When performing an eye examination, the nurse will assess for accommodation by

(3) Color sense is tested by using specially designed color plates to distinguish reds, greens, and blues.

(4) Visual acuity testing is done with the Snellen chart or one of its modifications. Each eye is tested separately, both with and without glasses, if worn.

(a) Since the distance at which rays of light from an object are practically parallel and no accommodation of the lens is necessary to focus the object, the test is performed at a distance of 6 meters (20 feet),

(b) The Snellen chart contains rows of letters of varying sizes, arranged to that the normal eye can see them at distances of 6, 9, 12, 15, 21, 30, and 60 meters. (20, 30, 40, 50, 70, 100, and 200 feet.) If a patient is seated 6 meters (20 feet) from the chart and can read the line of letters for 6 meters, his vision is expressed by the fraction 6/6 (or 20/20).

(c) Vision is expressed by a fraction, the numerator denoting the distance at which the test was performed (normally, 6 meters or 20 feet), and the

denominator denoting the smallest line of letters which could be read at that distance. If a patient is seated 6 meters from the chart and the smallest line of letters he is able to read is the one that should be read at a distance of 30 meters, then his vision is expressed at 6/30 (or 20/100).

(d) If the largest letters on the chart cannot be read at a distance of 6 meters, the patient is moved toward the chart until he can read the largest letters. Vision is then expressed as a fraction, with the numerator denoting the distance at which the largest line could be read, and the denominator denoting the number of the largest line.

(e) If the patient cannot read the largest line at a distance of one meter, the examiner tests the patient's ability to see hand motion in front of his face. If the patient cannot see the examiner's hand at a distance of one or two meters, he is tested for light perception. A light is flashed from different directions and the patient is asked from which direction the light appears and when it goes on and, it goes off. If the patient can do this, the examination is recorded as "light perception present". If no light perception is present, a person is technically blind.

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1-13. INSTILLING EYE DROPS OR OINTMENTS

a. Review the patient's clinical record to verify the order.

b. Wash your hands and assemble the necessary equipment.

(1) Prescribed medication.

(2) Normal saline solution.

(3) Two by two inch gauze squares.

(4) Tissues.

c. Approach and identify the patient.

d. Explain the procedure and the purpose of the medication to the patient.

e. Provide for privacy, if appropriate.

f. If the patient is wearing an eye dressing, remove it by gently pulling down and away from the forehead. Discard the dressing and wash your hands.

g. Remove any accumulation of discharge by cleansing around the eye. Use the procedure outlined in paragraph 1-12a.

(1) If secretions are crusted, apply a moistened gauze square over the closed eye and leave in place for several minutes.

(2) Reapply as necessary until secretions are soft enough to be removed without traumatizing the mucosa.

h. Position the patient.

(1) Supine in bed is the position of choice.

(2) Seated in a steady chair is acceptable.

i. Prepare the medication.

(1) Remove the cap of the medication container, being careful to avoid contamination of the cap.

(2) If administering drops with a measured dropper, fill the dropper to the prescribed dose. (Many medications come in plastic containers that deliver a set dose per drop when the container is gently squeezed.)

(3) If administering an ointment, squeeze out a small amount onto to a sterile gauze square in order to remove any crust that may have formed. Discard the gauze.

j. Instill the medication.

(1) Steady the hand holding the medication against the patient's forehead.

(2) Instruct the patient to look up and to the side.

(3) With your free hand, gently pull down the lower lid of the affected eye, exposing the conjunctival sac.

(4) Instill the prescribed amount of drops or a thin ribbon of ointment into the conjunctival sac (figure 1-4). NEVER instill the medication directly onto the eyeball.

Figure 1-4. Instilling eye drops.

k. Instruct the patient to close the eyes gently (without squeezing the lids shut), and roll the eyes. This will distribute the medication.

l. Remove any excess solution or ointment from around the eye by blotting gently with a clean tissue or gauze square.

m. Apply a fresh dressing if required.

n. Provide for the patient's comfort.

o. Remove supplies from the bedside and store or discard as appropriate.

p. Wash your hands.

q. Record the procedure in the patient's clinical record.

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1-16. INSTILLING EAR DROPS

a. Review the patient's clinical record to verify the physician's order.

b. Wash your hands and assemble the necessary equipment.

(1) Prescribed medication.

(2) Cotton balls and gauze squares.

(3) Normal saline solution.

