lecture-2-ortho-neuro-professor-lindor.pdf

lOMoARcPSD|6976302 Lecture 2 - Ortho neuro, professor lindor Health Alterations Ii (Broward College) StuDocu is not sponsored or endorsed by any college or university Downloaded by Taje' St. John ([email protected]) ...

lOMoARcPSD|6976302 Lecture 2 - Ortho neuro, professor lindor Health Alterations Ii (Broward College) StuDocu is not sponsored or endorsed by any college or university Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 Lecture 2 (Visual and Auditory Problems) Visual Problems  Correctable Refractive Errors  Refractive errors prevent light rays from converging into a single focus on the retina  In normal vision, incoming light rays focus directly on the retina  Causes  Abnormal curvature of the cornea  Changes in the focusing power of the lens  Alteration in the length of the eyeball  The major symptom is blurred vision  Patient may also complain of ocular discomfort, eyestrain, or headaches  Myopia (Nearsightedness)  Image falls in front of the retina  Excessive light refraction by the cornea or lens  The eye has too much focusing power  The eye is too long, or the cornea is too steep  At risk for Retinal Detachment  Hyperopia (Farsightedness)  Image goes behind the retina  The eyeball is too short, or the cornea is too flat  Presbyopia  Loss of accommodation associated with old age  Occurs between age 40-50  Lens of the eye hardens and muscles weaken  Inability to accommodate for near objects  Reading glasses are needed  Bifocals if they already wear glasses for vision  Astigmatism  Caused by an irregular corneal curvature  Eye is shaped like a football, not spheric like the normal eye  Uneven surface of the eye  Incoming light rays bend unequally  Image has more than 1 focal point on the retina  Blurred vision near or far  Treatment  Non-surgical Corrections  Corrective Glasses  Contact Lenses  Corneal Molding ○ Rigid, gas-permeable contact lenses to alter the shape of the cornea  Surgical Therapy Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Laser ○ LASIK (Laser-assisted in situ keratomileusis)  A laser or thin blade is used to create a thin flap in the cornea  The laser is then programmed to correct or sculpt the cornea to correct the refractive error  The flap adheres on it’s own without sutures ○ PRK (Photorefractive keratectomy)  Only the epithelium is removed and the laser sculpts the cornea to correct the refractive error ○ LASEK (Laser-assisted epithelial keratomileusis)  Similar to PRK except that the epithelium is replaced after surgery  Implant ○ ICR’s (Intracorneal ring segments)  Two semicircular pieces of plastic that are implanted between the layers of the cornea  Designed to change the shape of the cornea by adjusting the focusing power ○ Refractive IOL (Refractive intraocular lens)  Removal of the patient’s natural lens, and implantation of an IOL  Small plastic lens to correct the patient’s refractive error  The risk is higher because this involves entering the eye ○ Phakic IOL (Phakic intraocular lens)  Implantable contact lens  Implanted into the eye without removing the eye’s natural lens  It is placed in front of the eye’s natural lens  Thermal Procedures ○ LTK (Laser thermal keratoplasty) and CK (conductive keratoplasty)  Heat is applied to the peripheral area of the cornea to tighten it (like a belt) and make the central cornea steeper  For patients with hyperopia or presbyopia  Only the less dominant eye is treated  The desired effect is monovision  Enables one eye to focus at close proximity  The other is left untreated to focus at a distance  A pre-op trial with a contact lens is a useful test to see if a patient will adapt to the refractive outcome  Uncorrectable Visual Impairment  Severe visual impairment  Inability to read newsprint; even with glasses  Levels of visual impairment Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Legally blind  Central visual acuity for distance ○ 20/200 or worse in the better eye (with correction)  Visual field ○ No greater than 20 degrees in its widest diameter (in the better eye)  They have peripheral vision, but no central vision  Vision enhancement techniques are not helpful  May use vision substitutes (guide dogs/canes)  May have some usable vision  Total blindness ○ No light perception ○ No usable vision  Functional blindness ○ Some light perception ○ No usable vision  Partially sighted individual  Not legally blind  Corrected visual acuity greater than 20/200 in the better eye, 20/50 or worse in the better eye  Nursing Management  Assessment  Assess how long the patient has had the visual impairment  Determine how the visual impairment affects their normal functioning  Ask how much difficulty they have when reading, writing, moving from one room to the next, or watching TV  Ask how the vision loss has affected certain aspects of their life  Determine the patient’s coping strategies, emotional reactions, strengths, and support systems  Diagnoses  Disturbed sensory perception r/t visual deficit  Risk for injury r/t visual impairment and inability to see potential dangers  Self-care deficits r/t visual impairment  Fear r/t inability to see potential danger or accurately interpret the environment  Grieving r/t loss of functional vision  Implementation  Always communicate in a normal tone and manner  Common courtesy ○ Address the patient, not the caregiver who may be with the patient ○ Introduce yourself and any other person who approaches the blind Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Make eye-contact (it ensures that you are speaking while facing the patient so the patient has no difficulty hearing you) ○ Say good-bye when leaving  Orientation to the environment lessens the patient’s anxiety or discomfort and facilitates independence ○ Identify one object as the focal point and describe the location of other objects in relation to it  Explain any activities or noises occurring in the patient’s immediate surroundings  Assist the patient to each major object using the slight-guide technique ○ Stand slightly in front and to the side of the patient ○ Offer an elbow for the patient to hold ○ Describe the environment to help orient the patient  Assist the patient to sit by placing one of his or her hands on the back of the chair  Know what services and devices are available ○ Be prepared to make appropriate referrals  Vision substitute techniques ○ Braille ○ Audio books for reading ○ Cane ○ Guide dog  Optical Devices for vision enhancement ○ Telescopic lenses for near or far vision ○ Magnifiers of various types  Non-optical methods for vision enhancement ○ Approach magnification  Have the patient sit closer to the TV  Hold books closer to the eyes ○ Contrast enhancement  Watch TV in black and white  Use contrasting colors (red stripe at the edge of steps/curbs) ○ Increase lighting  Halogen lamps  Direct sunlight  Gooseneck lamps  Gerontologic Considerations  Decreased vision + Confusion = ↑ risk for falls  Eye Trauma  All eye injuries are considered medical emergencies  Immediate evaluation and intervention is needed  Corneal