1. Description

a. A detailed imaging and recording of ocular circulation by a series of photographs taken after the administration of a dye

b. This test is useful for assessing problems with retinal circulation, such as those that occur in diabetic retinopathy, retinal bleeding, and macular degeneration, or to rule out intraocular tumors.

2. Preprocedure interventions

a. Assess the client for allergies and previous reactions to dyes.

b. Obtain informed consent.

c. A mydriatic medication, which causes pupil dilation, is instilled into the eye 1 hour before the test.

d. The dye is injected into a vein of the client’s arm.

e. Inform the client that the dye may cause the skin to appear yellow for several hours after the test and is eliminated gradually through the urine. Urine may be bright green or orange for up to 2 days following the procedure.

f. The client may experience nausea, vomiting, sneezing, paresthesia of the tongue, or pain at the injection site.

g. If hives appear, antihistamines such as diphenhydramine (Benadryl) are administered as prescribed.

3. Postprocedure interventions

a. Encourage rest.

b. Encourage fluid intake to assist in eliminating the dye from the client’s system.

c. Remind the client that the yellow skin appearance will disappear.

d. Inform the client that the urine will appear bright green or orange until the dye is excreted.

e. Advise the client to avoid direct sunlight for a few hours after the test and to wear sunglasses if staying inside is not possible.

f. Inform the client that the photophobia will continue until pupil size returns to normal.

1. Description

a. A slit lamp allows examination of the anterior ocular structures under microscopic magnification.

b. The client leans on a chin rest to stabilize the head while a narrowed beam of light is aimed so that it illuminates only a narrow segment of the eye.

2. Interventions

a. Explain the procedure to the client.

b. Advise the client about the brightness of the light and the need to look forward at a point over the examiner’s ear.

1. Description

a. A topical dye is instilled into the conjunctival sac to outline irregularities of the corneal surface that are not easily visible.

b. The eye is viewed through a blue filter, and a bright green color indicates areas of a nonintact corneal epithelium.

2. Interventions

a. If the client wears contact lenses, the lenses must be removed.

b. The client is instructed to blink after the dye has been applied to distribute the dye evenly across the cornea.

1. Description: The test is used primarily to assess for an increase in intraocular pressure and potential glaucoma.

2. Noncontact tonometry

a. No direct contact with the client’s cornea is needed and no topical eye anesthetic is needed.

b. A puff of air is directed at the cornea to indent the cornea, which can be unpleasant and may startle the client.

c. It is a less accurate method of measurement as compared with contact tonometry.

3. Contact tonometry

a. Requires a topical anesthetic

b. A flattened cone is brought into contact with the cornea and the amount of pressure needed to flatten the cornea is measured.

c. The client must be instructed to avoid rubbing the eye following the examination if the eye has been anesthetized because of the potential for scratching the cornea.

Normal intraocular pressure is 10 to 21 mm Hg; intraocular pressure varies throughout the day and is normally higher in the morning (always document the time of intraocular pressure measurement).

1. Description

a. Refraction is the bending of light rays; any problem associated with eye length or refraction can lead to refractive errors.

b. Myopia (nearsightedness): Refractive ability of the eye is too strong for the eye length; images are bent and fall in front of, not on, the retina.

c. Hyperopia (farsightedness): Refractive ability of the eye is too weak; images are focused behind the retina.

d. Presbyopia: Loss of lens elasticity because of aging; less able to focus the eye for close work and images fall behind the retina.

e. Astigmatism: Occurs because of the irregular curvature of the cornea; image focuses at two different points on the retina.

2. Assessment

a. Refractive errors are diagnosed through a process called refraction.

b. The client views an eye chart while various lenses of different strengths are systematically placed in front of the eye, and is asked whether the lenses sharpen or worsen the vision.

3. Nonsurgical interventions: Eyeglasses or contact lenses

4. Surgical interventions

a. Radial keratotomy: Incisions are made through the peripheral cornea to flatten the cornea, which allows the image to be focused closer to the retina; used to treat myopia.

b. Photorefractive keratotomy: A laser beam is used to remove small portions of the corneal surface to reshape the cornea to focus an image properly on the retina; used to treat myopia and astigmatism.

c. Laser-assisted in-situ keratomileusis (LASIK): The superficial layers of the cornea are lifted as a flap, a laser reshapes the deeper corneal layers, and then the corneal flap is replaced; used to treat hyperopia, myopia, and astigmatism.

d. Corneal ring: The shape of the cornea is changed by placing a flexible ring in the outer edges of the cornea; used to treat myopia.

1. Description: The best visual acuity with corrective lenses in the better eye is 20/200 or less, or the visual field is no greater than 20 degrees in its widest diameter in the better eye

2. Interventions

a. When speaking to the client who has limited sight or is blind, the nurse should use a normal tone of voice.

b. Alert the client when approaching.

c. Orient the client to the environment.

d. Use a focal point and provide further orientation to the environment from that focal point.

e. Allow the client to touch objects in the room.

f. Use the clock placement of foods on the meal tray to orient the client.

g. Promote independence as much as is possible.

h. Provide radios, televisions, and clocks that give the time orally, or provide a Braille watch.

i. When ambulating, allow the client to grasp the nurse’s arm at the elbow; the nurse keeps his or her arm close to the body so that the client can detect the direction of movement.

j. Instruct the client to remain one step behind the nurse when ambulating.

k. Instruct the client in the use of the cane for the blind, which is differentiated from other canes by its straight shape and white color with red tip.

l. Instruct the client that the cane is held in the dominant hand several inches off the floor.

m. Instruct the client that the cane sweeps the ground where the client’s foot will be placed next to determine the presence of obstacles.

