EMILIO AGUINALDO COLLEGE - CAVITE

NCM 104 ~ SENSORY DISORDERSSkin, Eyes, EarsJHOANNE D. DUERO 7/13/2009

Management of Sensory Disorders : Burns, Eyes and Ears Disorders

Management of Sensory Disorders SKIN Largest organ of the body Functions: Protection Sensation Fluid balance Temperature regulation Vitamin D production Immune response

Primary Skin Lesions Macule Flat, circumscribed area that is a change in color of the skin; less than 1 cm in diameter

Papule

An elevated, firm, circumscribed area less than 1 cm in diameter e.g.Wart (Verruca), elevated moles, lichen planus, cherry angioma, skin tag

Plaque

Elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter e.g.Psoriasis, seborrheic and actinic keratoses, eczema

Wheal

Elevated irregular-shaped area of cutaneous edema; solid, transient, variable diameter Ex. Insect bite, urticaria, allergic reaction

Nodule

Elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1 to 2 cm in diameter Ex. Dermatolfibroma, erythema nodosum, lipomas, melanoma, hemangioma, neurofibroma

Tumor

Elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter Ex. Neoplasma, lipoma, hemangioma

Vesicle

Elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameter Ex. Varicella (chickenpox, herpes zoster, impetigo, acute eczema)

Bulla Vesicle greater than 1 cm in diameter Ex. Blister, lupus, impetigo, drug reaction

Pustule

Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid Ex. Impetigo, acne, folliculitis, herpes simplex

Cyst Elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material Ex. Sebaceous cyst, cystic acne

SKIN CONFIGURATIONS

Secondary Skin Lesions Scale

Heaped-up keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in size Ex. Seborrheic dermatitis following scarlet fever

Lichenification Rough, thickened epidermis secondary to persistent rubbing, itching or skin irritation; often involves flexor surface of extremity

Scar Thin to thick fibrous tissue that replaces normal skin following injury or laceration to the dermis

Keloid Irregular-shaped elevated, progressively enlarging scar, grows beyond the boundaries of the wound; caused by excessive collagen formation during healing

Excoriation Loss of the epidermis linear hollowed-out crusted area Ex. Abrasion or scratch scabies

Fissure Linear crack or break from the epidermis to the dermis, may be moist or dry Ex. Athletes foot, cracks at the corner of the mouth, eczema

Erosion

Loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla Ex. Varicella, variola after rupture, candidiasis, herpes simplex

Ulcer

Loss of epidermis and dermis, concave; varies in size Ex. Decubiti, stasis ulcers, syphillis chancre

Atrophy

Thinning of the skin surface and loss of skin markings; skin appears translucent and paperlike Ex. Aged skin, striae, discoid lupus erythematosus

Vascular Skin Lesions Telangiectasia Fine, irregular red lines produced by capillary dilation Ex. Vascular spider, lupus erythematosus

Cherry Angioma Small, slightly raised, bright red areas that appear on the face, neck and trunk of the body. These increase in size and number with advanced age.

Petechiae

Spider Angioma

Ecchymoses

Anatomic Distribution of Common Skin Disorders Contact Dermatitis

Seborrheic Dermatitis and Acne

Scabies and Herpes Zoster

Skin Appearance Cyanosis Jaundice

Normal Aging Changes

Thinning of skin Uneven pigmentation Wrinkling, skin folds, and decreased elasticity Dry skin Diminished hair Increased fragility and increased potential for injury Reduced healing ability

Assessment of the Skin Prepare the patient: explain the purpose and provide privacy and coverings Ask assessment questions Inspect the patients entire body including mucosa, scalp, hair, and nails Wear gloves Assess any lesions; palpate and measure them Note hair distribution Photographs may be used to document nature and extent of skin conditions and to document progress resulting from treatment; they may also be used to track moles MALE PATTERN BALDNESS

Diagnostic Procedures

Skin biopsy Immunofluorescence Patch testing Skin scrapings Tzanck smear Woods light examination Management of Patients with Burn Injury

Causes:

1. dry heat - fire 2. moist heat - steam or hot liquids

3. 4. 5. 6. 7.

