MSN 2 Notes PDF

“When I drift off, I will dream about you. It’s always you.” Ashok  Contents Unit: 1 Nursing Management of Patient with Disorders of Ear, Nose & Throat..............

“When I drift off, I will dream about you. It’s always you.” Ashok  Contents Unit: 1 Nursing Management of Patient with Disorders of Ear, Nose & Throat..............................................................................1 Otalgia........................................................................................................ 1 Otosclerosis............................................................................................ 3 Otitis Media............................................................................................. 5 Meniere’s Disease.............................................................................. 10 Mastoiditis............................................................................................ 13 Hearing Loss/Deafness................................................................... 16 Hearing Aids......................................................................................... 19 Epistaxis................................................................................................. 21 Sinusitis.................................................................................................. 24 Rhinitis.................................................................................................... 29 Pharyngitis............................................................................................ 34 Laryngitis............................................................................................... 38 Tonsillitis............................................................................................... 41 Unit: 2 Nursing Management of Patient with Disorders of Eye........................................................................................................ 44 Conjunctivitis (Pink Eye)............................................................... 44 Cataract.................................................................................................. 47 Refractive Errors............................................................................... 52 Uveitis..................................................................................................... 55 Retinal Detachment.......................................................................... 58 Glaucoma............................................................................................... 62 Blindness............................................................................................... 69  Contents Unit: 3 Nursing Management of Patient with Neurological Disorders............................................................................................ 75 Meningitis.............................................................................................. 75 Encephalitis.......................................................................................... 78 Glasgow Coma Scale (GCS)............................................................ 81 Brain Tumor......................................................................................... 82 Bell’s Palsy............................................................................................ 89 Epilepsy.................................................................................................. 92 Status Epilepticus.............................................................................. 97 Cerebral Aneurysm........................................................................... 99 Multiple Sclerosis (MS)................................................................ 101 Parkinson’s Disease....................................................................... 106 Spinal Cord Injuries....................................................................... 110 Headache............................................................................................ 114 Head Injury........................................................................................ 117 Guillain–Barré Syndrome (GBS/Polyradiculoneuritis)................................................................................................................. 123 Myasthenia Gravis (MG).............................................................. 125 Alzheimer Disease (AD)............................................................... 128 Brain Abscess................................................................................... 130 Cerebrovascular Accident (Stroke)........................................ 132 Unit: 4 Nursing Management of Patient with Disorders of Female Reproductive System.....................................................136 Breast Self Examination (BSE)................................................. 136 Menstrual Disorders..................................................................... 136 Dysmenorrhea (Menstrual Cramps)................................ 136  Contents Amenorrhea................................................................................. 139 Premenstrual Syndrome (PMS)......................................... 142 Abnormal Uterine Bleeding....................................................... 145 Menorrhagia (Heavy Menstrual Bleeding)................... 145 Metrorrhagia............................................................................... 146 Pelvic Inflammatory Disease (PID)........................................ 149 Ovarian & Fallopian Tube Disorders..................................... 151 Ovarian Cysts.............................................................................. 151 Polycystic Ovary Syndrome (PCOS)................................. 153 Uterine & Cervical Disorders.................................................... 156 Endometriosis............................................................................. 156 Polyps............................................................................................. 159 Uterine Fibroids......................................................................... 159 Uterine Prolapse (Uterine Displacement)..................... 161 Vaginal Disorders........................................................................... 164 Vaginitis......................................................................................... 164 Vaginal Discharge...................................................................... 166 Vulvar Disorders............................................................................. 170 Vulvitis............................................................................................ 170 Abortion.............................................................................................. 172 Infertility............................................................................................. 174 Toxic Shock Syndrome................................................................. 176 Contraceptive Methods................................................................ 177 Barrier Method........................................................................... 177 Intrauterine Devices (IUD)................................................... 179 Hormonal Method..................................................................... 180 Sterilization.................................................................................. 182  Contents Unit: 5 Nursing Management of Patients with Burns........184 Burns.................................................................................................... 184 Unit: 6 Nursing Management of Patients with Oncological Conditions........................................................................................205 Cancer [Ca.]........................................................................................ 205 Cancer of the Larynx..................................................................... 216 Cancer of the Oral Cavity............................................................. 219 Cancer of the Lungs....................................................................... 221 Cancer of the Stomach (Gastric Cancer).............................. 225 Cancer of the Colon & Rectum (Colorectal Cancer)....... 227 Cancer of the Liver......................................................................... 230 Cancer of the Kidneys (Renal Tumors)................................ 233 Leukemia............................................................................................ 237 Cancer of the Cervix....................................................................... 241 Cancer of the Breast...................................................................... 244 Cancer of Uterine (Endometrial)............................................. 250 Cancer of the Ovary....................................................................... 254 Cancer of the Prostate.................................................................. 257 Unit: 7 Nursing Management of Patients in Emergency and Disaster Situations........................................................................262 Emergency......................................................................................... 262 Disaster................................................................................................ 268 Disaster Management................................................................... 271 Unit: 8 Nursing Care of the Elderly..........................................277 Introduction...................................................................................... 277 Demography...................................................................................... 277  Contents Concepts of Geriatric Nursing................................................... 278 Theories of Ageing......................................................................... 278 Age Related Changes/Aspects of Ageing............................. 280 General Principles of Geriatric Care...................................... 283 Principles Guidance Gerontological Nursing Practice.. 