IMPAIRED SOCIAL INTERACTION R/T LOSS
OF SIGHT
C. RISK FOR INJURY R/T VISUAL IMPAIRMENT
D. SELF-CARE DEFICIT R/T VISUAL LOSS
EYE DISORDERS
BLINDNESS
NURSING CARE PLAN / IMPLEMENTATION
A. GOAL: PROMOTE INDEPENDENCE & PROVIDE
EMOTIONAL SUPPORT
1. FAMILIARIZE W/ SURROUNDINGS &
ENCOURAGE USE OF TOUCH
2. ESTABLISH COMMUNICATION LINES &
ANSWER QUESTIONS
3. DEAL W/ FEELINGS OF LOSS &
OVERPROTECTIVENESS BY FAMILY
MEMBERS
EYE DISORDERS
BLINDNESS
4. PROVIDE DIVERSIONAL ACTIVITIES, ie:
A. RADIO
B. TALKING BOOKS, TAPES, RECORDS
5. ENCOURAGE SELF-CARE ACTIVITIES
6. ALLOW VOICING OF FRUSTRATIONS
WHEN ACTIVITY IS NOT DONE TO
SATISFACTION – TO DECREASE ANGER &
DISCOURAGEMENT
EYE DISORDERS
BLINDNESS
NURSING CARE PLAN / IMPLEMENTATION
B. GOAL: FACILITATE ACTIVITIES OF
DAILY LIVING
1. EATING:
A. ESTABLISH ROUTINE PLACEMENT
FOR TABLEWARE, ie: PLATES
B. HELP PERSON MENTALLY
VISUALIZE THE PLATE AS A CLOCK /
COMPASS
C. TAKE PERSON’S HAND & GUIDE THE
FINGERTIPS TO ESTABLISH SPATIAL
RELATIONSHIP
EYE DISORDERS
BLINDNESS
NURSING CARE PLAN / IMPLEMENTATION
B. GOAL: FACILITATE ACTIVITIES OF
DAILY LIVING
2. WALKING:
A. HAVE PERSON HOLD YOUR
FOREARM & WALK HALF A STEP IN
FRONT
B. TELL THE PERSON WHEN
APPROACHING STAIRS, CURB, etc.
EYE DISORDERS
BLINDNESS
NURSING CARE PLAN / IMPLEMENTATION
B. GOAL: FACILITATE ACTIVITIES OF
DAILY LIVING
3. TALKING:
A. SPEAK WHEN APPROACHING PERSON &
TELL THEM BEFORE YOU TOUCH THEM
B. TELL THEM WHO YOU ARE & WHAT YOU
WILL BE DOING
C. DO NOT AVOID USING WORDS SUCH AS
“SEE” / DISCUSSING THE APPEARANCE
OF THINGS
EYE DISORDERS
BLINDNESS
NURSING CARE PLAN / IMPLEMENTATION
C. GOAL: HEALTH TEACHING
1. ACCIDENT PREVENTION IN THE HOME
2. COMMUNITY RESOURCES
A. VOLUNTARY AGENCIES
* American Foundation for the Blind
* Nat’l. Society for the Prevention of Blindness
B. GOVERNMENT AGENCIES
* Social & Rehabilitative Service
* Veteran’s Administration
c. CARE OF ARTIFICIAL EYE
CARING FOR AN ARTIFICAL EYE
• W/ GLOVED HAND PULL LOWER EYELID DOWN OVER THE
INFRAORBITAL BONE & EXERT PRESSURE BELOW THE
EYELID
• PRESSURE WILL MAKE THE EYE POP OUT
• HANDLE EYE PROSTHESIS CAREFULLY
• USING ASEPTIC TECHNIQUE, CLEANSE SOCKET W/
SALINE-MOISTENED GAUZE – STROKING FROM THE
INNER TO OUTER CANTHUS
• WASH THE PROSTHESIS IN WARM NORMAL SALINE
• TO REINSERT – GENTLY PULL THE PATIENT’S LOWER LID
DOWN, RAISE THE UPPER LID IF NECESSARY, SLIP THE
SALINE-MOISTENED EYE PRSOSTHESIS GENTLY INTO
THE SOCKET, & RELEASE THE LIDS
EYE DISORDERS
BLINDNESS
EVALUATION / OUTCOME CRITERIA
A. ACCEPTANCE OF DISABILITY
* PARTICIPATES IN SELF-CARE ACTIVITIES
* REMAINS SOCIALLY INVOLVED
B. REGAINS INDEPENDENCE W/
REHABILITATION
TRAUMA
•
•
•
•
•
Hematoma
Chemical burns
Corneal abrasions
Penetrating/Non-penetrating wounds
Foreign bodies
EYE DISORDERS
INFLAMMATION & INFECTIONS
• BLEPHARITIS
1. AN INFLAMMATION OF THE EYELID EDGES
2. MOST COMMON IN THE OLDER ADULT
3. OFTEN ASSOCIATED W/ DRY EYE SYNDROME
4. LACK OF SUFFICIENT TEARS W/ THIS DX. MAY
LEAD TO BACTERIAL INVASION OF THE EYE
STRUCTURES, BECAUSE TEARS ARE
BACTERIOSTATIC
5. SX.& SX. – ITCHY, RED & BURNING EYES W/
SEBORRHEA OF THE EYEBROWS & EYELIDS
6. TREATMENT – EYELID CARE OF WARM, MOIST
COMPRESSES FOLLOWED BY GENTLE SCRUBBING
W/ BABY SHAMPOO
EYE DISORDERS
INFLAMMATION & INFECTIONS
• CHALAZION
1.
2.
3.
4.
5.
6.
A STERILE INFLAMMATION OF A SEBACEOUS GLAND IN THE
EYELID
SX. & SX. - BEGINS W/ AN INFLAMMATION & TENDERNESS ,
FOLLOWED BY A GRADUAL PAINLESS SWELLING @ THE
GLAND
IN ITS FULLY DEVELOPED STATE NO SX. OF
INFLAMMATION ARE PRESENT
C/O EYE FATIGUE, SENSITIVITY TO LIGHT, POSSIBLEY
EXCESSIVE TEARING
TREATMENT – USE OF WARM COMPRESSES FOR 15’ QID,
FOLLOWED BR INSTILLATION OF AN ANTI-INFECTIVE
OPHTHALMIC OINTMENT
M.D. MAY EXCISE CHALAZION IF IT INTERFERES W/ VISION
EYE DISORDERS
INFLAMMATION & INFECTIONS
• CONJUNCTIVITIS
1.
AN INFLAMMATION / INFECTION OF THE CONJUNCTIVA
2.
INFLAMMATORY CONJUNCTIVAITIS RESULTS FROM
EXPOSURE TO ALLERGENS / IRRITANTS & IS NOT
CONTAGIOUS
SX. & SX. – CONJUNCTIVAL EDEMA, BURNING SENSATION,
EXCESSIVE TEARING , ITCHING & VASCULAR
ENGORGEMENT W/ BLOODSHOT APPEARANCE OF EYE/S
TREATMENT – INSTILLATION OF VASOCONSTRICTORS &
CORTICOSTEROIDS EYEDROPS AS WELL AS INSTRUCTION
FOR THE CLIENT TO AVOID USING EYE MAKE-UP UNTIL
CONDITION SUBSIDES
4.
5.
EYE DISORDERS
INFLAMMATION & INFECTIONS
CONJUNCTIVITIS -- CONT’D
1.
2.
3.
3.
4.
5.
AN INFLAMMATION / INFECTION OF THE CONJUNCTIVA
INFECTIOUS CONJUNCTIVITIS OCCURS AS A RESULT OF
BACTERIAL / VIRAL INFECTION & IS CONTAGIOUS
ALSO KNOWN AS BACTERIAL CONJUNCTIVITIS / “PINK
EYE”
SX. & SX. – BLOOD VESSEL DILATION, CONJUNCTIVAL
EDEMA, TEARING & DISCHARGE
DISCHARGE IS USUALLY WATERY @ FIRST THEN
BECOMES THICKER, W/ SHREDS OF MUCUS
TREATMENT – AIMED @ CONTOLLING THE INFECTION W/
C&S DONE OF DRAINAGE FOR APPROPRIATE ANTIINFECTIVE – HYGIENE INSTRUCTION GIVEN – ISOLATE
LINENS & OTHER CLOTHING TO PREVENT SPREAD
EYE DISORDERS
INFLAMMATION & INFECTIONS
HORDEOLUM
1.
2.
3.
ALSO KNOWN AS A “STYE”
THIS “STYE” CAN BE INTERNAL / EXTERNAL
USUALLY AFFECTS ONLY ONE EYE @ A TIME W/ NO VISION
IMPAIRMENT
3. EXTERNAL STYE IS AN INFECTION OF THE SWEAT GLANDS IN
THE EYELID, OCCURING NEAR THE EMERGENCE OF THE
EYELASHES FROM THE EYELID
5. INTERNAL STYE IS CAUSED BY AN INFECTION OF THE EYELID
SEBACEOUS GLAND
4. SX. & SX. – A RED, SWOLLEN, TENDER AREA IS NOTED ON
THE SKIN SURFACE SIDE OF THE EYELID & PAIN IS PRESENT
R/T PURULENT DSCHG IN STYE
5. TREATMENT - WARM COMPRESSES – QID, & ANTIINFECTIVE OINTMENT
EYE DISORDERS
GLAUCOMA
PATHOPHYSIOLOGY
A.
ACUTE (CLOSED ANGLE)
IMPAIRED PASSAGE OF AQUEOUS
HUMOR INTO THE CIRCULAR CANAL OF
SCHLEMM DUE TO CLOSURE OF THE
ANGLE BETWEEN THE CORNEA AND THE
IRIS.
** MEDICAL EMERGENCY -- REQUIRES
SURGERY
EYE DISORDERS
GLAUCOMA -- CONT’D
B.
PATHOPHYSIOLOGY
CHRONIC (OPEN-ANGLE)
LOCAL OBSTRUCTION OF AQUEOUS
HUMOR BETWEEN THE ANTERIOR
CHAMBER AND THE CANAL..
MOST COMMONLY TREATED WITH
FOLLOWING MEDICATION :
1. MIOTICS
2. CARBONIC ANHYDRASE INHIBITORS
EYE DISORDERS
GLAUCOMA -- CONT’D
C.
