NRSG 110 Ears:Eyes - Med surg ears and eyes notes PDF

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Med surg ears and eyes notes...

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Retinal Detachment: separation of the sensory retina and the RPE( retinal pigment epithelium)  There are 4 different types of retinal detachments, but all are basically the same. The inner most layer of the eye detaches and falls inward.  Patient at risk with high myopia or aphakia (without lens) after cataract surgery. Trauma, Retinopathy associated with diabetic neovascularization or proliferated retinopathy  Manifestations: SHADE OR CURTAIN/ FLOATERS (COWBWEBS) NO COMPLAINT OF PAIN  Surgical Tx: Scleral buckle (bring two retinal layers in contact)/Vitrectomy (gas bubble injected into vitreous cavity)  Post op positioning is crucial: so the bubble can float into position (Vitrectomy)  Important measures to take after retinal repair: monitor IOP and infection

Retinal Vein or Artery Occlusion  Occlusions may result from atherosclerosis, cardiac valvular disease, venous stasis, hypertension, or increased blood viscosity; associated risk factors are diabetes, glaucoma, and aging.  Patient may report decreased visual acuity or sudden loss of vision  Visual loss associated with central retinal artery is severe and permanent Macular Degeneration (AMD)  DRY (85-90%)- slow breakdown of retinal later with drusen  WET- abrupt and report straight lines look crooked or letters appear broken. Proliferation of abnormal blood vessels growing under the retina—choroidal revascularization  The most common cause of vision loss in persons older than age 65 years in the United States  Drusen –tiny yellow spots beneath the retina.  Drusen are small clusters of debris or waste material that lie deep in the Retinal pigment epithelium (RPE)/ macular area and affect vision.  No cure.  However study large doses of Vit C, Vit E, and beta-carotene and zinc can prevent or slow progression. Fish oil protects the macula.  Tx includes Photodynamic therapy to slow progression of AMD  Light-sensitive verteporfin dye is injected into vessels. A laser then activates the dye, shutting down the vessels without damaging the retina  The result is to slow or stabilize vision loss

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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  Patients used Amsler grids to monitor progression Trauma  Emergency treatment  Flush chemical injuries – Flush 15-20 minutes  Do not remove foreign objects (unless superficial)  Protect using metal shield or paper cup – Figure 63-14  Potential for sympathetic ophthalmia causing blindness in the uninjured eye with some injuries Emergency  Foreign bodies  Burns  Abrasions  Lacerations  Penetrating wounds  Therapeutic Interventions  Foreign object  (irrigate) Normal saline Chemicals  15- to 20-minute irrigation **  Ocular trauma is the leading cause of blindness in children and young adults.  Removal of the eyeball and part of the optic nerve is not done until about 2 weeks after the injury and only if it has no light perception or useful vision. Sympathetic ophthalmia: inflammation created in the uninjured eye by the affected eye causes blindness in the unaffected eye Conjunctivitis (pink eye)  Feels like something is in the eye, scratching, itching, burning and light sensitivity  Manifestation: exudate: watery, mucous, purulent or mucopurulent/ redness, tearing  Medical management: depends on the cause. Broad spectrum antibiotics Blepharitis  Inflammation of the eyelid margins- usually the entire eyelid lining  Itching and burning of the eyes, scales on lashes Hordeolum (sty)  Staph abscess in sebaceous gland  Redness and swelling of LOCALIZED area of the eyelid  Warm compress 3-4 times daily for 10-15 minutes Chalazion- inflamed granulomas on eyelid  Warm compress 3-4 times daily for 10-15 min. May require surgical removal

