Week 2 Lecture - NUR 326 Skin, Sensory & Pain PDF

WEEK 2 LECTURE NUR 326 Skin, Sensory & Pain  Chapter 55: Assessment of Integumentary Function Skin L ar gest o r gan o f t h e bo dy Fu n ct i o n s: - P r ot e c t i o n - Se n sat i o n - Fl u i d Bal anc e - Tempe r at u r e Re gul at i o n Assessment of th...

WEEK 2 LECTURE NUR 326 Skin, Sensory & Pain  Chapter 55: Assessment of Integumentary Function Skin L ar gest o r gan o f t h e bo dy Fu n ct i o n s: - P r ot e c t i o n - Se n sat i o n - Fl u i d Bal anc e - Tempe r at u r e Re gul at i o n Assessment of the Skin Preparation of the Patient: - Explain the Purpose - Provide Privacy and Covering Subjective Survey (Asking Appropriate Questions) Inspect the Entire Body Photographs can be used to Document - Must Ask Patient  Nails - Confi guration - Color Assessmen - Consistency t of the Nails and Hair Hair - Color - Texture - Distribution Normal Aging Changes Thinning of skin Uneven pigmentation Wrinkling, skin folds, and decreased elasticity Dry skin Diminished hair Increased fragility and increased potential for injury Reduced healing ability Skin Appearance Erythema Rash Cyanosis Pruritus: Jaundice itching  Skin biopsy Patch testing Diagnostic Skin scrapings Procedures Tzanck smear Wood light examination  Chapter 56: Management of Patients with Dermatological Disorders  Care of Patients with Skin Conditions Goals of therapy are to prevent additional damage, prevent secondary infection, reverse infl ammatory processes, and relieve symptoms Nursing management includes obtaining a health history, direct observation, complete physical assessment and educating on self-care Nursing care includes administration of topical and systemic medications, wound care and dressings, and providing for patient hygiene Pruritis Most common symptom of dermatologic disorders May be fi rst indication of internal disease: diabetes, blood disorder, cancer Causes: - Medications: aspirin, antibiotics, hormones, opioids - Soaps and chemicals, radiation therapy, prickly heat - Psychological factors Care for the Patient with Pruritis Re i n fo r ce pr e scr i be d t h e r ape ut i c r e gi me n Educ at e o n se l f- car e U se t e pi d wat e r fo r bat h Avo i d r u bbi n g vi go r o u sl y wi t h t o we l L ubr i cat e ski n aft e r bat hi n g Avo i d si t u at i o n s t hat cau se vaso di l at i o n - Ove r l y war m e n vi r o n me n t - I n ge st i o n o f al co h o l , h o t fo o ds, an d l i qu i ds Psoriasis A chronic, noninfectious infl ammatory disease of the skin in which epidermal cells are produced at an abnormally rapid rate Aff ects about 2% of the population Primarily those of European ancestry Improves and recurs; a life-long condition May be aggravated by stress, trauma, and seasonal and hormonal changes Psoriasis Clinical Manifestations - Raised, red patches of skin - Silvery scales - Bleeding - Scalp, elbows, knees, lower back, genitals - Bilateral symmetry - M ay i nv ol v e the na i l s Tr e a t m e n t - Baths to remove scales - Medications Nursing Interventions Patient teaching regarding the disease Measures to prevent skin injury - I n st r u ct cl i e n t t o ke e p fi nge r nai l s t r i mme d t o l o w r i sk o f bl e e di ng Measures to prevent skin dryness - Bat h i n g i s o kay, bu t no t t o o h o t - L u br i can t s / l o t i o n s ar e r e c o mme n de d Use of the therapeutic relationship for support and to aid coping Infectious Diseases of the Skin Bacterial infections - I m p e t i g o – s u p e r fi c i a l , y e l l o w i s h , h i g h l y contagious - Fo l l i c u l i t i s – s h a v i n g - Fu r u n c l e s – d e e p f o r m o f f o l l i c u l i t i s ( b o i l ) - Carbuncles – worsening furuncles (abscess) Vi r a l i n f e c t i o n s - Herpes zoster – shingles, occurs later in life - Herpes simplex – type 1 mouth, type 2 genital Infectious Diseases of the Skin Fu n g a l i n f e c t i o n s - Tinea Pedis – foot - Tinea Corporis – on body - Tinea Capitis – head - Tinea Cruris – groin - Tinea Unguium – nails Herpes Zoster (Shingles) Patient