PATHOPHYSIOLOGY
GLAUCOMA (UNTREATED)
IMBALANCE BETWEEN RATE OF SECRETION
OF INTRAOCULAR FLUIDS AND RATE OF
ABSORPTION OF AQUEOUS HUMOR >
INCREASED INTRAOCULAR PRESSURE >
DECREASED PERIPHERAL VISION > CORNEAL
EDEMA > HALOS AND BLURRING VISION >
BLINDNESS
EYE DISORDERS
GLAUCOMA -- CONT’D
RISK FACTORS
5.
6.
7.
8.
9.
*UNKNOWN, BUT ASSOCIATED WITH:
1.
EMOTIONAL DISTURBANCES
2.
HEREDITARY FACTORS
3.
ALLERGIES / AGE
4.
VASOMOTOR DISTURBANCES
NEARSIGHTNESS (MYOPIA)
EYE TRAUMA / SYSTEMIC CORTICOSTEROIDS
CV DISEASE & DIABETES
MIGRAINE SYNDROMES
AFRICAN AMERICAN / ASIAN MALES
EYE DISORDERS
GLAUCOMA -- CONT’D
ASSESSMENT
A.
SUBJECTIVE DATA
ACUTE (CLOSED-ANGLE)
1.
2.
3.
4.
5.
B.
PAIN: SEVERE, IN & AROUND EYE
HEADACHE
RAINBOW HALOS AROUND LIGHTS
BLURRING OF VISION
N& V
CHRONIC (OPEN-ANGLED)
1. EYES TIRE EASILY
2. LOSS OF PERIPHERAL VISION
EYE DISORDERS
GLAUCOMA -- CONT’D
ASSESSMENT
OBJECTIVE DATA
1.
2.
3.
4.
5.
6.
CORNEAL EDEMA
DECREASED PERIPHERAL VISION
INCREASED CUPPING OF OPTIC DISC
TONOMETRY - PRESSURES > 22mmHg
PUPILS DILATED
REDNESS OF EYE
EYE DISORDERS
GLAUCOMA -- CONT’D
NURSING DIAGNOSES
A. VISUAL SENSORY/ PERCEPTUAL
ALTERATIONS R/T INCREASED
INTRAOCULAR PRESSURE
B. PAIN R/T SUDDEN INCREASE IN
INTRAOCULAR PRESSURE
C. RISK FOR INJURY R/T BLINDNESS
D. IMPAIRED PHYSICAL MOBILITY
R/T IMPAIRED VISION
EYE DISORDERS
GLAUCOMA -- CONT’D
GOALS & IMPLEMENTATIONS
1. REDUCE IOP
• ACTIVITY: BEDREST
• POSITION: SEMI-FOWLER’S
• MEDS AS ORDERED:
A. MIOTICS
B. CARBONIC ANHYDRASE
INHIBITORS
C. ANTICHOLINESTERASE
D. OPHTHALMIC
EYE DISORDERS
GLAUCOMA MEDICATIONS
1. MIOTICS (PILOCARPINE & CARBACHOL)
* USED TO LOWER THE IOP > INCREASED
BLOOD FLOW TO THE RETINA & DECREASED
RETINAL DAMAGE AND LOSS OF VISION
* MIOTICS CAUSE A CONTRACTION OF THE
CILIARY MUSCLE & WIDENING OF TRABECULAR
MESHWORK
* PILOCARPINE PRODUCES MIOSIS &
DECREASES IOP
EYE DISORDERS
GLAUCOMA MEDICATIONS
2.
CARBONIC ANHYDRASE INHIBITORS
(acetazolamide)
* INTERFERE WITH PRODUCTION OF
CARBONIC ACID, WHICH LEADS TO DECREASED
AQUEOUS HUMOR FORMATION & DECREASED IOP
* USED FOR LONG-TERM TREATMENT OF
OPEN-ANGLE GLAUCOMA
* RECOMMENDED ONLY AFTER PILOCARPINE,
BETA BLOCKERS, EPINEPHRINE, &
CHOLINESTERASE INHIBITORS ARE INEFFECTIVE
EYE DISORDERS
GLAUCOMA MEDICATIONS
3. ANTICHOLINESTERATE
* FACILITATES OUTFLOW OF AQUEOUS
HUMOR
SHORT-ACTING (PHYSOSTIGMINE SALICILATE)
LONG-ACTING (DEMECARIUM BROMIDE )
EYE DISORDERS
GLAUCOMA MEDICATIONS
4. OPHTHALMIC: BETA-ADRENERGIC BLOCKERS
* (BETAXOLOL) BETOPTIC - USED TO
DECREASE ELEVATED IOP IN CHRONIC OPENANGLE GLAUCOMA & OCULAR HYPERTENSION
* (TIMOLOL MALEATE) TIMOPTIC - REDUCES
PRODUCTION OF AQUEOUS HUMOR
EYE DISORDERS
GLAUCOMA -- CONT’D
GOALS & IMPLEMENTATIONS
2. PROVIDE EMOTIONAL • PLACE PERSONAL OBJECTS
SUPPORT
WITHIN FIELD OF VISION
• ASSIST WITH ACTIVITIES
• ENCOURAGE VERBALIZATION
OF CONCERNS, FEARS OF
BLINDNESS, LOSS OF
INDEPENDENCE
EYE DISORDERS
GLAUCOMA -- CONT’D
GOALS & IMPLEMENTATIONS
4. HEALTH
TEACHING
A. PREVENT > IOP BY AVOIDING:
1. ANGER, EXCITEMENT, WORRY
2. CONSTRICTIVE CLOTHING
3. HEAVY LIFTING
4. EXCESSIVE FLUID INTAKE
5. STRAINING @ STOOL
6. EYE STRAIN
7. ATROPINE, OR OTHER MYDRIATICS
WHICH CAUSE DILATION
EYE DISORDERS
GLAUCOMA -- CONT’D
GOALS & IMPLEMENTATIONS
4. HEALTH
B.
TEACHING
C.
RELAXATION & STRESS
MANAGEMENT TECHNIQUES
PREPARE FOR SURGERY, IF
ORDERED
* LASER TRABECULOPLASTY
* TRABECULECTOMY (FILTERING)
D. ACTIVITY ALLOWED:
* MODERATE EXERCISE - WALKING
EYE DISORDERS
GLAUCOMA -- CONT’D
GOALS & IMPLEMENTATIONS
4. HEALTH E. SAFETY MEASURES:
TEACHING
1. EYE PROTECTION - SHIELD/GLASSES
2. Medic Alert BAND/TAG
3. AVOID DRIVING 1-2 HR. AFTER
INSTILLING MIOTICS
F. MEDICATIONS:
1. PURPOSE, DOSAGE & FREQUENCY
3. EYEDROP INSTILLATION
G. COMMUNITY RESOURCES, AS NEEDED
EYE DISORDERS
GLAUCOMA -- CONT’D
EVALUATION/OUTCOME CRITERIA
A.
EYESIGHT PRESERVED, IF POSSIBLE
B.
IOP LOWERED ( < 22 mm Hg )
C.
CONTINUES MEDICAL SUPERVISION FOR LIFE -REPORTS REAPPEARANCE OF SYMPTOMS
IMMEDIATELY
EYE DISORDERS -- CATARACTS
PATHOPHYSIOLOGY/ETIOLOGY
*
*
*
*
* DEVELOPMENT or DEGENERATIVE
OPACIFICATION OF THE
CRYSTALLINE LENS
* CATARACTS CAN DEVELOP @ ANY AGE
THEY MAY BE DUE TO A VARIETY OF CAUSES
MOST COMMON IN LATER LIFE &
ASSOCIATED WITH AGING
CAN DEVELOP IN BOTH EYES -- USUALLY ONE
EYE IS MORE COMPROMISED
VISUAL IMPAIRMENT USUALLY PROGRESSES
@ SAME RATE IN BOTH EYES
EYE DISORDERS -- CATARACTS
RISK FACTORS
*
*
*
*
* AGING (MOST COMMON)
* TRAUMA
* TOXINS
* CONGENITAL DEFECTS
ASSOCIATED OCULAR CONDITIONS
NUTRITIONAL FACTORS
PHYSICAL FACTORS
SYSTEMIC DISEASES & SYNDROMES
EYE DISORDERS -- CATARACTS
ASSESSMENT
SUBJECTIVE DATA
* VISION ( DIMMING )
*
*
*
*
*
BLURRING ( PAINLESS )
LOSS OF ACUITY (SEE BEST IN LOW LIGHT)
DISTORTION
DIPLOPIA
PHOTOPHOBIA
* SENSITIVITY TO GLARE
EYE DISORDERS -- CATARACTS
ASSESSMENT
OBJECTIVE DATA
* BLINDNESS
A. UNILATERAL
B. BILATERAL ( PARTICULARLY, IN
CONGENITAL CATARACTS)
* LOSS OF RED REFLEX
* GRAY OPACITY OF LENS
* MYOPIC SHIFT & COLOR SHIFT
* ASTIGMATISM
* REDUCED LIGHT TRANSMISSION
EYE DISORDERS -- CATARACTS
ANALYSIS / NURSING DIAGNOSES
A. VISUAL SENSORY/PERCEPTUAL
ALTERATIONS R/T OPACITY OF LENS
B. RISK FOR INJURY R/T ACCIDENTS
C. SOCIAL ISOLATION R/T IMPAIRED
VISION
EYE DISORDERS -- CATARACTS
CATARACT REMOVAL
* REMOVAL OF OPACIFIED LENS
BECAUSE OF LOSS OF VISION
A. EXTRACAPSULAR CATARACT EXTRACTION
( ECCE ) FOLLOWED BY INTRAOCULAR LENS
( IOL ) INSERTION
B. PHACOEMULSION - USES AN ULTRASONIC
DEVICE THAT LIQUEFIES THE NUCLEUS &
CORTEX WHICH ARE THEN SUCTIONED OUT
THROUGH A TUBE
EYE DISORDERS -- CATARACTS
GOALS & IMPLEMENTATIONS
PREOPERATIVE CARE
1. PREPARE 1. ANTIBIOTIC DROPS/OINTMENT, AS
FOR
ORDERED
SURGERY
2. MYDRIATIC EYEDROPS, AS ORDERED
(NOTE DILATATION OF PUPILS)
3. AVOID GLARING LIGHTS
4. SURGERY OFTEN DONE UNDER LOCAL
ANESTHESIA WITH SEDATION
EYE DISORDERS -- CATARACTS
GOALS & IMPLEMENTATIONS
PREOPERATIVE CARE
2. HEALTH
TEACHING
PRE-OP.
