0133427269 Module18 SensoryPerception LectureOutline

Module 18 Sensory Perception The Concept of Sensory Perception Sensory organs provide pathways for stimuli to reach the brain The five senses -- vision, hearing, touch, smell, taste are essential for growth, development, and survival Sensory perception is protective Normal sensory perception Sensory reception ( the process of receiving stimuli External stimuli ( visual, auditory, olfactory, tactile, gustatory Internal stimuli ( gustatory, kinesthetic, stereogenesis, visceral Four aspects of sensory process Stimulus Receptor Impulse conduction See Figure 181 THE NERVE IMPULSES RUN ALONG, p. 1278 See Table 181 CRANIAL NERVES AND THEIR FUNCTIONS, p.1279 Perception Brain has capacity to adapt to sensory stimuli Awareness ( ability to perceive environmental stimuli and body reactions and to respond appropriately through thought and action Alterations of sensory perception Alterations and manifestations Vertigo ( feeling of rotation or imbalance Color blindness Impaired sense of smell Taste disturbances See CONCEPTS RELATED TO SENSORY PERCEPTION, p. 1280 See ALTERATIONS AND THERAPIES Sensory Perception, p. 1281 Genetic considerations and nonmodifiable risk factors Congenital and hereditary conditions Many conditions lead to temporary or permanent impairment Premature infants at high risk for visual and/or hearing problems 50 of all hearing loss at birth linked to genetic abnormalities Older adults ( prevalence of some visual disorders have cultural or genetic component Illness Certain diseases such as atherosclerosis or hypertension contribute to sensory impairment Case Study Part 1 ( Simon Thompson is a 10-year-old Caucasian male who is currently in the fifth grade , p. 1282 Prevention Modifiable risk factors Smoking ( causes problems with taste, smell, and vision UV light exposure ( can cause serious eye problems Medication ( can decrease awareness of stimuli Stress ( increased stress can overload the senses Isolation ( importance of touch in early life Injuries ( may damage sensory organs Many eye injuries are minor, but without timely and appropriate intervention, vision is threatened Ear injuries are common in children Screenings Often, sensory changes happen very slowly or without the client noticing any symptoms Careful routine screening Hearing Most newborns are screened for hearing loss before leaving the hospital Most preschoolers and school-age children are screened at school or at well-child check-ups Adults should be screened at least every 10 years until age 50, and then every 3 years Vision All children between ages 3 and 5 should receive vision screening at least once Most children receive screening at school Adults should be screened anually or bi-annually Annual screens recommended for adults with diabetes or hypertension Taste, smell, and touch Currently no recommended screening guidelines Most alterations are found when clients present with complaints Assessment Nursing assessment Present sensory perception, usual functioning, sensory deficits, potential problems See ASSESSMENT INTERVIEW Sensory-Perceptual Functioning, p. 1284 Mental status and cognition Recent history of mood swings, delirium, orientation, memory, attention span Client environment Quantity, quality, type of stimulation Restricted physical activity Limited social contact Radio, auditory device Clock or calendar Reading material for adults, toys for children Number and compatibility of roommates Number of visitors Note excessive stimuli in healthcare environment Social support network Degree of isolation ( lives alone, visitors, signs of social isolation Physical assessment Vision, hearing, olfactory, gustatory, tactile, kinesthetic senses Visual acuity ( Snellen chart Hearing acuity( observing clients conversation with others, whisper test Olfactory ( identifying specific aromas Gustatory sense ( three tastes ( lemon, salt, sugar Tactile ( light touch, sharp and dull sensation, two-point discrimination, hot and cold sensation, vibration sense, position sense, stereognosis Determine if adaptive devices used and functioning properly Eye and vision assessment Snellen chart or Rosenbaum chart Cardinal fields of vision Internal structures of the eye See EYE AND VISION ASSESSMENT, page 1286 Ear and hearing assessment Inspection of external ear Otoscope to inspect external auditory canal and tympanic membrane Presence of cerumen Whisper test Tuning fork See EAR AND HEARING ASSESSMENT, p. 1292 Taste and smell assessment Often not adequately tested Inspect mucous membranes Test familiar smells ( alcohol swab, vanilla See CRANIAL NERVE ASSESSMENT, p. 1294 See LIFESPAN CONSIDERATIONS Assessing Sensory Function in Children, p. 1291 Other diagnostic tests Used to diagnose specific injury, disease, vision problems Provide information to identify or modify assistive devices Monitor client response to treatment, nursing care interventions Case Study Part 2 ( Simon has been trying to ignore the teasing from his sister and her friends , p. 1294 Interventions and therapies Independent Assess clients understanding of alterations and treatments Client teaching is essential Common outcomes Preventing injury Maintaining function of existing