Care of Clients with

Sensory Problems

Pocholo Santos
Chinese General Hospital College of Nursing
NCM 104
 Diagnostic Assessment
1. Eye
a. Snellen’s Chart
 To check visual acuity
b. Tonometry
 To measure intra-ocular pressure
 N=12-20 mmHg
c. Perimetry
a. To check peripheral vision
d. Bjerrum’s tangent screen
 For central vision
e. Ishihara plate
 Color vision
 Diagnostic Assessment
2. Ear
a. Audiometry
Decibels
 Unit of measurement in hearing
 70 decibels do not damage the ear
 Conductive Hearing Loss
 Problems with tympanic membrane, middle ear
or mastoid
 Sensorineural Hearing Loss
 Problems of the Cochlea (sensory) and acoustic
nerve (neural)
 Mixture Hearing Loss
 Combinatation of conductive and sensorineural
affectation
 Diagnostic Assessment

Vestibular function
• Diagnostic test for balance and
equilibrium
• Oculovestibular reflex or calorie test
• Test 8th cranial nerve
• Cold or hot water into external
auditory canal produces nystagmus
Diagnostic Assessment

Tuning fork
Weber test
• On patient’s forehead or teeth
Rinnes test
• Shifted between mastoid bone and 2
inches from the ear canal opening
Eyes Disorders
 Anatomy & Physiology
Outer Protective Layer [EYES]
 Sclera - the white visible portion of the eyeball. The muscles that move the eyeball
are attached to the sclera.
 Cornea - the clear, dome-shaped surface that covers the front of the eye.
Middle Vascular Layer
 Choroid - the thin, blood-rich membrane that lies between the retina and the sclera;
responsible for supplying blood to the retina.
 Ciliary body - the part of the eye that produces aqueous humor.
 Iris - the colored part of the eye. The iris is partly responsible for regulating the
amount of light permitted to enter the eye.
Inner Neural Layer
 Pupil - the opening in the middle of the iris through which light passes to the back of
the eye.
 Retina - the light-sensitive nerve layer that lines the back of the eye. The retina
senses light and creates impulses that are sent through the optic nerve to the brain.
Anatomy of the Eye
 Anatomy & Physiology
[EYES]
Refractive Media
 Cornea - transparent layer that forms the external coat of the
anterior portion of the eye
 Aqueous humor - the clear, watery fluid in the front of the
eyeball.
 Lens (Also called crystalline lens.) - the transparent structure
inside the eye that focuses light rays onto the retina.
 Vitreous body - a clear, jelly-like substance that fills the back
part of the eye.
 Glaucoma
 increased intraocular pressure which can damage
optic nerve that eventually lead to blindness
• Causes:
• Congenital, inherited, trauma
 2 TYPES of GLAUCOMA

( Narrow Angle or Close Angle) ( Simple, Wide or Open Angle)

 Imbalance in the production
and excretion of aqueous
humor that leads to
intraocular tension and
displacement of iris against
the angle of anterior
chamber
 Actual obstruction in the
excretion of the aqeuous
humor
 Slow, gradual development
 Asymptomatic at first
 GLAUCOMA (ACUTE AND CHRONIC)

Risk factors:
1. Unknown
2. Emotional disturbances
3. Hereditary factors
4. Allergies
 GLAUCOMA (ACUTE AND CHRONIC)

Subjective Data
1. Acute (Close-angle)
a. Pain, severe in and around eyes
b. Headache
c. *Rainbow halos around lights
d. Blurring of vision
e. Nausea, vomiting
2. Chronic (Open-angle)
a. Eyes tire easily
b. *Loss of peripheral vision
 GLAUCOMA (ACUTE AND CHRONIC)

Objective Data
1. Corneal edema
2. *Decreased peripheral vision
3. Increased cupping of optic disc
4. Tonometry pressures 22 mm. Hg
5. Pupils dilated
6. Redness of eye
 GLAUCOMA (ACUTE AND CHRONIC)

Analysis/Nursing Diagnosis
1. Visual sensory/perceptual alterations
2. Pain
3. Risk for injury
 GLAUCOMA (ACUTE AND CHRONIC)

Nursing Care Plan/Implementation

1. Goal: reduce intraocular pressure
a. Bed rest
b. Semi Fowler’s
c. Medications:
                  i.      Miotics (pilocarpine, carbachol)
                 ii.      Carbonic anhydrase inhibitors
(acetazolamide [Diamox])
                iii.      Anticholinesterase
(demecarium bromide [Humorsol])
                iv.      Ophthalmic (timolol)
 GLAUCOMA (ACUTE AND CHRONIC)

