Visual & Auditory - Week 11

CONDUCTIVE HEARING LOSS (box)

CAUSES: - Cerumen - Foreign body - Perforation of the tympanic membrane - Edema - Infection of the external ear or middle ear - Tumor - Otosclerosis ASSESSMENT FINDINGS: - Evidence of obstruction with otoscope - Abnormality in tympanic membrane - Speaking softly - Hearing best in a noisy environment - Rinne test: air conduction greater than bone conduction - Weber test (top head): lateralization to affected ear

SENSORINEURAL HEARING LOSS (box)

CAUSES: - Prolonged exposure to noise - Presbycusis - Ototoxic substance - Ménière's disease - Acoustic neuroma - Diabetes mellitus - Labyrinthitis - Infection - Myxedema ASSESSMENT FINDINGS: - Normal appearance of external canal and tympanic membrane - Tinnitus common - Occasional dizziness - Speaking loudly - Hearing poorly in loud environment - Rinne test: air conduction less than bone conduction - Weber test: lateralization to unaffected ear

Surgery Preop Care

Eye-care practitioner provides pt with accurate info so they can make informed decisions about treatment and obtain informed consent. - Reinforce this info & teach about nature of cataracts, progression, & treatment. Assess how reduced vision affects ADLs. Stress that *postop care requires instillation of different types of eyedrops several times a day for 2-4 weeks.* If pt is unable to perform these tasks, help pt make arrangements for this care. *Ask whether pt takes any drugs that affect blood clotting, such as aspirin, warfarin, clopidogrel, and dabigatran. These drugs may need to be discontinued before cataract surgery. A series of ophthalmic drugs are instilled just before surgery to dilate pupils & cause vasoconstriction. Other eyedrops are instilled to induce paralysis to prevent lens movement. When pt is in surgical area, a local anesthetic is injected into muscle cone behind eye for anesthesia & eye paralysis.*

Eye Trauma - Foreign Bodies

Eyelashes, dust, dirt, and airborne particles can come in contact with the conjunctiva or cornea and irritate or abrade surface. If nothing is seen on cornea or conjunctiva, eyelid is everted to examine conjunctivae. Pt usually has a feeling of something being in eye and may have blurred vision. Pain occurs if corneal surface is injured. Tearing and photophobia may be present. Visual SENSORY PERCEPTION is assessed before treatment. Eye is examined with fluorescein, followed by irrigation with normal saline (0.9%) to gently remove the particles.

Keratoconus Surgical Interventions

For a misshaped cornea that is still clear, surgical mgmt involves a corneal ring implant that adjusts shape of cornea. During this procedure, shape of cornea is changed by placing a flexible ring in outer edges of cornea (outside of optical zone). Performed under local anesthesia. Improvement to best vision is immediate. Removal, replacement, or adjustment of ring tightness can enhance refraction, especially when pt's vision changes further as a result of aging. Because ring is placed outside of optical zone, risk for corneal clouding or scarring is low.

Corneal Disorders

For a sharp retinal image, cornea must be transparent and intact. Corneal problems may be caused by irritation or infection (keratitis) with ulceration of corneal surface, degeneration of cornea (keratoconus), or deposits in cornea. All corneal problems reduce visual SENSORY PERCEPTION, and some can lead to blindness.

Finger Testing - Distant Vision Test

For pts who cannot see the 20/400 character, assess visual acuity by holding fingers in front of eyes & asking them to count number of fingers. Acuity is recorded as "counts finger vision at 5 feet," or farthest distance at which fingers are counted correctly.

Glaucoma

Glaucoma is a disturbance of the functional or structural integrity of the optic nerve. Decreased fluid drainage or increased fluid secretion increases IOP & can cause atrophic changes of the optic nerve & visual defects. Expected ref range for IOP is 10-21 mm/Hg (For proper eye function, gel in posterior segment (vitreous humor) and fluid in anterior segment (aqueous humor) must be present in set amounts that apply pressure inside eye to keep it ball shaped.) Most common cause of blindness in the US

Glaucoma Therapeutic Procedures

Glaucoma surgery Laser trabeculectomy (meshwork), iridotomy (hole in iris for drainage), or placement of a shunt are procedures used to improve flow of aqueous humor ny opening a channel out of the anterior chamber of the eye Educate pt about disease & importance of adhering to med schedule to treat IOP

Keratoplasty Graft Rejection

Graft rejection can occur and starts as inflammation in cornea near graft edge that moves toward center. Vision is reduced, and cornea becomes cloudy. Topical corticosteroids and other immunosuppressants are used to stop rejection process. If rejection continues, graft becomes opaque, & blood vessels branch into opaque tissue.

Electroretinography

Graphs retina's response to light stimulation. Helpful in detecting & evaluating blood vessel changes from disease or drugs. Graph is obtained by placing an electrode on an anesthetized cornea. Lights at varying speeds and intensities are flashed, and neural response is graphed. Measurement from cornea is identical to response that would be obtained if electrodes were placed directly on retina.

Meclizine

Has antihistamine & anticholinergic effects & is used to treat vertigo that accompanies inner ear probs. Nursing: - Observe for sedation & take appropriate precautions to ensure safe ambulation Pt Education: - Be aware of sedative effects of meclizine. (Avoid driving or operating heavy machinery.)

S/S Meniere's

Headache, increasing tinnitus, and fullness of the affected ear can precede the attack of vertigo. Patients often describe the tinnitus as a continuous, low-pitched roar or a humming sound, which worsens just before and during an attack. Hearing loss occurs first with the low-frequency tones but progresses to include all levels and, with repeated attacks, can become permanent. The vertigo, coupled with periods of a "whirling" sensation, may cause patients to fall. It is so intense that, even while lying down, the patient often holds the bed or ground to keep from falling. Severe vertigo usually lasts 3 to 4 hours, but the patient may feel dizzy long after the attack. Nausea and vomiting, rapid eye movement (nystagmus), and severe headaches often accompany vertigo.

Middle Ear Disorders S/S

Hearing loss Feeling of fullness and/or pain in ear Red, inflamed ear canal & tympanic membrane Bulging TM Fluid &/or bubbles behind TM Diffuse appearance of or inability to visualize normal light reflex Fever

Inner Ear Disorders S/S

Hearing loss Tinnitus Dizziness or vertigo Vomiting Nystagmus Alterations in balance

IOP Varies

IOP varies throughout the day and typically peaks at certain times of the day. Therefore always document the type and time of IOP measurement.

Retinal Detachment Therapeutic Procedures

If a retinal hole or tear is discovered before it causes a detachment, defect may be closed or sealed. Closure prevents fluid from collecting under retina and reduces risk for a detachment. Treatment involves creating a scar that will bind retina and choroid together around break. Common methods to create scar are with laser photocoagulation or a freezing probe (cryopexy). Spontaneous reattachment of a totally detached retina is rare. Surgical repair is needed to place retina in contact with the underlying structures. A common repair procedure is scleral buckling.

Corneal Infection Drugs - Patient Teaching

If eye infection occurs only in one eye, teach pt not to use drug in unaffected eye. Instruct pt to wash hands after touching affected eye and before touching or doing anything to healthy eye. If both eyes are infected, separate bottles of drugs are needed for each eye. Teach pt to clearly label the bottles "right eye" and "left eye" and not to switch drugs from eye to eye. Also teach pt to completely care for one eye, wash hands and, using drugs designated for other eye, care for that eye. Remind pt not to wear contact lenses during entire time that these drugs are being used because eye is more vulnerable to infection or injury and because drugs can cloud or damage contact lenses. Drug therapy may continue for 3+ weeks to ensure eradication of infection. Warn pts to avoid using makeup around eye until infection has cleared. Instruct them to discard all open containers of contact lens solutions and bottles of eyedrops because these may be contaminated. Pts should not wear contact lenses for weeks to months until infection is gone and ulcer is healed.

Otitis Media Surgical Mgmt

If pain persists after antibiotic therapy and eardrum continues to bulge, a myringotomy (surgical opening of the eardrum) is performed. - Drains middle ear fluids & immediately relieves pain. - Procedure is a small surgical incision, which is often performed in an office or clinic setting, and incision heals rapidly. Another approach is the removal of fluid from middle ear with a needle. For relief of pressure caused by serous otitis media and for pts who have repeated episodes of otitis media, a small grommet (polyethylene tube) may be surgically placed through eardrum to allow continuous drainage of middle ear fluids

Imaging Assessments

CT - Contrast agent used unless trauma is suspected. Test is not painful but does require being in a confined space and keeping head still. MRI - Cannot be used to evaluate injuries involving metal in eyes. Metal in eye is an absolute contraindication for MRI. Radioisotope scanning - Requires pt sign an informed consent. Pt receives a tracer dose of radioactive isotope, either orally or by injection, & must then lie still. Scanner measures radioactivity emitted by radioactive atoms concentrated in area being studied. Sedation may be used for pts who are anxious. No special follow-up care is required. Ultrasonography - noninvasive test helps diagnose trauma, intraorbital tumors, proptosis, and choroidal or retinal detachments. Also used to determine length of eye & any gross outline changes in eye & orbit in pts with cloudy corneas or lenses that reduce direct examination of fundus. - Test is painless because it is either performed with eyes closed or, when eyes must remain open, anesthetic eyedrops are instilled first. Pt sits upright with chin in chin rest. Probe is touched against pt's anesthetized cornea, & sound waves are bounced through eye. Sound waves create a reflective pattern on a computer screen that can be examined for abnormalities. No special follow-up care is needed. Remind pt not to rub or touch eye until anesthetic agent has worn off.

Cataracts Diagnostic Procedures

Can be determined upon exam of lens using an ophthalmoscope

Caloric Testing

Can be done concurrently with ENG Water (warmer or cooler than body temp) is instilled in ear in an effort to induce nystagmus. The eyes response to instillation of cold & warm water is diagnostic of vestibular disorders. Nursing actions: Pt should follow the same restrictions as those for an ENG Pt Education: Be aware of above restrictions

External Eye Structures

Canthus: place where two eyelids meet at corner of eye Conjunctivae: mucous membranes of the eye Lacrimal gland: Produces tears Punctum: Tear duct

Conditions of Middle Ear

Caused by injury, disease, aging process Acute otitis media is a viral or bacterial infection of the middle ear Manifestations include ear pain, pressure, fever, headache, conductive hearing loss, & purulent or bloody drainage if perforation of eardrum occurs Otoscopic exam can show redness, bulging tympanic membrane, & inability to visualize usual landmarks Medical mgmt includes systemic antibx therapy, analgesics, & application of heat for pain, & decongestants Surgical mgmt includes *myringotomy* (opening of eardrum made surgically) & placement of a grommet to equalize pressure

Ocular Lacerations

Caused by sharp objects and projectiles. Injury occurs most commonly to eyelids & cornea, although any part of eye can be lacerated. Pt should receive medical attention as soon as possible. *Initially eye is closed, and a small ice pack is applied to decrease bleeding. * Minor lacerations of eyelid can be sutured in an emergency department, an urgent care center, or an eye-care practitioner's office. A microscope is needed in OR if pt has a laceration that involves eyelid margin, affects lacrimal system, involves a large area, or has jagged edges. *Corneal lacerations are an emergency because eye contents may prolapse through laceration*

Cerumen Patient-Centered Care

Cerumen is generally moist and tan or brown in white people and black people. It is dry and light brown-to-gray in Asians and American Indians. The color of the lining of the external ear canal varies with the patient's skin tone. Variations should not be mistaken for indications of problems. Patients with more moist earwax form cerumen impactions more easily than patients with drier, flaky earwax and require more frequent ear irrigations.

Drug Alert - Corneal Meds

Check the route of administration for ophthalmic drugs. Most are administered by the eye instillation route, not orally. Administering these drugs orally can cause systemic side effects in addition to not having a therapeutic effect on the eye.

Cataracts Nursing Care

Check visual acuity using Snellen chart Examine external & internal eye structures using ophthalmoscope Determine pt's functional capacity due to decreased vision Increase amt of light in a room Provide adaptive devices that accommodate for reduced vision - Magnifying lens & lare print books/newspapers - Talking devices such as clocks

Types of Glaucoma Meds

Cholinergic agents Adrenergic agonists Beta bockers Carbonic anhydrate inhibitors Prostaglandin analogs Systemic ostmotics - IV mannitol - Oral glycerin [ABCC PS]

Light Perception - Distant Vision Test

If pt cannot detect HM, assess light perception (LP). - Ask pt first to cover left eye. - In a darkened room, direct beam of a penlight at pt's right eye from a distance of 2 to 3 ft for 1 to 2 secs. - Instruct pt to say "on" when beam of light is perceived and "off" when it is no longer detected. If pt identifies presence or absence of light 3x correctly, acuity is documented as LP. If pt unable to identify presence or absence of light, test result is documented as NLP, meaning "no light perception"

Cochlear Implant for Sensorineural Hearing Loss

Cochlear impalnts consist of a microphone that picks up sound, a speech processor, a transmitter & receiver that onvert sounds into electric impulses, & electrodes that are attached to auditory nerve. Implant's transmitter is located outside th head behind the ear & connects via a magnet to receiver located mmediately below it, under the skin Young children & adults who lost their hearing after speech development adapt to cochlear implants more quickly than those born totally deaf. Intense & prolonged language training is necessary for pts who did not develop speech.. Nursing: - Follow pre-, intra-, & postop outpatient surgery guidelines Pt Education: - Immediately after surgery, unit is not turned on - External unit is applies & speech processor is programmed 2-6 wks after surgery - Be aware of precautions to prevent infection - Avoid MRIs

Patient Hx - Assessment

Collect info to determine whether probs with eye or vision have impact on ADLs. Age: - Glaucoma & cataract formation increases with aging. - Presbyopia commonly begins in the 40s. Gender: - Retinal detachments occur more often in men - Dry eye syndromes occur more often in women. Occupation and leisure: - In occupations such as computer programming, constant exposure to monitors may lead to eyestrain. - Machine operators are at risk for eye injury because of high speeds at which particles can be thrown at eye. - Chronic exposure to infrared or UV light may cause photophobia & cataract formation. - Teach pt about use of eye protection during work. - Ask whether pt wears eye protection when participating in sports. A blow to the head near the eye, such as with a baseball, can damage external structures, the eye, connections with brain, or area of brain where vision is perceived. Systemic health problems Ask about past accidents, injuries, surgeries, or blows to the head that may have led to the present problem. Specifically ask about previous laser surgeries.