senses Developing effective method of communication Preventing sensory overload or deprivation Reducing social isolation Performing ADLs independently and safely Promoting healthy sensory function Children with chronic ear infections, noisy environment ( routine auditory testing Environmental stimuli that provide appropriate sensory input ( neither excessive nor too limited Teach clients at risk of sensory loss ( how to prevent, reduce loss Preventing sensory overload Assist with reducing number and type of environmental stimuli Dark glasses, window shade Earplugs Minimize odor from draining wound Preventing sensory deprivation Increase environmental stimulation Arrange for visitors Managing acute sensory deficits Encourage use of sensory aids Service dogs Home and healthcare settings See Box 181 SENSORY AIDS FOR VISUAL AND HEARING DEFICITS, p. 1296 Promoting use of other senses Teach client to use other senses to supplement loss Music, clocks that chime, variety in diet Flowers, candles Touch Communicating effectively Convey respect, enhance persons self-esteem, ensure exchange of correct information See Box 182 COMMUNICATING WITH CLIENTS WHO HAVE A VISUAL OR HEARING DEFICIT, p. 1297 Promoting effective coping Moderate to acute sensory deficits impact quality of life Mobility, ADLs, and independence are affected Impaired vision Greater disability on ADLs Increased risk of depression among older adults Affects how individuals obtain information Safe environment includes Uncluttered environment Clear pathways Organizing self-care articles within clients reach Orienting client to new location when traveling, running errands Keeping call lights, assistive devices within easy reach Assisting with ambulation by standing at clients side, walking about 1 foot ahead, allowing person to grasp arm Impaired hearing Assessed frequently ( cannot hear alarms At home ( amplify sounds, flashing light ( doorbell, smoke detector, baby crying, burglar alarm Impaired olfactory sense Dangers of cleaning with chemicals Gas leak Food poisoning Impaired tactile sense Hot temperatures Pressure Collaborative Based on cause and severity of problem Clients are referred to specialists and ancillary services Pharmacologic therapy Eye vulnerable to many conditions ( many can be prevented, controlled, reversed with proper treatment Glaucoma ( controllable with medication Macular degeneration ( can be slowed Olfactory impairment ( may be resolved by treating underlying cause of impairment Review The Concept of Sensory Perception Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part 3 ( Simon has been instructed to keep his eye patch on for 3 days , p. 1298 Exemplar 18.1 Hearing Impairment Overview Approximately 1 million children in U.S., about 36 million adults (17 of adults) have some form of hearing impairment Impairs ability to communicate in a world filled with sound, hearing individuals Partial or total, congenital or acquired See Table 182 SEVERITY OF HEARING LOSS, p. 1299 Pathophysiology and etiology Etiology Lesions, aging, conductive, sensorineural or mixed Conductive hearing loss Anything that disrupts transmission of sound from external auditory meatus to inner ear Most common ( obstruction Perforation of tympanic membrane, disruption of ossicles, fluid, scarring, tumors of middle ear Chronic untreated middle ear infections Sensorineural hearing loss Disorders that affect inner ear, auditory nerve auditory pathways of brain Significant cause of sensorineural hearing deficit ( damage to hair cells of organ of Corti ( noise exposure Ototoxic drugs Tumors, vascular disorders, demyelinating or degenerative diseases, infections Presbycusis With aging ( hair cells of cochlea degenerate Higher pitched tones, conversational speech lost initially Risk factors 50 of hearing loss in children genetically caused 25 is due to environmental causes around time of birth Other risk factors Positive titer for TORCH infections Craniofacial abnormalities Very low birth weight Bilirubin greater than 16 mg/dL Aminoglycocide medication administration for more than 5 days Low Apgar score at 1 or 5 minutes Bacterial meningitis Mechanical ventilation for over 5 days Presence of syndromes associated with hearing loss Prevention Both loudness and length of exposure contribute to hearing damage Hearing impairment from use of ear buds or head phones can affect individuals of any age group Noise-induced hearing loss (NIHL) ( serious public health concern Medications can cause hearing loss ( see Table 18-4 OTOTOXIC MEDICATIONS, p. 1300 Clinical manifestations Symptoms Conductive hearing loss involves equal loss of hearing at all sound frequencies Sensorineural typically affects ability to hear high-frequency tones more than low-frequency tones ( speech discrimination difficult Presbycusis ( gradual ( may be described as unsociable or paranoid, forgetful, absentminded, senile May also be depressed, confused, inattentive Functional problems Tinnitus Perception of sound or noise without stimulus from environment Usually associated with hearing loss Often early symptom of noise-induced hearing damage, drug-related ototoxicity Early identification of hearing loss key element in successful treatment See