Sensorineural System Disorders

1. MANGEMENT OF PATIENTS WITH EYE AND VISION PROBLEMS
JOFRED M. MARTINEZ, RN, MAN
NG Review and Training Center, Inc.
Iloilo City, Philippines

2. • Conjunctivitis - inflammation
of the conjunctiva caused by
either a virus or a bacterium.
• Viral conjunctivitis lasts 2 to 4
weeks.
• Bacterial conjunctivitis is due
to staphylococcal or
streptococcal bacteria and is
also highly contagious.
INFECTION AND INFLAMMATION

3. • Conjunctivitis can also be
caused by the organisms
Haemophilus influenzae,
Chlamydia trachomatis, and
Neisseria gonorrhoeae.
INFECTION AND INFLAMMATION

4. • Eyewashes or eye irrigations
cleanse the conjunctivas and
relieve the inflammation and
pain.
• Bacterial conjunctivitis is
treated with antibiotic eye
drops or ointments.
MANAGEMENT

5. • Blepharitis - inflammation of
the eyelid margins, is a
chronic inflammatory process.
• Causes: staphylococcal
infection, seborrhea, rosacea,
dry eye, or abnormalities of
the meibomian glands and
their lipid secretions.
INFECTION AND INFLAMMATION

6. Two types:
• Seborrheic blepharitis -
reddened eyelids with scales
and flaking at the base of the
lashes.
• Ulcerative blepharitis - crusts
at eyelashes, reddened eyes,
and inflamed corneas.
INFECTION AND INFLAMMATION

7. • Daily cleansing with cotton-tipped swabs dipped in
diluted baby shampoo or sterile eyelid cleanser
solutions
• Antistaphylococcal antibiotic ointment (bacitracin,
erythromycin) is applied to the lid margins one to four
times a day
• Warm compresses
MANAGEMENT

8. • Hordeolum (sty) – small
external staphylococcal
abscess in the sebaceous
gland at the base of the
eyelash (either the glands of
Zeis or glands of Moll).
INFECTION AND INFLAMMATION

9. • Chalazion (internal
hordeolum), may form in the
connective tissue of the
eyelids, specifically in the
meibomian glands.
INFECTION AND INFLAMMATION

10. • Hordeolums form and heal spontaneously within a few
days and require no treatment.
• Chalazions may require surgical incision and drainage
(I&D) if they do not drain spontaneously.
• Oral antibiotics may be prescribed along with
application of warm compresses to aid healing.
MANAGEMENT

11. • Keratitis - inflammation of the
cornea and may be acute or
chronic and superficial or
deep.
• Associated with bacterial
conjunctivitis, a viral infection
such as herpes simplex, a
corneal ulcer, or diseases such
as tuberculosis and syphilis
INFECTION AND INFLAMMATION

12. Signs and symptoms:
• pain increases with movement
of the lid over the cornea.
• decreased vision, photophobia,
tearing, and blepharospasm
• conjunctiva is reddened.
• opaque cornea in advance
cases
INFECTION AND INFLAMMATION

13. Diagnostic tests:
• slit lamp or a handheld light-
show opacity in the cornea
• fluorescein stain - outline the
area of involvement.
INFECTION AND INFLAMMATION

14. Therapeutic interventions:
• topical antibiotics
• topical corticosteroids
• topical interferons,
• antiviral medications for herpes
simplex
• cycloplegic agents
• warm compresses
INFECTION AND INFLAMMATION

15. Surgical interventions:
• If the cornea is severely
damaged, corneal transplant
may be required.
• The eye may be patched to
decrease the amount of eyelid
movement over the cornea
during healing.
INFECTION AND INFLAMMATION

16. Complications:
• perforation
• permanent scarring of the
cornea
• permanent loss of vision.
INFECTION AND INFLAMMATION

17. Nursing diagnoses
• Acute Pain related to inflammation or infection of the
eye or surrounding tissues
• Risk for Injury related to visual impairment
• Deficient Knowledge related to eye disease process,
prevention, and treatment from lack of previous
experience

18. • Refraction - bending of light rays as they enter the eye.
• Emmetropia (normal vision) - light rays are bent to
focus images precisely on the macula of the retina.
• Ametropia - any refractive error. Ametropia occurs when
parallel light rays entering the eye are not refracted to
focus on the retina.

19. • Hyperopia (farsightedness) -
light rays focusing behind the
retina.
• The globe or eyeball is too short
from the front to the back,
causing the light rays to focus
beyond the retina.
• Hyperopia is corrected with
convex lenses.

20. • Myopia (nearsightedness) -
light rays focusing in front of the
retina.
• The eyeball is elongated, and
thus the light rays do not reach
the retina.
• Myopia is corrected with
concave lenses

21. • Astigmatism - unequal curvatures in the shape of the
cornea.
• The person with astigmatism has blurred vision with
distortion. Irregular cornea causes the light rays to be
refracted to focus on two different points. This can result
in either myopic or hyperopic astigmatism.
• The corneal irregularities can be caused by injury,
inflammation, corneal surgery, or an inherited autosomal
dominant trait.

