NCMB316 LECTURE:
18
BSN 3RD YEAR 2ND SEMESTER FINAL 2023
Bachelor of Science in Nursing 3YB
Professor: Dr. Potenciana A. Maroma
Final Topics:
• Parkinson’s Disease, Multiple Sclerosis, and
Myasthenia Gravis
• Guillain Barre Syndrome, Amyotophic Lateral
Sclerosis, and Huntington’s Disease
• Musculoskeletal System: Anatomy and Physiology,
Diagnostic Tests, and Disorders
• Eyes: Anatomy and Physiology, Diagnostic Test, and
Disorders
• Ears: Anatomy and Physiology, Diagnostic Test, and
Disorders
PARKINSON’S DISEASE, MULTIPLE SCLEROSIS, AND
MYASTHENIA GRAVIS
Parkinson’s Disease (PD)
- The basal ganglia are a collection of nuclei deep to the
white matter of cerebral cortex.
- The name includes: caudate, putamen, nucleus
accumbens, globus pallidus, & substantia nigra.
Pathophysiology
• Disorder causes degeneration of the dopamine-producing
neurons in the substantia nigra in the midbrain
• Dopamine influences purposeful movement
• Depletion of dopamine results in degeneration of the basal
ganglia.
Parkinson’s Disease (PD) / Paralysis agitans
- A progressive disorder with degeneration of the nerve cells
in the basal ganglia resulting in generalized decline in
muscular function; disorder of the extrapyramidal system
(neural network located in the brain that is part of the
motor system involved in the coordination of movement)
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Exam Week
- Usually occurs in the older population: sxs occur during
the 5th decade of life some diagnosed at age 30
- Affects men more frequently than women
- Cause: UNKNOWN; predominantly idiopathic
- but sometimes disorder is postencephalitic, toxic,
arteriosclerotic, traumatic, or drug induced ( reserpine,
methyldopa [Aldomet], haloperidol [Haldol],
phenothiazine )
- Dxtic tests: not helpful …PET used only for evaluating
levodopa uptake = diagnosed clinically from patient’s hx,
presence of 2 of the 3 cardinal sxs, neuro examinations
Assessment findings
• Tremor:
- mainly of the upper limbs
- "pill-rolling"
- resting tremor; most common initial symptom
• Rigidity: cogwheel type
• Bradykinesia: slowness of movement
• Fatigue
• Stooped posture; shuffling, propulsive gait
• Difficulty rising from sitting position
• Masklike face with decreased blinking of eyes
• Quiet, monotone speech
• Emotional lability, depression
• Increased salivation, drooling
• Cramped, small handwriting
• Autonomic symptoms:
- excessive sweating
- constipation
- seborrhea
- decreased sexual capacity
- lacrimation
Nursing interventions
• Administer medications as ordered
1) Antiparkinsonian: Levodopa (Dopar, Larodopa)
- Increases level of dopamine in the brain; relieves
tremor, rigidity, and bradykinesia
- Side Effects: anorexia; nausea and vomiting;
postural hypotension; mental changes such as
confusion, agitation, and hallucinations; insomnia;
renal damage; cardiac arrhythmias; dyskinesias
(purposeless involuntary movements that may be
hyperkinetic =rapid and repetitive)
- Contraindications:
o avoid multiple vitamin preparations containing
vitamin B6 (pyridoxine) and foods high in vitamin
B6 (tuna, pork, dried beans, salmon)
o avoid Tyramine rich foods ( cheese, yogurt,
coffee, raisins, sausage, red wine, beer)=may
cause hypertensive crisis
o administer with food or snack to decrease GI
irritation.
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
2) Carbidopa (Sinemet): prevents breakdown of dopamine
in the periphery and causes fewer side effects.
3) Antiviral: Amantadine (Symmetrel):
- used in early/mild cases to reduce rigidity, tremor,
and bradykinesia
- act by releasing dopamine from neuronal storage
sites
4) Anticholinergic: Benztropine mesylate (Cogentin),
procyclidine (Kemadrin)
- inhibit action of acetylcholine
- used in mild cases or in combination with Levodopa
- relieve tremor and rigidity
- side effects: dry mouth, blurred vision, constipation,
urinary retention
5) Dopamine agonist: Bromocriptine mesylate (Parlodel)
- stimulates release of dopamine in the substantia
nigra
- often employed when Levodopa loses effectiveness
6) Tricyclic antidepressants given to treat depression
7) Antihistamines have mild central anticholinergic &
sedative effects & may reduce tremors
• Provide a safe environment.
- Side rails on bed; rails and handlebars in toilet, bathtub,
and hallways; no scatter rugs
- Hard-back or spring-loaded chair to make getting up
easier
• Provide measures to increase mobility.
- Physical therapy: active and passive ROM exercises;
stretching exercises; warm baths
- Assistive devices. If client "freezes," suggest thinking of
something to walk over.
• Improve communication abilities: instruct client to
practice reading aloud, to listen to own voice, and
enunciate each syllable clearly.
• Maintain adequate nutrition.
- Cut food into bite-sized pieces.
- Provide small, frequent feedings.
- Allow sufficient time for meals, use warming tray.
Multiple Sclerosis (MS)
- An immune-mediated progressive demyelinating disease of
the CNS which results in impaired transmission of nerve
impulses
- Typically present in young adults 20-40
- Affects women more than men
- More frequent in cool or temperate climates
- Cause UNKNOWN; may be a slow-growing virus or possibly
of autoimmune origin
- Characterized by remissions and exacerbations
Pathophysiology
1) Sensitized T cells that would typically cross the blood-brain
barrier to check for antigens in the CNS and then leave; in
MS would remain in the CNS
2) Promote infiltration of other agents that damage the
immune system
3) Immune system attack leads to inflamm that destroys
myelin and oligodenroglial cells
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Major types
1) Relapsing-remitting MS (RRMS) = 85%of cases
- relapses develop over 1-2 weeks & resolve over 4-8
months then returns to baseline.
- 50% may develop secondary progressive MS within 10
yrs; 90% develop it within 25 yrs
2) Progressive-relapsing MS (PRMS) = 5% of cases
- absence of remission & client’s condition does not
return to baseline
- progressive, cumulative sxs & deterioration occur over
several yrs
3) Primary progressive MS (PPMS) = onset tend to be bet
40&60 years of age
- steady, gradual neurologic deterioration w/o remission
of sxs
- progressive disability with no acute attacks
4) Secondary progressive MS (SPMS)
- begins with RRMS course that later becomes steadily
progressive
- attacks & partial recoveries may continue to occur
Diagnostic tests:
• CSF studies: increased protein and IgG (immunoglobulin)
• EEG: abN
• CT scan: increased density of white matter
• MRI: shows areas of demyelination
Symptoms:
• 1st sx: visual disturbances: blurred vision, scotomas
(patchy blindness), diplopia
• Impaired sensation: touch, pain, temperature, or position
sense; numbness, tingling
• Impaired motor function: weakness, paralysis, spasticity
• Impaired cerebellar function: scanning speech, ataxic gait,
nystagmus, dysarthria, intention tremor
• Euphoria or mood swings
• Bladder: retention or incontinence
• Constipation
• Sexual impotence in the male
Nursing interventions
• Promote optimum mobility.
- Muscle-stretching and strengthening exercises
- Walking exercises to improve gait: use wide-based gait
- Assistive devices: canes, walker, rails, wheelchair as
necessary
• Administer medications as ordered.
- For acute exacerbations: corticosteroids (ACTH [IV],
prednisone) to reduce edema at sites of
demyelinization
- For spasticity: baclofen (Lioresal), dantrolene
(Dantrium), diazepam (Valium)
- Beta interferon (Betaseron) for relapsing-remitting MS
patients
• Prevent injury related to sensory problems.
- Test bath water with thermometer.
- Avoid heating pads, hot-water bottles.
- Inspect body parts frequently for injury.
- Make frequent position changes.
• Prepare client for plasma exchange (to remove antibodies)
if indicated
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
Plasmapheresis
- This treatment — also known as plasma exchange — is a
type of "blood cleansing" in which damaging antibodies are
removed from your blood.
- Plasmapheresis consists of removing the liquid portion of
your blood (plasma) and separating it from the actual
blood cells.
- The blood cells are then put back into your body, which
manufactures more plasma to make up for what was
removed.
- It's not clear why this treatment works, but scientists
believe that plasmapheresis rids plasma of certain
antibodies that contribute to the immune system attack on
the nerves.
Myasthenia Gravis (MG)
- A neuromuscular disorder in which there is a disturbance
in the transmission of impulses from nerve to muscle cells
at the neuromuscular junction (PNS), causing extreme
muscle weakness
- Highest between ages 15-35 for women, over 40 for men.
- Affects women more than men
- Cause: thought to be autoimmune disorder whereby
antibodies destroy acetylcholine receptor sites on the
postsynaptic membrane of the neuromuscular junction.
- Voluntary muscles are affected, especially those muscles
innervated by the cranial nerves.
- The first noticeable symptoms of myasthenia gravis may be
weakness of the eye muscles, difficulty in swallowing, or
slurred speech.
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Assessment findings
• Ptosis, diplopia , dysphagia, Extreme muscle weakness,
increased with activity and reduced with rest (identifying
characteristic)
• Masklike facial expression
• Weak voice, hoarseness
Diagnostic tests
• Tensilon test: IV injection of Tensilon provides
spontaneous relief of symptoms (lasts 5-10 minutes)
• Electromyography (EMG): amplitude of evoked potentials
decreases rapidly
• Presence of anti-acetylcholine receptor antibodies in the
serum
Medical management
• Drug therapy
a) Anticholinesterase drugs: neostigmine bromide
(Prostigmin), pyridostigmine bromide (Mestinon),
edrophonium chloride (Tensilon)
- block action of cholinesterase and increase levels of
acetylcholine at the neuromuscular junction
- side effects: excessive salivation and sweating,
abdominal cramps, nausea and vomiting, diarrhea,
fasciculations (muscle twitching)
b) Corticosteroids: prednisone.
- used if other drugs are not effective
- suppress autoimmune response
• Administer anticholinesterase drugs as ordered.
- Give medication exactly on time.
- Give with milk and crackers to decrease GI upset.
- Monitor effectiveness of drugs: assess muscle strength
and vital capacity before and after medication.
- Observe for side effects.
• Promote optimal nutrition.
- Mealtimes should coincide with the peak effects of the
drugs: give medications 30 minutes before meals.
- Check gag reflex and swallowing ability before feeding.
- Provide a mechanical soft diet.
- If the client has difficulty chewing and swallowing, do
not leave alone at mealtimes
- Keep emergency airway and suction equipment nearby.
• Monitor respiratory status frequently: rate, depth; vital
capacity; ability to deep breathe and cough
• Observe for signs of myasthenic or cholinergic crisis.
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
• Provide nursing care for the client with a thymectomy.
GUILLAIN BARRE SYNDROME, AMYOTOPHIC LATERAL
SCLEROSIS, AND HUNTINGTON’S DISEASE
GUILLAIN BARRE SYNDROME (GBS)/ Polyradiculoneuritis
J.A.K.E 4 of 31
Assessment findings
• Mild sensory changes; in some clients severe
misinterpretation of sensory stimuli resulting in extreme
discomfort
• Clumsiness: usually first symptom
• Progressive motor weakness in more than one limb
(classically is ascending and symmetrical)
• Cranial nerve involvement (dysphagia)
• Ventilatory insufficiency if paralysis ascends to respiratory
muscles
• Absence of deep tendon reflexes
• Diagnostic tests
- CSF studies: increased protein
- EMG: slowed nerve conduction
Medical Management
• Considered as medical emergency patient is managed in
the ICU
• Mechanical ventilation if respiratory problems present
• Plasmapheresis to reduce circulating antibodies
• Continuous ECG monitoring to detect alteration in heart
rate and rhythm
• Propranolol to prevent tachycardia
• Atropine may be given to prevent episodes of bradycardia
during endotracheal suctioning and physical therapy.
Nursing interventions
• Maintain adequate ventilation.
• Check individual muscle groups every 2 hours in acute
phase to check for progression of muscle weakness.
• Assess cranial nerve function: check gag reflex and
swallowing ability; ability to handle secretions; voice.
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
• Monitor vital signs and observe for signs of autonomic
dysfunction such as acute periods of hypertension
fluctuating with hypotension, tachycardia, arrhythmias.
• Administer corticosteroids to suppress immune reaction
as ordered.
• Administer antiarrhythmic agents as ordered.
• Prevent complications of immobility.
• Promote comfort (especially in clients with sensory
changes)
• Promote optimum nutrition.
- Check gag reflex before feeding.
- Start with pureed foods.
- Assess need for nasogastric tube feedings if unable to
swallow.
Amyotrophic Lateral Sclerosis (ALS)
- A disease of UNKNOWN cause in which there is loss of
motor neurons in the anterior horns of the spinal cord & the
motor nuclei of the lower brain stem
- Onset occurring usually in the 5th or 6th decade of life
- Leading theory: overexcitation of nerve cells by
neurotransmitter glutamate leads to cell injury and
neuronal degeneration.
Pathophysiology
1) Motor neurons in the anterior horns of the spinal cord and
motor nuclei of lower brainstem dies.
2) Muscle fibers that they supply undergo atrophic changes.
3) Neuronal degeneration may occur in both upper and lower
neuron system
Diagnostic tests
• Diagnosed on the basis of the signs & sxs
• No clinical or lab test are specific for this disease
• EMG- may indicate reduction in the # of functioning motor
units
• MRI – may show high signal intensity in the corticospinal
tracts -differentiates it from a multifocal motor neuropahy
Symptoms
• Progressive weakness and atrophy of the muscles of the
arms, trunk, or legs
• Dysarthria, dysphagia
• Spasticity
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• Fasciculations("muscle twitch") – a small, local,
involuntary muscle contraction visible under the skin
• DTRs becomes brisk and overactive
• Respiratory insufficiency
• 25% of patients: weakness starts in the muscles supplied
b the cranial nerves = difficulty talking, swallowing and
ultimately breathing
• Death usually occurs as a result of infection, respiratory
failure, or aspiration and generally occurs about 3 years
after the onset of the disease. Few patients survive for
longer periods.
Medical Management
• Drugs
- Riluzole (Rilutek)-glutamate antagonist; slows
deterioration of motor neurons
- Baclofen (Lioresal)/ Diazepam (Valium) -used to control
spasticity that interferes with ADL
- Quinine -relieve muscle cramps
• NGT feeding
• Cervical esophagostomy or gastrostomy to prevent
aspiration & for long-term nutritional support
• Mechanical ventilation if hypoventilation develops
Nursing interventions
• Provide nursing measures for muscle weakness and
dysphagia.
• Promote adequate ventilatory function.
• Prevent complications of immobility.
• Encourage diversional activities; spend time with the client.
• Provide compassion and intensive support to
client/significant others.
• Provide or refer for physical therapy as indicated.
• Promote independence for as long as possible.
Huntington’s Disease (HD) / Huntington’s Chorea (Dance)
- A chronic, progressive, hereditary disease of the nervous
system that results in slow progressive involuntary
choreiform movement and dementia
- Onset occurs between the ages of 35 & 45 years, though
10% of patients are children
- Affects men and women of all races
- Transmitted as an autosomal dominant genetic disorder:
each child of a parent w/ HD has a 50% risk of inheriting
the illness
Pathophysiology
1) Premature death of cells in the striatum, (caudate &
putamen) of the basal ganglia (for control of movts)
2) + loss of cells in the cortex (for thinking, memory,
perception & judgment)
3) + loss of cells in the cerebellum (for coordination)
4) Cells’ destruction results in lack of GABA & AcH
5) A ↓ in GABA & Ach (both excitatory neurotransmitters
leads to brisk, jerky, purposeless movements, particularly
the hands, face tongue and legs which the client is unable
to stop
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