CLINICAL MANIFESTATIONS AND THERAPIES Hearing Impairment, p. 1301 Collaboration Diagnostic tests See EAR AND HEARING ASSESSMENT, p. 1292 Surgery Reconstructive surgeries of middle ear ( may help restore conductive hearing loss Stapedectomy Tympanoplasty Cochlear implant Microphone, speech transmitter, receiver/stimulator, electrodes Function similar to way ear normally receives and processes sounds See Figure 189 A COCHLEAR IMPLANT, p. 26 Provide sound perception but not normal hearing Pharmacologic therapy Hearing loss from upper respiratory infections or seasonal allergies( decongestants Sudden sensorineural hear loss ( steroids Otitis media ( antibiotics See MEDICATIONS TEMPORARY HEARING LOSS, p. 1303 Nonpharmacologic therapy Amplification Hearing aid, amplification device ( do not prevent, minimize or treat hearing loss ( amplify sound presented Fewer than 20 of older clients with hearing deficit have or use hearing aid All hearing aids include microphone, amplifier, speaker, earpiece, volume control Canal hearing aids ( least noticeable, fitting in ear canalfor mild to moderately severe hearing loss In-ear style ( fits into external earfor mild to severe hearing loss See Figure 1810 AN IN-EAR HEARING AID, p. 1303 Behind-ear hearing aid ( allows finer adjustment of level of amplification, easier for client to manipulate See Figure 1811 A BEHIND-EAR HEARING AID, p. 1303 Body hearing aid ( profound hearing loss Assistive listening device Ear piece and external microphone White noisemasking device for clients with tinnitus TTD/TTY telephones, phones available to assist deaf/hearing impaired clients in communicating with outside world Internet accessibility ( good communication mode for those with hearing impairment Additional therapies For those with uncorrectable hearing loss ( Speech therapy Lip reading Signing Cuing Finger-spelling See Table 185 COMMUNICATION TECHNIQUES FOR CLIENTS WHO HAVE A HEARING IMPAIRMENT, p. 1302 Nursing process Assessment Health history Physical examination Diagnoses Risk for Injury Impaired Verbal Communication Social Isolation Planning Client will remain free from injury Client will wear hearing protection and have no further loss of hearing client will find best method of communication Client will remain involved in the community and not experience social isolation Implementation Promote optimal wellness Encourage client to talk about the hearing loss, its effect on ADLs Provide information about type of hearing loss Replace batteries in hearing aids regularly and as needed If hearing aid has toggle switch for microphone/telephone, be sure it is in appropriate position Talk with family members about techniques to facilitate communication Facilitate communication Use following techniques to improve communication Wave hand, tap the shoulder before beginning to speak If client wears corrective lenses, ensure that they are clean, encourage client to wear them When speaking, face client, keep hands away from face Keep face in full light Reduce noise in environment before speaking Use low voice pitch with normal loudness Use short sentences and pause at end of each sentence Speak at normal rate, do not overarticulate Use facial expressions or gestures Provide magic slate for written communication Be sure hearing aid is properly placed, turned on, has fresh batteries Do not place IV catheters in dominant hand Rephrase sentences when client has difficulty understanding Repeat important information Inform other staff about clients hearing deficit and effective strategies for communication Encourage socialization Identify the extent and cause of the social isolation Encourage client to interact with friends and family on a one-to-one basis in quiet settings Treat client with dignity and remind friends and family that hearing deficit does not indicate loss of mental faculties Involve client in activities that do not require acute hearing, such as checkers, chess Obtain a pocket talker or encourage client and family to do so Refer the client to an audiologist for evaluation and possible hearing-aid fitting Refer to resources such as support groups, senior citizen centers Community-based care Teaching focuses on managing the deficit and developing coping strategies Evaluation Client will demonstrate successful establishment of a communication method Client will manifest growth and developmental milestones to maximum potential Client and family will demonstrate positive methods of coping Review Hearing Impairment Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 18.2 Cataracts Cataract ( opacification of the lens of the eye Pathophysiology and etiology Pathophysiology Majority of cataracts ( senile cataracts, result of aging process Four types occur independent of aging process Secondary cataracts ( can form after surgery to treat another eye disorder Traumatic cataracts Radiation cataracts Congenital cataracts Etiology 50 adults aged 65 to 74 are affected 70 adults aged 70 and over Risk factors Age Genetics Environmental Ultraviolet B (UVB) Smoking, alcohol consumption Eye trauma Diabetes mellitus Certain drugs Clinical manifestations Tend to occur bilaterally at different rates Light rays scattered as they pass through lens