NCLEX: Caring for the Client with Sensorineural Disorders

Terms you’ll need to understand:
Aqueous humor
Astigmatism
Canal of Schlemm
Cataract
Conductive hearing loss
Conjunctiva
Cornea
Decibel
Glaucoma
Hyperopia
Intraocular pressure
Legally blind
Lens
Macular degeneration
Meniere’s syndrome
Mydriatic
Myopia
Myotic
Otitis media
Otosclerosis
Ototoxic
Presbycusis
Presbyopia
Retinal detachment
Sensorineural hearing loss

Nursing skills you’ll need to master:
Performing sterile dressing change
Administering eye drops, eye ointments, and ear drops
Use of an earwick
Inserting and removing eye prosthesis
Performing eye and ear irrigations
Caring for hearing aids

Most of us will agree that the abilities to see, hear, taste, perceive touch, and smell are pretty important. Without the ability to smell, food would have little, if any, taste. The sense of touch lets us know when we experience something pleasurable or have been injured. No one would argue that this is unimportant. But of all the senses, the abilities to see and hear are considered most important, for they keep us informed about the world around us. In this chapter, we review problems affecting vision and hearing.

Disorders of the Eyes
Disorders of the eyes can be divided into the following categories:
- Intraocular disorders—Examples include cataracts and glaucoma.
- Retinal disorders—Examples of these are hypertensive retinopathy, diabetic retinopathy, and macular degeneration.
- Refractive errors—Examples include myopia, hyperopia, presbyopia, and astigmatism.
- Traumatic injury—Examples include hyphema, contusions, foreign bodies, lacerations, and penetrating injuries.

Intraocular Disorders
Intraocular disorders arise from within the eyeball. The primary intraocular disorders you need to understand include cataracts and glaucoma. These two diseases are discussed in the following sections.

Cataracts
Cataracts, opacities in the lens of the eye, result in the distortion of images projected onto the retina. Cataracts are associated with aging, trauma, disease of the eye, prolonged use of steroids, and exposure to sunlight or ultraviolet light. Congenital cataracts of the newborn are characterized by the absence of the red reflex. A. infant should be able to visually follow a moving object by 3 months of age. If unable to do so, the infant should have the vision evaluated by an ophthalmologist.

Symptoms of cataracts include
- Blurred, hazy vision
- Glare from bright lights
- Yellow, white, or gray discoloration of the pupil
- Gradual loss of vision

Cataract surgery is generally performed in an outpatient surgery center. The client is given a sedative to lessen anxiety. Medications such as Diamox (acetazolamide) are given to reduce intraocular pressure. Mydriatic eye drops such as Neo-Synephrine (phenylephrine) are used in combination with cycloplegics such as Cyclogyl (cyclophenolate HCl) to paralyze the muscles of accommodation. After the client is in the operative area, an intravenous injection of Versed (midazolam) can be given to induce light anesthesia followed by local anesthesia.
Removal of the affected lens is usually accomplished by an extracapsular cataract extraction (ECCE). The anterior portion of the lens is opened and removed along with the lens cortex and nucleus. The posterior lens capsule is left in place to provide support for the intraocular lens implant. Antibiotic steroid drops or ointments are instilled in the operative eye and a sterile patch and shield are applied.
Post-operatively the client is maintained in a semi-Fowler’s position to prevent stress on the implant. Clients are usually discharged within 2–3 hours following surgery. Before discharging the client, the nurse should instruct the client
- To avoid activities that would increase intraocular pressure, such as bending from the waist, blowing the nose, wearing tight shirt collars, closing the eyes tightly, and placing the head in dependent position
- To report sharp, sudden pain in the operative eye
- To report bleeding, increased discharge, or lid swelling in the operative eye
- To report decreasing vision, flashes of light, or visual floaters
- To take a tub bath or to face away from the shower head when bathing
- In the proper way to administer eye medication
- To wear the protective shield when sleeping

