AUDIO-VISUAL DISTURBANCES

EXTERNAL STRUCTURES OF THE EYE EYELIDS (PALPEBRAL) & EYELASHES Protect the eye from foreign particles CONJUNCTIVA PALPEBRAL CONJUNCTIVA Pink; lines inner surface of eyelids BULBAR CONJUNTIVA White with small blood vessels, covers anterior sclera LACRIMAL APPARATUS (LACRIMAL GLAND & ITS DUCTS AND PASSAGES) Produces tears to lubricate the eye & moisten the cornea Tears drain into nasolacrimal duct which empties into nasal cavity

INTERNAL STRUCTURES OF THE EYE 1. EYEBALL 3 LAYERS OF THE EYEBALL A. OUTER LAYER - fibrous coat that supports the eye A. SCLERAE - Tough, white connective tissue white of the eye - located anteriorly & posteriorly B. CORNEA - Transparent tissue through which light enters the eye. - Located anteriorly

B. MIDDLE LAYER second layer of the eyeball - vascular & highly pigmented A. CHOROID - a dark brown membrane located between the sclera & the retina -it lines most of the sclera & is attached to the retina but can easily detach from the sclera

- contains blood vessels that nourishes the retina

- located posteriorly

B. MIDDLE LAYER

B. CILIARY BODY
- connects the choroid with the iris

- secretes aqueous humor that helps give the eye its shape C. IRIS
-the colored portion of the eye

- located in front of the lens

- it has a central opening called the pupil

INTERNAL STRUCTURES OF THE EYE C. INNER LAYER (RETINA) - a thin, delicate structure in which the fibers of the optic nerve are distributed - bordered externally by the choroid & sclera and internally by the vitreous - contains blood vessels & photoreceptors (cones & rods) - light sensitive layer CONTAINS THE FOLLOWING STRUCTURES 1. CONES - Specialized for fine discrimination, central vision & color vision - Functions at bright levels of illumination 2. RODS - More sensitive to light than cones - Aid in peripheral vision - Functions at reduced levels of illumination

2. FLUIDS OF THE EYE A. AQUEOUS HUMOR - Clear, watery fluid that fills the anterior & posterior chambers of the eye - produced by the ciliary processes, & the fluid drains in the Canal of Sclemm - The anterior chamber lies between the cornea & iris - the posterior chamber lies between the iris & lens - serves as refracting medium & provides nutrients to lens & cornea - contributes to maintenance of IOP

2. FLUIDS OF THE EYE

B. VITREOUS HUMOR
- Clear, gelatinous/jell-like material that fill the posterior cavity of the eye - Maintains the form & shape of the eye - Provides additional physical support to the eye - It is produced by the vitreous body

3. VITREOUS BOD
- contains a gelatinous substance that occupies the vitreous chamber which is the space between the lens & retina

- transmits light & gives shape to the posterior eye

4. OPTIC DISK - a creamy pink to white depressed area in the retina - the optic nerve enters & exits the eyeball in this area - Referred to as the BLIND SPOT - contains only nerve fibers - lack photoreceptors - insensitive to light 5. MACULA LUTE - Small, oval, yellowish pink area located lateral & temporal to the optic disk

- the central depressed part of the macula is the FOVEA CENTRALIS which is an area where acute vision occurs

6. CANAL OF SCHLEMM - a passageway that extends completely around the eye - permits fluid to drain out of the eye into the systemic circulation so that a constant IOP is maintained 7. LENS - A transparent circular structure behind the iris & in front of the vitreous body - Bends rays of light so that the light falls on the retina 8. PUPILS - Control the amount of light that enters the eye & reaches the retina - Darkness produces dilation while light produces constriction

9. EYE MUSCLES - Muscles do not work independently but work in conjunction with the muscle that produces the opposite movement A. RECTUS MUSCLES - Exert their pull when the eye turns temporarily B. OBLIQUE MUSCLES - Exert their pull when the eye turns nasally

10. NERVES A. CRANIAL NERVE II - Optic nerve (nerve of sight) B. CRANIAL NERVE III - Oculomotor C. CRANIAL NERVE IV - Trochlear D. CRANIAL NERVE VI
- Abducens

VISION
INTERNAL STRUCTURES OF THE EYE
11. BLOOD VESSELS
A. OPTHALMIC ARTERY
- Major artery supplying the structures in the eye

B. OPTHALMIC VEINS
- Venous drainage occurs through vision

ASSESSMENT OF VISION
VISUAL ACUITY TEST
- measures the clients distance & near vision

SNELLEN CHART
- simple tool to record visual acuity - the client stands 20 ft from the chart & covers 1 eye and uses the other eye to read the line that appears more clearly - this procedure is repeated for the other eye - the findings are recorded as a comparison between what the client can read at 20 ft and the no. of feet normally required by an individual to read the same line

EXAMPLE: 20/50
- The client is able to read at 20 ft from the chart what a healthy eye can read at 50 ft

ASSESSMENT OF VISION
CONFRONTATIONAL TEST
- Performed to examine visual fields or peripheral vision - The examiner & the client sit facing each other - The test assumes that the examiner has normal peripheral vision

EXTRAOCULAR MUSCLE FUNCTION

- tests muscle function of the eyes
- tests 6 cardinal positions of gaze 1. Clients right (lateral position) 2. Upward & right (temporal position) 3. Down & right 4. Clients left (lateral position) 5. Upward & left (temporal position) 6. Down & left - client holds head still & asked to move eyes & follow a small object - the examiner looks for any parallel movements of the eye or for nystagmus - an involuntary rhythmic rapid twitching of the eyeballs

ASSESSMENT OF VISION
COLOR VISION TEST
- Tests for color vision which involve picking nos. or letters out of a complex & colorful picture

ISHIHARA CHART
- consists of nos. that are composed of colored dots located within a circle of colored dots - client is asked to read the nos. on the chart - each eye is tested separately - the test is sensitive for the diagnosis of red/green blindness but not effective for the detection of the discrimination of blue

PUPILS
- Increasing light causes pupillary constriction Decreasing light causes pupillary dilation - the client is asked to look straight ahead while the examiner quickly brings a beam of light ( penlight) in from the side & directs it onto the side - Constriction of the eye is a direct response to the light shining into the eye; constriction of the opposite eye is known as CONSENSUAL RESPONSE
- Normal: round & of equal size

DIAGNOSTIC TESTS FOR THE EYE

FLUORESCEIN ANGIOGRAPHY
- detailed imaging & recording of ocular circulation by a series of photographs after administration of the dye

PRE-OP NURSING CARE

Assess for allergies & previous reactions to dyes Obtain informed consent A mydriatic medication is instilled in the eye 1 hr. before the test The dye is injected into the vein of the clients arm Inform client that the dye may cause the skin to appear yellow for several hrs. after the test & this is gradually eliminated through the urine The client may experience N&V, sneezing, paresthesia of the tongue or pain at the injection site If hives appear, oral or IM antihistamines such as Diphenhydramine (Benadryl) are given as prescribed.

DIAGNOSTIC TESTS FOR THE EYE

FLUORESCEIN ANGIOGRAPHY
- detailed imaging & recording of ocular circulation by a series of photographs after administration of the dye

POST-OP NURSING CARE

Encourage rest. Encourage oral fluids. Remind the client that the yellow skin appearance will disappear Instruct the client that the urine will appear bright green until the dye is excreted Instruct the client to avoid direct sunlight for a few hrs after the test. Instruct the client that the photophobia will continue until pupil size returns to normal

DIAGNOSTIC TESTS FOR THE EYE COMPUTED TOMOGRAPHY

- a beam of x-ray scans the skull & orbits of the eye - a cross-sectional image is formed by the use of a computer - contrast material is not usually administered

NURSING CARE
No special client preparation or follow-up care required Instruct the client that he or she will be positioned in a confined space & need to keep the head still during the procedure

DIAGNOSTIC TESTS FOR THE EYE

SLIT LAMP
- allows examination of the anterior ocular structures under microscopic magnification - the client leans on a chin rest to stabilize the head while a narrow beam of light is aimed so that it illuminates only a narrow segment of the eye.