Diagnosis made on history, eye examination Opthalmoscopy reveals dark area instead of red reflex See CLINICAL MANIFESTATIONS AND THERAPIES Cataracts, p. 1307 Collaboration Diagnostic tests Visual acuity test Dilated eye exam Surgery Surgical removal only treatment at this time Indicated when cataract has developed to point that vision, ADLs affected Typically outpatient using local anesthesia Extracapsular extraction procedure of choice See Figure 1812 EXTRACAPSULAR CATARACT EXTRACTION, p. 1308 After removal of lens ( polymethylmethacrylate intraocular lens implanted at time of surgery If lens cannot be implanted ( convex corrective glasses or contact lenses may be used to correct vision Complications unusual Loss of vitreous humor, corneal edema, increased intraocular pressure, hemorrhage, inflammation or infection, retinal detachment, displacement of implanted lens Up to 35 develop opacification of remaining posterior capsule Nonpharmacologic therapy Magnifying glasses Stronger prescription lenses Brighter lighting Antiglare sunglasses Complementary and alternative therapies Insufficient data to support treatment of cataracts with alternative therapies Nursing process Assessment Health history ( lifestyle, activities Physical examination ( presence of red reflex Diagnosis Risk for Injury Decisional Conflict Cataract Removal Risk for Ineffective Therapeutic Regimen Management Planning Client will remain free from injury Client will be able to articulate understanding of reasons for, risks involved with surgery Client will participate in self-care activities to protect eyes from further damage, maximize safety Client will follow self-care instructions following surgery to ensure healing to maximize benefits of surgery Implementation Prevent injury Prior to surgery Wear sunglasses Use reading or prescription glasses or contact lenses Maximize lighting Limit or discontinue nighttime driving After surgery Wear eye protection as ordered Avoid rubbing the eye Facilitate informed decision making Explain nonemergent nature of condition, help client determine the extent to which the cataract is affecting daily life Attend to verbalized concerns about surgery and its outcome Teach principles of self-care Assess for factors that may interfere with the clients ability to provide self-care postoperatively Assess for other care needs that may be affected by vision changes in early postoperative period Preoperative and postoperative teaching Limitations ( avoid reading, lifting, bending to pick up objects, strenuous activity, sleeping on operative side Importance of not disturbing eye dressing Prescribed medications and side effects Importance of follow-up appointments Manifestations of postoperative complications Administration of eyedrops, application of eye patch or shield Care, insertion, removal of contact lenses as appropriate Visual changes associated with thick-lensed eyeglasses as appropriate Promote wellness Encourage clients with diabetes, history of visual problems, disorders requiring frequent use of corticosteroids to see ophthalmologist at least every 2 years Encourage clients who smoke to enroll in smoking cessation program Encourage all clients to use appropriate protection when using tools, when spending time outside Conduct eye, vision assessment at each healthcare interaction with clients ages 65 and older Evaluation Client will remain free from injury Client will make informed decision regarding cataract surgery Client will verbalize concerns about home care Client will verbalize appropriate home care activities Client will demonstrate correct medication administration Review Cataracts Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Exemplar 18.3 Eye Injuries Overview Any part of eye may be affected by trauma Abrasions, lacerations, and foreign bodies most common Pathophysiology and etiology Etiology Affect 2.5 million Americans every year 73 occur in males Each year, 50,000 will permanently lose all or part of their vision due to injury 2000 workers each day sustain a work-related eye injury Certain sports are associated with eye injuries ( boxing, paintball, baseball, lacrosse, basketball, hockey, football, soccer, raquet sports External eye injuries common in children Two black eyes in children rarely occur by accident ( assess for abuse Prevention Protective eyewear Proper UV protection Clinical manifestations Corneal abrasion ( disruption of superficial epithelium of cornea Superficial abrasions ( extremely painful, generally heal rapidly Photophobia, tearing common When stroma damaged ( increased risk of infection, slow healing, scar formation Burns ( heat, radiation, explosion, chemical (most common) Explosions, flash burns, ultraviolet rays Clients with burn to eye ( history of face and eye contact with caustic substance Eyelids may be swollen lips, face affected Penetrating trauma Perforation of eye occurs from variety of causes ( metal flakes, particles produced by high-speed drilling or grinding, glass shards, gunshots, arrows, knives Penetrating injury (layers of eye spontaneously reapproximate after entry of sharp-pointed object or small missile into globe May not be readily apparent Perforating injury ( layers of eye do not