• Arthrocentesis
Bone x-ray
- observations of bone density, alignment & swelling, &
intactness are made
- conditions of joints like: size of the joint space,
smoothness of articular cartilage & synovial swelling can
be determined
- Nursing considerations:
• inform client that there is low radiation exposure & not
dangerous
- Accdg to researches, GLUTAMINE –building block for • remove all jewelry
protein abnormally collects in the cell nucleus, causing
• instruct to remain still during the filming process
cell death
• inform the health care provider if pregnant ---pregnant
- Reason that the protein destroys only certain brain cells is
women and children are more sensitive to the risks of
UNKNOWN
the x-ray, a protective shield may be worn over areas
Diagnostic tests
not being scanned (like pregnant abdomen, testes,
• clinical presentation of characteristic sxs
ovaries)
• (+) family hx Bone Scan
• CT & MRI - may show atrophy of the caudate nuclei once
the dse is well established
2 Main Symptoms
1) Progressive mental status changes leading to dementia
– significant loss of intellectual abilities such as memory
capacity, severe enough to interfere with social or
occupational functioning
2) Choreiform movements (rapid, jerky movements) in the
limbs, trunk & facial muscles
- Other sxs: Emotional disturbance: fits of anger, suicidal
depression, impaired judgment & memory,
hallucinations, delusions & paranoid thinking
3 stages
• Onset of neurologic or psychological sxs
• ↑ng dependence on others for care
• Loss of independent functions
- Death follows from complications such as choking, fall, - Done to evaluate damage to the bones, detect cancer that
infection, pneumonia or heart failure and generally has spread (metastasized) to the bones, and monitor
occurs 10-20 years after onset of the disease. conditions that can affect the bones (including infection
Medications and trauma).
1) Phenothiazine – blocks dopamine receptors - A bone scan can often detect a problem days to months
2) Reserpine – depletes presynaptic dopamine earlier than a regular X-ray test.
3) Tetrabenezine – reduces dopaminergic transmission • "cold" spots - areas that absorb little or no amount of
Nursing interventions tracer appear as dark which may indicate a lack of
• Frequent assessment/ evaluation of patient’s motor signs blood supply to the bone (bone infarction) or the
• Interact with the patient in a creative manner presence of certain types of cancer.
• Learn how this particular patient expresses need and want • "hot" spots - areas of rapid bone growth or repair,
absorb increased amounts of the tracer and show up as
MUSCULOSKELETAL SYSTEM: ANATOMY AND bright. This may indicate the presence of a tumor, a
PHYSIOLOGY, DIAGNOSTIC TESTS, AND DISORDERS fracture, or an infection.
Musculoskeletal System - Bone scan of the spread of prostate cancer
- Diagnostic tests: - Nursing considerations:
• Bone X-ray • BEFORE:
o Consent form
• CT scan & MRI
o Tell your doctor if you are pregnant
• Bone Scan / Nuclear Scan / Scintigraphy
o Limit your fluids for up to 4 hours before the test –
• Bone biopsy
because you will be asked to drink extra fluids after
• Muscle biopsy
the radioactive tracer is injected (about 4 to 6
• Electromyography (EMG) glasses of water to help eliminate any of the
• Arthrogram/ Arthrography radioactive substance that does not collect in your
• Arthroscopy bones.
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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

o Empty your bladder – to prevent any radioactive Muscle Biopsy

urine from blocking the view of your pelvic bones
during the scan
o patient may want to bring some reading materials or
a project to pass the time during the waiting period –
they have to wait 1 to 3 hours after the radioactive
tracer is injected before their bone scan is done
o remove any jewelry that might interfere with the scan
o may need to take off all or most of their clothes,
depending on which area is being examined
• AFTER:
o some soreness or swelling may develop at the - May be done to identify or detect:
injection site= relieved by applying moist, warm • Muscular disorders such as muscular dystrophy or
compresses to the arm congenital myopathy
o encourage the client to increase fluid intake to • Metabolic defects of the muscle
facilitate urinary excretion – isotope excreted in the • Infections that affect the muscles
urine and feces within 48 hours; not harmful to • Difference between nerve and muscle disorders
others - More than one needle insertion may be needed to get a
Bone Biopsy large enough sample.
- Nursing considerations:
• no fasting or other special preparation is usually
necessary for closed biopsy
• aftercare is the same as bone biopsy
Electromyography

- to tell the difference between cancerous and non-

cancerous bone tumors and to identify other bone problem
- The sample of bone can be removed by:
• Inserting a needle through the skin and directly into the
bone (closed, needle, or drill biopsy); local anesthetic;
IV pain medication and sedative may be given.
• Making an incision through the skin to expose an area of
the bone (open biopsy); general anesthesia, spinal - Measures electrical potential associated with skeletal
anesthesia or nerve block is given for this procedure. muscle contraction
- Nursing considerations: - Nursing considerations:
• Before: • Before:
o Consent form o Consent form
o For a closed biopsy (needle biopsy), no special o Avoid using any creams or lotions on the day of the
preparation is needed. Before the test, you will be test – no other special preparation is usually
asked to undress and put on a hospital gown. You necessary-
will be awake during the procedure. You may go • After:
home shortly after a closed bone biopsy is done. If o The muscle may feel tender or bruised for a few
you have received a sedative, you may need to stay days=rest; ice
longer and have someone drive you home. Arthrogram / Arthrography
o For an open biopsy, certain preparation is needed.
Do not eat or drink anything for 8 to 12 hours before
the biopsy. You can resume normal eating after the
procedure. If an open biopsy is done, you may need
to stay in the hospital overnight.
• After:
o a bandage will be placed over the biopsy site
o keep the biopsy site covered, elevated for 24 hrs.
and dry for 48 hours.
o ice packs can prevent the development of
hematoma
o monitor for edema, bleeding & pain
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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- During arthrography, a contrast material is injected to
enable the radiologist to study the joint space that appears
on the x-ray image.
- Nursing considerations:
• notify physician if patient is pregnant
• remove jewelries
• generally, you can resume your usual activities
immediately
Arthroscopy
- Both as diagnostic test and surgical procedure
- endoscopic examination of various joints
- articular cartilage abnormalities can be assessed, loose
bodies can be removed
- large bore needle is inserted into the joint under GA or local
anesthesia
- Nursing considerations:
• Before:
o consent form
o do not consume any food or fluid for 8-12 hours
before the procedure
o you may be instructed to shave your joint area
o given a sedative before leaving for the hospital
o hospital gown
• After:
o limit activity for 1-4 days, walking w/o weight bearing
is usually permitted
o elastic wrap is worn for 2-4 days
o elevate extremity and place ice on the site
Arthrocentesis (Closed Joint Aspiration)
- Reasons for Procedure:
• Diagnose and/or treat a painful, swollen, fluid-filled
joint
• diagnose the specific type of arthritis occurring within a
joint like rheumatoid arthritis (RA)
• check for crystals in the joint fluid, which could be a
sign of gouty arthritis (GA) / gout
J.A.K.E 8 of 31
• reveal the presence of hemarthrosis (bleeding into the
joint cavity) which suggests trauma or tendency to
bleed
• verify the presence of an infection, identify the
causative agent, and follow the progress of antibiotic
therapy
• inject medications into the joint space, such as an anti-
inflammatory agent (e.g. cortisone)
- Nursing considerations:
• Before: consent form
• After:
o Compression bandage post procedure, it may take
about 5 -10 mins.
o Rest joint for 8-24 hrs.
o Take acetaminophen, ibuprofen, or some other
relatively mild pain killer for a day or two after the
procedure
o Instruct client to notify physician if fever or swelling
occurs
Musculoskeletal Disorders
Inflammatory conditions
(Synovitis, Tendonitis/ Tendinitis, Bursitis)
- Treatment:
• Rest of the extremity
• Intermittent ice & heat
• NSAIDs
- Arthroscopic synovectomy – a surgery in which the
swollen lining of the joint is removed using arthroscope to
see inside the joint like the knee.
Traumatic conditions (Contusions, Strains & Sprains)
1) Contusion
- A soft tissue injury produced by blunt force, such as
blow, kick or fall
- many small blood vessels rupture and bleed into soft
tissues = ecchymosis / bruising
- sxs; pain, swelling & discoloration
- resolves in 1-2 weeks
- There are three types of bruises:
a) Subcutaneous – beneath the skin,
b) Intramuscular – within the belly of the underlying
muscle
c) Periosteal – bone bruise
- Bruises can last from days to months, with the bone bruise
being the most severe and painful.
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

• If sprain is severe, like torn muscle fibers &

disrupted ligaments:
o Surgical repair
o Cast mobilization
• Neurovascular status (circulation, motion,
sensation) of the injured extremity is monitored
frequently.
• After the acute inflamm stage (24-48 hrs), heat may
be applied intermittently, for 15-30 mins, 4x a day to
relieve muscle spasm & to promote vasodilation,
2) Strain absorption & repair.
- a “muscle pull” • Depending on the severity of the injury, passive &
- caused by improper use, overuse, overstretching or active exercises may begin in 2-5 days.
excessive stress • Severe sprains may require 1-3 wks of
- microscopic, incomplete muscle tears w/ some immobilization.
bleeding into the tissue Joint Dislocation
- sxs: soreness, sudden pain, local tenderness on - A condition in which the articular surfaces of the bones
muscle use forming the joint are no longer in anatomic contact
- traumatic dislocations are orthopedic emergencies bec the
associated joint structures, blood supply & nerves are
distorted & severely stressed
- if not treated immediately, avascular necrosis & nerve
palsy may occur
- s/sxs: pain, change in contour of the joint, change in the
3) Sprain length of extremity, loss of normal mobility, change in the
- injury to the ligaments surrounding a joint that is caused axis of the
by a twisting motion - dislocated bones
- blood vessels rupture & edema occurs - x-ray confirms the dx & shows any assoc fracture
- sxs: joint is tender & movt becomes painful
- pain ↑ during the first 2-3 hrs. after the injury bec of
swelling and bleeding
- x-ray is needed to R/O bone injury

