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Sensory System Chapter 40
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Eye abbreviations: Left eye Right eye Both eyes Drop/s OS OD OU
gtt/ gtts
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Conjunctivitis Inflammation of the conjunctiva AKA “pink eye”
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Conjunctivitis Caused by Spread by Bacteria Viral Direct contact
Hand Tissue Towel
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Conjunctivitis S&S (mild) Redness Itching pruritus Tearing Discharge
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Conjunctivitis Dx History Visual examination “conjunctival scraping”
Culture
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Conjunctivitis Rx Antibiotics Topical
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Nursing assessment Symptoms Effects on vision Associate symptoms
Date of last eye exam Corrective lenses???
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Nursing Assessment Past medical history Test vision Snellen eye chart
Rosenbaum chart
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Snellen Eye chart Rosenbaum chart Pic from book
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Nursing Assessment Inspect eye Check pupil PERRLA
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PERRLA Pupils Equal Round Reactive to Light Accommodation
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Priority Nursing Diagnosis: Risk for disturbed sensory perception (visual)
Instruct to wash hands Instruct to avoid touching or rubbing eyes Emphasize proper contact care
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NRS DX: Acute pain Administer analgesics routinely Patch both eyes PRN
Teach to apply warm compresses for 15 minutes, 3-4 x day
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NRS DX: Acute pain Wear dark glasses Avoid excessive reading
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NRS DX: Knowledge deficit
Teach Hand washing Correct eye care Do not share Makeup Towels Contact lenses Do not use old makeup Cleaning techniques for contacts
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Eye trauma Common types of eye injury Foreign body Abrasion Laceration
Burn
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Corneal Abrasion AKA Scratched cornea
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Corneal Abrasion S&S Pain! Photophobia Tearing
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Corneal Abrasion Prognosis Usually heal without scarring
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Burns Types of burns Chemical burns Thermal burns UV burns
Ammonia Cleaners (oven, drain) Acids (car batteries) Thermal burns Explosions UV burns Snow-blindness Welder’s-arc burn
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Burns S&S Pain Affects vision Swollen eyelids
Conjunctiva red & edematous Slough Cornea cloudy or hazy
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Perforated eye Examples of causes Metal flakes Glass shards Weapons
Bullets Arrows Knives
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Perforated eye S&S Pain Partial or complete loss of vision Bleeding
Loss of eye contents
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Blunt eye trauma Common cause Sports injuries
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Blunt eye trauma Minor Ecchymosis (lid) Subconjunctival hemorrhage
AKA: Black eye Subconjunctival hemorrhage Subconjunctival hemorrhage Bleeding into the conjunctiva
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Eye trauma Assessment Eye exam Vision Movement Inspect
Unless penetrating objects Inspect Foreign objects Lacerations Vision With corrective lenses ON Movement Unless penetrating objects Inspect Foreign objects Lacerations
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Eye trauma treatment Topical anesthetic Before inspection
Relieve Pain Photophobia
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Eye trauma DX Test Fluorescein staining Can you find the abrasion? ID
Foreign bodies Abrasions Can you find the abrasion?
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Eye trauma DX Test Ophthalmoscopic examination
Detect bleeding Trauma to the interior chamber
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Eye trauma DX Test X-ray CT scan Orbital fx Foreign bodies
Computed tomography (CT or CAT) scan: The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into images of the part of your body being studied. CT scans are sometimes used to see if a melanoma has spread outside of the eye into nearby structures. It may also be used to look for spread of the cancer to distant organs such as the liver. Before the scan, you may be asked to drink a contrast solution and/or get an intravenous (IV) injection of a contrast dye that helps better outline abnormal areas in the body. You may need an IV line through which the contrast dye is injected. The injection can cause some flushing (redness and warm feeling). Some people are allergic and get hives or, rarely, more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor is you have ever had a reaction to any contrast material used for x-rays. You need to lie still on a table while the scan is being done. During the test, the table moves in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring, but you have to lie [still] while the pictures are being taken. Coronal CT scan of the orbit which shows a blowout fracture in the region of infraorbital nerve.
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Eye trauma: Irrigate Small foreign bodies Chemical burns Irrigate
sterile saline Chemical burns Copious amounts of fluid
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Eye trauma: Irrigate Procedure
“from the inner canthus of the eye to the outer” Head tipped slightly to the affected side Procedure “Fluid is directed from the inner canthus of the eye to the outer” Inside outside Head tipped slightly to the affected side Prevents contamination of the other eye
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NOTE!!! Immediately irrigate the eye is a chemical burn is suspected. Irrigation to remove the chemical is of higher priority than assessment of the eye
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Eye trauma TX Remove loose foreign bodies Use a Moist Sterile
Cotton-tipped applicator
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Eye trauma TX Severe or penetrating injury Bed rest Stabilize eye
Apply eye pad Over both eyes Rational Reduces eye movement Helps preserve vision
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Eye trauma TX Post-care Eye-drops / ointment Eye pad/shield per order
Avoid wearing contacts until cornea has healed completely Post-care Eye-drops / ointment Eye pad/shield per order Rational Reduce pain Decrease photophobia Promote healing Avoid wearing contacts until cornea has healed completely
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Nursing Care Teach to prevent eye injuries!
