NURSING CARE OF

PATIENTS WITH
AUSIO VISUAL
DISTURBANCES
External Structures of the Eye
 VISION
EYELIDS (PALPEBRAL) & EYELASHES
• Protect the eye from foreign particles

CONJUNCTIVA
PALPEBRAL CONJUNCTIVA
• Pink; lines inner surface of eyelids

BULBAR CONJUNCTIVA
• White with small blood vessels, covers
anterior sclera

LACRIMAL APPARATUS (LACRIMAL GLAND

& ITS DUCTS AND PASSAGES)
• Produces tears to lubricate the eye & moisten the cornea
• Tears drain into nasolacrimal duct which empties into nasal cavity
 VISION
1. EYEBALL
3 LAYERS OF THE EYEBALL
A. OUTER LAYER
- fibrous coat that supports the eye
A. SCLERAE
- Tough, white connective tissue “white of the eye”
- located anteriorly & posteriorly
B. CORNEA
- Transparent tissue through which light enters the
eye.
- Located anteriorly
 VISION
B. MIDDLE LAYER
- second layer of the eyeball
- vascular & highly pigmented

A. CHOROID
- a dark brown membrane located between the
sclera & the retina
- it lines most of the sclera & is attached to the
retina but can easily detach from the sclera
- contains blood vessels that nourishes the retina
- located posteriorly
 VISION
B. MIDDLE LAYER
B. CILIARY BODY
- connects the choroid with the iris
- secretes aqueous humor that helps
give the eye its shape

C. IRIS
- the colored portion of the eye
- located in front of the lens
- it has a central opening called the pupil
 VISION
INTERNAL STRUCTURES OF THE EYE
C. INNER LAYER (RETINA)
- a thin, delicate structure in which the fibers of the optic nerve
are distributed
- bordered externally by the choroid & sclera and internally by the
vitreous
- contains blood vessels & photoreceptors (cones & rods)
- light sensitive layer
CONTAINS THE FOLLOWING STRUCTURES
1. CONES
- Specialized for fine discrimination, central vision & color
vision
- Functions at bright levels of illumination
2. RODS
- More sensitive to light than cones
- Aid in peripheral vision
- Functions at reduced levels of illumination
 VISION
INTERNAL STRUCTURES OF THE EYE
2. FLUIDS OF THE EYE
A. AQUEOUS HUMOR
- Clear, watery fluid that fills the anterior &
posterior chambers of the eye
- produced by the ciliary processes, & the fluid
drains in the Canal of Sclemm
- The anterior chamber lies between the cornea &
iris
- the posterior chamber lies between the iris & lens
- serves as refracting medium & provides nutrients
to lens & cornea
- contributes to maintenance of IOP
 VISION
INTERNAL STRUCTURES OF THE EYE
2. FLUIDS OF THE EYE
B. VITREOUS HUMOR
- Clear, gelatinous/jell-like material that fill the posterior cavity of
the eye
- Maintains the form & shape of the eye
- Provides additional physical support to the eye
- It is produced by the vitreous body

3. VITREOUS BODY
- contains a gelatinous substance that occupies the
vitreous chamber which is the space between the lens & retina
- transmits light & gives shape to the posterior eye
 VISION
INTERNAL STRUCTURES OF THE EYE
4. OPTIC DISK
- a creamy pink to white depressed area in the retina
- the optic nerve enters & exits the eyeball in this area
- Referred to as the “BLIND SPOT”

5. MACULA LUTEA
- Small, oval, yellowish pink area located lateral
& temporal to the optic disk
- the central depressed part of the macula is the “FOVEA
CENTRALIS” which is an area where acute vision occurs
 VISION
INTERNAL STRUCTURES OF THE EYE
6. CANAL OF SCHLEMM
- a passageway that extends completely around the eye
- permits fluid to drain out of the eye into the systemic circulation
so that a constant IOP is maintained

7. LENS
- A transparent circular structure behind the iris & in front of the
vitreous body
- Bends rays of light so that the light falls on the retina

8. PUPILS
- Control the amount of light that enters the eye & reaches the
retina
- Darkness produces dilation while light produces constriction
 VISION
INTERNAL STRUCTURES OF THE EYE
9. EYE MUSCLES
- Muscles do not work independently but work in
conjunction with the muscle that produces the
opposite movement

A. RECTUS MUSCLES
- Exert their pull when the eye turns temporally

B. OBLIQUE MUSCLES
- Exert their pull when the eye turns nasally
 VISION
INTERNAL STRUCTURES OF THE EYE
10. NERVES
A. CRANIAL NERVE II
- Optic nerve (nerve of sight)

B. CRANIAL NERVE III

- Oculomotor

C. CRANIAL NERVE IV
- Trochlear

D. CRANIAL NERVE VI
- Abducens
 VISION
INTERNAL STRUCTURES OF THE EYE
11. BLOOD VESSELS
A. OPTHALMIC ARTERY
- Major artery supplying the structures in the eye

B. OPTHALMIC VEINS
- Venous drainage occurs through vision
 ABBREVIATION
– L Eye OS
– R Eye OD
– Both Eyes OU
– REM
– Rapid eye movement
– EOM
– Extra ocular muscles
– PERRLA
 ASSESSMENT OF VISION
VISUAL ACUITY TEST
- measures the client’s distance & near vision

1. SNELLEN CHART
- simple tool to record visual acuity

Normal: 20/20
• Numerator
→Distance from chart
• Denominator
→ Distance at which a
normal eye
can read
2. CONFRONTATIONAL TEST
- Performed to examine visual fields or peripheral vision

3. EOM FUNCTION
- tests muscle function of the eyes
- tests 6 cardinal positions of gaze
1. Client’s right (lateral position)
2. Upward & right (temporal position)
3. Down & right
4. Client’s left (lateral position)
5. Upward & left (temporal position)
6. Down & left
-
 ASSESSMENT OF VISION
COLOR VISION TEST
- Tests for color vision which involve picking nos. or letters out of a
complex & colorful picture

• Color vision
• Colored numbers
within a circle of
colored dots

• Nursing care:
– Read the numbers
– Each eye tested
• PUPILS
• - Normal:
Normal round & of equal size
• - Increasing light causes pupillary constriction
• Decreasing light causes pupillary dilation
• - the client is asked to look straight ahead while the examiner
quickly
• brings a beam of light ( penlight) in from the side & directs it
onto the side
• - Constriction of the eye is a direct response to the light
shining into the eye;
• constriction of the opposite eye is known as CONSENSUAL
RESPONSE
 DIAGNOSTIC TESTS FOR THE EYE
FLUORESCEIN ANGIOGRAPHY
- detailed imaging & recording of ocular circulation by
a series of photographs after administration of the dye

COMPUTED TOMOGRAPHY
- a beam of x-ray scans the skull & orbits of the eye
- a cross-sectional image is formed by the use of a computer
- contrast material is not usually administered

SLIT LAMP
- allows examination of the anterior ocular structures under
microscopic magnification
- the client leans on a chin rest to stabilize the head while a
narrow beam of light is aimed so that it illuminates only
a narrow segment of the eye.
 DIAGNOSTIC TESTS FOR THE EYE

CORNEAL STAINING
- installation of a topical dye into the conjunctival sac to outline
the irregularities of the corneal surface that are not easily visible
- the eye is viewed through a blue filter, and a bright green color
indicates areas of non-intact corneal epithelium

TONOMETRY
- the test is primarily used to assess for an increase in
IOP and potential glaucoma
TONOMETER APPARATUSES
 OPHTHALMOSCOPY
• An ophthalmoscope is an
instrument used to
examine the retina and
vitreous. Ophthalmoscopy
requires dilating the pupils
with drops to give the
doctor the best view inside
the eye.
• Internal and external eye
structures
REVIEW FOR 10 MINUTES AND WE
WILL HAVEA QUIZ!!!
DISORDERS
OF THE EYE
 Risk factors of eye
disorders

 AGING PROCESS
 CONGENITAL
 DIABETES
MELLITUS
 HEREDITARY
 MEDICATIONS
 TRAUMA
 LEGALLY BLIND
- a person is legally blind if the best visual acuity with corrective
lenses in the better eye is 20/200 or less or a visual field of 20
degrees or less in the better eye

NURSING CARE
• When speaking to a client who has limited sight or blind, the nurse
uses a normal tone of voice
• Alert the client when approaching
• Orient the client to the environment
• Use a focal point & provide further orientation to the environment
from the focal point
• Allow the client to touch objects in the room
• Use the clock placement of foods on the meal tray to orient the
client
• Promote independence as much as possible
 LEGALLY BLIND
NURSING CARE
• Provide radios, TVs, & clocks that give the time orally or provide a
Braille watch.
• 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
• Instruct the client to remain one step behind the nurse when
ambulating
• Instruct the client in the use of the cane used for the blind client,
which is differentiated from other canes by its straight shape & white
color with red tip
• Instruct the client that the cane is held in the dominant hand several
inches off the floor
• Instruct the client that the cane sweeps the ground where the client’s
foot will be placed next to determine the presence of obstacles
 CATARACTS
- an opacity of the lens that distorts the image projected onto the
retina & that can progress to blindness
- Intervention is indicated when visual acuity has been reduced to
a level that the client finds to be unacceptable or adversely
affecting lifestyle

