NUR 145 Care of Mother and Child At-Risk or

with Problems (Acute and Chronic)-Lecture

BS NURSING / SECOND YEAR
Session # 50
Materials: Notebook, pens, paper.

LESSON TITLE: NURSING CARE OF A FAMILY WHEN A

CHILD HAS SENSORY ALTERATIONS References

LEARNING OUTCOMES: Pilliteri, Adele (2010) Maternal and Child Health

Nursing, 8th Edition. USA: Lippincott Williams and
At the end of the lesson, the nursing student can: Wilkins

1. Define the structure and function of the eyes and ears Perry, Shannon, Hockenberry, Marilyn J.,
and disorders of these organs as they affect children. Lowdermilk Deitra Leonard and Wilson, David
2. Integrate the knowledge of the structure and function (2015) Maternal and Child Nursing Care,6th
of the eyes and ears and disorders of these organs as they Edition. USA: Elsevier
affect children and describe these disorders that occur in
these classifications of children in formulating nursing care Hockenberry, Marilyn and Wilson, David (2013)
plan in giving quality maternal and child health nursing care. Wong’s Essential of Pediatric Nursing,9th Edition.
USA: Elsevier

MAIN LESSON (50 minutes)

Please refer to Chapter 50: Nursing Care of a Family When a Child Has a Vision or Hearing Problems-Inner Eye
Condition p. 1422 and Disorders of the Ear p. 1427
INNER EYE CONDITIONS
CATARACTS CONGENITAL GLAUCOMA
• is marked opacity of the lens. • a condition of the eye characterized by increased
• This may be present at birth, or it may become IOP, potential damage to the optic nerve, and
apparent in early childhood. possible vision loss.
• a dominantly inherited condition, whereas in ASSESSMENT
others, it may be as a result of another disease • The condition is bilateral and is caused by the
process such as galactosemia or scarring from an inheritance of a recessive gene.
injury. • Symptoms may be noticeable as soon as shortly
• A few children develop cataracts as a result of after birth, and they are readily noticeable at 1
steroid use or radiation exposure. year of age.
• If the opacity occurs on the anterior surface of the • The cornea, which appears enlarged, may also be
lens, the cause is thought to be a birth injury or edematous and hazy; it feels tense to finger
possibly contact between the lens and the cornea palpation. There may be accompanying tearing,
during intrauterine life. pain, and photophobia (sensitivity to light)—all
• If the opacity is located at the edge of the lens, it difficult signs to identify in a newborn.
may be a result of nutritional deficiency during • Eye pressure is measured by means of a
intrauterine life, such as hypocalcemia. tonometer, a pressure-sensitive device that is
• A quarter of infants born to women who were placed against the anterior eye globe and
exposed to or contracted rubella may develop measures eye pressure by a beam of light
cataracts directed toward the eye.
ASSESSMENT • Tension greater than the normal range of 12 to 20

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 • inspect the pupil of a child with a cataract, the red mmHg is suggestive that glaucoma has
reflex elicited by shining a light into the pupil developed.
appears white. • If local anesthesia is needed for tonometry,

