1

NLE TEST PLAN

PROFESSIONAL REGULATION COMMISSION-

BOARD OF NURSING

NURSING PRACTICE I
Test Description:

Theories, concepts, principles and processes basic to the practice of

nursing with emphasis on health promotion and health maintenance. It includes
basic nursing skills in the care of clients across age groups in any setting.

Moreover, it encompasses the varied roles, functions and responsibilities

of the professional nurse in varied health care settings.

TEST SCOPE

I. Safe and Quality Care, Health Education, Communication, and

Collaboration and Teamwork

A. The nursing process

B. Basic nursing skills

1. Admission and discharge

2. Vital signs
3. Physical examination and health assessment
4. Administration of medications
5. Asepsis and infection control
6. First aid measures
7. Wound care
8. Peri-operative care
9. Post-mortem care

C. Measures to meet physiological needs

1. Oxygenation
2. Nutrition
3. Activity, rest and sleep
4. Fluid and electrolyte balance
5. Urinary elimination
6. Bowel elimination
7. Safety, comfort and hygiene
8. Mobility and immobility

D. Health Education

1. Teaching and learning principles in the care of clients

2. Health education in all levels
3. Discharge planning

E. Communication

1. Dynamics of communication
2. Nurse-client relationship
3. Professional-professional relationship
4. Therapeutic use of self
5. Use of information technology

www.nurseslabs.com
2

F. Collaboration and Teamwork

1. Networking
2. Inter-agency partnership
3. Teamwork strategies
4. Nursing and partnership with other professions and agencies

II. Ethico-Moral Responsibility and Legal Responsibility

A. Bioethical principles

1. Beneficence
2. Non-malefescence
3. Justice
4. Autonomy
5. Stewardship
6. Truth telling
7. Confidentiality
8. Privacy
9. Informed consent

B. Patients Bill of Rights

C. Code of Ethics in Nursing

D. Legal Responsibility

1. Legal aspects in the practice of nursing

2. The Philippine Nursing Act of 2002 (R.A. 9173)
3. Related laws affecting the practice of nursing

III. Personal and Professional Growth and Development

A. Historical perspectives in nursing

B. Nursing as a profession

C. Theoretical foundation of nursing applied in health care situations

D. Continuing professional education

E. Professional organizations in nursing

F. The nurse in health care

1. Eleven Key Areas of Responsibilities

2. Fields of nursing
3. Roles and functions

IV. Management of Environment and Resources and Environment

A. Theories and principles of management

B. Nursing administration and management

C. Theories, principles and styles of leadership

D. Concepts and principles of organization

E. Patient care classification

www.nurseslabs.com
3

F. Nursing care systems

G. Delegation and accountability

H. Records Management

1. Anecdotal report
2. Incident report
3. Memorandum
4. Hospital manual
5. Documentation
6. Endorsement and end-of-shift report
7. Referral

V. Quality Improvement and Research

A. Standards of nursing practice

B. Nursing audit

C. Accreditation/certification in nursing practice

D. Quality assurance

E. Research

1. Problem identification
2. Ethics and science of research
3. The scientific approach
4. Research process
5. Research designs and methodology
a. Qualitative
b. Quantitative

6. Utilization and dissemination of research findings

NURSING PRACTICE II
Test Description :

Theories, concepts, principles and processes in the care of individuals,

families, groups and communities to promote health and prevent illness, and
alleviate pain and discomfort, utilizing the nursing process as framework. This
includes care of high risk and at-risk mothers, children and families during the
various stages of life cycle.

TEST SCOPE

Part I: CHN

I. Safe & Quality Care, Health Education, and Communication,

Collaboration and Teamwork

A. Principles and Standards of CHN

B. Levels of Care

C. Types of Clientele
3

www.nurseslabs.com
4

D. Health Care Delivery System

E. PHC as a Strategy

F. Family-based Nursing Services (Family Health Nursing Process)

G. Population Group-based Nursing Services

H. Community-based Nursing Services/Community Health Nursing Process

I. Community Organizing

J. Public Health Programs

II. Research and Quality Improvement

A. Research in the Community

B. National Health Situation

C. Vital Statistics

D. Epidemiology

E. Demography

III. Management of Resources & Environment and Records

Management

A. Field Health Services and Information System

B. Target-setting

C. Environmental Sanitation

IV. Ethico-Moral-Legal Responsibility

A. Socio-cultural values, beliefs, and practices of individuals,

families, groups and communities.

B. Code of Ethics for Government Workers

C. WHO, DOH, LGU policies on health

D. Local Government Code

E. Issues

V. Personal and Professional Development

A. Self-assessment of CHN competencies, importance, methods

and tools

B. Strategies and methods of updating ones self, enhancing

competence in community health nursing and related areas.

4

www.nurseslabs.com
5

Part II: MCN

I. Safe & Quality Care, Health Education, and Communication,

Collaboration and Teamwork

A. Principles and Theories of Growth and Development

B. Nursing Care in the Different Stages of Growth and

Development including

a. Nutrition
b. Safety
c. Language development
4. Discipline
5. Play
6. Immunization
7. Anticipatory guidance
8. Values formation

C. Human Sexuality and Reproduction including Family

Planning

D. Nursing Care of Women during Normal Labor, Delivery and

Postpartum

E. Nursing Care of the Newborn

1. APGAR scoring
2. Newborn screening
3. Maintenance of body processes (oxygenation, temperature, etc.)

F. Nursing Care of Women with complications of pregnancy, labor, delivery and

postpartum period (High-risk conditions)

G. Nursing Care of High-Risk Newborn

1. Prematurity
2. Congenital defects
3. Infections

H. Nursing Care of Women with disturbances in reproduction and gynecology

II. Research and Quality Improvement

A. Fertility Statistics

B. Infant Morbidity and Mortality

C. Maternal Mortality

D. Standards of Maternal and Child Nursing Practice

III. Management of Resources and Record Management

www.nurseslabs.com
6

A. Home-Based Mothers Record

B. Under Five Clinic Record

IV. Ethico-Moral-Legal Responsibility

A. Socio-cultural values, beliefs, and practices of individuals, families related to

MCN

B. WHO, DOH, LGU policies on health

C. Family Code

D. Child and Youth Welfare Code

E. Issues related to MCN

V. Personal and Professional Development

A. Self-assessment of MCN competencies, importance, methods and

tools

B. Strategies and methods of updating ones self, enhancing

competence in MCN and related areas.

www.nurseslabs.com
7

NURSING PRACTICE III, IV, and V

Test Description :

Theories, concepts, principles and processes in the care of clients with

altered health patterns, utilizing the nursing process and integrating the key
areas of nursing competencies.

TEST SCOPE

I. Safe & Quality Care, Health Education, Communication, Collaboration

and Teamwork

Test III

A. Client in Pain

B. Perioperative Care

C. Alterations in Human Functioning

1. Disturbances in Oxygenation
2. Disturbances in Metabolic and Endocrine Functioning
3. Disturbances in Elimination

Test IV

A. Alterations in Human Functioning

1. Disturbances in Fluids and Electrolytes

Fluids in Human Body

I. Fluid Status of Human Body

A. Homeostasis: state of the body when maintaining a state of balance in the presence
of constantly changing conditions
B. Includes balance of fluid, electrolytes, and acid-base balance
C. Body water intake and output approximately equal (2500 mL/24 hr.)

Adult body: 40L water, 60% body weight

2/3 intracellular
1/3 extracellular (80% interstitial, 20% intravascular)
Infant: 70-80% water
Elderly: 40-50% water

II. Body Fluid Composition

A. Water: 60% of body weight
B. Electrolytes: substances that become charged particles in solution
1. Cations: positively charged (e.g. Na+, K+)
2. Anions: negatively charged (e.g. Cl-)
3. Both are measured in milliequivalents per liter (mEq/L)
C. Osmolality: concentration of a solution measured in milliosmoles per liter
D. Balance of hydrostatic pressure and osmotic pressure regulates movement of water
between intravascular and interstitial spaces

III. Body Fluid Distribution:

A. 2 body compartments:
7

www.nurseslabs.com
8

1. Intracellular fluids (ICF): fluids within cells of body [major intracellular

electrolytes: Potassium (K+), Magnesium (Mg +2)]
2. Extracellular fluids (ECF): fluid outside cells; [major extracellular
electrolytes: Sodium (Na+), Chloride(Cl-)]; this is where transportation of
nutrients, oxygen, and waste products occurs
B. Locations of ECF:
1. Interstitial: fluid between most cells

2. Inflammatory and Infectious Disturbances

3. Disturbances in Immunologic Functioning

4. Disturbances in Cellular Functioning
5. Client in Biologic Crisis

6. Emergency and Disaster Nursing

TERM USE:
Trauma
-Intentional or unintentional wounds / injuries on the human body from
particular mechanical mechanism that exceeds the bodys ability to protect itself
from injury.
Emergency Management
-Traditionally refers to care given to patient with urgent and critical needs.
Triage
-Process of assessing patients to determine management priorities.
First Aid
-An immediate or emergency treatment given to person who has been injured
before complete medical and surgical treatment can be secured.
BLS (BASIC LIFE SUPPORT)
-Level of medical care which is used for patient with illness or injury until medical
care can be given.
ACLS
-Set of clinical interventions for the urgent treatment of cardiac arrest and often
life threatening medical emergencies as well as the knowledge and skills to
deploy those interventions.
Defibrillation
-Restoration of normal rhythm to the heart in ventricular or atrial fibrillation.
Disaster
-Any catastrophic situation in which the normal patterns of life (or ecosystems)
have been disrupted and extraordinary emergency, interventions are required to
save and preserve human lives and/or the environment.
Mass Casualty Incident
-Situation in which the number of casualties exceeds the number of resources
Post-Traumatic Stress Syndrome
-Characteristic of symptoms after a psychological stressful event was out of
range of a normal human experience

SCOPE AND PRACTICE OF EMERGENCY NURSING

The emergency nurse has had specialized education, training, and
experience.
The emergency nurse establishes priorities, monitors and continuously
assesses acutely ill and injured patients, supports and attends to families,
supervises allied health personnel, and teaches patients and families
within a time-limited, high pressured care environment.
Nursing interventions are accomplished interdependently, in consultation
with or under the direction of a licensed physician.
Appropriate nursing and medical interventions are anticipated based on
assessment data.
The emergency health care staff members work as a team in performing
the highly technical, hands-on skills required to care for patients in an
emergency situation.
Patients in the ED have a wide variety of actual or potential problems, and
their condition may change constantly.

www.nurseslabs.com
9

Although a patient may have several diagnosis at a given time, the focus
is on the most-life threatening ones.

ISSUES IN EMERGENCY NURSING CARE

Emergency nursing is demanding because of the diversity of conditions
and situations which are unique in the ER.
Issues include legal issue, occupational health and safety risk for ED staff,
and the challenge of providing holistic care in the context of fast-paced,
technology-driven environment in which serious illness and death are
confronted on a daily basis.
The emergency nurse must expand his or her knowledge base to
encompass recognizing and treating patients and anticipate nursing care
in the event of a mass casualty incident.
Legal issues include:
-Actual consent
-Implied consent
-Parental consent
Good Samaritan Law
-Gives legal protection to the rescuer who act in good faith and are not
guilty of gross negligence or willful misconduct.

Focus of Emergency Care

Preserve or Prolong life
Alleviate suffering
Do no further harm
Restore to Optimal Function

Golden Rules of Emergency Care

Dos
-Obtain Consent
-Think of the Worst
-Respect Victims Modesty and Privacy
Donts
-let the patient see his own injury
-Make any unrealistic promises

Guidelines in Giving Emergency Care

o A- Ask for help
o I- Intervene
o D- Do no further harm

Stages of Crisis
1. Anxiety and Denial
-encouraged to recognize and talk about their feelings.
-asking questions is encouraged
-honest answers given
-prolonged denial is not encouraged or supported.
2. Remorse and Guilt
-verbalize their feelings
3. Anger
-way of handling anxiety and fear
-allow the anger to be ventilated
4. Grief
-help family members work through their grief
-letting them know that it is normal and acceptable

Core Competencies in Emergency Nursing

Assessment
Priority Setting/Critical Thinking Skills
Knowledge of Emergency Care
Technical Skills
Communication

Assess and Intervene

Check for ABCs of life

www.nurseslabs.com
10

A- Airway
B- Breathing
C- Circulation

Team Members
Rescuer
Emergency Medical Technician
Paramedics
Emergency Medicine Physicians
Incident Commander
Support Staff
Inpatient Unit Staff

Emergency Action Principle

Test V

A. Disturbances in Perception and coordination

1. Neurologic disorders
NEUROLOGIC SYSTEM
*The neurological or nervous system is composed of two primary areas:
The Central Nervous System, which includes the brain and the spinal
cord, and the Peripheral Nervous System, which includes the entire
network of nerves extending from the Central Nervous System.

PHYSIOLOGY OF NEUROLOGICAL SYSTEM

Central Nervous System
The brain and the spinal cord within the vertebral column make up the central
nervous system (CNS).
A. The brain and the spinal cord are protected by the rigid bony structure of
the skull and by the vertebral column, respectively

-Spinal Cord serves as a connecting link between the brain and the
periphery.

B. Meninges: the protective membranes that cover the brain and are
continuous with those of the spinal cord.

PIA MATER: covers the surface of the brain and the spinal column
10

www.nurseslabs.com
11

ARACHNOID: waterproof membrane that encases the entire CNS; the

subarachnoid space contains the cerebrospinal fluid.
DURA MATER: a tough membrane that provides protection to the brain
and spinal cord.

C. Cerebrospinal Fluid (CSF)

1. Serves to cushion and protect the brain and spinal cord; the brain
literally floats in CSF.
-Surrounds brain and spinal cord
-Offer protection by functioning as a shock absorber.
2. CSF is clear, colorless, watery fluid; approximately 100- to 200-ml
Total volume, with a normal fluid pressure of 70 to 150 cm of water
(average: 125 cm of water pressure).
3. Formation and circulation of CSF: CSF is formed continuously by the
choroid plexus located in the ventricles of the brain. It is reabsorbed
by the arachnoid villi in the ventricles at the same rate it is formed.
-Allows fluid shifts from the cranial cavity to the spinal cavity.
-Carries nutrients to & waste product away from the nerve cells.
4. Components of CSF: CHON, WBC, Glucose.

D. Brain: The basic brain anatomy consists of the cerebrum, the

cerebellum, the brain stem, and the interior structures.
1. Cerebrum:
-The largest portion of the brain; separated into hemispheres. Each
hemisphere is divided into four lobes: frontal, parietal, occipital, and
temporal.
-outermost area (cerebral cortex) is gray matter.

-deeper area is composed of white matter

-Function of Cerebrum: integration, sensory, motor

-Composed of two hemisphere: The Right Cerebral Hemisphere and

Left Cerebral Hemisphere enclosed in the Corpus Callosum.

-Each hemisphere divided into four lobes; many of the functional

areas of the cerebrum have been located in these lobes:
a. Frontal Lobe: memory, language, personality and emotions are
primarily controlled here; highly vulnerable to traumatic brain injury.
-controls personality, behavior
-higher cortical thinking, intellectual functioning
-Precentral gyrus: controls motor function
-Brocas Area: specialized motor speech area- when damaged result
to garbled speech.
b. Temporal Lobe: controls auditory, verbal, visual, memory and
personality functions.
-hearing, taste, smell
-short term memory
-Wernickes Area: sensory speech area (understanding/formulation
of language).
c. Parietal Lobe: integrates sensory information and interprets spatial
relationships.
-for appreciation
-integrates sensory information
-discrimination of sensory impulses to pain, touch, pressure, heat,
cold, numbness.
-Postcentral gyrus: registered general sensation (ex. Touch,
pressure)
d. Occipital Lobe: central for visual perception and integration.
-for vision
e. some functions of the brain occur in more than one lobe.

2. Cerebellum:
-contains more neurons than the rest of the brain combined. It serves
to interpret motor and mental dexterity, as well as sense of balance.
-smallest part of the brain, lesser brain.

11

www.nurseslabs.com
12

-coordinates muscle tone and movements and maintains position in

space (equilibrium)
-controls balance, equilibrium, posture and gait.

3. Brain Stem:
-conduit for all information transmission between upper and lower
nervous system. Consists of Pons Midbrain, and Medulla.
-located at lowest part of brain.
-extends from cerebral hemisphere to the foramen magnum at the
base of the skull.
-contains nuclei of the cranial nerves and the long ascending and
descending tracts connecting the cerebrum and the spinal cord.
-contains vital center of respiratory vasomotor, and cardiac functions.
a. Pons: responsible for alertness; relays sensory information between
cerebellum and cerebrum.
-Pneumotaxic center controls the rate, rhythm and depth of
respiration.
b. Midbrain: interprets auditory and visual reflexes.
c. Medulla Oblongata: lower portion of the brain stem. Controls
autonomic functions.
1. Respiratory center for changes in rate and depth of breathing.
2. Controls heart rate.
3. Vomiting reflex center
4. Swallowing reflex center.
-controls respiration, heart rate, swallowing, vomiting, hiccup,
vasomotor center (dilation and constriction of bronchioles).

4. Diencephalon/interbrain:
-Connecting part of the brain, between the cerebrum and the brain
stem
-contains several small structures: thalamus and hypothalamus are
most important.
a. Thalamus: receives and relays auditory, sensory, and visual
signals.
-acts as relay station for discrimination of sensory signals
(ex. Pain, temperature, touch)
-controls primitive emotional responses (ex. Rage, fear)

c. Hypothalamus: controls body temperature regulation,

sleep/wake cycles, and appetite; regulates the pituitary
gland.
-found immediately beneath the thalamus.
-plays a major role in regulation/controls of vital function: blood
pressure, thirst, appetite, sleep and wakefulness, temperature
(thermoregulatory center)
-acts as control center for pituitary gland and affects both division of
the autonomic nervous system.
-controls some emotional responses like fear, anxiety, and excitement.
-androgenic hormones promotes secondary sex characteristics.
-early sign for males are testicular and penile enlargement.
-late sign is deepening of voice.
-early sign for females telarch and late sign is menarch.

5. Mesencephalon/Midbrain:
-acts as relay station for sight and hearing.
-size of pupil is 2-3mm.
-equal size of pupil is isocoria.
-unequal size of pupil is anisocoria.
-hearing acuity is 30-40 dB
-positive PERRLA.

6. Limbic system: regulates emotions drives, and appetite.

E. Spinal cord: a nerve bundle transmitting messages to and from the body.
1. Extends from medulla to first or second lumbar vertebra.

12

www.nurseslabs.com
13

2. Nerve exit and enter the spinal cord at each vertebral body and
communicate with specific areas of the body.
3. Rings of bony vertebrae surrounds and protect cord and nerve roots.
4. Intervertebral disks cushion and provide flexibility to the spinal
column.
-serves as a connecting link between the brain and the periphery.
-extends from foramen magnum to second lumbar vertebra
-H-shaped gray matter in the center (cell bodies) surrounded by white
matter (nerve tract and fibers).

Gray Matter

1. Anterior Horns
Contains cell bodies giving rise to efferent (motor) fibers
2. Posterior Horns
Contains cell bodies connecting with afferent (sensory) fibers from
dorsal root ganglion
3. Lateral Horns

In thoracic region, contain cells giving rise to autonomic fibers of

sympathetic nervous system
White Matter

1. Ascending Tracts (sensory pathways)

a. Posterior Column
Carry impulses concerned with touch, pressure, vibration,
& position sense
b. Spinocerebellar
Carry impulses concerned with muscle tension & position
sense to cerebellum
c. Lateral Spinothalamic
Carry impulses resulting in pain & temperature sensations
d. Anterior Spinothlamic
Carry impulses concerned with crude touch & pressure
2. Descending Tracts (motor pathways)
a. Corticospinal (pyramidal, upper motor neurons)
Conduct motor impulses from motor cortex to anterior
horn cells (cross in the medulla)
b. Extrapyramidal
Help to maintain muscle tone & to control body
movement, especially gross automatic movements such as
walking

Reflex Arc
-Reflex consists of an involuntary response to a stimulus occurring over a neural
pathways called a reflex arc.
-Not relayed to and from brain: take place at cord levels

Components
a. Sensory Receptors

13

www.nurseslabs.com
14

Receives/reacts to stimulus
b. Afferent Pathways
Transmits impulses to spinal cord
c. Interneurons
Synapses with a motor neuron (anterior horn cell)
d. Efferent Pathways
Transmits impulses from motor neuron to effector
e. Effectors
Muscle or organ that responds to stimulus
Supporting Structures
1. Skull
- Rigid; numerous bones fused together
- Protects and support the brain
2. Spinal Column
-Consists of 7 cervical, 12 thoracic, and 5 lumbar vertebrae as
well as sacrum and coccyx
- supports the head and protect the spinal cord
3. Meninges
-Membranes between the skull and brain and the vertebral
column and spinal cord
-3 fold membrane that covers brain and spinal cord.
-For support and protection; for nourishment; blood supply
-Area between arachnoid and pia mater is called subarachnoid
space: were the CSF aspiration is done.
-Subdural space between the dura and arachnoid
-LAYERS:
Dura Mater
Outermost layer, tough, leathery
Arachnoid Mater
Middle layer, weblike
Pia Mater
Innermost layer, delicate, clings to surface of brain
4. Ventricle
-Four fluid-filled cavities connecting with one another and spinal
canal
-Produce and circulate cerebrospinal fluid
5. Cerebrospinal Fluid (CSF)
-Surrounds brain and spinal cord
-Offer protection by functioning as a shock absorber
-Allows fluid shifts from the cranial cavity to the spinal cavity
-Carries nutrient to and waste product away from nerve cells
-Components of CSF: CHON, WBC and Glucose
6. Vascular Supply
-Two internal carotid arteries anteriorly
-Two vertebral arteries leading to basilar artery posteriorly
-These arteries communicate at the base of the brain through
the circle of willis
7. Blood-Brain-Barrier (BBB)
-Protective barrier preventing harmful agents from entering the
capillaries of the CNS; protect brain and spinal cord.

Substance That Can Pass Blood-Brain Barrier

1. Ammonia
-Cerebral toxin
-Hepatic Encephalopathy (Liver Cirrhosis)
-Ascites
-Esophageal Varices
Early Signs of Hepatic Encephalopathy
-Asterixis (Flapping hand tremors).

14

www.nurseslabs.com
15

Late Sign of Hepatic Encephalopathy

-Headache
-Dizziness
-Confusion
-Fetor Hepaticus (ammonia like breath)
-decrease LOC
2. Carbon Monoxide and Lead Poisoning
-Can lead to Parkinsons Disease.
-Epilepsy
-Treated with calcium EDTA.
3. Type 1 DM (IDDM)
-Causes diabetic ketoacidosis.
-and Increases breakdown of fats.
-and free fatty acids
-Resulting to cholesterol and positive to ketones (CNS
depressants)
-Resulting to acetone breath odor/fruity odor.
-and Kussmauls respiration a rapid shallow respiration.
-Which may lead to diabetic coma.
4. Hepatitis
-Signs of jaundice (icteric sclerae).
-Caused by bilirubin (yellow pigment)
5. Bilirubin
-Increase bilirubin in the brain (kernicterus).
-Causing irreversible brain damage.

Peripheral Nervous System

The PNS consists of sensory and motor neurons. The PNS is subdivided into the
sensory/somatic nervous system and the autonomic nervous system.
A. Types of Nerves.
1. Sensory (afferent or ascending) nerves relay sensations to the brain for
response.
2. Motor components of cranial nerves (efferent or descending) send
messages
B. Functions of PNS: both sensory/somatic and autonomic responsibilities.
1. Sensory/somatic nervous system consists of cranial nerves and spinal
nerves.
*a. Cranial nerves: responsible for a variety of functions, from hearing and balance
to regulation of chemoreceptors in the aortic body.
12 pairs: carry impulses to & from the brain.
May have sensory, motor, or mixed functions.
Name and Number Function
CN I OLFACTORY SENSORY: Carries impulses for sense of smell.

CNII OPTIC SENSORY: Carries impulses for vision.

CNIII OCULOMOTOR MOTOR: Muscles foe papillary constriction, elevation of

upper eyelid; 4 OUT 6 EOM

CNIV TROCHLEAR MOTOR: Muscles for downward, inward, movement of

the eye

CNV TRIGEMINAL MIXED: Impulses from face, surface of eyes (corneal

reflex); Muscle controlling mastication.

CNVI ABDUCENS MOTOR: Muscles for lateral deviation of the eys

CNVII FACIAL MIXED: Impulses for taste from anterior tongue;

15

www.nurseslabs.com
16

Muscle for facial movement.

CN VIII ACOUSTIC SENSORY: Impulses for hearing (COCHLEAR DIVISION)

and balance (VESTIBULAR DIVISION).

CN IX MIXED: Impulses for sensation to posterior tongue and

GLOSSOPHARYNGEAL pharynx; Muscle for movement of pharynx (elevation)
and swallowing

CN X VAGUS MIXED: Impulses for sensation to lower pharynx and

larynx; Muscle for Movement of soft palate, pharynx,
and larynx.

CN XI SPINAL MOTOR: Movement of Sternocleidomastoid Muscle and

ACCESSORY upper part of trapezius muscle.

CN XII HYPOGLOSSAL MOTOR: Movement of tongue.

*b. Spinal nerves: each pair of nerves is numbered according to the level of the
spinal cord from which it originates.
-31 pairs: carry impulses to & from spinal cord
-Each segment of the spinal cord contains a pair of spinal nerves (one of each side of
the body)
-Each nerve is attached to the spinal by two roots:
1. Dorsal (posterior) roots
contains afferent (sensory) nerve whose cell body is in the dorsal
roots ganglion
2. Ventral (anterior) roots
Contains efferent (motor) nerve whose nerve fibers originate in the anterior horn cell
of the spinal cord (lower motor neuron)
2. Autonomic Nervous System: regulates involuntary activities (e.g.,
cardiovascular, respiratory, metabolic, body temperature)
-*Part of the peripheral nervous system
-Include those peripheral nerves (both cranial and spinal) that regulates smooth
muscles, cardiac muscles, and glands.
-Components:
1. Sympathetic Nervous System: Prepares the body to meet a challenge or an
emergency; fight or flight.
-Generally, accelerates some body functioning response to stress
2. Parasympathetic Nervous System: Maintains and/or control normal body
functions.
Sympathetic Nervous System Parasympathetic Nervous System
(Adrenergic) Effect (Cholinergic) Effect, Vagal, Sympatholytic
- Involved in fight or aggression - Involved in flight or withdrawal
response. response.
- Release of Norepinephrine - Release of Acetylcholine.
(cathecolamines) from adrenal glands - *Decreases all bodily activities except
and causes vasoconstriction. GIT.
- *Increase all bodily activity except GIT

EFFECTS OF SNS EFFECTS OF PNS

- Dilation of pupils (mydriasis) in order to - Constriction of pupils (miosis).
16

www.nurseslabs.com
17

be aware. - Increase salivation.

- Dry mouth (thickened saliva). - Decrease BP and Heart Rate.
- Increase BP and Heart Rate. - Bronchoconstriction, Decrease RR.
- Bronchodilation, Increase RR - *Diarrhea
- *Constipation. - Urinary frequency.
- Urinary Retention.
- Increase blood supply to brain, heart
and skeletal muscles.
- SNS
I. Cholinergic Agents
I. Adrenergic Agents - Mestinon, Neostignin.
- Give Epinephrine. SE:
SE: - PNS effect
- SNS effect
Contraindication:
- Contraindicated to patients suffering
from COPD (Broncholitis, Bronchoectasis,
Emphysema, Asthma). II. Anti-cholinergic Agents
- To counter cholinergic agents.
II. Beta-adrenergic Blocking Agents - Atrophine Sulfate
- Also called Beta-blockers.
- all ending with lol SE:
- Propranolol, Atenelol, Metoprolol. - SNS effect
Effect of Beta-blockers
B bronchospasm
E elicits a decrease in myocardial
contraction.
T treats hypertension.
A AV conduction slows down.
- Should be given to patients with
Angina, Myocardial Infarction,
Hypertension

ANTI- HYPERTENSIVE AGENTS

1. Beta-blockers lol
2. Ace Inhibitors Angiotensin pril
(Captopril, Enalapril)
3. Calcium Antagonist Nifedipine
(Calcibloc)
- In chronic cases of arrhythmia give
Lidocane, Xylocane.

EFFECTOR SYMPATHETIC(Adrenergic PARASYMPATHETIC(Cholinergic)

) EFFECT EFFECT
S
EYE Dilate pupil (mydriasis) Constrict pupil (miosis)
LACRIMAL No effect Stimulate secretions
SALIVARY Scanty thick, viscous Copious thin watery secretions
secretions, dry mouth

17

www.nurseslabs.com
18

HEART Increase rate and force of Decrease rate

contraction
BLOOD Constrict smooth muscles of No effect
VESSEL the skin, Abdominal blood
vessels, and Cutaneous blood
vessels, Dilates smooth
muscles of bronchioles, Blood
vessels of the heart and
skeletal muscles
LUNGS Bronchodilation Bronchoconstriction
GI TRACT Decrease motility Increase motility
Constrict sphincters Relaxed sphincters
Possibly inhibits secretion Stimulate secretions
Inhibits activity of gallbladder Stimulate activity of gallbladder and
and ducts ducts
Inhibits glycogenolysis in liver
ADRENAL Stimulates secretion of No effect
GLAND epinephrine and
Norepinephrine
URINARY Relaxes detrusor muscles Contract detrusor muscles
TRACT

TABLE 15-1 AUTONOMIC NERVOUS

SYSTEM
AREA AFFECTED SYMPATHETIC (FIGHT OR PARASYMPATHETIC
FLIGHT)
PUPIL DILATES CONSTRICT
BRONCHI
DILATES CONSTRICT
HEART
INCREASE RATE DECREASE RATE
GASTROINTESTINA
INHIBITS PERISTALSIS STIMULATES PERISTALSIS
L STIMULA
INHIBITS SPHINCTER
TES SPIHINCTER
CONT
RELAXES BLADDER MUSCLE RACT BLADDER MUSCLES
BLAD
CONSTRICT SPHINCTER RELAXES SPHINCTER
DER

3. Most of the organs of the body receive innervation from both the
parasympathetic and the sympathetic divisions.

NEUROTRANSMITTE DECREASE INCREASE

R

Acetylcholine Myasthenia Gravis Bi-polar

Dopamine Parkinsons Disease Schizophrenia

System Data Collection

Comprehensive Neuro Exam

A. History

18

www.nurseslabs.com
19

1. Neurological History.
1.a. Level of Consciousness
a. Orientation to time, place, person
b. Speech: clear, garbled, rambling.
c. Ability to follow command
d. If does not respond to verbal stimuli, apply a painful stimulus (ex.,
Pressure on the nailbeds, squeeze trapezius muscle); note response to
pain
Appropriate: withdrawal, moaning
Inappropriate: non-purposeful
e.Abnormal posturing (may occur spontaneously or in response to
stimulus)
Decorticate Posturing: extension of leg, internal rotation and
abduction of arms with flexion of elbows, wrist, and finger:
(Damage to corticospinal tract; cerebral hemisphere)
Decerebrate Posturing: back ached, rigid extension of all four
extremities with hyperpronation of arms and plantar flexion of feet:
(Damage to upper brain stem, midbrain, or pons).
2. Medical History.
a. Chronic, concurrent medical problems.
b. Medications (especially tranquilizers, sedatives, and narcotics).
c. If client is an infant or young child, a pregnancy and delivery
history of the mother is obtained.
d. Sequence of growth and development.
3. Family History: presence of hereditary or congenital problems.
4. Personal History: activities of daily living, any change in routine.
5. History and symptoms of current problems.
a. Paralysis or paresthesia.
b. Syncope, dizziness.
c. Headache.
d. Speech problems.
e. Visual problems.
f. Change in personality.
g. Memory loss.
h. Nausea, vomiting

B. Physical Assessment.
1. General observation of client.
a. Posture, gait.
b. Position of rest for the infant or young child.
c. Personal hygiene, grooming.
d. Evaluate speech and ability to communicate.
(1) Pace of speech: rapid, slow, halting.
(2) Clarity: slurred or distinct.
(3) Tone: high pitched, rough.
(4) Vocabulary: appropriate choice of words.

e. Facial features may suggest specific syndromes in

children.

BOX 15-1 OLDER ADULT CARE FOCUS

Assessing Neurologic Function in Older Adults

Significant memory loss (person, place, and time).

Person: Does client know who he or she is, and can client give you his or her full
name?

Place: Can client identify his or her home address and where he or she is now?

Time: What was the most recent holiday; what month, time of day, day of the
week is it now?

19

www.nurseslabs.com
20

Does client show a lack of judgment?

Is client agitated and/or suspicious?

As determined from clients appearance and familys response, does client have
problems with ADLs?

Short-term memory: Can the client recall your name, name of the President, or
name of his or her doctor?

Short-term recall: Ask the client to name three or four common objects; then ask
client to recall them within the next 5 minutes.

Does the client have sensory deficits (hearing and vision) of which he or she is not
aware?

Neurologic Exam

2. Mental Status and speech (Cerebral function) (must

take into consideration the clients age, culture, and
educational background).
a. General appearance and behavior.
b. Level of Consciousness (LOC).
(1) Oriented to person, place, and time.
(2) Appropriate response to verbal and tactile
stimuli.
(3) Memory, problem-solving abilities.
c. Mood.
d. Thought content and intellectual capacity.
e. Judgement and abstract thinking.
f. Perceptual distortion.
3. Assess pupillary status and eye movements.
a. Size of pupil should be equal.
-Observe size, shape, and equality of pupil (note
size in millimeter)
b. Reaction of pupils. Reaction to light: pupillary
constriction
Corneal reflex: blink reflex in response to light
stroking of cornea
Oculocephalic reflex (dolls eyes): present in
unconscious client with intact brainstem.
(1) Direct light reflexes: constriction of
pupil when light is shown directly into eye.
(2) Accommodation: pupillary constriction to
accommodate near vision.
c. Evaluate eye movements.
(1) Note nystagmus: fine, jerking eye
movement.
(2) Ability of eyes to move together.
(3) Resting position should be at mid-position
of the eye socket.
d. PERRLA: Indicates the Pupils are Equal, Round,
and Reactive to Light, and the Accommodation is
present.
4. Evaluate motor function.
a. Assess face and upper extremities for equality of
movement and sensation; evaluate swallow
reflex.
b. Evaluate appropriateness of motor movement
spontaneous and on command.
c. Movement of extremities should always be
evaluated bilaterally, comparing tone, strength,
and muscle movement of each side.
-Movement of extremities (paralysis)
d. Presence of inappropriate, nonpurposeful
movement (e.g., posturing).

