Medsurg Neuro Sense Organs
Medsurg Neuro Sense Organs
Medsurg Neuro Sense Organs
II. TASTE:
Tongue – responsible for the taste sensation
Taste buds located on sides of the papillae of the tongue
4 basic types of buds: sweet, salty, sour, bitter
Anterior 2/3 of tongue – innervated by facial nerve; Posterior 1/3 –
innervated by glossopharyngeal nerve
Saliva – dissolves substances so they enter the taste pores & stimulate
the receptors
Pathway: taste sensation conducted to taste center (medulla) > thalamus
> cerebral cortex
IV. HEARING
V. EQUILIBRIUM
Vestibular portion of the ear is responsible for the sense of balance
Structures: semicircular canals in 3 different planes; Utricle; Saccule
Utricle – tiny hair cells that have small stones (otoliths or calcium
carbonates); these hair cells bend backward when you begin to move
forward
Semicircular canals have hair cells that are stimulated by movement of
the endolymph (fluid in the cochlear channel)
Cerebellum – adjust position of body so that equilibrium is maintained
Basal Ganglia – involved in coordination
Propioceptors & visual receptors are also important in maintaining
sense of balance
VI. VISION
I. EYES
A. VISUAL DEFECTS:
Emmetropia – Normal; rays coming from an object at a distance of 20
feet or more are brought to a focus on the retina by the lens
Ammetropia – Abnormal
1. Hyperopia: farsightedness; eyeball is too short, light rays are brought
to focus in the back of the retina; corrected by convex lens; (“FAR-
VEX”)
2. Myopia: nearsightedness; light rays are brought to focus in front of
the retina; corrected by concave lens; (“NEAR-CAVE”)
3. Astigmatism: uneven curvature of the cornea; causing inability to
focus horizontal & vertical rays on the retina at the same time;
corrected by cylinder lens; (“ASTIG-CY-LINDER”)
4. Presbyopia: aka “elder vision”; the elasticity of the lens decreases
with increasing age; decreased ability to accommodate; requires
prescription lenses (reading glasses) PRESBY = ELDER PEOPLE
B. STRABISMUS: ( LIBAT)
Deviation of one eye from the other in an inward, outward, upward,
downward manner
Common symptom of CNS, ocular or other general systemic problems
2 Types:
1. Paralytic (damage of nerves controlling the extraocular muscles);
MGT: Correct underlying cause of neural damage.
2. Non-paralytic (result of a defect in the position of the two eyes)
Non-paralytic – corrected by surgery (advance, resect, or tuck muscles
that support the eye to align eyes equally)
C. CATARACTS – no pain
Opacity or cloudiness of the lens
PRED FACTORS:
1. Most commonly results of the
aging process, after 70 years of
age (senile cataracts)
2. Occurrence at birth (congenital
cataract)
3. Occasionally a result of disease
or following trauma
CLINICAL MANIFESTATIONS:
1. Alterations in Vision -
a. Objects are distorted & blurred (color shift - aging lens more
absorbent at the blue end of the color spectrum; brunescens –
color values shifts to yellow brown)
b. Glare annoys the pt when there are bright lights
c. There is no pain or eye redness
d. Visual loss is gradual
2. Alterations in Appearance –
a. The pupil, usually dark, progresses to a milky white color
b. Eventually, opacity becomes complete
MANAGEMENT:
1. General -
a. Surgical removal of the lens is indicated
b. Usually a pt with one cataract can manage without surgery
c. If cataract occurs in both eyes, surgery is recommended when
vision in the better eye causes problems in daily activities. Surgery
is done on only one eye at a time
d. Cataract surgery is usually done under local anesthesia.
