Nursing Management of

Clients with Stressors of

Sensory Function
NUR133
Lecture # 14
K. Burger, MSEd, MSN, RN, CNE
Eye Disorders
Nursing Assessment
History:
Acuity changes, blurring, diplopia,
photophobia, pain, use of gtts or other
eye meds, hx of trauma, familial eye
disease, occupational risks

Risk Factors for Eye Disorders:
Aging process, DM, HTN, HIV, +++others,
Medications, Gender, Nutritional
deficiencies
Eye Disorders
Nursing Assessment

Visual testing: distance, near,
peripheral, color
External examination: lids,
conjunctivae, sclerae, pupils, extraocular
muscles
Internal examination: opthalmoscopy
to observe- lens clarity, red reflex, fundus
Sample Eye Assessment Note
Near vision 20/40 each eye uncorrected, corrected
to 20/20 with glasses. Distant vision 20/20 by
Snellen. Color vision intact. Visual fields full by
confrontation. Extraocular movements intact
and full, no nystagmus. Corneal light reflex
equal.
Lids and globes symmetric. No ptosis, edema, or
lesions
Conjuntivae pink, sclerae white. No discharge
evident. Cornea clear, corneal reflex intact.
Irides brown; PERRLA
Opthalmoscopic exam reveals red reflex. Discs
cream colored, borders well-defined. Maculae
yellow OU
No venous pulsations, hemorrhages, exudates,
Drusen bodies.
Eye Disorders
Diagnostic Assessments

Tonometry IOP testing
(normal = 10-21mmHg )
Slit lamp close examination of specific
area of eye
Corneal staining detects corneal defects
Angiography detects circulatory defects
Electroretinography retinal light
response

Glaucoma
Etiology/ Incidence / Prevalence

Increased ocular pressure resulting from:
inadequate drainage of aqueous humor
overproduction of aqueous humor
Pressure leads to damage of retina and
optic nerve
Primary Secondary Associated
Increased incidence in African-Americans
Increased incidence with aging
Glaucoma
Types
Open Angle

Most common
Bilateral
Slow onset
Usually painless
Blurred vision

Closed Angle

Sudden onset
Emergency
Severe pain radiating
around eyes & face
Colored halos around
lights


Glaucoma
Assessment
Early signs = IOP, blurred vision,
decreased accommodation, difficulty
adjusting to darkness

Later signs = loss of peripheral vision,
decreased acuity (uncorrectable), halos
around lights, pain
Glaucoma
Interventions
Medication Rx:
-Miotics
-Sympathomimetic
-Beta blockers
-Carbonic anhydrase inhibitors
-Osmotic diuretics
-Prostaglandin agonist
Surgical Rx:
-Trabeculoplasty
-Iridectomy

Glaucoma Medications
Increase
Drainage of Aqueous
Humor
Miotics
Pilocarpine hydrochloride
(Isopto Carpine)

Osmotic Diuretics
Glycerin
Mannitol ( Osmitrol )

Prostaglandin Agonists
Latanoprost (Xalatan)
Decrease
Production of
Aqueous Humor
Beta Blockers
Timolol maleate
(Timoptic)

CAIs
Actetazolamide
(Diamox)

Sympathomimetics
Dipivefrin ( Propine)
Ophthalmic Medication
Nursing Implications for Pt Teaching
Instill drops into conjunctival sac not
directly onto the cornea
Apply pressure to inner canthus X30sec
Do not touch dropper to eye
Wait 3-5 minutes between drops
Close eyes gently after administration
Do not rub eyes; dab gently prn




Glaucoma
Surgical Interventions
Trabeculoplasty
May be used in open-
angle glaucoma if
pharm rx ineffective
or as primary rx
Laser rx to trabecular
meshwork increases
space between fibers
and increased outflow
of aqueous humor
into conjunctivae
Iridectomy

Emergency rx for
acute closed angle
glaucoma
Section of iris is
removed to create
pathway for flow of
aqueous humor

http://dmc.org/videolibrary/ek_gla
ucoma.html
Cataracts
Etiology / Incidence / Prevalence

An opacity of lens; distorts image
Age related etiology = most common
All people >70y.o. have some degree
Exposure to ultraviolet light increases risk
Other etiology r/t trauma, congenital
defects, associated diseases
5-10 million affected worldwide each year

