For infants and children younger than 3 years, pull the lobe back and down. (From Lilley, L., Harrington, S., & Snyder, J. .Pharmacology and the nursing process [4thed.]. St. Louis: Mosby.)
FIG. 36-2 Location of various tonsillar masses. (From Hockenberry, M., Wilson, D., & Winkelstein, M. . Wong's essentials of pediatricnursing [7th ed.]. St. Louis: Mosby.)
The cloudy appearance of a lens affected by cataract. (From Black, J., & Hawks, J., . Medical-surgical nursing: Clinical management for positive outcomes [7th ed.]. Philadelphia: W.B. Saunders. Courtesy of Ophthalmic Photography at the Universityof Michigan, W.K. Kellogg EyeCenter, Ann Arbor, MI.)
The scleral buckling procedure for repair of retinal detachment. (From Ignatavicius, D., & Workman, M. .Medical surgical nursing: Critical thinking for collaborative care [5th ed.]. Philadelphia: W.B. Saunders.)
Eye, ear, and throat disorders
Eye, Ear, and Throat Disorders
I. STRABISMUSA. Description 1. Called “squint” or “lazy eye” 2. Condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles 3. Most often results from muscle imbalance or paralysis of extraocular muscles but also may result from conditions such as a brain tumor, myasthenia gravis, or infection 4. Normal in the young infant but should not be present after about age 4 months
B. Assessment1. Amblyopia (reduced visual acuity) if not treated early2. Permanent loss of vision if not treated early3. Loss of binocular vision4. Impairment of depth perception5. Frequent headaches6. Squinting or tilting of the head to see
C. Interventions1. Corrective lenses may be indicated.2. Instruct the parents regarding patching (occlusion therapy) of the “good” eye to strengthen the weak eye.3. Injection of botulinum toxin (Botox) may be prescribed (injected into the eye muscle) as a nonsurgical intervention (treatment produces temporary paralysis to allow the muscles opposite the paralyzed muscle to straighten the eye).4. Inform the parents that the injection of botulinum toxin wears off in about 2 months and, if successful, correction will occur.5. Prepare for surgery to realign the weak muscles as prescribed if nonsurgical interventions are unsuccessful; this is performed before the age of 2 years.6. Instruct the parents about the need for follow-up visits.
II. CONJUNCTIVITISA. Description 1. Also is known as “pinkeye”; is an inflammation of the conjunctiva 2. Conjunctivitis usually is caused by allergy, infection, or trauma. 3. Bacterial or viral conjunctivitis is extremely contagious. 4. Chlamydial conjunctivitis is rare in older children and, if diagnosed in a child who is not sexually active, the child should be assessed for possible sexual abuse.
B. Assessment1. Itching, burning, or scratchy eyelids2. Redness3. Edema4. Discharge
C. Interventions1. Instruct in infection control measures such as good hand washing and not sharing towels and washcloths.2. Administer antibiotic or antiviral eye drops or ointment as prescribed if infection is present.3. Administer antihistamines as prescribed if an allergy is present.4. Instruct the child and parents about the administration of the prescribed medications.5. Instruct the parents that the child should be kept home from school or day care until antibiotic eye drops have been administered for 24 hours.6. Instruct about the use of cool compresses to lessen irritation and wearing dark glasses for photophobia.7. Instruct the child to avoid rubbing the eye to prevent injury.8. Instruct the child who is wearing contact lenses to discontinue wearing them and to obtain new lenses to eliminate the chance of reinfection.9. Instruct the adolescent that eye makeup should be discarded and replaced.
III. OTITIS MEDIAA. Description 1. Otitis media is an inflammatory disorder usually caused by an infection of the middle ear occurring as a result of a blocked eustachian tube, which prevents normal drainage. 2. Otitis media is a common complication of an acute respiratory infection. 3. Infants and children are more prone to otitis media because their eustachian tubes are shorter, wider, and straighter.
B. Assessment1. Fever2. Irritability and restlessness3. Loss of appetite4. Rolling of head from side to side5. Pulling on or rubbing the ear6. Earache or pain7. Signs of hearing loss8. Purulent ear drainage9. Red, opaque, bulging, or retracting tympanic membrane
C. Interventions1. Encourage fluid intake.2. Teach the parents to feed infants in upright position, to prevent reflux.3. Instruct the child to avoid chewing as much as possible during the acute period because chewing increases pain.4. Provide local heat and have the child lie with the affected ear down.5. Instruct the parents in the appropriate procedure to clean drainage from the ear with sterile cotton swabs.6. Instruct the parents in the administration of analgesics or antipyretics such as acetaminophen (Tylenol) to decrease fever and pain.7. Instruct the parents in the administration of the prescribed antibiotics, emphasizing that the 10- to 14-day period is necessary to eradicate infective organisms.8. Instruct the parents that screening for hearing loss may be necessary.9. Instruct the parents about the procedure for administering ear medications.