1. Description

a. A cataract is an opacity of the lens that distorts the image projected onto the retina and that can progress to blindness.

b. Causes include the aging process (senile cataracts), heredity (congenital cataracts), and injury (traumatic cataracts); cataracts also can result from another eye disease (secondary cataracts).

c. Causes of secondary cataracts include diabetes mellitus, maternal rubella, severe myopia, ultraviolet light exposure, and medications such as corticosteroids.

d. Intervention is indicated when visual acuity has been reduced to a level that the client finds unacceptable or that adversely affects his or her lifestyle.

2. Assessment

a. Blurred vision and decreased color perception are early signs.

b. Diplopia, reduced visual acuity, absence of the red reflex, and the presence of a white pupil are late signs. Pain or eye redness is associated with age-related cataract formation.

c. Loss of vision is gradual.

3. Interventions

a. Surgical removal of the lens, one eye at a time, is performed.

b. With extracapsular extraction, the lens is lifted out without removing the lens capsule; the procedure may be performed by phacoemulsification, in which the lens is broken up by ultrasonic vibrations and extracted.

c. With intracapsular extraction, the lens and capsule are removed completely.

d. A partial iridectomy may be performed with the lens extraction to prevent acute secondary glaucoma.

e. A lens implantation may be performed at the time of the surgical procedure.

4. Preoperative interventions

a. Instruct the client regarding the postoperative measures to prevent or decrease intraocular pressure, such as bending over, coughing, straining, and rubbing the eye.

b. Stress to the client that care after surgery requires instillation of various types of eye drops several times a day for 2 to 4 weeks.

c. Administer eye medications preoperatively, including mydriatics and cycloplegics as prescribed.

5. Postoperative interventions

a. Elevate the head of the bed 30 to 45 degrees.

b. Turn the client to the back or nonoperative side.

c. Maintain an eye patch as prescribed; orient the client to the environment.

d. Position the client’s personal belongings to the nonoperative side.

e. Use side rails for safety (per agency guidelines).

f. Assist with ambulation.

6. Client education

Avoid eye straining.

Eye itching and mild discomfort are normal for a few days after the procedure.

Avoid rubbing or placing pressure on the eyes.

Avoid rapid movements, straining, sneezing, coughing, bending, vomiting, or lifting objects heavier

than 5 lb.

Take measures to prevent constipation.

Follow instructions for dressing changes and prescribed eye drops and medications.

Wipe excess drainage or tearing with a sterile wet cotton ball from the inner to the outer canthus.

Use an eye shield at bedtime.

If lens implantation is not performed, accommodation is affected and glasses must be worn at all times.

Cataract glasses act as magnifying glasses and replace central vision only.

Because cataract glasses magnify, objects will appear closer; therefore, the client needs to accommodate, judge distance, and climb stairs carefully.

Contact lenses provide sharp visual acuity but dexterity is needed to insert them.

Contact the health care provider about any decrease in vision, severe eye pain, increase in redness, or increase in eye discharge.

1. Description

a. A group of ocular diseases resulting in increased intraocular pressure

b. Intraocular pressure is the fluid (aqueous humor) pressure within the eye (normal intraocular pressure is 10 to 21 mm Hg).

c. Increased intraocular pressure results from inadequate drainage of aqueous humor from the canal of Schlemm or overproduction of aqueous humor.

d. The condition damages the optic nerve and can result in blindness.

e. The gradual loss of visual fields may go unnoticed because central vision is unaffected.

2. Types

a. Primary open-angle glaucoma (POAG) results from obstruction to outflow of aqueous humor and is the most common type.

b. Primary angle-closure glaucoma (PACG) results from blocking the outflow of aqueous humor into the trabecular meshwork; causes include lens or pupil dilation from medications or sympathetic stimulation.

3. Assessment

a. Early signs include diminished accommodation and increased intraocular pressure.

b. Primary open-angle glaucoma (POAG): Painless, and vision changes are slow; results in “tunnel” vision.

c. Primary angle-closure glaucoma (PACG): Blurred vision, halos around lights, and ocular erythema.

4. Interventions for acute angle-closure glaucoma

Acute angle-closure glaucoma is a medical emergency that causes sudden eye pain and possible nausea and vomiting.

a. Treat acute angle-closure glaucoma as a medical emergency.

b. Administer medications as prescribed to lower intraocular pressure.

c. Prepare the client for peripheral iridectomy, which allows aqueous humor to flow from the posterior to the anterior chamber.

5. Interventions for the client with glaucoma

a. Instruct the client on the importance of medications to constrict the pupils (miotics), to decrease the production of aqueous humor (carbonic anhydrase inhibitors), and to decrease the production of aqueous humor and intraocular pressure (β-blockers).

b. Instruct the client of the need for lifelong medication use.

c. Instruct the client to wear a Medic-Alert bracelet.

d. Instruct the client to avoid anticholinergic medications.

e. Instruct the client to report eye pain, halos around the eyes, and changes in vision to the health care provider (HCP).

f. Instruct the client that when maximal medical therapy has failed to halt the progression of visual field loss and optic nerve damage, surgery will be recommended.

g. Instruct the client to contact the HCP before taking medications, including over-the-counter medications.

h. Prepare the client for trabeculectomy as prescribed, which allows drainage of aqueous humor into the conjunctival spaces by the creation of an opening.

1. Description

a. Detachment or separation of the retina from the epithelium

b. Retinal detachment occurs when the layers of the retina separate because of the accumulation of fluid between them, or when both retinal layers elevate away from the choroid as a result of a tumor.

c. Partial detachment becomes complete if untreated.

d. When detachment becomes complete, blindness occurs.

