Module 13 Sensory

Module Overview

• Focus: Assessment and care for patients with visual and auditory impairments.

• Chapters: 22 and 23

Learning Outcomes

• Utilize interviewing and assessment skills for clients with vision/auditory alterations.

• Assess the impact of these alterations on overall human functioning.

• Apply the nursing process for sensory problem care.

• Identify nursing responsibilities regarding retinal detachment, orbital trauma, enucleation, and vision/auditory surgeries.

• Recognize common medications for auditory and visual disturbances.

Assessment of Visual System

Health History Components

• Last ocular exam date, use of glasses/contacts.

• Medication considerations:

  • Eye drops and cold meds (may contain epinephrine).

  • Corticosteroids and thyroid medications (risks for cataracts/glaucoma).

• History of ocular and non-ocular surgeries.

Nursing Assessment Techniques

• Color Vision Testing: Checks ability to perceive color.

• Visual Acuity Testing:

  • Use Snellen Chart, assess each eye separately.

  • Record results as a fraction (e.g., Right eye 20/30 with glasses).

• Tonometry: Measures intraocular pressure.

• Keratometry: Assesses curvature of the cornea.

• Ophthalmoscopy: Examines interior structures of the eye.

• Pupil Function Testing: Checks pupil responsiveness (PERRL).

Assessment Abnormalities

Visual System Symptoms:

• Blurred vision

• Diplopia (double vision)

• Dryness

• Spots

• Pain

• Photophobia

• Floaters

Eyelid Abnormalities:

• Allergic reactions

• Blepharitis - inflammation of eyelid

• Ectropion - eyelid flipped out away from eye

• Hordeolum - sty

• Ptosis - drooping of upper eyelid

Common Diagnostic Tests

• Amsler Grid Test - measure macular (waves, missing lines, abnormalities - issues)

• Fluorescein Angiography (assess IV site because it is a vesicant, can cause orange/yellow)

• Perimetry Testing (flashing light to test central and peripheral vision)

• Refractometry (look for refraction issues)

• Ultrasonography (size and structure of eye)

Refractive Errors

• Myopia: Nearsightedness; light focuses in front of the retina. most common

• Hyperopia: Farsightedness; light focuses behind the retina.

• Astigmatism: Light focuses on multiple points. Irregular curvature

• Presbyopia: Age-related loss of near vision. Lenses become larger, firmer, less elastic

• Aphakia: Absence of the lens.

Common Corrections

• Corrective glasses, contact lenses, surgical options (LASIK, PEK (cornea not thick enough for LASIK), IOL- replacement of lenses).

Visual Impairment

• Defined as uncorrectable vision issues, ranging to blindness.

• Vision is classified by the best eye

• Legal blindness: best-corrected vision ≤ 20/200 or restricted visual field.

• Major causes include cataracts, glaucoma, AMD, diabetic retinopathy.

Responsible Eye Care

• Regular hand hygiene and protective measures.

• Utilization of sunglasses and protective eye wear and nutrition for eye health.

Sight Guide Technique

• Assist visually impaired individuals properly:

  • Offer elbow, indicate environment changes, and allow independent seating orientation.

Gerontological Considerations

• Visual impairment in elderly may lead to isolation and financial issues.

• Medication handling can be impacted due to decreased dexterity.

Eye Injury/Trauma

• Common causes include falls, fights, and home accidents.

• Emergency management should prioritize airway, breathing, circulation.

• Immediate eye irrigation for chemical burns; stabilize foreign bodies.

• Traumas are usually avoidable

• Many times injury is caused by improper contact use and failure to wear protective eye wear

Morgan Lens

• Provides continuous irrigation for chemical or thermal burns.

Common Eye Conditions

Hordeolum (Sty)

• Infection of meibomian glands; treat with warm moist compresses x4 an day and, if recurrent, lid scrubs.

Bacterial Conjunctivitis (Pink Eye)

• Caused by Staphylococcus aureus; involves redness and discharge. Treat with antibiotic eye drops.

• Itches and discomfort

• Highly contagious

• Moist wet compresses

• Good hygiene

• Cannot use contacts

• Dispose of contacts, solution, and any cosmetics and cosmetic tools that come in contact with the eye

Epidemic Keratoconjunctivitis (EKC)

• Serious viral infection; requires good hygiene practices to prevent spread.

