Sensory Skin Disorder

Management of Sensory Disorders Dean Jane L. Olid

SKIN • Largest organ of the body • Functions: – – – –

Protection Sensation Fluid balance Temperature regulation – Vitamin D production – Immune response

Primary Skin Lesions Macule • Flat, circumscribed area that is a change in color of the skin; less than 1 cm in diameter

Papule An elevated, firm. Circumscribed area less than 1 cm in diameter e.g.Wart (verruca), elevated moles, lichen planus, cherry angioma, skin tag

e.g.

Primary Skin Lesions PLAQUE • Elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter e.g.Psoriasis, seborrheic and actinic keratoses, eczema

Primary Skin Lesions WHEAL • Elevated irregular-shaped area of cutaneous edema; solid, transient, variable diameter • Ex. Insect bite, urticaria, allergic reaction

Primary Skin Lesions NODULE • Elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1 to 2 cm in diameter • Ex. Dermatolfibroma, erythema nodosum, lipomas, melanoma, hemangioma, neurofibroma

Primary Skin Lesions TUMOR • Elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter • Ex. Neoplasma, lipoma, hemangioma

Primary Skin Lesions VESICLE • Elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameter • Ex. Varicella (chickenpox, herpes zoster, impetigo, acute eczema

BULLA • Vesicle greater than 1 cm in diameter • Ex. Blister, lupus, impetigo, drug reaction

PUSTULE • Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid • Ex. Impetigo, acne, folliculitis, herpes simplex

PUSTULE • Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid • Ex. Impetigo, acne, folliculitis, herpes simplex

SKIN CONFIGURATIONS

Secondary Skin Lesions SCALE • Heaped-up keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in size • Ex. Seborrheic dermatitis following scarlet fever

Secondary Skin Lesions LICHENIFICATION • Rough, thickened epidermis secondary to persistent rubbing, itching or skin irritation; often involves flexor surface of extremity

Secondary Skin Lesions SCAR • Thin to thick fibrous tissue that replaces normal skin following injury or laceration to the dermis

Secondary Skin Lesions KELOID • Irregular-shaped elevated, progressively enlarging scar, grows beyond the boundaries of the wound; caused by excessive collagen formation during healing

EXCORIATION • Loss of the epidermis linear hollowed-out crusted area • Ex. Abrasion or scratch scabies

FISSURE • Linear crack or break from the epidermis to the dermis, may be moist or dry • Ex. Athlete’s foot, cracks at the corner of the mouth, eczema

EROSION • Loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla • Ex. Varicella, variola after rupture, candidiasis, herpes

ULCER • Loss of epidermis and dermis, concave; varies in size • Ex. Decubiti, stasis ulcers, syphillis chancre

ATROPHY • Thinning of the skin surface and loss of skin markings; skin appears translucent and paperlike • Ex. Aged skin, striae, discoid lupus erythematosus

Vascular Skin Lesions • TELANGIECTASIA • Fine, irregular red lines produced by capillary dilation • Ex. Vascular spider, lupus erythematosus

Vascular Skin Lesions CHERRY ANGIOMA • Small, slightly raised, bright red areas that appear on the face, neck and trunk of the body. These increase in size and number with advanced age.

Vascular Skin Lesions • Petechiae

Spider Angioma

• Ecchymoses

Anatomic Distribution of Common Skin Disorders—Contact Dermatitis

Anatomic Distribution of Common Skin Disorders—Seborrheic Dermatitis and Acne

Anatomic Distribution of Common Skin Disorders—Scabies and Herpes Zoster

Skin Appearance CYANOSIS

JAUNDICE

Normal Aging Changes • Thinning of skin • Uneven pigmentation • Wrinkling, skin folds, and decreased elasticity • Dry skin • Diminished hair • Increased fragility and increased potential for injury • Reduced healing ability

•

Assessment of the Skin Prepare the patient: explain the purpose and provide privacy and coverings

• Ask assessment questions • Inspect the patient’s entire body including mucosa, scalp, hair, and nails • Wear gloves • Assess any lesions; palpate and measure them • Note hair distribution • Photographs may be used to document nature and extent of skin conditions and to document progress resulting from treatment; they may also be used to track moles

