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 EyesEye color determined by 6-12 monthsEyeball occupies a larger space in orbit so more prone to injuryNewborn’s lens can only accommodate 8-10 inches and color discrimination incompleteVisual acuity improves with age, 20/20 by 6-7 yearsRectus muscle uncoordinated at birth and matures over time. Binocular vision (simultaneous focus by both eyes) achieved by 4 months
3 Nursing Process Overview AssessmentHealth historyPhysical examinationInspection and observationPalpationLaboratory and diagnostic testingNursing diagnosesDisturbed sensory perceptionRisk for infectionPainDelayed growth and developmentImpaired verbal communicationDeficient knowledgeInterrupted family processesRisk for injury
4 Inspecting the eye Assessment of Vision Infancy: Childhood: Note use of eyeglasses or lensesObserve positioning, symmetry, presence of strabismus, nystagmus and squintingEyelids should open fully (ptosis is lid not fully open); Look for edemaNote eye slant, epicanthal foldsObserve pupils and reactions, corneal light reflex, iris and sclera colorTest for extraocular movementInvert eyelid to check conjunctive for rednessAssessment of VisionInfancy:Response to visual stimuliParental observations and concernsExpect binocularity by age 6 monthsChildhood: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 examNormal view – the retina should be a “red reflex”Ophthalmoscopic ExamDarken 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. 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 PrenatalNewborns through preschoolersChildren of all agesUse age-appropriate visual acuity test
7 Visual Disorders Refractive errors Nursing assessmentNursing managementEducating about eyeglasses useEducating about contact lens useMonitoring for fit and visual correctionHealthy People 2020: Goal to increase use of protective equipment (eye goggles) when engaged in potentially dangerous activities.
8 EarsCongenital deformities usually associated with other anomalies and genetic syndromesInfants short, wide and horizontally placed Eustachian tube allows bacteria and viruses to reach middle ear more easily, so more prone to ear infectionsAs child matures, tubes more slantedIf 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 anomaliesConduct hearing testing with infants and children
10 Otoscopic Examination of Ear Note presence of cerumen, discharge, inflammation or foreign body in ear canalVisualize tympanic membrane for color, landmarks, and light reflex. Also for abnormalities like perforation, bulging, scars or retractionView of a normal tympanic membrane
12 Conjunctivitis Inflamation of the bulbar or palpebral conjunctiva. In newborns: causes are chlamydia, gonorrhea, or herpes simplex virusIn infants: may be sign of tear duct obstructionIn children: causes are bacterial (most common, also called “Pink Eye”), viral, allergic, or foreign bodySigns and SymptomsPurulent eye drainage, crustingInflamed conjunctiva and swollen lids
14 Bacterial Conjunctivitis Redness of conjunctivaCopious, discolored drainage with mattingEyelid swelling
15 Allergic Conjunctivitis Caused by perennial or seasonal allergiesConjunctiva redDischarge clear, wateryChild rubs eyes frequently
16 Therapeutic and Nursing Management Treatment depends on causeViral is self-limiting, remove secretionsBacterial: Culture of eye drainage. Topical antibacterial agents like polymycin and bacitracin, Sulamyd or PolytrimDrops during day and ointment at nightNursing CareKeep 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 eyeMedications:topical antibacterials to eye: Polysporin, Sulamyd or PolytrimTeach prevention of infection to child and family: discard tissues, wash cloths separately, don’t rub eyes. GOOD HAND-WASHINGChildren don’t attend school until infection treated. CONTAGIOUS if bacterial causeTeach parent to administer medicationsCaution with use of steroids—may exacerbate viral infections
17 Nasolacrimal Duct Obstruction Stenosis or simple obstruction of the nasolacrimal ductCommon in infancy: 5-20% population, usually resolves by 1 year oldUnilateral in 65% casesNursing assessmentS&S: Tearing or discharge from one or both eyes by 2 weeks oldRedness of lower lid of affected eyeCulture may be done to rule out conjunctivitisNursing managementTeach 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 neededUsually 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 upGently push downward along the side of the nose
