Assessing Clients with Eye or Ear Disorders

1. Assessing Clients with Eye or Ear Disorders Chapter 40

2. Review of Anatomy and Physiology • Extraocular Structures • eyebrows • eyelids • eyelashes • conjunctiva • lacrimal apparatus • eye muscles

3. Review of Anatomy and Physiology • Intraocular Structures • sclera • iris • pupil • lens • retina • optic disc • anterior and posterior cavity

4. Vision • 1. Light passes through the cornea and is focused onto the retina by the lens. • Cells in the retina then transmit this information through optic nerve to the vision area of the cortex.

5. Review of Anatomy and Physiology • Optic nerves • Refraction • bending of light rays • Accommodation- Response of the pupil, constrict and dilate.

6. The Ear and Hearing • External Ear • auricle or pinna • external auditory canal • tympanic membrane • Acoustic antenna, focus Sound waves.

7. Middle Ear • The middle ear consists of: • The inner part of the ear drum • The hammer (malleus) • The anvil (incus) • The stirrup (stapes) • Delivers sound to the inner ear where it is processed into a signal that the brain can recognize

8. The Ear and Hearing Inner Ear The inner ear contains the most important parts of the hearing mechanism - two chambers called the vestibular labyrinth and the cochlea. The vestibular labyrinth consists of elaborately formed canals (3 semicircular tubes that connect to one another), which are largely responsible for the sense of balance. The cochlea, which begins at the oval window, curves into a shape that resembles a snail shell. Tiny hairs line the curves of the cochlea. Both the labyrinth and cochlea are filled with various fluids.

9. Inner Ear

10. Hearing and the Ear

11. Hearing and the Cochlea • The cochlea as microphoneWhen sound waves from the world outside strike the eardrum, it vibrates. These vibrations from the eardrum pass through the three bones of the middle ear and into the inner ear through the oval window. Action of the oval window causes fluids in the cochlea to create waves where they disturb the basilar membrane. Inner hairs attached to the basilar membrane convert the waves into electrical impulses that are transmitted to the brain by the auditory nerve. The hair cells are critical to hearing; it is the inner hairs that move in the Organ of Corti fluids, and translate the fluid movements to chemical messengers that can in turn be converted to electrical impulses that the brain understands.

12. Assessment of Eye and Ear • Health Assessment Interview • ask about chief complaint • Blurred vision? • Eye infection? • Halos? • Difficulty reading? • Difficulty hearing? • Ringing in ears?

13. Physical Assessment of Eye and Vision • Snellen’s eye chart- Test for vision. • Assessment of the pupils. • Extra movements of the eyes nystagmus or non Parallel movements strabismus, may indicate disease, cranial nerve dysfunction or muscle weakness and should be reported.

14. Physical Assessment of Eye and Vision • Pupils, Equal Round Reactive to Light and Accommodation (PERRLA) • direct a beam of light into the pupil, look for constriction • hold object a few feet from client, pupils should dilate, move closer pupils should constrict • Inspection - sclera, iris cornea and internal structures

15. Physical Assessment of Ear and Hearing • Hearing • Weber test • Rinne test • Whisper test • Inspection • auricle and external canal- • Lesions, drainage, redness, pain. • tympanic membrane- color.

16. Disorders of the Eye • Eyelid disorders constantly exposed to the environment. • Hordeolum- sty is an infection of the sebaceous glands of the eyelid. Staphylococcus aureus. • Red and painful • Conjunctivitis- Inflammation of the conjunctiva is common. Direct contact bacterial or viral • Also known as “Pink Eye”. Redness, itching, tearing and discharge. • Gonorrhea and trachoma can damage cornea.

17. Eye Disorders • Cornea- transmits and helps focus light and images onto the retina. Protects the internal eye. • The cornea has no blood supply. Scarring or ulceration of the cornea can lead to blindness. • Corneal ulcers caused by infection, trauma or contact lens. Herpes viruses (shingles) can cause corneal ulcers. Can lead to blindness. • Nr Care- Prompt treatment to preserve vision. • Diagnosed by history and examination of the eye. • Topical anti-infectives as eyedrops.

