Sensory Problems
Pocholo Santos
Chinese General Hospital College of Nursing
NCM 104
Diagnostic Assessment
1. Eye
a. Snellen’s Chart
To check visual acuity
b. Tonometry
To measure intra-ocular pressure
N=12-20 mmHg
c. Perimetry
a. To check peripheral vision
d. Bjerrum’s tangent screen
For central vision
e. Ishihara plate
Color vision
Diagnostic Assessment
2. Ear
a. Audiometry
Decibels
Unit of measurement in hearing
70 decibels do not damage the ear
Conductive Hearing Loss
Problems with tympanic membrane, middle ear
or mastoid
Sensorineural Hearing Loss
Problems of the Cochlea (sensory) and acoustic
nerve (neural)
Mixture Hearing Loss
Combinatation of conductive and sensorineural
affectation
Diagnostic Assessment
Vestibular function
• Diagnostic test for balance and
equilibrium
• Oculovestibular reflex or calorie test
• Test 8th cranial nerve
• Cold or hot water into external
auditory canal produces nystagmus
Diagnostic Assessment
Tuning fork
Weber test
• On patient’s forehead or teeth
Rinnes test
• Shifted between mastoid bone and 2
inches from the ear canal opening
Eyes Disorders
Anatomy & Physiology
Outer Protective Layer [EYES]
Sclera - the white visible portion of the eyeball. The muscles that move the eyeball
are attached to the sclera.
Cornea - the clear, dome-shaped surface that covers the front of the eye.
Middle Vascular Layer
Choroid - the thin, blood-rich membrane that lies between the retina and the sclera;
responsible for supplying blood to the retina.
Ciliary body - the part of the eye that produces aqueous humor.
Iris - the colored part of the eye. The iris is partly responsible for regulating the
amount of light permitted to enter the eye.
Inner Neural Layer
Pupil - the opening in the middle of the iris through which light passes to the back of
the eye.
Retina - the light-sensitive nerve layer that lines the back of the eye. The retina
senses light and creates impulses that are sent through the optic nerve to the brain.
Anatomy of the Eye
Anatomy & Physiology
[EYES]
Refractive Media
Cornea - transparent layer that forms the external coat of the
anterior portion of the eye
Aqueous humor - the clear, watery fluid in the front of the
eyeball.
Lens (Also called crystalline lens.) - the transparent structure
inside the eye that focuses light rays onto the retina.
Vitreous body - a clear, jelly-like substance that fills the back
part of the eye.
Glaucoma
increased intraocular pressure which can damage
optic nerve that eventually lead to blindness
• Causes:
• Congenital, inherited, trauma
2 TYPES of GLAUCOMA
Risk factors:
1. Unknown
2. Emotional disturbances
3. Hereditary factors
4. Allergies
GLAUCOMA (ACUTE AND CHRONIC)
Subjective Data
1. Acute (Close-angle)
a. Pain, severe in and around eyes
b. Headache
c. *Rainbow halos around lights
d. Blurring of vision
e. Nausea, vomiting
2. Chronic (Open-angle)
a. Eyes tire easily
b. *Loss of peripheral vision
GLAUCOMA (ACUTE AND CHRONIC)
Objective Data
1. Corneal edema
2. *Decreased peripheral vision
3. Increased cupping of optic disc
4. Tonometry pressures 22 mm. Hg
5. Pupils dilated
6. Redness of eye
GLAUCOMA (ACUTE AND CHRONIC)
Analysis/Nursing Diagnosis
1. Visual sensory/perceptual alterations
2. Pain
3. Risk for injury
GLAUCOMA (ACUTE AND CHRONIC)
Pathophysiology
1. Developmental or degenerative opacification of the
crystalline lens.
