Final Exam Study Guide Adult II

From memory, go through the tracheostomy care validation

Validation Steps

PRIOR TO ENERING THE ROOM

Check the medical order.

Gather supplies: PPE, trach care kit, oxygen equipment, ambu-bag, pulse oximeter (suction canister, and connecting tubing, if not in room).

UPON ENTERING THE ROOM (PRE-PROCEDURE)

Pre-Procedure routine (Sandwich!)

DURING PROCEDURE (INTRA-PROCEDURE)

Raise the HOB to semi-Fowler’s (30-45 degrees) if conscious and drape the chest with chux pad or towel.

Adjust the bed to a comfortable working height.

Lower the side rail.

Place pulse oximeter on client.

Prepare supplemental oxygen, ambu-bag, and suction canister with tubing.

Check suction equipment. Occlude suction tubing on continuous suction and ensure it is at 100-120 mm Hg.

Open sterile tracheostomy kit, sterile catheter package, and open normal saline solution.

Don sterile gloves.

Place sterile drape on overbed table.

Place items from sterile container onto sterile field.

Pour sterile saline into 3-4 of the trays/suction cup with non-dominant hand or assistant may pour.

Pick up sterile catheter with dominant hand wrapping tube around hand, pick up connective suction tubing with non-dominant hand and connect the two together.

Moisten catheter in sterile saline with dominant hand then occlude suction port with non-dominant hand to check suction in chamber #1.

Use non-dominant hand to hyperventilate client (3 squeezes of ambu-bag) or assistant may bag. Check pulse ox.

Advance suction catheter with dominant hand to cough reflex (4-5 inches or 10-11 cm). DO NOT SUCTION WHILE INSERTING CATHETER.

Apply suction intermittently with non-dominant thumb and rotate while being withdrawn. DO not suction more than 10-15 seconds at a time.

Hyperventilate client (3 squeezes of ambu-bag) with non-dominant hand or assistant may perform and replace O2 collar.

Ask client to take several deep breaths and cough.

Verbalize to instructor: may suction up to 3 times allowing 30 seconds to 1 minute between each time.

Flush catheter in saline between suctioning in chamber #1.

Suction oropharynx. Do not reinsert catheter into trachea after suctioning the mouth.

Disconnect suction tubing from catheter with non-dominant hand and dispose of catheter. Have assistant turn off suction.

Remove O2 collar with non-dominant hand, have assistant stabilize faceplate. Remove inner cannula with non-dominant hand and place in sterile saline in chamber #2.

Have assistant replace O2 collar over outer cannula.

Clean inner cannula with brush keeping dominant hand sterile.

Place cannula in clean sterile saline chamber #3 with non-dominant hand to rinse. Remove cannula with dominant hand and tap dry on sterile field.

Reinsert inner cannula with dominant hand using non-dominant hand to stabilize faceplate. Sterility is complete.

Remove soiled trach dressing and discard in trash. If no assistant available to help leave old ties/Velcro in place.

Assess skin integrity around stoma.

Dip a cotton swab into sterile saline in chamber #3 and clean around stoma under faceplate. Use applicator only once per area, moving from stoma outward.

Pat skin dry with sterile gauze.

Apply fenestrated 4x4 under faceplate with help of assistant to keep faceplate stable.

Remove trach ties while stabilizing faceplate.

Assess skin on the back of the neck. Clean back of neck with sterile gauze dipped in chamber #3 if needed.

Have assistant hold faceplate in place and apply clean trach holder with a new Velcro holder/tie.

Replace O2.

Dispose of items used for procedure.

Remove pulse oximeter (do not throw away)

Educated client ·         trach care performed, ·         do not pull-on trach ·         can cough secretions into suction catheter or tissues/gauze ·         notify if feeling short of breath

Post-Procedure routine (Sandwich!)

