sensorineural chapter the

1. Care of Clients with
Disturbances in
Sensorineural
Adult Health Nursing 2 - Theory
Level 6, Academic Year (AY) 1442—1443 H

2. Assessment and Management of
Patients With Eye and Vision
Disorders
1 Glaucoma
2 Cataracts
3 Keratoconus
4 Conjunctivitis

3. 3
On completion of this chapter, the learner will
be able to:
1. Identify the major structures and function of
the eye.
2. Define terms related to sensorineural
distubances
3. Identify the causes, risk factors and clinical
manifestations
4. Identify common laboratory and diagnostic
examinations

4. 4
5. Understand medical and nursing
management associated to sensorineural
disturbances
6. Recognize complications & management
7. List the pharmacologic actions and nursing
management of common sensorineural
disturbances

5. 5
Anatomic and Physiologic Overview

6.  The eyeball, or globe, sits in the bony protective
orbit. The eyeball is moved through all fields of
gaze by the extraocular muscles.
 Lined with muscle and connective and adipose
tissues, the orbit is shaped like a four-sided
pyramid.
 The optic nerve and the ophthalmic artery enter the
orbit at its apex through the optic foramen.
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7.  The four rectus muscles and two oblique
muscles are innervated by cranial nerves (CNs)
III, IV, and VI. Normally, the movements of the
two eyes are coordinated and the brain
perceives a single image.
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8. THE CONJUNCTIVA
 The conjunctiva, a thin transparent mucous
membrane, provides a barrier to the external
environment extending under the eyelids
(palpebral conjunctiva) and over the sclera
(bulbar conjunctiva).
 The junction of the two portions is known as
the fornix.
 The conjunctiva meets the cornea at the
limbus on the outermost edge of the iris.
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9. EYEBALL
The eyeball is composed of the following three
layers:
 The outer dense fibrous layer, including the
sclera and transparent cornea
 The middle vascular layer, containing the iris,
ciliary body, and choroid
 The inner neural layer, including the retina,
optic nerve, and visual pathway
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10. EYEBALL
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11. Structure

12. GLAUCOMA
 Glaucoma is a group of disorders
characterized by increased IOP and
its’ consequences, optic nerve
atrophy, and peripheral visual field
loss
 2nd leading cause of blindness in
adults in the United States.
 More prevalent in people older than
40 years of age

13. Risk Factors for Glaucoma
 • Family history of glaucoma
 • Thin cornea
 • race : African American
 • Older age
 • Diabetes mellitus
 • Cardiovascular disease
 • Migraine syndromes
 • Nearsightedness (myopia)
 • Eye trauma
 • Prolonged use of topical or systemic corticosteroids

14. Etiology and Pathophysiology
 A proper balance between the rate of aqueous production (inflow)
and the rate of aqueous reabsorption (outflow) is essential to
maintain the IOP within normal limits.
 We call the place where the outflow occurs the angle because it is
the angle where the iris meets the cornea.
 When the rate of inflow is greater than the rate of outflow, IOP can
increase above the normal limits.
 If IOP stays increased, permanent vision loss may occur.

15. Pathophysiology
There are two theories regarding how increased IOP damages the
optic nerve in glaucoma:
1. The direct mechanical theory suggests that high IOP
damages the retinal layer as it passes through the optic nerve head.
2. The indirect ischemic theory suggests that high IOP compresses
the microcirculation in the optic nerve head, resulting in cell injury
and death.

16. Types of Glaucoma
 Primary open-angle glaucoma (POAG) is the most common type of
glaucoma. In POAG the outflow of aqueous humor is decreased in the
trabecular meshwork.
 Angle-closure glaucoma (ACG) is due to a reduction in the outflow of
aqueous humor that results from angle closure. Usually, this is caused
by the lens bulging forward because of the aging process. Angle
closure may also occur because of pupil dilation in the patient with
anatomically narrow angles.

18. Manifestation of Glaucoma
 often called “silent thief of sight”
 Seeing halos around lights
 Vision loss / Blurred vision
 Redness in the eye
 Eye that looks hazy (particularly in infants)
 Nausea or vomiting
 ocular -Eye pain/discomfort/ aching /
headache around eyes
 Narrowed vision (tunnel vision)
 loss of peripheral vision

19. Diagnostic Findings
 Tonometry to measure IOP
 Ophthalmoscope to inspect optic
nerve
 Perimetry to assess visual fields.

