SENSE ORGANS

I. CHARACTERISTICS & MECHANISMS OF SENSATION:

 SENSATION – the result of processes taking place in the brain in
response to nerve impulses from the sense receptors.
 Important Components:
A. Functioning Receptor (extroceptors, enteroceptors, propioceptors,
thermoreceptors, mechanoreceptors, nocireceptors, photoreceptors,
chemoreceptors)
B. Nerve Pathway (spinal & cranial nerves)
C. Brain Cortex (thalamus to brain cortex)
 Special Senses: Taste, Smell, Hearing, Equilibrium, Vision
 General Senses: Cutaneous (touch, heat, cold, pain); Organic/Visceral
(hunger, nausea, thirst)

II. TASTE:
 Tongue – responsible for the taste sensation
 Taste buds located on sides of the papillae of the tongue
 4 basic types of buds: sweet, salty, sour, bitter
 Anterior 2/3 of tongue – innervated by facial nerve; Posterior 1/3 –
innervated by glossopharyngeal nerve
 Saliva – dissolves substances so they enter the taste pores & stimulate
the receptors
 Pathway: taste sensation conducted to taste center (medulla) > thalamus
> cerebral cortex

III. SMELL – the only sense that easily tires

 Nose – responsible for the sensation of smell
 Closely related to the taste sensation
 Stimulus must be a gaseous substance that becomes dissolved in the
fluid of the nasal chamber
 Sniffing increases amount of stimulus reaching the olfactory area
 Pathway: olfactory nerve > interpreted by temporal lobe
 Olfactory receptors are easily fatigued & sensory adaptation can occur
rapidly
 Olfactory receptors can recognize multitude of distinct odors

IV. HEARING

 Ears – responsible for sense of

hearing
 External Ear:
A. Auricle (pinna) – outer
protection of ear composed of
cartilage & covered by skin;
collects sound waves
 B. External auditory canal – lined with skin; glands secrete cerumen
(wax), providing protection; transmits sound waves to tympanic
membrane
C. Tympanic membrane (eardrum) – at end of external canal; vibrates
response to sound & transmits vibrations to inner ear
 Middle Ear:
A. Ossicles – smallest bones in the body
1. Three small bones: Malleus (hammer) attached to tympanic
membrane; Incus (anvil), Stapes (stirrup)
2. Ossicles are set in motion by sound waves from tympanic
membrane
3. Sound waves are conducted by vibration to the footplate of the
stapes in the oval window
B. Eustachian tube – connects nasopharynx & middle ear; brings air
into middle ear thus equalizing pressure on both sides of eardrum
 Inner Ear (aka Labyrinth):
A. Cochlea – responsible for sense of hearing
1. Contains Organ of Corti – the receptor end-organ for hearing
2. Transmits sound waves from the oval window & initiates nerve
impulses carried by CNVIII (acoustic branch) to the brain
(temporal lobe of the cerebrum)

B. Vestibular Apparatus – organ of balance

C. Endolymphs- fluid in the inner ear

V. EQUILIBRIUM
 Vestibular portion of the ear is responsible for the sense of balance
 Structures: semicircular canals in 3 different planes; Utricle; Saccule
 Utricle – tiny hair cells that have small stones (otoliths or calcium
carbonates); these hair cells bend backward when you begin to move
forward
 Semicircular canals have hair cells that are stimulated by movement of
the endolymph (fluid in the cochlear channel)
 Cerebellum – adjust position of body so that equilibrium is maintained
 Basal Ganglia – involved in coordination
 Propioceptors & visual receptors are also important in maintaining
sense of balance
VI. VISION

