Nursing of Adults with Medical & Surgical Conditons Eyes, Ears, and Special Senses.

Nursing of Adultswith

Medical & Surgical Conditons

Eyes, Ears,and

Special Senses

Layers of the Eyeball

Outer Layer Sclera

Tough, white fibrous, protective layer

Anterior portion is the cornea

• transparent • “Eye’s Window”• lies over the colored part

(iris) of the eyeRemainder is white, and

is commonly known as the “white of the eye”.

Layers of the EyeballMiddle Layer

Choroid coatContains the blood vessels that

supply the eyeAnterior portion has three separate

structures• Iris

– the colored part of the eye– shaped like a donut– attaches to the ciliary body– opening in the middle is called

the pupil• Ciliary Body

– muscular ring that alters the shape of the iris

• Suspensory Ligament– structure that holds the lens in

place

Layers of the EyeballInner Layer

Retina“The camera of the eye”

• receives image formed by the lens

Only in the posterior portion of the eye

consists of specialized nerve tissue for the reception of light

Structure upon which light rays come to focus

Contains tiny receptors• rods - night vision• cones - day vision

Optic Nerve• conducts impulses from the

receptors to the brain

Humors of the Eyeball

Aqueous Humor Watery, transparent liquid

that circulates through the anterior cavity of the eye.

Maintains intraocular pressure

Vitreous Humor Clear, jelly-like fluid in the

posterior cavity Fills the vitreous body to

give shape to the eye

Eye MusclesExtrinsic Eye Muscles

Attach to the outside of the eyeball and to the bones of the orbit

Voluntary muscles Move the eyeball in any

desired direction Four are straight muscles

superior rectus, inferior rectus, medial rectus, lateral rectus

Two are oblique musclessuperior oblique, inferior oblique

Eye Muscles

Intrinsic Eye Muscles Located inside the eyeball Two involuntary muscles

Iris• donut shaped sphincter

muscle• regulates the size of the pupil;

amount of light entering eyeCiliary Body

• flattened ring the size of the iris

• alters the shape of the iris• changes the focus of the lens;

adjusts the eye for distant and close-up vision

Accessory Structures of the Eye

Eyebrows and EyelashesProtect against foreign objects

entering the eye Eyelids

Located in front of the eyeballBlink as a result of sensory stimuliConsist of voluntary muscle and

skinConjunctiva

• mucous membrane lining eyelids• transparent and is continuous

over the surface of the eyePalpebral Fissure

• Opening between the eyelidsInner and Outer Canthus

• angles at the ends of the eyelids

Accessory Structures of the Eye

Lacrimal Glands and Ducts

Secrete tears• keep anterior surface

moist and free from irritating particles

Size of small almondsLocated in the upper,

outer portion of each orbit

Nasolacrimal Ducts• small tubes extending

from the lacrimal sacs into the nose to drain tears from the eye to the nose

Parts of the EarExternal Ear

Pinna (auricle)The outer, extended

portionComposed of cartilage and

covered with skin External Auditory Canal

About 1 inch in lengthContains cerumenous

glands Tympanic Membrane

(eardrum)Stretches across the end

of the auditory canalSeparates the external ear

from the middle ear

Parts of the EarMiddle Ear

Small air cavity located in the temporal bone

Contains three ossicles Malleus (hammer)

• attached to tympanic membrane

Incus (anvil)• attached to the head of the

malleus Stapes (stirrup)

• fits in the oval window Allows transmission of sound by

the vibrations of the ossicles Eustachian Tube

• Connects the middle ear with the nasopharynx

• Allows equalization of air pressure on both sides of the eardrum

Parts of the Ear

Internal Ear Contains essential organs for

hearing and equilibrium Sends equilibrium and hearing

sensations to the auditory nerve

Membranous LabyrinthLies within the bony labyrinthFilled with fluid (endolymph)Contains receptors for

• equilibrium • sense of position• sense of head movement• hearing

Parts of the Ear Bony Labyrinth

Cochlea• resembles the shape of a snail• filled with fluid (perilymph)• contains receptors for hearing• Organ of Corti

– hearing sense organ– sends sensations to the cochlear nerve

Semi-circular Canals• Three canals placed at right angles to each other• Filled with fluid (endolymph)• Contain receptors for equilibrium• Movement of fluid stimulates the receptors; send the

message to the brainVestibule

• Between the cochlea and the semi-circular canals• Maintain a sense of “up and down”.

