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OPHTHALMIC AND OTIC MEDICATIONS From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B. Saunders. From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B. Saunders. PYRAMID POINTS • Actions, side effects, contraindications, and nursing considerations when administering eye and ear medications • Procedure for administering eye and ear drops • Procedure for irrigation of an ear • Client education regarding prescribed medications ADMINISTERING OPHTHALMIC MEDICATIONS • Place prescribed dose of eye medication in the lower conjunctival sac, never directly onto the cornea • Avoid touching any part of the eye with the dropper or applicator • Administer drops or liquid preparations before ointments • Administer glucocorticoid preparations before other medications • When two or more eye medications are to be administered, wait at least 3 minutes between medications ADMINISTERING OPHTHALMIC MEDICATIONS • To prevent overflow of medication into the nasal and pharyngeal passages, thus reducing systemic absorption, occlude the nasolacrimal duct with one finger for 1 to 2 minutes after instilling the medication • Monitor the pulse of the client receiving an ophthalmic beta-blocker and instruct the client to do the same; if the pulse is below 50 to 60 beats per minute (adult), withhold the next dose of eye medication and notify the physician ADMINISTERING OPHTHALMIC MEDICATIONS • CLIENT INSTRUCTIONS – How to instill medication correctly; supervise instillation until the client can do it safely – Avoid driving or operating hazardous equipment if vision is blurred – Wear sunglasses and avoid bright lights if photophobia occurs – Administer a missed dose of the eye medication as soon as remembered, unless the next dose is scheduled to be administered in 1 to 2 hours ADMINISTERING OPHTHALMIC MEDICATIONS • CLIENT INSTRUCTIONS – Report the development of any eye irritation – Inform the client using eye gel to store the gel at room temperature or in the refrigerator but not to freeze it; discard unused eye gel kept at room temperature after 8 weeks ADMINISTERING OPHTHALMIC MEDICATIONS • CLIENT INSTRUCTIONS – Soft contact lenses may absorb certain eye medications and that preservatives in eye medications may discolor the contact lenses – In infants, inform the parents that atropine sulfate eye drops may contribute to abdominal distention; the parents should keep a record of the bowel movements of the infant MYDRIATIC, CYCLOPLEGIC, AND ANTICHOLINERGIC MEDICATIONS • DESCRIPTION – Mydriatics and cycloplegics dilate the pupils (mydriasis) and relax the ciliary muscles (cycloplegia) – Anticholinergics block responses of the sphincter muscle in the ciliary body, producing mydriasis and cycloplegia – Used preoperatively or for eye examinations to produce mydriasis MYDRIATIC, CYCLOPLEGIC, AND ANTICHOLINERGIC MEDICATIONS • DESCRIPTION – Contraindicated in clients with glaucoma because of the risk of increased intraocular pressure – Mydriatics are contraindicated in cardiac dysrhythmias and cerebral atherosclerosis and should be used with caution in the elderly and in clients with prostatic hypertrophy, diabetes mellitus, or parkinsonism MYDRIATIC, CYCLOPLEGIC, AND ANTICHOLINERGIC MEDICATIONS • SIDE EFFECTS – Tachycardia – Photophobia – Conjunctivitis – Dermatitis MYDRIATIC, CYCLOPLEGIC, AND ANTICHOLINERGIC MEDICATIONS • ATROPINE TOXICITY – Dry mouth – Blurred vision – Photophobia – Tachycardia – Fever – Urinary retention – Constipation – Headache, brow pain MYDRIATIC, CYCLOPLEGIC, AND ANTICHOLINERGIC MEDICATIONS • SYSTEMIC REACTIONS OF ANTICHOLINERGICS – Dry mouth and skin – Fever – Thirst – Confusion – Hyperactivity MYDRIATIC, CYCLOPLEGIC AND ANTICHOLINERGIC MEDICATIONS • IMPLEMENTATION – Monitor for allergic response – Assess for risk of injury – Assess for constipation and