22. • Presbyopia – crystalline 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.
• Associated with aging and generally occurs after age 40.
• Reports of eyestrain and mild frontal headache are
common.
• Symptoms are relieved with eye rest and corrective lenses.

24. Diagnostic tests:
• Snellen’s chart - roughly
estimates a refractive error
• Retinoscopic examination -
definitive refractive error
measurement

25. Therapeutic Measures:
• Eyeglasses or contact lenses.
• Laser-assisted in situ
keratomileusis (LASIK) and
photorefractive keratectomy
(PRK) - surgical procedures

26. • Low vision - visual impairment that requires patients to
use devices and strategies in addition to corrective
lenses to perform visual tasks. Low vision - best
corrected visual acuity (BCVA) of 20/70 to 20/200.
• Blindness - BCVA that can range from 20/400 to no light
perception.
• Absolute blindness is the absence of light perception.

27. • Blindness is caused by trauma,
complications from various
diseases such as hypertension
and diabetes and conditions
such as cataracts and glaucoma.
• Blindness may be permanent or
transient, complete or partial, or
may occur only in darkness
(night blindness).

29. Assessment and diagnosis:
• thorough history
• examination of distance and near visual acuity
• visual field
• contrast sensitivity
• glare testing - realistic evaluation of the patient’s ability
to function in his or her environment
• color perception
• refraction

30. Therapeutic Measures:
• low-vision aids - optical and nonoptical devices
(magnifiers and spectacles; telescopic devices);
• antireflective lenses that diminish glare;
• electronic reading systems, such as closed-circuit
television and computers with large print.

31. Nursing diagnoses
• Dressing and Feeding Self Care Deficit related to altered
vision.
• Risk for Injury related to altered vision
• Deficient Knowledge

32. • Retinopathy - vascular changes
occur in the retinal blood vessels.
Most common in persons with
diabetes.
• Related to excess glucose,
changes in the retinal capillary
walls, formation of
microaneurysms, and constriction
of retinal blood vessels.

33. Three stages:
• Background retinopathy - earliest stage, in which
microaneurysms form on the retinal capillary walls.
• Preproliferative retinopathy - swollen and irregularly
dilated veins, which results in sluggish or blocked
blood flow. There are no symptoms.
• Proliferative retinopathy -formation of new blood
vessels growing into the retinal and optic disc area

34. Assessment and diagnosis:
• reduction in central visual acuity or color vision as a
result of macular edema
• no symptoms until the proliferative stage, at which point
vision is lost
• visual loss at the last stage usually cannot be restored.

35. Diagnostic Tests
• ophthalmoscope following
dilation of the pupil with a
cycloplegic agent.
• retinoangiography
• In the initial stages, vessels
may appear swollen and
tortuous (twisted).

36. Therapeutic Measures
• laser photocoagulation
• vitrectomy – vitreous
humor is drained out of
the eye chamber and
replaced with saline or
silicon oil
• intravitreal corticosteroids

37. • Retinal detachment - separation of the retina from the
choroid layer beneath it.
Causes:
• hole or tear in the retina that allows fluid to flow
between the two layers
• fibrous tissue in the vitreous humor that contracts and
pulls the retina away from its normal position
• fluid or exudate accumulation in the subretinal space
that separates the retinal layers

38. Signs and Symptoms
• flashing lights and then floaters
• “looking through a veil” or
“cobwebs” and finally “like a
curtain being lowered over the
field of vision,” with darkness
resulting
• loss of peripheral vision
• loss of acuity in the affected eye

39. Diagnostic Tests
• Indirect ophthalmoscopy -
visualize the retina, which
may be pale, opaque, and
in folds with retinal
detachment
• Slit-lamp examination -
magnify the lesions.

40. Therapeutic Measures
• Laser surgery - laser beam
at the torn area of the
retina, causing a controlled
burn, which scars around
the tear and reattaches the
retina to surrounding tissue.

41. Therapeutic Measures
• Cryopexy - placement of a
supercooled probe on the
sclera over the affected area.
• The probe freezes and scars
the tear or hole.

42. Therapeutic Measures
• Scleral buckling - placing a
silicon implant in
conjunction with a belt like
device around the sclera to
bring the choroid in contact
with the retina.

43. Therapeutic Measures
• Pneumatic retinopexy -
injecting air or gas into the
chamber to hold the retina
in place.
• Patient must maintain a
position that keeps the air
bubble against the detached
area for up to 8 hours a day
for 3 weeks.

44. Complications
• increased intraocular
pressure (IOP)
• tears
• recurrent detachment

45. • Glaucoma - damage to the
optic nerve.
• The damage is silent,
progressive, and irreversible
until the end stages, when
loss of peripheral vision
occurs, followed by
reductions in central vision
and eventually blindness.

46. • Primary glaucoma - most common, consists of two
types: primary open-angle glaucoma (POAG) and acute
angle-closure glaucoma (AACG).
• Secondary glaucoma - caused by infections, tumors, or
injuries.
• Congenital glaucoma – developmental abnormalities.

47. Primary glaucoma:
• acute angle-closure glaucoma - anatomically narrowed
angle at the junction where the iris meets the cornea.
• primary open-angle glaucoma - drainage system of the
eye, the trabecular meshwork and Schlemm’s canal,
degenerate and subsequently block the flow of aqueous
humor.

