vision

Dxics Tool Tests for - clinical Clinical findings

Slit map Examines eye 10-40x Cataracts/inflammation

Color testing Colorblindness - malesAlter in color = optic nerveTests c/ chromatic plates - intensity of color

Acquired color vision loss - digitalis/ cataractsCentral vision probs more commonly difficulty with color - b/c cones in center - macula

Amsler grid Macular degeneration - each eye tested separately Lines are wavy/brokenBox - which one looks darker, more prominent

Ultrasonography Helpful when cataracts of hemorrhage obstruct view of retina Lesions

Optical coherence to-mography

Ø invasiveRetinal & macular diseases

Color fundus photogra-phy

Pupils dilated - eval macular edema

FLOURESCEIN angiog-raphy

Dye in vein. Looks at blood flow to eye, yellow dye .QUESTION: allergies to dye

No blood flow to eye - damageMacular edema

Indocyanine green an-giography

IV green dye injected - multiple images 30 sec-20 min- using videoagniography

Abnormalities in choroidal vasculature - macular degen.

Tonometry Ø invasive - May use topical anestheticmeasures applanation- pressure needed to flatten anterior globe

Increased IOP - schemia to optic nerve - blindness quickly,

Perimetry testing“perimeter”

Field of vision - with primary gazeNorm = 65° up, 75° down, 60° inward, 95° outward

Scotomas -blind areas in visual field from macular degen-eration, & peripheral field defects in glaucoma & retinitis pigmentosa

Ophthalmoscope Focus on back or front of eye

Red reflex

Direct - vasculature - veins lgr than artsIndirect - 20 diopeter lensHemorrhages - red smudge, if HTN may be flame-shapedLipids - hypercholesterolemia or DM, has yellowish appearanceMicroaneurysms - little red dots & nevi

Silvery coppery appearance = arteriosclerosisCellophane effect = glistening/in young personDrusen - macular degen.- yellow c/ indistinct edges

Snellen chart Visual acuityRecord each eyeSAFETY ASSESS*****

20/20 =patient can read the “20” line at a distance of 20 feet Finger count or hand motion

Physical examcheck external 1°

Look at external anatomy: lid, sclera, conjunctiva Ptosis, red, inflamed, swollen, crusty, watery

Dxics Tool Tests for - clinical Clinical findings

Cardinal gazes Pupillary response - PERRLA Nystagmus, dolls eyes

Refractive errors

Commonly known What happens?

Emmetropia Normal vision Visual image focuses precisely on macula

Myopia Nearsightedness Image falls short - elongated eyeball ////////////////// Blurry distance vision

Hyperopia Farsightedness image goes beyond focusing of retina - short eyeball ///////////// Blurry close-up vision

Astigmatism Cornea irregularly shaped Acuity/near vision decreased

presbyopia Loss of accommodation from far away to close up

Heminopsia Loss of visual field r/t CVA Optic chiasm effected - CVA

Low Vision/Blindness

S/S Rq’s devices, strategies, corrective lenses to perform visual tasksLOW= BCVA 20/70 to 20/200BLIND = BCVA of 20/400 to Ø light perception (clinical = Ø light percept.)(Legal blind = BCVA not > 20/200 in better eye OR visual field 20° or <)

Dx-ics Thorough Hx, distance & near visual field, color perception, refractioncontrast sensitivity - if pt. Can read better c/ lights on - magnification helpsGlare - brightness acuity - lights calibrated to create a glare while reading Snellen chart

Treatment/Rx Low vision aid, strategies, referrals to community/social service for helpOptical - convex lenses - magnify, anti-reflective, electronic reading systems, computers c/ large printnon-optical -cell phone system PHS: large screen, telephone/internet email responds to voice commands, community referrals - for indepen-dent living, recreational activs & occupational provisionsOphthalmologists - retinal implants: for pt’s retina that functions, cortical implants - bad optic nerve - experimental

Low Vision/Blindness

NRSG mgmt p1767

Emotional - promoting coping effortsPhysical - promoting spacial orientation & mobility, safetySocial - promoting home & community based care - braille, guide dogsInteraction - approaching - ID self, Ø pity when speaking with them, same tone of voice, tell when leaving the room, if assisting - allow per-son to hold on to arm above elbow, 1/2 step behind you, seating: put hand on chair, upstairs: hand on banister, path has no obstacles - doors, cabinets, read menu, specify location of food on plate using clock, make sure assistive devices w/in reach and tell location, Ø distract service animal unless given permission, ask “how can I help you”

