Altered Sensory Input Eye and Ear Disorders

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Altered Sensory InputEye and Ear Disorders

• Deborah R. Cary, MSN, BC
• Broward Community College

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Structures and Functions Vision

• Definitions
• Aqueous humor bathes/ nourishes
• lens/cornea
• Accomodation process allowing pt
• to focus on near objects
• Refraction -ability to bend light rays
• Emmotropia focusing light on retina
• Refractive error when light does not
• focus correctly

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Definitions continued

• Myopia (nearsighted) can see objects closely
  distant objects blurred image focuses in front
  of retina
• Hyperopia (farsighted) distant objects clear
  near ones blurred image behind retina
• Astigmatism unevenness iin cornea vision
  distorted can by myopic or hyperopic
• Presbyopia form of hyperopia aging lens
  less elastic eye cant accommodate for near

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External Structures

• Eyebrows, eyelashes, eyelids, bony orbit and fat
  pads all protect eye
• Blinking tears distribution/controls light
• Muscles innervated by CN VII facial nerve
• Conjunctiva transparent mucous membrane forms
  pocket under eyelid
• Sclera collagen white eye protects
  yellowish with age due to lipid deposits or blue
  due to thinning (also in infant) dark pigmented
• Cornea allows light entry Trigeminal nerve
  (CN V) innervates avascular O2 from tear film
  normclear,transparent and shiny

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• Lacrimal apparatus gland and ducts
• Provides tears to moisten eye and provide O2 to
  coronea
• Extraocular muscles 3 pairs eyes move in same
  direction (conjugate movement)

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External Structures

• Iris provides eyes color can be diff in some
• Pupil constricts from muscles innervated by
  CN III dilate via CN V
• Pupil size affected by ANS
• SNS dilates
• PNS constricts
• Crystalline lens behind iris bends light
  rays

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Assessment

• Health History ocular/nonocular
• Question re systemic disease, STD, Diabetes, HTN,
  CA, RA, AIDS, MS, MD,MG
• Thyroid diseases
• Meds Beta blockers tx glaucoma,
  corticosteroids, OTC
• Visual acuity tests hx strabismus, amblyopia,
  cataracts, glaucoma, retinal
• Surgery and hx head injury

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Health Perception/Management

• Men gt color blindness aged - blue end
• African Americans -gtrisk optic nerve damage from
  glaucoma
• Ask ptwhy are you here today?
• Prolonged exposure UV retina
• Ask re driving at night
• Contact lens wearer?
• ?Allergies leading eye sx

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Physical Examination

• Inspect ocular structure
• Judge ability to judge closeness/distance
• Extraocular muscle fx
• Visual fields
• Pupil fx anisocoria (not )
• IOP with Tono-pen
• Depth perception
• Visual Acuity Snellen chart
• Slit lamp- brightly illuminates
• Opthalmoscope bl/vessels and optic disc red
  reflex will decrease with cataracts look for
  nicks/narrowing

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• Stereoscopic vision allows one to see objects
  in 3 dimensions monocular vision results in
  loss (enucleation, patching) without loss of
  ability to judge distances
• Diagnostic studies of the eye review Table 20-6
  pg. 429

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Structures and FunctionsAuditory System

• External ear auricle (pinna) external auditory
  canal
• Auricle cartilage/connective tissue
• Auditory canal S shaped 1 long
• Lined with fine hairs and sebaceous glands plus
  ceruminous (wax) glands
• Fx keep free of debris/bacteria
• Tympanic membrane (eardrum) receive sound waves
  from the external ear/canal separates external
  auditory canal from ear

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Middle Ear

• Continuous from nasal pharynx via eustachian tube
  by mucucous membranes
• Cavity is an aiir space in temporal bone
• 3 tiny bones maleeus, incus and stapes
  (ossicular chain) vibrations from the tympanic
  membr. Cause fluid in inner ear to move and
  stimulate receptors hearing
• Cavity filled with ar atmospheric pressure
  equalizes during swallowing/yawning
• CN VII (facial nerve) crosses over middle ear
• Can be damaged by trauma, skull fx, infections
• Air conduction problems in mid ear cause
  hearing loss

