Med Surg 1 Exam 1

Risk for Injury and Impaired Comfort

Risk for Injury: Dementia/Mental Health

- Factors that Affect Cognition in Older Adults

* Sensory Impairment
* Physiological Health
* Environment
* Sleep
* Psychosocial Influences
* Hospitalization/Rehab  temporary; related to change of environment, role
performance, or medical therapy

- Factors that Lead to Improved Cognition in Older Adults

* Good sleep hygiene  also helps with depression and anxiety
* Good cardiovascular health
* A stimulating environment
* High levels of education/Occupational status
* Income
* Good nutrition
* Good sensory function

- Fluid Intelligence  biologically determined intelligence used for flexibility in thinking

and problem solving
* Declines with aging

- Crystallized Intelligence  gained through education and lifelong experiences (ex: verbal
skills)
* Remains intact with aging

- Factors that May Lead to Change in Mental Health

* Change in diet/fluid/electrolyte
* Fever
* Low O2 (common in many cardio/pulmonary diseases)
* Age (risk increases with age, but it is not a “normal” part of aging)
- They are less likely to acknowledge or seek treatment
- Depression  most common mood disorder of old age; sometimes is confused with
dementia
* Types of Depression
- Dysthymic Disorder  mild to moderate chronic depression for 2+ years
- Major Depressive Disorder  primary psychiatric illness manifested by
characteristic symptoms clusters such as depressed mood and pessimistic
thoughts for at least 2 weeks
- Masked Depression  concealed depression; patient isn’t aware of
depressed mood or doesn’t display obvious sadness; depression is when
through other psychiatric symptoms such as phobias or compulsions
* Men have a greater tendency for this and often mask with drugs,
alcohol, or working long hours
- Seasonal Affective Disorder (SAD)  associated with shortened daylight in
winter and fall; disappears during spring and summer
- Postpartum Depression
* Etiology
- Biological  insufficiency of neurotransmitters
(serotonin/norepinephrine)
* Abnormal melatonin metabolism is associated with SAD
- Genetic  family history
- Psychological  personal history of trauma, loss, or deprivation
* Learned helplessness
* Distorted thinking
* Faulty development of self
* Risk Factors
- Major precipitating event or loss
- Chronic illness/pain (MI, cancer, diabetes, MS, dementia, stroke, tumors)
- Secondary to medication interaction or undiagnosed physical condition
* Antihypertensive, steroids, benzo’s, chemo, alcohol, opioids
- Self-destructive behaviors
* Signs/Symptoms
- Sadness
- Fatigue
- Diminished memory/concentration
- Feelings of guilt/worthlessness
- Sleep disturbance
-Change in appetite (excessive weight loss/gain)
- Restlessness
- Impaired attention span
- Suicidal thoughts
- Anhedonia: loss of pleasure in activities or interests that used to be enjoyed
- Psychomotor Agitation: classic symptom cluster of depression including
restlessness with rapid, agitated, purposeless movements like pacing or
wringing hands
- Psychomotor Retardation: classic symptom cluster of depression including
slow movements and speech
 * Management
- Evaluation of patient’s medication regimen (are any contributing to
depression?)  may need to change meds or eliminate meds
- Treatment of underlying conditions that are contributing to depression
- Exercise
- Bright lighting
- Increased interpersonal interactions
- Cognitive therapy or reminiscence therapy
- Antidepressants (SSRI, MAOI)
- Herbal (St. Johns wort, Gingko, SAM-e, ephedra)
- Electroconvulsive therapy
* Nursing Implications
- Antidepressants
* May cause anticholinergic cardiac and orthostatic effects
- Assess for hypotensive events
- Assess fall risk
- Educate patient to change positions slowly
* May interact with other medications
* Educate patient it may take 4-6 weeks for symptoms to diminish
* Offer support/encouragement and strategies to maintain safety