20

www.nurseslabs.com
21

(1) Decerebrate: extension and

adduction of the arms; hyperextension of
the legs.
(2) Decorticate:
(3) Presence of nonpurposeful
involuntary movements such as tremors,
jerking, twitching.
(4) Opisthotonos position: rigid
arching of the back.
e. Ability of an infant to suck and swallow.
f. Asymmetrical contraction of facial muscles.
5. Evaluate reflexes.
a. Gag or cough reflex
b. Swallow reflex
c. Pathologic: Babinski reflex (dorsiflexion of
the great toes):indicates damages to
corticospinal tracts Normal signs is negative in
adults and children over 1 year; positive sign is
dorsal flexion of the foot and large toe with
fanning of the other toes.
d. Deep tendon reflex: grade from 0 (no
response); to 4 (hyperactive); 2 (normal)
e. Superficial
6. Assess vital signs and correlate with other date; changes
often occur slowly, and the overall trend needs to be
evaluated.
a. Blood pressure and pulse rate: Intracranial
problems precipitate changes: blood pressure
may increase and pulse rate may decrease.
b. Respirations: Rate, Depth, and Rhythm are
sensitive indicators of intracranial problems.
c. Temperature: Evaluate changes in temperature
as related to a neurological control versus
infection.

Vital Signs: Respiratory Patterns (may help localize

possible lesion)
a. Cheyne-stokes Respiration: regular rhythmic
alternating between hyperventilation and apnea;
may be caused by structural cerebral dysfunction or
by metabolic problems such as diabetic coma.
b. Central Neurogenic Hyperventilation: sustained,
rapid, regular respiration (rate of 25/min) with
normal oxygen level; usually due to brainstem
dysfunction.
c. Apneustic Breathing: prolonged inspiratory phase,
followed by a 2-to3- sec. pause; usually indicates
dysfunction respiratory center in pons.
d. Cluster Breathing: cluster of irregular breathing,
irregular followed by periods of apnea; usually
caused by a lesion in upper medulla and lower pons.
e. Ataxic Breathing: breathing pattern completely
irregular; indicates damage to respiratory center of
the medulla.

C. Bedside neurological checks: parameters for frequent nursing

evaluation of neurological symptoms.
1. Assess level of consciousness (LOC)
a. Verbal and motor response to command.
b. Appropriate conversation and speech.
c. Appropriate behavior in infants and young children.
d. Be explicit in describing LOC; may use a specific coma scale

21

www.nurseslabs.com
22

TABLE 15-2 GLASGOW

COMA SCALE

CATEGORY OF APPROPRIATE RESPONSE

RESPONSE STIMULUS

Eyes Open Approach Spontaneous response 4

bedside Opening of eyes to 3
Verbal name or command
command Lack of Opening of eyes 2
Pain to previous stimuli but
opening to pain
Lack of opening of eyes 1
to any stimulus
Untestable U

Best verbal Verbal Appropriate orientation, 5

response questioning conversant, correct
with identification of self,
maximum place, year, and month
arousal Confusion; conversant, 4
but disoriented in one
or more spheres
Inappropriate or 3
disorganized use of
words (e.g cursing),
lack of sustained
conversation
Incomprehensible 2
words, sounds (e.g.,
moaning)
Lack of sound, even 1
with painful stimuli
Untestable U

Best motor Verbal Obedience in response 6

response command to command
(e.g., raise Localization of pain, lack 5
your arm, of obedience but
hold up two presence of attempts to
fingers. remove offending
Pain stimulus
(pressure on Flexion withdrawal*, 4
proximal nail flexion of arm in
bed) response to pain
without abnormal
flexion posture
Abnormal flexion, 3
flexing of arm at elbow
and pronation, making a
fist
Abnormal extension, 2
extension of arms at
elbow, usually with
adduction and internal
rotation of arm at
shoulder
Lack of response 1
Untestable U

Level of Consciousness (LOC)

1. Conscious: awake
2. Lethargy: lethargic (drowsy, sleepy, obtunded)
3. Stupor
Stuporous: (awakened by vigorous stimulation)
Generalized body weakness
Decrease body reflex
22

www.nurseslabs.com
23

4. Coma
Comatose
Light coma: positive to all forms of painful stimulus
Deep coma: negative to all forms of painful stimulus

Different Painful Stimulation

1. Deep sternal stimulation / deep sternal pressure

2. Orbital pressure

3. Pressure on great toes

4. Corneal or blinking reflex

Conscious client: use a wisp of cotton

Unconscious client: place 1 drop of saline solution

Test of Memory

1. Short term memory

Ask most recent activity
Positive result mean ANTEROGRADE AMNESIA and damage to
temporal lobe.
2. Long term memory
Ask for birthday and validate on profile sheet.
Positive result mean RETROGRADE AMNESIA and damage to
limbic system.
Consider educational background.

Level of Orientation

1. Time: first asked

2. Person: second asked
3. Place: third asked

Cranial Nerves

Cranial Nerves Function

1. Olfactory Sensory
2. Optic
3. Oculomotor Sensory
4. Trochlear
5. Trigeminal Motor
6. Abducens
7. Facial
Motor (smallest)
8. Acoustic
9. Glossopharen
geal Both (largest)
10. Vagus
11. Spinal Motor
Accessory

23

www.nurseslabs.com
24

12. Hypoglossal Both

Sensory

Both

Both (longest)

Motor

Motor

CRANIAL NERVE I: OLFACTORY

Sensory function for smell

Material Used

Dont use alcohol, ammonia, perfume because it is irritating and highly

diffusible.
Use coffee granules, vinegar, bar soap, cigarette

Procedure

Test each nostril by occluding each nostril

Abnormal Findings

1. Hyposnia: decrease sensititvity to smell

2. Dysosmia: distorted sense of smell
3. Anosmia: absence of smell

Either of the 3 may indicate head injury damaging the cribiform plate of ethmoid
bone where olfactory cells are located may indicate inflammatory conditions
(sinusitis)

CRANIAL NERVE II: OPTIC

Sensory function for vision or sight

Functions:

1. Test visual acuity or central vision or distance

Use snellens Chart
Snellens Alphabet chart: for literate client
Snellens E chart: for illiterate client
Snellens Animal chart: for pediatric client
Normal visual acuity 20/20
Numerator: is constant, it is the distance of person from the chart (6-7m, 20
feet)
Denominator: changes, indicates distance by which the person normally can
see letter in the chart.
20/200 indicates blindness
20/20 visual acuity if client is able to read letters above the red line.
2. Test of visual field or peripheral vision
a. Superiorly
b. Bitemporaly
c. Nasally
d. Inferiorly

24

www.nurseslabs.com
25

CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS

Controls or innervates the movement of extrinsic ocular muscle (EOM)

6 muscles:

SUPERIOR RECTUS SUPERIOR OBLIQUE

LATERAL RECTUS MEDIAL RECTUS

INFERIOR OBLIQUE INFERIOR RECTUS

TROCHLEAR: controls superior oblique (S.O)

ABDUCENS: controls lateral rectus (LR)
OCULOMOTOR: controls the 4 remaining EOM

Oculomotor

Controls the size and response of pupil

Normal pupil size is 2-3 mm
Equal size of pupil: Isocoria
Unequal size of pupil: Anisocoria
Normal response: positive PERRLA

CRANIAL NERVE V: TRIGEMINAL

Largest cranial nerve

Consists of ophthalmic, maxillary, mandibular
Sensory: controls sensation of face, mucous membrane, teeth, soft palate
and corneal reflex
Motor: controls the muscle of mastication or chewing
Damage to CN V leads to Trigeminal Neuralgia / Tic Douloureux
Medications: Carbamazepine (Tegretol)
25

www.nurseslabs.com
26

CRANIAL NERVE VII: FACIAL

Sensory: controls taste, anterior 2/3 of tongue

Pinch of sugar and cotton applicator placed on tip of tongue
Motor: controls muscle of facial expression
Instruct the client to smile, frown and if results are negative there is facial
paralysis or Bells Palsy and the primary cause is forcep delivery.

CRANIAL NERVE VIII: ACOUSTIC, VESTIBULOCOCHLEAR

Controls balance particularly kinesthesia or position sense, refers to

movement and orientation of the body in space.

CRANIAL NERVE IX, X: GLOSSOPHARYNGEAL, VAGUS

Glossopharyngeal: controls taste, posterior 1/3 of tongue

Vagus: controls gag reflex
Uvula should be midline and if not indicative of damage to cerebral
hemisphere.
Effects of vagal stimulation is PNS

CRANIAL NERVE XI: SPINAL ACCESSORY

Innervates with sternocleidomastoid (neck) and trapezius (shoulder)

CRANIAL NERVE XII: HYPOGLOSSAL

Controls the movement of tongue

Let client protrude tongue and it should be midline and if unable to do
indicative of damage to cerebral hemisphere and/or has short frenulum.

Pathognomonic Signs:

1. PTB low grade afternoon fever

2. PNEUMONIA rusty sputum.

3. ASTHMA wheezing on expiration.

4. EMPHYSEMA barrel chest.

5. KAWASAKI SYNDROME strawberry tongue

6. PERNICIOUS ANEMIA red beefy tongue

7. DOWN SYNDROME protruding tongue

8. CHOLERA rice watery stool.

9. MALARIA step ladder like fever with chills.

26

www.nurseslabs.com
27

10. TYPHOID rose spots in abdomen.

11. DIPTHERIA pseudo membrane.

12. MEASLES koplicks spots

13. SLE butterfly rashes.

14. LIVER CIRRHOSIS spider like varices

15. LEPROSY lioning face

16. BOLIMIA chipmunk face.

17. APPENDICITIS rebound tenderness

18. DENGUE petichae or positive hermans sign.

19. MENINGITIS kernigs sign (leg pain), brudzinski sign (neck pain).

20. TETANY hypocalcemia (+) trousseus sign or carpopedal spasm/ (+)

chvostek sign (facial spasm).

21. TETANUS risus sardonicus

22. PANCREATITIS cullens sign (echymosis of umbilicus) / (+) grey turners

spots.

23. PYLORIC STENOSIS olive like mass.

24. PDA machine like murmur

25. ADDISONS DISEASE bronze like skin pigmentation.

26. CUSHINGS SYNDROME moon face appearance and buffalo hump.

27. HYPERTHYROIDSM/GRAVES DISEASE exopthalmus.

2.Respiratory Patterns: Evaluate current respiratory pattern and assess

for changes in pattern.

3. Pupillary response.
a. Equality of pupils.
b. Presence of direct and accommodation reflexes.
c. Position of pupils at rest.

4. Motor function.

a. Ability to move all extremities with equal strength.

b. Presence of posturing.

c. Babinski reflex.

27

www.nurseslabs.com
28

d. Presence of seizure activity.

e. Presence of gag and cough reflexes.

5. Vital Signs.

a. Correlate blood pressure and pulse rate changes.

b. Assess respiratory pattern.

c. Assess temperature in regard to overall condition.

6. Assess for presence of pain, headache.

7. Presence of projectile vomiting not associated with nausea.

8. Infants: assess fontanel(s) and suture lines.

a. Size of fontanel(s) for growth and development level.

b. Fontanel(s) should be soft to touch, with slight pulsations.

c. Normal approximation of cranial suture lines.

INCREASE INTRACRANIAL PRESSURE

* An increase in intracranial pressure (ICP) occurs any time

there is an increase in the size or amount of intracranial
contents.

A. The cranial vaults is rigid, and there is minimal room for expansion of the
intracranial components.

B. An increase in any one of the components necessitates a reciprocal change in

other cranial contents; this frequently results in ischemia of brain tissue. An increase
in ICP results from one of the following:

1. Increase intracranial blood volume (vasodilation).

2. Increased CSF.

3. Increased in the bulk of the brain tissue (edema).

C. Cerebral edema.

1. Edema occurs when there is an increase in the volume of brain tissue caused by
an increase in the permeability of the walls of the cerebral vessels.

a. Protein-rich fluid leaks into the extracellular space.

b. Edema is most often the cause of increased ICP in adults, which reaches
maximum pressure in 48 to 72 hours.
28

www.nurseslabs.com
29

2. Cytotoxic (cellular) edema occurs as a result of hypoxia. This results in abnormal

accumulation of fluid within cells (intracellular) and a decrease in extracellular fluid.

D. Poor ventilation will precipitate respiratory acidosis, or an increase in PaCO2.

1. Carbon dioxide has a vasodilating effect on the cerebral arteries, which increases
cerebrovascular blood flow and increase ICP.

2. Client should be adequately ventilated to prevent cyclic vasodilation, which

increases intracranial pressure.

E. regardless of the cause, increased ICP will result in progressive neurologic

deterioration; the specific deficiencies seen are determined by the area and extent of
compression of brain tissue.

F. If the infants cranial suture lines are open, increased ICP will cause separation of
the suture lines and an increase in the circumference of the head.

NURSING PRIORITY: There is no single set of

symptoms for all clients with increased ICP;
symptoms depend on the cause and on how
rapidly increased ICP develops.

Data Collection

A. Risk factors/etiology.
1. Cerebral edema caused by some untoward event or trauma.
2. Brain tumors
3. Intracranial hemorrhage (closed head injuries or ruptured blood vessels).
4. Subarachnoid hemorrhage, hydrocephalus.
5. Cerebral embolism and thrombosis.
6. Encephalitis/meningitis.
7. Reyes syndrome
B. Clinical manifestations (bedside neurologic checks)

NURSING PRIORITY: Determine change in a

clients neurological status. Be able to rapidly
evaluate the client and recognize neurologic
signs that indicate an increase in ICP.
29

www.nurseslabs.com
30

1. Assess for changes in level of consciousness, because change is the

cardinal indicator of increased in intracranial pressure.
a. Any alteration in level of consciousness (early sign for both adults and
children)- irritability, restlessness, confusion, lethargy, and difficulty in
arousing- maybe significant.

NURSING PRIORITY: The first sign of a

change in the level of consciousness; this
may progress to a decrease in level of
consciousness.

b. Inappropriate verbal and motor response; delayed or sluggish responses.

c. ***As the client loses consciousness, hearing is the last sense to be lost.
2. Changes in Vital Signs.
a. Increase in systolic blood pressure with increase in pulse pressure.
b. Decrease in pulse rate.
c. Alteration in respiratory pattern (Cheyne-Stokes respiration,
hyperventilation, ataxia).
d. Assess temperature with regard to overall problems; temperature usually
increases.
3. Pupillary response: normal pupils should be round, midline, equal in size, and
equally briskly reactive to light and should accommodate to distance.
4. Decrease in motor and sensory function, unilateral or bilateral weakness or
paralysis, failure to withdraw from painful stimuli, seizure activity.
5. Headache, Photophobia.
6. Vomiting: projectile vomiting without prior nausea.
7. Infants.
a. Tense, bulging fontanel(s)
b. Separated cranial sutures.
c. Increasing frontal-occipital circumference.
d. High-pitched cry.

C. Diagnostics***

Treatment

A. Treatment of the underlying cause of increasing pressure.

B. Neurologic checks every hour or as ordered.
1. May involve correlation of several variables including level of
consciousness, vital signs, speech, facial symmetry, grasp strength, leg
strength, and pupil response.
2. Careful comparison to previous assessment is critical to detect incremental
changes.
C. Intravenous (IV) and oral fluids.
D. Medications:
1. Osmotic diuretics, corticosteroids.
2. Anticonvulsants, antihypertensives.

E. Maintain adequate ventilation by means of mechanical

ventilation to lower PaCO2.

F. Placement of ventriculoperitoneal shunt during decompression

surgery.
30

www.nurseslabs.com
31

Complications

A. CSF leaks may cause meningitis.

B. Herniation: shifting of intracranial contents from one
compartment to another.
1. Brain compression occurs.
2. Obstruction of the cerebrospinal fluid.
3. Irreversible brain damage and death.

C. Permanent brain damage.

Nursing Interventions

Goal: To identify and decrease problem of increased ICP.

A. Neurologic checks, as indicated by clients status.
B. Maintain head of bed in semi-Fowlers position (15-30 degrees) to
promote venous drainage and respiratory function.

NURSING PRIORITY: Changes clients

position. If the client with increased ICP
develops hypovolemic shock, do not place
client in Trendelenburg position.

C. Change clients position slowly; avoid extreme hip flexion and extreme rotation
or flexion of neck. Maintain the head midline.

INCREASING INTRACRANIAL PRESSURE

Adult
Early: Restlessness, Irritable, Lethargic
Intermediate: Unequal pupil response, Projectile vomiting, Vital
signs changes. Late: Decreased level of consciousness,
decreased reflexes, Hypoventilation, Dilated pupils, Posturing
Infant/Child
Early: Poor feeding, Tense fontanel, Headache, Nausea and
Vomiting, Increased pitch of cry, Unsteady gait.
Intermediate: (Younger than 18 moths): Increased head
circumference, altered consciousness, bulging fontanel; Shrill cry,
Severe headache, Blurred vision, Stiff neck
Late: Same as Adult.

D. Monitor urine specific gravity.

E. Evaluate intake and output.
1. In response to diuretics.
31

www.nurseslabs.com
32

2. As correlated with changes in daily weight.

F. Maintain intake evenly during therapeutic treatment.
G. Minimize respiratory suctioning and ensure hyperoxygenation before suctioning.
H. Sedatives and narcotics can depress respiration; use with caution because they
mask symptoms of increasing ICP.
I. Client should avoid strenuous coughing, Valsalva maneuver, and isometric
muscle exercises.
J. Avoid straining with stools (increases intrathoracic pressure sporadically).
K. In Infants, measure frontal-occipital circumference to evaluate increase in size
of the head.
L. Control hyperthermia.
M. Maintain head and spinal column in midline position.

Goal: To maintain respiratory function.

NURSING PRIORITY: An obstructed airway is

one of the most common problems in the
unconscious client; position to maintain patent
airway or use airway adjuncts.

A. Prevent respiratory problems of immobility.

B. Evaluate patency of airway frequently; as level of consciousness decreases,
client is at increased risk for accumulating secretions and airway obstruction
by the tongue.
C. Suction secretions as necessary, but in short duration with rest periods.
D. Do not suction the nasopharyngeal area of a client when a cerebrospinal fluid
leak is present (craniotomy, head injury or basilar skull fracture).

Goal: To protect client from injury.

A. Maintain seizure precautions
B. Restrain client only if absolutely necessary; struggling against restraints
increases ICP.
C. Do not clean the ears or nasal passages of a client with a head injury or a
client who has had neurosurgery.
1. Check for evidence of a CSF leak: CSF has glucose in it; test it with a
dipstick.
2. CSF also leaves a yellow halo stain.
D. Aspiration is a major problem in the unconscious client; place the client in the
semi-Fowlers position for tube feeding after ensuring correct tube placement
by x-ray.
E. Maintain quiet, nonstimulating environment.
F. Inspect eyes and prevent corneal ulceration.
1. Protective closing of eyes, if eyes remain open.
2. Irrigation with normal saline solution or methylcellulose drops to restore
moisture.

Goal: To maintain psychologic equilibrium.

A. Neurologic checks should be done on a continual basis to detect potential
problems.
B. Encourage verbalization of fears regarding condition.
C. Give simple explanation of procedures to client and family.
D. Altered states of consciousness will cause increased anxiety and confusion;
maintain reality orientation.
E. If client is unconscious, continue to talk to him or her; describe procedures
and treatments; always assume that client can hear.
F. Assist parents and family to work through feelings of guilt and anger.

32

www.nurseslabs.com
33

Goal: To prevent complications of immobility.

Goal: To maintain elimination.

A. Urinary Incontinence: may use condom catheter or indwelling bladder
catheter.
B. Keep perineal area clean, prevent excoriation.
C. Monitor bowel function; evaluate for fecal impaction.

NURSING PRIORITY: Notify charge nurse or

primary health care provider when client
demonstrates signs of potential complications;
interpret what data for a client need to be
reported immediately.

Home Care
A. Teach client and family signs of increased ICP.
B. Call the doctor if any of the following are observed:
1. Changes in vision.
2. Increased drainage from incision area or clear drainage in the ears.
3. Abrupt changes in sleeping patterns or irritability.
4. Headache that does not respond to medication.
5. Change in coordination, disorientation.
6. Slurred speech, unusual behavior.
7. Seizure activity, vomiting.
C. Review care of surgical incision, wounds or drains.

BRAIN TUMORS
*Brain tumors may be benign, malignant, or metastatic;
malignant brain tumors rarely metastasize outside the CNS.
Regardless of the origin, site or presence of malignancy, problems of
increased ICP occur because of the limited area in the brain to
accommodate an increase in the intracranial content.

Data Collection

A. Clinical Manifestations: Symptoms correlate with the area of the brain initially
involved.

1. Headache.

a. Recurrent. May vomit on arising and then feel better.

b. More severe in the morning.

c. Affected by position.

d. Headache in infant may be identified by persistent, irritated crying and head

rolling.

2. Vomiting: initially with or without nausea; progressively becomes projectile.

33

www.nurseslabs.com
34

3. Papilledema (edema of the optic disc).

4. Seizures (focal or generalized).

5. Dizziness and vertigo.

6. Mental status changes: lethargy and drowsiness, confusion, disorientation, and

personality changes

7. Localized manifestations:

a. Focal weakness: hemiparesis.

8. Sensory disturbances.

a. Language disturbances.

b. Coordination disturbances.

c. Visual disturbances.

9. Head tilt: child may tilt the head because of damage to extraocular muscle; may
be first indication of a decrease in visual acuity.

10. Changes in vital signs indicative of increasing ICP.

11. Cranial enlargement in the infant younger than 18 months.

B. Diagnostics***

Treatment

A. Medical.

1. Dexamethasone

2. Chemotherapy.

3. Anticonvulsants

4. Complementary and alternative medicine.

B. Radiation: x-rays, gamma knife, stereotactic radiosurgery.

C. Surgical Intervention: Craniotomy/Craniectomy, biopsy, shunt placement,

reservoir placement, laser removal.

Complications

Complications include meningitis, brainstem herniation, diabetes insipidus. Residual

effect include wide array of complications such as seizures, dysarthria, dysphasia,
disequilibrium, and permanent brain damage.

34

www.nurseslabs.com
35

Nursing Interventions

Goal: To provide appropriate preoperative nursing interventions.

A. General preoperative care with exceptions, as noted

B. Carefully assess and discuss with surgeon the appropriateness of a preoperative

enema.

C. Prepare client and family for appearance of the client after surgery, including
partial or complete hair loss.

D. Encourage verbalization regarding concerns about surgery.

E. Skin preparation is usually done in the operating room.

Goal: To monitor changes in ICP after craniotomy

INCREASING INTRACRANIAL PRESSURE

Adult
Early: Restlessness, Irritable, Lethargic
Intermediate: Unequal pupil response, Projectile vomiting, Vital
signs changes. Late: Decreased level of consciousness,
decreased reflexes, Hypoventilation, Dilated pupils, Posturing
Infant/Child
Early: Poor feeding, Tense fontanel, Headache, Nausea and
Vomiting, Increased pitch of cry, Unsteady gait.
Intermediate: (Younger than 18 moths): Increased head
circumference, altered consciousness, bulging fontanel; Shrill cry,
Severe headache, Blurred vision, Stiff neck
Late: Same as Adult.

A. Obtain vital signs and perform neurologic checks and cranial nerve
assessments as necessary.
B. Maintain pulmonary function and hygiene.
C. Anticipate use of anticonvulsants and antiemetics.
D. Discourage coughing.
E. Carefully evaluate level of consciousness; increasing lethargy or irritability
may be indicative of increasing ICP.
F. Evaluate dressing.
1. Location and amount of drainage.
2. Clarify with surgeon whether the nurse or the surgeon will change
dressing.
3. Evaluate for CSF leak through the incision and report any drainage to
charge nurse.
G. Maintain semi-Fowlers position if there is a CSF leak from ears or nose.
H. Postoperative positioning for client who has had infratentorial
surgery:***
1. Bed should be flat.
2. Position client on either side; avoid supine position.
3. Maintain head and neck in midline.
4. Keep NPO for 24 hours to reduce edema around medulla and reduce
vomiting.
I. Postoperative position for client who has had supratentorial
surgery:***
35

www.nurseslabs.com
36

semi- to low-Fowlers position.

J. Trendelenburg position is Contraindicated.
K. Maintain fluid regulation.
1. After client is awake and swallow and gag reflexes have returned, begin
offering clear liquids by mouth.
2. Closely monitor intake and output.
L. Evaluate neurologic status in response to fluid balance and diuretics.
M. Evaluate changes in temperature: may be due to respiratory
complications or to alteration in the function of the hypothalamus.
N. Provide appropriate postoperative pain relief.
1. Avoid narcotic analgesics.
2. Acetaminophen is frequently used.
3. Maintain quiet, dim atmosphere.
4. Avoid sudden movements.
O. Prevent complications of immobility.
P. Maintain seizure precautions.

Home Care
A. Teach client and family signs of increased ICP.
B. Call the doctor if any of the following are observed:
1. Changes in vision.
2. Increased drainage from incision area or clear drainage in the ears.
3. Abrupt changes in sleeping patterns or irritability.
4. Headache that does not respond to medication.
5. Change in coordination, disorientation.
6. Slurred speech, unusual behavior.
7. Seizure activity, vomiting.
C. Review care of surgical incision, wounds or drains.

HEAD INJURY

A. Classification.
1. Penetrating head injury: dura is pierced, as in stabbing or shooting.
2. Closed or blunt head injury: head is either drastically accelerated (whiplash)
or decelerated (collision); most common head injury in civilian life.
B. Children and infants are more capable of absorbing direct impact because of
the pliability of the skull.
C. Coup-countrecoup injury. Damage to the site of impact (coup) and damage on
the side opposite the site of impact (contrecoup) when brain bounces freely
inside skull.
D. Primary injury to the brain occurs by compression and/or tearing and
shearing stresses on vessels and nerves.
E. Although brain volume remains unchanged, secondary injury occurs from the
cerebral edema in response to the primary injury and frequently precipitate in
increase in ICP.
F. Types of Head Injuries.
1. CONCUSSION: Temporary interference in brain function; may affect
memory, speech, reflexes, balance, and coordination.
a. Only small number of victims actually black out.
b. Usually from blunt trauma including contact sports.
c. Usually does not cause permanent damage.
d. Transient, self-limiting.
2. CONTUSION (a bruise on the brain).
a. Multiple areas of petechial hemorrhages.
b. Headache, pupillary changes, dizziness, unilateral weakness.
c. Blood supply is altered in the area of injury; swelling, ischemia, and increased
ICP.
d. May last several hours to weeks.
3. INTRACRANIAL HEMORRHAGE:
a. Epidural (extradural) hematoma: a large vessel (generally an artery) in
the dura mater is damaged; a hematoma rapidly forms between the dura and
the skull, precipitating an increase in ICP.
(1) Momentary loss of consciousness, then free of symptoms (lucid period),
and then lethargy and coma seldom evident in children.

36

www.nurseslabs.com
37

(2) Symptoms of increasing ICP may develop within minutes after the lucid
interval.
b. Subdural hematoma: a collection of blood between the dura and arachnoid
area filling the brain vault; *usually the result of serious head injury.
(1) May be acute (manifesting in less than 24 hours) or chronic
(developing over days to weeks).
(2) When neurologic compromise presents, subdural hematoma becomes an
emergent event. Emergency neurosurgery may be required to relieve
pressure.

Data Collection
A. Clinical Manifestations.
1. Epidural hematoma: decreased GCS, pupillary changes, unilateral
weakness.
2. Subdural hematoma: headache, changes in LOC, numbness, headache,
slurred speech, or inability to speak.
B. Diagnostics

Complications
Complications include residual increased ICP, meningitis, diabetes insipidus,
seizures, and permanent neurologic compromise.

Treatment

NURSING PRIORITY: The primary treatment

objectives for the client with a head injury are to maintain a
patent airway, to prevent hypoxia and acidosis, and to identify the
occurrence of increased ICP.

A. The majority of clients who experience concussion are treated at home.

B. A period of unconsciousness or presence of seizures is considered a serious
indication of injury.
C. Surgical Intervention.
1. Burr holes to evacuate the hematoma.
2. Craniotomy/craniectomy.

Nursing Interventions

Goal: To provide instruction for care of the client in the home

environment.

DISCHARGE INSTRUCTIONS FOR

CLIENTS WITH HEAD INJURY

Arouse the client every 3 to 4 hours for

the first 24 hours.
Anticipate complaints of dizziness,
headaches.
Do not allow client to blow his nose; try to
prevent sneezing.
No alcohol or sedatives for sleep.
Acetaminophen for headaches.
No exercising over next 2 to 3 days.

Call the doctor if any of the following

is noted:
Change in vision: Blurred or diplopia.
Poor coordination: Walking, grasping.
Drainage (serous or bloody) from the nose
or ears.
Forceful vomiting.
Increasing sleepiness, more difficult to

37

www.nurseslabs.com
38

arouse.
Slurred speech.
Headache that does not respond to
medication and continues to get worse.
Occurrence of a seizure.

A. Problems frequently do not occur until 24 hours or more after the initial
injury.
B. Observe the client for increased periods of sleep; if client is asleep,
awaken every 3 to 4 hours to determine whether client can be aroused
normally.
C. Maintain contact with physician for reevaluation if complications occur.
D. Health care provider should be notified when any of the following are
observed:
1. Any changes in level of consciousness (increased drowsiness, confusion).
2. Inability to arouse client, seizures.
3. Bleeding or watery drainage from the ears or nose.
4. Loss of feeling or sensation in any extremity.
5. Blurred vision, slurred speech, vomiting.

NURSING PRIORITY: Written and oral

instructions should be given to the client
and to the family. Increased anxiety may
affect comprehension of oral directions

Goal: To maintain homeostasis and to monitor and identify early

symptoms of increased ICP.
A. Bed rest and clear liquids initially.
B. Frequent neurologic checks for increased ICP.
1. Change or decrease in level of consciousness is frequently the first indication.
2. Instruct the clients with head injury not to cough, sneeze, or blow nose.
C. Notify the PCP of any drainage from nose, ears, and mouth.
1. Do not clean out the ears: place loose cotton in the auditory canal and
changed when soiled.
2. Check continuous clear drainage from the nose with DEXTROSTIX; if glucose
is present, it is indicative of CSF leak, spinal fluid also dries with a yellow halo
around edges of drainage.
3. If a CSF leak occurs, keep the head of the bed elevated and monitor for
development of an infection (meningitis).
D. Seizure precautions
E. Maintain adequate fluid intake by IV infusion or oral intake; do not
overhydrate.
F. Assess for other undetected injuries; stabilized spine after head injury until
spinal cord injury is ruled out.

Goal: To provide appropriate nursing interventions for the client

experiencing an increase in ICP

Goal: To provide adequate nutritional and caloric intake for the client with
a head injury.
A. Provide enteral feedings if client is unable to eat.
B. Assist client to take oral feedings once swallow reflex is normal; client is at
increased risk for aspiration.

HYDROCEPHALUS
* Hydrocephalus is a condition caused by an imbalance in the
production and absorption of CSF in the ventricles of the brain.

Data Collection

38

www.nurseslabs.com
39

A. Risk factors/etiology.
1. Neonate: usually the result of a congenital malformation.
2. Older child, adult.
a. Space-occupying lesion.
b. Preexisting developmental defects.
B. Clinical manifestations: infant.
1. Head enlargement: increasing circumference in excess of normal 2 cm per
month for first 3 months.
2. Separation of cranial suture lines.
3. Fontanel becomes tense and bulging.
4. Dilated scalp veins.
5. Frontal enlargement, bulging sunset eyes.
6. Symptoms of increasing ICP.
C. Clinical manifestations: older child, adult.
1. Symptoms of increasing ICP.
2. Specific manifestations related to site of the lesion.
D. Diagnostics
1. Increasing head circumference is diagnostic in infants.

Treatment
A. Ventriculoperitoneal shunt; CSF is shunted into the peritoneum.
B. Surgery: removal of the obstruction (cyst, hematoma, tumor).
Nursing Interventions

Goal: To monitor for the development of increasing ICP.

A. Daily measurement of the frontal-occipital circumference of the

head in infants.

B. Assess for symptoms of increasing ICP.

C. Infants is often difficult to feed; administer small feedings at
frequent intervals because vomiting may be a problem.

Goal: To maintain patency of the shunt and monitor ICP after

shunt procedure.
A. Position supine, with head turned opposite side up to prevent
pressure on the shunt valve and to prevent too-rapid depletion of
CSF. B. Position is not a problem with
children who are having a shunt revision; they have not had an
increase in ventricular pressure.
C. Monitor for increasing ICP and notify a charge nurse.
D. Monitor for infection, especially meningitis or encephalitis.

Home Care
A. Teach parents symptoms of increasing ICP.
B. Have parents participate in care of the shunt before clients discharge.
C. Encourage parents and family to ventilate feelings regarding clients condition.
D. Refer client to appropriate community agencies.

REYES SYNDROME
* Reyes Syndrome is a rare acute illness that occurs after a viral
illness (frequently, after aspirin has been consumed) and results in liver
problems and increased intracranial pressure.

Data Collection

A. Clinical manifestations.

1. Primarily affects children from the age of 6 months to adolescence.

2. Frequently, the affected child has received salicylate (aspirin) for control of fever
during the preceding viral infection.

39

www.nurseslabs.com
40

3. Severe persistent vomiting, lethargy leading to irritability, and Increase ICP.

Treatment

A. Measures to decrease ICP.

Nursing Interventions

Goal: To monitor progress of disease state and maintain homeostasis.

A. IV fluids.

B. Monitor serum electrolytes and liver function studies.

C. Maintain respiratory status; prevent hypoxia.

D. Assess for problems of impaired coagulation due to liver problems.

E. Decrease stress, anxiety: child may not remember events before the critical
phase.

Goal: To monitor for and implement nursing actions appropriate for increasing
ICP.

STROKE (Brain Attack)

* Stroke or brain attack is the disruption of the blood supply to an
area of the brain, resulting in tissue necrosis and sudden loss of brain
function. It is the leading cause of adult disability in the United States.

A. Atherosclerosis, resulting in cerebrovascular disease, frequently precedes the

development of a stroke.

B. Types of stroke.

1. Ischemic stroke.
a. Thrombotic Stroke: formation of a clot that results in the narrowing of a vessel
lumen and eventual occlusion; most common stroke.
(1) Associated with hypertension and diabetes.
(2) Produces ischemia of the cerebral tissue.
b. Embolic Stroke: occlusion of a cerebral artery by an embolus.
(1) Common site of origin is the endocardium.
(2) May affect any age group

2. Hemorrhagic Stroke:
a. Rupture of cerebral artery caused by hypertension, trauma, or aneurysm.
b. Bleeding compresses the brain and causes inflammation.
c. The areas of edema resulting from tissue damage may precipitate more damage
than the vascular damage itself.