284 Geriatric Syndrome........................................................................ 285 Factor Helping Successful Aging............................................. 287 Mental Health Problems in the Older Adults..................... 287 Gerontological Nursing................................................................ 288 Ethical & Legal Issues Affecting Older Adults................... 290 Programs of the Older Person.................................................. 290 Older Abuse....................................................................................... 292 Unit: 9 Nursing Management of Patient in Critical Care Unit (CCU)..................................................................................................294 Concept................................................................................................ 294 Critical Illness................................................................................... 294 Nursing Practice in Critical Care Unit................................... 296 Organization of CCU...................................................................... 299 Infection Control Protocols in CCU........................................ 305 Prevention of Infection during Invasive Procedure....... 310 Mechanical Ventilator................................................................... 312 Cardioversion & Defibrillation................................................. 316 Cardiac Monitoring........................................................................ 318 Emergency Drugs in CCU............................................................ 321  Contents Unit: 10 Nursing Management of Patient Adults Including Elderly with Occupational & Industrial Disorders.............328 Skin Disorders.................................................................................. 328 Urticaria (Hives)........................................................................ 328 Dermatitis (Eczema)................................................................ 331 Respiratory Disorders.................................................................. 335 COPD (Chronic Obstructive Pulmonary Disease)...... 335 Bronchitis...................................................................................... 335 Emphysema................................................................................. 336 Bronchiectasis............................................................................ 339 Tuberculosis (TB)..................................................................... 341 Silicosis........................................................................................... 343 Asbestosis..................................................................................... 346 Syndromic Disorders.................................................................... 349 Carpal Tunnel Syndrome....................................................... 349 Occupational Overuse Syndrome (OOS)........................ 352 Computer Vision Syndrome................................................. 354 Lead Poisoning........................................................................... 356 Unit: 1 Disorders of Ear, Nose & Throat Nursing Management of Patient with Disorders of Ear, Nose & Throat Otalgia- It is refers as ear pain or pain in the inner or outer ear that may interface with ability to hear, often caused by excess fluid & infection. Etiology:  Exterior ear trauma  Foreign body in ear  Obstruction in ear  Eustachian tube infection  Infection of tympanic membrane  Otitis media Types: 1) Primary otalgia 2) Secondary otalgia 1) Primary otalgia: When the ear disorder is cause of otalgia. 2) Secondary otalgia: When the ear disorder is not the cause of otalgia. Clinical manifestation:  Sense of fullness  Otorrhea  Mild to severe degree fever  Tenderness  Hearing loss  Occasional dizziness Ashok saini 3000 1 Unit: 1 Disorders of Ear, Nose & Throat Management: Goal:  To promote hearing  To relieve pain  To restored the normal ear function. 1) Medical management: Provide antibiotics to the patients to prevent the infection. Provide analgesic to the patient to relieve pain. Myringotomy to ventilate the middle ear. Using the hearing aids. 2) Surgical management: i. Myringoplasty: Surgery is performing on tympanic membrane which use of operating microscope closure of simple perforation is called myringoplasty. ii. Tympanoplasty: It is surgical procedure of correction of perforated membrane. It is divided in four types: Type-I: Graft rest on malleus Type-II: Graft rest on incus Type-III: Graft attached to head of stapes Type-IV: Graft attached to for plate of stapes iii. Ossiculoplasty: It is surgical procedure of ossicular reconstruction. iv. Myringotomy: An incision s made in tympanic membrane through which fluid is removed by suctioning. Ashok saini 3000 2 Unit: 1 Disorders of Ear, Nose & Throat v. Mastoidectomy: It is procedure performed to remove the mastoid air cells. 3) Nursing management: Avoid exposing of loud noise. Treat upper respiratory infection. Obtain complete history of the patient. Proper care must be take is otoscope examination is performing. i. Pre-operative care: An audiogram & typanogram is obtained to assess pre operative to assess preoperative hearing capacity. Provide psychological support. Explain the procedure to the patient. Instruct about anesthesia recovery & surgery duration. ii. Post-operative care: Provide comfortable position avoid heavy lifting. Assess the general condition of the patient. Observe for any discharge from ear. Instruct to patient sneeze with open mouth. Otosclerosis - It is autosomal disorder characterized by fixation of footplate of stapes on the oval window that results in decrease transmission of vibration of inner ear that leads to impaired hearing. Etiology:  Development of spongy bone  Immobilization of foot plate  Heredity Ashok saini 3000 3 Unit: 1 Disorders of Ear, Nose & Throat Clinical manifestation:  Deafness  Otalgia  Conductive hearing loss Diagnostic evaluation:  History collection  Physical examination  X-ray  CT scan  Otoscopy  Weber test & Rinne test Management: 1) Medical management: Auditory rehabilitation use of machine spent life with disability. Calcium carbonate with vitamin-D for mineralization. 2) Surgical management: Stapedectomy: It is a surgical procedure which is performed under local anesthesia. It is surgery endure incision is made using operating microscope. The stapes structure is removed and small hale is made footplate with a lesser. 3) Nursing management: Postoperatively assess the general condition. Minimize the straining & movement during straining lifting & coughing. Avoid heavy decrease the post operative complication. Provide the rest to the patient observe the patient to the discharge. Ashok saini 3000 4 Unit: 1 Disorders of Ear, Nose & Throat i. Preoperative diagnosis: Pain related to disease condition as evidence by patient complains by relative. Impaired auditory presence related as evidence by heaviness & deafness. Anxiety related to fear of surgery. ii. Postoperative diagnosis: Impaired nutrition level related less than body requirement. Risk of infection related to knowledge deficit about infection in children. Otitis Media- Definition: Otitis media is the inflammation of the mucus membrane of the middle ear, eustachian tube & mastoid process. Types: 1) Acute suppurative otitis media 2) Chronic suppurative otitis media 3) Serous or secretory otitis media 1) Acute suppurative otitis media: It is an acute infection usually lasting less than 6 weeks. It is most commonly seen in children’s are affecting. Etiology:  Entrance of pathogenic bacteria into the middle ear.  Infection of upper respiratory track.  Inflammation of surrounding tissue.  Perforation of tissue. E.g. – Rhinitis. Ashok saini 3000 5 Unit: 1 Disorders of Ear, Nose & Throat Clinical manifestation:  Otalgia  Earache  Drainage of ear  Irritability  Hearing loss  Discharge  Nausea & vomiting Diagnostic evaluation:  History collection  Physical examination  Culture of ear discharge  Hearing test: Rinne & Weber test Management: 1) Medical management: Control the infection by administered the antibiotic Amphicillin & Amoxicillin. Administered the analgesic to the patient. E.g. – Acetaminophen Administered anti-inflammatory drug. E.g. – Aspirin Administered antihistamine drug therapy. E.g. – Livocetrizine. 2) Surgical management: Myringotomy (Tympanostomy): It is an incision made on the tympanic membrane to relieve pressure & too returned serous or purulent fluid from middle ear. This is painless procedure 15minutes. Ashok saini 3000 6 Unit: 1 Disorders of Ear, Nose & Throat 3) Nursing management: Provide the positioning to head on pillow, or lie on unaffected ear. Apply heating pad or warm hot water bottle to relive the pain. Provide the therapeutic diet to cure fast. Teach the patient & family membrane to cover mouth & nose when sneezing or coughing & to wash hand frequently. Assess the hearing ability frequently. Complication:  Chronic otitis media  Meningitis  Brain abscess  Facial nerve paralysis  Intra cranial complication 2) Chronic suppurative otitis media: Definition: It is defined as a condition characterized by irreversible pathological the result of aspect episodic otitis media. It is associated with persistent perforation of middle ear or mastoid cavity. Etiology:  Untreated acute suppurative otitis media  Repeated auditory infection  Arthritis  Antibiotic resistant strength  Eustachian infection  Trauma of tympanic membrane Ashok saini 3000 7 Unit: 1 Disorders of Ear, Nose & Throat Classification: i. Tubule type of chronic suppurative otitis media: Low social economic conditions that are arise from Eustachian tube. ii. Tympanic type suppurative otitis media: Mostly affected the adults & arise from tympanic membrane. Clinical manifestation:  Pain in the ear  Hearing loss  Otorrhea  Persistent or intermediate foul smelling  Episodic of dizziness  Cholesteatoma Diagnostic evaluation:  History collection  Physical examination  Mastoid X-ray  Culture & sensitive test  Middle ear drainage Management: 1) Medical management: Provide the antibiotic to the patient. Provide the analgesic to the patient. Provide the antiemetic to the patient. 