MALE PATTERN BALDNESS

Diagnostic Procedures • Skin biopsy

• Skin scrapings

• Immunofluorescence

• Tzanck smear

• Patch testing

• Wood’s light examination

Management of Patients with Burn Injury Causes: • dry heat - fire, • moist heat - steam or hot liquids, • Radiation • friction • heated objects, • the sun, • Electricity • or chemicals. • Thermal burns are the most common type. • Most burns occur in the home. • Young children and the elderly are at high risk for

•

Goals Related to Burns

• Prevention • Institution of life-saving measures for the severely burned person • Prevention of disability and disfigurement through early specialized and individualized care • Rehabilitation through reconstructive surgery and rehabilitation programs

Classification of Burns • Superficial partialthickness (1ST DEGREE BURN)

• First-degree burns affect only the outer layer of the skin epidermis. Manifestation: • minor pain, • redness (erythema) • Mild swelling. • cause: e.g.sunburn

First-degree burns Management: • Remove jewelry or tight clothing from the burned area before it begins to swell. • Flush the burn with cool running water or apply cold-water compresses (a wet towel or handkerchief) until the pain lessens. Do not use ice or ice water, which can cause more damage to the tissues. • Cover the burn with a clean (sterile, if possible), dry, nonfluffy bandage such as a gauze pad. Do not put tape on the burn.

Classification of Burns • 2nd degree burn

• affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. Causes: deep sunburn exposure to flames contact with hot liquids burning gasoline or kerosene contact with chemicals.

2 degree burn nd

Manifestations: • skin is bright red and blotchy • blisters. It usually looks wet because of the loss of fluid through the damaged skin. • very painful.

3rd Degree Burn CAUSES: • contact with: • corrosive chemicals, • flames, • electricity, or extremely hot objects; • immersion of the body in extremely hot water, • clothing that catches fire.

• Third-degree burns can also damage fat, muscle, and bone

• Skin with a third-degree burn may appear white

or black and leathery on the surface. • Because the nerve endings in the skin are destroyed, the burned area may not be painful, but the area around the burn may be extremely painful. • Pain causes the breathing rate and pulse to increase. • Some areas of the burn may appear bright red, or may blister.

3rd Degree Burn • Electrical burns damage the deep tissues. Often only the area of the skin where the electricity entered the body looks black and charred. Electrical shocks can make a person stop breathing and interrupt the rhythm of the heart. • Shock occurs when loss of fluids causes the blood pressure to become so low that not enough blood reaches the brain and other major organs.

3 Degree Burn rd

The symptoms of shock : • fainting, general weakness, nausea and vomiting, rapid pulse and breathing, a blue tinge to the lips and finger nails, and pale, cold, moist skin. • If the victim has been burned in a fire and has been exposed to large amounts of smoke, he or she may also have chest pain, red and burning eyes, and a cough. • All third-degree burns require emergency medical treatment.

Estimation of Total Body Surface Area (TBSA) Burned

• Rule of Nines

Pathophysiology of Burns • Burns are caused by a transfer of energy from a heat source to the body. • Thermal (includes electrical) • Radiation • Chemical

Physiologic Changes • Burns less than 25% TBSA produce a primarily local response. • Burns more than 25% may produce a local and systemic response and are considered major burns. • Systemic response includes release of cytokines and other mediators into the systemic circulation. • Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction.

Effects of Major Burn Injury • Fluid and electrolyte shifts • Cardiovascular effects • Pulmonary injury – – – –

Upper airway Inhalation below the glottis Carbon monoxide poisoning Restrictive defects

• Renal and GI alterations • Immunologic alterations • Effect upon thermoregulation

Nomenclat Tradition ure al nomencl ature

Depth

Clinical findings

Superficial thickness

Firstdegree

Epidermis involvement

Erythema, minor pain, lack of blisters

Partial thickness — superficial

Seconddegree

Superficial (papillary) dermis

Blisters, clear fluid, and pain

Partial thickness — deep

Seconddegree

Deep (reticular) dermis

Whiter appearance, with decreased pain. Difficult to distinguish from full thickness

Full thickness

Third- or fourthdegree

Dermis and underlying tissue and possibly fascia, bone, or muscle

Hard, leather-like eschar, purple fluid, no sensation (insensate

FOR MAJOR BURNS: Initial Care • Make sure that the person is no longer in contact with smoldering materials. However, DO NOT remove burnt clothing that is stuck to the skin. • If breathing has stopped, or if the person's airway is blocked, open the airway. If necessary, begin CPR. • Cover the burn area with a cool, moist sterile bandage (if available) or clean cloth. A sheet will do if the burned area is large. DO NOT apply any ointments. Avoid breaking burn blisters. • If fingers or toes have been burned, separate them with dry, sterile, non-adhesive dressings. • Elevate the body part that is burned above the level of the heart. Protect the burnt area from pressure and friction. • Take steps to prevent shock. Lay the person flat, elevate the feet about 12 inches, and cover him or her with a coat or blanket. However, DO NOT place the person in this shock position if a head, neck, back, or leg injury is suspected or if it makes the person uncomfortable.

