Ncmb316 Lec: BSN 3Rd Year 2Nd Semester Final 2023: Parkinson'S Disease, Multiple Sclerosis, and Myasthenia Gravis
Ncmb316 Lec: BSN 3Rd Year 2Nd Semester Final 2023: Parkinson'S Disease, Multiple Sclerosis, and Myasthenia Gravis
Ncmb316 Lec: BSN 3Rd Year 2Nd Semester Final 2023: Parkinson'S Disease, Multiple Sclerosis, and Myasthenia Gravis
Eli 1 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- inhibit action of acetylcholine - progressive, cumulative sxs & deterioration occur over
- used in mild cases or in combination with Levodopa several yrs
- relieve tremor and rigidity 3) Primary progressive MS (PPMS) = onset tend to be bet
- side effects: dry mouth, blurred vision, constipation, 40&60 years of age
urinary retention - steady, gradual neurologic deterioration w/o remission
5) Dopamine agonist: Bromocriptine mesylate (Parlodel) of sxs
- stimulates release of dopamine in the substantia - progressive disability with no acute attacks
nigra 4) Secondary progressive MS (SPMS)
- often employed when Levodopa loses effectiveness - begins with RRMS course that later becomes steadily
6) Tricyclic antidepressants given to treat depression progressive
7) Antihistamines have mild central anticholinergic & - attacks & partial recoveries may continue to occur
sedative effects & may reduce tremors Diagnostic tests:
• Provide a safe environment. • CSF studies: increased protein and IgG (immunoglobulin)
- Side rails on bed; rails and handlebars in toilet, bathtub, • EEG: abN
and hallways; no scatter rugs • CT scan: increased density of white matter
- Hard-back or spring-loaded chair to make getting up • MRI: shows areas of demyelination
easier Symptoms:
• Provide measures to increase mobility. • 1st sx: visual disturbances: blurred vision, scotomas
- Physical therapy: active and passive ROM exercises; (patchy blindness), diplopia
stretching exercises; warm baths • Impaired sensation: touch, pain, temperature, or position
- Assistive devices. If client "freezes," suggest thinking of sense; numbness, tingling
something to walk over. • Impaired motor function: weakness, paralysis, spasticity
• Improve communication abilities: instruct client to • Impaired cerebellar function: scanning speech, ataxic gait,
practice reading aloud, to listen to own voice, and nystagmus, dysarthria, intention tremor
enunciate each syllable clearly. • Euphoria or mood swings
• Maintain adequate nutrition. • Bladder: retention or incontinence
- Cut food into bite-sized pieces. • Constipation
- Provide small, frequent feedings.
• Sexual impotence in the male
- Allow sufficient time for meals, use warming tray.
Nursing interventions
• Promote optimum mobility.
Multiple Sclerosis (MS)
- Muscle-stretching and strengthening exercises
- An immune-mediated progressive demyelinating disease of
- Walking exercises to improve gait: use wide-based gait
the CNS which results in impaired transmission of nerve
- Assistive devices: canes, walker, rails, wheelchair as
impulses
necessary
- Typically present in young adults 20-40
• Administer medications as ordered.
- Affects women more than men
- For acute exacerbations: corticosteroids (ACTH [IV],
- More frequent in cool or temperate climates
prednisone) to reduce edema at sites of
- Cause UNKNOWN; may be a slow-growing virus or possibly
demyelinization
of autoimmune origin
- For spasticity: baclofen (Lioresal), dantrolene
- Characterized by remissions and exacerbations
(Dantrium), diazepam (Valium)
Pathophysiology
- Beta interferon (Betaseron) for relapsing-remitting MS
1) Sensitized T cells that would typically cross the blood-brain
patients
barrier to check for antigens in the CNS and then leave; in
MS would remain in the CNS • Prevent injury related to sensory problems.
- Test bath water with thermometer.
2) Promote infiltration of other agents that damage the
- Avoid heating pads, hot-water bottles.
immune system
- Inspect body parts frequently for injury.
3) Immune system attack leads to inflamm that destroys
- Make frequent position changes.
myelin and oligodenroglial cells
Major types • Prepare client for plasma exchange (to remove antibodies)
1) Relapsing-remitting MS (RRMS) = 85%of cases if indicated
- relapses develop over 1-2 weeks & resolve over 4-8 Plasmapheresis
months then returns to baseline. - This treatment — also known as plasma exchange — is a
- 50% may develop secondary progressive MS within 10 type of "blood cleansing" in which damaging antibodies are
yrs; 90% develop it within 25 yrs removed from your blood.
2) Progressive-relapsing MS (PRMS) = 5% of cases - Plasmapheresis consists of removing the liquid portion of
- absence of remission & client’s condition does not your blood (plasma) and separating it from the actual
return to baseline blood cells.
