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Essentials of Pediatric Nursing Chapter 39: Nursing Care of the Child With a Disorder of the Eyes or Ears.

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Presentation on theme: "Essentials of Pediatric Nursing Chapter 39: Nursing Care of the Child With a Disorder of the Eyes or Ears."— Presentation transcript:

1 Essentials of Pediatric Nursing Chapter 39: Nursing Care of the Child With a Disorder of the Eyes or Ears

2 Variations in Pediatric Anatomy and Physiology
Eyes Eye color determined by 6-12 months Eyeball occupies a larger space in orbit so more prone to injury Newborn’s lens can only accommodate 8-10 inches and color discrimination incomplete Visual acuity improves with age, 20/20 by 6-7 years Rectus muscle uncoordinated at birth and matures over time. Binocular vision (simultaneous focus by both eyes) achieved by 4 months

3 Nursing Process Overview
Assessment Health history Physical examination Inspection and observation Palpation Laboratory and diagnostic testing Nursing diagnoses Disturbed sensory perception Risk for infection Pain Delayed growth and development Impaired verbal communication Deficient knowledge Interrupted family processes Risk for injury

4 Inspecting the eye Assessment of Vision Infancy: Childhood:
Note use of eyeglasses or lenses Observe positioning, symmetry, presence of strabismus, nystagmus and squinting Eyelids should open fully (ptosis is lid not fully open); Look for edema Note eye slant, epicanthal folds Observe pupils and reactions, corneal light reflex, iris and sclera color Test for extraocular movement Invert eyelid to check conjunctive for redness Assessment of Vision Infancy: Response to visual stimuli Parental observations and concerns Expect binocularity by age 6 months Childhood: Visual acuity testing

5 Opthalmoscopic Exam of Eye
Go to the above hyperlink (right click, go to open hyperlink) for instructions to complete the eye exam Normal view – the retina should be a “red reflex” Ophthalmoscopic Exam Darken the room as much as possible. ++ Adjust the ophthalmoscope so that the light is no brighter than necessary. Adjust the aperture to a plain white circle. Set the diopter dial to zero unless you have determined a better setting for your eyes. [6] Use your left hand and left eye to examine the patient's left eye. Use your right hand and right eye to examine the patient's right eye. Place your free hand on the patient's shoulder for better control. Ask the patient to stare at a point on the wall or corner of the room. Look through the ophthalmoscope and shine the light into the patient's eye from about two feet away. You should see the retina as a "red reflex." Follow the red color to move within a few inches of the patient's eye. Adjust the diopter dial to bring the retina into focus. Find a blood vessel and follow it to the optic disk. Use this as a point of reference. Inspect outward from the optic disk in at least four quadrants and note any abnormalities. [pictures on p208] Move nasally from the disk to observe the macula. Repeat for the other eye.

6 Periodic Recommended Screening
Prenatal Newborns through preschoolers Children of all ages Use age-appropriate visual acuity test

7 Visual Disorders Refractive errors
Nursing assessment Nursing management Educating about eyeglasses use Educating about contact lens use Monitoring for fit and visual correction Healthy People 2020: Goal to increase use of protective equipment (eye goggles) when engaged in potentially dangerous activities.

8 Ears Congenital deformities usually associated with other anomalies and genetic syndromes Infants short, wide and horizontally placed Eustachian tube allows bacteria and viruses to reach middle ear more easily, so more prone to ear infections As child matures, tubes more slanted If adenoids enlarged may lead to obstruction of Eustachian tubes > infection

9 Inspect Ears Outside Note size, shape, position on head
Look for skin tags, dimples or other anomalies Conduct hearing testing with infants and children

10 Otoscopic Examination of Ear
Note presence of cerumen, discharge, inflammation or foreign body in ear canal Visualize tympanic membrane for color, landmarks, and light reflex. Also for abnormalities like perforation, bulging, scars or retraction View of a normal tympanic membrane

11 Disorders of the Eyes

12 Conjunctivitis Inflamation of the bulbar or palpebral conjunctiva.
In newborns: causes are chlamydia, gonorrhea, or herpes simplex virus In infants: may be sign of tear duct obstruction In children: causes are bacterial (most common, also called “Pink Eye”), viral, allergic, or foreign body Signs and Symptoms Purulent eye drainage, crusting Inflamed conjunctiva and swollen lids


14 Bacterial Conjunctivitis
Redness of conjunctiva Copious, discolored drainage with matting Eyelid swelling

15 Allergic Conjunctivitis
Caused by perennial or seasonal allergies Conjunctiva red Discharge clear, watery Child rubs eyes frequently

