Adult 1 Exam 5 Neuro, Eyes & Ears

• I - Olfactory (smell)
• II - Optic (sight, visual acuity & fields)
• III - Oculomotor (movement of eye muscles; pupil constrict)
• IV - Trochlear ( downward inward eye movement)
• V- Trigeminal (Sensory of cornea, eyelids, foreheadMotor: jaw opening & chewing)
• VI - Abducens (lateral eye movement)
• VII - Facial (facial expression & taste anterior tongue)
• VIII - Acoustic (hearing & equilibrium)
• IX - Glossophayngeal (swallowing, gag & taste post. tongue)
• X - Vagus (heart, lungs, digestion & guttural sounds)
• XI – Spinal Accessory -( turn head, shrug shoulders)
• XII - Hypoglossal (tongue movement for speech & swallow)

• Sympathetic
• -EPI & NOR
• increased heart rate
• dilated pupil
• increased sweat
• decreased saliva & peristalsis (GI)
• bladder relaxed
• bronchodilate

• Parasympathetic
• -ACh
• decreased heart rate
• Constriction of pupil
• normal sweat
• increased saliva & peristalsis (GI)
• bladder contracted
• bronchoconstrict

• Loss of neurons - don't regenerate
• Enlargement of ventricles - brain
• Decreased blood flow & CSF flow
• Decreased brain weight
• Myelin sheath degeneration -decreased nerve conduction
• Changes in BP lying to standing(Orthostatic Hypotension)- decreased thirst, use of diuretics or cardiac meds
• Sluggish reflexes & loss of balance
• Loss of body temp control (in extremes)-Hypothalamus, metabolism , fat = loss of metabolism
• Smaller pupils results in vision problems

X-rays - look for fractures (basilar skull orspinal), calcification, bone loss

Blood Chemistries & ABG’s - to check electrolytes as well as acid-base balance

Angiography - radio opaque medium used to visualize vessels on x-ray, esp. spasm or stenosis of arteries; dye reaction - iodine or seafood

CT scan - computer assisted thin cross section x-rays show tumors, hemorrhage,aneurysm, ischemia, edema & tissue necrosis

MRI – uses magnetic energy to visualize internal structures; detects shifting brain tissue due to hemorrhage

PET Scan (Positron Emission Tomography) -uses radioactive compounds to measure cell damage or death in the brain; can ID stroke size

SPECT Scan (Single-Photon Emission Computed Tomography) – like PET yet ID seizure activity

EEG (Electroencephalogram) – records electrical activity of the brain esp. seizures

EMG (Electromyogram) - tests nerve stimulation to muscles (nerve conduction)

Lumbar Puncture - withdraw CSF for analysis; contraindicated ICP as herniates brainstem; flat x 4-24 hrs.

Evoked Potentials - sensory pathway nerves are examined by generating &tracking a stimulus; also have visual and auditory evoked potentials

Carotid Duplex Studies - sound waves determine blood flow in carotid

Transcranial Ultrasound Doppler study(TCD) - sound waves used to determine blood flow in intracranial vessels

=(Cerebral Vascular Accident)AKA: “Stroke” or “Brain Attack”

• Interruption of blood flow leading to inadequate O2 supply to brain by clot, bleed,or tumor
• Brain uses 20% of the body’s oxygen & 20% of glucose so needs constant blood flow
• Autoregulation unless SBP < 50 or >160; vasodilation due to:
• -Hypercapnia (CO2)
• -Acidosis (H+ ions)
• -Hypoxia (O2)

“Penumbra”- core of dead cells surrounded by minimally perfused cells - will not regenerate

• Age >65 yrs. But 25% < 65 yrs.
• Gender: males > females
• Race esp. African American & Hispanic
• Hypertension
• Family history or history of TIA/stroke
• Alcohol consumption, IV drug abuse
• Smoking
• Obesity/high fat diet (hyperlipidemia)
• DM Type II
• Cardiac disease (atherosclerosis, atrial fib.)
• Sickle cell (increased blood viscosity)
• Stroke belt (SE includes FL, 10%)- possibly diet and heat related
• A-fib increases risk of stroke (Mr. GD)

• Thrombotic
• Formation of clot in vessel
• More common where plaque is
• TIAs common; sudden onset & disappear
• (TIA = Transient Ishemic Attack)
• Esp. elderly during or just after sleep
• Men > more than women