2. Goal: health teaching

a. Prevent increased IOP by avoiding
    i.      Anger, excitement, worry
   ii.      Constrictive clothing
  iii.      Heavy lifting
  iv.      *Atropine or other mydriatics, which
cause dilation
    v.      Straining at stool
   vi.      Eye strain
b. Relaxation techniques
c. Prepare for surgical correction if indicated: laser
trabeculoplasty, trabeculectomy
 CATARACT

Pathophysiology
1. Developmental or degenerative opacification of the
crystalline lens.
 CATARACT

Risk Factors
1. Aging
2. Trauma
3. Toxins
4. Congenital defect
 CATARACT

Subjective Data
1. Blurring
2. Loss of acuity
3. Distortion
4. Diplopia
5. Photophobia
 CATARACT

Objective Data
1. Blindness (bilateral or unilateral)
2. Loss of red reflex
3. Gray opacity of lens
 CATARACT

Analysis/Nursing Diagnosis
1. Visual sensory/perceptual alterations
2. Risk for injury
3. Social isolation
 Nursing Management
 ECCE- extracapsular cataract extraction- anterior portion of the
lens capsule plus the capsule contents are removed
 ICCE- intracapsular cataract extraction
 Cryoextraction- use of frozen probes to remove lens
 Iridectomy - creation of an opening for the flow of aqeous humor
which may be blocked post op; prevention of secondary glaucoma
 Phacoemulsification- ultrasonic vibratin to breakup the lens
 Intraocular lens implant- lens prosthesis
 Cataract glasses
 Nursing Management
 Post op care
 Eye dressing with Eye shield AAT
 Eye shield at night for the 1st month
 Cataract lens (aphakic glasses) - appears 1/4 closer
 IOL implant - an alternative for better binocular vision
 Made of polyethyl methacrylate
 OOB 1day post op
 COD OD until 7 -10 days
 Eye drops as ordered
 Retinal Detachment
 Sensory retina separates from the pigment
epithelium of the retina
 Causes: Retinal Detachment
 congenital malformations  high myopia or vitreous
 trauma (including disease, or degeneration
previous ocular surgery)  Exudates that occur in front
or behind the retina
 vascular disease
 Aphakia (absence of
 choroidal tumors crystalline lens)
 hemorrhage
 Management
 Eye bandaged
 Specific positioning prescribed by MD.
 Head positioned so that retinal tear or hole is at
the lowest point of the eye.
 Surgical
 Both eyes bandaged
 Resume activities in 3-5 weeks
 Cold compresses to decrease edema
 Signs and Symptoms
 Flashes of lights
 Floating spots
 Progressive blurring of vision - visual field deficits - visual
loss
 Visual curtain
 Anxiety, confusion, fear
Diagnostics
 Opthalmoscopic exam - gray, opaque retina, with folds,
holes, tears
 Nursing Management
Discuss surgical options
 Photocoagulation- intense beam of light directed to close the retinal
tear
 Cryosurgery- subfreezing temperatures applied to the surface of the
sclera in the area of the hole to produce inflammatory reaction
 Diathermy- needle point electrode applied through sclera
 Scleral buckling- sclera and corroid are intended or buckled toward the
retinal break
 Injecting an intraocular gas bubble to promote adhesion
 Nursing Management
 Bed rest with eyes covered
 Place on a dependent position
 Immediate Surgery - reattach the retina
 Pre Op care and Mydriatics OU as ordered; eye patches OU
 Post op care
 Affected area should be on the upper position
 Activities - consulted with the MD
 Pressure patch over the affected eye
 Rest the eyes and head immediate post op
 Avoid increase IOP (coughing, straining, NV)
 COD OD
 Uveitis

 inflammation of the eye's uvea

Uveal tract - middle vascular layer of the
eye, contributing to the retina’s blood
supply
 Types
 Anterior uveitis

