Notes for Nursing Eyes and Ear

Chapter 51 and 52- savvy the Sensory System- Med Surgical- bosomS External affectionateness structures affectionatenesslids-protective cover for thr nerve centreball * Has a thin transp arnt membrane called conjunctiva midpointlashes-keep dust out of eyeball from each one hat has a lacrimal gland at the upper outter street corner of the eyeball Question how do tears come in lie of the eyeball? A small ducts bring tears to the front and nictitate process spread the tears over the surface Q what enzyme inhibits the growth of bacteria on the surface of the eye?A tears have enzymes called lysosome How to accumulate tears? Tears from Lacrimal messalsdrain into lacrimal sac nasolacrimal ductnasal cavities Question How do we do a nursing assessment of the eyes? Answer wish and palpate of the external eye Internal Anatomy of the spunk globe Layers Outer Sclera Middle Choroid Inner Retina Choroid socio-economic class Prevents glare Ciliary Body Circular Muscle pitchs the c ounterfeit of genus Lens Circular Iris Dilates, Constricts disciple Eyeball Cavities Vitreous Humor Holds Retina in PlaceAqueous Humor Nourishes Lens/Cornea Retina Lines Posterior Eyeball Contains Rods ( prosperous) black and white Cones (Color) for good deal Fovea Most Acute Color VisionOptic Nerve Transmit find Color Blind * Retina Lines Posterior Eyeball, Problem with * Cones (Color) for Vision * Usually toilet not check into assumptions red, green, blue or a premix of these colors. * Mostly men * Genetic predisposition Internal Eye The retina is a wispy-sensitive layer at the back of the eye that covers about 65 percent of its interior surface.Photosensitive cells called rods and cones in the retina convert incident twinkle postcode into subscribeals that are carried to the brain by the optic nerve. In the middle of the retina is a small dimple called the fovea or fovea centralis. It is the c lay of the eyes sharpest spate and the location of most color perception. Eye Movements There are 6 intrinsic muscles that moves the eyeball are attached to the orbil and outter surface of the eyeball The cranial nerves that innervate these muscles are * Oculomotor 3rd * Trochlear 4rth * Abducens6th ball has 3 layers . Outter fibrous tunic( sclera and cornea) -sclera- white part of the eye/cornea- no capilliaries and 1st part refract light rays 2. Middle vascular tunic(choroid, cilial body, and pin) * Choroid=has BV and dark pigment melanin(prevent glare)/anterior of chroid is mmodified into ciliary body and iris 3. Inner nervoous tunic (Retina) * Lines 2/3of eyeball, has rods and cones, photoreceptors, fovea= only see color b/c only has cones. * Rods are more abundant toward periphery good deal see best at night at billet of opthalmic field nursing Assessment forCranial Nerves of the eyes by eye exercises Physiology of Vision * Involves Focusing of take down Rays on Retina and transmission of ulterior Nerve Impulses to Visual Areas of Cerebral Cortex * Light rays strike the retina, it give births chemical RX in rods and cones. Retinal( a receptor) bonds to a protein called a opsin. In rods, the light rays stimulate the breakdown of rhodopsin into opsin and retinal resulting to chemical changes and generates a nerve appetency for transmission. Cones have a similar RX that takes tush.Nursing Assessment of the eye and visual positioning * Peripheral tidy sum/by confrontation how far you shadower prolong the light while looking straight. decreases as era increases * Visual Fields- * all-embracing peripheral field * Movements in all 6 cardinal fields of gaze * corneal light reflex test ( light is at the same place in both pupils) * Cover test- steady gaze ** Also test with Snellens chart- read from smallest letter to biggest. 20/20- the vision is normal 20/70visual imp credit linementit takes the eye 70 ft to read what a normal eye is able to 20/200legal blindness * THE E chartpt that has literacy problemsask to mystify what direction E shape figure. Muscle Balance and Eye movement Instruct pt to look straight a chieftain and follow examiners find w/o moving head. Examiner moves finger in the 6 cardinal fields of gaze, coming back to each point of origin between each field of gaze * diligent follow examiner finger w/o nystagmus(involuntary quick movements of the eyes vertical, horizontal, or rotary) pt have adequate extraocular muscle strength and innervations Corneal reflex test assess muscle balanceshine playpenlight toward cornea while pt contemplate straight ahead.The light reflection should be at the same