Transcript Assessment - rivier.instructure.com.

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
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Change prescription of glasses
Use magnifiers
Increasing lighting
Administer topical drugs for pupil dilation
–Cycloplegics / Mydriatics
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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
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Dry mouth
Blurred vision
Photophobia
Tachycardia
Fever
Urinary retention
Constipation
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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
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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
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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
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Mydriatics and Cycloplegics
• Side Effects
– Tachycardia
– Photophobia
– Conjunctivitis
– Dermatitis
Mydriatics and Cycloplegics
Atropine toxicity
–
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Dry mouth
Blurred vision
Photophobia
Tachycardia
Fever
Urinary retention
Constipation
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–
–
–
–
–
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
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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
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Myopia
Headache
Eye pain
Decreased vision
in poor light
– Local irritation
•Toxicity
Vertigo and syncope
Bradycardia
Hypotension
Cardiac dysrhythmias
Tremors
Seizures
• Systemic effects
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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
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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
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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
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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
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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
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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
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–
–
–
–
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
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–
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–
–
–
–
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
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–
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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)