Verbalize documentation ·         size ___ French suction catheter ·         how many times suctioned (1, 2, or 3) ·         color, clarity, consistency, and amount (scant, small, moderate, large, copious) of secretions ·         sterile trach care performed ·         skin integrity around stoma and back of the neck ·         drainage around stoma and on dressing (sanguineous, serosanguineous, serous, purulent) ·         oxygen saturation and pulse rate throughout the procedure ·         how client tolerated procedure (pain level, before, during, after procedure) ·         client educated and verbalized understanding of education

What is epistaxis?

What is the cause?

Epistaxis: Hemorrhage from the nose (nosebleed); common problem

Cause:

• Caused by the rupture of distended blood vessels (capillaries) in the mucous membranes of the nares (usually in the anterior septum area)

List risk factors for epistaxis.

1. Use of Aspirin/NSAIDs

2. Local infections (vestibulitis, rhinitis, rhinosinusitis)

3. Systemic infections (scarlet fever, malaria)

4. Drying of nasal mucous membranes

5. Nasal inhalation of corticosteroids (e.g., beclomethasone) or illicit drugs (e.g., cocaine)

6. Trauma (digital trauma, blunt trauma, fracture, forceful nose blowing)

7. Arteriosclerosis

8. Hypertension

9. Tumor (sinus or nasopharynx)

10. Thrombocytopenia

11. Liver disease

12. Rendu–Osler–Weber syndrome (hereditary hemorrhagic telangiectasia)

What does tx for epistaxis depend on?

What does the initial tx consist of?

• The tx depends on the cause and location of the bleeding site

Initial Tx

1. Initial treatment usually involves applying direct pressure to the affected nare

2. During a nosebleed occurrence, the patient is instructed to sit upright; tilt the head forward (so will not swallow or aspirate blood); and pinch the soft outer portion of the nose against the midline septum for 5-10 minutes

What pharmacologic intervention might be used to tx epistaxis?

A nasal decongestant (Phenylephrine) may be used as a vasoconstrictor to aid in stopping the bleeding

If pressure application and a nasal decongestant (phenylephrine) do not stop epistaxis, what interventions might be next?

• The nose is examined, suctioned, and the bleeding site(s) are cauterized with silver nitrate or electrocautery

• Can also use a Surgicel or Gelfoam patch; a cotton tampon; or a nasal sponge tamponade (contains an agent to promote blood clotting)

What txs can be performed if epistaxis does not stop and the site of bleeding cannot be identified?

1. The nose can be packed with petroleum gauze or gauze with antibiotic ointment (excessive petroleum jelly into the lungs can cause increased risk for pneumonia)

—>—>A topical anesthetic spray and decongestant may be used before the packing gauze is inserted

2. Another option of treatment: A balloon-inflated catheter in the affected nare (nasal tamponade)

—>—>Tubes or packing usually removed after 1-3 days

List options for the nursing management of epistaxis.

1. Continuously assesses airway and breathing (observe for respiratory distress, tolerance of packing/tubes)

2. Monitor vital signs

3. Assist with procedures

4. Provide the patient with tissues and an emesis basin (so patient can blow nose/spit out blood)

5. Control patient’s anxiety

6. Humidity, oxygen, bedrest, and/or antibiotics may be prescribed

7. Once bleeding is controlled, instruct patient to avoid vigorous exercise, hot/spicy foods, tobacco (may cause vasodilation)

8. Educate the patient on ways to prevent epistaxis (avoid forceful nose blowing, straining, high altitudes, nasal trauma)

9. Educate patient how to apply direct pressure in case of another nosebleed

10. Instruct the patient to get medical attention if the nosebleed cannot be stopped

What is glaucoma?

Glaucoma is characterized as a group of ocular conditions where the IOP is elevated; it is an age-related eye disease

What IOP is normal? What if IOP is higher than this range?

Normal IOP is 10-21 mmHg, higher than that = glaucoma

What causes the increased IOP in glaucoma?

Increased IOP results from inadequate drainage of aqueous humor from the canal of Schlemm or overproduction of aqueous humor

In what age group does glaucoma mostly occur in?

