Nursing 304

Nursing Care of the Client/Family with Select

Sensory Health Deviations

I. The Eye
A. Internal Structures of Eye
1. Conjunctivae--thin, transparent mucous membranes--lines eyelid and covers eyeball
2. Eyeball has 3 layers
a. Outer--the fibrous coat
1. Sclera--Opaque,"White of eye"; posterior 5/6 of eye;
2. Cornea--dense, transparent, avascular (gets O2 from atmosphere); remaining
anterior 1/6 of eye; Bends and directs light to retina;
b. Middle layer--Uvea or uveal tract; vascular and pigmented;
Iris--colored part in front of lens; has opening called pupil.
2. Ciliary body--Around outer edge of iris; Connects choroid with iris; Secretes
aqueous humor.
3. Choroid--Posterior, largest of middle coat; A dark brown membrane between sclera
and retina; Consists of many blood vessels supplying nutrients to retina.
Absorbs light.
c. Internal Layer--Retina--Seeing tissue of eye found in back of eye--Like film in a camera;
Optic nerve fibers throughout; When focused light hits retina, picture taken
and messages sent to brain through optic nerve; Bordered externally by
choroid and sclera and internally by vitreous (a gel-like subtance that maintains
spherical shape of eye.)
1. Retina contains:
a. Blood vessels--nourishment
b. Photoreceptors
1. Rods--responsible for peripheral vision
2. Cones--responsible for central vision and color vision
2. Two main cavities within eyeball:
a. Anterior cavity (by iris)--filled with acqueous humor which is continuously
being made; secreted by ciliary body each; Aq. humor flows
in and out to maintain intraocular pressure in normal range of 12 -
20. Continuously replaced; Drains out canal of Schlemm
(trabecular meshwork) into systemic circulation for a fairly
constant IOP.
a. Anterior chamber between cornea and iris
b. Posterior chamber between iris and lens
b. Vitreous Body/chamber (between lens and retina)--filled with vitreous
humor, a gelatinous mass (about 99% water) which gives
shape to posterior eye and holds retina in place; Not
continously replaced.

c. Crystalline lens separates ant. cavity and vitreous body; transparent,

colorless, biconvex structure; Bends light entering eye so that
it converges on retina to form images. Accomodation is the
process whereby lens changes shape and refractive ability to adjust
vision at near or far distances. (Cataracts due to cloudy
crystalline lens)
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B. Giving eye meds

1.

2.

3.

4.

5.

6.

7.

8.

9.

C. Assessment of eye
1. PERRLA
2. Consensual response
3. Accomodation
4. Visual acuity--Snellen chart at 20 ft distance
5. Refractive errors
a. Emmetropia
b. Hyperopia
c. Myopia
d. Presbyopia

D. Disorders of the Eye and Nursing Management

1. External Eye Disorders
a. Hordeolum

1. S&S:

2. Treatment:
a.

b.

c.

d.

e.

f.

b. Conjunctivitis
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1. Allergic

2. Bacterial Conjunctivitis

c. Corneal Disorders -- Keratitis (corneal ulcer)

a. Causes

b. S&S:

c. Prevention and treatment important:

1.

2.

3.

4.

5.

6.

a.

b.

c.

d. Post-op care [applies to all eye surgeries]:

1.

2.
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a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

k.

l.

m.

n.

o.

p.

4. Blindness now called visual impairment;

Know method of walking client with visual impairment;
Provide orientation as needed (room, plate, equipment);
Don’t move things without permission and orientation to change.
Consider sensory impairment and provide personal contact (touch, etc.) as needed,
especially with acute loss of vision due to eye patches or disease/injury.

II. The Ear

A. Function of the Ear
1. Organ of hearing
Hearing Impairment---Common--one out of every five affected; Can range from slight to total
hearing loss
a. Types of Hearing Impairment
1. Air Conduction Hearing Loss (transmission deafness); Interference in sound conduction
through external canal, eardrum, or middle ear. Inner ear usually not involved.
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Causes: foreign bodies in external canal, Upper resp. infections,

allergies, eustachian tube blockage, middle ear infection, tumors. Usually
correctable by medical or surgical treatment.

