Alterations in Eye, Ear, Nose,

8/10/2019 Alterations in Eye, Ear, Nose,

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Alterations In Eye, Ear, Nose,and Throat Function


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Pediatric Differences- Eyes

Visual Acuity ranges between 20/100 and 20/400;20/50 by 2-3 years; 20/20 by 6-7 years

Lens are more spherical and cannot accommodate toboth near and far objects

The ability to distinguish color and other details isdecreased


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Snellen Chart


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Pediatric Differences- Eyes

The rectus muscles that control binocular vision maybe uncoordinated at birth

Alignment and coordinated movement by three

months Nystagmus(involuntary rapid eye movement) and

esotropia(momentary turning inward of the eyes) arecommon in neonates

Conjunctival and retinal hemorrhages may be observedin newborns as a result of the trauma of birth


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Retinal Hemorrhage


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Eyeball- that of an adult and unprotected laterally ,thus more easily injured. By 14 years normal adult size

Tears are produced but only produced enough tears tolubricate and protect the eye


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Note

Vision allows a child to acquire meaning from whatis seen

The brain learns to interpret messages as acuityimproves

Disturbances in vision affects the brains ability tointerpret visual input.


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DISORDERS OF THE EYES


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Infectious Conjunctivitis or pink eye

Inflammation of the conjunctiva

Causes- bacterial, viral, allergies, trauma or irritant .Bacterial more common in children

-Staph. A-H. Influenzae

-Strep. P

-E.coli

Usually a yellow or white discharge is seen

For infants under 30 days- opthalmia neonatarum

A blocked lacrimal duct can mimic conjunctivitis


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Manifestations- Bacterial

Edema of the eyelid

Reddened conjunctiva

Mucopurulent discharge

Itching Burning

photophobia


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Bacterial Conjunctivitis

Spread- hand eye contact

Common in institutions; schools, day are etc.

May be bilateral or unilateral


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Management

Culture

Antibiotic eye medication e.g. ciprofloxacin,norfloxacin

Antiviral acyclovir Antihistamine


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Nursing Interventions

Assessment and referral Give medication as prescribed

Educting parents

The importance of keeping child home

Careful hand hygiene practices

Avoidance of shared towels

Not rubbing eyes

Keep toddlers busy

How to instill eye drops

For children with allergies; s&s, use of wash cloth with

cold water over the eyes, avoiding contact lenses


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Periorbital Cellulitis

Infection of the eyelid and surrounding tissue Can occur after a scratch or bug bite around the eye

allow micro-organism to cause an infection.

Infection may extend to another site, e.g sinusitis

Average age of occurene; 6-8 yrs

Manifestations- Edema, tender red of purple eyelids,painful movement of the eye, fever

Treatment- hospitalization, IV antibiotics,application of hot packs. Must be prompt to avoidspread to the posterior orbit and nerves


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Nursing Intervention

Assessment and referral

Give antibiotics as prescribed

Monitor vital signs

Teach family members about infection


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Visual DisordersErrors of Retraction

Hyperopiafarsightedness; light rays focus posteriorto the retina resulting in the inability to focus on nearbyobjects. All children have some degree until 9 10 years

Myopianearsightedness ; light rays focus on the

anterior of the retina, resulting in an inability to see farobjects. Commonly develops at about age 8 yrs.Squinting and complaints of headaches are common

Astigmatism-light rays are refracted differently

depending on their place of entry to the eye. Thecurvature or cornea of the lens is not uniformly spherical,causing blurred vision. The child often holds pages closeto face


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Normal Refraction


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Visual Disorders- Strabismus

Strabismus- deviation of the eye (lazy eye) Lack of coordination between the extraocular muscles

problems with cranial nerve III, IV and VI

May be congenital or acquired

Symptoms; squinting, frowning when reading, closingone eye to see, trouble picking up objects, dizziness,headache

Associated with other conditions as cerebral palsy,

hydrocephalus, down syndrome Diagnosis vision testing

Treatment- Occlusion therapy, lenses, surgery of rectusmuscles, eye exercise


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Visual Disorders- Amblyopia

Reduced Vision in one or both eyes

Common caused- untreated strabismus alsocongenital cataract

Diagnosis- vision testing Treatment lenses, occlusion therapy 2-6 hours

daily, eye exercises, atropine 1%,

20/20 vision rarely attained


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Amblyopia


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Visual Disorders-Cataracts

Opaque lens prevents refraction of light ontoretina

May be congenital or acquired

Lens may be cloudy, symptoms of vision loss,distorted red reflex

Associated with fetal alcohol syndrome and downsyndrome

Treatment- surgical, corrective lenses

Post op- restraints, antibiotics, steroids


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Cataracts

RED REFLEX


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Visual Disorders -Glaucoma

Childhood glaucoma

also referred to ascongenital glaucoma, pediatric, or infantileglaucomaoccurs in babies and young children.It is usually diagnosed within the first year of life.