abrasion  disruption of the superficial epithelium of the cornea  Causes  Automobile accidents Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Sports (can be prevented by wearing protective eyewear)  Leisure activities  Work-related situations  Emergency Management  Etiology  Blunt Injury ○ Fist ○ Other blunt objects  Penetrating Injury ○ Fragments (glass, metal, wood) ○ Knife ○ Stick ○ Other large object  Chemical Injury (most common eye injury) ○ Alkaline  More serious than acid  Does not stop burning ○ Acid  Thermal Injury ○ Direct burn (curling iron, other hot surface) ○ Indirect burn (UV light [welding torch, sun lamp])  Foreign Bodies ○ Glass ○ Metal ○ Wood ○ Plastic  Trauma ○ Blunt ○ Penetrating/Perforating  Burns ○ Chemical ○ Thermal  Assessment Findings  Pain  Photophobia  Redness (diffuse or localized)  Swelling  Echymosis  Tearing  Hyphema (blood in the eye)  Blood in the anterior chamber  Absent eye movement  Fluid drainage from the eye (blood, CSF, aqueous humor)  Abnormal or decreased vision  Visible foreign body  Prolapsed globe Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Abnormal IOP  Visual field defect  Nursing Interventions  Initial ○ Determine the mechanism of injury ○ Ensure airway, breathing, circulation ○ Assess for any other injuries ○ Assess for chemical exposure  Begin ocular irrigation immediately in case of a chemical exposure  Do not stop until emergency personnel have arrived  Use sterile saline or water ○ Assess visual acuity ○ Do not put pressure on the eye ○ Instruct the patient not to blow their nose ○ No sudden movements of the eye (reading) ○ Do not attempt to treat the injury (except for chemical exposure) ○ Stabilize foreign objects  Cover the eye(s) with a dry, sterile patch and a protective shield (cup) ○ Do not give the patient food/fluids ○ Elevate the head of the bed to 45 degrees (Semi-Fowler’s) ○ Do not put medication or solutions in the eye (unless ordered by a physician) ○ Administer analgesia as appropriate  Ongoing Management ○ Reassure the patient ○ Monitor pain ○ Anticipate surgical repair for  Penetrating injury  Globe rupture/avulsion  Inflammation and Infection  Hordeolum (Sty)  Infection of the sebaceous glands in the lid margin  Staph. aureus  most common bacterial infective agent  Clinical Manifestations  Red, swollen, circumscribed, acutely tender area that develops rapidly  Treatment  Apply warm, moist compresses (4 times a day) until it improves  If there is a tendency for reoccurrence  lid scrubs daily  Appropriate antibiotic ointment or drops may be indicated ○ Culture is done first  Surgery if it gets too large  Nursing Management Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Teach about good hand washing (it is contagious, and can spread to the other eye)  Takes longer to heal in Diabetic patients  Chalazion  Chronic inflammatory granuloma of the sebaceous glands in the lid  May evolve from a hordeolum  Clinical Manifestations  Usually appears on the upper lid  Swollen, tender, reddened area  May be painful (usually painless)  Treatment  Similar to hordeolum  If warm compresses are ineffective  surgery to remove the lesion ○ Or injection with corticosteroids  Blepharitis  Chronic bilateral inflammation of the lid margins  Clinical Manifestations  Lids are red rimmed with many scales/crusts on the lid margins and lashes  Itching  Burning  Irritation  Photophobia  Conjunctivitis may occur simultaneously  Treatment  Antibiotic ointment if caused by a staphylococcal infection  Antiseborrheic shampoo if caused by dandruff of the scalp and eyebrows  Treatment must be vigorous to avoid hordeolum, keratitis (inflammation of the cornea) and other infections  Teach about thorough cleaning practices of the skin and scalp  Gentle cleansing of the lid margins with baby shampoo can soften and remove crusting (dilute the shampoo with warm water)  Conjunctivitis  Infection or inflammation of the conjunctiva  Causes  Infection ○ Bacterial or Viral microorganisms  Inflammation ○ Allergens ○ Chemical irritants (including cigarette smoke) ○ Chronic foreign body in the eye (contact lens, ocular prosthesis)  Bacterial Infections Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Acute bacterial conjunctivitis (pinkeye)  Occurs more in children (poor hygiene habits)  Most common causative agent  Staph. aureus  Clinical Manifestations ○ Irritation ○ Tearing ○ Redness ○ Mucopurulent drainage ○ Crusting  Generally spreads within 48 hours to the unaffected eye  Treatment ○ Usually self-limiting ○ Antibiotic drops shorten the course of the disorder  Besivance  Viral Infections  May be contracted in contaminated swimming pools or by direct contact with an infected person  Clinical Manifestations ○ Tearing ○ Foreign body sensation ○ Redness ○ Mild photophobia ○ No crusting  Treatment ○ Usually mild and self-limiting ○ Topical corticosteroids  Just to provide temporary relief ○ It can be severe  Increased discomfort  Subconjunctival hemorrhaging (emergency, can lead to blindness)  Chlamydial Infections  Trachoma ○ Chronic conjunctivitis caused by Chlamydia trachomatis ○ STD  Transmitted mainly by the hands and flies  Seen in 3rd world countries  Chief cause of preventable blindness  Clinical Manifestations ○ Mucopurulent ocular discharge ○ Irritation ○ Redness ○ Lid swelling  Treatment ○ Antibiotic therapy (only drug of choice that will clear it up)  Allergic Conjunctivitis Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Caused by exposure to an allergen (pollen, animal dander, ocular solutions/medications, contact lenses)  Clinical Manifestations ○ Itching (defining symptom) ○ Burning ○ Redness ○ Tearing ○ White or clear exudate  Treatment ○ Artificial tears  dilute the allergen and wash it out from the eye ○ Antihistamines ○ Corticosteroids  Keratitis  Inflammation or infection of the cornea  Medical emergency  Causes  Pathogens  Hypersensitivity  Ischemia (tissue death)  Tearing defects (problems with the lacrimal gland)  Trauma  Bacterial Infections  Risk Factors ○ Mechanical or chemical corneal epithelial damage ○ Contact lens wear ○ Nutritional deficiencies ○ Immunosuppressed state ○ Contaminated products  Lens care solutions/cases  Topical medications  Cosmetics  Treatment ○ Topical antibiotics ○ Subconjunctival antibiotic injection ○ IV antibiotics in severe cases  Viral Infections  Herpes simplex virus (HSV) keratitis ○ Clinical Manifestations  The resulting corneal ulcer has a dendritic (tree-branching) appearance  Pain  Photophobia ○ Treatment  Viroptic drops for 2-3 weeks  Corneal debridement Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Topical Vira-A ointment  Oral Zovirax  Topical corticosteroids are contraindicated  Contribute to a longer course  Possible deeper ulceration  Varicella-zoster virus (VZV) ○ Occurs in older adults and Immunosuppressed patients ○ Treatment  Opioid or non-opioid analgesics (for pain)  Topical corticosteroids (reduce inflammation)  Antiviral agents (Zovirax) (to ↓ viral replication)  Mydriatic agents (to dilate the pupil and relieve pain)  Topical antibiotics (combat