NUR 611 HUMAN BIOSCIENCES: ALTERED BODY FUNCTIONS DISORDERS OF THE VISUAL AND AUDITORY SYSTEMS compiled by Venina Navuta 23/1/17
DISORDERS OF THE AUDITORY SYSTEM
Diagnostic Tests §Laboratory tests -routine blood tests -Culture -If clear fluid draining from ear, rule out cerebrospinal fluid
§Radiological tests - Computed tomography (CT scan) - Magnetic resonance imaging - Arteriography and venography
Special Tests Auditory Acuity Tests – whispered voice test, tuning fork tests, Rinne test, Weber test. Audiometric Hearing Tests Balance Testing
EAR ASSESSMENT Inspection and palpation only Inspect mastoid process for redness/swelling External ear: inspected for shape, location of attachment to the head and condition of the visible external canal
Otoscope Assessment Otoscope is used to visually see and test the external ear canal Consists of a light, a handle, a magnifying lens and a bulb for injecting air to test eardrum mobility
Otoscope Assessment Tympanic Membrane(TM) Observations -color, intactness and shape Characteristics shiny, transparent and opaque/pearly gray slightly concave, movable, & free from lesions
Abnormalities Visual Inspection ◦ Pinna: swelling, nodules (gout/skin cancer/rheumatoid arthritis) and lesions (malignant skin cancer) Otoscopic Examination ◦ Tympanic Membrane: redness, of infection
Auditory Assessment Completed after bilateral external ear and otoscope examination Sound is transmitted by both air conduction and bone conduction Air conduction of sound is normally more sensitive than bone conduction Voice Test Watch Test
Auditory Assessment Tuning Fork Tests: useful, although limited, in differentiating between conductive and sensorineural hearing losses
AUDIOMETRY Measurement of hearing acuity Hearing: measured in intensity of sound expressed as decibels Conversational speech is generally around 60 decibels Hearing loss of 45 -50 decibels – need a hearing aid Hearing loss of 90 decibels – may not be able to hear speech – even with a hearing aid
EAR INSPECTION Normal external ear canal is free from lesions, is dry, clean and not reddened Any deviation from the normal ear shape and attachment is recorded The nurse notes any drainage
Outer and Middle Ear Disorders § Structural defects due to embryologic malformations § Structural changes secondary to infection or trauma
Outer Ear Disorders • Microtia and atresia Microtia: abnormal smallness of auricle Atresia: absence of an opening of the external ear • Impacted cerumen: very common cause of temporary conductive HL. Very treatable and preventable. HL that results is flat, conductive, and of varying degree.
DISORDERS OF THE EXTERNAL EAR Infections e. g. otitis externa Masses e. g. cysts, malignant tumors Foreign body Impacted cerumen Pruritis Microtia and atresia(congenital)
EXTERNAL OTITIS Allergic Reactions Bacterial/fungal Infection Swimming Trauma Pain Itching Hearing loss Plugged feeling in ear Redness and edema
TREATMENT §Topical antibiotics §Corticosteroids §Oral analgesics §Local heat
DISORDERS OF THE MIDDLE EAR §Infections e. g. otitis media, mastoiditis §Perforated tympanic membrane §Otosclerosis
OTITIS MEDIA Exudate, pain, Bacterial or viral pressure infection Hearing Fluid accumulation loss/Tinnitus Fever/Malaise Nausea/Vomiting Bulging Tympanic Membrane
TREATMENT §Systemic antibiotics §Analgesics/local heat §Antipyretics §Antihistamines §Decongestants §Myringotomy (surgical perforation of eardrum – drains fluid/relieves pain
DISORDERS OF THE INNER EAR Acoustic neuroma – benign tumor of the 8 th cranial nerve -occurs at any age -Common in women between 30 -60 years.