NURSING CARE
Explain the procedure to the client. Advise the client about the brightness of the light & the need to look forward at the point over the examiners ear

DIAGNOSTIC TESTS FOR THE EYE

CORNEAL STAINING
- installation of a topical dye into the conjunctival sac to outline the irregularities of the corneal surface that are not easily visible - the eye is viewed through a blue filter, and a bright green color indicates areas of non-intact corneal epithelium

NURSING CARE
If a client wears contact lenses, they must be removed The client is instructed to blink after the dye has been applied to distribute the dye evenly across the cornea

DIAGNOSTIC TESTS FOR THE EYE

TONOMETRY
- the test is primarily used to assess for an increase in IOP and potential glaucoma - NORMAL IOP: 8-21 mm Hg

NURSING CARE
Each eye is anesthetized. The client is asked to stare forward at a point above the examiners ear A flattened cone is brought in contact with the cornea The amount of pressure needed to flatten the cone is measured The client is instructed to avoid rubbing the eye following the examination if the eye has been anesthetized - the potential for scratching the cornea exists

DISORDERS OF THE EYE

Risk factors of eye disorders

AGING PROCESS CONGENITAL DIABETES MELLITUS HEREDITARY MEDICATIONS TRAUMA

LEGALLY BLIND
- a person is legally blind if the best visual acuity with corrective lenses in the better eye is 20/200 or less or a visual field of 20 degrees or less in the better eye

NURSING CARE
When speaking to a client who has limited sight or blind, the nurse uses a normal tone of voice Alert the client when approaching Orient the client to the environment Use a focal point & provide further orientation to the environment from the focal point Allow the client to touch objects in the room Use the clock placement of foods on the meal tray to orient the client Promote independence as much as possible

LEGALLY BLIND
NURSING CARE
Provide radios, TVs, & clocks that give the time orally or provide a Braille watch. When ambulating, allow the client to grasp the nurses arm at the elbow - the nurse keeps his or her arm close to the body so that the client can detect the direction of movement Instruct the client to remain one step behind the nurse when ambulating Instruct the client in the use of the cane used for the blind client, which is differentiated from other canes by its straight shape & white color with red tip Instruct the client that the cane is held in the dominant hand several inches off the floor Instruct the client that the cane sweeps the ground where the clients foot will be placed next to determine the presence of obstacles

CATARACTS
A lens opacity or cloudiness

CATARACTS
- an opacity of the lens that distorts the image projected onto the retina & that can progress to blindness - Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or adversely affecting lifestyle

CAUSES
Aging process (Senile cataracts) Inherited (Congenital cataracts) Injury (Traumatic cataracts) Can occur as a result of another eye disease (Secondary cataracts)

Cataract
Risk factors 1. Aging, DM, Toxic factors, aging, etc causes lens opacification 2. Visual impairment progresses as the opacification blocks the visual field

CATARACTS
ASSESSMENT
Opaque or cloudy white pupil Gradual loss of vision Blurred vision Decreased color perception Vision that is better in dim light with pupil dilation Photophobia Absence of red reflex

Cataract
DIAGNOSTIC TEST 1. Snellen chart for visual acuity 2. Ophthalmoscopy 3. Slit-lamp to establish the degree of cataract formation

CATARACTS
MEDICAL MANAGEMENT
- surgical removal of the lens, one eye at a time - a lens implantation may be performed at the time of surgical procedure

EXTRACAPSULAR EXTRACTION
- the lens is lifted out without removing the lens capsule - may be performed with Phacoemulsion PHACOEMULSION - the lens is broken up by ultrasonic vibrations & extracted

INTRACAPSULAR EXTRACTION PARTIAL IRIDECTOMY

- the lens is removed within its capsule through a small incision - may be performed with lens extraction to prevent acute secondary glaucoma

CATARACTS
PRE-OP NURSING CARE
Instruct measures to prevent or decrease IOP Administer pre-op eye medications including mydriatics & cycloplegics as prescribed

POST-OP NURSING CARE

Elevate the head of the bed 30-45 degrees Turn the client to the back or un-operative side Maintain an eye patch & orient the client to the environment Position the clients personal belongings on the un-operative side Use side rails for safety Assist with ambulation

CATARACTS
CLIENT EDUCATION AFTER CATARACT SURGERY
Avoid eye straining Avoid rubbing or placing pressure on the eyes Avoid rapid movements, straining, sneezing, coughing, bending, vomiting, or lifting objects over 5 lbs Teach measures to prevent constipation Wipe excess drainage or tearing with a sterile wet cotton ball from the inner to the outward canthus Use an eye shield at bedtime If an eye implant is not performed, the eye cannot accommodate & glasses must be worn at all times Cataract glasses act as magnifying glasses & replace central vision only Cataract glasses magnify, & objects appear closer therefore teach client to judge distance & climb stairs carefully Contact lenses provide sharp visual acuity but dexterity is needed to insert them Contact the MD for any decrease in vision, severe eye pain or increase in eye discharge

GLAUCOMA
Increased intra-ocular pressure

Glaucoma
Two types
1. Open angle

2. Closed angle

Glaucoma

GLAUCOMA
- increased IOP as a result of inadequate drainage of aqueous humor from the canal of Schlemm or over production of aqueous humor

- the condition damages the optic nerve & can result in blindness

TYPES
ACUTE CLOSED-ANGLE/NARROW ANGLE GLAUCOMA - results from obstruction to outflow to aqueous humor CHRONIC CLOSED-ANGLE GLAUCOMA - follows an untreated attack of acute close-angled glaucoma CHRONIC OPEN-ANGLE GLAUCOMA - results from an overproduction or obstruction to the outflow of aqueous humor ACUTE GLAUCOMA - a rapid onset of IOP > 50-70 mm Hg CHRONIC GLAUCOMA - a slow, progressive, gradual onset of IOP > 30-50 mm Hg

GLAUCOMA
PATHOPHYSIOLOGY 1. Direct mechanism direct pressure damages retina 2. indirect mechanism high IOP compresses the microcirculation in the optic head resulting to nerve injury and death

Glaucoma
Classification of Glaucoma 1. Open-angle glaucoma the anterior chamber angle is open and appears normal 2. Angle-closure glaucoma the AH outflow is obstructed due to partial or complete closure of the angle

GLAUCOMA
ASSESSMENT
Progressive loss of peripheral vision followed by a loss of central vision Elevated IOP (Normal pressure is 10-21 mm Hg) Vision worsening in the evening with difficulty adjusting to dark rooms Blurred vision Halos around white lights Frontal headaches Photophobia Increased lacrimation Progressive loss of central vision

Glaucoma
DIAGNOSTIC TEST 1. Tonometry to measure the IOP 2. Ophthalmoscopy to inspect the optic nerve 3. Gonioscopy to examine the angle 4. Perimetry to detect visual field changes

Glaucoma
MEDICAL MANAGEMENT 1. Laser surgery 2. Drug therapy to lower Increased IOP A. MiOtics to cause cOnstriction B. Adrenergics, beta-blockers and CAI to cause reduced production

GLAUCOMA
NURSING CARE FOR ACUTE GLAUCOMA
Treat as medical emergency Administer medications as prescribed to lower IOP Prepare the client for peripheral iridectomy - allows aqueous humor to flow from the posterior to anterior chamber

NURSING CARE FOR CHRONIC GLAUCOMA

Instruct the client the importance of medications
a. MIOTICS: to constrict the pupils b. CARBONIC ANHYDRASE INHIBITORS: to decrease the production of aqueous humor c. BETA-BLOCKERS: to decrease the production of aqueous humor & IOP Instruct the client the need for life-long medication use Instruct the client to wear a Medic-Alert bracelet

GLAUCOMA
NURSING CARE FOR CHRONIC GLAUCOMA
Instruct the client to avoid anti-cholinergic medications Instruct the client to report eye pain, halos around eyes & changes of vision to the physician Instruct the client that when maximal medical therapy has failed to halt the progression of visual field loss & optic nerve damage, surgery will be recommended Prepare the client for TRABECULOPLASTY as prescribed - to facilitate aqueous humor drainage Prepare client for TRABECULECTOMY as prescribed - allows drainage of aqueous humor into the conjuctival spaces by the creation of an opening

RETINAL DETACHMENT
- occurs when the layers of the retina separate because of accumulation of fluid between them - also occurs when both retinal layers elevate away from the choroid as a result of a tumor

TYPES
PARTIAL RETINAL DETACHMENT
- becomes complete if left untreated

COMPLETE RETINAL DETACHMENT

- when detachment is complete, blindness may occur

RETINAL DETACHMENT
ASSESSMENT
Flashes of light Floaters Increase in blurred vision Sense of curtain being drawn Loss of a portion of the visual field

RETINAL DETACHMENT
IMMEDIATE NURSING CARE
Provide bedrest
Cover both eyes with patches to prevent further detachment Speak to the client before approaching Position the clients head as prescribed Protect the client from injury Avoid jerky head movements Minimize eye stress Prepare the client for surgical procedure as prescribed

RETINAL DETACHMENT
MEDICAL MANAGEMENT
- draining fluid from the subretinal space so that the retina can return to the normal position

SEALING RETINAL BREAKS BY CRYOSURGERY DIATHERMY

- a cold probe applied to the sclera to stimulate an inflammatory response leading to adhesions - the use of electrode needle & heat through the sclera to stimulate an inflammatory response leading to adhesions

LASER THERAPY

SCLERAL BUCKLING
closing the tear

- to stimulate an inflammatory response to seal small retinal tears before the detachment occurs

