Term
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Definition
1. Light passes through the cornea and is focused onto the retina by the lens.
2. Cells in the retina then transmit this information through optic nerve to the vision area of the cortex.
3. Optic nerves
4. Refraction
–bending of light rays
–Accommodation- Response of the pupil, constrict and dilate. |
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Term
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Definition
External Ear
–auricle or pinna
–external auditory canal
–tympanic membrane
–Acoustic antenna, focus
Sound waves. |
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Term
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Definition
The middle ear consists of:
–The inner part of the ear drum
–The hammer (malleus)
–The anvil (incus)
–The stirrup (stapes)
–Delivers sound to the inner ear where it is processed into a signal that the brain can recognize |
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Term
| The Ear and Hearing Inner Ear |
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Definition
The inner ear contains the most important parts of the hearing mechanism - two chambers called the vestibular labyrinth and the cochlea.
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.
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.
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Term
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Definition
The cochlea as microphone
When sound waves from the world outside strike the eardrum, it vibrates. These vibrations from the eardrum pass 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 cochlea to create waves where they disturb the basilar membrane. Inner hairs attached to the basilar membrane convert the waves into electrical impulses that are transmitted to the brain by the auditory nerve. The hair cells are critical to hearing; it is the inner hairs that move in the Organ of Corti fluids, and translate the fluid movements to chemical messengers that can in turn be converted to electrical impulses that the brain understands.
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Term
| Assessment of Eye and Ear |
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Definition
Health Assessment Interview---ask about chief complaint
Blurred vision
Eye infection
Halos
Difficulty reading
Difficulty hearing
Ringing in ears
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Term
| Physical Assessment of Eye and Vision |
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Definition
Cardinal field- test for extraocular eye mov.
Cover-uncover test---test for stabisms
Snellen’s eye chart- Test for vision (20 ft)
Assessment of the pupils.
Extra movements of the eyes syntagmus or non
Parallel movements strabismus, may indicate
disease, cranial nerve dysfunction or muscle weakness and should be reported. |
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Term
| Physical Assessment of Eye and Vision |
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Definition
Pupils, Equal Round Reactive to Light and Accommodation (PERRLA)
–direct a beam of light into the pupil, look for constriction
–hold object a few feet from client, pupils should dilate, move closer pupils should constrict
Inspection - sclera, iris cornea and internal structures |
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Term
| Physical Assessment of Ear and Hearing |
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Definition
Hearing
-Weber test
-Rinne test
-Whisper test
Inspection
–auricle and external canal-
–Lesions, drainage, redness, pain.
–tympanic membrane- color. |
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Term
Disorders of the Eye
(Eyelid disorders...eyes constantly exposed to the environment) |
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Definition
Hordeolum-sty is an infection of the sebaceous glands of the eyelid Staphylococcus aureus.
Red and painful
Conjunctivitis- Inflammation of the conjunctiva is common. Direct contact bacterial or viral.....Also known as “Pink Eye”. Redness, itching, tearing and discharge.
TREATMENT- topical anti-infectives, anti-inflammatiories
Gonorrhea and trachoma can damage cornea. |
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Term
| Nursing care for Eye Disorders |
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Definition
Cornea- transmits and helps focus light and images onto the retina. Protects the internal eye.
The cornea has no blood supply. Scarring or ulceration of the cornea can lead to blindness.
Corneal ulcers caused by infection, trauma or contact lens. Herpes viruses (shingles) can cause corneal ulcers. Can lead to blindness.
Nr Care- Prompt treatment to preserve vision.
Diagnosed by history and examination of the eye.
Topical anti-infectives as eyedrops. |
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Term
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Definition
Corneal Transplant- Corneas taken from cadavers under the age of 65 who died as a result of trauma or noninfectious illness.
Transplant rejection is low cornea has limited blood supply.
Graft is sutured in place, for one year.
Patch for 24 hours
Avoid increasing intraocular pressure.
Eye drops to reduce inflammation and prevent infection. |
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Term
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Definition
Soaking the eyelids with warm saline compresses may remove exudates seen in conjunctivitis.
Eye irrigation with saline is used to remove purulent discharge with conjunctivitis.
Local heat may treat sty.
Infectious eye disorders Nr care focus is on prevention and immediate treatment!
Prevent complications promote healing. Reduce pain.
Careful and frequent handwashing, not sharing towels, make-up. No contacts until healed. |
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Term
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Definition
Foreign bodies, abrasions and lacerations most common types of eye injury.