Glaucoma
Glaucoma refers to a group of diseases that result in an increase in intraocular pressure. The three types of glaucoma and their characteristics are
- Primary open-angle glaucoma (POAG)—This is the most common form of glaucoma. POAG affects both eyes, is usually asymptomatic, and is caused by a decrease in the outflow of aqueous humor. The intraocular pressure in those with primary open-angle glaucoma averages between 22mm Hg and 32mm Hg. Symptoms of primary open angle glaucoma include
- Tired eyes
- Diminished peripheral vision
- Seeing halos around lights
- Hardening of the eyeball
- Increased intraocular pressure
- Acute glaucoma—This is sometimes called narrow-angle glaucoma and is less common. This is caused by a sudden increase in the production of aqueous humor. The onset of severe eye pain is sudden and without warning. Emergency treatment is necessary because rising intraocular pressure can exceed 30 mm Hg. Symptoms of acute glaucoma include the following:
- Sudden, excruciating pain around the eyes
- Headache or aching in the eyebrow
- Nausea and vomiting
- Cloudy vision
- Pupil dilation
- Secondary glaucoma—This is related to ocular conditions that narrow the canal of Schlemm or that alter eye structures that are involved in the production and circulation of aqueous humor.
Normal intraocular pressure is 10–21mm Hg.

Management of a Client with Glaucoma
Conservative management of the client with glaucoma is aimed at reducing intraocular pressure with medications. Miotic eye drops such as Isopto Carpine (pilocarpine HCl) are instilled to constrict the pupil and increase the flow of aqueous humor. Beta blockers such as Timoptic (timolol) and carbonic anhydrase inhibitors like Diamox (acetazolamide) decrease the production of aqueous humor, thereby lowering the intraocular pressure.
Osmotics like Osmitrol (mannitol) can be administered via IV to clients with acute glaucoma to rapidly reduce intraocular pressure and prevent permanent damage to the optic nerve.
Surgical management is indicated when medications fail to control the symptoms associated with open-angle glaucoma as well as for the client with acute glaucoma. A laser is used to create a hole, allowing the aqueous humor to drain more freely. Standard surgical therapy that creates a new drainage canal or destroys the structures responsible for the increase in intraocular pressure is reserved for the client whose condition does not respond to either medications or laser surgery.
Post-operatively the client is instructed to lie on the nonoperative side, to avoid taking aspirin, and to report severe eye or brow pain. Changes in vital signs, a decrease vision, and acute pain deep in the eye are symptoms of choroidal hemorrhage.
Clients with known or suspected glaucoma should avoid over-the-counter medications that can increase intraocular pressure. Medications such as Visine cause vasoconstriction, which is followed by rebound vasodilation. Rebound vasodilation can raise pressures within the eye.

Atropine is contraindicated in the client with glaucoma because it closes the Canal of Schlemm and raises intraocular pressure.

Retinal Disorders
Retinal disorders involve disorders of the innermost layer of the eye. The most common retinal disorders are hypertensive retinopathy, diabetic retinopathy, and macular degeneration. The following sections cover these retinal disorders in greater detail.

Hypertensive Retinopathy
Hypertensive retinopathy occurs in the client with a long history of uncontrolled hypertension. Elevations in diastolic blood pressure create a copper wire appearance in the retinal arterioles. If the blood pressure remains elevated, arterioles become occluded by the formation of soft exudates known as cotton wool spots. Treatment focuses on control of systemic hypertension.
Left untreated, hypertensive retinopathy can result in retinal detachment and loss of vision.

Diabetic Retinopathy
Diabetic retinopathy is the result of vascular changes associated with uncontrolled diabetes mellitus. Vascular changes are inherent in all diabetics; however, good control of blood sugar helps reduce the severity of the disease.
The two types of diabetic retinopathy are
- Background diabetic retinopathy—This leads to the development of microaneurysms and intraretinal hemorrhages.
- Proliferative diabetic retinopathy—This leads to the development of new, fragile blood vessels that leak blood and protein into the surrounding tissue.
The treatment of diabetic retinopathy depends on the type and the degree of tissue involvement. Laser surgery can be used to seal microaneurysms and prevent bleeding.

Macular Degeneration
Macular degeneration affects the portion of the eye involved with central vision. The two types of macular degeneration are
- Atropic (dry)—This form is characterized by sclerosing of retinal capil- laries with loss of rod and cone receptors, decreased central vision, and complaints of mild blurred vision. The condition progresses faster in smokers than nonsmokers. The risk for macular degeneration can be reduced by a diet rich in antioxidants; lutein; zeaxanthin; and carotenoids found in dark green, leafy vegetables.
- Exudative (wet)—This form is characterized by a sudden decrease in vision due to serous detachment of the pigmented epithelium of the macula. Blisters composed of fluid and blood form underneath the macula, resulting in scar formation and decreasing vision.
Treatment of macular degeneration is aimed at slowing the process. Laser therapy can be used to seal leaking blood vessels near the macula.

