Lecture 8 Sensory - Porterville College

Report
Sensory System
Chapter 40
Eye abbreviations:
• Left eye
– OS
• Right eye
– OD
• Both eyes
– OU
• Drop/s
– gtt/ gtts
Conjunctivitis
• Inflammation of the
conjunctiva
• AKA
– “pink eye”
Conjunctivitis
• Caused by
– Bacteria
– Viral
• Spread by
– Direct contact
Conjunctivitis
• S&S (mild)
– Redness
– Itching
• pruritus
– Tearing
– Discharge
Conjunctivitis
• Dx
– History
– Visual examination
– “conjunctival scraping”
• Culture
Conjunctivitis
• Rx
– Antibiotics
• Topical
Nursing assessment
•
•
•
•
•
Symptoms
Effects on vision
Associate symptoms
Date of last eye exam
Corrective lenses???
Nursing Assessment
• Past medical history
• Test vision
– Snellen eye chart
– Rosenbaum chart
Snellen Eye chart
Rosenbaum chart
• Pic from book
Nursing Assessment
• Inspect eye
• Check pupil
– PERRLA
PERRLA
•
•
•
•
•
•
Pupils
Equal
Round
Reactive to
Light
Accommodation
Priority Nursing Diagnosis: Risk for
disturbed sensory perception (visual)
• Instruct to wash hands
• Instruct to avoid
touching or rubbing
eyes
• Emphasize proper
contact care
NRS DX: Acute pain
• Administer analgesics
routinely
• Patch both eyes PRN
• Teach to apply warm
compresses for 15
minutes, 3-4 x day
NRS DX: Acute pain
• Wear dark glasses
• Avoid excessive reading
NRS DX: Knowledge deficit
• Teach
– Hand washing
– Correct eye care
– Do not share
• Makeup
• Towels
• Contact lenses
– Do not use old makeup
– Cleaning techniques for
contacts
Eye trauma
• Common types of eye
injury
–
–
–
–
Foreign body
Abrasion
Laceration
Burn
Corneal Abrasion
• AKA
– Scratched cornea
Corneal Abrasion
• S&S
– Pain!
– Photophobia
– Tearing
Corneal Abrasion
• Prognosis
– Usually heal without
scarring
Burns
• Types of burns
– Chemical burns
– Thermal burns
– UV burns
Burns
• S&S
–
–
–
–
Pain
Affects vision
Swollen eyelids
Conjunctiva red &
edematous
• Slough
– Cornea cloudy or hazy
Perforated eye
• Examples of causes
– Metal flakes
– Glass shards
– Weapons
Perforated eye
• S&S
– Pain
– Partial or complete loss
of vision
– Bleeding
– Loss of eye contents
Blunt eye trauma
• Common cause
– Sports injuries
Blunt eye trauma
• Minor
– Ecchymosis (lid)
• AKA:
– Black eye
– Subconjunctival
hemorrhage
Eye trauma Assessment
• Eye exam
– Vision
– Movement
• Unless penetrating
objects
– Inspect
• Foreign objects
• Lacerations
Eye trauma treatment
• Topical anesthetic
– Before inspection
Eye trauma DX Test
• Fluorescein staining
– ID
• Foreign bodies
• Abrasions
• Can you find the
abrasion?
Eye trauma DX Test
• Ophthalmoscopic
examination
Eye trauma DX Test
• X-ray
• CT scan
– Orbital fx
– Foreign bodies
Eye trauma: Irrigate
• Small foreign bodies
– Irrigate
• sterile saline
• Chemical burns
– Irrigate
• Copious amounts of fluid
Eye trauma: Irrigate
• Procedure
– “from the inner canthus
of the eye to the outer”
– Head tipped slightly to
the affected side
NOTE!!!
• Immediately irrigate the
eye is a chemical burn is
suspected. Irrigation to
remove the chemical is
of higher priority than
assessment of the eye
Eye trauma TX
• Remove loose foreign
bodies
– Use a
• Moist
• Sterile
• Cotton-tipped applicator
Eye trauma TX
• Severe or penetrating
injury
– Bed rest
– Stabilize eye
• Apply eye pad
• Over both eyes
Eye trauma TX
• Post-care
– Eye-drops / ointment
– Eye pad/shield per order
– Avoid wearing contacts
until cornea has healed
completely
Nursing Care
• Teach to prevent eye
injuries!