secondary infections)  Warm compresses and povidone-iodine gel to the affected skin  Gel should not be applied near the eye  Epidemic keratoconjunctivitis (EKC) ○ Spread by direct contact (hands and instruments), including sexual activity ○ Clinical Manifestations  Tearing  Redness  Photophobia  Foreign body sensation ○ Treatment  Primarily palliative (ice packs, dark glasses)  Severe cases  Mild topical corticosteroids  Topical antibiotic ointment ○ Nursing Management  Teach the patient about good hygiene practices to avoid spreading the disease  Other Causes  Fungi ○ Akanthamoeba keratitis  Caused by a parasite that is associated with contact lens wear  Homemade saline solution is susceptible  Treatment  Treatment is difficult  The Acanthamoeba organism is resistant to most drugs  Natacyn (the only antifungal eye drop that is approved)  If the antimicrobial therapy fails  corneal transplant  Nursing Management Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Teach the patient about good lens care practices  Exposure keratitis ○ Occurs when patients cannot adequately close their eyelids ○ The patient with exopthalmus (protruding eyeball) is susceptible  Corneal Ulcer  Tissue loss caused by infection of the cornea  produces a corneal ulcer  Clinical Manifestations ○ Very painful ○ Feels like there is a foreign body in the eye ○ Tearing ○ Purulent watery discharge ○ Redness ○ Photophobia  Treatment ○ Usually aggressive to avoid permanent vision loss ○ Antiviral, antibacterial, or antifungal eye drops  As frequently as every hour night and day for the first 24 hrs ○ An untreated ulcer  corneal scarring and perforation (hole in the cornea) ○ Corneal transplant may be indicated  Nursing Management  Assessment  Assess for ocular changes ○ Edema ○ Redness ○ ↓ visual acuity ○ Feeling as if a foreign body is present ○ Discomfort  Consider the psychosocial aspects of the patients condition  Diagnoses  Acute pain r/t irritation or infection of the external eye  Anxiety r/t uncertainty of the cause of the disease and outcome of treatment  Disturbed sensory perception (visual) r/t diminished or absent vision  Implementation  Frequent asepsis and thorough hand washing to prevent the spread of infection  Inform the patient about appropriate use of and care of lenses and lens care products  Apply warm or cool compresses for the patient’s condition  Darken the room  Provide appropriate analgesics  Modify the patients environment for safety  If 2 different eye drops are ordered hourly Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Administer 1 drop on the hour and the other on the ½ hour ○ Promotes maximum absorption ○ The patient who needs frequent eye drops may be sleep deprived  Teach patient proper techniques for medication administration  Inform patients who wear contacts to discard all opened or used lens care products and cosmetics to ↓ the risk of re-infection  Dry Eye Disorders  Keratoconjunctivitis sicca  Common complaint in the elderly  Caused by a decrease in the quality or quantity of tear film  Clinical Manifestations  Irritation  “sand in my eyes”  Worsens throughout the day  Treatment  Directed at the underlying cause  Lacrimal duct dysfunction ○ Hot compresses ○ Lid massage  ↓ tear secretion ○ Artificial tears ○ Ointments  Severe cases ○ Closure of the lacrimal puncta  Cataract  Opacity (clouding) within the lens  Causes  Age-related  Blunt or penetrating trauma  Maternal rubella  Radiation or UV light exposure  Long-term exposure to sunlight  Certain drugs  Systemic corticosteroids  Long-term topical corticosteroids  Ocular inflammation  Patients with Diabetes Mellitus tend to develop cataracts at a younger age  Cigarette smoking and heavy alcohol consumption  Pathophysiology  An altered metabolic process within the lens causes an accumulation of water and alterations in the lens fiber structure  These changes affect lens transparency, causing vision changes Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Secondary Glaucoma can occur if the enlarging lens causes ↑ IOP  Clinical Manifestations  Tend to occur bilaterally  ↓ in vision  Abnormal color perception (red/blue/yellow)  Glare  Light scatter due to lens opacity  Worse at night when the pupil dilates  The visual decline is gradual  No pain  If pain, may be glaucoma  Diagnostic Studies  ↓ visual acuity and other visual dysfunction  Opacity is observable by an ophthalmoscope or slit lamp  A totally opaque lens creates the appearance of a white pupil  Treatment  There is no cure other than surgical removal  Non-surgical Therapy  Change prescription of glasses ○ Can improve the level of visual acuity  Strong reading glasses or magnifiers ○ May help the patient with close vision  Increased lighting ○ To read or accomplish other near-vision tasks  Lifestyle adjustment ○ Driving only during the day and having a family member drive at night  Reassurance  Surgical Therapy  Removal of the lens  Reasons: ○ When palliative measures no longer work ○ Lens induced problems (↑ IOP) ○ Ophthalmologist is no longer able to view the retina  Pre-op ○ Pre-op antibiotic eye drops ○ NPO 6-8 hours before surgery ○ Dilating drops  Mydriatic ( - adrenergic agonist)  Neo-Synephrine  May cause tachycardia and ↑ BP  Cycloplegic (Anticholinergic agent)  Drug Alert  Make sure the patient doesn’t have glaucoma  ↑ IOP because of the dilating pupils Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Have patient wear dark sunglasses to minimize photophobia  Monitor for signs and symptoms of systemic toxicity  Tachycardia  CNS effects ○ Anti-inflammatory eye drops (↓ inflammation) ○ Anti-anxiety medication  Intra-op ○ The lens nucleus and cortex is removed, leaving the capsular bag intact ○ Extracapsular extraction  Lens nucleus is removed by “scooping” it out with a lens scoop ○ Phacoemulsification  Lens nucleus is fragmented by ultrasonic vibration and aspirated from the capsular bag ○ Implantation of an IOL (intraocular lens)  Post-op ○ Topical antibiotic drops to prevent infection ○ Topical corticosteroid or other anti-inflammatory agent to ↓ post- op inflammatory response ○ Mild analgesia if necessary ○ Eye shield/activity as preferred by the physician  Nursing Management  Assessment  Visual acuity  Psychosocial impact of the visual disability  Comfort post-op and the ability to follow the post-op regimen  Diagnoses  Self-care deficits r/t visual acuity  Anxiety r/t surgery  Implementation  Suggest that the patient wear sunglasses  Avoid radiation  Maintain proper intake of antioxidant vitamins (Vitamin C and E) and good nutrition  Provide information about vision enhancement techniques for the patient who decides not to have surgery  Pre-op ○ The patient needs accurate information about the disease process and treatment options ○ The patient needs to know that without surgery there will be some degree of visual disability ○ For the patient who decides to have surgery  Provide information, support, and reassurance about the surgical experience to ↓ anxiety Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ When administering topical