Corneal abrasion- scratch of the cornea
Burns- chemical, UV
Perforation- metal flakes, weapons
Blunt eye trauma- sports injury
-->The extent of the injury is determined by eye exam.
-->Topical anesthetic, irrigation, surgery
NR- Protecting the eye, preserving vision, prevention! |
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Term
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Definition
Changes in the shape of the cornea, lens or eyeball affect the focus of light on the retina.
Result= blurred or indistinct vision, also called
Refractive errors- Most common cause of impaired vision.
Myopia- nearsightedness
Hyperopia- farsightedness
Detected routine vision screening
Corrected with glasses or contacts
Nr- Identify and seek treatment. Safety!! |
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Term
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Definition
Clouding of the lens of the eye that impairs vision, common over 65yrs.
As the lens ages its cells become less clear. Mature cataract involves entire lens....Near and distant vision are affected.....Details become obscured.......Pupil appears cloudy gray or white rather than black.
Dx: History and eye exam, the red reflex is lost.
Tx: Surgical removal incision through cornea
Intraocular lens is implanted to focus light &vision...
POST OP: assessment, eye patch and semi-folwer....Avoid coughing, sneezing straining...these increase intraocular pressure...Assess for post-op pain....Assess for surgical complications....Approach from unaffected side.....Teach Home Care...meds., symptoms to report, photophobia
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Term
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Definition
Manifestations: increased intraocular pressure and gradual loss of vision....“Silent” thief of vision...Narrowing of visual field...impaired night vision, halos...(prob with side vision) Glaucoma if not treated can and will lead to blindness.
Angle-closure glaucoma can recur thus avoid medications that can dilate the pupil. One eye is at risk for the other eye.
Atropine must be avoided in clients with history of angle-closure glaucoma.
Glaucoma cannot be cured, chronic disease can be controlled and vision preserved if it is dx and tx..
TX: miotics--pilocarpine....Routine eye examinations early detection.
Laser Surgery (trabeculoplasty) cause scar tissue to create tension to stretch opening to drain aqu. fluid |
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Term
| Acute angle-closure glaucoma |
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Definition
Acute angle-closure glaucoma is an ocular emergency that requires immediate intervention!
Surgery is indicated when chronic open-angle glaucoma can not be controlled with medication.
Lower intraocular pressure.
Glaucoma is a chronic disease that requires lifelong management. Can lead to blindness if not identified and treated.
Nursing- Increased risk for injury, psychological effects of a chronic disease= anxiety. Early vision screening!!!!!!! |
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Term
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Definition
Increased intraocular pressure and gradual loss of vision. Silent thief of vision.
Leading cause of blindness worldwide.
Normal intraocular pressure is 12-20 mm Hg is maintained by a balance between aqueous humor production and drainage, disrupted intraocular pressure increases.
Open angle – common (90%)...>35yrs, genetic link, African-American... drainage of the aqueous humor through the trabecular meshwork is impaired...usually bilateral
Angle-closure- Angle between the cornea and iris closes, completely blocking aqueous humor drainage. |
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Term
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Definition
Retina contains neurons that allow us to see light and images.
Retina separated from the choroid, the vascular layer of the eye. Fluid seep between retina and choroid, thus separating the layers. The neurons become ischemic and die causing permanent vision loss.
Can occur spontaneously or from trauma as we age it increases our risk for detached retina.
Medical emergency
CM- painless, floaters, flashes of light. Dx- eye examination. Surgical procedures.
Early identification is a priority for the nurse! May have gradual loss of vision.
The affected area of the eye inferior to maintain contact between the retina and choroid. |
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Term
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Definition
Neurons of the macula may atrophy with age or separate from the choroid. May cause blindness.
Smoking, over 65 yrs, family hx.
Central vision becomes blurred, peripheral vision remains intact. One eye common early symptom.
Any change in vision needs evaluation!!!!!! Nursing!
Laser treatment may slow the process. Early treatment may help slow disease and preserve vision. |
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Term
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Definition
85% of diabetics will develop...leading cause of new blindness bet age 20-74.
The capillaries of the retina are no longer able to transport blood and oxygen to the retina.
Develops 15 years after being diagnosed either type one or type 2 diabetes.
Initially venous capillaries dilate and develop microscopic aneurysms may leak or rupture; thus edema and small hemorrhages into the retina. Areas become ischemic. New blood vessels form causing more damage...caps become sclerotic.
