University of South Florida:MDC1507 Module 7 MDC Notes Sensory & Perception: • Interaction with our environment depends on an intact sensory perceptual system. • Vision, hearing, smell, taste... , touch and the ability to perceive how our body is positioned in our environment helps us interact with the environment in a purposeful way. • To interact in a positive way we need to be aware of the stimulus and respond to it Ocular Functions: • Refraction o Bends light rays from the outside into the eye • Pupillary Constriction & Dilatation o Control the amount of light that enters the eye • Accommodation o Allows the eye focus images sharply on the retina o Close or distant • Convergence o Ability to turn both eyes inward toward the nose at the same time Ocular: Age- Related Changes: STRUCTURE/ FUNCTION CHANGE IMPLICATION Appearance Eyes appear “sunken.” Do not use eye appearance as an indicator for hydration status. Arcus senilis forms. Reassure patient that this change does not affect vision. Sclera yellows or appears blue. Do not use sclera to assess for jaundice. Cornea Cornea flattens, which blurs vision. Encourage older adults to have regular eye examinations and wear prescribed corrective lenses for best vision. Ocular muscles Muscle strength is reduced, making it more difficult to maintain an upward gaze or a focus on a single image. Reassure patient that this is a normal happening and to re-focus gaze frequently to maintain a single image. Lens Elasticity is lost, increasing the near point of vision (making the near point of best vision farther away). Encourage patient to wear corrective lenses for reading. Lens hardens, compacts, and forms a cataract. Stress the importance of annual vision checks and monitoring. Iris and pupil Decrease in ability to dilate results in small pupil size and poor adaptation to darkness. Teach about the need for good lighting to avoid tripping and bumping into objects. Color vision Discrimination among greens, blues, and violets decreases. The patient may not be able to use color- indicator monitors of health status. Tears Tear production is reduced, resulting in dry eyes, discomfort, and increased risk for corneal damage or eye infections. Teach about the use of saline eyedrops to reduce dryness. Teach patient to increase humidity in the home. Auditory Functions: • Auditory o Sound waves rebound in the eardrum creating vibrations. o Bony ossicle allows the vibrations transfer to the malleus, incus and stapes. o The stapes sends the vibration to the cochlea. o The cochlea changes the vibrations into action potentials • Action Potentials o Conducts the message to the brain as a nerve impulse. CN VIII = Auditory • Nerve impulses o Are translated into sound by the brain in the auditory cortex of the temporal lobe. Auditory: Age Related Changes: EAR OR HEARING CHANGE NURSING ADAPTATIONS AND ACTIONS Pinna becomes elongated because of loss of subcutaneous tissues and decreased elasticity. Reassure the patient that this is normal. When positioning a patient on the side, do not “fold” the ear under the head. Hair in the canal becomes coarser and longer, especially in men. Reassure the patient that this is normal. More frequent ear irrigation may be needed to prevent cerumen clumping. Cerumen is drier and impacts more easily, reducing hearing function. Teach the patient and caregiver to irrigate the ear canal weekly or whenever he or she notices a change in hearing. Tympanic membrane loses elasticity and may appear dull and retracted. Do not use this finding as the only indication of otitis media. Hearing acuity decreases (in some people). Assess hearing with the voice test or the watch test. If a deficit is present, refer the patient to a specialist to determine hearing loss and appropriate intervention. Do not assume that all older adults have a hearing loss! The ability to hear high-frequency sounds is lost first. Older adults may have particular problems hearing the f, s, sh, and pasounds. Provide a quiet environment when speaking (close the door to the hallway) and face the patient. Avoid standing or sitting in front of bright lights or windows, which may interfere with the patient's ability to see your lips move. If the patient wears glasses, be sure that he or she is using them to enhance speech understanding. Speak slowly, clearly, and in a deeper voice and emphasize beginning word sounds. Some patients with a hearing loss that is not corrected may benefit from wearing a stethoscope while listening to you speak. Assessment: • Client history: o Change in performance in ADLs related to visual changes o Age o Gender (men have more issues with