- On the outside of the ankle, there are three main

ligaments which help to stabilize the ankle:
• Anterior talofibular
• Posterior talofibular
• Calcaneofibular Structural defects (Scoliosis, Kyphosis, Lordosis)
- The front band (anterior talo-fibular ligament) is most 1) Scoliosis
commonly injured during severe sprains. - Scoliosis is a curving of the spine.
- Management: - The spine curves away from the middle or sideways.
• R – rest = to prevent addtnal injury & promote
healing
• I – ice = moist/ dry cold applied intermittently for 20-
30 mins during the first 24-48 hrs after injury
produces vasoconstriction bleeding, edema &
discomfort
• C – compression = elastic compression bandage
controls bleeding, reduces edema & provides
support for the injured tissues
• E – elevation = controls swelling
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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
2) Kyphosis
- Kyphosis is a curving of the spine that causes a bowing
of the back, such that the apex of the angle points
backwards leading to a hunchback or slouching posture.
3) Lordosis
- Lordosis is excessive curvature in the lumbar portion of
the spine, which gives a swayback appearance.
Spinal instrumentation – is the use of metal implants fixed to
the spine to improve spinal deformity while the fusion matures.
Fracture
- A break or disruption in the continuity of a bone
- Classification of fractures:
• by the extent of the break
1) Complete Fracture – involves a break across the
entire cross-section of the bone
2) Incomplete Fracture – the break occurs through only
part of the cross-section of the bone
• by the extent of associated soft-tissue damage
1) Closed / Simple – does not cause a break in the skin
2) Open / Compound / Complex – one in w/c the skin or
mucous membrane wound extends to the fractured
bone
- Specific types of fracture:
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- Fractures are characterized by their CAUSE:
1) Pathologic /Spontaneous fracture – occurs after
minimal trauma to a bone that has been weakened by
disease. ex. client with bone cancer or osteoporosis
2) Fatigue/ Stress fracture – results from excessive strain
or stress on the bone
3) Compression fracture – produced by loading force
applied to the long axis of cancellous bone. Often occur
in the vertebrae of clients with osteoporosis
- Clinical manifestations:
• Pain – continuous & ↑ ses in severity until bone
fragments are immobilized
• Loss of Function – fx of muscles depends on the
integrity of the bones to w/c they are attached
• Deformity – displacement, angulation or rotation of
fragments either visible or palpable
• Shortenng –due to the contraction of muscles attached
above & below the site
• Crepitus –caused by rubbing of bone fragments against
each other
• Swelling as a result of trauma & bleeding into the
tissues;
• Discoloration may not develop for several hrs after the
injury
- 4 R’s Management of Fracture
1) Recognition
2) Reduction
- Closed Reduction
- Open Reduction
3) Retention
- Fixation (internal/ external)
- Cast
- Traction
- Braces & Splints
- Bandage
4) Rehabilitation
- Fracture Reduction
• the procedure by which a fractured bone is realigned in
normal position
• it can be either closed or open
1) Closed reduction
- refers to realigning bones without breaking the
skin
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- It is performed with manual manipulation and/or
traction and is commonly done with some kind of
anesthetic (LA or GA).
- cast or splint may be applied after
2) Open reduction
- primarily refers to surgery that is performed to
realign bones or fragments
- may be treated with internal fixation devices
- cast or traction may be applied after the
procedure
• Fractures with little or no displacement may not require
any form of reduction.
- An internal fixation device may be used to keep fractured
bones stabilized and in alignment. The device is inserted
surgically to ensure the bones remain in an optimal
position during and after the healing process.
- An external fixation device – commonly used in children.
When the skin over the fracture has been damaged.
Provides more freedom of movement than with traction
- Stages of bone healing
1) Within 48-72 hrs after the injury , hematoma (a localized
swelling filled with blood) forms at the site of the
fracture because bone is extremely vascular blood
supply to and within the bone usually diminishes bec. of
the injury causes an area of bone necrosis
2) Dead cells prompt the migration of fibroblasts and
osteoblasts to the fracture site / inflammatory process
3) Formation of fibrocartilage=providing foundation for
bone healing within 3 days -2 weeks
4) Due to vascular & cellular proliferation fracture site is
surrounded by callus= a new vascular tissue within 2-6
weeks. Callus formation is the beginning of a nonbony
union
5) As healing continues, callus is transformed from loose,
fibrous tissue into bone within 3weeks- 6 months
6) Excess callus is resorbed
7) Healing, consolidation & remodeling continues up to a
year
Fracture Healing Complications
2 CATEGORIES:
1) Early
• Shock
- Hypovolemic shock resulting from hemorrhage
- May occur in fractures of extremities, thorax, pelvis
or spine
- Tx:
o restoring of blood volume &circ
J.A.K.E 11 of 31
o relieving patient’s pain
o provide adeq splinting
o protect patient from further injury & other
complications
• Fat Embolism
- most freq in young adults (20-30 y.o.) & elderly w/
proximal femur fractures
- fat globules may move into the blood bec.
o marrow pressure >capillary pressure
o cathecolamines ↑by the patient’s stress rxn
mobilize fatty acids ►promote devt. of fat
globules in the bloodstream
- fat globules (emboli) occlude small blood vessels
that supply the lungs, brain, kidneys, etc
- onset of sxs is rapid ,occurring w/in 24-72 hrs
- but may occur up to a week after injury
• Clinical Features
a) Pulmonary features: respiratory insufficiency occurs
in 75% of patients with FES presenting with dyspnea,
tachypnea, and fine inspiratory crackles 2-3 days
after injury. The chest x-ray is often normal initially
but bilateral fluffy shadows develop as respiratory
insufficiency worsens → ARDS
b) Cerebral features: neurological features often
precede pulmonary features by 6-12 hours. Patients
often present in an acute confusional state. Seizures
and decorticate posturing have also been seen in
FES. Fortunately, almost all neurological deficits are
reversible.
c) Cutaneous features: due to embolisation within the
dermal capillaries. This produces a petechial rash in
the conjunctiva, oral mucous membrane and skin
folds of the upper body, especially the neck and
axilla. The rash appears within the first 36 hours and
is self-limiting, disappearing completely within 7
days.
• Treatment: Notify MD immediately. Support respiratory
system
• Compartment syndrome
• Tx:
o Notify MD immediately (bec delay may result in
permanent nerve & muscle damage or even
necrosis)
o Elevation of extremity to the heart level
o Release of restrictive devices like dressings or cast
>>if it doesn’t relieve pain w/in 1 hr
o Fasciotomy may be needed
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

Auto-immune Disorders
Systemic Lupus Erythematosus (SLE)

• DVT
• THROMBOEMBOLISM
• PULMONARY EMBOLUS - Prevalence is 100 per 100,00 persons
• DIC - occurs 10x more freq in women
• INFECTION - 2-3x times more prevalent among people of color,
2) Late including African-Americans, Hispanics, Asians, and
- DELAYED UNION = occurs when healing does not occur Native Americans
@ a normal rate for the location & type of fracture Pathophysiology
- assoc w/ distraction (pulling apart) of bone fragments, Combination of:
systemic or local infection, poor nutrition or • Genetic
comorbidity; eventually, the fracture heals • Hormonal (evidenced by the usual onset during the
- NONUNION = failure of the ends of the fractured bone childbearing yrs bet 15-40 y.o)
to unite • Environmental factors (sunlight, thermal burns)
- problems include infection, interposn of tissue bet. The • Chemical or drug-induced:
bone ends, inadq immobilization or manipulation that • Hydralazine (Apresoline), procainamide (Pronestyl),
disrupts callus formation, excessive bone gap, limited isoniazid (INH), chlorpromazine (Thoraxine) & some
bone contact, impaired blood supply ► avascular antiseizure medications
necrosis
- Tx: internal fixation, bone grafting, electrical bone
stimulation or combination of these
- MALUNION=heal incorrectly
Avascular Necrosis

- occurs after a fracture w/ disruption of blood supply esp in

femoral neck fractures
- also seen in dislocations, bone transplantation, prolong
high dosage corticosteroid therapy, chronic renal dse,
sickle cell anemia, etc
- sxs: pain, limited movt, decrease sensation
- x-ray: Ca loss & structural collapse
- Tx: bone grafts, prosthetic replacement or arthrodesis
( joint fusion)

- Onset may be insidious or acute.

- SLE may remain undiagnosed for yrs.
- Clinical features: involves multiple body systems

J.A.K.E 12 of 31
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
Systemic Manifestations
Musculoskeletal Sys
- arthralgias (joint pain) & arthritis (synovitis) is a common
presenting sx
- joint swelling, tenderness & pain on movt are also common,
freq accompanied by morning stiffness
Skin
a) Subacute cutaneous lupus erythematosus
papulosquamous or annular polycyclic lesions
b) Discoid lupus erythematosus – chronic rash that has
erythematous papules/ plaques & scaling & can cause
scarring & pigmentation changes
c) Acute cutaneous lesion – butterfly-shaped rash across the
bridge of the nose & cheeks & most familiar occurring in <
half of patients
- Lesion worsen during flare ups (exacerbations) & provoked
by sunlight or artificial UV light
- oral ulcers may also occur
Cardiac
- pericarditis is the most common
Renal
- screening: serum creatinine levels & urinalysis
- may lead to HPN
Kidney involvement
- leading cause of death
- renal biopsies show progressive changes within the
glomeruli:
• glomeruli slightly irregular – minimal lupus nephritis
• Further glomerular changes; shows clinical signs of
renal impairment – focal/mild lupus nephritis
• 50% of glomeruli are affected; client is in renal failure –
diffuse/ severe proliferative nephritis
CNS
- widespread, encompassing the entire range of neurologic
dses
- neuropsychiatric presentations as demonstrated by
• Subtle changes of in behavior patterns or cognitive
ability
• Depression
• Psychosis
Diagnostic Tests
• Hx, physical examination & blood tests
• BUT NO SINGLE LAB TEST CONFIRMS SLE
Medical Management:
- There is no cure for SLE.
- TX is aimed to manage the disease aggressively until
remission.
• NSAIDs for minor clinical manifestations.
• Corticosteroid=single most impt. medication available
o topically to promote fading of the skin lesions
o low oral doses for minor dse activity
o high doses or IV doses for major dse activity
• Anti-malarial agent called hydroxychloroquine
(Plaquenil) for cutaneous, musculoskeletal & mild
systemic features of SLE
• Immunosuppressive agents (alkylating agents & purine
analogs) bec of its effect on immune function & for
J.A.K.E 13 of 31
patients w/ serious forms of SLE who have not
responded to conservative therapies
Nursing management
• Instruct patient abt the importance of continuing
prescribed meds.
• Addresses the changes & side effects likely w/ the use of
these meds.
– • Remind patient of the importance of monitoring bec of the
high risk for systemic involvement including renal &
cardiovascular effects.
Rheumatoid Arthritis (RA)
- CAN OCCUR @ ANY AGE, USUALLY 25 & 55 Y.O.
- 2-3x greater incidence in women
- Pathophysiology:
1) T- & B- cell proliferation. Angiogenesis in synovial lining.
2) Neutrophil accumulation in synovial fluid. Cell
proliferation. No cartilage invasion
3) Synovitis. Early pannus (proliferation of synovial tissue)
invasion. Degradation of cartilage.
4) Subchondral bone (bony plate that support the articular
cartilage) erosion. Pannus invasion of cartilage. Laxity
of ligaments.
Clinical manifestations:
- may vary, depends on the stage & severity of the dse.
- CLASSIC: joint pain, swelling, warmth, erythema & lack of
fx
- upon palpation: joints reveal spongy or boggy tissue
- begins w/ small joints in the hands, wrists & feet
progresses to the knees, shoulder, hips, elbows, ankles,
cervical spine & temporomandibular joints
- BILATERAL & SYMMETRIC
- JOINT STIFFNESS ESP IN THE MORNING LASTING FOR >30
MINS
- IMMOBILIZATION FOR EXTENDED PERIODS = RESULTS TO
CONTRACTURES, CREATING SOFT TISSUE DEFORMITY
- SYSTEMIC: fever, wt loss, fatigue, anemia, lymph node
enlargement, Raynaud’s phenomenon ( cold- & stress-
induced vasospasm causing episodes of digital blanching
or cyanosis)
- ADVANCED: NODULES ARE PRESENT
• Nontender & movable in the subq tissues
• appear over bony prominences like elbows; vary in size
& disappear spontaneously
• Other extra-articular features: neuropathy, scleritis,
pericarditis, spenomegaly & Sjögren’s syndrome ( dry
eyes & dry mucous membranes.
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