This disease occurs mostly in people older than 40

List risk factors for glaucoma

1. Black or Asian race

2. Cardiovascular disease

3. Diabetes

4. Family history of glaucoma

5. Migraine syndromes

6. Myopia (nearsightedness)

7. Obstructive sleep apnea

8. Older age

9. Previous eye trauma

10. Prolonged use of topical or systemic corticosteroids

11. Thin cornea

What are the 3 types of glaucoma?

1. Wide-angle glaucoma (POAG = primary open-angle glaucoma)

2. Narrow-angle glaucoma (PACG = primary angle closure glaucoma)

3. Congenital glaucoma

What causes wide angle glaucoma (POAG)?

POAG results from obstruction of the outflow of aqueous humor into the trabecular meshwork = buildup of aqueous humor = increased IOP

Causes:

1. Hereditary factors

2. Aging

List late-stage manifestations of wide-angle glaucoma (POAG)

1. Visual field defects

2. Possible ocular pain

3. HAs

List characteristics of wide-angle glaucoma (POAG).

• It is the most common type of glaucoma

• It usually affects both eyes and has no manifestations in the early stages

• In POAG, the anterior chamber angle is open and appears normal

• Develops slowly, so tx is not as aggressive

• In open-angle glaucoma, the tonometry reading is between 22-32 mmHg.

• Considered the “silent thief of sight” b/c most patients are unaware that they have the disease until they have experienced visual changes and vision loss

→—>The patient may not make an appointment with their doctor/NP until they experience blurred vision or “halos” around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and/or headaches

How does wide-angle glaucoma (POAG) present?

• Usually bilateral, but one eye may be more severely affected than the other

• in wide-angle glaucoma, the anterior chamber angle is open and appears normal

• Slow development

What occurs in narrow-angle glaucoma (PACG = primary angle closure glaucoma)?

The aqueous humor encounters resistance to flow through the pupil due to complete or partial closure of the anterior chamber angle

How does narrow-angle glaucoma (PACG) manifest, and what is it considered?

Has a sudden onset and is an emergency→requires immediate treatment

List clinical manifestations of narrow-angle glaucoma (PACG).

Manifestations include:

→Rapidly progressive visual impairment

→Periocular pain

→Congestion

→Transient blurring of vision (Refers to a temporary, sudden, and brief [seconds to minutes] loss of clear eyesight in one or both eyes, often described as a "curtain" descending, dimming, or fogginess, followed by full recovery)

→Reduced central vision

—>Rapid rise in IOP (like from 20 to 30) and/or tonometry reading of 30mmHg or higher

List potential causes of narrow-angle glaucoma (PACG).

• Lens or pupil dilation from medications

• Sympathetic stimulation

What is tonometry?

Used to measure the IOP

Give an example of IOP change that indicates PACG vs POAG

• A sudden jump in IOP from 21 to 30 = PACG

Versus

• A gradual rise for POAG, such as 21 to 22 b/t appointments

List tests used to diagnose and monitor glaucoma.

1. Tonometry

2. Central visual field testing

3. Gonioscopy

4. Optic nerve imaging (ophthalmoscopy)

What is gonioscopy used for w/ glaucoma?

Gonioscopy visualizes the anterior chamber angle to assess fluid drainage to determine whether the angle is open or closed (so diagnosing POAG vs PACG)

What is ophthalmoscopy (optic nerve imaging) used for w/ glaucoma?

What abnormal findings might you see in glaucoma?

Ophthalmoscopy is used to inspect the optic nerve to determine the degree of nerve damage present in glaucoma

Abnormal findings that indicate glaucoma:

1. Pallor and cupping of the optic nerve disc

—>—>Cupping is the exaggerated bending of the blood vessels as they cross the optic disc

→—>Cupping progresses in glaucoma due to the gradual loss of retinal nerve fibers and the loss of blood supply

What is the goal of the management of glaucoma?

Prevent further optic nerve damage

What should patients be educated on about the pathology and treatment of glaucoma?

Glaucoma cannot be cured

—>—>This means lifelong tx therapy

List potential treatment measures for glaucoma

1. Pharmacologic therapy

2. Laser procedures

3. Surgery

4. Or a combination of these approaches (all of these measures have potential complications and side effects)

Why should nurses stress the importance of f/u appts on glaucoma to patients?