 Eyes – responsible for sense of vision

 Vision – the passage of rays of light from an object through the cornea,
aqueous humor, lens, & vitreous humor to the retina & its appreciation
in the cerebral cortex
 External Structures of Eye:
A. Eyelids (palpebrae) & Eyelashes – protect the eye from foreign
particles
B. Conjunctiva –
1. Palpebral Conjunctiva – pink; lines inner surface of eyelids
 2. Bulbar Conjunctiva – white; with small vessels; covers
anterior sclera
C. Lacrimal Apparatus (lacrimal gland & its ducts & passage) –
produces tears to lubricate the eye & moisten the cornea; tears
drain into the nasolacrimal duct which empties into nasal cavity
D. Movement of the eye is controlled by six extraocular muscles
(OTA)
 Internal Structures of Eye:
A. Three Layers of the Eyeball
1. Outer Layer:
a. Sclera – tough, white connective tissue (“white of the eye”);
located anteriorly and posteriorly
b. Cornea – transparent tissue through which light enters the
eye; located anteriorly
2. Middle Layer:
a. Choroid – highly vascular layer, nourishes retina; located
posteriorly
b. Ciliary Body – anterior to choroids, secretes aqueous humor;
muscles change shape of the lens
c. Iris – pigmented membrane behind cornea; gives color to
eye; located anteriorly; Pupil – is a circular opening in the
midlle of the iris that constricts & dilates to regulate amount
of light entering the eye
3. Inner Layer:
a. Light-sensitive layer composed of rods & cones (visual cells)
> Cones: specialized for fine discrimination & color vision
> Rods: more sensitive to light than cones; aid in peripheral
b. Optic Disk – area in retina for entrance of optic nerve, has
no receptors. OPTIC CHIASM is where the nerves decussate.
B. LENS – transparent body that focuses image on retina
C. Fluids of the Eye:
a. Aqueous Humor – clear, watery fluid in anterior & posterior
chambers in anterior part of eye; serves as refracting medium &
provides nutrients to lens & cornea; contributes to maintenance
of intraocular pressure
b. Vitreous Humor – clear, gelatinous material that fills posterior
cavity of eye; maintains transparency & form of eye
 Visual Pathways
A. Retina (rods & cones) translates light waves into neural impulses
that travel over the optic nerves
B. Optic nerves for each eye meet at the optic chiasm
a. Fibers from median halves of the retinas cross here & travel to the
opposite side of the brain
b. Fibers from lateral halves of retinas remain uncrossed
C. Optic Nerves continue from optic chiasm as optic tracts and travel
to the cerebrum (occipital lobe) where visual impulses are perceived
& interpreted
 DISORDERS OF THE SENSORY ORGANS

I. EYES

A. VISUAL DEFECTS:
 Emmetropia – Normal; rays coming from an object at a distance of 20
feet or more are brought to a focus on the retina by the lens
 Ammetropia – Abnormal
1. Hyperopia: farsightedness; eyeball is too short, light rays are brought
to focus in the back of the retina; corrected by convex lens; (“FAR-
VEX”)
2. Myopia: nearsightedness; light rays are brought to focus in front of
the retina; corrected by concave lens; (“NEAR-CAVE”)
3. Astigmatism: uneven curvature of the cornea; causing inability to
focus horizontal & vertical rays on the retina at the same time;
corrected by cylinder lens; (“ASTIG-CY-LINDER”)
4. Presbyopia: aka “elder vision”; the elasticity of the lens decreases
with increasing age; decreased ability to accommodate; requires
prescription lenses (reading glasses) PRESBY = ELDER PEOPLE

B. STRABISMUS: ( LIBAT)
 Deviation of one eye from the other in an inward, outward, upward,
downward manner
 Common symptom of CNS, ocular or other general systemic problems
 2 Types:
 1. Paralytic (damage of nerves controlling the extraocular muscles);

 MGT: Correct underlying cause of neural damage.
  2. Non-paralytic (result of a defect in the position of the two eyes)
 Non-paralytic – corrected by surgery (advance, resect, or tuck muscles
that support the eye to align eyes equally)

C. CATARACTS – no pain
 Opacity or cloudiness of the lens

 PRED FACTORS:
1. Most commonly results of the
aging process, after 70 years of
age (senile cataracts)
2. Occurrence at birth (congenital
cataract)
3. Occasionally a result of disease
or following trauma

 CLINICAL MANIFESTATIONS:
1. Alterations in Vision -
a. Objects are distorted & blurred (color shift - aging lens more
absorbent at the blue end of the color spectrum; brunescens –
color values shifts to yellow brown)
b. Glare annoys the pt when there are bright lights
c. There is no pain or eye redness
d. Visual loss is gradual
2. Alterations in Appearance –
a. The pupil, usually dark, progresses to a milky white color
b. Eventually, opacity becomes complete

 MANAGEMENT:
1. General -
a. Surgical removal of the lens is indicated
b. Usually a pt with one cataract can manage without surgery
c. If cataract occurs in both eyes, surgery is recommended when
vision in the better eye causes problems in daily activities. Surgery
is done on only one eye at a time
d. Cataract surgery is usually done under local anesthesia.
Preoperative medications produce ↓ response to pain & lessened
motor activity. Oral medications are given to ↓ intraocular pressure
e. Intraocular lens implants are usually implanted at the time of
cataract extraction
f. In some instances following lens extraction and the healing process,
the patient may be fitted with appropriate eyeglasses or contact
lenses to correct refraction
2. Surgical Procedures –
A. Two types of Extractions:
 a. INTRACAPSULAR EXTRACTION – the lens as well as the
capsule are removed through a small incision
b. EXTRACAPSULAR EXTRACTION – the lens capsule is
incised, & the nucleus, cortex & anterior capsule are extracted
> The posterior capsule is left in place & is usually the base to
which an IOL is implanted
> A conservative procedure of choice, simple to perform &
usually done under local anesthesia
B. Two types of Procedures for Extractions:
a. CRYOSURGERY – a special technique in which a pencil-like
instrument with a metal tip is super-cooled (-35degrees), then is
touched to the exposed lens, freezing to it so that the lens is
easily lifted out
b. PHACOEMULSIFICATION – the mechanical breaking up
(emulsifying) of the lens by a hollow needle vibrating at
ultrasonic speed. This action is coupled with irrigation &
aspiration of the emulsified particles from the anterior chamber

C. INTRAOCULAR LENS IMPLANTATION – the implantation of

a synthetic lens (IOL) designed for distance vision; the patient may
wear prescription glasses for near vision & reading.