- Substance Abuse  depression may lead to misuse of alcohol/drugs

* Alcohol abuse is especially dangerous in older adults
- Decreased liver and kidney function
- High risk of interaction with prescription medications
* Adverse reactions could be dangers (ex: falls)
- Delirium: acute confused state; starts as confusion then leads to disorientation
* Common complication of hospitalized older adult; can be confused with dementia
* Delirium is a medical emergency because of acute/unexpected onset with
unknown underlying cause
- Untreated could lead to dementia, coma, or death depending on cause
* Etiology
- Biological
* Medical Conditions
* Exposure to toxins/drugs
- Psychological
* Sensory deprivation/overload
* Sudden changes
* Relocation
* Sleep deprivation
* Immobilization
* Risk Factors
- Physical illness
- Medication/alcohol toxicity
- Dehydration
- Fecal impaction
- Malnutrition (electrolyte changes)
- Anesthesia
- Infection
- Head trauma
- Cancer/Terminally Ill
- Lack of environmental cues
- Sensory deprivation/overload (ICU delirium)
- Children are more susceptible than adults
- Common in ill older adults (UTI are a major issue; also stroke, sepsis, MI)
* Signs/Symptoms
- Altered level of consciousness
* Stupor  hypoalert/hypoactive
- Falls; falls asleep between questions, difficult to arouse
- Decreased activity
- Follows simple commands; passively cooperative
- Difficulty focusing, poor attention, disorganized
* Excessive Activity  hyperalet/hyperactive
- Overly attentive to cues
- Moves quickly
- May be combative, pull at tubes, or climb out of bed
- Easily distracted, rambles, mumbles, swear/yell
 * Mixed
- Alternates between 2 types with in hours or days
- Alternates within one episode of delirium
- May be unpredictable
* Hypoalert-Hypoactive delirious patients have a higher mortality rate
and poorer outcomes because their delirium is not always
recognized/treated
- Disorganized thinking
- Short attention span
- Hallucinations
- Delusions
- Fear, anxiety, and/or paranoia
* Prevention  is the most effective approach
- Control pain
- Minimize use of psychoactive drugs
- Prevent sleep deprivation
- Enhance communication methods (eye glasses, hearing aids)
- Maintain good oxygen levels
- Maintain fluid/electrolyte balance
- Prevent surgical complications
- Provide therapeutic activity for cognitive impairment
- Ensure early mobilization
* Treatment  treat the underlying cause
* Nursing Implications
- Management of patient safety
* Delirium increases risk of fall
- Nonessential medications should be discontinued (incase of toxicity)
- Supervise/monitor nutritional/hydration status
- Keep environment calm and quiet
- Provide familiar environmental cues and ask family/friends to touch/talk to
patient to provide comfort
- Complete on-going mental status assessments
- Dementia  cognitive, functional, behavioral changes that eventually destroy a person’s
ability to function; typically a subtle and slow onset
* Types
1.) Alzheimer’s disease (AD)
2.) Vascular Dementia (multi-infarct dementia)
3.) Non-Alzheimer Dementias
- Parkinson’s
- AIDS-related dementia
- Pick’s disease
- Other frontotemporal dementia
4.) Mixed Dementia (vascular and Alzheimer’s both)
- Pseudodementia: depression in elderly that presents as dementia
