Sensory Issues

Nursing care of patients with visual or auditory issues. 

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Hey and welcome to nursing with Dr. Hobbick. Today I am thinking about patients with sensory issues. Patients who have visual or auditory issues as those are our most common. The first thing that I want to think about are changes that are normal with aging. Let's talk about eyes first. For elderly persons. As we age, we get a little bit of a sunken appearance that's not abnormal. We also see something called an Arcus Senlis it's most noticeable in people who have dark eyes, dark colored eyes, and it usually shows up as a blue ring on the outside of the iris. This is something that we see in older folks, we also might see a little bit of a yellow or blue tinge to the sclera. Making that and not an accurate place to look for jaundice. Of course, we often see some changes in visual function. So if this person had a stigmatism, we'd see a little bit of worsening there, we might see some problems with discrimination between blues and greens and violets. We see some structural changes. So as we age, it's harder for the eyes to dilate. So they're more likely to be very small pupils. It also makes it difficult for us to perform any testing for pupillary constriction. And of course, we have this thing called presbyopia, that causes people to need reading glasses as we get older, because it's harder to focus on things that are near us, especially writing. Now, if you're recognizing cues, meaning we're doing our assessment, we are looking for things like age demographics, most importantly, what things are putting the patient potentially at risk. So what are their leisure activities? What kind of occupation do they have? Do they have any systemic health problems? Specifically, we think about hypertension, or diabetes, those two problems are going to cause issues with the retina and the blood flow. We want to know if the patient has any medications that they take that could be affecting their eyes, their nutrition, family history, things that we might see head tilting might be some squinting, we're looking for symmetry, we of course are observing the areas around the eyes, the eyes themselves, and maybe doing some vision testing. Now as a nurse we don't typically do in depth vision testing, we might use some charts, but mostly this is going to fall into the realm of the ophthalmologist or optometrist, especially the diagnostic testing. Now there's three big problems with the eyes, not big but rather more most common that I'm going to talk about. The first one is cataracts. Cataracts are something that happens usually with aging or a lot of exposure to UV light, the lens itself becomes opaque and distorts the image, these patients will begin to complain of cloudiness in their vision, they could have cataracts in both eyes, and they progress at different rates. You don't necessarily have a cataract in both eyes at the same time, it could be just one and you may go on for years with the other eye until it needs to be managed. We could also have cataracts that are congenital, the patient can be born with them or pathologic. There are some diseases and other eye disorders that can happen at the same time as cataracts. But most of the time they're age related or they're caused by trauma or exposure, most Americans will have developed a cataract by the age of 75. The things that we can educate our patients to do to help them prevent getting cataracts or things like avoiding the sun, avoid UV light exposure, wear sunglasses every time you're outside, wear eye and head protection and of course, stop smoking, smoking. As far as cataracts, we want to help our patient as best we can. But really, the only thing that can be done is surgery. This is where they'll go in and break up that lens and then actually replace it. These patients once they've had surgery on their eyes, they're going to need a couple of different types of eyedrop that they'll need to give themselves and they'll need to know things like don't bend over. Don't do any heavy lifting, avoid straining, we don't want to do anything that's going to increase that inter ocular pressure for a little bit. The next condition we're going to talk about is glaucoma. And some of the things to know about glaucoma is it's an increase in intra ocular pressure. So these patients have pressure on the inside of their eyes that can actually cause damage to the optic nerve. Folks who are at risk are African Americans over 40 and then anybody over 60 If you have a family history, that patient has hypertension, Corneal thinness or optic nerve abnormalities. These patients will begin to they don't normally have pressure that they complain of but they'll start to complain of losing the peripheral vision they will have blackness that comes in From the outside things that we can do for them non surgical management, there are some eyedrops the patients can use that will help them and otherwise maybe some surgical management. The last condition, at least for eyes that I wanted to talk about is macular degeneration. And this usually starts as a mild blurring and visual distortion and it's right in the central field, these patients eventually can lose their vision to the point where they can't really see anything that they're looking at the difference between the three conditions, we have a cataract that causes blurred vision, we have glaucoma, that's going to manifest as losing the vision blackness moving in from the outside. And then macular degeneration is from the center, there are two kinds of macular degeneration, there's dry and wet dry is the most common. And this is where we have just a gradual blockage of capillaries by pigmented residue and waste products. And it causes the macula, which is the center of the retina become ischemic and necrotic. And so this is where the patient starts to lose that it's a gradual process wet progresses quickly, the patient has a sudden decrease in vision. And they have some issues with bleeding, maybe underneath that macular like a blister. And they eventually developed scar formation there. This can occur at any age, maybe in one eye, both eyes, patients with dry, macular degeneration can actually develop wet. That's something that we want to try to help our patients avoid if we can, the sort of things we're going to help our patients with is of course, diabetes, hypertension, not smoking because the rate of dry macular degeneration in smokers is much higher. And there's some suggestion in the research that there's some dietary things that can be added, like carotenoids, lutein, but there isn't really a cure for these things. With the wet version, we might be able to do some laser therapy to help stop the blood vessel from leaking and limit the damage that's happened, there isn't really anything that can cure it. Now audio auditory problems, patients who have problems with hearing course, we see this in the elderly population as well. We have some changes that are associated with aging, we usually have presbycusis, which is the loss of higher pitched. So when we go to take care of these patients, we want to make sure we lower our tone so that we can be heard better, we don't want to get higher because that makes it harder for them to hear us. There are three types of hearing loss conductive sensory, neural and mixed conductive hearing loss can be caused by inflammation, obstructions of the external or middle ear changes in the eardrum or auto Sclerosis which is an overgrowth of bone. sensory neural hearing loss is usually caused by damage to a nerve. So damage to the inner ear or the auditory nerve, which is cranial nerve eight prolonged exposure to loud noises. I think we all know that right? There are some medications that are auto toxic. And of course, the presbycusis that we just talked about things that we want to assess our patient for when we're recognizing cues, do they explain or complain of any hearing changes? What is their age have they been exposed to noise either at work or in their leisure activities? Do they have any history of ear problems like recurrent infections do they have struggles communicating? Have they had any diagnostic testing done not going to cover diagnostic testing because this usually is in the realm of an EMT or a specialist. As far as analyzing cues and prioritizing our hypothesis, we want to recognize that they have a decrease in functional ability to communicate so that we can focus on helping them to communicate as best we can. Because as nurses, that's really all that we can do. We need to know about non surgical management hearing aids are something that are very common, we need to understand how the hearing aid fits in the ear, is it a behind the ear and open fit, there's multiple different types of hearing aids that you should be aware of, and you got to make sure that the battery is working that is turned on, the patient can typically help you with that sort of thing. We just want to make sure that we maximize their communication. Our goal is going to be for the patient to have at least a partial improvement in hearing or the use of appropriate hearing compensation behavior. We want to alleviate an anxiety we want to make sure that they can communicate effectively in most situations. If we need to get an interpreter for sign language. That's what we should be doing if we can help them with closed captioning or video descriptions. And of course, there's always the use of nonverbal language. Something else that is common is a writing board. If we can get a writing board for our patients sometimes that really helps. I hope that you've enjoyed this discussion of caring for patients with sensory issues as far as visual and auditory and I'll see you next time on nursing with Dr. Hobbick.