Administration of Medications• In a child younger than age 3, pull the lobe down and back.• In a child older than 3 years, pull the pinna up and back.
D. Myringotomy1. Description: Insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated
2. Postoperative interventionsa. Instruct the parents and child to keep the ears dry.b. The client should wear earplugs while bathing, shampooing, and swimming,c. Diving and submerging under water are not allowed.d. Instruct the parents that if the tubes fall out, it is not an emergency, but the physician should be notified.e. Parents can administer an analgesic such as acetaminophen (Tylenol) to relieve discomfort following insertion of tympanoplasty tubes.f. Parents should be taught that the child should not blow his or her nose for 7 to 10 days after surgery.
IV. TONSILLECTOMY AND ADENOIDECTOMYA. Description 1. Tonsillitis refers to inflammation and infection of the tonsils (Fig. 36-2). 2. Adenoiditis refers to inflammation and infection of the adenoids. 5. Fever 6. Cough 7. Enlarged adenoids may cause nasal quality of speech, mouth breathing, hearing difficulty, snoring, and/or obstructive sleep apnea.
C. Preoperative interventions1. Assess for signs of active infection.2. Assess bleeding and clotting studies because the throat is vascular.3. Prepare the child for a sore throat postoperatively, and inform the child that he or she will need to drink liquids.4. Assess for any loose teeth to decrease the risk of aspiration during surgery.
D. Interventions postoperatively1. Position the child prone or side-lying to facilitate drainage.2. Have suction equipment available, but do not suction unless there is an airway obstruction.3. Monitor for signs of hemorrhage (frequent swallowing may indicate hemorrhage); if hemorrhage occurs, turn the child to the side and notify the physician.4. Discourage coughing or clearing the throat.5. Provide clear, cool, noncitrus and noncarbonated fluids.6. Avoid milk products initially because they will coat the throat.7. Avoid red liquids, which simulate the appearance of blood if the child vomits.8. Do not give the child any straws, forks, or sharp objects that can be put into the mouth.9. Administer acetaminophen (Tylenol) for sore throat as prescribed.10. Instruct the parents to notify the physician if bleeding, persistent earache, or fever occurs.11. Instruct the parents to keep the child away from crowds until healing has occurred.
V. EPISTAXIS (NOSEBLEEDS)A. Description 1. The nose, especially the septum, is a highly vascular structure, and bleeding usually results from direct trauma, foreign bodies, and nose picking, or from mucosal inflammation. 2. Recurrent epistaxis and severe bleeding may indicate an underlying disease.
B. Interventions1. Have the child sit up and lean forward (not lying down).2. Apply continuous pressure to nose with the thumb and forefinger for at least 10 minutes.3. Insert cotton or wadded tissue into each nostril, and apply ice or a cold cloth to the bridge of the nose if bleeding persists.4. Keep the child calm and quiet.5. If bleeding cannot be controlled, packing or cauterization of the bleeding vessel may be prescribed.
Refractive Errors1. Description a. Refraction is the bending of light rays; any problem associated with eye length or refraction can lead to refractive errors. b. Myopia (nearsightedness): Refractive ability of the eye is too strong for the eye length; images are bent and fall in front of, not on, the retina. c. Hyperopia (farsightedness): Refractive ability of the eye is too weak; images are focused behind the retina. d. Presbyopia: Loss of lens elasticity because of aging; less able to focus the eye for close work and images fall behind the retina. e. Astigmatism: Occurs because of the irregular curvature of the cornea; image does not focus on the retina.
2. Assessmenta. Refractive errors are diagnosed through aprocess called refraction.b. The client views an eye chart while variouslenses ofdifferent strengths are systematicallyplaced in front of the eye and is askedwhether the lenses sharpen or worsen thevision.
3. Nonsurgical interventions: Eyeglasses or contact lenses4. Surgical interventions a. Radial keratotomy: Incisions are made through the peripheral cornea to flatten the cornea, which allows the image to be focused closer to the retina; used to treat myopia.
