Unit 18 Nursing Care for Patients with Eye & Ear Problems

voice test

by asking the patient to block one external ear canal while standing 1 to 2 feet (30 to 60 cm) away. Quietly whisper a statement, and then ask the patient to repeat it

Laser imaging of the retina and optic nerve

creates a three-dimensional view of the back of the eye. It is often used for those people with ocular hypertension or who are at risk for glaucoma from other problems. This computerized examination assesses the thickness and contours of the optic nerve and retina for changes that indicate damage as a result of high IOP

ototoxic

damaging to the ear

Visual field testing

determines the degree of peripheral vision

ptosis

drooping of eyelid

Snellen eye chart

measures distance vision; This chart has letters, numbers, pictures, or a single letter presented in various positions; Have the patient stand or sit 20 feet from the chart, cover one eye, and use the other eye to read the line that appears most clear; For example, 20/50 means that the patient sees at 20 feet from the chart what a healthy eye sees at 50 feet.

vertigo

spinning sensation

Tuning fork

tests for hearing are the Weber and Rinne tests. These tests are useful, although limited, in distinguishing between conductive and sensorineural hearing losses.

Electroretinography

graphs the retina's response to light stimulation. This test is helpful in detecting and evaluating blood vessel changes from disease or drugs

Visual acuity tests

measure both distance and near vision

Myopia (nearsightedness)

occurs when the eye overbends the light and images converge in front of the retina

TABLE 48-1 Decibel Intensity and Safe Exposure Time for Common Sounds

PG 1002!! Med-Surg

Chart 48-3 Instillation of Eardrops

PG 1004! Med-surg

Chart 48-4 Ear Irrigation

PG 1004!! Med-surg

Chart 48-5 Nursing Focus on the Older Adult Cerumen Impaction

PG 1005!! Med-Surg

Chart 48-6 Recovery from Ear Surgery

PG 1006!!

Chart 46-1 Nursing Focus on the Older Adult Changes in the Eye and Vision Related to Aging

PG 969! Med-Surg

far point

(farthest point at which an object can be distinguished) decreases with age

near point of vision

(the closest distance at which the eye can see an object clearly) increases with age

Chart 46-2 Patient and Family Education: Preparing for Self-Management Using Eyedrops

PG 970! Med-Surg

before instilling travoprost (Travatan)

A Measuring the client's blood pressure B Measuring the client's intraocular pressure C Checking the cornea for abrasions or open areas D Assessing heart rate and rhythm for 1 full minute

Cataract

A cataract is a lens opacity that distorts the image. With aging, the lens gradually loses water and increases in density; Teach people to reduce the risk for cataract by wearing sunglasses that limit exposure to UV light whenever they are outdoors in the daytime. Cataracts also may result from direct eye injury. Urge all people to wear eye and head protection

Stapedectomy.

A partial or complete stapedectomy with a prosthesis can correct some hearing loss, especially in patients with hearing loss related to otosclerosis. Prevent infection before surgery.

Penetrating Injuries

A penetrating eye injury often leads to permanent loss of visual sensory perception. Glass, high-speed metal or wood particles, BB pellets, and bullets are common causes of penetrating injuries. The particles can enter the eye and lodge. X-rays and CT scans of the orbit are usually performed. MRI is contraindicated because the procedure may move any metal-containing projectile and cause more injury. Surgery is usually needed to remove the foreign object, and sometimes vitreal removal is needed. IV antibiotics are started before surgery.

Antiinfectives for the Ear

A significant decline in AOM(acute otitis media) has occurred since the pneumococcal conjugate vaccine (PCV) was introduced in 2000. Amoxicillin is usually the drug of choice when antibiotics are indicated for AOM, but azithromycin and clarithromycin are often ordered if the patient has a severe allergy to penicillin. Treatment of OE(otitis externa) is usually with topical antibacterial or antifungal drugs, depending on the source of the infection. These are often prescribed as a combination product containing an antiinflammatory drug. If the EAC becomes so swollen that eardrops cannot reach the inner recesses of the EAC, a wick must be inserted; neomycin-polymyxin B-hydrocortisone are very effective in treating OE, however, if this drug combination is given to a patient with a perforated TM, there is a significant risk of ototoxicity. The most common side effect of otic antimicrobials is burning and stinging. Ototoxicity can occur with aminoglycoside antibiotics. Chloroamphenical may cause bone marrow suppression and opportunistic overgrowth of nonsusceptible organisms may occur.

External Ear and Mastoid Assessment

Abnormalities of the pinna include swelling, nodules, and lesions. Gout, collections of uric acid crystals result in hard, irregular, painless nodules called tophi. Other nodules on the pinna might also be from basal cell carcinoma or rheumatoid arthritis. Small, crusted, ulcerated, or indurated lesions on the pinna that fail to heal could be squamous cell carcinoma. To assess for tenderness, gently tap with one finger over the mastoid process, compress the tragus with one finger, and gently move the pinna forward and backward. Any tenderness suggests an inflammation in either the external ear or the mastoid. Assess for and record these problems: • Furuncles(boil) • Large amounts of cerumen • Scaliness • Redness • Swelling of the ear • Drainage and its character

Otitis Media

Acute otitis media and chronic otitis media are similar. An infecting agent in the middle ear causes inflammation of the mucosa, leading to swelling and irritation of the ossicles within the middle ear, followed by purulent inflammatory exudate. The patient with acute or chronic otitis media has ear pain. The patient may notice tinnitus in the form of a low hum or a low-pitched sound. Headaches and systemic manifestations such as malaise, fever, nausea, dizziness, and vomiting. With progression, the eardrum spontaneously perforates and drains which decreases pain. Management can be as simple as putting the patient in a quiet environment. Bedrest limits head movements that intensify the pain. Application of low heat may help reduce pain. Systemic antibiotic therapy is prescribed. Teach the patient to complete the antibiotic therapy. Analgesics may be used. A myringotomy (surgical opening of the eardrum) may be performed. A small grommet (polyethylene tube) may be surgically placed through the eardrum to allow continuous drainage of middle ear fluids. Instruct him or her to not wash the hair or shower for several days.

Health Promotion and Maintenance r/t Hearing Loss

Address barriers to the use of hearing protection, exposure to loud music, and other modifiable risk factors. Teach everyone the danger in using objects such as bobby-pins, Q-tips, or toothpicks to clean the ear canal. Teach all people to use protective ear devices, such as over-the-ear headsets or foam ear inserts, when exposed to persistent loud noises. Suggest using earplugs when engaging in water sports to prevent ear infections, as well as using an over-the-counter product such as Swim-Ear to assist with drying the ears.

Postoperative Care

After surgery an eye patch and shield usually are applied. Monitor the patient's vital signs, and check the eye patch and shield for any drainage. Teach the patient to keep his or her head in the position prescribed by the surgeon to promote reattachment. Teach the patient to report any sudden increase in pain or pain occurring with nausea to the surgeon immediately. Remind the patient to avoid activities that increase intraocular pressure (IOP). Instruct the patient to avoid reading, writing, and close work, such as sewing, in the first week after surgery because these activities cause rapid eye movements and detachment. Teach him or her the manifestations of infection and detachment (sudden reduced visual acuity, eye pain, pupil that does not constrict in response to light) and to notify the surgeon immediately.

History r/t Cataracts

Age is important because cataracts are most prevalent in the older adult. Ask about these predisposing factors: • Recent or past trauma to the eye • Exposure to radioactive materials, x-rays, or UV light • Systemic disease (e.g., diabetes mellitus, hypoparathyroidism) • Prolonged use of corticosteroids, chlorpromazine, beta blockers, or miotic drugs • Intraocular disease (e.g., recurrent uveitis) • Family history of cataracts

Alpha-Adrenergic Agonists

Alpha-adrenergic agonists decrease IOP by decreasing production and improving outflow of aqueous humor. The most common effects of topical administration are burning, stinging, blurred vision, and headache. Epinephrine and dipivefrin cause adverse cardiovascular effects such as tachycardia and hypertension. Patients with narrow-angle glaucoma should not take epinephrine and dipivefrin because dilation of the pupil may allow the iris to block the outflow of aqueous humor, triggering acute closed-angle glaucoma.

Acoustic Neuroma

An acoustic neuroma is a benign tumor of cranial nerve VIII that often damages other structures as it grows. Manifestations begin with tinnitus and progress to gradual sensorineural hearing loss. Later, patients have constant mild to moderate vertigo. The tumor is diagnosed with CT scanning and MRI. Usually a craniotomy is performed, and usually the remaining hearing is lost.

Postoperative Care r/t Tympanoblasty

An antiseptic-soaked gauze, such as iodoform gauze (NU GAUZE), is packed in the ear canal. Keep the dressing clean and dry, using sterile technique for changes. Keep the patient flat, with the head turned to the side and the operative ear facing up for at least 12 hours after surgery. Give prescribed antibiotics.