CAUSES
 Aging process (Senile cataracts)
 Inherited (Congenital cataracts)
 Injury (Traumatic cataracts)
 Can occur as a result of another eye disease (Secondary cataracts)
 CATARACTS
ASSESSMENT
 Opaque or cloudy white pupil
 Gradual loss of vision
 Blurred vision
 Decreased color perception
 Vision that is better in dim light with pupil dilation
 Photophobia
 Absence of red reflex
 CATARACTS
MEDICAL MANAGEMENT
- surgical removal of the lens, one eye at a time
- a lens implantation may be performed at the time of
surgical procedure
• EXTRACAPSULAR EXTRACTION
- the lens is lifted out without removing the lens capsule
- may be performed with Phacoemulsion
PHACOEMULSION
- the lens is broken up by ultrasonic vibrations & extracted
• INTRACAPSULAR EXTRACTION
- the lens is removed within its capsule through a small
incision
• PARTIAL IRIDECTOMY
- may be performed with lens extraction to prevent acute
secondary glaucoma
 CATARACTS
PRE-OP NURSING CARE
• Instruct measures to prevent or decrease IOP
• Administer pre-op eye medications including mydriatics &
cycloplegics as prescribed

POST-OP NURSING CARE

• Elevate the head of the bed 30-45 degrees
• Turn the client to the back or un-operative side
• Maintain an eye patch & orient the client to the environment
• Position the client’s personal belongings on the un-operative side
• Use side rails for safety
• Assist with ambulation
 CATARACTS
CLIENT EDUCATION AFTER CATARACT SURGERY
• Avoid eye straining
• Avoid rubbing or placing pressure on the eyes
• Avoid rapid movements, straining, sneezing, coughing, bending,
vomiting, or lifting objects over 5 lbs
• Teach measures to prevent constipation
• Wipe excess drainage or tearing with a sterile wet cotton ball from
the inner to the outward canthus
• Use an eye shield at bedtime
• If an eye implant is not performed, the eye cannot accommodate &
glasses must be worn at all times
• Cataract glasses act as magnifying glasses & replace central vision only
• Cataract glasses magnify, & objects appear closer therefore teach
client to judge distance & climb stairs carefully
• Contact lenses provide sharp visual acuity but dexterity is needed to
insert them
• Contact the MD for any decrease in vision, severe eye pain or increase
in eye discharge
 GLAUCOMA
- increased IOP as a result of inadequate drainage of aqueous
humor from the canal of Schlemm or over production of aqueous
humor
- the condition damages the optic nerve & can result in blindness
TYPES
ACUTE CLOSED-ANGLE/NARROW ANGLE GLAUCOMA
- results from obstruction to outflow to aqueous humor
CHRONIC CLOSED-ANGLE GLAUCOMA
- follows an untreated attack of acute close-angled glaucoma
CHRONIC OPEN-ANGLE GLAUCOMA
- results from an overproduction or obstruction to the outflow of
aqueous humor
ACUTE GLAUCOMA
- a rapid onset of IOP > 50-70 mm Hg
CHRONIC GLAUCOMA
- a slow, progressive, gradual onset of IOP > 30-50 mm Hg
 GLAUCOMA
ASSESSMENT
 Progressive loss of peripheral vision followed by a
loss of central vision
 Elevated IOP (Normal pressure is 10-21 mm Hg)
 Vision worsening in the evening with difficulty
adjusting to dark rooms
 Blurred vision
 Halos around white lights
 Frontal headaches
 Photophobia
 Increased lacrimation
 Progressive loss of central vision
 GLAUCOMA
NURSING CARE FOR ACUTE GLAUCOMA
• Treat as medical emergency
• Administer medications as prescribed to lower IOP
• Prepare the client for peripheral iridectomy
- allows aqueous humor to flow from the posterior to anterior
chamber
NURSING CARE FOR CHRONIC GLAUCOMA
• Instruct the client the importance of medications
a. MIOTICS: to constrict the pupils
b. CARBONIC ANHYDRASE INHIBITORS: to decrease the
production of aqueous humor
c. BETA-BLOCKERS: to decrease the production of aqueous
humor & IOP
• Instruct the client the need for life-long medication use
• Instruct the client to wear a Medic-Alert bracelet
 GLAUCOMA
NURSING CARE FOR CHRONIC
GLAUCOMA
• Instruct the client to avoid anti-cholinergic medications
• Instruct the client to report eye pain, halos around eyes & changes
of vision to the physician
• Instruct the client that when maximal medical therapy has failed to
halt the progression of visual field loss & optic nerve damage,
surgery will be recommended
• Prepare the client for TRABECULOPLASTY as prescribed
- to facilitate aqueous humor drainage
• Prepare client for TRABECULECTOMY as prescribed
- allows drainage of aqueous humor into the conjuctival spaces by
the creation of an opening
 RETINAL DETACHMENT
- occurs when the layers of the retina separate because of
accumulation of fluid between them
- also occurs when both retinal layers elevate away from the
choroid as a result of a tumor

TYPES
PARTIAL RETINAL DETACHMENT
- becomes complete if left untreated

COMPLETE RETINAL DETACHMENT

- when detachment is complete, blindness may occur
RETINAL DETACHMENT
ASSESSMENT
 Flashes of light
 Floaters
 Increase in blurred vision
 Sense of curtain being drawn
 Loss of a portion of the visual field
RETINAL DETACHMENT
IMMEDIATE NURSING CARE
• Provide bedrest
• Cover both eyes with patches to prevent further detachment
• Speak to the client before approaching
• Position the client’s head as prescribed
• Protect the client from injury
• Avoid jerky head movements
• Minimize eye stress
• Prepare the client for surgical procedure as prescribed
 RETINAL DETACHMENT
MEDICAL MANAGEMENT
- draining fluid from the subretinal space so that the retina can return to the normal
position

• SEALING RETINAL BREAKS BY CRYOSURGERY

- a cold probe applied to the sclera to stimulate an inflammatory response
leading to adhesions
• DIATHERMY
- the use of electrode needle & heat through the sclera to stimulate an
inflammatory response leading to adhesions
• LASER THERAPY
- to stimulate an inflammatory response to seal small retinal tears before
the detachment occurs
• SCLERAL BUCKLING
- to hold the choroid & retina together with a splint until scar tissue forms
closing the tear
• INSERTION OF A GAS OR SILICONE OIL
- to encourage attachment because these agents have a specific gravity less
than vitreous or air & can float against the retina
 RETINAL DETACHMENT
POST-OP NURSING CARE
• Maintain eye patches bilaterally as prescribed
• Monitor hemorrhage as prescribed
• Prevent N&V and monitor for restlessness which can cause hemorrhage
• Monitor for sudden, sharp eye pain (notify the MD stat)
• Encourage DBE but avoid coughing
• Provide bedrest for 1-2 days as prescribed
• If gas has been inserted, position as prescribed on the abdomen & turn the
head so unaffected eye is down
• Administer eye medications as prescribed
• Assist client with ADL
• Avoid sudden head movements or anything that increases IOP
• Instruct the client to limit reading for 3-5 weeks
• Instruct client to avoid squinting, straining & constipation, lifting heavy objects &
bending from the waist
• Instruct the client to wear dark glasses during the day & an eye patch at night
• Encourage follow-up care because of the danger of recurrence or occurrence in
the other eye
 STRABISMUS
- called “SQUINT EYE” or “LAZY EYE”
- a condition in which the eyes are not aligned because of lack of
muscle coordination of the extraocular muscles
- most often results from muscle imbalance or paralysis of
extraocular muscles, but may also result from conditions such as
brain tumor, myasthenia gravis or infection
- normal in young infant but should not be present after about age
4 months

ASSESSMENT
 Amblyopia if not treated early
 Permanent loss of vision if not treated early
 Loss of binocular vision
 Impairment of depth perception
 Frequent headaches
 Squints or tilts head to see
 STRABISMUS
NURSING CARE
• Corrective lenses as indicated
• Instruct the parents regarding patching (occlusion therapy) of the “good” eye
- to strengthen the weak eye
• Prepare for botulinum toxin (Botox) injection into the eye muscle
- produces temporary paralysis
- allows muscles opposite the paralyzed muscle to strengthen the eye
• Inform the parents that the injection of botulinum toxin wears off in about 2
months & if successful, correction will occur
• Prepare for surgery to realign the weak muscles as Rx if nonsurgical
interventions are unsuccessful
• Instruct the need for follow-up visits
 CONJUNCTIVITIS
- also known as “PINK EYE”
- inflammation of the conjunctiva
- usually caused by allergy, infection, or trauma

TYPES
BACTERIAL OR VIRAL CONJUNCTIVITIS
- extremely contagious
CHLAMYDIAL CONJUNCTIVITIS
- is rare in older children & if diagnosed in a child who is not sexually
active, the child should be assessed for possible sexual abuse