2) Surgical management: Tympanoplasty prevents the recurrent infection. Mastoidectomy to remove cholesteatoma. Ashok saini 3000 8 Unit: 1 Disorders of Ear, Nose & Throat 3) Nursing management: Nursing diagnosis: 1) Pain related inflammatory process as evidence by patient complaint about pain. 2) Impaired auditory perception related to congestive in tympanic membrane as evidence by patient required more repetition. 3) Risk of injury related to impaired to auditory perception. 4) Distress sensory perception related to potential damage the facial nerve. 5) Risk of infection related to surgical procedure. 6) Risk for comma related to balance difficulty of veritable. 7) Anxiety related to surgical procedure & potential loss of hearing. 8) Knowledge deficit related to disease condition. 9) Nutrition imbalance related to lack of knowledge. 10) Self care deficit related to disease condition. 3) Serous otitis media or secretory otitis media: It is the presence of fluid in the middle ear without evidence of active infection, most commonly found in children. Ear look like presence glue. Etiology:  Upper respiratory infection  Eustachian tube infection  Radiotherapy  Barotraumas & Allergy condition Clinical manifestation:  Loss of hearing  Popping & cracking noise  Fullness of ear  Congestive sensation  Air bubbles in middle ear Ashok saini 3000 9 Unit: 1 Disorders of Ear, Nose & Throat Diagnostic evaluation:  History collection  Physical examination  Audiometry  Otoscopy Management: 1) Medical management:  Provide corticosteroid therapy.  Uses of hearing aids. 2) Surgical management:  Myringotomy is done relieve to tube patient pressure in the ear. 3) Nursing management: Provide the positioning to head on pillow, or lie on unaffected ear. Apply heating pad or warm hot water bottle to relive the pain. Provide the therapeutic diet to cure fast. Teach the patient & family membrane to cover mouth & nose when sneezing or coughing & to wash hand frequently. Assess the hearing ability frequently. Meniere’s Disease- Definition: It is an abnormal inner ear caused by malabsorption in endolymphatic duct & blockage in the duct. Etiology:  Idiopathic Ashok saini 3000 10 Unit: 1 Disorders of Ear, Nose & Throat Risk factor:  Fluid & electrolyte imbalance. Types: 1) Cochlear disease: It is a recognized as fluctuating & progressive sensory neural hearing loss associated with tinnitus & aural fullness in the vestibular symptoms & finding. 2) Vestibular disease: It is characterized by occurrence episodic vertigo associated with aural fullness but no cochlear symptoms. Pathophysiology: Contraction of endolymphatic duct Alteration & production of endolymph Distraction of endolymphatic duct Increase in pressure & rupture the duct Vertigo, hearing loss & tinnitus Clinical manifestation:  Vertigo  Sensorineural hearing loss  Tinnitus  Fullness or pressure in the ear  Ataxia (Impaired coordination)  Nausea & vomiting Ashok saini 3000 11 Unit: 1 Disorders of Ear, Nose & Throat Diagnostic evaluation:  History collection  Physical examination  Neurological examination  Glasgow comma scale (GCS) Caloric reflex test: It is the test of the vestibule cochlear reflex that involve irritating warm water, cold water into the external auditory canal using the syringe injected water endolymph current into semicircular canal. Hot & cold water produced current in the opposite side of eye. Properly eye movement usually in same direction. Glycerol dehydration test: It is subjected injected glycerol observing the symptoms & measure in changes in hearing. 1.5g/kg body weight glycerol causes a transient reduction of the hearing loss. No glycerol effect is seen in normal cases of trochlear deafness of other type. The action of glycerol is purely & effect in Meniere’s disease due to a reduction of intra labyrinth’s pressure. Management: 1) Medical management: Provide antihistamine such as levocetirizine. Provide the tranquilizer such as diazepam control the vertigo. Provide diuretics such as furosemide. Provide the vasodilator drugs. E.g. – Sodium nitro furosemide. Provide the therapeutic diet. Ashok saini 3000 12 Unit: 1 Disorders of Ear, Nose & Throat 2) Surgical management: Labyrinthectomy. 3) Nursing management: 1) Prevention to injury to the patient: Assess for vertigo condition. Encourage the patient sit down when dizziness. 2) Maintaining fluid volume: Monitor & maintain of intake & output. Assess the sign of dehydration. Encourage the oral fluid as tolerated. 3) Adjusting disability identifies strength: Provide information of vertigo. Rehabilitation & promotion of self care & self limiting activity. Reliving the anxiety. Provide the comfort measures. Mastoiditis- It is a bacterial infection of mastoid air cell in the middle ear. An infection that affects the mastoid bone located behind the ear. Inflammation of the mastoid process. Etiology:  Otitis media  Bacterial infection  Immunosuppressant patient Types: 1) Acute mastoiditis:  It is affect most common children. Ashok saini 3000 13 Unit: 1 Disorders of Ear, Nose & Throat 2) Chronic mastoiditis:  Repeated infection of acute mastoiditis ear affected the adult & ear drainage discharge is present. Clinical manifestation:  Otalgia  Fever  Heaviness in ear  Redness & swelling behind ear  Inability to hearing Diagnostic evaluation:  History collection  Physical examination  Otoscopy  Culture for ear discharge  CT scan Management: 1) Medical management:  Provide the antibiotic therapy to the patient for chronic mastoiditis. E.g. – Penicillin  Ear irrigation.  Provide the anti-inflammatory drugs.  Provide antipyretic to the patient.  Using hearing aid for proper hearing. 2) Surgical management:  Myringotomy. Ashok saini 3000 14 Unit: 1 Disorders of Ear, Nose & Throat 3) Nursing management: Nursing diagnosis: 1) Pain related to inflammatory process as evidence by complains about pain. o Goal: Reduce the level of pain in the patient. o Intervention:  Assess the severity of pain  Provide the comfortable position  Provide the analgesic to the patient. 2) Impaired auditory perception related to congestion of middle ear. o Goal: Impaired auditory perception of patient. o Intervention:  Instruct the patient safe technique clean to ear  Teach some nonverbal gesture  Provide health teaching to family member  Assess patient ability to hear by performing. 3) Impaired nutrition status less than body requirement related unable to treating. o Goal: Maintain nutritional status. o Intervention:  Assess the nutritional status  Encourage the patient to increase intake of nutrition. 4) Risk of infection related to infection of mastoid bone. o Goal: Decrease the changes of infection in the patient. o Intervention:  Assess the patient of change in vital sign & sign of infection  Use of universal precaution for prevention infection  Administered antibiotic as prescribed. 5) Knowledge deficit may be related to disease condition. o Goal: Improve the knowledge regarding disease. o Intervention: Ashok saini 3000 15 Unit: 1 Disorders of Ear, Nose & Throat  Assess the patient problem  Provide the knowledge of disease to family member of patient  Assess the important of medication as prescribed by physician  Maintaining the hygienic condition of patient  Teach about the side effect & adverse effect of disease. Hearing Loss/Deafness- Definition: Deafness is the inability to understanding the word & loss of hearing power. It may be mild, moderate & severe. Clinical manifestation:  Fatigue  Speech deterioration  Loneness  False proud  Strained facial expression  Abnormal awareness of sound  Failure to respond oral communication  Inappropriate questioning & answering Types of hearing loss: 1) Conduction hearing loss 2) Sensory hearing loss 3) Mixed hearing loss 4) Central hearing or functioning loss 1) Conduction hearing loss: It’s occurs in the middle ear that impaired sound conduction from outer to inner. Ashok saini 3000 16 Unit: 1 Disorders of Ear, Nose & Throat Etiology:  Middle ear disorder. E.g. – otitis media  Tumor of auditory canal  Perforation of tympanic membrane  Stenosis of external auditory canal  Foreign particle in the ear & trauma Diagnostic evaluation:  History collection  Physical examination  Audiometry Management: Treat the associate condition. Treat the fungal infection. Repair the ossicles. Repair the tympanic membrane. 2) Sensory hearing loss: It’s upper due to impairment of function of inner ear resulting from damage of vestibulocochlear nerve. Etiology:  Congenital  Acquired: o Trauma to temporal bone o Noise injury o Meniere’s disease o Meningitis o Diabetes o Smoking o Exposure to environmental factor o Trauma of bone Ashok saini 3000 17 Unit: 1 Disorders of Ear, Nose & Throat Diagnostic evaluation:  History collection  Physical examination  Audiogram  Tympanometry Management: Monitor hearing sensation if the auto toxic drug. E.g. – Streptomycin Lip reading understanding the speech through observation of speaker lip movement. Teach sign language (Hand & body language used to communicate with others) by deaf people. 3) Mixed hearing loss: It caused by combination of conductive & sensory hearing loss. 4) Central or functional hearing loss: It is caused by problem in the CNS from auditory nucleus to cortex. In this type of hearing loss there is no structure damage in hearing mechanism. It is manifestation of emotional disturbance. Management:  Hearing aids.  If congenital it can be treated by cochlear implantation.  Training in sign language & lip reading. Prevention:  Identification of the client at risk for hearing loss.  Provide adequate protection to ear to maintain normal function. Ashok saini 3000 18 Unit: 1 Disorders of Ear, Nose & Throat  Minimize the risk of trauma & noise exposure.  Instruct to the patient hearing protective helmet.  To avoid insertion of hard instrument or object into ear canal.  Instruct the patient to avoid excessive exposure to noise level more than 80db.  Early detection of hearing impairment through screening.  Observe the auto toxic side effect after administered of drug.  Proper use of hearing aids.  