medications for pupil dilation  Note that patients with darker irides may need a larger dose  Photophobia is common so ↓ room lighting  These meds produce transient stinging and burning ○ Inform patients that will be wearing a patch that they will not have depth perception until the patch is removed  Avoid possible falls or injuries  Post-op ○ Patient usually experiences little or no pain  There may be some scratchiness in the operative eye  Mild analgesics can be used to relieve pain  If the pain is intense  Notify the surgeon  May indicate hemorrhage, infection, or ↑ IOP ○ Notify the surgeon if there is  ↑ purulent drainage  ↑ redness  ↓ visual acuity ○ Give the patients verbal and written instructions before discharge  Post-op eye care  Proper hygiene and eye care techniques  Activity restrictions  Head positioning  Bending  Coughing  Valsalva maneuver  Medications  How to instill them  Use aseptic technique  Adherence to prescribed medications  Follow-up visits  Signs and symptoms of possible complications/infection  Include the patient’s caregiver in the instructions  Suggest ways the patient and caregiver can modify activities and the environment to maintain adequate level of safe functioning ○ Getting assistance with steps ○ Removing area rugs or other potential obstacles ○ Preparing meals or freezing before surgery ○ Obtaining audio books for diversion until visual acuity improves  Diabetic Retinopathy  From long-standing uncontrolled diabetes  Process of microvascular damage to the retinal capillaries  Can develop slowly or rapidly  Leads to blurred vision and progressive vision loss Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Non-proliferative retinopathy  Most common form of diabetic retinopathy  Clinical Manifestations  Capillary microaneurysms  Retinal swelling  Hard exudates  Macular edema ○ Represents worsening of the retinopathy ○ Plasma leaks from the macular blood vessels  As capillary walls weaken, they can rupture  Leading to intraretinal “dot or blot” hemorrhaging  A severe loss in central vision can result  Proliferative retinopathy  As the disease advances  New blood vessels grow  Abnormal  Fragile  Predisposed to leaks  Causing vision loss  Large areas of retinal ischemia (occlusion)  Diagnostics  Fluorescein angiography  Used to detect macular edema  Treatment  Laser photocoagulation ○ Slows the progression of the disorder, but is not curative  Manage the diabetes  Retinal Detachment  Separation of the sensory retina and the underlying pigment epithelium, with fluid accumulation between the two layers  If untreated  blindness in the involved eye  Medical emergency  Etiology/Pathophysiology  Retinal break (most common cause)  Interruption in the full thickness of the retinal tissue  They can be classified as: ○ Tears  occurs as the vitreous humor shrinks during aging and pulls the retina ○ Holes  appear spontaneously  Risk Factors  ↑ age  Severe myopia  Eye trauma  Diabetic retinopathy  Cataract or Glaucoma surgery Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  This is why we say no sneezing/coughing  Family or personal history  Clinical Manifestations  Photopsia (light flashes)  Floaters  Ring in the field of vision  “Little black insects” (classic sign)  Once the retina has detached  Painless loss of peripheral or central vision (macular is affected)  “Like a curtain coming across the field of vision”  Diagnosis  Visual acuity measurements  Can be visualized using a ophthalmoscope or slit lamp  Eye appears normal on a visual inspection  Ultrasound (if cornea, lens, or vitreous is hazy/opaque)  Treatment  Surgery  Laser photocoagulation ○ Use an intense, precise light beam to create an inflammatory reaction at the are of the retinal break ○ It produces a scar that seals the hole or tear  No fluid will be able to enter the subretinal space to cause a detachment  Cryoretinopexy ○ Using extreme cold to create the inflammatory reaction to produce a scar  Scleral buckling procedure ○ The surgeon sutures an implant against the sclera, causing the sclera to buckle inward  The epithelium, choroid, and sclera move toward the detached retina ○ If any subretinal fluid is present it may be drained with a small gauge needle  Intraocular Procedures ○ Pneumatic retinopexy  Intravitreal injection of a gas to form a bubble in the vitreous to close the retinal breaks  The bubble is temporary, so it is combined with photocoagulation or cryotherapy  The patient must position their head so that the bubble is in contact with the retinal break  They must maintain this position for up to several weeks ○ Virectomy  Surgical removal of the vitreous  Post-op Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Patient may be on bed rest and may require special positioning to maintain proper position of the intravitreal bubble  Patient may need topical medications ○ Antibiotics ○ Anti-inflammatory agents ○ Dilating agents  Nursing Management  Retinal detachment is an urgent situation  The patient needs emotional support, especially during the immediate pre-op period  The patient is at risk for retinal detachment in the other eye  Teach the patient signs and symptoms of retinal detachment  Age-Related Macular Degeneration  Macula  An area of the retina where you have the highest visual acuity  Irreversible central vision loss in persons over 60  Divided into 2 forms  Dry (non-exudative)  Most common  May notice close vision tasks become more difficult  Macular cells start to atrophy  Slow, progressive, painless vision loss  Wet (exudative)  More severe  If untreated  blindness  More rapid onset  Development of abnormal blood vessels in or near the macula  Patients with wet AMD had dry AMD first  Etiology  Related to retinal aging  Genetic factors  Family history  Long-term exposure to UV light  Hyperopia  Cigarette smoking  Light-colored eyes  Nutritional factors  Vitamins C and E lower the development of advancing AMD  Eating lots of dark green leafy vegetables containing lutein (kale and spinach) may help reduce the risk of AMD  Pathophysiology  Dry  Abnormal accumulation of yellowish colored extracellular deposits called drusen in the retinal pigment epithelium  Atrophy and degeneration of the macular cells then result Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Wet  Growth of new blood vessels in an abnormal location in the retinal epithelium  As new blood vessels leak, scar tissue forms  Acute vision loss may occur in some cases with bleeding from the subretinal neovascular membranes  Clinical Manifestations  Blurred and darkened central vision  Peripheral vision remains intact  Presence of scotomas (blind spots in the visual field)  Metamorphopsia (distortion of vision)  Diagnosis  Visual acuity measures  Opthalmoscopy  The examiner looks for drusen and other fundus changes associated with AMD  Fundus photography  IV angiography with fluorescin  Treatment  No effective treatment  Teach client and family to adapt to gradual decline in vision  Ex. Place TV on side of patient instead of in front of them  Glaucoma  A group of disorders characterized by