Conductive Hearing Loss Risk Factors

Conductive hearing loss can be caused by any inflammation or obstruction of the external or middle ear. Changes in the eardrum such as bulging, retraction, and perforations may damage middle ear structures and lead to conductive hearing loss. Tumors, scar tissue, and overgrowth of soft bony tissue (otosclerosis) on the ossicles from previous middle ear surgery also lead to conductive hearing loss.

Cataracts Interprofessional Care

Consult with ophthalmologist (eye surgeon) for cataract surgery

AMD Patient Education

Consume foods high in antioxidants, carotene, vitamin E, & vitamin B12 - provider may prescribe daily vit E or carotene supplement - carotenoids include lutein and zeaxanthin. - These actions slow progression & reduce risk As loss of vision progresses, pts may be challenged with inability to eat, drive, write, read, & other ADLs. Refer pts to community orgs that can asist with transportation, reading devices, & large-print books.

Pupillary constriction and dilation

Control amount of light that enters eye. If level of light to one or both eyes is increased, both pupils constrict. Amount of constriction depends on how much light is available & how well retina can adapt to light changes. Miosis: Pupillary constriction Mydriasis: Pupillary dilation

Keratoconus and Corneal Opacities

Cornea can permanently lose it shape, become scarred or cloudy, or become thinner, reducing useful visual SENSORY PERCEPTION. Keratoconus: degeneration of corneal tissue resulting in abnormal corneal shape. - Can occur with trauma or may be an inherited disorder. - Inadequately treated corneal infection & severe trauma can scar cornea & lead to severe visual impairment that can be improved only by surgical interventions.

Corneal Abrasian, Ulceration, Infection

Corneal abrasion: Scrape or scratch injury of cornea. - Painful condition can be caused by a small foreign body, trauma, or contact lens use. - Other probs contributing to corneal injury are malnutrition, dry eye syndromes, & some cancer therapies. - Abrasion allows organisms to enter, leading to corneal infection. Bacterial, protozoal, and fungal infections can lead to corneal ulceration, which is a deeper injury. - *Emergency because cornea has no separate blood supply & infections that can permanently impair vision develop rapidly.*

Corneal Light Reflex - Extraocular Muscle Function Test

Corneal light reflex determines alignment of eyes. After asking pt to stare straight ahead, shine a penlight at both corneas from a distance of 12 to 15". Bright dot of light reflected from shiny surface of cornea should be in a symmetric position (e.g., at 1 o'clock position in right eye & 11 o'clock position in left eye). An asymmetric reflex indicates a deviating eye and possible muscle weakness.

Cranial Nerves in Eye

Cranial nerves: - CN II (optic): Sight - CN III (oculomotor): Muscle movement - CN IV (trochlear): Muscle movement - CN V (trigeminal): Blink reflex when cornea touched - CN VI (abducens): Muscle movement - CN VII (facial): Lid closure

Ultrasonic imaging of the retina and optic nerve

Creates a 3D view of back of eye. Often used for people with ocular htn or who are at risk for glaucoma from other problems. This computerized exam assesses thickness & contours of optic nerve fiber layer & retina for changes that indicate damage as a result of high IOP. Can be used serially for a pt at risk for glaucoma to detect early changes & indicate when intervention is needed.

Lab Assessments

Cultures of corneal or conjunctival swabs and scrapings help diagnose infections. Obtain a sample of exudate for culture before antibiotics or topical anesthetics are instilled. Take swabs from conjunctivae & any ulcerated or inflamed areas.

Corneal Infection Meds

*Antibiotics, antifungals, and antivirals* are prescribed to eliminate the organisms. A broad-spectrum antibiotic is prescribed first and may be changed when culture results are known. *Steroids* may be used with antibiotics to reduce the eye inflammation. Drugs can be given topically as eyedrops or injected subconjunctivally or intravenously. Nursing priorities are to begin drug therapy, to ensure pt understanding of drug-therapy regimen, & to prevent infection spread. Often anti-infective therapy involves instilling eyedrops every hour for first 24 hrs. Teach pt or family member how to instill eyedrops correctly

Retinitis Pigmentosa - Treatment

*No current therapy is effective in preventing degenerative process. * Mgmt strategies focus on protecting active retinal cells and slowing progression of disease. Teach pts with RP to *avoid drugs that are known to adversely affect retinal cells, such as isotretinoin and drugs for erectile dysfunction (e.g., sildenafil).* Remind pt to wear eyeglasses that provide UV protection. Research has not yet definitively concluded that ingestion of supplements benefits pts with RP. When macular edema is present, oral acetazolamide can reduce edema. Cataract surgery and lens replacement are recommended when cataracts further reduce vision. Other treatments under investigation include retinal transplantation, stem cell therapy, and gene therapy

Age-Related Changes in the Ear and Hearing

- - Pinna becomes elongated because of loss of subcutaneous tissues and decreased elasticity. - Reassure the patient that this is normal. When positioning a patient on the side, do not "fold" the ear under the head. - Hair in the canal becomes coarser and longer, especially in men. - Reassure the patient that this is normal. - More frequent ear irrigation may be needed to prevent cerumen clumping. - Cerumen is drier and impacts more easily, reducing hearing function. - Teach the patient and caregiver to irrigate the ear canal weekly or whenever he or she notices a change in hearing. - Tympanic membrane loses elasticity and may appear dull and retracted. - Do not use this finding as the only indication of otitis media. - Hearing acuity decreases (in some people). - Assess hearing with the voice test or the watch test. If a deficit is present, refer the patient to a specialist to determine hearing loss and appropriate intervention. - Do not assume that all older adults have a hearing loss! - The ability to hear high-frequency sounds is lost first. Older adults may have particular problems hearing the f, s, sh, and pa sounds. - Provide a quiet environment when speaking (close the door to the hallway) and face the patient. - Avoid standing or sitting in front of bright lights or windows, which may interfere with the patient's ability to see your lips move. - If the patient wears glasses, be sure that he or she is using them to enhance speech understanding. - Speak slowly, clearly, and in a deeper voice and emphasize beginning word sounds. - Some patients with a hearing loss that is not corrected may benefit from wearing a stethoscope while listening to you speak.

Carbonic Anhydrase Inhibitors

- Acetazolamide - Dorzolamide - Brinzolamide [ -zolamide] Decrease IOP by *reducing aqueous humor production* Ask pts whether allergic to sulfa. CAIs are sulfa-based.

Adrenergic Agonists - Glaucoma

- Apraclonidine - Brimonidine tartrate - Dipiverfrin Hcl Reduce IOP by limiting production of aqueous humor & dilates pupils to improve fluid flow to site of absorption *DILATION & DECREASED PRODUCTION* Pt education: Wear sunglasses in bright light because of pupil dilation

Prostaglandin analogs - Glaucoma

- Bimatoprost - Latanoprost Increase outflow of uveosclera by dilating blood vessels in trabecular mesh where aqueous humor collected & then *drains the humor at a more rapid rate*. Check for corneal abrasions & do not instill this med if cornea not intact! Can cause iris to change color by darkening with LT use

Cholinergic Agents - Glaucoma

- Carbachol - Echothiophate - Pilocarpine Miotic meds, which constrict pupil & allows for improved circulation & outflow or aqueous humor through trebecular meshwork *CONSTRICTION & DRAINAGE* Can cause blurred vision Policarpine is a second-line drug for POAG Pt education: Use good lighting to avoid falls

S/S Primary Open-Angle Glaucoma

- Headache - Mild eye pain - Loss of peripheral vision - Decreased accommodation - Halos seen around lights - Elevated IOP (>21 mm Hg - usually 22-32) (usually painless!)

Systemic Osmotics - Glaucoma

- IV mannitol - Oral glycerin IV mannitol is an osmotic diuretic used in emergency trmt for primary angle-closure glaucoma to *quickly decrease IOP.*

AMD Expected Findings

- Lack of depth percepton - Objects appear distorted (early) - Loss of central vision - Blurred vision (mild blurring is early) - Blindness

Glaucoma Nursing Care

- Monitor for ^ IOP (>21) - Monitor for decreased vision & light sensitivity - Assess for aching or discomfort around eye - Explain disease process & allow pts to express feelings - Treat severe pain & nausea that accompanies angle-closure glaucoma with analgesics & antiemetics

Vertigo-Reducing Activities - Patient Education

- Prevent stimuatlion/exacerbation of vertigo - Restrict mvmt f head, & change pos slowly - Avoid caffeine & alcohol - Rest in a quiet, darkened envt when vertigo is severe - Use assistive devices (can, walker) as needed for safe ambulation to assist with balance. - Maintain safe envt free of clutter - Take a diuretics, if prescribed, to decrease amt of fluid in semicircular canals - Space intake of fluid evenly throughout day - Decrease intake of salt & sodium-containing foods (processed meats, MSG) - Resume precaitons if vertigo returns

S/S Primary Angle-Closure Glaucoma

- Rapid onset of elevated IOP (30 mm Hg or higher) - Decreased or blurred vision - Colored halos seen around lights - Pupils nonreactive to light - Severe pain & nausea (acute) - Photophobia

Glaucoma Risk Factors

- Severe myopia - Htn - Age (pts >60 y.o., esp mexican americans) - DM - Eye trauma - Genetic predisposition (fam hx) - Retinal detachment - Infection - Tumors [SHADE GRIT] - High eye pressure, corneal thinness, and abnormality of optic nerve - African Americans over 40 years old,

Confrontation Test - Testing Near Vision

- Sit facing pt and ask pt to look directly into your eyes while you look into pt's eyes. - Cover your right eye and have pt cover his/her left eye so that you both have same visual field. - Then move a finger or an object from a nonvisible area into pt's line of vision. - Pt with normal peripheral vision notices object at about same time you do. - Repeat this exam by covering your left eye & having pt cover his/her right eye. - Document any areas in which you can see but pt cannot.

Cataracts Risk Factors

- Smoking - Heredity - Advanced age - DM - Eye trauma - Excessive exposure to sun - Chronic use of corticosteroids, phenothiazine derivatives, beta blockers, miotic medications [SHADE Eyes Carefully]

Ocular Irrigation (box)

1. Assemble equipment: • Normal saline IV (1000-mL bag) • Macrodrip IV tubing • IV pole • Eyelid speculum • Topical anesthetic (proparacaine hydrochloride) • Gloves • Collection receptacle (emesis basin works well) • Towels • pH paper 2. Quickly obtain a history from the patient while flushing the tubing with normal saline: • Nature and time of the injury • Type of irritant or chemical (if known) • Type of first aid administered at the scene • Any allergies to the "caine" family of medications 3. Evaluate the patient's visual acuity before treatment: • Ask the patient to read your name tag with the affected eye while covering the good eye. • Ask the patient to "count fingers" with the affected eye while covering the good eye. 4. Put on gloves. 5. Place a strip of pH paper in the cul-de-sac of the patient's affected eye to test the pH of the agent splashed into the eye and to know when it has been washed out. 6. Instill proparacaine hydrochloride eyedrops as prescribed. 7. Place the patient in a supine position with the head turned slightly toward the affected eye. 8. Have the patient hold the affected eye open or position an eyelid speculum. 9. Direct the flow of normal saline across the affected eye from the nasal corner of the eye toward the outer corner of the eye. 10. Assess the patient's comfort during the procedure. 11. If both eyes are affected, irrigate them simultaneously using separate personnel and equipment.

The nurse is caring for a client who reports slow onset of a gradual loss of vision in the center of both eyes. The client describes vision as "foggy" and reports concerns of ongoing headaches from "trying to concentrate to see." What condition does the nurse anticipate? A. Cataract B. Glaucoma C. Conjunctivitis D. Retinal detachment

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Diazepam

A benzo that has sedative effect that decreases stimuli to the cerebellum. Nursing: - Obsrve for sedation, & take appropriate precautions to ensure safe ambulation - Restrict use in pts who have closed-angle glaucoma - For older adult pts, use smallest effective dose (prevent oversedation, ataxia) Pt Education: - Be aware of sedative effects of diazepam. Avoid driving. - Be aware of addictive properties & approp use of med

Cataracts

A cataract is an opacity in the lens of an eye that impairs vision Both eyes can have cataracts, but rate of progression in each eye different.

Stapedectomy.

A partial or complete stapedectomy with a prosthesis can correct some hearing loss, especially in patients with hearing loss related to otosclerosis. Although hearing usually improves after primary stapes surgery, some patients redevelop conductive hearing loss after surgery, and revision surgery is needed.

Stapedectomy - Operative Care

A stapedectomy is usually performed through the external ear canal with the patient under local anesthesia. After removal of the affected ossicles, a piston-shaped prosthesis is connected between the incus and the footplate. Because the prosthesis vibrates with sound as the stapes did, most patients have restoration of functional hearing.

A 44-year-old client with diabetes asks how often a visit to the eye-care practitioner is recommended. What is the appropriate nursing response? A. "Annually." B. "Every 6 months." C. "Only if you have vision problems." D. "No examinations are necessary until you are 50 years old."

ANS: A

The nurse is caring for a client who has experienced an increased frequency in Ménière's disease attacks. When the client asks, "Will I have to have surgery?", what is the appropriate nursing response? Select all that apply. A. "If you eat a better balanced diet, you won't need surgery." B. "Surgery is not an option for this type of disorder." C. "You sound like you are concerned about having surgery." D. "It will be essential for you to have surgery if medications don't work." E. "Different types of surgery can be considered with your health care provider." F. "I wouldn't worry about surgery. Let's see how this new medication works for you."

