Nursing Care of

Clients with Eye

and Ear
Disorders
Funny Video

https://www.youtube.com/watch?v=7iBY7Yirq60
Learning Objectives

 Specify assessment and diagnostic findings used in the evaluation

of ocular disorders.
 Describe assessment and management strategies for patients with
low vision and blindness.
 Identify the pharmacologic actions and nursing management of
common ophthalmic medications.
 Describe the nursing management of patients with glaucoma,
cataracts, and ocular trauma.
 Differentiate problems of the external ear from those of the middle
ear and inner ear.
 Describe the different types of inner ear disorders, including
clinical manifestations, diagnosis, and management.
Required Readings

 ATI Materials
 Hinkle & Cheever: Brunner & Suddarth's Textbook of
Medical-Surgical Nursing, 13th Edition. Chapter 63 & 64
External Structures of the Eye Extraocular Muscles
Visual Pathways
Cross-Section of the Eye
History

 PMH  HPI
 Diabetes  Floaters and flashing lights
 Hypertension  Retinal detachment

 Coronary artery disease  Transient vision loss

 Thyroid problems
 Family history
 Glaucoma
 Blindness
 Macular degeneration
 Medications
 Eye drops (including OTC)
 Blurry vision
 Red, painful eyes
 Discharge
 Color, characteristics,
amount
 Chronic itching and tearing
Diagnostic Evaluation

 Tonometry
 Measures intraocular
pressure
 Gonioscopy
 Visualizes the angle of the
anterior chamber
 Perimetry testing
 Evaluates field of vision
 Scotomas: blind areas in the
visual field
Physical Assessment of Eye and
Vision
 Snellen chart or E chart for testing visional acuity
 20 feet
 Cardinal fields
 Test for extraocular eye movements
 Cover-uncover test
 Test for strabismus
 Deviation from perfect ocular alignment
 Nystagmus
 Involuntary oscillation of the eyeball
Eye Disorders

 Age related vision changes

 Flatting of the cornea
 Pupillary constriction
 Decrease in lens elasticity
 Loss of sensory cells
 Physical changes
 Inversion, eversion of lid, decreased tear secretion, “hollowed-
eyed”
Impaired Vision

 Refractive errors
 Can be corrected by lenses that focus light rays on the retina
 Emmetropia: normal vision
 Myopia: nearsighted
 Hyperopia: farsighted
 Astigmatism: distortion caused by irregularity of the cornea
Low Vision and Blindness

 Low vision
 Visional impairment that requires devices and strategies in
addition to corrective lenses
 Best corrected visual acuity (BCVA) of 20/70 to 20/200
 Blindness
 BCVA 20/400 to no light perception
 Legal blindness is BCVA that does not exceed 20/200 in better
eye or widest filed of vision is 20 degrees or less
 Impaired vision often is accompanied by functional
impairment
Nursing Assessment

History
 Examination of distance and near visual acuity, visual field,
contrast sensitivity, glare, color perception, and refraction
 Special charts may be used for low vision
 Nursing assessment must include assessment of functional
ability and coping and adaptation in emotional, physical,
and social areas
Management

 Support coping strategies, grief processes, and acceptance of visual loss

 Strategies for adaptation to the environment
 Placement of items in room
 “Clock method” for trays
 Communication strategies
 Collaboration with low-vision specialist, occupational therapist, or other
resources
 Braille or other methods for reading and communication
 Service animals
Conjunctivitis-red, pain, itchy,
sticky drainage
Eye Disorders

 Inflammatory disorders
 Conjunctivitis
 Inflammation of the conjunctiva
 Bacterial or viral
 Very contagious
 Treatment
 Topical anti-infectives
 Anti-inflammatories
Hordeolum(Stye)

 Forms on the eye lid

 Clogged duct gland
 Usually from bacteria from the skin that gets into the gland
 On the upper or lower lid where the lid meets the eye lashes
 Resembles a pimple- a red bump, tender to the touch
Nursing Care/Patient Teaching

 Warm/Hot compresses: opens pores

 Apply for 10 minutes, 4 times a day
 Antibiotic creams or ointments can help.
 DO NOT try to “pop” the stye! Let it drain on its own.
 Usually swell for 3 days and then break open and drain.
 Large styes sometimes need to be lanced, by a provider to
prevent further infection.
 Do not wear eye make-up or contact lenses
 Throw away ALL make-up
Prevention

 ALWAYS wash your hands before touching the eye or skin

around it.
 If styes are common, wash the edges of the eye lids
frequently.
 Do not rub your eyes: it can let in bacteria.
 For women- replace eye make-up, especially mascara, every
6 months
Chalazion

