Sensory EENT Disorders(2) Edited

Care of Clients with Care of Clients with Sensory ProblemsSensory Problems

Care of Clients with Care of Clients with Sensory ProblemsSensory Problems

Pocholo Santos Chinese General Hospital College of Nursing

NCM 104

Diagnostic AssessmentDiagnostic AssessmentDiagnostic AssessmentDiagnostic Assessment1. Eye

a. Snellen’s Chart To check visual acuity

b. Tonometry To measure intra-ocular pressure N=12-20 mmHg

c. Perimetrya. To check peripheral vision

d. Bjerrum’s tangent screen For central vision

e. Ishihara plate Color vision

Diagnostic AssessmentDiagnostic AssessmentDiagnostic AssessmentDiagnostic Assessment

2. Eara. AudiometryDecibels

Unit of measurement in hearing 70 decibels do not damage the ear

Conductive Hearing Loss Problems with tympanic membrane, middle ear

or mastoid Sensorineural Hearing Loss

Problems of the Cochlea (sensory) and acoustic nerve (neural)

Mixture Hearing Loss Combinatation of conductive and sensorineural

affectation


Vestibular function• Diagnostic test for balance and

equilibrium• Oculovestibular reflex or calorie test

• Test 8th cranial nerve• Cold or hot water into external

auditory canal produces nystagmus


Tuning forkWeber test

• On patient’s forehead or teethRinnes test

• Shifted between mastoid bone and 2 inches from the ear canal opening

Eyes DisordersEyes Disorders

Anatomy & PhysiologyAnatomy & Physiology[EYES][EYES]

Anatomy & PhysiologyAnatomy & Physiology[EYES][EYES]Outer Protective Layer

Sclera - the white visible portion of the eyeball. The muscles that move the eyeball are attached to the sclera.

Cornea - the clear, dome-shaped surface that covers the front of the eye. Middle Vascular Layer Choroid - the thin, blood-rich membrane that lies between the retina and the

sclera; responsible for supplying blood to the retina. Ciliary body - the part of the eye that produces aqueous humor. Iris - the colored part of the eye. The iris is partly responsible for regulating the

amount of light permitted to enter the eye.Inner Neural Layer Pupil - the opening in the middle of the iris through which light passes to the back

of the eye. Retina - the light-sensitive nerve layer that lines the back of the eye. The retina

senses light and creates impulses that are sent through the optic nerve to the brain.

Anatomy of the EyeAnatomy of the Eye



Refractive Media Cornea - transparent layer that forms the external coat of the

anterior portion of the eye Aqueous humor - the clear, watery fluid in the front of the

eyeball. Lens (Also called crystalline lens.) - the transparent

structure inside the eye that focuses light rays onto the retina. Vitreous body - a clear, jelly-like substance that fills the back

part of the eye.

GlaucomaGlaucomaGlaucomaGlaucoma increased intraocular pressure which can damage

optic nerve that eventually lead to blindness• Causes:

• Congenital, inherited, trauma

2 TYPES of GLAUCOMA2 TYPES of GLAUCOMA

( Narrow Angle or Close Angle)

Imbalance in the production and excretion of aqueous humor that leads to intraocular tension and displacement of iris against the angle of anterior chamber

( Simple, Wide or Open Angle)

Actual obstruction in the excretion of the aqeuous humor

Slow, gradual development Asymptomatic at first

GLAUCOMA (ACUTE AND CHRONIC)

Risk factors:1. Unknown2. Emotional disturbances3. Hereditary factors4. Allergies


Subjective Data1. Acute (Close-angle)

a. Pain, severe in and around eyesb. Headachec. *Rainbow halos around lightsd. Blurring of visione. Nausea, vomiting

2. Chronic (Open-angle)a. Eyes tire easilyb. *Loss of peripheral vision


Objective Data1. Corneal edema2. *Decreased peripheral vision3. Increased cupping of optic disc4. Tonometry pressures 22 mm. Hg5. Pupils dilated6. Redness of eye


Analysis/Nursing Diagnosis1. Visual sensory/perceptual alterations2. Pain3. Risk for injury