20 Periorbital Cellulitis Bacterial infection of eyelids or surrounding tissue of eyeEnters through break in skin, sinusitis, conjunctivitisMost common bacteria: Staph. aureus, Strep. pyogenes, Strep pneumoniaeInitiate inflammatory responseNursing assessmentS&S: redness, swelling, pain around eyeNursing managementWarm soaks to eye area 20 minutes every 2-4 hoursTeach family to complete full course of antibiotics at homeTeach parents to call PCP if eye doesn’t improveMay require hospitalization for IV antibioticsManage pain with analgesics
24 Eye Injuries Nursing assessment Nursing management Health history Physical examinationNursing managementManaging non-emergent eye injuriesSuture lacerationsChild may need sedation and pain medAssist physician with examinationEdema and black eye treated with ice pack on 20 minutes, off 20 minutes. Repeat cycle. May take 3 weeks to resolveScleral hemorrhages will resolve without interventionCorneal abrasions treated with topical antibiotic and analgesicsRemove foreign objects from eye using eyelid eversion. Irrigating with normal saline may help.Serious foreign body will need opthamologist to removeChemical injuries require immediate irrigation with copious amounts of waterVisit to opthamologist advisedTeach PREVENTION
25 Eversion of lid for examination Technique to remove foreign objects from eye
26 Measures to Prevent Visual Impairment Prenatal care, prevention of prematurityRubella immunizations for all childrenSafety counseling for preventing eye injuries
27 Visual ImpairmentGeneral term that refers to visual loss that cannot be corrected with regular prescription lenses
28 Visual Impairment Classification Partially sighted:Acuity of 20/70-20/200Education usually in public school systemLegal blindness:Acuity of 20/200 or lessLegal as well as medical term
29 Etiology of Visual Impairments Perinatal or postnatal infections:Gonorrhea, chlamydia, rubella, syphilis, toxoplasmosisRetinopathy of prematurityPerinatal or postnatal traumaOther disordersUnknown causes
30 Strabismus Common, occurs in 4% of children Most common types Exotropia – eyes turn outwardEsotropia – eyes turn inwardMay affect visual development, cause diplopia (double vision)Infants may have intermittent strabismus which resolves by 3 monthsStrabismus, 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 lightThis child with strabismus reflects light unevenly
33 Other Visual Impairments Astigmatism:unequal curvatures in refractive apparatus, usually myopicTreated with special lenses or laser surgeryAmblyopia:Reduced visual acuity in one eye, “Lazy eye”Treat primary vision defect such as strabismusStrabismus“Squint” or cross-eyeEsotropia – inward deviation of eyeExotropia – outward deviation of eyeTreatment depends on cause, may involve patching stronger eye (occlusion therapy) or surgeryEarly diagnosis essential to prevent vision loss from amblyopiaStrabismus 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 blinkingDifficulty reading or doing close work, poor school performancePerform vision screening or advise parent to bring child for eye exam with opthamologistEncourage child to wear corrective lensesTreatment may include laser surgery or eye surgery
35 Hospitalization of the Visually Impaired Child Work closely with the familySafe environmentReassuranceIntroduce yourself BEFORE touching childOrient child to surroundingsKeep items and furniture in the same placeEncourage independenceConsistency of team members
36 Promoting Child’s Optimum Development Play and socializationDevelopment of independenceEducation:BrailleAudio books and learning materials
38 Otitis Media Acute otitis media (AOM) Pathophysiology : Bacterial or viral infection of fluid in middle earPeak incidence: 0-2 years, especially 6-12 monthsTherapeutic managementNursing assessmentHealth historyPhysical 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 mediaA common cause of conductive/middle-ear hearing lossMedical tx:Wait and seeAntibioticsSurgical treatmentTympanostomy: placement of ear tubesfor 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 children...as might a laser myringotomy.Prenatal preventive measuresAvoid exposure to noise pollution
