Download Nursing Care of the Child With a Disorder of the Eyes or Ears

Essentials of
Pediatric Nursing
Chapter 39: Nursing Care of the Child
With a Disorder of the Eyes or Ears
Variations in Pediatric Anatomy and Physiology
• Eyes
– Eye color determined by 6-12 months
– Eyeball occupies a larger space in orbit so more prone to injury
– Newborn’s lens can only accommodate 8-10 inches and color
discrimination incomplete
– Visual acuity improves with age, 20/20 by 6-7 years
– Rectus muscle uncoordinated at birth and matures over time.
Binocular vision (simultaneous focus by both eyes) achieved by 4
months
Nursing Process Overview
• Assessment
– Health history
– Physical examination
• Inspection and observation
• Palpation
• Laboratory and diagnostic testing
• Nursing diagnoses
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Disturbed sensory perception
Risk for infection
Pain
Delayed growth and development
Impaired verbal communication
Deficient knowledge
Interrupted family processes
Risk for injury
Inspecting the eye
• Note use of eyeglasses or lenses
• Observe positioning, symmetry, presence of strabismus, nystagmus
and squinting
• Eyelids should open fully (ptosis is lid not fully open); Look for edema
• Note eye slant, epicanthal folds
• Observe pupils and reactions, corneal light reflex, iris and sclera color
• Test for extraocular movement
• Invert eyelid to check conjunctive for redness
Assessment of Vision
• Infancy:
– Response to visual stimuli
– Parental observations and concerns
– Expect binocularity by age 6 months
• Childhood:
– Visual acuity testing
Opthalmoscopic Exam of Eye
• http://medinfo.ufl.edu/year1/b
cs/clist/eye.html
• Go to the above hyperlink (right
click, go to open hyperlink) for
instructions to complete the eye
exam
• Normal view – the retina should
be a “red reflex”
Periodic Recommended Screening
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Prenatal
Newborns through preschoolers
Children of all ages
Use age-appropriate visual acuity test
Visual Disorders
• Refractive errors
– Nursing assessment
– Nursing management
• Educating about eyeglasses use
• Educating about contact lens use
• Monitoring for fit and visual correction
Healthy People 2020: Goal to increase use of
protective equipment (eye goggles) when engaged in
potentially dangerous activities.
Ears
• Congenital deformities
usually associated with other
anomalies and genetic
syndromes
• Infants short, wide and
horizontally placed
Eustachian tube allows
bacteria and viruses to reach
middle ear more easily, so
more prone to ear infections
– As child matures, tubes more
slanted
• If adenoids enlarged may
lead to obstruction of
Eustachian tubes > infection
Inspect Ears Outside
• Note size, shape, position on head
• Look for skin tags, dimples or other anomalies
• Conduct hearing testing with infants and children
Otoscopic Examination of Ear
• Note presence of cerumen,
discharge, inflammation or
foreign body in ear canal
• Visualize tympanic
membrane for color,
landmarks, and light reflex.
Also for abnormalities like
perforation, bulging, scars
or retraction
Disorders of the Eyes
Conjunctivitis
• Inflamation of the bulbar or palpebral conjunctiva.
• In newborns: causes are chlamydia, gonorrhea, or herpes simplex
virus
• In infants: may be sign of tear duct obstruction
• In children: causes are bacterial (most common, also called “Pink
Eye”), viral, allergic, or foreign body
• Signs and Symptoms
– Purulent eye drainage, crusting
– Inflamed conjunctiva and swollen lids
Bacterial
Conjunctivitis
• Redness of conjunctiva
• Copious, discolored
drainage with matting
• Eyelid swelling
Allergic Conjunctivitis
• Caused by
perennial or
seasonal allergies
• Conjunctiva red
• Discharge clear,
watery
• Child rubs eyes
frequently
Therapeutic and Nursing Management
– Treatment depends on cause
• Viral is self-limiting, remove secretions
• Bacterial: Culture of eye drainage. Topical antibacterial agents like polymycin and
bacitracin, Sulamyd or Polytrim
• Drops during day and ointment at night
– Nursing Care
• Keep eyes clean with warm, moist cloth. Wipe from inner canthus down
and away from other eye. DON”T leave compress on eye.
