EENT NURSING By: JOHN MARK B.

POCSIDIO, RN, MSN EYES PARTS OF THE EYES EYELIDS (PALPEBRAE)- loose folds of skin that covers the anterior portion of the eye. ( eyelashes & sebaceous glands) The eyelids contain three types of glands: Meibomian glands- sebaceous glands that secrete sebum (oily substance) Glands of Zeis- modified sebaceous glands connected to the follicles of the eye lashes Molls glands ordinary sweat glands

Conjunctiva: thin mucous membranes that line the inner surface of each eyelid Lacrimal Apparatus Lacrimal gland secretes tears (lubricates eyes and moisten cornea) Extraocular muscles responsible for the movement of the eyeball innervated by CN III (occulomotor), IV (trochlear), VI (Abducens): Anterior rectus Superior rectus Inferior rectus Superior oblique Inferior oblique Layers of the Eyeball Sclera - tough white connective tissue that covers all of the eye ( except cornea) Cornea transparent membrane through w/c white light enters the eye. ( window of the eye) Middle Layer Choroid highly vascular layer that nourishes the retina Ciliary body secretes aqueous humor (fluid of the eye) o Ciliary muscles changes the shape of the lens Iris pigmented membrane behind the cornea o Gives color to the eye Pupil circular opening in the middle of the iris, that constricts and dilates to regulates amount of light entering the eye Inner Layer

 Retina sensitive layer, it receives stimuli and sends them to the brain .

Composed of: o Rods night vision (color vision, fine discrimination) o Cones day light vision (peripheral vision) Optic Disc entrance of the optic nerve that supplies the eyeball Lens transparent tissue that focus image of the retina Aqueous humor colorless fluid found in the anterior portion of the eye Functions: Maintains intra-ocular pressure Serves as a refracting media Provides the nutrients to the lens and cornea Canal of schlemm Passageway that extends completely around the eye Permits fluid to drain out of the eye into the systemic circulation ( maintains constant IOP) Vitreous humor gelatinous found in the posterior portion of the eye Functions: maintains transparency and form of the eye

Ears External structures Pinna & auricle outer projection of the ear ( cartilage covered w/ skin) External auditory canal/meatus (lined with skin) Functions: transmit sound waves to the tympanic membrane Important Structure: ceruminous gland secretes cerumen/earwax Functions: lubricates and protects the ear from any foreign body Tympanic membrane (eardrum) vibrates in response to sound & transmits them to the middle ear (ossicles) Middle ear Has 3 smallest bone: Maleus (hammer) Incus (anvil) Stapes (stirrup) Function : transmit sound waves to the fluid in the cochlea

DIAGNOSTICS By: JOHN MARK B. POCSIDIO, RN, MSN VISUAL ACUITY Measures the clients distance and near vision HOW??? Client stands 20 feet from the chart ( covers one eye) uses the other eye to read the line that appears most clearly If client able to do this accurately, client reads next lower line. Sequence repeated until client is unable to identify correctly more than half of characters on the line Procedure repeated to other eye FINDINGS RECORDED AS: Comparison between what the client can read at 20 feet & the number of feet normally required by an individual to read the same line MEANING: 20/50 Client can read at 20 feet ( from the chart) what healthy eye can read at 50 feet Confrontation test To examine visual field or peripheral vision HOW? Examiner & client sit facing each other Client is asked to look directly into the eyes of the examiner throughout the test Examiner covers his right eye, client covers left eye Examiner moves a finger from a nonvisible area into the clients line of vision Client and examiner should see the object at approx same time Direct examination Direct Ophthalmoscopy To directly examine the Cornea, Lens and Retina Uses the Ophthalmoscope in a dark room REMEMBER: darken the room Red reflex is normal

Direct examination Slit-Lamp Examination The Slit-lamp is a binocular microscope that enables the user to examine the eye with magnification 10 to 40 times the real image