Radiation friction heated objects the sun Electricity 8. or chemicals Thermal burns are the most common type. Most burns occur in the home. Young children and the elderly are at high risk for burn injuries.

Goals Related to Burns Prevention Institution of life-saving measures for the severely burned person Prevention of disability and disfigurement through early specialized and individualized care Rehabilitation through reconstructive surgery and rehabilitation programs Classification of Burns

Superficial partial-thickness (1ST DEGREE BURN) First-degree burns affect only the outer layer of the skin epidermis. Manifestation: minor pain, redness (erythema) Mild swelling. cause: e.g.sunburn

Management:

Remove jewelry or tight clothing from the burned area before it begins to swell. Flush the burn with cool running water or apply cold-water compresses (a wet towel or handkerchief) until the pain lessens. Do not use ice or ice water, which can cause more damage to the tissues. Cover the burn with a clean (sterile, if possible), dry, nonfluffy bandage such as a gauze pad. Do not put tape on the burn.

2nd DEGREE BURN Affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. Causes: deep sunburn exposure to flames contact with hot liquids burning gasoline or kerosene contact with chemicals

Manifestations: skin is bright red and blotchy Blisters. It usually looks wet because of the loss of fluid through the damaged skin. very painful

3rd DEGREE BURN Causes: contact with corrosive chemicals flames electricity or extremely hot objects immersion of the body in extremely hot water

clothing that catches fire Third-degree burns can also damage fat, muscle, and bone

Skin with a third-degree burn may appear white or black and leathery on the surface. Because the nerve endings in the skin are destroyed, the burned area may not be painful, but the area around the burn may be extremely painful. Pain causes the breathing rate and pulse to increase. Some areas of the burn may appear bright red, or may blister. Electrical burns damage the deep tissues. Often only the area of the skin where the electricity entered the body looks black and charred. Electrical shocks can make a person stop breathing and interrupt the rhythm of the heart. Shock occurs when loss of fluids causes the blood pressure to become so low that not enough blood reaches the brain and other major organs. The symptoms of shock : a. fainting, general weakness, nausea and vomiting, rapid pulse and breathing, a blue tinge to the lips and finger nails, and pale, cold, moist skin. b. If the victim has been burned in a fire and has been exposed to large amounts of smoke, he or she may also have chest pain, red and burning eyes, and a cough. c. All third-degree burns require emergency medical treatment. Estimation of Total Body Surface Area (TBSA) Burned Rule of Nines

Pathophysiology of Burns Burns are caused by a transfer of energy from a heat source to the body. Thermal (includes electrical) Radiation Chemical

Physiologic Changes Burns less than 25% TBSA produce a primarily local response. Burns more than 25% may produce a local and systemic response and are considered major burns. Systemic response includes release of cytokines and other mediators into the systemic circulation. Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction. Effects of Major Burn Injury Fluid and electrolyte shifts Cardiovascular effects Pulmonary injury Upper airway Inhalation below the glottis Carbon monoxide poisoning Restrictive defects Renal and GI alterations

Immunologic alterations Effect upon thermoregulation Nomenclature Traditional nomenclature First-degree Depth Epidermis involvement Superficial (papillary) dermis Deep (reticular) dermis Clinical findings Erythema, minor pain, lack of blisters Blisters, clear fluid, and pain Whiter appearance, with decreased pain. Difficult to distinguish from full thickness Hard, leather-like eschar, purple fluid, no sensation (insensate

Superficial thickness

Partial thickness superficial Partial thickness deep

Second-degree

Second-degree

Full thickness

Third- or fourthdegree

Dermis and underlying tissue and possibly fascia, bone, or muscle

FOR MAJOR BURNS: Initial Care 1. Make sure that the person is no longer in contact with smoldering materials. However, DO NOT remove burnt clothing that is stuck to the skin. 2. If breathing has stopped, or if the person's airway is blocked, open the airway. If necessary, begin CPR. 3. Cover the burn area with a cool, moist sterile bandage (if available) or clean cloth. A sheet will do if the burned area is large. DO NOT apply any ointments. Avoid breaking burn blisters. 4. If fingers or toes have been burned, separate them with dry, sterile, non-adhesive dressings. 5. Elevate the body part that is burned above the level of the heart. Protect the burnt area from pressure and friction. 6. Take steps to prevent shock. Lay the person flat, elevate the feet about 12 inches, and cover him or her with a coat or blanket. However, DO NOT place the person in this shock

position if a head, neck, back, or leg injury is suspected or if it makes the person uncomfortable. Phases of Burn Injury

