Disorders of the external ear and middle ear
Otitis media
Pathophysiology
In respiratory infections the infective organism ascend along the eustachian tube into the middle ear.
The inflammatory reaction caused by these results in the eustachian tube becomes swollen and blocked.
Which results in a negative pressure in the middle ear.
Clinical manifestations
Signs and symptoms
Hearing loss low pitched sounds dizziness fatigue
Nursing care plan
Nursing diagnosis
Nursing intervention
Loss of function related to infection
Inflammation manifested by hoarseness and reported hearing loss
Encourage patient to rest the affected organ to promote healing
Prescribe otic antibiotics can be administered to clear the infection
Ear canal should be kept clean and dry by wicking
Otitis externa
Pathophysiology
Infection involves the auricle and the external ear canal
Begin in the skin lining of the ear canal and can cause swelling that occludes the canal
Clinical manifestations
Pain tenderness or a pulling feeling on the pinna
serious drainage from the air redness and itching
swelling of the skin lining of the ear the swelling may interfere with the movement of the cilia which transmits sound waves this impacting on hearing
Is the inflammatory process advances fever increases and hearing decreases
In the presence of perforation should the eardrum perforate there will be a purulent discharge from the ear
Nursing care plan
Nursing diagnosis
Acute pain related to the inflammation of the middle ear
Nursing interventions
Position the patient set up raise head on pillows or lie on an unaffected ear
The nurse should administration of prescribed medication such as in the form of paracetamol and antibiotics to relieve pain
the ear should be kept dry by wicking and discourage straining or nose blow
Disorders of the inner ear
Otosclerosis
Pathophysiology
There is a progressive loss of stapes movement due to the formation of sclerotic bone
Which fixes the stapes foot plate onto the oval window
Signs and symptoms
Nursing care plan
Nursing diagnosis
Risk of fall related to loss of hearing
Nursing interventions
The patient should be referred to audiometric testing order to get an appropriate hearing aid and to be assisted with speech management
Meniere disease
Pathophysiology
It has been postulated that issue changes in the labyrinth
Trigger production of excess and endolymph which distorts the contour of the membranous labyrinth and destroys the delicate vestibular and cochlear hair follicles
Clinical manifestations
Attacks of vertigo are sudden with little or no warning
attacks may be preceded by a sense of fullness in the ear
Increasing tinnitus and a decreased fluctuating sensoneural hearing loss
These may be accompanied by nausea and vomiting
Nursing care plan
Nursing diagnosis
Nursing interventions
The patient requires reassurance and counseling that the condition is not life-threatening and can be managed
Prescribed medication symptomatic should be implemented vertigo can be managed with first rest and sedation antiemetic
The patient should be kept in the quiet dark room in a comfortable position
Signs and symptoms
Benign paroxysmal positional vertigo
Clinical manifestations
Pathophysiology
It occurs when some of the custom cabinets crystals that are normally embedded in gel in the utricle become dislodged and migrate one or more of the fluid-filled semicircular canals where they are not supposed to be
Whole body vertigo: balance disorder dizziness or lightheadedness
gastrointestinal: nausea or vomiting
common motion sickness or rapid involuntary eye movement
Signs and symptoms
Nursing care plan
Nursing diagnosis
Impaired transfer ability related to postural instability during performing routine activities of daily living
Nursing interventions
Assess condition that can increase the patient level of fall risk as
such as history of falls and changes in the mental status, sensory deficit in balance medication and symptoms related to diseases.
Give medication as ordered
Assess the degree of impairment using the 0-4 functional level classification.
Acoustic neuroma
Pathophysiologyg
Are noncancerous usually slow-growing tumors that form along with the branches of the other cranial nerve they tend to occupy the cerebellopontine angle
acoustic neuroma is a benign noncancerous tumor on the eighth cranial nerve vestibulo cochlear leading from
the brain stem to the ear.
This nerve is involved in hearing and maintaining equilibrium.
Acoustic neuromas grow relatively slowly
Symptoms
Balance disorder dizziness hearing loss involuntary eye movement
Sensory: pins and headless or reduced sensation of touch.