ASSESSMENT
 Itching, burning or scratchy eyelids
 Redness
 Edema
 Discharge
 CONJUNCTIVITIS
NURSING CARE
• Instruct in infection control measures such as good handwashing & not
sharing towels & washcloths
• Administer antibiotic or antiviral eye drops or ointment as Rx if infection is
present
• Administer antihistamines as Rx if an allergy is present
• Instruct the parents that the child should be kept home from school or day
care until antibiotic eye drops have been administered for 24 hrs
• Instruct in the use of cool compresses to lessen irritation & in wearing dark
glasses for photophobia
• Instruct the child to avoid rubbing the eye to prevent injury
• D/C use of contact lenses & to obtain new lenses to eliminate the chance of
re-infection
• Instruct the adolescent that eye make-up should be discarded & replaced
 HYPHEM
A
- the presence of blood in the anterior chamber
- occurs as a result of injury
- condition usually resolves in 5-7 days

NURSING CARE
• Encourage rest in semi-Fowler’s position
• Avoid sudden eye movements for 3-5 days to decrease bleeding
• Administer cycloplegic eye drops as prescribed
- to place the eye at rest
• Instruct in the use of eye shields or eye patches as prescribed
• Instruct the client to restrict reading & watching TV
 CONTUSIONS
CONTUSIONS
- bleeding into the soft tissue as a result of an injury
- causes a black eye & the discoloration disappears in
approximately 10 days
- pain, photophobia, edema & diplopia may occur

NURSING CARE
• Place ice on the eye immediately
• Instruct the client to receive an eye examination
 FOREIGN
BODIES
- an object such as dust that enters the eye

NURSING CARE
• Have the client look upward, expose the lower lid, wet a cotton-
tipped applicator with sterile NSS & gently twist the swab over
the particle & remove it
• 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, & pull the upper lid outward
& over the cotton applicator, if the particle is seen, gently twist
over it to remove
PENETRATING OBJECTS
- an injury that occurs to the eye in which an object
penetrates the eye

NURSING CARE
• Never remove the object because it may be holding ocular
structures in place, the object must be removed by MD
• Cover the object with a cup
• Don’t allow the client to bend
• Don’t place pressure on the eye
• Client is to be seen by MD stat
 CHEMICAL BURNS
- an eye injury in which a caustic substance enters the eye

NURSING CARE
• Treatment should begin stat
• Flush the eyes at the site of injury with water for at least 15-20 mins
• At the site of injury, obtain a small sample of the chemical involved
• At the ER, the eyes is irrigated with NSS or an opthalmic irrigation
solution
• The solution is directed across the cornea & toward the lateral
canthus
• Prepare for visual acuity assessment
• Apply an antibiotic ointment as prescribed
• Cover the eye with a patch as prescribed
ENUCLEATION
- removal of the entire eyeball

EXENTERATION
- removal of the eyeball & surrounding tissues
• Performed for the removal of ocular tumors
• After the eye is removed, a ball implant is inserted to provide a firm
base for socket prosthesis & to facilitate the best cosmetic result
• A prosthesis is fitted approximately 1 month after surgery
PRE-OP NURSING CARE
• Provide emotional support to the client
• Encourage the client to verbalize feelings related to loss

POST-OP NURSING CARE

• Monitor V/S
• Assess pressure patch or dressing
• Report changes in V/S or the presence of bright red drainage on
the
pressure patch or dressing
 ORGAN DONATION
DONOR EYES
• Obtained from cadavers
• Must be enucleated soon after death due to rapid endothelial
cell death
• Must be stored in a preserving solution
• Storage, handling & coordination of donor tissue with surgeons
is provided by a network of state eye bank associations across
the country
 ORGAN DONATION
CARE OF THE DECEASED CLIENT AS
A POTENTIAL EYE DONOR
• Discuss the option of eye donation with MD & family
• Raise the head of the bed 30°
• Instill antibiotic eye drops as RX
• Close the eyes & apply a small ice pack to the closed eyes
 ORGAN DONATION
PRE-OP CARE OF THE RECIPIENT
• Recipient may be told of the tissue availability only several hrs
to 1 day before surgery
• Assist in alleviating client anxiety
• Assess for signs of eye infection
• Report the presence of any redness, watery or purulent
drainage or edema around the eyes to MD
• Instill antibiotic drops into the eyes as Rx to reduce the no. of
microorganisms present
• Administer IV fluids & medications as Rx
 ORGAN DONATION
POST-OP CARE TO THE RECIPIENT
• Eye is covered with a pressure patch and protective shield that
are left in place until the next day
• Don’t remove or change the dressing without the MD’s order
• Monitor V/S, LOC & assess dressing
• Position the client on unoperative side to reduce IOP
• Orient the client frequently
• Monitor for complications of bleeding, wound leakage, infection
& graft rejection
• Instruct the client in how to apply the patch & eye shield
• Instruct the client to wear the eye shield at night for 1 month &
whenever around small children or pets
 GRAFT
REJECTION
• Can occur at anytime
• Inform the client of signs of rejection
• Signs include redness, swelling, decreased
vision,
& pain (RSDP)
• Treated with topical steroids
 HEARING
FUNCTIONS OF THE EAR
• Hearing
• Maintenance & balance

EXTERNAL EAR
- Embedded in the temporal bone bilaterally at the level of
the eyes
- Extends from the auricle through the external canal to the
tympanic membrane or eardrum
- Includes the mastoid process, a bony ridge located over the

temporal bone
 HEARING
EXTERNAL EAR
A. AURICLE (PINNA)
- Outer projection of ear composed of cartilage & covered
by skin
- collects sound waves
B. EXTERNAL AUDITORY CANAL
- Lined with skin
- Glands secrete cerumen (wax)
- provides protection
- transmits sound waves to tympanic membrane
C. TYMPANIC MEMBRANE (EARDRUM)
- Located at the end of the external canal
- Vibrates in response to sound & transmit vibrations to
middle ear
 HEARING
MIDDLE EAR
- Consists of the medial side of the tympanic membrane
- The tympanic membrane is a thick transparent sheet of
tissue that provides a barrier between the external ear &
the middle ear
- The middle ear is protected from the inner ear by the round
& the oval window membranes
- The eustachian tube opens into the middle ear & allows for
equalization of pressure on both sides of the tympanic
membrane
 HEARING
MIDDLE EAR
A. OSSICLES
- Contains 3 small bones: Malleus (Hammer) attached to
tympanic membrane
Incus (Anvil)
Stapes (Stirrup)
- Ossicles are set in motion by sound waves from
to the footplate of the stapes in the oval window

OVAL WINDOW:
WINDOW an opening bet. the middle & inner ear

B. EUSTACHIAN TUBE
- Connects nasopharynx & middle ear
- Equalizes pressure on both sides of eardrum
 HEARING
INNER EAR
- Contains the semi-circular canals, the cochlea & the distal
end of the 8th cranial nerve
- Maintains sense of balance & equilibrium
A. SEMI-CIRCULAR CANALS
- Contains fluid & hair cells connected to sensory nerve
fibers of the vestibular portion of 8th cranial nerve
B. COCHLEA
- Spiral-shaped organ of hearing
- Connects organ of Corti, receptor and organ for hearing
- Transmits sound waves from the oval window & initiates
nerve impulses carried by cranial nerve VIII (acoustic
branch) to the brain ( temporal lobe of cerebrum)
 HEARING
INNER EAR
C. 8th CRANIAL NERVE

1. COCHLEAR BRANCH
- transmits neuro-impulses from the cochlea to the brain
where it is interpreted as sound

2. VESTIBULAR BRANCH
- maintains balance & equilibrium
HEARING & EQUILIBRIUM
• The external ear conducts sound waves to the middle
ear
• The middle ear also called the tympanic cavity conducts
sound waves to the inner ear
• The middle ear is filled with air which is kept at atmospheric
pressure by the opening of the eustachian tube
• The inner ear contains sensory receptors for sound & for
equilibrium
• The receptors in the inner ear transmit sound waves &
changes in body position to the nerve impulses
 ASSESSMENT OF THE EAR
OTOSCOPIC EXAM
GUIDELINES
- the speculum is never blindly introduced into the external canal
because of the risk of perforating the tympanic membrane
- tilt the head slightly away & hold the otoscope upside down as if
it were a large pen
- this permits the examiner’s hand to lie against the head for
support
- pull the pinna up & back to straighten the external canal in an
adult
- visualize the external canal while slowly inserting the speculum
 ASSESSMENT OF THE EAR
OTOSCOPIC EXAM
NORMAL FINDINGS OF THE EXTERNAL CANAL
 Pink & intact without lesions
 Has various amounts of cerumen & fine little hairs

NORMAL FINDINGS OF THE TYMPANIC MEMBRANE

 The tympanic membrane should be intact without perforations & free
from lesions
 The tympanic membrane is transparent, opaque, pearly gray &
slightly concave
 ASSESSMENT OF THE EAR
AUDITORY ASSESSMENT
• Sound is transmitted by air conduction & bone conduction
• Air is 2-3x longer than bone conduction

CATEGORIES OF HEARING LOSS

• Conductive
• Sensorineural
• Mixed Conductive & Sensorineural
 ASSESSMENT OF THE EAR
CONDUCTIVE HEARING LOSS
- due to any physical obstruction to the transmission of sound
waves

SENSORINEURAL HEARING LOSS

- due to a defect in the organ of hearing, in the 8th cranial
nerve, or in the brain itself

MIXED CONDUCTIVE, SENSORINEURAL

HEARING LOSS
- results in profound hearing loss
 ASSESSMENT OF THE EAR
VOICE TEST
• Ask the client to block one external canal
• The examiner stands 1-2 ft away & quickly whispers a
statement
• The client is asked to repeat the whispered statement
• Each ear is tested separately