16 Therapeutic and Nursing Management
Treatment depends on cause Viral is self-limiting, remove secretions Bacterial: Culture of eye drainage. Topical antibacterial agents like polymycin and bacitracin, Sulamyd or Polytrim Drops during day and ointment at night Nursing Care Keep eyes clean with warm, moist cloth. Wipe from inner canthus down and away from other eye. DON”T leave compress on eye. Instill eye medication after cleaning eye Medications:topical antibacterials to eye: Polysporin, Sulamyd or Polytrim Teach prevention of infection to child and family: discard tissues, wash cloths separately, don’t rub eyes. GOOD HAND-WASHING Children don’t attend school until infection treated. CONTAGIOUS if bacterial cause Teach parent to administer medications Caution with use of steroids—may exacerbate viral infections

17 Nasolacrimal Duct Obstruction
Stenosis or simple obstruction of the nasolacrimal duct Common in infancy: 5-20% population, usually resolves by 1 year old Unilateral in 65% cases Nursing assessment S&S: Tearing or discharge from one or both eyes by 2 weeks old Redness of lower lid of affected eye Culture may be done to rule out conjunctivitis Nursing management Teach parents to clean eye area frequently with moist cloth *Massage nasolacrimal duct (see page 564 in text, guideline 17.1 for technique) Teach how to give antibiotic drops if needed Usually resolves by 1 year old

18 Child with nasolacrimal duct stenosis
Child with nasolacrimal duct stenosis. Note redness, tearing and obstruction.

19 Nasolacrimal Duct Massage
Teach procedure to parents: Using the forefinger or little finger, push on the top of the bone (the puncta must be blocked) Gently push in and up Gently push downward along the side of the nose

20 Periorbital Cellulitis
Bacterial infection of eyelids or surrounding tissue of eye Enters through break in skin, sinusitis, conjunctivitis Most common bacteria: Staph. aureus, Strep. pyogenes, Strep pneumoniae Initiate inflammatory response Nursing assessment S&S: redness, swelling, pain around eye Nursing management Warm soaks to eye area 20 minutes every 2-4 hours Teach family to complete full course of antibiotics at home Teach parents to call PCP if eye doesn’t improve May require hospitalization for IV antibiotics Manage pain with analgesics

21 Child with cellulitis of left eye

22 Emergency Treatment for Eye Injuries
Foreign body Chemicals Sunburns Hematoma Penetrating injuries


24 Eye Injuries Nursing assessment Nursing management Health history
Physical examination Nursing management Managing non-emergent eye injuries Suture lacerations Child may need sedation and pain med Assist physician with examination Edema and black eye treated with ice pack on 20 minutes, off 20 minutes. Repeat cycle. May take 3 weeks to resolve Scleral hemorrhages will resolve without intervention Corneal abrasions treated with topical antibiotic and analgesics Remove foreign objects from eye using eyelid eversion. Irrigating with normal saline may help. Serious foreign body will need opthamologist to remove Chemical injuries require immediate irrigation with copious amounts of water Visit to opthamologist advised Teach PREVENTION

25 Eversion of lid for examination
Technique to remove foreign objects from eye

26 Measures to Prevent Visual Impairment
Prenatal care, prevention of prematurity Rubella immunizations for all children Safety counseling for preventing eye injuries

27 Visual Impairment General term that refers to visual loss that cannot be corrected with regular prescription lenses

28 Visual Impairment Classification
Partially sighted: Acuity of 20/70-20/200 Education usually in public school system Legal blindness: Acuity of 20/200 or less Legal as well as medical term

29 Etiology of Visual Impairments
Perinatal or postnatal infections: Gonorrhea, chlamydia, rubella, syphilis, toxoplasmosis Retinopathy of prematurity Perinatal or postnatal trauma Other disorders Unknown causes

30 Strabismus Common, occurs in 4% of children Most common types
Exotropia – eyes turn outward Esotropia – eyes turn inward May affect visual development, cause diplopia (double vision) Infants may have intermittent strabismus which resolves by 3 months Strabismus, also called a “crossed eye”, is a condition in which the eyes are misaligned.  Eye position is controlled by six muscles, called extraocular muscles, which surround the eye.  Strabismus is most often caused by an eye muscle imbalance rather than a "weak" eye muscle.  While one eye gazes straight ahead, the other may point inward, outward, up, down or be rotated either inward or outward (torsion.) Eye misalinment may cause double vision.  Strabismus occurs commonly in early childhood, or develops in young children, though it may develop in adulthood as well. Strabismus can be very successfully treated

31 Infant with esotropia. Test using corneal light reflex.

32 Corneal Light Reflex to Check Symmetry
Child on left has symmetrical reflection of light This child with strabismus reflects light unevenly