Teaching—Bacterial Infections I mpe t i go i s co n t agi o u s an d may spr e ad t o o t he r par t s o f a pat i e n t ’s bo dy o r t o o t h e r pe r so n s Pat i e n t Te ach i ng: - A n t i bi o t i cs - H ygi e n e - Ski n an d l e si o n car e D o no t sh ar e t o we l s an d co mbs Bat h e dai l y wi t h an t i bact e r i al so ap Fu r un cl e s, bo i l s, o r pi mpl e s sho u l d n e ve r be squ e e z e d Patient Teaching—Viral Infections Herpes Zoster - Provide instruction regarding prescribed antiviral medications - Assess if family members have infection as well - Dressings - Hand Hygiene Herpes simplex - Provide instruction regarding prescribed use of antiviral and prophylactic medications - Information about the spread of herpes - Measures to reduce contagion of partner Patient Teaching—Fungal Infections Instruction regarding medications, use of oral and topical agents, and shampoos Instructions regarding hygiene – use new washcloth daily Do not share towels, combs, etc. Ke e p s k i n f o l d s a n d f e e t d r y We a r c l e a n , d r y, c o t t o n c l o t h i n g Av o i d e x c e s s i v e h e a t a n d h u m i d i t y Hair loss associated with tinea capitus - temporary Parasitic Skin Infestations Pediculosis - lice - Aff ect people of all ages - Feed on human blood - Inject their digestive juices and excrement into the skin - Pediculosis capitus - Pediculosis corporus - Phthirius pubis Parasitic Skin Infestations Scabies - 4 weeks from point of contact to fi rst sign and symptom - Burrows appear - Between fi ngers and on the wrists - Increased itching at night Patient Teaching—Pediculosis Capitis H e a d l i c e m ay i n f e s t a n y o n e a n d a r e n o t a s i g n o f u n c l e a n l i n e s s P r o v i d e i n s t r u c t i o n i n u s e o f s h a m p o o a n d c o m b i n g o f h a i r w i t h fi n e - t o o t h c o m b dipped in vinegar to remove all nits (eggs) A l l a r t i c l e s o f c l o t h i n g a n d b e d d i n g m u s t b e d i s i n f e c t e d , w a s h e d i n h o t w a t e r, o r dry cleaned Fu r n i t u r e a n d fl o o r s s h o u l d b e f r e q u e n t l y v a c u u m e d Do not share combs, hats, etc. All family members and close contacts must be treated Patient Teaching—Pediculosis Corporis and Pubis Pediculosis corporis is a disease related to poor hygiene and occurs in those who live in close quarters P e d i c u l o s i s p u b i s i s c o m m o n a n d s p r e a d c h i e fl y b y s e x u a l c o n t a c t Bathe in soap and water; apply prescription scabicide or an OTC permethrin, s u c h a s N I X ; m e c h a n i c a l l y r e m o v e a n y n i t s ; i f e y e l a s h e s a r e i n v o l v e d , Va s e l i n e m ay b e a p p l i e d t w i c e a d ay f o r 8 d ay s All family members and sexual contacts must be treated and instructed regarding personal hygiene All clothing and bedding must be washed in hot water or dry cleaned Pa t i e n t a n d p a r t n e r s h o u l d b e s c h e d u l e d f o r a m e d i c a l c h e c k u p t o a s s e s s f o r coexisting sexually transmitted disease Patient Teaching—Scabies M i t e s f r e q u e n t l y i n v o l v e fi n g e r s a n d h a n d s C o n t a c t m ay s p r e a d i n f e c t i o n ; Health care personnel should wear gloves when providing care until infection is ruled out Instruct patient on treatment Wa s h c l o t h i n g a n d b e d d i n g i n h o t w a t e r a n d d r y i n a h o t d r y e r Tr e a t a l l c o n t a c t s a t t h e s a m e t i m e P r u r i t u s m ay c o n t i n u e f o r s e v e r a l w e e k s a n d d o e s n o t m e a n r e t r e a t m e n t i s required  Pathophysiology of Pressure Injuries Localized area of necrotic soft tissue Occurs when pressure applied to the skin is greater than the normal capillary closure pressure Over a period of time s u ffi c i e n t e n o u g h t o c a u s e tissue injury Assessment of Risk Factors for Pressure Injuries Evaluate level of mobility Assess neurovascular status Evaluate circulatory status Evaluate nutritional and hydration status Review the