urinary retention – Instruct the client that a burning sensation may occur on instillation MYDRIATIC, CYCLOPLEGIC, AND ANTICHOLINERGIC MEDICATIONS • IMPLEMENTATION – Instruct the client not to drive or operate machinery for 24 hours after instillation of the medication unless otherwise directed by the physician – Instruct the client to wear sunglasses until the effects of the medication wear off – Instruct the client to notify the physician if blurring of vision, loss of sight, difficulty breathing, sweating, or flushing occurs – Instruct the client to report eye pain to the physician ANTIINFECTIVE EYE MEDICATIONS • DESCRIPTION – Kill or inhibit the growth of bacteria, fungi, and viruses • SIDE EFFECTS – Superinfection – Global irritation ANTIINFLAMMATORY EYE MEDICATIONS • DESCRIPTION – Control inflammation, thereby reducing vision loss and scarring – Used for uveitis, allergic conditions, and inflammation of the conjunctiva, cornea, and lids • SIDE EFFECTS – Cataracts – Increased intraocular pressure – Impaired healing – Mask the signs and symptoms of infection ANTIINFECTIVE AND ANTIINFLAMMATORY EYE MEDICATIONS • IMPLEMENTATION – Assess for risk of injury – Instruct the client how to apply the eye medication – Instruct the client to continue treatment as prescribed – Instruct the client to wash hands thoroughly and frequently – Advise the client to notify the physician if improvement does not occur TOPICAL ANESTHETICS • DESCRIPTION – Produce corneal anesthesia – Used for anesthesia for eye examinations, surgery, or to remove foreign bodies from the eye • SIDE EFFECTS – Temporary stinging or burning of the eye – Temporary loss of corneal reflex TOPICAL ANESTHETICS • IMPLEMENTATION – Assess for risk of injury – Note that the medications should not be given to the client for home use and are not to be self-administered by the client – Note that the blink reflex is temporarily lost and that the corneal epithelium needs to be protected – Provide an eye patch to protect the eye from injury until the corneal reflex returns EYE LUBRICANTS • DESCRIPTION – Replace tears or add moisture to the eyes – Moisten contact lenses or an artificial eye – Protect the eyes during surgery or diagnostic procedures – Used for keratitis, during anesthesia, or in a disorder that results in unconsciousness or decreased blinking EYE LUBRICANTS • SIDE EFFECTS – Burning on instillation – Discomfort or pain on instillation • IMPLEMENTATION – Inform the client that burning may occur on instillation – Be alert to allergic responses to the preservatives in the lubricants MIOTICS • DESCRIPTION – Reduce intraocular pressure – Used for chronic open-angle glaucoma or acute and chronic closed-angle glaucoma – Used to achieve miosis during eye surgery – Contraindicated in clients with retinal detachment, adhesions between the iris and lens, or in inflammatory diseases MIOTICS • SIDE EFFECTS – Myopia – Headache – Eye pain – Decreased vision in poor light – Local irritation MIOTICS • SYSTEMIC EFFECTS – Flushing – Diaphoresis – GI upset and diarrhea – Frequent urination – Increased salivation – Muscle weakness – Respiratory difficulty MIOTICS • TOXICITY – Vertigo and syncope – Bradycardia – Hypotension – Cardiac dysrhythmias – Tremors – Seizures MIOTICS • IMPLEMENTATION – Assess vital signs – Assess for risk of injury – Assess the client for the degree of diminished vision – Monitor for side effects and toxic effects – Monitor for postural hypotension and instruct the client to change positions slowly MIOTICS • IMPLEMENTATION – Assess breath sounds for rales and rhonchi because miotic cholinergic medications can cause bronchospasms and increased bronchial secretions – Maintain oral hygiene because of the increase in salivation – Have atropine sulfate available as an antidote for pilocarpine – Instruct the client or family regarding the correct