• Embolic
• -sudden onset - immediate neuro defect -does not go away
• Clot formed elsewhere and occludes vessel
• Atrial Fib, DVT, Endocarditis etc.
• Usually no TIAs
• Esp. young who are awake & active
• Men > more than women

• Hemorrhagic/Intracerebral
• Rupture of vessels due to HT, aneurysm, AV (arteriovenous) malformation, trauma or tumor erodes vessel
• Sudden onset esp. with activity
• More women > than men
• Headache is a symptom due to blood irritating meninges & brain tissue

• Sudden Onset - Two Types:
• Intracerebral
• Subarachnoid

• Brief period of localized cerebral ischemia with reversible neurologic defects < 24 hrs.
• Transient Symptoms:
• Sudden onset & disappearance
• Contralateral numbness or weakness of hand, forearm, or corner of eye
• Visual disturbances/blurring, diplopia,amaurosis fugax (fleeting blindness described as a shade coming down) Speech difficulty/aphasia

• TIA -first 24 hours - if does not resolve then becomes stroke in evolution
• Stroke in evolution begins with TIA & worsens over 1-2 days esp. thrombotic - until all bad things stop happening
• Completed stroke usually in 3 days due to necrosis (penumbra)- healthy tissue that surrunds an ischemic event - goal of tx is to save penumbra by increasing O₂ transport and delivery to the area
• Cardiogenic embolic stroke due to atrial fibrillation - embolism becomes lodged in narrow cerebral vessels
• Recurrent stroke -

• Sudden onset, focal & 1-sided
• Weakness or numbness of face, arm or leg (contralateral); except vertebral artery unilateral
• Loss of vision of 1 eye or peripheral/sidevision (homonymous hemianopia)
• Speech difficulties
• Balance problems, unable to walk
• Sudden, severe, unexplained headache
• Dysphagia

• Lack of blood to brain from occlusion in carotid artery Surgical removal of plaque can restore circulation to brain
• Extracranial-intracranial bypass if plaque not directly accessible
• Carotid angioplasty &stent

• Nursing Interventions
• Position on unoperated side with HOB ­ 30degrees
• Support head when changing positions
• Look for:
• Hemorrhage
• Resp distress (bleeding near trachea)
• Cranial nerve impairment
• Hyper or hypotension(from carotid nerve stim.during surgery)

• Nutrition:
• Check for gag reflex
• Sit in high fowlers with head slightly flexed to prevent aspiration; food on unaffected side behind teeth & tilt head back slightly - Safety
• Thicken food/fluids if needed
• PEG tube if needed
• Speech Therapy evaluation
• Physical Therapy to prevent contractures
• Occupational Therapy to relearn ADL
• Discharge planning to Intermediate or Rehab setting

• Outpouching & weakness in cerebral artery;may rupture with hemorrhagic stroke
• 85% anterior at carotid & vertebro-basilar arteries in circle of Willis

• Risk Factors:
• Congenital
• Hypertension (cocaine)
• Head injury/trauma
• Atherosclerosis
• Age 30-60 years
• Female > male

S/S: Usually asymptomatic til rupture(leaking symptoms of HA, N&V, neck pain,dilated pupils & eye pain/visual deficits)

• Complications:
• Rebleed esp. 1st day & days 7-10 clot breaks down
• Vasospasm 3-10 days post-bleed
• Hydrocephalus as protein from blood lysis obstructs CSF (arachnoid villi)

• Types:
• Berry - congenital middle/media; no warning
• Saccular – outpouching due to trauma/force
• Fusiform – entire circumference of vessel swells due to arteriosclerosis

• Amicar – fibrinolysis inhibitor causes clotting1-2 wks. ( 1st wk. IV then 2nd wk. PO)
• Calcium Channel Blocker – decrease vasospasm x 3 wks.
  
• Anticonvulsants – Dilantin (filter)
• Stool softeners – prevent straining
• Analgesics – for headaches
• Surgical clipping (craniotomy)
• -Endovascular Gudlielmi coil with electric current causing coagulation
• -Balloon remodeling & stents
• -Parent vessel occlusion

= abnormal state when client is not aware of self or environment

Due to: Injury to cerebral hemispheresor metabolic disorders

• Arousal (wakefulness)
• Ability to awaken or elicit a response; Reticular Activating System (RAS)

• Consciousness
• Ability to reason, think, feel, respond to astimulus; Cerebral hemispheres

