Transcript Nursing of Adults with Medical & Surgical Conditons

Nursing of Adults
with
Medical & Surgical Conditons
Eyes, Ears,
and
Special Senses
Layers of the Eyeball
Outer Layer
Sclera
Tough, white fibrous,
protective layer
Anterior portion is the
cornea
• transparent
• “Eye’s Window”
• lies over the colored part (iris)
of the eye
Remainder is white, and is
commonly known as the
“white of the eye”.
Layers of the Eyeball
Middle Layer
Choroid coat
Contains the blood vessels that
supply the eye
Anterior portion has three
separate structures
• Iris
–
–
–
–
the colored part of the eye
shaped like a donut
attaches to the ciliary body
opening in the middle is
called the pupil
• Ciliary Body
– muscular ring that alters the
shape of the iris
• Suspensory Ligament
– structure that holds the lens
in place
Layers of the Eyeball
Inner Layer
Retina
“The camera of the eye”
• receives image formed by the
lens
Only in the posterior portion of
the eye
consists of specialized nerve
tissue for the reception of light
Structure upon which light rays
come to focus
Contains tiny receptors
• rods - night vision
• cones - day vision
Optic Nerve
• conducts impulses from the
receptors to the brain
Humors of the Eyeball
Aqueous Humor
Watery, transparent liquid
that circulates through the
anterior cavity of the eye.
Maintains intraocular
pressure
Vitreous Humor
Clear, jelly-like fluid in the
posterior cavity
Fills the vitreous body to
give shape to the eye
Eye Muscles
Extrinsic Eye Muscles
Attach to the outside of the
eyeball and to the bones of the
orbit
Voluntary muscles
Move the eyeball in any desired
direction
Four are straight muscles
superior rectus, inferior rectus, medial
rectus, lateral rectus
Two are oblique muscles
superior oblique, inferior oblique
Eye Muscles
Intrinsic Eye Muscles
Located inside the eyeball
Two involuntary muscles
Iris
• donut shaped sphincter muscle
• regulates the size of the pupil;
amount of light entering eye
Ciliary Body
• flattened ring the size of the iris
• alters the shape of the iris
• changes the focus of the lens;
adjusts the eye for distant and
close-up vision
Accessory Structures of
the Eye
 Eyebrows and Eyelashes
Protect against foreign objects
entering the eye
 Eyelids
Located in front of the eyeball
Blink as a result of sensory
stimuli
Consist of voluntary muscle and
skin
Conjunctiva
• mucous membrane lining eyelids
• transparent and is continuous
over the surface of the eye
Palpebral Fissure
• Opening between the eyelids
Inner and Outer Canthus
• angles at the ends of the eyelids
Accessory Structures of
the Eye
 Lacrimal Glands and Ducts
Secrete tears
• keep anterior surface
moist and free from
irritating particles
Size of small almonds
Located in the upper,
outer portion of each
orbit
Nasolacrimal Ducts
• small tubes extending
from the lacrimal sacs
into the nose to drain
tears from the eye to
the nose
Parts of the Ear
External Ear
Pinna (auricle)
The outer, extended
portion
Composed of cartilage
and covered with skin
External Auditory Canal
About 1 inch in length
Contains cerumenous
glands
Tympanic Membrane
(eardrum)
Stretches across the
end of the auditory
canal
Separates the external
Parts of the Ear
Middle Ear
Small air cavity located in the
temporal bone
Contains three ossicles
Malleus (hammer)
• attached to tympanic
membrane
Incus (anvil)
• attached to the head of the
malleus
Stapes (stirrup)
• fits in the oval window
Allows transmission of sound
by the vibrations of the ossicles
Eustachian Tube
• Connects the middle ear with
the nasopharynx
• Allows equalization of air
pressure on both sides of the
eardrum
Parts of the Ear
Internal Ear
Contains essential organs
for hearing and equilibrium
Sends equilibrium and
hearing sensations to the
auditory nerve
Membranous Labyrinth
Lies within the bony labyrinth
Filled with fluid (endolymph)
Contains receptors for
•
•
•
•
equilibrium
sense of position
sense of head movement
hearing
Parts of the Ear
Bony Labyrinth
Cochlea
•
•
•
•
resembles the shape of a snail
filled with fluid (perilymph)
contains receptors for hearing
Organ of Corti
– hearing sense organ
– sends sensations to the cochlear nerve
Semi-circular Canals
•
•
•
•
Three canals placed at right angles to each other
Filled with fluid (endolymph)
Contain receptors for equilibrium
Movement of fluid stimulates the receptors; send the
message to the brain
Vestibule
• Between the cochlea and the semi-circular canals
• Maintain a sense of “up and down”.