ANS: C, E

For which client will the nurse avoid performing an otoscopic examination? A. 29-year-old with abdominal pain B. 37-year-old with vertigo C. 45-year-old with new diagnosis of diabetes D. 59-year-old with confusion

ANS: D Never confused pts!

A client is being discharged after surgery to correct a retinal detachment. Which symptoms will the nurse teach the client to immediately report to the eye care provider? Select all that apply. A. Purulent discharge in the affected eye B. Fever of 102° F (38.9° C) C. Pupil that constricts in response to light D. Improved visual acuity E. Pain in the eye

ANSWER: A, B, E

Patho

About 1 mL of aqueous humor is always present, but it is continuously made and reabsorbed at a rate of about 5 mL daily. A normal IOP requires a balance between production and outflow of aqueous humor. If IOP becomes too high, extra pressure compresses retinal blood vessels & photoreceptors & their synapsing nerve fibers. This compression results in poorly oxygenated photoreceptors & nerve fibers. These sensitive nerve tissues become ischemic and die. When too many have died, vision is lost permanently.

Otitis Media - S/S

Acute or chronic otitis media: Ear pain. Acute otitis media causes more intense pain from increased pressure in middle ear. Conductive hearing is reduced and distorted as sound-wave transmission is obstructed. Pt may notice tinnitus in form of a low hum or a low-pitched sound. Headaches and systemic signs and symptoms such as malaise, fever, nausea, and vomiting can occur. As pressure on middle ear pushes against the inner ear, pt may have dizziness.

Retinal Detachment Postop Care

After surgery, eye patch & shield are applied. Monitor pt's vital signs, & check eye patch & shield for any drainage. Activity after surgery varies. If gas or oil has been placed in eye, teach pt to keep head in position prescribed by surgeon to promote reattachment. Teach pt to report any sudden increase in pain or pain occurring with nausea to surgeon immediately. Remind pt to avoid activities that increase IOP. Instruct pt to avoid reading, writing, and close work, such as sewing, in first week after surgery because these activities cause rapid eye movements and detachment. Teach pt s/s of infection & detachment (sudden reduced visual acuity, eye pain, pupil that does not constrict in response to light) & to notify surgeon immediately if these symptoms occur.

Tinnitus Causes

Age Sclerosis of the ossicles Ménière's disease Certain drugs (aspirin, NSAIDs, high-ceiling diuretics, quinine, aminoglycoside antibiotics) Exposure to loud noise Other inner ear problems.

Cataracts Causes (this is ATI, but also box in book)

Age-related: Drying of lens due to water loss; Increase in lens density due to lens fiber compaction (but may be present at birth) Traumatic: Blunt or penetrating injury or a foreign body in the eye, exposure to radiation or UV light Toxic: Long term use of - corticosteroids - phenothiazine derivatives - beta blockers - miotic meds Associated: - DM - Hypoparathyroidism - Down syndrome - Chronic sunlight exposure Complicated: Intraocular disease - Retinitis pigmentosa - Glaucoma - Retinal detachment (Note: Age-related is most common type. Some degree of cataract is expected in all adults >70 yrs.)

Acoustic Neuroma

An acoustic neuroma is a benign tumor of the vestibulocochlear nerve (cranial nerve VIII) that often damages other structures as it grows. Depending on the size and exact location of the tumor, damage to hearing, facial movements, and sensation can occur. An acoustic neuroma can cause many neurologic signs and symptoms as the tumor enlarges in the brain. Signs and symptoms begin with tinnitus and progress to gradual sensorineural hearing loss. Later patients have constant mild-to-moderate vertigo. As the tumor enlarges, nearby cranial nerves are damaged.

Tympanoplasty Postop

An antiseptic-soaked gauze, such as iodoform gauze (NU GAUZE®), is packed in the ear canal. If a skin incision is used, a dressing is placed over it. 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 to prevent infection. Patients often report hearing improvement after removal of the canal packing. Until that time, communicate as with a hearing-impaired patient, directing conversation to the unaffected ear. Instruct the patient in care and activity restrictions

Otitis Media

An infecting agent in middle ear causes inflammation of mucosa, leading to swelling and irritation of ossicles within middle ear, followed by purulent inflammatory exudate. Acute disease has a sudden onset and lasts 3 weeks or less. Chronic otitis media often follows repeated acute episodes, has a longer duration, and causes greater middle ear injury. It may be a result of continuing presence of a biofilm in middle ear. Therapy for complications associated with chronic otitis media usually involves surgical intervention.

Action Alert! Object protrusion

An object protruding from the eye is removed only by an eye-care practitioner because it may be holding the eye structures in place. Improper removal can cause structures to prolapse out of the eye.

Corneal Ring Placement

Another procedure, corneal ring placement, can enhance vision for nearsightedness, although this procedure is usually performed for keratoconus.

Corneal Laceration Meds & Surgery

Antibiotics are given to reduce the risk for infection. Depending on the depth of the laceration, scarring may develop. If scar alters vision, a corneal transplant may be needed later. If eye contents have prolapsed through laceration or if injury is severe, enucleation (surgical eye removal) may be indicated.

Cataracts Medications

Anticholinergic agents: - Atropine 1% ophthalmic solution Prevents pupil constriction for prolonged periods (mydriasis) & relaxes eye muscle (cycloplegia) Used to dilate eye preoperatively & for visualization of eye's internal structures Nursing: - This med has long duration, but fast onset Pt Education: - Effects of the med can last 7-12 days - Can cause photosensitivity, so wear sunglasses

Scopolamine

Anticholinergics, such as scopolamine, are effective in the treatment of nausea that accompanies inner ear probs Available transdermally & used for motion sickness Nursing - Observe for urinary retention - Observe for sedation & take approp precautions to ensure safe ambulation - Monitor pts who have open-angle glaucoma for ^ eye pressure. Contraindicated in pts who have angle-closure glaucoma. Pt Edyucation: - Be aware of sedative effects (avoid driving) - Dry mouth is expected

Diphenhydramine & Dimenhydrinate

Antihistamines are effective in the treatment of vertigo and nausea that accompany inner ear problems Nursing: - Observe for urinary retention - Observe for sedation & take approp precautions to ensure safe ambulation Pt Education: - Warn about sedative effects and avoid driving - Dry mouth is to be expected

Older Adult Eye Changes (box)

Appearance: - Eyes appear "sunken." Do not use eye appearance as an indicator for hydration status. - Arcus senilis forms. Reassure patient that this change does not affect vision. - Sclera yellows or appears blue. Do not use sclera to assess for jaundice. Cornea: - Cornea flattens, which blurs vision. Encourage older adults to have regular eye exams & wear prescribed corrective lenses for best vision. Ocular muscles: - Muscle strength is reduced, making it more difficult to maintain an upward gaze or a focus on a single image. Reassure patient that this is a normal happening and to re-focus gaze frequently to maintain a single image. Lens: - Elasticity is lost, increasing the near point of vision (making the near point of best vision farther away). Encourage patient to wear corrective lenses for reading. - Lens hardens, compacts, and forms a cataract. Stress the importance of annual vision checks and monitoring. Iris & Pupil: - Decrease in ability to dilate results in small pupil size and poor adaptation to darkness. Teach about the need for good lighting to avoid tripping and bumping into objects. Color vision: - Discrimination among greens, blues, and violets decreases. Pt may not be able to use color-indicator monitors of health status. Tears: - Tear production is reduced, resulting in dry eyes, discomfort, and ^ risk for corneal damage or eye infections. Teach about use of saline eyedrops to reduce dryness. Teach pt to increase humidity in home.

IOP

Aqueous Humor: Drains through the canal of Schlemm into the blood to maintain a balanced IOP Vitreous Body: Clear, thick gel that fills the large vitreous chamber (space between lens and retina). This gel transmits light and maintains eye shape. These work together to create IOP. If pressure too low, eyeball is soft and collapses, preventing light from getting to the photoreceptors on the retina in the back of the eye. If pressure too high, extra pressure compresses capillaries in the eye and nerve fibers. Pressure on retinal blood vessels prevents blood from flowing through them; therefore the photoreceptors and nerve fibers become hypoxic. Hypoxia --> Extensive photoreceptor and nerve fiber loss ---> vision is lost, and person is permanently blind.

The Patient After Cataract Surgery - Home Care Assmt (Box)

Assess the eye and vision: • Visual acuity in both eyes using a handheld eye chart • Visual fields of both eyes • Compare operative eye with nonoperative eye for presence or absence of: - Redness - Tearing - Drainage Ask the patient about: • Pain in or around the operative eye • Any change in vision (decreased or improved) in the operative eye • Whether any of these has been noticed in the operative eye: • Dark spots • Increase in the number of floaters • Bright flashes of light Assess the home environment for: • Safety hazards (esp tripping and falling hazards) • Level of room lighting Assess patient adherence with and understanding of treatment and limitations, such as: • Manifestations to report • Drug regimen • Activity restrictions • Ability to perform ADLs

The Patient With Suspected Hearing Loss (box)

Assess whether the patient has any of these ear problems: • Pain • Feeling of fullness or congestion • Dizziness or vertigo • Tinnitus • Difficulty understanding conversations, esp in a noisy room • Difficulty hearing sounds • The need to strain to hear • Need to turn head to favor one ear or need to lean forward Assess visible ear structures, particularly external canal & TM: • Position and size of pinna • Patency of external canal; presence of cerumen or foreign bodies, edema, or inflammation • Condition of TM: intact, edema, fluid, inflammation Assess functional ability, including: • Frequency of asking people to repeat statements • Withdrawal from social interactions or large groups • Shouting in conversation • Failing to respond when not looking in direction of sound • Answering questions incorrectly

Extraocular Muscle Function Test

Assessed using the corneal light reflex & six cardinal positions of gaze. These tests assess smoothness of eye movements and function of cranial nerves III, IV, & VI.

Ear Disorders Diagnostic Procedures

Audiometry Tympanogram Weber & Rinne Otoscopy Electronystagmography (ENG) Caloric Testing

Audiometry

Audiometry is a noninvasive test of hearing ability, including frequency, pitch, & intensity Pt indicates when a tone is heard through earphones. Nurses might collab with an audiologist for this & other diagnostic procedures

Pt Education Following Middle Ear Surgery

Avoid air travel 2-3 wks Avoid straining or coughing, & blow nose gently wth mouth open for 2-3 wks postop Keep ear canal clean & dry. Avoid washing hair or showering for several days to 1 week. When able to shower, loosely place a cotton ball with petroleum jelly into the ear canal to prevent water from entering. Expect some temporary hearing loss in affected ear due to presence of fluid or packing Drainage from ear canal should be reported to provider.

Action Alert! Ophthalmoscope

Avoid using an ophthalmoscope with a confused patient to prevent accidental injury to the eye.

Cataracts Expected Findings

Decreased visual acuity - prescription changes - reduced night vision - decreased color perception (early s/s) Blurred vision (early s/s) Diplopa (double vision) Progressive & painless vision loss Visible opacity Absent red reflex (may look bluish-white) (No pain or eye redness is associated with age-related cataract formation.) [mnemonic from sarah RN: C. A. T. S. = Cloudy/blurred vision, Acquiring frequent eyeglass rx, Toned down colors, Sensitivity to glare & light.]

Fluorescein angiography

Detailed image of eye circulation. Digital pictures are taken in rapid succession after dye is given IV. This test helps assess probs of retinal circulation (e.g., diabetic retinopathy, retinal hemorrhage, and macular degeneration) or to diagnose intraocular tumors. Explain procedure, check that pt has signed informed consent, & instill mydriatic eyedrops (cause pupil dilation) 1 hour before the test. Warn that dye may cause skin to appear yellow for several hours after test. Stain is eliminated through urine, which turns green. Encourage pts to drink fluids to help eliminate dye. Any staining of skin will disappear in a few hours. Instruct pt to wear dark glasses & avoid direct sunlight until pupil dilation returns to normal because bright light will cause eye pain.

Visual Field Testing

Determines degree of peripheral vision. Can be performed with a computerized machine or with a "confrontation test" for a rapid check of peripheral vision.

Disorders of the Eye

Disorders of the eye can be caused by injury, disease process, & aging process. Nurses should be familiar with: - Macular degeneration - Cataracts - Glaucoma

Irrigation - Action Alert!

Do not irrigate an ear with an eardrum perforation or otitis media because this may spread the infection to the inner ear. Also, do not irrigate the ear when the foreign object is vegetable matter because this material expands when wet, making the impaction worse. For vegetable matter, the object needs to be physically removed by an experienced health care professional.

Action Alert! Otoscope

Do not use an otoscope to examine the ears of any patient who is unable to hold his or her head still during the examination or who is confused. Observe the ear canal through the otoscope as you insert the speculum into the external canal to avoid the risk for perforating the eardrum.

Meniere's Disease Drug Therapy

Drug therapy may reduce the vertigo and vomiting and restore normal balance. Mild diuretics are prescribed to decrease endolymph volume, which reduces vertigo, hearing loss, tinnitus, and aural fullness. Other drugs, such as antihistamines, antivertiginous agents, and antiemetics may be used to reduce the severity of or stop an attack and to calm the patient. Intratympanic therapy with gentamycin or corticosteroids may be attempted.