48. Signs and Symptoms:
• severe pain
• blurred vision
• rainbows around lights
• photophobia
• eye redness
• steamy-appearing cornea
• Increased IOP can cause
nausea and vomiting.

49. Diagnostic Tests
• Tonometry - detects increased IOP
(N: 12–20 mmHg),
• AACG: IOP may exceed 50 mm Hg.
• visual field examination - loss of
peripheral vision
• distance vision is assessed
• Gonioscopy - determine if glaucoma
is open-angle or angle-closure.

50. Therapeutic Measures
• Cholinergics (miotics) (pilocarpine, carbachol) -
Increases aqueous fluid outflow
• Adrenergic agonists (dipivefrin, epinephrine) - Reduces
production of aqueous humor and increases outflow
• Beta-blockers (betaxolol, timolol) - Decreases aqueous
humor production
• Alpha-adrenergic agonists (apraclonidine, brimonidine)
- Decreases aqueous humor production

51. Therapeutic Measures
• Carbonic anhydrase inhibitors (acetazolamide,
methazolamide, dorzolamide) - Decreases aqueous
humor production
• Prostaglandin analogs (latanoprost, bimatoprost) -
Increases uveoscleral outflow

52. Therapeutic Measures
Acute attack of AACG:
• mannitol - rapidly reduce IOP
• analgesics
• complete bed rest
• Medications contraindicated in AACG: anticholinergics
(atropine), antihistamines (diphenhydramine),
hydroxyzine (Vistaril) - mydriatics.

53. Surgical Management
• For AACG, laser peripheral iridotomy or surgical
iridectomy is performed - remove a portion of the iris
• POAG is treated with laser trabeculoplasty - laser beam
creates openings in trabecular meshwork
• trabeculectomy - part of iris and trabecular meshwork
removed
• cyclocryotherapy - destroys part of ciliary body.

54. Nursing diagnoses
• Pain related to increased intraocular pressure
• Self-Care Deficit related to decreased vision
• Anxiety related to partial or total visual loss
• Risk for Injury related to decreased vision
• Deficient Knowledge related to medical regimen,
disease process due to no prior experience

56. • Cataract - opacity in the lens of
the eye that may cause a loss
of visual acuity.
• CATARACt: Congenital, Aging,
Toxicity (steroids, etc),
Accidents, Radiation (sunlight),
Altered metabolism (diabetes
mellitus) and Cigarette
smoking

57. Signs and Symptoms
• painless
• halos around lights
• difficulty reading fine print or
seeing in bright light
• increased sensitivity to glare
• double or hazy vision
• decreased color vision

58. Diagnostic Tests
• Visual acuity - near and far
vision.
• Direct ophthalmoscope and
slit-lamp microscope -
examine the lens and other
internal structures.

59. Surgical Management
• Phacoemulsification - ultrasonic
device is used to liquefy the
nucleus and cortex, which are
then suctioned out through a
tube.

60. Surgical Management
• Extracapsular cataract extraction
with removal of the lens and
anterior capsule.
• Implantable lenses inserted
after lens removal.
• Eyeglasses or contact lenses are
needed if no lens is reinserted.

62. Complications
• inflammation
• increased IOP
• macular edema
• retinal detachment
• vitreous loss
• hyphema
• endophthalmitis
• expulsive hemorrhage

63. Nursing Diagnoses
• Risk for Injury related to altered visual acuity
• Deficient Knowledge related to preoperative and
postoperative eye care
• Anxiety related to visual alteration and surgery

64. • Age-related macular
degeneration (AMD) -
deterioration and scarring
within the macula.
• People at risk include those
older than age 60, family
history, diabetes, smoking,
exposed to ultraviolet (UV)
light, and Caucasian people.

65. There are two types of AMD:
• Dry AMD – photoreceptors in the macula fail to function
and are not replaced because of advancing age. This
accounts for 70% to 90% of cases.
• Wet AMD - retinal tissue degenerates, allowing vitreous
fluid or blood into the subretinal space.

66. Prevention
• diet that includes dark green leafy vegetables (kale,
collard greens, lettuce, spinach), and orange (peppers)
and yellow (corn) color fruits and vegetables
• measuring macula pigment optical density -
preventative tool
• retinal carotenoids lutein and zeaxanthin and zinc
supplementation for a low macula pigment optical
density (less than 44)

67. Signs and Symptoms
• AMD of the dry type - slow, progressive loss of central
and near vision
• AMD of the wet - loss of central and near vision, but the
onset is sudden and results in more severe vision loss.
• Blurred vision, distortion of straight lines, and a dark or
empty spot in the central area of vision.
• Decreased ability to distinguish colors.

68. Diagnostic Tests
• visual acuity for near and far vision
• examination of the internal eye
structures with an ophthalmoscope
• Amsler grid - detect central vision
distortion
• color vision test - evaluate color
differentiation.

69. Diagnostic Tests
• digital imaging
• optical
• coherence tomography retinal scan
• intravenous fluorescein (dye)
angiography - evaluate blood
vessel leakage or abnormalities in
the eye.

