nursing of adults with medical & surgical conditons eyes, ears, and special senses
TRANSCRIPT
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Nursing of Adultswith
Medical & Surgical Conditons
Eyes, Ears,and
Special Senses
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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 eyeRemainder is white, and
is commonly known as the “white of the eye”.
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Layers of the EyeballMiddle Layer
Choroid coatContains the blood vessels that
supply the eyeAnterior 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
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Layers of the EyeballInner 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
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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
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Eye MusclesExtrinsic 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 musclessuperior oblique, inferior oblique
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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 eyeCiliary 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
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Accessory Structures of the Eye
Eyebrows and EyelashesProtect against foreign objects
entering the eye Eyelids
Located in front of the eyeballBlink as a result of sensory stimuliConsist of voluntary muscle and
skinConjunctiva
• mucous membrane lining eyelids• transparent and is continuous
over the surface of the eyePalpebral Fissure
• Opening between the eyelidsInner and Outer Canthus
• angles at the ends of the eyelids
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Accessory Structures of the Eye
Lacrimal Glands and Ducts
Secrete tears• keep anterior surface
moist and free from irritating particles
Size of small almondsLocated 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
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Parts of the EarExternal Ear
Pinna (auricle)The outer, extended
portionComposed of cartilage and
covered with skin External Auditory Canal
About 1 inch in lengthContains cerumenous
glands Tympanic Membrane
(eardrum)Stretches across the end
of the auditory canalSeparates the external ear
from the middle ear
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Parts of the EarMiddle 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
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Parts of the Ear
Internal Ear Contains essential organs for
hearing and equilibrium Sends equilibrium and hearing
sensations to the auditory nerve
Membranous LabyrinthLies within the bony labyrinthFilled with fluid (endolymph)Contains receptors for
• equilibrium • sense of position• sense of head movement• hearing
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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 brainVestibule
• Between the cochlea and the semi-circular canals• Maintain a sense of “up and down”.
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ConductionAir 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
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Process of Hearing
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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 rapidreceptors become fatigued
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Special SensesTaste
Gustatory Sense Organ of taste
Tongue
Receptors are the taste buds located in the papillae of the tongue
Four fundamental taste sensationsSalty - tip of the tongueSweet - tip of the tongueSour - sides of the tongueBitter - back of the tongue
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Taste Receptors
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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
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Touch and Pain Receptors
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Disorders of theEye
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Diagnostic Tests
Snellen’s Test Purpose
Assessment of visual aculityUsed as screening test
ProcedurePt stands 20 ft from chartCovers one eyeReads above or below the 20/20 line
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Snellen’s Test
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Color Vision Purpose
Assess ability to see colorPrerequisite for driver’s license
ProcedureColor dots are reflected on a background of
mixed colors.Pt identifies color patterns on the test field
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Color Vision
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Refraction Purpose
Measure visual acuity to determine refractory errors such as: myopia, hyperopia, presbyopia, and astigmatism
ProcedureOphthalmologist asks pt to indicate
clear/blurred vision with each lens change in the retinoscope.
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Ophtalmoscopy Purpose
Evaluation of underlying structures of the eyeRoutine screening
ProcedureMydriatic drops are applied
• Dilates pupilsRoom is darkenedPt is asked to focus on stationary objectExaminer uses ophthalmoscope to view internal eye
structure
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Ophthalmoscopy
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Tonometry Purpose
Measurement of intraocular pressure Determine tumors and glaucoma
ProcedureExaminer places tonometer on corneaPressure readings are obtainedNormal intraocular pressure ranges from 10
to 22 mm Hg
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Tonometer
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Amster Grid Test Purpose
Diagnose and monitor macular problems
ProcedurePatient fixates on center dot and records
any abnormalities of the grid lines, such as wavy, missing, or distorted areas.