Provide better community strategies. Hearing Aids- Introduction: A hearing aid is an electro acoustic apart which typically fit inner ear or behind the ear. It design to amplifier & modulate sound for wearer. Early device known as ―ear trumpet‖ or ―ear horn‖ vary amplification canal design to gather sound energy direct it into the ear canal. Part of the hearing aids: 1) Microphone: To receive sound waves & change the sound into electrical signal. 2) Amplifier: To increase electrical signal. 3) Receiver: Earphone to change the electrical signal to sound waves. 4) Battery: To provide the electrical energy needed to operate hearing aids. Types of hearing aids: They are many type of hearing aids which in different size & circuit. Among the different size models. 1) Pocket models: Worn in a pocket at chest level it consists of hearing aids containing the microphone, amplifier & controls. Ashok saini 3000 19 Unit: 1 Disorders of Ear, Nose & Throat A cord transmits the electrical output to the receiver. It converts this signal to sound. The receiver in attached which mould it in place. 2) Behind the Ear (BTE): BTE aids have a small plastic case that fit behind the pinna & provide sound to the ear via air conducting of sound through a small length tuning of electrically with a wire & speaker place in the ear canal. The delivery of sound is usually through & ear mode that is custom make for other treble fixture that counter to the individual ear. BTE can be used for mild to perform hearing loss are specially used for children’s because there durability & ability to correct to assistive listening device. 3) In the Ear (ITE): The complete hearing aid is in the ear or ear canal. The hearing aid is housed in hard plastic shell which is often custom made by an ear impression. This device is the outer ear there some time visible standing face to face wills someone. ITE hearing aids are custom made to fit teach individual ear. They can be used in mild to some severe hearing loss. 4) In the canal (ITC) & completely in the canal (CIC): ITC aids are smaller fitting only the bottom half of the external ear usually can’t see hearing when you are face to face someone. These aids are mild to moderate severe hearing loss. 5) Spectacle types: The hearing aids components are incorporated with in a spectacle frame. Ashok saini 3000 20 Unit: 1 Disorders of Ear, Nose & Throat It is used to for person to require glasses along with hearing aids. People to wear both glasses & hearing aid frequently choose a type hearing aid that was built into the temple pieces of spectacles. 7) Remote microphone: It is new category developed by resound the combined the advantages of the behind ear & in the ear models. The microphones have been more to the outer ear & are connected to the main body of the hearing aid by a thin transparent tube. 8) Bone conduction hearing aids: This is used when the ear canal is blocked is cases when conventional amplification as described about can’t be given. A bone conduction vibrator is placed on the mastoid bone behind the ear. It converts the amplified electrical signal into the vibration. Bone conduction vibrator can be used with body level behind the ear. Care & maintenance of hearing aids: Prevent it from falling down. Don’t spill liquid on the hearing aids. Hearing aid should be fitted well. Protect it from dust & heat. Remove the battery from the hearing aid when is not used. Core should not be twist. Remember to detach the ear hole from the receiver before washing mould; the receiver should not come in contact with water. Epistaxis- Epistaxis is the hemorrhage from the nose caused by ruptured distended vessels in the mucus membrane of the nose. Ashok saini 3000 21 Unit: 1 Disorders of Ear, Nose & Throat The common site is anterior septum where three major arteries into the nasal cavity that are: o Anterior ethemoidal artery o Maxillary artery o External carotid artery Anterior part → kiesselbach’s plexus Etiology:  Local causes: o Trauma o Fracture of nasal bone o Chemical inhalation o Dry climate o Operation trauma o Infection such as acute rhinitis, fungal infection  Physiological causes: o Excitement o Extreme heat o Extreme alteration of pressure o Congenital such as malignancy of nose & paranasal sinus  Systemic disease causes: o Hypertension o Leukemia o Anemia o Uremia o Vitamin-k deficiency  Hormonal causes: o Puberty o Pregnancy o Drug such as aspirin Risk factor:  Nasal inhalation of illicit drug Ashok saini 3000 22 Unit: 1 Disorders of Ear, Nose & Throat  Trauma  Arteriosclerosis  Hypertension  Thrombocytopenia Clinical manifestation:  Sudden bleeding from nose  Tenderness  Edema  Pain  Redness  Swelling Diagnostic evaluation:  History collection  Physical examination  Blood culture  X-ray for sinusitis, fracture & tumors  CBC Management: 1) Emergency management: Provide upright position to the patient to promote vasoconstriction in the nasal mucus membrane. Compress the soft outer portion of nose against the midline septum for 5 – 10 minutes continuously. Saturating piece of cotton with a local vasoconstriction for e.g. – Neosynephrine. Apply 4% of xylocaine Apply icepack on the bridge of nose Apply epinephrine insert in the nostril near bleeding site & then apply pressure. Ashok saini 3000 23 Unit: 1 Disorders of Ear, Nose & Throat 2) Medical management: Provide sedative to the patient as prescribed by physician. E.g. – Diazepam Provide the antibiotic to the patient. E.g. – Amoxicillin Provide vita.-K for blood clotting Nasal packing should remain of a minimum of 2 – 3 days. Administer of local vasoconstrictor. E.g. – Amphetamine Antibacterial ointment is applied in the nose. 3) Nursing management: Provide sitting bend head forward position to the patient & pinch the nose. Keep the patient provide the comfort. Apply direct pressure by pinching the entire soft lower portion of the nose for 10 – 15 minutes. Instruct the patient to breathe through his mouth. Monitor the patient closely for any manifestation of airway obstruction & bleeding from nose. Instruct the oral cavity for the presence of blood soft plate necrosis. Prophylactic antibiotic are used to prevent complication. Complication:  Hypoxia, shock & hemorrhage Sinusitis- Sinusitis is the inflammation of the mucus membrane of the sinus. These are sinus: o Frontal sinus o Ethmoid sinus o Maxillary sinus o Sphenoid sinus Ashok saini 3000 24 Unit: 1 Disorders of Ear, Nose & Throat Types: 1) Acute sinusitis 2) Chronic sinusitis 1) Acute sinusitis: It is an acute inflammation of sinus mucosa. Acute sinusitis is a condition requiring medical treatment. Etiology:  Upper respiratory tract infection  Allergic rhinitis  Swimming lead to water intake  Bacterial infection such as streptococcus, staphylococcus, pneumococcus  Dental infection  Nasal polyps  Deviated nasal septum Clinical manifestation:  Pain occur in sinus area  Purulent nasal secretion  Headache & body pain  Cough & sore throat  Epistaxis  Loss of normal vocal response  Referred pain in the ear  Nasal discharge  Nasal block  In maxillary sinusitis pain is felt in the cheeks below the eye  Fullness sensation in the ear Ashok saini 3000 25 Unit: 1 Disorders of Ear, Nose & Throat Diagnostic evaluation:  History collection  Physical examination  CT scan  Nasal endoscopy  MRI Management: 1) Medical management: Provide the antibiotics to the patient. E.g. – Amoxicillin, Amphicillin Provide the analgesic to the patient. E.g. – Acetaminophen Provide the antipyretics to the patient. E.g. – Paracetamol Oral & topical corticosteroids are provided they will help in relieving the nasal obstruction. E.g. – Ephedrine Provide antihistamines such as cetirizine & levocetirizine Provide saline irrigation to open blocks passes. 2) Surgical management: Antral puncture: Drainage from maxillary sinus by cannula. Correction of deviated septum (Rhinoplasty) 3) Nursing management: Increase fluid intake particularly of hot liquid. Provide warm & moist air by shower or humidification to relieve swelling of the mucus membrane. Avoid irritant such as dust, chemicals & smoke. Apply local heat. Patient education: o Instruct the patient about methods of promote drains such as inhaling steam. Ashok saini 3000 26 Unit: 1 Disorders of Ear, Nose & Throat o Inform the patient about side effect of nasal spray. o Teach the infective patient about preventive measures such as healthy practice & avoid contact with people to upper respiratory infection. o Explain the patient fever; severe headache & nuchal rigidity is sign of potential disease. 2) Chronic sinusitis: Chronic sinusitis inflammation of sinus that persists of more than 3 weeks in the adults & 2 weeks in the children’s that convert’s chronic sinusitis. Etiology:  Chronic nasal obstruction due to discharge & edema of the nasal mucus membrane.  Due to both aerobic & anaerobic organism. Clinical manifestation:  Nasal obstruction  Nasal discharge  Abnormal & unpleasant smell  Epistaxis  Dryness of throat  Facial pain (increase in morning)  Chronic headache  Fatigue  Nasal stiffness  Fullness in the ear  Decrease in smell & taste sensation  Impaired ventilation  Impaired mucocilliary clearance Ashok saini 3000 27 Unit: 1 Disorders of Ear, Nose & Throat Diagnostic evaluation:  History collection  Physical examination  CT scan  Nasal endoscopy Management: 1) Medical management: Medical management almost same as acute sinusitis. Provide the antibiotics to the patient. E.g. – Amoxicillin, Amphicillin Provide the analgesic to the patient. E.g. – Acetaminophen Provide the antipyretics to the patient. E.g. – Paracetamol Oral & topical corticosteroids are provided they will help in relieving the nasal obstruction. E.g. – Ephedrine Provide antihistamines such as cetirizine & levocetirizine Provide saline irrigation to open blocks passes. 2) Surgical management: Excising or cauterization of nasal polyps. Correction of deviated septum. Incision of sinus. When sinusitis is caused by fungal infection, surgery is required to excise the fungal & necrotic tissue & drain in the sinus. 