Medical-Surgical Nursing II

This free sample provided by CIMC www.okcimc.com 800.654.4502

Practical Nursing Series: Medical-Surgical Nursing II

Medical Surgical Nursing II, used in conjunction with Medical Surgical Nursing I, replaces the 2002 version of Nursing Focus. The curriculum adheres to the revised objectives approved by the Oklahoma Board of Nursing.

This full-color text builds on the concepts and skills for previous courses. It focuses on prevention of illness, health Practical Nursing: management, and care of the individual. Treatments, patient Medical-Surgical Nursing II 2013 care, diet and pharmacological therapy are included in each Teacher Edition: HO1039 module. Medical Surgical Nursing II is designed to teach the Student Workbook: HO3039 nursing student focused nursing skills and the ability to apply their knowledge to prepare for the NCLEX-PN. To order, call 800.654.4502 or visit Modules include: www.okcimc.com  Immune Nursing  Sensory Nursing

 Neurology Nursing  Digestive Nursing  Endocrine Nursing  Urinary Nursing  Reproductive Nursing  Oncology Nursing

We are offering “Sensory Nursing” as a free sample.

CIMCHO1039 MODULE 2 sensory Nursing

Free Sample Provided by CIMC 800-654-4502 okcimc.com

his module provides an understanding of interactions with their environment and other the sensory organs and their functions, individuals. Impairments of these senses must be disorders that affect these organs, and handled appropriately and carefully by the nurse. treatmentsT of these disorders. The most com- Completion of this module should provide an mon senses which display impairments are vision, understanding and knowledge of how to provide hearing, taste and smell. Additionally, the sense of appropriate nursing care to individuals with sen- touch, position and movement may be impaired. sory disorders and impairments. These senses are important for an individual’s Review the Learning i Objectives with the LE arning O bjE ctivE s students. Look ahead to the Learning Activities 1. Explain the function of the sensory system. in this module and plan to introduce them. 2. Distinguish among sensory disorders. 3. Relate diagnostic tests and surgical procedures to the nursing care of Teaching patients with sensory disorders. SUggestions 4. Evaluate pharmacological effects of medications used to treat sensory disorders.

• Along with many helpful 5. Contribute to the plan of care for patients experiencing alterations in websites, there are now sensory or perceptual function. many “apps” available to 6. Distinguish among patient education needs related to self-care for sensory help students and nurses disorders. obtain needed information from their smart phones, tablet devices, etc. Search iTunes or other application data- bases for the most up-to- date “apps” available for each content area. See the following links for possible apps related to the sensory system. • Be sure to advise theFree Sample Provided by CIMC students that these “apps” may cost to download. 800-654-4502 ■ Sensory apps okcimc.com http://itunes. apple.com/us/app/ hd-five-senses/ id373600865?mt=8 ■ Hearing http://itunes. apple.com/us/app/ senses-what-u-hear/ 2 CIMC • MEDICAL SURGICAL NURSING II id398460048?mt=8 http://itunes.apple.com/us/app/uhear/id309811822?mt=8

http://itunes.apple.com/us/app/soundamp-r/id318126109?mt=8 (amplifier)

http://itunes.apple.com/app/id450577890 — Continued on next page

module Overview

This module provides concise information regarding sensory disorders including their symptoms and associated medications, diagnostic tests, and nursing care. Students should be encouraged to reacquaint themselves with the sensory system information from their Anatomy and Physiology course.

2 CIMC • MEDICAL SURGICAL NURSING II LE arning ObjE ctivE Sense of Vision ■ Vision

Objective Explain the function of the sensory The actual mechanics of vision take place within the http://itunes. system. retina, the optic nerve, and the brain. Photoreceptors, apple.com/us/app/ specialized cells that are sensitive to light and color, The senses provide humans with the ability to inter- are the rods and cones of the retina. senses-what-u-see/ act with their environment through seeing, hearing, id411289776?mt=8 tasting, smelling, touching, and maintaining position and movement. These senses enable humans to http://itunes.apple. survive because of the appropriate responses. Should D i d You Know? com/us/app/vision/ these responses not occur, or occur inappropriately, Color blindness is caused by an patients may be injured or suffer disorders of the absence of one or more cones. id295144131?mt=8 sensory system. Cones are sensitive to the colors red, green, and blue. http://itunes. v isiO n apple.com/us/ The function of the eyeball is transformation of light Normal aging causes the eye to lose elasticity of the app/vision-test/ to nerve signals which are interpreted into visual im- lens; this causes the muscles of the eye to be unable id380288414?mt=8 ages in the cerebral cortex of the brain. to accommodate (move the lens as needed) and presbyopia (far sightedness due to aging) occurs. The lens may also become slightly opaque, causing http://itunes. difficult vision when glare is present. Because the apple.com/us/ pupil becomes smaller with age, more light is needed app/eyes-vision/ to read. id333809694?mt=8

Eye Glands ■ For iPad

Lachrimal gland http://itunes. (Tear gland) apple.com/us/app/ eye-chart-pro/ id364802332?mt=8 (Eye chart) Free SampleTear Provided ducts by CIMC 800-654-4502 learning okcimc.com wwwlink Tear sac

Vision www.webmd.com/eye- health/picture-of-the-eyes

MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 3

Teaching SUggestions

• Review the following information with the students. ■ Structure of the eye ■ Accessories of the eye ■ Intraocular anatomy ■ Physiology and function of the eye

MODULE 2 • Sensory Nursing • TEACHER EDITION 3 HE aring

learning The ear consists of three sections, which work to- Important Fact wwwlink gether to provide the sense of hearing. The outer ear receives the sound waves and propels them to the in- It’s easy for a throat infection to spread to the terior portions of the ear. The middle ear is small and ears because it can travel up the Eustachian contains air and three bones. The three bones are the tubes into the middle ear. These structures are all malleus (hammer), the incus (anvil), and the stapes lined with continuous mucous membrane. (stirrup). The inner ear contains fluid-filled cavities and canals. It also contains the cochlea, semicircular Hearing canals, and the vestibulocochlear nerve.

www.youtube.com/watch Semicircular canals ?v=PeTriGTENoc&featu Incus (anvil) re=related Malleus (hammer) Auditory nerve

To brain

Ear canal Cochlea Oval window Stapes (stirrup) Tympanic membrane

Eustachian Tube Free SamplePinna Provided by CIMC 800-654-4502 okcimc.com D i d You Know? Cerumen is earwax that protects the ear by trapping foreign particles and dust.