33 Other Visual Impairments
Astigmatism: unequal curvatures in refractive apparatus, usually myopic Treated with special lenses or laser surgery Amblyopia: Reduced visual acuity in one eye, “Lazy eye” Treat primary vision defect such as strabismus Strabismus “Squint” or cross-eye Esotropia – inward deviation of eye Exotropia – outward deviation of eye Treatment depends on cause, may involve patching stronger eye (occlusion therapy) or surgery Early diagnosis essential to prevent vision loss from amblyopia Strabismus symptoms may include: Eyes pointing in different directions. Decreased depth perception. Double vision, particularly in adults. Strabismus is often visually evident (by the misalignment of the eyes), and sometimes is noticed by a parent before diagnosed by a physician.  Some types, however, are very difficult to identify.  There are also cases of pseudostrabismus, in which an infant or toddler appears to have inwardly-crossing eyes, but is actually exhibiting incomplete facial development; this requires no treatment, and remedies itself with further growth.  If true strabismus goes untreated in children, it can often cause amblyopia (lazy eye) to develop. Amblyopia is a condition in which the brain ignores images coming from the poorer seeing eye. This interferes with the development of the visual cortex of the brain and can lead to poor vsion and even legal blindness (see section on Amblyopia.) For this reason, all children should be checked by a physician for strabismus by age three or four.  Children with a family history of the condition should be examined even earlier and possibly more often.

34 Nursing Management of Child with Visual Impairments
Be alert to clinical manifestations: Eye rubbing, headaches, dizziness, clumsiness, frequent blinking Difficulty reading or doing close work, poor school performance Perform vision screening or advise parent to bring child for eye exam with opthamologist Encourage child to wear corrective lenses Treatment may include laser surgery or eye surgery

35 Hospitalization of the Visually Impaired Child
Work closely with the family Safe environment Reassurance Introduce yourself BEFORE touching child Orient child to surroundings Keep items and furniture in the same place Encourage independence Consistency of team members

36 Promoting Child’s Optimum Development
Play and socialization Development of independence Education: Braille Audio books and learning materials

37 Disorders of the Ears

38 Otitis Media Acute otitis media (AOM)
Pathophysiology : Bacterial or viral infection of fluid in middle ear Peak incidence: 0-2 years, especially 6-12 months Therapeutic management Nursing assessment Health history Physical examination and diagnostic testing


40 Acute Otitis Media – note erythema and opacity of tympanic membrane

41 Prevention of Hearing Loss
Treatment and management of recurrent otitis media A common cause of conductive/middle-ear hearing loss Medical tx: Wait and see Antibiotics Surgical treatment Tympanostomy: placement of ear tubes for children less than about 5-6 years old, we allow bathing, hair washing, surface swimming, or ocean exposure...without any precautions.  Diving deeper under water, or swimming in (dirtier) lakes and rivers is more likely to cause infections.  In those cases, the preventitive use of certain antibiotic ear drops (such as Floxin Otic) may help.  Your ear doctor may be adamant about keeping your infant's ears dry... ENT docs like to see their tube patients every 3-6 months, or until the ears are normal.  Adenoidectomy, with just myringotomies (making an incision, no tubes) may be appropriate in certain might a laser myringotomy. Prenatal preventive measures Avoid exposure to noise pollution

42 Otitis Media Acute otitis media (AOM) (cont’d) Nursing management
Managing pain associated with AOM Analgesics like acetaminophen or ibuprofen Narcotic analgesics like codeine for severe pain Heat or cool compress: have child lay affected ear on compress Numbing eardrops like benzocaine (Auralgan) Educating the family Observe for S&S and call PCP Teach completion of antibiotics if ordered – VERY IMPORTANT! Follow-up to check progress, test hearing Preventing AOM Encourage breastfeeding 6-12 months Avoid exposing child to individuals with upper respiratory infections DON’T EXPOSE TO SECOND HAND SMOKE Immunize child, including flu vaccines Xylitol, a sucrose substitute, taken in liquid or gum form, may prevent AOM

43 Otitis Media Otitis media with effusion (OME)
Presence of fluid in middle ear space without S&S of infection Nursing assessment Health history Risk Factors: passive smoking, not breastfed, frequent upper respiratory infections, allergy, young age, male, congenital disorders Physical examination May be asymptomatic or experience popping or fullness behind eardrum Otoscopic exam may reveal dull, opaque tympanic membrane that’s gray, white or bluish. Tympanometry may diagnose OME Nursing management Educating the family Antihistamines, antibiotics and steroids usually don’t work Teach NOT to prop infant with bottle Monitoring for hearing loss and speech development Providing postoperative care for the child with pressure-equalizing tubes Tubes inserted and remain a few months May need to avoid water in ears, wear earplugs with baths and swimming

44 Otitis Media with Effusion

45 Myringotomy (Ear Tubes)
Small tubes(made of plastic, metal, or Teflon) that are surgically placed into child's eardrum by an ear, nose, and throat surgeon. The tubes help drain the fluid out of the middle ear in order to reduce the risk of ear infections. About one million children each year have tubes placed in their ears. The most common ages are from 1 to 3 years old. By the age of 5 years, most children have wider and longer eustachian tubes