Emergent or resuscitative phase Onset of injury to completion of fluid resuscitation Acute or intermediate phase From beginning of diuresis to wound closure Rehabilitation phase From wound closure to return to optimal physical and psychosocial adjustment

Emergent or Resuscitative Phase: On-the-Scene Care

Prevent injury to rescuer. Stop injury: extinguish flames, cool the burn, irrigate chemical burns. ABCs: Establish airway, breathing, and circulation. Start oxygen and large-bore IVs. Remove restrictive objects and cover the wound. Do assessment, surveying all body systems, and obtain a history of the incident and pertinent patient history. Note: Treat patients with falls and electrical injuries as for potential cervical spine injury.

Emergent or Resuscitative Phase Patient is transported to emergency department. Fluid resuscitation is begun. Foley catheter is inserted. Patients with burns exceeding 20-25% should have an NG tube inserted and placed to suction. Patient is stabilized and condition is continually monitored. Patients with electrical burns should have an ECG. Address pain; only IV medication should be administered. Psychosocial consideration and emotional support should be given to patient and family. Acute or Intermediate Phase 48-72 hours after injury Continue assessment and maintain respiratory and circulatory support. Prevention of infection, wound care, pain management, and nutritional support are priorities in this stage.

Rehabilitation Phase Rehabilitation is begun as early as possible in the emergent phase and extends for a long period after the injury. Focus is upon wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities so the patient can have the best-quality life, both personally and socially. The patient may need reconstructive surgery to improve function and appearance. Vocational counseling and support groups may assist the patient.

Management of Shock: Fluid Resuscitation

Maintain BP above 100 mm Hg systolic and urine output of 30-50 mL/hr. Maintain serum sodium at near-normal levels. Consensus formula Evans formula Brooke Army formula Parkland Baxter formula Hypertonic saline formula Note: Adjust formulas to reflect initiation of fluids at the time of injury.

Fluid and Electrotype Shifts: Emergent Phase

Generalized dehydration Reduced blood volume and hemoconcentration Decreased urine output Trauma causes release of potassium into extracellular fluid: hyperkalemia Sodium traps in edema fluid and shifts into cells as potassium is released: hyponatremia Metabolic acidosis

Acute Phase

Fluid re-enters the vascular space from the interstitial space. Hemodilution Increased urinary output Sodium is lost with diuresis and due to dilution as fluid enters vascular space: hyponatremia. Potassium shifts from extracellular fluid into cells: potential hypokalemia Metabolic acidosis Burn Wound Care

Wound cleaning Hydrotherapy Use of topical agents Wound dbridement Natural dbridement Mechanical dbridement Surgical dbridement Wound dressing, dressing changes, and skin grafting Use of Biobrane Dressing

Comparison of Integra Template and Split-Thickness Autograft

Pain Management Analgesics IV use during emergent and acute phases Morphine Fentanyl Other

Decrease level of anxiety Decrease/avoid sleep deprivation Non-pharmacologic measures Nutritional Support

Goal of nutritional support is to promote a state of nitrogen balance and match nutrient utilization. Nutritional support is based on patients preburn status and % of TBSA burned. Enteral route is preferred. Jejunal feedings are frequently used to maintain nutritional status with lower risk of aspiration in a patient with poor appetite, weakness, or other problems.