Healthcare professionals want to maintain the IOP within a range unlikely to cause further damage

What is the initial tx target for glaucoma patients?

The initial target for IOP is typically set at 30% lower than the current pressure

What are the preferred initial topical meds for glaucoma, and why?

Beta-blockers are the preferred initial topical medications because of their efficacy, minimal dosing (can be used once each day), and low cost

List the classes of glaucoma meds.

1. Cholinergics (i.e., miotics)

2. Beta-blockers

3. Alpha2-agonists (i.e., adrenergic agents)

4. Carbonic anhydrase inhibitors

5. Prostaglandin analogs

6. Hyperosmolar Agents/Osmotic Diuretics

What hyperosmolar agent/osmotic diuretic is more commonly used to tx glaucoma?

Mannitol (IV)—>draws water from ocular tissues into the bloodstream to be filtered out by the kidneys and urinated out, reducing vitreous fluid volume = decreases IOP

For alpha-adrenergic agonists used in the treatment of glaucoma, list example meds, potential side effects, and nursing implications for their use

Medications:

1. Brimonidine

2. Apraclonidine

Side effects

1. Eye redness

2. Dry mouth and nasal passages

Nursing Implications

1. Educate patients about punctal occlusion to limit systemic effects

For cholinergics (miotics) used in the treatment of glaucoma, list example meds, potential side effects, and nursing implications for their use

Medications:

1. Pilocarpine

2. Carbachol intraocular

Side effects

1. Periorbital pain

2. Blurry vision

3. Difficulty seeing in the dark

Nursing Implications

1. Caution patients about difficulty seeing in the dark

2. Pilocarpine can be stored at room temp for up to 8 wks

For beta-blockers used in the treatment of glaucoma, list example meds, potential side effects, and nursing implications for their use

Medications:

1. Timolol maleate

Side effects

1. Can have systemic effects (bradycardia, exacerbation of pulmonary disease b/c of bronchoconstriction, hypotension)

Nursing Implications

1. Contraindicated in patients with asthma, COPD, 2nd or 3rd degree heart block, brady cardia, or HF

2. Educate patients about punctal occlusion to limit systemic effects

For carbonic anhydrase inhibitors used in the treatment of glaucoma, list example meds, potential side effects, and nursing implications for their use

Medications:

1. Acetazolamide

2. Dorzolamide

Side effects

1. Oral meds (acetazolamide) are associated w/ serious side effects (anaphylactic reactions, electrolyte loss, depression lethargy, GI upset, impotence, and weight loss)

2. Topical form (dorzolamide) side effect = potential for topical allergy

Nursing Implications

1. Do not administer to patients with sulfa allergies

2. Monitor electrolyte levels

For prostaglandin analogues used in the treatment of glaucoma, list example meds, potential side effects, and nursing implications for their use

Medications:

1. Latanoprost

2. Bimatoprost

Side effects

1. Darkening of the iris

2. Conjunctival redness

3. Possible rash

Nursing Implications

1. Instruct patients to report any side effects

What is the priority nursing intervention for ocular meds?

Give examples.

The priority nursing intervention for ocular meds is education!

Examples:

1. Do not skip doses

2. Give medication on time

3. Wait 5-10 mins between most eye medications

How long must a patient wait b/t different eye drops being administered?

What about eye ointments?

1. Need to wait 3-5 minutes between eye drops if more than one med needs to be administered

2. Need to wait at least 10 minutes after eye drop administration to administer an eye ointment

What should patients w/ glaucoma be educated on?

1. Intraocular pressure measurements

2. Visual field tests

3. How eyedrops work

4. How to administer

5. Monitor for side effects

6. Compliance, timely dosing

How is acute angle-closure glaucoma (narrow-angle) treated?