Medical Management: Degenerative/ Metabolic Disorders

1) Early-Stage RA Osteoarthritis (OA)
- education, balance of rest & exercise & referral to
community agencies for support
- sx control within the first 2 yrs of dse onset
- more aggressive pharmacologic approach earlier in the
dse.
- COX-2 inhibitors = a class of NSAIDs; cyclo-oxygenase
blocks enzyme involved in inflammatory process while
leaving intact the enzyme involved in protecting the
stomach lining ► less likely to cause gastric irritation &
ulceration
- most common & frequently disabling of the joint disorders
- antirheumatic agents: antimalarials, gold,
- Classification:
penicillamine or sulfasalazine initiated early
1) Primary / Idiopathic – no prior event or dse related to OA
- if sx appears to be aggressive ( x-ray: early bony
2) Secondary – resulting from previous joint injury or
erosions) = methotrexate to pain, tender & swollen
inflammatory dse
joints ►improve the quality of life
• distinction is not always clear
2) Moderate, Erosive RA
- formal program w/ occupational & physical therapy • OFTEN BEGINS DURING 30s AND PEAKS BET. 50s &
- medication program is reevaluated periodically w/ 60s
appropriate changes made = cyclosporine an • @ 75 YEARS, 85% OF POPULATION HAS X-RAY OR
immunomodulator may be added CLINICAL EVIDENCE OF OA but only 15%-25%
3) Persistent, Erosive RA experience significant sxs
- reconstructive surgery when pain cannot be relieved by Pathophysiology:
conservative measures; cannot be performed during 1) Risk factors: ↑ age, obesity, previous joint damage,
dse flares repetitive use (occupational/ recreational), anatomic
• Synovectomy – excision of the synovial membrane deformity, genetic susceptibility
• Tenorrhaphy-suturing a tendon 2) Affects the articular cartilage, subchondral bone &
• Arthrodesis-surgical fusion of the joint snynovium
• Arthroplasty-surgical repair & replacement of the 3) Combination of cartilage degradation, bone stiffening &
joint reactive inflamm of synovium occurs
- systemic corticosteroids for unremitting inflamm or Clinical manifestations:
pain or needs “bridging” medication while waiting for
• Primary:
the slower dse-modifying antirheumatic agent
- pain due to an inflamed synovium, stretching of the
(methotrexate) to begin working joint capsule or ligaments, irritation of the nerve
- local injection of corticosteroid for severely inflamed endings, bursitis, tendonitis & muscle spasm
joint
- JOINT STIFFNESS MOST COMMONLY EXPERIENCED IN
4) Advanced, Unremitting RA
THE MORNING OR AFTER AWAKENING & LASTS <30
- Immunosuppressive agents are prescribed: high dose
MINS & DECREASES W/ MOVT
methotrexate (Rheumatrex), cyclophosphamide
- functional impairment is due to pain on movt & limited
(Cytoxan) & azathioprine (Imuran) motion caused by structural changes in the joint
- however, these are highly toxic meds S/E: bone marrow
• OCCURS MOST OFTEN IN WEIGHT-BEARING JOINTS (hips,
suppression, anemia, GI disturbances & rashes
knees, cervical & lumbar spine), PROXIMAL & DISTAL
- Prosorba= a protein A Immunoiadsorption column used
FINGER JOINTS ARE ALSO OFTEN INVOLVED
in 12 weekly 2-hr apheresis tx to bind IgG (circulating
• BONY NODES MAY BE PRESENT ONINSPECTIONN &
immune complex)
PALPATION = PAINLESS UNLESS INFLAMM IS PRESENT
Nursing Management
Diagnostic test:
• Assess & intervene in patient concerns & issues with this
• Physical examination reveals tender & enlarge joints
kind of chronic illness.
• INFLAMM IS NOT THE DESTRUCTIVE TYPE AS IN RA
• X-ray: narrowing of joint space bec there progressive loss
of joint cartilage
• blood tests are not useful
Medical Management
• Preventive measures
- wt reduction
- prevention of injuries
- perinatal screening for congenital hip dse
J.A.K.E 14 of 31
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- ergonomic modifications
• Conservative txs
- use of heat
- wt reduction
- joint rest /avoidance of joint overuse
- orthotic devices (splint or braces)
- isometric, postural & aerobic exercises
• Meds
- initial analgesic therapy: acetaminophen
- COX-2 inhibitors
- Opioids
- Intra-articular corticosteroids
- Topical analgesics: capsaicin & methysalicylate
Surgical Management
• Osteotomy – surgical cutting of bone to alter the force
distribution in the joint
• Arthroplasty – diseased joint components are replaced
with artificial products
• Visco supplementation – reconstitution of synovial fluid
viscosity, hyaluronic acid is used w/c stimulates the
production of synoviocytes, 3-5 weekly intra-articular
injections ► pain relief for 6 months
• Tidal irrigation - (lavage of the knee) involves the
introduction & removal of large volume of saline into the
joint thru cannulas ►pain relief for 6 months
Nursing Management
• Goal » pain mgmt & optimizing functional ability
• Referral for physical therapy or to an exercise program.
• Reinforce exercise programs
• Teach in the proper use of assistive devices.
• Osteoarthritis, the most common form of arthritis,
involves the wearing away of the cartilage that caps the
bones in your joints.
• Rheumatoid arthritis, the synovial membrane that
protects and lubricates joints becomes inflamed, causing
pain and swelling. Joint erosion may follow.
Gout
- considered a hereditary disease resulting from defective
uric acid metabolism.
- Purine rich foods > end product: uric acid > metabolized by
the body and excreted === GOUT, uric acid is not excreted
> urates form > goes to the joints
- There are recurrent attacks of the pain and swelling of the
joints.
J.A.K.E 15 of 31
2 Major Types of Gout:
1) Primary gout
- most common type
- results from inborn errors of purine metabolism –end
product is uric acid
- production of uric acid exceeds the excretion capability
of the kidneys
- sodium urate is deposited in synovium & other tissues
resulting in inflammation
- inherited as an X-linked trait - males are affected
through female carriers
- 25% of clients have a family hx
- 85%-90% affects middle-aged & older men
- peak time of onset: during a person’s 30s & 40s
2) Secondary gout
- involves hyperuricemia (excessive uric acid in the
blood) caused by another disease
- affects people of all ages
- renal insufficiency, diuretic therapy & certain
chemotherapeutic agents = ↓ in the normal excretion
of uric acid & other waste products
Pathophysiology
4 Phases of the Primary Disease
1) Asymptomatic hyperuricemic phase
- serum uric acid level is elevated but no overt sign of the
disease are present
2) Acute phase
- first “attack” begins
- excruciating pain & inflamm in one or more small joints
- 75% of clients experience inflammation of
metatarsophalangeal joint of the big toe = podagra as
initial manifestation (severe pain in the big toe caused
by gout)
- also in tarsal area, ankle or knee
- less common: wrists, fingers &elbows
- ESR & WBC count are increased due to the
inflammatory process
3) Intercritical (Intercurrent)
- months or years can pass before addtnal attacks occur
- client is asymptomatic & no abnormalities are found in
the joints
4) Chronic tophaceous phase
- deposits of urate crystals (TOPHI) develop under the
skin and within the major organs, particularly in the
renal system
- urate kidney stone formation
Definitive Diagnostic:
- established by polarized light microscopy of the synovial
fluid of the involved joint Arthrocentesis…
- This special light will reveal the presence of monosodium
urate (MSU) crystals, which will nearly always confirm a
diagnosis of gout.
- Other dxtics:
• Elevated serum uric acid level
• Joint x-rays which show damage consistent with gouty
arthritis
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
Medical Management
Drug therapy is the primary component of management for
clients with gout. Acute gouty attacks, inflamm subsides
spontaneously within 3-5 days.
1) Acute gout
- combination of colchicine (Colsalide, Novocolchicine)
& NSAIDs such as indomethacin (Indocin,
Novomethacin of ibuprofen (Motrin, Amersol)
- IV colchicine works within 12 hrs.
- client takes oral meds until inflamm subsides, usually
4-7 days
2) Chronic gout
- Uricosuric agents: Probenecid (Benemid, Benuryl) 
urinary excretion of uric acid; prevents tophi formation
- Allopurinol (Zyloprim) is the drug of choice when patient
has or at@ risk for renal insufficiency or renal calculi ;
xanthine oxidase inhibitor = interrupts the breakdown
of purines before uric acid is formed ; use is limited bec
of the risk for toxicity
- Aspirin is avoided because it inactivates the effects of
the drug-
- Corticosteroids may be used in resistant cases
Nursing Management
• Patients are encouraged to restrict consumption of foods
high in purines, esp organ meats & limit alc intake;
maintain N body wt
• In acute episodes: pain management is essential
Diet and gout
Purines (specific chemical compounds found in some foods)
are likely to be broken down into uric acid.
- Foods to limit (very high in purines):
• Beef
• Pork
• Lamb
• Seafood
• Yeast (used in beer and bread)
• Alcoholic beverages, particularly beer
• Bacon
• Liver
- Foods to eat occasionally (moderately high in purines,
but may not raise your risk of gout):
• Asparagus, cauliflower, mushrooms, peas, spinach
• Whole-grain breads and cereals
• Chicken, duck, ham, and turkey
• Kidney and lima beans
- Dairy products that may lower your risk of gout:
• Low-fat or skim milk
• Low-fat yogurt
- Foods that are safe to eat (low in purines):
• Green vegetables and tomatoes
• Fruits and fruit juices
• Breads and cereals that are not whole-grain
• Butter, buttermilk, cheese, and eggs
• Chocolate and cocoa
• Coffee, tea, and carbonated beverages
• Peanut butter and nuts
J.A.K.E 16 of 31
Osteoporosis
- a metabolic disease in which bone demineralization results
in decreased density and subsequent fractures= BONES
BECOME PROGRESSIVELY POROUS, BRITTLE & FRAGILE
- Often referred as “silent disease.” …because bone loss
occurs without symptoms.
- "You may not know that your bones have become porous
(not as dense) until a sudden strain, bump, or fall causes a
fracture."
- Most often affected bones: wrist, hip, vertebral column
- 40-45% of a woman’s bone mass is lost during her life
span.
- Bone density test being done at the ankle using a
peripheral device.
- Bone density (DEXA) measurements to assess overall bone
health status.
- These low energy Xray tests will be used to measure the
bone mineral density (BMD) of both hips, the lumbar spine
(both AP and lateral views).
- These DEXA tests usually require 20 to 30 minutes for
completion.
Management:
• Drug Therapy: HRT (Hormone replacement therapy)
- has been used as a primary prevention strategy for
reducing bone loss in the postmenopausal woman
- long-term effects: high woman’s risk of breast cancer,
cardiovascular dse & stroke
- conjugated estrogens/ medroxyprogesterone (Prempro,
Premphase) use are carefully evaluated by the health
care provider & client
• PTH
- approved tx for both men & women
- self-administered, daily subq injection teriparatide
(Forteo)
- stimulates new bone formation = increasing BMD
- monitor for s/sxs of hypercalcemia: fatigue, anorexia,
n&v, constipation, polyuria
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