Ringing tinnitus in the affected ear
Facial numbers and weakness or loss of muscle movement
Nursing care plan
Nursing diagnosis
Risk of falls related to loss of balance
Disturbed sensory perception
Risk for imbalanced nutrition less than body requirements
Nursing interventions
Observations if the tumor is very small the physician may just monitor it's growth
Give prescribed medication as directed
Disorders of the nose
Deviated septum
Sinusitis
Rhinitis
Pathophysiology
All forms of rhinitis cause sneezing ,nasal discharge with nasal congestion and headache
Acute rhinitis usually last 5 to 7 days with or without treatment
Secondary invasion by bacteria May complicates the cold causing pneumonia bronchitis sinusitis
nasal discharge is usually water at the first and only becomes mucoid later
Clinical manifestations
Headache may be pronounced and persisted
in chronic rhinitis acute symptoms are absent
The chief complained is nasal congestion accompanied by a feeling of stuffiness and pressure in the nose
The breath may be foul smelling
Signs and symptoms
Nursing care plan
Nursing diagnosis
Ineffective airway clearance related to obstruction or present of thickness secretions
Disturbed sleep pattern related to obstruction of the nose
Nursing interventions
The patient is usually seen in a primary health care centre in community or outpatient department in the hospital's
nursing care is directed toward patient teaching and home care
Treatment is symptomatic
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Pathophysiology
Mucous produced but their sinuses is removed through small openings in the nose called ostia
Inflammation there is edema and increased production of mucus these serve to block the ostia and impair ciliary action
The mucus then accumulates in the sinus causing congestion and with time the mucus becomes infected
Clinical manifestations
Fever and chills along with headaches and facial pains
Which are made worse by bending pain or numbness in the upper teeth and a purulent of discoloured nasal discharge may be present
Signs and symptoms
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Nursing care plan
Nursing diagnosis
Acute pain head and throat sinus related to inflammation of the nose
Anxiety related to lack of client knowledge about disease and medication procedures
Nursing interventions
Apply steam inhalations three to four times a day are recommended to loosen secretions
Local heat can be applied on the nose area to reduce oedema
Prescribed antibiotics can be administered to managed infection
Pathophysiology
The septum is the cartilage in the nose that separates the nostrils
Severe unevenness is known as a deviated septum
It can cause health complications such as a blocked nostril or difficult brething
Clinical manifestations
Difficult breathing especially through the nose having one side of the nose that easy to break through
Nose bleeding
Snoring or loud breathing during sleep
Nasal congestion or pressure
Signs and symptoms
Nasal congestion
Nursing care plan
Nursing diagnosis
Ineffective breathing related to nasal obstruction
Impaired swallowing related to pain in the pharynx
Pain related to infection or injury to the nose
Nursing interventions
Increase fluid intake
don't blow your nose elevate your head when you're sleeping avoid strenuous exercises including cardio
wear clothes that fasten in the front instead of pulling over your head
Congenital abnormalities of the eye
Congenital anomalies of the orbit
Anophthalmos:this is absence of the eyeball,it may be a result of failure in the formation of the optic vesicle.
