EYES & EARS

1. EYES & EARS By Darline Riggs RN, BSN, MSN

2. Eye

4. Corneal Injuries • Types: • Foreign bodies- Medically treated with flush of saline • Burns- treated with 15-20 minute tap water flush • Abrasion and Lacerations- medically cleaned with normal saline, topical antibiotic • Penetrating wounds- botheyes should be covered while patient is transport to hospital

5. Eye trauma • foreign body • use eversion procedure • if foreign body has penetrated, do not remove the foreign body • irrigate affected eye with sterile normal saline eye irritant • corneal abrasion • disruption of the cells and loss of superficial epithelium • caused by trauma, chemical irritant, foreign body, or lack of moisture • findings: severe pain, blurred vision, halo around lights, lacrimation, inability to open eye, photophobia • diagnosis by fluorescein sodium dye • abrasions heal usually within 48 hours with no scarring or visual deficit • treatment includes short-acting analgesic drops, eye rest with soft or rigid eye patch • corneal laceration • same causes and findings as with abrasions • lacerations are serious emergencies to require immediate attention • surgery is generally required • follow up care for client undergoing eye surgery Penetrating injury • immediate care • do not remove the object • do not apply pressure of any kind to the eye or the object • cover the injured eye to protect movement of the object, may use a paper or plastic cup or rigid eye patch • cover uninjured eye with soft or rigid eye patch to avoid sympathetic movement • get client to emergency room immediately • surgery will be required

6. Refractory Errors A refractive error is an irregularity in the way light passes through the eye • Strabismus(a.k.a: cross-eyed)- Inability of eyes to focus in the same direction • Non-symmetrical eyeball position

7. chemical irritants • flush eye with plenty of tap water or sterile normal saline if available • get client to emergency room immediately • alkaline substances penetrate the cornea rapidly and must be removed quickly; these injuries are a priority to care for • acids coagulate the eye's proteins and often result in relatively superficial, reversible damage • ultraviolet burns • often occur from sun exposure or welding flashes (looking at a welding flame without special glasses during the welding process) • irritate epithelium, which swells and scales off (desquamation) • care is the same as with lacerations • general pharmacotherapy for eye trauma • topical anesthetics • topical anti-inflammatory • topical mydriatic-cycloplegic agents to prevent papillary constriction • general management of any eye trauma • copious irrigation of the affected eye • apply bilateral rigid or soft eye patches to rest both eyes by decreased eye movement • have clients use tinted glasses for photophobia to reduce eye discomfort from artificial lights or sunlight • assist clients with activities of daily living as needed • review with clients to avoid activities which increase intraocular pressure

8. Glaucoma the second most common cause of vision loss in the U.S.; may be unilateral or bilateral most common type: chronic open-angle glaucoma (simple, adult primary, primary open-angle) • etiology/epidemiology • hereditary link • unknown etiology • aqueous humor does not drain adequately which leads to increased intraocular pressure (IOP) • this pressure on the optic nerve causes destruction of nerve fibers in the retina resulting in vision loss • findings • most clients are without findings until there is a loss of vision • peripheral vision loss is affected first prior to total loss of vision • three classic assessment findings • visual field loss (peripheral) • elevated intraocular pressure • cupping of the optic disk

9. management expected outcomes - reduction of IOP and prevention of visual field defects treatment of choice: pharmacotherapy miotic eye drops (parasympathomimetic agents) carbonic anhydrase inhibitors - Diamox beta-adrenergic blocking agents- Timoptic drops epinephrine eye drops (contraindicated in clients with cardiac conditions) - used more often in emergency care Post-op: cycloplegicand steroid eye drops are usually used antibiotics may be ordered a mydriatic eye drop medication is then used to prevent adhesions to the cornea; remember that use of this classification of medications is contraindicated with glaucoma

11. Cataract etiology - clouding of lens - may be unilateral or bilateral; one of the most common eye disorders first type: senile cataract - result of aging process second type: traumatic develops within a few months after eye trauma painless but progressive loss of sight in one or both eyes diagnostics – history, physical exam of eyes management expected outcome: correction of visual field defect treatment - only surgical cataract extraction: removal of cloudy lens

12. Retinal detachment etiology - holes or breaks (tears) in the retina • fluid, blood or a mass separates the retina's sensory layer from the pigment epithelium (pigment cells) • common causes are inflammation, trauma, hemorrhage, and tumors • retinal detachment often begins in the periphery and spreads posteriorly findings • a rapid separation gives the sense of a "curtain being pulled over the eye" so that clients have partial vision • a slow separation may be asymptomatic • the ophthalmic exam reveals the detached area as gray bulge, ripple or fold • flashes of light, followed by floating spots, loss of specific field of vision

13. management • expected outcome: correction of and/or prevention of further vision • laser surgery • photocoagulation: laser beam is directed through a dilated pupil • the effect is to seal localized breaks or rips in the retina • cryotherapy: extreme cold freezes rips in the retina • diathermy: heat is applied with ultrasonic probe to repair rips • scleral buckle • pharmacotherapy: local or systemic • adrenergic-mydriatic agents • cycloplegic agents • antibiotics

