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- 1. The Eyes Linda Silvestro MSN, APRN, FNP-C, CEN
- 2. Anatomy and Physiology of the Eye
- 3. Anatomy and Physiology of the Eye (cont’d)
- 5. Gerontological Considerations • Cataracts • “Floaters” • Entropion • Extropion • Presbyopia • Retina tears • Age Related Macular Degeneration
- 6. Nursing Assessment of Vision • Common symptoms • changes in vision • pain or discomfort • discharge • Medical history • Family history • Social history • Visual acuity • Snellen chart: • 20/20 is considered the standard of normal vision • CF at 3 feet • HM • LP • NLP • Near vision • Presbyopia • Examination • Pupillary response • Size, shape and symmetry • Extraocular movements
- 8. Diagnostic Tests of the Eye • Amsler grid: • Tests for macular problems • Tonometry: • Measures intraocular pressure • Perimetry testing: • Evaluates the field of vision • Slit-lamp examination: • Enables the user to examine the eye with high magnification • Color vision testing: • Tests the ability to differentiate colors • Ultrasonography: • Used to identify lesions in the globe or the orbit • Fluorescein angiography: • Dye is injected into retinal vessels
- 9. Vision Impairments • Refractive errors: • Vision is impaired because of a shortened or elongated eyeball • Myopia: • Nearsightedness (distant vision is blurred) • Hyperopia: • Farsightedness (near vision is blurred) • Astigmatism: • An irregularity in the curve of the cornea • Low Vision • BCVA 20/70 to 20/200 • Blindness: • BCVA 20/400 to NLP • History and examination. • Management • magnification and image enhancement through the use of low-vision aids • Referral • Lighthouse National Center
- 10. Nursing Management of Patients With Low Vision • Encompasses emotional, physical, and social dimensions • Nursing priorities include: • Promoting coping efforts • Promoting spatial orientation • Promoting mobility • Promoting home- and community-based care
- 11. Glaucoma
- 12. Glaucoma • A group of ocular conditions characterized by optic nerve damage related to intraocular pressure (IOP) • Related to the impedance of aqueous fluid outflow from the eye • Two major types • open-angle glaucoma • Loss of peripheral vision • Decreased accommodation • Elevated IOP (>21mmHg) • angle-closure glaucoma • Ocular emergency • Rapid onset of elevated IOP • Decreased or blurred vision • Seeing halos around lights • Pupils are nonreactive to light • Severe pain and nausea • Photophobia • Glaucoma is not curable and has few early symptoms: • Management • Surgical • Laser trabeculoplasty • Iridotomy laser incision • Medical • Occular emergency • IV Mannitol • Acetazolamide (Diamox) • Pilcarpine (Isopto Carpine) • Timolol (Timoptic) • Iridotomy laser • Nursing care is focused on teaching self-care and referrals to community resources
- 14. Glaucoma Surgery • trabeculectomy • creates an opening at the limbus under a partial-thickness scleral flap • opening circumvents the obstruction, & aqueous humor flows into subjunctival spaces • fibrosis can occur • treated with antimetabolites
- 15. Glaucoma Postop Care • Eye patch and metal or plastic shield • Self-care • Up ad lib once sedation wears off • Food as tolerated • Avoid lying on operative side • Increased IOP s/sxs • Sx & vision assessment • Follow-up Teaching • wound care + s/sxs infection • meds + s/sxs of increased IOP • surgical site care
- 16. Cataract • lens opacity • some degree in most people >70 • worldwide, primary cause of reduced vision & preventable blindness • >1 million cataract operations/year; most common surgery
- 17. Cataracts • Lens opacity or cloudiness • Risk Factors • Result primarily in painless, blurry vision • Surgery is commonly considered when reduced vision interferes with normal activities: • Extracapsular cataract extraction with lens implant • Preoperative • Postoperative
- 18. Cataract Surgery • only way to correct • >90% success rate • done when ADLs become impaired • most common is extracapsular cataract extraction • leaves posterior lens capsule intact • phacoemulsification is less traumatic • usually includes IOL implant
- 19. Postop • dressing + noc shield • review monocular vision • eye gtts/ungs as prescribed • sunglasses • moderate exercise, no driving, no heavy lifting, no sex till . . . • peripheral vision decreases without lens implant
- 20. Cataract Surgery Complications • infection • bleeding • elevated IOP, 2ndary glaucoma • long-term aphakia predisposes to retinal detachment • danger s/sxs = drainage, increased tearing, decreased visual acuity, unrelieved pain
- 21. Retina
- 22. Retinal Detachment [RD] • Separation of retina from choroid • deprives blood supply • loses function • May occur over long period or suddenly • May lead to blindness
- 23. Retinal Detachment • The separation of the retinal pigment epithelium (RPE) from the sensory layer • Risk Factors • Manifestations • “curtain drawing” • Bright flashes of light • Floating dark spots • Surgery • Retinal rebinding • Scleral buckling • Nursing Care • Teaching • Complications • Increased IOP • Infection
- 24. RD Surgery • cryopexy [cold-probe fixation] • stimulates scar formation • pneumatic retinopexy [gas bubble] • best for upper detachment
- 25. RD Surgery • laser photocoagulation • seals edges • vitrectomy
- 26. RD Surgery • scleral buckling • or silicone band • brings both retinal layers together
- 27. Diabetic Retinopathy • progressive disorder of retina characterized by microscopic damage to retinal vessels, resulting in occlusion • inadequate blood supply results in retinal deterioration & permanent vision loss • a leading cause of blindness worldwide
- 30. AMD
- 31. AMD
- 32. Macular Degeneration • Characterized by tiny, yellowish spots called drusen beneath the retina • Risk factors • Two types of age-related macular degeneration (AMD): Dry and wet • Manifestations • Loss of central vision • Treatments for wet includes laser therapy and photodynamic therapy (PDT) • Nursing management is primarily educational