Promote Independent Living in Patients With Impaired Vision (box)

Drugs: • Having a neighbor, relative, friend, or visiting nurse visit once a week to measure the proper drugs for each day may be helpful. • If the patient is to take drugs more than once each day, it is helpful to use a container of a different shape (with a lid) each time. For example, if the patient is to take drugs at 9 AM, 1 PM, and 9 PM, the 9 AM drugs would be placed in a round container, the 1 PM drugs in a square container, and the 9 PM drugs in a triangular container. • It is helpful to place each day's drug containers in a separate box with raised letters on the side of the box spelling out the day. • "Talking clocks" are available for the patient with low vision. • Some drug boxes have alarms that can be set for different times. Communication: • Telephones with large, raised block numbers may be helpful. The best models are those with black numbers on a white phone or white numbers on a black phone. • Telephones that have a programmable automatic dialing feature ("speed dial") are very helpful. Programmed numbers should include those for the fire department, police, relatives, friends, neighbors, and 911. Safety: • It is best to leave furniture the way the patient wants it and not move it. • Throw rugs are best eliminated. • Appliance cords should be short and kept out of walkways. • Lounge-style chairs with built-in footrests are preferable to footstools. • Nonbreakable dishes, cups, and glasses are preferable to breakable ones. • Cleansers and other toxic agents should be labeled with large, raised letters. • Hook-and-loop (Velcro) strips at hand level may help mark the locations of switches and electrical outlets. Food Prep: • Meals on Wheels is a service that many older adults find helpful. This service brings meals at mealtime, cooked and ready to eat. The cost of this service varies, depending on the patient's ability to pay. • Many grocery stores offer a "shop by telephone" service. The patient can either complete a computer booklet indicating types, amounts, and brands of items desired; or the store will complete this booklet over the telephone by asking the patient specific information. The store then delivers groceries to the patient's door (many stores also offer a "put-away" service) and charges the patient's bank card. • A microwave oven is a safer means of cooking than a standard stove, although many older patients are afraid of microwave ovens. If the patient has and will use a microwave oven, others can prepare meals ahead of time, label them, and freeze them for later use. Also, many microwavable complete frozen dinners that comply with a variety of dietary restrictions are available. • Friends or relatives may be able to help with food preparation. Often relatives do not know what to give an older person for birthdays or other gift-giving occasions. One suggestion is a homemade prepackaged frozen dinner that the patient enjoys. Personal Care: • Handgrips should be installed in bathrooms. • The tub floor should have a nonskid surface. • Male patients should use an electric shaver rather than a razor. • Choosing a hairstyle that is becoming but easy to care for (avoiding parts) helps in independent living. • Home hair-care services may be available. Diversional activity: • Some patients can read large-print books, newspapers, and magazines (available through local libraries and vision services). • Books, magazines, and some newspapers are available on audiotapes or discs. • Patients experienced in knitting or crocheting may be able to create items fashioned from straight pieces such as afghans. • Card games, dominoes, and some board games that are available in large, high-contrast print may be helpful for patients with low vision.

AMD Risk Factors

Dry AMD: - Smoking - Htn - Female sex - Short body stature - Family history - Diet lacking carotene & vitamin E Wet AMD: - Can occur at any age

Two types of Macular Degeneration

Dry macular degeneration: - The most common - Caused by a gradual blockage in retinal capillary arteries, which results in the macula becoming ischemic & necrotic due to lack of retinal cells. Wet macular degeneration: - A less common form - Caused by new growth of blood vessels that have thin walls that leak blood & fluid. (As dry AMD worsens it can deteriorate into wet AMD because of ^ development of blood vessels in the area)

Electronystagmography (ENG)

ENG detects involuntary eye mvmts (nystagmus) in order to assess for disease of vestibular system of the ear (inner ear, balance). Electrodes are taped near eyes, & mvmts of eyes are recorded when ear canal is stimulated with cold water instillation or injection of air. Recording of eye mvmts can be interpreted by a specialist as either normal or abnormal. Nursing actions: - Intraprocedure, nurse should ask simple questions (name recall, math probs) to ensure pt remains alert - Pt should be maintained on bed rest & NPO postop until vertigo subsides Client Education: - Fast immediatly bebfore procedure, & restrict caffeine, alcohol, sedatives, & antihistamines for several days prior to test - This test not performed on pts w pacemaker. Pacemaker signals inhibit sensitivity of ENG.

Retinitis Pigmentosa - S/S

Earliest manifestation of RP is night blindness, often occurring in childhood. Over time, decreased acuity progresses to total blindness. Examination of retina shows heavy pigmentation in a lacy pattern. Cataracts may accompany this disorder.

Hearing Loss Mgmt

Early detection Drug therapy: Focused on correcting underlying problem or reducing side effects of problems occurring with hearing loss. Antibiotic therapy is used to mng external otitis and other ear infections. By treating infection, antibiotics reduce local edema and improve hearing. When pain is also present, analgesics are used. Many ear disorders induce vertigo and dizziness with nausea & vomiting. Antiemetic, antihistamine, antivertiginous, and benzodiazepine drugs can help reduce these problems.

Refraction & Correction

Emmetropia: perfect refraction of eye in which light rays from a distant source are focused into a sharp image on the retina. Hyperopia: (farsightedness) occurs when eye does not refract light enough. Distant vision is normal, but near vision is poor. Corrected with a convex lens in eyeglasses or contact lenses. Myopia: (nearsightedness) occurs when eye overbends light. Near vision is normal, but distance vision is poor. Myopia is corrected with a concave lens. Astigmatism: refractive error caused by unevenly curved surfaces on or in the eye, esp cornea. These uneven surfaces distort vision.

Glaucoma Health Promo & Disease Prevention

Encourage annual eye exams & good eye health, esp adults over age 40 - every 2 to 4 years before age 40 - every 1 to 3 years ages 40 - 54 - every 1 to 2 years ages 55 -64 - every 6 to 12 months over age 65 Educate pts about disease process & early indications of glaucoma, such as reduced vision & mild eye pain.

Glaucoma Complications

Blindness is a potential consequence of untreated glaucoma Have regular glaucoma checks: - Before age 40: Every 2-4 yrs - Ages 40-54: Every 1-3 yrs - Ages 55-64: Every 1-2 yrs - Ages 65+: Every 6-12 months

Hearing Loss

Environmental or workplace exposure to noise can lead to hearing loss Conductive hearing loss is caused by factors such as otitis media, otosclerosis, & presence of a foreign body (such as impacted cerumen) Color of cerumen and external ear canal varies depending on pt's race & skin tone. Sensorineural hearing loss caused by damage to *CN VIII* Combined hearing loss is caused by mixture of conductive & sensorineural probs Changes in middle & inner ear related to aging include thickening of tympanic membrane (loss of elasticity), loss of sensory hair cells in organ of Corti, & limitations to mvmt of ossicles.

Patho of Meniere's

Excess of endolymphatic fluid that distorts the entire inner-canal system. This distortion decreases hearing by dilating the cochlear duct, causes vertigo because of damage to the vestibular system, and stimulates tinnitus. At first, hearing loss is reversible, but repeated damage to the cochlea from increased fluid pressure leads to permanent hearing loss.

Swimmer's Ear

External otitis occurs more often in hot, humid environments, especially in the summer, and is known as swimmer's ear because it occurs most often in people involved in water sports. Patients who have traumatized their external ear canal with sharp or small objects (e.g., hairpins, cotton-tipped applicators) or with headphones also are more susceptible to external otitis.

Eye Donation - Keratoconus

Eye donation is a common procedure and needed for corneal transplantation. The Eye Banking Association of America (EBAA, 2017) has published medical standards that detail donor eligibility and contraindications. If a deceased pt is a known eye donor, follow these recommended steps: • Raise the head of the bed 30 degrees. • Instill prescribed antibiotic eyedrops. • Close the eyes and apply a small ice pack.

Health Care Resources.

If pts not have family or friends to help before or after surgery, a referral to a home care agency is needed. Help with meal preparation, cleaning, & personal hygiene can be arranged by the case manager. Follow-up hearing tests are scheduled when lesions are well healed, in about 6-8 wks. Audiograms done before & after treatment are compared, & evaluation for further intervention to improve hearing begins. A complication of surgery is continued disability or complete loss of hearing in affected ear. Surgery is performed first on ear with greatest hearing loss. If surgery does not improve hearing, pts must decide to either attempt surgical correction of other ear or continue to use an amplification device. When underlying disorder causing hearing impairment is progressive, this decision is difficult. Support patients by listening to their concerns and giving additional information when needed. Costs to person with a hearing impairment can be extensive. Info and support can come from public and private agencies that specialize in counseling pts with disorders affecting auditory SENSORY PERCEPTION.

Cataracts Complications

Infection after surgery - Manifestations that should be reported include yellow or green drainaged, increased redness or pain, reduction in acuity, increased tear production, or photophobia Bleeding is potential risk several days after surgery - Immediately report any sudden change in visual acuity or increase in pain

Complications of LASIK

Infection, corneal clouding, chronic dry eyes, and refractive errors. Some pts 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 cornea. Cornea then becomes unstable and does not refract appropriately.

Keratoconus Education Postop

Instruct pt to lie on nonoperative side to reduce IOP. If a patch is to be used for more than a day, teach pt or family member how to apply it. Instruct pt to wear shield at night for first month after surgery & whenever pt is around small children or pets to avoid injury. Instruct pt not to use an ice pack on eye. Complications after surgery include bleeding, wound leakage, infection, & graft rejection. Teach pt how to instill eyedrops. Teach pt to examine eye (or have a family member examine it) daily for presence of infection or graft rejection. Stress that presence of purulent discharge, a continuous leak of clear fluid from around graft site (not tears), or excessive bleeding needs to be reported immediately to surgeon. Other complications include decreased vision, increased reddening of eye, pain, increased sensitivity to light, and presence of light flashes or "floaters" in field of vision. Teach pt to report any of these symptoms to surgeon if they develop after first 48 hours & persist for more than 6 hours. Eye should be protected from any activity that can increase pressure on, around, or inside eye. Teach pt to avoid jogging, running, dancing, and any other activity that promotes rapid or jerky head motions for several weeks after surgery.

Action Alert - Cataract Surgery

Instruct the pt who has had cataract surgery to immediately report any reduction of vision after surgery in the eye that had the cataract removed.

Mastoiditis Trmt

Interventions focus on halting the infection before it spreads to other structures. IV antibiotics are used but do not easily penetrate the infected bony structure of the mastoid. Cultures of the ear drainage determine which antibiotics should be most effective. Surgical removal of the infected tissue is needed if the infection does not respond to antibiotic therapy within a few days. A simple or modified radical mastoidectomy with tympanoplasty is the most common treatment. All infected tissue must be removed so the infection does not spread to other structures. A tympanoplasty is then performed to reconstruct the ossicles and the eardrum to restore hearing

Wet AMD Patient-Centered Care

Laser therapy to seal leaking blood vessels Ocular injections to inhibit blood vessel growth: 1) endothelial growth factor inhibitor 2) bevacizumab 3) ranibizumab These actions can improve vision

Cataracts Intraop Care

Lens is often extracted by phacoemulsification, in which a probe is inserted through capsule & high-frequency sound waves break lens into small pieces, which are then removed by suction. Replacement intraocular lens (IOL) is placed inside capsule to be positioned so light rays are focused in retina. IOL is a small, clear, plastic lens. Some pts have distant vision restored to 20/20 and may need glasses only for reading or close work. Some replacement lenses have multiple focal planes and may correct vision to extent that glasses or contact lenses may not be needed.

Mastoiditis

Lining of the middle ear is continuous with lining of mastoid air cells, which are embedded in the temporal bone. Mastoiditis is an infection of mastoid air cells caused by progressive otitis media. Antibiotic therapy is used to treat middle ear infection before it progresses to mastoiditis. If mastoiditis is not managed appropriately, it can lead to brain abscess, meningitis, and death.

Eye Assessment - Inspection

Look for head tilting, squinting, or other actions that indicate pt is trying to attain clear vision. Pts with double vision may cock the head to side to focus two images into one, or they may close one eye to see clearly. Exophthalmos (proptosis) is protrusion of the eye. Enophthalmos is the sunken appearance of the eye. Scleral and corneal assessment require a penlight. In dark-skinned adults, normal sclera may appear yellow; and small, pigmented dots may be visible Cornea is best seen by directing a light at it from the side. Assess the blink reflex by bringing a hand quickly toward the patient's face. NOT with confused adults. Anisocoria: Noticeable pupillary size difference - Older adults have smaller pupils - Smaller pupils reduce vision in low light conditions. Consensual response: Constriction of left pupil when light is shined at right pupil Pupil should immediately constrict when light directed at it (i.e., a brisk response). If pupil takes more than 1 second to constrict, response is sluggish. Pupils that fail to react are nonreactive or fixed. Accommodation: Assess by holding finger about 18 cm from pt's nose and move it toward nose. Pt's eyes normally converge during this movement, and pupils constrict equally.

Hearing Loss

Loss of auditory SENSORY PERCEPTION is common and may be conductive, sensorineural, or a combination of the two. Conductive hearing loss occurs when sound waves are blocked from contact with inner ear nerve fibers because of external or middle ear disorders. If the inner ear sensory nerve that leads to the brain is damaged, the hearing loss is sensorineural. Combined hearing loss is mixed conductive-sensorineural. Disorders that cause conductive hearing loss are often corrected with minimal or no permanent damage. Sensorineural hearing loss is often permanent.

Slit-lamp examination

Magnifies anterior eye structures. Pt leans on a chin rest to stabilize head. Narrow beam (slit) of light is aimed so only a segment of eye is brightly lighted. Examiner can then locate position of any abnormality in cornea, lens, or anterior vitreous humor.

Tinnitus S/S

Manifestations range from mild ringing, which can go unnoticed during day, to a loud roaring in the ear, which can interfere with thinking and attention span. Some pts feel as if constant ringing could drive them mad.