Coloboma:this is a condition where there is a incomplete development of structures due to the foetal cleft not closing during the embryonic stage of development
Microphthalmos: this is a small white that has an abnormal vision and may be associated with other abnormalities such as Coloboma and cataract
Congenital abnormalities of the eyelids
Congenital ptosis: this is a dropping eyelid which is present at birth and which may be due to congenital third nerve palsy
Congenital abnormalities of the lacrimal apparatus
Absence of the lacrimal gland: this is extremely rare
Congenital abnormalities of the sclera: this can occur as a hereditary defects and are characteristically associated with deafness and skeletal weakness
Congenital blockage of the lacrimal duct: this can occur at any sites of the criminal system the most common area for the blockage is at the end of the nasolacriminal duct management include antibiotics and expression of their criminal sex for the first 6 months
Congenital abnormalities of the pupil and iris
Abnormalities of the corner
Megalocornea: the cornea is abnormally large and is clear with normal functions this differentiates megalocornea from congenital glaucoma
Displacement of the pupil: this is usually upward or laterally
Aniridia: this is the absence of the iris and may cause secondary glaucoma and cataract
Congenital abnormalities of the vitreous humour
Congenital abnormalities of the choroid and retina
Congenital abnormalities of the optical nerve
Congenital abnormalities of the lens
This is very rare and is a cause of congenital blindness
Persisted hyperplastic primary vitreous humour: this is an important cause of cataracts or glaucoma in children
Chorioretinal scarring: this is often caused by in intrauterine toxoplasmosis resulting in diminished vision
Optical nerve hypoplasia: this condition which may be on unilateral or bilateral is a major cause of vision loss in children
Degenerative eye conditions
Degenerative of the eyelids
Entropion: this is a turning inward of the lid condition may be congenital due to ageing due to scarring following trauma to the eye
Ectropion: this is everision of the lower led usually bilateral the condition maybe congenital age-related
Signs and symptoms: include watering of the eye irritation and keratitis
Degenerative of the sclera
Degenerative of the cornea
Degenerative of the vitreous humour
Degenerative of the lens(cataracts)
Degenerative of the conjunctiva
Pinguecula: this is a common benign lesion of the conjunctiva consisting of a yellowish white nodule on the bulbar conjunctiva in the area of the palpebral fissure
Pterygium: this is a triangular growth of conjunctival tissue occurring on the nasal bulbar conjunctiva the apex slowly grows towards the cornea where it will interfere with the vision if it reaches the pupillary area
Staphyloma of the sclera: a staphyloma is a thinning and protrusion of part of the eyeball lined with uveal tissue
is caused by severe and prolonged increased intraocular pressure thinning of the sclera
Signs and symptoms:include lagophthalmos, conjunctivitis, lacrimation, ocular hypertension nearly always
Ketatoconus: this is a hereditary degenerative bilateral condition of the cornea that's rarely represents before puberty
Arcus senilis: this is a common form of bilateral peripheral corneal degeneration which appears as a grey line encircling the cornea
Causes
Floaters: these are spots that appears in the visual field and are mainly due to degeneration and increased the fluidity of the vitreous
Degenerative of the retina
Age-related macular oedema: this is a leading cause of blindness in the early and it affect central vision
the condition is usually bilateral that affects one eye more than the other
Signs and symptoms: blurred vision and there may also be blind spots resulting in a dark or empty area in the centre of the Field of vision colour vision may be diminished
Retinitis pigmentosa: this is a degenerative hereditary disease which is chronic and progressive degenerative changes may manifest early in life and would occur mainly in the neural epithelial layer of the rod cells
Cataracts maybe congenitally hereditary or acquired
Age-related and degenerative
Changes and demands are the most common cause cataract may follow trauma of the
Pathophysiology
Nursing diagnosis
Compaction and stiffening of the central lens material nuclear sclerosis as new layers of cortical fibers continues to proliferate over time
Disturbed visual sensory perception related to altered sensory reception
Nursing interventions
Use of anticoagulant is withheld to reduce the risk of vetrobulbar hemorrhage
Inflammatory conditions of the eye
Scleritis
Uveitis
Keratitis
Conjuvitis
Pathophysiology
They are a result of an alteration in the cornea defence mechanism that allows bacteria to invade when an epithelial defence is present
The organisms may come from the tear film or as a contaminant from foreign bodies contact lenses or irrigating solution
Miscellaneous eye conditions
Glaucoma
Cataract
Signs and symptoms
Gradual loss of peripheral vision
Redness of the eye
Pain in the eye
Visual disturbance
Pathophysiology
Glaucoma is caused the raised intraocular pressure, the pressure damages the optic nerve.