increased IOP  Elevated pressure  Optic nerve atrophy  Peripheral visual loss  Risk Factors  Family history  Over age 40  Diabetes  History of ocular problems  Medications (Mydriatics [dilate the pupil])  Pathophysiology  Related to the consequences of elevated IOP  A proper balance between the rate of aqueous production (inflow) and the rate of aqueous absorption (outflow) is essential to maintain the IOP within normal limits  The place where the outflow occurs is called the “angle”  The angle is where the iris meets the cornea  When the rate of inflow is greater than the rate of outflow, IOP can rise above normal limits  If IOP remains elevated  permanent vision loss can occur  Primary open-angle glaucoma (POAG)  Most common type of glaucoma Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  The outflow of aqueous humor is decreased  The drainage channels becomes clogged  Damage to the optic nerve can then result ○ Fluid starts to get pushed toward the optic nerve (CNII)  Primary angle-closure glaucoma (PACG)  Reduction of the outflow of aqueous humor from angle closure  Usually caused from the lens bulging forward as a result of the aging process  May also occur as a result of pupil dilation in the patient with anatomically narrowed angles  Instruct these patients not to take any mydriatic medications ○ They cause the pupils to dilate  angle gets narrower  ↑ IOP  Secondary glaucoma  Inflammation  Trauma  Tumors  Any condition that causes blocking of the outflow channels  Clinical Manifestations  POAG  Develops slowly without symptoms  No symptoms of pain or pressure  They do not notice the gradual visual field loss until peripheral vision has been severely compromised  Eventually, the patient with untreated glaucoma gets tunnel vision  Acute ACG  Sudden, excruciating pain in or around the eye accompanied by nausea and vomiting  See colored halos around lights  Blurred vision  Ocular redness  Corneal edema ○ From the ↑ IOP, giving the corneal a frosted appearance  Chronic ACG  Appear more gradually  History of blurred vision  Seeing colored halos around lights  Ocular redness  Eye or brow pain  Diagnostics  IOP is usually elevated in glaucoma  Normal 10-21 mmHG  Slit lamp  Open-angle glaucoma ○ Normal angle  Angle-closure glaucoma ○ Narrow or flat angle Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Edematous cornea ○ Fixed and moderately dilated pupil ○ Ciliary injection  Measures of peripheral and central vision  Central acuity may remain 20/20  Visual field may reveal subtle changes in the peripheral retina early in the disease process  Optic disc cupping  One of the first signs of chronic open-angle glaucoma  The optic disc becomes wider, deeper, and paler (light gray or white)  Treatment  Keep the IOP low enough to prevent the patient from developing optic nerve damage  Chronic Open-Angle Glaucoma  Drugs ○ Continued treatment is necessary because the drugs control, but do not cure the disease ○  - adrenergic blockers  Timoptic  Decreases aqueous humor production  Causes bradycardia and ↓ BP  Contraindicated in the patient with bradycardia, cardiogenic shock, cardiac failure, asthma, or COPD ○  - adrenergic agonists  Epinephrine eyedrops  Decreases aqueous humor production  Enhances outflow facility  Cause tachycardia, hypertension, and irregular HR  Contraindicated in the patient with narrow-angle glaucoma ○ Cholinergic agents (miotics)  Mitotic eyedrops  Stimulates iris sphincter contraction  Open the trabecular network and facilitate aqueous outflow  Drug Alert:  Warn patients about ↓ visual acuity, especially in dim light ○ Carbonic anhydrase inhibitors  Diamox  Decreases aqueous humor production  Side effects  Paresthesia (“tingling” in extremities)  Allergic reactions may occur in the patient who is allergic to sulfa  Should not be given to patients on high dose aspirin therapy (pt with rheumatoid arthritis)  Surgery Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Argon laser trabeculoplasty (ALT)  Non-invasive option to lower IOP when meds are not successful  Requires only topical anesthetic  The laser stimulates scarring and contraction of the trabecular meshwork  Which opens the outflow channels  The patient uses topical corticosteroids for 3-5 days following the procedure  The most common post-op complication is an acute rise in IOP  Uncommon side effects  Infection  Bleeding  Cataract development ○ Trabeculectomy (with or without filtering implant)  Filtration surgery  The surgeon makes conjunctival and scleral flaps, removes part of the iris and trabecular network and closes the scleral flap loosely  Aqueous humor can now “percolate” out through the area of missing iris where it is trapped under the repaired conjunctiva and absorbed in to the systemic circulation ○ Implant  Permanent surgical placement of a small plastic drainage tube and reservoir to shunt aqueous humor from the anterior chamber  Surrounding tissue absorbs the fluid  Acute Angle-Closure Glaucoma  Drugs ○ Topical cholinergic agent (miotics) ○ Hyperosmotic agent  Move fluid from the intracellular space to the extracellular space reducing IOP  May have severe dehydration  Assess patient for susceptibility to pulmonary edema and CHF before administering  Surgery ○ Laser peripheral iridotomy/Surgical iridotomy  Allow the aqueous humor to flow through a newly created opening in the iris and into normal outflow channels  Secondary Glaucoma  Treat the underlying problem  Antiglaucoma drugs  Nursing Management  Assessment Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Determine visual acuity, visual fields, IOP, and fundus changes  Diagnoses  Risk for injury r/t visual acuity deficits  Self-care deficits r/t visual acuity deficits  Acute pain r/t pathophysiologic process and surgical correction  Noncompliance r/t the inconvenience and side effects of glaucoma medications  Implementation  Teach the patient and caregiver about the risk of glaucoma  Stress the importance of early detection and treatment in preventing visual impairment  Encourage the patient to seek appropriate ophthalmic care  Teach the patient that the incidence of glaucoma increases with age  African Americans should have exams more often because of the increased incidence  The patient with acute angle-closure glaucoma requires immediate medication to lower IOP  Appropriate comfort interventions ○ Darkening the environment ○ Applying cool compresses to the patient’s forehead ○ Providing a quiet and private space for the patient  Encourage the patient to follow therapeutic regimen and follow-up recommendations prescribed  Help the patient identify the most convenient times for medication administration  Ocular Tumors  Uveal melanoma  Most common  Cancerous neoplasm of the iris, choroid, or ciliary body  Cancer stage and cell type are important variables in the prognosis  Risk factors  Light-skinned persons over age 60 with chronic UV exposure  Genetic factors (mutated gene)  Clinical Manifestations  Asymptomatic with vision loss (depending on the size and location)  Diagnostic Tests  Ultrasonography  MRI  Fine-needle aspiration biopsy  Commonly appears as a dome-shaped, well-circumscribed, solid brown to golden colored pigment in the iris, choroid, or ciliary body  Treatment  Enucleation  Plaque radiotherapy Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  External beam radiation  Photocoagulation  Eye wall resection  Tumor can cause IOP  Enucleation  Removal of the eye  Primary indications  Blind, painful eye  Trauma  Ocular malignancies  Extraocular muscles are severed  An implant is inserted to maintain intraorbital anatomy  Post-op  Pressure dressing to prevent post-op bleeding  Observe for complications  Excessive bleeding/swelling  Increased pain  Discplacement of the implant  ↑ temp  Nursing Management  Instillation of topical ointments or drops  Wound cleansing  Teach the patient how to insert the conformer into the socket in case it falls out  Provide support to the patient and family  Approx. 