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Assessment • Health History – Past health history – Medications (past, present, OTC, herbs) – Surgeries – Inspection Physical Examination • Eye – Symmetry, color, pupil size – PERRLA (pupils equally round and reactive to light accommodation) – Lacrimal apparatus nontender – Visual acuity 20/20 OU ; no diplopia (double vision) – Conjunctiva clear; sclera white – EOMI (extraocular movements intact) – Disc margins sharp – Retinal vessels normal; no hemorrhages, spots, or patches – Note whether eyelids meet completely Physical Examination – Palpation • Check the eyelids for nodules • Palpate the eye by gently pushing into the orbit without discomfort Diagnostic Studies • Visual Acuity Test – Snellen Chart at 20 feet (distance vision) – Jaeger’s Chart 14 inches ( near vision) – See previous Neuro assessment – NOTE: legal blindness is if the BEST visual acuity with corrective lenses in the better eye is 20/200 or less or visual field of 20 degrees or less in the better eye • Six Cardinal Positions of Gaze – See previous Neuro assessment • Confrontational Visual Field Test – See previous Neuro assessment Diagnostic Studies • Pupil Function Test – See Neuro assessment • Tonometry – Measures intraocular pressure • Instill anesthetizing opthalmic drops prior to applying tonometer • Apply tonometer to the corneal surface for pressure reading • Document intraocular pressure • Normal intraocular pressure is 10-21mmHg Diagnostic Studies • Slit Lamp Microscopy – Slit beam magnifies the ocular structures for examination – The slit-lamp inspection of the iris is done to assess whether the anterior angle of the eye is open or closed. – Instruct the client to place chin in chin rest – Instruct that powerful bright magnifier – Document data from the magnification assessment Diagnostic Studies • Ophthalmoscope – Provides a magnified view of the retina and optic nerve with the use of a light – Dilating eyedrops are contraindicated in head injury, coma, and narrow angle glaucoma – Instill mydriatic (dilating) drops into both eyes if not contraindicated – Glasses should be removed unless there is a marked nearsightedness or severe astigmatism – Darken room, turn on ophthalmoscope and adjust beam Diagnostic Studies • Color Vision Test – Determines the client’s ability to distinguish colors – Ask client to identify numbers or objects formed by a pattern of dots in series of color plates – Document the exam findings on the client’s color discrimination – Review previous exam for comparison Diagnostic Studies • Stereopsis – Evaluates the client’s ability to see objects in 3 dimensions – Examines depth perception – Instruct client to identify geometric patterns or figures that appear closer when viewed through special spectacles that provide a 3- dimentional view – Document client’s depth perception – Review the previous exam for comparison Diagnostic Studies • Keratometry – Measures the curvature of the cornea – Often done prior to fitting contact lenses, refractive surgery, or after corneal transplant – Instruct the client on the reason for testing the corneal curvature – Inform the client on the findings and how that may impact the reason for the test Cataract • Opacity within the crystalline lens • Cloudy appearance in the affected eye developing gradually • Decreased vision, abnormal color perception and glare that is worse at night when the pupil dilates Cataract • Diagnostic tests – Visual acuity test – Ophthalmoscopy – Slit lamp Cataract • Surgical Management – Considered an elective procedure – Lens removal – Implantation of intraocular lens Cataract • Nursing Interventions – Instruct client that topical drugs before surgery can produce stinging and burning – Postoperatively the client will not have depth perception until patch removal – May need special assistance until vision improves – Client and family need instructions for eye techniques to prevent infection – Postoperative instructions to avoid bending, sneezing, and coughing Cataract • Medical Management – Nonsurgical • • • • Change prescription of glasses Use magnifiers Increasing lighting Administer topical drugs for pupil dilation –Cycloplegics / Mydriatics • • • • • • • • • Red=Dilation (Mydriatics & Cycloplegics) Yellow= Beta Blockers