Eye protection Seat belts flush eye immediately if chemicals splash
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Nursing care If an abrasion or penetrating or blunt injury
Loosely cover with sterile gauze Do not remove penetrating objects Patch both eyes
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Nursing Care: After injury
Reinforce follow-up apt Discuss meds & application Teach how to apply eye patch Do not rub or scratch the eye
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Nursing Care: After injury
Teach to avoid activities that h intraocular pressure Lifting Straining Bending over
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Small Group Questions Define the following abbreviations: OS, OD, UO, gtts Describe conjunctivitis, how would you assess for it? What is the common treatment for conjunctivitis? You are fishing with a young child and the line breaks and the fish hook flies into their eye. What would you do? After the hook is removed, what instructions should be given to the child?
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Cataracts Clouding of the lens impaired vision Common >65
Affects both eyes
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Cataracts Age Cells become less clear Affects edges first
Spreads towards center
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Cataracts Affects Details obscured Glare Pupils appear Near vision
Far vision Details obscured Glare light / dark Pupils appear cloudy gray / white
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Cataracts Risk factors Age Sunlight Cigarette smoke
Senile cataracts Sunlight Cigarette smoke Heavy alcohol consumption Eye trauma Diabetes mellitus
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Cataracts: Dx History Eye examination
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Cataracts: Tx Surgical removal Clouded lens removed
Intraocular lens is implanted
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Nursing Care: Eye surgery
Pre-op Assess understand of procedure Assess vision of unaffected eye Reinforce post-op teaching Remove all eye make-up Admin. Pre-op meds per order
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Nursing Care: Eye surgery
Post-op Assess V/S LOC Comfort Status of eye dressing Maintain eye patch / shield per order Position Semi-Fowlers Fowlers
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Nursing Care: Eye surgery
Approach client on unaffected side Intervene PRN to prevent Vomiting Straining Coughing Sneezing Immediately report sudden / sharp pain to MD
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Nursing Care: Eye surgery
S&S to report to MD Redness or cloudiness Drainage i vision Floaters Flashes Halos
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Nursing Care: Eye surgery
Personal items & call light within reach Admin eye-drops and meds per order Arrange or referals
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Nursing Care: Eye surgery
Teach How to instill eye-drops How to apply eye patch Avoid rubbing Wear sun glasses Make & keep apt.
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Glaucoma Increased intraocular pressure Vision loss is permanent
Gradual vision loss Vision loss is permanent
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Chronic Glaucoma: S&S Painless Difficulty adapting light to dark
Blurred vision Halos Difficulty focusing on near objects
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Acute glaucoma: S&S Severe eye PAIN N&V Halos Red eye, cornea clouded
Pupil Dilated Fixed
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Clinical Alert! Acute glaucoma is a medical emergency. Without prompt treatment the affected eye will become blind. Immediately report manifestations of acute glaucoma to the charge nurse or MD
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Glaucoma: Dx Tonometry Visual field testing
Measures intraocular pressure Visual field testing Checks peripheral vision Tonometry Measures intraocular pressure Non-contact tonometry Recommended >60 yrs Visual field testing Checks peripheral vision
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Glaucoma: Rx Meds to i intraocular pressure
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Memory alert Mydriatics (drugs that dilate pupils) must be avoided with glaucoma. Remember “D” is in both myDriatic and Dilate
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Nursing Care: health promotion
Early screening >40 q 2-4 years > 60 q 1 – 2 years High risk groups African-Am Mexican-Am Asians
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Nursing Assessment Risk factors Ask about vision Family Hx Inspect eye
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Nursing Assessment Assess vision Assess pupils Eval. peripheral vision
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NRS DX: Risk for injury Assess ability to provide self care
Alert others not to move items in room
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Application of Eye drops
Use aseptic technique Have clients sit upright or lie supine with the head tilted slightly up Rest hand on the client’s forehead, hold the dropper 1 to 2 cm above his conjunctival sac and instill the medication into the center of the sac. Then instruct the client to close his eye gently. Apply gentle pressure with your finger and a clean tissue on the nasolacrimal duct for 30 to 60 seconds Use surgical aseptic technique when instilling medications in eyes. Have clients sit upright or lie supine with the head tilted slightly and looking up at the ceiling. With the radial aspect of your dominant hand resting on the client’s forehead, hold the dropper 1 to 2 cm above his conjunctival sac and instill the medication into the center of the sac. Then instruct the client to close his eye gently. Apply gentle pressure with your finger and a clean tissue on the nasolacrimal duct for 30 to 60 seconds to prevent systemic absorption of the medicationNursing Procedures: Assess the patient and the cart for any allergies Check the written orders on MAR Obtains the necessary equipments Follow the five rights of drug administration Determine