Assessing Clients with Eye or Ear Assessing Clients with Eye or Ear DisordersDisorders

Chapter 40Chapter 40

Review of Anatomy and Review of Anatomy and PhysiologyPhysiology

Extraocular StructuresExtraocular Structures– eyebrowseyebrows– eyelidseyelids– eyelasheseyelashes– conjunctivaconjunctiva– lacrimal apparatuslacrimal apparatus– eye muscleseye muscles

Review of Anatomy and Review of Anatomy and PhysiologyPhysiology

Intraocular StructuresIntraocular Structures– sclerasclera– irisiris– pupilpupil– lenslens– retinaretina– optic discoptic disc– anterior and posterior cavityanterior and posterior cavity

VisionVision

1. Light passes through the cornea and is 1. Light passes through the cornea and is focused onto the retina by the lens.focused onto the retina by the lens.

Cells in the retina then transmit this Cells in the retina then transmit this information through optic nerve to the vision information through optic nerve to the vision area of the cortex. area of the cortex.

Review of Anatomy and Review of Anatomy and PhysiologyPhysiology

Optic nervesOptic nerves

RefractionRefraction– bending of light raysbending of light rays– Accommodation- Response of the Accommodation- Response of the

pupil, constrict and dilate.pupil, constrict and dilate.

The Ear and HearingThe Ear and Hearing

External EarExternal Ear– auricle or pinnaauricle or pinna– external auditory canalexternal auditory canal– tympanic membranetympanic membrane– Acoustic antenna, focus Acoustic antenna, focus

Sound waves.Sound waves.

Middle EarMiddle Ear

The middle ear consists of:The middle ear consists of:– The inner part of the ear drum The inner part of the ear drum – The hammer (malleus) The hammer (malleus) – The anvil (incus) The anvil (incus) – The stirrup (stapes) The stirrup (stapes) – Delivers sound to the inner ear where Delivers sound to the inner ear where

it is processed into a signal that the it is processed into a signal that the brain can recognizebrain can recognize

The Ear and Hearing Inner The Ear and Hearing Inner EarEar

The inner ear contains the most important parts of the hearing The inner ear contains the most important parts of the hearing mechanism - two chambers called the vestibular labyrinth mechanism - two chambers called the vestibular labyrinth and the cochlea. and the cochlea.

The vestibular labyrinth consists of elaborately formed canals (3 semicircular tubes that connect to The vestibular labyrinth consists of elaborately formed canals (3 semicircular tubes that connect to one another), which are largely responsible for the sense of balance. one another), which are largely responsible for the sense of balance.

The cochlea, which begins at the oval window, curves into a shape that resembles a snail shell. Tiny The cochlea, which begins at the oval window, curves into a shape that resembles a snail shell. Tiny hairs line the curves of the cochlea. Both the labyrinth and cochlea are filled with various fluids. hairs line the curves of the cochlea. Both the labyrinth and cochlea are filled with various fluids.

Inner EarInner Ear

Hearing and the EarHearing and the Ear

Hearing and the CochleaHearing and the Cochlea The cochlea as microphoneThe cochlea as microphone

When sound waves from the world outside strike the eardrum, it When sound waves from the world outside strike the eardrum, it vibrates. These vibrations from the eardrum pass through the vibrates. These vibrations from the eardrum pass through the three bones of the middle ear and into the inner ear through the three bones of the middle ear and into the inner ear through the oval window. Action of the oval window causes fluids in the oval window. Action of the oval window causes fluids in the cochlea to create waves where they disturb the basilar membrane. cochlea to create waves where they disturb the basilar membrane. Inner hairs attached to the basilar membrane convert the waves Inner hairs attached to the basilar membrane convert the waves into electrical impulses that are transmitted to the brain by the into electrical impulses that are transmitted to the brain by the auditory nerve. auditory nerve. The hair cells are critical to hearing; it is the inner The hair cells are critical to hearing; it is the inner hairs that move in the Organ of Corti fluids, and translate the fluid hairs that move in the Organ of Corti fluids, and translate the fluid movements to chemical messengers that can in turn be converted movements to chemical messengers that can in turn be converted to electrical impulses that the brain understands.to electrical impulses that the brain understands.

Assessment of Eye and Assessment of Eye and EarEar

Health Assessment InterviewHealth Assessment Interview– ask about chief complaintask about chief complaint

Blurred vision?Blurred vision? Eye infection?Eye infection? Halos?Halos? Difficulty reading?Difficulty reading? Difficulty hearing?Difficulty hearing? Ringing in ears?Ringing in ears?