- Substance-Induced Persisting Dementia: caused by intoxication or
withdrawal from a substance
* Alzheimer’s Disease  5th leading cause of death in older adults
- Progressive, irreversible, degenerative neurologic disease that begins
insidiously and leads to gradual loss of cognitive function and disturbances
in behavior and affect
- Neurofibrillary tangles  amyloid plaques deposit in brain
- Risk Factors
* Increased age; 65+ years old
* Environment
* Diet
* Inflammatory factors
* Genetics
* Vascular abnormalities
* Stress hormones
* Circadian changes
* Head trauma
* Presence of seizure disorder
- Two Types of AD
1.) Familial/Early Onset
- Less than 10% of cases
- Usually associated with genetic mutations
- Occurs in middle-aged adults
2.) Sporadic/Late Onset
- Signs/Symptoms  definitive diagnosis can only be found during autopsy
* Forgetfulness/subtle memory loss
* Lose ability to recognize familiar faces, places, and objects (agnosia)
* Difficulty writing and drawing (agraphia)
* Repeating stories
* Difficulty with conversation/word-finding
* Unable to think abstractly
* Unable to carry out motor activities despite intact motor function
(apraxia)
* Unable to recognized consequences of actions
* May exhibit impulsive behaviors
* Personality/Mood changes
* May become combative
* May wander
* Incontinence
* Sundowning  increased confusion at night
- Diagnosis  MRI and PET scans along with history/assessment
- Treatment
* Manage cognitive and behavioral symptoms
- Behavioral and psychosocial therapy
* Medications  may help slow progression; not cure
- Cholinesterase Inhibitors (CEIs)
* Donepezil, rivastigmine, galantamine, buspirone
* Enhance acetylcholine uptake in brain  maintains
memory skills for a period of time
* Cognitive ability may improve within 6-12 months
- CEIs with Namenda may help with mild-moderate symptoms
- Nursing Implications
* Support cognitive function  cue/give guidance
- Provide a calm, predictable environment
- Establish a regular routine
- Give pleasant, clear, simple explanations
- Keep orienting patient
* Promote physical safety
- Remove hazards
- Provide adequate lighting
- No driving is allowed
- Supervise smoking
- Distract patient
- Place patient near nursing station
- Have patient wear an identification bracelet or neck chain
* Promote independence in self-care  simplify ADL’s
- Encourage patient to make choices & participate in activities
* Reduce anxiety/agitation
- Keep environment familiar and noise free
- Postpone activities until later if patient becomes upset
- Educate caregivers
* Improve communication
- Remain unhurried
- Reduce noise/distractions
- Use clear, short, and easy to understand sentences
- Use non-verbal cues
* Provide for socialization and intimacy needs
- Short visits with only 1-2 people at a time
- Encourage appropriate hobbies
* Promote adequate nutrition
- Offer food one dish at a time and cut into small pieces
* Promote balanced activity and rest
- Encourage activity during day
- Discourage long daytime sleeping
* Support caregivers
 * Vascular Dementia  10-20% of dementia patients
- Risk Factors
* Several strokes
* Large stroke
* Small vessel disease
* Hypertension
* Cardiovascular disease
* Smoking
- Treatment
* Decrease BP
* Lower cholesterol

