Chapter 39: Nursing Care of the Child With an Alteration in Sensory Perception/Disorder of the Eyes or Ears

A nursing instructor is teaching about eye disorders in childhood. Which statement made by a student indicates a need for further instruction?

"Cataracts are only present in adults." Rationale: A cataract is a marked opacity of the lens and may be present at birth. It can cause blindness if not treated early. The cataract can be removed as early as 2 weeks of age and the best results are achieved if removed by 3 months of age. Glaucoma is increased intraocular pressure causing damage to the optic nerve.

The nurse is obtaining the history from the parents of an infant who is suspected of having infantile glaucoma. Which statement by the parents would help to confirm this suspicion?

"It seems like bright lights really bother him." Rationale: Photophobia occurs with infantile glaucoma, so bright light may bother the infant. Typically, the infant with infantile glaucoma will keep his eyes closed most of the time. The affected eye may appear enlarged with infantile glaucoma. Tearing is associated with infantile glaucoma.

A toddler has been diagnosed with otitis media with effusion. The parents tell the nurse, "We really don't understand what that diagnosis means." How should the nurse respond?

"The diagnosis means unwanted fluid is within the middle ear space, and there may or may not be an infection present." Rationale: Otitis media with effusion refers to the presence of fluid within the middle ear space, without signs or symptoms of infection. It may occur independent of acute otitis media (AOM) or may persist after the infectious process of AOM has resolved.

The nurse is educating the parents of a 7-year-old boy who has hearing loss due to otitis media with effusion. Which statement by the parents indicates that further education is needed?

"We need to raise the volume of our voices significantly so he can hear us." Rationale: It is not necessary for the parents to raise their voices more than slightly in order to be heard. Speaking clearly is an appropriate technique for communicating with the child. Facing the child when speaking is an effective method for communicating with the child. Using visual clues, such as hand gestures, is an effective technique for communicating with this child.

A school-age child was admitted to the emergency department following a simple contusion to the eye from playing baseball. The nurse has given discharge instructions to the parents. Which comment(s) by the parents indicate they understood the discharge teaching? Select all that apply.

-"When we apply ice to the eye, it should only be for about 20 minutes at a time." -"It will likely take about 3 weeks or so for all of that bruising to go away." -"We should use ice intermittently for the first 24 hours." Rationale: To decrease edema in the child with a black eye (simple contusion), the nurse will instruct the parents to apply an ice pack to the area for 20 minutes, then remove it for 20 minutes, and continue to repeat the cycle as often as possible during the first 24 hours. The nurse will also inform the parents and child that bruising of the surrounding eye area may take up to 3 weeks to resolve. The blood in the sclera may take several weeks to resolve and is not damaging to the eye. Wearing an eye patch does not hasten recovery following a simple eye contusion.

The 12-year-old child has developed a stye. Which may be included in the child's care?

Apply hot, moist compresses to the affected area. Rationale: The stye is an infection of a ciliary gland (a modified sweat gland) that enters the hair follicle at the lid margin, most commonly caused by Staphylococcus. Management of the stye includes the use of hot, moist compresses. Manual expression is not indicated. Petroleum jelly will not be appropriate nor will it reduce inflammation. Cool, dry compresses will not be therapeutic. Heat provides for vasodilation, which will be useful in the resolution of the inflammation.

The nurse is preparing a nursing care plan for a 2-year-old child with hearing impairment. Which intervention will be part of the plan?

Assess the child's ability to convey information. Rationale: Children who are unable to hear during the first 36 months of life are unable to learn the language necessary for normal verbal communication; therefore, it will be important to assess the child's ability to convey information. Visual assessment is not indicated. Educating parents about botulinum injections is an intervention for strabismus. Vinegar and alcohol eardrops are a treatment for swimmer's ear.

A young child in the clinic has watery eyes and reddened conjunctiva. The child keeps the eyes closed a lot, because it hurts to have them open. Which problem does the nurse suspect for this client?