 Intermediate uveitis

 Posterior uveitis

 Diffuse uveitis
 Uveitis
 Uveitis  S/s
 Iritis  Pain in the eyeball radiating
 Iridocyclitis to forehead
 Choroiditis  Blurred vision
 Choroiretinitis  Photophobia
Causes:  Redness of the eyes without
purulent discharge
 Local/systemic disease
 Small pupil
 Injury
 lacrimation
 Unidentified factors
 Nursing Management
 Mydriatics (AtSO4, Scopolamine)
 To dilate pupils
 To prevent adhesion between ant capsule of the
lens and iris
 To relieve pain and photophobia
 To reduce congestion
 To rest the iris and ciliary body
 Steroids
 Dark glasses
 Analgesics
 Refraction errors:
 Hyperopia
 Farsightedness
(convex lens)
 Myopia
 Nearsightedness
(concave lens)
 Astigmatism
 Distorted vision
 Presbyopia
 Old sight
 Eye Surgeries
 Enucleation-removal of eyeball
 Evisceration- removal of the contents of the
eye with retention of the sclera
 Exenteration- removal of the entire eye and all
other soft tissues in the boney orbit
 Care of Patients
undergoing Eye Surgery
 If OU are covered post op, pt needs to be oriented to
hospital set up and staff
 Pediatric clients need to practice covering the eyes
pre op to allay anxiety, restlessness and fear post op
 Call light / bell should always be within reach
 Prep on the eyes on the day of surgery - dilate pupils
using mydriatics
 Care of Patients
undergoing Eye Surgery
 Post op care  Open mouth when sneezing,
 Prevent increase IOP coughing
 Prevent stress in the suture  Open eyes when vomiting
line  Avoid bending forward to prevent
 Prevent hemorrhage tension at suture line
 Prevent infection  Gradual mobility/positional
 Keep the head still changes
 Position on the unoperative  Side rails up
side or supine
 Bedside table at unoperative side
 Burning sensation - wearing off
of anesthesia  Assistance in ambulation
 Avoid lifting of head, hips,  Help them learn to feed
straining, squeezing eyelids themselves
 Care of Patients
undergoing Eye Surgery
 Cont…
 Post op dressing should not be loosened or removed
 Minimal bleeding is normal
 Edema of eyelids will subside 3-4 days post op
 Feeling of something in the eye 4-5 days due to
sutures
 Sensation of pressure within the eye/ sharp pain may
indicate bleeding - report to MD ASAP
 Rehabilitation
of a Blind Person
 Referrals
 Orient to the environment. Set up and location of things.
 Promote independence in ADL
 May have guide dog, use of cane for direction
 Talk before touching when approaching
 Assist in ambulation. Held the client in your arm so you are
one step ahead of him
 Talk to him frequently so he wont feel neglected
 Be relaxed and unhurried. Tell procedure before performing
 Rehabilitation
of a Blind Person
 Do not change the environment without describing the
change
 Promote safety
 Do not rush up and offer help unless it is clear that
the person wants help
 Choice of gifts to blind person: gifts that appeal to
senses other than vision
Ear Disorders
Anatomy & Physiology
 Anatomy & Physiology

External or outer ear

 pinna or auricle - the outside part of the ear.
 external auditory canal or tube - the tube that
connects the outer ear to the inside or middle ear.
tympanic membrane - also called the
eardrum. The tympanic membrane divides the
external ear from the middle ear.
 Anatomy & Physiology
Middle ear (tympanic cavity)
 ossicles - three small bones that are connected and transmit the sound waves to the
inner ear
 malleus
 incus
 stapes
 eustachian tube - a canal that links the middle ear with the throat area
 helps to equalize the pressure between the outer ear and the middle ear.
 Inner ear
 cochlea (contains the nerves for hearing)
 vestibule (contains receptors for balance)
 semicircular canals (contain receptors for balance)
 Conductive Hearing Loss

 Various problems involving impaired passage of

sound from the external ear to inner ear
 Causes:
 Cerumen impaction
 External otitis media
 Serous otitis media
 Suppurative otitis media
 Otosclerosis
 Pathophysiology
 Impacted cerumen in the external ear can block sound from
reaching the tympanic membrane
 External otitis media - inflammation of the external ear with crust
and edema
 Serous otitis media - involves sterile fluid accumulation in the
middle ear
 Suppurative otitis media - pus accumulation in the middle ear
extending to other structure
 Otosclerosis - spongy bone growth over the normal body
babyrinth causing the footplate of the stapes to become fixed
 Signs and Symptoms
 Cerumen impaction
 Visible impaction in the ear
canal
 External otitis media
 Itching
 Pain
 Water or purulent discharge
 Serous otitis media
 Plugged feeling in the ear
 Reverberation of own voice
 Hearing loss
 Suppurative otitis media
 Throbbing ear pain
 Fever, NV
 Hearing loss
 Feeling of increased pressure in
the ear
 Bright red, bulging or retracted
tympanic membrane
 Tympanic membrane rupture with
discharge
 Otosclerosis
 Mixed hearing loss
 tinnitus
Laboratory & Diagnostic Findings
 Otitis Media
 1st stage: tympanic membrane - retracted
 2nd stage: tympanic membrane dilate and appear red
 3rd stage: tympanic membrane becomes red, thickened,
and bulging with a loss of landmarks
 4th stage: perforation, pus and blood drain from the ear
 Otosclerosis
 Reduced air conduction with bone conduction
 Nursing Management

