EYE AND VISION

STRUCTURE
EYEBALL
Round, ball-shaped organ
2.5cm long and 2.3cm
diameter
Front part of the eye orbit
ORBIT
The bony socket of the skull
that surrounds & protect
the eye along with the
attached muscles, nerves,
vessels & tear-producing
glands
LAYERS
A. EXTERNAL
LAYER
SCLERA
Opaque tissue
making up of
the “white” of
the eye

CORNEA
Transparent
portion
B. MIDDLE LAYER
CHOROID
Dark brown
membrane between
the sclera & retina
Has many blood
vessels that supply
nutrients of the retina
CILIARY BODY
Connects the choroids
with the iris &
secretes aqueous
humor
IRIS
The colored portion
of the external
eye; center
opening is the pupil
Muscles of the iris
contracts & relax to
control pupil size &
amount of light
entering the eye
C. INNERMOST LAYER
RETINA
Thin, delicate structure
made up of sensory
receptors that transmit
impulses to the optic nerve
Contains blood vessel &
photoreceptor
RODS – work at low light
levels & provide peripheral
vision
CONES – active at bright
levels & provide color &
central vision
OPTIC FUNDUS
Area on the back of the
eye
Contains optic disk (blind
spot)
REFRACTIVE
STRUCTURES AND
MEDIA
CORNEA
Clear layer that forms
the external coat on
the front of the eye
AQUAEOUS HUMOR
Clear, watery fluid
that fills the anterior &
posterior chambers of
the eyes
produced by the ciliary
process
LENS
A circular, convex
structure that lies
behind the iris;
Transparent
Bends the rays of the
light entering through
the pupil
VITREOUS BODY
Clear, thick gel that
fills the vitreous
chamber
Transmit light &
shapes the eye
EXTERNAL STRUCTURE
EYELID
 Thin, movable fold of the
skin that protects the eyes
 Shut out light during sleep
 Keep the cornea moist
 Upper eyelid is larger
CANTHUS
 Place where two eyelids
met
CONJUNCTIVA
 Mucous membrane
 Thick membrane with many
blood vessel
LACRIMAL GLAND
 Located at the outer part of
the orbit
MUSCLES
Six voluntary muscle &
coordinate eye
movement
Coordinated eye
movement ensure that
the retina of each eye
receives an image at
the same time that a
single image is seen
CRANIAL NERVES
CN III (Oculomotor), IV
(Trochlear), VI (Abducens)
Innervates muscle around the
eyes
CN II (Optic)
Nerve of sight
Connect the optic disc to the
brain
CN V (Trigeminal)
Stimulates blink reflex when
the cornea is touched
CN VII ( Facial)
Innervates lacrimal gland &
muscles controlling lid closure
BLOOD VESSSEL