70. Therapeutic Measures
• No treatment for the dry type of
AMD, so prevention is important
when possible.
• Low-vision telescopic glasses
• Intermittent injection into the eye
of an antiangiogenesis medication
(e.g., ranibizumab [Lucentis]).

71. • Injuries to the eye include
foreign bodies, chemical burns,
ultraviolet, or direct heat sources,
abrasions, lacerations from
dragging something across the
eye, and penetrating wounds,
which are the most serious eye
injury and increase the risk for
infection and blindness.

72. Signs and Symptoms
• mild to severe pain
• conjunctival redness
• photosensitivity
• decreased visual acuity
• erythema
• pruritus

73. Diagnostic Tests
• visual acuity
• slit-lamp microscope
• direct ophthalmoscope.
• fluorescein staining -
evaluate abrasions.

74. Therapeutic Measures
• Foreign bodies are treated with a normal saline flush
• Topical antibiotic ointment -prevent infection.
• Chemical burns must be treated immediately with a 15-
to 20-minute irrigation of either tap water or sterile
solution.
• Topical antibiotic ointments are usually prescribed.
• If there is a protruding object, it should be stabilized but
not removed until the HCP can assess the patient.

75. Nursing Diagnoses
• Acute Pain related to inflammatory process and injury
• Risk for Infection related to eye trauma
• Anxiety related to visual-sensory deficit
• Deficient Knowledge related to medical regimen due to
lack of previous experience

76. Benign Tumors of the Eyelids
• Nevi - enlarge and darken
• Hemangiomas – vascular capillary tumors
• Milia - small, white, slightly elevated cysts
• Xanthelasm - yellowish, lipoid deposits on
both lids
• Molluscum contagiosum lesions - flat,
symmetric growths caused by a virus that
can result in conjunctivitis and keratitis

77. Benign Tumors of the Eyelids
• Treatment is rarely indicated, except
when visual function is affected.
• Corticosteroid injection to the
hemangioma lesion I
• Surgical excision, or electrocautery, is
primarily performed for cosmetic
reasons.

78. Benign Tumors of the Conjunctiva
• Conjunctival nevus - flat, slightly elevated,
brown spot
• Melanosis - wax and wane and become
malignant melanoma
• Keratin- and sebum-containing dermoid
cysts
• Dermolipoma - smooth, rounded growth
in the conjunctiva near the lateral canthus

79. Benign Tumors of the Conjunctiva
• Papillomas - soft with irregular surfaces
and appear on the lid margins.
• Treatment consists of surgical excision.

80. Malignant Tumors of the Orbit
• Rhabdomyosarcoma - most common
malignant primary orbital tumor
• Symptoms: sudden painless proptosis
of one eye followed by lid swelling,
conjunctival chemosis, and impairment
of ocular motility.
• The most common site of metastasis is
the lung.

81. Malignant Tumors of the Orbit
• Management: surgery, radiation
therapy, and adjuvant chemotherapy.

82. Malignant Tumors of the Eyelid
• Basal cell carcinoma - most common
malignant tumor of the eyelid.
• Squamous cell carcinoma - second most
common malignant tumor.
• Malignant melanoma is rare and occur
more frequently among people with a
fair complexion who have a history of
chronic exposure to the sun.

83. Malignant Tumors of the Eyelid
• Complete excision of these carcinomas
is followed by reconstruction with skin
grafting if the surgical excision is
extensive.

84. Malignant Tumors of the Conjunctiva
• Conjunctival carcinoma – gelatinous
and whitish due to keratin formation.
• Malignant melanoma - arise from a
preexisting nevus
• Squamous cell carcinoma - invasive.
• The management is surgical incision.

85. Malignant Tumors of the Globe
• Retinoblastoma - malignant tumor of
the retina
• Signs and symptoms: leukocoria or
“white” pupil, uveitis, glaucoma,
hyphema, nystagmus, and periorbital
cellulitis.
• Treatment: enucleation

86. Malignant Tumors of the Globe
• Ocular melanoma - rare,
malignant choroidal tumor.
• The diagnosis is confirmed at
biopsy after enucleation.

87. Malignant Tumors of the Globe
• Ocular melanoma - rare,
malignant choroidal tumor.
• The diagnosis is confirmed at
biopsy after enucleation.
• Treatment consists of
radiation, enucleation, or
both.

88. • Shake suspensions
• Wash hands thoroughly before
and after the procedure.
• Read the label of the eye
medication.
• Do not touch the tip of the
medication container to any part
of the eye or face.

89. • Hold the lower lid down; do not
press on the eyeball.
• Instill eye drops before applying
ointments.
• Apply a 1⁄2-inch ribbon of
ointment to the lower conjunctival
sac.

90. • Keep the eyelids closed, and apply
gentle pressure on the inner
canthus for 1 or 2 minutes
immediately after instilling
eyedrops.
• Wait 5 to 10 minutes before
instilling another eye medication.

91. ASSESSMENT OF PATIENTS WITH EAR ND HEARING PROBLEMS
JOFRED M. MARTINEZ, RN, MAN
NG Review and Training Center, Inc.
Iloilo City, Philippines

92. • Otitis externa - inflammation of
the ear canal.
• Commonly known as swimmer’s
ear.
• Pseudomonas aeruginosa - most
common cause, external otitis
• Other causes: fungal infection,
mechanical trauma, or a local
hypersensitivity reaction.

