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Sensory/integ final
sensory/integ final
| Question | Answer |
|---|---|
| Chapter 21: Nursing Assessment: | Visual and Auditory Systems |
| The visual system | includes external tissues and structures surrounding the eye. |
| visual system External structures | include the eyebrows, eyelids, eyelashes, lacrimal system, conjunctiva, cornea, sclera, and extraocular muscles. |
| visual system Internal structures | include the iris, lens, ciliary body, choroid, and retina. |
| The cornea, aqueous humor, lens, and vitreous | must all remain clear for light to reach the retina and stimulate the photoreceptor cells. |
| Refraction | is the ability of the eye to bend light rays so that they fall on the retina. When light does not focus properly, it is called refractive error. |
| Types of refractive errors | are myopia (nearsightedness) and hyperopia (farsightedness). |
| Astigmatism | is caused by corneal unevenness resulting in visual distortion. Presbyopia is a type of hyperopia due to aging. |
| The auditory system | consists of peripheral and central systems. |
| Peripheral system | includes the external, middle, and inner ear and is involved with sound reception and perception. |
| The central system (brain and its pathways) | integrates and assigns meaning to what is heard. |
| Presbycusis | can result from aging or insults from a variety of sources. |
| Tinnitus, | or ringing in the ears, may accompany the hearing loss that results from the aging process. |
| External and middle ear portions | conduct and amplify sound waves from the environment. Problems located in these areas cause conductive hearing loss with changes in sound perception/sensitivity. |
| The inner ear functions | in hearing and balance. Problems located in this area or along the nerve pathway from the brain cause sensorineural hearing loss with changes in tone perception/sensitivity. |
| Central auditory system problems | cause central hearing loss with difficulty in understanding the meaning of words. |
| Patient information obtained should include | past eye/ear health and family history. History also should include specific diseases and medications known to cause vision and hearing problems. Past history of visual and auditory tests and eye/ear trauma is also noted. |
| Visual assessment determines | visual acuity, ability to judge closeness and distance, extraocular muscle function, evaluating visual fields and pupil function, and measuring intraocular pressure. |
| Auditory assessment notes | head posturing and appropriateness of responses when speaking to the patient and balance. Problems with balance may present as nystagmus or vertigo. |
| Visual and auditory external structures | are assessed by inspection for symmetry and deformity. Some eye structures must be visualized with an ophthalmoscope; an otoscope is used for further assessment of certain ear structures. |
| Visual assessment can include | color vision and stereopsis with auditory assessment often including whisper/spoken word testing, audiometry, and tuning fork tests. |
| Chapter 22: Nursing Management: | Visual and Auditory Problems |
| Refractive errors | are the most common visual problems. They occur when light rays do not converge into a single focus on the retina. |
| Myopia | or nearsightedness, is the most prevalent refractive error. |
| Hyperopia | refers to farsightedness. |
| Presbyopia | is farsightedness due to decreased accommodative ability of the aging eye. |
| Most refractive errors | are corrected by lenses (eyeglasses or contact lenses), refractive surgery, or surgical implantation of an artificial lens. |
| A hordeolum (sty) | is an infection of sebaceous glands in the lid margin. |
| A chalazion | is a chronic inflammatory granuloma of meibomian (sebaceous) glands in the lid. |
| Blepharitis | is a common chronic bilateral inflammation of the lid margins. |
| Conjunctivitis | is infection or inflammation of the conjunctiva.Acute bacterial conjunctivitis (pinkeye) is common. |
| Conjunctivitis | It occurs initially in one eye and can spread rapidly to the unaffected eye.It is usually self-limiting, but antibiotic drops shorten the course of the disorder. |
| Trachoma | is a chronic conjunctivitis caused by Chlamydia trachomatis.It is a global cause of blindness. It is preventable and transmitted mainly by hands and flies. |
| Keratitis | is corneal inflammation or infection.The cornea can become infected by bacteria, viruses, or fungi.Topical antibiotics are generally effective, but eradicating infection may require antibiotics administered by subconjunctival injection or IV. |