spontaneously reapproximate ( resulting in rupture of globe Penetrating injuries may be hidden because of tissue swelling Blunt trauma Sports injuries common cause ( ball, contact sports, falls, physical assaults, motor vehicle crashes May lead to minor eye injury ( lid ecchymosis, subconjunctival hemorrhage Hyphema ( bleeding into anterior chamber of eye Uveal tract disrupted by blunt force ( hemorrhage may result ( filling anterior chamber Client complains of eye pain, decreased visual acuity, seeing reddish tint Orbital blowout fracture ( most likely ethmoid bone on orbital floor Client complains of diplopia, pain with upward movement of affected eye, decreased sensation on affected cheek Enophthalmos Detached retina Separation of retina from choroid May be precipitated by trauma ( usually occurs spontaneously With aging ( vitreous humor shrinks, may pull retina away from choroid Myopia, aphakia Lens may tear and fold back on itself Break or tear in retina allows fluid from vitreous cavity to enter defect ( detached area may rapidly increase in size ( increasing loss of vision Unless contact between retina, choroid reestablished ( neurons of retina become ischemic and die ( causing permanent vision loss Client experiences floaters, spots, lines, flashes of light in visual field Sensation like a curtain being drawn over a window See CLINICAL MANIFESTATIONS AND THERAPIES Eye Injuries, p. 1313 Collaboration Diagnostic tests(facial x-rays, CT scans, ultrasonography Surgery Severe chemical burns ( debridement, tissue grafting, corneal transplant Penetrating wounds Blunt trauma ( depends on type and severity of injury Retinal detachment ( surgical emergency Pharmacologic therapies Corneal abrasion and removal of foreign object ( antibiotic ointment Burns ( pain medications, steroids, cycloplegic drops Penetrating and perforating injuries ( pain meds, sedation, antiemetics, antibiotics See MEDICATIONS EYE INJURIES, p. 1315 Additional therapies Corneal abrasion Foreign bodies removed using irrigation, sterile cotton-tipped applicator, sterile needle Antibiotic ointment ye patch firmly applied after application of antibiotic to keep eye closed Burns Remove clothing that may contain chemical Flush affected eye with copious amounts of fluid ( preferably normal saline Morgan lens unit Eyelid everted Topical anesthetic Fluid directed from inner to outer canthus of eye Penetrating and perforating injuries Generally require surgical intervention by ophthalmic surgeon Pain relief, protecting eye from further injury Gently cover eye with sterile gauze Immobilize object with paper cup, other protective device Blunt trauma Client on bed rest in semi-Fowler position Protect eye from further injury with eye shield Foreign body on conjunctiva ( remove with Irrigation Sterile cotton-tipped applicator or sterile needle Treatment of retinal detachment Medical emergency ( early diagnosis, intervention vital ( untreated ( permanent blindness in that portion of eye If ophthalmologist unavailable ( head positioned so gravity pulls detached portion of retina into closer contact with choroid ( client lies flat in bed with head midline Nursing process Assessment Immediate intervention ( simultaneous assessment, history Nursing history Physical assessment Vision assessment Eye movement unless penetrating object present Inspection Early manifestations of retinal detachment Diagnosis Impaired Tissue Integrity Ocular Acute Pain Anxiety Ineffective Tissue Perfusion Retinal Planning Client will be free of pain associated with injury Client will articulate, follow instructions regarding eye protection and healing process Client will describe when to call primary care provider in event of worsening symptoms or condition Client will experience healing and restoration of vision to maximum extent possible Implementation Reduce risk for impaired vision Assess vision in each eye, both eyes, with and without corrective lenses upon clients entry into emergency department, primary care setting Inspect eye(s) carefully for evidence of foreign bodies, burns, penetrating injury, blunt trauma If burn or foreign body, consider administering anesthetic drops and irrigating eye before or after physician evaluates client Blepharism Remove loose foreign bodies using moist sterile cotton-tipped applicator For severe or penetrating injury, promote rest and stabilize injured eye by applying eye pad or gauze dressing loosely over both affected, unaffected eye Following treatment, apply eyedrops or ointment as prescribed and apply an eye pad or shield if ordered Following injury, discuss following topics with client and family Prescribed medications and possible adverse effects Strategies to prevent further trauma Application of eye pad or shield Avoidance of activities that increase intraocular pressure Importance of activity restrictions See CLIENT TEACHING Eye Injuries Prevention and First Aid, p. 41 Interventions for retinal detachment Notify physician and ophthalmologist immediately Position client so area of detachment is inferior Maintain calm, confident attitude while carrying out priority interventions Reassure client that most retinal detachments are successfully treated Explain all procedures