Coordinating Care for Patients With Visual & Hearing Disorders (HEENT) PDF

Coordinating Care for Patients With Visual & Hearing Disorders (HEENT) Carlie Hunt, MSN, RN NURS 3510 Clinical Judgement in Nursing for Simple and Stable Conditions Auburn University College of Nursing  1. Recognize assessment findings for patients with HEENT disorders....

Coordinating Care for Patients With Visual & Hearing Disorders (HEENT) Carlie Hunt, MSN, RN NURS 3510 Clinical Judgement in Nursing for Simple and Stable Conditions Auburn University College of Nursing  1. Recognize assessment findings for patients with HEENT disorders. 2. Employ appropriate nursing interventions for simple or stable HEENT disorders. 3. Evaluate the effectiveness of nursing interventions for Learning simple or stable HEENT disorders. 4. Identify individual risk factors for HEENT disorders and Objectives health promotion strategies to decrease incidence. 5. Collaboratively manage the care of patients experiencing HEENT alterations. 6. Identify appropriate health education for patients, families, and communities experiencing HEENT alterations. Conjunctivitis Conjunctivitis What is it? Infection or inflammation of the conjunctiva Commonly known as "pinkeye" Infections may be bacterial or viral Inflammation may be due to allergens or chemical irritants Very contagious Conjunctiva- protective mucous membrane barrier protecting the eye, lines the inside of our eyelids  Epidemiology Affects all ages, races, genders, and socioeconomic groups Prevalence of conjunctivitis in the US ages 1 to 74 is approximately 13 in 1,000 3% of all emergency department visits are related to eye disorders approximately 30% of these are conjunctivitis Risk Factors Sporadic or related to epidemic outbreaks Poor hygiene promotes transmission Contact lenses Use of contaminated makeup or opthalmic medications Types of Conjunctivitis & Clinical Manifestations Allergic- seasonal allergies Viral (most common)-clear watery discharge Bacterial- purulent discharge, feels like sand in their eye Staphylococcus aureus -most common Streptococcus pneumoniae Haemophilus influenzae Chlamydial Gonococcal Contact lens-related Mechanical-eyelash/ foreign body in the eye Traumatic-direct injury to the eye Chemical/Toxic Clinical Manifestations Clinical Manifestations Contact lens sensitivity to lens chemicals, lens, contact solution, dirty contacts Mechanical conjunctivitis eyelash, foreign body, etc Traumatic conjunctivitis laceration, abrasion, or chemical injury Chemical/Toxic conjunctivitis redness, necrosis of the conjunctiva marked by a deceptively white eye due to vascular closure possible (image) Medical Management—Treatment Treat causative agent Diagnosis H&P Slit lamp to determine presence of foreign body Culture the conjunctiva Visual acuity checks Before and after treatment No treatment for viral Bacterial- treat with meds Medical Management—Treatment Allergic-antihistamine drops Viral-no medication, comfort measures,cold compress/should resolve on it’s own Bacterial-treat with antibiotic drops/ systemic antibiotics Contact lens-related-depends on if its allergic or bacterial Mechanical Traumatic Chemical/Toxic Nursing Management—Assessment and Analysis Nursing Management—Nursing Diagnoses Risk for infectious transmission Pain Photophobia wash hands ABCs comfort from pain risk for infection Nursing Interventions Assessments Vital signs(increased HR from pain, temperature bc of infection) Appearance of eye Diagnostic results Actions Pharmacological therapy- Table 46.5 Provide comfort care Collaborative care Teaching Evaluating Care Outcomes Prevent transfer of infection Resolution of condition Cataracts  Cataracts What is it? Clouding of the eye’s crystalline lens Due to continual growth of lens protein fibers with aging & photo-oxidative stress from UV light exposure, smoking, diabetes, &/or obesity Lens is no longer completely transparent (decreased opacity), resulting in painless blurry vision  Epidemiolo gy 22 million Americans over age 40 By age 80, more than half of all Americans have cataracts slightly more likely to affect women than men Risk Factors Exposure to UV light Advanced age Family history Race and ethnicity Diabetes & other chronic medical conditions Obesity Elevated blood pressure Smoking(doubles your risks) and alcohol use Environmental