Asuhan Keperawatan

“Lansia dengan Perubahan

Sensori: Penglihatan dan
Pendengaran”

SHINTHA SILASWATI
 • Sheizi Prista Sari
• Padang Panjang, 06 Mei 1982
• Keperawatan Unpad: S1 (2006) dan S2 (2012)
• Aktif mengajar di Keperawatan Unpad sejak 2006
• Pengalaman belajar:
International Conference
Palliative care training (WHO)
In house training JICA-Jepang (Geriatric)
TOT : HIV/AIDS, Posyandu, Gerontik, IPE

Menjadi yang terbaik itu bukan tujuan, namun memberi yang terbaik itu lebih utama
 Tujuan Pembelajaran
1. Mendeskripsikan perubahan normal pada lansia yang
mempengaruhi fungsi penglihatan dan pendengaran
2. Mengidentifikasi gangguan umum yang terjadi yang
mempengaruhi fungsi sensori pada lansia
3. Menentukan cara terbaik dalam mengkaji status sensori pada
lansia
4. Mengidentifikasi diagnosis keperawatan dan strategi
keperawatan dalam menangani gangguan penglihatan dan
pendengaran pada lansia
5. Mengidentifikasi kebutuhan kolaborasi dalam mengatasi
masalah sensori (penglihatan dan pendengaran) pada lansia
“Safely experience and enjoy the
world around us”
Perubahan Fungsi Sensori

Gangguan berinteraksi
dengan lingkungan

Penurunan Kualitas Hidup

A goal of Healthy People 2020 is to
decrease the prevalence and severity
of disorders of vision, hearing,
balance, smell, and taste, as well as
voice, speech,
and language (USDHHS, 2010)
Epidemiologi
Gangguan Penglihatan
• Meningkat sesuai usia dan kondisi tempat tinggal
• Di US, kejadian sebesar 30% dari 12.8% populasi
lansia (Desai, Pratt, Lentzer, & Robinson, 2001
• Pada lansia > 70 th maka angka kejadian 70, 19%
(Desai et al., 2001 [Level V]). Evaluasi pada
layanan perawatan jangka panjang terdapat 40%
sampai 54% (Bron & Caird, 1997 [Level VI];
Cacchione, Culp, Dyck, & Laing, 2002
Gangguan Penglihatan
• Lebih dari 90% lansia mengatakan menggunakan kaca
mata (Campbell, Crews, Moriarty, Zack, & Blackman,
1999
• 8.8% lansia mengalami gangguan penglihatan dan 59%
diantaranya tidak bisa dikoreksi (Vitale, Cotch, &
Sperduto, 2006
• Penyebab gangguan penglihatan dianataranya: cataracts,
macular degeneration, danglaucoma (Congdon et al.,
2004
• Katarak, merupakan penyebab utama kebutaan dan
merupakan urutan kelima penyakit kronis pada lansia >
75 tahun (NAAS, 1999).
Gangguang Pendengaran
• Gangguan pendengaran merupakan penyakit
kronis ketiga yang mempengaruhi lansia usia >75
tahun (NAAS, 1999)
• > 50% lansia >75 tahun mengalami gangguan
pendengaran
• Pada lansia di panti maka angka kejadian
diestimasi sebesar 90% (Lewis-Culinan & Janken,
1990)
• Angka kejadian pada lansia laki-laki > perempuan
(NIDCD, 2007
 Perubahan Fisiologis Penglihatan
PERUBAHAN PADA LANSIA DAMPAK YANG DITIMBULKAN
• Penurunan kemampuan • Peningkatan resiko keamanan
adaptasi terhadap gelap sehubungan perubahan
• Penurunan kemampuan pencahayaan lingkungan
menengadah/ menoleh • Penurunan lapang pandang
• Mata menjadi kering dan • Iritasi mata kering
penurunan produksi air • Tidak mampu menyesuaikan
mata dengan perubahan cahaya dan
• Penurunan sensitifitas silau
kormea • Resiko keamanan pada saat
• Pengecilan ukuran pupil mengemudi dan melakukan
• Penurunan lapang aktivitas lainnya di lingkungan
pandang
 Perubahan Fisiologis Pendengaran
PERUBAHAN PADA LANSIA DAMPAK YANG DITIMBULKAN
• Gendang telinga menebal • Penurunan penjalaran
• Kehilangan ketajaman gelombnag suara pada
pendengaran frekuensi saluran telinga
tinggi • Penurunan kemampuan
• Penurunan kemampuan mendengar suara seperti as/
untuk memproses suara p/ w/t/sh dan suara wanita
setelah usia 50 tahun serta anak-anak
• Peningkatan impaksi • Membutuhkan waktu lebih
serumen lama untuk berespon
terhadap stimuli
• Penurunan pendengaran
Implications of Vision Changes in
Older Adults
Impact on Safety
• Inability to read medication labels
• Difficulty navigating stairs or curbs
• Difficulty driving
• Difficulty crossing streets
Impact on Quality of Life
• Reduces ability to remain independent
• Difficulty or unable to read
• Falls
Proses Keperawatan
Pengkajian