• Calcium
- Ca alone is not a tx but an impt part of a prevention
program to promote bone health
- OTC supplements like calcium carbonate (Tums/
Oscal) ; calcium citrate (Citracal)
- Taken with foods & 6-8 ozs of water
• Vitamin D
- for optimal Ca absorption in the intestines
- 400-800 International Units/day Treatment
• Biphosphonates
• Oral supplements of vitamin D, calcium, and phosphorus
- inhibit bone resorption by binding with crystal elements
may be given depending on the underlying cause of the
in bone, esp spongy, trabecular bone tissue
disorder.
- 3 BPs: alendronate (Fosamax), ibandronate (Boniva) &
• Larger doses of vitamin D and calcium may be needed for
risedronate (actonel) are commonly used for the
people with intestinal malabsorption.
prevention & management of osteoporosis
- side effects: not common but when it occurs, they tend • Mineral calcium – calcium is essential for the formation
to be serious and maintenance of bones and teeth, blood clotting,
= esophagitis & esophageal ulcers esp if the tablet is normal heart beat and hormone secretion. Food sources of
not completely swallowed calcium include diary products, green leafy vegetables and
= s/sxs: chest pain; d/c drug & call their doctor salmon and sardines.
- early AM with 8 ozs of water & wait 30 mins before • Vitamin D – the body itself makes vitamin D when it is
eating exposed to the sun. cheese, butter, margarine, fortified
- c/i to clients with poor renal fx, gi reflux dse (GERD) cereals are food sources of vitamin D.
• SERMs (Selective Estrogen Receptor Modulators)
- newer class of drugs designed to mimic estrogen in Infectious Disorders
some parts of the body while blocking its effect Osteomyelitis
elsewhere It became infected by one of 3 MODES:
- raloxifene (Evista) 1) Extension of soft tissue infection (infected pressure or
vascular ulcer, incisional infection)
• Calcitonin
2) Direct bone contamination fr bone surgery, open fracture
- thyroid hormone that inhibits osteoclastic activity, thus
or traumatic injury (GSW)
decreasing bone loss
3) Hematogenous (bloodborne) spread fr other sited of
- IM or subq salmon calcitonin (refrigerated); intranasally
infection (infected tonsils, boils, infected teeth, upper resp
Miacalcin = preferred bec it improves compliance,
infections). Typically occurs in a bone area of trauma or
minimizes side effects & is convenient ; alternate
lowered resistance.
nostrils to prevent s/e like nasal mucosal irritation
- salmon calcitonin may  its effect are use for 2 or more
years = requires holiday from this tx
Diet Therapy
• Increase Ca & vit D intake; alcohol & caffeine discouraged
• If w/ fracture: protein, vit C & iron intake
Exercise
• Plays a vital role in pain management & cardiovascular fx
together with the physician , PT prescribes exercises for
strengthening the abdominal and back muscles which
improve posture & provide improved support for the spine,
deep breathing
• General weight-bearing exercise program= walking for 30
mins 3x a week, swimming, biking
• High-impact recreational exercises (horseback riding,
bowling) are avoided bec it may cause vertebral
compression
Osteomalacia - At high risk:
- Osteomalacia is softening of the bones, caused by not • Poorly nourished
having enough vitamin D, or by problems with the • Elderly
metabolism (breakdown and use) of this vitamin. • Obese
- These softer bones have a normal amount of collagen that • Impaired immune system
gives the bones its structure, but they are lacking in • w/ chronic illness (DM, RA)
calcium. • w/ long term steroid therapy
J.A.K.E 17 of 31
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

Clinical Manifestation • to prevent pathologic fracture= internal fixation or

3 MODES external supportive devices may be needed
A. Extension of soft no sxs of septicemia Nursing Management
tissue infection • Relieving pain
B. Direct bone swollen, warm, painful & tender to • Improving physical mobility
contamination touch • Controlling infectious process
C. Hematogenous onset is sudden • Teaching self-care
(bloodborne) sxs of septicemia: chills, high fever, Pott's Disease
spread PR, general malaise - Tuberculosis (TB) of the backbone is not common, but is
=systemic sxs overshadow the local sxs still seen in poor communities, especially in children.
►as infection extends into the cortex of - It is the most common form of tuberculosis of the bone.
the bone - It is important to recognize and treat it early, before
infected area has constant, pulsating damage to the backbone causes nerve damage and
pain that intensifies w/ movt bec of paralysis.
pressure of the collecting pus+ it is - Signs
swollen & extremely tender • It begins little by little-often without pain at first.
• Patient w/chronic osteomyelitis presents w/ continuously • A bump develops in the backbone. This is because the
draining sinus; experiences recurrent periods of pain, front part of one or more vertebrae is destroyed and
inflamm, swelling & drainage = low-grade infection thrives collapses.
in scar tissue bec of its reduced blood supply • The child has trouble bending over to pick things up.
Diagnostic test - Prevention
1) Acute • consists of early diagnosis and treatment of
- Early X-ray: soft tissue swelling tuberculosis, and in the fight against poverty.
- After 2 wks X-ray: areas of irregular decalcification, • Vaccination against TB may also help.
bone necrosis, periosteal elevation & new bone - It is a presentation of extrapulmonary tuberculosis that
formation affects the spine, a kind of tuberculous arthritis of the
- Bone scan (isotope-labeled WBC scan) & MRI help w/ intervertebral joints.
early definitive dx - It is named after Percivall Pott (1714-1788), a London
- Wound & Blood culture studies: to identify appropriate surgeon.
antibiotic therapy - Scientifically, it is called tuberculous spondylitis.
2) Chronic - The usual sites to be involved are the lower thoracic and
- X-ray: large, irregular cavities, raised periosteum, upper lumbar vertebrae.
sequestra or dense bone formations - In adults, disc disease is secondary to the spread of
- Bone scan: to identify areas of infection infection from the vertebral body but in children it can be a
- ESR & WBC count: N; may present w/ anemia assoc w/ primary site, as the disc is vascular in children.
chronic infection - SXS:
- Abscess Culture to identify infective organism & • Back pain
appropriate antibiotic therapy • Fever
Treatment • Night sweating
• Acute: IV antibiotic therapy (Staph-sensitive to • Anorexia
semisynthetic penicillin & cephalosporin) RTC, continues • Weight loss
up to 3-6 weeks then orally for up to 3 months (taken w/o • Spinal mass, sometimes assoc with numbness, tingling,
food) or muscle weakness of the legs
• If patient did not respond to antibiotics: surgically exposed, Diagnostic Test
pus & necrotic tissue removed, area is irrigated w/ sterile • blood tests - elevated ESR
saline soln, antibiotic-impregnated beads may be placed in • tuberculin skin test
the wound for 2-4 weeks, IV therapy continued • radiographs of the spine
• Chronic: IV antibiotics + surgical debridement • bone scan
- SEQUESTRECTOMY-removal of enough involucrum to • CT & MRI of the spine
remove sequestrum • bone biopsy
- SAUCERIZATION-sufficient bone is removed to convert
Late complications:
a deep cavity into a shallow saucer
• closed suction irrigation system may be used to • Vertebral collapse resulting in kyphosis
remove debris for 7-8 days • Spinal cord compression
• w/ large defect= cavity may be filled w/ vascularized • Paraplegia (so called Pott's paraplegia)
bone transfer or muscle flap

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

Prevention: • symptoms are intermittent. They will commonly occur

• BCG vaccination at night or when driving.
• Improvement of socio-economic conditions • Many people will describe waking up in the night with
• Prevention of HIV and AIDS their hands feeling dead or numb, some say that their
• Patients who have a positive PPD test (but not active fingers feel like sausages.
tuberculosis) may  their risk by properly taking medicines • Holding the wrists bent will also bring on the problem.
to prevent tuberculosis - The best way of making the diagnosis is on the history,
• To effectively treat tuberculosis, it is crucial that patients however sometimes that is not enough.
take their medications exactly as prescribed. - There are several tests that can be done:
• Tinel's sign is performed by briskly tapping a nerve, the
Therapy:
median nerve at the wrist. (+) = results in shooting
• Non-operative - antituberculous drugs electric-like sensations in the distal distribution of the
• Analgesics nerve
• Immobilization of the spine region by rod (Hull) • Phalen's test is performed by asking the patient to hold
• Surgery may be necessary, especially to drain spinal her wrist in maximum flexion. (+) = if the thumb and
abscesses or to stabilize the spine finger becomes numb
Carpal tunnel syndrome (CTS)
Nonsurgical Treatment
Activities that are causing your symptoms need to be changed
or stopped:
• Avoid …
- repetitive hand motions
- heavy grasping
- holding onto vibrating tools
- positioning or working with your wrist bent down and
out
- smoking
• Lose weight if you are overweight.
- The carpal tunnel is an opening through the wrist to the • A wrist brace will sometimes decrease the symptoms in
hand that is formed by the bones of the wrist on one side the early stages of CTS. A brace keeps the wrist in a resting
and the transverse carpal ligament on the other. position, not bent back or bent down too far.
- This opening forms the carpal tunnel.
- The median nerve passes through the carpal tunnel into the
hand.
- It gives sensation to the thumb, index finger, long finger,
and half of the ring finger.
- Carpal tunnel syndrome (CTS) is a common problem
affecting the hand and wrist.
- Symptoms begin when the median nerve gets squeezed
inside the carpal tunnel of the wrist, a medical condition
known as nerve entrapment.
- This syndrome has received a lot of attention in recent
years because of suggestions that it may be linked with
occupations that require repeated use of the hands, such
as typing on a computer keyboard or doing assembly work.
- Actually, many people develop this condition regardless of
the type of work they do.
- any condition that makes the area inside the carpal tunnel
smaller or increases the size of the tissues within the
tunnel = can lead to symptoms of CTS.
- Example:
• after a wrist fracture or dislocation, the area inside the
tunnel can also be reduced, if the bone pushes into the
tunnel
• A traumatic wrist injury may cause swelling and extra
pressure within the carpal tunnel
- First symptoms of CTS
• Gradual tingling and numbness in the area

J.A.K.E 19 of 31
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
• Anti-inflammatory medications may also help common
OTC medications such as ibuprofen and aspirin oral
steroid medications
• High doses of vitamin B-6
• Cortisone injection may help ease symptoms and can aid
the doctor in making a diagnosis
• Open release procedure involves simply cutting the
transverse carpal ligament.
• Endoscopic carpal tunnel release
- Hallux valgus actually describes what happens to the big
toe.
- Hallux is the medical term for big toe, and valgus is an
anatomic term that means the deformity goes in a direction
away from the midline of the body.
- “the big toe begins to point towards the outside of the foot”
- A bunion is when your big toe points toward the second toe.
- Bunions are often caused by narrow-toed, high-heeled
shoes.
- These compress the big toe and push it toward the second
toe. The condition may become painful as extra bone and a
fluid-filled sac grow at the base of the big toe. This leads to
swelling and pain. Bunions occur more frequently in
women and sometimes run in families.
- If the bunion gets worse -- resulting in severe deformity or
pain -- surgery to realign the toe and remove the bony
bump = bunionectomy = can be effective.
- Hallux Valgus Splint – completely immobilizes the hallux
for uninterrupted healing
J.A.K.E 20 of 31
EYES: ANAPHYSIO, DIAGNOSTIC TEST, AND DISORDERS
Anatomy and Physiology
- Protected by:
• bony orbits & pads of fat surrounding each eye dorsally
• eyelids & eyelashes which close over the eyes
• lacrimal apparatus/ glands lubricating & washing off
foreign particles
• conjunctiva which lines the eyelids & covers exposed
scleral surface
1) The cornea is the clear surface of the outer eye which can
be damaged by infections.
2) The iris gives the eye color.
3) The pupil is the black hole within the iris that lets light into
the eye. It changes size in response to light levels, among
other things.
4) The lens is the internal focusing element of the eye, it is
curved on both sides. The clear lens becomes cloudy when
a cataract forms.
5) The conjunctiva is the thin lining of the inside of the eyelid.
It extends over the front of the white part of the eye.
6) The retina is the light sensitive part of the eye.
7) The optic nerve. In glaucoma, the rise in fluid pressure in
the eye damages the nerve fibers entering the optic nerve
from the retina.
- Wall of the eyeball is composed of 3 layers:
1) Outer fibrous protective layer
- Posteriorly = sclera, the ‘white of the eye’ with firm
tough connective tissue
- Anteriorly = cornea, ‘window of the eye’ a forward
continuation of the sclera, transparent & avascular
2) Middle vascular layer – pigmented
- posterior = choroid
- anterior = ciliary body & iris the iris being the
extension of the ciliary body +pupil which
regulates the amount of light entering the interior of
the eye
3) Inner neural layer – with layers of nerve cells including:
photo receptors
a) Rods
- concentrated along the outer perimeter of the
retina
- help us to see images that come into our
peripheral or side vision
- help us to see in dark and dimly lit environments
b) Cones
- concentrated in the macula, the center of the
retina
- allow us to perceive color
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- Together, rods and cones are the cells
responsible for converting light into electrical
impulses that are transmitted to the brain where
"seeing" actually occurs.
Process of vision
- Light waves from an object (such as a tree) enter the eye
first through the cornea, which is the clear dome at the
front of the eye.
- The light then progresses through the pupil, the circular
opening in the center of the colored iris.
- Next, the light passes through the crystalline lens, which is
located immediately behind the iris and the pupil.
- Initially, the light waves are bent or converged first by the
cornea, and then further by the crystalline lens, to a nodal
point (N) located immediately behind the back surface of
the lens.
- At that point, the image becomes reversed (turned
backwards) and inverted (turned upside-down).
- The light continues through the vitreous humor, the clear
gel that makes up about 80% of the eye’s volume, and then,
ideally, back to a clear focus on the retina behind the
vitreous.
- The small central area of the retina is the macula, which
provides the best vision of any location in the retina.
- If the eye is considered to be a type of camera, the retina is
equivalent to the film inside of the camera, registering the
tiny photons of light which interact with it.
- Within the layers of the retina, light impulses are changed
into electrical signals and then sent through the optic nerve,
along the visual pathway, to the occipital cortex at the
posterior or back of the brain.
- Actually, then, we do not “see” with our eyes but, rather,
with our brains. Our eyes merely are the beginnings of the
visual process.
- Visual acuity depends on a healthy, functioning eyeball and
an intact visual pathway. This pathway is made up of the
retina, optic nerve, optic chiasm, optic tracks, lateral
geniculate bodies, and optic radiations, and the visual
cortex area of the brain. The pathway is an extension of the
central nervous system.
- The optic nerve is also known as the second cranial nerve
(CN II). Its purpose is to transmit impulses from the retina
to the occipital lobe of the brain.
- The optic nerve head, or optic disc, is the physiologic blind
spot in each eye. The optic nerve leaves the eye and then
meets the optic nerve from the other eye at the optic
chiasm. The chiasm is the anatomic point at which the
nasal fibers from the nasal retina of each eye cross to the
opposite side of the brain.
- The nerve fibers from the temporal retina of each eye
remain uncrossed.
• Fibers from the right half of each eye, which would be
the left visual field, carry impulses to the right occipital
lobe.
• Fibers from the left half of each eye, or the right visual
field, carry impulses to the left occipital lobe.
- Beyond the chiasm, these fibers are known as the optic
tract. The optic tract continues on to the lateral geniculate
body. The lateral geniculate body leads to the optic
J.A.K.E 21 of 31
radiations and then to the cortex of the occipital lobe of the
brain.
Eye Diagnostic Tests
Snellen Chart
- Visual acuity (vision) is determined in each eye using the
Snellen Chart. This chart consists of random letters of
different sizes.
- The letters for normal vision (20/20) are 3/8-inch tall,
viewed at 20 feet. People with normal vision can read these
letters.
- A refraction test may also be performed (the doctor puts
several lenses in front of the eyes to determine if glasses
are needed).
Tonometry
- a procedure that measures the pressure inside the eyes.
The test is used to screen for glaucoma.
- There are three types of tonometry:
a) Air Puff – This is the only type of tonometry that does not
touch the surface of the eye. The patient sits upright at
the instrument, and a warm puff of air is directed at the
eye.
b) Applanation – The patient’s eye is first treated with
numbing drops and a stain called fluorescein. The
tonometer is then placed gently on the cornea, and a
very small amount of pressure is applied to the cornea.
A hand-held tonometer may be used.
c) Schiotz – older version of applanation. This type of
tonometer was formerly used in the operating room or
with people who are unable to sit upright (such as
infants or small children).
- The Keeler Pulsair Desktop Tonometer uses advanced
optical and sensor technology for positional detection and
puff control.
- Before the test:
• Remove contact lenses before the examination. The dye
can permanently stain contact lenses.
• Inform the health care provider if you have: corneal
ulcers and infections, an eye infection, taking any drugs,
with history of glaucoma
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