(4) Medicine dropper.

c. Approach and identify the patient.

d. Explain the procedure to the patient. Instruct him that it will be necessary to lie still for 10-15 minutes after the procedure.

e. Place the patient in a supine position with the head turned toward the unaffected side.

f. If necessary, cleanse the external ear with the saline and cotton balls or gauze squares.

g. Remove the cap from the medication container and, if a dropper is to be used, draw up the correct amount of medication. Do not contaminate the container cap.

h. With the non-dominant hand, straighten the external ear canal by gently pulling up and back on the ear for an adult, or down and back for a child.

i. Instill the prescribed amount of medication, one drop at a time.

(1) Direct the flow of the medication toward the roof of the ear canal.

(2) Do not allow the dropper (or the tip of the bottle) to touch the ear.

j. Place a cotton ball loosely into the opening of the ear canal to absorb any excess medication.

k. Instruct the patient to lie still for 10-15 minutes to allow the medication to be absorbed, rather than run out of the ear. (The head should remain turned toward the unaffected side.) After this period, assist the patient to a comfortable position.

l. Remove supplies from the bedside and store or discard as appropriate.

m. Wash your hands.

n. Record the procedure in the patient's clinical record.

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1-17. IRRIGATING THE EAR

a. Review the patient's clinical record to verify the physician's order to irrigate the ear.

b. Wash your hands and assemble the necessary equipment.

(1) Ear irrigation syringe.

(2) Irrigating solution.

(3) Cotton balls and gauze squares.

(4) Emesis basin.

(5) Large basin.

(6) Sterile solution thermometer.

(7) Chux pads.

c. Fill the large basin with hot water and place the container of irrigating solution into it.

d. Approach and identify the patient.

e. Explain the procedure to the patient.

f. Clean the external ear with moistened cotton balls or gauze squares.

g. Wash your hands.

h. Test the temperature of the irrigating solution with the sterile solution thermometer. The solution should be between 95ºF-105ºF (body temperature) to avoid causing dizziness.

i. Assist the patient to a sitting position with the head tilted slightly forward and toward the affected side.

j. Place a chux pad over the patient's shoulders to keep clothing dry.

k. Fill the irrigating syringe with solution and expel all air from the syringe.

l. Instruct the patient to hold the emesis basin against his neck, directly under the ear to be irrigated.

m. Straighten the ear canal.

n. Point the tip of the irrigating syringe upward and toward the back of the ear canal.

o. Direct a steady stream of solution into the ear, aiming toward the roof of the ear canal (figure 1-5).

Figure 1-5. Irrigating the ear.

p. Observe the solution as it returns. Note the presence of cerumen or other matter.

q. Observe the patient for signs of pain, nausea, or dizziness. Stop the irrigation immediately if these symptoms occur. Report to the professional nurse at once. These symptoms could be the result of a disturbance in the middle or inner ear, or may indicate a damaged tympanic membrane.

r. Refill the syringe and repeat the procedure until the return flow of solution is clear, or all of the prescribed solution has been used.

s. Assist the patient to a recumbent position, lying on the affected side for several minutes to facilitate complete drainage of the ear canal.

t. Clean the ear and surrounding skin with moistened cotton balls. Blot dry.

u. Remove supplies from the bedside and store or discard as appropriate.

v. Wash your hands.

w. Record the procedure in the patient's clinical record.

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Section IV. DISORDERS OF THE EYE

1-18. VISUAL DEFECTS

a. Myopia. Also referred to as "nearsightedness", myopia is a refractive error caused by a structural defect of the eye.

(1) The eyeball is too long from front to back, causing light rays to focus in front of the retina rather than on it.

(2) Close objects can be seen more clearly than distant objects, which appear blurred and unfocused.

(3) Vision may be corrected with the use of a concave lens, which will cause the light rays to focus on the retina.

b. Hyperopia. Also known as hypermetropia and "farsightedness", hyperopia is a refractive error caused by a structural defect of the eye.

(1) The eyeball is too short from front to back, causing light rays to focus behind the retina rather than on it.

(2) Distant objects can be seen more clearly than those close up. Near objects are blurred and unfocused.

(3) Vision may be corrected with the use of a convex lens, which will cause the light rays to focus on the retina.

c. Presbyopia. Presbyopia is a refractive error caused by a decrease

in the power of accommodation of the crystalline lens, due to weakening of the ciliary muscles with aging.

(1) The near point of distinct vision becomes further from the eye. (This is why you may see someone reading while holding the reading material at arm's length.)

(2) Vision may be improved with the use of corrective lenses such as bifocals, which have a small lens for near vision placed within the lower half of a larger lens for distant vision.

d. Astigmatism. This is a refractive error caused by uneven curvature of the refractive surfaces of the eye.

(1) Light rays are not focused along equal planes because of the curvature, causing vision to be unfocused.