Surgical interventions cont…b. Photorefractive keratotomy: A laser beam is used to remove small portions of the corneal surface to reshape the cornea to focus an image properly on the retina; used to treat myopia and astigmatism.c. Laser-assisted in-situ keratomileusis (LASIK): The superficial layers of the cornea are lifted as a flap, a laser reshapes the deeper corneal layers, and then the corneal flap is replaced; used to treat hyperopia, myopia, and astigmatism.d. Intacs corneal ring: The shape of the cornea is changed by placing a flexible ring in the outer edges of the cornea; used to treat myopia.
C. Legally blind1. Description: The best visual acuity with corrective lenses in the better eye of 20/200 or less or visual acuity of less than 20 degrees of the visual field in the better eye
2. Interventionsa. When speaking to the client who has limited sight or is blind, the nurse uses a normal tone of voice.b. Alert the client when approaching.c. Orient the client to the environment.d. Use a focal point and provide further orientation to the environment from that focal point.e. Allow the client to touch objects in the room.f. Use the clock placement of foods on the meal tray to orient the client.g. Promote independence as much as is possible.h. Provide radios, televisions, and clocks that give the time orally, or provide a braille watch.i. 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.
Interventions cont…j. Instruct the client to remain one step behind the nurse when ambulating.k. Instruct the client in the use of the cane for the blind, which is differentiated from other canes by its straight shape and white color with red tip.l. Instruct the client that the cane is held in the dominant hand several inches off the floor.m. Instruct the client that the cane sweeps the ground where the clients foot will be placed next to determine the presence of obstacles.
D. Cataracts1. Description a. A cataract is an opacity of the lens that distorts the image projected onto the retina and that can progress to blindness. b. Causes include the aging process (senile cataracts), inherited (congenital cataracts), and injury (traumatic cataract s); cataract s also can result from another eye disease (secondary cataract s). c. Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or adversely affects his or her lifestyle.
2. Assessmenta. Blurred vision and decreased colorperception are early signsb. Diplopia, reduced visual acuity, absence ofthe red reflex, and the presence of a whitepupil are late signs. Pain or eye redness isassociated with age-related cataractformation.c. Loss of vision is gradual.
3. Interventionsa. Surgical removal of the lens, one eye at a time, isperformed.b. With extracapsular extraction the lens is lifted outwithout removing the lens capsule; the procedure may beperformed by phacoemulsification, in which the lens isbroken up by ultrasonic vibrations and extracted.c. With intracapsular extraction, the lens and capsule areremoved completely.d. A partial iridectomy may be performed with the lensextraction to prevent acute secondary glaucoma.e. A lens implantation may be performed at the time of thesurgical procedure.
4. Preoperative interventionsa. Instruct the client regarding thepostoperative measures to prevent ordecrease intraocular pressure.b. Stress to the client that care after surgeryrequires instillation of different types of eyedrops several times a day for 2 to 4 weeksc. Administer eye medicationspreoperatively, including mydriatics andcycloplegics as prescribed.
5. Postoperative interventionsa. Elevate the head of the bed 30 to 45 degrees.b. Turn the client to the back or nonoperative side.c. Maintain an eye patch as prescribed; orient the client to the environment.d. Position the clients personal belongings to the nonoperative side.e. Use side rails for safety.f. Assist with ambulation.
6. Client education• Avoid eye straining. • If lens implantation is not• Avoid rubbing or placing pressure on performed, the eye cannot the eyes. accommodate and glasses must be• Avoid rapid worn at all times. movements, straining, sneezing, coug • Cataract glasses act as magnifying hing, glasses and replace central vision• bending, vomiting, or lifting objects only. heavier than 5 lb. • Because cataract glasses• Take measures to prevent magnify, objects will appear closer; constipation. therefore, the client needs to accommodate, judge distance, and• Follow instructions for dressing climb stairs carefully. changes and prescribed eye drops • Contact lenses provide sharp visual and medications. acuity but dexterity is needed to• Wipe excess drainage or tearing with insert them. a sterile wet cotton ball from the • Contact the physician about any inner to the outer canthus. decrease in vision, severe eye• Use an eye shield at bedtime. pain, or increase in eye discharge
E. Glaucoma1. Description a. A group of ocular diseases resulting in increased intraocular pressure b. Intraocular pressure is the fluid (aqueous humor) pressure within the eye (normal intraocular pressure is 10 to 21 mm Hg). c. Increased intraocular pressure results from inadequate drainage of aqueous humor from the canal of Schlemm or overproduction of aqueous humor. d. The condition damages the optic nerve and can result in blindness. e. The gradual loss of visual fields may go unnoticed because central vision is unaffected.