Conduction
Air Conduction
Occurs in the external ear
Sound waves come through the external auditory meatus
and set the tympanic membrane in vibration
Bone Conduction
Occurs in the middle ear
The chain of ossicles transmits the vibration of the
tympanic membrane to the inner ear
Fluid Conduction
Occurs in the inner ear
Vibration of the ossicles sets the fluid system into motion
Movement of fluid in the cochlea stimulates the Organ of
Corti; to the auditory nerve; to the brain
Process of Hearing
Special Senses
Smell
Olfactory sense
Organ of Smell
Nose
Receptors for the olfactory nerve lie in the
mucosa of the upper part of the nasal cavity
Adaptation to odors is very rapid
receptors become fatigued
Special Senses
Taste
Gustatory Sense
Organ of taste
Tongue
Receptors are the taste buds located in the
papillae of the tongue
Four fundamental taste sensations
Salty - tip of the tongue
Sweet - tip of the tongue
Sour - sides of the tongue
Bitter - back of the tongue
Taste Receptors
Special Senses
Touch
Tactile receptors
Located throughout the integumentary system
Respond to touch, pressure, and vibration
Pain
Pain receptors
Located in the skin and viscera
Gives warning of potentially harmful
environmental changes
Touch and Pain
Receptors
Disorders
of the
Eye
Diagnostic Tests
Snellen’s Test
Purpose
Assessment of visual aculity
Used as screening test
Procedure
Pt stands 20 ft from chart
Covers one eye
Reads above or below the 20/20 line
Snellen’s Test
Color Vision
Purpose
Assess ability to see color
Prerequisite for driver’s license
Procedure
Color dots are reflected on a background of mixed
colors.
Pt identifies color patterns on the test field
Color Vision
Refraction
Purpose
Measure visual acuity to determine refractory
errors such as: myopia, hyperopia, presbyopia,
and astigmatism
Procedure
Ophthalmologist asks pt to indicate clear/blurred
vision with each lens change in the retinoscope.
Ophtalmoscopy
Purpose
Evaluation of underlying structures of the eye
Routine screening
Procedure
Mydriatic drops are applied
• Dilates pupils
Room is darkened
Pt is asked to focus on stationary object
Examiner uses ophthalmoscope to view internal eye
structure
Ophthalmoscopy
Tonometry
Purpose
Measurement of intraocular pressure
Determine tumors and glaucoma
Procedure
Examiner places tonometer on cornea
Pressure readings are obtained
Normal intraocular pressure ranges from 10 to 22
mm Hg
Tonometer
Amster Grid Test
Purpose
Diagnose and monitor macular problems
Procedure
Patient fixates on center dot and records any
abnormalities of the grid lines, such as wavy,
missing, or distorted areas.
Amster Grid
Schimirmer Tear Test
Purpose
Measures tear volume
produced throughout fixed time
period
Procedure
One end of lacrimal filter paper
is placed in lower cul-de-sac
Area of tear saturation is
measured after 5 minutes
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)
Blindness
and
Near Blindness
Signs & Symptoms
Diplopia
double vision
Pain
Floaters and light flashes
Pruritus
Burning of the eyes
Loss of peripheral vision
Halos
Orbital pressure
Bulging of the eyes
Blindness
and
Near Blindness
Treatment
Corrective eyewear
Canes
Seeing eye dogs
Magnifying systems
Surgical procedures
Refractory Errors
Astigmatism
Strabismus
Myopia
Hyperopia
Refractory Errors
Etiology/Pathophysiology
Astigmatism
-unequal curve in the shape of the cornea or lens
Refractory Errors
Strabismus
-inability of the eyes to focus in one direction
-cross-eyed
Refractory Errors
Myopia
Nearsightedness
Eyeball is too long
Refractory Errors
Hyperopia
Farsightedness
Eyeball is too short
Refractory Errors
Signs & Symptoms
Diminished or blurred vision
Treatment
Corrective lenses
Surgical correction
Conjunctivitis
Etiology/Pathophysiology
Inflammation of the conjunctiva
Bacterial or viral infection
Allergy
Environmental factors
Commonly called “pink eye”
Conjunctivitis
Signs & Symptoms
Erythema of the conjunctiva
Edema of the eyelid
Crusting discharge
Pruritus
Burning
Excessive tearing
Conjunctivitis
Treatment
Warm compresses
Eye irrigations with normal saline
Antibiotic drops or ointment
Keep free of exudate
Keratitis
Etiology/Pathophysiology
Inflammation of the cornea
Injury, irritants, allergies, viral infection, or
diseases
Pneumoccoucs, staphylococcus,
streptococcus and Pseudomonas are most
common types of bacterial causes.