results of the patient’s laboratory studies Determine presence of incontinence Review current medications Assessment of Skin for the Patient with Pressure Injury Assess total skin condition at least twice a day Inspect each pressure site for erythema Assess areas of erythema for blanching response Palpate the skin for increased warmth Inspect for dry skin, moist skin, and breaks in skin Note drainage and odor Nursing Interventions for the Patient with Pressure Injury Relieving pressure Positioning the patient Using pressure-relieving devices Improving: mobility, sensory perception, tissue perfusion Improving nutritional status Reducing friction and shear Minimizing irritating moisture Toxic Epidermal Necrolysis Stevens-Johnson Syndrome Potentially fatal skin disorders 30-35% mortality rate Caused by a reaction to medications (anti-seizures, NSAIDs, sulfa drugs) - Burning and itching of eyes - Fev er - Cough/sore throat - Headache - Extreme malaise/myalgias Toxic Epidermal Necrolysis & Stevens-Johnson Syndrome Medical Management Fluid and electrolyte balance Prevention of infection/sepsis Prevention of complications with the eyes (conjunctivitis) D/C all nonessential medications C l i ent m ay l o o s e 1 0 0 % o f t he i r s k i n ( ri s k f o r i nf e c t i o n) Tr e a t l i k e a b u r n p a t i e n t - Dehydration - Pa i n - Infection Toxic Epidermal Necrolysis & Stevens-Johnson Syndrome Nursing Interventions - Maintain skin integrity - Careful oral hygiene - Monitor fl uid balance - Prevent hypothermia - Pain relief - Monitor for s/s of infection  Section of skin is transferred to a diff erent site Most common form of reconstructive surgery Autograft – own skin Skin Grafts Allograft – donor from same species Xenograft – donor from diff erent species Split thickness – thin layer, some dermis Full thickness – includes all dermis  Selection Criteria Skin Graft - Closest possible color match Donor - Texture and hair-bearing qualities - Thickness of skin graft Sites - Cosmetic issues COMMON DONOR GRAFT SITES Skin Graft Recipient Site Adequate blood supply Close contact Firmly fi xed in place Free of infection *So what are some assessments are will be worried about for a patient with a skin graft? Skin Grafts Nursing Interventions - Promote immobilization (depending on the order from physician) - Elevate extremity - Monitor drainage - Apply lotions as ordered - Avoid heating pads  Chapter 57 Management of Patient with Burn Injuries Burn Injuries A ppr o x i mat e l y 4 8 6 ,0 0 0 pe o pl e r e qu i r e me di cal at t e n t i o n fo r bu r ns e ve r y ye ar 4 ,5 0 0 pe r so n s di e o f bu r n s an d asso ci at e d i nh al at i o n i nj u r i e s e ve r y ye ar. Mo st bu r ns o ccu r i n t h e h o me. Yo un g ch i l dr e n , t h e e l de r l y, and t he so ci o e co n o mi c al l y di sadvan t age d ar e at h i ghe st r i sk fo r bu r n i nj u r i e s. 7 t h l e adi ng c au se o f de at h N ur se s must pl ay an act i ve r o l e i n t h e pr e ve n t i o n o f bu r n i nj ur i e s by e duc at i o n r e gar di n g pr e ve n t i o n co n ce pt s an d pr o mo t i n g safe t y l e gi sl at i o n  Prevention Institution of lifesaving measures for the severely burned person Goals of Prevention of disability and disfi gurement through early specialized Burn Care and individualized care Rehabilitation through reconstructive surgery and rehabilitation programs Classifi cation s of Burns F i r s t D e g r e e : s u p e r fi c i a l i n j u r i e s tha t i nv ol v e t he outerm os t l ay er of skin (sun burn) Second Degree: involve the entire dermis and varying portions of the dermis (blisters) Third Degree: total destruction of the epidermis, dermis, and underlying tissue (full thickness) Electrical Burns Entrance wound and exit wound Electricity destroys everything in its path Contracts muscles as it travels through the body (risk for Rhabdomyolysis) Cardiac dysrhythmias Spinal Injuries – usually from fall Can cause lifelong neurovascular problems Calculating Total Body Surface Area (TBSA) Ru l e o f N i n e s - Mo st co mmo n - Base d o n an at o mi c r e gi o ns L un d an d Br o wde r me t ho d - Re co gn i z es % o f TBSA o f var i o u s an at o mi c par t s Pal me r me t h o d - U se d t o e st i mat e e x t e n t o f scat t e r e d bu r ns - Si z e o f pat i e n t ’s h an d, i n cl u di n g fi n ge r s i s 1 % TBSA Rule of Nines Lund and Browder Palmer Method  Pathophysiolog y Burns are caused by: - Chemical injury Thermal such as electrical or fi re Radiation  ZONES OF BURN INJURY Pathophysiology: Large Burns Larger than 30% will produce local AND systemic responses This releases cytokines and will cause edema This fl uid shift will result in a state of shock ultimately resulting in hypoperfusion and organ hypofunction Physiologic Changes Burns less than 25% TBSA produce a primarily local response. Burns more than 25% may produce a local and systemic response and are considered major burns. Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction.  Fluid and electrolyte shifts Cardiovascular eff ects Pulmonary injury Eff ects of - Upper airway - Lower airway Major - Carbon monoxide poisoning - Restrictive defects Burns Renal and GI alterations Immunologic alterations Eff ect on thermoregulation  Phases of Burns Emergent or resuscitative phase - Onset of injury to completion of fl uid resuscitation Acute or intermediate phase - From beginning of diuresis to wound closure Rehabilitation phase - From wound closure to return to optimal physical and psychosocial adjustment Emergent/Resuscitative Phase—On-the-Scene Care Prevent injury to rescuer S t o p i n j u r y : e x t i n g u i s h fl a m e s , c o o l t h e b u r n , i r r i g a t e c h e m i c a l b u r n s A B C s : e s t a b l i s h a i r w ay, b r e a t h i n g , a n d c i r c u l a t i o n Start oxygen and large-bore IVs Remove restrictive objects and cover the wound Do assessment surveying all body systems and obtain a history of the incident and pertinent patient history N o t e : Tr e a t p a t i e n t w i t h f a l l s a n d e l e c t r i c a l i n j u r i e s a s f o r p o t e n t i a l c e r v i c a l spine injury Emergent/Resuscitative Phase Pa t i e n t i s t r a n s p o r t e d t o e m e r g e n c y d e p a r t m e n t Fluid resuscitation is begun Fo l e y c a t h e t e r i s i n s e r t e d Pa t i e n t w i t h b u r n s e x c e e d i n g 2 0 % t o 2 5 % s h o u l d h a v e a n N G t u b e i n s e r t e d a n d p l a c e d to suction Pa t i e n t i s s t a b i l i z e d a n d c o n d i t i o n i s c o n t i n u a l l y m o n i t o r e d Pa t i e n t s w i t h e l e c t r i c a l b u r n s s h o u l d h a v e E C G Address pain; only IV medication should be administered Ps y c h o s o c i a l c o n s i d e r a t i o n a n d e m o t i o n a l s u p p o r t s h o u l d b e g i v e n t o p a t i e n t a n d family Nursing Management of the Patient during the Emergent/Resuscitative Phase of Burn Injury ABC Vital signs and hemodynamic status Monitor for fl uid volume defi cit Assess extent of the burn Potential Complications during the Emergent/Resuscitative Phase of Burn Injury Acute respiratory failure Distributive shock Acute kidney injury Compartment syndrome Paralytic ileus Acute/Intermediate Phase 48 to 72 hours after injury Continue assessment and maintain respiratory and circulatory support, fl uid and electrolyte balance, GI and renal function Prevention of infection, burn wound care, pain management, modulation of the hypermetabolic response, and early positioning/mobility  R e s t o r i n g fl u i d b a l a n c e Preventing infection Nursing Modulating hypermetabolism Management Promoting skin integrity during the Relieving pain and discomfort Acute/Intermediate Promoting mobility Phase of Burn Strengthening coping strategies Injury Supporting patient and family processes Monitoring and managing complications Management of Shock Maintain blood pressure of greater than 100 mm Hg systolic and urine output of 30 to 50 mL/hr; maintain serum sodium at near- normal levels Consensus formula Evans formula Brooke Army formula Parkland Baxter formula Hypertonic saline