Chapter 13 CARE OF THE CLIENTS witH EYE AND EAR DISORDERS (Alteration in Sensation) Introduction Communicating is a basic human nee: i is ii ion is mone d. Essential to this interaction is the adequate functioning of the senses and the person unable to receive sensory input, (eg. through sight, sound, smell, taste and touch) has a communication disability. Persons with impaired vision and hearing are limited in the amount of stimuli they can take in, interpret and respond to. Our senses are also source of pleasure. Consider the joys of looking at the face of a loved one, watching MTV or a good movie, listening to music, talking to a friend through the telephone, reading text messages. Clients experiencing eye and ear disorders live with the reality and hardships of sensory deprivations. This Chapter aims to assist you, nursing students to develop the essential knowledge, skills and attitudes to provide quality, compassionate and humane care among clients with sensory disorders. Learning Outcomes i ter, the learner will be able to: A a ee caent for clinical manifestations of eye and ear disorders. 801basic pathophysioy i isk factors, 2 a iscuss the etiology, "S! n eye and ear disorders, Glin 2. Dist ions of commo! ention of lines, manifestations ‘of care for the prev’ a oe ote, 3. Develop eae of clients with eye a ne aa na sig interventions that Op Uae " «ee wt ar problems. , . Eval pea “alent sonar ey using outcome ° developed in the planning phase of 7 i id E: Overview of Anatomy and Physiology of the Eye and Ear Globe : Sate ne Eye. The eyeball has three main coats or layers; Layers of the Eye. eye. * Chambers of the Eye. vA v 1 Belera. Tough outer layer; appears white. It is covered by the mea. woe 2. ChaeanTeenae vascular layer, or uvea. This includes Ciliary body and iris. The pupil is the center of the iris. 3. Retina. The innermost layer. It has an inner sensory Portion Composed of photoreceptors (rods and cones); and N outer layer which is the melanin epithelial pigment. Macula lutea Of the retina. It is the area of sharpest vision. " The cones are the receptors for bright or daylight or color Vision, receptors for dim or night vision. Rods Contain thodopsin. Regeneration of the thodopsin fequires Vitamin A. Vitamin A deficiency affects hight vision. The melanin epithelial pigment absorbs the light that enters the is the center Interior of the eyeball is divided into two Cavities, the anterior and the Posterior, The anterior cavity which is in front of th is further divided into anterior chamber (between g of the lens is further ‘ornea and the iri sterior chamber {between the iris and the lens), ets) and po 'e anterior cavity ig filled with €queous h ich is produced bY a lumor, which is produ the ciliary body. The aqueous humor Maintains IOP, nourishes the lens Ha the cornea, transmits light Tays. ' rk e aque ; Baa canal of Se eaves the ye through the trabecular meshwo © Posterior cavity oF yj Sin . = tke Substance Called vwvenueeus vit recuse with clear, t ‘EDS reting attached ae to choroy “tteOuS maintains shape of the &* 10 choroid, transmits light rays. 802It refracts light rays to focu: is them on the reti retina, it is responsible for acc, gbjects £0 near objects) "OUation (change of focus from distant , bye Muscles 4, The extrinsic muscles r are as follows: 2 ws: uperior Rectus ~~ Rotates eye upward and toward iia toward the 2 n Inferior Re ictus Rotates eye downward and toward the Lateral Rectus Moves eye toward th Tr toward the temporal sic Medial Rectus Moves eye toward the oak aie Inferior Oblique Rotates eye upward and toward the a . i temporal side uperior Oblique Rotates eye downward and toward the temporal side. 2. The intrinsic muscles are the ciliary body which controls the shape of the lens, and the iris which controls pupil size and consequently the amount of light that enters the eye. + Eyelids (palpebrae) 1. They protect the eyes from external irritation, spread tears over the front of the eye, and interrupt ‘and restrict the amount of light entering the eye. 2. The conjunctiva, nutrients, antibodies an 3. The conjunctiva and glands within the eyel which help keep the cornea moist and clear at the lids blink over the cornea. * Lacrimal System : ; ‘aerial Sys eT gland produces tears that flow through puncti (small holes in the eyelid) and canaliculi (ducts) to the lacrimal sac. The tears drain into the nasolacrimal duct to the inferior meatus of Se nasal saul, 4 2 Tears keep the surface of the oye and conjunctiva ee ad an lubricated. Tears contain enzyme which act as an anti rial agent. Orbit I 1. The bony orbit contains the eyeball. the mucous membrane lining of the eyelid, provides d leukocytes to the avascular cornea. id secrete mucus and oil ind decrease friction when lo 803e Eye with Aging: Physiologic Shanges of La elasticity of the lens leads to decrease . le : Decreas® i resbyopia). | or 1. loss of Slr This causes difficulty in distinguish, 2. The ee at the blue end of the spectrum, especially Purple, ling Sans miosis (smaller sized pupil) aids in the distortion of Colors, Thi 3. ah diminishes ability of the person to adapt to dim light ana S. ; 4, come sclera, lens and vitreal changes produce creaseg light ” scatter in the eye causing glare. Glare masks and Teduces brightne of objects in the visual field. . 5. Decrease in lens transparency or increased Opaqueness of the leng (cataract). | 6. The quantity and quality of tears decrease. These causes dryness or scratchiness of the eye. 7. Itregular curvature of the cornea, causing distorted and blurred image (astigmatism). The Ear * The Ear is divided into three parts: external, middle and internal ear. © The external ear is composed of the following structures. 1. Auricle or pina. It Collects sound waves and directs them toward the auditory meatus, External auditory meatus (external auditor Waves to the tympanic membrane; hairs an Canal of foreign matter. Tympanic membrane (eardrum) Sound vibrations from the exten * The middle ear (tympanic Cavity) is composed of the following structures: 1. Ossicles (malleus, incus, stapes). Mechanically transmit sound waves from the tympanic membr rane through the oval window to the inner ear. 2. Windows: a. Oval window. Transmits sound vibrations from the stapes to the fluids in the inner ear. . Round window. Relieves Pressure as vibration exit the inner ear. 3. Eustachian tube (auditory tube). Provides air Passage from ie} caucpharynx to the middle ear. During yawning, sneezing ané NSOr Veli palatine Muscle opens the tube to equal 4. Mastoid. These Bee bad are air — fi nic membrane. dale ear i ray it — filled g nd adjusting to changes in Pressure. Paces that aid the 2. ry Canal). It directs sound id cerumen help cleanse the 3. ). Protects the middle ear and conducts nal ear to the ossicles. 