administration of eye medications MIOTICS • IMPLEMENTATION – Instruct the client not to stop the medication suddenly – Instruct the client to avoid activities such as driving while vision is impaired – Instruct clients with glaucoma to read labels on over-the-counter medications and to avoid atropine-like medications because atropine will increase intraocular pressure OCUSERT SYSTEM • DESCRIPTION – Ocusert is a thin eye wafer (disk) impregnated with time-release pilocarpine – It is placed in the upper or lower cul-de-sac of the eye – The pilocarpine is released over 1 week – The disk is replaced every 7 days – Drawbacks of its use include sudden leakage of pilocarpine, migration of the system over the cornea, and unnoticed loss of the system OCUSERT SYSTEM From Jeglleon El. Ocular Therapeutics. Nursing Clinic of North America 16 (3): 456, 1981. OCUSERT SYSTEM • IMPLEMENTATION – Assess the client’s ability to insert the medication disk – Store the medication in the refrigerator – Instruct the client to discard damaged or contaminated disks OCUSERT SYSTEM • IMPLEMENTATION – Inform the client that temporary stinging is expected but to notify the physician if blurred vision or brow pain occurs – Instruct the client to check for the presence of the disk in the conjunctival sac daily at bedtime and upon arising – Since vision may change in the first few hours after the eye system is inserted, instruct the client to replace the disk at bedtime BETA-ADRENERGIC BLOCKING EYE MEDICATIONS • DESCRIPTION – Reduce intraocular pressure – Used to treat chronic open-angle glaucoma – Contraindicated in the client with asthma because systemic absorption can cause increased airway resistance – Used with caution in the client receiving oral beta-blockers BETA-ADRENERGIC BLOCKING EYE MEDICATIONS • SIDE EFFECTS – Ocular irritation – Visual disturbances – Bradycardia – Hypotension – Bronchospasm BETA-ADRENERGIC BLOCKING EYE MEDICATIONS • IMPLEMENTATION – Monitor vital signs, especially blood pressure and pulse before administering medication – If the pulse is 60 or below or if the systolic blood pressure is below 90 mm Hg (adult), withhold the medication and contact the physician – Monitor for shortness of breath – Assess for risk of injury BETA-ADRENERGIC BLOCKING EYE MEDICATIONS • IMPLEMENTATION – Monitor I&O – Instruct the client to notify the physician if shortness of breath occurs – Instruct the client not to discontinue the medication abruptly – Instruct the client to change positions slowly to avoid orthostatic hypotension – Instruct the client to avoid hazardous activities – Instruct the client to avoid over-the-counter medications without the physician’s approval CARBONIC ANHYDRASE INHIBITORS • DESCRIPTION – Interfere with the production of carbonic acid, which leads to decreased aqueous humor formation and decreased intraocular pressure – Used for long-term treatment of open-angle glaucoma – Contraindicated in the client allergic to sulfonamides CARBONIC ANHYDRASE INHIBITORS • SIDE EFFECTS – Appetite loss and gastrointestinal upset – Paresthesias in the fingers, toes, and face – Polyuria – Hypokalemia – Renal calculi – Photosensitivity – Lethargy and drowsiness – Depression CARBONIC ANHYDRASE INHIBITORS • IMPLEMENTATION – Monitor vital signs – Assess visual acuity and the risk of injury – Monitor I&O and weight – Maintain oral hygiene and increase fluid intake unless contraindicated – Monitor electrolytes for hypokalemia CARBONIC ANHYDRASE INHIBITORS • IMPLEMENTATION – Advise the client to avoid prolonged exposure to sunlight – Encourage the use of artificial tears for dry eyes – Instruct the client not to discontinue the medication abruptly – Instruct the client to avoid hazardous activities while vision is impaired OSMOTIC MEDICATIONS • DESCRIPTION – Lower intraocular pressure – Used in emergency treatment of acute