Eli 2 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- The blood cells are then put back into your body, which Diagnostic tests
manufactures more plasma to make up for what was • Tensilon test: IV injection of Tensilon provides
removed. spontaneous relief of symptoms (lasts 5-10 minutes)
- It's not clear why this treatment works, but scientists
believe that plasmapheresis rids plasma of certain
antibodies that contribute to the immune system attack on
the nerves.
Assessment findings
• Ptosis, diplopia , dysphagia, Extreme muscle weakness,
increased with activity and reduced with rest (identifying
characteristic)
• Masklike facial expression
• Weak voice, hoarseness
Eli 3 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
Eli 4 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
• Monitor vital signs and observe for signs of autonomic • Fasciculations("muscle twitch") – a small, local,
dysfunction such as acute periods of hypertension involuntary muscle contraction visible under the skin
fluctuating with hypotension, tachycardia, arrhythmias. • DTRs becomes brisk and overactive
• Administer corticosteroids to suppress immune reaction • Respiratory insufficiency
as ordered. • 25% of patients: weakness starts in the muscles supplied
• Administer antiarrhythmic agents as ordered. b the cranial nerves = difficulty talking, swallowing and
• Prevent complications of immobility. ultimately breathing
• Promote comfort (especially in clients with sensory • Death usually occurs as a result of infection, respiratory
changes) failure, or aspiration and generally occurs about 3 years
• Promote optimum nutrition. after the onset of the disease. Few patients survive for
- Check gag reflex before feeding. longer periods.
- Start with pureed foods. Medical Management
- Assess need for nasogastric tube feedings if unable to • Drugs
swallow. - Riluzole (Rilutek)-glutamate antagonist; slows
deterioration of motor neurons
Amyotrophic Lateral Sclerosis (ALS) - Baclofen (Lioresal)/ Diazepam (Valium) -used to control
- A disease of UNKNOWN cause in which there is loss of spasticity that interferes with ADL
motor neurons in the anterior horns of the spinal cord & the - Quinine -relieve muscle cramps
motor nuclei of the lower brain stem • NGT feeding
- Onset occurring usually in the 5th or 6th decade of life • Cervical esophagostomy or gastrostomy to prevent
- Leading theory: overexcitation of nerve cells by aspiration & for long-term nutritional support
neurotransmitter glutamate leads to cell injury and • Mechanical ventilation if hypoventilation develops
neuronal degeneration. Nursing interventions
Pathophysiology • Provide nursing measures for muscle weakness and
1) Motor neurons in the anterior horns of the spinal cord and dysphagia.
motor nuclei of lower brainstem dies. • Promote adequate ventilatory function.
2) Muscle fibers that they supply undergo atrophic changes. • Prevent complications of immobility.
3) Neuronal degeneration may occur in both upper and lower • Encourage diversional activities; spend time with the client.
neuron system
• Provide compassion and intensive support to
client/significant others.
• Provide or refer for physical therapy as indicated.
• Promote independence for as long as possible.
Eli 5 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
• Arthrocentesis
Bone x-ray
- observations of bone density, alignment & swelling, &
intactness are made
- conditions of joints like: size of the joint space,
smoothness of articular cartilage & synovial swelling can
be determined
- Nursing considerations:
• inform client that there is low radiation exposure & not
dangerous
- Accdg to researches, GLUTAMINE –building block for • remove all jewelry
protein abnormally collects in the cell nucleus, causing
• instruct to remain still during the filming process
cell death
• inform the health care provider if pregnant ---pregnant
- Reason that the protein destroys only certain brain cells is
women and children are more sensitive to the risks of
UNKNOWN
the x-ray, a protective shield may be worn over areas
Diagnostic tests
not being scanned (like pregnant abdomen, testes,
• clinical presentation of characteristic sxs
ovaries)
• (+) family hx Bone Scan
• CT & MRI - may show atrophy of the caudate nuclei once
the dse is well established
2 Main Symptoms
1) Progressive mental status changes leading to dementia
– significant loss of intellectual abilities such as memory
capacity, severe enough to interfere with social or
occupational functioning
2) Choreiform movements (rapid, jerky movements) in the
limbs, trunk & facial muscles
- Other sxs: Emotional disturbance: fits of anger, suicidal
depression, impaired judgment & memory,
hallucinations, delusions & paranoid thinking
3 stages
• Onset of neurologic or psychological sxs
• ↑ng dependence on others for care
• Loss of independent functions
- Death follows from complications such as choking, fall, - Done to evaluate damage to the bones, detect cancer that
infection, pneumonia or heart failure and generally has spread (metastasized) to the bones, and monitor
occurs 10-20 years after onset of the disease. conditions that can affect the bones (including infection
Medications and trauma).