• Instill eye medication after cleaning eye
– Medications:topical antibacterials to eye: Polysporin, Sulamyd or Polytrim
• Teach prevention of infection to child and family: discard tissues, wash
cloths separately, don’t rub eyes. GOOD HAND-WASHING
• Children don’t attend school until infection treated. CONTAGIOUS if
bacterial cause
• Teach parent to administer medications
– Caution with use of steroids—may exacerbate viral infections
Nasolacrimal Duct Obstruction
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Stenosis or simple obstruction of the nasolacrimal duct
Common in infancy: 5-20% population, usually resolves by 1 year old
Unilateral in 65% cases
Nursing assessment
– S&S: Tearing or discharge from one or both eyes by 2 weeks old
– Redness of lower lid of affected eye
– Culture may be done to rule out conjunctivitis
Nursing management
– Teach parents to clean eye area frequently with moist cloth
– *Massage nasolacrimal duct (see page 564 in text, guideline 17.1 for
technique)
– Teach how to give antibiotic drops if needed
– Usually resolves by 1 year old
Nasolacrimal Duct Massage
• Teach procedure to parents:
– Using the forefinger or little finger, push on the
top of the bone (the puncta must be blocked)
– Gently push in and up
– Gently push downward along the side of the nose
Periorbital Cellulitis
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Bacterial infection of eyelids or surrounding tissue of eye
Enters through break in skin, sinusitis, conjunctivitis
Most common bacteria: Staph. aureus, Strep. pyogenes, Strep
pneumoniae
Initiate inflammatory response
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Nursing assessment
– S&S: redness, swelling, pain around eye
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Nursing management
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Warm soaks to eye area 20 minutes every 2-4 hours
Teach family to complete full course of antibiotics at home
Teach parents to call PCP if eye doesn’t improve
May require hospitalization for IV antibiotics
Manage pain with analgesics
Emergency Treatment
for Eye Injuries
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Foreign body
Chemicals
Sunburns
Hematoma
Penetrating injuries
Eye Injuries
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Nursing assessment
– Health history
– Physical examination
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Nursing management
– Managing non-emergent eye injuries
• Suture lacerations
• Child may need sedation and pain med
– Assist physician with examination
– Edema and black eye treated with ice pack on 20 minutes, off 20
minutes. Repeat cycle. May take 3 weeks to resolve
– Scleral hemorrhages will resolve without intervention
– Corneal abrasions treated with topical antibiotic and analgesics
– Remove foreign objects from eye using eyelid eversion. Irrigating with
normal saline may help.
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Serious foreign body will need opthamologist to remove
– Chemical injuries require immediate irrigation with copious amounts of
water
– Visit to opthamologist advised
– Teach PREVENTION
Eversion of lid for examination
Measures to Prevent
Visual Impairment
• Prenatal care,
prevention of
prematurity
• Rubella immunizations
for all children
• Safety counseling for
preventing eye injuries
Visual Impairment
• General term that refers to visual loss that
cannot be corrected with regular prescription
lenses
Visual Impairment Classification
• Partially sighted:
– Acuity of 20/70-20/200
– Education usually in public school system
• Legal blindness:
– Acuity of 20/200 or less
– Legal as well as medical term
Etiology of Visual Impairments
• Perinatal or postnatal infections:
– Gonorrhea, chlamydia, rubella, syphilis,
toxoplasmosis
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Retinopathy of prematurity
Perinatal or postnatal trauma
Other disorders
Unknown causes
Strabismus
• Common, occurs in 4% of
children
• Most common types
– Exotropia – eyes turn outward
– Esotropia – eyes turn inward
• May affect visual development,
cause diplopia (double vision)
• Infants may have intermittent
strabismus which resolves by 3
months
Corneal Light Reflex to Check Symmetry
• Child on left has
symmetrical reflection
of light
• This child with
strabismus reflects
light unevenly
Other Visual Impairments
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Astigmatism:
– unequal curvatures in refractive apparatus,
usually myopic
– Treated with special lenses or laser surgery
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Amblyopia:
– Reduced visual acuity in one eye, “Lazy eye”
– Treat primary vision defect such as strabismus
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Strabismus
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“Squint” or cross-eye
Esotropia – inward deviation of eye
Exotropia – outward deviation of eye
Treatment depends on cause, may involve
patching stronger eye (occlusion therapy) or
surgery
– Early diagnosis essential to prevent vision loss
from amblyopia
Nursing Management of Child with Visual
Impairments
• Be alert to clinical
manifestations:
– Eye rubbing, headaches,
dizziness, clumsiness, frequent
blinking
– Difficulty reading or doing close
work, poor school performance
• Perform vision screening or
advise parent to bring child
for eye exam with
opthamologist
• Encourage child to wear
corrective lenses
• Treatment may include laser
surgery or eye surgery
Hospitalization of the Visually
Impaired Child
• Work closely with the family
• Safe environment
• Reassurance
– Introduce yourself BEFORE touching child
• Orient child to surroundings
– Keep items and furniture in the same place
• Encourage independence
• Consistency of team members
Promoting Child’s Optimum
Development
• Play and socialization
• Development of independence
• Education:
– Braille
– Audio books and learning materials
Disorders of the Ears
Otitis Media
• Acute otitis media (AOM)
– Pathophysiology : Bacterial or viral infection of
fluid in middle ear
– Peak incidence: 0-2 years, especially 6-12 months
– Therapeutic management
– Nursing assessment
• Health history
• Physical examination and diagnostic testing
Acute Otitis Media – note erythema and opacity
of tympanic membrane
Prevention of Hearing Loss
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Treatment and management of recurrent otitis media
– A common cause of conductive/middle-ear hearing loss
– Medical tx:
• Wait and see
• Antibiotics
– Surgical treatment
• Tympanostomy: placement of ear tubes
• for children less than about 5-6 years old, we allow bathing, hair washing,
surface swimming, or ocean exposure...without any precautions. Diving
deeper under water, or swimming in (dirtier) lakes and rivers is more likely to
cause infections. In those cases, the preventitive use of certain antibiotic ear
drops (such as Floxin Otic) may help. Your ear doctor may be adamant about
keeping your infant's ears dry...