| Keratitis | Other causes are chemical damage,contact lens wear,contaminated products(lens solutions,cosmetics).Tissue loss due infection produces corneal ulcers.Treatment aggressive avoid permanent vision loss.untreated ulcer result corneal scarring &perforation. |
| A cataract | is an opacity within the lens.Symptoms of cataracts are decreased vision, abnormal color perception, and glare. |
| Removal of the cataract | is the most common surgery for older adults. Most patients undergoing cataract removal have an intraocular lens implanted during surgery.After cataract surgery, the eyes are temporarily covered with a patch and protective shield. |
| Postoperative nursing goals for cataract | include teaching about eye care, activity restrictions, medications, follow-up visit schedule, and signs/symptoms of possible complications.Healing is complete around 6 to 8 weeks postoperatively. |
| Retinopathy | is microvascular damage to the retina that can lead to blurred and progressive vision loss.It is often associated with diabetes mellitus and hypertension. |
| Nonproliferative diabetic retinopathy | is characterized by capillary microaneuryms, retinal swelling, and hard exudates. |
| Macular edema | represents a worsening as plasma leaks from macular blood vessels.It may be treated with laser photocoagulation. |
| Hypertensive retinopathy | is caused by high blood pressure that creates blockages in retinal blood vessels.On examination, retinal hemorrhages and macula swelling are noted. |
| Sustained, severe hypertension | can cause sudden visual loss with optic disc and nerve swelling.Treatment focuses on lowering the blood pressure. |
| Retinal detachment | is a separation of the retina and underlying epithelium with fluid accumulation between the two layers. |
| Detachment | is caused by a retinal break, which is interruption in the full thickness of retinal tissue. |
| Retinal detachment Untreated, symptomatic retinal detachment results | in blindness. |
| Retinal detachment Breaks | are classified as tears or holes. |
| Retinal detachment Symptoms | are light flashes, floaters, and/or rings in vision. Once detached, painless loss of peripheral or central vision occurs. |
| Treatment of retinal detachment | is to first seal retinal breaks and then relieve inward traction on retina. |
| Retinal detachment Several types of surgery | used include laser photocoagulation and cryopexy and then scleral buckling. |
| Visual prognosis | varies, depending on the extent, length, and area of detachment. |
| Retinal detachment Discharge planning and teaching | are important, with the nurse beginning this process early as the patient is not hospitalized for long. |
| Age-related macular degeneration (AMD) | is the most common cause of irreversible central vision loss in older adults. |
| AMD | is related to retinal aging. Family history is another strong predictor of risk. |
| AMD | has two forms: dry (nonexudative) and wet (exudative). |
| Dry AMD | is more common, with close vision tasks becoming more difficult. Atrophy of macular cells leads to slow, progressive, and painless vision loss. |
| Wet AMD | is more severe, with rapid onset and development of abnormal blood vessels related to the macula. Symptoms are blurred, distorted, and darkened vision with visual field blind spots. |
| Wet AMD treatment | includes laser photocoagulation, photodynamic therapy, and intravitreous injectable drugs. Vitamin and mineral supplements may be considered. |
| Glaucoma | is associated with increased intraocular pressure (IOP), optic nerve atrophy, and peripheral visual field loss. |
| Glaucoma | often occurs with advanced age and is a major cause of permanent blindness. |
| Glaucoma Etiology | is due to consequences of elevated IOP. Glaucoma is largely preventable with early detection and treatment. |
| Two types of glaucoma include: | primary angle-closure glaucoma (PACG) and primary open-angle glaucoma (POAG), which is the more common. |
| With POAG | , few symptoms exist and it is often not noticed until peripheral vision is severely compromised. |
| Symptoms of PACG | include sudden, excruciating eye pain along with nausea and vomiting. |
| PACG Therapy | is to lower IOP to prevent optic nerve damage through drugs, argon laser trabeculoplasty, trabeculectomy, and iridotomy. The nurse should teach about glaucoma risk and the importance of early detection and treatment. |
| External otitis | involves inflammation or infection of the auricle and ear canal epithelium due to infection. |
| External otitis Symptoms | are pain, ear canal swelling, and drainage. |