1) Phenothiazine – blocks dopamine receptors - A bone scan can often detect a problem days to months
2) Reserpine – depletes presynaptic dopamine earlier than a regular X-ray test.
3) Tetrabenezine – reduces dopaminergic transmission • "cold" spots - areas that absorb little or no amount of
Nursing interventions tracer appear as dark which may indicate a lack of
• Frequent assessment/ evaluation of patient’s motor signs blood supply to the bone (bone infarction) or the
• Interact with the patient in a creative manner presence of certain types of cancer.
• Learn how this particular patient expresses need and want • "hot" spots - areas of rapid bone growth or repair,
absorb increased amounts of the tracer and show up as
MUSCULOSKELETAL SYSTEM: ANATOMY AND bright. This may indicate the presence of a tumor, a
PHYSIOLOGY, DIAGNOSTIC TESTS, AND DISORDERS fracture, or an infection.
Musculoskeletal System - Bone scan of the spread of prostate cancer
- Diagnostic tests: - Nursing considerations:
• Bone X-ray • BEFORE:
o Consent form
• CT scan & MRI
o Tell your doctor if you are pregnant
• Bone Scan / Nuclear Scan / Scintigraphy
o Limit your fluids for up to 4 hours before the test –
• Bone biopsy
because you will be asked to drink extra fluids after
• Muscle biopsy
the radioactive tracer is injected (about 4 to 6
• Electromyography (EMG) glasses of water to help eliminate any of the
• Arthrogram/ Arthrography radioactive substance that does not collect in your
• Arthroscopy bones.
Eli 6 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- During arthrography, a contrast material is injected to • reveal the presence of hemarthrosis (bleeding into the
enable the radiologist to study the joint space that appears joint cavity) which suggests trauma or tendency to
on the x-ray image. bleed
- Nursing considerations: • verify the presence of an infection, identify the
• notify physician if patient is pregnant causative agent, and follow the progress of antibiotic
• remove jewelries therapy
• generally, you can resume your usual activities • inject medications into the joint space, such as an anti-
immediately inflammatory agent (e.g. cortisone)
Arthroscopy - Nursing considerations:
• Before: consent form
• After:
o Compression bandage post procedure, it may take
about 5 -10 mins.
o Rest joint for 8-24 hrs.
o Take acetaminophen, ibuprofen, or some other
relatively mild pain killer for a day or two after the
procedure
o Instruct client to notify physician if fever or swelling
occurs
Eli 8 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
2) Kyphosis
- Kyphosis is a curving of the spine that causes a bowing
of the back, such that the apex of the angle points
backwards leading to a hunchback or slouching posture.
3) Lordosis
- Lordosis is excessive curvature in the lumbar portion of
the spine, which gives a swayback appearance. - Fractures are characterized by their CAUSE:
1) Pathologic /Spontaneous fracture – occurs after
minimal trauma to a bone that has been weakened by
disease. ex. client with bone cancer or osteoporosis
2) Fatigue/ Stress fracture – results from excessive strain
or stress on the bone
3) Compression fracture – produced by loading force
applied to the long axis of cancellous bone. Often occur
in the vertebrae of clients with osteoporosis
- Clinical manifestations:
• Pain – continuous & ↑ ses in severity until bone
Spinal instrumentation – is the use of metal implants fixed to
the spine to improve spinal deformity while the fusion matures. fragments are immobilized
• Loss of Function – fx of muscles depends on the
integrity of the bones to w/c they are attached
• Deformity – displacement, angulation or rotation of
fragments either visible or palpable
• Shortenng –due to the contraction of muscles attached
above & below the site
• Crepitus –caused by rubbing of bone fragments against
each other
• Swelling as a result of trauma & bleeding into the
tissues;
• Discoloration may not develop for several hrs after the
injury
Fracture - 4 R’s Management of Fracture
- A break or disruption in the continuity of a bone 1) Recognition
- Classification of fractures: 2) Reduction
• by the extent of the break - Closed Reduction
1) Complete Fracture – involves a break across the - Open Reduction
entire cross-section of the bone 3) Retention
2) Incomplete Fracture – the break occurs through only - Fixation (internal/ external)
part of the cross-section of the bone - Cast
• by the extent of associated soft-tissue damage - Traction
1) Closed / Simple – does not cause a break in the skin - Braces & Splints
2) Open / Compound / Complex – one in w/c the skin or - Bandage
mucous membrane wound extends to the fractured 4) Rehabilitation
bone - Fracture Reduction
- Specific types of fracture: • the procedure by which a fractured bone is realigned in
normal position
• it can be either closed or open
1) Closed reduction
- refers to realigning bones without breaking the
skin
Eli 10 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
Auto-immune Disorders
Systemic Lupus Erythematosus (SLE)
• DVT
• THROMBOEMBOLISM
• PULMONARY EMBOLUS - Prevalence is 100 per 100,00 persons
• DIC - occurs 10x more freq in women
• INFECTION - 2-3x times more prevalent among people of color,