1. DO NOT RUB , TOUCH, or SQUEEZE EYES
SHUT AFTER SURGERY
2. EYE PATCH WILL BE ON AFFECTED EYE
3. ASSISTANCE WILL BE GIVEN FOR NEEDS
4. OVERNIGHT HOSPITALIZATION NOT
REQUIRED, UNLESS COMPLICATIONS
OCCUR
5. MILD IRITITIS USUALLY OCCURS
EYE DISORDERS -- CATARACTS
GOALS & IMPLEMENTATIONS
POSTOPERATIVE CARE
1. REDUCE STRESS
ON THE
SUTURES &
PREVENT
HEMORRHAGE
A.
1.
2.
B.
1.
2.
ACTIVITY:
AMBULATE , AS ORDERED,
SOON AFTER SURGERY
USUALLY DISCHARGED
5-6 HRS AFTER SURGERY
POSITION:
FLAT or LOW FOWLER’S
LIE ON BACK or TURN TO
UNOPERATIVE SIDE
EYE DISORDERS -- CATARACTS
GOALS & IMPLEMENTATIONS
POSTOPERATIVE CARE
C. AVOID ACTIVITIES THAT > IOP:
1. REDUCE
1. STRAINING @ STOOL
STRESS ON
2. VOMITING, COUGHING, SHAVING
THE SUTURES
& PREVENT
3. BRUSHING TEETH or HAIR
HEMORRHAGE
4. LIFTING OBJECTS > 20lb.
5. BENDING or STOOPING
6. WEAR GLASSES / SHADED LENS
DURING DAY
7. WEAR EYESHIELD @ NIGHT
EYE DISORDERS -- CATARACTS
GOALS & IMPLEMENTATIONS
POSTOPERATIVE CARE
1. REDUCE
STRESS ON
THE SUTURES
& PREVENT
HEMORRHAGE
D.
PROVIDE:
1. MOUTHWASH
2. HAIR CARE
3. PERSONAL ITEMS WITHIN EASY
REACH
4. “STEP-IN” SLIPPERS
EYE DISORDERS -- CATARACTS
GOALS & IMPLEMENTATIONS
POSTOPERATIVE CARE
• FREQUENT CONTACTS TO
2. PROMOTE
PREVENT SENSORY
PSYCHOLOGICAL
DEPRIVATION
WELL-BEING
•
ESPECIALLY , THE ELDERLY
EYE DISORDERS -- CATARACTS
GOALS & IMPLEMENTATIONS
POSTOPERATIVE CARE
3. HEALTH A. IF PRESCRIPTIVE GLASSES ARE USED,
TEACHING EXPLAIN ABOUT:
1. MAGNIFICATION
POST-OP.
2.
3.
4.
5.
PERCEPTUAL DISTORTION
BLIND AREAS IN PERIPHERAL VISION
GUIDE THRU ACTIVITIES WITH GLASSES
NEED TO LOOK THRU CENTRAL PORTION
OF LENS
6. TURNING HEAD TO SIDE WHEN LOOKING
TO THE SIDE TO PREVENT DISTORTION
EYE DISORDERS -- CATARACTS
GOALS & IMPLEMENTATIONS
POSTOPERATIVE CARE
3. HEALTH B. EYE CARE:
TEACHING
1. EYE SHIELD @ NIGHT x 1 MONTH
POST-OP.
2. EYE CARE - NO IOL INSERTION
* INSTILLATION OF MYDRIATIC &
CARBONIC ANHDRASE INHIBITORS TO PREVENT GLAUCOMA &
ADHESIONS
3. EYE CARE - WITH IOL INSERTION
* STEROID- ANTIBIOTIC USED
EYE DISORDERS -- CATARACTS
GOALS & IMPLEMENTATIONS
POSTOPERATIVE CARE
3. HEALTH C. SIGNS & SYMPTOMS of:
TEACHING
1. INFECTION
POST-OP.
2. IRIS PROLAPSE
* BULGING / PEAR SHAPED PUPIL
3. HEMORRHAGE
* SHARP PAIN
* HALF MOON OF BLOOD
EYE DISORDERS -- CATARACTS
GOALS & IMPLEMENTATIONS
POSTOPERATIVE CARE
3. HEALTH D. AVOID:
TEACHING
1.
HEAVY LIFTING
POST-OP.
2.
POTENTIAL EYE TRAUMA
EYE DISORDERS -- CATARACTS
EVALUATION/OUTCOME CRITERIA
1.
2.
3.
4.
5.
VISION RESTORED
NO COMPLICATIONS - ( ie. Severe eye pain
or Hemorrhage )
PERFORMS SELF-CARE ACTIVITIES - ( ie.
Instills own eyedrops )
RETURNS FOR FOLLOW-UP OPHTHALMOLOGY
CARE
RECOGNIZES SYMPTOMS REQUIRING
IMMEDIATE ATTENTION
EYE DISORDERS
RETINAL DETACHMENT
DESCRIPTION
• A RETINAL HOLE IS A BREAK IN THE INTEGRITY OF THE
PERIPHERAL SENSORY RETINA & CAN BE CAUSED BY
TRAUMA / CAN OCCUR W/ AGING
• A RETINAL TEAR IS A MORE JAGGED & IRREGULARLY
SHAPED BREAK IN THE RETINA – WHICH CAN RESULT
FROM TRACTION ON THE RETINA
• A RETINAL DETACHMENT IS THE SEPARATION OF THE
SENSORY RETINA FROM THE PIGMENTED EPITHELIUM –
A SEPARATION OF RETINA FROM CHOROID
EYE DISORDERS
RETINAL DETACHMENT
RISK FACTORS
A. TRAUMA
B. DEGENERATION
ASSESSMENT -- SUBJECTIVE DATA
A. FLASHES OF LIGHT BEFORE EYES
B. VISION IS:
1. BLURRED
2. SOOTY (SUDDEN ONSET)
3. SENSATION OF FLOATING PARTICLES
4. BLANK AREAS OF VISION
EYE DISORDERS
RETINAL DETACHMENT
ASSESSMENT – OBJECTIVE DATA
A. OPHTHALMIC EXAM REVEALS:
1. RETINA IS GRAYISH IN AREA OF TEAR
2.BRIGHT, RED HORSESHOE-TYPE TEAR
EYE DISORDERS
RETINAL DETACHMENT
ANALYSIS / NURSING DIAGNOSIS
A. VISUAL SENSORY/PERCEPTUAL ALTERATION
R/T BLURRED VISION
B. ANXIETY R/T POTENTIAL LOSS OF VISION
C. RISK FOR INJURY R/T BLINDNESS
EYE DISORDERS
RETINAL DETACHMENT
A.
NURSING CARE PLAN / IMPLEMENTATION
PREOPERATIVE CARE
1. GOAL: REDUCE ANXIETY & PREVENT FURTHER
DETACHMENT
A. ENCOURAGE VERBALIZATION OF FEELINGS, ANSWER ALL
QUESTIONS, & REINFORCE PHYSICIAN’S EXPLANATION
OF SURGICAL PROCEDURE
B. ACTIVITY:
1. BEDREST
2. EYES USUALLY COVERED TO PROMOTE
EYE RELAXATION
3. SIDERAILS UP
EYE DISORDERS
RETINAL DETACHMENT
NURSING CARE PLAN / IMPLEMENTATION
A. PREOPERATIVE CARE
1. GOAL: REDUCE ANXIETY & PREVENT FURTHER
DETACHMENT
C. POSITION:
1. ACCORDING TO LOCATION OF RETINAL
TEAR
2. INVOLVED AREA OF EYE SHOULD BE IN
DEPENDENT POSITION
EYE DISORDERS
RETINAL DETACHMENT
A.
NURSING CARE PLAN / IMPLEMENTATION
PREOPERATIVE CARE
1. GOAL: REDUCE ANXIETY & PREVENT FURTHER
DETACHMENT
D. MEDICATIONS:
1. ADMINSTER AS ORDERED
2. CYCLOPLEGIC / MYDRIATICS – TO DILATE
THE PUPIL WIDELY & DECREASE
INTRAOCULAR MOVEMENT
E. RELAXING DIVERSION:
1. CONVERSATION
2. MUSIC
EYE DISORDERS
RETINAL DETACHMENT
A.
NURSING CARE PLAN / IMPLEMENTATION
PREOPERATIVE CARE
2. GOAL: HEALTH TEACHING
A. PREPARE FOR SURGICAL INTERVENTION
1. CRYOTHERAPY - SUPER-COOLED PROBE IS
APPLIED TO THE SCLERA, CAUSING A SCAR,
WHICH PULLS THE CHOROID & RETINA
TOGETHER
2. LASER PHOTOCOAGULATION – A BEAM OF
INTENSE LIGHT FROM A CARBON ARC IS
DIRECTED THROUGH THE DILATED PUPIL ONTO
THE RETINA & SEALS HOLE IF RETINA NOT
DETACHED
EYE DISORDERS
RETINAL DETACHMENT
A.