OPTHALMIC ARTERY
Brings oxygenated blood
to the eyes & structures
of the orbit
CILIARY ARTERY
Supply the sclera,
choroids, ciliary body &
iris
OPTHALMIC VEINS
Venous drainage
FUNCTIONS
A. REFRACTION
Different curved structures
& refractive media of the
eye allow light to pass
through the retina
Each surfaces & media
bends light differently to
focus image on the retina
Emmetropia
Perfect refraction
Normal refraction of light
within the eye
 Hyperopia
Hypermetropia,
Farsightedness
Occurs when the
eye does not refract
light enough
Beyond 20 feet is
normal but poor
near vision
Corrected with
convex lens in
eyeglasses or
contact lens
 Myopia
Nearsightedness
Occurs when the
eye overrefracts
the light
Near vision is
normal but poor
distance vision
Corrected with
biconcave
eyeglasses or
contact lenses
 Astigmatism
Caused by unevenly curved
surfaces
Distort vision
B. PUPILLARY
CONSTRICTION
Pupils controls the
amount of light that
enters the eye
Increase light to one or
both eyes  both pupil
constrict
Constriction depends on
the amount of light &
how well the retina
adapt to light changes
MIOSIS  papillary
constriction
MYDRIASIS  papillary
dilatation
C. ACCOMODATION
Process of
maintaining a
clear visual image
when the gaze is
shifted from a
distant to near
object.
The eye is able to
adjust its focus by
changing the
curve of the lens.
ASSESSMENT
Demographic Data
Age/Gender
Family History
Genetic factors that may lead
to visual impairment
Personal History
Systemic medical problems
Accidents, injuries, surgeries,
blows on the head.
Drugs
Food choices
Work
Current Health Problem
Onset Symptoms present on
the same degree for both
eyes
Trauma
Physical Assessment
1. Inspection
Look for head tilting,
squinting to attain clear
vision
Symmetry
Sclera
Cornea
Blink reflex
2. Pupil Assessment
A) Size
ANISOCORIA
Adult – smaller
pupil
MYOPIA – larger
pupil
HYROPIA – smaller
Normal pupil
diameter – 3 & 5
mm
B) Light
 light –
constriction of pupil
size
Consensual
Response
Constriction of
the left pupil when
the light is shined
at the right pupil
C) Sweep reaction
Brisk
Sluggish
Nonreactive/fixed
D) Accomodation
Eyes emerge
during movement
Pupils constrict
equally
Measurement of
Vision
1. Acuity
Measure
distance and
near vision
SNELLEN CHART
2. Near Vision Testing
client with difficulty of
reading & over 40
years of age
Rosenbaum Pocket
Vision Screener or
Jaeger Card
3. Visual Fields
Confrontation Test
used to examine the
clients visual fields or
peripheral vision
detects
• Hemianopia
(blindness in one half
the field of vision)
• Quadrantopia
(blindness in ¼ of the
field of vision)
• Scotomas (blind spot
in the visual field)
Extraocular Muscle Procedure:
a. Ask the patient to stare
1. Corneal Light
straight ahead.
determines alignment b. Shine a penlight from
of the eyes both corneas from a
distance of 12 to 15
inches
c. the bright dot of light
reflected from the shiny
surface of the cornea
should be symmetric in
position
assymmetric reflex
indicates a deviating eye
& possible muscle
imbalance
2. Six Cardinal procedure
Position of Gaze a) ask the client to hold
his/her head still
assess muscle
b) more the yes to follow a
function
small object
c) move the client right,
upward& right (temporal),
down & right, left (lateral)
upward & left temporal &
down & left
Nystagmus
involuntary & rapid
twitching of the eyeball
may also be caused by
nerve function or prolong
reduced vision
3. Cover-uncover Method
test muscle function
Procedure
a) Ask the client to look at
a specific fixed point
b) Place card over one of
the client’s eyes &
observe for the
uncovered eye to see if it
moves to fix on the
object
Normal Muscle function –
eye does not move
4. Color Vision
Ishihara chart
shows number
composed of dots of
one color within a
circle of dots of a
different color
test each eye
separately
reading the number
correctly indicates
normal vision
Psychological Assessment
Change in visual perception
anxious or fearful about
loss of vision
severe visual defects
unable to perform ADL
 dependency =  self
esteem
Assess clients knowledge &
use of services for the
visual impairment
DIAGNOSTIC ASSESSMENT
LABORATORY TEST
Culture & Smear
corneal & conjunctival
swabs
RADIOGRAPHIC EXAM
CT Scan
MRI
CI : metal in the eye
RADIOISOTOPIC
SCANNING
used to locate tumors &
lesions
 OTHER
SLIT-LAMP EXAM
• - permits exam of the
anterior ocular
structures under
microscopic
magnification
Corneal Staining
• - placing fluroscein or
other topical dye into
the conjunctional sac
 Tonometry
• Tanometer
(measures IOP = 10
to 21 mmhg)
• Indicated for clients
above 40 years old
Opthalmoscopy
• -opthalmoscope
(allows viewing of
the eye’s external &
interior structure)
• - preferably done in
a dark room
UTZ
LASIK (Laser Assisted In Situ
Keratomileusis)
• a state of the art procedure
that has been performed
around the world for ten
years
• combining the precision of
a computer-controlled laser
with the surgical
technology of the
microkeratome
• used to correct vision by
reshaping the cornea, the
eye’s clear outer window
EYE AND VISION
PROBLEMS
CONJUNCTIVITIS
inflammation or
infection
caused by allergens,
irritants
not contagious
Infectious
Conjunctivitis
occurs with bacterial or
viral infection
communicable
staphylococcus Aureus,
H. Influenza,
Pseudomonas
Aeruginosa
Manifestations
edema
burning sensation
engorgement of the
vessel
excessive tears
itching
watery discharge that
may become thicker
Diagnostics
Culture and
Sensitivity
Management
Nursing
Focus: LIMIT SPREAD
OF DISEASE TO OTHER
EYE AND PEOPLE
 instruct to avoid eye make
up
 document amount color &
type of drainage.
 Reinforce handwashing

Medical Management
Topical Antibiotics
Vasoconstrictor and
corticosteroid eye drop
• BEST PRACTICE FOR EYE
DROP ADMINISTRATION
Administer drug at frequent,
precise intervals. If each drug
is administered every hour,
create separate dosage
schedules.
If two medications must be
administered at the same
time, separate the instillation
by 5 minutes.
If the same medication is
required for both eyes and
one eye is infected, use
separate bottles of medication
Clearly label each bottle with
“left” or “right” for the
appropriate eye.
Wash hands before and after
administering the drug.
CATARACT
an opacity of the
lens that distorts
the image
projected to the
retina
COMMON CAUSES OF
CATARACT
Age Related
Cataract
 Lens water loss and
fiber compaction
Traumatic Cataract
 Blunt injury to the eye
or head
 Penetrating eye injury
 Intraocular foreign
body
 Radiation exposure,
therapy
 Toxic Cataract
 Corticosteroids
 Phenothiazine
derivatives
 Miotic agents
Associated Cataract
 DM
 Hypoparathyroidism
 Down Syndrome
 Chronic sunlight
exposure
Complicated Cataract
 Retinitis Pigmentosa
 Glaucoma
 Retinal Detachment
KEY FEATURES