Ear Trauma

May occur to the eardrum and ossicles by infection, by direct damage, or through rapid changes in the middle ear pressure. Objects placed in external canal exert pressure on eardrum and cause perforation. If objects continue through canal, ossicles may be damaged. Blunt injury to skull and ears can also damage or fracture middle ear structures. Slapping external ear increases pressure in ear canal and can tear eardrum. Excessive nose blowing and rapid changes of pressure (barotrauma) can increase pressure within the middle ear, leading to damaged ossicles and a perforated eardrum. Most eardrum perforations heal within a week or two without treatment. Repeated perforations heal more slowly, with scarring. Depending on the amount of damage to the ossicles, auditory SENSORY PERCEPTION may or may not return. Hearing aids can improve hearing in this type of hearing loss. Surgical reconstruction of the ossicles and eardrum through a tympanoplasty or a myringoplasty may also improve hearing. Nursing care priorities focus on teaching about trauma prevention. Caution adults to avoid inserting objects into external canal. Stress importance of using ear protectors when blunt trauma is likely.

Tonometry

Measures IOP using a tonometer. This instrument applies pressure to outside of eye until it equals pressure inside eye. Normal IOP readings are 10-21 mm Hg; This number is not absolute & must be considered along with corneal thickness. Thickness of cornea affects how much pressure must be applied before indentation occurs. For example, adult with a thicker cornea will have a higher tonometer reading that may falsely indicate increased IOP. An adult with a thinner cornea may have a low tonometer reading even when higher IOP is present. 5% of pts with healthy eyes have a slightly higher pressure. Tonometer readings indicated for all pts >40 yrs. Adults with a family hx of glaucoma should have their IOP measured once or twice a year. Most common method to measure IOP by an eye-care practitioner is the Goldmann applanation tonometer used with a slit lamp. - This method involves direct eye contact. Tono-Pen is designed for use by eye-care practitioners in extended care or LT care facilities or for other pts unable to be positioned behind a slit lamp.

Tympanogram

Measures mobility of the TM & middle ear structures relative to sound. Effective in diagnosing middle ear disease.

Ear Disorder Meds

Meclizine Antiemetics Diphenhydramine & dienhydrinate Scopolamine Diazepam

Nursing Care

Monitor functional ability & balance. Take fall risk precautions as necessary. Evaluate pt's home situation. Collab with home health to assess home safety & falls risks, as needed. Encourage a pt who has balance or functional limitations to rise slowly & use assistance & assitive devices as needed. Monitor blood levels of ototoxic meds, & teach pts about adverse effects. Routine audiometry is indicated with use of ototoxic IV antibiotics. Ototoxic meds inlude: - Antibiotics: gentamicin, erythromycin - Diuretics: Furosemide, ethacrynic acid - NSAIDs: asa, ibuprofen - Chemotherapeutic agents: cisplatin Assist with ENG & caloric testing as needed Administer antivertigo & antiemetic meds as needed.

Cerumen

Most common cause of an impacted canal. A canal can also become impacted as a result of foreign bodies that can enter or be placed in the external ear canal, such as vegetables, beads, pencil erasers, and insects. Although uncomfortable, cerumen or foreign bodies are rarely emergencies and can be removed carefully by a health care professional. Cerumen impaction in older adult is common, and removal of cerumen from older adults often improves hearing.

Surgical Mgmt of Refractive Errors

Most common vision-enhancing surgery is laser in-situ keratomileusis (LASIK). - can correct nearsightedness, farsightedness, and astigmatism. - superficial layers of cornea are lifted temporarily as a flap, and powerful laser pulses reshape deeper corneal layers. - After reshaping is complete, corneal flap is placed back into its original position. - Usually both eyes are treated at same time, which is convenient for pt, although this practice has some risks. - Many pts have improved vision within an hour after surgery, and complete healing to best vision takes up to 4 weeks. - outer corneal layer is not damaged, and pain is minimal.

Nursing Safety Priority - Drug Alert

Most eyedrops used for glaucoma therapy can be absorbed systemically and cause systemic problems. It is critical to teach punctal occlusion to patients using eyedrops for glaucoma therapy.

Necrotizing or malignant otitis

Most virulent form of external otitis. Organisms spread beyond external ear canal into ear and skull. Death from complications such as meningitis, brain abscess, and destruction of cranial nerve VII (facial) is possible.

Ménière's Disease

Ménière's disease usually first occurs in people between the ages of 20 and 50 years. It has three features: 1) tinnitus 2) one-sided sensorineural hearing loss 3) vertigo, occurring in attacks that can last for several days.

Cataracts Postop Care

Nursing Actions Postop: - Prevent ^ intraocular pressure - Prevent infection - Admin ophthalmic meds - Provide pain relief - Teach pt about self-care at home & fall prevention Immediately after surgery, antibiotic & steroid ointments are instilled. Pt usually is discharged within an hour after surgery. Instruct pt to wear dark glasses outdoors or in brightly lit environments until pupil responds to light. Teach pt & family how to instill prescribed eyedrops. Work with them in creating a written schedule for timing and order of eyedrops admin. Stress importance of keeping all follow-up appts. Remind patient that mild eye itching is normal, as is a "bloodshot appearance." Eyelid may be slightly swollen. However, significant swelling or bruising is abnormal. Cool compresses may be beneficial. Discomfort at site is controlled with acetaminophen or acetaminophen with oxycodone (Percocet, Endocet ). Aspirin is avoided because of effects on blood clotting. Pain early after surgery may indicate increased IOP or hemorrhage. Instruct pts to contact surgeon if pain occurs with nausea or vomiting. To prevent increases in IOP, teach pt & family about activity restrictions.

Totally Implantable Devices Interventions.

Nursing priorities focus on facilitating communication and reducing anxiety. Do not shout at the patient because sound may be projected at a higher frequency, making him or her less able to understand. Communicate by writing (if he or she is able to see, read, and write) or pictures of familiar phrases and objects. Many tv programs are now closed captioned or video described (subtitled). When available, use assistive devices to increase communication. Lip-reading & sign language can ^ communication. In lip-reading, pts are taught special cues to look for when lip-reading & how to understand body language. However, best lip-reader still misses more than half of what is being said. Because even minimal lip-reading assists hearing, urge pts to wear their eyeglasses when talking with someone to see lip movement. Sign languages, such as ASL, combine speech with hand mvmts that signify letters, words, & phrases. These languages take time & effort to learn, & many people are unable to use them effectively. Managing anxiety can ^ effectiveness of communication efforts. One source of anxiety is possibility of permanent hearing loss. Provide accurate info about likelihood of hearing returning. When hearing impairment is likely to be permanent, reassure pts that communication & social interaction can be maintained. To reduce anxiety & prevent social isolation, help pts use resources & communication to make social contact satisfying. Identify pt's most satisfying activities and social interactions & determine the effort necessary to continue them. Pt can alter activities to improve satisfaction. Instead of large gatherings, pt might choose smaller groups. A meal at home with friends can substitute for dining out, or consider requesting a table in a quiet area of a restaurant.

Macular Degeneration

Often called age-related macular degeneration (AMD). It is central loss of vision that affects macula of eye. There is no cure. AMD is a common cause of vision loss in older adults.

Penetrating Eye Injury

Often leads to permanent loss of visual SENSORY PERCEPTION. Glass, high-speed metal or wood particles, BB pellets, & bullets are common causes of penetrating injuries. Particles can enter eye and lodge in or behind eyeball.

Retinal Detachment Diagnostics

On ophthalmoscopic exam, detachments seen as gray bulges or folds in retina. Sometimes a hole or tear may be seen at edge of detachment.

Antiemetics

Ondansetron is one of severeal antiemetics used to treat nausea & vom assoc with vertigo Nursing: - Contraindicated for pts w certain cardiac dysrhythmias Pt education: - Report dizziness or rash

Retinal Detachment

Onset of a retinal detachment usually sudden & painless. Pts may suddenly see bright flashes of light (photopsia) or floating dark spots in affected eye. During initial phase of detachment or if detachment is partial, pt may describe sensation of a curtain being pulled over part of visual field. Visual field loss corresponds to area of detachment.

Operative Procedure - Keratoplasty

Operative procedures are keratoplasties and are usually performed with local anesthesia in an ambulatory surgical setting. Transplant may involve entire depth of corneal tissue (penetrating keratoplasty) or only certain layers of corneal tissue (lamellar keratoplasty). Nerves around eye are anesthetized so pt cannot move eye or see out of it. The center 7-8 mm of the diseased cornea is removed with an instrument that works like a cookie cutter. Same instrument is used to cut tissue graft from donor cornea so graft will be a perfect fit. Donor cornea is sutured into place on the eye. Procedure takes about an hour, and pt is discharged to home within 1-2 hrs.

Assessment

Ophthalmoscopic examination shows cupping and atrophy of the optic disc. It becomes wider and deeper and turns white or gray. In POAG the visual fields first show a small loss of peripheral vision that gradually progresses to a larger loss.

AMD Diagnostic Procedures

Ophthalmoscopy: Ophthalmoscope i used to examine back part of eyeball (fundus) including retina, optic disc, macula, & blood vessels Visual acuity tests: Snellen & Rosenbaum eye charts

Internal Eye Structures

Orbit: bony socket of skull that surrounds & protects eye Sclera: Outer layer. "White" of the eye Cornea: Transparent layer on front of eye Uvea: Middle layer. heavily pigmented and consists of the choroid, the ciliary body, and the iris - Choroid contains bv's that supply retina w nutrients - Ciliary body connects choroid & iris & secretes aqeous humor - Iris: colored portion of external eye Pupil: center opening of iris Retina: Innermost layer. Thin, delicate structure made up of sensory photoreceptors that begin transmission of impulses to the optic nerve Rods & Cones: Retina contains blood vessels and two types of photoreceptors called rods and cones. - Rods work at low light levels & provide peripheral vision. - Cones are active at bright light levels & provide color and central vision. Optic Fundus: area at the inside back of the eye that can be seen with an ophthalmoscope Optic disc: a pinkish-orange or white depressed area where nerve fibers that synapse with photoreceptors join together to form optic nerve & exit the eyeball. - Contains only nerve fibers & no photoreceptor cells. - To one side of optic disc is a small, yellowish pink area called macula lutea. - Center of macula is fovea centralis, where vision is most acute.

Otoscopy

Otoscope is used to exam external auditory canal, TM, & malleus bone visible through TM. Nursing actions: - Otoscopic exam is done if audiometry results indicated possible impairment or if a pt reports ear pain - After selection of a properly-sized speculum, an otoscope is introduced into external ear - If ear canal curves, pull up & back on auricle of children, to straighten out canal & enhance visualization. - TM should be pearly gray color & intact. Should provide complete structural separation of outer & middle ear structures - Light reflex should be visible from center of TM anteriorly (5 o'clock right ear; 7 o'clock left ear) - In presence of fluid or infection in middle ear, TM becomes inflamed & can bulge from pressure of exudate. Also displaces light reflex, causing it to look diffuse or completely obscured, a significant diagnostic finding. - Avoid touching lining of ear canal which causes pain due to sensitivity. Pt Education: To see TM clearly, auricle might need to be firmly pulled

Otitis Media - Otoscopic Exam

Otoscopic examination findings vary, depending on the stage of the condition. Eardrum is initially retracted, which allows landmarks of ear to be seen clearly. At this early stage, pt has only vague ear discomfort. As the condition progresses, eardrum's blood vessels dilate & appear red. Later eardrum becomes red, thickened, and bulging, with loss of landmarks. Decreased eardrum mobility is evident on inspection with a pneumatic otoscope. Pus may be seen behind the membrane. With progression, eardrum spontaneously perforates, and pus or blood drains from ear. Then pt notices a marked decrease in pain as pressure on middle ear structures is relieved. Eardrum perforations often heal if underlying problem is controlled. Simple central perforation does not interfere with hearing unless ossicles are damaged or perforation is large. Repeated perforations with extensive scarring cause hearing loss.

Corneal Disorder S/S

Pain, reduced vision, photophobia, & eye secretions. Cloudy or purulent fluid may be present on the eyelids or lashes.

External Otitis

Painful condition caused when irritating or infective agents come into contact with skin of external ear. Result is either an allergic response or inflammation with or without infection. Affected skin becomes red, swollen, and tender to touch or movement. Swelling of the ear canal can lead to temporary hearing loss from obstruction. Allergic external otitis is often caused by contact with cosmetics, hair sprays, earphones, earrings, or hearing aids. Most common infectious organisms are Pseudomonas aeruginosa, Streptococcus, Staphylococcus, and Aspergillus.

Perimetry - Testing Near Vision

Perimetry is computerized test. - pt is asked to look straight ahead into a viewer and then indicate, by pressing a control button, when a moving light enters peripheral vision. - This process maps pt's peripheral vision and any deficits.

Corneal Staining

Placing fluorescein or other topical dye into conjunctival sac. Dye outlines irregularities of corneal surface that are not easily visible. Test is used for corneal trauma, probs caused by a contact lens, or presence of foreign bodies, abrasions, ulcers, or other corneal disorders. Noninvasive & performed under aseptic conditions. Dye is applied topically to the eye, and eye is then viewed through a blue filter. Nonintact areas of cornea stain a bright green color.

Improving Vision

Planning: Expected Outcomes - Pt with cataracts is expected to recognize when ADLs cannot be performed safely & independently & then should have cataract surgery. This procedure is covered by Medicare for patients who are 65 years or older. Interventions: Responding - Surgery is only "cure" for cataracts & should be performed as soon as possible after vision is reduced to extent that ADLs are affected.

One common cause of retinal holes, tears, and detachments

Posterior vitreous detachment (PVD). With aging, vitreous gel often shrinks or thickens, causing it to pull away from retina. Patient may experience small flashes of light seen as "shooting stars" or thin "lightening streaks" in one eye, most visible in a dark environment. These flashes of light may be accompanied by "floaters." In addition to aging, risk factors for PVD include: - extreme myopia (nearsightedness) - inflammation inside eye - cataract or eye laser surgery. When PVD does not cause a retinal tear or detachment, no treatment is needed.

Postop Care

Postoperative care involves extensive patient teaching. Local antibiotics are injected or instilled. Usually eye is covered with a pressure patch & a protective shield until pt returns to surgeon.