Nursing Care Plan/Implementation1. Goal: reduce intraocular pressure

a. Bed restb. Semi Fowler’sc. Medications:

i. Miotics (pilocarpine, carbachol) ii. Carbonic anhydrase inhibitors (acetazolamide [Diamox]) iii. Anticholinesterase (demecarium bromide [Humorsol]) iv. Ophthalmic (timolol)


2. Goal: health teachinga. Prevent increased IOP by avoiding

i. Anger, excitement, worry ii. Constrictive clothing iii. Heavy lifting iv. *Atropine or other mydriatics, which

cause dilation v. Straining at stool vi. Eye strain

b. Relaxation techniquesc. Prepare for surgical correction if indicated: laser

trabeculoplasty, trabeculectomy

CATARACT

Pathophysiology1. Developmental or degenerative opacification of the

crystalline lens.

CATARACT

Risk Factors1. Aging2. Trauma3. Toxins4. Congenital defect

CATARACT

Subjective Data1. Blurring2. Loss of acuity3. Distortion4. Diplopia5. Photophobia

CATARACT

Objective Data1. Blindness (bilateral or unilateral)2. Loss of red reflex3. Gray opacity of lens

CATARACT

Analysis/Nursing Diagnosis1. Visual sensory/perceptual alterations2. Risk for injury3. Social isolation

Nursing ManagementNursing Management

ECCE- extracapsular cataract extraction- anterior portion of the lens capsule plus the capsule contents are removed

ICCE- intracapsular cataract extraction Cryoextraction- use of frozen probes to remove lens Iridectomy - creation of an opening for the flow of aqeous humor

which may be blocked post op; prevention of secondary glaucoma

Phacoemulsification- ultrasonic vibratin to breakup the lens Intraocular lens implant- lens prosthesis Cataract glasses


Post op care Eye dressing with Eye shield AAT Eye shield at night for the 1st month Cataract lens (aphakic glasses) - appears 1/4 closer IOL implant - an alternative for better binocular vision

Made of polyethyl methacrylate OOB 1day post op COD OD until 7 -10 days Eye drops as ordered

Retinal DetachmentRetinal Detachment Sensory retina separates from the pigment

epithelium of the retina

Causes: Retinal DetachmentCauses: Retinal Detachment

congenital malformations

trauma (including previous ocular surgery)

vascular disease

choroidal tumors

hemorrhage

high myopia or vitreous disease, or degeneration

Exudates that occur in front or behind the retina

Aphakia (absence of crystalline lens)

Management Eye bandaged Specific positioning prescribed by MD. Head positioned so that retinal tear or hole is at

the lowest point of the eye. Surgical

Both eyes bandagedResume activities in 3-5 weeksCold compresses to decrease edema

Signs and SymptomsSigns and Symptoms

Flashes of lights Floating spots Progressive blurring of vision - visual field deficits - visual

loss Visual curtain Anxiety, confusion, fearDiagnostics Opthalmoscopic exam - gray, opaque retina, with folds,

holes, tears


Discuss surgical options Photocoagulation- intense beam of light directed to close the retinal

tear Cryosurgery- subfreezing temperatures applied to the surface of the

sclera in the area of the hole to produce inflammatory reaction Diathermy- needle point electrode applied through sclera Scleral buckling- sclera and corroid are intended or buckled toward the

retinal break Injecting an intraocular gas bubble to promote adhesion


Bed rest with eyes covered Place on a dependent position Immediate Surgery - reattach the retina Pre Op care and Mydriatics OU as ordered; eye patches OU Post op care

Affected area should be on the upper position Activities - consulted with the MD Pressure patch over the affected eye Rest the eyes and head immediate post op Avoid increase IOP (coughing, straining, NV) COD OD

UveitisUveitis

inflammation of the eye's uvea

Uveal tract - middle vascular layer of the eye, contributing to the retina’s blood supply

TypesTypes

Anterior uveitis

Intermediate uveitis

Posterior uveitis

Diffuse uveitis

UveitisUveitis

Uveitis Iritis Iridocyclitis Choroiditis Choroiretinitis

Causes: Local/systemic disease Injury Unidentified factors

S/s Pain in the eyeball radiating

to forehead Blurred vision Photophobia Redness of the eyes without

purulent discharge Small pupil lacrimation


Mydriatics (AtSO4, Scopolamine) To dilate pupils To prevent adhesion between ant capsule of

the lens and iris To relieve pain and photophobia To reduce congestion To rest the iris and ciliary body