3) Nursing management: Promotion of drainage to the patient. Steam inhalation to the patient. Local application of heat to provide to the patient. Increase to the fluid intake to the patient. Increase the humidity by steam to provide to the patient. Ashok saini 3000 28 Unit: 1 Disorders of Ear, Nose & Throat Avoid contact with peoples having reparatory track infection. Avoid allergens to contact the patient. Maintain the general health & proper diet to the patient. Patient education: o Teach the patient how to promote sinus drainage by increasing the environmental humidity. o Instruct the patient importance of following medication. o Educate about the early signs of sinus infection. Rhinitis- It is refers to inflammation & irritation of mucus membrane of the nose. Types: 1) Acute viral rhinitis 2) Allergic rhinitis 3) Non allergic rhinitis 4) Atrophic rhinitis 1) Acute viral rhinitis: Viral rhinitis is an acute inflammation of mucus membrane of nasal cavity. It is also called ―common cold or coryza‖. Etiology:  Chills & humidity  Lack of exercise  Dietary hypersensitivity  Nasal obstruction  Infection  Thyroid problem  Emotional stress  Causative agents: Ashok saini 3000 29 Unit: 1 Disorders of Ear, Nose & Throat o Influenza virus o Rhinovirus o Para influenza virus Mode of transmission:  Droplet infection  Dust  Direct hand contact Clinical manifestation:  Sneezing  Nasal congestion  Irritation  Watery discharge from eye  Elevated temperature  Malaise  Discomfort  Headache  Muscles & body pain  Sore throat  Fever & chills  Ticking sensation in the nasal cavity Diagnostic evaluation:  History collection  Physical examination  Nasal endoscopy  CT scan Goal: To relieve the symptoms To reduce the changes of complication To inhibit the droplet infection Ashok saini 3000 30 Unit: 1 Disorders of Ear, Nose & Throat Management: Provide the antibiotics to the patient. E.g. – Amoxicillin, Amphicillin Provide the analgesic to the patient. E.g. – Acetaminophen Provide the antipyretics to the patient. E.g. – Paracetamol Oral & topical corticosteroids are provided they will help in relieving the nasal obstruction. E.g. – Ephedrine Provide antihistamines such as cetirizine & levocetirizine Provide the rest to the patient. Avoid fatigueless to the patient. Complication:  Pharyngitis  Sinusitis  Otitis media  Chest infection  Tonsillitis 2) Allergic rhinitis: It is a condition giving rise tube one or more symptoms of nasal obstruction, increase secretion of mucus & sneezing due to & altered reaction to an antigen. It is a reaction of nasal mucosa to specific allergen. Allergens:  Inhalants:  Dust & pollen  Food:  Fish & citrus food  Drugs:  Aspirin & hypertensive drugs  Cosmetics:  Powder  Irritants:  Perfumes & smoke Ashok saini 3000 31 Unit: 1 Disorders of Ear, Nose & Throat Types: 1) Seasonal rhinitis: It is cause due to flower, pollen. It is usually occur spring. 2) Perennial allergic rhinitis: It is due to dust, milk, egg & mold store animal tenders. Clinical manifestation:  Nasal congestion  Sneezing  Rhinorrhea  Cough  Nasal polyps  Irritation Diagnostic evaluation:  History collection  Physical examination  Nasal endoscopy Management: 1) Medical management: Provide the antibiotics to the patient. E.g. – Amoxicillin, Amphicillin Provide the analgesic to the patient. E.g. – Acetaminophen Provide the antipyretics to the patient. E.g. – Paracetamol Oral & topical corticosteroids are provided they will help in relieving the nasal obstruction. E.g. – Ephedrine Provide antihistamines such as cetirizine & levocetirizine Provide the rest to the patient. Avoid fatigue to the patient. Ashok saini 3000 32 Unit: 1 Disorders of Ear, Nose & Throat 2) Surgical management: Correction of septum deviation & removal of nasal polyps to reduce the nasal symptoms. 3) Non allergic rhinitis: Rhinitis without allergy. Etiology:  Respiratory tract infection  Foreign body in nose  Structure deformities  Chronic nasal decongestant  Uses of oral contraceptive  Antihypertensive drug  Cocaine abuse Clinical manifestation:  Nasal congestion  Nasal discharge  Nasal itching  Headache Management: Provide the antibiotics to the patient. E.g. – Amoxicillin, Amphicillin Provide the analgesic to the patient. E.g. – Acetaminophen Provide the antipyretics to the patient. E.g.- Paracetamol Oral & topical corticosteroids are provided they will help in relieving the nasal obstruction. E.g. – Ephedrine Provide antihistamines such as cetirizine & levocetirizine Provide the rest to the patient. Ashok saini 3000 33 Unit: 1 Disorders of Ear, Nose & Throat 4) Atrophic rhinitis: It is a chronic inflammatory condition of the nose. It is characterized by atrophic changes the mucosa of nose. Organism: o Klebsiella o Coccobacilli o Chronic sinusitis Clinical manifestation:  Nasal obstruction  Foul odor  Epistaxis  Drying nose Management: 1) Local management: Alkaline nasal cleanness 2) Systemic management: Provide the antibiotics to the patient. E.g. – Amoxicillin, Amphicillin Provide the analgesic to the patient. E.g. – Acetaminophen Provide the antipyretics to the patient. E.g. – Paracetamol Oral & topical corticosteroids are provided they will help in relieving the nasal obstruction. E.g. – Ephedrine Provide antihistamines such as cetirizine & levocetirizine. Pharyngitis- Pain, irritation in the throat that can occur with or without often accomplished infection such as cold or flu. Pharyngitis is also known as ―sore throat‖. Ashok saini 3000 34 Unit: 1 Disorders of Ear, Nose & Throat o Strep throat: Bacterial infection that cause a sore scratching throat. o Streptococcal Pharyngitis. Types of Pharyngitis: They are following types: 1) Acute Pharyngitis 2) Chronic Pharyngitis 1) Acute Pharyngitis: Acute pharyngitis is febrile (pyretic), acute inflammation of the throat caused by streptococcus which is than refers to as group throat. Clinical manifestation:  Neck swelling  Pain on swallowing  Severe dysphasia  Fever & malaise  Sore throat  Cough  Hoarseness  Rhinitis  Enlargement of cervical lymph node  White purple cough exudates Diagnosis evaluation:  History collection  Physical examination  Throat culture  Blood culture  Nasal swab culture Ashok saini 3000 35 Unit: 1 Disorders of Ear, Nose & Throat Management: Goal: To control infection To relieve the symptoms To prevent secondary complication 1) Medical management: Provide analgesic to the patient such as aspirin. Provide antitussive medication. E.g. – Codeine Provide antibiotics are prescribed to prevent the bacterial infection. E.g. – Amoxicillin 2) Nursing management: Instruct the patient to stay in bed during illness. Examine the skin one to twice daily for possible rashes. Warm saline gargles are used according to severity of lesions & degree of pain. The mouth care to the patient maximize comfort & to prevent oral inflammation. Explain the patient about full course of antibiotics therapy. Use an ice collar (ice bag) shape to fit around neck to relieve the severe sore throat. Provide a liquid or soft diet during acute stage. Ensure the patient to (drink to fluid as possible) at least 2 – 3 liter/day. Complication:  Sinusitis  Otitis media  Mastoiditis  Peritonsillar abscess. Ashok saini 3000 36 Unit: 1 Disorders of Ear, Nose & Throat 2) Chronic pharyngitis (Persistent sore throat): Chronic pharyngitis is a persistent inflammation. Etiology:  Excess voice (singing, speaking)  Leaving & working in dust surrounding  Alcoholism  Tobacco chewing  Smoking Types: 1) Hypertrophic: It is characterized by general thickening & congestion of the pharyngeal mucous membrane. 2) Atrophic pharyngitis: It is the late stage of hypertrophy & characterized by whitish & thick mucus membrane. 3) Chronic granular: It is characterized by swelling follicles of on the pharyngeal wall. Clinical manifestation:  Irritation & fullness of throat  Cough  Dysphasia  Blood strain sputum  Hoarseness  Fever  Tickling sensation in the throat  Expelling the mucus by cough Ashok saini 3000 37 Unit: 1 Disorders of Ear, Nose & Throat Diagnostic evaluation:  History collection  Physical examination  Chest X-ray  Throat swab culture Management: Goal: To avoid irritants. To correct any upper respiratory infection. To relieve the symptoms. 1) Medical management: Provide nasal decongestant. E.g. – Ephedrine Provide nasal spray Provide antihistamine to the patient Provide antibiotics such as amoxicillin to the patient. 2) Nursing management: Use of mask to avoid dust & smoke. Warm saline for gargles. Instruct the patient to avoid the contact with other until fever subsides. Avoid alcohol, tobacco, smoking & extreme cold. Instruct to avoid allergen & irritants. Instruct the patient to drink plenty fluid. Laryngitis- Laryngitis is an inflammation of larynx due to over use, irritation & infection. Incidence: More than 10 million cases per year in India. Ashok saini 3000 38 Unit: 1 Disorders of Ear, Nose & Throat Types: 1) Acute laryngitis: It is an acute inflammation of laryngeal mucus membrane. 2) Chronic laryngitis: It is chronic infection of laryngeal membrane beyond 3 weeks typically related to irritants. Etiology:  Infection due to bacteria, virus  Trauma due to vocal abuse  Irritation from inhaled fumes, gases including smoking, tobacco  Upper respiratory infection  Repeated infection  Specific disease such as tuberculosis Clinical manifestation:  Hoarseness  Aphonia  Discomfort in the throat  Severe cough  Fever & malaise  Dysphasia  Dyspnea  Vocal cord appear congested Management: Provide voice rest to patient. Provide steam inhalation to patient. Instruct the patient to avoid the smoking & tobacco. Speech therapy about knowledge to the patient. Use the codeine for relieve cough to the patient. Provide antibiotic to the patient. Ashok saini 3000 39 Unit: 1 Disorders of Ear, Nose & Throat Provide anti-inflammatory to the patient. Provide the mucolytic agent to patient for thin & mobilized mucus. E.g. – Ambroxol, Bromohexine Instruct the patient to avoid whispering which also cause excessive vocal cord strength. Instruct the patient to avoid eating or drinking for 2 – 3 hours before going to sleeping. Peri-Tonsillar Abscess (Quinsy)- It is a collection of purulent exudates between the tonsils & surrounding structure. Peritonsillar abscess is a complication of acute pharyngitis & acute tonsillitis. When bacterial infection affect one or both tonsils. Etiology:  Bacterial infection such as beta-hemolytic streptococci & staphylococcus bacteria.  