 Nursing Interventions:
A. Pre-op:
1. Routine pre-op care
2. Employ aseptic technique when performing eye treatment
3. Instruct patient not to touch eyes
4. Administer medications as prescribed:
a. Antiemetics – Prochlorperazine (Compazine); Hydroxyzine
(Vistaril)
b. Pain Control – Meperidine (Demerol)
c. Ocular Hypotensives (to prevent inc IOP) – Acetazolamide
(Diamox); Glycerol (Mannitol)
d. Mydriatics to dilate the pupils
B. Pos-op:
1. Prevent ↑ IOP (N- 8-20mmHg)
a. Refrain from coughing or sneezing
b. Avoid rapid movements & bending from the waist
2. Promote comfort & safety
a. PositionBQ) unoperative side or on back with pillows for
head elevation (30-40 degrees) semi fowlers
b. Report ASAP! – sudden eye pain – may be due to ruptured
vessel or suture; may lead to hemorrhage;

SX/SY of sudden eye pain – restlessness & ↑ pulse rate

c. Allow ambulation after recovery from anesthesia as prescribed
d. Wear eyeshield at night to protect eye from injury

3. Patient Teaching:
 a. Avoid strain on the eye: no heavy lifting & straining on defecation; no
vigorous shaking of head
b. Use dark glasses after eye dressings are removed to provide comfort
c. Adjusting to Eyeglasses: relearn space judgment (walking using stairs,
reaching for articles on the table, pouring liquids)

D. GLAUCOMA – with pain

 Results from a disturbance of the normal balance between the
production & the drainage of the aqueous humor causing an ↑ in
intraocular pressure (Normal IOP: 10-20mmHg)
 Leading cause of blindness if not recognized & treated
 Risk Factors:
 1.age over 40,
 2.DM,
 3.Hypertension,
 4.heredity,
 5.hx of previous eye surgery,
 6.trauma & inflammation

 Diagnostic Tests:
a. Visual Acuity - reduced
b. Tonometry – reading of 24-32mmHg suggests glaucoma; may be
50mmHg or more in acute closed angle glaucoma
c. Ophthalmoscopic Exam – reveals narrowing of small vessels of
optic disk, cupping of optic disk
d. Perimetry – reveals defect in visual fields
e. Gonioscopy – to determine whether it is open or close angle
glaucoma

 2 Types: Open Angle (Chronic); Close Angle (Acute or Chronic)

1. CHRONIC OPEN ANGLE GLAUCOMA

 Most common form caused by obstruction of the outflow of aqueous
humor in the canal of Schlemm
 SX/SY: symptoms develop slowly; impaired peripheral vision (tunnel
vision)-very common BQ; loss of central vision (if unarrested); mild
discomfort in the eyes; halos around lights (BQ)
 MEDS (one or a combination of the following):
a. Miotic Drugs (Pilocarpine) – to ↑ outflow of aqueous humor
b. Epinephrine eyedrops – to ↓ aqueous humor production & ↑
outflow
c. Acetalomide (Diamox)diuretic – to ↓ aqueous humor production
d. Timolol Maleate (Timoptic) – Beta2 blocker – to ↓ IOP

 SURGERY (if no improvement with drugs):

 a. TRABECULECTOMY OR TREPHINING – a filtering procedure
to create artificial openings for the outflow of aqueous humor
b. LASER TRABECULOPLASTY – noninvasive procedure
performed with argon laser that can be done on an outpatient basis;
produces similar results with trabeculectomy

2. ACUTE CLOSED ANGLE GLAUCOMA

 Due to forward displacement of the iris against the cornea obstructing
the outflow of aqueous humor
 Occurs suddenly & is an emergency situation; if untreated, may lead
to blindness within 3-5 days of onset

 SX/SY: severe eye pain; blurred, cloudy vision; halos around lights;
nausea & vomiting; steamy cornea; moderate pupillary dilation