Nr- Education, yearly eye exam, sudden loss of vision, black spot, flashing lights...laser photocoagulation (treatment).
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Term
Ear Disorders
External otitis
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Definition
External otitis- or swimmers ear affect sound conduction and hearing.
Inflammation of the ear canal (middle ear)...
Risk; swimmers, divers surfers, hearing aids or earplugs.
Caused by bacteria, fungas or trauma
Remove earwax and cleaning and drying ear canal.
CM- Pain, drainage, inflammation and swelling
Management-cleaning, antibiotics- local and systemic, education
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Term
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Definition
Older adults are at risk for impacedcerumen
Interferes with sound conduction and hearing.
Tinnitus is a clinical manifestation
Can be seen using an otoscope
Clearing with irrigation ear curet or forceps
Prevention is the focus of Nursing! No Q-tips. |
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Term
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Definition
Inflammation or infection of the middle ear.
Most common middle ear disorder.
COMMON IN INFANTS & YOUNGE CHILDREN. Adults too.
Organisms can enter the middle ear from the nose and throat through the eustachian tube
Eardrum protects middle ear from the environment.
CM- Red, bulging tympanic membrane. Pain, with a URI. Swelling of the ET impairs drainage of the middle ear, fluid collects with bacteria. Fever.
Complications: discussion. DX- Otoscope eardrum. |
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Term
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Definition
Genetic, hereditary disorder affects white females.
Abnormal bone forms in the stapes and causes a conductive hearing loss.
CM- hearing loss begins in adolescence or early adulthood. Tinnitus
Management- Surgical reconstruction of the middle ear.
Nursing- Referral to appropriate community agencies to evaluate hearing loss. |
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Term
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Definition
Occur less frequently than other ear disorders:
Labyrinthitis- inflammation of the inner ear
Meniere’s disease-chronic.....recurrent attack of vertigo with tinnitus....progressive hearing loss
Vertigo is the KEY symptom of inner ear disorders.
Contains the semicircular canals that help maintain balance and neural receptors for hearing. Thus may cause permanent hearing loss.
Bacterial or virus
CM- severe vertigo, NV, nystagmus. Falling!
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Term
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Definition
Meniere’s Disease- chronic inner ear disorder caused by excess fluid and pressure in the labyrinth of the inner ear. (Gradual or sudden)....No cure
Vertigo, tinnitus and gradual hearing loss
TX- Decrease inner ear pressure hydrochlorothiazide
Meds to relieve vertigo Vistaril, compazine.
Avoid caffeine, alcohol and tobacco.
May need surgery to relieve excess pressure .
Nr- discussion risk for injury! Evaluate vertigo, HL.
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Term
Hearing Loss
Conductive hearing loss |
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Definition
10 million adults in the US are hearing impaired
70% of older adults
TWO TYPES
Conductive hearing loss- Anything that impairs sounds transmission from the external opening of the ear to the inner ear. Impacted cerumen most common. Perforated eardrum, tumor of middle ear.
Hearing aid would be of benefit. |
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Term
| Sensorineural Hearing Loss |
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Definition
Sensorineural Hearing Loss- Disorders that affect the inner ear or the auditory pathways of the brain.
CAUSE BY: Trauma, infection, Meniere’s disease, ototoxic medications, prenatal exposure to rubella.
US- Noise exposure is the major cause of sensorineural hearing loss. Exposure to high level of noise damages the hair cells of the inner ear.
Affects the ability to hear high-frequency sounds more than low. Speech discrimination and communication noisy places.
Hearing aids may not help B/C they amplify speech and background noise.