ComplicationsP 1764

*age-related: eyelids & lacrimal structures, refractive changes; presbyopia, cataract, posterior vitreous detach., AMD (mac degen)

Risk factors Most common causes - adults 40y.o.+ is DIABETIC retinopathyMacular degen- CaucasianGlaucoma - Afr. AmericanCataracts - age related

Glaucoma

S/S IOP over 22mmHg1° s/s - OPEN - Peripheral vision decreaseTUNNEL VISIONBlurred vision, halos around lightsOcular rednessEye brow pain - bc pressure incrs - push on blood flow - causes painDifficulty seeing in low lightCLOSURE - sudden, Severe eye painN/V b/c - Incrs IOP (think incr.ICP- NV)HeadacheCornea frosty-quick

Diagnostic Test Eye exam, 22+ mmHg =dx-icClosure = OPTometry Emergency +50 mmHgTonometry - IOPOphthalmoscope - optic nerveGonioscopy - filtration angle of anterior chamberPerimetry - assess visual fields

Glaucoma

Treatment/Rxdcrs. IOP: prevent op-tic nerve damage

Cholinergics (miotics)pilocarpine, carbechol - constrict pupil - ciliary muscles - let flow outAdrenergic agonist Epi, dipivefrin - sympathomimetic - ↓Aq humor produxB blockers **betaxolol (given in AACG: betaxolol + pilocarpine) ↓ Aq humor produxCarbonic anhydrase inhib.(-mides) - ↓ Aq humor produxProstaglandin (-prosts)- ↑aq humor flow - 1x/day/// Ø effect pupil sizeOsmotic diuretics - osmotrol (ICP), europhil. - pull out fluidWhen they dont work - then do surgery: argon laser trabeculoplasty - holes in it.Iridotomy - ( for pupillary block Glauc.) take piece of iris out to open up channels to drainFiltering procedures- bleb - fistula - kind of like an ostomy - does not want scarringDrainage implants/shunt - forms scar capsule around episcleral plateTrabectome - small incision - not permanent hole, no bleb or implant

NRSG intvtn/mgmt Post op - dark room, calm enviro., cold compress to headHome care - long term effectTEACHING!!Early DetectionCheck periph. vision

Complications Dilated pupil, cornea swollen, changes in optic disc - (pallor= bad/cupping)2° leading cause of blindness

Risk factors Family hx, thin cornea, long term corticosteroids [causes thin cornea], older, age, DM, Afr. Am., Cardio Vasc Disease, Migrain syn-dromes, myopia, eye trauma

Hx/Patho-pupil dilated: closes angle-Pupil constrix: opens angle - can see better.

Damage to optic nerve from incr. OP caused by congest of Aq. Humor-imbalance of fluid production & eliminationStages: initiating event, structural alterations in aqueous outflow, functional alterations, optic nerve damage, visual loss.Secondary (injury or side effect of Rx)Primary - - outflow of aqueous dcrs. Trabecular mesh is plugged90% are open angle glauc10% angle closure glauc - happens fast - Pupillary block

HOOK UP Q’s Pressure, Optic nerve, Blindness, Lifetime treatment, African american, Thief of sight. PERIPHERAL VISION

Glaucoma

Cataracts

S/S Loss of central vision: Macular degenerationCloudy, MIlky, Opacity, Painless & Gradual - unless trauma Variable vision loss, changes in color perception, glare problems- light shatters in all directions1 or both eyes1° leading cause of Blindness in world

Diagnostic test Dx’d: =s/s, hx, cloudy lens, Snellen, ophthalmoscopy, slit lampPosterior /sub capsular- younger ppl. C/ prolonged cortico. Use, increased sensitivity to glare ---- caucasiansNuclear - substantial genetic components, assoc. C/ myopiaFrequent Rx changes of glasses - caucasians Cortical/- can’t see in bright lights - scattering of lites - risk: sunlight exposure - Af. American