Physical Assessment of Physical Assessment of Eye and VisionEye and Vision

Snellen’s eye chart- Test for vision.Snellen’s eye chart- Test for vision. Assessment of the pupils. Assessment of the pupils. Extra movements of the eyes nystagmus or Extra movements of the eyes nystagmus or

nonnon

Parallel movements strabismus, may indicateParallel movements strabismus, may indicate

disease, cranial nerve dysfunction or muscle disease, cranial nerve dysfunction or muscle weakness and should be reported.weakness and should be reported.

Physical Assessment of Physical Assessment of Eye and VisionEye and Vision

Pupils, Equal Round Reactive to Light Pupils, Equal Round Reactive to Light and Accommodation (PERRLA)and Accommodation (PERRLA)– direct a beam of light into the pupil, look direct a beam of light into the pupil, look

for constrictionfor constriction– hold object a few feet from client, pupils hold object a few feet from client, pupils

should dilate, move closer pupils should should dilate, move closer pupils should constrictconstrict

Inspection - sclera, iris cornea and Inspection - sclera, iris cornea and internal structuresinternal structures

Physical Assessment of Physical Assessment of Ear and HearingEar and Hearing

HearingHearing– Weber testWeber test– Rinne testRinne test– Whisper testWhisper test

InspectionInspection– auricle and external canal- auricle and external canal- – Lesions, drainage, redness, pain.Lesions, drainage, redness, pain.– tympanic membrane- color.tympanic membrane- color.

Disorders of the EyeDisorders of the Eye

Eyelid disorders constantly exposed to the Eyelid disorders constantly exposed to the environment.environment.

Hordeolum- sty is an infection of the sebaceous Hordeolum- sty is an infection of the sebaceous glands of the eyelid. Staphylococcus aureus. glands of the eyelid. Staphylococcus aureus.

Red and painfulRed and painful Conjunctivitis- Inflammation of the conjunctiva Conjunctivitis- Inflammation of the conjunctiva

is common. Direct contact bacterial or viralis common. Direct contact bacterial or viral Also known as “Pink Eye”. Redness, itching, Also known as “Pink Eye”. Redness, itching,

tearing and discharge.tearing and discharge. Gonorrhea and trachoma can damage cornea.Gonorrhea and trachoma can damage cornea.

Eye DisordersEye Disorders Cornea- transmits and helps focus light and Cornea- transmits and helps focus light and

images onto the retina. Protects the internal eye. images onto the retina. Protects the internal eye. The cornea has no blood supply. Scarring or The cornea has no blood supply. Scarring or

ulceration of the cornea can lead to blindness.ulceration of the cornea can lead to blindness. Corneal ulcers caused by infection, trauma or Corneal ulcers caused by infection, trauma or

contact lens. Herpes viruses (shingles) can cause contact lens. Herpes viruses (shingles) can cause corneal ulcers. Can lead to blindness.corneal ulcers. Can lead to blindness.

Nr Care- Prompt treatment to preserve vision.Nr Care- Prompt treatment to preserve vision. Diagnosed by history and examination of the eye.Diagnosed by history and examination of the eye. Topical anti-infectives as eyedrops.Topical anti-infectives as eyedrops.

Eye disordersEye disorders

Corneal Transplant- Corneas taken from Corneal Transplant- Corneas taken from cadavers under the age of 65 who died as a cadavers under the age of 65 who died as a result of trauma or noninfectious illness. result of trauma or noninfectious illness.

Transplant rejection is low cornea has limited Transplant rejection is low cornea has limited blood supply.blood supply.

Graft is sutured in place, for one year.Graft is sutured in place, for one year. Patch for 24 hoursPatch for 24 hours Avoid increasing intraocular pressure.Avoid increasing intraocular pressure. Eye drops to reduce inflammation and prevent Eye drops to reduce inflammation and prevent

infection.infection.

Eye DisordersEye Disorders Soaking the eyelids with warm saline compresses Soaking the eyelids with warm saline compresses

may remove exudates seen in conjunctivitis. may remove exudates seen in conjunctivitis. Eye irrigation with saline is used to remove Eye irrigation with saline is used to remove

purulent discharge with conjunctivitis.purulent discharge with conjunctivitis. Local heat may treat sty.Local heat may treat sty. Infectious eye disorders Nr care focus is on Infectious eye disorders Nr care focus is on

prevention and immediate treatment!prevention and immediate treatment! Prevent complications promote healing. Reduce Prevent complications promote healing. Reduce

pain.pain. Careful and frequent handwashing, not sharing Careful and frequent handwashing, not sharing

towels, make-up. No contacts until healed.towels, make-up. No contacts until healed.