Steroids Dark glasses Analgesics

Refraction errors:Refraction errors:Refraction errors:Refraction errors:HyperopiaFarsightedness (convex lens)

MyopiaNearsightedness (concave lens)

AstigmatismDistorted vision

PresbyopiaOld sight

Eye SurgeriesEye SurgeriesEye SurgeriesEye SurgeriesEnucleation-removal of eyeballEvisceration- removal of the contents of the

eye with retention of the scleraExenteration- removal of the entire eye and all

other soft tissues in the boney orbit

Care of Patientsundergoing Eye Surgery


If OU are covered post op, pt needs to be oriented to hospital set up and staff

Pediatric clients need to practice covering the eyes pre op to allay anxiety, restlessness and fear post op

Call light / bell should always be within reach Prep on the eyes on the day of surgery - dilate pupils

using mydriatics



Post op care Prevent increase IOP Prevent stress in the suture

line Prevent hemorrhage Prevent infection Keep the head still Position on the unoperative

side or supine Burning sensation - wearing off

of anesthesia Avoid lifting of head, hips,

straining, squeezing eyelids

Open mouth when sneezing, coughing

Open eyes when vomiting Avoid bending forward to prevent

tension at suture line Gradual mobility/positional

changes Side rails up Bedside table at unoperative side Assistance in ambulation Help them learn to feed

themselves



Cont… Post op dressing should not be loosened or removed Minimal bleeding is normal Edema of eyelids will subside 3-4 days post op Feeling of something in the eye 4-5 days due to

sutures Sensation of pressure within the eye/ sharp pain may

indicate bleeding - report to MD ASAP

Rehabilitation of a Blind Person


Referrals Orient to the environment. Set up and location of things. Promote independence in ADL May have guide dog, use of cane for direction Talk before touching when approaching Assist in ambulation. Held the client in your arm so you are

one step ahead of him Talk to him frequently so he wont feel neglected Be relaxed and unhurried. Tell procedure before performing



Do not change the environment without describing the change

Promote safety Do not rush up and offer help unless it is clear that

the person wants help Choice of gifts to blind person: gifts that appeal to

senses other than vision

Ear DisordersEar Disorders

Anatomy & PhysiologyAnatomy & PhysiologyAnatomy & PhysiologyAnatomy & Physiology

Anatomy & PhysiologyAnatomy & Physiology

External or outer ear pinna or auricle - the outside part of the

ear. external auditory canal or tube - the

tube that connects the outer ear to the inside or middle ear.

tympanic membrane - also called the eardrum. The tympanic membrane divides the external ear from the middle ear.

Anatomy & PhysiologyAnatomy & Physiology

Middle ear (tympanic cavity) ossicles - three small bones that are connected and transmit the sound waves to

the inner ear malleus incus stapes

eustachian tube - a canal that links the middle ear with the throat area helps to equalize the pressure between the outer ear and the middle ear.

Inner ear cochlea (contains the nerves for hearing) vestibule (contains receptors for balance) semicircular canals (contain receptors for balance)

Conductive Hearing LossConductive Hearing LossConductive Hearing LossConductive Hearing Loss

Various problems involving impaired passage of sound from the external ear to inner ear

Causes: Cerumen impaction External otitis media Serous otitis media Suppurative otitis media Otosclerosis

PathophysiologyPathophysiology

Impacted cerumen in the external ear can block sound from reaching the tympanic membrane

External otitis media - inflammation of the external ear with crust and edema

Serous otitis media - involves sterile fluid accumulation in the middle ear

Suppurative otitis media - pus accumulation in the middle ear extending to other structure

Otosclerosis - spongy bone growth over the normal body babyrinth causing the footplate of the stapes to become fixed

Signs and SymptomsSigns and SymptomsSigns and SymptomsSigns and Symptoms Cerumen impaction

Visible impaction in the ear canal

External otitis media Itching Pain Water or purulent discharge

Serous otitis media Plugged feeling in the ear Reverberation of own voice Hearing loss