Drugs for Macular Degeneration

An effective drug has not been identified to treat dry ARMD(age-related macular degeneration). Pharmacologic management of wet ARMD targets vascular endothelial growth factor (VEGF), a substance that plays a role in the formation of abnormal vessels in the eye. These VEGF inhibitors are intravitreal drugs that are injected into the eye

Patient-Centered Collaborative Care

Anti-infective therapy is started before the organism is identified because of the high risk for vision loss. For culture, obtain swabs from the ulcer and its edges. For corneal scrapings, the cornea is anesthetized with a topical agent and a physician or advanced practice nurse removes samples from the ulcer center and edge. Steroids may be used with antibiotics to reduce the eye inflammation. The nursing priorities are to begin the drug therapy, to ensure patient understanding of the drug therapy regimen, and to prevent infection spread. Often the anti-infective therapy involves instilling eyedrops every hour for the first 24. If both eyes are infected, separate bottles of drugs are needed for each eye. Teach the patient to clearly label the bottles "right eye" and "left eye" and not to switch the drugs from eye to eye. Also teach him or her to completely care for one eye, then wash the hands, and using the drugs designated for the other eye, care for that eye. Remind the patient not to wear contact lenses. Patients should not wear contact lenses for weeks to months until the infection is gone and the ulcer is healed.

Antiglaucoma Agents

Antiglaucoma drugs belong to one of the following categories: prostaglandin analogues, beta-adrenergic blockers, alpha-adrenergic agonists, cholinergic agents, carbonic anhydrase inhibitors, or systemic hyperosmotic drugs. Prostaglandin analogues and beta-adrenergic blockers are typically first-line therapy, followed by alpha-adrenergic agonists.

Antiinflammatories

Antiinflammatories should not be given if the patient has a viral infection. When allergies are the cause of eye inflammation, ophthalmic antihistamines and mast cell stabilizers are commonly prescribed to treat the underlying cause.

red reflex

As you direct the ophthalmoscope at the pupil, a red glare (red reflex) should be seen in the pupil as a reflection of the light on the retina. An absent red reflex may indicate a lens opacity or cloudiness of the vitreous.

Rosenbaum Pocket Vision Screener or a Jaeger card

Ask the patient to hold the card 14 inches away from his or her eyes and read the characters. Test each eye separately and then together.

What might you NOTICE if the patient is experiencing reduced visual sensory perception?

Assessment: • Patient squints or tilts the head when viewing objects or print at a distance. • Patient closes one eye to read or see at a distance. • Patient moves reading materials either very close to his or her face or as far away from the face as he or she can reach. • Patient may not startle when a sudden move is made at the face. • Pupils are unequal and may not react to light. • Eyes do not focus on a distant object and track it as it is moved closer to the face. • Red reflex may be absent or present in only one eye. • Patient does not make eye contact and turns head toward sounds rather than sights. • Patient walks with hesitation into a room or bumps into objects in his or her path. • Patient may seem confused about time and place.

Preoperative Care r/t Tympanoblasty

Assure the patient that hearing loss immediately after surgery is normal because of canal packing and that hearing will improve when it is removed. Stress that forceful coughing increases middle ear pressure and must be avoided.

Corneal ulceration

Bacterial, protozoal, and fungal infections can lead to corneal ulceration, which is a deeper injury. This problem is an emergency because the cornea has no separate blood supply and infections that can permanently impair vision develop rapidly

Beta-Adrenergic Blockers

Beta-adrenergic blockers, also known as beta blockers, are one of the first-line drugs used in the treatment of glaucoma. Beta-adrenergic blockers decrease IOP by decreasing the production of aqueous humor. May cause some eye discomfort, which is possible with most eye medications. Some types cause miosis. May experience vision problems at night. Can slow the heart rate, which can worsen bradycardia, AV heart block, and heart failure. Also, these drugs can prevent adequate bronchodilation in patients who have asthma and other obstructive pulmonary diseases.

Carbonic Anhydrase Inhibitors

Carbonic anhydrase inhibitors (CAIs) decrease IOP by decreasing the production of aqueous humor. These drugs, initially developed as diuretics, are sometimes used for adjunctive treatment of glaucoma. They are indicated for both open-angle and acute closed-angle glaucoma. CNS effects such as lethargy, drowsiness, headache, seizures, paresthesias, and mental status changes. GI effects such as nausea, vomiting, diarrhea, altered taste, and anorexia may occur. Because they have diuretic effects, polyuria and increased thirst are common, and fluid and electrolyte disturbances may occur as a result. They may promote hyperuricemia, which may precipitate gout attacks. They may also worsen liver disease.

Cerumen or Foreign Bodies

Cerumen (earwax) is the most common cause of an impacted canal. A canal can also become impacted as a result of foreign bodies. Cerumen impaction in the older adult is common. May have a sensation of fullness in the ear, with or without hearing loss, and may have ear pain, itching, dizziness, or bleeding from the ear. When the occluding material is cerumen, management options include watchful waiting, manual removal, and the use of ceruminolytic agents followed by either manual irrigation or the use of a low-pressure electronic oral irrigation device. Discourage the use of cotton swabs and ear candles to clean the ears or remove cerumen. Insects are killed before removal unless they can be coaxed out. A topical anesthetic can be placed in the ear canal for pain relief.

Conjunctivitis

Conjunctivitis is an inflammation with or without infection of the conjunctiva. Allergic conjunctivitis manifestations are edema, a sensation of burning, a "bloodshot" eye appearance, excessive tears, and itching. Management includes vasoconstrictor and corticosteroid eyedrops. Instruct patients to avoid using makeup. Bacterial conjunctivitis, or "pink eye," is most often caused by S. aureus. Manifestations are blood vessel dilation, edema, tears, and discharge. Ophthalmic antibiotics are prescribed to eliminate the infection. Nursing interventions focus on preventing infection spread to the other eye or to other people. Remind the patient to wash his or her hands after touching the eye and before using eyedrops. Warn him or her not to touch the unaffected eye without first washing the hands and to avoid sharing washcloths and towels with others. Instruct patients to discard 980eye makeup and applicators used at the time the infection developed. Contact lenses worn during the infection need to be discarded

consensual response

Constriction of the left pupil when light is shined at the right pupil and vice versa

Inner Ear

Contains the semicircular canals, the cochlea, the vestibule, and the distal end of the eighth cranial nerve.

Nursing Interventions.

Do not shout at the patient. Communicate by writing (if he or she is able to see, read, and write) or pictures of familiar phrases and objects. Use assistive devices. Lip-reading and sign language can increase communication. Managing anxiety can increase the effectiveness of communication efforts.

Laboratory Assessment

Cultures of corneal or conjunctival swabs and scrapings help diagnose infections. Obtain a sample of the exudate for culture before antibiotics or topical anesthetics.

Immunosuppressants

Cyclosporine suppresses the immune response that leads to inflammation, allowing tear production to resume. Ophthalmic corticosteroids are another type of immunosuppressant. Corticosteroids are used to treat a number of conditions that manifest as significant eye inflammation. Because they suppress the immune response, ophthalmic immunosuppressants should not be given to patients with bacterial infections of the eye unless accompanied by an antibiotic that treats the underlying infection. Ophthalmic immunosuppressants are contraindicated for viral eye infections such as herpes.

Vertigo and Dizziness

Dizziness is a disturbed sense of a person's relationship to space. True vertigo is a sense of whirling or turning in space. Problems that cause vertigo include Ménière's disease, labyrinthitis, acoustic neuromas, motion sickness, and drug or alcohol ingestion. Manifestations of vertigo include nausea, vomiting, falling, nystagmus, hearing loss, and tinnitus. Teach patients these strategies to reduce manifestations: • Restrict head motion and change position slowly • Take drugs that reduce the vertigo effects, such as over-the counter dimenhydrinate (Dramamine, Gravol ) or prescription drugs such as diazepam (Valium, Apo-Diazepam ), meclizine (Antivert, Bonamine ), and scopolamine (Transderm Scop, Transderm-V )

mydriasis

pupillary dilation

Nonsurgical Management r/t Hearing Loss

Early detection helps correct the problem causing the hearing loss. Drug therapy is focused on correcting the underlying problem or reducing the side effects of problems occurring with hearing loss. Assistive devices are useful for patients with permanent hearing loss. Flashing lights activated by the ringing telephone or a doorbell alert patients visually. Some patients may have a service dog to alert them to sound. A difficult aspect of a hearing aid is the amplification of background noise. Cochlear implantation may help patients with sensorineural hearing loss.

Physical Assessment/Clinical Manifestations of Cataracts

Early manifestations of cataracts are slightly blurred vision and decreased color perception. Without surgical intervention, visual impairment progresses to blindness. No pain or eye redness is associated with age-related cataract formation. When this occurs, the pupil is bluish white.