Other Major Care Issues Pulmonary care Psychological support of patient and family Patient and family education Restoration of function Nursing Process: Care of the Patient in the Emergent Phase of Burn Care Diagnosis Impaired gas exchange Ineffective airway clearance Fluid volume deficit Hypothermia Acute pain Anxiety Potential Complications/Collaborative Problems Acute respiratory failure Distributive shock Acute renal failure Compartment syndrome Paralytic ileus Curlings ulcer Nursing Process: Care of the Patient in the Acute Phase of Burn Care Diagnosis Excessive fluid volume Risk for infection Imbalanced nutrition Acute pain Impaired physical mobility

Ineffective coping Interrupted family processes Deficient knowledge

Potential Complications/Collaborative Problems Heart failure and pulmonary edema Sepsis Acute respiratory failure Visceral damage (electrical burns) Home Care Instructions Mental health Skin and wound care Exercise and activity Nutrition Pain management Thermoregulation and clothing Sexual issues Assessment and Management of Patients with Eye and Vision Disorders Extraocular Muscles

Visual Pathways

Cross-Section of the Eye

Internal Structures of the Eye

Assessment and Evaluation of Vision Ocular history Visual acuity Snellen chart Record each eye 20/20 means the patient can read the 20 line at a distance of 20 feet Finger count or hand motion Examination of the External Structures Note any evidence of irritation, inflammatory process, discharge, etc. Assess eyelids and sclera Assess pupils and pupillary response in a darkened room Note gaze and position of eyes Assess extraocular movements Ptosis: drooping eyelid Nystagmus: oscillating movement of eyeball Diagnostic Evaluation Ophthalmoscopy Direct and indirect Examines the cornea, lens, and retina Slit-lamp examination Color vision testing Amsler grid Ultrasonography Fluorescein and indocyanine green angiography Tonometry Measures intraocular pressure Gonioscopy Visualizes the angle of the anterior chamber Perimetry testing Evaluates field of vision Scotomas: blind areas in the visual field Impaired Vision Refractive errors Can be corrected by lenses that focus light rays on the retina Emmetropia: normal vision Myopia: nearsighted Hyperopia: farsighted

Astigmatism: distortion due to irregularity of the cornea Eyeball Shape Determines Visual Acuity in Refractive Errors

Glaucoma A group of ocular conditions in which damage to the optic nerve is related to increased intraocular pressure (IOP) caused by congestion of the aqueous humor Open-angle glaucoma Chronic open-angle glaucoma Normal-tension glaucoma Ocular hypertension Angle-closure (pupillary block) glaucoma Acute angle-closure Subacute angle-closure Chronic angle-closure Congenital glaucomas and glaucoma secondary to other conditions Pathophysiology of Glaucoma Normal outflow of aqueous humor

In glaucoma, aqueous production and drainage are not in balance When aqueous outflow is blocked, pressure builds up in the eye Increased IOP causes irreversible mechanical and/or ischemic damage

Clinical Manifestations Called the silent thief, glaucoma renders the patient unaware of the condition until there is significant vision loss, including peripheral vision loss, blurring, halos, difficulty focusing, and difficulty adjusting eyes to low lighting Patient may also experience aching or discomfort around the eyes or a headache Diagnostic Findings Tonometry to assess IOP Gonioscopy to assess the angle of the anterior chamber Perimetry to assess vision loss

Goal is to prevent further optic nerve damage Maintain IOP within a range unlikely to cause damage Pharmacologic therapy Surgery Laser trabeculoplasty Laser iridotomy Filtering procedures Trabeculectomy Drainage implants or shunts

Nursing Management Focus on maintaining the therapeutic regimen for lifelong control of a chronic condition Emphasize the need for adherence to therapy and continued care to prevent further vision loss Provide education regarding use and effects of medications Medications used for glaucoma may cause vision alterations and other side effects; the action and effects of medications need to be explained to promote compliance Provide support and interventions to aid the patient in adjusting to vision loss/potential vision loss

Cataracts An opacity or cloudiness of the lens Increased incidence with aging

Clinical Manifestations Painless, blurry vision Sensitivity to glare Reduced visual acuity Other effects include myopic shift, astigmatism, diplopia (double vision), and color shifts including brunescent c. (color value shift to yellow-brown) Diagnostic findings include decreased visual acuity and opacity of the lens by ophthalmoscope, slit-lamp, or inspection