WATCH TEST
• A ticking watch is used to test the high-frequency sounds
• The examiner holds a ticking watch about 5 inches from each
ear & asks the client if the ticking is heard
 ASSESSMENT OF THE EAR
TUNING FORK TESTS
A. WEBER TUNING FORK TEST
• Normal result: hearing the sound equally in both ears

FINDINGS
• If the client hears the sound louder in 1 ear,
- (+) LATERALIZATION is present
- applied to the side where the sound is heard the loudest
INTERPRETATION
• The finding may indicate the client has CONDUCTIVE
HEARING LOSS in the ear to which the ear is lateralized
• The finding may indicate that there is a SENSORINEURAL
HEARING LOSS in the opposite ear
 ASSESSMENT OF THE EAR
TUNING FORK TESTS
B. RINNE TUNING FORK TEST
• Compares the client’s hearing by air conduction & bone conduction
• AIR CONDUCTION is 2-3X longer than BONE CONDUCTION

• NORMAL RESULT: (+) RINNE TEST

- the client normally continues to hear the sound
2x louder in front of the pinna
• The examiner records the duration of both phases, bone conduction
followed by air conduction and compares the times
 ASSESSMENT OF THE EAR
TUNING FORK TESTS
B. RINNE TUNING FORK TEST
FINDINGS
• If the client is unable to hear the sound through the ear in front
of the pinna,
- (-) RINNE TEST
- Bone conduction is greater than air conduction
INTERPRETATION
• Client may have a CONDUCTIVE HEARING LOSS on the side
tested
• The Rinne test is of no value in determining sensorineural
hearing loss
 VESTIBULAR ASSESSMENT OF
THE EAR
TEST FOR FALLING
• The examiner asks the client to stand with the feet together &
arms hanging loosely at the sides & eyes closed
• The client normally remains erect with slight swaying

ABNORMAL RESULT: (+) ROMBERG SIGN

- presence of significant swaying
VESTIBULAR ASSESSMENT OF
THE EAR
TEST FOR PAST POINTING
• NORMAL TEST RESPONSE:
- The client can easily return to the point of reference

FINDINGS
• The client with vestibular function problem lacks a normal sense
of position sense and is unable to return to the extended fingers
to the point of reference, the fingers instead either goes to the
right or left of the reference point
 VESTIBULAR ASSESSMENT OF
THE EAR
GAZE NYSTAGMUS EVALUATION
• Examine the client’s eyes as they look straight ahead, 30
degrees to each side, upward & downward

FINDINGS
• Any spontaneous nystagmus is a (+) result
- ABNORMAL FINDING
- a constant involuntary cyclic movement of the eyeball in any
direction represents a problem with the vestibular system
 VESTIBULAR ASSESSMENT
OF THE EAR
HAPLIKE MANEUVER
• Assesses for positional vertigo or induced dizziness
• The client assumes a supine position
• The head is rotated to one side for 1 minute

FINDINGS
• (+) test result is presence of nystagmus after 5-10 sec
- ABNORMAL FINDING
- a constant involuntary cyclic movement of the eyeball in any
direction represents a problem with the vestibular system
 DIAGNOSTIC TESTS FOR THE
EAR
TOMOGRAPHY
- may be performed with or without contract medium
- assesses the mastoid, middle ear & inner ear structures
- multiple x-rays of the head are done

NURSING CARE
• All jewelry are removed
• Lead eye shields are used to cover the cornea to diminish the radiation dose
to the eyes
• The client must remain still in a supine position
• No follow-up care is required
 DIAGNOSTIC TESTS FOR THE
EAR
AUDIOMETRY
- measures hearing acuity
- uses 2 types: PURE TONE AUDIOMETRY & SPEECH AUDIOMETRY
- after testing, audiogram patterns are depicted on a graph to determine
the type & level of hearing loss
PURE TONE AUDIOMETRY
- used to identify problems with hearing, speech, music & other sounds in
the environment
SPEECH AUDIOMETRY
- the client’s ability to hear spoken words is measured

NURSING CARE
• Inform the client regarding the procedure
• Instruct the client to identify the sounds as they are heard
 DIAGNOSTIC TESTS FOR THE
EAR
ELECTRONYSTAGMOGRAPHY
- a vestibular test that evaluates spontaneous &
induced eye movements known as nystagmus
- used to distinguish between normal nystagmus &
either medication-induced nystagmus or nystagmus
caused by a lesion in the central or peripheral
vestibular pathway
- records changing electrical fields with movement of
the eye, as monitored by electrodes placed on the
skin around the eye
 DIAGNOSTIC TESTS FOR THE
EAR
NURSING CARE
• NPO for 3 hrs before testing
• Unnecessary medications are omitted for 24 hours
• Instruct client that this is a long & tiring procedure
• Client should bring prescription eyeglasses to the exam
• The client is instructed to gaze at lights, focus on a moving pattern, focus on
a moving point, & sit with the eyes closed
• While sitting in a chair, the client may be rotated to provide info about
vestibular function
• Client’s ears are irrigated with cool & warm water which cause N & V
• After the procedure, the client begins taking clear fluids slowly & cautiously
because N & V may occur
• Assistance may be necessary following the procedure
 DIAGNOSTIC TESTS FOR THE
EAR
CALORIC TEST (BI-THERMAL TEST)
- performed to evaluate the client experiencing dizziness
- Nystagmus, nausea, vomiting or ataxia
- may indicate a pathological condition of the labyrinth system,
whereas a decreased response may indicate that the vestibular
system is affected

NURSING CARE
• Warm water causes a greater response than cold water
• Warm water caloric testing (irrigation) precedes cool water caloric testing
(irrigation)
• The character & duration of the eye movements are measured
• The client must assume a supine position with eyes closed & head elevated
to 30 degrees
• After the procedure, the client begins taking clear fluids slowly & cautiously
because N & V may occur
• Assistance with ambulation may also be necessary following the procedure
DISORDERS
OF THE EAR
Risk factors of ear
disorders

 AGING PROCESS
 INFECTION
 MEDICATIONS
 OTOTOXICITY
 TRAUMA
 TUMORS
 CONDUCTIVE
HEARING LOSS
- occurs when sound waves are blocked to the inner ear fibers
because of external ear or middle ear disorders
- disorders can often be corrected with no damage to hearing, or
minimal permanent hearing loss

CAUSES
 Any inflammatory process or obstruction of the external or middle
ear
 Tumors
 Otosclerosis
 A build-up of scar tissue on the ossicles from previous middle ear
surgery
SENSORINEURAL HEARING
LOSS
- a pathological process of the inner ear or of sensory fibers that
lead to the cerebral cortex
- is often permanent, & measures must be taken to reduce further
damage or to attempt to amplify sound as a means of improving
hearing to some degree

CAUSES
 Damage to the inner ear structures
 Damage to the cranial nerve VIII
 Prolonged exposure to loud noise
 Medications, trauma, infections, surgery
 Inherited disorders
 Metabolic & circulatory disorders
 Meniere’s syndrome
 Diabetes mellitus
 Myxedema
 MIXED HEARING LOSS
- also known as conductive-sensorineural hearing loss
- client has both sensorineural & conductive hearing loss

SIGNS OF HEARING LOSS

 Frequently asking people to repeat statements
 Straining to hear
 Turning head or leaning forward to favor one ear
 Shouting in conversations
 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
 FACILITATING COMMUNICATION
 Use of written words if the client is able to see, read, & write
 Providing plenty of light in the room
 Getting the attention of the client before you begin to speak
 Facing the client when speaking
 Talking in a room without distracting noises
 Moving close to the client & speaking slowly & clearly
 Keeping hands & other objects away from the mouth when talking to the client
 Talking in lower tones, because shouting is not helpful
 Rephrasing sentences & 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 movements that signify
letters, words or phrases
 Using telephone amplifiers
 Facing lights that are activated by ringing of the telephone or doorbell
 Specially trained dogs that help the client to be aware of sound & to alert the
client of potential dangers
 COCHLEAR
IMPLANTATION
- used for sensorineural hearing loss
- a small computer converts sound waves into
electrical impulses
- electrodes are placed by the internal ear with
a computer device attached to the external
ear
- electronic impulses directly stimulate nerve
fibers
HEARING AIDS
- used for the client with conductive hearing
loss
- can help the client with sensorineural loss,
although it is not as effective
- a difficulty that exists in its use is the
amplification of background noise as well
as voices
 CLIENT EDUCATION REGARDING A
HEARING AID
 Encourage to begin using the hearing aid slowly to develop an adjustment to
the service
 Adjust the volume to a minimal hearing level to prevent feedback squeaking
 Teach the client to concentrate on the sounds that are to be heard & to filter
out background noise
 Instruct the client to clean ear mold with mild soap & 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 off the hearing aid & 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 & face products from coming into
contact with the receiver of the hearing aid
 PRESBYCUSIS
- associated with aging
- leads to degeneration or atrophy of the ganglionic cells in
the cochlea & a loss of elasticity of the basilar membranes
- leads to compromise of the vascular supply to the inner ear
with changes in several areas of the ear structure