Auditory Brainstem-Evoked Response

Electrodes are placed on the scalp during the test. Auditory brainstem-evoked response (ABR) assesses hearing in patients who are unable to indicate their recognition of sound stimuli during standard hearing tests.

Ocular Antiinfectives

Examples of other ocular conditions treated with ophthalmic antiinfective drugs include the following: •Blepharitis (infection of margins of eyelid) •Chalazion (infection of meibomian glands of the eyelids that may produce cysts, causing blockage of the ducts) •Bacterial and fungal endophthalmitis (infection and inflammation of structures of the inner eye) •Hordeolum (local infection of eyelash follicles and glands on lid margins, also known as a stye) •Infectious keratitis (corneal infection and inflammation) •Infectious uveitis (infection of vascular layer of eye [ciliary body, choroid, and iris])

Decongestants

Eye inflammation typically presents with redness due to vascular congestion of the conjunctiva. Ophthalmic decongestants are vasoconstrictors that manage these effects by narrowing these blood vessels.

Lubricants

Eye lubricants replace tears to alleviate discomfort associated with eye dryness. They are also used to moisten contact lenses and artificial eyes.

Foreign Bodies

Eyelashes, dust, dirt, and airborne particles can come in contact with the conjunctiva or cornea and irritate or abrade the surface. If nothing is seen on the cornea or conjunctiva, the eyelid is everted to examine the conjunctivae. The patient usually has a feeling of something being in the eye and may have blurred vision. Pain occurs if the corneal surface is injured. The eye is examined with fluorescein, followed by irrigation with normal saline (0.9%) to gently remove the particles. Best practices for ocular irrigation are listed in Chart 47-7. PG 991! Med-Surg

Home Care Management r/t Cataract Surgery

Family members can be taught the procedure or adaptive equipment that positions the bottle of eyedrops directly over the eye can also be purchased. Before discharge, review these indications of complications after cataract surgery with the patient and family: • Sharp, sudden pain in the eye • Bleeding or increased discharge • Green or yellow, thick drainage • Lid swelling • Reappearance of a bloodshot sclera after the initial appearance has cleared • Decreased vision • Flashes of light or floating shapes Remind the patient to avoid activities that might increase IOP. Instruct the patient to avoid getting water in the eye for 3 to 7 days after surgery.

Laboratory Assessment r/t Ear

For an external ear infection, the typical causative organisms are known and this infection is managed without obtaining cultures.

Nutrition History

For example, vitamin A deficiency can cause eye dryness, keratomalacia, and blindness. Some nutrients and antioxidants, such as lutein and beta carotene, help maintain retinal function. A diet rich in fruit and red, orange, and dark green vegetables is important to eye health.

silver nitrate 1% (Dey-Drop)

For prophylaxis of ophthalmia neonatorum caused by N. gonorrhoeae

Glaucoma

Glaucoma is a group of eye disorders resulting in increased IOP (intraocular pressure). There are several causes and types of glaucoma (Table 47-3), classified as primary, secondary, or associated.

Speech Audiometry.

In speech audiometry, the patient's ability to hear spoken words is measured. Speech reception threshold is the minimum loudness at which a patient can repeat simple words. Speech discrimination testing determines the patient's ability to discriminate among similar sounds or among words that contain similar sounds. This test assesses the patient's understanding of speech.

enucleation

If the eye contents have prolapsed through the laceration or if the injury is severe, enucleation (surgical eye removal) may be indicated.

light perception (LP)

In a darkened room, direct the beam of a penlight at the patient's right eye from a distance of 2 to 3 feet for 1 to 2 seconds. Instruct the patient to say "on" when the beam of light is perceived and "off" .

Occupation and leisure activities

In occupations such as computer programming, constant exposure to monitors may lead to eyestrain. Machine operators are at risk for eye injury because of the high speeds at which particles can be thrown at the eye. Chronic exposure to infrared or ultraviolet light may cause photophobia and cataract formation. Teach the patient about the use of eye protection during work.

Diagnostic Assessment of Glaucoma

In open-angle glaucoma, the tonometry reading is between 22 and 32 mm Hg (normal is 10 to 21 mm Hg). In angle-closure glaucoma, the tonometry reading may be 30 mm Hg or higher.

What should you INTERPRET and how should you RESPOND to a patient experiencing reduced visual sensory perception?

Interpret by: • Assessing visual acuity with an eye chart, counting fingers, hand motion, or light perception • Asking the patient to describe the objects in the room and their colors • Asking the patient what he or she can see well and what is more difficult to see Respond by: • Orienting the patient to the immediate surroundings • Offering your arm for the patient to hold when he or she is moving to a different location • Not leaving the patient alone in the center of a strange room • Asking him or her what assistance is needed for independent activity • Assessing the immediate environment for safety hazards and removing the hazard

Audiometry.

Is the most reliable method of measuring the acuity of auditory sensory perception. The lowest intensity at which a young, healthy ear can detect sound about 50% of the time is 0 dB. Sound at 110 dB is so intense (loud) that it is painful for most people with normal hearing. Conversational speech is around 60 dB, and a soft whisper is around 20 dB (Table 48-1). With a hearing loss of 45 to 50 dB, speech cannot be heard without a hearing aid.

Labyrinthitis

Labyrinthitis is an infection of the labyrinth, which may occur as a complication of acute or chronic otitis media. Labyrinthitis also may result from the growth of a cholesteatoma (benign overgrowth of squamous cell epithelium) from the middle ear into the semicircular canal. Manifestations include auditory sensory perception loss, tinnitus, nystagmus to the affected side, and vertigo with nausea and vomiting. Labyrinthitis is usually a self-limiting condition. Teach the patient to complete the antibiotic therapy. Advise patients to stay in bed in a darkened room until manifestations are reduced. Antiemetics and antivertiginous drugs, such as dimenhydrinate (Dramamine, Gravol ) and meclizine (Antivert, Bonamine ), relieve nausea and dizziness.

Lacerations

Lacerations are caused by sharp objects and projectiles. The injury occurs most commonly to the eyelids and cornea. Initially the eye is closed and a small ice pack is applied to decrease bleeding. Minor lacerations of the eyelid can be sutured. Corneal lacerations are an emergency because eye contents may prolapse through the laceration. Manifestations include severe eye pain, photophobia, tearing, decreased vision, and inability to open the eyelid. Antibiotics are given to reduce the risk for infection. Depending on the depth of the laceration, scarring may develop. If the scar alters vision, a corneal transplant may be needed later.

Inspection

Look for head tilting, squinting, or other actions that indicate the patient is trying to attain clear vision. Assess for symmetry in the appearance of the eyes. In dark-skinned people, the normal sclera may appear yellow and small, pigmented dots may be visible. The cornea is best seen by directing a light at it from the side. Assess the blink reflex. Observe pupils for response to light. The pupils are usually round and of equal size. Evaluate each pupil for speed of reaction. Assess for accommodation by holding your finger about 18 cm from the patient's nose and move it toward the nose.

Hearing Loss

Loss of auditory sensory perception is common and may be conductive, sensorineural, or a combination of the two. Conductive hearing loss can be caused by any inflammation or obstruction of the external or middle ear, changes in the eardrum, tumors, scar tissue, and overgrowth of soft bony tissue (otosclerosis). Sensorineural hearing loss occurs when the inner ear or auditory nerve (cranial nerve VIII) is damaged. Prolonged exposure to loud noise, ototoxic drugs.

Nonsurgical Management.

Loss of visual sensory perception from glaucoma can be prevented by early detection, lifelong treatment, and close monitoring. Use of ophthalmic drugs that reduce ocular pressure delays or prevents damage. Drug therapy for glaucoma works to reduce IOP in several ways. Eyedrop drugs can reduce the production, increase the absorption of aqueous humor, or constrict the pupil so that the ciliary muscle is contracted, allowing better circulation of the aqueous humor to the site of absorption. These drugs do not improve lost vision but prevent more damage by decreasing IOP. Teach patients the importance of instilling the drops on time and not skipping doses. When more than one drug is prescribed, teach him or her to wait 5 to 10 minutes between drug instillations to prevent one drug from "washing out" or diluting another drug. Stress the need for good handwashing, keeping the eyedrop container tip clean, and avoiding touching the tip to any part of the eye. Also teach the technique of punctal occlusion.

Mastoiditis

Mastoiditis is an infection of the mastoid air cells caused by progressive otitis media. The manifestations of mastoiditis include swelling behind the ear and pain when moving the ear or the head. Cellulitis develops on the skin or external scalp over the mastoid process, pushing the ear sideways and down. The eardrum is red, dull, thick, and immobile. Lymph nodes behind the ear are tender and enlarged. Patients may have low-grade fever, malaise, and ear drainage. Hearing loss occurs, and CT scans show fluid in the air cells. Interventions focus on halting the infection before it spreads to other structures. Surgical removal of the infected tissue is needed if the infection does not respond to antibiotic therapy.