Once the nerve is damages it fails to carry visual information to the brain this result to the loss of vision
Causes
Inflammation
Tumors
Diabetes
Nursing diagnosis
Acute pain related to pathophysiological process or surgical corrections
Disturbed sensory perception due to damage in the optic nerve as evidenced by loss of vision
Nursing interventions
Drugs are the first line of therapy and the drug chosen should be used at the lowest dosage possible for effectiveness regular follow-up is essential including gonioscopy and perimeter of assess the patient respond to treatment
Causes
Nursing diagnosis
Signs and symptoms
Pathophysiology
As the cataracts continues to develop the clouding becomes denser and involved a bigger part of the lens
cataract scatters and block the light as it passes through the lens preventing a sharply defined image from reaching the retina
Halos around the eye
Sensitivity to light
Clouding of the lens
Congenital
Aging
Trauma
Risk of injury related to poor vision
High risk of falls related to blurred vision
Nursing interventions
The patient should be orientated to the environment and access future should be removed to prevent bumping and falling post-operatively
prophylactic antibiotics and corticosteroids may be prescribed to prevent postoperative infection
Cerebrovascular disease
Pathophysiologyg
Symptoms
Nursing care plan
Difficulty with comprehension.
Nursing diagnosis
Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury
Nursing interventions
Risk factors
Clinical manifestations
Nutritional interventions and choices of
feeding route are determined by the abovementioned factors
Speak in normal tones and avoid talking too
fast. Give patient ample time to respond,
Assist patient with head control, and position
based on specific dysfunction. Good
positioning can facilitate intake and reduce
risk of aspiration
Paralysis or numbness of the face,
arm or leg
Problems seeing in one or
both eyes
Trouble walking, dizziness, or loss of
balance or coordination
Ischemic stroke is caused by
deficient blood and oxygen supply
to the brain
Hemorrhagic stroke is caused by
bleeding or leaky blood vessels
Ischemic occlusions contribute to
around 85% of casualties in stroke
patients, with the remainder due to
intracerebral bleeding
Age- in adults, the risk for stroke
increases with age
Family history and
genetics
Viral infections or conditions that cause
inflammation, such as lupus or
rheumatoid arthritis
Acute pain related to hemiplegia and disuse.
Dizziness, nausea, or vomiting.
Assist patient with head control, and position
based on specific dysfunction. Good
positioning can facilitate intake and reduce
risk of aspiration
Neurological assessment
Assessment of sensory neuron
Motor response
Cranial nerve examination
Assessing metal status
Impaired cerebral circulation
Signs and symptoms
Causes
Pathophysiology
Hamorrhage
Intracerebral hemorrhage
Subarachnoid hemorrhage
Convulsive conditions
Nursing care plan
Causes
Clinical manifestations
Pathophysiology
Congenital conditions
Causes
Clinical manifestations
Nursing care plan
Ineffective conditions
Signs and symptoms
Pathophysiology
Clinical manifestations
Malignant conditions(brain tumours)
Nursing care plan
Clinical manifestations
Symptoms
Pathophysiologyg
Degenerative conditions
Multiple sclerosis
Alzheimer's disease
Parkinson disease
Spinal chord disorders(Injured spine)
Signs and symptoms
Pathophysiology
Clinical manifestations
Nurses care plan
In epilepsy a spontaneous electrical discharge occurs from a group of neurones referred to as a seizures focus seizures activity may involve the entire brain.
Trauma such as birth injuries
Congenital defect of the cerentral nervous system
Inborn errors of metabolism and hyperpyrexia especially in children
High fever, which can be associated with an infection such as meningitis
Lack of sleep
Flashing lights, moving patterns or other visual stimulants
Low blood sodium hyponatremia
which can happen with diuretic therapy
Medications, such as certain pain relievers, antidepressants or smoking cessation therapies, that lower the seizure threshold
Nursing diagnosis
Risk for trauma injury related to loss of sensory coordination and muscular control
Nursing interventions
Ascertain knowledge of various stimuli that may precipitate seizure activity.
symptoms
Note client’s age, gender, developmental age, decision-making ability, level of cognition or competence.
Determine factors related to the individual situation, as listed in Risk Factors, and extent of risk.
Severe headache. Headaches may occur after a grand mal seizure.
Loss of bowel and bladder control. This may happen during or following a seizure
Fatigue. Sleepiness is common after a grand mal seizure.