ConductionAir Conduction

Occurs in the external ear Sound waves come through the external auditory meatus

and set the tympanic membrane in vibration

Bone Conduction Occurs in the middle ear The chain of ossicles transmits the vibration of the

tympanic membrane to the inner ear

Fluid Conduction Occurs in the inner ear Vibration of the ossicles sets the fluid system into motion Movement of fluid in the cochlea stimulates the Organ of

Corti; to the auditory nerve; to the brain

Process of Hearing

Special Senses

Smell Olfactory sense Organ of Smell

Nose

Receptors for the olfactory nerve lie in the mucosa of the upper part of the nasal cavity

Adaptation to odors is very rapidreceptors become fatigued

Special SensesTaste

Gustatory Sense Organ of taste

Tongue

Receptors are the taste buds located in the papillae of the tongue

Four fundamental taste sensationsSalty - tip of the tongueSweet - tip of the tongueSour - sides of the tongueBitter - back of the tongue

Taste Receptors

Special Senses

Touch Tactile receptors Located throughout the integumentary

system Respond to touch, pressure, and vibration

Pain Pain receptors Located in the skin and viscera Gives warning of potentially harmful

environmental changes

Touch and Pain Receptors

Disorders of theEye

Diagnostic Tests

Snellen’s Test Purpose

Assessment of visual aculityUsed as screening test

ProcedurePt stands 20 ft from chartCovers one eyeReads above or below the 20/20 line

Snellen’s Test

Color Vision Purpose

Assess ability to see colorPrerequisite for driver’s license

ProcedureColor dots are reflected on a background of

mixed colors.Pt identifies color patterns on the test field

Color Vision

Refraction Purpose

Measure visual acuity to determine refractory errors such as: myopia, hyperopia, presbyopia, and astigmatism

ProcedureOphthalmologist asks pt to indicate

clear/blurred vision with each lens change in the retinoscope.

Ophtalmoscopy Purpose

Evaluation of underlying structures of the eyeRoutine screening

ProcedureMydriatic drops are applied

• Dilates pupilsRoom is darkenedPt is asked to focus on stationary objectExaminer uses ophthalmoscope to view internal eye

structure

Ophthalmoscopy

Tonometry Purpose

Measurement of intraocular pressure Determine tumors and glaucoma

ProcedureExaminer places tonometer on corneaPressure readings are obtainedNormal intraocular pressure ranges from 10

to 22 mm Hg

Tonometer

Amster Grid Test Purpose

Diagnose and monitor macular problems

ProcedurePatient fixates on center dot and records

any abnormalities of the grid lines, such as wavy, missing, or distorted areas.

Amster Grid

Schimirmer Tear Test Purpose

Measures tear volume produced throughout fixed time period

ProcedureOne end of lacrimal filter

paper is placed in lower cul-de-sac

Area of tear saturation is measured after 5 minutes

Blindness and

Near Blindness

Etiology/Pathophysiology Loss of visual acuity Congenital or acquired Legal blindness

20/200 with corrective eyewear (normal 20/20)

visual field less than 20 degrees (normal 180)

Blindness and

Near Blindness

Signs & Symptoms Diplopia

double vision

Pain Floaters and light flashes Pruritus Burning of the eyes Loss of peripheral vision Halos Orbital pressure Bulging of the eyes

Blindness and

Near Blindness

Treatment Corrective eyewear Canes Seeing eye dogs Magnifying systems Surgical procedures

Refractory Errors

Astigmatism

Strabismus Myopia Hyperopia

Refractory Errors

Etiology/Pathophysiology

Astigmatism

-unequal curve in the shape of the cornea or lens

Refractory ErrorsStrabismus

-inability of the eyes to focus in one direction

-cross-eyed

Refractory ErrorsMyopia

Nearsightedness

Eyeball is too long

Refractory Errors

HyperopiaFarsightedness

Eyeball is too short

Refractory Errors

Signs & Symptoms Diminished or blurred vision

Treatment Corrective lenses Surgical correction

Conjunctivitis

Etiology/Pathophysiology Inflammation of the conjunctiva Bacterial or viral infection Allergy Environmental factors Commonly called “pink eye”

Conjunctivitis

Signs & Symptoms Erythema of the conjunctiva Edema of the eyelid Crusting discharge Pruritus Burning Excessive tearing

Conjunctivitis

Treatment Warm compresses Eye irrigations with normal saline Antibiotic drops or ointment Keep free of exudate

Keratitis

Etiology/Pathophysiology Inflammation of the cornea Injury, irritants, allergies, viral infection,

or diseases Pneumoccoucs, staphylococcus,

streptococcus and Pseudomonas are most common types of bacterial causes.