fully, including reason for positioning Allow supportive family members, friends to remain with client as much as possible Discuss following with client and family to prepare for home care Limitations on positioning head before or following repair Activity restrictions such as no bending or straining at stool Use of eye shield Early manifestations and importance of seeking immediate treatment Follow-up treatment with ophthalmologist Evaluation Client maintains optimal vision following injury Client experiences no loss of vision as result of preventable complications Client reports pain management to acceptable levels Review Eye Injuries Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 18.4 Glaucoma Overview Condition characterized by optic neuropathy with gradual loss of peripheral vision and (usually) increased intraocular pressure of eye Client typically experiences no manifestations other than narrowing of visual field Pathophysiology and etiology Aqueous humor occupies anterior and posterior chambers of the eye Normal intraocular pressure of approximately 1215 mmHg maintained ( balance between production of aqueous humor in ciliary body, its flow through pupil from posterior to anterior chamber of eye, and outflow or absorption through trabecular meshwork and canal of Schlemm Increased pressure injures optic nerve Primary glaucoma has two major forms ( open-angle and angle-closure glaucoma See Figure 1813 FORMS OF PRIMARY ADULT GLAUCOMA, p. 1319 Congenital glaucoma, genetically caused glaucoma Secondary or acquired glaucoma ( result from eye injury or prolonged steroid use Open-angle glaucoma ( chronic simple glaucoma 90 of all glaucoma Chronic, gradually progressive, affects both eyes ( pressure and progression may not be symmetric Anterior chamber angle between iris and cornea is normal ( flow obstructed ( neuronal ischemia, optic nerve degeneration Angle-closure glaucoma 510 of glaucoma Occurs because of corneal flattening or bulging of iris into anterior chamber Intraocular pressure rises abruptly ( rapid, permanent loss of vision if not treated promptly Episodes of angle-closure glaucoma typically unilateral ( history in one eye increases risk that it will occur in other eye Pupil dilation ( blocks aqueous outflow ( episodes often occur in association with darkness, emotional upset Must avoid medications that cause mydriasis Risk factors Leading cause of blindness in the world Age Race ( Occurs 6 to 8 times more often in African Americans than Whites Rate rises rapidly in Mexican Americans over age 60 Family history Long-term steroid use Clinical manifestations Open-angle glaucoma ( painless, gradual loss of peripheral vision Angle-closure glaucoma ( severe eye and face pain, general malaise, nausea and vomiting, seeing colored halos around lights, experiencing abrupt decrease in visual acuity Conjunctiva may be reddened, cornea clouded with corneal edema Congenital glaucoma ( more difficult to diagnose Collaboration Cannot be predicted, prevented, cured ( controlled, vision preserved Diagnostic tests Tonometry Fundoscopy Gonioscopy Visual field testing Surgery Surgical management of chronic open-angle glaucoma involves improving drainage of aqueous humor from anterior chamber of eye Laser trabeculoplasty ( noninvasive ( multiple laser burns ( scars create tension ( stretching and opening meshwork Trabeculectomy ( filtration surgery ( permanent fistula created to drain aqueous humor from anterior chamber of eye Photocoagulation, cyclocryotherapy ( destroy portions of ciliary body ( reduces production of aqueous humor Acute angle-closure glaucoma Gonioplasty ( healing and scarring of microscopic lesions at periphery of iris Laser iridotomy ( creates multiple small perforations in iris of the eye Pharmacologic therapies Topical beta-adrenergic blocking agents reduce intraocular pressure ( decreasing production of aqueous humor in ciliary body Can produce systemic effects ( bronchospasm, bradycardia, heart failure Prostaglandin analogs ( increase aqueous outflow Conjunctival hyperemia, permanent changes in color of iris, eyebrows Adrenergic agonists ( with beta blocker, or if beta blockers contraindicated Carbonic anhydrase inhibitor (dorzolamide) decreases production of aqueous humor, reduces intraocular pressure Acute angle-closure glaucoma ( diuretic may be administered IV to achieve rapid decrease in intraocular pressure prior to surgical intervention Acetazolamide, mannitol Fast-acting miotic drops ( acetylcholine See MEDICATIONS Glaucoma, p. 1322 Nursing process Consider specific form of disease, concurrent diagnoses, actual and potential effects on client Over age 40 ( encouraged to receive eye examination every 24 years that includes tonometry screening Assessment Health history Physical examination Distant and near vision, peripheral fields, retina for optic nerve cupping Diagnosis Risk for Injury Risk for Ineffective Self-Health Management Anxiety Planning Client will follow glaucoma care guidelines and have no further vision loss Client will remain free from injury Client will report control over environment and reduced anxiety Implementation Prevent injury If clients vision loss unilateral and recent, provide instructions related to