Orange= Carbonic Anhydrase Inhibitors Dark Green= Miotics Tan= Anti-Infectives Pink= Anti-Inflammatory (Steroids) Gray= Non-steroidal Anti-inflammatory (NSAIDS) Purple= Adrenergic Agonists Dark Blue- Beta Blocker Combinations Typical Eye Medications that Dilate Pupils • Mydriatics – dilate the pupils • Cycloplegics – relax ciliary muscles • Anticholinergics – block responses of the sphincter muscle in the ciliary body » Tropicamide (Mydriacacyl, Tropicacyl) » Scopolamine (Isopto Hyoscine) » Atropine (Atropisol, Atropair) » Contraindicated if glaucoma Mydriatics and Cycloplegics • Used preoperatively or for eye examinations to produce mydriasis • Contraindicated in patients 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 patients with prostatic hypertrophy, diabetes mellitis or parkinsonism Mydriatics and Cycloplegics • Dilate the pupils (mydriasis) • Relax 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 • Contraindicated in patients 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 patients with prostatic hypertrophy, diabetes mellitis or parkinsonism Mydriatics and Cycloplegics • Side Effects – Tachycardia – Photophobia – Conjunctivitis – Dermatitis Mydriatics and Cycloplegics Atropine toxicity – – – – – – – Dry mouth Blurred vision Photophobia Tachycardia Fever Urinary retention Constipation – – – – – – Headache, brow pain Confusion Hallucinations Delirium Coma Worsening of narrow-angle glaucoma Mydriatics and Cycloplegics • Systemic reactions of anticholinergics – Dry mouth and skin – Fever – Thirst – Confusion – hyperactivity Mydriatics and Cycloplegics • Nursing Implementation – – – – – Monitor for allergic response Assess for risk of injury Assess for constipation and urinary retention Instruct that a burning sensation may occur on instillation Instruct not to drive or operate machinery for 24 hours after instillation of the med unless otherwise directed by MD – Instruct to wear sunglasses until med wears off – Instruct to notify MD if blurring, loss of sight, difficulty in breathing, sweating, or flushing occurs – Instruct to report eye pain to MD • Alpha-adrenergic blocker – Med: dapiprazole hydrochloride (Rev-Eyes) – Use: to counteract mydriasis Retinal Detachment • A tear, or hole in the retina, that separates it from its blood supply, resulting in blindness • This is an emergency situation!!!!! • Assessment – Light flashes, photophobia – Ring in the field of vision – Described as like a “curtain being drawn” Retinal Detachment • Diagnostic Tests – Visual acuity – Slit lamp – Ophthalmoscopy Retinal Detachment • Surgical Management – Photocoagulation – Cryoretinopexy – Scleral buckling procedure – Vitrectomy – Intravitreal bubble Retinal Detachment • Nursing Interventions – Prepare the client for surgery – Administer antibiotics and corticosteroids as ordered – Administer analgesia as needed – Instruct client to avoid positioning and activity that could increase intraocular pressure, such as lifting and bending – Protect eye with glasses or an eye shield – Administer and educate client about topical ophthalmic drugs Macular Degeneration • Degenerative process of the retina and macula resulting in the loss of central vision • Most common in adults over 52 years of age • Assessment – Appearance of drusen (yellowish exudate) in the fundus – Blurred vision – Presence of scotomas (shimmering island in the field of vision) Macular Degeneration • Diagnostic Tests – Visual acuity test – Ophthalmoscopy • Nursing Interventions – – – – – Provide emotional support and direct services as needed Engage in active listening and grief work facilitation Identify successful coping strategies; involve the family Discuss environmental concerns to promote safety Inform client on devices that may provide some vision enhancement Glaucoma • Increased intraocular pressure (IOP) with peripheral vision filed loss and optic nerve atrophy – The third leading cause of blindness • When the rate of production of aqueous fluid is greater than the outflow, IOP can rise above normal limits • If IOP remains elevated, permanent visual damage may begin Glaucoma Pathophysiology • As the cells making up the nerve die, due at least in part to a pressure inside the eye that is too great for that particular eye to tolerate, they die and disappear. • When