804ianer ear is composed of the following structures: re in tabytinth. Surrounds and protects the membranous laby 1 4, BOY stibule. Contains the utricle and Saccule, which fume sense ofbalance, =. * Inction in the ochlea. Contains auditory receptors Which a . b. Semicircular canals. Function in the sense ane in hearing. mbranous labyrinth, Contains 8, Feceptor cells for heay 2. utricle and saccule. Organ of Static ne, 5 equilibrium, ” Cochlear duct. Contains Organ of Corti, which i Ee acute hearing. It contains the receptors for wet : the center for c. Semi- circular canals. Function in dynamic equilibrium, ‘logic Changes of the Ear with Aging mse erumen that accumulate in the external ear Contribute to hearing loss especially in low frequency range, 2, Degeneration of the receptor cells in the Organ of Corti (presbycussis) 3, Ossicles may become less movable and interfere with ransmcces sound waves. 4, Decrease in cochlear branch of the Cranial nerve VIII Contributes to hearing loss; reduction in the vestibular branch interferes with balance and equilibrium. 5, Bacterial and viral infections in the temporal bone may cause sensorineural hearing loss. + Diagnostic Assessment for Eye Disorders ¥ Snellen’s Chart " Tests visual acuity * Normal result is 20/20 * Result of 20/200 indicates legal blindness - 2 3 4 5 6 7 8 e "1jhara Plate 4 te Tests color vision inoscop| a e ’ Re ormines ferraane error of an ey’ 1 — Uncover test igmus y e Differentiates various types of strabis! v met . Pndrect measure of IOP (intraocular pressure) * Normal is 11-21 mmHg ¥ Gonioscopy men isuali < * A biomicroscopic examination that visualizes the anterior Chambe, angle 3 * Diagnoses congenital and secondary glaucoma y¥ Perimetr 7 “ . ese remert of the peripheral visual field. Normal peripheral Visual} field is 90°. ¥ Bjerrum Tangent Screen = Measures central vision ¥ Ophtalmoscopy « Examines the fundus of the eye Y Slit Lamp Biomicroscopy . : * Assesses the eye's anterior portion under high magnification and in optical section. It can diagnose astigmatism. Normal Physical Assessment of the Visual System Visual acuity 20/20 OU; no diplopia External eye structures symmetric and without lesions or deformities, Lacrimal apparatus nontender and without drainage. Conjunctiva clear, sclera white PERRLA Lens clear EOMI Disc margins sharp Retinal vessels normal with no hemorrhage or spots Notes: EOMI~ Extraocular Movements int: OU ~ Both eyes ac DZRVANAEASS PERRLA — Pupils equal, round, reactive to light and accommodationcardinal Positions of Gaze d Elevation Inferior oblique Superior 7? fectus eral 4 poacton dice 7 ral Z Late! _# NI Medial Superior Inferior oblique rectus Depression Right and Up Up Left and Up Right lateral Front Left lateral Right and Down, Down Left and Down , Vision Protection and General Eye Care / Regular ocular and physical examinations. ¥ Avoid dangerous items (toys, guns, arrows, fireworks, rocks, sticks, etc.). v cai identification and treatment of strabismus in children. ¥ Routine eye assessment programs in schools. / Early treatment when eye symptoms occur. Y Routine instillation of appropriate drops in the eyes of every newborn. ¥ Blood tests during pregnancy to identify syphilis. ¥ Inoculation against rubella. Y Regulation of oxygen concentrations administered to premature infants. Y Avoid habitual rubbing of the eyes. ’ Have adequate lighting when reading. | iM Periodically rest eyes during prolonged periods of 4 feading or watching television. Reduce glare and wear protective goggles. close eye work,AAS clean, eye glasses : prove hg ashes, eye drops, or any Medications jp Do not use ey‘ 4 aor d by a dol Never Peeled wash eon aroun eyes. ing aerosol sprays. 1 Maintain wate of good health and eat a well — balanceg diet a lal itami and C. , adequate vitamins en solvents, lye solutions, ammonia, eo sation to avoid i illing into eyes. Stig solutions to avoid splashing or spilling protected from scratching ang Preakag, a the Sey Preoperative Care of the Client for Eye Surgery v v v v Post Operative Care of the Client Orient the client to the staff and physical environment if both ¢ ‘YES wil overed after surgery. | : ia client is a child, practice covering the eyes, To decrease postoperative fear and restlessness. inister mydriatics/ cyclopegics as prescribed. paige ‘Atropine, Ocwn Iropine, Atropair, Atropisol = Cyclomydril (Cyclopentolate and Phenylephrine) * Cyclogyl (Cyclopentolate HC!) = Scopolamine * Mydriacyl (Tropicamide) Mydriatics and cyclopegies dilate th ciliary muscles (cyclopegia). These medications are contraindicated in glaucoma because of the tisk of increase in intraocular pressure. (Atropine Sutfate) @ pupils (mydriasis) and Telax the in Eye Surgery General goals of Postoperative care, * To prevent or relieve the following: © Increased intraocular Pressure, © Stress on the suture side. © Hemorrhage into the anterior cha ibe © Infection ier (hyphema) ° Pain Position the client supine or tu ie med to the unaffected side. Prevent pressure on the operated eye and to prevent possible the dressin, Contamination of Ss wil i - A burning sensation abor one neo. @ ut one ho: ally means that the anesthetic is Wearing off. This is neneeeY at 808eye is protected with 3. THe Gye shield during the Eye Patch and eye shield for 5 client should be instructed t weeks. 107 days, } jperease in intraocular pressure: 0 avoid the followin Rubbing the eyes. Lifting the head or hips. Sudden, jerky head movement. Sneezing, coughin: . cannot be avoided). (follow through with open mouth if these Nausea and vomitin i Straining at stool. ig (keep eyelids open if vomiting occurs) Bending, stooping. , Heavy lifting (more than 5 Ibs.) Reading (for few days) ° wang as — moving objects The feeling of “something in ” " ig because 7 the Sa ese to 5 days postop usually ¢, Sensation of pressure within the z ini indicate bleeding. These chouta) be ea et a in the eye immediately. je surgeon Administer miotics as prescribed. These medications constrict th pupils. - s Carbotic (Carbachol) « Humorsol (Demecarium Bromide) « Floropryl (Isoflurophate) » [sopto Carpine (Pilocarpine HCl) 19 to prevent ° e008 eo0000 ul. Common Disorders of the Eye Eyelid Disorders Y Blepharitis + Inflammation of eyelid margins. + Irritation, burning, itching, ulcera' Y Chalazion «Internal stye. Ae » Inflammation of Meibomian gland. . 