Herpes simplex is most common viral cause.
Keratitis
Signs & Symptoms
Severe eye pain
Photophobia
Tearing
Edema
Visual disturbances
Keratitis
Treatment
Topical antibiotic therapy
Systemic antibiotics
Analgesics
Pressure dressings
relax eye muscle and decrease discomfort
Warm or cold compresses
Epithelial debridement
Keratoplasty
corneal transplant
Cataracts
Etiology/Pathophysiology
Noninfectious opacity or clouding of the lens
Congenital
Acquired
Senile
associated with older adults
most common
Cateracts
Cataracts
Signs & Symptoms
Blurred vision
Diplopia
double vision
Photosensitivity
Decreased night vision
Opacity in the center portion of lens
Cataracts
Treatment
Surgical
removal
Lens implant
or glasses
Post-Op
Avoid direct sunlight
Bedrest with BRP’s
Analgesics
No bending down or straining
Avoid coughing, sneezing, and blowing nose
Diabetic Retinopathy
Etiology/Pathophysiology
Disorder of retinal blood vessels
Capillary microaneurysms, hemorrhage,
exudates and formation of new vessels and
connective tissue
Usually occurs approximately 10 years after
onset of DM
Diabetic Retinopathy
Signs & Symptoms
Microaneurysms
identified by ophthalmoscopy
Progressive loss of vision
“floaters”
Diabetic Retinopathy
Treatment
Photocoagulation
destroys new blood vessels
seals leaking vessels
helps prevent retinal edema
Vitrectomy
used if photocoagulation is not possible
Removal of vitreous and replaces it with saline
Macular Degeneration
Etiology/Pathophysiology
Slow, progressive loss of central and near
vision due to aging retina
Macular Degeneration
Signs & Symptoms
Gradual and variable bilateral loss of vision
Color perception may also be affected
Macular Degeneration
Treatment
Usually no treatment
May use photocoagulation if new vessels
have not involved the macular retina
Retinal Detachment
Etiology/Pathophysiology
Separation of the retina from the choroid in
the posterior area of the eye
Usually results from a hole in the retina that
allows vitreous humor to leak between the
choroid and the retina
Trauma
Aging
Inflammation
Retinal Detachment
Signs & Symptoms
Sudden or gradual development of flashes of
light, followed by floating spots and loss of a
specific field of vision
Retinal Detachment
Treatment
Photocoagulation
burn localized tears or breaks
Cryosurgery
freeze the borders of a retinal hole
Diathermy
burns retina break using ultrasonic probe
Scleral buckling
pulls the choroid and sclera back together using
an encircling band around the outside of the
eyeball
Glaucoma
Etiology/Pathophysiology
An abnormal condition of elevated pressure
within an eye
Obstruction of outflow of aqueous humor
Causes damage to optic nerve
Two types
Open-angle
• slowly progressive; results from degeneration
Closed-angle
• occurs if there is an abrupt angle change of the iris
Glaucoma
Signs & Symtoms
Open-angle
No s/s during early stages
Tunnel vision
Eye pain
Difficulty adjusting to darkness
Halos around lights
Inability to detect colors
Closed-angle
Severe pain
Decreased vision
Nausea and vomiting
Erythema of the sclera
Enlarged and fixed pupil
Halos around lights
Glaucoma
Treatment
Open-angle glaucoma
Beta-blockers
• Betoptic
• reduces intraocular pressure
Miotics
• Piolcarpine
• causes the pupil to constrict; drawing the iris away from
the cornea; allowing drainage of aqueous humor
Carbonic anhydrase inhibitors
• Diamox
• decreases production of aqueous humor
Glaucoma
Closed-angle
Osmotic diuretics
• Mannitol, carbonic anhydrase inhibitors, and miotics
Iridectomy
• removal of part of the iris
• restores drainage of the aqueous humor
Corneal Injuries
Etiology/Pathophysiology
Result from injuries to corneal layers of the
eye
Foreign bodies are the most common cause
dust particles, propellants, and eyelashes
Burns
chemical irritants
Abrasions and lacerations
usually superficial caused by fingernails or
clothing
Penetrating wounds
Corneal Injuries
Signs & Symptoms
pain with movement of eye
excessive tearing
erythema of conjunctiva
pruritis
Corneal Injuries
Treatment
Flush with normal saline or water
Antibiotic drops or ointment
Penetrating wounds
do not remove object if present
cover both eyes
• may need to use a cup to cover object
seek medical attention
Disorders
of the
Ear
Diagnostic Tests
Otoscopy
Visualize external canal and eardrum
Tuning Fork Tests
Weber’s Test
Assesses auditory acuity
Uses tuning forks
Distinguishes conductive
from sensorineural loss
Tuning fork is placed on the
center of the patient’s
forehead
Rinne Test
Distinguishes conductive from senorineural
hearing loss
Uses tuning forks
Tuning fork is placed close to the external
auditory meatus
Audiometric Testing
Assesses frequencies and tones
Vestibular Testing
Romberg Test
Measures ability to perform specific tasks with
eyes open and then closed
Assesses balance
Past-point Test
Ability to place a finger accurately on a selected
point on the body
Assesses coordination
Hearing Loss
(Deafness)
Etiology/Pathophysiology
Decreased auditory acuity
Partial
Complete
Most common disability in the U.S.