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Inner Ear

• Cochlea organ of Corti pitch sounds
• Vestibulocochlear nerve (CN VIII) sends sound to
  brain to process/interpret
• Nervous stimuli by vestibular portio of VIII
• Pathology sensorineural hearing loss
  (sensitivity to high-pitched tones)
• Central hearing loss difficulty in understanding
  the meaning of words heard

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Gerontologic Coonsiderations

• Prebycusis hearing loss due to aging
• Increased risk D/T
• noise exposure over life
• vascular or systemic diseases
• nutrition
• ototoxic drugs (ASA, Aminoglycosides,
  chemo, NSAIDS, diuretics
• pollution over life

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Assessment

• Vestibular system included since so close
• Health history
• ? Childhood infections otitis media
• surgery myringotomy
• perforated eardrum
• mumps? Measles? Scarlet fever?
• Congenital d/t infections
• Teratogenic meds
• Hypoxia during 1st trimester pregnancy
• Head injury? Impacted
  cerumen

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• Hx swimming
• Occupational hx
• Recreational hx
• Use of ETOH and Na
• Menieres disease sx gt evening
• Vertigo? Chronic?
• Sleep patterns?
• Pain in ear?
• Clues posturing head appropriate responses

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Ear Exam

• Ear speculum smaller than size ear canal
• Head tipped to opposite
• Auricle up and back adults
• horizontally back in children
• Otoscope stabilized on pts head
• Inspect tympanum for color, contour, landmarks
  and intactness pearly-gray, white or pink shin

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Hearing Acuity Tests

• Tuning Fork
• differentiates conductive/sensorineural loss
• Rinne test activated tuning fork held
  against mastoid bone results if AC (air
  conduction) heard longer than bone conduction
  (BC)
• Weber test activated tuning fork placed
  midline skull, forehead or teeth where is sound
  heard best norm midline tone if conduction
  loss, sound louder in that ear if sensorineural
  loss, sound louder in unaffected ear

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Audiometry

• Hertz unit of measurement
• Yioung adults can hear at 16-20,000 Hz - Most
  sensitive at 500-4000Hz
• Hearing loss affected by sound frequencies
• Intensity sound waves expressed in dB (decibels)
  loss of 40-45dB difficulties
• Hearing aids amplify sound, but not clarity not
  helpful with discimination of sound or sound
  information used with loss of 25-35dB normal
  speech is about 40-65dB
• Mass screenings 10-20dB

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Vestibular Function test

• Nystagmus abnormal involuntary repetitive
  movement of the eyes
• cause- disturbance in endolymph fluid
• seen in MS and drug toxicity
• pt. looks straight ahead and then follows
  examiners fingers laterally if quick, jerking
  movements abnormal
• Caloric test measures fx - norm nystagmus
• on opposite side of H2O instillation in ear
• No reaction suspect brain lesion alcohol
  affects test, CNS depressant and barbiturates - ?
  Re intake before test

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Visual and Auditory Problems

• Correctable Refractive Errors
• Most common visual problem!!
• Major sx blurred vision
• other sx HA, ocular discomfort,
  eyestrain
• TX corrective lenses
• young children leads to amblyopia
• vision

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• Review terms pg. 441
• Blindness assistance with meals let patients
  know where different foods are located on plate
  using clock face
• Sighted-guide technique with ambulation
  walk ahead and slightly to patients side pt
  holds your elbow
• Tape note to top of bed to alert all who
  enter patients room that pt. is blind
• Assistance services state agency for rehab
• Optical devices closed circuit TV books
  on tape
• seeing-eye dogs, etc.

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Inflammation/Infections

• Hordeolum sty infection sebaceous glands in
  lid Staph aureus
• red, swollen, tender, circumscribed
• rapid onset
• warm, moist compress 4x/day
• Chalazion inflammation sebaceous glands
• evolve from hordeolum
• swollen, nonpainful, red upper lid
• rx same as above and excision

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• Blepharitis common, chronic, bilateral
  inflammation of lids
• Red, scaly crusts on lids margins/lashes
• Itchy, burning, irritation, photophobia
• Conjunctivitis concurrently
• Tx antibiotic ointment
• baby shampoo gently to lids

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Conjunctivitis

• Infection or inflammation of conjuctiva
• Common
• Epidemics common in children due to poor hygiene
• Most common organism Staph, strept pneumoniae,
  haemophilus influenzae
• Irritation, tearing, redness, mucopurulent
  drainage spreads from affected eye to
  unaffected eye