NURSING CARE PLAN / IMPLEMENTATION
PREOPERATIVE CARE
2. GOAL: HEALTH TEACHING
A. PREPARE FOR SURGICAL INTERVENTION
3. SCLERAL BUCKLING – THE SCLERA IS
RESECTED / SHORTENED TO ENHANCE
THE CONTACT BETWEEN THE CHOROID
& RETINA
4. BANDING / ENCIRCLEMENT – SILICANE BAND
/ STRAP IS PLACED UNDER THE
EXTRAOCULAR MUSCLES AROUND THE
GLOBE
EYE DISORDERS
RETINAL DETACHMENT
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
1. GOAL: REDUCE INTRAOCULAR STRESS &
PREVENT HEMORRHAGE
A. POSITION:
1. FLAT / LOW FOWLER’S
2. SANDBAGS MAY BE USED TO POSITION HEAD
3. TURN TO NON-OPERATIVE SIDE, IF ALLOWED W/
RETINAL TEAR DEPENDENT
4. SPECIAL POSITIONS MAY BE:
PRONE
SIDE-LYING
SITTING W/ FACE DOWN ON TABLE
EYE DISORDERS
RETINAL DETACHMENT
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
1. GOAL: REDUCE INTRAOCULAR STRESS & PREVENT
HEMORRHAGE
B. ACTIVITY:
1. BEDREST
2. DECREASE INTRAOCULAR PRESSURE BY
NOT:
A. STOOPING
B. BENDING
C. ASSUMING PRONE POSITION
EYE DISORDERS
RETINAL DETACHMENT
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
1. GOAL: REDUCE INTRAOCULAR STRESS &
PREVENT HEMORRHAGE
C. MEDICATIONS:
1. MYDRIATICS – REDUCE EYE MOVEMENT
2. ANTI-INFECTIVES – PREVENT INFECTION
3. CORTICOSTEROIDS - INFLAMMATION
EYE DISORDERS
RETINAL DETACHMENT
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
1. GOAL: REDUCE INTRAOCULAR STRESS &
PREVENT HEMORRHAGE
D. RANGE OF MOTION EXERCISES:
1. ISOMETRIC
2. PASSIVE
3. ELASTIC STOCKINGS TO PREVENT
THROMBUS R/T IMMOBILITY
EYE DISORDERS
RETINAL DETACHMENT
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
2. GOAL: SUPPORT COPING MECHANISMS
A. PLAN ALL CARE W/ PATIENT
B. ENCOURAGE VERBALIZATION OF FEELINGS,
FEARS
C. ENCOURAGE FAMILY INTERACTION
D. DIVERSIONAL ACTIVITIES
EYE DISORDERS
RETINAL DETACHMENT
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
3. GOAL: HEALTH TEACHING
A. EYE CARE:
1. EYE PATCH / SHIELD @ NIGHT
2. DARK GLASSES
3. AVOID RUBBING / SQUEEZING EYES
B. MEDICATIONS:
1. DRUG TEACHING
2. AVOID OTC MEDICATION
EYE DISORDERS
RETINAL DETACHMENT
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
3. GOAL: HEALTH TEACHING
C. LIMITATIONS:
1. NO READING FOR 3 WEEKS
2. NO PHYSICAL EXERTION FOR 6 WEEKS
D. SIGNS OF REDETACHMENT:
1. FLASHES OF LIGHT
2. INCREASE IN “FLOATERS”
3. BLURRED VISION
EYE DISORDERS
RETINAL DETACHMENT
EVALUATION / OUTCOME CRITERIA
A. VISION RESTORED
B. NO FURTHER “DETACHMENT “ –
RECOGNIZES SIGNS & SYMPTOMS
C. NO INJURY OCCURS
D. ACCEPTS LIMITATIONS
EYE DISORDERS
RETINITIS PIGMENTOSA
• A CHRONIC PROGRESSIVE DISEASE
• ONSET IN EARLY CHILDHOOD
• PATHOLOGY
1. DEGENERATION OF THE RETINAL EPITHELIUM
– ESPECIALLY THE RODS – W/OUT
INFLAMMATION
2. ATROPHY OF THE OPTIC NERVE
3. WIDESPREAD PIGMENTARY CHG. IN RETINA
EYE DISORDERS
RETINITIS PIGMENTOSA
• CAUSE OF THE DISEASE IS UNKNOWN
• HEREDITARY TENDENCY IS SUSPECTED
• SX. & SX.
1. DEFECTIVE NIGHT VISION – EARLY SX.
2. CONSTRICTED FIELD OF VISION – LATER SX.
• TREATMENT
1. NO SPECIFIC THERAPY – GENETIC
COUNSELING
2. FAMILY VISION CHECKS FOR SAME
PROBLEM
MACULAR DEGENERATION
Two Types
• Dry (Atrophic)
• Wet (Exudative)
•
•
•
•
Clinical Manifestations
Diagnostic Studies
Treatments
Nursing Care
CANCERS
•Retinoblastoma
- Definition
- Etiology/Incidence
- Clinical Manefestations
- Diagnostic Tests
- Teatments
TYPES OF OPHTHALMIC DRUGS
F.
TOPICAL ANESTHETIC
ACTION -- 1. DECREASES SENSATION (PAIN)
USES -- 1. SURGERY, TREATMENTS
2. EYE INFLAMMATIONS
G. TOPICAL ANTIBIOTIC
ACTION -- 1. ANTI- INFECTIVE
USES -- 1. EYE INFLAMMATIONS
H. STEROID
ACTION -- 1. EYE INFLAMMATIONS
USES -- 1. EYE INFLAMMATIONS &
ALLERGIC REACTIONS
TYPES OF OPHTHALMIC DRUGS
I.
CARBONIC ANHYDRASE INHIBITORS
ACTION-- 1. REDUCES PRODUCTION OF
AQUEOUS HUMOR
USES -- 1. GLAUCOMA
J. BETA-ADRENERGIC BLOCKERS
ACTION -- 1. REDUCES FORMATION OF
AQUEOUS HUMOR W/OUT
PRODUCING MIOSIS /
HYPEREMIA
USES -- 1. CHRONIC GLAUCOMA
2. OCULAR HYPERTENSION
TYPES OF OPHTHALMIC DRUGS
A. MYDRIATICS
ACTION-- 1. DILATES PUPIL
USES -- 1. EXAMINATION OF INTERIOR OF
EYE
2. PREVENTS ADHESIONS OF IRIS
W/ CORNEA IN EYE
INFLAMMATIONS
TYPES OF OPHTHALMIC DRUGS
B. CYCOPLEGIC
ACTION-- 1. DILATES PUPIL
2. PARALYZES CILIARY MUSCLE &
IRIS
USES -- 1. DECREASES PAIN &
PHOTOPHOBIA
2. PROVIDES REST IN:
A.
INFLAMMATIONS OF IRIS &
CILIARY BODY
B.
DISEASES OF CORNEA
TYPES OF OPHTHALMIC DRUGS
C. MIOTICS
ACTION-- 1. CONTRACTS PUPIL
2. PERMITS BETTER DRAINAGE OF
INTRAOCULAR FLUID
USES -- 1. GLAUCOMA
TYPES OF OPHTHALMIC DRUGS
D. OSMOTIC
ACTION-- 1. DECREASES IOP
USES -- 1. ACUTE GLAUCOMA
2. EYE SURGERY
E. SECRETORY INHIBITOR
ACTION-- 1. DECREASES PRODUCTION OF
INTRAOCULAR FLUID
USES -- 1. GLAUCOMA
EAR ALTERATIONS
SX. OF HEARING LOSS
• FREQUENTLY ASKING PEOPLE TO REPEAT
STATEMENTS
• STRAINING TO HEAR
• TURNING HEAD/LEANING FORWARD TO FAVOR
ONE EAR
• SHOUTING IN CONVERSATION
• RINGING IN THE EARS
• FAILING TO RESPOND WHEN NOT LOOKING IN
THE DIRECTION OF THE SOUND
SX. OF HEARING LOSS (CONT’D)
• IRRITABILITY
• ANSWERING QUESTIONS INCORRECTLY
• RAISING THE VOLUME OF THE TELEVISION /
RADIO
• AVOIDING LARGE GROUPS
• BETTER UNDERSTANDING OF SPEECH WHEN IN
SMALL GROUPS
• WITHDRAWING FROM SOCIAL INTERACTIONS
PERMISSIVE NOISE EXPOSURES
DURATION/DAY (HR)
8
6
4
3
2
1½
1
½
¼
SOUND LEVEL (dbA,slow)
90
92
95
97
100
102
105
110
115
INTENSITY RANGE OF HUMAN HEARING &
INTENSITY LEVEL OF VARIOUS ENVIRON. SOUNDS
DECIBELS
140
DECIBELS
60
Jet Engine
130
Conversation
50
Average Office
120
40
Thunder
110
30
Avg. Residence
100 Rivet Hammer
90
20
10
Low Whisper
0
Threshold of
Hearing
Air Hammer
80
Heavy Traffic
70
AUDITORY ASSESSMENT
• WHEN EVALUATING HEARING, THREE CHRX. ARE
IMPORTANT:
A.
FREQUENCY
B.
PITCH
C.
INTENSITY
AUDITORY ASSESSMENT
FREQUENCY
• FREQUENCY REFERS TO THE NUMBER OF SOUND
WAVES EMANATING FROM A SOURCE PER
SECOND – CYCLES PER SECOND OR HERTZ (Hz)
• THE NORMAL HUMAN EAR PERCEIVES SOUNDS
RANGING IN FREQUENCY FROM 20 – 20,000 Hz
• THE FREQUENCIES FROM 500 – 2,000 Hz ARE
IMPORTANT IN UNDERSTANDING EVERYDAY
SPEECH & ARE REFERRED TO AS THE SPEECH
RANGE OR SPEECH FREQUENCIES
AUDITORY ASSESSMENT
PITCH
• PITCH IS THE TERM USED TO DESCRIBE
FREQUENCY
• A TONE WITH 100 Hz IS CONSIDERED OF LOW
PITCH
• A TONE OF 10,000 Hz IS CONSIDERED OF HIGH
PITCH
AUDITORY ASSESSMENT
LOUDNESS
• THE UNIT FOR MEASURING LOUDNESS (INTENSITY OF
SOUND) IS THE DECIBEL (dB), THE PRESSURE EXERTED
BY SOUND
• HEARING LOSS IS MEASURED IN DECIBELS, A
LOGARITHMIC FUNCTION OF INTENSITY THAT IS NOT
EASILY CONVERTED INTO %.
• THE CRITICAL LEVEL OF LOUDNESS IS APPRX. 30 Db
• SOUNDS LOUDER THAN 80 dB IS PERCEIVED BY THE
HUMAN EAR TO BE TOO HARSH & CAN BE DAMAGING
TO THE INNER EAR.
