Chapter 52 Nursing Care of Patients with Sensory Disorders Vision and Hearing

Answers CHAPTER 52 NURSING CARE OF PATIENTS WITH SENSORY DISORDERS: VISION AND HEARING AUDIO CASE STUDY Sally and Ménière Disease 1. Balance 2. Vertigo, unsteadiness, and nausea. 3. Falling without warning. 4. Antiemetic for nausea and meclizine (Antivert) for vertigo. VOCABULARY 1. (5) 2. (4) 3. (3) 4. (6) 5. (2) 6. (1) ERRORS OF REFRACTION VISUAL AND HEARING DATA COLLECTION • Macular degeneration (dry type): The patient reports slow, progressive loss of central and near vision in one or both eyes. The visual loss is described as blurred vision, distortion of straight lines, and a dark or empty spot in the central area of vision. Examination of visual acuity for near and far vision will reveal loss of vision. Use of the Amsler grid will allow the examiner to detect central vision distortion. The examiner may use intravenous fluorescein angiography to evaluate blood vessel abnormalities. • Cataract: The patient reports difficulty seeing at night, when reading, and in bright light; increased sensitivity to glare; double vision; and decreased color vision. Visual acuity is tested for near and far vision. The direct ophthalmoscope and slit lamp are used to examine the lens and other internal structures. The lens will appear cloudy on examination, and the visual acuity may be reduced. • Hordeolum: Small, raised, lightly colored area observed on the palpebral border without pain. • Acute angle-closure glaucoma: The patient reports unilateral severe pain of rapid onset, blurred vision, halos around lights, sensitivity to light, and tearing. The patient may also experience nausea and vomiting. A tonometry test will reveal increased intraocular pressure. The visual field examination may demonstrate a loss of peripheral vision. • External otitis: The patient has pain and may have pruritus. Redness, swelling, and drainage may be observed during otoscopic examination. Rinne and Weber tests may indicate conductive hearing impairment. Laboratory tests such as complete blood count, white blood cell count, and culture may indicate infection. • Impacted cerumen: The patient may experience hearing loss, a feeling of fullness, or blocked ear. Otoscopic examination reveals cerumen blocking the ear canal. Audiometric testing, whisper voice, and Rinne and Weber tests may indicate conductive hearing loss. • Otitis media: The patient may have a fever, earache, and a feeling of fullness in the affected ear. If purulent drainage has formed, there may be pain and conductive hearing loss. Otoscopic examination will reveal a reddened and bulging tympanic membrane. Audiometric studies and Rinne, Weber, and whisper tests will likely reveal hearing loss. Laboratory studies may indicate an elevated white blood cell count. 1 2 Chapter 52 Answers • Otosclerosis: The patient will have progressive bilateral hearing loss, particularly with soft, low tones. The patient may experience tinnitus. Otoscopic examination may reveal a pinkish, orange tympanic membrane. Audiometric testing and the whisper voice test will show decreased hearing. The patient will hear best with bone conduction with the Rinne test, whereas lateralization to the most affected ear will occur with the Weber test. Imaging studies will indicate the location and the extent of the excessive bone growth. PRESBYOPIA Corrections are in boldface. Presbyopia is a condition in which the lenses lose their elasticity, resulting in a decrease in ability to focus on close objects. The loss of elasticity causes light rays to focus beyond the retina, resulting in hyperopia. This condition is usually associated with aging and generally occurs after age 40. Because accommodation for close vision is accomplished by lens contraction, people with presbyopia exhibit the inability to see objects at close range. They often compensate for blurred close vision by holding objects to be viewed farther away. Complaints of eye strain and mild frontal headache are common. GLAUCOMA Corrections are in boldface. Glaucoma may be characterized by abnormal pressure within the eyeball. This pressure causes damage to the cells of the optic nerve, the structure responsible for transmitting visual information from the eye to the brain. The damage is silent, progressive, and irreversible until the end stage, when loss of peripheral vision occurs and eventually blindness. Once glaucoma occurs, the patient will always have it and must follow treatment to maintain stable intraocular eye pressures. CONDUCTIVE HEARING LOSS Corrections are in boldface. Conductive hearing loss is interference with conduction of sound impulses through the external auditory canal, eardrum, or middle ear. The inner ear is not involved in a pure conductive hearing loss. Conductive hearing loss is a mechanical problem. Causes of conductive hearing loss include cerumen, foreign bodies, infection, perforation of the tympanic membrane, trauma, fluid in the middle ear, cysts, tumor, and otosclerosis. Many causes of conductive hearing loss, such as infection, foreign bodies, or impacted cerumen, can be corrected. Hearing devices may improve hearing for conditions that cannot be corrected. Hearing devices are most effective with conductive hearing loss when no inner ear and nerve damage are present. OTOSCLEROSIS Corrections are in boldface. Otosclerosis results from the formation of new bone along the stapes. With new bone growth, the stapes becomes immobile, which causes conductive hearing loss. Hearing loss is most apparent after the fourth decade. Otosclerosis