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Nursing Care of Patients with Sensory Disorders — Vision and Hearing
Chapter 52 Nursing Care of Patients with Sensory Disorders — Vision and Hearing
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Eye Infections and Inflammation
Conjunctivitis: Inflammation of the Conjunctiva Blepharitis: Inflammation of the Eyelid Margins Hordeolum: Staphylococcal Abscess in Sebaceous Gland
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Eye Infections and Inflammation (cont’d)
Chalazion: Abscess in Meibomian Glands Keratitis: Inflammation of the Cornea
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Nursing Diagnoses Acute Pain Disturbed Sensory Perception
Risk for Injury Risk for Infection Deficient Knowledge
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Refractive Errors Emmetropia: Normal Vision Hyperopia: Farsightedness
Myopia: Nearsightedness Astigmatism: Unequal Curvatures in Cornea Presbyopia: Loss of Lens Elasticity
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Refractive Errors (cont’d)
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Blindness Obstacle to Rays of Light Disease of Optic Nerve or
Tract of Brain Connected with Vision
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Visual Field Abnormalities
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Nursing Diagnoses Disturbed Sensory Perception Self-Care Deficit
Risk for Injury Risk for Impaired Home Maintenance Interrupted Family Processes Ineffective Role Performance
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Nursing Diagnoses (cont’d)
Deficient Knowledge Deficient Diversional Activity Fear
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Diabetic Retinopathy Vascular Changes in Retinal Blood Vessels
Microaneurysms Preproliferative Retinopathy Therapeutic Interventions Laser Photocoagulation Vitrectomy
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Diabetic Retinopathy (cont’d)
Nursing Diagnoses Impaired Home Maintenance Ineffective Therapeutic Regimen Management Disturbed Sensory Perception
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Retinal Detachment Separation of Retina from Choroid Layer of Eye
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Retinal Detachment (cont’d)
Signs and Symptoms Sudden Change in Vision Flashing Lights, Floaters Looking Through a Veil Curtain Being Lowered Over Vision No Pain
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Retinal Detachment (cont’d)
Therapeutic Interventions Laser Reattachment Cryosurgery Scleral Buckling
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Glaucoma Abnormal Pressure Within Eyeball
Damage is Silent, Progressive, Irreversible Lifelong Diagnosis with Tonometry
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Glaucoma (cont’d) Acute Angle-closure
Narrowed Angle Blocks Aqueous Fluid Medical Emergency
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Glaucoma (cont’d) Acute Angle-closure Severe Eye Pain Blurred Vision
Rainbows Around Lights Eye Redness, Steamy Cornea Photophobia, Tearing
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Glaucoma (cont’d) Primary Open-angle
Degenerate of Drainage System Blocks Aqueous Fluid Gradual and Painless
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Glaucoma (cont’d) Primary Open-angle Mild Eye Aching Headache
Halos Around Lights Frequent Visual Changes
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Glaucoma (cont’d) Medications Miotics
Agents to Decrease Production of Aqueous Fluid Mannitol
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Glaucoma (cont’d) Contraindicated in Acute Angle-closure Mydriatics
Can Cause Blindness!