EAR ANATOMY

Outer Ear  Auricle (pinna)  Ear Canal  Cerumen Middle Ear  Eardrum (Tympanic Membrane)  Malleus, Incus, Stapes  Oval Window – transmits sound to inter ear  Eustachian Tubes – connects the middle ear to the nasopharynx. Normally closed, but opens with Valsalva maneuver, yawns, and swallowing Inner Ear  Bony Labyrinth – surrounds and protects the labyrinth membranous which is bathed in a fluid call perilymph  Perilymph –  Endolymph  Cochlea (hearing)  Utricle, Saccule, Semicircular Canals (Balance) – in the utricle is calcium carbonate crystals that if misplaced can cause Benign paroxysmal positional vertigo (BPPV)  Cranial nerves VII (facial)  Cranial nerves VIII (vestibulocochlear)  Oval window is the footplate for the stapes and transmits sound to inner ear  Round window is an exit for sound vibrations. Data collection (hearing)  SUBJECTIVE: Clinical manifestations: pain, hearing loss, vertigo, tinnitus, ear drainage, infection, medication  OBJECTIVE: patient behavior, how does patient communicate, inspection, palpation Assessment  Pull the ear up and back to do otoscopic exam steady hand on the clients head to avoid inserting the otoscope too far, again, ear drum should appear pearly gray in color  Whisper – the patient occludes one ear with a finger and the nurse stands 1 foot away and whispers two – syllable numbers softly and have patient repeat. Repeat soft, medium and loud voice.  Weber test: bone conduction to test lateralization of sound. Tuning fork is place on patient head or forehead sound should be heard equally in both ears  Conductive hearing loss: will hear sound better in affected ear (from otosclerosis or otitis media)  Sensorineural hearing loss: will hear sound better in unaffected ear (damage to inner parts of ear or nerve damage)  Rinne test: tests both air conduction and bone conduction. Two inches from opening of ear to the mastoid bone. normal: air conduction louder than bone conduction.  Normal: air conduction should be twice as long as bone conduction.  conductive hearing loss: bone conducted sounds as long as or longer than air conducted  sensorineural hearing loss: air conducted sound longer than bone conducted

What assessment is completed with the Weber test? A. Air conduction of sound B. Bone conduction of sound C. Air and bone conduction of sound D. Neither air or bone conduction of sound Diagnostic evaluation  Audiometric Testing – in sound proof booth and raise hand when hearing the tone. – frequency, pitch and intensity  Tympanogram: measures middle ear muscle reflex by changing the air pressure in a sealed ear canal  Auditory brainstem response: tests cranial nerve VIII ; determines any impairments along the nerve. Can help indicate tumors  Electronystagmography: measurement and graphic recording of changes in electrical potentials created by eye movements. Nystagmus – helps to dx Meniere’s and tumors. Make sure to withhold vestibular suppressants, such as sedative, tranquilizers, and antihistamines, and alcohol 24 hours before the test.  Endoscopy: the tympanic membrane is anesthetized topically for about 10 minutes before the procedure. Then irrigated with sterile normal saline solution. A tympanotomy is created with a laser beam so that the endoscope can be inserted into the middle ear. Used to evaluate perilympthatic fistula and new-onset conductive hearing loss, treatment of Meniere disease and mastoid or middle ear infections. Types of hearing loss:  Conductive; caused by external (cerumen) or middle ear problem (otitis media) o External auditory, eardrum, middle ear  Sensorineural; caused by damage to the cochlea or vestibulocochlear nerve o Inner ear, the eight cranial nerve or the brain  Mixed; both conductive and sensorineural o Patient has both conductive and sensorineural  Functional (psychogenic); caused by emotional problem  Presbycusis: gradual loss of hearing as you grow older. Caused by sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Early manifestations of hearing loss:  Tinnitus: ringing in the ears  As hearing loss increases, person may experience deterioration of speech, fatigue, indifference, social isolation or withdrawal, and other symptoms. Communicating with hearing impaired person: Reduce background noise and distractions, low tone, speak slowly, use gestures and facial expressions, face the person, write information

CONDITIONS OF THE EXTERNAL EAR  Cerumen impaction o Remove by irrigation, suction, or instrumentation o Use warm H20  Foreign bodies o Remove by irrigation, suction, or instrumentation o Objects that can swell such as vegetables or insects should not be irrigated. Use mineral oil to kill insect.  External otitis (swimmers ear)- most common form o Inflammation caused by staph o Manifestations include pain and tenderness, discharge, edema, erythema, pruritus, hearing loss o A wick may be inserted in the canal to keep it open for med administration  Malignant External otitis: RARE, can affect the external auditory canal, surrounding tissue and skull    

