Nursing Care of the Child With a Disorder

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Nursing Care of the Child With a Disorder of the Eyes or Ears Chapter

Nursing Care of the Child With a Disorder of the Eyes or Ears Chapter 17

What we are going to cover • Differentiate between the anatomic and physiologic differences

What we are going to cover • Differentiate between the anatomic and physiologic differences of the eyes and ears in children as compared with adults. • Identify various factors associated with disorders of the eyes and ears in infants and children. • Discuss common laboratory and other diagnostic tests useful in the diagnosis of disorders of the eyes and ears. • Discuss common medications and other treatments used for treatment and palliation of conditions affecting the eyes and ears. • Recognize risk factors associated with various disorders of the eyes and ears. • Distinguish between different disorders of the eyes and ears based on the signs and symptoms associated with them • Discuss nursing interventions commonly used in regard to disorders of the eyes and ears. • Devise an individualized nursing care plan for the child with a sensory impairment or other disorder of the eyes or ears. • Develop child/family teaching plans for the child with a disorder of the eyes or ears. • Describe the psychosocial impact of sensory impairments on children.

Variations in Pediatric Anatomy and Physiology • Eyes – Eye color determined by 6

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

Variations in Pediatric Anatomy and Physiology of the Eyes and Ears • Eyes –

Variations in Pediatric Anatomy and Physiology of the Eyes and Ears • Eyes – Visual acuity develops from birth through early childhood. – Eyeball occupies larger space, within the orbit than the adult’s does, making it more susceptible to injury. – Color discrimination is incomplete. – Retinal vascularization is incomplete.

Variations in Pediatric Anatomy and Physiology of the Eyes and Ears • Ears –

Variations in Pediatric Anatomy and Physiology of the Eyes and Ears • Ears – Hearing is intact at birth. – Recurrent ear disorders may affect hearing. – Placement of Eustachian tubes and enlarged adenoids make ears prone to infection. – Infant’s relatively short, wide, and horizontally placed Eustachian tubes allow bacteria and viruses to gain access to the middle ear easily, resulting in increased numbers of ear infections as compared to the adult.

Ears • Congenital deformities usually associated with other anomalies and genetic syndromes • Infants

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

Common Laboratory and Diagnostic Tests • Culture of the eye or ear discharge •

Common Laboratory and Diagnostic Tests • Culture of the eye or ear discharge • Tympanic fluid culture • Tympanometry – used to detect problems in the middle ear – looks inside the ear to make sure nothing is blocking the eardrum – a device is placed into ear – changes the air pressure in ear and makes the eardrum move back and forth – A machine records the results on graphs called tympanograms.

Common Drugs for Ear and Eye Disorders Adapted from Taketokmo, C. K. , Hodding,

Common Drugs for Ear and Eye Disorders Adapted from Taketokmo, C. K. , Hodding, J. H. , & Kraus, D. M. (2010). Lexi-comp’s pediatric dosage handbook (17 th ed. ). Hudson, OH: Lexi-comp.

Common Medical Treatments for Eye and Ear Disorders • Therapeutic management for both hyperopia

Common Medical Treatments for Eye and Ear Disorders • Therapeutic management for both hyperopia and myopia is prescription eyeglasses or contact lenses. • Warm compress • Patching • Therapeutic management of amblyopia focuses on strengthening the weaker eye using patching or atropine drops in the better eye, vision therapy, or eye muscle surgery if the cause is strabismus. • Eye muscle surgery • Pressure-equalizing (PE) tubes • Hearing aids • Cochlear implants

Types of infectious and inflammatory Diseases of the Eye • Conjunctivitis • Nasolacrimal duct

Types of infectious and inflammatory Diseases of the Eye • Conjunctivitis • Nasolacrimal duct obstruction • Eyelid lesions • Periorbital cellulitis • The risk factors for each type of infection

Conjunctivitis • Inflamation of the bulbar or palpebral conjunctiva. • In newborns: causes are

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

Signs and Symptoms of Conjunctivitis • • • Redness of conjunctiva Edema Tearing Discharge

Signs and Symptoms of Conjunctivitis • • • Redness of conjunctiva Edema Tearing Discharge Eye pain Itching of the eyes (usually with allergic conjunctivitis)

Types of Conjunctivitis Adapted from Braverman, R. S. (2011). Eye. In W. W. Hay,

Types of Conjunctivitis Adapted from Braverman, R. S. (2011). Eye. In W. W. Hay, M. J. Levin, J. M. Sondheimer, & R. R. Deterding (Eds. ), Current pediatric diagnosis and treatment (20 th ed. ). New York: Mc. Graw-Hill.

