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Chapter 019
- 1. Chapter 19 Care of the Eye and Ear Copyright © 2018, Elsevier Inc. All rights reserved.
- 2. Vision and Hearing • Risks to a patients’ eye or ear structures or function can alter independence, safety, body image, and self-confidence • Nurses can help protect the vision and hearing of patients and assist a patient with adaptation to artificial sensory devices that help to replace or restore sensory function Copyright © 2018, Elsevier Inc. All rights reserved. 2
- 3. Principles for Practice Receiving and understanding environmental stimuli promote healthy functioning Alteration in a patient’s vision and hearing affects health literacy, independence, and adherence to medical and pharmacological therapies Artificial sensory aids can restore some vision and hearing loss Understand how to clean and care for these aids Copyright © 2018, Elsevier Inc. All rights reserved. 3
- 4. Patient-Centered Care • With altered communication, the patient may feel isolated • Health care facilities are environments that make hearing difficult • Hearing impaired patients need time to adjust to their hearing aid • Consider cultural differences • Identify patient’s usual practices in using sensory assistive devices Copyright © 2018, Elsevier Inc. All rights reserved. 4
- 5. Evidence-Based Practice • Dual sensory impairment (DSI) consists of concurrent losses in vision and hearing • DSI has the potential to cause cognitive function decline or to contribute to acute confusion or depression • DSI decreases independence, socialization, and quality of life of individuals and, in many cases, their families Copyright © 2018, Elsevier Inc. All rights reserved. 5
- 6. Quick Quiz! An Italian-American female patient with severe hearing impairment is sitting in her room, surrounded by a dozen family members, all talking happily. The patient appears disconnected from the group. How can the nurse engage the patient in communication? A.Instruct all family members to be silent. B.Gently touch the patient’s shoulder. C.Speak loudly in the direction of the patient. D.Leave the family alone; the patient is fine. Copyright © 2018, Elsevier Inc. All rights reserved. 6
- 7. Safety Guidelines 1. Whenever you care for patients with sensory alterations, safety is a priority. 2. Select interventions based on the type of sensory loss, patient preference, and patient safety. 3. Orient patient to any new environment or changes within an existing environment to minimize safety hazards. 4. When patients have visual impairments, they may have difficulty with tasks requiring visual detail. Copyright © 2018, Elsevier Inc. All rights reserved. 7
- 8. Safety Guidelines (Cont.) 5. Provide additional time for patients with hearing loss to ask repeated questions about their care or upcoming procedure. 6. If a patient must sign a consent form for a procedure or surgery, be sure to have a method to verify that the patient read, heard, and understood the procedure. Copyright © 2018, Elsevier Inc. All rights reserved. 8
- 9. Eye Care for Comatose Patients Procedural Guideline 19-1 Comatose patients do not have natural protective mechanisms, including blinking and lubrication of the eye, to protect the cornea Left unprotected, damage to the cornea can occur Simple nursing measures can decrease risk and prevent damage to the cornea Copyright © 2018, Elsevier Inc. All rights reserved. 9
- 10. Delegation and Collaboration The task of eye care for a comatose patient can be delegated to nursing assistive personnel (NAP) The nurse directs NAP to: Adapt the task for specific patients Immediately report to the nurse any eye drainage or irritation for further assessment Copyright © 2018, Elsevier Inc. All rights reserved. 10
- 11. Taking Care of Contact Lenses Procedural Guideline 19-2 Contact lenses correct refractive errors of the eye or abnormalities in the shape of the cornea that distort vision Rigid gas permeable (RGP) Daily disposable soft lens All lenses must be removed periodically and cleaned to prevent infection and corneal damage It is critical to determine if patient is wearing contact lenses Copyright © 2018, Elsevier Inc. All rights reserved. 11
- 12. Delegation and Collaboration The task of taking care of contact lenses can be delegated to NAP. However, it is the nurse’s responsibility to assess a patient’s eyes The nurse directs NAP to: Know a patient’s contact lenses and routine Report immediately to the nurse any eye pain or discomfort, redness, swelling, tearing, or drainage Carefully handle lenses to prevent damage and injury Copyright © 2018, Elsevier Inc. All rights reserved. 12
- 13. Quick Quiz! The nurse inserts a contact lens into the patient’s left eye, which comes to rest on the sclera. What action should the nurse take next? A.No action required; the lens is in its proper placement. B.Remove the lens immediately and reinsert. C.Ask the patient to slowly close the eye and look toward the lens. D.Irrigate the eye with normal saline solution. Copyright © 2018, Elsevier Inc. All rights reserved. 13
