Chapter 53
Care of the Patient with a
Visual or Auditory Disorder
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Overview of Anatomy and
Physiology
• Anatomy of the eye

Accessory structures of the eye
•
•
•
•
Eyebrows
Eyelashes
Eyelids
Lacrimal apparatus
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Slide 2
Figure 53-1
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
Lacrimal apparatus.
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Slide 3
Overview of Anatomy and
Physiology
• Anatomy of the eye (continued)

Structures of the eyeball
•
•
•
•
•
•
•
Sclera
Cornea
Choroid
Ciliary body
Iris
Pupil
Retina
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Slide 4
Overview of Anatomy and
Physiology
• Anatomy of the eye (continued)

Chambers of the eye
• Anterior chamber

Aqueous humor
• Posterior chamber

Vitreous humor
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Slide 5
Figure 53-2
(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.
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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
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Slide 7
Figure 53-3
(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 53-4
(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
The inner ear.
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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
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Slide 11
Laboratory and Diagnostic
Examinations
• Diagnostic eye tests

Snellen test
 Color vision
 Refraction
 Ophthalmoscopy
 Tonometry
 Amster grid test
 Schirmer’s tear test
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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
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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
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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
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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
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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
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Slide 20
Disorders of the Eye
• Keratitis (continued)

Clinical manifestations/assessment
•
•
•
•
•
Severe eye pain
Photophobia
Tearing
Edema
Visual disturbances
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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
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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
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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
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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
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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
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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 53-8
(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 53-9
(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
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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
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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 53-13
(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 53-14
(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
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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
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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
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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
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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
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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
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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
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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
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Slide 54