Preoperative medications produce ↓ response to pain & lessened
motor activity. Oral medications are given to ↓ intraocular pressure
e. Intraocular lens implants are usually implanted at the time of
cataract extraction
f. In some instances following lens extraction and the healing process,
the patient may be fitted with appropriate eyeglasses or contact
lenses to correct refraction
2. Surgical Procedures –
A. Two types of Extractions:
a. INTRACAPSULAR EXTRACTION – the lens as well as the
capsule are removed through a small incision
b. EXTRACAPSULAR EXTRACTION – the lens capsule is
incised, & the nucleus, cortex & anterior capsule are extracted
> The posterior capsule is left in place & is usually the base to
which an IOL is implanted
> A conservative procedure of choice, simple to perform &
usually done under local anesthesia
B. Two types of Procedures for Extractions:
a. CRYOSURGERY – a special technique in which a pencil-like
instrument with a metal tip is super-cooled (-35degrees), then is
touched to the exposed lens, freezing to it so that the lens is
easily lifted out
b. PHACOEMULSIFICATION – the mechanical breaking up
(emulsifying) of the lens by a hollow needle vibrating at
ultrasonic speed. This action is coupled with irrigation &
aspiration of the emulsified particles from the anterior chamber
Nursing Interventions:
A. Pre-op:
1. Routine pre-op care
2. Employ aseptic technique when performing eye treatment
3. Instruct patient not to touch eyes
4. Administer medications as prescribed:
a. Antiemetics – Prochlorperazine (Compazine); Hydroxyzine
(Vistaril)
b. Pain Control – Meperidine (Demerol)
c. Ocular Hypotensives (to prevent inc IOP) – Acetazolamide
(Diamox); Glycerol (Mannitol)
d. Mydriatics to dilate the pupils
B. Pos-op:
1. Prevent ↑ IOP (N- 8-20mmHg)
a. Refrain from coughing or sneezing
b. Avoid rapid movements & bending from the waist
2. Promote comfort & safety
a. PositionBQ) unoperative side or on back with pillows for
head elevation (30-40 degrees) semi fowlers
b. Report ASAP! – sudden eye pain – may be due to ruptured
vessel or suture; may lead to hemorrhage;
3. Patient Teaching:
a. Avoid strain on the eye: no heavy lifting & straining on defecation; no
vigorous shaking of head
b. Use dark glasses after eye dressings are removed to provide comfort
c. Adjusting to Eyeglasses: relearn space judgment (walking using stairs,
reaching for articles on the table, pouring liquids)
SX/SY:
MGT:
a. Wear gloves to prevent dissemination
of infection
b. Meds: Antihistamine for allergies;
appropriate antibiotics if cause is bacteria
G. EYE INJURIES:
1. CORNEAL ABRASION
- first external part of the eye that is transparent.
An injury to the cornea that goes deeper than the epithelium
Is a common occurrence as a result of inadvertent contact with objects
such as fingernails, tree branches, or overwearing of contact lenses
Can lead to infection or ulcer formation
MGT:
a. A solution is instilled to relieve pain & facilitate eye examinations
b. The area is stained with fluorescein to detect existence of an
abrasion & its extent
1. The conjunctival surface of lower lid is touched with the
fluorescein paper strip
2. The damaged corneal epithelium will take the stain & turn green;
undamaged areas remain unstained. The stained area is viewed
with a Wood‟s lamp, slit lamp, or a blue light
3. Following use of fluorescein, the eye is flushed as other pt have
allergic reactions to it
4. A drop of antibiotic is instilled since patching creates a moist
environment conducive to flora growth
NSG INTERVENTIONS:
a. Rest eyes for 24 hours for greater comfort; corneal epithelium
usually heals in 24-48 hours
b. Apply dressing (as directed) firmly but gently over eye to put eye to
rest & to prevent movement of the eyelid with resultant irritation
of abraded corneal area
c. Oral Analgesics are given bec corneal abrasion is very painful
d. Instruct pt to return to ophthalmologist the following day for