7 Saree — growing, hard, non — tender round mass on eyelid. ¥ Hordeolum " External stye. * Pustular infection of eyelash follicle 01 margin. | "Painful, red swelling on eyelid margin. tion, eyelashes fall out. 1 sebaceous gland on an eyelidjococcus. Commonly caused DY staph Disorders ia) ocular ia, heterotropl , ¥ Strabismus (squint the patient cannot consistently focus 9 oe \dition i rng . 15 ancously ‘on the same obj ies jation of the eyes + Bye deviations nvergent deviation o leone a 7 aivergent deviation of the eyes © Exotropia — outward deviation of the eyes (“sunrise eyes”) ° yea “downward deviation of the eyes. (“sunset eyes’) yp = . ‘Collaborative Management o Corrective eyeglasses : See resection, tucking > Tenotomy, recession 3 . i P Note: Cover/ patch the “good eye” to train the “bad eye. Disorders of the Conjunctiva, Sclera and Cornea 7 Connancinit ot tammation of the conjunctiva which results from bacterial / viral infections. ; . . * Redness, swelling, lacrimation, pain, itching, discharge from the eye. E.g., acute bacterial, gonococcal conjunctivitis ¥ Trachoma * A chronic infectious disease of the conjunctiva and comea caused by chlamydia trachomatis. * Spread by direct contact and very contagious; causes blindness " Treatment o Sulfonamides, Tetra clines, i Y Scleritis / Iritis 7 ervthremycin P A Nery ina eye, painful to move. orneal Inflammation (Keratitis it : ous (Keratitis) and Corneal Ulceration o Pain © Photophobia © Lacrimation © Blepharospasm © Decreased vision 810q jeatment Trifluridine (Viroptic), Idoxuridine (IDU) jira — A) h a Mechanical / Chemical Debridement comeal Ulcerations — medical emergency May result to corneal perforation, scarrin permanent impairment of vision. Causes Trauma o Exposure © Allergy o Vitamin deficiency ° Lowered resistance ° Bacterial, viral, fungal infections ‘orneal Opacity — lack of corne: i coeration or injury. al transparency due to inflammation, Corneal Transplantation (Keratoplasty) o Torepair corneal opacity, perforation of corneal ulcer. o Donor eyes for corneal transplantations come from cadavers o Ideally, a donated eye is transplanted immediately or is removed from the body within 2 — 4 hours of death. Cornea may still be viable within 12 hours after death if the body has been refrigerated; may be transplanted up to 48 hours after death if it is kept in a sterile container, on a piece of gauze soaked in NSS at 4°C. Adenine Arabinoside 1g OF intraocular infection, + Uveal Tract Disorders ¥ Uveal Tract — middle vascular layer of the eye, contributing to the tetina's blood supply. It is composed of iris, ciliary body, and choroid ¥ Uveitis Iritis — inflammation of iris Iridocyclitis — inflammation of the iris and ciliary body Choroiditis — inflammation of the choroid Choroiretinitis — inflammation of choroid and retina o Causes > Local or systemic disease > Injury > Unidentified factors o Assessment > Pain in the eyel > Blurred vision ball radiating to the forehead and temple. gil. Raraser ered without purulent discharge > Small pupil > faoteneson ‘ement ive Mana, iM 3 yaad (Atopine SOx 1% oF 0.25%, Scopotaming) ilate pupils. : ut et adhesion between anterior Capsule of the and the iris. | ¢ Torelieve pain and photophobia. ¢ Toreduce congestion. @ Torest the iris and the ciliary body. » Steroids (local/systemic) ; > Dark glasses (to relieve photophobia) » Analgesics (Aspirin, Acetaminophen) ¥ Sympathetic Ophthalmia (Sympathetic Uveitis) | ; " arare, severe, bilateral, granulomatous uveitis of unknown cause "occurs anytime from 10 days to several years following Penetrating injury near the ciliary body or following a retained foreign body. * Leads to bilateral blindness. " Assessment © Inflammation of the injured or previously operated eye (exciting eye), followed by the other eye (sympathizing eye). o Photophobia o Blurred vision = Collaborative Management © Enucleation. Done if with Perforation of sclera and Ciliary body, vitreous humor loss, retinal damage © Steroids © Local atropine * Retinal Disorders Y Retinitis * Inflammation of the retina. ‘en associated with disease of the choroid. " Caused by bacteria, iungi, toxoplasmosis, cytomegalovirus. = Assessed through opthalmoscopy. " Assessment 9° Reduced visual acuity ° Changes, in the visual field © Alterations in the shape of objects 812[ piscomfort in the eyes ° photophobia Collaborative Management a Rest the eyes. be protect eyes from light. 3 Atropine SOx. ! tachment Is separation of the two primiti : aor epithelial pigment and the rods and coal antes othe retina (mn n of the entire retina from thi Or it may be al at e choroid due to the presence of A m0" Gifferent causes of retinal det e S lachment are as 7 . et eneration, trauma, hemorrhage, exudates in front oF bana retina, 2 hakia (absence of lens), sudden and severe physical ind the amon debilitated clients. exertion e clinical manifestations of retinal detachment are as follows: Floating spots or opacities before the eyes. These are blood : retinal cells that cast shadows on the retina. a Flashes of light. The light that enters the eye is not detached melanin epithelial pigment. " absorbed by the » Progressive constriction of vision in one area. There is sensaii that a curtain has been drawn before the eyes or as if ome looking over a fence. » Ophthalmoscopy shows cloudy vitreous and portion of retina appears like a hanging gray cloud. / Collaborative management for retinal detachment include the following: » Promote bedrest and cover the eyes. To prevent further detachment. + Position the head so that the retinal hole is in the lowest part of the eye (dependent position). d (e.g. scleral buckling). * Early surgery is require nt for Eye Surgery) Preop care (refer to Care of Clier Postop Care Position: the area affected should be in upper (superior position). * Apply pressure patch over the eye. " Activity and ambulation will be prescribed by the surgeon. " Sedentary activities are resumed after 3 weeks. . e "Activities or occupations requiring heavy physical exertion may Pemitted after 6 weeks. As part of the eye 813ar a. Is an eye disorder characterized by increase j, int « Glaucoma. pressure. v Agents humor fluid, fills anterior and posterior chambers g = Crys' Z " a tthe is a refraction medium, provides nutrition to the lens a ee n . helps maintain lOF ea Close Angle Glaucoma Narrow Angle or pales ) v ote eae eerecterized by suddenly impaired Vision Ue * nlraccular tension caused by an imbalance jn py _ excretion is ‘Uction It is the result of ang ion of aqueous humor. | of an apn Geplacornent of iris against the angle of the anterior Chamber ic Glaucoma (Simple, Wide Angle or Open Angle Glaucom, y es ae cherauianzed by impaired vision due to ir 2) tension caused by an actual obstruction in the excretion Of aquep humor. It develops slowly; at first, symptoms may absent Permanent vision loss may occur before the individual is aware of having the disease. | . = It may be due to hereditary thickening of the trabecular Meshwor, or degenerative narrowing of the canal of Schlemm, Y Vision loss in glaucoma is IRREVERSIBLE due to compressi damage of the retina and/or optic ‘nerve. The blo circulation of the aqueous humor may be secondary to: * Infection e.g. uveitis (acute glaucoma) * Injury (acute glaucoma) " Hereditary predisposition to thickenii (found at the angle of the anterior peripheral iris and the cornea meet) Narrowing of the canal of Schlemi lon ang kage to the ing of the trabecular meshwork chamber of the eye where the ) (chronic glaucoma) im (chronic glaucoma) Y Chronic / Simple Glaucoma = Assessment © Characteristic sign — before central vision is affected, the Peripheral visual fields are impaired so that Objects to the sie are ignored (tunnel vision). ° Insiduous. onset — generally no discomfort. © Patients may bump into other person in the street or fail to & Passing Vehicles, yet not realize that the fault lies on their o¥" ion. 814Nui ° ° ° ° Collaborative management loss of peripheral vision (“tu Ay the person is legally blind, a ‘he non) can progress well straight ahead, SON may be able t, vTtl Usually begins in one eye, if it is left ae ‘come affected. untreated Persistent dull eye pain in the mornit ing. Frequent eee of glasses, difficulty in adjusti failure to detect changes in color accuratel) ijusting to darkness, Steamy appearance of the cornea and further blur " Tearing, misty vision, blurred appearances of the jn. becomes fixed and dilated), headache, pain b f the itis (which nausea and vorniting. ’ ehind the eyeball Rainbows or halos resembling street li steamy windshield may be pa around tae Seen trough a both eyes often rsing Diagnoses for the Patient with Glau Risk for injury related to visual acuity deficits ea — care seficts related to visual acuity deficits cute pain related to pathophysiologi i eis ysiologic process and surgical Noncompliance rela‘ glaucoma medications. ted to inconvenience and side effects of for the client with chronic glaucoma: ice intraocular pressure and keep it at a safe 3) > The patient is advi Objective : To redut level. > Miotics. Used to constrict the pupil and to draw the smooth muscle of the iris away from the canal of Schlemm to permit aqueous humor to drain out at this point. Drug Alert: Miotics - Wam_ patients about decreased visual acuity, especially in the daylight > Acetazolamide (Diamox). ‘A drug that tends to reduce the formation of aqueous humor ; is used successfully for some of chronic glaucoma. . The p jised to avoid fatigue or stress and to avoid drinking large uantities of fluids. . > euery ra be performed to produce a pau eae pathway for aqueous fluid. Filtenng procedure: 815Y Acute Glaucoma Assessment ° 0000000 Collaborative management for the client with acute glaucoma: ° ° 0000 ° . iri leisis, trabecy jridectomy, iridenct sclerotomy, omens provide @ permanent fistula fe, My trephin ‘chamber to the subconjunctival space, are cases, the production of aqueous fluid > In , decreased by destroying part of the ciliary body, Yb, Rapid onset of severe pain in eye(s) Blurred vision ie Peniene or halos around lights Nausea and vomiting Inflamed eye(s) Fixed, dilated pupil(s) Visual impairment Maintain bed rest in quiet, darkened room, elevate head 30 degrees. Monitor vital signs. Administer miotic eyedrops as ordered. Administer acetazolamide, glycerol orally as ordered. » Acetazolamide is carbonic anhydrase inhibitor. It reduces aqeous humor production. Thereby, decreasing intraocular pressure. ” » Glycerol is an osmotic drug which act to reduce intraocular pressure. Provide emotional support. Assess patient's ability to see. Assist according to degree of visual impairment. Prepare for eye examinations as ordered — tonometry (IOP is 25 mmHg and above in glaucoma). Avoid Atropine Preparations and other mydriatics. These drugs diate the pupils, and the iris is brought closer to the angle of outflow of aqueous humor. This causes further obstruction in the excretion of aqueous humor. In glaucoma, avoid ABC: * A-tropine : * B-enadryl = C~ogentin 816Administer antiemetics as o1 © provide diet as tolerated. dered for nausea, 5 prepare for surgery if ordered. nerapy in Acute and Chroni / 08 a ~ adrenergic blockers onic Glaucoma -~ These drugs decrease a petaxolol (Betoptic) queous humor production Carteolol (Ocupress) Levobunolol (Betagan) Metipranolol (Optipranolol) Timolo! Maleate (Timoptic, Istalol) . Alpha — edreneraic Agonists » These drugs decrease 5 outflow facility aqueous humor production and enhance Dipivefrin (Propine) Epinephrine (Epifrin, Eppy G: i . Apraclomidine {Lopidine). jaucon, Epitrate, Epinal, Eppy/N) Brimonidine (Alphagan) Latanoprost (Xalatan) 3. Cholinergic Agents (Miotics) » These drugs are parasympathomimetics: causing constricti pupils, opening of trabecular meshwork, facilitating anuoeus outflow. Carbachol (Isopto Carbachol) Pilocarpine (Okarpine, Isopto Carpine, Pilocar Pilopine, Piloptic, Pilostat) 4. Carbonic Anhydrase Inhibitors » These drugs decrease aqueous humor production a. Systemic Acetazolamide (Diamox) Dichlorphenamide (Daramide) Methazolamine (Neptazane) b. Topical Brinzolamide (Azopt) Dorzolamide (T1 ruzopt) 5. Combination Therapy Timolol Maleate and Dorzol 2. amide (Cosopt) $17jents : 6. Seneca eee extracellular osmolarity, 54 ie, fluid moves to the extracellular and vascular Spaces Tec, i Pp Ghoetin Liquid (Ophthalgan, Osmoglyn) Isosorbide solution (Ismotic) Mannitol solution (Osmitrol) ° Cataract Y Etiology = Cataract is a clouding, or opacity of the lens that leads to blur, vision and eventual loss of sight. The opacity of the lens is dat by chemical changes in the Protein of the lens becay of seq degenerative changes of age, injury, poison or intraocular infecgo™ Cataracts occur so often in the aged. At 80 years of age, a re 85% of all people have some clouding of the lens. * Bout Classification of Cataracts © Senile. Those associated with aging. ‘Traumatic. Those associated with injury. Congenital. Those which occur at birth. Secondary. Those which occur