Care of Client with Sensory Disorders and neuro

Care of the Client with Sensory Disorders and neuro Most of us will agree that the abilities to see, hear, taste, perceive touch, and smell are pretty important. Without the ability to smell, food would have little, if any, taste. The sense of touch lets us know when we experience something pleasurable or are injured. But of all the senses, the abilities to see and hear are considered most important because they keep us most informed about the world around us. This chapter reviews problems affecting vision and hearing. 9780133391794/c 9780133391794/c 9780133391794/ Disorders of the Eyes Before discussing the various disorders of the eyes, it is important that you understand the anatomical structure of the eye. Figure 8.1 offers an illustration for reference. FIGURE 8.1 Structure of the eye. Disorders of the eyes can be divided into the following categories: Intraocular disorders: These arise from within the eyeball. Examples include cataracts and glaucoma. Retinal disorders: These arise from the innermost layers of the eyeball. Examples include hypertensive retinopathy, diabetic retinopathy, and macular degeneration. Refractive errors: These affect the eye’s ability to focus. Examples include myopia, hyperopia, presbyopia, and astigmatism. Traumatic injuries: These pose the risk of infection and loss of vision. Examples include hyphema, contusions, foreign bodies, lacerations, and penetrating injuries. Intraocular Disorders Intraocular disorders arise from within the eyeball. The primary intraocular disorders you need to understand include cataracts and glaucoma. The sections that follow discuss these two diseases in greater detail. Cataracts Cataracts, opacities in the lens of the eye, result in the distortion of images projected onto the retina. Cataracts are associated with aging, trauma, disease of the eye, prolonged use of steroids, and exposure to sunlight or ultraviolet light. Congenital cataracts of the newborn are characterized by the absence of the red reflex. Symptoms of cataracts include the following: Blurred, hazy vision Glare from bright lights Yellow, white, or gray discoloration of the pupil Gradual loss of vision Caution Cataract surgery is generally performed in an outpatient surgery center. The client is given a sedative to lessen anxiety. Medications such as Diamox (acetazolamide) are given to reduce intraocular pressure. Mydriatic eye drops such as Neo-Synephrine (phenylephrine) are used in combination with cycloplegics such as Cyclogyl (cyclophenolate HCl) to paralyze the muscles of accommodation. After the client is in the operative area, an intravenous injection of Versed (midazolam) can be given to induce light anesthesia during administration of local anesthesia. Removal of the affected lens is usually accomplished by an extracapsular cataract extraction (ECCE). The anterior portion of the lens is opened and removed along with the lens cortex and nucleus. The surgeon uses sound waves to break the affected lens into small pieces. These small pieces are then removed by suction. (This process is known as phacoemulsion.) The posterior lens capsule is left in place to provide support for the intraocular lens implant, a small plastic lens individually designed for the client. Although binocular vision and depth perception are immediately improved, most clients experience their best vision from four to six weeks after surgery. If an intraocular lens cannot be implanted, the client will be fitted with convex corrective glasses or contact lenses to correct vision. Antibiotic drops and steroid ointments are instilled in the operative eye immediately after surgery. In most instances, the operative eye is left unpatched. Postoperatively, the client is maintained in a semi-Fowler’s position to reduce swelling and to prevent stress on the new lens implant. Clients are usually discharged within two to three hours following surgery. Before discharging the client, the nurse should instruct the client to do the following: Avoid activities that would increase intraocular pressure, such as bending from the waist, blowing the nose, wearing tight shirt collars, closing the eyes tightly, and placing the head in a dependent position. Report sharp, sudden pain in the operative eye. Pain early after surgery might indicate bleeding or increased intraocular pressure. Report signs of infection, which include yellow or green discharge. Creamy white or whitish dry, crusty drainage is normal following cataract surgery. Report changes in vision including decreasing vision, flashes of light, or visual floaters. Take a tub bath or shower facing away from the water. Administer eye medication as directed. Wear a protective shield when sleeping. Return for follow-up visits as directed. Glaucoma Glaucoma refers to a group of diseases that result in an increase in intraocular pressure. Glaucoma is the second leading cause of permanent blindness in the United States and the second leading cause of blindness in the world, according to the World Health Organization. Blindness from glaucoma is largely preventable with early detection and treatment. The three types of glaucoma and their characteristics are as follows: Primary open-angle glaucoma (POAG): This is the most common form of glaucoma. POAG affects both eyes, is usually asymptomatic, and is caused by a decrease in the outflow of aqueous humor. The intraocular pressure in those with POAG averages between 22 mm Hg and 32 mm Hg. Symptoms of POAG include the following: Tired eyes Diminished peripheral vision Seeing halos around lights Hardening of the eyeball Increased intraocular pressure Acute glaucoma: This condition, sometimes called narrow-angle glaucoma or primary angle-closure glaucoma (PACG), is less common than primary open-angle glaucoma. Acute glaucoma is caused by a sudden reduction in the outflow of aqueous humor due to angle closure. Angle closure can result from the lens bulging forward (an age-related process) or from pupil dilation in the client with anatomically narrow angles. The condition can be precipitated by the use of mydriatics, emotional upset, or darkness. The onset of severe eye pain is sudden and without warning. Emergency treatment is necessary because rising intraocular pressure can exceed 30 mm Hg. Symptoms of acute glaucoma include the following: Sudden, excruciating pain around the eyes Headache or aching in the eyebrow Nausea and vomiting Cloudy vision Pupil dilation Secondary glaucoma: This is caused by ocular conditions that narrow the canal of Schlemm or that alter eye structures that are involved in the production and circulation of aqueous humor. Secondary glaucoma is managed by treating the underlying ocular condition and by the use of anti-glaucoma medications. Note The normal intraocular pressure ranges from 10 to 21 mm Hg. Management of a Client with Glaucoma Conservative management of the client with POAG is aimed at reducing intraocular pressure with medications. Miotic eye drops such as Isopto Carpine (pilocarpine HCl) are instilled to constrict the pupil and increase the outflow of aqueous humor. Beta blockers such as Timoptic (timolol) and carbonic anhydrase inhibitors like Diamox (acetazolamide) decrease the production of aqueous humor, thereby lowering the intraocular pressure. Prostaglandin analogs such as Xalatan (latanoprost) administered daily are the drugs of choice for the treatment of chronic glaucoma. Prostaglandin analogs have fewer side effects, but can cause permanent changes in the color of the iris and eyebrows. Trabeculoplasty and trabeculectomy filtration surgery are the most commonly used surgical procedures used for the treatment of chronic open angle glaucoma. Note Nursing Skill: Application of Eye Medications Before instilling medication into the eyes, the lids and lashes should be cleaned using warm water. Only sterile ophthalmic preparations should be used. The nurse should avoid touching the eye with the applicator. Ointments should be applied from the inner to outer canthus of the eye. Eye drops should be dropped into the lower lid while the client is looking up. Gentle pressure should be placed over the tear duct, and the client should be instructed to refrain from tightly closing the eyelids. Argon laser trabeculoplasty is an option when medications are not effective in reducing the intraocular pressure. A filtering procedure or trabeculectomy is indicated when medication and laser therapy are not successful. The success rate for trabeculectomy is between 75% and 85%. Surgical implantation of a small tube to shunt the aqueous humor away from the anterior chamber to an implanted reservoir is reserved for those in whom the filtering procedure failed.