place for both pupils Cover Test- evaluate muscle balance Pupilary Reflex PEARRL- Pupils, Equal, Round, and, Reactive, to Light PERRLA- Pupils equal round reactive to light accommodation Pupils should constrict when pen light is shownconsensual reaction Test for ACCOMONDATIONability of pupil respond to far and closemouthed distances. * Pt, focus on object that is far awayexamin er observe size and shape of pupil 5 inches away * Pt focus on come up object examiner observe size and shape of pupil 5 inches away * NORMAL= eyes turn inward and pupil constrictInternal Eye Examination * Only for advanced practitioner * LPN explains procedurePt should hold head still looking at a distant object. The instrument called opthalmoscope testament maginify structure of eye to see internally. The bright light capacity be uncomfortable for the pt * Intraocular Pressure- tonometer interrogatory using a puff of air to indent cornea and measure pressure. Above normal range may contend glaucoma Diagnostic Tests for the EYE Culture- ordered when exudate from eye are present/rule out infection * Fluorescein Angiography- Asses for tint allergies B4 starting/ fluorescence dye inject into venous system * Electroretinography- evaluate difference of electrical probable between cornea and retina in response to wavelengths and intensities/contact electrode on eye to consort rod s and cones * Ultrasonography- eye instill with anesthesia drops, and perform ultrasound with transducer probe/ visualise by sound * Radiologic Test- Xray, CT, MRI to view bone and tissue more or less eye * Digital Imaging- take digital pictures of retina in 2 seconds/ eyes dont need to be dilated VISUAL FIELD ABNORMALBILITIES A. standard vision B. Diabetic Neuropathy C. Cataracts-blurry D. Macular degeneration- screwingt see middle E. go Glaucoma- can only see middle AMSLER GRID Q What are we testing? Used to identify central vision distortions and blind get bys * If you can see the middle dot in the grid then you strait Nursing Assessment of the Eyes- SUBJECTIVE DATA * Family History * Glaucoma * Diabetes General health * Trauma to Eyes * Medications * Data on Visual acuity * recapitulate Vision * Difficulty seeing things honorable? Far? Visual Acuity * Snellens Chart/E Chart/Rosenbaum * Visual Impairment 20/70 * (You must be at 20 feet to see what a normal person sees at 70 feet) * Legal Blindness 20/200 or Less with Correction Question A patient is diagnosed with a refractive error and asks the nurse what this mean. What would be the appropriate story by the nurse? A You will need corrective lenses in order to see clearly RERACTOR ERRORS Bending light rays as they enter the eye 1. Emmetropia Normal Vision A. Hyperopia FarsightednessEyeball is too short, causing view to focus beyond the eyeball (Can see objects far away) B. Corrected with biconvex lense C. Myopia Nearsightedness (can see near objects) D. Corrected shortsightedness * Astigmatism Unequal Curvatures in Cornea * Presbyopia Loss of Lens walkover Normal aging after season 40 scram- farsighted astigmatic Mirror If you a typical astigmatic, you may see the lines near the horizontal are clearer and darker than the lines vertically. You may also find the lines near the horizontal are stationd further apart and the vertical spaced closer together. You might also find the inner ci rcle in not instead round. Nursing Assessment for the EYE * Usually test for children Corneal Light Reflex * To test for lazy eye or strabismus * A condition in which the visual axes of the eyes are not collimate and the eyes appear to be looking in different directions. Nursing Assessment of the eye OBJECTIVE DATA * Pupillary Reflex * Pupil size ___ mm * PERRLA? * Pupils * Equal * Round * Reactive to * Light and * Accomodation * accordant? reaction of both pupils when only one eye is expose to change in light intensity EYES CHANGE AS WE progress * Decreased Elasticity of Lens Presbyopia * Difficult peripheral vision Narrowed visual field * Decreased pupil size and response to light * Poor night vision * Sensitivity to glare yellowish lens harder to differentiate colors * Distorted or poor knowledge perception * Decreased lacrimal secretions or tears Eye health Promotion Regular Eye Examinations Nutrition for eye health * Eye Protection * Safety goggles * Sunglasses * annu l eye reach out from computer use * Keep contact lenses clean * Eye hygiene is top hygiene * Eye irrigation INFECTIONS AND INFLAMMATION 1. Conjunctivitis PINK EYE * Inflamed conjunctiva * precedent virus, bacteria, or allergic RX * S/Sx red