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

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

Allergic Conjunctivitis • Caused by perennial or seasonal allergies • Conjunctiva red • Discharge

Allergic Conjunctivitis • Caused by perennial or seasonal allergies • Conjunctiva red • Discharge clear, watery • Child rubs eyes frequently • The nurse would be alert to the child's increased risk for Atopic dermatitis

Conjunctivitis Therapeutic and Nursing Management – Treatment depends on cause • Viral is self-limiting,

Conjunctivitis 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 cool, 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 and drainage has stopped • CONTAGIOUS if bacterial cause • Teach parent to administer medications – Caution with use of steroids—may exacerbate viral infections

Child Teaching to Reduce Allergens on Child’s Skin and Hair • Encourage the child

Child Teaching to Reduce Allergens on Child’s Skin and Hair • Encourage the child not to rub or touch the eyes. • Rinse the child’s eyelids periodically with a clean washcloth and cool water. • When the child comes in from outdoors, wash the child’s face and hands. • Ensure that the child showers and shampoos before bedtime.

Nasolacrimal Duct Obstruction • • • Stenosis or simple obstruction of the nasolacrimal duct

Nasolacrimal Duct Obstruction • • • Stenosis or simple obstruction of the nasolacrimal duct is a common disorder of infancy, occurring in about 6% to 20% of the general 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

Nasolacrimal Duct Massage • Teach procedure to parents: – Using the forefinger or little

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

Disorder of Eyelid and Management • Types – Hordeolum (stye) – Chalazion – Blepharitis

Disorder of Eyelid and Management • Types – Hordeolum (stye) – Chalazion – Blepharitis • Management – Topical antibiotic ointment

Periorbital Cellulitis • Bacterial infection of eyelids or surrounding tissue of eye • Enters

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 • Focuses on intravenous antibiotic administration during the acute phase followed by completion of the course with oral antibiotics. – 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

Complications of periorbital cellulitis • Bacteremia • Progression to orbital cellulitis – more extensive

Complications of periorbital cellulitis • Bacteremia • Progression to orbital cellulitis – more extensive infection involving the orbit of the eye. – Child doesn’t improve – Inability to move eye – Visual acuity change – Proptosis (displacement)occurs

Visual Impairment • General term that refers to visual loss that cannot be corrected

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

Signs and Symptoms of Visual Impairment • Any age: dull, vacant stare • Infant:

Signs and Symptoms of Visual Impairment • Any age: dull, vacant stare • Infant: does not “fix and follow, ” does not make eye contact, is unaffected by bright light, does not imitate facial expression • Toddler and older child: rubs, shuts, and covers eyes; squints and blinks frequently; holds objects close or sits close to television; bumps into objects; displays head tilt or forward thrust

Visual Impairment Classification • Partially sighted: – Acuity of 20/70 -20/200 – Education usually

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

Factors Increasing the Risk for Developing Visual Impairment • • Prematurity Developmental delay Genetic

Factors Increasing the Risk for Developing Visual Impairment • • Prematurity Developmental delay Genetic syndrome Family history of eye disease African American heritage Previous serious eye injury Diabetes, HIV Chronic corticosteroid use

Risk Factors for Retinopathy of Prematurity (ROP) • Low birthweight • Early gestational age

Risk Factors for Retinopathy of Prematurity (ROP) • Low birthweight • Early gestational age • Sepsis • High light intensity • Hypothermia

Measures to Prevent Visual Impairment • Prenatal care, prevention of prematurity • Rubella immunizations

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

Visual Impairments • Astigmatism: – unequal curvatures in refractive apparatus, usually myopic – Treated

Visual Impairments • Astigmatism: – unequal curvatures in refractive apparatus, usually myopic – Treated with special lenses or laser surgery – signs and symptoms of astigmatism including blurry vision, difficulty seeing letters as a whole, headaches, dizziness, eye fatigue, and tilting the head to see better. • Amblyopia: – Reduced visual acuity in one eye, “Lazy eye” – Treat primary vision defect such as strabismus