the identification armband Wash hand and don non-sterile gloves Explain the procedure to the patient and ask if he or she wants to instill his or her own eye drops Gently wash the eye if there is crust or drainage along the margins of inner canthus. (always wipe from the innter canthus to the outer and use warm soaks to soften material if necessary) Position patient in a supine position with the head slightly hyperextented Remove cap from eye bottle and place cap on its side Put a tissue below the lower lid Squeeze the amount of medication as prescribed into the eyedropper With dominant hand, hold eyedropper ½ to ¾ inch above the eyeball, the rest hand is on patient forehead to stabilize Place nondominant hand on cheekbone and expose lower conjunctival sac by pulling on cheek while applying slight pressure to the inner chantus Instruct the patient to look up and drop the drops into center of conjunctival sac If the patient blinks and the drops land on the outer lid or eyelash, repeat the procedure Do not instill medication drops directly into the cornea Instruct patient to close and move eyes gently Remove gloves and wash hands Record the route, site, and time administered on the MAR Health care professionals need to ensure that the proper drug is being instilled and that it has not passed its expiration date. Some ophthalmic solutions may be contraindicated or can cause allergic reactions. Eyedrop containers should be clearly labeled and checked before instillation. The eyedrops should also be monitored for discoloration or sedimentation, which indicate that the ophthalmic solution is decomposing. In that case, a new dose of medicine should be obtained and the affected bottle discarded. Moreover, the ophthalmic staff member dispensing the drops should double-check the patient's identification and chart to ensure the correct dose is being instilled into the correct eye. The dispensing ophthalmic professional should never touch the tip of the eyedropper to the patient's eye. Touching will contaminate the remaining medication. In case of direct eye contact, the medication should be thrown away. Sterilization is an important part of eyedrop instillation. Before eyedrops are instilled, the ophthalmic assistant, technician, nurse, optometrist, or ophthalmologist should wash his or her hands thoroughly. The ophthalmic staff member then should gather all necessary supplies. For some eyedrops, the dispenser may want to warm the drops to body temperature by holding the bottle in his or her hand for about two minutes. Next, the dispenser should position the patient correctly. The patient should sit back in the examination chair with their head slightly hyperextended. Once the patient is correctly positioned, the dispenser should clean the eyelids from the inner canthus outward with a sterile saline solution to remove any eye secretions or previously instilled medications. The dispenser should wash their hands after these preparations are completed. Immediately before instillation, the dispenser should depress the patient's lower lid with the finger of one hand and lightly pinch the patient's lower lid to make a pouch for the medication. The upper lid should also be held open to prevent blinking during instillation. The dispenser should tell the patient to look up. Using the other hand, the dispenser should instill the drop into the everted lower lid. The drops should not be instilled on the cornea. This precaution is necessary to avoid startling the patient, or causing unnecessary pain. After the appropriate amount of medication is instilled, the ophthalmic professional should release the lid and remove any excess fluid. The patient should be told to gently close their eyes so as to not release any medication. If another medication is to be instilled, a delay of at least 30 seconds is required between instillations. Preparation Patients should have the procedure explained to them before instillation to ensure best results. If patients are treated for certain eye ailments such as conjunctivitis, they should be warned in advance not to wear contact lenses or eye makeup. Before instillation, the ophthalmic staff should double-check the dosage and type of medication. They should also wash their hands thoroughly. Aftercare Patients who will be dispensing their own eyedrops after the initial treatment need careful instructions on proper instillation. Allied health professionals should guide patients step by step through the procedure to ensure maximum benefit from the medication. If patients are treated for infections or conjunctivitis, they should be advised to wash their hands regularly; avoid touching their eyes; avoid wearing eye makeup or contact lenses; and to discard any eye drops or eye makeup used before treatment for the infection began. Follow-up appointments for further treatment may also be necessary. Glaucoma patients using eyedrop medications should be monitored to determine if the drops are effective. Many times a combination of drops is necessary to treat glaucoma. Complications Eyedrops cause irritation in some patients that might result in eye redness or burning. Stronger medications can cause more extreme allergic symptoms, such as dizziness and disorientation. Some cycloplegic drops can cause such severe reactions as delirium, a rapid pulse, and difficulty swallowing. Patients should be monitored after instillation, and health care professionals should record any side effects. Results Properly instilled eyedrops should effectively treat a number of eye disorders. Dilatory drops facilitate eye refraction and retinal examination. Health care team roles Nursing and allied health professionals are usually responsible for eyedrop instillation. Ophthalmic assistants, technicians and nurses ensure that the proper dosage is administered to the correct patient, the medication is fresh, the medication and eyedropper are sterile and in good condition, and the patient is told step-by-step how the procedure is performed. The allied health professional may also need to repatch an affected eye, monitor patients for side effects, chart medications for each patient, and dispose of (used) equipment.