- Elder Neglect and Abuse

* Types
- Neglect  most common type
- Physical
- Psychological
- Emotional
- Sexual
- Abandonment
- Financial Exploitation
* Risk factors
- Family history of violence
- Mental illness
- Drug/alcohol abuse
- Financial dependency on older person
- Diminished cognitive/physical function of older person
- Disruptive or abusive behavior of older person
- Caregiver strain

- Causes if Increased Risk for Fall

* Stiff awkward movements
* Stooped leaning posture; shuffled gait
* Apraxia  inability to make or coordinate movements
* Overmedication
* Visual Changes  cataracts; near/far sightedness; poor depth perception; blurred
vision
* Hearing Problems
* Agnosia  may bump into furniture, not recognizing what it is
* Diminished sensory
* Sun downing
 Med Surg 1 Exam 1

Risk for Injury and Impaired Comfort

Risk for Injury: Falls, Seizures, and Restraints

- Falls  7th cause of death for older people and most common cause of non-fatal injuries
* Most common incident report in hospital/care facilities
* Infants and older adults are most at risk for injury from falls
* Older women who fall sustain greater degree of injury then men
* Men are more likely to die from a fall injury
* Hip fracture is the most common fracture as result from fall
* Falls are most common on nights, weekends, and holidays
* Causes
- Illness
- Poor lighting or poor vision
- Clutter; slippery floors; throw rugs; high bed; low toilet
- Neurologic changes or cognitive impairment
- Sensory Impairment (decreased vision, proprioception, hearing)
- Medication side effects/polypharmacy
- Improper footwear
- Mobility difficulty; poor balance
- Alcohol use
- Decreased coordination
- Drowsiness
- Postural hypotension; dizziness
- Pets
* Many who fall become fearful and lose self-confidence
* Encourage patients/families to make simple changes to reduce fall risk
- Ex: increase lighting, remove throw rugs, grab bars, and declutter walkways
* Upon admission assess fall risk; those at risk are assessed every 8 hours

- Seizures  episodes of abnormal motor, sensory, autonomic, or psychic activity that

result from sudden excessive discharge from cerebral neurons (electrical disturbance)
* Three main types
1. Generalized  tonic, clonic, atonic, atypical, eyelid myoclonia, myoclonic
* Occur in and rapidly engage bilaterally distributed networks
2. Focal
* Originate in one hemisphere of the brain
3. Unknown  epileptic spasms
* Incomplete data
* Symptoms
- Loss of consciousness
- Excessive movement (convulsions)  typically subside in 1-2 minutes
- Loss of muscle tone or movement
- Disturbance of behavior, mood, sensation, and/or perception
- Staring episode (absence seizure)
- Experience unusual sights, sounds, odors, or tastes
- Incontinence
- Postictal state after for several hours (confused and hard to arouse)
- May experience headache, sore muscles, fatigue, and depression after
* Causes
- Genetic
- Hypoxemia (vascular insufficiency)
- Fever (childhood)
- Head Injury
- Hypertension
- CNS Infection
- Metabolic and Toxic conditions (renal failure, hypernatremia,
hypocalcaemia, hypoglycemia, pesticide exposure)
- Brain tumor
- Drug and alcohol withdrawal
- Allergies
* Nursing Implications
- Observe and record sequence of signs
* Circumstances before (sensory alterations, emotional changes, sleep,
hyperventilation)
* Occurrence of an aura  premonitory warning sensation
* First think patient does during seizure (ex: stiffness or gaze)
* Type of movements and body parts involved
* Size of pupils and are eyes open/closed
* Whether eyes or head are turned to one side
* Presence/absence of automatisms (smacking lips; repeated
swallowing)
* Incontinence of urine or stool
* Duration of each phase of the seizure
* Unconsciousness if present and its duration
* Any obvious paralysis or weakness of arms or legs after