2. Typesa. Acute closed-angle or narrow-angle glaucomaresults from obstruction to outflow of aqueous humor.b. Chronic closed-angle glaucoma follows an untreatedattack of acute closed-angle glaucoma.c. Chronic open-angle glaucoma results fromoverproduction or obstruction to the outflow ofaqueous humor.d. Acute glaucoma is a rapid onset of intraocularpressure higher than 50 to 70 mm Hg.e. Chronic glaucoma is a slow, progressive, gradualonset of intraocular pressure higher than 30 to 50 mmHg.
3. Assessmenta. Early signs include diminishedaccommodation and increased intraocularpressure.b. Late signs include loss of peripheralvision, decreased visual acuity not correctablewith glasses, halos around lights; headache oreye pain occurs with acute closed-angleglaucoma.
4. Interventions for acute glaucomaa. Treat acute glaucoma as a medicalemergency.b. Administer medications as prescribed tolower intraocular pressure.c. Prepare the client for peripheraliridectomy, which allows aqueous humor toflow from the posterior to the anteriorchamber.
5. Interventions for chronic glaucomaa. Instruct the client on the importance f. Instruct the client that when maximal of medications (miotics) to constrict medical therapy has failed to halt the the pupils, (carbonic anhydrase progression of visual field loss and inhibitors) to decrease the optic nerve damage, surgery will be production of aqueous humor, and b- recommended. blockers to decrease the production g. Prepare the client for trabeculoplasty of aqueous humor and intraocular as prescribed to facilitate aqueous pressure. humor drainage.b. Instruct the client of the need for h. Prepare the client for trabeculectomy lifelong medication use. as prescribed, which allows drainagec. Instruct the client to wear a Medic of aqueous humor into the Alert bracelet. conjunctival spaces by the creation ofd. Instruct the client to avoid an opening. anticholinergic medications.e. Instruct the client to report eye pain, halos around the eyes, and changes in vision to the physician.
F. Retinal detachment1. Description a. Detachment or separation of the retina from the epithelium b. Retinal detachment occurs when the layers of the retina separate because of the accumulation of fluid between them, or when both retinal layers elevate away from the choroid as a result of a tumor. c. Partial detachment becomes complete if untreated. d. When detachment becomes complete, blindness occurs.
2. Assessmenta. Flashes of lightb. Floaters or black spots (signs of bleeding)c. Increase in blurred visiond. Sense of a curtain being drawn over the eyee. Loss of a portion of the visual field
3. Immediate interventionsa. Provide bed rest.b. Cover both eyes with patches as prescribed toprevent further detachment.c. Speak to the client before approaching.d. Position the clients head as prescribed.e. Protect the client from injury.f. Avoid jerky head movements.g. Minimize eye stress.h. Prepare the client for a surgical procedure asprescribed.
4. Surgical proceduresa. Draining fluid from the subretinal space so that the retina can return to the normal positionb. Sealing retinal breaks by cryosurgery, a cold probe applied to the sclera, to stimulate an inflammatory response leading to adhesionsc. Diathermy, the use of an electrode needle and heat through the sclera, to stimulate an inflammatory responsed. Laser therapy, to stimulate an inflammatory response and seal small retinal tears before the detachment occurse. Scleral buckling, to hold the choroid and retina together with a splint until scar tissue forms, closing the tearf. Insertion of gas or silicone oil to promote reattachment; these agents float against the retina to hold it in place until healing occurs.
5. Postoperative interventionsa. Maintain eye patches as h. Administer eye medications as prescribed. prescribed. i. Assist the client with activities of daily living. j. Avoid sudden head movements or anythingb. Monitor for hemorrhage. that increases intraocular pressure.c. Prevent nausea and vomiting and k. Instruct the client to limit reading for 3 to 5 monitor for restlessness, which weeks. can cause hemorrhage l. Instruct the client to avoid squinting, straining andd. Monitor for sudden, sharp eye constipation, lifting heavy objects, and pain (notify the physician). bending from the waist.e. Encourage deep breathing but m. Instruct the client to wear dark glasses during the day and an eye patch at night. avoid coughing. n. Encourage follow-up care because of thef. Provide bed rest for 1 to 2 days as danger of recurrence or occurrence in the prescribed. other eye.g. Position the client as prescribed (positioning depends on the location of the detachment).