D. TIA and Reversible ischemic neurologic deficit (RIND)

1. Transient Ischemic Attack (TIA, silent stroke).
a. Brief episode, less than 24 hours, of neurologic dysfunction; usually resolves
within 30-60 minutes.
b. Should be considered a warning sign of an impending stroke.
c. Neurologic dysfunction is present for minutes to hours, but no permanent
neurologic deficit remains.
2. Reversible Ischemic Neurologic Deficit (RIND).
a. Symptoms similar to TIA.
b. Neurologic symptoms last longer than 24 hours, but less than a week.
3. Stroke: Client has neurologic deficits related to mobility, sensation and cognition.

E. Neuromuscular deficits resulting from a stroke are due to damage of motor

neurons of the pyramidal tract.
1. Damage to the left side of the brain will result in paralysis of the right side of the
body.
40

www.nurseslabs.com
41

FIGURE15-4 Manifestations of right-brain and left-brain stroke.

2. Both upper and lower extremities of the involved side are affected.

Data Collection
A. Clinical manifestations.
1. Transient ischemic attack (TIA) and reversible ischemic neurologic deficit (RIND).
a. Visual defects: blurred vision, diplopia, blindness of one eye, tunnel vision.
b. Transient hemiparesis, gait problems.
c. Slurred speech, confusion.
d. Transient numbness of an extremity.
2. Complete stroke (occurs suddenly with an embolism, more gradually with
hemorrhage or thrombosis); symptoms vary according to which cerebral vessels are
involved.
a. Hemiplegia: loss of voluntary movement; damage to the right side of the brain
will result in left-sided weakness and paralysis.
b. Aphasia: defect in using and interpreting the symbols of language; may include
written, printed, or spoken words.
c. May be unaware of the affected side; neglect syndrome.
d. Cranial nerve impairment: chewing, gag reflex, dysphagia, impaired tongue
movement.
e. May be incontinent initially.
f. Agnosia: a perceptual defect that causes a disturbance in interpreting sensory
information; client may not be able to recognize previously familiar objects.
g. Cognitive impairment of memory, judgement, proprioception (awareness of ones
body position).
h. Hypotonia (flaccidity) for days to weeks, followed by hypertonia
(spasticity).
i. Visual defects.
B. Diagnostics

Treatment
A. Prophylactic.
1. Aspirin, platelet inhibitors.
2. Antihypertensives, anticoagulants.
B. Immediate treatment (differs depending on whether thrombotic or hemorrhagic
stroke).
1. Medical.
a. Medications to decrease cerebral edema.
(1) Osmotic diuretics.
(2) Corticosteroids (dexamethasone).
b. Anticoagulants for thrombotic stroke (**never administered to a client with
hemorrhagic stroke).
c. Anticonvulsants.
d. Thrombolytic therapy or fibrinolytic therapy (such as recombinant tissue

41

www.nurseslabs.com
42

plasminogen activator (rtPA [Retavase]) considered for non-hemorrhagic strokes

within 3 hours of first manifestation of stroke signs.
e. Antihypertensives and antidysrhythmics.
2. Surgical
a. Carotid endarterectomy, especially for transient ischemic attack.
b. Craniotomy for evacuation of hematoma.
c. Extracranial-intracranial bypass for mild strokes.

C. Specific therapies to resolve physical, speech or occupational complications,

including use of assistive devices.

Nursing Interventions

Goal: To prevent stroke through client education.

A. Identification of individuals with reversible risk factors and measures to reduce

them.

B. Appropriate medical attention for control of chronic conditions conducive to the

development of stroke.

C. Teach high risk clients early signs of TIA and RIND and to seek medical attention
immediately if they occur.

Goal: To maintain patent airway and adequate cerebral oxygenation.

A. Place client in side-lying position with head elevated.

B. Assess for symptoms of hypoxia; administer oxygen or assist with endotracheal

intubation and mechanical ventilation as necessary.

C. Maintain patent airway; use oropharyngeal airway to prevent airway obstruction

by the tongue.

RISK FACTORS ASSOCIATED WITH STROKE

Modifiable

Smoking

Obesity

Increased salt intake

Sedentary lifestyle

Increased stress

Oral contraceptives

Partially Modifiable

Hypertension

42

www.nurseslabs.com
43

Cardiac Valve disease

Dysrhythmias

Diabetes mellitus

Hypercholesterolemia

Nonmodifiable

Sex: Increased incidence in men

Age

Race: Increased incidence in the African-

American population

Hereditary predisposition

D. Client is prone to obstructed airway and pulmonary infection; have client cough
and deep breath every 2 hours.

Goal: To assess for and implement measures to decrease ICP.

Goal: To maintain adequate nutritional intake.

A. Before oral feedings, evaluate need for swallow studies.

B. Administer oral feedings with caution; start after first 24 hours; check for
presence of gag and swallowing reflexes before feeding.

C. Place food on the unaffected side of the mouth; begin with clear foods (gelatins).

D. Select foods that are easy to control in the mouth (thick liquids) and easy to
swallow; liquids often promote coughing, because client is unable to control them.

E. Maintain high-Fowlers position for feeding.

F. Maintain privacy and unrushed atmosphere.

G. If client is unable to tolerate oral intake, enteral feeding may be initiated.

TEST ALERT: Identify potential for aspiration;

assess clients ability to eat.

Goal: To preserve function of the musculoskeletal system.

A. Passive range of motion (ROM) on affected side; begin early because the
exercise are more difficult if muscles begin to tighten.

B. Active ROM on unaffected side.

43

www.nurseslabs.com
44

C. Prevent foot drop: passive exercises; rigid boots; have client out of bed as soon
as possible.

D. Legs should be maintained in a neutral position; prevent external rotation of

affected hip by placing a trochanter roll or rolled pillow at the thigh***

E. Reposition every 2 hours, but limit the period of time spent on the affected side.

NURSING PRIORITY:

Protect the clients affected side: do not give

injections on that side, watch for pressure areas
when positioning

F. Assess for adduction and internal rotation of the affected arm; maintain arm in a
neutral (slightly flexed) position with each joint slightly higher than the preceding
one.

G. Restrain should be avoided because they often increase agitation.

H. Maintain joints in position of normal function to prevent flexion contractures.

I. Assist client out of bed on the unaffected side; this allows client to provide some
stabilization and balance with the good side.

TEST ALERT: Mobility: Assist client to

ambulate, perform active and passive ROM
exercises, assess for complications of
immobility, prevent DVT, prevent skin
breakdown and encourage independence.

Goal: To maintain homeostasis.

A. Evaluate adequacy of cardiac output.

B. Monitor hydration status: prevent fluid overload.

1. Carefully regulate IV fluid intake.

2. Evaluate response to diuretics.

3. Assess for the development of peripheral edema.

4. Restrict fluid intake, as indicated.

5. Assess respiratory parameters indicative of fluid overload.

6. Monitor daily weight.

C. Determine previous bowel patterns and promote normal elimination.

44

www.nurseslabs.com
45

1. Avoid use of urinary catheter, if possible; if catheter is necessary, remove as soon

as possible.

2. Offer bedpan or urinal every 2 hours; help establish a schedule.

3. Prevent constipation: provide increased bulk in diet, stool softeners, etc.

4. Provide privacy and decrease emotional trauma related to incontinence.

TEST ALERT: Assess and manage a client with

an alteration in elimination. Establish a toileting
schedule; the client who has had a stroke will
need assistance in reestablishing a normal
bowel and bladder routine.

D. Prevent problems of skin breakdown through proper positioning and

good skin hygiene.

E. Assist client to identify problems of vision.

F. Maintain psychologic homeostasis.

1. Client may be very anxious because of a lack of understanding of what has

happened and because of his or her inability to communicate.

2. Speak slowly and clearly and explain what has happened.

3. Assess clients communication abilities and identify methods to promote

communication.

Home Care

A. Encourage independence in ADLs.

B. Provide clothing that is easy to get in and out of.

C. Active participation in ROM; have client do his or her own ROM on affected side.

D. Physical, occupational, and speech therapy for retraining of lost function.

E. Assist client to maintain sense of balance when in the sitting position; client will
frequently fall to the affected side (unilateral neglect syndrome).

F. Encourage participation in carrying out daily personal hygiene.

G. Teach client safe transfer from bed to wheelchair and provide assistance as
needed.

H. Bowel and bladder training program.

1. To promote bladder tone. Encourage urination (with or without assistance)

every 2 hours rather than allowing the client to void when he or she feels the urge.

2. Teach client to perform Kegels exercises regularly.

3. Advise client to avoid caffeine intake.

4. Increased bulk in diet will help avoid constipation.

45

www.nurseslabs.com
46

5. Increased fluids to 2000mL per day as tolerated.

6. Administer stool softener PRN.

7. Establish regular daily time for bowel movements.

I. Encourage social interaction.

1. Speech therapy.

2. Frequent and meaningful verbal stimuli.

3. Allow client plenty of time to respond.

4. Speak slowly and clearly; do not give too many directions at one time. Use
short sentences.

5. Do not talk down to client or treat client as a child (elder speak).

6. Clients mental status may be normal; do not assume it is impaired.

7. Nonverbal clients do not lose their hearing ability.

J. Evaluate family support and the need for home health services.

NURSING PRIORITY: Assist family to manage

care of a client with long-term care needs;
determine needs of family regarding ability to
provide homecare after discharge.

Cerebral Aneurysm, Subarachnoid Hemorrhage

* A cerebral aneurysm occurs when a weakened saccular outpouching of the

cerebral vasculature bulges from pressure on the weakened tissue. A Berry
aneurysm is a cerebral aneurysm occurring in the arterial junction of the
circle of Willis. A ruptured cerebral aneurysm often results in hemorrhagic
stroke.

A. A subarachnoid hemorrhage is a potentially fatal condition in which blood

accumulates below the arachnoid mater in the subarachnoid space; most often
occurs secondary to an aneurysm.

B. An aneurysm frequently ruptures and bleeds into the subarachnoid space.

C. Symptoms occur when an aneurysm enlarges, or when it ruptures. As blood

collects in the subarachnoid space, it compresses and damages the surrounding brain
tissue.

D. Subarachnoid hemorrhage may lead to neurologic compromise including seizures,

stroke, permanent brain damage, and even death.

E. Often, symptoms do not appear until rupture has occurred.

Data Collection

A. Clinical Manifestations.

46

www.nurseslabs.com
47

1. Rupture may be preceded by severe headache and nausea.

2. Rupture frequently occurs without warning.

a. Sudden severe headache; seizures.

b. Nuchal rigidity, hemiparesis.

c. Loss of consciousness.

d. Symptoms of increasing ICP: nausea, vomiting, photophobia.

3. Severity of symptoms depends on the site and amount of bleeding.

B. Diagnostics

Treatment

A. Aminocaproic acid: inhibits fibrinolysis in life threatening situations.

B. Osmotic diuretics, anticonvulsants.

C. Corticosteroids.

D. Calcium channel blockers: minimize vasospasm after hemorrhage.

E. Surgical intervention: ligation or clipping of the aneurysm to reduce the

swelling and minimize the risk for re-bleeding.

Nursing Interventions

Goal: To prevent further increase in ICP and possible rupture.

A. Immediate bed rest; bathroom privileges may be permitted.

B. Prevent Valsalva maneuver.

C. Client should avoid straining, sneezing, pulling up in bed, and acute flexion of the
neck.

D. Elevate head of the bed 30 degrees to 45 degrees to promote venous return.

E. Quiet, dim, nonstimulating environment: disconnect telephone; promote

relaxation.

F. Constant monitoring of condition to identify occurrence of bleeding, as evidenced

by symptoms of increasing ICP.

G. Administer analgesics cautiously; the client should continue to be easily aroused

so that neurologic checks can be performed.

H. No hot or cold beverages or food, no caffeine, no smoking.

I. Maintain seizure precautions.

47

www.nurseslabs.com
48

NURSING PRIORITY: If the client

survives the rupture of the aneurysm and
re-bleeding occurs, it is most likely to
occur within the next 24 to 48 hours.

Goal: To assess for and implement nursing measures to decrease ICP. (see
nursing goals for increased ICP).
Goal: To provide appropriate preoperative nursing interventions. (see nursing
goals for brain tumor).

Goal: To maintain homeostasis and monitor changes in ICP after craniotomy.

(see nursing goals for craniotomy).

Meningitis

* Meningitis is an acute viral or bacterial infection that causes

inflammation of the meningeal tissue covering the brain and spinal cord.
Bacterial meningitis is less common but more severe than viral meningitis.
Meningococcal meningitis is the only form that is readily contagious;
transmitted by direct contact with droplets from the airway of an infected
person.

Data Collection

A. Clinical Manifestations: older child and adult.

1. Rash, petechiae, purpura.

2. Nuchal rigidity.

3. Chills and high fever.

4. Severe and persistent headache.

5. Increasing irritability, malaise, changes in level of consciousness.

6. Respiratory distress.

7. Generalized seizures

8. Nausea and vomiting

9. Positive Kernig sign: resistance or pain at the knee and the hamstring muscles
when client attempts to extend the leg after thigh flexion.

10. Positive Brudzinski sign: reflex flexion of the hips when the neck is flexed.

11. Photophobia.

48

www.nurseslabs.com
49

C. Clinical Manifestations: neonate and infant

1. Fever.

2. Apneic episodes.

3. Bulging fontanel.

4. Seizures.

5. Crying with position change.

6. Opisthotonos positioning: a dorsal arched position.

7. Changes in sleep pattern, increasing irritability.

8. Poor sucking; may refuse feedings.

9. Poor muscle tone, diminished movement.

10. Irritability

D. Diagnostics

1. Lumbar puncture reveals increasing CSF pressure; if ICP is

present, a CT scan may be done prior to procedure.

2. Elevated WBCs.

3. CSF and blood culture positive for meningococcus bacteria.

Treatment

A. Droplet precautions until positive organism is identified.

B. IV antibiotics, steroids.

C. Optimum hydration.

D. Anticonvulsants medications.

E. Antivirals.

F. Maintain ventilation.

Complications

A. Increasing ICP resulting in permanent brain damage.

B. Visual and hearing deficits, paralysis.

C. Subdural effusion; may be aspirated or allowed to absorb when

meningitis treatment is started and protein leak stops.

49

www.nurseslabs.com
50

Nursing Interventions

Goal: To Identify the causative organism, control spread, and

initiate therapy.

A. Maintain respiratory droplet precautions until organism is identified;

place client in a private room.

B. Begin administration of IV antibiotics after lumbar puncture during

which CSF sample was obtained.

C. Identify family members and close contacts who may requires

prophylactic treatment.

Goal: To monitor course of infection and prevent complications.

A. Frequent nursing assessment for increased ICP

B. Maintain adequate hydration; cerebral edema may requiring

limiting fluid intake.

C. Monitor infusion site for complications of IV piggyback

antibiotics.

D. Assess for side effects of high dosage of antibiotics.

E. Decrease stimuli in environment: dim lights, quiet environment,

no loud noises.

F. Avoid movement or positioning that increases discomfort; client

generally assumes a side-lying position.

G. Seizure precautions.

H. Prevent complications of immobility.

I. Good respiratory hygiene.

J. Measures to decease fever.

Encephalitis

***Encephalitis is an inflammatory process of the CNS,

or inflammation of the brain.

Data Collection

A. Clinical Manifestations.

1. Severe headache, nuchal rigidity.

50

www.nurseslabs.com
51

2. Sudden fever.

3. Seizures, Irritability.

4. Changes in level of consciousness.

5. Motor involvement: ataxia, dyspnea, tremor, convulsions.

6. Drowsiness, confusion, disorientation.

7. Bulging, fontanels in infants.

B. Diagnostics.

1. Examination of the CSF.

2. Viral studies to isolate the virus.

3. EEG for seizure activity.

4. Blood test for West Nile virus.

Treatment

A. Anticonvulsants.

B. Treatment to decrease ICP.

C. Hydration, bed rest, proper nutrition.

Nursing Interventions

Nursing interventions for encephalitis are the same as those for

meningitis, with the exception of antibiotic therapy. Encephalitis
is caused by a viral agent and is not responsive to antibiotic therapy;
antibiotic therapy may be ordered to prevent bacterial infection.

Goal: To Identify the causative organism, control spread, and

initiate therapy.

A. Maintain respiratory droplet precautions until organism is identified;

place client in a private room.

B. Begin administration of IV antibiotics after lumbar puncture during

which CSF sample was obtained.

C. Identify family members and close contacts who may requires

prophylactic treatment.

51

www.nurseslabs.com
52

Goal: To monitor course of infection and prevent complications.

A. Frequent nursing assessment for increased ICP

B. Maintain adequate hydration; cerebral edema may requiring

limiting fluid intake.

C. Monitor infusion site for complications of IV piggyback

antibiotics.

D. Assess for side effects of high dosage of antibiotics.

E. Decrease stimuli in environment: dim lights, quiet environment,

no loud noises.

F. Avoid movement or positioning that increases discomfort; client

generally assumes a side-lying position.

G. Seizure precautions.

H. Prevent complications of immobility.

I. Good respiratory hygiene.

J. Measures to decease fever.

NURSING PRIORITY:
Identify changes in clients
mental status; treat client
with seizures.

Spinal Cord Injury

*** Spinal cord injury (SCI) is damage to the spinal cord

housed inside the spinal column. Most SCIs exist with the
spinal cord intact yet compromised from injury or disease. SCI
most often occurs as a result of direct trauma to the head or
neck area.

A. Initially after the injury, the nerve fibers swell, and circulating to the
spinal cord is decreased; hemorrhage and edema occurs, causing an
increase in the ischemic process, which progresses to necrotic
destruction of the spinal cord.

B. Consequences of SCI depend on the external damage, as well as

the level of cord injury.

52

www.nurseslabs.com
53

1. The higher the lesion, the more severe the injury.

2. Complete transection (complete cord dissolution, complete lesion):

immediate loss of all sensation and voluntary movement below the
level of injury; minimal if any, return of function.

3. Cord edema peaks in about 2 to 3 days and subsides within about 7

days after the injury.

C. Spinal cord shock (areflexia): temporary loss or dysfunction of

spinal reflex activity; occurs predominantly in complete cord lesions;
loss of communication with the higher centers of control results in
flaccidity and loss of functional control below the level of injury.

1. Interruption of nerve impulses leads to vasodilation, hypotension,

and shock-like symptoms.

2. Condition may persist for several weeks and reverse spontaneously;

resolution of spinal shock will be evident by return of reflexes.

3. Hyperreflexia will occur as recovery progresses; spastic

movements may be precipitated by emotion and cutaneous
stimulation.

D. Autonomic dysreflexia occurs in clients with an injury at T6 or

higher.

1. A noxious stimulus below the level of injury triggers the

sympathetic nervous system, which causes a release of
catecholamines (epinephrine, norepinephrine).

2. Most common stimuli causing the response are a full bladder or

bowel, UTI, pressure ulcers, and skin stimulatin.

53

www.nurseslabs.com
54

3. Rapidly occurring severe hypertension, nausea, pounding headache,

restlessness, flushing piloerection, and blurred vision are the most
common body responses.

E. Bladder dysfunction will occur as a result of the injury; normal

bladder control is dependent on the sensory and motor pathways and
the lower motor neurons being intact.

F. Long-term rehabilitation potential depends on the amount of

damage done to the cord, which may not be evident until several
weeks after the injury.

Data Collection

A. Clinical Manifestations: depend on level of SCI.

1. Injury at C3 through C5 will cause respiratory compromise.

2. Depending on degree of injury, the degree of paralysis and amount

of sensory loss below the level of injury will vary.

3. Spinal shock.

a. Generally occurs within 72 hours and may last for several weeks.

b. Flaccid paralysis.

c. Loss of sensation and absence of reflexes.

d. Bowel and bladder dysfunction.

e. Hypotension and bradycardia.

f. After spinal shock, reflexes and autonomic activity return, as

evidenced by development of spasticity.

4. Autonomic dysreflexia in clients with injuries at T6 or higher.

a. Severe hypertension, bradycardia.

b. Complaints of headache.

c. Flushing and diaphoresis above level of injury.

B. Diagnostics

C. Complications.

1. Respiratory stasis; pulmonary edema and emboli.

54

www.nurseslabs.com
55

2. Cardiovascular compromise from neurogenic shock, or autonomic

dysreflexia.

3. Skin breakdown resulting in localized and systemic infections.

4. Immobility issues causing renal and gastrointestinal compromise.

5. Psychologic, social, and body image issues.

Treatment

A. Emergency interventions required.

B. Corticosteroids within 8 hours of injury (methylprednisolone).

C. Immobilization of the vertebral column in cervical fracture.

1. Cervical tongs (Crutchfield, Gardner-Wells) for cervical

immobility.

2. Halo vest/jacket traction to promote mobility.

3. Sterno-occipital mandibular immobilizer (SOMI) brace worn

with cervical fusion.

D. Spinal surgery to remove bone fragments and assure spinal

alignment.

E. Respiratory support as necessary.

Nursing Interventions

Goal: To maintain stability of the vertebral column and prevent

further cord damage.

A. Emergency care and treatment.

1. Suspects SCI if there is any evidence of direct trauma to the head

or neck area (contact sports, diving accidents, motor vehicle
accidents).

2. Immobilize client and place on spinal board with the head and
neck in a neutral position; do not allow the neck to flex.

3. Airway, status of breathing and circulation are the primary

concerns initially after injury.

4. Neurogenic shock may occur within first 24 hours, observe for

decreased B/P, severe bradycardia.

NURSING PRIORITY: Do not

hyperextend the neck in a client with a
suspected cervical injury. Airway
should be opened by the jaw-lift method.
Improper handling of the client often
55

www.nurseslabs.com
56

results in extension of the damaged

area.

5. Maintain in extended position with no twisting or turning; do not

remove cervical collar or spinal board until area of injury is identified.

6. Maintain patent airway during transportation.

B. Maintain stability of the vertebral column as indicated by

the level of injury.

1. Prescribe and maintain bed rest on firm mattress with

supportive devices (sandbags, skin traction, etc.); maintain
alignment in the supine position; logroll without any flexion or
twisting.

2. Maintain cervical traction: tongs are inserted into the skull with
traction and weights applied; do not remove weights; logroll to
maintain spinal immobility.

3. Halo vest/jacket traction: maintain cervical immobility but allows

client to be mobile.

a. If bolts or screws come loose, keep the client immobilized and

call the doctor.

b. Clean pin sites according to facility policy, observe for infection.

c. Roll client onto his or her side at the edge of the bed and allow
client to push up from the mattress to a sitting position. Never use the
halo vest frame to assist the client to turn or sit up.

d. Correct size of wrench should be kept at bedside to remove the

anterior bolts in case of emergency.

e. Assist client to maintain balance when standing; the traction is

heavy for a person who is weak, and the client is at increased risk for
falling.

4. Maintain extremities in neutral and functional position.

TEST ALERT: Apply, maintain, or

remove orthopedic devices (e.g.
traction, splints, braces, casts).

C. Perform appropriate nursing intervention when surgery is

indicated to stabilize the injury.

Goal: To identify level of damage and changes in neurologic

status.

56

www.nurseslabs.com
57

A. Assess respiratory function: symmetrical chest expansion,

bilateral breath sounds, presence of retractions or dyspnea.

B. Motor and sensory evaluation.

1. Ability to move extremities; strength of extremities.

2. Sensory examination, including touch and pain.

3. Presence of deep tendon reflex.

C. Ongoing assessment and status of:

1. Bladder, gastric, bowel function.

2. Psychologic adjustment to the injury.

D. Evaluate history of how injury occurred; obtain information

regarding how client was transported.

E. Determine status of pain.

Goal: To maintain respiratory function.

A. Frequent assessment of respiratory function during the first

48 hours.

1. Changes in breathing pattern.

2. Observe breathing pattern for use of sternocleidomastoid and

intercostal muscles for respiration.

3. Evaluate arterial blood gas values and pulse oximetry.

4. Determine development of hypoxia.

B. Maintain respiratory function, as indicated.

1. Chest physiotherapy.

2. Incentive spirometry.

3. Changing position within limits of injury.

4. Assess for complications of atelectasis, pulmonary emboli, and

pneumonia.

5. Nasopharyngeal or endotracheal suctioning based on airway and

level of injury.

Goal: To maintain cardiovascular stability.

A. Spinal shock.

1. Monitor vital signs and evaluate changes.

57

www.nurseslabs.com
58

2. Vagal stimulation, hypothermia, and hypoxia may precipitate

spinal shock.

3. Assess deep tendon reflexes and muscle strength as resolution of

shock occurs.

B. Assess for development of autonomic dysreflexia; if it

occurs:

1. Elevate the head of the bed, and check the clients blood
pressure.

2. Assess for sources of stimuli: distended bladder (check urinary

tubing), fecal impaction, constipation, tight clothing.

3. Relieve the stimuli, and dysreflexia will subside.

4. Maintain cardiovascular support during period of hypertension.

5. A hypertensive crisis from dysreflexia will require immediate

intervention.

C. Evaluate cardiovascular responses when turning or suctioning client.

D. Apply anti-embolism stockings or elastic wraps to the legs

to facilitate venous return. (Lack of muscle tone and loss of
sympathetic tone in the peripheral vessels result in decrease in both
venous tone and venous return, which predispose client to deep vein
thrombosis.)

E. Implement measures to promote venous return.

TEST ALERT: Prevent complications of

immobility; prevent venous stasis: identify
symptoms of deep venous thrombosis,
apply compression stockings, and change
clients position.

Goal: To maintain adequate fluid and nutritional status.

A. During the first 48 hours, evaluate gastrointestinal function

frequently; decrease in function may necessitate use of a nasogastric
tube to decrease distention.

B. Prevent complications of nausea and vomiting.

C. Evaluate bowel sounds and clients ability to tolerate oral fluids.

D. Increase protein and calories in diet; may need to decrease

calcium intake.

E. Evaluate for presence of paralytic ileus.

F. Increase roughage in diet to promote bowel function.

58

www.nurseslabs.com
59

Goal: To prevent complications of immobility

Goal: To promote bowel and bladder function.

A. Urine is retained as a result of the loss of autonomic and

reflexive control of the bladder.

1. Intermittent catheterization or indwelling catheter may be

used initially to prevent bladder distention.

2. Perform nursing intervention to prevent urinary tract infection;

avoid urinary catheterization, if possible.

B. Determine type of bladder dysfunction based on level of

injury.

C. Assess clients awareness of bladder function.

D. Initiate measures to institute bladder control.

1. Establish a schedule for voiding; have client attempt to void

every 2 hours.

2. Use the Crede method (in adults) for manual expression of urine.

3. May be necessary to teach client self-catheterization.

4. Record output and evaluate for presence of residual urine.

E. Evaluate bowel functioning.

1. Incontinence and paralytic ileus frequently occur with spinal

shock.

2. Incontinence and impaction are common later.

F. Initiate measures to promote bowel control (after spinal

shock is resolved).

1. Identify clients bowel habits before injury.

2. Maintain sufficient fluid intake and adequate bulk in the diet.

3. Establish specific time each day for bowel evacuation.

4. Assess clients awareness of need to defecate.

5. Teach client effective of the Valsalva maneuver to induce

defecation.

6. Induce defecation by digital stimulation, suppository, or as a last

resort, enema.

NURSING PRIORITY: Assess and

manage

59

www.nurseslabs.com
60

a client with alteration in elimination; initiate

a toileting schedule; the client wit SCI may
need bowel and bladder retraining,
depending on level of the injury.

Goal: To maintain psychologic equilibrium.

A. Provide simple explanation of all procedures.

B. Anticipate outbursts of anger and hostility as client begins to work

through the grieving process and adjusts to changes in body image.

C. Anticipate and accept periods of depression in client.

D. Encourage independence in whenever possible; allow client to

participate in decisions regarding care and to gain control over
environment.

TEST ALERT: Plan measures to deal with

clients anxiety and promote clients
adjustment to changes in body image; assist
client and significant others to adjust to role
changes.

E. Encourage family involvement in identifying appropriate diversional

activities.

F. Avoid sympathy and emphasize clients potential.

G. Initiate frank, open discussion regarding sexual functioning.

H. Assist client and family to identify community resources.

I. Assist client to set realistic short-term goals.

Myasthenia Gravis

*** Myasthenia gravis is a sporadic, progressive

neuromuscular disease characterized by a decrease in the
acethylcholine level at the receptor sites in the neuromuscular
junction. This results in a disturbance in nerve impulse
transmission, causing progressive weakness in skeletal
muscles. Myasthenia gravis literally means grave muscle
weakness.

Data Collection

A. Risk Factors/Etiology.

60

www.nurseslabs.com
61

1. Autoimmune disease.

2. More common in women younger than 40 and men older

than 60 but may occur at any age.

B. Clinical Manifestations.

1. Primary problem is skeletal muscle fatigue with sustained muscle

contraction; symptoms are predominantly bilateral.

a. Muscular fatigue increases with activity.

b. Ptosis (drooping of the eyelids) and diplopia (double vision)

are frequently the first symptoms.

c. Impairment of facial mobility and expression.

d. Impairment of chewing and swallowing.

e. Speech impairment (dysarthria).

f. No sensory deficit, loss of reflexes, or muscular atrophy.

g. Poor bowel and bladder control.

2. Course is variable.

a. May be progressive.

b. May stabilize.

c. May be characterized by short remissions and exacerbations.

**3. Myasthenic crisis: an acute exacerbation of symptoms that

may require intubation and mechanical ventilation to support
respiratory effort; caused by major muscular weakness and inability to
maintain respiratory function.

a. Severe respiratory distress and hypoxia.

b. Increased pulse and blood pressure.

c. Decreased or absent cough or swallow reflex.

**4. Cholinergic crisis: a toxic response to the anticholinesterase

medications; anticholinesterase medications must be withheldthis
response is rare with proper dosing of Mestinon.

a. Nausea, vomiting, and diarrhea.

b. Weakness with difficulty in swallowing, chewing, and speaking.

c. Increased secretions and saliva.

61

www.nurseslabs.com
62

d. Muscle fasciculation, constricted pupils.

5. Diagnostics

1. Electromyography: shows a decreasing response of muscles to

stimuli.

2. Ice pack test: assess clients with ptosis; muscles improve with
cold applications; place pack on closed lids for 2 minutes to see
whether ptosis improves.

3. Tensilon test.

a. Used for diagnosing myasthenia gravis.

b. Used to differentiate cholinergic crisis from myasthenic crisis.

c. IV injection of neostigmine or endrophonium causes

immediate, although short-lived, relief of muscle weakness.

Treatment

A. Anticholinesterase (cholinergic) medications

1. Neostigmine (Prostigmine)

2. Pyridostigmine (Mestinon)

B. Corticosteroids

C. Plasma electrophoresis (plasmapheresis): separation of plasma

to remove autoantibodies from the bloodstream.

D. Immunosuppressive therapy.

E. Surgical removal of thymus (Thymectomy).

Nursing Interventions

Client may be hospitalized for acute myasthenic crisis or for

respiratory tract infection.

Goal: To maintain respiratory function.

A. Assess for increasing problems of difficulty breathing. Measure

forced vital capacity frequently to assess respiratory status.

B. Determine clients medication schedule. When was medication last

taken?
62

www.nurseslabs.com
63

C. Assess ability to swallow; prevent problems of aspiration.

NURSING PRIORITY: Identify clients at

high risk for aspiration; do not give the
client experiencing a myasthenic crisis
anything to eat or drink.

D. Evaluate effectiveness of cough reflex.

E. Be prepared to intubate or provide ventilator assistance.

Goal: To distinguish between a myasthenic crisis and a

cholinergic crisis.

A. Maintain adequate ventilatory support during crisis.

B. Assist in administration of Tensilon test to differentiate crisis.

1. Myasthenic crisis: clients condition will improve.

2. Cholinergic crisis: clients condition will temporarily worsen.

C. If myasthenic crisis occurs, neostigmine may be administered.

D. If cholinergic crisis occurs, atropine may be administered, and

cholinergic medications may be reevaluated.

E. Avoid use of sedatives and tranquilizers, which cause

respiratory depression.

F. Provide psychologic support during crisis.

Home Care

A. Teach client importance of taking medication on a regular basis;

peak effect of the medication should coincide with mealtimes.

B. If ptosis becomes severe, client may need to wear an eye patch

to protect cornea (alternate eye patches if problems is bilateral).

C. Emotional upset, severe fatigue, infections, and exposure to

extreme temperatures may precipitate a myasthenic crisis.

Multiple Sclerosis
63

www.nurseslabs.com
64

***Multiple sclerosis (MS) is characterized by multiple

areas of demyelination from inflammatory scarring of the
neurons in the brain and spinal cord (CNS).

A. The progression of the disease results in total destruction of the

myelin, and the nerve fibers become involved.

1. Loss of myelin sheath causes decreased impulse conduction,

destruction of the nerve fibers become involved.

2. The demyelination occurs in irregular scattered patches throughout

the CNS.

B. The condition is chronic with unpredictable remissions and

exacerbations.

Data Collection

A. Risk factors/Etiology: cause is unknown; possible auto immune or

exposure to viruses.

1. More common in women.

2. Problem of young adults.

3. More common in cooler climates.

B. Clinical Manifestations.

1. Signs and symptoms vary from person to person, as well as within

the same individual, depending on the area of involvement.

2. Cerebellar dysfunction: nystagmus, ataxia, dysarthria, dysphagia.

3. Motor dysfunction: weakness of eye muscles, weakness of

spasticity of muscles in extremities.

4. Sensory: vertigo, blurred vision, decreased hearing, tinnitus.

5. Bowel and bladder dysfunction.

6. Sexual dysfunction.

7. Psychosocial.

a. Intellectual functioning remains intact.

b. Emotional lability: increased excitability and inappropriate

euphoria.

c. Emotional effects of the chronic illness and changes in body

image.

64

www.nurseslabs.com
65

C. Diagnostics: no definitive diagnostic test.

Treatment

A. No cure; medical treatment is directed toward slowing of the

disease process and relief of symptoms.

B. Medications to decrease edema and inflammation of the nerve

sites.

1. Anti-inflammatory agents.

2. Immunosuppressive agents: interferons.

3. Adrenocorticotropic hormones for acute exacerbations.

Nursing Interventions

Client may be hospitalized for diagnostic workup or for treatment of

acute exacerbation and complications.

Goal: To maintain homeostasis and prevent complications

during an acute exacerbation of disease symptoms.