Infection of associated structure such as tonsil. Clinical manifestation:  Odynophagia (Severe pain in the mouth esophagus when attempting to swallow)  Dysphasia  Swelling on soft palate  Dehydration  Drooling Diagnostic evaluation:  History collection  Physical examination  Blood culture Ashok saini 3000 40 Unit: 1 Disorders of Ear, Nose & Throat Management: 1) Medical management: Provide antibiotics usually penicillin to the patient. Provide topic anesthetic throat spray. Provide analgesic to the patient. Provide hot saline throat irrigation. 2) Surgical management: The treatment is delay the abscess is evacuated as soon as possible by the surgery Quinsy tonsillectomy. 3) Nursing management: Using of the mouth washes gargles using saline at temperature of 105 – 110 0F Instruct the patient to gargles & interval of 1 – 2 hours for 2 – 3 days. Use of ice collar to make the throat more comfortable. Tonsillitis- Introduction: The tonsils are composed of lymphatic tissue & are situated each site of the oropharynx. The palatial tonsil & lingual tonsil are located behind the pillar of the tongue. Tonsils are lymphatic tissue work by trapping germs coming in through the mouth. Definition: Tonsillitis is an inflammation condition of the tonsils. Types: 1) Acute tonsillitis: It may occur as a primary infection of the tonsil itself or secondary occurs a result of infection of the upper respiratory tract. Ashok saini 3000 41 Unit: 1 Disorders of Ear, Nose & Throat Common causative bacteria include: o Streptococcus o Staphylococcus o Pneumococcus o Hemophilus influenza 2) Chronic tonsillitis: It is caused by repeated attack of acute tonsillitis. Adenovirus consists of abnormally large lymphatic tissue near the posterior wall of nasopharynx infection of adenovirus frequently known as acute tonsillitis. Note- Adenovirus & tonsillitis are both lymphatic tissue present both in throat & behind the nose & work together trapping the microorganism. Etiology:  Bacterial infection such as streptococcus.  Viral infection such as Influenza adenovirus. Clinical manifestation:  Sore throat  Dysphasia  Mouth breathing  Sneezing  Foul smelling  Voice impairment  Noisy respiration  Bronchitis  Deafness & drainage from ear Diagnostic evaluation:  History collection Ashok saini 3000 42 Unit: 1 Disorders of Ear, Nose & Throat  Physical examination  Throat swab culture  Laryngoscopy  Audiometry Management: 1) Medical management: Provide antibiotic to the patient. E.g. – Azithromycin Provide analgesic to the patient. E.g. – Acetaminophen Provide the anti-inflammatory drugs to the patient. E.g. – Ibuprofen 2) Surgical management: Tonsillectomy is performing correct severe cases of tonsillitis. 3) Nursing management: Post-operative care: Provide most comfortable position is prone position with head turn to side to head to side to allow drainage from the mouth & pharynx. Apply the Ice collar in the neck pain of the patient. The nurse should have a mirror, gauze & waste basin to examine of surgical site of bleeding. Provide basin for the expectoration of the blood & mucus. Continues observation after ligation of the patient tonsils. Teaching about the self care: o Explain about that sore throat may occur in the first 24 hours. o Instruct the patient to avoid milk & milk product. o Instruct the patient to take liquid & semi liquid diet. o The patient & family member must understand the sign. o Explain the patient halitosis & some time minor ear pain occurs for the first few days. o Instruct the patient to avoid brushing, gargling since these action lead to bleeding. o Instruct to the patient avoid spicy & acidic diet. Ashok saini 3000 43 Unit: 2 Disorders of Eye Nursing Management of Patient with Disorders of Eye Conjunctivitis (Pink Eye)- Definition: Conjunctivitis is a defined as inflammation of conjunctiva that are characterized by swelling & pink appearance of eye because of sub conjuctival blood vessels congestion so it is also known as ―pink eye‖. Etiology: Infection o Bacterial infection such as streptococcus pneumoniae, streptococcus aureus & homophiles influenza o Viral infection such as adenovirus o Fungal infection Allergic exposure to irritants to such as chemicals, thermal, electrical & radiations. Mechanical trauma Types of conjunctiva: 1) Microbial conjunctivitis 2) Allergic conjunctivitis 3) Toxic conjunctivitis 1) Microbial conjunctivitis: a. Bacterial conjunctivitis: The most common causative microorganisms are streptococcus pneumoniae, streptococcus aureus & H. influenza. Bacterial conjunctivitis can be acute & chronic. Ashok saini 3000 44 Unit: 2 Disorders of Eye Chronic conjunctivitis usually seen in patient is affected by lacrimal duct obstruction, chronic dacryocystitis (inflammation of lacrimal sack) & chronic blepharitis (inflammation of eye lids). Clinical manifestation:  Bacterial conjunctivitis manifested with an acute onset of redness, burning & discharge. b. Viral conjunctivitis: Most common organisms are adenovirus. Coronial involvement cause extreme photophobia. Symptoms includes: o Extreme tearing o Redness o Foreign body sensation that can involve one & both eye. 2) Allergic conjunctivitis: Immunological & allergic conjunctivitis is hypersensitivity reaction that occurs as a part of allergic rhinitis. The patient usually as history of pollen & allergen of environment. Clinical manifestation: There is extreme pruritus, epiphora (excessive secretions of tears) & usually severe photophobia, mucous discharge & usually associated rubbing the eye because severe itching. 3) Toxic conjunctivitis: Chemical for toxic conjunctivitis can be the result of medication. Chronic for swimming pulls. Exposure to toxic from among individual workers. Exposure to other irritants such as smoke, acid & alkaline. Clinical manifestation:  Itching  Tearing Ashok saini 3000 45 Unit: 2 Disorders of Eye  Discharge secretion  Burning sensation Diagnostic evaluation:  History collection  Physical examination  Slit lamp examination  Swab smear culture (this is confirmative diagnosis) Management: 1) Medical management: Provide topical & systemic or symptomatic antibiotics to the patient. To administered the topical ointment & eye drop of the antibiotic to prevent infection to the patient. o E.g. – Ciprofloxacin, Ofloxacin Provide the antiviral & antifungal drugs to prevent viral & fungal infection. o E.g. – Acyclovir 2) Nursing management: Prepare aseptic technique should use o avoid infection. Provide eye irrigation to the patient. To apply the cold compression on the pinkish are which cause vasoconstriction & relieve pain. Disinfectant all the instrument use for eye examination at all time. Instruct the patient for hand washing & avoid sepsis & towel, face cloths & eye drops. Wash the hand before & after the touching the eye to prevents infection. Complication:  Blindness  Generalized septicemia Ashok saini 3000 46 Unit: 2 Disorders of Eye Cataract- Definition: A cataract is opacity of lens or cloudiness that distracts the image project into the retina that can progress at blindness. Cataract is an opacification of normally, clear & transparent lens due to precipitation of the lens clothing. It may be congenital & acquired. It is usually a result of ageing but may be present at birth. Cataract alphabetically means: o C: Congenital o A: Acquired o T: Traumatic o A: Associated other disease. E.g.- Diabetes mellitus o R: Radiational o A: Age related (senile) o C: Complication (excessive heat) o T: Toxic According to WHO ―cataract is the leading cause of blindness in the world. Risk factor & etiology: 1) Ageing:  Loss of lens transparency  Decrease Oxygen intake  Accumulation of yellow brown pigment due to break down of lens protein. 2) Associated ocular condition:  Myopia  Retinal detachment  Infection such as herpes zoster virus. Ashok saini 3000 47 Unit: 2 Disorders of Eye 3) Toxic factor:  Cigarette smoking  Chemical eye bud  Poisoning  Long term used corticosteroid high dose. 4) Nutritional factor:  Reduce level of antioxidant  Poor nutrition  Obesity. 5) Physical factor:  Dehydration  Electrical shock  Exposure to ultra violet sunlight & X-ray  Perforation of lens with a sharp object. 6) Systemic disease & syndrome:  Diabetes mellitus  Disorder related to down syndrome. Clinical manifestation:  Blurred vision  Dimness visual power  Diplopia  Photophobia  Reduce light transmission  Severe pain  Disturb images  Scattering of light  Pupils may appearing gray or white (cloudiness) Ashok saini 3000 48 Unit: 2 Disorders of Eye Types of cataract: 1) Senile cataract: Due to ageing process. 2) Congenital cataract: If mother infected with mumps, measles, poliomyelitis, chicken pox during first trimester may caused congenital cataract. 3) Traumatic cataract: Due to injury. 4) Secondary cataract: Result from other disease such as maternal rubella, diabetes mellitus, severs myopia. Pathophysiology: Due to etiological factor (senile cataract) Altered metabolic process within the lens Alteration in the lens fibration structure & accumulation of water Affect lens transparency & opacity Vision changes Diagnostic evaluation:  History collection  Physical examination  Ophthalmoscopic examination  Slit lamp examination  Snellen visual acuity test  MRI for use image the edema  USG Ashok saini 3000 49 Unit: 2 Disorders of Eye Management: 1) Medical management: To make life style adjustment. Provide the antioxidant’s such as vitamin-C, E to the patient. Provide the strong reading glasses to the patient. Done eye irrigation to the patent. Provide the eye drops & antibiotics to the patient. Mydriatics can be used to short term treatment to dilate pupils. 