20. Medical Management
 Aim : prevention of optic nerve damage.
 Lifelong therapy is almost always necessary
because glaucoma cannot be cured.
 Goal = Maintain low IOP= a range unlikely to
cause further damage
 Specific therapies varies with type of
glaucoma

21. Drug therapy
Systemic and topical medications that lower IOP.
 Adrenergic agonists (dipivefrin, epinephrine)-Reduces
production of aqueous humor and increases outflow
 Cholinergic (miotics) (pilocarpine, carbachol) Increases
aqueous fluid outflow by contracting the ciliary muscle and
causing miosis (constriction of the pupil) and opening of
trabecular meshwork
 Alpha-adrenergic agonists (apraclonidine,brimonidine)
Decreases aqueous humor production
 Carbonic anhydrate inhibitors (acetazolamide, methazolamide,
dorzolamide) Decreases aqueous humor production
 Prostaglandin analogs (latanoprost, bimatoprost) Increases
aqueous humor outflow
 Beta-blockers (betaxolol,timolol)-Decreases aqueous humor
production

22. 22
Surgical therapy
Laser therapy “Argon laser trabeculoplasty”
 Aim: promoting outflow of aqueous humor and
decreasing IOP.
 Indication
IOP inadequately controlled by medications
Action : Laser applied to inner surface of
trabecular meshwork to open intratrabecular
spaces and widen canal of Schlemm, thereby
promoting outflow of aqueous humor and
decreasing IOP.

23. Surgical Management
 laser trabeculoplasty

24. 24
Surgical therapy
Trabeculectomy
 standard filtering technique used to remove part
of trabecular meshwork.
 Filtering procedures for chronic glaucoma to create an
opening or fistula in trabecular meshwork to drain
aqueous humor from anterior chamber to
subconjunctival space into a bleb (fluid collection on the
outside of the eye), thereby bypassing the usual drainage
structures.
 This allows the aqueous humor to flow and exit by
different routes (ie, absorption by the conjunctival vessels
or mixing with tears).

25. Surgical Management
Drainage implants or shunts:
open tubes implanted in the anterior chamber to
shunt aqueous humor to episcleral plate in
conjunctival space.

26. 26
Nursing diagnoses for the patient
with glaucoma include:
• Risk for injury
• Acute pain

27. 27
Teaching Patients Self-Care
importance of strict adherence to medication
regimen
Educate on disease process and treatments
Administer medication to lower IOP
Apply cool compresses to patient forehead
Provide quiet space
Periodic follow-up examinations essential to
monitor IOP

28. 28
Cataract

29. Cataract
 lens opacity or cloudiness (1 or 2 eyes)
A cataract is an opacity within the lens.
 cataract is leading cause of blindness in world
(CDC, 2020).

30. High Risk Factor
 Increasing age
 Diabetes
 Excessive exposure to sunlight
 Smoking
 Obesity
 High blood pressure
 Previous eye injury or inflammation
 Previous eye surgery
 Prolonged use of corticosteroid medications
 Drinking excessive amounts of alcohol

31. Clinical Manifestations
 Painless, blurry vision
 perceives that surroundings are
dimmer as if his or her glasses
need cleaning.
 Light scattering is common
 reduced contrast sensitivity
 Sensitivity to glare
 reduced visual acuity
Other effects include
 myopic shift (return of ability to do
close work [eg, reading fine print]
without eyeglasses)
 Astigmatism (focus of light)
 Monocular diplopia (double vision),
 color shift ( aging lens become
progressively more absorbent at blue
end of spectrum),
 brunescens (color values shift to
yellow-brown)
 reduced light transmission.

32. Diagnostic Investigations
 Snellen visual acuity test
 ophthalmoscopy
 slit-lamp biomicroscopic examination used
to establish degree of cataract formation

33. Medical management
 Currently, no treatment is available to “cure” cataracts other than
surgical removal.
 changing the patient’s eyewear prescription can improve visual acuity, at
least temporarily.
 Visual aids (palliative measures)
Strong reading eyeglasses
Change eye glasses
contact lenses
Increase lighting
Lifestyle adjustment

34. Surgical therapy
Surgical procedure is the only treatment for cure
 outpatient / day surgery procedure
 local anesthesia
 takes less than 1 hour
 Pt discharged soon afterward
 When both eyes have cataracts, 1 eye is treated first,
with at least several weeks, preferably months,
separating 2 procedures.