Treatment

Eye Drops or rx’d lenses - no cure

If effects ADL’s surgery = 1 eye at a timeShould not be extremely painful, if rq more than tylenol - needs to be checked - could be ↑ IOPPhacoemulsification- extracapsular surg. Portion of anterior capsule removed (intact zonular capsular diaphragm - anchors posterior chamber IOL. Ultrasonic device liquefies & sucks out nucleus & cortex . 1) Pupil dilated 2) small incision in cornea 3) viscoelastic substance injected into area b/t cornea & lensLens replacement - removal of crystalline lens = aphakic = 3 options: glasses, contacts or IOL

NRSG mgmt/invtns Pre- NPO 6-8hrs, take CBC, UA, ECGNdx - nervous, anxiousadminister diff kinds of eye drops - dilating q10mx4, antibiotic, corticosteroid, antinflam.Intra - less than 1 hr, lens phacoemulsificationAphacic - no lens - can’t see, IOL implants most common, Post - patch/shield - wear for 24 hr. - then wear at night for 1 -4 wks to protect, need sunglasses, Ø bend, stoop, strain, lift bc incrs IOPVision restored - 6-12 weeks. Teach about eye drops - may need to color code the different onesPsych - elderly - loses sense of independence, loss of control, feel like they don’t look the same. Developmental task -acceptance or despair.Prevention: SUNGLASSES, Nutrition - Vit C/E

Glaucoma

Complicaitons1774

Retrobulbar hemorrhage - immediate pre-opRupture of posterior capsule - intraopSuprachoroidal hemorrhageAcute bacterial endophthalmitis - early post-op - caused by bacteriaTASS - early post/op - toxic anterior segment syndrome - < 24 hrs. Pain, if extreme pain p/24 hrs., notify Dr.Late p/op - suture related, malposition of IOL, chronic endophthalmitis, opacification of post. capsule TELL DR if: new floaters, flashing lights, dcrs vision, pain, incrs redness3° leading cause of disability - behind arthritis & Heart disease

Risk Factors/Hxp1772

Senile age -Over 65 y.o.Associated ocular conditions: myopia, retinitis pigmentosa, retinal detach., infex - herpes zoster, uveitisToxins- corticosteroids, smoking, alkaline chemical eye burns, calcium, copper, iron, gold, silver, mercury - (b/c they tend to deposit in the pupillary area of the lens)Nutritional- low vit C., hi triglyc’s, low antioxidantsPhysical - trauma, dehydration, UV/sunSystemic diseases - dm, downs, disorders c/ lipid metabolism, renal, musculoskeletal

HOOK UP Q’s CENTRAL VISION, aging, CLOUDY, MILKY, OPAQUE of Lens, cortcosteroids

Macular Degeneration

S/S Age related macular degeneration (senile form) most common cause of vision loss in persons older than age 60Macule allows for clear, sharp, fine vision. Loses central vision, Can’t read, vision is not distinct - distorted, grid, wavy lines

Diagnostic test hx of changes of vision, will find: leaking of blood or drusen

Treatment wet- laserPhotodynamic therapy - use IV dye to tx bleeding, Photodynamic Therapy for Slowing Progression of AMDLight-sensitive verteporfin dye is injected into vessels. A laser then activates the dye, shutting down the vessels without damaging the retina.The goal/result is to slow or stabilize vision loss.Pt Teach: must avoid exposure to sunlight or bright light for 5 days after treatment to avoid activation of dye in vessels near the sur-face of the skin.

Rx Bevacizumab - avastin - tx of neovasc. AMD - off label - cheaper than LucentisRanibizumab - lucentis - may gain 1 or 2 lines on snellen

Macular Degeneration

NRSG mgmt/invtns Preventative measuresP/op - monitor for incr. IOP (always a risk of complication - with eyes)Patient teaching, Supportive care, Promote safety Recommendations to improve lighting, magnification devices, and referral to vision center to improve/promote function

Risk Factors Aging, Ultraviolet light, Cig. Smoking, low education/economic

Hx/Patho Dry Form - Non-exudative: Most common 85-90% development of drusen in the macule- retina that flakes and breaks off Wet form - have abn. Blood vessels that develop in/around macule. R/t diabetic - progression is much faster! Macule generates Diabetes - does not just effect eyes -heart, liver, kidneys, eyes.Proliferation of abnormal blood vessels growing under the retina—choroidal revascularization (CNV)

HOOK UP Q’s *any injury - anywhere - that has shifts in fluid/pressure - (bones - compartment syndrome)

Corneal disorders

Corneal dystrophy Autosomal DominantDeposits in corneal layers - decreased vision bc irregular corneal surfaceCorneal endothelial decompensation leads to corneal edema, blurred visionPersistent edema - leads to - bullous keratopathy (assoc c/ open angle glauc.)Tx: bandage contact lens - flatten bullae - bc so sensitive, most likely will need corneal surg.