93. Management
• Thorough cleansing of the ear canal
• Local antibiotics (Polymyxin B-
neomycin-hydrocortisone
(Cortisporin Otic); if cellulitis is
present - systemic antibiotics may
be necessary
• Medication to relieve the pain and
itching

94. • External auditory canal can be
obstructed by cerumen or foreign
bodies.
• Manifestations: sensation of fullness,
along with tinnitus and coughing due
to stimulation of the vagal nerve.
• The foreign body or impacted
cerumen may be visualized on
otoscopy.

95. • Impacted cerumen appears as a
yellow, brown, or black mass in the
canal.
• Impacted wax, objects, or insects
require physical removal using an
ear curet, forceps, or right-angle
hook inserted via an otoscope and
ear speculum.

96. • Mineral oil or topical lidocaine
drops are used to immobilize or
kill insects prior to their removal.

97. 1. Explain procedure to patient.
2. Check medication for dosage, strength, side effects,
contraindications, and expiration date. Make sure
medication is at room temperature.
3. Perform hand hygiene and apply gloves.
4. Position patient sitting up with head tilted toward
unaffected side or lying down on the unaffected side.
5. For a child, pull auricle down and back. For an adult, pull
auricle up and back.

99. 6. Instill prescribed number of drops, being careful not to
touch tip of dropper to anything to prevent
contamination.
7. Have patient remain in position for 2 to 3 minutes.
8. A small cotton plug may be inserted to prevent
medication from running out of ear.
9. Remove gloves. Perform hand hygiene.
10. Document eardrop administration and patient’s
tolerance of procedure.

101. • Otitis media - inflammation or
infection of the middle ear.
2 forms of otitis media:
• Serous OM - sterile effusion of
the middle ear
• associated with upper
respiratory infection and
eustachian tube dysfunction.

102. • Manifestations: decreased
hearing, “snapping” or “popping”
in the ear, decreased mobility of
tympanic membrane, acute pain,
hemorrhage, rupture of the
tympanic membrane, sensory
hearing loss and severe vertigo.
• Hemotympanum - bleeding into or
behind the tympanic membrane

103. • Acute OM - edema of the
eustachian tube impairs
drainage of the middle ear,
causing mucus and serous
fluid to accumulate.
• Caused by streptococcus
pneumoniae, Haemophilus
influenzae, and
Streptococcus pyogenes

104. Manifestations:
• Mild to severe pain, fever,
diminished hearing, dizziness,
vertigo, and tinnitus are common
associated complaints.
• Tympanic membrane is red and
inflamed or dull and bulging
• Spontaneous rupture of the
tympanic membrane releases a
purulent discharge.

105. Diagnosis
• Impedance audiometry
(tympanometry) - accurate
diagnostic test for OM with
effusion
• elevated WBC count and
increased numbers of
immature cells

106. Medications
• anti-inflammatory drug (e.g., oral
prednisone for 7 days)
• decongestant or antihistamine
• corticosteroid medications
• antibiotic therapy (amoxicillin,
trimethoprim-sulfamethoxazole,
cefaclor, or azithromycin) for 5 to
10 days.

107. Surgery
• Myringotomy - incision of the
tympanic membrane or
tympanocentesis to relieve excess
pressure in the middle ear and
prevent spontaneous rupture of
the eardrum.

109. • Mastoiditis - bacterial infection of
the mastoid process
• Manifestations: recurrent earache
and hearing loss, tenderness is
present over the mastoid process,
fever accompanied by tinnitus
and headache, profuse drainage
from the affected ear.

110. • Management: antibiotic therapy -
Intravenous ticarcillin-clavulanate
(Timentin) and gentamicin
• Mastoidectomy - surgical removal
of the infected mastoid air cells,
bone, and pus
• Tympanoplasty - surgical
reconstruction of the middle ear

111. • Otosclerosis - abnormal bone
formation in the osseous labyrinth
of the temporal bone
• Manifestations: reddish or pinkish-
orange tympanic membrane
• Rinne test – bone sound
conduction to be equal to or
greater than air conduction

112. • Management: sodium to
slow bone resorption and
overgrowth.
• Surgery: stapedectomy and
middle ear reconstruction or
a stapedotomy. A metallic
prosthesis is then inserted.

113. NURSING DIAGNOSIS:
• Risk for Injury related to hearing loss or postoperative
vertigo
• Disturbed Sensory Perception: Auditory related to bony
sclerosis of the stapes
• Impaired Verbal Communication related to hearing loss
• Anxiety related to concern about transmission of a genetic
disorder to children

114. • Vertigo - the sensation of
movement when there is none,
is a disorder of equilibrium.
• Attacks of vertigo are often
accompanied by nausea and
vomiting, nystagmus, and
autonomic symptoms such as
pallor, sweating, hypotension,
and salivation.

115. • Labyrinthitis/otitis interna -
inflammation of the inner ear.
• Manifestations: vertigo,
sensorineural hearing deficit,
and nystagmus
• Hearing loss in the ear affected
may be temporary or
permanent.