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Amster Grid
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Schimirmer Tear Test Purpose
Measures tear volume produced throughout fixed time period
ProcedureOne end of lacrimal filter
paper is placed in lower cul-de-sac
Area of tear saturation is measured after 5 minutes
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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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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
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Blindness and
Near Blindness
Treatment Corrective eyewear Canes Seeing eye dogs Magnifying systems Surgical procedures
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Refractory Errors
Astigmatism
Strabismus Myopia Hyperopia
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Refractory Errors
Etiology/Pathophysiology
Astigmatism
-unequal curve in the shape of the cornea or lens
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Refractory ErrorsStrabismus
-inability of the eyes to focus in one direction
-cross-eyed
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Refractory ErrorsMyopia
Nearsightedness
Eyeball is too long
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Refractory Errors
HyperopiaFarsightedness
Eyeball is too short
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Refractory Errors
Signs & Symptoms Diminished or blurred vision
Treatment Corrective lenses Surgical correction
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Conjunctivitis
Etiology/Pathophysiology Inflammation of the conjunctiva Bacterial or viral infection Allergy Environmental factors Commonly called “pink eye”
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Conjunctivitis
Signs & Symptoms Erythema of the conjunctiva Edema of the eyelid Crusting discharge Pruritus Burning Excessive tearing
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Conjunctivitis
Treatment Warm compresses Eye irrigations with normal saline Antibiotic drops or ointment Keep free of exudate
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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.
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Keratitis
Signs & Symptoms Severe eye pain Photophobia Tearing Edema Visual disturbances
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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
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Cataracts
Etiology/Pathophysiology Noninfectious opacity or clouding of the
lens Congenital Acquired Senile
associated with older adultsmost common
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Cateracts
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Cataracts
Signs & Symptoms Blurred vision Diplopia
double vision
Photosensitivity Decreased night vision Opacity in the center portion of lens
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Cataracts
Treatment Surgical
removal Lens implant
or glasses
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Post-Op Avoid direct sunlight Bedrest with BRP’s Analgesics No bending down or straining Avoid coughing, sneezing, and blowing
nose
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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
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Diabetic Retinopathy
Signs & Symptoms Microaneurysms
identified by ophthalmoscopy
Progressive loss of vision “floaters”
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Diabetic Retinopathy
Treatment Photocoagulation
destroys new blood vesselsseals leaking vesselshelps prevent retinal edema
Vitrectomyused if photocoagulation is not possibleRemoval of vitreous and replaces it with
saline
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Macular Degeneration
Etiology/Pathophysiology Slow, progressive loss of central and
near vision due to aging retina
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Macular Degeneration
Signs & Symptoms Gradual and variable bilateral loss of
vision Color perception may also be affected
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Macular Degeneration
Treatment Usually no treatment May use photocoagulation if new
vessels have not involved the macular retina
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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 retinaTraumaAgingInflammation
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Retinal Detachment
Signs & Symptoms Sudden or gradual development of
flashes of light, followed by floating spots and loss of a specific field of vision
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Retinal Detachment
Treatment Photocoagulation
burn localized tears or breaks
Cryosurgeryfreeze the borders of a retinal hole
Diathermyburns retina break using ultrasonic probe
Scleral bucklingpulls the choroid and sclera back together using an
encircling band around the outside of the eyeball
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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
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GlaucomaSigns & Symtoms
Open-angleNo s/s during early stagesTunnel visionEye painDifficulty adjusting to darknessHalos around lightsInability to detect colors
Closed-angleSevere painDecreased visionNausea and vomitingErythema of the scleraEnlarged and fixed pupilHalos around lights
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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
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Glaucoma
Closed-angleOsmotic diuretics
• Mannitol, carbonic anhydrase inhibitors, and miotics
Iridectomy• removal of part of the iris• restores drainage of the aqueous humor