| External otitis Therapy | is analgesics, antibiotics, and compresses. |
| ACUTE OTITIS MEDIA | Untreated or repeated attacks of acute otitis media in early childhood may lead to chronic middle ear infection. |
| ACUTE OTITIS MEDIA Symptoms | include purulent exudate and inflammation that can involve the ossicles, eustachian tube, and mastoid bone.It is often painless.Treatment may include antibiotics and surgery. |
| Ménière’s disease | is characterized by symptoms of inner ear disease with episodic vertigo, tinnitus, fluctuating sensorineural hearing loss, and aural fullness.The cause is unknown, but results in excessive accumulation of endolymph. |
| Ménière’s disease | Attacks may begin with sense of ear fullness, tinnitus, and decreased hearing acuity.The duration of attacks is hours to days, and attacks occur several times a year. |
| Ménière’s disease | Other symptoms are pallor, sweating, nausea, and vomiting.Hearing loss fluctuates, and with continued attacks, recovery lessens, eventually leading to permanent hearing loss. |
| Ménière’s disease | Drugs are used between and during attacks.If not relieved, surgeries include endolymphatic sac decompression and vestibular nerve resection. |
| Ménière’s disease Nursing care | minimizes vertigo and provides for patient safety with acute attacks. |
| Hearing disorders | are the primary handicapping disability in the United States. |
| Conductive hearing loss: | Occurs in outer/middle ear &impairs sound being conducted from outer to inner ear.It is caused by conditions interfering with air conduction, such as otitis media with effusion, impacted cerumen and foreign bodies, middle ear disease, and otosclerosis. |
| Sensorineural hearing loss: | due to impairment of inner ear or vestibulocochlear nerve.Causes include congenital &hereditary, noise trauma,aging,Ménière’s disease,&ototoxicity. main problems are ability to hear sound but not to understand speech &lack of understanding of prob |
| Signs of hearing loss | include asking others to speak up, answering questions inappropriately, not responding when not looking at speaker, straining to hear, and increasing sensitivity to slight increases in noise level. |
| Sensorineural hearing loss: Often the patient | is unaware of minimal hearing loss. Assistive devices and techniques include hearing aids, speech reading, and a cochlear implant. |
| Prevention of hearing loss | participation in conservation programs in work,monitoring for SE/level of ototoxic drugs(ASA,diuretics,antineoplastics),avoidance of continued exposure to high noise levels(+85-95decibels)&industrial drugs/chemicals(toluene,carbon disulfide,mercury) |
| Presbycusis | (hearing loss associated with aging) includes loss of peripheral auditory sensitivity, decline in word recognition ability, and associated psychologic and communication issues. |
| Chapter 24: Nursing Management: | Integumentary Problems |
| Health promotion activities for good skin health | include asvoidance of environmental hazards, adequate rest and exercise, and proper hygiene and nutrition. |
| Sun safety includes | sun avoidance, especially during midday hours, protective clothing, and sunscreen. |
| Actinic keratoses, basal cell carcinoma, squamous cell carcinoma, and malignant melanoma | problems associated with sun exposure. |
| Actinic keratosis: | Is a premalignant form of squamous cell carcinoma affecting nearly all the older white population. |
| Actinic keratosis: | A typical lesion is an irregularly shaped, flat, slightly erythematous papule with indistinct borders and an overlying hard keratotic scale or horn. |
| Actinic keratosis: Treatment | includes cryosurgery, fluorouracil (5-FU), surgical removal, tretinoin (Retin-A), chemical peeling agents, and dermabrasion. |
| Skin cancer | is the most common malignant condition. Patients should be taught to self-examine their skin monthly. |
| The cornerstone of self-skin examination | is the ABCD rule. Examine skin lesions for Asymmetry, Border irregularity, Color change/variation, and Diameter of 6 mm or more. |
| Risk factors for skin cancer include | fair skin type (blonde or red hair and blue or green eyes), history of chronic sun exposure, family history of skin cancer, and exposure to tar and systemic arsenicals. |
| Nonmelanoma skin cancers | do not develop from melanocytes, as melanoma skin cancers do. Instead, they are a neoplasm of the epidermis. Most common sites are in sun-exposed areas. |
| Basal cell carcinoma (BCC): | locally invasive malignancy from epidermal basal cells.most common type of skin cancer&least deadly.Tissue biopsy is needed to confirm the diagnosis. |
