Adult Health 2 Exam 3 NSG 4413
Chapter 58
● Foreign body in eye initial nursing action
○ DO NOT REMOVE FOREIGN OBJECT
● Glaucoma patient teaching
○ used to refer to a group of ocular conditions characterized by elevated IOP and
congestion of aqueous humor
○ Medication for glaucoma must be taken for life at prescribed times - increases
aqueous flor or decreases aqueous production
● Cataract extractions emergent client post op symptoms
○ a lens opacity or cloudiness
○ Nausea and severe eye pain over post op site = call surgeon ASAP
○ Instruct patient to notify physician ASAP if there are any vision changes,
blurriness worsens, continuous flashing lights, halos, extensive redness, swelling,
increase in pain, type and amount of drainage changes, or significant pain is not
relieved by acetaminophen
○ Complications RARE but can be SIGNIFICANT (hemorrhage, rupture, suture
related)
● S/s of detached retina
○ Pull or tear in that develops in the sensory retina allowing for some of the liquid to
seep through the sensory retina and detach
○ Manifestations: sensation of a shade or curtain coming across the vision of one
eye, bright flashing lights, sudden onset of floaters, typically do not complain of
pain
, Chapter 59
● Techniques for Using Otoscope
○ a. Adults: pinna up and back
○ b. Children: pinna down and back
● What is vertigo?
○ Vertigo: the illusion of motion or a spinning sensation
● Age related hearing loss nursing considerations
○ Prevalence increases with age; 50% over the age of 70
○ Increased incidence with age – presbycusis
■ Speak in normal tone + pitch, clearly and slowly
○ Risk factors include exposure to excessive noise levels
● Acoustic neuroma clinical manifestations
○ CN VIII tumor - hearing and balance
■ s/s - staggered gait, unilateral tinnitus and vertigo
Chapter 60
● Occipital lobe responsibilities (apply)
○ located posterior to the parietal lobe, this lobe is responsible for visual
interpretation and memory.
● Central posterior lobe: Visual interpretation
● Temporal lobe: Auditory receptive areas
● Parietal lobe: Spacial awareness of body position in space, size and shape
discrimination, and right–left orientation.
● Frontal lobe: Concentration, abstract thought, storage/memory, and motor
function.(remembering family names)
● Lumbar puncture
○ To obtain spinal cord fluid for exam, AKA spinal tap
● Importance of frequent neuro assessments
○ Neuro disorders may be stable or progressive, characterized by symptom
free-periods & fluctuation of symptoms, requiring use of OLDCARTS
○ Common symptoms of neurological disorders:
■ i. Pain
■ ii. Seizures
■ iii. Dizziness and vertigo
■ iv. Visual disturbances
■ v. Muscle weakness
■ vi. Abnormal sensation
○ A neurologic assessment is divided into five components:
■ consciousness and cognition
■ cranial nerves
■ motor system
■ sensory system
■ reflexes
Chapter 58
● Foreign body in eye initial nursing action
○ DO NOT REMOVE FOREIGN OBJECT
● Glaucoma patient teaching
○ used to refer to a group of ocular conditions characterized by elevated IOP and
congestion of aqueous humor
○ Medication for glaucoma must be taken for life at prescribed times - increases
aqueous flor or decreases aqueous production
● Cataract extractions emergent client post op symptoms
○ a lens opacity or cloudiness
○ Nausea and severe eye pain over post op site = call surgeon ASAP
○ Instruct patient to notify physician ASAP if there are any vision changes,
blurriness worsens, continuous flashing lights, halos, extensive redness, swelling,
increase in pain, type and amount of drainage changes, or significant pain is not
relieved by acetaminophen
○ Complications RARE but can be SIGNIFICANT (hemorrhage, rupture, suture
related)
● S/s of detached retina
○ Pull or tear in that develops in the sensory retina allowing for some of the liquid to
seep through the sensory retina and detach
○ Manifestations: sensation of a shade or curtain coming across the vision of one
eye, bright flashing lights, sudden onset of floaters, typically do not complain of
pain
, Chapter 59
● Techniques for Using Otoscope
○ a. Adults: pinna up and back
○ b. Children: pinna down and back
● What is vertigo?
○ Vertigo: the illusion of motion or a spinning sensation
● Age related hearing loss nursing considerations
○ Prevalence increases with age; 50% over the age of 70
○ Increased incidence with age – presbycusis
■ Speak in normal tone + pitch, clearly and slowly
○ Risk factors include exposure to excessive noise levels
● Acoustic neuroma clinical manifestations
○ CN VIII tumor - hearing and balance
■ s/s - staggered gait, unilateral tinnitus and vertigo
Chapter 60
● Occipital lobe responsibilities (apply)
○ located posterior to the parietal lobe, this lobe is responsible for visual
interpretation and memory.
● Central posterior lobe: Visual interpretation
● Temporal lobe: Auditory receptive areas
● Parietal lobe: Spacial awareness of body position in space, size and shape
discrimination, and right–left orientation.
● Frontal lobe: Concentration, abstract thought, storage/memory, and motor
function.(remembering family names)
● Lumbar puncture
○ To obtain spinal cord fluid for exam, AKA spinal tap
● Importance of frequent neuro assessments
○ Neuro disorders may be stable or progressive, characterized by symptom
free-periods & fluctuation of symptoms, requiring use of OLDCARTS
○ Common symptoms of neurological disorders:
■ i. Pain
■ ii. Seizures
■ iii. Dizziness and vertigo
■ iv. Visual disturbances
■ v. Muscle weakness
■ vi. Abnormal sensation
○ A neurologic assessment is divided into five components:
■ consciousness and cognition
■ cranial nerves
■ motor system
■ sensory system
■ reflexes