2) Late including African-Americans, Hispanics, Asians, and
- DELAYED UNION = occurs when healing does not occur Native Americans
@ a normal rate for the location & type of fracture Pathophysiology
- assoc w/ distraction (pulling apart) of bone fragments, Combination of:
systemic or local infection, poor nutrition or • Genetic
comorbidity; eventually, the fracture heals • Hormonal (evidenced by the usual onset during the
- NONUNION = failure of the ends of the fractured bone childbearing yrs bet 15-40 y.o)
to unite • Environmental factors (sunlight, thermal burns)
- problems include infection, interposn of tissue bet. The • Chemical or drug-induced:
bone ends, inadq immobilization or manipulation that • Hydralazine (Apresoline), procainamide (Pronestyl),
disrupts callus formation, excessive bone gap, limited isoniazid (INH), chlorpromazine (Thoraxine) & some
bone contact, impaired blood supply ► avascular antiseizure medications
necrosis
- Tx: internal fixation, bone grafting, electrical bone
stimulation or combination of these
- MALUNION=heal incorrectly
Avascular Necrosis
Eli 12 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
Eli 13 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
• Calcium
- Ca alone is not a tx but an impt part of a prevention
program to promote bone health
- OTC supplements like calcium carbonate (Tums/
Oscal) ; calcium citrate (Citracal)
- Taken with foods & 6-8 ozs of water
• Vitamin D
- for optimal Ca absorption in the intestines
- 400-800 International Units/day Treatment
• Biphosphonates
• Oral supplements of vitamin D, calcium, and phosphorus
- inhibit bone resorption by binding with crystal elements
may be given depending on the underlying cause of the
in bone, esp spongy, trabecular bone tissue
disorder.
- 3 BPs: alendronate (Fosamax), ibandronate (Boniva) &
• Larger doses of vitamin D and calcium may be needed for
risedronate (actonel) are commonly used for the
people with intestinal malabsorption.
prevention & management of osteoporosis
- side effects: not common but when it occurs, they tend • Mineral calcium – calcium is essential for the formation
to be serious and maintenance of bones and teeth, blood clotting,
= esophagitis & esophageal ulcers esp if the tablet is normal heart beat and hormone secretion. Food sources of
not completely swallowed calcium include diary products, green leafy vegetables and
= s/sxs: chest pain; d/c drug & call their doctor salmon and sardines.
- early AM with 8 ozs of water & wait 30 mins before • Vitamin D – the body itself makes vitamin D when it is
eating exposed to the sun. cheese, butter, margarine, fortified
- c/i to clients with poor renal fx, gi reflux dse (GERD) cereals are food sources of vitamin D.
• SERMs (Selective Estrogen Receptor Modulators)
- newer class of drugs designed to mimic estrogen in Infectious Disorders
some parts of the body while blocking its effect Osteomyelitis
elsewhere It became infected by one of 3 MODES:
- raloxifene (Evista) 1) Extension of soft tissue infection (infected pressure or
vascular ulcer, incisional infection)
• Calcitonin
2) Direct bone contamination fr bone surgery, open fracture
- thyroid hormone that inhibits osteoclastic activity, thus
or traumatic injury (GSW)
decreasing bone loss
3) Hematogenous (bloodborne) spread fr other sited of
- IM or subq salmon calcitonin (refrigerated); intranasally
infection (infected tonsils, boils, infected teeth, upper resp
Miacalcin = preferred bec it improves compliance,
infections). Typically occurs in a bone area of trauma or
minimizes side effects & is convenient ; alternate
lowered resistance.
nostrils to prevent s/e like nasal mucosal irritation
- salmon calcitonin may its effect are use for 2 or more
years = requires holiday from this tx
Diet Therapy
• Increase Ca & vit D intake; alcohol & caffeine discouraged
• If w/ fracture: protein, vit C & iron intake
Exercise
• Plays a vital role in pain management & cardiovascular fx
together with the physician , PT prescribes exercises for
strengthening the abdominal and back muscles which
improve posture & provide improved support for the spine,
deep breathing
• General weight-bearing exercise program= walking for 30
mins 3x a week, swimming, biking
• High-impact recreational exercises (horseback riding,
bowling) are avoided bec it may cause vertebral
compression
Osteomalacia - At high risk:
- Osteomalacia is softening of the bones, caused by not • Poorly nourished
having enough vitamin D, or by problems with the • Elderly
metabolism (breakdown and use) of this vitamin. • Obese
- These softer bones have a normal amount of collagen that • Impaired immune system
gives the bones its structure, but they are lacking in • w/ chronic illness (DM, RA)
calcium. • w/ long term steroid therapy
Eli 17 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
Eli 18 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
Eli 19 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
• Anti-inflammatory medications may also help common 1) The cornea is the clear surface of the outer eye which can
OTC medications such as ibuprofen and aspirin oral be damaged by infections.
steroid medications 2) The iris gives the eye color.