| Basal cell carcinoma (BCC): Treatments | of electrodessication and curettage, cryosurgery, and excision all have cure rate of more than 90%. |
| Squamous cell carcinoma (SCC): | malignant neoplasm of keratinizing epidermal cells.less common than BCC. |
| Squamous cell carcinoma (SCC): | Can be very aggressive, has the potential to metastasize, and may lead to death if not treated early. |
| Pipe, cigar, and cigarette smoking area | are risk factors for SCC; therefore SCC is also found on mouth and lips. |
| Biopsy | is performed when a lesion is suspected of being SCC. |
| Squamous cell carcinoma (SCC): | Treatment includes electrodesiccation and curettage, excision, radiation therapy, intralesional injection of 5-FU or methotrexate, and Mohs’ surgery. |
| Malignant melanoma: | Is a tumor arising in melanocytes.Melanomas can metastasize to any organ. |
| Malignant melanoma: | Is the most deadly skin cancer, and its incidence is increasing faster than that of any other cancer. |
| Malignant melanoma: | Individuals should consult health care provider if moles or lesions show any clinical signs (ABCDs) of melanoma. |
| Malignant melanoma: | can also occur in eyes, meninges, and lymph nodes. |
| Malignant melanoma: | Suspicious lesions should be biopsied using excisional biopsy. |
| Important prognostic factor of melanoma | is tumor thickness at time of diagnosis. |
| Initial treatment for melanoma | surgery. |
| Melanoma spread to lymph nodes or nearby sites often requires | chemotherapy, biologic therapy (e.g., α-interferon, interleukin-2), and/or radiation therapy. |
| Malignant melanoma: | Stage I is 100% curable with stage IV being mostly palliative care. |
| Abnormal nevus pattern called dysplastic nevus syndrome | identifies individual at increased risk of melanoma. Dysplastic nevi (DN), or atypical moles, are nevi >5 mm across with irregular borders and varying color. |
| Staphylococcus aureus and group A β-hemolytic streptococci | are major types of bacteria responsible for primary and secondary skin infections. Herpes simplex, herpes zoster, and warts are the most common viral infections affecting the skin. |
| Ultraviolet light, or a combination of two types (UVA and UVB), | used to treat many conditions. UV wavelengths cause erythema, desquamation, and pigmentation and may cause temporary suppression of basal cell mitosis followed by rebound increase in cell turnover. |
| Radiation use for treatment of | cutaneous malignancies varies greatly. Lasers are used for many dermatologic problems. |
| Antibiotics are used topically and systemically | to treat dermatologic problems, and are often used in combination. Common OTC topical antibiotics include bacitracin and polymyxin B. |
| Corticosteroids | effective in treating wide variety of dermatologic conditions &used topically,intralesionally,systemically.High-potency corticosteroids may produce SE when prolonged: skin atrophy,rosacea eruptions,severe exacerbations of acne,dermatophyte infections |
| Oral antihistamines are used to treat conditions that exhibit | urticaria, angioedema, and pruritus. Topical immune response modifiers such as pimecrolimus (Elidel) and tacrolimus (Protopic) are newer nonsteroidal medications used in atopic dermatitis. |
| Diagnostic and surgical therapy techniques | include skin scraping, electrodesiccation and electrocoagulation, curettage, punch biopsy, cryosurgery, and excision. |
| Wet dressings are commonly used | when skin is oozing from infection and/or inflammation, and to relieve itching, suppress inflammation, and debride a wound. |
| Baths are used when | large body areas need to be treated. They also have sedative and antipruritic effects. |
| Careful hand washing and safe disposal of soiled dressings | best means of preventing spread of skin problems. |
| Cosmetic procedures | chemical peels,toxin injections,collagen fillers,laser surgery,breast enlargement/reduction,face-lift, eyelid-lift, and liposuction. Preoperative management includes informed consent and realistic expectations of what cosmetic surgery can accomplish. |
| Skin grafts | may be necessary to provide protection to underlying structures or to reconstruct areas for cosmetic or functional purposes. Ideally, wounds heal by primary intention. |
| Two types of grafts | are free grafts and skin flaps. Soft tissue expansion is a technique for resurfacing a defect, such as a burn scar, removing a disfiguring mark, such as a tattoo, or as a preliminary step in breast reconstruction. |
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