Preop Keratoplasty Care

Preop care may be short, with little time for teaching because transplantation is performed when donor cornea becomes available. Examine eyes for signs & symptoms of infection and report any redness, drainage, or edema to eye care practitioner. Instill prescribed antibiotic eyedrops and obtain IV access before surgery.

Vertigo-Reducing Activities - Surgical Interventions

Pressure point treatments: Inserting a tympanostomy tube, which applies micropulses at intervals to relieve the vertigo of Meniere's disease by displacing fluid of inner ear Myringotomy: Incision to TM to drain fluid from middle ear to prevent ear drum perforation in otitis media. For persistent otitis media, a pressure-equalizing tube or grommet can be inserted to temporarily take the place of the eustachian tube. It stays in place 6-18 months. Stapedectomy: Surgical procedure of middle ear in which stapes is removed & replaced with a prosthesis. - Procedure done through external ear canal & TM - TM repaired & sterile ear packing is placed postop - Procedure is done when otosclerosis has developed & bones of middle ear fuse together - Otosclerosis is one of causes of conductive hearing loss in older adults Nursing actions: - Assess for facial nerve (CN VII) damage - Intervene for vertigo, nausea, & vomiting (common findings following procedure)

Action Alert! Stapedectomy

Prevent injury by assisting the patient with ambulation during the first 1 to 2 days after stapedectomy. Keep top bed side rails up and remind pt to move head slowly to avoid vertigo.

Common Causes of Glaucoma (box)

Primary Glaucoma • Aging • Heredity Associated Glaucoma • Diabetes mellitus • Hypertension • Severe myopia • Retinal detachment Secondary Glaucoma • Uveitis • Iritis • Neovascular disorders • Trauma • Ocular tumors • Degenerative disease • Eye surgery • Central retinal vein occlusion

Two Primary Types of Glaucoma

Primary open-angle glaucoma (POAG): - More common form - Open-angle refers to angle between iris & sclera - The aqueous humor outflow is decreased due to blockages in eye's drainage system (Canal of Schlemm & trabecular meshwork), causing a *gradual* rise in IOP Primary angle-closure glaucoma: - IOP rises suddenly - Angle between iris & sclera suddenly closes, causing a corresponding increase in IOP - Onset is *sudden* & requires immediate treatment Glaucoma is a frequent cause of blindness. Early diagnosis & treatment is essential in preventing vision loss from glaucoma. Secondary glaucoma can result from trauma, eye surgery, tumors of eye, uveitis, iritis neovascular disorders, degenerative disease, or central retinal vein occlusion.

Glaucoma Meds General

Priority intervention for treating glaucoma is meds!! Patient Education: - Prescribed eye med is beneficial if used every 12 hr - Instill 1 drop in each eye daily - Wait 5-10 mins between eye drops if more than 1 is prescribed to prevent one med from diluting the other - Avoid touching tip of application bottle to eye - Always wash hands before & after use - Once eye drop instilled, apply pressure using punctal occlusion technique (placing pressure on inner corner of eye)

Tinnitus Meds

Problem and its mgmt vary with the underlying cause. When no cause can be found or the disorder is untreatable, therapy focuses on ways to mask tinnitus with background sound, noisemakers, and music during sleeping hours. Ear-mold hearing aids can amplify sounds to drown out tinnitus during day. A drug that is helpful to some patients is pramipexole (Mirapex), an antiparkinson drug.

Accommodation

Process of maintaining a clear visual image when gaze is shifted from a distant to a near object is known as accommodation. Healthy eye can adjust focus by changing curve of lens. Convergence: Ability to turn both eyes inward toward nose at same time. Helps ensure that only a single image of close objects is seen.

Penetrating Injuries s/s

Pt has eye pain & reports, "I suddenly felt something hit my eye." wound may be visible. Depending on where object enters and rests within eye, vision may be affected.

Preop Care - Retinal Detachment

Pt is usually anxious and fearful about a possible permanent loss of vision. Nursing priorities include providing info & reassurance to allay fears. Instruct pt to restrict activity & head movement before surgery to prevent further tearing or detachment. An eye patch is placed over affected eye to reduce eye movement. Topical drugs are given before surgery to inhibit pupil constriction and accommodation.

Tympanoplasty Preop

Pt requires specific instructions before surgery. Systemic antibiotics reduce risk for infection. Teach pt to follow other measures to decrease risks for infection, such as avoiding people with upper respiratory infections, getting adequate rest, balanced diet, & drinking adequate amts of fluid. Assure pt 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.

Hand Motion - Distant Vision Test

Pts who cannot count fingers are tested for hand motion (HM) acuity. - Stand 2 to 3 feet in front of pt. - Ask pt to cover eye not being tested. - Direct a light onto your hand from behind pt. - Demonstrate three possible directions in which hand can move during test (stationary, left-right, or up-down). - Move your hand slowly (1 sec per motion) & ask pt, "What is my hand doing now?" - Repeat this procedure 5x. Visual acuity is recorded as HM at farthest distance at which most of HMs are identified correctly.

Nonsurgical Mgmt Otitis Media

Put pt in a quiet environment. Bedrest limits head movements that intensify pain. *Application of low heat* may help reduce pain. Systemic antibiotic therapy is prescribed. - Teach pt to complete antibiotic therapy as prescribed & to not stop taking drug when signs & symptoms are relieved. Analgesics such as aspirin, ibuprofen, and acetaminophen relieve pain & reduce fever. For severe pain, opioid analgesics may be prescribed. Antihistamines and decongestants are prescribed to decrease fluid in the middle ear.

Critical Rescue - Eye

Recognize that a sudden or persistent loss of visual SENSORY PERCEPTION within the past 48 hours, eye trauma, a foreign body in the eye, or sudden ocular pain is an emergency. Respond by notifying the eye-care practitioner immediately.

Middle Ear Disorder Risk Factors

Recurent colds & otitis media Enlarged adenoids Trauma Changes in air pressure (scuba diving, flying)

Structures Assessed by Direct Ophthalmoscopy (box)

Red Reflex • Presence or absence Optic Disc • Color • Margins (sharp or blurred) • Cup size • Presence of rings or crescents Optic Blood Vessels • Size • Color • Kinks or tangles • Light reflection • Narrowing • Nicking at arteriovenous crossings Fundus • Color • Tears or holes • Lesions • Bleeding Macula • Presence of blood vessels • Color • Lesions • Bleeding

Glaucoma Interprofessional Care

Refer to an ophthalmologist if surgery necessary

Eye functions that provide clear images and vision

Refraction, pupillary constriction, accommodation, and convergence.

Stapedectomy - Postop Care

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 to prevent infection. The surgical procedure is performed in an area where cranial nerves VII, VIII, and X can be damaged by trauma or by swelling after surgery. Assess for facial nerve damage or muscle weakness. Indications include an asymmetric appearance or drooping of features on the affected side of the face. Ask the patient about changes in facial perception of touch and in taste. 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 by assisting as needed and instructing the patient to move slowly from sitting to a standing position.

Retinal Holes, Tears, and Detachments

Retinal hole: Break in retina. - Caused by trauma or can occur with aging. Retinal tear: Jagged and irregularly shaped break in retina. - Can result from traction on retina. Retinal detachment: Separation of retina from epithelium. - Detachments are classified by type & cause of development.

Impaction S/S

Sensation of fullness in the ear, with or without hearing loss, and may have ear pain, itching, dizziness, or bleeding from the ear. The object may be visible with direct inspection.

Presbycusis

Sensorineural hearing SENSORY PERCEPTION loss that occurs with aging. Cause: - Degeneration of cochlear nerve cells - Loss of elasticity of basilar membrane - Decreased blood supply to inner ear. Deficiencies of vitamin B12 & folic acid increase risk Other causes include atherosclerosis, hypertension, infections, fever, Ménière's disease, diabetes, and ear surgery. Trauma to the ear, head, or brain also contributes to sensorineural hearing loss.

Sensorineural Hearing Loss Risk Factors

Sensorineural hearing loss occurs when the inner ear or auditory nerve (cranial nerve VIII) is damaged. Prolonged exposure to loud noise damages the hair cells of the cochlea. Many drugs are toxic to the inner ear structures, and their effects on hearing can be transient or permanent and dose related and affect one or both ears. When ototoxic drugs are given to patients with reduced kidney function, increased ototoxicity can occur because drug elimination is slower, especially among older patients.

Glaucoma Patient Education

Set up services such as community outreach progs, meals on wheels, & services for the blind

Retinitis Pigmentosa

Several types of retinal disorders can cause progressive degeneration of retina & lead to loss of visual SENSORY PERCEPTION. Retinitis pigmentosa (RP) is a condition in which retinal nerve cells degenerate and pigmented cells of retina grow and move into sensory areas of retina, causing further degeneration. There is a genetic component

S/S Corneal Laceration

Severe eye pain, photophobia, tearing, decreased vision, and inability to open the eyelid. If laceration is result of a penetrating injury, an object may be seen protruding from eye.

Ishihara Chart - Color Vision Test

Shows numbers composed of dots of one color within a circle of dots of a different color. Test each eye separately by asking pt what numbers pt sees on chart. Reading numbers correctly indicates normal color vision.

Snellen Test - Distant Vision Test

Snellen measures distant vision - letters, numbers, pictures, or a single letter presented in various positions. - chart with one letter in different positions is used for pts who cannot read, who do not speak language used at facility, or who cannot speak but do have adequate cognition. Pt should stand 20' from chart, cover one eye, & read line that appears most clear. If can, move to next. Record findings as comparison between what pt can read at 20' & distance that a person with normal vision can read same line. - 20/50 means pt sees at 20' from chart what a healthy eye sees at 50'.

Nutrition Hx - Assessment

Some eye probs caused by or made worse with vitamin deficiencies. Ask patient about food choices. 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. Teach adults to eat about 10 servings of these foods daily.

Otitis Media Health Promotion and Maintenance

Some, but not all, cases of otitis media can be prevented. Encourage adults to remain current on all immunization boosters and to receive the flu and pneumococcal vaccines as indicated. Remind adults that proper handwashing is important to minimize all types of infection.

Action Alert! Corneal Meds

Stress importance of applying drug as often as prescribed, even at night, and to complete entire course of antibiotic therapy. Stopping the infection at this stage can save the vision in the infected eye. Instruct pt to make and keep all follow-up appointments; usually pt is seen again in 24 hrs or less

Functions of Ocular Muscles (box)

Superior rectus: • Together with lateral rectus, moves eye diagonally upward toward side of head. • Together with medial rectus, moves eye diagonally upward toward middle of head. Lateral rectus: • Together with medial rectus, tholds eye straight. • Contracting alone, turns eye toward side of head. Medial rectus: • Contracting alone, this muscle turns eye toward nose. Inferior rectus: • Together with lateral rectus, moves eye diagonally downward toward side of head. • Together with medial rectus, moves eye diagonally downward toward middle of head. Superior oblique: • Contracting alone, pulls eye downward. Inferior oblique: • Contracting alone, pulls eye upward.

Tympanoplasty Operative Procedures

Surgery is performed only when the middle ear is free of infection. If an infection is present, the graft is more likely to become infected and not heal. Surgery of the eardrum and ossicles requires the use of a microscope and is a delicate procedure. Local anesthesia can be used, although general anesthesia is often used to prevent the patient from moving. The surgeon can repair the eardrum with many materials, including muscle fascia, a skin graft, and venous tissue. If the ossicles are damaged, more extensive surgery is needed for repair or replacement. The ossicles can be reached in several ways—through the ear canal, with an endaural incision, or by an incision behind the ear The surgeon removes diseased tissue and cleans the middle ear cavity. The patient's cartilage or bone, cadaver ossicles, stainless steel wire, or special polymers (Teflon) are used to repair or replace the ossicles.

Operative Care - Retinal Detachment

Surgery is performed with pt under general anesthesia. In scleral buckling, eye-care practitioner repairs wrinkles or folds in retina & indents eye surface to relieve tugging pressure on retina. Indentation or "buckling" is performed by placing a small piece of silicone against the outside of sclera and holding it in place with an encircling band. This device keeps retina in contact with choroid for reattachment. Any fluid under retina is drained. A gas or silicone oil placed inside eye can be used to promote retinal reattachment. These agents float up and against retina to hold it in place until healing occurs.

Penetrating Injuries Therapeutic Procedures

Surgery is usually needed to remove foreign object, and sometimes vitreal removal is needed. IV antibiotics are started before surgery, and a tetanus booster is given if necessary.

Keratoplasty

Surgery to improve clarity for a permanent corneal disorder that obscures vision is a keratoplasty (corneal transplant), in which diseased corneal tissue is removed & replaced with tissue from a human-donor cornea. This process improves vision by removing corneal deformities and replacing them with healthy corneal tissue.

Acoustic Neuroma Surgical

Surgical removal can be performed in a variety of ways. Usually a craniotomy is performed, and usually the remaining hearing is lost. Care is taken to preserve the function of the facial nerve (cranial nerve VII). Acoustic neuromas rarely recur after surgical removal.

Cataracts Therapeutic Procedures

Surgical removal of the lens: - A small incision is made & the lens is either removed in one piece or several pieces after being broken up using sound waves. - The posterior capsule is retained. - A replacement or intraocular lens is inserted. Replacement lenses can correct refractive errors, resulting in improved vision.

Labyrinthectomy

Surgical trmt for vertigo that involves removal of labyrinthine portion of inner ear. Nursing actions: Pt will have severe nausea & vertigo postpo. Take approp safety precautions & give antiemetics as needed. Pt Education: Hearing loss is to be expected in affected ear.