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Small Group Questions Differentiate between cataracts and glaucoma
What is the common treatment for cataracts? What would you teach a patient who had/ was having cataracts surgery? What is the common treatment for glaucoma? What is the prognosis for glaucoma? Describe how to put in eye drops
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Otitis Media Inflammation of the middle ear Ear drum Eustachian tube
Protects middle ear from environment Eustachian tube Connects with nasopharynx
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Otitis Media Risk factors URI Allergies Eustachian tube dysfunction
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Serous Otitis media Eustachian tube is obstructed
Air gradually absorbed Negative pressure Serous fluid drawn in
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Serous Otitis media S&S i hearing Snapping /popping sensation
Bulging or sunken eardrum Change in atmospheric pressure PAIN!
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Acute Otitis media URI Eustachian tube swelling Impairs drainage
Bacteria grows in fluid Inflammatory process Pus increases pressure Ear drum ruptures
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Acute Otitis media S&S Pain Fever Dizziness or Vertigo Eardrum Red
Inflamed Dull Bulging
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Otitis Media: Dx History Physical exam Otoscope
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Otitis Media: Rx Decongestants Antibiotics Mild Analgesics
Acetaminophen Decongestants Improve Eustachian tube function Antibiotics 5-10 days Mild Analgesics Acetaminophen Anti-pyretic
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Complementary therapies
Pain relief from Otitis Media Drop of lavender oil Warm cloth
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Otitis Media: Surgery Tympanocentesis Needle through eardrum
Extract fluid & pus
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Otitis Media: Surgery Myringotomy Surgical opening of the middle ear
drainage
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Otitis Media: Surgery Ventilation (tympanostomy) tubes
Ventilation and drainage of middle ear during healing Tube eventually come out *Avoid getting water in the ear canal
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Nursing Care: Ear surgery
Pre-op Assess hearing Discuss post-op hearing strategies Explain post-op restrictions Blowing nose Coughing Sneezing
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Nursing Care: Ear surgery
Post-op Assess Bleeding Nausea Admin antiemetics Vertigo / dizziness Hearing
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Nursing Care: Ear surgery
HOB Elevate Unaffected side Stand on unaffected side to communicate Remind to avoid Coughing Sneezing Blowing nose
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Nursing Care: Ear surgery
Instruction for home care Avoid showers until MD OKs Keep ear plug clean and change prn Do not remove inner ear dressing until MD OKs No swim, drive or travel by air until MD-OK Antiemetic per MD order Antihistamine per MD order
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Nursing Care: Ear surgery
Notify MD if Fever Bleeding h drainage h dizziness i hearing
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Assessment: Otitis Media
History Onset / duration S&S Hx URI Move auricle / pinna Inspect throat & ear Temperature Assess hearing Palpate mastoid process auricle, also called Pinna, in human anatomy, the visible portion of the external ear, and the point of difference between the human ear and that of other mammals. The auricle in humans is almost rudimentary and generally immobile and lies close to the side of the head. It is composed of a thin plate of yellow fibrocartilage covered by a tight-fitting skin. The external ear cartilage is molded into shape and has well-defined hollows, furrows, and ridges that form an irregular shallow funne
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NRS DX: Pain Mild analgesics Heat to affected side of face & head
Q4hour PRN Heat to affected side of face & head Instruct to report abrupt pain relief
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NRS DX: Knowledge Deficit
Take All antibiotics Discuss S/E of antibiotics Diarrhea Vaginitis Thrush Eat 8 oz yogurt q day
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NRS DX: Knowledge Deficit
Instruct pt w/ tubes No Swimming Diving Submerging head while bathing Air travel Enc Rest h fluid intake Nutritious diet
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Small Group Questions What are the S&S of otitis media
What is the pathophysiology of otitis media What medications are prescribed to a client with otitis media? What client teaching would you give in regards to the above medications? A 2 year old is having tubes placed in their ear bilaterally. The mother is confused about the procedure and what to expect. What would you teach her?
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