Phases of Burn Injury • Emergent or resuscitative phase – Onset of injury to completion of fluid resuscitation

• Acute or intermediate phase – From beginning of diuresis to wound closure

• Rehabilitation phase – From wound closure to return to optimal physical and psychosocial adjustment

Emergent or Resuscitative Phase: On-the-Scene Care • Prevent injury to rescuer. • Stop injury: extinguish flames, cool the burn, irrigate chemical burns. • ABCs: Establish airway, breathing, and circulation. • Start oxygen and large-bore IVs. • Remove restrictive objects and cover the wound. • Do assessment, surveying all body systems, and obtain a history of the incident and pertinent patient history. • Note: Treat patients with falls and electrical injuries as for potential cervical spine injury.

Emergent or Resuscitative Phase • • • • • • • •

Patient is transported to emergency department. Fluid resuscitation is begun. Foley catheter is inserted. Patients with burns exceeding 20-25% should have an NG tube inserted and placed to suction. Patient is stabilized and condition is continually monitored. Patients with electrical burns should have an ECG. Address pain; only IV medication should be administered. Psychosocial consideration and emotional support should be given to patient and family.

Acute or Intermediate Phase • 48-72 hours after injury • Continue assessment and maintain respiratory and circulatory support. • Prevention of infection, wound care, pain management, and nutritional support are priorities in this stage.

Rehabilitation Phase • Rehabilitation is begun as early as possible in the emergent phase and extends for a long period after the injury. • Focus is upon wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities so the patient can have the best-quality life, both personally and socially. • The patient may need reconstructive surgery to improve function and appearance. • Vocational counseling and support groups may assist the patient.

Management of Shock: Fluid Resuscitation • Maintain BP above 100 mm Hg systolic and urine output of 30-50 mL/hr. Maintain serum sodium at near-normal levels. • Consensus formula • Evans formula • Brooke Army formula • Parkland Baxter formula • Hypertonic saline formula • Note: Adjust formulas to reflect initiation of fluids at the time of injury.

Fluid and Electrotype Shifts: Emergent Phase • • • •

Generalized dehydration Reduced blood volume and hemoconcentration Decreased urine output Trauma causes release of potassium into extracellaur fluid: hyperkalemia. • Sodium traps in edema fluid and shifts into cells as potassium is released: hyponatremia. • Metabolic acidosis

Fluid and Electrolyte Shifts: Acute Phase • Fluid re-enters the vascular space from the interstitial space. • Hemodilution • Increased urinary output • Sodium is lost with diuresis and due to dilution as fluid enters vascular space: hyponatremia. • Potassium shifts from extracellular fluid into cells: potential hypokalemia. • Metabolic acidosis

Burn Wound Care • Wound cleaning – Hydrotherapy

• Use of topical agents Wound débridement – Natural débridement – Mechanical débridement – Surgical débridement

• Wound dressing, dressing changes, and skin grafting

• Use of Biobrane Dressing

Comparison of Integra Template and Split-Thickness Autograft

Pain Management • Analgesics – IV use during emergent and acute phases – Morphine – Fentanyl – Other

• Decrease level of anxiety

• Decrease/avoid sleep deprivation • Nonpharmacologic measures

Nutritional Support • Goal of nutritional support is to promote a state of nitrogen balance and match nutrient utilization. • Nutritional support is based on patient’s preburn status and % of TBSA burned.

• Enteral route is preferred. Jejunal feedings are frequently used to maintain nutritional status with lower risk of aspiration in a patient with poor appetite, weakness, or other problems.