 A stye can turn into a chalazion

 This is when the duct gland becomes fully blocked
 If it becomes so large, it can effect vision and deform the
cornea
 Treatment of chalazion

Injection of local anesthetic Insertion of clamp Incision & curettage

Eye Disorders

 Corneal infections/inflammations
 Corneal scarring and ulcerations are a major cause of world-wide blindness
 Treatment
 Corneal transplant
 Eye shield
 Pain medication
 Assess the client, and medicate or assist to avoid vomiting, coughing, sneezing, or
straining as needed.
 These activities increase intraocular pressure
Corneal Transplant
The Client with Cataracts

 Cataract
 A clouding of the lens of the eye
 Interferes with light transmission and the ability to perceive
images clearly
 Significant cause of visional problems in the elderly (50-70%)
 Senile cataracts
 Normal aging process
The Client with Cataracts

 Treatment
 Surgical removal of cataract and lens
 Implantation of intraocular lens
 Post-operative nursing care
 Assessment
 Eye patch
 Semi-folwer’s
Post-operative Nursing Care

 Avoid coughing, sneezing straining

 These increase intraocular pressure
 Assess for post-op pain
 Assess for surgical complications
 Approach from unaffected side
 Teach home care
 Medications, symptoms to report, photophobia
Glaucoma

 Characterized by increased intraocular pressure and gradual

loss of vision
 “Silent” thief of vision
 Narrowing of visual fields
 2 Types
 Open Angle and Closed Angle
Glaucoma: Inner Eye Pressure
Glaucoma

 Open angle
 Common (90%)
 >35yrs, genetic link, African-American
 Pathophysiology
 Impaired aqueous outflow
 Increased intraocular pressure
 Usually bilateral
Glaucoma

 Clinical manifestations
 None
 Frequent lens changes in glasses
 Impaired night vision
 Halos
 Reduction of vision field, become narrow
 Increased intraocular pressure (tonometry)
Glaucoma

 Treatment
 Miotics - Pilocarpine
 Laser Surgery (Trabeculoplasty)
 Cause Scar Tissue To Create Tension To Stretch
 Opening To Drain Aqueous Fluid
Diabetic Retinopathy
 Leading cause of new
blindness between ages of
20-74
 84% of diabetics will develop
some form
 Length of time as a diabetic

 Vascular disorder that affects

the retina
 Capillaries become sclerotic
Diabetic Retinopathy

 Management
 Yearly ophthalmologic exams
 Laser photocoagulation
 Focus is educational
 Vision changes -blurred
 Black spots (floaters)
 Flashing lights
 Sudden loss of vision
Retinal Detachment
 Description
 A retinal hole is a break in the
integrity of the peripheral
sensory retina & can be
caused by trauma / can occur
w/ aging
 A retinal tear is a more jagged
& irregularly shaped break in
the retina – which can result
from traction on the retina
 A retinal detachment is the
separation of the sensory
retina from the pigmented
epithelium – a separation of
retina from choroid
 Surgical Treatment
 Scleral buckle
 Pars plana vitrectomy
 Removal of vitreous locating the incisions at the pars plana
 Frequently used in combination with other procedures
 Pneumatic retinopexy
 Injected gas bubble, liquid, or oil is used is used to flatten the
sensory retina against the retinal pigment epithelium
 Postoperative positioning is critical
 To allow the bubble to apply pressure to the retinal tears
Macular Degeneration

 Two Types
 Dry (Atrophic)
 Slow breakdown of the layers of the retinal with the appearance
of drusen
 Wet (Exudative)
 May have abrupt onset
 Proliferation of abnormal blood vessels growing under the retina
—choroidal revascularization
Nursing Management

 Patient education
 Supportive care
 Promote safety
 Recommendations
 Improve lighting
 Magnification devices
 Referral to vision center to improve or promote function
Eye Trauma Introduction
 Disability instead of mortality
 Classifications
 Blunt
 Penetrating
 Burn
 Concurrent injuries
 Head, face, neck
Lid Injury
 Inspect for concurrent
injuries
 Consider consult with eye
specialist and/or plastic
surgeon
 Complications may result
from improperly closed lid
laceration
Corneal Abrasions and Lacerations

 Assessment findings
 Photophobia
 Tearing
 Pain
 Lid swelling
 Foreign body sensation
 Decreased vision with
laceration
Corneal Abrasions and
Lacerations
 Diagnosis
 Fluorescein Staining
 Slit lamp exam
 Treatment
 Ophthalmic drops/solutions
 Oral analgesics
Corneal Foreign Bodies