Conjunctivitis Rationale: Conjunctivitis is inflammation of the conjunctiva and is demonstrated by watery eyes with reddened conjunctiva and sensitivity to light. Sticking of eyelids with pustular drainage is also a sign. It is very contagious and requires antibiotics for treatment. Blepharitis is a chronic scaling with discharge along the eyelid margin. A stye is a localized infection of the sebaceous gland of the eyelid. A chalazion is a chronic painless infection of the meibomian gland. The stye and blepharitis will require antibiotic treatment. A chalazion will clear on its own.

A child with poor eye alignment cannot establish single binocular vision but has double vision. Which nursing action is most appropriate for this client?

Refer the child to a pediatric ophthalmologist Rationale: The nurse would refer the child experiencing diplopia (double vision) to a pediatric ophthalmologist for further testing; it is imperative to determine the cause to properly treat diplopia. Treatment may be as simple as eye exercises or glasses or could entail surgery. CT or magnetic resonance imaging (MRI) may be prescribed to assist in determining the cause. Knowledge of previous testing would not be a priority at this time. Botulinum toxin injections may be prescribed for treatment. Surgery may be discussed once the underlying cause is identified.

The nurse is performing a physical assessment for an 8-year-old child with an earache. Which sign or symptom indicates external otitis (acute otitis externa or swimmer's ear)?

The child cries out when the ear is grasped. Rationale: External otitis (acute otitis externa or swimmer's ear) is an infection and inflammation of the skin of the external ear canal. The classic sign of external otitis is pain on movement of the pinna or pain on pressure over the tragus. Upon examination, the ear canal is red and swollen. Many times the tympanic membrane cannot be visualized because the swelling does not allow the insertion of an otoscope. Symptoms of upper respiratory infection many times accompany otitis media but are not seen in external otitis. The tympanic membrane reacting to a puff of air is a sign that there is no fluid buildup in the middle ear. The absence of cerumen in the ear canal is not related to external otitis.

The nurse is assessing a child with an eye problem. Which symptom, if present, would rule out a hordeolum?

Reddened conjunctiva Rationale: The conjunctiva is clear with a hordeolum. A hordeolum is usually painful. Eyelid edema is present with a hordeolum. A hordeolum may be visible as an enlarged lesion along the lid margin.

The parents of a toddler have just learned that their child has profound hearing loss. The parents are very upset and state to the nurse, "It just isn't fair. We did everything right during our pregnancy all the way to this point." How should the nurse respond?

"I can't imagine how difficult this must be. When you're ready I would be happy to arrange a meeting with a support group of other parents with children who have hearing loss." Rationale: This comment is the most empathic and supportive. Encouraging a support group, when the parents are ready, is very helpful. Those in a support group know how these parents feel and can also offer helpful options for dealing with a hearing-impaired child. Telling the parents to "think positively" or that "things could be much worse" disregards the concern the parents have voiced to the nurse. The nurse generalizes the parents' feelings by telling them "many children who have a profound hearing loss function very well....."

The school nurse is instructing the classroom teacher regarding a student newly diagnosed with amblyopia. To prepare for classroom instruction, which concept is most important for the nurse to convey to the teacher?

Student placement in the room is important but all other teaching methods may remain the same. Rationale: Amblyopia is when the vision in one of the eyes is reduced because the eye and the brain are not working together properly. The eye itself looks normal, but it is not being used normally because the brain is favoring the other eye. This condition is also sometimes called "lazy eye." The student can still see and, in some cases, has limited impairment due to brain compensation. It is associated with other conditions such as poor refraction, ptosis, cataracts, or strabismus. The child should be placed where he or she can be in direct view of the teacher or blackboard but the other teaching methods may remain the same. The methods do not need to be shortened nor does the child require a large percentage of the learning to be hands-on.

A 5-year-old child is diagnosed with acute otitis media. Which nursing intervention would be priority?