Strabismus • Strabismus is a disorder in which the two eyes do not line

Strabismus • Strabismus is a disorder in which the two eyes do not line up in the same direction, and therefore do not look at the same object at the same time. The condition is more commonly known as "crossed eyes. “ • Common, occurs in 4% of children • Most common types – Exotropia – eyes turn outward – Esotropia – eyes turn inward • May affect visual development, cause diplopia • Infants up to 3 months may have intermittent strabismus – Treatment depends on cause, may involve patching stronger eye (occlusion therapy) or surgery – Early diagnosis essential to prevent vision loss from amblyopia

Nystagmus • is a term to describe fast, uncontrollable movements of the eyes that

Nystagmus • is a term to describe fast, uncontrollable movements of the eyes that may be: Side to side (horizontal nystagmus); Up and down (vertical nystagmus); Rotary (rotary or torsional nystagmus) • Depending on the cause, these movements may be in both eyes or in just one eye. The term "dancing eyes" has been used to describe nystagmus.

Visual Impairments • Cataracts – a congenital cataract is an opacity of the lens

Visual Impairments • Cataracts – a congenital cataract is an opacity of the lens of the eye that is present at birth and sensory amblyopia will result if the infant goes untreated. – Prevents light from refracting on retina – Symptoms include: gradual decrease in vision, nystagmus (with blindness), gray opacities of lens, strabismus, absence of red reflex • Nystagmus: very rapid, irregular eye movements which makes it hard for the brain and eyes to communicate, affecting vision. Result of congenital cataracts or neurological disorder. – Treatment: Surgery to remove cloudy lens and replace lens

Visual Impairments • Glaucoma – Increased intraocular pressure affects optic nerve, leading to atrophy

Visual Impairments • Glaucoma – Increased intraocular pressure affects optic nerve, leading to atrophy and blindness – Symptoms include: • • • vision loss halos around objects pain, redness, tearing photophobia, winking, enlarged eyeball Infant keeping eyes closed most of the time or rubbing eyes Corneal enlargement and clouding Enlarged appearance of the eye Tearing or conjunctivitis Eyelid squeezing or spasm

Glucoma • Treatment: – medications: beta-blockers or Alphaagonists eye drops – Oral meds acetazolamide

Glucoma • Treatment: – medications: beta-blockers or Alphaagonists eye drops – Oral meds acetazolamide (Diamox Sequels) and methazolamide (Neptazane) – Surgery to relieve pressure – Laser surgery. In the last couple of decades, a procedure called trabeculoplasty (truh-BEK-u -lo-plas-tee) has had an increased role in treating open-angle glaucoma.

Refractive Errors • Refraction: bending of light rays through the lens of the eye

Refractive Errors • Refraction: bending of light rays through the lens of the eye • Myopia: nearsightedness • Hyperopia: farsightedness • Strabismus (may or may not be refractive)

Visual Disorders • Refractive errors – Nursing assessment – Nursing management • Educating about

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.

Hospitalization of the Visually Impaired Child • • Work closely with the family Safe

Hospitalization of the Visually Impaired Child • • Work closely with the family Safe environment Reassurance Orient child to surroundings Encourage independence Consistency of team members To promote the most appropriate effective communication with the child use his name before touching him.

Promoting Child’s Optimum Development • Play and socialization • Development of independence • Education:

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

Nursing Process Overview • Assessment – Health history – Physical examination • Inspection and

Nursing Process Overview • Assessment – Health history – Physical examination • Inspection and observation • Palpation • Laboratory and diagnostic testing

Information Elicited in Health History of Present Illness • • • Onset and progression

Information Elicited in Health History of Present Illness • • • Onset and progression Fever Nasal congestion Eye or ear pain Eye rubbing Ear pulling Headache Lethargy Behavioral changes

Nursing diagnoses • • Disturbed sensory perception Risk for infection Pain Delayed growth and

Nursing diagnoses • • Disturbed sensory perception Risk for infection Pain Delayed growth and development Impaired verbal communication Deficient knowledge Interrupted family processes Risk for injury

Nursing Assessment of Vision • Infancy: – Response to visual stimuli – Parental observations

Nursing Assessment of Vision • Infancy: – Response to visual stimuli – Parental observations and concerns – Expect binocularity by age 6 months • Childhood: – Visual acuity testing

Nursing Management of Child with Visual Impairments • Be alert to clinical manifestations: –

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

External Examination of the Eyes • Use inspection and observation to assess for eye

External Examination of the Eyes • Use inspection and observation to assess for eye disorders • Note use of eyeglasses or lenses • Observe positioning, symmetry • Assess if eyelids open equally (failure to open fully is ptosis). • Check for presence of strabismus*, nystagmus**, and squinting.