Penglihatan

Pendengaran
Nursing Assessment of Vision
The health history is an essential part of vision assessment.
• Several health conditions predispose older adults to visual
impairment.
• Diabetes is one of the leading causes of disease-related
blindness related to diabetic retinopathy (Baker, 2003; Munoz
et al., 2000 ) Tielsch, Sommer, Witt, Katz, & Royall, 1990)
• Hypertension carries with it the risk of hypertensive
retinopathy.
• Ascertaining a thorough baseline health history with yearly
reviews and updates is essential in maintaining visual health.
Vision History Questions
• When was your last eye exam?
• How would you describe your eyesight?
• Any change in your eyesight?
• When did you notice this change?
• Are you experiencing any blurred vision?
• Are you having any double vision?
• Are you bothered by glare?
• Are you experiencing any eye pain?
• Are you using any eye drops for any reason?
• Any history of trauma or injury to your eyes?
• Have you had any eye surgeries?
• Do you have cataracts?
• Any family history of eye problems?
Examination of the Eye
• The external structures can cause decreased vision if the lids
lag due to laxity of the skin of the upper eyelid.
• Lid lag can interfere with visual acuity and fields and may
require surgery.
• Cataracts in severe cases can be visible with the naked eye and
appear as a whitish-gray pupil instead of black.
• Cloudiness of the whole cornea of the eye is indicative of a
corneal problem, not a cataract.
• If the person has had cataract surgery, the lens implant may be
visible on close inspection.
Examination of the Eye
• Fundus Exam.
• Vision Testing
• Distance Vision.
• ETDRS. The Early Treatment of Diabetic Retinopathy Study (ETDRS)
• Pin-Hole Test.
• Near Vision
• Light House for the Blind Near Vision Screener
• Contrast Sensitivity (The Pelli–Robson Contrast Sensitivity Chart )
• Visual Fields
• Conditions of the Eye
 Cataracts.
 Macular Degeneration
 Glaucoma.
 Diabetic Retinopathy.
 Hypertensive Retinopathy.
 Temporal Arteritis.
 Detached Retina.
Diagnosis Keperawatan
• Domain 1. Health Promotion
Class 1. Health Awareness
• 00097/ Deficient diversional activity
• 00168/ Sedentary lifestyle
• 00257/ Frail elderly syndrome
• 00231/ Risk for frail elderly syndrome
Class 2. Health Management
• 00099/ Ineffective health maintenance
• Domain 5. Perception/Cognition Class 4. Cognition
• 00126/ Deficient knowledge
• Domain 11. Safety/Protection Class 2. Physical Injury
• 00219/ Risk for dry eye
• 00155/ Risk for falls
• 00035/ Risk for injury
• 00245/ Risk for corneal injury
• Domain 12. Comfort Class 3. Social Comfort
• 00054/ Risk for loneliness
• 00053/ Social isolation
Key nursing diagnoses and outcomes in
Cataract

• Fear related to complete loss of vision caused by untreated cataracts

Treatment outcomes: The patient will state that he
feels less fearful and will exhibit no signs or symptoms of fear
• Risk for injury related to decrease in vision caused by the cataract
Treatment outcome: The patient will remain free from injury.
• Disturbed sensory perception (visual) related to diminishing ability to see
properly as a result of the cataract
Treatment outcome: The patient will regain lost vision with treatment.
Nursing-Care Strategies
in Vision Problems
• Nurses should obtain a past medical history to avoid disruption in
the management of chronic eye conditions, assuring continuation of
ongoing regimens such as eye drops for glaucoma. Without the
continuation of an individual’s eye drops, eye pressures could
precipitously increase causing an acute exacerbation of the
glaucoma, potentially dramatically limiting vision.
• If an acute change in an individual’s vision occurs, the primary-care
provider should be notified immediately.
• Depending on the signs and symptoms present, the individual may
need to see an ophthalmologist or go to the emergency room to
receive treatment to restore the vision or limit the deterioration.
• Provide a safe environment.
Implications of Vision Changes in Older
Adults

