306- Neurosensory

• Independence
• Self-Esteem
• Safety Issues
• Interaction with others and environment
• Overall quality of life

• **Leading Causes Associated with Aging
• 2/3 of affected population over 65 years

• Cornea
• Sclera

Sclera

Cornea

• Iris
• Ciliary Body
• Choroid

Choroid

Ciliary Body

Forms retina – complex nervous tissue layer – converts light rays into elec. Signals/relays via optic nerve to brain/interpretation of vision

• Visual disturbance?
•   * Pain?
•   *Are both eyes affected?
•   * Discharge? (how long has this been going on)
•   * Duration
•   * Other disease processes
•   * Visual & Cranial history (cranial nerves)
•   * Medications – can affect intraocular pressure
•   * Family history
•   * Nutrition

• •Pupillary Function
• •Assessment of EOM -- 6 fields of gaze
• •Visual Acuity
• •Color Vision
• •Stereopsis Testing --depth perception, ability to see 3D
• •Tonometry
• •Slit Lamp Microscopy
• •Opthalmoscopy
• •Inspection

Snellen Chart

Ishiria

• 10-22 mmHg
• important with glaucoma

Refraction Errors

• –Irregularities of corneal curvature
• –Focusing power of lens
• –Length of eye

• –Blurred vision
• –Headache
• –Eye strain
• –Ocular discomfort

Myopia

Concave Lens

Far-Sightedness-- Light rays focus BEHIND the retina

Convex Lens

Presbyopia 

Presbyopia-- loss of accomodation

• Reading Glasses
• Bifocal Lens

Astigmatism

Aphakia

–Congenital defect

–Surgical Removal- IOL implant

–Trauma causing dislocation

• Thick glasses 
• Aphakic glasses can magnify 25% (not used freq because of surgery 

• Know pattern of wear
• Daily or extended wear
• Remove in emergency/surgery
• Teach detection of problems
• Remove immediately if problems (RSVP)
• Teach prevention of infection/complications
• Redness, Sensitivity,Vision problems, Pain

Photorefractive keratectomy

LASIK (Laser assisted in-situ keratomileusis) 

Implants (Intracorneal ring segments)

Best Corrected Visual Acuity

•   - Length of impairment? (acute- glycoma v. chronic)
•   - Effects on ADL functioning?
•   - Coping Strategies?
•   - Support Systems?

• –American Foundation for the Blind
• –Center for the Visually Impaired

•www.cviatlanta.org

•Braille or Audio books

•Cane or guide dog

•Closed circuit TV

•High powered magnification

• •Hold book closer to eyes.  Sit closer to TV
• •Contrast enhancement – white on black, black felt-tip marker
• •Increased lighting
• •Large type print

Pain, photophobia, redness, swelling, ecchymosis, tearing,  absent eye movements, drainage, abnormal vision, prolapsed globe, abnormal IOP

• •ABC’s
• •Determine mechanism of injury
• •Assess for other injuries
• •Chemical exposure- flush eye
• •Do NOT put pressure on eye!
• •Instruct Not to blow nose!
• •Stabilize foreign object
• •Cover eye with dry sterile patch & protective shield (if not chemical)
• •Keep NPO, Elevate HOB 45 degrees
• •No eye meds. unless dr. order
• •Analgesia, Reassurance, Monitor pain.
• •Anticipate surgical repair for penetrating, globe rupture, or avulsion

Avulsion

  - Hordeolum (sty)

  - Chalazion

  - Blepharitis

  - Conjunctivitis

  - Keratitis

Hordeolum

Chalazion

Blepharitis

Keratitis

• –Bacteria – Staph. aureus --pink eye
• –Viral
• -Chlamydial -- blindness

redness, tearing, foreign body sensation, drainage, photophobia

Strict handwashing, individual towels/wipes, antibiotic drops, assess for STD

Keratitis

Pain, photophobia

• No corticosteroids for HSV!
• –Antibiotics
• –(viral) Acyclovir
• –Good hygiene – contact lens, soiled drsg, direct contact
• –Discard possibly contaminated products
• –Hot/cold packs, dark glasses, analgesics
• –Eye drops (stagger for max absorption)
• –Corneal Transplant