Pathophysiologyg
The accumulation of cerebrospinal fluid in the ventricles of the brain
It's may also be due to overproduction of cerebrospinal fluid as is the case of infection
The hydrocephalus may be associated with developmentally defence of the spinal cord
In hydrocephalus the cerebrospinal fluid accumulates within the cranial cavity ventricles of the brain causing an increase in pressure in the cranial cavity
exposure to certain medications and chemicals
genetics
lifestyle choices and behaviors
Nursing diagnosis
Nursing interventions
Symptoms
blue-tinted skin, shortness of breath, failure to feed
abnormal heart rhythms
swollen body tissue or organs.
Decrease cardiac output may be related to structural factors of congenital heart defect
Activity intolerance related to generalized weakness
Imbalance between oxygen supply and demand
Assess heart rate and blood pressure.
Assess for reports of fatigue and reduced activity tolerance.
Check for peripheral pulses, including capillary refill
Note skin colour, temperature, and moisture.
Inflammatory exudate increases intracranial pressure and the infection causes an increase in the cerebrospinal fluid production and pressure that is measurable on lumbar pant
The inflammatory reaction causes irritation of cerebral tissues and may cause convulsions
Bacteria. These one-cell organisms are responsible for illnesses such as strep throat, urinary tract infections and tuberculosis
Fungi. Many skin diseases, such as ringworm and athlete's foot, are caused by fungi.
Other types of fungi can infect your lungs or nervous system.
Fever (this is sometimes the only sign of an infection).
Chills and sweats.
Nursing care plan
Nursing diagnosis
Nursing interventions
The inflamed and irritated maninges cause neck stiffness and headache
The administration of an appropriate antibiotics or antiviral agents such as acyclovir
Careful observation of the patient's neurological status and prevention of further deterioration
Supportive measurements to maintain circulation respiration nutrition and hydration should be implemented
Measurement to reduce dangerously high temperature should be implemented such as tepid sponging and giving paracetamol regularly at 6 hour intervals
Sore throat or new mouth sore
Stiff neck.
They are classified into separate
Those originating from brain and metastatic lesions originating elsewhere in the body
Acoustic neuroma are those developing on cranial nerve
Pressure affects of pituitary adenomas and hormonal affects of pituitary adenomas
Dural meningioma are those arising from brain covering
Headache
Vomiting
Increased intercranial pressure
Changes of mental status and cognition
Blurred vision
Loss of balance confusion and seizures
Increasingly strong headaches
Nursing diagnosis
Nursing interventions
Administer analgesic as prescribed
Apply a cool compress on the head for low-to-moderate Spain
Assess the severity and duration of the headache
Acute pain related to biologic injuries and possible evidence by verbal complaints of pain
Risk injury related to sensory and effector dysfunction possible evidenced by behavioral changes
Pathophysiology
Essential defects is a depletion of dopamine due to loss of neurones in the Substantia negra
Local ceruleus as in other pigmented areas of the brain stem
Symptoms
Nursing care plan
Speech:difficulty speaking soft speech
Muscle: stiff muscles difficult standing
Fatigue, dizziness
Nursing diagnosis
Nursing interventions
Ineffective airway related to aspiration evidenced by cough with or without productivity
Disturbed thought process related to depression evidence to by insomnia
Assess patient for depression behaviour or causative event and Orient
Use non-judgemental attitude toward the patient and actively listen to his feelings and concerns
Pathophysiologyg
Is an inflammatory demyelinating disease of the central nervous system which activate immune cells
Symptoms
Pain in the back or eyes
Nursing care plan
Nursing diagnosis
Nursing interventions
Self care deficit related to memory loss evidence by patient will perform self-care activities within the level of own ability
Determine the current activity level and physical condition assess degree of functional impairment using 0-4 scale
Encouraged patient to perform self-care to maximum of ability as defined by the patient
Fatty cue related to decreased energy production evidence by verbalization of overwhelming lack of energy
Muscle: cramping, difficulty walking
Fatigue
Immune cells invade central nervous system and cause inflammation coma neurodegeneration and tissue damage
Pathophysiologyg
Symptoms
Nursing care plan
Agression, agitation, difficulty with self care
mental decline, difficulty thinking and understanding, confusion in the evening hours
Alzheimer disease causes progressive cognitive deterioration and is characterized by beta-amyloid deposits and neurofibrillary tangles in the cerebral cortex and subcortical gray matter.