A. Maintain adequate respiratory function.

1. Prevent respiratory tract infection.

2. Good pulmonary hygiene.

3. Prevent aspiration; sitting position for eating.

4. Evaluate adequacy of cough reflex.

B. Maintain urinary tract function.

1. Prevent urinary tract infection.

2. Increase fluid intake, at least 3000 mL/24hr.

3. Evaluate voiding: assess for retention and incontinence.

TEST ALERT: Monitor clients

elimination pattern. Use alternative
methods to promote client voiding.

C. Maintain nutrition.
65

www.nurseslabs.com
66

1. Evaluate coughing and swallowing reflexes.

2. Provide food that is easy to chew.

3. If client is experiencing difficulty swallowing, observe client closely

during fluid intake.

Goal: To prevent complications of immobility.

Goal: To promote psychologic well-being.

A. Focus on remaining capabilities.

B. Encourage independence and assist client to gain control over

environment.

C. If impotence is a problem, initiate sexual counseling.

D. Assist client to work through the grieving process.

E. Identify community resources available.

Home Care

A. Medical regimen and side effects of the medications.

B. Physical therapy to maintain muscle function and decrease

spasticity.

C. Measures to maintain voiding; may need to perform self-

catheterization.

D. Safety measures because of decreased sensation.

1. Check bath water temperature.

2. Wear protective clothing in the winter.

3. Avoid heating pads and clothing that is constrictive.

E. Client should understand that relapses are frequently associated

with an increase in physiologic and psychologic stress.

Guillain-Barre Syndrome

*** Guillain-Barre syndrome is an acute, rapidly

progressing motor neuropathy involving segmental
demyelination of nerve roots in the spinal cord and medulla.
This causes inflammation, decreased nerve conduction, and

66

www.nurseslabs.com
67

rapidly ascending paralysis. Both sensory and motor

impairment occur.

Data Collection

A. Clinical Manifestations

1. Progressive weakness and paralysis begin in the lower extremities

and ascend bilaterally.

2. Paralysis ascends the body symmetrically.

a. Paralysis of respiratory muscles.

b. Cranial nerve involvement, most often facial nerve (CN VII),

produces difficulty talking and swallowing.

3. Loss of sensation and function of bowel and bladder.

4, Manifestations may progress rapidly over hours or may occur over 2

to 4 weeks.

5. Muscle atrophy is minimal.

6. Paralysis decreases as the client begins recovery; most often, there

are no residual effects.

NURSING PRIORITY: Of the neuromuscular

disorders, Guillain-Barre syndrome is the
most rapidly developing and progressive
condition. It is potentially fatal if
unrecognized.

B. Diagnostics

1. Elevated protein concentration in CSF.

Treatment (Supportive)

A. Respiratory support, possibly mechanical ventilation.

B. Corticosteroids.

C. Immunosuppressives and immunoglobulins.

D. Plasmapharesis: plasma exchange.

Nursing Interventions

Goal: To evaluate progress of paralysis and initiate actions to

prevent complications.
67

www.nurseslabs.com
68

A. Evaluate rate of progress of paralysis; carefully assess changes in

respiratory pattern and report to charge nurse.

B. Frequent evaluation of cough and swallow reflexes.

1. Remain with client while client is eating; have suction equipment

available.

2. Maintain NPO (nothing by mouth) status if reflexes are

involved.

C. If ascent of paralysis is rapid, prepare for endotracheal

intubation and respiratory assistance.

D. Prevent complications of immobility during period of paralysis.

E. Assess for involvement of the autonomic nervous system.

1. Orthostatic hypotension.

2. Hypertension.

3. Cardiac dysrhythmias.

4. Urinary retention and paralytic ileus.

Goal: To prevent complications of hypoxia if respiratory muscles

become involved.

Goal: To maintain psychologic homeostasis.

A. Simple explanation of procedures.

B. Complete recovery is anticipated.

C. Provide psychologic support during period of assisted ventilation.

D. Keep client and family aware of progress of disease.

Amyotrophic Lateral Sclerosis

*** Amyotrophic lateral sclerosis (ALS), also known as

Lou Gehrigs disease, is a rapidly progressive, invariably fatal
degeneration of nerves controlling voluntary muscles.

Data Collection

A. Clinical Manifestations.

1. Twitching, cramping, and muscle weakness.

68

www.nurseslabs.com
69

2. Dysarthria and dysphagia.

3. Fatigue; asymmetrical muscle atrophy and weakness.

4. Progressive muscle weakness.

a. Begins with upper extremities and progressively involves

muscle of neck and throat.

b. Trunk and lower extremities are involved late in course of

disease.

5. Most often fatal within 2 to 5 years after onset.

6. Intellectual functioning and all five senses are usually unaffected.

B. Diagnostics: electromyography and nerve conduction studies.

Nursing Interventions

Goal: To provide ongoing assessment in assisting client to deal

with progressive symptoms.

A. Promote independence in ADLs.

1. Conserve energy; space activities.

2. Avoid extremes of hot and cold.

3. Use of appliances to prolong independence in ambulation and

ADLs.

B. Promote nutrition.

1. Small frequent feedings.

2. Have client sit upright with head slightly flexed forward while
eating.

3. Keep suction equipment easily available during meals.

C. Encourage family and client to talk about losses and the

difficult choices they face.

D. Assist family and client to identify need for advanced directives and
to complete them.

Muscular Dystrophy

*** Muscle dystrophy (MD) is a group of genetic

diseases characterized by progressive weakness and skeletal
muscle degeneration affecting a variety of muscle groups. The
term pseudohypertrophy describes the characteristic muscle
69

www.nurseslabs.com
70

enlargement (caused by fatty infiltration) that occurs in

muscular dystrophy.

A. Duchennes muscular dystrophy is the most common and most

severe form of Muscular Dystrophy.

B. Condition is characterized by gradual degeneration of muscle fibers

and progressive symmetrical weakness and wasting of skeletal muscle.

Data Collection

A. Risk Factors / Etiology.

1. Genetic: sex-linked disorder primarily affecting males, females are

carriers.

2. Onset generally occurs between the age of 3 and 5 years.

B. Clinical Manifestations.

1. History of delay in motor development, particularly a delay in

walking.
2. Abnormal waddling gait.
a. Child falls frequently and develops characteristic manner of
rising.
b. Gowers sign: from sitting or squatting position, the child
assumes a kneeling position and pushes the torso up by
walking his or her hands up the thighs.
3. Progressive muscle weakness, atrophy, and contractures.
a. Ambulation is frequently impossible by the age of 9 to 11
years.
b. Ultimately destroys essential muscles of respiration; death
occurs from respiratory tract infection or cardiac failure.

C. Diagnostics.

1. Electromyography, muscle biopsy.

2. Serum enzymes: creatinine phosphokinase level is

increased in neonate, then gradually declines.

Treatment

A. Steroids administered to boys older than 5 years of age.

Nursing Interventions

70

www.nurseslabs.com
71

Child is frequently cared for at home and hospitalized only when

complications occur.

Goal: To maintain optimal motor function as long as possible.

A. Regular physical therapy for stretching and strengthening muscles;

ROM exercises.

B. Maintain childs independence in ADLs.

C. Assist family to identify resources, to adapt physiologic barriers

within the home, and to promote mobility of the child in a wheelchair.

D. Assist family to identify methods of preventing respiratory tract

infection; assess for respiratory problems.

E. Provide braces, splints, and assistive devices as needed.

Goal: To assist parents and child to maintain psychologic

equilibrium and to adapt to chronic illness.

A. Assist parents to understand importance of independence and self-

help skills; frequently, parents are overprotected of the child.

B. Counseling to assist parents and family members to identify

activities that can be modified to meet childs needs.

C. Mother may feel particularly guilty because of transmission of

disease to her son.

D. Identify available community resources.

E. Counseling to assist family and child with chronic illness and childs
eventual death.

Cerebral Palsy

*** Cerebral palsy is a nonprogressive, lifelong

neuromuscular genetic disorder resulting from damaged motor
centers of the brain that cause nerve impulse to be incorrectly
sent and/or received. The overall result is impairment of
muscle control with poor muscle coordination.

Data Collection

A. Risk Factors/ Etiology.

1. May result from existing prenatal brain abnormalities (kernicterus,

hemolytic disease of newborn).

71

www.nurseslabs.com
72

2. Prematurity is single most important determinant of cerebral

palsy.

B. Clinical Manifestations.

1. Delayed achievement of developmental milestones.

2. Increased or decreased resistance to passive movement.

3. Abnormal posture.

4. Presence of infantile reflexes (tonic neck reflex, exaggerated Moro

reflex).

5. Associated disabilities.

a. Mental retardation, seizures.

b. Attention-deficit problems.

c. Vision and hearing impairment.

6. Muscle tightness and spasms.

C. Diagnostics.

1. Frequently difficult to diagnose in early months; condition may

not be evident until child attempts to sit alone or walk.

2. Neurologic exam and contributing history.

Treatment

A. Maintain and promote mobility with orthopedic devices and physical

therapy.

B. Skeletal muscle relaxants.

C. Anticonvulsants, as indicated.

Nursing Interventions

Child is frequently cared for at home and on an outpatient basis unless

complications occur.

Goal: To assist child to become as independent and self-

sufficient as possible.

72

www.nurseslabs.com
73

A. Physical therapy program designed to assist individual child to gain

maximum function.

B. Bowel and bladder training may be difficult because of poor control.

Goal: To maintain physiologic homeostasis.

A. Maintain adequate nutrition.

1. May experience difficulty eating because of spascticity; may

drool excessively use of manual jaw control when feeding.

2. Encourage independence in eating and use of self-help devices.

3. Provide a balanced diet with increased caloric intake to meet

extra energy demands.

B. Maintain safety precautions to prevent injury.

C. Increased susceptibility to infections, especially respiratory tract

infections, because of poor control of intercostal muscles and
diaphragm.

D. Increased incidence of dental problems; schedule frequent dental

checkups.

Goal: To promote a positive self-image in the child and provide

support to the family.

A. Assist parents to set realistic goals.

B. Encourage play activity.

C. Utilized principles in caring for chronically ill pediatric client

(Chapter 2).

Parkinsons Disease (Paralysis Agitans)

*** Parkinsons disease is progressive neurologic

disorder with gradual onset that causes destruction and
degeneration of nerve cells in the basal ganglia; results in
damage to the extrapyramidal system, causing difficulty in
control and regulation of movement.

Data Collection

A. Risk Factors / Etiology.

1. In general, onset occurs after age 60.

2. More common in males.

73

www.nurseslabs.com
74

B. Clinical Manifestations (Figure 15-6).

1. Tremor.

a. Affects the arms and hands bilaterally: often the first

sign.

b. Tremors usually occurs at rest; voluntary movement may

decrease tremors; tremors during voluntary movement are not as
common.

c. Described as pill-rolling tremor.

d. Exacerbated by emotional stress and increased

concentration.

2. Muscle rigidity.

a. Increased resistance to passive movement.

b. Movement may be described as cog-wheel rigidity because

of jerky movement of extremities.

3. Bradykinesia: slow activity.

a. Decreased blinking of the eyelids.

b. Loss of ability to swallow saliva.

c. Facial expression is blank or mask-like.

d. Loss of normal arm swing while walking.

e. Difficulty initiating movement.

4. Stooped posture, shuffling propulsive gait.

5. May exhibit mental deterioration similar to that associated with

alzheimers disease.

6. Depression occurs in two-thirds of clients.

C. Diagnostics: no specific diagnostic test.

Treatment

A. Medications (see Appendix 15-4).

B. Surgical Therapy: aim is to decrease symptoms.

1. Ablation (destruction of tissue).

2. Deep brain stimulation (DBS).

Nursing Interventions

Goal: To maintain homeostasis.

74

www.nurseslabs.com
75

A. Encourage independence in ADLs with use of self-help devices.

B. Maintain nutrition.

**1. Increase calories and protein; provide more easily chewed

foods.

2. Frequent small meals.

3. Allow ample time for eating.

4. Monitor weight loss.

5. Provide pleasant atmosphere at mealtime; client frequently

prefers to eat alone because of a difficulty swallowing and inability to
control saliva.

6. Increase fluid intake with increased bulk in the diet to decease

problem with constipation.

C. Maintain muscle function.

1. Full ROM to extremities to prevent contracture.

2. Decrease effects of tremors.

3. Exercise and stretch daily.

4. Physical therapy, as indicated.

D. Closely monitor response to or changes in response to medications.

Goal: To promote positive self-image.

A. Encourage diversional activities.

B. Assist in client to set realistic goals.

C. Explore reasons for depression; encourage client to discuss changes

occurring in lifestyle.

D. Assist client in gaining control of ADLs and environment.

E. Assist client to identify and avoid activities that increase frustration

levels.

F. Encourage good personal hygiene.

Headache

*** Headache is a very common symptom of various

underlying pathologic conditions in which pain-sensitive nerve
fibers respond to unacceptable levels of stress and tension,
75

www.nurseslabs.com
76

muscular contraction in the upper body, pressure from a

tumor, or increased ICP.

Data Collection

A. Types of Headaches.

1. Tension headaches (muscle contraction headache): most

common of all headaches; feeling of tightness like a band around the
head; onset is gradual; may be accompanied by dizziness, tinnitus, or
lacrimation; associated with stress and premenstrual syndrome.

2. Migraine: constriction of intracranial vessels leading to an

intense throbbing pain when vessels return to normal; prodromal or
aura; crescendo quality; unilateral pain, often beginning in eye area;
nausea, vomiting, photophobiamigraines are seriously debilitating
and may require lifestyle and occupational changes.

3. Cluster headache: rare headache that is more common in

men; occurs in numerous episodes or clusters; no aura; unilateral pain
often arising in nostril and spreading to forehead and eye; often occurs
at same time of day.

Treatment

A. ***Migraine: sumatriptan (Imitrex); dihydroergotamine mesylate

(Migranal).

B. Nonsteroidal anti-inflammatory drugs.

C. Relaxation, yoga, stress management.

D. Cluster headaches treated with high flow oxygen.

Nursing Interventions

A. Prevention: recognize triggers, decrease stress, adjust

medications during menstrual cycle.

B. Watch for signs of ominous headache: new-onset unilateral

headache in person older than 35 years; vomiting not accompanied by
nausea; pain that awakens client.

C. Encourage client to keep a headache diary for best management

and treatment.

Trigeminal Neuralgia

76

www.nurseslabs.com
77

*** Trigeminal neuralgia is a fleeting unilateral sensory

disturbance of cranial nerve V, causing brief, paroxysmal pain
and facial spasm; also known as tic douloureux.

Data Collection

A. Risk Factors/ Etiology:

1. Onset generally occurs between 20 and 40 years of age.

2. Increased frequency with aging.

B. Clinical Manifestations.

1. Abrupt onset of paroxysmal intense pain in the lower and upper jaw,
cheek and lips.

a. Tearing of the eyes and frequent blinking.

b. Facial twitching and grimacing.

c. Pain is usually brief; ends as abruptly as it begins.

d. Pain may be described as severe, stabbing and shock-like.

2. Recurrence of pain is unpredictable.

3. Pain is initiated by cutaneous stimulation of the affected nerve area.

a. Chewing.

b. Washing the face.

c. Extremes of temperature: either on the face or in food.

d. Brushing teeth.

Treatment

A. Medical Management of pain (see appendix 15-2):

Carbamazepine (tegretol) and gabapentin (Neurotin).

B. Surgical intervention.

1. Local nerve block.

2. Surgical intervention to interrupt nerve impulse transmission.

77

www.nurseslabs.com
78

Nursing Interventions

Goal: To control pain.

A. Assess the nature of a painful attack.

B. Identify triggering factors; adjust environment to decrease

factors.

1. Keep room at an even, comfortable temperature.

2. Avoid touching client.

3. Avoid jarring the bed.

4. Allow client to carry out own ADLs as necessary.

C. Administer analgesics to decrease pain.

Goal: To maintain nutrition.

A. Frequently, client does not eat because of reluctance to stimulate

the pain.

B. Provide lukewarm food that can easily chewed.

C. Increase protein and calories.

Home Care

A. Identify presence of corneal reflex; provide protective eye care if

reflex is absent.

B. If there is loss of sensation to the side of the face, client

should:

1. Chew on the unaffected side.

2. Avoid temperature extremes in foods.

3. Check the mouth after eating to remove remaining particles of

food.

4. Maintain meticulous oral hygiene.

5. Have frequent dental check ups.

Bells Palsy
78

www.nurseslabs.com
79

*** Bells palsy is a transient cranial nerve disorder

affecting the facial nerve (cranial nerve VII), characterized by
a disruption of the motor branches on one side of the face,
which results in muscle weakness or flaccidity on the affected
side.

Data Collection

A. Clinical Manifestations.

1. Lag or inability to close eyelid on affected side.

2. Drooping of the mouth.

3. Decreased taste sensation.

4. Upward movement of the eyeball when the eye is being closed.

B. Diagnostics (see Appedndix15-1)

Treatment

A. Corticosteroids: administration should be started immediately

after symptoms arise.

B. Antivirals.

C. Moist heat may relieve pain, if present.

Nursing Interventions

Goal: To assess nerve function and prevent complications.

A. Analgesics to decrease pain.

B. Evaluate ability of client to eat.

C. Meticulous oral hygiene.

D. Prevent drying of the cornea on the affected side.

1. Instill methylcellulose drops frequently during the day.

2. Ophthalmic ointment and eye patches may be required at night.

E. As function returns, active facial exercises may be performed.

79

www.nurseslabs.com
80

Goal: To assist client to maintain a positive self-image.

A. Changes in physical appearance may be dramatic.

B. Tell client that the condition is usually self-limiting with minimal, if

any, residual effects.

C. Client may require counseling, if change in facial appearance is

permanent.

4. Sensory disorders

REVIEW OF ANATOMY AND PHYSIOLOGY

THE EYE AND VISION

-The eyes are complex structures, containing 70% of the sensory receptors of
the body.
-Each eye is a sphere measuring about 1 in (2.5cm) in diameter, surrounding
and protected by a bony orbit and cushions of fat.
-The primary functions of the eye are to encode the patterns of light from the
environment through photoreceptors and to carry the coded information,
allowing us to make sense of what we see.
-Both extraocular and intraocular structures are considered a part of the eye.

Extraocular Structures

Extraocular or accessory structures of the eye are those portions of the eye
outside the eyeball yet vital to its protection. These structures are the eyebrows,
the eyelids, the eyelashes, the conjunctiva, the lacrimal apparatus, and the
extrinsic eye muscles.

The eyebrows are short, coarse hairs located above the eyes over the superior
orbital ridges of the skull. The eyebrows shade the eyes and keep perspiration
away from them.

The eyelids are thin, loose folds of skin covering the anterior eye. They protect
the eye from foreign bodies, regulate the entry of light into the eye, and
distribute tears by blinking.

The eyelashes are short hairs that project from the top and bottom borders of
the eyelids. When anything touches the eyelashes, the blinking reflex is initiated
to protect the eyes from foreign objects.

The conjunctiva is a thin, transparent membrane that lines the inner surfaces
of the eyelids and also folds over the anterior surface of the eyeball. The
palpebral conjunctiva lines the upper and lower eyelids, whereas the bulbar
conjunctiva loosely covers the anterior sclera (the white part of the eye). The
conjunctiva is a mucous membrane that lubricates the eyes.

80

www.nurseslabs.com
81

The lacrimal apparatus is composed of the lacrimal gland, the puncta, the
lacrimal sac, and the nasolacrimal duct. Together, these structures secrete,
distribute, and drain tears to cleanse and moisten the eyes surface.

The six extrinsic eye muscles control the movement of the eye, allowing it to
follow a moving object. The muscles also help maintain the shape of the eyeball.

Intraocular Structures

The intraocular structures transmit visual images and maintain homeostasis of

the inner eye. Those lying in the anterior portion of each eyeball are the sclera
and the cornea (forming the outermost coat of the eye, call the fibrous tunic),
the iris, the pupil, and the anterior cavity.

The white sclera lines the outside of the eyeball. The functions of the sclera are
to protect and give shape to the eyeball.

The sclera gives way to cornea over the iris and pupil. The cornea is
transparent, avascular and very sensitive to touch. The cornea forms a window
that allows light to enter the eye and is a part of its light-bending apparatus.
When the cornea is touched, the eyelids blink and tears are secreted.

The iris is a disc of muscles tissue surrounding the pupil and lying between the
cornea and the lens. The iris gives the eye its color and regulates light entry by
controlling the size of the pupil.

The pupil is the dark center of the eye through which light enters. The pupil
constricts when bring light enters the eye and when it is used for near vision; it
dilates when light conditions are dim and when eye is used for far vision. In
response to intense light, the pupil constricts rapidly in the papillary light reflex.

The anterior cavity is made up of the anterior chamber (the space between the
cornea and the iris) and the posterior (the space between the iris and the lens).
The anterior cavity is filled with a clear fluid called the aqueous humor. Aqueous
humor is constantly formed and drained to maintain a relatively constant
pressure of from 15-20 mmHg in the eye. The canal of schlemm, a network of
channels that circle the eye in the angle at the junction of the sclera and the
cornea, is the drainage system for fluid moving between the anterior and
posterior chambers. Aqueous humor provides nutrients and oxygen to the cornea
and lens.

The intraocular structures that lie in the internal chamber of the eye are the
posterior cavity and vitreous humor, the lens, the ciliary body, the uvea, and the
retina.

The posterior cavity lies behind the lens. It is filled with a clear gelatinous
substance called the vitreous humor. Vitreous humor supports the posterior
surface of the lens, maintains the position of the retina, and transmits light.

The lens is the biconvex, avascular, transparent structure located directly behind
the pupil. It can change shape to focus and refract light onto the retina.

The uvea, also called the vascular tunic, is the middle coat of the eyeball. This
pigmented layer has three components: the iris, ciliary body and choroid. The
ciliary body encircles the lens, and along with the iris, regulates the amount of
light reaching the retina by controlling the shape of the lens. Most of the uvea is
made up of the choroids, which is pigmented and vascular. Blood vessels of the
choroids nourish the other layers of the eyeball. Its pigmented areas absorb
light, preventing it from scattering within the eyeball.

The retina is the innermost lining of the eyeball. It has an outer pigmented
layer and an inner neural layer. The outer layer, next to the choroids, serves as
the link between visual stimuli and the brain. The transparent inner layer is made
up of millions of light receptors in structures called rods and cones. Rods allow
for vision in dim light as well as for peripheral vision. Cones allow for vision in
bright light and for the perception of color. The optic disk, a cream-colored round

81

www.nurseslabs.com
82

or oval area within the retina is the point at which the optic nerve enters the eye.
The slight depression in the center of the optic disc often called the physiologic
cup. Located laterally to the optic disc is the macula, which is a darker area with
no visible blood vessels. The macula contains primarily cones. The fovea centralis
is a slight depression in the center of the macula that contains only cones and is
a main receptor of detailed color vision.

THE VISUAL PATHWAY

The optic nerves are cranial nerves formed of the axons of ganglion cells. The
two optic nerves meet at the optic chiasma, axons from the medial half of each
retina cross to the opposite side to form pairs of axons from each eye. These
pairs continue as the left and right optic tracts. The crossing of the axons results
in each optic tract carrying information from the lateral half of the retina of the
left eye and the medial half of the retina of the right eye, whereas the right optic
tract carries visual information from the lateral half of the retina of the right eye
and the medial half of the retina of the left eye.

The ganglion cell axons in the optic tracts travel to the thalamus and create
synapses with neurons, forming pathways called optic radiation terminate in the
visual cortex of the occipital lobe. Here the nerve impulses that originated in the
retina are interpreted.

The visual field of each eye overlap considerably, and each eye sees a slightly
different view. Because of this overlap and crossing of the axons, information
from both eyes reaches each side of the visual cortex, which then fuses the
information into one image. This fusion of images accounts for the ability to
perceive depth; however, depth perception depends on visual input from two
eyes that both focus well.

Refraction

Is the bending of light rays as they pass from one medium to another medium of
different optical density. As light rays pass through the eye, they are refracted at
several points: as they enter the cornea, as they leave the cornea and enter the
aqueous humor, as they enter the lens, and as they leave the lens and enter the
vitreous humor. At the lens, the light is bent so that it converges at a single point
on the retina. This focusing on the image is called accommodation. Because the
lens is convex, the image protected onto the retina (the real image) is upside
down and reversed from left to right. The real image coded as electric signals
that are sent to the brain decodes the image so that the person perceives it as it
occurs in space.

The eyes are best adapted to see distant objects. Both eyes fix on the same
distant image and do not require any change in accommodation. For people with
emmetropic (normal) vision, the distance from the viewed object at which the
eyes require no accommodate the lens, constrict the pupils, and converge the
eyeballs.

Accommodation is accomplished by contraction of the ciliary muscles. This

contraction reduces the tension on the lens capsule so that it bulges outward to
increase the curvature. This change in shape also achieves a shorter focal length,
another requirement for the focusing of close images on the retina. The closest

82

www.nurseslabs.com
83

point on which a person can focus is called the near point of vision; in young
adults with normal vision this is usually 8-10 in. pupillary constriction helps
eliminate most of the divergent light rays and sharpens focus.

Convergence (the medial rotation of the eyeballs so that each is directed toward
the viewed object) allows the focusing of the image on the retinal fovea of each
eye.

ASEESSMENT OF THE EYES

1. Health History

A. Current Health Status

1. Problems

2. Corrective lenses

B. Past Health Status

1. Lens achange

2. Blurred vision

3. Spots, Floaters, Halos

4. Infections or Inflammations of the eyes

5. Eye surgery or injury

6. Styes (hordeolums)

7. High blood pressure

8. Diabetes

9. Eye medications

C. Family Health Status

Equipment Needed

A Snellen Eye Chart OR Pocket Vision Card

An Ophthalmoscope

Visual Acuity

In cases of eye pain, injury, or visual loss, always check visual acuity before
proceeding with the rest of the exam or putting medications in your patients
eyes.

83

www.nurseslabs.com
84

1. Allow the patient to use their glasses or contact lens if available. You are
interested in the patients best corrected vision.

2. Position the patient 20 feet in front of the Snellen eye chart (or hold a
Rosenbaum pocket card at a 14 inch reading distance).

3. Have the patient cover one eye at a time with a card.

4. Ask the patient to read progressively smaller letters until they can go no
further.

5. Record the smallest line in the patient read successfully

6. Repeat with the other eye.

7. Unexpected/unexplained loss of acuity is a sign of serious ocular pathology.

Inspection

1. Observe the patient for ptosis, exophthalmos, lesions, deformities, or

asymmetry.
2. Ask the patient to look up and pull down both lower eyelids to inspect the
conjunctiva and sclera.
3. Next spread each eye open with your thumb and index finger. Ask the
patient to look to each side and downward to expose the entire bulbar
surface.
4. Note any discoloration, redness, discharge, or lesions. Note any deformity
of the iris or lesion cornea.
5. If you suspect the patient has conjunctivitis, be sure to wash your
hands immediately. Viral conjunctivitis is highly contagious- protect
yourself!

Visual Fields

Screen Visual Fields by Confrontation

1. Stand two feet in front of the patient and have them look into your eyes.
2. Hold your hands to the side half way between you and the patient.
3. Wiggle the fingers on one hand.
4. Ask the patient to indicate which side they see your fingers move.
5. Repeat two or three times to test both temporal fields.
6. If an abnormality is suspected, test the four quadrants of each eye while
asking the patient to cover the opposite eye with a card.

Extraocular Muscles

Corneal reflections

84

www.nurseslabs.com
85

1. Shine a light from directly in front of the patient.

2. The corneal reflections should be centered over the pupils.
3. Asymmetry suggests extraocular muscle pathology.

Extraocular Movement

1. Stand or sit 3 to 6 feet in front of the patient.

2. Ask the patient to follow your finger with their eyes without moving their
head.
3. Check gaze in the six cardinal directions using a cross or H pattern.
4. Check convergence by moving your finger toward the bridge of the
patients nose.

Pupillary Reactions

Light

1. Dim the room lights as necessary.

2. Ask the patient to look into the distance.
3. Shine a bright light obliquely in each pupil in turn.
4. Look for both the direct (same eye) and consensual (other eye) reactions.
5. Record pupil size in mm and any asymmetry or irregularity.

Accommodation

If the pupillary reactions to light are diminished or absent, check the reactions to
accommodation (near reaction) [5] ++

1. Hold your finger about 10cm from the patients nose.

2. Ask them to alternate looking into the distance and at your finger.
3. Observe the pupillary response in each eye.

Ophthalmoscopic Exam

1. Darken the room as much as possible. ++

2. Adjust the ophthalmoscope so that the light is no brighter than necessary.
Adjust the aperture to a plain white circle. Set the diopter dial to zero
unless you have determined a better setting for your eyes.
3. Use your left hand and left eye to examine the patients left eye. Use your
right hand and right eye to examine the patients right eye. Place your
free hand on the patients shoulder for better control.
4. Ask the patient to stare at a point on the wall or corner of the room.
5. Look through the ophthalmoscope and shine the light into the patients
eye from about two feet away. You should see the retina as a red reflex.
Follow the red color to move within a few inches of the patients eye.
85

www.nurseslabs.com
86

6. Adjust the diopter dial to bring the retina into focus. Find a blood vessel
and follow it to the optic disk. Use this as a point of reference.
7. Inspect outward from the optic disk in at least four quadrants and note
any abnormalities.
8. Move nasally from the disk to observe the macula.
9. Repeat for the other eye.

Special Tests

Upper Eyelid Eversion

This procedure is performed when a foreign body is suspected. ++

1. Ask the patients to look down

2. Gently grasp the patients upper eyelashes and pull them out and down.
3. Place the shaft of an applicant or tongue blade about 1 cm from the lid
margin.
4. Pull the lid upward using the applicator as a fulcrum to turn the lid inside
out. Do not press down on the eye itself.
5. Pin the eyelid in this position by pressing the lashes against the eyebrow
while you examine the palpebral conjunctiva.

Ask the patient to blink several times to return the lid to normal.

Notes

1. Visual acuity is reported as a pair of numbers (20/20) where the first

number is how far the patient is from the chart and the second number is
the distance from which the normal eye can read a line of letters. For
example, 20/40 means that at 20 feet the patient can only read from
twice that distance.
2. You may, instead of wiggling a finger, raise one or two fingers (unilaterally
or bilaterally) and have the patient state how many fingers (total, both
sides) they see. To test for neglect, on some trials wiggle your right and
left fingers simultaneously. The patient should see movement in both
hands.
3. Additional Testing- Test marked with (++) may be skipped unless an
abnormality is suspected.
4. PERRLA is a common abbreviation that stands for Pupil Equal Round
Reactive to Light and Accommodation. The use of this term is so routine
that it is often used incorrectly. If you did not specifically check the
accommodation reaction use the term PERRLA. Pupils with diminished
response to light but a normal response to accommodation (Argyll-
Robertson Pupils) are a sign of neurosyphilis.
5. Diopters are used to measure the power of a lens. The ophthalmoscope
actually has a series of small lens of different strengths on a wheel
(positive diopters are labeled in green, negative in red). When you focus
on the retina you dial-in the correct number of diopters to compensate
for both the patients and your own vision. For example, if both you and
your patient wear glasses with -2 diopter correction you should expect to
set the dial to -2 with your glasses on or -4 with your glasses off.

86

www.nurseslabs.com
87

DIAGNOSTIC TEST FOR THE EYE

A. FLUORESCEIN ANGIOGRAPHY

It is detailed imaging and recording of ocular circulation by a series of

photographs after administration of a dye.

a. Assess client to allergies and previous reactions to dyes.

b. Obtain informed consent.
c. A mydriatic medication, which causes pupil dilation, is instilled in the eye,
1 hour before the test.
d. The dye is injected into a vein of the clients arm.
e. Inform the client that the dye may cause the skin to appear yellow for
several hours after the test and is eliminated gradually through the urine.
f. The client may experience nausea, vomiting, sneezing, paresthesia of the
tongue or pain at the injection site.
g. If hives appear, orally or intramuscularly administered antihistamines such
as diphenhydramine (Benadryl) are given as prescribed.

Postoperative Interventions
a. Encourage rest.
b. Encourage fluid intake to assist in eliminating the dye from the clients
system.
c. Remind the client that the tallow skin appearance will disappear.
d. Instruct the client that the urine will appear bright green until the dye
is excreted.
e. Instruct the client to avoid direct sunlight for a few hours after the
test.
f. Instruct the client that the photophobia will continue until pupil size
returns to normal.

B. COMPUTED TOMOGRAPHY

It is a diagnostic test for the eye wherein there is a beam of x-rays scans
the skull and orbits of the eye. A cross-sectional image is formed by the use of a
computer and a contrast material is not usually administered.

Nursing Interventions
No special client preparation or follow-up care is required.
Instruct the client that he or she will be positioned in a confined space
and will need to keep their heads still during the procedure.

C. SLIT LAMP

A slit lamp allows the examination of the anterior ocular structures

under microscopic magnification. The client leans on a chin rest to
stabilize the head while a narrowed beam of light is aimed so that it
illuminates only a narrow segment of the eye.

87

www.nurseslabs.com
88

Nursing Interventions
Explain the procedure to the client.
Advise the client about the brightness of the light and the need to look
forward at a point over the examiners ear.

D. CORNEAL STAINING

A topical dye is instilled into the conjunctival sac to outline irregularities of

the corneal surface that are not easily visible. The eye is viewed to a blue filter,
and a bright green color indicates areas of a non intact corneal epithelium.

Nursing Interventions
If the client wears contact lenses, the lenses must be removed.
The client instructed to blink after the dye has been applied to
distribute the dye evenly across the cornea.

E. TONOMETRY

This test is used primarily to assess for an increase of intraocular pressure

and potential glaucoma. Normal ocular pressure is 10-21 mmHg.

Nursing Interventions
Each dye is anesthetized.
The client is instructed to stare forward at a point above the
examiners ear.
A flattened cone is brought contact with the cornea is measured.
The client must instructed to avoid rubbing the eye following the
examination if the eye has been anesthetized because the potential for
scrubbing the cornea exists.

F. FUNDUS PHOTOGRAPHY

Special retinal cameras are use to document fine details of the fundus for the
study and future comparison. One of the most common applications is the
evaluation of insidious optic nerve changes in the client with glaucoma.
Photographs are compared over time to identify subtle changes in the clients
with glaucoma. Photographs are compared over time to identify subtle changes
in disc shape and color.

88

www.nurseslabs.com
89

G. SPECULAR MIMOGRAPHY

Specular mimography is a photographic technique used to count cells of the

corneal endothelium. A camera is focused on the endothelium layer, and the area
is magnified 200 times; then the cell is counted. This layer of the cornea is one
cell is thick. Cells in this layer do not reproduce but rather they expand to fill
gaps in the endothelium. The number or lack of number, of cells may indicate
healing potential.