This is an ocular emergency

1. Hyperosmotics (mannitol IV)

2. Acetazolamide

3. Topical ocular hypotensive agents

4. Possible laser iridotomy (incision in the iris) to release blocked aqueous and reduce IOP

5. Tx of the other unaffected eye w/ pilocarpine eye drops and/or surgical management to avoid a similar spontaneous attack

When is surgery used to manage glaucoma?

Surgical management of glaucoma is used for patients that are unresponsive to pharmacological treatment of increased IOP levels

List/describe the 4 types of surgeries used to tx glaucoma

1. Trabeculectomy surgery

—>—>Small incision into the eye to stabilize the optic nerve, restore the eye’s natural fluid balance, and minimize further visual field damage

2. Laser Trabeculoplasty

—>—>A laser beam is used to open the trabecular meshwork and widen the canal of Schlemm, which allows outflow of the aqueous humor and decreases the IOP

—>—>Contraindicated in patients with narrow-angle glaucoma because the trabecular meshwork is difficult to see

3. Peripheral (Laser) Iridotomy

—>—>Laser used to make an opening in the iris to eliminate the pupillary blockage

—>—>It is contraindicated in patients with corneal edema because the edema interferes with laser targeting and strength

4. Filtering Techniques

—>—>Various filtering surgical techniques can be used to create an opening where the aqueous humor can drain out of the anterior chamber while bypassing the usual drainage structures

What does retinal detachment involve?

Retinal detachment involves the separation of the two innermost layers of the retina from each other, the neurosensory area of the retina from the RPE (retinal pigment epithelium)

List risk factors for retinal detachment.

1. High myopia (near-sidedness)

2. Aphakia (absence of natural lenses) after cataract surgery

3. Trauma

4. Proliferative retinopathy (associated w/ diabetic patients)

5. Tension Forces

List the clinical manifestations of retinal detachment.

1. Sensation of a shade or curtain coming into the visual field

2. Seeing cobwebs

3. Bright flashing lights

4. “Floaters”

5. Typically painless b/c the retina lacks pain receptors

What diagnostic testing does a patient w/ potential retinal detachment require?

• Require a dilated fundus examination with an indirect ophthalmoscope and a slit-lamp biomicroscopy

• Optical coherence tomography (OCT) and ultrasound are used for a complete retinal detachment assessment, especially if the patient is suspected of having a cataract or vitreal hemorrhage

What non-surgical tx is used for retinal detachment? What is still required after this tx is performed?

• Using cryotherapy, photocoagulation, or diathermy, an inflammatory response can be created to bind the retina and choroid together around the break

• Surgical repair is still necessary to repair the detachment

How quickly do surgeries to manage retinal detachment need to be completed?

Retina detachment is a medical emergency and reattachment needs to occur the same day as the onset of sx to reduce the likelihood of permanent vision loss

List and describe the 2 common surgical interventions used for retinal detachment.

1. Scleral buckle

During scleral buckle surgery, the surgeon flattens and presses the sclera with a silicone band, called a buckle

This procedure brings the two retinal layers together and repairs the tear

2. Vitrectomy

—>—> A gas or oil bubble is placed to apply pressure and hold the retina in place to heal

—>—>If a gas bubble is used in the vitrectomy surgery, the patient has to stay in a prone position so the injected bubble can stay over the area of the detachment

Following surgery to fix a retinal detachment, what post-op instructions should the nurse educate the patient on?

1. Use of an eye patch and shield

2. If gas or oil has been placed, then the patient must be placed on his/her abdomen

→—>Lie with head turned so that the affected eye is facing up for several days

3. Nausea and pain are common post-surgery

4. Avoid activities that increase IOP→ Avoid lifting, pushing, or pulling objects heavier than 15 pounds

5. Avoid reading, writing, and close work in the first week after surgery

List signs/sx of post-op complications following a scleral buckle or vitrectomy

1. Inflammation of the eye

2. Cataracts

3. Infection

List the possible complications that can occur after a retinal detachment surgery

1. Increased IOP

2. Enopthalmitis (inflammation of the inner eye)

3. Another retinal detachment

4. Cataract development

5. Infection

What is one of the main signs of age-related macular degeneration (AMD)?