Eye TraumaEye Trauma Foreign bodies, abrasions and lacerations most Foreign bodies, abrasions and lacerations most

common types of eye injury.common types of eye injury. Corneal abrasion- scratch of the corneaCorneal abrasion- scratch of the cornea Burns- chemical, UVBurns- chemical, UV Perforation- metal flakes, weaponsPerforation- metal flakes, weapons Blunt eye trauma- sports injuryBlunt eye trauma- sports injury The extent of the injury is determined by eye exam.The extent of the injury is determined by eye exam. Topical anesthetic, irrigation, surgeryTopical anesthetic, irrigation, surgery NR- Protecting the eye, preserving vision, NR- Protecting the eye, preserving vision,

prevention!prevention!

Refractive ErrorsRefractive Errors

Changes in the shape of the cornea, lens or Changes in the shape of the cornea, lens or eyeball affect the focus of light on the retina. eyeball affect the focus of light on the retina.

Result= blurred or indistinct vision, also called Result= blurred or indistinct vision, also called Refractive errors- Most common cause of Refractive errors- Most common cause of

impaired vision.impaired vision. Myopia- nearsightednessMyopia- nearsightedness Hyperopia- farsightednessHyperopia- farsightedness Detected routine vision screeningDetected routine vision screening Corrected with glasses or contactsCorrected with glasses or contacts Nr- Identify and seek treatment. Safety!!Nr- Identify and seek treatment. Safety!!

CataractsCataracts Clouding of the lens of the eye that impairs vision, Clouding of the lens of the eye that impairs vision,

common over 65yrs.common over 65yrs. As the lens ages its cells become less clear.As the lens ages its cells become less clear. Mature cataract involves entire lensMature cataract involves entire lens Near and distant vision are affected.Near and distant vision are affected. Details become obscuredDetails become obscured Pupil appears cloudy gray or white rather than Pupil appears cloudy gray or white rather than

black.black. Dx: History and eye exam, the red reflex is lost.Dx: History and eye exam, the red reflex is lost. Tx: Surgical removal incision through corneaTx: Surgical removal incision through cornea Intraocular lens is implanted to focus light &vision.Intraocular lens is implanted to focus light &vision.

GlaucomaGlaucoma Increased intraocular pressure and gradual loss of Increased intraocular pressure and gradual loss of

vision. Silent thief of vision.vision. Silent thief of vision. Leading cause of blindness worldwide.Leading cause of blindness worldwide. Normal intraocular pressure is 12-20 mm Hg is Normal intraocular pressure is 12-20 mm Hg is

maintained by a balance between aqueous humor maintained by a balance between aqueous humor production and drainage, disrupted intraocular production and drainage, disrupted intraocular pressure increases.pressure increases.

Open angle – drainage of the aqueous humor Open angle – drainage of the aqueous humor through the trabecular meshwork is impairedthrough the trabecular meshwork is impaired

Angle-closure- Angle between the cornea and iris Angle-closure- Angle between the cornea and iris closes, completely blocking aqueous humor closes, completely blocking aqueous humor drainage.drainage.

GlaucomaGlaucoma Manifestations: DiscussionManifestations: Discussion Glaucoma if not treated can and will lead to Glaucoma if not treated can and will lead to

blindness.blindness. Angle-closure glaucoma can recur thus avoid Angle-closure glaucoma can recur thus avoid

medications that can dilate the pupil. One eye is at medications that can dilate the pupil. One eye is at risk for the other eye.risk for the other eye.

Atropine must be avoided in clients with history of Atropine must be avoided in clients with history of angle-closure glaucoma.angle-closure glaucoma.

Glaucoma cannot be cured, chronic disease can be Glaucoma cannot be cured, chronic disease can be controlled and vision preserved if it is dx and tx.controlled and vision preserved if it is dx and tx.

Routine eye examinations early detection.Routine eye examinations early detection.

GlaucomaGlaucoma Acute angle-closure glaucoma is an ocular Acute angle-closure glaucoma is an ocular

emergency that requires immediate intervention!emergency that requires immediate intervention! Surgery is indicated when chronic open-angle Surgery is indicated when chronic open-angle

glaucoma can not be controlled with medication. glaucoma can not be controlled with medication. Lower intraocular pressure.Lower intraocular pressure. Glaucoma is a chronic disease that requires Glaucoma is a chronic disease that requires

lifelong management. Can lead to blindness if not lifelong management. Can lead to blindness if not identified and treated.identified and treated.