• (measurement of patient’s level of consciousness)3 to 15 points with 15 being awake & alert; <7 coma
• assess 3 areas and add scores together

• Eyes open
• When approaching bedside(4)
• To verbal command (3)
• To pain (2)
• No response (1)

• Best Verbal Response
• Orient X 3 (person place &time) (5)
• Can converse but confused or disoriented (4)
• Swearing, inappropriate words(3)
• Gibberish or moaning (2)
• Lack of sound (1)

• Best Motor Response
• Obeys commands (6)
• Localizes to pain (5)
• Flexion withdrawal (4)
• Abnormal flexion (3)[may be also called Decorticate Posturing –indicates injury at or above brainstem]
• Abnormal extension (with internal rotation) (2)[may be called Decerebrate Posturing]
• Lack of response (1)

• Decorticate Posturing(lesion at or above the brain stem)
• Rigidly still
• Arms flexed
• Fists clenched
• Legs extended

• Decerebrate Posturing (lesion below brain stem –intracranial catastrophe)
• Rigid body position
• Arms stiff, extended& pronated inward

Persistent vegetative state –unawareness of self & environment; brainstem & cerebellum still function (chew,swallow, cough)

Locked-in syndrome – alert & aware of environment but locked inside body without speech or movement; infarct of pons yet RAS still working

• Brain death – no cerebral or brain stem function x 6-24 hrs. with normal temp. & not on depressant drugs or alcohol poisoning
• Glasgow scale 3
• No dolls eyes - ice cold water in ear - eyes deviate to other side
• Pupils fixed & dilated
• No caloric stimulation
• No spont. respirations
• Flat EEG

• Most common
• Bilat. pain from “band around head” radiating from back to front or starting above eyes
• Sustained muscle tension from head & neck due to stress or disorders of eyes, ears, sinuses
• TX with ice, ASA &NSAID

• Recurring vascular headache w or w/o aura
• Migraine Stages:
• Aura: 5-60 min, sensory/visual disturbances (spots,light flashes) due to vasoconstriction
• Headache: 1-2 days, due to vasodilation & reduced serotonin levels; throbbing unilat. HA with N/V, photophobia & light sensitivity
• Post-headache: Exhausted, sensitive to touch with deep aching pain
• TX:
• Quiet dark place
• Avoid tyramine foods (aged cheese, nuts, chocolate, ETOH/red wine)
• Stress management/biofeedback

• Cluster of headaches for days or weeks with periods of remission for months
• Esp. middle-aged men
• Spring & Fall with tearing & nasal congestion (? circadian mechanism or disorder of hypothalamus)
• Wake about 2 hours after sleep with unilat.HA near eye (same place)
• TX:
• Avoid ETOH & nitrates
• 100% O2 for 15 min.

Beta blockers (Inderal) prevent cerebral vasodilation & inhibit serotonin uptake

Calcium channel blockers (Verapamil)controls cerebral vasospams

Serotonin agonists (Imitrex) cause vasoconstriction of cerebral vessels

Tricyclic antidepressants (Elavil) for cluster & migraine HA’s as prevent norepinephrine & serotonin uptake

Ergotamine (Cafergot) or ergot derivatives(Sansert) vasoconstrict cerebral vessels

• NSAID/ASA anti-inflammatory analgesics
• Narcotic analgesics (Demerol, Codeine

• Seizure = spontaneous, abnormal synchronous discharges of collections of neurons in cerebral cortex
• Increases metabolic demands for ATP x 250%
• 60% increase in oxygen consumption
• 2.5 x increase in cerebral blood flow or cellular exhaustion

Epilepsy = disorder of recurrent seizures

• Unprovoked/Primary/Idiopathic unknown cause
• Provoked/secondary due to fever, trauma,metabolic, endocrine, infection or tumor

Partial (focal, localized to part of brain)

• Simple Partial Seizure (Pt. is conscious)
• -Motor-Muscle contractions of 1 body part (local or sequential/travels = Jacksonian march or seizure) -Autonomic phenomena (disrupted)
• Tachycardia
• Hypo or hypertension
• Sensory
• Hallucinations
• Feeling of Deja vu

• Complex Partial Seizure (Pt. is NOT conscious; amnesia)
• Motor (repetitive, nonpurposeful activity/”automatisms”)
• Lip smacking
• Picking at clothing
• Aimless walking
• Sensory
• Feeling of Deja vu
• Aura (smell, hallucination)
• Esp. temporal lobe