Early
Blurred vision
Decrease color perception

Late
Diplopia
Reduced visual acuity
progressing to blindness
Absence of red reflex
Presence of white pupil
Management
SURGERY – “ONLY CURE”

Operative Measures
INTRACAPSULAR
lens & capsule are removed
completely
Disadvantage: risk for
retinal detachment & result
in the loss of supportive
structure for the intraocular
lens implant
EXTRACAPSULAR
front position is removed
phacoemulsion – used of
sound waves to break
cataractous lens into small
pieces
Preoperative
Teach about the
nature, progression
& treatment.
Series of ophthalmic
drugs are instilled
to;
dilate pupils &
vasoconstriction
induce paralysis to
prevent lens
movement
Complication
Pain early after
surgery -  IOP &
hemorrhage
Infection – yellow
or greenish
drainage
Bleeding into the
anterior chamber
ACTIVITIES THAT
INCREASE IOP
bending from the
waist
sneezing, coughing
blowing the nose
straining to have a
BM
Vomiting
sexual intercourse
wearing tight shirt
collars
GLAUCOMA
group of ocular
diseases result in
 IOP
commonly painless
& have gradual
reduction in vision
KEY FEATURES
EARLY
increased IOP
diminished accommodation
LATE
diminished visual fields
(loss of peripheral vision)
decreased visual acuity not
correctable with glasses
halos around lights
headache or eye pain
(acute closed-angle
glaucoma)
increased cup-disc ratio
pale optic disc
ETIOLOGY
A. Primary Open-angle
Glaucoma (POAG)
Most common form
Bilateral,
asymptomatic
Reduced blood flow 
fluid cannot leave the
eye at the same rate is
produced   IOP
B. Angle-closure
Glaucoma
Less common
Sudden onset
An emergency
Problem: narrowed
angle & forward
displacement of the iris
 obstruction of
aqueous humor
Signs and Symptoms
sudden, severe pain
around the eye that
radiates over the face
headache, brow pain
Nausea & vomiting
colored halo’s around
lights
reddened sclera
cloudy aqueous
humor
non-reactive pupil
Diagnostic
Tonometry-  IOP
Open-angle = 22-32mm/hg
Angle-closure = 30mm/hg or 
Tonography
combination of electric
indentation tonometer with
recording device
measures the outflow of
humor
Gonioscopy
a special lens that helps view
the drainage angle in the
anterior chamber
MANAGEMENT
I. NONSURGICAL
MANAGEMENT
DRUG THERAPY
FOCUS:
constricting the pupil
so that the muscle is
contracted, allowing
better circulation of
the aqueous humor to
the site of absorption
reduction of the
production of aqueous
humor
A. Pupillary Constriction (Miotics)
Pilocarpine Hydrochloride
Isopto Carpine, Pilocar, Spersacarpine
Commonly used
Enhances aqueous flow
Carbachol
Isopto carbachol, Miostat
Can be used with or in place of Pilocarpine
Echothiophate Iodide
Phospholine Iodide
Produces miosis & Increase outflow
Prostaglandin Agonist
Latanoprost (Xalatan), Travapost (Travatan),
Brimatopost (Lumigen), Unoprostone (Rescula)
Improve outflow of aqueous humor
Nursing ALERT
MIOTICS
MAY
CAUSE
BLURRED
VISION
FOR
1 TO 2 HOURS!!!
B. Inhibition of Aqueous Epinephrine 0.5% to
Humor 2% and Dipiveform
Beta Blockers Hydrochloride
Timolol (Apo-Timop, Reduces aqueous humor
Timoptic) & production
Levobunolol (Betagan) Osmotic Drug
Decrease IOP Angle-closure glaucoma
Used as eye drops “E” treatment to rapidly
Carbonic Anhydrase reduce IOP
Acetazolamide Oral glycerene
(Acetazolam, Diamox) (Osmoglyn), Osmitrol
and Methazolamide (Mannitol, IV)
(Neptazane)
Reduces aqueous
humor production to
help maintain lowered
IOP
SURGICAL MANAGEMENT
Laser Surgery
when open-angle glaucoma
are not effective at
controlling IOP
Standard Surgical
Therapy
Create new drainage
channel for aqueous humor
or destroys structures that
produce it

Post Operative
Avoid taking aspirin
Avoid lying on operative site
Report brow pain and eye
pain
Nausea
RETINAL DETACHMENT