- 14. Eye Irrigation Skill 19-1 Flushes out exudates, irritating solutions, or foreign bodies from the eyes Typically used in emergency situations When chemicals or irritating substances contaminate eyes, irrigate immediately with copious amounts of cool water for at least 15 minutes to minimize corneal damage Copyright © 2018, Elsevier Inc. All rights reserved. 14
- 15. Delegation and Collaboration The task of eye irrigation cannot be delegated to NAP The nurse directs NAP to: Report any patient complaint of discomfort or excess tearing following irrigation Copyright © 2018, Elsevier Inc. All rights reserved. 15
- 16. Recording and Reporting • Record in nurses’ notes the condition of the eye and the patient’s report of pain and visual symptoms. Record amount and type of irrigation on patient’s MAR • Document your evaluation of patient learning • Report continuing symptoms of pain or blurred vision Copyright © 2018, Elsevier Inc. All rights reserved. 16
- 17. Special Considerations Teaching Home safety and hazard prevention Review first aid procedures Do not press or rub injured eye Pediatric A child may panic; it may be necessary to restrain the child to safely and quickly irrigate the eye Copyright © 2018, Elsevier Inc. All rights reserved. 17
- 18. Ear Irrigation Skill 19-2 Indicated in cases of foreign bodies, local inflammation, and buildup of cerumen in the ear canal Hazards include vertigo/nausea, risk of tympanic membrane rupture, damage to the auditory meatus Improperly drying the ear may lead to acute otitis externa Copyright © 2018, Elsevier Inc. All rights reserved. 18
- 19. Delegation and Collaboration The task of administering ear irrigation cannot be delegated to NAP The nurse directs NAP to: Immediately report any potential side effects of ear irrigation Help patient when ambulating because some light- headedness may be present, which increases the patient’s risk for falling Copyright © 2018, Elsevier Inc. All rights reserved. 19
- 20. Recording and Reporting • Record the procedure, amount of solution instilled, time of administration, and ear receiving irrigation on flow sheet or nurses’ notes in EHR or chart • Document your evaluation of patient learning • Record appearance of external ear and patient’s hearing acuity on flow sheet or nurses’ notes in EHR or chart • Report adverse effects/patient response and/or withheld drugs to nurse in charge or health care provider Copyright © 2018, Elsevier Inc. All rights reserved. 20
- 21. Special Considerations Teaching Cerumen has an antibacterial effect Clean ears daily; do not place any objects into the ear Pediatric Immobilize small children before cleaning ears, to avoid movement that may result in a punctured eardrum Copyright © 2018, Elsevier Inc. All rights reserved. 21
- 22. Special Considerations (Cont.) Home care Use a clean bulb syringe for irrigation Mineral oil or over-the-counter otic preparations can help with removal of cerumen Copyright © 2018, Elsevier Inc. All rights reserved. 22
- 23. Quick Quiz! A 2-year-old boy is brought to the ER by his mother after the child put several dried peas in his left ear. What will be the nurse’s first action in treating this patient? A.Straighten the ear canal. B.Irrigate the inner ear. C.Remove the peas with tweezers. D.Gently blow air into the ear. Copyright © 2018, Elsevier Inc. All rights reserved. 23
- 24. Care of Hearing Aids Skill 19-3 Hearing aid components: microphone, amplifier, receiver, power source Two main types: analog and digital Hearing impaired cannot hear alerts such as fire alarms and overhead announcements Copyright © 2018, Elsevier Inc. All rights reserved. 24
- 25. Delegation and Collaboration The task of caring for a hearing aid can be delegated to NAP The nurse directs NAP to: Report ear pain, inflammation, drainage, odor, or changes in hearing Identify ways to communicate with a patient while the aid is not in use Learn how to carefully handle the aid to prevent damage or injury Copyright © 2018, Elsevier Inc. All rights reserved. 25
- 26. Recording and Reporting • Record removal of hearing aid, storage location if not reinserted after cleaning, and patient’s preferred communication techniques. If family takes aid home, be sure that this information is included in the patient’s medical record. If family takes aid home, be sure that this information is recorded. • Document your evaluation of patient learning • Report any signs or symptoms of infection or injury or sudden decrease in hearing acuity Copyright © 2018, Elsevier Inc. All rights reserved. 26
- 27. Special Considerations Teaching Secure hearing aids and batteries when not in use Advise others in helpful communication techniques Pediatric Children need help to prevent acoustic feedback Copyright © 2018, Elsevier Inc. All rights reserved. 27
- 28. Special Considerations (Cont.) Gerontological Advise patient to protect hearing aid Consult an audiologist if hearing aid size is difficult to handle Home care Assess caregiver for level of support Assess home for hazards and need for special precautions Copyright © 2018, Elsevier Inc. All rights reserved. 28
Editor's Notes
- This chapter reviews three skills and two procedural guidelines: eye care for comatose patients, taking care of contact lenses, eye irrigation, ear irrigation, and care of hearing aids.