AUDITORY ASSESSMENT
LOUDNESS
• EXAMPLES OF LOUDNESS IN EVERYDAY LIFE
* 15 dB –
SHUFFLING OF PAPER IN QUIET
SURROUNDINGS
* 40 dB --
LOW CONVERSATION
* 150 dB --
JET PLANE 100 ft AWAY
AUDITORY ASSESSMENT
GOAL OF TREATMENT
• WITH SURGICAL TREATMENT OF PATIENTS
WITH HEARING LOSS, THE AIM IS TO
IMPROVE THE HEARING LEVEL TO 30 dB OR
BETTER WITHIN THE SPEECH FREQUENCIES
AUDITORY ASSESSMENT
SEVERITY OF HEARING LOSS
LOSS IN DECIBELS
• 0 - 15
•
•
•
•
•
•
>15 - 25
>25 – 40
>40 – 55
>55 – 70
> 70 – 90
> 90
INTERPRETATION
NORMAL HEARING
SLIGHT HEARING LOSS
MILD HEARING LOSS
MODERATE HEARING LOSS
MODERATE TO SEVERE LOSS
SEVERE HEARING LOSS
PROFOUND HEARING LOSS
AUDITORY ASSESSMENT
AUDIOMETRY TEST
• WITH AUDIOMETRY, THE AUDIOLOGIST PERFORMS THE
TESTING WHILE THE PATIENT WEARS EARPHONES &
SIGNALS WHEN HEARING A TONE – DONE IN
SOUNDPROOF ROOM
• WHEN THE TONE IS APPLIED DIRECTLY OVER THE
EXTERNAL AUDITORY CANAL, AIR CONDUCTION IS
MEASURED
• WHEN THE STIMULUS IS APPLIED TO THE MASTOID
BONE , BYPASSING THE CONDUCTIVE MECHANISM
(OSSICLES) NERVE CONDUCTION IS TESTED
• AUDIOMETRY GRAPH PLOTS TYPE OF CONDUCTION
AUDITORY ASSESSMENT
TYMPANOGRAM TEST
• A TYMPANOGRAM , OR IMPEDANCE
AUDIOMETRY, MEASURES MIDDLE EAR MUSCLE
REFLEX TO SOUND STIMULATION, &
COMPLIANCE OF THE TYMPANIC MEMBRANE.
• IT DOES THIS BY CHANGING THE AIR PRESSURE
IN A SEALED EAR CANAL.
• COMPLIANCE IS IMPAIRED W/ MIDDLE EAR
DISEASE
HEARING LOSS STATISTICS
• MORE THAN 28 MILLION PEOPLE IN THE USA
HAVE SOME TYPE OF HEARING IMPAIRMENT
• MOST CAN BE HELPED W/ MEDICAL OR
SURGICAL THERAPIES OR W/ A HEARING AID
• BY THE YEAR 2050, ABOUT ONE (1) OUT OF
EVERY FIVE (5) PEOPLE IN THE USA, OR ALMOST
58 MILLION PEOPLE, WILL BE AGE 55 OR >
• OF THIS POPULATION ALMOST ONE-HALF CAN
EXPECT A HEARING IMPAIRMENT
CONDUCTIVE HEARING LOSS
DESCRIPTION
1. WHEN SOUND WAVES ARE BLOCKED TO THE
INNER EAR FIBERS BECAUSE OF EXTERNAL EAR
OR MIDDLE EAR DISORDERS
2. DISORDERS CAN OFTEN BE CORRECTED W/
NO DAMAGE TO HEARING, OR MINIMAL
PERMANENT HEARING LOSS
CONDUCTIVE HEARING LOSS
CAUSES
1.
ANY INFLAMMATORY PROCESS OR OBSTRUCTION
OF THE EXTERNAL OR MIDDLE EAR
2. TUMORS
3. OTOSCLEROSIS
4. A BUILD-UP OF SCAR TISSUE ON THE OSSICLES
FROM PREVIOUS MIDDLE EAR SURGERY
SENSORINEURAL HEARING LOSS
DESCRIPTION
1. A PATHOLOGICAL PROCESS OF THE INNER
EAR OR OF THE SENSORY FIBERS THAT LEAD TO
THE CEREBRAL CORTEX
2. IS OFTEN PERMANENT & MEASURES MUST
BE TAKEN TO REDUCE FURTHER DAMAGE OR TO
ATTEMPT TO AMPLIFY SOUND AS A MEANS OF
IMPROVING HEARING TO SOME DEGREE
SENSORINEURAL HEARING LOSS
CAUSES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
DAMAGE TO THE INNER EAR
DAMAGE TO CRANIAL NERVE VIII (8)
PROLONGED EXPOSURE TO LOUD NOISE
MEDICATIONS
TRAUMA
INHERITED DISORDERS
METABOLIC & CIRCULATORY DISORDERS
INFECTIONS
SURGERY
MENIERE’S SYNDROME
DIABETES MELLITIS
MYXEDEMA
MIXED HEARING LOSS
• ALSO KNOWN AS CONDUCTIVE-SENSORINEURAL
HEARING LOSS
• CLIENT HAS BOTH SENSORINEURAL &
CONDUCTIVE HEARING LOSS
FACILITATING COMMUNICATION
• USING WRITTEN WORDS IF THE CLIENT IS ABLE
TO SEE, READ, & WRITE
• PROVIDING PLENTY OF LIGHT IN THE ROOM
• FACING THE CLIENT WHEN SPEAKING
• TALKING IN A ROOM WITHOUT DISTRACTING
NOISES
• MOVING CLOSE TO THE CLIENT & SPEAKING
SLOWLY & CLEARLY
• GETTING THE ATTENTION OF THE CLIENT BEFORE
YOU BEGIN TO SPEAK
FACILITATING COMMUNICATION
• KEEPING HANDS & OTHER OBJECTS AWAY FROM THE
MOUTH WHEN TALKING TO THE CLIENT
• TALKING IN LOWER TONES BECAUSE SHOUTING IS NOT
HELPFUL
• REPHRASING SENTENCES & REPEATING INFORMATION
• VALIDATING W/ THE CLIENT THE UNDERSTANDING OF
STATEMENTS MADE, BY ASKING THE CLIENT TO REPEAT
WHAT WAS SAID
• READING LIPS
• ENCOURAGING THE CLIENT TO WEAR GLASSES WHEN
TALKING TO SOMEONE TO IMPROVE VISION FOR LIP
READING
FACILITATING COMMUNICATION
• USING SIGN LANGUAGE, WHICH COMBINES
SPEECH WITH HAND MOVEMENTS THAT SIGNIFY
LETTERS, WORDS, OR PHRASES
• USING TELEPHONE AMPLIFIERS
• INSTALLING FLASHING LIGHTS THAT ARE
ACTIVATED BY RINGING OF THE TELEPHONE OR
DOORBELL
• USING SPECIALLY TRAINED DOGS THAT HELP THE
CLIENT TO BE AWARE OF SOUND & TO ALERT THE
CLIENT OF POTENTIAL DANGERS
COCHLEAR IMPLANTATION
• USED FOR SENSORINEURAL HEARING LOSS
• A SMALL COMPUTER CONVERTS SOUND WAVES
INTO ELECTRICAL IMPULSES
• ELECTRODES ARE PLACED BY THE INTERNAL EAR
W/ A COMPUTER DEVICE ATTACHED TO THE
EXTERNAL EAR
• ELECTRONIC IMPULSES DIRECTLY STIMULATE
NERVE FIBERS
HEARING AIDS
• USED FOR THE CLIENT W/ CONDUCTIVE HEARING
LOSS
• CAN HELP THE CLIENT W/ SENSORINEURAL
HEARING LOSS, ALTHOUGH NOT AS EFFECTIVE
• A DIFFICULTY THAT EXISTS IS THE
AMPLIFICATION OF BACKGROUND NOISE AS
WELL AS VOICES
• CLIENT EDUCATION
EAR PROCEDURES
IRRIGATION
A. WARM TAP WATER TO BODY TEMPERATURE
B. FILL A SYRINGE W/ WARM WATER
C. PLACE A BASIN UNDER THE EAR TO BE IRRIGATED
AS WELL AS A TOWEL AROUND THE CLIENT’S NECK
TO AVOID GETTING THE CLIENT WET
D. USE AN OTOSCOPE TO CHECK THE LOCATION OF
THE IMPACTED CERUMEN
E. PLACE THE TIP OF THE SYRINGE AT AN ANGLE SO
THAT THE FLUID PUSHES AT ONE SIDE OF THE
IMPACTION & NOT DIRECTLY ON THE IMPACTION
– THIS HELPS TO LOOSEN THE CERUMEN &
AVOIDS PUSHING IT BACK IN THE CANAL
EAR PROCEDURES
IRRIGATION
cont’d
F. WATCH FLUID RETURN FOR SIGNS OF
CERUMEN PLUG REMOVAL
G. CONTINUE TO IRRIGATE THE EAR W/
APPROXIMATELY 50 –70 ml. OF FLUID
H. IF THE CERUMEN DOES NOT DRAIN OUT,
WAIT ABOUT 10 MINUTES, THEN REPEAT
THE PROCEDURE
EAR PROCEDURES
IRRIGATION
cont’d
I. MONITOR FOR SIGNS OF NAUSEA – IF IT
DEVELOPS – STOP THE PROCEDURE
J. IF CERUMEN CANNOT BE REMOVED BY
IRRIGATION, GLYCERIN DROPS AS
PRESCRIBED MAY BE USED 3 X A DAY FOR 2
DAYS & THEN IRRIGATION IS REPEATED
EAR PROCEDURES
A. TILT THE CLIENT’S HEAD IN THE OPPOSITE
DIRECTION OF THE AFFECTED EAR & PLACE
DROPS IN THE EAR
B. INSERT A COTTON BALL INTO THE EAR
CANAL TO ACT AS PACKING
PRESBYCUSIS
DESCRIPTION
1. ASSOCIATED W/ AGING
2. LEADS TO DEGENERATION / ATROPHY OF
THE GANGLION CELLS IN THE COCHLEA & A
LOSS OF ELASTICITY OF THE BASILAR
MEMBRANES
3. LEADS TO COMPROMISE OF THE VASCULAR
SUPPLY TO THE INNER EAR W/ CHANGES IN
SEVERAL AREAS OF THE EAR STRUCTURE
PRESBYCUSIS
ASSESSMENT
1. HEARING LOSS IS GRADUAL & BILATERAL
2. CLIENTS STATE THEY HAVE NO PROBLEM
W/ HEARING, BUT THEY CANNOT
UNDERSTAND WHAT THE WORDS ARE
3. CLIENTS THINK THAT THE SPEAKER IS
MUMBLING
DEAFNESS
• HARD OF HEARING – SLIGHT OR MODERATE
HEARING LOSS THAT IS SERVICEABLE FOR
PERFORMING ACTIVITIES OF DAILY LIVING
• DEAF – HEARING IS NONFUNCTIONAL FOR
CARRYING OUT ACTIVITIES OF DAILY LIVING
DEAFNESS
RISK FACTORS
• CONDUCTIVE HEARING LOSSES -( TRANSMISSION DEAFNESS )
1. IMPACTED CERUMEN (WAX)
2. FOREIGN BODY IN EXTERNAL AUDITORY
CANAL
3. DEFECTS – THICKENING, SCARRING – OF
EARDRUM
4. OTOSCLEROSIS OF OSSICLES
DEAFNESS
RISK FACTORS
• SENSORINEURAL HEARING LOSSES –
( PERCEPTIVE OR NERVE DEAFNESS )
1. ARTERIOSCLEROSIS
2. INFECTIOUS DISEASES
MUMPS – MEASLES – MENINGITIS
3. DRUG TOXICITIES
QUININE – STREPTOMYCIN – NEOMYCIN
4. TUMORS
5. HEAD TRAUMA
6. HIGH-INTENSITY NOISES
DEAFNESS – ASSESSMENT
OBJECTIVE DATA
• INATTENTIVE OR STRAINED FACIAL
EXPRESSIONS
• EXCESSIVE LOUDNESS OR SOFTNESS OF
SPEECH
• FREQUENT NEED TO CLARIFY CONTENT OF
CONVERSATION OR INAPPROPRIATE
RESPONSES
• TILTING OF HEAD WHILE LISTENING
• LACK OF RESPONSE WHEN OTHERS SPEAK
DEAFNESS - ANALYSIS/ NSG.DX.