Other Major Care Issues • Pulmonary care • Psychological support of patient and family • Patient and family education • Restoration of function

Nursing Process: Care of the Patient in the Emergent Phase of Burn Care: Diagnosis • Impaired gas exchange • Ineffective airway clearance • Fluid volume deficit • Hypothermia • Acute pain • Anxiety

Potential Complications/Collaborat ive Problems • Acute respiratory failure • Distributive shock • Acute renal failure • Compartment syndrome • Paralytic ileus • Curling’s ulcer

Nursing Process: Care of the Patient in the Acute Phase of Burn Care: Diagnosis • • • • •

Excessive fluid volume Risk for infection Imbalanced nutrition Acute pain Impaired physical mobility • Ineffective coping • Interrupted family processes • Deficient knowledge

Potential Complications/Collaborati ve Problems • Heart failure and pulmonary edema • Sepsis • Acute respiratory failure • Visceral damage (electrical burns)

Home Care Instructions • • • • • • •

Mental health Skin and wound care Exercise and activity Nutrition Pain management Thermoregulation and clothing Sexual issues

Assessment and Management of Patients with Eye and Vision Disorders

Extraocular Muscles

Visual Pathways

Cross-Section of the Eye

Internal Structures of the Eye

Assessment and Evaluation of Vision • Ocular history • Visual acuity – Snellen chart  Record each eye  20/20 means the patient can read the “20” line at a distance of 20 feet

• Finger count or hand motion

Examination of the External Structures • Note any evidence of irritation, inflammatory process, discharge, etc. • Assess eyelids and sclera • Assess pupils and pupillary response in a darkened room • Note gaze and position of eyes • Assess extraocular movements • Ptosis: drooping eyelid • Nystagmus: oscillating movement of eyeball

Diagnostic Evaluation • Ophthalmoscopy – Direct and indirect – Examines the cornea, lens, and retina

• • • • •

Slit-lamp examination Color vision testing Amsler grid Ultrasonography Fluorescein and indocyanine green angiography

• Tonometry – Measures intraocular pressure

• Gonioscopy – Visualizes the angle of the anterior chamber

• Perimetry testing – Evaluates field of vision – Scotomas: blind areas in the visual field

Impaired Vision • Refractive errors – Can be corrected by lenses that focus light rays on the retina

• • • •

Emmetropia: normal vision Myopia: nearsighted Hyperopia: farsighted Astigmatism: distortion due to irregularity of the cornea

Eyeball Shape Determines Visual Acuity in Refractive Errors

Glaucoma • A group of ocular conditions in which damage to the optic nerve is related to increased intraocular pressure (IOP) caused by congestion of the aqueous humor

•

Open-angle glaucoma – Chronic open-angle glaucoma – Normal-tension glaucoma – Ocular hypertension

•

Angle-closure (pupillary block) glaucoma – Acute angle-closure – Subacute angle-closure – Chronic angle-closure

•

Congenital glaucomas and glaucoma secondary to other conditions

Pathophysiology of Glaucoma • Normal outflow of aqueous humor

• In glaucoma, aqueous production and drainage are not in balance • When aqueous outflow is blocked, pressure builds up in the eye • Increased IOP causes irreversible mechanical and/or ischemic damage

Clinical Manifestations • Called the “silent thief,” glaucoma renders the patient unaware of the condition until there is significant vision loss, including peripheral vision loss, blurring, halos, difficulty focusing, and difficulty adjusting eyes to low lighting • Patient may also experience aching or discomfort around the eyes or a headache

Diagnostic Findings • Tonometry to assess IOP • Gonioscopy to assess the angle of the anterior chamber • Perimetry to assess vision loss

• Goal is to prevent further optic nerve damage

• Maintain IOP within a range unlikely to cause damage • Pharmacologic therapy: • Surgery – – – – –

Laser trabeculoplasty Laser iridotomy Filtering procedures Trabeculectomy Drainage implants or shunts

Nursing Management • Focus on maintaining the therapeutic regimen for lifelong control of a chronic condition • Emphasize the need for adherence to therapy and continued care to prevent further vision loss

• Provide education regarding use and effects of medications • Medications used for glaucoma may cause vision alterations and other side effects; the action and effects of medications need to be explained to promote compliance • Provide support and interventions to aid the patient in adjusting to vision loss/potential vision loss

Cataracts • An opacity or cloudiness of the lens • Increased incidence with aging

Clinical Manifestations • • • •

Painless, blurry vision Sensitivity to glare Reduced visual acuity Other effects include myopic shift, astigmatism, diplopia (double vision), and color shifts including brunescent c. (color value shift to yellow-brown) • Diagnostic findings include decreased visual acuity and opacity of the lens by ophthalmoscope, slit-lamp, or inspection