The beta-amyloid deposition and neurofibrillary tangles lead to loss of synapses and neurons, which results in gross atrophy of the affected areas of the brain, typically starting at the mesial temporal lobe
Nursing diagnosis
Disturbed sensory perception related to CNS stimulants or depressants evidenced by nancompliance
Nursing interventions
Frequently orient client to reality and surroundings. Allow client to have familiar objects around him or her; use other items, such as a clock, a calendar
Use simple explanations and face-to-face interaction when communicating with client.
Do not shout
Impaired memory loss related to process
Changes in cognitive abilities evidenced by disorientation to time, place, person,
depression, hallucination, or paranoia
Also common: inability to combine muscle
finds it difficult to sleep related to stress
Pathophysiology
Clinical manifestations
Symptoms
Nursing care plan
Hypertension may lead to the rupture of a blood vessels in the cerebral circulation
Such weak spots may be congenital in which case an aneurysm occurs at the point of weakness
Cerebral tumours may cause erosion of blood vessels giving rise to subarachnoid hemorrhage
Nursing diagnosis
Nursing interventions
Ineffective tissue perfusion related to bleeding or vasospasm.
The person should be kept very quiet and kept at the absolute bed rest
Sedation and analgesia maintained to keep the patient comfortable and quiet
Calcium channel blockers that is nimodipine which is specially indicated for use in subarachnoid hemorrhage can be used to prevent vasospasm
Severe headache. The conscious patient most commonly reports a severe headache.
Sudden change in the level of consciousness. As the aneurysm presses on nerves and tissues, there is a sudden early change in the level of consciousness.
Anxiety related to illness and or medically imposed restrictions
severe headache, abnormal heart rhythm, altered level of consciousness
Pathophysiology
Symptoms
Clinical manifestations
Nursing care plan
weakness of one side of the body or paralysis of one side of the body
bleeding, decreased level of consciousness, altered level of consciousness
, compressing the brain stem and often causing secondary hemorrhages in the midbrain and pons.
If the hemorrhage ruptures into the ventricular system (intraventricular hemorrhage), blood may cause acute hydrocephalus.
Focal seizures. Focal seizures can possibly occur due to frequent brain stem involvement
Visual disturbances. Visual loss, diplopia, and ptosis occur if the aneurysm is adjacent the oculomotor nerve.
Nursing diagnosis
Nursing interventions
Risk for Ineffective Tissue Perfusion related to bleeding or vasospasm
Check blood pressure, pulse, level of consciousness, pupillary responses, and motor function hourly
monitor respiratory status and report changes immediately.
Nursing interventions
• mechanical ventilation in cases when a person
has difficulty breathing.
• if there are any broken bones then a traction CA
be used for the bone to be put back in place
• hydrotherapy is another way to improve muscle
tone
Nursing diagnosis
Risk for Ineffective Breathing Pattern related to impairment of innervation of diaphragm lesions at or above C-5
This can be known as acute impact or
compression.
these could lead to loss of sensation in
affected areas
sensations such as pain, temperature,
vibration, position and movement
reduced sensation of touch
• feeling pins and needles
permanent loss of strength
difficulty breathing
muscle spasms and rigidit
Impaired Urinary Elimination
May be related to disruption in bladder innervation
Motor vehicle accidents. Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for almost half of new spinal cord injuries each year.
Falls a spinal cord injury after age 65 is most often caused by a fall.