closedangle glaucoma – Used preoperatively and postoperatively to decrease vitreous humor volume OSMOTIC MEDICATIONS • SIDE EFFECTS – Headache – Nausea, vomiting, diarrhea – Disorientation – Electrolyte imbalances OSMOTIC MEDICATIONS • IMPLEMENTATION – Assess vital signs – Assess visual acuity and the risk of injury – Monitor I&O and weight – Monitor for electrolyte imbalances – Increase fluid intake unless contraindicated – Monitor for changes in level of orientation OTIC MEDICATION ADMINISTRATION • ADMINISTERING DROPS – In an adult, pull the pinna up and back to straighten the external canal to instill ear drops – Pull the pinna down and back for infants and children younger than 3 years of age; up and back for older children OTIC MEDICATION ADMINISTRATION • IRRIGATION OF THE EAR – Irrigation of the ear needs to be prescribed by the physician – Ensure that there is direct visualization of the tympanic membrane – Warm irrigating solution to 100° F because solutions that are not close to the client’s body temperature will cause ear injury, nausea, and vertigo OTIC MEDICATION ADMINISTRATION • IRRIGATION OF THE EAR – Irrigation must be done gently to avoid damage to the eardrum – When irrigating, do not direct irrigation solution directly toward the eardrum – If a perforation of the eardrum is suspected, irrigation is not done ANTIINFECTIVE EAR MEDICATIONS • DESCRIPTION – Kill or inhibit the growth of bacteria – Used for otitis media or otitis externa – Contraindicated if a prior hypersensitivity exists • SIDE EFFECT – Overgrowth of nonsusceptible organisms ANTIINFECTIVE EAR MEDICATIONS • IMPLEMENTATION – Monitor vital signs – Assess for allergies – Assess for ear pain – Monitor for nephrotoxicity – Instruct the client to report dizziness, fatigue, fever, or sore throat, which may be indicative of a superimposed infection – Instruct the client to complete the entire course of the medication – Instruct the client to keep ear canals dry ANTIHISTAMINES AND DECONGESTANTS • DESCRIPTION – Produce vasoconstriction – Stimulate the receptors of the respiratory mucosa – Reduce respiratory tissue hyperemia and edema to open obstructed eustachian tubes – Used for acute otitis media ANTIHISTAMINES AND DECONGESTANTS • SIDE EFFECTS – Drowsiness – Blurred vision – Dry mucous membranes ANTIHISTAMINES AND DECONGESTANTS • IMPLEMENTATION – Inform the client that drowsiness, blurred vision, and a dry mouth may occur – Instruct the client to increase fluid intake unless contraindicated and to suck on hard candy to alleviate a dry mouth – Instruct the client to avoid hazardous activities if drowsiness occurs LOCAL EAR ANESTHETICS • DESCRIPTION – Block nerve conduction at or near the application site to control pain – Used for pain associated with ear infections • SIDE EFFECTS – Allergic reaction – Irritation • IMPLEMENTATION – Monitor for effectiveness if used for pain relief – Assess for irritation or allergic reaction CERUMINOLYTIC MEDICATIONS • DESCRIPTION – Emulsify and loosen cerumen deposits – Used to loosen and remove impacted wax from the ear canal • SIDE EFFECTS – Irritation – Redness or swelling of the ear canal CERUMINOLYTIC MEDICATIONS • IMPLEMENTATION – Instruct the client not to use drops more often than prescribed – Moisten a cotton plug with medication before insertion – Keep the container tightly closed and away from moisture – Avoid touching the ear with the dropper CERUMINOLYTIC MEDICATIONS • IMPLEMENTATION – Thirty minutes after instillation, gently irrigate the ear as prescribed with warm water using a soft rubber bulb ear syringe – Irrigation may be done with hydrogen peroxide solution as prescribed, to flush cerumen deposits out of the ear canal – For a chronic cerumen impaction, 1 to 2 drops of mineral oil will soften the wax – Instruct the client to notify physician if redness, pain, or swelling persists