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Corneal InjuriesEtiology/Pathophysiology
Result from injuries to corneal layers of the eye
Foreign bodies are the most common cause dust particles, propellants, and eyelashes
Burnschemical irritants
Abrasions and lacerationsusually superficial caused by fingernails or clothing
Penetrating woundsmay cause blindness
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Corneal Injuries
Signs & Symptoms pain with movement of eye excessive tearing erythema of conjunctiva pruritis
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Corneal Injuries
Treatment Flush with normal saline or water Antibiotic drops or ointment
Penetrating woundsdo not remove object if presentcover both eyes
• may need to use a cup to cover object
seek medical attention
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Disorders of the
Ear
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Diagnostic Tests
Otoscopy Visualize external canal and eardrum
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Tuning Fork Tests Weber’s Test
Assesses auditory acuityUses tuning forksDistinguishes conductive
from sensorineural lossTuning fork is placed on
the center of the patient’s forehead
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Rinne TestDistinguishes conductive from senorineural
hearing lossUses tuning forksTuning fork is placed close to the external
auditory meatus
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Audiometric TestingAssesses frequencies and tones
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Vestibular Testing Romberg Test
Measures ability to perform specific tasks with eyes open and then closed
Assesses balance
Past-point TestAbility to place a finger accurately on a
selected point on the bodyAssesses coordination
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Hearing Loss(Deafness)
Etiology/Pathophysiology Decreased auditory acuity Partial Complete Most common disability in the U.S. Affects development of speech and
conceptual ability
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Hearing Loss(Deafness)
Six types of hearing lossConductive
• 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
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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
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Hearing Loss(Deafness)
Signs & Symptoms Requests for repeating information Nonresponse Delayed speech development
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Hearing Loss(Deafness)
Treatment According to cause Hearing aids Surgical procedures Cochlear implant
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External Otitis
Etiology/Pathophysiology Inflammation or infection of the external
canal “Swimmer’s Ear” Allergy, bacteria, fungi, viruses, and
trauma
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External Otitis
Signs & Symptoms Pain with movement of auricle or
chewing Erythema, scaling, pruritus, edema,
watery discharge and crusting of the external ear
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External Otitis
Treatment Oral analgesics Corticosteroids Antibiotic or antifungal ear drops Systemic antibiotics
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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
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Otitis Media
Signs & Symptoms Fullness in the ear Severe, deep, throbbing pain
may disappear if tympanic membrane ruptures
Hearing loss Tinnitus Fever
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Otitis Media
Treatment Antibiotics
organism specific
Analgesics Local heat Nasal decongestants Aspiration of fluid from behind eardrum Myringotomy
surgical incision of the tympanic membranemay also place tubes
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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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Labyrinthitis
Signs & Symptoms Severe and sudden vertigo Nausea and vomiting Nystagmus
involuntary movement of eyes
Photophobia Headache Ataxic gait
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Labyrinthitis
Treatment Antibiotics Dramamine or Meclizine for vertigo IV fluids if N/V
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Obstructions of the Ear
Etiology/Pathophysiology Impaction or excessive secretion of
cerumen Foreign bodies
insects, beans, pebbles, small toys
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Obstructions of the Ear
Signs & Symptoms Tinnitus or buzzing Pain in the ear Slight hearing loss Tugging at ear
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Obstructions of the Ear
Treatment Removal of cerumen by irrigation Foreign objects are removed with
forcepsMay require surgery
Carbamide peroxide to soften cerumen
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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
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Otosclerosis
Signs & Symptoms Slowly progressive conductive hearing
loss Tinnitus Dizziness to vertigo
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Otosclerosis
Treatment Stapedectomy Air conduction hearing aid
if stapedectomy is not indicated
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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
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Meniere’s Disease
Signs & Symptoms Vertigo Nausea Tinnitus Hearing loss Vomiting Diaphoresis Nystagmus
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Meniere’s DiseaseTreatment
No specific treatment Decrease fluid pressure
Fluid restrictionDiureticsLow salt diet
Dramamine, Meclizine, and Benadryl Surgery
Destruction of labyrinthEndolymphatic shuntCryosurgeryVestibular nerve section