G. Macular degeneration1. A deterioration of the macula, the area of central vision2. Can be atrophic (age-related or dry) or exudative (wet)3. Age-related: Caused by gradual blocking of retinal capillaries leading to an ischemic and necrotic macula; rods and cones photoreceptors die.4. Exudative: Serous detachment of pigment epithelium in the macula occurs; fluid and blood collect under the macula, resulting in scar formation and visual distortion.5. Interventions are aimed at maximizing the remaining vision.
6. Assessmenta. A decline in central visionb. Blurred vision and distortion
7. Interventionsa. Initiate strategies to assist in maximizing remaining vision and maintaining independence.b. Provide referrals to community organizations.c. Laser therapy or photodynamic therapy may be prescribed to seal the leaking blood vessels in or near the macula.
Contusions1. Description a. Bleeding into the soft tissue as a result of an injury. b. A contusion causes a black eye; the discoloration disappears in about 10 days. c. Pain, photophobia, edema, and diplopia may occur.
2. Interventionsa. Place ice on the eye immediately.b. Instruct the client to receive a thorough eyeexamination.
Foreign bodies1. Description: An object such as dust or dirt that enters the eye and causes irritation
2. Interventionsa. Have the client look upward, expose the lower lid, wet a cotton-tipped applicator with sterile normal saline, gently twist the swab over the particle, and remove it.b. 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, and pull the upper lid outward and over the cotton applicator; if the particle is seen, gently twist a swab over it to remove.
Penetrating objects1. Description: An eye injury in which an object penetrates the eye
2. Interventionsa. Never remove the object because it may be holding ocular structures in place; the object must be removed by the physician.b. Cover the object with a cup.c. Do not allow the client to bend over.d. Do not place pressure on the eye.e. Client is to be seen by a physician immediately.f. X-rays and CT scans of the orbit are usually obtained.g. Magnetic resonance imaging (MRI) is contraindicated because of the possibility of metal-containing projectile movement during the procedure.
Chemical burns1. Description: An eye injury in which a caustic substance enters the eye
2. Interventionsa. Treatment should begin immediately.b. Flush the eyes at the scene of the injury with water for at least 15 to 20 minutes.c. At the scene of the injury, obtain a sample of the chemical involved.d. At the emergency room, the eye is irrigated with normal saline solution or an ophthalmic irrigation solution for at least 10 minutes.e. The solution is directed across the cornea and toward the lateral canthus.f. Prepare for visual acuity assessment.g. Apply an antibiotic ointment as prescribed.h. Cover the eye with a patch as prescribed.
A. Risk factors related to ear disorders• Aging process• Infection• Medications• Ototoxicity• Trauma• Tumors
B. Conductive hearing loss1. Description a. Conductive hearing loss occurs when sound waves are blocked to the inner ear fibers because of external or middle ear disorders. b. Disorders often can be corrected with no damage to hearingor minimal permanent hearing loss.
2. Causesa. Any inflammatory process or obstruction of the external or middle earb. Tumorsc. Otosclerosisd. A buildup of scar tissue on the ossicles from previous middle ear surgery
C. Sensorineural hearing loss1. Description a. Sensorineural hearing loss is a pathological process of the inner ear or of the sensory fibers that lead to the cerebral cortex. b. Sensorineural hearing loss is often permanent, and measures must be taken to reduce further damage or to attempt to amplify sound as a means of improving hearing to some degree.
2. Causesa. Damage to the inner f. Inherited disorders ear structures g. Metabolic andb. Damage to the eighth circulatory disorders cranial nerve h. Infectionsc. Prolonged exposure to i. Surgery loud noise j. Menières syndromed. Medications k. Diabetes mellituse. Trauma l. Myxedema
D. Mixed hearing loss1. Mixed hearing loss also is known as conductive-sensorineural hearing loss.2. Client has sensorineural and conductive hearing loss.
E. Signs of hearing loss and facilitating communication• Signs of Hearing Loss• Frequently asking others to repeat statements• Straining to hear• Turning head or leaning forward to favor one ear• Shouting in conversation• 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
Facilitation of Communication• Using written words if the client is able to • Validating with the client the understanding see, read, and write of statements made by asking the client to• Providing plenty of light in the room repeat what was said• Getting the attention of the client before • Reading lips beginning to speak • Encouraging the client to wear glasses when• Facing the client when speaking talking to someone to improve vision for lip• Talking in a room without distracting noises reading• Moving close to the client and speaking • Using sign language, which combines speech slowly and clearly with hand movements that signify letters, words, or phrases• Keeping hands and other objects away from • Using telephone amplifiers the mouth when talking to the client• Talking in normal volume and at a lower pitch • Flashing lights that are activated by ringing of because shouting is not the telephone or doorbell• helpful and higher frequencies are less easily • Specially trained dogs that help the client be heard aware of sound and alert the client to potential danger• Rephrasing sentences and repeating information
H. Presbycusis1. Description a. Presbycusis is a sensorineural hearing loss associated with aging. b. Presbycusis leads to degeneration or atrophy of the ganglion cells in the cochlea and a loss of elasticity of the basilar membranes. c. Presbycusis leads to compromise of the vascular supply to the inner ear, with changes in several areas of the ear structure.