Ocular Melanoma

Melanoma is the most common malignant eye tumor in adults. This tumor occurs most often in the uveal tract among people in their 30s and 40s and is associated with exposure to ultraviolet (UV) light. Blurred vision may occur if the macular area is invaded. Vision is reduced if the tumor grows inward toward the center of the eye and alters the visual pathway. Increased intraocular pressure (IOP) can result if the tumor obstructs flow of aqueous humor. Iris color changes when the tumor infiltrates the iris. Sudden loss of a visual field may result from tumor invasion that causes retinal detachment.

Pharmacotherapy r/t Ménière's Disease

Mild diuretics are prescribed to decrease endolymph volume, which reduces vertigo, hearing loss, tinnitus, and aural fullness. Nicotinic acid has been found to be useful because of its vasodilatory effect. Antihistamines, such as diphenhydramine hydrochloride (Benadryl, Allerdryl image) and dimenhydrinate (Dramamine, Gravol image), and antivertiginous drugs, such as meclizine (Antivert, Bonamine image), help reduce the severity of or stop an acute attack. Antiemetics, such as chlorpromazine hydrochloride (Thorazine, Novo-Chlorpromazineimage), droperidol (Inapsine), promethazine (Phenergan), and ondansetron (Zofran), help reduce the nausea and vomiting. Diazepam (Valium, Apo-Diazepam image) calms the patient; reduces vertigo, nausea, and vomiting.

Patient-Centered Collaborative Care r/t Reduced Visual Sensory Perception

Moving the head slightly up and down can enhance a three-dimensional effect. When shaking hands or pouring water, the patient can line up the object and move toward it. He or she should choose a position that favors the eye with better vision. For example, people with vision in the right eye should position people and items on their right. Nursing interventions for the patient with reduced sight focus on communication, safety, ambulation, self-care, and support. Chart 47-8 PG993 lists ways to help patients with reduced vision to function as independently as possible. Larger font sizes and auditory cues in public and private environments assist reduced perception.

Anticholinergic Mydriatics and Cycloplegics

Mydriatics dilate the pupils; cycloplegics paralyze the muscles of accommodation. Both are used in diagnostic procedures and ophthalmic surgery. Side effects of topical anticholinergics include xerophthalmia (dry eyes), photophobia (sensitivity to light), and blurred vision; and include dry mouth, increased heart rate, and constipation.

Ménière's Disease

Ménière's disease has three features: tinnitus, one-sided sensorineural auditory sensory perception loss, and vertigo, occurring in attacks that can last days. The pathology of Ménière's disease is an excess of endolymphatic fluid that distorts the entire inner-canal system. More common in men. Patients often have certain manifestations before an attack of vertigo, such as headaches, increasing tinnitus, and fullness in the affected ear. Nausea and vomiting are common. Other manifestations include rapid eye movements (nystagmus) and severe headaches. Teach patients to move the head slowly to prevent worsening of the vertigo. Nutrition and lifestyle changes can reduce the amount of endolymphatic fluid. Encourage patients to stop smoking because of the blood vessel constricting effects.

presbyopia

Near objects, especially reading material, must be placed farther from the eye to be seen clearly

Cholinergic Agents

Ophthalmic cholinergic agents cause miosis, which is a constriction of the pupil, and contraction of the ciliary muscle. These actions result in a widening of the trabecular meshwork to improve outflow of excess aqueous humor.

Physical Assessment/Clinical Manifestations r/t Glaucoma

Ophthalmoscopic examination shows cupping and atrophy of the optic disc. It becomes wider and deeper and turns white or gray. Manifestations of acute angle-closure glaucoma include a sudden, severe pain around the eyes that radiates over the face. Headache or brow pain, nausea, and vomiting may occur. Other manifestations include seeing colored halos around lights and sudden blurred vision with decreased light perception. The sclera may appear reddened and the cornea foggy.

Osmotics

Osmotics are generally used preoperatively and postoperatively to decrease vitreous humor volume, reducing IOP. These drugs are primarily used in the emergency treatment of acute closed-angle glaucoma because of their ability to rapidly reduce IOP. Osmotic medications can cause headache, nausea, vomiting, and diarrhea. Disorientation resulting from electrolyte imbalances can result.

Chart 46-3 Best Practice for Patient Safety & Quality Care image Instillation of Eyedrops

PG 975!! Med-Surg *When instilling eyedrops, teach patients to use nasal punctal occlusion to reduce the risk for systemic absorption and side effects. †When more than one topical ophthalmic drug is prescribed, teach patients to separate the instillation of each drug by 5-10 minutes (or package recommendations).

Chart 47-1 Instillation of Ophthalmic Ointment

PG 977!! Med-Surg

Chart 47-3 Application of an Ocular Compress

PG 978!! Med-Surg

Chart 47-4 The Patient After Cataract Surgery

PG 984 Med-Surg

Chart 47-5 Promote Independent Living in Patients with Impaired Vision

PG 987!! Med-Surg

Chart 48-1 Nursing Focus on the Older Adult Age-Related Changes in the Ear and Hearing

PG 998!! Med-Surg

Chart 48-2 Self-Ear Irrigation for Cerumen Removal

PG 999!! Med-Surg

Safety r/t Reduced Visual Sensory Perception 2

Patients with reduced vision prefer to establish the location of important objects, such as the call light, water pitcher, and clock. Once their location has been fixed, do not move these items without the patient's consent. Do not move the location of chairs, stools, and wastebaskets. At mealtime, set up food on the tray using clock placement. Ambulation with a patient who has reduced vision is best when he or she holds your arm at the elbow. Patients may use a cane to detect obstacles. Self-care and the ability to control the environment are important. Knock on the door before entering. State your name and the reason for visiting. They need to hear that it is normal to mourn, to cry, and to feel the loss. Help them move toward acceptance by encouraging the mastery of one task at a time.

Home Care Management.

Patients with vertigo are at risk for falls. Assess home environment for obstacles such as furniture and poor lighting.

Perichondritis

Perichondritis is an infection of the perichondrium, a tough, fibrous tissue layer that surrounds the cartilage and shapes the pinna. The purposes of management are to eliminate the infection and ensure that the perichondrium stays in direct contact with the cartilage. In addition to systemic antibiotic therapy, a wide incision is made and suction drainage is used to remove pus and other fluid.

A patient with adequate visual sensory perception:

Physical assessment: • Eyes are symmetric on the face on a line just about even with the tops of the ears. • Eyes are clear with no drainage or open areas. • Patient does not squint or tilt the head. • Patient does not close one eye to read or see at a distance. • Patient startles when a sudden move is made at the face. • Patient blinks 5 to 10 times per minute. • Pupils are the same size in each eye. • Both pupils constrict when a light is shined at only one eye. • Patient comments on the presence of art or unusual visual objects in the immediate environment. • Patient walks without hesitation into a room without bumping into objects in his or her path. Psychological assessment: • Patient is oriented and not confused. • Patient makes eye contact when speaking.

Patient History

Posture changes, such as tilting the head to one side or leaning forward when listening to another person speak, may indicate the presence of a hearing problem. Other indicators of hearing difficulty include frequently asking the speaker to repeat statements or frequently saying "What?" or "Huh?" Notice whether the patient responds to whispered questions and startles when an unexpected sound occurs in the environment. Also assess whether the patient's responses match the question asked. During the interview, sit in adequate light and face the patient to allow him or her to see you speak. Use short, simple language the patient is comfortable with. The patient's gender is important. Some hearing disorders, such as otosclerosis, are more common in women. Other disorders, such as Ménière's disease, are more common in men. If the patient uses foreign objects to clean the ear canal, explain the danger in using these objects. They can scrape the skin of the canal, push cerumen up against the eardrum, and even puncture the eardrum.

miosis

Pupillary constriction

Pure-Tone Audiometry.

Pure-tone audiometry generates tones that are presented to the patient at frequencies for hearing speech, music, and other common sounds. Pure-tone air-conduction testing determines whether a patient hears normally or has a hearing loss. It tests air-conduction hearing sensitivity (through earphones). Pure-tone bone-conduction testing determines whether the hearing loss detected by air-conduction testing is due to conductive or sensorineural factors or to a combination of the two. It is used only when air-conduction testing results are abnormal. Testing is similar to air-conduction testing except that a bone-conduction vibrator is used.

Reduced Visual Sensory Perception

Reduced vision may be temporary, such as when cataracts obscure vision but surgery has not yet been performed. Patients are legally blind if their best visual acuity with corrective lenses is 20/200 or less in the better eye or if the visual field is 20 degrees or less.