* Inability to speak after
* Movements at the end
* Whether or not patient sleeps after
* Cognitive status (confused or not confused)
- Prevent Injury
- Support patient physically and psychologically
- Prevent complications such as hypoxia, vomiting, and pulmonary aspiration
- Restraints  physical (by person), material (by device), or chemical (by medication)
* Device/method used to restrict patient’s freedom of movement or access to his
body with or without his permission
* Increase risk of injury: ulcers, nerve damage, and strangulation
- Try not to use (LAST resort, follow protocol)
- Less restraints saves time, money, and reduces injury
* Use careful ongoing assessment/surveillance instead
* Side rails (check protocol, could be a form of restraint)
- They may lead to falls and injuries when patient tries to get up
* JC considerations
- Promotes staff to reduce use of restraints and seclusion
- Educate caregivers before they take part in any restraint related activity
- Document restraint episodes specifically, in detail
- Maintain one-on-one viewing of patients in restraints and seclusion
- Include staff members when deciding whether to explore new technology
that is considered a safe alternative to traditional restraint devices
- Budget for an adequate number of qualified staff to attend to patients
* Avoiding and Using Restraints  current standard of care is restraint free; it is
only a LAST resort
- Provide Consistency  environment, caregivers, and family members
* Have familiar objects from home brought in
- Review the patient’s medications  may alter mental status or balance
- Provide relaxation and relieve anxiety
* Keep patient oriented
* Have family/friends help with ADL’s as appropriate
* Use therapeutic touch and relaxation techniques (massage)
* Use least invasive and most comfortable method to deliver care
* Discontinue treatments that cause discomfort or agitation as soon as
possible (ex: NG tubes or IV’s)
- Provide frequent assessment and surveillance  encourage family to sit
with them or have hired sitters for those who need constant supervision
* Place near nursing station
* Assess for cognitive changes frequently
- Find ways to communicate
- Modify environment  reduce noise, provide adequate light, lower bed, etc.
- Anticipate unmet needs  urinate frequently, assess pain, and provide
diversion activities
* Applying Restraints
- Determine whether dangerous behaviors continue despite all attempts to
eliminate using less restrictive measures
- Obtain a Dr.’s order  type, reason for use, site of application, and duration
* Max of 24 hours per prescription then a new Dr. assessment and
prescription are needed
* No standing or prn orders are allowed
- Notify family of change in status and that they need restraints
* Obtain patient/family consent when clinically feasible
* Consent is not necessary if they are an immediate threat
- Pad bony prominences and apply the appropriately sized restraint and
correct knotting technique (quick release knot) (tie to bed frame)
- Adjust restraint to maintain good body alignment, comfort, and safety
* Should be able to slide 2 fingers under wrist or ankle restraint
* Snug enough it can’t be slipped off, but not impair circulation
- Release at least every 2 hours to provide skin care and ROM
* Assess restraint every 30 minutes though
- Place patient on fall risk precautions
- Remove restraint as soon as possible
- Document
* All interventions tried before using restraints
* Reason for placing restraint
* Initial restraint placement, location, circulation, and skin integrity
* Teaching session with patient and family
* Circulation checks, ROM & restraint removal per protocol
* Entries on fall risk assessment sheet, restraint flow sheet, and
nursing notes per agency policy
 Med Surg 1 Exam 1