18. Eye disorders • Corneal Transplant- Corneas taken from cadavers under the age of 65 who died as a result of trauma or noninfectious illness. • Transplant rejection is low cornea has limited blood supply. • Graft is sutured in place, for one year. • Patch for 24 hours • Avoid increasing intraocular pressure. • Eye drops to reduce inflammation and prevent infection.

19. Eye Disorders • Soaking the eyelids with warm saline compresses may remove exudates seen in conjunctivitis. • Eye irrigation with saline is used to remove purulent discharge with conjunctivitis. • Local heat may treat sty. • Infectious eye disorders Nr care focus is on prevention and immediate treatment! • Prevent complications promote healing. Reduce pain. • Careful and frequent handwashing, not sharing towels, make-up. No contacts until healed.

20. Eye Trauma • Foreign bodies, abrasions and lacerations most common types of eye injury. • Corneal abrasion- scratch of the cornea • Burns- chemical, UV • Perforation- metal flakes, weapons • Blunt eye trauma- sports injury • The extent of the injury is determined by eye exam. • Topical anesthetic, irrigation, surgery • NR- Protecting the eye, preserving vision, prevention!

21. Refractive Errors • Changes in the shape of the cornea, lens or eyeball affect the focus of light on the retina. • Result= blurred or indistinct vision, also called • Refractive errors- Most common cause of impaired vision. • Myopia- nearsightedness • Hyperopia- farsightedness • Detected routine vision screening • Corrected with glasses or contacts • Nr- Identify and seek treatment. Safety!!

22. Cataracts • Clouding of the lens of the eye that impairs vision, common over 65yrs. • As the lens ages its cells become less clear. • Mature cataract involves entire lens • Near and distant vision are affected. • Details become obscured • Pupil appears cloudy gray or white rather than black. • Dx: History and eye exam, the red reflex is lost. • Tx: Surgical removal incision through cornea • Intraocular lens is implanted to focus light &vision.

23. Glaucoma • Increased intraocular pressure and gradual loss of vision. Silent thief of vision. • Leading cause of blindness worldwide. • Normal intraocular pressure is 12-20 mm Hg is maintained by a balance between aqueous humor production and drainage, disrupted intraocular pressure increases. • Open angle – drainage of the aqueous humor through the trabecular meshwork is impaired • Angle-closure- Angle between the cornea and iris closes, completely blocking aqueous humor drainage.

24. Glaucoma • Manifestations: Discussion • Glaucoma if not treated can and will lead to blindness. • Angle-closure glaucoma can recur thus avoid medications that can dilate the pupil. One eye is at risk for the other eye. • Atropine must be avoided in clients with history of angle-closure glaucoma. • Glaucoma cannot be cured, chronic disease can be controlled and vision preserved if it is dx and tx. • Routine eye examinations early detection.

25. Glaucoma • Acute angle-closure glaucoma is an ocular emergency that requires immediate intervention! • Surgery is indicated when chronic open-angle glaucoma can not be controlled with medication. • Lower intraocular pressure. • Glaucoma is a chronic disease that requires lifelong management. Can lead to blindness if not identified and treated. • Nursing- Increased risk for injury, psychological effects of a chronic disease= anxiety. Early vision screening!!!!!!!

26. Detached Retina • Retina contains neurons that allow us to see light and images. • Retina separated from the choroid, the vascular layer of the eye. Fluid seep between retina and choroid, thus separating the layers. The neurons become ischemic and die causing permanent vision loss. • Can occur spontaneously or from trauma as we age it increases our risk for detached retina. • Medical emergency • CM- painless, floaters, flashes of light. Dx- eye examination. Surgical procedures.

27. Detached retina • Early identification is a priority for the nurse! May have gradual loss of vision. • The affected area of the eye inferior to maintain contact between the retina and choroid.

