1. Visual and Auditory Problems
Zoya Minasyan, RN, MSN-Edu

2. Structures and Functions of Visual System

3. Assessment of Visual Systems
Magnified view of retina through the ophthalmoscope.

4. Structures and Functions of Visual System
External eye and lacrimal apparatus. Tears produced in the lacrimal gland pass over the surface of theeye and enter the lacrimal canal. From there the tears are carried through the nasolacrimal duct to the nasal cavity.

5. Structures and Functions of Visual System
External Structures and Functions, continued
Conjunctiva
Sclera
Cornea
Lacrimal apparatus
Extraocular muscles
Internal Structures and Functions
Iris
Lens
Ciliary body
Choroid
Retina

6. Gerontologic Considerations: Effects of Aging on Visual Systems
Arcus senilis. Age-related degeneration of the cornea.

7. Cataract Opacity within lens Leading cause of blindness
The patient may have a cataract in one or both eyes.
Leading cause of blindness
Most common surgical procedure for those aged over 65

8. Etiology and Pathophysiology
Influencing factors
Age
Blunt trauma
Congenital factors
Radiation/UV light exposure
Long-term corticosteroid use
Ocular inflammation
Senile cataract
Most common type
Altered metabolic processes cause
Accumulation of water
Altered lens fiber structure

9. Clinical Manifestations
Decrease in vision
Abnormal color perception
Glaring of vision
Glare is due to light scatter caused by lens opacities, and it may be significantly worse at night when the pupil dilates.
Secondary glaucoma can also occur if the enlarging lens causes increased intraocular pressure (IOP).

10. Diagnostic Studies History and physical examination
Visual acuity measurement
Ophthalmoscopy
Glare testing

11. Collaborative Care Nonsurgical therapy
The patient may be willing to adjust his or her lifestyle to accommodate for visual decline. For example, if glare makes it difficult to drive at night, a patient may elect to drive only during daylight hours or to have a family member drive at night.
Visual aids (palliative)
Changing eyewear prescription
Reading glasses
Magnifiers
Increased lighting

12. Surgical Therapy Preoperative phase History and physical assessment
Antibiotic eyedrops
Dilating eyedrops

13. Surgical Therapy
The patient’s occupational needs and lifestyle changes are factors affecting the decision to have surgery.
Preoperative Phase
local anesthesia,
most cataract patients are older adults and may have several medical problems that should be evaluated and controlled before surgery.
Almost all patients with cataracts are admitted to a surgical facility on an outpatient basis.
Dilating drops and a nonsteroidal antiinflammatory eyedrop are used to reduce inflammation and to help maintain pupil dilation.
for dilation -mydriatic, an α-adrenergic agonist that produces pupillary dilation by contraction of the iris dilator muscle.
Another type of drug is a cycloplegic, an anticholinergic agent that produces paralysis of accommodation (cycloplegia) by blocking the effect of acetylcholine on the ciliary body muscles.

14. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Surgical Therapy
Intraoperative phase
Corneoscleral incision
Cataract extracted and sutured
Cortex irrigated and aspirated
Corticosteroid ointment applied with protective shield
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

15. Surgical Therapy
Cataract extraction is an intraocular procedure. Rarely, intracapsular extraction is performed, in which the entire lens is removed with the capsule intact (this procedure may be necessary in instances of trauma). More commonly, extracapsular extraction is done, in which the anterior capsule is opened and the lens nucleus and cortex are removed, leaving the remaining capsular bag intact.
In extracapsular extraction, the surgeon can remove the lens nucleus by “scooping” it out with a lens loop, or by phacoemulsification, in which the nucleus is fragmented by ultrasonic vibration and is aspirated from inside the capsular bag.
In either case, the remaining cortex is aspirated with an irrigation and aspiration instrument. Placement and type of incision vary among surgeons.
At the end of the procedure, additional medications such as antibiotics and corticosteroids may be administered.16 Depending on the type of anesthesia, the patient’s eye may be covered with a patch or protective shield. If used, the patch/protective shield usually is worn overnight and is removed during the first postoperative visit.

16. Implementation of Intraocular Lens
Intraocular lens implant after cataract surgery. Almost all patients now have an intraocular lens implanted at the time of cataract extraction surgery. Because most patients have an extracapsular procedure, the lens of choice is a posterior chamber lens that is implanted in the capsular bag behind the iris.