Risk for Injury and Impaired Comfort

Risk for Injury: Impaired Sensory

- Factors that Affect Sensory

* Age/Stage of life
- Newborns: vision is less acute, but can follow objects; hearing is especially
acute at low frequencies; can discriminate between tastes (prefer sweet
over sour); feet hands, and soles of feet are the most sensitive
- Infants: Need tactile stimulation (cuddling) for bonding and growth and
development; Begins to develop auditory nervous system through various
noises (voices, music); Begin to see lights, colors, and contrasts to observe
the world around them
- Kids/Adolescence: Visual acuity improves; Full depth perception; hearing is
fully developed; steady on feet; driven towards peers
- Adults/Older Adults: Senses at peak unless effected by injury or illness
* Changes with vision:
- Decreased peripheral vision
- Decreased tear production
- Vitreous humor becomes thinner: “floaters”
- Lens becomes discolored and opaque; smaller pupil; less light
reaches retina
- Lens becomes less flexible and less able to focus on near
objects
- Lens thickens; loss of visual acuity; decreased
accommodation
- Poor night vision
* Changes with hearing
- Cerumen is drier and more solid creating hearing loss
- Scarring
- Presbycusis (loss of hearing high frequency)
- Decreased speech discrimination
* Changes with taste
- Taste buds atrophy and decrease in number; harder to taste;
especially sweet
- Dry mouth may alter taste
* Changes with smell
- Atrophy and loss of olfaction neurons (may alter taste)
* Changes with touch
- Harder to perceive light touch, pain, and temperature
variations
 * Changes with kinesthesia
- Decreased muscle fibers
- Slow speed of nerve pathways
- Higher risk for fall
* Culture: vary in amount of eye contact, person space, and touch
* Illness: MS slows nerve impulse; diseases that effect sensory organs;
neurological disorders
* Medication: aspirin and Lasix can impair auditory nerve; opioids,
depressants, sedatives
* Stress
* Personality: some people like to be quiet and alone, others like a lot of noise
and chaos
* Lifestyles
- Impaired Vision can effect eating, hygiene, or balance
* Visual acuity of 20/40 or worse in the better-seeing eye
- Most common causes among adults 40+
* Attend to glasses
* Provide sufficient light (but not glare)
* Protect eyes in sunlight
* Magnify lens/large print books
* Evaluate ability to perform ADL’s and remain safe in environment
* See if there is a need for assistance (seeing eye dog,, offer arm while walking)
* Common Visual Deficits
- Myopia: near sidedness
- Hyperopia: far sidedness
- Presbyopia: change in vision associated with aging
- Astigmatism: irregular curvature of cornea; blurred vision with distortion
- Cataracts: clouding of lens
- Glaucoma: pressure in anterior cavity of eye that distorts cornea and shifts
lens; loss of peripheral vision and eventual blindness; more common in
African Americans
- Diabetic retinopathy
- Macular Degeneration: loss of central vision (leading visual impairment in
50+); more common in Caucasians
- Strabismus: cross eyed
* Refractive errors  impaired vision from shortened or elongated eyeball
- Prevents light rays from focusing sharply on retina
- Corrected with contacts or glasses
- Emmetropia  image focuses directly on macula and don’t need glasses
- Myopia  distant image focuses in front of retina nearsighted; blurred
distance vision; deeper eyeballs
- Hyperopia  farsighted; good distance vision but blurry near vision
* Age Related Changes in Eye
- Eyelids and Lacrimal
* Loss of elasticity and orbital fat; deceased muscle tone
(wrinkles)
* Lid margins turn in  lashes irritate cornea
* Lid margins turn out  increased corneal exposure
* Commonly report burning, foreign body sensation, tearing
* Refractive Changes; presbyopia
- Loss of accommodation power
- Reading materials held at increasing distance
- Commonly report need for increased light or reading glasses
* Cataract
- Opacities in normally crystalline lens
- Interference with the focus of a sharp image on the retina
- Commonly reports increased glare, decreased vision, changes
in color values (especially yellow)
* Posterior Vitreous Detachment
- Liquefaction and shrinkage of vitreous body
- May lead to retinal tears and detachment
- Reports light flashes, cobwebs, and floaters

