Ch. 17: Nursing Care of the Child with an Alteration in Sensory Perception/Disorder of the Eyes or Ears

Nursing Management of Nasolacrimal Duct Obstruction

- teach parents to clean eye area frequently with moist cloth - teach parents to massage nasolacrimal duct to change pressure and open up, allowing drainage - ensure parents educated on when and how to administer antibiotic eye drops if ordered

Ears

- congenital deformities of ear often associated with other system anomalies and genetic syndromes - relatively short, wide, and horizontally place eustachian tubes allow bacteria and viruses to gain access to middle ear easily, increasing ear infections - as maturing, tubes assume more slanted position, decreasing middle ear effusion and infection - enlargement of adenoids contributes to obstruction of eustachian tubes causing infection

Levels of Hearing Loss

- 0 to 20 dB: normal - 20 to 40 dB: mild loss - 40 to 60 dB: moderate loss - 60 to 80 dB: severe loss - Greater than 80 dB: profound loss

Visual Impairment

- acuity between 20/60 and 20/200 in better eye on exam - "legal blindness" refers to vision less than 20/200 or peripheral vision less than 20 degrees - some blind children can differentiate light versus dark while others live in total darkness - vision impairment and blindness are mostly caused by refractive error, astigmatism, strabismus, amblyopia, nystagmus, infantile glaucoma, congenital cataract, ROP, and retinoblastoma - risk factors are prematurity, developmental delay, genetic syndrome, family history of eye disease, african american heritage, previous serious eye injury, diabetes, HIV, chronic corticosteroid use - trauma can also cause blindness - albinism can also lead to blindness -children may show motor or cognitive delays - blind children lack stimulation, may develop self-stimulatory actions in compensation, often called blindisms like eye pressing, rocking, spinning, bouncing, head banging

Visual Disorders

- adequate visual development requires appropriate sensory stimulation to both eyes over first few years of life - visual development doesn't progress appropriately is stimulation is withheld and visual impairment or blindness may occur - when visual disorders go untreated, child's developing vision may be reduced significantly - common visual disorders include refractive errors, strabismus, amblyopia, nystagmus, glaucoma, and cataracts

Otitis Externa Pain Management

- administer analgesics (possibly narcotics) to manage pain - apply warm compress or heating pad to affected ear as it's helpful in some children

Managing Pain Associated with Acute Otitis Media

- administer analgesics like acetaminophen and ibuprofen for mild to moderate pain and fever - narcotic analgesics may be prescribed for severe pain - apply warm heat or cool compress if helpful to child - instruct family to have child lie on affected side with heating pad or covered ice pack in place to ear - administer numbing eardrops like benzocaine (auralgan) in even of acute, severe pain, using only in conjunction with analgesics because of short duration of action

Otitis Externa Treatment

- administer antibiotic or antifungal eardrops as prescribed - if wick placed in ear canal, teach parents that it keep antibiotic drops in contact with skin of ear canal and promotes healing - assist wick insertion, can be painful, younger children will need to be restrained during insertion for safety

Common Drugs for Ear and Eye Disorders

- antibiotics (oral, otic, ophthalmic) - treat bacterial infections of eye and ear, acute otitis media, otitis externa, conjunctivitis, teach families to complete entire course as prescribed, check for drug allergies prior to administration - antihistamines - block histamine reaction, allergic conjunctivitis, topical drops used, oral agents usually prescribed if allergic rhinitis accompanies conjunctivitis - analgesics - pain relief, otitis media, otitis externa, after eye or ear surgery, narcotic analgesics may be necessary in some instances

Infantile Glaucoma

- autosomal recessive disorder more common in interrelated marriages or relationships - obstruction of aqueous humor flow and increased intraocular pressure that results in large, prominent eyes - vision loss may occur as result of corneal scarring, optic nerve damage, most commonly amblyopia - unlike adult glaucoma, therapeutic management is focused on surgical intervention - goniotomy (removal of obstruction of the aqueous humor) - laser surgery is an option as well

Therapeutic Management of Conjunctivitis

- bacterial treated with ophthalmic antibiotic preparation (drops or ointment) - viral conjunctivitis is self-limiting disease and doesn't require topical med - allergic conjunctivitis can be helped with eye drops with antihistamine or mast cell stabilization

Simple Contusion Assessment

- black eye occurs as result of blunt trauma to eye area - bruising and edema of lids or area surrounding eye - PERRLA - extraocular movements intact - visual acuity intact - no diplopia or blurred vision - pain surrounding eye but not within the eye

Scleral Hemorrhage Assessment

- caused by blunt trauma or increased pressure such as with coughing - painless - appears as erythema in sclera; can be quite large initially - vision unaffected

Physical Exam for Eye Injuries

- children with eye injury often have acute pain - area surrounding eye swells quickly after blunt trauma - edema and tearing make eye exam difficult, help with coping - approach calmly and gently, soothe and coax child as eye examined - younger children may need to be restrained briefly for safe exam - note eyelid placement and look for signs of trauma like bleeding, edema, eyelid malformation - evaluate ability to open eyes and pupil response to light and accommodation (in nonemergent trauma, pupils remain equally round and reactive to light and accommodation - PERRLA) - note redness, irritation of sclera or conjunctiva - observe for excessive tearing - in nonemergent, evaluate visual acuity with screening tool

