Pediatric Eye and Ear Disorders

• Sensory perception involves receiving and interpreting stimuli.
• Disorders of the eyes or ears can cause alterations in sensory perception.
• Nurses need to know how to intervene for sensory perception alterations and other eye and ear disorders.

Common Pediatric Eye and Ear Disorders

• Children often experience eye and ear disorders.
• Conjunctivitis and otitis media are common infectious and inflammatory disorders.
• Refractive error, strabismus, and amblyopia can affect visual acuity development.
• Hearing loss can impact a child’s language acquisition.
• Eye and ear disorders, if chronic or recurrent, can affect visual acuity or cause hearing impairment.
• Nurses must consider developmental differences when planning care for children with visual or hearing impairments.

Variations in Pediatric Anatomy and Physiology: Eyes

• Light-skinned children are often born with blue eyes, with the iris pigmentation completing by 6–12 months.
• Newborns have a bluish-tinged sclera that turns white within weeks.
• Infants' and young children's eyeballs occupy a larger space in the orbit, making them more prone to injury.
• Newborns have immature vision due to an unmyelinated optic nerve until 3 months and the shape of the lens.
• At birth, visual acuity is around 20/400, improving to 20/20 by age 5.
• Rectus muscles are uncoordinated at birth, with binocular vision achieved between 3–7 months.
• Preterm infants may have incomplete retinal vascularization, affecting visual acuity.

Variations in Pediatric Anatomy and Physiology: Ears

• Congenital ear deformities can indicate other body system anomalies and genetic syndromes.
• Short, wide, and horizontal Eustachian tubes in infants increase the risk of ear infections.
• As children mature, the Eustachian tubes become more slanted, reducing the frequency of middle ear infections.
• Enlarged adenoids can obstruct Eustachian tubes, leading to infection.

Common Medical Treatments for Eye and Ear Disorders

• Treatments often require a physician’s order in hospitalized children.

Nursing Process Overview

• Nursing care includes assessment, nursing analysis, planning, interventions, and evaluation.
• Care should be individualized based on the child and family specifics.
• Assessment involves health history, physical assessment, and diagnostic testing.
• Health history includes past medical history, family history, history of present illness, and treatments used at home.
• Significant past medical history includes prematurity, genetic defects, eye or ear deformities, visual or hearing impairment, recurrent ear infections, or ear surgeries.
• Family history should include eye or ear deformities, vision or hearing impairment, or infectious exposure.
• History of present illness includes onset, progression, fever, nasal congestion, eye or ear pain, rubbing or pulling, headache, lethargy, or behavioral changes.
• Document the use of corrective lenses or hearing aids.

Physical Examination: Inspection and Observation

• Note the use of eyeglasses, corrective lenses, or hearing aids.
• Observe eye positioning, symmetry, strabismus, nystagmus, and squinting.
• Eyelids should open equally (ptosis).
• Note variations in eye slant and epicanthal folds.
• Assess for eyelid edema, sclera color, discharge, tearing, pupillary equality, size, and shape.
• Evert the eyelid to check for redness.
• Test extraocular movements, pupillary light response, and accommodation.
• Check symmetry of corneal light reflex and red reflex.
• Perform an age-appropriate visual acuity test.
• Inspect ears for size, shape, position, skin tags, dimples, and anomalies.
• Otoscopic examination assesses cerumen, discharge, inflammation, or foreign bodies.
• Visualize the tympanic membrane for color, landmarks, light reflex, perforation, scars, bulging, or retraction.
• Test auditory acuity via whisper test, audiometry, or other age-appropriate methods.

Physical Examination: Palpation

• The eyes are not usually palpated except in the case of injury of the upper eyelid. Palpate the ear for tenderness over the tragus or pinna.
• Note tenderness over the mastoid area (mastoiditis).
• Palpate for enlarged cervical lymph nodes (infection).

Laboratory and Diagnostic Testing

• Common tests include cultures of eye or ear discharge, tympanic fluid culture, and tympanometry.
• Cultures identify specific bacteria and guide antibiotic use.
• Tympanometry measures eardrum movement to determine middle ear effusion.

Nursing Analyses

• Injury risk is analyzed and plans are made to prevent injury.
• Fear is analyzed and plans are made to reduce fear.
• Delayed growth and development is analyzed and plans are made to encourage development.
• Communication impairment is analyzed and plans are made to improve communication.
• Knowledge deficiency is analyzed and plans are made to educate the family.

Nursing Interventions

• Orient the child to the hospital to prevent injury.
• Encourage parents to stay at the bedside.
• Use assistive devices to promote safety.
• Allow the child to share feelings.
• For visually impaired children, identify yourself and describe the environment.
• Encourage a nutritious diet.
• Isolate the child as required.
• Teach preventive measures like hand washing and covering coughs.
• Encourage attainment of developmental milestones.
• Foster independence in ADLs.
• Encourage play with other children.
• Help families set limits and discipline.
• Encourage friendships with other children who have sensory impairment.