Herpes simplex is most common viral cause.

Keratitis

Signs & Symptoms Severe eye pain Photophobia Tearing Edema Visual disturbances

Keratitis

Treatment Topical antibiotic therapy Systemic antibiotics Analgesics Pressure dressings

relax eye muscle and decrease discomfort

Warm or cold compresses Epithelial debridement Keratoplasty

corneal transplant

Cataracts

Etiology/Pathophysiology Noninfectious opacity or clouding of the

lens Congenital Acquired Senile

associated with older adultsmost common

Cateracts

Cataracts

Signs & Symptoms Blurred vision Diplopia

double vision

Photosensitivity Decreased night vision Opacity in the center portion of lens

Cataracts

Treatment Surgical

removal Lens implant

or glasses

Post-Op Avoid direct sunlight Bedrest with BRP’s Analgesics No bending down or straining Avoid coughing, sneezing, and blowing

nose

Diabetic Retinopathy

Etiology/Pathophysiology Disorder of retinal blood vessels Capillary microaneurysms, hemorrhage,

exudates and formation of new vessels and connective tissue

Usually occurs approximately 10 years after onset of DM

Diabetic Retinopathy

Signs & Symptoms Microaneurysms

identified by ophthalmoscopy

Progressive loss of vision “floaters”

Diabetic Retinopathy

Treatment Photocoagulation

destroys new blood vesselsseals leaking vesselshelps prevent retinal edema

Vitrectomyused if photocoagulation is not possibleRemoval of vitreous and replaces it with

saline

Macular Degeneration

Etiology/Pathophysiology Slow, progressive loss of central and

near vision due to aging retina

Macular Degeneration

Signs & Symptoms Gradual and variable bilateral loss of

vision Color perception may also be affected

Macular Degeneration

Treatment Usually no treatment May use photocoagulation if new

vessels have not involved the macular retina

Retinal Detachment

Etiology/Pathophysiology Separation of the retina from the

choroid in the posterior area of the eye Usually results from a hole in the retina

that allows vitreous humor to leak between the choroid and the retinaTraumaAgingInflammation

Retinal Detachment

Signs & Symptoms Sudden or gradual development of

flashes of light, followed by floating spots and loss of a specific field of vision

Retinal Detachment

Treatment Photocoagulation

burn localized tears or breaks

Cryosurgeryfreeze the borders of a retinal hole

Diathermyburns retina break using ultrasonic probe

Scleral bucklingpulls the choroid and sclera back together using an

encircling band around the outside of the eyeball

Glaucoma

Etiology/Pathophysiology An abnormal condition of elevated pressure

within an eye Obstruction of outflow of aqueous humor Causes damage to optic nerve Two types

Open-angle• slowly progressive; results from degeneration

Closed-angle• occurs if there is an abrupt angle change of the iris

GlaucomaSigns & Symtoms

Open-angleNo s/s during early stagesTunnel visionEye painDifficulty adjusting to darknessHalos around lightsInability to detect colors

Closed-angleSevere painDecreased visionNausea and vomitingErythema of the scleraEnlarged and fixed pupilHalos around lights

Glaucoma

Treatment Open-angle glaucoma

Beta-blockers• Betoptic• reduces intraocular pressure

Miotics• Piolcarpine• causes the pupil to constrict; drawing the iris away from

the cornea; allowing drainage of aqueous humor

Carbonic anhydrase inhibitors• Diamox• decreases production of aqueous humor

Glaucoma

Closed-angleOsmotic diuretics

• Mannitol, carbonic anhydrase inhibitors, and miotics

Iridectomy• removal of part of the iris• restores drainage of the aqueous humor

Corneal InjuriesEtiology/Pathophysiology

Result from injuries to corneal layers of the eye

Foreign bodies are the most common cause dust particles, propellants, and eyelashes

Burnschemical irritants

Abrasions and lacerationsusually superficial caused by fingernails or clothing

Penetrating woundsmay cause blindness

Corneal Injuries

Signs & Symptoms pain with movement of eye excessive tearing erythema of conjunctiva pruritis

Corneal Injuries

Treatment Flush with normal saline or water Antibiotic drops or ointment

Penetrating woundsdo not remove object if presentcover both eyes

• may need to use a cup to cover object

seek medical attention

Disorders of the

Ear

Diagnostic Tests

Otoscopy Visualize external canal and eardrum

Tuning Fork Tests Weber’s Test

Assesses auditory acuityUses tuning forksDistinguishes conductive

from sensorineural lossTuning fork is placed on

the center of the patient’s forehead

Rinne TestDistinguishes conductive from senorineural

hearing lossUses tuning forksTuning fork is placed close to the external

auditory meatus

Audiometric TestingAssesses frequencies and tones

Vestibular Testing Romberg Test

Measures ability to perform specific tasks with eyes open and then closed

Assesses balance

Past-point TestAbility to place a finger accurately on a

selected point on the bodyAssesses coordination

Hearing Loss(Deafness)

