Chapter 13

Care of the Patient with a

Visual or Auditory Disorder

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 2Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• Anatomy of the eye Accessory structures of the eye

• Eyebrows• Eyelashes• Eyelids• Lacrimal apparatus

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Figure 13-1Figure 13-1

Lacrimal apparatus.

(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)

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Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• Anatomy of the eye (continued) Structures of the eyeball

• Sclera• Cornea• Choroid• Ciliary body• Iris• Pupil• Retina

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Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• Anatomy of the eye (continued) Chambers of the eye

• Anterior chamber Aqueous humor

• Posterior chamber Vitreous humor

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Figure 13-2Figure 13-2

Horizontal section through the left eyeball. The eye is viewed from above.

(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)

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Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• Anatomy of the ear External ear

• Auricle• External auditory canal• Tympanic membrane

Middle ear• Eustachian tube• Malleus• Incus• Stapes

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Figure 13-3Figure 13-3

The ear. External, middle, and inner ear. (Not to scale.)

(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)

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Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• Anatomy of the ear (continued) Inner ear

• Labyrinth Bony labyrinth—filled with perilymph

o Semicircular canalso Vestibuleo Cochlea—organ of Corti

Membranous labyrinth—filled with endolymph

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Figure 13-4Figure 13-4

The inner ear.

(From Thibodeau, G.A., Patton, K.T. [2005]. The human body in health and disease. [4th ed.]. St. Louis: Mosby.)

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Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• Other special senses Taste and smell

• Taste buds: salty, sweet, sour, bitter• Olfactory receptors: sense of smell

Touch• Tactile receptors

Position/movement• Proprioceptors

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Laboratory and Diagnostic ExaminationsLaboratory and Diagnostic Examinations

• Diagnostic eye tests Snellen test Color vision Refraction Ophthalmoscopy Tonometry Amster grid test Schirmer’s tear test

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Disorders of the EyeDisorders of the Eye

• 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)

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Disorders of the EyeDisorders of the Eye

• Blindness and near-blindness (continued) Clinical manifestations/assessment

• Diplopia• Pain• Floaters and light flashes• Pruritus; burning of the eyes• Loss of peripheral vision• Halos• Orbital pressure• Bulging of the eyes

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Disorders of the EyeDisorders of the Eye

• Blindness and near-blindness (continued) Medical management/nursing interventions

• Corrective eyewear• Canes• Seeing-eye dogs• Magnifying systems• Surgical procedures

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Disorders of the EyeDisorders of the Eye

• Refractory errors Etiology/pathophysiology

• Astigmatism—unequal curve in the shape of the cornea or lens

• Strabismus—inability of the eyes to focus in one direction; cross-eyed

• Myopia—nearsightedness; eyeball is too long• Hyperopia—farsightedness; eyeball is too short

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Disorders of the EyeDisorders of the Eye

• Refractory errors (continued) Clinical manifestations/assessment

• Diminished or blurred vision Medical management/nursing interventions

• Corrective lenses• Surgical correction

Radial keratotomy (RK) Photorefractive keratectomy (PRK) Laser-assisted in-situ keratomileusis (LASIK)

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Disorders of the EyeDisorders of the Eye

• Conjunctivitis Etiology/pathophysiology

• Inflammation of the conjunctiva• Bacterial or viral infection• Allergy• Environmental factors• Commonly called pink eye

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Disorders of the EyeDisorders of the Eye

• Conjunctivitis (continued) Clinical manifestations/assessment

• Erythema of the conjunctiva• Edema of the eyelid; crusting discharge• Pruritus; burning; excessive tearing

Medical management/nursing interventions• Warm compresses• Eye irrigations with normal saline• Antibiotic drops or ointment• Keep free from exudate

Slide 20Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Keratitis Etiology/pathophysiology

• Inflammation of the cornea• Injury, irritants, allergies, viral infection, or diseases• Pneumococcus, Staphylococcus, Streptococcus, and