• Assess for
– High-speed MOI
– Penetration of the globe
• Assessment findings
– Photophobia, tearing and pain
• Treatment From Stevens, S. (2005). How to remove a
– Topical anesthesia and removal corneal foreign body. Community Eye Health
Journal, 18(55), 110.
Intraocular Foreign Body
 Considered a true ocular
emergency
 Misshapen pupils
 Treatment:
 Elevate HOB
 Immobilize the foreign body
 Protect/shield eye
 Ophthalmology consult
 Surgery to close globe
Orbital Fracture
 Assessment findings
 Periorbital ecchymosis
 Diplopia with upward gaze
 Enophthalmos
 Infraorbital numbness
 Muscle entrapment
 Limits EOM’s
 Treatment
 Cool compresses
 Do not blow nose
 Ophthalmology and
maxillofacial consult
 Surgery
Hyphema
 Assessment findings
 Pain
 Collection of blood
 Photophobia
 Blurred vision
 Increased IOP
 Treatment
 Admit if > 30% hyphema
 Elevate HOB
 Avoid NSAIDs and ASA
 Eye Shield
Retrobulbar Hematoma
 Assessment findings
 Severe pain
 Decreased vision
 Reduced eye movement
 IOP > 40 mm Hg
 Emergency decompression
Globe Rupture
 Assessment findings
 Flat anterior chamber
 Extruded eye contents
 Hyphema
 Irregular-shaped pupil
 Periorbital ecchymosis
 Severe subconjunctival hemorrhage
 Treatment: Protect the eye/repair the globe
Ocular Burns
 True emergency
 Alkali: causes liquefaction necrosis (deep)
 Acid: coagulation necrosis, forms barrier to
deeper penetration
 Antibiotics and tetracaine
 Immediate treatment
 Determine baseline pH
 Copious flushing with saline solution
 Check pH and continue flushing
 Nitrazine paper
 Irrigate until pH returns to normal range (7.0–
7.3)
Ultraviolet Keratitis
 Photokeratitis
 Welders
 Sunlamps
 People working in snowy landscapes without adequate
eye protection
 Assessment findings
 Severe pain and photophobia
 Conjunctival irritation and tearing
 Decreased visual acuity
 Treatment
 Topical ophthalmic antibiotics
 Cycloplegics
 Oral analgesics
NCLEX Question

When assisting a patient who is legally blind, which

intervention would not be appropriate?
a) Allow the patient to hold the nurse’s arm above the elbow
while walking a step behind when ambulating to bathroom.
b) Describe food items on meal tray using a clock terms.
c) Offer to feed the patient all meals.
d) Remove obstacles in room and describe furniture
placement.
Assessment and Management
of Patients With Hearing and
Balance Disorders
Physical Assessment of Ear and
Hearing
 Hearing

 Weber test

 Rinne test

 Whisper test
Anatomy of the Ear
Anatomy of the Inner Ear
Ear Disorders

 External Otitis
 Swimmers ear
 Pseudomonas, bacteria, fungus or trauma
 Treatment
 Cleansing
 Antibiotics - local and systemic
 Education
Conditions of the External Ear
 Cerumen impaction
 Removal may be by irrigation,
suction, or instrumentation
 Gentle irrigation should be used
with lowest pressure, directing
stream behind the obstruction
 Glycerin, mineral oil, ½ strength
H2O2, or peroxide in glyceryl may
help soften cerumen
 Foreign bodies
 Removal may be by irrigation,
suction, or instrumentation
 Objects that may swell (e.g.,
vegetables or insects) should not be
irrigated
 Foreign body removal can be
dangerous and may require
extraction in the operating room
Insects

 Live insects may cause a buzzing in

the ear
 The insect should be killed prior to
removal, using mineral oil or
lidocaine (2%)
https://www.youtube.com/watch?v=J0A
2Nz2xiCg
Conditions of the External Ear

 External otitis
 Inflammation most commonly caused by bacteria Staphylococcus or
Pseudomonas, or fungal infection from Aspergillus spp.
 Manifestations include pain and tenderness, discharge, edema, erythema,
pruritus, hearing loss, feelings of fullness in the ear
 Therapy is aimed at reducing discomfort, reducing edema, and treating the
infection.
 A wick may be inserted in the canal to keep it open and facilitate medication
administration.
 Malignant external otitis: rare, progressive infection that effects the
external auditory canal, surrounding tissue, and skull
Ear Infection check up
Middle Ear Disorders
 Otitis Media
 Inflammation of middle ear
 Common in infants and young children
 Pathogens
 Streptococcus pneumonia
 Haemophilus influenza
 Moraxella catarrhalis
 Signs & Symptoms
 Otalgia (ear pain)
 Fever
 Hearing loss
 Red bulging tympanic membrane
Middle Ear Disorders