- Artificial sensory aids can restore some vision and hearing loss. However, these aids must fit and work properly for patients to function optimally in their environments. When caring for patients who use aids to assist with visual or auditory loss it is important that you and the health care team, along with the patient and their family, understand how to clean and care for these aids. Breakage or loss of the aid is expensive.
- When a patient is without visual or hearing devices communication is altered, the patient is isolated socially, and there is an increase in patient dependence, it interferes with communication, and increases patient dependence. When a patient has auditory impairments, the increased background noise in an unfamiliar environment often makes a patient more anxious and decreases his or her ability to adjust to new surroundings. Understand the cause of a person’s sensory loss and then determine the patient’s own perception of the reason for the loss. [Ask students: what kind of effect does a hospital have on hearing or vision impaired patients? Discuss: hospitals, rehabilitation centers, and skilled nursing facilities are inherently noisy places. They have many hard surfaces to deflect sound, as well as medical equipment and televisions that produce sound. The constant need to communicate surrounds the patient with voices. For the hearing impaired, all of this noise makes hearing even more difficult. For the vision impaired, it becomes difficult to rely on hearing to orient the patient to new surroundings.]
- Dual sensory impairment (DSI) can affect a patient’s success in using assistive devices and rehabilitation services, preventing the patient from progressing to a higher level of independent function. Although the evidence is not conclusive, some literature suggests that DSI is more debilitating than a single sensory impairment. Older adults may not actually perceive their hearing loss because initially it is mild; however, as it progresses, they usually avoid or delay hearing evaluation. Identify patients at risk for hearing impairments: Male over age 65, male or female over age 75, resident in nursing agency, existing visual impairment, chronic ear infection, prolonged exposure to loud noises, and use of ototoxic medication. [Ask students: what are some examples of visual impairments? Discuss: reduced visual acuity, visual field loss, contrast sensitivity reduction, glare disability.] Involving patients with DSI in volunteer work has been shown to result in fewer depressive symptoms compared to people without sensory loss who volunteer. Patients with DSI will have unique communication needs that require a thorough assessment.
- Correct answer: B Rationale: Because of the comfort with silence, one can easily mistake a patient’s silence for a measure of comfort and never correctly assess what a patient is able to hear, or whether the information is heard correctly. At times the nurse will use touch to get the attention of a patient with decreased hearing.
- [Ask students: how does sensory alteration place a patient at risk for injury? Discuss: ability to maneuver through home, climb stairs, respond to alarms.] Select interventions based on the type of sensory loss, patient preference, and patient safety. Educate family and friends about the best way to help patient adapt to sensory loss. This increases the risk of improper administration of medications in the home setting. In addition, certain eye conditions such as cataracts and macular degeneration cause a patient difficulty when adjusting to changes in contrast and brightness.
- [Discuss ways to ensure that the patient understands about care or an upcoming procedure.]