• AUDITORY SENSORY/PERCEPTUAL ALTERATION
R/T LOSS OF HEARING
• IMPAIRED SOCIAL INTERACTION R/T DEAFNESS
DEAFNESS – NURSING CARE /
IMPLEMENTATION
• GOAL: MAXIMIZE HEARING ABILITY & PROVIDE
EMOTIONAL SUPPORT
1. GAIN PERSON’S ATTENTION BEFORE
SPEAKING – AVOID STARTLING
2. PROVIDE ADEQUATE LIGHTING SO PERSON
CAN SEE YOU WHEN YOU ARE SPEAKING
3. LOOK AT THE PERSON WHEN SPEAKING
4. USE NONVERBAL CUES TO ENHANCE
COMMUNICATION, ie:
* WRITING – HAND GESTURES - POINTING
DEAFNESS – NURSING CARE /
IMPLEMENTATION
4. SPEAK SLOWLY, DISTINCTLY; DO NOT SHOUT
( EXCESSIVE LOUDNESS DISTORTS VOICE )
5. IF PERSON DOES NOT UNDERSTAND, USE
DIFFERENT WORDS: WRITE IT DOWN
6. SUPPORTIVE, NONSTRESSFUL ENVIRONMENT
7. USE ALTERNATIVE COMMUNICATION SYSTEM:
A.
SPEECH (LIP) READING
B.
SIGN LANGUAGE
C.
HEARING AID
D.
PAPER & PENCIL
E.
FLASH CARDS
DEAFNESS – NURSING CARE /
IMPLEMENTATION
• GOAL: HEALTH TEACHING
1. PREPARE FOR EVALUATIVE STUDIES
( AUDIOGRAM )
2. APPROPRIATE COMMUNITY RESOURCES, ie:
* NAT. ASSOC. FOR DEAF
3. USE OF HEARING AID, ie:
* CARE OF -- TESTING – SPARE BATTERIES
4. SAFETY PRECAUTIONS, ie:
* WHEN CROSSING STREETS -- DRIVING
DEAFNESS – EVALUATION /
OUTCOME CRITERIA
• METHOD OF COMMUNICATION ESTABLISHED
• ACHIEVES INDEPENDENCE, ie:
1. DOGS FOR DEAF
2. SPECIAL TELEPHONES
3. VISUAL SIGNALS
• COPES W/ LIFE-STYLE CHANGES, ie:
1. MINIMAL DEPRESSION
2. ANGER
3. HOSTILITY
EAR DISORDERS
OTOSCLEROSIS
DESCRIPTION
A. INSIDIOUS, PROGRESSIVE DEAFNESS
B. MOST COMMON CAUSE OF CONDUCTIVE
DEAFNESS
C. CAUSE UNKNOWN
D. DISEASE OF THE LABYRINTHE CAPSULE OF
THE MIDDLE EAR THAT RESULTS IN A BONY
OVERGROWTH OF TIESSUE SURROUNDING
THE OSSICLES
EAR DISORDERS
OTOSCLEROSIS
DESCRIPTION
E.
CAUSES THE DEVELOPMENT OF IRREGULAR AREAS
OF NEW BONE FORMATION & CAUSES THE
FIXATION OF THE BONES
F. STAPES FIXATION LEADS TO A CONDUCTIVE
HEARING LOSS
G. IF THE DISEASE INVOLVES THE INNER EAR,
SENSORINEURAL HEARING LOSS IS PRESENT
H. IT IS NOT UNCOMMON TO HAVE BILATERAL
INVOLVEMENT, ALTHOUGH HEARING LOSS MAY BE
WORSE IN ONE EAR
I. A PARTIAL STAPEDECTOMY W/ PROSTHESIS –
FENESTRATION – MAY BE FORMED
EAR DISORDERS
OTOSCLEROSIS
PATHOPHYSIOLOGY
• FORMATION OF NEW SPONGY BONE IN
LABYRINTH >
B. FIXATION OF STAPES >
C. PREVENTION OF SOUND TRANSMISSION
THRU OSSICLES TO INNER EAR FLUIDS
EAR DISORDERS
OTOSCLEROSIS
RISK FACTORS
A. HEREDITY
B. FEMALES
C. PUBERTY TO 45 yrs OLD
EAR DISORDERS
OTOSCLEROSIS
ASSESSMENT – SUBJECTIVE DATA
A. TINNITUS – CONSTANT RINGING / ROARING
B. DIFFICULTY HEARING – GRADUAL LOSS IN
BOTH EARS
C. SLOWLY PROGRESSIVE CONDUCTIVE
HEARING LOSS
EAR DISORDERS
OTOSCLEROSIS
ASSESSMENT – OBJECTIVE DATA
A. RINNE TEST
1. TUNING FORK PLACED OVER MASTOID
BONE
2. REDUCED SOUND CONDUCTION BY AIR &
INTENSIFIED BY BY BONE
3. NEGATIVE RINNE TEST W/ OTOSCLEROSIS
EAR DISORDERS
OTOSCLEROSIS
ASSESSMENT – OBJECTIVE DATA
B. WEBER TEST
1. TUNING FORK PLACED ON TOP OF
HEAD
2. INCREASED SOUND CONDUCTION
TO AFFECTED EAR
3. LATERALIZATION OF SOUND TO THE
EAR W/ THE MOST CONDUCTIVE
HEARING LOSS
EAR DISORDERS
OTOSCLEROSIS
ASSESSMENT – OBJECTIVE DATA
C. AUDIOMETRY
1. DIMINISHED HEARING
D. PINKISH DISCOLORATION – SCHWARTZE’S
SX. – OF THE TYMPANIC MEMBRANE, WHICH
INDICATES VASCULAR CHANGES W/IN THE
EAR
EAR DISORDERS
OTOSCLEROSIS
ANALYSIS / NURSING DIAGNOSIS
A. AUDITORY SENSORY/PERCEPTUAL
ALTERATION R/T HEARING LOSS
B. BODY IMAGE DISTURBANCE R/T HEARING
AID
C. INEFFECTIVE INDIVIDUAL COPING R/T GRIEF
REACTION TO LOSS
D. IMPAIRED SOCIAL INTERACTION R/T
HEARING LOSS
EAR DISORDERS
OTOSCLEROSIS
NURSING CARE PLAN / IMPLEMENTATION
&
EVALUATION / OUTCOME CRITERIA
SAME AS STAPEDECTOMY CARE PLAN
EAR DISORDERS
LABYRINTHITIS
DESCRIPTION
A. INFECTION OF THE LABYRINTH THAT OCCURS AS A
COMPLICATION OF ACUTE / CHRONIC OTITIS MEDIA
ASSESSMENT
A. HEARING LOSS THAT MAY BE PERMANENT ON THE
AFFECTED SIDE
B. TINNITUS
C. SPONTANEOUS NYSTAGMUS TO THE AFFECTED SIDE
D. VERTIGO
E.
NAUSEA & VOMITING
EAR DISORDERS
LABYRINTHITIS
IMPLEMENTATION
A. MONITOR FOR SX. OF MENINGITIS – MOST
COMMON COMPLICATION – AEB.
1.
HEADACHE
2.
STIFF NECK
3.
LETHARGY
B. ADMINISTER SYSTEMIC ANTIBIOTICS
C. ADVICE THE CLIENT TO STAY IN BED IN A DARKENED
ROOM
EAR DISORDERS
LABYRINTHITIS
IMPLEMENTATION
D. ADMINISTER ANTIEMETICS & ANTIVERTIGO
MEDS.
E. INSTRUCT THE CLIENT THAT THE VERTIGO
SUBSIDES AS THE INFLAMMATION RESOLVES
F. INSTRUCT THE CLIENT THAT BALANCE
PROBLEMS THAT PERSIST MAY REQUIRE
GAIT TRAINING THROUGH PHYSICAL
THERAPY
EAR DISORDERS
MENIERE’S DISEASE
• CHRONIC, RECURRENT DISORDER OF INNER EAR,
IE:
1. ATACKS OF VERTIGO
2. TINNITUS
3. VESTIBULAR DYSFUNCTION
• LASTS 30 MINUTES TO FULL DAY
• USUALLY NO PAIN OR LOSS OF CONSCIOUSNESS
EAR DISORDERS
MENIERE’S DISEASE
PATHOPYSIOLOGY
• ASSOCIATED W/ EXCESSIVE DILATATION OF
COCHLEAR DUCT ( UNILATERAL )
• RESULTING FROM OVERPRODUCTIVE OR
DECREASED ABSORPTION OF ENDOLYMPH >
• PROGRESSIVE SENSORINEURAL HEARING LOSS
EAR DISORDERS
MENIERE’S DISEASE
•
•
•
•
•
•
•
RISK FACTORS
EMOTIONAL OR ENDOCRINE DISTURBANCE, ie.:
DIABETES MELLITIS
SPASMS OF INTERNAL AUDITORY ARTERY
HEAD TRAUMA
ALLERGIC REACTION
HIGH SALT INTAKE
SMOKING
EAR INFECTIONS
EAR DISORDERS
MENIERE’S DISEASE
•
•
•
•
•
ASSESSMENT: SUBJECTIVE DATA
TINNITUS
HEADACHE
TRUE VERTIGO, ie:
A.
SUDDEN ATTACKS
B.
ROOM APPEARS TO SPIN
DEPRESSION – IRRITABILITY – WITHDRAWAL
NAUSEA ON SUDDEN HEAD MOVEMENT
EAR DISORDERS
MENIERE’S DISEASE
•
•
•
•
•
•
ASSESSMENT – OBJECTIVE DATA
IMPAIRED HEARING, ESPECIALLY LOW TONES
CHANGE IN GAIT – LACK OF COORDINATION
VOMITING W/ SUDDEN HEAD MOTIONS
NYSTAGMUS – DURING ATTACKS
DX. TEST – CALORIC
A.