Separation of the retina

from the epithelium
Onset : sudden and painless
(no pain fibers at the retina)
Photopsia – bright flashes of
light or floating dark spots in
the affected eye
Initial detachment is usually
partial – describe as the
sensation of a curtain being
pulled over part of the visual
fields
MANAGEMENT
Inflammatory Response
Will bind the retina & choroids
together around the break
Cryotherapy (freezing probe)
Photocoagulation (laser)
Diatherapy (high frequency
current)
Scleral Buckling
Repair of the underlying
structure
A small piece of silicone is
placed against the sclera &
held in place by encircling
band
Keep the retina in contact
with the choroids & sclera to
promote attachment
A gas or silicon oil placed
inside the eye can be used to
promote retinal detachment
POST OPERATIVE
Position patient in
prone position
expect for nausea
& pain
instruct the patient
that on the 1st
week avoid
reading, writing &
close work
ANY QUESTIONS?
 ANATOMY & PHYSIOLOGY
Structure:
3 Divisions
1. external ear
2. middle ear
3. inner ear
 ANATOMY & PHYSIOLOGY
EXTERNAL EAR
Description
• It is curved about
2.5 cm long in adult
and ends at the
tympanic membrane.
• The ear is
attached to the head
by skin and cartilage
at about a 10 degree
angle.
• Adult- 1 to 11/2
inches (2.5-3.75 cm)
 ANATOMY & PHYSIOLOGY
EXTERNAL EAR
Description
• It is covered with
skin that has many
fine hairs, glands
and nerve endings
• It develops in
embryo at the
same time as the
kidneys and urinary
tract.
 ANATOMY & PHYSIOLOGY
STRUCTURES OF THE
EXTERNAL EAR
Auricle or Pinna
• which is composed of
cartilage covered by skin , it
is embedded in the
temporal bone on both
sides of the head at the
level of the eyes.
Tympanic membrane or
“ear drum”
• is a thick transparent sheet
of tissue providing a barrier
between the external ear
and the middle ear.
 ANATOMY & PHYSIOLOGY
STRUCTURES OF THE
EXTERNAL EAR
Cerumen (wax) producing
glands
• protect and lubricate
the ear canal,
sebaceous glands and
hair follicles.

Follicles and cerumen

protect the ear drum and
middle ear.
 ANATOMY & PHYSIOLOGY
STRUCTURES OF THE
EXTERNAL EAR
landmark of auricle
- lobule (earlobe)
- helix (posterior curve
of the auricle’s upper
aspect)
- antihelix (the anterior
curve of the auricle’s
upper aspect
 ANATOMY & PHYSIOLOGY
STRUCTURES OF
THE EXTERNAL EAR
• external auditory
canal
• mastoid process
the bony bridge
located over the
temporal behind the
pinna.
 ANATOMY & PHYSIOLOGY
MIDDLE EAR
Description
• begins at medial side
of the ear drum that
starts at the
tympanic membrane
• it consist of the
EPITYMPANUM, an
air filled cavity
(compartment)
containing 3 bony
ossicles (bones of
sounds transmission)
 ANATOMY & PHYSIOLOGY
3 ossicles of the
middle ear
• malleus –“hammer”
– Most easily seen
• incus – “anvil”
• stapes - “stirrups”
• eustacian tube
– Connects the middle
ear to the
nasopharynx.
– The tube estabilizes
the air pressure
between the external
atmosphere and
middle ear
 ANATOMY & PHYSIOLOGY
INNER EAR
Description
• Lies on the other side
of the oval window
• Contains the semi
circular canals,
cochlea, vestibule, and
the distal end of the
8th cranial nerve
 
ANATOMY & PHYSIOLOGY
STRUCTURES OF
THE INNER EAR
• Semicircular canals
• These are tubes made
of cartilage that
contains air cells and
fluid
• These canals are
connected to sensory
fibers of the vestibular
portion of the 8th
cranial nerve.
• contains the organs of
equilibrium
 ANATOMY & PHYSIOLOGY
STRUCTURES OF
THE INNER EAR
Cochlea
• is the spiral organ of
hearing
• A sea shell shaped
structure essential for
sound transmission and
hearing
Vestibule
Endolymph
• a fluid similar to
intracellular fluid
Perilymph
ANATOMY & PHYSIOLOGY
AIR CONDUCTION PROCESS