factors Clinical Manifestations Clouded, blurred, or dim vision Night vision difficulty Sensitivity to light and glare Halo vision around light sources Fading or yellowing of colors Double vision (diplopia) in a single eye Progressive and painless loss of vision Visible opacity Absent red light reflex Red Light Reflex Assessment Medical Management—Di agnosis Visual acuity test Direct ophthalmoscope examination with a slit lamp Opaqueness on exam Medical Management—Treatment Surgical removal of opaque lens- most effective ▪ https://www.youtube.com/watch?v=icYLMmENk_c Corrective lenses Medical Management—Treatment Possible Complication of Cataract Surgery: Retinal Detachment Possible Complication of Cataract Surgery: Retinal Detachment MEDICAL EMERGENCY May cause permanent vision loss Must seek immediate attention by an eye care professional Retinal Detachment Clinical manifestations Floaters in visual field Light flashes Appearance of curtain over field of vision Cataracts Nursing Management—Assessment and Analysis Nursing Management—Nursing Diagnoses Disturbed visual sensory perception Risk for injury Anxiety Difficulty seeing at night Blurry vision Light sensitivity Nursing Interventions—Assessments Visual acuity Diagnostic results Age-related considerations Nursing Interventions—Action s Implement safety measures Administer eye drops in preparation for surgery Elevate head of bed (HOB)(prevent swelling and intraocular pressure)(normal eye pressure 10-21 mmHg) Maintain eye patch Administer stool softeners( want to do this bc when you strain on the toilet it increases the pressure so you want to administer stool softener) prophylaxis(prevention) eyedrops eye shield Nursing Interventions—Teaching Pre- and postoperative teaching Decrease risk factors Safety concerns Follow-up appointments( slit lamp test, visual acuity test) Accessibility to community agencies(eyecare of america) Nursing Management—Evaluating care outcomes Correction of vision Follow up with eye care professionals Glaucoma  Glaucoma What is it? A group of eye conditions that present with increased IOP & result in damage to the optic nerve, leading to peripheral vision loss Caused by congestion of aqueous humor by one of these mechanisms: Inadequate draining from the canal of Schlemm Overproduction of aqueous humor High IOP is > 21 mm Hg Unknown cause- however, there are theories and identified risk factors https://www.youtube.com/watch?v=TgjdPgSxeYg Glaucoma Pathophysiology Normal outflow of aqueous humor (images) Unimpeded outflow of aqueous fluid depends on an intact drainage system & an open angle (about 45 degrees) between the iris & the cornea A narrower angle places the iris closer to the trabecular meshwork, diminishing the angle When aqueous fluid is inhibited from flowing out, pressure builds up within the eye & damages the optic nerve Types of Glaucoma 1. Primary open-angle glaucoma (most common) 2. Angle-closure glaucoma (second most common but still rare) also known as acute glaucoma or narrow-angle glaucoma Medical emergency* 3. Normal-tension glaucoma also known as low-tension glaucoma or normal-pressure glaucoma 4. Secondary glaucoma 5. Pediatric glaucoma  Glaucoma Risk Factors Family history Age > 60 Individuals who are Black or of Mexican ancestry Comorbid diabetes, hypothyroidism, myopia (nearsightedness) Prolonged corticosteroid use Risk Factors Specific to Normal-Tension Glaucoma People with family history of this type of glaucoma Individuals of Japanese ancestry Patients with heart disease such as irregular heart rhythm More common in females  Glaucoma Epidemiology 3 million Americans have been diagnosed with glaucoma Approximately another 2 million have glaucoma without knowing it(think it’s normal and it’s a slow progressive problem) Open Angle Glaucoma Angle-closure Glaucoma Open Angle vs. Angle Closure Glaucoma Open Angle Glaucoma Clinical Manifestations Progressive, irreversible peripheral vision loss Tunnel vision (image F) headaches, mild eye pain, halos around light sources, decrease accodmondation with PEERLA Peripheral Vision Loss in Open Angle Glaucoma Acute Angle-Closure Glaucoma Clinical Manifestations Colored halos seen around lights Rapid onset of elevated IOP (30 mm Hg or higher) Decreased or blurred vision Pupils nonreactive to light Severe pain and nausea Photophobia Glaucoma Treatment