Keratitis

Keratoconus protuberance of cornea- women @ puberty-hereditary. Irregular astigmat.Tx: gas-permeable contactsPenetrating keratoplasty if Ø work

Corneal sugeries Phototherapeutic Keratectomy - PTK - removes diseased corneal tissue - Ø for herpetic keratitis. Side effect - hyperopia, stromal haze, delayed re-epithelializationPenetrating Keratoplasty - corneal transplant - cadaver. Ok for herpes keratitis & chem. Burns. Descemet’s stripping endothelial keratoplasy - DSEK - layers of cornea dissected, selectively replaced w/ donor tissue - good b/c less p/op astigmatism, faster recovery, stronger wound integrity. Bad bc poor refractory results. *stay in supine position for 1 hrCOMPLIC’s: s/s graft failure - blurred vision, discomfort, tearing, redness of eye. Tx topical w/ corticosteroids, may try immunosuppress.NRSG - need ongoing eval of graft site & visual acuity

Corneal disorders

Refractive surg-eries“cosmetic”

PRK & LASIK- re-contour corneal tissue. Uses excimer lasers. Helps w/ night vision. Does not stop normal aging process of eye. PRK - good for ppl w/ thin cornea. limitations: p/op pain, corneal haze, prolonged recovery of visionLASIK- improvement over PRK - particularly corrects severe myopia. Removes stromal lamella - makes Corneal flap & reshapes. Cornea invaded at deeper level. No corneal haze. Any complic’s = more signif. than PRK. Surgically induced abnorm = central islands b/c invol eye mvmt. (diplopia, ghost images, halo, glare, dcrs acuity) DLK - diffuse lamellar keratitis - dcrs. contrast sensitivity for 6mo. P/op*PT teaching: stop wearing contacts for 2-4 weeks; corneal structure must be normal and refractive error stablePhacic intraocular lenses IOL - anterior or posterior - more predictable refract results than those that alter the corneal curve. Conductive keraoplasty - for mild myopia, use radiofrequency, Ø remove corneal tissue

NRSG mgmt/invtns Pt. Needs to be infection-free a/oplots of nerve endings - scratched= watery eyes, light-sensitive - sunglasseslow blood flow - healing takes longer - incrs. Risk of infex.

HOOK UP Q’s

Retinal Detachment

S/S Emergency: MAIN- flashes of light, with cobweb or curtain/veil over one eye, black spots, floater, black areas, Sudden development of floater, begin to use vision based on where attachment occurred.

Diagnostic test assess visual acuity, assessment of retina by indirect ophthalmoscope, slit-lamp, stereo fundus photography, and fluorescein angiogra-phy. Tomography and ultrasound may also be usedRhegmatogenous detach. - most common.- trauma could play a roleTraction retinal detach- scar tissueCombo - rheg & tractionExudative retinal detach. Serous fluid under retina (produced by choroid) Could be caused-uveitis/ macular degen.

Treatment scleral bucklingpars plana vitrectomy - remove vit. HumorPneumatic-retinoplexy - gas, liquid, oil bubble flattens the sensory retina against the RPE- positioning p/op, bubble moves - need to be face downLaser surg is good, but wherever is lasered/will have scar tissue.

Retinal Detachment

NRSG mgmt/invtns Highly flooded with blood flow, rcvc msgs, has multiple layer - Goal - restore blood supply to back of eyeComfort measuresSpecial positioning - retinoplexyOutpatient procedure - so be sure they know when to call Dr. Incr IOP, infex

Complications Complication - incr. IOP - aka - 2° glaucoma

Risk Factors High: myopia, diabetes, trauma,

Hx/Patho Separation of the sensory retina and the RPE (retinal pigment epithelium)*diabetic retinopathy: Separates from back of eye, in layers, or hole/tear, pulled away from back of eye. Will see ischemia - leads to permanent blindness quickly

HOOK UP Q’s Diabetic retinopathy - proliferative retinopathy (assoc c/ rhegmat.)