6 weeks following surgery the wound is healed for permanent prosthesis  Teach the patient how to remove, clean, and insert the prosthesis Auditory Problems External Ear and Canal  Trauma  Trauma to the external ear can cause injury to the subcutaneous tissue that may result in a hematoma  If the hematoma is not aspirated  Inflammation of the membranes of the ear cartilage (perichondritis) can result  Antibiotics are given to prevent infection  Blows to the ear can cause conductive hearing loss if there is damage to:  The ossicles in the middle ear  Perforation of the tympanic membrane  Head trauma  Injures to the temporal lobe of the cerebral cortex Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Can impair the ability to understand the meaning of sounds  External Otitis  Inflammation or infection of the epithelium of the auricle and ear canal  Causes  Frequent swimming  May alter the flora of the external ear canal due to chemicals and contaminated water  Can result in an infection (often referred to as “swimmer’s ear”)  Picking the ear or the use of sharp objects  Causes the initial break in the skin  Piercing of cartilage in the upper part of the auricle  Patient is at a higher risk for infection than an earlobe piercing  Etiology  Bacteria  Pseudomonas aeruginosa most common cultured bacterium  Malignant external otitis ○ Serious infection caused by Pseudomonas aeruginosa ○ Occurs mainly in elderly patients with diabetes ○ Can extend from the external ear to the parotid gland and temporal bone (osteomyelitis) ○ Difficult to treat  Fungi  Candida albicans  Aspergillus  The warm, dark environment of the ear canal provides a good growth medium for microorganisms  Clinical Manifestations  Ear pain (otaglia)  one of the first signs of external otitis  Patient may experience significant discomfort with:  Chewing  Moving the auricle  Pressing on the tragus  Swelling on the ear canal can muffle hearing  Serosanguineous (blood-tinged fluid) or purulent (white to green thick fluid) drainage  Fever (when the infection spreads to surrounding tissue)  Diagnosis  Otoscopic examination of the ear canal  Treatment  Pain  Moist heat  Mild analgesics  Topical anesthetic drops  Topical treatments  Antibiotics for infection (7-14 days) Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Corticosteroids for inflammation  If the surrounding tissue is involved  Systemic antibiotics  Nursing Management  Avoid pain when pulling on the pinna  Straightening the ear canal  Inserting the otoscope  The eardrum may be difficult to see due to the swelling in the canal  Culture and sensitivity of the drainage  Hands should be washed before and after administration of eardrops  Drops should be administered at room temperature  Cold drops can cause vertigo  Heated drops can burn the tympanum  The tip of the dropper should not touch the ear during administration to prevent contamination of the entire bottle of drops  The ear is positioned so the drops can run into the canal  This position is maintained for 2 minutes to allow spreading of the drops  Prevention of External Otitis  Do not put anything in your ear canal  Report itching if it becomes a problem  Earwax is normal  It lubricates and protects the canal  Report chronic, excessive cerumen if it impairs hearing  Keep your ears as dry as possible  Use earplugs when swimming  Turn head to each side for 30 seconds at a time to help water run out of the ears  Do not dry with cotton-tipped applicators  A hair dryer set to low and held at least 6 inches away from the ear can speed water evaporation  Cerumen and Foreign Bodies in External Ear Canal  Cerumen  Impacted cerumen (ear wax) can cause discomfort and ↓ hearing  In the older person  Cerumen becomes dense and drier  The hair in the ear becomes thicker and coarser ○ Entrapping the hard, dry cerumen in the canal  Clinical Manifestations  Hearing loss  Otaglia (ear pain)  Tinnitus (ringing in the ear)  Vertigo (dizziness)  Conductive hearing loss  Nursing Management Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Irrigation of the canal with body temperature solutions ○ To soften the cerumen ○ Special syringes can be used ○ The patient is placed in a sitting position with an emesis basin under the ear  The head is tilted toward the affected ear ○ The auricle is pulled up and back ○ The flow of solution is directed above or below the impaction ○ It is important that the ear canal not be completely occluded with the syringe tip  Mild lubricant drops may be used to soften the ear wax  Foreign Bodies  Attempts to remove an object occasionally results in pushing it further into the canal  Mineral oil or lidocaine drops can be used to kill an insect before removal with microscopic guidance  Malignancy of the External Ear  Skin cancers are the only common malignancies of the ear  Cause  Chronic sun exposure  Rough, sandpaper-like changes to the upper boarder of the auricle are pre-malignant lesions  Treatment  Often removed with liquid nitrogen  Skin cancers are usually not life-threatening  Nursing Management  Teach the patient about the dangers of sun exposure  Importance of using hats and sunscreen when outdoors Middle Ear and Mastoid  Acute Otits Media  Infection of the  Tympanum  Ossicles  Space of the middle ear  Causes  Colds/Allergies  Swelling of the auditory tubes trap bacteria, causing a middle ear infection  Viruses or Bacteria  Clinical Manifestations  Pain  Fever  Malaise Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  ↓ hearing  Pressure from the inflammation causes a red, bulging, painful tympanic membrane  Normal tympanic membrane ○ Pearly grey ○ Shiny ○ Transparent  Treatment  Antibiotics (if an infection is present)  Amoxicillin (drug of choice)  Surgical intervention  For the patient who does not respond to medical treatment  Myringotomy ○ Incision into the tympanum to release the increased pressure and exudate from the middle ear ○ A tympanostomy may be placed for short or long-term use  Prompt treatment prevents perforation of the tympanic membrane  Antihistamines may be prescribed for the patient with allergies  Otits Media With Effusion  Inflammation of the middle ear  A collection