• High doses of vitamin B-6 3) The pupil is the black hole within the iris that lets light into
the eye. It changes size in response to light levels, among
• Cortisone injection may help ease symptoms and can aid
other things.
the doctor in making a diagnosis
4) The lens is the internal focusing element of the eye, it is
• Open release procedure involves simply cutting the
curved on both sides. The clear lens becomes cloudy when
transverse carpal ligament.
a cataract forms.
• Endoscopic carpal tunnel release
5) The conjunctiva is the thin lining of the inside of the eyelid.
It extends over the front of the white part of the eye.
6) The retina is the light sensitive part of the eye.
7) The optic nerve. In glaucoma, the rise in fluid pressure in
the eye damages the nerve fibers entering the optic nerve
from the retina.
- Wall of the eyeball is composed of 3 layers:
1) Outer fibrous protective layer
- Posteriorly = sclera, the ‘white of the eye’ with firm
tough connective tissue
- Anteriorly = cornea, ‘window of the eye’ a forward
continuation of the sclera, transparent & avascular
2) Middle vascular layer – pigmented
- Hallux valgus actually describes what happens to the big - posterior = choroid
toe. - anterior = ciliary body & iris the iris being the
- Hallux is the medical term for big toe, and valgus is an extension of the ciliary body +pupil which
anatomic term that means the deformity goes in a direction regulates the amount of light entering the interior of
away from the midline of the body. the eye
- “the big toe begins to point towards the outside of the foot” 3) Inner neural layer – with layers of nerve cells including:
- A bunion is when your big toe points toward the second toe. photo receptors
- Bunions are often caused by narrow-toed, high-heeled a) Rods
shoes. - concentrated along the outer perimeter of the
- These compress the big toe and push it toward the second retina
toe. The condition may become painful as extra bone and a - help us to see images that come into our
fluid-filled sac grow at the base of the big toe. This leads to peripheral or side vision
swelling and pain. Bunions occur more frequently in - help us to see in dark and dimly lit environments
women and sometimes run in families. b) Cones
- If the bunion gets worse -- resulting in severe deformity or - concentrated in the macula, the center of the
pain -- surgery to realign the toe and remove the bony retina
bump = bunionectomy = can be effective. - allow us to perceive color
- Hallux Valgus Splint – completely immobilizes the hallux
for uninterrupted healing
Eli 20 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- Together, rods and cones are the cells radiations and then to the cortex of the occipital lobe of the
responsible for converting light into electrical brain.
impulses that are transmitted to the brain where
"seeing" actually occurs.
Process of vision
- Light waves from an object (such as a tree) enter the eye
first through the cornea, which is the clear dome at the
front of the eye.
- The light then progresses through the pupil, the circular
opening in the center of the colored iris.
- Next, the light passes through the crystalline lens, which is
located immediately behind the iris and the pupil.
- Initially, the light waves are bent or converged first by the
cornea, and then further by the crystalline lens, to a nodal
point (N) located immediately behind the back surface of
the lens.
- At that point, the image becomes reversed (turned
backwards) and inverted (turned upside-down).
- The light continues through the vitreous humor, the clear
gel that makes up about 80% of the eye’s volume, and then,
ideally, back to a clear focus on the retina behind the
vitreous. Eye Diagnostic Tests
- The small central area of the retina is the macula, which Snellen Chart
provides the best vision of any location in the retina. - Visual acuity (vision) is determined in each eye using the
- If the eye is considered to be a type of camera, the retina is Snellen Chart. This chart consists of random letters of
equivalent to the film inside of the camera, registering the different sizes.
tiny photons of light which interact with it. - The letters for normal vision (20/20) are 3/8-inch tall,
- Within the layers of the retina, light impulses are changed viewed at 20 feet. People with normal vision can read these
into electrical signals and then sent through the optic nerve, letters.
along the visual pathway, to the occipital cortex at the - A refraction test may also be performed (the doctor puts
posterior or back of the brain. several lenses in front of the eyes to determine if glasses
- Actually, then, we do not “see” with our eyes but, rather, are needed).
with our brains. Our eyes merely are the beginnings of the Tonometry
visual process. - a procedure that measures the pressure inside the eyes.