formula  Wound cleaning - Hydrotherapy Burn Topical Agents - Bacitracin, Santyl, Dakins, Sulfamylon Wound Wound Debridement - Natural Care - Mechanical - Surgical Burn Grafting Allograft - self Autograft – cadaver Xenograft – animal Sheet graft Mesh graft Sheet vs Mesh Burn Pain Burn pain has been described as one of the most severe forms of acute pain Pain accompanies care and treatments such as wound cleaning and dressing changes Types of burn pain - Background or resting - Procedural - Breakthrough Pain Management A nal ge si cs - I V u se du r i n g e me r ge n t an d ac ut e ph ase s - Mo r phi n e - Fe n t an yl Ro l e o f an x i e t y i n pai n Eff e ct o f sl e e p de r i vat i o n o n pai n N o nph ar maco l o gi c me asur e s Nutritional Support Bu r n i n j u r i e s pr o du ce pr o fo u n d me t abo l i c abn o r mal i t i e s. Pat i e n t s wi t h bu r n s have gr e at n ut r i t i o n al ne e ds r e l at e d t o st r e ss r e spo n se , h ype r me t abo l i sm, an d wo un d h e al i n g. N ut r i t i o n al su ppo r t i s base d o n pat i e n t ’s pr e bu r n st at us an d % o f TBSA bu r n e d. En t e r al r o u t e i s pr e fe r r e d. J e j u nal fe e di n gs ar e fr e qu e n t l y u se d t o mai n t ai n n u t r i t i o nal st at u s wi t h l o we r r i sk o f aspi r at i o n i n a pat i e n t wi t h po o r appe t i t e , we akn e ss, o r o t h e r pr o bl e ms.  Chapter 58 Assessment and Management of Patients with Eye and Vision Disorders External Structures of the Eye EXTRAOCULAR MUSCLES  CROSS- SECTION OF THE EYE Impaired Vision Refractive errors - Can be corrected by lenses that focus light rays on the retina Emmetropia – normal vision Myopia – nearsighted Hyperopia – far sighted Astigmatism – both near and far sight are bad  20/400 on Snellen Eye Chart Absence of light perception “Legally” blind Causes Blindness - Diabetic retinopathy - Macular degeneration - Glaucoma - Cataracts  Nursing Management P r o m o t e c o p i n g e ff o r t s - Acceptance of permanence of blindness - Fe a r - Process through the stages of grieving Promote spatial orientation and mobility Blindness - Adapt to environment - Keep items within client’s reach - O r i e n t c l i e n t t o l o c a t i o n o f m e a l t r ay, e t c. - Knock on door when entering client’s room Promote home care –B r a i l l e –G u i d e d o g s Glaucoma A group of ocular conditions in which damage to the optic nerve is related to increased intraocular pressure (IOP) caused by congestion of the aqueous humor The leading cause of blindness in adults in the U.S Incidence increases with age Clinical Manifestations Eventual signifi cant loss of vision - Peripheral vision loss - Blurring halos - Diffi culty focusing - Diffi culty adjusting to low lighting Aching around the eyes HA Treatment Goal is to prevent further optic nerve damage M a i n t a i n I O P w i t h i n a r a n g e u n l i ke l y t o c a u s e d a m a g e Life-long therapy Medications - P i l o c a r p i n e – h e l p s fl u i d t o d r a i n - T i m o l o l – d e c r e a s e s p r o d u c t i o n o f fl u i d Surgery - To i n c r e a s e d r a i n a g e o f a q u e o u s h u m o r - Decreases IOP Nursing Management Focus on maintaining the therapeutic regimen for lifelong control of a chronic condition Emphasize the need for adherence to therapy and continued care to prevent further vision loss Provide education regarding use and eff ects of medications Nursing Management M e d i c a t i o n s u s e d f o r g l a u c o m a m ay c a u s e v i s i o n a l t e r a t i o n s a n d o t h e r s i d e e ff e c t s - Blurry vision - Night blindness - Redness and burning - S y s t e m i c e ff e c t s Te a c h p u n c t a l o c c l u s i o n – r e d u c e s y s t e m i c e ff e c t s ; a p p l y p r e s s u r e a t n o s e w h e n giving eye drops Provide support and interventions to aid the patient in adjusting to vision loss/potential vision loss Cataracts An opacity or cloudiness of the lens Leading cause of blindness in the world Increased incidence with aging By age 80, more than