Relieving the child's pain Rationale: Acute otitis media is caused by a bacterial or viral infection of fluid in the middle ear. The fluid behind the eardrum has difficulty draining back out because of the horizontal positioning of the eustachian tube. This causes increased pain. Antibiotics are prescribed to cure the infection. Children need pain relief until the antibiotic prescribed reduces the inflammation and pressure. Children pull on the ear as an attempt to reduce the pain and equalize the pressure. Pulling on the ears, especially in an infant, is one of the first signs the parent sees to warn of the ear infection. Blowing the nose is also an attempt by the child to equalize the pressure in the ear and help reduce the pain. A mydriatic is a drug that induces dilation of the pupils.

A 13-year-old reports she recently saw a television program showing surgery to correct vision problems. She states she hates wearing glasses and wants to have this procedure done. What is the best response by the nurse?

"Although there are surgeries for vision, they are not normally recommended for someone your age." Rationale: In most cases, laser surgery for someone this young is not recommended. Explaining that other girls wear glasses does not answer the teen's original question. While contact lenses may be an option for consideration, this response does not address the teen's question.

The parent of a child having tympanoplasty tubes placed asks, "Will my child lose hearing while the tubes are in place?" What is the nurse's best answer?

"The tubes are inserted into a section of eardrum in which the hearing is not affected." Rationale: Tymanostomy tubes help to ventilate the cavities of the middle ear and balance the pressure on each side of the tympanic membrane..Tympanoplasty tubes do not interfere with hearing because they are inserted into a portion of the tympanic membrane that is not instrumental to hearing. There is no risk of permanent deafness and hearing will be increased while the tubes are in place, not decreased. The nurse should answer the parent's question honestly without dismissing it or referring to another health care provider. This indicates to the parent that something may be wrong or serious. The nurse can refer the parent to the surgeon if the parent's questions have not been adequately addressed.

The parents of an 8-year-old child report that the child's teachers noted the child is having problems seeing the board in school but state they do not understand this since the child is able to read from the computer with no difficulty. Which response from the nurse is most appropriate?

"What you are describing may be what is called myopia." Rationale: Myopia (nearsightedness) occurs when light rays focus anterior to the retina, causing objects that are far away to be unfocused. Typically, this develops around age 8 years and then progresses. These children can read a book or a computer screen immediately in front of them but are unable to read the blackboard clearly from a distance. There is no indication that the child is experiencing issues with paying attention. This suggestion does not address the parent's initial complaint. Accommodation disorders present with complaints of diplopia and headaches. Hyperopia (farsightedness) presents with vision that is blurry at a close range and clear at a far range, which is opposite of what is being reported for this child.

A child returns to the clinic after an episode of external otitis (acute otitis externa or swimmer's ear) that has resolved. What would the nurse emphasize as the priority for preventing future episodes?

Keeping ear canals dry Rationale: Since moisture contributes to external otitis (acute otitis externa or swimmer's ear), the priority is to keep the ear canals dry. Handwashing would be a priority for preventing infections such as conjunctivitis. Upper respiratory tract infections are associated with otitis media, not external otitis (acute otitis externa or swimmer's ear). Hearing loss is not associated with otitis externa.

A nurse is assessing a child's vision. Which test should the nurse use to test for accommodation?

Moving a penlight toward the client's nose and observing whether the eyes can follow it Rationale: To test for accommodation, ask a child (over 6 months of age) to follow a penlight as you move it in toward the nose. Children who cannot accommodate are unable to fuse their vision to follow a penlight toward their nose this way; instead, they demonstrate double vision (diplopia). The Stereo-Fly dot test, a test where the image of a fly is constructed from a series of colored dots, is used to test stereopsis. When asked to touch the fly's wings, a child with good depth perception touches them accurately. A child with poor depth perception touches a spot 2 or 3 inches above the pattern. Hirschberg test is used to detect true strabismus. The Weber test is a test for hearing.

The nurse is educating the parents of a 4-year-old boy with strabismus. Teaching for the parents would include the:

importance of patching as prescribed. Rationale: Teaching the parents the importance of patching the child's eye as prescribed is most important for the treatment of strabismus. The need for UV-protective glasses postoperatively is a subject for the treatment of cataracts. The possibility of multiple operations is a teaching subject for infantile glaucoma. Teaching the importance of completing the full course of oral antibiotics is appropriate to periorbital cellulitis.