Keloid

SYSTEMSYSTEM

ANATOMY & PHYSIOLOGY OF EYESANATOMY & PHYSIOLOGY OF EYESEXTERNAL STRUCTURES

EYELIDS

CONJUNCTIVAPALBEBRALBULBAR

LACRIMAL APPARATUSLACRIMAL GLAND, DUCTS & PASSAGES

6 EXTRAOCULAR MUSCLES

Levator palpebrae muscle

EXTERNAL STRUCTURES

EYELIDS

CONJUNCTIVAPALBEBRALBULBAR

LACRIMAL APPARATUSLACRIMAL GLAND, DUCTS & PASSAGES

6 EXTRAOCULAR MUSCLES

Levator palpebrae muscle

ANATOMY & PHYSIOLOGYEYESORBIT

EYEBALL : 3 LAYERS: OUTER

SCLERACORNEA

MIDDLE CHOROIDCILIARY BODY IRIS

•INNER–RODS

–SENSITIVE TO LIGHT–PERIPHERAL VISION

–CONES–FINE DESCRIMINATION–COLOR VSION

EYESEYES

ANATOMY & PHYSIOLOGYEYESLENS – FOCUS IMAGE

FLUIDS OF THE EYE:AQUEOUS HUMOR

ANTERIOR & POSTERIOR CHAMBERS ANTERIOR EYE CAVITY NUTRIENTS TO LENS & CORNEA INTRAOCULAR PRESSURE MAINTENANCE

20-25 mmHgVITREOUS HUMOR

POSTERIOR EYE CAVITY TRANSPARENCY & FORM OF THE EYE

EYESEYES

VISUAL PATHWAYSRETINARETINA

OPTIC NERVEOPTIC NERVE

OPTIC CHIASMOPTIC CHIASM

OPTIC TRACTOPTIC TRACT

OCCIPITAL LOBEOCCIPITAL LOBE

Physical Examination-EYEVISUAL ACUITY : SNELLEN’S CHARTVISUAL FIELDS: PERIMETRYEXTERNAL STRUCTURES

POSITION & ALIGNMENT OF EYESPUPILS (PERRLA)

EXTRAOCULAR MOVEMENTSPARALYSISNYSTAGMUS

CORNEAL REFLEX

DIAGNOSTIC TESTSSNELLENOPHTHALMOSCOPEBIOMICROSCOPE / SLITLAMP

EXAMINE THE ANTERIOR SEGMENT OF THE EYETONOMETER

14-20 mmHgBJERRUM’S TANGENT SCREEN

CENTRAL FIELD OF VISIONISHIHARA COLOR PLATE TEST

IDENTIFY 3 PRIMARY COLORSGONIOSCOPY

ANGLE OF ANTERIOR CHAMBER

PLANNING FOR HEALTH PROMOTIONCARE OF THE EYES

EYEDROPS, DISCOURAGEDPRINTED MATTER: 14 INCHES AWAYTV: 10-12 FT AWAYREAD WITH ILLUMINATION: 100-150

WATTSLIGHT FROM BEHINDTEACH ABOUT DANGER SIGNALS OF

VISUAL DISORDER

•PERSISTENT REDNESSPERSISTENT REDNESS•CONTINUED DISCOMFORT & PAIN ESP CONTINUED DISCOMFORT & PAIN ESP

FOLLOWING INJURYFOLLOWING INJURY•CHILDREN: CROSSING OF EYESCHILDREN: CROSSING OF EYES•BLURRED VISION/ SPOTS BEFORE THE EYESBLURRED VISION/ SPOTS BEFORE THE EYES•GROWTH ON THE EYE/ OPACITIESGROWTH ON THE EYE/ OPACITIES•CONTINUAL DISCHARGE, CRUSTING ORCONTINUAL DISCHARGE, CRUSTING OR