• Intraocular Disorders
• (ie:  Cataracts, Retinal Detachment, Age-Related Macular Degeneration, Glaucoma)

age, congenital (maternal rubella), radiation/UV exposure, corticosteroids, trauma

gradual decline in vision, abn. color perception, glare

• •No non-surgical cure
• •Visual aids
• •Mydriatics to dilate pupil
• •Cycloplegic- paralysis of  accommodation

• Phacoemulsification
• Lens Replacement

• –Eye drops – Mydriatics, Cycloplegics, NSAIDs, antibiotics
• –Antianxiety meds
• –NPO X 6-8 hrs

• –Topical antibiotics & corticosteroids
• –Mild analgesia prn
• –Eyeshield & activity restrictions per MD
• –Home within few hrs

• •Pre-op - Expect photophobia and transient stinging/burning from eye drops
• •Will not have depth perception until patch removed
• •Expect minimal pain/scratchiness in operative eye
• •Call MD for   pain, redness, purulent drainage, or   visual
• acuity
• •Environmental safety measures
• •Administration of eye drops
• •Avoid stooping, bending, coughing, lifting
• •Wear eye shield at night
• •Health promotion – wear sunglasses, good nutrition (Vit. C & E)

•Separation of sensory retina and pigment epithelium• •Fluid accumulation between layers •1 out of 10,000 people yearly•Untreated usually results in blindness

• •Severe Myopia
• •Aphakia
• •Proliferative Diabetic Retinopathy
• •Ocular Trauma

•   - Photopsia –light flashes
•   - Altered field of vision – floaters/cobweb/hairnet

• “Curtain coming down”
•   - Small detachment may not be noticed, cobweb

•   - Laser photocoagulation
•   - Cryopexy

•   - Scleral Buckling
•   - Vitrectomy
•   - Pneumatic retinopexy

Laser Photocoagulation

Cryopexy

Vitrectomy

Retinopexy

•   - Positioning
•   - Activity
•   - Topical medications as ordered
•   - Pain Assessment

Age-Related Macular Disorder

• –Increasing Age
• –Smoking History
• –Hypertension
• –Overweight
• –Hyperopia
• –Family History
• –Wet ARMD
• –Use of thyroid hormones/HCTZ’s
• –Arthritis

Central Vision Loss after age 60

• - Nourish Macula
• - Remove metabolic waste
• - Aging decreases efficiency

• drusen-
• results in atrophy and degeneration of macular cells; 

Scotomas

Metamorphopsia

Nonexudative ARMD (dry)

Exudative ARMD (wet)

Opthalmoscopy

Amsler Grid Test

Fluorescein Angiography

• -Wet ARMD
• - Seals leaking blood vessels
• - IV injection of verteporfin dye to visualize vessels
• -“Cold” Laser activates dye to close vessels
• -Prevents further vision loss

• Lucentis-
• -preserves vision, monthly, side effects-  conjunctival hemorrhage, eye pain, inflammation, and floaters

High Dose Vitamin Therapy

Avoid Direct Sunlight Exposure

• Encourage that remaining vision can be retained
• Arrange social supports

• Information for independent ADL functioning
• - Organize aids for low vision
• - Reduce glare when outside

Glaucoma

Glaucoma

• intact drainage system - Trabecular meshwork
• (Open angle (45 degrees) between iris and cornea) 

• •Family History
• •African American
• •Age
• •Diabetes
• •Cardiovascular disease
• •Migraine Syndromes
• •Myopia
• •Eye Trauma
• •Prolonged use of topical or systemic corticosteroids

Open Angle Glaucoma

22-32 mmHg

• Definite symptoms-Sudden severe pain, N&V, colored halos around lights, blurred vision, ocular redness, “frosted cornea”
• Outflow decreased due to decreased angle between Iris and Cornea
•   - Bulging Lens  - age
•   - Pupil Dilation
•   - Drug Induced
•   - Trauma, neoplasms
• **VERY SERIOUS...PATIENT CAN LOSE EYE