- After: Slit-lamp Biomicroscopy

• If the applanation method is used, there is a small - Looks at structures that are at the front of the eye.
chance the cornea may be scratched (corneal abrasion). - The slit-lamp is a low-power microscope combined with a
This will normally heal itself within a few days. high-intensity light source that can be focused to shine as
Gonioscopy a slit beam.
- an eye examination to look at the front part of your eye - No special preparation is necessary for this test.
(anterior chamber) between the cornea and the iris. - The slit lamp exam is usually done at an optometry or
- Gonioscopy is done to: ophthalmology office. The exam is also called
• Evaluate the anterior chamber of the eye when biomicroscopy; Slit-Lamp Biomicroscopy. It allows the
glaucoma is suspected. doctor to microscopically examine your eyes for any
• Determine whether the drainage angle of the eye is abnormalities or problems.
closed or nearly closed. - can determine type of - What does this exam help diagnose? A slit lamp exam
glaucoma- can help diagnose the following conditions:
• Treat glaucoma. – laser light can be directed through • Macular degeneration, a chronic condition affecting the
the goniolens at the drainage angle. part of the eye that is responsible for central vision
• Check for birth defects that may be causing glaucoma. • Detached retina, a condition when the retina, which is
- Before the test: an important layer of tissue at the back of the eye,
• Remove contact lenses before this test becomes detached from its base
• Do not put them back in until at least an hour after the • Cataracts, a clouding of the lens that negatively affects
test , until the anesthetic medication wears off. the ability to see images clearly
- After: • Injury to the cornea, an injury to one of the tissues that
• If your eyes may be dilated during your examination, you covers the surface of the eye
should arrange for someone to drive you home after the • Blockages of the retinal vessel, obstructions in the
test. eye’s blood vessels that can cause a sudden or gradual
• You should not rub your eyes for at least 20 minutes loss of vision
after the test, or until the anesthetic wears off. Perimetry/ Automated perimetry
Ophthalmoscopy / Fundoscopy - You sit in front of a concave dome and stare at a central
- An examination of the back part of the eyeball (fundus), target within the dome.
which includes the retina, optic disc, choroid, and blood - A computer-driven program flashes small lights at different
vessels. locations within the dome's surface, and you press a
• The direct ophthalmoscope is an instrument about the button when you see the small lights in your peripheral
size of a small flashlight (torch) with several lenses that vision.
can magnify up to about 15x. - Your responses are compared to age-matched controls to
• The binocular indirect ophthalmoscope, or indirect determine the presence of defects within the visual field.
ophthalmoscope, is an optical instrument worn on the - The test will detect any loss of peripheral vision and
examiner's head, and sometimes attached to provide a map of that loss which will be helpful in
spectacles, that is used to inspect the fundus or back of diagnosing the cause.
the eye. It produces an stereoscopic image with - No special preparation is necessary for these tests.
between 2x and 5x magnification. Uses Drug Action
- Before the test:
• Indirect ophthalmoscopy are performed after eye drops -eye 1.Local Anesthetics =decrease pain
are placed to dilate the pupils. examinations; a. Topical perception in the
-surgery; Tetracaine HCl eyes
• Direct ophthalmoscopy can be performed with or
-treatment (Pontocaine)
without dilation of the pupil.
b. Injectable
• Inform the health care provider if you have: corneal
Lidocaine HCl
ulcers and infections, an eye infection, taking any drugs,
(Xylocaine)
with history of glaucoma
- After: -examination 2. Mydriatics =dilate pupils by
• The dilating drops may impair focusing of the eyes for of the Phenylepherine causing
several hours. interior of the HCl contraction of
o Arrangements should be made for someone else to eye; (Neo-Synephrine) dilator muscle of
drive after the examination. -prevent the iris with
o Wearing sunglasses or tinted lenses will make the adhesions of minimal effect on
patient with dilated pupils more comfortable. iris with ciliary muscle
cornea in which lessen
inflammations effect on
accommodation

J.A.K.E 22 of 31
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

-eye 3. Cycloplegics =dilate pupil Measurement of Vision

examination; Atropine Sulfate =paralyze ciliary - Visual Acuity – measures both distance & near vision…
-decrease (Isoptoatropine) muscle & iris Snellen chart (dxtic test)
pain & Scopolamine • Near-vision testing-for clients with difficulty reading &
photophobia hydrobromide over 40 yrs old
& provide rest • Handheld snellen chart (Rosenbaum Pocket Vision
for Screener or Jaeger card); held 14 inches away from his
inflammation eyes & read
of the iris & • Record the value of the lowest line which the client can
ciliary body & identify more than half the characters
for diseases - Visual Field or peripheral vision
of cornea • Crude estimation
• Automated perimetry
Physical Assessment of the Eye • hemianopia-blindness in one half the field of vision
Inspection • quadrantanopia-blindness in one fourth of the field of
- Compensatory stances: head tilting, squinting vision large scotomas-blind spots in the visual field
- Assess for symmetry in the appearance of the eyes Assessment of Extraocular Muscle Function
• Equal distance from the nose - Tests: Six cardinal position of gaze-eye will not turn to a
particular position
• Same size
- if the muscle is weak or if the controlling nerve is affected.
• Same degree of prominence
nystagmus-involuntary & rapid twitching of the eyeball is a
- Assess for placement in the orbits & for symmetry &
normal finding for the far lateral gaze or it may also be
movement
caused by abnormal nerve function
• Exophthalmos(proptosis)-protrusion of the eyes
• Enophthalmos-sunken appearance of the eyes
- Hair distribution & direction of eyebrows & eyelashes –
normally point outward & away from the eyelid
- Eyelid: ptosis (drooping), redness, lesions or swelling
Scleral & Corneal Assessment
- Color: white
• Yellow - jaundice or systemic problems
• For dark-skinned, normally yellow & with small
pigmented dots
- Cornea: transparent, smooth, shiny, & bright. Cloudy
areas my be a result of accidents or injuries
- Blink reflex:
• Bringing a fist quickly toward the client’s face
• Expelling a syringe full of air toward the eyes
Pupillary Assessment
- Round & equal in size
- Smaller in older adults
- Normal pupil diameter 3 - 5 mm Assessment of Color Vision
- Observe for response to light - Ishihara chart-shows numbers composed of dots of one
• Assess for the normal response to light: Direct color within a circle of dots of different color
response-constriction of the right pupil while shining a - test each eye separately by asking the client what numbers
penlight into the right eye. Consensual response- he sees on the chart; reading the numbers correctly
constriction of the left pupil when light is shined at the indicates normal vision
right pupil
Inflammatory Conditions of the Eye
• Assess for speed of reaction: brisk-rapid response ;
Conjunctivitis
sluggish-takes more than 1 sec to constrict;
- Inflammation or infection of the membrane lining the
nonreactive or fixed-fail to react
eyelids (conjunctiva).
- Assess for accommodation: hold the index finger abt 18
- Viruses are the most common cause.
cm from the client’s nose & move it toward the nose;
- Other causes: bacteria, chlamydia, fungus, and rarely,
client’s eye should converge & pupils constrict equally
parasitic agents.
- "Pink eye" refers to a viral infection of the conjunctiva.
- These infections are especially contagious among children.
- Handwashing is key to preventing the spread of the virus,
which is similar to the type that cause the common cold.
J.A.K.E 23 of 31
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- Treatment depends on the cause.
- Allergic conjunctivitis may respond to treatment for
underlying allergies, or it may disappear on its own when
the allergen that caused it is removed.
- Cool compresses may be soothing for allergic
conjunctivitis.
- Antibiotic medication, usually eye drops, is effective for
bacterial conjunctivitis.
- Viral conjunctivitis will disappear on its own.
- Discomfort can be soothed by applying warm compresses
– a clean cloth soaked in warm water to closed eyes
Iritis/ uveitis
- An inflammation (swelling and irritation) of the the uvea.
- The uvea is the layer of the eye between the sclera and the
retina.
- This layer includes the iris, ciliary body, and the choroid.
- The uvea provides most of the blood supply to the retina.
- Causes of uveitis can include autoimmune disorders,
infection, or exposure to toxins.
- However, in many cases the cause remains unknown.
- Iritis/ uveitis is usually mild.
- Pain caused by spasm of the pupil constriction muscle is
relieved by drops to dilate the pupil.
- Dark glasses may be helpful.
- Steroid eye drops or ointment may be needed.
- More severe cases require a search for an underlying cause.
Interstitial keratitis
- The inflammation of the connective tissue of the cornea,
which can lead to vision loss.
- Interstitial keratitis is a serious condition, in which blood
vessels grow into the cornea.
- Such growth can cause loss of the normal transparency
(clarity) of the cornea.
- This condition is often caused by infections and may cause
severe visual problems.
- Syphilis is the most common cause of interstitial keratitis,
but rare causes include leprosy and tuberculosis.
- Interstitial keratitis is the most common cause of blindness
in the world.
- Symptoms: Eye pain, Photophobia, Excessive tearing
- The underlying disease must be treated.
- Treatment: Corticosteroid drops may minimize scarring
and help preserve the clarity of the cornea.
Retinitis Pigmentosa (RP)
- the name given to a group of hereditary retinal diseases
characterized by progressive loss of visual field, night
blindness and reduced or absent electroretinogram (ERG
test) recording, which indicates that a large portion of the
retina is damaged.
- RP causes the degeneration of photoreceptor cells in the
retina. Photoreceptor cells capture and process light
helping us to see.
- As these cells degenerate and die, patients experience
progressive vision loss.
- Symptoms
• Normal visual acuity in early stages, possibly -- but not
usually – progressing to no light perception
• Donut shaped visual field loss progressing to severe
constriction (loss of peripheral vision)
J.A.K.E 24 of 31
• Night blindness
• Decreased response to magnification
• Need for more light
Scleritis
- An inflammation (redness and swelling) of the sclera.
- The sclera is the hard, white outside coating of the eye that
provides rigid structural support to the eye.
- The sclera is closely related to the connective tissues that
provide support to joints.
- Causes
• Most of them are related to joint diseases (arthritis) like
rheumatoid arthritis or lupus (SLE).
• Sometimes scleritis occurs as part of an eye infection,
especially shingles.
• In many patients no cause can be found for the scleritis.
• Most patients with scleritis undergo a number of blood
tests to determine if there is an underlying cause.
• In many patients the disease appears to be localized to
the eye and there is no disease elsewhere in the body.
- Treatment
• Depends very much on how severe the inflammation is
o Oral steroids (prednisolone)
o Simply use oral Naprosyn (or other non steroidal
anti-inflammatory drug).
o Mild disease: simply eye drops or steroid injections
• Unfortunately, even though scleritis can be treated, it
cannot be cured.
• Moreover, scleritis is a relapsing disease and even if
one recovers fully from an attack, it is quite possible
that the scleritis will recur.
• One good thing about scleritis is that it is very
uncommon for the vision to be permanently affected.
• Even though vision may be blurred and the eye may be
very painful during the attacks, the usual pattern is for
the vision to return completely to normal at the end of
the attack.
Uses Drug Action
-eye 1.Local Antibiotics =antiinfectives
inflammations Gentamicin sulfate =antiinflammatory
(Garamycin)
2. Adrenal
Corticosteroids
Prednisone
Hydrocortisone
(Solucortef)
Refractive Error
- Means that the light rays are not focused properly on the
retina which results in blurred vision.
Myopia (Short sight / Nearsightedness)
- Eye is longer than normal or cornea is too steep, so that
light rays focus in front of the retina.
- Near objects are clear but distance objects appear blurred.
- Nearsightedness typically is corrected with a concave lens.
Hypermetropia (Long sight / Farsighted)
- Eye is shorter than normal or the cornea is too flat, so that
light rays focus behind the retina.
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- Light rays from the close object such as pages of the book
cannot focus clearly on retina.
- Farsightedness typically is corrected with a convex lens.
Astigmatism (Distorted vision)
- Cornea is more curved in one direction than in the other.
Vision is blurred for both near and distant object.
- Astigmatism is corrected optically with a cylindrical lens.
Presbyopia (Aging eye)
- When we are young, the lens in the eye is soft and
moldable. It changes its shape easily allowing us to focus
on near objects.
- After the age of 40, the lens becomes hard and rigid. As the
lens cannot change the shape, it is more difficult to read at
close range. This condition is called presbyopia.
- Bifocal lenses have two different optical powers within the
same lens.
• Eye glasses or contact lenses are the most common
methods of correcting the refractive errors.
• Refractive surgery is also an option to correct or to improve
the vision.
• These surgical procedures are used to adjust the eyes
focusing ability by reshaping the cornea or front surface of
the eye.
• The refractive surgeries can be done after the age of 18 or
after the stabilization of refractive power.
• There is no adequate scientific evidence to suggest that
eye exercise, vitamins or pills can prevent or cure refractive
errors.
General Care for Eye Surgeries
Preop:
- orient patient to staff & physical environment
- if both eyes are to be covered, provide call light
- prepare meds to dilate the pupils
Post-op:
- General goal is to prevent IOP, stress on suture line,
hemorrhage into the anterior chamber (hyphema), &
infection
• Keep head still & avoid coughing, vomiting, sneezing,
moving suddenly, bending forward, lifting head or hips,
straining, or squeezing the eyelids
- if sneezing or coughing—open mouth
- if vomiting –eyelids should be kept open
- meds: cough medicines, antiemetics, stool
softeners & laxatives
• Patient should lie on unoperated side down
• Patient may lie on his back
• Side rails up
• Burning sensation 1 hr after operation –anesthetic
wearing off
• Advise client:
- edema of eyelids subside within 3-4 days
- feeling of “something in the eye” 4-5 days –due to
sutures
- not to bend, stoop or lift objects for several weeks
- sensation of pressure within the eye & sharp pain —
may indicate bleeding, report to surgeon
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EARS: ANAPHYSIO, DIAGNOSTIC TEST, AND DISORDERS
Anatomy and Physiology
- Ear – both functionally and anatomically, it can be divided
into three parts.
External Ear
- Function: collect sound waves and direct them to the
middle portion of the ear
- Consists of:
• Auricle / pinna
• Air canal /external auditory canal
Middle ear
- The bridge of ossicles hangs across the air space in the
middle ear.
- This bridge starts with the malleus which is attached to the
eardrum and ends with the stapes which is attached to the
oval window, another kind of eardrum.
Inner ear
- Consists of: fluid-filled labyrinth
• Functions to convert mechanical energy into neural
impulses
• Fluid surrounding the membranous labyrinth =
perilymph (communicates directly with CSF via the
cochlear aqueduct)
• fluid within = endolymph
- There are 3 main divisions of the labyrinth:
• Vestibule an antechamber just medial to the oval
window leading to both the cochlea and the
semicircular canals
• Cochlea responsible for converting sound vibrations
into nerve impulses that the human brain interprets as
sound and what we call "hearing“
• Semicircular canals organ for balance; including the
utricle & saccule
- The utricle lies horizontally in the ear, and detects motion
in the horizontal plane.
- The saccule is oriented vertically, so detects motion in the
sagittal plane (up and down, forward and back).
- The oval window sits immediately behind the stapes, and
begins vibrating when "struck" by the stapes. This sets the
fluid of the inner ear sloshing back and forth.
- The round window serves as a pressure valve, bulging
outward as fluid pressure rises in the inner ear.
- Organ of Corti – the sensitive element in the inner ear. Can
be thought of as the body's microphone. It is situated on
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