(involve both hemispheres so impaired consciousness)

• Absence/Petit Mal Seizure
• Sudden, brief cessation of motor activity with blank stare/unresponsiveness
• Esp. children
• Sometimes automatisms like eyelid flutter, lip smaking
• Last 5-30 sec. & may have hundreds in a day

• Tonic-Clonic Seizure/Grand Mal Seizure
• Aura (smell, bright light, vague feeling)
• Sudden LOC
• Tonic muscle contractions with rigid arms, legs & jaw,urine/bowel incontinence, cyanosis with fixed dilated pupils lasting 15 - 60 sec.
• Clonic phase of alternating contractions & relaxation of muscles with hyperventilation & eyes rolled back plus frothing at mouth lasting 60-90 sec.

• Post-ictal period/phase where breathes & regains consciousness but still confused , fatigue, muscle aches(sleeps for several hours, amnesia)
• Esp. adults

• Anticonvulsant drugs – lowest dose
• Increase seizure threshold
• Limit spread of abnormal activity
• Dilantin w NS, Cerebyx, Tegretol, Gabitril with food, Neurontin 2 hrs. after antacids(drugs with many interactions)
• Dilantin SE/ADR - hyperplasia of gums - mouth/ dental care needed

• Surgery esp. temporal lobe (excise tissue)
• Vagal nerve stimulation for partial seizures

• Nursing Interventions
• Airway maintenance
• Protect
• Loosen clothing
• Seizure precautions ( Padded side rails)
• Education esp. medications

Progressive, irreversible deterioration of general intellectual function (cognitive,emotional, & social behavior); hereditary component

• Stages –
• I (2-4 yrs.) memory lapses, subtle personalty changes, & problems calculating; family covers up
• II (2-12yrs.) obvious memory deficits &confusion; easily agitated; paces; unable to write; uses wrong words; safety concerns;sundowning with more agitation &disoriented in evening
• III (7yrs. from dx) disoriented x3, rigid limbs, bowel & bladder incontinence, unable to communicate; death due to aspiration pneumonia

• Impaired Memory
• Anxiety
• Hopelessness

• Monitor disease progression/stages
• Family education/anticipatory guidance
• Discuss client needs
• Face, talk directly using simple sentences/explanations in calm voice
• Decrease stimuli
• Re-orient frequently yet don’t argue
• Ensure adequate rest
• Allow client to make decisions if possible
• Document changes
• Refer to appropriate agencies

Progressive neuro disorder of muscle wasting yet cognition intact (trapped in body)

• S/S: muscle weakness/atrophy
• Flaccid & spastic paralysis
• Intact mental status
• Dysphagia/swallow & dysarthria/speech

• DX: EMG/electromyogram (fasciculations) or muscle biopsy; increased CPK & decreased pulm.function tests
• Death in 2-6 yr. usually due to resp. failure

• TX: no cure
• Riluzole extends time til ventilatory support
• Communication method (eye muscles intact)
• Family social support

=(Tic Douloureax)

• Chronic disorder of CN #V (5) causing sudden, brief severe facial pain
• Trigger zones (chewing, temp., wind)

• TX:
• Tegretol (tricyclic anti-convulsant)
• Other meds (Dilantin, Neurontin orLioresal)
• Surgery to sever CN (rhizotomy)
• -Closed/percutaneous (glycerol,radiofrequency heat, ballooncompression)
• -Open (Jannetta procedure pads vessel & nerve)

Unilat. facial paralysis of CN VII (7)

• S/S: acute pain with paralysis of ½ face
• Upper eyelid paralysis & loss of corneal reflex
• Asymmetric face
• Increased tearing
• Impaired taste
• ? Herpes simplex

• TX:
• Corticosteroids
• Acyclovir
• Warm moist heat
• Artificial tears
• Soft diet

Neurotoxin that interferes with muscle contraction

• Signs & Symptoms:
• Rigid, spastic muscles of jaw, neck, back &esophagus
• Opisthotonus (arched back)
• Risus sardonicus (rigid, fixed smile)
• Increased saliva, perspiration & drooling
• Intact mental status !

• Treatment:
• Prevention: wash wounds & immunize
• Penicillin or Flagyl
• Ventilation with Pavulon & Valium
• Quiet dark environment

GI absorption of neurotoxin blocks release of acetylcholine with resp. & skeletal muscle paralysis

• S/S:
• N & V, diarrhea
• Diplopia (double vision), ptosis, fixed dilated pupils
• Slurred speech (dystonia of larynx)
• Resp. & skeletal muscle paralysis
• Intact mental status !

