Sensory/Integumentary System (Exam One) Flashcards
(153 cards)
1
Q
What are the essential functions of the structures of the eye?
A
- Protect the eye
- Prevent the eye from drying out
2
Q
The vitreous humor gives the eyeball its what? How is the consistency of the vitreous humor described?
A
- Gives the eyeball its shape
- Jelly like consistency
3
Q
The aqueous humor encompasses which portion of the eyeball? How is the consistency of the aqueous humor described?
HINT: Think “aque” and “aqua” where “aqua” = water
A
- Located in the frontal portion of the eyeball
- Water like consistency
4
Q
Cones are responsible for what?
A
Colored vision
5
Q
Rods are responsible for what?
A
Various shades of grey color
6
Q
The optic nerve protrudes from which portion of the eyeball?
A
Posterior (back) portion of the eyeball
7
Q
The optic nerve is known as which cranial nerve?
A
Cranial nerve II
8
Q
What two tests assess visual acuity?
A
- Snellen
- E-chart
9
Q
How many feet away from the chart is the patient during the Snellen test? How would the nurse assess each eye individually?
A
- 20 feet
- The patient will cover one eye with their hand
10
Q
How far is the E-chart held from the face during testing?
A
14 inches
11
Q
The E-chart is used for individual who struggle with this task.
A
Reading
12
Q
The nurse should take note of which eye diseases when assessing family history? Why are these diseases specifically important?
A
- Glaucoma
- Diabetes
- Blindness
- Cataracts
-They are genetic
13
Q
What is normal vision? How is this interpreted?
A
- 20/20
- At 20 feet the patient can read what the normal eye can read at the same distance
14
Q
Low vision occurs at what?
A
20/70
15
Q
Legal blindness occurs at what?
A
20/200
16
Q
How is the term ‘right eye’ written when documenting?
A
OD
17
Q
How is the term ‘left eye’ written when documenting?
A
OS
18
Q
How is the term ‘both eyes’ written when documenting?
A
OU
19
Q
Besides the visual acuity, the nurse should include what in her documentation?
A
Whether visual acuity is achieved with/without corrective lenses
20
Q
How is muscle balance and movement assessed in the eyeball?
A
Six Cardinal Field Test
21
Q
The six cardinal field test assesses which cranial nerves?
A
- Cranial nerve III (3)
- Cranial nerve IV (4)
- Cranial nerve VI (6)
22
Q
Define esotropia.
A
Deviation of eye towards nose
23
Q
Define exotropia.
A
Deviation of eye away from nose
24
Q
Define hypotropia.
A
Deviation of eye downward
25
Define hypertropia.
Deviation of eye upward
26
What is ptosis? Ptosis is often seen in what disease?
- Drooping of the eyelid
| - Seen in stroke patients
27
The eyes should be ______.
Symmetrical
28
Yellowish discoloration of the eyes is indicative of what?
Jaundice
29
What is a tonometer? Tonometer assesses for which disease? Can this be performed by the nurse?
- Checks intraocular pressure of the eyeball
- Assesses for glaucoma
-Yes
30
Distorted depth perception puts the patient at an increased risk for what?
Falls
31
What is arcus senilis? What clinical manifestation is associated with arcus senilis?
- Lipid deposit within the cornea
| - White ring around the iris
32
List important vision changes within the older adult.
- Yellowing of the lens
- Distorted depth perception
- Dry eyes
- Arcus senilis
33
What should be obtained before a patient begins antibiotic treatment?
Culture
34
How often is an eye exam needed if the patients wears corrective lenses, has an eye disease, or experiences change in vision?
Annually
35
In what direction should the eye be wiped?
From the inner eye to the outer eye
36
What mechanism or method is used to irrigate the eyeball?
- Morgan Lens
| - IV tubing
37
The nurse should educate the patient to cover what when inserting eye drops or eye ointment? Why is this important?
- Cover the punctum (tear duct)
| - Prevents medications from being absorbed systemically
38
When administering medication to the eye, what should never come in contact with the eye itself?
The tip of the medicine dropper
39
How long should the patient wait between eye drop administration?