Acute Otitis Media

- common illness, resulting from infection (bacterial or viral) of fluid in middle ear - infants and young child increased risk due to short length and horizontal positioning of Eustachian tube, limited response to antigens, and lack of previous exposure to common pathogens - occurs mostly fall through spring, highest in winter - most significant risk is eustachian tube dysfunction and susceptibility to recurrent upper respiratory infections

Lab and Diagnostic Testing

- culture of eye or ear discharge - fluid draining from eye or ear is cultured to determined specific bacteria present and appropriate antibiotic coverage, easy to collect, relatively pain-free, if drainage must be removed from within the ear canal, more likely to be painful - tympanic fluid culture - culture of fluid aspirated from middle ear to determine specific bacteria present and appropriate antibiotic coverage, painful; usually performed only by specifically trained physicians - tympanometry - probe in ear canal measures movement of eardrum to determine extent of effusion of middle ear, quick and easy to perform (seconds), requires accurate sized probs for adequate seal of ear canal

Health History for Hearing Loss

- current and past medical history for risk factors such as congenital anomalies, genetic syndrome, infection, family history, kernicterus, neonatal ventilator use, ototoxic med, or exposure to excess noise - note if newborn hearing screening were done and results

Health History for Otitis Externa

- description of present illness and chief complaint - note history of ear itching or pain, ear drainage, or a feeling of fullness in the ear canal, with possible difficulty hearing - note onset and progression of symptoms, as well as response to treatments - explore child's current and past medical history for risk factors such as previous episodes of otitis externa or history of recent swimming in a pool, lake, or ocean

Physical Exam and Diagnostic Testing Hearing Loss

- determine child's level of interaction with environment - administer whisper test to preschoolers or older children - perform weber and rinne tests - administering otoacoustic emissions test or auditory brain stem evoked response test

Health History of OME

- determine extent of symptoms - could be asymptomatic or experience popping sensation or fullness behind eardrum - explore health history for risk factors like passive smoking, absence of breastfeeding, frequent viral upper respiratory infections, allergy, or recent history of AOM

Young Child Symptoms of Hearing Loss

- does not speak by 2y/o - communicates needs through gestures - does not speak distinctly, as appropriate for his or her age - displays developmental (cognitive) delays - prefers solitary play - displays immature emotional behavior - does not respond to ringing of telephone or doorbell - focuses on facial expression when communicating

Health History for Visual Impairments

- dull, vacant stare - infants can't "fix and follow," make eye contact, unaffected by bright light, don't imitate facial expression - toddlers and older children rub, shut, cover eyes, squint, frequent blinking, hold objects close or sit close to television, bump into objects, head tilt or forward thrust - assess for symmetry or asymmetry of corneal light reflex, "cover test", and screening tool

Augmenting Hearing

- educate family compliance with hearing aids and communication curricula is critical to develop hearing and speech - teach child and family that hearing aids should be cleaned daily with a damp cloth and to change batteries weekly - ensure parents understand hearing aid batteries are serious aspiration risk and should always be kept out of reach of young children - teach parents when inserting aid, volume should be turned down, then adjusted to appropriate level - teach families that with child growth, hearing aid will need to be reassessed for proper fit - with cochlear implants focus on postop care of incision and pain management

Providing Postoperative Care for the Child with Pressure-Equalizing Tubes

- educate parents about surgical insertion of pressure-equalizing tubes into tympanic membrane (via myringotomy) - PE tubes equalize pressure behind ear drum, allowing for tympanic membrane movement. allows for adequate hearing, in turn encourages speech development - procedure is usually done as an outpatient surgery and child returns home in evening - tubes stay in place for at least several months and generally fall out on their own - teach parents to administer ear drops postop if prescribed - advise parents to have child wear earplugs when swimming in potentially contaminated water such as lakes or rivers - teach parents if middle ear becomes infected with PE tubes in place, tubes allow infected fluid to drain from ear (if occurs, they should contact physician or np)

Educating about Eyeglass Use

- encourage child with newly prescribed eyeglasses to wear them by having parent spend "special time" with child doing activity requiring glasses (reading, drawing) - provide positive reinforcement for wearing glasses - teach parent and child to remove glasses with both hangs and lay them on side (not on lens) - instruct child and family about cleaning glasses daily with mild soap and water or commercial cleansing agent provided by optometrist, soft cloth to clean glasses, not paper towels, tissues, or toilet paper

Nursing Management for Visual Impairments

- encourage corrective lens use to enhance vision - encourage compliance with vision screening appointments to determine acuity progression or problems - support family efforts for vision therapy and other habilitation programs for vision enhancement - promoting socialization, development, and education

Providing Support

- encourage families to express their feelings as diagnosis of significant disability can be stressful - provide emotional support - ensure needs of any siblings are also attended to - encourage family to network with other families who have children with similar needs - educate family about child's prescribed plan of care

Monitoring for Fit and Visual Correction

- encourage family to complete visual assessments as scheduled - vision is developing so refraction isn't stable meaning prescription may change frequently - head size is growing so eyeglass frames may hurt or pinch as it grows - teach families to check fit of glasses monthly - monitor for signs of ill fit, like constant removal of glasses in older child or rubbing at glasses or eyes in young children - monitor for squinting, eye fatigue, strain, complaints of headache or dizziness (change prescription)