 MEDS:
a. Miotic Eyedrops (ex. Pilocarpine) – pupil contracts; iris is drawn
away from cornea; aqueous humor may drain into canal of Schlemm
b. Osmotic Agents (Glycerin – oral; Mannitol – IV) – to ↓ IOP
c. Beta blocker – may ↓ production of aqueous humor or may
facilitate outflow of aqueous humor
d. Analgesics for pain
 SURGERY (if trabecular measure is beyond repair)
a. PERIPHERAL IRIDECTOMY – excision of a small portion of the
iris whereby aqueous humor can bypass pupil; Tx of Choice
b. ARGON LASER BEAM SURGERY – noninvasive procedure
using laser that produces same effect as iridectomy; done on an
outclient basis

3. CHRONIC CLOSED ANGLE GLAUCOMA

 Similar to Acute Closed Angle Glaucoma with the potential for acute
attack
 Similar Drugs & Surgery as Acute type

 GENERAL NURSING MGT. WITH GLAUCOMA:

 Provide quiet, dark environment
 Maintain accurate I&O with the use of osmotic diuretics
 Tell patient that glaucoma cannot be cured but can be controlled
 Periodic eye check-ups are essential since pressure changes occur
 Avoid stooping, heavy lifting, pushing, emotional upsets, excessive
fluid intake, constrictive clothing around neck
 Avoid use of antihistamines or sympathomimetic drugs (found in cold
preparations) in closed angle-galucoma since they may cause
mydriasis
E. RETINAL DETACHMENT
 Detachment of the sensory retina (rods & cones) from the pigment
epithelium of the retina
 Tear in the retinal allows vitreous humor to seep behind sensory retina
& separate it from the pigment epithelium

 CAUSES: trauma, aging process, severe myopia; postcataract

extraction, severe diabetic retinopathy

 SX/SY:

 1. Flashes of light(1st sign),

 2. floaters (bleeding);
 3. visual field loss;
 4. veil-like curtain coming across field of vision;
 5. patients do not complain of pain

 DX: Ophthalmoscopic examination confirms the diagnosis

 SURGERY (the only treatment):

1. PHOTOCOAGULATION – a light beam is passed through the pupil
causing a small burn & producing exudates between the pigment
epithelium & retina
2. ELECTRODIATHERMY – an electrode needle is passed through
the sclera to allow subretinal fluid to escape; an exudates forms from
the pigment epithelium & adheres to the retina
3. CRYOSURGERY OR RETINAL CRYOPEXY – a supercooled
probe is touched to the sclera, causing minimal damage; as a result
of scarring, the pigment epithelium adheres to the retina
4. SCLERAL BUCKLING – a technique whereby the sclera is
shortened to allow a buckling to occur, which forces the pigment
epithelium closer to the retina
 MGT:
1. Pre Op -
a. Maintain bed rest as ordered with HOB flat & detached area in a
dependent position.
b. Use bilateral eyepatches as ordered
c. Elevate side rails to prevent injury
d. Instruct pt to remain quiet
e. Identify yourself when entering the room
2. Post Op –
a. Proper positioning is important after the operation & is prescribed
according to individual need (Pt may be permitted out of bed on
DRs directive as long as straight-lined vision(like in horses) is
maintained; rapid eye movements from side to side should be
avoided)
b. Avoid pt bumping his head causing the retina to detached further
c. Ff gen anest. – pt is encouraged to breathe deeply but not to cough;
vomiting & sneezing is avoided also
d. Moderate TV viewing allowed (as long as straight-lined vision is
concerned.). Avoid handwork or reading until DR permits (rapid
eye movement)
3. Pt Teaching & Discharge Planning –
a. Encourage self care but carry out in unhurried manner
b. Avoid falls, jerks, bumps, accidental injury
c. Rapid eye movements avoided for several weeks
d. Driving is restricted for several weeks- coz of rapid eye
movement
e. Avoid straining & bending below the waist
f. Apply clean, warm, moist washcloths to eyes & eyelids several
times a day for 10 minutes – to provide soothing & relaxing
comfort
g. Use eyeshields at night
F.EYE INFECTIONS:

1. SUPERFICIAL LID INFECTIONS

 BLEPHARITIS – infection of eyelids, with crusting lids, redness,
irritation & mucopurulent secretion

 HORDEOLUM – aka „STY‟, infection of eyelash follicle

 CHALAZION – infection of the meibomian gland (small sebaceous

gland located within the upper lids)

 MGT: (eye infections)

a. Clean lid margins by applying warm, moist compresses for 5
minutes. 3-4x/day
b. Carefully wipe loose crusts away from lashes
c. Apply ophthalmic antibacterial ointment/drops as directed
d. Continue until infection clears
e. Advise pt to keep hands away from eyes & wash hands after care
f. Chronic chalazion may require incision & curettage

2. CONJUNCTIVITIS (sore eyes)

 Aka “PINK EYE”; an inflammation of the conjunctiva due to allergy
or microorganisms
  SX/SY: redness, pain, swelling, lacrimation; lids are frequently stuck
together with crusting upon awakening