ASSESSMENT
 Hearing loss is gradual & bilateral
 Client states that he/she has no problem with hearing but can’t
understand what the words are
 Client thinks that the speaker is mumbling
 EXTERNAL OTITIS
- infective inflammatory or allergic responses involving the
structure of the external auditory canal or the auricles
- an irritating or infective agent comes into contact with
epithelial layer of the external ear
- this leads to either an allergic response or S/S of infection
- the skin becomes red, swollen, & tender to touch on
movement
- the excessive swelling of the canal lead to conductive
hearing loss
- due to obstruction
- more common in children & termed as “SWIMMER’S EAR”
- occurs more often in hot, humid environments
- prevention includes the elimination of irritating or infecting agents
EXTERNAL OTITIS
ASSESSMENT
 Pain
 Itching
 Plugged feeling in the ear
 Redness & edema
 Exudate
 Hearing loss
 EXTERNAL OTITIS
NURSING CARE
• Apply heat locally for 20 minutes 3x a day
• Encourage rest to assist in reducing pain
• Administer analgesics such as aspirin or acetaminophen (Tylenol) for
the pain as prescribed
• Instruct the client that the ears should be kept clean & dry
• Instruct the client to use earplugs for swimming
• Instruct the client that cotton-tipped applicators should not be used to
dry ear because their use can lead to trauma to the canal
• Instruct the client that irritating agents such as hair products or
headphones should be discontinued
 OTITIS MEDIA
- infection of the middle ear occurring as a result of a blocked
eustachian tube, which prevents normal drainage
- a common complication of an acute respiratory infection
- infants & children are more prone
- their eustachian tubes are shorter, wider & straighter

ASSESSMENT
 Fever
 Irritability, restlessness & loss of appetite
Rolling of head from side to side
 Pulling on or rubbing the ear
 Earache or pain
 Signs of hearing loss
 Purulent ear drainage
 Red, opaque, bulging or retracting tympanic membrane
 OTITIS MEDIA
NURSING CARE
• Encourage oral fluids
• Teach the parents to feed infants in an upright position
• Instruct the child to avoid chewing during the acute period
- chewing increases the pain
• Provide local heat & have the child lie with affected ear down
• Instruct the parents in the appropriate procedure to clean drainage from the
ear with sterile cotton swabs
• Instruct in the administer of analgesics or antipyretics such as
Acetaminophen (Tylenol) to decrease fever & pain
• Instruct the parents in the administration of prescribed antibiotics,
emphasizing that the 10-14 day period is necessary to eradicate positive
organisms
• Instruct the parents that screening for hearing loss may be necessary
• If ear drops are prescribed, instruct the parents that the auditory canal is
straightened by pulling the pinna down & back in children younger than
3 yrs. & by pulling the pinna up & back for a child older than 3 yrs.
 MYRINGOTOM
Y
- insertion of tympanoplasty tubes in the middle ear to
equalize pressure & keep the ears dry

POST-OP NURSING CARE

• Instruct the parents & child to keep the ears dry
• Earplugs should be worn during bathing, shampooing &
swimming
• Diving & submerging under water are not allowed
 Client education post
myringotomy
 Avoid strenuous exercise
 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 a week as
Rx
 Instruct the client that if she/he needs to blow the nose, blow one
side at a time with wide mouth open
 Instruct the client to keep ears dry by keeping a ball of cotton coated
with petroleum jelly in the ear & to change cotton ball daily
 Instruct the client to report excessive ear drainage to the physician
 CHRONIC OTITIS
MEDIA
- a chronic infective, inflammatory, or allergic response involving
the structure of the middle ear
- surgical treatment is necessary to restore hearing
- the type of surgery can vary & include a simple reconstruction of
the tympanic membrane, a myringotomy, or replacement of the
ossicles within the middle ear

TYMPANOPLASTY
- a reconstruction of the middle ear may be attempted to improve
conductive hearing loss
 chronic OTITIS
MEDIA
PRE-OP NURSING CARE
• Administer antibiotic eye drops as Rx
• Clear the ear of debris as Rx & irrigate ear with a solution of
equal parts of vinegar & sterile water as Rx
- to restore normal pH of the ear
• Instruct to avoid persons with URTI
• Instruct client to obtain adequate rest, eat a balanced diet &
drink adequate fluids
• Instruct in DBE & coughing but forceful coughing avoided.
- increases pressure in the middle ear esp. post-op
 chronic OTITIS MEDIA

POST-OP NURSING CARE

• Inform client that initial hearing after surgery is diminished &
hearing will improve after the ear canal packing is removed
• Keep dressing clean & dry
• Keep client flat with operative ear up for at least 12 hours
• Administer antibiotics as Rx
• Instruct the client that he/she may return to work in
approximately 3 weeks post-op
 MASTOIDITIS

- may be acute or chronic & results from untreated or inadequately

treated chronic or acute otitis media
- the pain is not relieved by myringotomy

ASSESSMENT
 Swelling behind the ear & pain with minimal movement of the head
 Cellulitis on the skin or external scalp over the mastoid process
 A reddened, dull, thick, immobile tympanic membrane with or without
perforation
 Tender & enlarged post-auricular lymph nodes
 Low-grade fever
 Anorexia
 MASTOIDITIS
PRE-OP NURSING CARE
• Prepare the client for surgical removal of the infected
material
• Monitor for complications
• SIMLPLE OR MODIFIED RADICAL MASTOIDECTOMY
WITH TYMPANOPLASTY is the common treatment
• Once tissue that is infected is removed, tympanoplasty is
performed to reconstruct the ossicles & the tympanic
membranes, in an attempt to restore normal hearing
 MASTOIDITIS
COMPLICATIONS
 Damage to the abducens & facial cranial nerves
 Damage exhibited by inability to look laterally (cranial nerve
VI) & a drooping of the mouth on the affected side (cranial
nerve VII)
 Meningitis
 Chronic purulent otitis media
 Wound infections
 Vertigo, if the infection spreads into the labyrinth
 MASTOIDITIS
POST-OP NURSING CARE
• Monitor for dizziness
• Monitor for signs of meningitis as evidenced by a stiff neck &
vomiting
• Prepare for wound dressing change 24 hrs post-op
• Monitor the surgical incision for edema, drainage, & redness
• Position the client flat with the operative side up
• Restrict the client to bed with bedside commode privileges
for 24 hrs as Rx
• Assist the client with getting out of bed
- to prevent falling or injuries from dizziness
• With reconstruction of the ossicles via a graft, precautions
are taken to prevent dislodging of the graft
 OTOSCLEROSIS
- disease of the labyrinthine capsule of the middle ear that results in a
bony overgrowth of the tissue surrounding the ossicles
- causes the dev’t of irregular areas of new bone formation & causes
fixation of the bones
- stapes fixation leads to CONDUCTIVE HEARING LOSS
- if the disease involves the inner ear, SENSORINEURAL HEARING
LOSS is present
- it is not uncommon to have bilateral involvement, although hearing loss
may be worse in one ear
- cause is unknown, although has familial tendency
- nonsurgical intervention promotes the improvement of hearing through
amplification
- surgical intervention involves removal of the bony growth that is
causing the hearing loss
- a PARTIAL STAPEDECTOMY or COMPLETE STAPEDECTOMY
WITH PROSTHESIS (FENESTRATION) may be surgically performed
 OTOSCLEROSIS

ASSESSMENT
 Slowly progressing conductive hearing loss
 Bilateral hearing loss
 A ringing or roaring type of constant tinnitus
 Loud sounds heard in the ear when chewing
 Pinkish discoloration (SCHWARTZE’S SIGN) of the tympanic
membrane
- indicates vascular changes in the ear
 (-) Rinne test
 Weber test shows lateralization of the sound to the ear with
the most conductive hearing loss
FENESTRATION
- removal of the stapes with a small hole drilled in
the footplate & a prosthesis is connected
between the incus & footplate
- sounds cause the prosthesis to vibrate in the
same manner as the stapes

COMPLICATIONS
 Complete hearing loss
 Prolonged vertigo
 Infection
 Facial nerve damage
 FENESTRATION
PRE-OP NURSING CARE
• Instruct the client in measures to prevent middle ear or
external ear infections
• Instruct the client to avoid excessive nose blowing
• Instruct not to clean the ear canal with cotton-tipped
applicators
• Instruct the client to remove the hearing aid 2 weeks before
surgery to ensure the integration of local tissue
 FENESTRATION
POST-OP NURSING CARE
• Inform the client that hearing is initially worse after the surgical procedure & no
noticeable improvement in hearing may occur for as long as 6 weeks
- due to swelling
• Inform the client that the Gelfoam ear packing interferes with hearing but is
used to decrease bleeding
• Assist with ambulating during the first 1-2 days after surgery
• Provide side rails when the client is in bed
• Administer antibiotics & antivertiginous & pain meds as Rx
• Assess for facial nerve damage, weakness, changes in taste sensation,
vertigo, nausea & vomiting
• Instruct to move head slowly when changing positions
- to prevent vertigo
• Instruct to avoid showering & getting the head & wound wet
• Instruct to refrain from using small objects to clean the external ear canal
• Instruct to avoid rapid, extreme changes in pressure caused by quick head
movements, sneezing,nose blowing, straining & changes in altitude
• Instruct to avoid changes in the middle ear pressure
- it could dislodge the graft prosthesis
LABYRINTHITIS
- infection of the labyrinth that occurs as a
complication of acute or chronic otitis media