Pseudomonas are most common types of bacterial causes

• Herpes simplex is most common viral cause

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Disorders of the EyeDisorders of the Eye

• Keratitis (continued) Clinical manifestations/assessment

• Severe eye pain• Photophobia• Tearing• Edema• Visual disturbances

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Disorders of the EyeDisorders of the Eye

• Keratitis (continued) Medical management/nursing interventions

• Pharmacological management Topical and systemic antibiotics Analgesics

• Pressure dressings• Warm or cold compresses• Epithelial debridement• Keratoplasty

Slide 23Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Dry eye disorders (keratoconjunctivitis sicca) Etiology/pathophysiology

• Lacrimal gland dysfunction from an autoimmune mechanism

Clinical manifestations/assessment• Complaints of sandy or gritty sensation in the eye

Medical management/nursing interventions• Artificial tear replacement• Punctal plugs or repair if injured

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Disorders of the EyeDisorders of the Eye

• Ectropion and entropion Etiology and pathophysiology

• Noninfectious disorders of the eye lid causing abnormal eyelid margins

Clinical manifestations• Abnormal direction of the eyelid• Corneal dryness

Medical management/nursing interventions• Topical medications to reduce conjunctival and corneal

drying• Surgery

Slide 25Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Cataracts Etiology/pathophysiology

• Noninfectious opacity or clouding of the lens• Congenital; acquired; senile

Clinical manifestations/assessment• Blurred vision• Diplopia• Photosensitivity• Decreased night vision• Opacity in the center portion of lens

Slide 26Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Cataracts (continued) Medical management/nursing interventions

• Surgical removal Lens implant or glasses

• Postoperative Avoid direct sunlight Bed rest with bathroom privileges (BRPs) Analgesics No bending down or straining Avoid coughing, sneezing, and blowing nose

Slide 27Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Diabetic retinopathy Etiology/pathophysiology

• Capillary microaneurysms, hemorrhage, exudates, and formation of new vessels and connective tissue in the retina

Clinical manifestations/assessment• Microaneurysms• Progressive loss of vision; “floaters”

Medical management/nursing interventions• Photocoagulation• Vitrectomy

Slide 28Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Macular degeneration Etiology/pathophysiology

• Slow, progressive loss of central and near vision due to aging retina

Clinical manifestations/assessment• Gradual and variable bilateral loss of vision• Color perception may also be affected

Medical management/nursing interventions• Usually no treatment• May use photocoagulation

Slide 29Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Retinal detachment Etiology/pathophysiology

• Separation of the retina from the choroid in the posterior area of the eye

Clinical manifestations/assessment• Flashes of light; floating spots• Loss of a specific field of vision

Medical management/nursing interventions• Photocoagulation; cryosurgery; diathermy• Scleral buckling

Slide 30Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 13-8Figure 13-8

Retinal break with detachment: surgical repair by scleral buckling technique.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.)

Slide 31Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Glaucoma Etiology/pathophysiology

• An abnormal condition of elevated pressure within an eye; obstruction of outflow of aqueous humor

Open-angle Closed-angle

Slide 32Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 13-9Figure 13-9

A, Chronic open-angle glaucoma. B, Acute-angle closure glaucoma.

(From Havener, W.H. [1997]. Synopsis of ophthalmology. St. Louis: Mosby.)