Retinal vascular disorders

Central retina vein occlusion - CRVO - watch for neovascularization & neovasc. glaucoma (r/t neovasc. Iris)Branch retinal vein occlusion - BRVOLoss of vision- from retinal vein or artery occlusionOcclusions may result from atherosclerosis, cardiac valvular disease, venous stasis, HTN, or increased blood viscosityRisk factors: DM, glaucoma, and agingCentral retinal artery occlusion - Emergency! EMBOLI. Rare 1 in 10,000. Pupillary defect, may not be able to count examiners fin-gers.cherry red fovea. Tx: ocular massage, ant. Chamber paracentesis, IV acetazolamide, high concentration of O2Macular degeneration….see AMD

Retinal Detachment

other

Trauma: Orbital - head injrySoft tissues/hemorrhagePenetrating- nerve damageFractures - blowout, Zygomatic, maxillary, midfacial, orbital apex, orbital roof

Blowout- small, blunt force - fist, ball, etc.Orbital roof - **** watch for brain injury

Foreign bodies- usually well tolerated - except copper, iron, veg-etable materials

Xray & CT, ID metallic bodies - b/c MRI! Surgery if irritating adjacent structures, superficial, sharp edges, copper, iron, plant materials

Patient and public education - Emergency treatmentFlush chemical injuriesDo not remove foreign objects - Protect using metal shield or paper cupPotential for sympathetic ophthalmia causing blindness in the uninjured eye with some injuriesProtective Eye Patches

Conjunc-tivitis (pink eye) -

Microbial, allergy, or irritating stimuli, virus, fungus, parasites - Worldwide - associated with poor living conditionsBacterial///////// Viral ////////// Allergic - pt c/ lots of allergiesclear/white/stringy drainage, can get 2° bacterial infex. Bc irritationToxic - from smoke, chemicals (pool) Tx: handwashing, self-limiting - teach - flush eyes

Retinal Detachment

Ocular Meds

Ability of the eye to absorb medication is limited. -Barriers to absorption include the size of the conjunctival sac, corneal membrane barriers, blood-ocular barriers, and tearing, blinking, and drainageIntraocular injection or systemic medication may be needed to treat some eye structures or to provide high concentrations of medication.Topical medications (drops and ointments) are most frequently used because they are least invasive, have fewest side effects, and permit self administration.Topical anestheticsMydriatics (dilate) and cycloplegics (paralyze): Contraindicated with narrow angles or shallow anterior chambers and in patients on taking MAOI’s or trycyclics (May cause CNS symptoms and increased BP especially in kids & elderly)Anti-infective medications: Antibiotic, antifungal, or antiviral productsMedications used for glaucoma

Increase aqueous outflow or decrease aqueous productionMay constrict the pupil and may affect ability to focus the lens of the eye; affects vision May also may produce systemic effects

Anti-inflammatory drugs; corticosteroid suspensions ----- Side effects of long-term topical steroids include glaucoma, cataracts, and increased risk of infection. To avoid these effects, oral NSAID as an alternate to steroid use

Ear Problems - Functional/Sensory

Diagnostic Test Weber test assesses bone conduction of sound. Rinne test assesses both air and bone con-duction of sound.Inspection of external earOtoscopic examinationGross auditory acuityWhisper test

Vestibule - if busted - Ø sense of up or down

Audiometry - sensory or conductiveTympanogram - middle ear muscle reflexAuditory Brainstem response -Elec Potential from CN8 - dB’sElectronystagmography- Meniere’s - Ø sedatives 24 a/testCaloric testing - looking for lesions in CNS, drug toxicities, check vestibular… of ear. Put water in ear, look for s/s of nystagumus (happens when they have seizures), vomit, vertigo, feeling like they are going to fall = NORMAL. If no s/s - NEURO impairment. Platform posturography - vertigo - platform/screen- tests 6 conditionsSinusoidal harmonic acceleration- spin in a chair - vestibulo-ocular compensarory eye mechanisms - Meniere’sMiddle ear endoscopy-cuts open the tympanic to see round window for Meniere’s, conductive hearing loss, chronic middle ear infex.