35. Surgical therapy
Lens replacement
 Insertion of intraocular lens implant after
removal of lens
 Eyeglasses still needed for distant or close
vision, because intraocular lens implant is
single-focus lens, unlike natural lens of eye

37. Surgical Management
There are 3 lens replacement options:
1. Aphakic glasses- effective, but rarely used.
Objects are magnified by 25%, making them appear
closer than they actually are. This magnification creates
distortion. Peripheral vision is also limited
2. Contact lenses : provide patients with almost normal
vision but contact lenses need to be removed
occasionally. patient also needs a pair of aphakic glasses
3. IOL implants Insertion of IOLs during cataract
surgery is usual approach to lens replacement.

38. Nursing management
Prevention
Patients should be educated by primary providers about:
 risk reduction strategies such as smoking cessation,
weight reduction,
 Optimal blood sugar control for patients with diabetes,
 wear sunglasses outdoors to prevent early cataract
formation

39. Nursing management
Preoperative care for ambulatory surgery
NPO 6-8 hours before surgery
History and physical assessment
Dilating eye drops (mydriatics ) every 10
minutes for 4 doses at least 1 hour before
surgery
Antianxiety medications
Antibiotic, corticosteroid, and anti-inflammatory
drops may be administered prophylactically to
prevent postoperative infection and
inflammation

40. Postoperative care
Teaching pt and family (post op)
postoperative eye care
protect the eye
Wear eye shield over operative eye for 24
hours after surgery, followed by eyeglasses
worn during the day and a metal shield worn at
night for 1 to 4 weeks.
A clean, damp washcloth may be used to
remove slight morning eye discharge.
Prevent accidental rubbing or poking of eye
May experience blurring of vision for several
days to weeks

41. Nursing management
Activity restrictions
administer Medications
Antibiotic, anti-inflammatory, and corticosteroid eye
drops or ointments are prescribed postoperatively.
Signs and symptoms of possible complications
(infection)
Instruct patient to call physician immediately if: vision
changes; continuous flashing lights appear; redness,
swelling, or pain increase; type and amount of
drainage increases; or significant pain is not relieved
by drugs

42. KERATOKONUS
42
• Keratoconus is a noninflammatory, usually bilateral disease with a
familial tendency.
• Keratoconus usually appears during adolescence and slowly
progresses between ages 20 and 60 years.
• This hereditary condition has a higher incidence among women.
• The anterior cornea thins and protrudes forward, taking on a cone
shape.
• Keratoconus, the most common type of corneal dystrophy, is
characterized by a conical protuberance of the cornea with
progressive thinning on protrusion and irregular astigmatism.

43. Clinical Manifestations
 Corneal scarring occurs in severe cases.
 Blurred vision is a prominent symptom
 irregular astigmatism.

44. KERATOKONUS
44
Treatment
• Rigid, gas-permeable contact lenses correct
irregular astigmatism and improve vision.
• Advances in contact lens design have
reduced the need for surgery.

45. KERATOKONUS
45
Intacs inserts are generally used to delay the need for a corneal
transplant when contact lenses or glasses no longer help a patient
achieve adequate vision.
They are clear plastic lenses surgically inserted on the cornea
perimeter to reduce astigmatism and myopia.
Sometimes, the cornea can perforate as central corneal thinning
progresses. In these cases, a corneal transplant is done before the
cornea can perforate.

46. Penetrating Keratoplasty
 PKP (corneal transplantation or corneal grafting)
involves replacing abnormal host tissue with
healthy donor (cadaver) corneal tissue.
 Penetrating keratoplasty (PKP) is indicated
when contact lens correction is no longer
effective.
 Common indications are keratoconus, corneal
scarring from herpes simplex, keratitis, and
chemical burns.
46

47. CONJUNCTIVITIS
47
• Conjunctivitis is an infection or inflammation of the
conjunctiva.
• Infections may be bacterial or viral. Conjunctival
inflammation may result from exposure to allergens or
chemical irritants.
• It is characterized by a pink appearance (hence the
common term pink eye) because of subconjunctival
blood vessel congestion.

48. TYPES OF CONJUNCTIVITIS
• ACCORDING TO ITS CAUSE
Bacterial conjunctivitis
 Acute bacterial conjunctivitis (pinkeye) is a
common infection.
 Although it occurs in every age group, epidemics
are common among children. S. aureus is the
most common cause.
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49. MANIFESTATIONS OF BACTERIAL
CONJUNCTIVITIS
 Acute onset of redness
 Burning sensation
 Presence of discharge/exudates usually in the morning
 Papillary formation
 Conjunctival irritation
 Purulent discharge (acute cases)
 Micropurulent discharge (mild cases)
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50. Viral Conjunctivitis
 Caused by adenovirus and herpes simplex virus
 Adenovirus conjunctivitis may be contracted in
contaminated swimming pools and through
direct contact with an infected patient
 The patient with viral conjunctivitis may have
tearing, foreign body sensation, redness, and
mild photophobia.
 This condition is usually mild and self-limiting.
 However, it can be severe, with increased
discomfort and subconjunctival hemorrhaging.