116. • Ménière’s disease/
endolymphatic hydrops -
chronic disorder characterized
by recurrent attacks of vertigo
with tinnitus and a progressive
unilateral hearing loss.
• Risk factors: viral injury, trauma,
bacterial infections such as
syphilis, autoimmune processes,
and vascular disorders

117. Manifestations:
• Recurrent attacks of vertigo, gradual loss of hearing, and
tinnitus.
• Attack linked to increased sodium intake, stress, allergies,
vasoconstriction, or premenstrual fluid retention.
• Hearing loss progresses and the vertigo can be severe
enough to cause immobility, nausea, and vomiting. Attacks
are often accompanied by hypotension, sweating, and
nystagmus.

118. Diagnosis:
• Caloric testing
(electronystagmography) -
evaluates the vestibulo-ocular
reflex by identifying eye
movements (nystagmus) in
response to caloric testing.

119. Diagnosis:
• Rinne and Weber tests
of hearing - decreased
air and bone conduction
on the affected side
• X-rays and CT scans of
the petrous bones –
evaluate the internal
auditory canal

120. Diagnosis:
• Glycerol test is conducted by giving
the patient oral glycerol to
decrease fluid pressure in the
inner ear. An acute temporary
hearing improvement is
considered diagnostic for
Ménière’s disease.

121. Medications
• Diuretic such as acetazolamide (Diamox) or
hydrochlorothiazide to reduce endolymphatic pressure.
• CNS depressant such as diazepam (Valium) or
lorazepam (Ativan) - halt an attack of vertigo.
• Parenteral droperidol (Inapsine) - sedative and
antiemetic effect, making it a useful drug for acute
attacks.

122. Medications
• Antivertigo/antiemetic medications such as meclizine
(Antivert), prochlorperazine (Compazine), or
hydroxyzine hydrochloride (Vistaril) – reduce the
whirling sensation and nausea.
• Intratympanic gentamicin - reducing the vertigo of
Ménière’s disease.

123. Treatments
• Bed rest in a quiet, darkened room with minimal
sensory stimuli and minimal movement
• Low-sodium diet - reduce labyrinthine pressure. A very
low salt diet (1 gm) may be prescribed if moderate
sodium restriction is ineffective in controlling attacks.
• Avoid tobacco, which causes vasoconstriction and can
precipitate an attack, along with alcohol and caffeine.

124. Surgery
• Surgical endolymphatic decompression - relieves the
excess pressure in the labyrinth
• Vestibular neurectomy - portion of cranial nerve VIII
that controls balance and sensations of vertigo is
severed.
• Labyrinthectomy - labyrinth is completely removed,
destroying cochlear function.

125. • Acoustic neuroma or
schwannoma - benign tumor
of cranial nerve VIII.
• Early manifestations:
tinnitus, unilateral hearing
loss, nystagmus, dizziness or
vertigo.

126. Diagnosis
• Tumor identified on CT or
MRI scans.
• X-ray films of the petrous
pyramid of the temporal
bone may show erosion
caused by the tumor.

127. Treatment
• Surgical excision
• Translabyrinthine approach
provides good access to the
tumor and allows the facial
nerve to be preserved.

128. • Hearing loss impairs the
ability to communicate in a
world filled with sound and
hearing individuals.
• Lesions in the outer ear,
middle ear, inner ear, or
central auditory pathways
can result in hearing loss.

129. • The process of aging also can
affect the structures of the
ear and hearing.
• Hearing loss is classified as
conductive, sensorineural, or
mixed, depending on what
portion of the auditory
system is affected.

130. • Turns up volume on the television or radio.
• Frequently asks, “What did you say?”
• Leans forward or turns head to one side during
conversations to hear better.
• Cups hand around ear during conversation.
• Mentions that people are talking softly or mumbling.
• Speaks in an unusually quiet or loud voice.
• Answers questions inappropriately or not at all.

131. • Has difficulty hearing high-frequency consonants.
• Avoids group activities.
• Shows loss of sense of humor.
• Has strained or serious look on face during conversations.
• Appears to ignore people or is aloof; does not participate.
• Is irritable or sensitive in interpersonal relations.
• Reports ringing, buzzing, or roaring noise in the ears.

132. CONDUCTIVE HEARING LOSS
• Anything that disrupts the transmission of sound from the
external auditory meatus to the inner ear.
• Most common cause - obstruction of the external ear
canal (impacted cerumen, edema of the canal lining,
stenosis, and neoplasms).
• Other causes: perforated tympanic membrane, disruption
or fixation of the ossicles of the middle ear, fluid, scarring,
or tumors of the middle ear.

133. SENSORINEURAL HEARING LOSS
• Disorders that affect the inner ear, the auditory nerve, or
the auditory pathways of the brain.
• A significant cause of sensorineural hearing deficit is
damage to the hair cells of the organ of Corti.
• Ototoxic drugs damage the hair cells

134. OTOTOXIC DRUGS
Aminoglycoside antibiotics Amikacin
Gentamicin
Neomycin
Streptomycin
Tobramycin
Other antibiotics Erythromycin
Minocycline
Vancomycin

135. OTOTOXIC DRUGS
Diuretics Bumetanide
Furosemide
Hydrochlorothiazide
Other drugs Cisplatin
Indomethacin
Methotrexate
Salicylates

136. SENSORINEURAL HEARING LOSS
• Other causes: prenatal exposure to rubella, viral
infections, meningitis, trauma, Ménière’s disease, and
aging.
• Tumors such as acoustic neuromas, vascular disorders,
demyelinating or degenerative diseases, infections
(bacterial meningitis in particular), or trauma.