Preventing Acute Otitis Media

- encourage mothers to breastfeed for at least 6-12mos to lower incidence of AOM for immunologic benefits - instruct families to avoid excess exposure to individuals with upper respiratory infections to decrease incidence of infections - educate families that infants and children shouldn't be exposed to second hand smoke, encourage parents to stop smoking, if not possible instruct parents not to smoke inside house or automobiles - encourage parents to have child immunized with prevnar and influenza vaccine - xylitol have protective benefits, educate them that studies thus far have inconclusive and with excessive dosing, xylitol can cause diarrhea

Nursing Assessment of Retinopathy of Prematurity

- ensure all former premature infants are routinely screened for visual deficits - developmental progress with parents - observe strabismus, manifested by asymmetric corneal light reflex - ensure family compliance with follow-up recommendations - recurrent illness or rehospitalization of premature infants may interfere scheduled eye follow-up appts - ensure family knows importance of them

Palpation

- eyes not palpated - if injury, upper eyelid may be everted for examination - palpate ear for tenderness over tragus or pinna - note presence of tenderness over mastoid area (otitis media progression to mastoiditis) - palpate for enlarged cervical lymph nodes (occurs when eyes or ears are infected)

Nursing Assessment for Infantile Glaucoma

- family history of infantile glaucoma or other genetic disorders - health history, noting history of infant keeping eyes closed most of time or rubbing eyes - observe for corneal enlargement and clouding; eye may appear enlarged - photophobia, bright light may bother infant - tearing or conjunctivitis and eyelid squeezing, or spasm may occur - tonometer to measure intraocular pressure during diagnostic phase

Common Signs and Symptoms AOM

- fever (may be low grade or higher) - complaints of otalgia (ear pain) - fussiness or irritability - crying inconsolably, particularly when lying down - batting or tugging at ears (may also occur with teething or OME, or may be a habit) - rolling head from side to side - poor feeding or loss of appetite - lethargy - difficulty sleeping or awakening crying in the night - fluid draining from ear

Educating the Family for AOM

- for observation or watchful waiting, explain rationale to family - ensure family understand importance of returning for re-evaluation if no improvement within 48-72hrs or if AOM progresses to severe illness - when antibiotics are prescribed, ensure family understands importance of completing entire course of antibiotics - follow-up resolution of AOM necessary for all children and physician or nurse practitioner determine follow-up - educate about OME and potential to impact hearing and speech

Nursing Assessment for Refractive Errors

- health history, noting blurred vision, complaints of eye fatigue with reading, or complaints of eye strain (headache, pulling sensation, or eye burning) - note complaints of difficulty concentrating on or maintaining clear focus objects up close, avoidance up-close work or poor work performance (hyperopia) - note risk factor family history myopia - observe for squinting when looking at objects at distance - observe hyperopic child for presence of esotropia - hyperopia isn't identified with visual acuity screening along and requires retinal examination by ophthalmologist

Nursing Assessment of Eyelid Disorders

- health history, onset of symptoms, extent and character of eye discharge, presence of pain (hordeolum usually painful) - inspect eyelids, noting redness along eyelid margin and presence of eyelid edema (hordeolum, blepharitis) - hordeolum may be quite visible as enlarged lesion along lid margin, with purulent drainage present - chalazion may be visible as small nodule on lid margin - conjunctivae remain clear with all three disorders

Common Complications of AOM

- hearing loss - expressive speech delay - tympanosclerosis (scarring of tympanic membrane; usually has not effect on hearing) - tympanic membrane perforation (acute with resolution or chronic) - chronic suppurative otitis media (chronic drainage via perforation or tympanostomy tubes) - acute mastoiditis (infection of mastoid process) - intracranial infections, including bacterial meningitis and abscesses

Eyelid Disorders

- hordeolum (stye) - localized infection of sebaceous gland of eyelid follicle, usually by bacterial invasion, antibiotic ointment - chalazion - chronic painless infection of meibomian gland, may resolve spontaneously - blepharitis - chronic scaling and discharges along eyelid margin, antibiotic ointment

Nursing Management for Eyelid Disorder

- hordeolum and blepharitis parents should know how to administer antibiotic ointment - encourage hot, moist compress - inform that stye may require several weeks to resolve completely - inform parents chalazion will usually resolve spontaneously; if not minor surgical drainage required

Encouraging Education

- if less than 3y/o refer to early intervention for case management and developmental needs - education families that at 3y/o and up, IEP should be developed and put into place

Eye Injuries

- infants and young children are more susceptible to eye injuries since eyeball is relatively larger in relation to space within orbit - as infants and toddlers learn to walk and run, they don't have awareness and maturity to avert disaster - older children involved in sports and science experiment are at increased risk for eye injuries - common injuries are eyelid injuries, contusion, scleral hemorrhage, corneal abrasion, foreign body in eye, chemical injury - eyelid lacerations may require suturing - deep lacerations may result in ptosis at later date, refer to ophthalmologist - simple contusion (black eye) usually only need observation, ice, and analgesics - scleral hemorrhages resolve gradually without intervention over a few weeks - corneal abrasion may be allow to self-heal or antibiotic ointment - foreign bodies in eye require removal to prevent further irritation or abrasion - chemical injuries require irrigation and vision evaluation