Affects development of speech and
conceptual ability
Hearing Loss
(Deafness)
Six types of hearing loss
Conductive
• Sound is inadequately conducted through the external or
middle ear
• Common cause is buildup of cerumen
Sensorineural
• Defect in inner ear results in distortion
• Trauma, infectious processes, age, or exposure to
ototoxic drugs
• Destruction of cochlear hair by intense noise
Mixed
• Combined conductive and sensorineural
Hearing Loss
(Deafness)
Congenital
•
•
•
•
Present from birth or early infancy
Anoxia or trauma during delivery
Rh incompatibility
Mother’s exposure to syphilis or rubella, or exposure to
ototoxic drugs
Functional
• No known cause for loss
Central
• Brain’s auditory pathways are damaged
• CVA
Hearing Loss
(Deafness)
Signs & Symptoms
Requests for repeating information
Nonresponse
Delayed speech development
Hearing Loss
(Deafness)
Treatment
According to cause
Hearing aids
Surgical procedures
Cochlear implant
External Otitis
Etiology/Pathophysiology
Inflammation or infection of the external canal
“Swimmer’s Ear”
Allergy, bacteria, fungi, viruses, and trauma
External Otitis
Signs & Symptoms
Pain with movement of auricle or chewing
Erythema, scaling, pruritus, edema, watery
discharge and crusting of the external ear
External Otitis
Treatment
Oral analgesics
Corticosteroids
Antibiotic or antifungal ear drops
Systemic antibiotics
Otitis Media
Etiology/Pathophysiology
Inflammation or infection of the middle ear
Occurs most often in children (6-36 months)
shorter and straighter eustachian tubes
Bacterial, viral, allergies
Otitis Media
Signs & Symptoms
Fullness in the ear
Severe, deep, throbbing pain
may disappear if tympanic membrane ruptures
Hearing loss
Tinnitus
Fever
Otitis Media
Treatment
Antibiotics
organism specific
Analgesics
Local heat
Nasal decongestants
Aspiration of fluid from behind eardrum
Myringotomy
surgical incision of the tympanic membrane
may also place tubes
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
Labyrinthitis
Signs & Symptoms
Severe and sudden vertigo
Nausea and vomiting
Nystagmus
involuntary movement of eyes
Photophobia
Headache
Ataxic gait
Labyrinthitis
Treatment
Antibiotics
Dramamine or Meclizine for vertigo
IV fluids if N/V
Obstructions of the Ear
Etiology/Pathophysiology
Impaction or excessive secretion of cerumen
Foreign bodies
insects, beans, pebbles, small toys
Obstructions of the Ear
Signs & Symptoms
Tinnitus or buzzing
Pain in the ear
Slight hearing loss
Tugging at ear
Obstructions of the Ear
Treatment
Removal of cerumen by irrigation
Foreign objects are removed with forceps
May require surgery
Carbamide peroxide to soften cerumen
Otosclerosis
Etiology/Pathophysiology
Chronic progressive
deafness
Formation of spongy bone,
esp around the oval
window
Cause unknown
Familial
Women are affected twice
as often as men
Otosclerosis
Signs & Symptoms
Slowly progressive conductive hearing loss
Tinnitus
Dizziness to vertigo
Otosclerosis
Treatment
Stapedectomy
Air conduction hearing aid
if stapedectomy is not indicated
Meniere’s Disease
Etiology/Pathophysiology
Chronic disease of the inner ear
Recurrent episodes of vertigo, progressive
unilateral nerve deafness, and tinnitus
Most common in women; 50-60 years of age
Cause unknown
Increase in endolymph fluid
increased production or decreased absorption
Meniere’s Disease
Signs & Symptoms
Vertigo
Nausea
Tinnitus
Hearing loss
Vomiting
Diaphoresis
Nystagmus
Meniere’s Disease
Treatment
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