Ear Problems - Functional/Sensory

NRSG Consids

Speech deteriorationFatigueIndifferenceSocial withdrawlInsecurityIndecisionProcrastinationSuspiciousnessFalse prideLonelinessUnhappinessTendency to dominate convo.

Patient Undergoing Mastoid SurgeryAssessmentHealth HistoryInclude data related to the ear disorder, hearing loss, otalgia, otorhea, and vertigoMedications DiagnosesAnxietyAcute painRisk for infectionDisturbed auditory sensory perceptionRisk for trauma related to imbalance or vertigoDisturbed sensory perception related to damage to facial nerveImpaired skin integrityDeficient knowledge

Planning/ Major goals include: Reduction of anxiety Freedom from pain and discomfort Prevention of infection Stable or improved hearing and communi-cation Absence of vertigo and injury Absence of or adjustment to altered sen-sory perception, return of skin integrity Increased knowledge of disease Surgical procedure and postoperative careAvoid getting water in earFollow-up care

Patient TeachingMedications teaching; analgesics, antivertigo medicationsActivity restrictions - to prevent dislodging of tympanic membraineGently blow nose only one side at a time, and sneeze and cough with mouth open, avoid heavy lifting, exertion, and nose blowing

Interventions - overallReduction of anxietyReinforce information and patient teaching Provide support and allow to discuss anxietiesRelieving painMedicate with analgesics for ear discomfort•Occasional sharp shooting pains may occur as the eustachian tube opens and allows air in the middle ear. Constant throbbing pain/fever: may indicate infection, elevated tem, purulent drainage - Tell DR.Preventing injurySafety measures such as assisting with ambulationProvide antiemetics or antivertigo medicationsImproving communication and hearing•hearing may reduced for several weeks following surgery d/t edema, accumulation of blood and fluid in middle ear, drsg & packings.Preventing & Monitor for s/s of infection.Administer antibiotics as ordered.Prevent contamination of ear with water from showers, washing hair, etc.Preventing Altered sensory perceptionPatient may report altered taste and dry mouth on surg. Side for several months until nerve regen’sHome & Community Based Care - patient teachingReport Immediately: facial nerve weakness, s/s infex., difficulty swallowing, facial droop

Hearing Loss & Risk Factors

Affects more than 28 million people in U.S. ////// Increased incidence with age—presbycussis Risk factors: family hx ///// congen malforms- cranial ///// low birth wieght ///// ototoxicity meds ///// recurrent ear infex. //////////// expo-sure to excessive noise levels ////bacterial meningitis /////// perforation of tymp. membrane

Ear Problems - Functional/Sensory

Types Conductive; due to external of middle ear problemSensorineural; due to damage to the cochlea or vestibulocochlear nerve Mixed; both conductive and sensorineuralFunctional (psychogenic); due to emotional problem

Manifestations Early symptoms include Tinnitus: perception of sound; often “ringing in the ears”Increased inability to hear in a groupTurning up the volume on the TV Impairment may be gradual and not recognized by the person experiencing the lossAs hearing loss increases, person may experience deterioration of speech, fatigue, indifference, social isolation or withdrawal, and other symptoms

CommunicationGuidelines

Use a low-tone, normal voiceSpeak slowly and distinctlyReduce background noise and distractionsFace the person and get his or her attentionSpeak into the less-impaired earUse gestures and facial expressionsIf necessary, write out information or obtain a sign language translator

ExternalCerumen impaction

Foreign bodies

External otitis

InterventionRemoval may be by irrigation, suction, or instrumentationGentle irrigation should be used with lowest pressure, directing stream behind the obstruction. Glycerin, mineral oil, ½ strength H2O2, or peroxide in glyceryl may help soften cerumen

Removal may be by irrigation, suction, or instrumentationObjects that may swell (such as vegetables or insects) should not be irrigatedForeign body removal can be dangerous and may require extraction in the operating room

Therapy is aimed at reducing discomfort, reducing edema, and treating the infection.A wick may be inserted in the canal to keep it open and facilitate medication administration.PATHO: Inflammation most commonly due to bacteria Staphylococcus or Pseudomonas, or fun-gal infection due to Aspergillus.