 MGT:
a. Wear gloves to prevent dissemination
of infection
b. Meds: Antihistamine for allergies;
appropriate antibiotics if cause is bacteria

c. Irrigate eye with saline to remove

discharge
d. Apply warm or cold compresses for 15 minutes, 3-4x/day
e. Avoid cross-contamination to unaffected eye

G. EYE INJURIES:

1. CORNEAL ABRASION
- first external part of the eye that is transparent.
 An injury to the cornea that goes deeper than the epithelium
 Is a common occurrence as a result of inadvertent contact with objects
such as fingernails, tree branches, or overwearing of contact lenses
 Can lead to infection or ulcer formation

 MGT:
a. A solution is instilled to relieve pain & facilitate eye examinations
b. The area is stained with fluorescein to detect existence of an
abrasion & its extent
1. The conjunctival surface of lower lid is touched with the
fluorescein paper strip
2. The damaged corneal epithelium will take the stain & turn green;
undamaged areas remain unstained. The stained area is viewed
with a Wood‟s lamp, slit lamp, or a blue light
3. Following use of fluorescein, the eye is flushed as other pt have
allergic reactions to it
4. A drop of antibiotic is instilled since patching creates a moist
environment conducive to flora growth

 NSG INTERVENTIONS:
a. Rest eyes for 24 hours for greater comfort; corneal epithelium
usually heals in 24-48 hours
b. Apply dressing (as directed) firmly but gently over eye to put eye to
rest & to prevent movement of the eyelid with resultant irritation
of abraded corneal area
c. Oral Analgesics are given bec corneal abrasion is very painful
 d. Instruct pt to return to ophthalmologist the following day for
dressing change & inspection of eye for evidence of infection or
ulcer formation

2. FOREIGN BODIES LODGED IN THE CORNEA

 MGT:
a. Determine the nature of particle – wood, metal, magnetic, copper,
projectile
b. Remove particle from the eye:
1. As pt looks upward, evert lower lid to expose conjunctival sac bec
dust particles are often washed downward by the upper lid
2. With small cotton applicator in saline, gently remove particle; wipe
gently across lid from inner to outer aspect; use hand magnifying
lens if necessary
3. If offending particle is not found, proceed to examine upper lid
4. Have pt look downward while you stand in front of him
5. Place cotton applicator stick horizontally on outer surface of eyelid
6. Apply pressure about 1cm above lid margin
7. Grasp upper eyelashes with fingers of other hand & pull the upper
lid outward & upward over the cotton applicator
8. Use fluorescein strip to detect corneal abrasion
c. For penetrating injuries to the eye:
1. Examples: darts, scissors, flying metal
2. Do not attempt to remove object
3. Do not allow pt to apply pressure to the eye
4. Cover lightly with sterile patch for embedded objects (protective
shield or paper cup)
5. cover uninjured eye to prevent excessive movement of injured eye
6. Refer pt to an emergency room ASAP

3. BURNS OF THE EYES

 Disrupts the integrity of the cornea & cause drying of the cornea with
resulting chronic conjunctivitis & corneal ulceration
 MGT:
a. THERMAL BURNS:
1. Associated with face & body burns
2. Treated the same way as burns of skin structures
3. Call ophthalmologist
b. ACTINIC TRAUMA:
 1. Associated with damage to the cornea from UV rays; ex. bright
sun, sun lamp
2. Damage may be superficial & resolves in 48 hours
3. Reassure pt & keep him quiet
4. Apply patch to both eyes
5. Apply mydriatics-cyclopegic drugs as directed to relax ciliary
muscles & iris sphincter spasms
6. Instill emollient antibiotic ointment as prescribed
c. CHEMICAL BURN:
1. Associated with either acid or alkali solutions.
2. Both cause intense pain & inflammation – this is a true ocular
emergency!
3. Irrigate eyes with copious amounts of water – hold pt‟s eye directly
under running water with lids retracted by gauze pads when
immediate irrigation is required
4. Irrigate for at least 25 minutes
5. Repeat irrigation in 15-20 minutes (use eye irrigation equipment)
until pt is seen by ophthalmologist
6. Instill topical anesthetic for pain
II. EARS

A. EXTERNAL EAR

1. OTITIS EXTERNA
 An inflammation of the external ear canal that may occur 2-3 days
after swimming & diving
 Aka “SWIMMER‟S EAR”

 PREVENTION:
a. Dry ear canal thoroughly after coming in contact with water or
moist environment
b. Use ear drops after swimming may assist in preventing swimmer‟s
ear. Usually these solutions contain alcohol & glycerol to reduce
moisture; boric acid or acetic acid to limit growth of microorganisms
& maintain normal acidity of the ear canal