of fluid is present in the middle ear space  The fluid may be  Thin  Mucoid  Purulent  This problem commonly follows an  Upper respiratory and/or chronic sinus infection  Barotrauma (caused by pressure change)  Otitis media  Clinical Manifestations  Feeling of fullness of the ear  “Plugged” feeling or popping  ↓ hearing  No pain, fever, or discharge from the ear  Usually resolves without treatment, but may recur  Chronic Otitis Media and Mastoiditis  Repeated attacks of Otits Media  The mucous membrane of the middle ear is continuous with the hair cells of the mastoid bone  Both can be involved in the chronic infectious process  Clinical Manifestations  Purulent exudate  Inflammation that can involve  The ossicles Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Auditory tube  Mastoid bone  Painless  Hearing loss  Nausea  Episodes of dizziness  Swelling of the lymph nodes  Problems with chewing (nutrition problems)  Complications  Hearing loss  Inflammatory destruction of the ossicles  Tympanic membrane perforation  Accumulation of fluid in the middle ear space  At risk for meningitis  Infection can go to the brain  A mass of epithelial cells + cholesterol in the middle ear = cholesteatoma (cyst/mass)  The cholesteatoma can enlarge and destroy adjacent bones  Unless removed surgically, it can cause ○ Extensive damage to the ossicles and impair hearing ○ Facial palsy  If it erodes the bony protection of the facial nerve ○ Vertigo  From the creation of a labyrinthine fistula ○ Neurological deficits  If it invades the dura  Treatment  Asses CN 8, 5 (chewing), and 7  We want to clear the middle ear of infection, repair perforations, and preserve hearing  Ear irrigations  Otic, oral, or parenteral antibiotics  Based on culture and sensitivity results ○ Broad spectrum first, before culture comes back  Analgesics  Antiemetics  Surgery  Chronic tympanic membrane perforations will not heal with conservative treatment, so surgery is necessary  Tympanoplasty ○ Reconstruction of the tympanic membrane and/or ossicles ○ Post-op  Impaired hearing is normal if there is packing in the ear  Instruct the patient to change the cotton packing and dressing daily Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Monitor the tightness of the dressing to prevent tissue necrosis  Assess the amount and type of drainage  Avoid sudden head movements  Do not try to get out of bed without assistance  Take drugs to reduce dizziness if prescribed  Change positions slowly  Patient is positioned flat and side-lying with the operative side up  Avoid getting the head wet (including showering) until directed by the surgeon  Report  Fever  Pain  ↑ hearing loss  Drainage from the ear  Do not cough or blow the nose  Causes ↑ pressure in the eustachian tube and middle ear cavity  Disrupts healing  If need to cough or sneeze  leave the mouth open to help reduce the pressure  Avoid crowds where respiratory infections can be contracted  Avoid situations where pressure or popping in the ears is normally experienced  High elevations  Airplane travel  Sudden pressure in the ear and post-op infections can disrupt healing or cause facial nerve paralysis  Mastoidectomy ○ Often performed with a tympanoplasty to remove infected portions of the mastoid bone  Otosclerosis  Hereditary autosomal dominant disease  Spongy bone develops from the bony labyrinth  Preventing movement of the footplate of the stapes in the oval window  Stapes is not moving as it’s supposed to  This ↓ the transmission of vibrations to the inner ear fluids  Causes conductive hearing loss  Most common in young women  May accelerate during pregnancy  Diagnosis  Otoscope exam will show  Reddish blush of the tympanum (Schwartz’s sign) Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Caused by the vascular and bony changes within the middle ear  Tuning fork tests (Rine test, Weber test) / Audiogram  Good hearing by bone conduction  Poor hearing by air conduction  Treatment  Oral sodium fluoride with vitamin D and calcium carbonate  Retard bone resorption  Encourage the calcification of bony lesions  Hearing aid  Effective because the inner ear is functional  Surgery  Stapedotomy ○ Opening the footplate  Stapes prosthesis ○ Replacement of the stapes with a metal or Teflon substitute  The ear with poorer hearing is repaired first ○ The other ear may be operated on within a year  Post-op ○ Immediately after surgery the patient will often report a significant improvement in hearing in the operative ear ○ Because of the accumulation of blood and fluid in the middle ear during the post-op period  Hearing level decreases but improves gradually with healing  Nursing Management  A cotton ball is placed in the ear canal and a small dressing is used to cover the ear  The patient may experience dizziness and N/V  As a result of stimulation of the labyrinth during surgery  Decrease sudden movements by the patient that may bring on or exacerbate vertigo  Actions that increase inner ear pressure should be avoided  Coughing/Sneezing  Lifting/Bending  Straining during bowel movements Inner Ear Problems  3 symptoms that indicate disease of the inner ear  Vertigo  Sensorineural hearing loss  Tinnitus  Meniere’s Disease  Characterized by symptoms caused by inner ear disease  Episodic vertigo  Tinnitus  Fluctuating sensorineural hearing loss Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Aural fullness  Sudden severe attacks of vertigo with N/V, sweating and pallor  Pathophysiology  Excessive accumulation of endolymph in the membranous labyrinth  The volume of endolymph increases until the membranous labyrinth ruptures  Mixing of endolymph with perilymph  Clinical Manifestations  Attacks may be preceded by a sense of fullness in the ear, increasing tinnitus, and muffled hearing  The patient may experience the feeling of being pulled to the ground (“drop attacks”)  The duration of the attacks may be hours or days  Attacks may occur several times a year  Sensorineural hearing loss  Photosensitivity  Diagnosis  Rule out other causes of the symptoms, including CNS disease  Audiogram  Mild, low-frequency sensorineural hearing loss  Vestibular tests  Caloric test  Positional test  Glycerol test  On oral dose of glycerol is given  Followed by serial audiograms over 3 hours  Improved hearing or speech supports the diagnosis  Glycerol pulls fluid from the inner ear  Treatment  Antihistamines  ↓ abnormal sensation  ↓ N/V  Acute vertigo is treated symptomatically  Bed rest  Sedation  Antiemetics  Antivertigo drugs  For motion sickness  Administered orally, rectally, or IV  Management between attacks  Diuretics (ototoxic, may cause tinnitus) ○ Antibiotics also cause tinnitus  Antihistamines  Calcium channel blockers  Hydrops diet: restriction of ○ Sodium Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Caffeine ○ Nicotine ○ Alcohol ○ Foods with MSG ○ Water follows sodium, and there is already an ↑ of endolymph  Surgery  Endolymphatic shunt ○ Decompression of the endolyphatic sac ○ Shunting to reduce the pressure on the cochlear hair cells to prevent further damage and