1. A sound stimulus enters the external

canal and reaches the tympanic
membrane.
2. The sound waves vibrate the tympanic
membrane and reach the ossicles.
3. The sound waves travel from the ossicles
to the opening in inner ear (oval window).
4. The cochlea receives the sound vibrations
5. The stimulus travels to the auditory nerve
(the eight cranial nerve) and the cerebral
cortex
 ASSESSMENT
• Ear and Hearing problems are common
among adults of all ages. Assessment of
the ear and hearing is important skill for
nurses in any care environment.
 ASSESSMENT
•History
•Demographic
data
•Family history
and genetic
risk
 ASSESSMENT
Personal history
• ear trauma
• ear surgery
• past infection
• excessive cerumen
• ear itch
• any invasive
instrument routinely
used to clean the ear
• type and pattern of ear
hygiene
• exposure to loud and
noise music
• air travel
 ASSESSMENT
Personal history
• swimming habits and
protection when swimming
• history of hereditary factors
and health problems
causing changes of blood
supply into the ear (heart
diease, HPN, and DM)
• vitiligo
• smoking
• vitamin B12 and folate
deficiency
• ototoxic drugs
 ASSESSMENT
PHYSICAL ASSESSMENT OF THE EAR WITH
THE AID OF THESE INSTRUMENTS
 ASSESSMENT
Direct inspection of the ear and inspection
of the remaining part by OTOSCOPE
(determination of the auditory acuity)
 ASSESSMENT
Palpation of the external ear
Usually assessed during initial physical
examination
Periodic reassessment may be
necessary for long – term clients or
those with hearing problems 
 ASSESSMENT
WEBER’S TEST
(procedure)
- to assess bone
conduction by
testing the
lateralization
(sideward
transmission)
of sounds
process
 ASSESSMENT
WEBER’S TEST
• hold the tuning
fork at its base.
Activate it by
tapping the fork
gently against the
back of your hand
near the knuckles
or by stroking the
fork between your
thumb and index
fingers. It should
be made to ring
softly
 ASSESSMENT
WEBER’S TEST
• place the base of
the vibrating
fork on top of
the client’s head
and ask the
client hears the
noise
 ASSESSMENT
RINNE TEST
this test
compares air
conduction to
bone
conduction
process.
 ASSESSMENT
RINNE TEST (procedure)
• ask the client to block the
hearing in one ear
intermittently by moving a
fingertip in and out of the
ear canal
  hold the handle of the
activated tuning fork on the
mastoid process of one ear
until the client states that
the vibration cannot longer
be heard
 ASSESSMENT
RINNE TEST (procedure)
• immediately hold the still
vibrating fork prongs in
front of the ear canal.
Ask whether the client
now hears the sound.
Sound conducted by air
is heard more readily
than sound conducted by
bone. The tuning fork
vibrations conduced by
air are normally heard
longer.
 ASSESSMENT
PHYSICAL ASSESSMENT
• EXTERNAL EAR
• MASTOID ASSESSMENT
• OTOSCOPIC ASSESSMENT
• AUDITORY ASSESSMENT
• VOICE TEST
• WATCH TEST
• AUDIOSCOPY
• TUNING FORK (Weber test
and Rinne test)
DIAGNOSTIC EXAMINATION
• CT
• MRI
 TYMPANOPLASTY
• Reconstructs the
middle ear to improve
hearing caused by
conductive hearing
loss.
• Varies from simple
reconstruction of the
eardrum
(myringoplasty) to
replacement of the
ossicles within the
eardrum.
TYMPANOSTOMY
EAR SURGERY
 VOICE TEST
• A simple hearing
acuity test by asking
the client to block
one external ear
canal while standing
1-2 feet away.
• Quietly whisper a
statement and then
ask the client to
repeat it. Test each
ear separately.
 AUDIOMETRY
• Is the measurement
of hearing acuity.
Frequency
• Highness/ lowness
of tones (expressed
in hertz)
Intensity
• Expressed in
decibels
 AUDIOMETRY
Threshold
• Lowest level of intensity
at which pure tones and
speech are heard by a
client (about 50% of the
time)
Pure Tones
• Are generated by an
audiometer to determine
hearing acuity.
 SPEECH AUDIOMETRY
• to check the
client’s ability to
hear spoken
words is
measured
through a
microphone
connected to an
audiometer.
 ELECTRONYSTAGMOGRAPHY
(ENG)
• A cost effective test
that is sensitive in
detecting both
central and
peripheral disease
of the vestibular
system in the ear.
• Detects nystagmus
that can be
recorded.
 ELECTRONYSTAGMOGRAPHY
(ENG)
• Electrodes are taped
to the skin near the
eyes
• One or more
procedures (caloric
testing, changing
gaze position or
changing head
position ) are
performed to
stimulate
nystagmus.
 DIX HALLPIKE TEST
• A test for vertigo
performed by
assisting the
client to a sitting
position on an
examination
table
 DIX HALLPIKE TEST
(W/ MAT TABLE)
• Stand to the side of the
client and quickly
reposition her from sitting
to supine with the head
extending beyond the end
of the table.
• This change of position is
done first to one side and
then to the other side.
• A client with benign
positional vertigo will
have a burst of
nystagmus after a delay
of 5-10 seconds.
 CALORIC TESTING
• Evaluates the
vestibular (inner-ear)
portion of the auditory
nerve.
• Water warmer or
cooler than body
temperature is infused
into the ear.
• A normal response is
the onset of vertigo
(spinning sensation)
and nystagmus within
20-30 seconds.
BONE CONDUCTION TEST
• Pure-tone bone-
conduction testing
determines whether
the hearing loss
detected by an air-
conduction testing is
due to conductive or
sensorineural factors
or to a combination of
two.
OTITIS EXTERNA/
EXTERNAL OTITIS
 OTITIS EXTERNA/
EXTERNAL OTITIS
• Painful condition
cause when
irritating or
infective agents
come into
contact with the
skin of the
external ear.
 OTITIS EXTERNA/
EXTERNAL OTITIS
• Affected skin
becomes red and
swollen and
tender to touch
when movement
• The most
common
infectious
organism usually
bacteria or
fungal
 OTITIS EXTERNA/
EXTERNAL OTITIS
Collaborative Management
Instillation of eardrops
• gather the solutions to be
administered
• check the labels to ensure
correct dosage and time
• remove and discard any ear
packing
• irrigate the ear if the
eardrum is intact
• place the bottle of ear drops
(with the top on tightly) in a
bowl of warm water for 5
minutes
 OTITIS EXTERNA/
EXTERNAL OTITIS
• tilt the clients head in
the opposite direction
of the affected ear and
place the drops in the
ear.
• with the head titled,
gently move the head
back and forth five
times
• insert a cotton ball into
the opening of the ear
canal to act as packing
 OTITIS EXTERNA/
EXTERNAL OTITIS
Collaborative
Management