• One of the main signs is tiny, yellowish spots known as “drusen” beneath the retina

• It is normal for people older than 60 to have a small amount of drusen (clusters of debris or waste material) beneath the retina

• The drusen become a problem when they are in the macular area of the eye, and they start to affect a person’s vision

What part of the vision does age-related macular degeneration (AMD) affect?

• AMD affects central vision the most

• Still have peripheral vision

• These patients have a wide range of visual loss, but only a few have total blindness

List risk factors for age-related macular degeneration (AMD).

1. Older age

2. Family hx of macular degeneration

3. Smoking

4. Being Caucasian

5. HTN

6. Previous cataract surgery

Describe dry age-related macular degeneration (AMD).

• Much more common than wet AMD

• Dry AMD is non-neovascular and non-exudative

• It is a condition in which the outer layers of the retina slowly break down, and drusen starts to form

• If the drusen form outside of the macular area, the patient is asymptomatic

• If the drusen forms within the macula, there is a gradual blurring of vision (especially when reading)

What is the treatment for dry age-related macular degeneration (AMD)?

There is no effective therapy for dry AMD

Describe wet age-related macular degeneration (AMD).

1. Wet AMD is neovascular and exudative

2. Wet AMD has an abrupt onset and is more damaging to the vision = much worse than dry AMD

3. Patients with wet AMD often see lines that are crooked or distorted and letters or words that are broken in appearance

4. With wet AMD, choroidal neovascularization occurs (where the blood vessels leak fluid and blood under the retina→which causes the retina to elevate and affect the vision)

What is the treatment for wet age-related macular degeneration (AMD)?

It can be treated by intravitreal injections of Ranibizumab (Lucentis) and/or Bevacizumab (Avastin), or with laser therapy to stop the leaking blood vessels

In the management of age-related macular degeneration (AMD), what is given to patients to take home and how are patients supposed to use them?

1. Amsler grids are given to patients to take home

—>—>They use these grids to test their sight and assess if their vision is getting worse (an early sign of AMD)

—>—>If the lines on the Amsler grid are wavy and not straight, they need to call their Dr. and get in immediately b/c either dry is getting worse or injections are not working for wet

2. Patients should use the grids several times a week (testing one eye at a time)

3. The patients are informed if the lines/images are distorted, faded, or harder to see, they need to contact their ophthalmologist

How is an otoscopic exam performed?

The pinna is grasped and pulled back to straighten the ear canal so the MD has a clear view of the canal and membrane

Describe a healthy tympanic membrane.

A healthy tympanic membrane is pearly gray, intact, and sits at the base of the ear canal

What is the snellen chart used for?

How are right eye, left eye, and both eyes documented in the chart?

Snellen chart: Is the standardized test for visual acuity (distance: 20 feet) performed on each eye

—>It determines the smallest letters a person can read on a standardized chart from a distance of 20 feet (6 meters)

For documentation:

• Right eye (OD)

• Left eye (OS)

• Both eyes (OU)

What do the numbers mean on a Snellen chart score?

20/20 = normal vision

• The first number is the testing distance (always 20 for 20ft)

• The 2nd number is the distance at which a person with normal vision could read that line (so for 20/40 vision, a person with normal vision could read that line at 40ft while the person being tested can only read it at 20ft)

What visual acuity is legal blindness

Defined in the U.S. as a visual acuity of 20/200 or worse in the better eye with best correction

How are the 6 cardinal directions of gaze tested? What does checking this area of vision screen for?

The six cardinal directions of gaze: Up, down, left, right, and both diagonals

→Are tested by the patient following the examiner’s finger, a light, etc.

→The six directions of gaze test can screen for any ocular trauma, or neurologic disorders (such as stroke or myasthenia gravis)

What is a direct ophthalmoscopy? What is visualized on this diagnostic test?

Direct Ophthalmoscopy: Handheld instrument with various plus and minus lenses

• Lenses can be rotated so examiner can closely view the cornea, lens, and retina

• The eye’s fundus, optic nerve, and optic cup can also be visualized

How is a direct ophthalmoscopy performed?

