Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 22: Nursing Management: Visual and Auditory Problems

Key Points – Printable

VISUAL Problems 
CORRECTABLE REFRACTIVE ERRORS
•	Refractive errors, the most common visual problems, occur when light rays do not converge into a single focus on the retina.
o	Myopia, or nearsightedness, is the inability to accommodate for objects at a distance.
o	Hyperopia, or farsightedness, is inability to accommodate for near and far objects. 
o	Presbyopia is farsightedness caused by decreased accommodative ability of the aging eye.
o	Astigmatism is due to an irregular corneal curvature.
o	Aphakia is the absence of the lens, either congenitally or surgically following trauma or caused by a cataract.
•	Most refractive errors are corrected by lenses (eyeglasses or contact lenses), refractive surgery, or surgical implantation of an artificial lens.

UNCORRECTABLE VISUAL IMPAIRMENT
•	Patients who are legally blind are categorized by level of visual loss. 
o	Total blindness is defined as no light perception and no usable vision.
o	Functional blindness is present when there is some light perception but no usable vision.
•	Almost all blindness in the United States is the result of common eye diseases. 

NURSING MANAGEMENT: VISUAL IMPAIRMENT
•	Various levels of visual impairment exist. You must assess the length of impairment and its impact on the patient’s functional abilities.
•	Treatment and assistive interventions depend on each patient’s visual abilities. 
o	The patient with recent impairment will require a great deal of emotional support and direct care focusing on safety and promoting functional abilities.
o	The rehabilitation period focuses on independence, self-esteem, and productivity.

GERONTOLOGIC CONSIDERATIONS: VISUAL IMPAIRMENT
•	The elderly are at risk for vision loss caused by a variety of eye diseases, which may be compounded by other deficits.
•	Vision loss in the elderly poses an increased risk for falls and confusion or disorientation.

EYE TRAUMA
•	Everyday activities can result in ocular trauma, including sports and leisure activities, work-related situations, and automobile injuries.
•	Your role in individual and community education is extremely important in reducing the incidence of ocular trauma.

EXTRAOCULAR DISORDERS
INFLAMMATION AND INFECTION
•	A hordeolum (sty) is an infection of sebaceous glands in the lid margin.
•	A chalazion is a chronic inflammatory granuloma of meibomian (sebaceous) glands in the lid.
•	Blepharitis is a common chronic bilateral inflammation of the lid margins.
•	Conjunctivitis is infection or inflammation of the conjunctiva.
o	Acute bacterial conjunctivitis (pinkeye) is common. It occurs initially in one eye and can spread rapidly to the unaffected eye. It is usually self-limiting, but antibiotic drops shorten the course of the disorder.
o	Trachoma is a preventable, chronic conjunctivitis caused by Chlamydia trachomatis, which is transmitted mainly by hands and flies.
•	Keratitis is corneal inflammation or infection.
o	The cornea can become infected by bacteria, viruses, or fungi. Other causes are chemical damage, contact lens wear, and contamination.
o	Topical antibiotics are generally effective, but eradicating infection may require antibiotics administered by subconjunctival injection or IV.
o	Tissue loss resulting from infection produces corneal ulcers. An untreated ulcer can result in corneal scarring and perforation.
o	Treatment is aggressive to avoid permanent loss of vision. Topical antibiotics are generally effective, but eradicating infection may require antibiotics administered by subconjunctival injection or IV.

NURSING MANAGEMENT: INFLAMMATION AND INFECTION
•	Treatment focuses on avoiding the spread of infection, maintaining or improving visual acuity, and promoting comfort and functioning during therapy.
•	Since these problems are usually treated in the ambulatory or home setting, the patient’s primary need is for education about the necessary care for the specific problem.

NONINFECTIOUS DISORDERS
•	Keratoconjunctivitis sicca, or dry eyes, is caused by a decrease in tear film.
•	Strabismus occurs when the eyes are unable to focus on an object simultaneously.
•	Corneal wounds result in decreased transparency of the cornea; the growth of the cornea in keratoconus results in its being cone shaped. Both may be corrected by lenses or surgery.

INTRAOCULAR DISORDERS
CATARACT
•	A cataract is an opacity within the lens.
•	Symptoms of cataracts are decreased vision, abnormal color perception, and glare.
•	Removal of the cataract is the most common surgery for older adults. Most patients undergoing cataract removal have an intraocular lens implanted during surgery.
•	After cataract surgery, the eyes may be temporarily covered with a patch and/or protective shield.
•	Postoperative nursing goals include teaching about eye care, activity restrictions, medications, follow-up visit schedule, and signs/symptoms of possible complications.
•	Healing is complete around 6 to 8 weeks postoperatively.