sufficient numbers of these cells are gone, they leave behind a small crater or "cup" in the nerve. • A portion of the nerve then appears to have been "scooped out." So one important thing doctors look for when they examine the optic nerve is the presence and extent of the "cup," how deep and wide it is. Glaucoma • Two Types – Primary open-angle glaucoma (POAG) – Primary closed-angle glaucoma )PACG) • Assessment – Primary open-angle glaucoma (90%) develops slowly without clinical manifestations but gradually notices a gradual loss of peripheral vision and may be described as “tunnel vision” – Closed angle glaucoma (10%) has sudden severe pain in and around the eye, Nausea and vomiting, and “colored halos around lights” Glaucoma • Diagnostic tests – Slit lamp – Tonometry – Visual field test – Ophthalmoscopic exam Glaucoma • Nursing interventions – Instruct client regarding the type of glaucoma and treatment plan – Emphasize the importance of monitoring vision – Instruct client regarding the daily use, timing, and purpose of eyedrop administration – Darken the environment – Apply cool compresses to the forehead – Provide quiet space – If surgery is performed, instruct the client to avoid sudden head movements, coughing, and bending down because these can increase IOP; wear an eye shield at night to protect the operative eye; take the stool softeners and increase fluids to avoid straining at stool Glaucoma • Medical Management – Acute angle-closure glaucoma • Cholinergic and hyperosmotic topical agents • Laser peripheral iridotomy (new opening in the iris) • Surgical iridotomy (new opening in the iris) – Chronic open-angle glaucoma • Drug therapy such as beta-blockers, adrenergic antagonists and miotics Glaucoma • Surgical Management – Argon laser trabeculoplasty (open outflow of fluid channel) – Trabeculectomy, with or without filtering implant (removal of a portion of the iris) – Cryotherapy destruction of ciliary body (decreases production of aqueous humor) Mydriatics and Cycloplegics • Used preoperatively or for eye examinations to produce mydriasis • Contraindicated in patients 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 patients with prostatic hypertrophy, diabetes mellitis or parkinsonism Mydriatics and Cycloplegics • Dilate the pupils (mydriasis) • Relax 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 • Contraindicated in patients 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 patients with prostatic hypertrophy, diabetes mellitis or parkinsonism dDwxMDY Mydriatics and Cycloplegics • Side Effects – Tachycardia – Photophobia – Conjunctivitis – Dermatitis Mydriatics and Cycloplegics Atropine toxicity – – – – – – – Dry mouth Blurred vision Photophobia Tachycardia Fever Urinary retention Constipation – – – – – – Headache, brow pain Confusion Hallucinations Delirium Coma Worsening of narrow-angle glaucoma Mydriatics and Cycloplegics • Systemic reactions of anticholinergics – Dry mouth and skin – Fever – Thirst – Confusion – hyperactivity Mydriatics and Cycloplegics • Nursing Implementation – – – – – Monitor for allergic response Assess for risk of injury Assess for constipation and urinary retention Instruct that a burning sensation may occur on instillation Instruct not to drive or operate machinery for 24 hours after instillation of the med unless otherwise directed by MD – Instruct to wear sunglasses until med wears off – Instruct to notify MD if blurring, loss of sight, difficulty in breathing, sweating, or flushing occurs – Instruct to report eye pain to MD • Alpha-adrenergic blocker – Med: dapiprazole hydrochloride (Rev-Eyes) – Use: to counteract mydriasis Ophthalmic medications • Eye medications are usually available in drop form or ointments • To prevent the overflow of medication into nasal passages, instruct client to occlude the nasolacrimal duct with one finger for 1 to 2 minutes after instilling the medication • When several eye medications are to be administered, wait 3 minutes between medications Ophthalmic medications • Perform good handwashing before using meds • Good handwashing after to rinse off residue • Use a separate bottle or tube of med for each client to avoid cross contamination • Instill dose of med in lower conjunctival sac, never directly onto cornea Using Eyedrops (Patient