Retinal Detachment
Retinal detachment can result from a blow to the head, fluid accumulation in the subretinal space, or the aging process. Generally, the condition is painfree; however, the client might complain of the following symptoms:
- Blurred vision
- Flashes of light
- Visual floaters
- A veil-like loss of vision

Management of Clients with Detached Retinas
Conservative management usually involves placing the client with the area of detachment in dependent position. The most common site for retinal detachment is the superior temporal area of the right eye. Sedatives and anxiolytics will make the client more comfortable. Spontaneous reattachment of the retina is rare, so surgical management is often required.
Surgical management includes the creation of a scar to seal the retina to the choroid or by scleral buckling to shorten the sclera and improve contact between the retina and choroid.
Post-op activity varies with the procedure used. If gas or oil has been instilled during the scleral buckling, the client is positioned on the abdomen with the head turned so that the operative eye is facing upward. This position is maintained for several days or until the gas or oil is absorbed. An alternative is to allow the client to sit on the bedside and place his head on an overbed table.
Bathroom privileges are allowed, but the client must keep his head bowed.

The following discharge instructions should be given to the client with a scleral buckling:
- Report any sudden increase in pain or pain accompanied by nausea.
- Avoid reading, writing, and close work for the first post-op week.
- Do not bend over so that the head is in a dependent position.
- Be careful not to bump the head.

Refractive Errors
Refractory errors refer to the capability of the eyes to focus images on the retina. Refractory errors are due to an abnormal length of the eyeball from front to back and the refractive power of the lens. Refractory errors include the following:
- Myopia (nearsightedness)—Images focus in front of rather than on the retina; this is corrected by a concave lens.
- Hyperopia (farsightedness)—Images focus behind rather than on the retina; this is corrected by a convex lens.
- Presbyopia—The crystalline lens loses elasticity and becomes unable to change shape to focus the eye for close work so that images fall behind the retina; this is age related.
- Astigmatism—An uneven curvature of the cornea causes light rays to be refracted unequally so that a focus point on the retina is not achieved.
Nonsurgical management of refractory errors includes the use of eyeglasses and contact lenses. Surgical management includes the following:
- Radial keratotomy (RK)—This treatment is used for mild to moderate myopia. Eight to sixteen cuts are made through 90% of the peripheral cornea. The incisions decrease the length of the eye by flattening the cornea. This allows the image to be focused nearer the retina.
- Photorefractive keratotomy (PRK)—This is used for the treatment of mild to moderate stable myopia and low astigmatism. An excimer laser is used to reshape the superficial cornea using powerful beams of ultraviolet light. One eye is treated at a time with a wait period of 3 months between surgeries. Complete healing can take up to 6 months.
- Laser in-situ keratomileusis (LASIK)—This is used for the treatment of nearsightedness, farsightedness, and astigmatism. An excimer laser is used to reshape the deeper corneal layers. Both eyes are treated at the same time. Complete healing can take up to 4 weeks. LASIK is thought to be better than PRK because the outer layer of the cornea is not damaged, there is less pain, and the healing time is reduced.
- Intact corneal ring—This is the newest vision enhancement for near- sightedness. The shape of the cornea is changed by using a polymeric ring on the outer edges of the cornea. The surgery does not involve the use of laser and is reversible. Healing to best vision is immediate, and replacement rings can be applied if the client’s vision changes with aging.