dressing change & inspection of eye for evidence of infection or
ulcer formation
A. EXTERNAL EAR
1. OTITIS EXTERNA
An inflammation of the external ear canal that may occur 2-3 days
after swimming & diving
Aka “SWIMMER‟S EAR”
PREVENTION:
a. Dry ear canal thoroughly after coming in contact with water or
moist environment
b. Use ear drops after swimming may assist in preventing swimmer‟s
ear. Usually these solutions contain alcohol & glycerol to reduce
moisture; boric acid or acetic acid to limit growth of microorganisms
& maintain normal acidity of the ear canal
MGT:
a. If canal is swollen & tender, topical corticosteroids may ↓
inflammation & swelling
b. Topical antibiotics can curb infection
2. IMPACTED CERUMEN (ear wax)
Accumulated cerumen does not have to be removed unless it becomes
impacted & interferes with hearing
Use of cotton-tipped applications to dry the canal or remove ear wax
should be avoided because:
a. Cerumen may be forced against the tympanic membrane
b. The canal lining may be abraded making it more susceptible to
infection
c. Cerumen that occurs & protects the canal may be removed
MGT: Irrigation of the External Auditory Canal (but make sure the
ear drum is not damaged)
B. MIDDLE EAR
MGT:
1. Give Penicillin – DOC
2. Relieve pain & pressure (aspirin & analgesics; local cold
compresses)
3. Report signs of mastoid & meningeal involvement (headache,
slow pulse, vomiting, vertigo)-KNOB
4. Provide safety (side rails up, assist in ambulation, slow
movement changes)
5. Patient Teaching:
a. Until tympanic membrane heals, avoid activities such as
swimming, shampooing hair, showering
b. Practice good hygiene to prevent reinfection (avoid
earpicking, inserting toothpick in ear to relieve itch)
DX:
o History will indicate several episodes of acute otitis media,
possible rupture of tympanic membrane
o Audiometric Test: air conductive hearing loss
o Xray: may note mastoid pathology (ex. (+) of
CHOLESTEATOMA – soft ball of dead skin cells that erodes
surrounding vital structures)
MGT:
1. Medical Therapy -
a. Antibiotic & steroid eardrops may control inflammation &
infection
b. Frequent removal of epithelial debris & purulent drainage may
protect tissue from damage
2. Surgical Interventions –
a. Indicated when cholesteatoma is present
b. Indicated when there is pain, profound deafness dizziness,
sudden facial paralysis, or stiff neck
c. Types of Procedures –
o SIMPLE MASTOIDECTOMY – removal of the mastoid cells;
indicated when there is persistent tenderness, fever, discharge
from ear or headache
o RADICAL MASTOIDECTOMY – removal of all diseased
tissue from mastoid area & middle ear
o POSTEROANTERIOR MASTOIDECTOMY – combines
simple mastoidectomy with tympanoplasty (reconstruction of
middle ear structures)
DX:
o Audiometry – reveals conductive hearing loss
o Weber‟s & Rinne‟s Tests: show bone conduction is greater than air
conduction
SURGERY: STAPEDECTOMY
o Treatment of choice
o Removal of otosclerotic lesions at the footplate of stapes & the
creation of a tissue implant with prosthesis to maintain suitable
conduction
o Otologic binocular microscope is used to perform the delicate surgery
o Nursing Interventions:
1. Position pt according to DR‟s orders (possible with operative ear
uppermost to prevent displacement of the graft)
2. Have pt deep breathe q2hours while in bed but no coughing
3. Elevate side rails; assist pt with ambulation & move slowly
4. Administer medications as ordered: analgesics, antibiotics,
antiemetics, anti-motion sickness drugs
5. Check dressings frequently for excessive drainage or bleeding
6. Assess for facial nerve function (ask pt to wrinkle forehead, close
eyelids, puff out cheeks, smile & show teeth, check for asymmetry)
7. Reportable signs:
-pain,
-headache,
-vertigo,
-unusual sensations in the ear
8. Patient Teaching:
a. There may be a temporary hearing loss for a few weeks after
surgery because of tissue edema, packing, etc.