17. Surgical Therapy Postoperative phase
Outpatient procedure unless complications occur
Antibiotic and corticosteroid eyedrops
to prevent infection and to decrease the postoperative inflammatory response.
Limiting activities
avoid activities that increase the IOP, such as bending or stooping, coughing, or lifting.
Follow-up visits
The ophthalmologist usually will see the patient 2 to 3 times throughout the 6 to 8 weeks following surgery

18. Nursing Management Assessment
Visual acuity
Psychosocial impact of visual disability
Level of knowledge of disease
Comfort and ability to comply with postop treatment

19. Nursing Management Nursing Diagnoses
Self-care deficits
Anxiety

20. Nursing Management Planning
Preoperative goals
Make informed decisions regarding therapeutic options.
Experience minimal anxiety.
Postoperative goals
Understand and comply with postoperative therapy.
Maintain level of comfort.
Remain free of infection and other complications.

21. Nursing Management Implementation
Health promotion
Wear sunglasses.
Avoid unnecessary radiation.
Adequate antioxidant vitamins (e.g., vitamins C and E)
Ensure good nutrition.

22. Nursing Management Implementation
Acute intervention
Educate about disease process and treatment options.
the patient needs to know that without surgery, some degree of visual disability will occur. Be available to give the patient and the family information to help them make an informed decision about appropriate treatment.
Administer medication.
Photophobia is common; therefore decreasing the room lighting is helpful. These medications produce transient stinging and burning.
Inform those with patch that they will not have depth perception until their patch is removed.
This necessitates special considerations to avoid possible falls or other injuries. The patient with significant visual impairment in the un-operated eye requires more assistance while the operative eye is patched. Once the patch is removed (usually within 24 hours), most patients with visual impairment in the un-operated eye will have adequate vision for necessary activities
Ensure little to no pain.
Teach signs and symptoms of infection.
of increased or purulent drainage, increased redness, or any decrease in visual acuity.

23. Nursing Management Implementation
Ambulatory and home care
Activity restrictions
Medications
Follow-up visits
Signs and symptoms of possible complications
Educate on postoperative visual acuity.
Instruct family to modify activities and environment.
Remove area rugs.
Prepare frozen meals.
Provide audio books.

24. Nursing Management Evaluation
Expected outcomes
Improved vision
Ability to care for self
Minimal to no pain
Optimistic expectations

25. Glaucoma A group of disorders characterized by
Increased IOP and consequences of elevated pressure
Optic nerve atrophy
Peripheral visual field loss

26. Etiology and Pathophysiology
Balance between aqueous production and reabsorption needed for normal level of IOP
Glaucoma related to elevation of IOP

27. Etiology and Pathophysiology
Primary open-angle glaucoma (POAG)
Most common type of glaucoma
Outflow of aqueous humor is ↓, the drainage channels become clogged, like a clogged kitchen sink. Damage to the optic nerve can then result.

28. Etiology and Pathophysiology
Primary angle-closure glaucoma (PACG)
Angle closure ↓ the flow of aqueous humor
Caused by age, pupil dilation(it causes peripheral iris bulging forward and blocking the outflow channels
Possibly drug induced
An acute attack may be precipitated by situations in which the pupil remains in a partially dilated state long enough to cause an acute and significant rise in IOP. This may occur because of drug-induced mydriasis (dilation), emotional excitement, or darkness.
Check drug records and documentation before administering medications to the patient, and instruct the patient not to take any mydriatic-producing medications.

29. Etiology and Pathophysiology
Secondary glaucoma
Results from other ocular or systemic conditions that block outflow
Associated with inflammatory processes

30. Clinical Manifestations
POAG
Develops slowly
No symptoms
Unnoticed until all peripheral vision is lost“tunnel vision,” in which only a small center field can be seen and all peripheral vision is absent.

31. Clinical Manifestations
Acute angle-closure glaucoma
Sudden excruciating pain around eyes
Nausea and vomiting
Seeing colored halos around lights
Blurred vision
Ocular redness
Corneal edema
IOP elevated in glaucoma
Normal IOP 10 to 21 mm Hg
Open-angle glaucoma 22 to 32 mm Hg
Acute angle-closure glaucoma >49 mm Hg

32. Diagnostic Studies
Gonioscopy (allows better visualization of the anterior chamber angle)
Peripheral and central vision test
Ophthalmoscopy (The optic disc becomes wider, deeper, and paler (light gray or white). This is visible with direct or indirect ophthalmoscopy)

33. Ophthalmoscopy
In the normal eye, the optic cup is pink with little cupping. B, In glaucoma, the optic disc is bleached and optic cupping is present. (Note the appearance of the retinal vessels, which travel over theedge of the optic cup and appear to dip into it.)