Hearing Loss and Deafness

- infants born with sense of hearing fully developed - language development in infancy and early childhood is dependent upon adequate hearing, and even fluctuating hearing loss associated with intermittent bouts of AOM can hinder language development - hearing loss may be unilateral (one ear) or bilateral (both ears) - extent of hearing loss based on softest intensity of perceived sound in decibels - hearing loss may be congenital or acquired - most congenital hearing loss is inherited through single gene or associated with syndrome but can occur though prenatal infection - premature infants and those with persistent pulmonary hypertension of newborn increased risk for hearing loss compared with other infants - newborn hearing tests - delayed-onset (acquired) hearing loss may be conductive, sensorineural, or mixed - conducive - transmission of sound through middle ear is disrupted, as in case of OME, tympanic membrane unable to move properly due to fluid filling middle ear - sensorineural - caused by damage to hair cells in cochlea or along auditory pathway - may result from kernicterus, ototoxic meds, intrauterine infection with cytomegalovirus or rubella, neonatal or postnatal infection like meningitis, severe neonatal respiratory depression, exposure to excess noise - mixed hearing loss is both conducive and sensorineural - hearing aids, cochlear implants, communication devices, and speech education may enable children to communicate verbally

Otitis Externa

- infection or inflammation of skin of external ear canal - pseudomonas aeruginosa and staph aureus typically cause this or aspergillus fungi and other bacteria - moisture in ear canal contributes to pathogen growth - "swimmer's ear" - occurs more frequently in those who swim often - changing pH in ear canal contributes to inflammatory process

Conjunctivitis

- inflammation of bulbar or palpebral conjunctiva - can be infectious, allergic, or chemical in nature, can be caused by bacteria or virus - adenoviruses and influenza are most cases of viral conjunctivitis - most common bacterial causes are staph aureus, strep pneumoniae, haemophilus influenzae - in newborns, chlamydia trachomatis and neisseria gonorrhoeae are more common causes - risk factors for acute infectious conjunctivitis is younger than 2wks old, day care, preschool, or school attendance, concomitant viral upper respiratory infection, pharyngitis, otitis media - neonates with chlamydial conjunctivitis may be at risk for chlamydial pneumonia - allergic conjunctivitis results from exposure to particular allergens, may be seasonal or year-round complaint - genetic predisposition like asthma, allergic rhinitis, atopic dermatitis - allergic conjunctivitis more common in school-age and adolescents due to exposure to allergens over time

Foreign Body Assessment

- may be dirt, glass, or other small particle - tearing - compliant of "something in the eye" - PERRLA - vision may be blurry

AOM Physical Exam

- may complain of pain where ear is examined - otoscopic exam, tympanic membrane dull or opaque appearance and bulging or red - sometimes pus (greenish or yellowish) visible behind eardrum - eardrum immobile - if tympanic membrane perforated, drainage present in ear canal, but otherwise looks normal - palpate for possible cervical lymphadenopathy - tympanometry used to determine presence of middle ear effusion

Eyelid Injury Assessment

- may occur as laceration to eyelid - laceration is noted at any point along the lid - vision is unaffected

Educating the Family

- may take several months to resolve - educate family about natural history of OME and anatomic differences in young children contribute to OME - inform parents that antihistamines, decongestants, antibiotics, and corticosteroids do not quicken resolution of OME and not recommended - OME usually resolves spontaneously, but should be rechecked every 4 wks while resolution occurs - teach parents not to feed infants in supine position and avoid bottle propping

Health History for Eye Injuries

- mechanism of injury and obtain as much detail about injury - when occurred, what happened, was object involved, what type of object, how fast was it going, is it splash injury, was child wearing eye protection - determine extent of pain if present - doc photosensitivity, sensation of foreign body in eye, blurry or lost vision - inquire of past medical history, previous eye injury or surgery or vision problems - immunization status

Strabismus

- misalignment of eyes - common and most common is exotropia and esotropia - exotropia eye turn outward, esotropia turn inward - unequal alignment visual development proceed at different rates - diplopia (double vision) may result, one eye may be "turned off" by brain to avoid diplopia - strabismus usually resolves by 3-6mos - persistent esotropia that persists past 4mos or constant strabismus refer to ophthalmologist - treat strabismus early so equal visual acuity may be achieved in both eyes - patching of stronger eye or eye muscle surgery helps - corrective lenses are also helpful - complications include amblyopia and visual deficits

Refractive Errors

- most common cause of visual difficulties in children - when light that enters lens does not bend appropriately to allow it to fall directly on retina - infants and young children natural mild hyperopia (farsightedness) bc depth of eye globe isn't fully developed until about 5y/o, may have blurriness at close range but usually resolves - when light entering eye focuses in front of retina, myopia (nearsightedness) see well at close range but difficulty focusing on blackboard or distant objects - therapeutic management for both hyperopia and myopia is prescription eyeglasses or contact lenses