 Impacted cerumen
 Soften with instilled peroxide or glycerol preparation
 Irrigate ear in 2-3 days to remove the wax
 Keep the otic solution in the ear for 15 mins - tilting head
sideways and putting cotton
 Notify MD if irritation/inflammation occurs
 Nursing Management

 Care of client with tympanic membrane perforation

 Maintain strict asepsis
 Do not irrigate the ear
 Protect from water contamination (use of ear plugs)
 Recognize the risk for meningitis
 Use message board if necessary
 Hearing aid if indicated
 Nursing Management

 Treat external otitis media

 Topical antibiotics, steroids
 Gentle debridement
 Acid alcohol solutions to sterilize auditory canal
 Prepare in possible myringotomy (serous OM)
 Incision in the tympanic membrane to relieve pressure and
pus
 Nursing Management
 Suppurative OM  Assist in surgical
 Systemic antibiotics management for otosclerosis
 Nasal decongestants a. Stapedectomy - replacement
of diseased ossicles with
 Analgesics prosthesis
 Discuss possible surgery b. Fenestration - creation of a
new window into the labyrinth
 Mastoidectomy to provide new pathway for
 Myringoplasty sound
 Tympanoplasty c. Hearing aid
d. Communication techniques
 EAR DISORDERS
MENIERE’S DISEASE

1. Chronic recurrent disorder of

inner ear
2. Attacks of vertigo, tinnitus, and
vestibular dysfunction
3. Lasts 30 min. to a full day
4. Associated with excessive
dilatation of cochlear duct
(unilateral) resulting from
overproduction or decreased
absorption of endolymph
5. Characterized by progressive
sensorineural hearing loss
 EAR DISORDERS
MENIERE’S DISEASE
Risk factors
1. Emotional or endocrine disturbance
2. Spasms of internal auditory artery
3. Head trauma
4. Allergic reaction
5. High salt intake
6. Smoking
7. Ear infections
 EAR DISORDERS
MENIERE’S DISEASE

Subjective Data
1. Tinnitus
2. Headache
3. True vertigo: sudden attacks, room appears to spin
4. Depression, irritability, withdrawal
5. Nausea on sudden head motion
 EAR DISORDERS
MENIERE’S DISEASE
Objective Data
1. Impaired hearing, especially low tones
2. Change in gait, lack of coordination
3. Vomiting with sudden head motion
4. Nystagmus—during attacks
5. Diagnostic test:
a. Cold caloric may precipitate attack
b. Loss of hearing by audiometry
 EAR DISORDERS
MENIERE’S DISEASE
Analysis/Nursing Diagnosis
1. Risk for injury
2. Auditory/sensory perceptual alteration
3. Risk for activity intolerance
 EAR DISORDERS
MENIERE’S DISEASE
Nursing Care Plan/Implementation
1. Goal: Minimize occurrence of attacks
a. Medications
                       i.      Diuretics (clorothiazide [Diuril],
acetazolamide [Diamox])
                      ii.      Antihistamines (dimenhydrinate
[Dramamine], diphenhydramine HCL [Benadryl)
 EAR DISORDERS
MENIERE’S DISEASE

                      iii.      Vasodilators (nicotinic acid) to

control vasospasms
                      iv.      Antiemetics and antivertigo
agents (diazepam [Valium], meclizine HCL
[Antivert])
b. Diet: Low sodium, avoid caffeine, limited
fluids
c. Avoid precipitating stimuli: bright, glaring
lights, noise, sudden jarring, turning head or
eyes
2. Goal: health teaching
a. No smoking
b. Play radio to mask tinnitus particularly at
 Acoustic Neuroma

 a benign tissue growth that arises on

the eighth cranial nerve leading from
the brain to the inner ear
 AKA: vestibular schwannoma or
neurolemmoma
 Acoustic Neuroma