External Examination of the Eyes • Note variations in eye slant and the presence

External Examination of the Eyes • Note variations in eye slant and the presence of epicanthal folds. • Assess for eyelid edema, sclera color, discharge, tearing, and pupillary equality, as well as size and shape of the pupils • Observe pupils and reactions, corneal light reflex, iris and sclera color • Red Reflex • Test for extraocular movement

Eversion of lid for examination

Eversion of lid for examination

Testing of Eyes Performed During Physical Examination Extraocular movements Pupillary light response and accommodation

Testing of Eyes Performed During Physical Examination Extraocular movements Pupillary light response and accommodation Symmetry of corneal light reflex Presence of red reflex with an ophthalmoscope • Age-appropriate visual acuity test • •

Ocular Motility Rt superior rectus Lt inferior oblique Lt superior rectus Rt inferior oblique

Ocular Motility Rt superior rectus Lt inferior oblique Lt superior rectus Rt inferior oblique Rt lateral rectus Lt medial rectus Lt lateral rectus Rt medial rectus Rt inferior rectus Lt superior oblique Lt inferior rectus Rt superior oblique

Corneal Light Reflex to Check Symmetry • Child on left has symmetrical reflection of

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

Red Reflex • AKA "Bruchner's test" can detect many different ophthalmologic problems in children

Red Reflex • AKA "Bruchner's test" can detect many different ophthalmologic problems in children and should be performed as part of a normal newborn screening. • In normal eyes, the practitioner will shine a light into the eye and will see a red reflection with the ophthalmoscope. This is also what causes "red eye" in pictures. • no red reflex (leukocoria, which means white pupil • Cataract, Retinoblastoma, chorioretinal coloboma, persistent hyperplastic primary vitreous, endophthalmitis, Coats disease, retinal detachment,

Outcomes The images below show the possible outcomes. You can show these images to

Outcomes The images below show the possible outcomes. You can show these images to parents as they may have taken photographs demonstrating usual red reflexes. Normal red reflex = no referral Red reflex absent Obvious +/- asymmetry = urgent referral Unsure/difficult assessment = Pediatric Ophthalmology Primary Care Clinic referral Red reflex abnormal = urgent referral

Periodic Recommended Screening • • Prenatal Newborns through preschoolers Children of all ages Use

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

Periodic Recommended Screening • Vision impairment in children refers to acuity between 20/60 and

Periodic Recommended Screening • Vision impairment in children refers to acuity between 20/60 and 20/200 in the better eye on examination • “legal blindness” is a term used to refer to vision of less than 20/200 or peripheral vision less than 20 degrees.

Adolescent Dumbass

Adolescent Dumbass

Types of Eye Injuries Requiring Referral to Ophthalmologist Chemicals Sunburns Hematoma Penetrating injuries Traumatic

Types of Eye Injuries Requiring Referral to Ophthalmologist Chemicals Sunburns Hematoma Penetrating injuries Traumatic hyphema Blowout fracture Ruptured globe Thermal injury/corneal flash burn Extensive animal bite Lid laceration with underlying structural involvement Corneal abrasion in which corneal penetration is suspected • Foreign body embedded in the globe • • •

Eye Injuries • Nursing management – Managing non-emergent eye injuries • Suture lacerations •

Eye Injuries • 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 – manage a black eye (ice pack for 20 minutes on and 20 minutes off for first 24 hours)

Disorders of the Ears

Disorders of the Ears

Observation of the Ear • Must inspect their size and shape, position, and the

Observation of the Ear • Must inspect their size and shape, position, and the presence of skin tags, dimples, or other anomalies. • Otoscopic examination – Note the presence of cerumen, discharge, inflammation, or a foreign body in the ear canal. • Visualize the tympanic membrane. – Observe its color, landmarks, and light reflex, as well as presence of perforation, scars, bulging, or retraction.