 MGT:
a. If canal is swollen & tender, topical corticosteroids may ↓
inflammation & swelling
b. Topical antibiotics can curb infection
 2. IMPACTED CERUMEN (ear wax)
 Accumulated cerumen does not have to be removed unless it becomes
impacted & interferes with hearing
 Use of cotton-tipped applications to dry the canal or remove ear wax
should be avoided because:
a. Cerumen may be forced against the tympanic membrane
b. The canal lining may be abraded making it more susceptible to
infection
c. Cerumen that occurs & protects the canal may be removed

 MGT: Irrigation of the External Auditory Canal (but make sure the
ear drum is not damaged)

 Guidelines for Ear Irrigation:

a. Ask history of draining ears, perforation or complications from
previous ear irrigation
b. Use a cotton tip applicator to remove any discharge on outer ear
c. Place basin close to patient‟s head & under the ear
d. Test temperature of solution(lukewarm), it should be comfortable to
the inner aspect of wrist area
e. Ascertain whether impaction is due to a foreign hydroscopic
/hydrophyllic (attracts or absorbs moisture) body before proceeding
f. Gently pull outer ear upward & backward (adult); or downward &
backward (child-3 yrs below) to straighten ear canal (BOARD
QUESTION)
g. Place tip of syringe or irrigating catheter at opening of the ear;
gently direct stream of fluid against sides of canal (never directly
straight to the canal)
h. If an irrigating container is used, elevate only high enough to
remove secretions or no more than 15 cm (6 inches) above patient‟s
ear
i. Observe for signs of pain or dizziness
j. Dry external ear
k. Pt should lie on irrigated (affected) side for a few minutes after
procedure to allow any remaining solution to drain out
l. Record time of irrigation, kind & amount of solution, nature of
return flow & effect of treatment
m. If irrigating does not dislodge the wax, instill several drops of
prescribed glycerin or other solutions as directed 2-3x/day for 2-
3days

B. MIDDLE EAR

1. OTITIS MEDIA (BOARD QUESTION)

 Inflammation or infection of the middle ear caused by the entrance of
pathogenic organisms
 Maybe Acute or Chronic
 Usually seen in children because the Eustachian tube is more straight
than adults.

 A. ACUTE OTITIS MEDIA:

 SX/SY:
 pain (usually the 1st symptom);
 fever,
 purulent drainage (otorrhea) is present when eardrum is perforated;
 headache,
 hearing loss;
 hx of respiratory infection,
 immunologic defect or head injury

 DX: Otoscopy shows a tympanic membrane that is full, bulging,

opaque with impaired mobility; Culture of discharge may suggest
causative organism

 MGT:
1. Give Penicillin – DOC
2. Relieve pain & pressure (aspirin & analgesics; local cold
compresses)
3. Report signs of mastoid & meningeal involvement (headache,
slow pulse, vomiting, vertigo)-KNOB
4. Provide safety (side rails up, assist in ambulation, slow
movement changes)
5. Patient Teaching:
a. Until tympanic membrane heals, avoid activities such as
swimming, shampooing hair, showering
b. Practice good hygiene to prevent reinfection (avoid
earpicking, inserting toothpick in ear to relieve itch)

 SURGERY: MYRINGOTOMY (myringo-ear drum)

o An incision into the posterior inferior aspect of the tympanic
membrane for draining purposes (to relieve pressure & drain pus
from middle ear infection)
o Performed on selected patients to prevent recurrent episodes
o May be done because of failure of pt to respond to antimicrobial
therapy; for severe, persistent pain & for persistent conductive
hearing loss

 B. CHRONIC OTITIS MEDIA

 A chronic inflammation of the middle ear lasting more than 3
months from initial onset accompanied by a non-intact tympanic
membrane & discharge
 Maybe caused by an antibiotic-resistant organism or a particularly
virulent strain of organism

 SX/SY:
 painless discharge from affected ear;
 otorrhea may be odorless or foul-smelling;
 vertigo or pain may be present if CNS complications have occurred

 DX:
o History will indicate several episodes of acute otitis media,
possible rupture of tympanic membrane
o Audiometric Test: air conductive hearing loss
o Xray: may note mastoid pathology (ex. (+) of
CHOLESTEATOMA – soft ball of dead skin cells that erodes
surrounding vital structures)

 MGT:
1. Medical Therapy -
a. Antibiotic & steroid eardrops may control inflammation &
infection
b. Frequent removal of epithelial debris & purulent drainage may
protect tissue from damage
2. Surgical Interventions –
a. Indicated when cholesteatoma is present
b. Indicated when there is pain, profound deafness dizziness,
sudden facial paralysis, or stiff neck
c. Types of Procedures –
o SIMPLE MASTOIDECTOMY – removal of the mastoid cells;
indicated when there is persistent tenderness, fever, discharge
from ear or headache
o RADICAL MASTOIDECTOMY – removal of all diseased
tissue from mastoid area & middle ear
o POSTEROANTERIOR MASTOIDECTOMY – combines
simple mastoidectomy with tympanoplasty (reconstruction of
middle ear structures)