5 to 10 minutes
40
Eye ointment is always administer to which portion of the eye? In what direction should the ointment be applied?
- The bottom eyelid
| - Inner to outer
41
The nurse should encourage a patient with an eye patch to avoid which activities?
- Watching television
| - Reading
42
What is conjunctivitis?
Inflammation of the conjunctiva that is either bacterial or viral
43
Bacterial conjunctivitis is also referred to as what?
Pinkeye
44
What are the signs and symptoms of conjunctivitis?
- Redness
- Crusty exudate
- Pain
- Itching
- Excessive tearing
45
What is the most effective method in preventing bacterial and bacterial transfer?
Handwashing!
46
What is a hordeolum? It is also known as what?
- Abscess in the sebaceous gland at the eyelid
| - Sty
47
What is a chalazion? How does it differ from hordeolum? What might a chalazion require?
- Sty that is larger in size
- Can cause pain and pressure to the cornea
- May require I&D (incision and drainage)
48
What is blepharitis? Is it short-term or long-term? What is required with blepharitis?
- Inflammation of eyelid
- Long-term problem
- Requires daily cleaning
49
What is keratitis?
Inflammation of the cornea
50
Patients with keratitis have a sensitivity to what?
Light
51
What is astigmatism? What does it cause?
- Uneven curves of the cornea
| - Causes blurry vision
52
Define hyperopia.
Farsightedness (can see far away)
53
Define myopia.
Nearsightedness (can see close)
54
What is presbyopia? At what age does this occur?
- Age related changes to vision
| - After 40 years old
55
How are refractive vision disorders generally treated?
- Glasses
| - Contact lenses
56
What is the nursing priority for visually impaired patients?
Safety
57
How might a patient describe their vision if they have diabetic retinopathy? What is diabetic retinopathy? What causes diabetic retinopathy?
- Dark spots or strings floating in the vision
| - Vascular change of retinal vessels caused by lack of blood sugar control
58
What might the patient experience if they suffer from retinal detachment?
- Sudden vision changes
- Loss of peripheral vision
- Decreased visual acuity
59
Will retinal detachment cause pain? Why or why not?
- No pain
| - There are no sensory nerves in the retina
60
What are the treatment options for a patient with a detached retina?
- Laser Surgery
- Cryopexy
- Pneumatic retinopexy
61
What is pneumatic retinopexy?
Injects air or gas into the chamber to hold the retina in place
62
What is the biggest issue regarding patients and retinal detachment surgeries?
Patient compliance
63
What is glaucoma?
- Damage to the optic nerve
| - Silent, progressive and irreversible
64
What are the two major forms of glaucoma?
- Primary open angle glaucoma (POAG)
| - Acute angle closure glaucoma (AACG)
65
Which form of glaucoma has a unilateral rapid onset, is considered an emergency, and can result in blindness? What occurs in this form of glaucoma?
- Acute angle closure glaucoma (AACG)
| - Blocks flow of aqueous humor
66
How would a patient with acute angle closure glaucoma describe their vision?
- Blurred
- Rainbows appear around light
- Painful
67
Which form of glaucoma is most common and considered silent, progressive, painless, and irreversible? Does it occur unilaterally or bilaterally?
- Primary open angle glaucoma
| - Occurs bilaterally
68
What occurs in primary open angle glaucoma (POAG)?
Degeneration of the eye drainage system blocking the flow of aqueous humor
69
Which medications are commonly prescribed to treat glaucoma?
HINT: Little word = little pupil
Miotic medications
70
Which medications are contraindicated in patients with glaucoma?
HINT: Big word = big pupil
-Mydriatic medications:
-Anticholinergics: Atropine
-Antihistamines: Hydroxyzine
and Diphenhydramine
71
What is a lifelong requirement for patients with glaucoma? What is the most prominent issue with this requirement?
- Daily eye drops
| - Compliance
72
Patients with glaucoma should wear what? What is the importance of this?
- Medical alert bracelet
| - Prevents receiving contraindicated medication in the event of an emergency
73
List possible nursing diagnosis for glaucoma.