- to hold the choroid & retina together with a splint until scar tissue forms

INSERTION OF A GAS OR SILICONE OIL

- to encourage attachment because these agents have a specific gravity less

than vitreous or air & can float against the retina

RETINAL DETACHMENT
POST-OP NURSING CARE
Maintain eye patches bilaterally as prescribed Monitor hemorrhage as prescribed Prevent N&V and monitor for restlessness which can cause hemorrhage Monitor for sudden, sharp eye pain (notify the MD stat) Encourage DBE but avoid coughing Provide bedrest for 1-2 days as prescribed If gas has been inserted, position as prescribed on the abdomen & turn the head so unaffected eye is down Administer eye medications as prescribed Assist client with ADL Avoid sudden head movements or anything that increases IOP Instruct the client to limit reading for 3-5 weeks Instruct client to avoid squinting, straining & constipation, lifting heavy objects & bending from the waist Instruct the client to wear dark glasses during the day & an eye patch at night Encourage follow-up care because of the danger of recurrence or occurrence in the other eye

STRABISMUS
- called SQUINT EYE or LAZY EYE
- a condition in which the eyes are not aligned because of lack of muscle coordination of the extraocular muscles

- most often results from muscle imbalance or paralysis of extraocular muscles, but may also result from conditions such as brain tumor, myasthenia gravis or infection - normal in young infant but should not be present after about age 4 months

ASSESSMENT
Amblyopia if not treated early
Permanent loss of vision if not treated early

Loss of binocular vision

Impairment of depth perception Frequent headaches Squints or tilts head to see

STRABISMUS
NURSING CARE
Corrective lenses as indicated Instruct the parents regarding patching (occlusion therapy) of the good eye - to strengthen the weak eye Prepare for botulinum toxin (Botox) injection into the eye muscle - produces temporary paralysis - allows muscles opposite the paralyzed muscle to strengthen the eye Inform the parents that the injection of botulinum toxin wears off in about 2 months & if successful, correction will occur Prepare for surgery to realign the weak muscles as Rx if nonsurgical interventions are unsuccessful Instruct the need for follow-up visits

CONJUNCTIVITIS
- also known as PINK EYE
- inflammation of the conjunctiva - usually caused by allergy, infection, or trauma

TYPES
BACTERIAL OR VIRAL CONJUNCTIVITIS
- extremely contagious

CHLAMYDIAL CONJUNCTIVITIS
- is rare in older children & if diagnosed in a child who is not sexually
active, the child should be assessed for possible sexual abuse

ASSESSMENT
Itching, burning or scratchy eyelids
Redness
Edema Discharge

CONJUNCTIVITIS
NURSING CARE
Instruct in infection control measures such as good handwashing & not sharing towels & washcloths Administer antibiotic or antiviral eye drops or ointment as Rx if infection is present

Administer antihistamines as Rx if an allergy is present

Instruct the parents that the child should be kept home from school or day care until antibiotic eye drops have been administered for 24 hrs Instruct in the use of cool compresses to lessen irritation & in wearing dark glasses for photophobia Instruct the child to avoid rubbing the eye to prevent injury D/C use of contact lenses & to obtain new lenses to eliminate the chance of re-infection Instruct the adolescent that eye make-up should be discarded & replaced

HYPHEMA
- the presence of blood in the anterior chamber - occurs as a result of injury - condition usually resolves in 5-7 days

NURSING CARE
Encourage rest in semi-Fowlers position Avoid sudden eye movements for 3-5 days to decrease bleeding Administer cycloplegic eye drops as prescribed - to place the eye at rest Instruct in the use of eye shields or eye patches as prescribed Instruct the client to restrict reading & watching TV

CONTUSIONS
- bleeding into the soft tissue as a result of an injury - causes a black eye & the discoloration disappears in approximately 10 days - pain, photophobia, edema & diplopia may occur

NURSING CARE
Place ice on the eye immediately Instruct the client to receive an eye examination

FOREIGN BODIES
- an object such as dust that enters the eye

NURSING CARE
Have the client look upward, expose the lower lid, wet a cottontipped applicator with sterile NSS & gently twist the swab over the particle & remove it If the particle cannot be seen, have the client look downward, place a cotton applicator horizontally on the outer surface of the upper eye lid, grasp the lashes, & pull the upper lid outward & over the cotton applicator, if the particle is seen, gently twist over it to remove

PENETRATING OBJECTS
- an injury that occurs to the eye in which an object penetrates the eye

NURSING CARE
Never remove the object because it may be holding ocular structures in place, the object must be removed by MD Cover the object with a cup Dont allow the client to bend Dont place pressure on the eye Client is to be seen by MD stat

CHEMICAL BURNS
- an eye injury in which a caustic substance enters the eye

NURSING CARE
Treatment should begin stat Flush the eyes at the site of injury with water for at least 15-20 mins At the site of injury, obtain a small sample of the chemical involved At the ER, the eyes is irrigated with NSS or an opthalmic irrigation solution The solution is directed across the cornea & toward the lateral canthus Prepare for visual acuity assessment Apply an antibiotic ointment as prescribed Cover the eye with a patch as prescribed

ENUCLEATION
- removal of the entire eyeball

EXENTERATION
- removal of the eyeball & surrounding tissues Performed for the removal of ocular tumors After the eye is removed, a ball implant is inserted to provide a firm base for socket prosthesis & to facilitate the best cosmetic result A prosthesis is fitted approximately 1 month after surgery

PRE-OP NURSING CARE

Provide emotional support to the client Encourage the client to verbalize feelings related to loss

POST-OP NURSING CARE

Monitor V/S Assess pressure patch or dressing Report changes in V/S or the presence of bright red drainage on the pressure patch or dressing

ORGAN DONATION
DONOR EYES
Obtained from cadavers Must be enucleated soon after death due to rapid endothelial cell death Must be stored in a preserving solution Storage, handling & coordination of donor tissue with surgeons is provided by a network of state eye bank associations across the country

ORGAN DONATION
CARE OF THE DECEASED CLIENT AS A POTENTIAL EYE DONOR
Discuss the option of eye donation with MD & family Raise the head of the bed 30 Instill antibiotic eye drops as RX Close the eyes & apply a small ice pack to the closed eyes

ORGAN DONATION
PRE-OP CARE OF THE RECIPIENT
Recipient may be told of the tissue availability only several hrs to 1 day before surgery Assist in alleviating client anxiety Assess for signs of eye infection Report the presence of any redness, watery or purulent drainage or edema around the eyes to MD Instill antibiotic drops into the eyes as Rx to reduce the no. of microorganisms present Administer IV fluids & medications as Rx

ORGAN DONATION
POST-OP CARE TO THE RECIPIENT
Eye is covered with a pressure patch and protective shield that are left in place until the next day Dont remove or change the dressing without the MDs order Monitor V/S, LOC & assess dressing Position the client on unoperative side to reduce IOP Orient the client frequently Monitor for complications of bleeding, wound leakage, infection & graft rejection Instruct the client in how to apply the patch & eye shield Instruct the client to wear the eye shield at night for 1 month & whenever around small children or pets

GRAFT REJECTION
Can occur at anytime Inform the client of signs of rejection Signs include redness, swelling, decreased vision, & pain (RSDP) Treated with topical steroids

Anatomy of the Ear

The ear is divided into three areas
Outer (external) ear Middle ear Inner ear

Figure 8.12

HEARING
FUNCTIONS OF THE EAR
Hearing Maintenance & balance

EXTERNAL EAR
- Embedded in the temporal bone bilaterally at the level of the eyes - Extends from the auricle through the external canal to the tympanic membrane or eardrum - Includes the mastoid process, a bony ridge located over the temporal bone

EXTERNAL EAR A. AURICLE (PINNA) - Outer projection of ear composed of cartilage & covered by skin - collects sound waves B. EXTERNAL AUDITORY CANAL - Lined with skin - Glands secrete cerumen (wax) - provides protection - transmits sound waves to tympanic membrane C. TYMPANIC MEMBRANE (EARDRUM) - Located at the end of the external canal - Vibrates in response to sound & transmit vibrations to middle ear

MIDDLE EAR - Consists of the medial side of the tympanic membrane - The tympanic membrane is a thick transparent sheet of tissue that provides a barrier between the external ear & the middle ear - The middle ear is protected from the inner ear by the round & the oval window membranes - The eustachian tube opens into the middle ear & allows for equalization of pressure on both sides of the tympanic membrane

MIDDLE EAR A. OSSICLES - Contains 3 small bones: Malleus (Hammer) attached to tympanic membrane

Incus (Anvil)
Stapes (Stirrup) - Ossicles are set in motion by sound waves from to the footplate of the stapes in the oval window OVAL WINDOW: an opening bet. the middle & inner ear B. EUSTACHIAN TUBE - Connects nasopharynx & middle ear - Equalizes pressure on both sides of eardrum