4 CIMC • MEDICAL SURGICAL NURSING II

4 CIMC • MEDICAL SURGICAL NURSING II Sense of Hearing Sources of damage to hair cells in the organ of Corti, causing permanent hearing loss, include: • The eardrum, or tympanic membrane, separates learning the outer ear from the middle ear. • Jet engines wwwlink • The eustachian tubes connect the middle ear • Factory equipment with the nasopharynx. They function to equal- • Race car engines ize pressure on either side of the eardrum. This is why yawning or swallowing, which opens the • Loud amplifiers (music or drums) tube and allows air to enter the middle ear, helps “pop” the ears when at high altitudes. • Wearing earphones with electronic equipment turned to high volumes Taste • Sound waves travel through the middle ear from www.wisc-online.com/ the vibrating tympanic membrane causing the sEnsE s O f t astE anD malleus to vibrate. objects/ViewObject. sMELL • The malleus movement triggers the incus to aspx?ID=AP14104 move and transfer the sound waves to the stapes. Smell and taste are two very closely related senses. The movement of the stapes transfers the sound These senses protect us from eating food that is Smell wave to the oval window, which transfers the spoiled or poisonous. Many of the toxins in poison- sound waves into the inner ear. ous plants have a bitter taste. Our tongues are most www.entnet.org/HealthIn- sensitive to bitter tastes, and our brain interprets • The ossicles of the middle ear are the small bones them as something to reject, thereby protecting the formation/smellTaste.cfm that carry the sound waves; they are the malleus, body from possible harm. incus, and stapes. www.nidcd.nih.gov/ • The endolymph and perilymph conduct sound Taste and Smell health/smelltaste/smell. waves from the middle ear through the inner ear. The location of the taste receptors are: html • The organ of Corti transmits sound waves to the brain through the hair cells. The inside of • Sweet receptors—tip of the tongue the organ contains many, many hair cells that • Sour receptors—sides of the tongue stimulate the cochlear nerve (part of the vestibu- lar cochlear nerve, the eighth cranial nerve) in • Salty receptors—tip of the tongue response to sound waves. • Bitter receptors—back of the tongue • The cochlear nerve then transmits the sound to Normal aging affects smell and taste by causing a the brain for interpretation. decrease in the nerve receptors for smell and taste. • The semicircular Freecanals contain hair Sample cells also. Sweet and Providedsalty taste receptors are the most by affected. CIMC The movement of endolymph within the semicircular canals stimulates these hair cells. The message is sent to the brain, which interprets it 800-654-4502to maintain balance and equilibrium.

Normal aging affects hearing by causing a decrease in okcimc.com the ability to distinguish high frequencies of sound. This is thought to be due to declining function of the nerve fibers in the cochlear nerve and the cells of the organ of Corti. The ability to distinguish consonant sounds in hearing also decreases for the same reasons

MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 5

MODULE 2 • Sensory Nursing • TEACHER EDITION 5 Sour Bitter

Sour Sweet

Salty

The glossopharyngeal nerve transmits the messages sEnsE O f tOUc H of taste to the brain. The olfactory receptors are located in the upper section of the nasal cavity. This Sensory receptors cover the skin and epithelia, skel- is why people breathe deeply when smelling a flower. etal muscles, bones and joints, internal organs, and the cardiovascular system. The sense of touch reacts The olfactory nerve transmits the messages of smell to diverse stimuli using different receptors: to the brain. • Thermoreceptors (temperature) • Certain odors stimulate memories because the • Nocireceptors (pain) brain stores the odor and the events associated with it in long-term memory. • Mechanoreceptors (pressure) Free Sample• When olfactory cells are Provided damaged, the person’s • by Chemoreceptors (chemical) CIMC sense of smell will be lost since the body cannot regenerate800-654-4502 olfactory cells. • Food does not taste good when you have a cold because the sense of smell is impaired by nasal congestion. When okcimc.comwe cannot smell what we eat, some of the taste is lost. The senses of smell and taste work together in our brain.

6 CIMC • MEDICAL SURGICAL NURSING II

6 CIMC • MEDICAL SURGICAL NURSING II LE arning ObjE ctivE Objective Distinguish among sensory D i d You Know? learning disorders. www • Severe visual impairment is defined link as the inability to read newspapers v isU a L DisO r DErs with the use of corrective lenses.

Many eye conditions can affect a patient’s vision and • Total blindness is absence of light understanding a patient’s vision impairment will perception and usable vision. allow the nurse to provide care that will meet the • Functional blindness occurs when Eye Health Slide Show patient’s needs. Refractory errors prevent light rays there is some light perception but — visual examples of eye from converging into focus on the retina. no usable vision. disorders www.webmd.com/eye- Refractory Errors health/slideshow-eye- Treatment/Nursing Disorder Structure Affected Physical Findings conditions-overview Care Hyperopia Causes light rays to focus Blurred vision • LASIK (laser-assisted Lasik Eye Procedures • Farsightedness behind the retina in-situ keratomileusis) Myopia Causes light rays to be fo- • PRK (photorefractive www.tlcvision.com/lasik- • Nearsightedness cused in front of the retina keratectomy) • I CR’s (intra-corneal laser-vision-expectations/ Presbyopia • The lens becomes less ring segments) • Farsightedness elastic lasik/ • Refractive IOL (in- due to aging • Decreases accommoda- traocular lens) implan- tive ability of the eye Hyperopia tation Astigmatism • Irregularity of curve of • Phakic I OL’s www.aoa.org/x4696.xml cornea ▶ Administer medica- • Causes light rays to tions as directed by bend unequally physician www.nlm.nih.gov/ ▶ Teach patient signs medlineplus/ency/ar- and symptoms of infection ticle/001020.htm Free Sample Provided ▶ Patient will return by CIMC for follow-up care as Myopia 800-654-4502directed • Corrective lenses www.aoa.org/x4688.xml • Contact lens okcimc.com www.nlm.nih.gov/ medlineplus/ency/article/001023.htm Presbyopia www.aoa.org/x4697.xml

www.nlm.nih.gov/ medlineplus/ency/ar- MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 7 ticle/001026.htm Astigmatism www.aoa.org/Astigmatism. xml

www.nlm.nih.gov/ medlineplus/ency/article/001015.htm

MODULE 2 • Sensory Nursing • TEACHER EDITION 7 EyE i njU riE s

learning Eye injuries can result in permanent visual impair- to the eye occurs, first aid measures include having www ment. Causes of eye injury include trauma, through the victim lie down to prevent fluid from escap- link auto accidents and sports injuries, or chemical expo- ing from the eye. The penetrating object should be sure. The patient may experience pain,photophobia , stabilized (a Styrofoam cup works well to cover the redness, edema, tearing, blood present in chamber, eye and the object), and the victim transported to an abnormality in vision, abnormal intraocular pres- emergency department as soon as possible. Only a sure, or deficits in peripheral vision. physician should remove the penetrating object.