Other causes: vitamin deficiency and endocrine disorders as well as, inflammation also from dermatitis psoriasis/ eczema) Medication administration – analgesics, antimicrobials, antifungals, ATB, and steroids Instruct patient to avoid getting the canal wet when swimming g or shampooing the hair. Do not use cotton-tipped applicators to cause any other trauma. Osteomyelitis of the temporal bone can be a complication

CONDITIONS OF THE MIDDLE EAR 

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Tympanic membrane perforation (ear drum) o Usually caused by infection or trauma o Medical treatment: most heal on their own within weeks, may require surgical intervention Acute otitis media o Most frequently seen in children due to URI o Pathogens are most commonly Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis o Manifestations include otalgia (ear pain), fever, and hearing loss o Most often treated with broad spectrum antibiotics/surgical intervention (tympanotomy/tubes)

Serous otitis media: o fluid in the middle ear without evidence of infection –eustachian tubes to help with the obstruction or steroids Chronic otitis media o Result of recurrent acute otitis media

o Chronic infection damages the tympanic membrane, ossicle, and involves the mastoid o Treatment  Prevent by treatment of acute otitis  Tympanoplasty, ossiculoplasty, or mastoidectomy  

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Perforation – infection or trauma heal within weeks of rupture – protect from water Trauma includes perforation from foreign object such as q tip or hair pain, key. Tympanic membranes can also rupture with severe middle ear infections when there is too much pressure behind the ear drum Treatment: ear must be protected from water o With trauma we want to make sure no clear watery fluid is leaking from the earcould be CSF Otitis media: antibiotics are administered permanent hearing loss is rare with the acute form Serous otitis media does not need to be treated unless an infection occurs.

Otosclerosis  New bone growth along the stapes that causes conductive hearing loss and mixed hearing loss that effects both ears. It is a hereditary disease that has no cure. A stapedectomy is a surgical Tx that involves removing the stapes and adding a footplate CONDITIONS OF THE INNER EAR  Dizziness: any altered sense of orientation in space  Vertigo: the illusion of motion or a spinning sensation  Nystagmus: involuntary rhythmic movement of the eyes associated with vestibular dysfunction

Meniere’s disease  Abnormal inner ear fluid balance cause by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct  Manifestations include fluctuating, progressive hearing loss; tinnitus; feeling of pressure or fullness; and episodic, incapacitating vertigo that may be accompanied by nausea and vomiting  Tx: LOW SODIUM DIET 1000-1500 mg/day Acoustic neuroma  tumor of the VIII cranial nerve. Unilateral tinnitus and hearing loss without vertigo or balance disturbance. Conservative treatment is recommended because of facial nerve damage. Tinnitus

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Ringing that can be described as roaring or buzzing symptom of an underlying disorder associated with hearing loss; can be caused by underlying disease or medications – ASA, quinine, furosemide

Labyrinthitis  inflammation or infection of inner ear caused from otitis media; bacterial or viral in origin  tends to occur in spring and early summer and proceed by URI  SUDDEN ON SET vertigo, N/V, hearing loss, tinnitus Benign positional vertigo  brief period of incapacitating vertigo with a change of position of the head.  Caused by disruption of debris within the semicircular canal. This debris is formed from small crystals of calcium carbonate from the inner ear structure (the utricle).  Tx: short term with meclizine then the Epley maneuver.

Neurological function 

Assess the presence of illness and general condition – overall appearance, mental status, posture, movement, and affect.

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Symptoms may be subtle or intense, fluctuating or permanent, inconvenient or devastating. History: Onset, character, duration, severity, location, frequency of signs and symptoms, associated complaints, what makes it worse, better Pain: completely subjective, acute or chronic Seizures: precipitating factors – an abnormal electrical discharge in the cerebral cortex Dizziness and vertigo: most common complaints related to the neuro system Visual disturbances: abnormalities of eye movement (ex nystagmus with multiple sclerosis – can cause double vision or diplopia Muscle weakness: common manifestation of neurological disease; can be sudden and permanent Abnormal sensations: lack of sensation; can manifest in both central and peripheral nervous system disease; can place person at risk for falls or injury Family history: Genetic disease, trauma – head or spinal injury