2. Assessmenta. Hearing loss is gradual and bilateral.b. Client states that he or she has no problem with hearing but cannot understand what the words are.c. Client thinks that the speaker is mumbling.
I. External otitis1. Description a. External otitis is an infective inflammatory or allergic response involving the structure of the external auditory canal or auricles. b. An irritating or infective agent comes into contact with the epithelial layer of the external ear. c. Contact leads to an allergic response or signs and symptoms of an infection. d. The skin becomes red, swollen, and tender to touch on movement. e. The extensive swelling of the canal can lead to conductive hearing loss because of obstruction. f. External otitis is more common in children; it is termed swimmers ear and occurs more often in hot, humid environments. g. Prevention includes the elimination of irritating or infecting agents
2. Assessmenta. Painb. Itchingc. Plugged feeling in the eard. Redness and edemae. Exudatef. Hearing loss
3. Interventionsa. Apply heat locally for 20 minutes three times a day.b. Encourage rest to assist in reducing pain.c. Administer antibiotics or corticosteroids as prescribed.d. Administer analgesics such as aspirin or acetaminophen (Tylenol) for the pain as prescribed.e. Instruct the client that the ears should be kept clean and dry.f. Instruct the client to use earplugs for swimming.g. Instruct the client that cotton-tipped applicators should not be used in dry ears because their use can lead to trauma to the canal.h. Instruct the client that irritating agents such as hair products or headphones should be discontinued.
K. Chronic otitis media1. Description a. Chronic otitis media is a chronic infective, inflammatory, or allergic response involving the structure of the middle ear. b. Surgical treatment is necessary to restore hearing. c. The type of surgery can vary; it includes a simple reconstruction of the tympanic membrane, a myringoplasty, or replacement of the ossicles within the middle ear. d. A tympanoplasty, reconstruction of the middle ear, may be attempted to improve conductive hearing loss.
2. Preoperative interventionsa. Administer antibiotic drops as prescribed.b. Clean the ear of debris as prescribed; irrigate the earwith a solution of equal parts of vinegar and sterilewater as prescribed to restore the normal pH of theear.c. Instruct the client to avoid persons with upperrespiratory infections.d. Instruct the client to obtain adequate rest, eat abalanced diet, and drink adequate fluids.e. Instruct the client in deep breathing and coughing;forceful coughing, which increases pressure in themiddle ear, is to be avoided postoperatively.
3. Postoperative interventionsa. Inform the client that initial hearing after surgery is diminished because of the packing in the ear canal; hearing improvement will occur after the ear canal packing is removed.b. Keep the dressing clean and dry.c. Keep the client flat, with the operative ear up for at least 12 hours.d. Administer antibiotics as prescribed.e. Instruct the client that he or she may return to work in about 3 weeks postoperatively as prescribed.
L. Mastoiditis1. Description a. Mastoiditis may be acute or chronic and results from untreated or inadequately treated chronic or acute otitis media. b. The pain is not relieved by myringotomy.
2. Assessmenta. Swelling behind the ear and pain with minimal movement of the headb. Cellulitis on the skin or external scalp over the mastoid processc. A reddened, dull, thick, immobile tympanic membrane, with or without perforationd. Tender and enlarged postauricular lymph nodese. Low-grade feverf. Malaiseg. Anorexia
3. Interventionsa. Prepare the client for surgical removal of infected material.b. Monitor for complications.c. Simple or modified radical mastoidectomy with tympanoplasty is the most common treatment.d. Once tissue that is infected is removed, the tympanoplasty is performed to reconstruct the ossicles and tympanic membranes in an attempt to restore normal hearing.