CATARACT
Risk Factors
1. Aging
2. Trauma
3. Toxins
4. Congenital defect
CATARACT
Subjective Data
1. Blurring
2. Loss of acuity
3. Distortion
4. Diplopia
5. Photophobia
CATARACT
Objective Data
1. Blindness (bilateral or unilateral)
2. Loss of red reflex
3. Gray opacity of lens
CATARACT
Analysis/Nursing Diagnosis
1. Visual sensory/perceptual alterations
2. Risk for injury
3. Social isolation
Nursing Management
ECCE- extracapsular cataract extraction- anterior portion of the
lens capsule plus the capsule contents are removed
ICCE- intracapsular cataract extraction
Cryoextraction- use of frozen probes to remove lens
Iridectomy - creation of an opening for the flow of aqeous humor
which may be blocked post op; prevention of secondary glaucoma
Phacoemulsification- ultrasonic vibratin to breakup the lens
Intraocular lens implant- lens prosthesis
Cataract glasses
Nursing Management
Post op care
Eye dressing with Eye shield AAT
Eye shield at night for the 1st month
Cataract lens (aphakic glasses) - appears 1/4 closer
IOL implant - an alternative for better binocular vision
Made of polyethyl methacrylate
OOB 1day post op
COD OD until 7 -10 days
Eye drops as ordered
Retinal Detachment
Sensory retina separates from the pigment
epithelium of the retina
Causes: Retinal Detachment
congenital malformations high myopia or vitreous
trauma (including disease, or degeneration
previous ocular surgery) Exudates that occur in front
or behind the retina
vascular disease
Aphakia (absence of
choroidal tumors crystalline lens)
hemorrhage
Management
Eye bandaged
Specific positioning prescribed by MD.
Head positioned so that retinal tear or hole is at
the lowest point of the eye.
Surgical
Both eyes bandaged
Resume activities in 3-5 weeks
Cold compresses to decrease edema
Signs and Symptoms
Flashes of lights
Floating spots
Progressive blurring of vision - visual field deficits - visual
loss
Visual curtain
Anxiety, confusion, fear
Diagnostics
Opthalmoscopic exam - gray, opaque retina, with folds,
holes, tears
Nursing Management
Discuss surgical options
Photocoagulation- intense beam of light directed to close the retinal
tear
Cryosurgery- subfreezing temperatures applied to the surface of the
sclera in the area of the hole to produce inflammatory reaction
Diathermy- needle point electrode applied through sclera
Scleral buckling- sclera and corroid are intended or buckled toward the
retinal break
Injecting an intraocular gas bubble to promote adhesion
Nursing Management
Bed rest with eyes covered
Place on a dependent position
Immediate Surgery - reattach the retina
Pre Op care and Mydriatics OU as ordered; eye patches OU
Post op care
Affected area should be on the upper position
Activities - consulted with the MD
Pressure patch over the affected eye
Rest the eyes and head immediate post op
Avoid increase IOP (coughing, straining, NV)
COD OD
Uveitis
Intermediate uveitis
Posterior uveitis
Diffuse uveitis
Uveitis
Uveitis S/s
Iritis Pain in the eyeball radiating
Iridocyclitis to forehead
Choroiditis Blurred vision
Choroiretinitis Photophobia
Causes: Redness of the eyes without
purulent discharge
Local/systemic disease
Small pupil
Injury
lacrimation
Unidentified factors
Nursing Management
Mydriatics (AtSO4, Scopolamine)
To dilate pupils
To prevent adhesion between ant capsule of the
lens and iris
To relieve pain and photophobia
To reduce congestion
To rest the iris and ciliary body
Steroids
Dark glasses
Analgesics
Refraction errors:
Hyperopia
Farsightedness
(convex lens)
Myopia
Nearsightedness
(concave lens)
Astigmatism
Distorted vision
Presbyopia
Old sight
Eye Surgeries
Enucleation-removal of eyeball
Evisceration- removal of the contents of the
eye with retention of the sclera
Exenteration- removal of the entire eye and all
other soft tissues in the boney orbit
Care of Patients
undergoing Eye Surgery
If OU are covered post op, pt needs to be oriented to
hospital set up and staff
Pediatric clients need to practice covering the eyes
pre op to allay anxiety, restlessness and fear post op
Call light / bell should always be within reach
Prep on the eyes on the day of surgery - dilate pupils
using mydriatics
Care of Patients
undergoing Eye Surgery
Post op care Open mouth when sneezing,
Prevent increase IOP coughing
Prevent stress in the suture Open eyes when vomiting
line Avoid bending forward to prevent
Prevent hemorrhage tension at suture line
Prevent infection Gradual mobility/positional
Keep the head still changes
Position on the unoperative Side rails up
side or supine
Bedside table at unoperative side
Burning sensation - wearing off
of anesthesia Assistance in ambulation
Avoid lifting of head, hips, Help them learn to feed
straining, squeezing eyelids themselves
Care of Patients
undergoing Eye Surgery
Cont…
Post op dressing should not be loosened or removed
Minimal bleeding is normal
Edema of eyelids will subside 3-4 days post op
Feeling of something in the eye 4-5 days due to
sutures
Sensation of pressure within the eye/ sharp pain may
indicate bleeding - report to MD ASAP
Rehabilitation
of a Blind Person
Referrals
Orient to the environment. Set up and location of things.