(2) Vision can be improved with the use of a lens called a cylinder lens, which compensates for the uneven curvature and allows the light rays to focus sharply.

e. Cataract. A cataract is an opacity of the crystalline lens or its capsule. It is the leading cause of blindness in the United States.

(1) Vision becomes distorted and/or unfocused. Bright lights produce a glare.

(2) Vision is improved by surgical removal of the opaque lens. The missing lens is compensated for by the use of special eyeglasses or contact lenses, or by intraocular implant

of an artificial lens.

f. Glaucoma. Glaucoma is a condition in which there is increased pressure within the eyeball. If uncorrected, glaucoma will lead to blindness.

(1) Increased pressure is caused by faulty drainage of aqueous fluid.

(2) Drug therapy is used to promote drainage of the aqueous fluid, or decrease the production rate of the aqueous fluid, or both.

(3) When drug therapy is not effective, surgical intervention is indicated. There are many different procedures used, but the objective of all is to decrease intraocular pressure by facilitating the filtration and drainage of the aqueous fluid.

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1-21. PREOPERATIVE NURSING CARE OF THE PATIENT UNDERGOING OPHTHALMIC SURGERY

The eye is a delicate and important organ, and its care and protection are of the utmost importance. Common conditions of the eye that may require surgical intervention include trauma, cataract, glaucoma, and detached retina. The ophthalmologist will determine the treatment required and procedure of choice in each patient's case. The procedure may vary from a simple incision to facilitate drainage to total removal of the eyeball (enucleation).

a. Physical Orientation. The patient will require a thorough orientation to his immediate hospital environment. This is done to help the patient during the postoperative period, since he may be blind as a result of the procedure or the need for the eyes to be patched.

(1) Assist the patient to learn details of his room such as the location of furniture, doors, windows, and so forth.

(2) Familiarize the patient with the voices of those who will care for him after surgery. Familiarize him with the daily sounds and noises in the environment, since he will be more aware of sound without his vision.

b. Observation. The patient should be observed for tendencies to cough or sneeze (smoker's cough, allergies, and so forth). Such observations should be reported to the professional nurse for consideration in the plan of care. Such violent movements of the head during the postoperative course may cause increased intraocular pressure, leading to hemorrhage or rupture of incisions.

c. Education. The patient must receive a thorough education about the postoperative course of events and his responsibilities and restrictions. The patient must understand the objective of resting the eyes and avoiding actions that increase intraocular pressure.

(1) The head must be kept very still.

(2) No reading.

(3) No showers, no shampooing, no tub baths.

(4) No bending over at the waist.

(5) No lifting of heavy objects.

(6) No sleeping on the operative side. If both eyes are affected, the patient must sleep on his back.

d. Physical Preparation.

(1) A bowel prep is done the evening prior to surgery to prevent the patient from straining at stool during the immediate post-op period.

(2) Shaving of eyebrows, cutting of eyelashes, and shaving of face should be done only on the order of the surgeon.

(3) After the patient has been taken to surgery, prepare a post-op bed, ensuring that the bed is equipped with side rails.

(4) Sand bags should be made available for use in immobilizing the head.

e. Family. Often, if the patient must be kept absolutely still or will be temporarily blinded after surgery, a member of the family may be asked to stay with the patient. If this is the case, the family member should receive the same orientation and education given to the patient.

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1-23. NURSING CARE OF THE PATIENT WITH VISION LOSS

a. Physical Orientation. To prevent injury and encourage independence, the patient with vision loss should receive a thorough orientation to his surroundings.

(1) Describe the room and its contents in detail, so that the patient can form a mental image of his room.

(2) Lead the patient around the room, letting him feel the furniture, windows, and doorways. (3) Orient the patient to any personnel that may be expected to enter his room. For example, housekeeping personnel or laboratory technicians.

(4) Familiarize the patient with the sounds of his environment. Explain the source of those he is unfamiliar with. Remember, a patient with vision loss depends heavily on his hearing for environmental cues and orientation.

(5) Orient the patient to things around him by comparing their location to the numbers on the face of a clock, with the patient located in the center of the clock.

(a) When describing his room, identify locations by clock reference. For example, the bathroom door is at 2 o'clock and the door to the hallway is at 9 o'clock.

(b) When describing the food on his plate, identify the location of the food items by clock reference. For example, the potatoes are at 12 o'clock, the green beans are at 3 o'clock, the roast beef is at 6 o'clock, and the biscuit is at 9 o'clock.

b. Precautions. To protect the patient from accidental injury, follow these guidelines.

(1) Inform the patient when something in his room has been moved or is different from usual.

(2) Keep doors completely opened or completely closed. This will prevent walking into a partially opened door.