Cataracts
Assessment
Blurred vision
Decreased color perception
Opacity of lens
Absence of red reflex
Vision better in dim light w/ pupil dilation
Gradual loss of vision
Painless

Cataract Interventions
Surgery =
only option for Rx
Surgical removal of
diseased lens and
replacement with
silicone prosthetic
lens
Extracapsular
procedure = most
common
Outpatient surgery



Cataract Surgery
Nursing Implications

Usually no eye patch
Client to wear dark sunglasses
Antibiotic/steroid eye gtts
Instruct client to visit MD following day
Instruct client in measures to avoid
increasing IOP
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5
th
edition
The client is a 62-year-old woman who works as a
stockbroker. She has recently been diagnosed with
bilateral cataracts. She lives in the Denver area and her
hobbies include long-distance biking and downhill skiing.
She has a glass or two of wine with dinner every night.
She smoked when she was in college but has not
smoked for more than 30 years. She is surprised by her
diagnosis because she is a vegetarian and keeps herself
physically fit. She also tells you that neither of her
parents nor any of her four brothers and sisters have
cataracts.
How should you explain the influence of genetics on the
development of cataracts?
What factors may have influenced the development of
her cataracts?
What additional personal and family information should
you obtain from this client?
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5
th
edition
Your 62-year-old client with bilateral cataracts is
scheduled to have an extracapsular cataract removal
with immediate intraocular lens implantation for her left
eye (the one with the worse vision). She asks why both
eyes can't be done at the same time so that she will not
have to go "through all of this rigmarole twice." She also
is concerned about her facial appearance after surgery
and whether any bruising will be present.
Should both eyes be done at the same time? Why or
why not?
How will her appearance be changed during the first
week after surgery?
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5
th
edition
Your 62-year-old client had the cataract
removed from her left eye and a multifocal lens
implanted on Friday afternoon. She plans to go
back to work on Monday and does not want her
co-workers to know about the surgery. (She
worries that people will think she is "old" and
not on the cutting edge of her profession).
Should she go back to work on Monday? Why or
why not?
What accommodations will she have to make at
her workplace?
What specific activities will you tell her to avoid?
Macular Degeneration

Dry (age-related)
Most common
Gradual
Wet
Sudden onset
Macula = area of
central vision
Increased risk for
smokers
Antioxidant intake
decreases risk and
slows progression
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5
th
edition
The client is a 75-year-old man who was
diagnosed with age-related "dry" macular
degeneration after he was involved in a car
accident in which he failed to stop at an
intersection and hit another car at a low rate of
speed. No injuries resulted from the car accident
although the client received a citation for a
moving violation. The client is very upset with
the diagnosis. His wife has never driven nor has
she managed the household accounts. He is
concerned about "going blind" and wants to
know if the LASIK procedure would restore his
vision.
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5
th
edition

Can the client continue to drive? Why or
why not?
Will a LASIK procedure be helpful for this
problem? Why or Why not?
How will you address the issue of "going
blind?"
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5
th
edition
Your client with macular degeneration (dry)
wants to know if continuing to use his limited
vision will increase the progression of the
macular degeneration. He also worries that he
will "lose his mind" if he has to give up all his
usual activities.
How will you address his concerns?
How will you proceed to assist the client and his
wife in maintaining independence and quality of
life?
LIGHTHOUSE INTERNATIONAL
Retinopathy
Hypertensive
Diabetic
Retinal Detachment

Partial detachment
Layers of retina separate because of fluid
accumulation between them

Complete detachment
if above left untreated; leads to blindness

Retinal Detachment
Assessment
Flashes of light
( photopsia)
Floaters
Blurred vision
Sense of curtain being
drawn
Loss of portion of
visual field

Retinal Detachment
Interventions & Nsg Implications
Emergency RX
Apply eye patches to both eyes
Provide bed rest

Surgical RX
Gas / Oil inserted inside eye to compress retina.
Postop position on abdomen, head turned with
unaffected eye up X 1 week
Scleral buckling silicone band around eye to hold
choroid and retinal layers together
Ear Disorders
Nursing Assessment
History
Infections, trauma, exposure to loud
noises, swimming habits,smoking,
nutritional deficiencies, family hx,
concurrent diseases (HTN, DM),
medications, allergies
Questions
Acuity changes? Vertigo? Tinnitus?
Hyperacusis? Excessive cerumen?
The Aging Ear