unilateral vision loss and change in depth perception as follows Caution client about loss of depth perception, teach safety precautions such as reaching slowly for objects, using visual cues as to distance Teach client to scan, turning head fully toward affected side to identify potential hazards and looking up and down to compensate for the loss of depth perception If clients vision loss is sudden and for those who have had surgery Assess clients ability to perform ADLs Discuss possible adaptations in the home For hospitalized clients Notify housekeeping and place sign on clients door to alert all personnel not to change arrangement of clients room Raise two or three side rails on the clients bed Facilitate orientation and environmental modifications Address client by name, identify self with each interaction Provide any visual aids that are routinely used Orient client to environment Provide other tools or items that can help compensate for diminished vision as follows Bright, nonglare lighting Books, magazines, instructions in large print Books on tape Telephones with oversize buttons Clock with numbers and hands that can be felt Assist with meals by Reading menu selections and marking choices Describing position of foods on meal tray according to clock system Placing utensils in a readily accessible position Removing lids from containers, buttering bread, cutting meat as needed Feeding client, providing continued assistance as needed during the meal if clients visual impairment is new or temporary Assist as needed with mobility and ambulation as follows Have client hold arm or elbow and walk slightly ahead as guide Describe the surroundings and progress as you proceed Teach the client to feel the chair, bed, commode with hands and back of legs before sitting Promote psychosocial wellness Assess verbal and nonverbal indications of anxiety level and for normal coping mechanisms Encourage client to verbalize fears, anger, feelings, anxiety Discuss clients perception of eye condition and its effects on lifestyle and roles Introduce yourself when entering room Identify coping strategies that have been useful in the past and adapt these strategies to the present situation Evaluation Client demonstrates proper self-administration of eyedrops Client describes need for compliance with plan of care and follow-up care to avoid complications or vision loss Client lists resources available in community Review Glaucoma Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 18.5 Macular Degeneration Overview Leading cause of legal blindness and impaired vision in people over age 60 is age-related macular degeneration (AMD) Over age 75, approximately one third are affected by AMD Pathophysiology and etiology Macula is area of retina that provides sharp central vision Two forms Nonexudative (dry macular degeneration) ( gradual process Accumulation of deposits (drusen) beneath pigment epithelium that increase in size and number Pigment epithelium detaches in small areas, becomes atrophic Typically vision loss not significant, progresses slowly Risk that disorder will progress to exudative stage Exudative macular degeneration (wet) Characterized by formation of new, weak blood vessels between choroid and retina New vessels prone to leak ( elevating retina from choroid Bleeding can occur ( acute vision loss Etiology Approximately 15 million Americans have AMD 200,000 new diagnoses each year Lower risk for Asians ( may be diet and sun connection Darker pigmentation ( less likely to develop AMD Risk factors Aging Smoking Race ( Whites higher than African Americans, Hispanics, Asian ancestry Risk may be reduced by consuming certain antioxidant nutrients vitamin C, vitamin E, beta-carotene, zinc Clinical manifestations Macula damaged ( central vision becomes blurred, distorted ( peripheral vision remains intact Blurry vision, central scotomas, micropsia or macropsia Wet AMD ( straight lines appear crooked or wavy AMD ( affects central vision, peripheral vision intact See CLINICAL MANIFESTATIONS AND THERAPIES Macular Degeneration, p. 52 Collaboration Diagnostic tests Vision and retinal examination Amsler grid Fluorescein angiogram Surgery Wet AMD ( laser surgery, photodynamic therapy Photodynamic therapy Verteporfin ( drug that tends to adhere to surface of new blood vessels injected systemically Shining light into affected eye ( activates drug, destroys new blood vessels Pharmacologic therapy Antiangiogenic drugs (primary therapy See MEDICATIONS Macular Degeneration, p. 1329 Nonpharmacologic therapy Early to intermediate stages ( dry AMD can be slowed with high-dose antioxidants and zinc Assistive devices ( large-print magazines, books, magnifying glass, high-intensity lighting, computers, handheld electronic readers Talking clocks, watches may be helpful Nursing process Assessment Health history Lifestyle, activity alterations Family history Physical examination Visual acuity, including Amsler grid Diagnosis Risk for Injury Risk for Ineffective Self Health Management Fear Planning Client will remain free from injury Client will express feelings related to diagnosis and reduced vision Client will identify strategies to promote self-care and daily routine Implementation