MS 316 Lec Merge Yarn

BACHELOR OF SCIENCE IN NURSING
NCMB 316 - CARE OF CLIENTS WITH PROBLEMS IN

NUTRITIONAL AND GASTROINTESTINAL METABOLISM AND
ENDOCRINE, PERCEPTION AND COORDINATION (ACUTE AND CHRONIC)
COURSE MODULE COURSE UNIT WEEK
3 11 13
Review of the Anatomy and Physiology of the Musculoskeletal System / Assessment of Function
✓ Read the course and unit objectives

✓ Read the study guide before class begins
✓ Read required reading materials and
understand terminologies
✓ Participate in classroom discussion
✓ Participate in discussion board (Canvas)
✓ Answer and submit course unit tasks
At the end of the course unit (CU), learners will be able to:
Cognitive:
1. Review the anatomy and physiology of the skeletal system.
2. Correlate clinical assessment with alterations of function.
Affective
1. Show mastery of the skeletal system structures and functions.
2. Listen attentively during discussion.
Psychomotor
1. Participate in an interactive discussion.
2. Perform assessment of clients with problems on the skeletal system.
Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical
Nursing (14th ed) Philadelphia: Wolters Kluwer
Norris T. (2018) Porth’s Pathophysiology: Concepts of Altered Health States, (10th ed) Wolters Kluwer
Read on the Review of the Anatomy and Physiology of the Musculoskeletal System / Assessment
of Function
Introduction
The skeletal system is an important system that serves the
framework of the body. This system is closely related to the
muscular system. Both systems work together for movement of the
body. Disorders affecting mobility primarily affect the bones, joints
and the surrounding soft tissues.
Functions of the Skeletal System
The bones protect vital organs of the
body. The skull protects the brain, the
ribs protect the heart and the lungs and
the pelvis protect the abdominal organs.
The bones are highly vascularize
connective tissues. Bone marrows
contain fat cells (yellow marrow) and
hematopoeitic cells ( red marrow) the red
marrow is the site of blood cell
production. The bones contain calcium
and other minerals that make it hard and
responsible for compressional strength
of the bones, it is also composed of
protein collagen for resilience. It is also
responsible for tensile strength. The
bone is the framework of the body
providing support. The bone also serves
as attachment of muscles for mobility.
The muscle are attached to the bones by
a connective tissue called tendon and
the bones are attached to one nother by
another connective tissue called
ligament.
The 206 bones of the body have different types or classications. The skull and ribs are composed
of flat bones, the bones of the extremities are long bones, the hands and feets are short bones and
vertebrae are irregular bones.
There are three types of bone cells, the osteocytes are mature bone cells responsible for maintaining
the matrix. The osteoblasts which are responsible for bone formation and the osteoclasts which are
responsible for bone resorption. In children the osteoblasts are very active and in the elderly the
activity of the osteoclasts become greater than usual. In adult, the osteoblast and the osteoclast
actions should be balanced and this is maintained by stress of the bone. Weight bearing exercises
make the bone healthy.
Joints are areas where two or more joints meet. There are different types of joints, non – movable
joints ( fibrous ), slightly movable joint ( cartilagenous ) and freely movable joints ( synovial ).
Skeletal muscles
Skeletal muscles are voluntary muscles and are attached to the skeletal system for moving the body
parts.
Muscle tone
Relaxed muscles demonstrate a state of readiness to respond to contraction stimuli. This state of
readiness, known as muscle tone (tonus), is produced by the maintenance of some of the muscle
fibers in a contracted state. Muscle spindles, which are sense organs in the muscles, monitor muscle
tone. Muscle tone is minimal during sleep and is increased when the person is anxious. A muscle
that is limp and without tone is described as flaccid; a muscle with greater-thannormal tone is
described as spastic. In conditions characterized by lower motor neuron destruction (eg, polio),
denervated muscle becomes atonic (soft and flabby) and atrophies.
Muscles accomplish movement by contraction. When muscles contract they can produce different
types of movement. Together with the skeletal system, the muscles maintain posture and proper
body movement.
Sarcomere is the smallest unit of the the skeletal muscles and shortening of the sarcomere produces
movement. Calcium entry into the skeletal muscles stimulate impulses tobe transmitted to the
myofibrils to promote contraction.
Skeletal muscles are innervated by nerves that make up the somatic nervous system. Alteration in
nerve functioin may also alter muscle functions.
Assessment of Musculoskeletal functions
Health History
Common symptoms manifested by patients with musculoskeletal dysfunction is pain. Complete
assessment of pain can indicate the actual problem of the patient. Altered sensation is another
common clinical manifestations. Numbness and tingling sensation and even loss of sensations affect
the musculoskeletal functions.
Past health history, social history and family history provide pertinent data on several disorders
affecting the musculoskeletal system.
Physical Assessment
Inspection and palpation techniwues are used to evaluate patient’s posture, gait, bone integrity, joint
function, muscle strength and size. Assessment of skin and neurovascular status are important part
of musculoskeletal assessement.
Inspection can detect kyphosis, lordosis and scoliosis of the spine. It can also determine the cient’s
gait, muscle tone and unsteadiness. Bony skeleton is assessed for alignment and deformities. This
may check posible fracture or dislocation of joints.
Joint integrity is assessed by doing normal body movements. Inability to move joints and feeling or
hearing for grating sounds may indicate increase friction in the joint area. Palpatig for sweeing or
tenderness in the joints for possible effusion are assessed to indicate any inflammatory response.
Muscle strength and size are assessed for possible atrophy or hypertrophy, muscle tone is assesed
as well. Fasciculations, clonus, spasm and even tremors are indicative of musculosketal or
neuromuscular dysfunctions.
Skin integrity is included in the assessment and checking for neurovascular status on 6 P’s (pain,
paralysis, pallor, paresthesia, pulselessness and poikilothermia) may indicate a musculoskeletal
dysfunction.
Diagnostic tests
1. Radiologic tests 7. Electromyography
2. CT scan 8. Biopsy
3. Arthrography 9. Laboratory tests
4. Bone densitometry a. Urine
5. Bone scan b. Blood
6. Arthroscopy c. Enzyme elevation
Atonic – without tone; enervated muscle that atrophies.
Atrophy – shrinkage like decrease in the size of a muscle.
Bursa – fluid-filled sac found in connective tissue, usually in the area of joints.
Callus – cartilaginous / fibrous tissue at fracture site.
Cancellous bone – lattice like bone structure; trabecular bone.
Cartilage – tough, elastic, avascular tissue at ends of bone.
Clonus – rhythmic contraction of muscle.
Contracture – abnormal shortening of muscle or joint, or both; fibrosis.
Cortical bone – compact bone.
Crepitus – grating or crackling sound or sensation; may occur with movement of ends of a broken
bone or irregular joint surface.
Diaphysis – shaft of long bone.
Effusion – excess fluid in joint endosteum: a thin, vascular membrane covering the marrow cavity
of long bones and the spaces in cancellous bone.
Epiphysis – end of long bone.
Fascia (epimysium) – fibrous tissue that covers, supports, and separates muscles.
Fasciculation – involuntary twitch of muscle fibers flaccid: limp; without muscle tone.
Hypertrophy – enlargement; increase in size of muscle.
Isometric contraction – muscle tension increased, length unchanged, no joint motion.
Isotonic contraction – muscle tension unchanged, muscle shortened, joint moved.
Joint – area where bone ends meet; provides for motion and flexibility.
Joint capsule – fibrous tissue that encloses bone ends and other joint surfaces.
Kyphosis – increase in the convex curvature of the spine.
Lamellae – mature compact bone structures that form concentric rings of bone.
Matrix – lamellar bone.
Ligament – fibrous band connecting bones.
Lordosis – increase in lumbar curvature of the spine.
Ossification – process in which minerals (calcium) are deposited in bone matrix.
Osteoblast – bone-forming cell.
Osteoclast – bone resorption cell.
Osteocyte – mature bone cell.
Osteogenesis – bone formation.
Osteon – microscopic functional bone unit paresthesia: abnormal sensation (eg, burning, tingling,
numbness).
Periosteum – fibrous connective tissue covering bone.
Remodeling – process that ensures bone maintenance through simultaneous bone resorption and
formation.
Resorption – removal / destruction of tissue, such as bone.
Scoliosis – lateral curving of the spine.
Spastic – having greater-than-normal muscle tone.
Synovium – membrane in joint that secretes lubricating fluid.
Tendon – cord of fibrous tissue connecting muscle to bone.
Tone (tonus) – normal tension (resistance to stretch) in resting muscle.
Trabeculae – lattice like bone structure; cancellous bone.
Rizzo, D. C. (2016) Fundamentals of Anatomy and Physiology (4th ed) Cengage

Kumar V., Abbas A., Aster J. (2020) Robbins & Cotran Pathologic Basis of Disease (10th ed)
Elsevier
Create a knowledge matrix on different diagnostic tests for musculoskeletal assessment, write their
indications and nursing procedural teachings following the format:
Diagnostic tests Indications Nursing procedural teaching
Norris T. (2018) Porth’s Pathophysiology: Concepts of Altered Health States, (10th ed) Wolters
Kluwer
Illustration / Images:
[Musculoskeletal System] Anatomy Academy Retrieved from
https://anatomyacademy.wordpress.com/chapters/chp-5-6/
Marcela (2015, Oct 26) Body Stories: What is the kinaesthetic Sense? Retrieved from
https://embodiedpractices.com/what-is-the-kinaesthetic-sense/
Andrew, W. (2012) Britannica: Health & Medicine: Anatomy & Physiology [Human Skeleton]
Retrieved from https://www.britannica.com/science/human-skeleton
[Function of the Skeletal System] Oregon State University Retrieved from
https://open.oregonstate.education/aandp/chapter/6-1-the-functions-of-the-skeletal-system/
Chahar, P. (2016, Jul 15) [Classification of Joints] Slide share: TMJ and prosthodontic implications
slide #5 Retrieved from https://www.slideshare.net/pramodchahar9/tmj-and-prosthodontic-
implications
[Structure of a Skeletal Muscle] Retrieved from https://www.sciencesource.com/archive/Skeletal-
Muscle-Structure--Illustration-SS2603872.html
Flowers, C. (2016) Slide Player: Skeletal Muscle Unit slide #2 [Functions of skeletal muscles]
Retrieved from https://slideplayer.com/slide/10919519/
Meducationdotnet (2016, Jan 22) Slide share: Musculoskeletal Exam slide #4 [Inspection of joint]
Retrieved from https://www.slideshare.net/meducationdotnet/musculoskeletal-exam
NCMB 316 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITIONAL AND
GASTROINTESTINAL METABOLISM AND ENDOCRINE, PERCEPTION
AND COORDINATION (ACUTE AND CHRONIC)
3 12 14
Musculoskeletal System Disorders: RA-OA-GA comparisons; Osteoporosis, Osteomyelitis,

Pott’s Disease, Carpal Tunnel Syndrome
Read course and unit objectives

Read study guide prior to class attendance
Read required learning resources; refer to unit
terminologies for jargons
Proactively participate in classroom discussions
Participate in weekly discussion board (Canvas)
Answer and submit course unit tasks
At the end of this unit, the students are expected to:

Cognitive:
1. Describe the assessment and diagnostic findings seen in patients with different musculoskeletal
disorder.
2. Evaluate the clinical manifestations and identify priority problems of clients with bone diseases.
Affective
1. Show high level of confidence in caring for clients with bone diseases.
Psychomotor
1. Participate in an interactive discussion
2. Devise a teaching plan for the patient with newly diagnosed rheumatic disease.
Read on Fracture & Bone Diseases
OSTEOARTHRITIS (DEGENERATIVE JOINT DISEASE)
OA, also known as degenerative joint disease or osteoarthrosis, is the most common and most
frequently disabling joint disorder. It is characterized by a progressive loss of joint cartilage. Besides
age, risk factors for OA include congenital and developmental disorders of the hip, obesity, previous
joint damage, repetitive use (occupational or recreational), anatomic deformity, and genetic
susceptibility. OA has been classified as primary (idiopathic) and secondary (resulting from previous
joint injury or inflammatory disease). Obesity, in addition to being a risk factor for OA, increases
symptoms of the disease. OA peaks between the fifth and sixth decades of life.
Clinical Manifestations
• Pain, stiffness, and functional impairment are primary clinical manifestations.
• Stiffness is most common in the morning after awakening. It usually lasts less than 30 minutes and
decreases with movement.
• Functional impairment is due to pain on movement and limited joint motion when structural
changes develop.
• OA occurs most often in weight-bearing joints (hips, knees, cervical and lumbar spine); finger joints
are also involved.
• Bony nodes may be present (painless unless inflamed).
Assessment and Diagnostic Findings
• X-ray study shows narrowing of joint space and osteophytes (spurs) at the joint margins and on
the subchondral bone. These two findings together are sensitive and specific.
• There is a weak correlation between joint pain and synovitis.
• Blood tests are not useful in the diagnosis of this disorder.
Medical Management
Management focuses on slowing and treating symptoms because there is no treatment available that
stops the degenerative joint disease process.
Prevention
• Weight reduction
• Prevention of injuries
• Perinatal screening for congenital hip disease
• Ergonomic modifications
Conservative Measures
• Heat, weight reduction, joint rest, and avoidance of joint overuse
• Orthotic devices to support inflamed joints (splints, braces) • Isometric and postural exercises, and
aerobic exercise
• Occupational and physical therapy
Pharmacologic Therapy
• Acetaminophen; nonsteroidal anti-inflammatory drugs (NSAIDs)
• COX-2 enzyme blockers (for patients with increased risk for GI bleeding)
• Opioids and intra-articular corticosteroids
• Topical analgesics such as capsaicin and methyl salicylate •Other therapeutic approaches:
glucosamine and chondroitin; viscosupplementation (intra-articular injection of hyaluronic acid)
Surgical Management
Use when pain is severe and function is lost.
• Osteotomy
• Joint arthroplasty (replacement)
Nursing Management
The nursing care of the patient with OA is generally the same as the basic care plan for the patient
with rheumatic disease (see Arthritis, Rheumatoid). Managing pain and optimizing functional ability are
the major goals of nursing intervention,
and helping patients understand their disease process and
symptom pattern is critical to a plan of care.
• Assist patients with management of obesity (weight loss and an increase in aerobic activity) and
other health problems or diseases, if applicable.
• Refer patient for physical therapy or to an exercise program. Exercises such as walking should be
begun in moderation and increased gradually.
• Provide and encourage use of canes or other assistive devices for ambulation as indicated.
GOUT
Gout is a heterogeneous group of inflammatory conditions related to a genetic defect of purine

metabolism and resulting in hyperuricemia.
Pathophysiology
In gout, there is an oversecretion of uric acid or a renal defect resulting in decreased excretion of uric
acid, or a combination of both. Primary hyperuricemia may be due to severe dieting or starvation,
excessive intake of foods high in purines (shell- fish, organ meats), or heredity. In secondary
hyperuricemia, the gout is a clinical feature secondary to any of a number of genetic or acquired
processes, including conditions with an increase in cell turnover (leukemias, multiple myeloma,
psoriasis, some anemias) and an increase in cell breakdown.
Gout is characterized by deposits of uric acid in various joints. Four stages of gout can be identified:
asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout, and chronic tophaceous gout.
• Acute arthritis of gout is the most common early sign.
• The metatarsophalangeal (MTP) joint of the big toe is most commonly affected; the tarsal area,
ankle, or knee may also be affected.
• The acute attack may be triggered by trauma, alcohol ingestion, dieting, medication, surgical
stress, or illness.
• Abrupt onset occurs at night, causing severe pain, redness, swelling, and warmth over the affected
joint.
• Early attacks tend to subside spontaneously over 3 to 10 days without treatment.
• The next attack may not come for months or years; in time, attacks tend to occur more frequently,
involve more joints, and last longer.
Tophi are generally associated with frequent and severe inflammatory episodes.
• Higher serum concentrations of uric acid are associated with tophus formation.
• Tophi occur in the synovium, olecranon bursa, subchondral bone, infrapatellar and Achilles’
tendons, subcutaneous tissue, and overlying joints.
• Tophi have also been found in aortic walls, heart valves, nasal and ear cartilage, eyelids, cornea,
and sclerae. • Joint enlargement may cause loss of joint motion.
• Uric acid deposits may cause renal stones and kidney damage.
Assessment and Diagnostic Methods
A definitive diagnosis of gouty arthritis is established by polarized light microscopy of the synovial fluid
of the involved joint. Uric acid crystals are seen within the polymorphonuclear leukocytes in the fluid.
Medical Management
• Colchicine (oral or parenteral), an NSAID such as indomethacin, or a corticosteroid is prescribed to
relieve an acute attack of gout.
• Hyperuricemia, tophi, joint destruction, and renal problems are treated after the acute inflammatory
process has sub- sided.
• Uricosuric agents, such as probenecid, correct hyperuricemia and dissolve deposited urate.
• Allopurinol is effective when renal insufficiency or renal calculi are a risk.
• Corticosteroids may be used in patients who have no response to other therapy.
• Prophylactic treatment considered if patient experiences several acute episodes or there is
evidence of tophi formation.
Nursing Management
Encourage patient to restrict consumption of foods high in purines, especially organ meats, and to limit
alcohol intake. Encourage patient to maintain normal body weight. These measures may help to prevent
a painful episode of gout.
In an acute episode of gouty arthritis, pain management is essential. Review medications with patient
and family. Stress the importance of continuing medications to maintain effectiveness.
OSTEOPOROSIS
Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and diminished bone
architectural strength. The rate of bone resorption is greater than the rate of bone formation. The bones
become progressively porous, brittle, and fragile, and they fracture easily. Multiple compression
fractures of the vertebrae result in skeletal deformity (kyphosis). This kyphosis is associated with loss
of height. Patients at risk include postmenopausal women and small- framed, nonobese Caucasian
women.
Risk factors include inadequate nutrition, inadequate vitamin D and calcium, and lifestyle choices (eg,
smoking, caffeine intake, and alcohol consumption); genetics; and lack of physical activity. Age-related
bone loss begins soon after peak bone mass is achieved (in the fourth decade). Withdrawal of estrogens
at menopause or oophorectomy causes decreased calcitonin and accelerated bone resorption, which
continues during menopausal years. Immobility contributes to the development of osteoporosis.
Secondary osteoporosis is the result of medications or other conditions and diseases that affect bone
metabolism. Specific disease states (eg, celiac disease, hypogonadism) and medications (eg,
corticosteroids, antiseizure medications) that place patients at risk need to be identified and therapies
instituted to reverse the development of osteoporosis.
• Osteoporosis is identified on routine x-ray films when there has been 25% to 40%
demineralization.
• Dual-energy x-ray absorptiometry (DEXA; DXA) provides information about spine and hip bone
mass and bone mineral density (BMD).
• Laboratory studies (eg, serum calcium, serum phosphate, serum alkaline phosphatase, urine
calcium excretion, urinary hydroxyproline excretion, hematocrit, erythrocyte sedimentation rate
[ESR]) and x-ray studies are used to exclude other diagnoses.
Medical Management
• Adequate, balanced diet rich in calcium and vitamin D.
• Increased calcium intake during adolescence, young adult- hood, and the middle years, or
prescribe a calcium supplement with meals or beverages high in vitamin C.
• Regular weight-bearing exercise to promote bone formation (20 to 30 minutes aerobic exercise 3
days/week).
• Other medications: the bisphosphonates alendronate (Fosamax), risedronate (Actonel),
ibandronate (Boniva), and zoledronic acid (Reclast); calcitonin (Miacalcin); selective estrogen
receptor modulators (SERMs) such as raloxifene (Evista); teriparatide (Forteo).
Osteoporotic compression fractures of the vertebrae are managed conservatively. Patients who
have not responded to first-line approaches to the treatment of vertebral compression fracture can
be considered for percutaneous vertebroplasty or kyphoplasty (injection of polymethylmethacry-
late bone cement into the fractured vertebra, followed by inflation of a pressurized balloon to
restore the shape of the affected vertebra).
OSTEOMYELITIS
Osteomyelitis is an infection of the bone. It may occur by extension of soft tissue infections, direct bone
contamination (eg, bone surgery, gunshot wound), or hematogenous (bloodborne) spread from other
foci of infection. Staphylococcus aureus causes more than 50% of bone infections. Other pathogenic
organisms frequently found include Gram-positive organisms that include streptococci and enterococci,
followed by Gram-negative bacteria that include pseudomonas species. Patients at risk include poorly
nourished, elderly, and patients who are obese; those with impaired immune systems and chronic illness
(eg, diabetes); and those on long-term corticosteroid therapy or immunosuppressive agents. The
condition may be prevented by prompt treatment and management of focal and soft tissue infections.
• When the infection is bloodborne, onset is sudden, occur- ring with clinical manifestations of sepsis
(eg, chills, high fever, rapid pulse, and general malaise).
• Extremity becomes painful, swollen, warm, and tender.
• Patient may describe a constant pulsating pain that intensifies with movement (due to the pressure
of collecting pus).
• When osteomyelitis is caused by adjacent infection or direct contamination, there are no
symptoms of sepsis; the area is swollen, warm, painful, and tender to touch.
• Chronic osteomyelitis presents with a nonhealing ulcer that overlies the infected bone with a
connecting sinus that will intermittently and spontaneously drain pus.
• Acute osteomyelitis: Early x-ray films show only soft tissue swelling.
• Chronic osteomyelitis: X-ray shows large, irregular cavities, a raised periosteum, sequestra, or
dense bone formations. •Radioisotope bone scans and magnetic resonance imaging (MRI).
Blood studies and blood cultures.
Medical Management
• Initial goal is to control and arrest the infective process.
• General supportive measures (eg, hydration, diet high in vitamins and protein, correction of
anemia) should be instituted; affected area is immobilized.
• Blood and wound cultures are performed to identify organisms and select the antibiotic.
• Intravenous antibiotic therapy is given around-the-clock; continues for 3 to 6 weeks.
• Antibiotic medication is administered orally (on empty stomach) when infection appears to be
controlled; the medication regimen is continued for up to 3 months.
• Surgical debridement of bone is performed with irrigation; adjunctive antibiotic therapy is
maintained.
POTT'S DISEASE
Pott's disease, is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of
tuberculous arthritis of the intervertebral joints. Scientifically, it is called tuberculous spondylitis. Pott’s
disease is the most common site of bone infection in TB; hips and knees are also often affected. The
lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected.
SYNONYMS:
Pott's disease, which is also known as Pott’s caries, Pott's syndrome, Pott's caries, Pott's curvature,
angular kyphosis, kyphosis secondary to tuberculosis, tuberculosis of the spine, tuberculous
spondylitis and David's disease , and Pott's curvature, which is a medical condition of the spine.
DISCOVERER:
It is named after Percivall Pott (1714-1788), a London surgeon who trained at St Bartholomew's
Hospital, London.
ETIOLOGY:
Pott’s disease is caused when the vertebrae become soft and collapse as the result of caries or
osteitis. Typically, this is caused by mycobacterium tuberculosis. As a result, a person with Pott's
disease often develops kyphosis, which results in a hunchback. This is often referred to as Pott’s
curvature. In some cases, a person with Pott's disease may also develop paralysis, referred to as
Pott’s paraplegia, when the spinal nerves become affected by the curvature.
A person with Pott's disease may experience additional complications as a result of the curvature.
For example, an infection can more easily spread from the paravertebral tissue, which can cause
abscesses to occur. Regardless of the complications that may occur, Pott's disease is typically slow
spreading and can last for several months or years.
• The usual sites to be involved are the lower thoracic and upper lumbar vertebrae.
• The source of infection is usually outside the spine. It is most often spread from the lungs via the
blood.
• There is a combination of osteomyelitis and infective arthritis.
• Usually more than one vertebra is involved. The area most affected is the anterior part of the vertebral
body adjacent to the subchondral plate. Tuberculosis may spread from that area to adjacent
intervertebral discs.
• In adults, disc disease is secondary to the spread of infection from the vertebral body but in children it
can be a primary site, as the disc is vascular in children.
• It is the commonest place for tuberculosis to affect the skeletal system although it can affect the hips
and knees too.
• The infection spreads from two adjacent vertebrae into the adjoining disc space.
• If only one vertebra is affected, the disc is normal, but if two are involved the disc between them
collapses as it is avascular and cannot receive nutrients.
• Caseation occurs, with vertebral narrowing and eventually vertebral collapse and spinal damage. A
dry soft tissue mass often forms and superinfection is rare.
TYPE/STAGE/CLASSIFICATION:
- Bone/Spinal Disease
- Non-Communicable Disease
SIGNS AND SYMPTOMS:
- back pain
- fever
- night sweating
- anorexia
- weight loss
- Spinal mass, sometimes associated with numbness, paresthesia, or muscle weakness of the legs
atonic: without tone; denervated muscle that atrophies
atrophy: shrinkage like decrease in the size of a muscle
bursa: fluid-filled sac found in connective tissue, usually in the area of joints
callus: cartilaginous/fibrous tissue at fracture site cancellous bone: latticelike bone structure;
trabecular bone
cartilage: tough, elastic, avascular tissue at ends of bone clonus: rhythmic contraction of muscle
contracture: abnormal shortening of muscle or joint, or both; fibrosis
cortical bone: compact bone
crepitus: grating or crackling sound or sensation; may occur with movement of ends of a broken bone
or irregular joint surface
diaphysis: shaft of long bone
effusion: excess fluid in joint
endosteum: a thin, vascular membrane covering the marrow cavity of long bones and the spaces in
cancellous bone
epiphysis: end of long bone
fascia (epimysium): fibrous tissue that covers, supports, and separates muscles
ankylosis: fixation or immobility of a joint
arthritis: inflammation of a joint
arthroplasty: replacement of a joint
osteoarthritis: degenerative joint disease
osteophyte: a bony outgrowth or protuberance; bone spur
pannus: proliferation of newly formed synovial tissue infiltrated with inflammatory cells
rheumatic diseases: numerous disorders affecting skeletal muscles, bones, cartilage, ligaments,
tendons, and joints
rheumatoid arthritis: autoimmune disease of unknown origin
subchondral bone: bony plate that supports the articular cartilage
tophi: accumulation of crystalline deposits in articular surfaces, bones, soft tissue, and cartilage
fasciculation: involuntary twitch of muscle fibers
flaccid: limp; without muscle tone
hypertrophy: enlargement; increase in size of muscle
isometric contraction: muscle tension increased, length unchanged, no joint motion
isotonic contraction: muscle tension unchanged, muscle shortened, joint moved
joint: area where bone ends meet; provides for motion and flexibility
joint capsule: fibrous tissue that encloses bone ends and other joint surfaces
kyphosis: increase in the convex curvature of the spine
lamellae: mature compact bone structures that form concentric rings of bone matrix; lamellar bone
ligament: fibrous band connecting bones
lordosis: increase in lumbar curvature of the spine
ossification: process in which minerals (calcium) are deposited in bone matrix
osteoblast: bone-forming cell
osteoclast: bone resorption cell
osteocyte: mature bone cell
osteogenesis: bone formation
osteon: microscopic functional bone unit
paresthesia: abnormal sensation (eg, burning, tingling, numbness)
periosteum: fibrous connective tissue covering bone
remodeling: process that ensures bone maintenance through simultaneous bone resorption and
formation
resorption: removal/destruction of tissue, such as bone
scoliosis: lateral curving of the spine
spastic: having greater-than-normal muscle tone
synovium: membrane in joint that secretes lubricating fluid
tendon: cord of fibrous tissue connecting muscle to bone
tone (tonus): normal tension (resistance to stretch) in resting muscle
trabeculae: latticelike bone structure; cancellous bone