52. Allergic Conjunctivitis
 The patient may develop allergic conjunctivitis in response to
pollens, animal dander, ocular solutions, and medications.
 Immunologic or allergic conjunctivitis is a hypersensitivity
reaction that occurs as part of allergic rhinitis (hay fever)
 The patient usually has a history of an allergy to pollens and
other environmental allergens
 Conjunctivitis caused by exposure to an allergen can be mild
and transitory, or it can be severe enough to cause significant
swelling.
 The defining symptom of allergic conjunctivitis is itching.
 The patient may have burning, redness, and tearing.

53. Toxic Conjunctivitis
Chemical conjunctivitis can be the result of
medications; chlorine from swimming pools;
exposure to toxic fumes among industrial
workers; or exposure to other irritants such as
smoke, hair sprays, acids, and alkalis.
 Irrigation with sterile water or normal saline can
help in management of Toxic Conjunctivitis

54. General MANIFESTATIONS of
conjunctivitis
 Corneal involvement causes extreme
photophobia.
 Symptoms include tearing, redness, and
foreign-body sensation that can involve one
or both eyes
 There is lid edema, ptosis, and conjunctival
hyperemia (red eyes caused by dilation of
blood vessels)
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55. General MANIFESTATIONS of conjunctivitis
There is extreme pruritus
Epiphora (excessive secretion of
tears),
usually severe photophobia.
The stringlike mucoid discharge is
usually associated with rubbing the
eyes because of severe pruritus.
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56. General MANIFESTATIONS of
conjunctivitis
56
• General symptoms include foreign-body
sensation, scratching or burning sensation,
itching, and photophobia.
• Conjunctivitis may be unilateral or bilateral,
but the infection usually starts in one eye
and then spreads to the other eye by hand
contact.

57. Assessment and Diagnostic
Findings
57
 The four main clinical features important to evaluate are the
type of discharge (watery, mucoid, purulent, or
mucopurulent).
 presence or absence of lymphadenopathy (enlargement of
the preauricular and submandibular lymph nodes where the
eyelids drain).
presence of pseudomembranes or true membranes

58. Pseudomembranes consist of
coagulated exudate that adheres to the
surface of the inflamed conjunctiva.
True membranes form when the
exudate adheres to the superficial
layer of the conjunctiva, and removal
results in bleeding

59. DIAGNOSTICS
Diagnosis is based on the distinctive
characteristics of ocular signs, acute
or chronic presentation, and
identification of any precipitating
events. Positive results of swab smear
preparations and cultures confirm the
diagnosis.
59

60. MEDICAL MANAGEMENT
BACTERIAL CONJUNCTIVITIS
- Acute bacterial conjunctivitis is almost
always self-limiting, lasting 2 weeks if left
untreated.
- If treated with antibiotics, it may last a few
days, except for gonococcal and
staphylococcal conjunctivitis
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61. MEDICAL MANAGEMENT
VIRAL CONJUNCTIVITIS
- Viral conjunctivitis is not responsive to
any treatment.
- Cold compresses may alleviate some
symptoms.
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62. Allergic Conjunctivitis
Management
 Teach the patient to avoid known allergens if
possible.
 Artificial tears can be effective in diluting the
allergen and washing it from the eye.
 Topical medications include antihistamines and
corticosteroids.
 The use of vasoconstrictors, such as topical
epinephrine solution, cold compresses, ice packs,
and cool ventilation usually provide comfort by
decreasing swelling

63. Nursing Management
Although conjunctivitis typically occurs
initially in one eye, it generally spreads to
the unaffected eye.
It is usually self-limiting, but treatment with
antibiotic drops shortens the course of the
disorder.
Teach patients the importance of hand
washing and avoiding contact with an
infected person.

64. Nursing Managment-PATIENT EDUCATION
64

65. 65

66. 66

67. References
 Lewis, S.M.,Heitkemper, M., Dirksen, S.
Medical-Surgical Nursing(10th edition) St.
Louis: MOSBY
Brunner &Suddarth’s Textbook of Medical-
Surgical Nursing by Suzanne C. Smeltzer et
al., 14th edition, Lippincott Williams &
Wilkins. Philadelphia.