following other €YE OF systemig diseases. ° ° ° " Collaborative management for the client with Cataract: © Surgery is the only satisfactory treatment for cataracts. It is advised when the Cataract interferes with @ person's mobility and ability to carry out normal activities, > Intracapsular technique. Removal of cataract within its capsule. (ICCE) > Extracapsular Technique. An opening is made in the capsule and the lens is lifted wi i i Person with aphaki Of lens) is very farsighted (hyperopic). (ECCE) Cryoextraction. The cataract is lifted from the eye by a small Probe that has been cooled to a temperature below zero and adheres to the wet Surface of the cataract. > Iridectomy. Done Preceding cataract extraction to create a! Opening for the flow of the aqueous humor which my 818> Phacoemulsion. A method of > » v vvv preop Care: (refer to general Care for eye gs, Postop Care 'ye Surgery) become blocked Postop when the vil forward. This is to prevent secondary gaunt oe Cataract removal Which breaks up the lens and flushes it out in tiny pieces, The eye is covered with a dressin, i to protect it from injury. 9 (evepad) and ®ve shield The patient is usually allowed out of bed th it surgery. vou folowing Daily change of dressing is done, After 7 dressings are usually removed, '0 10 days, a During the first month, protect the eye with a shield at ni Administer eye drops as ordered. a Ho Note = Temporary glasses May be prescribed 1 to 4 weeks after surgery. Usually within 6 to 12 weeks healing has been sufficient for fitting of Permanent glasses or contact lenses. Remember = Cataract glasses (aphakic glasses) magnify so that everything appears about one fourth closer than it is, Patients need to know that it will take time to lear to judge distance, to climb stairs and do other simple things. Use of contact lens improves visual correction and better cosmetic appearance. Intraocular lens implant. Is an alternative to cataract glasses and contact lenses. The lens, which is made of polylethyl methacrylate, is implanted at the time of cataract extraction; may be held in position either by suture to the itis or by implanting it into the capsular sac (The main advantage of the implanted lens is better binocular vision). * Tumors of the Eye and Related Structures ¥ Benign or malignant tumors. YR ¥ Col isplace the eyeballl and interfere with vision. ‘ctinoblastomas (children), malignant melanomas (adult). *_ Are the most common primary intraocular tumors. laborative management for the client with tumor of the eyes: : Enucleation (removal of the eyeball). Brachytherapy (internal radiation therapy). 819. fraction Errors . Sy cametont Normal refractive state. ¥ Ammetropia. Abnormal refractive state."Sight not in proper Measy, res Hyperopia ; ightedness. . ; ° Persia rays of light focus behind the retina. © Corrected with convex lens. Myopia o Nearsightedness. | : o Parallel rays of light focus in front of the retina, © Corrected with concave lens. o Radial keratotomy (RK Surgery). Presbyopia © “Old sight” o Lessening of the effective powers of accommodation; because of hardening of the lens due to aging process." Cus © Blurring of near objects or visual fatigue when doing “Close work.” ee © Convex reading glasses are recommended Astigmatism © “Distorted visior © Caused by variation in refractive power along different Meridiang of the eye. © Optical distortion is most often caused by irregular comea) curvature, which prevents clear focus of light from any point. Aphakia © Is the absence of lens. It may be absent congenitally or it may be removed during cataract ‘surgery. © Images are projected behind the retina (farsightedness) v Non-Surgical Corrections 1. Corrective Glasses © Myopia requires concave lens © Hyperopia, aphakia, Presbyopia require convex lens 5 © Glasses for presbyopia are often called “reading glasse? because they are usually wom for close work only. ch © Presbyopia maybe corrected with the “no-line” bifocal which actually a multifocal lens that allows the patient to see any distance. 820contact Lenses ; i 2. These are made of plastic and silicone substances whic very permeable to oxygen and have highawater eons ae allows greater See time with greater comfort, Which The patient shoul now the signs and sympto: lens problems that must be imianaged( (by) the 3 i eo professional which are as follows: ane R - edness S — ensitivity V —ision problems P-ain The nurse must stress the importance removii ° immediately if any of these problems occur. eee 3. Corneal Molding ° Is also called orthokeratology. It is the use of specially designed, rigid, gas permeable contact lenses to alter the shape of the cornea. It reduces or corrects myopia and moderate degrees of astigmatism. : ° y Surgical Therapy 4, Laser . . © Laser-assisted-in-situ keratomileusis (LASIK) may be considered for patients with low to moderately high amounts of myopia, hyperopia, and astigmatism 2. Refractive Intraocular lens implant (IOL) o Itis usually done following cataract removal. 3. Thermal Procedure o Laser Thermal Keratoplasty (LTK) and conductive keratoplasty (CK) are indicated for patients with hyperopia or presbyopia. These procedures use laser or high radio frequency, and heat is applied to the peripheral area of the cornea to tighten it like a belt and make the central cornea steeper. Only the less dominant eye is treated and the desired effect is monovision. Monovision enables one eye to focus at close proximity; the other eye is left untreated or, if needed , is treated to focus at a distance. ° : Trauma to the Eye and Related Structures Penetrating Eye Injuries * Requires surgery (repair/enucleation). 