42 Otitis Media Acute otitis media (AOM) (cont’d) Nursing management Managing pain associated with AOMAnalgesics like acetaminophen or ibuprofenNarcotic analgesics like codeine for severe painHeat or cool compress: have child lay affected ear on compressNumbing eardrops like benzocaine (Auralgan)Educating the familyObserve for S&S and call PCPTeach completion of antibiotics if ordered – VERY IMPORTANT!Follow-up to check progress, test hearingPreventing AOMEncourage breastfeeding 6-12 monthsAvoid exposing child to individuals with upper respiratory infectionsDON’T EXPOSE TO SECOND HAND SMOKEImmunize child, including flu vaccinesXylitol, 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 infectionNursing assessmentHealth historyRisk Factors: passive smoking, not breastfed, frequent upper respiratory infections, allergy, young age, male, congenital disordersPhysical examinationMay be asymptomatic or experience popping or fullness behind eardrumOtoscopic exam may reveal dull, opaque tympanic membrane that’s gray, white or bluish. Tympanometry may diagnose OMENursing managementEducating the familyAntihistamines, antibiotics and steroids usually don’t workTeach NOT to prop infant with bottleMonitoring for hearing loss and speech developmentProviding postoperative care for the child with pressure-equalizing tubesTubes inserted and remain a few monthsMay need to avoid water in ears, wear earplugs with baths and swimming
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, VSThe operation usually takes 15 to 20 minutes.Child will go home 2-4 hours after surgery.Post-Op Care and TeachingNormal to have fluid 3-4 days, grey/brown and slight smell. Fluid may leak from your child’s earThe tubes will stay in your child’s ears for several monthsDo not put anything into your child’s earMay have a bath. Ear plugs may or may not be recommended by surgeon. Consult surgeon about other water activities like swimming.MedicinesAntibiotic 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 IbuprofenMay 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 monthsREASONS TO CALL SURGEONEars 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 canalBacterial or fungalNursing assessmentHealth historyPhysical examinationEar red, edematous, itchy, painful, may affect hearingNursing managementManaging painTreating the infectionPreventing reinfectionRecent 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 aidHard of hearing: generally able to hear with hearing aidIncidenceOne of the most common disabilitiesEstimated 3 in 1000 well babies have some degree of hearing lossNeonates in ICU: 2-4 per 100In US about 1 million children from birth to 21 years have hearing loss1/3 of these children have other sensory or cognitive problems
49 Pathology of Hearing Impairments Conductive hearing loss—middle earSensori-neural hearing loss—nerve deafnessMixed conductive-sensorineural loss—may follow recurrent otitis media with complicationsCentral 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 assessmentHealth historyPhysical examination and laboratory and diagnostic testsNursing managementAugmenting hearingPromoting communication and educationEncouraging educationProviding support
51 Causes of Hearing Impairments Anatomic malformationLow birth weightOtotoxic drugs:Include: aspirin, lasix, vancomycin, gentamycin, vicodin, many psych and antineoplastic drugsChronic ear infectionsPerinatal asphyxiaPerinatal infections:rubella, herpes, syphilis, bacterial meningitisCerebral palsyHearing TestingMeasured in decibels (dB)A unit of loudnessMeasured at various frequenciesSpeech range is 2000 cycles/secHearing thresholdMeasurement of a person’s hearing threshold with audiometerDegree of symptom severity as it affects speech
52 Manifestations of Hearing Impairment in Infancy Lack of startle reflexAbsence of babbling by age 7 monthsGeneral indifference to soundLack of response to spoken wordEARLY DETECTION, best within 3-6months, essential to improve language and educational outcomes
53 Therapeutic Management of Hearing Impairment MedicalAntibiotic therapy for otitis mediaSurgical interventionsTympanostomy tubes for chronic otitis mediaHearing aidLearn how to use hearing aidTeach child to manage when old enoughManaging acoustic feedbackReinsert aidCheck for hairClean ear mold or earLower volumeCochlear implants:ay help children with sensorineural hearing loss
54 Hearing AidsFIG. 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 infancyConcerns with speech developmentOne reason number of words and speech assessed at PCP’s visitMethods of CommunicationLip-readingCued speechSign languageSpeech language therapySocializationAdditional aidsCochlear implantA 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
57 Care for Hearing Impaired Child During Hospitalization Reassess understanding of instructions givenSupplement with visual and tactile mediaCommunication devices:Picture boardCommon words and needs (food, water, toilet)Sign language (need an interpreter)Computer