S/S Mastoiditis

Swelling behind ear & pain when moving ear or head. Pain is not relieved by myringotomy. Cellulitis develops on skin or external scalp over mastoid process, pushing ear sideways and down. Eardrum is red, dull, thick, & immobile. Perforation may or may not be present. Lymph nodes behind ear are tender and enlarged. Pts may have low-grade fever, malaise, and ear drainage. Hearing loss occurs, and CT scans show fluid in the air cells of the mastoid process.

Action Alert - Eye Injury or Infection

Teach adults to see a health care provider immediately when an eye injury occurs or an eye infection is suspected.

Action Alert! Cerumen

Teach patients the safe way to clean their ears, stressing that nothing smaller than his or her own fingertip should be inserted into the canal.

Meniere's Disease Pt Education

Teach patients to move the head slowly to prevent worsening of the vertigo. Nutrition and lifestyle changes, such as reducing sodium intake, can reduce the amount of endolymphatic fluid. Encourage patients to stop smoking because of the blood vessel-constricting effects.

Cataracts Health Promo & Disease Prevention

Teach pts to wear sunglasses while outside Educate pts to wear protective eyewear while playing sports & performing hazardous activities, such as welding & yard work Encourage annual eye exams & good eye health, esp in adults over age 40

Gonioscopy

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

Near Vision Test

Tested for patients who have difficulty reading without using glasses or other means of vision correction. Use a small, handheld miniature eye chart called a Rosenbaum Pocket Vision Screener or a Jaeger card. - Ask pt to hold the card 14" away from eyes & read characters. - Test each eye separately and then together. Document lowest line on which pt can identify more than half characters.

ATA

The American Tinnitus Association helps patients cope with tinnitus. Refer patients with tinnitus to local and online support groups to help them cope with this problem.

Totally Implantable Devices cont.

The devices and the surgery may lead to possible complications, including temporary facial paralysis, changes in taste sensation, and ongoing or new-onset tinnitus. Unlike cochlear implants, the middle ear is entered, and it is considered a surgical procedure. Care before and after surgery is similar to that required with stapedectomy. The cost of the implant and procedure can exceed $40,000, which is not currently covered by Medicare or Medicaid but is covered by a few private insurers.

Middle & Inner Ear Disorders

The ear is a sensory organ with 2 functions: Hearing & balance Middle ear consists of: - tympanic membrane (ear drum) - 3 smallest bones (ossicles) of body (malleus, incus, stapes) - connects to nasopharynx via Eustachian tube Inner ear is located deep within temporal bone, separated from middle ear by the oval window. Consists of: - Cochlea (hearing organ) - Semicircular canals (responsible for balance) - Cranial nerves VII (facial) & VIII (vestibulocochlear nerve) Visual, vestibular, & proprioceptive systems provide brain with input regarding balance. Probs with any of these systems pose a risk for loss of balance.

Acoustic Neuroma Diagnostics

The tumor is diagnosed with CT scanning and MRI. Cerebrospinal fluid assays show increased pressure and protein.

Decibel Intensity and Safe Exposure Time for Common Sounds

Threshold of hearing: - 0 dB Whispering: - 20 dB Average residence or office: - 40 dB Conversational speech: - 60 dB Car traffic: - 70 dB - Safe exposure time is >8 hrs Motorcycle: - 90 dB - Safe exposure time is 8 hrs Chain saw: - 100 dB - Safe exposure time is 2 hrs Rock concert, front row: - 120 dB - Safe exposure time is 3 min Jet engine: - 140 dB - Safe exposure time: Immediate danger Rocket launching pad: - 180 dB - Safe exposure time: Immediate danger

Beta Blockers - Glaucoma

Timolol Beta blockers are first-line drug therapy for glaucoma decrease IOP by *reducing acqueous humor production*. Can be absorbed systemically & cause bronchoconstriction & hypoglycemia. Use with caution in asthma, COPD, DM. Can potentiate systemic effects of oral beta-blockers & cause bradycardia & hypotension

Tinnitus

Tinnitus (continuous ringing or noise perception in ear) is a common ear problem that can occur in one or both ears. Diagnostic testing cannot confirm tinnitus; however, testing is performed to assess hearing and rule out other disorders. A Tinnitus and Hearing Survey may be used to help pts and clinicians determine whether intervention for tinnitus is warranted.

Stapedectomy - Preop Care

To prevent infection, the patient must be free from external otitis at surgery. Teach the patient to follow measures that prevent middle ear or external ear infections Review with the patient the expected outcomes and possible complications of the surgery. Initially hearing is worse after a stapedectomy. The success rate of this procedure is high. However, there is always a risk for failure that might lead to total deafness on the affected side. Other possible complications include vertigo, infection, and facial nerve damage.

External Otitis Meds

Topical antibiotic and steroid therapies are most effective in decreasing inflammation and pain. Observe the patient self-administer the eardrops to make sure that proper technique is used. Oral or IV antibiotics are used in severe cases, especially when infection spreads to surrounding tissue or area lymph nodes are enlarged. Analgesics, including opioids, may be needed for pain relief during the initial days of treatment. NSAIDs, such as acetylsalicylic acid and ibuprofen or acetaminophen may relieve less severe pain. After 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 prevent recurrence. Teach pt to use preventive measures for minimizing ear-canal moisture, trauma, or exposure to materials that lead to local irritation or contact dermatitis.

Hearing Loss - Totally Implanted Devices.

Totally implanted devices, such as the Esteem®, can improve bilateral moderate-to-severe sensorineural hearing loss without any visible part. These devices have three totally implanted components: a sound processor, a sensor, and a computer. Vibrations of the eardrum and ossicles are picked up by the sensor and converted to electric signals that are processed by the sound processor. The processor is programmed to the patient's specific hearing pathology. The processor filters out some background noise and amplifies the desired sound signal. The signal is transferred to the computer, which then converts the processed signal into vibrations that are transmitted to the inner ear for auditory SENSORY PERCEPTION.

Eye Trauma

Trauma to eye or orbital area can result from almost any activity. Care varies, depending on area of eye affected and whether globe of eye has been penetrated.

Exernal Otitis Treatment

Treatment focuses on reducing inflammation, edema, and pain. Nursing priorities include comfort measures, such as *applying heat to the ear for 20 minutes 3x a day*. This can be accomplished by using towels warmed with water and then wrapped in a plastic bag or by using a heating pad placed on a low setting. Teach patient that minimizing head movements reduces pain.

Tympanoplasty

Tympanoplasty reconstructs the middle ear to improve conductive hearing loss. The procedures vary from simple reconstruction of the eardrum (myringoplasty) to replacement of the ossicles within the middle ear (ossiculoplasty).

Weber & Rinne Tsts

Use tuning forks to determine whether hearing loss is present

Assistive Devices for Hearing Loss

Useful for pts with permanent hearing loss. - Portable amplifiers can be used while watching television to avoid increasing the volume and disturbing others. - Telephone amplifiers increase telephone volume, allowing caller to speak in a normal voice. Some telephones also have a video display of words that are being spoken by the caller. - Flashing lights activated by the ringing telephone or a doorbell alert patients visually. - Some pts may have a service dog to alert them to sounds (ringing telephones or doorbells, cries of other people, and potential dangers). - Provide information about agencies that can assist the hearing-impaired person. - Small, portable audio amplifiers can help communicate with patients with hearing loss who do not use a hearing aid. Using amplifiers or allowing patients to use a stethoscope for listening helps you communicate with an adult who requires additional volume to hear speech. - A hearing aid is a small electronic amplifier that assists patients with conductive hearing loss but is less effective for sensorineural hearing loss. The styles vary by size, placement, and the degree to which they amplify sound. Most common hearing aids are small. Some are attached to a person's glasses and are visible to other people. Another type fits into the ear and is less noticeable. Newer devices fit completely in the canal with only a fine, clear filament visible. The cost of smaller hearing aids varies with size and quality. Some people benefit from classes that explain the best use and care of these devices. - Remind patients that hearing with a hearing aid is different from natural hearing. Teach the patient to start using the hearing aid slowly, at first wearing it only at home and only during part of the day. Listening to television and the radio and reading aloud can help the patient get used to new sounds. A difficult aspect of a hearing aid is the amplification of background noise. - The patient must learn to concentrate and filter out background noises. - Teach the patient how to care for the hearing aid. Hearing aids are delicate devices that should be handled only by people who know how to care for them properly.

Conditions of the Inner Ear

Vertigo occurs when pt ha sensation that they or their surroundings are in motion Benign proxysmal positional vertigo occurs in response to a change in position. - Thought to be caused by disruption of debris located within semicircular canal (small crystals of calcium carbonate). - Onset is sudden & can last a few weeks or years. - Bed rest is prescribed along with short course of meclizine. Meniere's disease is characterized by episodic vertigo, tinnitus, & fluctuating sensorineural hearing loss. Labyrinthitis: Inflammation of labyrinth in inner ear, often secondary to otitis media. - Characterized by sudden onset of severe vertigo, n/v, & possible hearing loss or tinnitus. - Manifestations are treated with bed rest in darkened envt. - Meclizine or dimenhydrinate is prescribed for nausea & vertigo. - Systemic antibx therapy can also be prescribed.

Ear Disorders Interprofessional Care

Vestibular rehab is an option for pts who experience frequent episodes of vertigo or are incapacitated due to vertigo. A team of providers treats the cause & teaches the pt exercises to help them adapt to & minimize effects of vertigo. A combo of biofeedback, PT, & stress mgmt can be used. Postural education can teach pt positions to avoid & positional exercises that can terminate attack of vertigo.

Ophthalmoscopy

Viewing of eye's external and interior structures with an ophthalmoscope. It is easiest to examine fundus when room is dark because pupil dilates. - Stand on same side as eye being examined. - Tell pt to look straight ahead at an object on wall behind you. - Hold ophthalmoscope firmly against your face and align it so your eye sees through sight hole - Move scope toward pt's eye from 12-15 inches away and to side of pt's line of vision. - As you direct ophthalmoscope at pupil, a red glare (red reflex) should be seen in pupil as a reflection of light off of retina. - An absent red reflex in an adult may indicate a lens opacity or cloudiness of vitreous. - Move toward pt's pupil while following red reflex. - Retina should then be visible through ophthalmoscope. - Examine optic disc, optic vessels, fundus, & macula.

Inner Ear Disorder Risk Factors

Viral or bacterial infection Damage due to ototoxic meds

Diagnostic Procedures - Glaucoma

Visual assessments: Measures decrease in visual acuity & peripheral vision Tonometry: Measures IOP (expected ref range is 10-21). IOP elevated with glaucoma, esp open-angle. Gonioscopy: Used to determine drainage angle of anterior chamber of eyes.

Corneal Disorder Diagnostics

Wear gloves when examining eye. Cornea looks hazy or cloudy with a patchy area of ulceration. When fluorescein stain used, patchy areas appear green. Microbial culture & corneal scrapings are used to determine causative organism. Anti-infective therapy is started before organism is identified because of high risk for vision loss. For culture, obtain swabs from ulcer & its edges. For corneal scrapings, the cornea is anesthetized with a topical agent, and a physician or APRN removes samples from ulcer center and edge.

Patient Education After Surgical Removal of Lens (Cataracts) (ATI & box)

Wear sunglasses outside or bright area Report manifestations of infection (yellow or green drainage) Avoid activites that increase IOP: - Bending over at waist - Sneezing - Blowing nose - Coughing - Straining (BM) - Lifting >10 lbs - Head hyperflexion - Restrictive clothing such as tight shirt collars - Sexual intercourse Limit activities: - Tilting head back to wash hair (dependent position) - Cooking & housekeeping - Rapid, jerky mvmts such as vacuuming - Driving & operating machinery - Playing sports Report pain with nausea/vomiting (indications of increased IOP or hemorrhage) Best vision is not expected until 4-6 wks following surgery Report if any changes occur, such as lid swelling, decreased vision, bleeding or discharge, sharp sudden eye pain, flashes of light, or floating shapes. Avoid getting water in eye 3-7 days postop

Glaucoma Surgery Patient Education

Wear sunglasses outside or in bright lit Report infection (yellow, green drainage) Avoid activities that ^ IOP - Bending at waist - Sneezing, coughing - Straining - Head hyperflexion - Restrictive clothing, such as tight shirt collars - Sexual intrcourse Do not lie on operative side & report severe pain or nausea (possible hemorrhage) Report if any changes occur (lid swelling, decreased vision, bleeding, discharge, a sharp sudden pain in eye, flashes of light, floating shapes) Limit activities - Tilting head back to wash hair - Cooking, housekeeping - Rapid jerky mvmts such as vacuuming - Driving & operating machinery - Playing sports Report pain w n/v (indications of ^ IOP or hemorrhage) Final best vision not expected until 4-6 wks postop

Meniere's Surgical Mgmt

When drug therapy is not effective in controlling symptoms or attacks, other procedures may be considered. Pressure pulse treatments, such as the Meniett device, which use a tympanostomy tube to apply low-pressure micropulses to the inner ear several times daily, displace inner ear fluid. Surgical procedures such as a labyrinthectomy, which involves resection of the vestibular nerve or total removal of the labyrinth, may be done after weighing risks and benefits to the patient. This procedure results in total auditory SENSORY PERCEPTION loss on the operative side.

Impaction Trmt

When 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. The canal can be irrigated with a mixture of water and hydrogen peroxide at body temperature, following best practices for proper irrigation. Removal of a cerumen obstruction by irrigation is a slow process and may take more than one sitting. When it is the cause of hearing loss, cerumen removal may improve hearing. *50-70 mL of solution is max amt the pt usually can tolerate at one sitting.*

Penetrating Injuries Diagnostics

X-rays and CT scans of orbit are usually performed. MRI is contraindicated because procedure may move any metal-containing projectile and cause more injury.

Vertigo

a sense of whirling or turning in space. Some patients have continuous signs and symptoms of varying intensity rather than intermittent attacks. Patients are almost totally incapacitated during an attack, and recovery takes hours to days.