821ed rest with bathroom rivileges: for 1 to 2 days. ; Eaane for sympathetic ophthalmia. ign Bodies (IOFB) : 7 Intraoeurads thoroughly before touching the eye, + Tmrediate copious flushing of the eye with water when acig irritatit been introduced. » Alkali other irritating substance has. Saas or * If foreign body is lodged into the cornea, ttempt to r, m see a physician. Emay . id pressure on the eye, do not touch, do not rub the eye, ener ath dressing or plastic or metal eye shield for Protection limit eye movement and prevent further trauma. , = Avoid activities that increase IOP. Use sterile technique, when treating the eyes. Consult ophthalmologist immediately. « Sympathetic Ophthalmia. Occurs from 10 days to severaj 2 following penetrating injury near the ciliary body or retention of formes body in the eye. This may lead to bilateral blindness. ‘an Y This requires enucleation, steroids, topical atropine. © Eye Surgeries ¥ Enucleation. Removal of the eyeball. Y Evisceration. Removal of the entire eyeball contents and comea, except the sclera. eae ¥ Exanteration. Removal of the eyelid, eyeball and orbital contents. * Legal Blindness Y Central visual acuity for distance of 20/200 or worse in th (with correction) cere v Visual field no greater than 20 degrees in its widest diameter or in the better eye. . Rehabilitation of a Blind Person Refer blind Persons to available facilities. fa to the environment. Describe the surroundings and location of Promote independence — ADL (Activiti ily livit e ities of Di May have a guide dog, or use cane for dreston bh When approaching, talk before touching. When assistin, i that you are a Step ahead of him. Sema natient fold) your forser . v 45 ig in ambulation, ha 822 Tienes ee 4ient frequently, so he / she doesn’ talk to the Pd unhurried when performing, ‘raged ai pe elainat is being done and what is to be done next. Procedures, a expla? change location of objects in the foom or in the enviro 7 00.00 Gescribing the change. nment vious safety in the environment, 7 proms rush up and offer help to a bli 7 097 son wants help. : the Prficant others ask advise about gifts for a blit vif ooh at appeal to senses other than vision, 9 stuff toys perfume, ind person Unless it is Clear that ind person, sy eg, CDIDVD wet tape, 1. care of the Clients with Common Ear Disorders I vf ostics Tests for Auditory Acuity ing Fork Tests Rinne's Test o Compares air conduction from bone cor conductive and sensorineural hearing los: o The vibrating tuning fork is placed behind the ear lobe (bone Conduction); then, it is Placed 2 inches from the opening of the ear canal (air conduction) Interpretation of results is as follows: > Normal : air conduction is better than bone conduction (the tone is louder in front of the ear) » Conductive hearing loss: bone Conduction is better than air conduction (the tone is louder behind the ear) > Sensorineural hearing loss: same as the normal finding o It is more accurate in diagnosing conductive hearing loss like in otosclerosis. ag pan ‘ induction; differentiates S. against the mastoid bone/ ° * Weber Test © The rounded tip of the handle of the vibrating tuning fork is Placed on the client’s head or teeth. © Interpretation of results is as follows: > Normal : tone is heard in center of head or equally in both ears. > Conductive hearing loss: tone is heard in poorer ear, e.g. otosclerosis > Sensorineural hearing loss: tone is heard in better ear. > The test is useful in cases of unilateral loss, 823is more accurate in diagnosing sensorineural Nearing lon i“ isin Meniere's disease. ty Tost h the palm of the hisper Voico 10 ear with 2 ‘ 7 The exarmingt ee nES words from a distance Of 1 oro foot they, whispers. ae ‘and out of the pationt’s sight (¢ 9 thintact® the unocclude¢ . on, en, fifteen). 4 culty can corract s i Pepe with normal hearing acuity can rectly repeat hi was whispered. Y Audiometry : ; ic inst 1 “ It is the single most important diagnostic instrument jn detecting hearing loss. , ; = Types of Audiometry ee piS — tone Audiometry. The louder the tone before the Client perceives it, the greater the hearing loss. “ © Speech Audiometry. Spoken word is used to determine the ability to hear and discriminate sounds and words. The louder the sound before the client perceives it, the greater the hearing loss. ¥ Tympanogram or Impedance Audiometry : * It measures middle ear muscle reflex to sound stimulation and compliance of the pea membrane, by changing the air Pressure in a sealed ear canal. : * Compliance is impaired with middle ear disease. ¥ Oculovestibular Test / Ice Water Caloric Test * Irrigate the ear with cold water. Normal result: lateral conjugate nystagmus of the eyes towards area of stimulation. Abnormal result : dysconjugate nystagmus of the eyes * Then, irrigate the ear with warm water. * Normal result: lateral conjugate hystagmus of the eyes away from the area of stimulation. Abnormal result: d Vang ySconjugate nystagmus of the eyes 824weder's Test Rinne’s Test = — ee V= = = oe Sak pam nenaten SQ prota _ Meta w ee ew een you re ym f froweearene? | aa shoe ptoms of Ear Diseases 5yF ness i 7 pet ans that the patient has a hearing loss which may be mild or severe. . Hearing loss may be conductive, sensorineural or mixed types, he most common cause of deafness in childhood is iti redial whereas in adults, presbycussis is most common cae, otis Presbycussis means deafness of the elderly and it is a sensorineural hearing loss caused by the degeneration of the nervous tissue. It is more common among men, over 50 years of age. . Hearing loss in presbycussis is predominantly in the higher frequencies (high- pitched sounds like women's voice). ¥ Pain 2 Earache or otalgia is a very common complaint. + Inchildren, the most common cause is acute otitis media whereas in adults, it is otitis externa. The pain may arise from the ear itself or from an adjacert site with a shared nerve supply. * The most common site for referred pain is the throat, where infections or, more rarely, malignant tumors are responsible. Y Discharge * Adischarge from the ear may be mucoid, purulent or bloody. It must be distinguished from the escape of wax which is a normal process. * Commonly the cause of a discharge is otitis externa or otitis media and in the latter event, a perforation will be present in the tympanic Membrane. * If perforation of the tympanic membrane is suspected or diagnosed, vy tigation of the ear should be avoided. Vertigo ; * Is a form of dizziness where the patient experiences a sp! Sensation. It is a common symptom when the balance or vesti inning fibular 825tem of the inner ear is diseased. It is accompanieg by sys' and vomiting. 7 Y Tinnitus is a very common complaint. : OF no aries from a high — pitched whistle to the clan, i ‘Sing of or recognizable snatches of music. bet, « Classification of Hearing Loss ive hearing loss. it involves interference with Conducg, ” Sound impulses through the external auditory canal, the ear dra the middle ear. It is validated by Rinne's Test. ¥ Sensorineural hearing loss. It results from disease or trauma to the inner ear or acoustic nerve. It is validated by Weber's Test. ¥ Mixed hearing loss. It involves both conductive and Sensorineyrs, hearing loss. : Assessment in a Client with Hearing Loss ¥ Irritable, hostile or hypersensitive in interpersonal relations. ¥ Has difficulty in following directions. Y Complains about people mumbling. v Turns up volume on TV. Y Asks for frequent repetition. ¥ Answers questions inappropriately. ¥ Leans forward to hear better; face looks serious and strained. ¥ Loses sense of humor; becomes grim and lonely. v Experiences social isolation. ¥ Develops suspicious attitude. ¥ Has abnormal articulation. ¥ Complains of ringing in the ears. Y¥ Has unusually soft or loud voice. ¥ Dominates conversation. Guidelines for Communicating with the Client with Hearing Impairment Y Talk directly to the rson facil Si d lip movements. Le facing him/her. So, he/she can rea . Spe ee enunciated words, using normal tone of voice. 