Cerumen drier
Tympanic membrane less elastic
Bony ossicles and cochlea function
diminish
Changes in vestibular function
Acuity diminishes

Ear Disorders
Assessment
External Examination:
Swelling, lesions, symmetry, position,
external canal, odor

Internal Examination:
Otoscope exam: assess tympanic
membrane color, intactness, bulging
Assess cerumen
Ear Disorders
Diagnostic Assessment
Hearing Tests
Whisper
Weber
Rinne
Audiometry
Vertigo Tests
Caloric
Dix-Hallpike
Electronystagmography
Menieres Disease
Etiology / Incidence / Prevalence

Etiology unknown
Possible contributing factors:
infections, allergies, fluid imbalance, stress
Overproduction or decreased reabsorption
of endolymphatic fluid
First occurring between ages 20-50
More prevalent in men

Menieres Disease
Assessment

Feeling of fullness in ear
Tinnitus; low pitched roar/hum
Vertigo
Nystagmus
Nausea / Vomiting
Severe headache
Hearing Loss
Menieres Disease
Interventions
Protect from injury
Bedrest
Avoid rapid head movements
Sodium and fluid restrictions
Advise client to stop smoking
Medications: Nicotinic acid, antiemetics,
antihistamines, sedatives
Surgery: Endolymphatic decompression,
labyrinthectomy
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5
th
edition
The client is a 52-year-old man who is the
conductor of a symphony in a large city.
He is admitted to the emergency
department with severe dizziness and
vomiting. He tells you he was eating
dinner in a restaurant when his symptoms
began suddenly. He has had such
episodes in the past and has been
diagnosed with Mnire's disease. He tells
you he would rather die than lose his
hearing because music is his life.
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5
th
edition
What vital signs should you take first for
this client? Why?
What nursing diagnoses are appropriate at
this time for this client?
What interventions can you initiate for the
symptoms he has before he is seen by a
physician?
What lifestyle alterations can you suggest
for his chronic condition?

Ear Disorders
Hearing Loss
CONDUCTIVE
Sound waves blocked
d/t external or middle
ear disorders
Causes:
inflammatory process
tumors
scar tissue on ossicles
otosclerosis
Correctable
SENSORINEURAL
Pathological process
of inner ear or 8
th

cranial nerve
Causes: trauma
ototoxic medications
loud noise exposure
presbycusis
Permanent and
progressive

Otosclerosis
Etiology
Bony overgrowth
around ossicles
Fixation of bones
Stapes fixation leads
to conductive loss
Inner ear involvement
leads to sensorineural
loss
Familial tendency
Otosclerosis
Assessment
Slowly progressing conductive loss
Bilateral ; may be worse in one ear
Ringing/roaring tinnitus
Loud sounds when chewing
Negative Rinne test
Weber test shows lateralization of sound
to ear with most conductive loss
Otosclerosis
Interventions
Surgical
Stapedectomy
Fenestration

- removal of stapes
- prosthesis placed
between incus and
stapes footplate

CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5
th
edition
You are the home care nurse for a 74-year-old woman
with diabetes, stasis ulcers, and rheumatoid arthritis who
lives alone at home. She has had a conductive hearing
loss for 10 years and has been using a hearing aid
successfully for that time. She has had a kidney
infection for the past 2 weeks and was seen by her
internist for this problem. At first she was taking Septra
orally (prescribed by her internist) for the infection but
when her symptoms didn't subside, she went to an
urgent care center and was started on streptomycin 8
days ago. The other drugs she takes routinely are
insulin, bumetanide, and ibuprofen. She says her hearing
has decreased during the last 4 days.
CRITICAL THINKING CHALLENGE
Ignatavicius & Workman Medical-Surgical Nursing 5
th
edition
What questions should you ask this client?
Exactly how will you test her hearing in this
setting?
What interventions could you perform
immediately for her change in hearing?
Can you determine whether she has any
sensorineural hearing loss? Why or why not?
What drugs or health factors could be
contributing to her difficulty hearing?