Traumatic Injuries
Traumatic injuries to the eyes can occur from any activity. Traumatic injuries and their treatments include
- Hyphema—Hemorrhage in the anterior chamber as the result of a blow to the eye, Treatment includes bedrest in semi-Fowler’s position, no sudden eye movement for 3–5 days, cycloplegic eyedrops, use of an eye patch and eye shield to protect the eye, and limited television viewing and reading.
- Contusion—Bruising of the eyeball and surrounding tissue. Treatment includes ice to the affected area and a thorough eye exam to rule out other eye injuries. Elevating the client’s head 30 to 45 degrees will help to minimize edema and swelling.
- Foreign bodies—Objects that irritate or abrade the surface of the con- junctiva or cornea. Treatment includes transporting the client to the ER with both eyes covered by a cupped object, a visual assessment by a physician before treatment and instillation of fluorescein followed by irrigation with normal saline to remove foreign particles.
- Lacerations and penetrating injuries—Corneal lacerations are consid- ered emergencies because ocular contents can prolapse through the laceration. Treatment can require the administration of IV antibiotics and surgery.
Objects protruding from the eye should never be removed by anyone except an ophthalmologist because greater damage can occur, including the displacement of ocular structures. Clients with penetrating eye injuries have the poorest prognosis for retaining vision.

Visual Tests for Review
Several tests are commonly used during a routine eye examination. These tests include the Snellen chart, which assesses visual acuity, and the Ishihara polychromatic chart, which assesses color vision. Some medications, such as antituberculars, can affect both visual acuity and color vision; therefore, the client should have a thorough eye exam every 6 months. The Ansler grid is used to detect changes caused by macular degeneration, while tonometry detects changes in intraocular pressure that are associated with glaucoma.
These tests should be done at least once a year for clients over 40.

Pharmacology Categories for Review
A number of medications are used to treat eye disorders. Mydriatics and cycloplegics are used for the client with cataracts. Miotics, beta blockers, and carbonic anhydrase inhibitors are ordered for the client with glaucoma to constrict the pupil and reduce pressure within the eye. It is important for you to review the side effects and contraindications for these medications:
- Cycloplegics
- Miotics
- Mydriatics
- Beta blockers
- Carbonic anhydrase inhibitors

Ear Disorders
Most of what we know about our world is gained through vision; however, a well-functioning auditory system is also important. Disorders of the ears and hearing loss create problems with everyday living. Some conditions, such as
Meniere’s syndrome, interfere with balance and coordination. Other conditions, such as otosclerosis and age-related presbycusis, affect our ability to receive and give information accurately. The client with a significant hearing loss often becomes confused, mistrustful, and socially isolated from family and friends. Disorders of the ears can be divided into the following conditions:
- Conditions affecting the external ear (otitis externa)
- Conditions affecting the middle ear (otitis media)
- Conditions affecting the inner ear (Meniere’s, otosclerosis)
- Age-related hearing loss (presbycusis)
- Ear trauma

Otitis Externa
Otitis externa is often referred to as swimmer’s ear because it occurs more often in hot, humid environments. The condition can result from an allergic response or inflammation. Allergic external otitis media is often the result of contact with hair spray, cosmetics, earrings, earphones, and hearing aids. It can occur from infectious organisms, including bacteria or fungi. Most infections are due to pseudomonas aeruginosa, streptococcus, staphylococcus, and aspergillas. In rare cases, a virulent form of otitis externa develops, spreading the infection into the adjacent structures of the brain and causing meningitis, brain abscess, and damage to cranial nerves.
The treatment of otitis externa is aimed at relieving pain, inflammation, and swelling. Topical antibiotics and steroids are used. Systemic antibiotics, either oral or intravenous, are used in severe cases.

Otitis Media
Otitis media is an infection of the middle ear that occurs more often in young children than adults because the eustachian tube of the child is shorter and wider than that of the adult. H. influenza is the most common cause of acute otitis media. Signs and symptoms of acute otitis media include pain, malaise, fever, vomiting, and anorexia.
Increased pressure can cause the tympanic membrane to rupture. Rupture of the tympanic membrane usually results in relief of pain and fever; however, repeated rupture can lead to scarring of the membrane with eventual loss of hearing.
Treatment of acute otitis media includes the use of systemic antibiotics, analgesics for pain, as well as antihistamines and decongestants to decrease fluid in the middle ear. Antibiotic therapy is continued for 7–10 days to ensure that the causative organism has been eliminated. If the tympanic membrane continues to bulge following antibiotic therapy, a small surgical incision is made in the tympanic membrane (myringotomy) and a PE (polyethelene tube) is inserted to allow continuous drainage of the middle ear.