RETINOPATHY
•	Retinopathy is microvascular damage to the retina that can lead to blurred and progressive vision loss.
•	It is often associated with diabetes mellitus and hypertension.
•	Nonproliferative diabetic retinopathy is characterized by capillary microaneurysms, retinal swelling, and hard exudates. It may be treated with laser photocoagulation.
•	Hypertensive retinopathy is caused by high blood pressure that creates blockages in retinal blood vessels.
o	On examination, retinal hemorrhages and macula swelling are noted.
o	Sustained, severe hypertension can cause sudden visual loss with optic disc and nerve swelling.
o	Treatment focuses on lowering the blood pressure.

RETINAL DETACHMENT
•	Retinal detachment is a separation of the retina and underlying epithelium with fluid accumulation between the two layers.
•	One cause of detachment is a retinal break, which is interruption in the full thickness of retinal tissue. Breaks are classified as tears or holes. Other less common causes are tractional or exudative.
•	Symptoms are light flashes, floaters, and/or rings in vision. Once detached, painless loss of peripheral or central vision occurs.
•	Untreated, symptomatic retinal detachment results in blindness.
•	Treatment of retinal detachment is to first seal retinal breaks and then relieve inward traction on the retina.
•	Several types of surgery for retinal detachment include laser photocoagulation and cryopexy and then scleral buckling.
•	Visual prognosis varies, depending on the extent, length, and area of detachment.
•	Discharge planning and teaching are important; begin this process early since the patient is not hospitalized for long.

AGE-RELATED MACULAR DEGENERATION 
•	Age-related macular degeneration (AMD) is the most common cause of irreversible central vision loss in older adults. Family history is another strong predictor of risk.
•	AMD has two forms: dry (nonexudative) and wet (exudative).
o	Dry AMD is more common, with close vision tasks becoming more difficult. Atrophy of macular cells leads to slow, progressive, and painless vision loss.
o	Wet AMD is more severe, with rapid onset and development of abnormal blood vessels related to the macula. Symptoms are blurred, distorted, and darkened vision with visual field blind spots.
o	Wet AMD treatment includes laser photocoagulation, photodynamic therapy, and intravitreous injectable drugs. 
o	Vitamin and mineral supplements may be considered for dry and wet AMD.

Glaucoma
•	Glaucoma is a group of disorders characterized by increased intraocular pressure (IOP), optic nerve atrophy, and peripheral visual field loss.
•	Glaucoma often occurs with advanced age and is a major cause of permanent blindness.
•	Etiology is due to consequences of elevated IOP from decreased outflow of aqueous humor. Two types of glaucoma include primary angle-closure glaucoma (PACG) and primary open-angle glaucoma (POAG), which is the more common.
o	With POAG, the outflow is decreased in the trabecular network. Few symptoms exist and it is often not noticed until peripheral vision is severely compromised.
o	With PACG, outflow is reduced because of angle closure. Symptoms are definite, and include sudden, excruciating eye pain along with nausea and vomiting.
•	The goal of therapy is to lower IOP to prevent optic nerve damage. This is accomplished through drugs, argon laser trabeculoplasty, trabeculectomy, and iridotomy. 
•	Because glaucoma is largely preventable with early detection and treatment, the nurse needs to teach glaucoma risk and the importance of early detection and treatment.
•	Since glaucoma is a chronic condition, the nurse needs to stress to the patient and family the importance of following the therapeutic regimen.
•	Secondary glaucoma can develop with the use of certain medications. This may be more prevalent in older patients with multiple systemic illnesses and medications.

INTRAOCULAR INFLAMMATION AND INFECTION
•	Uveitis is inflammation of the uveal tract, the retina, the vitreous body, or the optic nerve.
•	Cytomegalovirus retinitis (CMV) is an opportunistic infection that occurs in immunosuppressed patients.
•	Endophthalmitis is inflammation of the vitreous cavity.
•	The patient with panophthalmitis has inflammation of the vitreous, retina, choroid, and sclera.
•	Treatment of intraocular inflammation depends on the cause. This may include antimicrobial or antiinflammatory agents.

Ocular Tumors 
•	Benign and malignant tumors can occur in many areas of the eye.
•	Depending on the cause, treatment options include radiation therapy, photocoagulation, and surgery, including resection, exenteration, and enucleation.
•	Enucleation, or removal of the eye, may be done in ocular malignancies, as well as trauma, infection, or glaucoma. 

ENUCLEATION
•	Enucleation is the removal of the eye. It is usually done for a blind, painful eye, as well as glaucoma, infection, or trauma.
•	After the wound is healed, the patient is fitted with a permanent prosthesis.
	