0° . High- i ; ee cole difficult to idee Pitched sound is used when shouting. This is ™ stand especi: ¥ Use gestures with speech” among older people. 826- wnisper to anybody in front of the honring ~ i 0 wid convorsation with a person who ha: ree i pow annoyance BY caroloss facial oxp — fe cl ros 7 p00" agor to the person oF Cee aoc " i par if he/she does not i smile, do not chew gum or cover the mouth wh on, SO, the person can read the lip movements. eae por rage the use of hearing aid if the client has one, he u! r capsule L communication with Hearing Impairod Pationt nonverbal Aids Draw attention with hand movements. Have speaker's face in good light. Avoid covering face and mouth with hands. Avoid chewing, eating, smoking while talking. Maintain eye contact. Avoid distracting environments Avoid careless expression that the pat Use touch: Move close to the better ear. Avoid light behind speaker. The patient will not be able to see the speaker's fi jal expressions that will help him understand ace and faci what is being com! . tient may misinterpret. municated. Verbal Aids Speak normally and slowly. Do not overexaggerate facial expressions. Do not overenunciate. Use simple sentences. Rephrase sentence; use different words. Write name or difficult words. Avoid shouting. Speak in norma tly into better ear. @ | voice dire’ | use the ridge of e side of the head pews a ne gension in incision * Diseases of the Outer Ear ¥ Bat Ear * The pinna protrudes from th Df the antihelix has not formed. The child may D¢ rn a * The antihelix can be econstructed fairly easily throug} on the back of the pinna. 827(impacted Cerumen) normal substance produced in 4 v Wax rumen = Wax or cel 4 I g, ithelial scales mix “xtey Lit is made UP fie skin of the Outer ea, th iN Ca a from special glan itis formed but in some, it te ” hog she wax escapes endl causing deafness. Olive ail gat in le, ting i . " . , the ear canal cea varogen peroxide will soften the impadtia eardro} irrigation. parattich is then ine i. the syringe should be at b «It is important that jot to stimulate the inner ear 4 cay temperature so o ater is directed at the wall of the « re dizziness. The peated out. The ear must be dried Gently after nal and the an should be examined by a doctor to &Xclude any aaa to the tympanic membrane. lami one found in the ears of children and the Varies * These 7 Soames they can be removed by a probe or inigae® wath warm water but the child is often frightened and UNCooperati and a general anesthetic will be necessary. The ear must always be checked to exclude any underlying damage. ; / An insect in the ear is treated similarly. If the foreign body is a vegetable seed, do not irrigate the ear. Vegetable seeds expand when exposed to water. Y Otitis Externa * This is an inflammation condition is usually bilat The patient scratches the ear which be: sometimes blocked by a thin muco — stress and the Presence of contaminate but the treatment is the same. Any precipi and a swab is taken for cult cleaned gently, Wool on the tip of a Suitable probe, OF used to j the ear for Or may be co; and steroids recur. of the outer ear whi ich is lined by skin. The teral and the s\ ymptoms start with itching. comes infected, painful and - isinfectants No le drops may be simple disinfectan mbinations of topical antibiotics (to kill the bacteria (to reduce the inflammation). The condition tends 828v D sollS | it or furuncle is found in the outer hair-beari ir 7A ml it is very painful because the skin at the sen fi tethered to the underlying cartilage. Like boils elsewhere " caused bY staphylococcus and the Televant antibiotic is a necessary when the symptoms are severe. Analgesics only necessary and the possibility of underlying diabetes must te excluded. the ear ors ‘ Tun falignant tumors of the ear are most common in the outer ¢, where both basal cell carcinoma and Squamous carcinoma fa found. The small lesion is treated with fadiotherapy but the la Be will need surgical excision. "ger y serous (Secretory) Otitis Media + When the Eustachian tube becomes blocked, the air trapped in the middle ear is absorbed into the ‘Surrounding tissues and is teplaced by thin fluid. In time, small glands appear in the lining of the middle ear and the mucus which they secrete, explain the popular name of “glue ears” which is given to this condition. It is seen most in those children where an immature musculature and repeated upper respiratory tract infections, predispose to tubal obstruction. * The child develops a hearing loss which May pass unnoticed, However, the parents may have noted that the child’s school work has deteriorated or that he turns up the television. There may also be associated episodes of earache caused by a supurative infection of the fluid. An examination of the ear will reveal the presence of fluid behind the tympanic membrane and a simple whisper test or an audiogram will confirm the presence of a hearing loss, * If the condition is temporary or intermittent, nothing needs to be done since most children outgrow the condition. If it is more severe, an alternative means of allowing air into the middle ear, must be found. A hole is made in the tympanic membrane (a myringotomy) and the hole is prevented from healing by inserting a small Plastic tube (grommet, dottle or stopple). At the same time, any underlying Cause (sinusitis or enlarged adenoids) is treated. * As long as the grommet remains in place and remains unblocked the hearing is normal. However, the grommet drops out after an 829nths. When the condition is Fecurr iod of 6 mo ddl ent, a average period o' to aerate the middle ear. The mai larg, tubes may be inaertot in place can be allowed to go g¥!Xtity ¢ atients with gromm« aithough ear plugs ie have outgrown the prob! = yt reinserted if fluid reaccumulates. i Wim; dvisable. It is hoped that the pati nin I by then, but a grommet may need at a ore is in continuity with the nasopharynx a infection from