Refractive Errors

Refraction is the bending of light rays. Myopia is nearsightedness, in which the eye over-refracts the light and the bent images fall in front of, not on, the retina. Hyperopia, also called hypermetropia, is farsightedness, in which refraction is too weak, causing images to be focused behind the retina. Presbyopia is the age-related problem in which the lens loses its elasticity and is less able to change shape to focus the eye for close work. As a result, images fall behind the retina. This problem usually begins in people in their 30s and 40s. Astigmatism occurs when the curve of the cornea is uneven. Because light rays are not refracted equally in all directions, the image does not focus.

Nonsurgical Management r/t Refractive Errors

Refractive errors are corrected with eyeglass lenses or contact lenses that focus light rays on the retina. Hyperopic vision is corrected with a convex lens that moves the image forward. Myopic vision is corrected with a biconcave lens to move the image back to the retina.

Postoperative Care r/t Stapedectomy

Remind the patient that improvement in hearing may not occur until 6 weeks after surgery. Drugs for pain help reduce discomfort, and antibiotics are used. Vertigo, nausea, and vomiting usually occur after surgery because of the nearness to inner ear structures. Antivertiginous drugs, such as meclizine (Antivert, Bonamine ), and antiemetic drugs, such as droperidol (Inapsine), are given. Take care to prevent falls.

Gender

Retinal detachments occur more often in men, and dry eye syndromes occur more often in women.

Retinitis Pigmentosa

Retinitis pigmentosa (RP) is a condition in which retinal nerve cells degenerate and the pigmented cells of the retina grow and move into the sensory areas of the retina, causing further degeneration. The earliest manifestation of RP is night blindness, often occurring in childhood. Over time, decreased acuity progresses to total blindness. Examination of the retina shows heavy pigmentation in a lacy pattern. Cataracts may accompany this disorder. No current therapy is effective in preventing the degenerative process. Teach patients with RP to avoid drugs that are known to adversely affect retinal cells, such as isotretinoin (Accutane) and drugs for erectile dysfunction (e.g., sildenafil [Viagra]). Also remind them to wear eyeglasses that provide ultraviolet protection. The ingestion of 15,000 international units of vitamin A daily is recommended to slow the progression of the disorder, as is the daily ingestion of docosahexaenoic acid (DHA), an omega-3 fatty acid and antioxidant. Additional supplements that may slow the progression of RP include beta carotene, lutein, and zeaxanthin.

Chart 48-7 PG 1010 The Patient with Suspected Hearing Loss

Skull x-rays determine bony involvement in otitis media and the location of otosclerotic lesions. CT and MRI are used to determine soft-tissue involvement and the presence and location of tumors.

hand motion (HM) acuity

Stand about 2 to 3 feet in front of the patient. Ask him or her to cover the eye not being tested. Direct a light onto your hand from behind the patient. Demonstrate the three possible directions in which the hand can move during the test (stationary, left-right, or up-down) (1 second per motion).

Operative Care r/t Cataracts

Stress that care after surgery requires the instillation of different types of eyedrops several times a day for 2 to 4 weeks. Ask whether the patient takes any drugs that affect blood clotting, such as aspirin, warfarin (Coumadin), clopidogrel (Plavix), and dabigatran (Pradaxa). Immediately after surgery, antibiotic and steroid ointments are instilled. The patient usually is discharged within an hour. Instruct him or her to wear dark glasses outdoors or in brightly lit environments until the pupil responds to light. Remind the patient that mild eye itching is normal, as is a "bloodshot appearance." The eyelid may be slightly swollen. Discomfort at the site is controlled with acetaminophen (Abenol, Tylenol) or acetaminophen with oxycodone (Endocet, Percocet, Tylox). Instruct patients to contact the surgeon if pain occurs with nausea or vomiting r/t IOP. Creamy white, dry, crusty drainage on the eyelids and lashes is normal. However, yellow or green drainage indicates infection and must be reported. Remind them that final best vision will not occur until 4 to 6 weeks after surgery.

Safety r/t Reduced Visual Sensory Perception 1

Stress to family members not to change item locations without input from the patient. Teach family members with vision to make these home adaptations to increase the patient's independence and safety: • Using tape and a heavy black marker, mark the 350-degree temperature setting on the oven and mark the 70-degree temperature setting on the heating or cooling thermostat. • Paint or mark light switches in a deep color that contrasts with the surrounding wall. • Label canned goods with large, bold, black letters on white tape. • Teach the patient to feel for the crease in paper milk cartons that indicates the place to open the spout. • Differentiate different drugs by altering the shape of a bottle. Rubber bands can be wound around a bottle to change its texture. Raised symbols can be glued to caps to make identification easier. First orient the patient to the immediate environment, including the size of the room. Use one object in the room, such as a chair or hospital bed, as the focal point for the description. Guide the person to the focal point, and orient him or her to the environment from that point. Highlight the location of the toilet, sink, and toilet paper.

Surgical Management of Glaucoma

Surgery is used when drugs for open-angle glaucoma are not effective at controlling IOP. If glaucoma fails to respond to common approaches, an implanted shunt procedure may be used.

Health Promotion and Maintenance

Teach people to protect the eyes by using sunglasses that filter UV light whenever they are outdoors, at tanning salons, and when work involves UV exposure. Teach people to avoid rubbing the eyes to avoid trauma to outer eye surfaces. Teach everyone to wash their hands before touching the eye or eyelid. Teach everyone to wash their hands before touching the eye or eyelid. Teach all people who have a refractive error to have an eye examination yearly.

Refractive Structures and Media

The cornea is the clear layer on the front of the eye.The curve of the lens changes to focus on near or distant objects. A cataract is a lens that has lost its transparency. The vitreous body is a clear, thick gel that transmits light and maintains eye shape. The aqueous humor is a clear, watery fluid that fills the anterior and posterior chambers and contributes to intraocular pressure. IOP has to be just right. If the pressure is too low, the eyeball is soft and collapses, preventing light from getting to the photoreceptors on the retina in the back of the eye. If the pressure becomes too high, the extra pressure compresses capillaries in the eye as well as nerve fibers.

Antihistamines and Decongestants for the Ear

The effects on multiple short- and long-term outcomes repeatedly demonstrated no benefit for use of these medications over placebo for treating OME(otitis media w/ effusion). The reviewed studies found evidence of increased side effects and harms with use of these medications. Numerous OTC antihistamine-decongestant medications are readily available to unknowing patients.

Eustachian Tube

The eustachian tube begins at the floor of the middle ear and extends to the throat. The tube opening in the throat is surrounded by adenoid lymphatic tissue (Fig. 48-4). The eustachian tube allows the pressure on both sides of the eardrum to equalize.

External Ear

The external ear includes the mastoid process, which is the bony ridge located over the temporal bone behind the pinna. The ear canal is slightly S-shaped and lined with cerumen-producing glands, oil glands, and hair follicles.

Herbal Alert 49-1 Herbs and Antiglaucoma Agents

The following herbs should be avoided in patients with glaucoma: bitter orange, blood root, celandine, coffee, corkwood, ephedra, goldenseal, and jimsonweed. Because all herbs have inherent risks, it is important to receive approval from the patient's health care provider .

Neoplasms

The growth of any lesion within the middle ear area disrupts conductive auditory sensory perception, erodes the ossicles, and may affect the inner ear and cranial nerves. Patients have progressive hearing loss and tinnitus. Infection and pain are rare. Diagnosis is made by physical examination, tomography, and angiography. Tumors are removed by surgery, which often destroys hearing. Benign tumors are removed becuase of possible structural changes.

Age

The incidence of glaucoma and cataract formation increases with aging. Presbyopia commonly begins in the 40s.

Tympanic Membrane

The landmarks on the eardrum include the annulus, the pars flaccida, and the pars tensa. These correspond to the parts of the malleus that can be seen through the transparent eardrum.

Middle Ear

The middle ear consists of a compartment called the epitympanum. 9Located in the epitympanum are the top opening of the eustachian tube and three small bones known as the bony ossicles, which are the malleus (hammer), the incus (anvil), and the stapes (stirrup).

Structure of the Eye

The orbit is the bony socket of the skull that surrounds and protects the eye. The external layer is the sclera (the "white" of the eye) and the transparent cornea on the front. The middle layer, or uvea, is heavily pigmented and consists of the choroid, the ciliary body, and the iris. It has many blood vessels that supply nutrients to the retina. The ciliary body connects the choroid with the iris and secretes aqueous humor. The iris is the colored portion of the external eye; its center opening is the pupil. The muscles of the iris contract and relax to control pupil size. The innermost layer is the retina, made up of sensory photoreceptors. Two types of photoreceptors called rods and cones. The rods work at low light levels and provide peripheral vision. The cones are active at bright light levels and provide color and central vision. The optic fundus is the area at the inside back of the eye that can be seen with an ophthalmoscope. This area contains the optic disc. To one side of the optic disc is a small, yellowish pink area called the macula lutea. The center of the macula is the fovea centralis, where vision is most acute.