50 mmHg or greater

• •Prevention of Optic Nerve damage
• •Damage control/not cure
• •Pharmacologic Therapy
• •Surgical Management

• Beta-Adrenergic Blockers
•   - Timolol (Timoptic)
•   - Decrease aqueous humor (AH) production
•   - Contraindicated in bradycardia/asthma/COPD

• Alpha Adrenergic Agonists
•   - Propine
•   - Decreased AH production/Increased Outflow
•   - Systemic effects
•   - Punctal Occlusion

• Discomfort/blurred vision/low blood pressure -
• ***Watch for postsystemic absorption

 Redness/tachycardia/hypertension

• Pilocarpine
•   - Iris sphincter contraction opens meshwork
•   - Increase AH outflow
•   - Decreased visual acuity 

• Diamox (systemic)
•   - Decreases AH production – Diuretic effect
•   - Extremity tingling/tinnitus/GI disturbances
•   - ? Sulfa allergy/electrolytes/high dose ASA therapy

• Azopt (topical)
• Stinging/redness/blurred vision (SE)

• Decreased visual acuity due to miosis –
• S/E headaches/vomiting/hypotension

Electrolytes

• •Argon Laser Trabeculoplasty (ALT)
•   - Outpatient/ only Topical Anesthetic
•   - Laser to meshwork – Opens spaces – Increase outflow

• •Trabeculectomy
•   - Filtering procedure
•   - Removal of part of iris/meshwork
•   - Increase AH outflow

• •Cyclocryotherapy
•   - Freezes parts of ciliary body
•   - Decreased production of AH

Miotics (cholinergic agents)

• Hyperosmotics – Glycerin liquid/Mannitol
•   - Increases extracellular osmolarity
•   - Reduces IOP

Laser iridotomy/Surgical Iridectomy

•   - Compliance with treatment
•   - Psychologic reaction
•   - Support systems
•   - Changes in visual acuity/visual fields/Opthalmoscopy

•   - No progression of disease
•   - Understand disease
•   - Compliance
•   - No Postoperative complication

• Teaching
•   - Risks
•   - Prevention
•   - Medication administration / Other meds?
•   -  Safety at home / referrals
•  PACG
•   - Requires acute intervention – medication
•   - Comfort measures
•   - Postoperative teaching (also POAG)

• Expected Outcomes
• – No further loss of vision/compliance/safely function/relief from pain

Pain, dizziness, vertigo, tinnitus, hearing deficit

• –Childhood problems
• –Head trauma
• –Surgeries
• –Allergies

Aspirin, Loop Diuretics, Aminoglycoside antibiotics, Antimalarial, Neoplastic agents

• Trauma 
• –Hematoma
• –aspirate, antibiotics
• –Assess hearing

• External Otitis
• –Pain w/ movement of auricle/tragus
• –Drainage, Fever, Dizziness, Impaired Hearing

• *Collaborative & Nursing Care
• •C&S of drainage
• •Warm compresses
• •Antibiotic drops/systemic
• •Mild Analgesics

• •Ear drops at room temp.
• •Do Not touch dropper to ear
• •Position ear so drops can run down canal – hold position X 2 minutes after given
• •Handle material saturated with drainage carefully

• •Discomfort, decreased hearing (conductive hearing loss), otalgia, tinnitus, vertigo, cough
• •Bradycardia (Vagal)
• •Irrigation of ear canal

–Pain, fever, malaise, h/a, decreased hearing

• Collaborative Care:
• •Antibiotics
• •Myringotomy
• •Antihistamines - adults

• •Drainage
• •Hearing loss
• –Destruction of ossicles
• –TM perforation
• –Fluid in middle ear
• •Ear pain, nausea, dizziness

• Complication: 
• **Cholesteatoma
• –Skin overgrowth that destroys adjacent bone & tissue