ASSESSMENT
 Hearing loss that may be permanent on the
affected side
 Tinnitus
 Spontaneous nystagmus to the affected side
 Vertigo
 Nausea & vomiting
 LABYRINTHITIS
PRE-OP NURSING CARE
• Monitor for signs of meningitis, the most common
complication
- evidenced by headache, stiff neck lethargy
• Administer systemic antibiotics as Rx
• Advise client to rest in bed in a darkened room
• Administer antiemetics & antivertiginous medications as Rx
• Instruct the client that the vertigo subsides as inflammation
resolves
• Instruct the client that balance problems that persist may
require gait training through physical therapy
MENIERE’S SYNDROME
- a syndrome also called ENDOLYMPHATIC
HYDROPS
- refers to dilation of the endolympathic system by either
overproduction or decreased reabsorption of endolymphatic
fluid
- characterized by tinnitus, unilateral sensorineural hearing loss,
& vertigo
- symptoms occur in attacks & last for several days, & the client
becomes totally incapacitated
- initial hearing loss is reversible, but as the frequency of attacks
continues, hearing loss becomes permanent
- repeated damage to the cochlea caused by increased fluid
pressure leads to the permanent hearing loss
MENIERE’S SYNDROME
CAUSES
 Any factor that increases endolymphatic secretion in
the labyrinth
 Viral & bacterial infections
 Allergic reactions
 Biochemical disturbances
 Vascular disturbances producing changes in the
microcirculation in the labyrinth
MENIERE’S SYNDROME
ASSESSMENT
 Feelings of fullness in the ear
 Tinnitus, as a continuous low-pitched roar or humming sound
- is present most of the time but worsens just before &
during severe attacks
 Hearing loss is worse during an attack
 Vertigo
- periods of whirling which might cause the client to fall to the
ground
- sometimes so intense that even when lying down, the client
holds the bed or ground in an attempt to prevent the whirling
 Nausea & vomiting
 Nystagmus
 Severe headaches
MENIERE’S SYNDROME
NON-SURGICAL MANAGEMENT
• Preventing injury during vertigo attacks
• Providing bed rest in a quiet environment
• Provide assistance with walking
• Instruct the client to move the head slowly
- to prevent worsening of vertigo
• Initiate Na & fluid restrictions as Rx
• Instruct to avoid smoking
• Administer Nicotinic acid (Niacin) as Rx
- promote vasodilating effect
• Administer antihistamines as Rx
- reduce the production of histamine & reduces inflammation
• Administer antiemetics as Rx
• Administer tranquilizers & sedatives as Rx
- to calm client & allow rest, control the vertigo, N&V
MENIERE’S SYNDROME
SURGICAL MANAGEMENT
- performed when medical therapy is ineffective & the
functional level of the client has decreased significantly

• ENDOLYMPHATIC DRAINAGE
& INSERTION OF THE SHUNT
- may be performed early in the course of the disease to assist
with the drainage of excess fluids

• RESECTION OF THE VESTIBULAR NERVE

• LABYRINTHECTOMY
- removal of the labyrinth may be performed
 MENIERE’S
SYNDROME
POST-OP NURSING CARE
• Assess packing & dressing on the ear
• Speak to the client on the side of the unaffected ear
• Perform neurological assessments
• Maintain side rails
• Assist with ambulating
• Encourage the use of bedside commode
• Administer antivertiginous& antiemetic medications as Rx
 acoustic neuroma
- a benign tumor of the vestibular or acoustic nerve
- the tumor may cause damage to hearing & to facial
movements & sensations
- treatment includes surgical removal of the tumor via
craniotomy
- care is taken to preserve the function of the facial nerve
- the tumor rarely recurs after surgical removal
- post-op nursing care is similar to post-op craniotomy care

ASSESSMENT
 Symptoms usually begin with tinnitus & progress to gradual
sensorineural hearing loss
 As tumors enlarges, damage to adjacent cranial nerves occurs
 TRAUMA
- the tympanic membrane has a limited stretching ability & gives
way under high pressure
- foreign objects placed in the external canal may exert pressure
on the tympanic membrane & cause perforation
- if the object continues thorough the canal, the bony structures
of stapes, incus & malleus may be damaged
- a blunt injury to the basal skull & ear can damage the middle
ear structures through fractures extending to the middle ear
- excessive blowing & rapid changes of pressure that occur with
non-pressurized air flights can increase pressure in the middle
ear
- depending on the damage to the ossicles, hearing loss may or
may not return
 TRAUMA
NURSING CARE
• Tympanic perforations usually heal within 24 hours
• Surgical reconstruction of the ossicles & tympanic
membrane through tympanoplasty or myringotomy
may be performed to improve hearing
 CERUMEN &
FOREIGN BODIES
CERUMEN/EAR WAX
- the most common cause of impacted canals

FOREIGN BODIES
- can include vegetables, beads, pencil erasers & insects

ASSESSMENT
 Sensation of fullness in the ear with or without hearing loss
 Pain, itching or bleeding
 CERUMEN
NURSING CARE
• Removal of the wax by irrigation is a slow process
• Irrigation is C/I in clients with a hx of tympanic membrane
perforation
• To soften cerumen, add 3 gtts of glycerin to the ear @ hs
& 3 gtts of hydrogen peroxide BID
• After several days the ear is irrigated
• 50-70 ml of solution is the maximal amount a client can
tolerate during an irrigation sitting
 FOREIGN
BODIES
NURSING CARE
• If the foreign matter is vegetable, irrigation is used with care
- the material expends with hydration
• Insects are killed before removal unless they can be coaxed
out by flashlight or a humming noise
• Mineral oil or alcohol is instilled to suffocate the insect which
is then removed with ear forceps
• Use small ear forceps to remove the object & avoid pushing
the object farther into the canal & damaging the tympanic
membrane
OPTHALMIC
AND
OTIC
MEDICATIONS
 INSTALLATION OF EYE DROPS

EYE DROPS
• Wash hands
• Put on gloves
• Check the name, strength, & expiration date of the medication
• Instruct the client to tilt the head backward, open the eyes & look up
• Pull the lower lid down against the cheekbone
• Hold the bottle, gently rest the wrist of the hand on the client’s cheek
• Squeeze the bottle gently to allow the drop to fall into the conjunctival
sac
• Instruct the client to close the eyes gently & not to squeeze the eyes shut
• Wait 3-5 minutes before instilling another drop, if more than 1 is Rx
- to promote maximal absorption of the medication
• Don’t allow the medication bottle, dropper, or applicator to come in
contact with the eyeball
 Installation of eye
medications
EYE OINTMENTS
• Hold the ointment tube near, but not touching, the eye or
eyelashes
• Squeeze a thin ribbon of ointment along the lining of the lower
conjunctival sac from the inner to the outer canthus
• Instruct the client to close the eyes gently
• Instruct the client that vision may be blurred by the ointment
 MYDRIATICS,
MYDRIATICS, Cycloplegic
Cycloplegic &
&
anticholinergic
anticholinergic medications
medications

MYDRIATICS
- dilate the pupils (mydriasis)

CYCLOPLEGIA
- relax the ciliary muscles

ANTICHOLINERGICS
- block responses of the sphincter muscle in the ciliary body,
producing mydriasis
MYDRIATICS,
MYDRIATICS, Cycloplegic
Cycloplegic &
&
anticholinergic
anticholinergic medications
medications
- used pre-op or for eye examinations to produce mydriasis
- C/I in clients with glaucoma because of the risk of increased
IOP
- Mydriatics are C/I in cardiac dysrhythmias & cerebral
atherosclerosis & should be used with caution in the elderly
and in clients with prostatic hypertrophy, diabetes mellitus or
parkinsonism
 MYDRIATICS
MYDRIATICS && Cycloplegic
Cycloplegic eye
eye
medications
medications

EXAMPLES
• Atropine sulfate (Isopto-Atropine, Ocu-Tropine, Atropair, Atropisol)
• Scopolamine hydrobromide (Isopto-Hyoscine)
• Cyclopentolate hydrochloride (Cyclogyl, AK-Pentolate, Pentolair)
• Homotropine hydrobromide (Isopto Homatrine, AK-Homatropine,
Spectro-Homatrine)
• Tropicamide (Mydriacyl, I-Picamide, Tropicacyl)
• Phenylephrine hydrochloride (AK-Dilate, Dilatair, Mydfrin, Ocu-Phrin)
MYDRIATICS,
MYDRIATICS, Cycloplegic
Cycloplegic &
&
anticholinergic
anticholinergic medications
medications

SIDE EFFECTS
 Tachycardia
 Photophobia
 Conjunctivitis
 Dermatitis
 ATROPINE
ATROPINE
TOXICITY
TOXICITY
 Dry mouth
 Blurred vision
 Photophobia
 Tachycardia
 Fever
 Urinary retention
 Constipation
 Headache, brow pain
 Confusion
 Hallucinations, delirium
 Coma
 Worsening of narrow-angled glaucoma
 SYSTEMIC
SYSTEMIC REACTIONS
REACTIONS
OF
OF ANTICHOLINERGICS
ANTICHOLINERGICS
 Dry mouth & skin
 Fever
 Thirst
 Confusion
 Hyperactivity