Elsevier
Describe the three classifications of Osteomyelitis then compare and contrast each.
Contiguous- Osteomyelitis
Hematogenous
Focus with Vascular
Osteomyelitis
Osteomyelitis Insufficiency
Description
Mechanism
of Bone
Infection
Examples
etc...etc...
Smeltzer, S., Bare, B., et.al. (2010) Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 12th
Edition. (pp 336-394). Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins.
Norris T. (2018) Porth’s Pathophysiology: Concepts of Altered Health States, (10th ed)
Wolters Kluwer
3 13 15
Joint Diseases

Cognitive:
1. Analyze causes, classifications and pathogenesis of joint diseases.
2. Evaluate the clinical manifestations and identify priority problems of clients with joint diseases.
Affective
1. Show high level of confidence in caring for clients with different types of joint diseases.
Psychomotor
2. Formulate nursing care plans in clients with different typed of joint diseases.
Read on Joint Diseases
Introduction
Joints are the areas where bones meet. The joint structure is composed of ligaments, cartilages and
attachment of muscles to bones called tendons. These connective tissues stabilize the joint for better
movement and support. Disorders of the joints usually cause pain and impaired mobility. This is one
most common complain of clients. This module will discuss Rheumatoid arthritis, Osteoarthritis and
Gouty Arthritis.
RHEUMATOID ARTHRITIS
This is an autoimmune, systemic inflammatory
disease of the synovial joints. Autoimmune disease
is characterized by antibodies that destroy the
tissues of the patient. The etiology is unknown
although most autoimmune conditions might
develop after a viral infection. Females are most
commonly affected than men, so hormonal factors
are being considered as well. Rheumatoid arthritis
usually affect middle aged adult women.
Antibodies destroy the synovial membrane of the

joints causing inflammatory reaction in the joint
areas. Dead cells and injured tissues release
chemical mediators causing pain, swelling, heat,
redness and impaired mobility. The most common joints affected are the joints of the hands,
metacarpophalangeal joints. Affectations are usually bilateral and symmetrical. When the right hand
is affected, the left hand is affected as well. Inflammatory responses in the joints will cause formation
of PANNUS in the joint area. Pannus is an abnormal layer of fibrovascular tissue or granulation
tissue caused by inflammatory cells. This is not seen on X - ray being a soft tissue, however, pannus
can cause joint deformities. Rheumatoid arthritis causes too much deformity of the joints.
Rheumatoid arthritis is a systemic inflammatory disease. Aside from joint pain, clients may manifest
morning stiffness and fatigue. The condition is irreversible and progressive.
Joint affectation is bilateral and migratory affecting one joint after another.
Nursing interventions are focus on controlling the pain and providing comfort. Clients are encouraged
to move the joints up to the limits of pain. Clients are encouraged to prevent flexion contracture and
deformities. There must be periods of rest between activities. Adequate sleep is required and
avoidance of stress.
Diagnostic tests for rheumatoid arthritis include the presence of rheumatoid factor in the blood, anti
– nuclear antibody test is positive, elevated ESR and elevated WBC on complete blood count. The
most definitive being the positive rheumatoid factor.
Medical management
Pain is controlled by giving NSAIDs. The drug of choice is COX – 2 inhibitors like Celecoxib and
Etoricoxib, Steroids are given to decrease inflammation. Rehabilitation therapy is indicated to slow
down progression of the disease.
OSTEOARTHRITIS
Osteoarthritis is called a degenerative
joint disease. There is destruction or
deterioration of cartilage in the joints.
Cartilages in the joint decreases friction
as the joint moves. Age is the most
common risk factor for osteoarthritis
and in the past considered as part of
aging, commonly seen among people
60 years of age and above but today,
there are recorded cases of young
adults to have osteoarthritis. Other risk
factors include over used of joints, trauma and obesity. The most common joints affected are weight
bearing joints usually knees or hips. Affectation is unilateral, asymmetrical and non-migratory unlike
the rheumatoid arthritis.
Destruction of the cartilage increases the friction in the affected joint causing a grating sound or
sensation upon palpation called crepitus. Initially, there is no inflammation because the cartilages
are avascular, the cause of pain in clients with osteoarthritis is the spasm cause by the surrounding
muscles. Inflammation sets in when injury affects the synovial membrane and obliteration of the
joints happen.
When cartilages are destroyed, osteoblast occupy the

area where chondrocytes die. Osteoblast produce a
bone in the joint called bone spur or OSTEOPHYTE.
This may cause more pain especially when causing
compression of the muscles.
Clients usually complain of joint pain. Warm

compress and liniments producing heat may relieve
the pain because heat relaxes the muscles. X – ray showing osteophyte is the most definitive
diagnostic test.
Like rheumatoid arthritis, pain management is the focus of nursing interventions. Medical
management provide pain relief. Since there is no inflammatory symptoms initially, acetaminophen
or paracetamol is very effective in these clients. This medication is safer especially among elderly
clients. NSAIDs may be given as well and steroid are preserved if there is a full inflammatory process.
Surgical management include removal of the osteophyte. It is called osteotomy. In clients with
obliterated hips due to osteoarthritis, total hip arthroplasty may be done on them to promote better
mobility.
Rehabilitation therapy will prevent progression and disability in the clients. The goal of rehabilitation
is to promote optimum function of the joint.
GOUTY ARTHRITIS
Gouty arthritis is a metabolic joint disease
caused by hyperuricemia ( more than
7mg/dl). Gouty arthritis usually happens to
clients with Gout. A metabolic disease
characterized by hyperuricemia. When uric
acid becomes to high in the blood, it
precipitates in the joints causing injury and
inflammation of the joints. The first joint
affected is the joint of the big toe. Affectation
is asymmetrical but migratory, it may affect
one joint after another. Uric acid may also
precipitate in soft tissues like the ear lobe. Uric acid crystals in the joints are called TOPHI.
Identifying tophi in the joints by polarized light microscopy or arthroscopy is the most definitive
diagnostic test for gouty arthritis. Elevated serum uric acid, ESR and WBC may also be detected.
Gouty arthritis is characterized by acute attacks that may be caused by high purine diet, trauma,
alcohol, medical and surgical illnesses. Management of gouty arthritis is focus on relieving pain and
controlling the uric acid in the blood.
Nursing interventions are done to relieve the pain and promote comfort as well. An important part of
health teaching is the diet of the patient. Avoidance of purine rich food would help control the level
of uric acid in the blood.
Management
For acute attack of Gouty arthritis, Colchicine is given. This drug has anti – inflammatory effect and
it may decrease the precipitation of uric acid crystals in the joints. NSAIDs is the best drug for pain.
Maintaining the level of uric acid is an important part of therapy. The use of Allopurinol, Probenecid
and Feboxustat are used to control hyperuricemia. Management is palliative and rehabilitation
therapy will help slow down the progression of disease and promote optimal function of the joints.
Ankylosis – fixation or immobility of a joint

Arthritis – inflammation of a joint.
Arthroplasty – replacement of a joint.
Osteoarthritis – degenerative joint disease.
Osteophyte – a bony outgrowth or protuberance; bone spur.
Pannus – proliferation of newly formed synovial tissue infiltrated with inflammatory cells.
Rheumatic diseases – numerous disorders affecting skeletal muscles, bones, cartilage, ligaments,
Tendons, and joints.
Rheumatoid arthritis – autoimmune disease of unknown origin.
Subchondral bone – bony plate that supports the articular cartilage
Tophi – accumulation of crystalline deposits in articular surfaces, bones, soft tissue, and cartilage.