Priority intervention: medication therapy Prevent optic nerve damage Goal is to maintain normal IOP (10 to 21 mm Hg) Pharmacologic therapy, laser procedures, surgery, or a combination  Glaucoma Treatment- Medications Medications to reduce aqueous fluid production &/or increase aqueous fluid outflow, thereby reducing IOP Systemic &/or topical ocular medications to lower IOP Prostaglandin Analogs are the preferred first-line topical medications for chronic open-angle § Bimatoprost (lumigan) & Latanoprost (xalatan) § Carbonic anhydrase inhibitors (i.e. Acetazolamide (Diamox)) and hyperosmotic agents (i.e. Mannitol (Osmitrol)) are first line for acute angle-closure § Beta blockers (i.e. Timolol) decrease the production of aqueous humor which decreases IOP § Commonly used in addition to above meds for both types Surgical Management Laser trabeculoplasty Filtering surgery/trabeculectomy Drainage implants See following slides Figure 46.7 Laser trabeculoplasty A high-energy laser beam is used to open clogged drainage canals, allowing the aqueous humor to drain more easily from the eye Figure 46.8 Filtering surgery or trabeculectomy The surgeon uses specialized instruments and places an opening in the sclera of the patient, removing a small piece of the trabecular meshwork to allow for the aqueous humor to freely exit the eye Figure 46.9 Drainage implants The surgeon inserts a small silicone tube in the eye to help drain the aqueous humor Nursing Management—Nursing Diagnoses Disturbed visual sensory perception Anxiety Impaired home maintenance Increased intraocular pressure Visual field defects (peripheral vision) Nursing Interventions—A ssessments Physical assessment Diagnostic results- increased IOP & decreased visual acuity Age-related considerations Nursing Interventions—Actions Administer medications Follow proper procedure for eye drops (next slide) Elevate HOB(30-45) Avoid bending at the waist Administer stool softeners Nursing Interventions—Actions https://www.youtube.com/watch?v=OPysGXkdDho https://www.youtube.com/watch?v=--gB5FqWl_A Nursing Interventions—Teaching Progressive nature of disease Medication instructions Postoperative instructions When to notify provider( severe pain, purulent drainage, fever, abnormal swelling, further vision loss, bleeding ,sharp pain, floaters, experiencing nausea/ vomiting) Nursing Management—Evaluating Care Outcomes Minimize eye damage Promote eye health  Clouding of the lens Inadequate drainage or over production of Use the aqueous humor following Increased intraocular pressure Vision progressively blurs or clouds items to fill Damage to the optic nerve in the flow Progressive irreversible peripheral vision chart on loss Treated with surgical removal of opaque the next lens slide: Treated with eye drops, oral medications, &/or surgery  Glaucoma Vs. Cataracts Inadequate drainage or over production of aqueous humor Clouding of the lens Increased intraocular pressure Vision progressively blurs or Damage to the optic nerve clouds Progressive irreversible peripheral vision loss Treated with surgical removal of opaque lens Treated with eye drops, oral medications, &/or surgery Macular Degeneration (MD)  Macular Degeneration What is it? A deterioration of the macular area of the retina that causes irreversible central vision loss Often called age-related macular degeneration (AMD) Caused by impaired blood supply to the macula, which results in cellular waste accumulation & ischemia Leading cause of severe, irreversible vision loss in people over 60 years of age Central vision is generally the most affected, with most individuals retaining peripheral vision https://youtu.be/Sqr6LKIR2b8 Macula  Epidemiolo gy Middle-aged people have a 2% risk of developing macular degeneration risk increases to nearly 30% in individuals over age 75 Common cause of vision loss in older adults  Macular Degeneration Risk Factors Modifiable risk factors Hypertension High cholesterol Obesity Smoking Decrease in zinc blood levels Diet lacking carotene and vitamin E  Macular Degeneration Risk Factors Nonmodifiable risk factors Age Family history of macular degeneration Sex Race  Macular Degeneration Two types: Dry and Wet Dry macular degeneration (most common) Light-sensitive cells in macula break down causing drusen (yellow deposits beneath the retina) Can turn into wet macular