half of all Americans have cataracts A leading cause of disability in the U.S. Clinical Manifestations Painless, blurry vision Sensitivity to glare Reduced visual acuity Myopic shift – more nearsighted Astigmatism Diplopia Color shifts – more blue Decreased visual acuity Opacity of the lens Surgical Management If reduced vision does not interfere with normal activities, surgery is not needed Surgery is performed on an outpatient basis with local anesthesia Surgery usually takes less than 1 hour and patients are discharged soon afterward  Preoperative care Withhold anticoagulants (per MD order) Dilating eye drops Antibiotic eye drops Nursing A n t i - i n fl a m m a t o r y e y e d r o p s Postoperative care Eye drops Managemen When to call MD - Vision changes t - C o n t i n u o u s fl a s h i n g l i g h t s - Redness or swelling increases - Ty p e a n d a m o u n t o f d r a i n a g e i n c r e a s e s - S i g n i fi c a n t p a i n  Protective eye patch Eyeglasses Metal shield Washing of hands Nursing Cleaning of eye Shampoo hair cautiously Managemen Decrease intraocular pressure - Use stool softener daily (Colace) - Restrict activity t - Do not lift anything > 15 lbs - Av o i d b e n di n g - Av o i d c o u g h i n g - Av o i d l y i n g o n s i de o r s u p i n e p o s i t i o n Retinal Detachment Se par at i o n o f t h e se n so r y r e t i n a and t h e r e t i nal pi gme n t e pi t he l i u m (RP E) H o l e o r t e ar de ve l o ps i n t h e r e t i na L i qu i d se e ps t hr o u gh an d cause s t h e r e t i n a t o de t ac h C l i ni c al Man i fe st at i o n s - Se n sat i o n o f a sh ade o r cu r t ai n c o mi n g ac r o ss t h e vi si o n o f o n e e ye - Br i gh t fl ash i n g l i gh t s - Su dde n o nse t o f fl o at e r s (bl ack spo t s) Nursing Management Patient teaching - Eye surgery is most often done as an outpatient procedure, so patient education is vital - Te a c h t h e s i g n s a n d s y m p t o m s o f c o m p l i c a t i o n s , e s p e c i a l l y i n c r e a s e d I O P and infection Promote comfort Patient may need to lie in a special position with pneumatic retinopexy Retinal Detachment Nursing Management IOP Promoting comfort - Positioning; HOB up Pa t i e n t t e a c h i n g - Increased IOP - Cataracts - Fu r t h e r d e t a c h m e n t s Trauma Emergency treatment - Flush chemical injuries - Do not remove foreign objects - Protect using metal shield or paper cup Potential exists for sympathetic ophthalmia, causing blindness in the uninjured eye with some injuries Trauma Orbital trauma - Usually associated with head injury - Soft tissue injury and hemorrhage - Orbital fractures - Fo r e i g n b o d i e s Ocular trauma - Leading cause of blindness in the young - Chemical burn - Fo r e i g n o b j e c t  Keratoconjunctivitis Scratchy or foreign body sensation Dry Eye Inability to produce tears Itchiness Syndrome Artifi cial tears Eye ointment Conjunctivitis Mo st co mmo n o cu l ar di se ase i n t h e wor l d “pi n k e ye ” Fo r e i gn bo dy se n sat i o n Bu r n i n g, i t ch i n g P h o t o ph o bi a C an e asi l y spr e ad fr o m o n e e ye t o t h e o t h e r H i gh l y c o nt agi o u s t o o t he r s C an be cau se d by bact e r i a, vi r u se s, fu ngu s, an d par asi t e s Surgery Orbital surgeries Enucleation – removal of eye and part of optic nerve Evisceration – removal of all intraocular content Exenteration – removal of eye lids, eye, and content Ocular prostheses  Chapter 59 Assessment and Management of Patients With Hearing and Balance Disorders ANATOMY OF THE EAR ANATOMY OF THE INNER EAR WEBER TEST RINNE TEST Hearing Loss Ty p e s Conductive - Due to external middle ear problem Sensorineural - Due to damage to the cochlea or vestibulocochlear nerve Mixed - Both conductive and sensorineural Fu n c t i o n a l - Psychogenic - Due to emotional problem Clinical Manifestations Early symptoms - Tinnitus - D i ffi c u l t y h e a r i n g i n a g r o u p - Tu r n i n g u p t h e v o l u m e o n t h e T V I m p a i r m e n t m ay b e g r a d u a l a n d n o t r e c o g n i