2. Assessment

a. Flashes of light

b. Floaters or black spots (signs of bleeding)

c. Increase in blurred vision

d. Sense of a curtain being drawn over the eye

e. Loss of a portion of the visual field; painless loss of central or peripheral vision

3. Immediate interventions

a. Provide bed rest.

b. Cover both eyes with patches as prescribed to prevent further detachment.

c. Speak to the client before approaching.

d. Position the client’s head as prescribed.

e. Protect the client from injury.

f. Avoid jerky head movements.

g. Minimize eye stress.

h. Prepare the client for a surgical procedure as prescribed.

4. Surgical procedures

a. Draining fluid from the subretinal space so that the retina can return to the normal position

b. Sealing retinal breaks by cryosurgery, a cold probe applied to the sclera, to stimulate an inflammatory response leading to adhesions

c. Diathermy, the use of an electrode needle and heat through the sclera, to stimulate an inflammatory response

d. Laser therapy, to stimulate an inflammatory response and seal small retinal tears before the detachment occurs

e. Scleral buckling, to hold the choroid and retina together with a splint until scar tissue forms, closing the tear

f. Insertion of gas or silicone oil to promote reattachment; these agents float against the retina to hold it in place until healing occurs.

5. Postoperative interventions

a. Maintain eye patches as prescribed.

b. Monitor for hemorrhage.

c. Prevent nausea and vomiting and monitor for restlessness, which can cause hemorrhage.

d. Monitor for sudden, sharp eye pain (notify the HCP).

e. Encourage deep breathing but avoid coughing.

f. Provide bed rest for 1 to 2 days as prescribed.

g. Position the client as prescribed (positioning depends on the location of the detachment).

h. Administer eye medications as prescribed.

i. Assist the client with activities of daily living.

j. Avoid sudden head movements or anything that increases intraocular pressure.

k. Instruct the client to limit reading for 3 to 5 weeks.

l. Instruct the client to avoid squinting, straining and constipation, lifting heavy objects, and bending from the waist.

m. Instruct the client to wear dark glasses during the day and an eye patch at night.

n. Encourage follow-up care because of the danger of recurrence or occurrence in the other eye.

1. A deterioration of the macula, the area of central vision

2. Can be atrophic (age-related or dry) or exudative (wet)

3. Age-related: Caused by gradual blocking of retinal capillaries leading to an ischemic and necrotic macula; rod and cone photoreceptors die.

4. Exudative: Serous detachment of pigment epithelium in the macula occurs; fluid and blood collect under the macula, resulting in scar formation and visual distortion.

5. Interventions are aimed at maximizing the remaining vision.

6. Assessment

a. A decline in central vision

b. Blurred vision and distortion

7. Interventions

a. Initiate strategies to assist in maximizing remaining vision and maintaining independence.

b. Provide referrals to community organizations.

c. Laser therapy, photodynamic therapy, or other therapies may be prescribed to seal the leaking blood vessels in or near the macula.

1. Most common malignant eye tumor in adults

2. Tumor usually found in the uveal tract and can spread easily because of the rich blood supply

3. Assessment

a. Tumor can be discovered during routine examination.

b. If macular area is invaded, blurring of vision occurs.

c. Increased intraocular pressure (IOP) is present if the canal of Schlemm is invaded.

d. Change of iris color is noted if the tumor invades the iris.

e. Ultrasonography may be performed to determine tumor size and location.

4. Interventions

a. Surgery: Enucleation

b. Radiation is given via a radioactive plaque that is sutured to the sclera; the radioactive plaque remains in place until the prescribed radiation dose is delivered.

1. Description

a. Enucleation is the removal of the entire eyeball.

b. Exenteration is the removal of the eyeball and surrounding tissues and bone.

c. The procedures are performed for the removal of ocular tumors.

d. After the eye is removed, a ball implant is inserted to provide a firm base for a socket prosthesis and to facilitate the best cosmetic result.

e. A prosthesis is fitted about 1 month after surgery.

2. Preoperative interventions

a. Provide emotional support to the client.

b. Encourage the client to verbalize feelings related to loss.

3. Postoperative interventions

a. Monitor vital signs.

b. Assess a pressure patch or dressing as prescribed.

c. Report changes in vital signs or the presence of bright red drainage on the pressure patch or dressing.

1. Description

a. Presence of blood in the anterior chamber that occurs as a result of an injury

b. The condition usually resolves in 5 to 7 days.

2. Interventions

a. Encourage rest with the client in a semi-Fowler’s position.

b. Avoid sudden eye movements for 3 to 5 days to decrease the likelihood of bleeding.

c. Administer cycloplegic eye drops as prescribed to relax the eye muscles and place the eye at rest.

d. Instruct the client in the use of eye shields or eye patches as prescribed.

e. Instruct the client to restrict reading and limit watching television.

1. Description

a. Bleeding into the soft tissue as a result of an injury.

b. A contusion causes a black eye; the discoloration disappears in about 10 days.

c. Pain, photophobia, edema, and diplopia may occur.

2. Interventions

a. Place ice on the eye immediately 

1. Description: An object such as dust or dirt that enters the eye and causes irritation

2. Interventions

a. Have the client look upward, expose the lower lid, wet a cotton-tipped applicator with sterile normal saline, gently twist the swab over the particle, and remove it.

b. If the particle cannot be seen, have the client look downward, place a cotton applicator horizontally on the outer surface of the upper eye lid, grasp the lashes, and pull the upper lid outward and over the cotton applicator; if the particle is seen, gently twist a swab over it to remove.