3. Nursing Interventions Post-Op:

a. Provide relief or comfort (aspirin, cold compress)
b. Assist with dressing change since area is packed with gauze for
drainage – this may be done daily or every other day; packing
is removed on 3rd or 4th day
c. WOF (watch out for) complications:
a. facial weakness or paralysis may indicate facial nerve injury;
b. infection (↑temp, chills, stiff neck, nausea, vomiting);
c. vertigo may be apparent ff radical mastoidectomy due to inner ear
disturbance
d. Note status of hearing:
o If stapes has been removed or dislodged, then hearing is lost
 o If stapes or cochlea has not been removed or disturbed, then
hearing will probably be regained; a hearing aid may be
required

2. OTOSCLEROSIS (“nakapilit na ang stapes sa oval window at

nagtigas”)
 Formation of new spongy bone in the labyrinth, fixation of the stapes,
& prevention of sound transmission through the ossicles to the inner
fluids resulting in deafness
 Found more in females; cause is unknown but there is familial tendency

 SX/SY: progressive hearing loss; tinnitus

 DX:
o Audiometry – reveals conductive hearing loss
o Weber‟s & Rinne‟s Tests: show bone conduction is greater than air
conduction

 SURGERY: STAPEDECTOMY
o Treatment of choice
o Removal of otosclerotic lesions at the footplate of stapes & the
creation of a tissue implant with prosthesis to maintain suitable
conduction
o Otologic binocular microscope is used to perform the delicate surgery

o Nursing Interventions:
1. Position pt according to DR‟s orders (possible with operative ear
uppermost to prevent displacement of the graft)
2. Have pt deep breathe q2hours while in bed but no coughing
3. Elevate side rails; assist pt with ambulation & move slowly
4. Administer medications as ordered: analgesics, antibiotics,
antiemetics, anti-motion sickness drugs
5. Check dressings frequently for excessive drainage or bleeding
6. Assess for facial nerve function (ask pt to wrinkle forehead, close
eyelids, puff out cheeks, smile & show teeth, check for asymmetry)
7. Reportable signs:
-pain,
-headache,
-vertigo,
-unusual sensations in the ear
8. Patient Teaching:
a. There may be a temporary hearing loss for a few weeks after
surgery because of tissue edema, packing, etc.
b. Packing is removed by surgeon in 5-6 days post-op; pt should
protect the ear by placing cotton ball in outer ear & changing it
2x/day
c. No blowing of nose or coughing (sneeze with mouth open)
d. Need to keep ear dry in the shower; no shampooing until allowed
 e. No flying for 6 mos; no diving
f. Avoid crowds or exposure to colds so that URTI is prevented

C. INNER EAR

1. MENIERE‟S DISEASE (BOARD QUESTION)

 Disease of the inner ear resulting from dilation of the endolymphatic
system & increased volume of endolymph accompanied by destruction
of cochlear hair cells
 Aka “ENDOLYMPHATIC HYDROPS”

 TRIAD SX: (BOARD QUESTION)

 Vertigo (sudden, lasting hours or days; occurring several times a year),
 Tinnitus,
 Hearing Loss

 CAUSE: unknown; theories include allergies, toxicity, infections,

edema, localized ischemia, hemorrhage

 DX: Audiometry reveals sensorineural hearing loss (coz inner ear

affected); Vestibular test – reveal ↓ function (romberg‟s test) (-) balance

 MEDS:
a. Acute: Atropine (↓ autonomic nervous system activity; Diazepam
b.Chronic: Vasodilators (Nicotinic Acid); Sedatives (Diazepam);
Antivertigo (Meclizine)

 DIET: (BOARD QUESTION) low Na; restricted fluid intake

(FURSTERNBERG DIET)

 SURGERY:
a. Conservative: Simple sac decompression or sac shunt to equalize
pressure in the endolymphatic space
b. Destructive:
o LABYRITHECTOMY – recommended if pt experiences
progressive hearing loss & severe vertigo attacks so that he cannot
perform normal task; surgical destruction of labyrinth causing loss
of vestibular & cochlear function (if disease is unilateral)
o VESTIBULAR NERVE NEURECTOMY – removal of the
vestibular portion of CNVIII

 NURSING INTERVENTIONS:
 a. Maintain bed rest in a quiet, darkened room in position of choice
(noises, glaring & bright lights may initiate attack)
b. Only move pt for essential care (bath may not be essential); move
slowly since jerking & sudden movements may precipitate attack
c. Assist with ambulation when attack is over
d. Provide a call system for pt if assistance is needed
e. Eliminate smoking & intake of coffee, tea, alcohol, stimulating drugs
due to vasoconstriction effect