ENT docs like to see their tube patients every 3-6 months, or until the ears
are normal.
• Adenoidectomy, with just myringotomies (making an incision, no tubes) may
be appropriate in certain children...as might a laser myringotomy.
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Prenatal preventive measures
Avoid exposure to noise pollution
Otitis Media
• Acute otitis media (AOM) (cont’d)
– Nursing management
• Managing pain associated with AOM
– Analgesics like acetaminophen or ibuprofen
– Narcotic analgesics like codeine for severe
pain
– Heat or cool compress: have child lay
affected ear on compress
– Numbing eardrops like benzocaine
(Auralgan)
• Educating the family
– Observe for S&S and call PCP
– Teach completion of antibiotics if ordered –
VERY IMPORTANT!
– Follow-up to check progress, test hearing
• Preventing AOM
– Encourage breastfeeding 6-12 months
– Avoid exposing child to individuals with
upper respiratory infections
– DON’T EXPOSE TO SECOND HAND SMOKE
– Immunize child, including flu vaccines
– Xylitol, a sucrose substitute, taken in liquid
or gum form, may prevent AOM
Otitis Media
• Otitis media with effusion (OME)
– Presence of fluid in middle ear space without S&S of infection
– Nursing assessment
• Health history
– Risk Factors: passive smoking, not breastfed, frequent upper respiratory infections,
allergy, young age, male, congenital disorders
• Physical examination
– May be asymptomatic or experience popping or fullness behind eardrum
– Otoscopic exam may reveal dull, opaque tympanic membrane that’s gray, white or
bluish. Tympanometry may diagnose OME
– Nursing management
• Educating the family
– Antihistamines, antibiotics and steroids usually don’t work
– Teach NOT to prop infant with bottle
• Monitoring for hearing loss and speech development
• Providing postoperative care for the child with pressure-equalizing tubes
– Tubes inserted and remain a few months
– May need to avoid water in ears, wear earplugs with baths and swimming
Otitis Media with Effusion
Myringotomy (Ear Tubes)
• Small tubes(made of plastic,
metal, or Teflon) that are
surgically placed into child's
eardrum by an ear, nose, and
throat surgeon. The tubes help
drain the fluid out of the middle
ear in order to reduce the risk of
ear infections.
• About one million children each
year have tubes placed in their
ears.
• The most common ages are from
1 to 3 years old.
• By the age of 5 years, most
children have wider and longer
eustachian tubes
Myringotomy – Pre and Post-Op Nursing Care *
• Prepare child and parent for surgery: Assessment, VS
• The operation usually takes 15 to 20 minutes.
• Child will go home 2-4 hours after surgery.
• Post-Op Care and Teaching
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Normal to have fluid 3-4 days, grey/brown and slight smell. Fluid may leak from your child’s ear
The tubes will stay in your child’s ears for several months
Do not put anything into your child’s ear
May have a bath. Ear plugs may or may not be recommended by surgeon. Consult surgeon about
other water activities like swimming.
Medicines
– Antibiotic ear drops: may or may not order antibiotic ear drops. Show parent how to put the
antibiotic ear drops in child’s ear.
– Pain medicine: Acetaminophen or Ibuprofen
May return to day care or school the day after leaving the hospital, if your child is feeling well.