INNER EAR - Contains the semi-circular canals, the cochlea & the distal end of the 8th cranial nerve - Maintains sense of balance & equilibrium A. SEMI-CIRCULAR CANALS - Contains fluid & hair cells connected to sensory nerve fibers of the vestibular portion of 8th cranial nerve B. COCHLEA - Spiral-shaped organ of hearing - Connects organ of Corti, receptor and organ for hearing - Transmits sound waves from the oval window & initiates nerve impulses carried by cranial nerve VIII (acoustic branch) to the brain ( temporal lobe of cerebrum)

INNER EAR C. 8th CRANIAL NERVE 1. COCHLEAR BRANCH - transmits neuro-impulse from the cochlea to the brain where it is interpreted as sound 2. VESTIBULAR BRANCH - maintains balance & equilibrium

HEARING & EQUILIBRIUM

The external ear conducts sound waves to the middle ear The middle ear also called the tympanic cavity conducts sound waves to the inner ear The middle ear is filled with air which is kept at atmospheric pressure by the opening of the eustachian tube The inner ear contains sensory receptors for sound & for equilibrium The receptors in the inner ear transmit sound waves & changes in body position to the nerve impulses

ASSESSMENT OF THE EAR

OTOSCOPIC EXAM
GUIDELINES
- the speculum is never blindly introduced into the external canal because of the risk of perforating the tympanic membrane - tilt the head slightly away & hold the otoscope upside down as if it were a large pen - this permits the examiners hand to lie against the head for support - pull the pinna up & back to straighten the external canal in an adult - visualize the external canal while slowly inserting the speculum

ASSESSMENT OF THE EAR

OTOSCOPIC EXAM
NORMAL FINDINGS OF THE EXTERNAL CANAL
Pink & intact without lesions Has various amounts of cerumen & fine little hairs

NORMAL FINDINGS OF THE TYMPANIC MEMBRANE

The tympanic membrane should be intact without perforations & free from lesions The tympanic membrane is transparent, opaque, pearly gray & slightly concave

ASSESSMENT OF THE EAR

AUDITORY ASSESSMENT
Sound is transmitted by air conduction & bone conduction Air is 2-3x longer than bone conduction

CATEGORIES OF HEARING LOSS

Conductive Sensorineural Mixed Conductive & Sensorineural

ASSESSMENT OF THE EAR

CONDUCTIVE HEARING LOSS
- due to any physical obstruction to the transmission of sound waves

SENSORINEURAL HEARING LOSS

- due to a defect in the organ of hearing, in the 8th cranial nerve, or in the brain itself

MIXED CONDUCTIVE, SENSORINEURAL HEARING LOSS

- results in profound hearing loss

ASSESSMENT OF THE EAR

VOICE TEST
Ask the client to block one external canal The examiner stands 1-2 ft away & quickly whispers a statement The client is asked to repeat the whispered statement Each ear is tested separately

WATCH TEST
A ticking watch is used to test the high-frequency sounds The examiner holds a ticking watch about 5 inches from each ear & asks the client if the ticking is heard

ASSESSMENT OF THE EAR

TUNING FORK TESTS
A. WEBER TUNING FORK TEST
Normal result: hearing the sound equally in both ears

FINDINGS
If the client hears the sound louder in 1 ear, - (+) LATERALIZATION is present - applied to the side where the sound is heard the loudest
INTERPRETATION The finding may indicate the client has CONDUCTIVE HEARING LOSS in the ear to which the ear is lateralized The finding may indicate that there is a SENSORINEURAL HEARING LOSS in the opposite ear

ASSESSMENT OF THE EAR

TUNING FORK TESTS
B. RINNE TUNING FORK TEST
Compares the clients hearing by air conduction & bone conduction AIR CONDUCTION is 2-3X longer than BONE CONDUCTION

NORMAL RESULT: (+) RINNE TEST

- the client normally continues to hear the sound 2x louder in front of the pinna

The examiner records the duration of both phases, bone conduction followed by air conduction and compares the times

ASSESSMENT OF THE EAR

TUNING FORK TESTS
B. RINNE TUNING FORK TEST
FINDINGS
If the client is unable to hear the sound through the ear in front of the pinna, - (-) RINNE TEST - Bone conduction is greater than air conduction

INTERPRETATION
Client may have a CONDUCTIVE HEARING LOSS on the side tested The Rinne test is of no value in determining sensorineural hearing loss

VESTIBULAR ASSESSMENT OF THE EAR TEST FOR FALLING

The examiner asks the client to stand with the feet together & arms hanging loosely at the sides & eyes closed The client normally remains erect with slight swaying

ABNORMAL RESULT: (+) ROMBERG SIGN

- presence of significant swaying

VESTIBULAR ASSESSMENT OF THE EAR TEST FOR PAST POINTING

NORMAL TEST RESPONSE: - The client can easily return to the point of reference

FINDINGS
The client with vestibular function problem lacks a normal sense of position sense and is unable to return to the extended fingers to the point of reference, the fingers instead either goes to the right or left of the reference point

VESTIBULAR ASSESSMENT OF THE EAR

GAZE NYSTAGMUS EVALUATION
Examine the clients eyes as they look straight ahead, 30 degrees to each side, upward & downward

FINDINGS
Any spontaneous nystagmus is a (+) result - ABNORMAL FINDING - a constant involuntary cyclic movement of the eyeball in any direction represents a problem with the vestibular system

VESTIBULAR ASSESSMENT OF THE EAR

HAPLIKE MANEUVER
Assesses for positional vertigo or induced dizziness The client assumes a supine position The head is rotated to one side for 1 minute

FINDINGS
(+) test result is presence of nystagmus after 5-10 sec - ABNORMAL FINDING - a constant involuntary cyclic movement of the eyeball in any direction represents a problem with the vestibular system

DIAGNOSTIC TESTS FOR THE EAR

TOMOGRAPHY
- may be performed with or without contract medium - assesses the mastoid, middle ear & inner ear structures - multiple x-rays of the head are done

NURSING CARE
All jewelry are removed Lead eye shields are used to cover the cornea to diminish the radiation dose to the eyes The client must remain still in a supine position No follow-up care is required

DIAGNOSTIC TESTS FOR THE EAR

AUDIOMETRY
- measures hearing acuity - uses 2 types: PURE TONE AUDIOMETRY & SPEECH AUDIOMETRY - after testing, audiogram patterns are depicted on a graph to determine the type & level of hearing loss

PURE TONE AUDIOMETRY

- used to identify problems with hearing, speech, music & other sounds in the environment

SPEECH AUDIOMETRY

- the clients ability to hear spoken words is measured

NURSING CARE
Inform the client regarding the procedure Instruct the client to identify the sounds as they are heard

DIAGNOSTIC TESTS FOR THE EAR

ELECTRONYSTAGMOGRAPHY
- a vestibular test that evaluates spontaneous &

induced eye movements known as nystagmus - used to distinguish between normal nystagmus & either medication-induced nystagmus or nystagmus caused by a lesion in the central or peripheral vestibular pathway - records changing electrical fields with movement of the eye, as monitored by electrodes placed on the skin around the eye

DIAGNOSTIC TESTS FOR THE EAR

NURSING CARE
NPO for 3 hrs before testing Unnecessary medications are omitted for 24 hours Instruct client that this is a long & tiring procedure Client should bring prescription eyeglasses to the exam The client is instructed to gaze at lights, focus on a moving pattern, focus on a moving point, & sit with the eyes closed

While sitting in a chair, the client may be rotated to provide info about vestibular function
Clients ears are irrigated with cool & warm water which cause N & V After the procedure, the client begins taking clear fluids slowly & cautiously because N & V may occur Assistance may be necessary following the procedure

DIAGNOSTIC TESTS FOR THE EAR

CALORIC TEST (BI-THERMAL TEST)
- performed to evaluate the client experiencing dizziness - Nystagmus, nausea, vomiting or ataxia - may indicate a pathological condition of the labyrinth system, whereas a decreased response may indicate that the vestibular system is affected

NURSING CARE
Warm water causes a greater response than cold water Warm water caloric testing (irrigation) precedes cool water caloric testing (irrigation) The character & duration of the eye movements are measured The client must assume a supine position with eyes closed & head elevated to 30 degrees After the procedure, the client begins taking clear fluids slowly & cautiously because N & V may occur Assistance with ambulation may also be necessary following the procedure

DISORDERS OF THE EAR

Risk factors of eye disorders

AGING PROCESS INFECTION MEDICATIONS OTOTOXICITY TRAUMA TUMORS

CONDUCTIVE HEARING LOSS

- occurs when sound waves are blocked to the inner ear fibers because of external ear or middle ear disorders - disorders can often be corrected with no damage to hearing, or minimal permanent hearing loss

CAUSES
Any inflammatory process or obstruction of the external or middle ear Tumors Otosclerosis A build-up of scar tissue on the ossicles from previous middle ear surgery

SENSORINEURAL HEARING LOSS

- a pathological process of the inner ear or of sensory fibers that lead to the cerebral cortex - is often permanent, & measures must be taken to reduce further damage or to attempt to amplify sound as a means of improving hearing to some degree