z e d b y t h e p e r s o n e x p e r i e n c i n g t h e loss As hearing loss increases Deterioration of speech Fa t i g u e I n d i ff e r e n c e Social isolation or withdrawal Guidelines for Communicating With the Hearing Impaired U se a l o w- t o n e , n o r mal vo i ce Spe ak sl o wl y an d di st i n ct l y Re du ce backgr o u n d n o i se an d di st r act i o n s Face t h e pe r so n an d ge t h i s at t e nt i o n Spe ak i n t o t h e l e ss- i mpai r e d e ar U se ge st u r e s an d fac i al e x pr e ssi o n s I f n e c e ssar y, wr i t e o ut t he i nfo r mat i o n o r use a si gn l an gu age t r an sl at o r Hearing Aids Keep track of them Have family members bring them in If you hear a whistling sound - Take the hearing aids out and reinsert them Cerumen Impaction Removal may be by irrigation, suction, or instrumentation Gentle irrigation should be used with lowest pressure, directing stream behind the obstruction - G l y c e r i n , m i n e r a l o i l , h a l f- s t r e n g t h H 2 O 2 o r p e r o x i d e i n g l y c e r y l m ay h e l p soften cerumen  Removal may be by irrigation, suction, or instrumentation Objects that may swell Foreign should not be irrigated Bodies Foreign-body removal can be dangerous and may require extraction in the operating room External Otitis I n fl a m m a t i o n i s m o s t c o m m o n l y d u e t o t h e b a c t e r i a s t a p h y l o c o c c u s o r p s e u d o m o n a s , o r t o fungal infection Manifestations - Pain and tenderness - Discharge - Edema - Erythema - Pruritus - Hearing loss - Fe e l i n g s o f f u l l n e s s i n t h e e a r Therapy is aimed at reducing discomfort, reducing edema, and treating the infection A w i c k m ay b e i n s e r t e d i n t o t h e c a n a l t o ke e p i t o p e n a n d t o f a c i l i t a t e m e d i c a t i o n administration Tympanic Membrane Perforation Infection or trauma Heals spontaneously Otorrhea – C SF leakage from ear Rhinorrhea – C SF leakage from nose Surgery Tympan o pl ast y - Can be cadaver if TM cannot be repaired Otitis Media Acute infection of the middle ear Lasts less than 6 weeks Clinical Manifestations - Otalgia – sensation of fullness (pain in ear) - Drainage from the ear - Fe v e r - Hearing loss Otitis Media Chronic - From recurrent acute otitis media - Irreversible damage - Can lead to mastoiditis (can spread to jaw) Clinical Manifestations - Hearing loss - Foul smelling otorrhea Middle Ear Surgical Procedures Tympanoplasty - Reconstruction of the tympanic membrane Ossiculoplasty - Reconstruction of the bones of the middle ear - Prostheses are used to reconnect the ossicles to reestablish sound conduction Mastoidectomy - Removal of diseased bone, mastoid air cells, and cholesteatoma to create a non-infected, healthy ear Middle Ear Surgery Nursing Interventions Reduce anxiety - Reinforce information and patient teaching - Provide support and allow patient to discuss anxieties Relieve pain - Medicate with analgesics for ear discomfort - O c c a s i o n a l s h a r p / s h o o t i n g p a i n s m ay o c c u r - C o n s t a n t t h r o b b i n g p a i n a n d f e v e r m ay i n d i c a t e i n f e c t i o n Prevent injury - Implement safety measures such as assisting with ambulation - Provide antiemetics or antivertigo medications Improve communication and hearing - H e a r i n g m ay b e r e d u c e d f o r s e v e r a l w e e k s f o l l o w i n g s u r g e r y d u e t o e d e m a , a c c u m u l a t i o n o f b l o o d a n d fl u i d i n t h e m i d d l e e a r, a n d d r e s s i n g s a n d p a c k i n g s Motion Sickness D i st ur ban ce o f e qu i l i br i u m c au se d by mo t i o n C l i ni c al Man i fe st at i o n s - Swe at i ng - Pal l o r - N/V Manage me nt - D r amami n e , A nt i ve r t - G i n ge r  Ménière’s Disease A b n o r m a l i n n e r e a r fl u i d b a l a n c e Clinical Manifestations - Fluctuating, progressive hearing loss - Tinnitus - Fe e l i n g o f p r e s s u r e o r f u l l n e s s - Episodic, incapacitating v erti g o t hat m ay b e ac c om p ani ed by nausea and vomiting