1. Description: An eye injury in which an object penetrates the eye

2. Interventions

a. Never remove the object because it may be holding ocular structures in place; the object must be removed by the HCP.

b. Cover the eye with a cup (paper or plastic) and tape in place.

c. Do not allow the client to bend over or lie flat; these positions may move the object.

d. Do not place pressure on the eye.

e. Client is to be seen by an HCP immediately.

f. X-rays and CT scans of the orbit are usually obtained.

g. Magnetic resonance imaging (MRI) is contraindicated because of the possibility of metalcontaining projectile movement during the procedure.

1. Irrigate the eye.

2. Check the pH of the eye.

3. Assess visual acuity.

4. Document the event, actions taken, and the client’s response.

Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. If the injury occurred outside the hospital, the eye is irrigated immediately with tap water and then the client is brought to the emergency department. In the emergency department, the irrigation should be maintained for at least 10 minutes (and at least 1 L should be used to irrigate). After irrigation, the pH of the eye is checked and, if a pH of 6 to 7 has not returned, the irrigation should be continued. Some health care providers prefer the use of lactated Ringer’s solution for irrigation because its pH is 6 to 7.5, which is closer to the pH of tears (7.1) than that of normal saline, which may range from 4.5 to 7. Following this emergency treatment, visual acuity is assessed. It is also important for the nurse to find out what chemical splashed into the eye. Finally, the event is documented, as well as the actions taken and the client’s response.

1. Donor eyes

a. Donor eyes are obtained from cadavers.

b. Donor eyes must be enucleated soon after death because of rapid endothelial cell death.

c. Donor eyes must be stored in a preserving solution.

d. Storage, handling, and coordination of donor tissue with surgeons is provided by a network of state and national eye bank associations.

2. Care to the deceased client as a potential eye donor

a. Discuss the option of eye donation with the HCP and family.

b. Raise the head of the bed 30 degrees.

c. Instill antibiotic eye drops as prescribed.

d. Close the eyes and apply a small ice pack as prescribed to the closed eyes.

3. Preoperative care to the recipient of the cornea

a. Recipient may be told of the tissue (cornea) availability only several hours to 1 day before the surgery.

b. Assist in alleviating client anxiety.

c. Assess the recipient’s eye for signs of infection.

d. Report the presence of any redness, watery or purulent drainage, or edema around the recipient’s eye to the HCP.

e. Instill antibiotic drops into the recipient’s eye as prescribed to reduce the number of microorganisms present.

f. Administer fluids and medications intravenously as prescribed.

4. Postoperative care to the recipient

a. Eye is covered with a pressure patch and protective shield that is left in place for 1 day.

b. Do not remove or change the dressing without an HCP’s prescription.

c. Monitor vital signs.

d. Monitor level of consciousness.

e. Assess the eye dressing.

f. Position the client with the head elevated and on the nonoperative side to reduce intraocular pressure.

g. Orient the client frequently.

h. Monitor for complications of bleeding, wound leakage, infection, and tissue rejection.

i. Instruct the client how to apply a patch and eye shield.

j. Instruct the client to wear the eye shield at night for 1 month and whenever around small children or pets.

k. Advise the client not to rub the eye.

5. Graft rejection

a. Rejection can occur at any time.

b. Inform the client of the signs of rejection.

c. Signs include redness, swelling, decreased vision, and pain (RSVP).

d. The eye is treated with topical corticosteroids.

1. Description

a. Audiometry measures hearing acuity.

b. Audiometry uses two types, pure tone audiometry and speech audiometry.

c. Pure tone audiometry is used to identify problems with hearing, speech, music, and other sounds in the environment.

d. In speech audiometry, the client’s ability to hear spoken words is measured.

e. After testing, audiographic patterns are depicted on a graph to determine the type and level of the hearing loss.

2. Interventions

a. Inform the client regarding the procedure.

b. Instruct the client to identify the sounds as they are heard.

1. Description

a. Electronystagmography is a vestibular test that evaluates spontaneous and induced eye movements known as nystagmus.

b. ENG is used to distinguish between normal nystagmus and medication-induced nystagmus, or nystagmus caused by a lesion in the central or peripheral vestibular pathway.

c. ENG records changing electrical fields with the movement of the eye, as monitored by electrodes placed on the skin around the eye.

2. Interventions

a. The client is instructed to remain NPO for 3 hours before testing, avoiding caffeinecontaining beverages for 24 to 48 hours before the test.

b. Unnecessary medications are withheld for 24 hours before testing.

c. Instruct the client that this is a long and tiring procedure.

d. The client should bring prescription eyeglasses to the examination.

e. The client sits and is instructed to gaze at lights, focus on a moving pattern, focus on a moving point, and then close the eyes.

f. While sitting in a chair, the client may be rotated to obtain information about vestibular function.

g. In addition, the client’s ears are irrigated with cool and warm water, which may cause nausea and vomiting.

h. Following the procedure, the client begins taking clear fluids slowly and cautiously because nausea and vomiting may occur.

i. Assistance with ambulation may also be necessary following the procedure.

1. Description

a. Conductive hearing loss occurs when sound waves are blocked to the inner ear fibers because of external or middle ear disorders.

b. Disorders often can be corrected with no damage to hearing or minimal permanent hearing loss.

2. Causes

a. Any inflammatory process or obstruction of the external or middle ear

b. Tumors

c. Otosclerosis

d. A buildup of scar tissue on the ossicles from previous middle ear surgery

1. Description

a. Sensorineural hearing loss is a pathological process of the inner ear or of the sensory fibers that lead to the cerebral cortex.

b. Sensorineural hearing loss is often permanent, and measures must be taken to reduce further damage.