Light is shone in the patient’s left or right eye as he/she gazes at a target

• The patient is instructed to keep both eyes open during the examination

An examiner performing direct ophthalmoscopy sees intraretinal hemorrhages. What could this indicate?

HTN

An examiner performing direct ophthalmoscopy sees that the retina has a yellowish appearance. What could this indicate?

If the retina has a yellowish appearance, the patient may have hypercholesterolemia or diabetes

An examiner performing direct ophthalmoscopy sees Drusen. What could this indicate?

Drusen (small, hyaline, globular deposits under the retina area) found in the eye can indicate macular degeneration

What is indirect ophthalmoscopy?

The use of an instrument with a bright and intense light attached to a pair of binocular lenses attached to the examiners head to see the retina w/o magnification

What is slit-lamp examination?

The use of a mounted binocular microscope to magnify the anterior eye structures to identify any abnormality in the cornea, lens, anterior chamber, fundus, or anterior vitreous humor

• Can see 10-40 times the real image

• Can be used to evaluate patients for cataracts

What does tonometry measure? What is it used for?

• Measures intraocular pressure = the pressure used to flatten the cornea (10-20 mmHg is normal)

• Can be used to screen for and manage glaucoma

What is typically done before a tonometry test and why?

The tonometry probe touches the cornea (which is sensitive), so a topical anesthetic is usually given before the measurement is done

What should the nurse instruct the patient to avoid while getting an IOP measurement done?

1. Squeezing the eyelids

2. Holding their breath

3. Performing a Valsalva maneuver

4. Doing any other action that could increase the eye’s IOP

How is color vision checked?

Polychromatic plates can be utilized to establish whether a person’s color vision is within normal range

What is an Amsler grid?

How is an Amsler grid used?

Amsler Grid: A test used for patients with possible macular problems (macular degeneration)

How is an Amsler grid used?

• The test uses a geometric grid of identical squares with a central fixation area to test the patient’s vision

• The eyes are tested one at a time

What result on the Amsler grid indicates macular problems (macular degeneration)?

Patients with macular problems complain of the squares looking faded or of seeing wavy lanes

What is ultrasonography used for regarding the eyes?

Ultrasonography is used for assessing the orbit and eye for trauma, intraorbital tumors, proptosis (protrusion of the eyeball), and choroidal or retinal detachments

What is angiography used for regarding the eyes?

Used to evaluate macular edema, macular capillary non-perfusion, retinal and choroidal neovascularization (growth of abnormal new blood vessels) which occurs in acute macular degeneration

What tests should be done before angiography?

What is recommended for patients?

What are patients given 1 hour before the angiography?

1. Before these tests, BUN and Creatinine should be checked to ensure the kidneys can excrete the dye

2. The patient is encouraged to drink clear liquids up until the exam time, so that he/she is well hydrated

3. The patient is also given mydriatic drops one hour before the procedure to dilate the pupils

What instructions should be given to the patients prior to angiography?

• The patients have to remain immobile during this test, and they are informed that they will feel a brief feeling of warmth in the face, behind the eyes, or in the jaw, teeth, tongue, and lips area

→—>These patients also complain of having a metallic taste in the mouth

• The dye may cause skin to be yellow or gold for a few hours (up to 24 hours) and turn urine green, deep yellow, or orange

What is a side effect of indocyanine green used for angiography of the eyes?

When is it contraindicated?

• Indocyanine green has side effects of nausea and/or vomiting

• Patients allergic to iodine cannot have this dye injected

What is perimetry testing, and what does perimetry testing identify/assess for?

• Evaluates the field of vision

• This test helps identify which parts of the patient’s central and peripheral visual fields have accurate vision

• It assesses for blindness or partially blind visual fields in patients with glaucoma, macular degeneration, or retinitis pigmentosa

How is a whisper test performed, and why is it performed?