COLD WATER IN EAR CANAL
B.
MAY PRECIPITATE ATTACK
DX. TEST – AUDIOMETRY
A.
LOSS OF HEARING
EAR DISORDERS
MENIERE’S DISEASE
ANALYSIS / NURSING DIAGNOSIS
• RISK FOR INJURY R/T VERTIGO, LACK OF COORDINATION
• AUDITORY SENSORY/PERCEPTUAL ALTERATION R/T
•
•
•
•
PROGRESSIVE HEARING LOSS
ANXIETY R/T UNCERTAINTY ABOUT TREATMENT
RISK FOR ACTIVITY INTOLERANCE R/T SUDDEN ONSET
OF VERTIGO
SLEEP PATTERN DISTURBANCE R/T TINNITUS
INEFFECTIVE INDIVIDUAL COPING R/T CHRONIC
DISORDER
EAR DISORDERS
MENIERE’S DISEASE
NURSING CARE PLAN / IMPLEMENTATION
A. GOAL : PROVIDE SAFETY & COMFORT DURING
ATTACKS
1. ACTIVITY:
A. BEDREST DURING ATTACKS
B. SIDERAILS UP
C. LOWER TO CHAIR / FLOOR IF ATTACK
OCCURS WHILE STANDING
D. ASSIST W/ AMBULATION – SUDDEN
DIZZINESS COMMON
EAR DISORDERS
MENIERE’S DISEASE
NURSING CARE PLAN / IMPLEMENTATION
A. GOAL : PROVIDE SAFETY & COMFORT DURING
ATTACKS
2. POSITION:
A. RECUMBENT
B. AFFECTED EAR UPPERMOST,
USUALLY
3. IDENTIFY PRODROMAL SX.
A. AURA
B. EAR PRESSURE
C. INCREASED TINNITUS
4. CALL BELL WITHIN REACH
EAR DISORDERS
MENIERE’S DISEASE
NURSING CARE PLAN / IMPLEMENTATION
B. GOAL: MINIMIZE OCCURRENCE OF ATTACKS
1. GIVE MEDICATIONS AS ORDERED
1. DIURETICS – TO DECREASE
ENDOLYMPHATIC FLUIDS ( DIAMOX )
2. ANTIHISTAMINES – TO INHIBIT TISSUE
EDEMA ( BENADRYL )
3. VASODILATORS – TO CONTROL
SPASMS ( NICOTINIC ACID )
4. ANTIEMETICS & ANTIVERTIGO AGENTS TO CONTROL NAUSEA & VOMITING
( ANTIVERT )
EAR DISORDERS
MENIERE’S DISEASE
NURSING CARE PLAN / IMPLEMENTATION
B. GOAL: MINIMIZE OCCURRENCE OF ATTACKS
2. DIET:
1. LOW SODIUM
2. LIMITED FLUIDS TO REDUCE
ENDOLYMPHATIC PRESSURE
3. AVOID PRECIPITATING STIMULI:
1. BRIGHT, GLARING LIGHTS
2. NOISE
3. SUDDEN JARRING
4. TURNING HEAD OR EYES - STAND IN
FRONT OF CLIENT WHILE TALKING
EAR DISORDERS
MENIERE’S DISEASE
NURSING CARE PLAN / IMPLEMENTATION
C. GOAL: HEALTH TEACHING
1. NO SMOKING – CAUSES VASOSPASMS
2. NO ALCOHOLIC BEVERAGES
1. CAUSES FLUID RETENTION
2. CONTRAINDICATED W/ MEDS
3. MANAGEMENT OF SYMPTOMS
1. PLAY RADIO TO MASK TINNITUS,
PARTICULARLY @ NIGHT
EAR DISORDERS
MENIERE’S DISEASE
NURSING CARE PLAN / IMPLEMENTATION
C. GOAL: HEALTH TEACHING
3. KEEP MEDICATION AVAILABLE @ ALL
TIMES
4. PREPARE FOR SURGERY IF INDICATED:
1. LABYRINTHECTOMY – IF HEARING IS
GONE
2. ENDOLYMPHATIC SAC
DECOMPRESSION – TO PRESERVE
HEARING
EAR DISORDERS
MENIERE’S DISEASE
EVALUATION / OUTCOME CRITERIA
A. DECREASED FREQUENCY OF ATTACKS
B. COMPLIES W/ TREATMENT REGIMEN &
RESTRICTIONS
1.
LOW – SODIUM DIET
2.
NO SMOKING
C. HEARING PRESERVED
EAR DISORDERS
MENIERE’S DISEASE
DRUG REVIEW
•
•
•
•
•
ANTIEMETICS – TIGAN / PHENERGAN
ANTIHISTAMINES – BENADRYL / DRAMAMINE
ANTIVERTIGO – VALIUM / ANTIVERT
DIURETICS – DIAMOX / DIURIL
VASODILATORS – NICOTINIC ACID
EAR DISORDERS
MASTOIDITIS
• DESCRIPTION
A. MAY BE ACUTE / CHRONIC
B. RESULTS FROM UNTREATED / INADEQUATELY
TREATED CHRONIC / ACUTE OTITIS MEDIA
C. PAIN IS NOT RELIEVED BY MYRINGOTOMY
• ASSESSMENT
A. SWELLING BEHIND THE EAR & PAIN W/
MINIMAL MOVEMENT
B. CELLULITIS ON THE SKIN / EXTERNAL SCALP
OVER THE MASTOID PROCESS
EAR DISORDERS
MASTOIDITIS
ASSESSMENT
C. A REDDENED , DULL, THICK, IMMOBILE
TYMPANIC MEMBRANE W/ OR W/OUT
PERFORATION
D. TENDER & ENLARGED POSTAURICULAR
LYMPH NODES
E. LOW-GRADE FEVER
F. MALAISE
G. ANOREXIA
EAR DISORDERS
MASTOIDITIS
IMPLEMENTATION
A. PREPARE THE CLIENT FOR SURGICAL REMOVAL OF
INFECTED MATERIAL
B. MONITOR FOR COMPLICATIONS
C. SIMPLE / MODIFIED RADICAL
MASTOIDECTOMY W/ TYMPANOPLASTY IS
THE MOST COMMON TREATMENT
D. ONCE TISSUE THAT IS INFECTED IS REMOVED,
TYMPANOPLASTY IS PERFORMED TO
RECONSTRUCT THE OSSICLES & THE TYMPANIC
MEMBRANE IN AN ATTEMPT TO RESTORE NORMAL
HEARING
EAR DISORDERS
MASTOIDITIS
COMPLICATIONS
A. DAMAGE TO THE ABDUCENS & FACIAL
CRANIAL NERVES
B. DAMAGE EXHIBITED BY INABILITY TO LOOK
LATERALLY - CRANIAL NERVE VI
C. DAMAGE EXHIBITED BY A DROOPING OF THE
MOUTH ON THE AFFECTED SIDE - CRANIAL
NERVE VII
D. MENINGITIS
EAR DISORDERS
MASTOIDITIS
COMPLICATIONS
E.
F.
G.
H.
BRAIN ABCESS
CHRONIC PURULENT OTITIS MEDIA
WOUND INFECTIONS
VERTIGO, IF THE INFECTION SPREADS INTO
THE LABYRINTH
EAR DISORDERS
MASTOIDITIS
POSTOPERATIVE IMPLEMENTATION
A. MONITOR FOR DIZZINESS
B. MONITOR FOR SIGNS OF MENINGITIS AS
EVIDENCED BY A STIFF NECK & VOMITING
C. PREPARE FOR A WOUND DRESSING CHANGE
24hrs POSTOPERATIVELY
D. MONITOR THE SURGICAL INCISION FOR
EDEMA DRAINAGE & REDNESS
E. POSITION THE CLIENT FLAT W/ THE
OPERATIVE SIDE UP
EAR DISORDERS
MASTOIDITIS
POSTOPERATIVE IMPLEMENTATION
F. RESTRICT THE CLIENT TO BED W/ BEDSIDE
COMMODE PRIVILEGES FOR 24hrs AS
PRESCRIBED
G. ASSIST THE CLIENT W/ GETTING OUT OF BED
TO PREVENT FALLING / INJURIES FROM
DIZZINESS
H. W/ RECONSTRUCTION OF OSSICLES VIA
GRAFT, PRECAUTIONS ARE TAKEN TO
PREVENT DISLODGING THE GRAFT
EAR DISORDERS
STAPEDECTOMY
DESCRIPTION
A. REMOVAL OF THE STAPES & REPLACEMENT W/ A
PROSTHESIS CONSISTING OF EITHER A:
1. STEEL WIRE /
2. TEFLON PISTON /
3. POLYETHYLENE
B. TREATMENT FOR DEAFNESS DUE TO OTOSCLEROSIS
C. FIXES THE STAPES, PREVENTING IT FROM
OSCILLATING & TRANSMITTING VIBRATIONS TO
THE FLUIDS IN THE INNER EAR
EAR DISORDERS
STAPEDECTOMY
ANALYSIS / NURSING DIAGNOSIS
A. SENSORY/PERCEPTUAL ALTERATION R/T EDEMA &
EAR PACKING
NURSING CARE PLAN / IMPLEMENTATION
A. PREOPERATIVE CARE: HEALTH TEACHING
1. IMPORTANT POSTOPERATIVELY TO KEEP
HEAD IN POSITION ORDERED BY M.D.