Penetrating Eye Injury Penetrating wounds to the eye can result in complete To provide care for an eye injury, the nurse should loss of vision and loss of the eye itself. It is important cover the eye with a dry sterile patch and a protec- www.insidermedicine. for the nurse to assess the size of the object that is tive shield, stabilize any foreign objects, elevate head com/insidermedicine-if- penetrating the eye and whether fluid is leaking from of bed 45 degrees, avoid pressure on the eye, and the eye. When vitreous humor, the jelly-like fluid instruct patient not to blow their nose. In the case i-had.aspx?Category=349 that gives the eyeball its shape, escapes from the eye, of chemical exposure, the eye should be irrigated as vision is usually lost. When a penetrating wound soon as possible with sterile saline or water. Hordeolum Infections and Inflammation of the Eye Treatment/Nursing http://health-pictures. Disorder Structure Affected Physical Findings Care com/hordeolum.htm Hordeolum Sebaceous glands in the • Red • Treatment consists of • Stye eyelid • Swollen application of warm, www.ncbi.nlm.nih. • Tender area moist compresses four gov/pubmedhealth/ times daily until healed • Antibiotic ointment or PMH0002004/ drops Chalazion Sebaceous glands in the • Swelling • Wa r m , moist com- Chalazion upper lid • Tender presses • Red • If this treatment is www.mayoclinic.com/ not effective, then an health/medical/IM03093 ophthalmologist may remove it surgically or www.webmd.com/ inject it with corticos- teroids eye-health/tc/styes-and-Free SampleBlepharitis Infection Provided of follicles of the • Itching by CIMC• Wa r m compresses chalazia-topic-overview eyelash along the rim of • Burning • Antibiotic eyedrops 800-654-4502the eyelid • Crusting mucus Blepharitis Conjunctivitis Inflammation of the • Redness of the eye • Antibiotic eyedrops (pink eye) conjunctiva caused by a • Pain www.southcoasteyecare- okcimc.combacterial infection • Tearing inc.com/pages/blepharitis. • Itching Keratitis Inflammation of the • Pain and discomfort • Antibacterial, antifun- html cornea • Photophobia gal, and antiviral drugs • Blurred vision • Response to trauma www.nei.nih.gov/health/ • Response to immune- mediated reactions blepharitis/blepharitis.asp • Replacement of vita- min A due to deficiency www.medicinenet.com/ blepharitis/article.htm

8 CIMC • MEDICAL SURGICAL NURSING II Conjunctivitis www.webmd.com/eye-health/slideshow-pinkeye

www.webmd.com/eye-health/eye-health-conjunctivitis

www.aoa.org/x4720.xml Keratitis www.lyme.org/gallery/keratitis.html

www.medicinenet.com/keratitis/article.htm

www.nlm.nih.gov/medlineplus/ency/article/001609.htm

8 CIMC • MEDICAL SURGICAL NURSING II Important Fact Pink eye (conjunctivitis) is highly contagious learning and can easily be spread to others. Reinfection wwwlink within a house or school can occur if preventative measures aren’t followed. These include: • Hand washing • Not sharing eye makeup • Not sharing towels and handkerchiefs Cataracts • Changing pillowcases frequently www.nei.nih.govw.nei.nih. gov/health/cataract/cata- Conditions Affecting Vision ract_facts.asp Treatment/Nursing Disorder Structure Affected Physical Findings Care www.geteyesmart.org/eyes- Cataract Opacity of the lens, caus- • Blurred vision/ photo- Surgical removal of cata- ing cloudiness phobia ract mart/diseases/cataracts.cfm • Double vision • Decreased night vision Teach patient it is ex- Cataract Simulation • Increased nearsighted- tremely critical to follow ness their physician’s instruc- www.cataracteye.com/ • Need for increased light tions following cataract simulation.html with detailed work or surgery for optimal reading healing • The lens becomes Open-Angle Glaucoma cloudy in appearance (Chronic) Open-angle Increased intraocular pres- • Decrease in peripheral • Photocoagulation is Glaucoma (chronic) sure, causing damage to vision used to seal the leaking www.visionrx.com/library/ the optic disc • Occurs more gradually of serous fluid and blood enc/enc_oaglaucoma.asp and has mild symptoms vessels in the region • Medication • Surgery www.glaucoma.org/glauco- Free Sample Provided by CIMCma/types-of-glaucoma.php Postop care includes: • Notify physician if 800-654-4502worsening pain is experienced • Avoid strenuous activity okcimc.com• Do not strain with stool or bend over • Ta k e a stool softener

MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 9

MODULE 2 • Sensory Nursing • TEACHER EDITION 9 Conditions Affecting Vision Continued Treatment/Nursing learning Disorder Structure Affected Physical Findings Care wwwlink Narrow-angle Iris is too close to the canal • Severe eye pain with • Treatment is aimed at Glaucoma (acute) that drains aqueous humor colored haloes decreasing the intraoc- and blocks it • Blurry vision ular pressure • Nausea • A laser is used to create • Comprises a medical openings that allow the emergency excess fluid to escape Narrow-Angle Glau- • Teach patient proper coma (Acute) after-surgery care and medication usage www.youtube.com/ Retinal detachment Separation of retinal layers • Flashes of light with • Laser surgery is often from the choroid floaters used to repair the reti- watch?v=gDfM3s7jxqM • Possible complete loss nal tear of vision • Scleral buckling www.webmd.com/eye- • More invasive repair health/glaucoma-eyes • Reinforce instructions regarding the need to wear eye patches and/ Retinal Detachment or eye shields after surgery www.ncbi.nlm.nih. • Explain that light sen- gov/pubmedhealth/ sitivity is common for PMH0002022/ several weeks post-op Retinopathy Rupture of aneurysms on • Symptoms occur later • The best treatment retinal blood vessels and include blurred is prevention, which www.maculacenter.com/ vision involves management EyeConditions/retinal- • Missing areas in vision of diabetes and/or Detachment.htm • Abnormal spots or lines hypertension in vision • Photocoagulation Scleral Buckling Macular Photoreceptors, bleeding • Inability to see colors or • Laser therapy is effec- degeneration of abnormal vessels near details tive if initiated early in www.webmd.com/eye-Free Samplemacula Provided• Blurry by vision CIMCprogression of disorder health/scleral-buckling-sur- • Straight lines appearing • Photocoagulation wavy gery-for-retinal-detachment 800-654-4502• Loss of central vision with intact peripheral www.youtube.com/ okcimc.comvision watch?v=YftCbXIw11k Nursing Care for Patient Having Eye Important Fact The most common cause of loss of vision from Surgery aging is macular degeneration. http://wps.prenhall. com/wps/media/objects/737/755395/ eye_surgery.pdf 10 CIMC • MEDICAL SURGICAL NURSING II

Retinopathy Amsler Grid to Check for Macular Degeneration www.bmj.com/content/328/7440/625.full www.allaboutvision.com/conditions/amsler-grid.pdf Diabetic Retinopathy www.nei.nih.gov/health/diabetic/retinopathy.asp Macular Degeneration www.nei.nih.gov/health/maculardegen/armd_facts.asp

www.allaboutvision.com/conditions/amd.htm

www.macular.org/1_blindness.html

10 CIMC • MEDICAL SURGICAL NURSING II s trabisMUs aUDitO ry DisO r DEr s

Strabismus (crossed eyes) occurs when the eye There are two different types of hearing loss attributed learning muscles are weak in one or both eyes. This muscle to problems with the ear. Sensorineural hearing loss is wwwlink weakness may occur because of muscle imbalance, due to dysfunction of the auditory nerve. When the muscle paralysis, or a congenital condition. Often hearing loss is caused by problems with sound trans- the good eye is patched for six to eight weeks mission through the ear it is conductive hearing loss. to strengthen the muscles of the affected eye. Sometimes glasses may be prescribed as well as Causes of Hearing Loss eye exercises. In some cases, surgery is indicated to straighten the deviated eye. Conductive: Strabismus • Obstruction by cerumen (earwax) www.pedseye.com/strabis- • Scarring of tympanic membrane (repeated otitis mus_adult_strabismus.htm D i d You Know? media) Intraocular pressure is the • Congenital disorder www.aapos.org/terms/con- pressure within the eye and Sensorineural: ditions/11 is determined by the amount • Ototoxic drugs www.nlm.nih.gov/ of aqueous humor present. • Repeated exposure to loud noise medlineplus/ency/ar- • History of mumps, measles, meningitis, or Meniere’s disease ticle/001004.htm Q: How would you communicate differently with a • Acoustic neuroma patient with severely impaired vision? Deaf Communication Technologies Q: How would you communicate with a patient with severe hearing loss? www.assistech.com/deaf- communication.htm Causes of Hearing Loss Treatment/Nursing Disorder Structure Affected Physical Findings Ototoxicity Care Ototoxicity Damage to the inner ear • Problems with hearing • Determine cause such www.hearinglosshelp.com/ Freeor vestibulocochlear Sample nerve and/or balance Providedas the use of ototoxicby CIMCarticles/ototoxicupheaval. from certain drugs • Permanent or temporary drugs • Ototoxicity- ringing in • Instruct patients to htm (Part 1) 800-654-4502the ears and a decrease report hearing loss, in hearing ability problems with balance www.hearinglosshelp.com/ • Low urine output • Wa r n patients about the articles/ototoxicaudiology. okcimc.comuse of aspirin and other Drugs causing condition medications, which can htm (Part 2) include: cause condition • Antibiotics • Monitor urine output • Antineoplastics • Loop diuretics • Non-steroidal anti- inflammatory drugs

MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 11

CRITICAL THINKING question answers

Q: How would you communicate differently with a patient with severely impaired vision? Answer: How a nurse communicates with a person with severe vision impairment may depend on whether there are other concurrent health issues. See the links below for information on this topic. Vision impaired: www.afb.org/Section.asp?SectionID=36&TopicID=163&DocumentID=194

Q: How would you communicate with a patient with severe hearing loss? Answer: Several tips for communicating with people who have severe hearing loss can be found at: www.mich- dhh.org/hearing/comm_tips.html

MODULE 2 • Sensory Nursing • TEACHER EDITION 11 Causes of Hearing Loss Continued Treatment/Nursing learning Disorder Structure Affected Physical Findings Care wwwlink Meniere’s disease Increased fluid in the • Hearing loss • Treatment includes labyrinth spaces, causing • Ve r t i g o drugs such as: swelling of the membranes • Loss of balance ▶ Atropine of the cochlea • Dizziness ▶ Epinephrine • Nausea ▶ Va l i um Increased pressure in the ▶ Antihistamines Meniere’s Disease inner ear, causing damage ▶ Antiemetics to structures ▶ Anticholinergics www.nidcd.nih.gov/health/ ▶ Vasodilators balance/meniere.html ▶ Diuretics • Surgical removal of the endolymph sac www.medicinenet.com/ • Assess and document meniere_disease/article.htm symptoms and frequency • Instruct patient on Otitis Media safety precautions during acute attacks www.nidcd.nih.gov/health/ • Assist patient to determine if they experi- hearing/earinfections ence an aura and what actions to take should www.umm.edu/altmed/ar- it occur • Instruct patient to rest ticles/otitis-media-000121. in dark, quiet room htm • Tell patient to avoid: ▶ Caffeine Image of Tympanic ▶ Decongestants ▶ Stimuli that cause at- Membrane with and tacks such as bright without OM lights or noisy places ▶ Bending over with www.pedisurg.com/ptFree- Sample Provided by CIMChead down educent/otitis_media.htm • A low-sodium diet and diuretics may help 800-654-4502 reduce excess fluid Otitis media Infection of the middle ear • Occurs after a respira- • Antibiotics, antihista- from bacteria or viruses tory infection and causes mines, and/or decon- okcimc.comfluid to build up gestants • Pain in infected ear, • Incision may be made fever into the eardrum and a • Feeling of fullness in tube inserted to drain the ear the fluid and equalize • Impairment in hearing pressure • Redness and bulging of • Administer pain meds the tympanic membrane as needed

12 CIMC • MEDICAL SURGICAL NURSING II

Teaching SUggestions

• Remind students that when a patient experiences hearing loss while on a medication known to cause ototoxicity, it isn’t necessarily ototoxicity. The nurse should always assess if the patient has had prior hearing loss or if the hearing loss they are experiencing is different from what they normally experience.