H. EXOPTHALMOMETRY

The exopthalmometry is an instrument designed to measure the forward

protrusion of the eye. This instrument provides a method of evaluating and
recording the progression and regression of the prominence of the eye in
disorders such as thyroid disease and tumors of the orbit.

I. OPTHALMIC RADIOLOGY

X-ray study, tomography, and CT scan are useful in the evaluation of orbital
and intracranial conditions. Common abnormalities evaluated by these methods
include neoplasms, inflammatory masses, fractures and extraocular muscle
enlargement associated with Graves eye disease. Radiology is also useful in the
detection of foreign bodies.

J. MAGNETIC RESONANCE IMAGING

MRI has the advantage of not exposing the patient to ionizing radiation. Also,
multidimensional views are possible without repositioning the patient. This is
used to image edema, areas of demyelination, and vascular lesions. However,
the availability of MRI equipment is often limited and the examination takes
longer. MRI may also cause movement of a metallic foreign body.

K. ULTRASONOGRAPHY

Ultrasonography uses the principle of sonar to study structures not directly

visible high frequency sound waves are transmitted to a probe placed directly on
the eyeball. As the sound waves bounce back off the various tissue components,
they are collected by a receiver that amplifies them on an oscilloscope screen.
Sound waves derived from the most distal structures arrive last, having travel
the farthest. Ultrasonography may be used to evaluate tissue characteristics of a
lesion as well as size and growth over time. It may also be used to measure axial
length (distance from the cornea to the retina) in order to calculate the power for
an intraocular lens implant in cataract surgery.

L. OPTHALMODYNAMOMETRY

Opthalmodynamometry is a test that consists of exerting pressure on the

sclera with a string plunger while observing the central retinal vessels emerging
from the disc through an opthalmoscope. This instrument gives an approximate
measurement of the relative pressures in the central retinal arteries and is an
indirect method of assessing the carotid arterial flow on either sound.

M. ELECTRORETINOGRAPHY
89

www.nurseslabs.com
90

An electrical potential exist between the cornea and retina of the eye.
Because the retina is neurologic tissue, the normal retina is exhibit certain
electrical responses when stimulated by light. Electroretinography (ERG)
measures the normal change in electrical potential of the eye caused by a diffuse
flash of light. For this test, electrodes incorporated into a contact lens are placed
directly on the eye. Eye movements disrupt the values of the test, so the client
must be able to fixate on a target while keeping the eye still. A normal ERG
signifies functional integrity of the retina. Examples of retinal disease that may
be evaluated with ERG include retinitis pigmentosa (progressive degeneration of
photoreceptor cells), massive ischemia, disseminated infection, or toxic effects
from drugs or chemicals.

N. VISUAL EVOKED RESPONSE

Visual evoked response (VER) is similar to ERG in that it also measures the
electrical potential resulting from a visual stimulus. The entire visual pathway
from the retina to the cortex maybe evaluated in the examination through the
placement of electrodes on the scalp. Reduces speed of neuronal conduction,
such as with demyelination, results in an abnormal VER. Retina or optic nerve
disease may be diagnosed by stimulating each eye separately.

EYE DISORDERS

Degenerative Disorders

A. GLAUCOMA

Glaucoma includes a group of ocular disorders characterized by increase

intraocular pressure, optic nerve atrophy and visual field loss. The individual
response to intraocular pressure varies. Therefore, some people sustain damage
from relatively low pressures and others sustain no damage from high pressure.
The degree of increase pressure that cause ocular damage is not the same in
every eye, and some individuals may tolerate a pressure for long periods of time
that would rapidly blind another.

Incidence

It is estimated that over 50,000 person in the US are blind as a result of

glaucoma. The incidence of glaucoma is about 1.5%, and in black, between the
ages of 45 and 65, prevalence is at least five times that of the whites in the
same age group. In most cases, blindeness can be prevented if treatment is
began early.

Glaucoma is called the sneak thief of sight because it strikes without

obvious symptoms. People with glaucoma are usually unaware of it until they
have a serious loss of vision. In fact, about half of those who have glaucoma do
not know it. Currently, that damage cannot be reversed.

90

www.nurseslabs.com
91

While there are usually no warning signs, some symptoms may occur in the
later stages of the disease, such as a loss of peripheral vision, difficulty focusing
on close work, seeing halos around lights, and frequent changes of prescription
glasses. Unfortunately, though, once the vision is lost, it is gone forever.

African American are at a higher risk of developing glaucoma than other racial
groups. Others at risk include:

Anyone with close relative who has glaucoma;

Seniors;
People with diabetes;
People taking steroids medications for extended periods of time.

Pathophysiology

Intraocular pressure is determined by the rate of aqueous production in the

ciliary body and the resistance to ouflow aqueous from the eye. Increase
intraocular pressure (usually greater than 23mmHg) indicates the need for
further evaluation. Intraocular pressure varies with diurnal cycles. (the highest
pressure is usually on awakening) and position of the body (increase when lying
down). Normal variation do not usually exceed 2-3 mmHg. Intraocular pressure
and blood pressure are independent of each other but variations in the systemic
blood pressure may be associate with corresponding variations in the intraocular
pressures. Increase intraocular pressure may result from hyper production of
aqueous or obstruction of the outflow. As aqueous fluid builds up in the eye, the
increase pressure inhibits blood supply to the optic nerve and the retina. These
delicate tissues become ischemic and gradually loss function.

Etiology/Risk Factors

Many terms are used to describe the various types of glaucoma. The terms
primary and secondary refer to whether the etiology is the disease alone or due
to another condition. Acute and Chronic refer to the onset and duration of the
disorder. The terms open (wide) and closed (narrow) describe the width of the
angle between the cornea and the iris. Anatomically narrow anterior chamber
angles predispose clients to an acute onset of angle-closure glaucoma.

TYPES OF GLAUCOMA

Primary Open-Angle Glaucoma

Approximately 90% of primary glaucoma cases occur in clients with
open angles. It is multifunctional disorder that is often genetically
determined, bilateral, insidious, in onset, and slow to progress. Symptoms
appear late when vision is impaired by damage to the optic nerve.
Because there are no early warning symptoms, it is imperative that
regular ophthalmic examinations include tonometry and assessment of the
optic nerve head (disc). This type of glaucoma is often referred as the
THIEF IN THE NIGHT because there are no early symptoms alerting the
client that vision is being lost. The most common cause of chronic open
angle glaucoma is degenerative change in the trabecular meshwork
resulting in the decrease outflow of aqueous humor.
91

www.nurseslabs.com
92

Angle-Closure Glaucoma
An acute attack angle-closure glaucoma can develop only in an eye in
which the anterior chamber angle is anatomically narrow. The attack
occurs due to a sudden blockage of an anterior angle by the base of the
iris. When the aqueous flow is obstructed, intraocular pressure becomes
markedly elevated, causing severe pain and blurred vision or vision loss.
Some client will see rainbow halos around lights, and some will experience
nausea and vomiting.

Low Tension Glaucoma

Low-tension glaucoma resembles primary open-angle glaucoma. The

angle is normal, the optic nerves are cupped and the visual fields show
characteristic glaucomatous effects. (peripheral vision deficits). These
changes, however, develop in the presence statistically normal intraocular
pressures. The etiology of low tensions glaucoma is not known. Although the
pressure readings are in the normal range, treatment is indicated to lower
the pressure even further to avoid progressive optic nerve damage and visual
field loss.

Secondary Glaucoma
Increase intraocular pressure may occur as a postoperative
complication. Edematous tissue may inhibit the outflow of aqueous
through the trabecular meshwork. Delayed healing of corneal would edges
may result in epithelial cell growth into the anterior chamber.
Glaucoma may occur as a result of trauma. Lens displacement,
hemorrhage into the anterior chamber, laceration, and contusions can
disrupt the flow pattern of aqueous humor.

Clinical Manifestations

Clinical Manifestation of glaucoma include:

1. Increase intraocular pressure.
2. Cupping or indentation of the optic nerve head (disc) and
3. Visual field defects.

Diagnostic Assessment

-An opthalmoscopic examination shows atrophy (pale color) and cupping

(indentation) of the optic nerve head. The visual field examination is used to
determine the extent of peripheral vision loss (see the section on visual fields).
In chronic open angle glaucoma, a small crescent-shape scotoma (blind spot)
appears early in the disease. In acute angle-closure glaucoma, the fields
demonstrate larger areas significant vision loss.

-In clients with angle-closure glaucoma, a slit lamp examination may

demonstrate an erythematous conjunctiva and corneal cloudiness. The anterior
chamber aqueous may also appear turbid and the pupil may be nonreactive.

Slit lamp examination is used in open angle glaucoma to look for any secondary
causes and associate findings.

-Intraocular pressure is measured at the slit lamp with the applanation

tonometer. Gonioscopy is performed to determine the depth of the anterior
chamber and to examine the entire circumference of the angle for any abnormal
change in the filtering meshwork.

92

www.nurseslabs.com
93

Medical Management

The goal of medical management is to facilitate the outflow of aqueous through

remaining channels. This is achieved through the use of

Topical miotics, which constricts the pupil and increase outflow;

Topical epinephrine, which also increase the outflow;
Topical beta blockers or alpha adrenergics, which suppress the
secretion of aqueous humor; and
Oral carbonic anhydrase inhibitors, which also reduce the production of
aqueous humor.

When medical management is no longer effective, surgical intervention may be

indicated.

Surgical Management

When maximum medical therapy has failed to halt the progression of visual field
loss and optic nerve damage, surgical intervention is recommended. There are
many procedures that are use to correct the aqueous outflow; however, there is
no operation that is uniformly successful.

Laser Trabeculoscopy

-The use of laser to create an opening in the trabecular meshwork is often

indicated before filtration surgery is considered. The laser produces scars
in the trabecular meshwork fibers. The tightened fibers allow increased
outflow of aqueous Intraocular pressure is reduced through improved
outflow in about 80% of cases.

Filtering Procedures
-Operative procedures such as trephination, thermal sclerostomy, or
sclerotomy create an outflow channel from the anterior chamber to the
subconjunctival space. These are called filtering procedures. Aqueous is
absorbed through the conjunctival vessels. In about 25% of cases, The
opening closes due to scar tissue formation, and reoperation is necessary.

Cyclodestructive Procedures
-When other surgical procedures have failed, cyclocryotherapy (application
of freezing tip) or cyclophotocoagulation may be used to damage the
ciliary body and decrease the production of aqueous.

ASSESSMENT
-Progressive loss of peripheral vision followed by loss of central vision
-Elevated intraocular pressure (normal pressure is 10-21 mmHg)
-Vision worsening in the evening with difficulty adjusting to dark rooms
-Blurred vision
-Halos around white lights
-Frontal headaches
-Eye pain
-Photophobia
-Lacrimation
-Progressive loss of central vision

NURSING INTERVENTIONS
93

www.nurseslabs.com
94

Acute Glaucoma
Administer medications as prescribe to lower intraocular pressure.
And prepare the client for peripheral iridectomy, which allows
aqueous humor to flow form the posterior to anterior chamber.

Chronic Glaucoma

Instruct the client on the importance of medications (miotics) to

constrict the pupils, (carbonic anhydrase inhibitors) to decrease
production of aqueous humor, and beta blockers to decrease the
production of aqueous humor and intraocular pressure.
Instruct the client on the need for lifelong medication use and to
avoid anticholinergic medications.
Instruct the client to report eye pain, halos around the eyes, and
changes in vision to the physician.
Teach the client that when maximal medical therapy has failed to
halt the progression of visual field loss and optic nerve damage,
surgery will be recommended.
Prepare the client for trabeculoplasty as prescribed to facilitate
aqueous humor drainage and to allow drainage of aqueous humor
into the conjunctival spaces before the creation of an opening.

B. CATARACT

A cataract is a cloudy or opaque area (an area you cannot see through) in the
lens of the eye. It is an opacity of the lens that distorts the image projected onto
the retina and that can progress to blindness.

Alternative Names: Lens opacity.

Causes, Incidence, and Risk Factors:

The lens of the eye is normally clear. If the lens become cloudy , the
condition is known as cataract. Rarely, cataracts may be present at or shortly
after birth. These are called congenital cataracts.

Adults cataracts usually develop with advancing age and may run in families.
Cataracts develop more quickly in the presence of some environmental factors,
such as smoking or exposure to other toxic substances. They may develop at any
time after an eye injury. Metabolic disease such as diabetes also greatly increase
the risk for cataracts. Certain medications, such as cortisone, can also accelerate
cataract formation.

Congenital cataracts may be inherited. The gene for such cataracts is

dominant (autosomal dominance inheritance), which means that the defective
gene will cause the condition even if only one parent passes it along. If families
where one parent carries the gene, there is 50% chance in every pregnancy that
the child will be affected.

94

www.nurseslabs.com
95

Congenital cataracts can also be caused by infections affecting the mother

during pregnancy, such as rubella. They are also associated with metabolic
disorders such as galactosemia. Risk factors include inherited metabolic disease,
a family history of cataracts, and maternal viral infection during pregnancy.

Adult cataracts are generally associated with aging. They develop slowly and
painlessly, and vision in the affected eye or eyes slowly gets worse.

Visual problems may include the following changes:

Difficulty seeing at night

Seeing halos around lights
Being sensitive to glare.

Vision problems associated with cataracts generally move towards decreased

vision, even in daylight.

Adults cataracts are classified as immature, mature, and hypermature. A lens

that has some remaining clear areas is referred to as an immature cataract. A
mature cataract is completely opaque. A hypermature cataracts has a liquefied
surface that leaks through the capsule, and may cause swelling and irritation of
other structures in the eye.

Most people develop some clouding of the lens after the age of 60. About
50% of people aged 65-74, and about 70% of those 75 and older, have cataracts
that affect their vision.

Most people with cataracts have similar changes in both eyes, although one
eye may be worse than the other. Many people with this condition have only
slight visual changes, and are not aware of their cataracts.

Factors that may contribute to cataract develop are low serum calcium levels,
diabetes, long-term use of corticosteroids, and various inflammatory and
metabolic disorders. Environmental causes include trauma, radiation exposure,
and too much exposure to ultraviolet light (sunlight).

Symptoms

Cloudy, fuzzy, foggy, or filmy vision

Loss of color intensity

Frequent changes in eyeglass prescription

The glare from bright lights causes vision problems at night, especially
while driving

Sensitivity to glare from lamps or the sun

Halos around lights

95

www.nurseslabs.com
96

Double vision in one eye

Decreased contrast sensitivity (the ability to see shades, or shapes

against a background)

Signs and tests

Standard ophthalmic exam, including slit lamp examination

Ultrasonography of the eye in preparation for cataract surgery

Other tests that may be done (rarely) include:

Glare test

Contrast sensitivity test

Potential vision test

Specular microscopy of the cornea in preparation for cataract surgery

Treatment

The only treatment for cataract is surgery to remove it. This is done when a
person cannot perform normal activities, even with glasses. For some people,
changing glasses, getting stronger bifocals, or using a magnifying lens is helpful
enough. Others choose to have cataract surgery.

If a cataract is not bothersome, then surgery is usually not necessary.

Sometimes there is an additional eye problem that cannot be treated without
first having cataract surgery.

Cataract surgery consists of removing the lens of the eye and replacing it with an
artificial lens. A cataract surgeon will discuss the options with the patient, and
together they will decide which type of removal and lens replacement is best.

LENS REMOVAL:

There are 2 types of surgery that can be used to remove lenses that have a
cataract.

Extracapsular surgery consists of surgically removing the lens, but leaving

the back half of the capsule (the outer covering of the lens) whole. High-
frequency sound waves (phacoemulsification) may be used to soften the lens to
help removing it through a smaller cut. With extracapsular extraction, the lens is
lifted out without removing the lens capsule; the procedure may be performed
by phacoemulsification in which the lens is broken up by ultrasonic vibrations and
is extracted.

Intracapsular surgery involves surgically removing the entire lens,

including the capsule. Today this procedure is done very rarely. In this
procedure, lens is removed within capsule through a small incision.

LENS REPLACEMENT:

People who have cataract surgery are usually fitted with an artificial lens at
the same time. The artificial lens is a synthetic (manufactured) disc called an
intraocular lens. It is usually placed in the lens capsule inside the eye.

Other options include contact lenses and cataract glasses.

Surgery can be done in an outpatient center or hospital. Most people do not need
to stay overnight in a hospital. The patient will need a friend or family member

96

www.nurseslabs.com
97

to assist with travel and home care after outpatient surgery. Follow-up care by
the surgeon is important.

NURSING INTERVENTIONS

Preoperative Interventions

Instruct the client regarding the postoperative measures to prevent or

decrease intraocular pressure.
Administer eye medications preoperatively, including mydriatics and
cycloplegics as prescribed.

Postoperative Interventions

Elevate the head of the bed 30- 45 degrees.

Turn the client to the back or unoperative side
Maintain an eye patch; orient the client to the environment
Position the clients personal belongings to the unoperative side
Use side rails for safety
Assist with ambulation

AGE RELATED MACULAR DEGENERATION

Previously known as the senile macular degeneration, age related macular

degeneration is an atrophic degenerative process that affects the macula and
surrounding tissues, resulting in central visual deficits.

Age related macular degeneration can be found in some degree to some

adults over the age of 65. It is one of the most common causes of visual loss in
the elderly. The exact etiology is unknown, but the incidence increases with each
decade over 50. It may also be hereditary.

Age- related macular degeneration falls into two categories:

1. Nonexudative
2. Exudative
Both are usually bilateral and progressive.
Also referred to as dry macular degeneration, nonexudative age
related macular degeneration is characterized by atrophy and
degeneration of the outer retina and underlying structures. Yellowish
round spots called drusen may be seen in the retina and macula with an
opthalmoscope. Drusen are deposits of amorphous material from the
pigment epithelial cells of the retina. Overtime, these spots increase,
enlarge and may calcify.
At this, wet, exudative stage of age-related macular degeneration,
Bruchs membrane, which lies just beneath the pigment epithelial cell
layer of the retina, becomes compromised and this results in serous fluid
leaks from the colloid with accompanying proliferation of choroidal blood
vessels.
A dome-shaped retinal pigment epithelium may be seen when
examining the fundus. These leak produce a visual effect called
tamorphopsia, which is the blurred, wavy distortion vision. The client may
also notice blurred scotomo or decrease central visual acuity. Fundus
photograpghy and angiography may be performed on a regular basis of
documents and evaluate changes.

Management

There is no known means of medical treatment or prevention for age elated

macular degeneration. Further damage from exudative macular degeneration
sometimes may be arrested by the use of argon photocoagulation, even though
laser bamage to the retina in this area results in a blind spot. When the fovea is
involved, central vision is lost and he only helpful measures are low-vision aids.

97

www.nurseslabs.com
98

The client with age-related macular degeneration is threatened with the loss
of central vision. In order to evaluate change in vision, the client is taught to use
an Amsler grid at home. The nurse may be able to assist the client to maximize
remaining vision with low vision aids and community referral to a low vision
specialist and low vision support groups.

A. RETINAL DETACHMENT

Retinal detachment occurs when the layers of the retina separate because of
the accumulation of fluid between them, or when both retinal layers elevate
away from the choroid as a result of a tumor. Partial separation becomes
complete if untreated. When detachment becomes complete, blindness occurs.

Assessment

Flashes of lights
Floaters
Increase in blurred vision
Sense of curtain being drawn
Loss of a portion of the visual field

Immediate Interventions
Provide bed rest
Cover both eyes with patches to prevent further detachment
Speak to the client before approaching
Position the client head as prescribed
Protect the client from injury
Avoid jerky head movements
Minimize eye stress
Prepare the client for the surgical procedure as prescribed.

Surgical Procedures

Draining fluid from the subretinal space so that the retina can return to
the normal position.
Sealing retinal breaks by cryosurgery, a cold probe applied to the sclera,
to stimulate an inflammatory response leading to adhesions.
Diathermy, the use of an electrode needle and heat through the sclera, to
stimulate an inflammatory response.
Laser therapy to stimulate an inflammatory response, to seal small retinal
tears before the detachment occurs.
Sclera buckling, to hold the choroid and retina together with a splint until
scar tissue forms closing the tear.
Insertion of gas or silicon oil to encourage attachment because these
agents have a specific gravity less than vitreous or air and can float
against the retina.

Postoperative Interventions

Maintain eye patches bilaterally as prescribed.

Monitor for hemorrhage.
Prevent nausea and vomiting and monitor for restlessness, which can
cause hemorrhage.
Monitor for sudden sharp eye pain and monitor the physician.
Encourage deep breathing exercise but avoid coughing.
Provide bed rest for 1-2 days and position the client as prescribed.
If gas has been inserted, position the client as prescribed on the
abdomen and turn the head so unaffected eye is down.
Administer eye medications as prescribed.
Assist the client with activities of daily living.
98

www.nurseslabs.com
99

Avoid sudden head movements or anything that increases intraocular

pressure.
Instruct the client to limit reading for 3-5 weeks.
Instruct the client to avoid squinting, straining and constipation, lifting
heavy objects and bending from the waist.
Instruct the client to wear dark glasses during the day and an eye
patch at night.
Encourage follow-up care because of the danger of recurrence in the
other eye.

REFRACTIVE DISORDERS

Light is bent (refracted) as it passes through the cornea and lens of the eye.
Refractive errors exist when light rays are not focused appropriately on the retina
of the eye. Three basic abnormalities of refraction occur in the eye:
1)myopia
2)hyperopia,
and3)astigmatism.
Optical correction is important to distinguish between visual loss caused by
disease and visual loss caused by refractive error. Refractometry is the
measurement of refractive error and should not be confused with refraction, the
method used to determine which lens or lenses (if any) will most benefit the
client.

a. Myopia
Myopia, or nearsightedness, is a condition in which the light rays
come into focus in front of the retina. In this case the refractive
power of the eye is too strong and a concave, or minus, lens is
used to focus light rays on the ey. In most cases myopia is caused
by an eyeball that is longer than normal, which may be a familial
triat. Transient myopia may occur with the administration of a
variety of medications (sulfonamides, acetozolamide, salicylates,
and steroids) and has been associated with other disorders, such
as influenza, typhoid fever, severe dehydration, and large intakes of
antacids. Correction is accomplished with eyeglasses or contact
lenses.

b. Hyperopia
The hyperopic, or farsighted, eye focuses light rays behind the eye,
and consequently the image that falls on the retina is blurred.
Vision may be brought into focus by placing a convex, or plus, lens
in front of the eye. The lens supplies the magnifying power that the
eye is lacking. Hyperopia may be caused by an eyeball that is
shorter than normal or a cornea that has less curvature than
normal. Because children have a greater ability to accommodate,
they are less often affected than adults. Demands for close work
and reading usually bring on manifestations of headache or eye
strain. Correction is based on a persons age and individual needs
and complaints.
c. Astigmatism
Astigmatism is a refractive condition in which rays of light are not
bent equally by the cornea in all direction so that a point of focus is
not attained. In most instances, astigmatism is caused because the
curvature of the cornea is not perfectly spherical. This is the cause
of poor vision for both distant and near objects. Astigmatism is
corrected with cylindrical lenses.

Surgical management
The following are the three main types of refractive surgery and new procedure.

99

www.nurseslabs.com
100

Laser in situ keratomileusis (LASIK) is currently the most commonly used

corrective surgery for nearsightedness in the United States. An extremely thin
layer of the cornea is peeled back for the laser reshaping on the middle layer of
the cornea and then put back in place. There is little postoperative discomfort,
rapid recovery of clear vision, and quick stabilization of refractive change. LASIK
is performed in a surgeons office or samed-day surgery center and does not
require a hospital stay. It takes about 10-15 minutes per eye. It has a high
success rate and low complication rate for low to moderate nearsightedness and
may also be used to correct more severe nearsightedness.

Excimer laser photorefractive keratectomy (PRK) uses short-wavelenght, high-

energy ultraviolet radiation laser to reshape the corneal surface. In PRK for
myopia, the central cornea is flattened with the excimer laser. The same laser
may be used to reshape the cornea by making the central curvature steeper to
correct hyperopia. It may be used to correct nearsightedness and astigmatism at
the same time. PRK is performed on an outpatient basis in a surgeons office or
same-day surgery center. The PRK procedure takes about 30 minutes, most of
which is spent teaching the client to hold the eye still. The actual treatment
takes less than a minute. Recovery from PRK is longer and more painful than
recovery from ether radial keratotomy (RK) or LASIK. Vision will be reduced for
several days after surgery.

Radial keratotomy (RK) involves making tiny cuts in the cornea, which flatten
it and reduce nearsightedness. In people who have both astigmatism and
nearsightedness, the surgeon may make additional cutrs to flatten the
misshapen part of the cornea that is causing the astigmatism. RK is an
outpatient procedure. It is done under local or topical anesthesia in a surgeons
office or same day surgery center.

Corneal ring implants are clear pieces of acrytic that can be surgically
implanted into the cornea. The implants are shaped like crescents or half circles.
Two implants are used for each eye, and the implants are inserted along the
sides of the cornea.

Nursing management of the surgical client

Clients are assessed preoperatively for degree of myopia or astigmatism. Clients

with a severe case usually cannot achieve full correction. Surgery is performed
on an out patient basis with local anesthesia. Eye protection is used, such as
goggles to prevent dry eyes. Vigorous activities, activities that cold get water in
the eye, and eye makeup are to be avoided. The eye is treated with steroid eyed
drops, and most clients report watering of the eyes and minimal pain. Refraction
slowly stabilizes after surgery. There is a period of adjustment during which
visual acuity waxes and wanes. Reduced contrast sensitivity in night vision and
daytime glare is common. Some clients require re treatment for scarring that is
unresponsive to topical steroids.

Infectious and Inflammatory Conditions

Inflammation and infection of eye structures are common. Eye infection is a

leading cause of blindness worldwide.

Dry eye syndrome

Dry eye syndrome, or keratoconjuctivitis sicca, is a deficiency in the production

of any of the aquaeous, mucin, or lipid tear film components; lid surface
abnormalities; or epithelial abnormalities related to systemic diseases (eg,
thyroid disorders, Parkinsons disease), infection, injury, or complications of
medications (eg. Antihistamines, oral contraceptives, phenothiazines)

Clinical manifestations

The most common complaint in dry eye syndrome is a scratchy or foreign body
sensation. Other symptoms include itching, excessive mucus secretions, inability
to produce tears, a burning sensation, redness, pain, and difficulty moving the
lids.
100

www.nurseslabs.com
101

Assessment and diagnostic findings

Slit-lamp examination shows an absent or interrupted tear meniscus at the lower

lid margin, and the conjuctiva is thickened, edematous, and hyperemic and has
lost its luster. A tear meniscus is the crescent-shaped edge of the tear film in the
lower lid margin. Chronic dry eyes may result in chronic conjuctival and corneal
irritation that can lead to corneal erosion, scarring, ulceration, thinning, or
perforation that can seriously threaten vision. Secondary bacterial infection can
occur.

Management

Management of dry eye syndrome requires the complete cooperation of the

patient with a regimen that needs to be followed at home for a long period;
otherwise, complete relief of symptoms is unlikely. Instillation of artificial tears
during the day and an ointment at night is the usual regimen to hydrate and
lubricate the eye and preserve a moist ocular surface. Anti-inflammatory
medications are also used, and moisture chambers (eg, moisture chamber
spectacles, swim goggles) may provide additional relief.

Patients may become hypersensitive to chemical preservatives such as

benzalkonium chloride and themerosal. For these patients, preservative-free
ophthalmic solutions are used. Management of the dry eye syndrome also
includes the concurrent treatment of infections such as chronic blepharitis and
acne rasacea, and treating the underlying systemic disease.

Conjunctivitis

Conjunctivitis (inflammation of the conjuctiva) is the most common ocular

disease worldwide. It is characterized by a pink appearance (hence the common
term pink eye) because of subconjuctival blood vessel congestion.

Clinical manifestations

General symptoms include foreign body sensation, scratching or burning

sensation, itching, and photophobia. Conjunctivitis may be unilateral or bilateral,
but the infection usually starts in one eye and then spreads to the other eye by
hand contact.

Assessment and Diagnostic Findings

The four main clinical features important to evaluate are the type of discharge
(watery, mucoid, purulent, or mucopurulent), type of conjuctival reaction
(follicular or papillary), presence of pseudomembranes or true membranes, and
presence or absence of lymphadenopathy (enlargement of the preauricular and
submandibular lymph nodes where the eyelids drain). Pseudomembranes consist
of coagulated exudates that adheres to the surface to the superficial layer of the
ocnjuctiva, and moval results in bleeding. Follicles are multiple, slightly elevated
lesions encircled by tiny blood vessels; they look like grains of rice. Papillae are
hyperplastic conjuctival epithelium in numerous projections that are usually seen
as a fine mosaic pattern under slit-lamp examination. Diagnosis is based on the
distinctive characteristics of ocular signs, acute or chronic presentation, and
identification of any precipitating events. Positive results of swab smear
preparations and cutures confirm the diagnosis

Types of conjunctivitis:

1. Microbial conjunctivitis

Bacterial conjunctivitis can be acute or chronic. The acute type can develop into
a chronic condition. Signs and symptoms can vary from mild to severe. Chronic

101

www.nurseslabs.com
102

bacterial conjunctivitis is usually seen in patients with lacrimal duct obstruction,

chronic dacryocystitis, and chronic blepharitis. The most common causative
microorganisms are streptococcus pneumoniae, haemophilus influenzae, and
staphylococcus aureaus. It is manifested with an acute onset of redness,
burning, and discharge.

2. Viral conjunctivitis

Viral conjunctivitis can be acute and chronic. The discharge is watery, and
follicles are prominent. Severe cases include psudomemebranes. The common
causative organisms are adenovirus and herpes simplex virus. Conjunctivitis
caused by adenovirus is highly contagious. The condition isusually preceded by
symptoms of upper respiratory infection. Corneal involvement causes extreme
photophobia. Symptoms include extreme tearing, redness, and foreign body
sensation that can involve one or both eyes. There is lid edema, ptosis, and
conjuctiva hyperemia (dilation of the conjuctival blood vessels). These signs and
symptoms vary from mild to severe and may last for 2 weeks.

3. Allergic conjunctivitis

Immunologic or allergic conjunctivitis is a hypersensitivity reaction that occurs as

part of allergic rhinitis (hay fever), or it can be an independent allergic reaction.
The patient usually has a history of an allergy to pollens and other environmental
allergens. There is extreme pruritus, epiphora (excessive secretion of tears),
injection, and usually severe photophobia.

4. Toxic conjunctivitis

Chemical conjunctivitis can be the result of medications; chlorine from swimming

pools; exposure to toxic fumes among industrial workers; or exposure to other
irritants such as smoke, hair sprays, acids, and alkalis.

Management

The management of conjunctivitis depends on the type. Most types of mild and
viral conjuctivits are self-limiting, benign conditions that may not require
treatment and laboratory procedures. For more severe cases, topical antibiotic
therapy, eye drops, or ointments are prescribed. Patients with gonococcal
conjunctivitis require urgent antibiotic therapy. If left untreated, this ocular
disease can lead to corneal perforation and blindness. The systemic
complications can include meningitis and generalized septicemia.

UVIEITIS

Inflammation of the uveal tract (uveitis) can affect the iris, the ciliary body, or
the choroids. There are two types of uveitis: nongranulomatous and
granulomatous.

The more common type of uveitis is the nongranulomatous type, which

manifests as an acute condition with pain, photophobia, and a pattern of
conjuctival injection, especially around the cornea. The pupil is small or irregular,
and vision is blurred. There may be small, fine precipitates on the posterior
corneal surface and cells in the aqueous humor. If the uveitis is severe, a
hypopyon (accutmulation of pus in the anterior chamber) may occur. The
condition may be unilateral or bilateral and may be recurrent.

Management

Because photophobia is a common symptom, patients should wear dark glasses

outdoors. Ciliary spasm and synechia are best avoided through mydriasis;
cyclopentolate and atropine are commonly used. Local corticosteroid drops such
as Pred Forte 1% and Flarex 0.1%, instilled four to six times a day are also used
to decrease inflammation. In very severe cases, systemic corticosteroids as well
as intravitreal corticosteroids, may be used.

102

www.nurseslabs.com
103

DISORDER OF THE AUDITORY SYSTEM

Ear disease causes significant discomfort and hearing loss. It also creates
work loss and decrease productivity- this increases as the persons
communicative skills decrease when associated hearing loss increases. In
children, developmental delays and academic failure may result due to
manifestation of auditory problem if not properly treated. Ear complications such
as deafness, meningitis, brain abscesses, and facial nerve paralysis may also
occur. Proper management of ear disease is critical and immediate attention is
necessary.

COMMON DISEASE AND DISORDER OF THE MIDDLE EAR

Otitis Media (Middle Ear Infections)

The basic underlying problem causing most forms of otitis media is

Eustachian tube dysfunction. Most otitis occurs in patients whose Eustachian
tube, the tube between the nose and the middle ear the area behind the
eardrum, does not work properly. When air cannot adequately get through this
tube to the middle ear, the negative pressure created can suck fluid out of the
lining of the middle ear/mastoid, filling the middle ear and mastoid air cells with
fluid. A mild hearing loss usually accompanies the fluid. The hearing loss
disappears when the fluid is gone as long as there are no other causes for the
hearing loss. Three kind of otitis can result from Eustachian tube dysfunction.
They are serous and secretory otitits, where fluid fills the middle ear and
mastoid, acute otitis, where pus fills the middle ear and mastoid but its
presences is of short duration, chronic otitis, where pus fills the middle ear and
mastoid and it has been present for months or years. Chronic otitis is associated
with infection of the bone itself and thickening and polyp formation of the
mucosal lining of the middle ear and mastoid. The highest incidence of otitis
media occurs in preschool children and decreases gradually after age 6. The
highest incidence occurs poor children, children in day care, and Native
Americans. Additional factors that cause or aggravate otitis include the presence
of enlarged adenoid tissue, lack of proper muscle in the back of the throat (as in
those with a cleft palate), allergy, immune deficiencies, sudden change in
atmospheric pressure (like poor pressurization in an airplane dropping from a
high altitude), scarring or tumors in the nasopharynx, and abnormal cell function
of the mucosa of the ear and nose. Diabetes does not increase the incidence of
otitis, but can make it much more difficult to treat.

Types of Otitis Media

Serous otitis- where fairly clear fluid fills the middle ear and mastoid
occurs with fairly sudden obstruction of the eustachian tube. A sudden
descent of an airplane with poor pressurization or a bad cold are two of
the most common causes of acute serous otitis media. Usually

103

www.nurseslabs.com
104

decongestants will clear the fluid or even bloods that can be sucked from
the mucosa into the middle ear with wither of these processes. If the fluid
does not clear within a few weeks, it is considered chronic serous otitis.
Older people with poorly functioning eustachian tubes commonly have
recurrent serous otitis and may require intermittent tube placement over
many years. Hearing loss is present depending on the amount of fluid in
the ear. The hearing loss usually resolves when the fluid is cleared out of
the ear, either medically or surgically.