- Visual acuity depends on a healthy, functioning eyeball and The test is used to screen for glaucoma.
an intact visual pathway. This pathway is made up of the - There are three types of tonometry:
retina, optic nerve, optic chiasm, optic tracks, lateral a) Air Puff – This is the only type of tonometry that does not
geniculate bodies, and optic radiations, and the visual touch the surface of the eye. The patient sits upright at
cortex area of the brain. The pathway is an extension of the the instrument, and a warm puff of air is directed at the
central nervous system. eye.
- The optic nerve is also known as the second cranial nerve b) Applanation – The patient’s eye is first treated with
(CN II). Its purpose is to transmit impulses from the retina numbing drops and a stain called fluorescein. The
to the occipital lobe of the brain. tonometer is then placed gently on the cornea, and a
- The optic nerve head, or optic disc, is the physiologic blind very small amount of pressure is applied to the cornea.
spot in each eye. The optic nerve leaves the eye and then A hand-held tonometer may be used.
meets the optic nerve from the other eye at the optic c) Schiotz – older version of applanation. This type of
chiasm. The chiasm is the anatomic point at which the tonometer was formerly used in the operating room or
nasal fibers from the nasal retina of each eye cross to the with people who are unable to sit upright (such as
opposite side of the brain. infants or small children).
- The nerve fibers from the temporal retina of each eye - The Keeler Pulsair Desktop Tonometer uses advanced
remain uncrossed. optical and sensor technology for positional detection and
puff control.
• Fibers from the right half of each eye, which would be
- Before the test:
the left visual field, carry impulses to the right occipital
lobe. • Remove contact lenses before the examination. The dye
can permanently stain contact lenses.
• Fibers from the left half of each eye, or the right visual
field, carry impulses to the left occipital lobe. • Inform the health care provider if you have: corneal
- Beyond the chiasm, these fibers are known as the optic ulcers and infections, an eye infection, taking any drugs,
tract. The optic tract continues on to the lateral geniculate with history of glaucoma
body. The lateral geniculate body leads to the optic
Eli 21 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
Eli 22 of 31
NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
- Light rays from the close object such as pages of the book EARS: ANAPHYSIO, DIAGNOSTIC TEST, AND DISORDERS
cannot focus clearly on retina. Anatomy and Physiology
- Farsightedness typically is corrected with a convex lens. - Ear – both functionally and anatomically, it can be divided
Astigmatism (Distorted vision) into three parts.
- Cornea is more curved in one direction than in the other.
Vision is blurred for both near and distant object.
- Astigmatism is corrected optically with a cylindrical lens.
Presbyopia (Aging eye)
- When we are young, the lens in the eye is soft and
moldable. It changes its shape easily allowing us to focus
on near objects.
- After the age of 40, the lens becomes hard and rigid. As the
lens cannot change the shape, it is more difficult to read at
close range. This condition is called presbyopia.
- Bifocal lenses have two different optical powers within the
same lens.
• Eye glasses or contact lenses are the most common External Ear
methods of correcting the refractive errors. - Function: collect sound waves and direct them to the
• Refractive surgery is also an option to correct or to improve middle portion of the ear
the vision. - Consists of:
• These surgical procedures are used to adjust the eyes • Auricle / pinna
focusing ability by reshaping the cornea or front surface of • Air canal /external auditory canal
the eye. Middle ear
• The refractive surgeries can be done after the age of 18 or - The bridge of ossicles hangs across the air space in the
after the stabilization of refractive power. middle ear.
• There is no adequate scientific evidence to suggest that - This bridge starts with the malleus which is attached to the
eye exercise, vitamins or pills can prevent or cure refractive eardrum and ends with the stapes which is attached to the
errors. oval window, another kind of eardrum.
Inner ear
General Care for Eye Surgeries - Consists of: fluid-filled labyrinth
Preop: • Functions to convert mechanical energy into neural
- orient patient to staff & physical environment impulses
- if both eyes are to be covered, provide call light • Fluid surrounding the membranous labyrinth =
- prepare meds to dilate the pupils perilymph (communicates directly with CSF via the
Post-op: cochlear aqueduct)
- General goal is to prevent IOP, stress on suture line, • fluid within = endolymph
hemorrhage into the anterior chamber (hyphema), & - There are 3 main divisions of the labyrinth:
infection • Vestibule an antechamber just medial to the oval
• Keep head still & avoid coughing, vomiting, sneezing, window leading to both the cochlea and the
moving suddenly, bending forward, lifting head or hips, semicircular canals
straining, or squeezing the eyelids • Cochlea responsible for converting sound vibrations
- if sneezing or coughing—open mouth into nerve impulses that the human brain interprets as
- if vomiting –eyelids should be kept open sound and what we call "hearing“
- meds: cough medicines, antiemetics, stool • Semicircular canals organ for balance; including the
softeners & laxatives utricle & saccule
• Patient should lie on unoperated side down - The utricle lies horizontally in the ear, and detects motion
• Patient may lie on his back in the horizontal plane.