2. Causes

a. Damage to the inner ear structures

b. Damage to the eighth cranial nerve or brain itself

c. Prolonged exposure to loud noise

d. Medications

e. Trauma

f. Inherited disorders

g. Metabolic and circulatory disorders

h. Infections

i. Surgery

j. Meniere’s syndrome

k. Diabetes mellitus

l. Myxedema

■ Frequently asking others to repeat statements

■ Straining to hear

■ Turning head or leaning forward to favor one ear

■ Shouting in conversation

■ Ringing in the ears

■ Failing to respond when not looking in the direction of the sound

■ Answering questions incorrectly

■ Raising the volume of the television or radio

■ Avoiding large groups

■ Better understanding of speech when in small groups

■ Withdrawing from social interactions 

■ Using written words if the client is able to see, read, and write

■ Providing plenty of light in the room

■ Getting the attention of the client before beginning to speak

■ Facing the client when speaking

■ Talking in a room without distracting noises

■ Moving close to the client and speaking slowly and clearly

■ Keeping hands and other objects away from the mouth when talking to the client

■ Talking in normal volume and at a lower pitch because shouting is not helpful and higher frequencies are less easily heard

■ Rephrasing sentences and repeating information

■ Validating with the client the understanding of statements made by asking the client to repeat what was said

■ Reading lips

■ Encouraging the client to wear glasses when talking to someone to improve vision for lip reading

■ Using sign language, which combines speech with hand movements that signify letters, words, or phrases

■ Using telephone amplifiers

■ Using flashing lights that are activated by ringing of the telephone or doorbell

■ Using specially trained dogs to help the client be aware of sound and alert the client to potential danger

1. Cochlear implants are used for sensorineural hearing loss.

2. A small computer converts sound waves into electrical impulses.

3. Electrodes are placed by the internal ear with a computer device attached to the external ear.

4. Electronic impulses directly stimulate nerve fibers. 

1. Hearing aids are used for the client with conductive hearing loss.

2. Hearing aids have limited value for the client with sensorineural hearing loss, because they only make sounds louder, not clearer.

3. A difficulty that exists in the use of hearing aids is the amplification of background noise and

voices.

4. Hearing aids are costly and often not covered by insurance. Some clients can obtain hearing aids through a rehabilitation facility or through other resources.

5. Client education

Begin using the hearing aid slowly to adjust to the device.

Adjust the volume to the minimal hearing level to prevent feedback squealing.

Concentrate on the sounds that are to be heard and to filter out background noise.

Clean the ear mold with mild soap and water.

Avoid excessive wetting of the hearing aid and try to keep the hearing aid dry.

Clean the ear cannula of the hearing aid with a toothpick or pipe cleaner.

Turn the hearing aid off before removing from the ear to prevent squealing feedback; remove the battery when not in use.

Keep extra batteries on hand.

Keep the hearing aid in a safe place.

Prevent hair sprays, oils, or other hair and face products from coming into contact with the receiver of the hearing aid.

1. Description

a. Presbycusis is a sensorineural hearing loss associated with aging.

b. Presbycusis leads to degeneration or atrophy of the ganglion cells in the cochlea and a loss of elasticity of the basilar membranes.

c. Presbycusis leads to compromise of the vascular supply to the inner ear, with changes in several areas of the ear structure.

2. Assessment

a. Hearing loss is gradual and bilateral.

b. Client states that he or she has no problem with hearing but cannot understand what the words are.

c. Client thinks that the speaker is mumbling.

1. Description

a. External otitis is an infective inflammatory or allergic response involving the structure of the external auditory canal or auricles.

b. An irritating or infective agent comes into contact with the epithelial layer of the external ear.

c. Contact leads to an allergic response or signs and symptoms of an infection.

d. The skin becomes red, swollen, and tender to touch on movement.

e. The extensive swelling of the canal can lead to conductive hearing loss because of obstruction.

f. External otitis is more common in children; it is termed swimmer’s ear and occurs more often in hot, humid environments.

g. Prevention includes the elimination of irritating or infecting agents.

2. Assessment

a. Pain

b. Itching

c. Plugged feeling in the ear

d. Redness and edema

e. Exudate

f. Hearing loss

3. Interventions

a. Apply heat locally for 20 minutes three times a day.

b. Encourage rest to assist in reducing pain.

c. Administer antibiotics or corticosteroids as prescribed.

d. Administer analgesics such as acetaminophen (Tylenol) for the pain as prescribed.

e. Instruct the client that the ears should be kept clean and dry.

f. Instruct the client to use earplugs for swimming.

g. Instruct the client that cotton-tipped applicators should not be used because their use can lead to trauma to the canal.

h. Instruct the client that irritating agents such as hair products or headphones should be discontinued.

Avoid strenuous activities.

Avoid rapid head movements, bouncing, or bending.

Avoid straining on bowel movement.

Avoid drinking through a straw.

Avoid traveling by air.

Avoid forceful coughing.

Avoid contact with persons with colds.

Avoid washing hair, showering, or getting the head wet for 1 week as prescribed.

Instruct the client that if he or she needs to blow the nose, to blow one side at a time with the mouth open.

Instruct the client to keep ears dry by keeping a ball of cotton coated with petroleum jelly in the ear and to change the cotton ball daily.

Instruct the client to report excessive ear drainage to the health care provider.