* Age-Related Macular Degeneration

- Drusen  yellowish age spots in retina
- Fibrotic scars in macula
- Distortion and loss of central vision
- Reports words missing letters, straight lines appearing wavy
* Low Vision  visual impairment that requires use of devices and strategies to
perform visual tasks
* Blindness  20/400 to no light perception
- Complete blindness: absence of light perception
- Legal blindness: best corrected vision that doesn’t exceed 20/200
* Nursing Implications  provide emotional, physical, and social adaption support
- Promote coping efforts
- Promote spatial orientation and mobility
- Use therapeutic communication
- Consult with low vision specialist or occupational therapist
- Implement appropriate interventions such as Braille or service animals
- Identify yourself as you approach the person and before physical contact
- Tell person when you are leaving the room and when anyone else enters or
leaves room
- Be specific when communicating direction (ex: walk 20 feet to the right)
- Allow person to hold onto your arm above elbow and to walk a half step
behind you when assisting
- Place person’s hand on back of arm or seat when helping sit
- Free environment of obstacles
- Offer to read written information
 - Use clock clues to tell where food is on plate
- Make sure all objects person will need are in reach and told where they are
in relation to them
- Don’t distract service animals
- Always ask, “How can I help you?” and allow them as much independence as
possible
* Glaucoma  increased pressure in eye leading to optic nerve damage; not curable
- Physiology
* Outflow of aqueous humor depends on intact drainage system and
an open angle between iris and cornea
* IOP determined by rate of aqueous production, resistance when
flowing out, and venous pressure of episcleral veins
* Normal IOP is 10-20 mmHG
* Fluctuations are caused by time of day, exertion, diet, & medications
- Increases with blinking, upward gazing, & tight lid squeezing
* Two Causes of Damage to Optic Nerve
1.) Mechanical  damages retinal layer as it passes through
optic nerve head
2.) Ischemic  IOP compresses microcirculation in optic nerve
head resulting in cell injury and death
- Classifications
* Open-Angle  Primary (POAG) is one of most common types
* Closed-Angle (pupillary block) other most common type
* Congenital
* Associated with Other Conditions (ex: corticosteroid use)
* Primary or Secondary (depending on cause of rise in IOP)
- Risk Factors
* Family history
* Thin cornea
* African American
* Older age
* Diabetes
* Cardiovascular disease
* Migraine syndromes
* Nearsightedness (myopia)
* Eye trauma
* Prolonged use of topical or systemic corticosteroids
- Signs/Symptoms
* Blurred vision
- As optic nerve damage increases, visual perception decreases
* “Halos”
* Difficulty focusing or adjusting eyes in low lighting
* Loss of peripheral vision
* Aching or discomfort around eyes
* Headache
- Treatment  can’t reverse or cure, but can prevent further damage
* Life-long treatment once diagnosed
* Initial target is to lower IOP by 30%
* Pharmacologic  systemic and topical ocular
- Beta-blockers are preferred initial topical med (timolol)
* Decrease aqueous production
* Efficient and minimal one time a day dosing
* Low cost
* One eye treated first and other eye acts as a control
- Once proven effective other eye treated too
- If not effective, new medication is substituted
- Mitotics (Cholinergic)  cause pupillary constriction
* Increase outflow of aqueous humor
- Alpha2-agonist
* Decrease aqueous production
- Carbonic anhydrase inhibitors
* Decrease aqueous production
- Prostaglandins (latanaprost)
* Increase aqueous outflow
* Surgical
- Laser Trabeculoplasty  burns applied to inner surface of
trabecular meshwork to open the intratravecular spaces and
widen the canal of Schlemm
* Promotes outflow of aqueous humor
* Decreased IOP
* Used with IOP can’t be controlled with medications
* Contraindicated when meshwork can’t be fully
visualized because of narrow angle
* Complications
- Transient increase in IOP (usually 2 hours after
surgery) that may become persistent
- Peripheral Iridotomy  opening made in iris to eliminate the
pupillary blockage
* Contraindicated with patients with corneal edema
- Interferes with laser targeting and strength
* Complications
- Burns to cornea, lens, or retina
- Transient elevated IOP
- Closure of Iridotomy
* Pilocarpine (Pilocar) is typically
prescribed to prevent this
- Uveitis  eye inflammation
- Blurring
 - Filtering Procedures  creates opening/fistula in trabecular
meshwork to drain aqueous humor from anterior chamber to
the subconjunctival space into a bleb, therefor bypassing the
usual drainage structures
* Allows aqueous to flow and exit through different
routes
* Trabeculectomy: removes part of meshwork
* Complications
- Hemorrhage
- Extremely elevated IOP
- Uveitis
- Cataracts
- Bleb failure or bleb leak
- Endophthalmitis  intraocular infection
* Unlike other surgeries, the goal is to prevent wound
healing; scarring is inhibited by using an antifibrosis
agent such as mitomycin C (only intraoporativly)
- Drainage Implants/Shunts  tubes implanted into the
anterior chamber to shunt aqueous humor to the episcleral
plate in the conjunctival space