Nursing- Increased risk for injury, psychological Nursing- Increased risk for injury, psychological effects of a chronic disease= anxiety. Early vision effects of a chronic disease= anxiety. Early vision screening!!!!!!!screening!!!!!!!

Detached RetinaDetached Retina Retina contains neurons that allow us to see light Retina contains neurons that allow us to see light

and images. and images. Retina separated from the choroid, the vascular Retina separated from the choroid, the vascular

layer of the eye. Fluid seep between retina and layer of the eye. Fluid seep between retina and choroid, thus separating the layers. The neurons choroid, thus separating the layers. The neurons become ischemic and die causing permanent vision become ischemic and die causing permanent vision loss.loss.

Can occur spontaneously or from trauma as we age Can occur spontaneously or from trauma as we age it increases our risk for detached retina.it increases our risk for detached retina.

Medical emergencyMedical emergency CM- painless, floaters, flashes of light. Dx- eye CM- painless, floaters, flashes of light. Dx- eye

examination. Surgical procedures.examination. Surgical procedures.

Detached retinaDetached retina

Early identification is a priority for Early identification is a priority for the nurse! May have gradual loss the nurse! May have gradual loss of vision.of vision.

The affected area of the eye The affected area of the eye inferior to maintain contact inferior to maintain contact between the retina and choroid.between the retina and choroid.

Macular DegenerationMacular Degeneration

Neurons of the macula may atrophy with age or Neurons of the macula may atrophy with age or separate from the choroid. May cause blindness.separate from the choroid. May cause blindness.

Smoking, over 65 yrs, family hx.Smoking, over 65 yrs, family hx. Central vision becomes blurred, peripheral vision Central vision becomes blurred, peripheral vision

remains intact. One eye common early remains intact. One eye common early symptom.symptom.

Any change in vision needs evaluation!!!!!! Any change in vision needs evaluation!!!!!! Nursing!Nursing!

Laser treatment may slow the process. Early Laser treatment may slow the process. Early treatment may help slow disease and preserve treatment may help slow disease and preserve vision.vision.

Diabetic RetinopathyDiabetic Retinopathy 85% of diabetics will develop85% of diabetics will develop The capillaries of the retina are no longer able to The capillaries of the retina are no longer able to

transport blood and oxygen to the retina.transport blood and oxygen to the retina. Develops 15 years after being diagnosed either type Develops 15 years after being diagnosed either type

one or type 2 diabetes.one or type 2 diabetes. Initially venous capillaries dilate and develop Initially venous capillaries dilate and develop

microscopic aneurysms may leak or rupture; thus microscopic aneurysms may leak or rupture; thus edema and small hemorrhages into the retina. Areas edema and small hemorrhages into the retina. Areas become ischemic. New blood vessels form causing become ischemic. New blood vessels form causing more damage. more damage.

Nr- Education, yearly eye exam, spots, loss of vision.Nr- Education, yearly eye exam, spots, loss of vision.

Ear DisordersEar Disorders

External otitis- or swimmers ear affect sound External otitis- or swimmers ear affect sound conduction and hearing. Inflammation of the conduction and hearing. Inflammation of the ear canalear canal

Risk; swimmers, divers surfers, hearing aids or Risk; swimmers, divers surfers, hearing aids or earplugs.earplugs.

Caused by bacteriaCaused by bacteria Remove earwax and cleaning and drying ear Remove earwax and cleaning and drying ear

canal.canal. CM- Pain, drainage, inflammation and swellingCM- Pain, drainage, inflammation and swelling Management- DiscussionManagement- Discussion

Impacted CerumenImpacted Cerumen

Older adults are at risk for impaced cerumenOlder adults are at risk for impaced cerumen Interferes with sound conduction and hearing.Interferes with sound conduction and hearing. Tinnitus is a clinical manifestationTinnitus is a clinical manifestation Can be seen using an otoscopeCan be seen using an otoscope Clearing with irrigation ear curet or forcepsClearing with irrigation ear curet or forceps Prevention is the focus of Nursing! No Q-tips.Prevention is the focus of Nursing! No Q-tips.

