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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 – – – – – – – – 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 • • • • 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 • • • • • 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 • • • • 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 • Nursing assessment – S&S: redness, swelling, pain around eye • Nursing management – – – – – 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 • • • • • Foreign body Chemicals Sunburns Hematoma Penetrating injuries Eye Injuries • Nursing assessment – Health history – Physical examination • 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. • 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 • • • • 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 • Astigmatism: – unequal curvatures in refractive apparatus, usually myopic – Treated with special lenses or laser surgery • Amblyopia: – Reduced visual acuity in one eye, “Lazy eye” – Treat primary vision defect such as strabismus • Strabismus – – – – “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 • 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. • • 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 • • • • • 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 • • • • 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) • • Infection and inflammation of external ear canal Bacterial or fungal • Nursing assessment – Health history – Physical examination • Ear red, edematous, itchy, painful, may affect hearing • Nursing management – – – – 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 • • • • • • 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: – • 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 • • • • • 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 • • • • 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 • • • • • • • 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: – – – – Picture board Common words and needs (food, water, toilet) Sign language (need an interpreter) Computer Deaf-Blind Children • • • • • Profound effects on development Motor milestones usually achieved Other development often delayed Finger spelling Developing future goals for the child End of Presentation