First visit is normally 7-10 days after surgery, then every 2-4 months
REASONS TO CALL SURGEON
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Ears leak fluid for more than 4 days after the operation.
Your child has a fever over 38.5°C (101°F).
Your child’s ears start to leak fluid again after they have stopped leaking, or the color of the
drainage changes to thick greenish pus with a strong smell.
Your child’s ears become sore.
Otitis Externa (Swimmer’s ear)
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Infection and inflammation of
external ear canal
Bacterial or fungal
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Nursing assessment
– Health history
– Physical examination
• Ear red, edematous, itchy,
painful, may affect hearing
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Nursing management
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Managing pain
Treating the infection
Preventing reinfection
Recent studies recommend
leaving ear wax in place as
protection.
Hearing Impairment
• Ranges from mild to profound
• Deaf: a person whose hearing disability precludes
processing linguistic information with or without hearing
aid
• Hard of hearing: generally able to hear with hearing aid
• Incidence
– One of the most common disabilities
– Estimated 3 in 1000 well babies have some degree of hearing
loss
– Neonates in ICU: 2-4 per 100
– In US about 1 million children from birth to 21 years have
hearing loss
– 1/3 of these children have other sensory or cognitive problems
Pathology
of Hearing Impairments
• Conductive hearing loss—middle ear
• Sensori-neural hearing loss—nerve
deafness
• Mixed conductive-sensorineural loss—may
follow recurrent otitis media with
complications
• Central auditory interception:
– Organic: defect involves reception of auditory stimuli along
central pathways and expression of message (aphasia)
– Functional: no organic lesion exists to explain central
auditory loss(conversion hysteria, infantile autism, childhood
schizophrenia)
Nursing Care of Child with
Hearing Loss and Deafness
• Nursing assessment
– Health history
– Physical examination and laboratory and
diagnostic tests
• Nursing management
– Augmenting hearing
– Promoting communication and education
– Encouraging education
– Providing support
Causes of Hearing Impairments
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Anatomic malformation
Low birth weight
Ototoxic drugs: http://www.nvrc.org/wp-content/uploads/Drugs-that-Cause-HL.pdf
Include: aspirin, lasix, vancomycin, gentamycin, vicodin, many psych and antineoplastic
drugs
Chronic ear infections
Perinatal asphyxia
Perinatal infections:
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rubella, herpes, syphilis, bacterial meningitis
Cerebral palsy
Hearing Testing
• Measured in decibels (dB)
– A unit of loudness
– Measured at various frequencies
– Speech range is 2000 cycles/sec
• Hearing threshold
– Measurement of a person’s hearing threshold with audiometer
– Degree of symptom severity as it affects speech
Manifestations of Hearing Impairment
in Infancy
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Lack of startle reflex
Absence of babbling by age 7 months
General indifference to sound
Lack of response to spoken word
EARLY DETECTION, best within 3-6months,
essential to improve language and educational
outcomes
Therapeutic Management
of Hearing Impairment
• Medical
– Antibiotic therapy for otitis media
• Surgical interventions
– Tympanostomy tubes for chronic otitis media
• Hearing aid
– Learn how to use hearing aid
– Teach child to manage when old enough
– Managing acoustic feedback
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Reinsert aid
Check for hair
Clean ear mold or ear
Lower volume
• Cochlear implants:ay help children with sensorineural hearing loss
Hearing Aids
FIG. 19-7 On-the-body hearing aids are convenient for
young children, such as this child with severe bilateral
hearing loss. Note eye patching for strabismus.
Deafness and Promoting
Communication
• Profound deafness likely to be diagnosed in infancy
• Concerns with speech development
– One reason number of words and speech assessed at PCP’s visit
Methods of Communication
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Lip-reading
Cued speech
Sign language
Speech language therapy
Socialization
Additional aids
Cochlear implant
– A cochlear implant is a small, complex electronic device that can help to provide a sense of
sound to a person who is profoundly deaf or severely hard-of-hearing. The implant consists of
an external portion that sits behind the ear and a second portion that is surgically placed
under the skin
Diagram of Cochlear Implant
Care for Hearing Impaired Child During
Hospitalization
• Reassess understanding of instructions given
• Supplement with visual and tactile media
• Communication devices:
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Picture board
Common words and needs (food, water, toilet)
Sign language (need an interpreter)
Computer
Deaf-Blind Children
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Profound effects on development
Motor milestones usually achieved
Other development often delayed
Finger spelling
Developing future goals for the child
End of Presentation