Nursing Assessment to Congenital Cataract

- note history lacking visual awareness - observe eyes for apparent cloudiness of cornea (not always visible) - red reflex won't be observed in affected eye - postop protection of operative site and developmentally appropriate activities - ensure protective eye patch is secure - elbow restraints may be needed - teach families to administer antibiotic or corticosteroid ophthalmic drops if prescribed for post op use - once surgical site healed, healthy eye may be patched several hours daily to promote visual development in eye with intraocular lens or contact - regular visual assessments are critical for adequacy of visual development after cataract removal - importance of sunglasses

Inspection and Observation for Eyes

- note if child uses eyeglasses, corrective lenses, or hearing aid - observe eye positioning and symmetry, presence of strabismus, nystagmus, squinting - eyelids should open equally (failure to open fully is ptosis) - note variations in eye slant and presence of epicanthal folds - assess for eyelid edema, sclera color, discharge, tearing, pupillary equality, size and shape of pupils - evert eyelid to inspect palpebral conjunctivae for redness - test extraocular movement and pupillary light response and accommodation - note symmetry of corneal light reflex - not presence of red reflex with ophthalmoscope - age appropriate visual acuity test performed

Inspection and Observation for Ears

- note size and shape, position, and presence of skin tags, dimples, or other anomalies - note otoscopic examination usually performed by advanced practice nurse - otoscopic exam, note presence of cerumen, discharge, inflammation, foreign body in canal - visualize tympanic membrane and observe color, landmarks, light reflex, presence of perforation, scars, bulging, retraction - tympanic membrane mobility may be tested with pneumatic otoscopy - auditory acuity tested via whisper test, audiometry, other age-appropriate test

Physical Exam for Conjunctivitis

- observe eyelid for swelling or redness - inspect conjunctivae for redness - note quantity, color, consistency of discharge - bacterial infections generally thick, colored, discharge - viral infections generally clear or white discharge - allergic infections generally watery discharge - contact with an allergen rubbed into one eye may cause unilateral symptoms - document runny nose or cough as well

Older Child Symptoms of Hearing Loss

- often asks for statements to be repeated - is inattentive or daydreams - performs poorly at school - displays monotone or other abnormal speech - gives inappropriate answers to questions except when able to view face of speaker

Health History for Conjunctivitis

- onset and progression of symptoms and the response to at home treatment - assess risk for infectious conjunctivitis like day care or school attendance - note history of upper respiratory infection, sore throat, earache - question parents about possible infectious exposure - review health history for risk factors for allergic conjunctivitis like family history and history of asthma, allergic rhinitis, atopic dermatitis - determine seasonality related to symptoms and whether symptoms occur after exposure to allergens like pollen, hay or animals

Congenital Cataract

- opacity of lens of the eye present at birth - sensory amblyopia will result if infant is untreated - visual developmental delay related to amblyopia - bilateral cataracts may be associated with metabolic or genetic syndromes - surgery to remove opaque lens can be done as early as 2wks - intraocular lens implant is used or infant is fitted with contact lens - best visual outcomes are when cataracts are removed prior to 3mos - glaucoma may occur as complication after cataract surgery

Infectious and Inflammatory Disorders of Ears

- otitis media is inflammation of middle ear with presence of fluid can be acute or effusion - acute otitis media is an acute infectious process of middle ear that may produce rapid onset of ear pain and possibly fever - otitis media with effusion is a collection of fluid in middle ear space without signs and symptoms of infection - chronic OME lasts longer than 3mos - otitis externa is inflammation of external ear canal

Physical Exam and Diagnostic Testing OME

- otoscopic examination may reveal dull, opaque tympanic membrane may be white, gray, or bluish - if tympanic membrane not opaque, fluid level or air bubble may be visualized - mobility may be absent or diminished upon pneumatic otoscopy - tympanometry may be used to confirm OME

Preventing Infectious Spread of Conjunctivitis

- parent wash hands after caring for child - teach parents and children about appropriate hand washing and discourage from sharing towels and washcloths - viral conjunctivitis can allow for return to school or daycare when symptoms lessen - when mucopurulent is no longer present (typically after 24-48hrs of treatment), bacterial conjunctivitis can return to school

Health History

- past medical history, family history, history of present illness, treatments used at home - past medical history may be significant for prematurity, genetic defect, eye or ear deformities, visual acuity deficit of blindness, hearing impairment or deafness (complete inability to hear sound), recurrent ear infections/surgeries - family history for eye or ear deformities or vision or hearing impairments, contacts for infectious exposure - onset and progression and presence of fever, nasal congestion, eye or ear pain, eye rubbing, ear pulling, headache, lethargy, behavioral changes - doc corrective lenses or hearing aids for child - assess with inspection and observation then testing of visual acuity and hearing

Children at Risk for Speech, Language, or Learning Difficulties

- permanent hearing loss (without otitis media with effusion) - speech/language delay (suspected or diagnosed) - craniofacial disorder that may interfere with speech - any pervasive developmental disorder - genetic disorders or syndromes associated with speech or learning problems - cleft palate - blindness or significant visual impairment