Explain nature of condition and help client determine extent to which it is affecting daily life Attend to verbalized concerns Assess for factors that may interfere with clients ability to provide self-care Recommend visual aids when appropriate Teach client and caregiver about benefits of a diet high in antioxidants Offer resources on smoking cessation Explain need for regular eye exams Assess for other care needs that may be affected by vision changes Encourage use of other senses such as touch Encourage use of radios, compact discs, and audio books If needed, consult with occupational therapy for assistive devices Make referrals to appropriate home health agency Educate family and caregivers and provide resources Evaluation Client will verbalize concerns and identify appropriate resources Client will demonstrate ability to safely compensate for visual deficits Client will describe strategies to promote self-care Review Macular Degeneration Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 18.6 Peripheral Neuropathy Overview Peripheral neuropathy results when trauma or disease interferes with innervation of peripheral nerves Effectiveness of blood vessels decreases ( superficial blood vessels constrict to divert blood to larger vessels Constriction of peripheral vessels ( decreased blood flow to peripheral nerve endings ( neuropathy Pathophysiology and etiology Peripheral nervous system (PNS) links central nervous system (CNS) with rest of body Components of peripheral nerves ( axon and myelin Polyneuropathies ( bilateral sensory disorders Most common type associated with diabetes Mononeuropathies ( isolated peripheral neuropathies ( affect a single nerve Injury, trauma, repetitive motions Neuropathies ( acquired, hereditary, or idiopathic Etiology Polyneuropathy often caused by complications of disease Diabetes, exposure to toxins, poor nutrition Guillain-Barr syndrome (GBS) ( acute inflammatory demyelinating disorder of PNS characterized by acute onset of motor paralysis One of most common Progressive ascending flaccid paralysis, accompanied by paresthesias and numbness Destruction of myelin sheaths as result of humoral- and cell-mediated immunologic response Systemic diseases often cause of peripheral neuropathy Autoimmune disorders and infections ( untreated Lyme disease Alcoholic neuropathy Inflammation, cancer, toxins Inflammation and swelling in tendon sheaths ( carpal tunnel syndrome Risk factors Diabetes Alcohol abuse Vitamin deficiencies, particularly B vitamins Immune system suppression Kidney, liver, thyroid disorders Exposure to toxins Age Prevention Controlling medications that increase risk Health diet Avoiding triggers that contribute to nerve damage Clinical manifestations Depend on affected nerve or nerves, amount of damage Commonly has distal paresthesias GBS ( stocking, glove pattern Weakness in arms or legs ( damage to motor nerves See CLINICAL MANIFESTATIONS AND THERAPIES Peripheral Neuropathy, p. 1332 Collaboration Diagnostic tests Electromyography CBC Thyroid function tests Serum levels for B12 and thiamine Metabolic panel Urine screening Nerve biopsy Surgery May be appropriate if cause is compression such as carpal tunnel syndrome Pharmacologic therapy No specific treatment Pain relievers Anticonvulsants Antidepressants Lidocaine patch Nonpharmacologic therapy Compliance with therapeutic regimen for primary condition Health well-balanced diet Regular exercise Smoking cessation Limits on alcohol intake Daily foot care Complementary and alternative therapies Acupuncture Biofeedback Transcutaneous electrical nerve stimulation (TENS) Massage Nursing process Assessment Nursing history Sensory impairments, comorbidities Exposure to chemicals, substances Location, intensity, exacerbating and relieving factors Physical assessment Cranial nerve and sensory/motor assessment Diagnosis Risk for Injury Pain Ineffective Peripheral Tissue Perfusion Anxiety Planning Client will remain free from injury Client will report effective pain management Client will verbalize feelings and concerns Implementation Prevent injury Ensure client safety Teach clients and family members preventive and comfort measures Teach foot care Encourage exercise, smoking cessation, avoidance of toxic chemicals, good nutrition, avoidance of repetitive motion, massage to improve circulation Referrals as appropriate Promote comfort Listen to description of pain determine presence of triggers or a pattern Use pain scale for determining extent of pain Use following complementary therapies to help manage pain Application of heat/cold Guided imagery Relaxation techniques Massage Provide analgesics as indicated administer on a regular schedule rather than waiting until pain becomes severe For clients with GBS, monitor for side effects of analgesics, particularly respiratory depression assess respirations and lung sounds Evaluation Client experiences pain control to allow for rest and comfort Client lists strategies to reduce the risk of injury and promote safety Client describes treatment plan to reduce further deterioration of sensation Review Peripheral Neuropathy Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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