12 CIMC • MEDICAL SURGICAL NURSING II Causes of Hearing Loss Continued Treatment/Nursing Disorder Structure Affected Physical Findings learning Care www Otosclerosis Affects the bones of the • Difficulty hearing exter- • Hearing aid link middle ear, causing the sta- nal sounds • Surgical procedure pes to become fixed so it • The sound of patient’s called a stapedectomy, cannot vibrate or produce own voice becomes or a tympanoplasty sound waves louder • Provide post-operative treatment Otosclerosis OtHEr sEnsO r y www.entnet.org/HealthIn- iMpairMEnts formation/otosclerosis.cfm Other sensory impairments can be problematic to the patient. If a patient is unable to smell or taste Otosclerosis and food, they may become malnourished. The sense of Stapedectomy smell and taste work together to make the dining experience more appealing. www.audiologynet.com/ Other Sensory Impairments otosclerosis-stapedectomy. Treatment/Nursing html Disorder Structure Affected Physical Findings Care Dysgeusia Taste buds • Foul, salty, rancid, or • Determine cause such Loss of Taste Sensation metallic taste sensa- as smoking, flu, medi- — Dysgeusia tion will persist in the cations mouth • Prepare foods with a www.medicinenet.com/ • Burning mouth syn- variety of colors and drome, a condition in textures loss_of_taste_sensation/ which a person experi- • Use spices symptoms.htm ences a painful burning • Add foods that have sensation in the mouth butter, olive oil and other forms of fat • Avoid dishes that have Free Sample Provideda combination byof ingre- CIMC dients Hyposomia Diminished sense of smell • Total or partial loss of • Assess to determine if 800-654-4502smell condition is related to ag- Presbyosomia – loss • Think they smell bad ing or other conditions of smell due to aging okcimc.comodors • Determine if medica- • Headaches, dizziness, tions could be possible shortness of breath, or cause anxiety • Support treatment of underlying cause such as flu, cold, infection, nasal swelling • Recommend patient stop smoking if applicable • Tell patient to check for spoilage of foods

MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 13

MODULE 2 • Sensory Nursing • TEACHER EDITION 13 Other Sensory Impairments Continued Treatment/Nursing learning Disorder Structure Affected Physical Findings Care wwwlink Sensory integration Inability to integrate cer- • Over-sensitivity to • Therapeutic body disorder or dysfunc- tain information received touch, movement, brushing to override tion (SID) from the body’s basic sights, or sounds stimulation sensory systems • Under-reactivity to • TENS units touch, movement, • Music therapy sights, or sounds • Biofeedback Sensory Integration • Easily distracted Disorder (SID) • Activity level that is un- usually high or unusu- www.sinetwork.org/ ally low • Physical clumsiness or apparent carelessness www.youtube.com/ • Impulsivity or lack of watch?v=6O6Cm0WxEZA self-control • Difficulty in making Benign Paroxysmal transitions from one situation to another Positional Vertigo • Inability to unwind or calm self www.mayoclinic.com/ Benign paroxysmal Inner ear • Dizziness • Teach exercises health/vertigo/DS00534 positional vertigo • Unsteady gait/balance • Assess to determine • Frequent falls cause and remove caus- Movement Disorders • Labyrinth becomes ative agent infected or swollen • Administer antibiotics www.movementdisor- • Small calcium stones in as ordered the inner ear become • Assist ambulation as ders.org/education/ displaced needed • Fluid in the inner ear www.nlm.nih.gov/med- Movement disorders Disruption of any portion • Dystonia • Assist with physical lineplus/movementdisor- of nervous system can • Tr e m o r therapy as directed cause a person to produce • Tics • Teach medication use ders.html Free Sampleundesirable Provided movement • Akathisia – restless leg by CIMC• Provide perioperative syndrome (a desire to care www.wemove.org/ move to relieve uncom- 800-654-4502fortable sensations) • Rigidity okcimc.com• Postural instability

14 CIMC • MEDICAL SURGICAL NURSING II

14 CIMC • MEDICAL SURGICAL NURSING II LE arning ObjE ctivE

Objective Relate diagnostic tests and surgical learning procedures to the nursing care of wwwlink patients with sensory disorders.

Various external devices are used for assessment of the eye. They are:

• Slit lamp — diagnosing cataracts- allows better visualization of the opacity of the lens. Snellen Eye Chart • Tonometer — measurement of intraocular pres- www.i-see.org/eyecharts. sure html • Ophthalmoscope — retinal detachment by direct visualization Online Eye Tests Sensory Disorder Tests and Surgical Procedures www.websightmd.com/ Test/ Procedure Purpose Procedure Nursing Care id23.html Snellen eye chart Test visual acuity - ability Chart is placed twenty feet Teach patient about the to see images at a distance away and the individual results of testing reads downward as letters • The results include a E-Activity Showing decrease in size on each line fraction, comparing the Different Eye Disorders individual’s vision with normal vision www.richmondeye.com/ (e.g. the results are eyemotil.asp 20/30 means the individual sees letters at 20 feet as others see at 30 feet) Rosenbaum’s vision Tests near vision Holding the chart 14 inches Explain purpose and screener away while patient reads the results of test smallest print possible Cover-uncover test Used to assess extraocular The individual focuses on an Freemuscle function Sampleobject far away Provided and covers by CIMC one eye

800-654-4502The uncovered eye is ob- served for movement

Theokcimc.com test is performed on both eyes

MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 15

Classroom Activity

• Many of these eye/vision tests are easy to do on each other. Have the students pair up and complete the tests on their partner.