the basilar membrane in one of the three compartments of Hearing assessment

the cochlea Whisper test
1) Stand 1-2 feet behind client so they can not read your lips.
2) Instruct client to place one finger on tragus of left ear to
obscure sound.
3) Whisper word with 2 distinct syllables towards client's right
ear. (ex. baseball)
4) Ask client to repeat word back.
5) Repeat test for left ear.
6) Client should correctly repeat 2 syllable word.
Weber test
1) Distinguishes between conductive and sensorineural
hearing.
2) Strike a 512 Hz tuning fork softly
- 8th Cranial Nerve – fibers arise from the hearing and 3) Place the vibrating fork on the middle of the client's head
equilibrium apparatus of the inner ear, pass through the 4) Ask client if the sound is heard better in one ear or the
internal acoustic meatus, and enter the brainstem at the same in both ears
pons-medulla border a) If hearing is normal, the sound is symmetrical with no
- Two divisions: lateralization
1) Cochlear (hearing) b) Sound localizes toward the poor ear; with a conductive
2) Vestibular (balance) loss
- Functions are solely sensory – equilibrium and hearing c) Sound localizes toward the good ear; with a
- Hearing structures innervated by the 7th Cranial Nerve sensorineural hearing loss
- Stapedius muscle – the function of this muscle is to place Rinne test
tension on the bones of the middle ear 1) Test compares air and bone conduction hearing.
Functions of the Ear 2) Strike a 512 Hz tuning fork softly.
1) Hearing 3) Place the vibrating tuning fork on the base of the mastoid
- Most basic function bone.Ask client to tell you when the sound is no longer
- Vibrations are interpreted as sound in the brain after heard.
being transmitted and transformed into nerve signals by 4) Note the time interval and immediatly move the tuning fork
the cochlea to the auditory meatus.
- 2 pathways: 5) Ask the client to tell you when the sound is no longer heard.
a) Air conduction – sounds transmitted travel over air- Note the time interval and findings
filled external & middle ear thru vibration of the a) Normal hearing clients will note air conduction twice as
tympanic membrane & ossicles. More efficient long as bone conduction AC>BC (+) Rinne
pathway b) With conductive hearing loss, bone conduction sound
b) Bone conduction – travel directly thru bone & inner is heard longer than or equally as long as air conduction
ear, bypassing tympanic membrane & ossicles BC≥AC (-) Rinne
2) Balance
- Other important function Diagnostic Tests
- Oriented at the right angles to each other are three Audiometry
semicircular canals of the inner ear - Hearing test / Audiography / Audiogram
- Whenever the head is turned or change position, the - Testing of a person's ability to hear various sound
resulting movement of fluids within these canals help frequencies measures hearing acuity
the brain to identify or detect the extent of movement - The test is performed with the use of electronic equipment
and positioning of the head. called an audiometer.
- This testing is usually administered by a trained technician
The normal tympanic membrane is thin and semi- called an audiologist.
transparent. • No special precautions are required.
- When viewed through an otoscope it has a pearly grey • The ears may be examined with an otoscope prior to
appearance and often some structures within the middle audiometry testing to determine if there are any
ear, such as the long process of the incus and the opening blockages in the ear canal due to ear wax or other
of the eustachian tube, can be seen if it is sufficiently material.
transparent. The handle of the malleus, which extends - An adult with normal hearing can detect a range of low and
downwards and backwards, is a reliable landmark. high pitched sounds that are played as softly as between
nearly 0-20 decibels.
- Normal speech is generally spoken in the range of 20-50 dB.
- The inability to hear pure tones below 25 dB indicates
some extent of hearing loss.
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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

Tympanometry • Client assumes a supine position w/ head elevated to

- test used to detect disorders of the middle ear. 30 degrees
- Air pressure in the ear canal is varied. It may test the • Character & duration of eye movts.is noted
condition and mobility of the ear drum. • n&v may occur after
• Otoscopic exam • assist w/ ambulation
• It is important not speak, move, swallow, or startle (all - COWS:
these actions can alter the pressure in the middle ear • Cold water = nystagmus to the Opposite side,
and invalidate the test results). • Warm water = nystagmus to the Same side.
• The sounds heard during the test may be loud and
potentially startling, so a conscious effort is required to General Care for Ear Surgeries
avoid a startle reflex. Preop
Auditory Brain stem Response / Brain Stem Auditory • Assess for upper respiratory tract infection
Evoked Response (BAER) • Shampoo hair
- Performed to help diagnose nervous system abnormalities, Postop
hearing losses (especially in low-birth weight newborns), • Nose blowing is to be avoided for a few weeks after surgery
and to assess neurologic functions. • Sneeze or cough with mouth open for few weeks after
- The test focuses on changes and responses in brain waves. surgery
- The brain waves are stimulated by a clicking sound to
• Heavy lifting, straining & bending over are to be avoided
evaluate the central auditory pathways of the brainstem.
• Lie on the unoperated side
• You may be asked to wash your hair the night before the
• Avoid physical activity for 1 week; exercises & sports for 3
test.
weeks
Electronystagmography
• Protect ear with 2 pieces of cotton (outer pc. saturated
- Vestibular test that evaluates spontaneous & induced eye
with petrolatum)
movts. (nystagmus)
• Change cotton ball in ear daily
- records changing electrical fields with movts. of the eye.
The test is used to determine whether ear nerve damage is • Keep ear dry for 6 weeks postop
the cause of dizziness or vertigo. • Do not shampoo hair for 1 week
- Damage to the nerve of the inner ear is one of the more • Avoid airplane travel for 1 week; for sensation of ear
common causes of vertigo. pressure, hold nose, closed mouth and swallow to
• Do not take any anti-dizziness, anti-depressant, anti- equalize pressure
histamine, tranquilizing, or sedative drugs/narcotics of • Report any drainage other than slight amount of bleeding to
any kind for 24-48 hours prior to the balance test. This the physician
includes codeine and medications containing codeine • Avoid reading, watching TV or fast moving objects for 1 wk
as well as alcohol (beer, wine, liquor). posto
• Do not eat for 3 hours before the examination is • Seek for supervision when ambulating for the first time:
scheduled. dizziness or lightheadedness may occur
• Do not use facial creams or any make-up. They will
interfere with accurate recordings during the test. Conditions of the External Ear
• You MUST arrange for someone to accompany you to Cerumen Impaction
the test to drive you home. There is a chance that you - ear wax blockage
may become dizzy during testing. - Home treatment
• Soften wax in the ear:
Caloric Test o mineral oil
- One ENG test evaluates the movement of the eyes as they o baby oil
follow a moving target. o glycerin
- Another observes eye movements as the head is o commercial drops
positioned in different directions. o detergent drops: like hydrogen peroxide (half
- During the caloric test (sometimes called bi-thermal strength) for 30 mins; ceruminolytic agents 2-3x a
caloric or mono-thermal caloric), warm or cold water or air day like carbamide peroxide
is circulated in the ear canal. • Other methods: irrigation
- The temperature change stimulates the inner ear in order o Body-temperature water should be used (cooler or
to test the nystagmus response. warmer water may cause brief but severe dizziness
- CALORIC TEST – test which uses differences in or vertigo)
temperature to diagnose ear nerve damage as a cause of o With the head upright, straighten the ear canal by
dizziness or vertigo holding the external ear and gently pulling upward
- performed to evaluate client with dizziness o Use a syringe to gently direct a small stream of water
• Warm water causes a greater response than cold water against the ear canal wall next to the wax plug
• Warm H2O caloric testing precedes cold H2O o Tip the head to allow the water to drain