Malignant external otitis: rare, progressive infection that effects the external auditory canal, sur-rounding tissue, and the skull.

Other

S/S: pain, tenderness, dis-charge, edema, erythema, pruritis, hearing loss, feel-ings of fullness in the ear.

Ear Problems - Functional/Sensory

INNERDizziness: ………………..Vertigo:……………………Ataxia…………………….Syncope………………...

Nystagmus:……………..

Motion sick………………..

Ménière’s Disease……….ATTACKS: 2-4 hrsIncapacitating vertigo *Adults - onset 40yo

vestibular disorders - more than 30 million in the U.S. Resulting falls = 100,000 hip fractures a year.

Tinnitus…………………

Labrynthitis……………

Manifestedany altered sense of orientation in space the illusion of motion or a spinning sensation - room or selfFailure of muscular coordination. R/t vestibular diseaseFainting - not r/t vestibular - r/t Cardio

involuntary rhythmic movement of the eyes. R/t vestibular dysfunction. CNS or PNS*occurs normally when person watching moving object - car/train

Disturb. in equillibrium -d/t constant motion.vestibular overstimulation. Sweating/pallor, N/V. Give dramamine, anavert, scopolamine patches (antagonize histamine response). Ø drive car!

Abnormal inner ear fluid balance cause by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct. Cochlear: fluctuating, progressive hearing loss; tinnitus; feeling of pressure or fullnessVestibular: episodic, incapacitating vertigo, N/V, aural pressure*diaphoresis/imbalance - may wake at night*Weber test c/ tuning fork - may lateralize to the ear w/o hearing loss - (the ear w/ Meneire’s)Audiogram - looks like Pike’s PeakElectronystag. - normal or show reduced vestib. Response.TreatmentLow-sodium diet, 2000 mg a dayPsych help - if pt anxious, uncertain, fearful, depressedMeclizine (Antivert), valium, phenergan and diuretics Pavabid - (vasoldilator) sometimes used with Banthine take 1h a/motion begins s/s- (drowsy, drymouth, h/a)Transderm scopol. - reduces secretion ginger

Ring, buzz, roar, hiss. Assoc c/ hearing loss. R/t Ototoxic meds, RISK: thyroid disease, hyperlipi-demia, vit b12 deficit, psychological, fibromyalgia, meneire’s, MS, head injury. May just need counseling to deal with. Dxics: audiograph speech discrim., tympanogram

S/s similar to Meniere’s.INFECTION! Bacterial: Can be complic. Of otitis media. Viral: Mumps, rubella, rubeola, fluViral illness of URT & herpetiform disorders - facial & acoustic (ramsay hunt syndrome)

Acoustic neuroma:tumor of the VIII cranial nerve

Surg Meniere’s

endolymphatic sac de-compres. - shunt/drain

vestibular nerve section-ing- elim’s attacks of ver-tigo, cuts nerve- prevents brain from getting input from semicirc. canals

Rotational vertigoPallor, diaphoresis, yawning

Tx:Bacter: antibioticAnivert & antiemetic

Ear Problems - Functional/Sensory

Hearing loss type

Manifest Patho Eval Med Mgmt NRSG

Conductive

Or MIX

InfectionCerumenForeign body Otosclerosis (loss of movement of bones in mid ear)- aging

Loss of vibration of soundCan hear them-selves talk, so they talk low

StapectomyHearing aids on the back of the ear

Safety, communication, instrux., Speak distinctly, towards good ear, body lan-guage, gestures, face the person when we are talking, talk in steth. To patient.

Sensoroneu-ral

Everything sounds muffled, dont interpret word clearly

Behaviors: rude, interrupt, Ø fol-low directions, loud TV, turning head towards direction of noise, ir-ritability, hostile, complain that the person speaking is mumbling, pain, vertigo,

Nerve deafness - CN 8From noiseTraumaAgingOtotoxicityDiabetesSyph.

Hearing aids don’t work - louder, but still muffled

Tx Dependent of what type: Referrals: ASL, alarm clock

Functional/psych - No organic cause, voluntary, usually precipitated by stress

CONDI-TIONSExternal otitis

Swimmer’s ear, painful auricle, sometimes fever, lymph adenopa-thy, pruritis, itching, drainage,

Inflam of ext. Ear, trauma, vit. Disor-ders, endocrine disordersEar canal - red.in-flamed

Bact., fungus, staph, pseu-domonas, chemicals

Tx:Antibiotic, corticosteroids - has to be room temp!