MODULE 2 • Sensory Nursing • TEACHER EDITION 15 Sensory Disorder Tests and Surgical Procedures Continued learning Test/ Procedure Purpose Procedure Nursing Care www Cardinal gaze test Determines eye muscle The individual is asked Explain purpose, proce- link strength and function of to focus on an object 12 dure and results of test cranial nerves inches away and the exam- iner moves the object in six different positions while watching the individual’s eye movements Cardinal Gaze Test Movement should be www.websightmd.com/ smooth in all directions id57.html Ophthalmoscopy Examination of the inte- Physician uses ophthalmo- rior portion of the eye scope to provide illumina- tion of the eye, allowing for Ophthalmoscopy visualization of the inner www.youtube.com/ structures of the eye Tonometry Intraocular pressure A tonometer is applied watch?v=leMexvs9HVU directly on the surface of the eye which flattens the surface Tonometry Another method includes www.youtube.com/ the use of a noncontact watch?v=TTnLVw6yzB8 tonometer, which blows a puff of air onto the eye Amsler grid Problems with the macula Grid of identical sized Amsler Grid exist squares with a central point www.amd.org/living- is used, and the individual is asked to stare at the central with-amd/resources-and- point and notice if squares tools/31-amsler-grid.html are uniform and straight. Vascularity Observation of the eye Use of retinal angiography www.opt.indiana.edu/ vessels Free Sample ProvidedDye is injectedby through CIMC a riley/HomePage/Amsler_ vein and special photographs Grid/4TEXTamsler_grid. are taken of the dye perfusing through the eye vessels html 800-654-4502

Retinal Angiography Preoperative careokcimc.com for an eye surgery includes admin- Postoperative care for an eye surgery includes pre- istration of stool softeners to prevent straining with vention of anything that may cause straining, such www.webmd.com/eye- stool after surgery, administration of eyedrops if as constipation, vomiting, bending over, etc. Eye ordered, and patient education. patches are often used on affected eye after surgery health/eye-angiogram for protection. Patient education on medications prescribed and follow-up care is very important. www.nlm.nih.gov/ medlineplus/ency/article/003846.htm

Preoperative Care for 16 CIMC • MEDICAL SURGICAL NURSING II Eye Surgery http://eyerepublic.com/cataract-surgery-manila-phil- NOTE ippines/preop-instructions.html One of the primary nursing interventions for the Postoperative Care for Eye Surgery postoperative care of the patient having had eye surgery is to take measures to prevent increased http://nursing411.org/Courses/MD0919_Nursing_ intraocular pressure (IOP). Assist the students with care_sensory_neurologic/1-22_Nursing_Care_sen- identifying common actions to avoid that may increase sory_neuro.html IOP (i.e. bending over to tie shoes, picking up small http://eyerepublic.com/cataract-surgery-manila-phil- children, coughing and sneezing). ippines/postop-instructions.html

16 CIMC • MEDICAL SURGICAL NURSING II Ear ExaM s Preoperative care of the patient undergoing ear surgery may involve administration of ear drops and Instruments used for ear exams are: cleaning of the surgical site. learning • An otoscope is an instrument used to inspect the wwwlink tympanic membrane and the external acoustic Postoperative care for the patient undergoing ear sur- canal. The normal tympanic membrane should gery may involve specific positioning in bed, depend- appear pearly gray and transmit light. The nor- ing on type of surgery and ear affected. The nurse mal canal should be smooth. should monitor for signs of damage to the facial nerve, which includes inability to shut eyes, pucker • A tuning fork is used to perform the Rinne and lips, or wrinkle forehead. There may be a dressing in Weber tests. place over the ear. Safety is an important factor as Otoscope — Examina- balance may be impaired. ▶ In the Rinne test, the tuning fork is struck to tion of the Ear produce vibration and placed on the mastoid For administration of eye ointments, the steps are process until the individual can no longer www.youtube.com/watch? the same except for actual administration, where you hear the vibration. squeeze a thin line of ointment along the length of v=KfHW3ES0IA4&featur ▶ The tuning fork is moved at once to a posi- the conjunctival sac. e=related tion lateral to the ear until patient can no longer hear the vibration. Air conduction Taste and smell disorders are identified by both www.youtube.com/ should be twice as long as bone conduction. subjective and objective data. The physician will use a variety of tools, such as the ones listed below, to watch?v=iIbaq15t1L0 ▶ The Weber test is done by striking the tun- confirm a diagnosis of a taste or smell disorder: ing fork to produce vibration and placing it Rinne and Weber Test midline along the individual’s skull. • Skull X-ray ▶ Sound should be heard equally in both ears. • MRI www.youtube.com/watch? If the sound lateralizes to one ear, hearing v=4WzGmDD0Zq8&feat loss may be indicated. • CT scan ure=related • Olfactory nerve testing • Nasal cytology www.webster.edu/~davittdc/ Diagnostic Tests for Ear Disorders ear/rinne/rinne.htm Test Purpose Procedure Nursing Care Romberg test Checks for balance The individual is asked • Explain purpose, proce- www.webster.edu/~davittdc/ to stand with their arms dure and results of test ear/weber/weber.htm Free Sampleextended to theirProvided sides, • Prevent patient by from CIMC their feet together, and falling during exam Romberg Test 800-654-4502their eyes closed www.neuroexam.com/neu- There should not be sway- ingokcimc.com or loss of balance roexam/content.php?p=37 Audiometry Measure hearing acuity Headset is worn and vari- Explain purpose, proce- ous intensities of sound dure and results of test Audiometry are produced through the headset one ear at a time www.ncbi.nlm.nih.gov/ books/NBK239/ http:// The results are based on when the individual is first able to hear sound www.nlm.nih.gov/ medlineplus/ency/article/003341.htm MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 17 http://itunes.apple.com/ Class Discussion us/app/audiometry/ id298494364?mt=8 • At this point, consider asking your students about which nursing diagnoses they think are appropriate for the patient having undergone ear surgery. Then discuss interventions and rationales for each diagnosis.