PUPIL EXAM Pupil are round equal in size Increasing light: pupillary constriction Decreasing light: pupillary dilation Constriction of both pupils is normal response to light ( consensual response) SCLERA & CORNEA EXAM Normal color of sclera is white Yellow means jaundice or systemic problem Dark skinned person ( normal yellow with pigmented dots) Cornea is transparent, smooth, shiny and bright Cloudy areas or specks on cornea maybe the result of an accident or eye injury Ishihara chart sensitive for the diagnosis of green/red blindness but not effective for detection of blue discrimination Tonometry Measures IOP Normal pressure is 10-21 mmHg INTERVENTIONS: Eye is anesthetized Client ask to stare forward ( above examiners ear) Flattened cone is brought in contact with cornea Amount of pressure needed to flatten the cone is measured Instruct your patient not to rub the eye following examination ( damage to cornea) EAR EXAMINATION OTOSCOPIC EXAMINATION using a otoscope, held in the examiners right hand, in a pencil hold position. Auricle is pulled downward and backward to straighten the ear canal. Audiometry the single most important diagnostic instrument in detecting hearing loss. Pure-tone Audiometry the sound stimulus consist of a pure or musical note ( the longer the tone before the patient perceives it, the greater the hearing loss ) Speech Audiometry the spoken word is used to determine the ability to hear and discriminate sounds and words.

Webers Test Uses bone conduction to test lateralization of sound HOW?:Place the tuning fork on the forehead NORMAL: Should hear sound equally on both ears. Conductive hearing loss: sound is heard better in the affected ear. Sensorineural hearing loss: The sound lateralizes to the better hearing ear. RINNES TEST HOW?:the examiner shift the stem of vibrating tuning fork between two positions; 2 inches from the opening of the ear canal ( for air conduction), and against the mastoid bone (for bone conduction) Normally sound by air conduction is longer than sound in bone conduction. Conductive hearing loss- sound in bone conduction is heard longer than air conduction. Sensorineural hearing loss- air conducted sound is longer than the bone conduction. EYE disorders By: JOHN MARK B. POCSIDIO, RN, MSN HYPHEMA Is the presence of blood in the anterior chamber It is the result of an injury Condition resolves in 5-7 days HYPHEMA NURSING INTERVENTIONS Encourage rest in a semi-fowlers position Avoid sudden eye movements for 3-5 days Administer cycloplegic eye drops Instruct the client in the use of eye shields or eye patches as prescribed Instruct the client to restrict reading and limit watching television PENETRATING OBJECTS An injury that occurs in the eye in which an object penetrates the eye NURSING INTERVENTIONS: Never remove the object ( only MD is allowed) Cover the object with a cup-CBQ Do not allow the client to bend Do not place pressure on the eye

CHEMICAL BURNS An eye injury in which a caustic substance enters the eye NURSING INTERVENTIONS: Treatment should begin immediately Flush the eye at the site of injury with water ( 15-20mins) Obtain sample of chemical involved ( at the scene) In the ER, the eye is irrigated with NSS at least 10 mins Solution is directed across the cornea and toward the lateral canthus Antibiotics as prescribed Cover eye patch as prescribed Prepare visual acuity assessment CONJUNCTIVITIS Inflammation of the conjunctiva Results from infection, allergy, chemical reactions Bacterial and viral conjunctivitis is highly contagious but is self-limiting after a couple of weeks Causes Staphylococcus aureus Streptococcus pneumoniae Neisseria gonorrhoeae N. meningitidis Chlamydia trachomatis Herpes simplex type 1 Adenovirus type 3, 7,8 Allergic reactions Assessment Excessive tearing Itching, burning Mucopurulent discharge Hyperemia ( engorgement of the conjunctiva) DIAGNOSTICS Culture and sensitivity test MEDS Antiviral ( zovirax) Corticosteriods Topical antibiotics

Nursing interventions Teach proper hand washing techniques Avoid sharing wash cloth, towels, pillows, avoid rubbing the eye Apply warm compress and ointment or drops Dont irrigate the eye Have client wash hands before use of medication and use clean wash cloth Teach how to instill eye drops properly, avoid touching the bottle tip to the eye or lashes CATARACTS Opacity of the ocular lens Incidence increases with age CLASSIFICATION Senile associated with aging Traumatic associated with injury Congenital Occur at birth Secondary occurs following other eye or systemic diseases Assessment Opaque or cloudy white pupil- CBQ Gradual loss of vision Blurred vision Decreased color perception Vision better in dim light Photophobia Absence of red reflex- SEEN Through opthalmoscope-CBQ Diagnosis: Visual field examination by Snellens chart reveals a distorted blurred, hazy vision Opthalmoscopic eye exam- absence of red-reflex Management: Surgery INTRACAPSULAR CATARACT EXTRACTION- removes the entire lens and lens capsule EXTRACAPSULAR CATARACT EXTRACTION- removes the lens but leaves the majority of lens capsule intact ( supports the lens implant NURSING INTERVENTION PRE-OP Assess vision in the unaffected eye Provide health teachings regarding measures to prevent increased IOP post-op