Elsevier
Make a nursing care plan for the three types of arthritis. Make a nursing diagnosis except PAIN.
Kluwer
[Assessing Joints] Your Healthy Joints: Inflammatory Arthritis Symptoms and Treatment Retrieved
from http://yourhealthyjoints.com/inflammatory-arthritis-symptoms-and-treatment/
Warburton, M. (2019, Jan 25) Joint Pain Clinic: What are the 5 stages of Rheumatoid Arthritis?
[Rheumatoid Arthritis Late Stage] Retrieved from https://www.jointpainclinic.co.uk/5-stages-
of-rheumatoid-arthritis/
eOrthopod (2006, Jul 20) Orthogate: Rheumatiod Arthritis [Pannus Formation] Retrieved from
https://www.orthogate.org/patient-education/general/rheumatoid-arthritis
(2018, Oct 31) Optima Health Physio Consult: Evidence-based Physiotherapy for Gouty Arthritis
[Swollen and inflamed joint with uric acid crystals] Retrieved from
https://www.optimaphysio.com/blog/evidence-based-physiotherapy-for-gouty-arthritis
3 14 16
Review of the Anatomy and Physiology of the Eyes & Assessment
Read the course and unit objectives

Read the study guide before class begins
Read required reading materials
Participate in classroom discussion
Participate in discussion board (Canvas)
Cognitive:
1. Have a mastery of the anatomy & physiology of the eyes.
2. Evaluate alterations in the normal assessment of eye.
Affective
2. Perform eye assessment confidently.
Psychomotor
1. Participate in an interactive discussion.
2. Formulate nursing diagnosis and care plans in clients with visual impairment.
Read on the Anatomy and Physiology of the Eyes & its Assessment
Introduction
The eyes are highly specialized sense organ
for vision. Loss of this function causes too
much disability in a person. Before the
discussion of eye disorders, this module
reviews the structures and functions of the
eyes.
The external structures of the eyes are composed of the eyelids and eyebrows which function is to
protect the eyes from sweat or any foreign body. Externally, the sclera, the white of the eye is seen,
the pupils where light enters the eyes and the iris, the colored portion of the eye. The eyeball is
located in the orbital cavity which is part of the skull. In the medial portion of the eye is the lacrimal
caruncle and the tear duct.
There is a conjugate movement of the eyes. They follow the same direction. The eyes move by the
contraction of the extraocular muscles. Superior rectus moves the eyeball upward. Inferior rectus
moves the eyeball downward. Medial rectus moves the eyeball medially, lateral recuts moves the
eyeball laterally. Superior rectus moves the eyeball upward and inward. Inferior rectus muscle
moves the eyeball upward and outward. Extraocular muscles are innervated by cranial nerves III,
IV and VI. Most of the extraocular muscles are innervated by CN III except the lateral rectus which
is innervated by CN IV and superior oblique which is supplied by CN IV. The eyes move together as
one and the brain sees one image only, binocular vision.
The tears are produced by the lacrimal glands and it is helpful to maintain a healthy eyes as it
washes away dirt and prevent irritation.
The eyes are capable of refraction. Refractive indices include the cornea, the transparent
membrane covering the eyes. The aqueous humor, a fluid produced by the ciliary bodies that
nourishes the eyeball, from the ciliary body, it flows to the posterior chamber, then it goes out of the
pupil into the anterior chamber and drains into the canal of schlemm in the venous circulation.
Another refractive index is the lens, this is also responsible for accommodation. And the last is the
vitreous humor, a jelly like substance at the back of the lens that gives shape to the eyeball.
The eyes have three layers, the outer layer is the fibrous layer, the second layer is the vascular
layer and the third layer is the nervous layer. The fibrous layer is composed of the sclera, the white
of the eyes, this is covered by a membrane called conjunctiva that lines the eyeball as well as the
lining of the inner lids. The vascular layer is composed of the ciliary bodies, the iris and the
suspensory ligaments that support the lens. The innermost layer is the nervous layer which
contains the retina where the photoreceptors, rods responsible for dim vision and cones for light
vision are located. Cranial nerve II or the optic nerve innervates the eyes for vision.
Light rays enter the eyes through

the pupils, the size of the pupils
regulate the amount of light
entering the eyes. The light rays
bend as it passes the refractory
indices and the image forms in
the retina is inverted. When the
optic nerve carries this image to
the brain ( occipital lobe) it is the
brain that actually see an upright
image.
ASSESSMENT OF THE EYES
Assessment of Patient
Assess history of eyestrain, headache, and double vision.
Assess family history of squint and amblyopia.
Assess history oy eye and head injury.
Notice abnormal head adaptation such as head tilt and face turn.
Required Instrument
Occluder
Pen light
Fixation target
Patient Preparation
Explain patient about the nature of the test to seek his or her confidence and
co-operation.
Ensure that the patient is comfortably seating in a dimly illuminated room.
Assessment starts with thorough history and physical examination. Instrument like ophthalmoscope
and Snellen’s chart are important. Patient should be placed in a very well lit place.
Inspection is done by looking at both eyes and the movement. EOMs are checked as the person
looks straight without moving the head and will be asked to follow the fingers as they move upward,
downward, sideways, in and out. The color of the sclera should be noted as well as the
conjunctiva.
Using the penlight, pupillary movements are checked. Any opacity of the lens may be detected by
the light also.
Visual acuity is checked by using the Snellen’s chart. The normal vision is 20/20. The numerator is
the patient’s vision and the denominator is the normal person’s vision. Example if the visual acuity
is 20/100. This means that the patient can see at 20 feet where a normal person can see at 100
feet. Legal blindness is having a visual acuity of 20/400.
Accommodation – process by which the eye adjusts for near distance (eg, reading) by changing
the curvature of the lens to focus a clear image on the retina.
Anterior chamber – space in the eye bordered anteriorly by the cornea and posteriorly by the iris
and pupil.
Aqueous humor – watery fluid that fills the anterior and posterior chambers of the eye.
Binocular vision – normal ability of both eyes to focus on one object and fuse the two images into
one.
Emmetropia – absence of refractive error enucleation: complete removal of the eyeball and part of
the optic nerve.
Rods – retinal photoreceptor cells essential for bright and dim light.
Vitreous humor – gelatinous material (transparent and colorless) that fills the eyeball behind the
lens.

Elsevier
INDIVIDUAL ASSIGNMENT for Week 7

List down the structures of the eyes according to the Outer , Middle and Inner Layers of the
Eyeball, as discussed in the given modules and ppts , use the pattern below: Thank you
Layers Eye structures Function
Kluwer
Choate, W. (2015, Oct 31) [Assessing the Eyes] Choate eye associates: Common Age – Related
Eye Problems. Retrieved from https://www.choateeye.com/blog/2015/10/31/common-age-
related-eye-problems-163971
Pawlowski, A. (2018 Aug 24) Today: Mind and Body – A Key to early Alzheimer’s detection may be
in your eyes [Eye] Retrieved from https://www.today.com/health/how-diagnose-alzheimer-s-
early-eye-changes-may-be-clue-t136244
Carlson, D. [Eye Anatomy 2 Illustration] Carlson Stock Art: Life Science Illustration and More
Retrieved from https://www.carlsonstockart.com/photo/human-eye-eyeball-anatomy-
illustration-2/
[Eye Anatomy] Human Diseases and Conditions: Glaucoma. Retrieved from
http://www.humanillnesses.com/original/Gas-Hep/Glaucoma.html
NCMB 316 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITIONAL
AND GASTROINTESTINAL METABOLISM AND ENDOCRINE,
PERCEPTION AND COORDINATION (ACUTE AND CHRONIC)
3 14 16
EYE: Diagnostic Tests and Disorders