14. nursing interventions • maintain the client in proper position for bed or chair rest as ordered • apply a post-op rigid/soft eye patch to rest eye (or both eyes) • suggest dark lens glasses for photophobia • administer medications as ordered • prevent activities that increase IOP Visual impairment and blindness • legal blindness: a maximum visual acuity of 20/200 (with optimum correction) and/or a visual field that is reduced to a range of 20 degrees (normal range=180 degrees) • most common causes: retinal degeneration, glaucoma, cataract, amblyopia, macular degeneration ("central" loss of vision) • nursing interventions • speak to clients upon entering the room • implement safety measures based on how clients accommodate the loss of sight • orient clients to new surroundings; use numbers on traditional clock for the placement of furniture or food on plates • assist clients with activities of daily living as needed • for walking, do not take client's arm to lead; offer client an arm so that the blind person holds the arm at the elbow of the lead person who walks a little in front of the blind person

19. Lab and Diagnostic Exam • Otoscopy- Initial exam of the ear. Visually exam ear with otoscope • Whisper Voice Test- 12-24 inches away speaking softly (whispering) and getting louder until patient hears. • Tuning fork test- • Weber- vibrating fork is placed on forehead or maxillary incisors. Sound should be equally heard from both ears. • Rinne test- performed by placing a vibrating tuning fork against the patient's mastoid bone. Once they signal they can't hear it, quickly position the still vibrating tuning fork 1-2 cm from the auditory canal, and again ask the patient to tell you if they are able to hear the tuning fork.

20. Ear Structures of Ear • External auditory meatus • Middle ear • tiny, air-filled cavity containing three small bones: incus (anvil), malleus (hammer) and stapes (stirrup) • these bones (ossicles) are connected by joints and supported by muscles • ossicles bridge the tympanic membrane and the oval window • ossicles magnify small sounds by transmitting them from the tympanic membrane to the oval window Inner ear general • contains the sensory receptors for sound and equilibrium • is connected to nasopharynx by the eustachian tube • the eustachian tube opens during swallowing to equalize inner ear pressure to the atmospheric pressure • is composed of fluid-filled membranous labyrinth in a similarly shaped bony labyrinth • membranous labyrinth components include the cochlea and the vestibular apparatus cochlea: a spiral tube • within the cochlea is a membranous duct with a triangular cross section: • impulses travel via the acoustic or eighth cranial nerve to the brain

21. Ear Disorders External ear • external otitis, also called "swimmer's ear • use earplugs for swimming • preventable if 70% alcohol is used to cleanse ears after swimming Middle ear: otitis media Inner ear: Ménière's disease • an inner ear disorder: the endolymphatic system dilates and the volume of endolymph expands • etiology unknown • usually develops between the ages of 40 and 60 years-old • acute attack may require hospitalization • clients may average two to three attacks per year findings • attacks intermittent • three recurrent and progressive findings • vertigo with prostrating nausea and vomiting • tinnitus • hearing loss on involved side persists and progresses diagnostics – history, direct inspection

24. management • expected outcomes - prevention of hearing loss and control of vertigo • medical • pharmacologic - routine • cholinergic blocking agents such as atropine • antihistamines or decongestants • pharmacolgoic - during remission • diuretics - decrease fluid accumulation • vestibular suppressants, e.g., diazepam (Valium) • adrenergic neuron-blocking agents, e.g., epinephrine • low salt, low triglyceride diet surgical • decompression of endolymphatic sac: insertion of an endolymphatic subarachnoid shunt • labyrinthectomy: client will lose all hearing in affected ear nursing interventions during an acute attack of Ménière's disease • keep clients on bed rest in a quiet, dark room • avoid unnecessary movement of clients especially of their head • give general care to clients with nausea and vomiting • restrict salt and water intake as ordered • have clients avoid tobacco, caffeine • institute precautions to prevent clients from falling • discuss the need to avoid a high triglyceride diet

25. Otosclerosis a hereditary degenerative disorder that results in conduction deafness • the formation of new bone growth in labyrinth adheres the stapes to the oval window findings • hearing loss, tinnitus diagnostics - bone conducts more sound than air does management • expected outcome: improvement of hearing in the affected ear • medical: use of a hearing aid • surgical: stapedectomy - replacement of stapes with a prosthesis postoperative care • teach clients to avoid anything that might displace prosthesis, such as coughing, blowing nose, swimming • limit activity as ordered and as tolerated • give medications as ordered: antiemetics, analgesics, antibiotics • assess facial nerve function for asymmetry • keep external ear area dry • instruct client not to fly for at least six months

26. Medications used to manage glaucoma Therapeutic class: miotic cholinergic medications (direct-acting) action: constrict the pupil and increase drainage of aqueous humor by stimulating the ciliary muscle to contract examples - pilocarpine hydrochloride: (IsoptoCarpine, OcusertPilo) carbachol(Carboptic) uses: open-angle glaucoma, xerostomia, compromised lacrimal and salivary function adverse effects life-threatening: increased risk of toxicity in children; hypotension; vertigo and syncope other: diaphoresis, stimulation of salivation and gastrointestinal tract without significant cardiovascular effects; flushing contraindications: asthma, hyperthyroidism, coronary insufficiency, peptic ulcer disease client teaching: blurred vision, poor vision at night, periorbital discomfort