• Impact on Safety
• Inability to read medication labels
• Difficulty navigating stairs or curbs
• Difficulty driving
• Difficulty crossing streets
• Impact on Quality of Life
• Reduces ability to remain independent
• Difficulty or unable to read
• Falls
 Lighting
• Lighting is important in an individual’s environment.
• Too little light can limit vision.
• Too much light, depending on an individual’s eye condition such as
cataracts, may cause eye pain and glare.
• It is important to ascertain whether an individual is sensitive to light. If so,
indirect light and night lights may be helpful to provide a safe
environment. The majority of older adults benefit from improved lighting.
• To avoid glare, directing incandescent lamps directly on a task, such as
sewing or reading, often improves visual acuity and is well tolerated.
• Glare occurs when a light shines directly into the eye or reflects off a shiny
surface.
• Low-vision specialists recommend trying different positions and wattage of
lighting to find what works best for each individual (Community Services
for the Blind and Partially Sighted, 2004).
Eyeglasses
• Encourage the use of the person’s eyeglasses.
Older adults’ eyeglasses should be labeled with
their name so they can be reconnected to their
owner if they are set down and left behind.
• Even with eyeglasses, magnification may be
helpful. Have family provide lighted
magnification if needed (large lighted magnifiers
are available at low-vision centers).
• Contrast sensitivity is a problem with several
eye conditions, including cataracts, glaucoma,
and macular degeneration. Adding contrast to
the fixtures in the home if light switches blend
into the wall or faucets blend into the sink can
create a safer and more functional
environment.
• Nurses should encourage an annual dilated-eye
examination with either an optometrist or an
ophthalmologist. This is crucial in people who
have a diagnosis of diabetes or hypertension.
• Nurses are members of the interprofessional
team responsible for preventing unnecessary
disability. Therefore, nurses should ensure that
there is a mechanism in place to trigger these
visits on an annual basis.
Pengkajian

Penglihatan

Pendengaran
 It is easy to determine

cup their hand behind their ear

lean closer

complain that
people are have trouble
mumbling hearing their
grandchildren’s or other’s
high-pitched voices

ask for things to be repeated turn their head to their “good ear
Hearing Changes Common in
Older Adults

• Conductive hearing loss (Presbikusis)

• Sensorineural hearing loss
• Central auditory processing disorder
• Tinnitis
• Meniere’s disease
Assessment
• The Hearing Handicap for the Elderly- Screen
• (is a 10-item scale to determine how hearing impacts an
older adult’s daily life and to assist in identifying who
might benefit from a hearing aid and an audiologic
referral)
• Whisper Test
• Finger-Rubbing Test
• Handheld Audioscope
• Pure Tone Audiometry
• Tuning Fork Tests
Implications of Hearing
Changes
• experience a decreased quality of communication
• social isolation
• Speech paucity
• low self-esteem
• generally lower quality of life

significant safety issues

NURSING ACTIONS
• Assess for cerumen impactions. Request cerumen-
softening drops followed by cerumen removal or ENT
consultation.
• Get the person’s attention and face them before
speaking to assist the individual with lip reading, a
common compensatory mechanism for older adults.
• Have at least one pocket amplifier on the nursing unit to
use with hearing-impaired individuals.
• Do not shout at people with hearing impairments; rather,
use a lower tone of your voice.
NURSING ACTIONS
• Provide written instructions (use a large black marker if the
person is also visually impaired).
• Ensure appropriate care for hearing aids: remove batteries at
night; use the brush provided to gently clean the tubes to
reduce wax accumulation.
• Before sending bed linens or clothing to the laundry, make
sure the hearing aid is in the patient’s ear or in the designated
location (e.g., bedside table or medication cart).
• Notify the primary-care provider of any sudden change in
hearing.
• Referral to an audiologist and/or ENT as indicated.
EXPECTED OUTCOMES
• Baseline visual acuity and hearing acuity for all older patients will be
performed prior to discharge from the hospital and upon admission
to home care or a nursing home.
• Fall precautions should be in place for all older patients with
sensory impairments.
• Older adults should avoid falls and injuries
• Accidental exposure

FOLLOW-UP MONITORING
Thank you
Praktikum dan Diskusi
Kasus
Tn. A usia 68 tahun tinggal di rumah berdua dengan istrinya. Katz index
Tn. A termasuk pada kategori A dan pengkajian status mental
menunjukan fungsi intelektual utuh. Perawat mengunjungi Tn.A untuk
melakukan follow up care karena tiga hari yang lalu Tn. A datang ke
Puskesmas dengan keluhan luka pada kaki akibat terjatuh. Pada kedua
mata Tn.A terlihat lingkaran putih keabuan di bagian pupilnya. Tn.A
mengatakan kadang dia juga tidak dapat melihat secara keseluruhan
benda yang ada didepannya. Tn. A juga mengungkapkan ketakutannya
menjadi buta. Perawat juga mencurigai istri Tn.A mengalami gangguan
pendengaran karena setiap berbicara Ny.A mendekatkan kepala dan
meminta perawat mengulang atau memperjelas kembali apa yang
telah disampaikan.
1. Jelaskan gejala yang terlihat pada Tn.A dikaitkan dengan proses
penuaan
2. Buatlah asuhan keperawatan pada Tn.A dan keluarganya
3. Demonstrasikan pengkajian (kel.2) dan salah satu intervensi (kel.
4) pada Tn.A dan keluarga.