MENIERE’S DISEASE Occurs due the imbalance of fluid and electrolytes in the inner ear. S/S – severe tinnitus, feelings of ear fullness, vertigo
MENIERE’S DISEASE Consists of three distinct characteristics: 1) Tinnitus 2) Unilateral sensorineural hearing loss 3) Vertigo **Occurs in attacks that can last for several days. Attacks render the client almost totally incapacitated during attack and several days are needed for full recovery
MENIERE’S DISEASE Pathologic changes: either overproduction or decreased reabsorption of endolymphatic fluid, causing a distortion of the entire inner-canal system Distortion leads to decreased hearing from dilation of the cochlear duct, vertigo because of damage to the vestibular system, and tinnitus from unknown cause Usually occurs unilaterally
MENIERE’S DISEASE Initial hearing loss is reversible Repeated damage to the cochlea, caused by increased fluid pressure, leads to permanent hearing loss Cause of disease unknown – but is associated with viral or bacterial infections, allergic reactions and biochemical disturbances that increase fluid imbalances
MENIERE’S DISEASE Usually occurs between 20 -50 years of age – greater prevalence in men and Caucausians Tinnitus is a continuous, low pitched roar or humming sound, worsens just before and during an attack Hearing loss is worse during an attack – permanent hearing loss develops as the attacks increase
HEARING LOSS ØInability of the ear to detect and perceive sound Ø 3 main types: conductive, sensorineural and mixed
CONDUCTIVE HEARING LOSS § Can be caused by anything that blocks the external ear. § Interference of conduction of sound through the external auditory canal, eardrum or the middle ear
SENSORINEURAL LOSS Occurs from a disease or trauma to the inner ear, neural structures or nerve pathways leading to the brainstem.
Cochlear Disorders §Syndromes and inherited disorders §Noise induced hearing loss §Other trauma §Infections §Ototoxicity
Infections Congenital ◦ Cytomegalovirus ◦ HIV ◦ Rubella ◦ Syphilis ◦ Toxoplasmosis
Infections Acquired ◦Herpes Zooster Oticus (Chicken Pox) ◦Mumps ◦Syphilis
Ototoxicity §Some antibiotics that are often ototoxic: §Amikacin §Dihydrostreptomycin §Garamycin §Gentamicin §Kanamycin §Neomycin §Netilmicin §Streptomycin §Tobramycin §Viomycin
§Chemotherapy üCarboplatin üCisplatin §Drugs that cause reversible hearing loss üQuinine üSalicylates (aspirin) üLoop diuretics §Drugs that may be harmful during pregnancy üAccutane üDilantin üQuinine üThalidomide
Central Auditory Disorders §VIII Nerve tumors §Other diseases of the VIII Nerve §Neural disorders üCochlear neuritis üDiabetes mellitus §Brain Stem disorders üInfarcts üGliomas üMultiple sclerosis §Temporal Lobe disorders
DISORDERS OF THE EYE
ACCESSORY ORGANS OF EYE Eyebrow Eyelids and eyelashes Lacrimal apparatus
NURSING CONSIDERATION §preservation of vision §prevention of further visual loss in those patients who have already experienced some degree of loss. §maximal practical use should be sought for any remaining vision §Skilful listening & interviewing are critical tools for the rehabilitation of the distressed patient
Common eye diseases seen at the CWMH : -Pterygium -Tarsal cyst -Granuloma -chalazion
THEATRE CASES Cataract -evisiation -Enucleation • Corneal perforation repair • iridectomy
IMPORTANCE OF CLIENT HISTORY Family history of eye problems (refractive errors, night blindness, colorblindness) Gender – retinal detachments are more common in men and dry-eye symptoms are more common in women Age: incidence of glaucoma/cataract formation increases with aging Presbyopia (inability of the eye to read close up, due to aging of the natural lens of the eye)
MEASUREMENT OF VISION Visual acuity tests measure both distance and near vision Snellen Chart: tool to measure distance vision Client stands 20 feet away from the chart, covers one eye and uses other eye for testing. e. g. 20/50 means that client is able to see at 20 feet what a “healthy eye” can see at 50 feet
COMMON MEDICATIONS USED §Topical anaesthetic §Mydriatic §Cyclopedic agents §Anti-infective §Corticosteroids §NSAIDS §anti-allergy §Eye irrigant §lubricants
Eye Disorders v. Refractive errors v. Muscular disorders v. Disorders of the eyelid v. Disorders of the globe of the eye
Refractive Errors Hyperopia Myopia Astigmatism Presbyopia
Hyperopia (Farsightedness) Mechanism ◦object focuses behind the retina ◦able to see only far objects Etiology ◦genetic link