Surgical Management • If reduced vision does not interfere with normal activities, surgery is not needed • Surgery is performed on an outpatient basis with local anesthesia • Surgery usually takes less than 1 hour and patients are discharged soon afterward • Complications are rare

Types of Cataract Surgery •

Intracapsular cataract extraction (ICCE): removes entire lens; rarely done today

•

Extracapsular cataract extraction (ECCE): maintains the posterior capsule of the lens, reducing potential postoperative complications

•

Phacoemulsification: an ECCE that uses an ultrasonic device to suction the lens out through a tube; incision is smaller than with standard ECCE

•

Lens replacement: after removal of the lens by ICCE or ECCE, the surgeon inserts an intraocular lens implant (IOL), which eliminates the need for aphakic lenses; however, the patient may still require glasses

Nursing Management • •

Preoperative care Usual preoperative care for ambulatory surgery • Dilating eye drops or other medications as ordered

• •

Postoperative careProvide written and verbal instructions Instruct patient to call physician immediately if: vision changes; continuous flashing lights appear; redness, swelling, or pain increase; type and amount of drainage increases; or significant pain is not relieved by acetaminophen

Corneal Disorders • Treatment of diseased corneal tissue – Phototherapeutic keratectomy – Keratoplasty – Use of donor tissue for transplant: see Chart 58-9 – Need for follow-up and support – Potential graft failure; teach signs and symptoms

• Refractive surgery – Elective procedures to recontour corneal tissue and correct refractive errors – Patients need counseling regarding potential benefits, risks, and complications

LASIK

Retinal Disorders • Retinal detachment

• Retinal vascular disorders – Central retina vein occlusion – Branch retinal vein occlusion – Central retinal vein occlusion – Macular degeneration

Retinal Detachment •

•

•

Separation of the sensory retina and the retinal pigment epithelium (RPE) Manifestations: sensation of a shade or curtain coming across the vision of one eye, bright flashing lights, and sudden onset of floaters Diagnostic findings: assess visual acuity; assess retina by indirect ophthalmoscope, slit-lamp, stereo fundus photography, and fluroescein angiography; tomography and ultrasound may also be used

Surgical Treatment • Scleral buckle • Pars plana vitrectomy – Removal of the vitreous, locating the incisions at the pars plana – Frequently used in combination with other procedures

• Pneumatic retinopexy – Injected gas bubble, liquid, or oil is used to flatten the sensory retina against the RPE – Postoperative positioning is critical

Nursing Management • Patient teaching – Eye surgery is most often done as an outpatient procedure, so patient education is vital • Teach the signs and symptoms of complications, especially increased IOP and infection

• Promote comfort • Patient may need to lie in a special position with pneumatic retinopexy

Retinal Vein or Artery Occlusion • Loss of vision can occur from retinal vein or artery occlusion • Occlusions may result from atherosclerosis, cardiac valvular disease, venous stasis, hypertension, and increased blood viscosity; associated risk factors are diabetes mellitus, glaucoma, and aging • Patients may report decreased visual acuity or sudden loss of vision

Macular Degeneration • Age-related macular degeneration (AMD) • The most common cause of vision loss in persons older than age 60

• Types – Dry or nonexudative type is most common, 85%-90%  Slow breakdown of the layers of the retina with the appearance of drusen

– Wet type  May have abrupt onset  Proliferation of abnormal blood vessels growing under the retinachoroidal revascularization (CNV

Vision Loss Associated With Macular Degeneration

Retina Showing Drusen and AMD

Nursing Management • Patient teaching • Supportive care • Safety promotion

• Recommendations include improving lighting, getting magnification devices, and referring patient to vision center to improve/promote function

Trauma • Emergency treatment – Flush chemical injuries – Do not remove foreign objects – Protect using metal shield or paper cup

• Potential exists for sympathetic ophthalmia, causing blindness in the uninjured eye with some injuries

Infectious and Inflammatory Disorders • Dry eye syndrome • Conjunctivitis (“pink eye”) – Classified by cause: bacterial, viral, fungal, parasitic, allergic, and toxic – Viral conjunctivitis is contagious: see Chart 58-11

• Uveitis • Orbital cellulitis

Hyperemia in Viral Conjunctivitis

Ocular Consequences of Systemic Disease • Diabetic retinopathy – Diabetes is a leading cause of blindness in people age 20 to 74