Amblyopia

- poor visual development in otherwise structurally normal eye - develops within first decade of life and if untreated, most common cause of vision loss - vision in one eye is reduced because eye and brain aren't working together properly, one eye is stronger than the other while both are trying to focus - "lazy eye" - could be caused by strabismus, differences in visual acuity between two eyes, astigmatism (cornea or lens is not perfectly spherical) - may result from eye trauma, ptosis, cataract - if untreated amblyopia will have worsening acuity of poorer eye and strain in better eye may lead to worsening acuity in that eye, blindness may result in one or both eyes - strengthening of the weaker eye can be achieved by patching, atropine drops in better eye, vision therapy, eye muscle surgery if cause is strabismus - patching better eye for several hours daily encourages poorer eye to be used appropriately and promotes development - once daily atropine drops in better eye blurs vision in eye, encouraging sue and development of weaker eye

Otitis Media with Effusion

- presence of fluid within middle ear space, without signs or symptoms of infection - may occur independent of AOM or persist after infectious process of AOM has resolved - risk factors for OME include passive smoking, absence of breastfeeding, frequent viral upper respiratory infections, allergy, young age, male sex, adenoid hypertrophy, eustachian tube dysfunction, certain congenital disorders - complications of OME include AOM, hearing loss, and deafness

Monitoring for Hearing Loss

- primary concern is effect on hearing if OME persists - impaired hearing can depress language acquisition significantly - children with OME are at risk for speech, language, or learning problems may be referred for evaluation of hearing earlier than child with OME not at risk - children with chronic OME (more than 3mos) should be referred to specialist for hearing evaluation - children not already at risk for speech concerns and not experiencing difficulty with language acquisition may be reassessed every 3-6 mos as long as hearing loss is not identified

Supporting Child and Family with Visual Impairment

- provide emotional support to family - ensure child's environment provides familiarity and security - encourage activities to stimulate development depending on other impairments - educate parents about other indicators child or infant is acknowledging parent presence, eye contact won't be made (increased motor activity, eyelid movement, changes in breathing pattern, making sounds) - encourage family to display affection through touch and tone of voice - refer to resources

Nursing Management for Infantile Glaucoma

- providing postop care and education to family - focus on protection of surgical site - maintain eye patching and ensure child remains on bedrest - if necessary for infants and toddler, elbow restraints to avoid eye rubbing - use calm and soothing approach, distraction and developmentally appropriate play activities to calm anxiety associated with inability to see with patch - prep parents before surgery about 3-4 operations that may be necessary - postop families should be taught med admin - instruct parents and children to avoid roughhousing and contact sports for at least 2 wks after surgery - encourage parents to comply with recommended visual assessments

Nursing Assessments of Strabismus

- question parents about onset of problem and if continuous or intermittent - if intermittent is it more often when child is tired - health history, noting complaints of blurred vision, tired eyes, squinting or closing one eye in bright sunlight, tilting head to focus on object, history of bumping into objects - observe child's eyes for obvious exotropia or esotropia - assess symmetry of corneal light reflex, "cover test" is useful for identification of strabismus - true strabismus shouldn't be confused with pseudostrabismus which eyes may appear slightly crossed but corneal light reflex remains symmetric - encourage family to comply with modality of patching - encourage eyeglass wearing if prescribed - postop care by protecting operative site with patching

Retinopathy of Prematurity

- rapid growth of retinal blood vessels in premature infant - 4mo fetus begins retinal vascularization and progresses until 9mos or shortly after birth, premature is born with incomplete retinal vascularization, new vessels continue to grow - risk factors include low birthweight, early gestational age, sepsis, high light intensity, and hypothermia - oxygen tension changes from hypoxia, oxyhemoglobin dissociation curve changes that occur when adult blood transfused to premature infant, and duration/concentration of supplemental oxygen thought to play important role in development of ROP - premature infants should have serial exams until ROP regressed and normal vascularization is seen - if ROP progresses, laser surgery may be necessary to prevent blindness - complications include myopia, glaucoma, blindness - strabismus may occur even if resolved - refractive errors and amblyopia may occur as early as 3mos corrected age

Common signs and symptoms:

- redness - edema - tearing - discharge - eye pain - itching of eye (usually with allergic conjunctivitis Bacterial: - purulent, mucoid discharge, mild pain, occasional edema Viral: - water, mucoid discharge, lymphadenopathy, photophobia, tearing, edema usually present Allergic: - watery or stringy discharge, itching, edema usually present

Corneal Abrasion Assessment

- results from foreign body such as sand, grit, or other small objects scratching the cornea - may have tearing - eye pain - PERRLA - vision may be blurry - photophobia may be present

Nursing Assessment Amblyopia

- screening by 3y/o - observe asymmetry of corneal light reflex - support and encourage children and parents to comply with patching protocol or atropine drop use - eye safety is extremely important for child with amblyopia - if better eye suffers serious injury, both eyes may become blind

Intro

- sensory perception - receiving and interpreting stimuli - eye and ear disorders are common amongst children - conjunctivitis and otitis media are two very common infectious and inflammatory disorders - refractive error, strabismus, and amblyopia affect development of visual acuity in children - hearing impairments can have impact on language acquisition - hearing impairment - varying degrees of hearing loss - chronic or recurrent disorders of the eyes and ears can hinder development of visual acuity and hearing

Diagnosis of AOM is based on:

- signs of fluid in middle ear: moderate to severe bulging of tympanic membrane, or mild bulging of tympanic membrane with recent (within 48 hours) compliant of ear pain, presence of middle ear infusion noted on pneumatic otoscopy or tympanometry - signs or symptoms of inflammation in middle ear: complain of ear pain or intense erythema of tympanic membrane - new onset otorrhea in absence of otitis externa

Eyes

- some kids born with blue eyes and iris becomes pigmented over time, eye color determined by 6-12 mos - sclera may be bluish but whitens within weeks - infant and young child eyeball has a larger space within orbit making more susceptible to injury - newborns have immature vision, optic nerve not fully myelinated until 3mos and spherical shape of lens negatively affects distance accommodation - at birth, vision acuity around 20/400 and improves over first 5years of life with 20/20 usually by 5y/o - rectus muscles uncoordinated at birth and mature so binocular vision (ability to focus with both eyes simultaneously) may occur between 3-7mos - in preterm, retinal vascularization incomplete, may affect visual acuity

Any Age Symptoms of Hearing Loss

- speaks loudly - sits very close to TV or radio or turns volume up too loud - responds only to moderate or loud voices

Nasolacrimal Duct Obstruction

- stenosis or simple obstruction of nasolacrimal duct is common disorder of infancy, occurring in 6-20% newborns and infants - in most cases it's unilateral - chronic tearing occurs and build-up in lacrimal sac causes mucoid or mucopurulent drainage - most cases resolve spontaneously by 6mos old - no apparent risk factors - therapeutic management involves watchful waiting approach - massage may be prescribed and if secondary bacterial infection suspected or confirmed, antibiotic ointment or drops can be ordered - if obstruction not resolved by 12mos, ophthalmologist may probe duct to relieve obstruction

Promoting Communication and Education

- talk with families about learning communication with child - if child learns ASL, parents and siblings should too - teach families communication may be enhanced by use of text telephone service in home, closed-caption television, and lights rather than bells or alarms to alert child - provide sign language interpreter for child at healthcare visits if parents not present

Preventing Reinfection of Otitis Externa

- teach children and parents about prevention of further episodes once infection resolved - since moisture contributes to otitis externa, explain importance of keeping ear canals dry - encourage child and parents to avoid cotton swabs, headphones, and earphones, wear earplugs when swimming, promote ear canal dryness and alternate pH

Educating about Contact Lens Use

- teach older child or adolescent how to care for contact lenses properly, including lens hygiene and lens insertion and removal - inform child and parents about protective eyewear during contact sports - if eye becomes inflamed, remove contact lens and wear glasses until improved

Alleviating Symptoms of Conjunctivitis

- teach parents eye drop/ointment application, warm compresses - encourage child to avoid perennial allergens once offending allergen is determined - seasonal allergies may include tree pollen in winter or spring, grass pollen in summer, and ragweed or flower pollen in fall - teach families to minimize seasonal allergens on child's skin and hair - educate families to encourage child not to rub or touch eyes, rinse eyelids with clean washcloth and cool water, when inside from outdoors wash face and hands, ensure a shower and shampoo before bedtime

Nursing Assessment for Nasolacrimal Duct Obstruction

- tearing or discharge from one or both eyes first noted at 2wk check-up - obtain history of eye drainage to distinguish from neonatal conjunctivitis - onset and progression of symptoms, newborn response to interventions attempted - note redness of lower lid, if drainage present note consistency, color, quantity - diagnosed by clinical presentation or culture

Communicating Effectively with OME children

- turn off music or television - position self within 3ft of child before speaking - face child while speaking - use visual cues - increase the volume of your speech only slightly - speak clearly - request preferential classroom seating

Patho of AOM

- upper respiratory infection frequently precedes - fluid and pathogens travel up from nasopharyngeal area, invading middle ear space - fluid behind eardrum has difficulty draining due to positioning of eustachian tube - pathogens gain access to eustachian tube proliferating and invading mucosa, fever and pain occur - increased pressure behind tympanic membrane may result in perforation resulting in decreased pain, yield drainage in ear canal, most perforations heal spontaneously and completely benign - strep pneumoniae, haemophilus influenzae, moraxella catarrhalis, all resolve spontaneously - after infection, fluid remains in middle ear space behind tympanic membrane, sometimes for several months (OME), resulting in difficulty of draining back to nasopharyngeal area because of tube position - OME may occur because high frequency upper respiratory infections in infants and young children causing back-up of fluid from nasopharyngeal area

Nursing Management for Eye Injuries

- urgent or emergent condition should refer to ophthalmologist to preserve vision - nonemergent eye injuries usually need only simple management - position and distract child for eyelid laceration suturing, may require sedation or pain medication - to decrease edema in child with black eye (simple contusion), instruct parent to apply ice pack to area for 20 min, then remove for 20min, continue to repeat cycle for first 24hours, bruising may take up to 3wks to resolve - instruct parents and child about benign nature of scleral hemorrhage (appearance may be frightening) - educate about natural history of resolution of scleral hemorrhage without intervention over few weeks - if child with corneal abrasion has pain, administer analgesics as needed - corneal abrasions heal on own, if antibiotics prescribed, teach administration - foreign bodies may be removed from eye gently everting eyelid and wiping foreign body away with sterile cotton-tipped applicator, irrigation with normal saline may wash it away - chemical injuries, irrigate eye with a lot of water