MODULE 2 • Sensory Nursing • TEACHER EDITION 17 Class Discussion Touch, position and movement conditions are diag- LE arning ObjE ctivE nosed using: Objective Evaluate pharmacological effects of • This portion of the • Brain imaging studies medications used to treat sensory course provides a good • CT scan disorders. opportunity to review • PET scan the administration of • MRI ophthalmic medica- • Blood and urine studies, positron emission tions and the application of eye patches/ • Lumbar puncture

dressings. Medications for Sensory Disorders Category and Uses Actions Side Effects Nursing Care Examples Antibiotics Used to treat Interferes • Confusion • Assess for possible • Gentamicin or prevent with protein • Seizures allergic reaction to drug sulfate bacterial infec- synthesis of the • Hypo/hypertension • Observe for signs and • Neomycin sulfate tions of the eye bacterial cell • Oliguria symptoms of infection • Polymyxin B • Hematuria • Get culture and sensi- sulfate • Renal damage tivity before giving first • Ciprofloxacin • Rash dose of medication • Monitor changes in vital signs Mydriatic & Dilate pupils Used for surgi- • Restlessness • Assess for eye pain cycloplegic and paralyze cal procedures • Dry mouth • Monitor intake and • Atropine muscles of ac- of the eyes • Abdominal output • Scopolamine commodation distress • Assess for abdominal • Homatropine Enhances abil- • Blurred vision complications such as ity to examine • Rash constipation inside of eye • Assess mental status and prevents Alteration in vital moving of lens signs: Free Sample Provided • byRapid pulse CIMC • Palpitations, hypotension Topical anesthetics800-654-4502Anesthetize Block nerve • Pain in the eye • Assess for possible • Alcaine the eye conduction • Redness allergic reaction to drug • Pontocaine causing anes- • Eye irritation • Observe for signs and okcimc.comthetic effect • Allergic reaction symptoms of infection

18 CIMC • MEDICAL SURGICAL NURSING II

Additional Learning Activity

Using 3x5 note cards have your students write the name of a medication/classification on one side of a card. Next write down the uses, actions, side effects and nursing considerations each on their own card. Do this for each of the medications/classifications listed. Have the students mix all of the cards then match them appropriately using the chart to grade their progress. This can be done as a team or individually. If using teams, have each side see who can match the correct cards the fastest.

18 CIMC • MEDICAL SURGICAL NURSING II Medications for Sensory Disorders Continued Category and Uses Actions Side Effects Nursing Care Examples Miotics Treatment of Constrict the • Difference in taste • Assess for possible • Cholinergics- glaucoma pupil, which • Ocular burning allergic reaction to drug pilocarpine increases flow and stinging • Observe for signs and hydrochloride of aqueous • Blurred vision symptoms of infection • Cholinesterase humor and • Abdominal pain • Treat symptoms as pre- inhibitors-echo- decreases • Back pain scribed by physician thiophate iodide intraocular • Cough • Beta-adrenergic pressure • Dizziness blockers-timolol • Headache maleate • Hypertension • Urinary tract infection Sympathomimetics Decrease Aids in outflow • Tachycardia • Assess for possible • Epinephrine intraocular of aqueous • Arrhythmias allergic reaction to drug • Dipivefrin pressure fluid and • Hypertension • Observe for signs and decreases the • Blurred vision symptoms of infection body’s produc- • Headache • Treat symptoms as pre- tion of aqueous • Eye pain scribed by physician fluid • Conjunctivitis Carbonic anhydrase Decrease Decrease • Dry eye • Assess for possible inhibitors intraocular formation of • Headache allergic reaction to drug • Azopt pressure aqueous humor • Ocular discharge • Observe for signs and by decreasing • Ocular pain symptoms of infection production of • Chest pain • Treat symptoms as pre- carbonic acid • Eye fatigue scribed by physician • Urticaria • Dry mouth • Dizziness • Eye pain Free Sample• Conjunctivitis Provided by CIMC 800-654-4502 okcimc.com

MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 19

MODULE 2 • Sensory Nursing • TEACHER EDITION 19 LE arning ObjE ctivE LE arning ObjE ctivE

Objective Contribute to the plan of care for Objective Distinguish among patient patients experiencing alterations in education needs related to self-care sensory or perceptual function. for sensory disorders.

LPNs will be assigned the task of direct patient The patient should receive teaching that is appropri- care and will be responsible for contributing to the ate for self-care of disorders of the senses. Examples patient’s plan of care. The following is a partial list of patient teaching follow. of nursing diagnoses that may be associated with patients experiencing sensory impairments. Patient teaching for glaucoma: • Always wear ID tab stating “glaucoma” • Disturbed sensory perception related to (hearing, visual, taste) deficit • Ta k e medications as prescribed • Risk of injury related to (hearing, visual, taste) • Do not take over-the-counter medications with- impairment and inability to (hear, see, taste) out consulting physician potential dangers • Signs of increased intraocular pressure to report • Self-care deficits related to sensory (hearing, include eye pain, blurry vision, and presence of visual, taste) deficit halos • Fear of inability to sense potential danger or • Prevention of increased intraocular pressure accurately interpret environment includes low sodium diet, prevention of constipation • Grieving related to loss of function Patient teaching after ear surgery: Goals for the patient with a sensory impairment include: • Avoid sneezing, coughing, or blowing nose

• Successfully adjusting to the impairment • Avoid heavy lifting or bending over for 3 weeks • Verbalizing feelings related to the loss • Avoid flying until physician permits • Using appropriate coping strategies • Do not drink from a straw or from plastic bottle for 3 weeks • Maintaining safety during daily life • Avoid people with illness and loud noises • Performing activities of daily living as indepen- Free Sampledently as possible Provided by CIMC 800-654-4502 okcimc.com

20 CIMC • MEDICAL SURGICAL NURSING II

20 CIMC • MEDICAL SURGICAL NURSING II LE arning a ctivity 1 Learning Activity Answers n a ME Answers will vary. Introduction

LPNs will be involved in identifying interventions promoting desired patient outcomes.

Activity

List two different nursing interventions for each of the nursing diagnoses listed below. Include rationale, or reasoning, for the intervention.

• Glaucoma • Ear surgery

Compare and contrast identified interventions with a peer.

Application

Present list to the facilitator.

Free Sample Provided by CIMC 800-654-4502 okcimc.com

MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 21

MODULE 2 • Sensory Nursing • TEACHER EDITION 21 Learning LE arning a ctivity 2 Activity Answers n a ME Answers will vary. Introduction

It is important for the nurse to be able to answer questions and provide instructions to the patient as their questions arise. Patients with sensory impairment often need reassurance and directions.

Activity

Wo r k individually or in groups of three as assigned by the facilitator. Review the following scenario and discuss nursing care and appropriate patient instructions to be given to the patient.