• Treatment focused
on reducing
inflammation,
edema and pain.
• topical antibiotic,
steroid therapy,
• analgesics for pain.
 FURUNCLE
• Localized
external otitis
caused by
bacterial
infection usually
staphylococcus,
of a hair follicles.
• Most furuncles
occur on the
outer half of the
external canal.
 FURUNCLE
Management
• local and systemic
antibiotics and
local heat
application
• I and D if does
not resolved to
the antibiotics
 IMPACTED CERUMEN
Cerumen is the most
common cause of
an impacted canal.
Vegetables, beads,
pencil erasers, and
insects are other
common items that
may also enter the
ear with or without
clients help
 IMPACTED CERUMEN
Management
Ear irrigation
1. Gather the proper
equipment: basin, syringe,
otoscope, towel.
2. warm tap towel to body
temperature
3. fill a syringe with warm
water
4. place a towel around a pts
neck
5. place a basin under the ear
to be irrigated
6. use an otoscope to check the
location of the impacted
cerumen
 IMPACTED CERUMEN
Ear Irrigation
7. place the tip of the syringe
at an angle so that the fluid
pushes on one side and not
directly on the impaction
8.watch the fluid return for
signs of cerumen plug
removal
9. continue to irrigate the ear
with about 70 ml of fluid.
10. if the cerumen does not
drain out wait for 10
minutes and repeat the
irrigation procedure.
 IMPACTED CERUMEN
Ear Irrigation
11.monitor the client for
signs of nausea
12. if the client becomes
nauseated stop the
procedure
13 if the cerumen cannot be
removed by irrigation, the
client may place mineral
oil into the ear three
times a day for 2 days to
soften dry, impacted
cerumen, after which
irrigation maybe
repeated.
OTITIS MEDIA
 OTITIS MEDIA
• The three most
common forms
of otitis media
are acute otitis
media, chronic
otitis media
and serous
otitis media.
 OTITIS MEDIA
Assessment
• assess for pain
with or without
movement of the
external ear
• otoscopic
examination
• cultures of
drainage
 OTITIS MEDIA
Intervention
1. Non surgical management
a. putting the client in quiet
environment
b. bed rest, limits head
movements that intensify the
pain heating pad may be
applied
c. antibiotic therapy
d. topical antibiotic
e. analgesic
f. antihistamines and
decongestant
 MASTOIDITIS
• Infection of
the mastoid
air cells
caused by
untreated
and
inadequately
treated otitis
media
 MASTOIDITIS
ASSESSMENT

assess for the

swelling behind
the ear and
pain with
minimal
movement of
the tragus,
pinna or the
head
 MASTOIDITIS
INTERVENTIONS COMPLICATIONS

• IV antibiotics • damage to cranial

• Cultures of the ear nerves IV, VI and VII,
drainage vertigo, meningitis,
• Surgical removal of brain abscess, chronic
vthe infected tissue is purulent otitis media
needed if the infection and wound infection.
does not respond to
antibiotic therapy in a
few days.
 TINNITUS
• Continuous
ringing or
noise
perception of
the ear
common ear
hearing
disorder.
 TINNITUS
COLABORATIVE
MANAGEMENT
• When clients reports
tinnitus you must be alert
to many factors that
caused tinnitus
– Presbycusis
– Otosclerosis
– Meniers disease
– Certain drugs
– Exposure to loud noise and
other inner ear problems.
 LABYRHINTHITIS
• Is an infection
of the labyrinth
which may occur
in acute or
chronic otitis
media.
• Infection may
results from an
erosion of the
bony capsule
allowing
organism to
invade the inner
ear.
 LABYRHINTHITIS
Management
• use of systemic
antibiotics such as
ampicillin
• advise in bed in
darker room until
manifestation are
reduced
• anti emetics
• antivertiginous
medications such as
dymenhydrinate
(Dramamine, Gravol)
 MASTOIDITIS
• Infection of the
mastoid air cells caused
by untreated and
inadequately treated
otitis media
Assessment
• assess for the swelling
behind the ear and pain
with minimal
movement of the
tragus, pinna or the
head
 MASTOIDITIS
INTERVENTION
• IV antibiotics
• Cultures of the ear
drainage
• Surgical removal of the
infected tissue is
needed if the infection
does not respond to
antibiotic therapy in a
few days