Instructions) • Most eyedrops are generally safe, but be sure to inform your doctor if you are using any eye medication, including any over-thecounter eyedrops. Like most medicines, they can have side effects, or they might not work well with other medicines you are taking. • Keep all eyedrops away from children. • First, check the label on the bottle to make sure that you are using the right medicine. • Wash your hands. • Before you open the bottle, shake it a few times. • Bend your neck back so that you're looking up at the ceiling. Use your thumb and forefinger to pull down your lower eyelid. Using Eyedrops (Patient Instructions) • Without letting the tip of the bottle touch your eye or eyelid, squeeze one drop of the medicine into the space between your eye and your lower eyelid. If you squeeze in more than one drop, you're wasting medicine. • After you squeeze the drop of medicine into your eye, close your eye. Then press a finger between your eye and the top of your nose (directly over the lacrimal sac). Press for several minutes. This way, more of the medicine stays in your eye. You'll be less likely to have side effects. • Wash your hands again after you put the drops in your eyes. • Don't let the tip of the bottle touch a table, the cabinet or anything else. If you are using multiple eyedrops..... • Put a drop of the first medicine in your eye. Wait at least 10 minutes to put the second medicine in your eye. By allowing these 10 minutes in between eyedrops, you will reduce the risk of adverse interaction between the two medications. In addition, eyedrops will need this time to be absorbed completely and work effectively before the instillation of another drop. • If someone else puts your medicines in your eye for you, remind that person to wait 10 minutes between each medicine. Ophthalmic medications • Avoid touching any part of eye with dropper • Administer eye drops or liquids before ordered ointments • In a client receiving a beta blocker, withhold the next dose if the pulse is below 50 to 60 bpm and report to MD • Instruct client on correct instillation of med and supervise instillation to assess client is able to comply safely Ophthalmic medications • Instruct client to carefully read labels to ensure administration of the correct strength and medication • Instruct client if vision is blurred to avoid driving or operating hazardous equipment • Instruct client to get someone else to drive home after eye exam Ophthalmic medications • Instruct to wear sunglasses and avoid bright lights • Instruct that a missed dose should be administered as soon as recalled, unless the next dose is due in 1 to 2 hours • Instruct client with glaucoma that the disorder can only be controlled with a regular scheduled dosage • Inform clinet that the treatment for glaucoma may initially cause pain and blurred vision Ophthalmic medications • Inform to report any eye irritation that may develop • Instruct to store eye medication as directed • Inform the client with soft contact lenses that certain meds may discolor the lenses • Advise client with contact lenses to ask about any special precautions with medication • Advise client to keep these and all meds out of reach of children Miotics • Reduce intraocular pressure by constricting the pupil and contracting the ciliary muscle, thereby increasing the blood flow to the retina and decreasing retinal damage and loss of vision • Open the anterior chamber angle and increase the outflow of aqueous humor • Miotic cholinergic meds reduce intraocular pressure by mimicking the action of acetylcholine • Miotic acetycholine inhibitors reduce intraocular pressure by inhibiting the action of cholinesterase Miotics • Used for chronic open-angle glaucoma or acute and chronic closed-angle glaucoma • Used to achieve miosis during eye surgery • Contraindicated in those with retinal detachment, adhesions between the iris and lens, or inflammatory diseases • Use with caution in those with asthma, hypertension, corneal abrasion, hyperthyroidism, coronary vascular disease, urinary tract obstruction, gastrointestinal (GI) obstruction, ulcer disease, parkinsonism, or bradycardia Miotics • Acetylcholine chloride (Miochol) • Carbachol (Miostat) • Pilocarpine hydrochloride (Isopto, Carpine, Pilocar) • Pilocarpine nitrate (Pilofrin, Liquifilm, Pilagan) • Echothiophate iodide (Phospholine Iodide) • Side Effects Miotics – – – – Myopia Headache Eye pain Decreased vision in poor light – Local irritation •Toxicity Vertigo and syncope Bradycardia Hypotension Cardiac dysrhythmias Tremors Seizures • Systemic effects – – – – – – – Flushing Diaphoresis GI upset and diarrhea Frequent urination Increased salivation Muscle weakness Respiratory difficulty Miotics • Nursing Implementation – Assess vital signs – Assess for risk of injury – Assess for degree of diminished vision – Monitor for side effects and toxic effects – Monitor for postural hypotension and instruct to change positions slowly – Assess breath sounds for rales and rhonchi because cholinergic meds can cause bronchospasms and increased bronchial secretions Miotics • Nursing Implementation – Maintain oral hygiene because of the increase in salivation – Have atropine sulfate available as an antidote for pilocarpine – Instruct client or family regarding the correct administration of eye meds – Instruct client not to stop the med suddenly – Instruct client to avoid activities such as driving while vision is impaired – Instruct client with glaucoma to read labels on OTC meds and to avoid atropine-like meds because atropine will increase intraocular pressure Beta-Adrenergic Blocking Eye Medications • Reduces intraocular pressure by decreasing sympathetic impulses and decreasing aqueous humor production without affecting accommodation or pupil size • Used to treat chronic open-angle glaucoma • Contraindicated with asthma because systemic absorption can cause increased airway resistance • Use with caution with those receiving oral betablockers Beta-Adrenergic Blocking Eye Medications • Side Effects – Ocular irritation – Visual disturbances – Bradycardia – Hypotension – bronchospasm Beta-Adrenergic Blocking Eye Medications • Nursing Implementation – Monitor VS, especially BP and pulse, before administrating meds – If the pulse is 60 or below or if the systolic blood pressure is below 90mmHg, withhold the med and contact the MD – Monitor for shortness of breath – Monitor I and O – Instruct to notify MD if SOB occurs Beta-Adrenergic Blocking Eye Medications – Instruct not to discontinue the med abruptly – Instruct to change positions slowly to avoid orthostatic hypotension – Instruct to avoid hazardous activities – Instruct to avoid OTC meds without approval • • • • • Betaxolol hydrochloride (Betoptic) Carteolol hydrochloride (Ocupress) Levobunolol hydrochloride (Betagan) Metipranolol (Optiprannolol) Timolol maleate (Timoptic) Adrenergic medications • Decrease production of aqueous humor and lead to a decrease in intraocular pressure • Used to treat glaucoma – Apraclonidine hydrochloride (Iopidine) – Brimonidine tartrate (Alphagan) – Dipivefrin hydrochloride (Propine) – Epinephrine borate (Epinal, Eppy) – Epinephrine hydrochloride (Epifrin, Glaucon) Antiinfective Eye Medications • Kills or inhibits the growth of bacteria, fungi, or viruses • Side effects – Superinfection – Global irritation • Nursing Implementation – – – – – Assess for risk of injury Instruct in how to apply the eye medication Instruct to continue treatment as prescribed Instruct to wash hands thoroughly and frequently Advise that if improvement does not occur, notify MD Antiinfective Eye Medications • Antibacterial – Choramphenicol (Chloromycetin, Chloroptic) – Ciprofloxacin hydrochloride (Cipro) – Erthromycin (Ilotycin) – Gentamycin sulfate (Garamycin, Genoptic) – Norfloxin (Chibroxin) – Tobramycin (Nebcin, Tobrex) – Silver Nitrate 1% Antiinfective Eye Medications • Antifungal – Natmycin (Natacyn Ophthalmic) • Antiviral – Idoxuridine (Herplex Liquifilm) – Trifluridine (Viroptic) – Vidarabine (Vira-AOphthalmic) Antiinflammatory Eye Medications • Controls inflammation, thereby reducing vision loss and scarring • Used for uveitis, allergic conditions, and inflammation of the conjuctiva, cornea, and lids • Side effects – – – – Cataracts Increased intraocular pressure Impaired healing Masking signs and symptoms of infection • Nursing Implementation – Refer to implementation, antiinfective eye medications – Note that dexamethasone (Maxidex) should not be used for eye abrasions and wounds Antiinflammatory Eye Medications • • • • • • • • Dexamethasone (Maxidex) Diclofenac (Voltaren) Flurbiprofen sodium (Ocufen) Suprofen (Profenal) Ketorolac tromethamine (Acular) Prednisolone acetate (Predforte, Econopred) Prednisolone sodium phosphate (AK-Pred, Inflamase) Rimaxolone (Vexol) Topical Anesthetics for the Eye • Produce corneal anesthesia • Used for anesthesia for eye examinations, for 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 for the Eye • Nursing Implementation – Asses for risk of injury – Note that the medications should not be given to the client for home use and are not to be selfadministered 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 Topical Anesthetics for the Eye • Proparacaine hydrochloride (ophthaine, Ophthetic) • Tetracaine hydrochloride (Pontocaine) Cap Color Tan Drug Class Antibiotics Pink Anti-inflammatory/Steroids Red Mydriatics/Cycloplegics Grey Green Yellow or Blue NSAIDs Miotics Beta-blockers Purple Adrenic Agonists Orange Carbonic Anhydrase Inhibitors Turquoise Prostaglandin Analogues HOW DOES NORMAL HEARING WORK? • The ear is divided in three parts: the outer, middle, and inner ear. The part of the ear we see and the ear canal make up the external ear. The middle ear includes the ear drum (tympanic membrane) and three tiny bones (malleus, incus and stapes). The inner ear consists of the cochlea and the vestibule. • When sound enters the ear canal, it vibrates the eardrum. • This vibration then travels through the middle ear bones to the oval window, which is connected to the cochlea. The cochlea is a snail shaped tunnel filled with liquid and lined with “hair cells”. • When the sound vibration hits the oval window, it vibrates the liquid inside the cochlea, which “stimulates” the hair cells. The hair cells then send an electrical signal to the auditory nerve which then carries the sound information to the brain. Conditions of the Ear • Conductive hearing loss – When sound waves are blocked to the inner ear fibers because of external ear or middle ear disorders – Disorders can often be corrected with no damage to hearing, or minimal permanent hearing loss • Causes – Any inflammatory process or obstruction of the external or middle ear – Tumors – Otosclerosis – A buildup of scar tissue on the ossicles from previous middle ear surgery Sensorineural hearing loss • A pathological process of the inner ear or of the sensory fibers that lead to the cerebral cortex • Is often permanent, and measures must be taken to reduce further damage or to attempt to amplify sound as a means of improving hearing to some degree Sensorineural hearing loss • Causes – – – – – – – – – – – – Damage to the inner ear structure Damage to cranial nerve VIII Prolonged exposure to loud noise Medications Trauma Inherited disorders Metabolic and circulatory disorders Infections Surgery Meniere’s disease Diabetes mellitus Myxedema Mixed hearing loss • AKA conductive- sensorineural hearing loss • Client has both sensorineural and conductive hearing loss Cochlear Implantation • Used for sensorineural hearing loss • A small computer converts sound waves into electrical impulses • Electrodes are placed by the internal ear with computer device attached to the external ear • Electronic impulses directly stimulate nerve fibers Hearing Aids • Used for the client with conductive hearing loss • Can help the client with sensorineural loss, although it is not as effective • A difficulty that exists in its use is the amplification of background noise as well as voices • Client education Hearing aids – Begin using it slowly to develop an adjustment to the device – Adjust volume to the minimal hearing level to prevent feedback squeaking – Differentiate and filter out background noises – Clean ear mold with warm water and soap – Avoid excessive wetting, keep dry – Clean device crevices with toothpick or pipe cleaner – Keep extra batteries on hand – Keep in safe place at night – Turn off when not using Presbycusis • Associated with aging • Leads to degeneration or atrophy of the ganglion cells in the cochlea and a loss of elasticity of the basilar membranes • Leads to compromise of the vascular supply to the inner ear with changes in several areas of the ear structure Presbycusis • Assessment – Hearing loss is gradual and bilateral – Client states no problem with hearing, but cannot understand what the