Clinical manifestation
Nursing care plan
Decreased vision
Excess tears or other dicharge from your eye
Eye redness
Feeling that something is in your eye
Nursing interventions
Nursing diagnosis
Encourage good personal hygiene
Administer antibiotic
Causes
Contaminated water
Injury if any object scratches or injures the surface of your cornea
Contaminated contact lens
Causes
Clinical manifestations
Pathophysiology
Nursing care plan
Conjunctivitis is defined as inflammation of bulbar and palpebral conjuctiva
Fungi parasitis
May be secondary to dermatitis and other allergic conditions
Nursng diagnosis
Conjunctivitis has many etiologies, however the majority of instances can be induced by means of hypersensitive reaction or infection
Viruses
Bacteria
Nursing intervention
Cleaning the eye discharge in cases of purulent discharge
Gently wipe from the lower lead with wet sterile gauze
Isolate the patient with the infection
Heath education with regard to good hygiene good hand washing and not sharing of face towels and stuff
Irritation
Swollen lining of the eye
Investigation of the cause and treatment as per doctors orders
Administer analgesia for pain antibiotic for lesion heaing
Causes
Clinical manifestations
Pathophysiology
Nursing care plan
Uveitis may occur as a consequence of various causes and background such as autoimmune disease
Injury or trauma of the effect
Blurred vision swelling
Nursing diagnosis
Nursing intervention
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Administer eye drops especially corticosteroids
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Pupil dilators to reduce inflammation and pain
Watery discharge of the eye
Sensitivity to light irritation of the eye
Infection
Injuries caused by surgery
Infections and hematopoitetic malignancy
Causes
Clinical manifestations
Pathophysiology
Nursing care plan
The inflammation of the sclera is associated with the autoimmune disease as characterized by zonal necrosis of the sclera surrounded by granulomatous inflammation and vasculitis
It can present as a very painful red eye usually sectoral with associated oedema
The necrotising type that can cause thinning of the sclera making it look blue
Eye infections
Granulomatsis
Scleroderma
Tendeness of the eye
Inflammation of the white part of the eye blurred vision
Extreme sensitivity
Tearing
Nursing diagnosis
Nursing intervention
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Administer NSAIDS, corticosteroid
Immunomodulatory agents and surgery at last if the problem is not treated
Aims
Nursing
Aims
Nursing indications
Aims
Nursing indication
Aims
Indications
Determine which if any components of the sosnory system or sesnsory loss resulting from diseases of the various levels of the sensory system
Flings limbs around
Difficulty holding objects
Easily distracted by noises smell
One component of the examination used is the pupillary light reflex to assess the status of the oculomotor nerve
Alterations in balance especially when looking up or with Closed Eyes
Altered or poor coordination
Change in sleep-wake cycle
Diagnose mental health conditions such as anxiety depression schizophrenia post-natal depression eating disorders and psychotic illnesses
Speed accelerated racing
Quality of speech minimal complete absence of speech
Rate of speech pressure slowed
Abnormal beliefs delusion
Assess their consciousness states of the patients following traumatic brain injury
It's covers monitoring of diseases progression
Clinicians must use their clinica judgement in association with the GCS to assess conscious state
Management of symptoms in particular muscle weakeness, excess secretions breathing and nutrition problems
Nursing care plan
Cerebral blood flow and its control vary as a function of age.
This review focuses on the perinatal period and compares contrasts this age period to that of the juvenile
Mechanisms important in the control of the cerebral circulation as a function
Inability to ask for help
Disturbed communication
Not being able to effectively make use of defense
Difficulty in problem solving
Prolonged bed rest
After a major surgery
Postprandial hypetensin
Post tissue syncope
Nursing diagnosis
Nursing intervention
Impaired physical
Give psychological support let the person Express feelings and emotions freely
Impaired verbal communication
Risk for ineffective cerebral tissue perfusion
Check if patient is sleep deprived and able to cope feeling withdrawn
Check for signs and symptoms which indicate further follow-up or decrease in functioning
Diagnostic studies
Barium anaemia
High blood pressure
Ineffective cerebral tissue perfusion
Nosebleeds
Dizziness fatigue or balance problems
impaired transfer ability related to postural instability during performing routine activity
hearing loss, felling fullness in your ear
dizziness, ear ache
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