- When patients are heavily sedated or in a coma, tear production is reduced; as a result, normal lubrication of the eye surface is decreased. Critically ill patients are often on mechanical ventilators and are heavily sedated, which alters normal blinking reflex. The blinking reflex flushes debris out of the eye. When patients are heavily sedated or in a coma, tear production is reduced; as a result the normal lubrication of the eye surface is decreased. Tears maintain a moist environment, lubricate the eyes, wash away foreign material and cell debris, prevent organisms from adhering to the ocular surface, and transport oxygen to the outer eye surface. When a patient’s normal protective eye mechanisms are not effective, the nurse is responsible for providing this care. [Ask students: what kind of damage can occur to the cornea as a result of losing these protective mechanisms? Discuss: corneal scarring, premature cataract formation, and vision changes.] Simple eye hygiene measures such as moisture chambers, lubrication, and corneal surface protection are the best interventions to decrease the risk for or prevent damage to the cornea.
- It is the nurse’s responsibility to assess a patient’s eyes and administer the sterile lubricant. [Ask students: what does it mean that nursing assistive personnel (NAP) can adapt the skill for specific patients? Discuss: for example, using skin-sensitive tape to affix eye pads for patients with sensitive skin.]
- Today rigid gas permeable (RGP) and soft contact lens are available. RGP lens are smaller than the soft lens and initial awareness of the lens is present, but total comfort usually occurs within a couple of weeks. Daily disposable soft contact lenses are made of a flexible hydrogel plastic and cover the entire cornea and a small rim of the sclera. As contact lenses are worn, secretions and foreign matter adhere to the lens surface. [Ask students: why is it important to determine whether patients wear contact lenses? Discuss: if a seriously ill patient is wearing contact lenses and this fact goes undetected, severe corneal injury can result.]
- [Ask students: what kinds of things should you know about a patient’s contact lenses and routine? Discuss: specific types of contact lenses, including cleaning solutions and routine, wear schedule, storage, and replacement schedule.]
- Correct answer: C Rationale: Gentle pressure on the eyelid may help to center the lens on the cornea. The nurse can also ask the patient to blink a few times.
- If the person wears contact lens and they did not wash out with the irrigation, have the person try to remove the lens. A chemical injury to the eye is considered an emergency and requires flushing the eye with copious amounts of irrigation fluid. Often cool tap water is recommended for emergency eye flushing because it is effective, immediately available for first aid, and initially helps to dilute the concentration of the chemical. The goal in treating ocular chemical injury is to prevent or reduce visual loss caused by the burn.
- [Discuss why this task cannot be delegated to NAP, when care of a prosthetic eye can be delegated.]
- [MAR = medication administration record.]
- Teaching Help patient identify potential hazards at home and work and take steps to prevent accidents such as use of safety goggles while working with dust or chemicals. Review first aid procedures for eye emergencies with patient and/or caregiver. Instruct patient to not press or rub an injured eye. Instruct patient to consult with personal eye care physician before reinserting contact lens. [Ask students: why is it sometimes necessary to restrain a child? Discuss: the child may rub the eye, causing additional damage, or the child may not want to hold still for irrigation, delaying treatment and resulting in additional damage.]
- [Ask students: how can irrigation lead to rupture of the tympanic membrane? Discuss: rupture of the tympanic membrane can occur by forcing an irrigant into the canal under pressure.] Warming the irrigation solution to body temperature may prevent vertigo or nausea in patients during ear irrigation. The greatest danger during ear irrigation is trauma to the tympanic membrane by forcing irrigant into the canal under pressure. Damage to the external auditory meatus may occur by scratching the lining of the canal if a patient suddenly moves or if there is inadequate control of the irrigating syringe. Ear emergencies can include the presence of foreign bodies, insect bites, or percussion injuries. A patient can also sustain damage from inside the ear, which includes blood and drainage. If a head or neck injury is suspected, immobilize the patient. Do not irrigate the ear if: You suspect a head or neck injury; cover the outside of the ear with a sterile dressing, if one is available, and get medical help immediately. Vegetable matter or an insect is present in the canal. The tympanic membrane is ruptured. The patient has otitis externa, myringotomy tubes, or a mastoid cavity.
- [Ask students: what are some potential side effects of ear irrigation? Discuss: pain, drainage, dizziness.]
- [MAR = medication administration record.]