1. Description

a. Chronic otitis media is a chronic infective, inflammatory, or allergic response involving the structure of the middle ear.

b. Frequent removal of debris from the canal may be required.

c. Myringoplasty can reconstruct the tympanic membrane and ossicles and improve conductive hearing loss.

d. Mastoidectomy may be performed if the infection has spread to involve the mastoid bone. Monitor the client with otitis media closely for response to treatment. Otic and systemic antibiotics may be used to treat the infection, but often the organism is resistant.

2. Preoperative interventions

a. Administer antibiotic drops as prescribed.

b. Clean the ear of debris as prescribed; irrigate the ear with a solution of equal parts of vinegar and sterile water as prescribed to restore the normal pH of the ear.

c. Instruct the client to avoid persons with upper respiratory infections.

d. Instruct the client to obtain adequate rest, eat a balanced diet, and drink adequate fluids.

e. Instruct the client in deep breathing and coughing; forceful coughing, which increases pressure in the middle ear, is to be avoided postoperatively.

3. Postoperative interventions

a. Inform the client that initial hearing after surgery is diminished because of the packing in the ear canal; hearing improvement will occur after the ear canal packing is removed.

b. Keep the dressing clean and dry.

c. Keep the client flat as prescribed, with the operative ear up for at least 12 hours.

d. Administer antibiotics as prescribed.

1. Description

a. Mastoiditis may be acute or chronic and results from untreated or inadequately treated chronic or acute otitis media.

b. The pain is not relieved by myringotomy.

2. Assessment

a. Swelling behind the ear and pain with minimal movement of the head

b. Cellulitis on the skin or external scalp over the mastoid process

c. A reddened, dull, thick, immobile tympanic membrane, with or without perforation

d. Tender and enlarged postauricular lymph nodes

e. Low-grade fever

f. Malaise

g. Anorexia

3. Interventions

a. Prepare the client for surgical removal of infected material.

b. Monitor for complications.

c. Simple or modified radical mastoidectomy with tympanoplasty is the most common treatment.

d. Once infected tissue is removed, the tympanoplasty is performed to reconstruct the ossicles and tympanic membrane in an attempt to restore normal hearing.

4. Complications

a. Damage to the abducens and facial cranial nerves

b. Damage is exhibited by inability to look laterally (cranial nerve VI, abducens) and a drooping of the mouth on the affected side (cranial nerve VII, facial).

c. Meningitis

d. Brain abscess

e. Chronic purulent otitis media

f. Wound infections

g. Vertigo, if the infection spreads into the labyrinth

5. Postoperative interventions

a. Monitor for dizziness.

b. Monitor for signs of meningitis, as evidenced by a stiff neck and vomiting.

c. Prepare for a wound dressing change 24 hours postoperatively.

d. Monitor the surgical incision for edema, drainage, and redness.

e. Position the client flat with the operative side up as prescribed.

f. Restrict the client to bed with bedside commode privileges for 24 hours as prescribed.

g. Assist the client with getting out of bed to prevent falling or injuries from dizziness.

h. With reconstruction of the ossicles via a graft, take precautions to prevent dislodging of the graft.

1. Description

a. Otosclerosis is a genetic disorder of the labyrinthine capsule of the middle ear that results in

a bony overgrowth of the tissue surrounding the ossicles.

b. Otosclerosis causes the development of irregular areas of new bone formation and causes the fixation of the bones.

c. Stapes fixation leads to a conductive hearing loss.

d. If the disease involves the inner ear, sensorineural hearing loss is present.

e. Bilateral involvement is common, although hearing loss may be worse in one ear.

f. It is thought to be a hereditary autosomal dominant disorder and is most commonly seen in young women.

g. Nonsurgical intervention promotes the improvement of hearing through amplification.

h. Surgical intervention involves removal of the bony growth causing the hearing loss.

i. A partial stapedectomy or complete stapedectomy with prosthesis (fenestration) may be performed surgically.

2. Assessment

a. Slowly progressing conductive hearing loss

b. Bilateral hearing loss

c. A ringing or roaring type of constant tinnitus

d. Loud sounds heard in the ear when chewing

e. Pinkish discoloration (Schwartze’s sign) of the tympanic membrane, which indicates vascular changes within the ear.

f. Negative Rinne test

g. Weber’s test shows lateralization of sound to the ear with the greatest degree of conductive hearing loss.

1. Description

a. Fenestration is removal of the stapes, with a small hole drilled in the footplate; a prosthesis is connected between the incus and footplate.

b. Sounds cause the prosthesis to vibrate in the same manner as the stapes.

c. Complications include complete hearing loss, prolonged vertigo, infection, and facial nerve damage.

2. Preoperative interventions

a. Instruct the client in measures to prevent middle ear or external ear infections.

b. Instruct the client to avoid excessive nose blowing.

c. Instruct the client not to clean the ear canal with cotton-tipped applicators and to avoid trauma or injury to the ear canal.

3. Postoperative interventions

a. Inform the client that hearing is initially worse after the surgical procedure because of swelling and that no noticeable improvement in hearing may occur for as long as 6 weeks.

b. Inform the client that the Gelfoam ear packing (if used) interferes with hearing but is used to decrease bleeding.

c. Assist with ambulating during the first 1 to 2 days after surgery.

d. Raise side rails per agency guidelines. when in bed.

e. Administer antibiotic, antivertiginous, and pain medications as prescribed.

f. Assess for facial nerve damage, weakness, changes in tactile sensation and taste sensation, vertigo, nausea, and vomiting.

g. Instruct the client to move the head slowly when changing positions to prevent vertigo.

h. Instruct the client to avoid persons with upper respiratory tract infections.

i. Instruct the client to avoid showering and getting the head and wound wet.

j. Instruct the client to avoid using small objects (cotton-tipped applicators) to clean the external ear canal.

k. Instruct the client to avoid rapid extreme changes in pressure caused by quick head movements, sneezing, nose blowing, straining, and changes in altitude.

l. Instruct the client to avoid changes in middle ear pressure because they could dislodge the graft or prosthesis.