CAUSES
Damage to the inner ear structures
Damage to the cranial nerve VIII Prolonged exposure to loud noise

Medications, trauma, infections, surgery Inherited disorders Metabolic & circulatory disorders Menieres syndrome Diabetes mellitus Myxedema

MIXED HEARING LOSS

- also known as conductive-sensorineural hearing loss - client has both sensorineural & conductive hearing loss

SIGNS OF HEARING LOSS

Frequently asking people to repeat statements
Straining to hear Turning head or leaning forward to favor one ear Shouting in conversations Ringing in the ears Failing to respond when not looking in the direction of the sound Answering questions incorrectly Raising the volume of the television or radio Avoiding large groups Better understanding of speech when in small groups Withdrawing from social interactions

FACILITATING COMMUNICATION
Use of written words if the client is able to see, read, & write
Providing plenty of light in the room Getting the attention of the client before you begin to speak Facing the client when speaking Talking in a room without distracting noises Moving close to the client & speaking slowly & clearly Keeping hands & other objects away from the mouth when talking to the client Talking in lower tones, because shouting is not helpful Rephrasing sentences & repeating information Validating with the client the understanding of statements made, by asking the client to repeat what was said Reading lips Encouraging the client to wear glasses when talking to someone to improve vision for lip reading Using sign language, which combines speech with movements that signify letters, words or phrases Using telephone amplifiers Facing lights that are activated by ringing of the telephone or doorbell Specially trained dogs that help the client to be aware of sound & to alert the client of potential dangers

COCHLEAR IMPLANTATION
- used for sensorineural hearing loss - a small computer converts sound waves into electrical impulses - electrodes are placed by the internal ear with a computer device attached to the external ear - electronic impulses directly stimulate nerve fibers

HEARING AIDS
- used for the client with conductive hearing loss - can help the client with sensorineural loss, although it is not as effective - a difficulty that exists in its use is the amplification of background noise as well as voices

CLIENT EDUCATION REGARDING A HEARING AID

Encourage to begin using the hearing aid slowly to develop an adjustment to
the service Adjust the volume to a minimal hearing level to prevent feedback squeaking
Teach the client to concentrate on the sounds that are to be heard & to filter out background noise Instruct the client to clean ear mold with mild soap & water Avoid excessive wetting of the hearing aid, and try to keep the hearing aid dry Clean the ear cannula of the hearing aid with a toothpick or pipe cleaner Turn off the hearing aid & remove the battery when not in use Keep extra batteries on hand Keep the hearing aid in a safe place Prevent hair sprays, oils, or other hair & face products from coming into contact with the receiver of the hearing aid

PRESBYCUSIS
- associated with aging

- leads to degeneration or atrophy of the ganglionic cells in the cochlea & a loss of elasticity of the basilar membranes - leads to compromise of the vascular supply to the inner ear with changes in several areas of the ear structure

ASSESSMENT
Hearing loss is gradual & bilateral
Client states that he/she has no problem with hearing but cant understand what the words are Client thinks that the speaker is mumbling

EXTERNAL OTITIS
- infective inflammatory or allergic responses involving the structure of the external auditory canal or the auricles

- an irritating or infective agent comes into contact with epithelial layer of the external ear
- this leads to either an allergic response or S/S of infection - the skin becomes red, swollen, & tender to touch on movement - the excessive swelling of the canal lead to conductive hearing loss - due to obstruction

- more common in children & termed as SWIMMERS EAR

- occurs more often in hot, humid environments - prevention includes the elimination of irritating or infecting agents

EXTERNAL OTITIS
ASSESSMENT
Pain
Itching

Plugged feeling in the ear

Redness & edema Exudate Hearing loss

EXTERNAL OTITIS
NURSING CARE
Apply heat locally for 20 minutes 3x a day Encourage rest to assist in reducing pain Administer analgesics such as aspirin or acetaminophen (Tylenol) for the pain as prescribed Instruct the client that the ears should be kept clean & dry Instruct the client to use earplugs for swimming Instruct the client that cotton-tipped applicators should not be used to dry ear because their use can lead to trauma to the canal Instruct the client that irritating agents such as hair products or headphones should be discontinued

OTITIS MEDIA
- infection of the middle ear occurring as a result of a blocked eustachian tube, which prevents normal drainage - a common complication of an acute respiratory infection - infants & children are more prone - their eustachian tubes are shorter, wider & straighter

ASSESSMENT
Fever
Irritability, restlessness & loss of appetite Rolling of head from side to side Pulling on or rubbing the ear

Earache or pain
Signs of hearing loss Purulent ear drainage Red, opaque, bulging or retracting tympanic membrane

OTITIS MEDIA
NURSING CARE
Encourage oral fluids
Teach the parents to feed infants in an upright position Instruct the child to avoid chewing during the acute period - chewing increases the pain Provide local heat & have the child lie with affected ear down Instruct the parents in the appropriate procedure to clean drainage from the ear with sterile cotton swabs Instruct in the administer of analgesics or antipyretics such as Acetaminophen (Tylenol) to decrease fever & pain

Instruct the parents in the administration of prescribed antibiotics, emphasizing that the 10-14 day period is necessary to eradicate positive organisms
Instruct the parents that screening for hearing loss may be necessary If ear drops are prescribed, instruct the parents that the auditory canal is straightened by pulling the pinna down & back in children younger than 3 yrs. & by pulling the pinna up & back for a child older than 3 yrs.

MYRINGOTOMY
- insertion of tympanoplasty tubes in the middle ear to equalize pressure & keep the ears dry

POST-OP NURSING CARE

Instruct the parents & child to keep the ears dry
Earplugs should be worn during bathing, shampooing & swimming Diving & submerging under water are not allowed

Client education post myringotomy

Avoid strenuous exercise
Avoid rapid head movements, bouncing or bending Avoid straining on bowel movement Avoid drinking through a straw Avoid traveling by air Avoid forceful coughing Avoid contact with persons with colds Avoid washing hair, showering or getting the head wet for a week as Rx Instruct the client that if she/he needs to blow the nose, blow one side at a time with wide mouth open Instruct the client to keep ears dry by keeping a ball of cotton coated with petroleum jelly in the ear & to change cotton ball daily Instruct the client to report excessive ear drainage to the physician

CHRONIC OTITIS MEDIA

- a chronic infective, inflammatory, or allergic response involving the structure of the middle ear - surgical treatment is necessary to restore hearing - the type of surgery can vary & include a simple reconstruction of the tympanic membrane, a myringotomy, or replacement of the ossicles within the middle ear

TYMPANOPLASTY
- a reconstruction of the middle ear may be attempted to improve conductive hearing loss

chronic OTITIS MEDIA

PRE-OP NURSING CARE
Administer antibiotic eye drops as Rx Clear the ear of debris as Rx & irrigate ear with a solution of equal parts of vinegar & sterile water as Rx - to restore normal pH of the ear Instruct to avoid persons with URTI Instruct client to obtain adequate rest, eat a balanced diet & drink adequate fluids Instruct in DBE & coughing but forceful coughing avoided. - increases pressure in the middle ear esp. post-op

chronic OTITIS MEDIA

POST-OP NURSING CARE
Inform client that initial hearing after surgery is diminished & hearing will improve after the ear canal packing is removed Keep dressing clean & dry Keep client flat with operative ear up for at least 12 hours Administer antibiotics as Rx Instruct the client that he/she may return to work in approximately 3 weeks post-op

MASTOIDITIS
- may be acute or chronic & results from untreated or inadequately treated chronic or acute otitis media
- the pain is not relieved by myringotomy

ASSESSMENT
Swelling behind the ear & pain with minimal movement of the head
Cellulitis on the skin or external scalp over the mastoid process A reddened, dull, thick, immobile tympanic membrane with or without perforation Tender & enlarged post-auricular lymph nodes Low-grade fever Anorexia

MASTOIDITIS
PRE-OP NURSING CARE
Prepare the client for surgical removal of the infected material Monitor for complications SIMLPLE OR MODIFIED RADICAL MASTOIDECTOMY WITH TYMPANOPLASTY is the common treatment Once tissue that is infected is removed, tympanoplasty is performed to reconstruct the ossicles & the tympanic membranes, in an attempt to restore normal hearing

MASTOIDITIS
COMPLICATIONS
Damage to the abducens & facial cranial nerves
Damage exhibited by inability to look laterally (cranial nerve VI) & a drooping of the mouth on the affected side (cranial nerve VII) Meningitis Chronic purulent otitis media Wound infections Vertigo, if the infection spreads into the labyrinth