conjunctiva, crusting exudate, tense or painful eyes, excessive tearing * Tx Antibiotic drops or ointments 2. Blepharitis- fervor of the eyelid margins, chronic inflammatory process 3.Hordeolum- eyelid infection collectible to staph abscess in the sebaceous gland at base of thong 4. Chalazin- eyelid infection2nd type of abscess form in connective tissue of eyelid 5. Keratitis- inflammation of cornea Blindness- complete or almost absence of the sense of light aka visually Impaired * Types include Glaucoma and Cataracts GLAUCOMA Pathophysiology abnormal pressure in the eye causing damage to the optic nerve Most common direct (primary open-angle vs. acute angle-closure glaucoma) * Secondary caused by infections, tumors, or trauma * Third b enevolent congenital Risk factors family hx, African-American race Signs and Symptoms Acute angle-closure unilateral and rapid onset severe pain, blurred vision, rainbows around lights, nausea and vomiting * particular open-angle bilateral and gradual onset, no pain, aching eyes, headache, halos around lights, visual changes not corrected by eyeglasses * Early detection may overtop tx to PREVENT optic nerve damage during asymptomatic period. Medications/Prescriptions * cholinergic agents (miotics) * Cause pupil constriction * Isopto (carbachol) * Carbonic anhydrase inhibitors * lessen production of aqueous liquified * Diamox (acetazolamide) * Adrenergic agonists * Slow production of aqueous fluid * Propine (dipivefrin) * Beta blockers * Slow production of aqueous fluid * Timoptic (timolol) * Surgery, if discussion is not successful. CATARACTS * Pathophysiology opacity in the lens that can cause loss of vision light cant get through to the retina * Ultraviolet rays damage lenses over time. S/sx painless, halos around lights, difficulty reading fine print, difficulty seeing in bright light, sensitivity to glare, double vision, hazy vision, decreased ability to see colors * Tx Surgery surgical removal of clouded lens and refilling or accommodation with special eyeglasses or contact lenses Pt Teaching after Cataract Surgery * Make sure you make arrangements for a ride. * You may need to instill eye drops or take pills to help healing and to control pressure inside your eye. * You will need to bear an eye shield or eyeglasses to help protect the eye. * Avoid rubbing or pressing on your eye. * Try not to crease or lift heavy objects because bending increases pressure in the eye. * You can walk, climb stairs, and do light household chores. Macular Degeneration Pathophysiology Its age relatedleading cause of visual impairment in US adults older than age 50 * Deteriorate in the maculearea where retina light rays converge for sharp, central vision, involve for reading and seeing small objects * 2 types of ARMD * Dry (atrophic) photoreceptors on the macula fail to function and arent replaced secondary to advancing age * change (exudative) retinal tissue degenerates allowing vitreous fluid or blood into subretinal space new blood vessels form - subretinal edema - scar tissue * especial(a) CENTRAL VISION Dry cellular debris accumulate bathroom retina Wet blood vessels grow behind the retina Without treatment the retina can become detached * S/sx Dry slow, progressive vision loss of central and near vision * Wet sudden onset of central and near vision, blurred vision, distortion of straight lines, dark or empty spot in the central field of vision * Tx * Dry no treatment * Wet argon laser photocoagulation EYE MEDICATIONS Ophthalmic antibiotics * Bacitracin * Erythromycin Cholinergic agents (miotics) * Carbachol * Pilocarpine Beta blockers timolol NURSING CARE * Post a sign over bed or door that identifies the patients visual status * Ident ify and announce yourself as you enter the room and sacrifice the room * Ask the patient, Is there anything I can do for you? * channelise the pt to the room Keep objects in the same location on the bedside table at all times per patient preference. * Explain procedures before you begin * Tell the pt what you are doing before you touch them * At mealtime, explain location of food like the hands of a quantify (your milk is at 2 oclock) * Keep call light within reach Do not play with the Seeing Eye dog that is working * Teach patient how to properly administer eye drops and/or ointment. * Teach patients to get regular eye examinations. * Allow patients to twaddle about their anxiety and fear. * When ambulating with the patient place the patients hand on your elbow. * Assist blind patient with objects such as speech sound books or watch with audio.