Suppurative otitis media Throbbing ear pain Fever, NV Hearing loss Feeling of increased pressure in

the ear Bright red, bulging or retracted

tympanic membrane Tympanic membrane rupture with

discharge Otosclerosis

Mixed hearing loss tinnitus

Laboratory & Diagnostic FindingsLaboratory & Diagnostic Findings

Otitis Media 1st stage: tympanic membrane - retracted 2nd stage: tympanic membrane dilate and appear red 3rd stage: tympanic membrane becomes red, thickened,

and bulging with a loss of landmarks 4th stage: perforation, pus and blood drain from the ear

Otosclerosis Reduced air conduction with bone conduction

Nursing ManagementNursing ManagementNursing ManagementNursing Management

Impacted cerumen Soften with instilled peroxide or glycerol preparation Irrigate ear in 2-3 days to remove the wax Keep the otic solution in the ear for 15 mins - tilting head

sideways and putting cotton Notify MD if irritation/inflammation occurs


Care of client with tympanic membrane perforation Maintain strict asepsis Do not irrigate the ear Protect from water contamination (use of ear plugs) Recognize the risk for meningitis Use message board if necessary Hearing aid if indicated


Treat external otitis media Topical antibiotics, steroids Gentle debridement Acid alcohol solutions to sterilize auditory canal

Prepare in possible myringotomy (serous OM) Incision in the tympanic membrane to relieve pressure and

pus


Suppurative OM Systemic antibiotics Nasal decongestants Analgesics

Discuss possible surgery Mastoidectomy Myringoplasty Tympanoplasty

Assist in surgical management for otosclerosis

a. Stapedectomy - replacement of diseased ossicles with prosthesis

b. Fenestration - creation of a new window into the labyrinth to provide new pathway for sound

c. Hearing aidd. Communication techniques

EAR DISORDERSMENIERE’S DISEASE

1. Chronic recurrent disorder of inner ear

2. Attacks of vertigo, tinnitus, and vestibular dysfunction

3. Lasts 30 min. to a full day4. Associated with excessive

dilatation of cochlear duct (unilateral) resulting from overproduction or decreased absorption of endolymph

5. Characterized by progressive sensorineural hearing loss


Risk factors1. Emotional or endocrine disturbance2. Spasms of internal auditory artery3. Head trauma4. Allergic reaction5. High salt intake6. Smoking7. Ear infections


Subjective Data1. Tinnitus2. Headache3. True vertigo: sudden attacks, room appears to spin4. Depression, irritability, withdrawal5. Nausea on sudden head motion


Objective Data1. Impaired hearing, especially low tones2. Change in gait, lack of coordination3. Vomiting with sudden head motion4. Nystagmus—during attacks5. Diagnostic test:

a. Cold caloric may precipitate attackb. Loss of hearing by audiometry


Analysis/Nursing Diagnosis1. Risk for injury2. Auditory/sensory perceptual alteration3. Risk for activity intolerance


Nursing Care Plan/Implementation1. Goal: Minimize occurrence of attacks

a. Medications i. Diuretics (clorothiazide [Diuril],

acetazolamide [Diamox]) ii. Antihistamines (dimenhydrinate

[Dramamine], diphenhydramine HCL [Benadryl)


iii. Vasodilators (nicotinic acid) to control vasospasms

iv. Antiemetics and antivertigo agents (diazepam [Valium], meclizine HCL [Antivert])b. Diet: Low sodium, avoid caffeine, limited

fluidsc. Avoid precipitating stimuli: bright, glaring

lights, noise, sudden jarring, turning head or eyes

2. Goal: health teachinga. No smokingb. Play radio to mask tinnitus particularly at

night

Acoustic NeuromaAcoustic NeuromaAcoustic NeuromaAcoustic Neuroma

a benign tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear

AKA: vestibular schwannoma or neurolemmoma


Causes: exposure to loud noise on a consistent basis prior exposure to head and neck radiation history of parathroid adenoma Use of hand held cellular phones (under study)

Diagnostic procedure Audiometry (hearing testing) MRI scanning of the head with contrast.


a one-sided, slowly progressive hearing impairment

hearing loss at low frequency Hearing loss Vertigo HA hearing loss at low frequency

OTOSCLEROSIS

Pathophysiology1. Insidious, progressive deafness2. Most common cause of conductive deafness3. Cause unknown4. Formation of new spongy bone in labyrinth5. Results in fixation of stapes6. Leads to prevention of sound transmission through

ossicles to inner ear fluids.