• Ophthalmic complications associated with AIDS • Eye changes associated with hypertension

•

Ophthalmic Medications Ability of the eye to absorb medication is limited

• Barriers to absorption include the size of the conjunctival sac; corneal membrane barriers; blood–ocular barriers; and tearing, blinking, and drainage • Intraocular injection or systemic medication may be needed to treat some eye structures or to provide high concentrations of medication • Topical medications (drops

• Topical anesthetics • Mydriatics (dilate) and cycloplegics (paralyze): • Contraindicated with narrow angles or shallow anterior chambers and for inpatients on monoamine oxidase inhibitors or tricyclic antidepressants – May cause CNS symptoms and increased BP especially in children and the elderly

•

Anti-infective medications – Antibiotic, antifungal, and antiviral products

•

Medications used for glaucoma – Increase aqueous outflow or decrease aqueous production – May constrict the pupil and affect ability to focus the lens of the eye; affects vision – May also may produce systemic effects

•

Anti-inflammatory drugs; corticosteroid suspensions – Side effects of long-term topical steroids include glaucoma, cataracts, and increased risk of infection; to avoid these effects, oral NSAID therapy may be used as an alternate to steroid use

Low Vision and Blindness • Low vision – Visional impairment that requires devices and strategies in addition to corrective lenses – Best corrected visual acuity (BCVA) of 20/70 to 20/200

• Blindness – BCVA of 20/400 to no light perception – Legal blindness is BCVA that does not exceed 20/200 in better eye, or widest field of vision is 20 degrees or less

• Impaired vision often is accompanied by functional impairment

Assessment of Low Vision • History • Examination of distance and near visual acuity, visual field, contrast sensitivity, glare, color perception, and refraction • Special charts may be used for low vision • Nursing assessment must include assessment of functional ability and coping and adaptation in emotional, physical, and social areas

Management • Support coping strategies, grief processes, and acceptance of visual loss • Strategies for adaptation to the environment – Placement of items in room – “Clock method” for trays

• Communication strategies: see Chart 58-3 • Collaboration with low vision specialist, occupational therapy, or other resources • Braille or other methods for reading/communication • Use of service animals

Guidelines for Instilling Eye Medications • Shake suspensions or “milky” solutions to obtain the desired medication level. • Wash hands thoroughly before and after the procedure. • Ensure adequate lighting. • Read the label of the eye medication to make sure it is the correct medication. • Assume a comfortable position. • Do not touch the tip of the medication container to any part of eye or face. • Hold the lower lid down; do not press on the eye-ball. Apply gentle pressure to the cheek bone to anchor the finger holding the lid • Instill eye drops before applying ointments. • Apply a ½-inch ribbon of ointment

Guidelines for Instilling Eye Medications • Instill eye drops before applying ointments. • Apply a ½-inch ribbon of ointment to the lower conjunctival sac. • Keep the eyelids closed, and apply gentle pressure on the inner canthus (punctal occlusion) near the bridge of the nose for 1 or 2 minutes immediately after instilling eyedrops. • Using a clean tissue, gently pat skin to absorb excess eyedrops that run onto the cheeks. • Wait 5 to 10 minutes before instilling another eye medication.

Assessment and Management of Patients with Hearing and Balance Disorders

Anatomy of the Ear

Anatomy of the Inner Ear

Bone Conduction Compared to Air Conduction

Assessment • Inspection of the external ear • Otoscopic examination • Gross auditory acuity • Whisper test • Weber test • Rinne test

• Otoscope

Assessment

• Weber test

Rinne Test

Speech Discrimination

Diagnostic Evaluation • • • • • • •

Audiometry Tympanogram Auditory brain stem response Electronystagmography Platform posturography Sinusoidal harmonic acceleration Middle ear endoscopy

Hearing Loss • • •

Increased incidence with age: presbycusis Risk factors include exposure to excessive noise levels: Types – Conductive: due to external middle ear problem – Sensorineural: due to damage to the cochlea or vestibulocochlear nerve – Mixed: both conductive and sensorineural – Functional (psychogenic): due to emotional problem

Manifestations: • Early symptoms include: – Tinnitus: perception of sound; often “ringing in the ears” – Increased inability to hear in a group – Turning up the volume on the TV

•

•

Impairment may be gradual and not recognized by the person experiencing the loss As hearing loss increases, patients may experience deterioration of speech, fatigue, indifference, social isolation, or withdrawal; for other symptoms see