Nr- Social isolation, type HL, finances. Ed |
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Term
| AGE RELATED VISION CHANGES |
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Definition
AGE RELATED -flatting of the cornea
-pupillary constriction
-decrease in lens elasticity
-loss of sensory cells
Physical changes
-inversion, eversion of lid, decreased tear secretion, “hollowed-eyed” |
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Term
| The Client with Psoriasis |
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Definition
Definition
–chronic
–non-infective
–raised reddened round plaques covered by silvery white scales
–most common on scalp, arms, legs
Diagnosed
–skin biopsy |
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Term
TREATMENT AND NURSING CARE FOR "P" |
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Definition
Treatment
–topical corticosteriods to decrease inflammation
–phototherapy
•exposure to ultraviolet light
•decreases the growth rate of epidermal cells
Nursing Care
–Impaired skin integrity
–Body Image Disturbance
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Term
Infections and Infestations |
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Definition
Bacterial Skin Infection–causative agent gram+ staph aureus---> and beta-hemolytic streptococci
Furuncle--->boils, inflammation of hair follicle
Carbuncles--->group of infected hair follicles
Cellulitis --->localized infection of dermis
Diagnosis–assessment--->–culture and sensitivity
Treatment-->antibiotics |
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Term
| Fungal Infections of the Skin |
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Definition
Tinea pedis - athlete’s foot
Tinea capitis - scalp - ringworm
Tinea corporis - body
Candidiasis Infections
–yeast like fungus, pustules, red rash
–skin folds, mouth, peri areas
–treatment - antifungal - nystatin, diflucan |
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Term
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Definition
Dermatitis
–inflammation of the skin characterized by erythema, pain and pruritus
Contact Dermatitis
–caused by hypersensitivity response or chemical irritation
Treatment
–topical oints and therapeutic baths
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Term
| Toxic Epidermal Necrolysis (TEN) |
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Definition
Rare, life threatening disease in which the skin peels off
leaves large areas of denuded skin
can also occur internally to mucose membranes
Treatment–ICU, Burn Unit
Surgery–skin graphing
Fluid replacement–IV therapy, TPN
Medications–Antibiotics -treat sepsis–Anelgesics - pain management |
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Term
| Neoplastic Skin Disorders |
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Definition
Benign lesions - moles, cysts, keloids, skin tags keratoses
Malignant lesions - skin cancers
–over time damage from ultraviolet radiation and chemicals
–basal cell carcinoma, squamous cell and melanoma
RISK FACTORS:
Environmental–ultraviolet radiation–pollution, chemicals viruses, trauma
Host Factors–skin pigmentation–life style
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Term
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Definition
Tumor that originates from basal layer
Most common but least aggressive
Tend to recur but rarely metastasize |
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Term
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Definition
Arises from squamous epithelium
Occurs on exposed areas of skin
More aggressive, faster growth rate
Harden nodule may ulcerate and bleed |
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Term
| Interdisciplinary Care for Skin cancer |
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Definition
Labs and Diagnostics
–biopsy
Treatment
–surgical excision
–curettage and electrodesiccation
–cryosurgery
–radiation therapy
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Term
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Definition
Arises from melanocytes
is life threatening
precursor lesions
–atypical moles (dysplastic nevi)
–congenital nevi - present at birth
–lentigo freckle - tan or black mole, usually on the side of the face, slow growing |
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Term
Interdisciplinary Care
assessment
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Definition
Assessment
–A = asymmetry
–B = border irregularity
–C = color variation
–D = diameter >6mm
–E = elevation
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Term
INTERDISPLINARY CARE
LABS/TESTS |
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Definition
Labs and Diagnostics
–biopsy
CT Scan, MRI, CXR, Bone Scan
Blood work
- CBC, Liver function
Surgery
–wide excision of lesion
–regional lymph node dissection
Chemotherapy and Radiation Therapy |
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Term
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Definition
Nursing Care
–Impaired skin Integrity
–Hopelessness
–Anxiety
–Teaching for Home Care
•wound care
•avoid exposure
•follow up appointments |
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Term
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Definition
Pressure Ulcer
–ischemic lesions of the skin and underlying tissue caused by external pressure that impairs blood and lymph flow
–ischemia causes tissue necrosis then ulcerations
Causes
–External pressure
–Shearing |
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Term
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Definition
Stage 1-->
•intact skin...•non-blanchable erythema
Stage 2-->
•open, partial layer skin loss •ulcer, abrasion, blister, shallow crater
Stage 3-->
full-thickness, damage or necrosis to subcutaneous tissue–deep crater
Stage 4-->
–full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, can have sinus tracts |
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Term
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Definition
Eschar
–black, leathery necrotic skin
–when is present, unable to accurately stage ulcer
–needs to be debrided - surgical, wet-to-dry normal saline drsg changes. |
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Term
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Definition
Assessment - Identify those at risk
Assessment of skin
–systematic once a day
Clean the skin
–keep hydrated - use lotion
Avoid massage over bony prominences
Minimize exposure to moisture
Avoid friction and shearing
Ensure adequate nutritional intake
Maintain activity level–What can you do for a client on bedrest? |
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Term
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Definition
Site...Size....Stage
Appearance
–color
–drainage
–odor
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Term
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Definition
Hirsutism
–excessive body hair
Alopecia
–loss of hair or baldness
Nail Disorders
–discolored, malformed, infected or separated from underlying tissue |
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