retinal detachment women with dry eyes) o Occupation and leisure activities use of eye protection at work and during leisure activities, exposure to UV light, eye strain o Systemic health problems such as diabetes, hypertension thyroid and others o Medications such as Antihistamines, opioids, Beta blockers and others listed in box Ocular Changes Related to Disease and Medications: Nutritional History: Vitamin Deficiencies: • Vitamin A eye dryness • Lutein and beta carotene help maintain retinal function • Diet rich in fruit and red, orange and dark green vegetables is important to visual health Family History: • Some eye health issues have genetic connections Physical Assessment: Inspection: • Watch for squinting, head tilting or other actions o Indicates the client is trying to see an object clearly. • Assess the appearance of the eye o Symmetry o Exophthalmos - protruding eyes o Enophthalmos-sunken appearance of the eye o Sclera should be white o Cornea- clear o Complete a pupil assessment • Vision Assessment: o Snellen eye chart o Visual field testing o Extraocular muscle function Medical Assessment: Laboratory Assessment: • Cultures of the cornea and conjunctivae help diagnosis of infections • Take the swabs from drainage in the conjunctivae and any ulcerated or inflamed areas Imaging Assessment: • CT scan can be used to assess the eyes, the bony structures and the extraocular muscles. Used to detect tumors in the orbital space. Instruct the client that the procedure is not painful but will require them to be in an enclosed space and keep their heads still. • MRI is used to assess the orbital space and the optic nerve. It is also used to evaluate optic tumors. Cannot be used to evaluate injuries involving metal!!!! • Radioisotope scanning: Used to locate tumors. Requires a signed consent. Client receives a radioactive isotope and must lay still after receiving the dye. The area being studied is then scanned for the amount of radioactivity it emits. • Ultrasonography is used to examine the orbit and eye with high frequency sound waves. It is helpful in diagnosing retinal detachment. o Test is painless o Eyes are usually closed, but if they need to be open, then anesthetic drops are instilled first o Sits in a chair with chin in a chin rest and the probe is touched to the anesthetized eye and the sound waves are recorded on a computer screen and examined for the injury Other Diagnostic Tests Performed by Providers, Optometrists or APRN’s: • Slit-lamp examination: o magnifies the anterior eye structures looking for abnormalities in the cornea, lens, or anterior vitreous humor. • Corneal staining: o Places a topical dye in the conjunctival sac to outline abnormalities in the cornea. The test is performed using aseptic technique. The eye is viewed using a blue filter. • Tonometry: o measures intraocular pressure. Intraocular pressure varies throughout the day. • Ophthalmoscopy: o Allows for viewing of the eye’s external and interior structures with an ophthalmoscope. Look for the red reflex which is the reflection of the light off of the retina. The optic disc, optic vessels, fundus and macula can be examined. Other Diagnostic Tests Performed by Physicians, Optometrists or APRN’s: • Fluorescein Angiography: o provides a detailed image of eye circulation ▪ Requires administration of dye ▪ Requires a signed consent form ▪ Mydriatic eye drops need to be administered 1 hour prior to the test ▪ Dye may turn skin yellow, but is eliminated In the urine which turns green ▪ Encourage patient to drink plenty of fluids to promote the elimination of the dye ▪ Wear dark glasses and avoid direct sunlight until pupil dilation returns to normal because bright light will cause eye pain. • Electroretinography: o Graphs the retina’s response to light. Helpful when diagnosing blood vessel changes from diseases and drugs. Place an electrode on an anesthetized cornea and light is flashed at varying speeds and intensities and the neural responses are graphed. • Gonioscopy: o is used when elevation intraocular pressure is diagnosed to determine if the glaucoma is open-angle or closed-angle. It allows the visualization of the angle where the iris meets the cornea. • Ultrasonic imaging of the retina and optic nerve: o creates a three dimensional view of the back of the eye. Used for clients with ocular hypertension or at risk for glaucoma from other problems. Used to evaluate the thickness, contour of optic nerve fiber layers and retina for changes indicating damage from high intraocular pressure. Cataracts: • Opacity of the lens of the eye that lies just behind the iris. • Most are related to age Causes