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
• Periodic Recommended
Screening
• Prenatal
• Newborns through preschoolers
• Children of all ages
• Use age-appropriate visual acuity
test
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/bcs/clist/eye.html
Normal view – the retina should be a “red reflex”
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:
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cerumen
discharge
inflammation
foreign body in ear canal
• Visualize tympanic
membrane for :
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Color
landmarks
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 1366 in
text, guideline 39.1 for technique)
– 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
– Teach how to give antibiotic drops if needed
– Usually resolves by 1 year old
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
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Nursing management
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– S&S: redness, swelling, pain around eye
– 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
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
Measures to Prevent
Visual Impairment
• Prenatal care, prevention
of prematurity
• Rubella immunizations for
all children
• Safety counseling for
preventing eye injuries
• Defined as:
– 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
Causes
• Perinatal or postnatal infections:
– Gonorrhea, chlamydia, rubella, syphilis, toxoplasmosis
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Retinopathy of prematurity
Perinatal or postnatal trauma
Other disorders
Unknown causes
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
Visual Impairments
Astigmatism:
– unequal curvatures in refractive apparatus, usually
myopic
– Treated with special lenses or laser surgery
Strabismus
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Common, occurs in 4% of children
Most common types
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May affect visual development, cause diplopia
(double vision)
Infants may have intermittent strabismus
which resolves by 3 months
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– Exotropia – eyes turn outward
– Esotropia – eyes turn inward
Amblyopia:
– Reduced visual acuity in one eye, “Lazy eye”
– Treat primary vision defect such as strabismus
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
Corneal Light Reflex to Check Symmetry
• Child on left has
symmetrical reflection
of light
• These children with
strabismus reflects
light unevenly
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
Promoting Child’s Optimum Development
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Encourage independence
Consistency of team members
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
• About one million children each year
have tubes placed in their ears.
– Therapeutic management
– Nursing assessment
• Health history
• Physical examination and
diagnostic testing
Acute Otitis Media – note
erythema and opacity of
tympanic membrane
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.
Don’t prop infant with bottle.
– 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
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.
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.
Hearing Impairment
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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
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Causes
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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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
rubella, herpes, syphilis, bacterial meningitis
Cerebral palsy
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
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
Therapeutic Management
of Hearing Impairment
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Medical
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Surgical interventions
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Hearing aid
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Antibiotic therapy for otitis media
Tympanostomy tubes for chronic otitis media
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
Methods of Communication
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Lip-reading
Cued speech
Sign language
Speech language therapy
Socialization
Additional aids
Cochlear implant
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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
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
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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