ALPHA-ADRENERGIC BLOCKER
- example Dapiprazole hydrochoride (Rev-Eyes)
- used to counteract mydriasis
 MYDRIATICS,
MYDRIATICS, Cycloplegic
Cycloplegic &
&
anticholinergic
anticholinergic medications
medications
NURSING CARE
• Monitor for allergic reactions
• Assess for risk of injury
• Assess for constipation & urinary retention
• Instruct the client that a burning sensation may occur on installation
• Instruct the client not to drive or operate machine for 24 hrs after
installation of the medication unless otherwise directed by the
physician
• Instruct the client to wear sunglasses until the effects of the
medication wear off
• Instruct to notify MD if blurring of vision, loss of sight, difficulty in
breathing, sweating or flushing occurs
• Instruct the client to report eye pain to the physician
 ANTI-INFECTIVE
ANTI-INFECTIVE
EYE
EYE
MEDICATIONS
MEDICATIONS
- Kill or inhibit the growth of bacteria, fungi, & viruses

SIDE EFFECTS
 Superinfection
 Global irritation

NURSING CARE
• Assess for risk of injury
• Instruct the client in how to apply the eye medication
• Instruct the client to continue treatment as Rx
• Instruct the client to wash hands thoroughly & frequently
• Advise the client that if improvement does not occur, notify the MD
ANTI-INFECTIVE
ANTI-INFECTIVEEYE
EYE
MEDICATIONS
MEDICATIONS
ANTIBACTERIAL
• Chloramphenicol (Chloromycetin, Chloroptic)
• Ciprofloxacin hydrochloride (Cipro)
• Erythromycin (Ilotycin)
• Gentamicin sulfate (Garamycin, Genoptic)
• Norfloxacin (Chibroxin)
• Tobramycin (Nebcin, Tobrex)
• Silver nitrate 1%

ANTIFUNGAL
• Natamycin (Natacyn Opthalmic)

ANTIVIRAL
• Idoxuridine (Herplex-Liquifilm)
• Trifluridine (Viroptic)
• Vidarabine (Vira-A Opthalmic)
 ANTI-INFLAMMATORY
ANTI-INFLAMMATORYEYE
EYE
MEDICATIONS
MEDICATIONS
- Control inflammation, thereby reducing vision loss & scarring
- Used for uveitis, allergic conditions, & inflammation of the conjunctiva,
cornea, & lids

SIDE EFFECTS
 Cataracts
 Increased IOP
 Impaired healing
 Masking S/S of infection

NURSING CARE
• Assess for risk of injury
• Instruct the client in how to apply the eye medication
• Instruct the client to continue treatment as Rx
• Instruct the client to wash hands thoroughly & frequently
• Advise the client that if improvement does not occur, notify the MD
• Note that dexamethasone (Maxidex) should not be used for eye abrasions
& wounds
 ANTI-INFLAMMATORY
ANTI-INFLAMMATORY
EYE
EYE MEDICATIONS
MEDICATIONS

EXAMPLES
• Dexamethasone (Maxidex)
• Diclofenac (Voltaren)
• Flurbiprofen Na (Ocufen)
• Suprofen (Profenal)
• Ketorolac tromethamine (Acular)
• Prednisone acetate (Predforte, Econopred)
• Prednisolone Na phosphate (AK-Pred, Inflamase)
• Rimaxolone (Vexol)
 TOPICAL
TOPICAL ANESTHETICS
ANESTHETICS
FOR
FOR THE
THE EYE
EYE
- Produce corneal anesthesia
- Used for anesthesia for eye examinations, for surgery, or to remove
foreign bodies from the eye

SIDE EFFECTS
 Temporary stinging or burning of the eye
 Temporary loss of corneal reflex

NURSING CARE
• Assess for risk of injury
• Note that the medications should not be given to the client for home use &
are not to be self-administered by the client
• Note that the blink reflex is temporarily lost & that the corneal epithelium
needs to be protected
• Provide an eye patch to protect the eye from injury until the corneal reflex
returns
TOPICAL
TOPICAL ANESTHETICS
ANESTHETICS
FOR
FOR THE
THE EYE
EYE

EXAMPLES
• Proparacaine HCl (Ophthaine, Opthenic)
• Tetracaine HCl (Pontocaine)
 EYE
EYE LUBRICANTS
LUBRICANTS
- Replace tears or add moisture to the eyes
- Moisten contact lenses or an artificial eye
- Protect the eyes during surgery or diagnostic procedures
- Used for keratitis, during anesthesia or in a disorder that results in
unconsciousness or decreased blinking

SIDE EFFECTS
 Burning in installation
 Discomfort or pain in installation

NURSING CARE
• Inform the client that burning may occur on installation
• Be alert to allergic responses to the preservatives in the lubricants
 EYE
EYE
LUBRICANTS
LUBRICANTS
EXAMPLES
• Hydroxypropyl methylcellulose (Lacril, Isopto Plain)
• Petroleum-based ointment (Artificial Tears, Liquifilm Tears)
 MIOTICS
MIOTICS
- reduce IOP by constricting the pupil & contracting the ciliary muscle,
thereby increasing the blood flow to the retina & decreasing retinal
damage & loss of vision
- open the anterior chamber angle & increase the outflow of aqueous
humor
- used for chronic open-angle glaucoma or acute & chronic closed-angle
glaucoma
- used to achieve miosis during eye surgery
- C/I in clients with retinal detachment, adhesions between the iris &
lens, or inflammatory diseases
- used with caution in clients with asthma, hypertension, corneal
abrasion,hyperthyroidism, coronary vascular disease, urinary tract
obstruction, GI obstruction, ulcer disease, parkinsonism, or
bradycardia
 MIOTICS
MIOTICS
MIOTIC CHOLINERGIC MEDS
- reduce IOP by mimicking the action of acetylcholine

MIOTIC ACETYLCHOLINE
INHIBITORS MEDS
- reduce IOP by inhibiting the action of cholinesterase
 MIOTICS
MIOTICS
SIDE EFFECTS SYSTEMIC EFFECTS
 Myopia  Flushing
 Diaphoresis
 GI upset & diarrhea
 Headache
 Frequent urination
 Eye pain  Increased salivation
 Decreased vision in poor light  Muscle weakness
 Local irritation  Respiratory difficulty

TOXICITY
 Vertigo & syncope
 Bradycardia
 Hypotension
 Cardiac dysrhythmias
 Tremors
 Seizures
 MIOTICS
MIOTICS
EXAMPLES
• Acethylcholine Cl (Miochol)
• Carbachol (Miostat)
• Pilocarpine HCl (Isopto Carpine, Pilocar)
• Pilocarpine nitrate (Pilofrin, Liquifilm, Pilagan)
• Echothiophate iodide (Phospholine iodide)
• Demecarium bromide (Humorsol)
• Isoflurophate (Floropryl)
 MIOTICS
MIOTICS
NURSING CARE
• Assess V/S & risk of injury
• Assess the client for the degree of diminished vision
• Monitor S/E & toxic effects
• Monitor for postural hypotension & instruct the client to change positions
slowly
• Assess breath sounds for rales & rhonchi
- cholinergic meds cause bronchospasms & increased bronchial secretions
• Maintain oral hygiene
- due to increased salivation
• Have Atropine sulfate available as antidote for Pilocarpine
• Instruct the client regarding the correct administration of eye meds
• Instruct the client not to stop the meds suddenly
• Instruct to avoid activities such as driving while vision is impaired
• Instruct clients with glaucoma to read labels on OTC meds & to avoid
Atropine-like meds
- Atropine increase IOP
 OCUSERT
OCUSERT
-
SYSTEM
SYSTEM
It’s a thin eye wafer (disk) impregnated with time-release Pilocarpine
- Devised to overcome the frequent application of Pilocarpine
- Placed in the upper or lower cul-de-sac of the eye
- Pilocarpine is released over 1 wk & disk is replaced every 7 days
- Drawbacks of its use include sudden leakage of Pilocarpine, migration
of the system over the cornea, & unnoticed loss of the system

NURSING CARE
• Assess the client’s ability to insert the medication disk
• Store the medication in the refrigerator
• Instruct the client to discard damage or contaminated disks
• Inform the client that temporary stinging is expected but to notify MD if
blurred vision or brow pain occurs
• Instruct the client to check for the presence of the disk in the conjunctival
sac daily qHS & upon arising
• Since vision may change in the first few hours after the eye system is
inserted, instruct the client to replace the disk at bedtime
 BETA-ADRENERGIC
BLOCKING EYE
MEDICATIONS
- Reduce IOP by decreasing sympathetic impulses & decreasing
aqueous humor production without affecting accommodation or
pupil size
- Used to treat chronic open-angle glaucoma
- C/I in the client with asthma
- systemic absorption can cause increased airway resistance
- Used with caution in the client receiving oral beta-blockers