Meniere’s Disease
Meniere’s is a disease of the inner ear characterized by a triad of symptoms: vertigo, tinnitus, and hearing loss of low tones. Symptoms can occur suddenly and can last from several hours to several days. The exact cause of Meniere’s is unknown, but it is associated with allergies, as well as vascular and inflammatory responses that alter fluid balance.
Conservative management includes the use of antihistamines, antiemetics, and diuretics to control edema of the labyrinth and vasodilators to decrease vasospasm. Salt and fluid restrictions are recommended to decrease the amount of endolymphatic fluid produced. Cessation of smoking can also improve symptoms by helping to reduce vasoconstriction. Nicotinic acid has proven beneficial by producing a vasodilating effect.
Surgical management can involve a labryinthectomy or an endolymphatic subarachnoid shunt. Surgical management is controversial because hearing in the affected ear can be lost. Following surgery, the client will experience vertigo, nausea, and vomiting for several days.

Otosclerosis
Otosclerosis refers to the progressive hardening of the bony configuration known as the stapes, leaving them incapable of movement. Otosclerosis is the most common cause of conductive hearing loss. Symptoms of otosclerosis include tinnitus and conduction deafness.
Management of otosclerosis involves a stapedectomy. The diseased stapes is removed; then the oval window is sealed and rejoined to the incus using a metal or plastic prosthesis. Key points included in the care of the client who has had a stapedectomy are as follows:
- Tell the client that hearing might decrease after surgery due to swelling and accumulation of fluid but should improve as blood and fluid are absorbed.
- Instruct the client to avoid activities that increase pressure within the ear (such as blowing the nose, extreme head movement, and air travel).
Avoiding crowds will lessen the chance of getting upper respiratory infections with symptoms such as coughing and sneezing. If the client must cough or sneeze, she should do it with an open mouth.
- Tell the client to report pain and changes in taste or facial sensation.
- Instruct the client to avoid getting water in the ears for at least 6 weeks.

Tubs are better than showers.
- Instruct the client to take medications (antibiotics and antiemetics) as prescribed.

Presbycusis
Presbycusis associated with aging is a common cause of sensorineural hearing loss. This type of hearing loss is the result of damage to the ganglion cells of the cochlea and decreased blood supply to the inner ear. Deficiencies in vitamins B9 and B12 also have been found to play a role in the development of presbycusis. Sensorineural hearing loss is also related to the use of ototoxic drugs as well as exposure to loud noises.

Hearing loss of 50 decibels affects the client’s ability to distinguish parts of speech.
Presbycusis affects the ability to hear high-frequency, soft consonant sounds (t, s, th, ch, sh, b, f, p, and pa).

Ear Trauma
Injury to the tympanic membrane can result in pain, infection, and hearing loss. Most ear trauma is the result of jabbing injuries that damage the ear drum and inner ear or blows to the ear that result in extreme changes in pressure. Children frequently use the ears (and the nose) as hiding places for foreign bodies that become lodged, interfering with hearing and creating a source of infection. Foreign bodies in the ear or nose should receive the attention of the physician who will remove them and provide appropriate follow-up treatment.

Assisting Clients with Hearing Loss
Devices to assist the client with a hearing loss include hearing aids and cochlear implants. If you are working with a client who is hearing impaired and he is not wearing a hearing aid, the following hints might prove helpful:
- Stand in front of the client when talking to him. Many hearing-impaired persons rely on lip reading and facial expression.
- Talk in a normal tone of voice. Raising your voice distorts the sound and can convey the wrong message.
- Keep the background noise to a minimum.
- Don’t forget other means of communicating, such as writing, using pic- tures, and so on.
- Try to speak in lower tones. People hard of hearing can usually hear lower voices easier than a higher pitch. For example, they usually can hear a male easier than a female.

Diagnostic Tests for Review
Several diagnostic tests provide useful information in caring for the client with disorders of the ears. The CBC lets you know whether infection is present, and CAT scans and MRIs tell you of structural alterations. The Weber and Rinne tests are used to assess air and bone conduction.

Pharmacology Categories for Review
Several drug categories are used in the care of the client with disorders of the ears. These drug categories include antiinfectives for those with ear infections and decongestants and antihistamines for those with otitis media:
- Antiinfectives
- Antihistamines
- Decongestants
- Steroids