2) Surgical management: i. Intra capsular cataract extraction (ICCE): It is the remove of entire lens & capsular also removed anterior & posterior. Implant a synthetic intra ocular lens. ii. Extra ocular cataract extraction (EOCE): Lens & anterior capsule are removing but posterior lens capsular remain intact. Microscopy is used to visualize eye structure during surgery. Leaving the posterior capsule & intact reduce the complication & receive a synthetic intraocular lens. iii. Lens replacement: The lens which focuses light on the retina must be replaced for the patient to see clearly such as contact lens. iv. Phacoemulsification: It is a type of extra capsular extraction this methods of extra capsular sugary uses an USG device that liquefies nucleus & cortex which are that suction out to a tube. The lens is removing to a smaller incision by using a high frequency USG device. Posterior capsule preserved to support an intraocular lens. Ashok saini 3000 50 Unit: 2 Disorders of Eye 3) Nursing management: i. Preoperative care: History collection & physical examination. Administered to the antibiotic to the patient. Administered local anesthesia to the patient. Instruct to the patient for all over process. Offer preoperative anti-anxiety medication before local anesthesia. ii. Postoperative care: Administered post medication usually includes antibiotic, corticosteroid drops to prevent infection & inflammation. Measure intraocular pressure of the eye to the patient. Provide high analgesia if necessary. Patient education: Educate to wear a protective eye patches for 24 hours after surgery. Instruct the family member about the disease. Instruct to wear the sun glasses while outdoor during the day because eye is sensitive to light. When sleeping lie on the back or side not on abdomen. Instruct to avoid for one week following: o Sleeping on the affected side o Rubbing of the eyes o Straining of bowel more o Sexual relation o Driving o Coughing, sneezing & vomiting Wash the hands before & after instillation eye medications. Ashok saini 3000 51 Unit: 2 Disorders of Eye Refractive Errors- In refractive errors vision is impaired because a shortened or elongated eyeball prevents light rays from focusing sharply on the retina. Blurred vision from refractive errors can be corrected with eyeglasses or contact lens. The appropriate eyeglass or contact lens is determined by refraction. Types: 1) Myopia 2) Hyperopia 3) Astigmatism 4) Presbyopia 1) Myopia (Near sightedness): It is a condition in which light rays come on focus in front of retina. It caused by elongation of eyeball. In this condition the patient can’t seen the far object clearly but do not have any problem is treat with using a biconcave lens. 2) Hyperopia (Far sightedness): In this condition light rays come & focus behind the retina. It is caused by shorting of the eyeball rather than normal. In this condition patient can’t able to see the near object properly but there is no problem is far vision. This is condition is treat with using a convex lens. 3) Astigmatism: In this condition light rays can’t able to send equal or properly so that a point of focus rays don’t attended. It is caused by the changes in curvature of the cornea. In this condition poor vision for both near & far object. It is treated by cylindrical lens. Ashok saini 3000 52 Unit: 2 Disorders of Eye 4) Presbyopia: In this condition loss of accommodation capacity of lens because of increase in the age. Ages are increase the lens become larger & less elastic. In this condition patient can’t focus on the near object. This is treated by convex lens. Clinical manifestation:  Blurred vision  Ocular discomfort  Headache  Blindness Diagnostic evaluation:  History collection  Physical examination  Contrast sensitivity  Color perception  Refraction / sensitivity test: The client view on the eye chart while various lens of different strength are systemically in front of the eye is asked whether the lens sharpen & worsen vision. Treatment:  Use of appropriate corrective lens.  Myopia requires a negative (-) curative lens (concave).  Hyperopia & presbyopia require a positive (+) curative lens (convex).  Use of contact lens generally provides better vision then glasses because the patient has more normal.  Peripheral vision without the distortion & obstruction of glass & their frames. Ashok saini 3000 53 Unit: 2 Disorders of Eye  Contact lens are generally made from various plastic or silicon substances which are very permeable to oxygen & have a high water contact which allow increase wearing tome with greater comfort.  Remove contact lens immediately with patient have redness, sensitivity, vision problem & pain. Surgical treatment: LASIK (Laser assisted in situ kerotomileusis): The superficial layers of cornea are lifted as a flip. A laser reshape deeper corneal layer & then the corneal is replaced. Immediately before your Lasik surgery numbing eye drop are apply to your eye to prevent any discomfort during the procedure. Your eye will be position under the laser & instrument called an eyelid speculum is used to keep your eye open. A suction ring is applied to front of the eye to prevent of eye movement or loss of contact that to affect quality of corneal flip. After the corneal flip is created a surgeon uses a computer to adjust the laser for your particular prescription. You will be asked to look at light for short time while he watches his eye through a microscope as the lesser same passes of light to your cornea. The laser light passes painlessly reset cornea but you may feel some pressure on your eye. You will also hear a clicking sound while is laser is operating. The laser treatment itself takes only about a minute. While the procedure has excellent, safely, Lasik complication can occur may include: o Infection o Halos & glare Ashok saini 3000 54 Unit: 2 Disorders of Eye Uveitis- Definition: Uveitis is defined as the inflammation of the uveal tract can affect the choroid, ciliary body & iris that are called uveitis. Etiology:  Bacterial infection  Viral infection  Parasite infection  Fungal infection  Ciliary body muscles spasm  Eye injury or surgery  Auto immune disorder  Cancer that affect the eye such as lymphoma Types: There are following types: 1) Non granulomatous uveitis 2) Granulomatous uveitis 3) Anterior uveitis 4) Intermediate uveitis 5) Posterior uveitis 6) Panuveitis 1) Non granulamatous: This is the more common type of uveitis. There may be small, fine precipitates on the posterior corneal surface & cell in the aqueous humor. If the uveitis is severe, a hypopyon (accumulation of pus in the anterior chamber) may occur. Ashok saini 3000 55 Unit: 2 Disorders of Eye Repeated attacks of non granulamatous anterior uveitis can cause anterior synechiae (peripheral iris adheres to the cornea & impedes outflow of aqueous humor) to the cornea & impaired outflow of aqueous humor). Posterior synechaie (adherence of the iris & lens block aqueous outflow from the posterior chamber. Secondary glaucoma can result from either anterior or posterior synechiae. Clinical features:  Pain  Photophobia  Blurred vision  Hypopyon  Pupils small & irregular 2) Granulamatous: Granulamatous uveitis can have a more insidious onset involve any portion of the uveal tract. It leads to chronic condition. Clinical features:  Photophobia  Pain  Vitreous clouding  Chrioretinitis  Choroidal hemorrhage 3) Anterior uveitis: It affects the front of the eye. It is often called iritis because it mainly affects the area around the eye iris. Anterior uveitis is the most common kind of the uveitis in children & adults making up to 40 – 70 % of the uveitis. Ashok saini 3000 56 Unit: 2 Disorders of Eye Clinical features:  Blurred vision  Redness of eye  Photophobia  Irregular pupil 4) Intermediate uveitis: It is the inflammation of the ciliary body & the front end of the retina & vitreous humor. Immediate uveitis is the least common type of uveitis make to 7 – 15% of cases. Clinical features:  Blurred vision  Floaters which are dark spot that float visual field. 5) Posterior uveitis: It is the inflammation of the choroid, retina & optic nerve. It can be seen 15 – 20% of uveitis cases. Generally it is chronic (long-lasting can last week to month, year recurrent affect both eye) Clinical features:  Floaters  Blurred vision  Photopsia (seeing flashing light) 6) Panuveitis: It is the inflammation that entire uveitis. Clinical features:  Floaters  Blurred vision Ashok saini 3000 57 Unit: 2 Disorders of Eye Diagnostic evaluation:  History collection  Physical examination  CBC  ESR (Erythrocyte sedimentation rate): o The ESR is a type of blood test measures how quickly erythrocytes (RBC) settle at the bottom of a test tube & that contain a blood sample. o Normally RBC settle relatively slowly a faster than normally rate may indicate infection in the body. o Normal value of ESR is descended in one hour that is 0 – 22 mm/hr.  Antinuclear antibodies (ANA): o This test is use a primary test to helpful evaluate a person for autoimmune disorder that affect many tissues & organ throughout the body. Management:  Because photophobia is common symptoms should wear dark glasses in outdoor.  Ciliary spasm & synechaie are avoided to Mydriatics. E.g.- Atropine & cyclopentolate  Local corticosteroids drugs such as prednisolon & fluorometholone acetate.  Instillation of eye drops 4 – 6 times in a day & also used to decrease inflammation.  Use of all aseptic technique to prevent further infection.  To prevent severe cases systemic corticosteroids may be used. Retinal Detachment- It is a secretion of sensory retina the underline pigment epithelium with fluid accumulation between two layers. Ashok saini 3000 58 Unit: 2 Disorders of Eye Incidence: Approximately one out of every 10, 000 individual each year to affected by retinal detachment. Etiology/Risk factor:  Eye trauma  Cataract or glaucoma surgery  Aphakia  Tension or pulling force  Retinopathy  Family or previous personal history  Old age  Atrophy of the vitreous body  Inflammation Types: They are following types: 1) Rhegmatogenous detachment: It is most common type of retinal detachment. In this condition a hole or tear develop in the sensory retina. It allows vitreous liquid to the surgery retina & detachment it form retinal pigment epithelium. 2) Traction detachment: Tension or pulling force is responsible for traction retinal detachment. The diabetic retinopathy, vitreous hemorrhage or retinopathy of prematurity is the most common cause of traction detachment. 