Visual or Auditory Impairments

PICTURES FROM SLIDES

Correctable Visual Impairment: Refractive errors: Blurred Vision major symptom

• Myopia: Nearsighted-can’t accommodate for distance

• Hyperopia: Farsightedness-can’t accommodate near

• Presbyopia: Farsightedness caused by Age (onset around 60-70) 

• Astigmatism: Corneal curvature causes distortion

• Aphakia: Absence of lens (congenital, laser surgery-replaced by implant, trauma)

Corrective interventions for blurred vision

• Glasses

• Contact lens

• Laser Surgery

• Treatment

Age-Related Functional Changes

• Yellowing of lens- bad perforation→ vessel in eyes are small (liver disease and age related) 

• Accommodation gradually lost 

• Presbyopia

• Far point decreases 

• Color perception decreases 

• Intraocular pressure (IOP) increases (symptom of Glaucoma)- lots of pressure on vessels starts damaging actual vision 

Assessment of Visual System

• Snellen Chart

• External eye

• Lacrimal duct

• Conjunctiva (thin membrane covering eye)

• Sclera (white)

• Lens (covering)

• EOM

• PERRLA

• Confrontation (peripheral vision)

Conjunctivitis Extraocular Disorder- younger population: teach hand washing 

• Infection or inflammation of conjunctiva 

  • Infection or inflammation- most common is bacterial (get ATB) 

• Bacterial: most common 

  • Pinkeye- very contagious (last on surface an skin) 

• Viral

  • Contaminated swimming pools

• Allergic

  • Allergen

• Contagious

prevention for Conjunctivitis Extraocular Disorder-

hand washing

Conjunctivitis Extraocular Disorder- manifestations

Edema, redness, drainage, pain, blurred vision

Conjunctivitis Extraocular Disorder-tx

• Warm or cool compress

• Possible Drug Therapy:

  • ATBs

  • Antihistamines

  • Corticosteroids

  • Eyedrops

Cataracts- blurry vision

• Opacity (cloudy) within the lens

• Causes: 

  • Age related (senile cataracts), trauma, smoking, alcohol use, medications

  • Sedentary life style 

Cataracts- blurry vision

• Decreased vision, glare, abnormal color perception

Cataracts- blurry vision tx and drug therapy

• Drug Therapy: mydriatic agents (pupil dilation), NSAID drops, topical ATBS

• Tx: glasses (not for cure), surgery with artificial lens

Post-op Cataract Surgery

• Postoperative phase

• Cloudy lens removed and replaced with artificial lens

• Outpatient procedure-ride home

• Eye cover/patch inside 

• Dark glasses outside

• Follow-up visits

• Don’t sleep on side of eye surgery

• Assess for bleeding; infection

• When patch removed-no depth perception so protect against falls

Post-op Cataract Surgery: eye drops for

•  2-4 weeks

  • Antibiotic & corticosteroid

  • Drops can cause stinging

Post-op Cataract Surgery: avoid

• activities that increase IOP

  • Valsalva, nose blowing (do it with open mouth), lifting, bending, coughing (increase intraocular pressure for weeks)

Retinopathy

• Microvascular damage to retina

• Blurred vision to start and may lead to loss of vision

• Causes DM, HTN (that hasn’t been treated) 

• Capillary walls weaken and cause bleeding

Retinopathy tx

• Injections. Anti-Vascular endothelial growth factor (VEGF) slow the abnormal growth of blood vessels.

• Laser treatment. Lasers to make the blood vessels shrink and stop leaking

• Eye surgery.

• Retinopathy starts with blurred vision (no treatment= blindness) 

Age-Related Macular Degeneration (AMD)

• AMD is most common cause of central vision loss in older adults  IRREVERSIBLE

• Familial tendencies

Age-Related Macular Degeneration (AMD) two forms

• dry and wet

  • DRY: Nonexudative is slower to progress and more common; painless. Close vision tasks are harder.

  • WET: Exudative is more severe and rapid onset; blurred, vision distortion, darkened, blind spots

Age-Related Macular Degeneration (AMD) tx

• Slowed by Vits C, E, Beta-carotene, Zinc

• Injections directly into eye

Glaucoma

• Increased IOP and consequences of elevated pressure

• Manifestations: Peripheral field loss until “tunnel vision”.

Glaucoma types

• Primary open-angle glaucoma

  • Gradual peripheral visual field loss

• Angle-closure glaucoma

  • Acute Angle-Closure-Emergency (intraocular is high→ leads to closed vessels and causes pain) 

    • Increased IOP (10-21 norm) and sudden excruciating pain, n, v, colored halos around lights, blurred vision, eye redness

Glaucoma treatment

 Drug Therapy (initially), surgery

Priority Problems and Goals

• Problems

  • Risk for injury

  • Self-care deficits R/T visual acuity deficits

  • Acute pain 

  • Noncompliance RT side effects

• Goals

  • No progression of visual impairment

  • Understanding of disease process and rationale for therapy

  • Compliance with all aspects of therapy 

  • No postoperative complications 

Applying Ophthalmic Ointment

• Ask pt to put their head back.

• Pull the lower lid down.

• Apply ointment into the pocket formed by the lid pulled away from the eye

• Blinking the eyes will spread the ointment to the upper lids as well.