• Side rails up - The saccule is oriented vertically, so detects motion in the
• Burning sensation 1 hr after operation –anesthetic sagittal plane (up and down, forward and back).
wearing off - The oval window sits immediately behind the stapes, and
• Advise client: begins vibrating when "struck" by the stapes. This sets the
- edema of eyelids subside within 3-4 days fluid of the inner ear sloshing back and forth.
- feeling of “something in the eye” 4-5 days –due to - The round window serves as a pressure valve, bulging
sutures outward as fluid pressure rises in the inner ear.
- not to bend, stoop or lift objects for several weeks - Organ of Corti – the sensitive element in the inner ear. Can
- sensation of pressure within the eye & sharp pain — be thought of as the body's microphone. It is situated on
may indicate bleeding, report to surgeon
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NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER FINAL 2023
o Irrigation may need to be repeated several times Conditions of the Middle Ear
o After the wax is removed, the ear should be dried Otitis Media
thoroughly - An inflammation and/or infection of the middle ear.
o A few drops of alcohol in the ear or a hair dryer set - Common Forms: Acute otitis media & Chronic otitis media
on low may be used to help dry the ear. - are similar; also called suppurant or purulent otitis
o Never irrigate the ear if the eardrum is not known to media. An infecting agent introduced into the middle
be intact, because irrigation with a ruptured eardrum ear
may cause ear infection or acoustic trauma. ▼
- If attempts to remove the wax plug are unsuccessful causes inflamm of the mucosa
consult a health care provider: ▼
• Who may remove the wax by repeating the irrigation leading to swelling & irritation of the ossicles
attempts ▼
• Suctioning the ear canal purulent inflammatory exudate follows
• Removing wax with a small device (curette)= 1) Acute otitis media has a sudden onset and duration of 3
instrumentation weeks or less
Otitis Externa 2) Chronic otitis media = often follows repeated acute
- or swimmer's ear, is an infection of the skin lining the ear episodes = has a longer duration = causes greater
canal. middle-ear injury
- Bacteria ( staph aureus; pseudomonas species) can enter - If otitis progresses or remains untreated, permanent
the skin of the ear canal and cause an infection through a conductive hearing loss results.
scratch, injury from a foreign object, or if the ear is wet for a - Less common in adults than in children.
prolonged period of time. - Ear infections are common in infants and children.
- May also be caused by fungus (Aspergillus). • Their ear canal is shorter & more horizontal than older
- Swimmer's ear is more common in pre-school and school- children
age children. • their eustachian tubes become clogged easily
- Symptoms: - Symptoms:
• Itching • Pain / earache (esp. in acute ear infection)
• Pain in the ear canal • Fever
• Often accompanied by a small amount of clear • Trouble sleeping
discharge • In infants:
• Occasionally fever o Irritability
• Hearing loss o Inconsolable crying (clearest sign)
- Signs and tests: - Signs and tests:
• When the doctor looks in the ear, it appears red and • The doctor will examine your child's throat, sinuses,
swollen, including the ear canal. head, neck, and lungs
• The ear canal may appear eczema-like, with scaly • Using an otoscope, the doctor will look inside your
shedding of skin. child's ears. If infected: areas of dullness / opaque
• Touching or moving the outer ear increases the pain. o Redness
• The eardrum may be difficult for the doctor to see with o Bulging or retracted eardrum
an otoscope because of the swollen outer canal. o Fluid behind the eardrum
• Taking some of the ear's drainage and doing a culture • Fluid may be bloody or purulent (filled with pus).
on it may identify bacteria or fungus. • sign of perforation in the eardrum will also be checked
- The goal of treatment is to cure the infection. • c/s of drainage
• Ear canal-cleaned of drainage – to allow topical • hearing test may be recommended if the child has had
medications to work effectively persistent (chronic & recurrent) ear infections
• Ear drops containing antibiotics & corticosteroids - Treatment:
- To fight infection & to reduce itching and • Relieving pain
inflammation • Curing the infection
- Used abundantly (four or five drops at a time) in • Preventing complications
order to penetrate the end of the ear canal • Preventing recurrent ear infections
- If ear canal is very swollen = wick may be used to
• Antibiotics, Analgesics, Antipyretics
allow the drops to travel to the end of the canal
o Administer antibiotics as ordered for a full 10 day
• Analgesics may be used if pain is severe course
• Warm compress may reduce pain o Avoid chewing during the acute period
• Keep ears clean and dry – do not let water enter the ears o Lie with affected ear down
when showering, shampooing, or bathing. Avoid o Instruct client that screening for hearing loss may be
swimming. necessary
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- Surgery – if there is fluid in the middle ear and the • There is a specific gene, which if present in the patient’s
condition persists, even with antibiotic treatment genetic make up, can result in the development of
• Myringotomy – surgical opening of the eardrum to otosclerosis.
