Nursing Care for Patients With Ear,Eye,Nose &Throat2

7/29/2019 Nursing Care for Patients With Ear,Eye,Nose &Throat2

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PRESENTER

Mrs.TUIKUBULAU/Mrs. Mackay

01/08/2011


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Upon completion of this session, you should

be able to:

Define key terms.

Identify the subjective and objectivedata when assessing the conditions

affecting the EENT.

Discuss the nursing care for the patient

with common EENT problems.


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SUBJECTIVE DATA

Vision difficulty(decreaseacuity, blurring, blindsports.

Pain Strabismus, diplopia

Redness, swelling

Watering, discharge

History of ocular

problems Uses of glasses/contact

lenses

Self care behavior.

STRUCTURE - EYE


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Preparation

Equipments needed

Snellens eye chart

Opaque card

/occluder

Penlight

Applicator stickOphthalmoscope


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Facial and ocularexpression

Eye lids &Conjunctiva

Lacrimal system

ScleraCornea

----Prominence ofeyes: alert or dullexpression.

__Symmetry, presence

of edema, ptosis,itching, redness,discharges, blinking,equality, growth.

___Tears, swelling,

growth___Color

___Clarity


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Anterior chamber

Iris & pupils

Pupillary reflex light

__Depth, presence ofblood/pus

__Irregularities in color,shape , size

__Constriction of pupilin response to light inthat eye (direct lightreaction);equalamount ofconstriction in theother eye (consensuallight reaction)


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Accommodation

Lens

Peripheral vision

Acuity with or without

glasses Supportive aids

__Convergence of eyes andconstriction of pupils asgaze shifts from far tonear object

__Transparent or opaque

__Ability to see movements& objects well on bothsides of field of vision

Ability to read newsprint,

clocks on wall, &recognize faces-b/side/door

Glasses, contact lenses,prosthesis.


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Test Central Visual

Acuity

Snellen Eye Chart

(SEC)

Place a Snellen chart

2o feet


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INJURY INTERVENTIONS

Burns: Chemical, Flame Flush eye immediately for 15 min

with cool water

Seek Medical assistance

Loose substance on

conjunctiva: Dirt, Insects

Lift upper lid over lower lid to

dislodge substance, produce

tearing; Irrigate eye with water.

Obtain Medical assistance if

intervention fail.

Contact injury: Contusion,

Ecchymosis, Laceration

Apply cold compression if no

laceration present.If laceration present-Seek

medical assistance.

Penetrating objects Do not remove object; Place

protective shield over eye/cover

uninjured eye to prevent excess

movement of injured eye.


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DISORDERS DESCRIPTION COLLABORATIVE

MANAGEMENT

Hordeolum (style) Infection Lid

margins; swollen

pustules,

resolves/ruptures.

Warm compression 3-

4 per day. Antibiotic

ointments if severe

Trachoma A chronic infectious

form of conjunctivitis

.

Early treatment with

antibiotics.

Corneal ulcer Administer

antibiotics&corticosteroids


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Inflammation of theconjunctiva

Collaborative care

management

Careful cleaning ofthe eye lids andlashes by warmcompression

Application of topicalantibiotics e.g.Tetracycline eyeoint/chrolophenicoleye drop


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1. Use sterile technique - infection or

ulceration clean technique - Allergic

reaction.

2. Separate equipment- bilateral eye infection3. Wash hands before treating each eye.

4. Temperature of compress should not be

more than 49 deg cent (120 deg fer)

5. Change compression frequently(5min) Washhands first


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6. Do not exert pressure on the eyeball.

7. I f sterility is not required, moist heat may

be applied by means of a clean face cloth.


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Teach about disease and its treatment

Patient to avoid crowded environments &

keep hand away from face.

Frequent hand washing(Before & aftertreatment)

Instruct pt correct technique of instilling

ophthalmic ointment( inner to the outer

canthus).