• Wipe off the excess with a clean tissue.

Applying Eye Drops

• Tilt head back

• Have patient look up to ceiling

• Open eye with thumb & fingers

• Hold dropper close to eye but do not touch eye/conjunctiva

• Drops into lower lid area

• May apply gentle pressure over inner canthus to prevent eye drops from flowing into tear duct

Caring for Visually Impaired Patients

• Acknowledge your presence in the patient's room.

• Speak in a normal tone of voice.

• Explain the reason for touching a person before doing so.

• Keep the call light within reach.

• Orient people to the environment.

• Assist with ambulation by walking slightly ahead of the person.

• Stay in a person's field of vision if he or she has partial vision.

• Provide diversion using other senses.

• Indicate conversation has ended when leaving room

Auditory System

• Hear problem: say “what” and high TV volume

• External ear problem: wax occlusion 

Auditory System: middle ear

• Transmission of sound

• Air conduction

• Bone conduction

• Problems here cause conductive (sound waves blocked) loss

Auditory System: inner ear

• Hearing, balance, and equilibrium

• Problems here cause sensorial (nerve damage) hearing loss with changes in tone perception and position sense

Auditory System: history and physical

• Ask about otitis media, surgeries, perforations, hx of mumps, measles, scarlet fever, DM, rheumatoid arthritis, multiple sclerosis

• Over 200 medications are ototoxic causing hearing loss, tinnitus (ringing), vertigo (dizziness)

  • ASA, some ATBs (erythromycin, vancomycin), loop diuretics, NSAIDs, chemo

Conductive hearing loss- middle ear related

• Sound transmission to the inner ear impaired

• Patients hear better in noisy environments because bone conduction better than air conduction

• Treat cause or recommend a hearing aid

Sensorineural hearing loss

• Results in ability to hear sound but inability to understand speech

• Can lead to misunderstanding by others 

• Hearing aids make sounds louder but not clearer, use cochlear implant 

Signs of Hearing Loss

• Does not respond to or understand oral communication

• Has excessively loud or soft speech

• Answers questions inappropriately

• Tilts head or leans forward when listening

• Constantly needs to clarify conversation

• Increases volume on TV

• Difficulty hearing on phone

Hearing Aids

• Fitted by an audiologist or speech & hearing specialist

• Provide amplification, sound lateralization, speech discrimination for conductive hearing loss

Hearing Aids requires

• a motivated, capable user for optimum success   

• Concerns about appearance

• Need to be able to manipulate small batteries. Concern for elderly

• Need regular cleaning; keep in dry cool place

Communication with Hearing Impaired

• Face pt in good light for lip reading

• Sign language for complete hearing loss

• Maintain eye contact

• Use face mask with a clear shield

• Avoid chewing when speaking

• Remove background noise

• Move closer to pt and speak normally. No shouting

• Write names or difficult words

• Use a communication board

Cochlear Implant

• For severe to profound sensorineural hearing loss in one or both ears

• Ideal candidates became deaf after acquiring speech and language

• Surgically implanted

• Works thru bone conduction

Assistive Devises for Hearing Impaired

• Amplification devices

• Alerting systems that flash when activated by sound

• Texting systems

• Closed caption

• Specially trained dogs that alert owners to specific sounds

• Teach measures to prevent hearing problems.

• Avoid exposure to continuous high-level noise

• Music not at > 50% of maximum

• Hearing Protection Devices (Earplugs)

• Hearing loss from noise is not reversible

• Immunizations against diseases that cause hearing loss (rubella, measles, mumps)

• Monitor medication side effects for ototoxicity

• Check for impacted cerumen.  Can be identified by muffled sounds, but no pain.  Teach to clean ears without impacting build up.

A 74-year-old male comes to the clinic for an eye and ear exam. For which reasons would the nurse involve the wife in the assessment? Select all that apply

a. The patient may not realize his deficits

b. A woman provides greater detail

c. His wife may notice things he does not

d. The wife may add history he forgets to add

e. His age keeps him from being accurate

A patient complains of partial loss of vision on the right side. The nurse should perform which of the following assessments? 

a. Administer the Snellen test 

b. Perform the confrontation test

c. Examine the pupil response to accommodation

d. Use tonometry to evaluate intraocular pressures

The 14-year-old patient complains of hearing muffled sounds in the right ear.  Vital signs are normal, there are no other manifestations, and the pt does not have any pain. What does the nurse  suspect?

a. Blocked eustachian tube

b. Ruptured tympanic membrane

c. Infection of the mastoid bone

d. Impacted cerumen

Which circumstance places the patient at the greatest risk for developing vision disturbances?

a. History of working with computer

b. Advanced age

c. History of diabetes mellitus 

d. Retired landscaper

Which nursing intervention would enhance an older adult’s sensory perception and thereby help prevent injury when walking from the bed to the bathroom? Select all that apply.

a. Providing adequate lighting

b. Raising the pitch of the nurse’s voice

c. Holding tightly onto the patient’s arm

d. Removing environmental hazards

e. Assessing gait when the pt gets out of bed

E.M., an 82-year-old female, is escorted by her daughter into preoperative area for removal of cataract. 

Her daughter asks you what can be done to prevent cataracts. What should you tell her?