HIT2 - Altered Sensory Perception PDF

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Lecture Notes consolidated with pictures...

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glaExam 3 Altered Sensory Perception (Eye, Ear, and Hearing) Ch. 63 and 64 Assessment and Management of Patients with Eye & Vision Disorders Anatomy and Physiology of Eye:

When assessing pts with liver problems looks at sclera. Iris is the color part, Pupil= PERRLA Normal size 3-5mm (milimeters) anything out of that range is not normal. Sclera is the outer area Choroid is the middle- houses the vessels Retina- inner most and receive light reflex LensAnterior Chamber vs Posterior chamber Cornea- protect pupils and houses anterior chamber. Ciliary Body- produces aqueous humor in the eye and controls the iris. Age Related Changes •

Skin around eye becomes wrinkled and loose

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Tear secretion diminishes

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Pupil becomes smaller and becomes less flexible. Accommodation decreases or reduces. Responds somewhat more slowly to light

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Lens becomes less elastic, more dense Causes sensitivity to light

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Presbyopia is common- Farsightedness in older people.

Nursing Assessment of the Eye History of Present Illness •

Always want to collect subjective data. What caused the patient to seek treatment? Remember use of PQRST or OLDCART to assess a chief complaint     

Changes in vision? Reports of pain? Sensitivity to light? Discharge or drainage? Redness, swelling, dryness, and irritation? Health Hx

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PMH- Dm: Neuro Ds- stroke can affect vision, Thyroid Ds- affects sensory, HTN- macular degeneration, etc

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Family hx- arteriosclerosis, DM, Thyroid ds

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Functional assessment: Any factors or activities= risk to the eyes, •

usual activities-

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occupations- construction workers or welders

Think of conditions that predispose a person to visual changes Physical Evaluation of Vision •

Visual acuity o

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Snellen chart 

Record each eye results

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20/20 means the patient can read the “20” line at a distance of 20 feet

Static and kinetic confrontation tests- Kinetic is moving fingers in, and static is tied with a number. Total times to shine the light is 4: 2 direct and 2 non-direct

Review how to perform those tests to evaluate vision of a person, the purpose of each test, & interpretation of visual findings Hishara test is done for color blindness. Examination of External Structures •

First thing is to look for symmetry of the eye.

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Note any evidence of irritation, inflammatory process, discharge…

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Assess eyelids and sclera

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Assess pupils and pupillary response; use darkened room

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Note gaze and position of eyes

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Assess extraocular movements

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Ptosis

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Nystagmus- oscillating movement of eyeball. When doing 6 cardinal fields you are looking at the control of the eye muscle. Diagnostic Test & Procedures r/t Eye and Vision Disorders

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Ophthalmoscopy (Direct & Indirect)- Direct-used in clinic and indirect is used in specialist

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Color Vision Testing- Ishihara Color blind test

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Amsler Grid- assess macular degeneration

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Ultrasonography- U/S looking at the vessels. Retinopathy

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Tonometry- test for Intraocular pressure/ Glaucoma

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Perimetry Testing (Visual Field Testing)- assess visual fields

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Fluorescein Angiography- test for macular degeneration

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Refraction- test to determine if you need glasses.

Know the purpose/indications for these tests. Nurse’s responsibility Impaired Vision •

Refractive errors- a person having other than normal 20/20

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Emmetropia- 20/20

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Myopia- nearsightedness

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Hyperopia- farsightedness

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Astigmatism- Cornea is not smooth Impaired Vision- Refractory Errors

Eyeball shape determines visual acuity in refractive errors. A. Normal eye. B. Myopic eye. C. Hypermetropic eye- eye ball shape is shorter (page 1883) Make sure patient follows up with specialties Amblyopia- lazy eye, seen in children. They use patch to correct it. Refractive Surgeries Lasik: •

Outpatient surgery used to treat some refractive errors

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Possible Complications: Hazy or blurry vision; Difficulty with night vision; Scratchiness, Dry eye; Glare, Halos or starbursts around lights; Light sensitivity; Discomfort or pain; Small pink or red patches on the white of the eye

Think of your responsibilities as a nurse—what to do to help the pt minimize/manage those possible complications. Vision Impairment and Blindness •