Secretory otitis- where somewhat thicker fluid fills the middle ear and
mastoid is common in small children and is often "outgrown" by the time
they reach their teens. It is the most common disease process requiring
the placement of PE tubes. This thicker fluid has components that are
actually "secreted" by the mucous glands of the middle ear. There are
actually tissue breakdown enzymes in this fluid; that, if left untreated, can
gradually eat away bone and cause chronic hearing loss/damage. Luckily,
it generally takes quite a while for these enzymes to cause damage to the
ear, so treating secretory otitis in children with medication for a few weeks
or months is safe. Leaving this kind of fluid in an ear for more than
several months, however, places the ear tissues (including the tiny ear
bones) at risk of damage or destruction by these enzymes. Not treating
infections with antibiotics at all places the ear structure at even higher
risk of permanent damage/destruction by the fluid.

Acute otitis- occurs when pus fills the middle ear. It is usually sudden in
onset and is often associated with sudden obstruction of the eustachian
tube at the same time infections bacteria are present to cause the acute
otitis. Without antibiotic treatment, a true bacterial acute otitis is often
associated with sudden perforation of the eardrum, with profuse drainage
from the ear. Often the eardrum will spontaneously heal over after the
infection has resolved, but a perforation can be left and damage to the
middle ear and/or the inner ear can accompany the infection. The
eardrum may be bright red or the creamy color of the fluid can sometimes
be seen through the eardrum. It sometimes looks "soggy." Pain and fever
may accompany an ear infection, but usually disappear rapidly if the
eardrum perforates. Pain and fever are rarely present if there is a whole
(perforation) in the eardrum before the infection starts. The standard
treatment of acute otitis media is oral antibiotics. Ear drops are added if
the eardrum perforates. IV antibiotics are indicated for severe infections,
if the mastoid bone is also infected, or if the facial nerve becomes
paralyzed as a "complication" of the acute infections. Hearing loss is
present but usually goes away when the infection clears.

Chronic otitis-occurs when chronic infection fills the middle ear space
and mastoid cavity. True chronic otitis media is almost always a form of
chronic mastoiditis, where the bone of the mastoid cavity (the
honeycombed bone behind the ear) is chronically infected along with the
tissues of the middle ear space. It is important to realize that antibiotics
alone usually cannot remove infection from the bone; surgical removal of
the infected bone is usually necessary to accomplish this. Even IV
antibiotics do not often eradicate a true bone infection, especially in the
mastoid, which has its connection to the bacteria-filled nose through the
eustachian tube. A cholesteatoma is a common additional finding along
with chronic otitis and mastoiditis. A cholesteatoma is a skin sac that
grows back into the middle ear or mastoid from the eardrum, creating a
mass of skin and debris that keeps getting larger and larger over time,
destroying anything in its path. The ear bones, the inner ear, the facial
nerve (the nerve that makes all the muscles of one side of your face
work), and the brain next to the ear can all be damaged or destroyed by
either spreading infection or cholesteatoma. These diseases must be
removed fore the safety of the ear, the head, and the brain. Infection or
cholesteatoma involving the inner ear, facial nerve, or the brain requires
immediate attention by an ear surgeon and often required immediate
surgery.

Symptoms of Middle Ear Infection

104

www.nurseslabs.com
105

Earache

Headache

Fever

Discharge from the ear

Mild deafness

Difficulties in sleeping

Loss of appetite.

The causes of middle ear infection:

A progressive head cold

A viral sinus infection that spreads

An otitis externa infection left too long that spreads to the inner ear

Blowing the nose too hard, forcing sinal or eustachian material into the
middle ear.

An opportunistic infection entering through a perforated eardrum

Treatments for Otitis Media

Mild bacterial infections often clear up by themselves in a matter of days.

Over-the-counter painkillers can help alleviate the pain. Warm olive oil dripped in
the ear can also soothe the pain as long as there is no ruptured eardrum. Repeat
every few hours.

In more severe cases, antibiotics might be needed which usually includes

an initial antibiotic shot, antibiotic pills and ear drops.

In many cases of middle ear infection, the Eustachian tube is blocked and
can cause or at least contributes to a middle ear infection. A Eustachian tube can
become blocked from any combination of the following:

The body's inflammation reaction to an infection, swelling the

Eustachian tube to where it closes completely.

A contributing factor can be the discharge of the dead bacteria and

dead lymphocytes from the middle ear. The lymphatic system contains
the white blood cells or lymphocytes which are the body's defense
against foreign objects such as bacteria. When the white blood cells kill
bacteria, the lymphatic fluid becomes pus-like due to a build up of
dead white blood cells and dead bacteria. This discharge from the
middle ear can irritate the Eustachian tube causing it to close.

A blocked Eustachian tube is often what causes the pain of a middle ear
infection. Pus builds up in the inner ear cavity with no where to go, putting
pressure on the inner ear and the ear drum. If left without treatment, the
pressure can be so great that it bursts the ear drum. The initial excruciating pain
of a burst eardrum is immediately compensated for by pain reduction from the
release of pressure. Whereas, prior to the burst eardrum, sleep was impossible,
the pain relief from the pressure reduction allows the sufferer to finally sleep. If
the middle ear infection is cured on its own, the ruptured ear drum will also
usually heal on its own, although sometimes surgery (tympanoplasty) is
indicated if the rupture is extremely large.

105

www.nurseslabs.com
106

Chronic Suppurative Otitis Media (CSOM)

CSOM is the name given to a condition when there is an infection of the

middle ear which fails to heal and is draining all the time.

Glue Ear

There is a natural flow of fluids from the middle ear (the fluids keep the
middle ear cavity moist) that migrate through the Eustachian tube to the back of
the throat. A blocked Eustachian tube prevents air from reaching the middle ear.
When this happens the middle ear can fill up with the fluid that can becomes
thick, like glue over time. This problem is called glue ear or otitis media with
effusion. The buildup of fluid in the middle ear reduces the movement of the
eardrum and ossicles, and hearing is reduced. This condition is quite prevalent in
children. Glue Ear is not a disorder in itself, it is just a visible symptom of a
discharge of bacterial waste from the middle ear.

Note: Glue ear is sometimes confused by anxious parents with the normal
discharge of wax from a child's ear canal. During an infant or child's growth,
there may be periods when ear wax is produced more copiously than normal,
causing wax to leak from the ear.

How to tell the difference:

If the child has not had a fever then it is a normal wax discharge

If the child has not complained of earache then it is a normal wax

discharge

If the discharge does not have a really smelly odor then it is a normal wax
discharge (there is a slight odor to normal wax, but nothing like that from waste
bacteria from the middle ear)

Predisposition factors for Otitis Media and Glue Ear

There are factors that can increase the risk of a child being susceptible to otitis
media and glue ear:

being a male

short length of breastfeeding

attendance at day care centers

parental smoking

wet climate

winter season

upper respiratory infection

housing with mold

allergies

Symptoms of Glue Ear

106

www.nurseslabs.com
107

A thick liquid discharge from the ear that looks like liquid wax and is
orange in color.

Ear aches

Headaches

Fever

Listlessness

They may be clumsy. With very small infants (1-3 years old), it might also
take them longer to start to walk, speak or understand language.

Older children may be able to tell you if they cannot hear very well. Or
you may notice that they say 'pardon' or 'what' a lot or that they turn the
television up loud. Glue ear also makes older children clumsy and dizzy.

Treatment for Glue Ear

1. Many children recover naturally from glue ear once the Eustachian tube
opens. Doctors usually adopt a wait-and-see approach to begin with. Your
child will normally be observed for about three months to see if they need
further treatment. If the eardrum has burst, it should heal over time
approximately 3-6 weeks.

2. Self medication can be performed by means of an OTC pediatric oral

decongestant to thin the fluid in the ear and help it drain away. The main
purpose of a decongestant is to dry the nasal passages so the Eustachian
tube opens and the fluid drains into the throat. If that does not work you
might want to try a small dose of an antihistamine such as Benadryl. Have
your pharmacist recommend a child's dosage. If that treatment still
doesn't work, see your family doctor or physician. They might prescribe
stronger antihistamines or nasal steroids in the form of drops or sprays -
both of which will help reduce the swelling of the Eustachian tube.

3. The second treatment is if there is a suspected infection. If the eardrum

has burst, this is usually the case. Antibiotics are sometimes prescribed,
often initially by injection, then a regimen orally three times a day for at
least 7 days. In the past, antibiotics such as penicillin, erythrosine, or
erythromycin were prescribed. However, in the last few decades, many in
the general population have become immune to the effects of these
antibiotics, and stronger ones are often prescribed. (The cause of
immunity is often blamed on antibiotics fed to the food supply (chickens
and beef) before they are brought to market).

Surgical Treatments for Glue Ear

Grommets-myringotomy

If your child has had glue ear over a few months and the eardrum
has not burst and antibiotics have not worked, the other option is
to have a small ventilation drain known as a grommet inserted into
the ear drum. The grommet is made of either stainless steel or
plastic. This procedure involves making a small hole in the eardrum
and inserting the grommet through the hole to keep it open.
107

www.nurseslabs.com
108

Initially fluid is sucked out of the middle ear through this hole, then
over a few months, the grommet lets air into the middle ear space
and lets fluid in the middle ear drain away. There are only simple
precautions to stop water getting into ear like swimming on the
surface of the water only and not dive and you need to use
earplugs or cotton wool with Vaseline to stop soap water getting
into the ears when showering or washing hair.

Plastic
grommet to
drain middle
ear fluids

Adenoidectomy

It is a surgical treatment for glue ear which aimed to remove the

adenoids. The adenoids are located above the tonsils, at the back of the
throat and are thought to assist the body in its defense against incoming
bacteria and viruses by helping the body to form antibodies. With ear
infections, the adenoids often swell, usually due to an infection in the
immediate area, in this case, the middle ear.

Tubo-Tympanic Otitis Media

The tubo-tympanic form usually involves a perforation of the central

part of the eardrum. This can be caused by infection, injury or surgery.

Symptoms of tympanic otitis media (triad)

Hearing loss

Discharge (which may come and go, and will become noticeable
particularly if you get a cold or the ear gets wet)

Tinnitus.

Treatment of tympanic otitis media

If the opening is not too large, it may close and heal on its own.
Failing that, an ENT specialist may close it with surgery or by
covering it with a special material to keep the opening closed while
it heals.

108

www.nurseslabs.com
109

You can usually help the symptoms by taking simple steps like
wearing an ear plug or keeping the ear dry when you are having a
bath or swimming. However, you may need an operation to repair
the hole in the eardrum (tympanoplasty or myringoplasty).

Attico-antral

The attico-antral form of CSOM might also involve a hole in the

eardrum usually in the upper part. This form of CSOM can be more of
a problem than the tubo-tympanic form because the eardrum sheds
dead skin which can build up and enter the middle ear. There are two
major complications of the attico-antral variant of CSOM -
Cholesteatomas and Mastoid infections (Mastoiditis).

Burst Eardrum

(Perforation of eardrum, Rupture of the tympanic membrane)

In the final stages of a middle ear infection, if the pressure becomes

too much, the eardrum may burst. This is actually a positive event if
controlled properly. The burst eardrum will immediately relieve the
pressure in the middle ear and the accompanying earache will diminish. A
smelly discharge (bacteria detritius from the middle ear) will spill out of
the ear and can be sopped up with a wet rag or a tissue.

Causes of a burst eardrum

External Causes of a Burst Eardrum - An external cause for a

burst eardrum is a head trauma such as a blow to the ear or an
object penetrating the ear canal and penetrating the eardrum.
Usually, the larger the perforation, the greater the loss of hearing.
The location of the perforation in the eardrum also affects the
degree of hearing loss. If severe trauma (skull fracture) disrupts
the bones in the middle ear which transmit sound or causes injury
to the inner ear structures, the loss of hearing maybe quite severe.
With a traumatic or explosive event, the loss of hearing can be
great and tinnitus may be severe. Side effects of a perforated
eardrum will definitely be excruciating pain. You will probably also
suffer from vertigo and tinnitus

Internal Causes of a Burst Eardrum- Perforated eardrums from

internal causes are usually from middle ear infections or otitis
Media. Detritus from the infection in the inner ear causes pressure
to build in the middle ear cavity and if not relieved, the eardrum
will burst outward.

Symptoms of a burst eardrum from internal causes

Sharp pain as the eardrum bursts, then initial pain relief.

Pus discharge from the ear, and usually very smelly
Bleeding from the ear
Hearing loss
Tinnitus
Vertigo
Throbbing pain as the middle and inner ear is subjected to direct contact
with the air

Treatment for a Burst Eardrum

109

www.nurseslabs.com
110

If you have had a middle ear infection that pushed out the eardrum, then
the throbbing pain has been greatly diminished. Wipe off the smelly pus
with a damp cloth, and sit quietly with a warm compress on that side of
the head.
Antibiotics are usually prescribed, sometimes initially by injection, then a
regimen orally three times a day for at least 7 days.
If the perforation is very small and it does not heal after 2-3 weeks, an
ENT may decide not to operate and allow nature to take its course and let
the eardrum heal naturally.
For a larger tear, an outpatient visit to the ENT will allow a small patch
(taken from under the skin behind the ear perhaps) to be attached (not
completely covering the hole) over the hole to help it shrink and
encourage new skin growth.
Another technique an ENT may use to encourage healing is to add a
chemical to the edges of the hole to stimulate growth and then place a
thin paper patch on the eardrum to act as a base for skin growth over the
hole.
There are a variety of surgical techniques, but all basically place tissue
across the perforation allowing healing. The name of this procedure is
called tympanoplasty or myringoplasty. Surgery is typically quite
successful in closing the perforation permanently, and improving hearing.

Allowable sound exposure times

110

www.nurseslabs.com
 Sound Level Intensity Maximum Hours of Exposure

In dBa Per 8-Hours Workday

111
80 dBa 24 hrs.

82 dBa 16 hrs.

83 dBa 12 hrs., 40 mins.

84 dBa 10 hrs., 04 mins.

85 dBa 8 hrs.

86 dBa 6 hrs., 21 mins.

87 dBa 5 hrs., 03 mins.

88 dBa 4 hrs.

89 dBa 3 hrs., 10 mins.

90 dBa 2 hrs., 31 mins.

91 dBa 2 hrs.

92 dBa 1 hr., 34 mins.

93 dBa 1 hr., 16 mins.

94 dBa 1 hr.

95 dBa 48 mins.

96 dBa 38 mins.

97 dBa 30 mins.

98 dBa 24 mins.

99 dBa 19 mins.

100 dBa 15 mins.

101 dBa 12 mins.

102 dBa 9 mins., 6 secs.

103 dBa 7 mins., 30 secs

106 dBa 3 mins., 45 secs

108 dBa 1 min., 52 secs

112 dBa 56 secs

115 dBa 28.07 secs

118 dBa 14.03 secs

121 dBa 7.01 secs

124 dBa 3.31 secs

127 dBa 1.45 secs

130 dBa .52 secs

133 dBa .26 secs 111

136 dBa .13 secs
www.nurseslabs.com
139 dBa .06 secs
112

Mastoid infection (Mastoiditis)

The mastoid is part of the skull and is made up of spongy bone just
behind the ear. Mastoiditis is an infection of the bony air cells in the
mastoid bone. In fact the middle ear and the inner ear are embedded in
the mastoid bone.
Indications of a mastoid infection are reddening and swelling
behind the ear. The cause is usually from an untreated middle ear
infection, so otitis media symptoms are often present. An untreated
middle ear infection can slowly spread into the mastoid cells. When
infection becomes trapped in the mastoid it is known as mastoiditis.

Note the mastoid bone Another example showing a

swelling behind the child's right ear being pushed
ear forward by the mastoid infection

Symptoms of mild mastoiditis

Reddening behind the ear

Swelling
112

www.nurseslabs.com
113

Sensitive to touch.

Symptoms of acute mastoiditis

Pronounce bulbous swelling that can push the ear forward (acute)
Large swelling behind the ear
High fever
Ear pain
Sensitive to touch
Hearing loss
Paralyzed facial nerves (serious cases)

Treatment for Mastoiditis

Antibiotics are the normal treatment for the mild of mastoiditis.

There are a number of antibiotics available to treat. Because there are few blood
vessels permeating the mastoid area, a normal 10 day protocol of antibiotics
may be extended to 14 days to make sure the medicine penetrates the bony
mass. While in acute form of mastoidectomy is inevitably needed.

Diagnostic Procedures for Mastoiditis

A number of procedures will usually be performed in a hospital setting to

ascertain the extent of the diseases progress and to rule out any complications.
A CT scan and X-rays will be used to assess the extent of the infection. To assist
with diagnostic procedures an antibiotic therapy through IV is needed, and if the
eardrum has not burst, a small incision will be made in the eardrum
(myringotomy) to allow drainage of the infection.

Mastoid Surgery- Mastoidectomy

A mastoidectomy is done under general surgery. It involves drilling away

the infected bone. This aims to remove all the infected bone. An incision is made
behind the ear and flap is lifted forward.

A circle is cut out of the bone covering the mastoid and showing the
infected area. The spongy mass that is infected is then cut away and removed.
The remaining cavity is cleaned, coated with antibiotics and if possible the bone
cover is place back to the rest of the skull, and the flap of skin stitched back
together. An outer pressure dressing is then worn for 1-2 days after surgery. If
too much mastoid material has been removed, and it is not possible to reattach
the bone covering, it is left off and the skin flap is stitched back to the
surrounding tissue. After healing, there will be depression behind the ear.

113

www.nurseslabs.com
114

The stay in the hospital is usually 1-3 days. After discharged from the
hospital, a full regimen of antibiotics will be given (10-14 day regimen). The
stitches will be removed after about 2 weeks. Full recovery will take 3-4 weeks
with possibly bouts of dizziness and headache during this time. Over time
headaches and dizziness should diminish.

Cholesteatoma

A cholesteatoma occurs if skin from the inner side of the tympanic

membrane sloughs off and mixes with ear wax that penetrates the open
hole in the eardrum to the middle ear chamber and fails to drain through
the Eustachian tube. Over time the accumulation of dead skin and wax
causes a cyst-like mass to grow -cholesteatoma. If left untreated and the
mass becomes larger, the mass can put pressure to nearby parts of the
ear causing serious damage such as the eardrum and ossicles. In serious
cases, cholesteatomas have been known to penetrate into the mastoid
area causing infection or into the cranial chamber causing meningitis-
infection of the covering of the brain or the meninges.

Symptoms

The attico-antral form of the condition initially causes a smelly discharge to leak
from the ear. You may also have a hearing loss and sometimes tinnitus. You can
get vertigo - dizziness - if the semicircular canals, which form part of the balance
system, are also affected.

Signs of cholesteatoma

114

www.nurseslabs.com
115

Extreme pain, especially in the side of the head where the problem is

Continual vertigo and nausea

Loss of hearing

A gradual weakening of the facial muscles causing a droopy look on one

side as if recovering from a stroke

Headaches similar to migraines

Treatment for Cholesteatoma

It is important to remove the cholesteatoma and all traces of infection. For this,
it is usually necessary to have a surgical procedure known as mastoidectomy.
Once the middle ear chamber is opened, the mass is removed and the surgeon
will check to make sure the ossicles are not damaged and that the
cholesteatoma has not penetrated to other areas of the cranium.

Damaged Ossicles (Ossicular Chain Disruption)

Causes of Damaged Ossicles

Trauma to the ear drum from external sources.

Continuous infections can slowly dissolve one or all three of the bones
that make up the ossicles.
Genetics: Babies are sometimes born with malformed ossicles. They can
be repaired or replaced by having an operation called an ossiculoplasty.

Surgical Procedures (Ossiculoplasty)

As with mastoid surgery, an incision is made behind the ear and a flap of skin
pulled back to access the inner ear chamber. The damaged ossicles is removed
and matched against various sized artificial bones to get a close match.

Titanium is often used to replace one or more of the bones and is custom
fitted for each patients unique bone lengths. Titanium is used as the body will
not reject the metal and after time will actually grow a slime covering over the
metal. The ossicles are very small and this makes the surgery very delicate.
Patients are put under local or general anesthesia in a hospital and the implant
procedure usually lasts about two hours. Because of the small size of the bones

115

www.nurseslabs.com
116

and the small workspace of the middle ear (about a 1" chamber), surgery is
performed using a special microscope. For more serious middle and inner ear
operations that are performed under general surgery, robotic machines are used.

Otosclerosis

Otosclerosis is a spongy bone-like tissue that grows at the place where

the stapes meets the oval window of the cochlea. As this growth grows, it slowly
prevents the ossicles from moving well. Otosclerosis is the most frequent cause
of middle ear hearing loss and affects about 10% of the United States
population. It is most commonly seen in more women than men often during
pregnancy, implying a hormonal cause. Caucasians are more likely to have this
disorder than any other race. Only 1% of African Americans have otosclerosis. It
is also rare among Orientals and Native Americans.

Image of otosclerosis occurring between the stapes and the oval window of the
cochlea.

Causes of Otosclerosis

The causes of otosclerosis are not exactly known. However, the most
generally accepted theory is that it has a genetic basis, combined with hormonal
production abnormalities. The gene that cause the otosclerosis appears to be a
dominant, rather than a recessive gene, but it has a characteristic called
reduced penetrance meaning it does not always dominate over a normal gene.
At first, hearing loss occurs in the low frequencies. High frequencies are affected
next, followed by the loss of hearing in the middle frequencies. Otosclerosis
usually begins in one ear, but the other ear often develops it as well. If left
untreated, otosclerosis will cause the hearing to steadily get worse and can lead
to profound deafness. It is rare for otosclerosis to occur after the age of fifty.

Categories of Otosclerosis

Subclinical Otosclerosis- occurs when the tissue does not interfere with
the ossicles. A person may have this form for many years and not know it.

Clinical Otosclerosis- This type can be present in the teen years, but not
detected until the young adult years.

Histologic Otosclerosis- occurs when the tissue is present, but it does not
grow larger. This rare condition may or may not cause a hearing loss. Very
occasionally, otosclerosis can also affect the inner ear. The condition can
affect either one, or more commonly, both ears.

Symptoms of Otosclerosis

Tinnitus

Hearing loss, often at lower frequencies

116

www.nurseslabs.com
117

You may also find that your hearing is better in noisy surroundings.

People with otosclerosis tend to speak quietly.

Treatment for Otosclerosis

In the early stage of otosclerosis, or when the condition is mild, you might
not need any treatment. Hearing aids are very useful initially. However, as the
tissue builds up on the stapes you will gradually lose your hearing. Sodium
fluoride tablets have been shown to help prevent progression of otosclerosis, but
only if the condition has also affected the inner ear.

Surgical procedures for Otosclerosis

Stapedectomy- this operation aims to improve hearing by replacing the

stapes- one of the ossicles with piston. The piston helps to restore the
movement of the ossicles so transmitting sounds into the inner ear.

Most of the stapes bone is removed, leaving just the portion called
the footplate, which sits in contact with the oval window. The oval window
is the link between the middle and the inner ear. A small hole is then
drilled in the footplate and the piston is inserted so that it sits in contact
with the oval window. At its other end, the piston is attached to the incus,
the middle of the three ossicles.

About 85% of people find the operation a success and report a

good improvement in hearing. However, there is a very small risk of fluid
loss in the years following surgery for example, if you have a sudden
blow to the head or sudden pressure change that cause the piston to
penetrate the membrane of the oval window.

Fenestration- the idea of the operation is that since the oval window is
obliterated by bony growth, a new window (fenestra) needs to be made,
and usually this window is to be drilled into the lateral semicircular canal
level of the promontory.

Stapedolysis (stapes mobilization)- The principle of the surgery is so

simple, if the stapes is stuck, free it. The procedure involves raising the
tympanic membrane, exposing the contents of the middle ear, attaching
the hook like instrument to crus of the stapes, and by jerking it, the
footplate from the otosclerosis growth.

COMMON DISEASE AND DISORDER OF THE INNER EAR

117

www.nurseslabs.com
118

It is estimated that upto 25% of any population in the

industrialized world will experience dizziess, with or without vertigo, at
some point in their lives. Older people experience it morethan the younger
population. It is important to understand that all vertigo comes with
dizziness, but not all dizziness comes with vertigo.

Dizziness

The main symptoms of dizziness include a feeling of light headedness.

There are numerous reasons why a person may be experiencing dizziness. It
may be related to anxiety or panic disorders, or mood disorders. Dizziness in the
form of light-headedness may result from a cardiovascular problem such as an
irregular heart beat (arrhythmia) or if your blood pressure drops when you
change positions (postural hypotension).

There are some medications that may cause light-headedness or

imbalance such as some blood pressure medications (antihypertensives),
medications to control convulsions or spasms (anticonvulsants), calming
medications (sedatives) or medications that help with sleep (hypnotics).
Problems with chemical changes within your body (metabolic problems) may also
cause dizziness, such as if your blood sugar drops too low (hypoglycemia) or
hormonal imbalances.

Symptoms of Dizziness

Light headedness
Motion sickness or nausea
Faintness or weakness

Tinnitus

Another symptom that is sometimes associated with true vertigo is

tinnitus. Tinnitus is noise in the ear that may be heard on and off, continuously
or in a pulsation form. This noise may be buzzing, ringing, roaring, whistling or
hissing. It often goes with many ear disorders, including Menieres disease,
infections such as an inflammation of the middle ear -otitis media, or
inflammation of the internal ear labrynthitis, eustachian tube obstruction or
noise-induced hearing loss.

Two general classes of Tinnitus

Vibratory- appears when the underlying etiology originates from outside

the patients like loud noise and head trauma.

Nonvibratory appears when the cause is due to disease, drugs or some

other internal process

118

www.nurseslabs.com
119

The Semi-Circular Canals as Balancers

The body senses its different positions and controls its balance through
organs of equilibrium (balance) that make you feel stable, or normal. These
organs of balance are located in the inner ear and are called the semicircular
canals. These canals look like loops of tubes. Their connections on one side are
to the cochlea where they receive sounds, and to the aural nerves going to the
brain.

The semicircular ducts are arranged roughly at right angles with each
other so that they represent all three planes in three-dimensional space. The
horizontal duct lies in a plane pitched up approximately 30 degrees from the
horizontal plane of the earth-erect head. The front canals are located in vertical
planes that project forward and outward by approximately 45 degrees. The rear
canals are located in vertical planes that project backward and outward by
approximately 45 degrees.

If you could take the upper portion of each inner ear on each side of the
head, they would be symmetrical the front canal on one side of the head is
parallel to the rear canal on the other.

Messages to the brain as to the head's changes in position are generated

by calcium carbonate crystals that shift on their bed of sensory hairs in the
utriculus and the sacculus. The changes as to which hairs are being stimulated
by the presence of crystals are reported to the cerebellum which in turn,
translates the information into knowledge of the position of the head relative to
gravity.

Vertigo

A major symptom of a balance disorder, it is the sensation of spinning or

swaying while the body is stationary with respect to the earth or surroundings.
The word vertigo comes from the Latin vertere to turn and igo, a condition,
meaning a condition of turning about.

Two classes of vertigo:

Subjective vertigo- is when a person feels a false sensation of

movement.

Objective vertigo- is when the surroundings will appear to move past a

person's field of vision

Symptoms of True Vertigo

Sense of movement

An illusion of spinning and circling

Worsened with head movements

119

www.nurseslabs.com
120

Nausea/vomiting

Episodes come and go

Rhythmic Eye Movement (Nystagmus)

Causes of Vertigo

The cause of all vertigo is when the semi-circular canals are not
functioning properly, ether due to infection, inflammation, trauma, hormonal
imbalances, blood disorders, or scarring. However, for vertigo that lasts off and
on or continuously for a few days, the following are some probable causes.

Low tolerance for vehicular motion such as cars, boats, cruise ships, and
airplanes that cause motion sickness.

A head cold or some infection of the ear or nasal passages that blocks or
swells the eustachian tube.

The subsequent inability of the middle ear to equalize air pressure in the
middle ear chamber causes undue pressure on the inner ear, and
subsequently the semicircular canals where balance is registered.

High blood pressure

High cholesterol

Diabetes

Anemia

Calcium disorders

Alcohol or drug abuse

Brain tumors and Syphilis (rare cause)

Most Common Types of Vertigo

Menieres Disease

Vertigo with hearing loss on one-side, noise in the ear and aural fullness.
Menieres Disease is an inner ear disorder that brings spontaneous episodes of
vertigo that can last minutes to hours. Along with the vertigo, there may be
some hearing loss in the affected ear that comes and goes, as well as an
increase in tinnitus and a sense of fullness in the Menieres affected ear. Between
episodes, you may have a persistent hearing loss and tinnitus in the affected ear.
The vertigo associated with Menieres Disease may happen suddenly, or may
build in intensity over several hours and you may begin to experience nausea or
vomiting.

Causes of Meniere's Disease

The underlying cause of Meniere's Disease is unknown. Meniere's Disease

is felt to be due to an abnormality in the fluid balance of the inner ear.

Symptoms of Meniere's Disease

Lasts minutes to hours

Usually an accompanying hearing loss or a change in hearing

Tinnitus

120

www.nurseslabs.com
121

Feeling of pressure in ears

Possible Treatments for Menieres Disease

The first is to treat the symptoms of vertigo with anti-vertigo medication.

Often an anti-nausea agent is necessary to combat the sick feeling that
comes with vertigo. During and following a vertigo attack, the affected
patient should avoid movements as they may increase the severity of the
symptoms.

The second form of treatment is prevention of further vertigo attacks.

Certain medications are effective in reducing the frequency and severity of
vertigo attacks.

Surgery may be necessary to treat Meniere's Disease. One option is

having surgery to place an antibiotic directly into the inner ear. This may
reduce the attacks of vertigo.

Lifestyle and Diet Changes

There are some changes to diet and lifestyle that may help you
manage Menire's Disease. These include a low-salt diet to help reduce
fluid retention as well as taking a medication that encourages urination.
You should also avoid sudden movements as they may aggravate these
symptoms.

Recurrent Vestibulopathy

Severe vertigo, with or without hearing loss

Patients who suffer multiple episodes of severe vertigo without hearing

loss likely have what is known as recurrent vestibulopathy. These attacks
of vertigo come and go, and last from minutes to hours. This disorder is
therefore similar to the later, but without any hearing loss or noise in the
ear. There is no evidence of brain dysfunction with recurrent
vestibulopathy, and it usually goes away over time. Some recurrent
vestibulopathy may turn into Meniere's Disease or benign paroxysmal
positional vertigo (BPPV).

Causes of Recurrent Vestibulopathy

The cause or causes of recurrent vestibulopathy are unknown.

Symptoms of Recurrent Vestibulopathy

Last minute to hours

No hearing loss or tinnitus

Treatments for Recurrent Vestibulopathy

Treatment for recurrent vestibulopathy is similar to Mnire's

Disease. These may include an anti-vertigo medication and anti-nausea
agent to combat the sick feeling that comes with vertigo.

There are some changes to diet and lifestyle that may help you
manage this type of vertigo. These include a low-salt diet to help reduce
fluid retention as well as taking a diuretic.

Benign Paroxysmal Positional Vertigo or BPPV

Vertigo caused by free floating particles in the inner ear organ of balance
or vestibule

121

www.nurseslabs.com
122

Debris in the posterior semicircular canal of the inner ear (BPPV)

The vestibular system located in and around the ear controls our bodys
sense of balance. When your head moves, the vestibular system sends
information to the organs inside the ear, and these organs then pass the
information on to the brain.

Symptoms of BPVV

Benign paroxysmal positional vertigo (BPPV) results from debris particles

that move freely within fluid in the canals of the inner ear. The debris is not
related to getting anything in the ear canal, it just forms on its own.

A change in your head position, lying down, getting up, turning over in
bed, or tipping your head backwards to look up may cause the debris to shift.
This shifted debris affects the balance receptor in the ear and causes vertigo.
The vertigo associated with BPPV comes on suddenly and usually only lasts for
seconds to minutes. There are usually no hearing symptoms.

Possible Treatments for BPPV

A skilled doctor can perform some maneuvers that can move the debris
out of the sensitive part of the ear (posterior canal). Your doctor can also teach
you how to do certain exercises at home, placing your head in various positions
at different angles. This may help move the debris in your ear as well.

The need for surgery is very rare, but in such cases a procedure known as
posterior canal plugging can be done. This blocks most of the canals function,
which can reduce the symptoms.

Vestibular Neuronitis

Disruption of vestibular input to the brain

The brain and the inner ear communicate information via nerves. The
cochlear nerve carries information about noise and hearing, the vestibular nerve
carries information about balance and body position. Viruses can affect either or
both nerves and the symptoms will vary according to which nerve has been
affected.

Vestibular neuronitis is an inflammation of the vestibular nerve that

causes a disruption of the message sent by the vestibular nerve to the brain. The
first attack of vertigo is usually severe, and is associated with nausea and
vomiting, lasting days to weeks. People with vestibular neuronitis do not have
hearing loss or tinnitus.

122

www.nurseslabs.com
123

Symptoms of Vestibular Neuronitis

Vertigo Lasts days to weeks

No hearing changes

Viral Labyrinthitis

Viral infection of the inner ear

It is a sudden disruption of the messages to the brain from within the

inner ear as a result of a sudden viral infection. As a result of this virus, you may
experience severe vertigo that usually comes on suddenly and can last from days
to weeks, depending on the length of time the body builds up anti-bodies to the
virus. There are no other symptoms related to the ear.

Symptoms of Viral Labyrinthitis

Vertigo Lasts days to weeks

May have hearing changes

Possible Treatments for Either Cause

It is important for people suffering from such symptoms to be examined

and diagnosed by an ENT specialist since other conditions, such as stroke can
present with similar symptoms. There are several medications that your
physician may recommend if they feel that the vertigo associated with the
vestibular neuronitis or viral labyrinthitis requires treatment. These include anti-
vertigo agents, antihistamines, sedatives and or anti-nausea agents.

There are some other things that you can do to help alleviate the
symptoms. Bed rest is recommended for the first 2 to 3 days from the initial
onset of your symptoms. If your vertigo symptoms last more than a few days,
staying active may be more helpful. There are also some exercises that your
doctor may suggest once the vertigo has subsided.