degeneration 3 phases  Macular Degeneration Wet macular degeneration (less common, but more serious/advanced) Vascular endothelial growth factor (VEGF) promotes the new growth of blood vessels beneath the retina that have thin walls that leak blood & fluid The blood & fluid raise the macula from its usual position at the back of the eye causing rapid damage to the macula Dry macular degeneration is present before developing wet for most patients with wet macular degeneration About 1-in-10 people who suffer from dry MD will eventually develop wet MD  Clinical Manifestations Straight lines that appear distorted/wavy (metamorphopsia) Often an early symptom Dark, blurry areas or whiteout on center vision Bind spots (scotomas) Absent or distorted central vision Diminished or changed color perception Clinical Manifestations Clinical Manifestations Associated with MD Type Dry MD : Gradual blurring of central vision Patient may have difficulty recognizing faces As the condition worsens, there is gradual loss of central vision Wet MD : Wet macular degeneration usually causes a quick loss of central vision Medical Management—Diagnosis Comprehensive eye examination Pupil dilation better assessment of the back of the eye Tonometry exam measures IOP Amsler grid (next slide) Fluorescein angiogram used to confirm wet MD  Medical Management—Diagnosis One of the earliest Amsler Grid symptoms of this disease is that straight lines begin to appear wavy  Medical Management—Treatment Dry MD: High-dose formulation of antioxidant & zinc (vitamin C, vitamin E, beta-carotene, zinc, copper) Nutritional recommendations- EBP table pg 1090 Vitamins A,C,E Omega-3s Zinc & copper avoid foods high in saturated fat and trans fat, fried foods, animal based foods, butter, salt  Medical Management—Treatm ent Wet MD: Laser surgery high-energy light beam destroys the fragile, leaky blood vessels accumulating behind the macula Medical Management—Treatment Wet MD: Photodynamic therapy (PDT) Light activated medication called Vertepforin (visudyne) given IVP A light is shined into the patient’s eye to activate the medication which destroys new blood vessels Injections into the eye Anti-VEGF Therapy Nursing Management—Assessment and Analysis Early detection to decrease progressive decrease in vision Vital signs(not a whole lot of change, but could potentially see high BP) Physical assessment Visual acuity Nursing Interventions—Actions Safety precautions Provider follow-up Education Community resource referrals place objects to the side bc of central vision loss so they can see them and for people with glaucoma place objects in the middle bc of peripheral vision loss pain, position, potty, personal items, pathway(5 p’s Nursing Management—Evaluating Care Outcomes No complete cure goal is to preserve vision Slowed progression of symptoms  Impaired blood supply to the macula leading to ischemia Use the (VEGF) promotes the new growth of blood vessels beneath the retina which leak blood & fluid following Treated with nutritional supplements (AREDs) and nutritional recommendations items to fill Light-sensitive cells in macula break down causing in the flow drusen (yellow deposits beneath the retina) Gradual loss of central vision charts on the Rapid loss of central vision next slide: Treated with laser surgery, PDT, or anti-VEGF therapy Macular Degeneration Dry vs Wet Flow Charts Impaired blood supply to the macula (VEGF) promotes the new growth of leading to ischemia blood vessels beneath the retina which leak blood & fluid Light-sensitive cells in macula break Rapid loss of central vision down causing drusen (yellow deposits beneath the retina) Gradual loss of central vision Treated with laser surgery, PDT, or anti-VEGF therapy Treated with nutritional supplements (AREDs) and nutritional recommendations Ménière’s Disease  Ménière’s Disease What is it? Disorder of the inner ear that affects balance & hearing Characterized by: Episodic vertigo Tinnitus (ringing in the ears), usually unilateral Fluctuating unilateral sensorineural hearing loss Quick review of inner ear function: https://www.youtube.com/watch?v=WeQluId1hnQ A&P Review of the Vestibular System Ménière’s Disease Patho Exact cause unknown Correlations: occurs most often with infections, during periods of high stress, traumatic injury, allergens Excess endolymphatic fluid (lymph fluid within the ear) in the inner canals of the ear Causes an obstruction of the inner canal system Can lead to distention of the labyrinth Ménière’s Disease Patho  Ménière’s Disease Epidemiology 615,000 people in US White or of European descent are affected most often Females more often than males Peak age range is between 40 & 60 years Ménière’s Disease Risk Factors Head injury Middle ear infection Syphilis Allergies Alcohol abuse Fatigue Respiratory infection History of recent viral illness Smoking Certain medications  Ménière’s Disease Clinical Manifestations Vertigo * Tinnitus * Unilateral & sometimes bilateral hearing loss* Nausea and vomiting Sweating Increase in symptoms with sudden movements Diarrhea Headaches Abdominal pain Uncontrollable eye movements Ménière’s Disease Medical Management—Treatmen t Symptomatic relief Medications (table 48.13): Benzodiazepines Antihistamines/antiemetic Anticholinergics/antiemetic Phenothiazines/antiemetic Loop diuretics Ménière’s Disease Medical Management—Treatment Low-sodium diet Avoiding sudden movements Avoiding bright lights Ensuring at least 8 hours of sleep per night Acupuncture Regular daily exercise Limit caffeine & alcoholic beverage intake Ménière’s Disease Surgical Management Indicated for frequent & incapacitating attacks Helps control vertigo Decompression of the endolymphatic sac and shunting Vestibular nerve transection (cutting the nerve) if decompression unsuccessful Labyrinthectomy (removal of part of the inner ear) Typically causes complete hearing loss Surgical injection of gentamicin(destroys the cells that are registering the vertigo and could have hearing loss as a side effect) through the tympanic membrane, directly into the middle ear Ménière’s Disease Nursing Management—Assessment & Analysis-Table 48.14 Ménière’s Disease Nursing Management—Assessment & Analysis- Table 48.14 Ménière’s Disease Nursing Management—Nursing Diagnoses Disturbed sensory perception Risk for injury/falls Ineffective coping Ménière’s Disease Nursing Interventions—Assessments Vital signs( shouldn’t cause vital signs changes) Positive Romberg’s test(close eyes and stand for 1 minute and if you sway it’s positive) Caloric test Magnetic resonance imaging (MRI)/computed tomography (CT) Ménière’s Disease Nursing Interventions—Actions Medications Limit sodium intake Positioning of patient Safety measures Collaboration with neurology Acupuncture Ménière’s Disease Nursing Interventions—Teaching Disease process Pre- and post-testing instructions Medications Safety information Follow-up care Ménière’s Disease Nursing Management—Evaluating Care Outcomes Control clinical manifestations Medications Patient teaching Follow-up care Questions ?  Helpful Resources https://www.aao.org/eye-health/anatomy/parts-of-eye - eye anatomy https://www.youtube.com/watch?v=D-kVWke0CD0 - Dr. Mike eye anatomy review 17 min https://www.youtube.com/watch?v=o0DYP-u1rNM - Vision A&P – 9mins https://www.cdc.gov/conjunctivitis/treatment/index.html - CDC Conjunctivitis treatment https://www.youtube.com/watch?v=FgKT78nOifE - Sarah's story living with glaucoma https://www.youtube.com/watch?v=y11zunRI9Q4 - Amanda's story living with glaucoma https://www.youtube.com/watch?v=hYBvVx1evPI- Janette's story living with glaucoma https://www.youtube.com/watch?v=IhEoxXB0YGY Emma's story living with glaucoma Helpful Resources https://www.youtube.com/watch?v=uF5Nlbu5cvs - What is glaucoma? https://www.youtube.com/watch?v=40eE6LY3Ss0 - What is glaucoma? *** https://www.youtube.com/watch?v=TgjdPgSxeYg - What is glaucoma? https://www.youtube.com/watch?v=lTTEmz-DxxE - AREDS for macular degeneration https://www.youtube.com/watch?v=4YVfa1JFhu0 - Understanding Ménière’s Disease Helpful Resources https://www.youtube.com/watch?v=9hsaw-BzG9c - Ménière’s Disease https://www.youtube.com/watch?v=YMIMvBa8XGs - inner ear functions and balance https://www.youtube.com/watch?v=WOgI5lAR_bQ - ear review https://www.youtube.com/watch?v=98-6WfdumZY - ear review Khan Academy - start at 4.5mins for the cochlea https://www.youtube.com/watch?v=Vghek9Bm42w - inner ear labyrinth ** https://www.osmosis.org/learn/Meniere_disease:_Nursing - Osmosis on Meniere's Disease** https://www.youtube.com/watch?v=Kgewv_9nV2M - living with Meniere's Disease https://www.youtube.com/watch?v=dEDZ6WThVPU - living with Meniere's Disease