1. Description: Infection of the labyrinth that occurs as a complication of acute or chronic otitis media

2. May result from growth of a cholesteatoma, a benign overgrowth of squamous cell epithelium in the middle ear

3. Assessment

a. Hearing loss that may be permanent on the affected side

b. Tinnitus

c. Spontaneous nystagmus to the affected side

d. Vertigo

e. Nausea and vomiting

4. Interventions

a. Monitor for signs of meningitis, the most common complication, as evidenced by headache, stiff neck, and lethargy.

b. Administer systemic antibiotics as prescribed.

c. Advise the client to rest in bed in a darkened room.

d. Administer antiemetics and antivertiginous medications as prescribed.

e. Instruct the client that the vertigo subsides as the inflammation resolves.

f. Instruct the client that balance problems that persist may require gait training through physical therapy.

1. Description

a. Ménière’s syndrome is also called endolymphatic hydrops; it refers to dilation of the endolymphatic system by overproduction or decreased reabsorption of endolymphatic fluid.

b. The syndrome is characterized by tinnitus, unilateral sensorineural hearing loss, and vertigo.

c. Symptoms occur in attacks and last for several days, and the client becomes totally incapacitated during the attacks.

d. Initial hearing loss is reversible but as the frequency of attacks continues, hearing loss becomes permanent.

A priority nursing intervention in the care of a client with Ménière’s syndrome is instituting safety measures.

2. Causes

a. Any factor that increases endolymphatic secretion in the labyrinth

b. Viral and bacterial infections

c. Allergic reactions

d. Biochemical disturbances

e. Vascular disturbance, producing changes in the microcirculation in the labyrinth

f. Long-term stress may be a contributing factor.

3. Assessment

a. Feelings of fullness in the ear

b. Tinnitus, as a continuous low-pitched roar or humming sound, that is present much of the time but worsens just before and during severe attacks

c. Hearing loss that is worse during an attack

d. Vertigo, that is, a sensation of whirling, that might cause the client to fall to the ground

e. Vertigo that is so intense that even while lying down, the client holds the bed or ground in an attempt to prevent the whirling

f. Nausea and vomiting

g. Nystagmus

h. Severe headaches

4. Nonsurgical interventions

a. Prevent injury during vertigo attacks.

b. Provide bed rest in a quiet environment.

c. Provide assistance with walking.

d. Instruct the client to move the head slowly to prevent worsening of the vertigo.

e. Initiate sodium and fluid restrictions as prescribed.

f. Instruct the client to stop smoking.

g. Instruct the client to avoid watching television because the flickering of lights may exacerbate symptoms.

h. Administer nicotinic acid (niacin) as prescribed for its vasodilatory effect.

i. Administer antihistamines as prescribed to reduce the production of histamine and the inflammation.

j. Administer antiemetics as prescribed.

k. Administer tranquilizers and sedatives as prescribed to calm the client, allow the client to rest, and control vertigo, nausea, and vomiting.

l. Mild diuretics may be prescribed to decrease endolymph volume.

m. Inform the client about vestibular rehabilitation as prescribed.

5. Surgical interventions

a. Surgery is performed when medical therapy is ineffective and the functional level of the client has decreased significantly.

b. Endolymphatic drainage and insertion of a shunt may be performed early in the course of the disease to assist with the drainage of excess fluids.

c. A resection of the vestibular nerve or total removal of the labyrinth (i.e., a labyrinthectomy) may be performed.

6. Postoperative interventions

a. Assess packing and dressing on the ear.

b. Speak to the client on the side of the unaffected ear.

c. Perform neurological assessments.

d. Maintain safety.

e. Assist with ambulating.

f. Encourage the client to use a bedside commode rather than ambulating to the bathroom.

g. Administer antivertiginous and antiemetic medications as prescribed.

1. Description

a. An acoustic neuroma is a benign tumor of the vestibular or acoustic nerve.

b. The tumor may cause damage to hearing and to facial movements and sensations.

c. Treatment includes surgical removal of the tumor via craniotomy.

d. Care is taken to preserve the function of the facial nerve.

e. The tumor rarely recurs after surgical removal.

f. Postoperative nursing care is similar to postoperative craniotomy care.

2. Assessment

a. Symptoms usually begin with tinnitus and progress to gradual sensorineural hearing loss.

b. As the tumor enlarges, damage to adjacent cranial nerves occurs. 

1. Description

a. The tympanic membrane has limited stretching ability and gives way under high pressure.

b. Foreign objects placed in the external canal may exert pressure on the tympanic membrane and cause perforation.

c. If the object continues through the canal, the bony structure of the stapes, incus, and malleus may be damaged.

d. A blunt injury to the basal skull and ear can damage the middle ear structures through fractures extending to the middle ear.

e. Excessive nose blowing and rapid changes of pressure that occur with nonpressurized air flights can increase pressure in the middle ear.

f. Depending on the damage to the ossicles, hearing loss may or may not be reversible.

2. Interventions

a. Tympanic membrane perforations usually heal within 24 hours.

b. Surgical reconstruction of the ossicles and tympanic membrane through tympanoplasty or myringoplasty may be performed to improve hearing.

1. Description

a. Cerumen, or wax, is the most common cause of impacted canals.

b. Foreign bodies can include vegetables, beads, pencil erasers, insects, and other objects.