Surgical Management r/t Refractive Errors

The most common vision-enhancing surgery is laser in-situ keratomileusis (LASIK). This procedure can correct nearsightedness, farsightedness, and astigmatism. Complications of LASIK include infection, corneal clouding, chronic dry eyes, and refractive errors. Some patients have developed blurred vision, halos around lights, and other refractive errors months to years after this surgery as a result of excessive laser-thinning of the cornea. The cornea then becomes unstable and does not refract appropriately.

Surgical Management r/t Ménière's Disease

The most radical procedure involves resection of the vestibular nerve or total removal of the labyrinth (labyrinthectomy). Endolymphatic decompression with drainage and a shunt.

Patient-Centered Collaborative Care r/t Retinal Holes, Tears, and Detachments

The onset of a retinal detachment is usually sudden and painless. Patients may suddenly see bright flashes of light (photopsia) or floating dark spots in the affected eye. During the initial phase of the detachment or if the detachment is partial, the patient may describe the sensation of a curtain being pulled over part of the visual field. The visual field loss corresponds to the area of detachment. Detachments are seen as gray bulges or folds in the retina. Instruct the patient to restrict activity and head movement before surgery to prevent further tearing or detachment.

Planning: Expected Outcomes r/t Cataracts

The patient with cataracts is expected to recognize when ADLs cannot be performed safely and independently and then is expected to have cataract surgery.

Tympanoplasty.

The procedures vary from simple reconstruction of the eardrum (myringoplasty) to replacement of the ossicles within the middle ear (ossiculoplasty).

Accommodation

The process of maintaining a clear visual image when the gaze is shifted from a distant to a near object

Otoscopic Assessment

The purpose of a brief otoscopic examination is to assess the patency of the external canal, identify lesions or excessive cerumen in the canal, and assess whether the tympanic membrane (eardrum) is intact or inflamed. Tilt the patient's head slightly away, and hold the otoscope upside down, like a large pen. Gently pull the pinna up and back with your other hand to straighten the canal. Redness is seen in otitis media. Reflection of the otoscope's light from the normal eardrum is the light reflex, and it appears as a clearly outlined triangle. The light reflex is termed diffuse when the light reflex is spotty or multiple because of a changed eardrum.

Patient-Centered Collaborative Care r/t Macular Degeneration

The risk for dry AMD can be reduced by increasing long-term dietary intake of antioxidants, vitamin B12, and the carotenoids lutein and zeaxanthin. Laser therapy to seal the leaking blood vessels can limit the extent of the damage. Ocular injections with the vascular endothelial growth factor inhibitors (VEGFIs), such as bevacizumab (Avastin) or ranibizumab (Lucentis), can improve vision for the patient with wet AMD.

Topical Anesthetics

The two most common topical ophthalmic anesthetics are proparacaine HCl and tetracaine HCl (Pontocaine). Both medications are administered as drops. The blink reflex is temporarily lost; therefore, the corneal epithelium may become dry. To protect the eye, a patch is usually worn until the effects of the drug are gone.

Prostaglandin Analogues

These drugs decrease IOP by improving trabecular outflow and by increasing the uveoscleral pathway, which is an alternate pathway of aqueous humor outflow. Change the color of the iris by increasing brown pigmentation. Darkening of the eyelids may also occur. Another unusual side effect is the development of eyelash hypertrichosis. May also develop blurred vision, redness of the conjunctiva, and itching or stinging of the eye.

Trauma

Trauma and damage may occur to the eardrum and ossicles by infection, by direct damage, or through rapid changes in the middle ear pressure. Most eardrum perforations heal within a week or two without treatment. Nursing care priorities focus on teaching about trauma prevention. Caution patients to avoid inserting objects into the external canal. Stress the importance of using ear protectors when blunt trauma is likely.

Tinnitus

Tinnitus (continuous ringing or noise perception in the ear) is a common ear problem. Factors that contribute to tinnitus include age, sclerosis of the ossicles, Ménière's disease, certain drugs (aspirin, NSAIDs, high-ceiling diuretics, quinine, aminoglycoside antibiotics), exposure to loud noise, and other inner ear problems. Factors that contribute to tinnitus include age, sclerosis of the ossicles, Ménière's disease, certain drugs (aspirin, NSAIDs, high-ceiling diuretics, quinine, aminoglycoside antibiotics), exposure to loud noise, and other inner ear problems. hen no cause can be found or the disorder is untreatable, therapy focuses on ways to mask the tinnitus with different sounds like music or white noise. A drug that is helpful to some patients is pramipexole (Mirapex), an antiparkinson drug.

Totally Implanted Devices.

Totally implanted devices, such as the Esteem, can improve bilateral moderate to severe sensorineural hearing loss without any visible part. Patient criteria for totally implantable devices include: • Bilateral stable sensorineural hearing loss • Speech discrimination score of 40% or higher • Healthy tympanic membrane, eustachian tube, and ossicles of the middle ear • Large enough ear cavity to fit the device components • At least 30 days experience with an appropriate hearing aid • Absence of middle ear, inner ear, or mastoid infection • Absence of Ménière's disease or recurring vertigo • Absence of sensitivity to device materials

Tympanometry.

Tympanometry assesses mobility of the eardrum and structures of the middle ear by changing air pressure in the external ear canal.

Patient-Centered Collaborative Care r/t Ocular Melanoma

Ultrasonography or MRI is performed to determine the tumor's location and size. Tumors of the choroid are treated by surgical enucleation or by radiation therapy with a radioactive plaque. Enucleation (surgical removal of the entire eyeball) is the most common surgery for ocular melanoma and is performed under general anesthesia. After the eye is removed, a ball implant is inserted as a base for the socket prosthesis, which is fitted about 1 month after surgery. Radiation therapy is an "eye-sparing" procedure that can reduce the size and thickness of melanomas and sometimes eliminates the tumor completely. The radioactive plaque—a round, flat disk about the size of a dime and containing a radioactive material—is sutured to the sclera overlying the tumor site. Complications of radiation therapy include vascular changes, retinopathy, glaucoma, necrosis of the sclera, and cataract formation.

retinal hole

a break in the retina. These holes can be caused by trauma or can occur with aging.

Trachoma

a chronic conjunctivitis caused by Chlamydia trachomatis. It scars the conjunctiva and is a common cause of preventable blindness worldwide; Follicles form on the upper eyelid conjunctiva. As the disease progresses, the eyelid scars and turns inward, causing the eyelashes to damage the cornea. Antibiotic therapy is used when the organism is identified. The most effective antibiotic is oral azithromycin (Zithromax). The infection also can be eliminated early in the disease with a 4-week course of tetracycline eye ointment.

retinal tear

a more jagged and irregularly shaped break in the retina. It can result from traction on the retina

anisocoria

a noticeable difference in the size of their pupils

External Otitis

a painful condition caused when irritating or infective agents come into contact with the skin of the external ear; is known as swimmer's ear because it occurs most often in people involved in water sports; Necrotizing or malignant otitis is the most virulent form of external otitis; Nursing priorities include comfort measures, such as applying heat to the ear for 20 minutes 3 times a day. Teach the patient that minimizing head movements reduces pain. Analgesics, including opioids, may be needed for pain relief during the initial days of treatment. After the inflammation has subsided, a solution of 50% rubbing alcohol, 25% white vinegar, and 25% distilled water may be dropped into the ear to keep it clean and dry and to prevent recurrence.

Astigmatism

a refractive error caused by unevenly curved surfaces on or in the eye, especially of the cornea. These uneven surfaces distort vision.

Corneal Abrasion

a scrape or scratch injury of the cornea. This painful condition can be caused by a small foreign body, trauma, or contact lens use; can lead to infection

Presbycusis

a sensorineural auditory sensory perception loss that occurs with aging; caused by degeneration of cochlear nerve cells, loss of elasticity of the basilar membrane, or a decreased blood supply to the inner ear. Deficiencies of vitamin B12 and folic acid increase the risk for presbycusis. Other causes include atherosclerosis, hypertension, infections, fever, Ménière's disease, diabetes, and ear surgery

Gonioscopy

a test performed when a high IOP is found and determines whether open-angle or closed-angle glaucoma is present. It uses a special lens that eliminates the corneal curve, is painless, and allows visualization of the angle where the iris meets the cornea.

Electronystagmography (ENG)

a test to assess for central and peripheral disease of the vestibular system in the ear by detecting and recording nystagmus (involuntary eye movements) • Tell the patient to fast for several hours before the test and to avoid caffeine-containing beverages for 24 to 48 hours before the test. • Tell patients with pacemakers that they should not have the test because pacemaker signals interfere with the sensitivity of ENG. • Carefully introduce oral fluids after the test to prevent nausea and vomiting.