Read required reading materials and
Cognitive:
1. Analyze causes, classifications and pathogenesis of eye disorders.
2. Evaluate the clinical manifestations and identify priority problems of clients with eye disorders
and describe how they occur.
Affective
1. Show high level of competence in managing clients with eye disorders.
Psychomotor
2. Formulate nursing care plans in clients with eye disorders.
Read the chapter of Eye Disorders
Introduction
Anatomy of the Eye
Diagnostic Evaluation
Direct Ophthalmoscopy
A direct ophthalmoscope is a hand-held instrument with various plus and minus lenses. The lenses
can be rotated into place, enabling the examiner to bring the cornea, lens, and retina into focus
sequentially. The examiner holds the ophthalmoscope in the right hand and uses the right eye to
examine the patient’s right eye. The examiner switches to the left hand and left eye when examining
the patient’s left eye. During this examination, the room should be darkened, and the patient’s eye
should be on the same level as the examiner’s eye. The patient and the examiner should be
comfortable, and both should breathe normally. The patient is given a target to gaze at and is
encouraged to keep both eyes open and steady.
When the fundus is examined, the vasculature comes into focus first. The veins are larger in diameter
than the arteries. The examiner focuses on a large vessel and then follows it toward the midline of the
body, which leads to the optic nerve. The central depression in the disc is known as the cup. The
normal cup is about one-third the size of the diameter of the disc. The size of the physiologic optic cup
should be estimated and the disc margins described as sharp or blurred. A silvery or coppery
appearance, which indicates arteriolosclerosis, should be noted. The periphery of the retina is
examined by having the patient shift his or her gaze. The last area of the fundus to be examined is the
macula, because this area is the most sensitive to light. The retina of a young person often has a
glistening effect, sometimes referred to as a cellophane reflex.
The healthy fundus should be free of any lesions. The examiner looks for intraretinal hemorrhages,
which may appear as red smudges, and, if the patient has hypertension, they may be somewhat
flame shaped. Lipid may be present in the retina of patients with hypercholesterolemia or diabetes.
This lipid has a yellowish appearance. Soft exudates that have a fuzzy, white appearance (cotton-wool
spots) should be noted. The examiner looks for microaneurysms, which look like little red dots, and
nevi. Drusen (small, hyaline, globular deposits), commonly found in macular degeneration, appear as
yellowish areas with indistinct edges. Small drusen have a more distinct edge. The examiner should
sketch the fundus and document any abnormalities.
Indirect Ophthalmoscopy
The indirect ophthalmoscope is an instrument commonly used by the ophthalmologist to see larger
areas of the retina, although in an unmagnified state. It produces a bright and intense light. The light
source is affixed with a pair of binocular lenses mounted on the examiner’s head. The
ophthalmoscope is used with a hand-held, 20-diopter lens.
Slit-Lamp Examination
The slit lamp is a binocular microscope mounted on a table. This instrument enables the user to
examine the eye with magnification of 10 to 40 times the real image. The illumination can be varied
from a broad to a narrow beam of light for different parts of the eye. For example, by varying the width
and intensity of the light, the anterior chamber can be examined for signs of inflammation. Cataracts
may be evaluated by changing the angle of the light. When a hand- held contact lens, such as a three-
mirror lens, is used with the slit lamp, the angle of the anterior chamber may be examined, as may the
ocular fundus.
Color Vision Testing
The ability to differentiate colors has a dramatic effect on the activities of daily living (ADLs). For
example, the inability to differentiate between red and green can compromise traffic safety. Some
careers (eg, commercial artist, [color] photographer, airline pilot, electrician) may be closed to people
with significant color deficiencies. The photoreceptor cells responsible for color vision are the cones,
and the greatest area of color sensitivity is in the macula, the area of densest cone concentration.
A screening test, such as the polychromatic plates discussed in the next paragraph, can be used to
establish whether a person’s color vision is within normal range. Color vision deficits can be inherited.
For example, red–green color deficiencies are inherited in an X-linked manner, affecting approximately
8% of men and 0.4% of women. Acquired color vision losses may be caused by medications (eg,
digitalis) or pathology (eg, cataracts). A simple test, such as asking a patient if the red top on a bottle
of eye drops appears redder to one eye than the other, can be an effective tool. A difference in the
perception of the intensity of the color red between the two eyes can be a symptom of a neurologic
problem and may provide information about the location of the lesion.
Because alteration in color vision sometimes indicates conditions of the optic nerve, color vision
testing is often performed in a neuro-ophthalmologic workup. The most common color vision test is
performed using Ishihara polychromatic plates. These plates are bound together in a booklet. On each
plate of this booklet are dots of primary colors that are integrated into a background of secondary
colors. The dots are arranged in simple patterns, such as numbers or geometric shapes. Patients with
diminished color vision may be unable to identify the hidden shapes. Patients with central vision
conditions (eg, macular degeneration) have more difficulty identifying colors than those with peripheral
vision conditions (eg, glaucoma) because central vision identifies color.
Tonometry
Tonometry measures IOP by determining the pressure necessary to indent or flatten (applanate) a
small anterior area of the globe of the eye. Pressure is measured in millimeters of mercury (mm Hg).
High readings indicate high pressure; low readings indicate low pressure. The procedure is
noninvasive and usually painless. A topical anesthetic eye drop is instilled in the lower conjunctival
sac, and the tonometer is then used to measure the IOP.
Perimetry Testing
Perimetry testing evaluates the field of vision. A visual field is the area or extent of physical space
visible to an eye in a given position. Its average extent is 65 degrees upward, 75 degrees downward,
60 degrees inward, and 95 degrees outward when the eye is in the primary gaze (ie, looking directly
forward). Visual field testing (ie, perimetry) helps identify which parts of the patient’s central and
peripheral visual fields have useful vision. It is most helpful in detecting central scotomas (blind areas
in the visual field) in macular degeneration and the peripheral field defects in glaucoma and retinitis
pigmentosa.
EYE DISORDERS
CATARACT
A cataract is a lens opacity or cloudiness.
Cataracts rank only behind arthritis and
heart disease as a leading cause of
disability in older adults.
Cataracts affect nearly 20.5 million
Americans who are 40 years of age or
older, or about one in every six people in
this age range. By age 80, more than half
of all Americans have cataracts.
According to the World Health
Organization, cataract is the leading
Cataract Normal
cause of blindness in the world (Preshel &
Prevent Blindness America, 2002).
Pathophysiology
Cataracts can develop in one or both eyes at any age for a variety of causes. Visual impairment
normally progresses at the same rate in both eyes over many years or in a matter of months.
Types of senile (age-related) cataracts are defined by their location in the lens: The extent of visual
impairment depends on the size, density, and location in the lens. More than one type can be present
in one eye.
A nuclear cataract is associated with myopia (ie, nearsightedness), which worsens when the
cataract progresses. If dense, the cataract severely blurs vision. Periodic changes in prescription
eyeglasses help manage this problem.
A cortical cataract involves the anterior, posterior, or equatorial cortex of the lens. A cataract in the
equator or periphery of the cortex does not interfere with the passage of light through the center of
the lens and has little effect on vision. Cortical cataracts progress at a highly variable rate. Vision is
worse in very bright light. Studies show that people with the highest levels of sunlight exposure
have twice the risk of developing cortical cataracts than those with low-level sunlight exposure (West
et al., 1998).
Posterior subcapsular cataracts occur in front of the posterior capsule. This type typically develops
in younger people and, in some cases, is associated with prolonged corticosteroid use,
inflammation, or trauma. Near vision is diminished, and the eye is increasingly sensitive to glare
from bright light (eg, sunlight, headlights).
Risk Factors for Cataract Formation
Clinical Manifestations: Aging

Painless Loss of lens transparency
Blurry vision Clumping or aggregation of lens
o Patient perceives that surroundings are protein (which leads to light
dimmer, as if glasses need cleaning. scattering)
Light scattering
Accumulation of a yellow-brown
o Individual experiences reduced contrast pigment to the breakdown of lens
sensitivity, sensitivity to glare, and
reduced visual acuity. protein.
Other effects; Decrease oxygen uptake
o Myopic shift, Increase in sodium and calcium
o Astigmatism, Decrease in levels of vitamin C,
o Monocular diplopia (ie, double vision), protein, and glutathione (an
o Color shift (ie, the aging lens becomes antioxidant)
progressively more absorbent at the Associated Ocular Conditions
blue end of the spectrum),
o Brunescens (ie, color values shift to Retinitis pigmentosa
yellow-brown),
Myopia
o Reduced light transmission.
Retinal detachment and retinal
surgery
Infection (ex. Herpes zoster, uveitis
Assessment and Diagnostic Findings:
1. Decreased visual acuity is directly proportionate Risk Factors for Cataract Formation
to cataract density.
Toxic Factors
a. Snellen visual acuity test,
b. Ophthalmoscopy Corticosteroids, especially at high
c. Slit lamp biomicroscopic examination doses and in long-term use
are used to establish the degree of cataract Alkaline chemical eye burns,
formation. poisoning
Cigarette smoking
Medical Management Calcium, copper, iron, gold, silver,
No nonsurgical treatment cures cataracts. Ongoing and mercury, which tend to deposit
studies are investigating ways to slow cataract in the pupillary area of the lens
progression, such as intake of
Nutritional Factors
1. Antioxidants
(eg, vitamin C, beta-carotene, vitamin E) (Age- Reduced levels of antioxidants
Related Eye Disease Research Study Group, Poor nutrition
2001). In the early stages of cataract Obesity
development, glasses, contact lenses, strong
Physical Factors
bifocals, or magnifying lenses may improve
vision. Reducing glare with proper light and Dehydration associated with chronic
appropriate lighting can facilitate reading. diarrhea, use of purgatives in
2. Mydriatics anorexia nervosa, and use of
hyperbaric oxygenation.
– can be used as short-term treatment to dilate
Blunt trauma, perforation of the lens
the pupil and allows more light to reach the with sharp object or foreign body,
retina, although this increases glare. electric shock.
Surgical Management Ultraviolet radiation in sunlight and
1. Intracapsular Cataract Extraction x-ray.
2. Extracapsular Cataract Extraction Systemic Disease and Syndromes
3. Phacoemulsification
4. Lens Replacement Diabetes mellitus
Down syndrome
Nursing Management:
Disorders related to lipid metabolism
1. Providing Preoperative care
Renal disorders
a. To reduce the risk for retrobulbar hemorrhage Musculoskeletal disorders
(after retrobulbar injection), any
anticoagulation therapy that the patient is receiving is withheld, if medically appropriate.
b. Aspirin should be withheld for 5 to 7 days,
c. Nonsteroidal anti-inflammatory medications (NSAIDs) for 3 to 5 days
d. Warfarin (Coumadin) until the prothrombin time of 1.5 is almost reached.
e. Dilating drops are administered every 10 minutes for four doses at least 1 hour before surgery.
Additional dilating drops may be administered in the operating room (immediately before
surgery) if the affected eye is not fully dilated.
f. Antibiotic, corticosteroid, and NSAID drops may be administered prophylactically to prevent
postoperative infection and inflammation.
2. Providing postoperative care
a. After recovery from anesthesia, the patient receives verbal and written instruction regarding
how to protect the eye, administer medications, recognize signs of complications, and obtain
emergency care.
b. Activities to be avoided.
c. The nurse also explains that there is minimal discomfort after surgery and instructs the patient
to take a mild analgesic agent, such as acetaminophen, as needed.
d. Antibiotic, anti-inflammatory, and corticosteroid eye drops or ointments are prescribed
postoperatively.
3. Promoting Home and |Community-Based Care
a. Teaching patient self-care
To prevent accidental rubbing or poking of the eye, the patient wears a protective eye patch
for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield
worn at night for 1 to 4 weeks.
The nurse instructs the patient and family in applying and caring for the eye shield.
Sunglasses should be worn while outdoors during the day because the eye is sensitive to
light.
Slight morning discharge, some redness, and a scratchy feeling may be expected for a few
days. A clean, damp washcloth may be used to remove slight morning eye discharge.
Because cataract surgery increases the risk for retinal detachment, the patient must know
to notify the surgeon if new floaters (ie, dots) in vision, flashing lights, decrease in vision,
pain, or increase in redness occurs.
b. Continuing Care
The eye patch is removed after the first follow-up appointment.
Patients may experience blurring of vision for several days to weeks.
Sutures left in the eye alter the curvature of the cornea, resulting in temporary blurring and
some astigmatism. Vision gradually improves as the eye heals.
Patients with IOL implants have visual improvement faster than those
Waiting for aphakic glasses or contact lenses. Vision is stabilized when the eye is completely
healed, usually within 6 to 12 weeks, when final corrective prescription is completed.
GLAUCOMA
– is an eye disorder
characterized by an
increase in the
intraocular pressure
resulting to an optic
nerve damage and
eventual blindness. This
is related to either of the
two accepted theories.
1. The direct mechanical theory suggests that high IOP damages the retinal layer as it passes
through the optic nerve head.
2. The indirect ischemic theory suggests that high IOP compresses the microcirculation in the
optic nerve head, resulting in cell injury and death.
Stages
1. Initiating events: precipitating factors include illness, emotional stress, congenital narrow
angles, long-term use of corticosteroids, and mydriatics (ie. medications causing pupillary
dilation). These events lead to the second stage.
2. Structural alterations in the aqueous outflow system: tissue and cellular changes caused by
factors that affect aqueous humor dynamics lead to structural alterations and to the third stage.
3. Functional alterations: conditions such as increased IOP or impaired blood flow create
functional changes that lead to the fourth stage.
4. Optic nerve damage: atrophy of the optic nerve is characterized by loss of nerve fibers and
blood supply, and this fourth stage inevitably progresses to the fifth stage.
5. Visual loss: progressive loss of vision is characterized by visual field defects.
Classification:
1. Open-angle or Angle-closure (pupillary block) glaucoma depends on which mechanisms

cause impaired aqueous outflow.
2. Primary or secondary, depending on whether associated factors contribute to the rise in IOP.
OPEN-ANGLE GLAUCOMA
TYPES of GLAUCOMA CLINICAL MANIFESTATIONS TREATMENT
Optic N. damage Decrease IOP 20%