• Ice packs, artificial tears, and dark glasses

Trachoma

• Major cause of blindness

• Spread by poor hand hygiene and rubbing eyes

• Another type of conjunctivitis

Allergic conjunctivitis

• Exposure to allergen

• Can be severe enough to cause significant swelling

• Burning, redness, tearing

• Try to avoid allergen

Keratitis

• Inflammation or infection of the cornea

• Bacterial or viral

• UV exposure

• Immunosuppressed, contact wearers, nutritional deficiencies- higher risk

• Treatment- antibiotic, antiviral (herpes simplex), analgesic, topical corticosteroids, mydriatic agents dilate pupil and relieve pain

Corneal Ulcers

• Tissue loss due to corneal infection

  • Bacterial

  • Viral

  • Fungus

Cataracts

• Visual opacity; gradual vision decline. Most are age-related. Treatment primarily surgical.

Retinal Detachment

• Emergency condition; symptoms include flashes of light, floaters, and curtain-like vision loss.

• Treatment can include surgical interventions like cryopexy or scleral buckling.

Age-Related Macular Degeneration (AMD)

• Major cause of irreversible vision loss; characterized by distorted vision and blind spots.

• Treatments involve injected medications to slow progression.

Glaucoma

• Disorder characterized by increased intraocular pressure leading to optic nerve damage.

• Two primary types: primary open-angle (most common) and angle-closure.

• Management may include medications, surgery, and regular eye exams to monitor IOP.

Auditory System Overview

• Hearing impairments can majorly affect social interaction and cognitive function.

• Common causes include external, middle, and inner ear conditions.

signs of Possible Hearing Loss

• Insufficient response to communication, need for loud volumes, inappropriate answers.

Common Conditions in Auditory System

Otitis Media

• Acute form often seen in children; treatment may involve antibiotics or surgical interventions.

Chronic Otitis Media

• Recurrent infections leading to potential hearing loss; surgical options may be required.

Otosclerosis

• Hereditary condition causing conductive hearing loss; treated surgically by replacing the stapes.

Ménière Disease

• Progressive disorder causing episodic vertigo and hearing impairment; management focuses on symptom relief.

• Ménière's Disease is a progressive inner ear disorder characterized by episodes of vertigo, hearing loss, tinnitus (ringing in the ears), and a sensation of fullness in the ear. The disease typically affects one ear, but in some cases, it can affect both. Symptoms can vary in duration and intensity, with episodes lasting from 20 minutes to several hours.

  Common Causes:

  • Abnormal inner ear fluid pressure

  • Allergies, infections, and genetic predispositions may contribute to the condition.

  Management and Treatment:

  • There is no cure, but treatments focus on symptom relief.

    • Medications to manage vertigo and nausea

    • Dietary changes, such as reducing salt intake, to help manage fluid balance

    • Diuretics to assist in reducing inner ear fluid buildup

    • In severe cases, surgical options may be considered to relieve inner ear pressure or to destroy the balance function of the affected ear.

  Lifestyle Adjustments:

  • Patients are advised to avoid triggers like stress and certain foods or beverages that may aggravate symptoms.

  • Balance therapy and hearing aids may also be recommended as part of comprehensive management.

Patient Teaching for Hearing Aids

• Introduce aids in quiet environments, progressively increase exposure.

• Care tips: keep aids dry, clean ear molds weekly, manage battery life.

Slide 27 - 43

cataracts

Retinal detachment

Macular degeneration

Glaucoma

Enclunation

Vertigo and dizziness are often confused but are distinct experiences.

• Vertigo:

  • A specific type of dizziness characterized by the false sensation of spinning or movement.

  • Individuals may feel as if they or their surroundings are moving when in fact they are not.

  • Typically related to inner ear disorders, such as Ménière's disease or vestibular neuritis.

  • Can be accompanied by nausea, balance problems, and visual disturbances.

• Dizziness:

  • A broader term encompassing various sensations including lightheadedness, faintness, or unsteady feelings.

  • It does not imply the hallmark sensation of movement associated with vertigo.

  • May be caused by a variety of factors including dehydration, low blood pressure, anxiety, or medication side effects.

In summary, while vertigo is a type of dizziness, not all dizziness is vertigo. Understanding the difference is crucial for diagnosing and treating the underlying causes of these symptoms effectively.