Surgical Management If reduced vision does not interfere with normal activities, surgery is not needed Surgery is performed on an outpatient basis with local anesthesia Surgery usually takes less than 1 hour and patients are discharged soon afterward Complications are rare Types of Cataract Surgery Intracapsular cataract extraction (ICCE): removes entire lens; rarely done today Extracapsular cataract extraction (ECCE): maintains the posterior capsule of the lens, reducing potential postoperative complications Phacoemulsification: an ECCE that uses an ultrasonic device to suction the lens out through a tube; incision is smaller than with standard ECCE Lens replacement: after removal of the lens by ICCE or ECCE, the surgeon inserts an intraocular lens implant (IOL), which eliminates the need for aphakic lenses; however, the patient may still require glasses Nursing Management Preoperative care Usual preoperative care for ambulatory surgery

Dilating eye drops or other medications as ordered Postoperative care Provide written and verbal instructions Instruct patient to call physician immediately if: vision changes; continuous flashing lights appear; redness, swelling, or pain increase; type and amount of drainage increases; or significant pain is not relieved by acetaminophen

Corneal Disorders Treatment of diseased corneal tissue Phototherapeutic keratectomy Keratoplasty Use of donor tissue for transplant: see Chart 58-9 Need for follow-up and support Potential graft failure; teach signs and symptoms Refractive surgery Elective procedures to recontour corneal tissue and correct refractive errors Patients need counseling regarding potential benefits, risks, and complications

LASIK

Retinal Disorders Retinal detachment Retinal vascular disorders Central retina vein occlusion Branch retinal vein occlusion Central retinal vein occlusion Macular degeneration

Retinal Detachment Separation of the sensory retina and the retinal pigment epithelium (RPE) Manifestations: sensation of a shade or curtain coming across the vision of one eye, bright flashing lights, and sudden onset of floaters Diagnostic findings: assess visual acuity; assess retina by indirect ophthalmoscope, slitlamp, stereo fundus photography, and fluroescein angiography; tomography and ultrasound may also be used

Surgical Treatment Scleral buckle Pars plana vitrectomy Removal of the vitreous, locating the incisions at the pars plana Frequently used in combination with other procedures Pneumatic retinopexy Injected gas bubble, liquid, or oil is used to flatten the sensory retina against the RPE Postoperative positioning is critical

Nursing Management Patient teaching Eye surgery is most often done as an outpatient procedure, so patient education is vital Teach the signs and symptoms of complications, especially increased IOP and infection Promote comfort Patient may need to lie in a special position with pneumatic retinopexy Retinal Vein or Artery Occlusion

Loss of vision can occur from retinal vein or artery occlusion Occlusions may result from atherosclerosis, cardiac valvular disease, venous stasis, hypertension, and increased blood viscosity; associated risk factors are diabetes mellitus, glaucoma, and aging Patients may report decreased visual acuity or sudden loss of vision

Macular Degeneration Age-related macular degeneration (AMD) The most common cause of vision loss in persons older than age 60 Types Dry or nonexudative type is most common, 85%-90% Slow breakdown of the layers of the retina with the appearance of drusen Wet type May have abrupt onset

Proliferation of abnormal blood vessels growing under the retinachoroidal

revascularization (CNV) Vision Loss Associated With Macular Degeneration

Retina Showing Drusen and AMD

Nursing Management Patient teaching Supportive care Safety promotion Recommendations include improving lighting, getting magnification devices, and referring patient to vision center to improve/promote function

Trauma Emergency treatment Flush chemical injuries Do not remove foreign objects Protect using metal shield or paper cup Potential exists for sympathetic ophthalmia, causing blindness in the uninjured eye with some injuries

Infectious and Inflammatory Disorders Dry eye syndrome Conjunctivitis (pink eye) Classified by cause: bacterial, viral, fungal, parasitic, allergic, and toxic Viral conjunctivitis is contagious Uveitis Orbital cellulitis

Hyperemia in Viral Conjunctivitis

Ocular Consequences of Systemic Disease Diabetic retinopathy Diabetes is a leading cause of blindness in people age 20 to 74 Ophthalmic complications associated with AIDS Eye changes associated with hypertension