Otitis MediaOtitis Media Inflammation or infection of the middle ear.Inflammation or infection of the middle ear. Most common middle ear disorder.Most common middle ear disorder. Infants and young children. Adults too.Infants and young children. Adults too. Organisms can enter the middle ear from the nose Organisms can enter the middle ear from the nose

and throat through the eustachian tubeand throat through the eustachian tube Eardrum protects middle ear from the Eardrum protects middle ear from the

environment.environment. CM- Red, bulging tympanic membrane. Pain, with a CM- Red, bulging tympanic membrane. Pain, with a

URI. Swelling of the ET impairs drainage of the URI. Swelling of the ET impairs drainage of the middle ear, fluid collects with bacteria. Fever. middle ear, fluid collects with bacteria. Fever.

Complications: discussion. DX- Otoscope eardrum.Complications: discussion. DX- Otoscope eardrum.

OtosclerosisOtosclerosis

Genetic, hereditary disorder affects white Genetic, hereditary disorder affects white females.females.

Abnormal bone forms in the stapes and causes Abnormal bone forms in the stapes and causes a conductive hearing loss.a conductive hearing loss.

CM- hearing loss begins in adolescence or CM- hearing loss begins in adolescence or early adulthood. Tinnitusearly adulthood. Tinnitus

Management- Surgical reconstruction of the Management- Surgical reconstruction of the middle ear.middle ear.

Nursing- Referral to appropriate community Nursing- Referral to appropriate community agencies to evaluate hearing loss.agencies to evaluate hearing loss.

Inner Ear DisordersInner Ear Disorders Occur less frequently than other ear disorders:Occur less frequently than other ear disorders: Labyrinthitis Labyrinthitis Meniere’s disease.Meniere’s disease. Vertigo is the KEY symptom of inner ear disorders.Vertigo is the KEY symptom of inner ear disorders. Contains the semicircular canals that help Contains the semicircular canals that help

maintain balance and neural receptors for maintain balance and neural receptors for hearing. Thus may cause permanent hearing loss.hearing. Thus may cause permanent hearing loss.

Labyrinthitis- inflammation of the inner earLabyrinthitis- inflammation of the inner ear Bacterial or virusBacterial or virus CM- severe vertigo, NV, nystagmus. Falling!CM- severe vertigo, NV, nystagmus. Falling!

Inner Ear disordersInner Ear disorders Meniere’s Disease- chronic inner ear disorder caused Meniere’s Disease- chronic inner ear disorder caused

by excess fluid and pressure in the labyrinth of the by excess fluid and pressure in the labyrinth of the inner ear.inner ear.

Gradual or suddenGradual or sudden Vertigo, tinnitus and gradual hearing lossVertigo, tinnitus and gradual hearing loss No cureNo cure TX- Decrease inner ear pressure hydrochlorothiazide.TX- Decrease inner ear pressure hydrochlorothiazide. Meds to relieve vertigo Vistaril, compazine.Meds to relieve vertigo Vistaril, compazine. Avoid caffeine, alcohol and tobacco.Avoid caffeine, alcohol and tobacco. May need surgery to relieve excess pressure .May need surgery to relieve excess pressure . Nr- discussion risk for injury! Evaluate vertigo, HL.Nr- discussion risk for injury! Evaluate vertigo, HL.

Hearing LossHearing Loss

10 million adults in the US are hearing 10 million adults in the US are hearing impairedimpaired

70% of older adults70% of older adults Conductive hearing loss- Anything that impairs Conductive hearing loss- Anything that impairs

sounds transmission from the external opening sounds transmission from the external opening of the ear to the inner ear. Impacted cerumen of the ear to the inner ear. Impacted cerumen most common. Perforated eardrum, tumor of most common. Perforated eardrum, tumor of middle ear.middle ear.

Hearing aid would be of benefit.Hearing aid would be of benefit.

Hearing LossHearing Loss Sensorineural Hearing Loss- Disorders that affect Sensorineural Hearing Loss- Disorders that affect

the inner ear or the auditory pathways of the brain.the inner ear or the auditory pathways of the brain. Trauma, infection, Meniere’s disease, ototoxic Trauma, infection, Meniere’s disease, ototoxic

medications, prenatal exposure to rubella.medications, prenatal exposure to rubella. US- Noise exposure is the major cause of US- Noise exposure is the major cause of

sensorineural hearing loss. Exposure to high level of sensorineural hearing loss. Exposure to high level of noise damages the hair cells of the inner ear.noise damages the hair cells of the inner ear.

Affects the ability to hear high-frequency sounds Affects the ability to hear high-frequency sounds more than low. Speech discrimination and more than low. Speech discrimination and communication noisy places. Hearing aids may not communication noisy places. Hearing aids may not help. Why? Nr- Social isolation, type HL, finances. help. Why? Nr- Social isolation, type HL, finances. EdEd