3) Exudative detachment: It results from production of serous fluid under the retina from the choroid. Condition such as uveitis & muscular degeneration may cause the production of serous fluid. Ashok saini 3000 59 Unit: 2 Disorders of Eye Clinical manifestation:  Photophobia  Sudden onset of a great numbers of floaters  Cob web  Blurred vision  Painless loss of peripheral & central vision  Patient may record sedation of shade report certain coming across the vision of one eye Diagnostic evaluation:  History collection  Physical examination  Visual acuity measurement  Ophthalmoscopy  Slit lamp examination  USG Management: 1) Medical management: There is no medical management available but symptomatic treatment can be done. 2) Surgical management: The replacement of retinal detachment is to placed the retina back to retina in connect with choroid. i. Cryopexy: It is use nitrous oxide to freeze the tissue behind the retinal tear, stimulating the scar tissue formation will seal the edge of the tear. It is an outpatient procedure. Ashok saini 3000 60 Unit: 2 Disorders of Eye ii. Scleral buckle: The retina surgeon compressed the sclera to intent the sclera wall from the outpatient of the eye & ring the retinal layers in contact with each other. iii. Pars plana vitrectomy: A vitrectomy is an intraocular procedure in which 1 – 4 mm incision are made at the pars plana. o Pars plana is the part of ciliary body in the uveal, the middle layer of three layers the comparison the eye. It is about 4 mm long, located near the junction of the iris & sclera. o One incision allowed the introduced of a high source & another incision severe as the portal of the vitrectomy instrument. o The surgeon desist the preretinal membrane under direct visualization why the retina is stabilize by an intra operative vitreous substitute. iv. Laser photocoagulation therapy: If the retina detachment is slight a laser can be used to burn the edge the tear & half toleration. In the detachment is slow the laser can be seal the retina against the choroid. v. Pneumatic retinopexy: It occurs in the upper portion of the eye is numbed local anesthesia & a small air bubble is injected into the vitreous body. The technique is most use for repair of rhegmatogenous retinal detachment. 3) Nursing management: i. Preoperative intervention: The sub pupil must be widely dilated before operation. Administration sedatives. Ashok saini 3000 61 Unit: 2 Disorders of Eye ii. Post operative intervention: Observe the eye patches for any discharge. Close monitoring during 24 hour. Encourage the patient resume the regular diet & fluid. Administer post operative medication it’s include antibiotics, steroids, eye drops to prevent infection & reduce inflammation. Apply either warms & cold compression for comfort several times a day. Administer pain relief medication when the patient experiences post operation pain. Patient & family teaching: o Proper hygiene & eye care technique. o If any sign of infection to immediate inform to doctor. o How to instillation of eye medications. Glaucoma- Definition: The term glaucoma is used to refers to a group of ocular condition characterized by: o Elevated intraocular pressure o Optic nerve damage o Peripheral vision loss Incidence: Glaucoma is the second leading cause of blindness in the adults in US. It is estimated that at least 2.2 million Americans have glaucoma & 3 – 6 millions more are at risk of this disease 2008. Risk factor:  Family history  Older age Ashok saini 3000 62 Unit: 2 Disorders of Eye  Diabetes mellitus  Eye trauma  Prolonged used of corticosteroid  Previous eye surgery Etiology:  Increased production of aqueous humor by ciliary body  Decrease absorption of aqueous humor by canal of schlemm  Intraocular trauma  Blockage of the trabecular meshwork  Heredity Pathophysiology: Due to etiological factor such as high production of aqueous humor & obstruction of aqueous humor Increase amount of aqueous humor Increased pressure Decreased blood supply optic nerve & retina Tissue ischemia Loss of function (Vision) Stages of glaucoma: They are following stages: 1) Initiative events 2) Structure alteration in outflow system 3) Functional alteration 4) Optic nerve damage 5) Visual loss Ashok saini 3000 63 Unit: 2 Disorders of Eye 1) Initiative events: Precipitating factor such as illness, emotional stress, congenital narrow angle, long term used of corticosteroids & used of Mydriatics. These events lead to second stage. 2) Structure alteration in outflow system: Tissue & cellular changes causes by factors that affects. Aqueous humor dynamics leads to structure alteration & may leads to third stage. 3) Functional alteration: Conditions such as increase intraocular pressure or impaired blood flow create functional changes that’s may leads to fourth stages. 4) Optic nerve damage: Atrophy is the optic nerve is characterized by loss of nerve fiber & blood supply & this stage progress to fifth stage. 5) Visual loss: Progressive loss of this characterized by visual filed affected. Types of glaucoma: 1) Open angle glaucoma: Increase production & normal absorption of aqueous humor. a) Primary open angle glaucoma: It represents 90% cases primary glaucoma. It is characterized by atrophy of the optic nerve typical visual defect. b) Secondary open angle glaucoma: In this elevated intraocular pressure result from increase resistance to aqueous humor out flow through the trabecular meshwork. Ashok saini 3000 64 Unit: 2 Disorders of Eye The trabecular present may be blocking any type of depress blood vessels. Increase resistance is due to long term corticosteroid used intraocular tumor, intraocular lens implanted & trauma. 2) Close angle glaucoma: To close angle glaucoma the iris is blocked is also called papillary block. The trabecular meshwork & limit the flow of aqueous humor to the anterior chamber is leads to close angle glaucoma. Decrease absorption & normal production of aqueous humor. a) Primary/ acute close angle glaucoma: It results from anatomical defect that cause the anterior chamber to be narrow. This produced a narrow drainage angle & peripheral angle. Patients are asymptomatic unless there is an acute closer. It blocks the outflow of the aqueous humor from trabecular. b) Secondary/ chronic close angle glaucoma: Increase resistance to outflow of aqueous humor closely blockage of trabecular meshwork by peripheral iris. Clinical manifestation:  Increase intraocular pressure  Blurred vision  Colorful halos around the light  Loss of peripheral vision  Difficulty in adjusting eyes in low light  Discomfort around the eye  Nausea & vomiting Ashok saini 3000 65 Unit: 2 Disorders of Eye  Headache  It is also known as ―silent thief of sight‖ because most of patients are unaware about to the disease until they may have experience visual changes or vision loss. Diagnostic evaluation:  History collection  Physical examination  Tonometry to measure the intraocular pressure  Ophthelmoscopy to inspect the inner structure of eye & optic nerve  Perimetry to assess the peripheral visual area of the patient  Slit lamp examination  Ishihara chart if color blindness is present/ to assess the color vision of the patient Management: Goals: 1) To facilitate the outflow of aqueous humor. 2) To maintain the intraocular pressure (IOP) within normal range. 3) To prevent the optic nerve damage. 4) To restore independence for the client. 1) Medical management: Provide Miotics drugs to increase the aqueous fluid outflow by contracting the ciliary muscles & opening of trabecular meshwork. E.g. – Pilocarpin, Carbochon Provide andregenic against to reduce production of aqueous humor. E.g. – Dipivefrin, Epinephrine Provide beta-blocker to the patient to reduce aqueous humor production. E.g. – Timolol, Betaxolol Ashok saini 3000 66 Unit: 2 Disorders of Eye Provide alpha-adregenic agonist to decrease aqueous humor production. E.g. – Apraclonidin Provide carbonic anhydrate to decrease aqueous humor production. E.g. – Acetozolamide Provide anti-inflammatory agent to patient to decrease the inflammation of surrounding structure. Provide prostaglandin analogs to increase the uveoscleral outflow. E.g. – Latanoprost 2) Surgical management: i. Trabeculoplasty: Lasers are applied to the inner surface of trabecular meshwork to open the intratrabecular & wide the canal of schlemm & there by providing outflow of aqueous humor & decrease intraocular pressure. This procedure is indicated when IOP is inadequately controlled by medication & it is contraindication when trabecular can’t be fully visualized because of narrow angle. IOP assessment into the immediate post operative period assessment. ii. Laser iridotomy: It is used for pupillar block glaucoma. In this opening is made in the iris to eliminate the pupillary block. Potential complications are burn, cornea, lenses & retina. iii. Filtering procedure: It is used to create an opening of fistula in the trabecular meshwork to drain aqueous humor. iv. Trabeculectomy: It is the standard filtrating technique use to remove part of trabecular meshwork. Complication includes hemorrhage extremely elevated of IOP, uveitis & cataract. Ashok saini 3000 67 Unit: 2 Disorders of Eye v. Drainage implant & shunt: The drainage to implant in the anterior chamber to shunt aqueous humor to the blister or bleb in the conjunctiva space. These implant are use when failure as occur with one or more trabeculectomies. vi. Trabectome surgery: This surgery is indicated this form of whom other treatment such as other This minimally invasive procedure specially designs fluid drainage from eye to maintain IOP. This surgery is performing by incision & implant filtering a bulb. vii. Peripheral sector iridotomy: Removal a portion of iris their by allow the aqueous humor to flow from posterior chamber to anterior chamber. 3) Nursing management: Collect the history of allergic reaction particularly to medication. Ask the patient to describe any changes in vision. Explain the effect of glaucoma control medication on vision. Assess the patient psychological reaction to diagnose potentially sight disorder. Teach the family member & patient about risk of glaucoma. Nursing diagnosis: 1) Risk for injury related to visual acuity deficit. 2) Anxiety related to potential sight disorder. 3) Acute pain related to surgical correction. 4) Disturb sensory perception related to recent loss of vision. Ashok saini 3000 68 Unit: 2 Disorders of Eye Patient education: To know IOP measurement & desire range. Be informing about the extent of vision loss & optic nerve damage. Keep a record of your eye pressure measurement & visual filed test. Review al