Increased Intraocular Pressure due to blockage of thecirculation of aqueous, or its drainage

Increased pressure may damage the optic nerve

Tearing, blinking, corneal clouding, progressiveenlargement of eye, photophobia

In older children the eye responds to increased intraocularpressure in a manner similar to adults. No increase in thesize of the eye and the cornea does not become cloudy.

Treatment surgery to reduce pressure followed by lenses


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Glaucoma


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Types

Congenital glaucoma is present at birth. Infantile glaucoma develops between the ages of 1-24 months. About

10% of primary congenital/infantile glaucoma cases are inherited Glaucoma with onset after age 3 years is juvenile glaucoma.

Another way to classify glaucoma is to describe the structural abnormalityor systemic condition which has caused the glaucoma. Most cases of pediatric glaucoma have no specific identifiable cause and

are considered primary glaucoma. When glaucoma is caused by, or associated with a specific condition or

disease, it is called secondary glaucoma. Examples of conditions whichcan be associated with childhood glaucoma include Axenfeld-ReigerSyndome, aniridia, Sturge-Weber Syndrome, neurofibromatosis,chronic steroid use, trauma, or previous eye surgery such as childhoodcataract removal.


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Danielle Fiarito, 16, was diagnosed with glaucoma atage 4


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Nursing Management

Assessment

Assess baby/child to see

How they follow objects

If they notice objects to right or left Move asymmetrically or one wanders off

Difficulty picking up objects

Learning difficulties


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Nursing Management

Disturbed Visual Sensory Perception

Risk for injury

Risk for altered growth an development

Risk for compromised family coping


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Desired Outcomes / Interventions

The child will receive adequate sensory input

Provide kinesthetic, tactile and auditory

stimulation e.g. talking, playing, noises during

daily activities

The child will be protected from hazards

Eliminate hazards


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Desired Outcomes/Interventions

The child has experiences necessary to foster

normal growth an development

Help parents plan activates

Provide opportunities for independent activities Provide environment rich in sensory input

Assess growth an development regularly


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Desired Outcomes/Interventions

The family identifies methods of coping

Provide explanation of disorder

Refer parents to organization and support groups

Assist parents to plan developmental, educational,safety needs

Allow to express feeling

Involve in the plan of care

Enhancing Development in Visually Impaired


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Enhancing Development in Visually ImpairedChild

Well lit setting Large print books

Expose to everyday sounds

Encourage the use of the sense of touch toys should

have different textures Encourage speech

Keep furniture in same position

Emphasize Childs abilities

Orient to new environment

Announce presence when approaching child

Identify contents of meals and positions


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Eye Injuries

Causes

Sports, fireworks, blunt or sharp instruments,chemical or thermal burns, irritants, abuse

See handout


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Ear Structure


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Pediatric Differences- Ear

The Eustachian tube which connects thenasopharynx the middle ear is shorter and wider andmore horizontal

During feeding the tube remains open formilliseconds allowing free passage

The external ear is soft with little cartilage

The external canal is small at birth thus the

tympanic membrane is close to the surface and easilydamaged


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Eustachian Tubes of Child vs Adult


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Otitis media

Inflammation of the middle ear About 70% of children have at least one case on their

first year of life

Occurs frequently in children with allergies, usepacifiers and in children exposed to tobacco smoke

Children with conditions as cleft palate and Downsyndrome also experience otitis media

Breast feeding appears to be a protective againstotitis media

May be acute or chronic which may lead to deafness


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Otitis Media

Causes Unknown

Dysfunction of the Eustachian tube

Upper respiratory tract infection

The infection causes the mucous membrane of theeustachian tube to become edematous. The air that flowsthrough the middle air is blocked and re-absorbed intothe blood stream. Fluid is pulled into the space from the

mucosal lining providing a good medium for rapidgrowth of the pathogen. The tympanic membrane andfluid behind it become infected


