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Sensory System

Sensory System. Chapter 40. Eye abbreviations:. Left eye OS Right eye OD Both eyes OU Drop/s gtt / gtts. Conjunctivitis. Inflammation of the conjunctiva AKA “pink eye”. Conjunctivitis. Caused by Bacteria Viral Spread by Direct contact. Conjunctivitis. S&S (mild) Redness

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Sensory System

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  1. Sensory System Chapter 40

  2. Eye abbreviations: • Left eye • OS • Right eye • OD • Both eyes • OU • Drop/s • gtt/ gtts

  3. Conjunctivitis • Inflammation of the conjunctiva • AKA • “pink eye”

  4. Conjunctivitis • Caused by • Bacteria • Viral • Spread by • Direct contact

  5. Conjunctivitis • S&S (mild) • Redness • Itching • pruritus • Tearing • Discharge

  6. Conjunctivitis • Dx • History • Visual examination • “conjunctival scraping” • Culture

  7. Conjunctivitis • Rx • Antibiotics • Topical

  8. Nursing assessment • Symptoms • Effects on vision • Associate symptoms • Date of last eye exam • Corrective lenses???

  9. Nursing Assessment • Past medical history • Test vision • Snellen eye chart • Rosenbaum chart

  10. Snellen Eye chart Rosenbaum chart Pic from book

  11. Nursing Assessment • Inspect eye • Check pupil • PERRLA

  12. PERRLA • Pupils • Equal • Round • Reactive to • Light • Accommodation

  13. Priority Nursing Diagnosis: Risk for disturbed sensory perception (visual) • Instruct to wash hands • Instruct to avoid touching or rubbing eyes • Emphasize proper contact care

  14. NRS DX: Acute pain • Administer analgesics routinely • Patch both eyes PRN • Teach to apply warm compresses for 15 minutes, 3-4 x day

  15. NRS DX: Acute pain • Wear dark glasses • Avoid excessive reading

  16. 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

  17. Eye trauma • Common types of eye injury • Foreign body • Abrasion • Laceration • Burn

  18. Corneal Abrasion • AKA • Scratched cornea

  19. Corneal Abrasion • S&S • Pain! • Photophobia • Tearing

  20. Corneal Abrasion • Prognosis • Usually heal without scarring

  21. Burns • Types of burns • Chemical burns • Thermal burns • UV burns

  22. Burns • S&S • Pain • Affects vision • Swollen eyelids • Conjunctiva red & edematous • Slough • Cornea cloudy or hazy

  23. Perforated eye • Examples of causes • Metal flakes • Glass shards • Weapons

  24. Perforated eye • S&S • Pain • Partial or complete loss of vision • Bleeding • Loss of eye contents

  25. Blunt eye trauma • Common cause • Sports injuries

  26. Blunt eye trauma • Minor • Ecchymosis (lid) • AKA: • Black eye • Subconjunctival hemorrhage

  27. Eye trauma Assessment • Eye exam • Vision • Movement • Unless penetrating objects • Inspect • Foreign objects • Lacerations

  28. Eye trauma treatment • Topical anesthetic • Before inspection

  29. Eye trauma DX Test • Fluorescein staining • ID • Foreign bodies • Abrasions • Can you find the abrasion?

  30. Eye trauma DX Test • Ophthalmoscopic examination

  31. Eye trauma DX Test • X-ray • CT scan • Orbital fx • Foreign bodies

  32. Eye trauma: Irrigate • Small foreign bodies • Irrigate • sterile saline • Chemical burns • Irrigate • Copious amounts of fluid

  33. Eye trauma: Irrigate • Procedure • “from the inner canthus of the eye to the outer” • Head tipped slightly to the affected side

  34. 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

  35. Eye trauma TX • Remove loose foreign bodies • Use a • Moist • Sterile • Cotton-tipped applicator

  36. Eye trauma TX • Severe or penetrating injury • Bed rest • Stabilize eye • Apply eye pad • Over both eyes

  37. Eye trauma TX • Post-care • Eye-drops / ointment • Eye pad/shield per order • Avoid wearing contacts until cornea has healed completely

  38. Nursing Care • Teach to prevent eye injuries! • Eye protection • Seat belts • flush eye immediately if chemicals splash

  39. Nursing care • If an abrasion or penetrating or blunt injury  • Loosely cover with sterile gauze • Do not remove penetrating objects • Patch both eyes

  40. Nursing Care: After injury • Reinforce follow-up apt • Discuss meds & application • Teach how to apply eye patch • Do not rub or scratch the eye

  41. Nursing Care: After injury • Teach to avoid activities that h intraocular pressure • Lifting • Straining • Bending over

  42. 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?

  43. Cataracts • Clouding of the lens  impaired vision • Common • >65 • Affects both eyes

  44. Cataracts • Age  • Cells become less clear • Affects edges first  • Spreads towards center

  45. Cataracts • Affects • Near vision • Far vision • Details obscured • Glare • light / dark • Pupils appear • cloudy gray / white

  46. Cataracts • Risk factors • Age • Senile cataracts • Sunlight • Cigarette smoke • Heavy alcohol consumption • Eye trauma • Diabetes mellitus

  47. Cataracts: Dx • History • Eye examination

  48. Cataracts: Tx • Surgical removal • Clouded lens removed • Intraocular lens is implanted

  49. 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

  50. 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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