MASTOIDITIS
POST-OP NURSING CARE
Monitor for dizziness Monitor for signs of meningitis as evidenced by a stiff neck & vomiting Prepare for wound dressing change 24 hrs post-op Monitor the surgical incision for edema, drainage, & redness Position the client flat with the operative side up Restrict the client to bed with bedside commode privileges for 24 hrs as Rx Assist the client with getting out of bed - to prevent falling or injuries from dizziness With reconstruction of the ossicles via a graft, precautions are taken to prevent dislodging of the graft

OTOSCLEROSIS
- disease of the labyrinthine capsule of the middle ear that results in a bony overgrowth of the tissue surrounding the ossicles - causes the devt of irregular areas of new bone formation & causes fixation of the bones - stapes fixation leads to CONDUCTIVE HEARING LOSS - if the disease involves the inner ear, SENSORINEURAL HEARING LOSS is present - it is not uncommon to have bilateral involvement, although hearing loss may be worse in one ear - cause is unknown, although has familial tendency - nonsurgical intervention promotes the improvement of hearing through amplification - surgical intervention involves removal of the bony growth that is causing the hearing loss - a PARTIAL STAPEDECTOMY or COMPLETE STAPEDECTOMY WITH PROSTHESIS (FENESTRATION) may be surgically performed

OTOSCLEROSIS
ASSESSMENT
Slowly progressing conductive hearing loss
Bilateral hearing loss

A ringing or roaring type of constant tinnitus Loud sounds heard in the ear when chewing Pinkish discoloration (SCHWARTZES SIGN) of the tympanic membrane - indicates vascular changes in the ear (-) Rinne test Weber test shows lateralization of the sound to the ear with the most conductive hearing loss

FENESTRATION
- removal of the stapes with a small hole drilled in the footplate & a prosthesis is connected between the incus & footplate
- sounds cause the prosthesis to vibrate in the same manner as the stapes

COMPLICATIONS
Complete hearing loss

Prolonged vertigo
Infection Facial nerve damage

FENESTRATION
PRE-OP NURSING CARE
Instruct the client in measures to prevent middle ear or external ear infections Instruct the client to avoid excessive nose blowing Instruct not to clean the ear canal with cotton-tipped applicators Instruct the client to remove the hearing aid 2 weeks before surgery to ensure the integration of local tissue

FENESTRATION
POST-OP NURSING CARE
Inform the client that hearing is initially worse after the surgical procedure & no - due to swelling Inform the client that the Gelfoam ear packing interferes with hearing but is used to decrease bleeding Assist with ambulating during the first 1-2 days after surgery Provide side rails when the client is in bed Administer antibiotics & antivertiginous & pain meds as Rx Assess for facial nerve damage, weakness, changes in taste sensation, vertigo, nausea & vomiting Instruct to move head slowly when changing positions - to prevent vertigo Instruct to avoid showering & getting the head & wound wet Instruct to refrain from using small objects to clean the external ear canal Instruct to avoid rapid, extreme changes in pressure caused by quick head movements, sneezing,nose blowing, straining & changes in altitude Instruct to avoid changes in the middle ear pressure - it could dislodge the graft prosthesis
noticeable improvement in hearing may occur for as long as 6 weeks

LABYRINTHITIS
- infection of the labyrinth that occurs as a complication of acute or chronic otitis media

ASSESSMENT
Hearing loss that may be permanent on the affected side Tinnitus Spontaneous nystagmus to the affected side Vertigo Nausea & vomiting

LABYRINTHITIS
PRE-OP NURSING CARE
Monitor for signs of meningitis, the most common complication - evidenced by headache, stiff neck lethargy

Administer systemic antibiotics as Rx Advise client to rest in bed in a darkened room

Administer antiemetics & antivertiginous medications as Rx Instruct the client that the vertigo subsides as inflammation resolves Instruct the client that balance problems that persist may require gait training through physical therapy

MENIERES SYNDROME
- a syndrome also called

- refers to dilation of the endolympathic system by either overproduction or decreased reabsorption of endolymphatic fluid - characterized by tinnitus, unilateral sensorineural hearing loss, & vertigo - symptoms occur in attacks & last for several days, & the client becomes totally incapacitated - initial hearing loss is reversible, but as the frequency of attacks continues, hearing loss becomes permanent - repeated damage to the cochlea caused by increased fluid pressure leads to the permanent hearing loss

HYDROPS

ENDOLYMPHATIC

MENIERES SYNDROME
CAUSES
Any factor that increases endolymphatic secretion in the labyrinth

Viral & bacterial infections

Allergic reactions Biochemical disturbances Vascular disturbances producing changes in the microcirculation in the labyrinth

MENIERES SYNDROME
ASSESSMENT
Feelings of fullness in the ear
Tinnitus, as a continuous low-pitched roar or humming sound - is present most of the time but worsens just before & during severe attacks Hearing loss is worse during an attack Vertigo - periods of whirling which might cause the client to fall to the ground - sometimes so intense that even when lying down, the client holds the bed or ground in an attempt to prevent the whirling Nausea & vomiting Nystagmus Severe headaches

MENIERES SYNDROME
NON-SURGICAL MANAGEMENT
Preventing injury during vertigo attacks Providing bed rest in a quiet environment Provide assistance with walking Instruct the client to move the head slowly - to prevent worsening of vertigo Initiate Na & fluid restrictions as Rx Instruct to avoid smoking Administer Nicotinic acid (Niacin) as Rx - promote vasodilating effect Administer antihistamines as Rx - reduce the production of histamine & reduces inflammation Administer antiemetics as Rx Administer tranquilizers & sedatives as Rx - to calm client & allow rest, control the vertigo, N&V

MENIERES SYNDROME
SURGICAL MANAGEMENT
- performed when medical therapy is ineffective & the functional level of the client has decreased significantly

ENDOLYMPHATIC DRAINAGE & INSERTION OF THE SHUNT

- may be performed early in the course of the disease to assist with the drainage of excess fluids

RESECTION OF THE VESTIBULAR NERVE

LABYRINTHECTOMY
- removal of the labyrinth may be performed

MENIERES SYNDROME
POST-OP NURSING CARE
Assess packing & dressing on the ear Speak to the client on the side of the unaffected ear Perform neurological assessments Maintain side rails Assist with ambulating Encourage the use of bedside commode Administer antivertiginous& antiemetic medications as Rx

acoustic neuroma
- a benign tumor of the vestibular or acoustic nerve - the tumor may cause damage to hearing & to facial movements & sensations - treatment includes surgical removal of the tumor via craniotomy - care is taken to preserve the function of the facial nerve - the tumor rarely recurs after surgical removal - post-op nursing care is similar to post-op craniotomy care

ASSESSMENT
Symptoms usually begin with tinnitus & progress to gradual sensorineural hearing loss As tumors enlarges, damage to adjacent cranial nerves occurs

TRAUMA
- the tympanic membrane has a limited stretching ability & gives way under high pressure - foreign objects placed in the external canal may exert pressure on the tympanic membrane & cause perforation - if the object continues thorough the canal, the bony structures of stapes, incus & malleus may be damaged - a blunt injury to the basal skull & ear can damage the middle ear structures through fractures extending to the middle ear - excessive blowing & rapid changes of pressure that occur with non-pressurized air flights can increase pressure in the middle ear - depending on the damage to the ossicles, hearing loss may or may not return

TRAUMA
NURSING CARE
Tympanic perforations usually heal within 24 hours

Surgical reconstruction of the ossicles & tympanic membrane through tympanoplasty or myringotomy may be performed to improve hearing

CERUMEN & FOREIGN BODIES

CERUMEN/EAR WAX
- the most common cause of impacted canals

FOREIGN BODIES
- can include vegetables, beads, pencil erasers & insects

ASSESSMENT
Sensation of fullness in the ear with or without hearing loss
Pain, itching or bleeding

CERUMEN
NURSING CARE
Removal of the wax by irrigation is a slow process Irrigation is C/I in clients with a hx of tympanic membrane perforation To soften cerumen, add 3 gtts of glycerin to the ear @ hs & 3 gtts of hydrogen peroxide BID After several days the ear is irrigated 50-70 ml of solution is the maximal amount a client can tolerate during an irrigation sitting

FOREIGN BODIES
NURSING CARE
If the foreign matter is vegetable, irrigation is used with care - the material expends with hydration Insects are killed before removal unless they can be coaxed out by flashlight or a humming noise Mineral oil or alcohol is instilled to suffocate the insect which is then removed with ear forceps Use small ear forceps to remove the object & avoid pushing the object farther into the canal & damaging the tympanic membrane

OPTHALMIC AND OTIC MEDICATIONS

INSTALLATION OF EYE DROPS

EYE DROPS
Wash hands Put on gloves Check the name, strength, & expiration date of the medication Instruct the client to tilt the head backward, open the eyes & look up Pull the lower lid down against the cheekbone Hold the bottle, gently rest the wrist of the hand on the clients cheek Squeeze the bottle gently to allow the drop to fall into the conjunctival sac Instruct the client to close the eyes gently & not to squeeze the eyes shut Wait 3-5 minutes before instilling another drop, if more than 1 is Rx - to promote maximal absorption of the medication Dont allow the medication bottle, dropper, or applicator to come in contact with the eyeball