- Teaching Instruct patient that cerumen has an antibacterial effect that maintains an acid pH in the auditory canal. Instruct patients to clean ears daily with a washcloth, soap, and warm water. Warn patients against placing objects (including cotton swabs) in ears. Pediatric When cleaning the ear of a small child, be certain that child’s head is immobilized to prevent puncturing eardrum. It may be necessary to have child’s parent or staff participate. [Ask students: a patient asks if it is okay to clean his ears with a cotton swab—how would you answer? Discuss: warn patients against placing any object, including cotton swabs, in the ears.]
- [Discuss the procedure for home instillation of mineral oil.]
- Correct answer: A Rationale: Always attempt to remove foreign objects in the ear by first simply straightening the ear canal. If vegetable matter (such as a dried bean or pea) is occluded in the canal, do not perform irrigation. The material can swell on contact with water, causing further damage to the canal.
- Hearing loss is the most common sensory deficit in older adults. Only one out of five people who actually need a hearing aid wear one. Those who do not wear a hearing aid often say that they do not wear a hearing aid because of the quality of sound that the aid produces. Initially a person with hearing loss may deny the condition or feel that there is a stigma attached to the actual hearing loss or the need for a hearing aid. Any hearing loss has social implications, and the person may not engage in social activities. In addition in social situation people with a hearing aid often feel that once their aid is observed conversation occurs “around them.” Not only do people with hearing loss have difficulty hearing car horns and emergency sirens; they also have difficulty understanding patient education and, as a result, may not safely manage their symptoms or therapies. The role of a hearing professional is to determine what type of aid the patient needs and how to establish the best auditory settings for individual patients. [Review Table 19-1 with students: Types of Hearing Aids] All hearing aids have four basic components: A microphone, which receives and converts sound into electrical signals An amplifier, which increases the strength of the electrical signal A receiver, which converts the strengthened signal back into sound A power source (batteries) The two main types of electronic hearing aids are analog and digital Analog technology converts sound waves into electrical waves, which are amplified Digital technology converts sound waves into numerical codes. Digital aids give the audiologist more flexibility in fine tuning the aid to meet the patient’s needs Be sure that a patient can see your face; speak slowly in a normal tone; and rephrase rather than repeat if he or she cannot understand you Remember that a patient is unable to hear alerts such as fire alarms and overhead announcements
- [Review options for communication when the aid is not in use.]
- [What could a sudden decrease in hearing acuity reflect?]
- Teaching [Ask students: why is it important to put away hearing aids and batteries securely when they are not in use? Discuss: batteries are toxic if swallowed; keep them away from pets and children. Dogs in particular and cats are attracted to the smell of used hearing aids. Advise patients to protect the hearing aids and their pets by properly storing aids out of reach.] Patients should insert the aid after their hair is dried and any hair spray has been applied. Heat from the hair dryer or perfumes and hair spray can damage the aid. Encourage patients to identify helpful communication tips and teach them to others. Many patients find facial cues informative. Speakers must: Face patient, stay within 3 to 4 feet away, and keep hands away from the mouth. Get the patient’s attention before speaking. Rephrase rather than repeat when the patient cannot understand. Reduce background noise or move to a quiet area. Pediatric Children are more often fitted with behind-the-ear (BTE) hearing aids because the ear canal is still growing. The aid is made less conspicuous with hair styling or becomes a statement of fashion and personality with a brightly colored or transparent case. Children need help to prevent acoustic feedback (whistling), which they are unable to hear. This is usually eliminated by removing and reinserting the device and making sure that no hair is caught between the earmold and the canal, or by lowering the volume of the device.
- Gerontological [Ask students: what should the hearing aid be protected from? Discuss: water, alcohol, hair spray or cologne, perspiration, rain, and snow, and to avoid exposing the hearing aid to extremes of temperature. Encourage the patient to store hearing aids and batteries with desiccant or in an electronic dryer to prolong life, minimize repairs, and preserve batteries.] The small size of some hearing aids may make them difficult to manipulate, particularly for individuals with decreased dexterity or visual acuity. Consult an audiologist to identify an aid that accommodates a patient’s particular need. Home care Determine presence and willingness of caregiver to perform necessary care of hearing aid Assess patient’s home and determine need for special precautions given patient’s limited hearing.