words are – Client thinks that the speaker is mumbling External Otitis • Infective inflammatory or allergic responses involving structure of external auditory canal or the auricles • An irritating or infective agent comes into contact with the epithelial layer of the external ear • This leads to either an allergic response or signs and symptoms of an infection • Skin becomes red, swollen, and tender to touch on movement • Extensive swelling of the canal can lead to conductive hearing loss because of obstruction • AKA “swimmer’s ear” • Prevention includes the elimination of irritating or infecting agents External Otitis • Assessment – Pain – Itching – Plugged feeling in the ear – Redness and edema – Exudate – Hearing loss External Otitis • Nursing Implementation – Apply heat locally for 20 minutes, 3 X day – Encourage rest to assist in reducing pain – Administer antibiotics or steroids as prescribed – Administer analgesics such as ASA or Tylenol for pain – Instruct to keep ears clean and dry – Instruct to use earplugs when swimming – Instruct not to put anything in ears (Q-tips!) – Instruct not to use irritating agents in ears such as hair spray or ear buds Chronic Otitis Media • A chronic infective, inflammatory or allergic response involving the middle ear • See your Pediatric notes Mastoiditis • May be acute or chronic and results from untreated or inadequately treated chronic or acute otitis media • The pain is not relieved by myringotomy • Assessment – Swelling behind ear and pain with minimal movement of the head – Cellulitus on the skin or external scalp over the mastoid process – A reddened, dull, thick, immobile tympanic membrane with or without perforation – Tender and enlarged postauricular lymph nodes – Low-grade fever – Malaise – anorexia Mastoiditis • Nursing Implementation – Prepare client for surgical removal of infected material – Monitor for complications – Simple or modified radical mastoidectomy with tympanoplasty is most common treatment – Once tissue that is infected is removed, the tympanoplasty is performed to reconstruct the ossicles and the tympanic membranes, in an attempt to restore normal hearing • Complications Mastoiditis – Damage to the abducens and facial cranial nerves – Damage exhibited by inability to look laterally (CN VI) and a drooping of the mouth on the affected side (CNVII) – Meningitis – Brain abscess – Chronic purulent otitis media – Wound infections – Vertigo, if the infection spreads into the labyrinth Mastoiditis • Postoperative Implementations – Monitor for dizziness – Monitor for signs of meningitis as evidenced by a stiff neck and vomiting – Prepare for a wound dressing change 24 hours postop – Monitor the surgical incision for edema, drainage, and redness – Position the client flat with the operative side up – Restrict the client to bed with bedside commode privileges for 24 hours as prescribed – Assist with getting OOB, to prevent falling or injuries from dizziness – With reconstruction of the ossicles via a graft, precautions are taken to prevent dislodging of the graft Otosclerosis • Disease of the labyrinthine capsule of the middle ear that results in a bony overgrowth of the tissue surrounding the ossicles • Causes the development of irregular areas of new bone formation and causes the fixation of the bones • Stapes fixation leads to a conductive hearing loss • If the disease involves the inner ear, sensorineural hearing loss is present Otosclerosis • It is not uncommon to have bilateral involvement, although hearing loss may be worse in one ear • The cause is unknown, although it is thought to have a familial tendency • Nonsurgical intervention promotes the improvement of hearing through amplification • Surgical intervention involves removal of the bony growth that is causing the hearing loss • A partial stapedectomy or complete stapedectomy with prosthesis (fenestration) may be surgically performed Otosclerosis • Assessment – Slowly progressive conductive hearing loss – Bilateral hearing loss – A ringing or roaring type of constant tinnitus – Loud sounds heard in the ear when chewing – Pinkish discoloration (Schwartze’s sign) of the tympanic membrane, which indicates vascular changes within the ear – Negative Rinne test – Weber test shows lateralization of sound to the ear with