Improving Communication

• Encourage communication habilitation programs.
• Maintain consistency in communication styles.
• Support the child’s speech efforts.
• Encourage spoken language at home.

Educating the Family

• Review the diagnosis and plan of care.
• Refer families to resources for sensory-impaired children.
• Demonstrate medical treatments and assistive devices.
• Encourage exploration of different communication and learning modes.

Common Medical Treatments

• Warm compresses for conjunctivitis
• Corrective lenses for astigmatism, refractive error, strabismus
• Patching for strabismus, amblyopia
• Eye muscle surgery for strabismus
• Pressure-equalizing (PE) tubes for chronic otitis media with effusion
• Hearing aids for hearing impairment
• Cochlear implants for sensorineural hearing loss

Drug Therapy

• Antibiotics treat bacterial infections.
• Antihistamines treat allergic conjunctivitis.
• Analgesics provide pain relief.

Infectious and Inflammatory Disorders of the Eyes: Conjunctivitis

• Conjunctivitis is inflammation of the conjunctiva.
• Causes include infectious (viral or bacterial), allergic, or chemical factors.
• Viral conjunctivitis is often caused by adenoviruses and influenza.
• Bacterial conjunctivitis is often caused by Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae.
• Newborns may get conjunctivitis from Chlamydia trachomatis and Neisseria gonorrhoeae.
• Risk factors include age under 2 weeks, day care, upper respiratory infection, pharyngitis, or otitis media.
• Allergic conjunctivitis is more common in school-age children and adolescents.

Pathophysiology of Conjunctivitis

• Infectious conjunctivitis involves an antigen–antibody reaction.
• Allergic conjunctivitis involves an allergic response with mast cell and histamine mediators.

Therapeutic Management of Conjunctivitis

• Bacterial conjunctivitis is treated with ophthalmic antibiotics.
• Viral conjunctivitis is self-limiting.
• Allergic conjunctivitis is treated with antihistamine or mast cell stabilization eye drops.

Nursing Assessment of Conjunctivitis

• Symptoms include redness, edema, tearing, discharge, and eye pain.
• Itching is common with allergic conjunctivitis.
• Assess onset, progression, and treatments used at home.
• Check for risk factors like day care or family history of allergies.
• Bacterial infections usually cause thick, colored discharge.
• Viral infections usually cause clear or white discharge.
• Allergic conjunctivitis often causes watery discharge.

Nursing Management of Conjunctivitis

• Teach parents how to apply eye drops or ointment.
• Use warm compresses to loosen crusts.
• Encourage avoiding perennial allergens.
• Minimize seasonal allergens on the child’s skin and hair.
• Encourage the child not to rub or touch the eyes.
• Rinse the child’s eyelids with a clean washcloth and cool water.
• Wash the child’s face and hands after being outdoors.
• Ensure the child showers and shampoos before bedtime.
• Wash hands diligently to prevent infectious spread.
• Discourage sharing towels and washcloths.
• Children with viral conjunctivitis may return to school or day care when symptoms lessen.
• Children with bacterial conjunctivitis may return after 24–48 hours of antibiotic treatment.
• Avoid vasoconstricting eye drops.

Nasolacrimal Duct Obstruction

• Common in infants, occurring in 6%–20% of newborns.
• Unilateral in about 65% of cases.
• Causes chronic tearing and mucoid or mucopurulent drainage.
• About 90% of cases resolve spontaneously by 6 months.
• Treatment involves watchful waiting and massage.
• Antibiotics may be prescribed if secondary bacterial infection is suspected.
• Probing of the duct may be needed if the obstruction does not resolve by 12 months of age.

Nursing Assessment of Nasolacrimal Duct Obstruction

• Note tearing or discharge first at the 2-week check-up.
• Determine onset, progression, and response to treatments.
• Note redness of the lower lid.
• Diagnosis is usually based on clinical presentation.

Nursing Management of Nasolacrimal Duct Obstruction

• Clean the eye area frequently with a moist cloth.
• Teach parents to massage the nasolacrimal duct.
• Educate parents about administering antibiotic eye drops.

Eyelid Disorders

• Eyelid disorders include hordeolum (stye), chalazion, and blepharitis.
• Hordeolum is a localized infection of the sebaceous gland.
• Chalazion is a chronic painless infection of the meibomian gland.
• Blepharitis involves chronic scaling and discharges.
• Hordeolum and blepharitis are treated with antibiotic ointment.