 COMMUNICATING WITH A PERSON WHO HAS A

HEARING IMPAIRMENT:

 When the person is able to lip-read:

1. Face the person as directly as possible when speaking
2. Place yourself in good light so that he can see your mouth
3. Do not chew, smoke, or have anything in your mouth when speaking
4. Speak slowly & enunciate distinctly
5. Provide contextual clues that will assist him in following your speech
(ex. point to a tray if you are talking about the food on it)
6. To verify that he understands your message, write it for him to read
(that is, if you doubt that he is understanding you)

 When it is difficult to understand the person when he speaks:

1. Pay attention when the person speaks; his facial & gestures may help
you understand what he is saying
2. Exchange conversation with him when it is possible to anticipate his
replies – this is particularly helpful in your initial context with him &
may help you become familiar with his speech peculiarities
3. Anticipate context of his speech to assist in interpreting what he is
saying
4. If unable to understand him, resort to writing or include in your
conversation someone who does understand him; request that he repeat
that which is not understood

 DISORDERS OF THE PERIPHERAL NERVOUS SYSTEM

 TRIGEMINAL NEURALGIA (TIC DOULOUREUX) CNV

 General Information
 Disorder of the CNV causing disabling & recurring attacks of
severe pain along the sensory distribution of one or more
branches of the trigeminal nerve
 Incidence increased in elderly women
 Cause is unknown

S/SX:
1. sensitive to pain, cold

 Medical Mgt:
  DOC: Carbamazepine (Tegretol)muscle relaxant; Phenytoin
(Dilantin) CNS depressant
 Nerve block: injection of alcohol or phenol into one or more
branches of the CNV; temporary, lasts 6-18 mos

 Surgery –
 Peripheral: avulsion of peripheral branches of trigeminal
nerve
 Intracranial:
 Retrogression Rhizotomy: total severance of the sensory
root of the trigeminal nerve intracranially; results in
permanent anesthesia, numbness, heaviness, stiffness in
affected part; loss of corneal reflex
 Percutaneous Radio-Frequency Trigeminal Gangliolysis –
current surgical treatment of choice; thermally destroys the
trigeminal nerve in the area of the ganglion; provides
permanent pain relief with preservation of the sense of
touch, proprioception, & corneal reflex, done under local
anesthesia
 Microvascular Decompression of trigeminal nerve:
decompresses the trigeminal nerve; craniotomy is
necessary; provides permanent relief while preserving the
facial sensations
 Assessment Findings:
 Severe shooting pain in one side of the face
 Attacks may be triggered by a cold breeze; foods/fluids of
extreme temperature; toothbrushing, chewing, talking or
touching the face
 During attack: twitching, grimacing & frequent blinking &
tearing of the eye
 Poor eating & hygiene habits
 Withdrawal from interactions with others

 Diagnostic Tests: Xrays of the skull, teeth & sinuses may

identify dental or sinus infection as an aggravating factor (to
rule out other causes)

 Nursing Interventions:
 Assess triggering factors
 Maintain room at an even, moderate temperature, freed from
drafts
 Approach client slowly
 Provide SFF of lukewarm, semiliquid, or soft foods that are
easily chewed
 Provide client with a soft washcloth & lukewarm water &
perform hygiene when pain is decreased
 Patient Teaching:
  Need to avoid outdoor activities during cold, windy or
rainy weather
 Importance of good nutrition & hygiene
 Use of medications, side effects
 Specific post-op instructions for residual effects of
anesthesia & loss of corneal reflex:
 Protective eye care
 Chew on unaffected side only
 Mouth care to remove particles
 Good oral hygiene, visit dentist every 6 mos.
 Protect face during extremes of temperature

 BELL’S PALSY
 General Information
 Disorder of CNVII (facial nerve) resulting in the loss of ability
to move the muscles on one side of the face

 Cause unknown: maybe viral or autoimmune

 Complete recovery in 3-5 weeks in majority of clients

 Assessment Findings
 Loss of taste over anterior 2/3 of tongue on affected side
 Complete paralysis of one side of the face
 Loss of expression, displacement of the mouth toward
unaffected side & inability to close eyelid (all on affected
side)
 Pain behind the ear

 Nursing Interventions:
 Assess nerve function regularly
 Administer medications as ordered:
 Corticosteroids to ↓ edema & pain
 Mild analgesics as necessary
 Provide soft diet with supplementary feedings as indicated
 Instruct to chew on the unaffected side, avoid hot fluids/foods
& perform mouth care after each meal
 Provide special eye care to protect the cornea
 Dark glasses (cosmetic & protective reasons) or
eyeshields
 Artificial tears to prevent drying of the cornea
 Ointment & eyepatch at night to keep eyelids closed, or
tape the eyelids to close
 Provide support & reassurance