Otoscopy, C&S, audiogram, sinus xrays, MRI, CT

• •Antibiotics (systemic)
• •2% acetic acid drops
• •Tympanoplasty
• –Reconstruction of TM &/or ossicles
• •Mastoidectomy
• Removal of diseased tissue/infection source

• •Pre-op teaching
• •Avoid complications
• –Avoid blowing nose, coughing, sneezing
• •If must, leave mouth open
• –Assist with getting up first time
• •Dizziness & loss of balance
• –Cotton ball dressing – endaural incision
• –Mastoid drain w/ post-auricular incision
• –Monitor tightness of dressing over ear to prevent necrosis

•Inflammation/Accumulation of fluid

•Etiology:  Eustachian tube malfunction, chronic otitis media, URI, barotrauma, overgrowth of adenoids

• •Collaborative Care:
• –Decongestants, Antihistamines, Corticosteroids, Antibiotics
• –Chewing gum, swallowing, Valsalva
• –Myringotomy w/ ventilating tube placement
• •Teach
• – No H2O in ear or swimming
• –Adenoidectomy

Myringotomy

• •Spongy bone overgrowth from labyrinth causing fixation of stapes
• •Conductive hearing loss – common, young adults.
• •Reddish blush of TM - from vascular/bone change

• •Collaborative Care:
• –Stapedectomy – stapes removed & prosthesis implant
• –Na Fluoride w/ Vit. D & Ca Carbonate – retard bone resorption & encourage calcification of bony lesions

• •Post-Op Nursing Care:
• –Avoid sudden movements
• –Avoid coughing, sneezing, lifting, bending, straining with BM

Meniere's Disease

• –Acute:  Antihistamines, anticholinergics, antiemetics, benzodiazepines -Valium & Meclizine(Antivert)
• –B/T attacks:  vasodilation, diuretics, antihistamines, low Na diet, no caffeine or nicotine
• –Vestibular nerve resection – alleviate vertigo & preserve hearing
• –Labyrinth Ablation – loss of vestibular & cochlear hearing function

• Goals:  Minimize vertigo & ensure safety
• •Reassure not life threatening
• •Bedrest; Quiet, dark room; comfortable position
• •Avoid sudden head movements or position changes
• •Keep emesis basin within reach
• •Side rails up, bed in low position
• •Assist when getting OOB
• •IV meds & fluids.  Monitor I&O.
• •After attack, assist w/ ambulation – unsteady.

Labrynthitis

Manifestations of Labrynthitis

• –Impacted cerumen
• –Otitis externa
• –Trauma
• –Otitis media
• –Otosclerosis Tumors

• –Trauma
• –CNS infections
• –Presbycusis
• –Vascular
• –Ototoxic drugs
• –Tumors
• –Meniere’s disease

Barotrauma, Cholesteatoma, Otosclerosis, Temporal bone fractures

Conductive Hearing Loss

Sensorineural Hearing Loss

Asking others to speak up

Answering questions inappropriately

Not responding when not looking at speaker

Straining to hear

Cupping hand around ear

Showing irritability when others don’t speak up

Behaviors:  Irritability, Denial, Withdrawal, Suspicion, Loss of self esteem, Insecurity

•Environmental Noise Control

•Immunizations - MMR

• •Ototoxic Drugs
• Salicylates
• Loop diuretics
• Aminoglycoside antibiotics
• Antineoplastics
• Antimalaria
• Manifestations- dizziness, tinnitus, hearing loss

• Keep in cool, dry place
• Disconnect/remove battery
• Clean ear molds weekly

• –Draw attention with hand movements
• –Have speaker’s face in good light
• –Avoid covering mouth or face with hands
• –Avoid chewing gum or food
• –Maintain eye contact
• –Avoid distracting environment
• –Move closer to better ear

• –Speak normally and slowly!
• –Do not over exaggerate facial expressions
• –Do not over enunciate
• –Use simple sentences
• –Rephrase sentence; use different words
• –Write name or difficult words
• –Avoid shouting
• –Speak in normal voice into better ear

• •Unwillingness to use aid
• •Difficulty with care and handling
• •Acceptance of loss with aging