Administer medications as ordered Topical mydriatics and cycloplegics to dilate the pupil Topical antibiotics to prevent infection Acetazolamide ( diamox)- osmotic agent to decrease IOP, to provide soft eyeball for surgery NURSING INTERVENTIONS (POST-OP) Reorient the client to surroundings Provide safety measures: elevate side rails Prevent increase IOP Elevate HOB 30-40 degrees Have client lie on back or unaffected side Avoid coughing, sneezing, bend over, stooping, lifting or moving head rapidly Avoid nausea, give antiemetics Avoid straining, give stool softeners Report severe eye pain ( SIGNS OF inc. IOP) Always use eye shield during the night cataract glasses CBQ Cataract glasses magnify objects by 1/3 and distort peripheral vision. Make sure you orient the client about this Have client practice manual coordination with assistance. Until patient becomes adjusted

RETINAL DETACHMENT Sensory retina separates from the pigment epithelium of the retina Can be related to age or trauma ASSESSMENT FLASHES IF LIGHT FLOATERS INCREASE IN BLURRED VISION SENSE OF CURTAIN FALLING DOWN LOSS OF PORTION OF VISUAL FIELD IMMEDIATE INTERVENTIONS Provide bed rest Cover both eyes with patches to prevent further detachment-CBQ Speak to the client before approaching Position the client on affected side-CBQ Avoid jerky movement Protect the client from injury Minimize eye stress Prepare the client for surgical procedures Management: Retinal Surgery

 Types of Surgery under the Retinal Surgery: Cryosurgery use of a super cooled probe in the sclera to produce scarring (to extract the tumor from retinal layers through the choroid) Photo coagulation use of a strong beam light directed through a dilated pupil to form a scar (produced by cryo-surgery) Scleral buckling- shortening of the sclera to enhance contact between choroid and retina (most commonly done surgery) -CBQ

Eye shield at night No bending from waist No heavy work (lifting) 6 wks Avoid reading ( for 3wks) May watch TV

GLAUCOMA Increase IOP results from inadequate drainage of aqueous humor from the cabal of schlemm or over production of aqueous humor This condition damages the optic nerve and can cause blindness

TYPES ACUTE CLOSED ANGLE- results from obstruction to outflow to aqueous humor CHRONIC CLOSED ANGLE- follows an untreated attack of acute closed angle glaucoma CHRONIC OPEN-ANGLE- results from overproduction or obstruction to the outflow of aqueous humor ACUTE GLAUCOMA- is a rapid onset of IOP greater than 50-70mmHg CHRONIC GLAUCOMA- is a slow , progressive , gradual onset of IOP greater than 30-50 mmHg ASSESSMENT Patient may bump people, trash cans- CBQ Loss of peripheral vision Mild headache Blurring of vision/ halos around lights Difficulty adapting to dark Extreme eye pain Nausea / vomiting Diagnostics Tonometry Opthalmoscopy

 Gonioscopy Surgery Trabeculectomy NURSING INTERVENTIONS Maintain bed rest ( quiet, darkened room) Monitor VS Provide safety Provide emotional support Avoid!!!! Exertion Stooping Heavy lifting Sneezing coughing. Wearing constrictive clothing Avoid atropine, Benadryl, cogentin Administer antiemetics Compliance to medication is emphasized Meds: pilocarpine Acetazolamide ( diamox) LEGALLY BLIND Best visual acuity with corrective lenses in better eye of 20/200 or less. NURSING INTERVENTIONS: Use normal tone of voice Alert client when approaching Orient client to environment Allow client to touch objects in the room Use clock placement of foods on the meal tray to orient the client Promote independence ( as much as possible) WHEN AMBULATING: ( CBQ) Allow client to grasp the nurses arm at the elbow, nurse keeps his arms close to the body ( so client can detect direction of movement) Instruct client to remain one step behind the nurse when ambulating Use cane using dominant hand several inches off the floor EAR DISORDERS By: JOHN MARK B. POCSIDIO, RN, MSN EXTERNAL OTITIS