137. PRESBYCUSIS
• Presbycusis – gradual hearing
loss associated with aging.
• Higher pitched tones and
conversational speech are lost
initially.
• Hearing aids and other
amplification devices are useful
for patients with presbycusis.

138. TINNITUS
• Tinnitus - perception of sound or
noise in the ears without stimulus
from the environment.
• The sound may be steady,
intermittent, or pulsatile and is
often described as a buzzing,
roaring, or ringing.

139. TINNITUS
• Tinnitus is associated with
salicylate, quinine, or quinidine
toxicity.
• Other etiologies: obstruction of the
auditory meatus, presbycusis,
middle or inner ear inflammations
and infections, otosclerosis, and
Ménière’s disease.

140. DIAGNOSIS
• Rinne and Weber tests - compare
air and bone sound conduction.
• Rinne test evaluates hearing loss
by comparing air conduction to
bone conduction.
• Weber test is another way to
evaluate conductive and
sensorineural hearing losses.

141. DIAGNOSIS
• Audiometry - identifies the type and
pattern of hearing loss.
• Tympanometry - indirect
measurement of the compliance and
impedance of the middle ear to
sound transmission.

142. DIAGNOSIS
• Acoustic reflex testing - evaluate
movement of the structures of
the middle ear.

143. AMPLIFICATION
• Hearing aid or other amplification
device help patients with hearing
deficits.
• All hearing aids include a
microphone, amplifier, speaker,
earpiece, and volume control.

144. AMPLIFICATION
• Canal hearing aids are the least
noticeable style, fitting in the ear
canal.
• In-ear style of hearing aid fits into
the external ear and is used for mild
to severe hearing loss

145. AMPLIFICATION
• Behind-ear hearing aid allows finer
adjustment of the level of
amplification and is easier for the
patient to manipulate
• Body hearing aid the microphone
and amplifier are contained in a
pocket-sized case that clips onto
clothing, slips into a pocket, or
carries in a harness.

146. SURGERY
• Stapedectomy or tympanoplasty
- help restore hearing with a
conductive hearing loss.
• Cochlear implant for restoring
sound perception.

147. • Insert hearing aid while over a soft surface such as a
pillow to prevent damage if the hearing aid is dropped
during insertion.
• Remove hearing aid before showering or bathing.
• Do not immerse in water.
• Turn the hearing aid off when not in use to conserve
battery.
• Do not expose the hearing aid to extreme heat or cold.
• Clean the hearing aid daily with a dry, soft cloth.

148. • Clean earmold with small brush or toothpick to keep free
of earwax.
• Turn off the hearing aid and turn the volume down before
inserting. Turn hearing aid on and increase volume once
it is inserted.
• Minimize whistling noise by ensuring that the volume is
not too high, the aid fits securely, and the aid is free from
earwax.

149. • Check battery or lower the volume if sound is not clear or
is intermittent. Buzzing noise may indicate that the battery
door is not completely closed.
• Do not expose the hearing aid to hair or medicinal sprays
by applying sprays before inserting hearing aid.

150. NURSING DIAGNOSES
• Disturbed Sensory Perception: Auditory
• Impaired Verbal Communication
• Social Isolation

151. A nurse is working with patients who have moderate to
severe hearing or vision impairment. Which of the following
does the nurse identify as the highest priority of care?
a. preventing sensory deprivation
b. encouraging social interaction
c. promoting family relationships
d. maintaining resident safety

152. The nurse teaching a patient with newly diagnosed
glaucoma emphasizes which of the following instructions?
a. turning the head side to side to compensate for
impaired peripheral vision
b. using the prescribed eyedrops as directed on a
continuing basis
c. contacting the physician if further decline in vision is
noticed
d. avoiding coughing, sneezing, or straining to have a
bowel movement

153. A patient with glaucoma has a history of heart failure.
Which medication should the nurse discuss with the
physician before administering it?
a. brimonidine (Alphagan)
b. dorzolamide (Trusopt)
c. timolol (Timoptic)
d. latanoprost (Xalatan)

154. A patient with Ménière’s disease experiences frequent
attacks of vertigo and tinnitus. Of the following teaching
points, which one has the highest priority for this patient?
a. Follow a low-sodium diet.
b. Stop smoking.
c. Take prescribed antiemetic medications.
d. Sit down when an attack develops.

155. On a patient’s return from cataract surgery, the nurse in the
ambulatory surgery recovery unit does which of the
following?
a. places the patient in semi-Fowler’s position
b. positions the patient on the affected side
c. places the patient in a private room
d. ensures the patient is in proximity to the nurses’ station

156. A patient calls her primary care provider’s office with complaints
of bright flashing lights to the side of her vision. Which is the
most appropriate response by the nurse?
a. Recommend that she lie down until the sensation has
passed.
b. Advise her to make an appointment to have her blood
pressure checked.
c. Initiate immediate referral to an ophthalmologist.
d. Reassure her that this is not unusual and should resolve
without treatment.