relieve pressure and allow drainage of the fluid. • About 50 percent of patients with otosclerosis have a
• 2 methods: family history of otosclerosis.
o A small tube is inserted through the incised eardrum • Some medical studies have implicated the measles
in order to dry out the middle ear and prevent the virus as a factor in causing otosclerosis.
fluid from re-accumulating • In some women with otosclerosis, pregnancy can
o The ear tubes fall out after a few months accelerate the process. Otosclerosis can react to
o those that don't may be removed in the doctor's female hormone. Pills & HRT can worsen the condition.
office - Symptoms:
Mastoiditis • Primary symptom - slowly progressive conductive
- Symptoms: hearing loss beginning anytime between the age of 15
• Ear pain or discomfort and 45, although it usually starts around age 20
• Earache • May hear better in noisy surroundings- other people’s
• Pain behind the ear voices are raised in frequency & loudness
• redness of the ear or behind the ear • Constant tinnitus
• Fever, may be high or spike (have sudden high • Balance problems may also occur:
increases) o Unsteadiness
• Headache o Dizziness
• Drainage from the ear o Vertigo, or other sensations of motion
- Signs and tests: • Schwartze’ sign-a pink blush hue behind the tympanic
• A skull X-ray or head CT scan or CT of the ear may show membrane
an abnormality in the mastoid bone. • (-) Rinne test
• A culture of drainage from the ear may show bacteria. • Weber test- with lateralization of sound
- Treatment: • bilateral hearing loss
• Mastoiditis may be difficult to treat because it is - Treatment:
difficult for medications to reach deep enough into the • There is no known cure for otosclerosis.
mastoid bone. • However, oral fluoride supplementation may slow or
• It may require repeated or long-term treatment. halt disease progression.
• Antibiotics by injection, then antibiotics by mouth are • Dizziness associated with active otosclerosis will
given to treat the infection. usually respond within two weeks of oral fluoride
- Surgery therapy.
• May be needed if antibiotic therapy is not successful. - Surgery: Stapedectomy
• Mastoidectomy – to remove part of the bone and drain • The ear drum is turned forward and the fixed stapes is
the mastoid removed.
• Tympanoplasty – a surgical procedure that repairs or • Tissue is placed over the opening to the inner ear and a
reconstructs the eardrum (tympanic membrane) to help wire, Teflon or metal prosthesis is inserted and
restore normal hearing. This procedure may also involve attached to the anvil.
repair or reconstruction of the small bones behind the • The ear drum is then returned to its normal position and
tympanic membrane (ossiculoplasty) if needed. Both the ear canal is filled with ointment.
the eardrum and middle ear bones (ossicles) need to • The stapes prosthesis allows sound vibrations to again
function well together for normal hearing to occur. pass from the ear drum to the inner ear fluids
- Post-op • The hearing improvement obtained is usually
• Monitor for dizziness permanent.
• Monitor for signs of meningitis • Following surgery, the use of a hearing aid on either or
• Wound dressing change 24 h post op both ears should be considered, depending on the
• Monitor surgical incision for edema, drainage, redness degree of improvement in the surgical ear.
• Position: flat with operative side up
• Assist in getting up and ambulation The stapes bone (stirrup) is attached to the
Otosclerosis incus bone (anvil) by thin membranes and is
- A condition affecting the stapes bone separated.
- A callus of bone accumulates on the stapes creating a
partial fixation, this limits the movement of the stapes
bone, which results in hearing loss. The stapes suprastructure is then "down-
- Cause: Unknown fractured" leaving the footplate still frozen
within the oval window.
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- Symptoms
• Loss of hearing occurs slowly over time
• Usually starts with problems hearing high-frequency
sounds, such as someone talking
• May be difficult to hear things in noisy areas
- Exams and Tests
• Wax in the ear that can be a contributing factor.
• Audiology determines the extent of hearing loss.
- Treatment
• There is no known cure for age-related hearing loss.
• Treatment is focused on functional improvement.
• Hearing aids, which provide amplification, may help.
• Developing skills such as lip reading and using visual
cues may aid communication, but these may be
difficult skills for older people to learn.
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