• TX: IV neuro antitoxin (Trivalent)
• Enemas, laxatives, GI lavage
• TPN & lipids for nutrition
• Ventilatory support
• Prevent by discarding bulging cans of food

• Altered tissue perfusion: Cerebral RT CVA
• Risk of ineffective airway clearance RT decreased gag reflex
• Impaired mobility RT CVA, ALS
• Impaired communication RT aphasia
• Self care deficit RT ADL
• Impaired memory RT Alzheimer’s
• Impaired swallowing RT dysphagia
• Self esteem deficit RT CVA, ALS, Huntington’s
• Risk of ineffective mgmt. of treatment regimen RT seizure medications
• Risk of impaired skin integrity RT immobility
• Sensory/ perceptual alterations R/T cerebral injury
• Acute Pain R/T headaches, Trigeminal Neuralgia
• Anxiety R/T change in health/genetic testing
• Body image disturbance RT Huntington’s disease
• Risk for imbalanced nutrition, less than required RT inability to swallow or fear of chewing
• Caregiver role strain RT Alzheimer’s
• Risk for aspiration RT Huntington’s Disease
• Chronic confusion RT Alzheimer’s
• Powerlessness RT ALS, Tetanus
• Risk for injury/falls RT seizures
• Risk for injury/bleeding RT use of anticoagulants

• tissue plasminogen activator
• -converts plasminogen to plasmin - fibrinolysis of the clot

DO NOT GIVE IN HEMORAGIC STROKE

• -must be give within 3 hours of onset
• -CT scan used to confirm not a hemoragic stroke
• -dont have any anti-coagulants if hemoragic stroke - bleed out faster

• Void on schedule (q2h) rather than in respone to urge
• Teach kegal exercises

• Encourage fluids and fiber
• physical activity at tolerated
• Us toilet at same time each day based on pattern of bowel elimination
• stool softener if necessary

sensory-perceptual deficit where the patient cannot integrate perceptions from affected side of body so ignores that part of the body - environment, perceptions, neglects personal care of effected part

• Assess gait - normal, heel-to-toe, on toes, on heels
• Rhomberg's test - stand with feet together & close eyes
• *should be minimal swaying

• Coordination
• -pat knees - alternate from and back of hands
• -touch thumb to fingers
• -touch nose finger & nose again

Ataxia - lack of coordination and a clumsiness of movements, with staggering, wide-based unbalanced gait (seen with stroke and cerebellar tumors)

Parkinsonian gait - stoops over while walking and shuffles feet - arms are held close to sides

Spastic hemiparesis - stroke - one leg stiffly dragging while the other leg circles out and forward - one arm flexed and held close to side

Steppage gait - disease of lower motor neurons - drags of lifts the foot high then slaps foot onto floor - cannot walk on heels

inability to use or understand language

Expressive aphasia - can understand what is being said but can only speak in short phrases (Broca's aphasia)

Receptive aphasia - one cannot understand spoken or written word - speech may be fluent but with inappropriate content (Wernicke's aphasia)

Mixed or global aphasia- disfunction in both understanding and expression

• Intervetions:
• Treat client as adult
• Dont assume client who cant respond verbally cant hear
• Dont raise voice when addressing patient
• face client and speak slowly
• when you dont understant their speech - be honest and say so
• try alternatvie methods of communication - writing tablets. flash cards, computerized taking boards

Hemiplasia - paralysis on left or right side of body

Hemiparesis - weakness on L or R side of body

Quadriplegia - complete or partial parlysis of upper limbs and complete parylisis of lower linbs

Paraplegia - parlysis of lower half of body

• Acute = inflammation of lining of eyelid (“pink eye”); highly contagious
• Due to: bacteria, viruses, or fungi, UV light, allergens or chemical irritants

S/S: redness, itching, gritty sensation,photophobia, tearing & discharge

• Chronic (Chlamydia trachomatis)
• Contagious – personal contact
• Scarring leading to blindness

• Treatments
• Clean eye with baby shampoo
• Warm NS compresses to remove crust
• Apply heat if sty or chalazion
• Don’t share towels, makeup, or rub eye
• Remove contact lenses & clean
• Antibiotic/antiviral medications
• Anti-histamines
• Corticosteroids
• Analgesics

Opacity/clouding of crystalline lens due to aging & denaturation of lens protein (bilat.)