Care of the Patient With Reduced Vision (box)

• Always knock or announce your entrance into the patient's room or area and introduce yourself. • Ensure all members of hc team also use this courtesy of announcement & introduction. • Ensure pt's reduced vision is noted in medical record, is communicated to all staff, is marked on call board, and is identified on the door of pt's room. • Determine to what degree the patient can see anything. • Orient pt to environment, counting steps with pt to bathroom. • Help pt place objects on bedside table or in bed and around bed and room & do not move them without pt's permission. • Remove all objects and clutter between pt's bed and bathroom. • Ask pt what type of assistance pt prefers for grooming, toileting, eating, and ambulating and communicate these preferences with the staff. • Describe food placement on a plate in terms of a clock face. • Open milk cartons; open salt, pepper, and condiment packages; and remove lids from cups and bowls. • Unless pt also has a hearing problem, use a normal tone of voice when speaking. • When walking with pt, offer pt your arm and walk a step ahead.

Cerumen Impaction (box)

• Assess the hearing of all older patients using simple voice tests. • Perform a gentle otoscopic inspection of the external canal and eardrum of any older patient who has a problem with hearing acuity, especially the patient who wears a hearing aid. • Use ear irrigation to remove any impacted cerumen. • Make certain that the irrigating fluid is about 98.6° F (37° C) to reduce the chance for stimulating the vestibular sense. • Use no more than 5 to 10 mL of irrigating fluid at a time. • If nausea, vomiting, or dizziness develops, stop the irrigation immediately. • Teach the patient how to irrigate his or her own ears. • Obtain a return demonstration of ear irrigation from the patient, observing for specific areas in which the patient may need assistance. • Encourage the patient to wash the external ears daily using a soapy, wet washcloth over the index finger (best done in the shower or while washing the hair).

Recovery From Ear Surgery (box)

• Avoid straining when you have a bowel movement. • Do not drink through a straw for 2 to 3 weeks. • Avoid air travel for 2 to 3 weeks. • Avoid excessive coughing for 2 to 3 weeks. • Stay away from people with respiratory infections. • When blowing your nose, blow gently, without blocking either nostril, with your mouth open. • Avoid getting your head wet, washing your hair, and showering for 1 week. • Keep your ear dry for 6 weeks by placing a ball of cotton coated with petroleum jelly (e.g., Vaseline) in it. Change the cotton ball daily. • Avoid rapidly moving the head, bouncing, and bending over for 3 weeks. • Change your ear dressing every 24 hours or as directed. • Report excessive drainage immediately to your health care provider.

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

Using Eyedrops (box)

• Check the eyedrop name, strength, expiration date, color, and clarity. • If both eyes are to receive the same drug and one eye is infected, use two separate bottles and label each bottle with "right" or "left" for the correct eye. • Wash your hands. • Remove the cap from the bottle. • Tilt your head backward, open your eyes, and look up at the ceiling. • Using your nondominant hand, gently pull the lower lid down against your cheek, forming a small pocket. • Hold the eyedrop bottle (with the cap off) like a pencil, with the tip pointing down, with your dominant hand. • Rest the wrist holding the bottle against your mouth or upper lip. • Without touching any part of the eye or lid with the tip of the bottle, gently squeeze the bottle and release the prescribed number of drops into the pocket of your lower lid. • Release the lower lid and gently close your eye without squeezing the lids. • Gently press and hold the corner of the eye nearest the nose to close off the punctum and prevent the drug from being absorbed systemically. • Gently blot away any excess drug or tears with a tissue. • Keep the eye closed for about 1 minute. • Place the cap back on the bottle and store it as prescribed. • Wash your hands again.

Instillation of Ophthalmic Ointment (box)

• Check the name, strength, and expiration date of the ointment to be instilled. Be sure that it is an ophthalmic (eye) preparation and not a general topical ointment. • Check whether only one eye or both eyes are to receive the drug. • If both eyes are to receive the same drug and one eye is infected, use two separate tubes and carefully label each tube with "right" or "left" for the correct eye. • Wash your hands and put on gloves. • Explain the procedure to the patient. • Ask the patient to tilt the head backward and look up at the ceiling. • Gently pull the lower lid down against the patient's cheek, forming a small pocket. • Hold the tube (with the cap off) like a pencil, with the tip down. • Rest the wrist holding the tube against the patient's cheek. • Without touching any part of the eye or lid with the tip of the tube, gently squeeze the tube and release a small thin strip of ointment into the pocket of the lower lid. Start at the nose side of the pocket and move toward the outer edge of the pocket. • Gently release the lower lid. • Tell the patient to close the eye without squeezing the lid. • While the eye is closed, gently wipe away excess ointment. • Remind the patient that vision in that eye will be blurred and to not drive or operate heavy machinery until the ointment is removed. • Remove your gloves and place the cap back on the tube. • Ask the patient to keep the eye closed for about 1 minute. • Wash your hands again. • To remove ointment, wear gloves if drainage is present. • Then ask the patient to close the eye; wipe the closed lids with a clean tissue from the corner of the eye nearest the nose outward. If you are wiping the same eye twice, use a different area of the tissue or use a new one.

Instillation of Eyedrops (box)

• Check the name, strength, expiration date, color, and clarity of the eyedrops to be instilled. • Check to see whether only one eye is to have the drug or if both eyes are to receive it. • If both eyes are to receive the same drug and one eye is infected, use two separate bottles and carefully label each bottle with "right" or "left" for the correct eye. • Wash your hands. • Put on gloves if secretions are present in or around the eye. • Explain the procedure to the patient. • Have the patient sit in a chair, and you stand behind the patient. • Ask the patient to tilt the head backward, with the back of the head resting against your body and looking up at the ceiling. • Gently pull the lower lid down against the patient's cheek, forming a small pocket. • Hold the eyedrop bottle (with the cap off) like a pencil, with the tip pointing down. • Rest the wrist holding the bottle against the patient's check. • Without touching any part of the eye or lid with the tip of the bottle, gently squeeze the bottle and release the prescribed number of drops into the pocket you have made with the patient's lower lid. • Gently release the lower lid. • Tell the patient to close the eye gently (without squeezing the lids tightly). • Gently press and hold the corner of the eye nearest the nose to close off the punctum and prevent the drug from being absorbed systemically. • Without pressing on the lid, gently blot away any excess drug or tears with a tissue. • Remove your gloves and place the cap back on the bottle. • Ask the patient to keep the eye closed for about 1 minute. • Wash your hands again.

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.

Systemic Conditions and Common Drugs Affecting the Eye and Vision (box)

• Diabetes mellitus • Hypertension • Lupus erythematosus • Sarcoidosis • Thyroid problems • Acquired immune deficiency syndrome • Cardiac disease • Multiple sclerosis • Pregnancy • Antihistamines (tend to dry & ^ IOP) • Decongestants (tend to dry & ^ IOP) • Antibiotics • Opioids • Anticholinergics • Cholinergic agonists • Adrenergic agonists • Adrenergic antagonists (beta blockers) • Oral contraceptives • Chemotherapy agents • Corticosteroids

Self-Ear Irrigation for Cerumen Removal (box)

• Do not attempt to remove earwax or irrigate the ears if you have ear tubes or blood, pus, or other drainage from the ear. • Use an ear syringe designed for the purpose of wax removal (available at most drugstores). • The safest type of ear syringe to use is one that has a right-angle or "elbow" in the tip. • Irrigating your ears in the shower is an easy method. • Always use tap water that feels just barely warm to you. Water that is warmer or colder can make you feel dizzy and nauseated. • If your earwax is thick and sticky, you may need to place a few warm commercial eardrops that soften earwax (or baby oil or mineral oil) into the ear an hour or so before you irrigate the ear. • Fill the syringe with the lukewarm tap water. • If you are using a syringe with an elbow tip, place only the last part of the tip into your ear and aim it toward the roof of your ear canal. • If you are using a straight-tipped syringe, insert the tip only about to inch into your ear canal, aiming toward the roof of the canal. • Hold your head at a 30-degree angle to the side you are irrigating. • Use one hand to hold the syringe and the other to push the plunger or squeeze the bulb. • Apply gentle but firm continuous pressure, allowing the water to flow against the top of the canal. • Do not use blasts or bursts of sudden pressure. • The ear canal should fill; and water will begin to flow out, bringing earwax and debris with it. • If a dental water-pressure irrigator is used, put it on the lowest possible setting. • This process should not be painful! If pain occurs, decrease the pressure. If pain persists, stop the irrigation. • Continue the irrigation until at least a cup of solution has washed into and out from your ear canal. (You may have to refill the syringe.) • Tilting your head at a 90-degree angle to the side should allow most, if not all, of the water to drain out of your ear. • Repeat the procedure on the other ear. • If you feel that water is still in the canal, hold a hair dryer on a low setting near the ear. • Irrigate your ears weekly to monthly, depending on how fast your earwax collects.

Prevention of Ear Infection or Trauma (box)

• Do not use small objects, such as cotton-tipped applicators, matches, toothpicks, keys, or hairpins, to clean your external ear canal. • Wash your external ear and canal daily in the shower or while washing your hair. • Blow your nose gently. • Do not block one nostril while blowing your nose. • Sneeze with your mouth open. • Wear sound protection around loud or continuous noises. • Avoid or wear head and ear protection during activities with high risk for head or ear trauma, such as wrestling, boxing, motorcycle riding, and skateboarding. • Keep the volume on head receivers at the lowest setting that allows you to hear. • Frequently clean objects that come into contact with your ear (e.g., headphones, telephone receivers). • Avoid environmental conditions with rapid changes in air pressure.

Ask the patient about:

• Ear trauma or surgery • Past ear infections • Excessive cerumen • Ear itch • Any invasive instruments routinely used to clean the ear (e.g., Q-tip, match, bobby pin, key) • Type and pattern of ear hygiene • Exposure to loud noise or music during work or leisure activities • Air travel (especially in unpressurized aircraft) • Swimming habits and the use of ear protection when swimming • History of health problems that can decrease the blood supply to the ear, such as heart disease, hypertension, or diabetes • History of vitiligo (pigment disorder that may include a loss of melanin-containing cells in inner ear, resulting in hearing loss) • History of smoking • History of vitamin B12 and folate deficiency

Assess for and record these problems:

• Furuncles • Large amounts of cerumen • Scaliness • Redness • Swelling of the ear • Drainage amount and character

Instillation of Eardrops (box)

• Gather the solutions to be administered. • Check the labels to ensure correct dosage, time, and expiration date. • Wear gloves to remove and discard any ear packing. • Wash your hands. • Perform a gentle otoscopic examination to determine whether the eardrum is intact. • Irrigate the ear if the eardrum is intact • Place the bottle of eardrops (with the top on tightly) in a bowl of warm water for 5 minutes. • Tilt the patient's head in the opposite direction of the affected ear and place the drops in the ear. • With his or her head tilted, ask the patient to gently move the head back and forth five times. • Insert a cotton ball into the opening of the ear canal to act as packing. • Wash your hands again.

Ask these questions if eye injury or trauma is involved:

• How long ago did the injury occur? • What was the patient doing when it happened? • If a foreign body was involved, what was its source? • Was any first aid administered at the scene? If so, what actions were taken?

Hearing Aid Care

• Keep the hearing aid dry. • Clean the ear mold with mild soap and water while avoiding excessive wetting. • Using a toothpick, clean debris from the hole in the middle of the part that goes into your ear. • Turn off the hearing aid when not in use. • Check and replace the battery frequently. • Keep extra batteries on hand. • Keep the hearing aid in a safe place. • Avoid dropping the hearing aid or exposing it to temperature extremes. • Adjust the volume to the lowest setting that allows you to hear to prevent feedback squeaking. • Avoid using hair spray, cosmetics, oils, or other hair and face products that might come into contact with the receiver. If the hearing aid does not work: • Change the battery. • Check connection between ear mold and receiver. • Check the on/off switch. • Clean the sound hole. • Adjust the volume. • Take hearing aid to an authorized service center for repair.

Communicating With a Hearing-Impaired Patient (box)

• Position yourself directly in front of the patient. • Ensure that you are not sitting or standing in front of a bright light or window, which can interfere with the patient's ability to see your lips move. • Make sure that the room is well lighted. • Get the patient's attention before you begin to speak. • Move closer to the better-hearing ear. • Speak clearly and slowly. • Do not shout (shouting often makes understanding more difficult). • Keep hands and other objects away from your mouth when talking to the patient. • Have conversations in a quiet room with minimal distractions. • Have the patient repeat your statements, not just indicate assent. • Rephrase sentences and repeat information to aid understanding. • Use appropriate hand motions. • Write messages on paper if the patient is able to read.

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

Ear Irrigation (box)

• Wash your hands. • Use an otoscope to locate the impaction; ascertain that the eardrum is intact and that the patient does not have otitis media. • Gather the equipment: basin, irrigation syringe, otoscope, and towel. • Warm tap water (or other prescribed solution) to body temperature. • Fill a syringe with the warmed irrigating solution. • Place a towel around the patient's neck. • Place a basin under the ear to be irrigated. • Place the tip of the syringe at an angle so the fluid pushes to one side of and not directly on the impaction (to loosen it without moving it deeper into the canal). • Apply gentle but firm continuous pressure, allowing the water to flow against the top of the canal. • Do not use blasts or bursts of sudden pressure. • If pain occurs, reduce the pressure. If pain persists, stop the irrigation. • Watch the fluid return for cerumen plug removal. • Continue to irrigate the ear with about 70 mL of fluid. • If the cerumen does not drain out, wait 10 minutes and repeat the irrigation procedure. • Monitor the patient for signs of nausea. • If the patient becomes nauseated, stop the procedure. • If the cerumen cannot be removed by irrigation, place mineral oil into the ear three times a day for 2 days to soften dry, impacted cerumen, after which irrigation may be repeated. • After completion of the irrigation, have the patient turn his or her head to the side just irrigated to drain any remaining irrigation fluid. • Wash your hands again.