- 33. Orbital Trauma • Prevention!!! • Usually associated with a head injury • Priority for care is the preservation of vision • Orbital injuries requires immediate surgery • Closed injuries • Management • Optic nerve damage • Orbital fractures • Surgery nonemergent
- 34. Ocular Trauma • Foreign bodies • Copper, iron and vegetable materials • Purulent infection • Surgery • Chemical burn and foreign body • First response • Critical • Management • Splash injuries • Foreign bodies and abrasions • Contact lens
- 35. Conjunctivitis • Inflammation of the conjunctiva • Manifestations • Major causes • microbial infection • Bacterial • Viral • allergy • irritating toxic stimuli
- 36. Orbital Cellulitis • Manifestations • Management • High dose broad spectrum systemic antibiotics
- 37. Orbital Surgeries • Enucleation: The removal of the entire eye and part of the optic nerve • Evisceration: The surgical removal of the intraocular contents • Exenteration: The removal of the eyelids, the eye, and various amounts of orbital contents
- 38. The Ears Linda Silvestro MSN, APRN, FNP-C, CEN
- 39. Anatomy of the Ear
- 40. Anatomy of the Ear (cont’d)
- 41. Assessment of the Ear • Health history should address hearing loss, hearing aids, medications, itching, ear drainage, tinnitus, vertigo, ear pain, and environmental exposure to loud noise • Physical assessment includes inspection and palpation of the external ear, inspection of the internal ear, and hearing evaluation
- 42. Inspection of the Internal Ear
- 43. Evaluation of Gross Auditory Acuity • Whisper test: Examiner whispers softly from a distance of 1 or 2 feet from the unoccluded ear and out of the patient’s sight • Weber test: Tests bone conduction and lateralization of sound using a tuning fork • Rinne test: For distinguishing between conductive and sensorineural hearing loss
- 44. Diagnostic Evaluations of the Ear • Audiometry: The most important hearing test • Tympanogram: Measures middle ear response • Auditory brain stem response: Measures the detectable electrical potential from cranial nerve VIII • Electronystagmography: The measurement and graphic recording of the changes in electrical potentials • Platform posturography: Used to investigate postural control capabilities, such as vertigo • Sinusoidal harmonic acceleration: Used to assess the vestibulo- ocular system • Middle ear endoscopy
- 45. Hearing Loss • May be the result of a conduction problem (usually results from an external ear disorder), a sensorineural loss (damage to the cochlea or vestibulocochlear nerve), mixed, or psychogenic issue • Occupational noise is a major risk factor • Hearing loss affects nearly every aspect of an individual’s life • Presbycusis: Progressive, age-related hearing loss
- 46. Medical Management of Hearing Loss • Cochlear implant: An auditory prosthesis used for people with profound bilateral sensorineural hearing loss: • A small receiver is implanted in the temporal bone through a postauricular incision, and electrodes are placed into the inner ear • Aural rehabilitation: Used to maximize the communication skills of the person with hearing impairment • Hearing aids: Are much smaller and more effective than in the past • Hearing guide dogs are available to assist people with hearing loss
- 47. Nursing Care of the Patient With Hearing Loss • It is important to adopt a communication style to fit the needs and preferences of every patient • Specific techniques should be used to enhance communication: • See Box 50-5 in the textbook
- 48. Conditions of the External Ear • Cerumen impaction: Can be removed by irrigation, suction, or instrumentation • Foreign bodies: Can be difficult to remove but are treated in the same way as impacted cerumen
- 49. Conditions of the Middle Ear: Tympanic Perforation • Usually caused by infection or trauma • Causes whistling sounds upon sneezing and blowing nose, reduced hearing, purulent drainage, and pain • May heal spontaneously or require tympanoplasty (surgical repair of the tympanic membrane)
- 50. Conditions of the Middle Ear (cont’d) • Otosclerosis: Hearing loss that results from the formation of new, abnormal spongy bone that impairs the functioning of the stapes: • There is no nonsurgical treatment • Surgical options include stapedectomy or stapedotomy
- 51. Conditions of the Inner Ear • Affect balance as well as hearing • Vertigo: The misperception or illusion of motion of the person or the surroundings • Nystagmus: An involuntary rhythmic movement of the eyes
- 52. Ménière’s Disease • A disorder of the inner ear that causes vertigo, tinnitus, a feeling of fullness or pressure in the ear, and fluctuating hearing loss • Results from changes in pressure within the inner ear or the mixing of inner ear fluids • Most patients can be successfully treated with diet and medication • Some patients require antihistamines, tranquilizers, antiemetics, or surgery • Meclizine (antihistamine and anticholinergic) sedating • Ondansetron (antiemetic) • Diphenhydramine and dimenhydrinate (antihistamine) • Scopolamine (anticholinergic) • Diazepam (benzodiazepine)
- 53. Conditions of the Inner Ear (cont’d) • Tinnitus: A roaring, buzzing, or hissing sound in one or both ears that may be irreversible: • A symptom of an underlying disorder of the ear that is associated with hearing loss • Benign paroxysmal positional vertigo (BPPV): A brief period of incapacitating vertigo that occurs when the position of the patient’s head is changed: • Treatment includes medications for nausea, vomiting, and anxiety, and vestibular rehabilitation
- 54. Conditions of the Inner Ear (cont’d) • Ototoxicity: The result of medications that have adverse effects on the cochlea, vestibular apparatus, or cranial nerve VIII: • Patients receiving potentially ototoxic medications should be counseled about this side effect • Acoustic neuroma: A slow-growing, benign tumor of cranial nerve VIII: • Causes tinnitus and hearing loss • Treated surgically