Viral diseases that cause hearing loss:

Cytomegalovirus

Mumps

Acquired Immunodeficiency Syndrome

Herpes

Bacterial diseases that cause hearing loss:

Meningitis

Syphilis
123

www.nurseslabs.com
124

Hearing loss associated with systemic disease

Thyroid Disease

Diabetes Mellitus

Kidney Disease

Multiple Sclerosis

Connective Tissue Disease

Menieres Disease

PEDIATRIC DEAFNESS

Normal hearing requires that all parts of the auditory pathway are working
correctly. This pathway includes the external ear, middle ear, inner ear, auditory
nerve, and the connection between the auditory nerve and the brain. The exact
location and nature of the problem in the auditory pathway determines the type
and severity of a person's hearing loss.

Some causes of hearing loss occur before a baby is born. These include genetic
disorders such as Warrensburg syndrome or Crouzon syndrome and infections
such as congenital rubella or congenital syphilis.

Genetic Factors

About half of all cases of hearing loss among children are thought to result from
genetic factors. Sometimes these children have a syndrome of which hearing loss
is only one feature. However, in most children with hearing loss that is due to a
genetic cause, the hearing loss is not part of a syndrome. A variant of the
connexin 26 gene is responsible for much of the hearing loss in this latter group
of children.

Postpartum Factors

Problems during or soon after birth can also be risk factors for developing
hearing loss. These include hypoxia, bleeding in the brain, and
hyperbilirubinemia. Children who are born early or at low birth weight are more
likely to have problems that may lead to hearing loss. However, children who are
normal birth weight can have hearing loss.

Other Factors

Hearing loss can also occur later in a child's or adult's life. Causes during this
time include infection such as meningitis, chronic middle ear infections, or
measles, injuries such as head injury, or certain drugs such as the antibiotic
gentamycin. High noise levels such as from firecrackers or loud rock concerts can
also damage a person's hearing. About 30 million workers are exposed to
dangerous noise levels on their jobs. Another nine million are at risk of hearing
loss as a result of working with certain metals or solvents. Some causes of
hearing loss can be prevented. For example, vaccines can prevent certain
infections, such as H-flu meningitis or measles, which can cause hearing loss.

The technology of Hearing Aids

124

www.nurseslabs.com
125

Body worn aids

This was the first type of hearing aid invented by Harvey Fletcher while
working at Bell Laboratories. These aids consist of a case containing the
components of amplification and an ear mold connected to the case by a cord.
The case is about the size of a pack of playing cards and is worn in the pocket or
on a belt. Because of their large size, body worn aids are capable of large
amounts of amplification and were once used for profound hearing losses.

Behind the ear aids (BTE)

BTE aids have a small plastic case that fits behind the ear and provides
sound to the ear via air conduction of sound through a small length of tubing, or
electrically with a wire and miniature speaker placed in the ear canal. The
delivery of sound to the ear is usually through an ear mold that is custom made,
or other pliable fixture that contours to the individuals ear. BTEs can be used for
mild to profound hearing losses and are especially useful for children because of
their durability and ability to connect to assistive listening devices such as
classroom FM systems.

In the ear aids (ITE)

These devices fit in the outer ear bowl or pinna they are sometimes visible
when standing face to face with someone. ITE hearing aids are custom made to
fit each individual's ear. They can be used in mild to some severe hearing losses.
Feedback, a squealing/whistling caused by sound leaking out of the aid and
being amplified again, may be a problem for severe hearing losses. Some
modern circuits are able to provide feedback regulation or cancellation to assist
with this. Traditionally, ITEs have not been recommended for young children
because their fit could not be as easily modified as the ear mold for a BTE, and
thus the aid had to be replaced frequently as the child grew.

Receiver In the ear aids (RITE)

At a first glance, these devices are similar to the BTE aid. There is
however one crucial difference, the receiver of the hearing aid is placed inside
the ear canal of the user and thin electrical wires replaces the acoustic tube of
the BTE aid. There are some advantages with this approach. First, the sound of
the hearing aid is arguably smoother than that of a traditional BTE hearing aid.
With a traditional BTE hearing aid, the amplified signal is emitted by the receiver
which is located within the body of the hearing aid behind the ear. The amplified
signal is then directed to the ear canal through an acoustic tube, which creates a
peaky frequency response. With a RITE hearing aid, the receiver is right in the
ear canal and the amplified output of the hearing aid does not need to be pushed

125

www.nurseslabs.com
126

through an acoustic tube to get there, and is therefore free of this distortion.
Secondly, RITE hearing aids can typically be made with a very small part behind-
the-ear and the wire connecting the hearing aid and the receiver is extremely
inconspicuous. For the majority of people this is one of the most cosmetically
acceptable hearing device types.

In the canal (ITC) and completely in the canal aids (CIC)

ITC aids are smaller, filling only the bottom half of the external ear. You
usually cannot see very much of this hearing aid when you are face to face with
someone. MIC and CIC aids are often not visible unless you look directly into the
patients ear. These aids are intended for mild to moderately-severe losses. CICs
are usually not recommended for people with good low frequency hearing, as the
occlusion effect is much more perceivable.

Open-fit devices

"Open-fit" or "Over-the-Ear" OTE hearing aids are small behind-the-ear type

devices. This type is characterized by a small plastic case behind the ear, and a
very fine clear tube running into the ear canal. Inside the ear canal, a small soft
silicone dome or a molded, highly vented acrylic tip holds the tube in place. This
design is intended to reduce the occlusion effect. Conversely, because of the
increased possibility of feedback, they are limited to moderate high frequency
losses.

Bone Anchored Hearing Aids (BAHA)

The BAHA is an auditory prosthetic which can be surgically implanted. The

BAHA uses the skull as a pathway for sound to travel to the inner ear. For people
with conductive losses, the BAHA, bypasses the external auditory canal and
middle ear, stimulating the functioning cochlea. For people with unilateral hearing
loss, the BAHA uses the skull to conduct the sound from the deaf side to the side
with the functioning cochlea. The implant vibrates the skull and inner ear, which
stimulate the nerve fibers of the inner ear, allowing hearing.

Eyeglass aids

Recently, a new type of eyeglass aid was introduced. These hearing

glasses feature directional sensitivity: four microphones on each side of the
frame effectively work as two directional microphones, which are able to discern
between sound coming from the front and sound coming from the sides or back
of the user. This allows for amplification of the sound coming from the front, the
direction in which the user is looking, and active noise control for sounds coming
from the sides or back. Only very recently has the technology required become
small enough, in size, to be put in the frame of the glasses.

Hearing aids are built from analog or digital circuits. Each technology processes
sound differently. Until recently, all hearing aids were analog. Digital hearing aids
are the newest kind of hearing aid and are superior to analog. All hearing aids,
whether analog or digital, are designed to increase the loudness of sounds
reaching the ear drum so that the hearing-impaired person can better
understand speech.

Components of Hearing Aids

1. A microphone to gather acoustic energy (sound waves in the air) and

convert it to electrical energy.
2. An amplifier to increase the strength of the electrical energy.
3. A receiver, which is like a miniature speaker that converts the electrical
energy back into acoustic energy (sound waves).

Difference between digital hearing aids and analog hearing aids in terms
of functioning

Analog Hearing Aids

126

www.nurseslabs.com
127

Analog hearing aids use a continuously varying electrical signal to produce

sound, just like a microphone and loudspeaker. Analog hearing aids have a
microphone that picks up sound and converts the sound into small electrical
signals. These signals vary according to the pattern of the sound. The signals are
then amplified (made louder) by transistors and fed to the ear phone on the
hearing aid which is next to your ear drum so you can hear them. Most of the
better analog hearing aids compress the sound using automatic gain control
(AGC). This amplifies quiet sounds until they are loud enough to be heard, but
gives less amplification to sounds that are already loud, so you're protected
against uncomfortably loud sound levels. Analog hearing aids dont have all the
features that come with advanced digital aids, but they are less expensive.

Digital Hearing Aids

Digital aids take the signal from the microphone and convert it into "bits" of data
- numbers that can be manipulated by a tiny computer chip in the hearing aid.
This makes it possible to tailor and process sounds very precisely in ways that
are impossible with analog aids. The digital chip takes the bits representing the
sound and analyzes and manipulates them using what is called DSP or Digital
Signal Processing. Software algorithms (a set of instructions), are used to
perform the precise complex DSP actions, and are then converted back into
electricity, which is finally changed back into sound that goes into the ear. This
process happens very rapidly with several million calculations occurring in the
hearing aid each second.

The digital sound representations can be manipulated in almost any way

imaginable, and this is what gives the digital hearing aid its big advantage.

When someone talks, you usually want to hear what they are saying, rather than
whatever noise is going on in the background. People who use traditional analog
hearing aids often complain that they find it difficult or impossible to follow

127

www.nurseslabs.com
128

conversations in noisy places. Many digital aids are designed to reduce steady
kinds of background noise, such as crowds in a restaurant or the rumble of traffic
or the whirr of a fan. This makes listening more comfortable. But it does not
necessarily help you to pick out a single voice from everything else that's going
on, especially when several people are talking. Some digital hearing aids also
have circuitry to protect whatever hearing is left. If a loud sound is detected
above the 90-100 Db range which can cause damage, dampening circuitry cut
out the sound.

To effectively use any sensory aid, clients must know and understand
the following:

1. Component parts and their specific function.

2. Benefits and limitation of available sensory aids.

3. How to clean and maintain the aid for daily use.

4. How to troubleshoot the operation and performance of selected aids.

5. How to adjust the aid for everyday use.

6. How to manage minor problem.

7. Who to contact in the event of a problem with the aid.

8. Cost of replacement aids and batteries on how to acquire them.

9. How to use aids in combination to enhance the performance over a single aid.

10. Insurance and manufacturer warranty conditions.

COCHLEAR IMPLANTS

Advances in computer technology as well as in ear surgery itself have

given us the opportunity to offer the world of sound, music, and speech to those
who would otherwise have spent their lives in a soundless cocoon.

Those who are born deaf prelingual deafness, as well as children and
adults who lost their hearing from either disease or trauma post lingual
deafness, can experience the gift of hearing thanks to cochlear implants.

Development of the devices came about through the surgical experiments

of a group of French medical scientists as well as the pioneering work of William
House of Los Angeles, Dr. Robert Schindler of San Francisco and a cochlear
implant team from Melbourne Australia. Miniaturization and advances in
computer technology over the last 30 years set the stage for the further
development of more sophisticated and effective cochlear implant devices.
Today, over 30,000 individuals have been implanted worldwide, over 3,000
cochlear implants were performed in 1999 alone.

128

www.nurseslabs.com
129

Sound is picked up through a tiny microphone housed in a headpiece that

is worn at the ear. The sound is sent along a cable to a processor, a mini-
computer that converts the sound into digital signals. The processor is worn on
the belt or, in some models at ear level.

Once processed, the digital signals go back up to a transmitter (in some

models, the transmitter and the microphone are in the same piece in other
models, the microphone is in a behind-the-ear piece that looks like a
conventional hearing aid). The transmitter, which is held by a magnet on the side
of the head behind the ear, sends the coded signals via radio waves across the
skin to the implant. The implant delivers the signals to electrodes that have been
inserted into the cochlea. The electrodes stimulate the auditory nerve, sending
impulses to the brain where they are interpreted as sound.

Initial experiments with deaf participants indicated that if an electrode

was placed on the bony wall of the inner ear and an electric current was passed
through the electrode, the deaf individual could perceive the sensation of sound.
From this very basic observation the concept of placing an active electrode into
the inner ear by way of the round window -the only non-bony entry into the
cochlea of the inner ear was born.

Initial implants were thus placed against the outer wall of the inner ear.
Soon, they were introduced into the cochlear chamber itself through the round
window. Not only was this introduction more effective in stimulating the residual
nerve endings of the inner ear, but it also allowed the surgeon to better anchor
the implant into the inner ear without risk of losing contact with the nerve
endings.

Individuals with deafness usually have lost most of their hair cell nerve endings
which normally conduct sound from the ear to the brain. Significant residual
nerve endings are needed to be present in the deaf to allow for their direct
stimulation by the neighboring electrodes. The cochlear implant is thought to
function by directly stimulating the surviving nerve population in the cochlea and
spiral ganglion.
129

www.nurseslabs.com
130

The earliest cochlear implants consisted of a single active electrode,

introduced into the inner ear, through the cochlear wall next to the round
window. Today, most investigators in the cochlear implant field agree that
stimulating the residual nerve cell population with multiple electrodes at different
sites within the cochlea, combined with sophisticated computer assisted
processing strategies allows for better recognition and understanding of speech.

Both the Nucleus 24 Contour and the Clarion High Focus devices have further
refined this concept with the closer placement of the electrode array to the
residual spiral ganglion cells of the auditory nerve.

The active electrodes in these newest devices allow them to hug the bony
inner wall of the cochlea instead of loosely fitting into the cochlear chamber. This
concept may allow for lower electrical stimulation levels of individual electrodes
which would prevent cross chatter between electrodes (jumping of electrical
fields from one electrode to another) and conserve battery life as well.

Long lasting batteries requiring little electric current will allow for a
completely implantable cochlear device in the future. For the present, the
implantable portion includes the electrode array and wire from the electrodes to
an implanted portion of the device which is behind the ear. The remaining
hardware of the device includes the microphone, receiver, speech processor and
magnetic link between the outer scalp and the implanted portion of the device.

The external portion of the unit receives and processes sounds which are
then fed into a specific electrode pair. These, in turn, stimulate the auditory
nerve and finally the auditory center of the brain.

OLFACTION

Anatomy and Physiology

NOSE

The nose is the organ involved in smell and breathing. It is located in the
middle of the face. The internal part of the nose lies above the roof of the mouth.
130

www.nurseslabs.com
131

It processes the air that you breathe before it enters your lungs. Most of this
activity takes place in and on the turbinates, located on the sides of the nasal
passages. In an adult, 18,000 to 20,000 liters of air pass through the nose each
day.

The nose is consists of:

External Nose- triangular-shaped projection in the center of the face.

Nostrils - The two openings into the nasal passages.

Nasal passages - passages that are lined with mucous membranes and
tiny hairs (cilia) that help to filter the air and move nasal and sinus
mucous to the back of the throat. Nasal passages are separated by the
nasal septum.

Septum - made up of cartilage and bone and covered by mucous

membranes. The cartilage also gives support to the lower part of the nose
and divides the nasal passages into right and left sides.

Sinuses - four-paired, air-filled cavities.

Sinuses

The sinuses are cavities, or air-filled pockets inside the face, near the
nasal passages. As in the nasal passages, the sinuses are lined with mucous
membranes. There are four sinuses:

Ethmoid sinus - located around the area of the bridge of the nose. This
sinus is present at birth, and continues to grow until puberty.

131

www.nurseslabs.com
132

Maxillary sinus - located around the area of the cheeks. This sinus is
also present at birth, and continues to grow until puberty.

Frontal sinus - located in the area of the forehead. This sinus does not
develop until around 7 years of age.

Sphenoid sinus - located deep in the face, behind the nose. This sinus
does not fully develop until adolescence.

ASSESSMENT of the NOSE and SINUSES

The nurse uses inspection and palpation to examine the nose and sinuses. The
structures assessed include the external nose, vestibule, nasal mucosa, septum,
turbinates, nasal canals, and sinuses. Function of the first cranial nerve
(olfactory) is usually not tested unless a deficit in the sense of smell is reported
or suspected.

NOSE

External Nose

The external nose is inspected and palpated for deviations from normal
alignment, symmetry, color, discharge, nasal flaring, lesions, and tenderness.
Normal findings are listed. The skin color over the nose is the same as that of
the facial skin. Alignment is straight and symmetric without deviation from
midline. Discharge from the nares should be absent and the nares should not
flare (spread) with respirations. The client is able to breath quietly through the
nose rather than mouth breathe. Masses, lesions, and tenderness are absent.
The nurse checks the nasal canals for patency by asking the client to occlude one
nares with a finger and to breathe through the open nares while closing the
mouth. This is repeated for the opposite nares. The client should be able to
breathe without difficulty through both nares. The nurse asks the client to tip the
head back and inspects the outer nares for crusting, bleeding, or dryness, which
should be absent.

Internal Nose
132

www.nurseslabs.com
133

The nurse next inspects the vestibules with use of a penlight while the
clients head is tipped back. Normal findings include the presence of coarse hairs,
a clear passage without discharge, and a midline septum. Further examination of
the internal nose requires use of a nasal speculum; this is not done unless it is
indicated.

If detailed examination of the internal nose is done, the nurse either

attaches a nasal speculum tip to the otoscope head or uses a metal nasal
speculum and penlight for illumination. The client tips the head back, and the
nurse gently inserts the speculum into one nares with care being taken not to
scrape the mucosa. One nares is inspected at a time.

Hold the speculum correctly and inserts the blade gently about inch
into the nostril. Gain additional control of the speculum by resting the index
finger of the dominant hand on the side of the clients nose. Steady the clients
head with the nondominant hand. Open the blades gently and vertically, avoiding
pressure on the septum and turbinates. Slowly move the head to inspect all
areas of the nasal chamber. Observe the condition of the mucous membrane
(e.g., pallor, redness, swelling). Normally, the mucosa is moist and dark pink
without sign of inflammation, pallor, or blue color. Presence of discharge is
abnormal. The septum is midline without deviation, masses, perforation, or
exudates. The turbinates (only the inferior and part of the middle turbinates are
visible, the superior is not) have the same color as the mucosa and should be
free of exudates, swelling, or inflammation. Look for polyps and other masses.
Observe plugs of mucus for color, consistency, amount, and odor.

Inspection may be hampered by nasal congestion. It may be necessary to

shrink the nasal mucosa with a topical vasoconstrictor (e.g., ephedrine, cocaine,
phenylephrine hydrochloride) for adequate inspection. When these agents are
instilled into the nose, the client should be instructed to say e and hold the
sound. This technique raises the posterior tongue, occludes the upper airway,
and prevents the fluid from running into the pharynx.

Nasopharynx

The nasopharynx is best examined with a mirror with the tongue

depressed with a tongue blade or gauze. Prevent the mirrors fogging by
warming it before putting it into a mouth. Hold the mirror to one side of the
uvula and focus light on it. A small part of the nasopharynx can be observed with
a nasal speculum. Specialists may use a nasopharyngoscope to examine the
nasopharynx.

Paranasal Sinuses

Assess the paranasal sinuses by (1) inspecting and palpating the soft
overlying tissues, (2) observing any nasal secretions (it is possible to determine
which sinus is infected according to where purulent discharge appears), and (3)
transillumination of the maxillary and frontal sinuses.

The nurse palpates and percusses the frontal and maxillary sinuses to
assess for swelling and tenderness, which should be absent. The frontal sinuses
are palpated simultaneously by placing the thumbs above the eyes, just under
the bony ridge of the orbits, and applying gentle pressure. The maxillary sinuses
are palpated by use of either the index and third fingers or thumbs to gently
press on each side of the nose just under the zygomatic bones. Direct percussion
is used over the eyebrows for the frontal sinuses and on either side of the nose
below the eyes in line with the pupils for the maxillary sinuses.

TRANSILLUMINATION

Transillumination is a technique to further assess the sinuses if tenderness

is present. Either a penlight or the otoscope handle fitted with a transilluminator
head is used. The room is darkened. The light is placed against the orbital bones
immediately below the eyebrows and directed upward. The nurse shields the
133

www.nurseslabs.com
134

light source with one hand. Normally, a reddish glow appears above the frontal
sinus area. Lack of illumination may indicate sinus congestion and pus
accumulation. The maxillary sinuses are assessed by placing the light beneath
the center of the eyes and the zygomatic bones and directing it down and in
toward the roof of the mouth. The nurse asks the client to open the mouth. A
glow should appear on the hard palate on the side being illuminated.

For more completely assessing sinus conditions, sinus radiographs may be

used. Air, normally present in the sinuses, appears as dark areas on a developed
film.

Smell

The senses of taste and smell are closely related. Many conditions affect
taste and smell, such as viral infections, normal aging, head injuries, and local
obstruction. Some medications can affect smell and taste, such as metronidazole
(Flagyl), local anesthetics, clofibrate (Atromid-S), some antibiotics, some
antineoplastics, allopurinol, phenylbutazone, levodopa, codeine, morphine,
lithium, and carbamazepine (Tegretol).

Smell impairment may be

(1) hyposmia (decrease in smell sensitivity) or

(2) anosmia (bilateral and complete absence of smell sensitivity). Smell

assessment is done by having the client identify various odors. Various
substances are placed in individual test tubes (covered to eliminate visual cues).
Testing each nostril separately, have the client sniff the tubes (first with eyes
closed and then with eyes open).

Document whether the client

(1) can perceive each odor and

(2) can identify each odor accurately. Smell is perceived mainly via the olfactory
nerves, although some are perceived via the trigeminal nerves. Trigeminal
irritants are perceived even by clients experiencing anosmia. (Therefore, a client
who claims not to smell trigeminal irritants has a hysterical loss of smell rather
than hyposmia or anosmia.)

DIAGNOSTIC PROCEDURES for the NOSE and SINUSES

A. Flexible Rhinolaryngoscopy

Flexible rhinolaryngoscopy is currently one of the most commonly used

techniques for visualizing the nasal cavity, the sinuses, the pharynx, and the
larynx. The technique utilizes a small-caliber flexible endoscope and can be
performed in an office setting. Before the procedure, the patient's nasal cavity is
decongested and anesthetized for maximum visualization and minimal
discomfort. In the procedure, the examiner threads the end of the scope into the
nasal aperture along the floor of the nasal cavity. As the scope is advanced, the
examiner can visualize the nasal cavity proper for any evidence of lesions or
masses. Once the scope approaches the nasopharynx, it is directed inferiorly and
advanced slowly, allowing direct visualization of the entire pharynx and larynx.

B. Functional Endoscopic Sinus Surgery (FESS)

Before undergoing FESS, patients have lab tests, CT scans and other
screenings to confirm the exact nature of the problem. During FESS, our
otolargyngolgists (ear, nose and throat doctors) introduce an endoscope into the
interior of the patients nose and sinuses. The slender, fiberoptic device has a
tiny light at its end, enabling the physician to view the problem area. Once the
instrument is positioned, tiny scalpels and other surgical tools are passed

134

www.nurseslabs.com
135

through the nostrils alongside the endoscope to remove polyps and other
obstructions. Since there are no external incisions, the patient rarely experiences
any bruising or swelling.

C. Image-guided Endoscopic Techniques

In select cases, UC Irvine Medical Center otolarngologists use image-

guided endoscopic techniques. By combining the power of computerized
tomography with endoscopy, theyre able to determine the anatomic location of
their instruments within the sinuses and perform three-dimensional
reconstructions of the surgical site.

D. Sinus X-ray

A sinus x-ray is a type of x-ray used to obtain images of the sinuses. The
sinuses are air-filled cavities lined with mucous membranes located within the
bones of the skull.

During a sinus x-ray, x-rays pass through the sinuses and form an image
on a special type of film. The sinuses are usually filled with air, which appears
black on x-ray film. An opaque (whitened) area on an otherwise normal film may
indicate the presence of sinusitis (inflammation of the mucous membranes of the
sinuses), hemorrhage, tumor, or other problems.

As computerized tomography (CT scan) and magnetic resonance imaging

(MRI) technologies are often able to provide improved imaging of the sinuses,
the use of these scans may replace sinus x-rays in certain circumstances.

Other related procedures that may be used to evaluate problems of the

sinuses include x-rays of the skull, CT scan of the brain, and MRI of the brain and
spine. Please see these procedures for more information.

E. Computed Tomography (Also called CT or CAT scan.)

A diagnostic imaging procedure that uses a combination of x-rays and

computer technology to produce cross-sectional images (often called slices),
both horizontally and vertically, of the body. A CT scan shows detailed images of
any part of the body, including the bones, muscles, fat, and organs. CT scans are
more detailed than general x-rays.

F. Cultures from the Sinuses

Laboratory tests that involve the growing of bacteria or other

microorganisms to aid in diagnosis.

SINUSITIS

Sinusitis is an infection of the sinuses near the nose. These infections usually
occur after a cold or after an allergic inflammation. There are four types of
sinusitis:

Acute - symptoms of this type of infection last less than four weeks and
get better with the appropriate treatment.

Subacute - this type of infection does not get better with treatment
initially, and symptoms last four to eight weeks.

135

www.nurseslabs.com
136

Chronic - this type of infection happens with repeated acute infections or

with previous infections that were inadequately treated. These symptoms
last eight weeks or longer.

Recurrent - three or more episodes of acute sinusitis a year.

Causes of Sinusitis

Sometimes, a sinus infection happens after an upper respiratory infection

(URI) or common cold. The URI causes inflammation of the nasal passages that
can block the opening of the paranasal sinuses, and result in a sinus infection.
Allergies can also lead to sinusitis because of the swelling of the nasal tissue and
increased production of mucus. There are other possible conditions that can
block the normal flow of secretions out of the sinuses and can lead to sinusitis
including the following:

abnormalities in the structure of the nose

enlarged adenoids

diving and swimming

infections from a tooth

trauma to the nose

foreign objects stuck in the nose

cleft palate

gastroesophageal reflux disease (GERD)

secondhand smoke

When the flow of secretions from the sinuses is blocked, bacteria may begin
to grow. This leads to a sinus infection, or sinusitis. The most common bacteria
that cause sinusitis include the following:

Streptococcus pneumonia

Haemophilus influenzae

Moraxella catarrhalis

Symptoms of Sinusitis

The symptoms of sinusitis depend greatly on the age of the child. The
following are the most common symptoms of sinusitis. However, each child may
experience symptoms differently. Symptoms may include:

Younger Children:

runny nose

o lasts longer than seven to 10 days

o discharge is usually thick green or yellow, but can be clear

nighttime cough

136

www.nurseslabs.com
137

occasional daytime cough

swelling around the eyes

usually no headaches younger than 5 years of age

Older children and adults:

runny nose or cold symptoms lasting longer than seven to 10 days

drip in the throat from the nose

headaches

facial discomfort

bad breath

cough

fever

sore throat

swelling around the eye, often worse in the morning

The symptoms of sinusitis may resemble other conditions or medical

problems. Always consult your child's physician for a diagnosis.

Treatment

Specific treatment for sinusitis will be determined by your child's physician

based on:

your child's age, overall health, and medical history

extent of the infection

your child's tolerance for specific medications, procedures, or therapies

expectations for the course of the infection

your opinion or preference

Treatment of sinusitis may include the following:

antibiotics, as determined by your child's physician (antibiotics are usually

given for at least 14 days)

acetaminophen (for pain or discomfort)

a decongestant (i.e., pseudoephedrine [Sudafed]) and/or mucus thinner

(i.e., guaifenesin [Robitussin])

cool humidifier in your child's room

nasal spray (to reduce inflammation)

medications to treat GERD

surgery to remove the adenoids

137

www.nurseslabs.com
138

endoscopic sinus surgery

Antibiotics may be withheld for 10 to 14 days, unless severe

symptoms develop, such as: fever, facial pain or tenderness, or swelling
around the eye. Surgery should be considered only if other treatments have
failed.

Referral to an allergist/immunologist is often needed, particularly for

people with chronic or recurrent sinusitis and for patients who have had sinus
surgery, but still experience sinusitis.

Antihistamines do not help the symptoms of sinusitis unless an allergy is

involved.

RHINITIS

Rhinitis is a reaction that occurs in the eyes, nose and throat when
airborne irritants (allergens) trigger the release of histamine. Histamine causes
inflammation and fluid production in the fragile linings of nasal passages,
sinuses, and eyelids.

The two categories of rhinitis are:

Allergic Rhinitis

There are two types of allergic rhinitis:

o Seasonal - occurs particularly during pollen seasons

o Perennial - occurs throughout the year

The most-common causes of allergic rhinitis are:

o pollen

o dust mites

o mold

o animal dander

Reactions from allergic rhinitis include:

o sneezing

o congestion

o runny nose

o itchy nose, throat, eyes, and ears

Preventive measures for avoiding allergic rhinitis include:

o environmental controls, such as air conditioning, during

pollen season

o avoiding areas where there is heavy dust, mites, molds

138

www.nurseslabs.com
139

o avoiding pets

Treatments for allergic rhinitis, as determined by your physician

and based on your condition, may include:

o oral medications

o inhaled medications

o immunotherapy

o allergy injections

Nonallergic Rhinitis

Types of nonallergic rhinitis are:

o vasomotor rhinitis (irritant rhinitis)

o eosinophilic

o rhinitis medicamentosa

o neutrophilic rhinosinusitis

o structural rhinitis

o nasal polyps

o primary vasomotor instability

Causes of nonallergic rhinitis include:

o fumes

o odors

o temperature

o atmospheric changes

o smoke

o other irritants

Reactions from nonallergic rhinitis include:

o sneezing

o congestion

o runny nose

o itchy nose, throat, eyes, and ears

The preventive measure for avoiding nonallergic rhinitis is avoiding

the primary cause.
Treatments for nonallergic rhinitis, as determined by your physician
and based on your condition, may include:

139

www.nurseslabs.com
140

o oral medications

o inhaled medications

o immunotherapy

o allergy injections

o surgery for some conditions

TONSILO-PHARYNGEAL

Anatomy and Physiology

Tonsils

Tonsils are clusters of lymphatic tissue just under the mucous membranes
that line the nose, mouth, and throat (pharynx). There are three groups of
tonsils. The pharyngeal tonsils are located near the opening of the nasal cavity
into the pharynx. When these tonsils become enlarged they may interfere with
breathing and are called adenoids. The palatine tonsils are the ones that are
located near the opening of the oral cavity into the pharynx. Lingual tonsils are
located on the posterior surface of the tongue, which also places them near the
opening of the oral cavity into the pharynx. Lymphocytes and macrophages in
the tonsils provide protection against harmful substances and pathogens that
may enter the body through the nose or mouth.

Tonsils are lymphoepithelial organs at the opening of the upper aerodigestive

tract. From above downwards, they can be divided into:

1. pharyngeal tonsil, adenoid, which lies on the roof and posterior wall of the
nasopharynx

2. tubal tonsil which lies around the eustachian tube

3. palatine tonsil which lies between the anterior and posterior faucial pillars

4. lingual tonsil which lies at the base of the tongue

These lymphoid organs developed from the epithelium of the primitive

oronasal cavity, the mesenchymal stroma and lymphoid cells then infiltrate these
areas. Although the tonsils are present at embryonal stage, they only acquire
their typical structure in the postnatal period. They begin increasing rapidly in
size between the first and third year of life, with peaks in the third and seventh
year. They involute slowly at early puberty. In contrast to other lymphoid
aggregates, tonsils do not filter lymph.

The palatine tonsil is supplied by the facial artery, ascending pharyngeal

artery, lingual artery and the maxillary artery. Venous drainage is by the lingual
and pharyngeal veins.

Immunology

Tonsils are composed primarily of B-lymphocytes. T-cell lymphocytes

constitute 40% of total volume in contrast to 70% in circulating plasma.
According to present knowledge, tonsils are involved in production of antibodies,
interferon-gamma and lymphokines and in inducing secretory immunity.

140

www.nurseslabs.com
141

Pharynx

The pharynx is a tubular structure extending from the base of the skull to
the esophageal inlet. Superiorly, it opens into the nasal and oral cavities;
inferiorly, it opens into the larynx and the esophagus. It is lined with mucous
membrane. The adenoids are located in the nasopharynx, the palatine tonsils in
the pharynx, and the lingual tonsils in the hypopharynx; all are lymphoid tissue.

The pharynx is subdivided into the nasopharynx, the oropharynx, and the
hypopharynx.

Nasopharynx. The nasopharynx extends from the posterior choanae to the

inferior surface of the soft palate. Malignancies of the nasopharynx can present
as nasal obstruction, epistaxis, tinnitus, headache, diminished hearing, and facial
pain.

Oropharynx. The oropharynx extends from the junction of the hard and soft
palates and the circumvallate papillae to the valleculae. It includes the soft
palate and uvula, the base of the tongue, the pharyngoepiglottic and
glossoepiglottic folds, the palatine arch (which includes the tonsils and the
tonsillar fossae and pillars), the valleculae, and the lateral and posterior
oropharyngeal walls. Carcinomas of the oro pharynx can present as pain, sore
throat, dysphagia, and referred otalgia.

Hypopharynx. The hypopharynx extends from the superior border of the hyoid
bone to the inferior border of the cricoid cartilage. It includes the pyriform
sinuses, the hypopharyngeal walls, and the postcricoid region (i.e., the area of
the pharyngoesophageal junction). Malignancies of the hypopharynx can present
as odynophagia, dysphagia, hoarseness, referred otalgia, and excessive
salivation.

The pharynx is the region of the tonsils, back part of the nose and swallowing
area. It is probably the most examined of all body regions, and reflects many
diseases.

141

www.nurseslabs.com
142

Assessment

To inspect the pharynx, the examiner asks the person to open the mouth
without protruding the tongue. A tongue blade is pressed firmly down on the
midpoint of the arched tongue; pressing farther back may cause gagging. The
person then says ah while breathing through the mouth to prevent gagging.

The oropharynx, that portion of the pharynx directly posterior to the oral
cavity bounded by the nasopharynx above and laryngopharynx below, is
examined with a tongue blade and a mirror. The anterior and posterior tonsillar
pillars, the uvula, tonsils and posterior pharynx are inspected for color,
symmetry, evidence of exudates, edema, ulceration, and tonsillar enlargement.
Redness and swelling of the tonsils, pillars and uvula with white or yellow
exudates on the tonsils may indicate streptococcal infection. Tonsils may be
enlarged without being infected.

Examination of oral cavity should be done properly. Very often, the size of
tonsils may be exaggerated during gagging and pressing hard with the use of a
tongue depressor. The proper way is to gently place the tongue depressor
anterior to the circumvallate papillae or if possible, just by inspection without the
use of tongue depressor. The size and percentage of the obstruction should be
recorded using the scale 0 to +4. 0 means the tonsil is in the fossa; +1 means
less than 25% obstruction; +2 is less than 50%; +3 is less than 75% and +4 is
more than 75% obstruction.

Examination of the Pharynx for Problems

The pharynx can be seen partially by forceful traction on the tongue, by
the fingers wrapped in a handkerchief. It begins in back of the one-half inch
uvula, which hangs down freely from the posterior rim of the palate.
1. Observe the sides of the pharynx where the tongue appears to originate, and
note the irregular flesh colored tonsils on each side. When removed, a small
cavity remains in their site. Adult tonsils may be atrophied to a pea size or if
irritated and infected, be as large as grapes and flecked with pus.

2. With a flashlight, examine the back of the pharynx while attempting to yawn.
An all-over redness, with noticeable soreness, usually means pharyngitis as in
colds, sore throats, etc.