- Pain
- Self care deficit
- Anxiety
- Risk for Injury
- Knowledge deficit
74
What are cataracts? Cataracts develop due to what?
- Painless opacity (cloud formation) of the eye lens
| - Develop due to aging
75
What are the risk factors for developing cataracts?
- Prolonged ultraviolet light
- Diabetes
- Smoking/Alcohol
- Steroid use
76
What are the signs and symptoms of cataracts?
- Increased sensitivity to glare
- Hazy or blurred vision
- Double vision
- Decreased color vision
77
What are the treatment options for cataracts?
- Implantation of lens (surgery)
| - Performed on one eye at a time
78
What is the leading cause of blindness in people over 50 years of age?
Age Related Macular Degeneration
79
What are the two types of macular degeneration? Which type accounts for 70% to 90% of cases?
- Dry accounts for 70% to 90% of cases
| - Wet
80
Who is most at risk for macular degeneration?
- People over age of 60
- Family history
- Diabetes
- Smoking
- UV light exposure
- Caucasians
81
What education should the nurse provide to the patient in relation to UV light exposure?
Protective eye wear!
82
What is the primary symptom of dry macular degeneration?
Slow progressive loss of central vision
83
What is the primary symptom of wet macular degeneration?
Sudden severe loss of central vision
84
_____ is key regarding macular degeneration.
Prevention
85
How is macular degeneration prevented?
- Healthy lifestyle
- No smoking
- Green/orange/yellow vegetables
- Zinc
86
What is an enucleation?
Removal of the eyeball
87
What is the most common treatment for trauma to the eyeball?
Saline flush to wash the eye out
88
What is strabismus? What can it cause?
- Crossed-eyed appearance
| - Double vision can cause children to appear clumsy
89
What is the most common childhood eye problems?
Strabismus
90
What are the treatment options for strabismus?
- Eye patch applied to stronger eye
- Glasses
- Eye exercises
91
Strabismus can lead to what condition?
Amblyopia
92
What is amblyopia? What can it cause?
- Lazy eye
| - Causes reduction or loss of vision in one eye
93
What is the chief cause of preventable vision loss in children?
Amblyopia
94
Restoration of sight is unlikely in a patient with amblyopia if they are older than what age?
7 years of age
95
The outer ear consists of what?
The visible, external portion of the ear to the ear drum
96
The middle ear consists of what?
The eardrum to the beginning of the cochlea
97
The inner ear consists of what?
Involves the cochlea
98
What does the inner ear control?
Equilibrium
99
Patients who present with inner ear problems are at an increased risk for what?
Falls
100
What is the name of cranial nerve VIII? What is it responsible for?
- Vestibulocochlear nerve
| - Hearing
101
What is the role of the eustachian tube?
Equalization of pressure within the ear
102
What is presbycusis? What causes this?
-Age related hearing changes -Loss of hair cells and decreased blood supply
103
Which frequency of hearing is generally lost first?
High frequencies
104
What is otorrhea?
Discharge from the ear
105
What is otalgia?
Ear pain
106
List medications that are ototoxic.
- Diuretics: Lasix or Bumex
- Certain antibiotics: Vancomycin, Gentamycin
- Aspirin
107
The nurse should assess for which disease when asking the patient about a family history of hearing loss?
Meniere's Disease
108
Describe the whisper test.
- Patient occludes one ear
- Standing 1 or 2 feet away the provider will whisper a word
- Patient should be able to repeat back the same word
109
The Rinne and Weber test utilize what assistive device?
-Utilize tuning forks
110
What is Romberg's test? If excessive swaying is present what might this indicate?
- Known as the fall test
- Patient should exhibit minimal swaying when eyes are closed
- Inner ear problem associated with excessive swaying
111
What therapeutic medications are given for hearing problems?
- Anti-infectives
- Anti-inflammatories
- Antihistamines
- Decongestants
- Cerumenolytics
- Diuretics
112
Cochlear implants are used for what type of ear problem? What population will benefit most from cochlear implants?