 Causes:
 exposure to loud noise on a consistent basis
 prior exposure to head and neck radiation
 history of parathroid adenoma
 Use of hand held cellular phones (under study)
 Diagnostic procedure
 Audiometry (hearing testing)
 MRI scanning of the head with contrast.
 Acoustic Neuroma

 a one-sided, slowly progressive hearing

impairment
 hearing loss at low frequency 
 Hearing loss
 Vertigo
 HA
 hearing loss at low frequency 
 OTOSCLEROSIS
Pathophysiology
1. Insidious, progressive deafness
2. Most common cause of conductive deafness
3. Cause unknown
4. Formation of new spongy bone in labyrinth
5. Results in fixation of stapes
6. Leads to prevention of sound transmission through
ossicles to inner ear fluids.
 OTOSCLEROSIS

Risk Factors
1. Heredity
2. Females, puberty to 45 yrs.
 OTOSCLEROSIS

Subjective Data
1. Tinnitus
2. Difficulty hearing; gradual loss in both ears
 OTOSCLEROSIS

Objective Data
1. Rinne (mastoid)- reduced sound conduction by air
and intensified by bone
2. Weber (top of head)- increased sound conduction to
affected ear
3. Audiometry—diminished hearing
 OTOSCLEROSIS

Analysis/Nursing Diagnosis
1. Auditory sensory/perceptual alteration
2. Body image disturbance
 OTOSCLEROSIS

Nursing Care Plan/Implementation

(Discussed in next section: stapedectomy)
 STAPEDECTOMY

Pathophysiology
1. Removal of the stapes and replacement with a
prosthesis
2. Treatment of deafness due to otosclerosis, fixes the
stapes preventing it from oscillating and transmitting
vibrations to the fluids in the inner ear
 STAPEDECTOMY

Analysis/Nursing Diagnosis
1. Sensory perceptual alteration
 STAPEDECTOMY

Nursing Care Plan/Implementation

1. Pre operative Care: health teaching
a. Keep head in position as ordered
b. Avoid sneezing, blowing nose, vomiting,
coughing
2. Post operative care
a. Goal: health teaching
               i.      Avoid
1.      Washing hair for 2 weeks
2.      Swimming for 6 weeks
3.      Air travel for 6 months
4.      People with URI
5.      Heavy lifting or straining
 DEAFNESS
Risk Factors
1. Conductive hearing losses (transmission deafness)
2. Impacted cerumen
3. Foreign body
4. Defects
5. Otosclerosis of ossicles
6. Sensorineural hearing losses (perceptive or nerve
deafness)
7. Arteriosclerosis
8. Infectious diseases (mumps, measles, meningitis)
9. Drug toxicities
10. Tumors
11. Head trauma
12. High intensity noises
 DEAFNESS
Objective Data
1. Inattentive or strained facial expression
2. Excessive loudness or softness of speech
3. Frequent need to clarify content of conversation
4. Tilting of head while listening
5. Lack of response
 DEAFNESS
Nursing Care Plan/Implementation
1. Goal: maximize hearing ability and provide
emotional support
a. Gain person’s attention before speaking
b. Provide adequate lighting
c. Look at the person when speaking
d. Use non verbal cues
e. Speak slowly and distinctly. Do NOT shout
f. Use different words if the person does not seem
to understand
g. Use alternative communication devices
 DEAFNESS

2. Goal: health teaching

a. Care of a hearing aid
                                 i.      Clean ear mold PRN
                                ii.      Keep hearing aid dry
                               iii.      Turn hearing aid off at night
                               iv.      Store away from pets
                                v.      Leave aid in same place
every night
b. Safety precautions: when crossing street, driving
 Communicating with a Client with
Hearing Impairment
 Talk directly to the patient facing her/him
 Talk in normal tone of voice. Clearly enunciate words
 Use gestures with speech
 Do not whisper in front of pt with hearing impairment
 Do no avoid conversation
 Do not show annoyance e.g. facial expressions
 Do not smile, do not chew gum, do not cover mouth
 Encourage use of hearing aids
 Care of Patient
undergoing Ear Surgery
 Pre-op
 Assess for URTI
 Shampoo the hair
 Inform re local anesthesia but sedated during surgery
 Post-op Care
 Lie on the unoperative side
 Blow nose gently, one side at a time
 Sneeze, cough with open mouth 1 week
 Avoid physical activity x 1week; exercise/sports x 3weeks
 Cotton ball in the ears daily
 Care of Patient
undergoing Ear Surgery
Cont…
 Keep ear dry for 6 weeks post op
 Do not shampoo hair x 1 week
 Protect ears with 2 pieces of cotton balls
 Avoid airplane travel 1 week post op
 Report drainage to MD; slight amount is normal (stain)
 Avoid reading, watching tv or fast moving objects 1 wk post op
 Seek supervision when ambulating for the 1st time, dizziness
and light headedness may occur