b. Packing is removed by surgeon in 5-6 days post-op; pt should
protect the ear by placing cotton ball in outer ear & changing it
2x/day
c. No blowing of nose or coughing (sneeze with mouth open)
d. Need to keep ear dry in the shower; no shampooing until allowed
e. No flying for 6 mos; no diving
f. Avoid crowds or exposure to colds so that URTI is prevented
C. INNER EAR
MEDS:
a. Acute: Atropine (↓ autonomic nervous system activity; Diazepam
b.Chronic: Vasodilators (Nicotinic Acid); Sedatives (Diazepam);
Antivertigo (Meclizine)
SURGERY:
a. Conservative: Simple sac decompression or sac shunt to equalize
pressure in the endolymphatic space
b. Destructive:
o LABYRITHECTOMY – recommended if pt experiences
progressive hearing loss & severe vertigo attacks so that he cannot
perform normal task; surgical destruction of labyrinth causing loss
of vestibular & cochlear function (if disease is unilateral)
o VESTIBULAR NERVE NEURECTOMY – removal of the
vestibular portion of CNVIII
NURSING INTERVENTIONS:
a. Maintain bed rest in a quiet, darkened room in position of choice
(noises, glaring & bright lights may initiate attack)
b. Only move pt for essential care (bath may not be essential); move
slowly since jerking & sudden movements may precipitate attack
c. Assist with ambulation when attack is over
d. Provide a call system for pt if assistance is needed
e. Eliminate smoking & intake of coffee, tea, alcohol, stimulating drugs
due to vasoconstriction effect
S/SX:
1. sensitive to pain, cold
Medical Mgt:
DOC: Carbamazepine (Tegretol)muscle relaxant; Phenytoin
(Dilantin) CNS depressant
Nerve block: injection of alcohol or phenol into one or more
branches of the CNV; temporary, lasts 6-18 mos
Surgery –
Peripheral: avulsion of peripheral branches of trigeminal
nerve
Intracranial:
Retrogression Rhizotomy: total severance of the sensory
root of the trigeminal nerve intracranially; results in
permanent anesthesia, numbness, heaviness, stiffness in
affected part; loss of corneal reflex
Percutaneous Radio-Frequency Trigeminal Gangliolysis –
current surgical treatment of choice; thermally destroys the
trigeminal nerve in the area of the ganglion; provides
permanent pain relief with preservation of the sense of
touch, proprioception, & corneal reflex, done under local
anesthesia
Microvascular Decompression of trigeminal nerve:
decompresses the trigeminal nerve; craniotomy is
necessary; provides permanent relief while preserving the
facial sensations
Assessment Findings:
Severe shooting pain in one side of the face
Attacks may be triggered by a cold breeze; foods/fluids of
extreme temperature; toothbrushing, chewing, talking or
touching the face
During attack: twitching, grimacing & frequent blinking &
tearing of the eye
Poor eating & hygiene habits
Withdrawal from interactions with others
Nursing Interventions:
Assess triggering factors
Maintain room at an even, moderate temperature, freed from
drafts
Approach client slowly
Provide SFF of lukewarm, semiliquid, or soft foods that are
easily chewed
Provide client with a soft washcloth & lukewarm water &
perform hygiene when pain is decreased
Patient Teaching:
Need to avoid outdoor activities during cold, windy or
rainy weather
Importance of good nutrition & hygiene
Use of medications, side effects
Specific post-op instructions for residual effects of
anesthesia & loss of corneal reflex:
Protective eye care
Chew on unaffected side only
Mouth care to remove particles
Good oral hygiene, visit dentist every 6 mos.
Protect face during extremes of temperature
BELL’S PALSY
General Information
Disorder of CNVII (facial nerve) resulting in the loss of ability
to move the muscles on one side of the face
Assessment Findings
Loss of taste over anterior 2/3 of tongue on affected side
Complete paralysis of one side of the face
Loss of expression, displacement of the mouth toward
unaffected side & inability to close eyelid (all on affected
side)
Pain behind the ear
Nursing Interventions:
Assess nerve function regularly
Administer medications as ordered:
Corticosteroids to ↓ edema & pain
Mild analgesics as necessary
Provide soft diet with supplementary feedings as indicated
Instruct to chew on the unaffected side, avoid hot fluids/foods
& perform mouth care after each meal
Provide special eye care to protect the cornea
Dark glasses (cosmetic & protective reasons) or
eyeshields
Artificial tears to prevent drying of the cornea
Ointment & eyepatch at night to keep eyelids closed, or
tape the eyelids to close
Provide support & reassurance