- Sensorineural hearing loss
| - Children
113
What are safety measures that can be utilized by hearing impaired individuals?
- Visual smoke detectors
- Alarms that vibrate the bed
- Hearing ear dog
114
Ear drops should be kept at _____ _______.
Room temperature
115
How are ear drops administered in an adult?
Pull ear back and up
116
How are ear drops administered in a child?
Pull the ear down and back for infants and children under 3 years old
117
How long should the patient remain in position after ear drops have been applied?
2 to 3 minutes
118
What are the three types of hearing loss?
- Conductive
- Sensorineural
- Mixed
119
What is conductive hearing loss? Where does this occur?
- Affects sound waves attempting to reach the ear
| - Affects outer and middle ear
120
What is sensorineural hearing loss? Where does this occur?
- Involves the cochlea and hair cells
| - Affects the nerve of the inner ear, specifically cranial nerve VIII
121
What are the causes of conductive hearing loss?
- Foreign body
- Cerumen
- Infection
- Perforation
- Trauma
122
What are the causes of sensorineural hearing loss?
- Measles
- Mumps
- Meningitis
- Ototoxic drugs
- Noise
- Aging
123
What are signs and symptoms of sensorineural hearing loss?
- Tinnitus
- Dizziness
- Hearing loss
124
What are the causes of mixed hearing loss?
- Tumors
| - Strokes
125
What is the most common problem of the external ear?
Infection (i.e. Swimmer's Ear)
126
What is the most common bacteria associated with external ear infections?
Staphylococci
127
How is impacted cerumen usually treated?
Ear irrigation
128
The ear can only be irrigated if the patient has not had what?
Perforated ear drum
129
What should not be put into a patients ear if they have had perforated ear drums?
Water
130
What is the most common type of infection and overall most common disease?
Otitis media
131
What is otitis media? What causes otitis media?
- Inflammation of the middle ear
| - Fluid, pus, or air builds up in middle ear canal blocking the eustachian tubes which prevents ventilation
132
What are the complications of otitis media?
Perforation of eardrum
133
When will pain be present if an eardrum ruptures or perforates?
- Pain present before the rupture
| - NO pain after the rupture
134
Otitis media is most common after what other disease process?
Upper respiratory infection
135
Why are children more prone to middle ear infections?
- Shorter ear tubes
- More horizontal ear tubes
- More flaccid
- Unable to drain well
136
What are the signs and symptoms of otitis media?
- Pulling at ears
- Possible purulent drainage
- Decreased appetite
- Sucking will aggravate pain
- Fever
137
What is a myringoplasty?
Surgical repair of eardrum
138
What is a myringotomy?
Surgical incision and placement of drainage tubes
139
What is a mastoidectomy?
Removal of mastoid if infection has spread
140
What is the only middle ear structure that can be seen from outside?
Tympanic membrane
141
What is otosclerosis?
- Hardening of the ear
| - New bone formation of stapes
142
What are possible sources of trauma to the middle ear?
- Blunt force
- Pressure changes
- Blast injuries
143
What is labyrinthitis?
Inflammation of the inner ear
144
What are causes of labyrinthitis?
- Virus
- Bacteria
- Drug intoxication
- Alcohol
- Allergies
145
Why might a patient be placed on bedrest if they have labyrinthitis?
Safety precaution
146
What is Meniere's disease?
Balance disorder
147
**What are the signs and symptoms of Meniere's disease?
- Vertigo
- Tinnitus
- Hearing loss
-N/V
148
What maneuver is done to help relieve vertigo? What does this maneuver do?
- Epley manuever
| - Aids in the repositioning of canalith
149
What are key concepts regarding the pediatric population and ear infections?
- Handwashing
| - Early detection
150
What other system is often affected if a child has a hearing difficulty?
Speech problems
151
Stuttering is normal for a child up to what age? Is it most common in males or females?
- Age 5
| - Most common in males
152
What should be addressed first: hearing or language?
Hearing
153
How is hearing enhanced in pediatric populations?
- Encourage hearing aid use
- Look directly at child
- Avoid background use
- Speak slowly
- Use visual aids