Ophthalmoscopy

allows viewing of the eye's external and interior structures with an instrument called an ophthalmoscope

Chalazion

an inflammation of a sebaceous gland in the eyelid. It begins with redness and tenderness, followed by a gradual painless swelling. Later, redness and tenderness are not present. Most chalazia protrude on the inside of the eyelid. The patient has eye fatigue, light sensitivity, and excessive tears. Management includes applying warm compresses 4 times a day, followed by instillation of ophthalmic antibiotic ointment.

Nystagmus

an involuntary and rapid twitching of the eyeball, is a normal finding for the far lateral gaze. It may also be caused by abnormal nerve function or problems with the inner ear.

Arcus senilis

an opaque, bluish white ring within the outer edge of the cornea, is caused by fat deposits. This change does not affect vision.

Keratoconjunctivitis sicca, or dry eye syndrome

changes in tear production, tear composition, or tear distribution. Drugs (e.g., antihistamines, beta-adrenergic blocking agents, anticholinergic drugs) also can reduce tear production. Diseases associated with dry eye syndrome include rheumatoid arthritis, leukemia, sarcoidosis, and Sjögren's syndrome. Radiation or chemical burns to the eye also decrease tear production. Injury to cranial nerve VII inhibits tears. The patient has a foreign body sensation in the eye, burning and itching eyes, and photophobia (sensitivity to light). The corneal light reflex is dulled. Tears contain mucus strands. Cyclosporine (Restasis) eyedrops may be prescribed to increase tear production. Artificial tears (HypoTears, Refresh) also can be used to reduce daytime dryness. A lubricating ointment (Lacri-Lube SOP, Refresh P.M.) is used at night.

The Rinne tuning fork test

compares hearing by air conduction with hearing by bone conduction; Perform this test by placing the vibrating tuning fork stem on the mastoid process (bone conduction) and asking the patient to indicate when the sound is no longer heard. When the patient no longer hears the sound, bring the fork quickly in front of the pinna (air conduction) without touching the patient. He or she should then indicate when this sound is no longer heard.

Corneal staining

consists of placing fluorescein or other topical dye into the conjunctival sac. The dye outlines irregularities of the corneal surface that are not easily visible. This test is used for corneal trauma, problems caused by a contact lens, or the presence of foreign bodies, abrasions, ulcers, or other corneal disorders.

Primary angle-closure glaucoma (PACG or acute glaucoma)

has a sudden onset and is an emergency. The problem is a forward displacement of the iris, which presses against the cornea and closes the chamber angle, suddenly preventing outflow of aqueous humor.

hordeolum, or stye

infection of the eyelid sweat glands (external hordeolum) or of the eyelid sebaceous gland (internal hordeolum). A red, swollen, painful area occurs on the skin surface side of the eyelid; applying warm compresses 4 times a day and an antibacterial ointment. When the lesion opens, the purulent material drains and the pain subsides. Nursing interventions include instructing the patient how to apply compresses to the eye and how to instill antibiotic ointment

Audioscopy

involves the use of a handheld device to generate tones of varying intensities to test hearing. Auditory sensory perception can be measured at a 40-decibel (dB) intensity at frequencies of 500, 1000, 2000, and 4000 cycles per second (cps), or hertz (Hz).

Slit-lamp examination

magnifies the anterior eye structures; A narrow beam (slit) of light is aimed so that only a segment of the eye is brightly lighted

Tonometry

measures intraocular pressure (IOP) using a tonometer. This instrument applies pressure to the outside of the eye until it equals the pressure inside the eye. Normal IOP readings have always been considered to range from 10 to 21 mm Hg

MRI r/t ear

most accurately reflects soft-tissue changes

Hyperopia (farsightedness)

occurs when the eye does not refract light enough

MRI

often used to examine the orbits and the optic nerves and to evaluate ocular tumors. MRI cannot be used to evaluate injuries involving metal in the eyes. Metal in the eye is an absolute contraindication for MRI

PERRLA

pupils equal, round, reactive to light, and accommodative

The Weber tuning fork test

performed by placing a vibrating tuning fork on the middle of the patient's head and asking him or her to indicate in which ear the sound is louder; The term lateralization is used if the sound is louder in one ear. For example, lateralization to the right means that the sound is heard louder in the right ear.

Exophthalmos (proptosis)

protrusion of the eye

Fluorescein angiography

provides a detailed image of eye circulation. Digital pictures are taken in rapid succession after the dye is given IV. This test helps assess problems of retinal circulation (e.g., diabetic retinopathy, retinal hemorrhage, and macular degeneration) or diagnose intraocular tumors.

tinnitus

ringing

Ishihara chart

shows numbers composed of dots of one color within a circle of dots of a different color

CT scan r/t ear

shows the structures of the ear in great detail. CT is especially helpful in diagnosing acoustic tumors.

Keratoconus

the degeneration of the corneal tissue resulting in abnormal corneal shape, can occur with trauma or may be an inherited disorder; cornea that is still clear, surgical management involves a corneal ring implant that adjusts the shape of the cornea; Surgery to improve clarity for a permanent corneal disorder that obscures vision is a keratoplasty (corneal transplant); Instruct the patient to lie on the nonoperative side to reduce intraocular pressure (IOP). If a patch is to be used for more than a day, teach the patient or family member how to apply it. Instruct the patient to wear the shield at night for the first month after surgery and whenever he or she is around small children or pets. Instruct him or her not to use an ice pack on the eye. Teach the patient to avoid jogging, running, dancing, and any other activity that promotes rapid or jerky head motions for several weeks after surgery. Topical corticosteroids and other immunosuppressants are used to stop the rejection process.

Macular Degeneration

the deterioration of the macula (the area of central vision) and can be age-related or exudative. Age-related macular degeneration (AMD) has two types. The most common type is dry AMD, caused by gradual blockage of retinal capillaries; Central vision declines, and patients describe mild blurring and distortion at first. Eventually the person loses all central vision. Progresses at a faster rate among smokers than among nonsmokers. Other risk factors include hypertension, female gender, short stature, family history, and a long-term diet poor in carotene and vitamin E. Another cause of AMD is the growth of new blood vessels in the macula, which have thin walls and leak blood and fluid (wet AMD). Exudative macular degeneration is also a type of wet macular degeneration but can occur at any age. Newly formed blood vessels invade this injured area and cause fluid and blood to collect under the macula (like a blister), with scar formation and visual distortion.

hyperacusis

the intolerance for sound levels that do not bother other people

Primary open-angle glaucoma (POAG)

the most common form of primary glaucoma, usually affects both eyes and has no manifestations in the early stages. Outflow of aqueous humor through the chamber angle is reduced. Because the fluid cannot leave the eye at the same rate it is produced, IOP gradually increases; develops slowly, with gradual loss of visual fields that may go unnoticed because central vision at first is unaffected. At times, vision is foggy and the patient has mild eye aching or headaches. Late manifestations occur after irreversible damage to optic nerve function and include seeing halos around lights, losing peripheral vision, and having decreased visual sensory perception

retinal detachment

the separation of the retina from the epithelium. Detachments are classified by the type and cause of their development.

Enophthalmos

the sunken appearance of the eye

entropion

the turning inward of the eyelid causing the lashes to rub against the eye; is seen more often among older adults because of age-related loss of tissue support; Surgery corrects eyelid position

ectropion

the turning outward and sagging of the eyelid caused by muscle relaxation or weakness, which often occurs with aging. This lid position reduces the washing action of tears, leading to corneal drying and ulceration; Surgery corrects

Ceruminolytics

topical otic agents that soften or break up the cerumen so that it can be removed. They are usually composed of mineral oil with hydrogen peroxide; Patients may also elect to use regular mineral oil to soften the wax or prevent cerumen impaction.

Ultrasonography

used to examine the orbit and eye with high-frequency sound waves. This noninvasive test helps diagnose trauma, intraorbital tumors, proptosis, and choroidal or retinal detachments. It is also used to determine the length of the eye and any gross outline changes in the eye and the orbit in patients with cloudy corneas or lenses that reduce direct examination of the fundus.

Radioisotope scanning

used to locate tumors and lesions. This test requires that the patient sign an informed consent. The patient receives a tracer dose of the radioactive isotope, either orally or by injection, and must then lie still. The scanner measures the radioactivity emitted by the radioactive atoms concentrated in the area being studied

CT scan

useful for assessing the eyes, the bony structures around the eyes, and the extraocular muscles. It can also detect tumors in the orbital space. Contrast dye is used unless trauma is suspected.

Psychosocial Integrity r/t Ears

• Allow the patient the opportunity to express fear or anxiety about a change in hearing status. Patient-Centered Care • Explain all diagnostic and therapeutic procedures, restrictions, and follow-up care to the patient and family. Patient-Centered Care • Refer patients newly diagnosed with hearing impairment or any chronic ear problem to appropriate local resources and support groups. • Teach family members ways to communicate with a hearing-impaired patient with and without a hearing aid. Patient-Centered Care • Assess the degree to which hearing problems interfere with the patient's ability to interact with others. Patient-Centered Care • Remind patients having ear surgery that hearing in the affected ear may be reduced immediately after surgery because of packing, swelling, or surgical manipulation.