– Eye protection
– Seat belts
• flush eye immediately if
chemicals splash
Nursing care
• If an abrasion or
penetrating or blunt
injury 
– Loosely cover with
sterile gauze
– Do not remove
penetrating objects
– Patch both eyes
Nursing Care: After injury
• Reinforce follow-up apt
• Discuss meds &
application
• Teach how to apply eye
patch
• Do not rub or scratch
the eye
Nursing Care: After injury
• Teach to avoid activities
that h intraocular
pressure
– Lifting
– Straining
– Bending over
Small Group Questions
1. Define the following abbreviations: OS, OD, UO,
gtts
2. Describe conjunctivitis, how would you assess
for it?
3. What is the common treatment for
conjunctivitis?
4. You are fishing with a young child and the line
breaks and the fish hook flies into their eye.
What would you do?
5. After the hook is removed, what instructions
should be given to the child?
Cataracts
• Clouding of the lens 
impaired vision
– Common
– >65
– Affects both eyes
Cataracts
•
•
•
•
Age 
Cells become less clear
Affects edges first 
Spreads towards center
Cataracts
• Affects
– Near vision
– Far vision
• Details obscured
• Glare
– light / dark
• Pupils appear
– cloudy gray / white
Cataracts
• Risk factors
– Age
• Senile cataracts
– Sunlight
– Cigarette smoke
– Heavy alcohol
consumption
– Eye trauma
– Diabetes mellitus
Cataracts: Dx
• History
• Eye examination
Cataracts: Tx
• Surgical removal
• Clouded lens removed
• Intraocular lens is
implanted
Nursing Care: Eye surgery
• Pre-op
– Assess understand of
procedure
– Assess vision of
unaffected eye
– Reinforce post-op
teaching
– Remove all eye make-up
– Admin. Pre-op meds per
order
Nursing Care: Eye surgery
• Post-op
– Assess
•
•
•
•
V/S
LOC
Comfort
Status of eye dressing
– Maintain eye patch /
shield per order
– Position
• Semi-Fowlers
• Fowlers
Nursing Care: Eye surgery
• Approach client on
unaffected side
• Intervene PRN to prevent
–
–
–
–
Vomiting
Straining
Coughing
Sneezing
• Immediately report
sudden / sharp pain to
MD
Nursing Care: Eye surgery
• S&S to report to MD
–
–
–
–
–
–
Redness or cloudiness
Drainage
i vision
Floaters
Flashes
Halos
Nursing Care: Eye surgery
• Personal items & call
light within reach
• Admin eye-drops and
meds per order
• Arrange or referals
Nursing Care: Eye surgery
• Teach
–
–
–
–
–
How to instill eye-drops
How to apply eye patch
Avoid rubbing
Wear sun glasses
Make & keep apt.
Glaucoma
• Increased intraocular
pressure 
– Gradual vision loss
• Vision loss is permanent
Chronic Glaucoma: S&S
• Painless
• Difficulty adapting light
to dark
• Blurred vision
• Halos
• Difficulty focusing on
near objects
Acute glaucoma: S&S
•
•
•
•
Severe eye PAIN
N&V
Halos
Red eye, cornea
clouded
• Pupil
– Dilated
– Fixed
Clinical Alert!
• Acute glaucoma is a medical emergency.
Without prompt treatment the affected
eye will become blind. Immediately
report manifestations of acute glaucoma
to the charge nurse or MD
Glaucoma: Dx
• Tonometry
– Measures intraocular
pressure
• Visual field testing
– Checks peripheral vision
Glaucoma: Rx
• Meds to i intraocular
pressure
Memory alert
• Mydriatics (drugs that dilate pupils) must
be avoided with glaucoma.
Nursing Care: health promotion
• Early screening
– >40
• q 2-4 years
– > 60
• q 1 – 2 years
Nursing Assessment
•
•
•
•
Risk factors
Ask about vision
Family Hx
Inspect eye
Nursing Assessment
• Assess vision
• Assess pupils
NRS DX: Risk for injury
• Assess ability to provide
self care
• Alert others not to
move items in room
Application of Eye drops
• Use aseptic technique
• Have clients sit upright or lie supine with the
head tilted slightly up
• Rest hand on the client’s forehead, hold the
dropper 1 to 2 cm above his conjunctival sac and
instill the medication into the center of the sac.