it. This is especially 5," 8 therefore very prone one Ener eonverint culture . in the presence of serous otitis me ia. The middle e, ium is available for the invading bacteria. fi hich ar mu becomes inflamed and the cavity fills with Pus whic! escapes by bursting out through the tympanic membrane into the external ear * The patient, who is usually a child with a cold, develops an earach, of increasing severity which ceases when the membrane burg The perforation usually heals after 2 to 3 days but this ‘Should checked after one month and the presence of an underlying Serous otitis media excluded. . = The patient should be confined to bed and given anal covered hot water bottle applied to the ear is helpful and oil drops will soothe the inflamed membrane. If a patient is seen before the perforation occurs, penicillin should be given and should be continued for at least 5 days and until the inflammation has settled. A swab should be taken from the discharging ear and sent for culture and sensitivity. Complications may arise but these are now rare. The most common is acute mastoiditis, a condition in which an abscess Ceveleps in the mastoid bone and burst out behind the ear. It is now only seen in children whose natural defense mechanisms are not functioning normally. I9esics, 4 wam olive Y Chronic Otitis Media "When a middle ear infection becomes persistent it is called chronic Otitis media. Permanent damage membrane and to the ossicles and 830for several months it is Suitabl ‘able erforation. A piece of fasci for : cia is ra i temporalis muscle and ne beara from thee Tepair of issue is Ce of the erforation. The graft ma y be laid o1 : Grafted of the tympanic membrane and or inner or the o oer the myringoplasty. Similarly, any to: @ operation is ra ler surface corrected by repositionin, SS Of ossicular continuity nx 42 a piece of bone or ae damaged ossicle or trae can be mpanoplasty. More poe ree This eee it with the tympanic membrane a id it has become Foss is called a cadaver. These homograft feared ossicles in eae bi ck trom - . sues can ; lock from suitable patient but the operation is aie into a ifficult. v Cholesteatoma This is a cyst lined by squam: itheli epithelial scales. The cyst ote amen i peat alot a segment of the tympanic membrane, ate cect Initially, the epithelial scales escape into the ee Se the mouth of the pouch narrows, they are retained ee fa ist The cholesteatoma is unique in that it has the property of fs most of the tissues which it encounters. The contents of the cyst becomes infected and the condition may be regarded as a form of chronic otitis media. The extent of the damage is determined by the direction in which the cholesteatoma enlarges. Usually the ossicles are damaged, but an upward extension will produce a brain abscess Or meningitis. Similarly, a downward extension may produce a facial paralysis or damage the inner ear. . ins of deafness and an offensive scanty f plication and an discharge. There may be evidence of 2 complication inati f the ear will reveal a marginal perforation wit! ts ‘ng, The treatment of a cholesteatoma 7 epithelial sca! necessary surgical and some form its removal. Y Otosclerosis i rows: ie ularized bone 9} * In otosclerosis, abnormal, spongy, highly at the footplate of the il ‘oval window 4 rndition iS more common de across the margins of the ovs col stapes which can NO jonger vibrate TH Tog and We Rinne’s i ewemen. It begins in ade ing loss: Finn n. conductive neat 9 progressively worsens. 831i ter than air indie e conduction is bett h Condy the einen ‘sia hole between a hearing ald and surge, ven The ee is known as stapedectomy. The mobile Part of ht ote ces removed and hole is made in the fixed footplate. A e (ora similar prosthesis) is placed in the hole and hooked Atouny the incus to reestablish sound transmission. The inner ear is during the operation and this must be clearly explained to patient Some dizziness almost always occur temporarily ang this ig countered by antivertigo drugs. the Inner Ear aa aires affecting the inner ear causes damage to the delica nerve endings responding for hearing and balance and the Patient may complain of vertigo, deafness or tinnitus. f ¥ Trauma, loud noises and some drugs may damage the inner ear and they should be avoided if possible. In Meniere’s disease, there is an accumulation of endolymph in the inner ear and the Patient Suffers from episodes of severe vertigo. ¥ A tumor known as an acoustic neuroma may occur in the interna) auditory canal and its symptoms will mimic those of inner ear disease. The ear, nose and throat surgeon carries out Many investigations to distinguish between these in an attempt to diagnose a neuroma at an early age. v Meniere's Disease (Endolymphatic Hydrops) * It is characterized by accumulation of endolymph in the inner €ar. It is chronic, with remissions and exacerbations, " Causes o Unknown o Virus © Emotional Stress * Assessment in Meniere’s disease © Vertigo (most characteristic manifestation) © Unilateral / bilateral gradual hearing loss © “Drop attacks” (the patient experiences the feeling of being Pulled to the ground) Feeling of as if one is whirling in space Tinnitus (described as “roar” or “like the ocean”) Nausea and vomiting Lieber Test shows that tone lateralizes better in the 9o%d ear. e000 832Collaborative management for the cli ‘1 : include the following: e client with Meniere's disease ° o0000 ° Bed rest during exacerbation, Low sodium diet. To prevent retenti Avoid drinking large volumes of fide, cnt Avoid reading during vertigo, i Provide quiet, darkened room di H luring vertigo, Provide soft, mellow music during tinni : patient's attention. ng tinnitus to divert the Avoid alcohol, caffeine, tobacco. of symptoms. These cause exacerbation Stress therapy. Medications: — tranquilizers, vagal block it antihistamines, vasodilators. diuretics Pine), To reduce vertigo, the followin prescribed: Diazepan (Valium) Meclizine (Antivert / Bonamine plus nicotinic acid) Fentanyl with Droperidol (Innovar) 19 Medications may be + Acoustic neuroma. Is a benign tumor of the vestibular or acoustic nerve. The tumor may cause damage to hearing and to facial movements and sensations. Symptoms begin with tinnitus and progress to gradual sensorineural hearing loss. Treatment includes surgical removal of the tumor via craniotomy. Care is taken to preserve the function of the facial nerve. Postop nursing care is similar to postoperative craniotomy care. v SAN ly mY \ \facial ) \ \ nerve cochlear ‘© Mayteld Clinic nerve acoustic neuroma 833