Visual field defects Topical and oral agents added as
Chronic open-angle IOP > 21 mm Hg necessary
glaucoma (COAG) Usually NO symptoms but Laser trabeculoplasy (LT), If
possible ocular pain, headache medical treatment is unsuccessful
and halos Glaucoma filtering surgery
Goal: lower IOP by at least 30%

IOP < 21 mm Hg
Normal tension Treatment same as COAG
Optic nerve damage
glaucoma Best management is yet to be
Visual field defects
established
Elevated IOP
Ocular hypertension Possible ocular pain or Goal: reduce IOP by at least 20%
headache
ANGLE-CLOSURE (PUPILLARY BLOCK) GLAUCOMAS
TYPES of GLAUCOMA CLINICAL MANIFESTATIONS TREATMENT
Rapidly progressive visual

impairment Ocular emergency; administration
of
periocular pain
o Hyperosmotics,
conjunctival hyperemia, and
o Azetazolamide, and
congestion.
o Topical ocular hypotensive
Pain may be associated with agents, such as pilocarpine
nausea, vomiting, bradycardia, and beta-blockers (betaxolol).
Acute angle-closure
and profuse sweating. Possible laser incision in the iris
glaucoma (AACG)
Reduced central visual acuity, (iridotomy) to release blocked
severely elevated IOP, corneal aqueous and reduce IOP. Other
edema. eye is also treated with pilocarpine
Pupil is vertically oval, fixed in a eye drops and/or surgical
semi- dilated position, and management to avoid a similar
unreactive to light and spontaneous attack
accommodation.
Transient blurring of vision, Prophylactic peripheral laser

Subacute angle-closure halos around lights; temporal iridotomy. Can lead to acute or
glaucoma headaches and/or ocular pain; chronic angle-closure glaucoma if
pupil may be semi-dilated. untreated.
Progression of glaucomatous
Management similar to that for
cupping and significant visual
Chronic angle-closure COAG: includes laser iridotomy
field loss; IOP may be normal or
glaucoma and medications.
elevated; ocular pain and
headache.
Assessment and Diagnostics:

1. Tonometry
measure the IOP
2. Ophthalmoscopy
inspect the optic nerve
pallor and cupping of the optic nerve disc
3. Gonioscopy
examine the filtration angle of the anterior chamber
4. Perimetry
assess the visual fields
scotomas (localized areas of visual loss )
Medical Management:
Aim: Prevention of optic nerve damage
Periodic follow-up examinations are essential to monitor IOP, appearance of the optic nerve, visual
fields, and side effects of medications. In considering a therapeutic regimen, the ophthalmologist
aims for the greatest effectiveness with the least side effects, inconvenience, and cost. Therapy
takes into account the patient’s health and stage of glaucoma. Comfort, affordability, convenience,
lifestyle, and personality are factors to consider in the patient’s compliance with the medical regimen.
1. Systemic and topical ocular medications that lower IOP.
a. Beta blockers Preferred initial topical.
b. Miotics ( Cholinergics ) Increase outflow of the aqueous humor by affecting ciliary muscle
contraction and pupil constriction allowing flow through a larger opening between theiris
and the trabecular meshwork.
c. Adrenergic agonists increase aqueous outflow but primarily decrease aqueous production
with an action similar to beta-blockers and carbonic anhydrase inhibitors
d. Alpha2-agonists
e. Carbonic anhydrase inhibitors
f. Prostaglandins
MACULAR DEGENERATION
Macular degeneration is the
most common cause of visual
loss in people older than age 60
Commonly called age-related
macular degeneration (AMD), it
is characterized by tiny,
yellowish spots called drusen
beneath the retina. Most people
older than 60 years of age have
at least a few small drusen.
There is a wide range of visual
loss in patients with macular
degeneration, but most patients do not experience total blindness. Central vision is generally the
most affected, with most patients retaining peripheral vision.
Types of AMD:
1. Dry type
Non-exudative type
The outer layers of the retina slowly break down resulting to the appearance of drusen.
When the drusen occur outside of the macular area, patients generally have no symptoms.
When the drusen occur within the macula, there is a gradual blurring of vision that patients may
notice when they try to read.
There is no known treatment that can slow or cure this type of AMD
2. Wet type.
Exudative type
Abrupt onset.
Patients complain that straight lines appear crooked and distorted or that letters in words
appear broken up.
Results from proliferation of abnormal blood vessels growing under the retina, within the
choroid layer of the eye, a condition known as choroidal neovascularization (CNV).
Affected vessels can leak fluid and blood, elevating the retina.
Some patients can be treated with the laser to stop the leakage from these vessels.
This treatment is not ideal because vision may be affected by the laser treatment and
abnormal vessels often grow back after treatment.
Medical Management:
Phytodynamic Therapy (PDT)
Visual loss from CNV lesions in AMD is a growing problem. With the growth of these new
vessels from the choriocapillar layer, fibrous tissue develops that can, over months, destroy
central vision.
Has been developed in an attempt to ameliorate the CNV while causing minimal damage to
the retina.
Can reduce the risk of visual loss for certain groups of patients who have classic subfoveal
choroidal neovascularization due to macular degeneration.
Nursing Management
Nursing management is primarily educational. Verteporfin is a light-activated dye, and patient
education is important preoperatively.
1. Instruct patient to bring dark sunglasses, gloves, a wide-brimmed hat, long-sleeved shirt, and
slacks to the PDT setting.
2. The patient must be cautioned to avoid exposure to direct sunlight or bright light for 5 days after
treatment.
3. If a patient must go outdoors within the first 5 days after treatment, he or she should be
counseled to wear long-sleeved shirts and slacks made of tightly woven fabrics. Gloves, shoes,
socks, sunglasses, and a wide-brimmed hat should also be worn if the patient has to go outdoors
during daylight hours during this period. Inadvertent sunlight exposure can lead to severe
blistering of the skin and sunburn that may require plastic surgery.
RETINAL DETACHMENT/ DIABETIC RETINOPATHY

Retinal detachment refers to the separation of the RPE from the sensory layer.
Four types of retinal detachment:

1. Rhegmatogenous detachment
Is the most common form. In this condition, a hole or tear develops in the sensory retina, allowing
some of the liquid vitreous to seep through the sensory retina and detach it from the RPE. People
at risk for this type of detachment include those with high myopia or aphakia after cataract
surgery. Trauma may also play a role in rhegmatogenous retinal detachment. Between 5% and
10% of all rhegmatogenous retinal detachments are associated with proliferative retinopathy, a
retinopathy associated with diabetic neovascularization.
2. Traction retinal detachment.
Secondary to tension, or a pulling force. An ophthalmologist must ascertain all of the areas of
retinal break and identify and release the scars or bands of fibrous material providing traction on
the retina. Generally, patients with this condition have developed fibrous scar tissue from
conditions such as diabetic retinopathy, vitreous hemorrhage, or the retinopathy of prematurity.
The hemorrhages and fibrous proliferation associated with these conditions exert a pulling force
on the delicate retina. Patients can have both rhegmatogenous and traction retinal detachment.
3. Combination of rhegmatogenous and traction
4. Exudative retinal detachments are the result of the production of a serous fluid under the retina
from the choroid. Conditions such as uveitis and macular degeneration may cause the production
of this serous fluid.
Clinical Manifestations:
Sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing
lights,
Sudden onset of a great number of floaters.
Patients do not complain of pain.
After visual acuity is determined, the patient must have a dilated fundus examination using an
indirect ophthalmoscope and a Goldmann three-mirror examination.
This examination is detailed and prolonged, and it can be very uncomfortable for the patient.
Many patients describe this as looking directly into the sun. All retinal breaks, all fibrous bands
that may be causing traction on the retina, and all degenerative changes must be identified. A
detailed retinal drawing is made by the ophthalmologist.
Surgical Management
In rhegmatogenous detachment, an attempt is made to reattach the sensory retina to the RPE
surgically. The retinal surgeon compresses the sclera to indent the scleral wall from the outside
of the eye and bring the two retinal layers in contact with each other. Gas bubbles, silicone oil,
or perfluorocarbon and liquids may also be injected into the vitreous cavity to help push the
sensory retina up against the RPE. Argon laser photocoagulation or cryotherapy is also used to
“spot-weld” small holes.
In traction retinal detachment, a vitrectomy is performed. A vitrectomy is an intraocular
procedure in which 1- to 4-mm incisions are made at the pans plana. One incision allows the
introduction of a light source (ie. endoilluminator), and another incision serves as the portal for
the vitrectomy instrument. The surgeon dissects pre-retinal membranes under direct
visualization while the retina is stabilized by an intraoperative vitreous substitute. Technologic
advances, including the use of operating microscopes, micro-instrumentation, irrigating contact
lenses, and instruments that combine vitreous cutting, aspiration, and illumination capabilities
into one device, have allowed tremendous progress in vitreoretinal surgery. The techniques of
vitreoretinal surgery can be used in various procedures, including the removal of foreign bodies,
vitreous opacities such as blood, and dislocated lenses. Traction on the retina may be relieved
through vitrectomy and may be combined with scleral buckling to repair retinal breaks. Treatment
of macular holes includes vitrectomy, laser photocoagulation, air-fluid-gas exchanges, and the
use of growth factor.
Nursing Management
For the most part, nursing interventions consist of educating the patient and providing supportive
care.
o Promoting comfort
o Teaching about complications
Accomodation – process by which the eye adjusts for near distance by changing the curvature of
the lens to focus a clear image on the retina
Anterior chamber – space in the eye bordered anteriorly by the cornea and posteriorly by the iris
and pupil
Cones – retinal photoreceptor cells essential for visual acuity and color discrimination
Mydriatics – medications that cause pupillary dilation
Myopia – nearsightedness, a refractive error in which the focus of light rays from a distant object is
anterior to the retina

Elsevier
Choose an eye disorder discussed in this course unit and make three nursing care plans.
Formulate a nursing diagnosis except PAIN.
Kluwer
[Eye illustration] Bangkok Hospital Chiang Mai Retrieved from https://www.bangkokhospital-
chiangmai.com/en/center/ophthalmology-clinic/
[The Internal Structure of the Eye] The visible world: The Human Eye. Retrieved from
https://thevisibleworld.weebly.com/the-internal-structure.html
Khazaeni L.M. (2019, June) MSD Manuals: Cataract [Western Ophthalmic Hospital / Science Photo Library]
Retrieved from https://www.msdmanuals.com/professional/eye-disorders/cataract/cataract
(2016, Apr 22) [Glaucoma] In Sight Vision Center: Treating and Controlling Glaucoma. Retrieved from
https://www.insightvisioncenter.com/treating-and-controlling-glaucoma/
(2020) 20/20 Vision for New Hampshire: Macular Degeneration [Healthy Eye and Eye with AMD] Retrieved from
https://2020vision4nh.org/macular-degeneration/
(2020) American Optometric Association: Diabetic retinopathy Retrieved from https://www.aoa.org/patients-and-
public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/diabetic-retinopathy
3 15 17
REVIEW of the Anatomy and Physiology of the Ear