34. Collaborative Care Chronic open-angle glaucoma Drug therapy
Argon laser trabeculoplasty
Therapeutic option to lower IOP
Laser stimulates scarring and contraction of trabecular meshwork
Trabeculectomy
removal of part of iris and trabecular meshwork
Implant
Reserved for patients in whom filtration surgery has failed
Permanent surgical placement of small drainage tube and reservoir
General glaucoma
The primary focus of glaucoma therapy is to keep the IOP low enough to prevent the patient from developing optic nerve damage. This damage is manifested by increasing visual field loss and progressive optic disc cupping. Specific therapies vary with the type of glaucoma.

35. Collaborative Care Acute angle-closure glaucoma
Miotics ( constriction of the pupils of the eyes)
Oral/IV hyperosmotic
Laser peripheral iridotomy
Surgical iridectomy
These procedures allow the aqueous humor to flow through a newly created opening in the iris and into normal outflow channels. One of these procedures may also be performed on the other eye as a precaution, because many patients often experience an acute attack in the other eye.

36. Collaborative Care Secondary glaucoma
Managed by treating underlying problems
Antiglaucoma medication
If treatment fails, glaucoma can progress to absolute glaucoma, resulting in a hard, sightless, and usually painful eye requiring enucleation (surgical removal of the eye).

37. Nursing Management Nursing Implementation
Health Promotion
Teach patient and family risks of glaucoma.
Loss of vision due to glaucoma is a preventable problem.
Stress importance of early detection.
the incidence of glaucoma increases with age
Provide ophthalmologic examination.
The current recommendation is for an ophthalmologic examination every 2 to 4 years for persons between ages 40 and 64 years, and every 1 to 2 years for persons age 65 years or older.

38. Nursing Management Nursing Implementation
Acute Intervention
Administer medication to lower IOP.
Darken the environment.
Apply cool compresses to the patient’s forehead.
Provide quiet space.
For surgical patients
Provide postop instructions.
Relieve discomfort.
Ambulatory and Home Care
Encourage patient to follow therapy.
Educate on disease process and treatments.
Discuss follow-up appointments.
Provide verbal and written instructions.

39. Nursing Management Evaluation
Expected Outcomes
No further loss of vision
Compliance with recommended therapy
Safe functioning in the environment
No pain from disease and surgery

40. Retinal Detachment
Is a separation of retina and epithelium with fluid accumulation between the two layers.
Risk factors: increasing age, eye trauma, cataract or glaucoma, family Hx
Symptoms: photopsia-light flashes, floaters, ring in the field of vision, painless loss of peripheral or central vision, “ like a curtain” coming across the field of vision.
Care: Surgical therapy

41. Inflammation and Infection
Hordeolum (sty)
Staph aureus- infection of the sebaceous glands in the lid margin
Chalazion
Inflammation in meibomian (sebaceous) glands in the lid, can be b/c of sty
Blepharitis
Scales or crusts on the lid and lashes. Burning, irritation photophobia, caused by staph infections
Conjunctivitis (infection or inflammation)
Bacterial infections (pink eye-influenza and pneumonia)
Viral infections ( foreign body sensation, redness)
Chlamydial infections 
Allergic conjunctivitis

42. Inflammation and Infection
Hordeolum (sty) on the upper eyelid caused by staphylococcal infection.

43. Inflammation and Infection
Keratitis- involved conjunctiva and/or the cornea
Bacterial infections
Viral infections
Other causes of keratitis 
Corneal ulcer

44. Inflammation and Infection
Corneal ulcer. Infection associated with poor contact lens care.

45. Strabismus
Is a condition in which patient cannot focus two eyes simultaneously on the same object.

46. Myopia- nearsightness; light rays to be focused in front of the retina (distant objects cannot be seen sharply)
Hyperopia- farsightness; light rays to be focus behind the retina (difficulty focusing on near objects, and in extreme cases unable to focus on objects at any distance)
Presbyopia- by aging less elastic lens and decrease eye accomodation (difficulty seeing in dim light, problems focusing on small objects and/or fine print )
Astigmatism-irregular corneal curvature, blurred vision

47. Structures and Functions of Auditory System
External, middle, and inner ear.

48. Structures and Functions of Auditory System
External Ear
Middle Ear
Inner Ear
Transmission of sound

49. Assessment of Auditory System
Normal Physical Assessment of Auditory System.

50. Assessment of Auditory System
The tympanic membrane. A, Landmarks of right tympanic membrane. B, Normal-appearing
tympanic membrane. C, Perforated tympanic membrane.

51. Presbycusis: hearing loss due to aging
Tinnitus: ringing in the ears- due to aging
Vertigo: person or objects around the person are moving or spinning or stimulated by the movement of the head