Slide 33Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Glaucoma (continued) Clinical manifestations/assessment

• Open-angle No signs or symptoms during early stages Tunnel vision Eye pain Difficulty adjusting to darkness Halos around lights Inability to detect colors

Slide 34Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Glaucoma (continued) Clinical manifestations/assessment

• Closed-angle Severe pain Decreased vision Nausea and vomiting Erythema of the sclera Enlarged and fixed pupil Halos around lights

Slide 35Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Glaucoma (continued) Medical management/nursing interventions

• Open-angle glaucoma Beta blockers Miotics Carbonic anhydrase inhibitors

• Closed-angle Osmotic diuretics Iridectomy

Slide 36Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Corneal injuries Etiology/pathophysiology

• Result from injuries to corneal layers of the eye Clinical manifestations/assessment

• Pain with movement of eye• Excessive tearing; pruritus• Erythema of conjunctiva

Slide 37Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Disorders of the EyeDisorders of the Eye

• Corneal injuries (continued) Medical management/nursing interventions

• Flush with normal saline or water• Antibiotic drops or ointment• Penetrating wounds

Do not remove object if present

Slide 38Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Surgeries of the EyeSurgeries of the Eye

• Enucleation Surgical removal of the eyeball

• Keratoplasty (corneal transplant) Excision of the corneal tissue, followed by

implantation of a cornea from a donor• Photocoagulation

A laser is directed into a small spot on the retina• Vitrectomy

Removal of excess vitreous fluid caused by hemorrhage and replacement with normal saline

Slide 39Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Laboratory and Diagnostic ExaminationsLaboratory and Diagnostic Examinations

• Diagnostic ear tests Otoscopy Tuning fork tests

• Weber’s test• Rinne test

Autometric testing Vestibular testing

• Romberg test• Past-point testing

Slide 40Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 13-13Figure 13-13

Weber tuning fork test.

(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)

Slide 41Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 13-14Figure 13-14

Rinne tuning fork test.

(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical examination. [5th ed.]. St. Louis: Mosby.)

Slide 42Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Loss of Hearing (Deafness)Loss of Hearing (Deafness)

• Hearing impairment Etiology/pathophysiology

• Decreased auditory acuity; partial or complete• Affects development of speech• Types

Conductive Sensorineural Mixed Congenital Functional Central

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Loss of Hearing (Deafness)Loss of Hearing (Deafness)

• Hearing impairment (continued) Clinical manifestations/assessment

• Requests for repeating information• Nonresponse• Delayed speech development

Medical management/nursing interventions• According to cause• Hearing aids• Surgical procedures• Cochlear implant

Slide 44Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Inflammatory and Infectious Disorders of the EarInflammatory and Infectious Disorders of the Ear

• External otitis Etiology/pathophysiology

• Inflammation or infection of the external canal Clinical manifestations/assessment

• Pain with movement of auricle or chewing• Erythema, scaling, pruritus, edema, watery discharge,

and crusting of the external ear Medical management/nursing interventions

• Oral analgesics; corticosteroids• Antibiotic or antifungal ear drops; oral antibiotics

Slide 45Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Inflammatory and Infectious Disorders of the EarInflammatory and Infectious Disorders of the Ear

• Otitis media Etiology/pathophysiology

• Inflammation or infection of the middle ear Clinical manifestations/assessment

• Fullness in the ear• Severe, deep, throbbing pain• Hearing loss• Tinnitus• Fever

Slide 46Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Inflammatory and Infectious Disorders of the EarInflammatory and Infectious Disorders of the Ear

• Otitis media (continued) Medical management/nursing interventions

• Pharmacological management Antibiotics Analgesics Nasal decongestants

• Local heat• Aspiration of fluid from behind eardrum• Myringotomy

Slide 47Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Inflammatory and Infectious Disorders of the EarInflammatory and Infectious Disorders of the Ear

• 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

Slide 48Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Inflammatory and Infectious Disorders of the EarInflammatory and Infectious Disorders of the Ear

• Labyrinthitis (continued) Clinical manifestations/assessment

• Severe and sudden vertigo; ataxic gait• Nausea and vomiting• Nystagmus; photophobia• Headache

Medical management/nursing interventions• Antibiotics• Dramamine or meclizine for vertigo• IV fluids if nausea and vomiting present

Slide 49Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Inflammatory and Infectious Disorders of the EarInflammatory and Infectious Disorders of the Ear

• Obstructions of the ear Etiology/pathophysiology

• Impaction of cerumen in canal; foreign bodies Clinical manifestations/assessment