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• Keratitis inflammation of cornea
• Causes damage to cornea, contact lenses,
  debilitation, nutritional deficiencies,immunosuppr
  essed states and contaminated products (lens
  solutions and cases, cosmetics, and topical meds)
• TEACHING!!!
• Viruses herpes simplex (HSV) most frequently
  occurring infectious cause of blindness growing
  problem
• Corticosteroids are contraindicated
• Epidemic keratoconjunctivitis MOST serious
  ocular adenoviral diseases

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Nursing Care

• Acute eye pain
• Extreme anxiety re fear of loss eyesight
• Disturbed sensory perception
• Careful asepsis to prevent spread
• Proprr disposal wastes
• Teaching re med aministration
• Acute dark room with modifications
• Med administration may be hourly or more often

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Cataracts

• Opacity of crystalline lens
• Third leading cause of preventable blindness
• Most common cause self-declared visual disability
  in US
• 50 age 63-75 some degree of formation
• gt75 70 incidence
• Most common surgical procedure in US gt65
• Congenital cataracts common 1250

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Pathophysiology

• Most are senile cataracts (aging)
• Other causes maternal rubella, trauma,
  radiation or UV,systemic corticosteroids or LT
  topic corticosteroids and ocular inflammation
• Aged accumulation of water and alterations in
  lens fiber

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Signs/Symptoms Cataracts

• Decrease in vision
• Abnormal color perception
• Glare dye to light scattering
• Worse at night when dilatation
• Secondary glaucoma if IOP
• Diagnosis visual acuity ophthalmoscope or
  slit lamp
• white pupil

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Surgery

• NPO for 6-8 hrs. preop
• Dilating drops nonsteoridal inflammatory
  eyedrops
• Mydriatics
• Cycloplegics (anticholinergic) cause mydriasis
• Pre-op anxiety meds
• Intraoperative extracapsular extraction
  (pharmacoemulsification or scooping)

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• Intracapsular lens
• Post-op No bending or stooping, coughing or
  lifting
• Eyeshields at night
• Visual acuity, IOP at post-op visits

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Nursing Management

• Assess patients distance/near visual acuity
• Assess visual acuity in nonoperative eye
• Assess psychosocial impact of disability
• Assess ability to care for self with decreased
  visual acuity
• Prevention Sunglasses, avoid unnecessary
  radiation, take antioxidants, (vitamins C and E)
  good nutrition

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Medications

• Pre-op meds dark irises, more med
• Photophobia common wear dark glasses
• Transient stinging/burning
• Contraindicated with narrow-angle glaucoma
• Mydratics cardiovascular effects
• Use punctual occlusion
• Inform re lack depth perception (24 hrs)
• Notify MD if pain intense may signal
  hemorrhage, infection or incr. IOP

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Retinal Detachment

• Separation of sensory retina and undelrying
  pigment epithelium
• Fluid accumulate between the 2 layers
• Increased with aphakia
• Causes blindness!!
• Caused by retinal break (tears or holes)
• holes spontaneous tears with aging
• Sx of photopsia (light flashes) floaters, and a
  cobweb hairnet or ring in visual field
• Curtain comes across vision
• Ultrasound to dx if opthalmoscope or slit lamp
  not definitive

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Macular Degeneration

• ARMD- dry (atrophic) and wet (exudative)
• Most common cause of vision loss in those over 55
• Dry reading/close-vision more difficult
• Slowly progressive 20/200
• Wet abnormal blood vessels - blurred,
  darkened, distorted vision occurs rapidly
• Hallmark sign drusen in fundus

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Glaucoma

• Group of disorders
• Increased IOP
• Optic nerve atrophy
• Peripheral Visual Loss
• Congenital or primary disease
• IOP regulated by formation/reabsorption of
  aqueous humor
• Glaucoma R/T balance or imbalance
• Can damage optic nerve atrophy/blindness
• 2nd leading cause of blindness in US and
  leading cause in African Americans 50 unaware
  they have it
• Incidence with age 150 whites 110
  African American