Complications
• damage to cranial
nerves IV, and VII, VI,
vertigo, meningitis,
brain, abscess, chronic
purulent otitis media
and wound infection.
 MENIERE’S DISEASE
Over production or
decreased reabsorption
of endolymphatic fluid,
causing a distortion of
the entire inner canal
system
Three features:
• Tinnitus
• one sided sensorineural
hearing loss
• Vertigo occurring in
attacks that can last for
several days.
 MENIERE’S DISEASE
This distortion decreases
hearing from dilation of
the cochlear duct.
Vertigo because of
damage to the
vestibular system
tinnitus from unknown
cause.
The cause of Meniere’s
disease is unknown but
it often occurs with
infections, allergic
reaction, and fluid
imbalances.
 MENIERE’S DISEASE
Assessment
1. occurs between 20
and 50 yrs old
2. greater in men and
in white individuals
3. headache
4. increasing tinnitus
5. feeling of fullness in
the affected area.
 MENIERE’S DISEASE
Common Nursing Diagnosis
anxiety r/t loss of control
risk of injury r/t loss of
balance
powerlessness r/t loss of
control
activity intolerance r/t
perception of dizziness
fear r/t potential of hearing
loss
risk for deficient fluid volume
r/t nausea and vomiting
 MENIERE’S DISEASE
Interventions
• instruct client to make
slow head movements to
prevent worsening of the
vertigo
• diet and lifestyle changes
such as salt and fluid
decrease
• advise clients to stop
smoking
• drug therapy aims to
control the vertigo and
vomiting and restore
normal balanced.
 MENIERE’S DISEASE
Interventions
• diuretics (mild)
• nicotinic acid
(vasodilator)
• antihistamines
(dyphenhydramine hcl)
• anti emetics
(chlorpromazine hcl)
• diazepam (calms the pt)
 MENIERE’S DISEASE
Surgical Management
• LABYRINTHECTOMY
– the most radical
procedure involves
resection of the
vestibular nerve or
total removal of the
labyrinth.
 HEARING LOSS
one the most
common physical
handicaps in
North America.
Hearing loss maybe
conductive,
sensorineural or
combination of
the two.
 HEARING LOSS

conduction hearing loss

• is the result of interrupted transmission of sound
waves through the outer and middle ear structures any
inflammatory process or obstruction of the external or middle ear
by cerumen or foreign objects leads to conductive hearing loss.

