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 children...as 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