2. Assessment

a. Sensation of fullness in the ear with or without hearing loss

b. Pain, itching, or bleeding

3. Cerumen

a. Removal of wax by irrigation is a slow process.

b. Irrigation is contraindicated in clients with a history of tympanic membrane perforation or otitis media.

c. If prescribed to soften cerumen, glycerin or mineral oil is placed in the ear at bedtime; hydrogen peroxide may also be prescribed.

d. After several days, the ear is irrigated.

e. The maximum amount of solution that should be used for irrigation is 50 to 70 mL.

Inform the client that ear candles should never be used to remove cerumen. Their use can cause burns and a vacuum effect, causing a perforation in the tympanic membrane.

4. Foreign bodies

a. With a foreign object of vegetable matter, irrigation is used with care because this material expands with hydration.

b. Insects are killed before removal, unless they can be coaxed out by flashlight or a humming noise; lidocaine may be placed in the ear to relieve pain.

c. Mineral oil or diluted alcohol is instilled to suffocate the insect, which then is removed using ear forceps.

d. Use a small ear forceps to remove the object; avoid pushing the object farther into the canal and damaging the tympanic membrane.

1. Eye medications are usually in the form of drops or ointments.

2. To prevent overflow of medication into the nasal and pharyngeal passages, thus reducing systemic absorption, instruct the client to apply pressure over the inner canthus next to the nose for 30 to 60 seconds following administration of the medication; instruct the client to close the eye gently to help distribute the medication

3. If both an eyedrop and eye ointment are scheduled to be administered at the same time, administer the eyedrop first.

4. Wash hands and don gloves before administering eye medications to avoid contaminating the eye or medication dropper or applicator.

5. Use a separate bottle or tube of medication for each client to avoid accidental crosscontamination.

6. Place the prescribed dose of eye medication in the lower conjunctival sac, never directly onto the cornea.

7. Avoid touching any part of the eye with the dropper or applicator.

8. Administer glucocorticoid preparations before other medications.

9. Monitor the pulse and blood pressure if receiving an ophthalmic β-blocker, and instruct the client to do the same; the nurse should obtain pulse parameters from the health care provider (HCP).

10. Instruct the client how to instill medication correctly and supervise instillation until the client can do it safely; adaptive devices that position the bottle of eyedrops directly over the eye can also be purchased if instillation is difficult for the client.

11. Instruct the client to read the medication labels carefully to ensure administration of the correct medication and correct strength.

12. Remind the client to keep these medications out of the reach of children.

13. Instruct the client to avoid driving or operating hazardous equipment if vision is blurred.

14. Inform the client that he or she may be unable to drive home after eye examinations when a medication to dilate the pupil (mydriatic) or to paralyze the ciliary muscle (cycloplegic) is used.

15. If photophobia occurs, instruct the client to wear sunglasses and avoid bright lights.

16. Instruct the client to administer a missed dose of the eye medication as soon as it is remembered, unless the next dose is scheduled to be administered in 1 to 2 hours.

17. Inform the client with glaucoma that the disorder cannot be cured, only controlled.

18. Reinforce the importance of using medications to treat glaucoma as prescribed and not to discontinue these medications without consulting the HCP.

19. Inform the client that medications used to treat glaucoma may cause pain and blurred vision, especially when therapy is begun.

20. Instruct the client to report the development of any eye irritation.

21. Inform the client using eye gel to store the gel at room temperature or in the refrigerator, but not to freeze it.

22. Instruct the client to discard unused eye gel kept at room temperature as recommended by the HCP and/or the pharmacist.

23. Inform the client that soft contact lenses may absorb certain eye medications and that preservatives in eye medications may discolor the contact lenses.

24. Advise the client wearing contact lenses to question the HCP carefully about special precautions to observe with eye medications.

25. Inform the parents of infants that atropine sulfate eyedrops may contribute to abdominal distention.

26. Instruct the parents to keep a record of the infant’s bowel movements if atropine sulfate eyedrops are being administered.

27. Auscultate bowel sounds of the infant or child receiving atropine sulfate eyedrops.

Because the timing of medication administration is critical, administer eye medications at frequent, precise intervals; separate the instillation by 3 to 5 minutes if two medications must be administered at the same time.

Instillation of eye medications

Drops

a. Wash hands.

b. Put gloves on.

c. Check the name, strength, and expiration date of the medication.

d. Instruct the client to tilt the head backward, open the eyes, and look up.

e. Pull the lower lid down against the cheekbone.

f. Hold the bottle like a pencil, with the tip downward.

g. Holding the bottle, gently rest the wrist of the hand on the client’s cheek.

h. Squeeze the bottle gently to allow the drop to fall into the conjunctival sac.

i. Instruct the client to close the eyes gently and not to squeeze the eyes shut.

j. Wait 3 to 5 minutes before instilling another drop, if more than one drop is prescribed, to promote maximal absorption of the medication.

k. Do not allow the medication bottle, dropper, or applicator to come into contact with the eyelid or conjunctival sac.

l. To prevent systemic absorption of the medication, apply gentle pressure with a clean tissue to the client’s nasolacrimal duct for 30 to 60 seconds

Instillation of eye medications

Ointments

a. Instruct the client to lie down or tilt head backward and look up.

b. Hold the ointment tube near, but not touching, the eye or eyelashes.

c. Squeeze a thin ribbon of ointment along the lining of the lower conjunctival sac, from the

inner to the outer canthus.

d. Instruct the client to close the eyes gently, rolling the eyeball in all directions (increases

contact area of medication to eye).

e. Instruct the client that vision may be blurred by the ointment.

f. If possible, apply ointment just before bedtime.