Physiological Integrity r/t Ears

• Ask the patient about hearing problems in any other members of the family, because many hearing problems have a genetic component. Patient-Centered Care • Check the hearing of any patient receiving an ototoxic drug for more than 5 days. Evidence-Based Practice • Ask the patient about current and past drug use (prescribed, over-the-counter), and check with a pharmacist to evaluate for ototoxicity. Patient-Centered Care • Avoid ear canal irrigation if the eardrum is perforated or if the canal contains vegetative matter. Safety • Stress the importance of completing an antibiotic regimen for an ear infection. Evidence-Based Practice • Remind patients to move the head slowly after ear surgery to prevent dizziness or vertigo. Patient-Centered Care • Use upper siderails for any patient experiencing dizziness or vertigo. Safety • Work with the case manager, home care nurse, speech-language pathologist, and occupational therapist to ensure safety and optimal function for the patient with a hearing or balance problem in the community setting.

Physiological Integrity

• Ask the patient about vision problems in any other members of the family, because many vision problems have a genetic component. Evidence-Based Practice • Teach patients the proper techniques for self-instillation of eyedrops and eye ointment. Safety • Stress the importance of completing an antibiotic regimen for an eye infection. Evidence-Based Practice • When instilling more than one type of eyedrop into the same eye, wait 5 to 10 minutes (or as directed by the manufacturer) between instillations. Evidence-Based Practice • Teach patients who are at risk for increased intraocular pressure (IOP) what activities to avoid (see Table 47-1). Patient-Centered Care • Teach patients with an infection of the eye or eyelid not to rub the eye (to avoid infecting the other eye). Evidence-Based Practice • Instruct the patient who has cataract surgery to report immediately any reduction in vision after initial improvement in vision in the eye that had cataract surgery. Patient-Centered Care • Stress the importance of using antiglaucoma eyedrop agents exactly as prescribed to prevent IOP from increasing and to prevent complications of glaucoma drug therapy. Patient-Centered Care • Never attempt to remove any object protruding from the eye. Safety • Use and teach punctal occlusion technique when administering antiglaucoma eyedrops. Safety • Work with the physician, occupational therapist, social worker, and other health care professionals to increase the patient's independence and safety within the home and the community.

Physiological Integrity

• Ask the patient about vision problems in any other members of the family, because some vision problems have a genetic component. Patient-Centered Care • Test the vision of both eyes immediately of any person who experiences an eye injury or any sudden change in vision. Patient-Centered Care

Types of Hearing Loss

• Conductive hearing loss, resulting from obstruction of sound wave transmission such as a foreign body in the external canal, a retracted or bulging tympanic membrane, or fused bony ossicles. • Sensorineural hearing loss, resulting from a defect in the cochlea, the eighth cranial nerve, or the brain. Exposure to loud noise or music causes this type of hearing loss by damaging the cochlear hair. • Mixed conductive-sensorineural hearing loss, resulting from both conductive and sensorineural hearing loss.

Hydrops diet for Ménière's Disease

• Distributing food and fluid intake evenly throughout the day and from day to day • Avoiding foods or fluids with a high salt content • Drinking adequate amounts of fluids daily • Avoiding caffeine-containing fluids and foods • Limiting alcohol intake to one serving per day • Avoiding monosodium glutamate (MSG)

Health Promotion and Maintenance.

• Identify people at risk for visual sensory perception problems as a result of work environment or leisure activities, and teach them specific ways to protect the eyes. Patient-Centered Care • Encourage all patients to wear eye protection when they are performing yard work, are working in a woodshop or metal shop, are using chemicals, or are in any environment in which drops or particulate matter is airborne. • Encourage all adult patients older than 40 years and those with chronic disorders that affect the eye and vision to have an eye examination with measurement of intraocular pressure every year. Patient-Centered Care • Encourage everyone to use polarizing sunglasses whenever outdoors in the daytime. Patient-Centered Care • Teach all patients to wash their hands before and after touching the eyes. Patient-Centered Care • Teach family members who have good vision to make the adaptations for the patient's home listed on p. 993 to increase the patient's independence and safety. Patient-Centered Care

What might you NOTICE if the patient has auditory sensory perception problems?

• Person tilts head to one side or leans forward to listen when another person speaks. • Person watches the lips of a speaker closely. • Person does not startle when a loud or unexpected sound occurs in the environment. • Person frequently asks the speaker to repeat statements or questions. • Person does not verbally interact with those around him or her. • When a sentence is whispered to the person, he or she does not accurately repeat it back to the speaker. • Person responds inappropriately to questions.

How should you RESPOND to a patient who has auditory sensory perception problems?

• Reduce the background sound when speaking to the person (close the door to the hall, use a private area, turn off televisions and radios). • Speak slowly, distinctly, and with a deeper tone. • Face the patient while speaking. • Ensure that all members of the health care team are aware of the patient's impairment and use an appropriate method to communicate with him or her. • Determine whether the patient can communicate by sign language. • Identify safety issues specific for the patient with a hearing impairment. • Use a certified medical interpreter when taking a history from, explaining procedures to, or teaching the patient who has a hearing impairment.

Psychosocial Integrity

• Teach patients and family members about what to expect during procedures to correct visual sensory perception and eye problems. • Provide opportunities for the patient and family to express concerns about a change in visual sensory perception. • Refer the patient with reduced visual sensory perception to local services, resources, and support groups for the blind and those with low vision. Patient-Centered Care • Teach the patient with reduced visual sensory perception techniques for performing ADLs and self-care independently. Patient-Centered Care • Use a normal tone of voice to talk with a patient who has a vision problem and normal hearing. • Knock on the door before entering the room of a patient with reduced visual sensory perception and introduce yourself. Patient-Centered Care

Health Promotion and Maintenance.

• Teach patients not to rub their eyes. Patient-Centered Care • Identify patients at risk for eye injury as a result of work environment or leisure activities. Patient-Centered Care • Urge all patients to wear eye protection when they are performing yard work, working in a woodshop or metal shop, using chemicals, or are in any environment in which drops or particulate matter is airborne. Safety • Teach everyone to wear sunglasses outdoors in bright sunlight. Patient-Centered Care

Health Promotion and Maintenance r/t Ears

• Teach patients the proper way to clean the pinna and external ear canal and how to remove cerumen from the external canal. Evidence-Based Practice • Identify patients at risk for hearing impairment as a result of work environment or leisure activities. Patient-Centered Care • Encourage all patients, even if they already have a hearing impairment, to use ear protection in loud environments. Patient-Centered Care • Inform all patients who smoke that smoking increases the risk for development of hearing problems. Evidence-Based Practice • Teach patients how to properly care for their hearing aids. Patient-Centered Care • Instruct patients to avoid closing off one naris when blowing the nose. Patient-Centered Care • Remind patients who engage in water sports and who are at risk for external otitis to wear earplugs when in the water. Patient-Centered Care • Teach patients the proper techniques for self-instillation of eardrops and ear irrigation

Safe and Effective Care Environment

• Use Contact Precautions with any patient who has drainage from the ear canal. Safety • Use a separate speculum cover for each ear when conducting an otoscopic examination. Safety • Slowly and gently introduce the otoscopic speculum into the external ear canal during assessment. Safety • Do not perform an otoscopic examination on a confused patient. Safety • Use the suggestions presented in the Patient History section (p. 998) to enhance communication with a patient who has an impairment of auditory sensory perception. Safety • Protect the patient with vertigo or dizziness from injury by assisting with ambulation. Safety • Follow the guidelines in Chart 48-4 when irrigating the ear canal. Safety

Safe and Effective Care Environment.

• Use aseptic technique when performing an eye examination or instilling drugs into the eye. Safety • Apply the principles of infection control when caring for a patient with an eye infection. Safety • Avoid performing an ophthalmoscopic examination on a confused patient. Safety • Orient the patient with reduced vision to his or her immediate surroundings, including how to call for help and where the bathroom is located. Safety • Identify the room of a patient with reduced vision. Safety • Never administer a topical ophthalmic liquid or ointment by the oral route. Safety

Patient Outcomes

• Uses hearing assistive devices • Uses sign language, lip-reading, closed captioning, or video description (for television viewing) • Accurately interprets messages • Uses nonverbal language • Exchanges messages accurately with others

Safe and Effective Care Environment.

• Wash your hands before moving a patient's eyelids or instilling drugs into the eye. Safety • If a patient has discharge from one eye, examine the eye without the discharge first. Safety • Wear gloves when examining an eye with drainage. Safety • Avoid using an ophthalmoscope on a confused patient. Safety