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completion of this session, you should be able to: Define key terms. Identify the subjective and objective data when assessing the conditions affecting the EENT. Discuss the nursing care for the patient with common EENT problems.
SUBJECTIVE DATA STRUCTURE - EYE Vision difficulty(decrease acuity, blurring, blind sports. Pain Strabismus, diplopia Redness, swelling Watering, discharge History of ocular problems Uses of glasses/contact lenses Self care behavior.
Preparation Equipments needed Snellens eye chart Opaque card /occluder Penlight Applicator stick Ophthalmoscope
and ocular expression Eye lids & Conjunctiva
----Prominence of eyes: alert or dull expression. __Symmetry, presence of edema, ptosis, itching, redness, discharges, blinking, equality, growth. ___Tears, swelling, growth ___Color ___Clarity
Anterior chamber Iris & pupils Pupillary reflex light
__Depth, presence of blood/pus __Irregularities in color, shape , size __Constriction of pupil in response to light in that eye (direct light reaction);equal amount of constriction in the other eye (consensual light reaction)
Lens Peripheral vision
__Convergence of eyes and constriction of pupils as gaze shifts from far to near object __Transparent or opaque __Ability to see movements & objects well on both sides of field of vision Ability to read newsprint, clocks on wall, & recognize facesb/side/door Glasses, contact lenses, prosthesis.
Acuity with or without glasses Supportive aids
Test Central Visual Acuity Snellen Eye Chart (SEC) Place a Snellen chart 2o feet
Burns: Chemical, Flame
Flush eye immediately for 15 min with cool water Seek Medical assistance Lift upper lid over lower lid to dislodge substance, produce tearing; Irrigate eye with water. Obtain Medical assistance if intervention fail. Apply cold compression if no laceration present. If laceration present-Seek medical assistance. Do not remove object; Place protective shield over eye/cover uninjured eye to prevent excess movement of injured eye.
Loose substance on conjunctiva: Dirt, Insects
Contact injury: Contusion, Ecchymosis, Laceration
Infection – Lid margins; swollen pustules, resolves/ruptures.
Warm compression 34 per day. Antibiotic ointments if severe
A chronic infectious Early treatment with form of conjunctivitis antibiotics. . Administer antibiotics& corticosteroids
conjunctiva Collaborative care management Careful cleaning of the eye lids and lashes by warm compression Application of topical antibiotics e.g. Tetracycline eye oint/chrolophenicol eye drop
2. 3. 4.
Use sterile technique - infection or ulceration clean technique - Allergic reaction. Separate equipment- bilateral eye infection Wash hands before treating each eye. Temperature of compress should not be more than 49 deg cent (120 deg fer) Change compression frequently(5min) Wash hands first
Do not exert pressure on the eyeball. I f sterility is not required, moist heat may be applied by means of a clean face cloth.
about disease and its treatment Patient to avoid crowded environments & keep hand away from face. Frequent hand washing(Before & after treatment) Instruct pt correct technique of instilling ophthalmic ointment( inner to the outer canthus).
/opacity of lens that leads to painless blurring & loss of vision. Nursing Management Preoperative care Eye lashes may be cut(Eye depart) Dilatation of the pupil operative eye (mydriacyl eye drop)
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.
aches Infections Discharges Hearing loss Environmental noise Tinnitus Self care behavior
Inspect & Palpate the External ear Size & shape Skin condition Tenderness External auditory meatus Inspect -otoscope
otoscope Pull the pinna up & back(straightens S –shape-canal) Hold the otoscope & inspect Note any redness, swelling,lesions, f/b, discharge.
Whispered Voice Test
Test one year at a time: 1-2 ft from pt’s ear whisper 2 syllable word-Tuesday-pt’s to repeat.
Test hearing by Air conduction (AC) or by Bone conduction(BC).
Tuning Folk (TF)Tests
Weber Test (Hearing better with one ear than the other)
Place a vibrating TF –midline of the person’s skull- tone sounds the same /equally loud in both ears.
Place the stem of the vibrating TF –person’s mastoid processsignal sound goes away; quickly invert the fork-vibrating end near the ear canal-still hear a sound. (N- AC >BC).
Rinne Test (Compares AC & BC sounds)
data Pain-severe & throbbing Sense of fullness/pressure in the ear Change in hearing
data Inflamed, budging tympanic membrane Drainage ear: bloody, serous, purulent Perforation – tympanic membrane Fever
N/diagnosis Pain due to buildup of fluid in ear spaces, swelling, trauma. Knowledge deficit: treatment of otitis ,self care after ear surgery.
Intervention Administer medications e.g. Paracetamol, Antibiotics as prescribed. 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.
Evaluation Pt states that no pain is present
Has no ear drainage, no redness edema, itching. Ear canal is clean & healed.
colds(upper respiratory infections) Sinus pain Trauma Epistaxis Allergies Altered smell
Equipment Needed Otoscope-short wide tip nasal attachment Penlight 2 tongue blades Gloves Cotton gauze pad
Inspect and palpate :symmetric ,midline in proportion to other facial features Inspect for any deformity, asymmetry, inflammation, or skin lesions Palpate for any pain/break in contour. Palpate the sinus areas-Tenderness
Inspect with penlight: Lips, teeth, & gums, tongue, buccal mucosa- note color: lesions. Palate & uvula- Note integrity & mobility as person phonates Inspect tonsils Pharyngeal wall- Note color, exudates /lesions Palpate –lesions
Nosebleed Collaborative nursing care
(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.