TEARINGTEARING•PUPIL IRREGULARITIESPUPIL IRREGULARITIES

DISORDERS - EYEINJURIES &

TRAUMA

INFECTIONS

CATARACT

GLAUCOMA

DETACHMENT OF THE RETINA

REFRACTIVE ERRORS

INJURIES & TRAUMAEMERGENCY:TREAT THE PATIENT, LEAVE THE EYE

ALONE, EXCEPT IN CHEMICAL INJURY - FLUSH EYES STAT

FOREIGN BODIES: FLUSH WITH WATER FOR 15 MIN WHILE GOING TO THE DOCTOR; DON’T TOUCH CORNEA

INFECTIONSHORDEOLUM/ STY -Zeis gland in the

follicle

CHALAZION –meibomian glandsCONJUNCTIVITIS – pink eye

bacterial infection, allergy, trauma

UVEITIS - irisKERATITIS - corneaPTERYGIUM – triangular fold

From white of the eye to the cornea

Conjunctivitis

Sty

Chalazion

Pterygium

CATARACTOpacity of the lens & its capsule which interferes

with transparency

S/SX:Dimness in visual acuityRapid & marked refraction error

CLASSIFICATION:Primary/ senileSecondary/ traumaticCongenital

Cataract

TreatmentReplacement of the intra ocular lens

Commonly done by phakoemulsification technique

EYE SURGERYNURSING CARE PRE-OP

Orient to new environment

Teach deep breathing & how to close eyes without squeezing

Eye antibiotics preop

Mydiatrics if ordered

EYE SURGERYNURSING CARE POST-OP

Reorient patient to his surroundings

Prevent increase in IOP & stress on the suture line

Contd….ACTIVITIES THAT INCREASE IOP:ACTIVITIES THAT INCREASE IOP:

• CoughingCoughing• Vomiting Vomiting • Bending Bending • Stooping Stooping

• Promote comfort of the patient: mild Promote comfort of the patient: mild analgesic to control painanalgesic to control pain

EYE SURGERYNURSING CARE POST-OP

Observe & treat complicationsCOMPLICATIONS:COMPLICATIONS:•NAUSEA & VOMITINGNAUSEA & VOMITING

•AntiemeticsAntiemetics•Cold compressCold compress

•HEMORRHAGEHEMORRHAGE•Sudden pain of the eyeSudden pain of the eye

•PROLAPSE OF THE IRISPROLAPSE OF THE IRIS•Most common postop complicationMost common postop complication•Can precipitate glaucomaCan precipitate glaucoma

• Promote the rehab of the patientPromote the rehab of the patient•Encourage the patient to become Encourage the patient to become

independent- walk with him when he first independent- walk with him when he first become ambulatorybecome ambulatory•Health teachingsHealth teachings

EYE SURGERY HEALTH TEACHINGS:

1-4 wks : dark glasses; temporary corrective lenses

6-8 wks: permanent lensesIt will take time to learn distances & climb

stairsColor slightly changedUse one eye at a time unless with contact lensDecreased peripheral vision

GLAUCOMA INCREASED IOP PROGRESSIVE LOSS OF PERIPHERAL VISION

CAUSE: OBSTRUCTION TO CIRCULATION OF AQUEOUS HUMOR

TYPES:1. CHRONIC/ SIMPLE/ OPEN-ANGLE2. ACUTE ANGLE CLOSURE3. Congenital4. Secondary – trauma, uveitis, postop5. Absolute – uncontrolled- enucleation

EYESEYES

CORNEACORNEA

IRISIRIS

CILIARY BODYCILIARY BODYANTERIORANTERIORCHAMBERCHAMBER

LENSLENS

CANAL OF SCHLEMMCANAL OF SCHLEMM

ZONULESZONULES

OPEN-ANGLE GLAUCOMAOPEN-ANGLE GLAUCOMA

EYESEYES

CORNEACORNEA

IRISIRIS

CILIARY BODYCILIARY BODYANTERIORANTERIORCHAMBERCHAMBER

LENSLENS

CANAL OF SCHLEMMCANAL OF SCHLEMM

ZONULESZONULES

ACUTE-ANGLE CLOSURE GLAUCOMAACUTE-ANGLE CLOSURE GLAUCOMA

OPEN ANGLE GLAUCOMAS/SX:

Loss of peripheral vision (tunnel)Difficulty in adjusting to darknessFailure to detect changes in colorHeadache, pain behind the eyeballHalosNausea & vomiting

OPEN ANGLE GLAUCOMAMANAGEMENT:

Conservative :Miotics : pupillary constriction

draw iris smooth muscle away from the canal

Acetazolamide : decrease aqueous production

Fluid restriction

Definitive managementPrinciple: improve drainage of aqueous

• Iridocleisis-anterior chamber & subconjunctival space

• Corneoscleral trephening – junction of cornea & sclera

• Trabeculotomy

• Laser therapy to meshwork

Acute Angle GlaucomaCAUSE:Pupillary dilation by mydiatricsAbnormal anterior displacement of iris

S/SX:Severe eye painNausea & vomitingBlurred visionColored halos around lightsDilated pupilsIncreased IOP

MANAGEMENT:

• Miotics• Azetazolamide• Osmotic agents – glycerol• Surgery - iridectomy

GLAUCOMANURSING CARE – SURGERY

PRE-OPExplain that vision lost cannot be restored,

but further loss can be prevented

POST-OPFlat 24H- prevent iris prolapseNarotics or sedativesLiquid diet until 1st dressingTurn to unoperative site

LONG TERM CARE:

• No restriction on the use of the eyes• No fluid restriction; exercise permitted• Medical follow up needed for life

RETINARETINA CHOROIDCHOROID

SCLERASCLERA

OPTIC NERVEOPTIC NERVE

RETINAL DETACHMENTRETINAL DETACHMENT

RETINAL DETACHMENTFluid accumulationTumor

CAUSE:Myopic

degenerationTraumaAphakia

S/SX: Floating spots or

opacities before the eye

Casts shadows on the retina

BrightFlashes of light

Progressive constriction of vision in 1 eye

Management

Conservative :• Quiet in bed with eyes covered• Head: positioned so that retinal holes lower• Photocoagulation – small burn to retina

• Cryotherapy – cold probe to freeze retina

Surgical: • Scleral buckling- Scleral buckling- sealing break & reattachingsealing break & reattaching

RETINAL DETACHMENTPOST-OP NURSING CARE:Cover eyesArea of detachment, dependentMydiatricsDischarge instructions:

No strenuous exercises & acivity x 6mosContact sports restrictedNo sudden jarring head motionNo restriction with use of eyes

REFRACTIVE ERRORSREFRACTION – bending of light raysACCOMMODATION – ability to adjust from near to

far visionADAPTATION – ability to see light from darkness

COMMON ERRORS:MyopiaHyperopiaPresbyopia

•Astigmatism•Blindness

myopiaNEAR-SIGHTED

Long A-P dimension of the eyeballLight rays focus infront of the retinaGood vision for near distancesConcave lenses

Myopia

hyperopiaFAR-SIGHTED

Eyeball A-P dimension too shortLight rays focus behind the retinaGood vision for far distancesConvex lenses

Hyperopia

presbyopiaFARSIGHTEDNESS OF OLD AGE

Gradual loss of accommodationLoss of lens elasticityInability to read without holding the material

more than 13 ft from the eyeBifocal lenses

ASTIGMATISM

Asymmetry or irregular curvature of the cornea

Cylindrical lenses

BLINDNESS

Vision: 20/200

ANATOMY & PHYSIOLOGYEARSEXTERNAL EARAURICLEPINNATYMPANIC MEMBRANE

MIDDLE EAROSSICLES: MALLEOUS, INCUS, STAPESEUSTACHIAN TUBE

EAREAR

ANATOMY & PHYSIOLOGYEARSINNER EARORGAN OF CORTI

HEARING

VESTIBULAR APPARATUSBALANCE3 SEMICIRCULAR CANALSUTRICLE

EAREAR

ANATOMY & PHYSIOLOGYEARS

SOUND WAVES TO TYMPANIC MEMBRANESOUND WAVES TO TYMPANIC MEMBRANE

OSSICLES IN MOTIONOSSICLES IN MOTION

VIBRATION FROM STAPES TO OVAL WINDOWVIBRATION FROM STAPES TO OVAL WINDOW

COCHLEA : ORGAN OF CORTICOCHLEA : ORGAN OF CORTI

CRANIAL NERVE 8 TO TEMPORAL LOBECRANIAL NERVE 8 TO TEMPORAL LOBE

HEARINGHEARING

AUDITORY ASSESSMENTEXTERNAL EAR EXAMINATION

Inspection & palpation of auricleVisualization: straighten the auditory canal:

PULL AURICLE UP, & BACK

NORMAL EARDRUM: slightly conicalShinypearly gray in color

AUDITORY ASSESSMENTHEARING TEST:

Tests for acuteness of hearing or degree of deafness:

Whisper or spoken voice testAudiometer :

Pure tone – mx loudness in decibelSpeech – ability to understand & descriminate

Watch tick testTuning fork test

AUDITORY ASSESSMENTHEARING TEST:

Test to localize cause of deafness:

Rinne’s

Weber’s

Auditory assessmentWEBER’S

• Tuning fork top midline of the head• Sound heard: normal ear vs affected ear• Better in affected ear: conductive• Better in normal ear : sensorineural

AUDITORY ASSESSMENTTEST FOR VESTIBULAR FUNCTON

CALORIC TESTCheck direction of nystagmusCOWS ( cold-opposite; warm-same side of

stimulated ear)ROTATION (BARANY) TEST

Rotating chairNystagmus is opposite to the direction of

rotation

HEALTH PROMOTIONEAR PROTECTION

Noise over 70 decibels is potentially damaging to hearing

Most common & impt type of occupational hearing is caused by LOUD NOISE

GENERAL EAR CAREEar is self-cleaning

Cerumen-lubricant; traps dirt

Cleanse the external ear reached by vision

NURSING INTERVENTIONSEAR DROPSWarmAfter adm’n, head should remain tiltedSOFTENING & REMOVING IMPACTED

CERUMENFew drops of hydrogen peroxide/ warm

glycerineIrrigate the ear

NURSING INTERVENTIONSEAR IRRIGATION

To clean the external canalRemove impated cerumenCaloric testApply antiseptic solutionsRemove foreign bodies

COMMON EAR PROBLEMS

1. OTOSCLEROSIS

2. MENIERE’S DISEASE

3. HEARING IMPAIRMENT

OTOSCLEROSISNormal bone is replaced by spongy bone

Ankylosis of the footplate of the stapes

Impaired vibration system

OTOSCLEROSISASSESSMENT

Gradual hearing loss Difficulty hearing a whisperOwn voice is loudParacusis : hear better in loud

environmentRinne’s test: bone conduction better

OTOSCLEROSISPLANNING & IMPLEMENTATION

Hearing aidSurgery – primary form of tx

StapedectomyStapes mobilization operationFenestration operation : new window is

created

EAR SURGERYPRE-OP CARE;

Hair shampooInform client:

Head still during surgeryPost op: get out of bed with assistance

avoid nose blowing until 1 week

EAR SURGERYPOST OP

Promote comfort & safety

Promote psychological well-being

Prevent complications

Complications

• Facial nerve involvement• Facial paralysis, facial weakness• Inability to show teeth, wrinkle forehead, raise eyebrows or close eyes

• Meningitis – bacterial• Report signs & symptoms

• Bleeding

MENIERE’S DSEChronic Increase in endolymphatic pressure

ASSESSMENT:TinnitusUnilateral hearing lossVertigo

MENIERE’S DSEPLANNING & IMPLEMENTATION

CONSERVATIVE: palliativeBed restMeds

Sedative :Phenobarbital Antihistamine Antiemetics

Low salt diet

MENIERE’S DSEPLANNING & IMPLEMENTATION

SURGERY- delayed until client’s hearing below the serviceable levelDestruction of the labyrinthDecompression of endolymphatic sacSectioning of the vestibular nerveCryosurgery of the labyrinth

HEARING IMPAIRMENTTYPES OF HEARING LOSS

CONDUCTIVE Damage to the conducting system Hearing aid is useful

SENSORINEURAL Damage to the:1. Organ of Corti2. Cochlear nerve3. Acoustic branch of the auditory nerve

COMMUNICATING WITH HEARING-IMPAIRED CLIENTSAvoid use of gestures without speechDo not shoutSpeak distinctly & as close to the clientUse short phrasesDo not communicate with someone else in

front of a hearing-impaired clientHearing impairment goes with visual

problems in elderly

SOUND AMPLIFICATIONTYPES OF HEARING AIDS;

Post-auricularBody-typeIn-the ear model

Select hearing aid that has cotrollable volume & is properly fitted