During a routine health physical, a patient reports changes in his vision. He states these changes have become increasingly prevalent during the past 2 to 3 years. The patient is currently 78 years old. He asks questions about what other changes can be anticipated in his visual abilities related to aging. What information should be provided the patient? What recommendations concerning preventive behaviors can be made to the patient at this time?

Application

Check the answers with the facilitator.

Free Sample Provided by CIMC 800-654-4502 okcimc.com

22 CIMC • MEDICAL SURGICAL NURSING II

Learning Activity Related Content Normal Age-Related Vision Loss and Related Services for the Elderly, by Donia E. Nolan www.laurenscharff.com/research/donia/aging_visual_changes.htm

22 CIMC • MEDICAL SURGICAL NURSING II LE arning a ctivity 3 Learning Activity Answers n a ME Answers will vary. Introduction

Patient teaching is important for the patient with sensory impairment.

Activity

A 78-year-old Native American patient with hearing loss who has had retinal reattachment surgery is assigned. The physician has explained surgical options to the patient, but the patient is still unsure of the difference between the various procedures.

Using the teaching plan developed by the RN and the information provided by the physician, determine specific modifications to the teaching plan for the patient.

Application

Perform the patient teaching with a student or facilitator.

Free Sample Provided by CIMC 800-654-4502 okcimc.com

MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 23

MODULE 2 • Sensory Nursing • TEACHER EDITION 23 Learning LE arning a ctivity 4 Activity Answers n a ME Answers will vary. Introduction

Patient teaching and safety are important for the patient with sensory impairment.

Activity

Prepare a list of safety instructions for a patient who has recently experienced severely impaired touch, taste, and smell.

Application

Perform patient teaching to a student or the facilitator.

Free Sample Provided by CIMC 800-654-4502 okcimc.com

24 CIMC • MEDICAL SURGICAL NURSING II

Teaching Suggestion • Have students search for online resources related to this patient’s condition/situation. Guide students in developing a teaching plan. Have the students blindfold themselves, wear ear plugs and role-play how they would present the information to a patient with similar impairments. Discuss the challenges of this activity and whether options exist to address them.

24 CIMC • MEDICAL SURGICAL NURSING II KEy s UMMary

• The senses provide individuals with interactions with their environment, interactions with other individuals, and contribute to their safety within their environment.

• Treatment for sensory disorders may include corrective lenses, medications, and/or surgery. There are numerous disorders which may affect an individual’s hearing. Some of these include otitis media, otosclerosis, and Meniere’s disease.

• There are two different types of hearing loss attributed to problems with the ear. Sensorineural hearing loss is due to dysfunction of the auditory nerve. When the hearing loss is caused by problems with sound transmission through the ear it is conductive hearing loss.

• The sense of touch, position and movement assist in ambulation and mobility. If the patient is unable to move or moves uncontrollably, optimum wellness may not be possible.

• Taste and smell disorders are identified by both subjective and objective data.

• Disorders that affect the senses provide unique challenges because they have significant impact on the patient’s ability to interact with others and their ability to maintain safety.

Free Sample Provided by CIMC 800-654-4502 okcimc.com

MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 25

HOSA Spotlight

Health Education Competitive Event www.hosa.org/natorg/sectb/cat-iv/he.pdf • A teamwork event for 2-4 members. One of the sensory disorders/diseases could be selected. A lesson is prepared on the topic, instruction presented to a class of students, and results evaluated. This event includes the use of multimedia presentation tools.

MODULE 2 • Sensory Nursing • TEACHER EDITION 25 g LOssary

Blepharitis: An inflammation of the lid margins of the eye.

Cataract: Opacity of the lens of the eye.

Conjunctivitis: An inflammation of conjunctiva.

Endolymph sac: A pouch in the inner ear which contains endolymph.

Hordeolum: An infection causing inflammation of an oil gland located on margin of eyelid (also referred to as a stye).

Intraocular pressure: The amount of pressure in the eye, determined by amount of aqueous humor present.

Keratitis: An inflammation of the cornea.

Macular degeneration: A condition in which macula is damaged or destroyed.

Narrow angle glaucoma: Also known as angle-closure glaucoma, this occurs due to a narrow angle present where iris and cornea meet, causing susceptibility to angle closure; requires immediate treatment.

Open angle glaucoma: This occurs when methods of drainage of aqueous humor are blocked and intraocular pressure increases. It occurs gradually.

Photophobia: Sensitivity to light.

Retinal angiography: A procedure in which dye is injected into a peripheral vein and a Free Sample camera records Providedthe blood flow through the by retinal CIMCvessels. Retinal detachment: A condition in which the sensory layer and the pigmented layer of the800-654-4502 retina become separated. Retinopathy:okcimc.com A condition in which vessels of the retina are destroyed. Sensorineural hearing loss: Hearing loss caused by nerve damage.

Stapedectomy: A procedure in which the stapes or portion of the stapes is removed surgically and replaced with prosthesis for improvement of hearing.

Tympanoplasty: A procedure in which the tympanic membrane is repaired following perforation.

26 CIMC • MEDICAL SURGICAL NURSING II

26 CIMC • MEDICAL SURGICAL NURSING II rEs OUrcE b ibL i O grapH y

Publications

Burke, L. (2007). Medical-Surgical Nursing Care (2nd ed.). Pearson, Prentice Hall.

DeWitt, Susan (2009). Medical Surgical Nursing Concepts and Practice. Portland; Saunders.

Hogan, M. A. (2008). Medical Surgical Nursing (2nd ed.). Pearson Education.

Nursing Focus. Stillwater, OK: Oklahoma Department of Career and Technology Education, Curriculum and Instructional Materials Center, 2002.

Timby, B., Smith, N. (2007). Introductory Medical Surgical Nursing (9th ed.). Lippincott, Williams &Williams.

White L. (2005). Foundations of Nursing (2nd ed.). United States; Thompson Delmar.

Free Sample Provided by CIMC 800-654-4502 okcimc.com

MODULE 2 • S ENSo R y NURSING • stUDEnt EDitiO n 27

MODULE 2 • Sensory Nursing • TEACHER EDITION 27 nOt E s

Free Sample Provided by CIMC 800-654-4502 okcimc.com

28 CIMC • MEDICAL SURGICAL NURSING II