27. Therapeutic class: cholinesterase inhibitors usedfor management of glaucoma not controlled with short-acting miotics or other agents action: increases drainage of aqueous humor, pulls iris away from anterior chamber angle by constricting the ciliary muscle and iris sphincter example: physostigmine ophthalmic (IsoptoEserine) client teaching: may experience periorbital discomfort, watery eyes, burred vision Therapeutic class: beta-adrenergic agents – used in the management of chronic open-angle glaucoma and other forms of ocular hypertension action: decrease intraocular pressure (IOP) by decreasing production of aqueous humor and increasing drainage example: timolol maleate (Timoptic) nursing care establish baseline data and monitor blood pressure, heart rate may cause bronchospasm in clients with reactive airway disease, carefully review medication profile of clients with cardiac history

28. Therapeutic class: carbonic anhydrase inhibitors – used in the management of open-angle glaucoma or other forms of ocular hypertension action: inhibits the enzyme needed to produce aqueous humor leading to decreased production example: acetaZOLAMIDE (Diamox) 250-1000 mg by mouth daily in 1 to 4 divided doses or 500 mg extended-release capsules twice daily nursing care establish baseline data and monitor potassium client teaching: report paresthesias, tinnitus, gastrointestinal upset, or hearing loss Therapeutic class: adrenergic agents action: decreases production of aqueous humor to decrease intraocular pressure (IOP) example: epinephrine bitartrate (Epitrate) client teaching report tachycardia may experience blurred vision, periorbital discomfort, pigment deposits in cornea, conjunctiva, and lids

29. Therapeutic class: osmotic agents action: decreases IOP by moving water out of intraocular structures example: mannitol (Osmitrol) nursing care: establish baseline data and monitor serum electrolytes, glucose Therapeutic class: prostaglandin agonists action: increases outflow of aqueous example: latanoprost ophthalmic (Xalatan) nursing care: establish baseline data and monitor renal and liver function tests client teaching: may experience burning, blurred vision, itching, photophobia

31. The use of atropine for treatment of symptomatic bradycardia is contraindicated for a client with which of the following conditions? • A) Urinary incontinence • B) Glaucoma • C) Increased intracranial pressure • D) Right sided heart failure

32. The use of atropine for treatment of symptomatic bradycardia is contraindicated for a client with which of the following conditions? • A) Urinary incontinence • B) Glaucoma • C) Increased intracranial pressure • D) Right sided heart failure • B: Glaucoma. Atropine is contraindicated in clients with angle-closure glaucoma because it can cause pupillary dilation with an increase in aqueous humor, leading to a resultant increase in optic pressure.

33. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? • A) "I have constant blurred vision." • B) "I can't see on my left side." • C) "I have to turn my head to see my room." • D) "I have specks floating in my eyes."

34. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? • A) "I have constant blurred vision." • B) "I can't see on my left side." • C) "I have to turn my head to see my room." • D) "I have specks floating in my eyes." • C: "I have to turn my head to see my room." Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in the affected eye along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabeculae meshwork. If left untreated or undetected blindness results in the affected eye.

35. A client with sensorineural hearing loss should be examined using which of the following? Choice 1. Tympanocentesis Choice 2. Transillumination of the sinuses Choice 3. Electronystagmography Choice 4. Weber and Rinne tests

36. A client with sensorineural hearing loss should be examined using which of the following? Choice 1. Tympanocentesis Choice 2. Transilluminationof the sinuses Choice 3. Electronystagmography Choice 4. Weber and Rinnetests Correct 4. Weber and Rinne tests are used to differentiate conductive hearing loss from sensorineural. Tympanocentesis is the aspiration of fluid/pus from the middle ear to identify the causative organism of acute otitis media. Transillumination of the sinuses is a diagnostic tool used to examine for sinusitis. The diagnosis of Meniere's disease is confirmed by electronystagmography, a series of tests to evaluate vestibular-ocular reflexes

37. A client with Meniere's disease would probably complain of which of the following? Choice 1. Bilateral hearing impairment Choice 2. Vertigo and nausea Choice 3. Pain when the tragus is touched Choice 4. Tenderness over the mastoid area

38. A client with Meniere's disease would probably complain of which of the following? Choice 1. Bilateral hearing impairment Choice 2. Vertigo and nausea Choice 3. Pain when the tragus is touched Choice 4. Tenderness over the mastoid area Correct 2. Meniere's disease is associated with vertigo that may last for hours as well as fluctuating hearing loss, nausea, and vomiting. The disorder is unilateral, but because hearing is bilateral, the client often does not realize the extent of the hearing loss. Option 3 is indicative of swimmer's ear, and option 4 is indicative of acute otitis media.