• S/S:
• Cloudy, blurred vision both close & distant
• Poor night vision due to Glare
• Difficult adjusting to light & dark environments
• Unable to distinguish color hues
• Pupils appear cloudy, gray or white rather than black

• DX: dark area instead of red light reflex
• TX: Surgery for intraocular lens implant

• Check visual acuity before & after surgery(stabilizes several wks postop)
• No vomiting, sneezing, coughing, straining, or lifting > 5 lbs. as increases intraocular pressure
• Semi-Fowlers lying on unaffected side to decrease intraocular pressure except retinare-attachment (retinal) surgery
• Sunglasses for photophobia
• Complications (notify MD if):
• Pain or drainage from affected eye
• Hemorrhage/bleeding in anterior chamber
• Flashes of light, floaters, “curtain coming down”
• Cloudy appearance to cornea

Increased intraocular pressure damages retina & optic nerve (leading cause of blindness in U.S.)

• Open angle/chronic simple (90%) with decreased outflow of aqueous humor and increased pressure
• Asymptomatic except painless gradual loss of peripheral vision; bilateral; esp. Blacks

• Closed angle/narrow (10%) with lens shifted forward pushing iris laterally; unilateral; esp. Asians & Escamos
• Sharp eye pain with colored halo lights
• Abrupt decrease in visual acuity
• Fixed, nonreactive pupils

• Preventative Measures:
• Lower BP
• Regular eye exams

• RETINALDETACHMENT
• Separation of the retina from the choroid
• Medical emergency surgery needed
• Signs/Symptoms:
• •Floaters
• •Flashes of light
• •Blurred vision
• •Progressive deterioration of vision
• •Sensation of curtain or veil drawn across field of vision
• •Loss of central vision, if macula involved

Cryotherapy or laser coagulation to crease area of inflammation to band layers together

Scleral buckling – fold sclera to bring choroid in contact with retin

Vitrectomy – remove vitreous humor& replace with sterile NS

Pneumatic retinopexy – air bubble to push retina in contact with choroid

• Postop, position pt’s head so detached retina in closer contact to choroid
• 90% success rate retinal reattachments

• Degeneration of Macula resulting in central vision loss; slow & bilateral
• Abnormal accumulation of waste in the retinal epithelium called Drusen (flecks in eye) - not curable

• 2 Types:Atrophic – dry type (slow progressive);
• TX. with antioxidant vitamins & visual aids - vits C, E, A, zinc, and copper slow progression

• Exudative – wet type (more aggressive);
• TX. with laser photocoagulation - fragile blood vessels destroyed to prevent bleeding

photodynamic therapy with verteporfin - light shined into eye to avtivate drug (destroys new blood vessels) -(avoid sunlight x 5 d)

• Tx - large-print books
• magnifiers
• lighting

• Loss of central vision
• Blurred vision
• Visual distortion/wavy lines
• Risk Factors –􀂄 Age > 65
• Smoking 2X
• Race: Caucasian
• Lack of antioxidants

• Conductive loss involves middle & external ear due to mechanical cause
• Cerumen impaction
• Unable to hear “muffled” tones, all freq.
• Rinne test bone>air conduction
• Weber test lateralizes sound to deaf ear
• Hearing aid helpful

• Sensorineural loss due to structural changes to inner ear or auditory nerve
• Presbycusis/hearing loss high pitched tones
• Difficulty filtering out background noise
• Rinne test air>bone conduction but < 2:1
• Weber test lateralizes sound to unaffected ear
• Hearing aid doesn’t help as increase background

• Prevention:
• -environmental noise control < 85 decibels
• -care and cleaning of ear canals
• -dont place objects in ears
• -use plugs during swimming or diving
• -avoid exposure to loud noise
• -monitor or SE of ototoxic medicaitons
• -hearing evaluation

• Graying of eyebrows & lashes with coarser hair
• Decrease elasticity of eyelid muscles with crow’s feet & pseudoptosis
• -Ectropion = lower lid droops away from globe
• -Entropion = lower lid turns inward
• Decrease corneal sensitivity/reflex
• Decrease pupil size & reactivity so less light
• Decrease tearing so dry eyes
• Presbyopia = loss of lens elasticity & near vision
• Decrease color perception esp. blue, violet &green
• Decrease depth perception leading to falls
• Senile enophthalmos/recessed eyeballs