How:

• Ask the patient to block one external ear canal, while you stand 1-2 feet away and whisper a statement

• The patient is then asked to repeat the whispered statement

Why:

• Each ear is tested separately to assess high-frequency hearing acuity to detect potential hearing impairment

What are the two tuning fork tests?

1. Weber test

2. Rinne test

Weber test

1. What does this test for?

2. Describe the procedure

3. Describe normal results

4. Describe results that indicate conductive loss w/ an example

5. Describe results that indicate sensorineural loss w/an example

1. This test is used to detect unilateral hearing loss

2. Procedure: Place a vibrating tuning fork stem in the middle of the patient’s head, at midline of the forehead, or above the upper lip over the teeth, and ask whether the sound is heard equally in both ears (normal)

Results

3. Normal: Sound is heard equally in both ears

4. Conductive Loss: Sound lateralizes to the affected ear (louder on the side of damage)

→ So if the patient has bone conductive hearing loss, they hear the sound better in the affected (damaged) ear

→Ex: If a person has wax buildup in their right ear, that is “conductive hearing loss”, and they would hear the sound louder in the right ear

5. Sensorineural Loss: Sound lateralizes to the unaffected (better) ear

→ So if the patient has sensorineural loss (like from cochlear or vestibulocochlear nerve damage), the patient will hear the sound in the unaffected (better) ear, so if the nerve damage is to the right ear, they will hear better in their left ear

Rinne test

1. What is the Rinne test?

2. Describe its procedure

3. What can this test tell you?

4. Describe the results of a patient with normal hearing

5. Describe the results of a patient with conductive hearing loss

6. Describe the results of a patient with sensorineural hearing loss

1. Uses air conduction (AC) and bone conduction (BC) to test for sound (compares air conduction of sound to bone conduction of sound)

2. Procedure: Alternate a vibrating tuning fork stem between two positions (2 inches from the opening of the ear canal to test for air conduction) and against the mastoid bone (to test for bone conduction)

→—>The patient is asked as the positions are alternated to let the MD/NP know which tone is louder or when the tones (from air or bone conduction) are no longer audible

3. This test can be used to tell if the patient has conductive or sensorineural hearing loss

4. A patient with normal hearing should state that the air conduction sounds are louder than the bone conduction sounds in both ears

5. A patient with conductive hearing loss hears bone-conducted sound as long or longer than air-conducted sound

6. A patient with sensorineural hearing loss hears air-conducted sounds longer in the affected ear

1. What is audiometry?

2. Who performs audiometry?

3. During audiometry tests, what parts of hearing are evaluated?

1. Audiometry: The single most important diagnostic instrument for assessing patients for hearing disorders

2. Performed by an audiologist

3. During these tests, three parts of hearing are evaluated:

• Frequency

• Pitch

• Intensity

What is the unit for measuring hearing loss and loudness/intensity of sound?

What is normal hearing?

The unit for measuring hearing loss and loudness or intensity of sound: Decibel

→Normal hearing is 0-15 decibels

Describe what happens during an audiometry exam

During an audiometry exam, the patient wears earphones and raises his/her hand as he/she hears a tone in the earphone

→The responses are plotted on an audiogram (graph)

1. What does a tympanogram assess for?

2. What is it used for?

1. Assesses the mobility of the eardrum and structures of the middle ear by changing air pressure in the ear canal

2. Used for middle ear problems (is impaired with middle ear disease)

List the 3 types of hearing loss

1. Conductive

2. Sensorineural

3. Mixed conductive-sensorineural

1. Describe conductive hearing loss

2. Give example causes

3. What test is commonly used to determine if a patient has conductive hearing loss?

1. Caused by any physical obstruction to the transmission of sound waves, impairing sound transmission to the inner ear; a person with conductive hearing loss hears better in the affected ear

2. Examples of Causes of Conductive Hearing Loss

• A disorder of the external ear (impacted cerumen)

• A disorder of the middle ear (otitis media or otosclerosis)

3. A Weber test is used to determine conductive hearing loss

What usually causes sensorineural hearing loss?

A defect in the cochlea, eighth cranial nerve, the vestibulocochlear nerve, or the brain itself