46 Myringotomy – Pre and Post-Op Nursing Care *
Prepare child and parent for surgery: Assessment, VS The operation usually takes 15 to 20 minutes. Child will go home 2-4 hours after surgery. Post-Op Care and Teaching Normal to have fluid 3-4 days, grey/brown and slight smell. Fluid may leak from your child’s ear The tubes will stay in your child’s ears for several months Do not put anything into your child’s ear May have a bath. Ear plugs may or may not be recommended by surgeon. Consult surgeon about other water activities like swimming. Medicines Antibiotic ear drops: may or may not order antibiotic ear drops. Show parent how to put the antibiotic ear drops in child’s ear. Pain medicine: Acetaminophen or Ibuprofen May return to day care or school the day after leaving the hospital, if your child is feeling well. First visit is normally 7-10 days after surgery, then every 2-4 months REASONS TO CALL SURGEON Ears leak fluid for more than 4 days after the operation. Your child has a fever over 38.5°C (101°F). Your child’s ears start to leak fluid again after they have stopped leaking, or the color of the drainage changes to thick greenish pus with a strong smell. Your child’s ears become sore.

47 Otitis Externa (Swimmer’s ear)
Infection and inflammation of external ear canal Bacterial or fungal Nursing assessment Health history Physical examination Ear red, edematous, itchy, painful, may affect hearing Nursing management Managing pain Treating the infection Preventing reinfection Recent studies recommend leaving ear wax in place as protection.

48 Hearing Impairment Ranges from mild to profound
Deaf: a person whose hearing disability precludes processing linguistic information with or without hearing aid Hard of hearing: generally able to hear with hearing aid Incidence One of the most common disabilities Estimated 3 in 1000 well babies have some degree of hearing loss Neonates in ICU: 2-4 per 100 In US about 1 million children from birth to 21 years have hearing loss 1/3 of these children have other sensory or cognitive problems

49 Pathology of Hearing Impairments
Conductive hearing loss—middle ear Sensori-neural hearing loss—nerve deafness Mixed conductive-sensorineural loss—may follow recurrent otitis media with complications Central auditory interception: Organic: defect involves reception of auditory stimuli along central pathways and expression of message (aphasia) Functional: no organic lesion exists to explain central auditory loss(conversion hysteria, infantile autism, childhood schizophrenia)

50 Nursing Care of Child with Hearing Loss and Deafness
Nursing assessment Health history Physical examination and laboratory and diagnostic tests Nursing management Augmenting hearing Promoting communication and education Encouraging education Providing support

51 Causes of Hearing Impairments
Anatomic malformation Low birth weight Ototoxic drugs: Include: aspirin, lasix, vancomycin, gentamycin, vicodin, many psych and antineoplastic drugs Chronic ear infections Perinatal asphyxia Perinatal infections: rubella, herpes, syphilis, bacterial meningitis Cerebral palsy Hearing Testing Measured in decibels (dB) A unit of loudness Measured at various frequencies Speech range is 2000 cycles/sec Hearing threshold Measurement of a person’s hearing threshold with audiometer Degree of symptom severity as it affects speech

52 Manifestations of Hearing Impairment in Infancy
Lack of startle reflex Absence of babbling by age 7 months General indifference to sound Lack of response to spoken word EARLY DETECTION, best within 3-6months, essential to improve language and educational outcomes

53 Therapeutic Management of Hearing Impairment
Medical Antibiotic therapy for otitis media Surgical interventions Tympanostomy tubes for chronic otitis media Hearing aid Learn how to use hearing aid Teach child to manage when old enough Managing acoustic feedback Reinsert aid Check for hair Clean ear mold or ear Lower volume Cochlear implants:ay help children with sensorineural hearing loss

54 Hearing Aids FIG. 19-7  On-the-body hearing aids are convenient for young children, such as this child with severe bilateral hearing loss. Note eye patching for strabismus.

55 Deafness and Promoting Communication
Profound deafness likely to be diagnosed in infancy Concerns with speech development One reason number of words and speech assessed at PCP’s visit Methods of Communication Lip-reading Cued speech Sign language Speech language therapy Socialization Additional aids Cochlear implant A cochlear implant is a small, complex electronic device that can help to provide a sense of sound to a person who is profoundly deaf or severely hard-of-hearing. The implant consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin

56 Diagram of Cochlear Implant

57 Care for Hearing Impaired Child During Hospitalization
Reassess understanding of instructions given Supplement with visual and tactile media Communication devices: Picture board Common words and needs (food, water, toilet) Sign language (need an interpreter) Computer


59 Deaf-Blind Children Profound effects on development
Motor milestones usually achieved Other development often delayed Finger spelling Developing future goals for the child

60 End of Presentation

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