 also known as swimmers ear infective inflammatory or allergic response involving the external auditory canal or the auricles (external ear) skin becomes red, swollen, and tender to touch on movement NURSING INTERVENTIONS Encourage rest Apply heat locally for 20 minutes TID Administer antibiotics / anti-inflammatory / analgesics as prescribed Instruct the client to keep ears clean and dry Instruct the client to use ear plugs for swimming Instruct the client not to use cotton-tipped applicators for drying ears Instruct the client to discontinue the use of irritating agents (ex. hair products) or head/ear phones OTITIS MEDIA inflammation or infection of the middle ear Types of Otitis Media: Acute otitis media - presence of fluid ( pus) in the middle ear with: S/sx: pain, redness of the eardrum, and possible fever Chronic otitis media - presence of fluid in the middle ear for 6 or more weeks MEDICAL MANAGEMENT MYRINGOTOMY- incision is created in the eardrum, so as to relieve pressure caused by the excessive fluid buildup,or to drain pus ANTIBIOTIC THERAPY NURSING INTERVENTION POST-OP Client education following myringotomy: Avoid rapid head movements Avoid straining Avoid drinking through a straw Avoid traveling by air Avoid contact with persons with colds Avoid showering ( 1 week) Keep ears dry ( cotton w/ petroleum jelly) Instruct the client that if there is a need to blow the nose, blow one side at a time and with the mouth open- CBQ Instruct the client to report excessive ear drainage to the physician May return to work in about 3 weeks post-op

OTOSCLEROSIS Formation of new spongy bone in the labyrinth of the ear causing fixation of the stapes in the oval window---- prevents transmission of auditory vibration to the inner ear. Hereditary; increased incidence in women Assessment Conductive hearing loss: bilateral & progressive Tinnitus Reddish/pinkish orange tympanic membrane ( Schwartzs sign) Rinnes test result: bone conduction better than air conduction Diagnostics Tunning fork: reveals conductive hearing loss CT scan shows deposition of new bone in the oval window Audiometry: shows conducted hearing loss Management: Surgery Stapedectomy removal of diseased portion of stapes and prosthesis is inserted into the labyrinth STAPEDECTOMY Nursing interventions Focused on STAPEDECTOMY procedure: PREOP Provide general pre-op nursing care and explanations for procedure. Explain that hearing will improve during surgery and then decrease due to edema and packing POSTOP Position: Unaffected side (operative ear uppermost) Deep breathing but no coughing is encourage Elevate side rails, move slowly ( VERTIGO) MEDS: Analgesics, Antibiotics, Antiemetic, Anti motion sickness drugs Check dressings frequently for bleeding Assess facial nerve function ( for any asymmetry) PROVIDE TEACHINGS: Warning against blowing the nose or coughing; sneeze with mouth open No shampoo. ( keep ears dry) No flying for 6 months MENIERES DISEASE Chronic disease of inner ear causing vertigo Thought to be caused by an imbalance in the fluid that is normally present in the inner ear

 Either increase production of fluid or decreased reabsorption of fluid. The exact caused is unknown maybe hereditary, viral, immune dysfunction Common in adults 40-60 years old Occurs bilaterally ASSESSMENT Vertigo Tinnitus Sensorineural hearing loss Headache Nausea, vomiting Nystagmus DIAGNOSTICS CALORIC s TEST- detects disorders of the inner ear Nursing interventions Provide a safe, quiet, and dimly lit environment and enforced complete bed rest during acute episode ( eyes open or close????) assist in ambulation for safety Provide psychological support and reassurance Promote comfort measures with: Position the patient to the unaffected side ( affected ear should be upper most) Give meds like: Atropine sulfate/ diazepam ( for vertigo) Vasodilators ( decrease tinnitus) Antihistamine ( to decrease anxiety) Nursing interventions DIET??? Low sodium/salt free diet Avoid coffee, tea, alcohol, decongestants Avoid sudden movements HEARING LOSS Sensorineural Hearing Loss The organ of Corti is damaged Nerve impulses cannot be transmitted via the 8th cranial nerve Conductive Hearing Loss Failure in the efficient conduction of sound waves through the o outer ear o tympanic membrane (eardrum) or o middle ear (ossicles) Hearing Aid is best for conductive hearing loss! Communication

Ask the deaf person (preference) whether it be lip reading, writing or signing. Clue the person with the hearing loss about the topic of the conversation Face to face conversation-CBQ Be sure that lighting is in front of you when you speak.-CBQ During conversations, turn off the radio or television.