Installation of eye medications

EYE OINTMENTS
Hold the ointment tube near, but not touching, the eye or eyelashes Squeeze a thin ribbon of ointment along the lining of the lower conjunctival sac from the inner to the outer canthus Instruct the client to close the eyes gently Instruct the client that vision may be blurred by the ointment

MYDRIATICS, Cycloplegic & anticholinergic medications MYDRIATICS

- dilate the pupils (mydriasis)

CYCLOPLEGIA
- relax the ciliary muscles

ANTICHOLINERGICS
- block responses of the sphincter muscle in the ciliary body, producing mydriasis

MYDRIATICS, Cycloplegic & anticholinergic medications

- used pre-op or for eye examinations to produce mydriasis - C/I in clients with glaucoma because of the risk of increased IOP - Mydriatics are C/I in cardiac dysrhythmias & cerebral atherosclerosis & should be used with caution in the elderly and in clients with prostatic hypertrophy, diabetes mellitus or parkinsonism

MYDRIATICS & Cycloplegic eye medications

EXAMPLES
Atropine sulfate (Isopto-Atropine, Ocu-Tropine, Atropair, Atropisol)

Scopolamine hydrobromide (Isopto-Hyoscine) Cyclopentolate hydrochloride (Cyclogyl, AK-Pentolate, Pentolair) Homotropine hydrobromide (Isopto Homatrine, AK-Homatropine, Spectro-Homatrine) Tropicamide (Mydriacyl, I-Picamide, Tropicacyl) Phenylephrine hydrochloride (AK-Dilate, Dilatair, Mydfrin, Ocu-Phrin)

MYDRIATICS, Cycloplegic & anticholinergic medications

SIDE EFFECTS
Tachycardia Photophobia Conjunctivitis Dermatitis

ATROPINE TOXICITY
Dry mouth

Blurred vision Photophobia Tachycardia Fever Urinary retention Constipation Headache, brow pain Confusion Hallucinations, delirium Coma Worsening of narrow-angled glaucoma

SYSTEMIC REACTIONS OF ANTICHOLINERGICS

Dry mouth & skin Fever Thirst Confusion Hyperactivity

ALPHA-ADRENERGIC BLOCKER
- example Dapiprazole hydrochoride (Rev-Eyes) - used to counteract mydriasis

MYDRIATICS, Cycloplegic & anticholinergic medications

NURSING CARE
Monitor for allergic reactions Assess for risk of injury Assess for constipation & urinary retention Instruct the client that a burning sensation may occur on installation Instruct the client not to drive or operate machine for 24 hrs after installation of the medication unless otherwise directed by the physician Instruct the client to wear sunglasses until the effects of the medication wear off Instruct to notify MD if blurring of vision, loss of sight, difficulty in breathing, sweating or flushing occurs Instruct the client to report eye pain to the physician

ANTI-INFECTIVE EYE MEDICATIONS

- Kill or inhibit the growth of bacteria, fungi, & viruses

SIDE EFFECTS
Superinfection Global irritation

NURSING CARE
Assess for risk of injury

Instruct the client in how to apply the eye medication

Instruct the client to continue treatment as Rx Instruct the client to wash hands thoroughly & frequently Advise the client that if improvement does not occur, notify the MD

ANTI-INFECTIVE EYE MEDICATIONS

ANTIBACTERIAL
Chloramphenicol (Chloromycetin, Chloroptic) Ciprofloxacin hydrochloride (Cipro) Erythromycin (Ilotycin)

Gentamicin sulfate (Garamycin, Genoptic)

Norfloxacin (Chibroxin) Tobramycin (Nebcin, Tobrex) Silver nitrate 1%

ANTIFUNGAL
Natamycin (Natacyn Opthalmic)

ANTIVIRAL
Idoxuridine (Herplex-Liquifilm) Trifluridine (Viroptic) Vidarabine (Vira-A Opthalmic)

ANTI-INFLAMMATORY EYE MEDICATIONS

- Control inflammation, thereby reducing vision loss & scarring - Used for uveitis, allergic conditions, & inflammation of the conjunctiva, cornea, & lids

SIDE EFFECTS
Cataracts Increased IOP Impaired healing Masking S/S of infection

NURSING CARE
Assess for risk of injury Instruct the client in how to apply the eye medication Instruct the client to continue treatment as Rx Instruct the client to wash hands thoroughly & frequently Advise the client that if improvement does not occur, notify the MD Note that dexamethasone (Maxidex) should not be used for eye abrasions & wounds

ANTI-INFLAMMATORY EYE MEDICATIONS EXAMPLES

Dexamethasone (Maxidex) Diclofenac (Voltaren) Flurbiprofen Na (Ocufen) Suprofen (Profenal) Ketorolac tromethamine (Acular)

Prednisone acetate (Predforte, Econopred)

Prednisolone Na phosphate (AK-Pred, Inflamase) Rimaxolone (Vexol)

TOPICAL ANESTHETICS FOR THE EYE

- Produce corneal anesthesia - Used for anesthesia for eye examinations, for surgery, or to remove foreign bodies from the eye

SIDE EFFECTS
Temporary stinging or burning of the eye Temporary loss of corneal reflex

NURSING CARE
Assess for risk of injury Note that the medications should not be given to the client for home use & are not to be self-administered by the client Note that the blink reflex is temporarily lost & that the corneal epithelium needs to be protected Provide an eye patch to protect the eye from injury until the corneal reflex returns

TOPICAL ANESTHETICS FOR THE EYE EXAMPLES

Proparacaine HCl (Ophthaine, Opthenic)
Tetracaine HCl (Pontocaine)

EYE LUBRICANTS
- Replace tears or add moisture to the eyes

- Moisten contact lenses or an artificial eye

- Protect the eyes during surgery or diagnostic procedures - Used for keratitis, during anesthesia or in a disorder that results in unconsciousness or decreased blinking

SIDE EFFECTS
Burning in installation Discomfort or pain in installation

NURSING CARE

Inform the client that burning may occur on installation Be alert to allergic responses to the preservatives in the lubricants

EYE LUBRICANTS
EXAMPLES
Hydroxypropyl methylcellulose (Lacril, Isopto Plain) Petroleum-based ointment (Artificial Tears, Liquifilm Tears)

MIOTICS
- reduce IOP by constricting the pupil & contracting the ciliary muscle,
thereby increasing the blood flow to the retina & decreasing retinal damage & loss of vision - open the anterior chamber angle & increase the outflow of aqueous humor - used for chronic open-angle glaucoma or acute & chronic closed-angle glaucoma - used to achieve miosis during eye surgery - C/I in clients with retinal detachment, adhesions between the iris & lens, or inflammatory diseases - used with caution in clients with asthma, hypertension, corneal abrasion,hyperthyroidism, coronary vascular disease, urinary tract obstruction, GI obstruction, ulcer disease, parkinsonism, or bradycardia

MIOTICS
MIOTIC CHOLINERGIC MEDS
- reduce IOP by mimicking the action of acetylcholine

MIOTIC ACETYLCHOLINE INHIBITORS MEDS

- reduce IOP by inhibiting the action of cholinesterase

MIOTICS
SIDE EFFECTS
Myopia Headache Eye pain

SYSTEMIC EFFECTS
Flushing Diaphoresis GI upset & diarrhea Frequent urination Increased salivation Muscle weakness Respiratory difficulty

Decreased vision in poor light

Local irritation

TOXICITY
Vertigo & syncope Bradycardia Hypotension Cardiac dysrhythmias Tremors Seizures

MIOTICS
EXAMPLES
Acethylcholine Cl (Miochol) Carbachol (Miostat) Pilocarpine HCl (Isopto Carpine, Pilocar) Pilocarpine nitrate (Pilofrin, Liquifilm, Pilagan) Echothiophate iodide (Phospholine iodide) Demecarium bromide (Humorsol) Isoflurophate (Floropryl)

MIOTICS
NURSING CARE
Assess V/S & risk of injury Assess the client for the degree of diminished vision Monitor S/E & toxic effects Monitor for postural hypotension & instruct the client to change positions slowly Assess breath sounds for rales & rhonchi - cholinergic meds cause bronchospasms & increased bronchial secretions Maintain oral hygiene - due to increased salivation Have Atropine sulfate available as antidote for Pilocarpine Instruct the client regarding the correct administration of eye meds Instruct the client not to stop the meds suddenly

Instruct to avoid activities such as driving while vision is impaired

Instruct clients with glaucoma to read labels on OTC meds & to avoid Atropine-like meds - Atropine increase IOP

OCUSERT SYSTEM
Its a thin eye wafer (disk) impregnated with time-release Pilocarpine Devised to overcome the frequent application of Pilocarpine Placed in the upper or lower cul-de-sac of the eye Pilocarpine is released over 1 wk & disk is replaced every 7 days Drawbacks of its use include sudden leakage of Pilocarpine, migration of the system over the cornea, & unnoticed loss of the system