usually occurs more frequently in women than in men. The disease usually affects both ears. It is thought to be a hereditary disease. The primary symptom of otosclerosis is progressive hearing loss. The patient usually experiences bilateral conductive hearing loss, particularly with soft, low tones. Stapedectomy is the treatment of choice. CRITICAL THINKING 1. The key symptom is visual loss without pain. The eye examination reveals opacity of the lens, a primary indicator of cataract formation. The vision is diminished because the light rays are unable to get to the retina through the clouded lens. 2. Cataract formation is diagnosed through an eye examination. Visual acuity is tested for near and far vision. The direct ophthalmoscope and slit lamp are used to examine the lens and other internal structures. Instruct the patient that it is important for him to remain still while the health care provider uses the handheld ophthalmoscope. The slit lamp will require the patient to rest his chin and forehead against the machine while the health care provider performs this painless test. Instruct the patient that both tests require shining a bright light into the eye, which may be uncomfortable for a few seconds. 3. Refer to the Nursing Process for the Patient Having Eye Surgery in Chapter 52. Areas to include in a teaching plan are preoperative and postoperative care, medication administration, and no swimming after surgery. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (2) is correct. Myotics lower intraocular pressure by stimulating pupillary and ciliary sphincter muscles. (1) is incorrect. Osmotics decrease intraocular pressure by decreasing vitreous humor production. (3) is incorrect. Mydriatics dilate pupils. (4) is incorrect. Cycloplegics paralyze the muscles of accommodation and can increase intraocular pressure. 2. (1) is incorrect. A myringotomy is an incision made in the tympanic membrane to drain out fluid or suction the inner ear. (2) is incorrect. A myringoplasty is reconstructive repair of a perforated tympanic membrane. (3) is incorrect. A mastoidectomy is the excision of mastoid cells. (4) is incorrect. A stapedectomy involves removing or replacing part or all of the stapes with a prosthesis. Otosclerosis is the hardening of the stapes, so a stapedectomy is the treatment of choice. Chapter 52 3. (1) is correct. There are no specific medicines to relieve dizziness; however, antihistamines are helpful for some patients. (2, 3, 4) are incorrect. 4. (1) is correct. Hearing aids amplify sound and are most useful with conductive hearing loss. Hearing aids are less useful when nerve damage is also present. (2, 3, 4) are incorrect. 5. (3) is correct. Otitis media occurs in the middle ear. (1, 2, 4) are incorrect. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 6. (1, 3, 4) are correct. Decreased distinction of colors, loss of near vision, and loss of central vision occur with macular degeneration. (2, 5, 6) are incorrect. The patient with macular degeneration may have slow loss of vision and retain peripheral vision; dizziness or other vestibular changes are not associated with macular degeneration. 7. (2, 4, 5, 6) are correct. Swimming should be avoided after surgery until the eye is healed. Sudden sharp pain and increased drainage should be reported, as they can be rare complications. Keeping a follow-up appointment is important to ensure eye health. (1, 3) are incorrect. It is not necessary to elevate the head of the bed or avoid caffeine. 8. (2) is correct. The hearing aid should not be submerged in water. (1, 3, 4) are incorrect, as they state proper care for the hearing aid. 9. (1, 4, 5) are correct. These three symptoms are known as the triad of symptoms of Ménière disease. (2, 3, 6) are incorrect. 10. (1, 3, 4, 6) are correct. These would not help reduce vertigo and require further teaching. (2, 5) are incorrect. Answers 3 The labyrinth is involved with balance and equilibrium. Avoiding sudden movements can be helpful, and lying down promotes safety. These both show understanding of teaching. 11. (4) is correct. Acute bacterial conjunctivitis is commonly known as pink eye. (1, 2, 3) are incorrect. They are not associated with acute bacterial conjunctivitis. 12. (3) is correct. Blurring of vision is the first symptom of cataracts due to the clouding of the lens. (1, 2, 4) are incorrect. 13. (3) is correct. Sudden onset of acute pain could indicate increased intraocular pressure, bleeding, or detachment; all could lead to permanent eye damage. (1, 2, 4) are important nursing interventions but with lower priority. 14. (2) is correct. The intraocular pressure increases as the aqueous humor is prevented from flowing from the anterior to the posterior chamber. (1, 3, 4) are incorrect. 15. (3, 4, 5, 6) are correct. (1) is incorrect. Flashing lights occur in detached retina. (2) is incorrect. Lens opacity is found with a cataract. 16. (1, 3, 6) are correct. Coughing, sneezing, bending over, as well as vomiting all increase intraocular pressure and put the patient at risk of hemorrhage. (2, 4, 5) are incorrect. They do not directly increase intraocular pressure. 17. (2, 3) are correct. Mydriatics such as anticholinergics (atropine) and antihistamines (diphenhydramine) are contraindicated in acute angle-closure glaucoma. (1, 4, 5, 6) are incorrect. They do not cause angle closure. 18. (1, 4, 5, 6) are correct. (2) is incorrect. One side of the nose should be blown at a time. (3) is incorrect. It would be difficulty to avoid sneezing, so it should be done with the mouth open.