Avoid speaking while chewing food or covering mouth with your hands. Speak slightly louder than normal ( Do not shout!) Speak at your normal rate ( do not exaggerate sounds.) NOSE DISORDERS BY: JOHN MARK B. POCSIDIO, RN, MSN Epistaxis Bleeding from the nose caused by rupture of tiny, distended vessels in the mucus membrane Most common site- anterior septum Causes: Trauma Infection Hypertension Blood dyscrasias Nasal tumor Nursing Interventions Position patient: Upright, leaning forward, tilted prevents swallowing and aspiration Apply direct pressure. Pinch nose against the middle septum x 5-10 minutes If unrelieved, administer topical vasoconstrictors, silver nitrate, gel foams Assist in electrocautery and nasal packing for posterior bleeding SINUSITIS Inflammation of the paranasal sinuses It may be due to: Allergy Infection Autoimmune Most cases due to viral infection Maxillary and ethmoid sinuses are most frequently involved. SINUSITIS -Causes: URTI, Cigarette smoking and allergic rhinitis Acute or Chronic Sinusitis?

 Acute Sinusitis respiratory symptoms last longer than 10 days but less than 30 days. ( precipitated by URTI viral origin) Subacute sinusitis respiratory symptoms persist longer than 30 days without improvement. Chronic sinusitis respiratory symptoms last longer than 120 days. ASSESSMENT Pain Maxillary: cheek, upper teeth Frontal: above eyebrows Ethmoid: in & around the eyes Sphenoid: behind eye, occiput, top of the head General malaise Stuffy nose, purulent nasal discharges, decrease sense of smell Headache, eyelid edema, tenderness over the area Post-nasal drip Persistent cough Fever

Diagnostic tests: Sinus X-ray Ct scan is the most effective diagnostic tool NURSING INTERVENTION Provide Rest periods Advise Increased fluid intake- CBQ Hot wet packs and steam inhalation Give meds as ordered.. Give CODEINE for pain ( NEVER NEVER ASPIRIN!!!) PARACETAMOL ( Pain) AMOXICILLIN NASAL DECONGESTANT ( SUDAFED) for 72 hrs ANTIHISTAMINE( allergy) Irrigation of maxillary sinuses with warm NSS. Instruct patient to complete the drug regimen

SURGERY OF THE SINUS CALDWELL-LUC SURGERY ( radical antrum surgery) Nursing consideration is to advise patient: Do not chew on affected side Do not wear dentures for 10 days Do not blow nose for 2 weeks after removal of packing Avoid sneezing for 2 weeks after surgery Child should not dive.-CBQ Child should not travel by airplane.-CBQ Urge parent to eliminate triggers in the home (dust, smoking) Have all members of the family treated, if indicated. THROAT DISORDERS BY: JOHN MARK B. POCSIDIO, RN, MSN LARYNGITIS Inflammation of the larynx Common disorder that may occur alone or in conjunction with other respiratory infections Assessment Change in voice: aphonia, hoarseness, complete loss of voice Sorethroat Dry, harsh cough Fever Diagnostics Physical eamination Medical health history Neck or chest x-ray TREATMENT NO SPECIFIC TREATMENT FOR VIRAL LARYNGITIS!!!! Identification of precipitating factors: overuse of voice, exposure to chemicals ( needs to be eliminated) Voice rest Abstinence from tobacco, alcohol, other chemical irritants Nursing interventions Encourage voice rest Speak in short sentences, using alternative methods of communication such as writing Liberal fluid intake Help identify potential irritants, such as: fumes, chemical, or cold temperatures

 Use soothing lozenges, sprays, use comfort measures ( gargling with warm antiseptic solution)

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