of Cataracts: • Age-Related Cataracts o Lens water loss and fiber compaction • Traumatic Cataracts o Blunt injury to eye or head o Penetrating eye injury o Intraocular foreign bodies o Radiation exposure, therapy • Toxic Cataracts o Corticosteroids o Phenothiazine derivatives o Miotic agents • Associated Cataracts o Diabetes mellitus o Hypoparathyroidism o Down syndrome o Chronic sunlight exposure • Complicated Cataracts o Retinitis pigmentosa o Glaucoma o Retinal detachment Assessment: • Predisposing factors • Clinical signs and symptoms o Blurred vision o Decreased color perception o May think that glasses are smudged o Double vision o Problems with ADL’S o Without surgical intervention blindness follows o Affects reading and driving Diagnosis or Analysis: • Decreased visual acuity Planning and Intervention: • Improving vision • Recognition when ADLs cannot be performed safely and independently Surgical Procedure: • Pre-Operative Care: o Informed consent o Post-op care requires the instillation of eye drops several times per day for 2 -4 weeks. o Assess patient medication list for drugs that affect clotting o Given a series of eye drops prior to surgery that cause pupil dilatation and vasoconstriction o Other eye drops are given that cause paralysis to prevent eye movement making sure the lens will not move during surgery. o The surgeon gives a muscle block for anesthesia and paralysis • Intraoperative Care: o The opaque lens is destroyed by phacoemulsification and is suctioned out of the capsule and replaced by a small clear plastic lens. o Vision will need to test pot-op to determine new prescription for glasses • Post-Operative Care: o Antibiotic and steroid ointment are placed in the eye immediately post-op. o Discharged home one hour after surgery o Wear dark glasses and avoid bright sunlight until pupils respond to light. o Develop a schedule for the administration of post-op eye drops. Be sure client or family can demonstrate the correct technique for administering the drops. o Be sure the client understands the importance of attending all follow-up appointments. o Itching of the eye is normal. o Eyelid swelling is normal also and can be managed with a cool compress o Discomfort can be managed with Tylenol but aspirin needs to be avoided because it affects blood clotting. o Uncontrolled pain may indicate hemorrhage or increased intraocular pressure and the physician should be notified especially if nausea and vomiting accompanies the pain. • Prevention of Increased Intraocular Pressure: o Do no bend at the waist o Lift more than 10 pounds o Sneeze or cough o Blow your nose o Strain to move bowels o Have sexual intercourse o Vomit o Keep head in a dependent position o Wear tight shirt collars • Monitor for Infection: o Observe for increasing eye redness o Decrease in vision o Increase in tears o Photophobia o A Creamy, white, crusty drainage on eye lids and lashes is normal, but green or yellow indicates an infection o Stress importance of handwashing • Evaluation: o Visual acuity o Prevention of complications Glaucoma: • Increased intraocular pressure in a hollow organ. • When the intraocular pressure increase it leads to compression of the retinal blood vessels and photoreceptors and their nerve fibers resulting in hypoxemia and death of the tissue and loss of vision Etiology: • Common in African Americans over 40 • Individuals older than 60 especially Mexican Americans • Genetic • Corneal thinness • Abnormality of the optic nerve • Common cause of blindness in the US • Damage starts at the periphery and moves toward the center • Painless Three Types: • Primary open angle o Most common type o Affects both eyes o Gradual loss of vision o Signs and symptoms ▪ Foggy vision ▪ Mild eye aching ▪ Headache o Late Signs and Symptoms after irreversible eye damage ▪ Halos around lights ▪ Losing peripheral vision ▪ Decrease visual perception that does not improve with eyeglasses • Secondary Glaucoma o Related to another eye problem • Associated Glaucoma o Related to another disease process Assessment: • Ophthalmoscopic exam shows cupping and atrophy of the optic disc. • Optic disc turns white or gray • Loss of peripheral visual fields with a gradual increase in the loss of the fields tested by perimetry • Increased IOP measured by tonometry • Gonioscopy to determine whether the angle is open or closed. • Image of the optic nerve to determine the amount of damage that has occurred Primary Angle-Closure Glaucoma—Acute Onset Medical Emergency: • Sudden sever pain around the eyes radiating over the face • Headache or brow pain • Nausea and vomiting • Seeing colored halos around lights • Sudden blurred vision • Reddened sclera • Foggy cornea • Moderately dilated pupil that does not react to light Planning: • Maintain optimum vision by complying with treatment regimens Intervention: • Non-surgical Management o Drug therapy to reduce IOP o Priority intervention is patient education • Surgical Management o Laser trabeculoplasty o Trabeculectomy o Both procedures create a channel for the aqueous humor to drain decreasing the intraocular pressure in the eye. Home Care: • Follow-up to assure the patient can administer own eye drops correctly. • Keep follow-up appointments every 1-3 months to evaluate the IOP. • If the patient had surgical treatment be sure to educate on the S&S of hemorrhage and detachment including severe pain, and vision loss. • These should be reported immediately to the HCP Common Hearing Problems: • Hearing Loss: Conductive o Sound waves do not reach to inner ear nerve fibers because of external or middle ear disorders o Inflammation or obstruction of the external or middle ear o Changes in the ear drum o Tumors, scar tissue, or overgrowth of the bony tissue in the ossicles • Hearing Loss: Sensorineural: o Sensory nerve that leads to the brain is damaged o Exposure to loud noise o Medications o Presbycusis is hearing loss related to age ▪ Degeneration of the nerve cells in the cochleus, ▪ Loss of elasticity of the basilar membrane ▪ Decrease blood flow to the inner ear ▪ Deficiencies of vitamin B12 and folic acid Assessment: Medical History: • Length of time they have noticed a change in their hearing, • Exposure to loud or continuous noises • History of ear infections, perforated ear drum • Medications • Upper respiratory infections • Systemic diseases the cause peripheral neuropathy Assessment: Physical Assessment: • Vertigo • Pain • Tinnitus • Visually inspect to structures of the ear • How often do they request repeating a question • How loud do they speak Assessment: Psychosocial Assessment: • Social isolation • Communication Nursing Diagnosis: • Decreased functional ability communication related to difficulty hearing Planning or Outcomes: • Uses hearing assistive devices • Uses sign language, lip-reading, closed captioning, or video description (for television viewing) • Accurately interprets messages • Uses nonverbal language • Exchanges messages accurately with others Non-Surgical Intervention: • Prevention o Correct the underlying problem with treatment of infections and other signs and symptoms with appropriate pharmacological therapy • Education o Using appropriately assistive devices o Portable amplifiers when watching TV o Flashing lights when phone or doorbell rings o Hearing aids o Cochlear implants Non-Surgical Intervention: • Support o Maximizing communication o Protect your ears from damage o Communicate in writing o Use closed captioning o Use lip reading or sign language as appropriate. Be sure to face the client when speaking so lips can be observed. • Community support o Assist the client in finding support Evaluation: • Communicate Effectively • Have at least partial improvement of hearing • Have minimal anxiety • Use appropriate hearing compensation behaviors Diagnostic Testing: • Audiometry helps determine the type of hearing loss. • This assists with planning interventions and treatment. Surgical Intervention: Tympanoplasty: • Reconstruction of the middle ear from reconstruction of the ear drum to the replacement of the ossicles in the middle ear. o Pre-op ▪ Systemic antibiotics to decrease the risk of infection ▪ Hearing loss after surgery is normal because of post-op treatment ▪ Dressing are changes using sterile technique. Surgical Intervention: Stapedectomy: • Partial or complete with a prosthesis to correct hearing loss related to osteosclerosis. • Assure patient is infection free • High success rate, but has risks including total hearing loss on affected side, infection, vertigo and facial nerve damage • May take up to 6 weeks for hearing to improve • Medication for pain will be prescribed and many times will be on antibiotics to prevent infection. • Observe patient for damage of cranial nerves VII, VIII or X which includes asymmetric appearance or drooping of features on the affected side of the face. Ask client about changes in sensation on the face or taste. • Client may have c/o nausea, vomiting and vertigo • Client is at risk for falls and orthostatic hypotension Surgical Intervention: Implanted Devices: • Three parts implanted, a sound processor, a sensor and a computer. • Not currently covered by Medicare at a cost of 40,000 dollars. • [Show More]
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