Etiology/Pathophysiology Decreased auditory acuity Partial Complete Most common disability in the U.S. Affects development of speech and

conceptual ability

Hearing Loss(Deafness)

Six types of hearing lossConductive

• Sound is inadequately conducted through the external or middle ear

• Common cause is buildup of cerumen

Sensorineural • Defect in inner ear results in distortion• Trauma, infectious processes, age, or exposure to

ototoxic drugs• Destruction of cochlear hair by intense noise

Mixed• Combined conductive and sensorineural

Hearing Loss(Deafness)

Congenital• Present from birth or early infancy• Anoxia or trauma during delivery• Rh incompatibility• Mother’s exposure to syphilis or rubella, or

exposure to ototoxic drugs

Functional • No known cause for loss

Central• Brain’s auditory pathways are damaged• CVA

Hearing Loss(Deafness)

Signs & Symptoms Requests for repeating information Nonresponse Delayed speech development

Hearing Loss(Deafness)

Treatment According to cause Hearing aids Surgical procedures Cochlear implant

External Otitis

Etiology/Pathophysiology Inflammation or infection of the external

canal “Swimmer’s Ear” Allergy, bacteria, fungi, viruses, and

trauma

External Otitis

Signs & Symptoms Pain with movement of auricle or

chewing Erythema, scaling, pruritus, edema,

watery discharge and crusting of the external ear

External Otitis

Treatment Oral analgesics Corticosteroids Antibiotic or antifungal ear drops Systemic antibiotics

Otitis Media

Etiology/Pathophysiology Inflammation or infection of the middle

ear Occurs most often in children (6-36

months)shorter and straighter eustachian tubes

Bacterial, viral, allergies

Otitis Media

Signs & Symptoms Fullness in the ear Severe, deep, throbbing pain

may disappear if tympanic membrane ruptures

Hearing loss Tinnitus Fever

Otitis Media

Treatment Antibiotics

organism specific

Analgesics Local heat Nasal decongestants Aspiration of fluid from behind eardrum Myringotomy

surgical incision of the tympanic membranemay also place tubes

Labyrinthitis

Etiology/Pathophysiology Inflammation of the labyrinthine canals

of the inner ear Most common cause of vertigo Viral infection from URI Drugs and food Tobacco and alcohol

Labyrinthitis

Signs & Symptoms Severe and sudden vertigo Nausea and vomiting Nystagmus

involuntary movement of eyes

Photophobia Headache Ataxic gait

Labyrinthitis

Treatment Antibiotics Dramamine or Meclizine for vertigo IV fluids if N/V

Obstructions of the Ear

Etiology/Pathophysiology Impaction or excessive secretion of

cerumen Foreign bodies

insects, beans, pebbles, small toys

Obstructions of the Ear

Signs & Symptoms Tinnitus or buzzing Pain in the ear Slight hearing loss Tugging at ear

Obstructions of the Ear

Treatment Removal of cerumen by irrigation Foreign objects are removed with

forcepsMay require surgery

Carbamide peroxide to soften cerumen

Otosclerosis

Etiology/Pathophysiology Chronic progressive

deafness Formation of spongy

bone, esp around the oval window

Cause unknown Familial Women are affected

twice as often as men

Otosclerosis

Signs & Symptoms Slowly progressive conductive hearing

loss Tinnitus Dizziness to vertigo

Otosclerosis

Treatment Stapedectomy Air conduction hearing aid

if stapedectomy is not indicated

Meniere’s Disease

Etiology/Pathophysiology Chronic disease of the inner ear Recurrent episodes of vertigo, progressive

unilateral nerve deafness, and tinnitus Most common in women; 50-60 years of

age Cause unknown Increase in endolymph fluid

increased production or decreased absorption

Meniere’s Disease

Signs & Symptoms Vertigo Nausea Tinnitus Hearing loss Vomiting Diaphoresis Nystagmus

Meniere’s DiseaseTreatment

No specific treatment Decrease fluid pressure

Fluid restrictionDiureticsLow salt diet

Dramamine, Meclizine, and Benadryl Surgery

Destruction of labyrinthEndolymphatic shuntCryosurgeryVestibular nerve section