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Clouding /opacity oflens that leads topainless blurring &loss of vision.

NursingManagement

Preoperative care

Eye lashes may becut(Eye depart)

Dilatation of thepupil operative eye(mydriacyl eyedrop)


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Postoperative care

Position pt supine /unoperated side

Vital sign-4 hrly (TPR,B/P)

Eye dressing- Keep dressing intact(metal

dressing). Administer pain medication

Call light- Within reach/Bedside table unoperated eye.

Avoid stress activity e.g. Increase Intraocular pressure(IOP)

(sneezing, vomiting, coughing, straining)

Patient/Family education

Medication (>2 , wait 2-5 min, ointment last)

Avoid lifting heavy object, active exercise, straining-defecation

Review date.


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SUBJECTIVE DATA

Ear aches

Infections

Discharges

Hearing loss

Environmental

noiseTinnitus

Self care behavior


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Inspect & Palpate

the External ear

Size & shape

Skin conditionTenderness

External auditory

meatus Inspect -otoscope

Inspect otoscope

Pull the pinna up

& back(straightens

S shape-canal)Hold the otoscope

& inspect

Note any redness,

swelling,lesions,

f/b, discharge.


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Whispered Voice Test Test one year at a time: 1-2 ft

from pts ear whisper 2 syllable

word-Tuesday-pts to repeat.

Tuning Folk (TF)Tests Test hearing by Air conduction

(AC) or by Bone conduction(BC).

Weber Test (Hearing better with

one ear than the other)

Place a vibrating TF midline of

the persons skull- tone sounds

the same /equally loud in both

ears.

Rinne Test (Compares AC & BC

sounds)

Place the stem of the vibrating

TF persons mastoid process-signal sound goes away; quickly

invert the fork-vibrating end

near the ear canal-still hear a

sound. (N- AC >BC).


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ASSESSMENT

Subjective data

Pain-severe &

throbbing Sense of

fullness/pressure in

the ear

Change in hearing

Objective data

Inflamed, budging

tympanic membrane

Drainage ear:bloody, serous,

purulent

Perforation

tympanic membrane Fever


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N/diagnosis Intervention Evaluation

Pain due to buildup of

fluid in ear spaces,

swelling, trauma.

Administer medications

e.g. Paracetamol,

Antibiotics as

prescribed.

Pt states that no pain is

present

Knowledge deficit:

treatment of otitis ,self

care after ear surgery.

Instruct the pt to avoid

getting water in the ear

during treatment.

Teach pt/family on ear

wash

Minor earache &discomfort cheek &jaw

are common-managed

by analgesia.

Has no ear drainage, no

redness edema, itching.

Ear canal is clean &

healed.


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SUBJECTIVE DATADischarge Frequent

colds(upper

respiratoryinfections)

Sinus pain Trauma Epistaxis Allergies Altered smell


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Equipment NeededOtoscope-short wide tip

nasal attachment

Penlight

2 tongue bladesGloves

Cotton gauze pad

Inspect and palpate:symmetric ,midlinein proportion to otherfacial features

Inspect for any

deformity,asymmetry,inflammation, or skinlesions

Palpate for any

pain/break incontour.

Palpate the sinusareas-Tenderness


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Inspect with penlight:Lips, teeth, & gums,tongue, buccalmucosa- note color:lesions.

Palate & uvula- Noteintegrity & mobilityas person phonates

Inspect tonsils

Pharyngeal wall- Note

color, exudates/lesions

Palpate lesions


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Nosebleed

Collaborative

nursing care


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Jarvis,C., (2008). Physical examination &

health assessment(5th ed). St Louis,

Missouri: Saunders, Elsevier.

Phipps, W. J., Sands, J.K.,& Marek, J.F.(1999).

Medical-surgical nursing: concepts &

clinical nursing. (6th ed).

St Louis: Mosby.

Documents

Nursing Care for Patients With Ear,Eye,Nose &Throat2