Low vision - Visual impairment that requires devices and strategies in addition to corrective lenses Best corrected visual acuity (BCVA) of 20/70 to 20/200

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Blindness – BCVA (best corrective visual acuity) 20/400 to no light perception Legal blindness is BCVA that does not exceed 20/200 in better eye or widest field of vision is 20 degrees or less. Helps Medicaid determine if the patient needs services. inability to perceive light

Impaired vision often is accompanied by functional impairment Identify leading causes of blindness & visual impairment among middle aged and older adults Assessment of Low Vision •

History

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Examination •

Distance and near visual acuity,

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Visual field,

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Contrast sensitivity, glare, color perception, and refraction

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Special charts may be used for low vision

Nursing assessment: o o

Assess functional ability Assess coping and adaptation in emotional, physical, and social areas Management

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If vision is lost happened due to accident or disease process: Support coping strategies, grief processes, and acceptance of visual loss

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Strategies for adaptation: Introduce self before physical contact

Placement of items in room. Recommended if they are in a hospital or nursing home. But at home place things where the patient is used to having things at. “Clock method” for trays- set the patient’s food and utensils in a clock form. Ex; Your plate is at 6 o clock. •

Braille & service animals- Dog is used to help protect the person from danger. Glaucoma

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One of the Leading Causes of Blindness in the US

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Cause Exact Cause is unknown/ clear causes.

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Pathophysiology Pathophysiology: Imbalance between the production and drainage of aqueous humor resulting in increased intraocular pressure (IOP). There is something that affects the flow of fluid from posterior chamber to anterior chamber.

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Type(s) Two Types: Open Angle Glaucoma- still has some flow of aqueous humor just not enough and some pressure is still there. Have no sx and if sxs them advance. Angle Closure Glaucoma- No aqueous humor flows and it is more dangerous and causes blindness quicker.

Open Angle (CHRONIC) Glaucoma Gradual blockage of aqueous outflow resulting in an increase in eye pressure occurring slowly over time

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S/S: Initially no signs and symptoms; tired eyes, occasional blurred vision, halos around light; difficulty adjusting to darkness; Gradual loss of peripheral vision- usually in both eyes; Tunnel vision in the advanced stages

MORE COMMON FORM

Medical Management: • Beta-adrenergic blockers (Timolol maleate); nonselective • Alpha adrenergic agonists eye drops (epinephrine HCL, Iopidine); non-selective • Cholinergic miotics (Pilocarpine, carbachol, & laser surgery) • Carbonic anhydrase

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Can progress gradually and go unnoticed for years

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Normal IOP= 20 or less. If 21 or higher they are having glaucoma

• Open angle glucoma uses medication to control. 1. beta blocker- first line 2. alpha adrenergic agonist 3. Prostaglandin analogs

Angle Closure Glaucoma: “ER! HELP!!” •

Acute form of glaucoma

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S/S: sudden, acute pain, blurred vision, pupil enlargement, colored halos around lights, nausea & vomiting, headache on the affected side.

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Flow of aqueous humor is blocked

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Intraocular pressure often > 50 mm Hg

Medical Mgt: Iridotomy, miotics medicated eye drops (see previous slide) or PO/IV carbonic anhydrase inhibitors.

Glaucoma – Progressive loss of visual fields= tunnel vision

Diagnostic tests: Tonometry to assess IOP Nursing Management •

Pharmacologic therapy

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Surgical management: laser trabeculoplasty, Laser iridotomy L

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Home care: Chart 63-6 . Instruct pt they must take there medication because it is not curable and if not the sxs will get worse

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Cataracts

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Definition Clouding or opacity of the lens

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Risk Factors Age, existing ocular conditions, Toxic factors, Nutritional factors, Physical factors, systemic disease. DM increase risk for cataracts. If a

S/S Progressive loss of vision, light scattering, myopic shift, color value shift to yellow -brown Most people will go to the doctor •

person is taking corticosteroids.

because it affects their jobs and they need to be able to work. They will be referred to their primary for further test to confirm DM.

Cataract Treatment: Surgical Management •

Phacoemulsification

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If reduced vision does not interfere with normal activities, surgery is not needed.