SYMPTOMS AND SIGNS ◦ blurred vision ◦ Squinting ◦ eye rubbing ◦ headaches DIAGNOSIS ◦ Snellen visual acuity test ◦ ophthalmoscope TREATMENT ◦ Convex lens
Myopia (near sightedness) Mechanism ◦ object focuses in front of the retina ◦ able to see only close objects Etiology ◦ genetic link Symptoms and signs ◦ blurred vision ◦ Squinting ◦ eye rubbing
Diagnosis ◦Snellen visual acuity test ◦opthalmoscope Treatment ◦concave lens ◦radical keratotomy - shallow incision in the cornea causing it to flatten in desired area (could have significant complications)
Astigmatism Mechanism ◦Abnormal shaped cornea (egg shape instead of spherical) ◦object is partially clear & other blurred Etiology ◦genetic link
Symptoms and signs oblurred vision o. Squinting oeye rubbing oheadaches Diagnosis ◦ Snellen visual acuity test ◦ opthalmoscope Treatment ◦ artificial lens transplant ◦ radial keratotomy
Presbyopia Mechanism * Rigidity of the lens (old age) * unable to focus Etiology * genetic link Old age (< 40 year) Symptoms and signs * blurred vision * squinting * eye rubbing * headaches
Diagnosis ◦* Snellen visual acuity test * opthalmoscope Treatment ◦* lens transplant
Muscular Disorders Nystagmus Strabismus
Nystagmus Mechanism * repetitive involuntary movements of one or both eyes Etiology * Congenital * Brain tumors * CV lesions * Ear lesions * Alcohol/drug abuse
Symptoms and signs * Eye movements *Horizontal, vertical, circular, or combination * blurred vision Diagnosis * viewing of the eyes - involuntary movement * complete neurological tests Treatment * Treat the underlying condition * Congenital stays for life
Strabismus Mechanism * Failure of eyes to look in the same direction at the same time * Weakness of muscles of one eye (superior oblique, interior oblique, lateral) Etiology ◦ in childhood: associated with amblyopia (decreased vision in one eye) (reversible after 7 years of age) in adults: Usually caused by disease: i. e. diabetes, high blood pressure, brain trauma
Symptoms and signs ◦ Types: 1. Esotropia (convergent-cross eye of one eye) 2. Exotropia (divergent- one eye turns outward) 3. Diplopia (adults strabismus) 4. Congenital (no strabismus exists)
Diagnosis ◦ * complete ophthalmic examination * Diagnose underlying disease Treatment ◦ * Treat early * Corrective glasses * orthoptic training * surgery to restore eye muscle balance * treat underlying disorder
Nursing Care Goals §Environmental management – orientation to the environment anxiety & discomfort; facilitates independance §Emotional support §Family involvement
DISORDERS OF THE EYE Eyelid Abnormalities - ptosis : upper lid hangs down - Ectropian: lower lid hangs down - Trichiasis: eyelashes turn in - Chalazion: eyelid lump
PTOSIS is an abnormally low position (drooping) of the upper eyelid. The drooping may be worse at night, when the individual's muscles are tired.
ACUTE RED EYE Babies (0 -28 days)- conjunctivitis of the newborn Children (6/12 -6 yrs) – vit. A deficiency At any age – conjunctivitis/trachoma, corneal ulcer/foreign body, iritis, acute glaucoma
CONJUNCTIVA – DISEASES OF § Conjunctivitis – inflammation of the conjunctiva. § Causes – viral, bacterial, chemical agents, allergens, physical irritants, radiant energy
Acute Bacterial Conjunctivitis Mucopurulant conjunctivitis Caused by: Staph epidermidis and Staph aureus –usually. Strep pneumonae, H influensae and Morexella lucanatae occasionally
Symptoms: Acute onset of redness, grittiness, burning and discharge. *Photophobia may be present (corneal involvement) *Stickiness of the eyelids *Usually bilateral disease * Signs: Conjunctival hyperaema *Mild papillary reaction *Mucopurulant discharge *Lid crusting *No lymphadenopathy. *Normal VA *
TRACHOMA Chronic relapsing conjunctivitis Cause: chlamydia trachomatis Environmental factors: poor hygiene, personal & social
TRANSMISSION IS FAVOURED BY: Crowded living quarters Shortage of water Dirty housing Poor hygiene – animal and human faeces around the house All factors which favour the breeding of FLIES
TRACHOMA Also spread by sharing unwashed • Bedding • Clothing • Towels • Face cloths • handkerchiefs
MOST AT RISK ARE §Children §Young mothers
CLINICAL MANIFESTATIONS §Follicles on underlid §Inflammation §Scarring §Trichiasis §Corneal opacity
PREVENTION OF ACUTE TRACHOMA §Encourage hand & face washing with clean water §Clean up environment to §Eradicate flies
Intervention Surgery for trichiasis. Antibiotics. Facial cleanliness to prevent transmission. Environmental change to prevent transmission.