Nursing Assessment of Eyelid Disorders

• Note onset of symptoms, extent and character of eye discharge, and pain.
• Inspect eyelids for redness and edema.
• Chalazion may be visible as a small nodule.

Nursing Management of Eyelid Disorders

• Instruct parents on how to administer antibiotic ointment.
• Encourage hot, moist compresses.
• Inform parents that the stye may require several weeks to resolve.
• Chalazion will usually resolve spontaneously or may require surgical drainage.

Eye Injuries

• Infants and young children are more susceptible to eye injuries.
• Common injuries include eyelid injuries, contusion, scleral hemorrhage, corneal abrasion, foreign body, and chemical injury.
• Treatment depends on the type of injury, and may include suturing, ice, analgesics, antibiotic ointment, foreign body removal, and irrigation.

Nursing Assessment of Eye Injuries

• Obtain an accurate history, including the mechanism of injury.
• Determine if the injury is emergent or nonemergent.
• Questions to ask include when the injury occurred, what happened, what object was involved, and if eye protection was used.
• Evaluate pain, photosensitivity, foreign body sensation, and blurry vision.
• Note eyelid placement and signs of trauma.
• Evaluate the ability to open the eyes.
• Use a penlight to evaluate pupillary response.
• Evaluate visual acuity.

Nursing Management of Eye Injuries

• Refer urgent or emergent conditions to an ophthalmologist immediately.
• Assist with positioning and distraction for suturing.
• Apply an ice pack for 20 minutes on and off for black eyes.
• Educate about the natural resolution of scleral hemorrhage.
• Administer analgesics for corneal abrasion pain.
• Remove foreign bodies by everting the eyelid and wiping with a sterile cotton-tipped applicator or irrigating with normal saline.
• For chemical injuries, irrigate the eye with copious amounts of water.

Visual Disorders

• Adequate visual development requires sensory stimulation to both eyes during the first few years of life.
• Common visual disorders include refractive errors, strabismus, amblyopia, nystagmus, glaucoma, and cataracts.

Refractive Errors

• Light does not bend appropriately.
• Hyperopia (farsightedness) is common in young children.
• Myopia (nearsightedness) causes difficulty seeing distant objects.
• Treatment is prescription eyeglasses or contact lenses.

Nursing Assessment of Refractive Errors

• Note blurred vision, eye fatigue, eye strain, difficulty concentrating, and squinting.
• Test visual acuity using an age-appropriate screening tool.

Nursing Management of Refractive Errors

• Encourage the use of glasses with positive reinforcement.
• Teach proper cleaning and care of glasses.
• Teach older children and adolescents how to care for contact lenses.
• Monitor for fit and visual correction.

Strabismus

• Misalignment of the eyes.
• Common types are exotropia (outward) and esotropia (inward).
• Can lead to diplopia (double vision).
• Persistent esotropia after 4 months or constant strabismus at any age needs referral.
• Treatment includes patching, eye muscle surgery, and corrective lenses.

Nursing Assessment of Strabismus

• Note onset, frequency, blurred vision, squinting, and head tilting.
• Observe for exotropia or esotropia.
• Assess symmetry of the corneal light reflex.
• Perform the “cover test”.

Nursing Management of Strabismus

• Encourage compliance with patching and eyeglass wearing.
• Provide appropriate postoperative care.

Amblyopia

• Poor visual development in a structurally normal eye.
• Often called "lazy eye."
• Caused by strabismus, differences in visual acuity, or astigmatism.
• Treatment focuses on strengthening the weaker eye through patching, atropine drops, vision therapy, or eye muscle surgery.

Nursing Assessment of Amblyopia

• Screen all preschoolers for amblyopia.
• Begin visual acuity testing by 3 years of age.
• Observe for asymmetry of the corneal light reflex.

Nursing Management of Amblyopia

• Support and encourage compliance with patching or atropine drops.
• Promote eye safety.

Nystagmus

• Rapid, irregular eye movement
• Common cause is neurologic problem
• Vision development is affected
• Requires evaluation by ophthalmologist and neurologist.

Infantile Glaucoma

• Autosomal recessive disorder with obstruction of aqueous humor flow and increased intraocular pressure.
• Results in large, prominent eyes.
• Vision loss occurs from corneal scarring, optic nerve damage, or amblyopia.
• Treatment is surgical intervention via goniotomy or laser surgery.

Nursing Assessment of Infantile Glaucoma

• Note family history.
• Check for infant keeping eyes closed or rubbing eyes.
• Observe for corneal enlargement, clouding, and photophobia.