2. Sensorineural Hearing Loss or Bone Conduction Hearing Loss; Most common inner ear
disorder. Loss of hearing involves cochlea and hearing nerve. May be
temporary or permanent. Caused by: viral infection in inner ear, ototoxic drugs
(ASA, loop diuretics, garamycin, vancomycin), noise trauma, tumors, presbycusis.
Often preventable but usually not correctable. Acoustic Neuroma of 8th Cranial
Nerve; most common benign tumor and although benign, as it grows it exerts
pressure toward brain stem and is life threatening.

b. Prevention of Hearing Impairment: Early, adequate tx of disease, Prevention of trauma,

Early detection of hearing loss, Monitoring side effects of ototoxic drugs,
Monitoring noise pollution --Important to avoid nose greater than 85 - 95 dB,
Periodic ear exam

c. Clinical Manifestations of Hearing Impairment: Irritability, Ringing in ears, Better

understanding in small groups, Avoiding large groups, Withdrawing from
social interactions, Frequently asking people to repeat statements, Straining to hear,
Turning head to favor one ear or leaning forward, Failing to respond when not looking
in the direction of the sound, Answering questions incorrectly, Shouting in
conversation, Raising volume on TV or radio

2. Organ of balance

B. Structure of the Ear and Health Deviations of Each Structure

1. External Ear
a. Pinna/Auricle

b. External Auditory Canal/Meatus/or Ear Canal

c. Disorders of the External Ear--S&S:

1. Infections
a.

b.

c.

2. Obstructions
a..

b.

c.

. d.

e.
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d. TX of External Ear Problems:

2. Tympanic Membrane (Eardrum) Membrane between external ear canal and middle ear space; Separates
canal from middle ear and protects middle ear; Conducts sound vibrations from external ear to ossicles;
Should be pearly gray and shiny.

a. Types of Disorders of Tympanic Membrane

1.

2.

b. S&S of Disorders of Tympanic Membrane

c. TX of Tympanic Membrane Problems:

1.

2.

3. Middle Ear (Tympanic Cavity

a. Contains Three Ossicles (tiny bones)--malleus, incus, stapes--transmit sound vibrations mechanically from
air molecules of external ear to fluid molecules of inner ear. Important to avoid noise greater than 85 - 95
dB.
b. Eustachian Tube--Connects middle ear to nasopharynx for purpose of equalizing pressure on both sides of
eardrum

c. Disorders of the Middle Ear--must be evaluated by indirect means

1. Infections--usually from microorganisms via eustachia tube
Otitis Media

2. Otosclerosis
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3. Eustachian Tube Disorders--will get in Peds

d. S&S of Middle Ear Problems

e. Treatment of Middle Ear Problems--

4. Inner Ear (Labyrinth)--closed, fluid-filled space; deep within the temporal bone; Contains sense organs
for hearing and balance, and the eighth cranial nerve
a. Structures of Inner Ear
1. Bony labyrinth--a rigid capsule that surrounds and protects the membranous labyrinth; made up of
cochlea and semicircular canals (looks like snail shell)

2. Membranous labyrinth--Lies within bony labyrinth but doesn’t fill it; Bathed in a fluid called
perilymph which communicates with cerebrospinal fluid via the cochlea duct. (on
outside)
Contains fluid called endolymph--cushions and protects Organs of Corti against abrupt
movements of head. (on inside) Contains Vestibule which houses utricle and saccule
each of which are vestibular receptors that position the head as it relates to the pull of gravity;
contain tiny hair cells that move with position changes.
3. Semicircular Canals--for balance; sense rotational positional movements; contain tiny hair cells;
connect with utricle
4. Cochlea--contains Organ of Corti --End organ for hearing. Bathed in endolymph. Contains tiny hair
receptor cells. Sound enters external ear canal and causes movement of tympanic
membrane. This movement displaces the ossicles (malleus, incus, stapes). They amplify
the force of the sound and transmit to the cochlea. The periplymphatic fluid is set into motion
(endolymph movement) which subsequently stimulates the receptor hair cells in the Organ
of Corti. These signals are transformed from vibratory energy into electrical impulses by the
hair cells and then sent as electrical impulses to the brain via the acoustic nerve to the
temporal cortex of the brain to be interpreted. (Cochlea= hearing; Vestibule=
balance)

b. Disorders of the Inner Ear

1. Hearing Impairment

2. Tinnitus
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3. Balance Disorders

a. Labyrinthitis

b. Presbycusis

c. Meniere's Disease or Syndrome

4. Acoustic Neuroma--benign tumor of 8th cranial nerve; dangerous due to expansion in brain; removal
results in loss of hearing in that ear; death without removal; must catch early