•Older children may report blurred vision because caution parents that children should not rub their
of cataract formation. In the infant, this can be eyes after the procedure (an infant’s arms may
detected by lack of response to a smile or an need to be gently restrained to prevent eye
inability to reach and grasp a nearby object. rubbing for about 4 hours after such an
• The infant may also demonstrate nystagmus from examination).
being unable to focus the eye on objects. • Otherwise, corneal abrasions could occur because
• A few other conditions, such as retinoblastoma, of the cornea’s temporary lack of sensitivity.
retinopathy of prematurity, congenital glaucoma, or THERAPEUTIC MANAGEMENT
an abscess of the posterior chamber, simulate this • Surgery, such as trabeculotomy and goniotomy,
appearance. laser procedures that create shunts to allow fluid to
MANAGEMENT drain from the eye, as well as medical treatment
• Treatment of childhood cataract is the surgical are used to lower IOP
removal of the cloudy lens, followed by insertion of • A drug such as acetazolamide (Diamox), a
an internal intraocular lens. carbonic anhydrase inhibitor that suppresses the
• If the total lens is involved, this may be done as formation of aqueous humor, may be used
early as 3 months of age. If this is not done before temporarily to reduce eye pressure before surgery
6 years of age, amblyopia may result. can be scheduled.
• Introduce fluids cautiously after eye surgery so • Before surgery, the infant should not receive any
nausea and vomiting do not occur because drug, such as atropine sulfate, that dilates the pupil
vomiting increases intraocular pressure (IOP), because this will further occlude the canal of
which could injure the suture line. Schlemm.
• Encourage parents to stay with their infant and to • After surgery, rough play activities should be
help with care so the infant does not cry because restricted for 1 week.
crying also increases IOP. • Surgery may need to be repeated before the new
 opening for the drainage of fluid is adequate to
keep eye globe tension at a usual level.
• Inform parents of this possibility when surgery is
first proposed so that they will not think the
additional surgery is needed because the first
operation was inadequate or was done incorrectly.
• Children who have eye injuries are usually
scheduled for a follow-up appointment in 1 month
for eye pressure assessment.
• Stress the importance of this visit in order to
assess eye pressure and to prevent complications
DISORDERS OF THE EARS

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EXTERNAL OTITIS IMPACTED CERUMEN
• is inflammation of the external ear canal. • Cerumen (earwax) serves the important function of
• Although external ear inflammation rarely cleansing the external ear canal as it gradually
threatens hearing or causes permanent damage, it moves outward, bringing with it shed epithelial
does cause discomfort in the form of itching and cells and any foreign object.
sometimes extreme pain MANAGEMENT
• popularly called swimmer’s ear • it should not be removed routinely.
ASSESSMENT • Using cotton-tipped applicators to clean ears as a
• Children first notice itching of the canal and then regular practice can also scratch the ear canal,
pain. When the external ear is touched, the pain creating a site for a secondary infection.
becomes acute. • This practice may also push accumulated cerumen
• The moisture in the canal left from swimming or farther into the ear canal, resulting in plugging of
from decay of a food substance has caused wax.
inflammation, and a secondary infection then can • Commercial softeners are available if cerumen
occur in the closed space. accumulates to such an extent that hearing is
• Pseudomonas and Candida are agents frequently affected. In some instances, a dilute solution of
involved in these infections. hydrogen peroxide may be necessary to dissolve
cerumen.
• On otoscopic examination, the pain may be found
to be due to the sharply localized, tender swelling • Again, this should not be done regularly because
of a furuncle, or the entire canal may be swollen this will keep the ear canal constantly moist, an
shut and tender to the touch. environment that leads to external otitis.
ACUTE OTITIS MEDIA
• Fungal infections tend to turn the canal brown or