Ménière’s Disease Treatment - Low-sodium diet, 2000 mg a day - Meclizine (Antivert), tranquilizers, antiemetics, and diuretics - Surgical management to eliminate attacks of vertigo Other Inner Ear Conditions Tinnitus - Ringing in the ear Vertigo - The illusion of motion or a spinning sensation Ototoxicity - Usually caused by medications - Can result in irreversible hearing loss  Chapter 9 Pain Management Pain Concept Defi ned as “unpleasant sensory, emotional experience with actual or potential tissue damage” Personal and subjective experience Patient is the most reliable indicator of pain and essential component of pain assessment Most common reason for seeking health care Types of Pain A c u t e p a i n : D i ff e r s f r o m c h r o n i c b y d u r a t i o n Result of tissue damage; surgery; trauma Chronic pain: Can be time limited or last a lifetime Cancer N o n c a n c e r : p e r i p h e r a l n e u r o p a t h y, b a c k p a i n , o s t e o a r t h r i t i s Breakthrough pain: chronic pain with acute exacerbations Classifi cation of Pain Nociceptive (physiologic) pain - Tissue injury Neuropathic (pathophysiologic) pain - Damage to the peripheral or central nervous system Neuropathic Pain Results from damage or dysfunction of the peripheral or central nervous system May occur in the absence of tissue damage and infl ammation Peripheral mechanisms Central mechanisms Components of Pain Assessment Se l f- r e po r t L o cat i o n I n t e nsi t y Qu al i t y On se t an d du r at i o n A ggr avat i n g an d r e l i e vi n g fact o r s Eff e ct s o n fu n ct i o n an d qu al i t y o f l i fe C o mfo r t – fu n ct i o n go al Assessing Intensity—Pain Scales Numeric Rating Scale (NRS) Wong–Baker FACES Verbal descriptor scale (VDS) Visual Analog Scale (VAS) Assessing Pain for Specifi c Populations The Hierarchy of Pain Measures—nonverbal patient FLACC—young children PAINAD—patients with advanced dementia CPOT—patients in critical care units Pain Management Eff ective and safe analgesia Optimal relief Comfort function goal Responsibility of all members of the health care team Pharmacologic: multimodal Routes and dosing Patient-controlled analgesia (PCA) Pharmacologic Interventions Opioid analgesics act on the CNS to inhibit activity of ascending nociceptive pathways NSAIDs decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin) Local anesthetics block nerve conduction when applied to nerve fi bers Analgesic Agents Nonopioid - Acetaminophen - NSAIDs: ibuprofen, naproxen, celecoxib Opioid - Mu agonist: Morphine, hydromorphone, fentanyl, oxycodone - Agonist–antagonist: buprenorphine, nalbuphine, butorphanol Adjunctive Analgesics L o cal ane st h e t i cs - L i do cai n e pat ch 5 % A nt i c o n vu l san t s - G abape n t i n , pr e gabal i n A nt i de pr e ssan t s - TC A s: de si pr ami ne , n o r t r i pt yl i n e - SN RI s: du l o x e t i n e , ve n l afax i n e Ke t ami n e Opioid Physical Dependence and Tolerance Physical dependence: - Normal response with opioid use of 2 weeks or more - Manifested by withdrawal symptoms Tolerance: - Normal response with regular use of opioid - Decrease in one or more of the eff ects - Increased usage needed to eff ect pain relief Gerontologic Considerations Sensitive to agents that produce sedation and CNS eff ects Initiate with low dose and titrate slowly Increased risk for NSAID-induced GI toxicity Acetaminophen preferred for mild pain Opioid dose should be reduced 25% to 50% Natural products - Herbs, botanicals, vitamins, probiotics Mind and body practices - Acupuncture, chiropractic manipulation, massage therapy, yoga, tai chi Nonpharmacologic Methods Nursing Process Framework for Pain Management Identify goals for pain management Establish nurse–patient relationship, teaching Provide physical care Manage anxiety related to pain Evaluate pain management strategies Adverse Eff ects of Analgesic Agents Respiratory depression Sedation Nausea, vomiting Constipation Pruritis Care of Patients with Pain Requires a collaborative approach Must be evidence-based and comprehensive