2. AVOID SNEEZING, BLOWING NOSE,
VOMITING, COUGHING – INCREASES PRESSURE
IN EUSTACHIAN TUBES
3. BREATHING EXERCISES
EAR DISORDERS
STAPEDECTOMY
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
1. GOAL: PROMOTE PHYSICAL & PSYCHOLOGICAL
EQUILIBRIUM
A. POSITION:
1. AS ORDERED BY M.D.- VARIES
2. SIDE RAILS UP R/T COMMON
VERTIGO
B. ACTIVITY:
1. ASSIST W/ AMBULATION
2. AVOID RAPID TURNING - > VERTIGO
EAR DISORDERS
STAPEDECTOMY
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
1. GOAL: PROMOTE PHYSICAL &
PSYCHOLOGICAL EQUILIBRIUM
C. DRESSINGS:
1. CHECK FREQUENTLY
2. MAY CHANGE COTTON PLEDGET IN
OUTER EAR
EAR DISORDERS
STAPEDECTOMY
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
D. MEDICATIONS:
1. ANTIEMETICS
2. ANALGESICS
3. ANTIBIOTICS
E. REASSURANCE
1. REDUCTION IN HEARING IS NORMAL
2. HEARING MAY NOT IMMEDIATELY IMPROVE
AFTER SURGERY
EAR DISORDERS
STAPEDECTOMY
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
2. GOAL: HEALTH TEACHING
A. EAR CARE:
1. KEEP COVERED OUTDOORS
2. KEEP OUTER EAR PLUG CLEAN, DRY &
CHANGED
EAR DISORDERS
STAPEDECTOMY
NURSING CARE PLAN / IMPLEMENTATION
B. POSTOPERATIVE CARE
2. GOAL: HEALTH TEACHING
B. AVOID:
1. WASHING HAIR FOR 2 WEEKS
2. SWIMMING FOR 6 WEEKS
3. AIR TRAVEL FOR 6 MONTHS
4. PEOPLE W/ URI’s
5. HEAVY LIFTING / STRAINING
EAR DISORDERS
STAPEDECTOMY
EVALUATION / OUTCOME CRITERIA
A. HEARING IMPROVES
1. EVALUATE 1 MONTH POSTOPERATIVELY
2. MAY REQUIRE HEARING AID
B. RETURNS TO WORK
1. USUALLY 2 WEEKS AFTER SURGERY
C. CONTINUES MEDICAL SUPERVISION
EAR DISORDERS
FENESTRATION
DESCRIPTION
A. REMOVAL OF THE STAPES W/ A SMALL HOLE
DRILLED IN THE FOOTPLATE
B. A PROSTHESIS IS CONNECTED BETWEEN THE
INCUS & FOOTPLATE
C. SOUNDS CAUSE THE PROSTHESIS TO VIBRATE IN
THE SAME MANNER AS DID THE STAPES
D. COMPLICATIONS INCLUDE:
1. HEARING LOSS
2. PROLONGED VERTIGO
3. INFECTION
4. FACIAL NERVE DAMAGE
EAR DISORDERS
FENESTRATION
PREOPERATIVE IMPLEMENTATION
A. INSTRUCT THE CLIENT IN MEASURES TO PREVENT
MIDDLE EAR / EXTERNAL EAR INFECTIONS
B. INSTRUCT THE CLIENT TO AVOID EXCESSIVE NOSE
BLOWING
C. INSTRUCT THE CLIENT NOT TO CLEAN THE EAR
CANAL W/ ANY FOREIGN OBJECT
D. INSTRUCT THE CLIENT TO REMOVE HEARING AID 2
WEEKS BEFORE SURGERY TO ENSURE THE
INTEGRATION OF LOCAL TISSUE
EAR DISORDERS
FENESTRATION
POSTOPERATIVE IMPLEMENTATION
A. INFORM THE CLIENT THAT HEARING IS INITIALLY
WORSE AFTER THE SURGICAL PROCEDURE
BECAUSE OF SWELLING & THAT NO NOTICEABLE
IMPROVEMENT IN HEARING MAY OCCUR FOR AS
LONG AS 6 WEEKS
B. INFORM THE CLIENT THAT THE GELFOAM EAR
PACKING INTERFERES W/ HEARING BUT IS USED TO
DECREASE BLEEDING
C. ASSIST W/ AMBULATING DURING THE FIRST 1 TO 2
DAYS AFTER SURGERY
EAR DISORDERS
FENESTRATION
POSTOPERATIVE IMPLEMENTATION
D. PROVIDE SIDE RAILS WHEN THE CLIENT IS IN BED
E. ADMINISTER ANTIBIOTICS, ANTIVERTIGO & PAIN
MEDS
F. ASSESS FOR:
1.
FACIAL NERVE DAMAGE
2.
WEAKNESS
3.
CHANGES IN TACTILE SENSATION
4.
VERTIGO
5.
NAUSEA & VOMITING
EAR DISORDERS
FENESTRATION
POSTOPERATIVE IMPLEMENTATION
G. INSTRUCT THE CLIENT TO MOVE THE HEAD
SLOWLY WHEN CHANGING POSITIONS – TO
PREVENT VERTIGO
H. INSTRUCT THE CLIENT TO AVOID PERSONS
W/ URI’s
I. INSTRUCT THE CLIENT TO AVOID
SHOWERING & GETTING THE HEAD AND
WOUND WET
EAR DISORDERS
FENESTRATION
POSTOPERATIVE IMPLEMENTATION
J.
INSTRUCT THE CLIENT TO REFRAIN FROM USING
SMALL OBJECTS TO CLEAN THE EXTERNAL EAR
CANAL
K. INSTRUCT THE CLIENT TO AVOID RAPID, EXTREME
CHANGES IN PRESSURE CAUSED BY:
1. QUICK HEAD MOVEMENTS
2. SNEEZING & NOSE BLOWING
L.. INSTRUCT THE CLIENT TO AVOID CHANGES IN
MIDDLE EAR PRESSURE BECAUSE THEY COULD
DISLODGE THE GRAFT / PROSTHESIS
EAR DISORDERS
TRAUMA
DESCRIPTION
A. THE TYMPANIC MEMBRANE HAS A LIMITED
STRETCHING ABILITY & GIVES WAY UNDER
HIGH PRESSURE
B. FOREIGN OBJECTS PLACED IN THE EXTERNAL
CANAL MAY EXERT PRESSURE ON THE
TYMPANIC MEMBRANE & CAUSE PERFORATION
C. IF THE OBJECT CONTINUES THROUGH THE CANAL,
THE BONY STRUCTURE OF THE STAPES, INCUS, &
MALLEUS MAY BE DAMAGED
EAR DISORDERS
TRAUMA
DESCRIPTION
D. A BLUNT INJURY TO THE BASAL SKULL & EAR CAN
DAMAGE THE MIDDLE EAR STRUCTURES THROUGH
FRACTURES EXTENDING TO THE MIDDLE EAR
E. EXCESSIVE NOSE BLOWING & RAPID CHANGES OF
PRESSURE THAT OCCUR W/ NONPRESSURED AIR
FLIGHTS CAN INCREASE PRESSURE IN THE MIDDLE
EAR
F. DEPENDING ON THE DAMAGE TO THE OSSICLES,
HEARING LOSS MAY / MAY NOT RETURN
EAR DISORDERS
TRAUMA
IMPLEMENTATION
A. TYMPANIC MEMBRANE PERFORATIONS
USUALLY HEAL W/IN 24 HOURS
B. SURGICAL RECONSTRUCTION OF THE
OSSICLES & TYMPANIC MEMBRANE
THROUGH TYMPANOPLASTY /
MYRINGOPLASTY MAY BE PERFORMED TO
IMPROVE HEARING
EAR DISORDERS
CERUMEN & FOREIGN BODIES
DESCRIPTION
A. CERUMEN / WAX IS THE MOST COMMON
CAUSE OF IMPACTED CANALS
B. FOREIGN BODIES CAN INCLUDE:
1.
VEGETABLES
2.
BEADS
3.
PENCIL ERASERS
4.
INSECTS
EAR DISORDERS
CERUMEN & FOREIGN BODIES
ASSESSMENT
A. SENSATION OF FULLNESS IN THE EAR W/ W/OUT
HEARING LOSS
B. PAIN, ITCHING OR BLEEDING
CERUMEN
A. REMOVAL OF WAX BY IRRIGATION IS A SLOW
PROCESS
B. IRRIGATION IS CONTRAINDICATED IN CLIENTS W/
A HISTORY OF TYMPANIC MEMBRANE
PERFORATION
EAR DISORDERS
CERUMEN & FOREIGN BODIES
CERUMEN (cont’d)
C. TO SOFTEN CERUMEN, ADD 3 DROPS OF
GLYCERIN TO THE EAR @ BEDTIME & 3
DROPS OF HYDROGEN PEROXIDE 2 X A DAY
D. AFTER SEVERAL DAYS THE EAR IS IRRIGATED
E. 50 TO 70 ml. OF SOLUTION IS THE MAXIMAL
AMOUNT A CLIENT CAN TOLERATE DURING
AN IRRIGATION SITTING
EAR DISORDERS
CERUMEN & FOREIGN BODIES
FOREIGN BODIES
A. W/ A FOREIGN OBJECT OF VEGETABLE
MATTER, IRRIGATION IS USED W/ CARE
BECAUSE THIS MATERIAL EXPANDS W/
HYDRATION
B. INSECTS ARE KILLED BEFORE REMOVAL
UNLESS THEY CAN BE COAXED OUT BY
FLASHLIGHT / A HUMMING NOISE
EAR DISORDERS
CERUMEN & FOREIGN BODIES
FOREIGN BODIES (cont’d)
C. MINERAL OIL / ALCOHOL IS INSTILLED TO
SUFFOCATE THE INSECT, WHICH IS THEN
REMOVED USING EAR FORCEPS
D. USE A SMALL EAR FORCEPS TO REMOVE THE
OBJECT & AVOID PUSHING THE OBJECT
FARTHER INTO THE CANAL AND DAMAGING
THE TYMPANIC MEMBRANE
EAR DISORDERS
ACOUSTIC NEUROMA
DESCRIPTION
A. A BENIGN TUMOR OF THE VESTIBULAR /
ACOUSTIC NERVE
B. THE TUMOR MAY CAUSE DAMAGE TO
HEARING & TO FACIAL MOVEMENTS AND
SENSATIONS
C. TREATAMENT INCLUDES SURGICAL
REMOVAL OF THE TUMOR VIA CRANIOTOMY
EAR DISORDERS
ACOUSTIC NEUROMA
DESCRIPTION
D. CARE IS TAKEN TO PRESERVE THE
FUNCTION OF THE FACIAL NERVE
E. THE TUMOR RARELY RECURS AFTER
SURGICAL REMOVAL
F. POSTOPERATIVE NURSING CARE IS
SIMILAR TO POSTOPERATIVE CRANIOTOMY
CARE
EAR DISORDERS
ACOUSTIC NEUROMA
ASSESSMENT
A. SYMPTOMS USUALLY BEGIN W/ TINNITUS &
PROGRESS TO GRADUAL SENSORINEURAL
HEARING LOSS
B. AS THE TUMOR ENLARGES, DAMAGE IN
ADJACENY CRANIAL NERVES OCCURS