 Treatment
 Antibiotics
 Myringotomy
Inner Ear Disorders
Meniere’s Disease

 Abnormal inner ear fluid balance cause by malabsorption of

the endolymphatic sac or blockage of the endolymphatic
duct
 Acute
 Two or more episodes of vertigo lasting at least 20 minutes
each
 Tinnitus
 Temporary hearing loss
 A feeling of fullness or pressure in the ear
 Chronic
 Recurrent attacks of vertigo with tinnitus
 Progressive hearing loss
Risk Factors

Autonomic nervous system  Migraine headaches

dysfunction
 Stress
Family history
 Allergy
Head trauma
 High salt intake
Immune disorder
 Chronic exposure to loud noises
Middle ear infection
 Premenstrual edema
Inner Ear Disorders
Meniere’s Disease

 Treatment  Surgical management

 Meclizine  Endolymphatic sac decompression
 Diazepam
 Middle and inner ear perfusion
 Lorazepam  Injection of steroids and/or
 Glycopyrrolate aminoglycosides into the inner ear
 Anti-emetics  Vestibular nerve sectioning
 Low sodium diet
 Nursing Care
 Fall prevention
 Instruct patient to reduce salt intake,
and avoid caffeine and nicotine
substances
Benign Paroxysmal Positional
Vertigo
 Caused by calcium carbonate crystals
(otoconia) becoming displaced into
the semi-circular canals
 Dizziness when rolling over in bed
 Dizziness when looking up
 Most common in women over 50
 No specific treatment
 Meclizine
 Long term side effects
 Epley maneuver
https://www.youtube.com/watch?v=9SL
m76jQg3g
The Client with Hearing Loss

 Affects more than 28 million people in the United States

 Increased incidence with age—presbycusis
 2 Types
 Conductive
 Disruption transmission of sound
 Obstructions - cerumen, scarring, tumors

 Sensorineural
 Caused by damage to the cochlea or vestibulocochlear nerve
 Inner ear, auditory nerve or pathways
 Mixed; both conductive and sensorineural
 Functional (psychogenic); caused by emotional problem
Manifestations

 Early symptoms
 Tinnitus: perception of sound; often “ringing in the ears”
 Increased inability to hear in a group
 Turning up the volume on the TV
 Impairment may be gradual and not recognized by the
person experiencing the loss
 As hearing loss increases, person may experience
deterioration of speech, fatigue, indifference, social
isolation or withdrawal, and other symptoms
Guidelines for Communicating With
Hearing Impaired Persons

 Use a low-tone, normal voice

 Speak slowly and distinctly
 Reduce background noise and distractions
 Face the person and get his or her attention
 Speak into the less impaired ear
 Use gestures and facial expressions
 If necessary, write out information or obtain a sign language
translator
The Client with Hearing Loss

 Treatment
 Amplification
 Hearing aids
 Surgery
 Reconstruct the middle ear - tympanoplasty
 Cochlear implant
 Nursing Care
 Sensory/Perceptual Alteration
 Auditory
 Impaired communication
 Social isolation
NCLEX QUESTION

A client with Meniere’s disease is experiencing severe vertigo.

Which instruction would the nurse give to the client to assist in
controlling the vertigo?

a) Increase fluid intake to 3000 ml a day

b) Avoid sudden head movements
c) Lie still and watch the television
d) Increase sodium in the diet
NCLEX QUESTION

The nurse is performing an admission assessment on a client

with a diagnosis of detached retina. Which of the following is
associated with this eye disorder?
a) Pain in the affected eye
b) Total loss of vision
c) A sense of a curtain falling across the field of vision
d) A yellow discoloration of the sclera
NCLEX QUESTION

The nurse is performing an assessment in a client

with a suspected diagnosis of cataract. The chief
clinical manifestation that the nurse would expect to
note in the early stages of cataract formation is:
a) Eye pain
b) Floating spots
c) Blurred vision
d) Diplopia
NCLEX QUESTION

A client arrives at the emergency room with a foreign body in

the left ear that has been determined to be an insect. Which
intervention would the nurse anticipate to be prescribed
initially?

a) Instillation of mineral oil or lidocaine (2%)

b) Instillation of corticosteroids ear drops
c) Irrigation of the ear
d) Instillation of antibiotic ear drops