3. Examine the wall of the pharynx on all sides and the back of the tongue, if
possible, for any one particular sore, ulcer or bleeding point, which may mean
cancer.
Diagnostic Procedures for the Tonsils and Pharynx

A. Indirect Laryngoscopy

Indirect laryngoscopy has been used since the 1800s for visualizing the
pharynx and larynx. In this technique, the head light source illuminates the
mirror, which in turn illuminates the laryngopharynx. The patient is seated in the
sniffing position and protrudes the tongue while a warmed laryngeal mirror is
introduced firmly against the soft palate in the midline to elevate the uvula out of
the field (gently, so as not to elicit the gag reflex). The image seen on the mirror
can be used to assess vocal cord mobility, as well as to inspect for a mass or
foreign body of the larynx or pharynx. This technique can be performed rapidly
and is inexpensive.

B. Flexible Rhinolaryngoscopy

Flexible rhinolaryngoscopy is currently one of the most commonly used

techniques for visualizing the nasal cavity, the sinuses, the pharynx, and the
larynx. The technique utilizes a small-caliber flexible endoscope and can be
performed in an office setting. Before the procedure, the patient's nasal cavity is
decongested and anesthetized for maximum visualization and minimal
142

www.nurseslabs.com
143

discomfort. In the procedure, the examiner threads the end of the scope into the
nasal aperture along the floor of the nasal cavity. As the scope is advanced, the
examiner can visualize the nasal cavity proper for any evidence of lesions or
masses. Once the scope approaches the nasopharynx, it is directed inferiorly and
advanced slowly, allowing direct visualization of the entire pharynx and larynx.

C. Direct Laryngoscopy

Direct laryngoscopy has the advantage of permitting both diagnostic and

therapeutic intervention. It is performed with the patient under general
anesthesia and intubated. The procedure allows for direct visualization of the
pharynx and the larynx and permits the surgeon to perform biopsies and remove
small lesions. At the same time, the surgeon has the opportunity to palpate the
structures of the oral cavity, the oropharynx, and the hypo pharynx, which
cannot be properly palpated in an awake patient.

The laryngoscope can also be suspended from a table-mounted Mayo

stand (for hands-free use), and a microscope can be maneuvered into focal
distance to allow magnified visualization of the glottis and subglottis. During a
microscopic direct laryngoscopy, small lesions or topographic abnormalities can
be better characterized and removed if desired. Some examples of lesions that
can be diagnosed by direct laryngoscopy are vocal cord polyps, leukoplakia,
intubation granulomas, contact ulcers, webs, nodules, hematomas, and
papillomatosis. Additionally, small malignant lesions of the vocal cords can be
examined and ablated or extirpated by using a CO 2 laser under direct
microlaryngoscopic guidance.

D. Angiography

Angiography is a widely used examination in which radiopaque dye is

injected into the vessels by means of transcutaneous catheter insertion. It
visualizes the internal wall and caliber of the vessel lumen, as well as the
position of the vessel, which is usefl for the evaluation of certain parapharyngeal
masses.

Biopsy Procedures

A. Fine-needle Aspiration

FNA is often used to make an initial tissue diagnosis of a neck mass. The
advantages of this technique include high sensitivity and specificity; however,
5% to 17% of FNAs are nondiagnostic. Another advantage of FNA is speed: If a
cytologist or a pathologist is available, diagnosis can often be made within
minutes of the biopsy.

FNA is performed with a 10 ml syringe with an attached 21- to 25-gauge

needle. Larger needles are more likely to result in tumor seeding. The patient is
positioned to allow for optimal palpation of the mass. The skin overlying the
mass is prepared with a sterile alcohol prep sponge. Local anesthesia is not
necessary. The mass is grasped and held in a fixed and stable position. The
needle is introduced just under the skin surface. As the needle is advanced, the
plunger of the syringe is pulled back, to create suction. Once the mass is
entered, multiple passes are made without exiting the skin surface; this
maneuver is critical in maximizing specimen yield. After the final pass is
completed, the suction on the syringe is released and the needle withdrawn from
the skin. If a cyst is encountered, it should be completely evacuated and the fluid
sent for cytologic analysis.

A drop of aspirated fluid is placed on a glass slide. A smear is made by

laying another glass slide on top of the drop of fluid and pulling the slides apart
to spread the fluid. Fixative spray is then applied. Alternatively, wet smears are
placed in 95% ethyl alcohol and treated with the Papanicolaou technique and
stains.

FNA has several advantages over excisional biopsy. An FNA requires only
an office visit, with minimal loss of time from work for the patient. In contrast,
143

www.nurseslabs.com
144

excisional biopsy is commonly performed in an operating room, so the patient

must undergo preoperative testing. Patients with a significant medical history
may require formal medical clearance. An excisional biopsy exposes the patient
to the risks of anesthesia, postoperative wound infection, and tumor seeding.

B. Ultrasound-Guided FNA

Ultrasonographic guidance of FNA enables the surgeon to obtain a

cytologic specimen of deeper or nonpalpable masses that are not amenable to
standard FNA. Real-time imaging of the needle's passage allows the surgeon to
plot a more accurate trajectory and avoid underlying vital structures.
Furthermore, it provides an image of the mass, allowing its characterization as
solid, cystic, or heterogeneous. With cystic or complex masses, it is imperative to
place the tip of the needle into the wall to increase specimen yield.

C. CT-Guided FNA

CT-guided FNA is most commonly employed to diagnose poorly accessible

or deep-seated lesions of the head and neck. Like ultrasound-guided FNA, CT-
guided FNA provides visualization of the needle as it is passed through the tissue
and into the underlying structures, thus allowing a more accurate needle
trajectory and avoidance of underlying vital structures. Additionally, visual
guidance of the needle greatly increases the likelihood of obtaining a specimen
from the mass rather than the surrounding tissues.

Imaging Procedures

Because many of the deep structures of the head and neck are
inaccessible to either direct evaluation by palpation or indirect evaluation via
endoscopy, further information must be obtained by radiography. Imaging
procedures such as CT, MRI, ultrasound, and positron emission tomography
(PET) scanning permit the diagnosis and analysis of pathologic conditions
affecting these deep structures, including the temporal bone, skull base,
paranasal sinuses, soft tissues of the neck, and larynx.

A. Ultrasonography

Ultrasonography is a safe and inexpensive method of gaining high-

resolution real-time images of the structures of the head and neck. Palpable
masses in the neck can be assessed for changes in size, for association with
other local structures, and for character (i.e., solid, cystic, or complex).
Applications of ultrasonography include assessment of masses such as
thyroglossal duct cysts, branchial cleft cysts, cystic hygromas, salivary gland
tumors, abscesses, carotid body tumors, vascular tumors, and thyroid masses.
Additionally, ultrasonography combined with FNA and cytologic evaluation can
provide both a detailed visual description and an accurate cytologic evaluation of
masses in the neck.

B. Computed Tomography

A CT scan with intravenous contrast is often the first-line imaging

technique used to evaluate a mass of the neck and to assess for pathologic
adenopathy. CT has proved to be an effective method for primary staging of
tumors and lymph nodes. Additionally, it has been shown to be effective in
studying capsular penetration and extranodal extension. It is clearly superior to
MRI in evaluating bone cortex erosion, given that MRI cannot assess bone cortex
status at all. CT scans are also widely used for posttreatment surveillance in
cancer patients.

C. Magneic Resonance Imaging

MRI avoids exposing the patient to radiation and provides the investigator
with superior definition of soft tissue. For example, MRI can differentiate mucous
membrane from tumor, as well as detect neoplastic invasion of bone marrow. In
patients with nasal cavity tumors, MRI can distinguish between neoplastic,
inflammatory, and obstructive processes. MRI is also valuable in assessing the
144

www.nurseslabs.com
145

superior extent of metastatic cervical lymphadenopathy (i.e., intracranial

extension). A disadvantage of MRI is its limited ability to show bone detail; it
therefore cannot detect invasion of bone cortex by a neoplasm. Furthermore, an
MRI scan is significantly more expensive than a CT scan.

D. Positron Emission Tomography

PET scanning is a functional imaging technique that measures tissue

metabolic activity through the use of radioisotopically tagged cellular building
blocks, such as glucose precursors. A range of physiologic tracers has been
developed for PET imaging, with the glucose analogue 2-deoxy-2-[(18)F]fluoro-
D-glucose (FDG) the most commonly used. FDG has a half-life of 110 minutes.
Once given to the patient, FDG is taken up by glucose transporters and is
phosphorylated by hexokinase to become FDG-6-phosphate (FDG-6-P). Further
metabolism of FDG-6-P is blocked by the presence of an extra hydroxyl moiety,
which allows FDG-6-P to accumulate in the cell and serve as a marker for
glucose metabolism and utilization.

Because neoplastic cells have higher rates of glycolysis, localized areas of

increased cellular activity on PET scans may represent neoplastic tissue. In this
respect, PET is very different from CT and MRI, which depict tissue structure
rather than tissue metabolic activity.

Because FDG is nonspecifically accumulated in glycolytically active cells, it

demarcates areas of inflammation as well as neoplastic tissue, which can lead to
a false positive scan. Muscular activity during the scan can also lead to areas of
increased uptake in nonneoplastic tissue. Furthermore, healing bone, foreign
body granulomas, and paranasal sinus inflammation can produce false positive
results.

False negative scans occur when tumor deposits are very small (i.e., 3 to
4 mm or less in diameter). Thus, micrometastases are not reliably detected
using an FDG-PET image. Furthermore, a false negative scan can occur if the PET
scan is performed too soon after radiation therapy.

The role of PET imaging in head and neck oncology is rapidly expanding.
Currently, the majority of PET imaging used in head and neck oncology is FDG
based. FDG-PET is actively being used to look for unknown primary lesions and
second primaries, to stage disease before therapy, to detect residual or recurrent
disease after surgery or radiation therapy, to assess the response to organ
preservation therapy, and to detect distant metastases. Because false positive
and false negative PET scans do occur, accurate interpretation of PET scans
requires a thorough understanding of the potential confounding factors.

E. PET/CT

PET/CT is essentially an FDG-PET scan that has been coregistered with a

simultaneous CT scan to allow the radiologist to precisely correlate the area of
increased cellular activity with the anatomic structure. This technique removes
some of the guesswork involved with interpreting an area of increased activity on
a simple PET scan and provides the physician with a morphologic correlate for
the area of increased uptake.

After a histologic diagnosis has been made and correlated with the
imaging information, the patient and physician can have a comprehensive
discussion of the pathology, the stage of the disease, and the selection of
therapy.

NOSE DISORDERS

EPISTAXIS

145

www.nurseslabs.com
146

Epistaxis is bleeding from the nose caused by irritation, trauma,

coagulation disorders, hypertension, chronic infection or tumor.

Epistaxis is thought to have occurred at least once in over 10 % of the

normal population. It is either a primary disorder or secondary to another
condition such as hemophilia or leukemia and many cases are idiopathic. In
children, who are twice as likely to have epistaxis as adults, the bleeding is
usually mild and tends to originate from the posterior septum so that the
bleeding point is more difficult to locate and the bleeding may be profuse.
Epistaxis is equally common in men and in women.

Although epistaxis is a frightening experience for the patient, it generally

looks and feels worse than it actually is. The blood is usually briught red and the
patient may swallow some of it, which is an unpleasant sensation. Although
adults can lose up to 1 L per hour during severe bleeding, the mortality is
extremely low. When the patient bleeds enough to show signs of shock, the
nosebleed usually stops because of low blood pressure; some deaths are thought
to have been causes by coronary ischemia from blood loss.

PATHOPHYSIOLOGY

The most common cause of epistaxis is trauma to the nasal mucosa from
damage by a foreign object, picking crusts from the nasal septum, or dryness of
the nasal mucosa. Nosebleeds are fairly common in patients with coagulation
defects such as hemophilia, leukemia and purpura. Infection, tumors and some
drugs and toxins may cause nosebleeds; in many instances however, the cause is
simply not identified or is considered idiopathic.

There may be some relationship between the menstruation and epistaxis.

It may be that in some women with premenstrual syndrome the nasal mucosa
becomes congested at the time of menstruation, setting the stage for epistaxis.

The incidence of epistaxis is no higher in hypertensive patients than in

normotensive patients. However, hypertensive patients may bleed more
profusely, partly because of the direct effect of the increased pressure and also
because the small nasal arteries and arterioles of hypertensive patients tend to
have much of their muscular walls replaced by fibrous tissue and are incapable of
contracting adequately to attain hemostasis.

Children experience frequent nosebleeds from the anteroinferior part of

the septum known as the Littles area or Kiesselbachs plexus. The etiology is not
clear, but the area is richly vascular and children have hyperemic and congested
upper respiratory tracts. Children also pick up and rub their noses in the area
where the mucosa is stretched over the cartilage and bone.

Intractable nose picking is another cause of anterior nosebleeds. Some

patients cannot stop picking their noses, either because of a nervous habit or
because crusts are present from an earlier ulceration or perforation. Constant
nose picking can cause septal ulceration or even a perforation which leads to
epistaxis.

A hereditary disease that is an unusual cause of epistaxis is Rendu-Osler-

Weber disease of hemorrhagic hereditary telangiectasia. This disease is gene
dominant and may be passed from either parent to a child of either sex.
Epistaxis is usually the initial symptom, but telangiectasis is commonly found in
other mucous membranes or anywhere on the external surface of the body.
Bleeding usually occurs from the nose and gastrointestinal tract because mucosa
in those areas is very fragile, whereas other areas have protective layers of
squamous epithelium.

Most nosebleeds in the anterior part of the nose originate from

Kiesselbachs plexus, the highly vascular network in the anterior septum. It is
also anatomically closer to the rapid inspiratory air flow, which may dry the
normal mucus flow especially in cold, dry weather. Because the vessels are fairly
small and easily accessible, these nosebleeds are the easiest to treat. If the
bleeding is from the posterior part of the nose, the exact source of bleeding is
146

www.nurseslabs.com
147

more difficult to locate because it is sometimes impossible to see and bleeding is

more profuse. Usually just one source on one side of the nose bleeds, although
bleeding frequently originates from both sides in patients with blood dyscrasias.

Diagnostic Studies and Findings

Hematocrit

Hemoglobin

Platelets

Prothrombin time

Partial thromboplastin time

Reticulocyte count and differential

- done to rule out coagulation defect, results usually normal; bleeding

from other parts of body likely in patients with hematologic disorders.

Rhinoscopy

Nasopharyngoscopy

- to detect and localize site of planning

Medical and Surgical Management

1. Arterial ligation of ethmoid, maxillary or carotid artery if proper packing

fails to control nosebleed.

> an incision is made I the gumline above the incisor on the

affected side, and the maxillary sinus is entered. The artery that
supplies the area of bleeding is identified, and a metal clip or
suture is used to ligate the artery.

2. Endoscopic cautery chemical or electrical cauterization of bleeding

vessels using nasal endoscope to visualize bleeding.

3. Septal dermoplasty for Rendu-Osler-Weber disease - skin graft is placed

in nose to cover anterior parts of septum and floor and walls of nose
anteriorly to provide protective covering over fragile mucosa; combined with
laser therapy gains control of epistaxis for several years.

4. For anterior bleeding:

Anterior nasal packing may be all that is required. Antibacterial ointment such
as Bacitracin or Neosporin is applied to half inch gauze and gently, but firmly
inserted into the anterior nasal cavities to apply pressure to the bleeding
vessels

Nasal packing should be in place for a minimum of 48 to 72 hours.

147

www.nurseslabs.com
148

For posterior plugs

Figure 4. Posterior nasal packing. A. After adequate anesthesia has been

obtained, a catheter is passed through the affected nostril and through the
nasopharynx, and drawn out the mouth with the aid of ring forceps. B. A
gauze pack is secured to the end of the catheter using umbilical tape or
suture material, with long tails left to protrude from the mouth. C. The gauze
pack is guided through the mouth and around the soft palate using a
combination of careful traction on the catheter and pushing with a gloved
finger. This is the most uncomfortable (and most dangerous) part of the
procedure; it should be completed smoothly and with the aid of a bite block
(not shown) to protect the physician's finger. D. The gauze pack should come
to rest in the posterior nasal cavity. It is secured in position by maintaining
tension on the catheter with a padded clamp or firm gauze roll placed
anterior to the nostril. The ties protruding from the mouth, which will be used
to remove the pack, are taped to the patient's cheek.

A small, red rubber catheter is passed through the nose into the oropharynx
and mouth. A small gauze pack is tied to the catheter, and it is withdrawn;
this moves the pack into proper placement in the nasophrarynx and posterior
nose to apply pressure.

The nasal cavity is packed with half-inch gauze and the strings from the
posterior pack are tied around a rolled gauze for maintaining its position. The
ties from the oral cavity are taped to the clients face in order to prevent
loosening or dislodgement of the plug.

General comfort measures such as humidification, the use of drip pad to

collect bloody drainage and mucus, and providing lubrication to the nares.

Nurse must monitor for bleeding, and the proper placement of the posterior
plug. If the plug is visible in the oral cavity, notify the physician for
readjustment of the packing.

Posterior nasal packs should be in place for 5 days.

Prophylactic antibiotics are administered to prevent toxic shock syndrome and

sinusitis.

148

www.nurseslabs.com
149

5. Balloon pressure catheter tubes

stents look like very short (about 6 inches) urinary catheters. These tubes
have an exterior balloon along the tube length in addition to an anchoring
balloon on the end. These tubes are inserted into both nares. The physician
first inflates the anchoring balloon to keep the tubes in place. Then the
pressure balloons are inflated carefully for both tubes at the same time to
compress bleeding vessels. Placement of posterior packing or pressure tubes
is uncomfortable and airway may be obstructed.

Nurse should observe for respiratory distress and tolerance of the tubes. Pain
medication may be prescribed. Oral care and adequate hydration are
important because of mouth breathing.

The tubes are usually removed after 2-5 days; teach the client measures for
comfort and safety. Like the use of petroleum jelly for lubrication, nasal saline
sprays and humidification. Instruct the client to avoid vigorous nose blowing,
use of aspirin and other NSAIDS, and strenuous activities.

Medications:

Fibrinolytics VITAMIN K (Aquamephyton) 10mg po or IM; useful in some

cases of epistaxis, but packing remains therapy of choice

Anti-infective agents PENICILLIN 1.5 million U, IV q6h recommended for

prophylaxis because packing obstructs drainage of paranasal sinuses and
may precipitate a sinus infection.

Nursing Assessment/ Interventions

1. Assess for:

Nasal Bleeding

Bright red blood comes from the nares; patient may also
swallow or expectorate blood; history of trauma, nose picking or
other unknown cause.

2. Examination of patients body for bruises or petechiae that may

indicate underlying hematologic disorder.

3. Nursing Diagnoses:

Risk for fluid volume deficit r/t nasal bleeding

Fear r/t loss of blood

Risk for aspiration r/t inability to clear secretions; gagging

Altered cerebral and cardiopulmonary tissue perfusion r/t

large-volume blood loss

4. Interventions for:

ANTERIOR BLEEDING

Assess the location of bleeding

149

www.nurseslabs.com
150

Pinch the nose firmly and hold for at least 10 minutes. It is best if
you pinch the patients nose instead of asking the patient to do so.
This way, you can ensure steady and firm pinching.

If bleeding continues beyond the pinching 10 min. period, prepare

the client for additional treatment.

With the patient in a high Fowlers position, slightly hyper flex the
head and suction the clots in the nasal passage.

Observe the canal for continued bleeding. If present, apply

vasoconstriction agent such as 10% cocaine solution.

If bleeding continues, the nose may need to be cauterized with

silver nitrate or anterior nasal packing inserted.

POSTERIOR BLEEDING

The bleeding usually originates from the sphenopalatine artery,

anterior ethmoid artery or the nasopalatine artery.

Assess that the bleeding is posterior.

Place the patient in a high Fowler position.

As ordered, anesthetize the posterior nasal passage with 10%

cocaine solution

Pack the bleeding site with packing materials such epistaxis

catheter, Foley catheter tip and or tampon.

Monitor vital signs and estimate blood loss. If necessary, provide

fluid volume replacement

Instruct patient to (1) tilt head forward if bleeding occurs (2) not to
blow nose and (3) to apply steady pressure for at least 5 min. if
bleeding recurs.

NASAL FRACTURES

A nasal fracture is a traumatic injury to the nasal bones. Most common

causes are accidents, sports injuries, and assaults. In children, falls are the most
common cause of nasal fractures. They occur more commonly in men, however
when nasal fractures are diagnosed, it is essential to rule out fractures of the
associated facial bones such zygomatic or mandibular fractures because facial
injuries or trauma may also damage \these bones.

Even a nasal fractures that appear simple usually have associated damage
to the mucosal lining of the nose. If the patient suffered a facial trauma that
causes epistaxis, damage to the bone-cartilage structures of the nose is more
likely.

PATHOPHYSIOLOGY

A nasal fracture occasionally occurs in the birth canal during delivery.

These are usually greenstick fractures, and the babys nose inclines slightly to
one side. The nose can be grasped at the tip and pulled toward the midline to
realign it.
150

www.nurseslabs.com
151

Nasal fractures can be classified as unilateral, bilateral or complex.

Unilateral fracture may produce little no displacement and may appear on an
x-ray examination as a simple crack.

Bilateral fractures which are the most common, may be caused by a

swinging punch or blow that pushes both nasal bones to one side or by a frontal
blow that depresses the nasal bones and gives a flattened look to the nose. The
entire nose may be deviated and the nose may have a C or S deformity.

Complex fractures are usually caused by a powerful frontal blow.

Such blows may shatter the nasal pyramid and frequently the frontal bones as
well, causing a marked depression of the nasal and frontal bones.

The usual findings are epistaxis, a noticeable facial deformity and a history of
trauma. Edema occurs quickly at the injury site and depending on the severity
may include a periorbital swelling. Ecchymosis is common, the nose is exquisitely
tender, and nasal obstruction occurs. Complex fractures of the nose and face
may result in diplopia and subscleral hemorrhage.

Diagnostic Studies and Findings:

X-ray examination of the face and nose shows fractures

and depressed areas of facial and nasal bones; done to
complement clinical, visual evaluation.

Ophthalmoscopy performed to rule out eye injury such as

corneal abrasion or laceration, also to check lacrimal
apparatus and orbit.

Medical and Surgical Management

1. Reduction and Fixation of the fractures as quickly as possible

after injury (within first hour or two before swelling beings, or after
3 or 4 days when swelling has decreased) because fragments tend
to stabilize quickly; bilateral nasal packing or nasal splints usually
inserted during surgery to maintain stability and position of nasal
structure.

2. Rhinoplasty is a surgical reconstruction of the nose for cosmetic

purposes and to improve airflow. The client returns from surgery
with packing on both nostrils; the gauze packing is usually treated
with antibiotic to reduce risk for infection. A moustache dressing
(or drip pad) often a folded 2x2 gauze pad is usually placed under
the nose. A splint or cast may cover the nose for additional
alignment and protection.

After surgery:

Observe for edema and bleeding.check v/s q4. the client

with uncomplicated rhinoplasty may be discharge the day of
surgery.

Place the patient in a semi-Fowlers postion and instruct to

move slowly

Apply cool compresses to nose, eyes or face to reduce

swelling and bruising.

To prevent bleeding, instruct patient to limit Valsava

maneuvers for the first few days after packing is removed.

151

www.nurseslabs.com
152

Laxatives or stool softeners may be prescribed to ease

bowel movement. Instruct client to avoid aspirin and
NSAIDS to prevent bleeding.

Explain that edema and discoloration may last for weeks

and the final surgical result will be evident in 6 to 12
months.

3. Medications: Narcotic analgesics or antipyretics

Acetaminophen (TYLENOL), 325-650 mg with/without

codeine po q4-q6 prn

4. General Management: Simple thumb pressure on convex side of

the nose occasionally enough to push bones back together.

Nursing Assessment/ Interventions

1. Assess for:

Facial swelling; deformity; ecchymosis; epistaxis; nose very tender;

history of trauma to face and nose; possible accompanying
lacerations; leak of CSF fluid, a clear fluid dripping from then nose
and/or ears.

Respiratory Status; difficulty in breathing through the nose; mouth

breathing

2. Nursing Diagnoses and Interventions:

PAIN r/t facial trauma

Assess need for pain medication and provide adequate analgesia for
pain relief; evaluate and document effectiveness.

INEFFECTIVE BREATHING PATTERN r/t nasal obstruction

and swelling

- Monitor vital signs and level of consciousness.

- Assess for shortness of breath, dyspnea from nasal obstruction or

difficulty in swallowing.

- Apply ice to face and nose to minimize swelling and bleeding without
pressure to nose.

- Monitor amount and color of epistaxis and record

- Keep head of bed elevated, even when sleeping to prevent aspiration

of blood or secretions and minimize edema.

- Prevent patient from swallowing blood or aspirating; encourage patient

to breathe through mouth.

- Have basin nearby for patient to expectorate blood.

Provide frequent oral hygiene and encourage intake of oral fluids.

152

www.nurseslabs.com
153

SENSORY/PERCEPTUAL ALTERATIONS (visual) r/t periorbital edema

- Assess for eye swelling; apply ice to minimize edema

- Observe for scleral hemorrhage and periobital edema

- If eyes are not completely closed, assess patients ability

to see.

NASAL POLYPS

Polyps are benign grapelike cluster of mucous membrane and connective

tissue growths that appear as soft, pale gray, non tender masses and gradually
form from recurrent, localized swelling of the sinuses or nasal mucosa. Polyps
are seen in about 90% of patients with chronic maxillary sinusitis. Polyps may
become quite large. They are usually bilateral, occur in multiples and may cause
actual distention and enlargement of bony structures of the nose. Even after
surgical removal, some nasal polyps recur. Although rare in children, polyps are
occasionally found in children with cystic fibrosis and allergies and in those with
Peutz-Jeghers syndrome. The symptoms of this syndrome include pigmented
spots on the skin, especially around the mouth and polyposis of the
gastrointestinal tract. Many patients with polyps have anosmia or hyponosmia.

PATHOPHYSIOLOGY

The etiology of nasal polyps is not clear. They are often suspended in the
nasal cavity by stalks of varying lengths. The polyps and stalks usually originate
in the paranasal sinuses, particularly the ethmoid sinuses and pass into the
middle meatus of the nose through the ostia connecting them to the nasal
cavities. They are often called pseudotumors. Their pathogenesis is thought to
be the result of focal mucosal edema that causes a polypoid swelling. Because of
the polyps weight, the swelling tend to enlarge and eventually becomes
suspended on a stalk.

Polyps are usually found in the middle meatus near the openings of the
sinuses and in the roof of the nose. They are never found on the septum or in
the lower meatus; the reason for this is not known. Nasal polyps are often found
in patients with allergy, cystic fibrosis, asthma, disorders of ciliary motility,
chronic rhinitis and chronic sinusitis. The exact relationship is unknown but may
be related to an inflammatory response causing hypertrophy of the mucosa,
edema, and thinning of mucous membranes.

An interesting phenomenon that occurs in some patients with asthma and

nasal polyps is intolerance to aspirin, indomethacin and coal tar dyes. The
intolerance is severe, and can cause respiratory arrest if these substances are
ingested. This is thought to be related to the inhibitory action of these
substances on prostaglandin synthesis.

Diagnostic Studies and Findings:

X-ray examination of sinuses. Shadows over affected

areas ethmoid sinuses and sometimes maxillary sinuses
appear opaque.

Immunologic assessment. Performed if allergy is

considered a causative effect.

153

www.nurseslabs.com
154

Medical and Surgical Management

1. Polypectomy each polyp avulsed with wire snare.

2. Caldwell-Luc procedure may be performed if polyps originate

in maxillary sinus.

3. Functional endoscopic sinus surgery removal of polyps using

nasal endoscope.

Medications:

Corticosteroids. Prednisone high dose for 5 days.

Methyprednisolone decreasing doses may be used for severe nasal

obstruction to decrease size of polyps.

Steroids not recommended for long term use; steroid sprays may be
used for long term control of the size of polyps and to prevent recurrence
by reducing the inflammatory response.

Antihistamines

Decongestants

Anti infective agents

Nursing Assessment:

Nasal Obstruction; feeling of fullness in face or nose; nasal obstruction; difficulty

in breathing through nose; nasal discharge; anosmia; symptoms of allergic
rhinitis such as sneezing, watery eyes, eczema and asthma.

Nursing Dx and Interventions:

INEFFECTIVE AIRWAY CLEARANCE r/t swelling of the nasal mucosa and

nasal obstruction

Monitor patients vital signs.

Assess patients ability to clear secretions, and amount of swelling.

Increase humidification.

After polypectomy, elevate head of bed and apply ice compresses to nose
to minimize swelling and bleeding.

Change nasal drip pad as indicated and record amount and consistency of
drainage.

Encourage patient not to swallow blood or secretions and expectorate into

basin to prevent nausea.

Instruct patient not to blow nose to prevent tissue trauma and promote
healing.

Observe for bleeding, and if bleeding occurs, instruct patient to notify

physician, elevate head of bed, check vital signs, compress outside of
nose against septum and apply ice compress to nose.

154

www.nurseslabs.com
155

If bleeding persists, packing may be necessary.

SENSORY/PERCEPTUAL ALTERATIONS (olfactory) r/t anosmia, presence

of nasal edema

Assess patients ability to smell.

Assure patient that sense of smell should return postoperatively after

swelling has decreased.

Instruct patient to make appropriate adaptations to environment.

SEPTAL DEVIATION AND PERFORATION

A deviated septum is a shift of the septum from the midline,

which is common in many adults. It is either S or C shaped. Although the septum
is usually straight at birth, it may shift from one side to another as a result of
trauma or injury.

A septal perforation is a hole in the nasal septum between

the nostrils, which is usually in the anterior or cartilaginous septum but may
occasionally occur in the bony septum. A small perforation, which can be caused
by infections, nasal crusting, or nose picking is often asymptomatic, although a
slight whistle may be heard as the patient breathes. Larger perforations may
produce rhinitis, nasal crusting or epistaxis.

PATHOPHYSIOLOGY

The nasal septum, the dividing structure of the nose, is

usually straight and divides the nose into two equal chambers. The septum is
occasionally bent during birth, and the infant may have a twisted appearing
nose. With aging, the septum has a tendency to become deviated or to form a
hump. There is frequently no history of injury to account for the deviation. As a
result, few adults have a totally straight septum. Trauma during childhood may
also contribute to septal deviations in the adult. There is also a congenital
disorder called choanal atresia, where the back of the nasal passage is blocked,
usually by abnormal bony or soft tissue. It can be unilateral or bilateral.
Sometimes, a unilateral choanal atresia is not detected until much later in life
because the baby manages to get along with only one nostril available for
breathing

Septal perforations may be small or large. They may be

asymptomatic or may cause annoying symptoms such as crusting, watery
discharge, or a whistling noise as the patient breathes. Small perforations are
usually caused by repeated irritation of the nose such as picking it: they may
also be caused by septal surgery. Less frequent causes are repeated
cauterization because of epistaxis, abuse of intranasal lidocaine, and chronic
nasal infections. Ninety percent of perforations are in the anterior cartilaginous
portions of the nose, less than 10% are in the posterior bony portions.

Diagnostic Studies and Findings

Facial X-ray examination, examination with nasal speculum or endoscope.

- Show a shift of the septum or a septal

perforation.

Medical and Surgical Management

For deviation:

155

www.nurseslabs.com
156

Submucous resection (SMR) may be performed to reposition septum

and relieve nasal obstruction

Rhinoplasty may be done to correct nasal structure deformity

Septoplasty to replace septum in midline, may be done to relieve nasal

obstruction and to enhance external appearance of nose.

For perforation:

Surgical closure possible but not always successful; a Silastic button

prosthesis may be inserted to close perforation.

MEDICATIONS: Analgesics

Antihistamines

Decongestants

Antiinfective agents

General Management:

Local application of lanolin or petroleum twice a day to prevent crusting

Irrigate nose with normal saline or a dilute solution of sodium bicarbonate

two or three times a day to keep the nasal mucosa hydrated (for
perforations)

Packing to control bleeding, if present. (for deviation)

Nursing Assessment:

Irregularities or deformity of external nose; obstruction to nasal breathing;

feeling of facial fullness; headaches; epistaxis; crusting of nasal mucosa; whistle
sound when breathing (perforation); or sinusitis

Nursing Dx and Interventions:

INEFFECTIVE BREATHING PATTERN r/t septal deformity causing

obstruction

Assess and record respiratory status.

Postoperative care includes explanation in patient that facial and

periorbital edema may be present and that nasal packing or nasal splints
may be used.

Instruct patient to breathe though mouth during this time.

IMPAIRED SKIN INTEGRITY r/t surgery on septum

Keep head of bed slightly elevated to prevent edema and promote

drainage.
156

www.nurseslabs.com
157

Use ice compresses on face to decrease edema, pain and bleeding.

Use cool mist vaporizer to assist in liquefying secretions.

Point out that patient may experience difficulty swallowing if nasal packing
is used.

Change drip pad as necessary, recording color, consistency and amount of

drainage.

Provide meticulous mouth care because patient is breathing through

mouth.

RISK FOR INJURY r/t bleeding or tissue trauma

Assess and report presence of excessive bleeding, swallowing or purulent

discharge

Caution patient against attempting to blow nose, may cause bruising,

edema and bleeding.

Caution patient not to smoke for at least 2 days; limit physical activity for
several days to prevent irritation or trauma to tissues, which may cause
bleeding.

157

www.nurseslabs.com
158

158

www.nurseslabs.com
159

159

www.nurseslabs.com
160

160

www.nurseslabs.com
161

5. Musculoskeletal disorders

6. Degenerative disorders

B. Maladaptive Patterns of Behavior

1. Anxiety Response and anxiety related disorders

2. Psychophysiologic responses, somatoform and sleep disorders
3. Abuse and violence
4. Emotional responses and mood disorders
5. Schizophrenia and other psychotic and mood disorders
6. Social responses and personality disorders
7. Substance related disorders
8. Eating disorders
9. Sexual Disorders
10.Emotional disorders of infants, children and adolescents

II. Communication, Collaboration & Teamwork

A. Team Approach

B. Referral

C. Network/Linkage

D. Therapeutic communication

III. Ethico-Moral-Legal Responsibility

A. Confidentiality

B. Clients Rights

1. Informed consent
2. Refusal to take medications, treatment and admission procedures

C. Nursing accountability, liability

D. Documentation/Charting

E. Culture sensitivity

III. Personal & Professional Development

161

www.nurseslabs.com
162

A. Nurse-Client Relationship

B. Continuing Education

IV. Research and Quality Improvement

A. Evidence-based Practice

B. Standards of Safe Practice

V. Management of Resources, Environment and Record Management

A. Patient Safety

B. Standards of Documentation

162

www.nurseslabs.com