4. Complicationsa. Damage to the abducens and facial cranial nervesb. Damage is exhibited by inability to look laterally (cranial nerve VI, abducens) and a drooping of the mouth on the affected side (cranial nerve VII, facial).c. Meningitisd. Brain abscesse. Chronic purulent otitis mediaf. Wound infectionsg. Vertigo, if the infection spreads into the labyrinth
5. Postoperative interventionsa. Monitor for dizziness.b. Monitor for signs of meningitis, as evidenced by a stiff neck and vomiting.c. Prepare for a wound dressing change 24 hours postoperatively.d. Monitor the surgical incision for edema, drainage, and redness.e. Position the client flat with the operative side up.f. Restrict the client to bed with bedside commode privileges for 24 hours as prescribed.g. Assist the client with getting out of bed to prevent falling or injuries from dizziness.h. With reconstruction of the ossicles via a graft, take precautions to prevent dislodging of the graft.
M. Otosclerosis1. Descriptiona. Otosclerosis is a disease of the labyrinthine capsule of the middle ear that results in a bony overgrowth of the tissue surrounding the ossicles.b. Otosclerosis causes the development of irregular areas of new bone formation and causes the fixation of the bones.c. Stapes fixation leads to a conductive hearing loss.d. If the disease involves the inner ear, sensorineural hearing loss is present.e. To have bilateral involvement is not uncommon, although hearing loss may be worse in one ear.f. The cause is unknown, although it is thought to have a familial tendency.g. Nonsurgical intervention promotes the improvement of hearing through amplification.h. Surgical intervention involves removal of the bony growth causing the hearing loss.i. A partial stapedectomy or complete stapedectomy with prosthesis (fenestration) may be performed surgically.
2. Assessmenta. Slowly progressing conductive hearing lossb. Bilateral hearing lossc. A ringing or roaring type of constant tinnitusd. Loud sounds heard in the ear when chewinge. Pinkish discoloration (Schwartzes sign) of the tympanic membrane, which indicates vascular changes within the ear.f. Negative Rinne testg. Webers test shows lateralization of sound to the ear with the most conductive hearing loss.
N. Fenestration1. Descriptiona. Fenestration is removal of the stapes, with a small hole drilled in the footplate; a prosthesis is connected between the incus and footplate.b. Sounds cause the prosthesis to vibrate in the same manner as the stapes.c. Complications include complete hearing loss, prolonged vertigo, infection, or facial nerve damage.
2. Preoperative interventionsa. Instruct the client in measures to prevent middle ear or external ear infections.b. Instruct the client to avoid excessive nose blowing.c. Instruct the client not to clean the ear canal with cotton-tipped applicators and to avoid trauma or injury to the ear canal.
3. Postoperative interventionsa. Inform the client that hearing is initially worse after the surgical procedure because of swelling and that no noticeable improvement in hearing may occur for as long as 6 weeks.b. Inform the client that the Gelfoam ear packing interferes with hearing but is used to decrease bleeding.c. Assist with ambulating during the first 1 to 2 days after surgery.d. Provide side rails when the client is in bed.e. Administer antibiotic, antivertiginous, and pain medications as prescribed.f. Assess for facial nerve damage, weakness, changes in tactile sensation and taste sensation, vertigo, nausea, and vomiting.g. Instruct the client to move the head slowly when changing positions to prevent vertigo.h. Instruct the client to avoid persons with upper respiratory tract infections.
i. Instruct the client to avoid showering and getting the head and wound wet.j. Instruct the client to avoid using small objects (cotton- tipped applicators) to clean the external ear canal.k. Instruct the client to avoid rapid extreme changes inpressure caused by quick head movements, sneezing, nose blowing, straining, and changes in altitude.l. Instruct the client to avoid changes in middle ear pressure because they could dislodge the graft or prosthesis.
O. Labyrinthitis1. Description: Infection of the labyrinth that occurs as a complication of acute or chronic otitis media2. May result from growth of a cholesteatoma— benign overgrowth of squamous cell epithelium
3. Assessmenta. Hearing loss that may be permanent on the affected sideb. Tinnitusc. Spontaneous nystagmus to the affected sided. Vertigoe. Nausea and vomiting
4. Interventionsa. Monitor for signs of meningitis, the most common complication, as evidenced by headache, stiff neck, and lethargy.b. Administer systemic antibiotics as prescribed.c. Advise the client to rest in bed in a darkened room.d. Administer antiemetics and antivertiginous medications as prescribed.e. Instruct the client that the vertigo subsides as the inflammation resolves.f. Instruct the client that balance problems that persist may require gait training through physical therapy.