OTOSCLEROSIS

Risk Factors1. Heredity2. Females, puberty to 45 yrs.

http://www.tchain.com/cv/hain-t.htm

OTOSCLEROSIS

Subjective Data1. Tinnitus2. Difficulty hearing; gradual loss in both ears

OTOSCLEROSIS

Objective Data1. Rinne (mastoid)- reduced sound conduction by air

and intensified by bone2. Weber (top of head)- increased sound conduction to

affected ear3. Audiometry—diminished hearing

OTOSCLEROSIS

Analysis/Nursing Diagnosis1. Auditory sensory/perceptual alteration2. Body image disturbance

OTOSCLEROSIS

Nursing Care Plan/Implementation(Discussed in next section: stapedectomy)

STAPEDECTOMY

Pathophysiology1. Removal of the stapes and replacement with a

prosthesis2. Treatment of deafness due to otosclerosis, fixes the

stapes preventing it from oscillating and transmitting vibrations to the fluids in the inner ear

STAPEDECTOMY

Analysis/Nursing Diagnosis1. Sensory perceptual alteration

STAPEDECTOMY

Nursing Care Plan/Implementation1. Pre operative Care: health teaching

a. Keep head in position as orderedb. Avoid sneezing, blowing nose, vomiting,

coughing2. Post operative care

a. Goal: health teaching i. Avoid

1. Washing hair for 2 weeks 2. Swimming for 6 weeks3. Air travel for 6 months4. People with URI5. Heavy lifting or straining

DEAFNESS

Risk Factors1. Conductive hearing losses (transmission deafness)2. Impacted cerumen3. Foreign body4. Defects5. Otosclerosis of ossicles6. Sensorineural hearing losses (perceptive or nerve

deafness)7. Arteriosclerosis8. Infectious diseases (mumps, measles, meningitis)9. Drug toxicities10.Tumors11.Head trauma12.High intensity noises

DEAFNESS

Objective Data1. Inattentive or strained facial expression2. Excessive loudness or softness of speech3. Frequent need to clarify content of conversation4. Tilting of head while listening5. Lack of response

DEAFNESS

Nursing Care Plan/Implementation1. Goal: maximize hearing ability and provide

emotional supporta. Gain person’s attention before speakingb. Provide adequate lightingc. Look at the person when speakingd. Use non verbal cuese. Speak slowly and distinctly. Do NOT shoutf. Use different words if the person does not seem

to understandg. Use alternative communication devices

DEAFNESS

2. Goal: health teachinga. Care of a hearing aid

i. Clean ear mold PRN ii. Keep hearing aid dry iii. Turn hearing aid off at night iv. Store away from pets v. Leave aid in same place

every nightb. Safety precautions: when crossing street, driving

Communicating with a Client with Hearing Impairment

Communicating with a Client with Hearing Impairment

Talk directly to the patient facing her/him Talk in normal tone of voice. Clearly enunciate words Use gestures with speech Do not whisper in front of pt with hearing impairment Do no avoid conversation Do not show annoyance e.g. facial expressions Do not smile, do not chew gum, do not cover mouth Encourage use of hearing aids

Care of Patient undergoing Ear Surgery


Pre-op Assess for URTI Shampoo the hair Inform re local anesthesia but sedated during surgery

Post-op Care Lie on the unoperative side Blow nose gently, one side at a time Sneeze, cough with open mouth 1 week Avoid physical activity x 1week; exercise/sports x 3weeks Cotton ball in the ears daily



Cont… Keep ear dry for 6 weeks post op

Do not shampoo hair x 1 week Protect ears with 2 pieces of cotton balls

Avoid airplane travel 1 week post op Report drainage to MD; slight amount is normal (stain) Avoid reading, watching tv or fast moving objects 1 wk post op Seek supervision when ambulating for the 1st time, dizziness

and light headedness may occur

Documents

Sensory EENT Disorders(2) Edited