Nursing Management of Infantile Glaucoma

• Provide postoperative care and educate the family.
• Protect the surgical site, maintain eye patching, and ensure bed rest.
• Use elbow restraints if necessary.
• Prepare parents for multiple surgeries.
• Teach families how to administer medications.
• Advise avoiding roughhousing and contact sports for 2 weeks after surgery.
• Encourage compliance with visual assessments.

Congenital Cataract

• Opacity of the lens present at birth.
• Leads to sensory amblyopia if untreated.
• Surgery to remove the opaque lens can be done as early as 2 weeks of age.
• Glaucoma may occur as a complication.

Nursing Assessment of Congenital Cataract

• Note lack of visual awareness.
• Observe for cloudiness of the cornea.
• The red reflex will not be observed.

Nursing Management of Congenital Cataract

• Postoperative care focuses on protecting the operative site.
• Teach families how to administer drops.
• Patch the healthy eye to promote visual development.
• Regular visual assessments are critical.
• Use sunglasses that block ultraviolet rays.

Retinopathy of Prematurity

• Rapid growth of retinal blood vessels in premature infants.
• Risk factors include low birth weight, early gestational age, sepsis, high light intensity, and hypothermia.
• Premature infants need serial examinations by an ophthalmologist.
• Laser surgery may be necessary.
• Complications include myopia, glaucoma, and blindness.

Nursing Assessment of Retinopathy of Prematurity

• Ensure that all former premature infants are routinely screened for visual deficits.
• Observe for strabismus.

Nursing Management of Retinopathy of Prematurity

• Ensure compliance with follow-up appointments.

Visual Impairment

• Acuity between 20/60 and 20/200.
• "Legal blindness" is vision less than 20/200 or peripheral vision less than 20 degrees.
• Causes include refractive error, astigmatism, strabismus, amblyopia, nystagmus, infantile glaucoma, congenital cataract, ROP, and retinoblastoma.
• Factors increasing risk include prematurity, developmental delay, genetic syndrome, family history, African American heritage, eye injury, diabetes, HIV, and chronic corticosteroid use.
• Children may develop self-stimulatory actions or blindisms.

Nursing Assessment

• Dull, vacant stare is a sign of visual impairment.
• Infants may not fix and follow or make eye contact.
• Toddlers and older children may rub, shut, cover eyes, squint, blink frequently, hold objects close, bump into objects, or tilt their head.

Nursing Management

• Encourage corrective lenses.
• Refer children under 3 to Early Intervention and those over 3 for individualized education plans (IEPs).

Promoting Socialization, Development, and Education

• Provide emotional support.
• Encourage developmental activities.
• Display affection through touch and tone of voice.
• Refer families to support networks.
• Use child’s name, identify yourself, encourage independence, name objects, and make directions simple.

Infectious and Inflammatory Disorders of the Ears

• Otitis externa and types of otitis media
• Otitis media is inflammation of the middle ear with fluid.
• AOM (acute otitis media) is an acute infection with rapid onset of ear pain and fever.
• OME (otitis media with effusion) is fluid in the middle ear without infection.
• Otitis externa is inflammation of the external ear canal.

Acute Otitis Media

• Common illness in children.
• Increased susceptibility due to the short length and horizontal positioning of the Eustachian tube
• Occurs mostly in the fall through spring, with the highest incidence in the winter.
• Risk factors are Eustachian tube dysfunction and recurrent upper respiratory infections.

Pathophysiology

• Upper respiratory infection frequently precedes AOM.
• Fluid and pathogens travel from the nasopharyngeal area.
• Viral infections or bacterial invasion.
• Common pathogens: S. pneumoniae, H. influenzae, and Moraxella catarrhalis.

Complications

• Hearing loss
• Expressive speech delay
• Tympanosclerosis
• Tympanic membrane perforation
• Chronic suppurative otitis media
• Acute mastoiditis
• Intracranial infections include meningitis and abscesses.

Therapeutic Management

• Viral causes resolve spontaneously.
• Antibacterial use depends on timing, child's age, and if the episode is a first infection.
• Pain management is an important component.
• A clinical diagnosis is needed.
• Treatment Recommendations are dependent on if the the episode is mild or severe, and the child's history

Nursing Assessment

• Note signs and symptoms of acute, abrupt onset illness.
• Symptoms might include; fever, otalgia (ear pain), Fussiness or irritability Crying inconsolably, particularly when lying down Batting or tugging at the ears (may also occur with teething or OME, or may be a habit) Rolling the head from side to side, poor feeding, Lethargy, Difficulty sleeping or awakening crying in the night and Fluid draining from the ear
• Child may complain of pain when the ear is examined and previous medical history
• On examination Tympanic membrane will have a dull or opaque appearance and is bulging and/or red.

Nursing Management

• Nursing management of the child with AOM is mainly supportive in nature. and focuses on prevention and pain management associated with acute otitis media