sensorineural hearing loss

• result of damage to the inner ear, the auditory nerve, or
the hearing center in the brain
mixed hearing loss
• is combination of conduction and sensorineural loss
 HEARING LOSS
Causes of Conductive
Hearing Loss
• cerumen
• foreign bodies
• perforation of
tympanic membrane
• edema
• infection of the
external ear or middle
ear
• tumors
• otosclerosis
 HEARING LOSS
Conductive hearing loss
Assessment findings
• evidence of obstruction with
otoscope
• abnormality in tympanic
membrane
• speaking softly
• hearing best in noisy
environment
• Rinne test: air conduction
greater the bone conduction
• Weber test: lateralization to
affected ear
 HEARING LOSS
Sensorineural
hearing loss
• damage of the of
the auditory nerve
(8th cranial
nerve), prolonged
exposure to loud
noise can damage
the air cells of the
cochlea.
 HEARING LOSS
Causes of Sensorineural Loss
• prolonged exposure to noise
• presbycusis
• ototoxic substance
• meniere’s dse
• acoustic neuroma
• DM
• labyrinthitis
• infection
• myxedema
 HEARING LOSS
Assessment findings of
Sensorineural Loss
1. normal appearance of
external canal and
tympanic membrane
2. Occasional dizziness
3. tinnitus
4. speaking loudly
5. hearing poorly in loud
environment
6. Rinne test
7. webers test
 HEARING LOSS
ASSESSMENT
a. History
b. physical assessment
c. clinical manifestation
• pain
• feeling of fullness or
congestion
• dizziness or vertigo
• tinnitus
• difficulty of understanding
conversation specially ion
noisy room
• difficulty of hearing sound
• the need to strain to hear
• the need to turn the head
to favor one ear
 HEARING LOSS
ASSESSMENT
• tunning fork test
• otoscopic examination
• laboratory assessment
• Wbc
• radiographic
assessment
• CT and MRI
 HEARING LOSS
Nursing Diagnosis
• disturbed sensory
perception (auditory) r/t
obstruction, infection,
damage to middle ear,
damage to auditory nerve
• impaired verbal
communication r/t reduced
sensory perception
• activity intolerance r/t pain
• impaired physical mobility
r/t vertigo
 HEARING LOSS
MANAGEMENT
• Hearing aids
• Cochlear implant
• Tympanoplasty.
 ANATOMY AND
PHYSIOLOGY
• Organ of smell with
receptors from cranial
nerve I (Olfactory)
located in the upper
area.
• Separated by two
passages called
septum which is rich
in blood supply
• Upper 1/3 is
composed of bone
• Lower 2/3 is cartilage
 ANATOMY AND
PHYSIOLOGY
• The anterior nares are lined
with skin and hair which help
keen foreign particles or
organisms from entering the
lungs
• Turbinates (three bony
projections) protrude into the
nasal cavities from the walls
of the internal portion of the
nose. It increases the total
surface area for filtering,
heating, and humidifying
inspired before it passes into
the nasopharynx.
 ANATOMY AND
PHYSIOLOGY
• Cilia (hairlike projections)
moves particles not filtered in
the mucous layer of the
turbinates
• the paranasal sinuses are
air – filled cavities within the
bones that surround the
nasal passages. Lind with
ciliated membrane, the
purposes of the sinuses are
to provide resonance during
speech and to crease the
weight of the skull.
 ANATOMY AND
PHYSIOLOGY
SINUSES
1.      frontal
sinuses
2.      ethmoid
sinuses
3.      sphenoid
sinuses
4.      maxillary
sinuses
 ASSESSMENT
equipment use
• nasal speculum
• flashlight/ penlight
• otoscope – with a
nasal attachment
facilities
 ASSESSMENT
1.Inspect the external nose
the shape, any deviation
color and nasal flaring
2.palpate for any tenderness,
masses, displacement of
bone or cartilage
3.patency of nasal canal
4.inspect by using nasal
speculum
5.observe for redness ,
swelling,, growths, any
discharges
6.inspect the nasal septum
 ASSESSMENT
• inspection and palpation
of the external nose
• the upper third of the
nose is bone, the
remainder is cartilage
• patency of the cavities
• help identify abnormality
in smell by testing the
olfactory sense by letting
him smell common odors • FACIAL SINUSES
• palpate the nasal sinuses – palpate the
maxillary and
frontal sinuses
– document findings
 NASAL POLYPS
• are benign grapelike
clusters of mucous
membrane and connective
tissue
• they often occur bilaterally
and are caused by irritation
to the nasal mucosa or
sinuses, allergies, or
infection (chronic sinusitis)
ASSESSMENT
• obstructed nasal breathing,
a change in the character of
nasal discharge, and a
change in speech quality
 NASAL POLYPS
INTERVENTIONS: surgery
• Benign – with nasal inhaled
steroids and surgical removal
(polypectomy). The nostrils
are usually packed with gauze
for 24 hours after surgery
• Inverting papilloma – is a
rare, benign lesion that
erodes nasal and facial bones
and is often first diagnosed as
a benign polyp.
• Juvenile angiofibromas – are
cellularly different from other
polyps.
• These tumors often occur in
adolescent males and may
resolve spontaneously when
adulthood is reached.
 NOSEBLEEDING
• Is common problem because of
the rich capillary network within
the nose.
• Occurs as a result of trauma,
hypertension, blood dyscrasia,
inflammation, tumor, decreased
humidity, nose picking, chronic
cocaine use, and procedures such
as nasogastric sunctioning.

ASSESSMENT
• bleeding started sneezing or
blowing the nose
• document the amount and color
of the blood and take vital signs
• ask the client about the number,
duration, and causes of previous
bleeding episodes.
 NOSEBLEEDING
Emergency Care of a Client with an
Anterior Nosebleed
• position the client upright and leaning
forward to prevent blood from entering the
stomach and possible aspiration
• reassure the client and attempt to keep
him/her quiet to reduce anxiety and blood
pressure
• apply direct lateral pressure to the nose
for 5 minutes, and apply ice or cool
compresses to the nose and face if
possible
 NOSEBLEEDING
• maintain standard or body
substance precautions
• if nasal packing is necessary,
loosely pack both nares with
gauze
• to prevent rebleeding from
dislodging clots, instruct the
client not to blow the nose fro
several hours after the
bleeding stops
• seek medical assistance if
these measures are
ineffective or if the bleeding
occurs frequently
 NOSEBLEEDING
• Observe the client for respiratory
distress and for tolerance of the
packing or tubes.
• Humidification, oxygen, bed rest ,
and antibiotics may be prescribes
• Uploads pain medication
• Teach the client interventions to use
at home for comfort and safety after
tube removal.
 DEVIATED NASAL
SEPTUM
• Usually straight
and separate
into two equal
chambers
• After trauma,
the septum may
become
deviated,
creating
asymmetrical
breathing