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 black; although, if mold forms around a foreign • Inflammation of the middle ear (otitis media) is one
body, such as the tip of a cotton applicator, it may of the most prevalent diseases of childhood.
appear white or gray. • It occurs most often in children 6 to 36 months of
• The skin under the object will be moist, red, and age and again at 4 to 6 years.
eroded. • Children most susceptible to it are males, Alaskan
• If doing a first assessment on a child, be certain to and Native American children, those with cleft
visualize the tympanic membrane if possible to be palate, and infants who are formula-fed rather than
certain it is intact and that it is not inflamed or to breastfed.
verify if the inflammation is about to extend into the • Formula-feeding leads to this because infants are
middle ear. held in a more slanted position while feeding,
• Before the tympanic membrane can be visualized allowing milk to enter the eustachian tube.
clearly, it is often necessary to remove superficial • The incidence of otitis media is highest in the
debris from the canal. winter and spring because it frequently follows an
• A Weber test should show that hearing is not upper respiratory infection and is higher in homes
decreased in the affected ear. If the sound of a in which a parent smokes cigarettes.
tuning fork vibrates louder in the affected ear, it ASSESSMENT
suggests otitis media is present. • Acute otitis media usually occurs following a
THERAPEUTIC MANAGEMENT respiratory tract infection.
• The treatment of otitis externa differs according to • Children have a “cold,” rhinitis, and perhaps a
the organism causing the infection. lowgrade fever for several days.
• If the canal is so swollen that ear drops cannot • fever peaks to about 102°F (38°C), and sharp,
flow back into the canal, a cotton wick moistened constant pain begins in one or both ears.
with Burow’s solution may be threaded into the
• Older children can verbalize they have pain and
canal.
point to where the pain is felt
• The cotton extending out into the auricle is kept
• Extremely irritable and frequently pull or tug at the
moistened by rewetting it periodically for the next
affected ear in an attempt to gain relief from pain
24 hours with Burow’s solution. THERAPEUTIC MANAGEMENT
• This usually reduces the swelling of the canal to a • An otitis media infection may resolve
point where further cleaning can be accomplished. spontaneously; however, if it does not, antibiotic
• Ear drops containing hydrocortisone, an antibiotic, therapy may be indicated.
or an antifungal mixture may be prescribed. • analgesic and antipyretic such as acetaminophen
• Hydrocortisone reduces inflammation, and the (Tylenol) and decongestant nose drops to open
antibiotic or antifungal preparation will reduce the the eustachian tubes and allow air to enter the
infection. middle ear.
• If ear pain is present, an analgesic, such as • These are given for only 2 to 3 days because if
acetaminophen or ibuprofen, may be necessary to they are given longer, a rebound effect can occur,
control discomfort. causing edema and a subsequent increase in
• It is important that children keep the ear canal dry mucous membrane inflammation.
until the inflammation subsides, so they need to • Providing a smoke-free home environment can
avoid swimming and washing their hair during this help prevent further episodes of otitis media
time.
• If they shower, they should first insert ear plugs
into the external meatus or wear a shower cap to
keep out moisture

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OTITIS MEDIA WITH EFFUSION
• occurs when otitis media becomes chronic.
• becomes so filled with this and the fluid becomes so thick and tenacious that it appears glue-like.
• Some children notice a feeling of fullness or the sound of popping or ringing in their ears.
• There may be a drop in hearing of 20 to 40 dB because of the inability of the ossicles to function effectively.
• Involvement is usually bilateral.
• The condition occurs most frequently in children 3 to 10 years of age
ASSESSMENT
• A child experiences muffled hearing and a feeling of pressure in the ear with otitis media with effusion.
• Otoscopic examination may show a level of fluid behind the tympanic membrane.
• the collected fluid becomes thick, it tends to retract the eardrum.
• This makes the malleus more prominent and perhaps displaced to a horizontal angle as the membrane is
retracted around it; the light reflex from the otoscope light becomes distorted. If a pneumatic otoscope is used,
gentle introduction of air against the eardrum produces no movement of the tympanic membrane (as there
would be normally).
MANAGEMENT
• For mild involvement, the daily administration of an antihistamine or a nasal decongestant to shrink the mucous
membrane of the eustachian tube may be enough to achieve an air supply.
• In a few children, the eustachian tube is blocked by enlarged adenoids, and their removal is indicated.
• Fluid from the middle ear can be removed by tympanocentesis (a needle inserted through the tympanic
membrane);
• tubal myringotomy is undertaken.
• Tubal Myringotomy A source of air can be supplied to the middle ear by the insertion of small plastic (Teflon)
tubes inserted through the tympanic membrane (tympanostomy).
• When myringotomy tubes are in place, the child has to be careful to not allow water to enter the ears.
• It’s better if they bathe rather than shower, but showering is all right if ear plugs are used, especially while
washing hair.
• Similarly, swimming is either contraindicated or allowed only with ear plugs in place.

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