Tips for Interacting with Visually Impaired Child

- use the child's name to gain attention - identify self and let child know you're there before touching child - encourage child to be independent while maintaining safety - name and describe people/objects to make child more aware of what's happening - discuss upcoming activities with child - explain what other children or individuals are doing - make directions simple and specific - allow child additional time to think about the response to a question or statement - use touch and tone of voice appropriate to situation - use parts of child's body as reference points for location of items - encourage exploration of objects through touch - describe unfamiliar environments and provide reference points - use sighted-guide technique when walking with visually impaired child

Physical Exam of Otitis Externa

- usually a white or colored discharge can be seen in ear canal or running from ear - canal is red and edematous, often too swollen for insertion of speculum and viewing of tympanic membrane - occasionally ear drainage is cultured for bacteria or fungus, particularly if otitis externa not improving with treatment

Nystagmus

- very rapid, irregular eye movement - "bouncing" of eyes - may occur in children with congenital cataracts but most common is neurologic problem - difficult for brain and eyes to communicate when eyes are continuous motion - visual development may be affected - need further evaluation by ophthalmologist and possibly neurologist

Therapeutic Management of AOM

- viral cases resolve spontaneously, bacterial may require treatment with antibiotics - unreasonable to get culture of middle ear fluid - tympanostomy (creation of a hole in tympanic membrane) for child with AOM - antibiotic resistance develops due to overuse of antibiotics - antibiotic choice is dependent on timing, child's age, number of episodes of infection - pain management is important for treatment and follow-up for disease resolution

Variations in Pediatric Anatomy and Physiology

- visual acuity (sharpness of vision) develops from birth throughout early childhood - hearing intact at birth, recurrent ear disorders may adversely affect child's hearing

Infant Symptoms of Hearing Loss

- wakes only to touch, not environmental noises - does not startle to loud noises - does not turn to sound by 4mos of age - dose not babble at 6mos of age - does not progress with speech development

Common Medical Treatments

- warm compress - warm, moist, washcloth typically used for conjunctivitis, use very warm water from tap (don't microwave to avoid risk of burning) - corrective lenses - in eyeglass form or as contact lenses used to correct astigmatism, refractive error, strabismus, use a safety strap to help young children wear their glasses - patching - an adhesive patch applied to healthier eye for several hours each day for strabismus, amblyopia, any other eye condition that results in one eye being weaker than the other, inform parents that though difficult to obtain, compliance with patching is critical, "pirate patch" may coax preschoolers into compliance - eye muscle surgery - surgical alignment of the eyes for strabismus, protect operative site with patching, use elbow restraints if necessary - pressure-equalizing (PE) tubes (tympanostomy tubes) - tiny plastic tubes inserted in tympanic membrane, chronic otitis media with effusion, teach parents dry ears precautions if prescribed or preferred by the surgeon, dry ears can be achieved by placing a cotton ball coated in petroleum jelly over ear canal, to create watertight seal - hearing aids - amplification device worn in ear for hearing impairments, ensure appropriate fit and adequate amplification, direct families to outfitters that provide loaner aids of various brands and styles to determine best fit and amplification for child - cochlear implants - surgically inserted electronic prosthetic device for sensorineural hearing loss, inform families that the usual minimum age for this procedure is 12 mos

Patho of Conjunctivitis

- when bacteria or virus come in contact with bulbar or palpebral conjunctiva, they're considered foreign antigens and antibody immune reaction occurs causing inflammation - allergic conjunctivitis causes an allergic response (overreaction of immune response), mast cell and histamine mediators are activated resulting in inflammation

Promoting Socialization, Development, and Education

- work with parents to determine alternative behavioral development is necessary - if less than 3y/o refer to early intervention for blind or visually impaired - after 3y/o IEP should be set into place with school - braille training should be a focus for the severely impaired or blind child - education on using a cane or other method for navigation in environment

Risk Factors for AOM

- young age - day care attendance (increases exposure to viruses causing upper respiratory infections) - previous history of AOM or OME - antecedent or concurrent upper respiratory infection - eustachian tube dysfunction - recurrent upper respiratory infection - first episode of AOM before 3 mos - family history - passive smoking - crowding in home or large family size - native american, inuit, or australian aborigine ethnicity - absence of infant breastfeeding - immunocompromise - poor nutrition - craniofacial anomalies - presence of allergies (possibly)

Communication Options for Hearing Impaired

Spoken Language - Oral deaf education (auditory-verbal therapy) - Uses technology to boost auditory potential; teaches children to notice sound and give it meaning. Develops oral speech - Cued speech - A system using hand signs to clarify lip-reading; gives the person clues about the sounds the speaker is making Signed Language - American Sign Language (ASL) - Entirely communicated through hand signs, gestures, and facial expressions. Has its own grammar and syntax - Combination: Total Communication - Combines auditory training and teaching of spoken language with SEE ("signing exact English"; corresponds to the words and syntax of English) Augmentative and Alternative Communication (AAC) - May use gestural communication - Can also include physical devices such as notebooks, communication boards, charts, or computers. Ranges from very low tech to technologically complex