SIDE EFFECTS
 Ocular irritation
 Visual disturbances
 Bradycardia
 Hypotension
 Bronchospasm
BETA-ADRENERGIC
BETA-ADRENERGIC
BLOCKING
BLOCKINGEYE
EYE
MEDICATIONS
MEDICATIONS
EXAMPLES
• Betaxolol HCl (Betoptic)
• Carteolol HCl (Ocupress)
• Levobunolol HCl (Betagan)
• Metipranolol (Optipranolol)
• Timolol maleate (Timoptic)
 BETA-ADRENERGIC
BETA-ADRENERGIC
BLOCKING
BLOCKINGEYE
EYE
MEDICATIONS
MEDICATIONS
NURSING CARE
• Monitor V/S before administering medication esp. BP & PR
• If the pulse is below 60 or if systolic BP is below 90 mm Hg, withhold the
medication & contact MD
• Monitor for shortness of breath and I&O
• Assess for risk of injury
• Instruct the client to notify MD if shortness of breath occurs
• Instruct not to D/C medication abruptly
• Instruct to change positions slowly to avoid orthostatic hypotension
• Instruct to avoid hazardous activities
• Instruct to avoid OTC meds without the MD’s approval
 ADRENERGIC
ADRENERGIC EYE
EYE
MEDICATIONS
MEDICATIONS
- Decrease the production of aqueous humor & lead to a decrease in
IOP
- Used to treat glaucoma

ADRENERGIC MEDICATIONS
• Apraclonidine HCl (Iopidine)
• Brimonidine tartrate (Alphagen)
• Dipivefrin HCl (Propine)
• Epinephrine borate (Epinal, Eppy)
• Epinephrine HCl (Epifrin, Glaucon)
CARBONIC
CARBONIC ANHYDRASE
ANHYDRASE
MEDICATIONS
MEDICATIONS
- Interfere with the production of carbonic acid which leads to
decreased aqueous humor formation & decreased IOP
- Used for long-term treatment of open-angle glaucoma
- C/I in the client allergic to sulfonamides

SIDE EFFECTS
 Appetite loss
 GI upset
 Paresthesias in the fingers, toes & face
 Polyuria
 Hypokalemia
 Renal calculi
 Photosensitivity
 Lethargy & drowsiness
 Depression
CARBONIC
CARBONIC ANHYDRASE
ANHYDRASE
MEDICATIONS
MEDICATIONS
NURSING CARE
• Monitor V/S
• Assess visual acuity
• Assess for risk of injury
• Monitor I&O
• Monitor weight
• Maintain oral hygiene
• Monitor for side effects such as lethargy, anorexia, drowsiness, polyuria,
nausea, & vomiting
• Monitor electrolytes for hypokalemia
• Increase fluid intake unless C/I
• Advise the client to avoid prolonged exposure to sunlight
• Encourage the client to use artificial tears for dry eyes
• Instruct not to D/C the medication abruptly
• Instruct to avoid hazardous activities while vision is impaired
OSMOTIC
OSMOTIC MEDICATIONS
MEDICATIONS
- Lower IOP
- Used in emergency treatment of acute closed-angle glaucoma
- Used pre-op & post-op to decrease vitreous humor volume

SIDE EFFECTS
 Heache
 Nausea, vomiting, diarrhea
 Disorientation
 Electrolyte imbalance

NURSING CARE
• Assess V/S, visual acuity & risk for injury
• Monitor weight and I&O
• Monitor electrolytes
• Increase fluid intake unless C/I
• Monitor for changes in level of orientation
OSMOTIC
OSMOTIC EYE
EYE
MEDICATIONS
MEDICATIONS
EXAMPLES
• Glycerin (Glyrol, Osmoglyn)
• Mannitol (Osmitrol)
• Urea (Ureaphil)
 Otic
Otic MEDICATION
MEDICATION
ADMINISTRATION
ADMINISTRATION

ADMINISTERING EAR DROPS

ADULT
• Pull the pinna up & back to straighten the external canal to instill
ear drops

CHILD
• Pull the pinna down & back for infants & children younger than 3
years of age
• Pull the pinna up & back for children for children more than 3 years
 Otic
Otic MEDICATION
MEDICATION
ADMINISTRATION
ADMINISTRATION

IRRIGATION OF THE EAR

• Irrigation of the ear needs to be prescribed by MD
• Ensure that there is direct visualization of the tympanic membrane
• Warm irrigating solution to 100° F
- solutions not close to the client’s body temp will cause ear injury,
nausea & vertigo
• Irrigation must be done gently to avoid damage to the eardrum
• When irrigating, don’t direct irrigating solution directly toward the
eardrum
• If perforation of the eardrum is suspected, irrigation is not done
 MEDICATIONS
MEDICATIONSTHAT
THATAFFECT
AFFECT
HEARING
HEARING
ANTIBIOTICS
• Amikacin (Amikin)
DIURETICS
• Chloramphenicol
• Acetazolamide (Diamox)
- Chloromycetin • Furosemide (Lasix)
- Chloroptic • Ethacrynic acid (Edecrine)
- Ophthoclor
• Erythromycin
- E-Mycin
- ERYC OTHERS
- Ery-Tab • Cisplatin (Platinol, Platinol-AQ)
- PCE Dispertabs • Nitrogen mustard
- Ilotycin • Quinine (Quinamn)
• Gentamicin (Garamycin) • Quinidine
• Streptomycin sulfate - Cardioquin
(Streptomycin) - Quinaglute
• Tobramycin sulfate (Nebcin) - Quindex
• Vancomycin (Vancocin)
 ANTI-INFECTIVE
ANTI-INFECTIVE
MEDICATIONS
MEDICATIONS
- Kill or inhibit the growth of bacteria
- Used for otitis media or otitis externa
- C/I if a prior hypersensitivity exists

SIDE EFFECTS
 Overgrowth of non-susceptible organisms

NURSING CARE
• Assess V/S
• Assess for allergies & pain
• Monitor for nephrotoxicity
• Instruct the client to report dizziness, fatigue, fever, or sore throat
- indicative of superimposed infection
• Instruct to complete the entire course of medication
• Instruct to keep the ear canals dry
 ANTI-INFECTIVE
ANTI-INFECTIVE
MEDICATIONS
MEDICATIONS
EXAMPLES
• Amoxicillin (Amoxil)
• Ampicillin trihydrate (Polycillin)
• Cefaclor (Ceclor)
• Clindamycin HCl (Cleocin)
• Trimethoprim (TMP) & Sulfamethaxazole (SMZ)
- Bactrim, Cotrim, Septra
• Erythromycin (Ilotycin, E-Mycin)
• Penicillin V potassium (Pen V)
• Loracarbef (Lorabid)
• Clarithromycin (Biaxin)
• Polymyxin B sulfate (Aerosporin)
• Tetracycline HCl (Achromycin)
• Acetic acid and Aluminum acetate (Otic Domeboro)
 ANTI-HISTAMINES
ANTI-HISTAMINES &
&
DECONGESTANTS
DECONGESTANTS
- Produce vasoconstriction
- Stimulate the receptors of the respiratory mucosa
- Reduce respiratory tissue hyperemia & edema to open obstructed
eustachian tubes
- Used for acute otitis media

SIDE EFFECTS
 Drowsiness
 Blurred vision
 Dry mucous membranes

NURSING CARE
• Inform the client that drowsiness, blurred vision, & dry mouth may occur
• Instruct the client to increase fluid intake unless C/I & to suck on hard
candy to alleviate dry mouth
• Instruct the client to avoid hazardous activities if drowsiness occurs
 ANTI-HISTAMINES
ANTI-HISTAMINES &
&
DECONGESTANTS
DECONGESTANTS
EXAMPLES
• Tripolidine & pseudoephedrine (Actifed)
• Naphazoline HCl (Allerest, Albalon)
• Chlorpheniramine (Chlor-Trimeton, Teldrin)
• Brompheniramine (Bromphen, Dimetane)
• Terfenadine (Seldane)
• Clemastine (Tavist)
• Cetirizine (Zyrtec)
• Astemizole (Hismanal)
 LOCAL
LOCAL
ANESTHETICS
ANESTHETICS
- Block nerve conduction at or near the application site to control pain
- Used for pain associated with ear infections

MEDICATION : Benzocaine (Americaine Otic; Tympagesic)

SIDE EFFECTS
 Allergic reaction
 Irritation

NURSING CARE
• Monitor for effectiveness if used for pain relief
• Assess for irritation or allergic reaction
 CERUMINOLYTIC
CERUMINOLYTIC
MEDICATIONS
MEDICATIONS
- Emulsify & loosen cerumen deposits
- Used to loosen & remove impacted ear wax from the ear canal

SIDE EFFECTS
 Irritation
 Redness or swelling of the ear canal

NURSING CARE
• Instruct the client not to use drops more often than prescribed
• Moisten a cotton plug with medication before insertion
• Keep the container tightly closed & away from moisture
• Avoid touching the ear with the dropper
• 30 minutes after installation, gently irrigate the ear as Rx with warm
water using a rubber bulb ear syringe
• Irrigation may be done with hydrogen peroxide sol’n as Rx
- to flush cerumen deposits out of the ear canal
• For chromic cerumen impaction, 1-2 gtts of mineral oil will soften the wax
• Instruct the client to notify MD if redness, pain or swelling persists
CERUMINOLYTIC
CERUMINOLYTIC
MEDICATIONS
MEDICATIONS
EXAMPLES
• Carbamide peroxide (Debrox)
• Boric acid (Ear-Dry)
• Trolamine polypeptide oleate-condensate
- Cerumenex