– Hearing impairment: Mild, moderate, severe, or profound – Consequences • Depends on age and severity • <3 years: Affects language development; communication and safety

• Medical Management – Hearing aids; sign language; speech reading – Technologic devices (TDDs) – Use of products to perceive sound: Lightactivated alarms; hearing dogs

• Surgical Management – Cochlear implant – Bone conduction device – Semi-implantable hearing aid

Guidelines for Communicating With the Hearing Impaired • Use a low-tone, normal voice • Speak slowly and distinctly • Reduce background noise and distractions • Face the person and get his attention • Speak into the less-impaired ear • Use gestures and facial expressions • If necessary, write out the information or use a sign language translator

• Nursing Management – Observe signs of hearing loss – Assess speech and communication skills – Teach client and family • Use of hearing aids, communication aids, support services

– Take actions to promote self-care and self esteem – Evaluate and follow up client referral

Conditions of the External Ear Impacted Cerumen • Pathophysiology and Etiology – Interferes with sound carried on airwaves

• Assessment Findings – Otalgia; diminished hearing; orange-brown accumulation of cerumen

• Medical Management – Hydration; irrigation or removal with cerumen spoon

• Gentle irrigation should be used with lowest pressure, directing stream behind the obstruction  Glycerin, mineral oil, half-strength H2O2 or peroxide in glyceryl may help soften cerumen

• Nursing Management – Inspects ear and implements measures to remove excessive cerumen – Ear drops; irrigation • Proper administration and precautions – Warm ear drops – Avoid inserting syringe too deeply – Direct the flow toward the roof of the canal

Disorders of the External Ear: Foreign Objects • Pathophysiology and Etiology – Scratched skin – Blunt penetration of eardrum – Local inflammation of tissue

• Assessment Findings – – – – –

Discomfort Diminished hearing Feeling movement Buzzing sound Inspection with penlight or otoscope

– Removal may be by irrigation, suction, or instrumentation – Objects that may swell (such as vegetables or insects) should not be irrigated – Foreign-body removal can be dangerous and may require extraction in the operating room

Conditions of the External Ear

• External otitis • Pathophysiology and Etiology

– Overgrowth of pathogens – Infected hair follicle

• Assessment Findings – Red tissue; swelling – Reduced hearing; fever – Enlarged lymph nodes behind ear – Otoscope examination; C and S results

• Medical Management – Warm soaks; analgesics; antibiotics

– Therapy is aimed at reducing discomfort, reducing edema, and treating the infection – A wick may be inserted into the canal to keep it open and to facilitate medication administration

•

Conditions of the Middle Ear: Otitis Media Pathophysiology and • Serous otitis media: fluid Etiology

– Overgrowth of pathogens – Infected hair follicle

• Assessment Findings – Red tissue; swelling – Reduced hearing; fever – Enlarged lymph nodes behind ear – Otoscope examination; C and S results

• Medical Management – Warm soaks; analgesics; antibiotics

in the middle ear without evidence of infection

Conditions of the Middle Ear: Otitis Media

• Acute otitis media

– Most frequently seen in children – Pathogens are most commonly Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis – Manifestations include otalgia (ear pain), fever, and hearing loss – Treatment  Antibiotic therapy  Myringotomy or tympanotomy

• Chronic otitis media – Result of recurrent acute otitis media – Chronic infection damages the tympanic membrane and ossicle, and involves the mastoid – Treatment  Prevent by treatment of acute otitis  Tympanoplasty, ossiculoplasty, or mastoidectomy

Middle Ear Surgical Procedures • Tympanoplasty – Reconstruction of the tympanic membrane

• Ossiculoplasty – Reconstruction of the bones of the middle ear – Prostheses are used to reconnect the ossicles to reestablish sound conduction

• Mastoidectomy – Removal of diseased bone, mastoid air cells, and cholesteatoma to create a non-infected, healthy ear – Cholesteatoma: a benign tumor that is an ingrowth of skin that causes persistently high pressure in the middle ear, causing hearing loss, neurologic disorders, and destroying structures

Disorders of the Middle Ear: Otosclerosis • Pathophysiology and Etiology – Interference: Vibration of stapes; transmission of sound to inner ear

• Assessment Findings – Signs and symptoms • Progressive, bilateral hearing loss; Tinnitus (at night); pinkish-orange eardrum