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

o Irrigation may need to be repeated several times Conditions of the Middle Ear
o After the wax is removed, the ear should be dried Otitis Media
thoroughly - An inflammation and/or infection of the middle ear.
o A few drops of alcohol in the ear or a hair dryer set - Common Forms: Acute otitis media & Chronic otitis media
on low may be used to help dry the ear. - are similar; also called suppurant or purulent otitis
o Never irrigate the ear if the eardrum is not known to media. An infecting agent introduced into the middle
be intact, because irrigation with a ruptured eardrum ear
may cause ear infection or acoustic trauma. ▼
- If attempts to remove the wax plug are unsuccessful causes inflamm of the mucosa
consult a health care provider: ▼
• Who may remove the wax by repeating the irrigation leading to swelling & irritation of the ossicles
attempts ▼
• Suctioning the ear canal purulent inflammatory exudate follows
• Removing wax with a small device (curette)= 1) Acute otitis media has a sudden onset and duration of 3
instrumentation weeks or less
Otitis Externa 2) Chronic otitis media = often follows repeated acute
- or swimmer's ear, is an infection of the skin lining the ear episodes = has a longer duration = causes greater
canal. middle-ear injury
- Bacteria ( staph aureus; pseudomonas species) can enter - If otitis progresses or remains untreated, permanent
the skin of the ear canal and cause an infection through a conductive hearing loss results.
scratch, injury from a foreign object, or if the ear is wet for a - Less common in adults than in children.
prolonged period of time. - Ear infections are common in infants and children.
- May also be caused by fungus (Aspergillus). • Their ear canal is shorter & more horizontal than older
- Swimmer's ear is more common in pre-school and school- children
age children. • their eustachian tubes become clogged easily
- Symptoms: - Symptoms:
• Itching • Pain / earache (esp. in acute ear infection)
• Pain in the ear canal • Fever
• Often accompanied by a small amount of clear • Trouble sleeping
discharge • In infants:
• Occasionally fever o Irritability
• Hearing loss o Inconsolable crying (clearest sign)
- Signs and tests: - Signs and tests:
• When the doctor looks in the ear, it appears red and • The doctor will examine your child's throat, sinuses,
swollen, including the ear canal. head, neck, and lungs
• The ear canal may appear eczema-like, with scaly • Using an otoscope, the doctor will look inside your
shedding of skin. child's ears. If infected: areas of dullness / opaque
• Touching or moving the outer ear increases the pain. o Redness
• The eardrum may be difficult for the doctor to see with o Bulging or retracted eardrum
an otoscope because of the swollen outer canal. o Fluid behind the eardrum
• Taking some of the ear's drainage and doing a culture • Fluid may be bloody or purulent (filled with pus).
on it may identify bacteria or fungus. • sign of perforation in the eardrum will also be checked
- The goal of treatment is to cure the infection. • c/s of drainage
• Ear canal-cleaned of drainage – to allow topical • hearing test may be recommended if the child has had
medications to work effectively persistent (chronic & recurrent) ear infections
• Ear drops containing antibiotics & corticosteroids - Treatment:
- To fight infection & to reduce itching and • Relieving pain
inflammation • Curing the infection
- Used abundantly (four or five drops at a time) in • Preventing complications
order to penetrate the end of the ear canal • Preventing recurrent ear infections
- If ear canal is very swollen = wick may be used to
• Antibiotics, Analgesics, Antipyretics
allow the drops to travel to the end of the canal
o Administer antibiotics as ordered for a full 10 day
• Analgesics may be used if pain is severe course
• Warm compress may reduce pain o Avoid chewing during the acute period
• Keep ears clean and dry – do not let water enter the ears o Lie with affected ear down
when showering, shampooing, or bathing. Avoid o Instruct client that screening for hearing loss may be
swimming. necessary

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- Surgery – if there is fluid in the middle ear and the
condition persists, even with antibiotic treatment
• Myringotomy – surgical opening of the eardrum to
relieve pressure and allow drainage of the fluid.
• 2 methods:
o A small tube is inserted through the incised eardrum
in order to dry out the middle ear and prevent the
fluid from re-accumulating
o The ear tubes fall out after a few months
o those that don't may be removed in the doctor's
office
Mastoiditis
- Symptoms:
• Ear pain or discomfort
• Earache
• Pain behind the ear
• redness of the ear or behind the ear
• Fever, may be high or spike (have sudden high
increases)
• Headache
• Drainage from the ear
- Signs and tests:
• A skull X-ray or head CT scan or CT of the ear may show
an abnormality in the mastoid bone.
• A culture of drainage from the ear may show bacteria.
- Treatment:
• Mastoiditis may be difficult to treat because it is
difficult for medications to reach deep enough into the
mastoid bone.
• It may require repeated or long-term treatment.
• Antibiotics by injection, then antibiotics by mouth are
given to treat the infection.
- Surgery
• May be needed if antibiotic therapy is not successful.
• Mastoidectomy – to remove part of the bone and drain
the mastoid
• Tympanoplasty – a surgical procedure that repairs or
reconstructs the eardrum (tympanic membrane) to help
restore normal hearing. This procedure may also involve
repair or reconstruction of the small bones behind the
tympanic membrane (ossiculoplasty) if needed. Both
the eardrum and middle ear bones (ossicles) need to
function well together for normal hearing to occur.
- Post-op
• Monitor for dizziness
• Monitor for signs of meningitis
• Wound dressing change 24 h post op
• Monitor surgical incision for edema, drainage, redness
• Position: flat with operative side up
• Assist in getting up and ambulation
Otosclerosis
- A condition affecting the stapes bone
- A callus of bone accumulates on the stapes creating a
partial fixation, this limits the movement of the stapes
bone, which results in hearing loss.
- Cause: Unknown
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• There is a specific gene, which if present in the patient’s
genetic make up, can result in the development of
otosclerosis.
• About 50 percent of patients with otosclerosis have a
family history of otosclerosis.
• Some medical studies have implicated the measles
virus as a factor in causing otosclerosis.
• In some women with otosclerosis, pregnancy can
accelerate the process. Otosclerosis can react to
female hormone. Pills & HRT can worsen the condition.
- Symptoms:
• Primary symptom - slowly progressive conductive
hearing loss beginning anytime between the age of 15
and 45, although it usually starts around age 20
• May hear better in noisy surroundings- other people’s
voices are raised in frequency & loudness
• Constant tinnitus
• Balance problems may also occur:
o Unsteadiness
o Dizziness
o Vertigo, or other sensations of motion
• Schwartze’ sign-a pink blush hue behind the tympanic
membrane
• (-) Rinne test
• Weber test- with lateralization of sound
• bilateral hearing loss
- Treatment:
• There is no known cure for otosclerosis.
• However, oral fluoride supplementation may slow or
halt disease progression.
• Dizziness associated with active otosclerosis will
usually respond within two weeks of oral fluoride
therapy.
- Surgery: Stapedectomy
• The ear drum is turned forward and the fixed stapes is
removed.
• Tissue is placed over the opening to the inner ear and a
wire, Teflon or metal prosthesis is inserted and
attached to the anvil.
• The ear drum is then returned to its normal position and
the ear canal is filled with ointment.
• The stapes prosthesis allows sound vibrations to again
pass from the ear drum to the inner ear fluids
• The hearing improvement obtained is usually
permanent.
• Following surgery, the use of a hearing aid on either or
both ears should be considered, depending on the
degree of improvement in the surgical ear.
The stapes bone (stirrup) is attached to the
incus bone (anvil) by thin membranes and is
separated.
The stapes suprastructure is then "down-
fractured" leaving the footplate still frozen
within the oval window.
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
A laser and drill are used to make a small
hole in the footplate.
A prosthesis is placed over the incus and
into the hole in the footplate. The surgeon
then confirms that movement of the first
middle ear bone, the manubruim (hammer),
is transmitted through the incus and
prosthesis into the hole and inner ear.
Finally, the prosthesis is tightened around
the incus to prevent sliding of the prosthesis
away from the incus.
Conditions of the Inner Ear
Meniere’s Syndrome (Endolymphatic Hydrops)
- A disorder of the inner ear affecting balance and hearing
- Usually characterized by four symptoms:
• Episodes of vertigo or dizziness
• Fluctuating, progressive, low-frequency hearing loss
• Tinnitus ("ringing" in the ears)
• A sensation of fullness or pressure in the ear
- The inner ear is designed with a series of canals.
- These canals separate important fluids, like endolymph
and perilymph, and keep them from mixing.
- However, when these fluids do mix, as would occur if there
is a rupture in these canals, the microscopic hair cells in
the inner ear stiffen, or the hair cells can become bent or
broken.
- These tiny hair cells play a major role in hearing and
maintaining balance.
- Causes:
• Meniere's disease involves a swelling of part of the
canal (endolymphatic sac). The endolymphic sac
controls the filtration and excretion of the fluid in the
semicircular canals.
• The exact cause of Meniere's disease is unknown.
- In some cases, it may be related to:
• otitis media
• syphilis
• head injury
• recent viral illness
• respiratory infection
• stress
• fatigue
• use of prescription or nonprescription drugs including
aspirin
• hx of allergies, smoking, and alcohol use
• genetic risk factors
- Symptoms:
• Vertigo – may be episodic – lasts from minutes to more
than 8 hours – worse with sudden movement
• Dizziness
• Hearing loss in one ear – low frequency noises lost first
– extent of hearing loss may change
• Noises or ringing in one ear (tinnitus)
• Nausea, vomiting
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• Sweating (may be profuse)
• Uncontrollable eye movements
- Signs and tests: A neurologic examination may show an
abnormality of cranial nerve VIII that may include
abnormalities of hearing, balance, or eye movement.
- Tests to distinguish Meniere's disease from other
causes of vertigo may include:
• Head CT scan or head MRI scan
• Evoked potential studies (BAER)
• Electronystagmography with Caloric stimulation test –
abnormal results indicate Meniere's disease
• Audiology/audiometry
- Treatment:
• There is no known cure for Meniere's disease.
• Treatment is focused on lowering the pressure within
the endolymphatic sac and on treating symptoms,
which tend to occur in discrete "attacks.“
• Medications such as antihistamines, anticholinergics,
and diuretics may lower endolymphatic pressure by
reducing the amount of endolymphatic fluid.
• A low-salt diet to reduce fluid retention may also help.
• Symptoms such as dizziness, vertigo, and associated
nausea and vomiting may respond to sedative/
hypnotics, benzodiazepines like diazepam, and anti-
emetics.
• Surgery on the labyrinth (labyrinthectomy),
endolymphatic sac, or the vestibular nerve may be
required if symptoms are severe and do not respond to
other treatments.
• Hearing aids may be needed for severe hearing loss.
• Avoid sudden movements that may aggravate
symptoms.
• Help may be needed with walking due to loss of balance
during attacks.
• Rest during severe episodes, and gradually increase
activity.
• During episodes, avoid bright lights, TV, and reading,
which may make symptoms worse.
• Avoid hazardous activities such as driving, operating
heavy machinery, climbing, and similar activities until
one week after symptoms disappear.
Presbycusis
- sensorineural hearing loss that occurs as a result of aging.
- The disorder occurs in about 25% of people aged 65 to 75
and in 70 - 80% of those over age 75.
- Causes:
• Degeneration or atrophy of the ganglion cells in the
cochlea
• Loss of elasticity of the basilar membrane
• Decreased blood supply to the inner ear
• Vit B12 & folic acid deficiencies
• Atherosclerosis, HPN, infections, prolonged fever
• Meniere’s dse., DM & ear surgery, trauma to ear or head
- It is unknown whether a specific cause such as noise
trauma leads to presbycusis, but there appears to be a
genetic predisposition.
- Age-related hearing loss tends to occur in families.
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023

- Symptoms
• Loss of hearing occurs slowly over time
• Usually starts with problems hearing high-frequency
sounds, such as someone talking
• May be difficult to hear things in noisy areas
- Exams and Tests
• Wax in the ear that can be a contributing factor.
• Audiology determines the extent of hearing loss.
- Treatment
• There is no known cure for age-related hearing loss.
• Treatment is focused on functional improvement.
• Hearing aids, which provide amplification, may help.
• Developing skills such as lip reading and using visual
cues may aid communication, but these may be
difficult skills for older people to learn.

Otic Medication Administration

• Wash hands
• Warm and shake bottle
• The person receiving otic meds should lie on his/her side
with the infected ear up.
• Patients should have 3-5 drops*** put into the infected ear.
The tip of the bottle should not touch the fingers, or the ear,
or any other surfaces.
• For Patients with Middle Ear Infection with Tubes:
- The person giving the drops should gently press the
tragus 5 times in a pumping motion.
- This will allow the drops to pass through the tube in the
eardrum and into the middle ear.
• For Patients with Outer Ear Infection (“Swimmer's
Ear”):
- Drops should gently pull the outer ear lobe upward and
backward.
- This will allow the ear drops to flow down into the ear
canal.
• The person who received the ear drops should remain on
his/her side for at least 60 seconds.
• Repeat Steps for the other ear if both ears are infected.

GOOD LUCK SA FINAL EXAMS!!

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