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Surgery is performed on an outpatient basis with local anesthesia.

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Surgery usually takes less than 1 hour, and patients are discharged soon afterward.

Complications are rare but may be significant. •

Pre-op Care Pre-op testing: CBC, EKG, UA. If they have cardiovascular problems, make sure they are cleared. Assess for anticoagulant use, if they are on it they need approval to before surgery. Pupil is dilated, sedation initiated Patient must have driver Ensure patient/family understand post op restrictions

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Post-op Care Positioned on back or unoperated side to prevent pressure on operated eye Call physician immediately if vision changes; continuous flashing lights appear; redness, swelling, or pain increase; type and amount of drainage increases; or significant pain is not relieved by acetaminophen Stress importance of actions that increase IOP: Teach them to avoid sneezing, coughing, constipation, vomiting, straining, or sudden bending over the head below the waist. Retinal Disorders: Retinal Detachment

Separation of the sensory layer of the eyeball from the pigmented layer • Deprives the sensory layers of and oxygen • Inner most layer peeling away delivers nutrients. Leads to damage to nerve tissue or complete loss of vision THIS IS URGENT • Causes: Vitreous gel leaks into a space the retina and peals away from underlying tissue. • Risk factors: Trauma Family history of retinal detachment Uncontrolled diabetes Previous retinal surgery •

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Signs/Symptoms Floaters Light Flashes Blurred Vision Reduced peripheral vision Curtain shadow over visual field.

Retinal Detachment Treatment Laser Surgery (photcoagulation) Burns around retinal tear • Freezing Freezing that secures retina to eyewall • Pneumatic Retinopexy Injecting air bubble into the vitreous cavity. Pushes the injured area against the wall of the eye, STOPPING the fluid flow. Then it will fill back up w/ vitreous humor. • Pars Plana Vitrectomy Vitreous tissue removed • Scleral Buckling Surgeon sutures silicone to the sclera; indents Post Op- Care: • Maintaining pt in prone position • s/s of increased IOP •

Retinal Disorders – Retinal Detachment: Nursing Diagnosis, Goals, & Interventions Pain

Anxiety and Fear

Risk for Infection

High risk for injury

Knowledge Deficit Corneal Disorders

Corneal Dystrophies

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Keratoconus- hereditary- higher in female, makes vision blurry and develops slowly Fuchs Endothelial Dystrophy- different layers of the cornea affects. Causes vision like if they Corneal Surgical Procedures

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Phototherapeutic Keratectomy Penetrating keratoplasty Keratoprosthesis •

Nursing Management

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Encourage compliance

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Graft rejection: s/s- blurred vision, tearing, redness, discomfort. Medication steroid therapy and systemic immunosuppression.

Retinal Disorders: Age Related Macular Degeneration (AMD)- opposite from Glaucoma

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Causes vision loss in the center of

Leading cause of blindness and visual impairment among people > 60 Can’t see central vision/ vision affected in the center. • • Dry Type (most Two Types: common): • • Dry Type

Wet Type: May have abrupt

the field of vision

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Wet Type

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Slow breakdown of the layers of the retinal with the appearance of drusen (tiny yellow or white deposits in a layer of the retina) causing central vision to get gradually worse

onset; Proliferation of abnormal blood vessels growing under the retina resulting in loss of vision in a specific area

S/S of Retinal Disorders: Age Related Macular Degeneration (AMD) •

Difficulty Reading

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A gradual increase in the haziness of the central or overall vision

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Increasing difficulty adapting to low light levels

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A blurred or blind spot in the center of the field of vision

Photodynamic Therapy for Slowing Progression of AMD

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Light-sensitive verteporfin dye is injected into vessels. Laser deactivates the dye, shutting down the vessels without damaging the retina.

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The result is to slow or stabilize vision loss. Do NOT mean it treats the condition.

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Patient must avoid exposure to sunlight or bright light for 5 days after treatment to avoid activation of dye in vessels near the surface of the skin. Nursing Management

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Patient teaching- proper light, supp. Tx

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Supportive care- The Lions Club- provides assistance for people with vision impairments.