- Impaired Hearing
* Attend to hearing aids
* Close captioned TV
* Regular inspection of ear canals (especially if they wear hearing aids)
* Teach techniques to improve communication
* Promote safety
* Assess for social isolation (are they confused, angry, or withdrawn?)
* Face client with good lighting for lip-reading and nonverbal communication
-Use simple sentence structure
- Don’t ask too many questions; only ask one at a time
- Have patient validate what you say and ask them to repeat it
- Allow patient to question what you say and validate what they have heard
*Common Hearing Deficits
- Conduction deafness: structure that transmits vibrations is affected
- Nerve deafness: damage to cranial nerve VIII or receptors in cochlea
- Presbycusis: loss with aging due to deterioration of the hair cells in cochlea
- Central Deafness: damage to auditory areas of temporal lobe (tumor,
trauma, CVA)
- Tinnitus: ringing in ears
- Impacted cerumen: blocked ear canal (earwax)
- Otosclerosis: hardening of bones in middle ear (stapes)
- Otitis Media: middle ear infection
* Hearing Loss
- Occurs in 3/1000 births; ½ are genetically related
* Genetic Syndromes associated with hearing loss
- Waardenburg Syndrome
- Usher Syndrome
- Pendred Syndrome
- Jervell and Lange-Nielsen Syndrome
-Risk Factors
* Male gender
* Family history
* Low birth weight
* Use of Otoxic medications
* Recurrent ear infections
* Bacterial meningitis
* Chronic exposure to loud noise
* Perforation of tympanic ear drum
* Occupation (carpentry, plumbing, coal mining, etc.)
* Impacted cerumen (conductive hearing loss)
* Otitis media
* Otosclerosis
* Damage to cochlea or vestibulocochlear nerve (sensoneural loss)
* Emotional reaction leading to psychogenic nonorganic hearing loss
- Signs/Symptoms
* Deafness  partial or complete loss of ability to hear
* Tinnitus
* Increasing inability to hear when in a group
* Need to turn up volume of TV
* Lead to change in attitude, awareness of surroundings, or ability to
protect one’s self
* May have feelings of isolation
* Difficulty communicating and hearing parts of conversation
- Prevention
* Avoid loud noise
- Noise-induced hearing loss  long period of exposure to loud
noise
- Acoustic Trauma  hearing loss caused by a single exposure
to an intense noise
- Minimum level known to cause noise- induced hearing loss is
85-90 dB
* Wear ear protection when exposed to loud noises
- Hearing loss is permanent because the hairs are destroyed
- Gerontologic Considerations
* Cerumen tends to become harder and drier  impactions occur
* Tympanic membrane may atrophy or become sclerotic
* Cells at base of cochlea degenerate
* Presbycusis  progressive hearing loss in elderly
* Difficulty hearing high frequencies
* Some of their medications may produce Otoxic effects
* Increased risk for depression, isolation, and confusion
* Increases risk of falls
- Nursing Implications
* Nurse should assess for
- Speech deterioration
- Fatigue when trying to follow conversation
- Indifference
- Social withdrawal
- Insecurity
- Indecision and procrastination
- Suspiciousness
- False pride; overcompensate
- Loneliness/unhappiness
- Tendency to dominate the conversation
* Use facial expressions and gestures
* Speak in normal tones
* Determine how person prefers to communicate
* Try to determine the context of what person is trying to say
* If you can’t understand them, have them write it out
* Always speak facing patient directly
* Speak slowly and distinctly with lots of pauses
* Tinnitus  symptom of an underlying disorder of ear that is associated with
hearing loss; roaring/buzzing/hissing sound in one or both ears
- Most prevalent between ages of 40-70
- Ranges from mild to sever
- Contributing Factors
* Otoxic Substances
- Diuretic agents (furosemide)
- Chemotherapeutic agents
- Antimalarial agents
- Anti-inflammatory agents (aspirin)
- Chemicals (alcohol, arsenic)
- Aminoglycoside antibiotics (gentamicin, neomycin)
- Other antibiotics (erythromycin, minocycline, polymyxin B,
vancomycin)
- Metals (gold, mercury, led)
* Underlying disorders
- Thyroid disease
- Hyperlipidemia
- Vitamin B12 deficiency
- Psychological disorders (depression/anxiety)
- Fibromyalgia
- Otologic disorders (Meniere’s disease, acoustic neuroma)
- Neurologic disorders (MS, head injury)