hearing loss  Vestibular nerve resection  Labyrinthotomy  Labyrinthectomy  Nursing Management  Plan nursing interventions to minimize vertigo and provide for patient safety  Patient is kept in a quiet darkened room in a comfortable position  Teach the patient to avoid sudden head movements or position changes  Fluorescent or flickering lights or watching TV may exacerbate symptoms and should be avoided  An emesis basin should be available because vomiting is common  To minimize the risk of falling  Side rails up  Bed low in position  The patient should be taught to call for assistance when getting out of bed  Medications and fluids are administered parenterally  ↓ N/V, prevent dehydration  Intake and output is monitored  Benign Paroxysmal Positional Vertigo  Common cause of vertigo  Pathophysiology  Free-floating debris in the semicircular canal causes vertigo with specific head movements  Getting out of bed  Rolling over in bed  Sitting up from lying down  The debris (ear rocks) are composed of small crystals of calcium carbonate that derive from the utricle in the inner ear  Clinical Manifestations  Dizziness  Vertigo  Light-headedness  Loss of balance Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Nausea  There is no hearing loss  The symptoms of BPPV may be confused with Meniere’s disease  In Meniere’s disease there is hearing loss  Treatment  Epley maneuver/Canalith repositioning procedure  Ear debris is moved to a less sensitive part of the ear  Acoustic Neuroma (Schwannoma)  Unilateral benign tumor that occurs where the acoustic nerve (CN VIII) enters the internal auditory canal  The tumor can compress the trigeminal (CN V) and facial nerve (CN VII)  Early symptoms  Associated with CN VIII compression and destruction  Unilateral, progressive, sensorineural hearing loss ○ On the side where the tumor is  Reduced touch sensation in the posterior ear canal  Unilateral tinnitus  Mild, intermittent vertigo  Diagnostic Tests  Neurologic tests  Audiometric tests  Vestibular tests  CT scans/MRI  Treatment  Surgery to remove tumors  Small tumors that are removed ○ Preserves hearing and vestibular function  Large tumors that are removed ○ Craniotomy ○ > 3 cm ○ Can leave the patient with permanent hearing loss and facial paralysis  Nursing Management  Instruct the patient to report any clear, colorless discharge from the nose  This may be CSF  ↑ the risk of infection  Teach the importance of follow-up care  Monitor hearing  Monitor recurrence of the tumor  Hearing Loss and Deafness  Causes of hearing loss  External ear  Impacted cerumen Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Foreign bodies  External otitis  Middle ear  Otitis media  Serous otitis  Otosclerosis  Tympanic membrane trauma  Cholesteatoma  Acoustic neuroma  Inner ear  Meniere’s disease  Noise-induced hearing loss  Presbycusis  Ototoxicity  Clinical Manifestations  Early Signs  Answering questions inappropriately  Not responding when not looking at the speaker  Asking others to speak up  Showing irritability with others who do not speak up  Straining to hear  Cupping the hand around the ear  Increased sensitivity to slight increases in noise level  Conductive Hearing Loss  When conditions in the outer or middle ear impair the transmission of sound through air to the inner ear  Causes  Otitis media with effusion  Impacted cerumen  Foreign bodies  Otosclerosis  Narrowing of the external auditory canal  Audiogram  Better hearing through bone conduction than air conduction  BC > AC  Clinical Manifestations  Patient often speaks softly ○ Hearing his or her own voice (which is conducted by bone) seems loud  Hear better in noisy environments  Identify and treat the cause if possible  Hearing aid may help  Sensorineural Hearing Loss  Caused by impairment of function of the inner ear or the vestibulocochlear nerve (CN VIII)  Causes Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Congenital and hereditary factors  Noise trauma  Aging (Presbycusis)  Meniere’s disease  Ototoxicity  Systemic infections ○ Paget’s disease of the bone ○ Immune diseases ○ Diabetes mellitus ○ Bacterial meningitis ○ Trauma  Clinical Manifestations ○ They have the ability to hear sound, but can’t understand speech ○ The ability to hear high-pitched sounds like consonants ↓ ○ Sounds become muffled and difficult to understand ○ Still able to hear on the unaffected side  A hearing aid may help some patients ○ But it only makes sound and speech louder, not clearer  Rubella infection during the first 8 weeks of pregnancy is associated with an 85% incidence of congenital rubella syndrome ○ Causes sensorineural deafness  Classification of Hearing Loss  Normal hearing 0-15 dB  Profoundly deaf > 91 dB  Hearing loss caused by noise is not reversible  Drugs commonly associated with Ototoxicity  Salicylates  Diuretics  Antineoplastic drugs  Antibiotics  The patient should be monitored for signs and symptoms of ototoxicity  Tinnitus  ↓ hearing  Changes in equilibrium  Assistive Devices and Techniques  Hearing Aids  Adjustment to different environments occur gradually (depending on the patient)  The battery should be disconnected or removed when not in use  Ear molds should be cleaned weekly or as needed  Speech Reading  Lip reading  Sign Language  Sign language is not universal  Cochlear implant Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  The ideal candidate is one who has become deaf after acquiring speech and language  Assisted Listening Devices  Direct amplification devices  Amplified telephone receivers  Altering systems that flash when activated by sound  Infrared system for amplifying the sound of the television  Text-telephone alerting systems  Closed captioning on the television  Specially trained dogs ○ The dogs are trained to alert their owners to specific sounds within the environment  Communication With Hearing-Impaired Patient  Non-verbal aids  Draw attention with hand movements  Have speaker’s face in good light  Avoid covering mouth or face with hands  Avoid chewing, eating, smoking while talking  Maintain eye contact  Avoid distracting environments  Avoid careless expression that the patient may misinterpret  Use touch  Move closer to the better ear  Avoid light behind the speaker  Verbal Aids  Speak normally and slowly  Do not over-exaggerate facial expressions  Do not over-nunciate  Use simple sentences  Rephrase sentences by using different words  Do not shout  Speak in a normal voice directly into the better ear  Gerontologic Considerations  Presbycusis  Hearing loss associated with aging  The cause is related to degenerative changes in the inner ear ○ Sensorineural hearing loss ○ Hair cells of the cochlea degenerate  Sound amplification with the proper device is often helpful in improving the understanding of speech  The older adult is often reluctant to use a hearing aid for sound amplification ○ Cost ○ Appearance ○ Insufficient knowledge about hearing aids ○ Amplification of competing noise Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Unrealistic expectations Downloaded by Taje' St. John ([email protected])