Ophthalmic Medications Ability of the eye to absorb medication is limited Barriers to absorption include the size of the conjunctival sac; corneal membrane barriers; bloodocular barriers; and tearing, blinking, and drainage Intraocular injection or systemic medication may be needed to treat some eye structures or to provide high concentrations of medication Topical medications (drops and ointments) are most frequently used because they are least invasive, have fewest side effects, and permit self-administration Topical anesthetics Mydriatics (dilate) and cycloplegics (paralyze) Contraindicated with narrow angles or shallow anterior chambers and for inpatients on monoamine oxidase inhibitors or tricyclic antidepressants May cause CNS symptoms and increased BP especially in children and the elderly Anti-infective medications Antibiotic, antifungal, and antiviral products Medications used for glaucoma Increase aqueous outflow or decrease aqueous production May constrict the pupil and affect ability to focus the lens of the eye; affects vision May also may produce systemic effects Anti-inflammatory drugs; corticosteroid suspensions

Side effects of long-term topical steroids include glaucoma, cataracts, and increased risk of infection; to avoid these effects, oral NSAID therapy may be used as an alternate to steroid use

Low Vision and Blindness Low vision Visional impairment that requires devices and strategies in addition to corrective lenses Best corrected visual acuity (BCVA) of 20/70 to 20/200 Blindness BCVA of 20/400 to no light perception Legal blindness is BCVA that does not exceed 20/200 in better eye, or widest field of vision is 20 degrees or less Impaired vision often is accompanied by functional impairment

Assessment of Low Vision History Examination of distance and near visual acuity, visual field, contrast sensitivity, glare, color perception, and refraction Special charts may be used for low vision Nursing assessment must include assessment of functional ability and coping and adaptation in emotional, physical, and social areas Management Support coping strategies, grief processes, and acceptance of visual loss Strategies for adaptation to the environment Placement of items in room Clock method for trays Communication strategies Collaboration with low vision specialist, occupational therapy, or other resources Braille or other methods for reading/communication Use of service animals Guidelines for Instilling Eye Medications Shake suspensions or milky solutions to obtain the desired medication level. Wash hands thoroughly before and after the procedure. Ensure adequate lighting. Read the label of the eye medication to make sure it is the correct medication.

Assume a comfortable position. Do not touch the tip of the medication container to any part of eye or face. Hold the lower lid down; do not press on the eye-ball. Apply gentle pressure to the cheek bone to anchor the finger holding the lid Instill eye drops before applying ointments. Apply a -inch ribbon of ointment to the lower conjunctival sac.

Instill eye drops before applying ointments. Apply a -inch ribbon of ointment to the lower conjunctival sac. Keep the eyelids closed, and apply gentle pressure on the inner canthus (punctal occlusion) near the bridge of the nose for 1 or 2 minutes immediately after instilling eye drops. Using a clean tissue, gently pat skin to absorb excess eye drops that run onto the cheeks. Wait 5 to 10 minutes before instilling another eye medication.

Assessment and Management of Patients with Hearing and Balance Disorders

Anatomy of the Ear

Anatomy of the Inner Ear

Bone Conduction Compared to Air Conduction

Assessment Inspection of the external ear Otoscopic examination Gross auditory acuity Whisper test Weber test Rinne test Otoscope Otoscope Weber

Rinne Test

Speech Discrimination

Diagnostic Evaluation Audiometry Tympanogram Auditory brain stem response Electronystagmography

Platform posturography Sinusoidal harmonic acceleration Middle ear endoscopy

Hearing Loss Increased incidence with age: presbycusis Risk factors include exposure to excessive noise levels Types 1. Conductive: due to external middle ear problem 2. Sensorineural: due to damage to the cochlea or vestibulocochlearnerve 3. Mixed: both conductive and sensorineural 4. Functional (psychogenic): due to emotional problem Manifestations: Early symptoms include: Tinnitus: perception of sound; often ringing in the ears Increased inability to hear in a group Turning up the volume on the TV Impairment may be gradual and not recognized by the person experiencing the loss As hearing loss increases, patients may experience deterioration of speech, fatigue, indifference, social isolation, or withdrawal; for other symptoms see Hearing impairment: Mild, moderate, severe, or profound Consequences Depends on age and severity