28. Macular Degeneration • Neurons of the macula may atrophy with age or separate from the choroid. May cause blindness. • Smoking, over 65 yrs, family hx. • Central vision becomes blurred, peripheral vision remains intact. One eye common early symptom. • Any change in vision needs evaluation!!!!!! Nursing! • Laser treatment may slow the process. Early treatment may help slow disease and preserve vision.

29. Diabetic Retinopathy • 85% of diabetics will develop • The capillaries of the retina are no longer able to transport blood and oxygen to the retina. • Develops 15 years after being diagnosed either type one or type 2 diabetes. • Initially venous capillaries dilate and develop microscopic aneurysms may leak or rupture; thus edema and small hemorrhages into the retina. Areas become ischemic. New blood vessels form causing more damage. • Nr- Education, yearly eye exam, spots, loss of vision.

30. Ear Disorders • External otitis- or swimmers ear affect sound conduction and hearing. Inflammation of the ear canal • Risk; swimmers, divers surfers, hearing aids or earplugs. • Caused by bacteria • Remove earwax and cleaning and drying ear canal. • CM- Pain, drainage, inflammation and swelling • Management- Discussion

31. Impacted Cerumen • Older adults are at risk for impacedcerumen • Interferes with sound conduction and hearing. • Tinnitus is a clinical manifestation • Can be seen using an otoscope • Clearing with irrigation ear curet or forceps • Prevention is the focus of Nursing! No Q-tips.

32. Otitis Media • Inflammation or infection of the middle ear. • Most common middle ear disorder. • Infants and young children. Adults too. • Organisms can enter the middle ear from the nose and throat through the eustachian tube • Eardrum protects middle ear from the environment. • CM- Red, bulging tympanic membrane. Pain, with a URI. Swelling of the ET impairs drainage of the middle ear, fluid collects with bacteria. Fever. • Complications: discussion. DX- Otoscope eardrum.

33. Otosclerosis • Genetic, hereditary disorder affects white females. • Abnormal bone forms in the stapes and causes a conductive hearing loss. • CM- hearing loss begins in adolescence or early adulthood. Tinnitus • Management- Surgical reconstruction of the middle ear. • Nursing- Referral to appropriate community agencies to evaluate hearing loss.

34. Inner Ear Disorders • Occur less frequently than other ear disorders: • Labyrinthitis • Meniere’s disease. • Vertigo is the KEY symptom of inner ear disorders. • Contains the semicircular canals that help maintain balance and neural receptors for hearing. Thus may cause permanent hearing loss. • Labyrinthitis- inflammation of the inner ear • Bacterial or virus • CM- severe vertigo, NV, nystagmus. Falling!

35. Inner Ear disorders • Meniere’s Disease- chronic inner ear disorder caused by excess fluid and pressure in the labyrinth of the inner ear. • Gradual or sudden • Vertigo, tinnitus and gradual hearing loss • No cure • TX- Decrease inner ear pressure hydrochlorothiazide. • Meds to relieve vertigo Vistaril, compazine. • Avoid caffeine, alcohol and tobacco. • May need surgery to relieve excess pressure . • Nr- discussion risk for injury! Evaluate vertigo, HL.

36. Hearing Loss • 10 million adults in the US are hearing impaired • 70% of older adults • Conductive hearing loss- Anything that impairs sounds transmission from the external opening of the ear to the inner ear. Impacted cerumen most common. Perforated eardrum, tumor of middle ear. • Hearing aid would be of benefit.

37. Hearing Loss • Sensorineural Hearing Loss- Disorders that affect the inner ear or the auditory pathways of the brain. • Trauma, infection, Meniere’s disease, ototoxic medications, prenatal exposure to rubella. • US- Noise exposure is the major cause of sensorineural hearing loss. Exposure to high level of noise damages the hair cells of the inner ear. • Affects the ability to hear high-frequency sounds more than low. Speech discrimination and communication noisy places. Hearing aids may not help. Why? Nr- Social isolation, type HL, finances. Ed