Then instruct the client to close his eye gently.
• Apply gentle pressure with your finger and a
clean tissue on the nasolacrimal duct for 30 to 60
seconds
Small Group Questions
1. Differentiate between cataracts and glaucoma
2. What is the common treatment for cataracts?
3. What would you teach a patient who had/ was
having cataracts surgery?
4. What is the common treatment for glaucoma?
5. What is the prognosis for glaucoma?
6. Describe how to put in eye drops
Otitis Media
• Inflammation of the
middle ear
– Ear drum
• Protects middle ear from
environment
– Eustachian tube
• Connects with
nasopharynx
Otitis Media
• Risk factors
– URI
– Allergies
– Eustachian tube
dysfunction
Serous Otitis media
• Eustachian tube is
obstructed 
• Air gradually absorbed

• Negative pressure 
• Serous fluid drawn in
Serous Otitis media
• S&S
– i hearing
– Snapping /popping
sensation
– Bulging or sunken
eardrum
– Change in atmospheric
pressure  PAIN!
Acute Otitis media
•
•
•
•
•
•
•
URI 
Eustachian tube swelling 
Impairs drainage 
Bacteria grows in fluid 
Inflammatory process 
Pus increases pressure 
Ear drum ruptures
Acute Otitis media
• S&S
–
–
–
–
Pain
Fever
Dizziness or Vertigo
Eardrum
•
•
•
•
Red
Inflamed
Dull
Bulging
Otitis Media: Dx
• History
• Physical exam
– Otoscope
Otitis Media: Rx
• Decongestants
• Antibiotics
• Mild Analgesics
– Acetaminophen
Complementary therapies
• Pain relief from Otitis
Media
– Drop of lavender oil
– Warm cloth
Otitis Media: Surgery
• Tympanocentesis
– Needle through eardrum

– Extract fluid & pus
Otitis Media: Surgery
• Myringotomy
– Surgical opening of the
middle ear
Otitis Media: Surgery
• Ventilation
(tympanostomy) tubes
– Ventilation and drainage
of middle ear during
healing
Nursing Care: Ear surgery
• Pre-op
– Assess hearing
– Discuss post-op hearing
strategies
– Explain post-op
restrictions
• Blowing nose
• Coughing
• Sneezing
Nursing Care: Ear surgery
• Post-op
– Assess
• Bleeding
• Nausea
– Admin antiemetics
• Vertigo / dizziness
• Hearing
Nursing Care: Ear surgery
• HOB
– Elevate
– Unaffected side
• Stand on unaffected
side to communicate
• Remind to avoid
– Coughing
– Sneezing
– Blowing nose
Nursing Care: Ear surgery
• Instruction for home care
– Avoid showers until MD
OKs
– Keep ear plug clean and
change prn
– Do not remove inner ear
dressing until MD OKs
– No swim, drive or travel by
air until MD-OK
– Antiemetic per MD order
– Antihistamine per MD
order
Nursing Care: Ear surgery
• Notify MD if
–
–
–
–
–
Fever
Bleeding
h drainage
h dizziness
i hearing
Assessment: Otitis Media
• History
–
–
–
–
–
–
–
–
Onset / duration
S&S
Hx URI
Move auricle / pinna
Inspect throat & ear
Temperature
Assess hearing
Palpate mastoid process
NRS DX: Pain
• Mild analgesics
– Q4hour PRN
• Heat to affected side of
face & head
• Instruct to report
abrupt pain relief
NRS DX: Knowledge Deficit
• Take All antibiotics
• Discuss S/E of
antibiotics
–
–
–
–
Diarrhea
Vaginitis
Thrush
Eat 8 oz yogurt q day
NRS DX: Knowledge Deficit
• Instruct pt w/ tubes
– No
• Swimming
• Diving
• Submerging head while
bathing
• Air travel
• Enc
– Rest
– h fluid intake
– Nutritious diet
Small Group Questions
1. What are the S&S of otitis media
2. What is the pathophysiology of otitis media
3. What medications are prescribed to a client with
otitis media?
4. What client teaching would you give in regards
to the above medications?
5. A 2 year old is having tubes placed in their ear
bilaterally. The mother is confused about the
procedure and what to expect. What would you
teach her?

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