Teach how to prevent - keep ear canals dry, barrier to h2o to water - cot-ton ball with vaseline, no q-tips

Ear Problems - Functional/Sensory

Otitis media Acute or chronic

OtalgiaEar drainageFeverHearing lossPain is suddenly relieved by perifo-ration - bulging tympanic mem-brate - maybe pink

Acute - middle ear infex - peds/kids

Dysfunx. Eustacian tubeTympanic mem-brane perforation

short eustacian tubes, when they have allergic rhini-tis - bact enter eus. Tubes thru nasal

Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis

Broad spec. Antibiotic,

otic prep. If drainage!

Rarely causes perm. Hearing loss

Risk - infantsChronic exposure to 2° smoke

Complications - mastoiditis, meningi-tis, brain abscess,

RISK: under 12 mo., chronic URI’s, downs syndrome, CF, Cleft palate, 2° hand smoke

CHRONIC recurrent bouts of AOMSmelly EarTissue path - persistentComplic’s -MeningitisMastoiditis

Cholesteatoma - white mass from behind eardrum -ingrowth of eardrum material -high negative pressure - skin makes sac with de-generated skin & sebaceous mate-rialCan enlarge - & damage facial nerve horizontal canal

If cholesteatoma - delayed treatment may lead to de-strux. Of temporal bone - hearing loss, neuro disor-ders

Asymptomatic or - hearing loss, facial pain, paralysis, tin-nitus, vertigo

May have some hearing loss - ear drum probably rup-tured - may have healing perforation

Audiometric test shows conductive or mixed hearing loss

Dxics: visual-ization, CT, MRI

Graft if rupture

Ventilating Tube or Pres-sure wqualizing tube 6-18 mo.

•can culture drainage

Otic anitbiotics, powder antibiotics for purulent drainage.Systemic - only if acute

OTHER SURGTympanoplasty1-5 (myringoplasty=1)Goal - reestab. Mid ear fxn. Transcanal Postauricular 1)ossicular interruptions 2) malrformations3) Ossicular disloc - bc of head

trauma

Ossiculoplasty - reconstruct mid ear bones -restore hearing

Mastoidectomy- Removal of dis-eased bone, mastoid air cells, and cholesteatoma to create a noninfected, healthy ear

Ear Problems - Functional/Sensory

SEROUS

Risk: pilots, divers, flight attends.

Fluid - NO infex

℅ hearing loss, fullness, popping, crackling

Eustacian tube ob-struxRadiationBarotrauma

If persistent unilateral - need to r/o na-sopharyngeal Ca

No need unless infex oc-curs AOM

If hearing loss - myringo-tomy

Low doses of corticoster. To dcrs. Edema by baro-trauma

Ø nasal decongestants

Valsalva - carefully - may worsen pain

Otosclero-sis

RISK: women, preg, inheritedTinnitusConductive or mixed hearing loss

Stapes can’t vi-brate - ineffective transmission of soundRinne - can hear bone better than air condux.

Audiogram - mixed or both- esp. Low freq’s

Stapedectomy - re-move stapes & part of foot plate - insert tissue graft

stapedotomy

Pts. May have Hearing aids on the back of the ear

Ototoxicity Tinnitus - by aspirin or quinidine = reversible

Adverse effects on cochlea, vestib. Ap-paratus, CN8

Causes:IV aminoglycos - de-stroy hair cells of organ of Corti

Ø use in Kids, elderly, pregnant, kidney or liver probs, or ppl with current hear-ing probs

Meds that cause oto-tox

DiureticsEthacrynicFurosemideAcetazolamide

Chemo agentsCisplatinNitrogen mustard

AntimalarialQuinidinechloroquine

Anti inflam’sAspirinindomethacin

ChemicalsAlcoholarsenic

AminoglycsAmikacinGentamicinKanamycinNetilmycinStreptomycintobramycin

Other antibioticsErythromycinMinocyclinePolymyxin B.Vancomycin

MetalsGoldMercuryLead