157. On a patient’s return from cataract surgery, the nurse in the
ambulatory surgery recovery unit does which of the
following?
a. places the patient in semi-Fowler’s position
b. positions the patient on the affected side
c. places the patient in a private room
d. ensures the patient is in proximity to the nurses’ station

158. An elderly patient complains to the nurse that his head
“feels stuffy” and he has ringing in his ears. How should the
nurse respond?
a. Make an appointment with the resident’s primary care
physician.
b. Refer the patient for evaluation by a local audiologist.
c. Provide nonprescription eardrops for daily use.
d. Inspect the ear canals for patency.

159. The nurse caring for a patient with a severe hearing deficit
identifies which of the following as an appropriate goal
toward improving the patient’s social interactions?
a. Will plan to have dinner with one or two friends weekly.
b. Will participate in senior center communal lunches at
least twice per week.
c. Will engage in activities such as card tournaments and
dancing.
d. Will attend religious services of choice.

160. When assessing a patient, the nurse notes absence of the red
reflex in the patient’s right eye. The patient responds, “Yes, my
doctor told me I have cataracts. When do you think I should have
them removed?” How should the nurse respond?
a. “It appears that the right eye is due for surgery.”
b. “Are you having difficulty reading or doing activities you enjoy?”
c. “Are you starting to experience pain in your right eye or
frequent headaches?”
d. “Cataracts can be removed any time that it is convenient for
you.”

161. The nurse is caring for a patient who is diagnosed with
otosclerosis. The patient asks the nurse what this disease is.
Which is the most appropriate response by the nurse?
a. “Infection of the external ear commonly caused by
moisture.”
b. “Tumor of the eighth cranial nerve.”
c. “Hardening of the stapes due to new bone growth.”
d. “Inflammation of the inner ear caused by pathogens.”

162. The nurse is caring for a patient who is diagnosed with a
refractive error. The patient asks the nurse what this means.
What would be the appropriate explanation by the nurse?
a. “You will lose your vision and become blind.”
b. “You will need corrective lenses in order to see clearly.”
c. “The pressure in your eyes is higher than normal.”
d. “Your vision is 20/20.”

163. A patient comes to the health clinic for a suspected ear
infection. Which of the following data collection findings does
the nurse expect with an external ear infection?
a. Pain
b. Fullness in ears
c. Fever
d. Dizziness

164. A patient has been prepped for an internal eye examination.
Anesthetic drops and a mydriatic drug have been
administered. Which of the following should the patient be
taught for eye safety following the examination?
a. “Wear sunglasses after the exam.”
b. “Rub your eye hourly to increase blood circulation.”
c. “You may reapply contact lenses when the eye exam is
completed.”
d. “Flush your eye with water to remove the eye drops.”

165. The nurse cares for patients after eye surgery. Which of the
following patients would the nurse provide specific positioning
instructions to after eye surgery to prevent complications?
a. 19-year-old after removal of congenital cataract
b. 30-year-old woman after pneumatic retinopexy
c. 52-year-old man after trabeculectomy
d. 82-year-old man after corneal transplant

166. The nurse is caring for a patient with a history of acute angle-
closure glaucoma. The nurse is preparing to administer the
patient’s medications. Which medications should the nurse
question before administration?
a. Morphine
b. Cefazolin (Kefzol)
c. Atropine
d. Ranitidine (Zantac)
e. Hydroxyzine (Vistaril)
f. Warfarin (Coumadin)

167. The nurse is assisting with discharge instructions for a patient.
For which of the following medications would the nurse teach
the patient that the medication can cause hearing loss?
a. Furosemide (Lasix)
b. Acetaminophen (Tylenol)
c. Warfarin (Coumadin)
d. Penicillin (Pen-Vee K)

168. The nurse is caring for a patient with macular degeneration.
During data collection, which symptom would the nurse
anticipate the patient to report?
a. Loss of peripheral vision
b. Sudden darkness
c. Dull ache in the eyes
d. Loss of central vision

169. The nurse is contributing to the plan of care for a patient with
Ménière’s disease. What is the primary goal for a patient with
Ménière’s disease that the nurse should recommend to
include in the plan of care?
a. Prevent dehydration
b. Decrease pain
c. Prevent injury
d. Preserve hearing

170. The nurse is caring for a patient with presbycusis. Which
technique is most important for the nurse to use to increase
communication with this patient?
a. Talk in a very loud voice.
b. Lower voice pitch.
c. Do not smile or chew gum when talking to the patient.
d. Allow extra time for patient to respond.

171. A patient with acute angle-closure glaucoma reports use of the
following medications. The use of which of these medications
indicates to the nurse that the patient requires further
instruction?
a. Acetaminophen
b. Cefazolin (Kefzol)
c. Ranitidine (Zantac)
d. Diphenhydramine (Benadryl)

173. ASSESSMENT OF PATIENTS WITH EYE AND VISION PROBLEMS
JOFRED M. MARTINEZ, RN, MAN
NG Review and Training Center, Inc.
Iloilo City, Philippines