NURSING CARE

Assess the clients ability to insert the medication disk

Store the medication in the refrigerator Instruct the client to discard damage or contaminated disks Inform the client that temporary stinging is expected but to notify MD if blurred vision or brow pain occurs Instruct the client to check for the presence of the disk in the conjunctival sac daily qHS & upon arising Since vision may change in the first few hours after the eye system is inserted, instruct the client to replace the disk at bedtime

BETA-ADRENERGIC BLOCKING EYE MEDICATIONS

- Reduce IOP by decreasing sympathetic impulses & decreasing aqueous humor production without affecting accommodation or pupil size - Used to treat chronic open-angle glaucoma - C/I in the client with asthma - systemic absorption can cause increased airway resistance - Used with caution in the client receiving oral beta-blockers

SIDE EFFECTS
Ocular irritation

Visual disturbances
Bradycardia Hypotension Bronchospasm

BETA-ADRENERGIC BLOCKING EYE MEDICATIONS

EXAMPLES
Betaxolol HCl (Betoptic) Carteolol HCl (Ocupress) Levobunolol HCl (Betagan) Metipranolol (Optipranolol) Timolol maleate (Timoptic)

BETA-ADRENERGIC BLOCKING EYE MEDICATIONS

NURSING CARE
Monitor V/S before administering medication esp. BP & PR If the pulse is below 60 or if systolic BP is below 90 mm Hg, withhold the medication & contact MD Monitor for shortness of breath and I&O Assess for risk of injury

Instruct the client to notify MD if shortness of breath occurs

Instruct not to D/C medication abruptly Instruct to change positions slowly to avoid orthostatic hypotension Instruct to avoid hazardous activities

Instruct to avoid OTC meds without the MDs approval

ADRENERGIC EYE MEDICATIONS

- Decrease the production of aqueous humor & lead to a decrease in IOP - Used to treat glaucoma

ADRENERGIC MEDICATIONS
Apraclonidine HCl (Iopidine) Brimonidine tartrate (Alphagen)

Dipivefrin HCl (Propine)

Epinephrine borate (Epinal, Eppy) Epinephrine HCl (Epifrin, Glaucon)

CARBONIC ANHYDRASE MEDICATIONS

- Interfere with the production of carbonic acid which leads to decreased aqueous humor formation & decreased IOP
- Used for long-term treatment of open-angle glaucoma - C/I in the client allergic to sulfonamides

SIDE EFFECTS
Appetite loss GI upset Paresthesias in the fingers, toes & face Polyuria Hypokalemia Renal calculi Photosensitivity Lethargy & drowsiness Depression

CARBONIC ANHYDRASE MEDICATIONS

NURSING CARE
Monitor V/S Assess visual acuity Assess for risk of injury Monitor I&O Monitor weight Maintain oral hygiene Monitor for side effects such as lethargy, anorexia, drowsiness, polyuria, nausea, & vomiting Monitor electrolytes for hypokalemia Increase fluid intake unless C/I Advise the client to avoid prolonged exposure to sunlight Encourage the client to use artificial tears for dry eyes Instruct not to D/C the medication abruptly Instruct to avoid hazardous activities while vision is impaired

OSMOTIC MEDICATIONS
- Lower IOP - Used in emergency treatment of acute closed-angle glaucoma

- Used pre-op & post-op to decrease vitreous humor volume

SIDE EFFECTS
Heache Nausea, vomiting, diarrhea Disorientation Electrolyte imbalance

NURSING CARE
Monitor weight and I&O Monitor electrolytes

Assess V/S, visual acuity & risk for injury

Increase fluid intake unless C/I Monitor for changes in level of orientation

OSMOTIC EYE MEDICATIONS

EXAMPLES
Glycerin (Glyrol, Osmoglyn) Mannitol (Osmitrol) Urea (Ureaphil)

Otic MEDICATION ADMINISTRATION

ADMINISTERING EAR DROPS
ADULT
Pull the pinna up & back to straighten the external canal to instill ear drops

CHILD
Pull the pinna down & back for infants & children younger than 3 years of age Pull the pinna up & back for children for children more than 3 years

Otic MEDICATION ADMINISTRATION

IRRIGATION OF THE EAR
Irrigation of the ear needs to be prescribed by MD
Ensure that there is direct visualization of the tympanic membrane Warm irrigating solution to 100 F - solutions not close to the clients body temp will cause ear injury, nausea & vertigo Irrigation must be done gently to avoid damage to the eardrum When irrigating, dont direct irrigating solution directly toward the eardrum If perforation of the eardrum is suspected, irrigation is not done

MEDICATIONS THAT AFFECT HEARING

ANTIBIOTICS
Amikacin (Amikin)

Chloramphenicol
- Chloromycetin - Chloroptic - Ophthoclor Erythromycin - E-Mycin - ERYC - Ery-Tab - PCE Dispertabs - Ilotycin

DIURETICS
Acetazolamide (Diamox) Furosemide (Lasix) Ethacrynic acid (Edecrine)

OTHERS
Cisplatin (Platinol, Platinol-AQ) Nitrogen mustard Quinine (Quinamn) Quinidine - Cardioquin - Quinaglute - Quindex

Gentamicin (Garamycin)
Streptomycin sulfate (Streptomycin) Tobramycin sulfate (Nebcin) Vancomycin (Vancocin)

ANTI-INFECTIVE MEDICATIONS
- Kill or inhibit the growth of bacteria - Used for otitis media or otitis externa

- C/I if a prior hypersensitivity exists

SIDE EFFECTS
Overgrowth of non-susceptible organisms

NURSING CARE
Assess V/S Assess for allergies & pain Monitor for nephrotoxicity Instruct the client to report dizziness, fatigue, fever, or sore throat - indicative of superimposed infection Instruct to complete the entire course of medication Instruct to keep the ear canals dry

ANTI-INFECTIVE MEDICATIONS
EXAMPLES
Amoxicillin (Amoxil)

Ampicillin trihydrate (Polycillin) Cefaclor (Ceclor) Clindamycin HCl (Cleocin) Trimethoprim (TMP) & Sulfamethaxazole (SMZ) - Bactrim, Cotrim, Septra Erythromycin (Ilotycin, E-Mycin) Penicillin V potassium (Pen V) Loracarbef (Lorabid) Clarithromycin (Biaxin) Polymyxin B sulfate (Aerosporin) Tetracycline HCl (Achromycin) Acetic acid and Aluminum acetate (Otic Domeboro)

ANTI-HISTAMINES & DECONGESTANTS

- Produce vasoconstriction - Stimulate the receptors of the respiratory mucosa - Reduce respiratory tissue hyperemia & edema to open obstructed eustachian tubes - Used for acute otitis media

SIDE EFFECTS
Drowsiness Blurred vision Dry mucous membranes

NURSING CARE
Inform the client that drowsiness, blurred vision, & dry mouth may occur Instruct the client to increase fluid intake unless C/I & to suck on hard candy to alleviate dry mouth Instruct the client to avoid hazardous activities if drowsiness occurs

ANTI-HISTAMINES & DECONGESTANTS

EXAMPLES
Tripolidine & pseudoephedrine (Actifed) Naphazoline HCl (Allerest, Albalon) Chlorpheniramine (Chlor-Trimeton, Teldrin) Brompheniramine (Bromphen, Dimetane) Terfenadine (Seldane) Clemastine (Tavist) Cetirizine (Zyrtec) Astemizole (Hismanal)

LOCAL ANESTHETICS
- Block nerve conduction at or near the application site to control pain - Used for pain associated with ear infections

MEDICATION : Benzocaine (Americaine Otic; Tympagesic) SIDE EFFECTS

Allergic reaction Irritation

NURSING CARE
Monitor for effectiveness if used for pain relief Assess for irritation or allergic reaction

CERUMINOLYTIC MEDICATIONS
- Emulsify & loosen cerumen deposits - Used to loosen & remove impacted ear wax from the ear canal

SIDE EFFECTS
Irritation Redness or swelling of the ear canal

NURSING CARE
Instruct the client not to use drops more often than prescribed Moisten a cotton plug with medication before insertion Keep the container tightly closed & away from moisture Avoid touching the ear with the dropper 30 minutes after installation, gently irrigate the ear as Rx with warm water using a rubber bulb ear syringe Irrigation may be done with hydrogen peroxide soln as Rx - to flush cerumen deposits out of the ear canal For chromic cerumen impaction, 1-2 gtts of mineral oil will soften the wax Instruct the client to notify MD if redness, pain or swelling persists

CERUMINOLYTIC MEDICATIONS
EXAMPLES
Carbamide peroxide (Debrox) Boric acid (Ear-Dry) Trolamine polypeptide oleate-condensate - Cerumenex