• Tinnitus and pain in the ear• Slight hearing loss; tugging at ear

Medical management/nursing interventions• Removal of cerumen by irrigation• Foreign objects are removed with forceps• Carbamide peroxide to soften cerumen

Slide 50Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Noninfectious Disorders of the EarNoninfectious Disorders of the Ear

• Otosclerosis Etiology/pathophysiology

• Chronic, progressive deafness due to formation of spongy bone, especially around the oval window

Clinical manifestations/assessment• Slowly progressive conductive hearing loss• Tinnitus; dizziness to vertigo

Medical management/nursing interventions• Stapedectomy• Air conduction hearing aid

Slide 51Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Noninfectious Disorders of the EarNoninfectious Disorders of the Ear

• Ménière’s disease Etiology/pathophysiology

• Chronic disease of the inner ear• Increase in endolymph fluid

Clinical manifestations/assessment• Vertigo• Nausea and vomiting• Hearing loss; tinnitus• Diaphoresis• Nystagmus

Slide 52Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Noninfectious Disorders of the EarNoninfectious Disorders of the Ear

• Ménière’s disease (continued) Medical management/nursing interventions

• No specific treatment• Decrease fluid pressure

Fluid restriction; diuretics; low-salt diet• Dramamine, meclizine, and Benadryl• Surgery

Destruction of labyrinth Endolymphatic shunt Cryosurgery Vestibular nerve section

Slide 53Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Surgeries of the EarSurgeries of the Ear

• Stapedectomy Removal of the stapes of the middle ear

• Tympanoplasty Operative procedures on the eardrum or ossicles of

the middle ear to restore hearing• Myringotomy

Surgical incision of the eardrum• Cochlear implant

Surgical implantation of a hearing device for the profoundly deaf

Slide 54Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

• Nursing diagnoses Health maintenance, ineffective Anxiety Self-care deficit Fear Impaired environmental interpretation syndrome Impaired home maintenance Impaired social interaction Risk for injury Risk for loneliness Sensory perception, disturbed: auditory or visual

Nursing ProcessNursing Process

Ophthalmic Drugs

Categories Local anesthetics

Used in procedures such as tonometry, gonioscopy, cataract surgery, and removal of foreign objects from the cornea

Antiseptic ointments Prevent gonorrheal ophthalmia neonatorum in

newborn infants, used to treat common eye infections, germicidal and astringent action

Ophthalmic antiinfectives Treat eye infections caused by bacteria, fungi, or

viruses

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Ophthalmic Drugs (cont.)

Artificial tears Other preparations Antiglaucoma agentsUses To control acute narrow-angle glaucoma before

surgery Wide-angle glaucoma Secondary glaucoma Congenital glaucoma before surgery

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Glaucoma

Three Major Forms Primary glaucoma

Narrow-angle: person has a shallow anterior eye chamber, may be genetic; requires surgery

Wide-angle glaucoma: gradual onset, controlled with medications

Secondary glaucoma Result of other eye problems, treated with

medications Congenital glaucoma

Birth defect requiring surgical correction

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Antiglaucoma Medications

Sympathomimetics Produce vasoconstriction and decrease intraocular

pressure in open-angle glaucoma Beta blockers

Reduce intraocular pressure by reducing the formation of aqueous humor

Miotics, direct-acting Cholinergic agonists

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Antiglaucoma Medications (cont.)

Miotics, cholinesterase inhibitors Inactivates acetylcholinesterase

Carbonic anhydrase inhibitors Blocks action of an enzyme in the ciliary body,

causing a decrease in aqueous humor secretion

59Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antiglaucoma Medications (cont.)

Mydriatic-Cycloplegics Block the action of acetylcholine

Mydriatics

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Otic Preparations

Control superficial infections of the ear Action is bacteriostatic or bactericidal

Prophylaxis for infections in swimmers Removing cerumen

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