Read required reading materials
Cognitive:
1. Analyze the structures and function of the ears and its alterations of functions.
2. Describe methods used to assess hearing and to diagnose hearing and balance disorders.
Affective
1. Show high level of competence in the enumerating and classifying the parts of the ear.
Psychomotor
2. Perform proper labeling of the parts of the ear.
Read on Anatomy & Physiology of the Ears, Assessment and Disorders
Introduction
The ear is a special sense organ
for hearing and balance. It is
actually protected by the bones
of the skull. There is so much
connection of the ear to the
temporal lobe of the brain as well
as the cerebellum.
The ear has three parts, the
external ear, the middle ear and
the inner ear. The ear is supplied
by cranial nerve VIII, which is a
pure sensory nerve responsible
for hearing and balance.
The external ear is composed of the pinna, this is responsible for getting the sound and
transmitting it to the middle and the inner ear. The pinna leads to the external auditory canal. This
also conducts sound waves to the middle ear. The auditory canal is lined by ceruminous gland
producing cerumen to protect the canal from entry of foreign cells. The lining of the canal contains
several pain receptors that any injury to the external auditory canal cause severe pain.
From the external ear, sound is conducted by the air to the middle ear through the tympanic
membrane (ear drum). The middle ear is composed by the three smallest bones of the body, the
mealeus, incus and stapes which conducts sound waves to the inner ear, from air conduction in the
external ear, the sound is conducted through the bones into the inner ear.
The inner ear contains the vestibulocochlear apparatus that holds the sensory receptors for
hearing and balance. It contains fluid inside, the endolymph and the perilymph surrounded by the
basement membrane in the cochlea where the organ of corti (receptors for hearing) are located.
The vestibules have also fluid inside that holds the receptors for equilibrium. The inner ear is
responsible for conducting sound to the inner ear to the brain through cranial nerve VIII.
From air conduction in the external ear, to bone conduction in the middle ear then finally sensory
neural conduction in the inner ear. The brain interprets the sounds.
acute otitis media: inflammation in the middle ear lasting less than 6 weeks cholesteatoma: tumor of
the middle ear or mastoid, or both, that can destroy structures of the temporal bone
chronicotitis media: repeated episodes of acute otitis media causing irreversible tissue damage and
persistent tympanic membrane perforation
conductive hearing loss: loss of hearing in which efficient sound transmission to the inner ear is
interrupted by some obstruction or disease process
deafness: partial or complete loss of the ability to hear
dizziness: altered sensation of orientation in space
endolymphatic hydrops: dilation of the endolymphatic space of the inner ear; the pathologic
correlate of Ménière’s disease
exostoses: small, hard, bony protrusions in the lower posterior bony portion of the ear canal
labyrinthitis: inflammation of the labyrinth of the inner ear
Ménière’s disease: condition of the inner ear characterized by a triad of symptoms: episodic vertigo,
tinnitus, and fluctuating sensorineural hearing loss
middle ear effusion: fluid in the middle ear without evidence of infection myringotomy (ie,
tympanotomy): incision in the tympanic membrane nystagmus: involuntary rhythmic eye
movement
ossiculoplasty: surgical reconstruction of the middle ear bones to restore hearing
otalgia: sensation of fullness or pain in the ear
otitis externa (ie, external otitis): inflammation of the external auditory canal
otorrhea: drainage from the ear
otosclerosis: a condition characterized by abnormal spongy bone formation around the stapes
presbycusis: progressive hearing loss associated with aging
rhinorrhea: drainage from the nose
sensorineural hearing loss: loss of hearing related to damage of the end organ for hearing or
cranial nerve VIII, or both
tinnitus: subjective perception of sound with internal origin; unwanted noises in the head or ear
tympanoplasty: surgical repair of the tympanic membrane
vertigo: illusion of movement in which the individual or the surroundings are sensed as moving

Elsevier
INDIVIDUAL ASSIGNMENT for Week 8

List down the structures of the Ear according to Parts: Outer, Middle and Inner Ear, as discussed
in the given modules and ppts , use the pattern below: Thank you
Parts Ear structures Function
Kluwer
Jaslow, R. (2019, Sep 06) Harvard Medical School: Hidden Hearing Loss Effects Retrieved from
https://hms.harvard.edu/news/hidden-hearing-loss-effects
[External Ear] Pixfeeds.com. Retrieved from
https://pixfeeds.com/images/topic/7565/1200-7565-hearing-sense-photo3.jpg
[Internal Ear] Pinterest: medwrite.biz Retrieved from https://www.pinterest.com.au/pin/829647562583139269/
[Otoscopic exam of the ear] Medline plus Retrieved from https://medlineplus.gov/ency/imagepages/8991.htm
[Otoscope] Retrieved from https://cornellsurgical.com/adc-5111ns-diagnostix-pocket-otoscope-w-soft-case/
[Tympanic Membrane] Academic Medical Dictionary. Retrieved from
https://medicine.academic.ru/139584/membrana_tympanica
[Whisper Test] Retrieved from http://www2.webster.edu/~davittdc/ear/whisper/whisper.htm
[Instructions for Whisper Test] *Pirozzo S. Whispered voice test for screening for hearing impairment in adults and
children: systematic review. BMJ. 2003 October 25;327(7421):967. Retrieved from
https://www.unmc.edu/media/intmed/geriatrics/reynolds/pearlcards/functionaldisability/whisper_test.htm
Henderson R. MD (2013, Oct 23) [Audiometry test] Netdoctor. Retrieved from
https://www.netdoctor.co.uk/procedures/examinations/a10285/audiometry-test/
Burry, M. (2020, Mar 9) Healthy Hearing: What is otosclerosis [Otosclerosis] Retrieved from
https://www.healthyhearing.com/report/53072-Otosclerosis
(2019, Apr) Harvard Health Publishing Harvard Medical School [Meniere’s disease] Retrieved from
https://www.health.harvard.edu/a_to_z/menieres-disease-a-to-z
Victory, J. (2020, Jan 27) Healthy hearing: Meniere’s disease. Retrieved from
https://www.healthyhearing.com/help/tinnitus/menieres-disease
NCMB 316 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITIONAL
AND GASTROINTESTINAL METABOLISM AND ENDOCRINE,
PERCEPTION AND COORDINATION (ACUTE AND CHRONIC)
3 15 17
EAR: Assessment, Diagnostic Tests and Disorders

Cognitive:
1. Compare the various types of diagnostic test used for ear disorders and appropriate nursing care.
2. Evaluate clinical manifestations of ear disorders and how they occurred in the disease process.
Affective:
1. Show high level of competence in the assessment of the ears.
Psychomotor:
2. Perform proper auditory assessment in the clinical settings.
Read on Anatomy & Physiology of the Ears, Assessment and Disorders
ASSESSMENT OF HEARING AND BALANCE involves inspection of the external, middle, and inner
ear. Evaluation of gross hearing acuity also is included in every physical examination.
Inspection of the External Ear

Inspection of the external ear is a simple procedure, but it is often overlooked. The external ear is
examined by inspection and direct palpation; the auricle and surrounding tissues should be inspected
for deformities, lesions, and discharge, as well as size, symmetry, and angle of attachment to the head.
Manipulation of the auricle does not normally elicit pain. If this maneuver is painful, acute external otitis
is suspected. Tenderness on palpation in the area of the mastoid may indicate acute mastoiditis or
inflammation of the posterior auricular node. Occasionally, sebaceous cysts and tophi (subcutaneous
mineral deposits) are present on the pinna. A flaky scaliness on or behind the auricle usually indicates
seborrheic dermatitis and can be present on the scalp and facial structures as well.
Otoscopic Examination
The tympanic membrane is inspected

with an otoscope and indirect palpation
with a pneumatic otoscope. To examine
the external auditory canal and tympanic
membrane, the otoscope should be held
in the examiner’s right hand, in a pencil-
hold position, with the examiner’s hand
braced against the patient’s face.
This position prevents the examiner from
inserting the otoscope too far into the
external canal. Using the opposite hand,
the auricle is grasped and gently pulled
back to straighten the canal in the adult.
If the canal is not straightened with this
tech- nique, the tympanic membrane is
more difficult to visualize because the
canal obstructs the view.
Otoscope Tympanic Membrane
The speculum is slowly inserted into the ear canal, with the examiner’s eye held close to the magnifying
lens of the otoscope to visualize the canal and tympanic membrane. The largest speculum that the canal
can accommodate (usually 5 mm in an adult) is guided gently down into the canal and slightly forward.
Because the distal portion of the canal is bony and covered by a sensitive layer of epithelium, only light
pressure can be used without causing pain. The external auditory canal is examined for discharge,
inflammation, or a foreign body. The healthy tympanic membrane is pearly gray and is positioned
obliquely at the base of the canal.
Evaluation of Gross Auditory Acuity

A general estimate of hearing can be made by assessing the patient’s ability to hear a whispered phrase
or a ticking watch, testing one ear at a time. The Weber and Rinne tests may be used to distinguish
conductive loss from sensorineural loss when hearing is impaired. These tests are part of the usual
screening physical examination and are useful if a more specific assessment is needed, if hearing loss
is detected, or if confirmation of audiometric results is desired.
Whisper Test
To exclude one ear from the testing, the examiner covers the untested ear with the palm of the hand.
Then the examiner whispers softly from a distance of 1 or 2 feet from the unoccluded ear and out of the
patient’s sight. The patient with normal acuity can correctly repeat what was whispered.
Weber Test
The Weber test uses bone conduction to test lateralization of sound. A tuning fork (ideally, 512 Hz), set
in motion by grasping it firmly by its stem and tapping it on the examiner’s knee or hand, is placed on
the patient’s head or forehead. A person with normal hearing hears the sound equally in both ears or
describes the sound as centered in the middle of the head. A person with conductive hearing loss,
such as from otosclerosis or otitis media, hears the sound better in the affected ear. A person with
sensorineural hearing loss, resulting from damage to the cochlear or vestibulocochlear nerve, hears
the sound in the better-hearing ear. The Weber test is useful for detecting unilateral hearing loss.
Rinne Test
In the Rinne test (pronounced rin-ay), the examiner shifts the stem of a vibrating tuning fork between
two positions: 2 inches from the opening of the ear canal (for air conduction) and against the mastoid
bone (for bone conduction). As the position changes, the patient is asked to indicate which tone is louder
or when the tone is no longer audible.
The Rinne test is useful for distinguishing between conductive and sensorineural hearing loss. A person
with normal hearing reports that air-conducted sound is louder than bone-conducted sound. A person
with a conductive hearing loss hears bone-conducted sound as long as or longer than air-conducted
sound. A person with a sensorineural hearing loss hears air-conducted sound longer than bone-
conducted sound.
Auditory test is done by the following:
Whisper test Rinne test Weber test
Whisper test
Instructions
1. The examiner stands at arm's length (~0.6 m) behind the patient (to prevent lip reading)
2. The opposite auditory canal is occluded by the patient or examiner and the tragus is rubbed in a
circular motion (goal; to block hearing from that ear)
3. The examiner exhales and whispers a combination of numbers and letters (example 4-K-2).
Whispering at the end of exhalation is to ensure as quiet and as standardized voice as possible.
4. If the patient responds correctly, hearing is considered normal and no further screening is
necessary on that ear.
5. If the patient responds incorrectly, then repeat using a different number-letter combination.
6. If on repeated testing, the patient can answer three out of a possible six numbers-letters
correctly, the patient passes. If they cannot answer three out of six or more, the patient fails in
that ear.
7. Repeat the sequence in the opposite ear using different combinations of numbers and letters.
(Note: patients with memory problems may need a simplified letter/number combination to
compensate for their inability to remember)
Significance
Hearing loss prohibits patients from understanding conversations, contributes to cognitive