P. Menières syndrome1. Description a. Menières syndrome is also called endolymphatic hydrops; it refers to dilation of the endolymphatic system by overproduction or decreased reabsorption of endolymphatic fluid. b. The syndrome is characterized by tinnitus, unilateral sensorineural hearing loss, and vertigo. c. Symptoms occur in attacks and last for several days, and the client becomes totally incapacitated during the attacks. d. Initial hearing loss is reversible but as the frequency of attacks continues, hearing loss becomes permanent. e. Repeated damage to the cochlea caused by increased fluid pressure leads to permanent hearing loss.
2. Causesa. Any factor that increases endolymphaticsecretion in the labyrinthb. Viral and bacterial infectionsc. Allergic reactionsd. Biochemical disturbancese. Vascular disturbance, producing changes in themicrocirculation in the labyrinthf. Long-term stress may be a contributing factor.
3. Assessmenta. Feelings of fullness in the earb. Tinnitus, as a continuous low-pitched roar or humming sound, that is present much of the time but worsens just before and during severe attacksc. Hearing loss that is worse during an attackd. Vertigo, as periods of whirling, that might cause the client to fall to the grounde. Vertigo that is so intense that even while lying down, the client holds the bed or ground in an attempt to prevent the whirlingf. Nausea and vomitingg. Nystagmush. Severe headaches
4. Nonsurgical interventionsa. Prevent injury during vertigo attacks.b. Provide bed rest in a quiet environment.c. Provide assistance with walking.d. Instruct the client to move the head slowly to prevent worsening of the vertigo.e. Initiate sodium and fluid restrictions as prescribed.f. Instruct the client to stop smoking.g. Administer nicotinic acid (niacin) as prescribed for its vasodilatory effect.h. Administer antihistamines as prescribed to reduce the production of histamine and the inflammation.i. Administer antiemetics as prescribed.j. Administer tranquilizers and sedatives as prescribed to calm the client, allow the client to rest, and control vertigo, nausea, and vomiting.k. Mild diuretics may be prescribed to decrease endolymph volume
5. Surgical interventionsa. Surgery is performed when medical therapy is ineffective and the functional level of the client has decreased significantly.b. Endolymphatic drainage and insertion of a shunt may be performed early in the course of the disease to assist with the drainage of excess fluids.c. A resection of the vestibular nerve or total removal of the labyrinth or a labyrinthectomy may be performed.
6. Postoperative interventionsa. Assess packing and dressing on the ear.b. Speak to the client on the side of the unaffected ear.c. Perform neurological assessments.d. Maintain side rails.e. Assist with ambulating.f. Encourage the client to use a bedside commode rather than ambulating to the bathroom.g. Administer antivertiginous and antiemetic medications as prescribed.
Trauma1. Description a. The tympanic membrane has a limited stretching ability and gives way under high pressure. b. Foreign objects placed in the external canal may exert pressure on the tympanic membrane and cause perforation. c. If the object continues through the canal, the bony structure of the stapes, incus, and malleus may be damaged. d. A blunt injury to the basal skull and ear can damage the middle ear structures through fractures extending to the middle ear. e. Excessive nose blowing and rapid changes of pressure that occur with nonpressurized air flights can increase pressure in the middle ear. f. Depending on the damage to the ossicles, hearing loss may or may not return.
2. Interventionsa. Tympanic membrane perforations usually heal within 24 hours.b. Surgical reconstruction of the ossicles and tympanic membrane through tympanoplasty or myringoplasty may be performed to improve hearing.
S. Cerumen and foreign bodies1. Description a. Cerumen, or wax, is the most common cause of impacted canals. b. Foreign bodies can include vegetables, beads, pencil erasers, insects, and other objects.
2. Assessmenta. Sensation of fullness in the ear with or without hearing lossb. Pain, itching, or bleeding
3. Cerumena. Removal of wax by irrigation is a slow process.b. Irrigation is contraindicated in clients with a history of tympanic membrane perforation or otitis media.c. To soften cerumen, add three drops of glycerin or mineral oil to the ear at bedtime, and three drops of hydrogen peroxide twice daily as prescribed.d. After several days, irrigate the ear.e. The maximum amount of solution that should be used for irrigation is 50 to 70 mL.
4. Foreign bodiesa. With a foreign object of vegetable matter, irrigation is used with care because this material expands with hydration.b. Insects are killed before removal, unless they can be coaxed out by flashlight or a humming noise.c. Mineral oil or diluted alcohol is instilled to suffocate the insect, which then is removed using ear forceps.d. Use a small ear forceps to remove the object and avoid pushing the object farther into the canal and damaging the tympanic membrane.