OCULAR MANIFESTATIONS OF SYSTEMIC DISEASES
•	It is important for the nurse to recognize that many systemic diseases have ocular manifestations.
•	Ocular signs and symptoms may be the first finding or complaint in a person with systemic disease. 

AUDITORY PROBLEMS 
EXTERNAL EAR AND CANAL
TRAUMA
•	Trauma to the ear can ultimately result in infection and hearing loss.

EXTERNAL OTITIS
•	External otitis involves inflammation or infection of the auricle and ear canal epithelium caused by infection.
•	Diagnosis is made by otoscopic examination. Symptoms are pain, ear canal swelling, and drainage. Muffled hearing and a fever may also be present.
•	Therapy is analgesics, antibiotics, and warm compresses.

CERUMEN AND FOREIGN BODIES IN EXTERNAL EAR CANAL
•	A variety of objects, including cerumen and foreign objects, may become impacted in the ear. Their removal should be performed by a health care provider.

MALIGNANCY OF EXTERNAL EAR
•	Skin cancers are the only common malignancies of the ear. 
•	Since most are related to skin exposure, teach the patient measures to reduce sun-exposure risk.

MIDDLE EAR AND MASTOID
ACUTE OTITIS MEDIA
•	This is an infection of the tympanum, ossicles, and space of the middle ear.
•	Symptoms include pain, fever, malaise, and reduced hearing.
•	Collaborative care includes antibiotics; surgery is reserved for those who do not respond to medical treatment.

CHRONIC OTITIS MEDIA AND MASTOIDITIS
•	Untreated or repeated attacks of acute otitis media in early childhood may lead to chronic middle ear infection. 
•	Symptoms include purulent exudate and inflammation that can involve the ossicles, eustachian tube, and mastoid bone.
•	It is often painless.
•	Treatment may include antibiotics and surgery.

OTOSCLEROSIS
•	Otosclerosis is a hereditary disease that causes abnormal bone growth in the middle ear, resulting in conductive hearing loss.
•	It is treated by medications that slow bone resorption, hearing aids, and surgery.

INNER EAR PROBLEMS
MÉNIÈRE’S DISEASE
•	Ménière’s disease is characterized by symptoms of inner ear disease. 
•	The cause is unknown, but results in excessive accumulation of endolymph.
•	Attacks may begin with a sense of ear fullness, tinnitus, and decreased hearing acuity. Other symptoms are pallor, sweating, nausea, and vomiting.
•	The duration of attacks is hours to days, and attacks occur several times a year.
•	Hearing loss fluctuates, and with continued attacks, recovery lessens, eventually leading to permanent hearing loss.
•	Drugs are used between and during attacks. If not relieved, surgeries include endolymphatic sac decompression and vestibular nerve resection.
•	Nursing care minimizes vertigo and provides for patient safety with acute attacks.

BENIGN PAROXYSMAL POSITIONAL VERTIGO
•	Benign paroxysmal positional vertigo is caused by free-floating debris in the semicircular canals. 
•	Symptoms include dizziness, vertigo, lightheadedness, nausea, and loss of balance.
•	The Epley maneuver may provide symptom relief.

ACOUSTIC NEUROMA
•	It is a benign tumor in which cranial nerve VIII enters the internal auditory canal.
•	Early symptoms include tinnitus, vertigo, and progressive sensorineural hearing loss.
•	Surgical treatment is usually indicated to preserve hearing.

Hearing LOSS AND DEAFNESS
•	Conductive hearing loss occurs in outer and middle ear and impairs the sound being conducted from outer to inner ear. It is caused by conditions interfering with air conduction, such as otitis media with effusion, impacted cerumen and foreign bodies, middle ear disease, and otosclerosis.
•	Sensorineural hearing loss is due to impairment of inner ear or vestibulocochlear nerve (CN VIII) resulting in the inability to understand speech. Causes include congenital and hereditary factors, noise trauma, aging, Ménière’s disease, and ototoxicity. 
•	Signs of hearing loss include asking others to speak up, answering questions inappropriately, not responding when not looking at speaker, straining to hear, and increasing sensitivity to slight increases in noise level. 
•	Often the patient is unaware of minimal hearing loss. Assistive devices and techniques include hearing aids, speech reading, and a cochlear implant.
•	Prevention of hearing loss focuses on participation in hearing conservation programs in the work environment, monitoring for side effects and level of ototoxic drugs (e.g., salicylates, diuretics, antineoplastics), and avoidance of both continued exposure to high noise levels (above 85-95 decibels) and industrial drugs and chemicals.
•	Presbycusis (hearing loss associated with aging) includes loss of peripheral auditory sensitivity, decline in word recognition ability, and associated psychologic and communication issues.