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Acute otitis media

Acute otitis media bacterial infection in the middleear from pathogens transferred from thenasopharynx

Cause ; S.pneumoniae, H.influenzae, M. catarrhalis

S&S; ear pain/pulling at ear, rapid onset, irritability,malaise, poor feeding

On exam; bulging tympanic, fluid or air behind

tympanic, red, white or gray tympanic, membranedisplaced by light reflex


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Light Reflex

Light Reflex

The light reflex is a cone of light reflecting back fromthe otoscope as a result of the slightly conical shapeof the tympanic membrane


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Otitis media with effusion

Otitis media with effusion- collection of fluid in themiddle ear behind the tympanic membrane, notinfected with a bacteria

S&S; difficulty hearing in most cases

On Exam; no signs of inflammation, tympanicretracted or neutral, immobile or partly mobilemembrane, yellow or gray, opaque or thickened


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Retracted EarDrum


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Otitis Media

Other Signs and symptoms

Middle ear effusion

Vomiting

Diarrhea Irritability/waking up at nights and crying

Acting out

Otorrhea


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Otitis Media- Diagnostics

Otoscopic examination

Special gradient acoustic reflectometry

Flat tympanogram

Culture of the middle ear fluid Pneumatic otoscopy

Tympanometry

Audiological testing


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Otitis Media- Treatment

Antibiotic Therapy for 10 days in children under 6years; 5-7 days for children 6 years and over

Antibiotics are delayed for 48-72 hours afterdiagnosis in children 6mths 2yrs with non severesymptoms at presentation or uncertain diagnosis

First line therapy amoxicillin; 2ndline amoxicillinwith clavulmante or cefuroxime

Ibuprofen for pain if antibiotics are not prescribed Topical anesthetic ear drops if tympanic membrane

is intact


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Nursing Management

ND-Altered comfort- acute pain

Goal- The child will indicate absence of pain

Interventions

Give analgesic as prescribed Have child sit up, raise head on pillows or lie on

unaffected side- elevation decreases pressure from fluid

Apply heating pad or warm hot bottle- heat increases

blood supply and reduces discomfort Have child chew on gum or blow balloon relieves

pressure in the ear


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ND- Infection r/t presence of pathogens

Goal- The child will be infection free

Interventions

Encourage breastfeeding of infants- affords naturalimmunity

Administer meds as prescribed

Encourage parents to keep follow up appointment


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ND- Risk for care role strain r/t chronic conditionGoal- The parents will manage the childs condition

with minimal stress

Interventions

Determine the parents ability to manage condition

Provide information

Encourage parent in the plan of care- increases

confidence and ability to manage condition Allow parents to express feelings- reacting

empathically encourages parents to communicate


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Otitis Externa

Inflammation of the skin and surrounding tissue ofthe ear canal- Called swimmers ear

Injury can also occur because of injury by foreignobjects , irritants, or drainage from broken tympanicmembrane. The canal can become infected

S&S; pain, itching, swelling and redness of ear,drainage in canal

Tx-cleaning and irrigation with NS, steroid eardrops for inflammation reduction, antibiotic drops


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Otitis Externa


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Advice

Follow up care

Child should not return to swimming for about 5days

On return ear plugs or swim caps Ensure canal is dry after swimming or bath

Do not place cotton tipped applicators or foreignobjects in the canal


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Injuries to Ear

Causes-

Lacerations, infections, hematomas, placing of foreign

objects, insects entering canal, blow to head or ear

See handout


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Nose, Throat and Mouth

Up to 6 mths, infants are primarily nasal breathers

Immature immune system puts young children at riskfor URTI

Enlarged adenoids are commonly infected


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Disorders of the Nose and Throat

Epistaxis

Common in school aged children

Kisselbachsplexus, an area of plentiful veins locatedin the anterior nares are usually the source

Causes- irritation, from nose picking, foreign bodies,low humidity, forceful coughing, allergies,

congestion or nasal mucosa


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Epistaxis

Assessment Hx of nose bleeds

Contributing factors

Vital signs esp. pulse Examination of nasal mucosa, allow to blow gently to

look for clots, suction if necessary

Assess flow, nose bleed on one side is often anterior,both sides posterior (suspect blunt trauma)