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• Normal IOP is 10-21mm Hg
• POAG primary open-angle 90 - outflow is decr
  in trabecular network
• PACG Primary angle-closure 10 mechanism is
  angle closure
• partial dilated states can cause
• drug-induced mydriasis
• always check ingredients OTC meds
• Teach NOT to take mydriatics

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• POAG develops slowly and with symptoms
• Gradual visual field loss
• tunnel vision
• PACG sudden, excruciating pain in or around the
  eye with N/V
• halos around lights, blurred vison
• ocular redness acute increase IOP
• leads to corneal edema
• POAG IOP between 22-32mm Hg or higher
• PACG - IOP over 50mm Hg
• With progressive glaucoma, optic disc cuppic
  occurs might be one of the firs tsigns photos
  useful for comparison over time
• Chronic POAG tx with drugs not cure
• Argon laser trabeculoplasty lowers IOP when
  meds dont followed by topical corticosteroids
  for 3-5 days
• Most common complication is acute rise in
  IOP
• ACUTE ANGLE CLOSURE MED EMERGENCY with miotics
  and IV hyperosmotic
• Surgical iridectomy done

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External Otitis

• Inflammation or infection of epithelium of the
  auricle/ear canal
• Swimming alters flora swimmers ear
• Trauma from hairpins and other objects
• Infections from pseudomonas, Klebsiella, E.Coli
  and Staph aureus, fungi candida, Aspergillus
• Occur in warm moist, dark environents of ear canal

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Clinical Manifestations Otitis

• Pain (otalgia) often disproportionate to the
  infection
• Pain from swelling of trhe bony ear canal
• Drainage serosanguineous or purulent
• Can cause hearing loss and dizziness
• NURSING use wicks with caution in the young,
  confused and psychotics
• Corticosteroids contraindicated with fungal
  infections
• Otic gtts at room temp do not touch tip to
  ear maintain ear for 2 mins. in position so
  gtts can run into ear canal

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Otitis Media

• ACUTE Most common problem of middle
• childhood disease assoc with colds,
  allergies, sore throats, blockage eustachian tube
• Earlier the 1st episode, gt risk subsequent
• Risk young, congenital, immune deficiencies,
  exposure to cig smoke, family hx, recent URI,
  males/allergy
• Meds amoxicillin for 10 days is the drug of
  choice surgery myringotomy with short or
  long-term use prompt rx prevents perforation
  tympanic membrane
• Antihistamines in aduts

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Chronic Otitis Media

• Untreated or repeated attacks of acute
• More common in those who have has children
• Middle ear and air cells of mastoid
• Chronic purulent, mucoid or serous discharge
  with hearing loss and ear pain, nausea, dizziness
• Ossicle destruction leads to hearing loss
• Also tympanic membrane perf or fluids (pain)
• DX sinus X-rays, MRI, CT scan of temporal
  bonecan show a cholesteatoma
• Antibiotic ear gtts acetic acid
• Parenteral antibiotics if a recurrence
• Surgery reconstruction (tympanoplasty)

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Otosclerosis

• Autosomal dominant disease
• Fixation of footplate of stapes
• Common cause of conductive hearing loss
• Bilateral in 80
• Otoscopic exam bluish-red blush of tympanum
  (Schwartzs sign)
• BC gt AC if loss is gt 25 dB
• Stapedectomy tx
• Prosthesis inserted returns hearing to normal
  in majority - postop N/V and nystagmus
  minimize coughing, sneezing, lifting, bending and
  straining
• Na Fluoride with Ca carbonate and Vit D

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Inner Ear Problems

• Vertigo
• Sensorineural hearing loss
• Tinnitus
• Vertigo from vestibular labyrinth
• Hearing loss/tinnitus from auditory labyrinth

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Menieres Disease

• Sx caused by inner ear disease
• Significant disability due to sudden, severe
  attacks of vertigo with N/V (sudden with little
  warning) sense of fullness in ear prior to
  attacks plus increasing tinnitus and a decrease
  in hearing feeling of being pulled to ground
  (drop attacks) feeling of whirling in space
• ANS pallor, sweating N/V
• Age 30-60 years 40 bilateral
• Cause unknown
• Accumulation of endolymph
• Tests to R/O CNS involvement
• DX glycerol test and audiograms 3 hrs. later
  improvement in hearing or speech for disease
• negative test does not R/O disease