Basic Neurological Assessment 

Five components 1. Cognition and consciousness (Glasgow coma scale to measure) 2. Cranial nerves 3. Motor system 4. Sensory system 5. Reflexes

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LOC: alertness and orientation (person, time, place, event). LOC is tested many times by a GCS: If a patient was unconscious, what would be the priority nursing intervention you would perform: MAINTAIN A PATENT AIRWAY Mental Status: MSE observe clients appearance, behavior, note dress, grooming, and personal hygiene, posture, gesture and movement. Are they aware and interact with their surroundings? Intellectual function: able to do simple calculations. Subtract 7 from 100, then 7 from that and so on. Thought process: clear and rational thoughts? – so good insight and judgment. “What would you do if you smelled smoke?” o Perception: show a paper and pencil – what is this? Are they having hallucinations o Memory – Long term (past health hx), short term recall recent information. Emotional status: note the clients affect (external manifestation of mood), mood swings, does their affect match their verbalizations? Blended/even, irritable, angry, anxious, apathetic/flat, or euphoric. Language ability: aphasia? Any problems with speech? Table 65-5 pg. 1959 shows types of aphasia as result of brain injury. o Dysarthria – defects in articulation. “Susie sells seashells by the sea shore.” or difficulty speaking

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o Dysphonia – abnormal production of sound from the larynx. The voice strained or horse. o Aphasia – absence of speech Mini Mental State Examination:  Helps to diagnose dementia/ tracks progression and severity of the disease (memory recall)  MMSE is the most common test used for complaints of memory loss  Physician will also use history, symptoms, physical exam, diagnostic tests as well as MMSE score to confirm a diagnosis of dementia

MOTOR SYSTEM 

Motor Ability: Extremity Strength 5- full power of contraction against gravity and resistance of muscle strength 4- fair but not full strength against gravity and a moderate amount of resistance or slight weakness 3- just sufficient strength to overcome the force of gravity or moderate weakness 2- the ability to move but not to overcome the force of gravity or severe weakness 1- minimal contractile power (weak muscle contraction can be palpated but no movement is noted or severe weakness 0 – no movement

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Extremity Movement: Involuntary movements (tremors, tics), Spasticity(increased muscle tone), Rigidity (resistance to passive stretch), and Flaccidity (lacking force or effectiveness.) Balance and Coordination: posture, gait, muscle tone and strength, coordination and balance, Romberg test - The patient stands with feet together and arms at the side, first with eyes open and then with both eyes closed for 20-30 seconds. The examiner stands close to support the patient if he or she begins to fall. Slight swaying is normal, but a loss of balance is abnormal.

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Coordination: pat thighs as fast as possible with each hand separately, then both hands alternate pronate and supinate the hands as rapidly as possible, last touch practitioners finger then touch nose, touch. LE – have patient take heel down tibia

SENSORY SYSTEM 

Tactile sensation tested by touching with cotton wisp or fingertip

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Superficial pain/temperature – assessing patient’s sensitivity to a sharp object can assess the patient’s superficial pain perception but usually reserved for those who cannot respond to or discriminate in touch sensation. Temperature – it is unnecessary to

test for temperature sense in most circumstances the sensations of pain and temperature are transmitted together in the lateral part of the spinal cord. 

Vibration and position sense (proprioception) are tested at the same time sense they are transmitted together in the posterior part of the cord. Tested with tuning fork which is placed against a bony prominence, and the patient is asked if he or she feels a sensation and then gives the examiner a signal when the sensation ceases (thumb and great toe).

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Pupil Assessment

REFLEXES 

*use reflex hammer*

DTR A. Bicep reflex, B. Triceps reflex, C. Patellar reflex, D. Ankle or Achilles reflex, E. Positive (abnormal) Babinski response.

Superficial Reflexes:  Corneal (cotton by the outer eye – elicits a blink (if no reflex; need eye protection and lubrication) – Bell’s palsy, trigeminal neuralgia  Palpebral (gage reflex) Pathologic reflexes –  Babinski -fanning of the toes is normal for newborn, but abnormal in adult and can indicate CNS disease Diagnostic Test CT Scan ...