decline, and leads to social isolation. This impairment is the third most chronic impairment among
older people. It is also useful to ask the patient and family if they have noticed any changes in
hearing, to describe any changes and if they have had any prior treatment. Patients with no wax
occlusion of their ear canal and who failed this test have a hearing loss that correlates with 30 dB
loss. This level of hearing loss has a significant effect on communication.
DIAGNOSTIC EVALUATION
Many diagnostic procedures are available to measure the auditory and vestibular systems indirectly.
These tests are usually performed by an audiologist who is certified by the American Speech-Language-
Hearing Association. Prior to each of the following tests, the nurse explains the procedure to the patient.
Audiometry
In detecting hearing loss, audiometry is the single most important diagnostic instrument. Audiometric
testing is of two kinds: pure-tone audiometry, in which the sound stimulus consists of a pure or musical
tone (the louder the tone before the patient perceives it, the greater the hearing loss), and speech
audiometry, in which the spoken word is used to determine the ability to hear and discriminate sounds
and words.
When evaluating hearing, three characteristics are important: frequency, pitch, and intensity.
Frequency refers to the number of sound waves emanating from a source per second, measured as
cycles per second, or Hertz (Hz). The normal human ear perceives sounds ranging in frequency from
20 to 20,000 Hz. The frequencies from 500 to 2000 Hz are important in understanding everyday speech
and are referred to as the speech range or speech frequencies.
Pitch is the term used to describe frequency; a tone with 100 Hz is considered of low pitch, and a tone
of 10,000 Hz is considered of high pitch.
The unit for measuring loudness (intensity of sound) is the decibel (dB), the pressure exerted by sound.
Hearing loss is measured in decibels, a logarithmic function of intensity that is not easily converted into
a percentage. The critical level of loudness is approximately 30 dB. The shuffling of papers in quiet
surroundings is about 15 dB; a low conversation, 40 dB; and a jet plane 100 feet away, about 150 dB.
Sound louder than 80 dB is perceived by the human ear to be harsh and can be damaging to the inner
ear.
With audiometry, the patient wears earphones and signals to the audiologist when a tone is heard. When
the tone is applied directly over the external auditory canal, air conduction is measured. When the
stimulus is applied to the mastoid bone, bypassing the conductive mechanism (ie, the ossicles), nerve
conduction is tested. For accuracy, testing is performed in a soundproof room. Responses are plotted
on a graph known as an audiogram, which differentiates conductive from sensorineural hearing loss.
Tympanogram
A tympanogram, or impedance audiometry, measures middle ear muscle reflex to sound stimulation
and compliance of the tympanic membrane by changing the air pressure in a sealed ear canal.
Compliance is impaired with middle ear disease.
Auditory Brain Stem Response
The auditory brain stem response is a detectable electrical potential from cranial nerve VIII and the
ascending auditory pathways of the brain stem in response to sound stimulation. Electrodes are placed
on the patient’s forehead. Acoustic stimuli (eg, clicks) are made in the ear. The resulting
electrophysiologic measurements can determine at which decibel level a patient hears and whether
there are any impairments along the nerve pathways (eg, tumor on cranial nerve VIII).
Electronystagmography
Electronystagmography is the measurement and graphic recording of the changes in electrical
potentials created by eye movements during spontaneous, positional, or calorically evoked nystagmus.
It is also used to assess the
oculomotor and vestibular systems and their corresponding interaction. It helps diagnose conditions
such as Mé niè re’s disease and tumors of the internal auditory canal or posterior fossa. Any vestibular
suppressants, such as sedatives, tranquilizers, antihistamines, and alcohol, are withheld for 24 hours
before testing.
DISEASES OF THE EARS
Otosclerosis Meniere’s disease
OTOSCLEROSIS
This disease involves the footplate of the stapes. There is hardening of the footplate of the stapes
causing it to be fixated in the oval window of the cochlea. It affects the conduction of sound from the
middle ear to the inner ear. The etiology is unknown and it is more common among women than
men. Affectation is unilateral so the client is not aware of the initial changes in hearing loss. Initially,
the client will have conductive hearing loss then progresses to sensory neural hearing loss.
Supplements of calcium and fluoride are given to lessen further sclerosis of the stapes. There is no
cure but surgery. Stapedectomy is done or the removal of the stapes and replaced with prosthesis.
Post operatively, teach the client to prevent increase pressure in the ear like going to high altitude
places or riding a plane.
MENIERE’S DISEASE
This is also called endolympathic hydrops. There
is malabsorption of endolymph leading to rupture
of membrane. The disease is causing vertigo,
tinnitus and sensory neural hearing loss. Most
commonly one ear is affected. The client will
manifest acute attack of symptoms.
Clients who manifest the three cardinal signs of
this conditions is diagnosed by complete history
and physical examination. An MRI is done to rule
out possibility of acoustic neuroma, a tumor which
manifest the same clinical manifestations. If there
are no other causes of tinnitus, vertigo and
sensorineural hearing loss, then it is diagnosed
as Meniere’s disease.
The most prominent manifestation is vertigo which

will cause nausea and vomiting to a client. Tinnitus
maybe masked by sound and sensory neural
hearing loss may not be determined because it is
unilateral. During an attack, providing safety is the
most important interventions. Low salt diet is given
because salt may attract more water and further
distention of the endolymph. Promethazine is given
for vertigo, this is a CNS depressant that may cause
client to sleep. The use of non CNS depressant anti
vertigo may also be used like Buclizine and
Meclizine.
Acute otitis media – Inflammation in the middle ear lasting less than 6 weeks.
Cholesteatoma – tumor of the middle ear or mastoid, or both, that can destroy structures of the
temporal bone.
Chronic otitis media – repeated episodes of acute otitis media causing irreversible tissue damage
and persistent tympanic membrane perforation.
Conductive hearing loss – loss of hearing in which efficient sound transmission to the inner ear is
interrupted by some obstruction or disease process.
Deafness – partial or complete loss of the ability to hear.
Dizziness – altered sensation of orientation in space.
Endolymphatic hydrops – dilation of the endolymphatic space of the inner ear; the pathologic
correlate of Ménière’s disease.
Exostoses – small, hard, bony protrusions in the lower posterior bony portion of the ear canal.
Labyrinthitis – Inflammation of the labyrinth of the inner ear.
Ménière’s disease – condition of the inner ear characterized by a triad of symptoms: episodic
vertigo, tinnitus, and fluctuating sensorineural hearing loss.
Middle ear effusion – fluid in the middle ear without evidence of infection.
Myringotomy (ie, tympanotomy): incision in the tympanic membrane.
Nystagmus – Involuntary rhythmic eye movement.
Ossiculoplasty – surgical reconstruction of the middle ear bones to restore hearing.
Otalgia – sensation of fullness or pain in the ear.
Otitis externa (ie, external otitis) – Inflammation of the external auditory canal.
Otorrhea – drainage from the ear.
Otosclerosis – a condition characterized by abnormal spongy bone formation around the stapes.
Presbycusis – progressive hearing loss associated with aging.
Rhinorrhea – drainage from the nose.
Sensorineural hearing loss – loss of hearing related to damage of the end organ for hearing or
cranial nerve VIII, or both.
Tinnitus – subjective perception of sound with internal origin; unwanted noises in the head or ear.
Tympanoplasty – surgical repair of the tympanic membrane.
Vertigo – Illusion of movement in which the individual or the surroundings are sensed as moving.
Elsevier
Consider the scenario and answer the questions.

Postoperative Care:
Genia is a 73-year-old who is scheduled for mastoid surgery to remove cholesteatoma, a cyst-like
fluid sac filled with keratin debris, which was large enough to occlude the ear canal.
1. The patient is informed that she will have a mastoid pressure dressing in place after surgery. The
nurse tells Genia that the dressing will be removed at what time?
2. Although infrequent, what type of nerve damage should the nurse assess for and immediately
report to the healthcare provider?
3. What should the nurse inform the patient are indicators of infection and should be reported
immediately to the healthcare provider?
Kluwer
Jaslow, R. (2019, Sep 06) Harvard Medical School: Hidden Hearing Loss Effects Retrieved from
https://hms.harvard.edu/news/hidden-hearing-loss-effects
[External Ear] Pixfeeds.com. Retrieved from
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BACHELOR OF SCIENCE IN NURSING

NCMB 316 - CARE OF CLIENTS WITH PROBLEMS IN

✓ Read the course and unit objectives

Assessment of Musculoskeletal functions

Rizzo, D. C. (2016) Fundamentals of Anatomy and Physiology (4th ed) Cengage

Musculoskeletal System Disorders: RA-OA-GA comparisons; Osteoporosis, Osteomyelitis,

Read course and unit objectives

At the end of this unit, the students are expected to:

OSTEOARTHRITIS (DEGENERATIVE JOINT DISEASE)

Gout is a heterogeneous group of inflammatory conditions related to a genetic defect of purine

SIGNS AND SYMPTOMS:

Rizzo, D. C. (2016) Fundamentals of Anatomy and Physiology (4th ed) Cengage

✓ Read the course and unit objectives

Antibodies destroy the synovial membrane of the

When cartilages are destroyed, osteoblast occupy the

Clients usually complain of joint pain. Warm

Ankylosis – fixation or immobility of a joint

Rizzo, D. C. (2016) Fundamentals of Anatomy and Physiology (4th ed) Cengage

Read the course and unit objectives

Light rays enter the eyes through

Rizzo, D. C. (2016) Fundamentals of Anatomy and Physiology (4th ed) Cengage

INDIVIDUAL ASSIGNMENT for Week 7

Read the course and unit objectives

Color Vision Testing

Risk Factors for Cataract Formation

Clinical Manifestations: Aging

1. Open-angle or Angle-closure (pupillary block) glaucoma depends on which mechanisms

TYPES of GLAUCOMA CLINICAL MANIFESTATIONS TREATMENT

Optic N. damage Decrease IOP 20%

Goal: lower IOP by at least 30%

TYPES of GLAUCOMA CLINICAL MANIFESTATIONS TREATMENT

Rapidly progressive visual

Transient blurring of vision, Prophylactic peripheral laser

Assessment and Diagnostics:

RETINAL DETACHMENT/ DIABETIC RETINOPATHY

Four types of retinal detachment:

Rizzo, D. C. (2016) Fundamentals of Anatomy and Physiology (4th ed) Cengage

Read the course and unit objectives

Rizzo, D. C. (2016) Fundamentals of Anatomy and Physiology (4th ed) Cengage

INDIVIDUAL ASSIGNMENT for Week 8

✓ Read the course and unit objectives

Inspection of the External Ear

The tympanic membrane is inspected

Evaluation of Gross Auditory Acuity

Hearing loss prohibits patients from understanding conversations, contributes to cognitive

The most prominent manifestation is vertigo which

Consider the scenario and answer the questions.

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