the most conductive hearing loss Labyrinthitis • Infection of the labyrinth that occurs as a result of acute or chronic otitis media • Assessment – Hearing loss that may be permanent on the affected side – Tinnitus – Spontaneous nystagmus to the affected side – Vertigo – Nausea and vomiting Labyrinthitis • Nursing Implementation – Monitor for signs of meningitis, the most common complication, as evidenced by headache, stiff neck, lethargy – Administer systemic antibiotics – Advise to rest in bed in darkened room – Administer antiemetics and antivertiginous medications as prescribed – Instruct that vertigo subsides as inflammation resolves – Instruct that balance problems that persist may require gait training through physical therapy Meniere’s Syndrome • A syndrome AKA endolymphatic hydrops, refers to dilation of the endolymphatic system by either overproduction or decreased reabsorption of endolymphatic fluid • Characterized by tinnitus, unilateral sensorineural hearing loss and vertigo • Symptoms occur in attacks and last for several days, and the client becomes totally incapacitated during the attacks • Initial hearing loss is reversible, but as the frequency of attacks continues, hearing loss becomes permanent • Repeated damage to the cochlea caused by increased fluid pressure leads to the permanent hearing loss Meniere’s Syndrome • Causes – Any factor that increase endolymphatic secretion in the labyrinth – Viral and bacterial infections – Allergic reactions – Biochemical disturbances – Vascular disturbances producing changes in the microcirculation in the labyrinth Meniere’s Syndrome • Assessment – Feeling of fullness in the ear – Tinnitus – Hearing loss worse during attack – Vertigo – Nausea and vomiting – Nystagmus – Severe headaches Meniere’s Syndrome • Nonsurgical Implementation – – – – – – – – – – Preventing injury during vertigo Providing bed rest in quiet environment Assist walking Instruct to move the head slowly Initiate sodium and fluid restrictions as prescribed No smoking Administer niacin Administer antihistamines Administer antiemetics Administer tranquilizers Meniere’s Syndrome • Surgical Implementation – Endolymphatic drainage – Resection of the vestibular nerve or total removal of the labyrinth or a labyringthectomy • Postoperative Implementation – – – – – – – Assess packing and dressing on the ear Speak to client on side of unaffected side Perform neurological assessments Maintain side rails Assist with ambulation Encourage use of bedside commode Administer antivertiginous and antiemetic med Acoustic Neuroma • A benign tumor of the vestibular or acoustic nerve • Tumor may cause damage to hearing and to facial movements and sensations • Treatment includes surgical removal of the tumor via craniotomy • Care is taken to preserve the function of the facial nerve • The tumor rarely recurs after surgical removal • Postoperatively nursing care is similar to postoperative craniotomy care Acoustic Neuroma • Assessment – Symptoms usually begin with tinnitus and progress to gradual sensorineal hearing loss – As the tumor enlarges, damage to adjacent cranial nerves occurs Otic Medication • Administering drops – In adult, pull pinna up and back to straighten external canal to instill ear drops • Irrigation of the ear – Irrigation of the ear needs to be prescribed by MD – Ensure there is a direct visualization of the tympanic membrane – Warm irrigating solution to 100 degrees F to prevent ear injury, nausea and vertigo – Irrigation to eardrum must be gentle – If a perforation is suspected, no irrigation Anti infective Ear Medication • • • • • Kills or inhibits growth of bacteria Used for otiitis media or otitis externa Contraindicated if a prior hypersensitivity exists Side effects: overgrowth of nonsusceptible organisms Nursing implementation – – – – – Monitor VS Assess for allergies Assess for pain Monitor for nephrotoxicity Instruct to report dizziness, fatigue, fever, or sore throat, indicating superimposed infection – Instruct to complete the entire course of the medication – Instruct to keep ear canals dry Antiinfective Ear Medication • • • • • • Amoxicillin (Amoxil) Ampicillin trihydrate (Polycillin) Cefaclor (Ceclor) Clindamycin hydrochloride (Cleocin) Erythromycin (Ilotycin, E-Mycin) Penicillin V potassium (Pen-V)