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Glaucoma (cont’d) Surgery Laser Peripheral Iridotomy
Surgical Iridectomy Laser Trabeculoplasty Trabeculectomy Cyclocryotherapy
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Flow of Aqueous Humor After Trabeculoplasty
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Glaucoma (cont’d) Nursing Diagnoses Pain Disturbed Sensory Perception
Self-Care Deficit Anxiety
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Glaucoma (cont’d) Nursing Diagnoses (cont’d) Risk for Injury
Impaired Home Maintenance Deficient Knowledge
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Cataracts Opacity in Eye Lens Causing Loss of Visual Acuity
Halos Around Lights, Difficulty Reading, Sensitivity to Glare, Double Vision, Decreased Color Vision
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Cataracts (cont’d) Surgical Removal of Lens
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Nursing Diagnoses: Eye Surgery
Disturbed Sensory Perception Deficient Knowledge Risk for Infection Risk for Injury Anxiety
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Macular Degeneration
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Macular Degeneration (cont’d)
Deterioration in Macula Wet Dry Slow, Progressive Loss of Central/Near Vision Amsler Grid Detects
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Amsler Grid
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Macular Degeneration (cont’d)
Therapeutic Interventions Wet Laser Treatment Dry None
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Nursing Diagnoses: Macular Degeneration
Disturbed Sensory Perception Self-Care Deficit Risk for Injury Risk for Impaired Home Maintenance Interrupted Family Processes Ineffective Role Performance
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Eye Trauma Emergency Foreign Bodies Burns Abrasions Lacerations
Penetrating Wounds
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Eye Trauma (cont’d) Therapeutic Interventions Foreign Object Chemicals
Irrigate Normal Saline Chemicals 15- to 20-Minute Irrigation
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Eye Trauma (cont’d) Therapeutic Interventions Penetrating Object
Do Not Remove Antibiotic Ointment Surgery
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Eye Trauma (cont’d) Enucleation Entire Eyeball Removal
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Nursing Diagnoses: Eye Trauma
Acute Pain Risk for Infection Anxiety Deficient Knowledge
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Hearing Loss Conductive Hearing Loss
Interference with Sound Conduction to External Auditory Canal, Eardrum, Middle Ear
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Hearing Loss (cont’d) Sensorineural Hearing Loss
Involves Hair Cells and Nerve Endings
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Hearing Loss (cont’d) Presbycusis Aging Process
Degeneration of Organ of Corti Inability to Decipher High-Frequency Sounds
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Hearing Loss (cont’d) Therapeutic Interventions Hearing Aid
Cochlear Implants
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Hearing Aids
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Nursing Diagnoses: Hearing Loss
Disturbed Sensory Perception Impaired Verbal Communication Impaired Social Interaction Disturbed Body Image Ineffective Coping Deficient Knowledge
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External Ear Infections External Otitis Ear Canal Furuncle Ostomycosis
Perichondritis
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External Ear (cont’d) Impacted Cerumen Normally Ear Self-cleaning
Older Adult at Risk Hearing Loss Feeling of Fullness
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External Ear (cont’d) Masses Trauma
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Therapeutic Interventions
Topical Antibiotics Irrigations Analgesics Incision and Drainage
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Nursing Diagnoses: External Ear
Acute Pain Disturbed Sensory Perception Risk for Injury Deficient Knowledge
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Middle Ear Infection Otitis Media
Fever, Earache, and Feeling of Fullness Antibiotics Myringotomy
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Otosclerosis New Bone Along Stapes Conductive Hearing Loss
Women Than in Men Both Ears Hereditary Disease No Cure
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Otosclerosis (cont’d)
Treatment Hearing Aids Ossiculoplasty Stapedectomy
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Nursing Care: Otosclerosis
Operative Ear is Upward When Lying Earplug to Protect Antiemetics Promptly Promote Safety
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Nursing Care: Otosclerosis (cont’d)
Teach Not to Cough, Sneeze Blow Nose Vomit Fly Lift Heavy Objects Shower
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Ear Trauma Tympanic Membrane Perforation Middle Ear Ossicle Fracture
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Ear Trauma (cont’d) Nursing Diagnoses Acute Pain Risk for Infection
Deficient Knowledge
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Inner Ear Labyrinthitis Inflammation or Infection of Inner Ear
Vertigo, Tinnitus, Sensorineural Hearing Loss Antibiotics Sedation Bedrest
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Inner Ear (cont’d) Neoplastic Disorders Acoustic Neuroma
Tumor of the Eighth Cranial Nerve Benign
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Ménière’s Disease Balance Disorder Due to Fluid Disturbance
Triad of Symptoms Vertigo Hearing Loss Tinnitus Episodic Bouts: 2 to 3 Times/Year
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Ménière’s Disease (cont’d)
Acute Treatment Tranquilizers Vagal Blockers Bedrest
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Ménière’s Disease (cont’d)
Prophylactic Treatment Salt-restricted Diet Diuretics Antihistamines Vasodilators
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Ménière’s Disease (cont’d)
Prophylactic Treatment (cont’d) Avoid Alcohol Caffeine Tobacco
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Nursing Diagnoses: Inner Ear
Anxiety Fear Ineffective Role Performance Impaired Social Interaction Grieving Risk for Injury
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Nursing Diagnoses: Inner Ear (cont’d)
Deficient Fluid Volume Imbalanced Nutrition: Less Than Body Requirements Deficient Knowledge
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