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Promote safety

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Recommendations to improve lighting, magnification devices, and referral to vision center to improve/promote function Orbital & Ocular Trauma

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Orbital Trauma Soft tissue injury & hemorrhage Fractures Foreign bodies Ocular Trauma Chemical burn- flush with water Foreign bodies

Management • Preventive Measures Chart 63-10: Patient Education • Patient and public education • Emergency treatment Flush chemical injuries Do not remove foreign objects- causes further damage. Protect using metal shield or paper cup (figure 63-16) want to minimize eye movement and further damage. Monitor for potential for sympathetic ophthalmia causing blindness in the uninjured eye with some injuries. Recognizes normal eye as a FB and attack the good eye. Monitor the good eye in the first couple of days.

Infection and Inflammatory Condition •

Dry eye syndrome Lack on inadequate tears. S/S: stinging or burning sensation in eyes, sensitivity to light, difficulty wearing contacts; uncomfortable feeling TX: replacement of artificial tears

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Conjunctivitis “pink eye” Infection of the conjunctiva caused by bacteria, viruses, allergic reactions. Bacteria= purulent d/c S/S: eye pain, itching, redness, sensitivity to light TX: depends on cause, viral body will take care of it, bacterial an antibiotic ointment or gtt. Teach the pt viral and bacterial is contagious. Good hand hygiene and proper administration of medications

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Uveitis Swelling and irritation of the uvea, the middle layer of the eye. A lot of swelling “injection. S/S: blurred vision, eye pain, seeing spots, sensitivity to light, decreased vision TX: medication and/or vitrectomy/ Require a specialist to dx

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Orbital Cellulitis Infection of the tissues immediately surrounding the eye, including the eyelids, eyebrow, and cheek S/S: Painful swelling of upper and lower eyelid; decreased vision TX: antibiotic/ cx and gram stain to find out organism. Give broad spectrum antibiotic

Surgical Procedures and Enucleation Orbital Surgery •

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Enucleation To repair fractures, remove foreign body, or growths  to preserve visual function & structures. Complications – hemorrhage, ptosis, diplopia, and/or blindness from poss. damage to optic nerve, retinal blood vessels.

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Removal of the eye Causes: • Infection, glaucoma, injury, or malignancies

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Nursing Mgt: • Post-op care- bleeding and infection • Observe for excessive bleeding and pain • Report any temperature elevation • Teach patient how to care for eye prosthesis. Infection control measures • Teach safety measures

Nursing mgt: Post-op care HOB 30-45 degree Meds adm.

Ocular Consequences of Systemic Disease •

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Diabetic Retinopathy leading cause of blindness in people age 20– 74 Retinal capillary walls thicken and develop microaneurysms; small hemorrhages occur that cause decrease in vision Hypertension Can cause hemorrhage, edema, and exudates in retina. Retinal arteries narrow, causing degenerative changes CVA Can cause hemianopsia or blindness Lupus Inflammation of the cornea, sclera, can occur

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Aids related Disorders Herpes zoster ophthalmicus Herpes can invade the cornea and create ulceration that is potentially blinding CMV Spreads rapidly through the cells of the retina and blood vessels and can destroy the retina Kaposi Sarcoma Lesions of Kaposi sarcoma can affect the skin of the eyelids and conjunctiva or the orbit itself Sickle Cell disease Can cause retinal hemorrhage, arterial occlusion Multiple Sclerosis Demyelination can result in optic neuritis, diplopia, and nystagmus

Common Ocular Medications •

Topical anesthetics Proparacaine & tetracaine – used before diagnostic procedures & for severe eye pain; overuse  softening of cornea, delay wound

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Nursing Management Implement infection control measures Common side effects of ocular meds. Patient Education:

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healing, permanent corneal opacification, visual loss. Mydriatics (dilate) and cycloplegics (paralyze): table 63-3 Alpha adrenergic sympathetic effects  Relaxes ciliary muscle Contraindicated with narrow angles or shallow anterior chambers and inpatients on monoamine oxidase inhibitors or tricyclic antidepressant May cause CNS symptoms and increased BP, especially in children or older adults Anti-infective medications Antibiotic, antifungal, or antiviral products Medications used for glaucoma Increase aqueous outflow or decrease aqueous production to lower ICP. May constrict the pupil and m...