Disorders of the Globe of the Eye Keratitis Corneal abrasion or ulcer Scleritis Cataract Glaucoma Macular degeneration Diabetic retinopathy Retinal detachment Uveitis
DISORDERS OF THE CORNEA Corneal edema – caused by damage to the epithelium and endothelium of the cornea. Keratitis – inflammation of the cornea. Divided into 2 types -Nonulcerative – epithelium affected and still remains intact -ulcerative – epithelium, stroma or both are destroyed
AQUEOUS HUMOR & INTRAOCULAR PRESSURE Glaucoma – group of conditions that cause an elevation of the intraocular pressure. -closed-angle glaucoma -Open-angle glaucoma * Congenital or infantile glaucoma
CLINICAL MANIFESTATIONS §Sudden, excruciating pain around eyes; §headache; §nausea/vomiting; §halos around lights and §sudden blurred vision
DIAGNOSTIC TEST/TREATMENT Tonometry, non-contact Puff test Medications: ◦ Miotics (which constrict the pupil allowing better circulation-blurs vision (Pilocarpine) ◦ Beta Blockers (which inhibit aqueous humor production (Timoptic/Betagan) ◦ Surgery – last resort when medication fails
DISEASES OF ACCOMMODATION Develops when patient cannot accommodate changes from far to near vision Cataracts – opacity of the lens and interferes with the transmission of light into the retina
COMMON CAUSE OF CATARACT AGE – over half are genetically determined Other causes – drugs, diseases, damage
PATHOLOGY OF CATARACT Precipitation of transparent protein in the lens – becomes opaque Like frying an egg
DISEASES Eye disease – iritis, glaucoma General diseases – diabetes, arthritis, syphilis, leprosy, Down’s syndrome.
DAMAGE §Contusion injury §Perforation §Acids and alkalis §Sunlight §Smoking/alcohol
DIFFERENT CAUSES Congenital • Genetic • Hereditary • Rubella • Other viruses
TYPES OF CATARACT §Immature §Mature §Intumescent §hypermature
CATARACTS Risk factors: age, trauma, toxic agents, disease, chronic sunlight exposure and glaucoma or retinal detachment No pain or eye redness is associated with agerelated cataracts Visual acuity is very reduced – without surgery, visual impairment can progress to blindness
TREATMENT the only treatment is surgery
CATARACTS Surgical approaches to lens removal for cataracts Replacement lenses are inserted – some clients have distant vision restored to 20/20 and may only need glasses for reading or close work Major complication: increased Intraocular Pressure and/or Hemmorhage Another complication: Infection
DISORDERS OF THE RETINA Blood Supply and Vascular Lesions – can give rise to papilledema Retinopathies – involve change in structure
RETINAL DETACHMENT Involves separation of the sensory retina from the pigment epithelium with fluid accumulation between the two layers. Macular Degeneration - loss of central vision, usually in both eyes.
DIABETIC RETINOPATHY The cells of the retinal vessels die and fluid leaks into the eye Fluid is absorbed; thick yellow-white hard exudates are formed Capillaries lose their ability to transport needed oxygen and nutrients Microaneurysms form in capillary walls. Capillaries become fragile – bleed easily and cause retinal ischemia or macular edema reducing visual acuity
DIABETIC RETINOPATHY Treatment: depends on the severity of retinal damage Laser therapy can seal microaneurysms and decrease bleeding Scattering of laser burns across the retinal can decrease the retina’s need for oxygen and control the growth of new blood vessels A vitrectomy can be performed if frequent bleeding into the vitreous occurs and fibrin bands threaten to detach the retina
REFERENCES Brown, D. , & Edwards, H (2012). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems (3 rd ed. ). Sydney. Elservier Dempsey, Maureen Farrell and J. S meltzer & Bare's Textbook of Medical Surgical Nursing, 3 rd Edition. Lippincott Williams & Wilkins, 10/2013. Vital. Book file
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