(3) Keep toilet articles in the location the patient places them. Do not move them without telling the patient.

(4) Remove hazardous items such as light cords, small trash cans, and other items that the patient could trip over.

c. Assisting the Patient.

(1) Always address the patient by name when entering his area.

(2) Always let the patient know when you are leaving his area.

(3) When walking with the patient, do not hold him or walk behind him and push him along. Allow the patient to place his hand on your arm or shoulder and walk beside you.

(4) Encourage the patient to be independent and self-sufficient.

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EXERCISES, LESSON 1

INSTRUCTIONS: Answer the following exercises by completing the incomplete statement or by answering the question.

After you have completed all of these the exercises, turn to "Solutions to Exercises" at the end of the lesson and check your answers. For each exercise answered incorrectly, reread the material referenced with the solution.

1. The stimulus for sight is _____________________________ .

2. The stimulus for equilibrium is _______________________ .

3. The receptor organ for hearing is the __________________ of the ear.

4. The receptor organ for balance is the _________________ of the

_______________ .

5. Airborne waves are converted to mechanical vibrations by the ______________

and ________________ .

6. When the pupil constricts as a result of light, the response is called a

_______________________ .

7. Prior to instillation of medication or the application of dressings, the eyelids should

be ______________________ .

8. Before instilling eye ointment, you must ________________ to remove any crust.

9. Eyedrops and eye ointments are instilled into the ____________________ .

10. When irrigating a patient's eye, the head should be turned _____________ .

11. After instilling eardrops, the patient should remain still with his head turned

_____________________ .

12. When irrigating the ear, the temperature of the solution should be

___________________ .

13. The visual defect in which close objects can be seen more clearly than distant

objects is called ________________________ .

14. A refractive error that results from weakening of the ciliary muscles is called

_________________________ .

15. The condition known as "pink eye" is called ___________________ .

16. Patient's undergoing ophthalmic surgery should not cough or sneeze

postoperatively because _____________________________ .

17. When a patient returns from ophthalmic surgery, how should he be transferred

from litter to bed? ____________________________ .

18. Hearing loss due to disease of the inner ear or nerve pathways is called

_________________________ .

19. Cerumen should be removed from the ear if it is ________________ or

____________________ .

20. Why should irrigation not be used to remove a vegetable matter foreign body from

the ear? _______________________________ .

Check Your Answers on Next Page

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LESSON ASSIGNMENT

LESSON 2 Nursing Care Related to the Neurological System.

TEXT ASSIGNMENT Paragraphs 2-1 through 2-45.

LESSON OBJECTIVES After completing this lesson, you should be able to:

2-1. Identify the parts of the central nervous system.

2-2. Identify the parts of the peripheral nervous

system.

2-3. Identify the parts of the meninges.

2-4. State the functions of the cerebellum.

2-5. State the functions of the medulla.

2-6. Name the parts of the brainstem.

2-7. Identify the functions of the frontal lobe.

2-8. Identify the functions of the parietal lobes.

2-9. Identify the functions of the temporal lobes.

2-10. Identify the functions of the occipital lobe.

2-11. Define neuraxis.

2-12. Identify the parts of the spinal cord.

2-13. Identify the parts of a spinal nerve.

2-14. Define afferent nerve.

2-15. Define efferent nerve.

2-16. Identify the pathway of a reflex arc.

2-17. State the functions of the autonomic nervous

system.

2-18. Describe five areas of concern to be evaluated

when assessing mental status.

2-19. Evaluate level of consciousness.

2-20. Identify the purposes for lumbar puncture.

2-21. Identify the patient care needs of the

unconscious patient.

2-22. Define the coup-contrecoup phenomenon.

2-23. Identify the signs and symptoms of infectious

nervous system disorders.

2-24. Identify nursing care objectives for the care of

patients with degenerative nervous system

disorders.

2-25. Identify the signs and symptoms of increased intracranial pressure.

2-26. State the nursing care objectives for the care of a patient with increased intracranial pressure.

2-27. Identify the signs and symptoms exhibited by a patient with a spinal cord injury.

2-28. Identify risk factors associated with cerebral

vascular accidents.

2-29. Identify the signs and symptoms of a stroke.

2-30. Identify the rehabilitation needs of a patient who has experienced a CVA.

2-31. Identify five types of seizure activity.

2-32. State the steps necessary to protect the patient

during a seizure.

2-33. Identify the nursing care considerations for the

patient who has had surgery for a brain tumor.

SUGGESTION After studying the assignment, complete the exercises

at the end of this lesson. These exercises will help you

to achieve the lesson objectives.

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