– Diagnostic findings • Audiometric tests; CT scan

• Medical and Surgical Management – Hearing aid; stapedectomy

• Nursing Management – Use of selected alternatives for communicating – Pre- and postoperative teaching: Care of prosthesis – Postoperative care • Position client on the nonoperative side • Monitor for nausea and dizziness • Assess facial nerve function

A wire prosthetic stapes is positioned in the middle ear

Stapedectomy for Otosclerosis

Nursing Process: Client Recovering From Stapedectomy • Assessment – Vital signs; monitoring for complications, drainage from affected ear, level of discomfort; report elevation in temperature

• Diagnosis, Planning, and Interventions – Impaired comfort; risks: Injury; infection

Interventions • Reduce anxiety – Reinforce information and patient teaching – Provide support and allow patient to discuss anxieties

• Relieve pain – Medicate with analgesics for ear discomfort – Occasional sharp, shooting pains may occur as the eustachian tube opens and allows air into the middle ear; constant throbbing pain

• Prevent injury – Implement safety measures such as assisting with ambulation – Provide antiemetics or antivertigo medications

• Improve communication and hearing – Hearing may be reduced for several weeks following surgery due to edema, accumulation of blood and fluid in the middle ear, and dressings and packings – Use measures to improve hearing and communication as discussed in “Communicating With the Hearing Impaired”

• Preventing infection – Monitor for signs and symptoms of infection – Administer antibiotics as ordered – Prevent contamination of ear with water from showers, washing hair, etc.

Conditions of the Inner Ear • Dizziness: any altered sense of orientation in space

• Tinnitus

• Vertigo: the illusion of motion or a spinning sensation

• Benign positional vertigo (BBPV)

• Nystagmus: involuntary rhythmic movement of the eyes associated with vestibular dysfunction

• Ototoxicity:

• Labyrinthitis

• Acoustic neuroma: tumor of cranial

Ménière’s Disease • Abnormal inner ear fluid balance caused by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct Manifestations: •

fluctuating, progressive hearing loss; tinnitus; feeling of pressure or fullness; and episodic, incapacitating vertigo that may be accompanied by nausea and vomiting

•

Pathophysiology and Etiology – Malabsorption of fluid in the endolymphatic sac

•

Treatment – Low-sodium diet, 2000 mg a day – Meclizine (Antivert), tranquilizers, antiemetics, and diuretics – Surgical management to eliminate attacks of vertigo; endolymphatic sac decompression; middle and inner ear perfusion; and vestibular nerve sectioning

Ménière’s Disease • Nursing Management – History: Symptoms; medical; drug; allergy – Assess gross hearing; Weber and Rinne tests – Provide emotional support; administer prescribed drugs; limit movement; promote safety – Client teaching: Treatments

Disorders of the Inner Ear: Ototoxicity • Signs and Symptoms – Tinnitus; sensorineural hearing loss – Vestibular toxicity; lightheadedness; vertigo; nausea; vomiting

• Nursing Management – Client teaching: Ototoxic effects of certain medications – Monitor dosage and frequency of drug administration – Assess changes in hearing

Disorders of the Inner Ear: Acoustic Neuroma • Pathophysiology and Etiology – Cochlear nerve compression; interference with the blood supply to the nerve and cochlea

• Assessment Findings – – – –

Gradual hearing loss; impaired facial movement Altered facial sensation; tinnitus Vertigo with or without balance disturbance MRI; CSF studies

Disorders of the Inner Ear: Acoustic Neuroma • Medical and Surgical Management – Surgical removal of tumor – Retain cranial nerve VIII function – Complications of surgery

• Nursing Management – – – –

Assessment: Evaluating hearing function Observing the client’s facial movements Testing for facial sensation Postoperative care: Continue preoperative assessment data; monitor for IICP – Maintain strict asepsis

Acoustic Neuroma • Pharmacologic Considerations – Nonprescription preparations are available for softening hardened cerumen • Refer client to a physician if hearing remains diminished

– Be aware of potentially ototoxic effects of certain medications – Monitor the prescribed dosages and the client for signs of impaired hearing

General Considerations • Gerontologic Considerations – Older clients • Form drier cerumen; experience an increased incidence of impaction in the external acoustic meatus • Experience disorientation and confusion in strange surroundings

– Hearing loss is common as adults age – Assess client’s ability to care for and maintain hearing aid or other treatments