Swallowed blood may cause nausea


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Management

Anterior Place child upright, tilt head forward Squeeze nares just below nasal bone and hold for 10-15

minutes while child breathes through mouth Application of ice packs or cold compress on bridge of

nose If bleeding does not stop insert cotton soaked with

topical vasoconstrictor and anesthesia epinephrine,lindocaine

CauterizationPosterior Packing


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Management

Avoid Bending over, hot drinks, hot showers,strenuous exercise

Sleeping elevated

i i i


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Sinusitis

Inflammation of one or more of the paranasalsinuses

Usually become infected following a viral URTI

S&S- purulent nasal drainage fever above 102

degrees F, facial pain, malodorous breath, mouthbreathing, hyponasal speech, anorexia, headache

Treatment; antibiotics

Some clear on its own

Repeated cases should be referred to anotolaryngologist

h i i


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Pharyngitis

Infection of the pharynx and tonsils Common in children 4-7 yrs

May be bacterial or viral

Viral Strep

Nasal congestionMild sore throatConjunctivitisCoughHoarsenessPharyngeal rednessFever 38.3 deg C

Ph i i S I f i


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Pharyngitis- Strep Infection

Ph i i


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Pharyngitis

Diagnosis/Treatment Throat culture Antibiotics Pain relief

lozenges containing benzocaine or other anesthetics Nursing Intervention Administering meds Cool non acidic drinks and soft foods Humidification Gargling with warm salt water Rest Parent education

Ph i i


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Pharyngitis

Complications Rheumatic fever

Sinusitis

Glomerulonephritis Meningitis

T illiti d Ad iditi


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Tonsillitis and Adenoiditis

Inflammation of the palatine tonsils and adenoids Bacterial and viral infections can cause tonsillitis.

A common cause is Streptococcus bacteria. Othercommon causes include:

Adenoviruses

Influenza virus

Epstein-Barr virus

Parainfluenza viruses Enteroviruses

Herpes simplex virus

Manifestations


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Manifestations

Throat pain or tenderness Redness of the tonsils A white or yellow coating on the tonsils Painful blisters or ulcers on the throat

Hoarseness or loss of voice Headache Loss of appetite, nausea, vomiting Ear pain Difficulty swallowing or breathing through the mouth Swollen glands in the neck or jaw area Fever, chills Bad breath

T illiti d Ad iditi


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Tonsillitis and Adenoiditis

T t t


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Treatment

Throat culture Antibiotics if bacterial

Rest

Drink warm or very cold fluids to ease throat pain

Eat smooth foods, such as flavoured gelatin, ice cream Use a cool-mist vaporizer or humidifier in your room

Gargle with warm salt water

Suck on lozenges containing benzocaine or other

anaesthetics Take over-the-counter pain relievers such

as acetaminophen or ibuprofen.

S i l


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Surgical

Tonsillectomy and adenoidectomy (T&As)recommended for recurrent infections ( about threeper year), obstructive sleep apnea, problems withspeech, mouth breathing

Complication of Surgery

Bleeding

Pain

infection

C Aft T ill t


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Care After Tonsillectomy

Most children go home about four hours after surgery and require aweek to 10 days to recover from it. Parents are adviced to

Give Cool fluids- reduces spasm and the muscles surrounding throat

Avoid giving child milk products for the first 24 hours after surgery.

Pain meds

Apply ice or cool compress around neck

Gargle with baking soda and salt

Rinse with lidocaine before swallowing

Rest

For several days after surgery, child may experience a low-gradefever and small specks of blood from the nose or saliva. If fever isgreater than 102 degrees F and bright red blood is seen, refer todoctor

Nursing Diagnosis


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Disorders of the Nose and Throat

Acute pain related to inflammation risk for fluid volume deficit

Ineffective breathing patterns

Impaired swallowing

Disorders of the Mouth


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Disorders of the Mouth

Mouth Ulcers see hand out for causes andmanifestations

Txkeep mouth clean, topical analgesics, nonirritating foods

ND

Altered comfort pain

Impaired oral mucous membrane

Imbalanced nutrition less than

Mouth and Dental Emergencies


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Mouth and Dental Emergencies

Causes Trauma to mouth due to falls, sports, MVAs

Problems

Fracture jaws, tooth avulsion

References


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References

Pediatric Nursing- Caring for Children Ball & Binder4thEdition

Documents

Alterations in Eye, Ear, Nose,