Otoscopic Examination of Ear • Note presence of cerumen, discharge, inflammation or foreign body

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

Otitis Media • Acute otitis media (AOM) – Pathophysiology : Bacterial or viral infection

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

Prevention of Hearing Loss • Treatment and management of recurrent otitis media – A

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 Acute Otitis Media – note erythema and opacity of tympanic membrane

Otitis Media • Acute otitis media (AOM) (cont’d) – Nursing management • Managing pain

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

Prevention of Hearing Loss • Surgical treatment – Tympanostomy: placement of ear tubes –

Prevention of Hearing Loss • Surgical treatment – Tympanostomy: placement of ear tubes – for children less than about 5 -6 years old, 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

Otitis Media with Effusion • Otitis media with effusion (OME) – Presence of fluid

Otitis Media with Effusion • 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

Pressure-equalizing tubes in place

Pressure-equalizing tubes in place

Myringotomy (Ear Tubes) • Small tubes(made of plastic, metal, or Teflon) • Surgically placed

Myringotomy (Ear Tubes) • Small tubes(made of plastic, metal, or Teflon) • Surgically placed into child's eardrum by an ear, nose, and throat surgeon • Help drain fluid out of the middle ear in order to reduce the risk of 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

Myringotomy – Pre and Post-Op Nursing Care * • Prepare child and parent for

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

Myringotomy – Pre and Post-Op Nursing Care * REASONS TO CALL SURGEON • Ears

Myringotomy – Pre and Post-Op Nursing Care * 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

Otitis Externa (Swimmer’s ear) • Infection and inflammation of external ear canal • Bacterial

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.

Types of Delayed-Onset Hearing Loss • Conductive hearing loss – Results when transmission of

Types of Delayed-Onset Hearing Loss • Conductive hearing loss – Results when transmission of sound through the middle ear is disrupted, as in the case of OME • Sensorineural hearing loss – Caused by damage to the hair cells in the cochlea or along the auditory pathway • Mixed hearing loss – Occurs when the cause may be attributed to both conductive and sensorineural problem

Hearing Loss and Deafness • Nursing assessment – Health history – Physical examination and

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

Hearing Impairment • Ranges from mild to profound • Deaf: a person whose hearing

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 in Children • One of the most common disabilities • Estimated 3 in

Incidence in Children • 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

Causes of Hearing Impairments • • • Anatomic malformation Low birth weight Ototoxic drugs

Causes of Hearing Impairments • • • Anatomic malformation Low birth weight Ototoxic drugs Chronic ear infections Perinatal asphyxia Perinatal infections: – rubella, herpes, syphilis, bacterial meningitis • Cerebral palsy

Levels of Hearing Loss • Hearing loss may be unilateral (involving one ear) or

Levels of Hearing Loss • Hearing loss may be unilateral (involving one ear) or bilateral (involving both ears) • Extent of hearing loss is defined based on the softest intensity of sound that is perceived, described in decibels (d. B) – 0 to 20 d. B: normal – 20 to 40 d. B: mild loss – 40 to 60 d. B: moderate loss – 60 to 80 d. B: severe loss – Greater than 80 d. B: profound loss (ASHA, 2011 b)

Symptom Severity • Measured in decibels (d. B) – A unit of loudness –

Symptom Severity • Measured in decibels (d. B) – 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

Pathology of Hearing Impairments • Conductive hearing loss—middle ear • Sensorineural hearing loss—nerve deafness

Pathology of Hearing Impairments • Conductive hearing loss—middle ear • Sensorineural 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)

Manifestations of Hearing Impairment in Infancy • • • Lack of startle reflex Absence

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 -6 months, essential to improve language and educational outcomes

Therapeutic Management of Hearing Impairment • Medical – Antibiotic therapy for otitis media •

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: May help children with sensorineural hearing loss

 • The diagnosis of a significant disability can be extremely stressful for the

• The diagnosis of a significant disability can be extremely stressful for the family. • Encourage families to express their feelings and provide emotional support • The child with hearing loss should receive early intervention with hearing aids or other augmentative devices to minimize the psychosocial impact of sensory deficits. 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.

Childhood Deafness • Profound deafness likely to be diagnosed in infancy • Entry into

Childhood Deafness • Profound deafness likely to be diagnosed in infancy • Entry into school • Concerns with speech development – One reason number of words and speech assessed at PCP’s visit

Promoting Communication • • Lipreading Cued speech Sign language Speech language therapy Socialization Additional

Promoting Communication • • Lipreading 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

Care for Hearing Impaired Child During Hospitalization • Reassess understanding of instructions given •

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

Deaf-Blind Children • • • Profound effects on development Motor milestones usually achieved Other

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