Promote independence in ADL
May have guide dog, use of cane for direction
Talk before touching when approaching
Assist in ambulation. Held the client in your arm so you are
one step ahead of him
Talk to him frequently so he wont feel neglected
Be relaxed and unhurried. Tell procedure before performing
Rehabilitation
of a Blind Person
Do not change the environment without describing the
change
Promote safety
Do not rush up and offer help unless it is clear that
the person wants help
Choice of gifts to blind person: gifts that appeal to
senses other than vision
Ear Disorders
Anatomy & Physiology
Anatomy & Physiology
Impacted cerumen
Soften with instilled peroxide or glycerol preparation
Irrigate ear in 2-3 days to remove the wax
Keep the otic solution in the ear for 15 mins - tilting head
sideways and putting cotton
Notify MD if irritation/inflammation occurs
Nursing Management
Subjective Data
1. Tinnitus
2. Headache
3. True vertigo: sudden attacks, room appears to spin
4. Depression, irritability, withdrawal
5. Nausea on sudden head motion
EAR DISORDERS
MENIERE’S DISEASE
Objective Data
1. Impaired hearing, especially low tones
2. Change in gait, lack of coordination
3. Vomiting with sudden head motion
4. Nystagmus—during attacks
5. Diagnostic test:
a. Cold caloric may precipitate attack
b. Loss of hearing by audiometry
EAR DISORDERS
MENIERE’S DISEASE
Analysis/Nursing Diagnosis
1. Risk for injury
2. Auditory/sensory perceptual alteration
3. Risk for activity intolerance
EAR DISORDERS
MENIERE’S DISEASE
Nursing Care Plan/Implementation
1. Goal: Minimize occurrence of attacks
a. Medications
i. Diuretics (clorothiazide [Diuril],
acetazolamide [Diamox])
ii. Antihistamines (dimenhydrinate
[Dramamine], diphenhydramine HCL [Benadryl)
EAR DISORDERS
MENIERE’S DISEASE
Causes:
exposure to loud noise on a consistent basis
prior exposure to head and neck radiation
history of parathroid adenoma
Use of hand held cellular phones (under study)
Diagnostic procedure
Audiometry (hearing testing)
MRI scanning of the head with contrast.
Acoustic Neuroma
Risk Factors
1. Heredity
2. Females, puberty to 45 yrs.
OTOSCLEROSIS
Subjective Data
1. Tinnitus
2. Difficulty hearing; gradual loss in both ears
OTOSCLEROSIS
Objective Data
1. Rinne (mastoid)- reduced sound conduction by air
and intensified by bone
2. Weber (top of head)- increased sound conduction to
affected ear
3. Audiometry—diminished hearing
OTOSCLEROSIS
Analysis/Nursing Diagnosis
1. Auditory sensory/perceptual alteration
2. Body image disturbance
OTOSCLEROSIS
Pathophysiology
1. Removal of the stapes and replacement with a
prosthesis
2. Treatment of deafness due to otosclerosis, fixes the
stapes preventing it from oscillating and transmitting
vibrations to the fluids in the inner ear
STAPEDECTOMY
Analysis/Nursing Diagnosis
1. Sensory perceptual alteration
STAPEDECTOMY